Immunosuppressive agents

PHRM 412

Immune Response
Highly sophisticated defense mechanism of the body. Composed of cell-mediated immunity and humoral immunity.

Immune Response
Both of these response have a high level of specificity. Activated by:
Infectious agents (bacteria, virus) Foreign (grafts) or transformed (malignants) cell Autologous cells (autoimmunity)

Cell-mediated immunity
Cell-mediated immunity is an immune response that does not involve antibodies or complement. Involves the activation of macrophages, natural killer cells (NK cells, lymphocyte), antigen-specific cytotoxic T-lymphocytes and the release of various cytokines in response to an antigen.

Lymphocyte is a type of white blood cell:

Large
NK Cell

Small
T Cell B Cell

Humoral immunity
The Humoral Immune Response (HIR) is the aspect of immunity that is mediated by secreted antibodies produced by B lymphocyte (B cell). Humoral immunity is so named because it involves substances found in the humours, or body fluids.

Immunosuppression
Immunosuppression is a process of inhibiting the immune response at different steps. Immunosuppressive drugs are used to dampen the immune response in organ transplantation and autoimmune disease.

General Principles
Primary immune response can be more effectively suppressed than secondary response . If immunologic memory has been established immunosuppressive therapy will have modest effects.

General Principles
Immunosuppressive therapy is most effective before generation of immune response. But autoimmune disease like rheumatoid arthritis are treated after the response is generated.

General Principles
However, such therapies require lifelong use and nonspecifically suppress the entire immune system, exposing patients to considerably higher risks of infection and cancer.

Sites of action of specific immunosuppressive drugs on various stages of immune response

Recognition of the antigens by antigen presenting cells (APC). Interleukin 1: IL 1 Antigens, combined with MHC (major histocompatibility complex) molecules of the APC, are recognised by the TCR (T cell receptor)/CD3 complex on the surface of the T cell.

Stimulate interleukin 2 (IL2) and other cytokines release

Resulting in clonal expansion of T helper cells and stimulation of other immune cells (CD8+ cytotoxic T cells, B cell).

T-cell receptors

Major histocompatibility complex

Antigen presentation stimulates T cells to become either "cytotoxic" CD8+ cells or "helper" CD4+ cells.

Classification of Immunosuppressant
Glucocorticoids: Immunosuppressive mechanism Anti -inflammatory effects Inhibit the activities of monocytes and Thelper cells. Inhibit the production of IL-1. e.g. Prednisolone, Hydrocortisone, etc.

Classification of Immunosuppressant
Antibodies: i. T-cell receptor directed antibodies ii. IL-2 receptor directed antibodies They are used generally in cases where steroid resistance occurs , they act as antibody and suppress the cell mediated responses and are generally T cell directed. e.g. Muromonab-CD3 (OKT3), Anti Thymocyte Globulin (ATG)

Classification of Immunosuppressant
Drugs acting on immunophilins: They are also called calcineurin inhibitors as they inhibit calceneurin which is responsible for production of IL-2 . e. g. Cyclosporine , Tacrolimus , Sirolimus

Classification of Immunosuppressant
Cytostatics: Alkylating agents, Antimetabolites, Cytotoxic drugs These drugs inhibit the conversion of CD8 cells to Cytotoxic T cells & B cells to plasma cells and memory cells by inhibition of purine synthesis. e.g. Azathioprine , Mercaptopurine

IMMUNOSUPPRESANT DRUGS

CALCINEURIN INHIBITORS

Cyclosporine
Initially Cyclosporine (cyclosporin A) isolated from the fungus Tolypocladium inflatum isolated from a soil sample obtained by Sandoz scientists at Hardangervidda, Norway in 1969. It was initially identified as antifungal drug.

Cyclosporine
Cyclosporine A still falls within top 25 drugs worldwide, although it has introduced in 1983. Cyclosporine (cyclosporin A), a cyclic polypeptide consisting of 11 amino acids and contains a single D-amino acid, which are rarely encountered in nature.

Cyclosporine
Cyclosporine (abbreviated as CsA) is a neutral, lipophilic. Cyclosporine is insoluble in water so suspension and emulsions are used for oral administration and for injection.

Cyclosporine (cyclosporin A)

The structure and confirmational analysis was done with chemical degradation, X-ray crystallography and nuclear magnetic resonance imaging.

Mechanism of Action
Cyclosporine enters through the cell membrane and binds to cyclophilins in the cytoplasm.
Cyclophilins are a family of small proteins that selectively bind cyclosporine as well as its active analogs.

The cyclosporine binding to cyclophilin results in the formation of a cyclosporinecyclophilin complex.

Mechanism of Action
During an immune response, activation of Tcell receptor results in an increase in intracellular Ca2+, which activates calcineurin. Calcineurin after its activation by Ca2+ dephosphorylates a cytosolic component of the nuclear factor of activated T cells (NFATc).

Mechanism of Action
After its dephosphorylation, NFATc migrates from the cytoplasm to the nucleus where it associates with the nuclear component of the nuclear factor of activated T cells (NFATn). This association of NFATc and NFATn results in the activation of the transcription of a number of genes including cytokine genes for IL-2, IL-3, IL-4, TNF-, GM-CSF and others.

Mechanism of action
After the administration of cyclosporine, a cyclosporinecyclophilin complex is formed, which binds to calcineurin, resulting in its inability to dephosphorylate NFATc, and as a result, the transport of NFATc to the nucleus is prevented and consequently its association with NFATn does not proceed.

Mechanism of action
The association of NFATc with NFATn is essential for the initiation of IL-2 production, which is achieved through binding of NFATc NFATn to the promoter of the IL-2 gene. As a result, IL-2 production is inhibited, which is necessary for the optimal function of the immune response.

Drug-drug interaction
Calcium channel antagonists like nifedipine, verampamil and diltiazepam increases the CsA concentration in blood and CsA metabolities reach 5 times higher concentration in plasma than without calcium channel antagonists. So, concomitant use of other medicine should be done very carefully.

Drug-drug interaction
Since CsA is extensively metabolized in liver by cytochrome P450 (drug metabolizing enzymes) so drugs which are inducers of CYP enzymes can reduce the concentration of CsA in plasma and can lead to increased requirement of CsA and in unmonitored situation can lead to organ rejection.

Drug-drug interaction
On the other hand when CYP inducers are withdrawn without appropriate reduction in dose can lead to elevated levels of CsA in the blood and causes adverse drug reactions.

CsA has also got anti-fungal, anti-parasitic and anti-inflammatory properties.

Tacrolimus
Tacrolimus (also FK-506 or Fujimycin) is an immunosuppressive drug that is mainly used after allogeneic organ transplant to reduce the activity of the patient's immune system and so lower the risk of organ rejection.

Tacrolimus

Tacrolimus
It is a 23-membered macrolide lactone discovered in 1984 from the fermentation broth of a Japanese soil sample that contained the bacteria Streptomyces tsukubaensis. It reduces interleukin-2 (IL-2) production by Tcells.

Tacrolimus
Tacrolimus is a 23-membered lactone chain isolated in 1984 from Streptomyces tsukubaensis, although it was originally found in a soil fungus. It is a macrolide antibiotic, and its name is derived from Tsukuba macrolide immunosuppressant.

Tacrolimus
Tacrolimus, previously known as FK506 is a macrolide immunosuppressant produced by Streptomyces tsukubaensis.

Mechanism of Action
Tacrolimus works by binding to the immunophilin FK506-binding protein-12 (FKBP-12) The tacrolimusFKBP-12 complex binds to calcineurin and inhibits calcineurin phosphatase activity.

Mechanism of Action
As a result, calcineurin is unable to dephosphorylate NFATc and thus its migration to nucleus is blocked where its association with NFATn is necessary for the activation of key cytokine genes.

Sirolimus
Sirolimus, also known as rapamycin, is an immunosuppressant drug used to prevent rejection in organ transplantation; it is especially useful in kidney transplants. (not for liver or lung transplantation) Sirolimus was originally developed as an antifungal agent.

Sirolimus: A macrolide

Mechanism of action of Sirolimus

Unlike the similarly named tacrolimus (tacrolimus inhibits the production of IL-2), sirolimus is not a calcineurin inhibitor, but it has a similar suppressive effect on the immune system. Sirolimus inhibits the response to interleukin2 (IL-2), and thereby blocks activation of Tand B-cells.

Unlike cyclosporine and tacrolimus, sirolimus does not inhibit the activation of NFAT responsive genes. After binding to its cytosolic receptors, sirolimus inhibits a protein kinase, the mammalian target of rapamycin (mTOR) pathway

Mechanism of action of Sirolimus

Sirolimus (SRL) binds to FK506-binding protein (FKBP, which is the same molecule that is bound by FK506). The complex that is formed between SRL and FKBP binds to the mammalian target of rapamycin (mTOR).

Mechanism of action of Sirolimus

The SRLFKBPmTOR complex inhibits biochemical pathways that are required for cell progression through the late G1 phase or entry into the S phase of the cell cycle. Thus, unlike cyclosporine (CsA) and FK506 (which block the production of cytokines), SRL blocks cytokine signal transduction.

Muromonab-CD3
Muromonab-CD3 (trade name Orthoclone OKT3, marketed by Janssen-Cilag) is an immunosuppressant drug given to reduce acute rejection in patients with organ transplants.

Muromonab-CD3
It is a monoclonal antibody targeted at the CD3 receptor, a membrane protein on the surface of T cells. It was the first monoclonal antibody to be approved for clinical use in humans.

Mechanism of action
T cells recognize antigens primarily via the T cell receptor. This receptor needs various co-receptors to function, one of which is CD3. [Muromonab targets CD3, a part of the T-cell receptor (TCR) complex.] The T cell receptor-CD3 complex transduces the signal for the T cell to proliferate and attack the antigen.

Mechanism of action
Muromonab-CD3 binds to the T cell receptorCD3-complex on the surface of circulating T cells, initially leading to an activation, but subsequently inducing blockage and apoptosis of the T cells. This protects the transplant against the T cells.

Adverse effects
Especially during the first infusion, the binding of muromonab-CD3 to CD3 can activate T cells to release cytokines. It creates flu like syndromes.

Immunoselective treatment
T cell requires two signals for full activation Signal 1: mediated through the T cell receptor engagement with antigen presented by the MHC on the APC. Signal 2: co-stimulatory signal- receptor ligand interaction that occurred between T cell (CD 28) and APC (CD 80/86) These two signals stimulates T cells to proliferate

Two signals are necessary for complete T cell activation. The first is provided by the binding of the T cell receptor to its specific peptide: MHC molecule. The co-stimulatory signal is provided by the binding of a B7 molecule on the antigen presenting cell (APC) to its ligand, CD28, on the T cell (Janeway et al., 2005).

Immunoselective treatment
Current therapy: Calceneurin inhibitors- target calceneurin phosphatase Mammalian target of rapamycin (mTOR) inhibitors- prevent IL-2 driven T-cell proliferation
Their targets are not specific: some targets are expressed in non-immune cells.

Immunoselective treatment
This may be associated with therapy related toxicity and ultimately organ rejection. There is a need for immunoselectivity

Immunoselective treatment
Multiple pathways are currently being investigated CD 28 is the best characterized receptor. CD 28 receptor is important for co-stimulation Prevention of interaction between CD 28 and CD 80/86 results blocking signal 2. The T cell become apoptotic.

Immunoselective treatment
CD 28 expressed predominantly on T cell, thus the pathway offers immunoselctivity. Can reduce the toxicity associated with less immunoselective agents.