European Journal of Pharmacology 877 (2020) 173090

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European Journal of Pharmacology

journal homepage: www.elsevier.com/locate/ejphar

Macrophage M1/M2 polarization T

a,b,c a,b,c a,b,c,d,∗∗ a,b,c,d,∗
Chen Yunna , Hu Mengru , Wang Lei , Chen Weidong
a
College of Pharmacy, Anhui University of Chinese Medicine, Hefei, 230012, China
b
Anhui Province Key Laboratory of Chinese Medicinal Formula, Hefei, Anhui, 230012, China
c
Institute of Pharmaceutics, Anhui Academy of Chinese Medicine, Hefei, Anhui, 230012, China
d
Engineering Technology Research Center of Modernized Pharmaceutics, Education Office of Anhui Province, Hefei, Anhui, 230012, China

A R T I C LE I N FO A B S T R A C T

Keywords: Macrophages can be affected by a variety of factors to change their phenotype and thus affect their function.
Macrophage polarization Activated macrophages are usually divided into two categories, M1-like macrophages and M2-like macrophages.
Tumor microenvironment Both M1 macrophages and M2 macrophages are closely related to inflammatory responses, among which M1
Nanocarriers macrophages are mainly involved in pro-inflammatory responses and M2 macrophages are mainly involved in
Nuclear receptor PPARγ
anti-inflammatory responses. Improving the inflammatory environment by modulating the activation state of
NF-κB
macrophages is an effective method for the treatment of diseases. In this review, we analyzed the mechanism of
macrophage polarization from the tumor microenvironment, nanocarriers, nuclear receptor PPARγ, phagocy-
tosis, NF-κB signaling pathways, and other pathways.

1. Introduction (CD206), anti-inflammatory factor (IL-10) and chemokines CCL17 and

Macrophages are widely present in the body and are commonly used
to maintain homeostasis and resist pathogen invasion (Davies et al.,
2013). Macrophages present in different tissues are polarized according
to changes in their environment, forming different macrophage sub-
types, such as M1 macrophages and M2 macrophages (Martinez and
Gordon, 2014). The microbial component lipopolysaccharide (LPS) can
drive macrophage polarization to the M1 phenotype while interleukin 4
(IL-4) can induce macrophage polarization to M2 (Sica and Mantovani,
2012). M1 macrophages are capable of proinflammatory responses and
produce pro-inflammatory related factors such as IL-6, IL-12 and tumor
necrosis factor (TNF). In contrast, M2 macrophages are capable of anti-
inflammatory responses and repair damaged tissues (Murray et al.,
2014; Ivashkiv, 2013). In infected tissues, macrophages are first po-
larized to pro-inflammatory M1 phenotype to assist the host against
pathogens. Subsequently, macrophages are polarized to form an anti-
inflammatory response to the M2 phenotype and repair damaged tissue.
Recently, the regulation of macrophage polarization to regulate its
immune function has been successfully stimulated.
A key aspect of macrophage polarization is the alteration of cell
surface marker expression. M1 macrophages overexpress CD80, CD86,
and CD16/32 and are capable of secreting pro-inflammatory cytokines.
In contrast, the expression of arginase-1 (Arg-1), mannose receptor
CCL22 were elevated in M2 macrophages. They play an important role
in tissue repair, angiogenesis, and metabolism (Van Dyken and
Locksley, 2013). Since macrophages play an important role in reg-
ulating the body's immune response and metabolism, macrophage po-
larization disorder may cause some diseases. By analyzing the causes of
macrophage polarization disorders, it contributes to the treatment of
the disease. Also, the direction of macrophage polarization in diseased
tissues can be modulated by drug interference to change to the desired
phenotype.
2. Overview of macrophage polarization
2.1. Tumor microenvironment
The tumor microenvironment (TME) includes tumor cells, macro-
phages, fibroblasts, endothelial cells, and pericytes as well as non-cel-
lular components such as extracellular matrix (ECM) and soluble signals
(Novikova et al., 2017). Mouse tumor models and patient samples
showed that macrophages accumulated significantly in the tumor mi-
croenvironment (Mantovani and Allavena, 2015). Tumor-associated
macrophages (TAMs), as the main tumor invasive immune cell popu-
lation, are usually educated by tumor cells to promote tumor immune
escape, angiogenesis, tumor growth, and metastasis. It is generally

∗
Corresponding author. Anhui University of Chinese Medicine, Hefei, 230012, China.
∗∗
Corresponding author. College of Pharmacy, Anhui University of Chinese Medicine, Hefei, 230012, China.
E-mail addresses: wanglei@ahtcm.edu.cn (W. Lei), wdchen@ahtcm.edu.cn (C. Weidong).

https://doi.org/10.1016/j.ejphar.2020.173090
Received 4 November 2019; Received in revised form 24 March 2020; Accepted 25 March 2020
Available online 29 March 2020
0014-2999/ © 2020 Elsevier B.V. All rights reserved.
C. Yunna, et al.
Fig. 1. Scheme of tumor microenvironment.
believed that macrophage polarization is driven by clues in the tumor
microenvironment, which can include low pH, hypoxia, and ECM
(Fig. 1). Notably, TAMs have the function of killing tumor cells and
promoting tumor cell growth. Among them, M2 macrophages are si-
milar in phenotype to TAMs, which promote tumor growth and me-
tastasis, and are associated with poor prognosis of tumors. In contrast,
M1 macrophages are generally considered to be tumor-killing macro-
phages, primarily anti-tumor and immune-promoting. Therefore, the
ideal method for tumor treatment is not to deplete TAMs but to convert
M2 TAMs to M1 anti-tumor macrophages.
Regulating the acidity of the tumor microenvironment is an effec-
tive strategy for altering the polarization phenotype of macrophages.
M2 macrophages repair damaged tissues by phagocytosis, and the
phagocytic function of macrophages is closely related to the pH of ly-
sosomes (Murray et al., 2014; Appelqvist et al., 2013; Lavine et al.,
2018). In contrast, the basic property of M1 macrophages is to promote
tissue damage (Murray et al., 2014; Lavine et al., 2018). Therefore,
changing the pH of lysosomes may be an effective strategy for resetting
the polarization phenotype of macrophages. Alkaline agents such as
chloroquine (CQ) are known to be trapped in the lysosomal compart-
ment, increasing lysosomal pH (Seglen et al., 1979). Thus, CQ (10 μM)
can act as an immunomodulator and mediate its anti-tumor efficacy by
increasing the lysosomal pH to reset TAMs from M2 to the M1 pheno-
type (Chen et al., 2018). Calcium carbonate (CaCO3) nanoparticles are
capable of regulating the acidity of the tumor microenvironment by
scavenging H+. Therefore, studies have incorporated biocompatible
CaCO3 nanoparticles into fibrin gels to act as release reservoirs for
immunomodulatory therapeutics as well as proton scavengers to mod-
ulate the tumor environment (Zhao et al., 2015). Besides, some re-
searchers combined anti-CD47 antibody and CaCO3 (1 mg/mouse) na-
noparticles to regulate the acidity of tumor resection environment, and
polarized tumor-associated macrophages into M1-like phenotype (Chen
et al., 2019b).
Due to the rapid growth of malignant tumors, there will be an area
of hypoxia inside the tumor (Wang et al., 2019). Hypoxia represents a
key microenvironmental stressor that plays an important and complex
role in tumorigenesis, development, metastasis, and cardiovascular
generation (Pakravan, 2013; Duffy et al., 2003). As a hallmark of ma-
lignant tumors, hypoxia is involved in the induction of epithelial-me-
tabolism and TAMs infiltration (Henze and Mazzone, 2016; Rahat et al.,
2011). Hypoxia may have a profound effect on the polarization of
macrophages due to the preferential accumulation of macrophages in
hypoxic tumor areas and the retention of relatively immature cell types
(Chen and Bonaldo, 2013; Murdoch and Lewis, 2005). Therefore, im-
proving the hypoxic tumor microenvironment is an effective method to
regulate the polarization phenotype of macrophages. The multi-
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European Journal of Pharmacology 877 (2020) 173090
functional single-transmembrane protein Neuropilin-1 (Nrp-1) acts as a
co-receptor for semaphorin (Sema) and TGF-β in a variety of hypoxic
tumors and plays an important role in regulating immune responses
(Rizzolio and Tamagnone, 2011; Jubb et al., 2012). Studies have shown
that hypoxic cervical cancer microenvironment can polarize macro-
phages into the M2 phenotype, and blocking the expression of Nrp-1
can effectively prevent macrophage polarization to M2 phenotype
(Chen et al., 2019c). In addition, the hypoxic tumor microenvironment
stimulates macrophages to secrete exosomes, which promote angio-
genesis, metastasize and inhibit host immunity, thereby promoting
disease progression (Park et al., 2010; Wilson and Hay, 2011). Exo-
somes secreted by hypoxic tumor cells are rich in immunoregulatory
proteins and chemokines, which promote macrophage polarization to
the M2 phenotype (Park et al., 2019). Tumor cells invade adjacent
tissues with the help of M2 TAMs and block the immune response. M2
TAMs stimulate normal-oxygen tumor cells to produce IL-6 as a factor
for cancer cell growth or survival while IL-6 promotes tumorigenesis by
regulating JAK-STAT3 (Jeong et al., 2017; Chang et al., 2013; Hu et al.,
2013).
ECM is a highly dynamic and complex macromolecular network
composed of a variety of fibrin, proteoglycan and stromal cell-asso-
ciated proteins (Hynes, 2009; Mouw et al., 2014). The development of
some diseases such as cancer is accompanied by changes in the com-
position of the ECM and contributes to the development of the disease.
Among them, the ECM component in the TEM has a regulatory effect on
macrophage polarization. For example, proteases and their inhibitors
are key physiological regulators of ECM remodeling. The extracellular
serine protease inhibitor (serpin) serpinE2 is overexpressed in various
human cancers including breast cancer and participates in tumor pro-
gression and metastasis (Fayard et al., 2009). By inhibiting the ex-
pression of serpinE2, M2-like macrophages can be promoted to M1-like
phenotype polarization and inhibit vascular invasion and tumor spread
(Smirnova et al., 2016). Notably, ECM-based biomaterials have been
developed as natural bioscaffolds for use in tissue engineering and re-
generative medicine (Song and Ott, 2011). The success or failure of its
application depends largely on the polarization direction of macro-
phages. In general, bioscaffolds that promote macrophage M1 polar-
ization cause damage to healing, while bioscaffolds with increased M2
polarization function facilitate tissue repair (Brown et al., 2012a; Smith
et al., 2017). Studies have found that ECMs from different tissue sources
have different roles in regulating macrophage polarization (Dziki et al.,
2017; Meng et al., 2015). Among them, cardiac-derived ECM promotes
M2 polarization, and bone-derived ECM favors M1 polarization (Sadtler
et al., 2016). Therefore, the selection of appropriate tissue source ECM
is critical to the clinical application of ECM biomaterials.
In addition to various solid tumors, the growth of non-solid tumors
C. Yunna, et al.
Fig. 2. Polarization of macrophages in non-solid tumors.
is also affected by the polarization of macrophages in the stroma
(Fig. 2). BMP4 produced by acute lymphocytic leukemia can up-reg-
ulate the expression of IL-10, TGF-β, IL-6, IL-8, and GAL-1, and promote
the polarization of M1-like macrophages to the M2 phenotype (Valencia
et al., 2019). Transcriptional repressor growth factor independence 1
(TRGF-1) can promote the polarization of macrophages to the M2
phenotype, thereby promoting the development of leukemia (Al-Matary
et al., 2016). Elevated NAMPT levels in chronic lymphocytic leukemia
cells induce eNAMPT production, which promotes the polarization of
monocytes into M2 macrophages (Audrito et al., 2015). Also, leukemia-
derived exosomes promote the polarization of macrophages into an M2-
like phenotype by reducing NO secretion (Jafarzadeh et al., 2019). The
development of lymphoma is also closely related to the polarizing
phenotype of macrophages. Lymphoma-derived exosomes polarize
macrophages to the M2 phenotype by mediating neuron-specific en-
olase (NSE) entry into macrophages and destroying classical NF-κB
activity (Zhu et al., 2019). Mantle cell lymphoma (MCL) can polarize
monocytes into M2-like macrophages by secreting CSF1 and IL-10.
However, BTK can inhibit the production of CSF1 and IL-10 in MCL
cells, thereby inhibiting the polarization of M2-like macrophages (Papin
et al., 2019). Recent studies have shown that the polarized phenotype
of macrophages in lymphomas correlates with age. In children over 10
years of age, macrophages tend to polarize to an M2-like phenotype. In
contrast, macrophages tend to polarize to an M1-like phenotype in
children under the age of 10 (Jimenez et al., 2019).
2.2. Nanocarriers and macrophage polarization
It is well known that nanocarriers cause macrophage polarization
phenotype changes in vivo mainly through macrophage internalization,
leading to changes in cellular uptake and secretion of cytokines and
chemokines (Chellat et al., 2005) (Fig. 3). Besides, a variety of nano-
carrier materials induce inflammatory and immune responses when
used in in vitro or in vivo experiments (Sun et al., 2013; Dostert et al.,
2008; Niikura et al., 2013; Wang et al., 2012; Morishige et al., 2010; Ji
et al., 2012; Yang et al., 2012; Lunov et al., 2011). Notably, material
parameters such as porosity (Sussman et al., 2014), stiffness (Blakney
et al., 2012), and nanotopography (Lee et al., 2011) change the in-
flammatory response. Therefore, understanding how nanocarriers affect
macrophage polarization and inflammatory response is an effective
strategy to promote the clinical application of nanocarriers. Various
engineered drug-free nanocarriers were used to reset the macrophage
polarization phenotype as it can be used to induce TAM polarization
from the M2 phenotype to the M1 phenotype (Zanganeh et al., 2016;
Pal et al., 2016). By analyzing the mechanism of interaction between
nanocarriers and macrophages, it will help to design and develop
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European Journal of Pharmacology 877 (2020) 173090
rational nanocarriers to adapt to therapeutic strategies.
2.2.1. Cancer
Mannosylated liposomes (500 μg/ml) can transform the M2 phe-
notype into the M1 phenotype to enhance the anti-tumor immunity of
immunomodulators (Ye et al., 2019). There are also researchers using
AuNPs (particle number of 3.72×1015/day) and AgNPs (particle
number of 1.07×1015/day) to maintain levels of reactive oxygen spe-
cies and reactive nitrogen species (RNS) in TAMs and promote proin-
flammatory responses, inducing TAMs polarization from the M2 phe-
notype to the M1 phenotype (Pal et al., 2016). Amphiphilic polymer-
modified Au and IO (iron oxide) NPs (5 nM) can be absorbed by mac-
rophages and induce macrophage polarization to the M1 phenotype.
Notably, nanoparticles with smaller particle sizes have a greater effect
on macrophage polarization than larger particles. Also, the size effect of
polyethylene glycol reduces the polarization of M0 macrophages to the
M1 phenotype (Cheng et al., 2019). Galactomannan (GM) nanoparticles
(62.1 μg/ml) promote the polarization of M2 macrophages to the M1
phenotype and enhance anti-tumor efficiency (Kumari et al., 2019).
Hyaluronic acid (HA) -modified Fe3O4-DOX nanoparticles (4 mg/kg)
can increase M1 macrophages in tumor tissues (Gong et al., 2019). In
addition, the elastic modulus of the surface of the material is the main
factor regulating the behavior of immune cells (Chen et al., 2019a). For
materials having a low modulus of elasticity, the nanostructures are
susceptible to deformation, resulting in cell stretching that adheres to
the surface. This result further increases the cell diffusion zone and
promotes macrophage polarization to the M1 phenotype to enhance
inflammation. Thus, by altering the physical properties of the surface of
the nanocarrier, the polarization direction of the macrophage can be
indirectly regulated to a phenotypic change that is beneficial for disease
treatment.
2.2.2. Tissue regeneration
Although M1 macrophages can aggravate the inflammatory re-
sponse by secreting pro-inflammatory cytokines. However, not all
treatments for diseases are expected to enhance the immune response.
Some biomaterials have been developed for implantation in the body
for repair and regeneration of damaged tissue (Taylor et al., 2007). The
nanomaterials implanted in the body activate the immune system to
produce an immune response that affects the therapeutic effect (Brown
et al., 2012b). Therefore, for some nanomaterials used for tissue re-
generation, M2 macrophages that exert anti-inflammatory effects be-
come ideal for macrophage polarization (Brown et al., 2012a). Emer-
ging research suggests that engineered biomaterials can regulate tissue
regeneration by polarizing macrophages into the M2 phenotype. Mag-
netic fields are used to remotely control the movement of magnetic
nanoparticles due to their good tissue penetration (Dobson, 2008).
High-frequency oscillations can promote macrophage polarization to
the pro-inflammatory M1 phenotype in the microenvironment by in-
hibiting the adhesion of macrophages (Kang et al., 2017). In stark
contrast, low-frequency oscillations promote macrophage polarization
to promote healing of the M2 phenotype. Therefore, the use of super-
paramagnetic iron oxide nanoparticles (SPIONs) promotes tissue repair
by regulating the oscillation frequency of the magnetic field to promote
macrophage polarization to the M2 phenotype. Bioactive glass (BG) is
widely used for tissue repair and regeneration because of its function of
enhancing blood vessel formation and wound healing (Wu and Chang,
2014). Notably, BG can inhibit pro-inflammatory responses due to the
effects of BG-released ionic products such as calcium, silicates, phos-
phates and so on (Mortazavi et al., 2010; Yu et al., 2016). The currently
developed BG nano delivery system is mainly composed of a calcium
ion-doped silica network (Valimaki and Aro, 2006). Folate-functiona-
lized BG nanoparticles (F-BGNs, 80–160 μg/ml) down-regulate the ex-
pression of pro-inflammatory molecules by inhibiting phosphorylation
involved in intracellular signaling cascades, thereby polarizing macro-
phages into an anti-inflammatory M2 phenotype (Kim et al., 2019b).
C. Yunna, et al. European Journal of Pharmacology 877 (2020) 173090

Fig. 3. Nanocarrier-regulated M1 and M2 macrophage polarization. Black represents the promotion of macrophage polarization to the M1 phenotype and red
represents the promotion of macrophage polarization to the M2 phenotype.

Recent studies have found that nanostructures on the surface of carrier

materials play an important role in regulating immune cell behavior
(Pan et al., 2017; Kianoush et al., 2017; Diener et al., 2012). For ex-
ample, small nanotubes are more likely to promote macrophage po-
larization to the M2 phenotype than large nanotubes (Ma et al., 2018).

2.2.3. Rheumatoid arthritis

Macrophages in rheumatoid arthritis (RA) are predominantly the
M1 phenotype, which promotes RA progression by releasing various
inflammatory cytokines (Wang et al., 2017). Hypoxia-inducible factor
(HIF-1α) and reactive oxygen species in RA are involved in the polar-
ization of macrophages. It is known that reactive oxygen species can
induce macrophage polarization to the M1 phenotype, while inhibition
of HIF-1α can promote macrophage polarization to M2. Manganese
ferrite nanoparticles can down-regulate the expression of HIF-1α by
Fig. 4. Regulation of macrophage polarization by nuclear receptor PPARγ.
Fenton reaction in the presence of H2O2 (Kim et al., 2017). Therefore, a
Nuclear receptors PPARγ can promote the polarization of macrophages to the
manganese ferrite and ceria nanoparticle-anchored mesoporous silica
M2 phenotype.
nanoparticles (MFC-MSNs, 40 μg/ml) were developed for the treatment
of RA by increasing M2 macrophages (Kim et al., 2019a).
by different metabolic programs (Odegaard et al., 2007). In proin-
flammatory M1 macrophages, aerobic glycolysis is driven by lipopoly-
2.3. Nuclear receptor PPARγ and macrophage polarization saccharide (LPS) or interferon-gamma (IFN-γ), whereas in anti-in-
flammatory M2 macrophages, lipid metabolism is regulated by IL-4,
The polarization of macrophages into different phenotypes is in- which is capable of upregulating the expression of PPARγ. The mTOR-
fluenced by different cytokines and signaling pathways, and peroxi- Semaphorin 6D (Sema6D)-PPARγ axis plays a key role in macrophage
some proliferator receptor gamma (PPARγ) regulated by small lipo- polarization (Kang et al., 2018). Inhibition of mTOR or Sema6D causes
philic molecules plays an important role in the process of macrophage down-regulation of PPARγ expression, thereby inhibiting macrophage
polarization (Evans and Mangelsdorf, 2014). The nuclear transcription polarization to the anti-inflammatory M2 phenotype.
factor PPARγ controls the direction of macrophage polarization by
promoting macrophage polarization to M2 phenotype and inhibition of
polarization to the M1 phenotype (Straus et al., 2000; Rossi et al., 2000) 2.3.1. Atherosclerosis
(Fig. 4). Therefore, regulating the expression level of PPARγ is an ef- Monocytes differentiate into macrophages in atherosclerosis.
fective strategy for changing the polarization direction of macrophages. Therefore, the inflammatory disease of atherosclerosis is closely related
It has been found that PPARγ in macrophages may regulate macrophage to the polarization of macrophages. PPARγ can interact with adipocytes
polarization in a ligand-independent manner (Daniel et al., 2018). or macrophages to produce inflammatory cytokines that exert insulin
Macrophage polarization of different phenotypes needs to be controlled sensitivity and inhibit inflammation (Bouhlel et al., 2007). MED1

4
C. Yunna, et al.
(mediator subunit 1) has a function of increasing PPARγ transcriptional
activity as a PPAR-binding protein (Zhu et al., 1997). PPARγ activation
causes human monocytes to become additional M2 macrophages.
Therefore, MED1 can be used to regulate the polarization of macro-
phages by regulating the activity of PPARγ (Zhu et al., 1997).
2.3.2. Adipose tissue inflammation
Polarized activation of macrophages in adipose tissue is critical to
maintaining homeostasis in adipose tissue. It is well known that mac-
rophages mainly exhibit an anti-inflammatory M2 phenotype in lean
tissues, whereas in obese tissues, macrophages are first polarized to the
M1 pro-inflammatory phenotype for the transmission of chronic in-
flammatory states and insulin resistance (Lumeng and Saltiel, 2011).
Deletion of PPARγ in adipose tissue macrophages caused macrophage
polarization to M1 type resulting in increased inflammation and insulin
sensitivity (Odegaard et al., 2007). MicroRNA-223 (miR-223) is an
important regulator of tissue inflammation and insulin resistance,
mainly through the regulation of macrophage polarization (Zhuang
et al., 2012). PPARγ can control the expression of miR-223 by directly
binding to the PPARγ regulatory element (PPRE) located in the miR-
223 promoter. The PPARγ/miR-223 regulatory axis controls macro-
phage polarization by targeting different downstream genes (Ying et al.,
2015).
2.4. Phagocytosis and macrophage polarization
Phagocytosis is a highly conserved process that is critical for host
defense and tissue remodeling. Macrophages, as specialized phagocytic
cells, engulf dead cells and debris to maintain tissue homeostasis. M2
macrophages and tissue-resident macrophages are typically similar to
the M2-like state, scavenging cell debris and dead cells by phagocytosis.
Therefore, M2 macrophages usually exhibit high phagocytic activity.
Apoptotic cells can regulate the polarizing phenotype of macrophages
and thus enhance the anti-inflammatory function of M2 macrophages
through phagocytosis. For example, endocytosis of apoptotic Adipose-
Derived Mesenchymal Stem Cells (AD-MSCs) reduces TNFα and NO
production and increases IL-10 levels to promote macrophage M2 po-
larization (Ghahremani Piraghaj et al., 2018). Macrophages digest
phagocytes with the production of a large number of nutrients, such as
amino acids and cholesterol. Recent studies have found that the amino
acid sensing complex formed by Lamtor1 and vacuolar HUC-ATPase is
an essential factor for macrophage polarization to the M2 phenotype
rather than the M1 phenotype (Kimura et al., 2016).
2.4.1. Cancer
IL-4 activates mTORC1 with the help of Lamtor1 and amino acids,
followed by activation of polarized macrophages into M2 macrophages.
Also, the enhanced TAK1/MKK7/JNK signaling complex recruits pha-
gosomes of macrophages that are activated by IL-4 (Guo et al., 2019a).
K63 polyubiquitination of macrophage scavenger receptor 1 (MSR1)
mediates this process. Activation of MSR1 promotes the polarization of
macrophages from the M2 phenotype to the M1 phenotype, which is
mainly caused by enhanced activation of JNK. The deletion of MSR1 or
inhibition of JNK will cause this polarization to be eliminated. Com-
pared with M2 macrophages, M1 macrophages have the stronger pha-
gocytic capacity. Therefore, we tend to polarize TAMs to the M1 phe-
notype to enhance phagocytosis and thus enhance anti-tumor efficiency
in cancer treatment. For example, dual inhibitors-loaded nanoparticles
(20 mg/kg) were used to treat breast cancer and melanoma by pro-
moting M2 macrophages repolarization to M1 macrophages and en-
hancing phagocytosis (Ramesh et al., 2019).
2.5. NF-κB signaling pathway
Inflammation is a major driver of the recruitment of immune cells,
including macrophages, and is closely related to the development of the
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European Journal of Pharmacology 877 (2020) 173090
disease. As one of the major inflammatory regulators, nuclear factor-
kappaB (NF-κB) is a key transcription factor that promotes transcription
of genes encoding pro-inflammatory cytokines (Yadav et al., 2003).
There is increasing evidence that the NF-κB signaling pathway plays a
crucial role in cancer metastasis and oxidative metabolism. TAMs
produce different interleukins, such as IL-10, VEGF, IL-8, through NF-
κB-mediated signaling to promote and mediate angiogenesis (Jallad
et al., 2014). Drugs or inhibitors can exert protective and im-
munomodulatory functions by inhibiting NF-κB signaling (He et al.,
2017). However, in some specific cancers, inhibition of the NF-κB sig-
naling pathway promotes the development of M2 macrophage polar-
ization and cancer. Stimulation of the NF-κB signaling pathway can also
polarize M2 macrophages into M1 macrophages (Hagemann et al.,
2009).
2.5.1. Cancer
As an inhibitor of NF-κB, Bay11-7082 (10 μM) can inhibit the po-
larization of TAMs to the M2 phenotype in THP-1 cells (Zhang et al.,
2019). In macrophages overexpressing SIRT1, potentiation of the NF-κB
signaling pathway promotes polarization of M1-like macrophages
(Zhou et al., 2019). The NADPH oxidase family (Nox) regulates com-
plex cellular processes primarily by controlling the production of re-
active oxygen species (Ushio-Fukai and Nakamura, 2008). As the major
members of Nox, Nox2 and Nox4 are closely related to the polarization
of macrophages. Among them, Nox2 and its activated product ·O2-
promoted the polarization of pro-inflammatory M1 macrophages, while
Nox4 facilitated the polarization of M2 macrophages (Serrander et al.,
2007; Kumar et al., 2016; Balce et al., 2011). Besides, knocking out
Nox4 resulted in increased expression of Nox2 in macrophages favoring
M1 macrophage polarization. The reason for this phenomenon may be
that the NF-κB signaling pathway is enhanced after knocking out Nox4,
further leading to increased expression of Nox2.
2.5.2. Other diseases
Natural monosaccharide L-fucose (250 mg/kg) can be utilized by
fucosyltransferases to regulate macrophage polarization and function
without side effects (Li et al., 2014; Becerra et al., 2015; Choi et al.,
2015). Due to the different bioenergy requirements of M1 and M2
macrophages, macrophages of different phenotypes are required to
regulate the nutritional status of the tissue. M1 macrophages rely on
aerobic glycolysis to produce ATP and increase glucose and glutamine
consumption, but they inhibit oxidative metabolism (O'Neill et al.,
2016a; O'Neill and Pearce, 2016b). M1 macrophages increase the ac-
cumulation of citrate and succinate by disrupting the tricarboxylic acid
(TCA) cycle and are useful in the production of antimicrobial molecular
fatty acids and itaconic acid (O'Neill and Pearce, 2016b). Besides, M2
macrophages are primarily used to maintain TCA cycling and promote
fatty acid oxidation (FAO), as a model for ATP production (Huang et al.,
2014). Glutaminase-derived αKG is an anti-inflammatory metabolite
that plays an important role in regulating macrophage polarization.
αKG impairs the proinflammatory response of M1 macrophages by in-
hibiting the NF-κB pathway (Liu et al., 2017). In general, the NF-κB
signaling pathway can be used to regulate macrophage polarization
(Fig. 5).
2.6. Other pathways
In addition to the above factors, many other factors play an im-
portant role in the polarization of macrophages (Table 1). They parti-
cipate in the development of related diseases by regulating the polar-
ization of macrophages. As the Akt subtype changes, the phenotype of
macrophages changes to affect the treatment of atherosclerosis (Linton
et al., 2019). Lack of Akt1 can induce M1 macrophage polarization and
lack of Akt2 can induce M2 macrophage polarization. Most im-
munologically responsive macrophages express a class A scavenger
receptor (SR-A) that regulates the polarization of macrophages (Wynn
C. Yunna, et al. European Journal of Pharmacology 877 (2020) 173090

induces M1 macrophage polarization via the Notch signaling pathway

Fig. 5. Regulation of macrophage polarization by NF-κB signalling. Stimulation
of NF-κB signaling pathway promotes polarization of M1 macrophages and
inhibition of NF-κB signaling pathway promotes polarization of M2 macro-
phages.
(Wei et al., 2019). R848, an agonist of the toll-like receptors TLR7 and
TLR8, was identified in a morphological-based screen and is an effective
driver of the in vitro M1 phenotype. The R848-loaded β-cyclodextrin
nanoparticles can effectively deliver drugs to tumor-associated macro-
phages in vivo and promote M1 macrophage polarization to control
tumor growth (Rodell et al., 2018). Melatonin is a guanamine hormone
secreted by the pineal gland and plays a pleiotropic role in the cardi-
ovascular system. Melatonin improves plaque inflammation by in-
hibiting the differentiation of macrophages in the plaque to the pro-
inflammatory M1 phenotype. The circadian rhythm nuclear receptor
retinoic acid receptor-associated solitary receptor alpha (RORα)-medi-
ated melatonin has vascular protective effects on vulnerable plaque
instability (Ding et al., 2019). Inhibition of the androgen receptor (AR)
has been shown to promote polarization of M2 macrophages and reduce
inflammation of autoimmune myocarditis (Ma et al., 2019).
3. Conclusions

et al., 2013; Mills, 2015). Zhipeng Xu et al. believe that pathogens in-
hibit the nuclear translocation of IRF5 by regulating the expression of
SR-A, thereby promoting M2 macrophage polarization for pathogen
infection (Xu et al., 2017). Broussonin E promoted M2 macrophage
polarization by inhibiting phosphorylation of ERK and p38 MAPK
(Huang et al., 2019). Also, broussonin E can be used to enhance the
JAK2-STAT3 signaling pathway to promote M2 macrophage polariza-
tion. Both methods can be used to suppress inflammation. The activity
of the drug metabolizing enzyme cytochrome P450 2E1 (CYP2E1) is
involved in the development of liver fibrosis. Guo YY et al. believed that
highly active CYP2E1 aggravated liver fibrosis by inhibiting the po-
larization of M2 macrophages (Guo et al., 2019b). In ovarian cancer
cells, the efflux of cholesterol and loss of lipid rafts promoted IL-4
signaling in macrophages and inhibited IFNg gene expression (Goossens
et al., 2019). Therefore, preventing the outflow of cholesterol is bene-
ficial to the polarization of M1 macrophages and enhances anti-tumor
immunity. The angiogenesis inhibitor kallikrein-binding protein (KBP)
promoted polarization and excessive accumulation of M1 macrophages,
increasing diabetic foot ulcer wounds (Feng et al., 2019). Therefore,
inhibition of KBP may be an effective strategy to promote the healing of
diabetic foot ulcers. A polysaccharide called RAP was isolated from
Astragalus membranaceus and was not cytotoxic, but induced cyto-
toxicity of RAW264.7 cells to cancer cells. Studies have shown that RAP
Recent studies have shown that macrophage polarization occurs in a
variety of diseases and plays an important role in the occurrence and
development of the disease. A variety of strategies have been used to
modulate macrophage polarization to treat disease. The weak acid or
hypoxic microenvironment of the tumor can modulate TAM to M2-like
polarization, while improving the tumor microenvironment can reset
TAM from M2-like macrophages to M1-like macrophages. Nanocarriers
are also used as drug delivery systems to modulate macrophage po-
larization. Nanocarriers themselves alter the inflammatory response
and affect macrophage polarization. Nuclear receptor PPARγ is a key
regulator of macrophage polarization, inhibits classical M1 activation
and promotes replacement of M2 macrophage responses. NF-κB is a key
transcription factor that regulates inflammation, stimulating the NF-κB
signaling pathway to alter the polarization phenotype of macrophages.
By modulating the above influencing factors, macrophages can be
turned into a desired phenotype for the treatment of diseases. In the
future, macrophage polarization phenotypes can be used to treat cancer
by drug intervention in nuclear receptor PPAR and NF-κB signaling
pathways, as well as other signaling pathways.
Declaration of competing interest
The authors declare no conflict of interest.

Table 1
Regulators of macrophage polarization.
Interference factor Function Effect on References Notes Disease Dose or
polarization concentration

Akt subtype mTORC2 assembly↓ Akt1↓→M1↑ 115 None Atherosclerosis None

Akt2↓→M2↑
SR-A Nuclear translocation of IRF5↓ M2↑ 118 None Pathogen infection None
Broussonin E Phosphorylation of ERK and M2↑ 119 TNF-α, IL-1β, IL-6, Inflammation 20 μM
p38 MAPK↓ COX-2 and iNOS↓
JAK2-STAT3 signaling pathway IL-10, CD206 and Arg-
↑ 1↑
CYP2E1 None M2↓ 120 CD163↓ Liver fibrosis None
CD68↑
The efflux of cholesterol and loss IL-4↑ M1↓ 121 None Cancer None
of lipid rafts IFNg↓
KBP Notch1/RBP-Jκ/Hes1 signalling M1↑ 122 iNOS↑ Diabetic foot ulcer None
pathway↑
RAP Notch signaling pathway↑ M1↑ 123 iNOS, IL-6,TNF-α and Cancer 30–300 μg/ml
CXCL10↑
R848 None M1↑ 124 None Cancer 2.0 mg/kg
Melatonin AMPKα-STATs pathway M1↑ 125 Inflammation 10 μM
AR None M2↑ 126 None Autoimmune None
myocarditis

Induction or promotion was expressed as ↑, suppression or reduction was expressed as ↓.

6
C. Yunna, et al.
Acknowledgement
This project was financially supported by the National Natural
Science Foundation of China (grant number 81773988).
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