Impact of the COVID-19 Pandemic on the Use of Antidepressants by Young Adults in the ASL TO4 Regione Piemonte (Italy)

The association between younger age and poorer mental health during the COVID-19 pandemic has been documented. Whether these changes were associated with a change in antidepressant (AD) use is not well understood. This study aimed to estimate the impact of the COVID-19 pandemic on AD use by young adults in the ASL TO4 Regione Piemonte (Italy). The impact of the pandemic on the weekly prevalence of AD users was assessed using interrupted time-series analysis with autoregressive integrated moving average models. A total of 1071 subjects (18-22 years with ≥1 AD dispensation) were included in the study. The observed prevalence was lower than the predicted value for several weeks after the introduction of the lockdown. However, it was consistently higher than the predicted values from week 134. The maximum difference between observed and predicted values (25 subjects per 10,000 young adults) was found at week 170. Changes in AD use were observed in both genders and were more pronounced for selective serotonin reuptake inhibitors. In conclusion, the impact of the COVID-19 pandemic on the mental health of young adults is likely to be significant in the coming years, which may place a future burden on pharmaceutical public health and community health.

Identification of Barriers for Active Disease Management and of Medication-Related Problems through Therapeutic Patient Education in Older Home-Care Patients

Combining therapeutic patient education (TPE) with a medication review service could foster the adoption of appropriate lifestyles by patients and support care-providers in identifying strategies to improve the quality of prescribed care. This study aimed to identify barriers experienced by patients in managing their diseases and medication-related problems. This was a monocentric, case series, observational study involving home-care patients from the Local Health Authority ASL TO4. Patients were enrolled for a TPE intervention where drug therapies and patient habits were collected through narrative interviews. Medication review was performed to identify potentially inappropriate prescriptions (PIPs). Twenty patients (13 females) with a mean age of 74.7 years were enrolled. Patients had an average of 4.3 diseases and 80.0% of them were treated with ≥5 daily medications. The main PIPs involved ibuprofen, furosemide and pantoprazole. The qualitative analysis of the interviews identified seven macro-themes relating to different aspects of medication management: therapy; diseases; patient; patient journey; professionals; family and caregivers; drug information. The results of this study revealed some critical aspects related to the treatment path and healthcare professionals. These results will be used to plan educational interventions for polypharmacy patients to improve medication adherence and the understanding and management of diseases.

Assessing Therapeutic Choices and Adherence to Antidiabetic Therapy in Naïve Patients: A Retrospective Observational Study in a Local Health Authority of the Piedmont Region (Italy)

Due to its prevalence and socio-economic burden on health systems, diabetes mellitus (DM) is considered a major health emergency. This retrospective, observational study aimed to describe a population of DM-naïve patients of the Local Health Authority (LHA) ASL TO4 Regione Piemonte and the prescriptive behavior of LHA general practitioners. Drug dispensing data collected between January 2018 and December 2021 was analyzed. Adult patients were included if they received their first prescription for an antidiabetic drug (AD) in 2019 and had ≥2 prescriptions/year of ADs during the follow-up. Patients who started antidiabetic therapy with metformin were selected to investigate comorbidities, medication adherence, and first treatment intensification. Comorbidities were identified through a modified version of the Rx-Risk Index; adherence was measured as the continuous measure of medication availability (CMA). Among 1927 DM-naïve patients, 1361 started therapy with metformin. Most of them received drugs related to cardiovascular diseases, hypertension, and infectious diseases during the study period. Median CMA was 58.8%, with the majority of patients being partially adherent to ADs (40 ≤ CMA < 80). Initial antidiabetic therapy was mostly modified (switch, add-on) with SGLT-2 inhibitors and sulfonylureas. These findings help to identify areas of intervention to improve the use of ADs in the LHA.

Clinical decision support systems to improve drug prescription and therapy optimisation in clinical practice: a scoping review

OBJECTIVE

Clinical decision support systems (CDSSs) can reduce medical errors increasing drug prescription appropriateness. Deepening knowledge of existing CDSSs could increase their use by healthcare professionals in different settings (ie, hospitals, pharmacies, health research centres) of clinical practice. This review aims to identify the characteristics common to effective studies conducted with CDSSs.

MATERIALS AND METHODS

The article sources were Scopus, PubMed, Ovid MEDLINE and Web of Science, queried between January 2017 and January 2022. Inclusion criteria were prospective and retrospective studies that reported original research on CDSSs for clinical practice support; studies should describe a measurable comparison of the intervention or observation conducted with and without the CDSS; article language Italian or English. Reviews and studies with CDSSs used exclusively by patients were excluded. A Microsoft Excel spreadsheet was prepared to extract and summarise data from the included articles.

RESULTS

The search resulted in the identification of 2424 articles. After title and abstract screening, 136 studies remained, 42 of which were included for final evaluation. Most of the studies included rule-based CDSSs that are integrated into existing databases with the main purpose of managing disease-related problems. The majority of the selected studies (25 studies; 59.5%) were successful in supporting clinical practice, with most being pre-post intervention studies and involving the presence of a pharmacist.

DISCUSSION AND CONCLUSION

A number of characteristics have been identified that may help the design of studies feasible to demonstrate the effectiveness of CDSSs. Further studies are needed to encourage CDSS use.

Italian Translation and Validation of the Original ABC Taxonomy for Medication Adherence

Medication adherence represents a complex and multifaceted process. Standardized terminology is essential to enable a reproducible process in various languages. The study's aim was to translate and adapt the original Ascertaining Barriers for Compliance (ABC) Taxonomy on medication adherence, first proposed in 2012, into Italian language. The study was carried out according to the Preferred Methods for Translation of the ABC Taxonomy for Medication Adherence adopted by the ESPACOMP. Key steps included: (1) a systematic literature review using PubMed and Embase according to the PRISMA Guidelines to identify published Italian terms and definitions, and Italian adherence experts; (2) a forward translation of terms and definitions; (3) panelists' selection; (4) a three-round Delphi survey. From the systematic review, 19 studies allowed detection of 4 terms, 4 definitions and 767 Italian experts. To these, Italian ESPACOMP members and experts though snowball sampling were added. The identified Italian adherence experts received the Delphi questionnaire. The Italian ABC Taxonomy was achieved after three rounds of Delphi survey by reaching at least a moderate consensus on unambiguous naming and definition of medication adherence-related terms. The Taxonomy is intended to be used in research, academic, and professional fields in order to harmonize adherence terminology and avoid confusion in comparing research findings.

Persistence to Medications for Benign Prostatic Hyperplasia/Benign Prostatic Obstruction-Associated Lower Urinary Tract Symptoms in the ASL TO4 Regione Piemonte (Italy)

BACKGROUND

Pharmacological treatment of benign prostatic hyperplasia (BPH)/benign prostatic obstruction (BPO)-associated lower urinary tract symptoms (LUTS) aims at improving patients' quality of life by managing urinary symptoms and preventing complications and disease progression. However, continuous use of drugs to treat BPH/BPO-associated LUTS decreases over time. The aim of this retrospective observational study was to describe use of α1-adrenoceptor antagonists (ABs) and steroid 5α-reductase inhibitors (5ARIs) by adult (age ≥ 40 years) men in the ASL TO4, a Local Health Authority in the northern area of the city of Turin (Italy).

METHODS

Persistence measures were adopted as a robust, informative, and feasible way to understand medication-taking behavior and to assess patient compliance.

RESULTS

A total of 4309 men (median age 71 years) were enrolled. Monotherapy was the treatment option prescribed to the largest part of the study population. However, ≥two drugs were prescribed to a substantial proportion of men (23%). Men prescribed alfuzosin or dutasteride had significantly greater persistence, which decreased over time.

CONCLUSIONS

Unmet needs and areas of intervention for healthcare systems aimed at improving the use of drugs for BHP/BPO-associated LUTS in the ASL TO4 Regione Piemonte were identified.

Proactive inter-disciplinary CME to improve medication management in the elderly population

BACKGROUND

The absence of collaboration between health professionals is known to influence prescriptions' quality, also disadvantaging elderly frail patients' polytherapies.

OBJECTIVES

This study aims to improve the adherence to medications of elderly patients suffering from multiple diseases through interpersonal continuing medical education (CME). The CME was organized for general practitioners (GPs) by hospital pharmacists (HPs) from a Territorial Pharmaceutical Centre of Piedmont, in collaboration with pharmacists from the Drug Science and Technology Department of the University of Turin, to enhance awareness on the management of chronic therapies and de-prescription.

METHODS

Pharmacists set face-to-face lessons for GPs between April 2018 and November 2018, while therapies' reconciliation and delivery of the Illustrated Therapy Schedules (ITS) lasted until September 2019. Polytherapies were evaluated by pharmacists and GPs in terms of appropriateness (number of potentially inappropriate prescriptions - PIPs according to 2019 Beers Criteria) and number of drug-drug interactions (DDIs), using a clinical decision support system (CDSS - NavFarma©) to help health professionals dealing with the process of review, reconciliation and individuation of possible adverse reactions.

RESULTS

From the CME organization it emerged that the collaboration between health professionals supported by a CDSS could improve the quality of elderly patients polytherapies. Two-hundred fifteen patients were enrolled by GPs; patients included were aged - results reported as average (sd) - 76.4 (6.3), mostly men (54.9%), number of daily medications per patient was 8.1 (2.4); 2.1 (1.8) DDIs per patient were individuated, 12.9% of which were solved thanks to the CME. Average number of PIPs found was 2.5 (1.4) per patient.

CONCLUSIONS

The CME represented a proactive approach by HPs to the management of elderly patients' polytherapies. Moreover, clinicians' engagement is a mean to enhance quality, safety, professionalism and communication in health processes.

EUROPEAN OLDER ADULTS FRAIL: FINDINGS FROM THE SURVEY OF HEALTH, AGEING AND RETIREMENT IN EUROPE (SHARE)

Frailty is a geriatric multidimensional syndrome whose signs and symptoms are predictors of increased vulnerability to minor stress events and risk of adverse outcomes such as falls, fractures, hospitalisation, disability and death. In this work, we aimed to update the data of frailty status in European community dwelling population, based on the latest data released (wave 6) of SHARE database, and to study the impact of each criterion on frailty assessment. Frailty status was assessed applying a version of the Fried Phenotype operationalised for SHARE. We included all participants who answered all the questions used in a frailty assessment and who disclosed their gender and, further, whose age was 50 or more. Our final sample was 60816 individuals. Of these, the mean age was 67.45 ± 9.71 years; 38497 (56.4%) were female. The overall prevalence of pre-frailty was 42.9% (ranging from 34.0% in Austria to 52.8% in Estonia) and frailty was 7.7% (ranging from 3.0% in Switzerland to 15.6% in Portugal). Pre-frailty and frailty prevalence increased along age and were more frequent among women. Regarding the five criteria considered on frailty assessment, exhaustion seems to be the criterion that contributes most to frailty status, followed by low activity, weakness, loss of appetite and slowness. With this work, we demonstrated that more than 50% of the 50+ European population are pre-frail/frail, which must be considered when designing interventions to reduce/postpone/mitigate the progression of this condition, reducing the burden associated with it.

Prevalence of frailty status among the European elderly population: Findings from the Survey of Health, Aging and Retirement in Europe

AIM

In the present study, we aimed to update the data of frailty status in the European community-dwelling population of older adults, based on the latest data released (wave 6) of the Survey of Health, Aging and Retirement in Europe database, and to study the impact of each criterion on frailty assessment.

METHODS

Frailty status was assessed applying a version of the Fried phenotype operationalized for the Survey of Health, Aging and Retirement in Europe. We included all participants who answered all the questions used in a frailty assessment and who disclosed their sex and, furthermore, who were aged ≥50 years. Our final sample was 60 816 individuals. Of these, the mean age was 67.45 ± 9.71 years; 38 497 (56.4%) were women.

RESULTS

The overall prevalence of pre-frailty was 42.9% (ranging from 34.0% in Austria to 52.8% in Estonia), and frailty was 7.7% (ranging from 3.0% in Switzerland to 15.6% in Portugal). Pre-frailty and frailty prevalence increased along with age, and were more frequent among women. Regarding the five criteria considered on frailty assessment, exhaustion seems to be the criterion that contributes most to frailty status, followed by low activity, weakness, loss of appetite and slowness.

CONCLUSIONS

With this work, we showed that >50% of the European population aged >50 years are pre-frail/frail, which must be considered when designing interventions to reduce/postpone/mitigate the progression of this condition, thus reducing the burden associated with it. Geriatr Gerontol Int 2019; 19: 723-729.

Prescription of proton pump inhibitors in older adults with complex polytherapy

OBJECTIVES

Prescription of proton pump inhibitors (PPIs) may be a source of potentially clinically relevant drug-drug interactions (DDIs) and related complications for elderly patients with complex polytherapy at discharge from hospital. The aim of the study was to identify, through the analysis of hospital discharge records, the co-administrations (PPIs + one or more drugs potentially generating DDIs) hypothetically leading to severe consequences according to the literature and online databases. Subsequently, alternatives to PPIs were evaluated for the treatment of gastric acidity and ulcers.

METHODS

The medical records of 1288 patients, discharged from a geriatric ward at the Città della Salute e della Scienza Hospital in Turin from January 2012 to December 2013, were collected in an Excel database for analysis of DDIs using the literature and online sources such as Micromedex. RESULTS : Six hundred and sixty-three of the 1288 clinical folders had a PPI prescription. A list of 18 drugs considered potentially hazardous and able to trigger a DDI when co-administrated with PPIs was drafted; the frequencies of the co-prescriptions of each PPI with one of the listed drugs were esomeprazole 65.38%, lansoprazole 52.87%, omeprazole 48.19% and pantoprazole 37.11%. An analysis of these co-prescriptions, according to Micromedex classification, gave a percentage of major interactions of 11.01% over 663 clinical folders including a PPI.

CONCLUSIONS

This study provides a collection of potentially hazardous drug associations and helpful suggestions to improve the quality of prescriptions for elderly patients and strengthens the case for synergic work between doctors and pharmacists in the wards.

Chemical modifications of Tonda Gentile Trilobata hazelnut and derived processing products under different infrared and hot-air roasting conditions: a combined analytical study

BACKGROUND

For the processing industry, it is crucial to know what effect the roasting process and conditions have on hazelnut quality. The present study investigates, for the first time, the effects of hot-air and infrared (IR) roasting at different time-temperature combinations on Tonda Gentile Trilobata hazelnut: whole kernels and derived processing products (paste and oil).

RESULTS

The nutritional and physical characteristics of hazelnuts and processing products were investigated to determine the influence of the different roasting conditions as a function of intended use. The antioxidant profile (2.2-diphenyl-1-picrylhydrazyl radical, oxygen radical absorbance capacity and total phenolic content) were analyzed on roasted hazelnut and paste extracts. For a comprehensive understanding of the complex biochemical phenomena occurring during roasting, E-nose and near-IR spectroscopy were also applied. All analytical data were processed using univariate and multivariate data analyses. Hazelnuts derived from IR roasting at higher temperatures (195 °C) showed a richer antioxidant profile and a more intense flavour. On the other hand, the yield associated with the oil extraction under the same conditions was unsatisfactory, making this process completely inadequate for oil production. Oil obtained by hot-air roasting and IR roasting at lower temperature (135 °C) was found to be of good quality, showing rather similar acidity grade, peroxide number and acidic composition. In particular, a slightly but significantly lower acidity was related to lower roasting temperatures (0.21-0.22% versus 0.27% for higher temperatures). All roasting conditions tested allowed the quantitative homogeneous hazelnut paste to be obtained and, from a rheological point of view, a higher roasting temperatures resulted in pastes characterized by higher density and viscosity values.

CONCLUSION

The use of IR was found to be a promising alternative method for hazelnut roasting, as a result of its capability with respect to preserving nutritional values and enhancing organoleptic quality. © 2018 Society of Chemical Industry.

A cooperation project between hospital pharmacists and general practitioners about drug interactions in clinical practice

Objectives

(1) To evaluate drug-drug interactions (DDIs) in general practitioners' (GPs) prescriptions; (2) to implement a cooperation project between pharmacists and GPs to improve DDI management and patient care.

Methods

In 2013, pharmacists from the Community Drug Assistance ASL TO1 launched a cooperation project involving 48 GPs. As a first step, GPs were asked to select, from a list, drug associations for which they recommended analysis of occurrence in their prescriptions. The pharmacists (1) analysed GPs' prescriptions dated 2012-2014, according to the list of DDIs selected (n= 9); (2) evaluated solutions for DDI management, using the Micromedex DDI checker database and literature analysis; they then (3) disseminated DDI-related information to GPs through training meetings and (4) assessed the efficacy of these actions through a questionnaire submitted to the GPs in 2013.

Results

(1) Prescriptions analysis: a reduction in the number of DDIs was observed (-14% in 2013 vs 2012, -9% in 2014 vs 2012); in some cases these reductions were statistically significant (calcium carbonate + proton pump inhibitors (PPIs) -50%, p<0.0041, amoxicillin+lansoprazole -42%, p<0.0088). (2) Questionnaire: this was completed by 75% of GPs. The literature analysis was considered interesting by 94% of GPs; solutions were adopted by 89% of GPs and 34% of GPs affirmed that clinical improvements after application of the measures were observed in their patients, even if they could not provide quantitative data for this outcome.

Conclusion

The cooperation project between pharmacists and GPs was effective because it established a professional exchange between the two health professionals. The pharmacist gave support to GPs, which benefited the patients, who gained clinical improvements and improved satisfaction with their medical care, as declared by the GPs in answers to the questionnaire.

Cystic "feminine" pancreatic neoplasms in men. Do any clinical alterations correlate with these uncommon entities?

INTRODUCTION

Mucinous cystic neoplasm (MCN) and solid pseudopapillary neoplasm (SPN) of the pancreas are uncommon hormone-related pancreatic tumors (HRPTs) with a clear predominance in young women. This trial aims to investigate the possible association between HRPTs development in males and phenotypic and sex hormone alterations.

METHODS

We performed a retrospective analysis of our database between February 1990 and February 2012. Risk factors for sexual dysfunction were considered exclusion criteria. We investigated secondary sexual characteristics development, sex hormone level and overall sexual dysfunction degree according with the International Index of Erectile Function Questionnaire (IIEF).

RESULTS

We initially identified 25 patients [(MCN: n = 16 (64%); SPN: n = 9 (36%)]. At follow-up, 5 patients were lost, 8 resulted dead and 3 were excluded according to exclusion criteria. We finally enrolled 9 patients (MCN: n = 5; SPN: n = 4). Puberty occurred within physiological age for 7 patients, whereas it was delayed in 2 cases. Three patients revealed mild to moderate sexual dysfunction, along with low testosterone level in two cases. One patient presented hormonal alteration with a normal IIEF score.

DISCUSSION

In this study, the first in literature with similar aim, hormonal and/or sexual dysfunction was present in 4 out of 9 patients affected by HRPT. The rarity of these lesions makes further trials to be needed for reliable conclusions.

(Nitrooxyacyloxy)methyl esters of aspirin as novel nitric oxide releasing aspirins

A series of (nitrooxyacyloxy)methyl esters of aspirin were synthesized and evaluated as new NO-donor aspirins. Different amounts of aspirin were released in serum from these products according to the nature of nitrooxyacyloxy moiety present. In the aromatic series, there is a rather good linear correlation between the amount of aspirin released and the potencies of the products in inhibiting platelet aggregation induced by collagen. Both the native compounds and the related nitrooxy-substituted acid metabolites were able to relax rat aorta strips precontracted with phenylephrine, in keeping with a NO-induced activation of the sGC as a mechanism that underlies the vasodilator effect. The products here described are new improved examples of NO-donor aspirins containing nitrooxy groups. They could represent an alternative to the use of aspirin in a variety of clinical applications.

Nitrooxymethyl-substituted analogues of celecoxib: synthesis and pharmacological characterization

Nitrooxymethyl-substituted analogues of celecoxib were synthesized and tested for their cyclooxygenase (COX)-inhibiting, vasodilator, and anti-aggregatory activities, as well as for their metabolic stability in human serum and whole blood. The results showed their potency and selectivity in inhibiting the COX isoforms, evaluated in whole human blood, as well as their anti-aggregatory activity to depend closely on the position at which the NO-donor moiety is introduced. All products dilated rat aorta strips precontracted with phenylephrine in a dose-dependent manner through a cGMP-dependent mechanism. They were stable in human serum while, in blood, they were metabolically transformed, principally to the related alcohols.

A novel hybrid aspirin-NO-releasing compound inhibits TNFalpha release from LPS-activated human monocytes and macrophages

Background

The cytoprotective nature of nitric oxide (NO) led to development of NO-aspirins in the hope of overcoming the gastric side-effects of aspirin. However, the NO moiety gives these hybrids potential for actions further to their aspirin-mediated anti-platelet and anti-inflammatory effects. Having previously shown that novel NO-aspirin hybrids containing a furoxan NO-releasing group have potent anti-platelet effects, here we investigate their anti-inflammatory properties. Here we examine their effects upon TNFα release from lipopolysaccharide (LPS)-stimulated human monocytes and monocyte-derived macrophages and investigate a potential mechanism of action through effects on LPS-stimulated nuclear factor-kappa B (NF-κB) activation.

Methods

Peripheral venous blood was drawn from the antecubital fossa of human volunteers. Mononuclear cells were isolated and cultured. The resultant differentiated macrophages were treated with pharmacologically relevant concentrations of either a furoxan-aspirin (B8, B7; 10 μM), their respective furazan NO-free counterparts (B16, B15; 10 μM), aspirin (10 μM), existing nitroaspirin (NCX4016; 10 μM), an NO donor (DEA/NO; 10 μM) or dexamethasone (1 μM), in the presence and absence of LPS (10 ng/ml; 4 h). Parallel experiments were conducted on undifferentiated fresh monocytes. Supernatants were assessed by specific ELISA for TNFα release and by lactate dehydrogenase (LDH) assay for cell necrosis. To assess NF-κB activation, the effects of the compounds on the loss of cytoplasmic inhibitor of NF-κB, IκBα (assessed by western blotting) and nuclear localisation (assessed by immunofluorescence) of the p65 subunit of NF-κB were determined.

Results

B8 significantly reduced TNFα release from LPS-treated macrophages to 36 ± 10% of the LPS control. B8 and B16 significantly inhibited monocyte TNFα release to 28 ± 5, and 49 ± 9% of control, respectively. The B8 effect was equivalent in magnitude to that of dexamethasone, but was not shared by 10 μM DEA/NO, B7, the furazans, aspirin or NCX4016. LDH assessment revealed none of the treatments caused significant cell lysis. LPS stimulated loss of cytoplasmic IκBα and nuclear translocation of the p65 NF-κB subunit was inhibited by the active NO-furoxans.

Conclusion

Here we show that furoxan-aspirin, B8, significantly reduces TNFα release from both monocytes and macrophages and suggest that inhibition of NF-κB activation is a likely mechanism for the effect. This anti-inflammatory action highlights a further therapeutic potential of drugs of this class.

Searching for new NO-donor aspirin-like molecules: a new class of nitrooxy-acyl derivatives of salicylic acid

A new class of products in which the phenol group of salicylic acid is linked to alkanoyl moieties bearing nitrooxy functions has been synthesized and studied for their polyvalent actions. The products were stable in acid and neutral media, while they were hydrolyzed in human serum. Their half-lives were dependent upon the structure of alkanoyl moieties. The products showed anti-inflammatory activities similar to aspirin when tested in the carrageenan-induced paw edema assay in the rat. Interestingly, unlike aspirin, they showed reduced or no gastrotoxicity in a lesion model in rats at equimolar doses. A number of them were able to inhibit platelet aggregation induced by collagen in human platelet-rich plasma. All of the products were capable of relaxing rat aortic strips precontracted with phenylephrine in a concentration-dependent manner. Selected members of this new class of nonsteroidal anti-inflammatory drugs might represent possible safer alternatives to aspirin in different clinical settings.

Multitarget drugs: Focus on the NO-donor hybrid drugs

The article addresses the design of multitarget drugs, namely, compounds capable of interacting with more than one target simultaneously. These agents could be useful tools in the therapy of complex diseases such as cardiovascular and inflammatory diseases. An interesting case of multitarget compounds are nitric oxide (NO)-donor hybrids, structures which combine the physiological properties of NO with those of a lead drug. In particular, the authors discuss the symbiotic approach used to design NO-donor nonsteroidal anti-inflammatory drugs (NO-NSAIDs) and NO-donor antioxidants. The former could be useful agents in the treatment of anti-inflammatory diseases being devoid of gastro- and cardiotoxicity, the latter could be a valid approach to the treatment of many cardiovascular diseases.

Nitric Oxide Donor β2-Agonists: Furoxan Derivatives Containing the Fenoterol Moiety and Related Furazans

The structure of fenoterol, a beta2-adrenoceptor agonist used in therapy, has been joined with furoxan NO-donor moieties to give new NO-donor beta2-agonists. The furazan analogues, devoid of the property to release NO, were also synthesized for comparison. All the compounds retained beta2-agonistic activity at micromolar or submicromolar concentration when tested on guinea pig tracheal rings precontracted with carbachol. Among the furoxan derivatives, the NO contribution to trachea relaxation was evident with product 15b at micromolar concentrations. All the new NO-donor hybrids were able to dilate rat aortic strips precontracted with phenylephrine. Both furoxan and furazan derivatives displayed antioxidant activity greater than that of fenoterol.

NO-donor melatonin derivatives: synthesis and in vitro pharmacological characterization

Numerous studies document that melatonin possesses a broad-spectrum antioxidant activity. It traps a number of reactive oxygen species (ROS) such as hydroxyl and peroxyl radicals, singlet oxygen and hypochlorous acid. It also inhibits peroxynitrite-induced reactions. It is known that atherosclerosis progression involves ROS-induced oxidation of low-density lipoproteins in sub-endothelial space and the depletion of nitric oxide (NO) in blood vessels, as well as a decreased sensitivity of the vessels to the actions of NO. Considering this, a series of new NO-donor antioxidants were designed and synthesized by joining melatonin with NO-donor nitrooxy and furoxan moieties as polyvalent agents potentially useful for the treatment of cardiovascular diseases involving atherosclerotic vascular changes. The in vitro antioxidant properties of the resulting products were assessed in the thiobarbituric acid reactive substances assay (TBARS), the ABTS(+.) as well as in the alkaline phosphatase (ALP) assay. The antioxidant capacities of NO-donor melatonins to inhibit lipoperoxidation (TBARS-IC(50)) was predominantly dependent on their lipophilicity, and therefore on their partitioning process into membranes. On the other hand, their comparable capacity to inhibit protein oxidation (ALP-IC(50)) was independent of their lipophilicity and was consistent with their similar ability to participate in electron transfer reactions. All the NO-donor melatonins were also evaluated for their ability to relax rat aorta strips precontracted with 1 microM phenylephrine. Finally, binding affinities and intrinsic activity studies, carried out at MT(1) and MT(2) receptor subtypes, showed a rather complex picture in need of further investigation.

NO-Donor COX-2 Inhibitors. New Nitrooxy-Substituted 1,5-Diarylimidazoles Endowed with COX-2 Inhibitory and Vasodilator Properties

A series of NO-donor diarylimidazoles derived from the lead compound Cimicoxib were synthesized and evaluated for their COX-2 inhibitory activity and their stability in whole blood as well as for vasodilator properties. The products are partly transformed into the corresponding alcohols following 24-h incubation in whole blood. All of them display good COX-1/COX-2 selectivity, but are less potent than the lead; a molecular modeling study was carried out to investigate their binding mode. The compounds are also capable of relaxing rat aorta strips precontracted with phenylephrine with a NO-dependent mechanism; this property could confer reduced cardiotoxicity with respect to traditional COX-2 inhibitors.

Mechanism of action of novel NO-releasing furoxan derivatives of aspirin in human platelets

Incorporation of a nitric oxide (NO)-releasing moiety in aspirin can overcome its gastric side effects. We investigated the NO-release patterns and antiplatelet effects of novel furoxan derivatives of aspirin (B8 and B7) in comparison to existing antiplatelet agents. Cyclooxygenase (COX) activity was investigated in purified enzyme using an electron paramagnetic resonance-based technique. Concentration-response curves for antiplatelet agents +/- the soluble guanylate cyclase inhibitor, ODQ (50 microM) were generated in platelet-rich plasma (PRP) and washed platelets (WP) activated with collagen using turbidometric aggregometry. NO was detected using an isolated NO electrode. The furoxan derivatives of aspirin (B8, B7) and their NO-free furazan equivalents (B16, B15; all 100 microM) significantly inhibited COX activity (P < 0.01; n = 6) in vitro and caused aspirin-independent, cGMP-dependent inhibition of collagen-induced platelet aggregation in WP. B8 was more potent than B7 (PRP IC(50) = 0.62 +/- 0.1 microM for B8; 400 +/- 89 microM for B7; P < 0.0001. WP IC(50)s = 0.6 +/- 0.1 and 62 +/- 10 microM, respectively). The NO-free furazan counterparts were less potent antiplatelet agents (WP IC(50)s = 54 +/- 3 microM and 62 +/- 10 microM, respectively; P < 0.0001, B8 vs B16). Of the hybrids investigated, only B8 retained antiplatelet activity in PRP.NO release from furoxan-aspirin hybrids was undetectable in buffer alone, but was accelerated in the presence of either plasma or plasma components, albumin (4%), glutathione (GSH; 3 microM) and ascorbate (50 microM), the effects of which were additive for B7 but not B8. NO generation from furoxans was greatly enhanced by platelet extract, an effect that could largely be explained by the synergistic effect of intracellular concentrations of GSH (3 mM) and ascorbate (1 mM). We conclude that the decomposition of furoxan-aspirin hybrids to generate biologically active NO is catalysed by endogenous agents which may instil a potential for primarily intracellular delivery of NO. The blunting of the aspirin effects of furoxan hybrids is likely to be due to loss of the acetyl moiety in plasma; the observed antiplatelet effects are thereby primarily mediated via NO release. Compounds of this class might represent a novel means of inhibiting platelet aggregation by a combination of NO generation and COX inhibition.

NO-Donor Phenols: A New Class of Products Endowed with Antioxidant and Vasodilator Properties

The synthesis and study of the antioxidant and vasodilator properties of a new class of phenols able to release nitric oxide are described. The products were designed through a symbiotic approach using selected phenols and selected nitrooxy and furoxan NO-donors as reference models. The antioxidant activities of the hybrid products were assessed by detecting the 2-thiobarbituric acid reactive substances (TBARS) produced in the ferrous salt/ascorbate-induced autoxidation of lipids present in microsomial membranes of rat hepatocytes. The vasodilator activity was assessed on rat aortic strips precontracted with phenylephrine. Some of the products (13, 35, 37, 60-62, 64) behave principally as vasodilators and others as antioxidants (24, 32, 72), and the two properties are relatively balanced in 19, 41, and 68. Further in vivo studies should clarify whether some of these products may become preclinical candidates for the treatment of cardiovascular disease underpinned by atheroma.

Synthesis, chiral HPLC resolution and configuration assignment of 1-phenylglyceryl trinitrate stereomers

As an introductory study of in vitro vasodilating activity, the access to the four stereomers of 1-phenylglyceryl trinitrate is described using achiral and chiral chromatography. For semi-preparative separation of the enantiomers, a Chiralcel OD (250 x 10 mm, 10 microm) was used. Catalytic reduction leading to the corresponding stereomers of 1-phenylglycerol allowed absolute configuration assignments. The same methods were used for the separation and configuration assignment of the enantiomers of 3-phenylpropane-1,2-diyl dinitrate.

Furoxan analogues of the histamine H3-receptor antagonist imoproxifan and related furazan derivatives

Synthesis and pharmacological characterisation of a series of compounds in which the oxime substructure present in imoproxifan was constrained in the pentatomic NO-donor furoxan ring, as well as their structurally related furazan analogues devoid of NO-donating properties, are described. The whole series of products displayed reversible histamine H3-antagonistic activity on guinea-pig ileum. 4-(4-(3-(1H-Imidazol-4-yl)propoxy)phenyl)furoxan-3-carbonitrile 16 was also able to induce partial relaxation when added to the bath after electrical contraction of the guinea-pig ileum during the study of its H3-antagonistic properties. This phenomenon seems to be dependent on NO-mediated sGC activation. The lipophilic-hydrophilic balance of all the products was investigated.

The Furoxan System: Design of Selective Nitric Oxide (NO) Donor Inhibitors of COX-2 Endowed with Anti-Aggregatory and Vasodilating Activities

Several NO donor 3,4-diphenylfuroxan (= 3,4-diphenyl-1,2,5-oxadiazole 2-oxide) derivatives were synthesized and tested for their COX-inhibiting activities. The products were found to be selective COX-2 inhibitors, similar to the structurally related furazans (3,4-diphenyl-1,2,5-oxadiazole), devoid of the NO release property. This behavior was confirmed by a molecular-docking study. The NO-dependent platelet anti-aggregatory and vasodilating activities of the new furoxans 5-7 were studied in vitro. These properties can be modulated by inserting an appropriate spacer between the 4-phenyl group and the furoxan ring, giving rise to new, selective COX-2 furoxan derivatives endowed with anti-aggregatory and vasodilating activities, and with potentially reduced cardiotoxicities.

Non-imidazole histamine NO-donor H3-antagonists

Recently a series of H3-antagonists related to Imoproxifan was realised (I); in these products the oxime substructure of the lead was constrained in NO-donor furoxan systems and in the corresponding furazan derivatives. In this paper, a new series of compounds derived from I by substituting the imidazole ring with the ethoxycarbonylpiperazino moiety present in the non-imidazole H3-ligand A-923 is described. For all the products synthesis and preliminary pharmacological characterisation, as well as their hydrophilic-lipophilic balance, are reported. The imidazole ring replacement generally results in a decreased H3-antagonist activity with respect to the analogues of series I and, in some cases, induces relaxing effects on the electrically contracted guinea-pig ileum, probably due to increased affinity for other receptor systems.

Development of a new class of potential antiatherosclerosis agents: NO-donor antioxidants

A new class of NO-donor phenol derivatives is described. The products were obtained by joining appropriate phenols with either nitrooxy or 3-phenylsulfonylfuroxan-4-yloxy moieties. All the compounds proved to inhibit the ferrous salt/ascorbate induced lipidic peroxidation of membrane lipids of rat hepatocytes. They were also capable of dilating rat aorta strips precontracted with phenylephrine.

Antiinflammatory, gastrosparing, and antiplatelet properties of new NO-donor esters of aspirin

A new series of NSAIDs in which aspirin is joined by an ester linkage to furoxan moieties, with different ability to release NO, were synthesized and tested for NO-releasing, antiinflammatory, antiaggregatory, and ulcerogenic properties. Related furazan derivatives, aspirin, its propyl ester, and its gamma-nitrooxypropyl ester were taken as references. All the products described present an antiinflammatory trend, maximized in derivatives 12, 16, and 17, they are devoid of acute gastrotoxicity, principally due to their ester nature, and show an antiplatelet activity primarily determined by their ability to release NO. They do not behave as aspirin prodrugs in human serum.

Platelet antiaggregatory effects and haemodynamic activity of two terfuroxan isomer pairs

A couple of terfuroxan isomer pairs 1a,b and 2a,b were studied for their in vivo vasodilating activity and in vitro antiplatelet action. The haemodynamic profiles of the products resemble that of other NO-donors. Their in vitro antiaggregating activity is influenced both by terfuroxan system and by the substituents.

A new class of ibuprofen derivatives with reduced gastrotoxicity

A new series of nonsteroidal antiinflammatory drugs (NSAIDs) obtained by linking ibuprofen to selected furoxan moieties and to related furazans were synthesized and tested for their antiinflammatory, antiaggregatory, and ulcerogenic properties. All the derivatives are endowed with antiinflammatory activity comparable to that of ibuprofen, but, unlike this drug, they display reduced acute gastrotoxicity. The masking of the ibuprofen-free carboxylic group seems to be principally at the basis of this reduced topical irritant action. The two furoxan derivatives 8 and 9 also trigger potent antiaggregatory effects, principally as a consequence of their NO-donor ability.

Studies on agents with mixed NO-dependent and calcium channel antagonistic vasodilating activities

PURPOSE

To obtain new cardiovascular agents with mixed Ca2+-channel antagonistic and NO-donor properties, a series of "hybrid" 1,4-dihydropyridines (1,4-DHPs), bearing NO-donating furoxan moieties on the 3-positioned lateral ester chain were synthesized and pharmacologically characterized. Furazan analogues were also prepared and investigated for control purposes, because they are unable to release NO.

METHODS

Synthesis of the models was achieved by a modified Hantzsch approach. All of the final furoxan 1,4-DHPs were assessed for their ability to produce nitrite in the presence of a large excess of cysteine by the Griess reaction. Vasodilating activity was evaluated on rat aorta and expressed as EC50 and EC50MB values, obtained in the absence and in the presence of methylene blue (MB) respectively, a well-known guanylate cyclase inhibitor. Affinities to 1,4-DHP receptor on Ca2+-channels, expressed as IC50 values, were determined through displacement experiments of [3H]-nitrendipine on rat cortex homogenates.

RESULTS

Some hybrid compounds (derivatives 15a, 15b, 16a, and 16b) displayed vasodilating activity depending predominantly on their Ca2+-channel blocker properties. By contrast, some others (derivatives 17a, 17b, and 21) behaved as well-balanced hybrids with mixed Ca2+-channel blocking and NO-dependent vasodilating activities.

CONCLUSION

This work demonstrates the possibility of obtaining well-balanced hybrids endowed with mixed NO-donor and Ca2+-channel blocker properties using appropriate 1,4-DHP and furoxan moieties. A procedure for the individual evaluation of the NO-dependent vasodilator component and that due to Ca2+-channel blocking is proposed.

Nicorandil analogues containing NO-donor furoxans and related furazans

The synthesis and in vitro vasodilating properties of hybrid compounds in which furoxan (1,2,5-oxadiazole 2-oxide) moieties, endowed with different NO-donor properties, were substituted for the nitroxy function of Nicorandil are reported. The corresponding cyanoguanidine analogues are also considered. This approach has led to a series of vasorelaxing compounds devoid of affinity for K(ATP) channels, whose activity is prevalently due to their ability to activate sGC, at the concentrations of the experiments. Related furazan (1,2,5-oxadiazole) derivatives, unable to release nitric oxide were also prepared and studied for control. The amide analogues of Nicorandil display feeble vasorelaxing action not involving the activation of K+ channels, while in the guanidine analogues, this mechanism seems to underlie this action.

Antisecretory and gastroprotective activities of compounds endowed with H2 antagonistic and nitric oxide (NO) donor properties

In spite of the well recognized gastric antisecretory activity, the gastroprotective potential of histamine H2 receptor antagonists is controversial. Most clinical studies in fact indicate that these drugs do not substantially protect the gastric mucosa from aggressive factors. Nitric oxide (NO) has been recently recognized as a fundamental mediator in gastric defence mechanisms, due to its ability to increase gastric mucosal blood flow and mucus production and to inhibit neutrophils adherence to endothelial cells. The aim of this study was to investigate the gastroprotective and H2 receptor antagonistic activity of a series of lamtidine analogues which contain different NO-releasing moieties (furoxan, nitroxy and nitrosothiol). These compounds were tested, in comparison with related H2 antagonists devoid of NO-donor structures, in different H2 receptor assays and in the conscious rat against 0.6 N HCl-induced gastric lesions. All the compounds tested were able to antagonize histamine-mediated responses at cardiac and gastric H2 receptors; however, furoxan and nitroxy derivatives were 10-fold less potent than the analogues devoid of NO-donor properties. By contrast, NO-donor compounds were more active than reference H2 antagonists as gastroprotective agents against mucosal injury induced by 0.6 N HCl. Among the different NO-donor moieties, the furoxan group conferred to the H2 antagonist molecule the highest gastroprotective potential; this finding closely correlates with the characteristics of NO release. In conclusions, lamtidine-analogue H2 antagonists combined with NO-donor moieties are endowed with gastric antisecretory and protective activity and could be the prototypes of a new class of anti-ulcer drugs. Finally, the furoxan NO donor group seems to be the most favourable among the different moieties tested.