Institute of Pharmacology http://www.pki.unibe.ch/ PKI

Immunopharmacology

Prof. Dr. Stephan von Gunten MD PhD MME

Lectures: Clinical Immunomodulation

Endogenous or exogenous molecules that influence immune responses

positively (immunostimulation)

or

negatively (immunoregulation) DC Based Vaccination

Freund complete adjuvans (FCA) Freund incomplete adjuvans (FIA) (mycobacteria + mineral oils) (mineral oils, without mycobacteria)

differential maturation alum (hydrated alumina)

dendritic cell (DC)

mycobacteria Toll-like Receptors alum, mineral NLR-Inflammasome oils in FCA/FIA Toll-Like Receptors

PAMPs

2 major adapters: MyD88 and TRIF

protein kinases

transcription factor (NFkB, IRF-3/-7) [IRF: Interferon regulatory factor]

gene transcription: inflammatory cytokines, IFNa/b, others BMSc Pharma Immuno Manicassamy S & Pulendran B, Seminars in Immunology 2009 (modified) TLR Agonists and Cancer Immunotherapy: BCG-CWS

BCG: Bacillus Calmette-Guérin, attenuated form of Mycobacterium bovis CWS (cell-wall skeleton ): major adjuvant–active part of mycobacterial cells; contains muramyldipeptide (MDP) -> activation of TLR-2 and -4 and NOD2

BCG-CWS TLR-2

MyD88-pathway

mDC

cytokines

CTL tumour cell killing

Carbohydrate-based vaccines in development Infectious disease Infectious

Cancer Astronomo RD & Burton DR Nat Rev Drug Discov 2016 (modified) Antibody repertoire: glycan immunogenicity linked to structure

Schneider et al. Sci Transl Med 2015 Cancer Immunotherapy

Galluzi L et al. Oncotarget 2014 Siglec expression on immune cells

Jandus C et al. Biochem Pharmacol 2011 Illustration by Aldona von Gunten The sialoglycan shield

Jandus C & Boligan KF et al. J Clin Invest. 2014 Siglecs on CD8 T cells? May 2019 Cover Story American Association of Cancer Research (AACR) Immunomodulation

Endogenous or exogenous molecules that influence immune responses

positively (immunostimulation)

or

negatively (immunoregulation) Antiinflammatory vs. immunosuppressive therapy

Components of Inflammation cellular or humoral immunity

E.g. inflammatory disease E.g. transplantation medicine, preventive Production of inflammatory mediators by arachidonic acid metabolites and cyclo-oxygenase

Gastric epithelial cytoprotection by prostaglandins: role of COX-1

COX-1 COX-1 Misoprostol Prostaglandin analogues

Substance Misoprostol: stable PGE1- Analogue

Pharmacodynamics Cytoprotective effects: inhibition of H+ - Secretion, stimulation of mucus and HCO3- production, increase of gastrical blood perfusion

Pharmakokinetics In contrast to endogenous PG oral uptake possible, short half-life (20 min)

Indication Ulcus prophylaxis for chronic treatment with NSAID (ASS, Diclofenac)

Side-effects

• Frequent diarrhoea due to increased intestinal secretion of H2O and electrolytes • Increases tone of uterus-> CAVE: pregnancy Cox-1 and -2 selectivity of widely used NSAID

Ev. higher risk of gastrointestinal events

Ev. higher risk of cardiovascular events

Modified from Park K & Bavry AA Vasc Health Risk Manag. 2014 Classes of immunoregulatory drugs

1. Drugs acting on immunophilins (cyclosporine, , )

2. Cytostatics (alkylating agents, antimetabolites)

3. Glucocorticoids

4. Antibodies: • Polyclonal • Monoclonal (lecture PD Dr. S. Adler: Biologics)

5. Other drugs (lecture PD Dr. S. Adler: Biologics) Inhibitors of and mTOR (‘mammalian target of rapamycin’) phosphatases

p-NFAT Cyclosporin A (CyA), Tacrolimus (T)

Calcineurin Binding partners (immunophilins): - (CyA) - FK-binding proteins (T) Lymphocyte Nucleus NFAT (TF)

TF = transcription factor

IL-2, other cytokines

IL-2 receptor

Sirolimus (Rapamycin)

mTOR Binding partners (immunophilins): - FK-binding proteins

Lymphocyte Proliferation Chemotherapeutics as immunosuppressive drugs

Chemotherapeutics kill or inhibit proliferation of cancer cells with unwanted side effects on healthy cells, in particular hematopoietic immune cells => certain cytotoxic drugs can be used as immuno-suppressive drugs. Mode of action: induction of apoptosis/necrosis, inhibition of proliferation.

i

Image source: undisclosed master thesis Glukocorticoids: molecular mechanisms

Ribonucleases Induction of IkB Transcortin/ Annexin I gene expression Interleukin-10 Albumin IL-1 rec. antagonist

Cortisol Cortisol Cortisol glucocorticoid responsive Cortisol Cortisol element receptor receptor

Hsp-90

NF-AT Cytokinee Adhesion molecules AP-1 Chemokines NF-kB Cyclooxygeneses Inhibition of gene expression

N. Engl. J. Med. 353 (2005), 1711-1723 CLINICAL USE OF INTRAVENOUS IMMUNOGLOBULINS (IVIG)

Schneider C et al., in preparation IVIG PLURIPOTENCY – BROAD RANGE OF INDICATIONS

von Gunten S et al. Nat Rev Immunol 2014 Schneider C et al. in preparation Fab- and Fc-mediated immunoregulatory effects of IVIG

Specific antigen binding sites Fab-linked characteristics

Specific binding (repertoire of donor population) • pathogens, superantigens • immunoregulatory molecules: cytokines, complement, immune receptors (e.g. Fas, MHC class I, CD4, Siglec-8, Siglec-9) • anti-idiotypic antibodies Fab Fab • DC-SIGN (sialylated Fab)?

Effects • cytokines: neutralization • complement: inhibition • neutralization of pathogenic autoantibodies • immune cells: inhibition of cellular activity, anti-proliferative, cell death • tissue: survival and protection

Fc Fc-linked characteristics

Binding • Fc-receptors • DC-SIGN (sialylated Fc)

Effects Modified from www.sci.sdsu.edu • increased turn-over of pathogenic antibodies (ITP; neonatal Fc-receptor blocking?) • sialylation-dependant anti-inflammatory effects in certain animal models

von Gunten S et al. Nat Rev Immunol, 2014 FUNCTIONAL ANTI-FAS ANTIBODIES IN IVIG

Blocking anti-Fas antibodies in IVIG Agonistic anti-Fas antibodies in IVIG - Toxic epidermal necrolysis [TEN]

Prasad NK et al. J Immunol. 1998

Viard I et al. Science. 1998

Sooryanarayana et al. Biochem Biophys Res Commun. 1999 F(ab’)2-mediated and cytokine-dependent regulation of granulocyte survival by IVIG

von Gunten S et al. Casulli S et al. PLoS One. 2011 J Allergy Clin Immunol. 2007

von Gunten S et al. Blood. 2006

Schneider C et al. Sci Rep 2016 Neutrophil-predominant vasculitis in Kawasaki disease

Scardina GA et al. Med. oral patol. oral cir.bucal 2007 Neutrophil counts drop within 24 hrs following IVIG treatment due to induction of apoptosis

Tsujimoto H et al. Clin Immunol 2002 IVIG-MEDIATED REGULATION OF GRANULOCYTE SURVIVAL

von Gunten S, Simon HU. J Clin Immunol. 2010 IVIG/SCIG AND ALTERNATIVE IMMUNOGLOBULIN PREPARATIONS

Späth P et al. Arch Immunol Ther Exp 2016