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INFLAMMATORY SITE
Sensitized lymphocytes release soluble factors ( which recruit & mobilize macrophages to the inflammed tissue.)
Additional activated macrophages produce enhanced levels of enzymes and mediators Thereby involving macrophages in the defense against microorganisms and foreign antigens BUT remember that the inflammatory cells have the potential to destroy surrounding tissue.
Mediators of inflammation
4 signs of inflammation
Redness - due to local vessel dilatation Heat - due to local vessel dilatation Swelling due to influx of plasma proteins and phagocytic cells into the tissue spaces Pain due to local release of enzymes and increased tissue pressure
Major pathways
Eicosanoids
Eicosanoids a family of compounds that are the products of three main pathways which use oxygen as a major cosubstrate. The three pathways are: the cyclooxygenase pathway the lipoxygenase pathway the epoxygenase pathway.
ANTI-INFLAMMATORY DRUGS
salicylates e.g., ASA phenylpropionic acids e.g., ibuprofen, ketoprofen pyrazalone derivatives e.g., phenylbutazone indole derivatives e.g., indomethacin Remission inducing / disease modifying drugs: e.g. chloroquine, aurothioglucose, penicillamine, prednisolone
MECHANISM OF ACTION
Non-steroidal anti-inflammatory drugs (NSAIDs) All NSAIDs inhibit the cyclooxygenase required for conversion of arachidonic acid to endoperoxide intermediate (PGG2 and PGH2). NSAIDs inhibit prostaglandin and thromboxane synthesis, they are potent inhibitors of cyclooxygenase and eliminate all prostaglandins and thromboxanes in every cell they reach Recall that prostaglandins and thromboxanes play crucial roles in: Pain, Inflammation, Fever , Excessive blood clotting
Salicylate structure
Pyrazolone structure
Indole structure
Due to the adverse effects of Aspirin (esp. GI and antiplatelet), many newer NSAIDS have been developed.
Ibuprofen: PROPIONIC ACID DERIVATIVE -same potency as ASA . -better tolerated (fewer side effects) -ex. Advil; Motrin Available over the counter (OTC) Indomethacin: INDOLE DERIVATIVE -more potent than ASA but inferior at doses tolerated by rheumatoid arthritis patients. -quite toxic -PDA
Phenylbutazone: PYRAZOLONE DERIVATIVE -powerful anti-inflammatory drug -usefulness is limited by its toxicity -chiefly short-term therapy Piroxicam: -half-life = 45 hours -administer once a day ( increased convenience) -some GI disturbance
Sulindac: -inactive pro-drug closely related to indomethacin -must be metabolized by hepatic microsomal enzymes to active form -long duration of action (half-life = 8h) -adverse effects less severe than other NSAIDS (ex. GI and renal) -ex. Clinoril
Ketoprofen: -inhibits both cyclooxygenase and lipoxygenase (decreases PGs, TXs, and LTs) *recall LTs: bronchospam;bronchoconstriction -may be desirable for asthmatics or inflammation plus allergic response -ex.Orudis
COX-2 INHIBITORS Cyclooxygenase-1 (COX-1): -constitutively expressed in wide variety of cells all over the body. -"housekeeping enzyme" -ex. gastric cytoprotection, hemostasis Cyclooxygenase-2 (COX-2): -inducible enzyme -immediate-early gene product in inflammatory and immune cells -dramatically up-regulated during inflammation (10-18X)
Adverse effects of NSAIDS are theorized to be due to inhibition of COX-1 (ex. GI complications via decreased PGE2 and potentially altered blood flow) In some instances cytoprotectives e.g., misoprostol (PGE2 analogue) may be taken with NSAIDS to reduce GI effects. Selective COX-2 inhibitors were developed e.g., Celecoxib (Celebrex); Roficoxib (Vioxx) which was withdrawn in 2004 due to serious CV effects and in Sept. 2007 Merck agreed to pay 4.8 billion dollars settlement.
NO-NSAIDS
Less GI effects than parent NSAID from which they are derived. Comparable anti-inflammatory effect and superior analgesic effect Example: NO-naproxen Parent NSAID: naproxen
EPA
EPA is found in fish oil It acts as a substrate for cyclooxygenases and lipoxygenases (thus it competes with arachidonic acid for the enzymes) The prostaglandins, thromboxanes, and leukotrienes produced from EPA are less active than AA metabolites.
EPA
continued
These products can then compete with products of AA metabolism for shared target receptors.
Macrophages with a high content of EPA produce less TNF and IL-l (key pro-inflammatory cytokines) Thus, Dietary EPA supplementation can reduce tissue injury due to PGs, TXs, LTs, and cytokines!!
EPA
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Clinical studies have shown decreased morning stiffness and joint pain in rheumatoid arthritis patients with EPA supplementation Potency approximates NSAIDS, with negligible side effects!!
Glucocorticoids
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inhibit phagocytosis inhibit synthesis of IL-1, TNF, PGs LTs. inhibit antigen processing by macrophages stabilizes lysosomal membranes inhibits accumulation of neutrophils and monocytes at inflammation site. inhibit phospholipase A2.
Glucocorticoids
examples: prednisone dexamethasone Side effects: osteoporosis impaired wound healing edema, hypertension, congestive heart failure CNS effects (euphoria - psychosis) Cushingoid Syndrome