Pharm, part 44: Immune Medications - Immunosuppressants/DMARDs

by Cathy Parkes September 24, 2021 Updated: April 07, 2022 7 min read

In this article, we begin our coverage of immune system medications.

The Nursing Pharmacology video series follows along with our Pharmacology Second Edition Flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.

Nursing care for patients on immunosuppressants

Any time a patient's immune system is suppressed, it makes them more likely to get an infection because their immune system is not operating at full capacity, and cannot fight off pathogens as well as it might.

In terms of nursing care of a patient who’s on an immunosuppressant, closely monitor their temperature and their white blood cell count. We want to limit visitors’ access to the patient. We also want to limit fresh flowers or plants in the patient’s room.

It is important to teach a patient being administered immunosuppressants that they should do all they can to prevent getting an infection:

  • Practice extremely good hand hygiene
  • Avoid sick people and crowds
  • Make sure they get their vaccinations
  • Avoid gardening (because of the bacteria and fungi that are associated with plants) and cleaning the cat litter box (where pathogens may lurk under the surface)
  • Make sure they cook their foods thoroughly

What are DMARDs?

DMARDs are disease-modifying antirheumatic drugs. According to the NIH, they are a class of drugs indicated for the treatment of several inflammatory arthritides, including rheumatoid arthritis, as well as for the management of other connective tissue diseases and some cancers. DMARDs are immunosuppressive and can place a patient at risk of severe infections, hepatotoxicity (liver damage caused by exposure to drugs), or renal dysfunction. Some DMARDs are contraindicated for women who are pregnant, so women of child-bearing age are tested for pregnancy before DMARDs may be administered.

methotrexate (Rheumatrex)

Methotrexate is an antimetabolite and is used to treat autoimmune disorders, such as psoriasis and rheumatoid arthritis. It is also used to treat certain types of cancer and to dissolve ectopic pregnancies.

Mode of action of methotrexate

Methotrexate’s mode of action is to cause the death of rapidly replicating cells, that is, it inhibits folic acid metabolism, which prevents cell replication. This causes death of rapidly replicating cells.

Methotrexate also has an immunosuppressive effect in the body.

Side effects of methotrexate

Due to its immunosuppressive effect, a key side effect of methotrexate is infection.

Other side effects include hepatotoxicity, bone marrow suppression, GI upset, and stomatitis (painful ulcerations in the mouth).

Methotrexate has a black box warning due to the risk of fetal death and fetal toxicity, which means pregnant women must not take methotrexate.

In addition to the standard nursing care and patient teaching associated with protecting the patient from infection, nursing care associated with methotrexate includes monitoring the patient's liver function because of the potential side effect of hepatotoxicity, and also monitoring the patient’s CBC levels due to the risk for bone marrow suppression.

cyclosporine (Sandimmune)

Cyclosporine is a cyclic polypeptide and used to prevent organ rejection in transplant patients. It's also used to treat autoimmune disorders such as ulcerative colitis, rheumatoid arthritis, and psoriasis.

Mode of action of cyclosporine

Cyclosporine works by inhibiting the body’s normal immune response.

Side effects of cyclosporine

A key side effect of cyclosporine is the risk of infection because it's an immunosuppressive agent. Other side effects include hepatotoxicity and nephrotoxicity (rapid deterioration of the liver and kidney functions caused by medicine, a chemical, or an herbal or dietary supplement, respectively), GI upset, hypertension, and tremor.

hydroxychloroquine (Plaquenil)

Hydroxychloroquine is used to treat autoimmune disorders such as rheumatoid arthritis and lupus. It is also used to treat malaria.

In terms of its use as a treatment for SARS-CoV-2, the virus that causes COVID-19, a National Institutes of Health clinical trial evaluating the safety and effectiveness of hydroxychloroquine for the treatment of adults with COVID-19 formally concluded that the drug provides no clinical benefit to hospitalized patients.

Mode of action of hydroxychloroquine

Hydroxychloroquine inhibits protein synthesis in susceptible organisms, including plasmodium (a type of protozoa/parasite) that causes malaria. It also reduces inflammation.

Side effects of hydroxychloroquine

The side effects of this medication include GI upset, vision changes, seizures, and agranulocytosis (a reduction in the number of granulocytes, a type of white blood cell, in the body)..

In terms of nursing care, monitor the patient’s CBC levels during therapy. Also advise the patient to take this medication with food in order to help reduce the GI upset that is common when taking hydroxychloroquine.


Full Transcript

Hi, I am Cathy, with Level Up RN. In this video, I'm going to begin my coverage of immune system medications. If you have our pharmacology second edition flashcards, definitely pull those out so you can follow along with me. Specifically in this video, I will be covering immunosuppressants, and at the end of the video, I'm going to give you guys a little quiz to test your knowledge of some of the key facts that I'll be covering in this video. So definitely stay tuned for that.

Before I get into specific medications, I want to talk to you a little bit about immunosuppressants in general, because any time we suppress a patient's immune system, it makes them more likely to get an infection because their immune system is not operating at full capacity, and it's not able to fight off those pathogens as well.

So in terms of nursing care of a patient who's on an immunosuppressant, we want to closely monitor their temperature, their white blood cell count. We want to limit visitors. We also want to limit fresh flowers or plants in the patient's room.

And then we want to provide teaching to the patient as well to help them prevent getting an infection. So they should have really good hand hygiene. They should avoid sick people and crowds. They should make sure they get their vaccinations, and they should avoid gardening and cleaning the cat litter box, and also make sure they cook their foods thoroughly. So this teaching and those nursing interventions will apply for all immunosuppressants, so definitely keep those key points in mind.

All right, let's get into specific medications starting with methotrexate, which is an anti-metabolite.

Methotrexate is used to treat autoimmune disorders such as psoriasis and rheumatoid arthritis. It is also used to treat certain types of cancer and to dissolve ectopic pregnancies.

So its mode of action is that it causes the death of rapidly replicating cells and also has an immunosuppressive effect in the body.

Due to that immunosuppressive effect, a key side effect with methotrexate is going to be infection. Other side effects include hepatotoxicity, bone marrow suppression, GI upset, stomatitis, which is painful ulcerations in the mouth.

Methotrexate also has a black box warning due to the risk for fetal death and fetal toxicity. So pregnant women are definitely not going to be taking methotrexate. We talked through some of the nursing care and patient teaching associated with protecting the patient from infection.

Other nursing care associated with methotrexate includes monitoring the patient's liver function because of that side effect of hepatotoxicity, and also monitoring the patient's CBC levels due to the risk for bone marrow suppression.

So the way we remember this medication and what it's for in our little cool chicken hint on this card, if you look at methotrexate, you see T-Rex in the name. So I think about a T-Rex who has to move around very slowly because it has rheumatoid arthritis, and so it needs methotrexate in order to treat its rheumatoid arthritis. So if you have an alternative idea or mnemonic to help everyone remember what this medication is for, definitely leave it in the comments so we can all benefit from it.

Next, we have cyclosporine, which is a cyclic polypeptide. It's used to prevent organ rejection in transplant patients. It's also used to treat autoimmune disorders such as ulcerative colitis, rheumatoid arthritis, and psoriasis.

It works by inhibiting the body's normal immune response.

So key side effects with cyclosporine include risk of infection because it's an immunosuppressive agent. Other side effects include hepatotoxicity nephrotoxicity, GI upset, hypertension, and tremor.

This medication carries a black box warning because it can cause the development of tumors. In terms of nursing care, of course, we're going to do all the teaching and care to help prevent infection in the patient. We're also going to closely monitor their liver function and their kidney function because of the side effects of hepatotoxicity and nephrotoxicity. Also, if the patient is taking this because they received a transplant, they need to know that they will need to take cyclosporine for the rest of their lives. So it's not going to be a short-term-type therapy.

The last medication I'm going to cover in this video is hydroxychloroquine, which became kind of famous during the COVID-19 pandemic.

Hydroxychloroquine is used to treat autoimmune disorders such as rheumatoid arthritis and lupus. It is also used to treat malaria.

The side effects of this medication include GI upset, vision changes, seizures, and agranulocytosis, which is a reduction in the number of granulocytes in the body, which is a type of white blood cell.

So in terms of nursing care, we're going to want to monitor the patient's CBC levels during therapy, and we also want to advise the patient to take this medication with food in order to help reduce the GI upset that is common when taking hydroxychloroquine.

All right. Time for quiz. I have three questions for you. First question, what is the key side effect that we need to know for all immunosuppressive agents? The answer is infection. So we want to do all the nursing care and patient teaching we can do to help prevent infection in patients taking immunosuppressive agents. Question number two, what immunosuppressive agent is used to dissolve an ectopic pregnancy? The answer is methotrexate. Question number three, what medication is used to prevent organ rejection in transplant patients? The answer is cyclosporine.

Okay. I hope you did well with that quiz. If you got some of those wrong, then definitely go back and read the flashcards, do some repetition with those cards because, really, repetition is where it's at when it comes to pharmacology. Take care and good luck with studying.


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