1

STEROID HORMONES: ADRENOCORTICOIDS

(ADRENAL STEROIDS)
The adrenal gland is a cap-like organ sitting at the upper pole of the
kidney. Histologically, the gland consists of the inner adrenal
medulla and the outer adrenal cortex (shell). In accord with this
histological differentiation, there are two endocrine organs within
the adrenal gland, one surrounding the other. The inner adrenal
medulla secretes the catecholamines: epinephrine and
norepinephrine. The outer adrenal cortex secretes corticosteroid
hormones: glucocorticoids and mineralocorticoids.
2
The adrenal cortex is divided into three zones:

zona glomerulosa (outer),
zona fasciculata (middle), and
zona reticularis (inner).

Although these three zones are variable in their anatomical
distinctness, they are definite in their biochemical
distinctness. All three cortical zones secrete corticosterone:
the zona glomerulosa biosynthesizes aldosterone; the zona
fasciculate and zona reticularis biosynthesize cortisol (and
sex hormones as well).
3
Like most endocrine glands, the adrenal cortex is regulated by
hypothalamo-pituitary peptides. The hypothalamus secretes
corticotropin releasing factor (CRF), which controls the release of
adrenocorticotropin (ACTH), a peptide consisting of 39 amino
acids. Corticotropin secretion is under feedback regulation by the
adrenal steroids, as well as being under the control of higher CNS
centers; stress or epinephrine can also increase corticosteroid
production. Adrenocortical secretion is controlled primarily by
ACTH from the anterior pituitary, but mineralocorticoid secretion
is also subject to independent control by circulating factors, of
which the most important is angiotensin II.
4
On the basis of biochemical effects, the two groups of
corticosteroids can be readily distinguished:

1. Glucocorticoids, which act on carbohydrate, fat,
and protein metabolism
2. Mineralocorticoids, which regulate electrolyte
balance through Na
+
retention

Since these two classes of corticosteroids are both
important in medicinal chemistry and drug design,
5
STEROID HORMONES:
ADRENOCORTICOIDSGLUCOCORTICOIDS


Glucocorticoids have important metabolic effects on carbohydrates,
proteins, and lipids; they stimulate phosphoenolpyruvate carboxykinase,
glucose-6-phosphatase, and glycogen synthase. Glucocorticoids
promote gluconeogenesis by increasing the pyruvate carboxylase
concentration, and thus increase the concentration of oxaloacetate in the
mitochondrial pathway of pyruvatephosphoenolpyruvate synthesis.


6
Glucocorticoid Receptor

The glucocorticoid receptor protein belongs to a superfamily of nuclear
receptor proteins that includes steroid, Vitamin D, thyroid, retinoic acid, and
other receptors that interact with promoters that regulate the transcription of
target genes. Although the glucocorticoid receptor differs from the estrogen
or progesterone receptors, the basic principles of its action seem to be the
same. The glucocorticoid receptor is 800 amino acids in length and has three
functional domains: the C-terminal has the glucocorticoid binding region, the
middle portion has the DNA binding region (containing nine cysteine residues
folded into a two finger structure stabilized by Zn
2+
ions), and the N-
terminal, which has the receptor-specific region. A gene for the classic
glucocorticoid receptor has been identified. Binding to the glucocorticoid
receptor is somewhatdependent on temperature, being optimal at 37C.
7
Glucocorticoids: StructureActivity Correlations

The structureactivity relationships of glucocorticoids are based on two
natural hormones, cortisol (15.1) and corticosterone (15.2). The
characteristic structural features of these hormones are the conjugated 3-
ketone, the 11-OH group, and the l7 beta-ketol side chain. Molecular
modifications have been aimed at deriving compounds with glucocorticoid
(and anti-inflammatory) actions but lacking in mineralocorticoid effects and
side effects. Substituents added to the cortisol molecule may alter
bioactivity and receptor binding affinity independently of other functional
groups present on the molecule.
Cortisol (15.1)
O
OH
H
H
H
OH
HO
O
Corticosteron (15.2)
O
H
H
H
OH
HO
O
8
1. Halogenation. 9 lfa-Fluorocortisone is only about 10 times more active
than its parent compound, but its mineralocorticoid activity is 300600 times
greater. This is undesirable since it leads to edema; thus, the compound
fludrocortisone (15.3) is used only topically, in ointments.
2. Additional double bonds. 1-compounds (where .1 indicates the position of a
double bond) were introduced, like prednisone (15.4), a .1-11-ketone, and
prednisolone, its 11-hydroxy analogue. Changing the geometry of the A ring
increased the potency without augmenting mineralocorticoid activity.
Fluorocortison (15.3)
O
OH
H
H
F
OH
HO
O
Prednison (15.4)
O
OH
H
H
H
OH
O
O
9
The introduction of a methyl group in methylprednisolone (15.5) resulted
in a slight increase in activity; however, the greatest improvements in
activity came from the combination of a double bond, halogen, and
methyl substituents. Triamcinolone (15.6), in the form of its acetomide (an
acetone ketal), shows a 9-fluoro group in addition to .1 unsaturation,
and a 16-OH. It is used in treating psoriasis and other dermatological
problems.
Methylprednison (15.5)
O
OH
H
H
H
OH
HO
O
Triamcinolon (15.6)
O
OH
H
H
F
OH
HO
O
OH
10
Dexamethasone (15.7), perhaps the most active and highly stable
glucocorticoid, is the 16lfa-methyl analog of triamcinolone. It is interesting to
note that progesterone binds well to the glucocorticoid receptor despite a
missing 11-oxygen functional group, but it fails to elicit gene activation in
glucocorticoid target cells, thus shedding light on the role of the 11-OH group.
The optimum glucocorticoid structure shows a 1lfa, 2bet-half-chair
conformation for ring A, with ring D as a 13-envelope (C-13 is bent up) or a
half-chair. Halogenation is most effective in positions 6, 7, 9, and 12. The
compounds bind on their face by hydrophobic binding forces.
Dexamethason (15.7)
O
OH
H
H
H
OH
HO
O
11
5.12.3 Glucocorticoids: Pharmacological Activity

The most important clinical application of glucocorticoids and their semisynthetic
analogs is their anti-inflammatory activity, discovered in 1949 by Hench and co-
workers. The profound anti-inflammatory effects of glucocorticoids arise from the
combined effects of these steroids on both the cellular and molecular mediators
of inflammation; these effects are separate from the metabolic effects described
above and further indication of the widespread diversity of macromolecules to
which steroids can bind. Glucocorticoids suppress inflammation at the cellular
level by downregulating the concentration, distribution, and function of
leukocytes (white blood cells) that profoundly influence inflammation and
response to infection within the body (In this way, steroids help to mediate the
overlap between the endocrine systems [chapter 5] and the immune systems
[chapter 6]). Glucocorticoids also suppress inflammation at the molecule level by
suppressing inflammatory cytokines, chemokines, and other molecular mediators
of inflammation.
12
Glucocorticoids: Inflammation versus Infection


The use of anti-inflammatory steroids also demands an appreciation
of the differences between the processes of infection and
inflammation. An infection is a pathological process whereby an
exogenous agent (fungus, bacterium, virus, prion) invades the body,
either locally or systemically, causing some form of injurious
dysfunction. Inflammation, on the other hand, is the bodys
physiological endogenous response to an injury, be it caused by an
infective agent or some other process (trauma, chemical). Although
inflammation is a normal physiological response, it may become
pathological under certain circumstances; for example, inflammation
of the bronchi in the lungs due to inhalation of a toxic chemical may
cause so much swelling in the bronchial lining that the flow of air into
the lung is blocked, resulting in a pathological state.
13
Infections are usually accompanied by inflammation. The reddened
area around a skin abscess reflects the bodys inflammatory response
to the infection. If one puts topical steroids on such an infection, the
redness disappears, reflecting suppression of the inflammation and
giving the erroneous impression that the infection has been
successfully treated; in truth, the infection is now spreading much more
aggressively since the bodys inflammatory defense system has been
suppressed. Nevertheless, sometimes it is necessary to cautiously use
anti-inflammatory steroids in the presence of an infection. For
example, pneumonia may be associated with a dangerous
inflammation of the airways, causing decreased air entry into the
lungs. Under such circumstances, the combined use of an anti-
inflammatory steroid with the appropriate antibiotic is justified.
14
STEROID HORMONES:
ADRENOCORTICOIDSMINERALOCORTICOIDS

Mineralocorticoids such as the natural hormone aldosterone (5.66)
regulate electrolyte concentration by stimulating Na
+
retention in kidney
cells. 11-Desoxycorticosterone (5.67) and fludrocortisone (5.62) are
much less active, but are used for maintaining electrolyte balance in
adrenal insufficiency. Aldosterone synthesis is probably regulated by
ACTH and angiotensin, a peptide hormone. This hormone has its own
receptors in kidney cells. Hyperaldosteronism can play a role in high
blood pressure.
Aldosterone (15.8)
O
H
H
H
OH
HO
O
O
11-Deoxycorticosteron (15.9)
O
H
H
H
OH
O
15
Spironolacton (15.10)
O
H
H
H
O
O
S
O
Aldosterone antagonists such as spironolactone (15.10) are
therefore useful as hypotensive diuretic agents, because the
increase in Na
+
excretion that they promote is always paralleled by
an increased urine volume.
16
Structurally, aldosterone differs from glucocorticoids in having an 18-
aldehyde group and lacking the 17-OH. The aldehyde participates in
a tautomeric equilibrium, forming a cyclic hemiacetal ring.
Spironolactone, a synthetic compound and antiandrogen, has a
lactone ring attached to C-17 through one common carbon (a spiro
compound) and the 7-thiolester group. The structure of the
mineralocorticoid receptor has been deduced through cloning of its
cDNA. It shows considerable structural and functional similarity to the
glucocorticoid receptor.
17
The most important pharmacological action of glucorticoids
and their semisynthetic analogues is their

a. antiinflammatory
b. and antirheumatic activity, discovered in 1949 by
Hench and co-workers.


18
Relative glucocorticoid and mineralocorticoid activity of some corticoid
derivatives
Relative glucocorticoid
potency
Relative meneralocorticoid
activity
Cortisol 1 1
Fluorocortison 10 300
Prednison 3 0,8
Methylprednisolone 5 0
Triamcinolone 6 0
Dexamethason 30 0
11-deoxycorticosterone 0 30
Aldosteron 0,2 600
19
Although the mode of action of glucocorticoids is unknown,
there are certain indications that:

a. they interfere with prostaglandin and collagenase
synthesis,
b. and the circulatory distribution of leukocytes in
inflamed tissue,
c. as well as inhibiting edema by decreasing capillary
permeablity.


20
These steroids are also effective:

a. in some allergic diseases, such as
bronchial asthma
b. and in urticaria
c. and other types of dermatitis.
21
LIPIDS AS DRUGS AND DRUG DESIGN TARGETS

In 1934, von Euler in Sweden discovered a group of polyunsaturated
fatty acids that had a powerful effect on smooth muscle and blood
pressure. They were isolated from seminal fluid and the prostate, and
were named prostaglandins. Their structure was elucidated by the
Samuelsson group in Stockholm, who, in 1975, also discovered even
more potent fatty acid metabolites, the thromboxanes and prostacyclin.
The effect of these compounds on blood platelet aggregation and the
contraction of blood vessels connected them to the etiology of stroke
and cardiovascular disease. Additionally, it was discovered that both
steroidal and nonsteroidal anti-inflammatory agents act through the
prostaglandin system, adding further impetus to the research in this
area. Consequently, the field of bioactive lipids became a center of
intense interest.
22
As the research area expanded, the leukotrienes were
discovered next. The leukotrienesare potent lipid mediators
associated with asthma and allergic reactions. In contrast
to prostaglandins, leukotrienes are made predominantly in
inflammatory cells, like leukocytes, macrophages, and mast
cells. Prostaglandins, thromboxane, and the leukotrienes
are lipids that are collectively called eicosanoids, since they
are all derived from the C20 fatty acid, arachidonic acid
[eicosa (Gr.) = twenty]. Over the past twenty years, the
eicosanoids have emerged as important molecules around
which to target drug design and development.
23
Prostaglandins A, PGB, PGC are inactive degradation products.
O
PGA
O
PGB
O
PGC
OH
PGD
O
O
PGE
HO
24
Pharmacological effects of prostaglandins and thromboxane
Blood vessels
Bronchi
Protaglandin E2 Dilatation Dilatation Oxytocic
Prostagcyclin ( PGI2) Dilatation Agregation ihb
Prostaglandin E2 Contriction Contriction Oxytocic
Thromboxane (TXA2) Contriction Agregation
Compouns Platelet
Uterus
25
Prostaglandins, prostacyclin, and thromboxane are
considered local hormones or autocoid,
synthesized in many different organs and acting
locally. They are not stored like neurotransmitters
or conventional hormones, but are continuously
synthesized and released immediately into the
circulation, where they are usually deactivated after
only one passage through the lungs. The synthesis
depends on the availability of the starting material,
arachidonic acid, and is modulated by c AMP.
26
3. The oxytocic activity of prostaglandin is used
clinically. Prostaglandin E2 can indude labor at term
in pregnant women, while PGF2 and its ester is
probably due to a direct effect on uterine muscle.

4. Other effects of the prostaglandins include
bronchodilation by the PGE series and constriction
by PGF2, as well as anti-ulcer and antisecretory
effects of some synthetic analogues in the stomach.
27
The following effects of prostaglandins
1. Vasodilation and constriction: PGE2 and especially PGI2
(prostagcyclin) are powerful, short-acting vasodilators,
probably involved in blood-pressure regulation.
Prostaglandin F2 and TXA2. on the other hand, are potent
vasoconstrictors.
2. Blood-phlatelet aggregation is an all-important mechanism
in normal blood-clot (thrombus ) formation, and therefore
also highly significant in the pathophysiology of
cardiovascular disease, stroke, coronary occlusion, and
other circulatory catastrophes.
28
E. Antiinflammatory Agents and Minor Analgesic
Antiinflammatory agents are believed to act by distrupting the
arachidonic-acid cascade. These drugs are widely used for the
treatment of minor pain and also for the management of
edema and the tissue damage resulting from arthritis.

The adrenal steroids (corticosteroids) probably act by
blocking phospholipase A
2
. the enzyme that liberates
arachidonic acid from phospholipids. These steroid also
inhibit collagenase, an enzyme responsible for damage to the
cartilaginous tissue in joints affected by arthritic diseases.


29
8.5.1 Prostaglandins and Thromboxanes

8.5.1.1 Prostaglandins: Structure and Biosynthesis
The biosynthesis of prostaglandins and thromboxanes starts from
arachidonic acid. Arachidonic acid, obtained from its phospholipid
form by the action of phospholipase A, is cyclized to prostaglandin
endoperoxide (15.11) in the form of PGG (a side-chain peroxide), from
which PGH2 (a side-chain hydroxyl) is obtained. Interleukin-1, a
cytokine produced by leukocytes and possessing multiple
immunological roles, mediates inflammation by increasing
phospholipase activity and thus prostaglandin synthesis. The first
reaction in prostaglandin biosynthesis is catalyzed by PG
cyclooxygenase in the presence of O2 and heme. The second
reaction requires tryptophan, probably as a source of electrons.
30
CO
2
H
O
O
Prostaglandine Endoperoxide (15.11)
OH
31
Structure of prostaglandin and thromboxanes
CO
2
H
O
HO
OH
PGE
1
CO
2
H
O
HO
OH
PGE
2
1
2
4
7
10
13
20
32
CO
2
H
Arachidonic acid
Phospholipase
Phospholipid
C
Phospholipid-esterified
arachidonic acid
O
CH
CH
2
OCO(CH
2
)
n
CH
3
CH
2
OPOR
O
O
33
CO
2
H
Arachidonic acid
Phospholipase
Phospholipid
Corticosteroids
34
The non steroidal antiinflammatory agents block the cyclooxygenase
that converts arachidonic acid to PGG2 and PGH2. Since the cyclic
endoperoxidides are the prcursors of all prostaglandins, the synthesis
of the latter is interupted.
CO
2
H
Arachidonic acid(AA)
CO
2
H O
O
Non steroidal antiinflammatory agents
AA cyclooxygenase
2 O
2
Prostaglandin endoperoxida
O[O]H
35
Leukotrienes,- which have been called slow-
reacting substance (SRS) -are compounds
intimately involved in anaphylactic reaction, allergic
reactions, and asthma. Like the prostaglandins,
thye are lipids, formed from arachidonic acid by
lipoxygenase and glutathione. Their structure and
biosynthesis were also elucidated by the
Samuelsson group (Samuelsson, 1980), and are
shown in Fiq.
36
CO
2
H
CO
2
H
OOH H
C
5
H
11
O
CO
2
H
Arachidonic acid(AA)
Lipoxygenase
5-HPETE
Leukotriene A (LTA)
37
Anti-Prostaglandins as Anti-Inflammatory
Agents and Minor Analgesics

Anti-inflammatory agents are believed to act by disrupting the
arachidonic acid cascade. These drugs are widely used for the
treatment of minor pain and arthritis. Some of them are antipyretics
(drugs that reduce fever) in addition to having analgesic and
antiinflammatory actions. Some of these agents are widely available in
over-the-counter (OTC) preparations. Collectively, these are referred to
as nonsteroidal anti-inflammatory drugs (NSAIDs). They may be
classified as follows:
38
1) NSAIDs: Non-selective cyclo-oxygenase inhibitors

a. Arylanthranilic acids (mefenamic acid, meclofenamate)
b. Arylbutyric acids (nabumetone)
c. Arylpropionic acids (ibuprofen, ketoprofen, fenoprofen, naproxen,
ketorolac)
d. Indene derivatives (sulindac)
e. Indole derivatives (indomethacin)
f. Naphthylacetic acid derivatives (nabumetone)
g. Oxicams (piroxicam, meloxicam, tenoxicam)
h. Phenylacetic acid derivatives (diclofenac)
i. Phenylalkanoic acid derivatives (flurbiprofen)
j. Pyrazolone derivatives (phenylbutazone, azapropazone)
k. Pyrrolealkanoic acid derivatives (tolmetin)
l. Salicylate derivatives (aspirin, diflunisal)

2) NSAID: Selective COX-2 inhibitors
a. Coxibs (celecoxib, rofecoxib)



39
The nonsteroidal anti-inflammatory agents block the
cyclooxygenase enzyme that catalyzes the
conversion of arachidonic acid to the prostaglandins
PGG2 and PGH2. Since these two cyclic
endoperoxides are the precursors of all other
prostaglandins, the implications of cyclooxygenase
inhibition are significant. Prostaglandin E1 is known
to be a potent pyrogen (fever-causing agent), and
PGE2 causes pain, edema, erythema (reddening of
the skin), and fever. The prostaglandin
endoperoxides (PGG2 and PGH2) can also produce
pain, and inhibition of their synthesis can thus
account for the action of the nonsteroidal anti-
inflammatory agents.
40
Most of the nonsteroidal anti-inflammatory drugs (NSAIDs) are
carboxylic acids. Aspirin (8.69) (acetylsalicylic acid, ASA) has
been used since the turn of the last century to reduce pain and
fever, but the parent compound, salicylic acid, has been known
and used since antiquity, owing to its common occurrence as a
glycoside in willow bark. Acetylation merely decreases its
irritating effect. Among the numerous other salicylates known and
used, flufenisal (8.70) has a longer duration of activity and fewer
side effects than aspirin.
41
Mefenamic acid (8.71) and flufenamic acid (8.72) are derivatives of
anthranilic acid, while ibuprofen (8.73) and naproxen (8.74) are
derivatives of phenylacetic and naphthylacetic acids, respectively.
42
Among indole derivatives, indomethacin (8.75) is very widely used despite side
effects. Its indene analog sulindac (8.76) is a pro-drug, the active form being
its SH derivative. Piroxicam (8.77) is a long-lasting anti-rheumatoid agent
but can have serious gastrointestinal side effects. The once widely used
phenylbutazone (8.78) derivatives have too many side effects and have fallen
into disrepute.
43
Among the nonselective cyclooxygenase (COX) inhibitors,
there is no clear-cut statistical evidence for the superiority of
one or another of these useful drugs. Individual patients may
do better with some than with others, and there are
differences in side effects, primarily gastric bleeding and
renal toxicity, which can be especially serious with the
prolonged administration of high doses necessary in chronic
diseases such as rheumatoid arthritis. Some of these
compounds are powerful enough to be effective against the
major pain caused by malignancies.
44
Most of the nonsteroidal antiinflammatory drugs
are carbocylic acids, Aspirin (acetylsalicylic acid,
ASA), has been used since the turn of the century to
reduce pain and fever, but the parent compound,
salicylic acid, has been known and used since
antiquity, owing to its common occurrence as a
glycoside in willo bark. Acetylation merely
decreases its irritating effect. Among the numerous
other salicylates known and used, flufenisal has a
longaer duration of activity and fewer side effects
than aspirin.
45
In theory the selective COX-2 inhibitors may offer some advantages.
There are at least two forms of the COX enzyme: COX-1 and COX-2.
COX-1 is located in most tissues, including stomach and kidneys.
COX-2, on the other hand, is undetectable in most tissues under
physiological conditions. COX-2 is induced at sites of inflammation,
secondary to the effects of cytokines. Accordingly, specific COX-2
inhibitors, such as celecoxib (8.79) and rofecoxib (8.80), are less likely
to cause stomach ulceration and gastrointestinal bleeding.
Nevertheless, they still have the capacity to cause fluid retention and
renal damage. More significantly, in 2004 it was recognized that COX-
2 inhibitors may pose an increased cardiovascular risk. For example,
rofecoxib was suddenly withdrawn from the market when it was noted
that there was an increased relative risk for confirmed cardiovascular
events, including heart attack and stroke, beginning after 18 months
of treatment, compared to placebo.
46
47
Anti-Leukotrienes as Anti-Inflammatory
Agents for Asthma

Like the other eicosanoids, the leukotrienes are also involved in inflammatory
diseases. Accordingly, leukotriene pathway inhibitors are emerging as
important agents. Two fundamental approaches to the design of leukotriene
pathway inhibitors have been pursued:

1. Inhibitors of 5-lipoxygenase (to prevent leukotriene biosynthesis)
2. Leukotriene receptor antagonists (to prevent leukotriene binding)

Zileuton (8.81) is an inhibitor of 5-lipoxygenase; montelukast (8.82) and
zafirlukast (8.83) are inhibitors of the leukotriene LTD4 receptor. All of these
agents have demonstrated efficacy in the treatment of asthma, a common
chronic inflammatory disease of the airways.
48
49
OC
COOH
Aspirin
CH
3
O
OC
COOH
Flufenisal
CH
3
O
F
Mefenemic acid and flufenamic acid are derivatives of anthranilic acid,
while ibuprofen and naproxen are derivatives of phenyl acetic acid and
naphthylacetic acid, respectively.
NH
COOH
Mefenemic Acid
CH
3
CH
3
NH
COOH
Flumefenemic Acid
CF
3
50
H
C
COOH
Ibuprofen
CH
3
CH
3
CH
3
H
2
C
CH
COOH
Naproxen
CH
3
CH
H
3
CO
COOH
Indomethazcin
CH
3
H
2
C
N
H
3
CO
C
Cl
O