Anti-inflammatory drugs : NSAIDs, COX-2

selective inhibitors, Glucocorticoids and anti-

cytokine agents

H-Y Yang
National Yang-Ming University

1
 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

2
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 ).

3
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.

4
 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

5
 Acute Inflection

Bacterial toxin releases

Host defense system activated

Plasma protein systems Cellular defense systems

Complement Kallikrein-kinin neutrophils

monocyte
cascade
Coagulation Endothelial
cell macophage lymphocyte
cascade

Proinflammatory mediators released

Cytokines Lipid Protease ROS Growth Adhesion NO
metabolite factors proteins
TNF LTs, PGs Elastase G-CSF Selectins
IL-1 PAF collagenase TGF- ICAMs
IL-6, -8 6
 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
PMN
Phagocytosis to granules and healing
1. chemotaxis : MCP-1, RANTES
2. Phagocytosis : peroxidase, eicosanoids, cytokines and
reactive oxygen and nitrogen intermediates
3. immune response : release of cytokines ( IL-1, TNF )
 Lymphocyte : chronic
1. Auto-immune disease :

7
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 disease
CDP 870 : anti TNF- Ab fragment for RA
Afelimomab : anti-TNF Ab for sepsis
 4 integrin antagonist
CDP 323 for inflammatory disease
Natralizumab ( 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 COPD
Roflumilast for COPD & asthma
 Corticosteroid
Ciclesonide ( inhaled ) for asthma

8
 Prostanoids : tissue specific autocoids

 Type IV cytosolic PLA2 ( cPLA2,especially sPLA2-IIa highly expressed during inflammation ) : the key player for eicosanoid
production ,
 Arachidonic acid ( 20:46) : 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 9
 PGs are peroxide, short half life
10
PGs 類發炎所涉及之相關之各種細胞

11
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)

 INFLAMMATION
1. 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

12
 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

13
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

14
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

15
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, TXA 2 synthesis is inhibited for 8 to 10 days
and "half an aspirin a day (50-75 mg )" prophylaxis against thromboembolic
disease.

16
 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).

17
 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; 5722 ),
Tenoxicam ( Tilcotil, Mobiflex, 6011 )
 New Approved :
Flurbiprofen, Indomethacin ( 4.6 ), Ibuprofen (OTC, 2.1 ), Oxaprozin ( 5810 ), Sulindac ( 14  8 ), Tolmetin
( 1.0, 6.8 , 2 phase ), Nabumetone ( 265 ), Meloxicam ( Mobic ), , Nimesulide ( Aulin,Mesulin ), Celecoxib
( Celebrex , 11), Rofecoxib ( Vioxx, 17 )** ( ) : the plasma half life
18
 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.

19
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

20
 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

21
Anti-thrombosis drugs
Antiplatelet agents Anticoagulant agents
1st Aspirin Heparin
generation Thienopyridine(ticlopidine & clopidogrel) Warfarin
2nd GPIIb/IIIa antagonists Low-MW heparins
generation Aspirin + clopidogrel Hirudin
Novel Inhibitors of vWf-GP1b interaction Inhibitors of tissue factor(VIIa)
approach Inhibitors of collagen-platelet interaction Selective factor Xa inhibitors
Inhibitors of thrombin-induced activation Selective thrombin inhibitors
Direct ADP receptor antagonists Human activated ptotein C
NO-releasing antiplatelet substances Soluble recombinant
thrombomodulin

 vWf-GP1b= von Willebrand factor-glycoproten

[Ref] TiPS 23: 25-32, ‘02

22
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. Vane

Kaarolinska Inst,Stockholm,Sweden The Wellcome Res. Lab., Beckenham, UK
Biochemical 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. 23
 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.
24
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 25
 1. Background :
Existence of two isozymes of COX was shown in 1991 by Xie et al. ( PNAS, 88, 2692-2692).
2. Structure : 64% similarity
Cox-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 –385
Pocket : 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 ),
glucocorticoids
The 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 k
Cell distribution stomach, kidney, platelet marcophage, monocyte, synovial
Function homeostasis inflammatory response ( ? )
Gene location chromosome 9 chromosome 1
Range 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
26
 
 
 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 element
3. CCAAT/ enhancer binding protein
4. 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

27
28
 COX-2 selective inhibitors
Proc. Nat. Acad. Sci. 96: 7563-68, ’99
JPET 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

29
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.

30
 COX-2 抑制劑 ( Celocoxib ) 使用須知
• 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 31

。
 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
32
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。
 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, toxic
epidermal necrolysis
Withdrawal due to : higher-than-normal CV risk and
potentially life-threatening skin reactions.
33
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 yr
2. 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)

34
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.

35
 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, IB-( 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 36
 Gout ( monosodium-urate ppt, ~50% normal [uric
acid] )
 Coating with IgGchemotatic, lysosomal, IL-1,-6,-
18, PGE2, LTB4, oxygen radical, collagense,
caspase
 Rx: acute : NSAIDs > steroids > colchicine (p.o.) ,steroids
FDA 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‧2H2O) crystal
37
 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 38

IL-6 : Fever, Induces acute phase protein production

anti-inflammatory cytokines : IL-10, TGF-, TNF-binding protein, IL-1R
anti-inflammatory hormones : glucocorticoids, -MSH
antiinflammatory autocoids : Spermine, PGE2, Fetuin, heat-shock protein, acute phase
proteins

39
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)


40
Asthma : an Chronic inflammation

41
42
Leukotrienes : Potent and sustained bronchoconstriction, Mucus hypersecretion, Edema formation

& Eosinophil chemoattraction

Leukotriene-Modifying Drugs for

1. 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®) 43
CysLTs in asthma & its blocker

44
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 CysLT 1 receptor
1. Zafirlukast antagonizes the activity of LTC 4, 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.
45
 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

46
 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
41 delayed-type hypersensitivity fibroblast activation, bone
destruction
47
Mechanism of action of drugs used to treat RA

48
 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.

49
 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,

50
51
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 process
that 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
N Engl J Med. 340: 253-59, ’99
TiPS. 25: 201-209, ‘04
Molecule Medicine Today 4: 277, ’98
Rheumatology 39: 689-92, ’00
52
 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
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 antibodies
c. 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) 53
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.

54
B. TNF expression as body’s fire alarm : essential
for invasive inflammation

55
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 leakage
3. 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 cytokines
2. Decrease synovial cell infiltration
3. Interference with osteoclast activation
4. Decrease angiogenesis
5. Also shown efficacy in Crohn’s disease, ankylosing spondylitis, psoriasis and psoriatic
arthritis, but it is ineffective, and even contraindicated in multiple sclerosis

56
 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 )

57
 Infliximab ( Remicade / Centocor ) : approved in Nov. '99.

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 )

58
 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.,

 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
59
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
60
 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 lymphocytes
Rituximab (non-Hodgkin’s lymphoma in ‘97) in ’06, anti-CD20 monoclonal Ab that causes lysis of CD20 B 61
cells combined with methotrexate for moderate to severe RA
Anti-TNF therapy of RA
 Mechanism of action :
1. ⇩ IL-6, IL-1, GM-CSF & VEGF- proinflammatory cytokine
2. ⇩ expression of adhesion molecules and chemokine-induced leukocyte trafficking
3. ⇩ 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 )
62
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.

63
 Leflunomide: dihydroorotate Dhase inhibitor
antiproliferative + antiinflammatory + immunosuppressive

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 NFB (via induction of
degradation of its inhibitor IB )
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
64
and the never ending rheumatoid arthritis story. Rheumatology 2000 39: 689-692.
 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

65
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 reactionsmethylprednisolone

66
67
68
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. 69
 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 inhibitors
e.g. AstraZeneca (Heterocyclic
carboxamide), Aventis (PS1145),
Novarits (NVPIKK004)
•IKK & IKK inhibitor :
sulfasalazine
•IKK inhibitor : aspirin,sulindac
•Nature products:curcumin,
quercetin, aspirin, geliotoxin,
lactacystin
70
Cytokine : an marker of Chronic inflammation involved in signal
transduction & activation of transcription factors

71
Health is the only worth in your heart

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