Basic and Clinical Pharmacology, 13th Ed.

Nitric Oxide

Samie R. Jaffrey, MD, PhD

Nitric oxide (NO) is a gaseous signaling molecule that readily diffuses across cell membranes and regulates a wide range of physiologic and pathophysiologic processes including cardiovascular, inflammatory, and neuronal functions. Nitric oxide should not be confused with nitrous oxide (N2O), an anesthetic gas; nor with nitrogen dioxide (NO2), a toxic pulmonary irritant gas.


Because NO is an environmental pollutant, the finding that NO is synthesized by cells and activates specific intracellular signaling pathways was unexpected. The first indication that NO is generated in cells came from studies of cultured macrophages, which showed that treatment with inflammatory mediators, such as bacterial endotoxin, resulted in the production of nitrate and nitrite, molecules that are byproducts of NO breakdown. Similarly, injection of endotoxin in animals elevated urinary nitrite and nitrate.

The second indication came from studies of vascular regulation. Several molecules, such as acetylcholine, were known to cause relaxation of blood vessels. This effect occurred only when the vessels were prepared so that the luminal endothelial cells covering the smooth muscle of the vessel wall were retained (see Figure 7-5). Subsequent studies showed that endothelial cells respond to these vasorelaxants by releasing a soluble endothelial-derived relaxing factor (EDRF). EDRF acts on vascular muscle to elicit relaxation. These findings prompted an intense search for the identity of EDRF.

At the same time, it was observed that administration of NO or organic nitrates, which are metabolized to NO, elicit a variety of effects including inhibition of platelet aggregation and vasorelaxation. Comparison of the biochemical and pharmacologic properties of EDRF and NO provided initial evidence that NO is the major bioactive component of EDRF. These findings also made it clear that exogenously applied NO and NO-releasing compounds (nitrates, nitrites, nitroprusside; see Chapters 11 and 12) elicit their effects by recruiting physiologic signaling pathways that normally mediate the actions of endogenously generated NO.



NO, written as NO to indicate an unpaired electron in its chemical structure, or simply NO, is a highly reactive signaling molecule that is made by any of three closely related NO synthase (NOS, EC isoenzymes, each of which is encoded by a separate gene and named for the initial cell type from which it was isolated (Table 19–1). These enzymes, neuronal NOS (nNOS or NOS-1), macrophage or inducible NOS (iNOS or NOS-2), and endothelial NOS (eNOS or NOS-3), despite their names, are each expressed in a wide variety of cell types, often with an overlapping distribution.

TABLE 19–1 Properties of the three isoforms of nitric oxide synthase (NOS).


These NOS isoforms generate NO from the amino acid L-arginine in an O2- and NADPH-dependent reaction (Figure 19–1). This enzymatic reaction involves enzyme-bound cofactors, including heme, tetrahydrobiopterin, and flavin adenine dinucleotide (FAD). In the case of nNOS and eNOS, NO synthesis is triggered by agents and processes that increase cytosolic calcium concentrations. Cytosolic calcium forms complexes with calmodulin, an abundant calcium-binding protein, which then binds and activates eNOS and nNOS. On the other hand, iNOS is not regulated by calcium, but is constitutively active. In macrophages and several other cell types, inflammatory mediators induce the transcriptional activation of the iNOS gene, resulting in accumulation of iNOS and increased synthesis of NO.


FIGURE 19–1 Synthesis and reactions of nitric oxide (NO). L-NMMA (see Table 19-3) inhibits nitric oxide synthase. NO binds to the iron in hemoproteins (eg, guanylyl cyclase), resulting in the activation of cyclic guanosine monophosphate (cGMP) synthesis and cGMP target proteins such as protein kinase G. Under conditions of oxidative stress, NO can react with superoxide to nitrate tyrosine. GTP, guanosine triphosphate.

Signaling Mechanisms

NO mediates its effects by covalent modification of proteins. There are three major targets of NO (Figure 19–1):

1. MetalloproteinsNO interacts with metals, especially iron in heme. The major target of NO is soluble guanylyl cyclase (sGC), a heme-containing enzyme that generates cyclic guanosine monophosphate (cGMP) from guanosine triphosphate (GTP). NO binds to the heme in sGC, resulting in enzyme activation and elevation in intracellular cGMP levels. cGMP activates protein kinase G (PKG), which phosphorylates specific proteins. In blood vessels, NO-dependent elevations in cGMP and PKG activity result in the phosphorylation of proteins that lead to reduced cytosolic calcium levels and subsequently reduced contraction of vascular smooth muscle. Interaction of NO with other metallo-proteins mediates some of the cytotoxic effects of NO associated with NO overproduction, eg, by activated macrophages. For example, NO inhibits metalloproteins involved in cellular respiration, such as the citric acid cycle enzyme aconitase and the electron transport chain protein cytochrome oxidase. Inhibition of heme-containing cytochrome P450 enzymes by NO is a major pathogenic mechanism in inflammatory liver disease.

2. ThiolsNO reacts with thiols (compounds containing the –SH group) to form nitrosothiols. In proteins, the thiol moiety is found in the amino acid cysteine. This posttranslational modification, termed S-nitrosylation or S-nitrosation, requires either metals or O2 to catalyze the formation of the nitrosothiol adduct. S-nitrosylation is highly specific, with only certain cysteine residues in proteins becoming S-nitrosylated. S-nitrosylation can alter the function, stability, or localization of target proteins. Major targets of S-nitrosylation include H-ras, a regulator of cell proliferation that is activated by S-nitrosylation, and the metabolic enzyme glyceraldehyde-3-phosphate dehydrogenase, which is inhibited when it is S-nitrosylated. Denitrosylation of proteins is poorly understood but may involve enzymes, such as thioredoxin, or chemical reduction by intracellular reducing agents such as glutathione, an abundant intracellular sulfhydryl-containing compound. Glutathione can also be S-nitrosylated under physiologic conditions to generate S-nitrosoglutathione. S-nitrosoglutathione may serve as an endogenous stabilized form of NO or as a carrier of NO. Vascular glutathione is decreased in diabetes mellitus and atherosclerosis, and the resulting deficiency of S-nitrosoglutathione may account for the increased incidence of cardiovascular complications in these conditions.

3. Tyrosine nitrationNO undergoes both oxidative and reductive reactions, resulting in a variety of oxides of nitrogen that can nitrosylate thiols and add nitrate to tyrosines (described below) or are stable oxidation products (Table 19–2). NO reacts very efficiently with superoxide to form peroxynitrite (ONOO), a highly reactive oxidant that leads to DNA damage, nitration of tyrosine, and oxidation of cysteine to disulfides or to various sulfur oxides (SOx). Several cellular enzymes synthesize superoxide, and the activity of these enzymes, as well as NO synthesis, is increased in numerous inflammatory and degenerative diseases, resulting in an increase in peroxynitrite levels. Numerous proteins are susceptible to peroxynitrite-catalyzed tyrosine nitration, and this irreversible modification can be associated with either activation or inhibition of protein function. Detection of tyrosine nitration in tissue is often used as a marker of excessive NO production, although a direct causal role of tyrosine nitration in the pathogenesis of any disease has not been definitively established. Peroxynitrite-mediated protein modification is mitigated by intracellular levels of glutathione, which can protect against tissue damage by scavenging peroxynitrite. Factors that regulate the biosynthesis and decomposition of glutathione may be important modulators of the toxicity of NO.

TABLE 19–2 Oxides of nitrogen.



NO is highly labile due to its rapid reaction with metals, O2, and reactive oxygen species. NO can react with heme and hemoproteins, including oxyhemoglobin, which oxidizes NO to nitrate. The reaction of NO with hemoglobin may also lead to S-nitrosylation of hemoglobin, resulting in transport of NO throughout the vasculature. NO is also inactivated by reaction with O2 to form nitrogen dioxide. As noted, NO reacts with superoxide, which results in the formation of the highly reactive oxidizing species, peroxynitrite. Scavengers of superoxide anion such as superoxide dismutase may protect NO, enhancing its potency and prolonging its duration of action.


Inhibitors of Nitric Oxide Synthesis

The primary strategy to reduce NO generation in cells is to use NOS inhibitors. The majority of these inhibitors are arginine analogs that bind to the NOS arginine-binding site. Since each of the NOS isoforms has high structural similarity, most of these inhibitors do not exhibit selectivity for individual NOS isoforms. In inflammatory disorders and sepsis (see below), inhibition of the iNOS isoform is potentially beneficial, whereas in neurodegenerative conditions, nNOS-specific inhibitors may be useful. However, administration of nonselective NOS inhibitors leads to concurrent inhibition of eNOS, which impairs its homeostatic signaling and also results in vasoconstriction and potential ischemic damage. Thus, NOS isoform-selective inhibitors are being designed that exploit subtle differences in substrate binding sites between the isoforms, as well as newer isoform-selective inhibitors that prevent NOS dimerization, the conformation required for enzymatic activity. The efficacy of NOS isoform-selective inhibitors in medical conditions is under investigation.

Nitric Oxide Donors

NO donors, which release NO or related NO species, are used clinically to elicit smooth muscle relaxation. Different classes of NO donors have differing biologic properties, depending on the nature of the NO species released and the mechanism that is responsible for its release.

1. Organic nitratesNitroglycerin, which dilates veins and coronary arteries, is metabolized to NO by mitochondrial aldehyde reductase, an enzyme enriched in venous smooth muscle, accounting for the potent venodilating activity of this molecule. Venous dilation decreases cardiac preload, which along with coronary artery dilation accounts for the antianginal effects of nitroglycerin. Other organic nitrates, such as isosorbide dinitrate, are metabolized to an NO-releasing species through a poorly understood enzymatic pathway. Unlike NO, organic nitrates have less significant effects on aggregation of platelets, which appear to lack the enzymatic pathways necessary for rapid metabolic activation. Organic nitrates exhibit rapid tolerance during continuous administration. This nitrate tolerance may derive from the generation of reactive oxygen species that inhibit mitochondrial aldehyde reductase, endogenous NO synthesis, and other pathways (see Chapter 12).

2. Organic nitritesOrganic nitrites, such as the antianginal inhalant amyl nitrite, also require metabolic activation to elicit vasorelaxation, although the responsible enzyme has not been identified. Nitrites are arterial vasodilators and do not exhibit the rapid tolerance seen with nitrates. Amyl nitrite is abused for euphoric effects and combining it with phosphodiesterase inhibitors, such as sildenafil, can cause lethal hypotension. Amyl nitrite has been largely replaced by nitrates, such as nitroglycerin, which are more easily administered.

3. Sodium nitroprussideSodium nitroprusside, which dilates arterioles and venules, is used for rapid pressure reduction in arterial hypertension. In response to light as well as chemical or enzymatic mechanisms in cell membranes, sodium nitroprusside breaks down to generate five cyanide molecules and a single NO. See Chapter 11 for additional details.

4. NO gas inhalationNO itself can be used therapeutically. Inhalation of NO results in reduced pulmonary artery pressure and improved perfusion of ventilated areas of the lung. Inhaled NO is used for pulmonary hypertension, acute hypoxemia, and cardio-pulmonary resuscitation, and there is evidence of short-term improvements in pulmonary function. Inhaled NO is stored as a compressed gas mixture with nitrogen, which does not readily react with NO, and further diluted to the desired concentration upon administration. NO can react with O2 to form nitrogen dioxide, a pulmonary irritant that can cause deterioration of lung function (see Chapter 56). Additionally, NO can induce the formation of methemoglobin, a form of hemoglobin containing Fe3+ rather than Fe2+, which does not bind O2 (see also Chapter 12). Therefore, nitrogen dioxide and methemoglobin levels are monitored during inhaled NO treatment.

5. Alternate strategiesAnother mechanism to potentiate the actions of NO is to inhibit the phosphodiesterase enzymes that degrade cGMP. Inhibitors of type 5 phosphodiesterase such as sildenafil result in prolongation of the duration of NO-induced cGMP elevations in a variety of tissues (see Chapter 12).



NO has a significant effect on vascular smooth muscle tone and blood pressure. Numerous endothelium-dependent vasodilators, such as acetylcholine and bradykinin, act by increasing intracellular calcium levels in endothelial cells, leading to the synthesis of NO. NO diffuses to vascular smooth muscle leading to vasorelaxation (Figure 19–2). Mice with a knockout mutation in the eNOS gene display increased vascular tone and elevated mean arterial pressure, indicating that eNOS is a fundamental regulator of blood pressure.


FIGURE 19–2 Regulation of vasorelaxation by endothelial-derived nitric oxide (NO). Endogenous vasodilators, eg, acetylcholine and bradykinin, cause calcium (Ca2+) efflux from the endoplasmic reticulum in the luminal endothelial cells into the cytoplasm. Calcium binds to calmodulin (CaM), which activates endothelial NO synthase (eNOS), resulting in NO synthesis from l-arginine. NO diffuses into smooth muscle cells, where it activates soluble guanylyl cyclase and cyclic guanosine monophosphate (cGMP) synthesis from guanosine triphosphate (GTP). cGMP binds and activates protein kinase G (PKG), resulting in an overall reduction in calcium influx, and inhibition of calcium-dependent muscle contraction. PKG can also block other pathways that lead to muscle contraction. cGMP signaling is terminated by phosphodiesterases, which convert cGMP to GMP.

Apart from being a vasodilator and regulating blood pressure, NO also has antithrombotic effects. Both endothelial cells and platelets contain eNOS, which acts via an NO-cGMP pathway to inhibit platelet activation, an initiator of thrombus formation. Thus, in diseases associated with endothelial dysfunction, the associated decrease in NO generation leads to an increased propensity for abnormal platelet function and thrombosis. NO may have an additional inhibitory effect on blood coagulation by enhancing fibrinolysis via an effect on plasminogen.

NO also protects against atherogenesis. A major antiatherogenic mechanism of NO involves the inhibition of proliferation and migration of vascular smooth muscle cells. In animal models, myointimal proliferation following angioplasty can be blocked by NO donors, by NOS gene transfer, and by NO inhalation. NO reduces endothelial adhesion of monocytes and leukocytes, which are early steps in the development of atheromatous plaques. This effect is due to the inhibitory effect of NO on the expression of adhesion molecules on the endothelial surface. In addition, NO may act as an antioxidant, blocking the oxidation of low-density lipoproteins and thus preventing or reducing the formation of foam cells in the vascular wall. Plaque formation is also affected by NO-dependent reduction in endothelial cell permeability to lipoproteins. The importance of eNOS in cardiovascular disease is supported by experiments showing increased atherosclerosis in animals treated with eNOS inhibitors. Atherosclerosis risk factors, such as smoking, hyperlipidemia, diabetes, and hypertension, are associated with decreased endothelial NO production, and thus enhance atherogenesis.


Sepsis is a systemic inflammatory response caused by infection. Endotoxin components from the bacterial wall along with endogenously generated tumor necrosis factor-α and other cytokines induce synthesis of iNOS in macrophages, neutrophils, and T cells, as well as hepatocytes, smooth muscle cells, endothelial cells, and fibroblasts. This widespread generation of NO results in exaggerated hypotension, shock, and, in some cases, death. This hypotension is reduced or reversed by NOS inhibitors in humans as well as in animal models (Table 19–3). A similar reversal of hypotension is produced by compounds that prevent the action of NO, such as the sGC inhibitor methylene blue. Furthermore, knockout mice lacking a functional iNOS gene are more resistant to endotoxin than wild-type mice. However, despite the ability of NOS inhibitors to ameliorate hypotension in sepsis, there is no overall improvement in survival in patients with gram-negative sepsis treated with NOS inhibitors. The absence of benefit may reflect the inability of the NOS inhibitors used in these trials to differentiate between NOS isoforms, or may reflect concurrent inhibition of beneficial aspects of iNOS signaling.

TABLE 19–3 Some inhibitors of nitric oxide synthesis or action.



The generation of NO has both beneficial and detrimental roles in the host immune response and in inflammation. The host response to infection or injury involves the recruitment of leukocytes and the release of inflammatory mediators, such as tumor necrosis factor and interleukin-1. This leads to induction of iNOS in leukocytes, fibroblasts, and other cell types. The NO that is produced, along with peroxynitrite that forms from its interaction with superoxide, is an important microbicide. NO also appears to play an important protective role in the body via immune cell function. When challenged with foreign antigens, Th1 cells (see Chapter 55) respond by synthesizing NO, which has roles in Th1 cells. The importance of NO in Th1 cell function is demonstrated by the impaired protective response to injected parasites in animal models after inhibition of iNOS. NO also stimulates the synthesis of inflammatory prostaglandins by activating cyclooxygenase isoenzyme 2 (COX-2). Through its effects on COX-2, its direct vasodilatory effects, and other mechanisms, NO generated during inflammation contributes to the erythema, vascular permeability, and subsequent edema associated with acute inflammation.

However, in both acute and chronic inflammatory conditions, prolonged or excessive NO production may exacerbate tissue injury. Indeed, psoriasis lesions, airway epithelium in asthma, and inflammatory bowel lesions in humans all demonstrate elevated levels of NO and iNOS, suggesting that persistent iNOS induction may contribute to disease pathogenesis. Moreover, these tissues also exhibit increased levels of nitrotyrosine, indicating excessive formation of peroxynitrite. In several animal models of arthritis, increasing NO production by dietary l-arginine supplementation exacerbates arthritis, whereas protection is seen with iNOS inhibitors. Thus, inhibition of the NO pathway may have a beneficial effect on a variety of acute and chronic inflammatory diseases.


NO has an important role in the central nervous system as a neurotransmitter (see Chapter 21). Unlike classic transmitters such as glutamate or dopamine, which are stored in synaptic vesicles and released in the synaptic cleft upon vesicle fusion, NO is not stored, but rather is synthesized on demand and immediately diffuses to neighboring cells. NO synthesis is induced at postsynaptic sites in neurons, most commonly upon activation of the NMDA subtype of glutamate receptor, which results in calcium influx and activation of nNOS. In several neuronal subtypes, eNOS is also present and activated by neurotransmitter pathways that lead to calcium influx. NO synthesized postsynaptically may function as a retrograde messenger and diffuse to the presynaptic terminal to enhance the efficiency of neurotransmitter release, thereby regulating synaptic plasticity, the process of synapse strengthening that underlies learning and memory. Because aberrant NMDA receptor activation and excessive NO synthesis is linked to excitotoxic neuronal death in several neurologic diseases, including stroke, amyotrophic lateral sclerosis, and Parkinson’s disease, therapy with NOS inhibitors may reduce neuronal damage in these conditions. However, clinical trials have not clearly supported the benefit of NOS inhibition, which may reflect nonselectivity of the inhibitors, resulting in inhibition of the beneficial effects of eNOS.


Nonadrenergic, noncholinergic (NANC) neurons are widely distributed in peripheral tissues, especially the gastrointestinal and reproductive tracts (see Chapter 6). Considerable evidence implicates NO as a mediator of certain NANC actions, and some NANC neurons appear to release NO. Penile erection is thought to be caused by the release of NO from NANC neurons; NO promotes relaxation of the smooth muscle in the corpora cavernosa—the initiating factor in penile erection—and inhibitors of NOS have been shown to prevent erection caused by pelvic nerve stimulation in the rat. An established approach in treating erectile dysfunction is to enhance the effect of NO signaling by inhibiting the breakdown of cGMP by the phosphodiesterase (PDE isoform 5) present in the smooth muscle of the corpora cavernosa with drugs such as sildenafil, tadalafil, and vardenafil (see Chapter 12).


NO is administered by inhalation to newborns with hypoxic respiratory failure associated with pulmonary hypertension. The current treatment for severely defective gas exchange in the newborn is with extracorporeal membrane oxygenation (ECMO), which does not directly affect pulmonary vascular pressures. NO inhalation dilates pulmonary vessels, resulting in decreased pulmonary vascular resistance and reduced pulmonary artery pressure. Inhaled NO also improves oxygenation by reducing mismatch of ventilation and perfusion in the lung. Inhalation of NO results in dilation of pulmonary vessels in areas of the lung with better ventilation, thereby redistributing pulmonary blood flow away from poorly ventilated areas. NO inhalation does not typically exert pronounced effects on the systemic circulation. Inhaled NO has also been shown to improve cardiopulmonary function in adult patients with pulmonary artery hypertension.

An additional approach for treating pulmonary hypertension is to potentiate the actions of NO in pulmonary vascular beds. Due to the enrichment of PDE-5 in pulmonary vascular beds, PDE-5 inhibitors such as sildenafil and tadalafil induce vasodilation and marked reductions in pulmonary hypertension (see also Chapters 12 and 17).

SUMMARY Nitric Oxide






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