CLINICAL PHARMACOLOGY II

CLINICAL
IMMUNOPHARMACOLOGY
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INTRODUCTION
• The introduction of a foreign antigen into the body may
provoke an immune reaction.
• Antigens (usually proteins, glycoproteins or high-
molecular-weight carbohydrates) usually have a molecular
weight 5000 Da.
• They are typically processed by macrophages before
presentation to T lymphocytes.
• The effector limb of the immune response is initiated by
interaction of the presented antigen with receptors on the
surface of the lymphocytes.
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• Immune responses are of two types, namely
humoral (via B lymphocytes, plasma cells and
antibody) or cellular (via T lymphocytes).
• The immune response is an essential defence
mechanism.
o However, it may be defective, disorganized or
overactive.
• The body has the potential to stimulate its own
immune system so that antibodies are produced
against itself.
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• Normally this situation is prevented, for example,
by tolerance, but if this fails then autoimmune
disease results.
• Deficiencies in the immune system may be
congenital or result from disease (notably AIDS
from HIV-1 infection) or the use of
immunosuppressant drugs, particularly cytotoxic
agents (e.g. cyclophosphamide, 6-
mercaptopurine), glucocorticosteroids and
immunophilins (e.g. ciclosporin and its analogues).
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• By the same token, these are the very drugs
that are used clinically as
immunosuppressants when it is necessary to
clamp down an inappropriate immune
response.

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IMMUNITY AND HYPERSENSITIVITY
HUMORAL IMMUNITY
• The humoral response occurs in two stages:
1. primary reactions – these occur with the first
exposure to the antigen.
o There is a small and short-lived rise in antibody
titre which consists largely of IgM;

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2. secondary reactions – these occur with
subsequent exposure to the antigen.
• The rise in antibody titre is greater and
persists for a long period.
• The antibody consists mainly of IgG.
• This reaction requires the interaction of helper
T cells and B lymphocytes.

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CELLULAR IMMUNITY
• This is mediated by sensitized T lymphocytes
which recognize and bind the antigen and
subsequently release a cascade of
lymphokines which control and amplify both
humoral and cellular immune responses.
• The effector arm of cellular immunity consists
of cytotoxic T cells.

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ACTIVE IMMUNITY
• This consists of immunity that is developed
either in response to infection or following
inoculation with an attenuated strain of
organism, or with a structural protein or toxic
protein to which the host produces protective
antibodies.

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PASSIVE IMMUNITY
• This is immunity that is transferred by the
administration of preformed antibodies (e.g.
immune globulin/serum) either from another
host or from recombinant techniques in vitro.

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HYPERSENSITIVITY
• Sometimes the immune response to an
antigen results in damage to the tissue; this is
known as hypersensitivity.
• There are four types of hypersensitivity.

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TYPE-I HYPERSENSITIVITY
• This results from the combination of antigen with
high affinity IgE (reaginic) antibody on the surface of
tissue mast cells and/or blood basophils, releasing
potently vasoactive and pro-inflammatory mediators.
• These mediators include histamine, leukotrienes C4,
D4 and E4, eosinophil chemotactic factor (ECF),
serotonin, tachykinins and prostaglandins.
• This can cause bronchospasm, anaphylaxis, hay fever
or urticaria.
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TYPE-II HYPERSENSITIVITY
• These reactions occur when antibody
combines with antigenic components on a cell
or tissue surface.
• This leads to cell lysis or tissue damage as a
result of antibody-directed cell-mediated
cytoxicity (ADCC) by macrophages and natural
killer (NK) cells through Fc receptors or by
activation of complement.
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• This reaction may form the basis of a drug
reaction (e.g. penicillin or quinidine-induced
haemolytic anaemia or thrombocytopenia).
• This is because although most drugs are low
molecular weight, they can bind to a protein
to form an immunologically active entity
(‘hapten’).

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• Another example of this type of reaction is
haemolytic disease of the newborn, when
antibodies produced by a rhesus-negative
mother against the rhesus factor on the red
cells of the fetus cross the placental barrier
and cause haemolysis.
• Such reactions may be mediated by IgM or IgG
antibodies.

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TYPE-III HYPERSENSITIVITY (ARTHUS REACTION
–IMMUNE COMPLEX MEDIATED)
• This is the result of the deposition of soluble
antigen–antibody complexes in small blood
vessels (e.g. in the renal glomeruli) or other
tissues.

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TYPE-III HYPERSENSITIVITY (ARTHUS REACTION –
IMMUNE COMPLEX MEDIATED)
• Immune complex deposition activates complement
and initiates a sequence which results in
chemotaxis of polymorphs, tissue injury and
vasculitis.
• This reaction is slower in onset than the immediate
type I reaction.
• Serum sickness is an example of this type of
response.
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TYPE-IV (DELAYED OR CELL-MEDIATED
HYPERSENSITIVITY)
• This is mediated by sensitized CD41 circulating
T lymphocytes reacting with antigen.
• Circulating antibodies are not involved.

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• Activation of primed CD41 T cells causes their
proliferation and the release of cytokines
which produce local inflammation, attracting
and activating NK cells, macrophages and
granulocytes.
• This type of reaction takes place after one to
two days and is exemplified by contact
dermatitis and organ transplant rejection.

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IMMUNOSUPPRESSIVE AGENTS
• For therapeutic purposes, immunosuppression
should ideally be specific and not impair immune
responses indiscriminately.
• The sites of action of immunosuppressive agents
are shown in Figure 50.1. Immunosuppressive
agents are inevitably a two-edged sword and
before considering individual agents it is worth
considering some of their general adverse effects.

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GENERAL ADVERSE EFFECTS OF IMMUNOSUPPRESSION
• Increased susceptibility to infection; Bacterial
infections are common and require prompt treatment
with appropriate antibiotics.
• Tuberculosis may also occur and sometimes takes
unusual forms.
• Viral infections may be more severe than usual and
include the common herpes infection, but
occasionally also such rarities as progressive
multifocal leukoencephalopathy.
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• Fungal infections are also common, including
Candida albicans (which may be local or
systemic).
• Protozoal infections (e.g. Pneumocystis carinii)
also occur with increased frequency.
• Sterility Azoospermia in men is common,
especially with alkylating agents.
• In women, hormone failure leading to
amenorrhoea is common.
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• Teratogenicity; This is less common than might
be anticipated.
– However, it is prudent to avoid conception while
on these drugs.
– Men should wait 12 weeks (the time required to
clear abnormal sperm) after stopping treatment.

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• Carcinogenicity; Immunosuppression is
associated with an increased incidence of
malignant disease.
• Large-cell diffuse lymphoma can present early
in treatment, but with prolonged treatment
other types of malignancy may arise.
• The incidence in transplant patients is about
1%.

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GLUCOCORTICOSTEROIDS
Uses
• Glucocorticosteroids are used in each of the
four kinds of hypersensitivity disease:

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GLUCOCORTICOSTEROIDS
1. Glucocorticosteroids are used in the treatment
of allergic rhinitis, atopic dermatitis, acute
severe asthma, chronic asthma and
anaphylaxis.
o In allergic rhinitis and atopic dermatitis (type-I
reactions), the principal benefit probably arises
from their non-specific anti-inflammatory effects,
including vasoconstriction and decreased vascular
permeability.
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2. Glucocorticosteroids are often effective in type-II
autoimmune diseases.
3. Immune complex disease (type-III hypersensitivity)
may also be treated with glucocorticosteroids,
although they often produce symptomatic relief
without altering the underlying disease process.
4. Glucocorticosteroids are potent inhibitors of the cell
mediated hypersensitivity (type IV) reactions.
Clinically they are used to prevent acute graft
rejection and improve severe contact dermatitis.
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CALCINEURIN INHIBITORS: CICLOSPORIN (AND ITS
CONGENERS)
• Ciclosporin is a cyclic hydrophobic decapeptide that
was originally extracted from fungal cultures.
Uses
• The main use of ciclosporin is in immunosuppression
for solid-organ transplantation, but it is also effective
in refractory psoriasis and bone marrow
transplantation and graft-versus host disease (donor
bone marrow or stem cells attacking recipient).
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CALCINEURIN INHIBITORS: CICLOSPORIN (AND
ITS CONGENERS)
• A high dose of ciclosporin is given 4–12 hours
before transplantation and then various oral
maintenance dose regimens are used.
• Therapeutic drug monitoring is used to
optimize therapy.

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CALCINEURIN INHIBITORS: CICLOSPORIN (AND ITS CONGENERS)
Mechanism of action
• Ciclosporin is a specific T-lymphocyte suppressor, primarily
acting on the T-helper (Th1) cells, with a unique effect on the
primary immune response.
• It inhibits the production of interleukin-2 (IL-2) and other
cytokines by activated lymphocytes.
• Ciclosporin binds to a cytosolic protein cyclophilin.
• This conjugate subsequently interacts with a Ca2–calmodulin
dependent calcineurin complex and inhibits its phosphorylase
activity.

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• This impairs access to the nucleus of the
cytosolic component of the transcription
promoter nuclear factor of activated T cells
(NF-ATc), which in turn reduces the
transcription of messenger RNA for IL-2, other
pro-inflammatory lymphokines and IL-2
receptors.

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Adverse effects
These include the following:
• nephrotoxicity, which may be minimized by
concomitant use of calcium channel
blockers;
• hyperkalaemia;
• nausea and gastro-intestinal disturbances;
• hypertension;
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Adverse effects
• hirsutism;
• gingival hypertrophy;
• tremor (which can be an early sign of increasing
plasma concentrations), paraesthesia(pins and
needles sensation) and fits;
• hepatotoxicity;
• anaphylaxis with intravenous administration.

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Pharmacokinetics
• Ciclosporin is variably absorbed after oral
administration.
• It undergoes variable presystemic metabolism
by gastro-intestinal cytochrome P450 3A4.
• The major route of clearance is metabolism
via hepatic CYP3A.

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Pharmacokinetics
• Renal dysfunction does not affect ciclosporin
clearance, but caution is needed because of
its nephrotoxicity.
• Dose reduction is required in patients with
hepatic impairment.

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Therapeutic drug monitoring
• Ciclosporin is assayed by radioimmunoassay
(RIA) or high-performance liquid
chromatography (HPLC).
• Effective immunosuppression occurs at trough
concentrations of 100–300 μg/L.

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Drug interactions
• These include allopurinol, cimetidine,
ketoconazole (and other azoles),
erythromycin, diltiazem (and other calcium
channel blockers), anabolic steroids,
norethisterone and other inhibitors of
cytochrome P450 3A4, which reduce the
hepatic clearance of ciclosporin leading to
increased toxicity.
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Drug interactions
• Phenytoin and rifampicin increase hepatic
clearance, thus reducing plasma
concentrations.
• Concomitant use of nephrotoxic agents such as
aminoglycosides, vancomycin and
amphotericin increases nephrotoxicity.
• ACE inhibitors increase the risk of
hyperkalaemia.
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• Tacrolimus (FK506) is another calcineurin
inhibitor.
• It is more potent than ciclosporin and often
used in patients who are refractory to
ciclosporin.
• It can be given intravenously or orally, and
has variable absorption, and is metabolized by
hepatic CYP3A4.

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• Therapeutic drug monitoring of trough
concentrations is useful.
• The side effect and drug–drug interaction
profile of tacrolimus is similar to that of
ciclosporin, but it may cause more
neurotoxicity and nephrotoxicity.

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ANTI-PROLIFERATIVE IMMUNOSUPPRESSANTS
AZATHIOPRINE
• Azathioprine is a prodrug and is converted to
6-mercaptopurine (6-MP) by the liver.
Uses
• Azathioprine is less widely used now than
previously to prevent transplant rejection.

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ANTI-PROLIFERATIVE IMMUNOSUPPRESSANTS
AZATHIOPRINE
• It may also be used to treat certain autoimmune
diseases (e.g. systemic lupus erythematosus,
rheumatoid arthritis, inflammatory bowel disease,
chronic active hepatitis and some cases of
glomerulonephritis).
• Owing to its potential toxicity, it is usually reserved
for patients in whom glucocorticosteroids alone are
inadequate.
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MYCOPHENOLATE MOFETIL
Uses
• Mycophenolate mofetil is an ester of a product of the
Penicillium mould.
• It is used in combination with immunophilins (e.g
ciclosporin) and glucocorticosteroids in solid-organ (e.g.
renal, cardiac) transplantation and is a more effective
alternative than azathioprine.
• Mycophenolate mofetil may also be effective in the
treatment of other autoimmune disorders, such as
rheumatoid arthritis and psoriasis.
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Mechanism of action
• In vivo the active entity, mycophenolic acid,
inhibits inosine monophosphate
dehydrogenase (a pivotal enzyme in purine
synthesis).
• It suppresses proliferation both of T and B
lymphocytes.
• In addition, mycophenolic acid inhibits the
production of pro-inflammatory cytokines.
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Pharmacokinetics
• Mycophenolate mofetil is a prodrug ester of
mycophenolic acid, with improved absorption.
• After oral administration in humans, the ester
is rapidly and completely cleaved to
mycophenolic acid.
• Mycophenolic acid undergoes hepatic
elimination to its inactive glucuronide
metabolite.
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Adverse effects
• These include the following:
• gastro-intestinal disturbances – diarrhoea and
haemorrhage;
• bone marrow suppression, especially
leukopenia and anaemia;
• CMV infection;
• lymphomas.
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Drug interactions
• Antacids decrease mycophenolate
absorption.
• For novel anti-proliferative agents, such as
sirolimus and everolimus

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BIOLOGIC IMMUNOSUPPRESSANTS
POLYCLONAL ANTIBODIES
ANTILYMPHOCYTE GLOBULIN
• Antilymphocyte globulin (ALG, also known as
antithymocyte globulin) is prepared by injecting
human T lymphocytes into animals (e.g. rabbits or
horses) to raise antibodies.
• The active immunoglobulin is largely in the IgG fraction
and ALG is a polyclonal antilymphocyte antibody with
inherent variability from batch to batch.
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• The major effect is probably to prevent
antigen from accessing the antigen-
recognition site on the T-helper cells.
• It is given intravenously for acute organ
transplant rejection.
• Adverse effects include anaphylaxis and serum
sickness (characterized by skin rash, joint
stiffness and fever).

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MONOCLONAL ANTIBODIES
ANTI-CD3 ANTIBODY (MUROMONAB-CD3)
Uses
• These monoclonal antibodies are used as adjuvant
(often as second-line) immunosuppressive therapy in
patients with acute transplant rejection.
• They are IgG2a antibodies produced from murine
hybridoma cells and are given intravenously.
• After a 10- to 14-day course, some patients develop
neutralizing antibodies.
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MONOCLONAL ANTIBODIES
ANTI-CD3 ANTIBODY (MUROMONAB-CD3)
Mechanism of action
• Anti-CD3 antibodies bind CD3 protein, blocking antigen
binding to the T-cell antigen–recognition complex, and
decreasing the number of circulating CD3-positive
lymphocytes.
• In addition, binding of anti-CD3 to its receptor causes
cytokine release (see Adverse effects below).
• The overall effect is to reduce T-cell activation in acute
solid-organ graft rejection.
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Adverse effects
These include the following:
• cytokine release syndrome, with chest pain,
wheezing and dyspnoea (pulmonary oedema
occurs after the first dose in 1% of patients);
• hypersensitivity reactions ranging from
anaphylaxis to an acute influenza-like syndrome;
• CNS effects – seizures, reversible meningo-
encephalitis and
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• Other humanized monoclonal antibodies used
as immunosuppressants include:
Daclizumab and basilixumab (organ transplant
rejection) which are anti-IL-2 receptor
antibodies, inhibiting IL-2- mediated T-cell
activation.
• They have similar toxicities as the anti-CD-3
monoclonal antibody, but do not cause
cytokine release syndrome on first dose.
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Infliximab and etanercept (which bind to TNF-
alpha)
• Are used in the treatment of refractory
rheumatoid arthritis and inflammatory bowel
disease.
•

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Natalizumab (an anti-alpha-4 beta-3 integrin
monoclonal antibody) used in patients with
progressive multiple sclerosis.
• Other drugs that attenuate the immune
response include penicillamine, gold and
chloroquine.
• These drugs are used in an attempt to modify
disease progression in patients with severe
rheumatoid arthritis
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