Immunosuppressants

Examining the Association between Immunosuppressants and Wound Healing: A Narrative Review

OBJECTIVE

To review how different classes of immunosuppressants affect wound healing.

DATA SOURCES

A literature search was conducted in PubMed, Google Scholar, and the University of Calgary Health Sciences Library.

STUDY SELECTION

The researchers initially screened article titles using key words such as "immunosuppressive medication," "wound healing," and "immunosuppression." Articles in which the title and/or abstract contained these key words, that addressed wound healing related to immunosuppressant medications, and were published after 2000 were included in the review. When human data were not available for an immunosuppressant (class), animal studies were included.

DATA EXTRACTION

The 61 included articles underwent full text review and summarization.

DATA SYNTHESIS

All included studies were summarized descriptively including immunosuppressive mechanism of action, study participants or subjects, and evidence of effects on wound healing.

CONCLUSIONS

Corticosteroids and mechanistic target of rapamycin inhibitors most consistently demonstrate detrimental effects on wound healing. For other classes of immunosuppressants, evidence is limited with varying effects on wound healing described. Larger, high-quality studies are required to better understand the effects of immunosuppressants, including those with new mechanisms of action, to identify those with the most impact on wound healing.

Lignans and [11]-chaetoglobosins from Pseudeurotium bakeri and their immunosuppressive activity

Two previously unreported lignans (1-2) and four undescribed [11]-chaetoglobosins (3-6) were obtained from the culture extract of an endophytic fungus Pseudeurotium bakeri P1-1-1. Their structures with absolute configurations were determined by spectroscopic data analysis, single-crystal X-ray diffraction, electronic circular dichroism (ECD) calculations, the modified Mosher's method, and Mo2(OAc)4-induced electronic circular dichroism (ICD) experiments. Compounds 5 and 6 showed moderate cytotoxic effects against seven human cancer cell lines. Compounds 2-4 exhibited immunosuppressive activities on concanavalin A-induced T cell proliferation with IC50 values of 3.7, 3.4, and 14.5 μM, and on lipopolysaccharide-induced B cell proliferation with IC50 values of 4.1, 3.9, and 14.2 μM, respectively. Further investigation revealed that 2 and 3 induced apoptosis in activated T cells in a dose-dependent manner.

In-situ preparation of norepinephrine-functionalized silver nanoparticles and application for colorimetric detection of tacrolimus in plasma samples

Tacrolimus (Tac) is a well-documented immunosuppressive agent for the prevention of graft-vs-host diseases in several types of organ transplants. The narrow therapeutic window and the individual-variable pharmacokinetics of Tac demonstrate the importance of regular therapeutic drug monitoring (TDM) as an imperative concept for its oral medication regimens. A simple, one-step, selective, and sensitive colorimetric platform is fabricated for the determination of Tac by surface modification of the silver nanoparticles (AgNPs) via norepinephrine (NE) molecules. The attachment of NE and Tac induces the aggregation of the AgNPs, which is observed by color distinction (yellow to brown) and a noteworthy shifting of the absorption peak in the visible region. The fabricated nanoprobe can detect Tac concentrations in plasma samples in two linear ranges from 2 ng/mL to 70 ng/mL and 70 ng/mL to 1000 ng/mL with R2 > 0.99. The limit of detection (LOD) was calculated as low as 0.1 ng/mL. The developed method was applied for the determination of Tac in patient's plasma samples under Tac medication therapy.

Two-photon fluorescence probe for quantification of cyclosporine

A novel ratiometric fluorescent sensor was fabricated for the fast and facile determination of cyclosporine A (CsA). Due to the narrow therapeutic index of CsA, its desired therapeutic effects are evident within a limited range of blood concentration, indicating the fundamental role of therapeutic drug monitoring in CsA pharmacological response. In this study, a two-photon fluorescence probe based on the zeolitic imidazolate framework (ZIF-8) and norepinephrine-capped silver nanoparticles (AgNPs@NE) was employed for the quantification of the CsA in human plasma samples. In the presence of CsA, the fluorescent emission intensity of ZIF-8-AgNPs@NE was quenched. Under the optimum conditions, the proposed probe determines CsA in plasma samples in two linear ranges of 0.01 to 0.5 μg mL^-1 and 0.5 to 10 μg mL^-1. The developed probe demonstrates the advantages of a facile and fast platform with limit of detection as low as 0.007 μg mL^-1. At last, this method was applied to find CsA concentration in four patients receiving oral CsA regimen which indicates it as a promising method for on-site detection applications.

Efficacy of Trevesia palmata (Roxb. ex Lindl.) Vis. Extract on MG 63 cell lines and arthritis-induced animal models

ETHNOPHARMACOLOGICAL RELEVANCE

Despite widespread use of herbal remedies for treating arthritis and osteosarcoma, many plants are still not pharmacologically evaluated for their efficacy. Contrary to many non-steroidal, immunosuppressants, antibiotics, and antineoplastic drugs that have adverse effects, phytotherapeutic compounds have promising benefits with fewer complications. In this study the unexplored Northeastern India indigenous plant Trevesia palmata (Roxb. ex Lindl.) Vis. used in traditional medicine to cure bone fractures is chosen for studying anti-proliferative and anti-rheumatic properties.

AIM OF THE STUDY

This study designed to explore the polyphenolic composition, antioxidant, anti-inflammatory and anti-arthritic potential of T. palmata leaf extracts. Further, the cellular activity was studied using MG 63 osteoblast cell lines and pharmacologically evaluated using Complete Freund's Adjuvant (CFA) induced arthritic rat model.

MATERIALS AND METHODS

In vitro free radical scavenging activity, anti-inflammatory and anti-arthritic activities of extracts were analyzed using standardized methods. The polyphenolic profiling and apoptosis inducing ability of T. palmata ethyl acetate (TPEA) extract on MG 63 osteoblast cell lines were analyzed. The in vivo pharmacological studies were carried out with low dose 250 mg/kg and high dose of 500 mg/kg of T. palmata. The biochemical and haematological parameters and in vivo antioxidant activity were evaluated for the control and treated groups. Radiological and histological study were done to understand the impact and penetration of inflammatory arthritis from tissues to joint bones.

RESULTS

TPEA showed highest free radical scavenging activity (DPPH - 4.72 IC₅₀, ABTS - 242.33 ± 6.81 mM TE/g extract), anti-inflammatory (40.04% inhibition of RBC lysis) and anti-arthritic activity (32.4% inhibition of protein denaturation) with the presence of gallic acid, catechin, caffeic acid, rutin, quercetin and naringenin. The TPEA extract inhibited cell proliferation of MG 63 osteoblast cells and induced apoptosis by arresting cell cycle at different phases. After acute toxicity studies the doses 250 mg/kg and 500 mg/kg were fixed and showed better results in CFA-induced arthritic animals. Thus, the extract phytoconstituents may have immense potential against chronic inflammation, joint ailments, bone cancer and arthritis which serves as a phytomedicine contrary to synthetic medications.

CONCLUSIONS

The potential treatment of polyphenolic compounds in the T. palmata extract on osteosarcoma and arthritis was demonstrated from this study. Thus, cellular inflammatory infiltrates are significantly reduced in bone and joint tissues as well.

Streptomyces: The biofactory of secondary metabolites

Natural products derived from microorganisms serve as a vital resource of valuable pharmaceuticals and therapeutic agents. Streptomyces is the most ubiquitous bacterial genus in the environments with prolific capability to produce diverse and valuable natural products with significant biological activities in medicine, environments, food industries, and agronomy sectors. However, many natural products remain unexplored among Streptomyces. It is exigent to develop novel antibiotics, agrochemicals, anticancer medicines, etc., due to the fast growth in resistance to antibiotics, cancer chemotherapeutics, and pesticides. This review article focused the natural products secreted by Streptomyces and their function and importance in curing diseases and agriculture. Moreover, it discussed genomic-driven drug discovery strategies and also gave a future perspective for drug development from the Streptomyces.

DNA damage, inflammation and aging: Insights from mice

Persistent DNA lesions build up with aging triggering inflammation, the body’s first line of immune defense strategy against foreign pathogens and irritants. Once established, DNA damage-driven inflammation takes on a momentum of its own, due to the amplification and feedback loops of the immune system leading to cellular malfunction, tissue degenerative changes and metabolic complications. Here, we discuss the use of murine models with inborn defects in genome maintenance and the DNA damage response for understanding how irreparable DNA lesions are functionally linked to innate immune signaling highlighting their relevance for developing novel therapeutic strategies against the premature onset of aging-associated diseases.

Rapamycin golden jubilee and still the miraculous drug: a potent immunosuppressant, antitumor, rejuvenative agent, and potential contributor in COVID-19 treatment

Although celebrating its golden jubilee, rapamycin’s importance keeps increasing by the day. Starting as a promising antifungal agent, then as a potent immunosuppressant, strong anticancer drug, and now rapamycin is attracting serious attention as a rejuvenative agent and a possible contributor in treating this era pandemic, COVID-19. Due to its diverse biological activities and promising medical applications, we aimed in this review to put rapamycin under the spot and highlight its discovery, famous microbial producers, reported biological activities, chemical structure, famous analogues, and biosynthesis. Moreover, discuss some rapamycin production approaches including solid-state fermentation, and stressing out producing strain. On the other hand, describe its action mechanism and trials to use it in treatment of COVID-19. Additionally, we highlighted some of the side effects accompanying its use, and describe some approaches reported to minimize these undesired effects. Finally, we report the current status of rapamycin and its analogues in global market, and discuss future prospects of this potent drug.

Genetic profile considerations for induction of allogeneic chimerism as a therapeutic approach for type 1 diabetes mellitus

The major therapeutic modality for type 1 diabetes mellitus (T1DM) remains sustaining euglycemia by exogenous administration of insulin. Based on a new understanding of bone marrow structural and functional dynamics, a conditioning-free bone marrow transplantation (BMT), with reduced adverse effects, opens the possibility for evaluating β cell regeneration and restoration of euglycemia by induction of allogeneic chimerism in patients T1DM, as shown in a mouse model. With this therapeutic modality, donor bone marrow (BM) selection based on T1DM-predisposing and preventive phenotypes will improve treatment outcomes by limiting the risk of exacerbating the autoimmune processes in the BM recipient.

Ex Vivo Major Histocompatibility Complex I Knockdown Prolongs Rejection-free Allograft Survival

Supplemental Digital Content is available in the text.

Background:

Widespread application of vascularized composite allotransplantation (VCA) is currently limited by the required lifelong systemic immunosuppression and its associated morbidity and mortality. This study evaluated the efficacy of ex vivo (after procurement but before transplantation) engineering of allografts using small interfering RNA to knockdown major histocompatibility complex I (MHC-I) and prolong rejection-free survival.

Methods:

Endothelial cells (ECs) were transfected with small interfering RNA targeted against MHC-I (siMHC-I) for all in vitro experiments. MHC-I surface expression and knockdown duration were evaluated using quantitative polymerase chain reaction (qPCR) and flow cytometry. After stimulating Lewis recipient cytotoxic lymphocytes (CTL) with allogeneic controls or siMHC-I–silenced ECs, lymphocyte proliferation, CTL-mediated and natural killer–mediated EC lysis were measured. Using an established VCA rat model, allografts were perfused ex vivo with siMHC-I before transplantation. Allografts were analyzed for MHC-I expression and clinical/histologic evidence of rejection.

Results:

Treatment with siMHC-I resulted in 80% knockdown of mRNA and 87% reduction in cell surface expression for up to 7 days in vitro (P < 0.05). Treatment of ECs with siMHC-I reduced lymphocyte proliferation and CTL-mediated cytotoxicity (77% and 50%, respectively, P < 0.01), without increasing natural killer–mediated cytotoxicity (P = 0.66). In a rat VCA model, ex vivo perfusion with siMHC-I reduced expression in all tissue compartments by at least 50% (P < 0.05). Knockdown prolonged rejection-free survival by 60% compared with nonsense-treated controls (P < 0.05).

Conclusions:

Ex vivo siMHC-I engineering can effectively modify allografts and significantly prolong rejection-free allograft survival. This novel approach may help reduce future systemic immunosuppression requirements in VCA recipients.

Psychiatric Aspects of Organ Transplantation in Critical Care: An Update

Transplant patients face challenging medical journeys, with many detours to the intensive care unit. Before and after transplantation, they have significant psychological and cognitive comorbidities, which decrease their quality of life and potentially compromise their medical outcomes. Critical care staff are essential in these journeys. Being cognizant of relevant psychosocial and mental health aspects of transplant patients' experiences can help critical care personnel take comprehensive care of these patients. This knowledge can empower them to understand their patients' psychological journeys, recognize patients' mental health needs, provide initial interventions, and recognize need for expert consultations.

A delicate balance: negotiating renal transplantation, immunosuppression and adherence to medical regimen

Despite the volume of biomedical and psychosocial discourse surrounding both renal transplantation and the immune system, there is a limit to current understandings of immunosuppression in the context of kidney transplantation. For example, we do not know how the immunosuppressed renal transplant recipient experiences and understands their immune system and body. In addition, we do not know if the patient is as fixated on `graft survival' as their healthcare team or whether other concerns are more relevant. What is missing is the discourse of those who actually `live' the medically altered immune system in the context of renal transplantation.

We propose that this gap in knowledge is bound to an acknowledged problem among renal transplant recipients and their healthcare teams — a lack of compliance with recommended medical regimens. Our argument here is that an exploration of patient intimacy with transplant-related immunosuppression might illuminate a different understanding of this experience that could enhance health professionals' understanding and their subsequent approach to treatment. We contend that the embodied and contextual experience of the patient needs to be equally valued in order to enhance patient outcomes.

Biological therapy and dentistry: a review paper

In recent years, a new class of drugs has revolutionized the treatment of autoimmune, allergic, infectious, and many more diseases. This new class of drugs is made of 3 groups-cytokines, monoclonal antibodies, and fusion proteins-that may target special damaged cells but not all the cells. These drugs may have side effects such as infection, hypersensitivity, hematologic disorders, cancer, hepatotoxicity, and neurologic disorders. However, there is not enough evidence or long-term studies of the mechanism of action and side effects of these drugs. Patients receiving biological therapies may need special consideration in dentistry. This paper is a review of the classification, mechanism of action, and side effects of these drugs and dental consideration for patients receiving biological therapies.

Organ transplant & the psychiatrist: An overview

Organ transplantation has emerged as the saving grace for those who are suffering from end organ disease. Advent of modern surgical procedures and immunosuppressants further decrease morbidity and mortality. Meta-analyses have shown that post-organ transplantation quality of life improves for social, physical and daily activity functioning, but not consistently for psychological health. Psychiatrists can play a useful role not only in selecting the best suitable candidate for the procedure by psychosocial screening but also to tackle post-operation psychological issues that trouble patients as well as caretakers and decrease their quality of life. Issues like selection of patients with psychiatric disorders and substance abuse for transplantation process and their treatment both pre- and post- operation, risky health behaviours, treatment adherence for immunosuppressants and psychological support for caretakers can be better addressed by a psychiatrist who is sensitive towards these issues. Prescribing various psychotropics and immunosuppressants in the background of impaired organ function and drug-drug interaction is further challenging. Thus, psychiatrists need to be knowledgeable about these issues and should be an integral part of organ transplantation team for overall better outcome.

Quantitative proteomic analysis of cyclosporine-induced toxicity in a human kidney cell line and comparison with tacrolimus

The calcineurin-inhibitors (CNIs) cyclosporine (CsA) and tacrolimus (TAC) remain the pillars of modern immunosuppression regimens used in solid organ transplantation. Nephrotoxicity is an adverse effect that limits their successful use. The precise molecular mechanisms underlying this nephrotoxicity remain unclear. Using SILAC together with LC-MALDI-TOF/TOF, we investigated the CNIs-induced proteomic perturbations in renal cells. Among the 495 proteins quantifiable in both forward and reverse SILAC, 69 displayed CsA-induced perturbations: proteins involved in ER-stress/protein folding, apoptosis, metabolism/transport or cytoskeleton pathways were up-regulated, while cyclophilin B as well as nuclear and RNA-processing proteins were down-regulated. Co-administration of CsA with the antioxidant N-acetylcysteine significantly decreased lipid peroxidation and also partially corrected the CsA-induced unfolded protein response. TAC toxicity profile was apparently different from that of CsA, especially without perturbation of cyclophilins A and B, up-regulation of ER-chaperones nor down-regulation of a number of nuclear proteins. These results provide a new insight and are consistent with recent data regarding the molecular mechanisms of CNIs-induced nephrotoxicity. Our findings offer new directions for future research aiming to identify specific biomarkers of CsA nephrotoxicity.

Psychiatric issues in solid organ transplantation

The identification and treatment of psychiatric comorbidity in patients undergoing solid organ transplantation present a unique opportunity for psychiatric involvement in the care of medically complex patients. The burden of psychiatric illness in patients awaiting transplant and following transplant is significant and associated with potential morbidity and mortality. Possibilities for psychiatric liaison with our colleagues in transplant medicine and surgery start with the comprehensive psychiatric evaluation that is often performed with potential organ recipients and donors. The vital role of the psychiatrist continues following transplantation, as adjustment is often a stressful experience with associated psychiatric comorbidity. The treatment of psychiatric illness in patients following transplantation requires an understanding of the immunosuppressant medications that patients may be taking, coupled with an awareness of the associated risks of adverse effects and drug-drug interactions.

Psychiatric aspects of organ transplantation in critical care

Intensive care unit teams are a critical part of the solid organ transplant process. The psychosocial issues involved during critical periods of transplantation are important for intensive care physicians and clinicians to understand to provide comprehensive care to transplant patients. This article provides a brief overview of transplant epidemiology, followed by a review of the psychosocial issues relevant to the phases of the transplant process. Considered are the pretransplant evaluation phase, psychiatric disorders in transplant patients, and cognitive impairments and delirium with additional issues specific to particular organs. Also covered are the side effects of immunosuppressive medications and special issues arising with living donors.

Depressive disorder associated with mycophenolate mofetil

Immunosuppressive pharmacologic agents are associated with a diverse array of adverse drug reactions. One of these agents, mycophenolate mofetil, is indicated for prevention of allogeneic organ transplant rejection and has recently been evaluated for treatment of autoimmune disease states, including myasthenia gravis. Although the prescribing information for mycophenolate mofetil reports depression as an adverse event, no descriptions of the onset or manifestation of this idiosyncratic reaction have been published. This case report describes a 64-year-old woman with myasthenia gravis who received mycophenolate mofetil and developed a severe depressive disorder requiring hospitalization 4 days after the start of therapy. The drug was discontinued, and she was treated with sertraline, quetiapine, and clonazepam. Within 2 days after mycophenolate mofetil discontinuation, the patient's depressive symptoms had markedly improved. Eight days later, mycophenolate mofetil was reintroduced under direct observation. After day 2 of this rechallenge, the patient reported a substantial increase in her depressive symptoms. Treatment was discontinued again, with improvement in the patient's symptoms within 2 days. Use of the Naranjo adverse drug reaction probability scale indicated a probable relationship between the patient's development of depression and mycophenolate mofetil therapy. Future evaluations of mycophenolate mofetil should include an assessment of psychological adverse effects. In addition, postmarketing surveillance should be encouraged to further delineate the association between depression and mycophenolate mofetil therapy.

Computational approach for the design of AP1867 analogs: aiming at new synthetic routes for potential immunosuppressant agents

Molecular modelling and synthetic arguments are valuable tools for the design of potential immunosuppressant agents. In this paper, eight proline-based compounds related to the AP1867 structure are studied and at least one of them is found to be a structurally good candidate for the inhibition of FKBP protein. Theoretical calculations were carried out to locate the most energetically favorable chemical substituent group relative to a core skeleton group on interaction with the FKBP binding cavity. Connolly accessible surface calculations have complemented the molecular mechanics and dynamics approaches. Calculated results were also analyzed on the basis of hydrogen bond interactions, relative energies of interaction, root-mean square deviations of amino acid residues of the crystallized protein, and orientation of the substituent groups within the active site. The results show a significant reduction in the relative interaction energies and very good shape complementarities between our final analog compound and the FKBP binding pocket.

Ciclosporin use in multi-drug therapy for meningoencephalomyelitis of unknown aetiology in dogs

OBJECTIVE

To evaluate the efficacy and safety of ciclosporin therapy alone or in combination with corticosteroids and/or ketoconazole in dogs with diagnosis of meningoencephalomyelitis of unknown aetiology.

METHODS

Medical records of 10 dogs diagnosed with meningoencephalomyelitis of unknown aetiology and treated with ciclosporin therapy alone or in combination with corticosteroids and/or ketoconazole were reviewed at the Veterinary Medical Teaching Hospital, University of Wisconsin-Madison. Laboratory abnormalities, side effects, clinical and cerebrospinal fluid responses to treatment and association between blood ciclosporin level and response to treatment were evaluated. Histopathological diagnosis was available in three patients.

RESULTS

No significant abnormalities were detected on serial complete blood count and serum chemistry panel in any of the dogs. Side effects of ciclosporin therapy included excessive shedding, gingival hyperplasia and hypertrichosis. Overall median survival time for all dogs in the study was 930 days (range, 60 to more than 1290 days). In all dogs, serial cerebrospinal fluid analysis showed a marked improvement in the inflammation.

CLINICAL SIGNIFICANCE

Results suggest that ciclosporin either alone or in combination with ketoconazole may be a safe and effective treatment for meningoencephalomyelitis of unknown aetiology in dogs.

Pharmacogenetic differences and drug-drug interactions in immunosuppressive therapy

With the advent of new immunosuppressants and formulations, the elucidation of molecular targets and the evolution of therapeutic drug monitoring, the field of organ transplantation has witnessed significant reductions in acute rejection rates, prolonged graft survival and improved patient outcome. Nonetheless, challenges persist in the use of immunosuppressive medications. Marked interindividual variability remains in drug concentrations and drug response. As medications with narrow therapeutic indices, variations in immunosuppressant concentrations can result in acute toxicity or transplant rejection. Recent studies have begun to identify factors that contribute to this variability with the promise of tailoring immunosuppressive regimens to the individual patient. These advances have uncovered differences in genetic composition in drug-metabolising enzymes, drug transporters and drug targets. This review focuses on commonly used maintenance immunosuppressants (including cyclosporin, mycophenolate mofetil, tacrolimus, sirolimus, everolimus, azathioprine and corticosteroids), examines current studies on pharmacogenetic differences in drug-metabolising enzymes, drug transporters and drug targets and addresses common drug-drug interactions with immunosuppressant therapies. The potential role of drug-metabolising enzymes in contributing to these drug-drug interactions is briefly considered.