5-α reductase inhibitors and prostate cancer prevention: where do we turn now?

With the lifetime risk of being diagnosed with prostate cancer so great, an effective chemopreventive agent could have a profound impact on the lives of men. Despite decades of searching for such an agent, physicians still do not have an approved drug to offer their patients. In this article, we outline current strategies for preventing prostate cancer in general, with a focus on the 5-α-reductase inhibitors (5-ARIs) finasteride and dutasteride. We discuss the two landmark randomized, controlled trials of finasteride and dutasteride, highlighting the controversies stemming from the results, and address the issue of 5-ARI use, including reasons why providers may be hesitant to use these agents for chemoprevention. We further discuss the recent US Food and Drug Administration ruling against the proposed new indication for dutasteride and the change to the labeling of finasteride, both of which were intended to permit physicians to use the drugs for chemoprevention. Finally, we discuss future directions for 5-ARI research.

Hydroxymethylglutaryl-CoA reductase inhibition with simvastatin in Acute lung injury to Reduce Pulmonary dysfunction (HARP-2) trial: study protocol for a randomized controlled trial

Background: Acute lung injury (ALI) is a common devastating clinical syndrome characterized by life-threatening respiratory failure requiring mechanical ventilation and multiple organ failure. There are in vitro, animal studies and pre-clinical data suggesting that statins may be beneficial in ALI. The Hydroxymethylglutaryl-CoA reductase inhibition with simvastatin in Acute lung injury to Reduce Pulmonary dysfunction (HARP-2) trial is a multicenter, prospective, randomized, allocation concealed, double-blind, placebo-controlled clinical trial which aims to test the hypothesis that treatment with simvastatin will improve clinical outcomes in patients with ALI.

Methods/Design: Patients fulfilling the American-European Consensus Conference Definition of ALI will be randomized in a 1: 1 ratio to receive enteral simvastatin 80 mg or placebo once daily for a maximum of 28 days. Allocation to randomized groups will be stratified with respect to hospital of recruitment and vasopressor requirement. Data will be recorded by participating ICUs until hospital discharge, and surviving patients will be followed up by post at 3, 6 and 12 months post randomization. The primary outcome is number of ventilator-free days to day 28. Secondary outcomes are: change in oxygenation index and sequential organ failure assessment score up to day 28, number of non pulmonary organ failure free days to day 28, critical care unit mortality; hospital mortality; 28 day post randomization mortality and 12 month post randomization mortality; health related quality of life at discharge, 3, 6 and 12 months post randomization; length of critical care unit and hospital stay; health service use up to 12 months post-randomization; and safety. A total of 540 patients will be recruited from approximately 35 ICUs in the UK and Ireland. An economic evaluation will be conducted alongside the trial. Plasma and urine samples will be taken up to day 28 to investigate potential mechanisms by which simvastatin might act to improve clinical outcomes.

Evaluating early administration of the hydroxymethylglutaryl-CoA reductase inhibitor simvastatin in the prevention and treatment of delirium in critically ill ventilated patients (MoDUS trial): Study protocol for a randomized controlled trial

Background: The incidence of delirium in ventilated patients is estimated at up to 82%, and it is associated with longer intensive care and hospital stays, and long-term cognitive impairment and mortality. The pathophysiology of delirium has been linked with inflammation and neuronal apoptosis. Simvastatin has pleiotropic properties; it penetrates the brain and, as well as reducing cholesterol, reduces inflammation when used at clinically relevant doses over the short term. This is a single centre randomised, controlled trial which aims to test the hypothesis that treatment with simvastatin will modify delirium incidence and outcomes. 

Methods/Design: The ongoing study will include 142 adults admitted to the Watford General Hospital Intensive Care Unit who require mechanical ventilation in the first 72 hours of admission. The primary outcome is the number of delirium- and coma-free days in the first 14 days. Secondary outcomes include incidence of delirium, delirium- and coma-free days in the first 28 days, days in delirium and in coma at 14 and 28 days, number of ventilator-free days at 28 days, length of critical care and hospital stay, mortality, cognitive decline and healthcare resource use. Informed consent will be taken from patient's consultee before randomisation to receive either simvastatin (80 mg) or placebo once daily. Daily data will be recorded until day 28 after randomisation or until discharge from the ICU if sooner. Surviving patients will be followed up on at six months from discharge. Plasma and urine samples will be taken to investigate the biological effect of simvastatin on systemic markers of inflammation, as related to the number of delirium- and coma-free days, and the potential of cholinesterase activity and beta-amyloid as predictors of the risk of delirium and long-term cognitive impairment. 

Discussion: This trial will test the efficacy of simvastatin on reducing delirium in the critically ill. If patients receiving the statin show a reduced number of days in delirium compared with the placebo group, the inflammatory theory implicated in the pathogenesis of delirium will be strengthened. 

Regulation of HMG-CoA reductase, HSL and ACAT expression and activity in testicular cholesterol metabolism in mink and in mouse following experimental genetic deletion

Introduction: L'homéostasie du cholestérol est indispensable à la synthèse de la testostérone dans le tissu interstitiel et la production de gamètes mâles fertiles dans les tubules séminifères. Les facteurs enzymatiques contribuent au maintien de cet équilibre intracellulaire du cholestérol. L'absence d'un ou de plusieurs enzymes telles que la HMG-CoA réductase, la HSL et l'ACAT-1 a été associée à l'infertilité masculine. Toutefois, les facteurs enzymatiques qui contribuent au maintien de l'équilibre intra-tissulaire du cholestérol n'ont pas été étudiés. Cette étude a pour but de tester l'hypothèse que le maintien des taux de cholestérol compatibles avec la spermatogenèse nécessite une coordination de la fonction intracellulaire des enzymes HMG-CoA réductase, ACAT1 et ACAT2 et la HSL. Méthodes: Nous avons analysé l'expression de l’ARNm et de la protéine de ces enzymes dans les fractions enrichies en tubules séminifères (STf) de vison durant le développement postnatal et le cycle reproductif annuel et dans les fractions enrichies en tissu interstitiel (ITf) et de STf durant le développement postnatal chez la souris. Nous avons développé deux nouvelles techniques pour la mesure de l'activité enzymatique de la HMG-CoA réductase et de celle de l'ACAT1 et ACAT2. En outre, l'immunohistochimie a été utilisée pour localiser les enzymes dans le testicule. Enfin, les souris génétiquement déficientes en HSL, en SR-BI et en CD36 ont été utilisées pour élucider la contribution de la HMG-CoA réductase, l'ACAT1 et l'ACAT2 et la HSL à l'homéostasie du cholestérol. Résultats: 1) HMG-CoA réductase: (Vison) La variation du taux d’expression de l’ARNm de la HMG-CoA réductase était corrélée à celle de l'isoforme de 90 kDa de la protéine HMG-CoA réductase durant le développement postnatal et chez l'adulte durant le cycle reproductif saisonnier. L'activité enzymatique de la HMG-CoA réductase augmentait de façon concomitante avec le taux protéinique pour atteindre son niveau le plus élevé à 240 jours (3.6411e-7 mol/min/μg de protéines) au cours du développement et en Février (1.2132e-6 mol/min/μg de protéines) durant le cycle reproductif chez l’adulte. (Souris), Les niveaux d'expression de l'ARNm et l'activité enzymatique de la HMG-CoA réductase étaient maximales à 42 jours. A l'opposé, le taux protéinique diminuait au cours du développement. 2) HSL: (Vison), l'expression de la protéine de 90 kDa de la HSL était élevée à 180- et 240 jours après la naissance, ainsi qu'en Janvier durant le cycle saisonnier chez l'adulte. L'activité enzymatique de la HSL augmentait durant le développement pour atteindre un pic à 270 jours (36,45 nM/min/μg). Chez l'adulte, l'activité enzymatique de la HSL était maximale en Février. (Souris) Le niveau d’expression de l'ARNm de la HSL augmentait significativement à 21-, 28- et 35 jours après la naissance concomitamment avec le taux d'expression protéinique. L'activité enzymatique de la HSL était maximale à 42 jours suivie d'une baisse significative chez l'adulte. 3) ACAT-1 et ACAT-2: Le présent rapport est le premier à identifier l’expression de l'ACAT-1 et de l'ACAT-2 dans les STf de visons et de souris. (Vison) L'activité enzymatique de l'ACAT-2 était maximale à la complétion du développement à 270 jour (1190.00 CPMB/200 μg de protéines) et en janvier (2643 CPMB/200 μg de protéines) chez l'adulte. En revanche, l'activité enzymatique de l'ACAT-1 piquait à 90 jours et en août respectivement durant le développement et chez l'adulte. (Souris) Les niveaux d'expression de l'ARNm et la protéine de l'ACAT-1 diminuait au cours du développement. Le taux de l'ARNm de l'ACAT-2, à l’opposé du taux protéinique, augmentait au cours du développement. L'activité enzymatique de l'ACAT-1 diminuait au cours du développement tandis que celle de l'ACAT-2 augmentait pour atteindre son niveau maximal à 42 jours. 4) Souris HSL-/ -: Le taux d’expression de l'ARNm et l'activité enzymatique de la HMG-CoA réductase diminuaient significativement dans les STf de souris HSL-/- comparés aux souris HSL+/+. Par contre, les taux de l'ARNm et les niveaux des activités enzymatiques de l'ACAT-1 et de l'ACAT-2 étaient significativement plus élevés dans les STf de souris HSL-/- comparés aux souris HSL+/+ 5) Souris SR-BI-/-: L'expression de l'ARNm et l'activité enzymatique de la HMG-CoA réductase et de l'ACAT-1 étaient plus basses dans les STf de souris SR-BI-/- comparées aux souris SR-BI+/+. A l'opposé, le taux d'expression de l'ARNm et l'activité enzymatique de la HSL étaient augmentées chez les souris SR-BI-/- comparées aux souris SR-BI+/+. 6) Souris CD36-/-: L'expression de l'ARNm et l'activité enzymatique de la HMG-CoA réductase et de l'ACAT-2 étaient significativement plus faibles tandis que celles de la HSL et de l'ACAT-1 étaient inchangées dans les STf de souris CD36-/- comparées aux souris CD36+/+. Conclusion: Nos résultats suggèrent que: 1) L'activité enzymatique de la HMG-CoA réductase et de la HSL sont associées à l'activité spermatogénétique et que ces activités ne seraient pas régulées au niveau transcriptionnel. 2) L'ACAT-1 et de l'ACAT-2 sont exprimées dans des cellules différentes au sein des tubules séminifères, suggérant des fonctions distinctes pour ces deux isoformes: l'estérification du cholestérol libre dans les cellules germinales pour l'ACAT-1 et l'efflux du cholestérol en excès dans les cellules de Sertoli au cours de la spermatogenèse pour l'ACAT-2. 3) La suppression génétique de la HSL diminuait la HMG-CoA réductase et augmentait les deux isoformes de l'ACAT, suggérant que ces enzymes jouent un rôle critique dans le métabolisme du cholestérol intratubulaire. 4) La suppression génétique des transporteurs sélectifs de cholestérol SR-BI et CD36 affecte l'expression (ARNm et protéine) et l'activité des enzymes HMG-CoA réductase, HSL, ACAT-1 et ACAT-2, suggérant l'existence d’un effet compensatoire entre facteurs enzymatiques et non-enzymatiques du métabolisme du cholestérol dans les fractions tubulaires. Ensemble, les résultats de notre étude suggèrent que les enzymes impliquées dans la régulation du cholestérol intratubulaire agissent de concert avec les transporteurs sélectifs de cholestérol dans le but de maintenir l'homéostasie du cholestérol intra-tissulaire du testicule.

Crystallographic and pre-steady-state kinetics studies on binding of NADH to wild-type and isoniazid-resistant enoyl-ACP(CoA) reductase enzymes from Mycobacterium tuberculosis

An understanding of isoniazid (INH) drug resistance mechanism in Mycobacterium tuberculosis should provide significant insight for the development of newer anti-tubercular agents able to control INH-resistant tuberculosis (TB). The inhA-encoded 2-trans enoyl-acyl carrier protein reductase enzyme (InhA) has been shown through biochemical and genetic studies to be the primary target for INH. In agreement with these results, mutations in the inhA structural gene have been found in INH-resistant clinical isolates of M. tuberculosis, the causative agent of TB. In addition, the InhA mutants were shown to have higher dissociation constant values for NADH and lower values for the apparent first-order rate constant for INH inactivation as compared to wild-type InhA. Here, in trying to identify structural changes between wild-type and INH-resistant InhA enzymes, we have solved the crystal structures of wild-type and of S94A, I47T and I21V InhA proteins in complex with NADH to resolutions of, respectively, 2.3 angstrom, 2.2 angstrom, 2.0 angstrom, and 1.9 angstrom. The more prominent structural differences are located in, and appear to indirectly affect, the dinucleotide binding loop structure. Moreover, studies on pre-steady-state kinetics of NADH binding have been carried out. The results showed that the limiting rate constant values for NADH dissociation from the InhA-NADH binary complexes (k(off)) were eleven, five, and tenfold higher for, respectively, I21V, I47T and S94A INH-resistant mutants of InhA as compared to INH-sensitive wildtype InhA. Accordingly, these results are proposed to be able to account for the reduction in affinity for NADH for the INH-resistant InhA enzymes. (c) 2006 Elsevier Ltd. All rights reserved.

Crystallographic studies on the binding of isonicotinyl-NAD adduct to wild-type and isoniazid resistant 2-trans-enoyl-ACP (CoA) reductase from Mycobacterium tuberculosis

The resumption of tuberculosis led to an increased need to understand the molecular mechanisms of drug action and drug resistance, which should provide significant insight into the development of newer compounds. Isoniazid (INH), the most prescribed drug to treat TB, inhibits an NADH-dependent enoyl-acyl carrier protein reductase (InhA) that provides precursors of mycolic acids, which are components of the mycobacterial cell wall. InhA is the major target of the mode of action of isoniazid. INH is a pro-drug that needs activation to form the inhibitory INH-NAD adduct. Missense mutations in the inhA structural gene have been identified in clinical isolates of Mycobacterium tuberculosis resistant to INH. To understand the mechanism of resistance to INH, we have solved the structure of two InhA mutants (121V and S94A), identified in INH-resistant clinical isolates, and compare them to INH-sensitive WT InhA structure in complex with the INH-NAD adduct. We also solved the structure of unliganded INH-resistant S94A protein, which is the first report on apo form of InhA. The salient features of these structures are discussed and should provide structural information to improve our understanding of the mechanism of action of, and resistance to, INH in M. tuberculosis. The unliganded structure of InhA allows identification of conformational changes upon ligand binding and should help structure-based drug design of more potent antimycobacterial agents. (c) 2007 Elsevier B.V. All rights reserved.

The Combination of Interferon-Beta and HMG-CoA Reductase Inhibition in Multiple Sclerosis: Enthusiasm Lost too Soon?

Recent studies support the notion that statins, widely prescribed cholesterol-lowering agents, may target key elements in the immunological cascade leading to inflammation and tissue damage in the pathogenesis of multiple sclerosis (MS). Compelling experimental and observational clinical studies highlighted the possibility that statins may also exert immunomodulatory synergy with approved MS drugs, resulting in several randomized clinical trials testing statins in combination with interferon-beta (IFN-?). Some data, however, suggest that this particular combination may not be clinically beneficial, and might actually have a negative effect on the disease course in some patients with MS. In this regard, a small North American trial indicated that atorvastatin administered in combination with IFN-? may increase disease activity in relapsing-remitting MS. Although other trials did not confirm this finding, the enthusiasm for studies with statins dwindled. This review aims to provide a comprehensive overview of the completed clinical trials and reports of the interim analyses evaluating the combination of IFN-? and statins in MS. Moreover, we try to address the evident question whether usage of this combination routinely requires caution, since the number of IFN-?-treated MS patients receiving statins for lowering of cholesterol is expected to grow.

NMR characterization of altered lignins extracted from tobacco plants down-regulated for lignification enzymes cinnamylalcohol dehydrogenase and cinnamoyl-CoA reductase

Homologous antisense constructs were used to down-regulate tobacco cinnamyl-alcohol dehydrogenase (CAD; EC 1.1.1.195) and cinnamoyl-CoA reductase (CCR; EC 1.2.1.44) activities in the lignin monomer biosynthetic pathway. CCR converts activated cinnamic acids (hydroxycinnamoyl–SCoAs) to cinnamaldehydes; cinnamaldehydes are then reduced to cinnamyl alcohols by CAD. The transformations caused the incorporation of nontraditional components into the extractable tobacco lignins, as evidenced by NMR. Isolated lignin of antisense-CAD tobacco contained fewer coniferyl and sinapyl alcohol-derived units that were compensated for by elevated levels of benzaldehydes and cinnamaldehydes. Products from radical coupling of cinnamaldehydes, particularly sinapaldehyde, which were barely discernible in normal tobacco, were major components of the antisense-CAD tobacco lignin. Lignin content was reduced in antisense-CCR tobacco, which displayed a markedly reduced vigor. That lignin contained fewer coniferyl alcohol-derived units and significant levels of tyramine ferulate. Tyramine ferulate is a sink for the anticipated build-up of feruloyl–SCoA, and may be up-regulated in response to a deficit of coniferyl alcohol. Although it is not yet clear whether the modified lignins are true structural components of the cell wall, the findings provide further indications of the metabolic plasticity of plant lignification. An ability to produce lignin from alternative monomers would open new avenues for manipulation of lignin by genetic biotechnologies.

Ubiquitin-mediated regulation of 3-hydroxy-3-methylglutaryl-CoA reductase

Regulation of the sterol-synthesizing mevalonate pathway occurs in part through feedback-regulated endoplasmic reticulum degradation of 3-hydroxy-3-methylglutaryl-CoA reductase (HMG-R). In yeast, the Hmg2p isozyme of HMG-R is regulated in this manner. We have tested the involvement of ubiquitination in the regulated degradation of Hmg2p, by using both genetic and direct biochemical approaches. Hmg2p degradation required the UBC7 gene, and Hmg2p protein was directly ubiquitinated. Hmg2p ubiquitination was dependent on UBC7 and was specific for the degraded yeast Hmg2p isozyme. Furthermore, Hmg2p ubiquitination was regulated by the mevalonate pathway in a manner consistent with regulation of Hmg2p stability. Thus, regulated ubiquitination appeared to be the mechanism by which Hmg2p stability is controlled in yeast. Finally, our data indicated that the feedback signal controlling Hmg2p ubiquitination and degradation was derived from farnesyl diphosphate, and thus implied conservation of an HMG-R degradation signal between yeast and mammals.

Sequence Determinants for Regulated Degradation of Yeast 3-Hydroxy-3-Methylglutaryl-CoA Reductase, an Integral Endoplasmic Reticulum Membrane Protein

The degradation rate of 3-hydroxy-3-methylglutaryl CoA reductase (HMG-R), a key enzyme of the mevalonate pathway, is regulated through a feedback mechanism by the mevalonate pathway. To discover the intrinsic determinants involved in the regulated degradation of the yeast HMG-R isozyme Hmg2p, we replaced small regions of the Hmg2p transmembrane domain with the corresponding regions from the other, stable yeast HMG-R isozyme Hmg1p. When the first 26 amino acids of Hmg2p were replaced with the same region from Hmg1p, Hmg2p was stabilized. The stability of this mutant was not due to mislocalization, but rather to an inability to be recognized for degradation. When amino acid residues 27–54 of Hmg2p were replaced with those from Hmg1p, the mutant was still degraded, but its degradation rate was poorly regulated. The degradation of this mutant was still dependent on the first 26 amino acid residues and on the function of the HRD genes. These mutants showed altered ubiquitination levels that were well correlated with their degradative phenotypes. Neither determinant was sufficient to impart regulated degradation to Hmg1p. These studies provide evidence that there are sequence determinants in Hmg2p necessary for degradation and optimal regulation, and that independent processes may be involved in Hmg2p degradation and its regulation.