Nitric Oxide - Therapeutics, Markets and Companies

Table of Contents

0. Executive Summary 13

1. Introduction 15

• Free radicals 15
• Nitric oxide 15
• Historical aspects 15
• Role of NO in biology and medicine 16
• Nitric oxide synthase 17
• Structure and function NOS 17
• Inducible nitric oxide synthase 19
• iNOS gene 19
• Regulation of iNOS 19
• Regulation of endothelial nitric oxide synthase 19
• Interaction between eNOS and other proteins 20
• Tetrahydrobiopterin 21
• NOS-independent NO generation and circulation 21
• Entero-salivary circulation of nitrate 21
• Methods of study of NO and NOS 22
• Bioimaging of NO 22
• Assays of NO in tissues 22
• Metabolomics approach to study of NO metabolism 23

2. Nitric Oxide Pathways 25

• Introduction 25
• Mechanisms action of NO 26
• NO-cGMP pathway 26
• Soluble guanylyl cyclase as the NO receptor 27
• Oxidative stress pathways 27
• NO and oxidative stress 27
• Oxidative stress and the NO-cyclic GMP signal transduction pathway 28
• NO and platelets 30
• Mitochondrial NO-cytochrome c oxidase signaling pathway 30
• Nitric oxide and cytochrome c oxidase 31
• Dual role of NO as a free radical and a scavenger 32
• NO and carbon monoxide 32
• NO signaling and apoptosis 33

3. Role of NO in Physiology 35

• Homeostasis of NO 35
• NO as a biomarker 35
• Functions of NO in various systems of the body 35
• NO and proteins 36
• A proteomic method for identification of cysteine S-nitrosylation sites 36
• Protein S-nitrosylation and intracellular transport processes 37
• Cellular inactivation NO by iNOS aggresome formation 37
• NO and mitochondria 37
• Mitochondrial permeability and reperfusion injury 38
• Endocrine role of NO 38
• Role of NO in the cardiovascular system 39
• NO and atrial natriuretic peptide 39
• NOS in the cardiac myocyte 39
• NO and the autonomic control of the heart rate 41
• NO and vasodilatation 41
• Role of NO in the plasma compartment 42
• Measurement of NO as a biomarker of cardiovascular function 42
• Hemoglobin, oxygen and nitric oxide 43
• Myoglobin and NO 44
• NO and pulmonary circulation 45
• Role of NO in the regulation of hypoxic pulmonary vasoconstriction 45
• Role of NO in the nervous system 45
• Neurovascular coupling of COX-2 and nNOS 46
• Neuroglobin 46
• Acute actions of NO in the CNS pathways 47
• Role of NO in memory and learning 47
• Role of NO in synaptic plasticity 47
• Role of NO in the peripheral nervous system 48
• Role of NO in the cochlea 48
• NO and neuroendocrine function 48
• NO and pregnancy 48
• Role of NO in penile erection 49
• Role of NO in immune regulation 50
• Role of NO in temperature regulation 50
• Role of NO in gastrointestinal system 50
• Role of NO in kidney function 51
• Role of NO in liver 51
• Role of NO in the skin 51

4. Role of NO in Diseases 53

• Introduction 53
• Cytotoxicity of reactive nitrogen species 53
• Peroxynitrite, mitochondria and cell death 53
• Diseases involving oxidative stress and nitric oxide 55
• Stress-related disorders 56
• Role of NO in allergic disorders 56
• Inflammatory diseases 56
• Autoimmune disorders 57
• Role of NO in rheumatoid arthritis 58
• Role of NO in infections 58
• NO-mediated cytoprotection in bacteria 59
• Trypanosomiasis 60
• Malaria and iNOS polymorphism 60
• Susceptibility of Mycobacterium leprae to NO 60
• Role of NO in the treatment of tuberculosis 61
• Septic shock 61
• Viral infections 62
• Role of NO in anaphylactic shock 62
• Role of NO in neurological disorders 63
• Neurodegenerative diseases 63
• NO-induced mitochondrial dysfunction in neurodegeneration 63
• White matter disorders 63
• Amyotrophic lateral sclerosis 64
• Alzheimer' s disease 64
• Role of NO in pathophysiology of Alzheimer' s disease 65
• Role of ApoE genotype 67
• Parkinson' s disease 67
• Traumatic brain injury 69
• Epilepsy 69
• Stroke 70
• Pathophysiology of cerebral ischemia 70
• Role of NO in cerebral ischemia 71
• eNOS gene polymorphisms as predictor of cerebral aneurysm rupture 72
• Role of NO in assessment of cerebral and retinal blood flow 72
• Role of NO in neuroprotection 73
• Stroke and heart disease 73
• Role of NO in peripheral neuropathy 73
• iNOS induction in experimental allergic neuritis 73
• Role of NO in sciatica 73
• Role of NO in the pathogenesis of muscular dystrophy 74
• Role of NO in psychiatric disorders 74
• NO-dysregulation in schizophrenia 74
• Role of NO in pathomechanism of cardiovascular disorders 75
• Oxidative stress as a cause of cardiovascular disease 75
• Role of NO in pathomechanism of cardiovascular diseases 75
• Role of iNOS in cardiovascular disease 76
• Role of eNOS in cardiovascular disease 76
• Role nNOS in cardiac arrhythmia and sudden death 77
• NO and atherosclerosis 77
• Role of NO in cardiopulmonary disorders 78
• Role of NO in disturbances of vasodilation 79
• Role of NO in hypercholesterolemia 79
• Pulmonary hypertension 80
• NO and systemic hypertension 81
• Coronary artery disease 82
• Role of NO in the pathophysiology of angina pectoris 82
• Congestive heart failure 82
• Calcium overload as a cause of heart failure 83
• NO/redox disequilibrium in the failing heart 83
• Myocardial ischemia/reperfusion injury 83
• Role of NO in sickle cell disease 85
• Role of NO in respiratory disorders 85
• Role of NO in the pathophysiology of asthma 85
• iNOS gene polymorphisms in asthma 86
• Role of S-nitrosoglutathione in bronchodilation in asthma 87
• Monitoring of exhaled NO 87
• Nasal NO as a biomarker of response to rhinosinusitis therapy 88
• Elevated urinary NO as a biomarker of improved survival in ARDS 89
• Role of NO in renal disorders 89
• Role of NOS in diabetic nephropathy 89
• Role of NO in cancer 89
• Inflammation, NO and colon cancer 90
• Tumor hypoxia and NO 91
• NO and p53 mutations 91
• NO and matrix metalloproteinase 92
• Role of NO in angiogenesis in cancer 92
• Role of NO in diseases of the eye 93
• Glaucoma 93
• Role of NO in metabolic disorders 94
• Obesity 94
• Diabetes mellitus 94
• Role of NO in gastrointestinal disorders 94
• Role of L-arginine in intestinal adaptation 95
• Role of NO in irritable bowel syndrome 95
• Role of NO in inflammatory bowel diseases 95
• Role of NO in celiac disease 95
• Role of NO in diabetic gastroparesis 96
• NO and diseases of the liver 96
• Cirrhosis of liver 96
• Hepatic encephalopathy 96
• Role of NO in skin disorders 97
• Role of NO and oxidative stress in the aging skin 97
• Role of NO in wound healing 97
• Role of NO in pain 98
• NO and pain of spinal cord origin 98
• NO interaction with other receptors in pain 98
• nNOS and pain 98
• Role of NO in various types of pain 99
• Neuropathic pain 99
• Role of NO in diabetic neuropathy 99
• NO in oral and facial pain 99
• Role of NO in migraine 100
• Role of NO in osteoarthritis 100
• NO and Fibromyalgia syndrome 101
• Role of spinal NO in analgesic action 101
• Role of NO in nicotine addiction 102
• Role of NO in carbon monoxide poisoning 102
• Role of NO in chemically-induced toxicity 102
• Peroxynitrite and drug-dependent toxicity 102
• Paraquat neurotoxicity 103
• Role of NO in radiation damage 103

5. Pharmacology of Nitric Oxide 105

• Introduction 105
• Cytoxic vs cytoprotective role of NO 105
• Antioxidants 105
• Ebselen 106
• Nicaraven 106
• Nitroxides 107
• Antioxidants in relation to NO 107
• Nitric oxide as an antioxidant 108
• NO-related drugs 108
• Drugs that activate endothelial NO production 110
• Dehydroepiandrosterone 110
• Drugs that scavenge free radicals/NO 110
• Peroxynitrite scavengers 110
• Ruthenium (III) polyaminocarboxylates 110
• Nitrones 111
• Drugs that inhibit NO 111
• Ginko biloba 111
• Epigallocatechin 112
• Delivery of nitric oxide 112
• Targeted delivery of NO donors 112
• Nitric oxide delivery by encapsulated cells 113
• NO-lipid combination 113
• NO-releasing coating to prevent infection of implanted devices 113
• Nanoparticles for controlled/sustained release of NO 114
• Hydrogel/glass nanoparticles 114
• Delivery of nanoparticles to vascular endothelium for release of NO 114
• Nitric oxide donors 114
• Nitroglycerine/glycerine trinitrate 115
• Isosorbide dinitrate 115
• Sodium nitrite 116
• Organic nitrites 116
• NO-releasing NSAIDs 116
• COX-inhibiting NO-donors 118
• Grafting of NO-releasing structures on to existing drugs 119
• Mesoionic Oxatriazoles 121
• Adding NO-donating structures to extend life cycle of existing drugs 121
• Cysteine-containing NO donors 121
• Ferrous nitrosyl complexes 121
• Syndnonimines 122
• S-Nitrosothiols 122
• Diazeniumdiolates 123
• COX-2 inhibitors 123
• NO hydrogels 124
• Novel NO donors 124
• NO mimetics 124
• Comparison of classical nitrates, grafted NO donors, and NO mimetics 125
• NO donors and soluble guanylate cyclase activation 125
• NO donors for increasing the efficacy of chemotherapy 126
• Factors that enhance availability of NO 126
• Modulators of cyclic guanosine-3' ,5' -monophosphate-dependent protein kinases 127
• NOS-modulating drugs 128
• Drugs that activate eNOS 128
• Statins 128
• Angiotensin converting enzyme inhibitors 129
• 17 Beta-estradiol 129
• C-2431 129
• NOS inhibitors 129
• Rationale of NOS inhibitors 129
• L-Arginine 131
• Design of NOS inhibitors 131
• Selective iNOS inhibitors 132
• Non-amino acid-based inhibitors 133
• Aminoguanidine 133
• Heme ligands 134
• Pterin antagonists 134
• Fused-ring bio-isoteric models of arginine as NOS inhibitors 134
• nNOS inhibitors 134
• Lubeluzole 136
• Neurotrophic factors 136
• Therapies based on action of NOS as a paraquat diaphorase 136
• Concluding remarks about NOS inhibiting drugs 137
• NO and stem cell-based therapy 137
• Nitric oxide and gene therapy 138
• NOS gene transfer 138
• Inhibition of NOS by antisense technology 139
• Drugs that modulate NO action on platelets 140
• Action of NO and NO donors on platelets 140
• NOS inhibitors and NO scavengers 140
• Phosphodiesterase inhibitors 140
• Activators of soluble guanylate cyclase 141
• YC-1 141
• A-350619 141
• Cinaciguat 141
• Secondary role of NO in the action of drugs 141
• Selective serotonin reuptake inhibitors 142
• P2Y receptors and NO 142
• Calcium channel blockers and NO 142
• Nitric oxide-based transdermal drug delivery 142
• NO and nutraceuticals 143
• L-arginine as a nutraceutical 143
• Oleuropein 143
• Role of NO in beneficial effects of chocolate 144

6. Therapeutic Applications 145

• Introduction 145
• Role of NO in the management of pulmonary disorders 145
• Manufacture of NO gas for inhalation 145
• NO inhalation for acute respiratory distress syndrome 145
• NO inhalation for premature children with pulmonary dysplasia 146
• NO inhalation for premature children with respiratory failure 146
• Pulmonary hypertension 147
• NO-based treatment of pulmonary hypertension 147
• Inhaled nebulized nitrite for neonatal pulmonary hypertension 148
• Gene therapy for pulmonary hypertension 148
• Asthma 149
• iNOS inhibitors for asthma 149
• NO for bronchodilation in asthma 149
• Role of NO in acute lung injury after smoke inhalation 150
• Cardiovascular disorders 150
• Role of NO in cardioprotection 150
• Role of NO in the management of angina pectoris 151
• Role of NO in therapy of coronary heart disease 151
• NO-releasing aspirin in patients undergoing CABG 152
• Management of coronary restenosis 152
• Modified NO donors 153
• NO-generating stent for coronary restenosis 153
• eNOS gene therapy for restenosis 154
• Congestive heart failure 155
• Limitation of antioxidant therapy in congestive heart failure 155
• NO-based therapies for congestive heart failure 155
• eNOS gene therapy for congestive heart failure 156
• Gene transfer of nNOS in congestive heart failure 156
• NO-based therapy for management of cardiogenic shock 156
• NO-based therapy for cardiac arrhythmias 157
• Prophylaxis of cardiovascular disorders 157
• Prevention of atherosclerosis with aging 157
• Peripheral vascular disorders 158
• Peripheral atherosclerotic arterial disease 158
• Peripheral ischemic disease 158
• An eNOS mutant as therapeutic for peripheral vascular ischemia 158
• Sodium nitrite therapy for peripheral vascular ischemia 159
• Raynaud' s phenomenon 159
• Neurological disorders 160
• Cerebrovascular ischemic disorders 160
• Attenuation of NO for neuroprotection in cerebral ischemia 160
• Use of NO donors in cerebral ischemia 161
• Use of NO donors in cerebral reperfusion injury 161
• Cerebral vasospasm and NO 162
• NOS gene therapy for cerebral vasospasm 162
• Degenerative CNS disorders 163
• Statins for Alzheimer' s disease 163
• NO mimetics for Alzheimer' s disease 163
• iNOS inhibitors for treatment of Alzheimer' s disease 164
• NO-NSAIDs for Alzheimer' s disease 164
• Ginko biloba for Alzheimer' s disease 165
• Personalization of NO-based therapy for Alzheimer' s disease 165
• Role of NO in the treatment of traumatic brain injury 165
• Neuroinflammatory disorders 165
• Muscular dystrophy 166
• Vestibulotoxicity 166
• NO for opening the blood-brain barrier 167
• Cochlear disorders 167
• Cochlear ischemia 167
• Role of NO in sensoryneural hearing loss 167
• Pain 167
• NO-based therapies for pain 168
• Treatment of diabetic neuropathy with isosorbide dinitrate spray 168
• NO-based therapies for migraine 168
• NO-based therapy for fibromyalgia syndrome 169
• NO-based therapies for inflammatory disorders 169
• NO-based therapies for gastrointestinal disorders 169
• Protection of gastrointestinal injury from NSAIDs 169
• Role of NO in the treatment of inflammatory bowel disease 170
• Topical nitroglycerin for chronic anal fissure 170
• Cancer 170
• Mechanism of action of NO in cancer 170
• Antineoplastic effect of iNOS-expressing cells 171
• Role of NO in drug resistance of cancer 171
• Role of NO in treatment of brain tumors 171
• NO-induced apoptosis 172
• Role of NO in antiangiogenesis therapies in cancer 172
• NO donors for the treatment of cancer 173
• NO-releasing NSAIDs and colon cancer chemoprevention 173
• Rationale of combining NO aspirin with cancer vaccines 174
• NO-based cancer gene therapy 174
• NO-based therapies for skin disorders 175
• NO-based therapies for skin infections 175
• Role of NO in the treatment of psoriasis 175
• NO-based therapy for sickle cell anemia 175
• Inhaled NO for acute respiratory distress syndrome in sickle cell disease 176
• NO inhalation for pulmonary hypertension in sickle cell anemia 176
• Role of NO in disorders associated with pregnancy 177
• Use of NO donors in management of labor 177
• Eclampsia 177
• Erectile dysfunction 178
• Selective inhibitors of phosphodiesterase 5 178
• Erectile dysfunction in diabetes 179
• NO-donating substances for treatment of ED 179
• NOS gene transfer for ED 180
• Organ transplant rejection 180
• Role of NO in the treatment of renal disorders 181
• Role of NO in the treatment of hepatic disorders 182
• Portal hypertension 182
• NO inhalation for restoration of liver function following transplantation 182
• Role of NO in blood transfusion 182
• Role of NO in the treatment of osteoporosis 183

7. Evaluation of NO-Based Drugs 185

• Current status 185
• Antioxidant vs. NO-based approaches 185
• SWOT analysis of selected approaches for NO modulation 185
• NO donors by grafting of NO-releasing structures 185
• NOS modulation 186
• Challenges of developing NO-based therapies 187
• Concluding remarks and future prospects 187

8. Markets for NO-based Therapies 189

• Introduction 189
• Impact of NO-based therapies on international markets 189
• Share of NO-based therapies in major therapeutic areas 189
• Share of NO-based therapies in cardiovascular disorders 190
• Hypercholesterolemia 190
• Myocardial infarction 191
• Angina pectoris 191
• Heart failure 191
• Coronary restenosis and stenting 191
• Strategies for developing NO-based therapy markets 192
• Addressing the unfulfilled needs 192
• Multidisciplinary approaches 192
• Collaboration between the academia and the industry 193
• Education of the public 193

9. Companies 195

• Introduction 195
• Profiles of companies with focus on NO 197
• Major pharmaceutical companies with involvement in NO 211
• Smaller biotech and pharmaceutical companies involved in NO 217
• Biopharmaceutical companies involved in antioxidant research 228
• Companies supplying NO equipment for healthcare 232
• Academic institutes with commercial collaboration in NO research 236
• Companies supplying NO products for research 237
• Collaborations 241

10. References 243

Tables

• Table 1 1: Historical landmarks in the discovery and applications of nitric oxide 16
• Table 3 1: Important functions of NO in the human body 36
• Table 4 1: Diseases involving nitric oxide 55
• Table 4 2: Role of nitric oxide in pathogenesis of autoimmune disorders 57
• Table 4 3: Role of nitric oxide in infections 59
• Table 5 1: Neuroprotective antioxidants 105
• Table 5 2: NO-related drugs 108
• Table 5 3: Methods of delivery of nitric oxide 112
• Table 5 4: Comparison of classical nitrates, grafted NO donors, and NO mimetics 125
• Table 5 5: Classification of NOS inhibitors 130
• Table 5 6: Potential clinical applications of gene transfer for NOS overexpression 138
• Table 6 1: Cardiovascular disorders for which NO-based therapies are used 150
• Table 6 2: Selected neurological applications of NO-based therapies 160
• Table 6 3: NO-related therapies for pain 168
• Table 7 1: SWOT of technology - NO donors by grafting of NO-releasing structures 186
• Table 7 2: SWOT of products - NO donors by grafting of NO-releasing structures 186
• Table 7 3: SWOT of NOS gene manipulation 186
• Table 7 4: SWOT of analgesic development by NOS isoform targeting 187
• Table 8 1: Share of NO-based therapies in major therapeutic areas 2008-2018 190
• Table 8 2: Share of NO-based therapies in cardiovascular diseases 2008-2018 190
• Table 9 1: Classification of companies involved in NO and antioxidant therapies 196
• Table 9 2: NicOx products in development 201
• Table 9 3: Product pipeline of Nitrox LLC 206
• Table 9 4: NO-related products of Sigma Aldrich 239
• Table 9 5: Collaborations of companies relevant to nitric oxide 241

Figures

• Figure 1 1: Biosynthesis of nitric oxide (NO) 18
• Figure 1 2: NO synthase pathway 19
• Figure 2 1: Reactivity of nitric oxide with heme proteins in oxygen or peroxide reaction cycles 25
• Figure 2 2: NO-cGMP pathway leading to vasorelaxation 26
• Figure 2 3: The biological pathways toward protein nitration 28
• Figure 2 4: NF-kβ activation and iNOS induction 29
• Figure 2 5: Overview of mitochondrial NO-cytochrome c oxidase signaling pathway 31
• Figure 3 1: NOS in the cardiac myocyte 40
• Figure 3 2: Interactions of the Mb compounds with O2 and NO 44
• Figure 4 1: Molecular mechanisms of peroxynitrite-mediated cell death 54
• Figure 4 2: NO neurotoxicity and neuroprotection in relation to Alzheimer' s disease 66
• Figure 4 3: Some steps in the ischemic cascade and site of action of neuroprotectives 70
• Figure 4 4: Dual role of nitric oxide (NO) in cerebral ischemia 71
• Figure 4 5: Blood cell-endothelial cell interactions induced by hypercholesterolemia 80
• Figure 4 6: Effects of NO on the pathophysiology of myocardial ischemia-reperfusion 84
• Figure 4 7: Nitric oxide: tumor enhancement or inhibition 90
• Figure 4 8: Role of nitric oxide in angiogenesis 93
• Figure 5 1: Nitrogen oxide mimetics - synergy by chemical modification 125
• Figure 5 2: Factors that enhance availability of NO 127
• Figure 6 1: Vicious circle of vascular occlusion following angioplasty and stenting 153
• Figure 6 2: PDE5 inhibition and the response to sexual stimulation 179
• Figure 8 1: Unfulfilled needs in NO therapeutics 192