Vous êtes sur la page 1sur 11

Ian Torres de Lima

Reg N: 201404442
Honours Immunology 2 Assessment
Class Coordinator: Catherine Lawrence
18 August 2014
!
!
Immunosuppressive Drugs
Molecular targets and clinical consequences of non-specific
and specific immunosuppressive drugs
!
The immune system can, in specific situations, fail, acting in an undesirable manner.
In autoimmune diseases, the immune system fails to tolerate self epitopes and begins to act
against the own system. In inflammatory diseases, the role of the immune system is
unbalanced, causing direct damage to the carrier. Organ transplant rejection, however it
represents a physiological action of the organism, is an undesirable conduct of the immune
system for the good prognosis of the patient. Immunosuppressive drugs are those which
inhibit the activity of the immune system, thus preventing organ rejection and symptoms of
autoimmune and inflammatory diseases.
The objectives of the following work are: describe the structure and mechanisms of
action and discuss the clinical implications of non-specific and specific immunosuppressive
drugs.
!
1- Non-specific Immunosuppressive Drugs
!
Drugs whose effect is nonspecific act by generally suppressing the action of the
immune system. They interfere mostly in the effector phase of the immune system (phase
characterised by intense cell multiplication and interaction), inhibiting the promotion of both
B and T cells. By having nonspecific action, the role of non-specific immunosuppressive drugs
usually affects the metabolism of other cells, leading to the emergence of several side effects.
The main non-specific immunosuppressive drugs that will be presented and discussed
below are: Azathioprine (Imuran), Cyclophosphamide and Mycophenolic Acid.
!
!
!
!
HONOURS IMMUNOLOGY 2 ASSESSMENT "1
Azathioprine (Imuran)
!
In 1951, the drug was initially tested in its inactive form, 6-mercaptopurine (6-MP), by
Gertrude Elion (1918-1999) and George Hitchings (1905-1998). The original idea was to
promote a drug capable of inhibiting the nucleic acids production in microorganisms and
neoplastic cells. Subsequently, studies in transplanted dogs, conducted by other scientists,
demonstrated the immunosuppressive action of the drug (Rubin, 2007).
Currently the drug has several indications, being used in the treatment of leukemias,
inflammatory bowel disease, rheumatoid arthritis, and other diseases.
!
Pathway
!
The prodrug azathioprine (AZA), when administered, is initially converted into 6-MP.
This reaction can occur via two pathways, one dependant of the liver enzyme glutathione-S-
transferase (GST), and the other, a non-enzymatic reaction promoted by glutathione (GSH), a
compound present in the liver, red blood cells and intestinal wall. The GSH pathway
predominates at the physiological pH of 7.0 - 7.5 (Sahasranaman and Howard, 2008).
Subsequently, 6-mercaptopurine, still unable to exert biological function is converted
by various other enzymatic reactions present in the liver and intestine. Some of those
enzymes promote 6-MP activation, others promotes its inactivation. These reactions compete
with each other by using the same reagent, 6-MP.
Two important reactions are responsible for 6-MP inactivation. The first converts 6-
MP in 6-thiouric acid, metabolite found in urine and serum after administration of
azathioprine. The second reaction converts 6-MP into 6-methylmercaptopurine (6-MEMP),
this reaction is the main way of the drug inactivation. The reactions are catalysed by the
following enzymes, xanthine oxidase (XO) and thiopurine methyl transferase (TPMT),
respectively (Sahasranaman and Howard, 2008).
The activation reaction of the drug is catalysed by the enzyme hypoxanthine-guanine-
phosphoribosyltransferase (HGPRT), which converts 6-MP in the active form, 6-thioguanine
(6-TG). The active form accumulates within the cell and acts as a false metabolite interacting
directly in the production of nucleotides, by binding the structure which is being formed. The
activated drug also interacts with essential coenzymes and impairs the DNA and RNA
production. For this reason the drug is known to inhibit the cell cycle S phase. The drug
mechanism of action causes death in cells with high mitotic rate such as immune cells, cells of
the gastrointestinal tract and cancer cells. However lymphocytes represent the most affected
group by the drug, since there is no alternative pathway for the nucleotide synthesis in these
cells (Pascal Frei, 2013), (A. Patel and A. Swerlick, 2006).
Another action mechanism of the drug is by the active form (6-TG) binding to Rac1
protein. This protein is involved in signal transduction promoted by CD28 co-stimulatory
molecule in T cells. T cells to be activated needs more than antigen recognition, they also

HONOURS IMMUNOLOGY 2 ASSESSMENT "2


depend on co-stimulation. Upon binding protein Rac1, the drug prevents co-stimulation, thus
inducing apoptosis or T cell anergy (S. Maltzman and A. Koretzky, 2003).
!
Clinical Consequences
!
The drug takes one to two months to elicit clinical effects, this occurs as the drug
affects one of the fundamental mechanisms of cell replication (A. Patel and A. Swerlick,
2006).
Some patients may experience intoxication even when receiving previously protocoled
doses of the drug. By the fact that TPMT enzyme catalyses the main inactivation reaction of
the drug AZA, patients who have a TPMT deficiency does not inactivate 6-MP properly, thus
contributing to the excessive accumulation of the activated form of the drug inside the cells.
This excessive buildup can cause bone marrow suppression. Conversely, patients who exhibit
high activity of the enzyme, TPMT, convert most of the 6-MP compound into its inactive
form, thus leading inadequate production of the active form of the drug. In this case the
patient does not reach the drug therapeutic dose properly (Sahasranaman and Howard,
2008).
The level of TPMT enzyme activity is heredity determined. Genetic testing can be
used to personalize the treatment of patients. A person may have 3 enzymatic features, high
enzymatic activity (approximately 90% of the specimen population), moderate activity (10%
of the specimen population) and little or no activity (0.3% of the specimen population)
(Sahasranaman and Howard, 2008).
By interfering directly in the synthesis of nucleotides, the drug affects cells with high
multiplication rate, thus the main side effects are vomiting, hair loss and skin damage.
!
Cyclophosphamide
!
Pathway
!
The prodrug Cyclophosphamide (CP), is mainly metabolised by the hepatic
cytochrome P450 complex. This complex is responsible for converting pro drug into its active
form, 4-hydroxycyclophosphamide. The active form is spontaneously converted into its
tautomer, aldophosphamide. The two forms, 4-hydroxycyclophosphamide and
aldophosphamide coexist in equilibrium. The aldophosphamide undergoes chemical
decomposition giving rise to two chemical compounds, both have great protein affinity:
phosphoramide mustard (compound known for its anti-tumor and immunosuppressive
action), and acrolein (compound responsible for urinary system toxicity) (Hall and Tilby,
1992), (Navin Pinto, 2009).

HONOURS IMMUNOLOGY 2 ASSESSMENT "3


The active metabolites derived from the CP conversion by cytochrome P450 enzymes
are inactivated by glutathione S-transferases (GST) and aldehyde dehydrogenases (ALDH)
(Navin Pinto, 2009).
Phosphoramide mustard, a CP active product, is responsible for causing the biological
immunosuppressive action. This compound is accumulated in cells with low ALDH enzyme
activity - ALDH is responsible for inactivation of cyclophosphamide active compounds.
When optimal concentrations are reached, phosphoramide mustard binds to guanine present
in DNA strands, promoting cross-links between DNA tapes. These connections block the
genetic material processing and promote apoptosis (Hall and Tilby, 1992).
!
Clinical Consequences
!
The drug has a non-specific immunosuppressive effect, promoting reduction of the
acquired immunity cell levels. CP is used in the treatment of autoimmune diseases.
The acrolein metabolite is toxic to the bladder epithelium. Prolonged use of
cyclophosphamide can cause hematuria and urinary tract related severe problems. Beceuse it
affects cell replication, cells that have high rates of multiplication are more susceptible to the
effect of the drug, therefore vomiting, infertility and reversible bone marrow suppression are
common side effects (Navin Pinto, 2009).
The enzymes glutathione S-transferase and aldehyde dehydrogenases have genetic
polymorphisms. Individuals carrying alleles corresponding to low activity of the respective
enzymes, exhibit greater accumulation of assets derived from the drug and therefore the side
and cytotoxic effects are more significant. In these individuals the nephrotoxic effect of
acrolein, compound derived from the tautomer aldophosphamide, is more aggressive (Navin
Pinto, 2009).
Bearers of glutathione S-transferase and aldehyde dehydrogenases high activity are
resistant to cyclophosphamide, a fact confirmed in cancer patients undergoing CP treatment
(Navin Pinto, 2009).
There are many genetic factors involved in cytochrome P450 complex. Cytochrome
P450 isoforms may be more or less active in certain individuals, that directly reflects the
availability of active forms of the drug (Navin Pinto, 2009).
!
Mycophenolate mofetil
!
The Mycophenolic acid (MPA) prodrug, mycophenolate mofetil (MMF), is a more
recent drug when compared to other non-specific immunosuppressive drugs. The drugs
azathioprine (AZA) and cyclosporin A (CsA) were used in transplant patients, however the
AZA and CsA combination seemed a bit controversial. Since they are nephrotoxic, kidney
transplant patients undergoing ASA and CsA treatment developed nephrological problems.

HONOURS IMMUNOLOGY 2 ASSESSMENT "4


By generating metabolites capable of reacting with various other enzymes such drugs cause
various side effects. Thereby it was thought to develop a new drug, more specific, able to act
only in lymphocytes, thus reducing the common AZA and CsA side effects (Anthony and
Elsie, 2000).
The purine synthesis is essential for maturation and cell proliferation. There are
basically two ways to produce purine, the salvage and the de novo pathways. The
lymphocytes depend on de novo pathway, which has inosine monophosphate dehydrogenase
(IMPDH) as a key enzyme. IMPDH converts inosine monophosphate (IMP) to guanosine
monophosphate (GMP). IMPDH enzyme is more present in the thymus and spleen, other
organs have lower concentrations. The distribution of IMPDH enzyme in the tissues confirms
its importance for lymphocyte metabolism. Tissues that have lower amounts of IMPDH
make use of an alternative pathway for the purine production, thus IMPDH enzyme was
chosen as a possible target for immunosuppressive drug, since the enzyme crucially affect the
lymphocyte metabolism and does not impair other tissues (Anthony and Elsie, 2000).
!
Pathway
!
MPA drug is a non-competitive inhibitor of IMPDH enzyme. The drug binds to the
enzyme in a reversible manner. Initially it is administered in the form of prodrug MMF,
which is esterified, reaction mediated by enzymes present in mononuclear cells, yielding an
active form of the drug, MPA. Through the action of beta-glucuronidase and glucuronosyl
transferase present in the liver and erythrocytes, the drug is converted to its inactive form,
Mycophenolic acid glucuronide, which is eliminated in the bile and urine bladder (Anthony
and Elsie, 2000).
In simple terms it can be said that there are two different isoforms of the IMPDH
enzyme, the type I and type II. The type I isoform is present in normal cells and non
activated lymphocytes. The type II is highly expressed in activated lymphocytes. The type II
isoform is five times more sensitive to MPA inactivation than type I. Therefore the action of
the drug mainly affects activated lymphocytes (Anthony and Elsie, 2000).
The drug MPA binds IMPDH enzyme preventing the production of GMP, guanosine
triphosphate precursor compound (GTP). The GTP is essential for fucose and mannose
production, which function as adhesion molecules, participating in the lymphocytes adhesion
into inflammatory sites. The transport of secretory vesicles is coordinated by GTPase
enzymes, thus the reduction of GTP levels hinder the vesicle secretion mechanism. Thereby it
can be said that in addition to its cytostatic propriety (by preventing maturation of activated
lymphocytes through depletion of purine levels), the drug has anti adhesion and anti
secretory effects. Such mechanisms induce immune tolerance (Anthony and Elsie, 2000).
!
!
!
HONOURS IMMUNOLOGY 2 ASSESSMENT "5
Clinical Consequences
!
Some studies have reported the drug efficacy in the treatment of rheumatoid arthritis,
myasthenia gravis, skin diseases, kidney diseases, inflammatory bowel disease, autoimmune
haemolytic anemia. This demonstrates the important immunosuppressive effect of the drug
(Anthony and Elsie, 2000).
The MMF causes similar side effects to those caused by the drugs AZA and CP,
however by affecting more specifically the de novo pathway of purine production, other
body tissues are not harmed crucially, thus the side effects are milder .
UGTA19 is an enzyme present in the liver and is involved in the inactivation process
of MPA. Polymorphisms of this enzyme provides greater resistance or susceptibility to drug,
depending on the individual polymorphism (O and C, 2004). The IMPDH enzyme has
polymorphisms, which can provide different drug responses (Glander, Hambach and Liefeldt,
2011).
!
2 - Specific immunosuppressive drugs
!
Specific immunosuppressive drugs affect the metabolic dynamics of specific cells.
They act, in general, in specific lymphocytic pathways.
!
Cyclosporin A / FK506 / Rapamycin
!
Cyclosporin A, its usage was approved in 1983. Was initially tested in kidney
transplants.
FK506, a drug approved by the FDA in 1994, an alternative to the cyclosporin A use.
FK506 has similar action to CsA (inhibiting calcineurin phosphatase), however a 100 times
lower dose of the first is required to elicit the same results.
Rapamycin, among the specific immunosuppressive drugs mentioned is the most
recent discovered, approved in 1999 by FDA and in 2000 by the European Commission. Was
originally discovered as an anti fungal drug. For possessing very similar structure to FK506, its
immunosuppressive properties were investigated. Unlike FK506, rapamycin has large
antitumor properties and also act as a cytostatic drug. Rapamycin has a greater
immunosuppressive effect when compared to FK506.
!
Cyclosporin A / FK506 Pathway
!
T cells, when activated by their receptors, undergo increased cytoplasm influx of Ca.
The increase in Ca concentrations initiates several reactions. A protein that is activated due to

HONOURS IMMUNOLOGY 2 ASSESSMENT "6


this large influx of calcium is the nuclear factor of activated T-cells (NFAT), which is
responsible for activating the transcription of several cytokines related to T cell maturation.
To be activated, NFAT is dependent on elevated calcium levels. NFAT is activated
when dephosphorylated by calcineurin, the protein that needs to be attached to the Ca-
calmodulin complex to have activity- the calmodulin acts as a calcium carrier protein and
mediates the connection between the ion and other cytoplasmic proteins. When
dephosphorylated, NFAT undergoes a translocation into the nucleus and there promotes
transcription of IL-2, IL-4, notch genes, and other cytokines related to T cell maturation. If
for some reason the intracellular calcium levels decrease, NFAT is immediately expelled from
the nucleus, this fact shows the high dependence of the transcription factor on calcium
cytoplasm high levels (Jin and C. Harrison, 2002).
When they enter the cells, both drugs bind to imunophilins present in the intracellular
environment. CsA binds to the imunophilin cyclophilin (A and D) and FK506 binds to FKBP.
FKBP and cyclophilin imunophilins, are naturally capable of binding to calcineurin, however,
when assembled, the respective drugs, CsA and FK506, become more avid for calcineurin,
thereby promoting the inhibition of the latter. The drug rapamycin also binds to FKBP
imunophilin, however the FKBP-rapamycin complex do not inhibits calcineurin but mTOR
(mammalian target of rapamycin), a protein responsible for controlling synthesis of proteins
and cell proliferation.
Two subunits, A and B, composes Calcineurin. A is responsible for their catalytic
action (dephosphorylation of NFAT) and B for binding Ca-calmodulin complex.
Imunophilins associated drugs bind to the B calcineurin subunit and therefore prevents the
binding of Ca-calmodulin complex thereby preventing the activation of A calcineurin
subunit. Factor NF-kB depends on the activity of calcineurin to exercise its cytokine
production function (Masatsugu and Anjana, 2008).
CsA can also bind cyclophilin D (CyPD). CyPD functions as a pore modulator factor
which controls the permeability of the mitochondrial membrane present in cardiac muscle
cells. When opened, the pore allows entry of ions including calcium. Calcium influx leads to
the activation of calcineurin and subsequent desphosphorilation of NFAT, which when
activated controls the production of proteins related to cell hypertrophy, as well as anti-
apoptotic proteins. When the CsA binds CyPD prevents the pore opening, thereby preventing
muscle cell hypertrophy (J.L, D and Freeman, 2004).

Rapamycin Pathway
!
Insulin-like receptors are targets for several cytokines, among which IL-2 took part.
These cytokines are of great importance to signal multiplication and cell growth. When
insulin like receptors are activated by their ligands, a intracellular reaction cascade mediated
by a protein complex called mTOR initiates. This complex allows transcription of cyclins
(essential proteins for the cell cycle), insulin-like growth factor (IGF) and ribosomal proteins.

HONOURS IMMUNOLOGY 2 ASSESSMENT "7


As known, upon entering the cell, rapamycin binds to FKBP imunophilin forming the
rapamycin-FKBP complex, which binds to mTOR causing its inactivation. Thereby,
rapamycin acts independently of calcium metabolism, not inhibiting the production of
cytokines as FK506 and cyclosporin A drugs do, but the cell responsiveness to these cytokines
(Shile, Bjornsti and Houghton, 2003).
Rapamycin is responsible causes cell cycle arrest in G1. This mechanism specially
affects IL-2 responsive cells.
!
Clinical Consequences
!
By inhibiting the development of T lineage cells and by interfering in B cell
development, the drugs cyclosporin A and FK506 act as potent immunosuppressor, which is
used in the treatment of rheumatoid arthritis, transplant recipients and patients with other
autoimmune diseases.
CsA drug is used in the treatment of patients with heart problems, as it influence the
metabolic dynamics of cardiac cells (by binding to cyclophilin D).
As known, CsA and FK506 drugs induce NFAT inactivation, which is also responsible
for promoting the activation of cyclooxigenase-2 (COX-2) factor. This leads to low
production of COX-2 which causes imbalance in the sodium and potassium metabolism
(inducing their body accumulation).
Cyclosporin A activates the renin angiotensin system, reducing the blood inflow to the
kidneys, impairing the metabolism of juxtaglomerular cells, and is therefore nephrotoxic
(Naesens, Kuypers and Sarwal, 2009).
The imunophilins present polimorfisms, which determine more or less drug
responsiveness (Shile, Bjornsti and Houghton, 2003).
The therapeutic effects of rapamycin are known for their action on the mTORC1
complex, however the drug is also responsible for binding mTORC2 complex, causing insulin
tolerance, thereby eliciting similar diabetes effects (Dudley, Lan and Pekka, 2012). Rapamycin
is not nephrotoxic, however can cause testicular atrophy and vascular problems.
!
Conclusion
!
Immunosuppressive drugs were only possible after the construction of knowledge and
attempts. Currently, a wide variety of drugs capable of promoting effective treatments for
various autoimmune diseases is available. However, many gaps still exist in the knowledge
about these drugs. Several studies aimed at promotion of increasingly effective drugs will in
future enable more effective and specific treatments for each type of immunodeficiency.
!
!
HONOURS IMMUNOLOGY 2 ASSESSMENT "8
!
References
!


A. Patel, A. and A. Swerlick, R.
Azathioprine in dermatology: The past, the present, and the future
In-text: (A. Patel and A. Swerlick, 2006)
Bibliography: A. Patel, A. and A. Swerlick, R. (2006). Azathioprine in dermatology: The past,
the present, and the future. [online] Sciencedirect.com. Available at: http://
www.sciencedirect.com/science/article/pii/S0190962205023844 [Accessed 15 Aug. 2014].
!

Anthony, A. and Elsie, E.


Mycophenolate mofetil and its mechanisms of action


In-text: (Anthony and Elsie, 2000)


Bibliography: Anthony, A. and Elsie, E. (2000). Mycophenolate mofetil and its
mechanisms

of action. [online] Available at: http://Mycophenolate mofetil and its mechanisms of


action [Accessed 16 Aug. 2014].


Dudley, L., Lan, Y. and Pekka, K.

Rapamycin-induced insulin resistance is mediated by mTORC2 loss and
uncoupled from

longevity

In-text: (Dudley, Lan and Pekka, 2012)

Bibliography: Dudley, L., Lan, Y. and Pekka, K. (2012). Rapamycin-induced insulin


resistance is mediated by mTORC2 loss and uncoupled from longevity.
!


Glander, P., Hambach, P. and Liefeldt, L.
Inosine 5'-monophosphate dehydrogenase activi... [Clin Chim Acta. 2012] - PubMed - NCBI
In-text: (Glander, Hambach and Liefeldt, 2011)
Bibliography: Glander, P., Hambach, P. and Liefeldt, L. (2011). Inosine 5'-monophosphate
dehydrogenase activi... [Clin Chim Acta. 2012] - PubMed - NCBI. [online] Ncbi.nlm.nih.gov.
Available at: http://www.ncbi.nlm.nih.gov/pubmed/21889500 [Accessed 16 Aug. 2014].

!

Hall and Tilby


Mechanisms of action of, and modes of resistance t... [Blood Rev. 1992] - PubMed -


NCBI


In-text: (Hall and Tilby, 1992)


Bibliography: Hall, and Tilby, (1992). Mechanisms of action of, and modes of resistance
t...

[Blood Rev. 1992] - PubMed - NCBI. [online] Ncbi.nlm.nih.gov. Available at: http://


www.ncbi.nlm.nih.gov/pubmed/1422285 [Accessed 15 Aug.
2014].

J.L, M., D, Z. and Freeman, J.


Cardiac disease due to random mitochondrial DNA mutations is prevented by cyclosporin A
In-text: (J.L, D and Freeman, 2004)
Bibliography: J.L, M., D, Z. and Freeman, J. (2004). Cardiac disease due to random
mitochondrial DNA mutations is prevented by cyclosporin A. [online] Sciencedirect.com.
Available at: http://www.sciencedirect.com/science/article/pii/S0006291X04010952
[Accessed 17 Aug. 2014].

Jin, L. and C. Harrison, S.
Crystal structure of human calcineurin complexed with cyclosporin A and human cyclophilin
In-text: (Jin and C. Harrison, 2002)
Bibliography: Jin, L. and C. Harrison, S. (2002). Crystal structure of human calcineurin
complexed with cyclosporin A and human cyclophilin.

HONOURS IMMUNOLOGY 2 ASSESSMENT "9



Masatsugu, O. and Anjana, R.
Calcium signaling in lymphocytes
In-text: (Masatsugu and Anjana, 2008)
Bibliography: Masatsugu, O. and Anjana, R. (2008). Calcium signaling in lymphocytes.
[online] Sciencedirect.com. Available at: http://www.sciencedirect.com/science/article/pii/
S0952791508000460 [Accessed 17 Aug. 2014].

!


Naesens, M., Kuypers, D. and Sarwal, M.
Calcineurin Inhibitor Nephrotoxicity
In-text: (Naesens, Kuypers and Sarwal, 2009)
Bibliography: Naesens, M., Kuypers, D. and Sarwal, M. (2009). Calcineurin Inhibitor
Nephrotoxicity. Clinical Journal of the American Society of Nephrology, [online] 4(2), pp.
481-508. Available at: http://cjasn.asnjournals.org/content/4/2/481.long [Accessed 18 Aug.
2014].
!


Navin Pinto, M. E. D.
Pharmacogenetic studies related to cyclophosphamide-based therapy
In-text: (Navin Pinto, 2009)
Bibliography: Navin Pinto, M. (2009). Pharmacogenetic studies related to cyclophosphamide-
based therapy. Pharmacogenomics, [online] 10(12), p.1897. Available at: http://
www.ncbi.nlm.nih.gov/pmc/articles/PMC2820268/ [Accessed 15 Aug. 2014].
!


O, B. and C, G.
The main role of UGT1A9 in the hepatic met... [Drug Metab Dispos. 2004] - PubMed - NCBI
In-text: (O and C, 2004)
Bibliography: O, B. and C, G. (2004). The main role of UGT1A9 in the hepatic met... [Drug
Metab Dispos. 2004] - PubMed - NCBI. [online] Ncbi.nlm.nih.gov. Available at: http://
www.ncbi.nlm.nih.gov/pubmed/15258099 [Accessed 16 Aug. 2014].
!


Pascal Frei, G. R.
Use of thiopurines in inflammatory bowel disease
In-text: (Pascal Frei, 2013)
Bibliography: Pascal Frei, G. (2013). Use of thiopurines in inflammatory bowel disease.
World Journal of Gastroenterology : WJG, [online] 19(7), p.1040. Available at: http://
www.ncbi.nlm.nih.gov/pmc/articles/PMC3581991/ [Accessed 14 Aug. 2014].
!


Rubin, R.
A Brief History of Great Discoveries in Pharmacology: In Celebration of the Centennial
Anniversary of the Founding of the American Society of Pharmacology and Experimental
Therapeutics
In-text: (Rubin, 2007)
Bibliography: Rubin, R. (2007). A Brief History of Great Discoveries in Pharmacology: In
Celebration of the Centennial Anniversary of the Founding of the American Society of
Pharmacology and Experimental Therapeutics. Pharmacological Reviews, [online] 59(4), pp.
289-359. Available at: http://pharmrev.aspetjournals.org/content/59/4/289.full.pdf+html
[Accessed 14 Aug. 2014].

S. Maltzman, J. and A. Koretzky, G.
Azathioprine: old drug, new actions
In-text: (S. Maltzman and A. Koretzky, 2003)
Bibliography: S. Maltzman, J. and A. Koretzky, G. (2003). Azathioprine: old drug, new

HONOURS IMMUNOLOGY 2 ASSESSMENT "10


actions. The Journal of Clinical Investigation.
!

Sahasranaman, S. and Howard, D.


Clinical pharmacology and pharmacogenet... [Eur J Clin Pharmacol. 2008] - PubMed - NCBI


In-text: (Sahasranaman and Howard, 2008)


Bibliography: Sahasranaman, S. and Howard, D. (2008). Clinical




pharmacology and pharmacogenet... [Eur J Clin Pharmacol. 2008] - PubMed - NCBI.


[online] Ncbi.nlm.nih.gov. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18506437


[Accessed 16 Aug. 2014].


Shile, H., Bjornsti, M. and Houghton, P.

Rapamycins, mechanism of action and cellular resistance

In-text: (Shile, Bjornsti and Houghton, 2003)

Bibliography: Shile, H., Bjornsti, M. and Houghton, P. (2003). Rapamycins, mechanism of

action and cellular resistance. [Accessed 17 Aug. 2014].

HONOURS IMMUNOLOGY 2 ASSESSMENT "11