Nitric Oxide

Therapeutics, Markets and Companies

By
Prof. K. K. Jain
MD, FRACS, FFPM

Jain PharmaBiotech
Basel, Switzerland

July 2012

A Jain PharmaBiotech Report

AUTHOR'S

BIOGRAPHY

Professor K. K. Jain is a neurologist/neurosurgeon by training and has been working in

the biotechnology/biopharmaceuticals industry for several years. He received graduate
training in both Europe and USA, has held academic positions in several countries, and is
a Fellow of the Faculty of Pharmaceutical Medicine of the Royal College of Physicians of
UK. Currently, he is a consultant at Jain PharmaBiotech.
Prof. Jain is the author of 440 publications including 21 books (4 as editor) and 50 special
reports which have covered important areas in biotechnology, gene therapy and
biopharmaceuticals. He has also written a textbook of gene therapy which is the first book
on this subject to be translated into the Chinese language. A book on gene therapy
companies was published in 2000 by John Wiley & Sons. Updated material from both
these books have been included in 2011 edition of a special report on Gene Therapy
published by Jain PharmaBiotech Publications. Prof. Jain has edited "Drug Delivery
Systems" (Humana/Springer 2008) and Drug Delivery to the Central Nervous System
(Humana/Springer 2010). His other recent books include "Handbook of Nanomedicine"
(Springer 2008; Chinese edition, Peking University Press 2011, 2nd ed Springer 2012),
Textbook of Personalized Medicine (Springer 2009), "Handbook of Biomarkers"
(Springer 2010), "Handbook of Neuroprotection" (Springer in 2011), Application of
Biotechnology in Cardiovascular Disorders (Springer 2011), and Application of
Biotechnology in Neurology (Springer 2012, in preparation).

July 2012 (first edition published in 2002)

Copyright 2012 by
Jain PharmaBiotech
Blsiring 7
CH-4057 Basel
Switzerland
Tel & Fax:
Email:
Web site:

+4161-6924461
info@pharmabiotech.ch
http://pharmabiotech.ch/

All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted in any form or by any means, electronic, mechanical, photocopying,
or otherwise without the prior written permission of the Publisher. This report may not be
lent, resold or otherwise traded in any manner without the consent of the Publisher. While all
reasonable steps have been taken to ensure the accuracy of the information presented, the
Publisher cannot accept responsibility for inadvertent errors or omissions.

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TABLE

OF

CONTENTS

0. Executive Summary .............................................................................. 13

1. Introduction ......................................................................................... 15
Nitric oxide ........................................................................................................................ 15
Historical aspects ............................................................................................................. 15
Free radicals ...................................................................................................................... 16
Nitrogen cycle and NO ...................................................................................................... 16
Role of NO in biology and medicine .................................................................................... 17
Nitric oxide synthase ......................................................................................................... 18
Structure and function NOS ............................................................................................... 18
Inducible nitric oxide synthase ........................................................................................... 19
iNOS gene .................................................................................................................. 19
Regulation of iNOS ...................................................................................................... 19
Regulation of endothelial nitric oxide synthase ..................................................................... 20
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
Nitrate-nitrite-NO pathway ................................................................................................ 27
Soluble guanylyl cyclase as the NO receptor ........................................................................ 27
Oxidative stress pathways ................................................................................................. 27
NO and oxidative stress .................................................................................................... 28
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
Role of NO in adaptation to high altitude ........................................................................... 35
NO as a biomarker ............................................................................................................. 36
Functions of NO in various systems of the body ................................................................. 36
NO and proteins ............................................................................................................... 37
A proteomic method for identification of cysteine S-nitrosylation sites ............................... 37
Protein S-nitrosylation and intracellular transport processes ............................................. 37
Cellular inactivation NO by iNOS aggresome formation .................................................... 37
NO and mitochondria ........................................................................................................ 38
Mitochondrial permeability and reperfusion injury ........................................................... 39
Endocrine role of NO ........................................................................................................ 39
Role of NO in the cardiovascular system ............................................................................. 39
NO and atrial natriuretic peptide ................................................................................... 40
NOS in the cardiac myocyte.......................................................................................... 40
NO and the autonomic control of the heart rate .............................................................. 41
NO and vasodilatation.................................................................................................. 42
Role of NO in the plasma compartment .......................................................................... 43
Measurement of NO as a biomarker of cardiovascular function .......................................... 43
Hemoglobin, oxygen and nitric oxide .................................................................................. 44
Myoglobin and NO ....................................................................................................... 45
NO and pulmonary circulation ............................................................................................ 45
Role of NO in the regulation of hypoxic pulmonary vasoconstriction ................................... 46
Role of NO in the nervous system ...................................................................................... 46
Neurovascular coupling of COX-2 and nNOS ................................................................... 47
Neuroglobin ................................................................................................................ 47
Acute actions of NO in the CNS pathways ....................................................................... 48
Role of NO in memory and learning ............................................................................... 48
Role of NO in synaptic plasticity .................................................................................... 48

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Role of NO in the peripheral nervous system .................................................................. 49

Role of NO in the cochlea .................................................................................................. 49
NO and neuroendocrine function ........................................................................................ 49
NO and pregnancy ........................................................................................................... 49
Role of NO in penile erection ............................................................................................. 50
Role of NO in immune regulation........................................................................................ 50
Role of NO in temperature regulation ................................................................................. 51
Role of NO in gastrointestinal system ................................................................................. 51
Role of NO in kidney function............................................................................................. 51
Role of NO in liver ............................................................................................................ 52
Role of NO in the skin ....................................................................................................... 52

4. Role of NO in Diseases .......................................................................... 55

Introduction....................................................................................................................... 55
Cytotoxicity of reactive nitrogen species ............................................................................. 55
Peroxynitrite, mitochondria and cell death ........................................................................... 55
Diseases involving oxidative stress and nitric oxide .......................................................... 57
Stress-related disorders .................................................................................................... 58
Role of NO in allergic disorders .......................................................................................... 58
Inflammatory diseases ...................................................................................................... 58
Autoimmune disorders ....................................................................................................... 59
Role of NO in rheumatoid arthritis ...................................................................................... 60
Role of NO in infections ..................................................................................................... 60
NO-mediated cytoprotection in bacteria .............................................................................. 61
Trypanosomiasis .............................................................................................................. 62
Malaria and iNOS polymorphism ........................................................................................ 62
Susceptibility of Mycobacterium leprae to NO ...................................................................... 62
Role of NO in the treatment of tuberculosis ......................................................................... 63
Septic shock .................................................................................................................... 63
Viral infections ................................................................................................................. 64
Role of NO in anaphylactic shock ....................................................................................... 64
Role of NO in anemia and hypoxia ..................................................................................... 65
Role of NO in neurological disorders .................................................................................. 65
Neurodegenerative diseases .............................................................................................. 65
NO-induced mitochondrial dysfunction in neurodegeneration ............................................ 66
White matter disorders ................................................................................................ 66
Amyotrophic lateral sclerosis ........................................................................................ 67
Alzheimer's disease ..................................................................................................... 67
Role of NO in pathophysiology of Alzheimer's disease ...................................................... 67
Role of ApoE genotype ................................................................................................. 70
Parkinson's disease ..................................................................................................... 70
Traumatic brain injury ...................................................................................................... 72
Epilepsy .......................................................................................................................... 73
Stroke ............................................................................................................................ 73
Pathophysiology of cerebral ischemia............................................................................. 73
Role of NO in cerebral ischemia..................................................................................... 74
eNOS gene polymorphisms as predictor of cerebral aneurysm rupture ............................... 76
Role of NO in assessment of cerebral and retinal blood flow.............................................. 76
Role of NO in neuroprotection ....................................................................................... 76
Stroke and heart disease ............................................................................................. 76
Role of NO in peripheral neuropathy ................................................................................... 77
iNOS induction in experimental allergic neuritis ............................................................... 77
Role of NO in sciatica ................................................................................................... 77
Role of NO in the pathogenesis of muscular dystrophy .......................................................... 77
Role of NO in psychiatric disorders .................................................................................... 78
NO-dysregulation in schizophrenia ..................................................................................... 78
Role of NO in pathomechanism of cardiovascular disorders ............................................... 79
Oxidative stress as a cause of cardiovascular disease ........................................................... 79
Role of NO in pathomechanism of cardiovascular diseases ..................................................... 79
Role of iNOS in cardiovascular disease ........................................................................... 80
Role of eNOS in cardiovascular disease .......................................................................... 80
Role nNOS in cardiac arrhythmia and sudden death ......................................................... 81
NO and atherosclerosis ..................................................................................................... 81
Role of NO in cardiopulmonary disorders ............................................................................. 82
Role of NO in disturbances of vasodilation ........................................................................... 83
Caveolin-1 deficiency impairs NO synthesis and vasodilation ............................................ 83
Role of NO in hypercholesterolemia .................................................................................... 83
Pulmonary hypertension ................................................................................................... 84
NO and systemic hypertension. .......................................................................................... 85
Coronary artery disease .................................................................................................... 86
Role of NO in the pathophysiology of angina pectoris ............................................................ 86

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Congestive heart failure .................................................................................................... 87

Calcium overload as a cause of heart failure ................................................................... 87
NO/redox disequilibrium in the failing heart .................................................................... 87
Myocardial ischemia/reperfusion injury ............................................................................... 87
NO pathway in cardiac hypertrophy .................................................................................... 89
Role of NO in sickle cell disease ......................................................................................... 90
Role of NO in respiratory disorders .................................................................................... 90
Role of NO in the pathophysiology of asthma ....................................................................... 90
iNOS gene polymorphisms in asthma ............................................................................. 91
Role of S-nitrosoglutathione in bronchodilation in asthma ..................................................... 92
Monitoring of exhaled NO .................................................................................................. 92
Nasal NO as a biomarker of response to rhinosinusitis therapy .............................................. 93
Elevated urinary NO as a biomarker of improved survival in ARDS ......................................... 93
Role of NO in renal disorders ............................................................................................. 94
Role of NOS in diabetic nephropathy................................................................................... 94
Role of NO in cancer .......................................................................................................... 94
Inflammation, NO and colon cancer .................................................................................... 95
Tumor hypoxia and NO ..................................................................................................... 96
NO and p53 mutations ...................................................................................................... 96
NO and matrix metalloproteinase ....................................................................................... 97
Role of NO in angiogenesis in cancer .................................................................................. 97
Role of NO in diseases of the eye ....................................................................................... 98
Glaucoma ....................................................................................................................... 98
Role of NO in metabolic disorders ...................................................................................... 99
Metabolic syndrome ......................................................................................................... 99
Obesity ........................................................................................................................... 99
Diabetes mellitus ............................................................................................................. 99
Role of NO in gastrointestinal disorders........................................................................... 100
Role of L-arginine in intestinal adaptation ......................................................................... 100
Role of NO in irritable bowel syndrome ............................................................................. 100
Role of NO in inflammatory bowel diseases ....................................................................... 100
Role of NO in celiac disease ............................................................................................. 101
Role of NO in diabetic gastroparesis ................................................................................. 101
NO and diseases of the liver ............................................................................................ 101
Cirrhosis of liver ............................................................................................................ 101
Hepatic encephalopathy .................................................................................................. 102
Role of NO in skin disorders ............................................................................................. 102
Role of NO and oxidative stress in the aging skin ............................................................... 102
Role of NO in wound healing ............................................................................................ 103
Role of NO in pain ............................................................................................................ 103
NO and pain of spinal cord origin ..................................................................................... 103
NO interaction with other receptors in pain........................................................................ 104
nNOS and pain .............................................................................................................. 104
Role of NO in various types of pain ................................................................................... 104
Neuropathic pain ....................................................................................................... 104
Role of NO in diabetic neuropathy ............................................................................... 104
NO in oral and facial pain ........................................................................................... 105
Role of NO in migraine ............................................................................................... 105
Role of NO in osteoarthritis ........................................................................................ 106
NO and Fibromyalgia syndrome .................................................................................. 106
Role of spinal NO in analgesic action ............................................................................ 107
Role of NO in nicotine addiction ....................................................................................... 107
Role of NO in carbon monoxide poisoning ........................................................................ 108
Role of NO in chemically-induced toxicity ........................................................................ 108
Peroxynitrite and drug-dependent toxicity. ........................................................................ 108
Paraquat neurotoxicity .................................................................................................... 108
Role of NO in radiation damage ....................................................................................... 109

5. Pharmacology of Nitric Oxide ............................................................. 111

Introduction..................................................................................................................... 111
Cytoxic vs cytoprotective role of NO ................................................................................ 111
Antioxidants .................................................................................................................... 111
Ebselen .................................................................................................................... 112
Nicaraven................................................................................................................. 112
Nitroxides ................................................................................................................ 113
Antioxidants in relation to NO .......................................................................................... 113
Nitric oxide as an antioxidant .......................................................................................... 114
NO-related drugs ............................................................................................................. 114
Drugs that activate eNOS production ................................................................................ 116
Aspirin ..................................................................................................................... 116
Dehydroepiandrosterone ............................................................................................ 116

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Drugs that scavenge free radicals/NO ............................................................................... 116

Peroxynitrite scavengers ............................................................................................ 116
Ruthenium (III) polyaminocarboxylates ....................................................................... 117
Nitrones ................................................................................................................... 117
Drugs that inhibit NO ...................................................................................................... 117
Ginko biloba ............................................................................................................. 117
Epigallocatechin ........................................................................................................ 118
Delivery of nitric oxide ..................................................................................................... 118
Targeted delivery of NO donors........................................................................................ 119
Nitric oxide delivery by encapsulated cells ......................................................................... 119
NO-lipid combination ...................................................................................................... 119
NO-releasing coating to prevent infection of implanted devices ............................................ 120
Nanoparticles for controlled/sustained release of NO .......................................................... 120
Hydrogel/glass nanoparticles ...................................................................................... 120
Delivery of nanoparticles to vascular endothelium for release of NO ................................ 120
Nitric oxide donors........................................................................................................... 121
Nitroglycerine/glycerine trinitrate ..................................................................................... 121
Isosorbide dinitrate ........................................................................................................ 122
Sodium nitrite ............................................................................................................... 122
Organic nitrites .............................................................................................................. 122
NO-releasing NSAIDs...................................................................................................... 123
COX-inhibiting NO-donors ............................................................................................... 124
Grafting of NO-releasing structures on to existing drugs ..................................................... 126
Mesoionic Oxatriazoles.................................................................................................... 127
Adding NO-donating structures to extend life cycle of existing drugs .................................... 127
Cysteine-containing NO donors ........................................................................................ 127
Ferrous nitrosyl complexes .............................................................................................. 128
Syndnonimines .............................................................................................................. 128
S-Nitrosothiols ............................................................................................................... 128
Diazeniumdiolates .......................................................................................................... 129
COX-2 inhibitors ............................................................................................................ 130
NO hydrogels ................................................................................................................ 130
Novel NO donors ............................................................................................................ 130
NO mimetics ................................................................................................................. 131
Comparison of classical nitrates, grafted NO donors, and NO mimetics ................................. 131
NO donors and soluble guanylate cyclase activation ........................................................... 132
NO donors for increasing the efficacy of chemotherapy ....................................................... 132
Factors that enhance availability of NO............................................................................ 132
Modulators of cyclic guanosine-3,5-monophosphate-dependent protein kinases ................... 133
NOS-modulating drugs ..................................................................................................... 134
Drugs that activate eNOS ................................................................................................ 134
Statins ..................................................................................................................... 134
Angiotensin converting enzyme inhibitors ..................................................................... 135
17 Beta-estradiol ...................................................................................................... 135
C-2431 .................................................................................................................... 135
NOS inhibitors ............................................................................................................... 135
Rationale of NOS inhibitors ......................................................................................... 135
L-Arginine ................................................................................................................ 137
Design of NOS inhibitors ............................................................................................ 137
Selective iNOS inhibitors ............................................................................................ 138
Non-amino acid-based inhibitors ................................................................................. 139
Aminoguanidine ........................................................................................................ 139
Heme ligands ........................................................................................................... 140
Pterin antagonists ..................................................................................................... 140
Fused-ring bio-isoteric models of arginine as NOS inhibitors ........................................... 140
nNOS inhibitors......................................................................................................... 140
Lubeluzole ................................................................................................................ 142
Neurotrophic factors .................................................................................................. 142
Therapies based on action of NOS as a paraquat diaphorase........................................... 142
Concluding remarks about NOS inhibiting drugs ............................................................ 143
NO and stem cell-based therapy ...................................................................................... 143
Nitric oxide and gene therapy .......................................................................................... 144
NOS gene transfer ......................................................................................................... 144
Inhibition of NOS by antisense technology......................................................................... 145
Drugs that modulate NO action on platelets .................................................................... 146
Action of NO and NO donors on platelets ........................................................................... 146
NOS inhibitors and NO scavengers ................................................................................... 146
Phosphodiesterase inhibitors ........................................................................................... 146
Activators of soluble guanylate cyclase ........................................................................... 147
YC-1 ............................................................................................................................. 147
A-350619...................................................................................................................... 147

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Cinaciguat ..................................................................................................................... 147

Secondary role of NO in the action of drugs ..................................................................... 147
Selective serotonin reuptake inhibitors ............................................................................. 148
P2Y receptors and NO ..................................................................................................... 148
Calcium channel blockers and NO..................................................................................... 148
Nitric oxide-based transdermal drug delivery ..................................................................... 148
Mechanism of resistance of NO-based drugs ...................................................................... 149
NO and nutraceuticals ...................................................................................................... 149
L-arginine as a nutraceutical ........................................................................................... 149
Oleuropein .................................................................................................................... 150
Role of NO in beneficial effects of chocolate ....................................................................... 150

6. Therapeutic Applications .................................................................... 151

Introduction..................................................................................................................... 151
Role of NO in the management of pulmonary disorders ................................................... 151
Manufacture of NO gas for inhalation ................................................................................ 151
NO inhalation for acute respiratory distress syndrome ........................................................ 151
NO inhalation for premature children with pulmonary dysplasia ...................................... 152
NO inhalation for premature children with respiratory failure .......................................... 152
Pulmonary hypertension ................................................................................................. 153
NO-based treatment of pulmonary hypertension ........................................................... 153
Inhaled nebulized nitrite for neonatal pulmonary hypertension........................................ 154
Gene therapy for pulmonary hypertension .................................................................... 154
Asthma ......................................................................................................................... 155
iNOS inhibitors for asthma ......................................................................................... 155
NO for bronchodilation in asthma ................................................................................ 155
Role of NO in acute lung injury after smoke inhalation ........................................................ 155
Cardiovascular disorders ................................................................................................. 156
Role of NO in cardioprotection ......................................................................................... 156
Role of NO in the management of angina pectoris .............................................................. 157
Role of NO in therapy of coronary heart disease ................................................................. 158
NO-releasing aspirin in patients undergoing CABG.............................................................. 158
Management of coronary restenosis ................................................................................. 159
Modified NO donors ................................................................................................... 159
NO-generating stent for coronary restenosis ................................................................. 159
eNOS gene therapy for restenosis ............................................................................... 160
NO-based management of cardiac hypertrophy .................................................................. 161
Congestive heart failure .................................................................................................. 161
Limitation of antioxidant therapy in congestive heart failure ........................................... 161
NO-based therapies for congestive heart failure ............................................................ 162
eNOS gene therapy for congestive heart failure ............................................................ 162
Gene transfer of nNOS in congestive heart failure ......................................................... 162
NO-based therapy for management of cardiogenic shock .................................................... 163
NO-based therapy for cardiac arrhythmias ........................................................................ 163
Prophylaxis of cardiovascular disorders ............................................................................. 163
Prevention of atherosclerosis with aging....................................................................... 164
Peripheral vascular disorders ........................................................................................... 164
Peripheral atherosclerotic arterial disease..................................................................... 164
Peripheral ischemic disease ........................................................................................ 164
An eNOS mutant as therapeutic for peripheral vascular ischemia .................................... 165
Sodium nitrite therapy for peripheral vascular ischemia ................................................. 165
Raynaud's phenomenon ............................................................................................. 166
Neurological disorders ..................................................................................................... 166
Cerebrovascular ischemic disorders .................................................................................. 166
Attenuation of NO for neuroprotection in cerebral ischemia ............................................ 167
Use of NO donors in cerebral ischemia ......................................................................... 167
Use of NO donors in cerebral reperfusion injury ............................................................ 168
Cerebral vasospasm and NO ....................................................................................... 168
NOS gene therapy for cerebral vasospasm ................................................................... 169
Degenerative CNS disorders ............................................................................................ 169
Statins for Alzheimer's disease ................................................................................... 170
NO mimetics for Alzheimer's disease ........................................................................... 170
iNOS inhibitors for treatment of Alzheimers disease ...................................................... 170
NO-NSAIDs for Alzheimer's disease ............................................................................. 171
Ginko biloba for Alzheimer's disease ............................................................................ 171
Personalization of NO-based therapy for Alzheimer's disease .......................................... 171
Role of NO in the treatment of traumatic brain injury ......................................................... 171
Neuroinflammatory disorders........................................................................................... 172
Muscular dystrophy ........................................................................................................ 172
Vestibulotoxicity ............................................................................................................ 173
NO for opening the blood-brain barrier ............................................................................. 173

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Cochlear disorders ........................................................................................................... 173

Cochlear ischemia .......................................................................................................... 173
Role of NO in sensoryneural hearing loss .......................................................................... 174
Pain ................................................................................................................................. 174
NO-based therapies for pain ............................................................................................ 174
Treatment of diabetic neuropathy with isosorbide dinitrate spray ......................................... 174
NO-based therapies for migraine ...................................................................................... 175
NO-based therapy for fibromyalgia syndrome .................................................................... 175
NO-based therapies for inflammatory disorders .............................................................. 175
NO-based therapies for gastrointestinal disorders ........................................................... 176
Protection of gastrointestinal injury from NSAIDs ............................................................... 176
Role of NO in the treatment of inflammatory bowel disease ................................................. 176
Topical nitroglycerin for chronic anal fissure ...................................................................... 176
Cancer.............................................................................................................................. 177
Mechanism of action of NO in cancer ................................................................................ 177
Antineoplastic effect of iNOS-expressing cells .................................................................... 177
Role of NO in drug resistance of cancer ............................................................................. 177
Role of NO in treatment of brain tumors ........................................................................... 178
NO-induced apoptosis ..................................................................................................... 178
Role of NO in antiangiogenesis therapies in cancer ............................................................. 179
NO donors for the treatment of cancer .............................................................................. 179
NO-releasing NSAIDs and colon cancer chemoprevention .................................................... 179
Rationale of combining NO aspirin with cancer vaccines ...................................................... 180
NO-based cancer gene therapy ........................................................................................ 180
Transdermal nitroglycerine for prostate cancer .................................................................. 181
NO-based therapies for skin disorders ............................................................................. 181
NO-based therapies for skin infections .............................................................................. 181
Role of NO in the treatment of psoriasis ............................................................................ 182
NO-based therapy for sickle cell anemia .......................................................................... 182
Inhaled NO for acute respiratory distress syndrome in sickle cell disease .............................. 183
NO inhalation for pulmonary hypertension in sickle cell anemia ............................................ 183
Role of NO in disorders associated with pregnancy.......................................................... 183
Use of NO donors in management of labor ........................................................................ 183
Eclampsia ..................................................................................................................... 184
Erectile dysfunction ......................................................................................................... 184
Selective inhibitors of phosphodiesterase 5 ....................................................................... 184
Erectile dysfunction in diabetes ........................................................................................ 185
NO-donating substances for treatment of ED ..................................................................... 186
NOS gene transfer for ED ................................................................................................ 186
Organ transplant rejection ............................................................................................... 186
Role of NO in the treatment of renal disorders................................................................. 187
Role of NO in the treatment of hepatic disorders ............................................................. 188
Portal hypertension ........................................................................................................ 188
NO inhalation for restoration of liver function following transplantation ................................. 188
Role of NO in blood transfusion ....................................................................................... 189
Role of NO in the treatment of osteoporosis .................................................................... 189
NO-based wound healing ................................................................................................. 189

7. Evaluation of NO-Based Drugs ............................................................ 191

Current status .................................................................................................................. 191
Antioxidant vs. NO-based approaches.............................................................................. 191
SWOT analysis of selected approaches for NO modulation ............................................... 191
NO donors by grafting of NO-releasing structures............................................................... 191
NOS modulation............................................................................................................. 192
Challenges of developing NO-based therapies ................................................................. 193
Concluding remarks and future prospects ........................................................................ 193

8. Markets for NO-based Therapies ......................................................... 195

Introduction..................................................................................................................... 195
Impact of NO-based therapies on international markets ................................................. 195
Share of NO-based therapies in major therapeutic areas ................................................. 195
Share of NO-based therapies in cardiovascular disorders ................................................ 196
Hypercholesterolemia ..................................................................................................... 196
Myocardial infarction ...................................................................................................... 197
Angina pectoris .............................................................................................................. 197
Heart failure .................................................................................................................. 197
Coronary restenosis and stenting ..................................................................................... 197
Strategies for developing NO-based therapy markets ...................................................... 198
Addressing the unfulfilled needs....................................................................................... 198
Multidisciplinary approaches ............................................................................................ 198
Collaboration between the academia and the industry ........................................................ 199

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Education of the public ................................................................................................... 199

9. Companies .......................................................................................... 201

Introduction..................................................................................................................... 201
Profiles of companies with focus on NO ........................................................................... 203
Major pharmaceutical companies with involvement in NO ............................................... 218
Smaller biotech and pharmaceutical companies involved in NO ....................................... 224
Biopharmaceutical companies involved in antioxidant research ...................................... 233
Companies supplying NO equipment for healthcare ......................................................... 237
Academic institutes with commercial collaboration in NO research ................................. 241
Companies supplying NO products for research ............................................................... 242
Collaborations .................................................................................................................. 246

10.

References .................................................................................. 247

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Historical landmarks in the discovery and applications of nitric oxide ................................ 15

Important functions of NO in the human body ................................................................ 36
Diseases involving nitric oxide ..................................................................................... 57
Role of nitric oxide in pathogenesis of autoimmune disorders ........................................... 59
Role of nitric oxide in infections .................................................................................... 61
Neuroprotective antioxidants ..................................................................................... 111
NO-related drugs ..................................................................................................... 114
Methods of delivery of nitric oxide .............................................................................. 118
Comparison of classical nitrates, grafted NO donors, and NO mimetics ............................ 131
Classification of NOS inhibitors ................................................................................... 136
Potential clinical applications of gene transfer for NOS overexpression ............................ 144
Cardiovascular disorders for which NO-based therapies are used .................................... 156
Selected neurological applications of NO-based therapies .............................................. 166
NO-related therapies for pain ..................................................................................... 174
SWOT of technology NO donors by grafting of NO-releasing structures ......................... 192
SWOT of products NO donors by grafting of NO-releasing structures ............................ 192
SWOT of NOS gene manipulation ............................................................................... 192
SWOT of analgesic development by NOS isoform targeting ............................................ 193
Share of NO-based therapies in major therapeutic areas 2011-2021 ............................... 196
Share of NO-based therapies in cardiovascular diseases 2011-2021 ............................... 196
Classification of companies involved in NO and antioxidant therapies .............................. 202
NicOx products in development .................................................................................. 207
Product pipeline of Nitrox LLC .................................................................................... 212
NO-related products of Sigma Aldrich ......................................................................... 244
Collaborations of companies relevant to nitric oxide ...................................................... 246

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Nitrogen cycle in the human body ............................................................................... 17

Biosynthesis of nitric oxide (NO) ................................................................................. 18
NO synthase pathway ................................................................................................ 19
Reactivity of nitric oxide with heme proteins in oxygen or peroxide reaction cycles ............ 25
NO-cGMP pathway leading to vasorelaxation ................................................................ 26
The biological pathways toward protein nitration ........................................................... 28
NF-B activation and iNOS induction ............................................................................ 29
Overview of mitochondrial NO-cytochrome c oxidase signaling pathway ........................... 31
Role of NO in adaptation to high altitude ...................................................................... 35
NOS in the cardiac myocyte........................................................................................ 41
Interactions of the Mb compounds with O 2 and NO ........................................................ 45
Molecular mechanisms of peroxynitrite-mediated cell death ............................................ 56
NO neurotoxicity and neuroprotection in relation to Alzheimer's disease ........................... 69
Some steps in the ischemic cascade and site of action of neuroprotectives ....................... 74
Dual role of nitric oxide (NO) in cerebral ischemia ......................................................... 75
Blood cell-endothelial cell interactions induced by hypercholesterolemia ........................... 84
Effects of NO on the pathophysiology of myocardial ischemia-reperfusion ........................ 89
Nitric oxide: tumor enhancement or inhibition .............................................................. 95
Role of nitric oxide in angiogenesis .............................................................................. 98
Nitrogen oxide mimetics synergy by chemical modification ........................................ 131
Factors that enhance availability of NO ...................................................................... 133
Mechanism of resistance to NO-based therapeutics ..................................................... 149
Vicious circle of vascular occlusion following angioplasty and stenting ............................ 160
PDE5 inhibition and the response to sexual stimulation ................................................ 185
Unfulfilled needs in NO therapeutics ......................................................................... 198

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