Chapter 47 Biologic Response–Modifying - PowerPoint Presentation

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Chapter 47 Biologic Response–Modifying - PPT Presentation

and Antirheumatic Drugs Copyright 2017 Elsevier Inc All rights reserved Alter the bodys response to diseases such as cancer and autoimmune inflammatory and infectious diseases Hematopoietic drugs ID: 778888

elsevier 2017 reserved rights 2017 elsevier rights reserved copyright cells cont immune drugs system cell cancer marrow bone chemotherapy

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Slide1

Chapter 47

Biologic Response–Modifying and Antirheumatic Drugs

Slide2

Alter the body’s response to diseases such as cancer and autoimmune, inflammatory, and infectious diseases

Hematopoietic drugs Immunomodulating drugs Interferons (IFNs)Monoclonal antibodies (MABs)Interleukin (IL) receptor agonists and antagonistsMiscellaneous drugsBiologic Response–Modifying Drugs

Slide3

Medications that therapeutically alter a patient’s immune response to malignant tumor cells

Slide4

Fourth part of cancer therapy, in addition to:

SurgeryChemotherapyRadiationAlso used for other diseasesAutoimmuneInflammatoryInfectiousImmunomodulating Drugs (Cont.)

Slide5

Hematopoietic drugsIFNs

MABsIL receptor agonists and antagonistsDisease-modifying antirheumatic drugs (DMARDs)Miscellaneous drugsBiologic Response–Modifying Drugs: SubclassesCopyright © 2017, Elsevier Inc. All rights reserved.

Slide6

Enhancement or restoration of the host’s immune system defenses against the tumor

Direct toxic effect on the tumor cells, which causes them to lyse, or ruptureAdverse modification of the tumor’s biology, which makes it harder for the tumor cells to survive and reproduceBiologic Response–Modifying Drugs: Mechanisms of ActionCopyright © 2017, Elsevier Inc. All rights reserved.

Slide7

Two components of the immune system work together to recognize and destroy foreign particles and cells in the blood or other body tissues.

Slide8

Tumor antigens (chemical or tumor “markers”) label tumor cells as abnormal cells

Antibodies attack tumor cellsB-lymphocytes (B cells) from the humoral immune systemT-lymphocytes (T cells) from the cell-mediated immune systemThe Immune System (Cont.)Copyright © 2017, Elsevier Inc. All rights reserved.

Slide9

B-lymphocytes (B cells)Originate from bone marrow

When a foreign substance (antigen) is present, these turn into plasma cells, which in turn produce antibodies.Antibody–antigen complex Memory cellsHumoral Immune SystemCopyright © 2017, Elsevier Inc. All rights reserved.

Slide10

Antibodies also known as immunoglobulins

(Ig)MABs: antibodies that a single plasma cell makes that are all identicalFive major types of naturally occurring immunoglobulinsA, D, E, G, and MHumoral Immune System (Cont.)Copyright © 2017, Elsevier Inc. All rights reserved.

Slide11

Cells of the Humoral (Antibody-Mediated) Immune System

Slide12

T-lymphocytes (T cells)

Originate from bone marrow but mature in the thymus glandThree types with different functionsCytotoxic T cellsT-helper cellsT-suppressor cellsCell-Mediated Immune SystemCopyright © 2017, Elsevier Inc. All rights reserved.

Slide13

Cytotoxic T cells directly kill their targets by causing cell

lysis or rupture.T-helper cells direct the actions of many other components of the immune system.T-suppressor cells serve to limit or control the immune response.Cell-Mediated Immune System (Cont.)Copyright © 2017, Elsevier Inc. All rights reserved.

Slide14

A healthy immune system has about twice as many T-helper cells as T-suppressor cells at any one time.

Overactive T-suppressor cells may be responsible for clinically significant cancer cases by permitting tumor growth beyond immune system control.Cell-Mediated Immune System (Cont.)Copyright © 2017, Elsevier Inc. All rights reserved.

Slide15

Other cells of the cell-mediated immune system help to destroy cancer cells:

Slide16

Cells of the Cellular Immune System

Slide17

Enhancement of hematopoietic function

Regulation or enhancement of the immune response, including cytotoxic or cytostatic activity against cancer cellsInhibition of metastases, prevention of cell division, or inhibition of cell maturationTherapeutic Effects of Biologic Response–Modifying DrugsCopyright © 2017, Elsevier Inc. All rights reserved.

Slide18

Hematopoietic drugs (HDs) promote the synthesis of various types of major blood components by promoting the growth, or differentiation, and function of their precursor cells in the bone marrow.

Slide19

HDs are used to:Decrease the duration of chemotherapy-induced anemia, neutropenia, and thrombocytopenia

Slide20

Erythropoietic drugsepoetin alfa

darbepoetin alfa Colony-stimulating factors (CSFs)filgrastim pegfilgrastimsargramostin Platelet-promoting drugsoprelvekin romipliostimHematopoietic Drugs (Cont.)

Slide21

Decrease the duration of chemotherapy-induced anemia, neutropenia, and thrombocytopenia

Allow for higher dosages of chemotherapyDecrease bone marrow recovery time after bone marrow transplantation or irradiationStimulate other cells in the immune system to destroy or inhibit the growth of cancer cells, as well as virus- or fungus-infected cellsHematopoietic Drugs: Mechanism of ActionCopyright © 2017, Elsevier Inc. All rights reserved.

Slide22

Filgrastim (Neupogen)Granulocyte colony-stimulating factor (G-CSF)

Stimulates precursor cells for the type of white blood cells known as granulocytes (including basophils, eosinophils, and neutrophils)Administered before patient develops infectionHematopoietic Drugs (Cont.)Copyright © 2017, Elsevier Inc. All rights reserved.

Slide23

Pegfilgrastim (Neulasta)Longer acting form of filgrastim

Slide24

Sargramostim (Leukine)Granulocyte-macrophage colony-stimulating factor (GM-CSF)

Stimulates bone marrow precursor cells that make both granulocytes and phagocytic (cell-eating) cells; known as monocytesIndicated for promoting bone marrow recovery after autologous (own marrow) or allogenic (donor marrow) bone marrow transplantation in patients with leukemia and lymphomaHematopoietic Drugs (Cont.)Copyright © 2017, Elsevier Inc. All rights reserved.

Slide25

Oprelvekin (Neumega)

Both a hematopoietic drug and one of the ILs (IL-11)Enhances synthesis of platelets Indicated for the prevention of chemotherapy-induced severe thrombocytopenia and avoidance of the need for platelet transfusionsStimulates the bone marrow cells, specifically megakaryocytes that eventually give rise to plateletsHematopoietic Drugs (Cont.)Copyright © 2017, Elsevier Inc. All rights reserved.

Slide26

Romiplostim

Slide27

Used in patients who have experienced destruction of bone marrow cells as a result of cytotoxic chemotherapy

Slide28

Decrease the duration of low neutrophil counts, thus reducing the incidence and duration of infections

Enhance the functioning of mature cells of the immune system, resulting in greater ability to kill cancer cells as well as viral- and fungal-infected cellsHematopoietic Drugs:Indications (Cont.)Copyright © 2017, Elsevier Inc. All rights reserved.

Slide29

Also enhance red blood cell and platelet counts in patients with bone marrow suppression resulting from chemotherapy

Slide30

Audience Response System Question

A patient’s chemotherapy has ended at 1800 on a Tuesday afternoon. When is it appropriate to start therapy with filgrastim?1800 on Tuesday

0600 on Wednesday

1800 on Wednesday

1 week later, 1800 the next Tuesday

Slide31

Usually mildMost common include:

Slide32

Proteins with three basic propertiesAntiviral

Slide33

Recombinantly manufactured substances that are identical to the IFN cytokines that are naturally present in the human body

IFNsProtect human cells from virus attackPrevent cancer cells from dividing and replicatingIncrease the activity of other cells in the immune system, such as macrophages, neutrophils, and NK cellsInterferons (Cont.)Copyright © 2017, Elsevier Inc. All rights reserved.

Slide34

Recombinantly made IFNs are identical to the IFNs that are present within the human body and have the same properties.

Slide35

Interferons:

Effects on Immune SystemRestore the immune system’s function if it is impaired.Augment the immune system’s ability to function as the body’s defense.Inhibit the immune system from working.Helpful in autoimmune disordersCopyright © 2017, Elsevier Inc. All rights reserved.

Slide36

Viral infectionsGenital warts, hepatitis

CancerChronic myelogenous leukemia, follicular lymphoma, hairy-cell leukemia, Kaposi’s sarcoma, malignant melanomaAutoimmune disordersMultiple sclerosis (MS)Interferons: IndicationsCopyright © 2017, Elsevier Inc. All rights reserved.

Slide37

Flulike effectsFever, chills, headache, myalgia

Dose-limiting adverse effect is fatigueOther adverse effectsAnorexiaDizzinessNauseaVomitingDiarrheaInterferons: Adverse Effects

Slide38

IFN alfa products: “leukocyte IFNs”—produced from human leukocytes

IFN alfa-2a (Roferon-A) IFN alfa-2b (Intron-A) IFN alfa-n3 (Alferon-N) IFN alfacon-1 (Infergen) peginterferon alfa-2a (Pegasys) peginterferon alfa-2b (PEG-Intron)Interferons (Cont.)Copyright © 2017, Elsevier Inc. All rights reserved.

Slide39

IFN beta productsIFN beta-1a (Avonex, Rebif)

Slide40

Treatment of cancer, rheumatoid arthritis (RA), MS, and organ transplantation

Specifically target cancer cells and have minimal effect on healthy cellsFewer adverse effects than traditional antineoplastic medicationsMonoclonal AntibodiesCopyright © 2017, Elsevier Inc. All rights reserved.

Slide41

Monoclonal Antibodies (Cont.)

adalimumab+++ alemtuzumabbasiliximabbelimumabbevacixumabcetuximabcertolizumab+++ golimumab+++ ibritumomab tiuxetan

infliximab+++

natalizumab

panitumamab

rituximab

trastuzumab

Slide42

Audience Response System Question

Which statement regarding use of MABs in the treatment of cancer does the nurse identify as being true? MABs are not as effective as other chemotherapy drugs.

MABs have few adverse effects.

MABs may cause flulike effects but do not cause the typical adverse effects associated with chemotherapy.

MABs are only used in cases of last resort when other chemotherapy drugs have failed.

Slide43

Natural part of the immune

system: classified as lymphokinesBeneficial antitumor actionIL receptor agonistsaldesleukin (IL-2)oprelvekin (IL-11)*denileukin diftitoxtocilizumab (IL-6)anakinra*Also classified as an HD.

Interleukins

Slide44

Antitumor action: IL-2 is produced by activated T cells in response to macrophage-“processed” antigens and secreted IL-1.

IL-2 derivative aldesleukin: stimulates or restores immune responseAldesleukin: binds to receptor sites on T cells, which stimulates the T cells to multiplyLymphokine-activated killer cells: recognize and destroy only cancer cells and ignore normal cellsInterleukins (Cont.)Copyright © 2017, Elsevier Inc. All rights reserved.

Slide45

Severe toxicity of aldesleukin therapy

Capillaries lose ability to retain vital colloids in the blood; these substances are “leaked” into the surrounding tissuesResult: massive fluid retentionRespiratory distressHeart failureMyocardial infarction

Dysrhythmias

Reversible after IL therapy is discontinued

Interleukins: Capillary Leak Syndrome

Slide46

Aldesleukin (Proleukin) Treatment of metastatic renal cell carcinoma and metastatic melanoma

Slide47

Anakinra (Kineret)IL-1 receptor antagonist

Slide48

Autoimmune disorder causing inflammation and tissue damage in jointsDiagnosis primarily symptomatic

Slide49

Rheumatoid Arthritis (Cont.)

Slide50

Another type of arthritisAge-related degeneration of joint tissues

Slide51

Modify the disease of RAExhibit antiinflammatory, antiarthritic, and immunomodulating effects

Inhibit the movement of various cells into an inflamed, damaged area, such as a jointSlow onset of action of several weeks versus minutes to hours for NSAIDsAlso referred to as slow-acting antirheumatic drugsDisease-Modifying Antirheumatic DrugsCopyright © 2017, Elsevier Inc. All rights reserved.

Slide52

methotrexateleflunomide

Slide53

Biologic Disease-Modifying Antirheumatic Drugs

adalimumabtofacitinibanakinracertolizumabetanerceptgolimumabinfliximabadalimumababataceptrituximab

tocilizumab

Slide54

Etanercept (Enbrel)Used to treat RA (including juvenile RA) and psoriasis

Patients must be screened for latex allergy (some dosage forms may contain latex)Onset of action: 1 to 2 weeksContraindicated in presence of active infectionsReactivation of hepatitis and tuberculosis have been reported.Disease-Modifying Antirheumatic Drugs(Cont.)Copyright © 2017, Elsevier Inc. All rights reserved.

Slide55

Abatacept (Orencia)Used to treat RA

Caution if the patient has a history of recurrent infections or chronic obstructive pulmonary diseasePatients must be up to date on immunizations before starting therapyMay increase risk of infections associated with live vaccinesMay decrease response to vaccinesDisease-Modifying Antirheumatic Drugs (Cont.)Copyright © 2017, Elsevier Inc. All rights reserved.

Slide56

Assess for allergies, specifically allergies to egg proteins, IgG, or neomycin.

Assess for conditions that may be contraindications.Assess baseline blood counts; perform cardiac, renal, and liver studies.Assess for presence of infection.Nursing ImplicationsCopyright © 2017, Elsevier Inc. All rights reserved.

Slide57

Follow specific guidelines for preparation and administration of drugs.

Slide58

Teach patients to report signs of infection immediately:

Slide59

Monitor for therapeutic responses:Decrease in growth of lesion or mass

Slide60

Case Study

A 40-year-old female patient is seen in the clinic. She has been newly diagnosed with RA. Which medication does the nurse anticipate being ordered for the patient?methotrexate

adalimumab

infliximab

etanercept

Slide61

Case Study (Cont.)

Before administering methotrexate, it is most important for the nurse to assess the patient for:allergy to eggs.

congestive heart failure.

atent tuberculosis.

hypothyroidism.

Slide62

Case Study (Cont.)

The patient is scheduled for discharge. Which information does the nurse include when teaching the patient about methotrexate therapy?You can expect to develop mouth sores that will improve with time when taking this medication.

Administer the methotrexate injection daily in the early morning.

Mix the methotrexate with sterile saline before administration.

Administer the methotrexate

subcutaneously into the thigh, abdomen, or upper arm, rotating injection sites.

Slide63

Case Study (Cont.)

The patient improves within the first 3 months of treatment with methotrexate. Six months later, the patient experiences worsening of symptoms. The prescriber will most likely order which monoclonal antibody for the treatment of RA?adalimumab (Humira)

trastuzumab (Herceptin)

rituximab (Rituxan)

cetuximab (Erbitux)