|
|
 
Immunosuppressives
Immunosuppressive agents are generally
used to reduce rejection of transplanted
organs. They are also used in serious,
systemic cases of lupus in which major
organs such as the kidneys are affected
or in which there is severe muscle
inflammation or intractable arthritis.
Because of their steroid-sparing effect,
immunosuppressives may also be used
to reduce or sometimes eliminate the
need for corticosteroids, thereby sparing
the patient from undesirable side effects
of corticosteroid therapy.
Immunosuppressives can have
serious side effects. Patients need to
understand, however, that side effects
are dose-dependent and are generally
reversible by reducing the dose or
stopping the medication.
Types of
Immunosuppressives
A variety of immunosuppressive drugs
is available to treat lupus. Although
they have different mechanisms of
action, each type functions to decrease
or prevent an immune response. The
immunosuppressives most frequently
used with SLE patients are:
- azathioprine (Imuran®).
Azathioprine, one of the most
widely used immunosuppressives
for lupus, is an antimetabolite.
Antimetabolites work by
blocking metabolic steps
within immune cells and
then interfering with immune
function. Used to control the
underlying disease process,
azathioprine has fewer serious
side-effect risks than some other
drugs used to control lupus.
- cyclophosphamide (Cytoxan®).
An alkylating agent and
strong immunosuppressive,
cyclophosphamide is reserved
for treating lupus with kidney
disease or other internal
organ involvement. It works
by targeting and damaging
autoantibody-producing cells,
thereby suppressing the
hyperactive immune response
and reducing disease activity. It
has the potential for severe side
effects, including risk of serious
infection.
- methotrexate (Rheumatrex®).
Originally developed as a cancer
treatment and later approved
for rheumatoid arthritis,
methotrexate, like azathioprine,
is an antimetabolite. It is
predominantly used for lupus
arthritis. It requires monitoring
of the CBC and liver function
tests. To reduce toxicity, daily
folic acid is prescribed.
- cyclosporine (Neoral®).
Originally developed to
prevent the body from
rejecting transplanted organs,
cyclosporine is now commonly
used to treat rheumatic diseases,
including lupus. Cyclosporine is
an antimetabolite.
- mycophenolate mofetil
(CellCept®). A strong
immunosuppressive drug
developed to prevent the
rejection of transplanted organs,
mycophenolate is sometimes
used as an alternative to
cyclophosphamide for lupus
with kidney involvement.
Mycophenolate works by
keeping T and B lymphocytes
from replicating.
There are many serious risks associated
with the use of immunosuppressives.
They include immunosuppression
(resulting in increased susceptibility to
infection), bone marrow suppression
(resulting in decreased numbers of RBCs,
WBCs, and platelets), and development of
malignancies.
Side/Adverse Effects
Dermatologic: alopecia
(cyclophosphamide and methotrexate)
Gastrointestinal: nausea, vomiting,
stomatitis, esophagitis, and hepatotoxicity
Genitourinary: hemorrhagic
cystitis, hematuria, amenorrhea,*
impotence,* and gonadal suppression
(cyclophosphamide only) **
Hematologic: thrombocytopenia,
leukopenia, pancytopenia, anemia, and
myelosuppression
Respiratory: pulmonary fibrosis***
Other: increased risk of serious infections
or malignancies
Pregnancy and Lactation
Use of immunosuppressives presents
definite risks to the fetus. Female patients
should use contraceptive measures during
treatment and for 12 weeks after ending
azathioprine therapy. Azathioprine
may pass into breast milk, and women
using this drug should consult with their
doctors before breastfeeding.
* temporary or reversible once drug therapy is
discontinued
** recovery of function after drug is discontinued is
unpredictable
*** with high doses
|
|
|
Considerations for Health Professionals
Assessment:
History: allergy to
immunosuppressive drugs,
infections, impaired hepatic
or renal function, pregnancy,
lactation, corticosteroid therapy,
immunosuppression, bone marrow
suppression, and appropriate
contraception
Laboratory data: CBC,
differential, platelet count, renal
function studies, liver function tests,
pulmonary function tests, chest X
ray, and electrocardiogram (ECG)
Physical: all body systems to
determine baseline data and
alterations in function, temperature,
pulse, respiration, weight, skin
color, lesions, hair, and mucous
membranes
Evaluation:
therapeutic response and adverse
effects
Administration:
orally or intravenously
Precaution: Drug administration
protocols can vary. The nurse must
work closely with the prescribing
physician to administer the drug
safely and to monitor the patient
to minimize adverse effects and
achieve expected outcomes.
Teaching Points:
See Patient Information Sheet on Azathioprine, Cyclophosphamide, Methotrexate (Rheumatrex®), Cyclosporine (Neoral®), and Mycophenolate Mofetil.
|
|
Source: National Institutes of Health, U.S.Dept of Health and Human Services
|
|
|
|
