11.2 Drugs used in the treatment of autoimmune disorders

Autoimmune disorders occur when the immune system attacks the body's own tissues. This section explores drugs that help manage these conditions by suppressing or modulating immune responses. From corticosteroids to biologics, various medications target different aspects of the immune system.

Treatment strategies for autoimmune disorders are complex and often involve multiple drug classes. We'll look at how these medications are used to manage conditions like rheumatoid arthritis, lupus, and inflammatory bowel disease. We'll also cover important side effects and monitoring requirements for these powerful drugs.

Drug Mechanisms in Autoimmune Disorders

Immunosuppressants and DMARDs

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• Immunosuppressants suppress various aspects of the immune response
  • Corticosteroids reduce inflammation and immune activity
  • Calcineurin inhibitors block T-cell activation
  • Antimetabolites interfere with DNA synthesis in immune cells
• Disease-modifying antirheumatic drugs (DMARDs) slow progression of rheumatoid arthritis
  • Methotrexate inhibits folate metabolism
  • Sulfasalazine reduces inflammation through multiple mechanisms
  • Hydroxychloroquine modulates immune responses (originally an antimalarial)

Biological Response Modifiers

• TNF inhibitors block tumor necrosis factor to reduce inflammation
  • Adalimumab (Humira)
  • Etanercept (Enbrel)
• Monoclonal antibodies target specific immune components
  • Rituximab depletes B cells (targets CD20)
  • Tocilizumab blocks IL-6 receptors
• Janus kinase (JAK) inhibitors block intracellular signaling
  • Tofacitinib inhibits JAK1 and JAK3
  • Baricitinib inhibits JAK1 and JAK2
• Complement inhibitors target the innate immune response
  • Eculizumab blocks terminal complement complex formation

Therapeutic Applications of Autoimmune Drugs

Rheumatoid Arthritis and Related Conditions

• Rheumatoid arthritis treatment uses combination therapy
  • NSAIDs for pain relief (ibuprofen, naproxen)
  • Corticosteroids for acute flares (prednisone)
  • DMARDs to slow joint damage (methotrexate, sulfasalazine)
  • Biologics for moderate to severe disease (adalimumab, etanercept)
• Psoriatic arthritis managed with similar approach to rheumatoid arthritis
  • Additional focus on skin manifestations
  • Topical treatments for mild skin involvement (corticosteroids, vitamin D analogs)
  • Systemic treatments for severe skin and joint disease (methotrexate, biologics)

Systemic Lupus Erythematosus (SLE)

• SLE management tailored to disease severity and organ involvement
  • Antimalarials for mild disease (hydroxychloroquine)
  • Corticosteroids for acute flares (prednisone)
  • Immunosuppressants for organ-threatening disease (mycophenolate, cyclophosphamide)
  • Biologics for refractory cases (belimumab)

Neurological and Gastrointestinal Autoimmune Disorders

• Multiple sclerosis therapy aims to reduce relapses and slow progression
  • Interferons modulate immune response (interferon beta-1a)
  • Glatiramer acetate alters T-cell activation
  • Monoclonal antibodies target specific immune components (natalizumab, ocrelizumab)
• Inflammatory bowel diseases require multi-faceted approach
  • Aminosalicylates for mild to moderate ulcerative colitis (mesalamine)
  • Corticosteroids for acute flares (budesonide)
  • Immunomodulators for maintenance therapy (azathioprine, 6-mercaptopurine)
  • Biologics for moderate to severe disease (infliximab, vedolizumab)

Vasculitis and Other Autoimmune Conditions

• Vasculitis treatment depends on specific type and severity
  • Corticosteroids for initial control (prednisone)
  • Immunosuppressants for maintenance (cyclophosphamide, methotrexate)
  • Targeted biologics for certain types (rituximab for ANCA-associated vasculitis)
• Other autoimmune conditions require tailored approaches
  • Sjögren's syndrome managed with symptomatic treatments and immunomodulators
  • Systemic sclerosis treated with organ-specific therapies and immunosuppressants

Side Effects and Contraindications of Autoimmune Drugs

Common Side Effects of Immunosuppressants

• Corticosteroids cause wide-ranging side effects
  • Osteoporosis due to decreased bone formation
  • Weight gain from increased appetite and fluid retention
  • Diabetes from insulin resistance
  • Increased susceptibility to infections
• Immunosuppressants like methotrexate and azathioprine have serious risks
  • Bone marrow suppression leading to low blood counts
  • Liver toxicity causing elevated liver enzymes
  • Increased risk of opportunistic infections
• Biological response modifiers increase infection and malignancy risks
  • Serious infections including tuberculosis reactivation
  • Increased risk of certain cancers (lymphoma)
  • Injection site reactions (for subcutaneous formulations)

Contraindications and Precautions

• Corticosteroids contraindicated in active infections
  • Use cautiously in patients with diabetes or osteoporosis
• Immunosuppressants contraindicated in pregnancy and severe organ dysfunction
  • Avoid in patients with severe liver or kidney disease
  • Require contraception due to teratogenic effects
• Biological agents contraindicated in active infections and certain cancers
  • Screen for latent tuberculosis before initiation
  • Avoid in patients with recent or current malignancies
• JAK inhibitors have specific contraindications
  • Avoid in severe liver disease
  • Use cautiously in patients with history of blood clots
• Antimalarials require careful use in patients with eye conditions
  • Regular eye exams needed to monitor for retinal toxicity

Monitoring and Counseling for Autoimmune Therapies

Laboratory Monitoring and Clinical Assessments

• Regular blood tests crucial for patients on immunosuppressants and DMARDs
  • Complete blood count to monitor for bone marrow suppression
  • Liver function tests to assess hepatotoxicity
  • Kidney function tests to evaluate renal effects
• Biological response modifiers require ongoing vigilance
  • Tuberculosis screening before initiation (PPD test or interferon-gamma release assay)
  • Periodic monitoring for signs of infection or malignancy
• Cardiovascular risk assessment important for long-term corticosteroid use
  • Regular blood pressure checks
  • Lipid profile monitoring
• Bone health monitoring for patients on chronic corticosteroids
  • Baseline and periodic bone density scans
  • Calcium and vitamin D supplementation as needed

Patient Education and Counseling

• Medication adherence crucial for treatment success
  • Explain importance of taking medications as prescribed
  • Discuss strategies for remembering doses (pill organizers, phone reminders)
• Infection awareness and prevention
  • Teach patients to recognize signs of infection
  • Encourage good hygiene practices
• Regular follow-up appointments essential
  • Stress importance of keeping scheduled visits
  • Explain purpose of frequent monitoring
• Drug interactions education
  • Warn about potential interactions with over-the-counter medications
  • Caution against using herbal supplements without consultation
• Vaccination guidance for immunosuppressed patients
  • Emphasize importance of inactivated vaccines
  • Explain contraindications for live vaccines
• Lifestyle modifications to support treatment
  • Discuss importance of balanced diet and regular exercise
  • Advise on stress management techniques