Chapter 48
Immunosuppressant Drugs
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Immune System
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The purpose of the immune system is to
distinguish self from nonself and to protect the
body from foreign material (antigens), including
cancer
Two types of immunity: humoral immunity, which
is mediated by B lymphocytes, and cellular
immunity, which is mediated by T lymphocytes
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Immune System (cont’d)
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Participates in anaphylactic reactions
Responsible for rejection of kidney, liver, and
heart transplants
Can also sometimes attack itself, causing
“autoimmune diseases” or immune-mediated
diseases
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Immunosuppressants
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Drugs that decrease or prevent an immune
response, thus suppressing the immune system
Used to prevent or treat rejection of transplanted
organs
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Immunosuppressants (cont’d)
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All suppress certain T-lymphocyte cell lines, thus
preventing their involvement in the immune
response
Results in a pharmacologically
immunocompromised state
Mechanisms of action vary according to drug
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Immunosuppressants (cont’d)
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Major classes used to prevent organ rejection
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Glucocorticoids
Calcineurin inhibitors
Antimetabolites
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Immunosuppressants (cont’d)
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cyclosporine (Sandimmune)
 azathioprine (Imuran)
 muromonab-CD3 (Orthoclone)
 daclizumab (Zenapax)
 sirolimus (Rapamune)
 basiliximab (Simulect)
 glatiramer acetate (Copaxone)
 tacrolimus (Prograf)
 mycophenolate mofetil (CellCept)
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Immunosuppressants (cont’d)
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Indications vary from drug to drug
Primarily indicated for the prevention of organ
rejection
Muromonab-CD3, mycophenolate, and
tacrolimus are indicated for both prevention of
rejection and treatment of organ rejection
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Classroom Response Question
The nurse should question the prescriber
regarding use of cyclosporine for the treatment of
which disease?
A. Arthritis
B. Psoriasis
C. Irritable bowel disease
D. Multiple sclerosis
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Immunosuppressants (cont’d)
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azathioprine (Imuran)
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Prophylaxis of organ rejection concurrently with other
immunosuppressant drugs, such as cyclosporine and
corticosteroids
Also used in the treatment of rheumatoid arthritis
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Immunosuppressants (cont’d)
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basiliximab (Simulect) and daclizumab
(Zenapax)
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Monoclonal antibodies
 Used to prevent rejection of transplanted kidneys
 Generally used as part of a multidrug
immunosuppressive regimen that includes
cyclosporine and corticosteroids
 Have a tendency to cause the allergy-like reaction
known as cytokine release syndrome
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Immunosuppressants (cont’d)
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cyclosporine (Sandimmune)
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Prevention of organ rejection
May be used for other autoimmune disorders
tacrolimus (Prograf)
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Used for the prevention of liver transplant rejection
Others uses are unlabeled uses
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Classroom Response Question
A patient who had a kidney transplant is receiving
cyclosporine PO in maintenance doses. What action would
decrease the potency of this drug?
A. Taking it with orange juice
B. Taking it with milk
C. Using a Styrofoam container to administer the drug
D. Mixing it with chocolate milk
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Immunosuppressants (cont’d)
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glatiramer acetate (Copaxone)
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Works by blocking T-cell autoimmune activity against
myelin protein, which reduces the frequency of the
neuromuscular exacerbations associated with
multiple sclerosis
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Immunosuppressants (cont’d)
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fingolimod (Gilenya)
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Failed as an antirejection drug
 Approved in 2010 for multiple sclerosis
 Only oral drug for relapsing forms of multiple sclerosis
 Significant adverse effects, including headache,
hepatotoxicity, flulike symptoms, back pain, AV block,
bradycardia, hypertension, and macular edema, may
occur
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Immunosuppressants (cont’d)
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muromonab-CD3 (Orthoclone OKT3)
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Reversal and prevention of graft rejection
Monoclonal antibody
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Immunosuppressants (cont’d)
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mycophenolate (CellCept)
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Indicated for the prevention of organ rejection as well
as the treatment of organ rejection
FDA black box warning for increased risk of
congenital malformations and spontaneous abortions
when used during pregnancy
Common side effects include hypertension,
hypotension, peripheral edema, tachycardia, pain,
headache, hyperglycemia, hyperlipidemia, electrolyte
disturbances, and others
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Immunosuppressants (cont’d)
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Adverse effects vary according to drugs and
may be devastating
All immunosuppressed patients have a
heightened susceptibility to opportunistic
infections
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Nursing Implications
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Perform a thorough assessment before
administering these drugs
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Renal, liver, and cardiovascular function studies
 CNS baseline function
 Respiratory assessment
 Baseline vital signs
 Baseline laboratory studies, including hemoglobin,
hematocrit, WBC, and platelet counts
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Nursing Implications (cont’d)
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Assess for contraindications, drug allergies, and
drug interactions
Monitor WBC counts throughout therapy; if the
count drops below normal range, contact the
prescriber
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Classroom Response Question
Which potential problem is of most concern for the
patient receiving immunosuppressant drugs?
A. Orthostatic hypotension
B. Increased susceptibility to infections
C. Neurotoxicity
D. Peripheral edema
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Nursing Implications (cont’d)
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Oral immunosuppressants should be taken with
food to minimize GI upset
Oral forms are used when possible to decrease
the risk of infection that may occur with
parenteral injections
Note that there are several possible drug
interactions
Grapefruit juice also interacts with some of these
drugs
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Nursing Implications (cont’d)
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Oral antifungal drugs are usually given with
these drugs to treat oral candidiasis that may
occur
Assess the oral cavity often for white patches on
the tongue, mucous membranes, and oral
pharynx
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Nursing Implications (cont’d)
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Mix oral cyclosporine solution in a glass
container
Do not use Styrofoam containers because the
drug adheres to the inside wall of the container
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Nursing Implications (cont’d)
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Follow guidelines for parenteral administration
carefully
Inform patients that lifelong therapy with
immunosuppressants is indicated with organ
transplantation
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Nursing Implications (cont’d)
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Patients taking immunosuppressants should be
encouraged to take measures to reduce the risk
of infection
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Avoiding crowds
 Avoiding people with colds or other infections
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Inform patients to immediately report fever, sore
throat, chills, joint pain, fatigue, or other signs of
a severe infection
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Nursing Implications (cont’d)
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Monitor for therapeutic responses
Monitor for adverse effects and signs of drug
toxicity
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Classroom Response Question
A male patient who received a kidney transplant 6 months
ago is taking cyclosporine. The patient tells the nurse that
he has started to take several herbal preparations. Which
does not pose a possible problem for the patient?
A. St. John’s wort
B. Ginkgo
C. Cat’s claw
D. Echinacea
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