Functional Immunology and Updates on the T-Helper System

Immunology Part-5: Functional Immunology and Updates on the T-helper System

Dr. Paul S. Anderson Date: January 19, 2021 © PS Anderson and www.ConsultDrA.com 2021

Immunology is an ever-emerging part of biomedical science. In this session Dr. Anderson will update attendees regarding the Cell Mediated immune response, specifically where it concerns the T-helper system effects, and their related immunology. The interrelationships between this portion of CMI and clinical medicine will be discussed.

• Immune response overview – General Structure – What triggers a TH response • Structure of the TH system – Discovery of the two-armed APC response – Inciting cytokines for differentiation – Treg / TH1 /TH17 / TH2 • Function of the TH system – Extra and Intra cellular infections – Allergy – Tolerance and Immunoregulation • Normal versus unregulated response

(c) PS Anderson - www.ConsultDrA.com 2021 3 VERY CRITICAL: THE SLIDES WILL NOT HAVE ANSWERS PRINTED ON ALL OF THEM. I WILL ANSWER VERBALLY WITH THE QUESTIONS WRITTEN ON SLIDES – SO PLEASE LISTEN TO THE AUDIO FOR A COMPLETE COVERAGE. Thank you!

Due to enhanced regulations for States awarding “Category-1” ND CE (HI, CA, WA etc.) **All of this is on the “Contact” tab on the home page under FAQ as well. • IF WATCHING LIVE WE WILL VERIFY AND EMAIL YOUR CE CERT. – This takes 72 hours minimum. If you do not see an email with your certificate after 72 hours: • Check your SPAM folder • If nothing email us: [email protected] (these are on the “Contact” page as well).

Due to enhanced regulations for States awarding “Category-1” ND CE (HI, CA, WA etc.) **All of this is on the “Contact” tab on the home page under FAQ as well.**

• IF WATCHING THE RECORDED WEBINAR YOU WILL TAKE THE QUIZ AT THE END AND THEN THE SYSTEM WILL GENERATE THE CE CERT. – AT the end of the video click “Mark Complete” and then at the end of the exam click “Click Here to Continue” → Under “Mark it complete to get your certificate” the “Click here to continue” button THEN YOUR CERTIFICATE WILL BE IN YOUR “My Profile” page.

(c) PS Anderson - www.ConsultDrA.com 2021 7 https://www.consultdranderson.com/courses/65-immunology-part-3- immunology-clinician-update/

1 – ANTIGEN PRESENTATION 1A – ALTERNATE COMPLIMENT = cytokine 2 – T-CELL ACTIVATION / CMI

2A – KILLER T-CELL ACTION

3 – B-CELL ACTIVATION / Ab IMMUNITY

4 – CLASSIC 3A – ANTIGEN – ANTIBODY REACTION COMPLIMENT

ATTACK ON INVADER

1. Antigen triggers an immune response 2. Antigen Presenting Cells (APC’s) present Ag to T Cells 3. Activates T cells / CMI *T cells are activated after phagocytes exposed to antigen 4. T cells attack the antigen and stimulate B cells 5. Activated B cells mature and produce antibody 6. Antibody attacks antigen

(c) PS Anderson - www.ConsultDrA.com 2021 12 (c) PS Anderson - www.ConsultDrA.com 2021 13 Cell Lines Thymus: Bone Marrow: Hemocytoblast

Myeloid Stem Lymphoid Stem Cells

Lymphoid Megakaryocyte T-Cell Lines Stem Proerythroblast Monoblast Myeloblast “TH” Cytotoxic

B-Cells NK Cells Platelets Retic’s

Peripheral Tissues: PLT RBC’s WBC’s

Cell Mediated Immunity Ab (Humoral)(c) PS Anderson Immunity - www.ConsultDrA.com Immunological 2021 Surveillance 14 Immune Reactions / Responses

• Antigen recognition – Antigenicity- ability to stimulate an immune resp0onse to produce antibodies- factors include- molecule size, foreignness, structural complexity, amount of different epitopes, dosage exposure, entrance route into the body, and its timing of exposure – Major histocompatability complexes (MHC) • MHC-1: presents viral antigen to CD8 T Lymphocytes, play a major role in killing virally infected cells and cancer cells • MHC-2: docking protein on Macrophage which hooks a CD4-Thelper cell to the Macrophage. – Haptens • Incomplete antigen • Unable to stimulate immune response on its own • Will react with other proteins, therefore making them antigenic. • Many Haptens have highly reactive moieties that create their “completion”

Activation of endogenous proteins (mainly enzyme precursors) in case of immunologic need. Two pathways: – Classical: activated by antigen – antibody (AG/AB) reaction – Alternate: goes ‘around’ the AG/AB reaction, activates the compliment cascade in the middle (at the C-3 locus) without the Ag / Ab reaction. • Large polysaccharide in the cell membranes of some pathogens stimulate this reaction. • Less effective than Classical pathway

Alternate Pathway Starts here: (Faster / weaker response)

Image: Rev Soc Bras Med Trop - Vol: 42: Suplemento II, 2009 (c) PS Anderson - www.ConsultDrA.com 2021 26 Function of the TH system

(c) PS Anderson - www.ConsultDrA.com 2021 27 Intracellular Pathogens Dendritic Cell or Incl. Viri Monocyte [Il-2, IFNa, TNFa]

Extracellular Bacteria [Il-17,21,22,23,26]

Immune Tolerance and Regulation [TGFb, Il-10,35]

Antibody Response Extracellular Parasites Allergy – Atopy Il-4,5,10,13] Image: Rev Soc Bras Med Trop - Vol: 42: Suplemento II, 2009 (c) PS Anderson - www.ConsultDrA.com 2021 28 Bio-pharmaceuticals affecting the TH system

(c) PS Anderson - www.ConsultDrA.com 2021 29 Interferon BRAND NAMES: Roferon-A, Intron-A, Rebetron, Alferon-N, Peg-Intron, Avonex, Betaseron, Infergen, Actimmune, Pegasys • Classes: – Alpha, beta and gamma. • Actions: – direct the immune system's attack on viruses, bacteria, tumors and other foreign substances that may invade the body. • Used in: – Leukemia, Hepatitis B, C, Genital Warts – The beta interferons have been found useful in managing MS • Adverse Effects: – Flu-like symptoms following each injection occur with all interferons. – Depression and suicide are possible, but not common – HYPOTHYROIDISM – Other side effects with all interferons (may be caused by higher doses) • Fatigue • diarrhea, nausea, vomiting, abdominal pain, anorexia • joint aches, back pain and dizziness. • congestion, increased heart rate, confusion, • low white blood cell count, low platelet count, low red blood cell count, • increase in liver enzymes, increase in triglycerides,

Thymus: Bone Marrow: Hemocytoblast

Lymphoid Stem Cells

T-Cell Lines

B-Cells NK Cells

Peripheral Tissues:

Cell Mediated Immunity Ab(c) PS(Humoral) Anderson - www.ConsultDrA.com Immunity 2021 Immunological Surveillance 31 Tacrolimus

• Pharmacology – Suppresses cell-mediated immune reactions and some humoral immunity, but exact mechanism is not known. The mechanism of action in atopic dermatitis is not known. • Indications and Usage – PO and IV Prophylaxis of organ rejection in patients receiving allogenic liver, kidney, or heart transplants. Used in conjunction with adrenal corticosteroids. – Topical As second-line therapy for the short-term and noncontinuous chronic treatment of moderate to severe atopic dermatitis. • Unlabeled Uses – PO and IV Prophylaxis of rejection for patients receiving bone marrow, pancreas, pancreatic island cell, and small bowel transplantation. – Topical Treatment of vitiligo in children; facial, flexural, and intertriginous psoriasis.

(c) PS Anderson - www.ConsultDrA.com 2021 32 Pimecrolimus Dosage Form: Cream 1% • TRADE NAME: Elidel® FOR DERMATOLOGIC USE ONLY NOT FOR OPHTHALMIC USE Elidel ® (pimecrolimus) Cream 1% contains the compound pimecrolimus, the immunosuppressant 33-epi-chloro-derivative of the macrolactam ascomycin.

• Actions – Inhibits cell-mediated immune responses – Exact mechanism(s) of immunosuppressive action not fully elucidated; appears to mainly involve inhibition of lymphocytic proliferation and function. – Produces nephrotoxic effects, which generally appear to be dose dependent and reversible • OTHER Uses: – Ophthalmic: (Dry Eye – [‘Restasis’] – Psoriasis…

Pichler W, J, Adam J, Watkins S, Wuillemin N, Yun J, Yerly D: Drug Hypersensitivity: How Drugs Stimulate T Cells via Pharmacological Interaction with Immune Receptors. Int Arch Allergy Immunol 2015;168:13-24. doi: 10.1159/000441280

Galluzzi L, et.al. Immunological Effects of Conventional Chemotherapy and Targeted Anticancer Agents. Cancer Cell 28, December 14, 2015

(c) PS Anderson - www.ConsultDrA.com 2021 36 (c) PS Anderson - www.ConsultDrA.com 2021 37 (c) PS Anderson - www.ConsultDrA.com 2021 38 (c) PS Anderson - www.ConsultDrA.com 2021 39 (c) PS Anderson - www.ConsultDrA.com 2021 40 (c) PS Anderson - www.ConsultDrA.com 2021 41 Normal versus Unregulated Responses

(c) PS Anderson - www.ConsultDrA.com 2021 42 Nature Reviews Immunology 2, 37-45 (January 2002) doi:10.1038/nri702 In the standard model, helper T cells are polarized to one of two subsets, TH1 and TH2, by the cytokines interleukin (IL)-12 and IL-4, respectively. TH1 cells promote cell-mediated immunity and host defence against intracellular organisms, but also contribute to the pathogenesis of autoimmune diseases such as rheumatoid arthritis, Crohn's disease and multiple sclerosis. TH2 cytokines, especially IL-4, antagonize TH1 differentiation and attenuate cell-mediated immunity but promote allergic and anti-helminth responses. Although this model has been extremely useful and explains a great deal, the role of cytokines in autoimmune disease is more complicated than is indicated by this simple model. IFN-gamma, interferon-gamma; IgE, immunoglobulin E; LT, lymphotoxin; STAT, signal transducer and activator of transcription.

(c) PS Anderson - www.ConsultDrA.com 2021 43 J Clin Invest. 2007;117(5):1119-1127. doi:10.1172/JCI31720. APC-derived cytokines guide the differentiation of naive T cells into an effector T cell subtype. Secretion of IL-12, in synergy with IL-18, leads to the generation of Th1 cells. Initial IL-12 production directs the upregulation of IL-18R and IL-12Rβ2 expression on the surface of Th1 precursor (Th1p) cells that allows IL-18 to aid IL-12 in Th1 polarization. TGF-β secretion can polarize naive cells toward a regulatory phenotype or an autoaggressive phenotype, depending on the cytokine environment: secretion of TGF-β alone by APCs supports Treg formation (which counteracts autoimmune inflammation) from Treg precursor cells (Treg-p cells). However, the additional presence of IL-6 results in the production of Th17 cells, which are now considered to be the pathogenic T cell population during autoimmunity. The pathogenic, APC-derived cytokine IL-23 is critical for the maintenance and survival of these autoreactive Th17 cells. The interaction of APCs and Th2 precursor (Th2p) cells in the absence of IL-12 and IL-18 induces the production of the Th2 cytokine IL-4 by T cells, which acts in an autocrine fashion to polarize committed Th2 cells. (c) PS Anderson - www.ConsultDrA.com 2021 44 An. Bras. Dermatol. vol.87 no.5 Rio de Janeiro Sept/Oct. 2012 http://dx.doi.org/10.1590/S0365-05962012000500001

Autoimmunity

Genetics Immune Stress

Allergy

(c) PS Anderson - www.ConsultDrA.com 2021 46 Autoimmunity • Allergens Leaky Gut → Unusual Proteins → Immune – GI / Food stimulation – Environmental Immune stimulation and poor regulation • Infections – Viral (etc) “Settle” in tissues → Trigger immune response → Trigger some excessive immune reaction → – Chronic bacterial Autoimmunity • Toxins (Propensity to find multiple viri in the CNS of patients with MS and – Metal other neurodegenerative diseases) – Chemical Can alter cell recognition (peripheral receptor loci) or inactivate receptors all together. May alter cell Th1/2/17/Treg balance. Often patients with generalized low elevation of Autoantibodies on panels are chemically toxic / sensitive.

(c) PS Anderson - www.ConsultDrA.com 2021 47 An. Bras. Dermatol. vol.87 no.5 Rio de Janeiro Sept/Oct. 2012 http://dx.doi.org/10.1590/S0365-05962012000500001 ***NOTE: Example only, this does not include newer info on TH17. (c) PS Anderson - www.ConsultDrA.com 2021 48 http://selfhacked.com/2014/11/09/il-10/

Nature Reviews Immunology 2, 37-45 (January 2002) doi:10.1038/nri702 In the standard model, helper T cells are polarized to one of two subsets, TH1 and TH2, by the cytokines interleukin (IL)-12 and IL-4, respectively. TH1 cells promote cell-mediated immunity and host defence against intracellular organisms, but also contribute to the pathogenesis of autoimmune diseases such as rheumatoid arthritis, Crohn's disease and multiple sclerosis. TH2 cytokines, especially IL-4, antagonize TH1 differentiation and attenuate cell-mediated immunity but promote allergic and anti-helminth responses. Although this model has been extremely useful and explains a great deal, the role of cytokines in autoimmune disease is more complicated than is indicated by this simple model. IFN-gamma, interferon-gamma; IgE, immunoglobulin E; LT, lymphotoxin; STAT, signal transducer and activator of transcription.

(c) PS Anderson - www.ConsultDrA.com 2021 51 TH Balance and Cancer Prognosis: (2019) 9:3260 | https://doi.org/10.1038/s41598-019-40078-8

In conclusion, T cell cytokines play an important role in hepatic function, tumor characteristics, and prognosis in patients with HCC. IL-6 was among the most significant predictive factors for poor OS in patients undergoing TACE. Baseline Tregs level could influence the direction of Th1 or Th2 response following treatment. A shift toward increased Th1 response and no increase in IL-6 level could exert favorable immunologic effects on HCC prognosis. This study showed the potential role of multiple cytokines as biomarkers for HCC, and the demand for multiple cytokine biomarkers will increase in the upcoming era of immunotherapy.

(c) PS Anderson - www.ConsultDrA.com 2021 52 T-Regulatory Cells Immunol Rev. 2014 May ; 259(1): 88–102. doi:10.1111/imr.12160.

Foxp3+ T-regulatory cells (Tregs) are primarily generated in the thymus (tTreg), but also may be generated extrathymically at peripheral sites (pTreg) or induced in cell culture (iTreg) in the presence of transforming growth factor β (TGFβ). A major unresolved issue is how these different populations of Tregs exert their suppressive function in vivo… Our studies demonstrate that one prominent mechanism of action of polyclonal tTregs is to inhibit T-effector cell trafficking to the target organ, while antigen-specific iTregs primarily prevent T-cell priming by acting on antigen- presenting dendritic cells (DCs). Interleukin-10 (IL-10) plays an important role in the suppressive function of antigen-specific iTregs by controlling the expression of MARCH1 and CD83 on the DC. Activated tTregs may mediate infectious tolerance by delivery of cell surface expressed TGFβ to naive responder T cells to generate pTregs.

(c) PS Anderson - www.ConsultDrA.com 2021 53 Vitamin D (and others): September 24, 2019https://doi.org/10.1371/journal.pone.0222313

Vitamin D supplementation may increase Treg/CD3 ratios in both healthy individuals and patients with autoimmune disorders and may increase Treg function. The function of Treg cells may also be increased by vitamin A supplements [28]. Moreover, the short chain fatty acid, butyrate, may be produced by commensal microbiota and prime Treg cells in the secondary lymphoid tissue of the gastrointestinal tract [29]. In mice, exogenous butyrate or the vitamin niacin or similar compounds acting via GPR109a, such as mono- or dimethyl-fumarate on lymphocytes, may increase Treg cell levels and function [30, 31]. Finally, gamma-amino butyric acid (GABA) has been used experimentally to increase Tregs in animals, but the effects of this butyrate derivative on Treg cell numbers and functions in humans is limited [32]. Melatonin (although less so when replete) https://doi.org/10.1016/j.lfs.2019.117191

(c) PS Anderson - www.ConsultDrA.com 2021 54 Herbs & Autoimmunity: Using Botanicals to Balance T-Cell Activity - Posted April 1, 2019 In Autoimmune/Allergy Medicine

• Excellent review by Tanya Lee, ND https://ndnr.com/autoimmuneallergy-medicine/herbs- autoimmunity-using-botanicals-to-balance-t-cell- activity/

(c) PS Anderson - www.ConsultDrA.com 2021 55 Guo, A., He, D., Xu, H. et al. Promotion of regulatory T cell induction by immunomodulatory herbal medicine licorice and its two constituents. Sci Rep 5, 14046 (2015). https://doi.org/10.1038/srep14046

The pivotal role of Treg cells in immune regulation has been widely appreciated. Transfer of Treg cells or increasing Treg cells induction have been proved to be an efficient therapeutic methods for autoimmune and inflammatory diseases in variety animal models. Oral administration of isoliquiritigenin, naringenin or Gly1 fraction ameliorated pathological symptoms of DSS-induced colitis. Our preliminary results suggest that isoliquiritigenin, naringenin and Gly1 fraction might serve as a potential therapeutic drug for inflammatory colitis or other autoimmune and inflammatory diseases, including inflammatory bowel disease, rheumatoid arthritis and multiple sclerosis.

PA Note: Of note the LDN dose was too high (eq to 7 mg IV in a human) so the larger suppression is likely exaggerated. “The OGF-OGFr pathway regulates proliferation of peripheral immune cells following stimulation by MOG35–55 antigen. Exogenous OGF or endogenous OGF following LDN treatment inhibited CD4+ and CD8+ T and B cell replication within the spleen and draining inguinal nodes within the first week of immune- related response, and in spinal cord tissue on day 15 following antigen stimulation. These data support that modulation of the OGF-OGFr pathway is an effective therapeutic paradigm for MS.” McLaughlin PJ, McHugh DP, Magister MJ, Zagon IS. Endogenous opioid inhibition of proliferation of T and B cell subpopulations in response to immunization for experimental autoimmune encephalomyelitis. BMC Immunol. 2015;16:24. Published 2015 Apr 24. doi:10.1186/s12865-015-0093-0

• “Our work reveals an unexpected role for GSH in restricting serine availability to preserve Treg functionality.” Cell Metabolism,Volume 31, Issue 5,2020,Pages 920- 936.e7,https://doi.org/10.1016/j.cmet.2020.03.004. • Also: J Biol Chem. 2010 Dec 31; 285(53): 41525–41532. Published online 2010 Oct 30. doi: 10.1074/jbc.M110.189944 • And: Biochemistry. 2010 Feb 16;49(6):1059-66. doi: 10.1021/bi902022n. Redox remodeling as an immunoregulatory strategy • etc.

• Heavy metal exposure • Chronic illness • Many chemotherapeutics • Some drugs • Cofactor depletion • etc.

(c) PS Anderson - www.ConsultDrA.com 2021 59 Just Glutathione? • Glutathione is critical for sure. –The research tends to focus on it as it has a crucial role in Treg activity

(c) PS Anderson - www.ConsultDrA.com 2021 60 Just Glutathione? • But –It is also a surrogate marker for broader function and cellular health.

(c) PS Anderson - www.ConsultDrA.com 2021 61 Redox: Three compartment model Anti-Oxidant effects of Vitamins E, C, GSH and the RBC - Lipid – Plasma Interaction

Plasma RBC/Hepatocyte/Cytosol LDL – Or Cell Membrane Reduced Glutathione ASC Toco R Toco Oxidized Glutathione ASC R DHA

2 GSH (Red) NADP+

Glut. Peroxidase [Se] [B2-FAD] Glut. Reductase

GSSG (Ox) [B3-NADPH+H] HMP Shunt

2 H2O

(c) PS Anderson - www.ConsultDrA.com 2021 63 ReDox Considerations: • Before other ReDox stabilizers do your best to assure balance of the primary ReDox triplet: [ASC – GSH – TOCO]

(c) PS Anderson - www.ConsultDrA.com 2021 64 ReDox Considerations: • Then the cell balance and ability to quench extra radicals will be more stable. –Always supply cofactors for metabolism intensive agents such as GSH –Sometimes the cofactor support is all that is required long term

(c) PS Anderson - www.ConsultDrA.com 2021 65 ReDox Considerations: • From this base THEN things such as EFA’s, Phospholipids and other natural Biological Response Agents will be more efficacious.

• Is GSH better Or • It’s Precursors: –NAC –ALA –Glutamine –Glycine

• Level of depletion • SNP effects: – Glutamate Cysteine Ligase (GCL) (previously gamma-glutamylcysteine synthetase “GCS”), is the first enzyme of the cellular glutathione biosynthetic pathway that catalyzes the chemical reaction: L-glutamate + L-cysteine + ATP →/ gamma-glutamyl cysteine + ADP + Pi – GSS (glutathione Synthetase) is the second enzyme in the glutathione (GSH) biosynthesis pathway. GSS catalyses the condensation of gamma- glutamylcysteine and glycine, to form glutathione. • Glutathione synthetase is also a potent antioxidant.

Homocysteine → CBS → Cystathionine Diet / Toxin: *CBS DONATES TO THIS PATHWAY: Cystathionine

Sulfite Cysteine GSH [Sulfite oxidase] (Mo)

Sulfate *[So, what if they never had these Sx until they took Methyl Support / Got a GSH IV etc…?]

(c) PS Anderson - www.ConsultDrA.com 2021 70 Intracellular Pathogens Dendritic Cell or Incl. Viri Monocyte [Il-2, IFNa, TNFa]

Extracellular Bacteria [Il-17,21,22,23,26]

Everyone Immune Tolerance and Regulation has a [TGFb, Il-10,35] purpose:

Antibody Response Extracellular Parasites Allergy – Atopy Il-4,5,10,13] Image: Rev Soc Bras Med Trop - Vol: 42: Suplemento II, 2009 (c) PS Anderson - www.ConsultDrA.com 2021 71 So:

• We tend to think of some TH system cell activities as “good” or “bad”. • In reality they are neither. • We need all of them to have appropriate immune responses (just as we need inflammation): – Some are specific to “particular” immune assaults • Intra vs extracellular pathogens • Antibody immunity • Tolerance • CMI • … – Some are regulatory – Some have multiple roles

• The body is stressed, sick too long, under particular chemical / epigenetic or genomic influences: –Their system becomes depleted in areas like redox, GSH etc and they cannot autoregulate the TH system. –Comorbidities (toxic, immune, GI, nutrient …) have a much greater direct and epigenetic influence.

• The role of “TH Manipulating Agents” (natural or synthetic): – Is necessary as a support while the above are worked on – Should always be seen as potentially not necessary long term. • The goal if possible: – Use what is needed to shift and balance the TH system – Work on comorbidities and determinants of health – Use the least amount of TH manipulation long term (as required by the case)

(c) PS Anderson - www.ConsultDrA.com 2021 75 Both 2021 AAMP Conferences (to the degree we can plan!) will be HYBRID events with on-site conference at the Doubletree Hilton Paradise Valley in Scottsdale, AZ and Live-stream / Virtual event available as well.

FOCUS AREAS: • Focus-1: Viral Infections • Focus-2: Fungal, Parasitic and Other Infections • Focus-3: Borrelia (Lyme), Co- infections and Superinfection • Focus-4: Clinical Management

(c) PS Anderson - www.ConsultDrA.com 2021 77 AAMP Fall 2021 Focus on Integrative Oncology September 24 – 26, 2021 • Focus-1: Integrative Oncology Updates o Nutrigenomics and Cancer Therapies • Focus-2: Treatment Modules on Specific Cancers o Prostate o Breast o Colorectal o Lung • Focus-3: Food, Diet and Cancer • Focus-4: Interventions through the Four Phases of Cancer Care o Primary Prevention o Diagnosis through Active Care o Recovery from Active Care o Secondary Prevention (c) PS Anderson - www.ConsultDrA.com 2021 78 New updated website coming soon!

www.aampconferences.com

Due to enhanced regulations for States awarding “Category-1” ND CE (HI, CA, WA etc.) **All of this is on the “Contact” tab on the home page under FAQ as well.**