Comprehensive Study Guide on Immune System Medications: Immunosuppressants and Epinephrine

Overview of Immunosuppressant Medications

• General Purpose and Indications:

  • Immunosuppressants are administered to prevent the body from attacking itself in patients with autoimmune disorders.
  • They are critical for patients who have undergone organ transplantation to prevent the body from rejecting the new organ.

• Mechanism of Action:

  • These drugs work by suppressing the immune system, effectively putting White Blood Cells (WBCs) "to sleep."
  • The primary benefit is the cessation of the body attacking its own normal organs or transplanted tissues.

• General Adverse Effects (Bone Marrow Suppression):

  • The suppression of the immune system leads to bone marrow suppression.
  • Major Infection Risk: Because the immune defense is lowered, patients are highly susceptible to infections.
  • Major Bleeding Risk: Bone marrow suppression results in lower platelet production.

Hydroxychloroquine

• Indications:

  • Primarily used to treat Systemic Lupus Erythematosus (Lupus), a condition where the body attacks its own skin and joints.

• Therapeutic Effects:

  • Decreases inflammation and fatigue.
  • Patients commonly report an increase in energy levels.

• Administration Timeline:

  • It takes several months of consistent use to reach a therapeutic level; benefits are not observed immediately.

• Major Adverse Effects and Monitoring:

  • Retinal Damage: This drug is known for causing significant retinal damage and vision problems.
  • Mandatory Monitoring: Patients must have regular eye examinations every $6$ to $12\,\text{months}$.
  • Memory Trick: Think của "Hydroxy" sounds like eye damage, and "Chloroquine" sounds like chlorine in the eyes. Just as chlorine irritates the eyes, this drug requires annual eye checks.

• Patient Education and Distractors:

  • Teaching is considered effective if the patient expresses the need to see an optometrist at least once per year.
  • Medical Alert Bracelet: Contrary to medications for seizures, hydroxychloroquine does not require a medical alert bracelet.
  • Osteoporosis Vitamins: There is no need for supplemental Calcium or Vitamin D specifically for this drug, despite these being common distractor options in exams.

Methotrexate

• Indications:

  • Rheumatoid Arthritis (RA): The body attacks its own joints.
  • Psoriasis: The body attacks its own skin.
  • Certain types of cancer: Used to slow down malignant growth.

• Mechanism of Action:

  • Stops folic acid metabolism, which in turn halts cellular reproduction in the body's fastest-replicating cells.

• Major Risks and Contraindications:

  • Populations at Risk: Targets the blood, the immune system, and a growing fetus in pregnant clients.
  • Immune System: Results in a very weak system prone to infection.
  • Platelets: Causes low platelet counts, leading to serious bleeding.
  • Pregnancy: Can cause fetal death. It is "no-baby safe."

• Memory Trick: "Metho-no-trexate":

  • No Pregnant clients.
  • No Crowds or live vaccines.
  • No Razors or hard teeth brushing (due to bleeding risk).

• Infection Risk Management:

  • Fever Reporting: Patients must report any fever over $100.3^{\circ}F$ ($38^{\circ}C$).
  • Avoidance: Stay away from crowds, sick people, fresh fruits, and live flowers.

• Thrombocytopenia (Low Platelets):

  • Definition: Platelets under $100,000\,\text{cells}/\text{mm}^3$.
  • Guidelines: Under $150,000$ is "iffy," but under $50,000$ is extremely "risky."
  • Symptoms to Report: Petechiae (tiny red/purple spots), Purpura (purple spots under the skin), Melena (black tarry stool indicating GI bleed), Hematemesis (vomiting blood), and bleeding gums.

• Vaccines and Biology:

  • The drug suppresses B and T lymphocytes.
  • Allowed: Inactivated vaccines (e.g., flu and pneumonia shots).
  • Contraindicated: Live vaccines (e.g., Herpes Zoster/Shingles).

• Pregnancy and Contraception:

  • Patients must use birth control.
  • Resumption Timelines: One menstrual cycle after treatment (for some providers) or $3\,\text{months}$ after treatment (for both men and women).

Tumor Necrosis Factor (TNF) Inhibitors

• Medications:

  • Includes Etanercept, Infliximab, and Adalimumab.

• Memory Tricks:

  • Etanercept: "Intercepts" the immune response.
  • -MAB ending: "Mad" immunosuppression (Infliximab/Adalimumab).

• Clinical Priority:

  • Report elevated WBCs or a fever over $100.3^{\circ}F$ ($38^{\circ}C$). Fever is the priority assessment finding because a suppressed system with a fever usually indicates a massive infection.

• Tuberculosis (TB) Specifics:

  • These drugs can reactivate latent TB.
  • Requirement: A negative TB skin test is mandatory before starting therapy.
  • Follow-up: Annual TB tests are required to ensure the patient remains negative. If a test is positive, the patient must finish anti-TB medication before starting TNF inhibitors.

• Contraindications and Labs:

  • Cannot be taken if an active, chronic, or recent infection exists (e.g., a patient on antibiotics cannot start Infliximab).
  • C-Reactive Protein (CRP): Elevated CRP is expected in autoimmune patients and is not the most important lab. It is a common distractor. WBC and fever are the true priorities.

Cyclosporine and Azathioprine

• Primary Application:

  • Preventing organ transplant rejection.
  • These are lifelong medications.

• Mechanism / Memory Trick:

  • Cyclosporine: "Cyclo-spare-ine" because it spares the organ from rejection.

• Major Side Effects and Monitoring:

  • Bone Marrow Suppression: Check WBCs and platelets before administration.
  • Leukopenia: Report WBC counts below $4,000\,\text{per } mm^3$.
  • Gingival Hyperplasia: Overgrowth of gum tissue. This is an expected side effect of cyclosporine and does not need to be reported to the provider.

• Patient Education:

  • Dietary: Never take with grapefruit juice.
  • Hygiene: Avoid crowds; use a soft-bristle toothbrush (to prevent bleeding gums).
  • Compliance: Take at the same time every day for life.
  • Contraception: Must be used as these are not baby-safe.

Epinephrine (EpiPen)

• Classification:

  • Vasopressor used to "press up" the vital signs.

• Mechanism of Action:

  • Stimulates Alpha and Beta receptors.
  • Vasoconstriction: Increases Blood Pressure (BP).
  • Bronchodilation: Opens lungs to facilitate breathing.
  • Cardiac Effects: Positive Chronotropic (increases beats per minute/heart rate) and Positive Inotropic (increases force of contraction).

• Indications for Use:

  • Anaphylaxis (severe allergic reactions) and Cardiac Arrest.
  • In anaphylaxis, it is the absolute first drug administered at the first sign of symptoms (hives, dyspnea, hypotension).

• Administration Guidelines:

  • Sequence: Give Epi first, then Diphenhydramine (Benadryl), then Albuterol and steroids.
  • Frequency: Repeat every $5$ to $15\,\text{minutes}$ if symptoms continue or until they resolve.
  • Technique: Inject into the outer thigh at a $90^{\circ}$ angle. No skin prep is needed; you can inject through clothes.
  • Contact Time: Hold the injector in place for a full $10\,\text{seconds}$.

• Post-Administration Care:

  • Seek immediate medical attention. Epinephrine wears off in $10$ to $20\,\text{minutes}$, and symptoms may return.
  • Side Effects: Tachycardia ($HR > 100$), palpitations, and dizziness are normal and expected.

• Storage:

  • Store in a dark place at room temperature.
  • Do not store in the refrigerator (too cold) or in a car (too hot), as heat and light deactivate the medication.

Questions & Discussion

• Scenario 1 (Methotrexate): If a patient on methotrexate reports tiny reddish-purple lesions (petechiae), this requires immediate intervention because it indicates a major bleed risk.
• Scenario 2 (Hydroxychloroquine): A patient needs to see an optometrist every $6$ to $12\,\text{months}$. It does not cause bone problems, so Calcium/Vitamin D are unnecessary distractors. It increases energy, rather than increasing fatigue.
• Scenario 3 (EpiPen Technique): Success is defined by the patient stating they will inject into the outer thigh at the first sign of an allergy and seek immediate medical attention afterward. Holding for $5\,\text{seconds}$ is insufficient; $10\,\text{seconds}$ is the standard.
• Scenario 4 (Etanercept Labs): Prior to administration, nurses must review the Tuberculin skin test (due to TB reactivation risk), WBC count (due to infection risk), and RBC count (due to potential anemia from bone marrow suppression). PTT (used for heparin) and Cholesterol are not relevant diagnostics for this drug class.
• Scenario 5 (Shock Management): Effective management of shock via Epinephrine is indicated by a stable BP, an apical pulse around $99$, and a capillary refill of less than $2\,\text{seconds}$, indicating improved perfusion.