Anti-inflammatory drugs: new multitarget compounds to face an old problem. The dual inhibition concept

In this short review we have tried to focus on some new relevant aspects of the pharmacological control of inflammation. The clinical availability of new drugs able to produce a selective inhibition of type 2 cyclooxygenase (COX-2), the enzyme thought to be mainly responsible for generating arachidonic-acid-derived inflammatory mediators, has been the origin of much hope. However, expectations of having an effective and completely safe non-steroidal anti-inflammatory drug (NSAID) have been only partially fulfilled. Emerging information has challenged some aspects of the original hypothesis indicating COX-2 as devoid of 'housekeeping' physiological functions. Moreover, the recently available clinical studies have indicated only a relatively small improvement in the tolerability of the newer 'selective' COX-2 inhibitors over the classical COX-1/COX-2 mixed type NSAIDs. The new appreciation of the role of other arachidonic acid derivatives, the leukotrienes (LTS), in producing and maintaining inflammation has generated considerable interest in drugs able to block LTS receptors or to produce a selective inhibition of 5-lipoxygenase (5-LO), the initial key enzyme of the leukotriene pathway. These drugs are now included among the effective therapies of asthma but appear, in the few clinical studies performed, to be an insufficient single therapeutic approach in other inflammatory diseases. Drugs able to block equally well both COX and 5-LO metabolic pathways (dual inhibitors) have been developed and experimentally evaluated in the last few years, but none are available on the market yet. The pharmacological rationale at the basis of their development is strong, and animal studies are indicative of a wide range of anti-inflammatory activity. What appears most impressive from the available studies on dual inhibitors is their almost complete lack of gastric toxicity, the most troublesome side effect of NSAIDs. The mechanism of the gastric-sparing properties of these drugs is not yet completely understood; however, it appears that leukotrienes significantly contribute to gastric epithelial injury particularly when these compounds represent the major arachidonic acid derivatives present in the gastric mucosa after inhibiton of prostanoid production.