FANS e tratto Gastrointestinale Attualità ed evidenze cliniche

1. FANS e tratto
Gastrointestinale
Attualità ed evidenze
cliniche
Stefano Fiorucci
Università di Perugia

2. NSAIDs related GI side effects
Chronic users in Italy ≈1.5.-2 million
30-40% of patients taking an NSAID
develops dyspepsia
1-3% develop serious GI side effects
with an overall mortality of 2000
patients/year

3. NSAIDs related GI side effects
30-40% of patients taking an NSAID
develops dyspepsia and gastrointestinal
lesions
1-3%/year treatment develop major GI side
effects (bleeding and perforation)

4. Number of deaths
USA 1997
25.000
20187
NUMBER OF DEATH
20.000 16685 16500
15.000
10503
10.000
5338 4441
5000
1437
0
Leukemia AIDS NSAIDs Multiple Asthma Cervical Hodgking
myeloma cancer disease
Wolfe MM et al. NEJM 1999

5. Gastrointestinal Lesions induced by NSAIDs
1. Acute Mucosal Lesions :
•Petequia
•Erosions
•Acute Ulcers
2. Chronic/Deep GD Ulcers
3. Complications:
•Perforations (rare)
•obstructions (rare)
•bleeding [“PUB”]

6. Gastropatia da FANS: fattori di rischio
Fattori di richio definiti
1. Eta’>65
2. Storia di ulcera duodenale o sanguinamento GI
3. Alte dosi di FANS
4. Uso simultaneo di 2 FANS
5. Uso concomitante di corticosteroidi
6. Uso di anticoagulanti
7. Malattie sistemiche severe (cardiovascolari)
Fattori di rischio possibili
• Infezione da H.pylori
• Consumo di alcolici

7. Upper GI lesions: risk
factor and NSAID
structrure
Drug R.R. (I.C. 95%)
Ibuprofen 2.0
Aspirin 2.6 (1.3-2.5)
Diclofenac 2.8 (1.4-2.3)
Sulindac 3.1 (1.6-2.7)
Naproxen 3.2 (1.7-2.9)
Indomethacin 3.4 (1.9-3.1)
Piroxicam 4.8 (2.7-5.2)
Ketoprofen 5.2 (2.7-6.4)
Garcia Rodriguez et al 1995

8. Pathogenesis of NSAID
Gastropathy
Gastrointestinal side effects are
related to the
mechanism of action
(i.e. COX inhibition)

9. Biosynthesis of the Products of Arachidonic Acid
Various Stimuli:
ESTERIFIED ACID Chemical Arachidonic Acid Dexamethasone
ESSENTIAL IN CELL LIPID and Mechanical
FATTY ACID
COOH
Cytokines
e.g., Phospholipids of Cell
Growth Factors
IN DIET Membrane ? Activation of Endotoxin
? Also Triglyceride Phospholipase A2 or Cyclooxygenase-2 or
Other Acylhydrolases Cyclooxygenase-1
Lipoxygenases X X
False substrates: e.g.
COOH
Antiinflammatory Drugs: .
COOH
e.g., Aspirin and
O O
O O .
5, 8, 11, 14- Indomethacin O COOH
Eicosatetraynoic Acid
Dazoxiben, Pirmagrel O
e
Synthas
O COOH O COOH
stacyclin
HOOC
Pro O
Thromb O
O
PGH2 X oxane S
OH
ynthase OOH
PGG2
Isomerases
OH OH
PGI2
Active COOH
Metabolites HYDROLYSIS O HO HO O
COOH COOH COOH COOH O
O
HO OH
TXA2
HO
OH PGE2 HO
OH PGF2α O
OH PGD2 HYDROLYSIS
OH
OH PGDH PGDH COOH
OH
6-keto O HO
Inactive PGF1α COOH COOH HO O
Metabolites β OXIDATION
OH
TXB2
HO OH
HO O O
OH β OXIDATION
O COOH ∆13 REDUCTION ∆13 REDUCTION COOH
HO β OXIDATION β OXIDATION COOH
ω OXIDATION ω OXIDATION O O
O HO HO O
COOH COOH OH
OH
Urinary OH OH COOH
Metabolites 2,3-Dinor- HO HO
COOH
11-Dehydro-TXB2 2,3-Dinor-TXB2
6-keto-PGF1α
O
PGE-M O PGF-M
40% of original ISIS draw

10. The Nobel Prize in Physiology or Medicine 1982
Sune K. Bergström Bengt I. Samuelsson John R. Vane
Sweden Sweden United Kingdom
Karolinska Institutet Karolinska Institutet The Wellcome
Stockholm, Sweden Stockholm, Sweden Research
Laboratories
Beckenham, United
Kingdom

12. Garavito et al. Ann Rev Pharmacol 1998

13. COX- 1 and COX-2
ARACHIDONIC ACID
COX-1 COX-2
TxA PGI2 PGE2 PGI2
Platelets CNS Endothelium
Kidney
PGE2 PGE2
Stomach Macrophages
Sinovial cells
Chondrocytes

14. COX-3, a cyclooxygenase-1 variant
inhibited by acetaminophen and
other analgesic/antipyretic drugs:
Cloning, structure, and expression
N. V. Chandrasekharan, Hu Dai, K. Lamar Turepu Roos, Nathan K.
Evanson, Joshua Tomsik, Terry S. Elton, and Daniel L. Simmons
Proc. Natl. Acad. Sci. USA, Vol. 99, Issue 21, 13926-13931, October 15, 2002

15. NSAIDs and gastrointestinal safety
Development of new safer NSAIDs
•Coxibs
•NO-releasing NSAIDs/CINOD
•Dual COX/5-LOX inhibitor

16. Struttura schematica di COX-1 e COX-2
COX-1 COX-2
sito catalitico sito catalitico
dell’enzima dell’enzima
Valina523,
o Isoleucina523,
n ic o
ido nic
PGH2 ac
h ido
Ar PGH2 ac
h
ido Ar
Ac ido
Ac
Arginina120 “tasca laterale”
Arginina120

17. FANS tradizionali: si legano a COX-1 e COX-2
COX-1 COX-2
sito attivo sito attivo
“ponte salino”
con
Arginina120
“ponte salino”
o
nic
con o
ido Arginina120 onic
rac
h h id
ac
o
A Ar
cid ido
A Ac

18. Coxib: interazione specifica solo con COX-2
COX-1 COX-2
sito attivo
sito attivo
coxib
PGH2 “tasca laterale”
co
o ni
id
a ch
o Ar
id co Arg 120
Ac
Arg
o ni 513
Arg 120 id hido
Ac rac
Hist
90
A
coxib

19. COX-2 selectivity of NSAIDs
Percent inhibition of COX-1 when COX-2 is inhibited by 80%
100
80
60
40
20
0
ox b
e
es m
en
L- DFP
clo ib
xic c
7
na am
xi
id
rin
na
ni ica
33
di cox
ox
ul
co
pi
fe
5,
pr
as
fe
le
74
ro
m
el
ce
ro
m
pi
Warner et al, PNAS 1999

20. NSAIDs SELECTIVITIES FOR COX-1/COX-2
specific
Rofecoxib
> 50-fold
Etodolac
Meloxicam selective
Celecoxib
Nimesulide 5 to 50-fold
Diclofenac < 5-fold COX-2 selective
Piroxicam
Ibuprofen
Naproxen Non selective
Aspirin
Indomethacin
Ketoprofen
-3 0
-2 -1 1 2 3
Log[IC ratio(COX-2/COX-1)]
80 Warner et al, PNAS 1999

21. COX-1 Activity: PGE2 Synthesis in GI Biopsies
Rofecoxib vs. Naproxen x 5 Days
170
160
PGE2 Synthesis ng/gm • min
150
140
130
120
110
100
90
80
70
60
50
40
30
Placebo Rofecoxib Placebo Naproxen
25 mg qd 500 mg bid
Hawkey CJ, Gastroenterology 2001

22. Rofecoxib and Acute Gastroduodenal
Mucosal Lesions after 7 days of
Treatment
% patients with Lanza score > 2
100 94
* †
80 71
* †
60
40
20
8 12
0
Placebo Rofecoxib 250 Ibuprofen 800 Aspirin 650
mg/day mg/8h mg/6h
* P<0.05 vs. placebo.
†
P<0.001 vs. rofecoxib. Lanza et al. Aliment Pharmacol Ther 1999; 13: 761-7

23. Investigator-Reported Thrombotic
Cardiovascular Events in the VIGOR Study
Compared with Phase IIb/III OA Study
3.5
3.0
Cumulative Incidence %
Rofecoxib (VIGOR)
2.5
2.0
1.5
1.0 Naproxen (VIGOR)
0.5
0.0
0 2 4 6 8 10 12 14
Months of Follow-up
CARDIOVASCULAR SAFETY PROFILE OF ROFECOXIB: A META-ANALYSIS:
A. Reicin, E. Barr, D. Shapiro - EULAR ORAL PRESENTATION, SAT. JUNE 16: 12:00 -

24. The CLASS study:
RESULTS
P = 0.02
6
Annualized incidence
P = 0.09 49/1384
3.5%
(%)
3
30/1441
20/1384 2.0%
11/1441 1.5%
0.76%
0
Celecoxib NSAIDS Celecoxib NSAIDS
Ulcer Symptomatic and
complications complicated ulcers

25. The CLASS study:
RESULTS
P = 0.49
17/293
6.0%
6 P = 0.02 14/298
Annualized incidence
4.6%
32/1101
3.0%
(%)
3
16/1143
1.3%
0
Celecoxib NSAIDS Celecoxib NSAIDS
Patients not Patients
taking aspirin taking aspirin

26. Fiorucci et al. GASTROENTEROLOGY 2002;123:1598-1606

27. The COX
pathway
Membrane Lip
ase Arachidonic Acid Lipoxins,
Lipid Storage re COOH
leas Leukotrienes
e 13
Lipoxygenases
HETEs
p450
11 15 EETs
Cyclooxygenase
COX-1
COX-1 PGH Synthase 15-R oxygenation COX-2
COX-2
X
SH HR SH HR
ASPIRIN
13 13
15 15
NSAIDs
NSAIDs
Prostaglandins Aspirin-Triggered Lipid Mediators
Parturition Renal Function Anti-inflammation
Inflammation Hemodynamics
15-epi-LXA
15-epi-LXA

28. Fiorucci et al. GASTROENTEROLOGY 2002;123:1598-1606

29. Fiorucci et al. GASTROENTEROLOGY 2002;123:1598-1606

30. Neutrophils
15-epi-LXA4
Aspirin LTB4 LTB4 AA
5-LOX
Inhibition of
gastric COX-1
Endothelial cell
Inhibition PGE2
AA 15(R)-HETE
Aspirin COX- 2
Gastric Damage
COX-2 inhibitors
COX-2 induction COX-2
inhibitors
COX-2 acetylation
5-LOX
ATL formation
LTB4
Gastric adapatation
Gastric damage
Wallace JL and Fiorucci S. Trends in Pharmacological Science 2003, in press

31. VIGOR
Confirmed Thrombotic Cardiovascular
Events
RA Patients with Events (Rates per 100 Patient-Years)
Rofecoxib Naproxen Relative Risk
Event Category N=4047 N=4029 (95% CI)
Confirmed 45 (1.7) 19 (0.7) 0.42
CV events (0.25, 0.72)
Cardiac 28 (1.0) 10 (0.4) 0.36
events (0.17, 0.74)
Cerebrovascular 11 (0.4) 8 (0.3) 0.73
events (0.29, 1.80)
Peripheral 6 (0.2) 1 (0.04) 0.17
vascular events (0.00, 1.37)
Bombardier et al. N Engl J Med. 2000;343:1520-1528

32. Effects of NSAIDs on
Thromboxane and Prostacyclin
Endothelial
Platelet Cell
Nonselective
COX-1 NSAIDs/ASA COX-1
COX-2 Inhibitor COX-2
Thromboxane (TxA2) Prostacyclin (PGI2)
Promotes Platelet Aggregation Inhibits Platelet Aggregation
Hemostasis Thrombosis
McAdam et al. Proc. Natl. Acad Sci. USA . 1999;96:272.

33. Development of new safer NSAIDs
•Coxibs
•NO-releasing NSAIDs/CINOD
•Dual COX/5-LOX inhibitor

34. Nitric oxide
NO

35. The Nobel Prize in Physiology or Medicine 1998
The Nobel Assembly at the Karolinska Institute in Stockholm, Sweden, has awarded the Nobel Prize in
Physiology or Medicine for 1998 to Robert F Furchgott, Louis J Ignarro and Ferid Murad for their
discoveries concerning "the nitric oxide as a signalling molecule in the cardiovascular system".
Robert F Furchgott, born 1916 Louis J Ignarro, born 1941 Ferid Murad, born 1936
Dept. of Pharmacology, Dept. of Molecular and Medical Dept. of Integrative Biology
SUNY Health Science Center Pharmacology Pharmacology and Physiology
New York UCLA School of Medicine University of Texas Medical
Los Angeles School, Houston

36. Nitric Oxide ( NO) -releasing
derivative of aspirin
NCX-4016
O
ONO2
O
O
O
Aspirin
Wallace JL, Ignarro JL, S. Fiorucci. Nature Reviews: Drug Discovery 1, 375-382 (2002)

37. Synergism between COX inhibition
and nitric oxide formation
Enhance gastrointestinal
Safety
Increase anti-inflammatory activity
Pain control

38. Aspirin NO
Anti-thrombotic
Analgesic
Anti-pyretic COX-1
Anti-inflammatory
Spares mucosa
Reduces mucosal blood flow
blood flow
Loss of mucosal barrier integrity
Gastric mucosal injury Gastric mucosal protection
Fiorucci S., et al Gastroenterology 1999, 116: 1089

39. Total score
95.2%
18 92.9%
*
Endoscopic score
16
14 *
12
10
8
6
4
2
0
Placebo NCX-4016 ASA
400 800 200 450
Fiorucci et al. , Gastroenterology. 2003 Mar;124(3):600- mg/b.i.d.

40. Erosions: stomach and duodenum
87%
98%
10
*
Endoscopic score
9
8 *
7
6
5
4
3
2
1
0
Placebo NCX-4016 ASA
400 800 200 450
Fiorucci et al. , Gastroenterology. 2003 Mar;124(3):600- mg/b.i.d.

41. Hemorrhagic lesions:
stomach and duodenum
99%
10 85%
Endoscopic score
9
*
8
7 *
6
5
4
3
2
1
0
Placebo NCX-4016 ASA
400 800 200 450
Fiorucci et al. , Gastroenterology. 2003 Mar;124(3):600- mg/b.i.d.

42. Inhibition of platelets aggregation
100
Percent of AA-induced
90
80
aggregation
70
60
50
40
30
20
10
0
Placebo NCX-4016 ASA
400 800 200 450
mg/b.i.d.
Fiorucci et al. , Gastroenterology. 2003 Mar;124(3):600-

43. Serum TxB2
Pre-treatment Post-treatment
1000
800
concentration
TxB2 serum
(ng/ml)
600
400
200
*
* * *
0
Placebo NCX-4016 ASA
400 800 200 450
mg/b.i.d.
Fiorucci et al. , Gastroenterology. 2003 Mar;124(3):600-

44. TxB2 generation
Pre-treatment Post-treatment
5000
TxB2 production
4000
(ng/ml)
3000
2000
1000
* * * *
0
Placebo NCX-4016 ASA
400 800 200 450
mg/b.i.d.
Fiorucci et al. , Gastroenterology. 2003 Mar;124(3):600-

45. Nitric oxide as an immunoregulator
• NO suppresses IL-2/IFN-γ gene expression
and enhances IL-4 production
• In APC, NO increases mediators that induce
Th2 differentiation
• NO induces apoptosis in T cells
• NO interferes with selectin-dependent adhesion,
iNOS ko mice develop Th1-dependent
autoimmune disease and Th1-cell reactivity

46. Nitric oxide in autoimmune disease
NO
Thr
IL-12
IL-18
IFNγ
IL-10
Th 1
NO
Hubert Kolb and Victoria Kolb-Bachofen, Immunol Today 1998
Fiorucci et al. Immunol Today, 2002
Fiorucci et al. PNAS, 2002

47. NO-aspirin releases nitric oxide
NO-aspirin Aspirin
DETA-NO NCX-4017
NO concentration (nM)
1800
1500
1200
900
600
*
300
0
0 1 10 100 500
(µM)
Fiorucci S, Mencarelli A, Mannucci R, Distrutti E, Morelli A,
del Soldato P, Moncada S. FASEB J. 2002 Oct;16(12):1645-7.

48. ICE has a key role in inflammation
PRO-IL-1β PRO-IL-18
ICE
IL-1β IL-18
Fiorucci S. Trends Immunol. 2001 May;22(5):232-5. Review.

49. NO-aspirin modulates cytokine release
1000 *** 750
A B *
IL-18 concentrations
IL-1β concentrations
750 * *
500 *
(pg/ml)
(pg/ml)
500
250
250
** **
0 0
C LPS C LPS
NCX Asp NCX Asp
Fiorucci et al. J. Immunol. 2000 ; 165 :5245-54

50. NO-aspirin modulates cytokine release
Aspirin NCX-4016 Aspirin NCX-4016
(caspase 1-like protease)
YVAD cleaving activity
900 120
B
Percent of inhibition
800
C 100
IL-1β concentrations
700
80
600 *
(pg/ml)
500 60
400
*
40
* *
300 *
20
200
* 0
100
0 0.1 1 10 50 100 200
0
Drug concentration (µM)
0 0.1 1 10 100 200
Drug concentration (µ M)
Fiorucci et al. J. Immunol. 2000 ; 165 :5245-54

51. Macrophages
Pro-IL-1β Pro-IL-18
NSAID
NO
COX-dependent
IL-1β IL-18
COX-1 COX-2 TNF-α, IL-8 IFN-γ
↓PGE2 Fiorucci S. Trends in Immunol 2001