Immunosuppressants

Immunosuppressants are powerful medications that work by controlling your body’s immune response. They are most commonly used to prevent organ transplant rejection and to manage autoimmune diseases like lupus, rheumatoid arthritis, and Crohn’s disease. While these drugs can be life-saving, they also require careful monitoring due to their potential side effects and impact on your body’s ability to fight infections.

Immunosuppressants are medications that prevent your immune system from attacking healthy cells and tissues by mistake. They are used to treat and prevent certain medical conditions, including autoimmune diseases such as psoriasis (a disease that causes raised, scaly patches on the skin because of systemic inflammation), rheumatoid arthritis (a condition where your body attacks its joints causing pain, swelling, and loss of function), lupus, leukemia (cancer that begins in the white blood cells), and organ transplantations. Because your immune system does not work normally, you are at an increased risk of certain complications, including infections and cancer.

Immunosuppressant drugs are designed to decrease your body’s immune response. These medications were originally developed to prevent organ rejection in transplant patients. Now they are also used to treat cancer and autoimmune disorders like lupus, rheumatoid arthritis (RA), and psoriatic arthritis. There are many types of immunosuppressants, and each works in a slightly different way.

Immunosuppressants are classified into several types based on how they work within your immune system. Some of the main types of immunosuppressive agents include:

Corticosteroids:

-Examples: Deltasone (prednisone), Medrol (methylprednisolone), and Decadron (dexamethasone).

-How They Work: These drugs block your body from making proteins that cause inflammation as well as suppress your immune system. Using corticosteroids for a long time puts you at risk for side effects such as weak bones, high blood pressure, high blood sugar, cataracts, and infections.

Calcineurin Inhibitors:

-Examples: Neoral (cyclosporine) and Protopic (tacrolimus).

-How They Work: These drugs inhibit the activity of calcineurin, an enzyme that activates T-lymphocytes or T-cells. By blocking calcineurin, they prevent the production of interleukin-2 (IL-2), an inflammatory cytokine (protein). The most common side effects include high blood pressure and decreased kidney function.

Antimetabolites and IMDH Inhibitors:

-Examples: Imuran (azathioprine), Cellcept (mycophenolate mofetil), Arava (leflunomide), and Rheumatrex (methotrexate).

-How They Work: These drugs interfere with the T and B cells, which your immune cells need to make DNA and RNA to grow and divide. Slowing this process down helps to control your immune response. You are at a higher risk of infection when taking these medications. You should have blood tests to check for viral infections, such as hepatitis B and C, before starting these medications.

Biologics and Monoclonal Antibodies:

-Examples: Rituxan (rituximab), Renflexis (infliximab-abda), Humira (adalimumab), and Simulect (basiliximab).

-How They Work: Biologics are a newer class of drugs that target a specific type of receptor on immune cells that are involved in your immune response. For example, TNF inhibitors like infliximab and adalimumab target tumor necrosis factor-alpha (TNF-α), a protein involved in inflammation. You are at an increased risk of serious infections (bacterial, fungal, and viral) with these medications. Your healthcare provider should test you for tuberculosis (TB), hepatitis B and C, HIV, and any fungal infections. You should also avoid live vaccines while on any of these drugs.

Mechanistic target of rapamycin (mTOR) inhibitors (mTOR Inhibitors):

-Examples: Rapamune (sirolimus) and Zortress (everolimus).

-How They Work: These drugs block a protein that is involved in cell growth. By inhibiting mTOR, these drugs reduce the actions of T-cells and B-cells. Some serious side effects include swelling in your brain, heart, and lungs. It can also increase your risk of infections and certain types of cancer.

Janus Kinase (JAK) Inhibitors:

-Examples: Xeljanz (tofacitinib), Olumiant (baricitinib).

-How They Work: JAK inhibitors block the activity of Janus kinases, a group of enzymes involved in your immune response and inflammation. As with all immunosuppressants, you are at an increased risk of infections. With this group, you are especially at an increased risk of herpes zoster (shingles).

Immunosuppressive drugs are used for various medical conditions and treatments where controlling your immune response is needed. Some common reasons your healthcare provider may use immunosuppressive medications include:

Organ Transplants:

-Prevention of Organ Transplant Rejection: Immunosuppressants are used as antirejection medications in transplant patients. They are needed because your immune system will recognize the transplanted organ as foreign and may attack it, leading to rejection. Immunosuppressants are commonly used in liver, heart, lung, and kidney transplants to prevent this from happening.

Autoimmune Disorders:

-Rheumatoid Arthritis: They are used to reduce inflammation and slow your disease progression.

-Systemic Lupus Erythematosus (SLE): Can be used to manage symptoms and prevent organ damage.

-Multiple Sclerosis (MS): Helps slow the progression of your disease and reduce flare-ups.

-Inflammatory Bowel Disease (IBD): Conditions like Crohn's disease and ulcerative colitis are treated with immunosuppressants to reduce inflammation in your gastrointestinal tract.

-Psoriasis and Psoriatic Arthritis: This helps reduce your immune response that causes the overproduction of skin cells or damage to your joints.

-Eczema (Atopic Dermatitis): In severe cases, immunosuppressive therapy is used to control chronic inflammation and itching.

-Vasculitis (Inflammation of Your Blood Vessels): They can be used to control inflammation and prevent damage to your blood vessels and organs.

Bone Marrow and Stem Cell Transplants:

-Prevention of Graft-Versus-Host Disease (GVHD): If you are undergoing bone marrow or stem cell transplants, immunosuppressants are used to prevent GVHD, where the donated immune cells attack your body. They are commonly used in blood cancers (leukemia, multiple myeloma, and lymphoma), certain blood disorders (sickle cell disease and thalassemia), and bone marrow issues, like aplastic or hemolytic anemia.

Severe Allergic Reactions:

-Management of Severe Allergies and Asthma: Immunosuppressants can be used to control severe allergic reactions and chronic asthma when other common treatments have failed.

Nephrotic Syndrome:

-Kidney Disease: In conditions like nephrotic syndrome, where your immune system causes kidney damage, immunosuppressants can help reduce proteinuria (protein in urine) and improve your kidney function.

Different immunosuppressants will have different side effects, and there is no way to predict how you will respond to a particular medication or how serious the side effects might be for you. However, all immunosuppressant drugs carry a serious risk of infection. Some other side effects you may see across this wide range of medications include:

-Upset stomach

-Diarrhea

-Nausea/vomiting

-Fatigue

-Hair loss or growth

-Increased blood sugar

-Headache

-Weight gain or loss

-Tremors (shaking)

-Mood changes

-Weak or thinning bones

These are not all the side effects you may see from immunosuppressants. If you have any questions or concerns about what to expect, contact your healthcare provider for medical advice before starting your treatment.

There is a wide variety of immunosuppressants, so their contraindications and warnings will vary greatly. Some common reasons people should avoid these medications include an active, untreated infection, certain cancers, and pregnancy/breastfeeding. Other important considerations include known allergies to the specific drug, severe liver or kidney disease, and uncontrolled heart failure. Also, patients on immunosuppressants should not receive live vaccines, as their suppressed immune system may not be able to respond correctly to the vaccine and could lead to complications.