IMMUNOPHARMACOLOGIC AGENTS

Dott.ssa Mariagrazia Grilli

IMMUNOPHARMACOLOGIC AGENTS:
TWO CATEGORIES

- those that suppress the immune system

- those that stimulate the immune system

IMMUNE SYSTEM
 hyper-active
against self
against foreign

IMMUNOSUPPRESSIVE
THERAPY
 IMMUNOSTIMULANTS
Over-
immuno- hypo-active
suppression

OPPORTUNISTIC
INFECTION
 IMMUNE RESPONSES:
TWO MAJOR MECHANISMS

1. CELL-MEDIATED IMMUNITY

2. HUMORAL (ANTIBODY)-MEDIATED IMMUNITY

" Soluble factors (cytokines) have a vital role in

Initiation and regulation of both immune responses
 ACTIVE IMMUNIZATION
1. Activation of lymphocytes
2. Proliferation of lymphocytes
3. Differentiation of lymphocytes
Differentiation

Bacteria activation Plasma cell

Macrophages Lymphocytes

Proliferation Antibody
 IMMUNE RESPONSE

Bacteria

Lysosomal Loading Peptide

Degradation Fragments on to
Of proteins Class II MHC
Macrophages/
APC
ANTIGEN PRESENTATION

CD4
MHC II

APC T-Cell

Peptide

TCR
LYMPHOCYTE ACTIVATION AND HELP

Th1
IL-2, IL-6,-IFN
or

Th2
T-Cell IL-4, IL-5, IL-10
B cell

Activated T cells Proliferate and differentiate

 IMMUNE RESPONSE
Primary Response Secondary Response

IgG

Antibody
levels
IgG

IgM
VIRUS INFECTED CELLS - CMI
virus

MHC-I

TCR
T-Cell
CD8

Epithelial Cell
OVERALL SCHEME OF IMMUNE RESPONSE

proliferation &
differentiation
MHC Class I/peptides CD8 T-cell CD8 cytolytic T-cells
APCs
IL-2
MHC Class II/peptides proliferation
APCs CD4 T-cell CD4 immune cell
(delayed hypersensitivity)
IL-1 (helper T-cells)

IL-1, -4,-5,-6
Protein B-cell Plasma cell
antigen proliferation &
differentiation antibody
production
IMMUNOSUPPRESSIVE
INTERVENTION
 CLINICAL INDICATIONS FOR hyper-active
against self
against
foreign

IMMUNOSUPPRESSANTS

1. Prevention/reduction of rejection in organ transplantation

2. Prevention of GVHD (Graft Versus Host Disease)

3. Treatment of autoimmune diseases

4. Treatment of some other inflammatory diseases resistant

to firstline therapy (eg glucocorticoids for asthma)
 TRANSPLANTATION

Different
Species
Autologous Xenogenic

Allogenic
 INDICATIONS FOR TRANSPLANT

1. ENDSTAGE ORGAN FAILURE

KIDNEY
PANCREAS
HEART
LUNG solid organ
LIVER
SMALL BOWEL

2. SYNGENEIC/ALLOGENEIC BONE MARROW TXPL

3. AUTOLOGOUS BONE MARROW TXPL

AUTOLOGOUS BONE MARROW TXPL
GRAFT REJECTION

Hyperacute
In minutes
Acute
7 to 21 Days
Chronic
3 Months
THE IDEAL IMMUNOSUPPRESSANT
CLASSES OF IMMUNOSUPPRESSANTS

Tcell blockers

Glucocorticoids

Cytotoxic Drugs

Antibody reagents
 CYCLOSPORIN-A

Struttura:

- undecapeptide ciclico
liposolubile di origine fungina

- nel 1976 Borel et al.

descrivono i potenti effetti inibitori sullattivazione dei
linfociti T, in assenza di tossicit sugli stessi e di attivit
antiproliferativa su altri tipi cellulari
 CICLOSPORIN A
USO CLINICO:

- prevenzione rigetto di allotrapianto

rene, fegato, cuore ( + azatioprina e prednisone), polmone, pancreas

- GVHD acuta e cronica

- malattie autoimmuni (AR, MG, PSORIASI, UVEITI)

(solo se divenute refrattarie ai farmaci convenzionali)

DOSAGGIO:

OS/IV
15 mg/kg 4-24 h prima + 1-2 w dopo trapianto ----- ridurre fino a 3-10 mg/kg/die

EFFETTI COLLATERALI:

nefrotossicit: dose-dipendente (att.ne alle interazioni con altri farmaci!)

neurotossicit
ipertensione
irsutismo, iperplasia gengivale
FK506 (TACROLIMUS)
- ORIGINE:
fungina

- STRUTTURA CHIMICA:
non correlata alla CsA

- ATTIVIT BIOLOGICA/MECCANISMO
simili alla CsA

- EFFETTI COLLATERALI:
nefrotossicit
neurotossicit
disturbi GI
iperglicemia
sindrome linfoproliferativa
infezioni

- UTILIZZO TERAPEUTICO:
ad oggi prevalentemente limitato a FK506
trapianto rene e fegato, in alternativa alla CsA (se troppo tossica o inefficace)
T- cell
MECHANISM OF ACTION OF CYCLOSPORIN
IMMUNOPHILINS

Cyclophilin (CsA)
FKBP12 (FK-506)
FKBPs (rapamycin)
SIROLIMUS: A NEW T-CELL BLOCKER

SOURCE: fungal product

MECHANISM OF ACTION: different than CsA and FK 506 (blocks

mTOR kinase)

USE: prophylaxis of organ transplant rejection in combination with CsA

and GC

SIDE EFFECTS: hyperlipidemia, anemia, leukopenia, thrombocytopenia,

fever, GI effects, hyper- or hypokalemia
CLASSES OF IMMUNOSUPPRESSANTS

T cell blockers

Glucocorticoids

Cytotoxic Drugs

Antibody reagents
 STEROIDS

SECRETED BY ADRENAL CORTEX

ANDROGENS

MINERALOCORTICOIDS

GLUCOCORTICOIDS

Precursor for synthesis - cholesterol (Lipid lowering drugs)

 STEROIDS
Mineralocorticoids
affect water and electrolyte (Na+/K+) balance
ALDOSTERONE

Glucocorticoids
affect carbohydrate and protein metabolism
(stress response)
HYDROCORTISONE (cortisol)
immunosuppressive/anti-inflammatory activity
(IN DOSES ABOVE NORMAL LEVELS)
 GLUCOCORTICOID-SENSITIVE SITES
OF IMMUNE RESPONDING
proliferation &
differentiation
MHC Class I/peptides CD8 T-cell X
CD8 cytolytic T-cells
APCs X
GC IL-2
IL-
GC
MHC Class II/peptides proliferation
APCs X CD4 T-cell X
CD4 immune cell
IL-1 (delayed hypersensitivity)
(helper T-cells)
IL-1, -4,-5,-6
Protein antigen B-cell Plasma cell
proliferation &
differentiation antibody
production
 USE OF GLUCOCORTICOIDS
(as immunosuppressants/antiinflammatory drugs)

- Autoimmune diseases

Reumathoid Arthritis
Dermatomyositis-Polimyositis
Myastenia gravis (GC o GC + /Azathioprine/CsA)
Colitis ulcerosa ( + sulfasalazina)

- organ txpl (in association with other immunosuppressants)

- allergic diseases (asthma; allergic drug reaction; dermatitis,

eczema; psoriasis)
 Half-life GC MC AI
activity activity activity
Short acting
Cortisol < 12 h 1 1 1
Cortisone < 12 h 0.8 0.8 0.8

Intermediate acting
Prednisone 12-36 h 4 0.25 4
Prednisolone 12-36 h 4 0.25 4

Long acting
Dexametasone > 36 h 10 < 0.01 25/30
Betametasone > 36 h 25 < 0.01 25/30
SIDE EFFECTS OF GLUCOCORTICOIDS
Major side effects are common due to high doses
necessary for immunesuppression
increased risk of infections
glucose intolerance
fluid retention (Na retention, K depletion)
weight gain
osteoporosis
hypertension
decreased wound healing and ulcerations
muscle wasting
CUSHING SYNDROME

due to excess production/

administration of GC

redistribution of body fat

from extremities (ie. Arms
and legs) to neck, face and
abdomen

from Pharmacology Rang et al

SIDE EFFECTS OF GLUCOCORTICOIDS

- Growth suppression in children

- Neuropsychiatric disturbances
apathy, depression, irritability, insomnia, sometime psychosis

- GC withdrawal syndrome
fever, myalgias, arthralgas; malaise
USE OF GC IN IMMUNOSUPPRESSION (1)

1. Use with other immunosuppressants

2. Natural GC not used for their MC activity and low

AI activity

3. Avoid long acting GC that can cause sustained

suppression of the HPA axis

4. Most common long term regimen is intermediate-

acting GC (prednisone)
 USE OF GC IN IMMUNOSUPPRESSION (2)

5. Most common long-term regimen is intermediate-

acting GC in divided doses (prednisone t.i.d.)
6. Alternate day therapy should be considered for
chronic therapy, especially for inflammatory
disorders (minimizes problems associated with feedback
suppression)

E.g. : single dose of GC on alternate mornings (8 AM) in an amount

equivalent to the total dose ordinarily given over a 48 h period.
- mimics natural circadian rhythm of cortisol
(cortisol peaks around 8 AM so HP-axis normally suppressed)
- shorter plasma half-life of GC allows HP-axis to undergo circadian
rhythm while pharmacodynamic effect will last about 36 h
 USE OF GC IN IMMUNOSUPPRESSION (3)
Patients on long-term therapy need dietary changes
high in protein and potassium
low sodium and overall calories
monitoring of serum calcium, glucose, and blood pressure
antacids for gastric problems if needed

Minimize GC-induced osteopenia

(Exercise; high Calcium intake, consider vitamin D, annual BMD)

Termination of treatment must be gradual

atrophy of HPA axis, cant respond to stress
 HPA AXIS
HYPOTHALAMUS

-
CRF

ANTERIOR PITUITARY

- ADRENAL CORTEX
(ADRENAL GLAND)
ACTH

STEROIDS

CRF = corticotrophin-releasing factor ACTH = adrenocorticotropic hormone /corticotrophin

REPRESENTATIVE GLUCOCORTICOIDS
Oral (Short-, Intermediate- and Long-acting)

cortisol(-S), cortisone(-S), corticosterone (-S) methylprednisolone(-S)

prednisolone(-I), triamcinolone(-I)
dexamethasone(-L) , betamethasone(-L)

Inhalation
beclomethasone, flunisolide, fluticasone

Topical (amcinonide), ophthalmic (medrysone), intranasal

(mometasone) and injectable versions also available
CLASSES OF IMMUNOSUPPRESSANTS

T cell blockers

Glucocorticoids

Cytotoxic Drugs

Antibody reagents
 CYTOTOXIC DRUGS AS
IMMUNOSUPPRESSANTS

Rationale

Antineoplastic drugs will also prevent clonal expansion of

both T- and B- cells nonspecifically via interfering with
DNA/RNA synthesis and function

Drugs (Mechanism)
Azathioprine (prodrug of nucleotide anti-metabolite)
Cyclophosphamide (DNA alkylating agent)
Methotrexate (inhibits dihydrofolate reductase)
Mycophenolate mofetil (becomes MPA; inhibits IMP dehydrogenase)
 USES OF CYTOTOXIC DRUGS
Azathioprine:
used in combination with other immunosuppressants (CsA
and/or prednisone) for organ transplants (kidney, liver) and
in severe rheumatoid arthritis (refractory to therapy)
Cyclophosphamide:
used in BMT
Methotrexate:
GVHD prophilaxis; rheumatoid arthritis, psoriasis (+ CsA)
Mycophenolate mofetil:
used in combination with CsA and prednisone for kidney txpl
SIDE EFFECTS OF CYTOTOXIC DRUGS

- bone marrow suppression --- risk for infections

- infertility

- GI toxicity

- increased risk of cancer

- lung and liver fibrosis (MTX)

- aseptic chronic pneumonia (MTX)

THE IDEAL IMMUNOSUPPRESSANT

.no such drug is currently available

COMBINING DIFFERENT CLASSES OF
IMMUNOSUPPRESSANTS
- to minimise side effects and reduce the doses of
individual drugs
- synergise therapeutic effects
- especially in organ transplantation
eg. maintenance immunosuppressive therapy in a renal txpl patient:
Prednisone 5 mg daily PO
Azathioprine 100 mg daily PO
Cyclosporin 75 mg bd PO
CLASSES OF IMMUNOSUPPRESSANTS

T cell blockers

Glucocorticoids

Cytotoxic Drugs

Antibody reagents
IMMUNOSUPPRESSIVE ANTIBODIES

Polyclonal
Ag
antibodies

Monoclonal
antibody
IMMUNOSUPPRESSIVE ANTIBODIES

Rh(D) immune globulin

Antithymocyte antibodies

Anti-TNF antibodies
ERYTHROBLASTOSIS FETALIS
Mother
Rh(D)
negative
Father
Rh (D)
Positive

Baby
Rh(D) positive

Antibody to RhD+ erythrocytes

First pregnancy OK. But sensitizes the mother
Second pregnancy - high risk.
Antibodies given < 72 hrs after delivery to prevent maternal
sensitization
 ANTITHYMOCYTES ANTIBODIES

Lymphocyte/thymocyte immune globulins (Atgam, thymoglobulin)

lytic to human thymic lymphocytes; blocks T-cell responding

Anti-CD3 monoclonal antibody (OKT3, muromonab-CD3)

binds CD3, blocks antigen binding; depletes T-cells

Anti-Tac, Anti-CD25(basiliximab, daclizumab) monoclonal antibodies

(anti-CD25 are humanized)
bind IL-2 receptors on activated T-cells causing their inactivation
 OKT3

Monoclonal antibody against T-cell receptor

Provokes T-cells apoptosis
Used in severe graft rejection
Profound immune suppression and infection
risk
 ANTI-TNF ANTIBODIES
Three approved drugs : infliximab1, etanercept, adalimumab

Approved for
1. treatment of refractory Rheumatoid Arthritis
used alone or 1with other DMARDs (e.g. methotrexate)
given S.C. (infliximab follow-up I.V.)

2. Crohn Disease

Adverse effects
exacerbation of heart failure (infliximab and etanercept)
increased infections, esp. tuberculosis with adalimumab (reactivation
of latent, test first)
exacerbations/development of demylelinating diseases
 GENERAL PRINCIPLES
REGARDING IMMUNOSTIMULATION

Stimulating cellular and/or humoral immunity

should benefit people with immune deficiencies

Degree of stimulation relatively small

CLINICAL USE OF IMMUNOSTIMULANTS

- CANCER

- VIRAL INFECTIONS

- CHRONIC DISEASE WITH IMMUNE PATHOGENESIS

- CHEMOTHERAPY

- BMT
CLASSES OF IMMUNOSTIMULANTS
(Biological Response Modifiers, BRM)

Cytokines

Bacteria-derived products

Synthetic Drugs

Intravenuos immune globulin

Vaccines
 CYTOKINES AS IMMUNOSTIMULANTS

Interferons: 3 types; , ,
All inhibit viral replication and modulate immune
responses
Low doses are immunostimulatory (especially
IFN- activating NK cells, macrophages and
cytotoxic T-cells)
bind IFN receptors, activate genes
 INTERFERONS
INF- INF- INF-
MAJOR PRODUCER CELLS Leukocytes/ Fibroblasts/ T cells/
macrophages epithelial cells NK cells

MAJOR INDUCERS virus Virus, LPS Antigens, mitogens

BIOLOGICAL PROPERTIES

1.Antiviral activity Yes Yes 0-100X less than INF-/

2. Immunomodulatory activity 100-1000X 100-1000X Yes

less than INF- less than INF-

3. Cytotoxic activity yes yes Yes

4. Cytostatic activity yes yes

CLINICAL USE OF INTERFERONS
Interferon-alfa (2a/2b)( rhIFN)
USE: approved for treatment of hairy cell leukemia, AIDS-related Kaposis
sarcoma, human papillomavirus and hepatitis B and >> C infections
pegylated-alfa-2b as monotherapy (1/wk) for HCV

Interferon--1a/1b (analogs of IFN-)

USE: may reduce number and severity of attacks in relapsing-remitting
multiple sclerosis

Interferon--1b
USE: approved for prevention of infections in chronic granulomatous
disease
TOXICITY OF INTERFERONS
Flu-like syndrome
fever
Fatigue
Headaches
Myalgias

GI disturbances

Cardiovascular disturbances
 INTERLEUKIN-2
Major T-cell growth factor
Binds to IL-2 receptor on immune cells
Induces proliferation and differentiation of
helper T-cells and cytotoxic T-cells
Elevates serum IL-1, TNF-, IFN levels
 USES OF INTERLEUKIN-2
rhIL-2 (human recombinant IL-2; aldesleukin)

approved to treat metastatic renal cancer and melanoma

highly toxic

capillary leak syndrome associated with edema,

reduced organ perfusion and hypotension
cardiac arrhythmias, myocardial infarction, GI bleeding,
changes in mental status
increase incidence of infections
 COLONY STIMULATING FACTORS
(G-CSF/GM-CSF)

1. CHEMOTHERAPY-INDUCED NEUTROPENIA
Rationale: neutrophils are the shortest-lived blood cells and both G- /GM-CSF stimulate neutrophil
production
Advantages:
- reduce infections secondary to the toxic therapy
- allow for dosage escalation of chemo/radiation; kill more cancer

2. BONE MARROW TRANSPLANTATION

Rationale: several weeks (2-4) after BMT, the transplanted marrow must graft and proliferate;
during this period the patient is extremely susceptible to infections

Advantages:
accelerate recovery of PBN counts; reduce infections; shorten hospitalization
 SIDE EFFECTS OF G-CSF/GM-CSF

Bone pain primary adverse effect of short-term treatment

Splenomegaly and abnormal urate levels may occur

Fluid accumulation most bothersome advers effect of

short-term GM-CSF
 BACTERIAL-DERIVED AGENTS

- Only Bacille Calmette-Guerin (BCG) licensed for use

in USA; several other in use world-wide
- BCG is an attenuated live strain of M. bovis
1. acts in part by stimulating TNF- release from macrophages
2. approved for intravescical therapy of superficial bladder
cancer
- Side effects:
Hypersensitivity, shock, chills, fever, immune complex disease
 SYNTHETIC AGENTS AS
IMMUNOSTIMULANTS

LEVAMISOLE-HCL
- Can potentiate stimulation of lymphocytes,
granulocytes and macrophages by various
factors
- Approved for use with 5-flurouracil in resected
patients with Dukes C colon cancer
 TYPES OF
IMMUNOTHERAPIES
Active Passive
immunization immunization
Vaccination Preformed antibodies
Longer duration of (anti-tetanus serum)
protection Immediate onset
Delayed onset Shorter duration of
protection
 VACCINES I
Bubonic Plague Inactivated Yersinia
Pestis
DPT adsorbed toxoids
Diphtheria, Tetanus,
Whooping cough Meningococcal
polysaccharide
Meningitis
Attenuated
Tuberculosis Mycobacterium bovis
Killed Salmonella
Typhoid typhosa
Pneumococcal
Pneumonia
capsule
 VACCINES II
Polio Attenuated virus
Rubella Attenuated virus
Mumps Attenuated virus
Yellow fever Attenuated virus
Influenza Inactivated virus
Small pox Vaccinia virus
Rabies Killed, fixed virus
hepatitis Purified coat protein
INTRAVENOUS IMMUNE GLOBULINS
(PASSIVE IMMUNIZATION)
IV IGs are pooled plasma from donors
they contain no IgM, variable IgA, normal IgG subclasses

Used as replacement therapy in primary

immune deficiency diseases
All except Gammagard are contraindicated in IgA deficiency

Specific preparations also available

hepatitis B, botulism, diptheria, tetanus, rabies