Chapter 17
Immune Modulators
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Immune Modulators
Modify the actions of the immune system
Immune stimulants energize the immune system
o When it is exhausted from fighting prolonged
invasion
o When it needs help fighting a specific pathogen
Immune suppressants used to block the normal
effects of the immune system
o Organ transplantation
o Autoimmune disorders
o Some cancers
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Use of Immune Modulators Across the
Lifespan
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Immune Stimulants
 Interferons
o Naturally produced and released by human cells that have
been invaded by viruses
o May also be released from cells in response to other
stimuli
 Interleukins
o Communicate between lymphocytes, which stimulate
cellular immunity and inhibit tumor growth
 Colony-stimulating factors
o Increase production of neutrophils in the bone marrow
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Interferons #1
 Therapeutic actions and indications
o
Prevent virus particles from replicating inside cells
o
Stimulate interferon receptor sites on noninvaded cells to
produce antiviral proteins
o
Inhibit tumor growth and replication
o
See Table 17.1 for usual indications of each
 Pharmacokinetics
o
Generally well absorbed after subcutaneous or intramuscular
injection
o
Rapid onset of action; peak in 3–8 hours (exception: interferon
beta-1a)
o
Broken down in the liver and kidneys, seem to be primarily
excreted in the kidneys
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Interferons #2
 Contraindications and cautions
o
Known allergy; pregnancy and lactation
o
Use with caution with cardiac disease, with myelosuppression,
and with CNS dysfunction
 Adverse effects
o
Related to immune or inflammatory reaction that is being
stimulated
o
Other common effect: headache, dizziness, bone marrow
depression, depression and suicidal ideation, photosensitivity,
liver impairment
 Drug–drug interactions
o
Theophylline; zidovudine or other myelosuppressive
treatment
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Interleukins #1
Two preparations
o Aldesleukin (Proleukin)
 Human interleukin produced by recombinant
DNA technology using E. coli bacteria
o Oprelvekin (Neumega)
 Interleukin-11. A thrombopoietic growth factor
that stimulates the hematopoietic stem cells
to mature into more platelets
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Interleukins #2
 Therapeutic actions
o
Activate cellular immunity and inhibit tumor growth
o
Increase natural killer cells and lymphocytes, cytokine
activity, and circulating platelets
 Indications
o
Aldesleukin: Treatment of metastatic renal carcinomas,
metastatic melanoma in adults
o
Oprelvekin: Prevention and treatment of severe
thrombocytopenia in adult patients being treated with
myelosuppressive chemotherapy
 Pharmacokinetics
o
Rapidly distributed after injection; primarily excreted by the
kidneys
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Interleukins #3
 Contraindications
o Known allergy, pregnancy, and lactation; caution with
renal, liver, or cardiovascular impairment and/or
arrhythmias
 Adverse effects
o Attributed to effect on the body during inflammation
o Respiratory difficulties, CNS changes, cardiac arrhythmias
 Drug–drug interactions
o Concurrent use with medications that are either cardio or
neurotoxic
o Other antineoplastic medications
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Colony-Stimulating Factors #1
 Therapeutic actions and indications
o Increase production of white blood cells
o Indications
 Reduce the incidence of infection in patients with bone
marrow suppression
 Decrease the neutropenia associated with bone marrow
transplants and chemotherapy
 Help in the treatment of various blood-related cancers
 Pharmacokinetics
o Varied based on specific drugs
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Colony-Stimulating Factors #2
 Contraindications and cautions
o Allergy to any component of the drug; caution with
pregnancy or lactation, patients with bone marrow cancer
or sickle cell disease; sargramostim: use caution with
renal or hepatic disease, radiation, and chemotherapy
 Adverse effects
o GI effects, headache, fatigue, generalized weakness,
alopecia and dermatitis, and generalized pain and bone
pain
 Drug–drug interactions
o Increase in the myeloproliferative effects of sargramostim
when combined with lithium or corticosteroids
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Question #1
You are doing an initial assessment on a 55-year-old
patient who is to receive aldesleukin (Proleukin) for
metastatic renal cell carcinoma. Which should the
nurse assess for?
A. Hepatic bleeding
B. Ascites
C. Allergy to any interferon
D. History of peptic ulcers
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Answer to Question #1
A. Hepatic bleeding
Rationale: Caution should be used with renal, liver,
or cardiovascular impairment and/or arrhythmias
because of the adverse effects of interleukins. The
nurse should assess for hepatic bleeding before the
patient takes this drug.
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Immune Suppressants #1
Immune modulators
T- and B-cell suppressors
Interleukin receptor antagonist
Monoclonal antibodies
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Immune Modulators #2
Block the release of various cytokines involved in
the inflammatory response and activation of
lymphocytes, decreasing immune activity
Fingolimod (Gilenya)
Lenalidomide (Revlimid)
Thalidomide (Thalomid)
Apremilast (Otezla)
Dimethyl fumarate (Tecfidera)
Pomalidomide (Pomalyst)
Teriflunomide (Aubagio)
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Immune Modulators #3
Therapeutic actions and indications
o Number of effects on the inflammatory system;
specific effects vary by drug
o See Table 17.2 for usual indications for specific
drugs
Pharmacokinetics vary by specific drug
Contraindications and cautions
o Pregnancy
o Teriflunomide also contraindicated with severe
hepatic impairment
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T- and B-Cell Suppressors #1
 Several are available for use
o Abatacept (Orencia)
o Azathioprine (Imuran)
o Belatacept (Nulojix)
o Cyclosporine (Sandimmune, Neoral)
o Glatiramer (Copaxone, Glatopa)
o Mycophenolate (CellCept)
o Pimecrolimus (Elidel)
o Sirolimus (Rapamune)
o Tacrolimus (Prograf)
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T- and B-Cell Suppressors #2
Therapeutic actions and indications
o Exact mechanisms vary
o Block antibody production by B cells, inhibit
suppressor and helper T cells, and modify the
release of interleukins and of T-cell growth
factor
o Indicated for prevention and treatment of
specific transplant rejections as well as treating
some types of arthritis
Pharmacokinetics vary by specific drug
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T- and B-Cell Suppressors #3
 Contraindications and cautions
o Known allergy; pregnancy and lactation; renal or hepatic
impairment; presence of known neoplasms
 Adverse effects
o Increased risk for infection, development of neoplasms;
hepatotoxicity; renal toxicity; renal dysfunction; and
pulmonary edema
o Headache, tremors, secondary infections, GI upset,
diarrhea, hypertension
 Drug–drug interactions
o Other drugs that are hepatotoxic or nephrotoxic
o Consult a drug guide for drug-specific interactions
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Interleukin Receptor Antagonist #1
 Works to block the activity of the interleukins that are released
in an inflammatory or immune response
 Only available drug is anakinra (Kineret)
 Actions
o Blocks activity of interleukin-1
o Used to reduce signs and symptoms of moderately to
severely active rheumatoid arthritis in adult patients
 Pharmacokinetics
o Absorbed slowly; peaks in 3–7 hours
o Metabolized in the tissues; excreted in the urine
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Interleukin Receptor Antagonist #2
 Contraindications and cautions
o Known allergy to E. coli–produced products or to
anakinra; pregnancy or lactation; renal impairment,
immunosuppression, or any active infection
o Live vaccines should not be given while on this drug
 Adverse effects
o Headache, sinusitis, nausea, diarrhea, upper respiratory
and other infections, injection site reactions
 Drug–drug interactions
o Etanercept
o Anakinra should not be combined with abatacept
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Monoclonal Antibodies #1
 Antibodies that attach to specific receptor sites developed to
respond to very specific situations
 Developed and approved at a rapid pace
 Therapeutic actions and indications
o Designed to attach to specific target
o Have specific functions and indications
 Pharmacokinetics
o All injected with exception of erlotinib
o Rapidly broken down in GI tract
o Processed by the body like naturally occurring
antibodies
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Monoclonal Antibodies #2
 Contraindications and cautions
o
Known allergy to the drug or murine products; in presence of
fluid overload; pregnancy or lactation
o
Use cautiously with fever, patients who have previous
administration
 Adverse effects
o
Most serious: pulmonary edema, cytokine release syndrome
o
Other drug-specific effects
 Drug–drug interactions
o
Combination with other immunosuppressant drugs
o
Others vary by drug; consult drug guide
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Question #2
When giving a patient an immunosuppressant, what
must be monitored if the patient is also receiving
gentamicin?
A. Hepatotoxicity
B. Nephrotoxicity
C. Visual disturbances
D. Dizziness
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Answer to Question #2
B. Nephrotoxicity
Rationale: There is an increased risk of toxicity if
these drugs are combined with other drugs that are
hepatotoxic or nephrotoxic. Extreme care should be
used if such combinations are necessary.
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