Immunosuppressive drug
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Immunosuppressive drugs, also known as immunosuppressive agents, immunosuppressants and antirejection medications, are drugs that inhibit or prevent the activity of the immune system.
Classification
Immunosuppressive drugs can be classified into five groups:[citation needed]
Glucocorticoids
In pharmacologic (supraphysiologic) doses, glucocorticoids, such as prednisone, dexamethasone, and hydrocortisone are used to suppress various allergic, inflammatory, and autoimmune disorders. They are also administered as posttransplantory immunosuppressants to prevent the acute transplant rejection and graft-versus-host disease. Nevertheless, they do not prevent an infection and also inhibit later reparative processes.
Immunosuppressive mechanism
Glucocorticoids suppress
Glucocorticoids also suppress the humoral immunity, causing B cells to express smaller amounts of IL-2 and IL-2 receptors. This diminishes both B cell clone expansion and antibody synthesis.
Anti-inflammatory effects
Glucocorticoids influence all types of inflammatory events, no matter their cause. They induce the
(both COX-1 and COX-2) expression is also suppressed, potentiating the effect.Glucocorticoids also stimulate the lipocortin-1 escaping to the extracellular space, where it binds to the
Cytostatics
Alkylating agents
The
Antimetabolites
Antimetabolites interfere with the synthesis of nucleic acids. These include:
- folic acid analogues, such as methotrexate
- purine analogues, such as azathioprine and mercaptopurine
- pyrimidine analogues, such as fluorouracil
- protein synthesis inhibitors.
Methotrexate
Azathioprine and mercaptopurine
Azathioprine (Prometheus' Imuran), is the main immunosuppressive cytotoxic substance. It is extensively used to control transplant rejection reactions. It is nonenzymatically cleaved to mercaptopurine, that acts as a purine analogue and an inhibitor of DNA synthesis. Mercaptopurine itself can also be administered directly.
By preventing the clonal expansion of
Cytotoxic antibiotics
Among these,
Antibodies
Antibodies are sometimes used as a quick and potent immunosuppressive therapy to prevent the acute rejection reactions as well as a targeted treatment of lymphoproliferative or autoimmune disorders (e.g., anti-CD20 monoclonals).
Polyclonal antibodies
Heterologous polyclonal antibodies are obtained from the serum of animals (e.g., rabbit, horse), and injected with the patient's thymocytes or lymphocytes. The antilymphocyte (ALG) and antithymocyte antigens (ATG) are being used. They are part of the steroid-resistant acute rejection reaction and grave aplastic anemia treatment. However, they are added primarily to other immunosuppressives to diminish their dosage and toxicity. They also allow transition to cyclosporin therapy.
Polyclonal antibodies inhibit T lymphocytes and cause their
As of March 2005, there are two preparations available to the market:
Because of a high
Monoclonal antibodies
T-cell receptor directed antibodies
The muromonab's mechanism of action is only partially understood. It is known that the molecule binds TCR/CD3 receptor complex. In the first few administrations this binding non-specifically activates T-cells, leading to a serious syndrome 30 to 60 minutes later. It is characterized by fever,
The patient may develop neutralizing antibodies reducing the effectiveness of muromonab-CD3. Muromonab-CD3 can cause excessive immunosuppression. Although CD3 antibodies act more specifically than polyclonal antibodies, they lower the cell-mediated immunity significantly, predisposing the patient to opportunistic infections and malignancies.[6]
IL-2 receptor directed antibodies
Drugs acting on immunophilins
Ciclosporin
Like tacrolimus, ciclosporin (Novartis' Sandimmune) is a calcineurin inhibitor (CNI). It has been in use since 1983 and is one of the most widely used immunosuppressive drugs. It is a cyclic fungal peptide, composed of 11 amino acids.
Ciclosporin is thought to bind to the cytosolic protein
Ciclosporin is used in the treatment of acute rejection reactions, but has been increasingly substituted with newer, and less
Calcineurin inhibitors and azathioprine have been linked with post-transplant malignancies and
This drug has been reported to reduce the frequency of
Tacrolimus
Tacrolimus (trade names Prograf, Astagraf XL, Envarsus XR) is a product of the bacterium
The drug is used primarily in liver and kidney transplantations, although in some clinics it is used in heart, lung, and heart/lung transplantations. It binds to the immunophilin FKBP1A, followed by the binding of the complex to calcineurin and the inhibition of its phosphatase activity. In this way, it prevents the cell from transitioning from the G0 into G1 phase of the cell cycle. Tacrolimus is more potent than ciclosporin and has less pronounced side-effects.
Sirolimus
Sirolimus (rapamycin, trade name Rapamune) is a macrolide lactone, produced by the
Contrary to ciclosporin and tacrolimus, drugs that affect the first phase of T lymphocyte activation, sirolimus affects the second phase, namely signal transduction and lymphocyte clonal proliferation. It binds to FKBP1A like tacrolimus, however the complex does not inhibit calcineurin but another protein, mTOR. Therefore, sirolimus acts synergistically with ciclosporin and, in combination with other immunosuppressants, has few side effects. Also, it indirectly inhibits several T lymphocyte-specific kinases and phosphatases, hence preventing their transition from G1 to S phase of the cell cycle. In a similar manner, Sirolimus prevents B cell differentiation into plasma cells, reducing production of IgM, IgG, and IgA antibodies.
It is also active against
Everolimus
Everolimus is an analog of sirolimus and also is an mTOR inhibitor.
Zotarolimus
Zotarolimus is a semi-synthetic derivative of sirolimus used in
Other drugs
Interferons
IFN-β suppresses the production of Th1 cytokines and the activation of monocytes. It is used to slow down the progression of multiple sclerosis. IFN-γ is able to trigger lymphocytic apoptosis.
Opioids
Prolonged use of opioids may cause immunosuppression of both innate and adaptive immunity.[9] Decrease in proliferation as well as immune function has been observed in macrophages, as well as lymphocytes. It is thought that these effects are mediated by opioid receptors expressed on the surface of these immune cells.[9]
TNF binding proteins
A
These drugs may raise the risk of contracting tuberculosis or inducing a latent infection to become active. Infliximab and adalimumab have label warnings stating that patients should be evaluated for latent TB infection and treatment should be initiated prior to starting therapy with them.
TNF or the effects of TNF are also suppressed by various natural compounds, including curcumin (an ingredient in turmeric) and catechins (in green tea).
Mycophenolate
Mycophenolic acid acts as a non-competitive, selective, and reversible inhibitor of inosine-5′-monophosphate dehydrogenase (IMPDH), which is a key enzyme in the de novo guanosine nucleotide synthesis. In contrast to other human cell types, lymphocytes B and T are very dependent on this process. Mycophenolate mofetil is used in combination with ciclosporin or tacrolimus in transplant patients.
Small biological agents
Fingolimod is a synthetic immunosuppressant. It increases the expression or changes the function of certain adhesion molecules (α4/β7 integrin) in lymphocytes, so they accumulate in the lymphatic tissue (lymphatic nodes) and their number in the circulation is diminished. In this respect, it differs from all other known immunosuppressants.
Myriocin has been reported being 10 to 100 times more potent than Ciclosporin.
Therapy
Immunosuppressive drugs are used in immunosuppressive therapy to:
- Prevent the )
- Treat ).
- Treat some other non-autoimmune inflammatory diseases (e.g., long term allergic asthma control).
Side effects
A common
However, the vaccination status of patients taking immunosuppressive drugs for chronic diseases such as Rheumatoid arthritis or Inflammatory bowel disease should be investigated before starting any treatment, and patients should eventually be vaccinated against Vaccine-preventable disease.[12] Some studies showed a low vaccination rate against some Vaccine-preventable disease among patients taking immunosuppressive drugs, despite a generally positive attitude towards vaccinations.[13]There are also other side-effects, such as
See also
- Immunosuppression
- BK virus
- Behcet's Disease
- Discovery and development of mTOR inhibitors
- Treatment methods for preventing organ rejection
References
- OCLC 1142934194.
- PMID 20398732.
- OCLC 993810322.
- PMID 22531442.
- PMID 22413885.
- PMID 15885124.
- PMID 19218475.
- S2CID 23118360.
- ^ S2CID 7652574.
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- PMID 24491087.
- ^ Kucharzik T., Ellul P., Greuter T., Rahier J.F., Verstockt B., Abreu C., Albuquerque A., Allocca M., Esteve M., Farraye F.A., et al. ECCO Guidelines on the Prevention, Diagnosis, and Management of Infections in Inflammatory Bowel Disease. J. Crohn’s Colitis. 2021;15:879–913. doi: 10.1093/ecco-jcc/jjab052.
- ^ Costantino A, Michelon M, Noviello D, Macaluso FS, Leone S, Bonaccorso N, Costantino C, Vecchi M, Caprioli F; AMICI Scientific Board. Attitudes towards Vaccinations in a National Italian Cohort of Patients with Inflammatory Bowel Disease. Vaccines (Basel). 2023 Oct 13;11(10):1591. doi: 10.3390/vaccines11101591. PMID 37896993; PMCID: PMC10611209.
- S2CID 31374180.
Further reading
- Gummert JF, Ikonen T, Morris RE (June 1999). "Newer immunosuppressive drugs: a review". Journal of the American Society of Nephrology. 10 (6): 1366–1380. PMID 10361877.
- Armstrong VW (February 2002). "Principles and Practice of Monitoring Immunosuppressive Drugs". LaboratoriumsMedizin. 26 (1–2): 27–36. S2CID 79514959.
External links
- "Pancreas-Kidney Transplantation: Drugs". pancreas-kidney.com. Archived from the original on 29 October 2013. a brief history of immunosuppressive drugs. Retrieved 21 August 2005.
- Papich M (2001). "Immunosuppressive drug therapy". World Small Animal Veterinary Association (WSAVA). Archived from the original on 30 November 2016. Retrieved 21 August 2005.
- "Are Immunosuppressive Drugs a Useful Adjuvant to Treatment of HIV with Antiretrovirals?". Hivandhepatitis.com. Archived from the original on 28 February 2019. Retrieved 21 August 2005.
- Induction of Tolerance at eMedicine
- "Immunosuppressants". A to Z Health Guide. National Kidney Foundation. 24 December 2015.
- "Immunosuppressants, Pharmacologic profile". Drugguide.com. Retrieved 15 March 2016.
- Immunosuppressive+Agents at the U.S. National Library of Medicine Medical Subject Headings (MeSH)