Immuno modulatorImmuno-modulator

Prof.AznanLelo,dr,PhD SpFK,dr.Datten Bangun MSc,SpFK

Dept. Pharmacology & Therapeutic

School of MedicineUniversitas Sumatera Utara

13 Mei 2009, KBK-FK USU, Medan

Introduction :Patients with autoimmune disease- Patients with autoimmune disease, and patients who received

l d itransplanted tissue or organs, require therapy with immunosuppressive drugs.

± 50 years ago, started with :- CorticosteroidsCorticosteroids- Antimetabolites- Alkylating agentsAlkylating agents..

Over the past 20 years,the field of immunosuppression has shifted to specificimmunosuppression has shifted to specific inhibitors of immunity that affect distinct immune pathwaysaffect distinct immune pathways.

This is important because:= greater efficacy greater efficacy= reduced toxicity= more insight are gained into the= more insight are gained into the

operation of the immune system

Immune ProblemsImmune Problems• Major Histocompatibility Complex (MHC)Major Histocompatibility Complex (MHC)

is the major concern.• Rejections: -. Antibody mediatedj y

-. T cells mediated• HIV/AIDS• HIV/AIDS• Chronic infection

M li• Malignancy• Organ transplantation

Simplified Schematic of I R

proliferation & diff ti ti

an Immune Response

Class I

CD8+ T cells CD8+ cytolytic T cellsdifferentiation

CD4+ T cells CD4+ immune cellsAPC

Class II

proliferation & differentiation

(delayed hypersensitivity)CytokinesCostim. Mol.

IL 4 5 6Protein antigens B cells Plasma cells

proliferation & differentiation

IL-4,-5,-6

MHC class II/peptidesAPCs

antibodyproduction

differentiation

APC=Antigen Presenting Cell

ImmunostimulatorImmunostimulators are agents that increase the immune responses.

Natural Synthetic1 Vaccine BCG 1 Chloroquine

increase the immune responses.

1. Vaccine BCG 1. Chloroquine2. Interferon 2. Levamisol3 Interleukin 3 Isoprinosine3. Interleukin 3. Isoprinosine4. Phyllantus niruri (Meniran)

4. Phyllantus niruri (Meniran)

5. Tincture Echinacea

5. Tincture Echinacea

Andrographis paniculata (Sambiloto)6.Andrographis paniculata (Sambiloto)

BCG (Bacille Calmette-Guerin)BCG (Bacille Calmette Guerin)• Vaccine against tuberculosisg• Mechanism of action: unknown, may be activate

– macrophages, – NK cellsNK cells, – B cells, and – various T cells

• in vitro and• in vitro and • in vivo

• Indication: treatment and prophylaxis of bladder carcinoma (in situ)carcinoma (in situ)

• Side effects: fever, nausea, vomiting, cough and reddish of skin

CytokinesGeneral properties of cytokinesGeneral properties of cytokines.• A large and heterogeneous of protein with many

functions.-- pleiotropic• Synthesized within lymphoreticular cells• Synthesized within lymphoreticular cells.

– different cell make different cytokines.

• Immunoregulatory.g y– regulate specific immune response.– stimulate hematopoiesis.– facilitate immune response & activate inflammatory response

• Similar to hormone.• Short lived.• Bind to specific receptor on target cells.p p g• Rarely work alone.• Chemotaxis

The first group discovered,the Interferon,were followed by the Colony-Stimulating Factors(CSFs)

CytokinesRole of cytokines in disease

B t i l ti h k• Bacterial septic shock• Cancer• Inflammatory• AutoimmuneAutoimmune

eg. IFN-α : treatment of neoplasm IFN β t t t f lti l l iIFN-β : treatment of multiple sclerosisIFN-γ : chronic granulomatousCSFs : regulate the proliferation and differentiation

of bone-marrow progenitor cells

Mechanism of Action of Cytokines

Mechanism of Action of Cytokines

InterferonIFNs interact with cell receptor to produce a wide variety of effects thatIFNs interact with cell receptor to produce a wide variety of effects thatdepend on the cell and IFNs types.

Interferon Mechanism of Action Indication

Alfa= natural lymphokin

Activate:• macrophage • T cell NK cell

Antiviral Hepatitis C

T cell NK cell• B cell Ab

Beta • anti-inflammatory action• repairing the destroyed

Multiple-Sclerosis (MS)• repairing the destroyed

BBB in MS patient

Gamma activate macrophages • Anti-viral, • Anti tumor kidney Ca= immune interferon • Anti-tumor, kidney Ca• Chronic

granulomatous

ChloroquineChloroquine

• Quinolin derivative• Quinolin derivative• Mechanism of action:

– inhibit DNA Polymerase and RNA Polymerase. i hibi f i f h– inhibit fusion of macrophage

– irreversibly inhibit NO synthesis• Indication: rheumatoid arthritis, psoriasis• Side effects: ototoxic

Levamisole• Anti parasitic agent, imidazothiazole synthetic

M h i f ti t ll d t d• Mechanism of action: not well understood– Stimulates antibody formation to various antigens, – stimulating T-cell activation and proliferation, g– potentiate monocyte and macrophage functions,

including • phagocytosis, • chemotaxis and • increases motility and adherence of neutrophil

• Indication: rheumatoid arthritis, viral infection and systemic lupus erythematosus

• Side effects: nausea, vomiting, urticaria and agranulocytosisagranulocytosis

Other ImmunomodulatorOther Immunomodulator

IsoprinosineIsoprinosine• purine synthetic

Old d f h it l t• Old drug for herpes, genital warts, influenza, tumors, hepatitis B

• Has an adjuvant effect• Mechanism of action : ?

– Increased of NK cell cytotoxicity and – T cell and monocyte functional activities.T cell and monocyte functional activities.

Other Immunomodulator1.Phyllantus niruri (Meniran)Traditional herbTraditional herb • Increases production of

– IFN-γ &IFN γ & – TNF-α

• Used as adjuvant in patient with HIV infection & TB jtherapy.

2.Echinacea tinctureTraditional herb, Echinae purpurea (ruddeckia).Anti-oxidantAnti oxidant

Other ImmunomodulatorAndrographis paniculata (Sambiloto)

Other Immunomodulatorg p p ( )

• Traditional herb used for treatment of• Traditional herb, used for treatment of dysentery, diarrhea, or malaria.I d• Increased – Macrophage Migration Index (MMI) and – Lymphocytes proliferation.

• Legal drugs for HIV infection in Germany.

General Principles of ImmunosuppressionImmunosuppression

• Primary immune responses are more easilyPrimary immune responses are more easily suppressed than secondary (memory)

• Different immunosuppressants have differentDifferent immunosuppressants have different effects on different immune reactions

• Suppression is more likely achieved if therapy pp y pybegins before exposure to the immunogen----

as in Rh(-) mother with Rh(+) infant.

Ideal ImmunosuppressantIdeal Immunosuppressant

St l i i• Strongly immunosuppressive• Specific, no overall immunosuppression• Anti-infection ability• Low Toxicity for Vital OrgansLow Toxicity for Vital Organs• Low cost

L i i bi ti it• Long in vivo bioactivity• Easy to use

The use of immunosuppresant• in the rejection of a transplanted organ

- alloimmunity :- transplant rejection- graft versus host disease

• in several diseases in which an autoimmune t t ib t t th th icomponent may contribute to the pathogenesis:

– various connective tissue diseases such as • vasculitis or • systemic lupus erythematosus,

– certain type of glomerulonephritis, – chronic active hepatitis, p ,– psoriasis, – Crohn’n disease and

some haematological disorders– some haematological disorders

Currently used ImmunosuppressantsCategory Drugs

Cytotoxic Agentsanti-metabolite Azathioprine

DNA alkylating agent Cyclophosphamideinhibits dihydrofolate reductase Methotrexatey

inhibits IMP dehydrogenase Mycophenolate mofetil

Steroids Prednisone, Methylprednisolone, Dexamethasone etcDexamethasone, etc

Biological Agents ALG (anti-lymphocyte globulins), ATG (anti-thymocyte globulins), OKT3

F ng s Prod cts Cyclosporine Tacrolimus (FK506) SirolimusFungus Products Cyclosporine, Tacrolimus (FK506), Sirolimus,Rapamicin, Mycophenolate mofetil, 15-Deoksispergualin

Monoclonal antibodies Infliximab Adalimumab EtanerceptMonoclonal antibodies(TNF-alfa Antibodies, Interleukins-2 Receptor Antibodies)

Infliximab, Adalimumab, EtanerceptDaclizumab and BasiliximabMuromonab-CD3

Cytotoxic AgentsCategory Drugs

anti-metabolite Azathioprine6-mercaptopurine

DNA alkylating agent Cyclophosphamideinhibits Methotrexate

dihydrofolate reductaseMethotrexate

inhibits Mycophenolate mofetilIMP dehydrogenase

Mycophenolate mofetil

Cytotoxic drugs act on rapidly dividing cells.y g y gPrevention of lymphocyte prolifertion and transformationPrevention of antibody and lymphokine synthesis

Uses of cytotoxic agentsUses of cytotoxic agents

• Azathioprine; with cyclosporine and/orAzathioprine; with cyclosporine and/or prednisone for

organ transplant rejection and– organ transplant rejection and – severe RA

M h l t f til ith l i• Mycophenolate mofetil; with cyclosporine and prednisone for renal transplants

• Cyclophosphamide; for BMT• Methotrexate; GVHD prophylaxis p p y

Mechanisms of Glucocorticoid ActionMechanisms of Glucocorticoid Action

1. Inhibit the production of ppro-inflammatory cytokines

2 P t th d ti2. Promote the production of inflammatory cytokines

like double-edged sword

3. Induce apoptosis in inflammatory cellsinflammatory cells

4. Interfere with cytokine signalsg

Newton, Thorax 2000;55:603-613

Use of Glucocorticoid as I tImmunosuppressant

• Most widely used effective anti-inflammatory drugsMost widely used effective anti inflammatory drugs• Used with other immunophilin inhibitors to prevent

transplant rejection and GVHD(Graft-versus-Host Disease

– natural glucocorticoids not used due to mineralocorticoid activity

• Prednisone and prednisolone are used orally atPrednisone and prednisolone are used orally at moderate to high doses;

• Very high doses of methylprednisolone used i.v. during acute organ rejection

• Used before and after anti-thymocyte Abs to inhibit allergic reactionsallergic reactions

Glucocorticoid effects related to i iimmunosuppression

• Reduced immune cell content of lymph nodes, spleen and blood– lymphopenia, monocytopenia, eosinopenia,

but neutrophilia• Interference with APC, T-cell and

macrophage functions

Clinical Concerns with CorticosteroidsG th i hibiti i di t i t l t• Growth inhibition in pediatric transplants

• Cataracts (10% incidence)• Bone disease (inhibition of osteoblastic activity, decreased ( y,

calcium absorption, increased urinary calcium excretion)• Diabetes (insulin-resistance, gluconeogenesis)• Hyperlipidemia (40 60% posttransplant accelerated• 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• Predisposition to infection (decr PMN T cell activityPredisposition to infection (decr. PMN, T cell activity.• Cushing syndrome

Calcineurin inhibitors(TCR activation blockers)

Antibioticproducts

(TCR activation blockers)

• Cyclosporine y p– commonly used with prednisone and other

immunosuppressants to prevent allograft rejections in renal hepatic and cardiac transplants and in RAin renal, hepatic and cardiac transplants, and in RA and psoriasis

– use is delayed post-transplantation due to t i itneurotoxicity concerns

• Tacrolimus (FK506) – is approved for prevention of solid-organ allograftis approved for prevention of solid organ allograft

rejection, and eczema (topical)– treatment begins prior to surgery, and is maintained

well afterwardswell afterwards

TCR=T Cell Receptor

Calcineurin inhibitors :Cyclosporine Tacrolimus and RapamycinCyclosporine, Tacrolimus and Rapamycin

• CsA and FK506 act on T-cells to inhibit T-cell receptor activation and induction of cytokinesC A l i hibit I E ti l t d t ll• CsA may also inhibit IgE-stimulated mast cell degranulation and stimulate TGF-α expressionR i t t i hibit l h t• Rapamycin acts to inhibit lymphocyte response to cytokines

• Rapamycin and analogues are also used to• Rapamycin and analogues are also used to sensitize cancer cells to chemotherapeutic reagentsreagents

Transforming Growth Factor

Cyclosporine• Fungi: Tolypocladium inflatum gams• Mechanism of actionMechanism of action

– Bind to imunophilin and then inhibit calcineurin activity, production of limphokin and interleukin release---<<<<<

• PharmacokineticsBi il bilit 20 50% T 3 4 h h lf lif 24 h– Bioavailability 20-50%, Tmax: 3-4 hrs, half-life: 24 hrs

– Hepatic metabolism CYP3A4– Excretion: bile and urine

• IndicationIndication– Transplantasi organ:

• 4-24 hrs prior to surgery: 15 mg/kg/d and for 2 weeks, and then the dose reduced untill 3-10 mg/kg/d.

– Rheumatoid arthritis : 2 5-4 mg/kg/dRheumatoid arthritis : 2,5 4 mg/kg/d– Psoriasis : 2,5-4 mg/kg/d

• Side effects– Nephrotoxic and hepatotoxic– Hypertension, hyperkalemia, tremor– Pancreatitis, peptic ulcer, nausea, vomiting and fever

Mechanism of action of cyclosporineImunophilin (cyclophillin)Cyclosporin

C l i i hili lCyclosporin-imunophilin complex

Activate T cell receptor, then enhance Ca concentration

( - )

Akib t d f f il i NFAT b k d i it l k kl

Calcineurin activation

Akibatnya defosforilasi NFATc bergerak dari sitoplasma ke nukleus

NFATc link to other nucleus components

Activate gen to encode cytokine

C t ki lCytokine release

Immune respons

Tacrolimus (Prograf)Tacrolimus (Prograf)StructureStructure

macrolide (structure like erythromycin)MechanismMechanism

similiar to cyclosporine except binds to different protein that inhibits calcineurin (a phosphatase enzyme i l d i i i f I 2 i finvolved in gene transcription of IL-2, gamma interferon and other cytokines)

Bioavailability: =given by IV infusion or orallyBioavailability: =given by IV infusion or orally=used concomitantly with cortico-steroids

Ad Eff tAdverse Effects:=nephrotoxicity, increased risk of

hypersensitivity, hyperglycemia, GI complaints, yp y yp g y phypertension, neurotoxicity(tremor,headache, motor disturbances, seizures) and lymphomas

FKBP= FK-binding proteinNFAT= Nuclear Factor of Activated T cellsCaN = Calcineurin

Monoclonal antibodiesMonoclonal antibodies• Monoclonal antibodies are developed to overcome:p

– Immune disease• Rheumatoid arthritis, SLE

– Malignancyg y• Lymphoma, breast cancer, etc

• TNF-alfa Antibodies – Infliximab, Adalimumab, EtanerceptInfliximab, Adalimumab, Etanercept

• Interleukins-2 Receptor Antibodies– Daclizumab, Basiliximab, Muromonab-CD3

Trast mab• Trastuzumab• Rituximab• Palivizumab

Key Actions Attributed to TNFαKey Actions Attributed to TNFα

TNF Antagonists: Ch i iTNF Antagonists: CharacteristicsCharacteristicsTNF Antagonists: Characteristics

S H Ab TNF I G1 Chi i Ab

Adalimumab1 Etanercept2 Infliximab3,4

Structure Human mAb TNF receptor-IgG1 Chimeric mAb Fusion Protein

Binding target TNF TNF, Lymphotoxin TNF

Bi di ffi it 2 3 1010 1010 1 8 109Binding affinity 2.3x1010 1010 1.8x109

Half-life ~14 days 3-5.5 days 8-10 days

Administration sc sc iv

Preparation Liquid Lyo Lyo

Dose 40 mg 25 mg 3-10 mg/kg eow q2w q4-8w

Use Alone or with other Alone With MTX onlyDMARDs, incl MTX (or with MTX - US)

Bioactive ImmunosuppressantsBioactive Immunosuppressants

• Anti-thymocyte antibodiesAnti thymocyte antibodies– 3 types available

• all derived from non-human sources

• Rh(D) immune globulin-- Rh(-) motherwith Rh(D)+ infantwith Rh(D) infant

• OKT3, OKT4, Anti-CD20, anti-TNF, anti-ICAMs, and CTLA4-IgICAMs, and CTLA4 Ig

• Repeated blood transfusion; transfusion of apoptotic cellsapoptotic cells