IMMUNOMODULATOR

Dr. Hj. Rika Yuliwulandari, PhD

OVERVIEW

I. Immune System Overview II. History of Immunology III. Current Treatment Techniques
Immunosuppressants Immunostimulants

Immunization
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IMMUNE RESPONSE

Non-specific (Basically just recognizes foreign vs native)

First line of defense Activation (endotoxin, MAF) Phagocytosis (m, neutrophils, All types of White Blood
Cells (Leukocytes), Dendritic Cells

Lysis (NK) Lysis (Complement cascade)

Antigen specific MHC restricted antigen presentation Humoral (antibody) Cell-mediated (T cells) DTH: Lymphokines produced by Agstimulated T cells recruit/activate m.

CHARACTERISTICS OF INNATE AND ADAPTIVE IMMUNITY Innate Immunity

Antigen independent No time lag Not antigen specific No Immunologic memory
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Adaptive Immunity
Antigen dependent A lag period Antigen specific Development of memory

CMI and Humoral (Ab) immunity)

EXAMPLE OF IMMUNOLOGIC CASES

Transplantation Rejection
Allografts from different individuals Xenograft from different species

Tissue rejection may occur by TH cells recognizing different MHC II, aid TC to destroy graft (recognize MHC I) TH cells also release cytokines, cue macrophages Graft vs host disease (bone marrow transplants)
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RHEUMATOID ARTHRITIS

Disease that leads to inflammation of the joints and surrounding tissues Can affect organs The immune system confuses healthy tissue with foreign and begins to attack itself Occurs at any age, usually affects women more than men Affects joints on both sides equally
Wrists, fingers, knees, feet, ankles

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SYSTEMIC LUPUS ERYTHEMATOSUS

Autoimmune disease Symptoms:

Chest pain, fatigue, fever, general discomfort, hair loss, mouth sores, sensitivity to sunlight, skin rash, swollen lymph nodes, arrhythmias, blood in urine, abdominal pain, coughing up blood, patchy skin colors

Other form: lupus nephrititis

Can cause kidney failure and lead to dialysis
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OTHER IMMUNOLOGICAL DISEASES

Type I diabetes mellitus Multiple sclerosis Asthma Allergies

TWO CATEGORIES

Drugs that suppress the immune system

Suppression overcomes rejection of organ/tissue transplantation and reduces effects of autoimmune diseases

Drugs that stimulate the immune system

Stimulation enhances activity of immune system against infectious agents and neoplastic cells

TREATMENT STRATEGIES

Immunosuppression involves downregulating immune system activity Tolerance the idea that a body can be taught not to reject something Immunostimulation involves upregulating immune system activity Immunization active or passive

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IMMUNOSUPPRESSIVE AGENTS
T-cell blockers/Calcineurin inh

Glucocorticoids

Cytotoxic drugs

CYCLOSPORINE TACROLIMUS SIROLIMUS CORTICOSTEROIDS CYCLOPHOSPHAMIDE AZATHIOPRINE MYCOPHENOLATE MOFETIL METHOTREXATE

ANTIBODIES
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Antibody reagents

T-CELL BLOCKER

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T-CELL BLOCKERS/CALCINEURIN INH: CYCLOSPORINE, TACROLIMUS, AND SIROLIMUS

Most effective immunosuppressive drugs Target intracellular signalling pathways Blocks induction of cytokine genes cyclosporine and tacrolimus act on helper T-cells: inhibit T-cell receptor-activated induction of IL2

cyclosporine may also inhibit IgEstimulated mast cell degranulation and stimulate TGF- expression

Structure

sirolimus inhibits T-cell activation and proliferation and IL-2 induction

Tacrolimus a.k.a. FK-506

Cyclospo rin A

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CsA and FK506 mechanism of action

Complex with binding protein (CpN, FKBP) inhibits calcineurin (CaN) CaN is required for dephosphorylation and nuclear translocation of NFAT (nuclear factor of activated T cells)

CaN inhibition, blocks NFAT resulting in inhibition of IL-2 gene

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ABSORPTION AND METABOLISM OF CYCLOSPORINE, TACROLIMUS

Oral bioavailability low and variable (20 -50% cyclosporine; 6 - 56% tacrolimus) Almost all excreted in bile after liver metabolism by CYP3A enzymes
bioavailability subject to drug interactions that can increase or decrease blood levels
new cyclosporine microemulsion gives more consistent absorption

Pharmacokinetics variable, incomplete oral absorption extensive hepatic metabolism, excreted in bile used alone or in combination with prednisone and azathioprine (or other antineoplastic drugs) Adverse Effects nephrotoxicity, hepatotoxicity, hirsutism, neurotoxicity 15 and inhibition of hepatic cytochrome Drug interactions due to induction P450

USES OF CALCINEURIN INHIBITORS (T-CELL BLOCKERS)

Cyclosporine commonly used with prednisone and other immunosuppressants to prevent allograft rejections in renal, hepatic and cardiac transplants, and in treatment of RA and psoriasis Tacrolimus is approved for prevention of solid-organ allograft rejection, and eczema (topical)

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TOXIC EFFECTS OF CYCLOSPORINE AND TACROLIMUS

Nephrotoxicity (C>T) Neurotoxicity (T>C) GI problems (T) Hypertension (C>>T) Hyperkalemia (T) Hyperglycemia and onset of diabetes
especially with glucocorticoids (T>C) Increased incidence of infections and secondary tumors least of immunosuppressants
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SIROLIMUS AND EVEROLIMUS: NEW T-CELL BLOCKERS WITH DIFFERENT ACTIVITY

Pre-drug sirolimus binds FKBP, but the complex inhibits mTOR kinase mTOR activates p70S6K mTOR inhibition prevents activity of p34cdc2 which complexes with cyclin E, thus preventing elimination of p27Kip which is a negative regulator of cdks and eIF-4F

Results in inhibition of cell cycle proogression at G1 to S phase

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SIROLIMUS AND EVEROLIMUS: NEW T-CELL BLOCKERS

similar poor bioavailability as cyclosporine and tacrolimus, much longer half-life; 62 h vs. 18 and 12 h same metabolism (CYP3A) and potential drug interactions used for prophylaxis of organ transplant rejection in combination with a calcineurin inhibitor and glucocorticoids toxicities include: hyperlipidemia, lymphocoele, anemia, leukopenia, thrombocytopenia, fever, GI effects, hyper- or hypokalemia

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GLUCOCORTICOID

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IMMUNOSUPPRESSION GLUCOCORTICOIDS

Prednisone Dexamethasone

Cortisol 21

GLUCOCORTICOID USES IN IMMUNOSUPPRESSION

Used with other immunosuppressants to prevent transplant rejection and GVHD (synergistic effect/lower toxicity).
natural glucocorticoids not used due to mineralocorticoid activity

prednisone and prednisolone are used orally at high moderate doses; Very high doses of methylprednisolone used i.v. during acute organ rejection Used before and after antithymocyte Abs to inhibit allergic reactions

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GLUCOCORTICOID-SENSITIVE SITES OF IMMUNE RESPONDING

proliferation & differentiation

MHC Class I/peptides APCs

CD8 T-cell

GC
IL-1

CD8 cytolytic T-cells

X X

GC
CD4 T-cell (helper T-cells)

MHC Class II/peptides APCs

proliferation

CD4 immune cell (delayed hypersensitivity)

IL-1, -4,-5,-6

Protein antigen

B-cell proliferation & differentiation

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Plasma cell antibody production

GLUCOCORTICOID EFFECTS AND TOXICITY

Reduced immune cell content in Major side effects are lymph nodes, spleen and blood common due to high doses necessary for suppression
lymphopenia, monocytopenia, eosinopenia, but neutrophilia

Interference with antigen presentation, T-cell and macrophage functions

Cushings syndrome glucose intolerance infections bone dissolution muscle wasting

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CLINICAL CONCERNS WITH CORTICOSTEROIDS

Growth inhibition in pediatric transplants Cataracts (10% incidence) Bone disease (inhibition of osteoblastic activity, decreased calcium absorption, increased urinary calcium excretion) Diabetes (insulin-resistance, gluconeogenesis) Hyperlipidemia (40-60% posttransplant accelerated atherogenesis, increased incidence if combined with calcineurin inhibitors and sirolimus) Hypertension (60-80% in transplant patients) Increased cardiovascular risk factors 25 Predisposition to infection (decr. PMN, T cell activity)

IMMUNOSUPPRESSION GLUCOCORTICOIDS

Usually co-administered with other suppressive agents to treat auto-immune disorders or treatment of transplant rejection
Exact mechanism not elucidated Very broad anti-inflammatory effects

Downregulate IL-1 and IL-6

Cause apoptosis in activated cells

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CYTOTOXIC DRUGS

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MECHANISM OF ACTION OF MYCOPHENOLATE MOFETIL

Because the salvage pathway of purine synthesis is less active than the de novo pathway, lymphocytes depend on PRPP conversion to IMP and in turn GMP for DNA synthesis

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USES OF CYTOTOXIC AGENTS

Azathioprine; with cyclosporine and/or prednisone for organ transplant rejection and severe RA Mycophenolate mofetil; with cyclosporine and prednisone for renal transplants Cyclophosphamide; for BMT

Methotrexate; GVHD prophylaxis

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ANTIBODY REAGENTS

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IMMUNOSUPPRESSION MONOCLONAL ANTIBODIES

Anti-CD3 Antibodies
Binds to chain of CD3, which is involved in T-cell antigen recognition, signaling, and proliferation Administration of mAb followed by depletion of T cells from bloodstream and lymphoid organs Lack of IL-2 production Reduction of multiple cytokines
Not IL-4 and IL-10

Used to treat organ transplant rejection Muromonab-CD3 (Orthoclone OKT3)

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IMMUNOSUPPRESSION MONOCLONAL ANTIBODIES

Anti-IL-2 Receptor [Anti-CD25] Antibodies Exact mechanism not understood Binds to IL-2 receptor on surface of activated T cells
No effect on resting T cells

Stops current response

Daclizumab and Basiliximab

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IMMUNOSUPPRESSION OTHER AGENTS

Others include
Alemtuzumab (mAb) targets CD52, causes lympholysis by inducing apoptosis of targeted cells IL-1 Inhibition

Alefacept protein, interferes with T-cell activation

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IMMUNOSTIMULANTS

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IMMUNOSTIMULANTS

Immunostimulants are applicable during infections, immunodeficiency, and cancer Levamisole

Restores depressed immune function of B and T Cells, monocytes, and macrophages

Causes agranulocytosis
Removed from market in 2005

Levamisole
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IMMUNOSTIMULANTS

Thalidomide
Teratogenetic BUT is useful to treat erythema nodosum leprosum and multiple myeloma

Thalidomide
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IMMUNOSTIMULANTS

Interferons
Bind to spefici cell-surface receptors that initiate series of intracellular events
Induction of enzymes Inhibition of cell proliferation Enhancement of immune activity

Intron A - peptide used for tumor treatment and infectious diseases; Actimmune - peptide that activates phagocytes and induces generation of oxygen metabolites that are toxic to a number of microorganisms

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IMMUNIZATION

Active Stimulation with an Antigen Passive Preformed antibody

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ACTIVE IMMUNIZATION

Vaccines Administration of antigen as a whole, killed organism, or a specific protein or peptide constituent of an organism Booster doses Anticancer vaccines immunizing patients with APCs expressing tumor antigen.

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IMMUNE GLOBULIN

Indications Individual is deficient in antibodies immunodeficiency Individual is exposed to an agent, inadequate time for active immunization
Rabies

Hepatitis B

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Nonspecific immunoglobulins
Antibody-deficiency disorders

Specific immune globulins

High titers of desired antibody Hepatitis B, Rabies, Tetanus

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RHO (D) IMMUNE GLOBULIN

Antibodies against Rh(D) antigen on the surface of RBC Rh-negative women may be sensitized to Foreign Rh antigen on fetal RBC Anti-RH Antibodies produced in mother can damage subsequent fetuses by lysing RBCs Hemolytic disease of newborn

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IMMUNE TOLERANCE

Induction and maintenance of immunologic tolerance - active state of antigenic specific nonresponsiveness Still experimental

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SUMMARY

Immunosuppresion
Calcineurin inhibitors Glucocorticoids Antimetabolites

Newer immunosuppresive agents

Effective control of rejection Glucocorticoid withdrawal

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IMMUNIZATION

Active or passive
Active stimulation with antigen to develop antigens for future prevention Passive administration of antibodies to individual already exposed or about to be exposed to antigens

Vaccines active; administration whole, killed organism, live organism, or specific peptide from organism Immune Globulin used in passive immunization; used in individuals deficient in antibodies

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