AINEs New Tricks

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Eur J Immunol. Author manuscript; available in PMC 2016 October 14.
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Eur J Immunol. 2015 March ; 45(3): 679–686. doi:10.1002/eji.201445222.
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NSAIDs: learning new tricks from old drugs

Federico Díaz-González1 and Francisco Sánchez-Madrid2
1Department of Internal Medicine, Universidad de La Laguna, Rheumatology Service, Hospital
Universitario de Canarias, Santa Cruz de Tenerife. Spain
2National Center for Cardiovascular Research, Immunology Service, Instituto Investigaciones
Sanitarias Princesa, Universidad Autónoma de Madrid. Spain
Summary
Nonsteroidal anti-inflammatory drugs (NSAIDs) comprise a heterogeneous group of
pharmacological agents used for the symptomatic treatment of fever, pain and inflammation.
Although the main mechanism of action of NSAIDs consists of inhibiting prostaglandin synthesis
by blocking the enzyme cyclooxygenase (COX), clinical and experimental data strongly indicate
the existence of additional mechanisms. Some of the COX-independent effects are related to the
ability of NSAIDs to penetrate biological membranes and disrupt important molecular interactions
necessary for a wide array of cellular functions, including cell adhesion. These effects, in
particular those that interfere with L-selectin function in neutrophils during the inflammatory
response, may contribute to the anti-inflammatory properties that NSAIDs exert in vivo. Recent
contributions in this field have shown that the anti-L-selectin effect of NSAIDs is related to the
NADPH-oxidase-dependent generation of superoxide anion at the plasma membrane. These
findings might represent a novel approach for developing new and effective anti-inflammatory
compounds with a better safety profile than the currently available NSAIDs.
Keywords
Non-steroidal anti-inflammatory drugs; L-selectin; NADPH oxidase
Introduction
Nonsteroidal anti-inflammatory drugs (NSAIDs) are a heterogeneous group of therapeutic
agents widely used for the symptomatic treatment of rheumatic disorders. Since the early
seventies of last century, it has been widely accepted that the main mechanism of action of
these compounds, which is also responsible for the main side effect of gastric mucosal
damage, is inhibition of cyclooxygenase (COX), a key enzyme in prostaglandin synthesis
[1]. Prostaglandins are group of hormone-like lipid compounds with a wide variety of strong
physiological effects, including regulation of inflammation, pain sensitization, and platelet
Corresponding author: Federico Díaz-González, Professor of Medicine. Department of Internal Medicine, Universidad de La
Laguna., Staff of Rheumatology, Hospital Universitario de Canárias. C/Ofra s/n, 38320, La Laguna, Santa Cruz de Tenerife. Spain,
federico.diaz.gonzalez@gmail.com, fax: +34-922646792.
Conflict of Interest Disclosure
The authors declare no commercial or financial conflict of interest
Díaz-González and Sánchez-Madrid Page 2
aggregation, among many others. However, a growing body of evidence suggests that
NSAIDs have additional anti-inflammatory properties (reviewed in [2]). Some of these
effects appear to be related to the ability of NSAIDs to penetrate biological membranes, as
evaluated in vitro using membrane mimetic models, cell cultures and molecular dynamic
simulation systems [3, 4], where they disrupt normal signaling events and modify important
processes necessary for cellular function, including cell adhesion [5, 6].
The ability of NSAIDs to interfere with either cell adhesion, for example by cleavage of
epithelial cell adhesion molecule protein on tumor cells [6], or with leukocyte adhesion
pathways essential for the inflammatory response, such as causing L-selectin shedding on
neutrophil [5], has been described. Interestingly, this anti-adhesive effect of NSAIDs has
also been shown to influence platelet adhesion, and it has been suggested that coagulation,
hemostasis and thrombus formation could be modulated by these compounds independently
of the release of pro-inflammatory mediators from platelets [7, 8]. In leukocytes, a group of
NSAIDs, including flufenamic, meclofenamic, and mefenamic acids, diclofenac and
aceclofenac has been shown to induce the downregulation of L-selectin, whereas another
group including phenylbutazone and the oxicams, piroxicam and meloxicam has been shown
to modulate the function of the integrin CD11b on neutrophils [5, 9, 10]. Some very recent
contributions in this field have shown that the anti-L-selectin effect of NSAIDs also causes a
significant anti-inflammatory response in vivo [11], and this anti-inflammatory response has
been shown, in vitro in human neutrophils, be related to the NADPH-oxidase-dependent
generation of superoxide anion at the plasma membrane [12].
In this work we review the “COX-centric” theory of NSAID mode of action, and then
dissect the non-prostaglandin-mediated effects of NSAIDs, and how some of these,
specifically those that interfere with cell adhesion, might explain the anti-inflammatory
effects that such compounds exert in vivo. We also discuss how the effects of NSAIDs that
do not rely on prostaglandin inhibition may represent a novel strategy for developing a new
family of anti-inflammatory compounds. The therapeutic action of this new compound
family would be based on decreasing cell adhesion, rather than on prostaglandin synthesis
inhibition, thereby presenting a better safety profile than that of currently available NSAIDs.
Recent advances in the understanding of non-prostaglandin-mediated antineoplastic [13] and
neuroprotective [14, 15] effects of NSAIDs have also been shown, but fall beyond the scope
of this review.
Challenging the “COX-centric” theory

In the early 1970s, it was proposed that inhibition of prostaglandin synthesis was the
mechanism through which aspirin, the first member of the NSAID family, inhibited
inflammation [16]. This mechanism later came to be the paradigm view of how NSAIDs
exert their action. COX is a key enzyme in prostaglandin synthesis, and most known
NSAIDs have been shown to inhibit COX activity. There are two highly related isoforms of
COX: COX-1 and COX-2 [17]. COX-1, the “constitutive isoform”, has mainly
cytoprotective effects, for instance in the production of gastric mucus and the maintenance
of renal blood flow. In contrast, COX-2, the “inducible isoform”, is usually undetectable in
most tissues, and its expression increases during the inflammatory response [18].

Based on their chemicals structure, there are now at least 20 different NSAIDs from six
major groups available for use in humans (Table 1). All of them are absorbed completely
orally, have negligible first-pass hepatic metabolism, and are tightly bound to albumin. In
general, NSAIDs are weak organic acids with hydrophobic properties, which facilitate their
binding to COX, since it is a membrane protein and the COX active site is located at the end
of a hydrophobic channel [17, 19]. Table 1 lists the different members of the NSAID family
classified by chemical structure, COX selectivity and proposed mechanism of action.
The effect of NSAIDs on prostaglandin synthesis provides an explanation for most of their
pharmacological actions, including their anti-pyretic, analgesic and platelet anti-aggregant
effects, as well as for their deleterious side effects, most notably stomach ulcer and renal
insufficiency [20]. However, several lines of evidence suggest that COX blockade may not
be the only or even the most important anti-inflammatory mechanism of action of this family
of compounds. Evidence challenging COX inhibition as the only mechanism of the anti-
inflammatory action of NSAIDs includes the observation that certain prostaglandins, such as
PGE1, exert anti-inflammatory activity in vivo [21]. Secondly, non-acetylated salicylates, a
group of poor COX inhibitors [22] have a similar anti-inflammatory effectiveness to that of
efficient COX-inhibiting NSAIDs in patients with rheumatoid arthritis, pointing to a
different mechanism of action [23]. Thirdly, there is a great disparity between the small
doses of aspirin required to inhibit prostaglandin synthesis (a few hundred milligrams) and
the higher doses required to exert an anti-inflammatory effect in vivo (several grams) [24].
Furthermore, in mice in which the gene encoding COX-2 has been disrupted, the
inflammatory response is largely intact [25, 26]. Finally, COX-1-deficient mice show a weak
inflammatory response to arachidonic acid, but not to tetradecanoyl phorbol acetate [27].
Surprisingly, these animals did not develop stomach ulcers spontaneously, and even
developed less gastric ulceration than wild-type mice when treated with the NSAID
indomethacin [27].
COX-independent anti-inflammatory actions of NSAIDs

There is a well-known variability in the clinical response of patients to NSAIDs, which
suggests that these agents might differ in their mechanism of action. The clinical evidence
suggests that the inter-individual variation in the NSAID response cannot be explained by
differences in pharmacokinetics, serum concentration or the enantiomeric state of the
products [28]. Rather, these data suggest that prostaglandin-independent, NSAID-triggered
responses must play an important role in determining patients’ clinical responsiveness to
these agents.
During the past twenty years, the description of a number of prostaglandin-independent

effects from NSAIDs has contributed to a better understanding of their anti-inflammatory
activity. Most of the described effects rely on the ability of NSAIDs to insert into the lipid
bilayers of biological membranes. The use of a wide range of in vitro experimental
techniques has provided significant information about the location of NSAIDs within
membranes, and also on their effect on diverse membrane properties, such as fluidity,
thickness, or phospholipid packaging, among others. These studies on the interaction
between NSAIDs and cell membranes have indeed provided evidence on additional

mechanisms to explain both the therapeutic action and toxicity of NSAIDs (reviewed in [3]).
For example, a recent study in AGS cells showed that NSAIDs have a strong affinity for
membrane phospholipids, especially phosphatidylcholine (PC) [29]. This feature may
explain the wide range of COX-independent, membrane-associated effects exerted by these
compounds, including anion transport, oxidative phosphorylation and cell-cell interactions.
Of special interest, in vitro data reported in several studies over two decades indicate that
NSAIDs interfere with cell membrane events associated with neutrophil activation. The
neutrophil events affected by NSAID insertion at the cell membrane include inhibition of
cell aggregation, release of lysosomal enzymes (reviewed in [30]) and chemotaxis [31],
activation of the NADPH oxidase complex and the oxidative burst in gastric mucosa cells
and neutrophils [12, 32] and upregulation of integrins and conformational changes, and the
shedding of L-selectin [5, 9, 33].
Other lines of investigation have postulated that the anti-inflammatory action of some
NSAIDs can be related to their ability to modulate transcription factors. Some NSAIDs,
including salicylates, aspirin, ibuprofen and some nitric oxide-donating aspirin derivatives,
might exert some of their anti-inflammatory actions by inhibiting nuclear factor-kappa B
(NF-kappa B), a key transcription factor that controls the inducible expression of many
genes involved in inflammation, including those encoding pro-inflammatory cytokines such
as TNF-α or IL-1β, iNOS and adhesion molecules such as ICAM-1 (Intercellular adhesion
molecule 1) and VCAM-1 (Vascular-cell adhesion molecule 1) [34]. At high doses, aspirin
and sodium salicylate are able to inhibit the activation of NF-kappa B in several cell lines by
a mechanism that prevents the degradation of the NF-kappa B inhibitor, I kappa B [35]. This
effect has been tested and shown to occur in different cell types, including fibroblasts,
epithelial cell, or endothelial cells [36–38]. Other NSAIDs act similarly, but at
concentrations comparable to those used in therapy. For example, the NSAID ibuprofen has
been shown to inhibit NF-kappa B activation in human T cells, at concentrations similar to
those obtained in human plasma (micromolar range) [39]. Although the NF-kappa B
inhibitory effect has also been described for other NSAIDs, such as indomethacin,
flurbiprofen or sulindac, it is not the mechanism of all NSAIDs, since naproxen, a highly
effective commonly used NSAID, does not affect NF-kappa B activity [40].
Several NSAIDs have been shown to significantly inhibit neutrophil chemotaxis toward
CXCL8 and C5a, an effect that has been linked to the polymerization of F-actin and
inhibition of the chemotactic pathway dependent on PI3K/Akt activation [41]. Other reports
have claimed that NSAIDs can also regulate other signaling pathways, such as
indomethacin, which has been shown to activate the MAPK pathway [42], or diclofenac and
celecoxib, which have been shown to function via PPAR [43]; there is the suggestion that
these actions may underlie the anti-neoplastic effects of these compounds [44]. However, the
implication of these anti-tumor effects in the anti-inflammatory properties of NSAIDs has
not yet been determined.
All these data suggest that NSAIDs have anti-inflammatory mechanisms of action other than
the inhibition of prostaglandin synthesis (Table 1). However, the role of most of these COX-
independent processes in clinical inflammation remains to be clarified.

Inhibition of cell adhesion by NSAIDs

Clinical experience shows that NSAIDs are more effective in acute rather than chronic
inflammatory diseases, suggesting that NSAIDs interfere preferentially with the early steps
of the inflammatory response. An early event essential for an effective inflammatory
response is the transmigration of leukocytes across the vascular endothelium, and their
accumulation in inflamed tissues. This cellular extravasation requires a succession of highly

coordinated adhesion events between flowing leukocytes and endothelial cells, a process
commonly known as the adhesion cascade. The adhesion cascade can be divided into four
successive steps (Figure 1), each of which is essential for leukocyte extravasation, such that
if one step is blocked, leukocyte emigration does not occur properly [45, 46].
A major effort in the field of inflammation is currently aimed at developing antagonists of

adhesion receptors, an approach known as anti-adhesive therapy [47–49]. This strategy is
based on the understanding that if any of the sequential adhesion events of the adhesion
cascade is inhibited, overall inflammation will decrease, ameliorating its deleterious effects.
In neutrophils, two groups of NSAIDs have been shown to have anti-adhesive properties,
one interfering with the function of L-selectin, the other with CD11b/CD18 [5, 9], two
adhesion molecules that play key roles in the adhesion cascade (Figure 1). Remarkably,
NSAID-induced shedding of L-selectin has been demonstrated not only in vivo in both
humans and mice [5, 11], but also in vitro, where the concentration of NSAIDs required to
induce L-selectin shedding in human neutrophils [5, 12] are within the range (micromolars)
reached in plasma by oral administration of NSAIDs in humans [50, 51].
L-selectin-based effects of NSAIDs

L-selectin is constitutively expressed by most leukocytes, and is enzymatically cleaved and
released after cell activation through the processing of its ectodomain by ADAM17 [52] and
ADAM8 [53], members of the disintegrin and metalloproteinase domain (ADAM) family of
surface metalloproteases (Figure 2). L-selectin plays a major role in the early recruitment of
neutrophils to inflammatory foci by mediating their rolling on the endothelial surface [54].
Both in vitro [55] and in vivo [56] experiments have shown that soluble L-selectin is able to
reduce intravascular leukocyte rolling and adhesion, and consequently decreases neutrophil
extravasation presumably by competing with cell surface L-selectin to binding to endothelial
ligands.
A number of NSAIDs have been shown to induce rapid cleavage and shedding of L-selectin
in human neutrophils in vitro [5, 10]. Analysis of the structure-function relationship of some
NSAIDs has shown that the ability to downregulate L-selectin expression is dependent on
the presence of diphenylamine or its related compound N-phenylanthranilic acid in the
NSAID structural core [10].
The anti-L-selectin action of NSAIDs involves neither non-specific activation of neutrophils

nor prostaglandin inhibition, but has been shown to require the presence of ADAM17 [10].
Shedding of L-selectin in neutrophils can be induced by oxidative attack on the pro-domain
thiol group of ADAM17, which masks its functional catalytic domain [57]. A group of
NSAIDs, including diclofenac and flufenamic acid, was recently shown to interfere with the

ability of human neutrophils to initiate interaction with endothelial cells by triggering L-

selectin-shedding through the production of reactive oxygen species (ROS), a highly
oxidizing agent generated at the plasma membrane [12]. Data obtained in vitro with
neutrophils from patients with chronic granulomatous disease (a hereditary defect in the
NADPH oxidase complex that results in the reduction of ROS production) demonstrate that
NSAIDs such as diclofenac, require NADPH oxidase-dependent generation of superoxide
anion to trigger L-selectin shedding [12] (Figure 2). How NSAIDs activate NADPH oxidase
remains unknown. However, given that PC has an inhibitory effect on the NADPH oxidase
complex [58], it is conceivable that NSAID–PC interaction at the plasma membrane might
reduce this inhibitory effect, facilitating superoxide anion production [29]. These findings
are in accordance with the emerging view that ROS have regulatory functions that limit
inflammation (reviewed in [59]).
Several studies have investigated whether induction of L-selectin shedding by NSAIDs is

sufficient to reduce inflammation in vivo. In healthy human volunteers, the basal surface
expression of L-selectin on circulating neutrophils is significantly reduced by therapeutic
doses of indomethacin [5]. In the zymosan air pouch model of acute inflammation,
intramuscular treatment with N-phenylanthranilic acid, a diphenylamine-related NSAID that
promotes L-selectin shedding in neutrophils in vitro [10] and in vivo [11], was shown to
interfere with the ability of neutrophils to accumulate at inflammatory foci [11]. At the doses
used in that study, N-phenylanthranilic acid did not block COX and did not show any
additive anti-inflammatory effect to treatment with Mel-14, a functional blocking
monoclonal antibody against murine L-selectin [11]. These observations indicate that the
anti-inflammatory effect of NSAIDs in vivo may be mediated by the induction of L-selectin
shedding. The development of new compounds specifically designed to target L-selectin
might therefore be a productive strategy for controlling the pathologic inflammatory
response.
NSAIDs and anti-adhesive therapy

A major effort in the field of inflammation is currently directed at developing antagonists of
adhesion receptors. For more than ten years the field of leukocyte cell adhesion has been
considered a potential source of novel and potent targets for the treatment of inflammation.
Until now, most advances in this field have been in the development of therapeutic agents
that block the function of integrins. Anti-adhesive therapies targeting the major leukocyte
integrins, such as LFA-1 and VLA-4, have proved relatively successful in the treatment of
human inflammatory disorders, including psoriasis, Crohn’s disease and multiple sclerosis
[47, 60]. However, the inhibition of selectins or their ligands has only proved beneficial in
certain animal models of inflammation, such as hemorrhagic-traumatic shock in baboons
[61] and ischemia/reperfusion injury in rat cells [62], with a limited clinical success in
human inflammatory conditions such as experimental endotoxemia and multiple trauma
(reviewed in [63]). The anti-inflammatory effect of the anti-L-selectin action of NSAIDs in
vivo [11] suggests that a strategy based on inducing L-selectin shedding could offer
advantages over L-selectin-ligand blockade using antibodies [64] or synthetic selectin
antagonist [65]. This approach would prevent the inflammatory response through a dual

action of i) reducing neutrophil L-selectin surface expression and ii) quenching endothelial
L-selectin ligands by generating higher concentrations of soluble L-selectin in plasma.
Conclusions
In addition to their unquestionable role in the human therapeutic arsenal, NSAIDs have
made an immense contribution to our knowledge of prostaglandin physiology, platelet

aggregation, cytoprotection and renal blood flow. Currently, NSAIDs continue to surprise us
with non-prostaglandin-related therapeutic effects of potential benefit in the field of
neuroprotection or cancer. In the field of cell adhesion, NSAIDs have effects that not only
provide a mechanistic explanation for their anti-inflammatory properties, but also provide
new ideas for managing inflammation. In this review we have summarized the most
important prostaglandin–independent anti-inflammatory effects of NSAIDs, emphasizing
their action on L-selectin expression in neutrophils, a capability that underlies their anti-
inflammatory action in vivo. The induction of L-selectin shedding, either dependent on
NADPH oxidase activation or by other as yet unknown mechanism, could develop into a
successful anti-inflammatory treatment by preventing neutrophil rolling and consequently
decreasing the intensity of the inflammatory response more effectively than L-selectin-
ligand blockade alone, a tested strategy with limited clinical effects. The development of
new compounds reproducing the ability of NSAIDs to induce L-selectin shedding might
yield new therapeutic tools for the clinical management of inflammatory conditions.
Acknowledgements
Funding for this project came from Fondo de Investigaciones Sanitarias, cofinanced by the European Regional
Development Fund (FIS PI12/02499), and REUNINVES (Asociación para la Ayuda a la Investigación en
Reumatología del Hospital Universitario de Canarias) to F.D-G, also from the Spanish Ministry of Science and
Innovation (SAF2011-25834), Comunidad de Madrid (INDISNET-S2011/BMD-2332), Instituto Salud Carlos III
(Red Cardiovascular RD 12-0042-0056), and ERC-2011-AdG 294340-GENTRIS to F-S-M. The authors thank S.
Bartlett for English editing, M. Vicente-Manzanares for critical reading of the manuscript and artwork, and
Mercedes Guerra for the documentation work.
List of abbreviations
ADAM a disintegrin and metalloproteinase domain
COX cyclooxigenase
ICAM-1 Intercellular adhesion molecule 1
IL-1 interleukin-1
iNOS inducible nitric oxide synthase
LFA-1 lymphocyte function-associated antigen 1
MAPK Mitogen-activated protein kinases
NADPH-oxidase nicotinamide adenine dinucleotide phosphate-oxidase
NF-kappa B nuclear factor kappa-light-chain-enhancer of activated B

cells

NSAIDs non-steroidal anti-inflammatory drugs
PC phosphatidylcholine
PGE1 prostaglandin E1
PI3K phosphatidylinositide 3-kinases

PPAR peroxisome proliferator-activated receptors
ROS reactive oxygen species
TNF-α tumor necrosis factor-α
VCAM-1 Vascular-cell adhesion molecule
VLA-4 very late antigen-4
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Figure 1.
The adhesion cascade. Members of three major cell-surface adhesion receptor families are
implicated in leukocyte extravasation: selectins (represented by L-selectin, blue, left),
integrins (represented by LFA-1, grey, left), and the immunoglobulin superfamily (not
shown). In response to tissue injury, proinflammatory mediators such as IL-1 and TNF-α are
released that induce a rapid change in the adhesive properties of the endothelial cells (EC)
lining the blood vessels near the damaged tissue. Flowing leukocytes (Lk) are immediately
captured and begin to roll over the endothelial surface (right). This initial leukocyte–
endothelium interaction is mainly mediated by selectins. L-selectin (CD62L) (constitutively
expressed by most leukocytes), E-selectin (CD62E) and P-selectin (CD62P) (both expressed
by activated endothelial cells) specifically interact with carbohydrate moieties linked to
mucin-like molecules expressed by activated endothelial cells and leukocytes (green). The
selectin–mucin interaction is responsible for the rolling of leukocytes along the endothelium.
During rolling, leukocytes are activated by locally produced chemokines bound to the

endothelium, which cause both the shedding of L-selectin, and the activation of the integrin
adhesion receptors CD11a/CD18 and CD11b/CD18, as well as the increased expression of
CD11b/CD18. The activated leukocyte integrins (open conformation) interact with their
endothelial counter-receptor intercellular adhesion molecule (ICAM)-1 (orange), resulting in
the firm adhesion of leukocytes to the vessel surface. Finally, leukocytes migrate across the
endothelium into the tissues, usually by squeezing between endothelial cells. Several
endothelial junctional proteins participate in this final step, including CD31, CD99 and
JAMs (junctional adhesion molecules). All of these interactions are required for neutrophil
transmigration, but in the case of lymphocytes the rolling and firm adhesion steps are mainly
mediated by interaction between the integrin adhesion receptor very late activation antigen
(VLA)-4 and its endothelial counter receptor vascular cell adhesion molecule (VCAM)-1
[66]. NSAIDs have been found to interfere with molecules essential for the rolling or firm
adhesion steps of the adhesion cascade.

Figure 2. NSAID activity on L-selectin shedding from neutrophils: a proposed mechanism.

Superoxide anion production by the NADPH oxidase complex is proposed to drive NSAID-
induced L-selecting shedding from neutrophils. NSAIDs insert into the lipid bilayer of the
cell membrane where they interact with phospholipids, such as phosphatidylcholine (PC,
green). PC is capable of interfering with the activation of the NADPH oxidase complex
(orange), and it is likely that NSAID–PC interaction at the plasma membrane ablates the
inhibitory effects of PC, causing activation of NADPH oxidase and consequently the release
of superoxide anion to the extracellular milieu. Superoxide generates an oxidative attack on
the pro-domain thiol group of ADAM-17 (grey), which masks its catalytic domain. Upon
removal of this mask, ADAM17 is activated and able to process the extracellular domain of
L-selectin (blue), causing its release from the cell membrane.

Table 1
NSAID families
Drug Mechanism of action Reference
Non-selective NSAID agents

Salicylate (acetylated) Aspirin • Inhibition of PG [16]
synthesis
[5, 10]
• L-selectin sheeding
[35]
• Inhibition of NF-
Kappa B [67]
• Inhibition of iNOS
Salicylates (non-acetylated) • Inhibition of [68]

COX-2 gene
transcription [69]
• L-selectin sheeding [35]
• Inhibition of NF- [67]

Kappa B
• Inhibition of iNOS
Diflunisal
Salsalate
Propionic acids • Inhibition of [1]

prostaglandin
synthesis
Ibuprofen • Inhibition of NF- [39]

Kappa B
Naproxen • Inhibition of [41]

neutrophil PI3K/
Akt-dependent
chemotactic
pathways
Ketoprofen • L-selectin sheeding [5]
Flurbiprofen • Inhibition of NF- [70]

Kappa B
[10]
• L-selectin sheeding
Oxaprozin • Inhibition of [41]

neutrophil PI3K/
Akt-dependent
chemotactic
pathways
Acetic acids • Inhibition of [1]

prostaglandin
synthesis


Diclofenac • L-selectin sheeding [5]
• Inhibition of [71]
VLA-4 activation
Etodolac
Tolmetin
Sulindac • Inhibition of NF- [72]

Kappa B
[6]
• Cleavage of
epithelial cell
adhesion molecule
Ketorolac
Indomethacin • Inhibition of NF- [73]

Kappa B
[5]
• Induction of L-
selectin shedding [71]
• Inhibition of
VLA-4 activation
Aceclofenac • Induction of L- [69, 74]

selectin shedding
[71]
• Inhibition of
VLA-4 activation
Oxicams (enolic acid) • Inhibition of [1]

prostaglandin
synthesis
Piroxicam • Inhibition of β2 [9]

integrin activation
Meloxicam • Inhibition of β2 [9]

integrin activation
Fenamates (anthanilic acid) • Inhibition of [1]

prostaglandin
synthesis
Meclofenamic acid • Induction of L- [10]

selectin shedding
Mefenamic acid • Induction of L- [10]

selectin shedding
Non-acidic (naphthylbutanone) Nabumetone • Inhibition of [1]

prostaglandin
synthesis by its
active metabolite:
6-methoxy-2-


naphthyl acetic
acid
Selective COX-2 inhibitors • Inhibition of [1]

prostaglandin
synthesis
Celecoxib
Eterocoxib

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Europe PMC Funders Group

NSAIDs: learning new tricks from old drugs

Challenging the “COX-centric” theory

Eur J Immunol. Author manuscript; available in PMC 2016 October 14.

classified by chemical structure, COX selectivity and proposed mechanism of action.

COX-independent anti-inflammatory actions of NSAIDs

During the past twenty years, the description of a number of prostaglandin-independent

Eur J Immunol. Author manuscript; available in PMC 2016 October 14.

Eur J Immunol. Author manuscript; available in PMC 2016 October 14.

Inhibition of cell adhesion by NSAIDs

accumulation in inflamed tissues. This cellular extravasation requires a succession of highly

A major effort in the field of inflammation is currently aimed at developing antagonists of

L-selectin-based effects of NSAIDs

The anti-L-selectin action of NSAIDs involves neither non-specific activation of neutrophils

Eur J Immunol. Author manuscript; available in PMC 2016 October 14.

ability of human neutrophils to initiate interaction with endothelial cells by triggering L-

Several studies have investigated whether induction of L-selectin shedding by NSAIDs is

NSAIDs and anti-adhesive therapy

Eur J Immunol. Author manuscript; available in PMC 2016 October 14.

made an immense contribution to our knowledge of prostaglandin physiology, platelet

ICAM-1 Intercellular adhesion molecule 1

iNOS inducible nitric oxide synthase

LFA-1 lymphocyte function-associated antigen 1

MAPK Mitogen-activated protein kinases

NADPH-oxidase nicotinamide adenine dinucleotide phosphate-oxidase

NF-kappa B nuclear factor kappa-light-chain-enhancer of activated B

Eur J Immunol. Author manuscript; available in PMC 2016 October 14.

NSAIDs non-steroidal anti-inflammatory drugs

PI3K phosphatidylinositide 3-kinases

PPAR peroxisome proliferator-activated receptors

ROS reactive oxygen species

TNF-α tumor necrosis factor-α

VCAM-1 Vascular-cell adhesion molecule

VLA-4 very late antigen-4

nonsteroidal antiinflammatory drugs. J Clin Invest. 1995; 95:1756–1765. [PubMed: 7535797]

Eur J Immunol. Author manuscript; available in PMC 2016 October 14.

12. Dominguez-Luis M, Herrera-Garcia A, Arce-Franco M, Armas-Gonzalez E, Rodriguez-Pardo M,

1995; 22:617–624. [PubMed: 7791151]

Eur J Immunol. Author manuscript; available in PMC 2016 October 14.

adhesion. Proc Natl Acad Sci U S A. 1998; 95:14540–14545. [PubMed: 9826736]

Pharmacol. 2007; 563:49–60. [PubMed: 17341418]

Eur J Immunol. Author manuscript; available in PMC 2016 October 14.

51. Kokki H, Kumpulainen E, Laisalmi M, Savolainen J, Rautio J, Lehtonen M. Diclofenac readily

Eur J Immunol. Author manuscript; available in PMC 2016 October 14.

nonsteroidal anti-inflammatory drugs: role of intracellular ATP concentration. Blood. 2000;

4/vascular cells adhesion molecule 1-mediated lymphocyte-endothelial cell adhesion. Arthritis

Eur J Immunol. Author manuscript; available in PMC 2016 October 14.

Eur J Immunol. Author manuscript; available in PMC 2016 October 14.

Eur J Immunol. Author manuscript; available in PMC 2016 October 14.

Figure 2. NSAID activity on L-selectin shedding from neutrophils: a proposed mechanism.

Eur J Immunol. Author manuscript; available in PMC 2016 October 14.

Drug Mechanism of action Reference

Non-selective NSAID agents

Salicylates (non-acetylated) • Inhibition of [68]

• L-selectin sheeding [35]

• Inhibition of NF- [67]

Propionic acids • Inhibition of [1]

Ibuprofen • Inhibition of NF- [39]

Naproxen • Inhibition of [41]

Ketoprofen • L-selectin sheeding [5]

Flurbiprofen • Inhibition of NF- [70]

Oxaprozin • Inhibition of [41]

Acetic acids • Inhibition of [1]

Eur J Immunol. Author manuscript; available in PMC 2016 October 14.