Immunostimulants Nursing Considerations & Management

Notes

Immunostimulants or immune stimulants are drugs that energize the immune system when it is exhausted from fighting prolonged invasion or when the immune system needs help fighting a specific pathogen or cancer cell. It is one of the classifications of drug class called immunomodulators.

Immunomodulators, as the name implies, are drugs that modify the actions of the immune system. The other classification is immune suppressants, drugs utilized to block the normal effects of the immune system in cases of organ transplantation and autoimmune disorders.

Immune stimulants include interferons, interleukins, and colony-stimulating factors (utilized to stimulate bone marrow to produce more white blood cells especially for patients at serious risk for infection).


Table of Common Drugs and Generic Names

Here is a table of commonly encountered immune stimulants, their generic names, and brand names:

Classification Generic Name Brand Name
Interferons interferon-alpha-2b Intron-A
interferon-alfacon-1 Infergen
interferon-alfa-n3 Alferon N
interferon-beta-1a Avonex
interferon beta-1b Betaseron
interferon gamma-1b Actimmune
peginterferon alfa-2b Peg-Intron
Interleukins aldesleukin Proleukin
oprelvekin Neumega
Colony-Stimulating Factors filgrastim Neupogen
pegfilgrastim Neulasta
sargramostim Leukine

Interferons

Description
  • Interferons are substances naturally produced and released by human cells that have been invaded by the viruses. They may also be released from cells in response to other stimuli, e.g. cytotoxic T-cell activity.
  • Through the advent of recombinant DNA technology, a number of interferons are now available for use.
Therapeutic Action

The desired and beneficial actions of interferons are as follows:

  • Preventing virus particles from replicating inside cells.
  • Stimulating interferon receptor sites on non invaded cells to produce antiviral proteins, which prevent viruses from entering the cell.
  • Others include inhibiting tumor growth and replication, stimulating cytotoxic T-cell activity, and enhancing inflammatory response.
  • Interferon gamma-1b also acts like an interleukin, stimulating phagocytes to be more aggressive.
Indications

Interferons are indicated for the following medical conditions:

  • Treatment of chronic hepatitis C in adults
  • Treatment of multiple sclerosis in adults
  • Treatment of leukemias, Kaposi sarcoma, warts, AIDS-related complex, and malignant melanoma

Here are some important aspects to remember for indication of immune modulators in different age groups:

Children

  • Most immune modulators are not recommended for use in children or have not been tested.
  • Exceptions include interferon alfa-2b, azathioprine, cyclosporine, tacrolimus, and palivizumab which should be used cautiously because of their toxic effects on GI, renal, hematological, or central nervous system.
  • Active children should be protected from infection and injury.

Adults

  • Emphasize the importance of avoiding exposure to infection. Regular follow-up and medical care should be stressed.
  • Educate about proper technique for injection, disposal of needles, and special storage precautions for the drug.
  • Immune modulators are contraindicated for pregnancy and lactation because of potential adverse effects to neonate or fetus (e.g. fetal abnormalities, increased maternal and fetal abnormalities, and increased maternal and fetal infections, suppressed immune responses in nursing babies).
  • Women of childbearing age should be advised to use barrier contraceptives while taking these drugs. Some drugs may also impair fertility.

Older adults

  • The aging immune system of this population makes them more susceptible to the effects of immunomodulators.
  • Monitor closely for GI, CNS, renal, and hepatic toxic effects.
  • Extensive health education on avoiding infection and injury is necessary.
Pharmacokinetics

Here are the characteristic interactions of interferons and the body in terms of absorption, distribution, metabolism, and excretion:

Route Onset Peak Duration
IM, subcutaneous Rapid 3-12 h
IV Rapid End of infusion
T1/2: 2-3 h
Metabolism: kidney
Excretion: unknown
Contraindications and Cautions

The following are contraindications and cautions for the use of interferons:

  • Allergy to any interferons or product component. Prevent hypersensitivity reaction.
  • Pregnancy and lactation. Potential adverse effects on the neonate or mother.
  • Cardiac disease. Hypertension and arrhythmias have been reported with the use of these drugs.
  • Myelosuppression. These drugs may suppress the bone marrow.
  • Central nervous system (CNS) dysfunction of any kind. Potential for CNS depression and personality changes have been reported.
Adverse Effects

Use of interferons may result to these adverse effects:

  • Flu-like syndrome: lethargy, myalgia, arthralgia, anorexia, nausea
  • CNS: headache, dizziness, bone marrow depression, depression and suicidal ideation
  • GI: liver impairment
  • Others: photosensitivity
Interactions

There are no reported clinically important drug-drug interactions with interferons.


Interleukins

Description
  • Interleukins are synthetic compounds that communicate between lymphocytes, thereby stimulating cellular immunity and inhibiting tumor growth.
  • Interleukin-2 stimulates cellular immunity by increasing the activity of natural killer cells, platelets, and cytokines.
Therapeutic Action

The desired and beneficial actions of interleukins are as follows:

  • Increasing the number of natural killer cells and lymphocytes, cytokine activity, and circulating platelets.
Indications

Interleukins are indicated for the following medical conditions:

  • Treatment of specific renal carcinomas in adults
  • Prevention of severe thrombocytopenia
Pharmacokinetics

Here are the characteristic interactions of interleukins and the body in terms of absorption, distribution, metabolism, and excretion:

Route Onset Peak Duration
IV 5 min 13 min 3-4 h
T1/2: 85 min
Metabolism: kidney
Excretion: urine
Contraindications and Cautions

The following are contraindications and cautions for the use of interleukins:

  • Allergy to any interleukins or E-coli-produced product. To prevent hypersensitivity reactions.
  • Pregnancy. These drugs were shown to be embryocidal and teratogenic in animal studies.
  • Lactation. Potential adverse effects to the baby as it is not clear whether drugs can cross into breast milk.
  • Renal, liver, cardiovascular impairment. Adverse effects of the drug.  
Adverse Effects

Use of interleukins may result to these adverse effects:

  • Flu-like effects: lethargy, myalgia, arthralgia, fatigue, fever
  • CNS changes
  • Respiratory difficulties
  • Cardiac arrhythmia
  • Oprelvekin has been associated with severe hypersensitivity reactions, and patients should be instructed to report difficulty breathing or swallowing, chest tightness, or swelling.
Interactions

There are no reported clinically important drug-drug interactions with interleukins.


Colony-Stimulating Factors

Description
  • Colony-stimulating factors are produced by recombinant DNA technology.
  • These drugs can increase production of neutrophils and can activate mature granulocytes and monocytes.
Therapeutic Action

The desired and beneficial action of colony-stimulating factors is:

  • Increasing the production of white cells.
Indications

Colony-stimulating factors are indicated for the following medical conditions:

  • Reduction of incidence of infection in patients with bone marrow suppression
  • Decrease in neutropenia associated with bone marrow transplants and chemotherapy
  • Treatment of various blood-related cancers
Pharmacokinetics

Here are the characteristic interactions of colony-stimulating factors and the body in terms of absorption, distribution, metabolism, and excretion:

Route Onset Peak Duration
IV 2 h 4 d
Subcutaneous 8 h 4 d
T1/2: 210-231 minutes
Metabolism: unknown
Excretion: unknown
Contraindications and Cautions

The following are contraindications and cautions for the use of colony-stimulating factors

  • Allergy to any interleukins or E-coli-produced product. To prevent hypersensitivity reactions.
  • Sargramostim is contraindicated in neonates because of benzyl alcohol in the solution and with excessive leukemoid myeloid blasts in the bone marrow or peripheral blood which could be worsened by the drug. Caution is also used in patients with hepatic or renal failure which could alter the pharmacokinetics of the drug.
  • Pregnancy and lactation. Effects on the fetus or neonate are not known.  
Adverse Effects

Use of colony-stimulating factors may result to these adverse effects:

  • CNS: headache, fatigue, generalized weakness
  • GI: nausea, vomiting, diarrhea, constipation, anorexia
  • Skin: alopecia, dermatitis
  • Musculoskeletal: generalized pain, bone pain
Interactions

These drugs have drug-drug interactions with:

  • Lithium or corticosteroids. Sargramostim’s increase in myeloproliferative effects.

Nursing Considerations

Here are important nursing considerations when administering immune stimulants:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and examination:

  • Assess for contraindications or cautions (e.g. history of allergy to the drug, pregnancy and lactating status, hepatic, renal, or cardiac disease, leukemic states, etc.) to avoid adverse effects.
  • Establish baseline physical assessment to monitor for any potential adverse effects.
  • Assess for presence of skin lesions to detect early dermatological effects.
  • Obtain weight to monitor for fluid retention.
  • Monitor temperature to detect any infection.
  • Evaluate CNS status to assess CNS effects of the drug.
  • Monitor laboratory tests like CBC and renal and liver function to determine the need for possible dose adjustment and to identify changes in bone marrow function.
Nursing Diagnoses

Here are some of the nursing diagnoses that can be formulated in the use of these drugs for therapy:

  • Acute pain related to CNS, GI and flu-like effects
  • Imbalanced nutrition: less than body requirements related to flu-like effects
  • Anxiety related to diagnosis and drug therapy
Implementation with Rationale

These are vital nursing interventions done in patients who are taking immune stimulants:

  • Arrange for laboratory tests before and periodically during therapy, including CBC and differential, to monitor for drug effects and adverse effects.
  • Monitor for severe reactions, such as hypersensitivity reactions, and arrange to discontinue the drug immediately if they occur.
  • Administer drug as indicated; instruct patient and significant other if injections are required to ensure that the drug will be given if the patient is not able to administer it.
  • Arrange for supportive care and comfort measures (e.g. rest, environmental control) to help patient cope with drug effects.
  • Provide patient education about drug effects and warning signs to increase knowledge about drug therapy and to increase compliance with drug.
Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

  • Monitor patient response to therapy (improvement in condition being treated).
  • Monitor for adverse effects (e.g. flu-like symptoms, GI upset, CNS changes, bone marrow depression).
  • Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
  • Monitor patient compliance to drug therapy.

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