The most important risk factor for stroke and neurodegeneration is aging. In fact,
survival after stroke diminishes largely with aging. In fact, recovery after brain
artery occlusion is dramatically worsened by aging, even normal aging is associated
with neuron damage and cognitive decline. Mechanisms involved in aging-related, cognitive
decline and susceptibility to neuron damage in stroke and neurodegeneration are largely
unknown. One of the most important mechanisms contributing to neural dysfunction and
death is excitotoxicity. This process is based on the fact that the excessive glutamate
receptor stimulation may lead to neuronal damage. This overstimulation may be due
to increased concentration of glutamate, or the prolonged activation of receptors.
Protecting the aging brain against damage remains a big challenge for neurologists
and neuroscientists. Interestingly, a large number of basic and clinical studies have
provided strong evidence indicating that the prolonged use of non-steroidal anti-inflammatory
drugs (NSAIDs) may reduce the incidence of Alzheimer's disease (AD) (Wang et al.,
2015), the most common form of dementia. NSAIDs also decreased glutamate excitotoxicity
both in vitro, in rat primary neuronal cultures and hippocampal slices (Grilli et
al., 1996), and in vivo, protecting rats against rotenone-induced parkinsonism (Madathil
et al., 2013). Recent evidence suggests also that NSAIDs may even protect against
the cognitive decline associated to healthy aging in humans (Kern et al., 2012).
NSAIDs present antipyretic, anti-inflammatory and analgesic effects. Therefore, they
are mainly used to relief pain, fever and inflammation. Their best characterized action
is inhibition of cyclooxygenase (COX), and thus the synthesis of prostaglandins, which
participate in the inflammatory response. NSAIDs can be non-selective COX inhibitors
such as aspirin, ibuprofen, indomethacin or sulindac; or selective COX-2 inhibitors,
such as rofecoxib and celecoxif. The action mechanism of neuroprotection by NSAIDs
is unknown, but reports suggest that it is not related to the classic anti-inflammatory
activity of these drugs. It is widely accepted that neuronal excitotoxicity induced
by glutamate is mainly caused by one kind of ionotropic glutamate receptor, the N-methyl-D-aspartate
receptor (NMDAR), probably because of its high permeability to Ca2+. The combination
of different subunits constitutes NMDARs: The NR1 subunit, is ubiquitous and essential
whereas the NR2 subunit, is a regulatory subunit (NR2A - NR2D). There is also a third
subunit named NR3 (NR3A - NR3B). A functional NMDA receptor requires the binding of
two NR1 subunits with two other NR2 subunits or with the combination of a NR2 and
NR3 subunits. In normal synaptic transmission, the NMDAR, blocked by the Mg2+ located
in the channel, is activated for short periods of time.
However, in pathological conditions, like the prolonged depolarization that takes
place in ischemic events, during which Mg2+ is fully removed from its binding site
at the NMDARs, an overly activation of the receptor causes excessive Ca2+ entry through
the channel. This Ca2+ entry, together with the Ca2+ released from the intracellular
stores, increases the cytosolic free Ca2+ concentration to levels that exceed the
capacity of the intracellular Ca2+ clearing mechanisms and pumps leading to mitochondrial
Ca2+ overload. This may cause impaired metabolism and certain processes that trigger
cell death such as the one in the neurodegenerative disorders (Pivovarova et al.,
2004).
We have reported that oligomers, but not fibrils, of the amyloid β peptide 1–42 (Aβ1–42),
the most likely toxin in AD, induce also a sustained entry of Ca2+ followed by mitochondrial
Ca2+ overload leading to cell death in cultures of rat cerebellar granule cells (Sanz-Blasco
et al., 2008). The pathway for Ca2+ entry remains unknown, but several reports suggest
it could be mediated, at least partially, by NMDA receptors. Interestingly, we showed
that a series of NSAIDs, including salicylate (the major metabolite of aspirin), ibuprofen,
sulindac sulfide, indomethacin and the structural analogue lacking anti-inflammatory
activity R-flurbiprofen, are able to depolarize partially mitochondria preventing
mitochondrial Ca2+ overload without affecting Ca2+ influx induced by oligomers of
Aβ1–42. All these effects were achieved at fairly low concentrations of NSAIDs, in
the μM range, far from those required for preventing inflammation or reducing the
Aβ burden. Mitochondrial depolarization could be easily explained by the chemical
structure of carboxylic NSAIDs, resembling mild mitochondrial uncouplers. These class
of compounds are able to decrease partially mitochondrial potential, the huge driving
force for mitochondrial Ca2+ uptake, in a similar manner to low concentrations of
established mitochondrial uncouplers as carbonyl cyanide-p-trifluoromethoxyphenylhydrazone
(FCCP).
Understanding the mechanisms of aging-related susceptibility to neuron damage and
neuroprotection by NSAIDs is critical since they may provide feasible ways of preventing
brain damage in the elderly. However, this study has been hampered by the lack of
suitable models of brain aging. Recently, several authors have provided evidence indicating
that long-term cultures of hippocampal neurons show many of the typical hallmarks
of aged neurons including accumulation of reactive oxygen species (ROS), lipofuscin
granules, heterochromatic foci, activation of the Jun N-terminal protein kinase (pJNK)
and p53/p21 pathways, gradual loss of cholesterol, and changes in Ca2+ channel density
and NMDA receptor expression (Sodero et al., 2011). In addition, studies show the
increased vulnerability of hippocampal neurons with age in culture (Brewer et al.,
2007). We have recently used long-term cultures of neonatal rat hippocampal neurons
to investigate age-related susceptibility to excitotoxicity and neuroprotection by
NSAIDS. We found that NMDA promoted cell death only in aged neurons cultured for several
weeks in vitro but not in young cultures (Calvo et al., 2015), despite both expressed
NMDA receptors and showed NMDA-induced rises in cytosolic [Ca2+]. However, the increases
in cytosolic [Ca2+] induced by NMDA were much larger in older cultures than in younger
neurons. These changes correlated with changes in the composition and density of NMDA
receptor subunits consistently with those observed in vivo (Cui et al., 2013). Most
importantly, NMDA induced mitochondrial Ca2+ uptake only in aged neurons. Thus, mitochondria
from young neurons are seemingly not sensitive to the changes in cytosolic [Ca2+].
Several mechanisms may contribute to differential behavior of mitochondria from young
and old neurons, but the most likely one is the increased rises in cytosolic [Ca2+]
and enhanced resting cytosolic [Ca2+] observed in older neurons (Calvo et al., 2015).
Whereas the mechanism for enhanced resting cytosolic [Ca2+] remains unknown, the basis
for increased responses to NMDA can be explained by the changes in NMDA receptor density
and composition (Calvo et al., 2015). In summary, mitochondrial Ca2+ overload is critical
for enhanced susceptibility to cell death in aged neurons (
Figure 1
). This view is supported by the fact that NMDA promotes permeability transition and
release of cytochrome c in older neurons and these effects are prevented by mitochondrial
depolarization with FCCP. The role of mitochondria is further supported by the fact
that several NSAIDs, including salicylate, indomethacin, sulindac sulphide and the
structural analogue R-flurbiprofen depolarize mitochondria and prevent also mitochondrial
Ca2+ uptake and neuron cell death without affecting the rise in cytosolic [Ca2+] induced
by NMDA. Therefore, these results strongly suggest that enhanced mitochondrial Ca2+
uptake contributes largely to aging-related susceptibility to neuron cell damage and
cognitive decline. Most importantly, they also support the view that these processes
could be prevented to some extent by the use of low concentrations of NSAIDs (
Figure 2
). Of course, clinical research is required to fully support this view.
Figure 1
A model of neurotoxicity induced by excessive Ca2+ entry induced by glutamate or by
Aβ1–42 oligomers in aged neurons.
Young hippocampal neurons show a similar expression of NR1/NR2A and NR1/NR2B receptors.
However, aged neurons show an increased expression of NR1/NR2A receptors. NMDA receptor
activation induces a greater Ca2+ entry in aged neurons than in the young ones, which
together with the Ca2+ released from the intracellular stores can cause mitochondrial
Ca2+ overload, cytochrome c release and apoptosis. Furthermore, aged neurons are more
susceptible to the Aβ1–42 oligomers induced Ca2+ entry. Aβ1–42: Amyloid β peptide
1–42; Cyt C: cytochrome C; ER: endoplasmic reticulum; GPCR: G protein-coupled receptor;
IP3: inositol trisphosphate; IP3R: inositol trisphosphate receptor; NR1, NR2A, NR2B:
subunits 1, 2A and 2B of the N-methyl-D-aspartate receptor; PMCA: plasma membrane
Ca2+-ATPase; RyR: ryanodine receptor; SERCA: sarcoplasmic and endoplasmic reticulum
Ca2+-ATPase.
Figure 2
A model of NSAID neuroprotection based on the inhibition of mitochondrial Ca2+ overload.
NSAIDs, used at low concentrations, partially depolarize mitochondria and inhibit
mitochondrial Ca2+ overload, thus preventing the release of cytochrome c and NMDA-
or Aβ1–42-induced apoptosis. Aβ1–42: Amyloid β peptide 1–42; NSAIDs: non steroidal
anti-inflammatory drugs.
Interestingly, some NSAIDs have been already proposed or even tested to prevent neuron
cell death in brain pathologies. For example, R-flurbiprofen (Flurizan™) was tested
for preventing AD in a large-scale clinical trial that failed in its phase three.
Notably, this compound was used at large concentrations aimed at reducing the Aβ burden.
The reasons for the failure of R-flurbiprofen in this trial are not clear at present
but it has been proposed that damage in AD patients might be too severe to be reversed
by even the best drugs. In support of this view, it has been shown recently that R-flurbiprofen,
a drug that lacks anti-inflammatory activity, prevents and attenuates primary progressive
experimental multiple sclerosis in mice, even if the treatment commenced on or after
the first signs of the disease (Schmitz et al., 2014). Further research is required
to test the use of selected NSAIDs and structural analogues without anti-inflammatory
activity in neuron damage associated to aging.
This work was supported by grants VA145U13, BIO/VA33/13, BIO103/VA45/11 from Junta
de Castilla y León, Spain and BFU2012-37146 from Ministerio de Economía y Competitividad,
Spain. MCR was supported by a pre-doctoral fellowship from Junta de Castilla y León,
Spain and The European Social Fund.