Current Pharmaceutical Design - Volume 10, Issue 14, 2004

Haemostasis is a finely balanced and complex process ideally initiated only in response to disruption of the vascular endothelium as a means of preventing loss of blood from an injured vessel. Deviations from the ideal can lead to serious disease. Firstly, thrombosis, which arises as a consequence of inappropriate platelet-platelet interactions at a region of vessel damaged by atherosclerosis, can lead to occlusion of the affected vessel as in myocardial infarction or stroke. Secondly, loss of the ability of platelets to form aggregates leads to Glanzmann's thrombasthenia (GT) with a tendency to bleed for prolonged periods following injury. Glycoprotein IIb / IIIa (GPIIb / IIIa) plays a major role in the regulation of platelet adhesion and aggregation during haemostasis. Upon platelet activation by an agonist a signalling process is initiated, termed “inside-out” signalling, which gives rise to conformational changes within GPIIb / IIIa. These conformational changes increase the affinity of the receptor for its primary ligand, fibrinogen. Bound fibrinogen then acts as a bridging molecule facilitating the interaction of adjacent platelets. Upon fibrinogen binding GPIIb / IIIa undergoes further conformational changes and through a process termed “outside-in” signalling the receptor signals in to the platelet ultimately resulting in acceleration of the aggregation process. Qualitative or quantitative abnormalities in GPIIb / IIIa give rise to GT, a recessive bleeding disorder, and analysis of affected individuals has provided invaluable insights into the structure / function relationship of this receptor. Due to its critical role in mediating platelet aggregate formation GPIIb / IIIa has become a primary target for the development of antithrombotic agents.

The intravenous Glycoprotein (GP) IIb / IIIa antagonists are potent antiplatelet agents that are particularly effective in patients who undergo percutaneous coronary intervention (PCI). Questions remain about their benefit in the setting of primary PCI, as well as in patients with acute coronary syndromes who do not undergo PCI. The dosing of these drugs is critical to their efficacy and for some agents may not yet be optimized. Differences in the level of platelet inhibition achieved with previous and current dosing strategies of these agents are discussed. In addition, the pharmacology of GPIIb / IIIa antagonists is more complex than initially appreciated. These drugs appear to have partial agonist properties and as a result may be prothrombotic at lower doses. Recent evidence also suggests that at least some of the GPIIb / IIIa antagonists may have anti-inflammatory as well as anti-thrombotic activity. Future research should clarify these issues. Because of the observed inter-individual variation in the response to GPIIb / IIIa antagonists, future trials of these agents should also look at individual tailoring of the dose to an optimum level of platelet inhibition. No definite clinical predictors of this inter-individual variation have been identified, but the PlA polymorphism in GPIIIa appears to be associated with an adverse response to treatment with the oral GPIIb / IIIa antagonists in particular.

GPIIb / IIIa receptor antagonists block fibrinogen binding to platelets and as a result inhibit platelet aggregation. They are very potent inhibitors due to the critical role fibrinogen binding plays in platelet aggregation. When given intravenously these drugs have been shown to be very effective as adjuvant therapy in percutaneous coronary intervention and in acute coronary syndromes. However, despite being as potent as their intravenous counterparts, all of the oral inhibitors showed no benefit or even increased mortality in clinical trials. There are a number of reasons for their failure. The target was different, chronic treatment to prevent thrombotic events as opposed to short-term treatment to prevent acute events and as a result, different dosing regimens were used. The acute use aims for a high level of inhibition (80- 90%) while the chronic use produced lower levels of inhibition. Many of the oral inhibitors had low bioavailability that led to a large peak-trough difference. Most GPIIb / IIIa antagonists have the ability to activate platelets through a GPIIb / IIIa-mediated process. This is known as partial agonism. In the presence of high drug levels, such as during an infusion this is not a problem, however combined with the low trough levels with oral inhibitors this can lead to an increase in platelet aggregation. Other problems include drug-induced conformational changes in GPIIb / IIIa (ligandregulated binding sites) and possible pharmacogenomics effects in the response to the drugs, in particular the PlA polymorphism in GPIIb / IIIa. By addressing these issues it is possible for a new generation of oral GPIIb / IIIa antagonist to be developed.

Various oral platelet GPIIb / IIIa receptor antagonists have undergone clinical investigations, but to date without success. Various factors have been proposed to explain their failure such as low affinity for the receptor, large peak / trough ratio, low bioavailability, partial agonist activity and pro-aggregatory effect. Efforts to discover a truly effective, safe, oral antagonist led to the discovery of UR-3216 (Fig. 1). The active form of UR-3216, UR-2922, possessed a high affinity for the human platelet receptor (Kd <1 nM) with a slow dissociation rate (koff = 90 min) in vitro. UR-2922 induced no ligandinduced binding sites (LIBS) expression or prothrombotic activity in human platelets, distinctly different from orbofiban and other small molecule antagonists. To date, UR-2922 is the only high affinity GPIIb / IIIa antagonist without LIBS expression. In vivo characteristics of UR-3216 showed prolonged duration of efficacy (>24 h) with its favorable pharmacokinetic profile, superior to all the other oral GPIIb / IIIa antagonists. UR-3216 showed high bioavailability, rapid bioconversion to the active form and biliary excretion. UR-3216 is a novel, orally active GPIIb / IIIa antagonist of a new generation, which has substantially improved the crucial compounding factors and will be useful for the treatment of cardiovascular diseases.

Extensive study in integrin research has seen the platelet specific receptor αIIbβ3 (Glycoprotein GPIIb / IIIa) under much scrutiny, and provided vast information as to the workings of this integrin within the blood. Glanzmann's thrombasthenia, a rare autosomal recessive bleeding disorder, highlights the vital role played by this receptor in platelet function [1]. Glanzmann's thrombasthenic platelets fail to aggregate due to a lack of surface expression of functional aIIb or β3 on the platelet surface. However, little is known about the precise molecular mechanisms involved in the operation of this receptor on the platelet surface. Clinical trials using intravenous antagonists to this receptor have shown them to be effective anti-thrombotics. However the recent observations that the oral αIIbβ3 antagonists have failed to show benefits in the treatment of acute coronary syndromes, and in fact, increase mortality, underscores the necessity for a more complete understanding of aIIbb3 and its functions [2, 3]. A more profound knowledge of the precise nature of the platelet integrin-activation, along with an understanding of its interactions with cellular signaling proteins, will undoubtedly lead to the identification of novel strategies for the effective inhibition of platelet integrin function.

The diatomic molecule of oxygen contains two uncoupled electrons and can therefore undergo reduction, yielding several different oxygen metabolites, which are collectively called Reactive Oxygen Species or ROS. They are invariably produced in aerobic environments through a variety of mechanisms, which include electron “leakage” during biologic oxidations, action of flavin dehydrogenases and specific membrane associated secretion, as well as by physical activation of oxygen by irradiation, e.g. UV sun-light. Organisms have developed efficient protective mechanisms against excessive accumulation of ROS, which include superoxide anion, hydrogen peroxide and hydroxyl radical, since all these metabolites are highly reactive and affect almost every kind of organism, either directly or through conversion into other derivatives, notably NO-derived radicals or RNS. Depending on their tissue concentration they can either exert beneficial physiologic effects (control of gene expression and mitogenesis) or damage cell structures, including lipids and membranes, proteins and nucleic acids, leading to cell death. In this brief overview we summarize the present state-of-theart, restricting the discussion to the role of ROS in physiology and pathology, not taking into account RNS. Discussion will focus on basic chemical and biochemical features of ROS, underlining how ROS can promote severe diseases, including neoplastic, cardiovascular and neurodegenerative diseases. This brief discussion should clarify the present huge interest in ROS, in the perspective to develop new and specific therapeutic approaches.

Nitric oxide (NO), a free radical molecule, produced by NO synthase (NOS) in the body exerts a number of pathophysiological actions due to its chemical reactivity. Low amounts of NO (nM) normally produced by constitutive NOS play a critical role in different physiological events such as vasodilation and neurotransmission. Higher amounts of NO (μM) locally and spatially produced by inducible NOS during inflammation act as double-edged sword exerting either beneficial or detrimental effects. Recently, new vision on the biological role of NO has been proposed based on the possible cross-talk between constitutive and inducible NOS. Accordingly, normally produced low amounts of NO may be involved in the regulation of NF-kB activation and successively the expression of inducible NOS. Under normal conditions NF-kB activation is suppressed by low amounts of NO. Under conditions in which massive amounts of NO produced by inducible NOS act detrimentally, NO-elicited down-regulation of NF-kB activation is compromised due to the drop in NO at the early phase of inflammation caused by inactivation of constitutive NOS. Any treatment which counterparts the drop in NO, therefore, may present a new approach either in preventing or in treating inflammatory diseases.

Oxidative agents are generated in large amounts during inflammation. These highly reactive intermediates interact with several extracellular and intracellular molecules and with each other, thus generating a complex network of responses culminating in an outcome that may be detrimental or beneficial for the host. Alongside with the well known systems involved in production of reactive oxygen species or reactive nitrogen species, such as the NADPH oxidase or the nitric oxide synthase, novel enzymatic pathways have been discovered. This has unveiled new targets and functions for oxidant species, and has prompted the development of innovative anti-inflammatory drugs. In the new integrate scenario stemming from these studies oxidant species are increasingly recognized as true messengers, and even their toxic effects are viewed as the result of the perversion of an otherwise physiological extra / intra cellular signaling.

Risk of gastrointestinal cancers is closely related to increased levels of oxidants in the balance between oxidant and anti-oxidant agents. A possible explanation of this epidemiological observation is the local loss of the epithelial barrier function with a focal inflammatory response. Accordingly, chronic inflammatory diseases represent well-known risk factors for cancer and, on the other hand, it is known that anti-inflammatory agents, demulcents and antioxidants markedly inhibit the development of colon cancer in animal models as well in humans. At molecular level a key role in the process that link inflammation to cellular transformation seems to be played by activation of Cyclooxygenase-2 (COX-2) together with production of Reactive Oxygen Intermediate (ROI). Both these events have been strictly linked with cell proliferation and transformation, although the intracellular pathways involved in these processes are still not completely understood. The uncontrolled proliferation, which is a landmark of cellular transformation, is accompanied by the deregulation of proteins involved in the control of cell cycle checkpoints. Altered expression and function of cyclooxygenase and nitric oxide synthase seem to influence, among others, the expression of proteins involved in the regulation of cell cycle progression. Similarly, anti-inflammatory and antioxidant agents may also act on the expression and function of several cell cycle regulating proteins. Understanding the mechanisms by which chronic inflammation contributes to genetic and epigenetic changes involved in the regulation of critical cell cycle checkpoints may help to develop more and more specific treatment strategies for reducing malignant transformation of these inflammatory diseases.

NO is considered to be an ubiquitous endogenous system which takes part in body's homeostatic regulations and in pathological events. NO derives from a) the actions of enzymes, the NO Synthases (NOS), which are constitutives (endothelial NOS (eNOS) and nervous NOS (nNOS)) and generate small amounts of NO and have homeostatic functions: and b) from the actions of inducible NOS (iNOS), which generate large amounts of NO and exert protective actions against noxious agents but also toxic effects (e.g. inhibition of enzymes) through the production of peroxynitrite (ONOO-). Modulation of the L-Arg / NO system may be used to obtain favourable therapeutic results, either by promoting (e.g. with NO donors) or by reducing (e.g. with NOS inhibitors) the production of NO. The present chapter will consider two approaches and four groups of potential therapeutic agents: 1) The stimulation of NO production with; a) agents which improve the efficiency of the Kallikrein-Kinin System; b) NO donors 2) The reduction of excessive NO production with: a) inhibitors of NO Synthases; b) agents that reduce the formation of reactive nitrogen / oxygen species (RNS / ROS).

Living beings have evolved over the past two billon years through adaptation, to an increasing atmospheric oxygen concentration, by both taking advantage of oxygen activating function and developing a complex control network. In these regards, potentially damaging species (reactive oxygen, nitrogen and chlorine species) arise as by-products of metabolism and also work as physiological mediators and signalling molecules. Oxidative stress may be an important factor in numerous pathological conditions, i.e. infection if micronutrients are deficient. Levels of these species are controlled by the antioxidant defence system, which is composed by antioxidants and pro-antioxidants. Several components of this system are micronutrients (e.g. vitamins C and E), are dependent upon dietary micronutrients (e.g. CuZn and Mn superoxide dismutase) or are produced by specific endogenous pathways. The antioxidant defences act, to control levels of these species, as a coordinated system where deficiencies in one component may affect the efficiency of the others. In this network some of the components act as direct antioxidants whereas others act indirectly (proantioxidants) either by modulation of direct agents or by regulation of the biosynthesis of antioxidant proteins. Thus, entities usually not considered as antioxidants, also act efficiently counteracting damaging effects of oxidative species. In this contest, the design of new molecules that take into account synergistic interactions among different antioxidants, could be useful both to address mechanistic studies and to develop possible therapeutic agents. In this review the principal categories of antioxidants and pro-antioxidants that goes from vitamins through phyto-derivatives to minerals, are critically reviewed, with particular emphasis on structure-function considerations, together with the perspective opened, in the design of possible therapeutic agents, by the antioxidants interplay.

A major cause for endothelial dysfunction in essential hypertension is decreased availability of nitric oxide (NO). Impairment in NO bioavailability is likely to be the consequence of multiple mechanisms affecting NO synthesis as well as NO breakdown. An alteration in the redox balance in endothelial cells leads to increased superoxide anion production and oxidative stress. This in turn not only exerts negative effects on vascular tone, but is also able to activate important mechanisms (such as platelet activity, leukocyte adhesion, vascular smooth muscle cell proliferation and expression of adhesion molecules) with an established central role in the pathogenesis of hypertensive target organ damage. As a consequence, a drug therapy able to restore NO availability in essential hypertensive patients would probably exert additional benefits, as compared to blood pressure lowering per se , in terms of prevention of target organ damage and improved prognosis of these patients. Unfortunately, as of today only the antagonists of the renin-angiotensin system and the calcium-channel blockers have shown some ability in this respect, whereas no longitudinal intervention study has been undertaken, so far, to prove that the restoration of NO bioavailability through an antihypertensive treatment may confer additional prognostic advantage to essential hypertensive patients.

Oxidative stress is a condition in which oxidant metabolites exert their toxic effect because of an increased production or an altered cellular mechanism of protection. The heart needs oxygen avidly and, although it has powerful defence mechanisms, it is susceptible to oxidative stress, which occurs, for instance, during postischaemic reperfusion. Ischaemia causes alterations in the defence mechanisms against oxygen free radicals, mainly a reduction in the activity of mitochondrial superoxide dismutase and a depauperation of tissue content of reduced glutathione. At the same time, production of oxygen free radicals increases in the mitochondria and leukocytes and toxic oxygen metabolite production is exacerbated by re-admission of oxygen during reperfusion. Oxidative stress, in turn, causes oxidation of thiol groups and lipid peroxidation leading first to reversible damage, and eventually to necrosis. In man, there is evidence of oxidative stress (determined by release of oxidised glutathione in the coronary sinus) during surgical reperfusion of the whole heart, or after thrombolysis, and it is related to transient left ventricular dysfunction or stunning. Data on oxidative stress in the failing heart are scant. It is not clear whether the defence mechanisms of the myocyte are altered or whether the production of oxygen free radicals is increased, or both. Recent data have shown a close link between oxidative stress and apoptosis. Relevant to heart failure is the finding that tumour necrosis factor, which is found increased in failing patients, induces a rapid rise in intracellular reactive oxygen intermediates and apoptosis. This series of events is not confined to the myocytes, but occurs also at the level of endothelium, where tumour necrosis factor causes expression of inducible nitric oxide synthase, production of the reactive radical nitric oxide, oxidative stress and apoptosis. It is therefore, possible that the immunological response to heart failure results in endothelial and myocyte dysfunction through oxidative stress mediated apoptosis. Clarification of these mechanisms may lead to novel therapeutic strategies.