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PRESENTED TO: PRESENTED BY:
Mrs. Vinay Kumari Amandeep Kaur
Associate Professor Roll No. 1915703
Medical Surgical Nursing M.Sc. (N) 2nd Year
SR.
NO.
CONTENT
1. Introduction to immunity
2. Types of immunity
3. What is antigen and antibody
4. Type of antigens
5. Type of antibody
6. Antibody targets and functions
7. Antigen and antibody action/reaction
8. Non specific defences
9. Introduction to immunosuppressant
10. Classification of immunosuppressants
11. Organ transplant rejection
12. Mechanism of cyclosporine and tacrolimus
13. Mechanism of sirolimus and tacrolimus
14. Mechanism of mycophenolate
15. Action of immunosuppressants
16. Side effects immunosuppressants
INTRODUCTION TO IMMUNITY
 Immunity is the resistance of an organism to
infection or disease.
 Immunity is the state of sufficient biological
defences to avoid infection, disease, or other
unwanted biological invasion.”
 In biology, immunity is the state of having
sufficient biological defences to
avoid infection, disease, or other unwanted
biological invasion. It is the capability of the
body to resist harmful microbes from entering it.
TYPES OF IMMUNITY
 2. A. INNATE IMMUNITY
 Innate immunity is non- specific. It is first lines of defence. They
defences include secretion of chemical signals, phagocytic activity,
antimicrobial substance and fever.
 Examples
Neutrophils, Eosinophils, Mast cells, Monocytes, Macrophages,
Killer cell, Platelets
 Innate immunity also comes in a protein chemical form, called
innate humoral immunity. If an antigen gets past these barriers, it is
attacked and destroyed by other parts of the immune system.

Examples
Cough reflex, Enzymes in tears and skin oils, Mucus (which
traps bacteria and small particles),Skin, Stomach acid
FIRSTLINE OFDEFENCE – NON-SPECIFIC BARRIERS
2.B. TYPE OFACQUIRED IMMUNITY
2.B. TYPE OFACQUIRED IMMUNITY
3.ANTIGEN &ANTIBODY
 An antigen
 May be a foreign substance from the environment such as
chemicals, bacteria, viruses, or pollen. An antigen may also
be formed within the body, as with bacterial toxins or tissue
cells. An antigen is any substance that causes our immune
system to produce antibodies against it.
 An antibody
 Also known as an immunoglobulin (Ig), is a large Y-
shape protein produced by B cells that is used by
the immune system to identify and neutralize foreign
objects such as bacteria and viruses. The antibody
recognizes a unique part of the foreign target, called an
antigen.
4. TYPE OFANTIGENS
1. Exogenous antigens
Exogenous antigens are antigens that have entered the
body from the outside, for example
by inhalation, ingestion, or injection.
2. Endogenous antigens
Endogenous antigens are antigens that have been
generated within previously normal cells as a result of
normal cell metabolism, or because of viral or
intracellular bacterial infection.
Cont…
3. Autoantigens
An autoantigen is usually a normal protein or complex of proteins
(and sometimes DNA or RNA) that is recognized by the immune
system of patients suffering from a specific autoimmune disease.
4. Tumour antigens or neoantigens
Those antigens that are presented by MHC I or MHC II molecules
on the surface of tumor cells. These antigens can sometimes be
presented by tumor cells and never by the normal ones. In this case,
they are called tumor-specific antigens (TSAs) and, in general,
result from a tumor-specific mutation.
5. TYPE OFANTIBODY
6.ANTIBODYTARGETSAND FUNCTIONS
7.ANTIGENANDANTIBODYACTION/REACTION
7.ANTIGENANDANTIBODYACTION/REACTION
8. NON SPECIFIC DEFENSES
Cont…
9. CELLSAND MOLECULES OFIMMUNE RESPONSE
Cont…
Functions In Immune System
Cont…
Molecule Functions In Immune System
Generation Of HumoralAnd Cell-mediated Immune
ResponseAnd Sites OfAction Of Immunosuppressant drugs
 Humoral immune response: The antigen (Ag) is
processed by macrophages or other antigen
presenting cells (APC), coupled with class II
major histocompatibility complex (MHC) and
presented to the CD4 helper T-cell which are
activated by interleukin-I (IL-1), proliferate and
secrete cytokines—these in turn promote
proliferation and differentiation of antigen
activated B cells into antibody (Ab) secreting
plasma cells. Antibodies finally bind and
inactivate the antigen.
 In cell-mediated immunity—foreign antigen is
processed and presented to CD4 helper T cell
which elaborate IL-2 and other cytokines that in
turn stimulate proliferation and maturation of
precursor cytotoxic lymphocytes (CTL) that
have been activated by antigen presented with
class I MHC. The mature CTL (Killer cells)
recognize cells carrying the antigen and lyse
them.
Immunological rejection pathways
IMMUNOSUPPRESSANT
INTRODUCTION
 Immunosuppressant drugs are a class of drugs that suppress
or reduce the strength of the body’s immune system. They are
also called anti-rejection drugs. One of the primary uses of
immunosuppressant drugs is to lower the body’s ability to reject
a transplanted organ, such as a liver, heart or kidney.
 Almost everyone who receives an organ transplant has to take
immunosuppressant drugs. The body recognizes a transplanted
organ as a foreign mass. This triggers a response by the body’s
immune system to attack it.
INTRODUCTION
 By weakening the immune system, immunosuppressant drugs
decrease the body’s reaction to the foreign organ. The drugs allow
the transplanted organ to remain healthy and free from damage
 Immunosuppressant drugs also are used to treat autoimmune
diseases such as lupus. An autoimmune disorder is a disease
process in which the body attacks its own tissue. Lupus results
from just such a misdirected activity of the body’s own immune
system. By suppressing this reaction, immunosuppressant drugs
can help control the impact of the disease on the body.
IMMUNOSUPPRESSANT DRUGS
These are drugs which inhibit cellular /humoral or both
immune response and have their major use in organ
transplantation and autoimmune diseases. The drugs are:
1. Calcineurin inhibitors
2. m-TOR inhibitors
3. Antiproliferative drugs (Cytotoxic drugs)
4. Glucocorticoids
5. Biological agents
Classification
1. Calcineurin inhibitors
(Specific T-cell inhibitors)
Cyclosporine (Ciclosporin), Tacrolimus
2. m-TOR inhibitors
Sirolimus, Everolimus
3. Antiproliferative drugs (Cytotoxic drugs)
Azathioprine, Methotrexate,
Cyclophosphamide, Chlorambucil,
Mycophenolate mofetil (MMF)
4. Glucocorticoids
Prednisolone and others
5. Biological agents
(a) TNFα inhibitors: Etanercept,
Infliximab, Adalimumab
(b) IL-1 receptor antagonist: Anakinra
(c) IL-2 receptor antagonists: Daclizumab,
(anti CD-25 antibodies) Basiliximab
(d) Anti CD-3 antibody: Muromonab CD3
(e) Polyclonal antibodies: Antithymocyte
antibody (ATG), Rho (D) immune globulin.
CALCINEURIN INHIBITORS
(Specific T-cell inhibitors)
Cyclosporine
It is a cyclic polypeptide with 11 amino acids,
obtained from a fungus and introduced in 1977 as a
highly selective immunosuppressant which has
markedly increased the success of organ
transplantations.
It profoundly and selectively inhibits T lymphocyte
proliferation, IL-2 and other cytokine production as
well as response of inducer T cells to IL-1, without any
effect on suppressor T-cells. Lymphocytes are arrested
in G0 or G1 phase.
Mechanism of action
 Cyclosporine, tacrolimus and sirolimus inhibit
antigen stimulated activation and proliferation of
helper T cells as well as expression of IL-2 and other
cytokines by them.
 Cyclosporine binds to an intracellular protein
‘Cyclophilin’ and this complex inhibits Ca2+
Calmodulin (Ca2+-CAM) activated phosphatase
‘Calcineurin’.
 Cyclosporine binds to an intracellular protein ‘Cyclophilin’ and
this complex inhibits Ca2+-Calmodulin (Ca2+-CAM) activated
phosphatase ‘Calcineurin.
Name of
drug
classification Dose and route Uses Side effects
Cyclospor
ine
(ciclospor
in)
Calcineurin
inhibitors
(Specific t-cell
inhibitors)
10–15 mg/kg/day with
milk or fruit juice till 1–2
weeks after
transplantation, gradually
reduced to maintenance
dose
Of 2–6 mg/kg/day.
Therapy may be started
with 3–5 mg/kg
I. V. Infusion.
Prevention
and
treatment of
graft
rejection
reaction.
Rise in BP,
precipitation of
diabetes,
Anorexia,
Lethargy,
Hyperkalaemia,
Hyperuricaemia,
Opportunistic
Infections,
Hirsutism,
Gum hyperplasia,
Tremor
And seizures.
Cyclosporine is most active when administered before
antigen exposure, but can, in addition, suppress the responses of
primed helper T cells; hence useful in autoimmune diseases as
well.
Cyclosporine selectively suppresses cellmediated
immunity (CMI), prevents graft rejection and yet leaves the
recipient with enough immune activity to combat bacterial
infection. Unlike cytotoxic immunosuppressants, it is free of
toxic effects on bone marrow and RE system. Humoral immunity
remains intact.
uses
 Cyclosporine is the most effective drug for prevention
and treatment of graft rejection reaction.
 It is routinely used in renal, hepatic, cardiac, bone marrow
and other transplantations. For induction
 it is started orally 12 hours before the transplant and
continued for as long as needed.
 When graft rejection has started, it can be given i.v.,
because oral bioavailability is low, dependent on presence of
bile and is highly variable.
 Blood level monitoring is required for effective therapy.
Pharmokinetics
 It is concentrated in WBCs and RBCs,
metabolized in liver by CYP3A4 and excrete in
bile.
 The plasma t½ is biphasic 4–6 hr and 12–18 hr.
Drug Interactions
 Cyclosporine can interact with a large number of
drugs.
 All nephrotoxic drugs like aminoglycosides,
vancomycin, amphotericin B and NSAIDs enhance its
toxicity.
 By depressing renal function, it can reduce excretion
of many drugs. Phenytoin, phenobarbitone, rifampin
and other enzyme inducers lower its blood levels so
that transplant rejection may result.
Tacrolimus
This immunosuppressant is chemically different
from cyclosporine, but has the same mechanism of
action, and is ~100 times more potent.
It binds to a different cytoplasmic immunophilin
protein labelled ‘FK 506 binding protein (FKBP)’,
but the subsequent steps are the same, i.e.
inhibition of helper T cells via calcineurin.
Tacrolimus also inhibits calcineurin, but after binding to a
different protein FKBP (FK binding protein).
Name of
drug
classification Dose and route Uses Side effects
Tacrolimus Calcineurin
inhibitors
(Specific t-cell
inhibitors)
0.05–0.1 mg/kg BD oral (for
renal transplant),
0.1–0.2 mg/kg BD (for liver
transplant).
It can also be given i.v. (no
i.v. preparation is available in
India);
0.03–0.1% topically.
Prevention
and
treatment of
graft
rejection
reaction.
Rise in BP,
precipitation of
diabetes,
Anorexia,
Lethargy,
Hyperkalaemia,
Hyperuricaemia,
Opportunistic
Infections,
Hirsutism,
Gum hyperplasia,
Tremor
And seizures.
Cont…
 Tacrolimus is administered orally as well as by
i.v. infusion.
 Oral absorption is variable and decreased by
food.
 It is metabolized by CYP3A4 and excreted in
bile with a t½ of 12 hour.
 Therapeutic application, clinical efficacy as well
as toxicity profile are similar to cyclosporine.
2. m-TOR inhibitors
a). Sirolimus
 This new and potent immunosuppressant is a macrolide
antibiotic (like tacrolimus), which was earlier named
Rapamycin.
 It binds to the same immunophillin FKBP as tacrolimus, but
the sirolimus-FKBP complex inhibits another kinase called
‘mammalian target of rapamycin’ (mTOR), and does not interact
with calcineurin.
 The mTOR is an important link in the cascade of signalling
pathways which lead to proliferation and differentiation of T-
cells activated by IL-2 and other cytokines.
 Sirolimus arrests the immune response at a later stage than
cyclosporine.
Sirolimus also binds to FKBP, but this complex acts at a later stage. It
binds to and inhibits a kinase termed m-TOR (mammalian target of
rapamycin) which is a key factor for progression of cell proliferation.
Pharmokinetics
 Sirolimus is absorbed orally, but fatty meal reduces
absorption.
 It is extensively metabolized, mainly by CYP3A4, so
that systemic bioavailability is only 15–20%.
 Elimination occurs primarily by the biliary route; the
t½ is ~60 hours.
 Inhibitors and inducers of CYP3A4 significantly alter
its blood level, which needs to be monitored.
 Cyclosporine shares the same isoenzyme and raises
the blood level of sirolimus.
Uses
For prophylaxis and therapy of graft rejection
reaction, sirolimus can be used alone, but is generally
combined with lower dose of cyclosporine/tacrolimus
and/or corticosteroids and mycophenolate mofetil.
The latter combination avoids use of a calcineurin
inhibitor, and is particularly suitable for patients
developing renal toxicity with cyclosporine.
Sirolimus is effective in some steroid refractory
cases, and has been used in stem cell transplant as well.
However, it is not recommended for liver transplant.
Sirolimus coated stents are being used to reduce the
incidence of coronary artery restenosis, by inhibiting
endothelial proliferation at the site.
 Everolimus
It is similar to sirolimus in mechanism,
clinical efficacy, doses, toxicity and drug
interactions, but is better absorbed orally and has
more consistent bioavailability.
The t½ is shorter (~40 hours) so that steady
state levels can be reached earlier.
3.ANTIPROLIFERATIVE DRUGS
(Cytotoxic immunosuppressants)
 Certain cytotoxic drugs used in cancer
chemotherapy exhibit prominent
immunosuppressant property, mainly by preventing
clonal expansion of T and B lymphocytes.
a). Azathioprine
It is a purine antimetabolite which has more marked
immunosuppressant than antitumour action.
The basis for this difference is not clear, but may be
due to its selective uptake into immune cells and
intracellular conversion to the active metabolite 6-
mercaptopurine, which then undergoes further
transformations to inhibit de novo purine synthesis and
damage to DNA.
It selectively affects differentiation and function of T
cells and inhibits cytolytic lymphocytes; CMI is primarily
depressed.
Uses
The most important application of azathioprine is
prevention of renal and other graft rejection, but it is less
effective than cyclosporine; generally combined with it or
used in patients developing cyclosporine toxicity.
Relatively lower doses (1–2 mg/kg/day) are used in
progressive rheumatoid arthritis and it is frequently
employed for maintening remission in inflammatory bowel
disease.
It may be an alternative to long-term steroids in some
other autoimmune diseases as well. It is not combined with
Methotrexate. Dose: 50–150 mg/day; orally
b). Methotrexate
This folate antagonist is a potent immunosuppressant
which markedly depresses cytokine production and cellular
immunity, and has antiinflammatory property.
It has been used as a first line drug in many
autoimmune diseases like rapidly progressing rheumatoid
arthritis, severe psoriasis, pemphigus, myasthenia gravis,
uveitis, chronic active hepatitis.
Low dose Mtx maintenance therapy is relatively well
tolerated.
c). Cyclophosphamide
This cytotoxic drug has more marked effect on B cells
and humoral immunity compared to that on T cells and CMI.
It has been particularly utilized in bone marrow
transplantation in which a short course with high dose is
generally given.
In other organ transplants it is employed only as a
reserve drug.
In rheumatoid arthritis, it is rarely used, only when
systemic manifestations are marked.
Low doses are occasionally employed for maintenance
therapy in pemphigus, systemic lupus erythematosus and
idiopathic thrombocytopenic purpura.
d). Chlorambucil
It has relatively weak immunosuppressant
action which is sometimes utilized in autoimmune
diseases and transplant maintenance regimens.
e). Mycophenolate mofetil (MMF)
It is a newer immunosuppressant; prodrug of
mycophenolic acid which selectively inhibits inosine
monophosphate dehydrogenase, an enzyme essential
for denovo synthesis of guanosine nucleotides in the T
and B cells (these cells, unlike others, do not have the
purine salvage pathway).
Lymphocyte proliferation, antibody production and
CMI are inhibited.
Uses
As ‘add on’ drug to cyclosporine
+glucocorticoid in renal transplantation, it has been
found as good or even superior to azathioprine, but
should not be combined with azathioprine.
It can help to reduce the dose of cyclosporine
and thus its toxicity. MMF + glucocorticoid +
sirolimus is a non-nephrotoxic combination that is
utilized in patients developing renal toxicity with
cyclosporine/tacrolimus
Pharmokinetic
 MMF is rapidly absorbed orally and quickly
converted to the active metabolite mycophenolic
acid.
 This is then slowly inactivated by glucuronidation
with a t½ of ~ 16 hours.
 The glucuronide is excreted in urine.
Name of drug classification Dose and route Uses Side effects
Mycophenolate
mofetil (MMF)
ANTIPROLIF
ERATIVE
DRUGS
(Cytotoxic
immunosuppres
sants)
1.0 g bd oral;
Cellmune, mycept,
mycophen
250, 500 mg tab/cap.
Renal
transplantation
Renal toxicity
With
cyclosporine/ta
crolimusn
Vomiting,
Diarrhoea,
Leucopenia and
Predisposition
To CMV
infection,
G.I. Bleeds
Glucocorticoids
Glucocorticoids have potent immunosuppressant and
anti-inflammatory action, inhibit several components of the
immune response.
They particularly inhibit MHC expression and
activation/proliferation of T lymphocytes.
Expression of several IL and other cytokine genes is
regulated by corticosteroids and production of adhesion
molecules is depressed.
Accordingly, they have marked effect on CMI but
little effect on humoral immunity.
Name of drug Classification Dose and route Uses Side effects
Dexametha-
sone
Gluco-
corticoids
Oral:
-initial dose: 0.75
mg to 9 mg orally
per day
parenteral:
-initial dose: 0.5
mg to 9 mg IV or
IM per day in
divided doses
every 12 hours
Severe
autoimmune
Diseases,
especially
during
exacerbation
Aggression
agitation
anxiety
blurred vision
decrease in
the amount of
urine
dizziness fast,
slow,
pounding, or
irregular
heartbeat or
pulse
headache
Name of drug Classification Dose and route Uses Side effects
Prednisolone Gluco-
corticoids
5 to 60 mg orally
per day
Severe
autoimmune
Diseases,
especially
during
exacerbation
Aggression
agitation
anxiety
blurred vision
decrease in
the amount of
urine
dizziness fast,
slow,
pounding, or
irregular
heartbeat or
pulse
headache
Uses
The corticosteroids are widely employed as
companion drug to cyclosporine or other
immunosuppressants in various organ transplants.
In case graft rejection sets in—large doses of
corticoids I.V. are employed for short periods.
They are used in practically all cases of severe
autoimmune diseases, especially during exacerbation.
BIOLOGICALAGENTS
These are biotechnologically produced
recombinant proteins or polyclonal/monoclonal
antibodies directed to cytokines or lymphocyte
surface antigens which play a key role in immune
response.
They are important recent additions, mostly as
supplementary/reserve drugs for severe and
refractory cases of autoimmune diseases and graft
versus host reaction.
TNFα inhibitors
TNFα is secreted by activated macrophages and
other immune cells to act on TNF receptors (TNFR1,
TNFR2) which are located on the surface of neutrophils,
fibroblasts, endothelial cells as well as found in free
soluble form in serum and serous fluids.
TNFα amplifies immune inflammation by releasing
other cytokines and enzymes like collagenases and
metalloproteinases.
The TNFα inhibitors are mainly used in
autoimmune diseases, and are briefly described with
disease modifying drugs for rheumatoid arthritis.
Etanercept
This fusion protein of human TNF receptor and Fc
portion of human IgG1 neutralizes both TNFα and TNFβ.
It prevents activation of macrophages and T-cells
during immune reaction.
It is used mostly in combination with Mtx in
rheumatoid arthritis patients who fail to respond adequately
to the latter.
It is also approved for severe/refractory ankylosing
spondylitis, polyarticular idiopathic juvenile arthritis and
plaque psoriasis.
IL-1 receptor antagonist
Stimulated macrophages and other
mononuclear cells elaborate IL-1 which activates
helper T-cells and induces production of other ILs,
metalloproteinases, etc.
An endogenous IL-1 receptor antagonist has
been isolated and several of its recombinant variants
have been produced for clinical use.
Anakinra
This recombinant human IL-1 receptor
antagonist prevents IL-1 binding to its receptor and
has been approved for use in refractory rheumatoid
arthritis not controlled by conventional DMARDs.
Anakinra along with continued Mtx has been
used alone as well as added to TNFα antagonists,
because its clinical efficacy as monotherapy appears
to be lower.
IL-2 receptor antagonist
The CD-25 molecule is expressed on the surface
of immunologically activated, but not resting T-cells.
It acts as a high affinity receptor for IL-2 through
which cell proliferation and differentiation are
promoted. Some anti CD-25 antibodies have been
developed as IL-2 receptor antagonist to specifically
arrest the activated T-cells.
Daclizumab
It is a highly humanized chimeric monoclonal
anti CD-25 antibody which binds to and acts as IL-2
receptor antagonist.
Combined with glucocorticoids, calcineurin
antagonists and/or azathioprine/MMF, it is used to
prevent renal and other transplant rejection reaction.
The plasma t½ of daclizumab is long (3 weeks),
and it has also been used in combination regimens for
maintenance of graft.
Anti-CD3 antibody
Muromonab CD3
It is a murine monoclonal artibody against the
CD3 glycoprotein expressed near to the T cell receptor
on helper T cells.
Binding of muromonab CD3 to the CD3 antigen
obstructs approach of the MHCIIantigen complex to the
T-cell receptor.
Consequently, antigen recognition is interfered,
and participation of T-cells in the immune response is
prevented.
Muromonab CD3 is the oldest (developed in the
1980s) monoclonal antibody that is still occasionally
used clinicallya
Uses
Induction therapy of organ transplantation is
infrequent now, since better alternatives are available.
It has also been used to deplete T cells from the
donor bone marrow before transplantation.
Side effects
 Chills,
 Rigor,
 High fever,
 Wheezing,
 Malaise, etc
 Occasionally aseptic meningitis,
 intra-graft thrombosis,
 life-threatening pulmonary edema,
 Seizures and a shock-like state
Polyclonal antibodies
Antithymocyte globulin (ATG)
It is a polyclonal antibody purified from horse or
rabbit immunized with human thymic lymphocytes which
contains antibodies against many CD antigens as well as
HLA antigens.
It binds to T lymphocytes and depletes them. It is a
potent immunosuppressant and has been used primarily
to suppress acute allograft rejection episodes, especially
in steroid resistant cases, by combining with other
immunosuppressants, including steroids.
It can also be used in induction regimens, but
this has the potential to produce serum sickness or
anaphylaxis.
Dosage
 LYMPHOGLOBULIN (equine) 100 mg/vial inj.; 10
mg/kg/day I.V.;
 THYMOGLOBULIN (rabbit) 25 mg/vial inj.; 1.5
mg/kg/day.
 ATG 100 mg inj; 200 mg I.V./day.
Anti-D immune globulin
It is human IgG having a high titer of antibodies
against Rh (D) antigen.
It binds the Rho antigens and does not allow them to
induce antibody formation in Rh negative individuals.
It is used for prevention of postpartum/post-abortion
formation of antibodies in Rho-D negative, DU negative
women who have delivered or aborted an Rho-D positive,
DU positive baby/foetus.
Administered within 72 hours of delivery/ abortion,
such treatment prevents Rh haemolytic disease in future
offspring.
It has also been given at 28th week of pregnancy.
Dose: 250–350 μg I.M. of freez dried preparation.
RHESUMAN, RHOGAM, IMOGAM 300 μg per
vial/prefilled syringe.
Higher doses (1000–2000 μg) are needed for
Rh negative recipients of inadvertantly administered
Rh positive blood. It should never be given to the
infant or to Rho-D positive, DU positive individuals.
ACTION OFIMMUNOSUPPRESSANTS
Nursing managemant
■ Assessment
■ Obtain a health history including allergies, drug
history, and possible drug interactions.
■ Assess for presence of metastatic cancer, active
infection, renal or liver disease and pregnancy.
■ Assess skin integrity; specifically look for lesions
and skin color.
■ Obtain results of laboratory work including complete
blood count (CBC), electrolytes, and liver enzymes.
■ Obtain vital signs, especially temperature and blood
pressure.
Potential Nursing Diagnoses
■ Risk for Infection, related to depressed immune
response secondary to drug
■ Risk for Injury, related to thrombocytopenia
secondary to drug
■ Assess renal function. (Drugs cause nephrotoxicity in
many clients because of physiological changes in the
kidneys such as micro-calcifications and interstitial
fibrosis.)
■ Monitor liver function tests. (Drugs increase the risk
for liver toxicity.)
■ Watch for signs and symptoms of infection,
including elevated temperature. (There is an increased
risk of infection owing to immune suppression.)
Interventions
■ Monitor vital signs, especially temperature and
blood pressure. (Drugs may cause hypertension,
especially in clients with kidney transplants.)
■ Monitor for hirsutism, leukopenia, gingival
hyperplasia, gynecomastia, sinusitis, and
hyperkalemia. (These are common side effects.)
■ Avoid permitting client to ingest grapefruit juice.
(Grapefruit juice increases cyclosporine levels 50%
to 200%.)
Client Education/Discharge Planning
Advise client to:
■ Keep accurate record of urine output, Report
significant reduction in urine flow.
■ Instruct client about the importance of regular
laboratory testing.
■ Wash hands thoroughly and frequently, Avoid
crowds and people with infection.
■ Monitor blood pressure and temperature,
ensuring proper use of home equipment.
■ Keep all appointments with healthcare provider.
■ Take medication with food to decrease GI upset.
■ Instruct client regarding a healthy diet that
avoids excessive fats and sugars.
REFERENCES
BOOKS
 Mosbey’s drug guide for nurses. Edition:-9th . P.-198-203.
 Medications , How do analgesics work on pain? , Craig C.
Freudenrich and Discovery Fit & Health , Retrieved August 02,
2012
INTERNET
 Analgesics Research & Articles, Analgesics, Retrieved August
02, 2012
 http://www.bookrags.com/research/analgesics-woc
 https://www.cdc.gov/vaccinesafety/concerns/adjuvants.html
THANK YOU…..

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Immunosuppressants final drug ppt

  • 1. PRESENTED TO: PRESENTED BY: Mrs. Vinay Kumari Amandeep Kaur Associate Professor Roll No. 1915703 Medical Surgical Nursing M.Sc. (N) 2nd Year
  • 2. SR. NO. CONTENT 1. Introduction to immunity 2. Types of immunity 3. What is antigen and antibody 4. Type of antigens 5. Type of antibody 6. Antibody targets and functions 7. Antigen and antibody action/reaction 8. Non specific defences 9. Introduction to immunosuppressant 10. Classification of immunosuppressants 11. Organ transplant rejection 12. Mechanism of cyclosporine and tacrolimus 13. Mechanism of sirolimus and tacrolimus 14. Mechanism of mycophenolate 15. Action of immunosuppressants 16. Side effects immunosuppressants
  • 3. INTRODUCTION TO IMMUNITY  Immunity is the resistance of an organism to infection or disease.  Immunity is the state of sufficient biological defences to avoid infection, disease, or other unwanted biological invasion.”  In biology, immunity is the state of having sufficient biological defences to avoid infection, disease, or other unwanted biological invasion. It is the capability of the body to resist harmful microbes from entering it.
  • 4.
  • 6.  2. A. INNATE IMMUNITY  Innate immunity is non- specific. It is first lines of defence. They defences include secretion of chemical signals, phagocytic activity, antimicrobial substance and fever.  Examples Neutrophils, Eosinophils, Mast cells, Monocytes, Macrophages, Killer cell, Platelets  Innate immunity also comes in a protein chemical form, called innate humoral immunity. If an antigen gets past these barriers, it is attacked and destroyed by other parts of the immune system.  Examples Cough reflex, Enzymes in tears and skin oils, Mucus (which traps bacteria and small particles),Skin, Stomach acid
  • 7. FIRSTLINE OFDEFENCE – NON-SPECIFIC BARRIERS
  • 10. 3.ANTIGEN &ANTIBODY  An antigen  May be a foreign substance from the environment such as chemicals, bacteria, viruses, or pollen. An antigen may also be formed within the body, as with bacterial toxins or tissue cells. An antigen is any substance that causes our immune system to produce antibodies against it.  An antibody  Also known as an immunoglobulin (Ig), is a large Y- shape protein produced by B cells that is used by the immune system to identify and neutralize foreign objects such as bacteria and viruses. The antibody recognizes a unique part of the foreign target, called an antigen.
  • 11. 4. TYPE OFANTIGENS 1. Exogenous antigens Exogenous antigens are antigens that have entered the body from the outside, for example by inhalation, ingestion, or injection. 2. Endogenous antigens Endogenous antigens are antigens that have been generated within previously normal cells as a result of normal cell metabolism, or because of viral or intracellular bacterial infection.
  • 12. Cont… 3. Autoantigens An autoantigen is usually a normal protein or complex of proteins (and sometimes DNA or RNA) that is recognized by the immune system of patients suffering from a specific autoimmune disease. 4. Tumour antigens or neoantigens Those antigens that are presented by MHC I or MHC II molecules on the surface of tumor cells. These antigens can sometimes be presented by tumor cells and never by the normal ones. In this case, they are called tumor-specific antigens (TSAs) and, in general, result from a tumor-specific mutation.
  • 17. 8. NON SPECIFIC DEFENSES
  • 19. 9. CELLSAND MOLECULES OFIMMUNE RESPONSE
  • 22. Generation Of HumoralAnd Cell-mediated Immune ResponseAnd Sites OfAction Of Immunosuppressant drugs
  • 23.  Humoral immune response: The antigen (Ag) is processed by macrophages or other antigen presenting cells (APC), coupled with class II major histocompatibility complex (MHC) and presented to the CD4 helper T-cell which are activated by interleukin-I (IL-1), proliferate and secrete cytokines—these in turn promote proliferation and differentiation of antigen activated B cells into antibody (Ab) secreting plasma cells. Antibodies finally bind and inactivate the antigen.
  • 24.  In cell-mediated immunity—foreign antigen is processed and presented to CD4 helper T cell which elaborate IL-2 and other cytokines that in turn stimulate proliferation and maturation of precursor cytotoxic lymphocytes (CTL) that have been activated by antigen presented with class I MHC. The mature CTL (Killer cells) recognize cells carrying the antigen and lyse them.
  • 27. INTRODUCTION  Immunosuppressant drugs are a class of drugs that suppress or reduce the strength of the body’s immune system. They are also called anti-rejection drugs. One of the primary uses of immunosuppressant drugs is to lower the body’s ability to reject a transplanted organ, such as a liver, heart or kidney.  Almost everyone who receives an organ transplant has to take immunosuppressant drugs. The body recognizes a transplanted organ as a foreign mass. This triggers a response by the body’s immune system to attack it.
  • 28. INTRODUCTION  By weakening the immune system, immunosuppressant drugs decrease the body’s reaction to the foreign organ. The drugs allow the transplanted organ to remain healthy and free from damage  Immunosuppressant drugs also are used to treat autoimmune diseases such as lupus. An autoimmune disorder is a disease process in which the body attacks its own tissue. Lupus results from just such a misdirected activity of the body’s own immune system. By suppressing this reaction, immunosuppressant drugs can help control the impact of the disease on the body.
  • 29. IMMUNOSUPPRESSANT DRUGS These are drugs which inhibit cellular /humoral or both immune response and have their major use in organ transplantation and autoimmune diseases. The drugs are: 1. Calcineurin inhibitors 2. m-TOR inhibitors 3. Antiproliferative drugs (Cytotoxic drugs) 4. Glucocorticoids 5. Biological agents
  • 30. Classification 1. Calcineurin inhibitors (Specific T-cell inhibitors) Cyclosporine (Ciclosporin), Tacrolimus 2. m-TOR inhibitors Sirolimus, Everolimus 3. Antiproliferative drugs (Cytotoxic drugs) Azathioprine, Methotrexate, Cyclophosphamide, Chlorambucil, Mycophenolate mofetil (MMF)
  • 31. 4. Glucocorticoids Prednisolone and others 5. Biological agents (a) TNFα inhibitors: Etanercept, Infliximab, Adalimumab (b) IL-1 receptor antagonist: Anakinra (c) IL-2 receptor antagonists: Daclizumab, (anti CD-25 antibodies) Basiliximab (d) Anti CD-3 antibody: Muromonab CD3 (e) Polyclonal antibodies: Antithymocyte antibody (ATG), Rho (D) immune globulin.
  • 32. CALCINEURIN INHIBITORS (Specific T-cell inhibitors) Cyclosporine It is a cyclic polypeptide with 11 amino acids, obtained from a fungus and introduced in 1977 as a highly selective immunosuppressant which has markedly increased the success of organ transplantations. It profoundly and selectively inhibits T lymphocyte proliferation, IL-2 and other cytokine production as well as response of inducer T cells to IL-1, without any effect on suppressor T-cells. Lymphocytes are arrested in G0 or G1 phase.
  • 34.  Cyclosporine, tacrolimus and sirolimus inhibit antigen stimulated activation and proliferation of helper T cells as well as expression of IL-2 and other cytokines by them.  Cyclosporine binds to an intracellular protein ‘Cyclophilin’ and this complex inhibits Ca2+ Calmodulin (Ca2+-CAM) activated phosphatase ‘Calcineurin’.
  • 35.  Cyclosporine binds to an intracellular protein ‘Cyclophilin’ and this complex inhibits Ca2+-Calmodulin (Ca2+-CAM) activated phosphatase ‘Calcineurin.
  • 36. Name of drug classification Dose and route Uses Side effects Cyclospor ine (ciclospor in) Calcineurin inhibitors (Specific t-cell inhibitors) 10–15 mg/kg/day with milk or fruit juice till 1–2 weeks after transplantation, gradually reduced to maintenance dose Of 2–6 mg/kg/day. Therapy may be started with 3–5 mg/kg I. V. Infusion. Prevention and treatment of graft rejection reaction. Rise in BP, precipitation of diabetes, Anorexia, Lethargy, Hyperkalaemia, Hyperuricaemia, Opportunistic Infections, Hirsutism, Gum hyperplasia, Tremor And seizures.
  • 37. Cyclosporine is most active when administered before antigen exposure, but can, in addition, suppress the responses of primed helper T cells; hence useful in autoimmune diseases as well. Cyclosporine selectively suppresses cellmediated immunity (CMI), prevents graft rejection and yet leaves the recipient with enough immune activity to combat bacterial infection. Unlike cytotoxic immunosuppressants, it is free of toxic effects on bone marrow and RE system. Humoral immunity remains intact.
  • 38. uses  Cyclosporine is the most effective drug for prevention and treatment of graft rejection reaction.  It is routinely used in renal, hepatic, cardiac, bone marrow and other transplantations. For induction  it is started orally 12 hours before the transplant and continued for as long as needed.  When graft rejection has started, it can be given i.v., because oral bioavailability is low, dependent on presence of bile and is highly variable.  Blood level monitoring is required for effective therapy.
  • 39. Pharmokinetics  It is concentrated in WBCs and RBCs, metabolized in liver by CYP3A4 and excrete in bile.  The plasma t½ is biphasic 4–6 hr and 12–18 hr.
  • 40. Drug Interactions  Cyclosporine can interact with a large number of drugs.  All nephrotoxic drugs like aminoglycosides, vancomycin, amphotericin B and NSAIDs enhance its toxicity.  By depressing renal function, it can reduce excretion of many drugs. Phenytoin, phenobarbitone, rifampin and other enzyme inducers lower its blood levels so that transplant rejection may result.
  • 41. Tacrolimus This immunosuppressant is chemically different from cyclosporine, but has the same mechanism of action, and is ~100 times more potent. It binds to a different cytoplasmic immunophilin protein labelled ‘FK 506 binding protein (FKBP)’, but the subsequent steps are the same, i.e. inhibition of helper T cells via calcineurin.
  • 42. Tacrolimus also inhibits calcineurin, but after binding to a different protein FKBP (FK binding protein).
  • 43. Name of drug classification Dose and route Uses Side effects Tacrolimus Calcineurin inhibitors (Specific t-cell inhibitors) 0.05–0.1 mg/kg BD oral (for renal transplant), 0.1–0.2 mg/kg BD (for liver transplant). It can also be given i.v. (no i.v. preparation is available in India); 0.03–0.1% topically. Prevention and treatment of graft rejection reaction. Rise in BP, precipitation of diabetes, Anorexia, Lethargy, Hyperkalaemia, Hyperuricaemia, Opportunistic Infections, Hirsutism, Gum hyperplasia, Tremor And seizures.
  • 44. Cont…  Tacrolimus is administered orally as well as by i.v. infusion.  Oral absorption is variable and decreased by food.  It is metabolized by CYP3A4 and excreted in bile with a t½ of 12 hour.  Therapeutic application, clinical efficacy as well as toxicity profile are similar to cyclosporine.
  • 45. 2. m-TOR inhibitors a). Sirolimus  This new and potent immunosuppressant is a macrolide antibiotic (like tacrolimus), which was earlier named Rapamycin.  It binds to the same immunophillin FKBP as tacrolimus, but the sirolimus-FKBP complex inhibits another kinase called ‘mammalian target of rapamycin’ (mTOR), and does not interact with calcineurin.  The mTOR is an important link in the cascade of signalling pathways which lead to proliferation and differentiation of T- cells activated by IL-2 and other cytokines.  Sirolimus arrests the immune response at a later stage than cyclosporine.
  • 46. Sirolimus also binds to FKBP, but this complex acts at a later stage. It binds to and inhibits a kinase termed m-TOR (mammalian target of rapamycin) which is a key factor for progression of cell proliferation.
  • 47. Pharmokinetics  Sirolimus is absorbed orally, but fatty meal reduces absorption.  It is extensively metabolized, mainly by CYP3A4, so that systemic bioavailability is only 15–20%.  Elimination occurs primarily by the biliary route; the t½ is ~60 hours.  Inhibitors and inducers of CYP3A4 significantly alter its blood level, which needs to be monitored.  Cyclosporine shares the same isoenzyme and raises the blood level of sirolimus.
  • 48. Uses For prophylaxis and therapy of graft rejection reaction, sirolimus can be used alone, but is generally combined with lower dose of cyclosporine/tacrolimus and/or corticosteroids and mycophenolate mofetil. The latter combination avoids use of a calcineurin inhibitor, and is particularly suitable for patients developing renal toxicity with cyclosporine. Sirolimus is effective in some steroid refractory cases, and has been used in stem cell transplant as well. However, it is not recommended for liver transplant. Sirolimus coated stents are being used to reduce the incidence of coronary artery restenosis, by inhibiting endothelial proliferation at the site.
  • 49.  Everolimus It is similar to sirolimus in mechanism, clinical efficacy, doses, toxicity and drug interactions, but is better absorbed orally and has more consistent bioavailability. The t½ is shorter (~40 hours) so that steady state levels can be reached earlier.
  • 50. 3.ANTIPROLIFERATIVE DRUGS (Cytotoxic immunosuppressants)  Certain cytotoxic drugs used in cancer chemotherapy exhibit prominent immunosuppressant property, mainly by preventing clonal expansion of T and B lymphocytes.
  • 51. a). Azathioprine It is a purine antimetabolite which has more marked immunosuppressant than antitumour action. The basis for this difference is not clear, but may be due to its selective uptake into immune cells and intracellular conversion to the active metabolite 6- mercaptopurine, which then undergoes further transformations to inhibit de novo purine synthesis and damage to DNA. It selectively affects differentiation and function of T cells and inhibits cytolytic lymphocytes; CMI is primarily depressed.
  • 52. Uses The most important application of azathioprine is prevention of renal and other graft rejection, but it is less effective than cyclosporine; generally combined with it or used in patients developing cyclosporine toxicity. Relatively lower doses (1–2 mg/kg/day) are used in progressive rheumatoid arthritis and it is frequently employed for maintening remission in inflammatory bowel disease. It may be an alternative to long-term steroids in some other autoimmune diseases as well. It is not combined with Methotrexate. Dose: 50–150 mg/day; orally
  • 53. b). Methotrexate This folate antagonist is a potent immunosuppressant which markedly depresses cytokine production and cellular immunity, and has antiinflammatory property. It has been used as a first line drug in many autoimmune diseases like rapidly progressing rheumatoid arthritis, severe psoriasis, pemphigus, myasthenia gravis, uveitis, chronic active hepatitis. Low dose Mtx maintenance therapy is relatively well tolerated.
  • 54. c). Cyclophosphamide This cytotoxic drug has more marked effect on B cells and humoral immunity compared to that on T cells and CMI. It has been particularly utilized in bone marrow transplantation in which a short course with high dose is generally given. In other organ transplants it is employed only as a reserve drug. In rheumatoid arthritis, it is rarely used, only when systemic manifestations are marked. Low doses are occasionally employed for maintenance therapy in pemphigus, systemic lupus erythematosus and idiopathic thrombocytopenic purpura.
  • 55. d). Chlorambucil It has relatively weak immunosuppressant action which is sometimes utilized in autoimmune diseases and transplant maintenance regimens.
  • 56. e). Mycophenolate mofetil (MMF) It is a newer immunosuppressant; prodrug of mycophenolic acid which selectively inhibits inosine monophosphate dehydrogenase, an enzyme essential for denovo synthesis of guanosine nucleotides in the T and B cells (these cells, unlike others, do not have the purine salvage pathway). Lymphocyte proliferation, antibody production and CMI are inhibited.
  • 57. Uses As ‘add on’ drug to cyclosporine +glucocorticoid in renal transplantation, it has been found as good or even superior to azathioprine, but should not be combined with azathioprine. It can help to reduce the dose of cyclosporine and thus its toxicity. MMF + glucocorticoid + sirolimus is a non-nephrotoxic combination that is utilized in patients developing renal toxicity with cyclosporine/tacrolimus
  • 58. Pharmokinetic  MMF is rapidly absorbed orally and quickly converted to the active metabolite mycophenolic acid.  This is then slowly inactivated by glucuronidation with a t½ of ~ 16 hours.  The glucuronide is excreted in urine.
  • 59. Name of drug classification Dose and route Uses Side effects Mycophenolate mofetil (MMF) ANTIPROLIF ERATIVE DRUGS (Cytotoxic immunosuppres sants) 1.0 g bd oral; Cellmune, mycept, mycophen 250, 500 mg tab/cap. Renal transplantation Renal toxicity With cyclosporine/ta crolimusn Vomiting, Diarrhoea, Leucopenia and Predisposition To CMV infection, G.I. Bleeds
  • 60. Glucocorticoids Glucocorticoids have potent immunosuppressant and anti-inflammatory action, inhibit several components of the immune response. They particularly inhibit MHC expression and activation/proliferation of T lymphocytes. Expression of several IL and other cytokine genes is regulated by corticosteroids and production of adhesion molecules is depressed. Accordingly, they have marked effect on CMI but little effect on humoral immunity.
  • 61. Name of drug Classification Dose and route Uses Side effects Dexametha- sone Gluco- corticoids Oral: -initial dose: 0.75 mg to 9 mg orally per day parenteral: -initial dose: 0.5 mg to 9 mg IV or IM per day in divided doses every 12 hours Severe autoimmune Diseases, especially during exacerbation Aggression agitation anxiety blurred vision decrease in the amount of urine dizziness fast, slow, pounding, or irregular heartbeat or pulse headache
  • 62. Name of drug Classification Dose and route Uses Side effects Prednisolone Gluco- corticoids 5 to 60 mg orally per day Severe autoimmune Diseases, especially during exacerbation Aggression agitation anxiety blurred vision decrease in the amount of urine dizziness fast, slow, pounding, or irregular heartbeat or pulse headache
  • 63. Uses The corticosteroids are widely employed as companion drug to cyclosporine or other immunosuppressants in various organ transplants. In case graft rejection sets in—large doses of corticoids I.V. are employed for short periods. They are used in practically all cases of severe autoimmune diseases, especially during exacerbation.
  • 64. BIOLOGICALAGENTS These are biotechnologically produced recombinant proteins or polyclonal/monoclonal antibodies directed to cytokines or lymphocyte surface antigens which play a key role in immune response. They are important recent additions, mostly as supplementary/reserve drugs for severe and refractory cases of autoimmune diseases and graft versus host reaction.
  • 65. TNFα inhibitors TNFα is secreted by activated macrophages and other immune cells to act on TNF receptors (TNFR1, TNFR2) which are located on the surface of neutrophils, fibroblasts, endothelial cells as well as found in free soluble form in serum and serous fluids. TNFα amplifies immune inflammation by releasing other cytokines and enzymes like collagenases and metalloproteinases. The TNFα inhibitors are mainly used in autoimmune diseases, and are briefly described with disease modifying drugs for rheumatoid arthritis.
  • 66. Etanercept This fusion protein of human TNF receptor and Fc portion of human IgG1 neutralizes both TNFα and TNFβ. It prevents activation of macrophages and T-cells during immune reaction. It is used mostly in combination with Mtx in rheumatoid arthritis patients who fail to respond adequately to the latter. It is also approved for severe/refractory ankylosing spondylitis, polyarticular idiopathic juvenile arthritis and plaque psoriasis.
  • 67. IL-1 receptor antagonist Stimulated macrophages and other mononuclear cells elaborate IL-1 which activates helper T-cells and induces production of other ILs, metalloproteinases, etc. An endogenous IL-1 receptor antagonist has been isolated and several of its recombinant variants have been produced for clinical use.
  • 68. Anakinra This recombinant human IL-1 receptor antagonist prevents IL-1 binding to its receptor and has been approved for use in refractory rheumatoid arthritis not controlled by conventional DMARDs. Anakinra along with continued Mtx has been used alone as well as added to TNFα antagonists, because its clinical efficacy as monotherapy appears to be lower.
  • 69. IL-2 receptor antagonist The CD-25 molecule is expressed on the surface of immunologically activated, but not resting T-cells. It acts as a high affinity receptor for IL-2 through which cell proliferation and differentiation are promoted. Some anti CD-25 antibodies have been developed as IL-2 receptor antagonist to specifically arrest the activated T-cells.
  • 70. Daclizumab It is a highly humanized chimeric monoclonal anti CD-25 antibody which binds to and acts as IL-2 receptor antagonist. Combined with glucocorticoids, calcineurin antagonists and/or azathioprine/MMF, it is used to prevent renal and other transplant rejection reaction. The plasma t½ of daclizumab is long (3 weeks), and it has also been used in combination regimens for maintenance of graft.
  • 71. Anti-CD3 antibody Muromonab CD3 It is a murine monoclonal artibody against the CD3 glycoprotein expressed near to the T cell receptor on helper T cells. Binding of muromonab CD3 to the CD3 antigen obstructs approach of the MHCIIantigen complex to the T-cell receptor. Consequently, antigen recognition is interfered, and participation of T-cells in the immune response is prevented.
  • 72. Muromonab CD3 is the oldest (developed in the 1980s) monoclonal antibody that is still occasionally used clinicallya
  • 73. Uses Induction therapy of organ transplantation is infrequent now, since better alternatives are available. It has also been used to deplete T cells from the donor bone marrow before transplantation.
  • 74. Side effects  Chills,  Rigor,  High fever,  Wheezing,  Malaise, etc  Occasionally aseptic meningitis,  intra-graft thrombosis,  life-threatening pulmonary edema,  Seizures and a shock-like state
  • 75. Polyclonal antibodies Antithymocyte globulin (ATG) It is a polyclonal antibody purified from horse or rabbit immunized with human thymic lymphocytes which contains antibodies against many CD antigens as well as HLA antigens. It binds to T lymphocytes and depletes them. It is a potent immunosuppressant and has been used primarily to suppress acute allograft rejection episodes, especially in steroid resistant cases, by combining with other immunosuppressants, including steroids.
  • 76. It can also be used in induction regimens, but this has the potential to produce serum sickness or anaphylaxis. Dosage  LYMPHOGLOBULIN (equine) 100 mg/vial inj.; 10 mg/kg/day I.V.;  THYMOGLOBULIN (rabbit) 25 mg/vial inj.; 1.5 mg/kg/day.  ATG 100 mg inj; 200 mg I.V./day.
  • 77. Anti-D immune globulin It is human IgG having a high titer of antibodies against Rh (D) antigen. It binds the Rho antigens and does not allow them to induce antibody formation in Rh negative individuals. It is used for prevention of postpartum/post-abortion formation of antibodies in Rho-D negative, DU negative women who have delivered or aborted an Rho-D positive, DU positive baby/foetus. Administered within 72 hours of delivery/ abortion, such treatment prevents Rh haemolytic disease in future offspring. It has also been given at 28th week of pregnancy.
  • 78. Dose: 250–350 μg I.M. of freez dried preparation. RHESUMAN, RHOGAM, IMOGAM 300 μg per vial/prefilled syringe. Higher doses (1000–2000 μg) are needed for Rh negative recipients of inadvertantly administered Rh positive blood. It should never be given to the infant or to Rho-D positive, DU positive individuals.
  • 80. Nursing managemant ■ Assessment ■ Obtain a health history including allergies, drug history, and possible drug interactions. ■ Assess for presence of metastatic cancer, active infection, renal or liver disease and pregnancy. ■ Assess skin integrity; specifically look for lesions and skin color. ■ Obtain results of laboratory work including complete blood count (CBC), electrolytes, and liver enzymes. ■ Obtain vital signs, especially temperature and blood pressure.
  • 81. Potential Nursing Diagnoses ■ Risk for Infection, related to depressed immune response secondary to drug ■ Risk for Injury, related to thrombocytopenia secondary to drug
  • 82. ■ Assess renal function. (Drugs cause nephrotoxicity in many clients because of physiological changes in the kidneys such as micro-calcifications and interstitial fibrosis.) ■ Monitor liver function tests. (Drugs increase the risk for liver toxicity.) ■ Watch for signs and symptoms of infection, including elevated temperature. (There is an increased risk of infection owing to immune suppression.)
  • 83. Interventions ■ Monitor vital signs, especially temperature and blood pressure. (Drugs may cause hypertension, especially in clients with kidney transplants.) ■ Monitor for hirsutism, leukopenia, gingival hyperplasia, gynecomastia, sinusitis, and hyperkalemia. (These are common side effects.) ■ Avoid permitting client to ingest grapefruit juice. (Grapefruit juice increases cyclosporine levels 50% to 200%.)
  • 84. Client Education/Discharge Planning Advise client to: ■ Keep accurate record of urine output, Report significant reduction in urine flow. ■ Instruct client about the importance of regular laboratory testing. ■ Wash hands thoroughly and frequently, Avoid crowds and people with infection.
  • 85. ■ Monitor blood pressure and temperature, ensuring proper use of home equipment. ■ Keep all appointments with healthcare provider. ■ Take medication with food to decrease GI upset. ■ Instruct client regarding a healthy diet that avoids excessive fats and sugars.
  • 86. REFERENCES BOOKS  Mosbey’s drug guide for nurses. Edition:-9th . P.-198-203.  Medications , How do analgesics work on pain? , Craig C. Freudenrich and Discovery Fit & Health , Retrieved August 02, 2012 INTERNET  Analgesics Research & Articles, Analgesics, Retrieved August 02, 2012  http://www.bookrags.com/research/analgesics-woc  https://www.cdc.gov/vaccinesafety/concerns/adjuvants.html