Best Practice & Research Clinical Gastroenterology 54-55 (2021) 101757

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Best Practice & Research Clinical Gastroenterology

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Immunosuppressive drugs modes of action

Maria Meneghini a, Oriol Bestard a, Josep Maria Grinyo b, *
a
Nephrology and Kidney Transplantation Unit. Vall D’Hebron University Hospital, Barcelona. Spain
b
University of Barcelona. Department of Clinical Sciences. Barcelona. Spain

A R T I C L E I N F O A B S T R A C T

Keywords: The innate and adaptive immune systems work as a complex interplay between different cell types, involving
Immunosuppression cytokines and chemokines mediating extracellular and paracrine effects. At the intracellular level, the inflam­
Allotransplantation matory cascade is mediated by multifaceted processes that have been better described in the last 10 years.
Autoimmunity
Immunosuppressive agents available in clinical practice act at different points of those cascades at the intra­
cellular or extracellular level. Those drugs can mediate their effects on one or more cell types finally limiting
inflammation and immune responses to antigens. Every immunosuppressive agent is characterized by intrinsic
toxicity and side effects that may be due to the same therapeutic pathways or to off-target secondary effect of
each molecule. We will here review the mechanisms of action of the most widely used immunosuppressive agents
in the field of solid organ transplantation and autoimmune disorders, describing the mechanisms underlying both
the therapeutic and secondary effects.

Introduction
The introduction of drugs able to modulate the innate and adaptive
harms of the immune system has allowed significant advances in the
outcomes of non- HLA identical solid organ transplantation as well as in
the control of autoimmune diseases. In fact, both alloimmunity and
autoimmunity share common biological mechanisms. The most widely
used immunosuppressants act at different levels of the immunological
response, both at the T cell and B-cell level.
We will here review the mechanisms of action of the immunosup­
pressive agents used in clinical practice (Table 1).
Immunosuppressive agents
Small molecules
Corticosteroids
Corticosteroids are the steroid hormones of adrenal cortex produc­
tion, further classified in glucocorticoids and mineralocorticoids. In
clinical practice, glucocorticoids and corticosteroids can be used as
synonyms. Corticosteroids are historically the cornerstone of most
immunosuppressive approaches, having pleiotropic effects (and side
effects).
Those molecules act at a different level according to their dosing [1].
When used at low dose (<30 mg of prednisone) the activity is mediated
by interaction with the intracellular cytoplasm glucocorticoid receptor
(GR) a member of the nuclear receptor family of ligand-activated tran­
scription factors. After binding of glucocorticoids to GR, the GR un­
dergoes hyperphosphorylation, dissociates from the multiprotein
complex usually associated and can translocate into the nucleus, where
it is involved in gene expression regulation (genomic action). The action
can be mediated by direct activation and repression of specific genes but
is mainly due to an interaction with transcription factors. One of the
most important is the NF-kb and AP-1 complexes, cytoplasmatic regu­
lators of several genes controlling the transcription and synthesis of
adhesion molecules and cytokines. NF-Kb activation is inhibited by the
presence of the complex corticosteroids-cytoplasmatic receptor through
the synthesis of the inhibiting factor IkB. This effect results in the inhi­
bition of proinflammatory cytokines (IL-1, IL-6, IFN, nitric oxide) in
different cell types [2,3]. Most of the effects are specific for each cell
type with different genes being targeted according to the GR binding site
and possible recruitment of coactivators.
At high doses (>30 mg of Prednisone) the effect is not mediated by
genetic transcription but through direct impact on membrane fluidity
because of the lipophilic structure of corticosteroids as well as by
interaction with cytosolic GR or membrane-bound GR (non-genomic
action). Since no protein synthesis is necessary, the action is faster,
within minutes. High doses steroids result in altering of physicochemical

* Corresponding author.
E-mail addresses: mmeneghini@vhebron.net (M. Meneghini), obestard@vhebron.net (O. Bestard), jgrinyo@ub.edu (J.M. Grinyo).

https://doi.org/10.1016/j.bpg.2021.101757
Received 5 June 2021; Accepted 11 June 2021
Available online 16 June 2021
1521-6918/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
M. Meneghini et al. Best Practice & Research Clinical Gastroenterology 54-55 (2021) 101757

Table 1 both T and B lymphocytes are dependent on the de novo pathway of

Description and mode of action of most used immunosuppressants. purine synthesis, those cells are the main target of MPA. Moreover, MPA
Description Mechanisms of action also blocks adhesion molecules by interacting with transfer of fucose and
mannose residues of glycoproteins. In particular, it inhibits the integrin
SMALL MOLECULES
Corticosteroids Steroid hormones Pleiotropic effects. VLA-4 synthesis reducing leukocyte adhesion to endothelial cells [7].
Inhibition of The MPA Cmin plasma has a discrete correlation with AUC (r = 0.64).
proinflammatory In practice it is recommended to maintain MPA Cmin values between 1
genes’transcription. and 3 mg/mL or AUC of MPA between 30 and 55 mcg/ml/h to prevent
Antimetabolite Competitive (Azathioprine, Interference with DNA
agents Methotrexate) or Non- synthesis and cell
acute rejection in kidney transplantation [8].
competitive (MPA) proliferation. Mycophenolate mofetil (MMF) has an oral bioavailability greater
inhibitors of nucleic acid than 90%, with high inter-individual pharmacokinetic variability. After
synthesis absorption, the ester is hydrolyzed releasing the MPA (having a 1st peak
Calcineurin CsA: lipophilic cyclic Binding to Calcineurin
between 0.6 and 1 h). MPA is metabolized to inactive glucuronide
inhibitors endecapeptide; TAC:
macrolide antibiotic (MPAG) with renal elimination. In cases of renal impairment, MPAG in
mTOR inhibitors SRL: macrolide antibiotic; Formation of a complex with excess can compete with MPA for protein binding resulting in an
EVL: SRL analogue the FKBP12, binding to the increased free fraction. MPAG also has biliary excretion and is decon­
mTOR kinase jugated by the intestinal flora, resulting in an enterohepatic circulation
POLYCLONAL BIOLOGIC PREPARATIONS
Polyclonal Polyclonal Depletion of Lymphocytes
which accounts for the second peak of MPA between 6 and 12 h after
antilymphocyte immunoglobulins from and other inhibitory oral administration of MMF [9]. Importantly, this entero-hepatic cir­
sera rabbits immunized with functions on T cells culation, is inhibited by the calcineurin-inhibitor Cyclosporin A, causing
human thymocytes or lower bioavailability of MPA when these two agents are used in
Jurkat cells
combination.
Intravenous Plasma-derived human Pleiotropic
immunoglobulins immunoglobulins immunomodulatory effects. Despite equivalent immunosuppressive effect, some differences exist
BIOLOGIC AGENTS between the two available formulations of MPA. The more recent
MONOCLONAL OR formulation of MPA is mycophenolate sodium enteric-coated (MPS),
FUSION specifically designed to attenuate gastrointestinal effects of MPA drugs.
PROTEINS
The main difference with MMF is that, due to the enteric coating, MPS is
Costimulation Chimeric CTLA-4 proteins Downregulation of CD28-B7
blockade costimulatory signal dissolved in the bowel and not in the gastric acid possibly limiting some
Anti -IL2 R Chimeric monoclonal Blocking and internalization of the gastrointestinal side effects [10].
antibody of IL2-R reducing IL-2 Methotrexate is also an anti-metabolite inhibiting DNA/RNA syn­
dependent T cell activation-
thesis by interference with purine metabolism. It is a folic acid antago­
proliferation
Anti-CD52 Humanized monoclonal Depletion of CD52 positive nist and by inhibiting the enzyme dihydrofolate reductase deprives of
monocolonal antibody cells RNA and DNA all those cells with rapid differentiating cell cycle. It also
antibody has an effect of downregulation of adhesion molecules, and interference
Anti- CD20 Chimeric monoclonal Depletion of CD20 positive at the IL-1β - IL-1R interaction. After rapid entrance into the different
monocolonal antibody cells
cell types, methotrexate is converted in methotrexate polyglutamates,
antibody
poorly moving through cellular membranes. This leads to cellular
Abbreviations: MPA: Mycophenolic acid; CsA: Cyclosporine A; TAC: Tacrolimus; entrapment, causing retention into liver and kidney and possible toxicity
SRL: Sirolimus; EVL: Everolimus; FKBP-12, FK binding protein; IL-2R Interleukin to those cells. The MTX polyglutamates are thought to be responsible for
2 receptor.
most of the anti-inflammatory effects.
Nowadays, it has a limited use as compared with Azathioprine and
properties of cell membrane and modification of intracellular Ca2+ MPA in the setting of antirejection treatments as well as autoimmune
concentrations and interaction with signaling cascades such as MAPK diseases [11].
signaling pathways [4]. In thymocytes, those agents can mediate regu­
lated apoptosis [5]. Calcineurin inhibitors (CNI)
These agents are of great importance in the prevention of solid organ
Antimetabolite agents transplant rejection and in the maintenance treatment of T-cell mediated
These drugs act by interfering with DNA synthesis and cell autoimmune diseases.
proliferation. Cyclosporin A (CsA) and Tacrolimus (TAC) have different structures
Azathioprine is a purine analogue that mediates its effect by pre­ but both act by binding to cytoplasmic proteins belonging to the family
venting the synthesis of nucleic acids. It is metabolized in the liver into of immunophilins and finally interacting with the action of calcineurin
thioinosinic acid and 6-methyl mercaptopurine. The active compound is (also known as Protein-phosphatase 2B) [12].
thioinosinic acid, a purine analogue of guanine interfering with RNA Cyclosporine (CsA) is a highly lipophilic cyclic endecapeptide iso­
and DNA synthesis and resulting in a cytotoxic effect on leukocytes. lated from the fungus Tolypocladium inflatum that binds to cyclophilin.
Degradation of azathioprine metabolites is mediated by xanthine oxi­ The CsA-cyclophilin complex inhibits the action of calcineurin. Tacro­
dase enzyme [6]. limus (TAC) is a macrolide isolated from Streptomyces tsukubaensis.
Mycophenolic acid (MPA) is the active ingredient of two drugs: The cytosolic immunophilin blocked by TAC is called FKBP-12 (FK
Mycophenolate mofetil (MMF) and enteric-coated mycophenolate so­ binding protein). The TAC-FKBP complex also inhibits the enzyme
dium (MPS). calcineurin.
MPA is a reversible and non-competitive inhibitor of the inosine By inhibiting calcineurin, both drugs block the transcription of nu­
monophosphate dehydrogenase (IMPDH) enzyme. This enzyme acts clear factors of activated T cells (NFAT). The result is that T cells are
catalyzing the conversion of inosine monophosphate into guanine. maintained in a resting state because T-cell stimulation signals do not
Therefore, the inhibition results in impaired de novo synthesis of guanine result in the transition of G0 to G1 of cell cycle. Also, calcineurin inhi­
and DNA replication. Both isoforms of IMPDH, the constitutive and bition prevents the synthesis of various cytokines such as IL-2, IL-4 and
inducible are targeted by MPA but the action is significantly stronger on IFN-γ, and IL-2 receptor. At the same time, CNIs act on regulatory
the inducible isoform, which is expressed during cell activation. Since molecules of T-cell activation such as NF-kB, JNK (N-terminal kinase c-

2
M. Meneghini et al.
Jun), Elk-1 and nitric oxide synthase [13]. Aside the action mediated
through calcineurin inhibition, CsA also increased transforming growth
factor β (TGF-β). IL-2 stimulated T lymphocytes are sensitive to TGF-β
actions that reduces their proliferation, contributing to the immuno­
suppressive effect. However, this effect can also mediate renal intersti­
tial fibrosis and associated nephrotoxicity. Since both CNIs decrease IL-2
synthesis, it must be noted that they have an undesired inhibitory effect
on the generation of T-reg cells, which are highly dependent on this
cytokine for their differentiation and expansion [14].
Cyclosporine A is soluble in lipids and administered mainly by oral
and in limited cases by intravenous route. Oral absorption of CsA suffer
of a high degree of intra and inter- individual variability. The
bioavailability is around 30%, therefore the intravenous dose recom­
mended is 30-30% of oral dose. Classic CsA formulation needed the
presence of bile for absorption. The CsA microemulsion (Neoral ®) im­
proves the oral bioavailability of the drug and increases drug exposure
by 34% (faster and higher peak, around 67%), decreasing the intra-
individual variability and improving the correlation between CsA-Cmin
and actual exposure to the drug [15]. In clinical practice, pharmacoki­
netic monitoring is performed by 12-h trough levels (C0) of CsA and TAC
in whole blood, but controversies exist on the optimal monitoring
strategy [16]. CsA metabolism takes place both in the liver and in in­
testinal epithelial cells through the cytochrome P450 (CYP3A). It is
therefore highly susceptible to drug-to-drug interactions.
The most relevant side effect of CNIs is nephrotoxicity, that can be
both acute-reversible and chronic associated to structural damage. A
hemodynamic effect is due to decreased glomerular filtration rate by
vasoconstriction of both the afferent arteriole and efferent arteriole. This
effect may depend on the activation of the renin-angiotensin-
aldosterone system induced by endothelin. In addition, an endothelial
dysfunction associated to CNIs has been described, due to increased
thromboxane production and decreased synthesis of vasodilating agents
such as nitric oxide and prostaglandin E2 [17]. Moreover, direct cyto­
toxicity on renal tubular cells can be exerted especially by the intrave­
nous formulations due to the vehicle, polyoxyethylated castor oil, the
Cremaphor, which also produces a decrease in renal plasma flow. Direct
CsA tubular toxicity has been shown in in vitro models [18].
The chronic non-reversible nephrotoxic effects are histologically
represented by arteriolar hyalinosis, interstitial fibrosis, and tubular
atrophy that can be described as “striped” [19]. The underlying mech­
anisms are the prolonged hemodynamic-ischemic effects, the increased
levels of TGF-β1 and angiotensin II, inhibition of P-glycoprotein and
induction of apoptosis in renal tubular epithelial cells [20,21].
TAC differentiates from CsA in the pathway it interferes with but has
the same final target. It has been shown to be superior to Cyclosporine A
in the prevention of kidney and liver allograft rejection and has a slightly
different spectrum of side effects (discussed in detail elsewhere). Among
these, it must be noted that tacrolimus leads to increased glucose
intolerance as compared to CsA [22].
Apart from the classical formulations, extended-release preparations
exist, allowing once-daily administration, possibly facilitating adher­
ence. A recent MELTDose technology formulation has also been intro­
duced. This solid solution galenic formulation has a different
pharmacokinetic profile and improved absorption, reducing the dose
from 1 to 0.7 in conversion studies. This formulation results in lower and
delayed Cmax, which results in a more sustained inhibition of calcineurin
activity [23].
Mammalian target of rapamycin (mTOR) inhibitors
The inhibitors of mTOR approved as antirejection treatments in solid
organ transplantation are Rapamycin (Sirolimus) and Everolimus (EVL).
Sirolimus (SRL) is a macrolide antibiotic produced by Streptomyces
hygroscopicus, an actinomycete originally isolated in Rapa Nui Island.
This molecule has been first used as an antifungal, but after the obser­
vation of immunosuppressive effect it is now included in antirejection
maintenance schemes. EVL is an analogue of rapamycin, 40-O-
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Best Practice & Research Clinical Gastroenterology 54-55 (2021) 101757
(hydroxyethyl)-rapamycin. The main difference between the two drugs
is the half-life, being 60 h for SRL and 22 h for EVL. Therefore, SRL is
administered once a day and EVL every 12 h.
Both molecules are prodrugs that bind to FKBP12 (cytoplasmic
immunophilin), the same binding protein as for TAC. However, they
mediate an effect independent of calcineurin inhibition.
The SRL/EVL-FKBP complex binds to the m-TOR protein kinase. It
mTOR is the catalytic subunit of two complexes named mTOR complex
(mTORC) 1 and mTORC2.
While both are downstream mediators of the PI3K/AKT pathway,
mTORC1 is especially involved in regulation of cell growth, prolifera­
tion, and protein synthesis control and mTORC2 has main functions in
cell survival, polarization and cell structure [24].
mTOR inhibitors mediate their action after forming a complex with
the FKBP12, which binds to mTOR with high affinity.
TORC1 is equally inhibited by SRL and EVL, while SRL has signifi­
cantly less effect on mTORC2.
The PI3/Akt/mTOR signaling cascade enhances cell proliferation
mediated by several cytokines and growth factors: IL-2/IL-2 receptor
complex but also IL-11, G-CSF, insulin growth factor (IGF-1), VEGF,
epidermal growth factor (EGF) and erythropoietin. Therefore, mTOR
inhibitors block cell-cycle progression from G1 to S phase [25]. The lack
of an inhibition on the axis IL-2/IL-2 receptor might explain a beneficial
effect on the T-reg population, that seem to be increased in mTORi
treated patients.
Importantly, these drugs are not nephrotoxic but may delay the re­
covery from acute tubular necrosis. Moreover, mTOR inhibitors may
exacerbate CNI-related nephrotoxicity, therefore low doses of CNI seem
recommendable when used in conjunction with mTOR inhibitors. Also,
regarding their impact on kidney function, a direct effect of mTOR in­
hibitors on renal podocytes is responsible for the appearance of pro­
teinuria for impaired integrity of the glomerular capillary wall.
In the field of solid organ transplantation, a possible anti-viral effect
of mTOR inhibitor has emerged, in fact in different cohorts of transplant
recipients it has been observed a reduced incidence of Cytomegalovirus
and Polyoma Virus infections in patients receiving those agents. It is not
fully explained the mechanism behind those observations. The most
interesting hypotheses are the increased CD8 memory T-cells response
and functionality, the interference with the mTOR (PI3K-AkT) cascade,
being this an anti-apoptotic signal necessary for viral survival and
transmission, and finally a direct antiviral effect by reduction of viral
protein synthesis [26].
Another important observation from clinical studies, is that patients
under mTOR inhibitor treatment display lower incidence of neoplasms
after solid organ transplantation. This effect possibly relies on the un­
controlled activation of the mTOR (AkT/PI3K) pathway in a large pro­
portion of malignancies. Additionally, mTOR inhibitors block
translation of some procarcinogenic mRNAs including VEGF (angio­
genesis), cyclin D1 (cell cycle), and IL-10 (decreased Jak/STAT activity)
[27].
mTOR inhibitors are substrates of cytochrome P-450 (CYP3A4) and
P-glycoprotein, therefore suffer from the same drug interference phe­
nomena as CNIs.
Polyclonal biologic preparations
Polyclonal ANTILYMPHOCYTE sera
The most widely used polyclonal anti-lymphocyte preparations are
anti-thymocyte globulins (ATG). ATG are obtained from rabbits immu­
nized with human thymocytes (Thymoglobulin) or Jurkat cells (ATG-
Fresenius) and therefore contain a mix of antibodies directed against
several lymphocyte surface molecules. Those sera have a depleting effect
on lymphocytes, mainly mediated by T-cell apoptosis in peripheral
lymphoid tissues by means of caspase-3 activation [28]. In addition,
ATG down-modulates surface CD3, CD2, CD4 and CD8 molecules on the
remaining lymphocytes impairing T-cell functional responses. When
M. Meneghini et al.
analyzing the composition of the polyclonal sera it has been possible to
identify antibodies directed against adhesion molecules on lymphocytes,
monocytes and neutrophils, and chemokine receptors on lymphocytes
and monocytes. All those mechanisms may have a role in reducing the
ability of T cells to infiltrate graft tissues during ischemia reperfusion
injury and acute allograft rejection [29].
The result of ATG treatment is a profound CD4+ T-cell depletion,
possibly in the long term. After depletion, the repopulation process takes
place, involving both naïve and memory T cells together with thymo­
poiesis. The administration of ATG induces peripheral expansion and
new thymic emigration of T cells with a T regulatory (Treg) phenotype
[30]. Additionally, functional studies indicate that ATG interfere with
the functionality of dendritic cells (DC) reducing the capacity of mature
DC to stimulate allogenic and autologous T cells [31].
Even if ATG administration often provokes the generation of anti­
bodies directed against rabbit immunoglobulins it has been reported
that a second course of rabbit ATG (rATG) results in similar lymphocyte
depletion and is as well tolerated as a first course [32].
ATG are used both for induction in allotransplantation and in
treatment of severe T-cell mediated rejection.
Intravenous immunoglobulins
Intravenous immunoglobulins (IVIG) are a compound of plasma-
derived immunoglobulins from several human donors, conferring a
wide immunological repertoire. IVIG have an immunomodulatory effect
whose mechanisms of action are not completely known. They modulate
expression and function of Fc receptors (common fragment of immu­
noglobulins), interfere with complement activity, interfere with cyto­
kines action, inhibit T and B-cell activation and differentiation. In vitro,
it has been shown that IVIG administration in mixed lymphocyte reac­
tion results in reduced expression of CD40, CD86, Class II MHC, CD19
and adhesion molecules [33].
This compound can be used in solid organ transplantation for
treatment of antibody-mediated rejection as well as in autoimmune
diseases.
Biologic agents, monoclonal antibodies or Fusion proteins
Costimulation blockade
After T cell receptor (TCR) interaction with MHC and antigenic
peptide by antigen presenting cells (APC), the activation of cos­
timulation pathways is the essential second step of T-cell activation.
The only therapeutic agents currently available in clinical practice
acting as costimulatory blockers are Abatacept and Belatacept.
Both drugs are fusion proteins designed to block the CD28 ligands on
antigen presenting cells, CD80 and CD86 (B7). B7 molecules are hyper-
expressed after APC activation and the interaction with CD28 results in
T-cell activation and proliferation, while its binding with the receptor
CTLA-4, expressed by already activated T cells, leads to hypo-activation
and reduced polyclonal expansion as negative regulation.
Abatacept and Belatacept are chimeric proteins CTLA-4 Ig with high
affinity for B7-1 (CD80) on the antigen presenting cells, resulting in a T-
cell hyporesponsiveness against specific antigens. Moreover, some in
vitro studies demonstrated an additional direct effect on B cells (inde­
pendent from the inhibition of follicular T helper cells) impairing acti­
vation and differentiation to antibody-secreting plasmablasts [34].
The difference between Abatacept and Belatacept consists of a
change in 2 amino acids in the B7 binding region, resulting in 4-times
higher affinity of Belatacept for CD80 and two times higher for CD86.
In vivo it leads to higher inhibition of T-cell activation up to 10 times,
therefore it is the only costimulation inhibitor drug approved for the
prevention of kidney transplant rejection. Some experiences in liver
transplantation are available, being an appealing option to avoid CNI
associated nephrotoxicity [35].
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Best Practice & Research Clinical Gastroenterology 54-55 (2021) 101757
ANTI-IL-2R monoclonal antibodies
IL-2 receptor (IL-2R) is constituted of three sub-units not covalently
bound: IL-2Rα (CD25, 55 kDa), IL2Rβ (CD122, 70/75 kDa) and IL-2Rγ
(CD132, 64 kDa). While β and γ chains are constitutively expressed, the
α chain is expressed only on activated T lymphocytes, conferring a high
affinity for IL-2 and consequent T-cell clonal expansion driven by the
cytokine.
Anti IL-2 receptor monoclonal antibodies (IL-2Ra) are directed
against this α chain (CD25) of the IL2-R. The binding of IL2Ra to CD25
leads to internalization of IL2-R blocking clonal T cell expansion
dependent of IL-2. A possible escaping pathway is activation because of
IL-7 or IL-15 pathways.
Two forms of IL2-R antagonists exist: a first humanized form,
daclizumab is now out of use while the chimeric version, Basiliximab, is
currently used for induction treatment in solid organ transplantation.
Basiliximab has a high avidity for its target, the half-life is 8 days and
standard dose is an administration of 20 mg on days 0 and 4 after
transplantation. The discontinuation of production of daclizumab in
2009 because of commercial reasons resulted in Basiliximab as the main
IL-2Ra available in clinical practice. In the few studies comparing both
IL2R antagonists in the prevention of acute rejection, there were no
significant differences between them [36].
Anti CD52 monocolonal antibody
Alemtuzumab (Campath-1H) is a humanized monoclonal antibody
directed against the pan-lymphocyte CD52 antigen present on human
lymphoid and myeloid cells. It is a depleting antibody inducing a pro­
found and durable lymphopenia through a Fc-mediated mechanism,
mediating antibody-dependent cell-mediated cytotoxicity of target cells.
Most B and T lymphocytes display high CD52 expression, but also the
majority of NK cells, monocytes and macrophages, and a small per­
centage of granulocytes. It is not expressed on erythrocytes or hemato­
poietic stem cells [37].
It is used as a depleting therapy in the induction treatment of solid
organ allotransplantation [38], as well as in autoimmune diseases.
ANTI-CD20 monoclonal antibody
The CD20 receptor is a transmembrane protein expressed on mature
B lymphocytes. Rituximab is a chimeric monoclonal antibody directed
against CD20, of the IgG1k subtype. It has a high affinity for CD20 and
mediates B-cell depletion through complement mediated toxicity as well
as antibody-mediated cytotoxicity by effector immune cells. The main
effect is observed in circulating B cells in peripheral blood, and to a
lesser extent in secondary lymphoid organs [39]. The consequent B cell
depletion is fast (72 h) with long-lasting effect up to 12 months. It is
usually not associated to hypogammaglobulinemia because plasma cells
are not targeted, since they do not express CD20. Importantly, since also
regulatory B cells express CD20, Rituximab can impair the regulatory
and anti-inflammatory functions of those cells producing IL-10. This
might explain the disappointing results of Rituximab alone as induction
therapy in allotransplantation or inflammatory bowel diseases, even
leading to exacerbations [40].
It is used for desensitization for AB0 incompatible liver trans­
plantation, for the treatment of antibody mediated rejection after allo­
transplantation and to target B cells in antibody mediated autoimmune
diseases such as autoimmune hepatitis, IgG4 mediated diseases, and
primary biliary cholangitis [41].
Ofatumumab, a completely humanized second generation anti-CD20
monoclonal antibody binds to a different CD20 epitope than Rituximab
[42] and may limit adverse reactions and constitute a possible alterna­
tive in cases of intolerance to Rituximab.
Other biologic agents
In recent years, a main advance in the field of immunosuppression
has been the generation of monoclonal antibodies targeting different
M. Meneghini et al.
mediators of the inflammatory cascade. Those agents have been already
incorporated as first-line treatment of different rheumatological diseases
and have potential use in many autoimmune mediated disorders, alone
or in combination with other immunosuppressive agents.
Currently available biologic agents more widely used in clinical
practice are anti-tumor necrosis factor-alpha (TNF-α), anti-integrin and
anti-interleukin IL-12-23.
Anti-Tumor necrosis factor α (TNF-α) agents (Infliximab, adalimu­
mab, certolizumab, and golimumab) are monoclonal antibodies inhib­
iting interaction of the pleomorphic TNF-α cytokine with both soluble
(sTNFR) and membrane bound (TNFR1 and TNFR2) receptors, therefore
blocking the inflammatory cascade including NK-kB. In addition, it has
been shown that TNF-α inhibitors can induce apoptosis of TNF-
α–producing immune cells, reducing further production and signaling
amplification. Infliximab is a chimeric engineered IgG1 monoclonal
antibody, Adalimumab and Golimumab are fully humanized IgG1 while
Certolizumab is a PEGylated Fab fragment of humanized IgG1 mono­
clonal antibody. Pegylation enhances antibody stability, half-life, and
bioavailability [43,44].
The anti-integrin drugs (vedolizumab, natalizumab) act by blocking
the interaction between endothelial cells and adhesion molecules, a
limiting step for immune cells migration and tissue inflammation.
Natalizumab blocks α4 integrin, necessary for white cells movement
toward target organs and migration of leukocytes to inflamed sites.
Vedolizumab is a humanized anti-α4β7-integrin IgG1 monoclonal anti­
body. It acts by blocking α4β7-integrin, a gut-specific homing receptor
necessary for adhesion of leukocytes to the gut selectively [45].
Fig. 1. Cell targets on T cells and antigen presenting cells and their interactions and immunosuppressive agents. Adapted from the book: Hernando Nefrología
Clinica, 5th edition, Panamericana.
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Best Practice & Research Clinical Gastroenterology 54-55 (2021) 101757
Anti interleukin IL-12-23 (ustekinumab) monoclonal antibodies
target two important cytokines involved in lymphocyte function. IL-12 is
produced by antigen-presenting cells and is necessary for the develop­
ment of T cells with Th1 profile, secreting interferon-gamma. IL-23 is
produced by antigen-presenting cells, monocytes, and macrophages and
triggers the differentiation and activation of Th17 cells. Ustekinumab
targets a subunit (p40) common to the IL-12 and IL-23 receptors
expressed on T cells and NK cells. It is a human monoclonal IgG1 anti­
body, of subcutaneous or intravenous administration [46].
Tofacitinib belongs to the family of Janus kinase (JAK) inhibitors,
and initially considered as specific JAK-3 inhibitor. JAK are enzymes
belonging to the Janus proteins family [47]. They belong to the group of
tyrosin-kinase, involved in the proximal steps of signal transduction
from positive cytokine signals (IL-9, IL-12, IL-23 and IFN-γ) toward cell
nucleus. While Tofacitinib is non-selective, targeting the different JAK
isoforms has been explored, in particular JAK-3 transmits activation
signals mediated by the shared γ chain of IL-2, IL-4, IL-7, IL-9, IL-15 e
IL-21 receptors on NK cells, thymocytes and activated B and T cells,
possibly limiting the effect to activated cells and not those in quiescent
state.
Fig. 1 shows the targets of the main immunosuppressants on T cells
and antigen presenting cells and their interactions.
Summary
In this review, the mechanisms of action of the main immunosup­
pressants have been discussed. It should be noted that more than one
M. Meneghini et al.
agent can target the same molecular pathway at different levels and
some drugs can display significant interactions between them. It is
important to know all those mechanisms when using and combining the
available drugs in the clinical practice. Also, the mechanisms underlying
most relevant side effects should be considered when choosing treat­
ment schemes as well as for the design of more modern and specific
molecules.
Practice points
- The development of effective immunosuppressive agents has
improved the control of immune-mediate injury in allo­
transplantation and autoimmunity
- Intrinsic toxicity and side effects limit the use of immunosuppressant
agents especially in chronic regimens
- Comprehension of biological mechanisms underlying alloimmunity
and alloimmune processes can identify new molecular targets or
uncover the potential use of other agents developed in oncology or
rheumatology.
Research agenda
- Modern technologies permit a deeper knowledge of the mechanisms
underlying therapeutic and toxic effects of immunosuppressive
agents and can be used to develop new molecules with more specific
molecular targets.
- The development of new molecules with more specific targets to
control immune responses without redundant effects is highly
recommendable.
Declaration of competing interest
None.
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