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The immune system is vital to fighting infection and disease. However, if our immune system is too active, it can harm the body rather than protect it. Immunosuppressants reduce the activity of the immune system and can be used in transplantology to prevent rejection of a transplant. They are also used in the treatment of allergies or autoimmune diseases.
Immunosuppressants – What Are They?
Immunosuppressants are a class of drugs that suppress or reduce the strength of our body’s immune system.
Some of these drugs are used to reduce the likelihood of the body rejecting a transplanted organ, such as the liver, heart or kidney. These drugs are called anti-rejection drugs.
Other immunosuppressive drugs are often used to treat autoimmune disorders such as lupus, psoriasis, and rheumatoid arthritis.
See also: How does the immune system work?
Immunosuppressants – types
Immunosuppressants fall into 6 groups:
- calcineurin inhibitors (tacrolimus, cyclosporine);
The exact mechanism of action of calcineurin inhibitors is unknown. However, it is assumed that they indirectly inhibit the activity of T lymphocytes by blocking the action of calcineurin, a protein that is part of the signaling pathway in the immune system.
- cytostatic drugs (cyclophosphamide, azathioprine);
Cytostatic drugs inhibit cell division. In immunotherapy, they are used in lower doses than in the treatment of neoplastic diseases. They affect the proliferation of both T-lymphocytes and B-lymphocytes. Due to the highest effectiveness, purine analogues are most often administered.
- serine / threonine kinase inhibitors (sirolimus, everolimus);
Serine-threonine kinase inhibitors are a group of drugs designed to block the action of serine-threonine kinase (mTOR). The mTOR kinase, in turn, is responsible for the regulation of growth, proliferation, cell movement and the synthesis of genetic material in the body.
- monoclonal antibodies (basiliximab);
Monoclonal antibodies are sometimes used as a rapid and potent immunosuppressive therapy to prevent acute rejection reactions as well as a targeted treatment for lymphoproliferative or autoimmune disorders (e.g. anti-CD20 monoclonal drugs).
- glucocorticosteroids (methylprednisolone, prednisone, prenisolone);
At pharmacological doses, glucocorticoids such as prednisone are used to suppress a variety of allergic, inflammatory and autoimmune disorders. They are also administered as post-transplant immunosuppressants to prevent acute rejection and graft versus host disease. Despite this, they do not prevent infection and also inhibit subsequent repair processes.
- other immunosuppressants (mycophenolate mofetil, mycophenolate sodium).
Mycophenolate mofetil and mycophenolate are both T and B lymphocytic cytostatic drugs. They are rapidly and almost completely absorbed after oral administration. In the case of mycophenolateic acid salts, they are used to prevent acute transplant rejection in combination with ciclosporin and glucocorticoids. However, it should be added that these drugs very often cause sepsis, gastrointestinal candidiasis and urinary tract infection.
Immunosuppressive drugs – application
Immunosuppressants are used for a variety of medical purposes. Some inhibit a specific part of the immune response. Others affect many different parts of the immune system. There are many different categories of immunosuppressants that work in slightly different ways.
Some of the same immunosuppressive drugs are used for different types of disease. Below are some of the most important categories.
Immunosuppressive drugs and autoimmune diseases
Immunosuppressants are used to treat many autoimmune diseases. In autoimmune disease, certain parts of the immune system become overactive. Ultimately, this leads to inflammation and damage to the body from its own immune system. Scientists have developed immunosuppressive drugs that target different parts of the immune system and can help treat autoimmune diseases.
Autoimmune diseases sometimes treated with immunosuppressants include:
- rheumatoid arthritis;
- ulcerative colitis;
- psoriasis;
- lupus;
- Sjögren’s syndrome;
- systemic scleroderma;
- multiple sclerosis;
- vasculitis.
Some of the immunosuppressive drugs used to treat autoimmune diseases are traditional pharmaceutical drugs. Examples include:
- corticosteroids (e.g., prednisone);
- methotrexate;
- plaquenil (hydroksychlorochina);
- sulfasalazyna;
- imuran (azathiopryne);
- cyclosporine.
Recently, biological drugs have become available. They are usually given by injection or infusion into a vein (drip). These newer drugs target specific parts of the immune system, such as blocking a specific type of receptor on immune cells.
Some of the broad categories of immunosuppressive biological drugs for the treatment of autoimmune diseases include:
- TNF inhibitors, such as Humira (adalimumab);
- IL-6 blockers such as Actemra (tocilizumab);
- IL-1 blockers such as Kineret (anakinra);
- Biologically blocking the activity of T lymphocytes such as Orencia (abatacept);
- JAK inhibitors such as Xeljanx (tofacitinib);
- Biologically affecting B cells such as Truxima (rituximab).
Some immunosuppressants are sometimes given temporarily. For example, we may need to take prednisone for a short period if our symptoms get out of control. We may also need a higher dose of an immunosuppressive drug such as prednisone if we have a disease flare. However, it may also be necessary to take long-term maintenance doses of some medications.
Not all medications that help with these conditions are immunosuppressants. For example, a person may be taking pain-relieving medications that do not affect the immune system.
Immunosuppressants and Organ Transplant
Immunosuppressants are also critical therapy for people who have undergone an organ transplant, such as a kidney or liver from a donor.
The immune system works hard to distinguish its own normal cells from potential invaders (such as bacteria) to attack. When we receive a donated organ, certain cells of the immune system can connect to the donated organ and “set off the alarm.” This can lead to the body attacking the newly donated organ (called ‘organ rejection’). If this happens, the new organ will not be able to function properly and the person may become seriously ill. This is true for everyone, with the exception of those who may have received an organ from a monozygotic twin.
To prevent organ rejection, it is imperative to silence part of the immune system. This makes it much less likely that the immune system will damage the new organ.
Stronger immunosuppressants may be needed soon after an organ transplant. However, people who have undergone an organ transplant must continue taking certain combinations of immunosuppressants for as long as they live.
Some of the main types of immunosuppressants used in organ transplantation include:
- Calcineurin inhibitors such as Prograf (tacrolimus);
- Antiproliferative agents such as CellCept (mycophenolate mofetil);
- MTOR inhibitors such as Rapamune (Sirolimus);
- Corticosteroids (e.g. prednisone).
See also: Transplants in Poland – what does it look like today?
Immunosuppressants and cancer
Cancer is another large category of drug-treated diseases that affect the immune system. Unlike autoimmune diseases and organ transplantation, weakening the immune system is not the goal of cancer treatment. However, immunosuppression is a side effect of many types of cancer treatments, including chemotherapy and radiation therapy. Chemotherapy to kill cancer cells also kills many immune cells, and the remaining immune cells may not work normally. This can expose you to infections.
Immunosuppressants and stem cell transplantation
Immunosuppressants are also a key part of stem cell (bone marrow) transplantation. Such transplants can be performed for a wide variety of medical problems. For example, such a medical procedure can be used to treat certain cancers of the blood (leukemia, lymphoma, and multiple myeloma) or of the bone marrow. However, stem cell transplants are now also used to treat some rare genetic diseases, such as sickle cell anemia.
Before receiving a stem cell transplant, a person undergoes heavy radiation and immunosuppressive therapy to kill any existing stem cells in the bone marrow. During this time, such people are at high risk of serious infection. People who receive stem cell transplants usually also need to take immunosuppressive drugs throughout their lives, as do people who have received organ transplants.
See also: Does donating bone marrow hurt? So everything you need to know before making up your mind
Immunosuppressants – Research
The patient must undergo a series of assessments and tests before taking an immunosuppressive drug
Medical evaluation
The doctor will need to perform a complete medical evaluation. This can include a medical history, laboratory tests, and sometimes diagnostic imaging. This will be adapted to the specific medical situation and the immunosuppressive drug you are taking. This will help make sure the risks and benefits of the therapy make sense.
Hepatitis research
For some immunosuppressive therapies, your doctor will need to screen you for hepatitis B and C before starting treatment. Depending on your risk factors, you may need blood tests to see if you are infected. Some people are infected with one of the viruses without even knowing it.
The virus responsible for hepatitis may be inactive and not cause any problems. However, if the patient starts immunosuppressive therapy, the virus may become more active. In some cases, this can lead to liver damage and even liver failure. Therefore, it is important to make sure that you are not affected by these viruses before starting therapy.
Tuberculosis (TB) screening
Screening for tuberculosis is sometimes done before starting immunosuppressive therapy. Tuberculosis is another important infection that many people may not know about. When it is inactive, it may not cause any symptoms. However, if we have inactive TB and start taking immunosuppressants, our infection can start to cause problems.
We may need a blood test or a skin prick test to see if we have a dormant tuberculosis infection. If any of the test results show problems with tuberculosis, we may need further tests, such as a chest x-ray. If it turns out that we have tuberculosis, we will most likely need treatment before we can start immunosuppressive treatment.
If we have any risk factors for tuberculosis, we may need regular screening as long as we continue with immunosuppressive treatment. For example, this may be the case if we regularly visit a part of the world where many people are still infected with tuberculosis.
Vaccinations
Certain vaccines cannot be administered safely while a person is taking immunosuppressive drugs. This is especially true for some “live” vaccines, vaccines that contain a small amount of a weakened live virus.
For example, it is not recommended to give the shingles vaccine to someone who is currently taking certain immunosuppressive medications. Other important vaccines to be assessed may be the measles, mumps, and rubella vaccine, which also cannot be taken with some immunosuppressive drugs. On the other hand, vaccines such as the pneumococcal pneumonia vaccine can be safely taken during immunosuppressive therapy.
For this reason, it’s a good idea to work with your healthcare provider to make sure our vaccines are up to date. If not, we may choose to be fully vaccinated before starting therapy.
Immunosuppressants – Side Effects
Immunosuppressants cover a wide variety of preparations, and each specific treatment carries a specific risk of side effects. Often such side effects are not of much concern, such as mild stomach discomfort, for example. However, more serious side effects are also possible, depending on the medication used. For example, some immunosuppressive drugs taken after organ transplantation may increase the risk of developing some types of cancer.
Side effects vary with the type of immunosuppressive drug. These drugs can cause, for example:
- acne;
- diabetes;
- tiredness;
- hair loss or growth;
- headaches;
- problems with concentration or remembering;
- high blood pressure;
- mouth ulceration;
- osteoporosis;
- chills;
- weight gain;
- upset stomach, and nausea and vomiting.
Immunosuppressants and the risk of infection
Immunosuppressants have one common risk – people using these drugs have a higher risk of getting infections. Often times, the risk increases if a person takes a higher dose of medication.
In some cases, this can result in a minor infection. However, sometimes serious and even life-threatening infections can occur. Taking an immunosuppressive drug may increase your likelihood of getting sick from a common illness such as a cold.
In some cases, this can make us sick of something that doesn’t usually make us sick. For example, we may be more prone to atypical pneumonia due to a fungal infection. We may also have problems recovering from illness if we become infected.
Not all immunosuppressants affect the immune system in the same way. Some affect the immune system more than others, which can put us at greater risk of infection. An immunosuppressive drug may put us at greater risk for some types of infection, but not others. For example, we may be at greater risk of bacterial infections, but not at greater risk of being infected with viruses or parasites.
The specific risk may vary depending on the specific immunosuppressive drug you are taking, the dose, and the overall medical situation.
See also: Human parasites: causes, symptoms, treatment
Immunosuppressants to reduce the risk of infection
Fortunately, there are several steps that can help you reduce your risk of infection while taking an immunosuppressive drug. These tips can also be helpful for people who have a reduced ability to fight infection from other causes, such as certain genetic conditions or HIV.
- Let’s wash our hands often. Let’s use soap and water for at least 20 seconds. Wash your hands before eating and preparing meals, after using the bathroom, working in the garden or touching animals.
- Let’s wash and cook the food well.
- Avoid touching animal excrements. (Use gloves when necessary.)
- We avoid people who have active infections.
- Let’s get all the vaccinations recommended by the doctor.
- Let’s adopt healthy habits. Getting enough sleep, exercising regularly, and eating a healthy diet can help reduce the risk of a serious illness.
See also: Washing your hands can protect against viruses. How to do it effectively?
Immunosuppressants – Infection prevention during the COVID-19 pandemic
People taking immunosuppressants may be at greater risk of developing severe, even life-threatening, disease from COVID-19. Such people may need additional precautions, such as:
Avoiding leaving home except when absolutely necessary.
- Proper hand washing after being in a public place.
- Covering the face and nose with a mask in public places.
- Keeping social distance by staying at least 1 meter from people outside their household.
- Regular cleaning of high-touch surfaces (such as door handles).
If you are using immunosuppressive medications, it is helpful to talk to your doctor about your current treatment. With some immunosuppressive therapies, an increased dose may increase the risk of serious complications from COVID-19. However, it is not entirely simple. Some immunosuppressive therapies are in fact being explored as possible treatments for some severe COVID-19 symptoms (such as a cytokine storm).
However, immunosuppressive treatment should not be discontinued without consulting your doctor. For many people, this would be a much greater medical risk. Instead, we can talk about whether lowering the current dose of an immunosuppressive drug (or switching to a different treatment) might make sense for us.
See also: Vitamin B6 against COVID-19? May protect against the cytokine storm that can cause death
Immunosuppressants – pregnancy and breastfeeding
Anyone taking immunosuppressants should speak to their doctor immediately if they become pregnant. Certain immunosuppressants can cause birth defects and be harmful when pregnant or breastfeeding. You may need to switch to another medication. The doctor can inform us about the risks associated with the specific drug that we may be taking.
Before use, read the leaflet, which contains indications, contraindications, data on side effects and dosage as well as information on the use of the medicinal product, or consult your doctor or pharmacist, as each drug used improperly is a threat to your life or health. Do you need a medical consultation or an e-prescription? Go to halodoctor.pl, where you will get online help – quickly, safely and without leaving your home.