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Transcript
Anti-Inflammatory &
Immunosuppressive Drugs
2
I-3 Fall 2012
The Inflammatory Cascade
Immunophilin ligands,
mycophenolate mofetil,
DMARDs, anti-TNF, etc.
Perceived threat
Adaptive immune
system
Tissue injury
Anti-gout
drugs
Leukocyte & endothelial cell activation
Inflammatory mediators
Inflammation (redness, edema,
warmth, pain, tissue destruction)
Infection
Innate immune
system
Immunophilin Ligands
Cyclosporine
Tacrolimus
Sirolimus
“Rapalogs”
•Everolimus
•Temsilolimus
Immune Cell Activation
Immunophilin
ligands
Immunophilin Ligands Inhibit T-Cell
Activation or Proliferation
Immunophilin Ligands: Adverse
effects
Neuropathy
Nephrotoxicity (cyclosporine)
Hypertension
Hyperglycemia
Hyperlipidemia
Hirsutism
gingival hyperplasia
cholelithiasis
Opportunistic infections !!!
Dose reduction
Combination Rx
Or use Tacrolimus
Immune Cell Activation
Mycophenolate mofetil,
leflunomide, cytotoxic drugs
A Theoretical Framework for Other
Immunosuppressants
Blocking Rapid Cell Division
Cyclophosphamide
Inhibits de novo GMP synthesis
A Big Advantage of Multiple Agents is
Non-Overlapping Toxicity
Drug
Dose-Limiting Toxicity
Cyclosporine &
tacrolimus
Nephrotoxicity, neurotoxicity
(CYP interactions for cyclosporine)
Sirolimus
Myelosuppression, hepatic tox,
hypertriglyceridemia
Mycophenolate
GI irritation, myelosuppression
All these drugs increase the risk of infection and
lymphoma
Clinical Use of Immunosuppressants
in Transplantation
Biologic Products
Biologic Products
• Exquisitely selective
• Less side effects compared to cytotoxic drugs
• Now standard in algorithm to manage RA
Challenges
• Pharmacokinetic: Parenteral
• Cost
• Long-term toxicity ?
• Antigenicity
• Oversight
Target: TNF alpha
• Adalimumab:
Humanized Fab
fragment
certolizumab
golimumab
Target: TNF alpha
• Adverse effects
– increased risk of infection (reactivation of
tuberculosis)
– GI upset
– local reactions at the injection site
– Antibody formation
Clinical Benefit in RA
Dose
Cost (4 weeks, lowest dose)
Lancet 372(9636):375-82,
Aug 2008; 1 year of therapy
Methotrexate
Etanercept
10-20 mg once/wk
PO
25 mg 2 injections/wk
SC
$55
$1,400
Other Disease Modifying
Antirheumatic Drugs (DMARDS)
Drug
Dose-Limiting Toxicity
Hydroxychloroquine GI upset, rash, ocular damage
Sulfasalazine
Leflunomide
Gold salts*
Myelosuppression, rash
Diarrhea, rash, hair loss,
myelosuppression, hepatotoxicity
Skin disorders,
myelosuppression, kidney
damage
Note: MTX is also a DMARD. We will revisit the cytotoxic drugs
used in RA, including MTX in the M3 block
Drugs for Gout
Acute Treatment (Anti-inflammatory)
NSAIDS (indomethacin); corticosteroids
Chronic Treatment (Decrease serum urate, anti-inflammatory)
Low-dose colchicine, allopurinol, uricosuric drugs
Colchicine Inhibits Microtubule
Assembly Tubulin dimer
Activated
macrophage
Sirolimus
Microtubule
Autumn Crocus
Toxicity
Diarrhea
Extraordinarily toxic in OD
Tubulin dimer
bound to
colchicine
Manipulating Serum Uric Acid Levels
(Allopurinol, febuxostat)
Allopurinol Inhibits Uric Acid
Production
Xanthine
oxidase
Hypoxanthine
Xanthine
oxidase
Xanthine
Uric acid
Irreversible
Reversible
Xanthine
oxidase
Adverse Effects
Acute gout
rash
hematologic reactions
drug interactions (with drugs that rely on xanthine oxidase
Allopurinol
Febuxostat
for metabolism)
Alloxanthine
Summary
• The immunosuppressants that are used to prevent
transplant rejection and to treat autoimmune disorders
inhibit T-cell function and proliferation.
• Newer biologic products, including anti-TNF drugs, are
very selective in their action and present unique
challenges.
• Treatment of acute gout is with anti-inflammatory drugs;
prevention of more attacks is with colchicine and/or
decreasing production of uric acid
(allopurinol/febuxostat) or increasing uric acid excretion
(probenecid).