chapter 34 summarizes drugs for immune system modulation this chapter begins on page 486 in your text and it is very complex and difficult to understand at times so I'll be pointing out some very specific themes that you need to pay attention to as well as a very specific figure that shows a summary of how the cells work in this chapter first off let's talk about immunomodulators immunomodulators or any drugs or therapies that affect body defenses they can stimulate or suppress and non-specific innate body defenses are physical barriers fight phagocytes natural killer cells which would be T cells fever interferon in inflammation up on page 487 figure 34.1 um and again this is the figure that I really want you to focus on now these are what I just mentioned were non-specific body defenses in these figures it's going to be going into more specific type situations within the cells that work really to mediate and attack or remember exactly what the body is fighting or killing so let's talk about the specific humeral response this is specific to the B cells and the plasm cells so the specific humeral response is initiated with antigen encounters a B cell so the antigen is anything that the body is fighting that may be virus bacteria fungus protists or toxins and this is anything that they're fighting inside this cell so plasma cells secrete antibodies which are immunoglobulins they neutralize foreign agents market for Destruction by other defense cells and the peak production occurs in about 10 days memory B cells can speed a future defense against a specific antigen by remembering exactly what was done in the past and activating that early on during the identification process now after activity is when the immune system two ways to provide active immunity one is exposure to antigens producing active immunity the second is vaccines boosted antibody production that produces active immunity for so the first example exposure would be you actually getting exposed to a virus bacteria Etc getting sick and then your body produces the immunity the second one the vaccine is going to bypass that sickness produce those antibodies and have them ready for you in those memory B cells now let's talk about passive immunity there's another way to obtain immunity and that's performed a few different ways one is performed antibodies transferred from one person to another and again there's three different ways this can happen this can happen through maternal antibody crossing the placenta if the mother has antibodies she's going to directly cross them over to the fetus it could be with immunoglobulin treatments so this would be a um active form that is a para enteral type immunity and then treatment for botulism tetanus and rabies for people who are exposed or have high risk exposure it's important that they receive passive immunity for immunosuppressed people as well and also for anybody that has the needs a suppression of the immune system to prevent a response for instance rhogam if a mother has a different blood type than the father being positive or negative the body can naturally respond to try to kill that often that would cause fetal demise so it's important to recognize that there are times where you're going to suppress your natural immunity to prevent that response talk about immunization agents so these are vaccines they are the process of introducing a foreign protein to trigger an immune response before their actual sickness or exposure it can prevent serious infectious disease they may be given severally for instance Hepatitis B you have to have multiple doses now there's new dosing you only have to have two in the series previously you had to have three so you can receive either one but they have to be given as certain dose pattern they can be measured by a Tighter and the goal is to introduce immunity without causing illness scene specifics so live vaccines may be live but weak or attenuated an example of that is your measles mumps and rubella vaccine you receive this as a baby and then again at five and then uh later on in your um career as a healthcare professional you may have had a tighter drawn and if your tighter is not showing high enough immunity you may actually receive a third dose now you may have a killed vaccine that's unable to replicate in the body and cause active infections some examples of that is an annual influenza vaccine as well as hepatitis A you may also have a toxoid vaccine examples of this would be diphtheria or tetanus and then lastly you may have a recombinant vaccine and again a good example of that is Hepatitis B in your prototype drug for vaccines is Hepatitis B it's a recombinant DNA it stimulates immunity the primary use is to provide active immunity adverse effects may be painted the injection site mild fever fatigue headache body aches hypersensitivity to yeast is a contraindication to this vaccine also it's important to recognize that this vaccine being recombinant it may not hold a high immunity standard meaning a lot of patients will actually have to get a booster over time because the immunity will Wane with time yeah nurse work with immunizations you want to assess for risk-based precautions pregnancy diabetes heart disease and renal failure provide education on the importance of a receiving vaccines answer questions concerns regarding risks and benefits of the vaccine instruct on a recommended immunization schedules and follow-up vaccines you can find these pretty easily on the CDC website foreign let's talk about specific cell-mediated response so I'm going to talk first a little bit about helper T cells and how that really works now this is part of or in between and often works with humoral immunity as well as cell mediated so I want to talk about this one first starts with a stimulation of both immoral and cell-mediated immunity by re releasing cytokines in the presence of the virus viral antigens present on the surface of the dendrick cells or macrophages and infected cells these t-receptors bind to the viral antigens and cytokines are released by helper T cells stimulating B cells those memory cells and the cytotoxic T cells to kill and contain the virus then the memory cells um confer for future immunity to this virus now so mediated response specifics Target effective body cells in response to infection or cancer cells so it causes an activation of a specific T cells with helper T cells CD4 receptors activating most other immune cells and then cytotoxic T cells those those are cd8 receptors traveling through the body killing bacteria parasites viruses and again cancer cells it's important to understand that cytokines are secreted by T cells so they're hormone-like proteins that regulate the intensity and duration of the immune response it's important to also know that mediate cell to cell communication occurs again across the B cells T cells and um further improving that immunity and examples of these are interferons and interleukins if you go back up to CD4 and cd8 if you recall some HIV labs are used to measure those levels now the reason why that's so important is without help or T cells we're not able to kill off these infections in cancers however when you're treating AIDS or HIV it's very important to understand that when you have active CD4 or cd8 cells then it can either help or suppress the HIV treatment so it's important to recognize these are Labs that you're going to be routinely doing for patients that do have HIV now let's talk about immunostimulants very few exist their biologic response modifiers so interferons and interleukins are great examples they boost patients immune system and they use to treat certain viral infections immunodeficiencies and various specific cancers now interleukins are used to treat metastatic renal carcinomaas so cancer of the kidney and there's used to stimulate platelet production in immunosuppressed patients they're also used to enhance capabilities of the immune system and stimulate cytotoxic T cells and increase b-cell and plasma cell production they also promote inflammation now interferons are secreted by lymphocytes and macrophages that have been infected with the virus so they slow the spread of the viral infection and enhance activity of the leukocytes to contain um and kill those infections specifically viruses two major Clauses interferon Alpha used to treat leukemia AIDS and Hepatitis B or C virus and then interferon beta used to treat multiple sclerosis granular granulomatosis disease in severe osteoporosis foreign otype drug for immunostimulants is interferon Alpha 2B this is a biologic response modifier it's used to treat cancers and viral infections patients can have a flux syndrome Headache nausea vomiting diarrhea depression and suicidal ideation and it's important to know it's not used in neonates because of containment of benzyl alcohol now nurse work stick immunostimulants assess for infections and cancer verification needing these drugs they are contraindicated with patients with renal or liver disease as well as pregnancy it's important to obtain baseline lab tests to assess how the body is doing prior to use it's also very important to keep the patient well hydrated and assess for changes in mental status including suicide now immunosuppressants inhibit patients immune system they're used to treat severe autoimmune disease disorders they prevent tissue reduction following organ transplant and it would be impossible to transplant organ because it would be seen in the body as a foreign object without immunosuppressants it may be toxic to bone marrow and increased risk for infections in lymphoma because the body's natural defenses are unable to work as expected on these drugs so the Prototype drug for immunosuppressants is cyclosporine it works to inhibit helper T cells primary use is suppression of transplant rejection patients may have adverse effects such as severe infection cancer decreased urine output hypertension Tremors and gingivital hyperplasia Black Box warning may cause or aggravate fatal Neuropsychiatric autoimmune ischemic or infectious disorders remember we're suppressing the immune system so the normal Cascade of immune properties are not going to work as expected now nurse work for immunosuppressants remember it's contraindicated in leukemia metastatic cancers active infection renal or liver disease and pregnancy it's important to get Baseline vital signs as well as Labs monitor the decree of bone marrow suppression via thrombocytopenia and leukopenia monitor patients taking as a thigh pain for development of secondary malignancies so secondary Cancers and monitor for indications of infection now immunosuppressants may come in a variety of forms one being corticosteroids which we have already discussed to inhibit inflammation anti-metabolites this inhibits aspects of lymphocyte replication so it does not allow lymphocytes to divide and create new lymphocytes it may also incur with antibodies in the creation of other animals as medications they recognize the human T cells as foreign and attack them and then calcium urine Inhibitors bind to Castle neuron and disrupt those T cells now prototype drugs for immunosuppressants is cyclosporine it inhibits helper T cells prevents the transplant tissue rejection Also may be used for psoriasis adverse effects hypertension Tremors neutropenia excuse me thrombocytopenia and their increased risk of malignancy Black Box warning serous infections malignancia nephrotoxicity now let's talk a little bit more about organ transplants transplanted organs have antigens that trigger immune response it's called rejection when it happens it's often a humoral response for acute rejection and antibodies destroyed transplanted tissue within days making it not usable by the body so mediator response however is very much slower and that takes about two weeks after the surgery for transplant now chronic rejection can occur over months to years later so it's important to use those immunosuppressant drugs so the organs are not rejected at any point in time after implementation now acute inflammatory disorders are severe inflammation leading to autoimmune disorders this may be things like rheumatoid arthritis lupus myosthenia gravis Hashimoto's thyroiditis and immunosuppressants can have serious adverse effects some require prophylaxis with anti-infectives and increased risk of cancers with these drugs so it's important for the patient to be on very specific treatment and only what is necessary