Pharmacology - Nurses Revision

Estrogen Receptor Modulators

Estrogen Receptor Modulators are agents that either stimulate or block specific estrogen receptor sites.

They are used to stimulate specific estrogen receptors to achieve therapeutic effects of increased bone mass without stimulating the endometrium and causing other less desirable effects i.e. these drugs stimulate the estrogen receptors in the body so as to produce estrogen as needed by the body.

Examples of Estrogen Receptor Modulators.

Two available estrogen receptor modulators are raloxifene (Evista) and toremifene (Fareston).

Raloxifene

Dose : 60 mg/day Orally.

Indications : –Used therapeutically to stimulate specific estrogen receptor sites, which results in an increase in bone mineral density without stimulating the endometrium in women; – reduces risk of invasive breast cancer in postmenopausal women with osteoporosis who are at
high risk for invasive breast cancer

Toremifene

Dose : 60 mg/day orally until disease progression occurs.

Indications: Used as an antineoplastic agent because of its effects on estrogen receptor sites for treatment of advanced breast cancer in postmenopausal women with estrogen receptor–positive and estrogen
receptor–unknown tumors

Contraindications of Estrogen Receptor Modulators

Allergy to estrogen receptor modulators.
Contraindicated in pregnancy and lactation because of potential effects on the fetus or neonate.
History of venous thrombosis or smoking. Increased risk of blood clot formation if smoking and estrogen are combined.

Adverse Effects of Estrogen Receptor Modulators

Raloxifene has been associated with GI upset, nausea, and vomiting.
Changes in fluid balance may cause headache, dizziness, visual changes, and mental changes.
Specific estrogen receptor stimulation may cause hot flashes, skin rash, edema, and vaginal bleeding.

Clinically Important Drug–Drug Interactions

Cholestyramine: reduced raloxifene absorption
Highly protein-bound drugs (e.g. diazepam, ibuprofen, indomethacin, naproxen): interference on binding sites
Warfarin: decreased prothrombin time if taken with raloxifene

Nursing Considerations

Assess for the mentioned cautions and contraindications (e.g. drug allergies, cardiovascular diseases, metabolic bone disease, history of thromboembolism, etc.) to prevent any complications.
Perform a thorough physical assessment (e.g. bowel sounds, skin assessment, vital signs, mental status, etc.) to establish baseline data before drug therapy begins, to determine effectiveness of
therapy, and to evaluate for occurrence of any adverse effects associated with drug therapy.
Assist with pelvic and breast examinations. Ensure specimen collection for Pap smear and obtain a history of patient’s menstrual cycle to provide baseline data and to monitor for any adverse
effects that could occur.
Arrange for ophthalmic examination especially for patients who are wearing contact lenses because hormonal changes can alter the fluid in the eye and curvature of the cornea, which can
change the fit of contact lenses and alter visual acuity.
Monitor laboratory test results (e.g. urinalysis, renal and hepatic function tests, etc.) to determine possible need for a reduction in dose and evaluate for toxicity.

Nursing Diagnoses

Ineffective tissue perfusion related to changes in the blood vessels brought about by drug therapy and risk of thromboemboli
Excess fluid volume related to fluid retention
Acute pain related to systemic side effects of gastrointestinal (GI) pain and headache

Implementation with Rationale
These are vital nursing interventions done in patients who are taking female sex hormones and estrogen receptor modulators:

Administer drug with food to prevent GI upset.
Provide analgesic for relief of headache as appropriate.
Provide small, frequent meals to assist with nausea and vomiting.
Monitor for swelling and changes in vision or fit of contact lenses to monitor for fluid retention and fluid changes.
Provide comfort measures to help patient tolerate drug effects.
Provide safety measures (e.g. adequate lighting, raised side rails, etc.) to prevent injuries.
Educate client on drug therapy to promote understanding and compliance.

Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

Monitor patient response to therapy (palliation of signs and symptoms of menopause, prevention of pregnancy, decreased risk factors for coronary artery disease, and palliation of certain cancers).
Monitor for adverse effects (e.g. GI upset, edema, changes in secondary sex characteristics, headaches, thromboembolic episodes, and breakthrough bleeding).
Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
Monitor patient compliance to drug therapy

Fertility Drugs/Gonadotropin Drugs

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Gonadotropin drugs

GONADOTROPINS

Gonadotropins are fertility medications given by injection that contain follicle-stimulating hormone (FSH) alone or combined with luteinizing hormone (LH).

Gonadotropins are hormones that stimulate the gonads, which are the sex organs in the body.

Gonadotropins are produced by the pituitary gland, which is a small gland located at the base of the brain. The release of gonadotropins is regulated by the hypothalamus.

In females, the gonads are the ovaries, and in males, they are the testes.

Gonadotropins are a class of medications used to treat infertility and disorders associated with reproductive functions.

Types of Gonadotropins

There are two main types of gonadotropins:

1. Follicle-stimulating hormone (FSH): This hormone stimulates the growth and development of follicles in the ovaries of females and sperm production in the testes of males.

Females

Males

– Normal Ovarian Function: FSH is useful for the development and maturation of follicles in the ovaries, which contain the eggs. This ensures regular ovulation and fertility.

– Estrogen Production: FSH stimulates the production of estrogen by the growing follicles. Estrogen is for the development of female secondary sexual characteristics, menstrual cycle regulation, and overall reproductive health.

– Improved Egg Quality: FSH contributes to the development of healthy eggs, increasing the chances of successful fertilization and pregnancy.

– Fertility Treatment: FSH is a key component of fertility treatments like in vitro fertilization (IVF) to stimulate multiple egg production.

– Sperm Production: FSH is essential for the production of sperm in the testes. It stimulates the Sertoli cells, which are responsible for nourishing and supporting sperm development.

– Improved Sperm Quality: FSH contributes to the production of healthy, motile sperm, increasing the chances of fertilization.

2. Luteinizing hormone (LH): This hormone triggers ovulation in females and testosterone production in males.

Females

Males

– Ovulation: LH triggers the release of the mature egg from the follicle (ovulation), which is essential for fertilization.

– Corpus Luteum Formation: After ovulation, LH stimulates the formation of the corpus luteum, which produces progesterone. Progesterone is for maintaining the uterine lining for potential pregnancy.

– Hormonal Balance: LH plays a role in regulating the production of estrogen and progesterone, contributing to hormonal balance in the female body.

– Fertility Treatment: LH is used in fertility treatments to trigger ovulation and support the development of the corpus luteum.

– Testosterone Production: LH stimulates the Leydig cells in the testes to produce testosterone. Testosterone is essential for male sexual development, sperm production, and overall health.

– Secondary Sexual Characteristics: LH-driven testosterone production is responsible for the development of male secondary sexual characteristics like facial hair, muscle mass, and deepening of the voice.

– Libido and Sexual Function: Testosterone, produced under the influence of LH, plays a crucial role in libido and sexual function.

GONADOTROPIN DRUGS (Fertility Drugs)

Gonadotropin Drugs/Fertility drugs are agents that stimulate the female reproductive system.

Fertility drugs are medications used to help women who are having trouble getting pregnant. They work by stimulating the ovaries to produce more eggs, increasing the chances of conception.

Indications for Fertility Drugs:

1. Treatment of infertility in women with functioning ovaries whose partners are fertile: This is a broad category encompassing various causes of infertility, including:

Anovulation: When a woman doesn’t ovulate regularly, fertility drugs can stimulate ovulation and increase the chances of pregnancy.
Polycystic Ovarian Syndrome (PCOS): PCOS often causes irregular ovulation. Fertility drugs can help regulate ovulation and improve fertility.
Endometriosis: This condition can affect ovulation and egg quality. Fertility drugs can help stimulate ovulation and improve chances of conception.
Premature Ovarian Failure: In some cases, women experience premature ovarian failure, leading to low egg reserves. Fertility drugs can help stimulate limited egg production.
Unexplained Infertility: When the cause of infertility is unknown, fertility drugs can be used to stimulate ovulation and see if it improves chances of pregnancy.

2. Used to stimulate multiple follicle development for harvesting of ova for in vitro fertilization (IVF): This is a crucial aspect of IVF, where multiple eggs are needed for fertilization and embryo transfer.

3. Menotropins are used to stimulate spermatogenesis in men with low sperm counts and otherwise normally functioning testes: While not directly related to female fertility, this highlights the broader application of fertility drugs in both men and women.

Contraindications for Fertility Drugs:

Allergy to fertility drug: Prevent hypersensitivity reactions.
Primary ovarian failure: These drugs only work to stimulate functioning ovaries.
Ovarian cysts: Can be stimulated by the drugs and can become larger.
Pregnancy: Due to the potential for serious fetal effects.
Idiopathic uterine bleeding: Can represent an underlying problem that could be exacerbated by the stimulatory effects of these drugs.
Lactation: Risk of adverse effects on the baby.
Thromboembolic disease: Increased risk of thrombus formation.
Women with respiratory diseases: Alterations in fluid volume and blood flow can overtax the respiratory system.

Adverse Effects:

Greatly increased risk of multiple births and birth defects.
Ovarian overstimulation: abdominal pain, distention, ascites, pleural effusion.
Others: headache, fluid retention, nausea, bloating, uterine bleeding, ovarian enlargement, gynecomastia, and febrile reactions possibly due to stimulation of progesterone release.

Fluid retention is a common side effect of fertility medications, because;

Hormonal Changes: Fertility drugs increase estrogen levels, which can lead to fluid retention. Estrogen promotes sodium retention in the body, and sodium attracts water, causing fluid buildup.

Increased Blood Flow: Fertility drugs increase blood flow to the ovaries and uterus, which can lead to fluid buildup in the pelvic area.

Drugs used in treatment of infertility

Name

Clinical uses and dosage

Contraindications

Clomifene

Available in tablet form of 50mg
Brand name Clomid

Infertility due to failure to ovulate.

Given 50 mg daily × 5/7

Starting from the 5th day of the cycle ,

Increase to 100mg ×5/7

From day 5-10 if no response.

Pregnancy.

Bromocriptine

Available in tablet form of 2.5mg

Female infertility associated with hyperprolactinemia

Dosage 1.25 – 2.5mg

Bid × 3-7 days with food.

Inhibition of lactation 2.5mg bid with meals × 14 days.

Severe ischemic heart disease

Uncontrolled hypertension

Pregnancy

Breast feeding.

FEMALE REPRODUCTIVE SYSTEM DRUGS

Drugs that affect the female reproductive system typically include hormones and hormonal-like agents.

These drug types include;

Gonadotropin Sites of Action

Female Sex Hormones

The female sex hormones can be used to replace hormones that are missing or to act on the control mechanisms of the endocrine system to decrease the release of endogenous hormones.
Drugs that act like estrogen, particularly at specific estrogen receptors, are also used to stimulate the effects of estrogen in the body with fewer of the adverse effects.

Female sex hormones include;

Estrogens
Progestins

Estrogens.

This hormone is naturally produced by the ovaries, placenta and adrenal glands. It stimulates the development of female sex characteristics, prepares the body for pregnancy, affects the release of FSH and LH, and is responsible for proliferation of the endometrial lining.

Low estrogen in the body is responsible for the signs and symptoms of menopause, in the uterus, vagina, breast and cervix.

Other Functions of estrogen include;

Breast development.
Increase cholesterol in bile, to prevent damaging effects of bile salts.
Increases fat storage, such as in breast tissue.
Maintains bone mineral density.
Maintains muscle strength.
Prevents atherosclerosis, by increasing HDL concentration and lowering LDL.
Estrogen is responsible for maintaining libido, memory, and mental health.
It stimulates ovulation, maintains the uterine walls and is important in vaginal lubrication.

Indications of Estrogen Therapy.

Estrogens are used for hormone replacement therapy (HRT) when ovarian activity is blocked or absent.
Is used to control the signs and symptoms of menopause.
They can also be used in therapy for prostate cancer and inoperable breast cancer, also as palliative care.
Treatment of female hypogonadism(when the body produces little or no hormones).
Treat ovarian failure.
Oral contraceptives (estrogen and progestin)
Morning after pill (emergency pills)
Endometriosis
Dysmenorrhea, used with progestin.

Progestin/Progesterone.

This promotes maintenance of pregnancy and it is called a pregnancy hormone.

Its functions include;

Transforms proliferative endometrium into secretory endometrium.
Prevents follicle maturation, ovulation and uterine contractions.
Used in contraceptives. It inhibits release of GnRH, FSH and LH, hence follicle development and ovulation are prevented.

Indications of Progestin.

Used as a contraceptive.
Maintains pregnancy and development of secondary sex characteristics.
Use to treat primary and secondary amenorrhea, and functional uterine bleeding.
Treatment of acne and premenstrual dysphoric disorder (PMDD).
For the relief of signs and symptoms of menopause .

Contraindications of Female Sex hormones.

Estrogen

Known allergies
Idiopathic vaginal bleeding.
Breast Cancer(Estrogen dependant cancer)
CVA since it increases clotting factor prodn.
Hepatic dysfunction.
Pregnancy.
Lactation.

Progestin/Progesterone

PID
STD
Endometriosis
Renal and hepatic disorders.
Epilepsy.
Asthma.
Migraine headaches
Cardiac Dysfunction —potential excerbation.

Adverse Effects.

Corneal Changes.
Photosensitivity.
Peripheral edema.
Chloasma ( patches on the face)
Hepatic adenoma.
Nausea
Vomiting.
Abdominal cramps.
Bloating.
Withdraw bleeding.
Changes in menstrual flow.

Important aspects/issues to remember.

Women receiving any of these drugs should receive an annual medical examination, including
breast examination and Pap smear, to monitor for adverse effects and underlying medical
conditions.
Women taking estrogen should be advised not to smoke because of the increased risk of
thrombotic events.
Women who are receiving these drugs for fertility programs should receive a great deal of psychological support and comfort measures to cope with the many adverse effects associated
with these drugs. The risk of multiple births should be explained.
Drugs are used in treatment of specific cancers in males and they should be advised about the
possibility of estrogenic effects.
Not indicated during pregnancy or lactation because of potential for adverse effects on the fetus
or neonate.

Examples of female sex hormones and dosages.

Estrogen

Estradiol, 1–2 mg/day orally or 1–5 mg IM every 3–4 weeks or 2–4 g intravaginal cream daily.
Estrogens, conjugated (C.E.S., Premarin), 0.3–1.25 mg/day orally.
Estropipate (Ortho-Est, Ogen), 0.625–5 mg/day orally.

Progestin/Progesterone.

Etonogestrel (Implanon) 68 mg implanted sub dermally for up to 3 yr, replaced or changed when needed.
Medroxyprogesterone (Provera) 5–10 mg/day PO for 5–10 days for amenorrhea or 400–1000 mg/week IM for cancer therapy or 150 mg of deep IM every 3 months (13 weeks) for contraception.

Clinically important Drug Interactions

Estrogen

Barbiturates, rifampin, tetracyclines, phenytoin: decreased serum estrogen levels
Corticosteroids: increased therapeutic and toxic effects of corticosteroids.
Nicotine: Increased risk of thrombi and emboli
Grapefruit juice: inhibition of metabolism of estradiols
St. John’s wort: can affect metabolism of estrogens and can make estrogen-containing
contraceptives less effective.

Progestins

Barbiturates, carbamazepine, phenytoin, griseofulvin, penicillin, tetracyclines, rifampin: reduced
effectiveness of progestins
St. John’s wort: can affect the metabolism of progestins and can make progestin-containing
contraceptives less effective..

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Immunization

Immunization is a process of deliberate inoculation of live attenuated or dead vaccines and toxoids to induce immunity against a specific disease.

Immunization against a specific disease provides artificially acquired active immunity.
Artificially acquired immunity against some diseases may require periodic booster injections to keep an adequate antibody level (or antibody titer) circulating in the blood.

A booster injection is the administration of an additional dose of the vaccine to boost the production of antibodies to a level that will maintain the desired immunity. The booster is given months or years after the initial vaccine and may be needed because the life of some antibodies is short.

Types of immunization agents

Toxoids: is a toxin that is attenuated (or weakened) but still capable of stimulating the formation of antitoxins.
Vaccines
Immune globulins.

Vaccines

Vaccine: Vaccines are special preparations of antigenic materials that can be used to stimulate the development of antibodies and thus confer active immunity against a specific disease or a number of diseases capable of causing fatal consequences.

Types of vaccines

Live attenuated vaccines: These vaccines contain live microbes that have been weakened (attenuated). Live attenuated vaccines usually confer immunity with a single dose which is of long duration. They may be dangerous in recipients who are immune-compromised because these patients are unable to mount an effective immune response.
Examples;
> Mumps vaccines
> Measles vaccines
> BCG vaccines
Killed or inactivated vaccines: This type of vaccines contains whole inactivated microbes. e.g. polio vaccines. Inactivated vaccines may require a series of injections in order to produce an adequate body response and in most cases booster doses are required.
Examples
> DPT (diphtheria, pertussis, tetanus) Vaccine.
> PCV(Pneumococcal Conjugate Vaccine)

Indications of vaccines and toxoids:

Routine immunization of infants and children
Immunization of adults against tetanus
Immunization of adults at high risk for certain diseases (e.g., pneumococcal and influenza vaccines)
Immunization of children or adults at risk for exposure to a particular disease (e.g., hepatitis A for those going to endemic areas)
Immunization of pre-pubertal girls or non-pregnant women of childbearing age against rubella and cervical cancer.

Adverse reactions of Vaccines and Toxoids

Adverse reactions from the administration of vaccines or toxoids are usually mild.

Chills, Fever, muscular aches and pains, rash, and lethargy may be present.
Pain and tenderness at the injection site may also occur.
Although rare, a hypersensitivity reaction may occur.

Contraindications and Precautions of Vaccines and Toxoids

Hypersensitivity
Vaccines and toxoids are contraindicated during acute febrile illnesses, leukemia, lymphoma, immunosuppressive illness or drug therapy, and non-localized cancer.
The measles, mumps, rubella, and varicella vaccines are contraindicated in patients who have had an allergic reaction to gelatin, neomycin, or a previous dose of one of the vaccines.
The measles, mumps, rubella, and varicella vaccines are contraindicated during pregnancy, especially during the first trimester, because of the danger of birth defects. Women are instructed to avoid becoming pregnant at least 3 months after receiving these vaccines

POLIO VACCINE

This is a live attenuated vaccine that gives protection against the three types of poliomyelitis that is: type 1, 2 and 3. It is a liquid that comes in two types of vials which have their fixed droppers.

STORAGE

It is stored at the temperature of +2 to +8 degrees centigrade.

INDICATION

Active immunization against poliomyelitis.

DOSE

It is given two drops orally.
If the child has diarrhea, give as usual but administer an extra dose, when administering polio vaccines the dropper should not touch the child’s lips.

KEY ISSUES:

Live polio vaccines loses potency opened, therefore any used preparation should be discarded after use.
Breast feeding dose not interfere with immunization even though polio vaccine may excreted in the breast milk
If vaccines are vomited repeat the dose immediately

INACTIVATED POLIO VACCINES (IPV)

This was introduce by World Health Organization (WHO) to supplement the Oral Polio Vaccine (OPV) due to resistance of poliomyelitis virus of type 2.

STORAGE

IPV is sensitive to heat and freezing, it should be stored at +2 to +8 degrees centigrade at all levels of cold chain.
Note: freezing and heating of IPV vaccine will lead to the loose of its potency.

DOSAGE

It’s given once at the fourteenth week (14 weeks). It is given together with OPV 3, PCV 3, DPT Hep Hib 3.
5mls is administered intramuscularly in the outer aspect of right thigh 2.5cm away from PCV site.
IPV is first administered before PCV – because PCV is more painful than IPV.

CONTRAINDICATION

Should not be given to children who had previous reaction to streptomycin, poliomixin B, which are components of polio vaccines

ADVERSE EFFECTS of IPV

Redness at the injection site
Swelling
Fever
Pain / irritability

BACILLUS CALMATTE GUARIN (BCG) VACCINE

BCG vaccine is a vaccine primarily used against tuberculosis. Or it’s used to prevent and protect against tuberculosis. It comes in powder form and it is reconstituted with its diluents of the same company or manufacturer before used
It should be given soon after birth or during the first contact.

INDICATION

Active immunization against Tuberculosis

CONTRAINDICATION

Immune suppressed patients
Previous TB infection
Generalized edema
Generalized skin diseases

STORAGE

It should be stored under a temperature of +2 to +8 degrees centigrade.
The reconstituted BCG vaccine should be discarded after 6 hours or at the end of the immunization/ session

DOSAGE

05ml are given to infant under 12 month or at births
1ml to children above 12 month.

ROUTE

It is given intradermal of the right upper Arm

SIDE EFFECTS

Pain at the injection site
Keloid formation
Localized necrotic ulceration
Lymphadenitis

DRUG INTERACTION

Concomitant administration with immune suppressant drugs

PNEUMOCOCAL CONJUGATE VACCINE (PCV)

It is a vaccine which protects children against (pneumonia) pneumococcal infections bacteremia and meningitis.

STORAGE

It is stored at the temperature of +2 to +8 degrees centigrade

INDICATION

Sickle cell disease in children above 2 years
Immune compromised patients above 5 years

CONTRAINDICATIONS

It should not be given to infants who had severe allergic reactions previous to the vaccine

DOSE

The first dose at 6 weeks.
Its given 0.5ml deep subcutaneous in the upper outer aspect of the thigh
The Second dose at 10 weeks
The third dose at 14 weeks

ADVERSE EFFECTS

Pain
Redness and swelling
Fever (38 degrees centigrade)
Drowsiness
Irritability and crying
Loss of appetite
Hardness at the site of injection

DPT-HEPB-HIB VACCINE

This vaccine protects the children against the five diseases, that’s why it’s called a prevalent vaccine. And the five diseases include

Diphtheria
Pertussis (whooping cough)
Tetanus
Hepatitis B
Hemophilus influenza of type B infection

SIDE EFFECTS

Fever
Head ach
Irritability
Swelling of the limb
Loss of appetite

STORAGE

It should be store at the temperature of +2 to +8 degrees centigrade. The vaccine should not be freezed because it can be damaged by freezing and it separated away from the freezing compartment
Mark the date of opening and should not exceed 4 weeks from the date of opening to avoid contamination

DOSE

5ml intramuscularly on the mid upper aspect of the left thigh.
It’s given in the first contact at 6 weeks
Second dose at 10^th week
Third dose at 14^th week
Note NEVER give DPT-HEPB-HIB vaccine to the buttocks because it can damage the nerves in the injection site

CONTRAINDICATIONS

Every sick children who are admission should receive their vaccination at the time of discharge
Children with the history of convulsions within 2 day or 48hourse fallowing the vaccination of previous same vaccine
Children one year of age

ADVERSE EFFECTS

Fever
Sore at the site of injection
Abscess may be formed a week or more after vaccination because of abnormal reaction which is takes place due to
The use of un sterile needles
The may not have been injected to the muscle
Improper insertion of the needle during the vaccine administration
Failure to hold the baby well
None cleaning and wiping of the site well

The side effects are managed like;

Fever by tepid sponging the child and giving Paracetamol
Abscess by giving antibiotics

Mother or the care taker is also health educated on how to be responsible following the health talk before discharge

TETANUS TOXOID VACCINE

The vaccine is an inactivated tetanus toxoid toxin that protects against Tetanus. It is an injection which comes in a vial containing 10 or 20 doses

STORAGE

It should be stored at the temperature of +2 to +8 degrees centigrade
It not be frozen and it should be kept away from the freezing chamber (fridge)
If it freezes shake test is performed

INDICATION

Active immunization against tetanus and Neonatal tetanus

DOSE

It is given to all women of child bearing age between 15 to 45 years
First dose;
It is given 0.5mls deep subcutaneous or intramuscular injection on the upper arm at the first contact or as early as possible during pregnancy (TT 1).
Second dose
5mls at least 4 weeks after (TT 1) or during subsequent pregnancy
Third dose
5mls at least 6 month after (TT 2) or during subsequent pregnancy
Fourth dose
5mls at least 1 year after TT 3
Fifth dose
5mls at least 1 year after TT 4

ADVERSE EFFECTS

Mild pain
Redness
Warmth or swelling for 1 to 3 days

All children should be immunized against because the antibodies transferred from the mother before birth lasts for a short time about 6 weeks
To have a long life protection against tetanus is to make you complete the five doses of tetanus toxoid vaccines required and ensure safe delivery practice

MEASLES VACCINES

It is a live attenuated vaccine that protects children against measles.
It must be reconstituted with its diluent from the same manufacturer

INDICATION

Active immunization against measles

STORAGE

It should be stored between the temperatures of +2 to +8 degrees centigrade
It can be stored at freezing temperature and it diluent kept at room temperature

CONTRAINDICATION

Hypersensitivity to any antibiotic present in the vaccine like neomycin and kanamycin.
Hypersensitivity to ages
Pregnant mothers
Immune suppressed patients

SIDE EFFECTS

Fever
Restlessness

ADVERSE EFFECTS

Pain within the 24 hours of immunization.
Tenderness at the injection site within the 24 hours of immunization which will resolve after 2-3 days without any medication or treatment.
Fever which may occur after 1-3 days of immunization
All children in the age between 6-9 month are admitted to the hospital should be given the dose of measles vaccine during the outbreak of measles

Cold Chain

Cold chain a system that ensures safe storage and maintenance of vaccines from the manufacturer to the consumer.

Vaccines are different from medical supplies because they are easily damaged by heat or sunlight therefore they need special care to keep them safe until they are used.
What does a cold chain consist of? It consists of the following;
– People
– Equipment/tools
– Procedure
The people
These organize and manage vaccines, they transport vaccines from;
– The manufacturer to Entebbe airport
– To National Medical Stores
– To the Hospitals, Health Centre, Dispensaries, sub-dispensaries and
maternity units
– Mobile clinics and outreach sessions.
Equipment
– Needed to store and transport vaccines.
– It keeps the vaccines properly cold at every place it is stored.
The procedures
– These set rules for the people and equipment on how to take care of
vaccines.
– Part of the procedures are records of how much vaccines have been
received and used.
– These records help people who supply in monitoring these vaccines.
– It also helps them find out problems in handling and wastage of vaccine.

Care of vaccines

a) When being delivered in Respective Places

– Vaccines are carried in Refrigerators from the manufacturer to Entebbe.
– From there vaccines are passed down through cold chain by vehicles to
District Medical Stores for supply to the Hospitals, Health Centres and
other lower units.
Note
– Make sure that the proper vaccines in the proper quantities are in place
where they are needed at the right time.
– Keep vaccines out of sunlight and heat.
– Keep vaccines at a temperature + 2 – + 8 o c
– Care properly for equipment by keeping it clean and in good working
order.

b) At Health Facility
– Vaccines are kept in a refrigerator and temperature monitored morning to evening and charted.
– Vaccines should be arranged in proper order in the fridge i.e.
> First in first out
> Polio, BCG, Measles should be near the deep freezer.
> DPT, Hep B, Hib, PCV, Tetanus toxoid should be a distance away
from the deep freezer.

– Vaccines that are to be used that day should be removed at once to
avoid over opening of the fridge.
– A vaccine control book should be used to register vaccines in and out of
the Refrigerator.

c) At the Immunization site
– Vaccine carriers are used to store vaccines for use at the site or outreach.
– Frozen ice packs are put in vaccine carriers to keep the vaccines at the
right temperature.
– A sponge is put on top of the vaccine carrier to prevent the ice packs
from getting hot and keep the right temperature.
– During the immunization session, the vaccine vial monitor should be
looked at/monitored to assess whether vaccines are still potent.

– After the immunization session DPT and polio vaccine if the Vaccine vial monitor (VVM) is still
white, they are put back in the fridge BUT they should be used first on the
net session.
– Measles, BCG and PVC should not be put back in the fridge for the next
use/session.
NB. While withdrawing the vaccine from the vial, we should ensure that the
vial is handled with care to prevent wastage of vaccine.

Defrosting the fridge/cleaning
– The fridge is supposed to be cleaned and more so if it is frozen.
– Remove all the vaccines and pack them in polythene bags with ice packs.
– Switch off the fridge and let the ice get defrosted then clean the fridge.
– Switch it on and place the thermometer in the fridge, so that the right
temperature is reached.
– When the right temperature is reached ( + 2 – + 8 o c) the vaccines are put back
and in proper order and according to expiry date (first in first out).

IMMUNOGLOBULINS

Immunoglobulins are proteins produced by the plasma cells and lymphocytes and have characteristic of these types of cells OR

Immunoglobulins are solutions obtained from human or animal blood containing antibodies that have been formed by the body to specific antigens

The five substances of antibodies are;

(1) Immunoglobulin A (IgA) which is found in high concentration in the mucus membrane particularly those lining the respiratory passages and gastrointestinal tract as well as saliva and tears

(2) Immunoglobulin G (IgG) is the most abundant type antibody found in all body fluids and protects against bacterial and viral infections.

(3) Immunoglobulin M (IgM) it’s found mainly in blood and in the lymph fluids is the first antibody to be made by the body to fight against new infections

(4) Immunoglobulin E (IgE) it’s mainly associated with allergic reaction (when the immune system overreact to environmental antigens such as pollen or pet dander) it is found in the lungs skin and mucous membranes.

(5) Immunoglobulin D (IgD) it exists in small amount in the blood, it is the least understood antibody.

Note IgA, IgG and IgM are often measured together that way they can give the doctor important information about the immune system functioning especially relating with infection or auto immune diseases.

Adverse effects

Fainting or feeling light head ach
Pain at the site of injection

Immunization Read More »

Immunity

Immunity refers to the body’s ability to prevent the invasion of pathogens

Pathogens are foreign disease-causing substances, such as bacteria and viruses, and people are exposed to them every day.

Antigens are attached to the surface of pathogens and stimulate an immune response in the body.

An immune response is the body’s defense system to fight against antigens and protect the body.

Types of immunity

Innate immunity
Acquired (adaptive) immunity
Passive immunity

1. Innate immunity

It is the general protection that a person is born with.

Including physical barriers (skin, body hair), defense mechanisms (saliva, gastric acid), and general immune responses (inflammation). This type of immunity is considered non-specific defense mechanisms.
Although the immune system does not know exactly what kind of antigen is invading the body, it can respond quickly to defend against any pathogen.

Types of innate immunity

First line of defenses
Second line of defenses

First line of defenses/external/physical/ barrier defenses

The stratum corneum of the epidermis of the skin is non-living, and when unbroken is an excellent barrier to pathogens of all kinds.
The fatty acids in sebum help limit the growth of bacteria on the skin. The living cells of the epidermis produce defensins, which are antimicrobial chemicals.
The mucous membranes of the respiratory, digestive, urinary, and reproductive tracts are living tissue, yet still a good barrier.
The ciliated epithelium of the upper respiratory tract is an especially effective barrier. Dust and pathogens are trapped on the mucus, the cilia sweep the mucus to the pharynx, and it is swallowed.
The hydrochloric acid of the gastric juice destroys most pathogens that enter the stomach, either in mucus or with food and drink.
Lysozyme, an enzyme found in present in saliva, perspiration, nasal secretions, and tissue fluids inhibit the growth of bacteria in the oral cavity and on the warm, wet surface of the eye.
One way flow of urine through the urethra to the exterior prevents the ascending microorganisms.
The lacrimal apparatus of the eyes manufactures and drains away tears in response to irritants.
Blinking spreads tears over the surface of the eyeball, and the continual washing action of tears helps to dilute microbes and keep them from settling on the surface of the eye. Tears also contain
lysozyme, an enzyme capable of breaking down the cell walls of certain bacteria.
Saliva, produced by the salivary glands, washes microbes from the surfaces of the teeth and from the mucous membrane of the mouth, much as tears wash the eyes. The flow of saliva reduces
colonization of the mouth by microbes.
Defecation and vomiting also expel microbes. For example, in response to some microbial toxins, the smooth muscle of the lower gastrointestinal tract contracts vigorously; the resulting diarrhea rapidly expels many of the microbes.
The acidity of the skin (pH 3–5) is caused in part by the secretion of fatty acids and lactic acid.
Perspiration helps flush microbes from the surface of the skin.
Gastric juice, produced by the glands of the stomach, is a mixture of hydrochloric acid, enzymes, and mucus. The strong acidity of gastric juice (pH 1.2–3.0) destroys many bacteria and most bacterial toxins.
Vaginal secretions also are slightly acidic, which discourages bacterial growth and Vaginal secretions likewise move microbes out of the body in females.

Second line of defense’s (internal defenses)

When pathogens penetrate the physical and chemical barriers of the skin and mucous membranes, they encounter a second line of defense which include the following:
1. Internal/Natural anti-microbial substances;

Interferons: (alpha-, beta-, and gamma-interferons) are proteins produced by cells infected with viruses and by T cells to prevent virus reproduction.
Complement: is a group of more than 20 plasma proteins that circulate in the blood until activated, it is involved in the lysis of cellular antigens and the labeling of non-cellular antigens and stimulate the release of histamine.
Iron-binding proteins: inhibit the growth of certain bacteria by reducing the amount of available iron. Examples include transferrin (found in blood and tissue fluids), lactoferrin (found in milk, saliva, and mucus), ferretin (found in the liver, spleen, and red bone marrow), and hemoglobin (found in red blood cells).
Antimicrobial proteins (AMPs): are short peptides that have a broad spectrum of antimicrobial activity. Examples of AMPs are dermicidin (produced by sweat glands), defensins and cathelicidins (produced by neutrophils, macrophages, and epithelia), and thrombocidin
(produced by platelets).

2. Defensive cells:

Phagocytes e.g. Macrophages (fixed and wandering), dendritic cells e.g. Langerhans cells: they carry out phagocytosis, Neutrophils ( When
the body is injured or invaded by a pathogen, neutrophils are rapidly produced and move to the site of the insult to attack the foreign substance. Because neutrophils are able to engulf and digest foreign material, they are called phagocytes.)
Eosinophils: Eosinophils are circulating myelocytic leukocytes whose exact
function is not understood. They are often found at the site of allergic reactions and may be responsible for removing the proteins and active components of the immune reaction from the site of an allergic response.
Basophils: Basophils are myelocytic leukocytes that are not capable of phagocytosis. They contain chemical substances or mediators that are important for initiating and maintaining an immune or inflammatory response. These substances include histamine, heparin, and other chemicals used in the inflammatory response.
Mast cells: These are basophils that are fixed and do not circulate. . They are found in the respiratory and GI tracts and in the skin. They release many of the chemical mediators of the inflammatory and immune responses when they are stimulated by local irritation

3. Inflammation;

This is the physiological response to tissue damage and is accompanied by a characteristic series of local changes.
Its purpose is protective: to isolate, inactivate and remove both the causative agent and damaged tissue, so that healing can take place.
The cardinal signs of inflammation are

Redness: Redness is as a result of increased blood flow.
Following injury, both the arterioles supplying the damaged area and the local capillaries dilate, increasing blood flow to the site. This is caused mainly by the local release of a number of chemical mediators from damaged cells, i.e. Histamines, Kinins, Prostaglandins, e.t.c.
Heat: It occurs as a result of an endogenous pyrogen (interleukin 1) which is released from macrophages and granulocytes in response to microbial toxins or immune complexes. Interleukin 1 is a chemical
mediator that resets the temperature thermostat in the hypothalamus at a higher level, causing pyrexia and other symptoms that may also accompany systemic inflammation, e.g. fatigue and loss of appetite.
The increased temperature of inflamed tissues has the twin benefits of inhibiting the growth and division of microbes, whilst promoting the activity of phagocytes.
Swelling: It is as a result of fluid leaving local blood vessels and entering the interstitial spaces i.e. Plasma proteins, normally retained within the bloodstream, also escape into the tissues through the leaky capillary walls; this increases the osmotic pressure of the tissue fluid and draws more fluid out of the blood.
Pain: This occurs when local swelling compresses sensory nerve endings. It is exacerbated by chemical mediators of the inflammatory process, e.g. bradykinin and prostaglandins which potentiate the
sensitivity of the sensory nerve endings to painful stimuli. Although pain is an unpleasant experience, it may indirectly promote healing, because it encourages protection of the damaged site.

4. Immunological surveillance; see IMMUNOLOGY for details.

2. Acquired (adaptive) immunity

It is a type of immunity that develops from immunological memory.

The body is exposed to a specific antigen (which is attached to a pathogen) and develops antibodies to that specific antigen.
It is referred to specific defense mechanisms or active immunity.
The next time said antigen invades; the body has a memory of the specific antigen and already has antibodies to fight it off.
Acquired immunity can occur from exposure to an infection, wherein a person gets a disease and develops immunity as a result.
Acquired immunity also occurs from vaccination wherein the vaccine mimics a particular disease, causing an immune response in the vaccinated individual without getting them ill.

Types of adaptive (active) immunity

There are two types of adaptive (active) immunity:

Naturally acquired (active) immunity
Artificially acquired (active) immunity.

Naturally Acquired (active) Immunity.

The body manufactures antibodies after the exposure to an infection or sub infection naturally and is exemplified by an individual who is exposed to chickenpox for the first time and who has no immunity to the disease. The body immediately begins to manufacture antibodies against the chickenpox virus.
However, the production of a sufficient quantity of antibodies takes time, and the individual gets the disease. At the time of exposure and while the individual still has chickenpox, the body continues to manufacture antibodies. These antibodies circulate in the individual’s blood stream for life. In the future, any exposure to the chickenpox virus results in the antibodies mobilizing to destroy the invading antigen.

Artificially Acquired Active Immunity

Artificially acquired active immunity occurs when an individual is given a killed or weakened antigen, which stimulates the formation of antibodies against the antigen. The antigen does not cause the disease, but the individual still manufactures specific antibodies against the disease. When a vaccine containing a live attenuated (weakened) antigen is given, the individual may experience a few minor symptoms of the disease or even a mild form of the disease, but the symptoms are almost always milder than the disease itself and usually last for a short time.

3. Passive immunity

It is the body’s capacity to resist pathogens by “borrowing” antibodies.

For example, antibodies can be transferred to a baby from a mother’s breast milk, or through blood products containing antibodies such as immunoglobulin that can be transfused from one person to another.

The most common form of passive immunity is that which an infant receives from its mother. Antibodies are transported across the placenta during the last one to two months of pregnancy. As a result, a full-term infant will have the same antibodies as its mother. These antibodies will protect the infant from certain diseases for up to a year, and act to defend against specific antigens. Although beneficial, passive immunity is temporary until the antibodies are gone (wane), since the body has not produced the antibodies.

Types of passive immunity

Passive naturally acquired immunity: This type of immunity is acquired before birth by the passage of maternal antibodies across the placenta to the fetus, and to the baby in breast milk. The variety of different antibodies provided depends on the mother’s active immunity. The baby’s lymphocytes are not stimulated and this form of immunity is short lived.
Passive artificially acquired immunity: In this type, ready-made antibodies, in human or animal serum, are injected into the recipient. The source of the antibodies may be an individual who has recovered from the infection, or animals, commonly horses, that have been artificially actively immunized. Specific immunoglobulins (antiserum)
may be administered prophylactically to prevent the development of disease in people who have been exposed to the infection, e.g. rabies, or therapeutically after the disease has developed.

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Immunological Agents

Immunological agents are a broad class of drugs that modify the immune system’s activity, either by enhancing or suppressing its function.

They are like tools that help your immune system work better or differently. For example, vaccines help your body fight off specific diseases(enhancing) or autoimmune drugs treat autoimmune diseases, where the immune system attacks the body’s own tissues (suppressing).

Types of Immunological Agents:

Immunostimulants: These are drugs that boost the immune system’s function, often used when the immune system is weakened or underperforming.
Immunosuppressants: These drugs reduce or suppress the immune system’s activity, essential in preventing transplant rejection and treating autoimmune diseases.

Examples include;

IMMUNE STIMULANTS
Interferons
interferon alfa-2b
interferon alfacon-1
interferon alfa-n3
interferon beta-1a
interferon beta-1b
interferon gamma-1b
peginterferon alfa-2a
peginterferon alfa-2b
Interleukins
aldesleukin
oprelvekin

IMMUNE SUPPRESSANTS
T- and B-Cell Suppressors
abatacept
alefacept
azathioprine
Interleukin-Receptor Antagonist
anakinra
Monoclonal Antibodies
adalimumab
alemtuzumab
basiliximab
bevacizumab
certolizumab

Immunostimulants

1. Interferons

Interferons are proteins produced naturally by cells in response to viral infections and other stimuli. They work by interfering with virus replication within host cells, activating immune cells like natural killer cells and macrophages, and increasing the antigen presentation to lymphocytes.

Drug	Indications	Therapeutic Action	Adverse Effects
Interferon alfa-2b	Chronic hepatitis C, Kaposi’s sarcoma, malignant melanoma	Inhibits viral replication, enhances immune response, and increases macrophage activity	Flu-like symptoms, myelosuppression, depression, suicidal ideation
Interferon alfacon-1	Hepatitis C	Inhibits viral replication and boosts immune system	Headache, dizziness, bone marrow suppression, photosensitivity
Interferon alfa-n3	Genital warts, basal cell carcinoma	Inhibits viral replication and tumor growth	Fatigue, anorexia, nausea, vomiting
Interferon beta-1a	Multiple sclerosis	Reduces the frequency of clinical exacerbations and slows the progression of disability in multiple sclerosis	Injection site reactions, flu-like symptoms, liver dysfunction
Interferon beta-1b	Multiple sclerosis	Similar to Interferon beta-1a; modulates the immune system to reduce inflammation	Fatigue, depression, flu-like symptoms, liver impairment
Interferon gamma-1b	Chronic granulomatous disease, severe osteopetrosis	Enhances the respiratory burst of macrophages, stimulating greater antimicrobial activity	Fever, rash, diarrhea, myalgia
Peginterferon alfa-2a	Chronic hepatitis C and B	Increases immune response against hepatitis viruses	Neutropenia, thrombocytopenia, liver enzyme abnormalities, flu-like symptoms
Peginterferon alfa-2b	Chronic hepatitis C	Longer-lasting effects due to its pegylated form, allowing less frequent dosing	Similar to Peginterferon alfa-2a, including hematologic toxicity and depression

Therapeutic Action:

Interferons prevent viral particles from replicating inside host cells.
They stimulate cells to produce antiviral proteins and enhance the cytotoxicity of T-cells and natural killer cells.
They inhibit tumor growth by enhancing the host’s immune response.

Pharmacokinetics:

Interferons are well absorbed via subcutaneous or intramuscular injection, reaching peak plasma levels within 3-8 hours.
They are metabolized in the liver and kidneys and excreted primarily through the kidneys.

Contraindications:

Allergies to interferons or their components.
Pregnancy and lactation (due to teratogenic effects).
Cardiac diseases, particularly arrhythmias and hypertension.
Myelosuppression.

2. Interleukins

Interleukins are cytokines that play an essential role in the immune response by promoting the proliferation of lymphocytes and other immune cells.

Cytokines: The general term for any small protein that helps cells communicate with each other.

Imagine your immune system as a big army. Interleukins are like the signals that tell different parts of the army what to do.

Activate immune cells: Tell certain cells to start fighting off invaders.
Control inflammation: Help regulate how much inflammation happens in response to an infection or injury.
Promote cell growth: Help immune cells multiply and become stronger.

Drug	Indications	Therapeutic Action	Adverse Effects
Aldesleukin	Metastatic renal cell carcinoma, metastatic melanoma	Stimulates the proliferation of T-cells and natural killer cells, enhances the immune response against cancer	Capillary leak syndrome, hypotension, anemia
Oprelvekin	Prevention of severe thrombocytopenia in chemotherapy	Increases platelet production by stimulating megakaryocyte production	Fluid retention, edema, dyspnea, arrhythmias

Therapeutic Action:

Interleukins boost immune cell activity, enhancing the body’s ability to fight tumors and increase platelet production.

Pharmacokinetics:

Interleukins are absorbed via subcutaneous injection, with peak levels occurring within hours.
They are metabolized in the kidneys and excreted in urine.

Contraindications:

Allergies to interleukins or E. coli-produced products.
Pregnancy and lactation due to potential teratogenic effects.
Patients with renal, liver, or cardiovascular impairments.

Immunosuppressants

Immunosuppressants are used primarily to prevent transplant rejection and treat autoimmune diseases by inhibiting the immune system.

These are like the “peacekeepers” of the immune system. They dampen down the immune response, preventing it from overreacting.

Used to treat autoimmune diseases where the immune system attacks the body’s own tissues. Cyclosporine is the most commonly used immunosuppressant.

1. T- and B-Cell Suppressors

T- and B-cell suppressors inhibit the activity of these lymphocytes, reducing the immune system’s ability to mount an attack against transplanted organs or self-tissues in autoimmune diseases.

Drug	Indications	Therapeutic Action	Adverse Effects
Abatacept	Rheumatoid arthritis, juvenile idiopathic arthritis	Inhibits T-cell activation by binding to CD80 and CD86 on antigen-presenting cells	Headache, infections, hypertension, nausea
Alefacept	Plaque psoriasis	Inhibits T-cell activation and reduces T-cell numbers	Lymphopenia, hepatotoxicity, infections
Azathioprine	Prevention of kidney transplant rejection, rheumatoid arthritis	Inhibits purine synthesis, reducing T and B-cell proliferation	Bone marrow suppression, hepatotoxicity, nausea

Therapeutic Action:

These drugs inhibit the proliferation and activity of T-cells and B-cells, essential for preventing transplant rejection and treating autoimmune conditions.

Pharmacokinetics:

T- and B-cell suppressors are generally well absorbed when administered orally or intravenously.
They are metabolized in the liver and excreted primarily via the kidneys.

Contraindications:

Allergies to the drugs or their components.
Pregnancy and lactation (due to potential teratogenic effects).
Renal or hepatic impairment.
Active infections or known neoplasms.

2. Interleukin-Receptor Antagonist

This class of drugs blocks interleukin activity, which is critical in the inflammatory and immune response.

Drug	Indications	Therapeutic Action	Adverse Effects
Anakinra	Rheumatoid arthritis	Blocks the interleukin-1 receptor, reducing inflammation and halting joint damage	Headache, sinusitis, nausea, infections, injection-site reactions

Therapeutic Action:

Interleukin-receptor antagonists prevent the binding of interleukins to their receptors, reducing inflammation and tissue damage.

Pharmacokinetics:

Anakinra is administered subcutaneously and reaches peak plasma levels within hours.
It is metabolized by the liver and excreted primarily in urine.

Contraindications:

Allergies to E. coli–produced products or anakinra itself.
Pregnancy and lactation due to the potential transfer of the drug to the fetus or infant.
Renal impairment, immunosuppression, or active infections.

3. Monoclonal Antibodies

Monoclonal antibodies are laboratory-produced molecules that can mimic the immune system’s ability to fight off harmful pathogens such as viruses.

These are like highly specific “guided missiles” of the immune system.

They’re designed to target and attack specific cells or molecules. They can be used to treat cancer, autoimmune diseases, and even infections. Think of them as a sniper team that only targets the enemy, leaving the rest of the army alone.

Drug	Indications	Therapeutic Action	Adverse Effects
Adalimumab	Rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis	Binds to tumor necrosis factor (TNF) alpha, inhibiting its inflammatory effects	Infections, malignancies, injection site reactions
Alemtuzumab	Chronic lymphocytic leukemia	Targets CD52 on lymphocytes, leading to cell lysis	Infusion reactions, infections, cytopenias
Basiliximab	Prevention of kidney transplant rejection	Blocks interleukin-2 receptor on T-cells, preventing their activation	GI disturbances, infections, hypersensitivity

Monoclonal antibodies include adalimumab (Humira), alemtuzumab (Campath), basiliximab (Simulect), bevacizumab (Avastin), cetuximab (Erbitux), certolizumab (Cimzia), daclizumab (Zenapax)

Indications

Prevention of renal transplant rejection
Treatment of B-cell chronic lymphocytic leukemia
Reduction of the signs and symptoms of Crohn disease
Treatment of paroxysmal nocturnal hemoglobinuria, to reduce haemolysis.
Treatment of B-cell non-Hodgkin lymphoma in conjunction with rituximab.
Treatment of asthma with a very strong allergic component and seasonal allergic rhinitis not occasionally controlled by common medicine.
Prevention of serious RSV(Respiratory syncytial virus) infection in high-risk children.
Treatment of metastatic breast cancer.
Treatment of psoriasis

Therapeutic Action:

Monoclonal antibodies specifically target and neutralize pathogens or inflammatory molecules, providing targeted immune suppression.

Pharmacokinetics:

These drugs are administered via intravenous injection and have variable half-lives depending on the specific antibody.
They are metabolized and excreted through the reticuloendothelial system.

Contraindications

Monoclonal antibodies are contraindicated in the presence of any known allergy to the drug or to murine products and in the presence of fluid overload.
They should be used cautiously with fever (treat the fever before beginning therapy)
They should not be used during pregnancy or lactation unless the benefit clearly outweighs the potential risk to the fetus or neonate.

Adverse Effects

The most serious adverse effects associated with the use of
monoclonal antibodies are acute pulmonary edema (dyspnea, chest pain, wheezing), which is associated with severe fluid retention.
Fever
Chills
Malaise
Myalgia
Nausea
Diarrhea
Vomiting
Increased susceptibility to infection
Intravascular hemolysis with resultant fatigue, pain, dark urine, shortness of breath, and blood clots.

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