Constitutive cyclooxygenase (COX-1) and inducible cyclooxygenase (COX-2): rationale for selective inhibition and progress to date

While a great deal has been discovered concerning the potential physiological and pathological role of prostanoids, much is left to be determined. The widespread distribution of both COX-1 and COX-2 coupled with the capacity of most vascular beds, smooth muscle, as well as leukocytes to respond to prostanoids make drawing generalities difficult. The problems with the majority of currently used NSAIDs are clear and ulcerogenic liability is of obvious concern. Interestingly enough, the mechanism of that damage is still the subject of controversy as illustrated by the recent review and hypothesis of Somasundaram et al. In this treatise, the suggestion is made that the initial gastric damage is the result of uncoupling of oxidative phosphorylation which is independent but simultaneous with COX inhibition. At least two currently marketed NSAIDs have improved G.I. liability (nabumetone and etodolac) with efficacy equivalent to other more ulcerogenic NSAIDs. These drugs appear to have achieved that by a mechanism distinct from selective inhibition of COX-2. Whether or not selective COX-2 inhibitors will demonstrate an improved profile over these compounds remains to be shown. Unfortunately, clinical experience with nimsulide and CGP 28238 suggest that NSAID-like toxicity may still be an issue. The promise of selective COX-2 inhibitors remains largely untested. It is with great interest and expectation that the clinical evaluation of the more selective compounds of different structural types is awaited.     

New non-steroidal anti-rheumatic drugs: selective inhibitors of inducible cyclooxygenase

MODE OF ACTION OF NON-STEROIDAL ANTI-INFLAMMATORY DRUGS: Non-steroidal anti-inflammatory drugs (NSAID) exert their major therapeutic and adverse effects by inhibition of prostanoid synthesis. Also the interactions with antihypertensive drugs and lithium are caused by this mechanism of action. Cyclooxygenation is a key enzymatic step in the synthesis of prostanoids. 1990 2 isoforms of the enzyme cyclooxygenase have been identified: Prostanoids synthesized by the constitutive cyclooxygenase (COX-1) are involved in physiological homeostasis. In contrast, the inducible cyclooxygenase (COX-2) produces large amounts of prostanoids, mainly contributing to the pathophysiological process of inflammation. COX-2 SELECTIVE NSAID: The discovery of the cyclooxgenase-isoenzymes ushered in a new generation of NSAID: A drug with selectivity for COX-2 would inhibit proinflammatory prostanoid synthesis while sparing physiologic prostanoid synthesis. Thus, a selective COX-2 inhibitor should be anti-inflammatory with less or no gastrointestinal or other NSAID-typical adverse effects. The experiences with currently used NSAID, which show an increasing incidence of side effects as COX-1 inhibition increases, and studies with the COX-2 selective NSAID salsalate and meloxicam, which have less adverse effects than nonselective COX inhibitors in equivalent antiphlogistic dosage, prove the concept of selective COX-2 inhibition to avoid the NSAID typical side effects. Newly developed drugs with a very high selectivity for COX-2 are now tested in clinical trials. CONCLUSION: So far the results suggest, that selective and highly selective COX-2 inhibitors have significantly fewer gastrointestinal and renal adverse effects and do not inhibit platelet aggregation.     

Cyclooxygenase-2 inhibitors: a new class of anti-inflammatory agents that spare the gastrointestinal tract

The NSAIDs are potent anti-inflammatory and analgesic agents. It is now believed that the NSAIDs exert their therapeutic activity through the inhibition of COX-2 at the site of inflammation. Unfortunately, these compounds are equally capable of inhibiting constitutively expressed COX-1 in tissues such as the gastrointestinal tract and kidney, which results in serious, mechanism-based toxicities that limit the drug's therapeutic utility. With the identification of selective COX-2 inhibitors, alternatives to traditional NSAID therapy should be available that will provide clinical usefulness with reduced toxicity.     

Nonenzymatic palmitoylation at Cys 3 causes extra-activation of the alpha-subunit of the stimulatory GTP-binding protein Gs

In cerebellar granule cells, potassium cyanide (KCN) activates the NMDA receptor resulting in generation of nitric oxide and reactive oxygen species (ROS). To study the mechanism by which KCN stimulates ROS generation, the action of cyanide on the enzymatic pathways known to generate ROS were studied. The oxidant-sensitive fluorescent dye, 2,7-dichlorofluorescin was used to measure intracellular levels of nitric oxide and ROS in cerebellar granule cells. Using selective enzyme inhibitors, it was shown that both protein kinase C and phospholipase A2 are involved in KCN-stimulated generation of NO and ROS. In cells treated with indomethacin or nordihydroguairetic acid, inhibitors of cyclooxygenase (COX) and lipoxygenase (LOX) respectively, attenuated (approximately 35%) KCN-induced generation of oxidant species. When L-NAME (LG-nitro-L-arginine methyl ester) (nitric oxide synthase inhibitor, NOS) was combined with either indomethacin or nordihydroguairetic acid, generation of oxidant species was blocked by more than 80%. Pretreatment with NS398 (COX-2 inhibitor) significantly decreased ROS generation indicating the involvement of COX-2 in KCN-induced oxidant generation. Treatment with L-NAME + NS398 blocked oxidant species generation, reflecting involvement of NOS. The participation of cytochrome P450 was not evident because SKF525A did not significantly reduce KCN-induced ROS generation. Furthermore, a correlation was observed between oxidant generation and lipid peroxidation of cellular membranes (as determined by thiobarbituric acid levels). Pretreatment with inhibitors of protein kinase C, phospholipase A2 or COX, LOX, COX-2 partially blocked KCN-induced formation of thiobarbituric acid reactive substance, whereas coincubation of L-NAME with the inhibitors decreased lipid peroxidation by 60 to 90%. In cytotoxicity studies, KCN-induced cell death was partially blocked by the inhibitors and significant protection was observed when L-NAME was combined with these compounds. These findings show that activation of phospholipase A2 and subsequent metabolism of arachidonic acid by the COX-2 and LOX pathways and NOS contribute to cyanide-induced ROS production.     

Contribution of cyclooxygenase-1 and cyclooxygenase-2 to prostanoid formation by human enterocytes stimulated by calcium ionophore and inflammatory agents

The stimulation of intestinal epithelial cell cyclooxygenase (COX) enzymes with inflammatory agents and the inhibition of COX-1 and COX-2 enzymes has the potential to increase understanding of the role of these enzymes in intestinal inflammation. The aim of this study was to determine the contributions of COX-1 and -2 to the production of specific prostanoids by unstimulated and stimulated intestinal epithelial cells. Cultured enterocytes were stimulated with lipopolysaccharide (LPS), interleukin-1 (IL-1)beta (IL-1 beta), and calcium ionophore (Ca Ion), with and without COX inhibitors. Valerylsalicylic acid (VSA) was employed as the COX-1 inhibitor, and SC-58125 and NS398 were used as the COX-2 inhibitors. Prostanoids were quantitated by Elisa assay. Western immunoblotting demonstrated the presence of constitutive COX-1 and inducible COX-2 enzyme. Unstimulated prostanoid formation was not decreased by the COX-1 inhibitor. All of the stimulants evaluated increased prostaglandin E2 (PGE2) production. Only Ca Ion stimulated prostaglandin D2 (PGD2) production while IL-1 beta, and Ca Ion, but not LPS, increased prostaglandin F2 alpha (PGF2 alpha) formation. Ca Ion-stimulated prostanoid formation was uniformly inhibited by COX-2, but not COX-1, inhibitors. IL-1 beta-stimulated PGE2 and PGE2 alpha formation was significantly decreased by both COX-1 and COX-2 inhibitors. VSA, in a dose-dependent manner, significantly decreased IL-1 beta-stimulated PGE2 and PGF2 alpha production. Unstimulated prostanoid formation was not dependent on constitutive COX-1 activity. The stimulation of intestinal epithelial cells by Ca Ion seemed to uniformly produce prostanoids through COX-2 activity. There was no uniform COX-1 or COX-2 pathway for PGE and PGF2 alpha formation stimulated by the inflammatory agents, suggesting that employing either a COX-1 or COX-2 inhibitor therapeutically will have varying effects on intestinal epithelial cells dependent on the prostanoid species and the inflammatory stimulus involved.     

COX-2 inhibition versus gastroprotection with dual COX inhibitors: an evidence-based approach

Highly selective inhibitors of cyclooxygenase-2 (COX-2i) were introduced to minimize peptic ulcers and their complications caused by dual COX inhibitors (COXi). Co-prescribing a (generally cheap) dual COXi with a gastroprotectant is an alternative strategy, proven to reduce the incidence of NSAID-associated endoscopic ulcers. This review compares the efficacies of these two strategies and makes some estimates of their relative cost-effectiveness. In standard risk patients, endoscopic ulcers are reduced to about the same extent (around 70-80%) by either co-prescribing omeprazole or lansoprazole with a dual COXi or preferring a COX-2i alone. COX-2i reduced ulcer complications by a weighted mean of around 60% in comparative studies with dual COXi. There is little information about the influence of PPI on this endpoint, although one study using H. pylori treatment as a possible surrogate for placebo intervention found 77% protection against recurrent upper gastrointestinal bleeding by co-administered omeprazole. One direct comparison of the two strategies in high-risk patients (recent ulcer bleed) found quite high rates of re-presentation with bleeding ulcer using either strategy, and the differences between them were not significant. Drug costs in four Western countries were compared for each strategy. In one, the costs were similar, but in the others the combination of a cheap dual COXi with omeprazole was usually more expensive than using a COX-2i. The safest strategy in highest risk patients may be to co-prescribe a gastroprotectant with a COX-2i, with resulting higher drug costs but possibly offset by savings in other health costs. The efficacy and cost-benefit of this alternative approach warrants investigation.     

Reduced COX-2 protein in colorectal cancer with defective mismatch repair

Most colorectal adenomas and carcinomas arise in the setting of chromosomal instability characterized by progressive loss of heterozygosity. In contrast, approximately 15-20% of colorectal neoplasms arise through a distinct genetic pathway characterized by microsatellite instability (MSI) associated with frequent loss of expression of one of the DNA mismatch repair enzymes, most often hMLH1 or hMSH2. These distinct genetic pathways are reflected by differences in tumor histopathology, distribution in the colon, prognosis, and dwell time required for progression from adenoma to carcinoma. To determine whether these two groups of tumors differ in their expression of cyclooxygenase-2 (COX-2), a putative chemopreventative target, immunostaining for this protein was performed in colorectal cancers categorized by the presence (n = 41) and absence (n = 66) of defective mismatch repair. Defective mismatch repair was defined by the presence of tumor microsatellite instability (MSI-H, > or =40% of markers demonstrating instability) and by the absence of protein expression for either hMLH1 or hMSH2. Overall, our results showed that low or absent COX-2 staining was significantly more common among tumors with defective mismatch repair (P = 0.001). Other features predictive of low COX-2 staining included marked tumor infiltrating lymphocytosis, and solid/cribiform or signet ring histological patterns. These observations indicate that colorectal cancers with molecular and phenotypic characteristics of defective DNA mismatch repair express lower levels of COX-2. The clinical implications of this biological distinction remain unknown but should be considered when assessing the efficacy of COX-2 inhibitors for chemoprevention in patients whose tumors may arise in the setting of defective DNA mismatch repair.     

Cyclooxygenase in biology and disease

Cyclooxygenase (COX), the key enzyme required for the conversion of arachidonic acid to prostaglandins was first identified over 20 years ago. Drugs, like aspirin, that inhibit cyclooxygenase activity have been available to the public for about 100 years. In the past decade, however, more progress has been made in understanding the role of cyclooxygenase enzymes in biology and disease than at any other time in history. Two cyclooxygenase isoforms have been identified and are referred to as COX-1 and COX-2. Under many circumstances the COX-1 enzyme is produced constitutively (i.e., gastric mucosa) whereas COX-2 is inducible (i.e., sites of inflammation). Here, we summarize the current understanding of the role of cyclooxygenase-1 and -2 in different physiological situations and disease processes ranging from inflammation to cancer. We have attempted to include all of the most relevant material in the field, but due to the rapid progress in this area of research we apologize that certain recent findings may have been left out.     

Size- and invasion-dependent increase in cyclooxygenase 2 levels in human colorectal carcinomas

Nonsteroidal anti-inflammatory drugs reduce the incidence and mortality of colorectal carcinoma. Their chemopreventive effects appear to be due to inhibition of cyclooxygenase (COX)-2. Here, we have studied the relationship between the COX-2 mRNA levels and pathological characteristics in 43 primary colorectal carcinomas. COX-2 levels were significantly higher in tumors with larger sizes and in those with deeper invasions but were not correlated with whether the patients had metastasis or not. These results suggest that larger carcinomas produce more COX-2 to support their own growth and that COX-2 inhibitors may be effective agents of carcinoma growth suppression.     

The advent of highly selective inhibitors of cyclooxygenase--a review

Cyclooxygenase (COX) exists in two isoforms, COX-1 and COX-2, COX-1 is present and is constitutively expressed in most cells and tissues, whereas COX-2 is felt to principally mediate inflammation. However, this distinction appears to be challenged by recent observations. This review addresses the roles of COX-1 and COX-2 isoforms in physiologic and pathophysiologic states and reviews potential therapeutic roles for selective COX inhibitors.     

Effects of cyclooxygenase-2 selective and nitric oxide-releasing nonsteroidal antiinflammatory drugs on mucosal ulcerogenic and healing responses of the stomach

Effects of selective cyclooxygenase-2 (COX-2) inhibitors (NS-398) and nitric oxide (NO) -releasing aspirin (NO-ASA) on gastric ulcerogenic and healing responses were examined in comparison with nonselective COX inhibitors such as indomethacin and aspirin (ASA). Hypothermic stress (28-30 degrees C, 4 hr) induced gastric lesions in anesthetized rats with an increase of acid secretion. The lesions induced by hypothermic stress were markedly worsened by subcutaneous administration of both indomethacin and ASA but were not affected by either NS-398 or NO-ASA, although the increased acid secretion during hypothermia was not affected by any of the drugs. On the other hand, the healing of gastric ulcers induced in mice by thermal cauterization (70 degrees C, 15 sec) was significantly delayed by daily subcutaneous administration of indomethacin and ASA as well as NS-398, but not by NO-ASA. COX-2 mRNA was not detected in the intact mucosa but was positively expressed in the ulcerated mucosa, most potently on day 3 after ulceration. Prostaglandin contents in the intact mouse stomach were reduced by indomethacin, ASA, and NO-ASA, while the increased prostaglandin generation in the ulcerated mucosa was inhibited by all drugs including NS-398. After subcutaneous administration of NO-ASA to pylorus-ligated rats and mice, high amounts of NOx were detected in both the gastric contents and serum. In addition, both NS-398 and NO-ASA showed an equipotent antiinflammatory effect against carrageenan-induced paw edema in rats as compared with indomethacin and ASA. These results suggest that both indomethacin and ASA not only increased the mucosal ulcerogenic response to stress but impaired the healing response of gastric ulcers as well. The former action was due to inhibition of COX-1, while the latter effect was accounted for by inhibition of COX-2 and was mimicked by the COX-2-selective inhibitor NS-398. NO-ASA, although it inhibited both COX-1 and COX-2 activity, had no deleterious effects on gastric ulcerogenic and healing responses.     

Eicosanoid biosynthesis in an advanced deuterostomate invertebrate, the sea squirt (Ciona intestinalis)

The eicosanoid generating potential of tunic, branchial basket, intestine, ovary and tadpole larvae from the sea squirt, Ciona intestinalis, was examined using a combination of reverse phase high performance liquid chromatography, gas chromatography-mass spectrometry and enzyme immunoassay. All organs examined synthesized the lipoxygenase products 12-hydroxyeicosapentaenoic acid (12-HEPE) and 8-HEPE implying that both 8- and 12-lipoxygenase activity are widely distributed in this species. In addition, tunic and branchial basket generated significant amounts of 8,15-diHEPE and smaller amounts of 8,15-dihydroxyeicosatetraenoic acid (8,15-diHETE), while tunic alone generated small amounts of conjugated tetraene-containing material with a UV chromophore and mass ion characteristic of a lipoxin-like compound. The broad range lipoxygenase inhibitors, esculetin and nordihydroguaiaretic acid, both caused a significant dose dependent inhibition of 12-HEPE and 8,15-diHEPE biosynthesis in tunic, while the specific 5-lipoxygenase inhibitor, REV-5901, and the specific 5-lipoxygenase activating protein inhibitor, MK-866, had no observable effect on the lipoxygenase profile of this tissue. Tunic, branchial basket, intestine and ovary all generated significant amounts of prostaglandin (PG) E and PGF immunoreactive material and smaller amounts of thromboxane B immunoreactive material as measured by enzyme immunoassay. The non-specific cyclooxygenase (COX) inhibitor, indomethacin, the selective COX-1 inhibitors, resveratrol and valerylsalicylate, and the specific COX-2 inhibitors, NS-398, etolodac and DFU (5,5-dimethyl-3-(3-fluorophenyl)-4-(4-methylsulphonyl) phenyl-2(5H)-furanone) all caused a significant dose dependent inhibition of the biosynthesis of PGE immunoreactive material. However, the specific COX-2 inhibitors were most effective, perhaps implying that a COX-2-like enzyme may be present in this species.     

Palliative care in chronic obstructive airways disease: a needs assessment

The oral administration of mofezolac, [3,4-di(4-methoxyphenyl)-5-isoxazolyl]acetic acid, resulted in the suppression of writhing induced by the intraperitoneal injection of phenyl-p-benzoquinone (phenylquinone, PQ) in mice. The analgesic activity of mofezolac was almost as potent as that of indomethacin, and more potent than that of sodium diclofenac, zaltoprofen, NS-398, and etodolac when their 50% effective doses were compared. The in vitro inhibitory activity of mofezolac against ovine cyclooxygenase (COX)-1 was also more potent than that of any other non-steroidal anti-inflammatory drugs (NSAIDs) tested, whereas the activity of mofezolac against COX-2 was relatively weak. A Western analysis revealed COX-1 to be constitutively expressed, whereas COX-2 was hardly expressed until 30 min after the PQ-injection in the peritoneal cells. Because the writhing terminated within 30 min after PQ-injection, the prostaglandins involved in the induction of writhing seem to be derived from COX-1. These data thus indicate that potent analgesic activity of mofezolac against the present model to be more closely related to its potent inhibitory activity against COX-1 but not against COX-2.     

Prostaglandin E2 amplifies cytosolic phospholipase A2- and cyclooxygenase-2-dependent delayed prostaglandin E2 generation in mouse osteoblastic cells. Enhancement by secretory phospholipase A2

We used the MC3T3-E1 cell line, which originates from C57BL/6J mouse that is genetically type IIA secretory phospholipase A2 (sPLA2)-deficient, to reveal the type IIA sPLA2-independent route of the prostanglandin (PG) biosynthetic pathway. Kinetic and pharmacological studies showed that delayed PGE2 generation by this cell line in response to interleukin (IL)-1beta and tumor necrosis factor alpha (TNFalpha) was dependent upon cytosolic phospholipase A2 (cPLA2) and cyclooxygenase (COX)-2. Expression of these two enzymes was reduced by cPLA2 or COX-2 inhibitors and restored by adding exogenous arachidonic acid or PGE2, indicating that PGE2 produced by these cells acted as an autocrine amplifier of delayed PGE2 generation through enhanced cPLA2 and COX-2 expression. Exogenous addition or enforced expression of type IIA sPLA2 significantly increased IL-1beta/TNFalpha-initiated PGE2 generation, which was accompanied by increased expression of both cPLA2 and COX-2 and suppressed by inhibitors of these enzymes. Thus, our results revealed a particular cross-talk between the two PLA2 enzymes and COX-2 for delayed PGE2 biosynthesis by a type IIA sPLA2-deficient cell line. cPLA2 is responsible for initiating COX-2-dependent delayed PGE2 generation, and sPLA2, if introduced, enhances PGE2 generation by increasing cPLA2 and COX-2 expression via endogenous PGE2.     

Cyclooxygenase-2 inhibitors in tumorigenesis (Part II)

The rate-limiting step in arachidonate metabolism is mediated by enzymes known as cyclooxygenases (COXs). These enzymes catalyze the biosynthesis of prostaglandin H2, the precursor of molecules such as prostaglandins, prostacyclin, and thromboxanes. The COX enzyme family consists of the classical COX-1 enzyme, which is constitutively expressed in many tissues, and a second isozyme, i.e., COX-2, which is induced by various stimuli, such as mitogens and cytokines, and is involved in many inflammatory reactions. Because nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit both COX-1 and COX-2, these drugs also cause unwanted side effects, exemplified by gastrointestinal bleeding. Accumulating evidence indicates that NSAIDs can reduce the incidence of colorectal cancers in human and experimental animals and can reduce the number and size of polyps in patients with familial adenomatous polyposis. This Part II (of a two-part review) focuses on the growing clinical and experimental evidence that NSAIDS and COX-2 inhibitors can influence the risk of colon (and possibly of other) cancers.     

An update on eicosanoids and inhibitors of cyclooxygenase enzyme systems

There are 3 main enzymatic pathways for synthesis of eicosanoids from arachidonic acid, however, some compounds are also formed non-enzymatically. Among the enzymatic pathways, cyclooxygenase (COX) also known as prostaglandin synthase (PGHS), generates endoperoxides (PGG/H). These are converted into prostaglandins (PGs) and thromboxanes (TXs). The second pathway involves lipooxygenase (LOX) group of enzymes to provide hydroperoxyeicosatetraenoic acid (HpETEs) which in turn can be converted into leukotrienes (LTs), hepoxilins (HXs), trioxilins and lipoxins (LXs). The third pathway involves cytochrome P-450 which catalyses the formation of a number of monohydroxy fatty acids (hydroxyeicostetraenoic acids or HETEs) dihydroxy fatty acids (dihydroxyeicostetrienoic acids or DiHETrEs) and epoxyeicosatrienoic acids (EpETrEs: formerly called EETs). This system also provides leukotoxins. The non-enzymatic pathway leads to the formation of isoprostanes by free radical catalysed peroxidation of arachidonic acid. In addition, brain cells also convert arachidonic acid into arachidonylethanolamide (anandamide) which have the ability to bind to cannabinoid receptors. Most of these eicosanoids are either biologically active or are converted into metabolites which have biological activities. Cyclooxygenase is now known to exist in two separate isoforms which are called COX-1 and COX-2. While both isoforms catalyse the same reactions, the former is a constitutive enzyme and its activity is not markedly changed once the cell is fully grown. The later isoform is however inducible and its activity is several fold increased following the exposure of body cells to a number of stimuli and its contribution in the process of inflammation is now well documented. It is now believed that eicosanoids produced by COX-1 activity are essential for the physiological (house keeping) functions while those produced by COX-2 lead to various pathological changes in body tissues. Older nonsteroidal antiinflammatory drugs like aspirin and indomethacin are non selective inhibitors of COX activity and therefore, in addition to inhibiting COX-2 activity, inhibit the formation of eicosanoids by COX-1. The later are required for normal house keeping functions such as secretion of mucus for protection of gastrointestinal mucosa, maintenance of renal function and control of haemostasis. Use of older non-selective NSAIDs has been associated with a number of gastrointestinal, renal and other side effects. Recently drugs such as nimesulide and meloxicam with selective action on COX-2 have been discovered and introduced into medicine. Evidence available so far has indicated the low incidence of side effects with these drugs. While being useful for various arthritic and other conditions, it is unlikely that these drugs will replace aspirin for the cardiovascular disease.     

"Ventricularization" of the pulmonary artery pressure curve: a hemodynamic sign of proximal pulmonary embolism

OBJECTIVE: To determine the relative expression of cyclo-oxygenase (COX)-1 and COX-2 in the chorion-decidual part of human fetal membranes following delivery at term and to identify any changes in expression associated with labour. METHODS: Fetal membranes were collected from 12 term pregnancies before labour following elective caesarean section and from 12 spontaneous vaginal deliveries. Expression of COX-1 and COX-2 mRNA was measured using a previously validated quantitative RT-PCR assay. RESULTS: COX-2 expression exceeded that of COX-1 by approximately eight-fold. COX-1 expression did not change but COX-2 expression was found to increase four-fold with labour. CONCLUSIONS: Chorion-decidua has the capacity to contribute to the increase in prostaglandin synthesis within the uterus associated with labour. As in the amnion, it is COX-2 and not COX-1 which is upregulated with labour. COX-2 selective anti-prostaglandins should therefore be as effective as nonselective drugs in inhibition of fetal membrane prostaglandin synthesis.