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Anti-inflammatory drugs : NSAIDs, COX-2 selective inhibitors, Glucocorticoids and anti-cytokine agents

H-Y YangNational Yang-Ming University

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Inflammation :

Soluble factor & cell interaction for damage

(erythema ) → → healing process → granuloma (lymphocyte aggregated ) , fibrosis (collagen bundles )

Persistent tissue damage →immunoresponse → sclerosis, arthritis, therosclerosis, oxidized DNA , tumor

Nonspecific acute or chronic response by :

1. Noxious radiation 2. toxic chemical

3. burn, wound ,trama

4. infections ( pyrogen, endotoxin )

5. autoimmune response (allergen )

Most prevalent disease in modern society → multibillion dollar market for pharmaceutical industry

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Multiple cells, mediators , symptoms are involved in inflammation

Cell types : nerve ( primary afferents, spinal, CNS ), cell-mediated immune system ( e.g. polymorphonuclear neutrophil in acute phase; monocyte, macrophage, mast cell & T lymphocyte in chronic phase) , endothelial cell

Receptors : NMDA, glutamate, sub. P, kinin, NO , Ca , autocoids, cytokines or modulators ( proteases, kinases, PLase- COX- Prostanoid, transcriptional factors, adhesion molecule )

Chronic Symptoms : 氣喘、腦膜炎、敗血症、紅斑性狼瘡、類風濕性關節炎以及糖尿病、血管粥狀硬化、青光眼、潰瘍性腸炎甚至可包括阿茲海默症、腫瘤等各式不同徵候 . 慢性發炎部位依序為皮膚 - 肺、腎、關節、腸肝、心、脾、眼

Pharmacological intervention : 1). Neutralizers of TNF, 2). Blockers of LT receptors, 3). Inhibitors of COX-2, LT synthetase, 3-OH-3-methylglutaryl CoA reductase, 4). Agonism at protease-activated receptor 1 by activated protein C

Telioderm ( the RGD ( arg-gly-asp) gel; the binding element of -3 subfamily of integrins): the first adhesion molecule-based product - a gel for promoting chronic dermal wound ( ulcer)-healing developed by Telios Pharmaceuticals ( San Diego, California ).

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Clinical signs in Acute Phase of inflammation

Signs : redness ( rubor ), calor ( heat ), dolor ( pain ), & tumor ( swelling ) by Celsus ( in AD40 )

皮膚 : formation of hives ( urticaria 蕁麻疹 ) or swelling ( angioedema )皮下 : neutrophils 聚集 ( neutrophil chemotactic factor (NCF), eosinophilotactic tetrapeptides, histamine, PAF, 及 leukotriene B4 等釋放 a mixed cellular infiltrate (eosinophils predominate) ganulomas, pannus or fibrosis

眼睛 : itching and tearing 鼻腔 : sneezing, increased secretions, and/or nasal congestion ( allergic rhinitis ) 肺部 : edema and broncho-constriction ( wheezing , asthma & chronic obstructive

pulmonary disease COPD) 腸胃道 : nausea, abdominal cramps, diarrhea or vomiting Helicobacter pylori-

dependent chronic gastritis with ulcer formation ( via PAR/MAPK kinase ) 全身性過敏發作反應 ( anaphylaxis ) : acute hypotension and loss of

consciousness 過敏反應 ( late phase reaction, 4-6 hr) : is dependent upon the prior IgE-mediated

reaction.

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Peripheral Sensitization

Cellular mediator :1. Vasoactive amine : 5-HT, His from

mast cell, basophil, platelet

2. NO from endothelial cell

3. Leukocyte adhesion molecule

4. Cytokines from marcophage & lymphocyte

5. Chemokines, protease & free radical from leukocyte

6. PGs & LTs from membrane PL

Plasma mediator : 1. Protease–activated bradykinin

2. Fibronogen & coagulation factor

3. Complement

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Acute Inflection

Bacterial toxin releases

Host defense system activated

Plasma protein systems Cellular defense systems

Complementcascade

Coagulation cascade

Kallikrein-kinin

Endothelial cell macophage

monocyte

lymphocyte

neutrophils

Proinflammatory mediators released

Cytokines Lipid Protease ROS Growth Adhesion NOmetabolite factors proteins

TNFIL-1

IL-6, -8

LTs, PGs

PAFElastase collagenase

G-CSF

TGF-Selectins

ICAMs

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Cellular events from acute to chronic inflammation

Chemtaxins : bacterial ( formyl-Met-Leu-Phe ), LPS ( Toll receptor ),peptidoglycan, lipoteichoic acid, C5a, PAF, LTB4, chemokines ( IL-8 )

PMN : the 1st WBC enter the area of inflammation

Leukocyte ( L-selectin )-endothelial interactions and PMN recruitment to local injury site

1. adehesion : adehesion : endothelial cell ( E-selectin, ICAM -1 ) + neutrophil ( sialyated Lewis X,

integrin )selectin ( L-, P-, )mediated WBC rolling is the

1st, & critical for skin inflammation 2. Invading : C3b ( opsonin ) link between neutrophil &

invadinng baceterial

Monocyte/ Macrophage: Days after the PMNPhagocytosis to granules and healing

1. chemotaxis : MCP-1, RANTES2. Phagocytosis : peroxidase, eicosanoids, cytokines and

reactive oxygen and nitrogen intermediates 3. immune response : release of cytokines ( IL-1, TNF )

Lymphocyte : chronic1. Auto-immune disease :

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Antiinflammatory drugs in clinical trial

Anti-TNF Ab :

infliximab ( Remicade ) : anti TNF- monoclonal Ab for early RA, psoriatic arthritis & ulcerative colitis

adalimumab : anti TNF- monoclonal Ab for RA CDP 571 ( Humicade ) : anti TNF- Ab for Crohn’s diseaseCDP 870 : anti TNF- Ab fragment for RA Afelimomab : anti-TNF Ab for sepsis

4 integrin antagonistCDP 323 for inflammatory diseaseNatralizumab ( Antegren ) :for multiple sclerosis

Anti-IL-b Ab :CDP 484 for RA

IL-10 : Recombinant hIL-10, Th2 cytokine for Crohn’s disease & RA

PDE4 inhibitor :Cilomilast ( Ariflo ) : for COPDRoflumilast for COPD & asthma

Corticosteroid Ciclesonide ( inhaled ) for asthma

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Prostanoids : tissue specific autocoids

Type IV cytosolic PLA2 ( cPLA2,especially sPLA2-IIa highly expressed during inflammation ) : the key player for eicosanoid production ,

Arachidonic acid ( 20:46) : the premier eicosanoid(20C fatty acid derivatives ) precursor in mammalian cells. Prostanoid receptors include DP, EP (1-4 ), FP, IP, TP COX (cyclooxygenase) =PGHS (Prostaglandin H synthase )

COX-1=PGHS-1, COX-2= PGHS-2 Endogenous antinflamatory mediators : COX-2-induced epi-lipoxins, glucocorticoid-regulated annexin 1 PGs are peroxide, short half life

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PGs類發炎所涉及之相關之各種細胞

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Prostaglandins Physiologic: temperature homeostasis, bronchial tone, cytoprotection

(gastric and renal mucosa), intestinal mobility, myometrial tone, semen viability (some prostaglandins like PGE1 have anti-inflammatory effects), renin secretion

Pathologic: fever (aberrant hypothalamic thermoregulation), asthma (airway responsiveness and immune hyperreactivity), ulcers (loss of cytoprotection), diarrhea (intestinal mobility), dysmenorrhea (myometrial tone), inflammation, bone erosion, pain (thought to be caused by PGD2)

INFLAMMATION1. PGI2: inhibits platelet aggregation, vasodilatation, vascular permeability

(edema) 2. PGE2: pain, hyperalgesia, heat, vasodilatation, bronchoconstriction,

synergistically act with other pro-inflammatory mediators (histamine, complement, LTB4)

3. TXA2: promotes platelet aggregation, vasoconstriction, bronchoconstriction

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Prostglandin E2 : The major target of traditional NSAID

PGE1 and PGE2 (but not PGF2) cause edema (vasodilation, ⇧ permeability) temporary ( few minutes ), but PGE2 or prostacyclin (PGI2) increase local blood flow (erythema )up to 10 hours

Unlike LTs, PGs are unlikely to be involved in chemotactic responses, even though they may promote the migration of leukocytes into an inflamed area by increasing blood flow.

NSAIDs do not direct affect either hyperalgesia or pain caused by PG, the analgesic effects are due to inhibition of PG synthesis and indirect alter the pain sensitization.

Feedback controlling system for autocoids ( e.g. PGE2↑inhibit COX2 & 5-lipooxygenase, shift to lipoxin formation )

Shift to another pathway ? (adverse effect or therapeutic effect )

Without affect the host defense

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Pathogenesis involved Eicosanoids

• Hyperalgesia sensitization is involved in EP2, 4, IP receptor-coupled adenylate cyclase induced cAMP-dependent PKA.

Transgenic mice with null mutation in the type 1 regulatory subunit of PKA exhibit diminished nociceptive inflammatory response. [ref ] Malmberg AB, et al. J Neurosci. 17: 7462-70, 1997

• Neuropathic Pain is involved in PKC activation

Transgenic mice lacking the isoform of PKC display reduced inflammatory nociceptive responses and fail to develop a neuropathic pain syndromes., but exhibit normal response to acute pain stimuli. [ref] Malmberg AB, Chen C, Tonegawa S & Basbaum AI. Science 278: 279-283, 1997

• Febrile response is involved in EP3

EP3(- / -) mice did not show the febrile response to PGE2, LPS ( exogenous pyrogen ), & IL-1 ( endogenous pyrogen ) [ref ] USHIKUBI F,etc. Nature 395: 281-284, 1998

• Ovulation , fertilization & salt-sensitive hypertension involved in EP2 receptor

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Aspirin 之發現 1763 年 : 英國 Reverend Edward Stone 發現柳葉

可用於瘧疾引起之發燒

1829 : Leroux 從白柳皮分離 salicin (glycoside ), 並證實具有解熱作用

1853 年 : 德國 Gergardt 合成 acetylsalicylic acid ( Aspirin )

1875 年 : Felix Hoffmann 首度用 Na salicylate 於治療父親風濕熱 , 隨後也被用於治療痛風

1899 年 : Frederich Bayer 之藥理主任 Heinrich Dreser 命名為 Aspirin, 才開用於醫療用途

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Aspirin (acetylsalicylic acid ) one of the most popular drugs in the world since1905. Each year 50,000m tablets are taken worldwide. Now the most popular uses are for preventing heart disease ( 37.6 %), arthritis (23.3 %), headache (13.8 %), body ache (12.2 %) and other pains (14.1 %).

- covalently and irreversibly acetylating Ser-530 in the active site of Cox-1 & Cox-2 - In platelets, only Cox-1 is available, TXA2 synthesis is inhibited for 8 to 10 days

and "half an aspirin a day (50-75 mg )" prophylaxis against thromboembolic disease.

                                     

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Aspirin: decrease formation of COX-1–related PGs, TXA2, but not PGI2 or LTs

Aspirin (< 3g per day), acetaminophen and phenacetin ( analgesic & antipyretic) have little anti-inflammatory action,

藉由 epi-lipoxin 可抑制白血球之聚集至血管內皮細胞 (PMN 中性球之化學趨性 ) 防患大腸癌 ( 離體於高劑量時活化 NF-B 引起癌細胞凋亡 ), like sulindac, celecoxib 於治療劑量下吸收部位在胃，但吸收能力 ileum > stomach( 因蓄積於肝腸循環中之血小板 ) 但 其代謝物 Salicylate 本身 lack antiplatelet action ( 因缺乏 acetylation 的功能 ) Tinnitus : the early sign for acute intoxication in adult Worsening of asthma, GI ulcer; contraindicated for gout , prolong labour , teratogenic (oral

cleft ): 懷孕婦女禁用 Serious hazardous with warfarin ( 抗凝劑 ) Reye’s symdrome ( live disorder & encephalopathy ) in children druing viral infection ( 現今

以 acetaminophen 為首選 ) Alter acid-base & electrolyte balance : Intoxication

In adult : Resp.stimulation → Hyperventilation → compensated Resp. alkalosis

In child : metabolic acidosis Chronic intoxication : Salicylism ( nausea, vomiting, diarrhea, and dehydration,

hyperventilation, headache, tinnitus, visual and auditory disturbances, confusion, stupor, and delirium).

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Major indication of NSAID as analgesics for moderate pain of musculoskeletal and inflammatory origin

(headaches, dysmenorrhea (75-85% effective), osteoarthritis, rheumatoid arthritis, gout, bone cancer pain, surgical pain, tendonitis, and bursitis).

NSAIDs also function as anti-inflammatory agents in many of these conditions and ulcerative colitis.

Aspirin anti-platelet effects are used for MI and stroke prophylaxis. Acetaminophen (technically not an NSAID) has no anti-inflammatory activity but is

widely used as an analgesic and anti-pyretic. inhibition of cell cycle progression, apoptosis and angiogenesis ( COX-independent

mechanism)

FDA approved NSAID : Aspirin ( OTC, 0.25 ), Choline salicylate, Mg salicylate, Na salicylate ( 2-15, dose-dependent ), Diflunisal ( 13 ), Acetaminophen ( Tylenol ), Diclofenac ( Voltaren , 1.1 ), Meclofenamate ( Meclomen ), Mefenamic acid ( Ponstel, Ponstan ), Ibuprofen ( Advil ,2.1), Fenoprofen ( 2.5 ), Ketoprofen ( Profenid, OTC, 1.8 ), Etodolac ( 3.0 & 6.5 , 2 phase ), Ketorolac ( Toradol , OTC, 5.0 ), Naproxen ( Seladin, OTC, 14 ), Piroxicam ( Feldene; 5722 ), Tenoxicam ( Tilcotil, Mobiflex, 6011 )

New Approved : Flurbiprofen, Indomethacin ( 4.6 ), Ibuprofen (OTC, 2.1 ), Oxaprozin ( 5810 ), Sulindac ( 14 8 ), Tolmetin ( 1.0, 6.8 , 2 phase ), Nabumetone ( 265 ), Meloxicam ( Mobic ), , Nimesulide ( Aulin,Mesulin ), Celecoxib

( Celebrex , 11), Rofecoxib ( Vioxx, 17 )** ( ) : the plasma half life

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Traditional NSAID

Acetaminophen( Tylenol ) since 1893, major active metabolite of both acetanilide and phenacetin Mechanism of action : very weak COX inhibitor, without gastric complaints, not interfere platelet function analgesic-antipyretic, with weak antinflammatory effects N-acetyl-p-benzoquinone ( active toxic metabolite of acetaminophen ) cause necrosis in liver & renal tubules acetylcysteine (

glutathione ), methionine ( conjugation ) within 12h

Indomethacine Mechanism of action : very potent , inhibits cyclooxygenase (IC50= 0.1 M) selectively over lipooxygenase ( IC50 > 100 M) It also uncouples oxidative phosphorylation, depress the biosynthesis of mucopolysaccharide inhibit phosphodiesterase, inhibit the motility of PMN leukocyte high incidence of GI , and CNS ( confusion & psychomotor impairment) adverse effect ( dose-related )

Sulindac : as a prodrug, with strong oxygen-radical-scavenging effcts Mechanism of action : like indomethacine, 1/2 potent, active metabolite sulfide, T1/2 = 18 hr for active metabolite not affect renal PGI2 synthesis

Etodolac : like indomethacin, less GI disturbance, but liver SGOT may affect

Ketorolac the only injectable NSAID available for analgesic use in the USA. analgesic efticacy comparable to moderate doses of morphine or meperidine, with a somewhat slower onset but a longer duration

of action. Even with parenteral administration, gastrointestinal bleeding can occur.

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Adverse Effects of NSAIDs GI : gastritis, gastric bleeding( 3.6-4.1%, dose-dependent ), mucosal and subepithelial

damage, and erosions, which may progress to ulcerations and perforations.

The most frequent problems are GI dyspepsia ( 消化不良 ). Peptic ulceration and its complication are less common

Prevent with 1). Hist 2 Antagonists (high doses of ranitidine), 2). Proton Pump Inhibitors (omeprazole), 3). Misoprostol (PGE1 analog which restores cytoprotective effects) , 4).

Sucralfate, 5). COX-2 Specific NSAIDs Renal : GFR, & tubular elctrolyte transport (Na retention) impairmant , interstitial nephritis, papillary

necrosis, CRF and hyperkalemia ( Reversible ) CNS : tinnitus (aspirin), dizziness, vertigo ( indomethacin ) Skin reaction :

Anaphyactic Rx in sensitive ( allergic rhinitis, nasal polyposis, asthma) pts : shunt of AA into LTs pathways when COX is inhibits

Hematologic:Decreased platelet aggregation ( COX-1, TXA2-induced ) possibly leading to bleeding, oozing gums, petechiae, anemia, marrow suppression, Coomb’s positive anemia

Hepatotoxicity : diclofenac, flubiprofen (transaminase ⇧ ), sulindac ( cholestasis ),aspirin (Reye’s Syndrome in children –induced microvesicular steatosis and hepatic encephalopathy)

hypersensitivity: piroxicam, benoxaprofen (skin rash & photosensitivity), Asthma, asthma/urticaria syndrome, urticaria, rashes, photosensitivity, Stevens-Johnson syndrome

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被禁用之 NSAIDs

1. Aminopyrine : Carcinogenic ( Rx with nitrite produces dimethylnitrosamine )

2. Sulpyrine : Agranulocytosis, Blood dyscrasia

3. Phenacetin : Nephrotoxicity, Carcinogenic

4. Phenylbutazone : Blood dyscrasia ( aplastic anemia, agranulocytosis, leucopenia )

5. Ketophenylbutazone : Nephrotoxicity, hepatotoxicity, GI ulcer, edema

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Anti-thrombosis drugs

Antiplatelet agents Anticoagulant agents

1st generation

Aspirin

Thienopyridine(ticlopidine & clopidogrel)

Heparin

Warfarin

2nd generation

GPIIb/IIIa antagonists

Aspirin + clopidogrel

Low-MW heparins

Hirudin

Novel approach

Inhibitors of vWf-GP1b interaction

Inhibitors of collagen-platelet interaction

Inhibitors of thrombin-induced activation

Direct ADP receptor antagonists

NO-releasing antiplatelet substances

Inhibitors of tissue factor(VIIa)

Selective factor Xa inhibitors

Selective thrombin inhibitors

Human activated ptotein C

Soluble recombinant thrombomodulin

vWf-GP1b= von Willebrand factor-glycoproten

[Ref] TiPS 23: 25-32, ‘02

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The Nobel Prize in Physiology or Medicine 1982 : "for their discoveries concerning prostaglandins and related biologically active substances"

Bengt I. Samuelsson Sune K. Bergstrom John R. VaneKaarolinska Inst,Stockholm,Sweden The Wellcome Res. Lab., Beckenham, UKBiochemical studies Structure identification Physiological effects

• Drs. Sune Bergstrom ( discovered at Karolinska Institute in Stockholm ) & Bengt Samuelsson ( student ) in 1964 purified & characterized the active

compound from arachidonic acid• Sir John Vane in 1971, use smooth muscle strip bioassay , and found NSAID could

block the synthesis of PGs. He also discover the major endothelial PG, prostacyclin in 1983.

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NSAIDs

1. anti-inflammatory action: the decrease in vasodilator prostaglandins (PGE2, PGI2) means less vasodilation and, indirectly, less edema. Accumulation of inflammatory cells is not reduced. Transgenic mice with null mutation in the type 1 regulatory subunit of PKA exhibit diminished nociceptive inflammatory response.

2. analgesic effect: decreased PG generation means less sensitization of nociceptic nerve endings to the inflammatory mediators bradykinin and 5-HT. Hyperalgesia sensitization is involved in EP-2, -4, IP receptor-coupled adenylate cyclase induced cAMP-dependent PKA Relief of headache is probably due to decreased mediated vasodilatation.

3. antipyretic effect: decrease PGE2 on EP3 receptor ( which is generated in response to the inflammatory pyrogen ( IL-1, IL-6, interferons, TNF- ) that is responsible for elevating the hypothalmic set-point for temperature control in fever. EP3(- / -) mice did not show the febrile response to PGE2, LPS ( exogenous pyrogen ), & IL-1 ( endogenous pyrogen )

4. Other ( Non-PG-mediated ) effects : Inhibit phagocyte recruitment & neutrophile activation & chemotaxis Scavenge superoxide radicals Inhibit NFκB-dependent transcription inhibit the expression of adhesion molecules, decrease NO synthase, decrease

proinflammatory cytokines (e.g., TNF-, IL-1), modify lymphocyte activity, and alter cellular membrane functions.

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COX2 structure & function

COX-l 與 .COX-2 於胺基酸序列上有 64% 相似，兩者在細胞膜上所形成的立體結構僅有少許之差異。 Position 523 is an isoleucine in COX-1, & valium in COX-2

但需牢記的是不同之細胞具有其特定之致炎物質；雖然 COX-2-selective 可避免傳統NSAIDs 所引起胃腸道與腎臟之副作用。但證據亦顯示缺乏 COX-2 之小鼠其腎元數目不足 ( COX-2 亦是 house-keeping gene in kidney & vas deferens )

COX-2 gene polymorphorism

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1. Background : Existence of two isozymes of COX was shown in 1991 by Xie et al. ( PNAS, 88, 2692-2692).

2. Structure : 64% similarityCox-1 : 599 aa., Cox-2 : 604 aa., N terminal : epidermal growth factor domain, a membrane-binding motif

C terminal catalytic domain : COX & peroxidase active site Common Substrate binding site : Arg-120, Tyr-355, Glu-524

Catalytic site : Tyr –385Pocket : COX-2 specific Val-523, Arg-513, Val-434

Cox-I specific : ILe-523, His-513, Ile-434 3. Physiological role :

Cox-2 expression is inducible by LPS & inflammatory cytokines ( e.g. IL-1, IL-2, TNF- ) Cox-2 expression is repressed by anti-inflammatory cytokines ( e.g. IL-4, IL-10, IL-13 ),

glucocorticoidsThe PGs that mediate inflammation, fever and pain are produced mainly via Cox-2 The PGs that are important in GI and renal function are produced mainly via Cox-1.

Parameter COX-1 COX-2 Regulation Usually Constitutive inducible MW 599 aa, 73 k 604 aa, 74 kCell distribution stomach, kidney, platelet marcophage, monocyte, synovialFunction homeostasis inflammatory response ( ? ) Gene location chromosome 9 chromosome 1Range of Induced Gene Expression 2 to 4-fold 10 to 80-fold Rate of Gene Activation 24 hours .5 to 4 hours Effect of Glucocorticosteroids Little or None Inhibits Expression Effect of aspirin on COX activity Inhibited not Affected  

 

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COX-2 gene as a primary response gene for

1.   cytokines ( IL-1, TNF-, IL-6, bacterial endotoxin & PMA ) :2. growth factors ( EGF, PDGF, chorionic gonadotrophin )3. autocoids ( 5-HT, endothelin )4. Fatty acid- related mediators ( AA, TX A2, Platelet activating factor 5. Mechanical forces ( pulsatile flow, cyclic stretch)6. Others ( PTH )

Cox-2 gene also contains the ( TATA box ) regulatory site for

1. cAMP response element 2. IL-6 response element3. CCAAT/ enhancer binding protein4. AP-2, NF-B, Sp-1, PEA-3, GATA-1 & glucocorticoid response element

後繼 : Donald Young, Kerry O’Banion & Virginia Winn in U. Rochester ( Patent of COX-2 gene ‘92 ) suit Pfizer & Pharmacia which

jointly market Celebrex 判決 : 專利未指名如何發現 COX-2 inhibitor, 更未曾發明任何特定化合物既無具體要來實踐發明 其止痛方法只屬空談

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COX-2 selective inhibitorsProc. Nat. Acad. Sci. 96: 7563-68, ’99JPET 300:367-75, ‘02

Aspirin : irreversibly inactivators of COX-1 & -2 Mefenamide : reversible competitive inhibitor indomethacin : slow, time-dependent reversible

inhibitor Celocoxib (Dec. ’98), Rofecoxib (May ’99): slow,

time-dependent, irreversible inhibitors of COX2防患大腸癌 ( 活化 NF-B only in colon cancer cell引起凋亡 apoptosis ) Top-one 1.5b in ’99 : celebrex

Rofecoxib ( Vioxx® ) 2nd generation : Novel COX-2 specific

inhibitor : Valdecoxib ( Bextra® from Pfizer) approved on Nov, ‘01 Parecoxib ( Dynastat ): im., iv.Etoricoxib ( MK 0663 , Arcoxia®)Lumiracoxib ( Prexige ): Most selective, not available in US

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The European Agency for the Evaluation of Medicinal Products (EMEA) currently allows the marketing of celecoxib, etoricoxib and the injectable parecoxib.

Lumiracoxib (Prexige) is approved in the UK only, but is not currently marketed.

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• COX-2對中樞或週邊之發炎性疼痛均有效 ， but the analgesic efficacy is not superior than traditional.

NSAIDs & glucocoticoids 此類抗炎藥並不能防止 the progressive destruction of the RA, e.g. joint destruction or future disability .

• nerve injury may not be sensitive to COX-2 inhibitors• 對神經傷害引發的劇痛 may not be sensitive to COX-2 inhibitors• 對腎功能異常的患者 , should be used cautiously .

1. 因所有 NSAIDs can inhibit PGs production in the nephron, thereby decreasing glomerular filtration

2. COX-2 knockout mice the development of renal cortex & glomerulogenesis are impaired ( Kidney Int. 57: 414-22, ’00 ).

• COX-2 specific inhibitor 最主要的賣點是減少腸胃的不適• 因抑制上皮細胞之 COX-1, 會壓抑黏膜保護之 PGI2 與 PGE2 ，故傷口不易癒

合• 大型臨床試驗 CLASS 之結果發現，長期服用選擇性 COX-2 抑制劑對血小板

之附著與凝集無影響，但卻會 a).降低內皮細胞 PGI2 合成高達 50%; 由於 b). 對血小板 COX-1 相關之 TX 合成不影響； 因而趨好產生 TX , 而較易發生凝血 prothrombotic ，加上 c ). 對腎正常細胞發育與功能亦受影響。

• 對有冠狀動脈繞道或支架之高危險群相較比傳統之 NSAIDs更有心肌梗塞或中風之危險性； 即使使用時亦須更謹慎

COX-2 抑制劑 ( Celocoxib )使用須知

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Rofecoxib (Vioxx®偉克適 ) withdrawal ?

COX II 選擇性抑制劑 , May, ’99 ( Feb, ’01 in Taiwan )核可上市 ,核准之適應症為「骨關節炎之短期及長期症狀治療、緩解疼痛、治療原發性經痛、緩解類風濕性關節炎之病徵及症狀」。

APPROVe 之長期臨床試驗發現具有預防老年失智與抑制直腸瘜肉（直腸癌前兆）。估計全球有兩百萬人服用偉克適，‘ 03 年為默克創造的營收達 25億美元，占默克總營收的 11% 。

‘02 之黑框警語 : dose-related swelling, BP increase & hyperkalemia, NOT indicated for chronic pain conditions.

心肌梗塞”之危險 ( 自 8000 RA 患者 9個月之VIGOR trial 臨床試驗中發現 50mg/d 甚至比傳統之naproxen ( 500 mg, bid) 高出 2X ←PGI2( antithrombotic )↓

自 Sep. 30,’04 ( Oct. 15 in Taiwan) 默克藥廠宣佈自願全球回收 ): 股價由 $45 跌至 $30

CV side-effect profile including dose-related edema, BP increase & hyperkalemia in most recent APPROVe trial ( Adenomatous Polyp Prevention in 2600 pts, after 18M, 2x the risk of MI ).

美國目前有 >4200件和偉克適醫療糾紛有關的案件待審。美國 FDA估計，偉克適 6 年前獲准上市後，造成近 28000 起心臟病發作或死亡病例。

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Valdecoxib ( Bextra® from Pfizer) approved on

Nov, ’01, withdrawal on Apr.’05

Indication: analgesic for osteoarthritis ,adult RA and for the treatment of primary dysmenorrhea

Warning :General: 皮膚過敏 (Hypersensitivity reactions ,including anaphylactic reactions and angioedema)Skin and appendages: Erythema multiforme, exfoliative dermatitis, Stevens-Johnson syndrome, toxicepidermal necrolysisWithdrawal due to : higher-than-normal CV risk and potentially life-threatening skin reactions.

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Clinical trail : Two Clinical Trials of Coxibs : • The Vioxx Gastroinyestinal Outcomes Research (VIGOR) Trial 50mg rofecoxib qd vs 500mg naproxen 8076 RA for a

median of 9 months 1. GI perforation, hemorrhage or symptomatic peptic ulcer: 2.1 vs 4.5

per 100 p’t yr2. Nonfatal MI, stroke and CV death: 0.8% vs 0.4% (p<0.05); M.I.:0.4%

vs 0.1%. (exclude 4% p’t taking aspirin)• The Celecoxib Long-Term Arthritis Safety Study (CLASS) Trial: 400mg Celecoxib bid vs diclofenac 75mg bid or ibuprofen

800mg tid OA for 13 months 1. Celecoxib vs ibuprofen or diclofenac: GI complications : 0.8% vs

1.5% (p=0.09); withdraw rate: 14.8% vs 12.6%. 2. Nondifference of major CV events (21% of patient taking aspirin)

35

COX2I risk due to PGI2–TXA2 inbalance should not be used in pts with

1. established ischaemic heart disease

2. cerebrovascular disease,

3. peripheral arterial disease should be used cautiously in

pts with risk factors for heart disease, e.g. 1. hypertension,

2. hyperlipidaemia

3. diabetes.

36

Glucocorticoids: antiinflammatory + immunosuppressive

可不經由 DNA 之交互作用而影響某些蛋白質之合成，進而改變發炎之反應；但其主要機轉仍是藉由改變基因之轉錄

Disease-modifying potential Increase transcription : lipocortin-I, 2-adrenoceptor, secretory leukocyte inhibitory protein, IB-( inhibitor of nuclear factor-B, anti-inflammatory or inhibit cytokines ( IL-10, IL-12, IL-1 receptor antagonist ) Decrease transcription : inflammatory cytokines [ IL-2,3,4,5,6,8,11,13, tumor necrosis factor-(TNF-), granulocyte-macrophage colony-stimulating factor(GM-CSF), stem cell factor (SCF)], Chemokines [ RANTES( released by activated normal T cells expressed and secreted ) ,MIP-1 ( macrophage inflammatory protein ), eotaxin ], inducible nitric oxide synthesis ( iNOS ), inducible cyclooxygenase(COX-2, Not COX-1 ), inducible cytoplasmic phospholipase A2 ( cPLA2 ), endothelin-1, NK1-receptor, adhesion molecules [ICAM-1 ( intercellular adhesion molecule), VCAM-1 ( vascular cell adhesion molecule) Direct repression of transcription factor : IP-1 ( activator protein-1), nuclear factor Kappa B ( NF-B )

Inhibitory effects ( including transcription, expression, synthesis, and activation ) on cytokine ( IL-1,IL-2, TNF )- mediated inflammation.

Chronic effects : downregulation of steroid receptors in circulating monocytes and lymphocytes

Adverse effects : adrenal suppression, growth retardation, abnormal fat accumulation (weight gain ), cataracts, hematologic changes, and hypertension; osteoporosis ( 成骨細胞 osteoblast 活性減弱 , 破骨細胞osteoclast 活性加強 , due to interfere 1 ). Ca & phosphate absorption & metabolism ( ** 故需補充鈣 1.5 g ¸vit D 400-800 IU/ D ) , 2). Collagen synthesis and degradation , and 3). Vit D3

定量吸入式 nebulized 類固醇至今仍是治療中度氣喘之第一線用藥 , 如Beclomethasone dipropionate, Triamcinolone, Flunisolide , Budesonide, Fluticasone propionate

37

Gout ( monosodium-urate ppt, ~50% normal [uric

acid] )

Coating with IgGchemotatic, lysosomal, IL-1,-6,-18, PGE2, LTB4, oxygen radical, collagense, caspase

Rx: acute : NSAIDs > steroids > colchicine (p.o.) ,steroidsFDA approved drugs: indomethacin, naproxen, sulindac, colchicine, allopurinol,

sulfinpyrazone.

adjunctive : losartan (24%↑), fenofibrate ( Urate 19%,excretion 36% )

Chronic : colchicine, probenecid, allopurinol for > 2-3 attacks/year initiate prophyllaxis

Colchicine : binds tubules, inhibits cell migration, adherence & degranulation. Inhibits IL-1.- 8, ICAM, E-selectin, L-Selectin. Also decreases insulin, thyroid, TSH,

amylase, catecholamine synthesis, lysosomal hydrolase release, fibroblast proliferation

Cautions: Probenecid: uricosuric, promotes excretion; Don’t use w/ CRI, nephrolithiasis, Tophaceous gout

Colchicine: (diarrhea) decr. PMN motility, activity Allopurinol: decrease formation- use w/ CRF, renal stones, tophaceous gout,

Uric acid > 11

Psudogout : deposition of calcium pyrophosphate dihydrate (Ca2P2O7 2H‧ 2O) crystal

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Cytokines secreted by LPS-activated macrophages Proinflammatory IL : II-1, 6, 8; Anti-inflammatory IL : IL-4, 10, 11

Local effects

IL-1 : Activates vascular endothelium, activates lymphocytes, Local tissue destruction, increases access of effector cells . A). a dominant cytokine associated with the destructive changes characteristic of RA, cartilage degradation by its induction of the rapid loss of proteoglycans, as well as stimulation of bone resorption 2 ). stimulate the production of PGE2, COX-2, & other cytokines that lead to inflammation.

IL-8 : Chemotactic factor for leukocytes , increases access of effector cells , activates binding by adhesion molecules

TNF-: Activates vascular endothelium (entry of leukocytes) and increases vascular permeability (entry of IgG, complement fluid drainage to lymph nodes)

IL-6 : Lymphocyte activation , Differentiation of Th0 cells to Th2 cells , increased antibody production

IL-10 : inflammatory bowel disease develops spontaneously in IL-10-knockout mice

IL-12 : Activates NK cells , differentiation of Th0 cells to Th1 cells

Systemic effects

IL-1 : Fever , Production of IL-6

TNF-: Fever , Mobilization of metabolites , Shock

IL-6 : Fever, Induces acute phase protein production

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anti-inflammatory cytokines : IL-10, TGF-, TNF-binding protein, IL-1Ranti-inflammatory hormones : glucocorticoids, -MSHantiinflammatory autocoids : Spermine, PGE2, Fetuin, heat-shock protein, acute phase proteins

40

Interleukin

interleukin family : IL-2R , c, and gp130.

Receptor activation initiates intracellular phosphorylation cascades that are mediated by kinases ( p38 MAPK, c-Jun N-terminal kinase, and JAKs)

41

Asthma : an Chronic inflammation

42

43

Leukotrienes : Potent and sustained bronchoconstriction, Mucus hypersecretion, Edema formation

& Eosinophil chemoattraction

Leukotriene-Modifying Drugs for1. Aspirin-sensitive asthma 2. Mild-to-moderate asthma in persons fearful or

intolerant of inhaled steroids 3. Patients with severe asthma on high-dose inhaled

steroids

4. Steroid-dependent asthma

Cys-Leukotriene receptor blockers : effectiveness in exercise-induced asthma

and aspirin-intolerant asthma - Pranlukast : 1st CysLT1 R antagonist (’95 )

- Zafirlukast (Accolate®) - Montelukast (Singulair®): for prophylaxis

and chronic treatment

5-Lipoxygenase inhibitor- Zileuton (Zyflo®)

44

CysLTs in asthma & its blocker

45

CysLTs (LTC4, LTD4, and LTE4 )

5-lipooxygenase products, act on CysLT1 receptor on airway smooth muscle & mucus cells.

Activation of the CysLT1 receptor results in smooth muscle constriction; LTC4 and LTD4 are equally potent bronchoconstrictors while LTE4 is only 10% as potent as LTC4

Cysteinyl LTs elicit many features of asthma, including contraction of airway smooth muscle, enhanced airway hyperreactivity, increased vascular permeability (leading to airway edema), mucus secretion, and recruitment of neutrophils in the airways

LTB4, acting on specific receptors, causes adherence, chemotaxis and activation of polymorphs and monocytes, and stimulates proliferation and cytokine production from macrophages and lympocytes

Zafirlukast and montelukast are selective and specific antagonists of the CysLT1 receptor 1. Zafirlukast antagonizes the activity of LTC4, LTD4 and LTE4.

2. Montelukast inhibits the activity of LTD4 in receptor-binding studies

Zileuton is a 5-LO inhibitor ,may cause hepatic toxicity and periodic monitoring of liver function tests is necessary

As 2nd-line adjunctive therapies , It appears that only 30-50% of patients will respond to therapy.

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Asthma : pharmacotherapy in advance

Asthma as Allergic Type-1 Immunologic Reaction Expressed in the Airways Potential Therapeutic Implications:- Anti-IgE Monoclonal Antibody- Interleukin 4 soluble receptor- Adhesion molecule antagonists- Interruption of TH-2 co-stimulation pathways

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Rheumatoid arthritis a symmetric polyarticular arthritis that primarily affects the small

diarthrodial joints of the hand and feet. Most common Inflammatory arthritis in the synovium pannus destroys

local articular structure major cause of disability ，主要由 T 細胞所引發的自體免疫疾病 , 故可在 synovium 發現 fibroblast, macrophage, T 細胞及細胞因子如 IL-1 , TNF- 會增高 .

B 細胞的活化所引發的體液 ( humoral) 免疫反應亦相當明顯 ,大部分產生的為非特異性 IgGs 抗體或屬 polyclone. autoAbs & T cell ( CD4+ ) infiltrate mediated “ rheumatoid factor “ & 第二類 major histocompatibility complex ( MHC ) in 3rd hypervariable ( or susceptibility epitope ) region of DR chain in 70-74 aa- QKRAA or QRRAA- in human leukocyte antigen ) Ag presentation ( 80 % ) & independent immune complexes release chemotactic factor( e.g.C5a ) local destruction .

COX inhibitor 可抑制其熱原，但其功能主要是經由 COX非相關的途徑達成。

PG 會抑制 TH 與 B 細胞的免疫反應與 IL-1 的生成； salicylate 會直接 抑制中性球之 integrin 引發之下游 Erk 活化

In synovial fluid : Low in T-cell cytokine ( IL-2, IFN- ); however, local macrophage-like & fibroblast-like synoviocytes –induced cytokines ( IL-1, 6, 10,18, TNF- , GM-CSF) are predominant ( cytokine network hyposis ) accumulate of memoryTH1 cell ( IL-17 expressed ), expression the chemokine receptor CCR5 , CXCR3 and the integrin adhesion molecule 41 delayed-type hypersensitivity fibroblast activation, bone destruction

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Mechanism of action of drugs used to treat RA

49

關節損毀之最終共同路徑

pro-inflammatory cytokines and tissue-destructive enzymes (matrix metalloproteinases) produced by T cells( CD4+), macrophages, type B synoviocytes(BlyS) and bone-destructive osteoclasts.

Macrophages interacting with activated T cells secretepro-inflammatory cytokines such as TNF and IL-1.

Osteoclast activation is mediated via cell membrane RANK (receptor activator of nuclear factor-B) binding to RANK ligand (RANKL) on synovial fibroblasts and T cells, and IL-17 production by the latter cell type.

Pro-inflammatory cytokines include TNF , IL-1 , IL-6, IL-15 and IL-17.

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DMARDS 主流藥物之開發 for RA

重點是此類 DMARDs愈早服藥 ( < 3M ) ，以控制病情惡化 ; 其 1-5 年後續成效較佳 .因診斷後 1-2 年會不可逆的損傷 . 其中第一線以 methotrexate 、 sulfasalazine ( 孕婦可用 ) 、 hydroxyquinone 、 leflunomide最常用， 而類固醇類仍以短期急性期使用為佳。

Methotrexate : 肝代謝之 polyglutamated 為活性代謝物 , 可抑制 aminoimidazole carboxyamide ribonucleotide transferase 及 thymidine synthetase, 必需與 folic acid共服

中度致嚴重者 : TNF antagonists ( Etanercept , Infliximab, Abatacept)+ methotrexate, Rituximab + methotrexate,

具有延緩惡化之藥物 : Anakinra, Leflunomide,

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近五年來對 RA 這典型自體免疫疾病之病程發生 ( pathogenssis ) 有更深入的了解﹐這也譽為是生物醫學進展光環中最閃亮之珠寶 . 治療之規劃是針對作用標地與自體免疫破壞之源頭 B 與T 細胞之訊息傳訊 ( TNF, ILs 等 cytokine ) 為主；儘早使用 DMARDs 是控制病情 ( 非治愈 ), 延緩惡化的關鍵

現今除有 COX-2 選擇性抑制之 NSAID 如 meloxicam 、 Celecoxib 、 Rofecoxib 外； 傳統之Immunosuppressant, DMARDs 類外亦有 leflunomide 及所謂 biological response modifier 如 infliximab and etanercept 之上市回提供更佳之治療選擇。 RA 治療守則 (2002 版 ) 已將DMARDs 列入初期治療之必要藥物 ( Arthritis & Rheumatism 46: 328-46, ’02 ).

In 2002, eight new drugs for osteoarthritis were undergoing clinical trials. (PhRMA 2002) In addition, clinical trials for 22 new medications for rheumatoid arthritis, including a vaccine to prevent the autoimmune processthat causes the disease, were in progress in 2002. (PhRMA 2002)

對類風濕性關節炎之免疫調節藥物是未來治療之重點 ; 如 (1). TNF- 阻斷劑 ( TNF- 單株抗體、 soluble TNF- 接受器 ) 如 infliximab, etanercept 、 IL-1 接受器拮抗劑 ( 人類 IL-1 接受器重組型之拮抗劑 如 Anakinra ) 、 IL- 6 、 IL-2 單株抗體、 Interferon-, lL-10, imunoconjuated to IL-2 receptor; (2). B cell surface Ag : CD22, ( 3). T-cell modulation: CD-4, -5 ， -7, -w52 單株抗體、 IL-2 單株抗體、 IL-2 + diphtheriatoxin ; ( 4). T cell surface Ag for activation : CD80, CD 86 ; (5) . Vaccination: T-cell ,T-cell receptor peptide 、 HLA peptides 等 ; 但均須注意嚴重感染之不良反應

[ Refences ] Arthritis & Rheumatism 40: 595-97, ’97 Molecule Medicine Today 4: 277, ’98 N Engl J Med. 340: 253-59, ’99 Rheumatology 39: 689-92, ’00 TiPS. 25: 201-209, ‘04

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1. Disease modifying anti-rheumatic drugs ( DMARDs ) , ’85 年後才加入a. D-Penicillamine : inconvenient dosing b. Hydroxychloroquine : visual macular damage

c. Sulfasalazine e. Gold : after 22W inj , maintenance initiated

2. Immunosuppressants ( also considered DMARDs ) a. Cyclosporine A: nephrotoxicity b. Methotrexate+ folic acid: dihydrofolate reductase inhibitor

c. Azathioprine: rarely use d. Leflunomide: dihydroorotate Dhase inhibitor

3. Biologic Response Modifiers : infliximab & etanercept 近年的主流 , 但藥費高達 US$1.6-2.0 萬 /Y.

a. Inhibit endothelial cell adhesion molecule expression. e.g. anti-ICAM, -ELAM, -VCAM, -VLA antibodies

b. Inhibition of cellular proliferation . e.g. anti-PDGF or -FGF antibodiesc. Inhibition of TNF- and/or IL-1 為主流 . e.g. Recombinant HuIL-1ra ( Anakinra ) & a soluble receptor for TNF- ( Etanercept ) or anti-TNF monoclonal antibody ( Infliximab , Adalimumab)

針對病理機制治療 RA 病程漫延期之主流藥物 : control the disease, not simply relieve the symptoms

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Critical Proinflammatory Cytokines : Target in RA therapy

IL-1 has been shown to be the dominant cytokine associated with the destructive changes characteristic of RA and IL-1 causes the rapid loss of proteoglycans, resulting in cartilage degradation.

In vivo studies with direct injections of IL-1 and TNF- into the knee joints of mice showed IL-1 to be 100 times more potent in preventing proteoglycan synthesis.

IL-1 decrease synthesis of collagen & proteoglycan in chondrocytes, causes impairment of repair. It also stimulates osteoclasts, resulting in bone resorption.

TNF- may be present during these

events, yet to a far lesser degree. Blocking TNF- did not seem to have an effect on swelling, cell influx, proteoglycan synthesis, or proteoglycan degradation.

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B. TNF expression as body’s fire alarm : essential for invasive inflammation

56

What is Tumor –necrosis factor (TNF-) ?

A cytokine, m.w. 17 kD , induced by activated macrophage in response to pathogen, as a essential for the complete expression of inflammation (local & systemic) during invasion : as a protective effect

Effects : 1. Local : inflammation sign ( heat, swelling, pain & redness ) 2. Systemic : CO, thrombosis in microvessel⇓ & capillary leakage3. Activate other cells to release cytokines ( e.g. IL-1, ), eicosanoids, NO, ROS Interaction : antiinflammatory cytokines ( IL-10, TGF-) inhibit the release of

proinflammatory TNF ; stress hormone (steroid, Epi, -MSH ) inhibit cytokine synthesis & its signal transduction.

Anti-TNF intervention : 1. Suppression of the other pro-inflammmatory cytokines2. Decrease synovial cell infiltration3. Interference with osteoclast activation4. Decrease angiogenesis5. Also shown efficacy in Crohn’s disease, ankylosing spondylitis, psoriasis and psoriatic

arthritis, but it is ineffective, and even contraindicated in multiple sclerosis

57

anti-TNF therapy protects joints from structural damage

:One of the major success of biologic therapy

Infliximab (Remicade® ) : immunogenicity ( chimeric, mouse x human )

Etanercept (Enbrel® , p75TNFR:FC , fusion) Adalimumab( Humira® ) was approved by FDA on 31st Dec.’02 CDP571: a humanised murine complementarity

– determining region-3 engrafted mAb. D2E7 (Adalimumab) : a ‘human’ antibody produced by phage

display. CDP870 anti-TNF Ab( Celltech/Pharmacia ): PEGylated

(linked to PEG) PEGylated anti-TNF receptor Ab (Pegsunercept, PEGylated

p55sTNFR construct, Amgen )

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1. It is the first chimeric human/mouse anti-TNF monoclonal antibody (mAB) 2. reduces inflammation in patients with Crohn‘s disease and rheumatoid arthritis ; 甚至

治療細菌漫延引發之菌 ( 敗 ) 血症 .3. Given iv. every two months ，現今推薦與 methotretrate 共服 ( 避免抗體產生 ) 4. Pathological evidence showed that TNF regulates IL-6, IL-8, MCP-1, and VEGF

production, recruitment of immune and inflammatory cells into joints, angiogenesis, and reduction of blood levels of matrix metalloproteinases-1 and -3.

5. Clinical trials have demonstrated their efficacy in controlling signs and symptoms, in approximately 2/3 of patients for up to 2 years, and their ability to retard joint damage. and they represent a significant new addition to available therapeutic options

6. SE : headache, resp. infection, cough, sinusitis, rash. 7. Warning : might cause lymphoma & infection ( e.g. TB, 70 cases, New Eng J Med 345:

1098, ‘01 )

Infliximab ( Remicade / Centocor ) : approved in Nov. '99.

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a true designer molecule -- a dimer consisting of 2 recombinant p75 TNF receptor joined to the Fc domain of a human IgG1 molecule ( receptor fusion protein ) , for juvenile rheumatoid arthritis approved in Nov. '98. It can be used as monotherapy.

block inflammation by inhibiting the downstream effects of this cytokine. can bind the cytokine lymphotoxin-a as well as TNF- & -. This feature may be

relevant to the treatment of juvenile RA, since lymphotoxin is present in inflamed synovial tissue in this disease.

25 mg, sc. twice a week ( standard dose, 59-75 % improved ), T1/2 = 70 hr, In clinical found that it decreased symptom; and slowed joint damage more rapidly

in patients who were recently diagnosed with RA when compared to the drug methotrexate, which is considered the gold standard in arthritis treatment.

Adverse effect : 1. "cytokine release syndrome" : fever, chills headache associated with the Ab. 2. Other Rare SE : CNS demyelinating disorders such as multiple sclerosis,

myelitis, optic neuritis, & blood disorder; including pancytopenia and aplastic anemia.

於 2001 年 1-9 月共締造 5.456億美元銷售額 . 但成本亦較抗體為高

Etanercept ( Enbrel / Immunex- Wyeth ) : 1st true 基因重組之生物製劑 或稱之為生物反應修飾劑 for R.A.,

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Adalimumab (HUMIRA®, Abbott ) 12/31/’02

a fully human recombinant IgG1 monoclonal Ab to TNF molecule , block the interaction with p55 & p75 cell surface TNF receptor

40 mg/ 2W, s.c. ; T1/2 = 2 W

reducing signs and symptoms and inhibiting the progression of structural damage in adult patients with moderately to severely active RA ( with methotrexate )

Infliximab & adalumimab, but not etanercept, are also active in Crohn’s disease

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Anti-cytokine agent

Most recently approved biologics for RA : Abatacept (Orencia, Bristol-Meyers Squibb) in ’05, binds to CD80 and CD86, which prevents their interaction with CD28 to fully activate T lymphocytesRituximab (non-Hodgkin’s lymphoma in ‘97) in ’06, anti-CD20 monoclonal Ab that causes lysis of CD20 B

cells combined with methotrexate for moderate to severe RA

62

Anti-TNF therapy of RA

Mechanism of action :1. ⇩ IL-6, IL-1, GM-CSF & VEGF- proinflammatory cytokine2. ⇩ expression of adhesion molecules and chemokine-induced leukocyte trafficking3. ⇩ MMP ( matrix metalloproteinases ) tissue-destructive enzyme 4. ⇩ VEGF-induced angiogenesis

Clinical benefits : response rate 50-60% in late-stage, 80% in early-stage

1. ⇩ pain, stiffness and lethargy symptoms ( originally for the treatment of sepsis )2. ⇩ tenderness and joint swelling sign of active disease ( acute phase )3. ⇩ cartilage & bone damage 4. Induction of tissue repair 5. No evidence of a cure , No clear benefit according to ACR criteria TNF- may be present during these events, yet to a far lesser degree. Blocking TNF- did not

seem to have an effect on swelling, cell influx, proteoglycan synthesis, or proteoglycan degradation.

Side Effects : 1. ⇧ risk of TB & pneumonia infection ( due to cytokines )⇩2. ⇧ level of IgM anti-nuclear Ab ( 15% ) drug-induced lupus ( rare, 1/1000 )3. ⇧ risk of lymphomas ( not proven )

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C. NF-B: central role in osteoclast –induced bone destruction

A heterodimer with 2 subunits: a 50k subunit (p50, NF-kB1) and a 65k subunit (p65, also known as RelA) in cytoplasm bind to inhibitory IkB as an inactive complex

activated by LPS , inflammatory cytokines( TNF, IL-1), viral infection, UV irradiation, stress.

Translocated to nucleus, NF-B dimers bind to target DNA elements and ubiquitous rapid activate transcription of genes encoding proteins involved with immune or inflammation responses and with cell growth control.

as a target for anti-inflammatory gene therapy ( e.g. thalidomide, Coricosteroid )

Deoxyspergualin inhibits NF- B by blocking its nuclear translocation.

Aspirin and salicylates inhibit upstream events inducing I B phosphorylation.

Tepoxalin and antioxidants inhibit NF-B activation by influencing the redox state of the cell.

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1. 為現今副作用較少之第三代 DMARDs ，較安全有效之藥物；但絕不是治愈藥物 . FDA approved as the 1st new DMARD agent for RA in Sept. ‘98.

2. A771726 ( Malononitrilamide ) is the active metabolite, as a dihydroorotate DHase inhibitor & epidermal growth factor tyrosine kinase inhibitor, 其機轉是使 dihydroorotate無法轉換為 orotate, 此步驟主要用來產生 uridine monophosphate, 而它是 pyrimidine 的受質 ; 而 uridine monophosphate 會使細胞內 pyrimidine排空 ,而使 T - & B-淋巴球核酸合成降低 ( pyrimidine synthesis inhibitor )

3. 單獨使用時 its efficacy was similar to methotrexate and as a viable alternative who have failed or intolerant to methotrexate.

4. T cell arrest in G1 (presumably by activation of p53 ), slowing the proliferation of the activated lymphocytes that linked to the pathogen of RA; also inhibit the proliferation of B cells and the production of Ab

5. inhibits the activation and gene expression of nuclear factor NFB (via induction of degradation of its inhibitor IB )

6. 其 onset較快 ( 4W ), elimination 長達 2 Y, 7. S.E. : reversible hair loss, 胃炎 , 皮膚紅疹，亦會使肝指數增加，故需 monitoring

complete blood count and hepatic on a monthly basis. 亦是 carcinogenic & teratogenic[ref] J . S. Smolen, W. B. Graninger, and P. Emery. Leflunomide, a new disease-modifying anti-rheumatic drug

and the never ending rheumatoid arthritis story. Rheumatology 2000 39: 689-692.

Leflunomide: dihydroorotate Dhase inhibitorantiproliferative + antiinflammatory + immunosuppressive

65

Anakinra ( Kineret®, Amgen ): 人類 IL-1Ra接受器拮抗劑

a recombinant, N-methionyl, nonglycosylated form of the human Interleukin-1Ra, approved in Nov. ’01, similar to native human IL-1Ra ( esp. express in monocyte ), 153 aa, except for the addition of a single methionine residue at its amino terminus

Reduction in signs and symptoms of moderately to severely active rheumatoid arthritis, in patients 18 years of age or older who have failed one or more disease modifying antirheumatic drugs (DMARDS) ，但可惜臨床效益較 TNF blocker 為差

block the binding of IL-1 & -1, prevent the activation of target cell. 1). Decrease production of proteolytic

enzyme 2). Repair the destructive effect of IL-1 ( new

synthesis of proteoglycan & collagen ), NOT TNF or PTH- induced.

100mg, daily

66

Anti-CD20 monoclonal Ab : Rituximab, ’06

causes lysis of CD20 B cell non-Hodgkin’s lymphoma in ’97 combined with methotrexate for moderate to severe

RA Black box : caused fatalities due to infusion reactions,

tumor lysis-syndrome, and severe mucocutaneous reactions. In Dec. ‘06, FDA issued a warning about 2 cases of fatal progressive multifocal leukoencephalopathy (PML) viral infection in lupus patients taking rituximab off-label.

infusion reactionsmethylprednisolone

67

68

69

Many genes for proinflammatory enzymes (e.g. COX-2, iNOS II), acute-phase proteins and cytokines (e.g. TNF- ) contain binding sites for multiple transcription factors in their regulatory elements, which are activated by a variety of inducing agents like bacterial lipopolysaccharide (LPS), tumor promoters, cytokines (e.g. IFN-, IL-6, 8) and growth factors. Inhibitors which specifically interfere with components of different intracellular signalling pathways or inhibit the activation of transcription factors responsible for the expression of disease-related genes may have applications as novel therapeutics in inflammation.

Cytokines and metalloproteinase activate the mitogen-activated protein (MAP) kinase pathways resulting in the stimulation of ERK1/2, c-Jun N-terminal kinases and p38 kinases which in turn activate transcription factors like activator protein (AP-1) and ATF-2.

Other proinflammatory agents like TNF-, IL-1 and LPS activate the transcription factor NF-kB which participates in the regulation of expression of immediate early genes involved in immune, acute phase and inflammatory responses.

Besides the transcription factors NF-kB and AP-1 which are immediate-early transcriptional activators, components of the JAK/STAT pathway play an important role in the transcriptional activation of many inflammatory genes. Consensus sequences for the transcription factors NF-kB, AP-1 and STAT1a have been found e.g. in the promoters of COX-2 and iNOS.

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Proteasome inhibitors e.g. PS-341,PS1(with CPT-11)

Glycogen synthase kinse-3(GSK-3) inhibitor e.g.GlaxoSmthKNline(SB410111), Chiron (CT98014) ( with TNF-)

IKK inhibitorse.g. AstraZeneca (Heterocyclic carboxamide), Aventis (PS1145), Novarits (NVPIKK004)•IKK & IKK inhibitor : sulfasalazine•IKK inhibitor : aspirin,sulindac•Nature products:curcumin, quercetin, aspirin, geliotoxin, lactacystin

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Cytokine : an marker of Chronic inflammation involved in signal transduction & activation of transcription factors

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Health is the only worth in your heart