+353-1-416-8900REST OF WORLD
1-800-526-8630U.S. (TOLL FREE)

Nitric Oxide - Therapeutics, Markets and Companies

  • ID: 39078
  • Report
  • March 2017
  • Region: Global
  • 280 Pages
  • Jain PharmaBiotech
1 of 4

This report describes the latest concepts of the role of nitric oxide (NO) in health and disease as a basis for therapeutics and development of new drugs. Major segments of the market for nitric oxide-based drugs are described as well as the companies involved in developing them.

Nitric oxide (NO) can generate free radicals as well as scavenge them. It also functions as a signaling molecule and has an important role in the pathogenesis of several diseases. A major focus is delivery of NO by various technologies. Another approach is modulation of nitric oxide synthase (NOS), which converts L-arginine to NO. NOS can be stimulated as well as inhibited by pharmacological and gene therapy approaches.

Important therapeutic areas for NO-based therapies are inflammatory disorders, cardiovascular diseases, erectile dysfunction, inflammation, pain and neuroprotection. The first therapeutic use of NO was by inhaltion for acute respiratory distress syndrome (ARDS). NO-donors, NO-mimics and NOS modulators are described and compared along with developmental status. NO-related mechanisms of action in existing drugs are identified.

Various pharmacological approaches are described along with their therapeutic relevance. Various approaches are compared using SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis. NO-based therapies are compared with conventional approaches and opportunities for combination with modern biotechnology approaches are described.

Share of drugs where NO is involved in the mechanism of action is analyzed in the worldwide pharmaceutical market for 2016 and is projected to 2021 and 2026 as new drugs with NO-based mechanisms are introduced into the market. Various strategies for developing such drugs are discussed.

Several companies have a product or products involving NO and free radicals. The report includes profiles of 35 companies involved in this area of which 9 have a significant interest in NO-based therapeutics. Other players are pharmaceutical and biotechnology companies as well as suppliers of products for NO research. Unfulfilled needs in the development of NO-based therapeutics are identified. Important 18 collaborations in this area are tabulated.

There are numerous publications relevant to NO. Selected 500 references are included in the bibliography. The text is supplemented with 26 tables and 29 figures.It is concluded that the future prospects for NO-based therapies are bright and fit in with biotechnology-based approaches to modern drug discovery and development. It is anticipated that some of these products will help in meeting the unfulfilled needs in human therapeutics.

Note: Product cover images may vary from those shown
2 of 4

0. Executive Summary

1. Introduction
Nitric oxide
Historical aspects
Free radicals
Nitrogen cycle and NO
Role of NO in biology and medicine
Nitric oxide synthase
Structure and function NOS
Inducible nitric oxide synthase
iNOS gene
Regulation of iNOS
Regulation of endothelial nitric oxide synthase
Interaction between eNOS and other proteins
eNOS gene
NOS-independent NO generation and circulation
Entero-salivary circulation of nitrate
Methods of study of NO and NOS
Colorimetric determination of NO2- using the Greiss reagent
High performance liquid chromatography
Bioimaging of NO
Electrochemical methods using amperometry
Method using micro ion electrodes
Metabolomics approach to study of NO metabolism

2. Nitric Oxide Pathways
Mechanisms action of NO
NO-cGMP pathway
Nitrate-nitrite-NO pathway
Soluble guanylyl cyclase as the NO receptor
Oxidative stress pathways
NO and oxidative stress
Oxidative stress and the NO-cyclic GMP signal transduction pathway
NO and platelets
Mitochondrial NO-cytochrome c oxidase signaling pathway
Nitric oxide and cytochrome c oxidase
Dual role of NO as a free radical and a scavenger
NO and carbon monoxide
NO signaling and apoptosis

3. Role of NO in Physiology
Homeostasis of NO
Role of NO in adaptation to high altitude
NO as a biomarker
Functions of NO in various systems of the body
NO and proteins
A proteomic method for identification of cysteine S-nitrosylation sites
Protein S-nitrosylation and intracellular transport processes
Cellular inactivation NO by iNOS aggresome formation
NO and mitochondria
Mitochondrial permeability and reperfusion injury
Endocrine role of NO
Role of NO in the cardiovascular system
NO and atrial natriuretic peptide
NOS in the cardiac myocyte
NO and the autonomic control of the heart rate
NO and vascular system
NO and vasodilatation
NO and blood pressure
Role of NO in the plasma compartment
Measurement of NO as a biomarker of cardiovascular function
Hemoglobin, oxygen and nitric oxide
Myoglobin and NO
NO and pulmonary circulation
Role of NO in the regulation of hypoxic pulmonary vasoconstriction
Role of NO in the lymphatic system
Role of NO in the nervous system
Neurovascular coupling of COX-2 and nNOS
NO and blood-brain barrier
NO as a neurotransmitter
Role of NO in memory and learning
Role of NO in synaptic plasticity
Role of NO in the peripheral nervous system
Role of NO in the cochlea
NO and neuroendocrine function
NO and pregnancy
Role of NO in penile erection
Role of NO in immune regulation
Role of NO in temperature regulation
Role of NO in gastrointestinal system
Role of NO in kidney function
Role of NO in liver
Role of NO in the skin

4. Role of NO in Diseases
Cytotoxicity of reactive nitrogen species
Peroxynitrite, mitochondria and cell death
Diseases involving oxidative stress and nitric oxide
Stress-related disorders
Role of NO in allergic disorders
Inflammatory diseases
Autoimmune disorders
Role of NO in rheumatoid arthritis
Role of NO in infections
NO-mediated cytoprotection in bacteria
Nanoscale nanoparticle delivery for cutaneous infection
Malaria and iNOS polymorphism
Susceptibility of Mycobacterium leprae to NO
Role of NO in the treatment of tuberculosis
Septic shock
Viral infections
Role of NO in anaphylactic shock
Role of NO in anemia and hypoxia
Role of NO in neurological disorders
Neurodegenerative diseases
NO-induced mitochondrial dysfunction in neurodegeneration
White matter disorders
Amyotrophic lateral sclerosis
Alzheimer's disease
Role of NO in pathophysiology of Alzheimer's disease
Role of ApoE genotype
Parkinson's disease
Traumatic brain injury
Pathophysiology of cerebral ischemia
Role of NO in cerebral ischemia
eNOS gene polymorphisms as predictor of cerebral aneurysm rupture
Role of NO in assessment of cerebral and retinal blood flow
Role of NO in cerebral vasospasm after subarachnoid hemorrhage
Role of NO in neuroprotection
Stroke and heart disease
Role of NO in peripheral neuropathy
iNOS induction in experimental allergic neuritis
Role of NO in sciatica
Role of NO in the pathogenesis of muscular dystrophy
Role of NO in neurological decompression sickness
Role of NO in psychiatric disorders
NO-dysregulation in schizophrenia
Role of NO in pathomechanism of cardiovascular disorders
Oxidative stress as a cause of cardiovascular disease
Role of NO in pathomechanism of cardiovascular diseases
Role of iNOS in cardiovascular disease
Role of eNOS in cardiovascular disease
Role nNOS in cardiac arrhythmia and sudden death
NO and atherosclerosis
Role of NO in cardiopulmonary disorders
Role of NO in disturbances of vasodilation
Caveolin-1 deficiency impairs NO synthesis and vasodilation
Role of NO in hypercholesterolemia
NO and systemic hypertension.
Coronary artery disease
Role of NO in the pathophysiology of angina pectoris
Congestive heart failure
Calcium overload as a cause of heart failure
NO/redox disequilibrium in the failing heart
Myocardial ischemia/reperfusion injury
NO pathway in cardiac hypertrophy
Role of NO in sickle cell disease
Role of NO in pulmonary disorders
Role of NO in the pathophysiology of asthma
iNOS gene polymorphisms in asthma
Role of S-nitrosoglutathione in bronchodilation in asthma
Monitoring of exhaled NO
Nasal NO as a biomarker of response to rhinosinusitis therapy
Elevated urinary NO as a biomarker of improved survival in ARDS
Pulmonary hypertension
Role of NO in renal disorders
Role of NOS in diabetic nephropathy
Role of NO in cancer
Inflammation, NO and colon cancer
Tumor hypoxia and NO
NO and p53 mutations
NO and matrix metalloproteinase
Role of NO in angiogenesis in cancer
Role of NO in diseases of the eye
Role of NO in metabolic disorders
Metabolic syndrome
Diabetes mellitus
Role of NO in gastrointestinal disorders
Role of L-arginine in intestinal adaptation
Role of NO in irritable bowel syndrome
Role of NO in inflammatory bowel diseases
Role of NO in celiac disease
Role of NO in diabetic gastroparesis
NO and diseases of the liver
Cirrhosis of liver
Hepatic encephalopathy
Role of NO in skin disorders
Role of NO and oxidative stress in the aging skin
Role of NO in wound healing
Role of NO in erectile dysfunction
Role of NO in pain
NO and pain of spinal cord origin
NO interaction with other receptors in pain
nNOS and pain
Role of NO in various types of pain
Neuropathic pain
Role of NO in diabetic neuropathy
NO in oral and facial pain
Role of NO in migraine
Role of NO in osteoarthritis
NO and Fibromyalgia syndrome
Role of spinal NO in analgesic action
Role of NO in nicotine addiction
Role of NO in carbon monoxide poisoning
Role of NO in chemically-induced toxicity
Peroxynitrite and drug-dependent toxicity.
Paraquat neurotoxicity
Role of NO in radiation damage
5. Pharmacology of Nitric Oxide
Introduction Source: Fosen and Thom 2014
Cytoxic vs cytoprotective role of NO
Antioxidants in relation to NO
Nitric oxide as an antioxidant
NO-related drugs
Drugs that activate eNOS production
Drugs that scavenge free radicals/NO
Peroxynitrite scavengers
Ruthenium (III) polyaminocarboxylates
Drugs that inhibit NO
Ginko biloba
Delivery of nitric oxide
Targeted delivery of NO donors
Nitric oxide delivery by encapsulated cells
NO-lipid combination
NO-releasing coating to prevent infection of implanted devices
Nanoparticles for controlled/sustained release of NO
Hydrogel/glass nanoparticles
Delivery of nanoparticles to vascular endothelium for release of NO
Release of NO in tissues by extracorporeal shock wave application
Nitric oxide donors
Nitroglycerine/glycerine trinitrate
Isosorbide dinitrate
Sodium nitrite
Organic nitrites
NO-releasing NSAIDs
COX-inhibiting NO-donors
Grafting of NO-releasing structures on to existing drugs
Mesoionic Oxatriazoles
Cysteine-containing NO donors
Sodium nitroprusside
COX-2 inhibitors
NO hydrogels
Novel NO donors
NO mimetics
Comparison of classical nitrates, grafted NO donors, and NO mimetics
NO donors and soluble guanylate cyclase activation
NO donors for increasing the efficacy of chemotherapy
Factors that enhance availability of NO
Modulators of cyclic guanosine-3',5'-monophosphate-dependent protein kinases
NOS-modulating drugs
Drugs that activate eNOS
Angiotensin converting enzyme inhibitors
17 Beta-estradiol
NOS inhibitors
Rationale of NOS inhibitors
Design of NOS inhibitors
Selective iNOS inhibitors
Non-amino acid-based inhibitors
Heme ligands
Pterin antagonists
Fused-ring bio-isoteric models of arginine as NOS inhibitors
nNOS inhibitors
Neurotrophic factors
Therapies based on action of NOS as a paraquat diaphorase
Concluding remarks about NOS inhibiting drugs
NO and stem cell-based therapy
Nitric oxide and gene therapy
NOS gene transfer
Inhibition of NOS by antisense technology
Drugs that modulate NO action on platelets
Action of NO and NO donors on platelets
NOS inhibitors and NO scavengers
Phosphodiesterase inhibitors
Activators of soluble guanylate cyclase
Secondary role of NO in the action of drugs
Selective serotonin reuptake inhibitors
P2Y receptors and NO
Calcium channel blockers and NO
Nitric oxide-based transdermal drug delivery
Mechanism of resistance of NO-based drugs
NO and nutraceuticals
L-arginine as a nutraceutical
Nitrate and nitrite
Role of NO in beneficial effects of chocolate

6. Therapeutic Applications
Role of NO in the management of pulmonary disorders
Manufacture of NO gas for inhalation
NO inhalation for acute respiratory distress syndrome
NO inhalation for premature children with pulmonary dysplasia
NO inhalation for premature children with respiratory failure
Pulmonary hypertension
NO-based treatment of pulmonary hypertension
Pediatric pulmonary hypertension
Gene therapy for pulmonary hypertension
Clinical trials of NO therapies for pulmonary arterial hypertension
iNOS inhibitors for asthma
NO for bronchodilation in asthma
Role of NO in acute lung injury after smoke inhalation
Cardiovascular disorders
Role of NO in cardioprotection
Role of NO in the management of myocardial infarction
Role of NO in the management of hypertension
Role of NO in the management of angina pectoris
Role of NO in therapy of coronary heart disease
NO-releasing aspirin in patients undergoing CABG
Management of coronary restenosis
Modified NO donors
NO-generating stent for coronary restenosis
eNOS gene therapy for restenosis
NO-based management of cardiac hypertrophy
Congestive heart failure
Limitation of antioxidant therapy in congestive heart failure
NO-based therapies for congestive heart failure
eNOS gene therapy for congestive heart failure
Gene transfer of nNOS in congestive heart failure
NO-based therapy for management of cardiogenic shock
NO-based therapy for cardiac arrhythmias
Prophylaxis of cardiovascular disorders
Prevention of atherosclerosis with aging
Role of iNO in cardiac surgery
Strategies for increasing NO signaling in cardiovascular disorders
Peripheral vascular disorders
Peripheral atherosclerotic arterial disease
Peripheral ischemic disease
An eNOS mutant as therapeutic for peripheral vascular ischemia
Sodium nitrite therapy for peripheral vascular ischemia
Raynaud's phenomenon
Neurological disorders
Cerebrovascular ischemic disorders
Attenuation of NO for neuroprotection in cerebral ischemia
Use of NO donors in cerebral ischemia
Use of NO donors in cerebral reperfusion injury
NO-based treatments for cerebral vasospasm due to SAH
NOS gene therapy for cerebral vasospasm
Degenerative CNS disorders
Statins for Alzheimer's disease
NO mimetics for Alzheimer's disease
iNOS inhibitors for treatment of Alzheimer’s disease
NO-NSAIDs for Alzheimer's disease
Ginko biloba for Alzheimer's disease
Personalization of NO-based therapy for Alzheimer's disease
Role of NO in the treatment of traumatic brain injury
Neuroinflammatory disorders
Role of NO-releasing sodium nitroprusside in the treatment of schizophrenia
Antidepressant effect of NOS inhibitors
Muscular dystrophy
NO for opening the blood-brain barrier
Cochlear disorders
Cochlear ischemia
Role of NO in sensoryneural hearing loss
Ophthalmic disorders
NO-based therapies for pain
Treatment of diabetic neuropathy with isosorbide dinitrate spray
NO-based therapies for migraine
NO-based therapy for fibromyalgia syndrome
NO-based therapies for inflammatory disorders
NO-based therapies for gastrointestinal disorders
Protection of gastrointestinal injury from NSAIDs
Role of NO in the treatment of inflammatory bowel disease
Topical nitroglycerin for chronic anal fissure
Mechanism of action of NO in cancer
Antineoplastic effect of iNOS-expressing cells
Role of NO in drug resistance of cancer
Role of NO in treatment of brain tumors
NO-induced apoptosis
Role of NO in antiangiogenesis therapies in cancer
NO donors for the treatment of cancer
NO-releasing NSAIDs and colon cancer chemoprevention
Rationale of combining NO aspirin with cancer vaccines
NO-based cancer gene therapy
Transdermal nitroglycerine for prostate cancer
NO-based therapies for skin disorders
NO-based therapies for skin infections
Role of NO in the treatment of psoriasis
NO-based therapy for sickle cell anemia
Inhaled NO for acute respiratory distress syndrome in sickle cell disease
NO inhalation for pulmonary hypertension in sickle cell anemia
Role of NO in disorders associated with pregnancy
Pre-eclampsia and intra-uterine growth restriction
Use of NO donors in management of labor
Erectile dysfunction
Selective inhibitors of phosphodiesterase 5
Erectile dysfunction in diabetes
NO-donating substances for treatment of ED
NOS gene transfer for ED
Organ transplant rejection
Role of NO in the treatment of renal disorders
Role of NO in the treatment of hepatic disorders
Portal hypertension
NO inhalation for restoration of liver function following transplantation
Role of NO in blood transfusion
Role of NO in the treatment of osteoporosis
NO-based wound healing
7. Evaluation of NO-Based Drugs
Current status
Antioxidant vs. NO-based approaches
SWOT analysis of selected approaches for NO modulation
NO donors by grafting of NO-releasing structures
NOS modulation
Challenges of developing NO-based therapies
Concluding remarks and future prospects

8. Markets for NO-based Therapies
Impact of NO-based therapies on international markets
Share of NO-based therapies in major therapeutic areas
Share of NO-based therapies in cardiovascular disorders
Myocardial infarction
Angina pectoris/coronary artery disease
Heart failure
Coronary restenosis and stenting
Strategies for developing NO-based therapy markets
Addressing the unfulfilled needs
Multidisciplinary approaches
Collaboration between the academia and the industry
Education of the public

9. Companies
Profiles of companies with focus on NO
Major pharmaceutical companies with involvement in NO
Smaller biotech and pharmaceutical companies involved in NO
Biopharmaceutical companies involved in antioxidant research
Companies supplying NO equipment for healthcare
Academic institutes with commercial collaboration in NO research
Companies supplying NO products for research

10. References
List of Tables
Table 1-1: Historical landmarks in the discovery and applications of nitric oxide
Table 3-1: Important functions of NO in the human body
Table 4-1: Diseases involving nitric oxide
Table 4-2: Role of nitric oxide in pathogenesis of autoimmune disorders
Table 4-3: Role of nitric oxide in infections
Table 5-1: Neuroprotective antioxidants
Table 5-2: NO-related drugs
Table 5-3: Methods of delivery of nitric oxide
Table 5-4: Comparison of classical nitrates, grafted NO donors, and NO mimetics
Table 5-5: Classification of NOS inhibitors
Table 5-6: Potential clinical applications of gene transfer for NOS overexpression
Table 6-1: Clinical trials of NO-based therapies for pulmonary hypertension
Table 6-2: Cardiovascular disorders for which NO-based therapies are used
Table 6-3: Selected neurological applications of NO-based therapies
Table 6-4: NO-related therapies for pain
Table 7-1: SWOT of technology ? NO donors by grafting of NO-releasing structures
Table 7-2: SWOT of products ? NO donors by grafting of NO-releasing structures
Table 7-3: SWOT of NOS gene manipulation
Table 7-4: SWOT of analgesic development by NOS isoform targeting
Table 8-1: Share of NO-based therapies in relevant therapeutic areas 2016-2026
Table 8-2: Share of NO-based therapies in cardiovascular diseases 2016-2026
Table 9-1: Classification of companies involved in NO and antioxidant therapies
Table 9-2: NicOx products in development
Table 9-3: NO-related products of Sigma Aldrich
Table 9-4: Collaborations of companies relevant to nitric oxide
List of Figures
Figure 1-1: Nitrogen cycle in the human body
Figure 1-2: Biosynthesis of nitric oxide (NO)
Figure 1-3: NO synthase pathway
Figure 2-1: Reactivity of nitric oxide with heme proteins in oxygen or peroxide reaction cycles
Figure 2-2: NO-cGMP pathway leading to vasorelaxation
Figure 2-3: The biological pathways toward protein nitration
Figure 2-4: NF-?B activation and iNOS induction
Figure 2-5: Overview of mitochondrial NO-cytochrome c oxidase signaling pathway
Figure 3-1: Role of NO in adaptation to high altitude
Figure 3-2: NOS in the cardiac myocyte
Figure 3-3: Pathways for generation and inhibition of NO in the vasculature
Figure 3-4: Interactions of the Mb compounds with O and NO
Figure 3-5: Role of NO in dynamics of lymphatic pumping
Figure 4-1: Molecular mechanisms of peroxynitrite-mediated cell death
Figure 4-2: NO neurotoxicity and neuroprotection in relation to Alzheimer's disease
Figure 4-3: Some steps in the ischemic cascade and site of action of neuroprotectives
Figure 4-4: Dual role of nitric oxide (NO) in cerebral ischemia
Figure 4-5: Blood cell-endothelial cell interactions induced by hypercholesterolemia
Figure 4-6: Effects of NO on the pathophysiology of myocardial ischemia-reperfusion
Figure 4-7: Nitric oxide: tumor enhancement or inhibition
Figure 4-8: Role of nitric oxide in angiogenesis
Figure 4-9: Role of NO in HBO-induced wound healing
Figure 5-1: Nitrogen oxide mimetics ? synergy by chemical modification
Figure 5-2: Factors that enhance availability of NO
Figure 5-3: Mechanism of resistance to NO-based therapeutics
Figure 6-1: Mechanism of development of tolerance to glyceryl trinitrate
Figure 6-2: Vicious circle of vascular occlusion following angioplasty and stenting
Figure 6-3: PDE5 inhibition and the response to sexual stimulation
Figure 8-1:  Unfulfilled needs in NO therapeutics

Note: Product cover images may vary from those shown
3 of 4
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 Colleges of UK. Currently he is a consultant at Jain PharmaBiotech. Prof. Jain is the author of 415 publications including 16 books (2 as editor) and 48 special reports, which have covered important areas in biotechnology, gene therapy and biopharmaceuticals.
Note: Product cover images may vary from those shown
4 of 4
Note: Product cover images may vary from those shown