Immune Modulators

1.

A patient has been diagnosed with hairy cell leukemia. The patient is to begin taking interferon alfa 2b. What will the nurse include in her instructions to the patient concerning this drug?
A)
Avoid drinking alcohol while taking the drug.
B)
Continue to maintain maximal physical activity.
C)
Increase fluid intake while taking the drug.
D)
Treat constipation with over-the-counter laxatives.
Ans:
C

Feedback:

Interferon alfa 2b is metabolized in the kidney so adequate fluid intake is needed to promote metabolism and excretion of the drug as well as to minimize common adverse effects including dry skin and dizziness. Maintaining maximal physical activity is a good idea but has no relationship to the use of the drug. Fluids should be increased not decreased while taking the drug. Constipation is not an associated adverse effect of this medication.

2.

The health care provider plans to inject an interferon directly into the patient’s wart. What interferon will the nurse prepare?
A)
Interferon alfa 2a (Roferon-A)
B)
Interferon alfacon 1 (Infergen)
C)
Interferon alfa n3 (Alferon N)
D)
Interferon beta 1a (Avonex)
Ans:
C

Feedback:

Interferon alf n3 is used for intralesional treatment of warts. Interferon alfa 2a is used in the treatment of leukemia. Interferon alfacon 1 is used in the treatment of chronic hepatitis C infection in adults. Interferon beta 1a is used to treat multiple sclerosis in adults.

3.

A 30-year-old woman has been diagnosed with leukemia and will be using an immune modulator for treatment. What will be important to discuss with the patient when the nurse provides patient teaching about her treatment?
A)
The need to continue oral contraceptives
B)
The need to use barrier contraceptives while taking the drug
C)
The need to avoid sexual intercourse while taking the drug
D)
The importance of taking an aspirin daily to decrease the adverse effects of the drug
Ans:
B

Feedback:

A patient taking an immune modulator would be advised to use barrier contraceptives to prevent pregnancy. The interaction of the immune modulator and the oral contraceptive may interfere with the oral contraceptive’s ability to work properly. Asking patients to avoid sexual intercourse is not necessary if barrier methods are properly used. Daily aspirin would not decrease adverse effects of this drug.

4.

The nurse has an order to administer oprelvekin (Neumega) to a patient for the first time. Before administering the drug, what allergy would the nurse want to specifically question the patient about?
A)
Egg products
B)
Escherichia coli–produced products
C)
Lactose intolerance
D)
Penicillin
Ans:
B

Feedback:

The interleukins are produced using deoxyribonucleic acid technology and E. colibacteria. Patients with known allergy to E. coli products should not receive oprelvekin. The allergies to penicillin, egg products, or lactose intolerance would not be of concern with this drug.

5.

The physician has decided to prescribe T- and B-cell suppressors for a patient diagnosed with psoriasis. What drug will be ordered for this patient?
A)
Alefacept (Amevive)
B)
Azathioprine (Imuran)
C)
Cyclosporine (Neoral)
D)
Glatiramer acetate (Copaxone)
Ans:
A

Feedback:

Alefacept is prescribed for patients with severe chronic plaque psoriasis. Cyclosporine is used to suppress rejection in a variety of transplant situations. Azathioprine is used to treat patients with rheumatoid arthritis and in prevention of rejection in renal homotransplants. Tacrolimus is used for prevention of rejection after renal or liver transplantation.

6.

A patient who is receiving an immune suppressant has been admitted to the unit. What would be a priority action by the nurse?
A)
Monitor nutritional status.
B)
Provide patient teaching regarding the drug.
C)
Protect the patient from exposure to infection.
D)
Provide support and comfort measures in relation to adverse effects of the drug.
Ans:
C

Feedback:

Patients taking immune suppressant drugs are more susceptible to infection because the patient’s normal body defenses will be diminished. As a result, the priority action by the nurse would to protect the patient from exposure to infection through room selection, good hand hygiene, and taking care to avoid exposure to sick staff members. Teaching will need to include avoiding crowded places and people with known infection and those working in soil. Nutritional status is important as are comfort and support measures and other instructions concerning the drug. However, protecting the patient from infection should be the priority action.

7.

A nurse is discussing interferon alfa 2b with a patient. What will the nurse encourage the patient to do while taking this drug?
A)
To avoid crowds
B)
To increase salt intake
C)
To decrease milk intake
D)
To eat three meals a day
Ans:
A

Feedback:

Potential adverse effects in addition to the types of conditions interferon alfa 2b is prescribed to contribute to the need for the patient to take care to avoid people with infections so the patient should be taught to avoid crowds whenever possible. Adverse effects include dizziness, confusion, rash, dry skin, anorexia, nausea, bone marrow suppression, and flu-like syndrome. Salt, diet, and milk do not interfere with this drug.

8.

A 70-year-old patient with acute myelocytic leukemia is receiving sargramostim (Leukine). What is a priority nursing action for this patient?
A)
Providing a quiet environment
B)
Increasing fluids
C)
Providing comfort measures related to nausea
D)
Encouraging appropriate dietary intake
Ans:
B

Feedback:

A common adverse effect of this drug is vomiting and diarrhea. Due to the patient’s age it would be important to keep him hydrated. Vomiting and diarrhea can cause dehydration quickly in the elderly. Providing a quiet environment and comfort measures for the nausea would be important but not as critical as increasing fluids. Diet is very important to this patient; however, usually this drug causes a loss of appetite. Therefore, increasing fluids would be extremely important to the patient’s nutritional status.

9.

The nurse is caring for a patient in the immediate postoperative period following cardiac transplantation who is receiving mycophenolate (CellCept) twice a day IV. What will the nurse teach the patient regarding drug therapy? (Select all that apply.)
A)
“The drug will be given orally as soon as possible.
B)
“Take the medication three times a day.”
C)
“Avoid people with contagious diseases.”
D)
“Ask a pharmacist about drug–drug interactions before taking any over-the-counter (OTC) drug.”
E)
“Never miss a dose of medication.”
Ans:
A, C, D, E

Feedback:

The nurse will explain that the IV medication will be changed to oral therapy when the patient is able to tolerate oral medications. The patient will take the medication twice a day, not three times a day. Care should be taken to never miss a dose. The patient should avoid other medications that are hepatotoxic or nephrotoxic due to a risk of increased toxicity so the patient should be taught to always consult a doctor or pharmacist before beginning an OTC drug. Patients who have immune suppression must be taught how to reduce risk of infection, including avoiding people with contagious diseases, such as colds or viruses.

10.

The nurse administers aldesleukin to a patient diagnosed with renal cell carcinoma. When assessing the patient a few days later, what abnormal findings would the nurse attribute to the medication? (Select all that apply.)
A)
Increased lymphocyte count
B)
Increased red blood cell count
C)
Increased platelet count
D)
Irregular pulse rate
E)
Increased blood pressure
Ans:
A, C, D

Feedback:

Aldesleukin activates human cellular immunity and inhibits tumor growth through increases in lymphocytes, platelets, and cytokines. Common adverse effects include hypotension, sinus tachycardia, arrhythmias, as well as pruritus, nausea, vomiting, diarrhea, anorexia, GI bleeding, bone marrow suppression, respiratory difficulties, fever, chills, pain, mental status changes, and dizziness. There is no impact on red blood cell count. It does not raise blood pressure.

11.

While studying for a pharmacology test, a student asks his peers about interferons. What statement about interferons is accurate?
A)
They stimulate B-lymphocyte activity.
B)
They interfere with multiplication of stem cells.
C)
They stimulate growth and differentiation of lymphoid cells into lymphocytes.
D)
They interfere with the ability of viruses in infected cells to replicate.
Ans:
D

Feedback:

Interferons are substances naturally produced and released by human cells that have been invaded by viruses. They may also be released from cells in response to other stimuli, such as cytotoxic T-cell activity. Interferons do not stimulate B-lymphocyte activity, interfere with multiplication of stem cells, nor do they stimulate growth and differentiation of lymphoid cells into lymphocytes.

12.

How do immune suppressants work when ordered for a patient who has had an organ transplant?
A)
Blocking normal effects of the immune system
B)
Stimulating immune system to fight off infection
C)
Working with corticosteroids to enhance healing
D)
Working with corticosteroids to promote suppressor cells
Ans:
A

Feedback:

Immune suppressants are used to block the normal effects of the immune system in cases of organ transplantation (in which non–self-cells are transplanted into the body and destroyed by the immune reaction) and in autoimmune disorders (in which the body’s defenses recognize self-cells as foreign and work to destroy them) in some cancers. Options B, C, and D are distracters for this question.

13.

A patient has just been told that her cancer has metastasized to her right kidney. An interferon (Aldesleukin) has been prescribed to treat this metastasis. The patient asks why this interferon is ordered. What is the nurse’s best response?
A)
“Aldesleukin has been shown to protect autologous tumor cells.”
B)
“Aldesleukin has been shown to inhibit tumor growth.”
C)
“Aldesleukin has been shown to enhance allogeneic stem-cell transplantation.”
D)
“Aldesleukin has been shown to have a direct proliferative effect on renal tumors.”
Ans:
B

Feedback:

Aldesleukin is prescribed for metastatic renal cell carcinoma in adults and treatment of metastatic melanomas (orphan drug use) working by activating human cellular immunity and inhibiting tumor growth through increases in lymphocytes, platelets, and cytokines. Aldesleukin does not protect autologous tumor cells, enhance allogeneic stem-cell transplantation, or have a direct proliferative effect on renal tumors.

14.

The nurse admits a patient who was newly diagnosed with Kaposi’s sarcoma to the unit. The physician has ordered an IV infusion of an interferon. What drug would be appropriate?
A)
Interferon beta1a
B)
Interferon gamma 1b
C)
Interferon alfa 2b
D)
Peginterferon alfa 2b
Ans:
C

Feedback:

Interferon alfa 2b indications include hairy cell leukemia, melanoma, AIDS-related Kaposi’s sarcoma, chronic hepatitis B and C infection, intralesional treatment of condyloma acuminatum in patients 18 years of age or older. No other interferons are indicated for treatment of Kaposi’s sarcoma.

15.

The pharmacology instructor is talking about interferon. The instructor explains that agents, such as interferons, have more than one biologic function. What are the functions of interferons? (Select all that apply.)
A)
Antibacterial
B)
Antiviral
C)
Immunomodulatory
D)
Antiproliferative
E)
Anticancer
Ans:
B, C, D

Feedback:

Interferons act to prevent virus particles from replicating inside the cells. They also stimulate interferon receptor sites on noninvaded cells to produce antiviral proteins, which prevent viruses from entering the cell. In addition, interferons have been found to inhibit tumor growth and replication, to stimulate cytotoxic T-cell activity, and to enhance the inflammatory response. Options A and E are incorrect.

16.

The nursing class is studying monoclonal antibodies. What monoclonal antibody reacts to human T cells, disabling them and acting as an immune suppressor?
A)
Adalimumab
B)
Cetuximab
C)
Rituximab
D)
Muromonab-CD3
Ans:
D

Feedback:

Muromonab-CD3, the first monoclonal antibody approved for use, is a T-cell–specific antibody, that is available as an IV agent. It reacts as an antibody to human T cells, disabling the T cells, acting as an immune suppressor. Adalimumab is an antibody specific for human tumor necrosis factor. Cetuximab is an antibody specific to epidermal growth factor receptor sites. Rituximab is an antibody specific to sites on activated B lymphocytes.

17.

What monoclonal antibody is used to prevent respiratory syncytial virus (RSV) in high risk children?
A)
Palivizumab
B)
Natalizumab
C)
Belimumab
D)
Eculizumab
Ans:
A

Feedback:

Palivizumab is specific to the antigenic site on respiratory syncytial virus (RSV); it inactivates that virus. It is used to prevent RSV disease in high-risk children. Natalizumab is an antibody specific to surface receptors on all leukocytes except neutrophils. Belimumab is a specific inhibitor of B-lymphocyte stimulator that inhibits the survival of B-lymphocytes and their differentiation into immune-globulin producing cells. Eculizumab binds to complement proteins and prevents the formation of the complement complex.

18.

The nurse is caring for a patient with an allograft transplant. The physician orders a monoclonal antibody to prevent rejection of the transplant. What monoclonal antibody would the nurse expect to be ordered?
A)
Alemtuzumab
B)
Daclizumab
C)
Erlotinib
D)
Omalizumab
Ans:
B

Feedback:

Daclizumab is specific to interleukin-2 receptor sites on activated T lymphocytes; it reacts with those sites and blocks cellular response to allograft transplants. Alemtuzumab is an antibody specific for lymphocyte receptor sites used to treat chronic lymphocytic leukemia patients who have been treated with alkylating agents and have been failed by fludarabine therapy. Erlotinib is effective against specific malignant receptor sites. Omalizumab is an antibody to immunoglobulin E, an important factor in allergic reactions.

19.

The pharmacology instructor is explaining interleukins to the class. What would be the best definition of interleukins?
A)
They are substances naturally produced and released by human cells that have been invaded by viruses.
B)
They block the inflammatory reaction and decrease initial damage to cells.
C)
They are chemicals used to communicate between leukocytes and stimulate immunity.
D)
They attach to specific receptor sites and respond to very specific situations.
Ans:
C

Feedback:

Interleukins are chemicals produced by T cells to communicate between leukocytes and stimulate cellular immunity and inhibit tumor growth. Immune suppressants block the inflammatory reaction and decrease initial damage to cells. Interferons are naturally produced and released by human cells that have been invaded by viruses. Monoclonal antibodies attach to specific receptor sites and respond to very specific situations.

20.

The nurse is caring for a female patient, aged 62, who has been admitted for treatment of metastatic melanoma. What agent would the nurse anticipate the physician is likely to order?
A)
Aldesleukin
B)
Interferon alfa 2b
C)
Cyclosporine
D)
Ipilimumab
Ans:
D

Feedback:

Ipilimumab is a human cytotoxic T-cell antigen-4 blocking antibody. By blocking this site, T cells are activated and proliferate at a faster rate. It is used to treat patients with unresectable or metastatic melanoma. Aldesleukin is an interleukin, used for metastatic renal cell carcinoma in adults; a treatment of metastatic melanomas. Interferon alfa 2b is indicated for hairy cell leukemia, melanoma, AIDS-related Kaposi’s sarcoma, chronic hepatitis B and C infections, intralesional treatment of condyloma acuminatum in patients 18 years of age or older. Cyclosporine is a T and B cell suppressor and is indicated for prophylaxis for organ rejection in kidney, liver, and heart transplants (used with corticosteroids); treatment of chronic rejection in patients previously treated with other immunosuppressants; treatment of rheumatoid arthritis; and recalcitrant psoriasis.

21.

While studying the T- and B-cell immune suppressors, the nursing students learn that the most commonly used immune suppressant is what?
A)
Cyclosporine (Sandimmune)
B)
Azathioprine (Imuran)
C)
Pimecrolimus (Elidel)
D)
Glatiramer (Copaxone)
Ans:
A

Feedback:

Several T- and B-cell immune suppressors are available for use. Of the numerous agents available, cyclosporine is the most commonly used immune suppressant. Options B, C, and D are all T- and B-cell immune suppressors, they are simply not the most commonly prescribed.

22.

What interleukin receptor antagonist would the nurse anticipate is most likely to be ordered for a patient, 25 years old, who has not responded to traditional antirheumatic drugs?
A)
Natalizumab (Tysabri)
B)
Anakinra (Kineret)
C)
Eculizumab (Soliris)
D)
Adalimumab (Humira)
Ans:
B

Feedback:

Anakinra is used to reduce the signs and symptoms of moderately to severely active rheumatoid arthritis in patients 18 years of age and older who have not responded to the traditional antirheumatic drugs. Options A, C, and D are monoclonal antibodies, therefore they are incorrect answers.

23.

A patient with chronic hepatitis C has been prescribed peginterferon alfa 2b (PEG-INTRON). By what route would the nurse administer this drug?
A)
Subcutaneously (SQ)
B)
Intramuscularly (IM)
C)
Intralesionally (IL)
D)
Orally
Ans:
A

Feedback:

PEG-INTRON, like many of the interferons, is administered subcutaneously. Avonex is given intramuscularly. Interferon alfa n3 is given intralesionally. There are no interferons given orally.

24.

The patient has arrived in the short stay unit for an infusion of tositumomab with 131 tositumomab (Bexxar). Before beginning the infusion, the nurse assesses the patient’s vital signs and finds the patient has a temperature of 101.5ºF, What is the nurse’s priority action?
A)
Holding the infusion until patient is afebrile
B)
Notifying the physician
C)
Starting the infusion and inform the physician
D)
Treating the fever before beginning the therapy
Ans:
D

Feedback:

Monoclonal antibodies should be used cautiously with fever (treat the fever before beginning therapy). This makes Options A, B, and C incorrect.

25.

A 72-year-old male patient has arrived at the outpatient unit to receive an infusion of alemtuzumab (Compath). The patient tells the nurse this is the second time his chronic lymphocytic leukemia has relapsed and the second time he will receive this drug because he failed alemtuzumab therapy after being treated with an alkylating agent. What is the priority nursing action?
A)
Calling the physician and questioning the order
B)
Washing your hands
C)
Beginning an intravenous infusion
D)
Canceling the infusion
Ans:
A

Feedback:

Monoclonal antibodies should be used cautiously in patients who have had previous administration of the monoclonal antibody (serious hypersensitivity reactions can occur with repeat administration). The nursing priority would be to question the order because the patient has already received alemtuzumab (Compath) previously and if the order is verified, this patient should be monitored very carefully, perhaps starting to infuse more slowly until the patient’s reaction can be determined. Only after questioning the order and having it verified would the nurse perform hand hygiene and begin the infusion.

26.

The nurse is writing a plan of care for a patient receiving immune suppressants for leukemia. What would be an appropriate nursing diagnosis for this patient?
A)
Anxiety related to diagnosis and drug therapy
B)
Acute pain related to central nervous system (CNS), gastrointestinal (GI), and flu-like effects
C)
Risk for infection related to immune stimulation
D)
Imbalanced nutrition: More than body requirements
Ans:
B

Feedback:

Nursing diagnoses related to drug therapy might include: Acute pain related to CNS, GI, and flu-like effects. Anxiety related to diagnosis and drug therapy is a nursing diagnosis for a patient on an immune stimulant. There is no risk for infection related to immune stimulation unless an adverse effect occurs. Imbalanced nutrition would be less than body requirements due to flu-like symptoms resulting in diminished appetite.

27.

The nurse is preparing a patient to receive immunosuppressant drugs on an outpatient basis. What is the priority for the nurse to arrange for this patient in the home environment?
A)
A caregiver who is skilled in cardiopulmonary resuscitation (CPR)
B)
A caregiver who will provide adequate nutrition
C)
Supportive care and comfort measures
D)
Arrange for a home care nurse to administer injections
Ans:
C

Feedback:

Arrange for supportive care and comfort measures for flu-like symptoms (rest, environmental control, acetaminophen) to decrease patient discomfort and increase therapeutic compliance. Patients may also need support and comfort measures related to diagnosis and drug therapy. Although knowledge of CPR and providing appropriate nutrition are always positive actions, they are not related to administration of immunosuppressants. The patient or caregiver can be taught to administer injections unless the medication is to be given IV, in which case the patient would go to an infusion center.

28.

The nurse is caring for a patient who has a diagnosis of chronic hepatitis B infection and has been prescribed an immune stimulant. After teaching the patient about the treatment plan, how might the nurse evaluate the effectiveness of teaching?
A)
The patient can state where to go to get the medication.
B)
The patient can state who will administer the medication.
C)
The patient can state what positive effects to watch for.
D)
The patient can state specific measures to avoid adverse effects.
Ans:
D

Feedback:

The nurse would evaluate that the teaching plan was successful if the patient can name drug, dosage, adverse effects to watch for, and specific measures to avoid adverse effects. Knowing where to get the medication, who will administer it, and the positive effects to watch for would not be an adequate assessment of the teaching plan.

29.

The patient underwent an allograft renal transplant 48 hours earlier and is showing signs of rejection. What drug would the nurse expect the physician to order?
A)
Muromonab
B)
Anakinra
C)
Mycophenolate
D)
Sirolimus
Ans:
A

Feedback:

Muromonab is indicated for the treatment of acute allograft rejection in patients undergoing renal transplantation. It also is indicated for the treatment of steroid-resistant acute allograft rejection in those receiving heart or liver transplants. Anakinra, mycophenolate, and sirolimus are useful for preventing renal or liver transplant rejection.

30.

The nurse, working with a nursing student, is caring for a patient who is to receive interleukins. The student nurse asks you what happens physiologically when a patient receives interleukins. What is the nurse’s best response?
A)
“It really helps the patient!”
B)
“The patient has increases in the number of natural killer cells.”
C)
“The patient has decreased cytokine activity.”
D)
“The patient gets really sick from flu-like symptoms and then they get better.”
Ans:
B

Feedback:

When interleukins are administered, there are increases in the numbers of natural killer cells and lymphocytes, in cytokine activity, and in the number of circulating platelets. Options A, C, and D are incorrect.

31.

The nurse is caring for a child requiring cyclosporine to prevent rejection. Cyclosporine is given to adults using a dosage of 15 mg/kg. The nurse calculates the child’s dosage is 20 mg/kg. What is the nurse’s priority action?
A)
Administer the drug.
B)
Hold the dose and question the ordering provider.
C)
Complete an incident report if this dosage has already been given before.
D)
Notify the nursing supervisor of the medication error.
Ans:
A

Feedback:

The nurse would administer the medication as ordered because doses larger than those given to adults are often needed when cyclosporine is administered to children. This is not an error so the nurse would not hold the drug, question the provider, complete an incident report, or notify the nursing supervisor.

32.

When caring for older adults receiving immune modulators, what are the nurse’s priorities of care? (Select all that apply.)
A)
Assess carefully for infection.
B)
Obtain baseline liver function studies and monitor follow-up studies.
C)
Determine dosage based on renal and liver function.
D)
Minimize teaching to avoid causing confusion.
E)
Encourage the family to visit often, especially young children.
Ans:
A, B, C

Feedback:

Older patients may be more susceptible to the effects of the immune modulators, partly because the aging immune system is less efficient and less responsive. These patients need to be monitored closely for infection, GI, renal, hepatic, and central nervous system effects. Baseline renal and liver function tests can help to determine whether a decreased dosage will be needed before beginning therapy. Because these patients are more susceptible to infection, they need to receive extensive teaching, not less teaching, about ways to avoid infection and injury. Contact with young children and large groups of people increase the risk of infection.

33.

The nurse teaches the female patient receiving immune modulating drugs about the need to use barrier contraceptives. The patient says, “I hate using barrier contraceptives. Why can’t I just take oral contraceptives?” What is the nurse’s best response?
A)
“Effects of oral contraceptives may be altered by liver changes or changes in immune response.”
B)
“Oral contraceptives increase the action of immune modulating drugs so dosage needs to be reduced.”
C)
“Immune modulators make oral contraceptives ineffective because of hormonal impact of drugs.”
D)
“Oral contraceptives are acceptable if barrier contraceptives are distasteful, but only high-estrogen pills can be used.”
Ans:
A

Feedback:

The use of barrier contraceptives is advised because the effects of oral contraceptives may be altered by liver changes or by changes in the body’s immune response, potentially resulting in unexpected pregnancy. The other options conflict with this information and are incorrect.

34.

The nurse is caring for a young adult woman taking immune modulating medications who has been advised to use barrier contraceptives but she wants to start her family. What information can the nurse provide about these drugs to help this patient with her decision-making?
A)
“Discuss the desire to start a family with the provider so risk can be minimized.”
B)
“Immune modulating drugs will need to be discontinued if pregnancy occurs.”
C)
“Immune modulating drugs have been proven to be highly teratogenic.”
D)
“Pregnancy is not an option when taking immune modulating drugs but adoption is an option.”
Ans:
A

Feedback:

If a patient taking immune modulators becomes pregnant or decides that she wants to become pregnant, she should discuss this with her health care provider and review the risks associated with use of the drug or drugs being taken. Monoclonal antibodies should be used with caution during pregnancy and lactation. Because results of long-term studies of most of these drugs are not yet available, it may be prudent to advise patients taking these drugs to avoid pregnancy if possible. Immune modulating drugs do not need to be discontinued, but the safest drug should be prescribed. Most immune modulating drugs have not been studied and there is not enough information to know whether they are teratogenic. The nurse cannot tell a patient that pregnancy is not an option.

35.

The nurse is caring for a patient diagnosed with rheumatoid arthritis (RA) who recently underwent a liver transplant. What immunosuppressant could this patient be prescribed that would treat both diagnoses?
A)
Anakinra (Kineret)
B)
Adalimumab (Humira)
C)
Sirolimus (Rapamune)
D)
Cyclosporine (Sandimmune)
Ans:
A

Feedback:

Anakinra is used to prevent rejection after kidney or liver transplantation and also reduces signs and symptoms of RA in patients who have had inadequate response to other drugs. Adalimumab would be effective for the patient’s RA but would not prevent rejection of the transplanted liver. Sirolimus is used to prevent rejection of kidney transplants but would not be effective for either of the patient’s diagnoses. Cyclosporine would be appropriate to prevent liver rejection but would not treat RA.