[Show abstract][Hide abstract] ABSTRACT: If we could predict and prevent idiosyncratic drug reactions (IDRs) it would have a profound effect on drug development and therapy. Given our present lack of mechanistic understanding, this goal remains elusive. Hypothesis testing requires valid animal models with characteristics similar to the idiosyncratic reactions that occur in patients. Although it has not been conclusively demonstrated, it appears that almost all IDRs are immune-mediated, and a dominant characteristic is a delay between starting the drug and the onset of the adverse reaction. In contrast, most animal models are acute and therefore involve a different mechanism than idiosyncratic reactions. There are, however, a few animal models such as the nevirapine-induced skin rash in rats that have characteristics very similar to the idiosyncratic reaction that occurs in humans and presumably have a very similar mechanism. These models have allowed testing hypotheses that would be impossible to test in any other way. In addition there are models in which there is a delayed onset of mild hepatic injury that resolves despite continued treatment similar to the "adaptation" reactions that are more common than severe idiosyncratic hepatotoxicity in humans. This probably represents the development of immune tolerance. However, most attempts to develop animal models by stimulating the immune system have been failures. A specific combination of MHC and T cell receptor may be required, but it is likely more complex. Animal studies that determine the requirements for an immune response would provide vital clues about risk factors for IDRs in patients.
Advances in pharmacology (San Diego, Calif.) 01/2012; 63:81-135.
[Show abstract][Hide abstract] ABSTRACT: Idiosyncratic drug reactions (IDRs) are poorly understood, but their clinical characteristics suggest that they are immune mediated. Penicillamine-induced autoimmunity in Brown Norway rats has been utilized as an animal model for mechanistic studies of one type of IDR because it closely mimics the autoimmune syndromes that it causes in humans. Our previous work suggested that it is T-cell mediated. It has been shown that T helper 17 (Th17) cells play a central role in many types of autoimmune diseases. This study was designed to test whether Th17 cells are involved in the pathogenesis of penicillamine-induced autoimmunity and to establish an overall serum cytokine/chemokine profile for this IDR. In total, 24 serum cytokines/chemokines were determined and revealed a dynamic process. In sick animals, interleukin (IL) 6 and transforming growth factor-β1, known to be driving forces of Th17 differentiation, were consistently increased at both early and late stages of penicillamine treatment; however, no significant changes in these cytokines were observed in animals that did not develop autoimmunity. IL-17, a characteristic cytokine produced by Th17 cells, was increased in sick animals at both the messenger RNA and serum protein level. In addition, serum concentrations of IL-22, another characteristic cytokine produced by Th17 cells, were found to be elevated. Furthermore, the percentage of IL-17-producing CD4 T cells was significantly increased but only in sick animals. These data strongly suggest that Th17 cells are involved in penicillamine-induced autoimmunity. Such data provide important mechanistic clues that may help to predict which drug candidates will cause a relatively high incidence of such autoimmune IDRs.
[Show abstract][Hide abstract] ABSTRACT: The mechanisms of idiosyncratic drug-induced liver injury (IDILI) are still a matter of dispute. Some of the characteristics of reactions that have been classed as metabolic idiosyncrasy could also be those of an immune-mediated reaction with an autoimmune component. Many auto-immune reactions appear to be mediated by T(H)17 cells, which are in part characterized by the production of interleukin (IL)-17. To test the involvement of T(H)17 cells in IDILI, we quantified a number of cytokines, chemokines, and autoantibodies in the serum of 39 patients with acute liver failure (ALF) due to IDILI and compared the values with those from 21 patients with acetaminophen-induced ALF and 10 patients with viral hepatitis-induced ALF. The IL-17 levels were elevated in 60% of patients with IDILI, but also in a similar number of patients with acetaminophen-induced ALF and occasionally in patients with viral hepatitis. Levels of other cytokines, such as IL-21, that are also produced by T(H)17 cells were higher in patients with IDILI, but again, there was overlap with acetaminophen DILI. Autoantibodies were more frequent in patients in the IDILI group but were absent in most patients. These data provide a picture of the cytokine/chemokine profile in patients with various types of ALF. The pattern varies from patient to patient and not specifically by etiology. This suggests that different underlying disease mechanisms may be at play in different individuals, even among those demonstrating injury from the same drug. Since cytokines may originate from more than one type of cell, interpretation of results of cytokine assays remains difficult in complex disease settings.
Journal of Immunotoxicology 07/2010; 7(3):157-64. · 1.57 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The danger hypothesis has had a profound effect on the way immunologists view the immune response. This hypothesis proposes that the major determinant of whether an immune response is mounted against some agent is determined by whether that agent causes some type of cell damage. Assuming that most idiosyncratic drug reactions (IDRs) are immune-mediated, this hypothesis also has the potential to explain many aspects of the mechanism of these adverse drug reactions. For example, most IDRs appear to be caused by chemical metabolites rather than the parent drug, but not all drugs that form reactive metabolites are associated with a significant incidence of IDRs. Therefore, using the danger hypothesis, one feature of a drug candidate that may predict whether it causes an IDR is whether the drug, or more likely its reactive metabolites, cause cell damage. Although the range of molecules that can act as danger signals is unknown, the most attractive candidates are high mobility group box 1 protein (HMGB1), heat shock proteins, and S100 proteins. These molecules act through the same receptors (toll-like receptors) as pathogen-associated molecules that stimulate the immune system. Therefore, other environmental factors such as infections or trauma might determine which patients would be at increased risk for IDRs. Although there are examples where this appears to be the case, in most cases there are no obvious environmental factors that determine IDR risk. In addition, in animal models of immune-mediated reactions, stimulation of toll-like receptors often does not increase the immune response, and depending on the timing, it can actually be protective. Therefore, there may be additional unknown control mechanisms that are involved. A better understanding of these fundamental immune mechanisms has the potential to have a significant impact on many areas of medicine.
[Show abstract][Hide abstract] ABSTRACT: Idiosyncratic drug reactions represent a serious health problem, and they remain unpredictable largely due to our limited understanding of the mechanisms involved. Penicillamine-induced autoimmunity in Brown Norway (BN) rats represents one model of an idiosyncratic reaction, and this drug can also cause autoimmune reactions in humans. We previously demonstrated that penicillamine binds to aldehydes on the surface of macrophages. There is evidence that an imine bond formed by aldehyde groups on macrophages and amine groups on T cells is one type of interaction between these two cells that is involved in the induction of an immune response. We proposed that the binding of penicillamine with aldehyde groups on macrophages could lead to their activation and in some patients could lead to autoimmunity. In this study, the transcriptome profile of spleen macrophages 6 h after penicillamine treatment was used to detect effects of penicillamine on macrophages with a focus on 20 genes known to be macrophage activation biomarkers. One biological consequence of macrophage activation was investigated by determining mRNA levels for IL-15 and IL-1 beta which are crucial for NK cell activation, as well as levels of mRNA for selected cytokines in spleen NK cells. Up-regulation of the macrophage activating cytokines, IFN-gamma and GM-CSF, and down-regulation of IL-13 indicated activation of NK cells, which suggests a positive feedback loop between macrophages and NK cells. Furthermore, treatment of a murine macrophage cell line, RAW264.7, with penicillamine increased the production of TNF-alpha, IL-6, and IL-23, providing additional evidence that penicillamine activates macrophages. Hydralazine and isoniazid cause a lupus-like syndrome in humans and also bind to aldehyde groups. These drugs were also found to activate RAW264.7 macrophages. Together, these data support the hypothesis that drugs that bind irreversibly with aldehydes lead to macrophage activation, which in some patients can lead to an autoimmune syndrome.
Chemical Research in Toxicology 08/2009; 22(9):1526-33. · 3.67 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Idiosyncratic drug reactions (IDRs) represent a major clinical problem, and at present, the mechanisms involved are still poorly understood. One animal model that we have used for mechanistic studies of IDRs is penicillamine-induced autoimmunity in Brown Norway (BN) rats. Previous work in our lab found that macrophage activation preceded the clinical autoimmune syndrome. It is thought that one of the interactions between T cells and macrophages involves reversible Schiff base formation between an amine on T cells and an aldehyde on macrophages, but the identity of the molecules involved is unknown. It is also known that penicillamine reacts with aldehyde groups to form a thiazolidine ring, which unlike a Schiff base, is essentially irreversible. Such binding could lead to macrophage activation. Generalized macrophage activation could lead to the observed autoimmune reaction. Hydralazine and isoniazid also react with aldehydes to form stable hydrazones, and they also cause an autoimmune lupus-like syndrome. In this study, isolated spleen cells from male BN rats were incubated with biotin-aldehyde-reactive probe (ARP, a hydroxylamine), biotin-hydrazide, or D-penicillamine. At all concentrations, ARP, hydrazide, and penicillamine preferentially "stained" macrophages relative to other spleen cells. In addition, preincubation of cells with penicillamine or hydralazine decreased ARP staining of macrophages, which further indicates that most of the ARP binding to macrophages involves binding to aldehyde groups. This provides support for the hypothesis that the interaction between aldehyde-containing signaling molecules on macrophages and penicillamine could be the initial event of penicillamine-induced autoimmunity. Several of the proteins to which ARP binds were identified, and some such as myosin are attractive candidates to mediate macrophage activation.
Chemical Research in Toxicology 06/2009; 22(7):1277-84. · 3.67 Impact Factor