Proton pump inhibitors (PPIs) block the gastric hydrogen potassium ATPase (H+/K+ ATPase) and inhibit gastric acid secretion. These drugs have emerged as the treatment of choice for acid-related diseases, including gastroesophageal reflux disease (GERD) and peptic ulcer disease.
History
Evidence emerged by the end of the 1970s that the newly discovered proton pump (H+/K+ ATPase) in the secretory membrane of the parietal cell was the final step in acid secretion. Literature from anaesthetic screenings led attention to the potential antiviral compound pyridylthioacetamide which after further examination pointed the focus on an anti-secretory compound with unknown mechanisms of action called timoprazole. Timoprazole is a pyridylmethylsulfinyl benzimidazole and appealed due to its simple chemical structure and its surprisingly high level of anti-secretory activity.
Optimization of substituted benzimidazoles and their antisecretory effects were studied on the newly discovered proton pump to obtain higher pKa values of the pyridine, thereby facilitating accumulation within the parietal cell and increasing the rate of acid-mediated conversion to the active mediate. As a result of such optimization the first proton pump inhibiting drug, omeprazole, was released on the market. Other PPIs like lansoprazole and pantoprazole would follow in its footsteps, claiming their share of a flourishing market, after their own course of development.
Basic structure
PPIs can be divided into two groups based on their basic structure. Although all members have a substituted pyridine part, one group has linked to various benzimidazoles, whereas the other has linked to a substituted imidazopyridine. All marketed PPIs (omeprazole, lansoprazole, pantoprazole) are in the benzimidazole group.
Proton pump inhibitors are prodrugs and their actual inhibitory form is somewhat controversial. In acidic solution, the sulfenic acid is isolated before reaction with one or more cysteines accessible from the luminar surface of the enzyme, a tetracyclic sulfenamide. This is a planar molecule thus any enantiomer of a PPI loses stereospecificity upon activation.
The effectiveness of these drugs derives from two factors: their target, the H+/K+ ATPase which is responsible for the last step in acid secretion; therefore, their action on acid secretion is independent of the stimulus to acid secretion, of histamine, acetylcholine, or other yet to be discovered stimulants. In addition, their mechanism of action involves covalent binding of the activated drug to the enzyme, resulting in a duration of action that exceeds their plasma half-life.
The gastric ATPase Acid secretion by the human stomach results in a median diurnal pH of 1.4. This very large (>106-fold) H+ gradient is generated by the gastric H+/K+ ATPase which is an ATP-driven proton pump. Hydrolysis of one ATP molecule is used to catalyse the electroneutral exchange of two luminal potassium ions for two cytoplasmic protons through the gastric membrane.
Structure The proton pump, H+/K+ ATPase is a α,β-heterodimeric enzyme. The catalytic α subunit has ten transmembrane segments with a cluster of intramembranal carboxylic amino acids located in the middle of the transmembrane segments TM4, TM5, TM6 and TM8. The β subunit has one transmembrane segment with N terminus in cytoplasmic region. The extracellular domain of the β subunit contains six or seven N-linked glycosylation sites which is important for the enzyme assembly, maturation and sorting.
Function The ion transport is accomplished by cyclical conformational changes of the enzyme between its two main reaction states, E1 and E2. The cytoplasmic-open E1 and luminal-open E2 states have high affinity for H+ and K+. The expulsion of the proton at 160 mM (pH 0.8) concentration results from movement of lysine 791 into the ion binding site in the E2P configuration.
Discovery In the year 1975, timoprazole was found to inhibit acid secretion irrespective of stimulus, extracellular or intracellular. Studies on timoprazole revealed enlargement of the thyroid gland due to inhibition of iodine uptake as well as atrophy of the thymus gland. A literature search showed that some substituted mercapto-benzimidazoles had no effect on iodine uptake and introduction of such substituents into timoprazole resulted in an elimination of the toxic effects, without reducing the antisecretory effect. A derivative of timoprazole, omeprazole, was discovered in 1979, and was the first of a new class of drug that control acid secretion in the stomach, a proton pump inhibitor (PPI). Addition of 5-methoxy-substitution to the benzimidazole moiety of omeprazole was also made and gave the compound much more stability at neutral pH. In 1980, an Investigational New Drug (IND) application was filed and omeprazole was taken into Phase III human trials in 1982. A new approach for the treatment of acid-related diseases was introduced, and omeprazole was quickly shown to be clinically superior to the histamine H2 receptor antagonists, and was launched in 1988 as Losec in Europe, and in 1990 as Prilosec in the United States. In 1996, Losec became the world's biggest ever selling pharmaceutical, and by 2004 over 800 million patients had been treated with the drug worldwide. During the 1980s, about 40 other companies entered the PPIs area, but few achieved market success: Takeda with lansoprazole, Byk Gulden (now Nycomed) with pantoprazole, and Eisai with rabeprazole, all of which were analogues of omeprazole.
Development
Pantoprazole The story of pantoprazole's discovery is a good example of the stepwise development of PPIs. The main focus of modification of timoprazole was the benzimidazole part of its structure. Addition of a trifluoromethyl group to the benzimidazole moiety led to a series of very active compounds with varying solution-stability. In general fluoro substituents were found to block metabolism at the point where they were attached. Later the more balanced fluoroalkoxy substituent, instead of the highly lipophilic and strongly electron-withdrawing trifluoromethyl substituent, led to highly active compounds with supposed longer half-lives and higher solution stability.
It was realized that activity was somehow linked to instability in solution and then came to the conclusion that the cyclic sulfenamides, formed in acidic conditions, were the active principle of the PPIs. Finally, it was understood that seemingly small alterations in the backbone of timoprazole led nowhere, and focus had to be centered on the substituents on the backbone. However, necessary intramolecular rearrangement of the benzimidazole into sulfenamide posed severe geometric constraints. Optimal compounds would be those that were stable at neutral pH but were quickly activated at low pH.
A clear-cut design of active inhibitors was still not possible because in the complex multi-step chemistry the influence of a substituent on each step in the cascade could be different, and therefore not predictable for the overall rate of the prerequisite acid activation. Smith Kline and French, which entered into collaboration with Byk Gulden mid-1984, greatly assisted in determining criteria for further development. From 1985, the aim was to identify a compound with good stability at neutral pH, sustaining this higher level of stability down to pH 5 but being rapidly activateable at lower pHs, combined with a high level of H+/K+ ATPase inhibition. From the numerous already synthesized and tested compounds that fulfilled these criteria the most promising candidates were pantoprazole and its salt, pantoprazole sodium.
In 1986 pantoprazole sodium sesquihydrate was synthesized and from 1987 onwards the development of pantoprazole was switched to the sodium salt which is more stable and has better compatibility with other excipients used in the drug formulation.
Pantoprazole was identified after nearly seven years of research and registered for clinical use after a further seven years of development, and finally reached its first market in 1994 in Germany. During the course of the studies on pantoprazole, more than 650 PPIs had been synthesized and evaluated. Pantoprazole obtained high selection criteria in its development process — especially concerning the favorable low potential for interaction with other drugs. Good solubility of pantoprazole and a very high solution stability allowed it to become the first marketed PPI for intravenous use in critical care patients.
Esomeprazole Omeprazole showed an inter-individual variability and therefore a significant number of patients with acid-related disorders required higher or multiple doses to achieve symptom relief and healing. Astra started a new research program in 1987 to identify a new analogue to omeprazole with less interpatient variability. Only one compound proved superior to omeprazole and that was the (S)-(−)-isomer, esomeprazole, which was developed as the magnesium salt. Esomeprazole magnesium (brand name Nexium) received its first approval in 2000 and provided more pronounced inhibition of acid secretion and less inter-patient variation compared to omeprazole. In 2004, Nexium had already been used to treat over 200 million patients.
Benzimidazoles Omeprazole (brand names Losec, Prilosec, Zegerid, Ocid, Lomac, Omepral, Omez, Ultop, Ortanol, Gastrozol)
Omeprazole was the first PPI on the market, in 1988. It is a 1:1 racemate drug with a backbone structure of timoprazole, but substituted with two methoxy and two methyl groups. One of the methoxy group is at position 6 of the benzimidazole and the other at position 4 of the pyridine and the methyl groups are at position 3 and 5 of the pyridine. Omeprazole is available as enteric-coated tablets, capsules, chewable tablets, powder for oral suspensions and powder for intravenous injection. Lansoprazole (brand names: Prevacid, Zoton, Inhibitol, Levant, Lupizole, Lancid, Lansoptol, Epicur)
Lansoprazole was the second of the PPI drugs to reach the market, being launched in Europe in 1991 and the US in 1995. It has no substitutions at the benzimidazole but two substituents on the pyridine, methyl group at position 3 and a trifluoroethoxy group at position 4. The drug is a 1:1 racemate of the enantiomers dexlansoprazole and levolansoprazole. It is available in gastroresistant capsules and tablets as well as chewable tablets. Pantoprazole (brand names: Protonix, Somac, Pantoloc, Pantozol, Zurcal, Zentro, Pan, Nolpaza, Controloc, Sunpras)
Pantoprazole was the third PPI and was introduced to the German market in 1994. It has a difluoroalkoxy sidegroup on the benzimidazole part and two methoxy groups in position 3 and 4 on the pyridine. Pantoprazole was first prepared in April 1985 by a small group of scale-up chemists. It is a dimethoxy-substituted pyridine bound to a fluoroalkoxy substituted benzimidazole. Pantoprazole sodium is available as gastroresistant or delayed release tablets and as lyophilized powder for intravenous use. Rabeprazole (brand names: Zechin, Rabecid, Nzole-D, AcipHex, Pariet, Rabeloc, Zulbex, Ontime, Noflux)
Rabeprazole is a novel benzimidazole compound on market, since 1999 in USA. It is similar to lansoprazole in having no substituents on its benzimidazole part and a methyl group at site 3 on the pyridine, the only difference is the methoxypropoxy substitution at site 4 instead of the trifluoroethoxy group on lansoprazole. Rabeprazole is marketed as rabeprazole sodium salt. It is available as enteric-coated tablets. Esomeprazole (brand names: Nexium, Esotrex, Emanera, Neo-Zext)
In 2001 esomeprazole was launched in USA, as a follow-up of omeprazoles patent.