An Updated Review on the Metabolite (AM404)-Mediated Central Mechanism of Action of Paracetamol (Acetaminophen): Experimental Evidence and Potential Clinical Impact.

Paracetamol remains the recommended first-line option for mild-to-moderate acute pain in general population and particularly in vulnerable populations. Despite its wide use, debate exists regarding the analgesic mechanism of action (MoA) of paracetamol. A growing body of evidence challenged the notion that paracetamol exerts its analgesic effect through cyclooxygenase (COX)-dependent inhibitory effect. It is now more evident that paracetamol analgesia has multiple pathways and is mediated by the formation of the bioactive AM404 metabolite in the central nervous system (CNS). AM404 is a potent activator of TRPV1, a major contributor to neuronal response to pain in the brain and dorsal horn. In the periaqueductal grey, the bioactive metabolite AM404 activated the TRPV1 channel-mGlu5 receptor-PLC-DAGL-CB1 receptor signaling cascade. The present article provides a comprehensive literature review of the centrally located, COX-independent, analgesic MoA of paracetamol and relates how the current experimental evidence can be translated into clinical practice. The evidence discussed in this review established paracetamol as a central, COX-independent, antinociceptive medication that has a distinct MoA from non-steroidal anti-inflammatory drugs (NSAIDs) and a more tolerable safety profile. With the establishment of the central MoA of paracetamol, we believe that paracetamol remains the preferred first-line option for mild-to-moderate acute pain for healthy adults, children, and patients with health concerns. However, safety concerns remain with the high dose of paracetamol due to the NAPQI-mediated liver necrosis. Centrally acting paracetamol/p-aminophenol derivatives could potentiate the analgesic effect of paracetamol without increasing the risk of hepatoxicity. Moreover, the specific central MoA of paracetamol allows its combination with other analgesics, including NSAIDs, with a different MoA. Future experiments to better explain the central actions of paracetamol could pave the way for discovering new central analgesics with a better benefit-to-risk ratio.

Secretion of MMP-2 and MMP-9 induced by VEGF autocrine loop correlates with clinical features in childhood acute lymphoblastic leukemia.

In children with acute lymphoblastic leukemia (ALL), leukemic cells express several members of the VEGF family and the three VEGF receptors which, via an autocrine loop are responsible for secretion of MMP-2/-9. MMP activity and the presence of elements of the autocrine loop are correlated with clinical and prognostic parameters as follows: i) high basal MMP-9 activity with tumoral syndrome, ii) MMP-2 activity with treatment failure, iii) VEGFR-1/-3 co-expression with high hemoglobin level and iv) expression of the VEGF-A 121 isoform and favorable response to treatment. These data implicate autocrine VEGF-induced secretion of MMP-2/-9 in the physiopathology of childhood ALL.

Spontaneous and cytokine-evoked production of matrix metalloproteinases by bone marrow and peripheral blood pre-B cells in childhood acute lymphoblastic leukaemia.

The present work focused on the study of the secretory activity of pre-B acute lymphoblastic leukaemia (ALL) cells harvested from bone marrow (BM) and peripheral blood (PB) in 16 children. The basal and cytokine (SDF-1, GM-CSF, bFGF, VEGF)-stimulated secretions of gelatinases 2 and 9 (MMPs-2 and -9) and expression of their genes were monitored by zymography and RT-PCR, respectively. A wide heterogeneity was found in the secretory capacities of these cells. The basal secretion of MMP-9 was more frequently observed than that of MMP-2 in both cell types. The cytokines VEGF and bFGF were found to induce predominant stimulatory effects on the MMP-2 secretion. In contrast, GM-CSF was shown to exert a more pronounced activation of the MMP-9 production. Experiments using inhibitors of metabolic pathways (U0126, LY294002 and SN50) revealed that the secretion of MMP-9 was mediated through PI3/MEK1 kinases. The MMP-2 secretion appeared to be however, stimulated through a different metabolic pathway. The microfluorimetric approach showed that the basal and stimulated secretions of MMPs-2 and -9 depended on the extracellular calcium pool. The cytokines VEGF and bFGF represent potent factors increasing the intracellular calcium concentration with similar kinetics. In contrast, GM-CSF was found to activate a verapamil-sensitive efflux of indo-1 from cytosol suggesting that this cytokine could be responsible for the activation of xenobiotic membrane transporters. Experiments using the trypan blue exclusion test demonstrated that bFGF, in contrast to VEGF and GM-CSF, markedly augmented pre-B ALL cell survival. Further investigations into a possible correlation between the plasma concentrations of MMP-2 and -9, VEGF, bFGF and GM-CSF, and the poor evolution of pre-B ALL in children could have valuable diagnostic implications.