Avaliação da atividade antinociceptiva da talidomida, pentoxifilina e clorpromazina em modelos experimentais

Detalhes bibliográficos
Ano de defesa: 2003
Autor(a) principal: Vale, Mariana Lima
Orientador(a): Ribeiro , Ronaldo de Albuquerque
Banca de defesa: Não Informado pela instituição
Tipo de documento: Tese
Tipo de acesso: Acesso aberto
Idioma: por
Instituição de defesa: Não Informado pela instituição
Programa de Pós-Graduação: Não Informado pela instituição
Departamento: Não Informado pela instituição
País: Não Informado pela instituição
Palavras-chave em Português:
Link de acesso: http://www.repositorio.ufc.br/handle/riufc/3724
Resumo: The release of cyclo-oxygenase products and sympathomimetic amines, the final mediators of inflammatory pain, is preceded by the generation of pro-inflammatory and nociceptive cytokines by resident cells. Recently drugs such as thalidomide (TALD), pentoxifylline (PTX) and chlorpromazine (CLP), despite of other effects, have been associated with immunomodulatory activity in clinical practice mainly for their modulatory properties upon cytokine production. Since those drugs are able to inhibit the production of pro-inflammatory cytokines and the pivotal role of resident cells in the development of inflammatory pain we have decided to test the possibility of TALD, PTX and CLP, to modulate inflammatory pain. TALD (5 – 45mg/kg), PTX (0.5 – 45mg/kg) or CLP (0.1 – 1mg/kgl) was given 30 min before either acetic acid (AAc) or zymosan (Zym) or iloprost (ILO) administration in the writhing model. TALD, PTX or CLP, at the same doses were injected, i.p., 30 min before Zym (1 mg/animal; intra-articular) in the zymosan-induced rat knee joint incapacitation test (JI). Those drugs were also tested upon hyperalgesic effect of carrageenin (Cg), bradykinin (Bk), tumor necrosis factor (TNF), interleukin (IL) -1 and prostaglandin E2 (PGE2) on mechanical hyperalgesia test (HYP). Doses of those drugs that exerted maximum effect in the writhing test were also injected 30 min before the hot plate test. These same doses were injected ip before naloxone administration in the AAc-induced writhing model in mice. Cytokines levels (TNF, IL-1, IL-10 and IL-4) were determined in the supernatant of a macrophage culture, which were collected from peritoneal fluid of mice treated with Zym and pre-treated with the drugs under test and in the supernatant of articular fluid of rats pre-treated with the drugs and stimulated with Zym (TNF, IL-1 beta, IL-10, IL-6 and CINC-1). Our results showed that TALD, PTX and CLP inhibited the writhing response in mice induced by AAc or Zym up to 60.3, 89.8 e 89%, and up to 85.6, 82.9 and 63.7% respectively (p<0.001), but not the nociceptive response to ILO. Similar results were observed in the JI induced by Zym: 75, 89 e 99% of inhibition, respectively (p<0.01). TALD inhibited hyperalgesic effect of Cg (78.6%) and Bk (82.4%), but not the hyperalgesic effect of TNF or PGE2. PTX inhibited Cg, TNF or Bk-induced HYP in 73.3, 55.2 and 45.6% of inhibition respectively, but not IL-1 or PGE2 hyperalgesic activity. CLP inhibited a hyperalgesic effect of all stimuli in different levels (68.16, 58.5, 42, 38.8 and 21.1% of inhibition for Cg, Bk, TNF, IL-1 e PGE2, respectively). The antinociceptive activity of TALD, PTX and CLP seems to be peripheral, since these drugs presented no effect in the reaction time of the animals on hot plate test. This antinociceptive effect seems to have no relation with endogen opioid release since naloxone (opioid receptor antagonist) had no effect in reverting the antinociceptive effect of these drugs in the Zym-induced writhing in mice. The antinociceptive activities seems to be dependent of the release inhibition of pro-nociceptive cytokines by resident cells since TALD, PTX and CLP inhibited the release of TNF (100, 85 e 54.4%, respectively - p<0.005) and of IL-1 (97%, PTX effect - p<0,01) by mice peritoneal resident cells as well as the production of both TNF (77 e 87.5% by TALD and PTX respectively) and IL-1 (47 e 32.6% by PTX and CLP, respectively) in the articular cavity of ZYM stimulates rats.
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spelling Vale, Mariana LimaRibeiro , Ronaldo de Albuquerque2012-09-05T11:31:47Z2012-09-05T11:31:47Z2003VALE, M. L. Avaliação da atividade antinociceptiva da talidomida, pentoxifilina e clorpromazina em modelos experimentais. 2003. 196 f. Tese (Doutorado em Farmacologia) - Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, 2003.http://www.repositorio.ufc.br/handle/riufc/3724The release of cyclo-oxygenase products and sympathomimetic amines, the final mediators of inflammatory pain, is preceded by the generation of pro-inflammatory and nociceptive cytokines by resident cells. Recently drugs such as thalidomide (TALD), pentoxifylline (PTX) and chlorpromazine (CLP), despite of other effects, have been associated with immunomodulatory activity in clinical practice mainly for their modulatory properties upon cytokine production. Since those drugs are able to inhibit the production of pro-inflammatory cytokines and the pivotal role of resident cells in the development of inflammatory pain we have decided to test the possibility of TALD, PTX and CLP, to modulate inflammatory pain. TALD (5 – 45mg/kg), PTX (0.5 – 45mg/kg) or CLP (0.1 – 1mg/kgl) was given 30 min before either acetic acid (AAc) or zymosan (Zym) or iloprost (ILO) administration in the writhing model. TALD, PTX or CLP, at the same doses were injected, i.p., 30 min before Zym (1 mg/animal; intra-articular) in the zymosan-induced rat knee joint incapacitation test (JI). Those drugs were also tested upon hyperalgesic effect of carrageenin (Cg), bradykinin (Bk), tumor necrosis factor (TNF), interleukin (IL) -1 and prostaglandin E2 (PGE2) on mechanical hyperalgesia test (HYP). Doses of those drugs that exerted maximum effect in the writhing test were also injected 30 min before the hot plate test. These same doses were injected ip before naloxone administration in the AAc-induced writhing model in mice. Cytokines levels (TNF, IL-1, IL-10 and IL-4) were determined in the supernatant of a macrophage culture, which were collected from peritoneal fluid of mice treated with Zym and pre-treated with the drugs under test and in the supernatant of articular fluid of rats pre-treated with the drugs and stimulated with Zym (TNF, IL-1 beta, IL-10, IL-6 and CINC-1). Our results showed that TALD, PTX and CLP inhibited the writhing response in mice induced by AAc or Zym up to 60.3, 89.8 e 89%, and up to 85.6, 82.9 and 63.7% respectively (p<0.001), but not the nociceptive response to ILO. Similar results were observed in the JI induced by Zym: 75, 89 e 99% of inhibition, respectively (p<0.01). TALD inhibited hyperalgesic effect of Cg (78.6%) and Bk (82.4%), but not the hyperalgesic effect of TNF or PGE2. PTX inhibited Cg, TNF or Bk-induced HYP in 73.3, 55.2 and 45.6% of inhibition respectively, but not IL-1 or PGE2 hyperalgesic activity. CLP inhibited a hyperalgesic effect of all stimuli in different levels (68.16, 58.5, 42, 38.8 and 21.1% of inhibition for Cg, Bk, TNF, IL-1 e PGE2, respectively). The antinociceptive activity of TALD, PTX and CLP seems to be peripheral, since these drugs presented no effect in the reaction time of the animals on hot plate test. This antinociceptive effect seems to have no relation with endogen opioid release since naloxone (opioid receptor antagonist) had no effect in reverting the antinociceptive effect of these drugs in the Zym-induced writhing in mice. The antinociceptive activities seems to be dependent of the release inhibition of pro-nociceptive cytokines by resident cells since TALD, PTX and CLP inhibited the release of TNF (100, 85 e 54.4%, respectively - p<0.005) and of IL-1 (97%, PTX effect - p<0,01) by mice peritoneal resident cells as well as the production of both TNF (77 e 87.5% by TALD and PTX respectively) and IL-1 (47 e 32.6% by PTX and CLP, respectively) in the articular cavity of ZYM stimulates rats.Já está estabelecido que a liberação de produtos da ciclooxigenase e aminas simpatomiméticas, medidores finais da hiperalgesia inflamatória é precedido pela geração de uma cascata de citocinas pró-inflamatórias e nociceptivas. Dados anteriores demonstraram que a ativação desta cascata de citocinas é dependente também da presença de células residentes como macrófagos e mastócitos no local da injúria. Talidomida (TALD), pentoxifilina (PTX) e clorpromazina (CLP) são drogas que dentre outras funções são descritas como imunomoduladoras por modularem a produção de algumas citocinas e vem chamando atenção pelas suas propriedades antiinflamatórias na prática clínica e em modelos experimentais. Com base nesses achados, o objetivo do presente trabalho foi estudar uma possível atividade antinociceptiva de TALD, PTX e CLP correlacionando à essa atividade imunomodulatória. Para tanto injetou-se por via i.p. talidomida (TALD; 5-45 mg;kg), pentoxifilina (PTX; 0.5 – 45 mgkg) ou clorpromazina (CLP; 0.1 – 1 mgkg) 30 min antes da administração de ácido acético (AAc), zymosan (Zym) ou iloprost (ILO) para o teste de contorções abdominais em camundongos (CA), ou 30 min antes do Zym intrarticular no teste da incapacitação articular (IA) em joelho de rato (teste de nocicepção articular). TALD, PTX e CLP também foram testadas em diferentes doses por via sistêmica (i.p.) ou local (intraplantar) no teste da hiperalgesia (HYP) mecânica induzida por carragenina (Cg), bradicinina (Bk), fator de necrose tumoral (TNF), interleucina-1 (IL-1) ou prostaglandina E2 (PGE2) e no teste da placa quente (PQ). TALD, PTX ou CLP também foi injetada em camundongos 30 min antes do zymosan e após 15 min foi feita a coleta do fluido peritoneal contendo células residentes onde o mesmo foi posto bem cultura para avaliar a produção de citocinas por essas células. O fluido articular de ratos tratados com TALD, PTX ou CLP e estimulados com Zym intrarticular também foi analisado no mesmo sentido. Nossos resultados demonstram que TALD, PTX e CLP são antinociceptivas tanto no modelo de CA induzidas por zymosan (85.6, 82.9 e 63.7% de inibição, respectivamente, p<0.001) ou AAc (60.3, 89.8 e 89% de inibição, efeito máximo respectivamente, p<0.001), como também a IA induzida por Zym (75, 89 e 99% de inibição, respectivamente, p<0.001), mas não nas CA induzidas por ILO . TALD foi capaz de inibir o efeito hiperalgésico da Cg (78.6%) e Bk (82.4%), mas não o de TNF e PGE2. PTX inibiu a HYP induzida por Cg (73.3%), Bk (55.2%), TNF (45.6%), mas não a por IL-1 ou PGE2. CLP inibiu a HYP induzida por todos os estímulos, mas em graus diferentes (68.16, 58.5, 42, 38.8 e 21.1%de inibição respectivamente para Cg, Bk, TNF, IL-1 e PGE2). Estes efeitos antinociceptivos parecem ser de domínio periférico visto que as drogas não modificaram o tempo de reação na PQ e não dependem da liberação de opióides endógenos, pois naloxona não reverteu a atividade antinociceptiva das drogas. Contudo a atividade antinociceptiva parece depender da inibição da liberação de citocinas pró-nociceptivas por células residentes visto que TALD, PTX e CLP inibiram a liberação de TNF (100, 85 e 54.4% de inibição respectivamente p< 0.001) e IL-1 (97% de inibição para PTX) por células peritoneais residentes de camundongos como também a produção de TNF (77 e 87.5%de inibição respectivamente para TALD e PTX) e IL-1 (47 e 32.6% de inibição respectivamente para PTX e CLP) na cavidade articular de ratos estimulados com Zym.TalidomidaPentoxifilinaClorpromazinaAvaliação da atividade antinociceptiva da talidomida, pentoxifilina e clorpromazina em modelos experimentaisStudy of the Antinociceptive activity of Thalidomide, Pentoxifillyne and Chlorpromazine in Experimental Modelsinfo:eu-repo/semantics/publishedVersioninfo:eu-repo/semantics/doctoralThesisporreponame:Repositório Institucional da Universidade Federal do Ceará (UFC)instname:Universidade Federal do Ceará (UFC)instacron:UFCinfo:eu-repo/semantics/openAccessLICENSElicense.txtlicense.txttext/plain; charset=utf-81748http://repositorio.ufc.br/bitstream/riufc/3724/2/license.txt8a4605be74aa9ea9d79846c1fba20a33MD52ORIGINAL2003_tese_mlvale.pdf2003_tese_mlvale.pdfapplication/pdf3516079http://repositorio.ufc.br/bitstream/riufc/3724/1/2003_tese_mlvale.pdfa5ef75c5be774086c5fdacd0ab55ee0aMD51riufc/37242019-10-25 15:32:57.658oai:repositorio.ufc.br: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Repositório InstitucionalPUBhttp://www.repositorio.ufc.br/ri-oai/requestbu@ufc.br || repositorio@ufc.bropendoar:2019-10-25T18:32:57Repositório Institucional da Universidade Federal do Ceará (UFC) - Universidade Federal do Ceará (UFC)false
dc.title.pt_BR.fl_str_mv Avaliação da atividade antinociceptiva da talidomida, pentoxifilina e clorpromazina em modelos experimentais
dc.title.en.pt_BR.fl_str_mv Study of the Antinociceptive activity of Thalidomide, Pentoxifillyne and Chlorpromazine in Experimental Models
title Avaliação da atividade antinociceptiva da talidomida, pentoxifilina e clorpromazina em modelos experimentais
spellingShingle Avaliação da atividade antinociceptiva da talidomida, pentoxifilina e clorpromazina em modelos experimentais
Vale, Mariana Lima
Talidomida
Pentoxifilina
Clorpromazina
title_short Avaliação da atividade antinociceptiva da talidomida, pentoxifilina e clorpromazina em modelos experimentais
title_full Avaliação da atividade antinociceptiva da talidomida, pentoxifilina e clorpromazina em modelos experimentais
title_fullStr Avaliação da atividade antinociceptiva da talidomida, pentoxifilina e clorpromazina em modelos experimentais
title_full_unstemmed Avaliação da atividade antinociceptiva da talidomida, pentoxifilina e clorpromazina em modelos experimentais
title_sort Avaliação da atividade antinociceptiva da talidomida, pentoxifilina e clorpromazina em modelos experimentais
author Vale, Mariana Lima
author_facet Vale, Mariana Lima
author_role author
dc.contributor.author.fl_str_mv Vale, Mariana Lima
dc.contributor.advisor1.fl_str_mv Ribeiro , Ronaldo de Albuquerque
contributor_str_mv Ribeiro , Ronaldo de Albuquerque
dc.subject.por.fl_str_mv Talidomida
Pentoxifilina
Clorpromazina
topic Talidomida
Pentoxifilina
Clorpromazina
description The release of cyclo-oxygenase products and sympathomimetic amines, the final mediators of inflammatory pain, is preceded by the generation of pro-inflammatory and nociceptive cytokines by resident cells. Recently drugs such as thalidomide (TALD), pentoxifylline (PTX) and chlorpromazine (CLP), despite of other effects, have been associated with immunomodulatory activity in clinical practice mainly for their modulatory properties upon cytokine production. Since those drugs are able to inhibit the production of pro-inflammatory cytokines and the pivotal role of resident cells in the development of inflammatory pain we have decided to test the possibility of TALD, PTX and CLP, to modulate inflammatory pain. TALD (5 – 45mg/kg), PTX (0.5 – 45mg/kg) or CLP (0.1 – 1mg/kgl) was given 30 min before either acetic acid (AAc) or zymosan (Zym) or iloprost (ILO) administration in the writhing model. TALD, PTX or CLP, at the same doses were injected, i.p., 30 min before Zym (1 mg/animal; intra-articular) in the zymosan-induced rat knee joint incapacitation test (JI). Those drugs were also tested upon hyperalgesic effect of carrageenin (Cg), bradykinin (Bk), tumor necrosis factor (TNF), interleukin (IL) -1 and prostaglandin E2 (PGE2) on mechanical hyperalgesia test (HYP). Doses of those drugs that exerted maximum effect in the writhing test were also injected 30 min before the hot plate test. These same doses were injected ip before naloxone administration in the AAc-induced writhing model in mice. Cytokines levels (TNF, IL-1, IL-10 and IL-4) were determined in the supernatant of a macrophage culture, which were collected from peritoneal fluid of mice treated with Zym and pre-treated with the drugs under test and in the supernatant of articular fluid of rats pre-treated with the drugs and stimulated with Zym (TNF, IL-1 beta, IL-10, IL-6 and CINC-1). Our results showed that TALD, PTX and CLP inhibited the writhing response in mice induced by AAc or Zym up to 60.3, 89.8 e 89%, and up to 85.6, 82.9 and 63.7% respectively (p<0.001), but not the nociceptive response to ILO. Similar results were observed in the JI induced by Zym: 75, 89 e 99% of inhibition, respectively (p<0.01). TALD inhibited hyperalgesic effect of Cg (78.6%) and Bk (82.4%), but not the hyperalgesic effect of TNF or PGE2. PTX inhibited Cg, TNF or Bk-induced HYP in 73.3, 55.2 and 45.6% of inhibition respectively, but not IL-1 or PGE2 hyperalgesic activity. CLP inhibited a hyperalgesic effect of all stimuli in different levels (68.16, 58.5, 42, 38.8 and 21.1% of inhibition for Cg, Bk, TNF, IL-1 e PGE2, respectively). The antinociceptive activity of TALD, PTX and CLP seems to be peripheral, since these drugs presented no effect in the reaction time of the animals on hot plate test. This antinociceptive effect seems to have no relation with endogen opioid release since naloxone (opioid receptor antagonist) had no effect in reverting the antinociceptive effect of these drugs in the Zym-induced writhing in mice. The antinociceptive activities seems to be dependent of the release inhibition of pro-nociceptive cytokines by resident cells since TALD, PTX and CLP inhibited the release of TNF (100, 85 e 54.4%, respectively - p<0.005) and of IL-1 (97%, PTX effect - p<0,01) by mice peritoneal resident cells as well as the production of both TNF (77 e 87.5% by TALD and PTX respectively) and IL-1 (47 e 32.6% by PTX and CLP, respectively) in the articular cavity of ZYM stimulates rats.
publishDate 2003
dc.date.issued.fl_str_mv 2003
dc.date.accessioned.fl_str_mv 2012-09-05T11:31:47Z
dc.date.available.fl_str_mv 2012-09-05T11:31:47Z
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dc.identifier.citation.fl_str_mv VALE, M. L. Avaliação da atividade antinociceptiva da talidomida, pentoxifilina e clorpromazina em modelos experimentais. 2003. 196 f. Tese (Doutorado em Farmacologia) - Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, 2003.
dc.identifier.uri.fl_str_mv http://www.repositorio.ufc.br/handle/riufc/3724
identifier_str_mv VALE, M. L. Avaliação da atividade antinociceptiva da talidomida, pentoxifilina e clorpromazina em modelos experimentais. 2003. 196 f. Tese (Doutorado em Farmacologia) - Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, 2003.
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