Pharm, part 49: Immune Medications - TB, Systemic Antifungal, and Antiviral
by Cathy Parkes September 25, 2021 Updated: March 21, 2022 8 min read
This article is the last to cover immune system medications, focusing on tuberculosis (TB) medications, antifungal medications, and antiviral 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.
When you see this Cool Chicken, that indicates one of Cathy's silly mnemonics to help you remember. The Cool Chicken hints in these articles are just a taste of what's available across our Level Up RN Flashcards for nursing students!
Antituberculars (TB medications)
Antituberculars are medications used to treat tuberculosis. These include rifampin, isoniazid, pyrazinamide, ethambutol.
Patients being treated for TB are likely to be taking several different antibiotics, possibly all four of these, and they may be taking them for a prolonged amount of time, sometimes between six months and a year, until they have cleared themselves of TB.
Don’t get TIPSY when taking TB meds. Think of a RIPE orange to remember TB meds (and the color of your secretions when using rifampin).
Also: “RIPE” refers to the first letter of each of these medications.
Mode of action of antitubercular medications
Antituberculars work by stopping the growth of the bacteria that causes TB (Mycobacterium tuberculosis). They are bactericidals (they kill the bacteria) and/or bacteriostatics.
Side effects of antitubercular medications
All four of these medications carry a black box warning for hepatotoxicity (damage to the liver). That means the patient should not drink alcohol, as these medications are already causing stress on the liver.
Side effects of rifampin
In addition to hepatotoxicity, rifampin will cause orange discoloration of the patient’s secretions, as well as GI upset. Rifampin decreases the effectiveness of oral contraceptives, so the patient will need to use an alternative form of birth control while they’re taking rifampin.
Side effects of isoniazid
In addition to hepatotoxicity, isoniazid can cause neuropathy.
Side effects of pyrazinamide
In addition to hepatotoxicity, pyrazinamide can cause arthralgia (joint pain).
Side effects of ethambutol
In addition to hepatotoxicity, ethambutol can cause issues with the eyes and with vision. Remember it this way: E for ethambutol, E for eyes. Advise the patient to report any issues they are having with their vision when they’re taking this medication and encourage them to get regular screening for their vision.
Nursing care for patients receiving antituberculars (and their families)
Note that, because of the increased risk for hepatotoxicity, it is important to monitor the patient’s liver function throughout therapy and to look for signs of liver damage.
Sputum samples need to be collected every 2 – 4 weeks. Remember, the patient is only considered no longer to be infectious after three negative sputum cultures.
Patients with active TB need to wear masks in public.
Finally, the patient's family members will need to be tested for TB because it is an extremely contagious disease.
Systemic antifungal agents include amphotericin B, ketoconazole, and fluconazole. These medications are used for systemic fungal infections as opposed to topical fungal infections. We’ll explore agents for topical infections when we cover medications for the integumentary system.
Amphotericin B will “terrorize” your body (i.e., it is very toxic).
Mode of action of systemic antifungal agents
Systemic antifungal agents disrupt ergosterol in the fungal cell membrane.
Side effects of action of systemic antifungal agents
Although none of these carries a black box warning, all three of these systemic antifungals carry the risk for hepatotoxicity. Patients should not drink alcohol, and their liver function should be closely monitored.
Side effects of amphotericin B (Fungizone)
Amphotericin B is particularly toxic. This medication should only be used for life-threatening fungal infections. In addition to hepatotoxicity, amphotericin B carries a side effect of nephrotoxicity (rapid deterioration of the liver and kidney functions), phlebitis, fever, chills, and nausea and vomiting.
Side effects of ketoconazole
Ketoconazole carries the risk for hepatotoxicity as well as GI upset and arrhythmias (irregular heartbeat).
Side effects of fluconazole (Diflucan)
Fluconazole carries the risk for hepatotoxicity as well as GI upset and rash.
Nursing care for patients receiving systemic antifungals
If giving amphotericin B, first administer a test dose to see if there is a patient reaction.
For all three of these medications, monitor for liver dysfunction. Signs and symptoms include pale stools, dark urine, nausea and vomiting, fatigue, and jaundice (yellowing of the skin or whites of the eyes).
Systemic antiviral agents treat viruses and include acyclovir, ganciclovir, oseltamivir, and zanamivir. These medications inhibit viral replication. Note that most end in -vir, which is how you know they are used to treat “vir”al infections.
It is also important to note that these medications do not cure conditions.
Side effects of acyclovir
The side effects of acyclovir include phlebitis, GI upset, and nephrotoxicity.
Ganciclovir is used to treat cytomegalovirus.
Side effects of ganciclovir
Oseltamivir (Tamiflu), Zanamivir (Relenza)
Oseltamivir and zanamivir are antivirals that are used to treat influenza A and B.
Side effects of oseltamivir and zanamivir
The side effects of oseltamivir and zanamivir include GI upset and headache.
Nursing care for patients receiving oseltamivir and zanamivir
When treating influenza, it is vital to start oseltamivir and zanamivir within 48 hours of the onset of symptoms. If a patient has been having symptoms for longer than that, these medications will not be as effective.
Hi, I'm Cathy, with Level Up RN. In this video, I'm going to wrap up my coverage of immune system medications. Specifically in this video, I will be covering TB medications, antifungal medications, and antiviral medications. At the end of the video, I'm going to provide you guys a little quiz to test your knowledge of some of the information I'll be covering, so definitely stay tuned for that. If you have our pharmacology flashcards from leveluprn.com, definitely pull those out so you can follow along. Also note that on these cards that I'm about to go over, there is a lot of bold red text on the card, so definitely some very important information for you to review.
First up, we have our tuberculosis medications, our TB medications, which include rifampin, isoniazid, pyrazinamide, and ethambutol. So when your patient is being treated for TB, it is likely that they're going to be taking several different antibiotics, possibly all four of these antibiotics, and they may be taking them for a prolonged amount of time, sometimes between six months and a year until they have cleared themselves of TB.
So all four of these medications carry a black box warning for hepatotoxicity, okay? So that's going to be super important to know.
And when the patient is on these medications, we want them to not drink alcohol, right, because these medications are already causing issues with the liver. We don't need them drinking, and that puts more stress on the liver. And we're also going to monitor their liver function throughout therapy.
Let's now talk about some of the other side effects we have with each of these medications.
So for rifampin, this is going to cause orange discoloration of the patient's secretions. It also can cause GI upset, and it will decrease the effectiveness of oral contraceptives. So your patient will need to use an alternative form of birth control while they're taking rifampin.
With isoniazid, this can cause neuropathy in addition to the hepatotoxicity. With pyrazinamide, this can cause joint pain.
And with ethambutol, this can cause issues with the eyes and with vision. So we have E for ethambutol and E for eyes.
You'll definitely want to advise your patient to report any issues they are having with their vision when they're taking this medication and encourage them to get regular screening for their vision.
So our little cool chicken hint here on the top of the card to remember these medications, I encourage you to think about a ripe orange. So the word ripe is like the first letter of each of these medications. So rifampin, isoniazid, pyrazinamide, and ethambutol. And then ripe orange helps you remember that you will have orange secretions with rifampin, which is the first medication on this list.
Next up, we have our systemic antifungal agents, which include amphotericin B, ketoconazole, and fluconazole. These medications are used for systemic fungal infections as opposed to topical fungal infections. We'll talk about agents for topical infections when we cover medications for the integumentary system.
So all three of these systemic antifungals carry the risk for hepatotoxicity. So any time your patient is on a systemic antifungal, you're going to want to closely monitor their liver function.
Amphotericin B is particularly toxic. So we're only going to use this medication for life-threatening fungal infections.
So in addition to hepatotoxicity, amphotericin B carries a side effect of nephrotoxicity, phlebitis, fever, chills, and nausea and vomiting.
As for ketoconazole and fluconazole, they both again carry the risk for hepatotoxicity, but also can cause GI upset.
So our little cool chicken hint here on the top of the card for amphotericin B, amphotericin B can terrorize your body, and that helps you to remember that this medication is very toxic, and it really can terrorize your body.
So you want to do that test dose first and then closely monitor your patient for those very serious side effects.
Finally, we have our antiviral agents, and I'm going to give you guys a heads up because these names are killing me. So I'm going to try very carefully to pronounce them correctly. Thank you for your patience.
Next, we have our systemic antiviral agents, which include acyclovir, ganciclovir, oseltamivir, and zanamivir.
So these medications are all used to treat viral infections, and they're all under that VIR, and that's how you know they're used to treat viral infections.
So with acyclovir, this is used to treat herpes and varicella-zoster viruses such as shingles. So when I was in nursing school, I got shingles because of all the stress in my life. So I ended up taking acyclovir.
Side effects of this medication can include phlebitis, GI upset as well as nephrotoxicity.
Ganciclovir is used to treat cytomegalovirus, and side effects of that one include phlebitis, GI upset, nephrotoxicity, and bone marrow suppression.
And then we have our oseltamivir and zanamivir, which are antivirals that are used to treat influenza A and B.
And the key side effect with these medications is GI upset. So what's important to remember when we're treating influenza is that we need to start oseltamivir and zanamivir within 48 hours of the onset of symptoms. So if a patient has been having symptoms for longer than that, then we are not going to use these medications because they're not going to be that effective. But if we can get them into the patient within those first 48 hours, then that is going to help them, for sure.
All right, time for quiz. I have three questions for you. First question, which TB medication causes orange discoloration of the secretions? The answer is rifampin. Second question, which TB medication causes vision issues? The answer is ethambutol. Remember E for ethambutol and E for eyes. Third question, oseltamivir needs to be administered within 48 hours of the onset of influenza symptoms. True or false? The answer is true.
Okay. I hope this video has been helpful. Thank you for your patience with me as I [laughter] was struggling with my antiviral drug names. I know these drugs inside and out, but some of these drug names are super challenging, so. Thank you for your patience. Be sure to hit your like button if you appreciate this video and leave me some words of encouragement as well as I try to get through the rest of these drug names. So we have two more videos in this playlist. So hang in there with me and good luck with studying.
There are four antiviral agents we're going to talk about. One is acyclovir, another is ganciclovir. Then we have oseltamivir. All right, here we go. This can be tragic. Literally, I don't know if I'm going to get this done for my dinner reservation at 5:30. It's 2:30, by the way. Okay. Finally, we have our antiviral agents, which include acyclovir, ganciclovir, oseltamivir, and zanamivir. I think that's right. Hang on.
Zanamivir. Okay. [laughter] Oh, I hate these words. Oh, God. Take me away. All right. Here we go. It's happening. Oseltamivir, zanamivir. [laughter] I guess I can't spell those. Acyclovir. I don't know why. This is the easiest word in the whole bunch. Acyclovir.
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