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ISSN: 2229-7006(online)
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Abstract
Pain is part and parcel of most health conditions from joint disorders to cancer. This explains
why several researchers were hooked on to unraveling the deep puzzle behind the pain
mechanism and finding a better way to relieving it with medicines that went far beyond killing
pain alone. When a landmark outcome emerged and identified prostaglandins, the bodys
chemical messengers, as the cause of inflammation, or pain, and that they could be blocked, it
catapulted research to a new frontier. The result: a novel pain-and-inflammation-relieving
medicinal assembly line called non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs are
a large group of medications. There are several types of NSAIDs, and aspirin is the most
familiar. Other examples of NSAIDs are ibuprofen, naproxen, piroxicam, nabumetone, and so
on. NSAIDs were predictably hailed as magic bullets to quash pain. Slowly, however, it
dawned that NSAIDs were effective, all right, but caused unwanted side-effects, some of them
serious. This prompted researchers to think of alternatives, medicines that had all the good
qualities of NSAIDs in the treatment of pain, but without their dangerous side-effects. The
emergence of cyclooxygenase-2 (COX-2) inhibitors, or coxibs, a new class of medications,
provided the means to that end, if not the end to a means. Besides, the arrival of coxibs that
work by inhibiting the enzyme, COX-2, which triggers the release of prostaglandins, one
thought, was a boon, until clinicians warned people with heart problems to exert caution and
avoid their use. COX-2 inhibitors were said to be superior to NSAIDs, in several ways.
Labelled super aspirins, COX-2 inhibitors were found to be as effective as the wonder
drug aspirin is in relieving arthritic pain, for instance, in clinical and patients trials and
treatment outcomes; they also had comparatively less tummy, or gastrointestinal, side-
effects in comparison to medications, like NSAIDs [1]. Besides, they were thought to provide
equivalent pain reducing and anti-inflammatory benefits associated with traditional NSAID
use but, without the inherent side-effects or platelet-related (blood-thinning) problems of
conventional NSAID agents. In addition, some researchers were of the opinion that they could
be useful agents in the management of a host of general and specific ailments, including
prevention and/or treatment of cancer. This brings us to the foundation of this review. Is there
something better than conventional COX-2 inhibitors?
Keywords: Pain, pain relief, COX inhibitors, arthritis, cancer, NSAIDs, herbs, natures
aspirin, ginger, turmeric, holy basil, green tea, conventional medicine, Ayurveda
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trauma, or from certain underlying causes, plays a key role in the creation of
such as arthritis. In certain cases, there is no prostaglandins involved in pain and
obvious cause of pain, or, one may inflammation. COX-2 inhibitors hamper the
erroneously attribute pain to a recent activity activity of specific COX enzymes, which
rather than a serious causal effect. Besides, it release prostaglandins. On the other hand,
is not uncommon for people to assume aches COX-1 produces prostaglandins that protect
as being caused, for example, by a recent the digestive system from its own erosive
sports activity, or hard work. In addition, most acids. So, it is important that the enzyme is
people would not know that aches might be best left to itself, and not interfered with [4].
symptomatic of a heart ailment, or a sign of COX is an enzyme naturally present in our
stomach cancer [3]. body. COX-1 enzymes are produced
abundantly throughout the body. These
Most individuals bogged down by pain reach enzymes are involved in the regulation of day-
by way of reflex for a bottle of pain-killers, or to-day cellular and metabolic activities
soothing balm to control, or get over pain. It maintaining stomach lining stability,
works. But, when the pain begins to stay, or regulating blood flow within the kidneys, and
leaves its visiting card in their body, or balancing platelet function. COX-1 should be
joints, they sense there is something wrong. present in the body always; also, it would not
They visit a physician or therapist to find out be the right thing for us to impede it. COX-2
whats gone wrong. The rest, as the clich enzymes, like COX-1 enzymes, are essential
goes, is elementary, nay alimentary. They for inducing pain. But, unlike the COX-1
are put on medication, most often a NSAID for enzyme, COX-2 enzyme is present in our body
pain relief. Soon enough, they get over their within a restricted area. Also, factors such as
pain syndrome, and also forget about it. They diet, stress, and injury can affect its formation.
are lucky. So, when COX-2 is produced on a constant
basis, persistent pain follows. The implication:
However, in certain instances, the pain only obstructing COX-2 is a choice wed rely upon
expands in its intensity and, over a period of for joint and muscular pain relief and
time, it becomes firmly established. When this management, among other things. COX-1
happens, they are at their wits end, not enzyme, as in vivo studies suggest, produces
because the NSAID medication they had prostaglandins that help maintain the
begun to take dutifully has given them relief, capability of the gastroduodenal mucosa, while
but because it has slowly led to some COX-2 enzymes form prostaglandins at sites
unpleasant side-effects; in certain cases, of tissue inflammation, or injury, which trigger
sombre side-effects. pain and swelling. To highlight one example;
aspirin and the other NSAIDs inhibit both
Its, therefore, not without reason that COX-1 and COX-2. They often cause
researchers were at their wits end and for long gastrointestinal bleeding and ulcers. On the
deliberated on a more acceptable line of other hand, herbal COX-2 inhibitors
treatment, with less side-effects. In the course selectively inhibit COX-2, while sparing
of time, like most scientific endeavours, their COX-1. Hence, they cause relatively less
sustained work paid dividends. As they gastrointestinal side-effects [5]. Prostaglandins
stumbled upon a group of novel medications, are natural chemicals, they are key elements
they found that they not only provided better involved in inflammation. Prostaglandins
pain relief, but were also relatively free of perform a variety of functions within the body,
side-effects. including the control of inflammation and
blood vessel permeability, regulation of
Their identity: herbal COX-2 inhibitors. There hormones, stomach acid secretion, body
are essentially two types of enzymes involved temperature, and smooth muscle contraction.
in prostaglandins production: COX-1 and The enzyme responsible for prostaglandins
COX-2. Prostaglandins are substances synthesis is, as already cited, COX. This is
responsible for pain as well as many other precisely the spoor vis--vis the COX
body functions, which also include protection enzymes significance. To go back to
of the stomach lining. COX-2, in essence, NSAIDs; NSAIDs reduce inflammation by
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Research & Reviews: A Journal of Pharmaceutical Science
Volume 6, Issue 3
ISSN: 2229-7006(online)
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Herbal Coxibs as Natural Aspirin Nidamboor and Nidamboor
acknowledged piece of evidence that NSAIDs NSAIDs, in the recent past, a lurking danger
anti-inflammatory effects are also due to the still looms large.
inhibition of COX-2 enzymes, not to mention
their side-effects. The term, COX-2, relates to a clue why the
enzyme works. COX has a specific job:
Besides, the action of conventional NSAIDs oxidising, or burning, a fat in the body called
for COX-1 and COX-2 enzymes differs arachidonic acid. This fat is an omega-6 fatty
substantially. Some NSAIDs (e.g., ketoprofen) acid, which occurs naturally in our cell
are relatively COX-1 selective, while drugs membranes, or walls. Omega-6 acids, found in
like ibuprofen and naproxen are fundamentally soybean, safflower, sunflower oil etc., are
non-selective. Also, drugs like diclofenac essential fats in our nutrition. They are
are relatively COX-2 selective. Besides, what fundamental for managing chronic
is often referred to as COX-2-selective- inflammatory conditions, thanks to their ability
NSAIDs continue to possess ample anti-COX- to alter prostaglandins production and also
1 enzyme activity. The result: they greatly yield to measurable changes in certain disease
inhibit gastric prostaglandins. This clearly parameters, especially osteoarthritis.
explains why none of the conventional, first-
generation NSAIDs, in its curative or One could think of the COX-2 enzyme as a
therapeutic concentration, or form, shows switch that turns on the fat and transforms
mercy to gastric COX-1 activity. Hence, they inflammatory substances. In other words, the
cause side-effects, some of them serious. enzyme is the source of power, the fat being
the electrical current, or cooking medium
As is well known, traditional NSAIDs are and, the end result being inflammation. We all
frequently used as first-line therapy for need the power of the COX-2 enzyme to fight
patients with rheumatoid arthritis and for bodily invasions, and react to trauma and
patients with osteoarthritis, who are not injury. However, when the power switch goes
responsive to the conventional medication, out of control, we may fall a victim to
acetaminophen, for e.g., paracetamol, which is friendly fire, like it sometimes happens in
commonly used for headache and pain. In fact, warfare. Result: we may develop some forms
an estimated 30 million people take traditional of arthritis and cancer, and even certain
NSAIDs regularly, and more than 90 million disorders that affect the brain. The situation
prescriptions are filled and 40 billion over-the- today, unlike before, is not desperate, or
counter (OTC) NSAID tablets are sold hopeless, thanks to the availability of herbal
annually worldwide. The inference is obvious; COX-2 inhibitor drugs, natural medicines that
long-term NSAID use can lead to can help beat the COX-2 inflammation.
gastrointestinal bleeding, peptic ulcer, and
other complications. Besides, some clinicians The first in the list of conventional drugs,
also underline the fact that NSAIDs are the which initiated new research, has, of course,
primary and major source of serious or adverse been the wonder drug, aspirin, which not only
drug reactions. inhibits the COX-2 enzyme, but also reduces
the gumminess of our blood platelets. In so
It is also estimated that 30 per cent of patients doing, aspirin helps ward-off heart attacks and
taking traditional NSAIDs develop persistent strokes. But, this effect comes with a hidden
gastrointestinal symptoms; more than 10 per cost. Aspirin and other NSAIDs cause adverse
cent discontinue treatment because of this side-effects, from time to time: severe
unfavourable side-effect. Figures estimate that gastrointestinal bleeding and kidney problems.
gastrointestinal bleeding and other Agreed that such anomalies have been
complications from long-term use of somewhat corrected with the introduction of
conventional NSAIDs account for at least modified, or safer, forms of aspirin. But, the
100,000 hospitalisations and 16,000 deaths in problem is, the newer versions of the wonder
the US alone, on a yearly basis [7]. Though drug lack the protective effect, or anti-
side-effects and adverse reactions have coagulant properties of their traditional
dropped somewhat by the use of selective cousin [8].
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Research & Reviews: A Journal of Pharmaceutical Science
Volume 6, Issue 3
ISSN: 2229-7006(online)
Also, with the emergence of COX-2 inhibitors dysfunction or liver damage (Note: Some
such as celebrex, which were yanked off the physicians use steroids, which are strong anti-
market, for their possible unpleasant inflammatory agents. They relieve pain
cardiovascular effects, it now looks like one quickly, but at a cost; they often diminish
celebrated too soon. Because, conventional white blood cell build-up at the location of
COX-2 inhibitors work on a different plane, infection or injury and, in so doing, slow down
not something through which our body the process of healing itself).
regulates inflammation and they also have
somewhat unpleasant side-effects? Possibly, Besides, the fact remains that more and more
yes. So, it would do us all a world of good if consumers in a growingly health-conscious
we go back to the basics again, and review world are becoming increasingly aware of the
joint affections and other disorders, with a harmful effects of NSAIDs. Also, their
holistic approach, and, in the process, examine numbers are expanding and for good reasons.
the biochemical pathways that often lead to It would, therefore, be heartening for us to
inflammation. know about the enormous benefits that
natures natural pharmacy: our herbs and
This simple approach has a definite advantage. plants hold as extremely effective and safe
It will help us understand the complexities of pain relievers, and also help us treat a host of
COX-2 inhibitors better and also show how we other disorders, from arthritic pain, obesity and
can circumnavigate the pain pathway with common cold to cancer. As a matter of fact,
good effect by the use of their herbal traditional herbs like green tea, turmeric,
cousins: natural, or herbal, COX-2 ginger, holy basil, oregano etc., used in pain
inhibitors. treatment work similarly to NSAIDs, and
COX-2 inhibitors, but without their
Scientists have (re)discovered several disagreeable side-effects.
traditional herbs that can safely inhibit the
COX-2 enzyme. These herbs are ginger, As Jill Hoppe, a certified nutritional herbalist
turmeric, holy basil, green tea, rosemary, puts it, Turmeric is a really good anti-
skullcap, oregano, Chinese goldthread, and so inflammatory with few side-effects, and it
on. To begin with, lets explore what herbal doesnt cause the gastric ulceration that aspirin
COX-2 inhibitors hold for us; a mirror to the does. Heres evidence: in a double-blind
future of pain relief gently, and purposefully, study, arthritis patients who were given
and without the troubled side-effect profile turmeric reported decreased inflammation and
of conventional, or synthetic, COX-2 pain. The studys researchers, in a report
medications; in other words, the safe and published in Carcinogenesis, attributed this
effective alternative mode for pain relief and effect to curcumin, a natural COX-2 inhibitor
physical, physiological, and emotional which is also turmerics active constituent [9].
wellness. Hoppe recommends 400 mg of turmeric daily
to reduce pain from swelling, or inflammation.
It may come as no surprise that more and more She also says that ginger and boswellia, an
people are disillusioned with the unwanted ancient Ayurvedic remedy, may be taken to
side-effects of conventional, or palliative, reduce pain from inflammation. Hoppe
therapies, and have turned, or now turn, to recommends chamomile too, as a mild anti-
natural herbs and plants to relieve discomfort inflammatory. Turmeric and ginger, she
and promote healing. As we all know, says, are both hot stimulating herbs.
conventional therapies often include NSAIDs Chamomile is good for someone with mild
such as aspirin and ibuprofen or even steroids. inflammation. She says chamomile is also
NSAIDs work by inhibiting COX-1 and COX- effective either as a poultice or tea.
2 enzymes, which cause inflammation. Long-
term use of NSAIDs, however, can produce It may safely be said that herbs can help
unwanted side-effects, including relieve pain, but it is important to look at the
gastrointestinal ulceration, or bleeding, and basic causes of pain and its discomfort.
peptic ulcers. They can also lead to kidney Besides, it may also be said that natural
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remedies dont characteristically relieve pain It is obvious that there is a pathway to pain,
as swiftly as conventional medications do, but the channel of pain. So, let us look at what this
it would only be sensible for us to stand by inflammatory pathway is all about and how
them with patience; because they are safe and COX-2 inhibition works on it. COX forms
also sure to cure pain from the root with the bodys inflammatory pathway. Aspirin and
relatively less, or no, side-effects. other NSAIDs obstruct COX in both its forms:
COX-1 and COX-2. COX-2 produces
There is, of course, no need to have the prostaglandins, which, as already cited, are
patience to move mountains but a little powerful triggers of pain and inflammation.
patience with herbs can bring us huge COX-1 is essential for stomach lining
dividends in terms of safety and long-lasting protection. Interfering with its activity can lead
relief. You know that this also comes with an to gastric smarting from minor discomfort to
added bonus: reduced reliance on bleeding ulcers. It is precisely for this reason
conventional drugs that dont actually go to that new COX-2 inhibitors, which block COX-
the source of pain, but often generate 2 selectively, and not COX-1, zoomed into
serious, long-term side-effects. prominence.
Pain is our bodys natural response to disease, While it is agreed that COX-2 inhibition
injury, or other conditions that could harm relieves pain symptoms, new research admits
health. We often experience pain as a result of that it has little or no effect on any underlying
the activation of specialised nerve endings degenerative process. To recall the words of
called nociceptors, which are found in most scientists that discovered COX, The short-
tissues in the body. These nerve endings excite term effects of COX-2 inhibitors on pain and
the feeling of pain in answer to: swelling of inflammation and arthritis may be
1. any type of stimulus that causes tissue achieved at the cost of an increased propensity
damage, pressure, heat, cold; to long-term tissue damage with which these
2. swelling, or excessive stretching of a cytokines, or non-antibody proteins, have been
structure; associated with [10]. To recall another
3. extended muscular contraction, or spasm; observation, Tumor necrosis factor (TNF)
4. insufficient blood flow to an organ; and, and interleukin-1 (IL-1) are considered to be
5. the presence of certain chemicals. master cytokines in chronic, destructive
arthritis. The reason is simple. The cytokine
In addition, any injury or irritation of tissues TNF-alpha figures more significantly in
can incite the nociceptors. Besides, pain can prompting inflammation, while IL-1 beta is
continue long after the injury or irritation has more involved in the destruction of cartilage
occurred, because the chemicals that influence and bone. The inference: it is important to
the nociceptors hang on at the site of the injury inhibit TNF-alpha and IL-1 beta just as well
even after the distress is well-entrenched. when using a COX-2 inhibitor.
Inflammation is also a natural response to This is the bright prospect herbal COX-2
pain, disease, or injury. The process is inhibitors hold for us without the side-effects
characterised by redness, pain, swelling and of conventional medications. Our body has
warmth. In some cases, there may be loss of two inflammatory pathways, both evolving
function. The suffix itis refers to the process from arachidonic acid, the inflammatory
of inflammation. For example: arthritis precursor. So, it is obvious that blocking one
signifies the inflammation of the joints; pathway while sparing the other isnt good
appendicitis relates to the inflammation of the medicine. This was reason enough for
appendix. However, it may be said that one pharmaceutical companies to embark on the
can have pain without inflammation, although development of drugs that blocked both
inflammation without pain is uncommon. branches of the inflammatory pathway.
Also, both pain and inflammation can be acute However, the pitfall for such conventional
(sudden onset, with shorter duration), or (NSAID) drugs has been, they block both
chronic (slow onset, and long-lasting). forms of COX (COX-1, and COX-2), and they
also lead to a persistent rebound effect on
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Research & Reviews: A Journal of Pharmaceutical Science
Volume 6, Issue 3
ISSN: 2229-7006(online)
A Japanese pharmaceutical company Shionogi Like all discoveries, the emergence of the
has one such medicinal candidate under COX-2 enzyme has given the medical world a
extension.The remedy illustrates the shot in the arm. It has also given the key to the
potential of the dual-inflammatory pathway fundamental cause of some of our most
blockade. Called S-2474, the medication is a devastating diseases. No wonder, conventional
potential dual-inhibitor of COX-2 and 5-LOX. drug companies have jumped on to the
In clinical studies, S-2474 significantly bandwagon for newer remedies and produced
inhibited experimentally induced arthritis and pharmaceutical substances that inhibit the
oedema, while suppressing inflammatory enzymes dreadful effects. The best part is;
activity, all without the mandatory research has also had a happy dual effect.
gastrointestinal ulcer/bleeding or side-effect When scientists synthesised COX-2 inhibitors,
profile of NSAIDs [11]. It has also been a hugely beneficial, and grossly unexpected,
reported in patient trials that S-2474 protects side-benefit also resulted from their efforts; the
brain cells from senile plaque which is motivation to find herbs and plant compounds
characteristic of Alzheimers disease, a to synthetically copy, or mimic, the former. In
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Herbal Coxibs as Natural Aspirin Nidamboor and Nidamboor
It is, again, in situations such as these, that It is a well-known fact that, for ages, natural
herbal COX-2 inhibitors offer us a far better remedies such as white willow bark (Salix
advantage, primarily because they are alba) and myrtle (Myrtus communis) have
natural. Hence, they are less likely to cause provided pain relief for millions of people.
unwanted side-effects, including gastric Willow bark, an ancient remedy, which is used
distress.Now, a bit of the fundamentals; this is to treat fevers and arthritic complaints, has
also the dull part. Cyclooxygenases catalyse often been referred to as natures aspirin.
the conversion of arachidonic acid. This leads Salicin is its active ingredient. Several human
to biologically active prostaglandins, which studies have evaluated and confirmed the
have a plethora of functional roles to perform, remedys ability to rapidly relieve pain and, in
management of the inflammatory process and the process, reduce inflammation.
protection of the gastrointestinal tract,
including the regulation of our inner biological Myrtle has also, for long, been used as a
clock. stimulant, astringent, emetic, anti-spasmodic,
expectorant, diaphoretic, and tonic. It finds
It may be acknowledged that the two reference in ancient Egyptian and Greek
cyclooxygenase forms (COX-1 and COX-2) manuscripts. Evidence also supports the fact
also differ in their pattern of tissue expression that it was prescribed by Hippocrates, father of
and regulation. COX-1 is constitutively modern medicine, to combat pain and fevers.
expressed in virtually all tissues, most notably What was not known for centuries was the
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Research & Reviews: A Journal of Pharmaceutical Science
Volume 6, Issue 3
ISSN: 2229-7006(online)
exact mechanism of its action. Salicin, as The real advance, therefore, is natural or
studies now report, does not cause stomach herbal coxibs, wonder medicines, derived from
upset, or gastric bleeding, as aspirin does. It nature, that have proved their worth for
lowers your bodys levels of prostaglandins thousands of years. Besides, they are easily
and has been known to have long-lasting affordable in terms of cost and ease of use.
effects. It has a noticeable action on acute and Whats more, COX-2 inhibition would have
chronic pain, including back and neck pain, been apparent with several common and
muscle and menstrual cramps. A large number widely recognised natural products, from the
of arthritis sufferers have experienced reduced time our ancients first used them. It is a
swelling and inflammation and eventually different narrative that it was not known for
increased mobility in the back, knees, hips, long why actual healing benefits resulted from
and other joints, with its use. their use, until scientists isolated the COX
enzymes responsible for such a function.
CONCLUSION
The quest for an herbal analgesic, or anti- This is, of course, the opening, not the
inflammatory agent, which could provide concluding, part of the story, because until
therapeutic efficacy equivalent to that of each of natures herbal coxibs, or newer
traditional NSAIDs, but without their medications, is systematically tested, verified,
gastrointestinal toxicity, has spurred on and replicated for scientific and beneficial
research efforts, as already cited, and from activity, there wont be a standard to measure
these forays statistics has also emerged. New actual clinical effects. The best part is, the
data correspond to a natural drug that inhibits probability, at the present time, seems to
COX-2 without affecting COX-1. This has led usefully support natural compounds, or herbal
to the emergence of a truly new era, the coxibs, serving us as natures original
development of natural COX-2 inhibitors. modulators of pain and as curative
medications. This also bids fair to the future of
From the thorough testing of such COX-2 safe, natural and effective pain relief.
inhibitors which began with in vivo animal
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AUTHOR BIBLIOGRAPHIES
Rajgopal Nidamboor, PhD, is a board-
certified wellness physician, Fellow of the
College of Chest Physicians (FCCP), Member
of the Centre of Applied Medicine (M-CAM),
writer-editor, commentator, critic, columnist,
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