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Roflumilast (1)	AstraZeneca	COPD	Launched - 2010
	Arcutis	Plaque psoriasis	Launched - 2022
		Atopic dermatitis	Phase Ⅲ
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Apremilast (3)	Amgen	Behcet's disease	Launched - 2019
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Difamilast (5)	Otsuka Pharmaceutical	Atopic dermatitis	Launched - 2022

Drug name	Manufacturer	Condition or disease	Current status
Roflumilast (1)	AstraZeneca	COPD	Launched - 2010
	Arcutis	Plaque psoriasis	Launched - 2022
		Atopic dermatitis	Phase Ⅲ
		Seborrheic dermatitis	Phase Ⅲ
Crisaborole (2)	Pfizer	Atopic dermatitis	Launched - 2017
Apremilast (3)	Amgen	Behcet's disease	Launched - 2019
		Arthritis, psoriatic	Launched - 2014
		Plaque psoriasis	Launched - 2014
Ibudilast (4)	Kyorin	Poststroke complications, bronchial asthma	Launched - 1989
	MediciNova	Amyotrophic lateral sclerosis	Phase Ⅱ/Ⅲ
		Alcohol use disorder	Phase Ⅱ
		Multiple sclerosis	Phase Ⅱ
		Methamphetamine dependence	Phase Ⅱ
		Glioblastoma	Phase Ⅰ/Ⅱ
Difamilast (5)	Otsuka Pharmaceutical	Atopic dermatitis	Launched - 2022

磷酸二酯酶4抑制剂临床及安全性研究进展

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王惠芳 , 王有志 , 支运宝 , 左琳飞 , 申慧珍 , 徐正文 , 王进欣 ^*

药学学报 | 综述 2023,58(9): 2601-2609

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药学学报 |综述 2023 , 58 (9) : 2601 -2609

磷酸二酯酶4抑制剂临床及安全性研究进展

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王惠芳, 王有志, 支运宝, 左琳飞, 申慧珍, 徐正文, 王进欣^*

作者信息

中国药科大学药学院药物化学系, 江苏省药物分子设计与成药性优化重点实验室, 江苏南京 210009

通讯作者:

*王进欣, Tel: 86-25-86185328, E-mail: jinxinwang@163.com

Advances in clinical and safety studies of phosphodiesterase 4 inhibitors

Hui-fang WANG, You-zhi WANG, Yun-bao ZHI, Lin-fei ZUO, Hui-zhen SHEN, Zheng-wen XU, Jin-xin WANG^*

Affiliations

Jiangsu Key Laboratory of Drug Design and Optimization, Department of Medicinal Chemistry, School of Pharmacy, China Pharmaceutical University, Nanjing 210009, China

出版时间: 2023-09-12 doi: 10.16438/j.0513-4870.2022-1401

文章导航

摘要

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磷酸二酯酶4 (phosphodiesterase 4, PDE4) 是磷酸二酯酶家族中重要成员之一, 可特异性水解环磷酸腺苷(cyclic adenosine monophosphate, cAMP), 通过改变cAMP浓度引发下游磷酸化级联反应, 与多种疾病密切相关。靶向PDE4的抑制剂临床研究包括呼吸系统疾病、自身免疫性疾病、中枢神经系统疾病及皮肤病等多种疾病领域。但是在已上市的PDE4抑制剂临床研究中发现, 大多数药物的恶心、呕吐等胃肠道不良反应发生率较高, 限制了其临床应用。因此本综述总结了已上市PDE4抑制剂的临床进展及安全性问题, 结合PDE4蛋白结构分析、PDE4抑制剂的作用机制及相关不良反应机制研究, 阐述了PDE4抑制剂产生不良反应的主要原因, 旨在为开发安全有效的PDE4抑制剂提供参考。

关键词

磷酸二酯酶 / 磷酸二酯酶4抑制剂 / 临床药效 / 安全性 / 不良反应

Abstract

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Phosphodiesterase 4 (PDE4) is an important member of the phosphodiesterase enzyme family that specifically catalyzes the hydrolysis of cyclic adenosine monophosphate (cAMP), activates the downstream phosphorylation cascade pathway by altering cAMP concentration, and is strongly associated with multiple diseases. Inhibition of PDE4 is clinically investigated as a therapeutic strategy in a broad range of disease areas, including respiratory system diseases, autoimmune disorders, central nervous system diseases, and dermatological conditions. However, the incidence of adverse reactions such as nausea and vomiting is relatively high in the marketed PDE4 inhibitors, which has stalled their clinical development. In this review, we provide an overview of the clinical progression and safety issues of the marketed PDE4 inhibitors. We also review the main causes underlying PDE4-mediated adverse effects by combining the structural analysis of the PDE4 protein, the mechanism of action of PDE4 inhibitors, and the related side effect mechanism research, aiming to provide a reference for the development of safe and effective PDE4 inhibitors.

Key words

phosphodiesterase / phosphodiesterase 4 inhibitor / clinical efficacy / safety / side effect

引用本文

王惠芳, 王有志, 支运宝, 左琳飞, 申慧珍, 徐正文, 王进欣. 磷酸二酯酶4抑制剂临床及安全性研究进展. 药学学报, 2023 , 58 (9) : 2601 -2609 . DOI: 10.16438/j.0513-4870.2022-1401

Hui-fang WANG, You-zhi WANG, Yun-bao ZHI, Lin-fei ZUO, Hui-zhen SHEN, Zheng-wen XU, Jin-xin WANG. Advances in clinical and safety studies of phosphodiesterase 4 inhibitors[J]. Acta Pharmaceutica Sinica, 2023 , 58 (9) : 2601 -2609 . DOI: 10.16438/j.0513-4870.2022-1401

正文

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磷酸二酯酶(phosphodiesterases, PDEs) 是一类负责水解环磷酸腺苷(cyclic adenosine monophosphate, cAMP) 和环磷酸鸟苷(cyclic guanosine monophosphate, cGMP) 的高度保守酶超家族^[1]。cAMP和cGMP作为体内的第二信使, 细胞内浓度处于动态平衡的状态^[2], 其细胞水平的上调将激活下游级联通路, 磷酸化下游靶蛋白参与各种生理功能。增加胞内cAMP/cGMP水平的方法有两种: 一是通过激素和神经递质等外部刺激激活腺苷酸环化酶/鸟苷酸环化酶, 以增加cAMP/cGMP的合成。二是通过抑制PDEs, 阻止cAMP/cGMP的水解。研究发现作为环核苷酸的关键调节酶, PDEs已成为哮喘、勃起功能障碍(erectile dysfunction, ED)、慢性阻塞性肺部疾病(chronic obstructive pulmonary disease, COPD)、自身免疫性疾病、高血压、间歇性跛行、心力衰竭、精神分裂症、脑卒中及抑郁症等多种疾病的重要药物靶点^[3]。

哺乳动物中的磷酸二酯酶由21个不同基因组编码, 根据不同的转录和翻译结果, 可基于氨基酸序列、调控域和催化特性将PDEs分为11个家族(PDE1~11)。不同结构的PDE具有不同的底物特异性, 其中PDE4、PDE7和PDE8可特异性水解cAMP, PDE5、PDE6和PDE9负责特异性水解cGMP, PDE1、2、3、10和11则对cAMP及cGMP均有水解作用^[4]。在各种PDEs中, PDE4是最大的PDE家族, 由4个同源基因组成, 相应编码4个PDE4亚型: PDE4A、PDE4B、PDE4C和PDE4D, 每个基因又会产生多种转录变异体(transcript variant), 进而翻译成不同的同源异构体(isoform) 蛋白(如PDE4D1-7)^[5]。PDE4在体内分布广泛, 在免疫细胞及多种炎症细胞(中性粒细胞、巨噬细胞、嗜酸性粒细胞和肥大细胞等) 中均有表达^[6], 参与介导多种疾病的病理生理过程因而备受关注与研究。

PDE4蛋白结构包含高度保守的催化域、N端调节域及C端调节域, 独特的N端结构域在调节PDE4与细胞骨架蛋白相互作用中发挥重要作用^[7], 使得各同源异构体呈现组织和细胞特异性分布, 从而实现cAMP信号高度区域化。PDE4的活性中心(图 1) 被划分三大区域, 分别是由保守的谷氨酰胺残基和两个疏水口袋构成的疏水区、包含负责催化cAMP水解的镁离子及锌离子的金属区以及溶剂暴露区^[8]。鉴于PDE4催化域的高度保守, PDE4抑制剂普遍具有的特征为P Clamp和Q Switch, 即含有能与催化域中的苯丙氨酸形成π-π堆积相互作用的平面芳香环骨架和含有能与疏水区保守的谷氨酰胺残基形成氢键相互作用力以锚定抑制剂的氢键供体。

PDE4抑制剂通过阻断cAMP水解, 提高胞内cAMP浓度, 进而激活蛋白激酶A (protein kinase A, PKA)、cAMP激活的交换蛋白(exchange protein activated by cAMP, Epac) 和环核苷酸门控离子通道(cyclic nucleotide-gated ion channel, CNGC)^[9], 通过多条信号通路影响疾病的发生与发展(图 2)。PDE4抑制剂历经多年发展^[10], 已在认知和情感障碍疾病(阿尔茨海默症、脆性X综合征、精神分裂、抑郁、物质依赖)、自身免疫疾病(多发性硬化、类风湿性关节炎、特应性皮炎、Behcet综合征)、呼吸系统疾病(慢性阻塞性肺部疾病、哮喘)、皮肤病(银屑病) 及癌症(成胶质细胞瘤) 等多种疾病领域中进行了研究。然而大多数PDE4抑制剂在临床研究中存在剂量依赖性的不良反应, 特别是胃肠道相关不良反应, 限制了其发展。本文首先对已上市PDE4抑制剂的临床概况及安全性问题进行概述, 总结了PDE4抑制剂引起胃肠道不良反应的主要原因, 并从药物设计角度提出了降低不良反应发生概率的可行策略, 为开发安全有效的PDE4抑制剂提供有价值的参考。

1 已上市PDE4抑制剂的临床表现

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截至目前已有5个PDE4抑制剂上市, 分别是ibudilast、roflumilast、apremilast、crisaborole和difamilast (表 1, 图 3), 被批准的适应症包括COPD、银屑病和特应性皮炎等。

1.1 Roflumilast

Roflumilast是2010年批准用于治疗COPD的第一个长效选择性PDE4抑制剂, 以剂量依赖的方式减少LPS诱导的趋化因子及人肺部巨噬细胞肿瘤坏死因子α的释放^[11], 抑制中性粒细胞释放白介素8 (interleukin-8, IL-8)、白三烯B4 (leukotriene B4, LTB4)、基质金属蛋白酶-9 (matrix metalloproteinase-9, MMP-9) 和中性粒细胞弹性蛋白酶^[12], 从而抑制COPD过程中的炎症。Roflumilast可改善重度COPD患者的肺部功能并减少急性加重的频率, 通常作为其他COPD疗法的补充或替代疗法。鉴于其良好的酶抑制活性, Rabe等^[13]开展的一项多中心、双盲、随机的Ⅲ期临床研究, 通过观测受试者支气管黏膜下层CD8炎性细胞数量的变化来评估roflumilast对重症COPD和慢性支气管炎患者的支气管黏膜炎症的抗炎作用, 经过持续16周的每日一次给药0.5 mg roflumilast治疗后, 与安慰剂组相比, roflumilast组受试者支气管黏膜下层CD8细胞数量无显著差异, 但roflumilast组支气管镜活检样本中嗜酸性粒细胞数量显著减少。因此推测roflumilast是通过影响肺嗜酸性粒细胞治疗COPD。

在该项研究中最常见的中度不良反应包括COPD恶化、咳嗽、腹泻和鼻咽炎, roflumilast组的严重不良反应发生率(10%) 高于安慰剂组(6%)。由于临床上服用roflumilast的部分患者在治疗前几周会出现腹泻、恶心、头痛、失眠、腹痛、食欲不振和体重减轻等不良反应^[14], 使得临床试验在早期中断。在一项为期52周的临床试验中^[15], 969名服用roflumilast的患者中有269名因为不良反应和COPD加重等其他原因停止给药, 停药率达27%左右。为了降低roflumilast早期治疗的停药率和提高耐受性, Watz等^[16]通过12周的临床试验探究不同给药方案对roflumilast产生不良反应的影响。1 323名患者按1∶1∶1比例随机分成3组, 第一组前4周剂量为每日一次0.25 mg, 后8周调整至每日一次0.5 mg, 第二组前4周剂量为隔日一次0.5 mg, 后8周调整至每日一次0.5 mg, 第三组在治疗的12周内每日一次0.5 mg, 结果显示由每日0.25 mg至每日0.5 mg剂量组发生不良反应频率显著降低。这一项研究说明在较短的治疗初期减少剂量可克服治疗前几周的耐受性问题, 从而降低停药率, 帮助患者坚持治疗。表明roflumilast的不良反应是剂量依赖的, 降低给药剂量可以减少不良反应的发生。但若将降低后的剂量用于长期治疗可能会因PDE4抑制程度较低而无法充分发挥0.5 mg剂量的临床疗效, 寻找其他减少roflumilast不良反应的方法有待进一步探究。

1.2 Crisaborole

Crisaborole是2016年批准用于治疗成人和2岁以上儿童特应性皮炎的含硼PDE4小分子抑制剂, 2020年其适应症扩展至3个月以上的患者^[17]。其较小的相对分子质量使得可以有效渗透皮肤, 进入靶细胞, 通过增加cAMP依赖的蛋白激酶A的激活, 抑制下游活化T细胞核因子(nuclear factor of activated T cells, NFAT) 和核因子活化B细胞κ轻链增强子(nuclear factor kappa-light-chain-enhancer of activated B cells, NF-κB) 信号通路^[18], 抑制促炎因子和T细胞细胞因子的产生, 从而减轻皮肤炎症。为了评估crisaborole在轻中度特应性皮炎患者上应用的疗效与安全性, Anacor制药公司在美国发起了两项多中心、随机、双盲、赋形剂对照的Ⅲ期临床试验(NCT02118766和NCT02118792)^[19]。1 522例受试者按照2∶1的比例分成两组, 分别接受crisaborole和赋形剂治疗28天, 在第29天通过研究者静态全面评估(investigator's static global assessment, ISGA) 评分来衡量crisaborole的有效性。将ISGA打分值为0 (皮损完全清除) 或1 (皮损几乎完全清除), 且与最初相比改善了两级或两级以上作为判定治愈的标准, 在这两项研究中, crisaborole治疗组患者治愈率(AD-301: 32.8%, AD-302: 31.4%) 均高于赋形剂组(AD-301: 25.4%, AD-302: 18.0%)。

口服PDE4抑制剂常见的胃肠道不良反应在crisaborole治疗患者上出现频率(2.7%) 较低, 与赋形剂组(2.4%) 几乎一致, 说明胃肠道不良反应与crisaborole无关, 其主要的不良反应是药物涂抹处产生的灼热和刺痛感。治疗期间与crisaborole相关的不良反应发生率较低, 无严重不良反应发生且停药率较低, 研究结果证实了crisaborole可显著减轻特应性皮炎的症状和体征, 同时具有良好的耐受性及安全性。Crisaborole具有较低的全身吸收, 并能迅速代谢为活性低的产物, 降低了全身不良反应的风险^[20], 使其成为现有局部治疗特应性皮炎非常有前景的治疗药物。

1.3 Apremilast

Apremilast^[21]于2014年被FDA批准用于治疗银屑病和中度至重度斑块状银屑病, 临床前研究表明apremilast通过抑制PDE4, 使细胞内cAMP水平升高, 从而抑制天然免疫细胞、获得性免疫细胞和非免疫细胞等表达促炎细胞因子和趋化因子^[22], 减轻银屑病斑块的组织病理学特点。在评估apremilast治疗中至重度斑块状银屑病的疗效和安全性的临床试验(efficacy and safety trial evaluating the effects of apremilast in psoriasis, ESTTEM) 1^[23]和2^[24]中, 入组患者按照2∶1的比例随机分组, 在前16周分别接受一日两次30 mg apremilast或安慰剂治疗, 第16周至第32周, 上一周期内服用安慰剂的患者改用apremilast进行治疗, 第32周至第52周, 达到PASI-75 (与基线相比, 银屑病面积与严重程度指数评分改善至少75%) 的患者按1∶1的比例随机分组后, 分别使用apremilast或安慰剂治疗。Apremilast治疗组在第16周达到PASI-75的患者比例显著高于安慰剂组(ESTEEM1: 33.1% vs 5.3%; ESTEEM2: 28.8% vs 5.8%), 且apremilast治疗组实现sPGA 0/1 (静态医生总体评估评分为皮损清除或基本清除) 的患者比例显著高于安慰剂组(ESTEEM1: 21.7% vs 3.9%; ESTEEM2: 20.4% vs 4.4%)。研究结果显示, apremilast可有效改善斑块状银屑病患者的体征和症状, 减小患病面积, 提高患者的生活质量。

在已发表的临床试验中apremilast展现出良好的耐受性, 试验期间出现的不良反应大多为轻度至中度, 且多数不良反应在停止治疗后消失。最常见的不良反应是腹泻、恶心、上呼吸道感染、鼻咽炎和头痛^{[25, 26]}。在ESTEEM 1和2试验中分别观察到有19%和20.2%的患者体重减轻了5%以上, 通过分析体重减轻与胃肠道不良反应间的关系, 判断体重减轻与腹泻或恶心/呕吐之间没有关联。

1.4 Ibudilast

Ibudilast是一个非选择性PDE抑制剂, 对PDE3、4、10和11均具有抑制作用^[27]。早期由Kyorin研发, 在日本上市用于治疗哮喘和中风后头晕。Ibudilast通过抑制T细胞激活和减少辅助性T细胞1 (T helper cell 1, Th1) 产生的细胞因子, 增加辅助性T细胞2 (T helper cell 2, Th2) 分泌的抗炎性细胞因子, 进而调节支气管平滑肌和免疫系统, 在哮喘和COPD等气道疾病中发挥良好的疗效^[28]。除了哮喘和COPD, 鉴于ibudilast可以穿透血脑屏障, 并且在多种体外和体内模型中显示出神经保护和减弱神经胶质细胞活性等特性^{[29, 30]}, 因此近年来ibudilast在多发性硬化^[31] (multiple sclerosis, MS)、神经性疼痛^[32] (neuropathic pain)、阿片类药物依赖^{[33, 34]} (opioid dependence)、酒精使用障碍^{[35, 36]} (alcohol use disorder)、肌萎缩性脊髓侧索硬化症^[37] (amyotrophic lateral sclerosis) 和甲基苯丙胺使用障碍^[38] (methamphetamine use disorder) 等多种中枢神经系统疾病中均开展了临床研究。在Fox等^[31]开展的为期96周ibudilast治疗进展型MS的临床Ⅱ期试验中, 纳入了255名患有原发进展型MS或继发进展型MS的患者, 其中129人每日口服ibudilast 100 mg, 126人接受等量的安慰剂治疗。该试验通过磁共振成像(magnetic resonance imaging, MRI) 测量脑实质区域面积, 计算脑实质分数, 进而判断脑萎缩的程度, 以评估ibudilast对进展型MS的疗效。结果显示, ibudilast组(-0.001 0/每年) 脑实质分数变化率与安慰剂组(-0.001 9/每年) 相差0.000 9单位, 表明在这96周安慰剂组大脑体积较ibudilast组缩小了2.5 mL, ibudilast可有效缩短进展型MS患者脑萎缩进程。

治疗期间ibudilast组和安慰剂组退出试验的患者比例分别为16%和11%, 因不良事件退出的患者分别占8%和4%。且ibudilast治疗组的不良反应发生率(92%) 高于安慰剂组(88%), ibudilast组中发生率高于安慰剂组的不良反应事件主要有胃肠道症状(恶心、腹泻、腹痛和呕吐) 和抑郁。

1.5 Difamilast

大冢制药的difamilast乳膏于2021年9月在日本获批上市, 用于2岁以上儿童和成人的轻中度特应性皮炎患者。Saeki等^[39]在日本进行的为期4周的随机双盲赋形剂对照的Ⅱ期临床试验中, 73名2~14岁患特应性皮炎的患者按照1∶1∶1的比例每天分别接受两次0.3% difamilast、1% difamilast和赋形剂治疗。涂抹difamilast组在研究者整体评价打分、湿疹面积和严重程度指数、视觉模拟量表评分、源自患者的湿疹评价等多方面均优于赋形剂组。另外一项随机双盲赋形剂对照的临床Ⅲ期试验^[40]显示, 0.3% difamilast治疗组、1% difamilast治疗组和赋形剂组在第4周研究者总体评估(investigator's global assessment, IGA) 评分评分为0 (皮损完全清除) 或1 (皮损几乎完全清除) 且至少提升两个等级的患者比例分别为44.6%、47.1%和18.1%。

在短期临床试验中difamilast组绝大多数不良反应为轻度至中度, 试验过程中无死亡或严重不良事件报告。为了评估difamilast长期使用的安全性, Saeki等^[41]进行了为期52周的临床Ⅲ期试验, 参与试验的166名成人患者和200名儿童患者中有120位成人患者和178名儿童患者在治疗过程中出现过不良反应。这些不良反应多为轻度或中度, 成人患者中最常见的不良反应为特应性皮炎加重和痤疮, 儿童患者中最常见的不良反应为特应性皮炎加重和色素沉着, 由于不良反应而停药的仅有13名成人患者(7.8%) 和7名儿童患者(3.5%)。这些临床结果均显示difamilast可显著减轻患特应性皮炎儿童及青少年瘙痒等症状, 是一种安全有效的药物。

2 PDE4抑制剂不良反应研究

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近年临床研究发现PDE4抑制剂在认知和情感障碍、自身免疫性疾病、呼吸系统疾病和癌症等诸多疾病领域中表现出较良好的治疗潜力, 但由于其普遍存在的胃肠道不良反应导致治疗窗口狭窄, 导致其临床开发受限。因此针对PDE4抑制剂所致不良反应的研究具有重要临床和科学意义。

2.1 PDE4的HARBS/LARBS构象与呕吐的相关性

据早期文献报道, PDE4亚型的催化单元存在两种不同构象, 根据与rolipram相互作用的亲和力不同可以划分成低亲和力rolipram结合位点(low affinity rolipram binding state, LARBS) 和高亲和力rolipram结合位点(high affinity rolipram binding state, HARBS)^[42]。Rolipram是第一代PDE4抑制剂的代表, 具有良好的抗抑郁活性^[43], 因恶心呕吐不良反应迫使其临床应用被停止。2006年Zhang等^[44]研究发现PDE4蛋白的HARBS是发挥抗抑郁样行为效应的主要构象, PDE4抑制剂的呕吐作用可能是通过与HARBS结合引起的^[45]。基于上述原因, 后续的研究致力于靶向LARBS, 设计了第二代PDE4抑制剂roflumilast和cilomilast, 二者临床表现的低致吐性说明设计倾向于结合LARBS或是无差别结合HARBS及LARBS的抑制剂更为安全^[46]。由于第二代抑制剂在临床试验中仍存在胃肠道不良反应, 因此仅考虑避免抑制剂与HARBS的结合并不能完全解决不良反应的发生。

2.2 PDE4抑制剂的血脑屏障通透性与呕吐的相关性

Zhu等^[47]研究发现中枢神经系统参与了静脉注射rolipram介导的呕吐, 因此降低PDE4抑制剂的血脑屏障通透性或许可以减少呕吐的发生。由Astellas制药公司研发的PDE4抑制剂YM976^[48], 化合物具有不能透过血脑屏障的理化特性, 其(ED₅₀ = 2.8 mg·kg^-1) 表现出与rolipram (3.5 mg·kg^-1) 相当的抗炎活性。YM976 (最大无呕吐剂量= 10 mg·kg^-1) 的致呕吐性要低于rolipram (1 mg·kg^-1)。研究结果表明YM976可以使外周组织中的腹膜巨噬细胞内cAMP含量增加而对脑内cAMP水平无影响, 相同剂量下rolipram则能使外周及脑内cAMP水平升高^[49], 证明了YM976是由于低血脑屏障通透性减轻了不良反应。在McDonough等^[50]进行的胃轻瘫实验中, YM976仅在显著较高的剂量(≥ 1 mg·kg^-1) 下才会引起胃轻瘫, 这说明非脑渗透性的PDE4抑制剂的耐受性表现更好。肠-脑轴线是一段位于胃肠道和大脑之间连续、双向的神经和内分泌通讯网络^[51]。肠-脑轴线的外周部分包括嵌在胃肠道壁上的肠道神经系统以及迷走神经和内脏神经。人们发现在胃肠调节中发挥关键作用的是肠-脑轴线, 多项研究表明PDE4抑制剂诱导的呕吐不仅仅与中枢系统有关, 还受到胃肠道迷走神经感觉神经元的外周因素影响, 仅通过降低化合物的血脑屏障通透性并不能完全避免呕吐的发生。

2.3 PDE4亚型与呕吐的相关性

PDE4存在4个亚型PDE4A、PDE4B、PDE4C和PDE4D, 对各个亚型的定位研究表明PDE4D是存在人脑的极后区和孤束核的主要亚型^[52], 而脑中与呕吐相关的区域是极后区和孤束核。同时在P物质支配的延髓神经元中也发现了PDE4D的表达, P物质在由PDE4抑制剂引起的呕吐中发挥重要作用^[53]。同时还发现在胃壁的迷走神经将冲动传至中枢延髓区, 胃迷走神经的胞体位于结状神经节内, 结状神经节的神经元中主要表达的是PDE4D^[53]。

为研究α₂肾上腺素在由PDE4抑制剂诱导的呕吐中的作用, Robichaud等^[54]在雪貂身上进行了动物实验。育亨宾(yohimbine) 作为一种α₂肾上腺素受体拮抗剂可引发雪貂呕吐, 且相较于对照组, 预给药α₂肾上腺素受体激动剂可乐定(clonidine) 组口服PDE4抑制剂后发生呕吐次数更少。在使用致吐量的PDE4抑制剂PMNPQ刺激后, 可乐定剂量依赖地减少了PMNPQ诱导的干呕和呕吐, 同时PDE4抑制剂和育亨宾均能缩短甲苯噻嗪/氯胺酮诱导的麻醉持续时间, 实验结果表明PDE4抑制剂可能是通过模拟α₂肾上腺素能受体拮抗剂的药理作用, 从而触发呕吐反射。基于啮齿类动物无法表现出呕吐样行为, 因此后续研究中大多使用甲苯噻嗪/氯胺酮麻醉试验评估PDE4抑制剂的催吐潜力^[55]。基因敲除实验表明PDE4D基因敲除小鼠较野生型小鼠在注射甲苯噻嗪/氯胺酮后麻醉时间缩短, 且在使用PDE4抑制剂PMNPQ治疗后, 野生型及PDE4B基因缺陷小鼠的麻醉持续时间均缩短, 而PDE4D敲除小鼠无影响^[56]。基于定位研究和基因敲除实验, 认为PDE4D参与了中枢及外周活动, 是导致呕吐发生的主要亚型。

虽然甲苯噻嗪/氯胺酮麻醉试验是PDE4抑制剂模拟α2肾上腺素受体拮抗剂从而诱导呕吐的可靠衡量指标, 但PDE4抑制剂导致呕吐的机制尚不明确, 可能受到多因素和多通路的影响, 因此通过麻醉时间作为预测PDE4抑制剂催吐潜力的指标存在局限性。鉴于胃潴留与人类恶心呕吐密切相关^[57], McDonough等^[50]通过观察用PDE4抑制剂治疗的小鼠中导致的异常胃潴留, 以此来评估PDE4抑制剂在人类身上可能引起的恶心和呕吐不良反应。胃轻瘫实验中针对单个PDE4亚型进行基因敲除的结果表明, 任何一种单独的PDE4亚型敲除并不会导致胃潴留, 这说明可能是两个或多个PDE4亚型共同导致的PDE4抑制剂相关的不良反应。据观察在人类及哺乳动物中发生恶心的同时伴随着低体温的体征, 因此在Boyd等^[58]研究中通过测量小鼠的核心体温作为PDE4抑制剂引起人类恶心的相关指标。研究发现选择性敲除单个PDE4亚型本身并不会产生体温降低, 这与胃轻瘫实验结果一致。同时随着GEBR-7b^[59]、D159687^[60]、BPN14770^[61]等PDE4D变构抑制剂的研究开发, 该类抑制剂的特点是在高浓度下不会达到完全抑制酶活性, 在比格犬上的呕吐实验证实其具有良好的耐受性。因此认为PDE4抑制剂不良反应的发生不完全归因于对PDE4D亚型的抑制, 而与不同中枢和外周组织中特定PDE4亚型和同源异构体的抑制有关。

3 降低PDE4抑制剂致吐性的策略

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基于PDE4抑制剂致吐机制的复杂性, 目前有3种主要的策略可以克服PDE4抑制剂临床剂量的限制, 并减轻PDE4抑制剂不良反应, 提高治疗指数。

策略一: 改变给药途径。根据靶向器官的不同, 采用局部给药的方式, 减少全身暴露量。2022年roflumilast的外用乳膏制剂已被FDA批准上市用于治疗斑块状银屑病, 在两项关键的Ⅲ期临床试验DERMIS-1和DERMIS-2中^[62], 患者持续8周每日使用一次roflumilast乳膏进行治疗, 结果显示roflumilast治疗组实现皮损清除或基本清除且与基线相比IGA评分至少提高两个等级的患者显著多于赋形剂治疗组(DERMIS-1: 42.4% vs 6.1%; DERMIS-2: 37.5% vs 6.9%), 试验中无腹泻和恶心等胃肠道不良反应事件出现。且对roflumilast乳膏剂治疗慢性斑块型银屑病的药代动力学研究发现, roflumilast外用给药与口服给药相比具有明显的PK差异, 口服给药时, roflumilast的生物利用度更高(79%), 且吸收迅速, 峰值出现在1 h内^[63]。而单次局部给药后, roflumilast的生物利用度约为1.5%, 吸收缓慢, 给药后血药浓度-时间曲线平坦, 峰谷比为1.2^[64]。且银屑病患者外用给药(1.78 ng·mL^-1) 比COPD患者口服给药(6.01 ng·mL^-1) 的峰值浓度低约3倍, roflumilast乳膏相对于口服制剂具有良好的安全性和耐受性的原因可能是胃肠道无高浓度药物局部刺激。

策略二: 设计更具亚型选择性的PDE4抑制剂或变构抑制剂。不同PDE4亚型和同源异构体呈组织和细胞特异性表达^[1], 提高抑制剂的选择性可以在维持疗效的同时减少不良反应。由Burgin等^[60]提出的设计PDE4D变构抑制剂, 可通过部分抑制cAMP水解实现保持生物活性的同时降低呕吐的可能性。在一项研究BPN14770治疗成人脆性X综合征的随机、安慰剂对照的临床Ⅱ期试验中^[65], 患者每日服用两次25 mg BPN114770, 持续12周。所有参与者均完成了试验, 无死亡事件或因治疗期出现的不良事件而中断治疗发生, 试验中出现的不良事件为呕吐和上呼吸道感染, 但BPN14770治疗组和安慰剂组无显著差异, 说明该剂量下的BPN14770对于胃肠道的影响是微小的, 具有良好的耐受性, 为PDE4D抑制剂的研发提供了新的方向。

策略三: 设计双重选择性抑制剂。因为PDE4和PDE其他家族酶在细胞水平上展示的协同效应, 可使在减少用药剂量的同时达到相似的治疗效果, 例如PDE3/4^[66]、PDE4/7^[67]双重抑制剂。联合抑制PDE3/4可有效抑制LPS诱导的细胞因子的释放, 放松支气管肌固有张力, 且能抑制由致敏原或白三烯C4诱导的人气道平滑肌收缩^[68], 从而改善肺功能, 缓解呼吸困难。RPL554是目前唯一进入临床的PDE3/4双重抑制剂, 临床试验显示RPL554可减少COPD患者痰液中的中性粒细胞和嗜酸性粒细胞数量, 同时还具有支气管扩张作用^[69]。与安慰剂相比, RPL554治疗产生的不良反应一般较轻, 具有良好的安全性。

4 总结与展望

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PDE4家族作为cAMP信号传导的重要调节者, 近年已成为多种疾病的研究热点, 尽管许多PDE4抑制剂在临床前研究表现出一定的潜力, 但其临床上普遍存在的胃肠道不良反应严重阻碍临床应用, 研发安全有效且治疗指数高的PDE4抑制剂具有重要意义。

关于引起PDE4抑制剂不良反应的机制目前有3种观点: ① PDE4存在LARBS和HARBS两种构象, 与HARBS构象结合可能是产生不良反应的原因; ②具有血脑屏障通透性的PDE4抑制剂可进入脑内, 通过抑制与呕吐相关区域的PDE4引起不良反应; ③ PDE4D是引起恶心呕吐的主要亚型, 对PDE4D的抑制可能与不良反应相关。为了提高疗效, 避免不良反应, 可以改变给药方式, 通过局部给药降低全身暴露水平; 或提高不同组织和细胞中PDE4亚型和同源异构体的选择性; 以及设计双重抑制剂, 以提高PDE4抑制剂的安全性。

作者贡献: 王惠芳完成综述撰写和部分文献查阅; 王有志、支运宝、左琳飞、申慧珍和徐正文完成部分文献查阅工作; 王进欣完成文章修改、审核。

利益冲突: 作者声明本文不存在任何利益冲突。

基金

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国家自然科学基金资助项目(82073710)

参考文献

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文献

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参考文献引证文献

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2023年第58卷第9期

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doi: 10.16438/j.0513-4870.2022-1401

接收时间：2022-12-22
首发时间：2025-11-21
出版时间：2023-09-12

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收稿日期：2022-12-22
修回日期：2023-01-31

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国家自然科学基金资助项目(82073710)

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中国药科大学药学院药物化学系, 江苏省药物分子设计与成药性优化重点实验室, 江苏南京 210009

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*王进欣, Tel: 86-25-86185328, E-mail: jinxinwang@163.com

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2种不同金属材料的力学参数

科 Family	属数 Number of genus	种数 Number of species	占总种数比例 Percentage of total species (%)	属 Genus	种数 Number of species	占总种数比例 Percentage of total species (%)
鹅膏菌科Amanitaceae	2	11	5.26	鹅膏菌属 Amanita	10	4.78
小菇科 Mycenaceae	2	12	5.74	丝盖伞属 Inocybe	5	2.39
多孔菌科 Polyporaceae	8	14	6.70	蜡蘑属 Laccaria	5	2.39
红菇科 Russulaceae	3	23	11.00	小皮伞属 Marasmius	6	2.87
				小菇属 Mycena	11	5.26
				光柄菇属 Pluteus	5	2.39
				红菇属 Russula	17	8.13
				栓菌属 Trametes	5	2.39

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