1. Bashir Alsiddiq yousef
IMMUNOPHARMACOLOGY
Bashir Alsiddiq yousef

2. Review *2 major components of the immune system: -INNATE -ADAPTIVE
Physical – skin, mucus membrane
Biochemical – complement, lyzosyme
Cellular – macrophages, neutrophils
-ADAPTIVE
Antibodies – HUMORAL immunity
T-lymphocyte – CELL MEDIATED immunity

3. TH1 TH2 Macrophage APC B lymphocyte T lymphocyte Plasma Cells:
IL-4,IL-5
IL-2
IL-2
TH1
TH2
IFN-
TNF-
IFN-
IFN-
Plasma Cells:
IgG IgM
IgA - IgD
Activated
Macrophage
Activated
Cytotoxic T cell
Activated
NK cells
Memory B Cells
CELL-MEDIATED IMMUNITY
HUMORAL IMMUNITY

4. Abnormal immune response
Hypersensitivity
Autoimmune diseases
Immunodeficiency

5. Types of Drugs
*Immunosuppressants
*Immunostimulants
*Immunomodulators

6. Immunosuppressants

7. Major Steps in Immune Responses
1- Antigen recognition
2- IL-1 production
3- IL-2 and other cytokine expression
4- lymphocyte proliferation & differentiation

8. MAJOR STEPS IN IMMUNE RESPONSES
CD8 T cell
Antigen
IL-2
cytotoxic
T cells 1 4 3 2
primed
CD4
T helper
cell
IL-2
IL-1
antigen
presenting
cell
(macrophage,
dendritic cell)
CD4
T helper
cell 4
plasma
cells
IL-2
B cell

9. X X X X X X IL-2 IL-2 IL-1 SITES OF ACTION OF IMMUNOSUPPRESSIVE DRUGS
CD8 T cell
Antigen
IL-2 X
cytotoxic
T cells X X
primed
CD4
T helper
cell X X
IL-2
IL-1
antigen
presenting
cell
CD4
T helper
cell
plasma
cells X
cytokines

10. Immunosuppressants Corticosteroids Cyclosporine Tacrolimus Sirolimus
Antimetabolites
Antibodies
Mycophenolate mofetil
TNF-alpha binding drugs
15-Deoxyspergualin
Thalidomide

11. Clinical uses *Prevention of organ transplant rejection
*Treatment of autoimmune diseases
-Multiple Sclerosis
-SLE
-Rheumatoid Arthritis
-Crohn’s Disease
*Treatment of allergic reactions like Bronchial asthma and Eczema.

12. (Steps 1 and 2 - T cell activation and IL2 production):
IL-2 mRNA
IL-2 Protein:
IL-1
[Ca2+]
NFAT
PO3
Nucleus
Calcineurin
NFAT = Nuclear Factor of Activated T cells

13. (Step 3 - IL2 stimulation of T cell proliferation):
Receptor
T Cell
T Cell
T Cell
mTOR
Cell Proliferation
Cytokine Production
Activation of multiple types of immune cells

14. T T T Molecular basis for rejection
(Steps 1 and 2 - T cell activation and IL2 production): T
IL-1
Prednisone
IL-2 Protein:
[Ca2+]
Tacrolimus(FK506)/FKBP T
Calcineurin T
Cyclosporine/Cyclophilin
IL-2 mRNA
NFAT
NFAT
PO3
NFAT = Nuclear Factor of Activated T cells
Nucleus

15. T T T T Molecular basis for rejection
(Step 3 - IL2 stimulation of T cell proliferation):
T Cell T
Anti-IL-2
Anti-IL-2
receptor T
IL2
Receptor
T Cell
T Cell
T Cell
mTOR T
Cell Proliferation
Sirolimus(rapamycin)/
FKBP T
Cytokine Production
Cyclophosphamide
Methotrexate
Mycophenolate Mofetil
Activation of multiple types of immune cells

16. Cyclosporine Mechanism *lipophilic cyclic peptide
*inhibits transcription of IL-2 gene plus other cytokine expression (IL-3, gamma interferon)
*site of action is a binding protein that inhibits calcineurin (a phosphatase) involved in signal transduction upon antigen stimulation of T cell receptor
*used for transplant rejection and Autoimmune disorders.

17. Tacrolimus *Pimecrolimus Mechanism
*macrolide (structure like erythromycin) produced by streptomyces tsukubaensis.
Mechanism
*similiar to cyclosporine except binds to different protein that inhibits calcineurin (a phosphatase enzyme involved in gene transcription of IL-2, gamma interferon and other cytokines)
*used for transplant rejection and Autoimmune disorders.
*Pimecrolimus
*Calcineurin inhibitor like Tacrolimus.
*Approved for topical treatment of eczema.

18. Corticosteroid
Steriod receptors

19. Corticosteroid

20. Corticosteroid
*Inhibition of IL-1 and TNF gene expression and synthesis
*Decreased activation of T lymphocytes by decreasing IL-1 release
*Decreased neutrophil functions esp chemotaxis
*Decreased antibody production (high doses)
*Decreased release of kinins and proinflammatory eicosanoids (prostaglandins and leukotrienes)
*Affects cell-mediated immunity more than humoral immunity

21. Autoimmune disorders
Modulate allergic reactions - asthma
Organ transplantation – rejection crisis

22. Sirolimus (Rapamycin)
*macrolide similiar to tacrolimus isolated from streptomyces hygroscopicus.
Mechanism
*binds to immunophilin protein that binds to a key regulatory kinase required for T cell activation
*(new unique mechanism to inhibit T lymphocyte activation by IL-2)
*different site of action than cyclosporine and tacrolimus

23. Sirolimus -Inhibits mammalian target of rapamycin (mTOR)
*mTOR is a protein kinase that plays pivotal role in IL-2 receptor responses
*IL-2 binds to its receptor on T cells and leads to mTOR activation
*mTOR initiates cascade of events (including cyclin dependent kinases) that promote T lymphocyte proliferation and differentiation
*Inhibition of mTOR blocks IL-2 dependent cell-cycle progression at G1→S phase transition

24. Sirolimus other theoretical actions include:
*blockade of B cell Ig synthesis
*inhibition of antibody-dependent cellular toxicity
*inhibition of lymphocyte activated killer cells
*inhibition of natural killer cells
*inhibition of immune and nonimmune cell proliferation (via inhibition of growth factor signaling) (may explain antitumor actions)

25. Mycophenolate Mofetil
*derivative of mycophenolic acid which isolated from penicillium glaucum.
Mechanism
*inhibits inosine monophosphate dehydrogenase involved in de novo synthesis of purines
*selectively suppressess T- and B-cell proliferation
*Also suppresses some macrophage functions (may explain anti-inflammatory actions)
*used for transplanations.

26. guanosine monophosphate (GMP)
NAD+
NADH
Gln + ATP
Glu+AMP+PPi
guanosine monophosphate
(GMP)
GTP
GDP
IMP
adenosine monophosphate
(AMP)
aspartate + GTP
ATP
ADP
fumarate
GDP + Pi
adenylosuccinase
IMP dehydrogenase
6-mercaptopurine
Mycophenolate Mofetil
adenylosuccinate
XMP
Formation of AMP and GMP from IMP

27. *Mizoribine *Brequinar Sodium
inhibit same nucleotide synthesis pathway and very effective in kidney transplants.
*Brequinar Sodium
inhibit de novo pathway of pyrimidine synthesis and used for cancer & organ transplantation

28. Antimetabolites (Cytotoxic drugs)
*Immunosuppresion by inhibition of lymphocyte proliferation and cause bone marrow suppression
-Azathioprine
-Cyclophosphamide
-Leflunomide

29. Azathioprine *Metabolized to 6-mercaptopurines
*Inhibit purine synthesis interferes with nucleic acid metabolism  inhibits cellular & humoral responses
*used for Renal allograft, SLE, rheumatoid arthritis, Crohn’s disease.

30. Leflunomide *Prodrug of an inhibitor of pyrimidine synthesis
*Inhibits lymphoid cells proliferation.
*Approved for treatment of rheumatoid arthritis.

31. Cyclophosphamide *Destroys proliferating lymphoid cells
*Most potent immunosuppressive drug act as alkylating agent.
*Destroys proliferating lymphoid cells
*Used for Autoimmune disorders: SLE

32. Other cytotoxic agents
*Methotrexate has been used extensively in rheumatoid arthritis and in the treatment of graftversus- host disease. *dactinomycin has also been used with some success at the time of impending renal transplant rejection. *Vincristine appears to be quite useful in idiopathic thrombocytopenic purpura refractory to prednisone.

33. 15-Deoxyspergualin *isolated from Bacillus laterosporus.
*Potent antimonocytic (by ↓ MHC antigen expression, ↓ antigen processing and presentation and inhibition generation of free radical)
*antilymphocytic effect (by inhibiting antibody production and suppressing cytotoxic cell generation)
*Inhibits T & B lymphocyte response
*Renal transplants; pancreas & heart transplants

34. Thalidomide *Sedative drug
*Favors TH2 over TH1 (immunomodulatory action) with up-regulation of IL-4 and IL-5.
*Suppress TNF-α production
*Anti-angiogenesis action related for teratogenicity & anticancer activity.
*Indications
-Erythema nodosum leprosum (skin manifestations of SLE)
-Lung transplantation

35. FTY720 *prodrug: requires phosphorylation
*Sphingosine 1-phosphate receptor (S1P-R) agonist
*Reduces recirculation of lymphocytes from lymphatic system to the blood
*Lymphocyte homing action which reversibly sequesters host lymphocytes into lymph nodes
*Useful in combination therapy but not alone for autoimmune diseases such as RA.

36. Drugs that target receptors
Anakinra:
*Human IL-1 receptor antagonist
*Disease modifier agent for Rheumatoid arthritis

37. TNF-α receptors antagonist
Infliximab, etanercept, and adalimumab:
*are new biologic agents that bind and block TNF receptors. results in suppression of downstream inflammatory cytokines such as IL-1 and IL-6 and adhesion molecules involved in leukocyte activation and migration.
*Used for Crohn's disease, rheumatoid arthritis, and psoriatic arthritis.

38. Antibodies OKT3 (Muromonab-CD3) Antilymphocyte Globulin
*monoclonal antibody to CD3 on T cell
*inhibits cytotoxic T killer cell function
*opsonizes circulating T lymphocytes and enhances their removal
*used to prevent or reverse acute graft rejection
Antilymphocyte Globulin
*polyclonal antibody similiar to OKT3

39. Antithymocyte Globulin-Rabbit (Thymoglobulin):
*Rabbit gamma immune globulin preparation
*Composed of antibodies to variety of T cell markers
*Mechanisms
-removal of T cells from circulation
-modulation of T cell activation, homing and cytotoxicity
-decreases cytokine induced reactions

40. IL-2 Receptor Antibodies
-Basiliximab and Daclizumab:
*monoclonal antibodies against human IL-2 receptor alpha subunit of activated T to block T cell
*Blocks activation and inhibits clonal expansion of T cells
*Used to induce immunosuppression and to prolong organ transplants in combination with immunosuppressants

41. Alefacept
*Recombinant DNA-derived humanized monoclonal antibody *It inhibits activation of T cells by binding to cell surface CD2 and inhibiting the normal CD2/LFA-3 interaction *approved for the treatment of plaque psoriasis

42. Efalizumab
*is a humanized IgG1 mAb targeting the LFA-1 (lymphocyte function associated antigen). *Efalizumab binds to LFA-1 and prevents the LFA-1-ICAM (intercellular adhesion molecule) interaction to block T-cell adhesion, trafficking, and activation. *used for graft rejection and psoriasis.

43. Alemtuzumab *New Immunosuppressant
*Recombinant DNA-derived humanized monoclonal antibody
*Binds to CD52. a nonmodulating antigen present on surface of all T and B cells
*Some bone marrow cells express CD52 including some CD34+ cells
*Produces profound T cell depletion
*Used for for selected leukemias and lymphomas also for stem cell transplant procedures

44. Other Antibody Preparations
Rh(D) Immune Globulin
*for Rh (neg.) mother after delivery of Rh(pos.) baby.
Abciximab
*for surface receptor on activated platelets to prevent restenosis after coronary angioplasty
Rituximab
*for CD20 on pre-B and mature B cells to treat non-hodgkins lymphoma

45. Palivizumab Trastuzumab
*monoclonal antibody that binds to the fusion protein of respiratory syncytial virus, preventing infection in susceptible cells in the airways.
Trastuzumab
*monoclonal antibody that binds to the extracellular domain of the human epidermal growth factor receptor HER-2/neu. Used for treatment of metastatic breast CA

46. View
Notes

47. Immunostimulants

48. *These drugs increase the immune response for patients therefore used in:
Infection treatment.
Immunodeficiency
cancer

50. Immunostimulatory Cytokines
Interleukins
*IL-2 (enhance antitumor actions of cytotoxic T cells and NK cells) and therefore use for treatment of cancer such as renal carcinoma and malignant melanoma.
Colony Stimulating Factors
*G-CSF (neutropenia) and GM-CSF (bone marrow transplant patients)
*GM-CSF can itself stimulate an antitumor immune response, resulting in tumor regression in melanoma and prostate cancer

51. INF uses *Interferon Alpha (prod. by leukocytes)
-(antiviral, antiproliferative)
-malignant melanoma, renal cell carcinoma, hairy cell leukemia, Kaposi’s sarcoma
*Interferon Beta (prod. by fibroblasts)
-relapsing type Multiple Sclerosis.
*Interferon Gamma (prod. by lymphocytes)
-(stimulates NK cells and macrophages)
-chronic granulomatous disease

52. Levamisole *antiparasitic agent
*Later studies suggested that it increases the magnitude of delayed hypersensitivity or T cell-mediated immunity in humans.
*potentiate action of fluorouracil in adjuvant therapy of colorectal cancer.
*Also may used for hodgkin’s lymphoma and RA

53. Bacillus Calmette-Guerin
*Suspension of attenuated Mycobacterium bovis
*Stimulates cell-mediated immunity (immune adjuvant)
*Used as a topical agent for superficial cancers of the urinary bladder with an 80% response rate.

54. * A variety of microbial products, including whole organisms and extracts, have been used in Japan as immunomodulators in standard cancer treatments. These have included picibanil (OK432), lentinan, and pachymaran. Clinical trials, usually historically controlled, showed a prolongation of remission and survival. These agents stimulate macrophages to release various cytokines, including IL-1, colony-stimulating factors, and TNF-α.

55. Other immunostimulants
Inosiplex, Diethylcarbamate (DTC), Azimexon, ciamexon, and imexon:
*has immunomodulating activities By increasing natural killer cell cytotoxicity as well as T cell and monocyte functional activities.
*These drugs found to reduce infections and slow progression in some patients with
advanced HIV infection.

56. Hematopoietic Agents Erythropoietin alpha Darbopoetin alpha
*Stimulates division and differention of erythroid progenitor cells
*Used for anemia due to renal failure or cancer chemotherapy
* Short duration of action.
Darbopoetin alpha
*Recombinant long-acting erythropoetin.

57. Thymic Hormones
*Thymosin consists of a group of protein hormones synthesized by the epithelioid component of the thymus. *Smaller peptides and recombinant molecules such as thymosin- 1, thymic humoral factor, and thymopentin, may have similar activity *Used for treatment of DiGeorge Syndrome of T cell deficiency

58. Cancer immunotherapy Active nonspecific immune stimulation eg, BCG
Active specific immune stimulation eg, melanoma cell vaccine
Immunomodulators eg, Levamisole
Cytotoxic cytokines eg, INF-α
Immunostimulatory cytokines eg, IL-2
Adaptive cellular immunotherapy eg, antigen pulsed dendritic cells
Monoclonal antibodies eg, anti-HER-2.

59. Immunotherapy and vaccination
Live attenuated
Whole killed
Subunit (purified /partially purified protein from organism)
Recombinant
Polysaccharide
Toxoid
Future: vectored, peptide and DNA.

60. Tolerogens

61. TOLEROGENS
-Two signals required for T cell activation
*Signal 1 via T cell receptor
*Signal 2 via costimulatory receptor-ligand pair
- While Immunosuppressants has concomitant risks of opportunistic infections and secondary tumors therefore tolerogens may solve this problem.

62. Normal T Cell Response

63. T Cell Anery (No Response)

64. Inhibitory and Stimulatory APC Molecules

65. Costimulatory Blockade
-Experimental approaches to inhibit costimulation include: 1- Anti-CD80 and anti-CD86 mAbs. approved for renal transplantation. 2- Anti-CD28 antibody which may used for rheumatoid arthritis 3- Anti-CD154 antibody block CD 40L to interact with CD 40 in APC used in clinical trials in renal transplantation and autoimmune diseases.

66. Thanks