methotrexate (abr. MTX) (Rheumatrex) Disease Modifying Antirheumatic Drug (DMARD) HIGH ALERT
Why is pt receiving this? Alone or w/ other modalities in treatment of RA and juvenile idiopathic arthritis unresponsive to conventional therapy. Immunosupressive function ALSO USED IN CA
Dose PO/Sub Q: 7.5 mg weekly, not to exceed 20 mg/wk. When response obtained, dose should decrease.
SE dizziness, drowsiness, HA, malaise, seizures, blurred vision, Pulmonary fibrosis , PENUMONITIS,
HEPATOTOXICITY , anorexia, diarrhea, stomatitis, n/v, TENS< SJS, painful plaque erosions, Aplastic anemia, anemia, leukopenia, thrombocytopenia, hypouricemia, nephropathy
Med admin concerns PREG CATEGORY X . Most rapid acting, but still takes up to 3-6 weeks for effect to be seen. Monitor resp function, bone marrow suppression, assess nutritional status, assess for rash.
Assess for pain and ROM prior to and throughout therapy.
Pt education Take as directed , if dose is missed, omit. Notify promptly for s/sx, inspect oral mucosa for ulceration, protect against photosensitivity, instruct technique for subq

etanerept (Enbrel) Biologic DMARD , TNF Antagonist
Why is pt receiving this? Decrease progression, s/sx of rheumatoid arthritis and other conditions. May be used with other agents. Inactivates TNF, a mediator of the inflammatory response . Used in moderate to severe RA
Dose SubQ 50 mg once weekly.
SE HA, rhinitis, Upper RTI, abd pain, dyspepsia, injection site reaction, INFECTIONS (due to decreased immunofunction), MALIGNANCY, SARCOIDOSIS
Med admin Administer TB test before use (positive PPD should be referred before therapy), assess for latex allergies (needle cover), do not administer w/in 1 inch of an old site or into area tender/red/hard/bruised .
Pt education Instruct self administration technique, not tor ecievie live vaccines during therapy, methotrexate, NSAIDS, corticosteroids MAY be continued during therapy, notify for infections, adverse s/sx , pregnancy

sulfasalazine (Azulfidine) Nonbiologic DMARD
Why is pt receiving this? used in RA and ulcerative colitis. Inhibits prostaglandin synthesis
Dose PO 500 mg-1 g /day for 1 week, then increase by 500 mg /wk until at 2 g/day, in 2 divided doses. If no benefit seen in 12 wk, increase to 3 g/day in 2 divided doses.
SE BONE MARROW DEPRESSION, HA, n/v, diarrhea, SJS, TENS, crystaluria, angioedema, anaphylaxis
Med admin May increase action/toxicity to oral hypoglycemic agents, phenytoin, methotrexate, and warfarin. Increased risk of drug induced hepatitis. May decrease iron and folic acid absorption. ASSESS
ALLERGY TO SULFA (CONTRAINDICATION) monitor Is and Os for crystaluria, assess for rash, ROM and degree of swelling/pain. Monitor labs for bone marrow depression. Administer w/ food to minimize GI upset.
Pt education Dizziness (fall precautions, dissuade from driving), notify adverse s/sx, orange/yellow discoloration of skin is normal. May cause sterility in men. Notify if no relief in 1-2 months.

natalizumab (Tysabri) Anti-ms agents, monoclonal antibodies
Why is pt receiving this? Reduce frequency of exacerbations of relapsing MS, also used in Chron’s. Binds to receptors on non-neutrophil leukocytes which may alter adhesion and migration characteristics involved in corssing of inflammatory cells into BBB
Dose IV 300 mg every 4 wk. Dilute 300 mg in 100 mL NS. Invert, but do not mix. DO NOT MIX WITH
OTHER DILUTENTS. [2.6 mg/mL] OVER 1 hr. DO not IV Push or Bolus.
SE depression, fatigue, HEPATOTOXICITY, cholelithiasis, melanoma, ALLERGIC RXNS, INFUSION RXNS ,
PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY (PML)
Med admin USE immediately after preparation or refrigerated and w/in 8 hours of prepreation.
INCREASED risk of infection w/ immunosuppressants. Observe pt during, and 1 hr after infusion. Assess for PML (mental function declining rapidly/progressively, dementia, difficulty speaking, partial blindness, difficulty walking, headaches (rare),
Pt education Requires pt participation in TOUCH prescribing program, report adverse s/sx incl s/sx of
PML, NOTIFY ALL health care professionals about treatment w/ natalizumab, notify if pregnancy planned/suspected

Interferon β-1a (Avenox or Rebif ) Immunomodulators, anti-MS, interferons
Why is pt receiving this? Relapsing MS. Binds to and inhibits proinflamatory leukocytes, prohibiting crossing of BBB
Dose Avonex: IM 30 mcg once weekly
Rebif: SubQ (target dose of 22 mcg 3 times/wk): start w/ 4.4 mcg 3x weekly for 2 week, then increase to
11 mcg for 2 wk, then increase to maintanence dosee; (target dose of 44 mcg 3 times week): start w/ 8.8 mcg 3 times weekly for 2 wk, then increase to 22, then to maintance dose of 44 mcg three times week
SE SEIZURES , depression, dizziness, GI sx, stomatitis, wt loss, pruritis, anemia, leuko-and thrombocytopenia, flu-like, chest pain, hyper/hypotension
Med admin VERY EXPENSIVE. Monitor BP, CBC, LFTs and renal fx, skin breakdown. Beta-1a has no listed drug-drug interactions.
Pt education Take as directed, instruct on how to inject, notify adverse s/sx INCLUDING
DEPRESSION/SUICIDAL THOUGHTS

hydrocortisone Glucocorticoids
Why is pt receiving this? Used in wide variety of inflammatory diseases, mgmt. of adrenocortical insufficiency. Suppress inflammation and normal immune process and result in intense metabolic effects. Has significant mineralcorticoid (sodium retaining) effects.
Dose Given orally, topically, drops, IV, injected.
SE IMMUNE SUPPRESSION , depression/euphoria, hypertension, peptic ulceration, anorexia, n/v, acne, decreased wound healing,
(alters glucose metabolism) thromboembolism, weight gain, muscle wasting, osteoporosis, cushing appearance.
Med admin incr risk of hypokalemia w/ thiazide/loop diuretics oramphotericin B (incr risk of digoxin toxicity), incr requirements for oral hypoclemic/insulin agents, hormonal contraceptives may decrease effectiveness, incr risk of
GI bleeding w/ NSAIDS, incr risk of tendon rupture from floroquinolones, knonw inhibitor of –virs, grapefruit juice increases serum levels; monitor s/sx of adverse reactions, adrenal insufficiency, GROWTH DELAYS in
children , if ordered daily, administer in AM to mimic natural cycles, PO admin w/ meals to minimize GI irritation
Pt education DO NOT DISCONTINUE (may result in Addisonian ciris) MUST TAPER OFF explore body image

cyclosporine (Neoral) Immunosupressants, DMARDs
Why is pt receiving this? Renal, heaptic or cardiac transplant generally in conj. w/ steroids. Inhibits IL2
Dose adjusted based on serum levels.
PO: 14-18 mg/kg dose 4-12 hr before transplant then 5-15 mg/kg/day divided q 12-24 postoperatively, taper by 5% weekly to maintanece dose of 3-10 mg/kg/day.
IV: 5-6 mg/kg/dose 4-12 hr before transplant, then 2-10 mg/kg/day in divided doses q 8-24 hrs; change to PO ASAP. Dilute each 1 mL (50 mg) in
20-100 mL of D5W or NS for injection. [2.5 mg/mL] over 2-6 hr via pump.
SE DOSE DEPENDENT: Posterior reversible encephalopathy syndrome, progressive multifocal leukoencephalopathy, leg cramps, n/v, acne or oily skin, tremors, bleeding gums, severe HTN, renal failure, HEPATOTOXICITY
Med admin MANY drug/drug interactions, increased immunosuppression, decreased antibody response to live vaccines, addative renal dysfunction. Baseline data q 2 weeks during first three months, then monthly. Dental exams for gingival hyperplasia. Mix oral soln w/ juice, milk, chocolate milk, stir well. Take w/ meals.
Pt education Take as directed at same time each day, LIFELONG THERAPY, notify for abnormal s/sx, tach correct method to monitor BP, proper oral hygiene

azathioprine (Imuran) Immunosupressants
Why is pt receiving this? Prevention of renal transplant rejection (start 1-5 days prior to surgery if possible). Suppresses production of T and B cells. Also used in RA
Dose PO/IV: 3-5 mg/kg/day initially, maintenance dose 1-3 mg/kg/day. Prepare in biologic cabinet.
DIV: dilute in NS, 1/2NS, or D5W to [10 mg/mL] given over 5 min
IVPB: may be diluted in 50 mL w/ NS, 1/2 NS or D5W. Usually infused over 30-60 min BUT could vary from 5 min-8hr.
SE retinopathy, PE, GI sx, megaloblastic anemia, hepatitis, skin rash, oportuntic infections, malignancy, anemia/leukopenia/thrombocytopenia/pancytopenia, Raynaud’s
Med admin Addative myelosupression, decreased w/ live vaccine viruses,, dose should be reduced when used with allopurinol. CBC monitoring weekly during first month, twice a month for next 2-3 months, then monthly. LFTs, renal function. Contraindicated in pregnancy.
Pt education Take as directed, report abnormal s/sx, Importance of follow ups for LFTs and CBC