Introduction

 Inflammation is a normal protective response to

tissue injury caused by physical trauma, noxious
chemicals, or microbial agents
 During the process certain mediators are released
including prostaglandins and leukotrienes
 These may cause edema and pain and can also raise
body temperature

2
Introduction
 These prostaglandins and leukotrienes are formed in
the body from arachidonic acid and other
eicosanoids (20-carbon essential fatty acids)

3
Introduction
 Arachidonic acid is stored in the body by forming an
ester with various phospholipids found in cell
membranes and thus the concentration of free
arachidonic acid is very low
 When needed, arachidonic acid is released from the
phospholipids by the action of acyl hydrolases, most
notably, phospholipase A2
 In human platelets, the releasing enzyme is
diacylglycerol lipase

4
Introduction
 Microbial products or physical trauma stimulates the
release of, and activates Phospholipase A2 to hydrolyze
the esterified arachidonic acid
 The released arachidonic acid initiates a cascade of
reactions catalyzed by cyclooxygenase (COX) or 5-
lipoxygenase
 These reactions lead ultimately to the production of
prostaglandins and leukotrienes as well as several
other products

5
 Phospholipase A is activated by microbial products or physical trauma.
 The release of arachidonic acid lead to the production of prostaglandins
and leukotrienes, as well as other products.
6
Prostaglandin Biosynthesis

A similar sequence of reactions starting from 8,11,14-eicosa-

trienoic acid produces prostaglandin E1 (PGE1) 7
Prostaglandin Biosynthesis

8
Leukotriene Biosynthesis

9
Cyclooxygenase
 From the biosynthesis pathways it is seen that PGH2 is
a common intermediate for other prostaglandins,
prostacyclins and thromboxanes
 The key step in formation of PGH2 is the reaction of
arachidonic acid with oxygen catalyzed by
cyclooxygenase (COX)
 Therefore drugs that inhibit COX activity also decrease
the production of these inflammation mediators
 This is the mechanism by which NSAIDS help to
alleviate the symptoms of inflammation

10
Cyclooxygenase
 It should be noted that corticosteroids also have an
anti-inflammatory effect
 Those drugs however work differently from the non-
steroidal agents
 Corticosteroids inhibit the activation of phospholipase
A2 which prevents the release of free arachidonic acid
 Since COX only works on free arachidonic acid those
steroids also inhibit the formation of PGH2
 The focus here however will be on the non-steroidal
anti-inflammatory agents

11
Cyclooxygenase
 Two cyclooxygenase enzymes have been identified in
humans, COX-1 and COX-2
 A third, COX-3, is present in dogs but not in humans
 COX-1
 Expressed in most tissues
 Involved in cell-signaling and tissue homeostasis (the
process by which cells are maintained in equilibrium
e.g., temperature, blood pressure, and acid-base
balance)
 COX-1 also mediates the production of prostacyclin,
which when released by the gastric mucosa is
cytoprotective
12
Cyclooxygenase
 COX-2
 Induced when inflammation is initiated in response to a
stimuli
 Many of the unwanted side-effects associated with
NSAIDs are due in large part to their inhibition of
COX-1
 Since COX-2 expression is most closely associated with
inflammation, inhibitors that are selective for COX-2
should, in concept, treat the inflammation while
minimizing undesirable side-effects
 Unfortunately, several such agents induce serious
cardiovascular effects which has led to their removal
from the market
13
NSAID Indications
 The NSAIDs are a group of compounds which
generally have three main actions:
 Antipyretic Activity
 Analgesic Activity
 Anti-inflammatory Activity

14
Antipyretic Activity
 Body temperature is regulated in the hypothalamus
which acts as a thermostat to ensure a balance between
heat loss and heat production
 Under conditions that induce a fever interleukin-1
(IL-1) is released in the hypothalamus
 This activates phospholipase A2 which liberates
arachidonic acid from phospholipids and signals COX
to form prostaglandin E2
 In the hypothalamus PGE2 induces an increase in cAMP
 This triggers an increase body temperature by
increasing heat generation and decreasing heat loss
 Drugs that reduce fever generally need to cross the
blood-brain barrier and enter the CNS
15
Antipyretic Activity
 NSAIDs help lower body temperature by inhibiting the
synthesis of PGE2 in the hypothalamus
 Once this has been accomplished the temperature-
lowering mechanisms in the body take over
 Dilation of peripheral blood vessels
 Sweating

16
Analgesic Activity
 Several prostaglandins, including PGE1 and PGE2
sensitize nerve endings to pain mediators such as
bradykinin and 5-hydroxytryptamine
 NSAIDs work by inhibiting the synthesis of these
prostaglandins which then represses the sensation of
pain
 NSAIDs are effective against pain associated with:
arthritis, bursitis, pain of muscular or vascular origin,
toothache, dysmenorrhea, cancer metastases in the
bone, etc.
 NSAIDs are also effective against headaches by
diminishing the vasodilation effect induced by
prostaglandins in cerebral blood vessels
17
Antiinflammatory Activity
 NSAIDS reduce those components of inflammation
and immune response in which prostaglandins play a
role: vasodilation, edema and pain
 COX inhibitors do not reverse tissue damage resulting
from chronic inflammatory conditions such as:
 Rheumatoid arthritis (a systemic synovial inflammation)
 Osteoarthiritis (a localized inflammation involving cartilage
destruction, usually >50 yr old)
 Vasculitis (inflammation of the small blood vessels)
 Nephritis (inflammation of the kidney)
 Lipoxygenase inhibitors may prove more beneficial in
this regard
18
GI Side-Effects
 Many NSAIDs cause gastro-intestinal upset and
some may contribute to gastric ulcer formation
 This is based on two pharmacological factors:
 Most NSAIDs are organic acids
 In the low pH of the stomach, especially when empty, these
organic acids are uncharged and readily cross into the
mucosal cells, where they become ionized and are then
present in the cells at high concentrations
 For example at pH 1 a carboxylic acid (pKa 4) would be only
0.1% ionized
 Thus, these agents potentially can cause direct damage to
those cells

19
GI Side-Effects
 Prostaglandins E2 and I2 (prostacyclin) are
produced by gastric mucosa
 These prostaglandins inhibit the secretion of HCl
and stimulate the secretion of mucus and
bicarbonate that protect mucosal cells
 NSAIDs that inhibit the production of these
prostaglandins therefore leave the mucosa cells
more exposed to ulcerative effects

20
Selective COX-2 Inhibitors
 Individual NSAIDS show different potencies
against COX-1 and COX-2 that correlates with
variations in their side-effects
 Drugs with high potency against COX-2 and with
high COX-2/COX-1 activity ratios have anti-
inflammatory activity with fewer side effects in the
stomach and kidneys
 Unfortunately, two selective COX-2 inhibitors,
Rofecoxib (Vioxx) and Valdecoxib (Bextra), have
been removed from the market due to
cardiovascular effects
21
 General structure and properties of NSAIDs
 In general, NSAIDs structurally consist of an acidic moiety
(carboxylic acid, enols) attached to a planar, aromatic
functionality. The NSAIDs are characterized by the following
chemical/ pharmacologic properties:
1. All are relatively strong organic acids with pKa in the 3.0–5.0
range. Most, but not all, are carboxylic acids. The acidic group
is essential for COX inhibitory activity.
2. The NSAIDs differ in their lipophilicities based on the
lipophilic character of their aryl groups and additional
lipophilic moieties.

22
 General structure and properties of NSAIDs
3. The acidic group in these compounds serves a major
binding group with plasma proteins  highly bound to
plasma proteins, a major source of potential drug
interactions with other medications.

4. The acidic group also serves as a major site of

metabolism by conjugation. Thus a major pathway of
clearance for many NSAIDs is glucuronidation (and
inactivation) followed by renal elimination.

23
Selective COX-2 Inhibitors
Celecoxib, Celebrex
4-[5-(4-Methylphenyl)-3-(trifluoromethyl)-1H-pyrazol-1-yl]-
benzenesulfonamide

 In 1998 Celebrex became the first selective COX-2 inhibitor in the US

 It is used for pain, fever and inflammation including arthritis
 Once or twice daily oral dosing
 The main phase I metabolite is the primary alcohol from oxidation of the
methyl group
 That can get further oxidized to a carboxylic acid, and both metabolites
can form glucuronide conjugates
 None of the metabolites are active 24
Salicylates

 The salicylate class of NSAIDs are derivatives of salicylic

acid
 In the U.S. alone 10-20 thousand tons are consumed
annually
 These compounds have antipyretic, analgesic and anti-
inflammatory activity
 As acids these compounds are highly protein bound
 Several side-effects are associated with some of the
salicylates:
 Bleeding
 GI Upset
 Reye’s Syndrome
25
Salicylates
Bleeding
 From the biosynthesis slides it is seen COX is a key enzyme
for the production of thromboxanes
 These compounds are involved in blood clotting
 Some salicylates may inhibit COX-1 in blood platelets which
in turn inhibits production of thromboxanes which results
in diminished ability of blood to clot
 This may lead to prolonged bleeding
 However, this problem has led to the use of aspirin as an
antithrombotic agent for use in patients with prior heart
attacks

26
Salicylates
GI Tract Upset
 This results from inhibiting COX-1 and thereby inhibiting
formation of prostacyclin as described earlier
Reye’s Syndrome
 This is usually only problematic in children under age 16
who have influenza, chicken pox or other flu-like symptoms
 Attempts to alleviate symptoms using salicylates may
induce Reye’s Syndrome which while rare can lead to
vomiting, violent headache, unusual behavior and can even
be fatal
 Acetaminophen is not associated with this condition and is
recommended for use in children in such cases
27
Salicylates
 Acetylsalicylic acid, Aspirin
 Benzoic acid, 2-(acetyloxy)-

 Used for pain, inflammation and fever

 Metabolized mainly by ester hydrolysis with a small
amount of aromatic hydroxylation
 The released salicyclic acid is conjugated as both a
glucuronide and as a glycine conjugate 28
Acetylsalicylic acid
 Unlike most NSAIDS, is an irreversible inhibitor of COX
 The acetyl group gets transferred to a serine residue on
COX which covalently alters the enzyme
 This then inhibits synthesis of thromboxane A2 which is a
platelet aggregating factor
 Platelets lack a nucleus and therefore cannot synthesize
additional COX (while other NSAIDs reversibly inhibit the production of TXA2. )

29
Acetylsalicylic acid
 For the lifetime of the platelet (7-10 days) thromboxane A2
is blocked and bleeding may be prolonged for several days
 This has led to the use of aspirin to reduce the risk of
death or nonfatal myocardial infarction in patients with
previous infarction

30
Methyl Salicylate
Salicylic Acid, methyl ester

 Used topically for muscle aches

 BenGay, Oil of Wintergreen

31
Salicylates Targeting the Colon
Mesalamine, Asacol, Pentasa, Rowasa
5-Aminosalicylic acid

 Used for the treatment of ulcerative colitis

 Works topically in the colon by inhibiting COX
 Tablets are coated with an acrylic resin or ethyl cellulose
that delays release of the drug until it reaches the ileum
32
Salicylates Targeting the Colon
Sulfasalazine, Azulfidine
Benzoic acid, 2-hydroxy-5-[[4-[(2-pyridinylamino)sulfonyl]-
phenyl]azo]-

 A prodrug used for ulcerative colitis and Crohn's Disease (a

form of inflammatory bowel disease)
 Two-thirds of the oral dose reaches the colon unchanged
where bacterial nitroreductase cleaves the azo-linkage forming
sulfapyridine and 5-aminosalicylic acid (the active drug)
 Sulfapyridine may cause nausea, vomiting and gastric
distress 33
Salicylates Targeting the Colon
Olsalazine Sodium, Dipentum
Disodium 5,5’-azodisalicylate

 Prodrug used for ulcerative colitis ( patients that cannot

tolerate sulfasalazine due to allergic reactions to sulfonamides)
 98-99% of the oral dose reaches the colon intact where it is
metabolized by bacterial nitroreductase into two molecules of
5-aminosalicylic acid
 It works topically in the bowel mucosa to diminish colonic
inflammation by inhibiting COX
34
ARYLACETIC ACIDS
Structure-Activity
 An -methyl group enhances activity
 With α-methyl analogs the (S)-enantiomer is the active form
and is more potent as a prostaglandin synthesis inhibitor
 The (R)-enantiomer may be inverted in vivo into the active (S)-
enantiomer in certain compounds and therefore many drugs in
this class are administered as racemates
 A second area of lipophilicity (X) that is non-coplanar with the
aromatic ring enhances activity and can be another aromatic
ring or an alkyl group
 As acids all of the drugs in this class are highly protein bound

35
ARYLACETIC ACIDS
Ibuprofen, Motrin, Advil
Benzeneacetic acid, -methyl-4-(2-methylpropyl)-, ()-

 Used for pain and to reduce fever

 Has fewer side effects than aspirin
 Metabolites are products of - and -1 oxidation on the
isobutyl group
36
ARYLACETIC ACIDS
Ibuprofen, Motrin, Advil

 A recent study indicates that concurrent use of ibuprofen and

aspirin may actually interfere with the cardioprotective effects

of aspirin, at least in patients with established cardiovascular
disease. This is because ibuprofen can reversibly bind to the
platelet COX-1 isozymes, thereby blocking aspirin’s ability to
inhibit TXA2 synthesis in platelets.

37
38
ARYLACETIC ACIDS
Ketoprofen
Benzeneacetic acid, 3-benzoyl--methyl-

 Used for fever and pain

 This compound inhibits both cyclooxygenase and lipoxygenase
 It also has antibradykinin activity (which helps with pain
management)
 Metabolized by reduction of ketone to alcohol and
glucuronide conjugation of the acid
39
ARYLACETIC ACIDS
Naproxen, Naprosyn, Anaprox; Naproxen Sodium,
Alleve
2-Naphthaleneacetic acid, 6-methoxy--methyl-, (S)-

 Used for pain, fever, arthritis.

 Highly protein bound and displaces most other protein bound
drugs
 It has a long half life (13 hr)
 Metabolized by O-demethylation and then glucuronide
formation 40
ARYLACETIC ACIDS
Indomethacin, Indocin
1H-Indole-3-acetic acid,
1-(4-chlorobenzoyl)-5-methoxy
-2-methyl-

 Use for fever, pain.

 Very potent analgesic
 Side effects (dose related) include gastric distress and peptic
ulcers
 Metabolites are derived from deacylation, O-dealkyation and
glucuronide formation at the carboxylic acid group
41
ARYLACETIC ACIDS
Ketorolac Tromethamine, Acular (opthalmic)
()-5-Benzoyl-2,3-dihydro-1H-pyrrolizine-1-carboxylic acid
2-amino-2-(hydroxymethyl)-1,3-propanediol salt (1:1)

 Used short-term (5 days or less) for the management of

moderately severe pain
 Given orally, by injection or intranasally
 This compound is a potent analgesic (equal to narcotic
analgesics for controlling post-operative pain) 42
ARYLACETIC ACIDS
Diclofenac Sodium, Voltaren
Benzeneacetic acid, 2-[(2,6-dichlorophenyl)amino]-, sodium salt

 Used for pain, migraine headaches.

 An opthalmic preparation is used for ocular inflammation and pain
 Metabolized by hydroxylation p-to the amino group in the non-
chlorinated ring
 Inhibits COX, lipoxygenase and inhibits arachidonic acid release
43
N-Arylanthranilic Acids
Mefenamic Acid, Ponstel
Benzoic acid, 2-[(2,3-dimethylphenyl)amino]-

 Used for mainly for pain

 Only moderate anti-inflammatory activity
 Metabolized by oxidation of m-methyl group to a primary
alcohol and then further to a carboxylic acid
44
Oxicams
Piroxicam, Feldene
2H-1,2-Benzothiazine-3-carboxamide, 4-hydroxy-2-methyl-N-
(2-pyridinyl)-, 1,1-dioxide

 Use for arthritis, both acute and long term

 Long lasting allowing daily dosing
 Better tolerated than aspirin
 Metabolized by amide hydrolysis and hydroxylation in the
pyridine ring (5-position)
45
Oxicams
Meloxicam, Mobic
4-Hydroxy-2-methyl-N-(5-methyl-2-thiazolyl)-2H-1,2-
benzothiazine-3-carboxamide 1,1-dioxide

 Used for arthritis

 Metabolized on the thiazole methyl group to a primary alcohol
and then further to the carboxylic acid
46
Miscellaneous Agents
Acetaminophen, Tylenol
Acetamide, N-(4-hydroxyphenyl)-

 Reduces fever and relieves pain

 Not an anti-inflammatory agent although it does weakly
inhibit COX 1 and 2 in peripheral tissues
 Produces very little GI irritation
 It does not inhibit platelet aggregation and does not affect uric
acid levels
47
Miscellaneous Agents
Acetaminophen, Tylenol
 Can be toxic with acute overdose giving rise to hepatic necrosis
and some nephrotoxicity
 It is fairly easy to over-dose on acetaminophen since it is a
component of many OTC cold preparations
 An iminoquinone metabolite is the toxic species
 This compound depletes glutathione, one of the body’s
defenses against xenobiotic electrophiles
 An antidote for acetaminophen overdose is N-acetylcysteine
sold as Mucomyst and Mucosol
 This compound substitutes for the
depleted glutathione
48
Miscellaneous Agents
Electrophile

Glutathione first
gets depleted

Thiols and amines are

nucleophiles

49
50
Gout
 Gout is a metabolic disease resulting from an over-
production of purines
 Attacks of gout can be acute or chronic
 The inability of certain individuals to recycle these
excess purines results in increased levels of uric acid
known as hyperuricemia
 Uric acid and its sodium salt, sodium urate, have poor
water solubility and can deposit as
crystals in the synovial tissue of the
joints

51
Gout

52
Gout
 The uric acid crystals induce leukocytes to migrate to
the joint and engulf the crystals by phagocytosis
 This process generates oxygen metabolites that cause
tissue damage and release lysosomal enzymes that
produce an inflammatory response
 This is known as acute gouty arthritis
 Drugs that treat gout fall into four categories:
 Inhibitors of uric acid synthesis
 Uricosuric Agents that increase the excretion of uric acid
 Inhibitors of leukocyte migration into joints
 NSAIDs

53
Gout
Chronic Gout
 This can be caused by a number of conditions including:
 A genetic defect such as one resulting in an increase in the
rate of purine synthesis
 Renal insufficiency
 Excessive synthesis of uric acid associated with certain forms
of cancer chemotherapy due to massive killing of cells
 Chronic gout is treated with:
 Uricosuric agents. These affect the active transport sites in the
kidney and decrease the reabsorption of uric acid in the
proximal tubule
 Inhibitors of uric acid synthesis

54
Gout
Acute Attacks of Gout
 These can result from a number of conditions
including:
 Excessive alcohol consumption
 Diet rich in purines
 Kidney disease
 An acute attack of gout is treated with:
 Drugs that decrease the movement of leukocytes into
the affected area
 NSAIDs such as indomethacin to decrease inflammation
and pain

55
Uricosuric Agents
Probenecid, Benemid
Benzoic acid, 4-[(dipropylamino)sulfonyl]-

 Probenecid enhances the excretion of uric acid by blocking its

reuptake from renal tubules for treating chronic gout
 Drink plenty of water to prevent the development of kidney
stones
 It also blocks the tubular excretion of penicillin and
cephalosporins and is sometimes used to increase and prolong
the plasma levels of these antibiotics
 It also inhibits the excretion of other acidic drugs such as
naproxen, ketoprofen and indomethacin
56
Xanthine Oxidase Inhibitors
Allopurinol, Purinol, Zyloprim
4H-Pyrazolo[3,4-d]pyrimidin-4-one, 1,5-dihydro-

 Allopurinol is a purine analog that is used to treat chronic gout

 It competetively inhibits xanthine oxidase resulting in a build-up
of xanthine and hypoxanthine
 These compounds are more water-soluble than uric acid and are
cleared by the kidney without depositing in the joints
 The major metabolite is alloxanthine which is also an inhibitor of
xanthine oxidase with a long half-life

57
Leukocyte Migration Inhibitor
Colchicine
Acetamide, N-(5,6,7,9-tetrahydro-1,2,3,10-tetramethoxy-
9-oxobenzo[a]heptalen-7-yl)-, (S)-

 Colchicine is a plant alkaloid

 In use since the 6th century for treating gout

58
Leukocyte Migration Inhibitor
Colchicine
 Colchicine binds to tubulin which causes depolymerization and
disappearance of the fibrillar microtubules in leukocytes

 This inhibits the migration of leukocytes into the inflammed

area and decreases their phagocytic activity

 Colchicine is often administered together with a uricosuric

agent for treating acute attacks of gout

 It gets recycled in the bile and is excreted largely unchanged

 Many side effects - diarrhea, bone marrow damage, anemia at high

59
doses and an overdose can be fatal