The use of nonsteroidal anti-inflammatory drugs (NSAIDs) can promote lower gastrointestinal detrimental effects. Proteinase-activated receptors 1 (PAR1) and PAR2 are involved in the pathophysiology of several digestive disorders. This study examines the contribution of PAR1 and PAR2 in NSAID-induced small intestinal injury, and to investigate the underlying mechanisms.
Male Wistar rats (40 weeks old) were treated with indomethacin (1.5 mg/kg BID) for 14 days. Subgroups of animals were treated intraperitoneally with TFFLR-NH2 (PAR1 agonist), AC55541 (PAR2 agonist), SCH79797 (PAR1 antagonist) or ENMD-1068 (PAR2 antagonist). After treatments, blood and feces were collected for the assessment of hemoglobin and calprotectin, respectively. The ileum was processed for the evaluation of myeloperoxidase (MPO), malondialdehyde (MDA), and the protein expression of occludin and activated caspase-3.
Indomethacin elicited a significant intestinal damage, associated with a decrease in blood hemoglobin and an increase in tissue MPO, MDA and fecal calprotectin. In this setting, either the PAR1 agonist or PAR2 antagonist counteracted these changes, with the exception of MDA, which was unaffected. By contrast, the PAR1 antagonist or PAR2 agonist did not exert any effect on all the parameters. Indomethacin also decreased occludin and increased activated caspase-3 expression in ileal tissues. The PAR1 agonist or PAR2 antagonist prevented the reduced occludin expression, while the PAR2 antagonist also decreased the levels of activated caspase-3.
PAR2 is involved in the pathogenesis of indomethacin enteropathy, through pro-inflammatory mechanisms and an impairment of the intestinal epithelial barrier. PAR1 activation and PAR2 inhibition could represent suitable strategies for the prevention of NSAID enteropathy.
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Pereira-Leite C, Nunes C, Jamal SK, Cuccovia IM, Reis S. Nonsteroidal anti-inflammatory therapy: a journey toward safety. Med Res Rev. 2017;37(4):802–59.
Wongrakpanich S, Wongrakpanich A, Melhado K, Rangaswami J. A Comprehensive review of non-steroidal anti-inflammatory drug use in the elderly. Aging Dis. 2018;9(1):143–50.
Walker C. Are all oral COX-2 selective inhibitors the same? A consideration of celecoxib, etoricoxib, and diclofenac. Int J Rheumatol. 2019;2019:8635073.
Wang X, Tian HJ, Yang HK, Wanyan P, Peng YJ. Meta-analysis: cyclooxygenase-2 inhibitors are no better than nonselective nonsteroidal anti-inflammatory drugs with proton pump inhibitors in regard to gastrointestinal adverse events in osteoarthritis and rheumatoid arthritis. Eur J Gastroenterol Hepatol. 2011;23(10):876–80.
Mallen SR, Essex MN, Zhang R. Gastrointestinal tolerability of NSAIDs in elderly patients: a pooled analysis of 21 randomized clinical trials with celecoxib and nonselective NSAIDs. Curr Med Res Opin. 2011;27(7):1359–66.
Hawkey CJ. NSAIDs, coxibs, and the intestine. J Cardiovasc Pharmacol. 2006;47(Suppl 1):S72–S7575.
Svistunov AA, Osadchuk MA, Kireeva NV, Hudarova AA, Achkasov EE. NSAID-induced enteropathy: the current state of the problem. Ter Arkh. 2018;90(8):95–100.
Tai FWD, McAlindon ME. NSAIDs and the small bowel. Curr Opin Gastroenterol. 2018;34(3):175–82.
Scarpignato C, Hunt RH. Nonsteroidal antiinflammatory drug-related injury to the gastrointestinal tract: clinical picture, pathogenesis, and prevention. Gastroenterol Clin N Am. 2010;39(3):433–64.
Syer SD, Blackler RW, Martin R, de Palma G, Rossi L, Verdu E, et al. NSAID enteropathy and bacteria: a complicated relationship. J Gastroenterol. 2015;50(4):387–93.
Wallace JL. Mechanisms, prevention and clinical implications of nonsteroidal anti-inflammatory drug-enteropathy. World J Gastroenterol. 2013;19(12):1861–76.
Bjarnason I, Scarpignato C, Holmgren E, Olszewski M, Rainsford KD, Lanas A. Mechanisms of damage to the gastrointestinal tract from nonsteroidal anti-inflammatory drugs. Gastroenterology. 2018;154(3):500–14.
Bueno L, Fioramonti J. Protease-activated receptor 2 and gut permeability: a review. Neurogastroenterol Motil. 2008;20(6):580–7.
Cenac N, Cellars L, Steinhoff M, Andrade-Gordon P, Hollenberg MD, Wallace JL, et al. Proteinase-activated receptor-1 is an anti-inflammatory signal for colitis mediated by a type 2 immune response. Inflamm Bowel Dis. 2005;11(9):792–8.
Van Spaendonk H, Ceuleers H, Witters L, Patteet E, Joossens J, Augustyns K, et al. Regulation of intestinal permeability: the role of proteases. World J Gastroenterol. 2017;23(12):2106–23.
Kahn M, Ishii K, Kuo WL, Piper M, Connolly A, Shi YP, et al. Conserved structure and adjacent location of the thrombin receptor and protease-activated receptor 2 genes define a protease-activated receptor gene cluster. Mol Med. 1996;2(3):349–57.
Schmidt VA, Nierman WC, Maglott DR, Cupit LD, Moskowitz KA, Wainer JA, et al. The human proteinase-activated receptor-3 (PAR-3) gene. Identification within a Par gene cluster and characterization in vascular endothelial cells and platelets. J Biol Chem. 1998;273(24):15061–8.
Xu WF, Andersen H, Whitmore TE, Presnell SR, Yee DP, Ching A, et al. Cloning and characterization of human protease-activated receptor 4. Proc Natl Acad Sci USA. 1998;95(12):6642–6.
Sébert M, Sola-Tapias N, Mas E, Barreau F, Ferrand A. Protease-activated receptors in the intestine: focus on inflammation and cancer. Front Endocrinol (Lausanne). 2019;10:717.
Dugina TN, Kiseleva EV, Chistov IV, Umarova BA, Strukova SM. Receptors of the PAR family as a link between blood coagulation and inflammation. Biochemistry (Mosc). 2002;67(1):65–74.
Vergnolle N. Clinical relevance of proteinase activated receptors (pars) in the gut. Gut. 2005;54(6):867–74.
Pontarollo G, Mann A, Brandão I, Malinarich F, Schöpf M, Reinhardt C. Protease-activated receptor signaling in intestinal permeability regulation. FEBS J. 2020;287(4):645–58.
Vergnolle N. Proteinase-activated receptors (PARs) in infection and inflammation in the gut. Int J Biochem Cell Biol. 2008;40(6–7):1219–27.
Hansen KK, Sherman PM, Cellars L, Andrade-Gordon P, Pan Z, Baruch A, et al. A major role for proteolytic activity and proteinase-activated receptor-2 in the pathogenesis of infectious colitis. Proc Natl Acad Sci USA. 2005;102(23):8363–8.
Ma L, Perini R, McKnight W, Dicay M, Klein A, Hollenberg MD, et al. Proteinase-activated receptors 1 and 4 counter-regulate endostatin and VEGF release from human platelets. Proc Natl Acad Sci USA. 2005;102(1):216–20.
Nguyen C, Coelho AM, Grady E, Compton SJ, Wallace JL, Hollenberg MD, et al. Colitis induced by proteinase-activated receptor-2 agonists is mediated by a neurogenic mechanism. Can J Physiol Pharmacol. 2003;81(9):920–7.
Yoshida N, Takagi T, Isozaki Y, Suzuki T, Ichikawa H, Yoshikawa T. Proinflammatory role of protease-activated receptor-2 in intestinal ischemia/reperfusion injury in rats. Mol Med Rep. 2011;4(1):81–6.
Zhao JH, Dong L, Shi HT, Wang ZY, Shi HY, Ding H. The expression of protease-activated receptor 2 and 4 in the colon of irritable bowel syndrome patients. Dig Dis Sci. 2012;57(1):58–64.
Watanabe T, Fujiwara Y, Chan FKL. Current knowledge on non-steroidal anti-inflammatory drug-induced small-bowel damage: a comprehensive review. J Gastroenterol. 2020;55(5):481–95.
Sostres C, Gargallo CJ, Lanas A. Nonsteroidal anti-inflammatory drugs and upper and lower gastrointestinal mucosal damage. Arthritis Res Ther. 2013;15(Suppl 3):S3.
Niikura R, Yamada A, Maki K, Nakamura M, Watabe H, Fujishiro M, et al. Associations between drugs and small-bowel mucosal bleeding: multicenter capsule-endoscopy study. Dig Endosc. 2018;30(1):79–89.
Lanas A, Goldstein JL, Chan FK, Wilcox CM, Peura DA, Li C, et al. Risk factors associated with a decrease ≥ 2 g/dL in haemoglobin and/or ≥ 10% haematocrit in osteoarthritis patients taking celecoxib or an on selective NSAID plus a PPI in a large randomised controlled trial (CONDOR). Aliment Pharmacol Ther. 2012;36(5):485–92.
Watanabe T, Tanigawa T, Nadatani Y, Nagami Y, Sugimori S, Okazaki H, et al. Risk factors for severe nonsteroidal anti-inflammatory drug-induced small intestinal damage. Dig Liver Dis. 2013;45(5):390–5.
Fornai M, Antonioli L, Colucci R, Pellegrini C, Giustarini G, Testai L, et al. NSAID-induced enteropathy: are the currently available selective COX-2 inhibitors all the same? J Pharmacol Exp Ther. 2014;348(1):86–95.
Fornai M, Antonioli L, Pellegrini C, Colucci R, Sacco D, Tirotta E, et al. Small bowel protection against NSAID-injury in rats: effect of rifaximin, a poorly absorbed, GI targeted, antibiotic. Pharmacol Res. 2016;104:186–96.
Antonioli L, Fornai M, Colucci R, Awwad O, Ghisu N, Tuccori M, et al. The blockade of adenosine deaminase ameliorates chronic experimental colitis through the recruitment of adenosine A2A and A3 receptors. J Pharmacol Exp Ther. 2010;335(2):434–42.
Fornai M, Pellegrini C, Benvenuti L, Tirotta E, Gentile D, Natale G, et al. Protective effects of the combination Bifidobacterium longum plus lactoferrin against NSAID-induced enteropathy. Nutrition. 2020;70:110583.
Colucci R, Pellegrini C, Fornai M, Tirotta E, Antonioli L, Renzulli C, et al. Pathophysiology of NSAID-associated intestinal lesions in the rat: luminal bacteria and mucosal inflammation as targets for prevention. Front Pharmacol. 2018;9:1340.
Fornai M, Colucci R, Antonioli L, Awwad O, Ugolini C, Tuccori M, et al. Effects of esomeprazole on healing of nonsteroidal anti-inflammatory drug (NSAID)-induced gastric ulcers in the presence of a continued NSAID treatment: characterization of molecular mechanisms. Pharmacol Res. 2011;63(1):59–67.
Bonnart C, Feuillet G, Vasseur V, Cenac N, Vergnolle N, Blanchard N. Protease-activated receptor 2 contributes to Toxoplasma gondii-mediated gut inflammation. Parasite Immunol. 2017;39(11):e12489.
Lohman RJ, Cotterell AJ, Suen J, Liu L, Do AT, Vesey DA, et al. Antagonism of protease-activated receptor 2 protects against experimental colitis. J Pharmacol Exp Ther. 2012;340(2):256–65.
Saeed MA, Ng GZ, Däbritz J, Wagner J, Judd L, Han JX, et al. Protease-activated receptor 1 plays a proinflammatory role in colitis by promoting Th17-related immunity. Inflamm Bowel Dis. 2017;23(4):593–602.
Bjarnason I, Zanelli G, Prouse P, Smethurst P, Smith T, Levi S, et al. Blood and protein loss via small-intestinal inflammation induced by non-steroidal anti-inflammatory drugs. Lancet. 1987;2(8561):711–4.
Bjarnason I, Hayllar J, Smethurst P, Price A, Gumpel MJ. Metronidazole reduces intestinal inflammation and blood loss in non-steroidal anti-inflammatory drug induced enteropathy. Gut. 1992;33(9):1204–8.
Chami B, Martin NJJ, Dennis JM, Witting PK. Myeloperoxidase in the inflamed colon: a novel target for treating inflammatory bowel disease. Arch Biochem Biophys. 2018;645:61–71.
Manceau H, Chicha-Cattoir V, Puy H, Peoc'h K. Fecal calprotectin in inflammatory bowel diseases: update and perspectives. Clin Chem Lab Med. 2017;55(4):474–83.
Ryu DG, Kim HW, Park SB, Kang DH, Choi CW, Kim SJ, et al. Clinical implications of fecal calprotectin and fecal immunochemical test on mucosal status in patients with ulcerative colitis. Medicine (Baltimore). 2019;98(36):e17080.
Ricciuto A, Griffiths AM. Clinical value of fecal calprotectin. Crit Rev Clin Lab Sci. 2019;56(5):307–20.
Rendek Z, Falk M, Grodzinsky E, Wahlin K, Kechagias S, Svernlöv R, et al. Effect of oral diclofenac intake on faecal calprotectin. Scand J Gastroenterol. 2016;51(1):28–322.
Kuramoto T, Umegaki E, Nouda S, Narabayashi K, Kojima Y, Yoda Y, et al. Preventive effect of irsogladine or omeprazole on non-steroidal anti-inflammatory drug-induced esophagitis, peptic ulcers, and small intestinal lesions in humans, a prospective randomized controlled study. BMC Gastroenterol. 2013;13:85.
Fukui A, Naito Y, Handa O, Kugai M, Tsuji T, Yoriki H, et al. Acetyl salicylic acid induces damage to intestinal epithelial cells by oxidation-related modifications of ZO-1. Am J Physiol Gastrointest Liver Physiol. 2012;303(8):G927–G936936.
Lai Y, Zhong W, Yu T, Xia ZS, Li JY, Ouyang H, et al. Rebamipide promotes the regeneration of aspirin-induced small-intestine mucosal injury through accumulation of β-catenin. PLoS ONE. 2015;10(7):e0132031.
Arisan ED, Ergül Z, Bozdağ G, Rencüzoğulları Ö, Çoker-Gürkan A, Obakan-Yerlikaya P, et al. Diclofenac induced apoptosis via altering PI3K/Akt/MAPK signaling axis in HCT 116 more efficiently compared to SW480 colon cancer cells. Mol Biol Rep. 2018;45(6):2175–84.
Vyas D, Robertson CM, Stromberg PE, Martin JR, Dunne WM, Houchen CW, et al. Epithelial apoptosis in mechanistically distinct methods of injury in the murine small intestine. Histol Histopathol. 2007;22(6):623–30.
Li S, Guan J, Ge M, Huang P, Lin Y, Gan X. Intestinal mucosal injury induced by tryptase-activated protease-activated receptor 2 requires β-arrestin-2 in vitro. Mol Med Rep. 2015;12(5):7181–7.
de Garavilla L, Vergnolle N, Young SH, Ennes H, Steinhoff M, Ossovskaya VS, et al. Agonists of proteinase-activated receptor 1 induce plasma extravasation by a neurogenic mechanism. Br J Pharmacol. 2001;133(7):975–87.
Gardell LR, Ma JN, Seitzberg JG, Knapp AE, Schiffer HH, Tabatabaei A, et al. Identification and characterization of novel small-molecule protease-activated receptor 2 agonists. J Pharmacol Exp Ther. 2008;327(3):799–808.
El Eter EA, Aldrees A. Inhibition of proinflammatory cytokines by SCH79797, a selective protease-activated receptor 1 antagonist, protects rat kidney against ischemia-reperfusion injury. Shock. 2012;37(6):639–44.
Kelso EB, Lockhart JC, Hembrough T, Dunning L, Plevin R, Hollenberg MD, et al. Therapeutic promise of proteinase-activated receptor-2 antagonism in joint inflammation. J Pharmacol Exp Ther. 2006;316(3):1017–24.
This study received funding from the BMS/Pfizer European Thrombosis Investigator Initiated Research Program (ERISTA). Award number: 2014-API-0020. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.
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Fornai, M., Colucci, R., Pellegrini, C. et al. Role of proteinase-activated receptors 1 and 2 in nonsteroidal anti-inflammatory drug enteropathy. Pharmacol. Rep (2020). https://doi.org/10.1007/s43440-020-00119-w
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Proteinase-activated receptors (PAR)
- Fecal calprotectin
- Intestinal epithelial barrier
- Intestinal inflammation