Chapter 48 Immunosuppressant Drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Chapter 48

Immunosuppressant Drugs

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

The purpose of the immune system is to distinguish self from nonself and to protect the body from foreign material (antigens), including cancer

Two types of immunity: humoral immunity, which is mediated by B lymphocytes, and cellular immunity, which is mediated by T lymphocytes

Immune System

Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 2

Participates in anaphylactic reactions Responsible for rejection of kidney, liver, and

heart transplants Can also sometimes attack itself, causing

“autoimmune diseases” or immune-mediated diseases

Immune System (cont’d)


Drugs that decrease or prevent an immune response, thus suppressing the immune system

Used to prevent or treat rejection of transplanted organs

Immunosuppressants


All suppress certain T-lymphocyte cell lines, thus preventing their involvement in the immune response

Results in a pharmacologically immunocompromised state

Mechanisms of action vary according to drug

Immunosuppressants (cont’d)


Major classes used to prevent organ rejection Glucocorticoids Calcineurin inhibitors Antimetabolites



cyclosporine (Sandimmune) azathioprine (Imuran) muromonab-CD3 (Orthoclone) daclizumab (Zenapax) sirolimus (Rapamune) basiliximab (Simulect) glatiramer acetate (Copaxone) tacrolimus (Prograf) mycophenolate mofetil (CellCept)



Indications vary from drug to drug Primarily indicated for the prevention of organ

rejection Muromonab-CD3, mycophenolate, and

tacrolimus are indicated for both prevention of rejection and treatment of organ rejection



Classroom Response Question

The nurse should question the prescriber regarding use of cyclosporine for the treatment of which disease?

A.Arthritis

B.Psoriasis

C.Irritable bowel disease

D.Multiple sclerosis


azathioprine (Imuran) Prophylaxis of organ rejection concurrently with other

immunosuppressant drugs, such as cyclosporine and corticosteroids

Also used in the treatment of rheumatoid arthritis



basiliximab (Simulect) and daclizumab (Zenapax) Monoclonal antibodies Used to prevent rejection of transplanted kidneys Generally used as part of a multidrug

immunosuppressive regimen that includes cyclosporine and corticosteroids

Have a tendency to cause the allergy-like reaction known as cytokine release syndrome



cyclosporine (Sandimmune) Prevention of organ rejection May be used for other autoimmune disorders

tacrolimus (Prograf) Used for the prevention of liver transplant rejection Others uses are unlabeled uses




A patient who had a kidney transplant is receiving cyclosporine PO in maintenance doses. What action would decrease the potency of this drug?

A. Taking it with orange juice

B. Taking it with milk

C. Using a Styrofoam container to administer the drug

D. Mixing it with chocolate milk


glatiramer acetate (Copaxone) Works by blocking T-cell autoimmune activity against

myelin protein, which reduces the frequency of the neuromuscular exacerbations associated with multiple sclerosis



fingolimod (Gilenya) Failed as an antirejection drug Approved in 2010 for multiple sclerosis Only oral drug for relapsing forms of multiple sclerosis Significant adverse effects, including headache,

hepatotoxicity, flulike symptoms, back pain, AV block, bradycardia, hypertension, and macular edema, may occur



muromonab-CD3 (Orthoclone OKT3) Reversal and prevention of graft rejection Monoclonal antibody



mycophenolate (CellCept) Indicated for the prevention of organ rejection as well

as the treatment of organ rejection FDA black box warning for increased risk of

congenital malformations and spontaneous abortions when used during pregnancy

Common side effects include hypertension, hypotension, peripheral edema, tachycardia, pain, headache, hyperglycemia, hyperlipidemia, electrolyte disturbances, and others



Adverse effects vary according to drugs and may be devastating

All immunosuppressed patients have a heightened susceptibility to opportunistic infections



Perform a thorough assessment before administering these drugs Renal, liver, and cardiovascular function studies CNS baseline function Respiratory assessment Baseline vital signs Baseline laboratory studies, including hemoglobin,

hematocrit, WBC, and platelet counts

Nursing Implications


Assess for contraindications, drug allergies, and drug interactions

Monitor WBC counts throughout therapy; if the count drops below normal range, contact the prescriber

Nursing Implications (cont’d)



Which potential problem is of most concern for the patient receiving immunosuppressant drugs?

A. Orthostatic hypotension

B. Increased susceptibility to infections

C. Neurotoxicity

D. Peripheral edema


Oral immunosuppressants should be taken with food to minimize GI upset

Oral forms are used when possible to decrease the risk of infection that may occur with parenteral injections

Note that there are several possible drug interactions

Grapefruit juice also interacts with some of these drugs



Oral antifungal drugs are usually given with these drugs to treat oral candidiasis that may occur

Assess the oral cavity often for white patches on the tongue, mucous membranes, and oral pharynx



Mix oral cyclosporine solution in a glass container

Do not use Styrofoam containers because the drug adheres to the inside wall of the container



Follow guidelines for parenteral administration carefully

Inform patients that lifelong therapy with immunosuppressants is indicated with organ transplantation



Patients taking immunosuppressants should be encouraged to take measures to reduce the risk of infection Avoiding crowds Avoiding people with colds or other infections

Inform patients to immediately report fever, sore throat, chills, joint pain, fatigue, or other signs of a severe infection



Monitor for therapeutic responses Monitor for adverse effects and signs of drug

toxicity




A male patient who received a kidney transplant 6 months ago is taking cyclosporine. The patient tells the nurse that he has started to take several herbal preparations. Which does not pose a possible problem for the patient?

A.St. John’s wort

B.Ginkgo

C.Cat’s claw

D.Echinacea


Chapter 48 Immunosuppressant Drugs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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