Prepared by:

BSc. Nursing Student;

SEIF SAID KHALFAN

Leaning objective1. Emergency

Define emergency

Define emergency drug in medicine

Describe drugs used in emergency

Explain nurse’s responsibilities on using emergency drugs.

2. Poisoning

Define poison

Understand what is poisoning

Identify types of poisoning

Identify nature of poisoning

Identify routes of poisoning

Explain fundamentals roles of poisoning management

Understand common poisoning and their antidotes

Explain nurse’s responsibilities on using poisoning drugs.

3. Immunization

Define immunization

Understand classification of immunization

Define vaccine

Identify types of vaccine

Understand vaccination schedules for infants, child bearing age and their dosage form.

Understand scheme of immunization

Understand immune response

State general side effects of vaccine

Understand cold chain

Explain nurse’s responsibilities on using vaccines.

4. Immunosuppression Define immunity

Understand immune system

Understand immuno suppressants

Identify group of immuno suppressants

Briefly explain the classes of immune suppressive drugs

Explain nurse’s responsibilities on using immuno suppressive drugs.

An emergency is a situation that poses an

immediate risk to health, life, property, or

environment.

Emergency in medicine is a medical specialty

involving care for adult and pediatric patients

with acute illnesses or injuries that require

immediate medical attention.

Emergencies include : acute aortic dissection,

eclampsia, catecholamine crisis, hypertensive

encephalopathy, subarachnoid HG and

preoperative HTN

1. Dangers to life

2. Dangers to health

3. Dangers to the environment

Many emergencies cause an immediate danger to

the life of people involved.

This can range from emergencies affecting a

single person, such as the entire range of medical

emergencies including heart,

attacks, strokes, cardiac arrest and trauma, to

incidents that affect large numbers of people such

as natural disasters including floods, disease

outbreaks like cholera, Ebola etc.

Some emergencies are not necessarily immediately

threatening to life, but might have serious

implications for the continued health and well-

being of a person or persons (though a health

emergency can subsequently escalate to life-

threatening).

Example broken limbs, which do not usually

cause death, but immediate intervention is

required if the person is to recover properly.

Some emergencies do not immediately endanger

life, health or property, but do affect the natural

environment and creatures living within it. Not all

agencies consider this a genuine emergency, but it

can have far reaching effects on animals and the

long term condition of the land. Examples would

include forest fires and marine oil spills.

DRUGS USED IN EMERGENCY

Oxygen therapy is the administration of oxygen at

concentrations greater than that in room air to treat

or prevent hypoxemia (not enough oxygen in the

blood).

Mechanism of action

Reverses hypoxemia

Indications

Confirmed or expected hypoxemia, ischemic chest

pain

Contraindications

Certain patients with COPD will not tolerate oxygen

concentrations over 35%.

Adverse reactions

Decreased level of consciousness (COPD patients),

decreased respiratory drive in COPD patients

Lactated Ringer’s (Hartmann’s Solution)

Mechanism of action

Replaces water and electrolytes

Indications

Hypovolemic shock; keep open IV

Contraindications

Should not be used in patients with congestive heart

failure or renal failure

Adverse reactions

Rare in therapeutic dosages

0.9% Sodium Chloride (Normal Saline)

Mechanism of action

Replaces water and electrolytes

Indications

Heat-related problems (heat exhaustion, heat stroke),

freshwater drowning, hypovolemia

Contraindications

Should not be used in patients with congestive heart failure

Adverse reactions

Rare in therapeutic dosages

10% Dextrose in Water (D10W)

Mechanism of action

Provides nutrients in the form of dextrose as well as free

water

Indications

Neonatal resuscitation, hypoglycemia

Contraindications

Should not be used as a fluid replacement for hypovolemic

states

Adverse reactions

Rare in therapeutic dosages

Dextrose&Glucagon (GlucaGen)

Mechanism of action

Rapidly increases serum glucose levels

Indications

Hypoglycemia, altered level of consciousness

Contraindications

Intracranial hemorrhage

Adverse reactions

Cerebral hemorrhage

Cerebral ischemia

Pulmonary edema

Peripheral VD as a result of direct action on the

vascular smooth muscles though nitric oxide.

The drug is of immediate action ( 0.5-2 min)

and ends on stopping the infusion due to rapid

biotransformation into thiocyanate.

its is metabolized in liver and excreted by renal

Indication

Emergency hypertension especially in aortic dissection

and catecholamine crisis together with B- blocker.

controlled hypotension in plastic surgery

Dose

On vial 50mg in 500 ml dextrose 50% ( 100ug / ml).

Range ( 0.5- 8 ug/kg/min).

Start with 0.2 ug/kg/min then incremental increase by

0.2ug/kg /min every 5 min till desirable Bp is obtained

and then start oral therapy immediately

Precautions

Use only IV.

Use freshly prepared solution (maximum 4h).

Covered with foil(photosensitive).

Continuous monitoring the patient.

Never stop drug suddenly.

Contraindications

Hepatic failure.

Pregnancy .

Sever renal failure.( monitor thiocyanate over 24h which causes delirium and psychosis).

cerebra hypoperfusion.

Increased Intracranial pressure.

Hypothyroidism.

Malnutrion

Heparin Sodium

Mechanism of action

Affects clotting factors IX, XI, XII, plasmin; does not lyse existing clots

Indications

Acute myocardial infarction, prophylaxis and treatment of thromboembolic disorders

Contraindications

Hypersensitivity, active bleeding

Adverse reactions

Pain, anaphylaxis, shock, hematuria

Epinephrine (Adrenalin)

Mechanism of action

Blocks histamine receptors

Indications

For stimulate the heart in syncope due to complete heart block or carotid sinus hypersensitivity.

For resuscitation in cardiac arrest following anesthetic accidents.

in the treatment of anaphylactic shock and under certain conditions in insulin shock.

Contraindications

Hypertension, hypothermia, pulmonary edema

Adverse reactions

Nervousness, restlessness, headache, tremor

Adults dose:

IV (0.1 mg/mL) solution: 0.1 to 1 mg (1 to 10

mL), repeated every 5 min, if necessary.

Alternatively, in intubated patients,

epinephrine can be injected via the

endotracheal tube directly into the bronchial

tree at the same dose as for IV injection.

Norepinephrine Bitartrate (Levophed) Mechanism of action

Potent alpha-agonist resulting in intense peripheral vasoconstriction

Indications

Cardiogenic shock, unresponsive to fluid resuscitation

Contraindications

Hypotensive patients with hypovolemia

Adverse reactions

Headache, anxiety, dizziness

Dosage

Add 1 ampoule “4ml=4mg” to 1000 dextrose 5% so every

“1ml=4mic”.

Initial dose of 2-3mL/min”8-12Ug/min” then 0.5-1 m L/min”(2-4mic/min).

Then gradual withdrawal to avoid vascular collapse.

Digoxin (Lanoxin) Mechanism of action

Increases force of myocardial contraction

Indications Congestive heart failure, ventricular rate control in

atrial flutter and atrial fibrillation

Contraindications

Ventricular fibrillation, ventricular tachycardia, digitalis toxicity

Adverse reactions

Fatigue, headache, blurred yellow or green vision, seizures

Atropine Sulfate

Mechanism of action

Increases heart rate in life-threatening bradydysrhythmias

Indications

Hemodynamically unstable bradycardia

Contraindications

- Tachycardia, hypersensitivity

Adverse reactions

Drowsiness, confusion, headache, tachycardia, palpitations

Aspirin (ASA) Mechanism of action

Prevents platelets from clumping together and forming emboli

Indications New onset chest pain suggestive of acute myocardial

infarction

Contraindications Relatively contraindicated in patients with active ulcer

disease or asthma

Adverse reactions

Bronchospasm, anaphylaxis, wheezing in allergic patients, prolonged bleeding

SALBUTAMOL (Proventil, Ventolin) Mechanism of action

Results in smooth-muscle relaxation in the bronchial tree

Indications

Treatment of bronchospasm in patients with COPD/asthma

Contraindications

Hypersensitivity reactions to albuterol

Adverse reactions

Often dose-related and include headache, fatigue, lightheadedness, irritability, restlessness

Morphine Sulfate (Roxanol, MS Contin) Mechanism of action

Alleviates pain through CNS action

Indications

Severe CHF, acute cardiogenic pulmonary edema

Contraindications

Head injury, exacerbated COPD, depressed respiratory drive

Adverse reactions

Confusion, sedation, headache, CNS depression

Plasma Protein Fraction (Plasmanate) Mechanism of action

Increases intravascular volume

Indications

Hypovolemic shock, especially burn shock

Contraindications

No major contraindications

Adverse reactions

Chills, fever, urticaria (hives), nausea, and vomiting

Atenolol (Tenormin)

Mechanism of action

Decreases heart rate, myocardial contractility, and

cardiac output

Indications

To reduce myocardial ischemia and damage in acute

myocardial infarction patients

Contraindications

Heart failure, cardiogenic shock, bradycardia

Adverse reactions

Dizziness, bronchospasm, bradycardia

Furosemide (Lasix) Mechanism of action

Causes increased urine output

Indications

CHF, pulmonary edema, hypertensive crisis

Contraindications

Hypovolemia, anuria, hypotension

Adverse reactions

Dizziness, headache, ECG changes, weakness

Nifedipine (Procardia, Adalat) Mechanism of action

Inhibits movement of calcium ions across cell membranes

Indications

Hypertensive crisis, angina pectoris

Contraindications

Compensatory hypertension, hypotension

Adverse reactions

Headache, dizziness, nervousness, weakness, mood changes

Mannitol (Osmitrol) Mechanism of action

Decreases cerebral edema and intracranial pressure

Indications

Cerebral edema

Contraindications

Hypotension, pulmonary edema, severe dehydration, intracranial bleeding, CHF

Adverse reactions

Headache, confusion, seizures, pulmonary edema

Haloperidol Lactate (Haldol) Mechanism of action

Inhibits central nervous system catecholamine receptors

Indications

Acute psychotic episodes

Contraindications

Parkinson's disease, depressed mental status

Adverse reactions

Seizures, sedation, confusion, restlessness

Diazepam (Valium and Others) Mechanism of action

Raises the seizure threshold; induces amnesia and sedation

Indications

Acute anxiety states and agitation, acute alcohol withdrawal

Contraindications

Hypersensitivity, narrow-angle glaucoma

Adverse reactions

Dizziness, drowsiness, confusion, headache

Insulin Mechanism of action

Allows glucose transport into cells of all tissues

Indications

Not used in emergency pre-hospital setting

Contraindications

Hypoglycemia, hypokalemia

Adverse reactions

Weakness, fatigue, confusion, headache

Oral Glucose (Insta-Glucose) Mechanism of action

Provides an increase in circulating blood glucose levels

Indications

Conscious patients with suspected hypoglycemia

Contraindications

Decreased level of consciousness, nausea, vomiting

Adverse reactions

Nausea, vomiting

Oxytocin (Pitocin) Mechanism of action

Increases uterine contractions

Indications

Postpartum hemorrhage after infant and placental delivery

Contraindications

Presence of second fetus, unfavorable fetal position

Adverse reactions

Coma, seizures, anxiety

Magnesium Sulfate Mechanism of action

Reduces striated muscle contractions

Indications

Seizures of eclampsia, hypomagnesemia

Contraindications

Heart block, myocardial damage

Adverse reactions

Drowsiness, CNS depression, respiratory depression

Dexamethasone Sodium Phosphate

(Decadron)

Mechanism of action

Suppresses acute and chronic inflammation

Indications

Anaphylaxis, asthma, spinal cord injury

Contraindications

Hypersensitivity, use caution in suspected systemic sepsis

Adverse reactions

Headache, restlessness, euphoria, psychoses

Hydrocortisone Sodium Succinate

(Solu-Cortef) Mechanism of action

Anti-inflammatory; immunosuppressive with salt-retaining actions

Indications Shock due to acute adrenocortical insufficiency,

anaphylaxis, asthma, and COPD

Contraindications Systemic fungal infections, premature infants

Adverse reactions

Headache, vertigo, pulmonary tuberculosis

Promethazine Hydrochloride (Phenergan)

Mechanism of action H-1 receptor antagonist; blocks action of histamine

Indications Nausea/vomiting, motion sickness, sedation for

patients in labor

Contraindications Coma, central nervous system depression from alcohol,

barbiturates, or narcotics

Adverse reactions Headache, dizziness, drowsiness, confusion,

restlessness, wheezing

Monitor Blood pressure, pulse rate, respiration, ECG and hemodynamic parameters every 5-15 minutes during and after administration.

Notify physician if significant changes in vital signs or arrythmias occur at any time.

Monitor urine output frequently throughout administration. Notify if urine output decreases.

Palpate peripheral pulses and asses and closely monitored for any changes in color or temperature and appearance of the skin of the extremities.

POISONING

Poison is a substance ( solid/ liquid or gaseous), which if introduced in the living body, or brought into contact with any part there of, will produce ill health or death, by its constitutional or local effects or both.

It endanger life by severely effecting one or more vital functions in the body.

Drugs in large dose either accidentally or for suicidal or homicidal purpose can produce poisons effects.

Any substance that can harm the body by altering cell structure or functions is called poison

• “The development of dose related adverse

effects following exposure to chemicals,

drugs or other xenobiotics.”

• Poisoning occurs when any substance

interferes with normal body functions after

it is swallowed, inhaled, injected, or

absorbed.

• The branch of medicine that deals with the

detection and treatment of poisons is

known as toxicology.

1. Acute poisoning – excessive single dose, or several smaller doses of a poison taken over a short interval of time.

2. Chronic poisoning – smaller doses over a period of time, resulting in gradual worsening eg. Arsenic , Phosphorus , Antimony etc.

Homicidal – killing of a human being by another

human being by administering poisonous substance

deliberately.

Suicidal – when a person administer poison himself to

end his/ her life.

Accidental – E.g. Household poisons- nail polish

remover , acetone .

Occupational – in professional workers. e.g.

insecticides, noxious fumes.

Inhalation

Poisons that are breathed in:

Gases: ammonia, chlorine

Vapors: carbon monoxide

Sprays: insecticides

Volatile liquid chemicals: change easily from liquid to

gas

Ingestion

Poisons that are swallowed:

Household and industrial chemicals

Medications

Improperly prepared food

Plant materials

Petroleum products

Injection

o Intra venous – Benzodiazepines, barbiturates, tricyclic antidepressants etc.

o Intramuscular – Benzodiazepines, opioids etc.

o Subcutaneous – Botulinum toxin

o Intra- dermal – Local anesthetics, organophosphates

Absorption

Poisons taken in through unbroken skin:

o Corrosives or irritants

o Through bloodstream

o Insecticides and chemicals

1. Initial resuscitation and stabilization

2. Removal of toxin from the body

3. Prevention of further poison absorption

4. Enhancement of poison elimination

5. Administration of antidote

6. Supportive treatment

7. Prevention of re - exposure

First priorities are ABC’s

I/V access – I/V fluids

Endo tracheal intubation - to prevent aspiration

• Unconscious patients

• Respiratory depression/ failure

Convulsions- give anticonvulsants

Copious flushing with water or saline of the

body including skin folds, hair

Inhalational exposure

• Fresh air or oxygen inhalation

i). Gastric levage

Done with water ,1:5000 potassium permanganate , 4%

Tannic acid, saturated lime water or starch solution with

orogastric or Ewald’s tube.

Performed until clear fluid is obtained or a maximum of 3L

Lavage decreases ingestant absorption by an average

of :-

52 % - if performed within 5 min. of ingestion

26 % - if performed at 30 min.

16 % - if performed at 60 min.

Contraindications:

o Corrosive poisoning

o Recent esophageal / gastric surgery

o Unconscious patient

ii). Ipecac Syrup induced emesis Administered orally

Dose :-

30 ml – adults

15 ml – children

10 ml – small infants

Contraindications:

Corrosives

CNS depression or seizures

Rapidly acting CNS poisons ( cyanide, strychnine, camphor )

iii). Activated Charcoal

o Charcoal adsorbs ingested poisons within gut lumen

allowing charcoal- toxin complex to be evacuated with

stool or removed by induced emesis / lavage

o Dose – 1 g/kg body wt.

o Given orally as a suspension ( in water ) or through NG

tube

Contraindications:

o Mineral acids, alkalis, cyanide, fluoride ,iron

iv) Whole bowel irrigation

Administration of bowel cleansing solution containing

electrolytes & polyethylene glycol

Orally or through gastric tube

Rate – 2 L/hr. ( 0.5 L /hr. in children)

End point- rectal fluid is clear

Position – sitting

Contraindications

Bowel obstruction

Ileus

Unprotected airway

i) Forced alkaline diuresis

Infusion of large amount of NS+NAHCO3

Used to eliminate acidic drug that mainly excreted by the

kidney e.g. salicylates

Serious fluid and electrolytes disturbance may occur

Need expert monitoring

ii) Acidification of urine:

Enhance elimination of weak bases such as Phencyclidine & Amphetamine

iii) Extracorporeal Removal:

Dialysis

Acetone, Barbiturates, Bromide, Ethanol, Ethylene

glycol, Salicylates, Lithium

Less effective when toxin has large volume of

distribution (>1 L/kg), has large molecular weight, or

highly protein bound.

Peritoneal Dialysis

Alcohols , long acting salicylates, Lithium

Chelation: Heavy metal poisoning

Complex of agent & metal is water soluble & excreted

by kidneys

E.g. BAL, EDTA,

BAL – Arsenic, Lead, Copper, Mercury

EDTA- Cobalt, Iron, Cadmium

• Not all poisons have antidotes

• Typical Examples are mentioned only.

Atropine Neostigmine/physiostigmine Benzodiazepine Flumazzenil Cupper Penicillamine Cyanide Sodium thiosulphate Heparin Protamine sulphate Mercury Dimercapol Methanol Ethanol Mushroom Atropine Organophosphates

Atropine/pralidoxine Oral anticoagulants Vitamin K Paracetamol N-acetyl cysteine

7.Supportive treatment

8.Prevention of re - exposure

Assessment, including evaluation of airway, breathing, and circulation (the ABCs).

Stabilize the ABCs.

Use the coma cocktail, if indicated.

Obtain a history and perform a physical exam.

Determine what toxic effects may be caused by the particular drug, poison, or other toxin.

Perform gastric decontamination, if indicated.

Consider enhanced elimination techniques.

Obtain laboratory and diagnostic tests.

Use an antidote, if indicated, and/or deliver specific care or symptomatic/supportive care.

Immunization

Immunization (vaccination) is a way to

trigger your immune system and prevent

serious, life-threatening diseases.

Immunization is classified into two groups

1-Active immunization

2-Passive immunization

Vaccination is a method of giving antigen to stimulate the immune response through active immunization.

A vaccine is an immuno-biological substance designed to produce specific protection against a given disease.

A vaccine is “antigenic” but not “pathogenic”.

Live vaccines

Attenuated live vaccines

Inactivated (killed vaccines)

Toxoids

Polysaccharide and polypeptide (cellular fraction) vaccines

Surface antigen (recombinant) vaccines.

Live vaccines are made from live infectious agents without any amendment.

The only live vaccine is “Variola” small pox vaccine, made of live vaccinia cow-pox virus (not variola virus) which is not pathogenic but antigenic, giving cross immunity for variola.

Virulent pathogenic organisms are treated to become attenuated

and avirulent but antigenic. They have lost their capacity to

induce full-blown disease but retain their immunogenicity.

Live attenuated vaccines should not be administered to persons

with suppressed immune response due to:

Leukemia and lymphoma

Other malignancies

Receiving corticosteroids and anti-metabolic agents

Radiation

pregnancy

Organisms are killed or inactivated by heat or chemicals but remain antigenic. They are usually safe but less effective than live attenuated vaccines. The only absolute contraindication to their administration is a severe local or general reaction to a previous dose.

Example Diphtheria, Tetanus and cholera

They are prepared by detoxifying the exotoxins of

some bacteria rendering them antigenic but not

pathogenic. Adjuvant (e.g. alum precipitation) is used

to increase the potency of vaccine.

The antibodies produces in the body as a

consequence of toxoid administration neutralize the

toxic moiety produced during infection rather than

act upon the organism itself. In general toxoids are

safe immunizing agents.

They are prepared from extracted cellular fractions

e.g. meningococcal vaccine from the

polysaccharide antigen of the cell wall, the

pneumococcal vaccine from the polysaccharide

contained in the capsule of the organism, and

hepatitis B polypeptide vaccine.

Their efficiency and safety appear to be high.

It is prepared by cloning HBsAg gene in yeast cells where it is expressed. HBsAg produced is then used for vaccine preparations.

Their efficacy and safety also appear to be high.

Live

vaccines

Live

Attenuated

vaccines

Killed

Inactivated

vaccines

Toxoids Cellular fraction

vaccines

Recombinan

t vaccines

•Small pox

variola

vaccine

•BCG

•Typhoid

oral

•Plague

•Oral polio

•Yellow

fever

•Measles

•Mumps

•Rubella

•Intranasal

Influenza

•Typhus

•Typhoid

•Cholera

•Pertussis

•Plague

•Rabies

•Salk polio

•Intra-

muscular

influenza

•Japanise

encephalitis

•Diphtheria

•Tetanus

•Meningococcal

polysaccharide

vaccine

•Pneumococcal

polysaccharide

vaccine

•Hepatitis B

polypeptide

vaccine

•Hepatitis B

vaccine

Age Vaccines

Birth

6 weeks

10 weeks

14 weeks

9 months

BCG, OPV0

DPT 1, OPV 1

DPT 2, OPV 2

DPT 3, OPV 3

Measles –

88

Immunization Schedule for Infants:Recommended by WHO - Expanded Program on Immunization

ANTIGEN SCHEDULE

TT1 Any time at first contact

TT2 One month after the first visit(TT1)

TT3 Six months after TT2

TT4 One year after TT3

TT5 One year after TT4

90

Primary vaccination

One dose vaccines (BCG, variola, measles, mumps, rubella, yellow fever)

Multiple dose vaccines (polio, DPT, hepatitis B)

Booster vaccination

To maintain immunity level after it declines after some time has elapsed (DT, MMR).

PRIMARY IMMUNE RESPONSE:

When an antigen is administered for the first time.

After 3-10 days antibodies appear in the blood.

The first antibody is IgM which rises steadily for 2-3 days

reaches to peak and then declines as fast as it developed.

If the antigenic stimulus was sufficient IgG antibody appears in a few days

IgG reaches to peak in7-10 days and falls over a period of weeks or months.

Secondary (BOOSTER) RESPONSE:

Secondary response is different from the primary response in a number of ways

Shorter latent period. Production of antibody more rapid. Antibody more abundant. Antibody response maintained at higher levels for

a longer period. The antibody have greater capacity to bind the

antigen.

Range from mild and transient to very serious or life threatening

Minor effects

Fever, minor rash, soreness at injection site, itching

Severe effects

Fever >38° C, encephalitis, convulsions, anaphylactic reaction, dyspnea, others

General Contraindications

Any acute illness

Severe malnutrition.

In known cases of immune deficiency.

The "cold chain" is a system of storage and

transport of vaccines at low temperature from the

manufacturer to the actual vaccination site.

The cold chain system is necessary because vaccine

failure may occur due to failure to store and

transport under strict temperature controls.

Among the vaccines, polio is the most sensitive to heat, requiring storage at minus 20 degree C.

Vaccines which must be stored in the freezer compartment are : polio and measles.

Vaccines which must be stored in the COLD PART but never allowed to freeze are : typhoid, DPT, tetanus toxoid, DT, BCG and diluents.

Before administration of the antiserum or antitoxin, it is necessary to test for sensitivity reaction.

The risk of adverse reactions can be reduced by proper sterilization of syringes and needles, by proper selection of the subject and the product, and if due care is exercised in carrying out the procedure. Measles and BCG vaccines should be reconstituted only with the diluent supplied by the manufacturer

Reconstituted vaccine should be discarded at the

end of each immunization session and NEVER

retained for use in subsequent sessions. In the

refrigerator of the immunization centre, no other

drug and substances should be stored beside

vaccines

Nurses have responsibility on cold chain.

Is the state of having sufficient biological

defenses to avoid infection, disease, or other

unwanted biological invasion.

It is the capability of the body to resist harmful

microbes from entering it.

Immunity involves both specific and non-

specific components

Is a system of biological structures and processes within an

organism that protects against disease.

To function properly, an immune system must detect a

wide variety of agents, from viruses to parasitic worms,

and distinguish them from the organism's own healthy

tissue.

The immune system recognizes foreign bodies and

responds with the production of immune cells and proteins

Barriers help an organism to defend itself from the many

dangerous pathogens it may encounter

These are drugs that suppress undesirable immunological responses. Since immunity confers resistance to diseases, the use of drugs for suppressing it appears odd at first sight, but at the immunity is the ability of the body to recognize self from non-self (foreign) , so suppression of immunity lead to failure to recognize and to tolerate antigens produced by its own tissues (auto-immunity)

1. General immunosuppressant: They suppress all

immune responses e.g, cytotoxic agents like

azathioprine, cyclophosphamide, mycophenolate

mofetil, methotrexate, chlorambucil

2. Specific Immunosuppressants: They suppress only

cell mediated immunity e.g, cyclosporine, tacrolimus,

antilymphocytic serum (ALS) or antilymphocytic

globulin (ALG) and Rho (D) immune globulin

3. Partial Immunosuppressants: They suppress

the unwanted reactions due to immune response,

probably by their anti-inflammatory actions e.g,

glucocorticosteroids, salicylates, phenylbutazone,

sulfasalazine and methoxalen

FOUR MAJOR CLASSES

1. Corticosteroids

e.g. Prednisone and Dexamethasone

2. Cytotoxic Agents

e.g. Cyclophosphamide and Azathioprine

3. T‐cell Suppressive Agents

e.g. Cyclosporine

4. Antibodies

e.g. Antilymphocyte globulin (ALG) and Muromonoab‐CD3

Prednisone (DELTASONE), Prednisolone

(HYDELTRASOL), Dexamethasone

Mechanism of action

Lymphocytic (lysis of lymphocytes)

Inhibit mitosis of lymphocytes

Reduce size and lymphoid content of the lymph

node and spleen

Inhibit the production of inflammatory mediators,

including leukotrienes, prostaglandins, histamine

and bradykinin.

Used for :-

Autoimmune diseases (e.g., Idiopathic thrombocytopenic

purpura and autoimmune hemolytic anemia)

Isoimmune disease (e.g., Hemolytic disease of the newborn)

Organ Transplantation (e.g., renal, heart, liver, bone marrow).

(Given in combination with cyclosporine, azathioprine and

methotrexate).

Prevention of cell proliferation (e.g. coronary stents)

Asthma

Associated with high‐dose long‐term glucocorticoid

therapy can produce

Sodium and fluid retention,

Muscle weakness,

Steroid myopathy,

Loss of muscle mass and osteoporosis,

Peptic ulcer with possible perforation and hemorrhage;

Pancreatitis, impaired wound healing, thin fragile skin,

Diabetogenesis.

Insomnia

Is an alkylating agent. It is a widely used as a cytotoxic agent.

It is given orally as well as intravenously with efficacy.

Suppress bone marrow function

They cross-link DNAs resulting in inhibition of DNA synthesis.

Usually large Doses of cyclophosphamide is associated with

Pancytopenia

Hemorrhagic cystitis

Nausea and vomiting

Cardiac toxicity

Electrolyte imbalances

Must be converted into active antimetabolite.

Interferes with purine nucleic acid metabolism

Primarily suppresses T‐cell production

Inhibit cellular immunity as well as primary and

secondary serum antibody responses.

Used for graft rejection

Normally used in combination with corticosteroids.

Bone marrow suppression (leukopenia,

anemia)

Skin rashes

Fever

Nausea, vomiting, diarrhea

Hepatic dysfunction

Oral formulation of cyclosporine that

immediately forms micro emulsion in an

aqueous environment. It is an 11‐amino‐acid

cyclic peptide derived from Tolypocladium

inflatum.

Binds to cyclophilin; complex inhibits

calcineurin phosphatase and T cell activation

Kidney, liver, heart organ transplantation used in

combination with azathioprine and

corticosteroids

Rheumatoid Arthritis used in combination with

methotrexate in rheumatoid arthritis patients who

do not respond adequately to methotrexate alone

Psosiasis non-immunocompromised patients with

severe (i.e. extensive and/or disabling),

recalcitrant, plaque psoriasis who have failed to

respond to at least one systemic therapy (e.g.

methotrexate) or in patients for whom other

systemic therapies are contraindicated, or cannot

be tolerated.

Nephrotoxicity, hemolytic-uremic syndrome,

hypertension, neurotoxicity, gum hyperplasia,

skin changes, post transplantation diabetes

mellitus, hyperlipidemia; trough monitoring or

checking levels two hours after administration

required.

Selective antibodies against lymphocytes and

thymocytes have been used as immuno-

suppressants.

Mechanism of Action

Polyclonal antibody, binds T‐lymphocytes

Graft rejection during acute phase

Allergic reactions;

Consequences of immune suppression

Mechanism of Action

Monoclonal antibody, binds to T‐lymphocytes

Acute graft rejection

Side effects:

Cytokine release syndrome (can be fatal)

Allergic reactions;

Consequences of immune suppression.

Perform a thorough assessment before administering these drugs

Renal, liver, and cardiovascular function studies

CNS baseline function

Respiratory assessment

Baseline vital signs

Baseline laboratory studies, including hemoglobin, hematocrit, WBC, and platelet counts

Cont…

Assess for contraindications, drug allergies, and drug interactions

Oral immunosuppressants should be taken with food to minimize GI upset

Patients taking immunosuppressants should be encouraged to take measures to reduce the risk of infection

Avoiding crowds

Avoiding people with colds or other infections

Inform patients to immediately report fever, sore throat, chills, joint pain, fatigue, or other signs of a severe infection

REFERENCE

Dr.G.L.Upunda & M.J. Mwaffisi (2004), National infection prevention and control Guidelines for health services in Tanzania.Textbook

Ritchie. B.A. (1995), Foundation and Control. pp 114-118

Vaughn.S.(1993), Disinfectants and their use. In Proceedings of MARE Seminars.

Dr.Joseph F. S. (2013), Pharmaceutical Handbook. (Ed 9th). DermNet New Zealand.

iii) Effect the synthesis or breakdown of the mitotic spindles:

Examples of drugs in this class of mioticdisrupters include: Vinblastine (Velban), Vincristine (Oncovin) and Pacitaxel (Taxol).