Aspirin

The acetyl (CH3CO) derivative of salicylic acid has been widely used as a general purpose pain
reliever for over a hundred years. It is potent, relatively safe and inexpensive. Annual production of
aspirin is in excess of 40,000 tons worldwide.

Written records from 500 B.C. indicate that the Greek doctor Hippocrates used the bark of
the willow tree as a pain reliever for individuals suffering from rheumatism and various forms of
inflammation.’ Research showed later that the active ingredient was Salicylic acid (see formula
below).

OH

OH
Salicylic acid

By the end of the 19th century, doctors regularly prescribed salicylic acid for
the treatment of arthritic pain. However, salicylic acid is no longer used as an oral medicine, since it
is very irritating to the stomach and can Cause serious gastrointestinal bleeding. lts main use is in
topical medications to remove warts and callouses.

Acetylsalicylic acid was discovered by the German chemist Felix Hoffmann, who tried to
make a less irritating medicine for his arthritic father. In 1897 he prepared aspirin, a more potent
and less irritating anti-inflammatory agent, and just two years later Bayer & Co. began marketing it
as Aspirin. Aspirin acts by inhibiting the enzyme cyclooxygenase (COX) that directs the synthesis of a
family of cell regulators called prostaglandins (PGs). In the stomach, a particular PG (PGE-) is
beneficial because it inhibits the excessive production of hydrochloric acid (HCI) and enhances the
formation of a protective layer of mucus.

Aspirin was widely used during the flu epidemic in Europe in 1917-1918 because it
effectively lowers dangerously high fevers. Such fevers are caused by elevated levels of PGE, in the
brain which are decreased by aspirin. By the 1950s aspirin became by far the most widely used
painkiller globally. That massive usage allowed the detection of aspirin's anticlotting properties and
the realization that it could be used to lower the risk of heart attack due to the clotting of blood in
disease-narrowed arteries. Taken soon after a heart attack, aspirin may also limit the size of the
infarcted area.”

Subsequent research indicated that aspirin inhibits blood clotting at low dosages (80-90 mg
per day). During the late 1980s studies also showed that aspirin can limit brain damage due to
occlusive stroke caused by a blood clot, if taken early. The use of aspinn is contraindicated in
hemorrhagic stroke, because it may increase bleeding.°

The anticlotting action of aspirin at low doses is due to the irreversible inhibition of
cyclooxygenase in blood platelets by transfer of the acetyl group from aspirin to a critical serine
hydroxyl group at the catalytic site of the enzyme. Since mature platelets have a lifetime of only
about 2 weeks and are not able to synthesize new protein, the clotting ability of aspirin-treated
platelets is permanently blocked.
 DIGOXIN (LANOXIN™)

Cardiac failure, which occurs when the heart can not deliver the required amount of blood
to the tissues and organs, is along with ischemia and arrhythmia (irregular heartbeat), a common
and major medical problem. This condition is usually caused by damaged and weakened heart
muscles (especially the ventricles) that do not contract efficiently. The net effect is reduced
circulation, accumulation of blood in the heart, lowered blood pressure and inadequate blood flow
to the lungs and kidneys. Digoxin is efficacious in people with heart failure because it increases the
contractile force of the heart and improves the blood flow to vital organs. Digoxin remains a useful
treatment for this condition despite the fact that the efficacious dose is not far below the toxic
dose.1

Cardiac glycosides have a long history in medical practice since their early use in the form of
plant extracts as diuretics and heart stimulants which dates back to 1500 B.C. The first modern
account of the beneficial effects of cardiac glycosides was made in the late 1700s by a British doctor,
William Withering, who described the effect of digitalis (extract from foxglove plants) for the
treatment of edema (also known as dropsy). Withering noted that the foxglove extract was both
beneficial and toxic and that correct dosing was critical to successful treatment.

We now know that the foxglove extract contains two main components, digoxin and
digitoxin that are easily separated. Digoxin proved to be the more effective and less toxic substance.
Digoxin works by binding to the oc- subunit of the Na+/K+ ATPase pump in the membranes of heart
cells (mycocytes). With the inhibition of the Na+/K+ pump, the concentration of Na+ increases in the
cells. This also leads to an increase of intracellular Ca2+ concentration and ultimately to an increase
in the force of heart muscle contraction (positive inotropic effect). Until recently digoxin was the
first-line treatment for individuals with congestive heart failure. However, it is now administered
mainly to those who remain symptomatic despite treatment with diuretics and ACE inhibitors.
Digoxin can only be used safely with strict medical monitoring since severe side effects, especially
heart rhythm disturbances, may occur.

The structure of digoxin is made up of two distinct moieties. The carbohydrate part (the
three six-membered rings at the left of the above structural formula) and the steroidal part (the right
side). The carbohydrate part improves aqueous solubility, but it is not essential for activity.
Numerous cardioactive glycosides occur in plants which share the steroid framework and differ
mainly in the carbohydrate units and in the number and location of OH groups attached to the
steroid part. The development of safer versions of digoxin would be medically useful.
 OMEPRAZOLE (PRILOSEC™)

During the late 1970s researchers at Astra Pharmaceuticals in Sweden (now AstraZeneca) developed
omeprazole (Prilosec™), the first gastric proton pump inhibitor. Proton pump inhibitors irreversibly
block the hydrogen/potassium adenosine triphosphate enzyme system (H+/K+ ATPase) that is
responsible for the secretion of acid into the stomach. Omeprazole allows the reduction of gastric
acid secretion to very low levels in a dose-dependent way. A key structural feature of omeprazole
(and other proton pump inhibitors) is the presence of a sulfoxide functional group (shown above in
green) between the benzimidazole (red) and pyridine (blue) rings.

Omeprazole is administered orally. At neutral pH, it is both stable and devoid of proton pump
inhibitory activity. However, it is activated once it reaches the parietal cells of the stomach via the
bloodstream. In the acidic environment of the stomach omeprazole undergoes an acid-catalyzed
rearrangement (see scheme at right) to form a reactive species (sulfenamide), which attacks and
inactivates the enzyme H+/K+ ATPase.1 As a result, the proton pump is shut off and gastric acidity is
lowered.

Due to the overall lipophilicity of omeprazole, it readily crosses cell membranes and has high
bioavailability. In terms of both potency and bioavailability, proton pump inhibitors have proved
superior to H2-receptor antagonists in the reduction of gastric acidity.2'3

Annual sales of omeprazole approached $7 billion in 2001.

Omeprazole is a mixture of enantiomers. The (S)-enantiomer, the active form, is now available as a
proprietary product under the brand name Nexium™.

CYCLOSPORIN (NEORAL™)

Cyclosporin A has played an important role in the modern era of organ transplantation. It allowed
for the first time selective suppression of T-cells without the bone marrow toxicity that is associated
with azathioprine therapy (see page 122). Cyclosporin A extends kidney graft survival rates and
greatly improves heart, liver, lung and even combined heart+lung transplantation. It also has been
applied to the treatment of several autoimmune diseases including severe rheumatoid arthritis and
psoriasis.1

Cyclosporin A is a fungal metabolite that was first isolated in the early 1960s at Sandoz (later
Novartis) in an effort to identify compounds with antibiotic activity. However, due to a narrow
spectrum of antimicrobial activity, it was never developed as an antibiotic. The reemergence of
cyclosporin A came as a result of a screening program to find other biological activities in the crude
fungal extract containing it. The extract was found to inhibit lymphocyte proliferation without
affecting other somatic cells. The active immunosuppressive ingredient was found to be cyclosporin
A. The exact chemical structure of cyclosporin A was first reported in 1976. Animal tests of the drug
were conducted by Roy Calne, who participated in the development of azathioprine. His
experiments supported the earlier findings that the compound suppresses the immune response
more potently than other drugs. The first human trials started in 1976 and the drug was approved
for use in the US in 1983. Long-term use of cyclosporin A can lead to nephrotoxicity, susceptibility to
infection, hypertension, and hyperlipemia.
Cyclosporin A acts by forming a complex with a binding protein, cyclophilin, and this complex inhibits
the enzyme calcineurin. The three-component complex of cycloxtrasporin A, cyclophilin and
calcineurin is depicted in the figure below.3 Calcineurin dephosphorylates the nuclear factor for
activated T-lymphocytes (NFAT), and causes its translocation into the nucleus, where it activates the
transcription of several cytokines, including interleukin-2 (IL- 2), which stimulate the growth,
differentiation, and survival of antigen activated T-cells. Inhibition of this process results in
diminished T-cell response to antigen stimulation. Cyclosporin also increases the expression of the
cytokine TGF-p\ which is a potent inhibitor of T-cell proliferation and of cytotoxic T- lymphocyte
formation.

VINBLASTINE (VELBAN™)

Vinblastine, a natural product in the vinca alkaloid family, is used for several types of cancer. It can
be a curative therapy for metastatic testicular cancer (in combination with cisplatin and bleomycin).
It also is a constituent of the ABVD chemotherapy (dacarbazine, bleomycin, vinblastine, and
doxorubicin) against Hodgkin's lymphoma. Other cancers treated with vinblastine include Kaposi's
sarcoma, small-cell lung cancer and cancers of the placenta and breast.

Vinblastine, along with a related vinca alkaloid used in chemotherapy, vincristine (Oncovin), was first
isolated in the late 1950s from the periwinkle plant of Madagascar. Because extracts of this plant
had been found to decrease the number of circulating white blood cells, scientists at Eli Lilly probed
the anticancer properties of the extract and showed that the active components, vinblastine and
vincristine were effective against leukemia and lymphoma cell lines. A few years later these agents
were approved for clinical use in the US. Although the structures of vinblastine and vincristine differ
in only one small part (the CH3 shown in red), they are not interchangeable medically. The most
important current application of vincristine is the treatment of childhood leukemia in combination
with corticosteroids. These chemotherapeutics are both administered intravenously.1

Vinblastine and vincristine act to inhibit microtubule formation by binding to tubulin, a structural
protein, which is the basic building block of microtubules (see figure below), and preventing its
aggregation.

Microtubules are hollow cylindrical protein structures that participate in many important cellular
processes. They serve as structural components of cells, and also play a role in intracellular transport
processes. Microtubules form the mitotic spindle, which is responsible for the segregation of
chromosomes during cell division. Inhibition of microtubule formation arrests cell division at the
metaphase stage of the cell cycle.2