Delivering Biological therapies the nurses role'

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Delivering Biological therapies the
nurses role.

• Delivering Biological therapies
• the nurses role.
• 
  Marian OConnor
• IBD Specialist Nurse
• St. Marks Hospital

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Background
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Background

• Nurse led service since 2004 within medical day
  unit
• St. Marks day unit since Aug 2005 managed by
  the IBD Nurses
• Biologicals treatments Infliximab Adalimumab
• Other therapies Methotrexate, Aphaeresis

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What is Anti-TNF) ?

• Tumor Necrosis Factor alpha (TNFa)
• Pro-inflammatory cytokines
• Made by the White blood cells and released in
  inflamed tissue
• Found in high concentrations within the lining of
  inflamed intestine of Crohns

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Anti-TNF monoclonal antibody

• Antibody is a protein which allows the body to
  fight foreign invaders
• Researchers had genetically engineered cells to
  make antibodies to specifically block TNF a
• Infliximab Adalimumab

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Infliximab

• Chimeric monoclonal anti-TNF antibody
• Intravenous administration
• Dose 5mg/kg
• Induction dose wk 0, wk 2 and wk6
• Maintenance infusions every 8 weeks

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Adalimumab

• Recombinant human anti-TNF monoclonal antibody
• Subcutaneous administration
• Pre-filled pen/syringe of 40mg
• Induction regime
• Stat dose of 160mg (wk 0), 80mg (wk 2)
• Stat dose of 80mg (wk 0), 40mg (wk 2)
• Maintenance
• Adalimumab 40mg every other week

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Nurse led biological serviceSt. Marks hospital

• High usage of infliximab
• 112 infusions (2004-2005)
• 250 infusions (2005-2006)
• 269 infusions (2006-2007)
• Approx 420 infusions (2007-2008)
• Induction Maintenance
• Fistulating refractory Crohns disease
• Ulcerative colitis

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Nurse led biological serviceSt. Marks hospital
cont.

• Adalimumab failed/ allergic to INF.
• 12 treated (2006-2007)
• 6 treated (2007-2008)

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Role
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Our Role

• Develop protocols agreed by medical colleagues
• Treatment - Infliximab, Adalimumab
• Infusion reaction protocol
• Assessment guides - proforma
• Manage day unit
• Audit

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Our Role cont.

• Assessment of patient/TB Screening proforma
• Administration of drug adhering to set
  protocols
• Train patients to self administer Adalimumab

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Our Role cont.

• Manage drug reactions
• Liaise with medical team
• Document
• Arrange scheduled treatment

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Delivering Biologicals
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Protocol Infliximab
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Infusion Times Reactions
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Reduced Infusion Time

• 2166 infusions in 234 patients
• Rh arthritis, Psoriatic arthritis, ank
  spondylitis
• First 4 infusions over 2 hrs
• Subsequent infusions over 1 hour
• Mild reaction in 6
• Anaphylactic - type reaction in 6
• Bush et al, 2004

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Infusion reaction protocol
(Cheifetz A et al, 2003)
Mild
Moderate
Severe
Slow infusion 10mls/hr Vital Obs Increase as
tolerated
Stop infusion (20 mins) IV Piriton Restart
20mls/15 mins
Stop infusion Airway/O2 Emergency meds Resus
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• Reduce incidence of Infusion reactions
• Hydrocortisone 200mg pre Infusion
• Consider
• Sporadic previous treatment
• Drug holiday
• Sub therapeutic immunosuppressant

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• Drug free interval of gt16 wks to 2 years risk
• of delayed hypersensitive reactions is unknown
• Sp
  Product leaflet

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Protocol Adalimumab

• Chronic Active Crohns Disease
• Lost response/reaction to Infliximab
• 2 treatment protocols 160mg,80mg,40mg s/c
• 80mg,
  40mg s/c
• Initial treatment 8/52 Hospital
• Maintenance Self inject Humira
  H/Care

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Conclusions

• Biologicals Service
• protocols, funding agreements, infra-structure
• Expeditious ways to deliver drugs
• Safety must be addressed proven protocols

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Background to Anti-TNF therapy