IκB kinase inhibition as a potential treatment of osteoarthritis - results of a clinical proof-of-concept study.

OBJECTIVE: This publication summarizes the clinical development of the compound SAR113945, an IκB kinase inhibitor injected intra-articularly in a slow-release formulation to treat patients with symptomatic osteoarthritis (OA) of the knee. RESULTS: In vitro experiments demonstrated a specific inhibition of the IκB kinase complex. Profiling of SAR113945 on kinases, enzymes and ion channels supported the initiation of a clinical development. Cellular assay systems also revealed an inhibition in the synthesis of interleukin 1ß, tumor necrosis factor α (TNFα) and the prostaglandin E2 (PGE2). In vivo studies demonstrated positive effects of SAR113945 on thermal and mechanical hyperalgesia and even showed superiority in comparison with triamcinolone. Pharmacokinetic measurements showed a sustained release of dissolved SAR113945 locally supporting a comparably high exposure in the knee joint combined with a low systemic exposure. Three phase 1 studies with a dose-escalating design confirmed safety and tolerability of SAR113945. In those studies SAR113945 showed a positive trend on the WOMAC scores. The proof-of-concept or phase 2a study failed to show any effect in the overall group of recruited study participants for the primary endpoint, the WOMAC pain subscore at day 56, but showed a statistically significant difference in a subgroup of patients who had presented with effusion at baseline. CONCLUSION: Inhibiting the NFκB signaling pathway is an attractive method to treat patients with signs and symptoms of OA. The preclinical work and the results of the phase 1 studies appeared promising for a full clinical development, however, the proof-of-concept study failed to show efficacy in a larger patient sample size.

The anion-transport inhibitor H2DIDS cross-links hemoglobin interdimerically and enhances oxygen unloading.

Human hemoglobin treated with equal concentrations of the anion-transport inhibitor H2DIDS produces a right shift in the oxygen dissociation curve. concomitantly, the Hill coefficient is reduced from n = 2.7 to 2.1. When higher concentrations of H2DIDS are applied (H2DIDS: hemoglobin = 5:0.5 mM), the Hill coefficient decreases further to 1.5 and the oxygen dissociation curve of hemoglobin is shifted slightly to the left of the control. Similar results were also obtained with DIDS instead of H2DIDS. SDS-PAGE shows that H2DIDS cross-links hemoglobin monomers mainly into dimers. Cross-linking is more effective under anaerobic conditions. With tritiated H2DIDS the larger part of the radioactivity is found in the dimer position of hemoglobin. Separation of the alpha and beta units of hemoglobin reacted with tritiated H2DIDS demonstrated a stoichiometry of 2.2 and 2.4 molecules H2DIDS per molecule alpha and beta unit hemoglobin, leading to about 8-9 H2DIDS molecules per native hemoglobin. The right shift produced in the hemoglobin oxygen dissociation curve and the cross-linking of monomers into dimers, especially under anaerobic condition, suggest that H2DIDS can also react with those amino groups of hemoglobin which are involved in 2,3-DPG binding. A comparison of H2DIDS, DIDS and 2,3-DPG at three different concentrations close to the hemoglobin concentration revealed a concentration dependent right shift in the oxygen dissociation curve with the order of potency 2,3-DPG greater than H2DIDS greater than DIDS. The Hill coefficients (n) at the three concentrations of 2,3-DPG demonstrated no changes, but H2DIDS and DIDS reduced in a concentration-dependent manner the cooperativity of hemoglobin. Again, H2DIDS is more potent than DIDS, especially at the low concentration. These anion-transport inhibitors provide novel approaches to the exploration of hemoglobin function.

Neuroprotective role of adenosine in cerebral ischaemia.

Several lines of evidence suggest that adenosine may be an endogenous protective agent in cerebral ischaemia. Adenosine is normally present in the extracellular fluid in most tissues of the body, including the brain, and its level increases dramatically following hypoxia or ischaemia. The rate of adenosine production is enhanced when the energy demand is larger than the rate of energy supply. Adenosine acts on specific receptors that are present in most cells in the body and that produce cellular effects that tend to antagonize a number of pathological events thought to be instrumental for ischaemic nerve cell death. Karl Rudolphi and colleagues review evidence for the neuroprotective potential of adenosine and indicate some targets for drug development.

Effect of theophylline on ischemically induced hippocampal damage in Mongolian gerbils: a behavioral and histopathological study.

We investigated the influence of the adenosine antagonist theophylline on the degree of hippocampal cell damage in the Mongolian gerbil following brief periods of forebrain ischemia. Male gerbils were randomly divided into nine groups. Ten minutes before surgery, four groups, which were later subjected to 1, 2, 3, or 5 min of bilateral carotid occlusion under halothane anesthesia, received theophylline (30 mg/kg, p.o.). Four groups served as nontreated ischemic controls; the ninth group was used to measure theophylline serum concentration. Neurological symptoms were classified by using a behavioral score. Fourteen days after ischemia, the brains were removed, and the hippocampus was histologically examined "blind" for the degree of cell damage in the CA1 sector, which was expressed as a semiquantitative histopathological score. There were no behavioral or histological abnormalities in either the control or theophylline group with 1 min of ischemia. With increasing duration of ischemia, the neurological symptoms worsened and the number of necrotic pyramidal cells increased significantly. The pretreatment with theophylline only moderately aggravated the neurological symptoms, whereas it enhanced the ischemic cell damage significantly. The results are discussed with respect to recent findings that theophylline may block putatively protective effects of endogenous adenosine, whose concentration in the brain is known to rise significantly during ischemia.

Ischemia-induced neuronal cell death, calcium accumulation, and glial response in the hippocampus of the Mongolian gerbil and protection by propentofylline (HWA 285).

The localization and timing of cellular calcium loading and glial cell reaction in relation to selective death of hippocampal neurons was studied in Mongolian gerbils following transient forebrain ischemia. Two days after a 5-min period of ischemia, heavy calcium staining was histochemically demonstrated in circumscribed groups of nerve cells, located in the transition zone between the CA1 and CA3 areas. This preceded complete neuronal cell death that was quantitatively assessed by measuring the intensity of Nissl staining. After a 12-min period of ischemia, extensive calcium loading was observed in conjunction with severe neuronal damage throughout the CA1 region as well in the dorsal nuclei of the thalamus. The extent of calcium staining decreased with time and was not seen at stages later than 7 days. Already at 2 days after a 5-min period of ischemia, a strong increase of glial fibrillary acidic protein immunoreactivity was seen. This indicates a marked and early hypertrophy of astrocytes that was not accompanied by an obvious proliferation. Neither the astrocytic response nor the neuronal calcium accumulation were observed in gerbils pretreated with propentofylline, HWA 285 (10 mg/kg, i.p.) 15 min before bilateral carotid artery occlusion. Also, the decrease of Nissl staining in the CA1 area after 5 and 12 min of ischemia was considerably less pronounced and did not significantly differ from sham-operated controls.

Effects of adenosine and its analogues on porcine basilar arteries: are only A2 receptors involved?

The aim of this study was to test the effect of adenosine and four of its analogues, 5'-(N-ethyl)carboxamidoadenosine (NECA), 2-chloroadenosine (2-CADO), L-phenylisopropyladenosine (L-PIA), and N6-cyclohexyl-adenosine (CHA), on prostaglandin (PG) F2 alpha-constricted pig basilar arteries, and from their rank order of potency determine the receptor type involved. The order of potency for the relaxation of the PGF2 alpha constriction was NECA greater than adenosine, 2-CADO greater than L-PIA greater than CHA, which is in keeping with the A2 receptor subtype. The study also investigated the effects of a known adenosine antagonist, namely, the xanthine derivative 8-phenyltheophylline, which at concentrations having no intrinsic effect (10(-8) and 10(-7) M) produced a significant shift to the right only for the NECA dose-response curve.

Modulation of intracellular formation of reactive oxygen intermediates in peritoneal macrophages and microglia/brain macrophages by propentofylline.

Ischemia-induced nerve cell death can partly be prevented by propentofylline, a pharmacon structurally related to xanthine derivates that interacts with the neuromodulatory function of endogenous adenosine. To evaluate a possible mechanism of neuroprotection by propentofylline, we studied its effect on the cellular production of reactive oxygen intermediates in microglial cells, which under pathological conditions can differentiate into brain macrophages, in comparison to peritoneal macrophages. Using a flow cytometric assay, we determined the intracellular formation of reactive oxygen intermediates by measuring the oxidation of the membrane-permeable and nonfluorescent dihydrorhodamine 123 to the cationic and intracellularly trapped, green fluorescent rhodamine 123 in single viable cells. Propentofylline at the therapeutic concentration of 50 microM completely inhibited the Ca(2+)-dependent Con A-induced increase in the production of reactive oxygen intermediates in peritoneal macrophages. In isolated and cultured microglial cells, which have a high spontaneous respiratory burst activity, the spontaneous production of reactive oxygen intermediates was reduced by approximately 30%. A phorbol 12-myristate 13-acetate-induced rise in the respiratory burst activity could not be inhibited by propentofylline in either cell type. An increased generation of reactive oxygen intermediates is thought to contribute to nerve cell death after brain ischemia, edema, and neurodegenerative diseases like Alzheimer's disease. These pathological conditions are all accompanied by an activation of microglial cells. We therefore suggest that the neuroprotective properties of propentofylline might in part be due to a modulation of the microglial production of potentially harmful reactive oxygen intermediates.

Synthesis, resolution, and SAR of (+/-)-2-amino-N-methyl-alpha-(3-methyl-2-thienyl)benzeneethanamine++ + and related analogs as noncompetitive NMDA antagonists with neuroprotective properties.

The preparation and structure-activity relationships of a series of 2-amino-alpha-thienylbenzeneethanamines are described. From this work, (+/-)-2-amino-N-methyl-alpha-(3-methyl-2-thienyl)-benzeneethanamine++ + (3a) and the homologous N-ethyl analog 3b emerged as novel noncompetitive NMDA antagonists with neuroprotective properties. Optical resolution of 3a and X-ray crystallography of (+)3a were performed. The racemate and enantiomers were evaluated for neuroprotective properties in models of ischemia-induced hippocampal damage (gerbil) and cerebral focal ischemia (rat). Pretreatment with 3a, (+)3a, or (-)3a significantly reduced ischemia-induced CA1 hippocampal damage. Posttreatment with 3a afforded a lower degree of neuroprotection. A highly significant reduction in infarct volume was observed with 3a in the cerebral focal ischemia model, with only weak positive effects being displayed by (+)3a. Dose-limiting side effects were associated with all three compounds in this model. In summary, the results demonstrate the utility of noncompetitive NMDA antagonists as neuroprotective agents for ischemia-induced neurodegeneration.

Effect of propentofylline (HWA 285) on extracellular purines and excitatory amino acids in CA1 of rat hippocampus during transient ischaemia.

1. The adenosine uptake blocker propentofylline (HWA 285) has previously been shown to protect hippocampal CA1 pyramidal cells from ischaemia-induced delayed neuronal death. The influence of propentofylline, on the extracellular concentrations of purines, aspartate and glutamate in the CA1 of the rat hippocampus during transient forebrain ischaemia was investigated. 2. Twenty min of ischaemia was induced by four-vessel occlusion in Wistar rats, extracellular compounds were sampled by use of microdialysis and EEG was recorded by a tungsten electrode attached to the dialysis probe. 3. Propentofylline (10 mg kg-1 i.p.) did not influence the basal levels of any of the compounds in the hippocampal dialysates. 4. The EEG became isoelectric within 20 s after induction of ischaemia. 5. Extracellular adenosine, inosine, hypoxanthine, aspartate and glutamate increased several fold during ischaemia and remained elevated during early reflow. Within 2 h of reperfusion the concentration of all compounds was normalized. Xanthine increased upon reperfusion and remained elevated after 2 h. 6. Propentofylline (10 mg kg-1 i.p.) administered 15 min before ischaemia significantly enhanced the ischaemia-evoked increase of adenosine but attenuated the increases of the other purine catabolites and of glutamate. 7. In separate in vitro experiments, propentofylline did not inhibit adenosine deaminase activity. 8. The present data show that propentofylline enhances extracellular adenosine and lowers extracellular glutamate in vivo during ischaemia. These findings may be important in relation to the neuroprotective properties of propentofylline.

Protective mechanisms of adenosine in neurons and glial cells.

As illustrated in Figure 1, a disturbance of the intracellular Ca2+ homeostasis is thought to be a common pathogenic factor for the generation of secondary nerve cell damage that develops after brain trauma or stroke or during the course of neurodegenerative diseases. A neuronal Ca2+ overload which may result from an excessive glutamate-evoked membrane depolarization and consecutive Ca2+ influx as well as from an activation of metabotropic receptors and consecutive intracellular Ca2+ mobilization is known to have direct toxic effects on the cytoskeleton and the cell metabolism of neurons. In addition, a Ca(2+)-dependent activation of glial cells along with the loss of physiologically required mature astrocyte functions and with the acquisition of potentially neurotoxic microglial properties, has more recently been recognized as an additive pathogenic factor. This may provide an effective target for pharmacological interference. Specifically, the reinforcement of an endogenous homeostatic regulator, which obtained its sophisticated know-how during evolution, may provide a neuroprotective therapy which can handle the complexity of the pathological process with a minor risk of pharmacological side effects. Adenosine is such an ancient molecular signal that acts on both neurons and glial cells. In neurons, adenosine activates K+ and Cl- conductances, which limits synaptically evoked depolarization, thus counteracting the Ca2+ influx through voltage-dependent and NMDA receptor-operated ion channels. This A1 receptor-mediated effect seems to be the major action by which adenosine adds directly to the protection of neurons against Ca(2+)-dependent damage. In glial cells, the prevalent effect of adenosine is its regulatory influence on the Ca2+ and cAMP-dependent molecular signaling that determines the cellular proliferation rate, the differentiation state and related functions. When mimicking the activation of metabotropic glutamate receptors in cultures of immature rat astrocytes, which largely resemble pathologically activated astrocytes, a transient Ca2+ mobilization was initiated by adenosine. This A1 receptor-mediated Ca2+ signal caused a prolonged potentiation of the A2 receptor-mediated intracellular cAMP rise. An experimentally sustained enhancement of the cAMP signaling initiated the differentiation of cultured astrocytes and the new expression of K+ and Cl- channels which are required for the physiological astrocyte function to maintain the extracellular ion homeostasis. Evidence is accumulating that a strengthening of the cAMP signaling, which can be achieved by adenosine agonists and also by the pharmacon propentofylline (an adenosine uptake blocker and phosphodiesterase inhibitor), stimulates the mRNA production of neurotrophic factors in astrocytes. In cultured microglial cells, several days' treatment with adenosine agonists or propentofylline markedly inhibited their proliferation rate, the in vitro spontaneously occurring transformation into macrophages and their particularly high formation of free oxygen radicals. Adenosine agonists also depressed the release of the potentially toxic cytokine TNF alpha and induced programmed cell death in immunologically activated microglial cells. We conclude that a pharmacological reinforcement of the endogenous cell modulator adenosine may provide neuroprotection by counteracting neuronal Ca2+ overload, by depressing potentially neurotoxic microglial functions and by regaining physiologically required properties of differentiated astrocytes. Further information about the influence of adenosine on the molecular signaling and on ischemic brain damage is given in Refs. 37 and 38, and about the implicated possible relevance for the treatment of stroke in Ref. 39.

HWA 285 (propentofylline)--a new compound for the treatment of both vascular dementia and dementia of the Alzheimer type.

The pharmacological profile of HWA 285 favors its use in patients with both Alzheimer's disease (PDD) and/or vascular dementia (MID). Clinical trials showed clinically relevant, statistically significant efficacy in the domains of cognitive function, global function and activities of daily living (ADL) in both PDD and MID. HWA 285 had a prolonged symptomatic effect for at least 12 months, although therapeutic effects were seen already after the first 3 months of treatment. HWA 285 was very well tolerated for at least 1 year.

Support of homeostatic glial cell signaling: a novel therapeutic approach by propentofylline.

A pathological glial cell activation, which forces microglia to transform into immunocompetent cells with cytotoxic properties and astrocytes to "de-differentiate," presumably adds to neurodegenerative diseases. We examined the modulatory effect of adenosine on the Ca2+ and cAMP-dependent regulation of such reactive glial cell properties in culture and tested possibilities of pharmacologic reinforcement. A strengthening of the cAMP-signaling, as could be achieved by adenosine agonists via a Ca(2+)-dependent action, favored the differentiation of proliferating astrocytes and associated neuroprotective properties (ion homeostasis, formation of trophic factors). But potentially neurotoxic properties of microglial cells were inhibited. Adenosine depressed their proliferation rate and transformation into macrophages, their particularly high formation of reactive oxygen intermediates and the release of the cytokine TNF-alpha. Similar effects were obtained with propentofylline, which acts as selective cAMP/cGMP phosphodiesterase inhibitor and also increases the effective concentration of adenosine by blocking its cellular reuptake. The recently observed induction of microglial apoptosis by elevated extracellular adenosine levels may further contribute to limit secondary nerve cell damage related to a pathological glial cell activation.

Propentosylline depresses amyloid and Alzheimer's CSF microglial antigens after ischaemia.

In the gerbil hippocampus activated microglial antigens are intensely stained by cerebrospinal fluid from patients with Alzheimer's disease (AD-CSF), OX18 and the amyloid precursor protein (beta-APP) up to 14 days after ischaemia. Propentosylline (PPF), which facilitates the adenosine A2 receptor action, has been shown to be neuroprotective, to depress O2- radical formation in macrophages and to interfere with the generation of phagocytotic macrophages from cultivated microglial cells. In this report we tested in ischaemic gerbils whether PPF treatment influences the potential neurotoxic properties of microglia. Daily post-treatment with PPF, started 24 h after ischaemia, depressed the immunostaining of activated microglia by AD-CSF, OX18 and APP in the hippocampus. Thus, PPF may protect against microglia-related brain damage.

Modulation of neuronal and glial cell function by adenosine and neuroprotection in vascular dementia.

Dementia is one of the major medical challenges in the industrialized countries. An increasing number of demented patients shows ischemic brain lesions. One strategy to treat dementia could be the reinforcement of the multifarious neuroprotective actions of the endogenous cell modulator adenosine. This involves the modulation of neuronal and glial cell functions. Adenosine appears to raise the threshold for the initiation of the pathophysiological cascade of ischemic neuronal death by counteracting ischemic membrane depolarization and the successive disturbance of intracellular Ca2+ homeostasis. When this threshold is overcome, adenosine seems to stimulate astrocyte differentiation and reinforce important protective astrocyte functions, e.g., synthesis and release of neurotrophic factors such as NGF and the clearance of abnormal neurotoxic levels of K+ and glutamate from the extracellular space. Propentofylline, a combined inhibitor of adenosine reuptake and cAMP phosphodiesterases, reinforces the actions of endogenous adenosine and cAMP. One important action of propentofylline is the inhibition of potentially neurotoxic functions of activated microglia (free radical formation and transformation into brain macrophages). Such drugs may help to inhibit the progressive neurodegenerative process in dementia.

Protective effect of adenosine and a novel xanthine derivative propentofylline on the cell damage after bilateral carotid occlusion in the gerbil hippocampus.

The role of adenosine in the development of ischemia induced pathological changes has been examined in Mongolian gerbils. A dramatic increase in the concentrations of adenosine, inosine and hypoxanthine was detected by microdialysis in the dorsal part of hippocampus and in the striatum immediately after 5 min bilateral occlusion of the carotid arteries. From a resting value of about 0.5 microM the concentration of adenosine increased to more than 10 microM. The adenosine levels became normalized within 30 min after ischemia. Inosine and hypoxanthine levels were higher and they increased and also returned towards control somewhat later than adenosine. A second occlusion resulted in a similar but somewhat smaller increase in purine levels. Carotid occlusion for up to 12 min had no major, lasting effect on the binding to adenosine A1-receptors in the CA-regions of the hippocampus, as determined by autoradiography. Neuronal and vascular changes (degeneration of neurons, mitochondrial destruction and ribosomal disaggregation, astroglial oedema) due to ischemia (3-12 min, followed by 48 h recirculation) was studied with light and electron microscopy in the selectively vulnerable CA1 area of hippocampus. In one series of experiments the adenosine antagonist theophylline (20 mg/kg i.p.), given 15 min prior to a 5 min occlusion, significantly enhanced the ischemia induced changes. In another experiment the adenosine uptake inhibitor propentofylline (HWA 285, 10 mg/kg), injected 15 min before a 12 min carotid occlusion, reduced the neuronal (90%) and astroglial changes (84%) due to ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Amyloid beta-(1-40) stimulates cyclic GMP production via release of kinins in primary cultured endothelial cells.

Increased beta-amyloid production is believed to play a central role in the pathogenesis of Alzheimer's disease. Amyloid is deposited not only in the brain of Alzheimer patients as senile plaques but also in the cerebral vessel wall leading to cerebral amyloid angiopathy. Freshly solubilised amyloid beta-(1-40) was previously reported to exert a vasoconstrictor effect. We investigated whether amyloid beta-(1-40) affects the nitric oxide (NO)/cyclic GMP pathway in primary cultured endothelial cells from bovine aorta and rat coronary microvessels. Surprisingly, a significant increase in cyclic GMP production after incubation with freshly dissolved amyloid beta-(1-40) was found. The stimulation of cyclic GMP production could be inhibited by the bradykinin B(2) receptor antagonist icatibant, the NO synthase inhibitor N-omega-nitro-L-arginine, the serine protease inhibitor 3, 4-dichloroisocoumarin and the selective plasma kallikrein inhibitor Pefabloc PK, suggesting activation of the plasma kallikrein-kinin system. This is supported by a three- to four-fold increase in kinins in the supernatant of both types of endothelial cells after incubation with amyloid beta-(1-40) at concentrations of 10(-7) and 10(-6) mol/l.

Antiischemic effects of propentofylline (HWA 285) against focal cerebral infarction in rats.

The effects of the xanthine derivative propentofylline (HWA 285), an inhibitor of adenosine transport, on ischemic brain damage have been evaluated in a model of permanent middle cerebral artery (MCA) occlusion in rats. During the postischemic survival period of 24 h, the animals were subjected to neurological and behavioral observations and then sacrificed to assess the extent of ischemic tissue damage by tetrazolium chloride. Posttreatment with propentofylline (0.01, 0.05 or 0.1 mg/kg/min, continuous i.v. infusion) initiated 15 min following MCA occlusion, produced significant reductions in infarct volumes; the highest being the most effective (reduction by 39%; P < 0.005) and improved the neurological symptoms when compared with an untreated control group. In contrast to other antiischemic agents, such as glutamate receptor antagonists, the drug induced no behavioral disturbances. This study indicates that propentofylline may provide neuroprotective effect against ischemic brain damage following stroke without negative behavioral side effects.

Ischaemic damage in gerbil hippocampus is reduced following upregulation of adenosine (A1) receptors by caffeine treatment.

We have used the fact that long-term caffeine treatment upregulates the adenosine receptors, to examine the role of adenosine in ischaemia. Four-week oral treatment with caffeine (0.2% in drinking water) caused a significant (10-17%) increase in the binding of the adenosine A1-receptor ligand [3H]cyclohexyl-adenosine (CHA) to several brain regions, including the hippocampal CA1 area, in Mongolian gerbils. Animals subjected to such treatment exhibited significantly less neuronal damage in the CA1 region following 5 min bilateral carotid occlusion than did control animals (50% of the caffeine-treated animals showed no damage at all compared to 11% in the control group). Our findings provide further evidence for a protective role of endogenous adenosine during ischaemia.

Propentofylline attenuates microglial reaction in the rat spinal cord induced by middle cerebral artery occlusion.

This study examines the effect of Propentofylline (PPF) on reactive microglia in the lumbar spinal cord in rats following focal cerebral ischaemia produced by permanent occlusion of the middle cerebral artery (MCA). Our results showed that daily treatment of PPF beginning at 24 h after MCA occlusion for 2 or 4 consecutive days markedly suppressed the microglial response as detected immunohistochemically with OX-42. The most dramatic effect was the prevention of transformation of ramified microglia into amoeboidic form as well as formation of perineuronal microglia in close association with the soma of motoneurons. This has greatly amplified the potentiality of PPF used as a neuroprotective drug against microglia-related neuron damage induced by cerebral ischaemia.