1. Introduction to Clinical Pharmacology Chapter 51 Immunomodulating Drugs

2. CSFs are a group of immunostimulants used in cancer treatment and chronic renal failure to support the hematopoietic system.
other agents used to modify the immune system—immunosuppressants—is also included.

3. Types and Functions of Blood Cells
Red blood cells (erythrocytes): supply oxygen
White blood cells (leukocytes): protect against microorganisms
Platelets (megakaryocytes): control bleeding

4. Drugs Used in Treatment of Anemia and Bleeding and Prevention of Infection
Colony-stimulating factors
Oprelvekin
Erythropoiesis-stimulating agents
Iron preparations
Folic acid
Vitamin B12

5. Drugs Used to Stimulate White Blood Cells: Actions and Uses
Colony-stimulating factors (CSF): glycoproteins act on hematopoietic cells to stimulate proliferation, differentiation, and maturation of white blood cells, used to treat or prevent infection (by minimizing neutropenia)
Filgrastim: used after a cycle of chemotherapy;The absolute neutrophil count (ANC) is monitored and therapy is continued until 10,000/mm3 is achieved.
Pegfilgrastim: used as single dose between chemotherapy cycle
Sargramostim: used following BMT and induction chemotherapy used with leukemia, and to stimulate stem cells for harvest

6. Drugs Used to Stimulate White Blood Cells: Adverse Reactions
Bone pain
Hypertension
Nausea and vomiting
Alopecia
Hypersensitivity or allergic reactions

7. Drugs Used to Stimulate White Blood Cells: Contraindications, Precautions, and Interactions
Contraindicated in patients with hypersensitivity
Pregnancy category C, caution when breastfeeding
Filgrastim: caution with hypothyroid disease
Pegfilgrastim: causes sickle cell crisis
Can stimulate cancer cell growth
Increased neutrophils when used with lithium

8. Drugs Used to Stimulate Blood Platelets: Actions and Uses
Oprelvekin: acts to stimulate thrombopoiesis
Reduces need for multiple platelet transfusions
Used to treat or prevent thrombocytopenia associated with chemotherapy for solid tumor cancer treatments
eltrombopag and romiplostim are used only for ITP and are not to be used to increase platelet count associated with immunosuppression during chemotherapy.

9. Drugs Used to Stimulate Blood Platelets: Adverse Reactions
General reactions:
Fluid retention, peripheral edema, dyspnea, syncope, fever, allergic reaction
Cardiovascular reactions:
Tachycardia, palpitations, atrial fibrillation, arrhythmias resulting in stroke and pulmonary edema, capillary leak syndrome

10. Drugs Used to Stimulate Blood Platelets: Contraindications, Precautions, and Interactions
Contraindicated in patients with hypersensitivity and not used with chemotherapy that is extremely myelosuppressive
Use cautiously in patients with renal and heart failure or atrial arrhythmias
Low potassium (hypokalemia) can occur with cancer chemotherapy agent ifosfamide
Pregnancy category C; stop breastfeeding
Anaphylactic-type reactions: discontinue use

11. Drugs Used in Treating Anemia Associated With Chronic Illness: Actions and Uses
Epoetin alfa: drug that stimulates erythropoiesis
Used to treat anemia associated with chronic renal failure; chemotherapy for cancer treatment; zidovudine therapy for human immunodeficiency virus; postsurgical blood replacement in place of allogeneic transfusions
Darbepoetin alfa, an erythropoiesis-stimulating protein: used to treat anemia

12. Drugs Used in Treating Anemia Associated With Chronic Illness: Adverse Reactions
Hypertension; headache; nausea; vomiting; diarrhea; rashes; fatigue; arthralgia; skin reaction at injection site

13. Drugs Used in Treating Anemia Associated With Chronic Illness: Contraindications and Precautions
Epoetin alfa: contraindicated in patients with uncontrolled hypertension; those needing emergency transfusion; those with hypersensitivity to human albumin
Darbepoetin alfa: contraindicated in patients with uncontrolled hypertension, those allergic to drug
Epoetin alfa darbepoetin alfa: used with caution in patients with hypertension; heart disease; congestive heart failure; history of seizures

14. Drugs Used in Treating Iron Deficiency Anemia: Actions and Uses
Iron preparations:
Act by elevating serum iron concentration, which replenishes hemoglobin and depleted iron stores
Iron is best absorbed on an empty stomach.
Parenteral iron:
Used when patient cannot take oral drugs or when patient experiences gastrointestinal intolerance to oral iron administration; treating iron deficiency anemia

15. Drugs Used in Treating Iron Deficiency Anemia: Adverse Reactions and Contraindications
Adverse reactions: gastrointestinal reactions: GI irritation, vomiting, constipation, diarrhea, darker stools; generalized system reactions, headache, backache, allergic reactions
Iron supplements: contraindicated in patients with known hypersensitivity to drug or any component of the drug

16. Drugs Used in Treating Iron Deficiency Anemia: Contraindications and Precautions
Iron compounds
Contraindicated in patients with hemochromatosis or hemolytic anemia
Used cautiously in patients with hypersensitivity to aspirin

17. Drugs Used in Treating Iron Deficiency Anemia: Interactions
Interactant drug
Effect of interaction
Antibiotics
Decreased GI absorption of the antibiotic
Levothyroxine
Decreased absorption of levothyroxine
Levodopa, methyldopa
Decreased effect of anti- Parkinson’s medication
Ascorbic acid (vitamin C)
Increased absorption of iron

18. Drugs Used in Treating Folic Acid Deficiency Anemia: Action and Uses
Folic acid: used in treating megaloblastic anemia; for women of childbearing age to decrease incidence of neural tube defects
Leucovorin: used to diminish hematologic effects of methotrexate
Used in treating certain types of cancer

19. Drugs Used in Treating Folic Acid Deficiency Anemia: Contraindications, Precautions, and Interactions
Folic acid, leucovorin: contraindicated for treating pernicious anemia, other anemias in which vitamin B12 is deficient
Used cautiously within RDA guidelines
Pregnant women with folate deficiency are at increased risk for complications of pregnancy, fetal abnormalities
Signs of folate deficiency: occur when sulfasalazine administered concurrently
Increase in seizure activity: occurs when folic acid is administered with hydantoins

20. Drugs Used in Treating Vitamin B12 Deficiency Anemia: Actions, Uses, and Adverse Reactions
Vitamin B12 used to treat patients with a vitamin B12 deficiency; also used to perform the Schilling test
Adverse reactions: mild diarrhea; itching; increase in RBC production; acne; peripheral vascular thrombosis; congestive heart failure; pulmonary edema

21. Drugs Used in Treating Vitamin B12 Deficiency Anemia: Contraindications, Precautions, and Interactions
Contraindicated in patients allergic to cyanocobalamin
Administered cautiously during pregnancy, in patients with pulmonary disease, anemia
Alcohol, neomycin, colchicine decrease the absorption of oral vitamin B12

22. Nursing Process: Assessment #1
Preadministration assessment:
Obtain general health history, ask about symptoms of anemia
Take vital signs to provide baseline during therapy
Physical assessments: patient’s general appearance and, in severely anemic patient, evaluation of patient’s ability to carry out activities of daily living

23. Nursing Process: Assessment #2
Ongoing assessment:
Monitor patient for adverse reactions; report any occurrence of adverse reactions to primary health care provider before next dose is due
Inform patient that color of stool will become darker or black
Assess patient for relief of symptoms of anemia

24. Nursing Diagnoses
Fatigue related to dilutional anemia caused by fluid retention
Imbalanced Nutrition: Less Than Body Requirements related to lack of iron, folic acid, other (specify) in the diet
Constipation related to adverse reaction to iron therapy

25. Nursing Process: Planning
The expected outcomes include:
Optimal response to therapy
Supporting the patient needs related to the management of adverse reactions
Understanding of and compliance with prescribed treatment regimen

26. Nursing Process: Implementation #1
Promoting an optimal response to therapy:
Iron: check with hospital pharmacist regarding simultaneous administration of iron salts with other drugs; monitor patient for allergic response for at least 1 hour after test dose and before administering remaining dose
Vitamin B12: patients with vitamin B12 anemia are treated with vitamin administered by parenteral route weekly

27. Nursing Process: Implementation #2
Promoting an optimal response to therapy (cont.)
Epoetin alfa: monitor blood pressure closely; report any rise of 20 mm Hg or more in systolic, diastolic pressure to primary health care provider

28. Nursing Process: Implementation #3
Monitoring and managing patient needs:
Altered nutrition: recommend balanced diet with emphasis on foods that are high in iron, folic acid, or vitamin B12; monitor amount of food eaten at meals; vegetarian patient: dietitian should be consulted to provide menus with appropriate iron-rich foods
Constipation: instruct patient to increase fluid intake to 10 to 12 glasses of water daily, eat a diet high in fiber, and increase activity

29. Nursing Process: Implementation #4
Educating the patient and family:
Explain medical regimen thoroughly to patient and family
Emphasize importance of following the prescribed treatment regimen
Iron:
Take this drug with water on empty stomach; if gastrointestinal upset occurs, take drug with food or meals

30. Nursing Process: Implementation #5
Educating the patient and family (cont.)
Iron (cont.)
This drug causes darkening of stools, constipation, or diarrhea; if constipation or diarrhea becomes severe, contact primary health care provider
Iron deficiency occurs: cause must be determined and therapy should be under the care of a health care provider

31. Nursing Process: Implementation #6
Educating the patient and family (cont.)
Epoetin alfa:
Strict compliance with antihypertensive drug regimen: important in patients with known hypertension during epoetin alfa therapy
Adverse reactions: dizziness; headache; fatigue; joint pain; nausea; vomiting; diarrhea

32. Nursing Process: Implementation #7
Educating the patient and family (cont.)
Folic acid:
Avoid use of multivitamin preparations unless such use has been approved by the primary health care provider
Follow diet recommended by primary health care provider because diet and drug are necessary to correct a folic acid deficiency

33. Nursing Process: Implementation #8
Educating the patient and family (cont.)
Leucovorin:
Megaloblastic anemia: adhere to diet prescribed by the primary health care provider
If purchase of foods high in protein becomes a problem, discuss this with primary health care provider

34. Nursing Process: Implementation #7
Educating the patient and family (cont.)
Vitamin B12:
Nutritional deficiency of vitamin B12: eat a balanced diet that includes seafood, eggs, meats, and dairy products
Pernicious anemia: lifetime therapy is necessary, avoid contact with infections, report any signs of infection to primary health care provider immediately

35. Nursing Process: Evaluation
Therapeutic effect of the drug is achieved
Patient has normal bowel movements
An adequate nutritional intake is achieved
Patient and family demonstrate an understanding of the drug regimen
Patient verbalizes the importance of complying with the prescribed treatment regimen

36. Question #1 Is the following statement true or false?
The hematopoietic system is composed of fluid and four types of cells.

37. Answer to Question #1 False
The hematopoietic system is composed of fluid and three types of cells. RBCs supply the body with oxygen, white blood cells protect the body from microorganisms, and platelets control bleeding.

38. Question #2 Is the following statement true or false?
Chronic diseases like kidney failure or treatments such as chemotherapy can reduce cells in the circulation, causing fatigue, bleeding, or infection.

39. Answer to Question #2 True
Chronic diseases like kidney failure or treatments such as chemotherapy can reduce cells in the circulation, causing fatigue, bleeding, or infection. Colony-stimulating factors are one type of immunostimulant that can boost the number of cells.

40. Question #3 Is the following statement true or false?
Anemia is a condition caused by increased amounts of hemoglobin, causing more oxygen to be delivered to the tissues.

41. Answer to Question #3 False
Anemia is a condition caused by reduced amounts of hemoglobin, causing less oxygen to be delivered to the tissues. Anemia occurs due to chronic illnesses or specific deficiencies such as iron.