WEEK 2 Pharm Notes- adrenal drugs PDF

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PHARM NOTES FOR PAULA'S CLASS...

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WEEK 2 PHARM NOTES- Adrenal (Endocrine) Drugs Immunomodulator Drugs & Vaccines

Adrenal (Endocrine) Drugs) •Corticosteroids include: •Mineralocorticoids •Glucocorticoids •Drugs may be: •Natural or synthetic •Systemic, topical, inhaled etc. •Short, intermediate, or long-acting

CORTICOSTEROIDS- MINERALOCORTICOIDS •Only one available •Fludrocortisone 21-acteatate (Florinef) •Synthetic, systemic •Used for: adrenocortical insufficiency (i.e. Addison’s disease) in conjunction with glucocorticoids •Adverse effects •Water retention-effects?- CHR, hypo/hypertension, pulmonary edema •Several drug interactions

CORTICOSTEROIDS- GLUCOCORTICOIDS Actions: •Inhibit inflammatory and immune response by: •Stabilizing inflammatory cell membranes •Decreasing capillary permeability to inflammatory cells •Decreasing WBC migration into inflamed areas

CORTICOSTEROIDS- GLUCOCORTICOIDS INDICATIONS

•Any autoimmune or inflammatory disorder •Adrenocortical deficiency •Allergic disorders (anaphylaxis) •Cancer •Cerebral edema •Collagen and connective tissue disorders •Dermatological conditions •GI disorders •Respiratory illnesses •Organ transplant (rejection prevention) •Optic disorders •Rheumatoid disorders •Shock

CORTICOSTEROIDS- GLUCOCORTICOIDS •Hydrocortisone, Cortisone: •Short-acting glucocorticoid •Variety of forms (IV = Solu-Cortef) •Uses: Preferred drug for adrenocortical insufficiency (Addison's disease) treatmen t, widely used for inflammatory conditions •High mineralocorticoid properties-effect?- FLUID RETENTION

Corticosteroids-Glucocorticoids •Prednisone •Synthetic, intermediate acting glucocorticoid •Oral administration •Used as anti-inflammatory or immunosuppressant •Treatment of exacerbations of asthma, COPD

•Minimal mineralocorticoid action •Methylprednisolone (Solu-Medrol) •Synthetic, intermediate acting glucocorticoid •IV administration •Systemic effects •Used as anti-inflammatory or immunosuppressant •Contraindicated in pregnancy and infants under 28 days ALERT: Solu-Medrol vs. Solu-Cortef •Betamethasone •Synthetic, long-acting •Uses: Shock, acute exacerbations of certain conditions •Also given to women in premature labour – (less than 34 weeks gestation) to promote fetal lung development and decrease mortality •Dexamethasone (Decadron) •Synthetic, long-acting •Oral, IV •Uses: Management of cerebral edema related to neurological issues (i.e. brain tumour, meningitis, brain surgery) •Why is this preferred for neurological issues?- crosses the blood brain barrier and reaches high concentrations in CSF •Intended for short-term use due to side-effects CONTRAINDICATIONS: GLUCOCORTICOIDS •Systemic fungal infection •Allergy or hypersensitivity •Used with caution in patients with: •Diabetes •Peptic ulcer disease •Inflammatory bowel disease •Congestive heart failure •Renal insufficiency

ADVERSE EFFECTS- GLUCOCORTICOIDS •Adrenal insufficiency (Addison’s) If patient automatically discontinues, drug this can happen •Manifestations-fatigue, headache, confusion, fever, nausea, vomiting, abdominal pain, tachycardia, diaphoresis, dehydration and hypotension •If severe  adrenal crisis-life-threatening! •Increased blood glucose  DM •Fluid retention effects-examples? •Electrolyte imbalances-what are they? Hypernatremia (increase Na) and hypokalemia (K decrease) •Slow wound healing, fragile skin, acne, hair growth •Muscle wasting and fat redistribution •Buffalo hump, moon face, truncal obesity and thinning of extremities •Mental status changes •Mood swings, nervousness, psychosis •Increased risk of GI ulcers, infection •Bone demineralization •Glaucoma •Growth suppression in children NURSING CONSIDERATIONS- PATIENT TEACHING •Do not discontinue abruptly must be tapered –why? Risk of adrenal supression •Take in the morning (06:00-09:00hrs) and with food –why? Helps to mimic adrenal cycle of the body-  decrease risk of adrenal supression •Diet and supplements •calcium, vitamins C & D, high protein, low sodium, high potassium –rationale? •Report weight gain to HCP •Body changes associated with long-term therapy •Avoid others with infection, crowds etc. •Medic alert bracelet •Rinse mouth after inhaled forms of drug

•Intraarticular injections-cold packs to treat steroid flares NURSING CONSIDERATIONS •Monitor for signs of adrenal insufficiency, infection, fluid retention •Many drug interactions •Monitor BP, weight, skin (risk for skin breakdown), fluid status, appetite/nutrition, labs (Na, K, glucose) •Skin care, wound monitoring/management •Support for body image changes •Dosage adjustments may be needed if the patient requires surgery-why might this needed?

IMMUNOMODULATING DRUGS •Immunostimulants-Vaccines (next section) •Immunosuppressants: •Calcineurin inhibitors •Antimetabolites •Corticosteroids •Miscellaneous •Immunomodulatory: •Biological response modifiers (BRM) interferons, monoclonal antibodies (MAB) IMMUNOSUPPRESANT DRUGS •Drugs that decrease or prevent an immune response •Used to treat immune mediated disorders such as: •Rheumatoid arthritis •Crohn’s disease •Multiple sclerosis •Myasthenia gravis •Psoriasis •Anaphylaxis •And many other disorders •Or prevention of immune mediated responses such as:

•Organ transplant rejection MECHANISM OF ACTION •Selective suppression of certain T-lymphocytes which decreases their involvement in immune responses •This leads to a drug-induced immunocompromised state •Each drug suppresses the immune system in a different way CLASSIFICATION OF IMMUNOSUPPRESSANTS Calcineurin inhibitors: •Example: Cyclophosphamide, tacrolimus •Action: inhibits interleukin-2 production which decreases T-cell synthesis •Uses: prevention and treatment of organ transplant rejection, psoriasis, rheumatoid arthritis, irritable bowel syndrome and nephrotic syndrome Antimetabolites: •Example: Azathioprine sodium (Imuran); mycophenolate mofetil (CellCept) •Action: Blocks purine metabolism which inhibits T-cell synthesis •Uses: prevention of organ transplant rejection; rheumatoid arthritis Biologics: •Example: Basiliximab (Simulect) •Action: monoclonal antibodies that inhibits T-cell function •Uses: prevention of organ transplant rejection Corticosteroids •can also be used as immunosuppressant drugs •Action: inhibit all stages of T-Cell activation and can be used to induce an immunosuppressed state •Uses: treatment of acute organ transplant rejection Miscellaneous biologic drugs 

used to reduce relapses in relapsing-remitting MS

• Examples: Glatiramer (Copaxone) and Fingolimod HCl • Action: thought to modify immune processes and somehow decrease the lymphocytes in the CNS

CONTRAINDICATIONS •Allergy •Liver or renal failure •Hypertension- MAKES IT WORST •Uncontrolled infection- MAKES IT WORST •Concurrent radiation therapy •Used with caution and increased monitoring in pregnancy (i.e. pt with prior transplant)

ADVERSE REACTIONS General: •Risk of opportunistic infections •Increased risk of certain cancers-i.e. skin •Many drug and food interactions Drug Specific: •Ciclosporin (Cyclosporin)-hypertension (50%); neurotoxicity (tremors 20%); renal and hepatotoxicity- monitor BUN, drug-related diabetes, drug toxicity •Basiliximab-cytokine syndrome (fever, aches, chills, sweating etc.) that may involve anaphylaxis •Azathioprine (Imuran): hepatoxicity- monitor BUN, low WBC and Plts

NURSING CONSIDERATIONS •Avoid others with infections, crowds etc. –why? •See HCP immediately if signs of infection •Transplant pts-lifelong therapy required, signs of organ rejection (examples?) kidney trans- decrease urine output •Take at the same time each day •Attend all follow-up medical appointments, blood work monitoring etc. (potential for toxicity) •Avoid grapefruit juice •Meds may cause GI upset-take with meals, milk •Some drugs cause photosensitivity

•Ensure a minimum of a one-week supply on-hand –why? To make sure you don’t run out and put yourself in a situation of organ rejection •Medical alert bracelet recommended •Assessment and health history prior to starting drugs •Monitor blood results: WBC, RBC, plts , BUN, creatinine, LFTs, drug levels •Monitor for infection, adverse drug effects •Many drug interactions: •May lead to increased drug levels  toxicity •Or decreased drug levels  organ rejection

BIOLOGICAL RESPONSE MODIFYING DRUGS (BRMDs) •Broad class of drugs which alter the body’s response to diseases •Also called: biomodulators, immunomodulators or biological response modifiers •Used for diseases such as: •Cancer, autoimmune disorders, inflammatory conditions, and infectious diseases •Drugs act to enhance or suppress the immune system response •Examples of this type of class of drugs include cytokines; monoclonal antibodies and vaccines •Classified by biological effect as: •Hematopoietic (i.e. colony stimulating factor) •Immunomodulators •(i.e. interferons, monoclonal antibodies, & interleukin receptor agonist and antagonists) •Miscellaneous Immunomodulator •Actions: •Enhance hematopoietic function •Regulate or enhance immune response •Treatment of cancer by altering responses against cancer cells, preventing cell division and inhibiting cell maturation

IMMUNOMODULATORS- INTERFERONS

•3 different groups: alfa, beta, gamma- (NOT AVAILABLE IN CANADA_ •Actions: identical to endogenous interferons •Restore immune function if impaired •Enhance immune function •Inhibit immune function •Basic properties of interferons: 1) Antiviral; 2) Antitumor; & 3) Immunomodulating •Most commonly used for: certain viral infections, cancers & autoimmune diseases •Dosed as MU (millions of units)

MONOCLONAL ANTIBODIES (MABs) •Rapidly increasing in use but expensive •Action: Contains specific antibodies derived from identical (cloned) immune cells. These antibodies will direct the immune system to attack cells with a specific antigen. •Each drug contains specific antibodies that work better for certain diseases. •Key uses: cancer, rheumatoid arthritis, inflammatory diseases, MS, organ transplant •Suffix “mab” in drug name Examples: •Adalimumab (Humira)-rheumatoid arthritis, Crohn’s disease, ulcerative colitis, psoriasis, ankylosing spondylitis •Bevacizumab (Avastin)-colorectal cancer •Muromonab-kidney transplant •Rituximab (Rituan)-Non-Hodgkin lymphoma •Trastuzumab (Herceptin)-breast cancer •Vedolizumab (Entyvio)-ulcerative colitis

NURSING CONSIDERATION: MABs •Thorough assessment before initiating treatment •Drugs are given IV/IM/SC

•Most common adverse effects are flu-like illness and fatigue-how can this be managed? Increase fluids, have rest, meds (Tylenol, ibuprofen, histamine (Benadryl), anti-inflammatory) •Risk of infection

VACCINES •Over 20 vaccines exist for the PREVENTION of infectious illnesses •“Routine” vaccines provided depends on region of the world •In Canada, the Canadian Public Health Agency determines which vaccines are needed and publishes the Canadian Immunization Guide to aid providers. •This agency also has a role in pandemic preparedness planning. •Some vaccines may only be given to those travelling to certain regions (i.e. yellow fever) or specific circumstances (i.e. rabies) •Creating new vaccines is complex and research is ongoing (i.e. HIV vaccine) TERMINOLOGY- VACCINE vs IMMUNIZATION •Vaccine: a solution containing live, attenuated (weakened) or killed microorganisms that can promote an artificial induced active immunity against a particular microorganism •Toxoids: modified or inactivated bacterial exotoxins that are no longer active but can still bind to host B cells in order stimulate production of antitoxin. Produce artificial active immunity (i.e. tetanus toxoid) •Immunization: The induction of immunity by administration of a vaccine or toxoid (active immunization) or antiserum (passive immunization) TYPES OF IMMUNITY PRODUCED BY VACCINES Type of immunity produced depends on the vaccine used: •Active Immunization:- natural (infection), artificial (vaccination) •Produced by toxoids or vaccine administration •Immune system response is stimulated and produces antibodies and cellular responses (i.e. memory cells) •Provides long-term immunity •Passive Immunization- natural (maternal antibodies) artificial (monoclonal antibodies) •Produced by administration of immunoglobulins, antitoxin, antivenin etc. •Temporarily boosts the immune system by supplying antibodies needed to fight or protect against infection.

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Does not lead to antibody production.

HOW VACCINES WORK- (ACTIVE IMMUNIZATION) •The vaccine is recognized as an antigen (foreign substance) and the body creates antibodies to bind with it •As B-lymphocytes interact with the antigen, 2 types of cells are produced: •Memory cells-role?- remembers antigen in case of future exposure •Plasma cells-role?- manufacture antibodies in case of re-exposure to the antigen CONTRAINDICATION TO VACCINATIONS Patients should not receive a vaccine if experiencing: •Active infection •Febrile illness •Prior serious reaction to the vaccine •Pregnancy (certain vaccines-MMR, HPV, Zoster) •Allergy to yeast (Hep B, HPV); anaphylactic reaction to eggs (MMR) or neomycin (MMR, Zoster) •Cautious use in immunocompromised pts (contraindications-Zoster, meningococcal) VACCINE SCHEDULUES •Most vaccines require at least 2 or more doses in order to produce an adequate and persistent antibody response •Some vaccines combine multiple types •Boosters may be required-why? Since the protection offered by certain vaccines may decrease with time. •Vaccine schedules recommend the ages and timing of vaccines to optimize protection or for the best efficacy of the vaccine •Ontario has a vaccine schedule based on the recommendations of the Canadian Immunization Guide from the Canadian Public Health Agency. NURSING CONSIDERATIONS •Respect client choice •Anticipate and address client concerns •i.e. fear of needles/pain, parent anxiety; will not “get” the disease from the vaccine •Educate-

•Vaccine purpose •Required to enroll in school •Schedule for next vaccine, booster or titre level (what does this measure?) •Enquire about any prior vaccine reaction or possibly of pregnancy before administration •Proper vaccine storage, dosage, route and administration site (infant vs adult) as per manufacture recommendations •Alert-some vaccines combine several types-ensure you have the right one •Ensure epinephrine is available for hypersensitivity reactions •Monitor for side effects: •Site pain-what advice would you give? Advise the patient this is common, recommend pain killers/anti inflammatory acetaminophen •Serious reaction-rash, itching, high fever, SOB etc.-action?- go to emergency room. Epinephrine is needed •Ensure record is updated (both medical and immunization card)...