Antidiarrheal Drugs for IBD- Immunosuppressants

Name of the Immunosuppressants Drugs

1.Azathioprine

Mechanism of Action

May prevent proliferation and differentiation of activated B and T cells by interfering with purine (protein) and nucleic acid (DNA and RNA) synthesis.

Pharmacokinetics

• Peak plasma time: PO, 1-2 hr
• Protein bound: 30%
• Metabolized in liver
• Half-life: Parent drug, 12 min; 6-MP, 0.7-3 hr; slightly prolonged in end-stage renal disease
• Dialyzable: Partially
• Excretion: Urine (primarily as metabolites)

Administration

• Give after meals.
• Be aware that I.V. administration is intended for use only when patients can’t tolerate oral medications.

Contraindications

• Hypersensitivity to drug
• Pregnancy or breastfeeding

Precautions :

• Chickenpox, herpes zoster, impaired hepatic or renal function, decreased bone marrow reserve
• Previous therapy with alkylating agents (cyclophosphamide, chlorambucil, melphalan) for rheumatoid arthritis
• Elderly patients
• Women of childbearing age.

Adverse reactions

• CNS: malaise
• EENT: retinopathy
• GI: nausea, vomiting, diarrhea, stomatitis, esophagitis, anorexia, mucositis, pancreatitis
• Hematologic: anemia, thrombocytopenia, leukopenia, pancytopenia
• Hepatic: jaundice, hepatotoxicity Musculoskeletal: muscle wasting, joint and muscle pain
• Skin: rash, alopecia
• Other: chills, fever, serum sickness, neoplasms, serious infection

Patient monitoring

• Monitor CBC, platelet level, and liver function test results.
• Assess for signs and symptoms of hepatotoxicity (clay-colored stools, pruritus, jaundice, and dark urine).
• Watch for signs and symptoms of infection.
• Monitor for bleeding tendency and hemorrhage.

Patient teaching

• Tell patient that drug lowers resistance to infection. Instruct him to immediately report fever, cough, breathing problems, chills, and other symptoms.
• Instruct patient to immediately report unusual bleeding or bruising.
• Tell patient that drug effects may not be obvious for up to 8 weeks in immunosuppression and up to 12 weeks for rheumatoid arthritis relief.
• Emphasize importance of avoiding pregnancy during therapy and for 4 months afterward.
• Caution patient to avoid activities that may cause injury. Tell him to use soft toothbrush and electric razor to avoid gum and skin injury.
• Advise patient to minimize GI upset by eating small, frequent servings of food and drinking plenty of fluids.
• Tell patient he’ll undergo regular blood testing during therapy
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, and herbs mentioned above.

Nursing Considerations

• Before I.V. use, add 20 ml sterile water for injection to azathioprine vial and swirl until clear solution forms. Resulting drug concentration is 100 mg and can be diluted further as prescribed. Calculate infusion rate based on final volume to be infused. Then give over 30 to 60 minutes or as prescribed (5 minutes to 8 hours).
• Obtain results of baseline laboratory tests, including WBC, RBC, and platelet counts. Expect to monitor results once a week during first month of therapy, twice a month during second and third months, and once a month or more thereafter. • Hematologic reactions typically are doserelated and may occur late in therapy, especially in patients with transplant rejection.
• Periodically monitor liver function test results for early signs of hepatotoxicity.
• If patient develops thrombocytopenia, take bleeding precautions, such as avoiding I.M. injections and venipunctures, applying ice to areas of trauma, and checking I.V. infusion sites every 2 hours for bleeding.
• If patient also receives an oral anticoagulant, monitor his PT.
• Azathioprine therapy increases risk of viral, fungal, bacterial, and protozoal infections. Watch for evidence of infection, such as fever, chills, sore throat, and mouth sores. Expect to administer aggressive antibiotic, antiviral, or other drug therapy and reduce azathioprine dosage.
• Minimize the risk of infection. If patient has severe leukopenia, take neutropenic precautions, such as placing him in a private room and limiting visitors.
• Rheumatoid arthritis requires at least 12 weeks of azathioprine therapy. During this time, continue other pain-relief measures, such as rest, physical therapy, and other drugs, such as salicylates and corticosteroids.
• If oral azathioprine causes GI upset, give it in divided doses or with meals.
• Expect to use lowest possible maintenance dosage for rheumatoid arthritis, reducing it gradually in 0.5-mg/kg (about 25-mg) increments at 4-week intervals.
• Drug can be stopped abruptly, but its effects may persist several days.

2.Methotrexate

Mechanism of Action

May exert immunosuppressive effects by inhibiting replication and function of T and possibly B lymphocytes. Methotrexate also slows rapidly growing cells, such as epithelial skin cells in psoriasis. This action may result from the drug’s inhibition of dihydrofolate reductase, the enzyme that reduces folic acid to tetrahydrofolic acid. Inhibition of tetrahydrofolic acid interferes with DNA synthesis and cell reproduction in rapidly proliferating cells.

Pharmacokinetics

• Bioavailability (PO): 60% at PO doses <30 mg/m², bioavailability is significantly less at doses >80 mg/m²
• Peak plasma time: PO, 1-2 hr; IM, 30-60 min
• Protein bound: 50%
• Metabolized by liver and intracellularly
• Half-life: Psoriasis, rheumatoid arthritis, and low-dose cancer treatment, 3-10 hr; high-dose treatment, 8-15 hr
• Excretion: Urine (80-100% within 24 hr), feces (small amounts)

Administration

• Be aware that methotrexate is a high-alert drug when used orally for nonchemotherapeutic use.
• Know that patient must be adequately hydrated before therapy and urine must be alkalized using sodium bicarbonate.
• Follow facility policy for handling, preparing, and administering carcinogenic, mutagenic, and teratogenic drugs.
• Be aware that oral administration is preferred. Give oral dose 1 hour before or 2 hours after meals. (Food decreases absorption of tablets and reduces peak blood level.)
• Reconstitute powder for injection with preservative-free solution, such as 5% dextrose solution or 0.9% sodium chloride injection. Reconstitute 20-mg and 50-mg vials to yield a concentration no greater than 25 mg/ml. Reconstitute 1-g vial with 19.4 ml to yield a concentration of 50 mg/ml.
• For high-dose I.V. infusion, dilute in 5% dextrose solution. Administer each 10 mg over 1 minute or by infusion over 30 minutes to 4 hours as directed.
• For intrathecal use, reconstitute immediately before administration, using preservative-free solution (such as 0.9% sodium chloride for injection), to a concentration of 1 mg/ml. 2For intrathecal or high-dose therapy, use preservative-free injection form.
• Avoid I.M. injections if platelet count is below 50,000/mm3.
• For osteosarcoma, make sure leucovorin rescue is used appropriately in patients receiving high methotrexate doses. Rescue usually starts 24 hours after methotrexate infusion begins.

Contraindications

• Hypersensitivity to drug
• Psoriasis or rheumatoid arthritis in pregnant patients
•   Breastfeeding

Precautions :

• Severe myocardial, hepatic, or renal disease; decreased bone marrow reserve; active infection; hypotension; coma
• Elderly patients
• Patients with childbearing potential
• Young children.

Adverse reactions

• CNS: malaise, fatigue, drowsiness, dizziness, headache, aphasia, hemiparesis, demyelination, seizures, leukoencephalopathy, chemical arachnoiditis (with intrathecal use)
• EENT: blurred vision, pharyngitis
• GI: nausea, vomiting, stomatitis, hematemesis, melena, GI ulcers, enteritis, gingivitis, pharyngitis, anorexia, GI bleeding GU: hematuria, cystitis, infertility, menstrual dysfunction, defective spermatogenesis, abortion, tubular necrosis, severe nephropathy, renal failure Hematologic: anemia, leukopenia, thrombocytopenia, severe bone marrow depression
• Hepatic: hepatotoxicity
• Metabolic: hyperuricemia, diabetes mellitus
• Musculoskeletal: joint pain, myalgia, osteonecrosis, osteoporosis (with longterm use in children)
• Respiratory: dry nonproductive cough, pneumonitis, pulmonary fibrosis, pulmonary interstitial infiltrates
• Skin: pruritus, rash, urticaria, alopecia, painful plaque erosions, photosensitivity
• Other: chills, fever, increased susceptibility to infection,septicemia, anaphylaxis, sudden death

Patient monitoring

• Watch for vomiting, diarrhea, or stomatitis, which may cause dehydration.
• Know that high-dose therapy may cause nephrotoxicity. Monitor renal function, hydration status, urine alkalization (for pH above 6.5), and methotrexate blood level.
• Assess for fever, sore throat, bleeding, increased bruising, and other signs and symptoms of hematologic compromise or infection.
• With high-dose or intrathecal therapy, watch for CNS toxicity.
• Monitor creatinine and methotrexate blood levels 24 hours after therapy starts and then daily. Adjust leucovorin dosage as prescribed.
• Check hematologic studies at least monthly; blood or platelet transfusions may be necessary.
• Monitor liver and kidney function studies every 1 to 3 months. Evaluate uric acid levels.
• Watch for signs and symptoms of pulmonary toxicity, such as fever, dry nonproductive cough, dyspnea, hypoxemia, and infiltrates on chest X-ray.
• Know that methotrexate exits slowly from third-space compartments (ascites, pleural effusions). Before therapy starts, fluid should be evacuated; during therapy, monitor drug blood level.

Patient teaching

• Review dosing instructions carefully with patient to avoid toxicity. Tell patient with rheumatoid arthritis or psoriasis to take doses weekly.
• Advise patient to take oral doses 1 hour before or 2 hours after meals.
• Instruct patient to report diarrhea, abdominal pain, clay-colored or black tarry stools, fever, chills, sore throat, unusual bleeding or bruising, sores in or around mouth, cough or shortness of breath, yellowing of skin or eyes, dark or bloody urine, swelling of feet or legs, or joint pain.
• Tell patient to take temperature daily and to report fever or other signs or symptoms of infection.
• Instruct patient to drink 2 to 3 L of fluid each day.
• Advise male patients to use reliable contraception during and for at least 3 months after therapy. Advise female patients to use reliable contraception during and for one ovulatory cycle after therapy; also caution them not to breastfeed.
• Advise patient to avoid sun exposure and to use sunscreen and protective clothing (especially if he has psoriasis).
• Instruct patient to avoid alcohol.
• Tell patient he’ll need to undergo blood tests during therapy.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, herbs, and behaviors mentioned above.

Nursing Considerations

• Follow facility policy for preparing and handling drug; parenteral form poses a risk of carcinogenicity, mutagenicity, and teratogenicity. Avoid skin contact.
• Monitor results of CBC, chest X-ray, liver and renal function tests, and urinalysis before and during treatment.
• Unless contraindicated, increase patient’s fluid intake to 2 to 3 L daily to reduce the risk of adverse GU reactions.
• Assess patient for bleeding and infection
• Be aware that high doses of methotrexate can impair renal elimination by forming crystals that obstruct urine flow. To prevent drug precipitation, alkalinize patient’s urine with sodium bicarbonate tablets, as ordered.
• Follow standard precautions because drug can cause immunosuppression.
• If patient becomes dehydrated from vomiting, notify prescriber and expect to withhold drug until patient recovers.
• If patient receives high doses of drug, keep leucovorin readily available as antidote.
• Be aware that methotrexate resistance may develop with prolonged use.

3.Cyclosporine

Mechanism of Action

Causes immunosuppression by inhibiting the proliferation of T lymphocytes, the production and release of lymphokines, and the release of interleukin-2.

Pharmacokinetics

• Bioavailability: Neoral >Sandimmune
• Protein Bound: 90%
• Metabolites: AM1, AM9, AM4N
• Half-Life: 8.4-27 hr
• Clearance: 5-7 mL/min/kg
• Excretion: Mainly bile and feces; 6% urine

Administration

• For I.V. infusion, dilute as ordered with dextrose 5% in water or 0.9% normal saline solution. Administer over 2 to 6 hours.
• Mix Neoral solution with orange juice or apple juice to improve its taste.
• Dilute Sandimmune oral solution with milk, chocolate milk, or orange juice. Be aware that grapefruit and grapefruit juice affect drug metabolism.
• In postoperative patients, switch to P.O. dosage as tolerance allows.
• Be aware that Sandimmune and Neoral aren’t bioequivalent. Don’t use interchangeably.
• Before administering eyedrops, invert unit-dose vial a few times to obtain a uniform, white, opaque emulsion.
• Know that eyedrops can be used concomitantly with artificial tears, allowing a 15-minute interval between products

Contraindications

• Hypersensitivity to drug and any ophthalmic components
• Rheumatoid arthritis, psoriasis in patients with abnormal renal function, uncontrolled hypertension, cancer (Gengraf, Neoral)
• Active ocular infections (ophthalmic use)

Precautions:

• Hepatic impairment, renal dysfunction, active infection, hypertension
• Herpes keratitis (ophthalmic use)
• Pregnant or breastfeeding patients
• Children younger than age 16 (safety and efficacy not established for ophthalmic use).

Adverse reactions

• CNS: tremor, headache, confusion, paresthesia, insomnia, anxiety, depression, lethargy, weakness
• CV: hypertension, chest pain, myocardial infarction
• EENT: visual disturbances, hearing loss, tinnitus, rhinitis; (with ophthalmic use) ocular burning, conjunctival hyperemia, discharge, epiphora, eye pain, foreign body sensation, itching, stinging, blurring
• GI: nausea, vomiting, diarrhea, constipation, abdominal discomfort, gastritis, peptic ulcer, mouth sores, difficulty swallowing, anorexia, upper GI bleeding, pancreatitis
• GU: gynecomastia, hematuria, nephrotoxicity, renal dysfunction, glomerular capillary thrombosis
• Hematologic: anemia, leukopenia, thrombocytopenia Metabolic: hyperglycemia, hypomagnesemia, hyperuricemia, hyperkalemia, metabolic acidosis
• Musculoskeletal: muscle and joint pain Respiratory: cough, dyspnea, Pneumocystis jiroveci pneumonia, bronchospasm Skin: acne, hirsutism, brittle fingernails, hair breakage, night sweats
• Other: gum hyperplasia, flulike symptoms, edema, fever, weight loss, hiccups, anaphylaxis

Patient monitoring

• Observe patient for first 30 to 60 minutes of infusion. Monitor frequently thereafter.
• Monitor cyclosporine blood level, electrolyte levels, and liver and kidney function test results.
• Assess for signs and symptoms of hyperkalemia in patients receiving concurrent potassium-sparing diuretic.

Patient teaching

• Advise patient to dilute Neoral oral solution with orange or apple juice (preferably at room temperature) to improve its flavor.
• Instruct patient to use glass container when taking oral solution. Tell him not to let solution stand before drinking, to stir solution well and then drink all at once, and to rinse glass with same liquid and then drink again to ensure that he takes entire dose.
• Tell patient taking Neoral to avoid high-fat meals, grapefruit, and grapefruit juice.
• Advise patient to dilute Sandimmune oral solution with milk, chocolate milk, or orange juice to improve its flavor.
• Instruct patient to invert vial a few times to obtain a uniform, white, opaque emulsion before using eyedrops and to discard vial immediately after use.
• Inform patient that eyedrops can be used with artificial tears but to allow 15-minute interval between products.
• Caution patient not to wear contact lenses because of decreased tear production; however, if contact lenses are used, advise patient to remove them before administering eyedrops and to reinsert 15 minutes after administration.
• Inform patient that he’s at increased risk for infection. Caution him to avoid crowds and exposure to illness.
• Instruct patient not to take potassium supplements, herbal products, or dietary supplements without consulting prescriber.
• Tell patient he’ll need to undergo repeated laboratory testing during therapy.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, and herbs mentioned above.

Nursing Considerations

• Be aware that capsules and oral solution aren’t interchangeable with modified capsules and modified oral solution. Modified forms have greater bioavailability.
• Prepare I.V. infusion by diluting each milliliter of concentrate in 20 to 100 ml of normal saline solution or D5W. Use glass containers because of possible leaching of diethylhexyphthalate from polyvinyl chloride bags into cyclosporine solution.
• Administer I.V. infusion over 2 to 6 hr. If needed, drug may be infused over 24 hr.
• Don’t draw blood to measure cyclosporine level through same I.V. tubing used to administer drug, even if line was flushed after administration. Blood level may be falsely elevated.
• Discard diluted solution after 24 hours.
• Be aware that oral solution contains alcohol and shouldn’t be administered to patient who drinks heavily or has a history of alcohol dependence.
• Don’t add water to oral solution because it will alter drug’s effectiveness.
• Avoid giving oral cyclosporine with grapefruit juice, which may raise trough level, increasing risk of nephrotoxicity.
• Monitor blood pressure, especially in patients with a history of hypertension, because drug can worsen this condition. Expect to decrease dosage if hypertension develops.
• Monitor liver and renal function tests, as ordered, to detect decreased function.
• Although uncommon, cyclosporine may cause neurotoxicity, especially after liver transplantation. Watch for evidence of encephalopathy (impaired consciousness, loss of motor function, psychiatric disurbance, seizures, visual disturbance).
• Be aware that cyclosporine use may result in increased serum cholesterol levels.
• Be aware that St. John’s wort may decrease blood cyclosporine level.
• Store capsules at 77° F (25° C) in prepackaged foil wrap to protect them from light.  
• Expect about 50% of patients treated for psoriasis to relapse about 4 months after therapy stops

4.Infliximab

Mechanism of Action

Binds with cytokine tumor necrosis factoralpha (TNF-alpha), preventing it from binding with its receptors. As a result, TNFalpha can’t produce proinflammatory cytokines and endothelial permeability. Infiltration of inflammatory cells into inflamed intestine and joints declines.

Pharmacokinetics

• Onset: 2 wk (Crohn disease)
• Duration: 12 wk
• Vd: 3-6 L
• Metabolism: Unknown
• Half-life: 7.7-9.5 days
• Development of antibodies to infliximab increased infliximab clearance
• Excretion: Unknown

Administration

• Know that latent TB should be treated before infliximab therapy begins.
• To reconstitute, use 21G or smaller needle to add 10 ml of sterile water to each vial. To mix, swirl (don’t shake). Solution may foam and appear clear or light yellow.
• Withdraw volume equal to amount of reconstituted drug from 250-ml polypropylene or polyolefin infusion bag or glass bottle of normal saline solution. Slowly add reconstituted drug to infusion bag or bottle and gently mix. Use within 3 hours.
• Know that concentration of infusion should be 0.4 mg/ml to 4 mg/ml.
• Give I.V. infusion over at least 2 hours. Use polyethylene-lined infusion set equipped with in-line filter, with pore size of 1.2 microns or less.
• Premedicate with antihistamines, acetaminophen, and corticosteroids, as prescribed.
• Watch for infusion reactions, especially after first infusion. Be aware that mild to moderate infusion reactions may improve after slowing or suspension of infusion. Upon resolution of reaction, restart infusion at lower infusion rate or administer antihistamines, acetaminophen, or corticosteroids. Discontinue drug in patients who don’t tolerate infusion following these interventions; permanently discontinue drug in patients who have severe infusion-related hypersensitivity reactions.
• Discard unused portions of infusion solution.
• Don’t give to patient with active infection.
• Be aware that patient who doesn’t respond by week 14 isn’t likely to respond, and therapy should cease.

Contraindications

• Hypersensitivity to drug, murine proteins, or other drug components
• Dosages above 5 mg/kg for patients with moderate to severe heart failure

Precautions:

• History of tuberculosis (TB), active infection, or exposure to TB; patients who have resided or travelled in areas of endemic TB or endemic mycoses, such as histoplasmosis, coccidioidomycosis, or blastomycosis
• Chronic or recurrent infection or underlying conditions that may predispose to infection; history of opportunistic infection; hepatitis B virus (HBV) carriers
• Jaundice or marked liver enzyme elevations, cytopenias
• Neurologic disorders (including CNS manifestation of systemic vasculitis, seizures), new-onset or exacerbation of demyelinating disorders (including multiple sclerosis and optic neuritis) and peripheral demyelinating disorders (including Guillain-Barré syndrome)
• Male patients with Crohn’s disease or ulcerative colitis who are receiving azathioprine or 6-mercaptopurine treatment
• Concurrent use of live vaccines, tocilizumab (avoid use)
• Concurrent use of anakinra or abatacept (use not recommended)
• When switching between biological disease-modifying antirheumatics (overlapping biological activity may further increase risk of infection)
• Elderly patients
• Pregnant or breastfeeding patients
• Children younger than age 6 (safety not established)

Adverse reactions

• CNS: fatigue, headache, anxiety, depression, dizziness, insomnia, CNS manifestation of systemic vasculitis, seizures, new-onset or exacerbation of demyelinating disorders (including multiple sclerosis, optic neuritis, Guillain-Barré syndrome)
• CV: chest pain, hypertension, hypotension, tachycardia, peripheral edema, worsening of heart failure
• EENT: conjunctivitis, rhinitis, sinusitis, laryngitis, pharyngitis GI: nausea, vomiting, diarrhea, constipation, abdominal pain, dyspepsia, flatulence, ulcerative stomatitis, intestinal obstruction
• GU: dysuria, urinary frequency, urinary tract infection Hematologic: hematoma, anemia, hemolytic anemia, pancytopenia
• Hepatic: HBV reactivation, hepatotoxicity
• Musculoskeletal: arthritis, joint pain, back pain, myalgia, involuntary muscle contractions
• Respiratory: upper respiratory tract infection, bronchitis, cough, dyspnea Skin: acne, diaphoresis, dry skin, bruising, eczema, erythema, flushing, pruritus, urticaria, rash, alopecia
• Other: oral pain, tooth pain, moniliasis, chills, hot flashes, flulike symptoms, herpes simplex, herpes zoster, autoimmunity, lupuslike syndrome, serious infections, malignancies, infusion reactions, hypersensitivity reaction including anaphylaxis or serum sickness-like reactions

Patient monitoring

• Stay alert for signs and symptoms of hypersensitivity and infusion reactions, including fever, chills, itching, rash, chest pain, dyspnea, facial flushing, and headache.
• Watch for evidence of infection, especially in patients who have chronic infections or are receiving immunosuppressants. Drug increases risk of life-threatening opportunistic infections and TB.
• Monitor platelets and CBC with white cell differential.
• Assess for heart failure in patients with history of cardiac disease.
• Be aware that CNS disorders (such as seizures, new-onset or exacerbation of demyelinating disorders), malignancies including lymphoma, HBV reactivation, hepatotoxicity, and cytopenias may occur.

Patient teaching

• Instruct patient to report signs or symptoms of hypersensitivity reaction, such as fever, chills, itching, rash, chest pain, dyspnea, and facial flushing (may occur up to 12 days after therapy)
• Tell patient to report infection symptoms, such as fever, burning on urination, cough, or sore throat.
• Advise patient to avoid potential infection sources, such as crowds and people with known infections.
• Advise patient not to receive live vaccines while receiving infliximab.
• Instruct patient how to recognize and immediately report signs and symptoms of blood dyscrasias, hepatotoxicity, or other new or worsening symptoms.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above

Nursing Considerations

• Infliximab therapy shouldn’t be started in a patient with an active infection, including serious localized infection.
• Use with extreme caution if patient has a history of chronic or recurrent infection, known exposure to tuberculosis, an underlying condition that predisposes to infection, or residence or travel to areas of endemic tuberculosis or mycoses, such as histoplasmosis, coccidioidomycosis, or blastomycosis.
• Use cautiously in elderly patients because they have a higher risk of infection.
• Use cautiously in patients with previous or ongoing hematologic abnormalities because infliximab may cause serious or even life-threatening adverse hematologic effects. Montior patient’s CBC regularly, as ordered. If adverse effects occur, expect drug to be discontinued.
• To reconstitute infliximab, use 21G (or smaller) needle to add 10 ml sterile water for injection to each vial of drug. Swirl to mix; don’t shake. Solution may foam and be clear or light yellow.
• Withdraw volume equal to amount of reconstituted drug from a 250-ml glass bottle or polypropylene or polyolefin infusion bag of normal saline solution. Then add reconstituted infliximab to bottle to dilute to 250 ml. Use within 3 hours.
• Infuse over at least 2 hours using polyethylene-lined infusion set and in-line, sterile, nonpyrogenic, low–protein-binding filter with pores 1.2 microns or less. Don’t reuse.
• Be prepared to stop infusion if hypersensitivity or CNS reaction occurs. Keep acetaminophen, antihistamines, corticosteroids, and epinephrine on hand. A reaction may occur 2 hours to 12 days after infusion
• Because severe hepatic reactions may occur, monitor liver function. Expect to stop drug if jaundice develops or liver enzymes are 5 times or more the upper limit of normal.
• Be aware that infliximab is a tumor necrosis factor (TNF) blocker. Malignancies, especially leukemia and such rare lymphomas as hepatosplenic T-cell lymphoma have been reported in patients, particularly children and adolescents, receiving TNF blockers. Patients at increased risk of leukemia are those with rheumatoid arthritis. Patients at increased risk of lymphomas are those with rheumatoid arthritis, Crohn’s disease, ankylosing spondylitis, psoriatic arthritis, and plaque psoriasis, especially those with long-term or very active disease. Monitor them closely.

REFERENCES

1. Robert Kizior, Keith Hodgson, Saunders Nursing Drug handbook,1st edition 2024, Elsevier Publications. ISBN-9780443116070
2. McGraw Hill- Drug Handbook, Seventh Edition, 2013, McGraw Hill Education Publications,9780071799430.
3. April Hazard, Cynthia Sanoski, Davi’s Drug Guide for Nurses -Sixteenth Edition 2019, FA Davis Company Publications,9780803669451.
4. Jones and Bartlet, Pharmacology for Nurses, Second Edition, 2020, Jones and Bartlet Learning Publications, ISBN 9781284141986.
5. Nursebro.com, Search – Nursebro

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