Inducible nitric oxide synthase (iNOS): More than an inducible enzyme? Rethinking the classification of NOS isoforms

Nitric oxide (NO) is a critical signaling molecule synthesized from L-arginine by nitric oxide synthase (NOS). The three NOS isoforms-neuronal NOS (nNOS; NOS1), inducible NOS (iNOS; NOS2), and endothelial NOS (eNOS; NOS3)-have traditionally been classified as either constitutive (nNOS and eNOS) or inducible (iNOS). However, this binary classification oversimplifies their functions, particularly by neglecting the physiological roles of iNOS and misrepresenting its involvement in pathological processes. Increasing evidence demonstrates that all three isoforms can exhibit both constitutive and inducible expression. Notably, iNOS is constitutively expressed at low levels in several tissues, including blood, heart, bone marrow, lung, brain, spinal cord, retina, colonic mucosa, liver, ileum, skeletal muscle, epidermis, adipose tissue, endometrium, ovary, and kidney under normal physiological conditions, a form we refer to as constitutive iNOS (ciNOS). This basal expression contributes to essential functions such as heart rate regulation, respiratory exchange, and microbiome balance in the gut. Moreover, in certain pathological contexts, iNOS may exert protective rather than harmful effects, challenging the prevailing view that it is solely a pro-inflammatory mediator. Current drug development strategies targeting NOS are largely based on the outdated dichotomy of constitutive "physiologic" versus inducible "pathologic" isoforms, focusing primarily on iNOS inhibition. The failure of iNOS inhibitors in most clinical trials highlights the limitations of this approach. To address these gaps, we propose a revised nomenclature that incorporates both gene expression mode (constitutive vs. inducible) and discovery order, offering a more nuanced framework for understanding NOS isoforms in both health and disease.