Novel Pharmacological Strategies for Analgesia
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Annals ofthe Rheumatic Diseases 1996;55:715-722 715 REVIEW: PAIN Series editor: Bruce L Kidd Ann Rheum Dis: first published as 10.1136/ard.55.10.715 on 1 October 1996. Downloaded from Novel pharmacological strategies for analgesia Martin Perkins, Andy Dray Acute transient pain, associated with negligible The two most studied of these are bradykinin tissue damage, serves as a physiological and kallidin, a nonapeptide and a decapeptide warning of potential tissue damage. Somewhat respectively. Both are cleaved from precursor more persistent pain, associated with molecules following the activation of a hyperalgesia and tenderness, is often associated biochemical cascade. In the plasma, bradykinin with inflammation. This is also a normal (Arg-Pro-Pro-Gly-Phe-Ser-Pro-Phe-Arg) is protective response to mild injury and resolves produced from high molecular weight rapidly once the injury has healed. However kininogen (HMWK) whereas in tissue kallidin there are various persistent pain conditions in (lysyl-bradykinin) is liberated from its which the stimulus and pain are unrelated. precursor, low molecular weight kininogen Thus the pain sensation outlasts its biological (LMWK)4 by the action ofproteolytic enzymes usefulness. In these conditions pain can no (fig 1). longer be regarded as a purely physiologically Both bradykinin and kallidin are rapidly protective symptom. This may arise as a result degraded by peptidases known as kininases of chronic pathological lesions or degenerative giving rise to inactive metabolites with the processes, but in many cases there may be no exception of des-Arg9bradykinin or des- discernible pathology. These types of chronic Arg'0kallidin which lack the carboxy- terminal pain state-which occur with migraine, arginine. These are the only metabolites of rheumatoid arthritis, osteoarthritis, low back bradykinin or kallidin with significant activity.4 pain, cancer pain, and neuropathic pain-are Bradykinin and kallidin mediate their effects poorly understood and for the most part diffi- through two main classes of receptor, B1 and cult to treat. Thus chronic pain sufferers of one B2.' The genes for both of these receptors have kind or another account for approximately 10- recently been cloned and have been shown to 20% ofthe adult population, while about 5-8% belong to the superfamily of receptors of G experience pain which is inadequately treated.' protein coupled, 7-transmembrane spanning http://ard.bmj.com/ Present treatment for most pain states has domains receptors.6 7 Less is known about the relied heavily on the use of non-steroidal anti- molecular characteristics ofthe B1 receptor but inflammatory drugs (NSAID) and opioid anal- it has little homogeneity with the B2 receptor8 gesics. Although variants of these classes of and in keeping with current pharmacological drug have been developed there has been little studies it seems likely that antagonists for this conceptual innovation in analgesia for many receptor will be different from those developed years. Furthermore both classes of drug at B2 sites. on October 1, 2021 by guest. Protected copyright. produce side effects, such as gastrointestinal Bradykinin and kallidin acts preferentially disturbances, gastric ulceration, renal damage, on the B2 receptor, and this accounts for the and hypersensitivity reactions with NSAID, majority of the acute pharmacological effects and nausea, constipation, confusion, respira- of bradykinin. The preferred agonists for the tory depression, and possibly dependence with B1 receptor, however, are the active metabolites, opioids. Despite considerable effort these des-Arg'bradykinin and desArg'0kallidin. problems have not yet been overcome. An Bradykinin exerts a variety of effects on important reason for this has been the many body tissues but it is its actions on noci- relatively slow advance, until recently, in ceptive neurones that are of most relevance to understanding the pathogenesis of chronic pain and analgesia. Bradykinin has two main pain. Some of these advances have been effects on these neurones-activation and reviewed and are leading a conceptual shift in sensitisation-and both of these actions have pain pathophysiology and management. In the been shown to be mediated primarily by the B, light of this we shall discuss some recent initia- receptor. Sandoz Institute for tives for the discovery and development of new Bradykinin depolarises sensory neurones by Medical Research, analgesic drugs based on knowledge of the activation of phospholipase C and stimulation Gower Place, London and neurochemical changes WC1E 6BN, United pathophysiological of protein kinase C, with an increase in Kingdom that occur in the nociceptive pathway after membrane sodium ion conductance.9 '0 This M Perkins injury. probably underlies the overt pain response to A Dray bradykinin. With respect to sensory neurone Correspondence to: Kinin receptor inhibition activity, bradykinin has been shown to increase Dr M N Perkins. Kinins are a family of small peptides which are nociceptor C fibre discharge in somatic and Accepted for publication produced locally in response to tissue injury or visceral sensory neurones both in vitrol' 1' and 19 February 1996 trauma and particularly during inflammation. in vivo." 716 Perkins, Dray Following administration to somatic and vis- Recently several studies have showed that ceral tissue sites bradykinin elicits powerful during inflammation there is an increasing nocifensor behaviours.13 '5 Bradykinin is also contribution ofB, receptors to the accompany- Ann Rheum Dis: first published as 10.1136/ard.55.10.715 on 1 October 1996. Downloaded from algogenic in man following topical application ing hyperalgesia. Thus B1 receptor antagonists or intracutaneous injection.16 17 Bradykinin also such as Leu8,des-Arg9bradykinin are consist- has a powerful sensitising action on nociceptors, ently antinociceptive.23 26 27 28 enhancing their responsiveness to mechanical The B, receptor appears to be expressed or and thermal stimulation.'8"20 This property of synthesised de novo in tissues following trauma bradykinin is possibly of more relevance in or when inflammatory mediators such as man, increasing both the perception and dura- cytokines are present.2329 Indeed a close tion of pain. interaction has been shown between kinins other Although bradykinin is one of the first inflammatory mediators, particularly cytokines. inflammatory mediators to be produced in In particular, interleukin-1[ upregulates B, and response to trauma or inflammation, prostaglan- B2 receptors as well as enhances responses to dins also play a major role in inflammation and bradykinin and desArg' bradykinin.23 27 3032 The enhance bradykinin induced responses. Not potential exists, therefore, for a powerful only is the neuronal activation by bradykinin reinforcement between kinins and other potentiated by prostaglandins but they may inflammatory mediators leading to a sustained also enhance bradykinin evoked release of the hyperalgesic state. neurogenic inflammatory mediators substance P and calcitonin gene related peptide Cyclo-oxygenase inhibition (CGRP).2 One of the major treatments for inflammatory There are therefore strong experimental pain has been the reduction of prostaglandin grounds for targeting the B2 receptor in the levels by inhibition of cyclo-oxygenase (COX) treatment of inflammatory pain and conse- activity with NSAID. However, the develop- quently selective B2 receptor antagonists based ment of tolerance and unacceptable side on the peptide structure of bradykinin have effects, such as gastric haemorrhage and neph- been developed (fig 2), the most potent being rotoxicity, have severely limited the usefulness HOE 140.22 The use of this and other of this approach with respect to chronic or per- peptidergic antagonists has shown that the sistent inflammatory pain. It had been thought acute activation and sensitisation of sensory that there was a single cyclo-oxygenase enzyme neurones by bradykinin are mediated by the B responsible for prostaglandin production; receptor.5 23 Furthermore, in several models of however, recently two isoforms of cyclo- nociception, selective B2 receptor antagonists24 25 oxygenase have been demonstrated-a consti- are antinociceptive. tutive and an inducible enzyme (fig 3).3 The BRADYKININ and INFLAMMATORY PAIN http://ard.bmj.com/ Activation of kallikrein enzymes Precursor molecules high and low molecular weight kininogen on October 1, 2021 by guest. Protected copyright. PLASMA TISSUE desArg9Bk BRADYKININ Kallidin desArqlOKd ArgProGlyPheSerProPheArg LysArgProProGlyPheSerProPheArg |RECEPTORS| Linked with trauma/injury Majority of Bk's actions Immunocompetent cells - inflammatory SENSORY NERVESA EXCITATION NOCICEPTORS SENSITISATION Figure 1 Theformation of kininsfoUlowing trauma andlor an inflammatory insult. Both bradykinin and kallidin act on the B2 receptor. In addition, kallidin can be converted to bradykinin by the action ofaminopeptidases. The preferred agonistsfor the B1 receptor are desArg9bradykinin (desArg9Bk) and desArgJ°kallidin (desArglOKd) which areformed by the action ofkininase I-peptidase which removes the carboxy-terminal arginine residue ofbradykinin and kallidin, respectively. Bradykinin and kallidin act directly on nociceptive neurones to cause overt excitation, leading to pain, and sensitisation of the terminals resulting in a reduction in thresholdfor activation. In addition, both these kinins act on immunocompetent cells (for example, macrophages) to release other inflammatory