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Immunosuppressants & Immunomodulators

Abnormal Immune Responses
Whereas the normally functioning immune response can successfully neutralize toxins, inactivate viruses, destroy transformed cells, and eliminate pathogens. Inappropriate responses can lead to extensive tissue damage (Hypersensitivity) or reactivity against self-antigens (Autoimmunity); conversely, impaired reactivity to appropriate targets (Immunodeficiency) may occur and abrogate essential defense mechanisms.

Autoimmunity
Autoimmune disease arises when the body mounts an immune response against itself due to failure to distinguish self-tissues and cells from foreign (nonself) antigens or loss of tolerance to self. This phenomenon derives from the activation of self-reactive T and B lymphocytes that generate cell-mediated or humoral immune responses directed against self-antigens. The pathologic consequences of this reactivity constitute several types of autoimmune diseases. Autoimmune diseases are highly complex due to MHC genetics, environmental conditions, infectious entities, and dysfunctional immune regulation. Examples of such diseases include Rheumatoid arthritis Systemic lupus erythematosus Multiple sclerosis Insulin-dependent diabetes mellitus (type 1 diabetes). In Rheumatoid arthritis, IgM antibodies (rheumatoid factors) are produced that react with the Fc portion of IgG and may form immune complexes that activate the complement cascade, causing chronic inflammation of the joints and kidneys. In systemic lupus erythematosus, antibodies are made against DNA, histones, red blood cells, platelets, and other cellular components. In multiple sclerosis and type 1 diabetes, cell-mediated autoimmune attack destroys myelin surrounding nerve cells and insulin-producing islet beta cells of the pancreas, respectively. In type 1 diabetes, activated CD4 TDTH cells that infiltrate the islets of Langerhans and recognize self islet beta cell peptides are thought to produce cytokines that stimulate macrophages to produce lytic enzymes, which destroy islet beta cells. Autoantibodies directed against the islet beta cell antigens are produced, but do not contribute significantly to disease.

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A number of mechanisms have been proposed to explain auto-immunity: Exposure of antigens previously sequestered from the immune system (eg, lens protein, myelin basic protein) to self-reactive T lymphocytes. Molecular mimicry by invading pathogens, in which immune responses are directed at antigenic determinants on pathogens that share identical or similar epitopes with normal host tissue. This phenomenon occurs in rheumatic fever following Streptococcus pyogenes infection, in which heart damage is thought to arise from an immune response directed against streptococcal antigens shared with heart muscle. Inappropriate expression of class II MHC molecules on the membranes of cells that normally do not express class II MHC (eg, islet beta cells). Increased expression of MHC II may increase presentation of self-peptides to T helper cells, which in turn induce CTL, TDTH, and B-lymphocyte cells that react against self-antigens. Examples of Autoimmune Diseases, Categorised by Type of Tissue Damage

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Pathophysiology Transplantation
Currently, most organ transplantation occurs between unrelated individuals. Donor and recipient tissues express different MHC class I molecules, and recipient immune cells therefore recognize the transplanted tissues as foreign. This is termed Alloimmunity, and it occurs when the recipients immune system attacks a transplanted organ. In the case of a bone marrow or stem cell transplant, Graft-versus-host disease (GVHD) can result when donor lymphocytes mount an assault on recipient tissues.

Solid Organ Rejection

Transplant rejection of solid organs can be divided into three major phases according to the time to onset: Hyperacute rejection Acute rejection Chronic rejection are caused by different mechanisms and are therefore treated differently.

Hyperacute Rejection
Hyperacute rejection is mediated by preformed recipient antibodies against donor antigen. Because these antibodies are present at the time of organ implantation, hyperacute rejection occurs almost immediately after reperfusion of the transplanted organ. In fact, the surgeon can observe the changes in the organ minutes after restoration of blood flow. The normal, healthy, pink appearance of the transplanted organ rapidly becomes cyanotic, mottled, and flaccid. This rapid change is the result of complement activation by antibody binding to endothelial cells of the transplanted organ, resulting in thrombosis and ischemia. Most commonly hyperacute rejection is mediated by recipient antibodies that react with blood group antigens in donor organs (e.g., type AB donor in a type O recipient). Matching of blood types between donor and recipient prevent hyperacute rejection; therefore, drug therapy for hyperacute rejection is typically not necessary. Hyperacute rejection also occurs in xenotransplantation (i.e., organ transplantation between species, such as pig heart transplanted into a human recipient), due to the presence of preformed human antibodies that react against antigenic proteins and carbohydrates expressed by the donor species.

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Acute Rejection
Acute rejection has cellular and humoral components. Acute cellular rejection is mediated by cytotoxic T Cells and causes interstitial as well as vascular damage. This cellular response is most commonly seen in the initial months after transplantation. Immunosuppression of T cells is highly effective at preventing or limiting activation of the recipient immune system by the transplanted organ, thereby preventing acute cellular rejection. In Acute humoral rejection, recipient B cells become sensitized to donor antigens in the transplanted organ and produce antibodies against these alloantigens after a period of 7-10 days. The antibody response is typically directed against endothelial cells and is thus also known as acute vascular rejection. Like acute cellular rejection, acute humoral rejection can usually be prevented by immunosuppression of the recipient after transplantation. Even with immunosuppression, however, episodes of acute rejection can occur months or even years after transplantation.

Chronic Rejection
Chronic rejection is believed to be both humoral and cellular in nature and does not occur until months or years after transplantation. Because hyperacute and acute rejection are generally well controlled by donor/recipient matching and immunosuppressive therapy, chronic rejection is now the most common life-threatening pathology associated with organ transplantation. Chronic rejection is thought to result from chronic inflammation caused by the response of activated T cells to donor antigen. Activated T cells release cytokines that recruit macrophages into the graft. The macrophages induce chronic inflammation that leads to intimal proliferation of the vasculature and scarring of the graft tissue. The chronic changes eventually lead to irreversible organ failure. Other contributing nonimmune factors can include ischemia-reperfusion injury and infection. No effective treatment regimens are currently available to eliminate chronic rejection. It is believed, however, that several experimental therapies have a reasonable chance of reducing chronic rejection.

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Graft-Versus-Host Disease (GVHD)

Leukemia, primary immunodeficiency, and other conditions can be treated with bone marrow or peripheral stem cell transplantation. In this procedure, hematopoietic and immune function is restored after the patients bone marrow has been eradicated by aggressive chemotherapy and/or radiation therapy. GVHD is a major complication of allogeneic bone marrow or stem cell transplantation. GVHD is an alloimmune inflammatory reaction that occurs when transplanted immune cells attack the cells of the recipient. The severity of GVHD ranges from mild to life-threatening and typically involves the skin (rash), gastrointestinal tract (diarrhea), lungs (pneumonitis), and liver (veno-occlusive disease). GVHD can often be ameliorated by removing T cells from the donor bone marrow before transplantation. Mild-to-moderate GVHD can also be beneficial when donor immune cells attack recipient tumor cells that have survived the aggressive chemotherapy and radiation therapy. (In the case of leukemia, this is called the graft-versus-leukemia effect, or GVL.) Therefore, although removing donor T cells from the graft reduces the risk of GVHD, this may not be the best approach for marrow transplants used in antineoplastic therapy.

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Immunosuppressants
Pharmacologic suppression of the immune system utilizes eight mechanistic approaches Inhibition of gene expression to modulate inflammatory responses Depletion of expanding lymphocyte populations with cytotoxic agents Inhibition of lymphocyte signaling to block activation and expansion of lymphocytes Neutralization of cytokines and cytokine receptors essential for mediating the Immune response Depletion of specific immune cells, usually via cell-specific antibodies Blockade of costimulation to induce anergy Blockade of cell adhesion to prevent migration and homing of inflammatory cells Inhibition of innate immunity, including complement activation

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1. 2. 3. 4. 5. 6. 7.

Inhibition of gene expression Selective attack on clonally expanding lymphocyte populations Inhibition of intracellular signaling Neutralisation of cytokines & cytokine receptors required for T-cell stimulation Selective depletion T cells Inhibition of costimulation by antigen-presenting cells Inhibition of lymphocyte-target cell interactions

Classification
Inhibitors of Gene Expression: Glucocorticoids Cytotoxic Agents: Antimetabolites: Azathioprine (AZA), Methotrexate (MTX), Mycophenolic Acid & Mycophenolate Mofetil (MPA), Leflunomide Alkylating Agents: Cyclophosphamide Specific Lymphocyte-Signaling Inhibitors: Cyclosporine Tacrolimus mTOR Inhibitors: Sirolimus, Everolimus, Zotarolimus Cytokine Inhibition: TNF- Inhibitors: Etanercept, Infliximab, Certolizumab pegol, Adalizumab, Golimumab IL-12/IL-23p40 Inhibitors: Ustekinumab IL-1 Inhibitors: Anakinra, Rilonacept, Canakinumab Cytokine Receptor Antagonists: Tocilizumab Depletion of Specific Immune Cells: Polyclonal Antibodies: Antithymocyte globulin (ATG) Monoclonal Antibodies Anti-CD3: OKT3 (Muromonab-CD3) Anti-CD20 mAb: Rituximab Anti-CD25 mAb: Daclizumab, Basiliximab Anti-CD52 mAb: Alemtuzumab LFA-3: LFA-3(CD58), Alefacept Inhibition of Costimulation: Abatacept, Belatacept Blockade of Cell Adhesion: Natalizumab Inhibition of Complement Activation: Eculizumab

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Glucocorticoids
Glucocorticoids (corticosteroids) were the first hormonal agents recognized as having lympholytic properties. Administration of any glucocorticoid reduces the size and lymphoid content of the lymph nodes and spleen, although it has no toxic effect on proliferating myeloid or erythroid stem cells in the bone marrow. Prednisone, Prednisolone, and other glucocorticoids are used alone and in combination with other immunosuppressive agents for treatment of transplant rejection and auto-immune disorders.

Mechanism of Action
Glucocorticoids are steroid hormones that exert their physiologic actions by binding to the cytosolic glucocorticoid receptor. The glucocorticoid-glucocorticoid receptor complex translocates to the nucleus and binds to glucocorticoid response elements (GREs) in the promoter region of specific genes, either up-regulating or down-regulating gene expression. Glucocorticoids have important metabolic effects on essentially all cells of the body and, in pharmacologic doses, suppress the activation and function of innate and adaptive immune cells. Glucocorticoids lyse and induce the redistribution of lymphocytes, causing a rapid transient decrease in peripheral blood lymphocyte counts. Glucocorticoids down-regulate the expression of many inflammatory mediators, including key cytokines such as TNF-, interkeukin-1 (IL-1), and IL-4. Glucocorticoids curtail (Reduce in extent or quantity) activation of NF-B, which increases apoptosis of activated cells. Pro-inflammatory cytokines such as IL-1 and IL-6 are downregulated. T cells are inhibited from making IL-2 and proliferating. The activation of cytotoxic T lymphocytes is inhibited.

Pharmacokinetics
Prednisone is converted to active prednisolone in the body and has multiple effects on the immune system. Prednisone is very well absorbed from the gastrointestinal (GI) tract and has a long biologic half-life, so it can be dosed once daily. Dosing and Administration An intravenous corticosteroid, commonly high-dose methylprednisolone, is given during the perioperative period. The dose of methylprednisolone is tapered rapidly and discontinued within days, and oral prednisone is initiated.

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Prednisone doses are tapered progressively over time, depending on the type of additional immunosuppression and organ function. As doses are tapered, it is preferable to administer corticosteroids every other day and between 7 AM and 8 AM to mimic the bodys diurnal release of cortisol

Adverse Effects
Long-term glucocorticoid administration has important adverse effects. Diabetes Osteoporosis Cataracts Hirsutism Bruising Acne Hypertension Abrupt cessation of glucocorticoid therapy can result in acute adrenal insufficiency because the hypothalamus and pituitary gland require a number of weeks to months to re-establish adequate ACTH production. Bone growth suppression Ulcerative esophagitis Reduced resistance to infections Sodium and water retention Increased appetite leading to weight gain

Therapeutic Uses
They are combined with other immunosuppressive agents to prevent and treat transplant rejection. High dose pulses of intravenous Methylprednisolone sodium succinate are used to reverse acute transplant rejection and acute exacerbations of selected autoimmune disorders. Glucocorticoids also are efficacious for treatment of graft-versus-host disease in bone-marrow transplantation. Glucocorticoids are used routinely to treat autoimmune disorders such as rheumatoid and other arthritides, systemic lupus erythematosus, systemic dermatomyositis, psoriasis and other skin conditions, asthma and other allergic disorders, inflammatory bowel disease, inflammatory ophthalmic diseases, autoimmune hematologic disorders, and acute exacerbations of multiple sclerosis. In addition, glucocorticoids limit allergic reactions that occur with other immunosuppressive agents and are used in transplant recipients to block firstdose cytokine storm caused by treatment with muromonab-CD3 and to a lesser extent ATG (Antithymocyte Globulin).

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Cytotoxic Agents
Cytotoxic Agents are used for immunosuppression as well as for antineoplastic chemotherapy. Two classes of cytotoxic agents, Antimetabolites and Alkylating agents are commonly used as Immunosuppressants. Antimetabolites are structural analogues of natural metabolites that inhibit essential pathways involving these metabolites. Alkylating agents interfere with DNA replication and gene expression by conjugating alkyl groups to DNA. The therapeutic goal in both antineoplastic chemotherapy and immunosuppressants is the elimination of undesirable cells.

Antimetabolites
They have powerful suppressive effect on immune cells. Also accompanied by many adverse effects related to their lack of selectivity. The older antimetabolites such as Azathioprine and Methotrexate, affect all rapidly dividing cells and can have damaging effects on the GI mucosa and Bone marrow. Newer antimetabolites, such as Mycophenolate mofetil and Leflunomide, cause fewer adverse effects. Mycophenolate mofetil mat also be more selective for immune cells, further reducing its toxicity. Antimetabolites typically affect both cell-mediated and humoral immunity, rendering patients more susceptible to infection.

Azathioprine
Azathioprine (AZA) is a prodrug for 6-mercaptopurine and has been used as an immunosuppressant in combination with corticosteroids. It is an imidazolyl derivative of 6-mercaptopurine. Although mercaptopurine can also be used directly as a cytotoxic agent, azathioprine has greater oral bioavailability and a longer duration of action and is more immunosuppressive than mercaptopurine. Azathioprine and mercaptopurine appear to produce immunosuppression by interfering with purine nucleic acid metabolism at steps that are required for the wave of lymphoid cell proliferation that follows antigenic stimulation.

Mechanism of Action
Azathioprine is an inactive compound that is converted rapidly to 6mercaptopurine (6-MP) in the blood. Following exposure to nucleophiles such as glutathione, azathioprine is cleaved to 6-mercaptopurine and is subsequently metabolized by three different enzymes. Xanthine oxidase, found in the liver and GI tract, converts 6-MP to the inactive final end product, 6-thiouric acid.
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Thiopurine S-methyltransferase, found in hematopoietic tissues and red blood cells, methylates 6-MP to an inactive product, 6-methylmercaptopurine. Finally, hypoxanthine-guanine phosphoribosyltransferase is the first step responsible for converting 6-MP to 6-thioguanine nucleotides (6-TGNs), the active metabolites, which are incorporated into nucleic acids, ultimately disrupting both the salvage and de novo pathways of DNA, RNA, and protein synthesis. This process is toxic to the cell and renders the cell unable to proliferate. 6-TGNs eventually are catabolized by xanthine oxidase and thiopurine Smethyltransferase to inactive products.

Pharmacokinetics
Oral bioavailability of azathioprine is approximately 40%. Metabolism of 6-MP is primarily by xanthine oxidase to inactive metabolites, which are excreted by the kidneys. The half-life of azathioprine, the parent compound, is very short, approximately 12 minutes. The half-life of 6-MP is longer, ranging from 0.7 to 3 hours. However, it is the activity of the 6-TGNs that determines the pharmacodynamic half-life of the drug. The half-life of 6-TGNs has been estimated to be 9 days. Initial doses of azathioprine are 3 to 5 mg/kg per day intravenously or orally.

Adverse Effects
Dose-limiting adverse effects of azathioprine are often hematologic.
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Leukopenia, anaemia, and thrombocytopenia can occur within the first few weeks of therapy and can be managed by dose reduction or discontinuation of azathioprine. Other common adverse effects include nausea and vomiting, which can be minimized by taking azathioprine with food. Alopecia, hepatotoxicity and pancreatitis are less-common adverse effects of azathioprine; they generally are reversible on dose reduction or discontinuation.

DrugDrug Interactions
Allopurinol inhibits xanthine oxidase and can increase the bioavailability of azathioprine and 6-MP concentrations by as much as fourfold. Doses of azathioprine should be reduced by 50% to 75% when allopurinol is added.

Therapeutic Uses
Beneficial in maintaining renal allografts and may be of value in transplantation of other tissues. It is indicated as an adjunct for prevention of organ transplant rejection and in severe rheumatoid arthritis. Lower initial doses (1 mg/kg per day) are used in treating rheumatoid arthritis. Have been used in the management of acute glomerulonephritis and in the renal component of systemic lupus erythematosus. Have also proved useful in some cases of Crohns disease, and multiple sclerosis.

Mycophenolate mofetil
Mycophenolate mofetil is the 2-morpholinoethyl ester of Mycophenolic acid (MPA). Mycophenolate mofetil (MMF) is a semisynthetic derivative of Mycophenolic acid, isolated from the mold Penicillium glaucus. Mycophenolate mofetil is a prodrug that is rapidly hydrolysed to the active drug, Mycophenolic acid (MPA), a selective, non-competitive, and reversible inhibitor of Inosine monophosphate dehydrogenase (IMPDH), an important enzyme in the de novo pathway of guanine nucleotide synthesis.

Mechanism of Action
The immunosuppressive effect of MPA is exerted through non-competitive binding to Inosine monophosphate dehydrogenase, the key enzyme responsible for guanosine nucleotide synthesis via the de novo pathway. Inhibition of Inosine monophosphate dehydrogenase results in decreased nucleotide synthesis and diminished DNA polymerase activity, ultimately reducing lymphocyte proliferation. The actions of MPA are more specific for T and B cells, which use only the de novo pathway for nucleotide synthesis. Other cells within the body have a salvage pathway by which they can synthesize nucleotides, making them less susceptible to the actions of MPA and thereby
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reducing, but not eliminating, the potential for the hematologic adverse effects seen with azathioprine, which affects both the de novo and salvage pathways. In addition to the decreasing lymphocyte proliferation, MPA also may downregulate activation of lymphocytes. Selectivity Two main factors contribute to this selectivity. First, lymphocytes are dependent on the de novo pathway of purine synthesis, whereas most other tissues rely heavily on the salvage pathway. Because IMPDH is required for de novo synthesis of guanosine nucleotides but not for the salvage pathway, MPA affects only cells such as lymphocytes that rely on de novo purine synthesis. Second, IMPDH is expressed in two isoforms, type I and type II. MPA preferentially inhibits type II IMPDH, the isoform expressed mainly in lymphocytes. Together, these factors confer on MPA and MMF selectivity against T and B cells, with relatively low toxicity to other cells. Inhibition of IMPDH by MPA reduces intracellular guanosine levels and elevates intracellular adenosine levels, with many downstream effects on lymphocyte activation and activity. MPA has a cytostatic effect on lymphocytes, but can also induce apoptosis of activated T cells leading to the elimination of reactive clones of proliferative cells. Because guanosine is required for some glycosylation reactions, the reduction in guanosine nucleotides leads to decreased expression of adhesion molecules that are required for recruitment of several immune cell types to sites of inflammation. Furthermore, because guanosine is a precursor of tetrahydrobiopterin (BH4), which regulates inducible nitric oxide synthase (iNOS), the reduction in guanosine levels leads to decreased NO production by neutrophils. Endothelial NOS (eNOS), which controls vascular tone and is regulated by Ca2+ and calmodulin, is not affected by changes in guanosine levels, again demonstrating the considerable selectivity of MPA.

Pharmacokinetics
Because MPA has low oral bioavailability, it is usually administered as a sodium salt or in its prodrug form, Mycophenolate mofetil (MMF), both of which have greater oral bioavailability. Because MPA is unstable in an acidic environment, Mycophenolate mofetil acts as a prodrug that is readily absorbed from the GI tract, after which it is rapidly and completely converted to MPA by first-pass metabolism. The enteric coating of Mycophenolate sodium protects MPA from the acidic gastric pH and allows for MPA to be released directly into the small intestine for absorption. The absolute bioavailability of MPA when delivered from Mycophenolate mofetil and Mycophenolate sodium is 94% and 72%, respectively.
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Peak concentrations of MPA are reached within 1 hour following administration of either preparation. A total of 97% of MPA is bound to albumin in the blood. MPA is eliminated by the kidney and also undergoes glucuronidation in the liver to an inactive glucuronide metabolite (MPAG) that is excreted in the bile and urine. The half-life of MPA is 18 hours. Mycophenolate mofetil is currently available in both oral and intravenous formulations.

Adverse Effects
The most common side effects are related to the GI tract, including nausea, vomiting, diarrhea, and abdominal pain. Mycophenolate also has hematologic effects, such as leukopenia and anaemia, particularly with higher doses. Because peripheral intravenous Mycophenolate administration is associated with local edema and inflammation, central venous administration may be the preferred route.

Therapeutic Uses
Mycophenolate mofetil is indicated for prophylaxis of transplant rejection, and it typically is used in combination with glucocorticoids and a calcineurin inhibitor, but not with azathioprine.

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Its antiproliferative properties make it the first-line drug for preventing or reducing chronic allograft vasculopathy in cardiac transplant recipients. Mycophenolate mofetil is used as prophylaxis for and treatment of both acute and chronic graft-versus-host disease in hematopoietic stem cell transplant patients. Newer immunosuppressant applications for MMF include lupus nephritis, rheumatoid arthritis, inflammatory bowel disease, and some dermatologic disorders. Animal models show that chronic rejection is also reduced more effectively in recipients treated with MMF than in those treated with AZA or cyclosporine. The efficacy of MMF in treating chronic rejection may be related to its inhibition of both the lymphocyte and the smooth muscle cell proliferation characteristic of chronic rejection.

Leflunomide
Activated lymphocytes both proliferate and synthesize large quantities of cytokines and other effector molecules, and these processes require increased DNA and RNA synthesis. Therefore, agents that reduce intracellular nucleotide pools have effects on these activated cells. Leflunomide is an inhibitor of pyrimidine synthesis, specifically blocking the synthesis of uridylate (UMP) by inhibiting Dihydroorotate dehydrogenase (DHOD). DHOD is a key enzyme in the synthesis of UMP, which is essential for the synthesis of all pyrimidines. Experimentally, Leflunomide has been shown to be most effective in reducing Bcell populations, but a significant effect on T cells has also been observed.

Pharmacokinetics
Leflunomide undergoes significant enterohepatic circulation, resulting in a prolonged pharmacologic effect. If Leflunomide must be removed quickly from a patients system, Cholestyramine may be administered. By binding to bile acids, Cholestyramine interrupts the enterohepatic circulation and causes a wash-out of Leflunomide.

Adverse Effects
The most significant adverse effects of leflunomide are diarrhea and reversible alopecia.

Therapeutic Uses
Leflunomide is currently approved for use in rheumatoid arthritis, but the drug has also shown significant efficacy in the treatment of other immune diseases, including systemic lupus erythematosus and myasthenia gravis. Leflunomide prolongs transplant graft survival and limits GVHD in animal models.
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Inhibition of pyrimidine synthesis by Leflunomide De novo pyrimidine synthesis depends on the oxidation of Dihydroorotate to orotate, a reaction that is catalysed by Dihydroorotate dehydrogenase. Leflunomide inhibits Dihydroorotate dehydrogenase and thereby inhibits pyrimidine synthesis. Because lymphocytes are dependent on de novo pyrimidine synthesis for cell proliferation and clonal expansion after immune cell activation, depletion of the pyrimidine pool inhibits lymphocyte expansion. Experimentally, Leflunomide appears to inhibit preferentially the proliferation of B cells; the reason for this preferential action is unknown.

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Cyclophosphamide
Cyclophosphamide is a highly toxic drug that alkylates DNA. Cyclophosphamide has a major suppressive effect on B-cell proliferation but can enhance T-cell responses, the use of Cyclophosphamide in immune diseases is limited to disorders of humoral immunity, particularly systemic lupus erythematosus. Another use under consideration for Cyclophosphamide is the suppression of antibody formation against xenotransplant grafts.

Adverse effects
Adverse effects of Cyclophosphamide are severe and widespread, including leukopenia, cardiotoxicity, alopecia, and an increased risk of cancer because of mutagenicity. The risk of bladder cancer is especially notable because Cyclophosphamide produces a carcinogenic metabolite, acrolein, which is concentrated in the urine. When high-dose Cyclophosphamide is administered by intravenous infusion, acrolein can be detoxified by co-administration of Mesna (a sulfhydryl-containing compound that neutralizes the reactive moiety of acrolein).

Specific Lymphocyte-Signaling Inhibitors

Calcineurin Inhibitors (Cyclosporine and Tacrolimus)
They are structurally unrelated and bind to distinct molecular targets, they inhibit normal T-cell signal transduction essentially by the same mechanism. These drugs bind to an Immunophilin (Cyclophilin for Cyclosporine or FKBP-12 for Tacrolimus), resulting in subsequent interaction with calcineurin to block its phosphatase activity. Calcineurin-catalyzed dephosphorylation is required for movement of a component of the Nuclear factor of activated T lymphocytes (NFAT) into the nucleus. NFAT, in turn, is required to induce a number of cytokine genes, including that for interleukin-2 (IL-2), a prototypic T-cell growth and differentiation factor.

Mechanism of Action
Inhibits the production of IL-2 by activated T-cells. Activated T-cells increase their production of IL-2 via a pathway that begins with dephosphorylation of a cytoplasmic transcription factor, NFAT (Nuclear factor of activated T lymphocytes). NFAT is dephosphorylated by the cytoplasmic Phosphatase Calcineurin. Upon dephosphorylation, NFAT translocates to the nucleus and enhances transcription of the IL-2 gene.
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Both Cyclosporine and Tacrolimus bind to Immunophilins (Cyclophilin and FK506-binding protein [FKBP], respectively), forming a complex that binds the phosphatase calcineurin. Calcineurin phosphatase activity is inhibited after physical interaction with the Drug-Immunophilin complex. This prevents NFAT dephosphorylation such that NFAT does not enter the nucleus, gene transcription is not activated, and the T lymphocyte fails to respond to specific antigenic stimulation. Cyclosporine also increases expression of transforming growth factor- (TGF-), a potent inhibitor of IL-2-stimulated T-cell proliferation and generation of cytotoxic T lymphocytes (CTLs).

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Cyclosporine
It is a cyclic decapeptide isolated from a soil fungus, Tolypocladium inflatum.

Pharmacokinetics
Cyclosporine can be administered intravenously or orally. The intravenous preparation is provided as a solution in an ethanolpolyoxyethylated castor oil vehicle that must be further diluted in 0.9% sodium chloride solution or 5% dextrose solution before injection. The oral dosage forms include soft gelatin capsules and oral solutions. Cyclosporine supplied in the original soft gelatin capsule absorbed slowly with 20% to 50% bioavailability. After oral administration of cyclosporine, the time to peak blood concentrations is 1.5 to 2 hours. Administration with food delays and decreases absorption. Cyclosporine is extensively metabolized in the liver by CYP3A4 and to a lesser degree by the gastrointestinal tract and kidneys. At least 25 metabolites have been identified in human bile, faeces, blood, and urine. Only 0.1% of drug is excreted unchanged in urine. Cyclosporine and its metabolites are excreted principally through the bile into the faeces, with only about 6% being excreted in the urine. In the presence of hepatic dysfunction, dosage adjustments are required.

Adverse Effects
The principal adverse reactions to cyclosporine therapy are Nephrotoxicity Hyperglycaemia Tremor Gum hyperplasia Hirsutism Hyperuricemia Hypertension Hypercholesterolemia Hyperlipidemia Hepatotoxicity Nephrotoxicity occurs in the majority of patients treated and is the major indication for cessation or modification of therapy.

Drug Interactions
Substances that inhibit the enzyme CYP3A4 can decrease cyclosporine metabolism and increase blood concentrations. These include Ca2+ channel blockers (e.g., Verapamil, Nicardipine) Antifungal agents (e.g., Fluconazole, Ketoconazole) Antibiotics (e.g., Erythromycin) Glucocorticoids (e.g., methylprednisolone) HIV-protease inhibitors (e.g., Indinavir) and Other drugs (e.g., Allopurinol, Metoclopramide)

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Drugs that induce CYP3A activity can increase cyclosporine metabolism and decrease blood concentrations. Such drugs include Antibiotics (e.g., Nafcillin, Rifampin) Anticonvulsants (e.g., Phenobarbital, Phenytoin)

Therapeutic Uses
Cyclosporine may be used alone or in combination with other immunosuppressants, particularly glucocorticoids. It has been used successfully as the sole immunosuppressant for cadaveric transplantation of the kidney, pancreas, and liver, and it has proved extremely useful in cardiac transplantation as well. In combination with methotrexate, cyclosporine is a standard prophylactic regimen to prevent graft-versus-host disease after allogeneic stem cell transplantation. Cyclosporine has also proved useful in a variety of autoimmune disorders, including uveitis, rheumatoid arthritis, and psoriasis. An ophthalmic preparation of Cyclosporine is approved for the treatment of chronic dry eyes. Dosing The usual intravenous dose of cyclosporine is 2 to 5 mg/kg per day, given as a continuous infusion or, more commonly, as a single or twice-daily injection. Initial oral cyclosporine doses range from 8 to 18 mg/kg per day divided into two doses administered every 12 hours.

Tacrolimus
Tacrolimus is a macrocyclic triene isolated from the soil bacterium Streptomyces

tsukubaensis. Pharmacokinetics
Tacrolimus is available for oral administration as capsules and as a sterile solution for injection (5 mg/ml). Gastrointestinal absorption is incomplete and variable. Food decreases the rate and extent of absorption. Plasma protein binding of Tacrolimus is 75% to 99%, involving primarily albumin and 1-acid glycoprotein. Its half-life is about 12 hours. Tacrolimus is extensively metabolized in the liver by CYP3A, with a half-life of ~12 hours; at least some of the metabolites are active. The bulk of excretion of the parent drug and metabolites is in the feces.
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Less than 1% of administered Tacrolimus is excreted unchanged in the urine.

Adverse Effects
Nephrotoxicity Neurotoxicity (Tremor, Headache, Motor disturbances, Seizures) GI complaints Hypertension Hyperkalaemia Hyperglycaemia and Diabetes are all associated with Tacrolimus

Drug Interactions Same as Cyclosporine Therapeutic Uses

Tacrolimus is indicated for the prophylaxis of solid-organ allograft rejection. A topical formulation is used for the treatment of atopic dermatitis and other eczematous diseases Dosing Starting dose for Tacrolimus injection is 0.03 to 0.05 mg/kg per day as a continuous infusion. Recommended initial oral doses are 0.15 to 0.2 mg/kg per day for adult kidney transplant patients, 0.1 to 0.15 mg/kg per day for adult liver transplant patients, and 0.15 to 0.2 mg/kg per day for paediatric liver transplant patients in two divided doses 12 hours apart.

mTOR Inhibitors
(Sirolimus, Everolimus, Zotarolimus)
These are the newest class of immunosuppressive agents which consists of drugs that target the mammalian target of Rapamycin and are collectively known as mTOR inhibitors.

Sirolimus
Sirolimus (which is also referred as Rapamycin) is a macrocyclic lactone produced by Streptomyces hygroscopicus. Sirolimus is structurally similar to Tacrolimus but have different mechanism of action. Both bind to FKBP (FK506-binding protein 12), but the Sirolimus-FKBP complex does not inhibit calcineurin; instead, it blocks the IL-2 receptor signalling required for T-cell proliferation.

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Mechanism of Action
Sirolimus inhibits T-lymphocyte activation and proliferation downstream of the IL-2 and other T-cell growth factor receptors. IL-2 receptor signal transduction involves a complex set of protein protein interactions that lead to increased translation of selected mRNAs encoding proteins required for T-cell proliferation. Specifically, IL-2 receptor activation initiates an intracellular signaling cascade that leads to phosphorylation of the molecular target of rapamycin (mTOR). mTOR is a serine-threonine Kinase that phosphorylates and thereby regulates the activity of PHAS-1 and p70 S6 kinase (P70 S6 kinase and PHAS-1 regulate translation). PHAS-1 inhibits the activity of a factor (eIF4E) required for translation, and p70 S6 kinase phosphorylates proteins involved in protein synthesis. The net effect of mTOR activation is to increase protein synthesis, thereby promoting the transition from G1 to S phase of the cell cycle. Sirolimus (also known as rapamycin) crosses the plasma membrane and binds to intracellular FK-binding protein (FKBP). (Sirolimus-FKBP-12 complex does not affect calcineurin activity) The SirolimusFKBP complex inhibits mTOR, thereby inhibiting translation and causing T cells to arrest in G1.

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Pharmacokinetics
Bioavailability after oral administration is low, only 15%, with peak concentrations being reached within 1 to 2hours. Sirolimus has a high volume of distribution, readily distributing into most tissues of the body, even though it binds extensively to erythrocytes because of the high FKBP12 concentration found in red blood cells. About 40% of sirolimus in plasma is protein bound, especially to albumin. Metabolism occurs primarily by CYP3A4 both in the gut and in the liver. The half-life is reported to be 60 hours but can be as long as 110 hours in patients with liver dysfunction.

Adverse Effects
Associated with a dose-dependent increase in serum cholesterol and triglycerides (Hyperlipidaemia) [mechanism of this adverse effect is related to an overproduction of lipoproteins or inhibition of lipoprotein lipase] Hyperlipidaemia Myelosupression Thrombocytopenia Leukopenia Anaemia GI effects (No Nephrotoxicity)

Drug Interactions
Since sirolimus is a substrate for CYP3A4 and is transported by P-glycoprotein, close attention to interactions with other drugs that are metabolized or transported by these proteins is required.

Therapeutic Uses
Sirolimus is indicated for prophylaxis of organ transplant rejection in combination with a calcineurin inhibitor and glucocorticoids. It is used as prophylaxis and as therapy for steroid-refractory acute and chronic graft-versus-host disease in hematopoietic stem cell transplant recipients. Topical sirolimus is also used in some dermatologic disorders and, in combination with cyclosporine, in the management of uveoretinitis. Recently, sirolimus-eluting coronary stents have been shown to reduce restenosis and other adverse cardiac events in patients with severe coronary artery disease. Dosing A fixed sirolimus dosing regimen is approved for concomitant use with cyclosporine that includes a loading dose of 6- or 15-mg followed by 2 or 5 mg daily.
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Cytokine Inhibition
Cytokines (Greek cyto-cell; and kinos-movement) are small cell-signaling protein molecules that are secreted by numerous cells and are a category of signaling molecules used extensively in intercellular communication. The term "cytokine" has been used to refer to the immunomodulating agents, such as interleukins and interferons. Cytokines are critical signaling mediators in immune function. Cytokines are also pleiotropic; that is, they exert different effects depending on the target cell and overall cytokine milieu. For this reason, pharmacologic uses of cytokines or cytokine inhibitors may have unpredictable effects. The first anticytokine agent approved for clinical use was Etanercept, an antiTNF- drug developed for rheumatoid arthritis. During the initial clinical studies, some patients with severe, drug-refractory rheumatoid arthritis literally got up from their wheelchairs and walked after receiving Etanercept. This dramatic efficacy ushered in a new age of biological therapies for autoimmune disease, and the number of new drugs that inhibit proinflammatory cytokines continues to grow rapidly.

TNF- Inhibitors
Tumor necrosis factor- (TNF- ) is a cytokine central to many aspects of the inflammatory response. Macrophages, mast cells, & activated TH cells (especially TH1 cells) secrete TNF-. TNF- stimulates macrophages to produce cytotoxic metabolites, thereby increasing phagocytic killing activity. TNF- also stimulates production of acute-phase proteins, has pyrogenic effects, and fosters local containment of the inflammatory response. Some of these effects are indirect and are mediated by other cytokines induced by TNF-. TNF- has been implicated in numerous autoimmune diseases. Rheumatoid arthritis, psoriasis, and Crohns dis-ease are three disorders in which inhibition of TNF- has demonstrated therapeutic efficacy. Proposed roles for Tumor Necrosis Factor in Rheumatoid Arthritis: Tumor necrosis factor (TNF) is secreted by activated macrophages in an affected joint, where this cytokine has multiple proinflammatory effects. First, TNF activates endothelial cells to up-regulate their expression of cell surface adhesion molecules (shown as projections on endothelial cells) and undergo other phenotypic changes that promote leukocyte adhesion and diapedesis.
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Second, TNF has a positive feedback effect on nearby monocytes and macrophages, promoting their secretion of cytokines such as IL-1. In turn, IL-1 activates T cells (among other functions), and the combination of IL-1 and TNF stimulates synovial fibroblasts to increase their expression of matrix metalloproteases, prostaglandins (especially PGE 2), and cytokines (such as IL-6) that degrade the joint cartilage. Synovial fibroblasts also secrete IL-8, which promotes neutrophil diapedesis.

Five therapies interfering with TNF- activity have been approved.

Etanercept, Infliximab, Certolizumab pegol, Adalizumab, Golimumab

Although all of these agents target TNF-, Etanercept is somewhat less specific because it binds to both TNF- and TNF-. Infliximab, Adalimumab, Certolizumab, and Golimumab are specific for TNF- and do not bind TNF- .

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Etanercept

Infliximab Adalimumab Certolizumab pegol

Golimumab

soluble TNF receptor dimer that links the extracellular, ligandbinding domain of human TNF receptor type II to the Fc domain of human immunoglobulin G1 (IgG1) partially humanized mouse monoclonal antibody against human TNF- Fully human IgG1 monoclonal antibody against TNF- pegylated anti-TNF- monoclonal antibody fragment that lacks the Fc portion of the antibody; as a result, unlike infliximab and Adalimumab, Certolizumab does not cause antibody-dependent cellmediated cytotoxicity or fix complement in vitro. fully human IgG1 monoclonal antibody against TNF- that has a longer half-life than the other anti-TNF- agents

Etanercept
Etanercept is a fusion protein consisting of two p75-soluble TNF receptors linked to an Fc fragment of human IgG1. MOA: The drug binds to TNF, making it biologically inactive and preventing it from interacting with the cell-surface TNF receptors that would lead to cell activation. The drug is given by subcutaneous injection, 50 mg once weekly or 25 mg twice weekly, usually through self-injections or administration by a caregiver. Adverse Effects Aside from local injection-site reactions, adverse effects are rare. There are case reports of pancytopenia and neurologic demyelinating syndromes like multiple sclerosis associated with use of Etanercept, but these are rare. Patients with multiple sclerosis should avoid use of this drug. Therapeutic Uses Etanercept is approved for use in Rheumatoid arthritis Juvenile idiopathic arthritis Plaque psoriasis Psoriatic arthritis Ankylosing spondylitis

Infliximab
Infliximab is a chimeric antibody combining portions of mouse and human IgG1. An anti-TNF antibody was created by exposing mice to human TNF. The binding portion of that antibody was fused to a human constant-region IgG1 to reduce the antigenicity of the foreign protein.
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This antibody, when injected in humans, binds to TNF and prevents its interaction with TNF receptors on inflammatory cells. (Mechanism) Infliximab is given by intravenous infusion at a dose of 3 mg/kg at 0, 2, and 6 weeks and then every 8 weeks. To prevent the formation of antibodies to this foreign protein, Methotrexate should be given orally in doses typically used to treat rheumatoid arthritis for as long as the patient continues on infliximab.

Adverse Effects
An acute infusion reaction with symptoms including fever, chills, pruritus, and rash may occur during infusion or within 1 to 2 hours after giving the drug. Treatment includes slowing infusion rates and administering acetaminophen, diphenhydramine, or corticosteroids, depending on the severity of symptoms. The drug may increase risk of infection. Autoantibodies and lupus-like syndrome also have been reported.

Therapeutic Uses
Infliximab is currently approved for use in Crohns disease Ulcerative colitis Rheumatoid arthritis Ankylosing spondylitis Plaque psoriasis Psoriatic arthritis

Adalimumab
Adalimumab is a human IgG1 antibody to TNF. Because it has no foreign protein components, it is less antigenic than Infliximab.

MOA
Like the other anti-TNF- biologicals, Adalimumab blocks the interaction of TNF with TNF receptors on cell surfaces; it does not bind TNF-. Adalimumab lyses cells expressing TNF- in the presence of complement.

Therapeutic Uses
Adalimumab is approved for use in Rheumatoid arthritis Juvenile idiopathic arthritis Psoriatic arthritis Ankylosing spondylitis Plaque psoriasis Crohns disease

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Certolizumab pegol
Certolizumab pegol is a recombinant humanized Fab fragment that binds to TNF. It is coupled to a 40-kDa polyethylene glycol. It neutralizes the activity of membrane-associated and soluble TNF- without lysing cells.(Mechanism) Certolizumab is indicated for patients with Crohns disease Rheumatoid arthritis

Golimumab
Golimumab is a human IgG monoclonal antibody that also binds to soluble and membrane-associated TNF-. It is an intact human IgG1 and, like certolizumab pegol, it does not lyse cells expressing membrane-associated TNF-. It is indicated for patients with Rheumatoid arthritis Ankylosing spondylitis Psoriatic arthritis It has the advantage of increased half-life such that subcutaneous injections may be self-administered only once per month. General considerations for TNF- Inhibitors: It is important to note that high levels of TNF- are likely mediators of underlying pathophysiologic processes. However, although treatment with an anti-TNF- agent often improves disease symptoms, it may not reverse the underlying pathophysiology. Etanercept, Infliximab, Adalimumab, Certolizumab, and Golimumab are proteins and must be administered parenterally. A number of important adverse effects must be considered when administering TNF inhibitors. All patients should undergo screening for tuberculosis before initiating therapy because of increased risk of reactivating latent tuberculosis. Any patient developing an infection while taking a TNF- inhibitor should undergo evaluation and aggressive antibiotic treatment. Orally active inhibitors of TNF- and inhibitors of TNF- converting Enzyme (TACE) are under investigation.

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IL-12/IL-23p40 Inhibitors
New biological therapies for the treatment of T-cell-mediated diseases include antibodies to IL-12 and IL-23. IL-12 and IL-23 are cytokines involved in natural killer cell activation and CD4+ Tcell differentiation and activation. IL-12, a heterodimer composed of p40 and p35 subunits, directs the differentiation of nave T cells into TH1 cells, which secrete IL-2, IFN-, and TNF-. IL-23 is also a heterodimer that has the same p40 subunit covalently linked to a p19 sub-unit. IL-23 directs the differentiation of nave T cells into TH17 cells, which secrete IL-17 and IL-22.

Ustekinumab
Ustekinumab is a high-affinity IgG1 human monoclonal antibody that binds to the p40 subunit shared by IL-12 and IL-23.

MOA
Ustekinumab is a human IgG1 monoclonal antibody that binds to the p40 subunit of IL-12 and IL-23 cytokines. It blocks IL-12 and IL-23 from binding to their receptors, therefore inhibiting receptor-mediated signaling in lymphocytes.

Therapeutic Uses
Ustekinumab is indicated for patients with moderate to severe plaque psoriasis and is in late-stage clinical trials for the treatment of multiple sclerosis and Psoriatic arthritis The advantage of Ustekinumab over anti-TNF-drugs for psoriasis is faster and longer term improvement in symptoms along with very infrequent dosing.

Adverse effects include an increased risk of infections.

IL-1 Inhibitors
Anakinra, Rilonacept, Canakinumab
Interleukin-1(IL-1) is an ancient cytokine, expressed in both vertebrates and invertebrates, that serves as a bridge between innate and adaptive immunity. Two forms of IL-1, IL-1 and IL-1, are encoded on different genes. In humans, IL-1 has primarily an immune role, while IL-1 may be involved in maintenance of epithelial cell function. Most IL-1 is generated by activated mononuclear cells. IL-1 stimulates IL-6 production, enhances adhesion molecule expression, and stimulates cell proliferation. IL-1 is very important in the pathogenesis of rheumatoid arthritis.
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It stimulates release of chemotactic factors and adhesion molecules, and these promote migration of inflammatory leukocytes to tissues. It also causes release of factors known to dilate blood vessels and direct cytotoxins that produce connective tissue damage. Modulation of IL-1 activity in vivo is accomplished in part by an endogenous IL-1 receptor antagonist (IL-1RA)

Anakinra
Anakinra, a recombinant, non-glycosylated form of IL-1RA, is approved for use in Rheumatoid arthritis.

Mechanism of Action
Prevents IL-1 from binding to its receptor. Anakinra has modest effects on pain and swelling but significantly reduces bony erosions, possibly because it decreases osteoclast production and blocks IL-1 induced metalloproteinase release from synovial cells. A number of rare syndromes that are mediated in part by increased levels of IL-1, including Muckle-Wells syndrome and Hibernian fever, have also been treated effectively with Anakinra. Collectively, these syndromes are termed Cryopyrin-associated periodic fever syndromes (CAPS a group of rare inherited inflammatory diseases associated with overproduction of IL-1 that includes Familial cold Auto inflammatory and Muckle-Wells Syndromes).

Adverse Effects
Neutropenia Increase susceptibility to infections It can be used alone or in combination with anti-TNF agents for Rheumatoid arthritis. Most rheumatologists feel Anakinra has a less-robust response than the TNF inhibitors and reserve it for use in patients who fail these agents.

Rilonacept
Rilonacept is a recombinant, soluble IL-1 receptor Fc fusion protein. It is a dimeric fusion protein consisting of the ligand-binding domains of the extracellular portions of the human interleukin-1 receptor component (IL-1RI) and IL-1 receptor accessory protein (IL-1RAcP) fused to the Fc portion of human IgG1. Approved for use in CAPS Rilonacept is now being evaluated in a phase3 study for Gout. (IL-1 is an inflammatory mediator of joint pain associated with elevated uric acid crystals)

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Canakinumab
Canakinumab is a human IgG1 monoclonal antibody to IL-1. It binds to human IL-1 and prevents it from binding to IL-1 receptors. Approved by the FDA for CAPS. It is also being evaluated for use in COPD.

Cytokine Receptor Antagonists

An alternate approach to block the action of inflammatory cytokines is to target the cytokine receptor. This approach is attempted less frequently in drug development because there may be an increased risk of adverse effects if the antibody should have even minimal agonist activity.

Tocilizumab
Tocilizumab is recombinant humanized IgG1.

MOA
Tocilizumab binds to soluble and membrane-associated IL-6 receptors. It inhibits IL-6-mediated signaling on lymphocytes, suppressing inflammatory processes. The drug is administered every 4 weeks as an intravenous infusion.

Therapeutic Uses
It is indicated for treatment of patients with rheumatoid arthritis who are refractory to other anti-TNF- biologicals. It may be used alone or in combination with Methotrexate or other diseasemodifying antirheumatic drugs. Patients taking Tocilizumab have the same increased risk of infection as those taking anti-TNF- monoclonal antibodies.

Depletion of Specific Immune Cells

Appropriately targeted antibodies deplete the immune system of reactive cells and thereby provide effective therapy for autoimmune diseases and transplant rejection. When the adaptive immune system reacts to an antigen, the resulting immunologic response includes the clonal expansion of cells specifically reactive against that antigen.

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Treatment with exogenous antibodies against cell-surface molecules that are expressed selectively on reactive immune cells can preferentially deplete the immune system of these reactive cells.

Polyclonal Antibodies

Antithymocyte Globulin (ATG)

Antithymocyte globulin is a purified gamma globulin from the serum of rabbits or Horses immunized with human Thymocytes. The rabbit or horse antibodies are polyclonal and target many antigens on human T cells. Because ATG targets essentially all T cells and leads to profound lymphocyte depletion.

Mechanism of Action
Antithymocyte globulin contains cytotoxic antibodies that bind to CD2, CD3, CD4, CD8, CD11a, CD18, CD25, CD44, CD45, and HLA class I and II molecules on the surface of human T lymphocytes. The antibodies deplete circulating lymphocytes by direct cytotoxicity (both complement and cell-mediated) and block lymphocyte function by binding to cell surface molecules involved in the regulation of cell function.

Therapeutic Uses
Antithymocyte globulin also is used for acute rejection of other types of organ transplants and for prophylaxis of rejection. ATG is approved for use in prevention or treatment of renal transplant rejection, and the equine-derived material is also approved for treatment of aplastic anemia. It is provided as a sterile, freeze-dried product for intravenous administration after reconstitution with sterile water. ATG is administered intravenously once daily for upto 28 days. The recommended dose for acute rejection of renal grafts is 1.5 mg/kg per day.

Adverse Effects
Polyclonal antibodies are xenogeneic proteins that can elicit major side effects, including fever and chills with the potential for hypotension. Premedication with corticosteroids, acetaminophen, and/or an antihistamine and administration of the antiserum by slow infusion (over 4 to 6 hours) into a largediameter vessel minimize such reactions. Serum sickness and glomerulonephritis (Complexes of host antibodies with horse ALG may precipitate and localize in the glomeruli of the kidneys) can occur. Anaphylaxis is a rare event.
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Hematologic complications include Leukopenia and Thrombocytopenia. There is an increased risk of infection and malignancy, especially when multiple immunosuppressive agents are combined.

Monoclonal Antibodies

Muromonab (Anti-CD3, OKT3)

OKT3 is a mouse monoclonal antibody against human CD3, one of the cell-surface signaling molecules important for activation of the T-cell receptor. CD3 is specifically expressed on T cells (both CD4 and CD8 cells). Treatment with OKT3 depletes the available pool of T cells via antibody-mediated activation of complement and clearance of immune complexes

Mechanism of Action
Muromonab binds to the chain of CD3, a monomorphic component of the T-cell receptor complex involved in antigen recognition, cell signaling, and proliferation. Antibody treatment induces rapid internalization of the T-cell receptor, thereby preventing subsequent antigen recognition. Administration of the antibody is followed rapidly by depletion and extravasation of a majority of T cells from the bloodstream and peripheral lymphoid organs such as lymph nodes and spleen. This absence of detectable T cells from the usual lymphoid regions is secondary both to cell death following complement activation and activation-induced cell death and to margination of T cells onto vascular endothelial walls and redistribution of T cells to nonlymphoid organs such as the lungs. Muromonab-CD3 also reduces function of the remaining T cells, as defined by lack of IL-2 production and great reduction in the production of multiple cytokines, perhaps with the exception of IL-4 and IL-10.

Pharmacokinetics
OKT3 has a volume of distribution of 6.5 L and half-life of about 18 hours. Concentrations above 0.9 mcg/mL are considered therapeutic. If CD3 levels begin to rise, this may signify the presence of antimurine antibodies antagonizing the actions of OKT3. Administration of Mycophenolate mofetil has been suggested to reduce the formation of antimurine antibodies during OKT3 administration. Although T-cell depletion is achieved within minutes of administration, resolution of rejection takes 3 to 4 days.

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Therapeutic Uses
Muromonab-CD3 is indicated for treatment of acute organ transplant rejection. Muromonab-CD3 is approved for the treatment of acute renal allograft rejection and steroid-resistant acute cardiac and hepatic transplant rejection.

Adverse Effects
OKT3 administration is associated with significant first-dose adverse reactions. The Cytokine-release syndrome related to OKT3, including fever, chills, rigors, pruritus, and alterations in blood pressure, may occur with the first several doses. Methylprednisolone, acetaminophen, diphenhydramine, Indomethacin, and pentoxifylline have been used as premedications to prevent or minimize the severity of this syndrome. Other adverse effects include Capillary leak syndrome and pulmonary edema, especially in fluid overloaded patients. Aseptic meningitis is another potential complication of OKT3 therapy. If encephalitic symptoms develop, OKT3 should be discontinued and appropriate care initiated. Other adverse effects include encephalopathy nephrotoxicity infection, and post-transplantation lymphoproliferative disorder Nausea/vomiting, diarrhea, abdominal pain, Malaise, Myalgias, Arthralgias, and generalized weakness. Potentially fatal severe pulmonary edema, acute respiratory distress syndrome, cardiovascular collapse, cardiac arrest, and arrhythmias have been described. Other toxicities associated with anti-CD3 therapy include anaphylaxis and the usual infections and neoplasms associated with immunosuppressive therapy. "Rebound" rejection has been observed when muromonab-CD3 treatment is stopped.

Dosing
OKT3 should be filtered with a 0.2-to 0.22-micron filter and then administered as an intravenous push over 1 minute. The dose of OKT3 usually is 5 mg/day for 5 to 14 days.

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Rituximab
Rituximab is a chimeric murine-human monoclonal IgG1 (human Fc) that binds to the CD20 molecule on normal and malignant B lymphocytes. CD20 is expressed on the surface of all mature B cells, and administration of Rituximab causes profound depletion of circulating B cells.

Mechanism of Action
The mechanism of action includes complement-mediated lysis, antibodydependent cellular cytotoxicity, and induction of apoptosis in the malignant lymphoma cells. Rituximab is a monoclonal chimeric antibody consisting of mostly human protein with the antigen-binding region derived from a mouse antibody to CD20 protein found on the cell surface of mature B lymphocytes. The binding of Rituximab to B cells results in nearly complete depletion of peripheral B cells, with a gradual recovery over several months.

Therapeutic Uses
It is also approved for the treatment of rheumatoid arthritis in combination with Methotrexate in patients for whom anti-TNF- therapy has failed. Approved for the therapy of patients with relapsed or refractory low-grade or follicular B-cell non-Hodgkins lymphoma and chronic lymphocytic leukemia. Recent reports indicate that rituximab may also be very useful in auto-immune diseases such as multiple sclerosis and systemic lupus erythematosus. Several additional anti-CD20 antibodies are in clinical development:

Ofatumumab
A fully human anti-CD20 monoclonal antibody that recognizes an epitope distinct from that of Rituximab. Ofatumumab is approved for use in Chronic lymphocytic leukemia.

Daclizumab and Basiliximab

Daclizumab and Basiliximab are monoclonal antibodies against CD25, the highaffinity IL-2 receptor. IL-2 mediates early steps in T-cell activation. Because CD25 is expressed only on activated T cells, anti-CD25 antibody therapy selectively targets T cells that have been activated by an MHC-antigen stimulus. Basiliximab is a chimeric mouse-human IgG1 that binds to CD25, the IL-2 receptor alpha chain on activated lymphocytes. Daclizumab is a humanized IgG1 that also binds to the alpha subunit of the IL-2 receptor.
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MOA: Both agents function as IL-2 antagonists, blocking IL-2 from binding to activated lymphocytes, and are therefore immunosuppressive.

Therapeutic Uses
Daclizumab is administered prophylactically in renal transplantation to inhibit acute organ rejection. It is also used as a component of general immunosuppressive regimens after organ transplantation. Daclizumab is typically administered in a five-dose regimen, with the first administration immediately after transplantation and then four additional doses at 2-week intervals. This type of dosing regimen, in which drug is administered for a limited period immediately after transplantation, is referred to as Induction therapy.

Alemtuzumab
Alemtuzumab is a humanized IgG1 with a kappa chain that binds to CD52 found on normal and malignant B and T lymphocytes, NK cells, monocytes, macrophages, and a small population of granulocytes. Campath-1 (CD52) is an antigen expressed on most mature lymphocytes and on some lymphocyte precursors. Its effects on depleting both T and B lymphocytes make it useful in solid-organ transplants.

Mechanism of Action
Alemtuzumab is a humanized monoclonal antibody directed at cells that express the CD52 surface antigen, which is found on both T and B lymphocytes, as well as macrophages, monocytes, eosinophils, and natural killer cells. When Alemtuzumab binds to the CD52 surface antigen, antibody-dependent lysis occurs, which removes both T and B lymphocytes from the blood, bone marrow, and organs, resulting incomplete lymphocyte depletion.

Therapeutic Uses
Alemtuzumab is approved for use in B-cell chronic lymphocytic leukemia.

Adverse Effects
The adverse effects of alemtuzumab include infusion-related reactions, hematologic effects, and infections. Infusion-related reactions include rigors, hypotension, fever, shortness of breath, bronchospasms, and chills. The potential for developing these reactions can be reduced by administering premedications, including corticosteroids,

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diphenhydramine, and acetaminophen, or by administering smaller doses and escalating the dose gradually. Hematologic effects include pancytopenia, neutropenia, thrombocytopenia, and lymphopenia. Dosing Commonly recommended dosing strategy for Alemtuzumab is 30 mg as a single dose.

LFA-3
LFA-3(also called CD58) is the counter-receptor for CD2, an antigen expressed at high levels on the surface of memory effector T cells. Interaction of CD2 on T cells with LFA-3 on antigen-presenting cells promotes increased T-cell proliferation and enhanced T-cell-dependent cytotoxicity. Because the memory effector T-cell population is elevated in patients with psoriasis, a pharmacologic agent (Alefacept) that disrupts the CD2LFA-3 interaction was tested for use in psoriasis.

Alefacept
Alefacept is an LFA-3(leukocyte-function-associated antigen-3)/Fc fusion protein [Alefacept is an engineered protein consisting of the CD2-binding portion of leukocyte-function-associated antigen-3 (LFA-3) fused to a human IgG1 Fc region]that interrupts CD2LFA-3 signaling by binding to T-cell CD2, and thereby inhibits T-cell activation. Additionally, the Fc portion of Alefacept may activate NK cells to deplete the immune system of memory effector T cells. Clinically, alefacept significantly decreases the severity of chronic plaque psoriasis. Because CD2 is expressed on other adaptive immune cells, administration of alefacept also causes a dose-dependent reduction in CD4 and CD8 T-cell populations. Its use is therefore contraindicated in patients with HIV, and patients taking alefacept may have an increased risk of serious infection. Alefacept therapy may also be associated with an increased risk of malignancy, primarily skin cancer.

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Inhibition of Costimulation
Abatacept, Belatacept Costimulationthe requirement for multiple simultaneous signals to initiate an
immune responseensures that stimulation of a single immune receptor does not activate a damaging immune reaction. Signal 1 provides specificity, while signal 2 is permissive, ensuring that an inflammatory response is appropriate. Regulation of costimulatory molecules is a mechanism whereby the innate immune system regulates the extent of an immune response. If antigen is presented with-out a coincident costimulatory signal (i.e., without innate immune activation), then anergy results, whereby a cell becomes unreactive and will not respond to further antigenic stimuli. Drugs that induce anergy could be therapeutically attractive, because such agents could allow long-term acceptance of an organ graft or limit the extent of an autoimmune disease.

Abatacept
Abatacept consists of CTLA-4 (Cytotoxic T-Lymphocyte Antigen 4) fused to an IgG1 constant region.

Mechanism of Action
Abatacept complexes with costimulatory B7 molecules on the surface of antigenpresenting cells. When the antigen-presenting cell interacts with a T cell, MHC:antigen TCR interaction (signal 1) occurs, but the complex of B7 with abatacept prevents delivery of a costimulatory signal (signal 2), and the T cell develops anergy or undergoes apoptosis. By this mechanism, Abatacept therapy appears to be effective in down-regulating specific T-cell populations.

Therapeutic Uses
Abatacept is approved for the treatment of rheumatoid arthritis that is refractory to methotrexate or TNF- inhibitors.

Adverse Effects
The major adverse effects of Abatacept are Exacerbations of bronchitis in patients with pre-existing obstructive lung disease Increased susceptibility to infection
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Abatacept should not be administered concurrently with TNF- inhibitors or anakinra because the combination carries an unacceptably high risk of infection.

Belatacept
Belatacept is a close structural congener of Abatacept that has increased affinity for B7-1 and B7-2. In a large clinical trial, Belatacept was as effective as cyclosporine at inhibiting acute rejection in renal transplant recipients. Belatacept is currently under further investigation as an immunosuppressant for organ transplantation.

Blockade of Cell Adhesion

The recruitment and accumulation of inflammatory cells at sites of inflammation is an essential element of most autoimmune diseases; the only exceptions to this rule are autoimmune diseases that are purely humoral, such as myasthenia gravis. Drugs that inhibit cell migration to sites of inflammation may also inhibit antigen presentation and cytotoxicity, thus providing multiple potential mechanisms of beneficial action.

Natalizumab
Alpha-4 integrins are critical to immune-cell adhesion and homing. The 4 1 integrin mediates immune-cell interactions with cells expressing vascular cell adhesion molecule 1 (VCAM-1), while the 4 7 integrin mediates immune-cell binding to cells expressing mucosal addressin cell adhesion molecule 1 (MAdCAM-1). Natalizumab is a monoclonal antibody against 4 integrin that inhibits immune-cell interactions with cells expressing VCAM-1 or MAdCAM-1. Natalizumab was approved for the treatment of relapsing multiple sclerosis. During post marketing surveillance of the drug, however, several patients treated with Natalizumab developed progressive multifocal leukoencephalopathy (PML), a rare demyelinating disorder caused by infection with JC virus. This finding resulted in voluntary withdrawal of the drug. After further FDA investigation, it was decided to resume testing of Natalizumab and to add a warning to the product label regarding the possible association. Natalizumab was subsequently reapproved for use in the treatment of multiple sclerosis and Crohns disease.

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Inhibition of Complement Activation

The complement system mediates a number of innate immune responses. Recognition of foreign proteins or carbohydrates leads to sequential activation of complement proteins and eventual assembly of the membrane attack complex, a multiprotein structure that can cause cell lysis. Patients with paroxysmal nocturnal hemoglobinuria (PNH) have acquired defects in complement regulatory proteins, leading to inappropriate activation of complement and complement-mediated lysis of erythrocytes.

Eculizumab
Eculizumab is a humanized monoclonal antibody against C5, a complement protein that mediates late steps in complement activation and triggers assembly of the membrane attack complex. Eculizumab is approved for the treatment of PNH; it significantly decreases hemoglobinuria and the need for erythrocyte transfusions in patients with this disorder. Genetic evidence indicates that complement activation may play an etiologic role in age-dependent macular degeneration, suggesting that inhibitors of the complement cascade could be useful local therapies for this disease.

Immunostimulants In contrast to immunosuppressive agents that inhibit the immune response in transplant rejection and autoimmunity, a few immunostimulatory drugs have been developed with applicability to infection, immunodeficiency, and cancer.

Levamisole Thalidomide Bacillus Calmette-Guerin (BCG) Recombinant Cytokines (Interferons) Interleukin-2

Levamisole
Levamisole was synthesized originally as an anthelmintic but appears to "restore" depressed immune function of B lymphocytes, T lymphocytes, monocytes, and macrophages. In combination with the antimetabolite 5-fluorouracil, this drug is now approved for use in the treatment of colon cancer.

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Thalidomide
Thalidomide is best known for the severe, life-threatening birth defects it caused when administered to pregnant women. For this reason, it is available only under a restricted distribution program and can be prescribed only by specially licensed physicians who understand the risk of teratogenicity if thalidomide is used during pregnancy. Thalidomide should never be taken by women who are pregnant or who could become pregnant while taking the drug. It is indicated for the treatment of patients with erythema nodosum leprosum and also is used in conditions such as multiple myeloma. Its mechanism of action is unclear. Thalidomide has been reported to decrease circulating TNF- in patients with erythema nodosum leprosum. Alternatively, it has been suggested that the drug affects angiogenesis. The anti-TNF- effect has led to its evaluation as a treatment for severe, refractory rheumatoid arthritis.

Bacillus Calmette-Guerin (BCG)

Live bacillus Calmette-Guerin is an attenuated, live culture of the bacillus of Calmette and Guerin strain of Mycobacterium bovis that induces a granulomatous reaction at the site of administration. By unclear mechanisms, this preparation is active against tumors and is indicated for treatment and prophylaxis of carcinoma in situ of the urinary bladder and for prophylaxis of primary and recurrent stage Ta and/or T1 papillary tumors after transurethral resection. Adverse effects include hypersensitivity, shock, chills, fever, malaise, and immune complex disease.

Recombinant Cytokines-Interferons
Although interferons (alpha, beta, and gamma) initially were identified by their antiviral activity, these agents also have important immunomodulatory activities. The interferons bind to specific cell-surface receptors that initiate a series of intracellular events: induction of certain enzymes inhibition of cell proliferation enhancement of immune activities, including increased phagocytosis by macrophages augmentation of specific cytotoxicity by T lymphocytes.

Recombinant interferon alfa-2b (IFN-alpha 2, INTRON A)

Obtained from Escherichia coli by recombinant expression.

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It is a member of a family of naturally occurring small proteins with molecular weights of 15,000 to 27,600 daltons, produced and secreted by cells in response to viral infections and other inducers.

Therapeutic Uses
Interferon alfa-2b is indicated in the treatment of a variety of tumors, including hairy cell leukemia, malignant melanoma, follicular lymphoma, and AIDS-related Kaposi's sarcoma. It also is indicated for infectious diseases, chronic hepatitis B, and condylomata acuminata. In addition, it is supplied in combination with ribavirin (REBETRON) for treatment of chronic hepatitis C in patients with compensated liver function not treated previously with interferon alfa-2b or who have relapsed after interferon alfa-2b therapy.

Adverse Effects
Flu-like symptoms, including fever, chills, and headache, are the most common adverse effects after interferon alfa-2b administration. Adverse experiences involving the cardiovascular system (hypotension, arrhythmias, and rarely cardiomyopathy and myocardial infarction) and CNS (depression, confusion) are less-frequent side effects.

Interferon gamma-1b (ACTIMMUNE)

Is a recombinant polypeptide that activates phagocytes and induces their generation of oxygen metabolites that are toxic to a number of microorganisms. It is indicated to reduce the frequency and severity of serious infections associated with chronic granulomatous disease. Adverse reactions include fever, headache, rash, fatigue, GI distress, anorexia, weight loss, myalgia, and depression.

Interferon beta-1a (AVONEX, REBIF) a 166-amino acid recombinant glycoprotein Interferon beta-1b (BETASERON), a 165-amino acid recombinant protein
Have antiviral and immunomodulatory properties. They are FDA approved for the treatment of relapsing and relapsing-remitting multiple sclerosis to reduce the frequency of clinical exacerbations. The mechanism of their action in multiple sclerosis is unclear. Flu-like symptoms (fever, chills, myalgia) and injection-site reactions have been common adverse effects.

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Interleukin-2
Human recombinant interleukin-2 (Aldesleukin, PROLEUKIN; des-alanyl-1, serine-125 human IL-2) is produced by recombinant DNA technology in E. coli. This recombinant form differs from native IL-2 in that it is not glycosylated, has no amino terminal alanine, and has a serine substituted for the cysteine at amino acid 125. The potency of the preparation is represented in International Units in a lymphocyte proliferation assay such that 1.1 mg of recombinant IL-2 protein equals 18 million International Units. Aldesleukin has the following in vitro biologic activities of native IL-2: Enhancement of lymphocyte proliferation and growth of IL-2dependent cell lines; Enhancement of lymphocyte-mediated cytotoxicity and killer cell activity; and induction of interferon-g activity. In vivo administration of Aldesleukin in animals produces multiple immunologic effects in a dose-dependent manner. Cellular immunity is profoundly activated with lymphocytosis, eosinophilia, thrombocytopenia, and release of multiple cytokines (e.g., TNF, IL-1, and interferon-g).

Therapeutic Uses
Aldesleukin is indicated for the treatment of adults with metastatic renal cell carcinoma and melanoma.

Adverse Effects
Administration of Aldesleukin has been associated with serious cardiovascular toxicity resulting from capillary leak syndrome, which involves loss of vascular tone and leak of plasma proteins and fluid into the extravascular space. Hypotension, reduced organ perfusion, and death may occur. An increased risk of disseminated infection due to impaired neutrophil function also has been associated with Aldesleukin treatment.

Tretinoin
Tretinoin, or all-trans retinoic acid (ATRA), is a ligand of the retinoic acid receptor (RAR). ATRA is used in the treatment of acute promyelocytic leukemia. This disease is characterized by a translocation t(15;17) in which part of the RAR gene is fused to the PML gene, creating a fusion protein that induces a block to differentiation and thereby allows development of the leukemia. Treatment with ATRA stimulates differentiation of these cells into more normal granulocytes.
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In some patients, the induction of differentiation can lead to a life-threatening over-production of white blood cells. ATRA can also induce a rapidly progressive syndrome of fever, acute respiratory distress with pulmonary infiltrates, edema and weight gain, and multisystem organ failure. Therapy with high doses of glucocorticoids is often an effective treatment for this ATRA syndrome.

References
Laurence Brunton, Bruce Chabner, Bjorn Knollman, Goodman & Gilmans The Pharmacological Basis Of Therapeutics, 12th Edition, Mc Graw Hill Medical, 2011 Pg No: 1005-1023 David E.Golan, Armen H.Tashjian, Ehrin J. Armstrong, April W. Armstrong, Principles of Pharmacology, The Pathophysiologic Basis Of Drug Therapy,3rd Edition, Lippincott Williams & Wilkins, 2012 Pg no: 790-806 H.P.Rang, M.M. Dale, J.M. Ritter, R.J. Flower, Rang and Dales Pharmacology, 6th Edition, Churchill Livingstone Elsevier, 2007 Bertram G. Katzung, Susan B. Masters, Anthony J. Trevor, Basic & Clinical Pharmacology, 12th Edition, Tata McGraw Hill Education Private Limited, New Delhi, 2012, Pg No: 977-999

Sumanth Dept of Pharmacology