MOI University

Department of Pharmacology and Medical Prescription

I. Anti-inflammatory drugs
II. Anti-allergic drugs
III. Immunomodulators
 Plan of lecture:
 Anti-inflammatory agents
 Anti-allergic drugs
 Immunomodulators
 Inflammation
 Inflammation is a complex protective response of the
organism to injury caused by damaging agents.
 It is aimed at inactivation or removal of these agents and
promoting healing.
 The traditional names for signs of inflammation come from
Latin:
 Dolor (pain)
 Calor (heat)
 Rubor (redness)
 Tumor (swelling)
 Functio laesa (loss of function)
 Mediators of inflammation
 Prostaglandins  Gamma-Interferon
 Bradykinin  Tumor Necrosis Factor
 Serotonin  Transforming Growth Factor
 Histamine
 Lymphotoxin

 Interleukins-2 – 6, 10,
12,13
 Platelet activating factor
 The role of some prostaglandins
in the body
 PGE 2 – vasodilation, bronchodilation, inhibition of
gastric acid secretion, stimulation of gastric mucus
secretion, sensitization of pain receptors to chemical
and mechanical stimuli, promotion of anterior pituitary
hormones release;
 PGF2α - uterus contraction, bronchoconstriction,
decrease in intraocular tension;
 TXA2 (thromboxane), produced by platelets, -
induction of platelet aggregation, vasoconstriction;
 PGI 2 - inhibition of platelet aggregation, potent
vasodilation;
 Cyclo-oxygenase (COX)
 Exists in the tissue as constitutive isoform
(COX-1).
 At site of inflammation, cytokines stim the
induction of the 2nd isoform (COX-2).
 Inhibition of COX-2 is thought to be due to
the anti-inflammatory actions of NSAIDs.
 Inhibition of COX-1 is responsible for their
GIT toxicity.
 Most currently used NSAIDs are
somewhat selective for COX-1, but
selective COX-2 inhibitors are available.
NSAIDs – nonsteroidal
anti-inflammatory drugs
 1. Nonsteroidal anti-
inflammatory drugs (NSAIDs)
Nonselective COX inhibitors
1. Salicylates  5. Antranilic acid
 *Acetylsalicylic acid (Aspirin) derivatives
 * Salicylamide  *Mephenamic acid
 2. Pyrazolone derivatives  6. Aryl – acetic acid
 *Phenylbutazone derivatives
 *Metamizol (Analginum)
 *Diclophenac sodium
 3. Indole derivatives
 7. Oxicam derivatives
 *Indomethacin
 *Piroxicam
 4. Propionic acid derivatives
 8. Dihydropyrrolizine
carboxylic acid derivative
 *Naproxen  *Ketorolac
 Selective COX inhibitors
 Preferential COX-2 inhibitors
 Nimesulide
 Meloxicam
 Nabumeton
 Selective COX-2 inhibitors
 Celecoxib
 Parecoxib
 Rofecoxib
NB!!!These drugs cause little gastric
mucosa damage, they do not inhibit platelet
aggrigation!!!
 Mechanism of action of NSAIDs
(Non-Steroidal Anti-Inflammatory Drugs)

• Act by inhibiting CycloOXygenases (COX) => no PG

production
– COX-1: Constitutively expressed => house-keeping function
– COX-2: Induced by pro-inflammatory factors (TNFα, IL-1)
– COX-3: Just recently discovered
• PGs do not cause pain, but sensitize nocireceptors to
stimulation (e.g. by 5-HT, Bradykinine, capsaicin, …)
• IL-1 release from activated macrophages (bacteria, etc.) induces
COX-2 in the brain =>PG E produced => affects thermoregulation
=> fever=> NSAIDs have anti-pyretic effects
• Classical NSAIDs: inhibit both COX-1 and COX-2 (inhibition is
reversible, with the exception of Aspirin) => housekeeping PGs
reduced => side effects (gastrointestinal, bronchospasms,…)
• 2nd generation NSAIDs: COX-2 specific => only the inflammatory
response is inhibited => fewer side effects.
Mechanism of anti-inflammatory
drugs’ action
Pharmacological effects of NSAIDs
 Anti-inflammatory
 Analgesic
 Antipyretic
 Antiplatelet(Aspirin)
 Closure of ductus arteriosus in newborn
 Clinical uses of NSAIDs
 1. Pain: headache, toothache, myalgia,
backpain;
 2. Fever;
 3. Arthritises: rheumatiod arthritis,
osteoarthritis, gout, ankylosing spondylitis;
 4. Dismenorrhoea (especially ibuprofen);
 5. Unclosure of ductus arteriosus (especially
aspirin);
 6. Prevention of MI, stroke, and reinfarction
(aspirin);
 Side effects of NSAIDs
 1. GIT disturbances: epigastric pain, nausea, gastric
peptic ulcer (especially aspirin), gastrointestinal
bleeding (especially indomethacin);
 2. CNS disturbances: dizziness, mental confusion,
hallucination and psychosis, depression (especially
indomethacin);
 3. Leukopenia, agranulocytosis (indomethacin,
phenylbutzone, metamizol);
 4. Water and sodium retention, edema
(phenylbutzone);
 5. Hypersensitivity reactions
 6. Reye’s syndrom, bronchospasm (aspirin)
 Contraindications
 A) Pregnancy
 B) Haemophilic patients
 C) Hypersensitivity reactions
 D) Viral infections mainly in children
 E) Peptic ulcers
 Drugs interaction

 Potentiates the gastric irritant effect of

alcohol
 Potentiates the hypoglycaemic effects of
oral hypoglycaemic drugs
 The Salicylates - ASPIRIN
 Duration of action ~ 4 hr.
 Orally taken.

 Weak acid (pKa ~ 3.5); so, non-ionized in

stomach  easily absorbed.
 Hydrolyzed by esterases in tissues and blood to
salicylate (active) and acetic acid.
 Most salicylate is converted in liver to H 2O-sol
conjugates that are rapidly excreted by kids.
 ASPIRIN - Therapeutic Uses
 Antipyretic, analgesic.
 Anti-inflammatory: rheumatic fever, rheumatoid arthritis
(joint dis), other rheumatological diseases. High dose
needed (5-8 g/day).
 But many pts cannot tolerate these doses (GIT); so,
proprionic acid derivatives, ibuprofen, naproxen tried first.
 Prophylaxis of diseases due to platelet aggregation.
 Pre-eclampsia and hypertension of pregnancy (excess
TXA2).
 Propionic acid derivatives
IBUPROFEN:
 Pharmacokinetics
 Rapidly absorbed after oral ingestion.
 Half-life 1-2 hours
 Highly bound to plasma proteins
 Excreted through kidney as metabolites.
 IBUPROFEN
 The same mechanism & pharmacological
actions of aspirin Except that it is
reversible inhibitor for COX enzymes
 More potent as antiinflammatory than
aspirin!!!
 Clinical uses

 A) Analgesic
 B) Antipyretic
 C) Anti-inflammatory
 D)Acute gouty arthritis
 E) Patent ductus arteriosus
 Preparations of Ibuprofen
 Oral preparations.
 Topical cream for osteoarthritis.
 A liquid gel for rapid relief of postsurgical
dental pain.
 Intravenous route as In patent ductus
arteriosus
 Adverse effects
 1.Gastric upset (less frequent
than aspirin).
 2.Fluid retention
 3.Hypersensetivity reactions
 4.Ocular disturbances
 5.Rare hematologic effects
(agranulocytosis & aplastic
anaemia).
 Contraindications

 1. Peptic ulcer
 2. Allergic patients to aspirin
 3. Kidney impairment
 4.Liver diseases
 5.Pregnancy
 6.Haemophilic patients
The concomitant administration of ibuprofen
antagonizes the irrevesible platelet inhibition of
ASPIRIN (limit cardioprotective effect of aspirin).
 Piroxicam
 Mechanism of actions:
 A) Non-selective inhibitors to
COX1 & COX2
 B) Traps free radicals
 C) Inhibits
polymorphonuclear
leukocytes migration
 D) Inhibits lymphocyte
function.
 Pharmacokinetics
 Well absorbed orally
 Half- Life 45 hours
 Given once daily
 Adverse effects
 Less frequent gastric upset (20%).
 Dizziness.
 Tinnitus.
 Headache.
 Allergy.
 Acetic acid derivatives
DICLOFENAC
 Mechanism of action
 Non-selective inhibitor to COX1 & COX2.
 More potent as anti-inflammatory than
analgesic and antipyretics.
 Clinical uses
DICLOFENAC
 A) Any inflammatory conditions
 B) Musculoskeletal pain
 C) Dysmenorrhoea
 D)Acute gouty arthritis
 E) Fever
 F) Locally to prevent or treat post opthalmic
inflammation
 G) A topical gel for solar keratoses
 Adverse effects
DICLOFENAC
 Gastric upset
 Renal impairment
 Elevation of serum aminotransferase
 Salt & water retention
Preparations of DICLOFENAC
 Diclofenac with misoprostol decreases upper
gastrointestinal ulceration, but result in diarrhea.
 Diclofenac with omeprazole to prevent recurrent
bleeding.
 1% opthalmic preparation for postoperative
opthalmic inflammation.
 A topical gel 3% for solar keratoses.
 Rectal suppository as analgesic or for
postoperative nausea.
 Selective COX 2 inhibitors
 Advantages:
 1. Highly selective inhibitors to COX2
enzyme.
 2. Potent anti-inflammatory.
 3. Have analgesic & antipyretic properties.
 4. Highly bound to plasma proteins.
 Selective Cox 2 inhibitors
 5. Lower incidence of gastric upset.
 6. No effect on platelet aggregation (COX1).
 7. Renal toxicities (they are not
recommended for patients with severe renal
insufficiency).
 8. High incidence of cardiovascular
thrombotic events with some of them as
ROFECOXIB.
Selective Cox 2 inhibitors
 9-They are recommended in
postoperative patients undergoing bone
repair.
 10- Also, indicated in primary familial

adenomatous polyposis, dysmenorrhea,

acute gouty arthritis, acute
musculoskeletal pain, ankylosing
spondylitis.
 SAIDs – steroidal
anti-inflammatory drugs
Steroidal anti-inflammatory drugs
 1. Short-acting  3. Long-acting
glucocorticoids Betamethasone
(natural) Dexamethasone
Hydrocortisone Paramethasone
Cortisone  4.Topically acting
 2. Intermediate-acting glucocorticoids
glucocorticoids Beclomethasone
Prednisone dipropionate
Prednisolone Budesonide
Methylprednisolone Fluocinolone acetonide
Triamcinolone Fluocortolone
 Preparations of SAIDs
Drugs Anti-inflam. Salt retaining Topical

Cortisol 1 1.0 1
Cortisone 0.8 0.8 0
Prednisone 4 0.8 0
Prednisolone 5 0.3 4
Methylpredni- 5 0 5
solone

Intermediate acting
Triamcinolone 5 0 5
Paramethasone 10 0 -
Fluoprednisolone 15 0 7
 Preparations of SAIDs

Drugs Anti-inflam. Salt retaining Topical

Long acting

Betamethasone 25-40 0 10

Dexamethasone 30 0 10

Mineralocorticoids

Fludrocortisone 10 250 10

DOCA 0 20 0
MECHANISM OF ACTION Corticosteroids
OF SAIDs
Phospholipids

Phospholipase A2

Arachidonic acids

Lipoxygenase Cycylooxygenase

Prostaglandins,
Leukotriene Thromboxane,
Prostacyclins.
 Clinical uses
of SAIDs
 Adrenal insufficiency
 Arthrities
 Collagen diseases (systemic lupus erhymatosis, scleroderma)
 Bronchial asthma
 Severe allergic reactions
 Autoimmune diseases
 Skin diseases
 Ulcerative colitis, Crohn’s disease
 Cerebral edema
 Organ transplantation and skin allograft
 Septic shock
Main side effects of SAIDs
 Susceptibility to infections
 Delayed healing of wounds
 Osteoporosis
 Growth retardation in children
 Peptic ulceration
 Cushing habitus
 Hyperglycaemia
 Muscular weakness
 Psychiatric disorders
 Withdrawal syndrom
ANTI-ALLERGIC DRUGS
 Allergy
 An allergy is a hypersensitivity disorder of the immune
system.
 Allergic reactions occur when a person's immune system
reacts to normally harmless substances in the
environment.
 A substance that causes a reaction is called an allergen.
These reactions are acquired, predictable, and rapid.
 Allergy is one of four forms of hypersensitivity and is
formally called type I (or immediate) hypersensitivity.
 Allergic reactions are distinctive because of excessive
activation of certain white blood cells - lymphocytes
called B cells, whose role is production of antibodies,
called Immunoglobulin E (IgE).
 Mast cells are activated and release mediator of allergy
(HISTAMINE) that results in an inflammatory response.
 Clinical Symptoms
Associated With Histamine
Release
 erythema, urticaria, and/or
 mild/cutaneous
itching

 mild to moderate  skin reactions, tachycardia,

dysrhythmias, moderate
hypotension, mild respiratory
 severe/ distress
anaphylactic  severe hypotension, ventricular
fibrillations, cardiac arrest,
bronchospasm, respiratory
arrest
Histamine exerts its effects on many tissues
and organs:

It is not a drug but is important due to its

physiological and pathophysiological actions.
Therefore, drugs that inhibit its release or block
its receptors have therapeutic value.

Physiological Actions of Histamine

• Primary stimulant for gastric acid and pepsin
secretion (H2) (acid secretion is enhanced by
gastrin and vagal stimulation)
• Has a role as a neurotransmitter (H3) (both in the
CNS and peripheral sites)
 Pathophysiological Actions of
Histamine
• Cellular mediator of immediate hypersensitivity
reaction and acute inflammatory response
• Anaphylaxis
• Seasonal allergies
• Duodenal ulcers
• Systemic mastocytosis
• Gastrinoma (Zollinger-Ellison Syndrome)
 Pharmacological Effects of
Histamine
 Ranges from mild allergic symptoms to
anaphylactic shock

 Involves both the H1 and H2 receptors

 dilatation of small blood vessels  flushing
(H1)
 decreased TPR and BP (H1 initial response,
H2 sustained reaction)
 increased capillary permeability, edema (H1)
(Oedema of Quincke, Stevence-Johnson syndrome)
 Antiallergic drugs

 1. Antihistaminics
 2. Corticosteroids
 3. Mast cell stabilisers
 4.Antileukotriene drugs
histaglobulin
 Histamine-related Drugs

 Mast Cell Stabilizers (Cromolyn Na, Nedocromil

–Tilade -, Albuterol)
 H1 Receptor Antagonists (1st and 2nd
generation)
 H2 Receptor Antagonists (Ranitidine,
Cimetidine)
 H3 Receptor Agonist and Antagonists (potential
new drugs being developed)
 First Generation
ANTIHISTAMINE Agents
Ethanolamines: DIPHENHYDRAMINE (Benadryl)
CLEMASTINE (Tavist)
Ethylenediamine:TRIPELENNAMINE
Alkylamine:CHLORPHENIRAMINE (Chlortrimeton)
Phenothiazine:PROMETHAZINE (Phenergan)
Piperazines: HYDROXYZINE (Vistaril)
CYCLIZINE (Antivert)
 First Generation Agents
Uses:
• Adjunctive in anaphylaxis and other cases where
histamine release can occur (H2 antagonist, and
epinephrine must also be used in anaphylaxis)
• Antiallergy (allergic rhinitis, allergic dermatoses,
contact dermatitis)
• Sedative/sleep aid
• To prevent motion sickness (MECLIZINE,
CYCLIZINE)
 First Generation Agents
Adverse Effects:
 Sedation (Paradoxical Excitation in children)
 Dizziness
 Fatigue
 Tachydysrhythmias in overdose - rare
 Allergic reactions with topical use
 Peripheral antimuscarinic effects
• dry Mouth
• blurred Vision
• constipation
• urinary Retention
 First Generation Agents
Drug interactions:
 Additive with classical antimuscarinics
 Potentiate CNS depressants
• opioids
• sedatives
• general and narcotic analgesics
• alcohol
 Second Generation Agents
Examples
• CETIRIZINE (ZYRTEC)
• FEXOFENADINE (ALLEGRA)
• LORATADINE (CLARITIN)
• DESLORATADINE (CLARINEX- Uses
FDA APPROVED IN 2002)
• LORATADINE (CLARITIN HIVES
 Antiallergy
RELIEF - FDA APPROVED
IN 2004)
• AZELASTIN (INTRANASAL SPRAY)
• ASTEMIZOLE
• ACRIVASTINE
Histamine H1- Antagonists
 FirstGeneration:
!!!Sedating!!!

 Second Generation:
!!!Non sedating!!!
 Advantages of 2nd generation
antihistaminics

 Higher H1 selectivity, absence of

anticholinergic side effects
 Absence of inhibitory action on CNS
 Additional antiallergic mechanisms: some of
them are acting on leukotrienes or by
antiplatelet activating factor
 Mast cell stabilisers

 Cromolyn sodium (Sodium cromoglycate)

 Nedocromil sodium
 Ketotifen
 Corticosteroids (vide supra)
 Antileukotriene drugs
 Montelukast
 Zafirlukast

Mechanism: competitive block of LT1 receptors

Clinical use: bronchial asthma
Immunomodulators
Thank You!!!