A look at targeted immune modulators

On Aug. 25, we lost the beautiful and talented Dolly Parton. She left a wonderful legacy as a country music writer and performer. Her kindness was legendary. Dolly worked with so many different artists and covered many different genres, but she was pure country in her early career. On her fifth album with country legend Porter Wagoner in 1970, they recorded the song "Before Our Weakness Gets Too Strong." In 1971, they won the Grammy award for Best Country Performance by a group or duo for the album "Once More." Science and medicine have been working on trying to find ways to stop diseases caused when our own bodies attack themselves and result in diseases such rheumatoid arthritis, Crohn's disease, ulcerative colitis, lupus, type 1 diabetes, psoriasis, celiac (gluten) disease, and multiple sclerosis. In the past, treating diseases caused by an overactive immune system often meant broadly suppressing the immune system with a substantial risk of infections. Drugs such as corticosteroids (steroids) can reduce inflammation quickly, but they can have some significant adverse events. More recent drug development has focused on a different approach with medications known as targeted immune modulators. These drugs interfere with specific immune cells, proteins or signaling pathways responsible for diseases. They target the weakness before it gets to strong and attempts to stop the body from attacking itself. A targeted immune modulator is a medication designed to alter a particular component of the immune response rather than suppressing the entire system indiscriminately. The FDA defines immunomodulators as biological products intended to inhibit or otherwise down-regulate a pre-existing pathological immune response. This concept has transformed the treatment of autoimmune and inflammatory diseases by finding the disease's immune weak point and target that area. The immune system is an extraordinarily complicated network. Immune cells use chemical messengers known as cytokines, while different receptors and signaling pathways determine how cells will respond. These systems can become activated both acutely and chronically. Research has identified important inflammatory molecules such as tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), IL-17 and IL-2 as potential targets for developing drugs. Scientific reviews describe excessive or persistent cytokine activity as an important driver of autoimmune diseases and inflammation. One of the first medications developed targeted TNF. Drugs that block TNF, including infliximab (Remicade®) and etanercept (Enbrel®), can reduce inflammation in rheumatoid arthritis, psoriasis, and inflammatory bowel disease. Rather than shutting down the entire immune system, these medications interfere with one particularly inflammatory signal. Another strategy is tocilizumab, an antibody blocking the IL-6 receptor showing significant clinical benefit in rheumatoid arthritis. The IL-17 and IL-23 pathways provide different pathways to precise treatment. IL-17 contributes to inflammation at the skin and joints, while IL-23 helps maintain inflammatory Th17 cells. Drugs targeting these pathways have produced substantial improvements in psoriasis and psoriatic arthritis. Targeted does not mean risk-free. Blocking an immune pathway can interfere with the body's ability to respond to infections. Depending on the medication, healthcare providers may monitor patients for infections, blood abnormalities, liver problems and other complications. There is an important distinction between controlling symptoms and actually curing the disease. Many targeted immune modulators suppress the inflammatory process; they do not eliminate the disease. These drugs offer a way to improve a patient's quality of life by significantly controlling symptoms and the disease states. On any given day watching the evening news on the networks, you may see 3 to 5 different drug ads within 30 minutes talking about these targeted immune modulators. The commercials focus on Crohn's disease, ulcerative colitis, psoriasis, psoriatic arthritis, and multiple sclerosis. These drugs provide a major advance in managing patients, but they often have a significant cost to treatment. It is very important to evaluate all options and costs prior to starting therapies. Talk to your healthcare professionals. It is important to talk to your pharmacist before starting many of these medications, because they may require additional vaccines prior to administration to help protect from the risk of infections. The research and investigational drug pipeline are developing and evaluating the next generation of even more precise immune targeted modulators. These medications can help get the weakness before it gets too strong and causes irreversible damage. Karen Kier is a pharmacist with Ohio Northern University HealthWise Pharmacy.