The immunosuppressive drugs are used in rheumatoid arthritis and certain other autoimmune conditions that are refractory to less toxic treatments. Their pharmacology and additional clinical uses are described in Chapter 57. Azathioprine (Imuran) is a prodrug that is metabolized to a purine antimetabolite. Its disease-modifying activity results from the inhibition of lymphocyte proliferation and secretion of certain cytokines. This drug is used in the treatment of rheumatoid arthritis, lupus nephritis, and psoriatic arthritis. Cyclosporine (Sandimmune, Neoral) is used in refractory rheumatoid arthritis, psoriasis, and inflammatory bowel disease. It acts by blocking the transcriptional activation of many genes involved in the first phase of T cell activation. Cyclophosphamide (Cytoxan) is an alkylating agent that was used in severe rheumatoid in the past but is seldom used today because of its severe bladder toxic-ity, bone marrow toxicity, and carcinogenicity.
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