Adalimumab-Humira uses

 Adalimumab 

(a-da-li-mu-mab) Humira

Classification Therapeutic: antirheumatics Pharmacologic: DMARDs, monoclonal antibodies 

Pregnancy Category B 

Indications

 Moderately to severely active rheumatoid arthritis (may be used alone or with methotrexate or other DMARDs). Psoriatic arthritis (may be used alone or with other DMARDs). Active ankylosing spondylitis. Moderately to severely active Crohn’s disease in patients who have responded inadequately to conventional therapy. Moderately to severely active ulcerative colitis in patients who have responded inadequately to immunosuppressants such as corticosteroids, azathioprine, or 6–mercaptopurine. Moderate to severely active polyarticular juvenile (4yr)idiopathic arthritis (to be used as monotherapy or with methotrexate). Moderate to severe chronic plaque psoriasis in patients who are candidates for systemic therapy or phototherapy and when other systemic therapies are deemed inappropriate. ..

Action

 Neutralizes and prevents the action of tumor necrosis factor (TNF), resulting in anti-inflammatory and antiproliferative activity.

 Therapeutic Effects: 

Decreased pain and swelling with decreased rate of joint destruction in patients with rheumatoid arthritis, psoriatic arthritis, juvenile arthritis, and ankylosing spondylitis. Reduced signs and symptoms and maintenance of clinical remission of Crohn’s disease. Induction and maintenance of clinical remission of ulcerative colitis. Reduced severity of plaques. 

Pharmacokinetics 

Absorption: 64% absorbed after subcut administration. Distribution: Synovial fluid concentrations are 3196%of serum. Metabolism and Excretion: Unknown. Half-life: 14 days (range 10–20 days)..

Contraindications/Precautions

 Contraindicated in: Hypersensitivity; Concurrent use of anakinra or abatacept; Active infection (including localized); 

Lactation: Potential for serious side effects in the infant; discontinue drug or provide formula.

 Use Cautiously in: 

History of chronic or recurrent infection or underlying illness/treatment predisposing to infection; History of exposure to tuberculosis; History of opportunistic infection; Patients residing, or who have resided, where tuberculosis, histoplasmosis, coccidioidomycoses, or blastomycosis is endemic; Pre-existing or recent-onset CNS demyelinating disorders; History of lymphoma; Geri:qrisk of infection/ malignancy; OB: Use only if clearly needed; Pedi: Children 4yr(safety not established);qrisk of lymphoma (including hepatosplenic T-cell lymphoma [HSTCL] in patients with Crohn’s disease or ulcerative colitis), leukemia, and other malignancies.

 Adverse Reactions/Side Effects 

CNS: headache , Guillain-Barre syndrome, multiple sclerosis. 

CV: hypertension. .

EENT: optic neuritis. 

GI: abdominal pain, nausea.

 GU: hematuria. Derm: rash nia. Local: injection site reactions , psoriasis. Hemat: neutropenia, thrombocytope. Metab: hypercholesterolemia, hyperlipidemia. MS: back pain.

 Misc: allergic reactions including ANAPHYLAXIS, ANGIOEDEMA, INFECTIONS (including reactivation tuberculosis and other opportunistic infections due to bacterial, invasive fungal, viral, mycobacterial, and parasitic pathogens), MALIGNANCY (including lymphoma, HSTCL, leukemia, and skin cancer), fever. 

Interactions Drug-Drug:

 Concurrent use with anakinra, abatacept, or other TNF blocking agentsqrisk of serious infections and is contraindicated. 

Concurrent use with azathioprine and/or methotrexate mayqrisk of HSTCL. Live vaccinations should not be given concurrently. ..

Route/Dosage 

RheumatoidArthritis, Ankylosing Spondylitis, and Psoriatic Arthritis Subcut (Adults): 40 mg every other week; patients not receiving concurrent methotrexate may receive additional benefit by increasing dose to 40 mg once weekly. 

Crohn’s Disease or Ulcerative Colitis Subcut (Adults): 160 mg initially on Day 1 (given as four 40-mg injections in one day or as two 40-mg injections given in two consecutive days), followed by 80 mg2wklateronDay15. Twowklater(Day 29), begin maintenance dose of 40 mg every other wk. Aminosalicylates, corticosteroids, and/or immunomodulatory agents (e.g. azathioprine, 6–mercaptopurine, methotrexate) may be continued during therapy.

Juvenile Idiopathic Arthritis Subcut

 (Children 4–17 yr): 15–30kg—30mg every other wk; 30kg—40mgeveryotherwk.

 Plaque Psoriasis Subcut (Adults): 80 mg initially, then in 1 wk, begin regimen of 40 mg every other wk. 

Availability Solution for subcutaneous injection (prefilled syringes): 20 mg/0.4 mL, 40 mg/0.8 mL. Solution for subcutaneous injection (vials): 40 mg/0.8 mL. Prefilled pen: 40 mg/0.8 mL.

 NURSING IMPLICATIONS

 Assessment 

● Assess for signs of infection (fever, dyspnea, flu-like symptoms, frequent or painful urination, redness or swelling at the site of a wound), including tuberculosis and Hepatitis B virus (HBV), prior to and periodically during therapy. Adalimumab is contraindicated in patients with active infection. New infections should be monitored closely; most commonareupper respiratory tract infections, bronchitis, and urinary tract infections. Infections may be fatal, especially in patients taking immunosuppressive therapy.

 ● Monitor for injection site reactions (redness and/or itching, rash, hemorrhage, bruising, pain, or swelling). Rash will usually disappear within a few days. Application of a towel soaked in cold water may relieve pain or swelling. 

● Assess patient for latex allergy. Needle cover of syringe contains latex and should not be handled by persons sensitive to latex. 

● Monitor patient for signs of anaphylaxis (urticaria, dyspnea, facial edema) following injection. Medications (antihistamines, corticosteroids, epinephrine) and equipment should be readily available in the event of a severe reaction. Discontinue adalimumabimmediately if anaphylaxis or other severe allergic reaction occurs. 

● Assess patient for latent tuberculosis with a tuberculin skin test prior to initiation of therapy. Treatment of latent tuberculosis should be started before therapy with adalimumab. 

● Assess for signs and symptoms of systemic fungal infections (fever, malaise, weight loss, sweats, cough, dypsnea, pulmonary infiltrates, serious systemic illness with or without concomitant shock). Ascertain if patient lives in or has traveled to areas of endemic mycoses. Consider empiric antifungal treatment for patients at risk of histoplasmosis and other invasive fungal infections until the pathogens are identified. Consult with an infectious diseases Canadian drug name. specialist. Consider stopping adalimumab until the infection has been diagnosed and adequately treated. ● Arthritis: Assess pain and range of motion before and periodically during therapy.

 ● Crohn’sDiseaseorUlcerative Colitis: Monitor frequency and consistency of bowel movements periodically during therapy.

 ● PlaquePsoriasis: Assess skin lesions periodically during therapy. 

● LabTestConsiderations:. May cause agranulocytosis, granulocytopenia, leukopenia, pancytopenia, and polycythemia.

 ● Monitor CBCwith differential periodically during therapy. May cause leukopenia, neutropenia, thrombocytopenia, and pancytopenia. Discontinue adalimumab if symptoms of blood dyscrasias (persistent fever) occur. 

● Monitor for HBVbloodtests before starting during, and for several months after therapy is completed. Potential Nursing Diagnoses Acute pain (Indications) Risk for infection (Side Effects) Implementation 

● Administer a tuberculin skin test prior to administration of adalimumab. Patients with active latent TB should be treated for TB prior to therapy. 

● Immunizations should be current prior to initiating therapy. Patients on adalimumab may receive concurrent vaccinations, except for live vaccines. 

● Administer initial injection under supervision of a health care professional. 

● Vial is for institutional use only. With training, patient may use pen and pre-filled syringes at home. 

● Donotadminister solutions that are discolored or contain particulate matter. Discard unused solution. 

● OtherDMARDsshouldbecontinued during adalimumabtherapy. 

● Subcut: Administer at a 45angle in upper thighs or abdomen, avoiding the 2 inches around the navel. Put pressure on injection site for 10 sec, do not rub. Rotate injection sites; avoid areas that are tender, bruised, hard, or red. Refrigerate prefilled syringes and pens. Patient/Family Teaching 

● Instruct patient on the correct technique for administering adalimumab. Review Medication Guide, preparation of dose, administration sites and technique, and disposal of equipment into a punctureresistant container.

 ● Advise patient to use calendar stickers provided by manufacturer to assist in remembering when dose.

Evaluation/Desired Outcomes

 ● Decreased pain and swelling with decreased rate of joint destruction in patients with rheumatoid arthritis. 

● Decreased signs and symptoms, slowed progression of joint destruction, and improved physical function in patients with psoriatic arthritis.

 ● Reducedsigns and symptoms of ankylosing spondylitis. .

● Decreased signs and symptoms and maintenance of remission in patients with Crohn’s disease or ulcerative colitis. 

● Reducedpain andswelling in patients moderate to severe polyarticular juvenile idiopathic arthritis (JIA) in children 4 yr of age and older.

 ● Reducedseverity of plaques in patients with severe chronic plaque psoriasis.