Received: 1 May 2020 | Revised: 9 July 2020 | Accepted: 2 August 2020

DOI: 10.1111/1440-1681.13392

REVIEW ARTICLE

Paracetamol – An old drug with new mechanisms of action

Grzegorz W. Przybyła1 | Konrad A. Szychowski2 | Jan Gmiński2

1
Medical Faculty, University of Opole,
Opole, Poland Abstract
2
Department of Lifestyle Disorders and Paracetamol (acetaminophen) is the most commonly used over-the-counter (OTC)
Regenerative Medicine, University of
drug in the world. Despite its popularity and use for many years, the safety of its
Information Technology and Management in
Rzeszow, Rzeszow, Poland application and its mechanism of action are still unclear. Currently, it is believed that
paracetamol is a multidirectional drug and at least several metabolic pathways are
Correspondence
Konrad A. Szychowski, Department of involved in its analgesic and antipyretic action. The mechanism of paracetamol action
Lifestyle Disorders and Regenerative
consists in inhibition of cyclooxygenases (COX-1, COX-2, and COX-3) and involve-
Medicine, University of Information
Technology and Management in Rzeszow, ment in the endocannabinoid system and serotonergic pathways. Additionally, par-
Sucharskiego 2, 35-225 Rzeszow, Poland.
acetamol influences transient receptor potential (TRP) channels and voltage-gated
Email: konrad.szychowski@gmail.com
Kv7 potassium channels and inhibits T-type Cav3.2 calcium channels. It also exerts
Funding information
an impact on L-arginine in the nitric oxide (NO) synthesis pathway. However, not all
University of Information Technology and
Management in Rzeszow, Grant/Award of these effects have been clearly confirmed. Therefore, the aim of our paper was to
Number: DS 503-07-02-21
summarize the current state of knowledge of the mechanism of paracetamol action
with special attention to its safety concerns.

KEYWORDS

acetaminophen, COX-1, COX-2, COX-3, paracetamol

1 | I NTRO D U C TI O N Prostaglandins are mainly mediators of inflammatory pain.7,8 The

Paracetamol (which is a recommended international nonpropri-
etary name of acetaminophen (acetyl-p-aminophenol, APAP)), was
synthesized in 1878 by Morse and first introduced into medicine
1-3
as an antipyretic/analgesic by Von Mering in 1893.
was rarely used in favor of phenacetin. However, after discovering
that paracetamol is the main metabolite of phenacetin with better
tolerance vs. phenacetin nephrotoxicity, in the 1950s paracetamol
4-6
replaced phenacetin in use and has become a widespread drug
since then.
enzymes responsible for the synthesis of these mediators are called
cyclooxygenases.9 In 1971, John Vane identified the first cycloox-
ygenase (COX-1).10 This discovery helped explain the mechanism
of action of aspirin, which has been extensively used since 1899 as
Initially, it an analgesic and anti-inflammatory drug.10 Afterwards, in 1991, Xie
et al at Daniel Simmons's laboratory, Brigham Young University, dis-
covered the second cyclooxygenase (COX-2).11,12 Interestingly, the
structure of the COX-2 enzyme did not differ substantially from the
previously discovered COX-1.13 However, they have different clinical
significance.14,15 Finally, in 2002, Chandrasekharan et al discovered

Abbreviations: 2-AG, 2-arachidonoylglycerol; 5-HT, 5-hydroxytryptamine; AA, arachidonic acid; ADHD, attention deficit hyperactivity disorder; AEA, N-arachidonoylethanolamine;
AM404, N-arachidonoylphenolamine; APAP, N-acetyl-p-aminophenol acetaminophen; Cav3.1, isoform of T-type voltage-gated calcium channel (T-channels); Cav3.2, isoform of T-type
voltage-gated calcium channel (T-channels); Cav3.3, isoform of T-type voltage-gated calcium channel (T-channels); CB1, cannabinoid receptors type 1; CNS, central nervous system;
COX, cyclooxygenase; COX-1, cyclooxygenase-1; COX-2, cyclooxygenase-2; COX-3, cyclooxygenase-3; CYP450, cytochrome P450; DRG, dorsal root ganglion; FAAH, fatty acid amido
hydrolase; GABA, gamma-aminobutyric acid; GluR1, ionotropic glutamate receptor; iNOS, inducible nitric oxide synthase; LPS, lipopolysaccharides; NAPQI, N-acetyl-p-
benzoquinoneimine; NF-κB, nuclear factor kappa B; NMDA, N-methyl-D-aspartate; nNOS, neuronal nitric oxide synthase; NO, nitric oxide; NS-398, N-(2-cyclohexyloxy-4-nitrophenyl)
methanesulfonamide; NSAIDs, nonsteroid anti-inflammatory drugs; OTC, over-the-counter; PAG, periaqueductal gray; p-BQ, p-benzoquinone; PG, prostaglandin; PGD2, prostaglandin
D2; PGE 2, prostaglandin E2; PGF2, prostaglandin F2; PGG2, prostaglandin G2; PGH2, prostaglandin H2; PGHS, prostaglandin endoperoxide-H synthase; PGI2, prostacyclin I2; pH, power of
hydrogen or potential for hydrogen; POX, peroxidase; PSD95, postsynaptic density protein 95; RTX, resiniferatoxin; RVM, rostral ventromedial medulla; SC560, (5-(4-chlorophenyl)-1-
(4-methoxyphenyl)-3-trifluoromethyl pyrazole); SNAP, S-nitroso-N-acetylpenicillamine; Syp, synaptophysin; THC, tetrahydrocannabinol; Trkb, tropomyosin receptor kinase B; TRP,
transient receptor potential; TRPA1, transient receptor potential channel subfamily ankyrin-1; TRPV1, transient receptor potential channel subfamily vanilloid-1; TRPV4, transient
receptor potential channel subfamily vanilloid-4; TTA-A2, (R)-2-(4-cyclopropylphenyl)-N-(1-(5-(2,2,2-trifluoroethoxy)pyridin-2-yl)ethyl) acetamide; TXA 2, thromboxane A 2; TXB2,
thromboxane B2; WIN 55,212-2, (R)-(+)-[2,3-Dihydro-5-methyl-3-(4-morpholinylmethyl)pyrrolo[1,2,3-de]-1,4-benzoxazin-6-yl]-1-naphthalenylmethanone mesylate.

Clin Exp Pharmacol Physiol. 2021;48:3–19. wileyonlinelibrary.com/journal/cep© 2020 John Wiley & Sons Australia, Ltd | 3
 |

14401681, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1440-1681.13392 by Readcube (Labtiva Inc.), Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
4 PRZYBYŁA et al.

the third cyclooxygenase (COX-3) in canines and suggested that
its expression might play a role in the antipyretic effect of parac-
etamol.16 However, the paracetamol impact on COX-3 activity did
not explain all of the observed effects.
Therefore, the aim of our paper was to summarize the current
state of knowledge of the mechanism of paracetamol action.
the highly specific oxygenation of arachidonic acid in the 11R con-
figuration and ends with a 15S oxygenation to form PGG2. Next, the
POX activity reduces PGG2 to PGH2.17 Prostaglandin H undergoes
further transformation by different tissue enzymes into the prosta-
glandins of the D (PGD2), E (PGE2), and F (PGF2) series, prostacyclin
(PGI2), and thromboxanes A 2 and B2(TXA 2 and TXB2, respectively)18

2 | C YC LO OX YG E N A S E S
Cyclooxygenases are part of a bifunctional enzyme, prostaglandin
endoperoxide-H synthase (PGHS), which together with the peroxi-
dase (POX) part converts arachidonic acid (AA) into prostaglandin
17
H2(PGH2). The COX biosynthesis of prostaglandin (PG) begins with
Highlights
• Paracetamol and cyclooxygenases
• Paracetamol effect on the TRP, Cav3.2, and Kv7 channels
• Nitric oxide pathway in paracetamol action
• Paracetamol administration safety aspects

F I G U R E 1 Simplified peripheral
schematic diagram of arachidonic acid
metabolism, showing that prostaglandin
endoperoxide-H synthase (PGHS)
consists of two enzymes: a clinically
more important cyclooxygenase
part and peroxidase. The conversion
of AA involves first cyclization to
unstable 15-hydroxyperoxide (PGG2)
by cyclooxygenase, and then the
peroxidase (POX) activity reduces the
generated PGG2 to PGH2. Prostaglandin
H undergoes further transformation
in tissues into different endogenous
regulators: prostaglandins of the D
(PGD2), E (PGE2), and F (PGF2) series,
prostacyclin (PGI2), and thromboxane
(TXA 2)

PRZYBYŁA et al.
(Figure 1). These lipid derivates exert a wide range of effects on the
human body (described in Table 1).
The common nonsteroid anti-inflammatory drug (NSAID) treat-
ment focuses on their inhibition of COX-1 and COX-2 in various
proportions.19,20 COX-1 is a constitutive enzyme, which is perma-
nently expressed in many tissues, mainly in the gastric mucosa and
kidneys.21,22 Therefore, frequent intake of high doses of NSAIDs de-
creases the production of protective prostaglandins E2 (PGE2) and I2
(PGI2) in the gastric mucosa, which can lead to gastrointestinal side
23
effects such as gastric ulceration. On the other hand, COX-2 shows
its activity only during ongoing inflammation.24 In consequence, se-
lective COX-2 drugs (coxibs) reduce side effects associated with the
therapy with COX-1-dependent drugs.25 Unfortunately, in blood
vessels, COX-2 is the preferred enzyme in the synthesis of PGI2 to
protect against vascular ischaemia. 26 Therefore, selective COX-2 in-
hibition leads to reduced PGI2 formation, thereby increasing vascular
ischaemia and heart disease.27 The discovery of selective inhibitors of
COXs facilitated individualization of therapy for the patient by choos-
ing the appropriate selective inhibitor, depending on the desired
clinical effect and related side effects such as gastrointestinal and
cardiovascular risk factors.28-30 Common NSAIDs show antipyretic
activity by inhibiting the lipopolysaccharide (LPS)-induced COX-2
enzyme expressed in hypothalamic endothelial cells, where it causes
PGE2-mediated pyrexia.31 However, this relationship does not occur
in the action of paracetamol and other drugs that have analgesic and
antipyretic effects. Because of the lack of anti-inflammatory effects
of these drugs, they were suggested to interact with COX-3.16
3 | U N I Q U E PRO PE RTI E S O F COX-3
The discovery of COX-3 gave considerable hope in understanding
the effects of some commonly used antipyretic and analgesic drugs,
16,32
in particular the effect of paracetamol. Although, as suggested
by Chandrasekharan et al, COX-3 might ultimately have similar
mechanisms of action to that of the previously discovered isoforms,
it seems to have some other particular distinctive features as well.16
The discovery of COX-3 in a dog by using molecular cloning has al-
20
ready raised many questions. The first extraordinary property was
the expression of COX-3. Although COX-3 is transcribed from the
same gene as the previously discovered COX-1, it produces func-
tionally different polypeptides which are highly sensitive to analge-
sic/antipyretic drugs but exert low anti-inflammatory effects.16 This
is possible by the additional retaining of intron 1 in its mRNA com-
pared to fully spliced COX-1.16 This modification caused an insertion
of two amino acids below the initiating methionine leading to addi-
tion of 30 amino acids to the signal peptide. Nevertheless, the exact
mechanism of the conversion of COX-3 mRNA to an active peptide
with enzyme activity is not clear.16,20,33
Chandrasekharan et al conducted research to compare the sensi-
tivity of the three cyclooxygenase isoenzymes expressed in cell cul-
16
tures to inhibition by a selection of NSAIDs. COX-3 was found to
be more sensitive than COX-1 or COX-2 to inhibition by paracetamol,
|
14401681, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1440-1681.13392 by Readcube (Labtiva Inc.), Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
5
indomethacin, diclofenac, ibuprofen, and aspirin.16 These results
suggested that COX-3 possesses COX activity that differs pharma-
cologically from both COX-1 and -2, but is more similar to COX-1.16,34
According to some data, inducible COX-3 produces less PGE2 com-
pared to COX-1 or COX-2.35 Unfortunately, this finding turned out to
be wrong. Since they are highly polar, the tested drugs are unlikely to
reach brain COX-3 in effective concentrations. 20
Another feature of COX-3 is the localization of expression.36
Initially, Chandrasekharan et al (2002) assumed that the enzyme was
expressed in the cerebral cortex and heart. However, the expression
of COX-3 mRNA rather appears to take place in the pituitary gland
and the hypothalamus, which seems to be in good agreement with
the finding of sites associated with fever.16,36-38 Similar to NSAIDs,
paracetamol can enter the central nervous system across the blood–
brain barrier, which allows it to reach the effective concentration in
the brain to inhibit COX-3, which could also explain why paracetamol
is often more effective against headache and fever than some other
NSAIDs.39 Interestingly, some literature reveals that COX-3 may be
capable of inducing a remission in chronic inflammatory conditions
and may be involved in the growth of cervical, ovarian, leukemia, and
colon cancer.35 Furthermore, there are promising data that patients
with Alzheimer's disease have an increased amount of COX-3, and
a long-term use of NSAIDs has been reported to somewhat reduce
this disease.39
4 | M EC H A N I S M S O F COX-3 I N H I B ITI O N
The proposed theories of COX-3 involvement in the induction of
fever and pain are unclear. The first discrepancies appeared after
taking into account studies of the enzyme producing prostanoids,
which underlie fever development. 20,40 After deletion of the COX-2
gene but not the COX-1 gene in mice, the fever blunted.40 This sug-
gests that the prostanoid-producing enzyme is associated with nei-
ther the COX-1 protein nor the COX-1 gene, which, importantly, also
encodes COX-3. Fever response is strongly related to a rapid induc-
tion of COX-2 expression and increased PGE2 production, with no
role for COX-1 or a COX-1 gene product (eg, COX-3).41 Hence, COX-
2-selective inhibitors having a weak effect on COX-1 and COX-3 are
as good at reducing fever as traditional NSAIDs.42-45
The COX-3 theories started declining after it had appeared that
COX-3, so sensitive to paracetamol in dogs, does not serve such a
function in the human organism.46 Nevertheless, a canine COX-3
analogue certainly exists in the organism of humans and rodents, es-
pecially in the central nervous system (CNS).47 The length of intron 1
in human COX-3 differs by one nucleotide from that observed in the
dog, thereby shifting the rest of the protein out of frame.34 In order
to confirm this, 24 cDNAs of COX-1 were cloned from the human
cerebral cortex. In all clones, intron 1 of human COX-1 is 94-nucle-
otide long, thus shifting the remaining sequence of human COX-3
out of frame vs. the open reading frame of COX-1.46,48 Therefore,
in rodents and humans, full-length proteins are formed with com-
pletely different amino acid sequences than COX-1 or COX-2 and
 |
6 PRZYBYŁA et al.
TA B L E 1 Receptors of prostaglandins, prostacyclins, and thromboxanes and their proposed physiological effects, based on articles19,190:
Main products of the
arachidonic acid (AA)
conversion
Prostacyclin (PGI2)
Prostaglandin E2 (PGE2)
Prostaglandin F2α (PGF2α)
Prostaglandin D2 (PGD2)
Thromboxane A 2 (TXA 2)
Note: AA, arachidonic acid; DP1, prostanoid receptor 1; DP2, prostanoid receptor 2; EP1, prostaglandin E2 receptor 1; EP2, prostaglandin E2 receptor
2; EP3, prostaglandin E2 receptor 3; EP4, prostaglandin E2 receptor 4; FP, prostaglandin F receptor; IP, prostaglandin I2 receptor; PGD2, prostaglandin
D2, PGF2α , prostaglandin F2α; PGI2, prostacyclin; TP, thromboxane receptor; TXA 2, thromboxane A2.
14401681, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1440-1681.13392 by Readcube (Labtiva Inc.), Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Receptors Function Localization of activity
191
IP Arterial vasodilatation, inhibition of platelet aggregation Cardiovascular system
192
Bronchodilation 193 Respiratory system
194
Cytoprotection Gastrointestinal system
EP1, EP3 Gastrointestinal tract smooth muscle contraction Gastrointestinal system
195,196
EP2 Gastrointestinal tract smooth muscle relaxation
EP1 Cytoprotection,197,198
EP3 ↓ Gastric acid secretion 199
EP4 ↑ Gastric acid secretion 200
Female: EP2, EP4; Regulation of blood pressure 201 Cardiovascular system
Male: EP1, EP3
EP2, EP4 Vasodilatation 202,203
EP4 Neonatal adaptation of circulatory system 204
EP2 Bronchodilatation 205 Respiratory system
EP3 Uterine contraction (when pregnant) 206,207 Female reproductive organs
oxytocic action 208,209
EP2 Fertility 203,210 Male reproductive organs
211,212
EP3 Regulation of neurotransmitters release Nervous system
fever generation 213,214
EP3, EP1 Pain 215,216
EP2, EP4 Renin release 217 Renal system
218
EP1, EP3 Inhibition of Na reabsorption in kidney
EP3, Inhibition of vasopressin-stimulated water reabsorption 218
EP4 Regulation renal blood flow and glomerular filtration rate
218
EP2 Inhibition of T lymphocyte activation and proliferation Immune system
219-221
EP2,EP4 Promotes differentiation of B-cell immunoglobulin 222
EP2, EP4 Regulate antigen presenting cells functions 221
Not specified FP Hyperalgesia, 223 pyrogenic 224 Nervous system
225
Uterine contraction, oxytocic action Female reproductive organs
Fertility 226 Male reproductive organs
227
Bronchoconstriction Respiratory system
Venous vasoconstriction 228 Cardiovascular system
229
↓ Intraocular pressure Eyes
DP1, DP2 Platelet inhibition 230,231 Cardiovascular system
232
DP1 Vasorelaxation
TP Bronchoconstriction, cough 233,234 Respiratory system
235
DP1 Regulation of eosinophil activity Immune system
DP2 Chemoattraction, 235 leukocyte activation 236,237
DP1, DP2 Activation of Th2 lymphocytes, 238,239 initiation and
maintenance of allergic diseases 239,240
TP Vasoconstriction, platelet activation, 241 thrombosis242 Cardiovascular system
243
Bronchoconstriction Respiratory system

PRZYBYŁA et al.
without catalytically active COX-3 as in dogs which converts AA into
prostaglandin H; thus it is improbable that COX-3 in these species
49,50
plays a role in prostaglandin-mediated fever. Moreover, the par-
ticipation of COX-3 in the mechanism of paracetamol action in hu-
mans has not been substantiated, which was confirmed by different
38,51
authors.
The suggestion of COX-3 liability for pain has not stood the test
of time either. Pain is a distinctly more complicated process than
pyresis, because it can be mediated through substantially more fac-
52
tors. One of these is the previously mentioned prostanoids, which
were supposed to be produced in humans eg by COX.53 However,
after it turned out that COX-3 in humans did not serve a cyclooxy-
genase function, the concept of COX-3 responsibility for pain forma-
49
tion also proved unlikely.
Finally, all these considerations appear to argue against the
hypotheses proposed by Chandrasekharan et al, ie COX-3 being
the site of action of antipyretic NSAIDs and COX-2-selective
16,49
drugs, even though their findings have contributed to the dis-
covery of two previously unknown COX-1 variants retaining in-
tron-1. They also promoted profound research on the real action
of paracetamol showing that it most likely works in a different site
50
than NSAIDs. However, there are currently only a handful of sci-
entific articles on this cyclooxygenase splicing variant. Therefore,
some scientists have still not lost their hope in the potential role of
the identified three COX isoenzymes in the mechanism of parac-
39,54-56
etamol action; hence, there are still ongoing discussions.
may be helpful to examine the transcription of COX genes care-
fully, in particular the COX-1 gene, to determine the exact pur-
pose of the COX-3 protein and its other protein variants. This can
ultimately provide greater understanding of the paracetamol ac-
tion, or even an effective anti-cancer treatment and therapy for
Alzheimer's disease. 39
5 | PA R AC E TA M O L – OTH E R
M EC H A N I S M S O F AC TI O N
5.1 | COX-dependent central mechanism
When the concept of the COX-3-dependent paracetamol action was
shown to be irrelevant, there were still theories regarding the pre-
viously discovered isoenzymes COX-1 and COX-2 that paracetamol
would act on in the CNS.
Firstly, paracetamol has no significant anti-inflammatory activity
and low incidence of adverse effects associated with classic COX-1
1,57
inhibitors like aspirin. Therefore, paracetamol could be a specific
prostaglandin inhibitor in the CNS. This was shown in observations
in which paracetamol reduced prostaglandin synthesis ten times
stronger in the brain than in the spleen16,58-60 or acted through an
analgesic mechanism independent of the inhibition of prostaglandin
formation.61,62
Secondly, studies conducted by Graham and Scott have shown
that paracetamol really inhibited prostaglandin synthesis, but only
|
14401681, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1440-1681.13392 by Readcube (Labtiva Inc.), Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
7
in well-functioning cells where the AA concentration was high
enough.60 Subsequently, research conducted by Hinz and Brune
(published in 2006–2012) and other investigations revealed that
paracetamol was even a preferential inhibitor of the COX-2 isoen-
zyme, provided that the peroxide concentration in the environment
was low.51,63-65 Such peroxide-dependent inhibition of COX may
explain why paracetamol does not suppress platelet activity and in-
flammation.59,63,64 Besides, Kalgutkaret et al showed that the parac-
etamol metabolite N-arachidonoylphenolamine (AM404) blocked
COX-1 and COX-2 in LPS-stimulated macrophages. In this context,
AM404 was almost as effective as the selective COX-2 inhibitor
N-[2-(cyclohexyloxy)-4-nitrophenyl]-methanesulfonamide (NS-398)
and the nonselective COX inhibitor indomethacin.66 Another postu-
late for the anti-inflammatory component of AM404 was proposed
by Saliba et al, who provided new significant insights demonstrating
that AM404 in activated microglia prevented prostaglandin synthe-
sis (PGE2, PGD2) by inhibiting COX-1 and COX-2 activity.67
A compelling argument in favor of the COX-dependent mecha-
nism of action of paracetamol was presented in research conducted
by Ayoub et al in 2004 and 2019. Paracetamol-induced hypother-
mia was shown to be reduced in parallel with its inhibitory effect on
the synthesis of brain prostaglandin E2 (PGE2) in cyclooxygenase-1
(COX-1) gene knockout mice compared to wild-type mice. However,
this effect was not seen in COX-2 gene knockout mice, suggesting
that the hypothermic mechanism of paracetamol action depends
It on the inhibition of the centrally expressed enzyme derived from
the COX-1 gene.68 Recent investigations have provided further sup-
port for this notion.69 Ayoub and Flower have demonstrated that,
in a COX-2-dependent and PGE2-mediated model of (LPS) endotox-
in-induced fever, paracetamol induced antipyretic and hypothermic
actions in COX-1 wild-type mice, but not in COX-1 knockout mice.
Moreover, therapeutically administered paracetamol also reduced
PGE2 biosynthesis in the hypothalamus in wild-type fever mice
with the COX-1 gene, but not in feverish COX-1 knockout mice.69
Therefore, paracetamol-induced hypothermia is temporarily cor-
related with a decrease in PGE2 synthesis in the brain.70 Thus, it is
known that the antipyretic effect of paracetamol depends on the in-
hibition of the enzyme derived from the COX-1 gene.54 After COX-3
exclusion, there are two possible targets for paracetamol-induced
hypothermia: either COX-1 or a COX-1 protein variant.69 To check
whether COX-1 is the target, a study with the use of a selective
COX-1 inhibitor 5-(4-chlorophenyl)-1-(4-methoxyphenyl)-3-(triflu-
oromethyl)-1H-pyrazole (SC560) and a dual inhibitor indomethacin
in normothermic mice was carried out. In both cases, hypothermia
at pharmacologically active doses was not induced,69 compared to
cases where paracetamol caused hypothermia in feverish mice even
at therapeutic doses, despite its antipyretic effects.71 This hypother-
mic effect may have been mediated through AM404,72,73 which is
not certain, since the reduction of the conversion of paracetamol to
AM404 by inhibition of fatty acid amido hydrolase (FAAH) did not
prevent the development of hypothermia induced by paracetamol
(Table 2).74 Therefore, a conclusion was formulated that a protein
variant of COX-1, which also probably mediates the antipyretic
 |
8 PRZYBYŁA et al.
Paracetamol compound Target of action
AM404(?) Protein variant of COX-1
(hypothalamus)
AM404 Endocannabinoid system and
serotonergic pathways
AM404 TRPV1 channels (CNS)
AM404 T-type Cav3.2 calcium channels
(CNS)
NAPQI and p-BQ TRPA1 channels (peripheral nerve
NAPQI endings)
NAPQI Kv7 potassium channels (dorsal root
ganglion and spinal dorsal horn
neurons)
Note: AM404, N-arachidonoylaminophenol; NAPQI, N-Acetyl-p-benzoquinone imine; p-BQ,
p-benzoquinone.
effect of paracetamol in the hypothalamus is the target of parac-
etamol-induced hypothermia rather than COX-1.69
In contrast, some research does not corroborate to the COX-
dependent central mechanism of paracetamol action. For instance, a
combination of paracetamol with a COX inhibitor, eg ibuprofen, im-
proves the analgesic effect and exhibits antipyretic activity, in con-
trast to the effect of both these compounds administered separately.
This may suggest that they act through different mechanisms.75,76 As
indicated in further studies, paracetamol actually reduces inflamma-
tory hyperalgesia associated with the mechanism of prostaglandin
production by COX in the central nervous system.16,58-60 In mice, hy-
peralgesia was induced through intrathecal PGE2 injection and com-
77-79
pared with paracetamol administration. The results also suggest
that paracetamol alleviates inflammatory hyperalgesia through a
mechanism independent of prostaglandin formation.62
Consequently, as demonstrated by current and previous re-
search, the COX-1- and COX-2-dependent central mechanism of
paracetamol action cannot be definitively excluded, but it is not
thought to be the primary mode of action.61 Nevertheless, regard-
ing the hypothermic and antipyretic effects of paracetamol, it seems
highly likely that they are mediated by a centrally expressed protein
69
variant of COX-1, as shown in recent studies.
5.2 | Endocannabinoid system-dependent action
In this context, it is worth noting that, through oxygenation, COX-2
contributes to the metabolism of endocannabinoids.80,81 For COX-2,
the maximal rate of anandamide (N-arachidonoylethanolamine; AEA)
oxygenation was 27% of that of AA. For COX-1, this value was 11%,
indicating that endocannabinoid-AEA is a preferred substrate for
COX-2.82 The degradation of another important endocannabinoid
system agonist 2-arachidonoylglycerol (2-AG) has also been shown,
82,83
but only by COX-2. It was also proved that competitive inhibitors
of AA oxygenation by COX-2, such as ibuprofen and mefenamic acid,
are potent time-dependent inhibitors of 2-AG. In turn, no inhibition
14401681, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1440-1681.13392 by Readcube (Labtiva Inc.), Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
TA B L E 2 Simplified summary of the
Function
major and most likely mechanisms of
Hypothermic and paracetamol action
antipyretic effects
Analgesic effect
Analgesic effect
Analgesic effect
Analgesic effect
Hypothermic and
antipyretic effects
Analgesic effect
was observed in the case of such potent time-dependent COX inhib-
itors as indomethacin.84,85 Therefore, the paracetamol-induced inhi-
bition of COX-dependent endocannabinoid degradation or blockade
of endocannabinoid transporters can lead to drug-induced analge-
sia, which remains to be determined.1,86,87
In the CNS, as a result of deacetylation and later conjugation with
AA by CNS FAAH, a paracetamol metabolite AM404 is generated,
first evidenced in humans in 2017.88,89 It was shown that AM404
increased tissue concentrations of endocannabinoid lipoamino acids
AEA and 2-AG through inhibition of anandamide reuptake into neu-
rons and astrocytes. This focused researchers' attention to possible
involvement of the endocannabinoid system in the mechanism of
paracetamol activity.90,91 In addition, it was also noticed in the previ-
ously mentioned studies conducted by Yu et al and Kozak et al that
paracetamol-induced inhibition of COX-2 contributed to reduced
degradation of endocannabinoids.80,81 Therefore, after spinal or sys-
temic application, AM404 exhibits analgesic activity against acute
pain provoked by harmful chemical stimuli and against inflammatory
and neuropathic pain.92,93 In turn, the paracetamol-induced analge-
sia was lost in mice with cannabinoid receptor deficiency and in mice
lacking FAAH.87,94 The presence of FAAH is essential for the analge-
sic effect of paracetamol.95 The above-mentioned studies described
the involvement of the endocannabinoid system in paracetamol-me-
diated analgesia. Klinger-Gratz et al tested paracetamol in mice in
a similar way, but the animals were stimulated with mild inflamma-
tory hyperalgesia, which is a clinical indication for administration of
paracetamol.62 In addition, Klinger-Gratz et al have demonstrated
that the cannabinoid receptors type 1(CB1) relevant for inflammatory
antihyperalgesia are located at the terminals of axons in the rostral
ventromedial medulla (RVM), which is a well-known site for endoge-
nous pain control.96 In addition, the periaqueductal gray (PAG) con-
trols RVM activity via descending gamma-aminobutyric acid-ergic
(GABA-ergic) axons.97 In this way, a pain inhibitory system is formed
comprising a network of cortical regions and brain stem nuclei, the
PAG matter, and the RVM projecting to the dorsal horn of the spinal
cord.98,99 It facilitates controlling the ascending nociceptive signal

PRZYBYŁA et al.
from the spinal cord with feedback,100 with subsequent serotonergic
101
activation. Therefore, it is possible that CB1 receptors relevant for
the analgesic effect of paracetamol are located at the terminals of
62
fibres that reach the RVM from the PAG located above. In this sce-
nario, it is likely that AM404 in the RVM increases the concentration
of endocannabinoids (AEA and/or 2-AG) and promotes the activa-
tion of CB1 receptors on GABA-ergic axon terminals. This reduces
GABA release from upstream brain regions such as the PAGto the
RVM. This disinhibits descending serotonergic fibres from the RVM
to the spinal cord, with subsequent activation of serotonin receptors
in the spinal cord to facilitate endogenous pain control (Figure 2).62
It is also worth mentioning that paracetamol does not manifest psy-
chotropic effects seen in classic CB1 receptor agonists like tetrahy-
drocannabinol (THC). These discrepancies may be explained by local
differences in the formation of pharmacologically active AM 404,
caused by varying FAAH activity in different CNS regions, or even
differences in the local activity of the endocannabinoid system.62
5.3 | Paracetamol and TRP channels
Transient receptor potential (TRP) channels belong to a 28-protein
superfamily, which can be divided into seven subfamilies.102 TRP
channels are claimed to be polypeptide subunits that assemble as
tetramers to form cation-permeable pores.102 By modulating intra-
103
cellular calcium levels, TRP channels play important roles as trans-
duction molecules, responding to a variety of physical and chemical
agents (change in shear stress, osmolarity, pH, temperature, reactive
molecules, and other agents) in the intracellular and extracellular
104
milieu. Disorders of the functions of these channels coexist with
genetic diseases: skeletal, skin, sensory, ocular, cardiac, and neu-
ronal disturbances.103 Nevertheless, TRP channels are best known
for their action in the peripheral nervous system.103 Their mediation
in action can be seen even while eating hot chili peppers or wasabi
103,105
or in the cooling sensation of menthol. Therefore, not surpris-
ingly, there is considerable interest in the current understanding of
TRP channels, with a focus on pain, pulmonary disorders, inherited
103,106
diseases, and CNS dysfunction.
The paracetamol metabolite AM404 not only inhibits endocan-
nabinoid reuptake and activates the CB1 receptors, but is also an
agonist of supraspinal heat-sensitive transient receptor potential
94,103,107,108
channel subfamily vanilloid-1 (TRPV1). Heat, protons,
and phospholipase C promote channel activation and link TRPV1 to
multiple pain pathways.109,110 TRPV1 agonists also show analgesic
properties, eg diluted (0.1%) capsaicin cream is attainable as an OTC
103,111
pain reliever. Furthermore, intrathecal injection of the ultrapo-
tent TRPV1 agonist resiniferatoxin (RTX) produced permanent an-
algesia by destroying the signalling potential of sensory neurons.112
For instance, intrathecal RTX injection in dogs suffering from osteo-
113
sarcoma pain, dramatically reduced pain behaviour. Therefore, it
is probable that the analgesic action of paracetamol is also medi-
ated by TRPV1 channels and cannabinoid CB1 receptors, which are
both present in the pain and thermoregulatory pathways.88,114-116
|
14401681, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1440-1681.13392 by Readcube (Labtiva Inc.), Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
9
Additional indications of the cooperation of CB1 and TRPV1 chan-
nels in the CNS in paracetamol-induced analgesia have been sug-
gested in the study by Fioravanti et al in 2008.117 It was shown that
AM404-induced analgesia was absent in TRPV1-/- mice and was also
abolished by an intracerebroventricular injection of capsazepine,
which is a TRPV1 antagonist.117 Interestingly, there are brain areas
where FAAH (which form the AM404 metabolite) is highly expressed
in the presence of both CB1 and TRPV1 channels (mesencephalic tri-
geminal nucleus, primary sensory neurons).118-120 Besides the brain,
FAAH is also expressed in the spinal cord and dorsal root ganglia.
However, the rate of AM404 formation in the latter two areas was
much lower than in the brain in identical experimental conditions.88
This seems to corroborate the theory proposed by Mallet et al that
paracetamol works through TRPV1 at the supravertebral level.94
Unfortunately, recent studies have complicated the issue of the
importance of TRP channels in the paracetamol action. Andersson
et al described that co-expression of different TRP channels takes
place in the nociceptive sensory neurons, and the analgesic effect
of paracetamol additionally occurs by activating another subfamily,
ie subfamily A (ankyrin 1) of transient receptor potential (TRPA1)
channels.121 TRPA1 is expressed in the soma and peripheral nerve
endings of the sensory neurons and is responsible for identifying
harmful stimuli.122-124 Like TRPV1, TRPA1 responds to an unusu-
ally broad variety of chemical stimuli,103 eg mustard oil,125 cannabi-
noids,125 garlic,123 and cinnamaldehyde.126 The chemical activation
of TRPA1 causes pain, irritation, and hyperreactivity in skin and vis-
ceral organs127-129 through reduction of voltage-gated calcium and
sodium currents in primary sensory neurons.121 More importantly,
TRPA1 receptors are activated also by other metabolites of parac-
etamol: the electrophilic N-acetyl-p-benzoquinoneimine (NAPQI)
and p-benzoquinone (p-BQ). This was confirmed by an intrathecal
test where NAPQI, p-BQ, and the electrophilic TRPA1 activator
cinnamaldehyde produced antinociception that was lost in TRPA1−/
−
mice in a hot-plate test. These paracetamol metabolites are formed
in the liver with involvement of such enzymes as monooxygen-
ase, peroxidase, and COX of cytochrome P450 (CYP450).121,130-132
Interestingly, many of these enzymes are present in the CNS.133,134
NAPQI is believed to cause the well-known hepato- and nephro-
toxic effects of paracetamol. However, NAPQI metabolites can be
found in human and mouse blood, urine, or even spinal cord after in-
gestion of therapeutic and non-toxic doses of this drug.121,130,135-137
These findings show the complexity of paracetamol metabo-
lism.137 To mediate analgesia, it has to be converted to distinct me-
tabolites that are agonists of two different TRP channel subtypes,
which are potential targets of therapeutic actions of drugs.88,94,121
Paracetamol is also assigned strong hypothermic and anti-
pyretic effects. These effects have been explained by a recent
study conducted by Gentry et al, who described that TRPA1 also
mediates paracetamol-evoked hypothermia and the antipyretic ef-
fect through the NAPQI metabolite.61 In their experiment, parac-
etamol-induced hypothermia was absent in TRPA1-/- mice and was
also inhibited by prior systemic treatment with a TRPA1 antago-
nist.61 In this context, the intraperitoneal administration of a TRPA1
 |

14401681, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1440-1681.13392 by Readcube (Labtiva Inc.), Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
10 PRZYBYŁA et al.

F I G U R E 2 Hypothetical scenario of paracetamol action in central nervous system (CNS) and liver. 2-AG, 2-arachidonoylglycerol; 5-HT,
5-hydroxytryptamine receptor (serotonin receptor); AM404, N-arachidonoylphenolamine; CB1, cannabinoid receptor type 1; CNS, central
nervous system; FAAH, fatty amide hydrolase; NAPQI, cN-acetyl-p-benzoquinoneimine; p-BQ, p-benzoquinone; PAG, periaqueductal
gray; PNS, peripheral nervous system; RVM, rostral ventromedial medulla; TRPA1, transient receptor potential subfamily ankyrin 1; TRPV1,
transient receptor potential subfamily vanilloid-1

agonist (cinnamaldehyde) in wild-type mice also caused significant
hypothermia. This additionally shows that TRPA1 agonism can af-
fect body temperature.61 Peripheral sensory neurons are the site
of the hypothermic action of TRPA1, which mediates the analgesic
effect.61 Body temperature is controlled by peripheral sensory neu-
rons controlled by the CNS and by a central thermoregulatory mech-
anism. Interestingly, after intrathecal injection, paracetamol does
not have a hypothermic effect, demonstrating that hypothermia is
not required for its spinal antinociceptive effect.61,138,139 In turn,
Mirrasekhian et al have shown that paracetamol exerts a TRPA1-
independent antipyretic effect associated with inhibition of the syn-
70
thesis of PGE2 (as well as other prostanoids) in the brain.
It has long been known that TRPV1 channels regulate body tem-
perature in vivo; for example, agonists such as capsaicin and RTX in-
duce the hypothermic effect in rodents.138,140,141 Therefore, TRPV1
activation may also underlie the hypothermic effect of paracetamol,
but studies on mice showed that paracetamol-induced hypothermia
was identical in wild-type and Trpv1−/− mice and did not decrease by
administration of a maximally effective dose of a TRPV1 antagonist.
In contrast, a TRPA1 antagonist inhibited paracetamol-induced hy-
pothermia, and paracetamol had no influence on body temperature
in Trpa1−/− mice.61
As regards the COX-1 and COX-2 inhibitory activity of parac-
etamol, the hypothermic mechanisms appear to be independent of
the cannabinoid system; however, the antipyretic effect may also be
a result of COX inhibition in the hypothalamus by AM404.62 This
was suggested by studies in which paracetamol reversed yeast-in-
duced hyperthermia in mice lacking both TRPA1 and TRPV1,61 even
though it can inhibit the COX-1 and COX-2 enzymes, but only at high
concentrations. In addition, paracetamol does not show strong an-
ti-inflammatory activity, which is characteristic of COX inhibition.
A combination of paracetamol and ibuprofen have been observed
to improve antipyretic activity and analgesia, suggesting that they
act through different mechanisms.75,76 Therefore, COX inhibition by
paracetamol is not thought to be the primary mode of action.61
Another member of the TRP superfamily is theTRPV4. This Caþ
permeable channel has been functionally identified as an osmotic
sensor.142,143 TRPV4, like the other channels, is widely distributed in

PRZYBYŁA et al.
the body, and is activated by hypoosmotic stimulation, mechanical
stimulation, relatively low temperatures, acid, AA metabolites, and
102,144
endogenous cannabinoids. To date, TRPV4 has not been de-
scribed as a paracetamol target molecule. Interestingly, it has recently
been observed that paracetamol promotes cell migration through
145
TRPV4. Further experiments using cell lines that endogenously
express TRPV4 and cell lines stably expressing exogenous TRPV4
have revealed that the Ca2þ channel activity of TRPV4 is inhibited
by paracetamol.146 The effects of paracetamol on TRPV4 differed
from the action on TRPV1 and TRPA1 reported previously. Firstly,
paracetamol metabolites are unlikely to be involved in these effects,
given the rapid response observed by Nakagawa et al . Secondly,
the effect on TRPV4 was suppressive, while both TRPV1 and TRPA1
146
were activated by paracetamol in vivo. However, the molecular
mechanism of paracetamol activity on the Ca2þ channel activity of
TRPV4 is complex, as it is not known whether it works outside or in-
side the cell membrane of theTRPV4 Ca2þ channel. Finally, inhibition
of Ca2þ entry into cells via TRPV4 may also contribute to the clin-
ical effects induced by paracetamol, which has not been reported
previously as a paracetamol target.146 This is suggested by studies
in which mice with TRPV4 genetic deficiency had reduced suscep-
tibility to stimuli that were harmful to acid and pressure and TRPV4
expression occurs, among others, in the peripheral nerve endings
of sensory ganglia.146 Furthermore, the sensitization of TRPV4 by
PGE2 was postulated to be involved in the hyperalgesic response to
heat, pressure stimulation at the site of inflammation, and hypotonic
pressure.147 There are also reports demonstrating that TRPV4 is in-
volved in the induction of pulmonary oedema associated with heart
failure and is related with cardiovascular homeostasis.148 Therefore,
it would be interesting not only to explain the role of TRPV4 in the
analgesic/antipyretic effect of paracetamol, but also to investigate
the effect of paracetamol used for other purposes such as cardio-
vascular homeostasis.146,149
5.4 | Paracetamol effect on Cav3.2
calcium channels
Through activation by very weak membrane depolarization, Cav3.2
calcium channels serve as a modulus of cellular excitability.150 In the
CNS, these channels have been shown to participate in the percep-
151,152 153 154
tion of pain, epilepsy, and slow-wave sleep. There are
three T-type calcium channels: Cav3.1, Cav3.2, and Cav3.3. They are
localized in small and medium diameter neurons of the dorsal root
ganglion (DRG), in the dorsal horn superficial laminae, and several
155
other brain structures. Compounds associated with AA, such as
ASA and 2-AG, through the aforementioned cannabinoid receptors
and TRPV1 are the main factors involved in pain modulation in the
analgesic effect of paracetamol. Additionally, thanks to their lipoam-
ino acids structure, they interact with T-type calcium channels, espe-
156
cially the Cav3.2 subtype, mediating pain relief. Since AM404 is a
lipoamino acid, the role of Cav3.2 channels in paracetamol activity
was investigated.157 Mice with knockout of the Cav3.2−/− gene did
|
14401681, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1440-1681.13392 by Readcube (Labtiva Inc.), Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
11
not show any analgesic effect after paracetamol administration and
intracerebroventricular injection of AM404.157 Before administra-
tion of paracetamol, a Cav3.2 blocker, (R)-2-(4-cyclopropylphenyl)-
N-(1-(5-(2, 2, 2-trifluoroethox y)pyridin-2-yl)ethyl)acet amide
(TTA-A2) was injected intracerebroventricularly, which prevented
the effect of paracetamol as well. It has also been shown that the an-
tinociceptive effect of paracetamol is dependent on Cav3.2 located
in the brain, but not in the spinal cord.157 Interestingly, the inhibit-
ing force of Cav3.2 by AM404 is not at all high (IC50 = 13.7 μmol/L),
compared to the specific TTA-A2 blocker with an IC50 value of
9.0 nmol/L. Therefore, the role of TRPV1 channels in the activation
of Cav3.2 as part of the analgesic action of paracetamol was hypoth-
esized. The analgesic effect of intracerebroventricular injection of
either a TRPV1 agonist (capsaicin) or a Cav3.2 antagonist (TTA-A2)
in Cav3.2−/− and TRPV1−/− mice, respectively, was evaluated. In con-
trast to the TTA-A2 activity, which persisted in TRPV1−/− mice, the
analgesic effect of capsaicin was suppressed in the Cav3.2−/− mice.
These results show that the activation of TRPV1 in the brain requires
Cav3.2 to mediate its analgesic action and suggest that TRPV1 is the
first target of AM404.157
5.5 | Nitric oxide pathway in paracetamol action
After harmful stimuli, activation of spinal N-methyl-D-aspartate
receptors (NMDARs) and release of substance P related to the
transmission of pain information occur.158 In turn, research on mice
has shown that the activation of NMDARs promotes the synthesis
of nitric oxide (NO), which is a neurotransmitter at the spinal level
conveying nociceptive information.159 The proposed alternative
mechanisms of the analgesic action of paracetamol also include in-
terference with activation of spinal NMDARs and inhibition of the
NO pathway.160 Administration of L-arginine (but not D-arginine)
inhibits the analgesic effect of paracetamol. This suggests that
the analgesic effect of paracetamol may be associated with inhibi-
tion of NO generation.161 Furthermore, intrathecal administration
of a neuronal nitric oxide synthase (nNOS) inhibitor enhances the
anti-nociceptive effect of submaximal doses of paracetamol.162
In turn, Ryu et al have suggested that paracetamol inhibits induc-
ible nitric oxide synthase (iNOS) expression at the transcriptional
level by suppressing binding of the nuclear factor kappa B (NF-
κB).163 Ultimately, the role played by NO in nociception remains
blurred, as NO donors (S-nitroso-N-acetylpenicillamine (SNAP)
or isosorbide dinitrate) were found to induce a dual effect in a
model of neuropathic pain. Low doses of NO donors reduce the
sensation of pain, while high doses intensify or have no effect on
tactile allodynia in rats.164 However, there are interesting studies
confirming that NO modulates the biological levels of signalling
molecules derived from the eicosanoid pathway by increasing or
inhibiting the activity of the COX-1 and COX-2 isoforms.165 The
way in which NO and eicosanoid biosynthesis pathways are linked
is not yet known.165-167 Moreover, recent studies have shown that
AM404 exhibits a neuroprotective effect against NMDA-induced
 |

14401681, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1440-1681.13392 by Readcube (Labtiva Inc.), Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
12 PRZYBYŁA et al.

TA B L E 3 Comparison of the main

Regular doses244,245 Toxic doses246
adverse effects of paracetamol depending
Gastrointestinal complaints247 Serious liver damage and acute liver on the dose
failure248
Hypersensitivity reactions, 249 angioedema250 Nausea, vomiting, sweating251
252
Kidney damage Pain in the right hypochondrium251
Gastrointestinal bleeding (doses > 2 g taken High increase of aminotransferases
chronically)253 (above 10 000 U/L) and the
international normalized ratio
(INR) ≥ 4.0246
Stevens–Johnson syndrome (SJS) and toxic epidermal Nausea and hepatic
necrolysis (TEN)254,255 encephalopathy246
Agranulocytosis, 256 anaemia, 257 thrombocytopenia258 Acute (tubular) kidney injury and
skeletal muscle cytolysis259
Small increased of systolic blood pressure, 260 Thrombocytopenia262
hypertension261

Note: The side effects may coexist or occur separately. Regular doses: up to 4 g/d in adults or up to
60 mg/kg/d in paediatric patients show slight adverse effects. 244,245 Toxic doses: intake by health
adults above 4 g/d of paracetamol or lower doses in combination with alcohol consumption. 246

hippocampal excitotoxicity, and could find application as a neu-
roprotective agent in Huntington's and Parkinson's diseases and
67,168
ischaemia.
5.6 | Paracetamol effect on Kv7 potassium channels
Recently, it has been described that NAPQI enhances the activity of
neuronal voltage-gated Kv7 potassium channels, Kv7.2 and Kv7.3, in
dorsal root ganglion and spinal dorsal horn neurons.169 In the cell cul-
ture environment of spinal dorsal horn cultures of Sprague–Dawley
rats, by enhancing Kv7 channel activity, NAPQI evokes hyperpolari-
sation of the membrane potential and reduces action potential fir-
ing, which might underlie the analgesic action of paracetamol and
169
contribute to paracetamol anticonvulsant properties. Moreover,
direct and indirect activation of Kv7 channels by NAPQI decreases
arterial tone, which can lead to a drop in arterial blood pressure. This
may be responsible for the clinical phenomenon of intravenous par-
170
acetamol-dependent transient hypotension. This is a new promis-
ing research field that should be explored in future research.
5.7 | Paracetamol administration safety aspects
The use of paracetamol raises considerable controversy, as it has
been shown to reach the fetal/neonatal brain after passing the pla-
171 172
centa and the blood brain barrier. Recent studies still under-
mine the safety of paracetamol administration in pregnant women
and young children.173 Given the common exposure to paracetamol
during this period of life, there were fears that it might affect intense
174
brain development in children. The use of paracetamol during this
time period has been associated with hyperkinetic disorders, hyper-
activity (attention deficit hyperactivity disorder, ADHD), and other
adverse behaviours later in life.175-177 In addition, it is claimed that
use of paracetamol by the mother during pregnancy is associated
with an increased risk of childhood asthma.178 In rodents, develop-
mental exposure to paracetamol has been shown to be associated
with impaired spatial learning, decreased habituation to a novel
home cage, altered spontaneous behaviour, reduced anxiolytic and
analgesic response to paracetamol, and effects on various neuro-
transmitters.179-182 This neurotoxicity in young children has been
shown to be caused by the metabolite AM404 which, as described
above, stimulates the endocannabinoid system.174 This system plays
an important role in regulating early brain development through the
proliferation of progenitor cells183 and migration of neurons.184 A
significant decrease in neuroprotein markers such as GluR1, post-
synaptic density protein 95 (PSD95), and synaptophysin in the pa-
rietal cortex has been demonstrated in adult mice after exposure
to neurological CB1 agonists: WIN 55,212-2 (WIN) and paracetamol
at the stage of brain development.185-187 The mice displayed a sig-
nificant lack of habituation in the spontaneous behaviour test, com-
pared with controls and single agent-exposed mice.174 After the WIN
and paracetamol exposure, at least some of these adverse effects
on adults can be explained by reduction of tropomyosin receptor
kinase B (Trkb), transcript levels of hippocampal synaptophysin (Syp),
and cerebral cortical FAAH, which are also important in brain de-
velopment. Assuming that the results are relevant for humans, they
raise concerns about paracetamol safety, due to its widespread use
among young children and pregnant women.174 However, consider-
ing the use of paracetamol in adults, some recent studies work in
favor of the drug. A double-blind randomized controlled study of
healthy adult men showed that paracetamol sharpened decision
making skills and planning strategy.188 This is probably a result of
the analgesic rather than thermic cascade of events, possibly with
a central role of serotonergic and cannabinoid systems.188 In turn,
some studies strongly question the safety of the chronic use of par-
acetamol in such diseases as osteoarthritis and lower back pain.189
They postulate that the chronic use of paracetamol, depending on

PRZYBYŁA et al.
the dose, increases the risk of gastrointestinal bleeding and a small
(~4 mm Hg) increase in systolic blood pressure, which may be rel-
evant for some patients.189 Adverse and toxic effects of paracetamol
are summarized in Table 3.
6 | CO N C LU S I O N S A N D PE R S PEC TI V E S
Despite many years of research, the precise mechanism of paraceta-
mol action remains unknown. It is certainly multidirectional, but
more research is needed to elucidate it thoroughly. Current research
results of the mechanism of paracetamol action are very promising.
Additionally, they have paved the way for the emergence of new
analgesics and antipyretics that could act specifically through the
serotonergic and endocannabinoid systems, TRP channels, Kv7 po-
tassium channels, Cav3.2 calcium channels, or even a yet unknown
protein variant of COX-1.
AC K N OW L E D G E M E N T S
This study was supported by statutory funds of the University of
Information Technology and Management in Rzeszow, Poland (DS
503-07-02-21).
C O N FL I C T O F I N T E R E S T
The authors declare that they have no conflict of interest.
E T H I C A L A P P R OVA L
Not applicable.
PEER REVIEW
The peer review history for this article is available at https://publo​
ns.com/publo​n/10.1111/1440-1681.13392.
ORCID
Grzegorz W. Przybyła https://orcid.org/0000-0003-2369-946X
Konrad A. Szychowski https://orcid.org/0000-0003-2207-1160
Jan Gmiński https://orcid.org/0000-0002-7971-860X
REFERENCES
1. Bertolini A, Ferrari A, Ottani A, Guerzoni S, Tacchi R, Leone
S. Paracetamol: new vistas of an old drug. CNS Drug Rev.
2006;12(3–4):250-275.
2. Smith PK, Acetophenetidin I. A critical bibliographic review. Med J
Aust. 1959;2(10):323.
3. Haas H. History of antipyretic analgesic therapy. Am J Med.
1983;75(5):1-3.
4. Brodie BB, Axelrod J. The fate of aminopyrine (pyramidon)
in man and methods for the estimation of aminopyrine and
its metabolites in biological material. J Pharmacol Exp Ther.
1950;99(2):171-184.
5. Brodie BB, Axelrod J. The estimation of acetanilide and its meta-
bolic products, aniline. J Pharmacol Exp Ther. 1948;94(1):22-28.
6. Prescott LF. Paracetamol overdosage: pharmacological consider-
ations and clinical management. Drugs. 1983;25(3):290-314.
7. Funk CD. Prostaglandins and leukotrienes: advances in eicosanoid
biology. Science. 2001;294(5548):1871-1875.
|
14401681, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1440-1681.13392 by Readcube (Labtiva Inc.), Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
13
8. Trebino CE, Stock JL, Gibbons CP, et al. Impaired inflammatory and
pain responses in mice lacking an inducible prostaglandin E syn-
thase. Proc Natl Acad Sci USA. 2003;100(15):9044-9049.
9. Smith WL, DeWitt DL, Garavito RM. Cyclooxygenases: struc-
tural, cellular, and molecular biology. Annu Rev Biochem.
2000;69(1):145-182.
10. Vane JR. Inhibition of prostaglandin synthesis as a mechanism of
action for aspirin-like drugs. Nat New Biol. 1971;231(25):232-235.
11. Flower RJ. The development of COX2 inhibitors. Nat Rev Drug
Discov. 2003;2(3):179-191.
12. Xie W, Chipman JG, Robertson DL, Eriksont RL, Simmons DL.
Expression of a mitogen-responsive gene encoding prostaglandin
synthase is regulated by mRNA splicing (cyclooxygenase/Rous
sarcoma virus/immediate-early gene/pp6OvsIT). Proc Nati Acad
Sci USA. 1991;88:2692-2696.
13. Picot D, Loll PJ, Garavito RM. The X-ray crystal structure of
the membrane protein prostaglandin H2 synthase-1. Nature.
1994;367(6460):243-249.
14. Trojan A, Tinguely M, Vallet S, et al. Clinical significance of cy-
clooxygenase-2 (COX-2) in multiple myeloma. Swiss Med Wkly.
2006;136(25–26):400-403.
15. Poorani R, Bhatt AN, Dwarakanath BS, Das UN. COX-2, aspirin
and metabolism of arachidonic, eicosapentaenoic and docosahex-
aenoic acids and their physiological and clinical significance. Eur J
Pharmacol. 2016;785:116-132.
16. Chandrasekharan NV, Dai H, Roos KLT, et al. COX-3, a cycloox-
ygenase-1 variant inhibited by acetaminophen and other analge-
sic/antipyretic drugs: cloning, structure, and expression. Proc Natl
Acad Sci USA. 2002;99(21):13926-13931.
17. Liu J, Seibold SA, Rieke CJ, Song I, Cukier RI, Smith WL.
Prostaglandin endoperoxide H synthases: peroxidase hydrop-
eroxide specificity and cyclooxygenase activation. J Biol Chem.
2007;282(25):18233-18244.
18. Gabbs M, Leng S, Devassy JG, Aukema HM. Advances in our un-
derstanding of oxylipins. Am Soc Nutr. 2015;6:513-540.
19. Anderson BJ. Paracetamol (Acetaminophen): mechanisms of ac-
tion. Paediatr Anaesth. 2008;18(10):915-921.
20. Hazarika I, Selvam P. Cyclooxygenase 3 inhibition: a probable
mechanism of acetaminophen in human: a review. Res Rev A J
Pharm Sci. 2015;53:23-29.
21. Crofford LJ. COX-1 and COX-2 tissue expression: implications and
predictions. J Rheumatol Suppl. 1997;49:15-19.
22. Zidar N, Odar K, Glavac D, Jerse M, Zupanc T, Stajer D.
Cyclooxygenase in normal human tissues - is COX-1 really a con-
stitutive isoform, and COX-2 an inducible isoform? J Cell Mol Med.
2009;13(9b):3753-3763.
23. Lazzaroni M, Bianchi PG. Gastrointestinal side-effects of tradi-
tional non-steroidal anti-inflammatory drugs and new formula-
tions. Aliment Pharmacol Ther. 2004;20(s2):48-58.
24. Rajakariar R, Yaqoob MM, Gilroy DW. COX-2 in inflammation and
resolution. Mol Interv. 2006;6(4):199-207.
25. Kurumbail RG, Kiefer JR, Marnett LJ. Cyclooxygenase enzymes:
catalysis and inhibition. Curr Opin Struct Biol. 2001;11(6):752-760.
26. Carnieto A, Dourado PMM, da Luz PL, Chagas ACP. Selective cyclo-
oxygenase-2 inhibition protects against myocardial damage in ex-
perimental acute ischemia. Clinics (Sao Paulo). 2009;64(3):245-252.
27. Ruan C-H, So S-P, Ruan K-H. Inducible COX-2 dominates over
COX-1 in prostacyclin biosynthesis: mechanisms of COX-2 inhib-
itor risk to heart disease. Life Sci. 2011;88(1–2):24-30.
28. Patrignani P, Panara MR, Greco A, et al. Characterization of the
cyclooxygenase activity of human blood prostaglandin endop-
eroxide synthases. Adv Prostaglandin Thromboxane Leukot Res.
1995;23(3):129-131.
29. Massó González EL, Patrignani P, Tacconelli S, García Rodríguez
LA. Variability among nonsteroidal antiinflammatory drugs
 |
14
in risk of upper gastrointestinal bleeding. Arthritis Rheum.
2010;62(6):1592-1601.
30. Brune K, Patrignani P. New insights into the use of currently avail-
able non-steroidal anti-inflammatory drugs. J Pain Res. 2015;8:105.
31. Li S, Ballou LR, Morham SG, Blatteis CM. Cyclooxygenase-2 me-
diates the febrile response of mice to interleukin-1β. Brain Res.
2001;910(1–2):163-173.
32. Simmons DL, Botting RM, Robertson PM, Madsen ML, Vane JR.
Induction of an acetaminophen-sensitive cyclooxygenase with re-
duced sensitivity to nonsteroid antiinflammatory drugs. Proc Natl
Acad Sci USA. 1999;96(6):3275-3280.
33. Warner TD, Mitchell JA. Cyclooxygenase-3 (COX-3): filling in
the gaps toward a COX continuum? Proc Natl Acad Sci USA.
2002;99(21):13371-13373.
34. Davies NM, Good RL, Roupe KA, Yáñez JA. Cyclooxygenase-3:
axiom, dogma, anomaly, enigma or splice error? - Not as easy as 1,
2, 3. J Pharm Pharm Sci. 2004;7(2):217-226.
35. Kam PCA, So A. COX-3: Uncertainties and controversies. Curr
Anaesth Crit Care. 2009;20(1):50-53.
36. Oksuz E, Atalar F, Tanırverdi G, Bilir A, Shahzadi A, Yazici Z.
Therapeutic potential of cyclooxygenase-3 inhibitors in the man-
agement of glioblastoma. J Neurooncol. 2016;126(2):271-278.
37. Aronoff DM, Neilson EG. Antipyretics: mechanisms of action and
clinical use in fever suppression. Am J Med. 2001;111(4):304-315.
38. Kis B, Snipes JA, Isse T, Nagy K, Busija DW. Putative cyclooxy-
genase-3 expression in rat brain cells. J Cereb Blood Flow Metab.
2003;23(11):1287-1292.
39. Sharma S, Verma A, Chauhan R, Kedar M, Kulshrestha R. Study of
cyclooxygenase-3 on the bases of its facts and controversies. Int J
Pharm Sci Res. 2019;10(1):387-392.
40. Li S, Wang Y, Matsumura K, Ballou L, Morham S, Blatteis C. The
febrile response to lipopolysaccharide is blocked in cyclooxy-
genase-2−/−, but not in cyclooxygenase-1−/− mice. Brain Res.
1999;825(1–2):86-94.
41. Cao C, Matsumura K, Yamagata K, Watanabe Y. Endothelial cells
of the rat brain vasculature express cyclooxygenase-2 mRNA in re-
sponse to systemic interleukin-1β: a possible site of prostaglandin
synthesis responsible for fever. Brain Res. 1996;733(2):263-272.
42. Kurumbail RG, Stevens AM, Gierse JK, et al. Structural basis for
selective inhibition of cyclooxygenase-2 by anti-inflammatory
agents. Nature. 1996;384(6610):644-648.
43. Luong C, Miller A, Barnett J, Chow J, Ramesha C, Browner MF.
Flexibility of the NSAID binding site in the structure of human cy-
clooxygenase-2. Nat Struct Biol. 1996;3(11):927-933.
44. Riendeau D, Percival MD, Boyce S, et al. Biochemical and pharma-
cological profile of a tetrasubstituted furanone as a highly selec-
tive COX-2 inhibitor. Br J Pharmacol. 1997;121(1):105-117.
45. Riendeau D, Percival MD, Brideau C, et al. Etoricoxib (MK-
0663): preclinical profile and comparison with other agents
that selectively inhibit cyclooxygenase-2. J Pharmacol Exp Ther.
2001;296(2):558-566.
46. Dinchuk JE, Liu RQ, Trzaskos JM. COX-3: in the wrong frame in
mind. Immunol Lett. 2003;86(1):121.
47. Botting R, Ayoub SS. COX-3 and the mechanism of action of parac-
etamol/acetaminophen. Prostaglandins Leukot Essent Fatty Acids.
2005;72(2):85-87.
48. Schwab JM, Beiter T, Linder JU, et al. COX-3 - A virtual pain target
in humans? FASEB J. 2003;17(15):2174-2175.
49. Kis B, Snipes JA, Busija DW. Acetaminophen and the cyclooxy-
genase-3 puzzle: sorting out facts, fictions, and uncertainties. J
Pharmacol Exp Ther. 2005;315(1):1-7.
50. Simmons DL, Chandrasekharan NV, Hu D, et al. Comments on ‘ac-
etaminophen and the cyclooxygenase-3 puzzle: Sorting out facts,
fictions, and uncertainties’ (multiple letters). J Pharmacol Exp Ther.
2005;315(3):1412-1416.
14401681, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1440-1681.13392 by Readcube (Labtiva Inc.), Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
PRZYBYŁA et al.
51. Hinz B, Brune K. Paracetamol and cyclooxygenase inhibition: is
there a cause for concern? Ann Rheum Dis. 2012;71(1):20-25.
52. Dray A. Inflammatory mediators of pain. Br J Anaesth.
1995;75(2):125-131.
53. Smyth EM, Grosser T, Wang M, Yu Y, FitzGerald GA. Prostanoids in
health and disease. J Lipid Res. 2009;50(Supplement):S423-S428.
54. Ayoub SS, Colville-Nash PR, Willoughby DA, Botting RM. The
involvement of a cyclooxygenase 1 gene-derived protein in the
antinociceptive action of paracetamol in mice. Eur J Pharmacol.
2006;538(1–3):57-65.
55. Botting RM, Bartholomew S, Mary Q. Inhibition 100 indomethacin
aspirin salicylic acid log concentration ( µg/mL) (Reproduced from
Vane, 1971). Physiol Pharmacol. 2006;57:113-124.
56. Botting RM. Vane’s discovery of the mechanism of action of aspirin
changed our understanding of its clinical pharmacology. Pharmacol
Rep. 2010;62(3):518-525.
57. Clissold SP. Paracetamol and phenacetin. Drugs. 1986;32(Suppl
4):46-59.
58. Flower RJ, Vane JR. Inhibition of prostaglandin synthetase in brain
explains the anti-pyretic activity of paracetamol (4-acetamidophe-
nol). Nature. 1972;240(5381):410-411.
59. Hanel AM, Lands WEM. Modification of anti-inflammatory drug
effectiveness by ambient lipid peroxides. Biochem Pharmacol.
1982;31(20):3307-3311.
60. Graham GG, Scott KF. Mechanism of action of paracetamol. Am J
Ther. 2005;12(1):46-55.
61. Gentry C, Andersson DA, Bevan S. TRPA1 mediates the hypother-
mic action of acetaminophen. Sci Rep. 2015;5(1):1-9.
62. Klinger-Gratz PP, Ralvenius WT, Neumann E, et al. Acetaminophen
relieves inflammatory pain through CB 1 cannabinoid re-
ceptors in the rostral ventromedial medulla. J Neurosci.
2018;38(2):322-334.
63. Ouellet M, Percival MD. Mechanism of acetaminophen in-
hibition of cyclooxygenase isoforms. Arch Biochem Biophys.
2001;387(2):273-280.
64. Boutaud O, Aronoff DM, Richardson JH, Marnett LJ, Oates JA.
Determinants of the cellular specificity of acetaminophen as an
inhibitor of prostaglandin H2 synthases. Proc Natl Acad Sci USA.
2002;99(10):7130-7135.
65. Hinz B, Dormann H, Brune K. More pronounced inhibition of cy-
clooxygenase 2, increase in blood pressure, and reduction of heart
rate by treatment with diclofenac compared with celecoxib and
rofecoxib. Arthritis Rheum. 2006;54(1):282-291.
66. Kalgutkar AS, Crews BC, Rowlinson SW, et al. Biochemically based
design of cyclooxygenase-2 (COX-2) inhibitors: Facile conversion
of nonsteroidal antiinflammatory drugs to potent and highly selec-
tive COX-2 inhibitors. Proc Natl Acad Sci. 2000;97(2):925-930.
67. Saliba SW, Marcotegui AR, Fortwängler E, et al. AM404, parac-
etamol metabolite, prevents prostaglandin synthesis in acti-
vated microglia by inhibiting COX activity. J Neuroinflammation.
2017;14(1):1-11.
68. Ayoub SS, Botting RM, Goorha S, Colville-Nash PR, Willoughby
DA, Ballou LR. Acetaminophen-induced hypothermia in mice is
mediated by a prostaglandin endoperoxide synthase 1 gene-de-
rived protein. Proc Natl Acad Sci USA. 2004;101(30):11165-11169.
69. Ayoub SS, Flower RJ. Loss of hypothermic and anti-pyretic action
of paracetamol in cyclooxygenase-1 knockout mice is indicative of
inhibition of cyclooxygenase-1 variant enzymes. Eur J Pharmacol.
2019;861(August):172609.
70. Mirrasekhian E, Nilsson JLÅ, Shionoya K, et al. The antipyretic effect
of paracetamol occurs independent of transient receptor potential
ankyrin 1–mediated hypothermia and is associated with prosta-
glandin inhibition in the brain. FASEB J. 2018;32(10):5751-5759.
71. Li S, Dou W, Tang Y, Goorha S, Ballou LR, Acetaminophen
BCM. Antipyretic or hypothermic in mice? In either case,

PRZYBYŁA et al.
PGHS-1b (COX-3) is irrelevant. Prostaglandins Other Lipid Mediat.
2007;85(3–4):89-99.
72. Borsani E, Labanca M, Bianchi R, Rodella LF. AM404 decreases
Fos-immunoreactivity in the spinal cord in a model of inflamma-
tory pain. Brain Res. 2007;1152(1):87-94.
73. Mitchell VA, Greenwood R, Jayamanne A, Vaughan CW. Actions
of the endocannabinoid transport inhibitor AM404 in neuro-
pathic and inflammatory pain models. Clin Exp Pharmacol Physiol.
2007;34(11):1186-1190.
74. Ayoub SS, Pryce G, Seed MP, Bolton C, Flower RJ, Baker D.
Paracetamol-induced hypothermia is independent of cannabinoids
and transient recep tor potential vanilloid-1 and is not mediated by
AM404. Drug Metab Dispos. 2011;39(9):1689-1695.
75. Derry CJ, Derry S, Moore RA. Single dose oral ibuprofen plus
paracetamol (acetaminophen) for acute postoperative pain.
Cochrane Database Syst Rev. 2013;(10):CD010210.
76. Wong T, Stang AS, Ganshorn H, et al. Combined and alternating
paracetamol and ibuprofen therapy for febrile children. Cochrane
Database Syst Rev. 2013;(10):CD009572.
77. Taiwo YO, Levine JD. Indomethacin blocks central nociceptive ef-
fects of PGF2α. Brain Res. 1986;373(1–2):81-84.
78. Uda R, Horiguchi S, Ito S, Hyodo M, Hayaishi O. Nociceptive ef-
fects induced by intrathecal administration of prostaglandin D2,
E2, or F2 alpha to conscious mice. Brain Res. 1990;510(1):26-32.
79. Reinold H, Ahmadi S, Depner UB, et al. Spinal inflammatory hyper-
algesia is mediated by prostaglandin E receptors of the EP2 sub-
type. J Clin Invest. 2005;115(3):673-679.
80. Yu M, Ives D, Ramesha CS. Synthesis of prostaglandin E2 etha-
nolamide from anandamide by cyclooxygenase-2. J Biol Chem.
1997;272(34):21181-21186.
81. Kozak KR, Rowlinson SW, Marnett LJ. Oxygenation of the endo-
cannabinoid, 2-arachidonylglycerol, to glyceryl prostaglandins by
cyclooxygenase-2. J Biol Chem. 2000;275(43):33744-33749.
82. Kozak KR, Crews BC, Morrow JD, et al. Metabolism of the endo-
cannabinoids, 2-arachidonylglycerol and anandamide, into pros-
taglandin, thromboxane, and prostacyclin glycerol esters and
ethanolamides. J Biol Chem. 2002;277(47):44877-44885.
83. Prusakiewicz JJ, Kingsley PJ, Kozak KR, Marnett LJ. Selective ox-
ygenation of N-arachidonylglycine by cyclooxygenase-2. Biochem
Biophys Res Commun. 2002;296(3):612-617.
84. Yuan C, Sidhu RS, Kuklev DV, et al. Cyclooxygenase allosterism,
fatty acid-mediated cross-talk between monomers of cyclooxy-
genase homodimers. J Biol Chem. 2009;284(15):10046-10055.
85. Prusakiewicz JJ, Duggan KC, Rouzer CA, Marnett LJ. Differential
sensitivity and mechanism of inhibition of COX-2 oxygenation of
arachidonic acid and 2-arachidonoylglycerol by ibuprofen and me-
fenamic acid. Biochemistry. 2009;48(31):7353-7355.
86. Dani M, Guindon J, Lambert C, Beaulieu P. The local antinocicep-
tive effects of paracetamol in neuropathic pain are mediated by
cannabinoid receptors. Eur J Pharmacol. 2007;573(1–3):214-215.
87. Mallet C, Daulhac L, Bonnefont J, et al. Endocannabinoid and sero-
tonergic systems are needed for acetaminophen-induced analge-
sia. Pain. 2008;139(1):190-200.
88. Högestätt ED, Jönsson BAG, Ermund A, et al. Conversion of acet-
aminophen to the bioactive N-acylphenolamine AM404 via fatty
acid amide hydrolase-dependent arachidonic acid conjugation in
the nervous system. J Biol Chem. 2005;280(36):31405-31412.
89. Sharma C, Long JH, Shah S, et al. First evidence of the conversion
of paracetamol to AM404 in human cerebrospinal fluid. J Pain Res.
2017;10:2703-2709.
90. Beltramo M, Stella N, Calignano A, Lin SY, Makriyannis A, Piomelli
D. Functional role of high-affinity anandamide transport, as re-
vealed by selective inhibition. Science. 1997;277(5329):1094-1097.
91. Fegley D, Kathuria S, Mercier R, et al. Anandamide transport is in-
dependent of fatty-acid amide hydrolase activity and is blocked by
|
14401681, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1440-1681.13392 by Readcube (Labtiva Inc.), Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
15
the hydrolysis-resistant inhibitor AM1172. Proc Natl Acad Sci USA.
2004;101(23):8756-8761.
92. Gühring H, Hamza M, Sergejeva M, et al. A role for endocanna-
binoids in indomethacin-induced spinal antinociception. Eur J
Pharmacol. 2002;454(2–3):153-163.
93. La Rana G, Russo R, Campolongo P, et al. Modulation of neuropathic
and inflammatory pain by the endocannabinoid transport inhibitor
AM404 [N-(4-hydroxyphenyl)-eicosa-5,8,11,14-tetraenamide]. J
Pharmacol Exp Ther. 2006;317(3):1365-1371.
94. Mallet C, Barrière DA, Ermund A, et al. TRPV1 in brain is involved in ac-
etaminophen-induced antinociception. PLoS One. 2010;5(9):e12748.
95. Dalmann R, Daulhac L, Antri M, Eschalier A, Mallet C. Supra-spinal
FAAH is required for the analgesic action of paracetamol in an in-
flammatory context. Neuropharmacology. 2015;91:63-70.
96. Ossipov MH, Dussor GO, Porreca F. Central modulation of pain. J
Clin Invest. 2010;120(11):3779-3787.
97. Morgan MM, Whittier KL, Hegarty DM, Aicher SA. Periaqueductal
gray neurons project to spinally projecting GABAergic neurons in
the rostral ventromedial medulla. Pain. 2008;140(2):376-386.
98. Millan MJ. Descending control of pain. Prog Neurogibol.
2002;66(6):355-474.
99. Hadjipavlou G, Dunckley P, Behrens TE, Tracey I. Determining
anatomical connectivities between cortical and brainstem pain
processing regions in humans: a diffusion tensor imaging study in
healthy controls. Pain. 2006;123(1–2):169-178.
100. Basbaum AI, Fields HL. Endogenous pain control systems: brain-
stem spinal pathways and endorphin circuitry. Annu Rev Neurosci.
1984;7(1):309-338.
101. Pickering G, Loriot M, Libert F, Eschalier A, Beaune P, Dubray
C. Analgesic effect of acetaminophen in humans: first evi-
dence of a central serotonergic mechanism. Clin Pharmacol Ther.
2006;79(4):371-378.
102. Moran MM, McAlexander MA, Bíró T, Szallasi A. Transient recep-
tor potential channels as therapeutic targets. Nat Rev Drug Discov.
2011;10(8):601-620.
103. Moran MM. TRP channels as potential drug targets. Annu Rev
Pharmacol Toxicol. 2018;58(1):309-330.
104. Parenti A, De Logu F, Geppetti P, Benemei S. What is the evidence
for the role of TRP channels in inflammatory and immune cells? Br
J Pharmacol. 2016;173(6):953-969.
105. Zhang ZM, Wu X, Zhang G-Y, Ma X, He D-X. Functional food develop-
ment: insights from TRP channels. J Funct Foods. 2019;56:384-394.
106. Benemei S, Dussor G. TRP channels and migraine: Recent devel-
opments and new therapeutic opportunities. Pharmaceuticals.
2019;12(2):1-17.
107. De Petrocellis L, Bisogno T, Davis JB, Pertwee RG, Di Marzo V.
Overlap between the ligand recognition properties of the anan-
damide transporter and the VR1 vanilloid receptor: inhibitors of
anandamide uptake with negligible capsaicin-like activity. FEBS
Lett. 2000;483(1):52-56.
108. Brauchi S, Orta G, Mascayano C, et al. Dissection of the compo-
nents for PIP2 activation and thermosensation in TRP channels.
Proc Natl Acad Sci USA. 2007;104(24):10246-10251.
109. Caterina MJ, Schumacher MA, Tominaga M, Rosen TA, Levine JD,
Julius D. The capsaicin receptor: a heat-activated ion channel in
the pain pathway. Nature. 1997;389(6653):816-824.
110. Prescott ED, Julius D. A modular PIP2 binding site as a
determinant of capsaicin receptor sensitivity. Science.
2003;300(5623):1284-1288.
111. Jones VM, Moore KA, Peterson DM. Capsaicin 8% topical
patch (Qutenza)—a review of the evidence. J Pain Palliat Care
Pharmacother. 2011;25(1):32-41.
112. Iadarola MJ, Gonnella GL. Resiniferatoxin for pain treatment: an
interventional approach to personalized pain medicine. Open Pain
J. 2013;6(1):95-107.
 |
16
113. Brown DC, Agnello K, Iadarola MJ. Intrathecal resiniferatoxin in a
dog model. Pain. 2015;156(6):1.
114. Piomelli D, Giuffrida A, Calignano A, Rodrı́guez de Fonseca F. The
endocannabinoid system as a target for therapeutic drugs. Trends
Pharmacol Sci. 2000;21(6):218-224.
115. Karai L, Brown DC, Mannes AJ, et al. Deletion of vanilloid recep-
tor 1-expressing primary afferent neurons for pain control. J Clin
Invest. 2004;113(9):1344-1352.
116. Pacher P, Bátkai S, Kunos G. The endocannabinoid system
as an emerging target of pharmacotherapy. Pharmacol Rev.
2006;58(3):389-462.
117. Fioravanti B, De Felice M, Stucky CL, et al. Constitutive activity at
the cannabinoid CB1 receptor is required for behavioral response
to noxious chemical stimulation of TRPV1: antinociceptive actions
of CB1 inverse agonists. J Neurosci. 2008;28(45):11593-11602.
118. Mezey E, Toth ZE, Cortright DN, et al. Distribution of mRNA for
vanilloid receptor subtype 1 (VR1), and VR1-like immunoreactivity,
in the central nervous system of the rat and human. Proc Natl Acad
Sci. 2000;97(7):3655-3660.
119. Egertová M, Cravatt B, Elphick M. Comparative analysis of fatty
acid amide hydrolase and cb1 cannabinoid receptor expression
in the mouse brain: evidence of a widespread role for fatty acid
amide hydrolase in regulation of endocannabinoid signaling.
Neuroscience. 2003;119(2):481-496.
120. Bae YC, Oh JM, Hwang SJ, Shigenaga Y, Valtschanoff JG.
Expression of vanilloid receptor TRPV1 in the rat trigeminal sen-
sory nuclei. J Comp Neurol. 2004;478(1):62-71.
121. Andersson DA, Gentry C, Alenmyr L, et al. TRPA1 mediates spinal
antinociception induced by acetaminophen and the cannabinoid Δ
9 -tetrahydrocannabiorcol. Nat Commun. 2011;2(1):1.
122. Story GM, Peier AM, Reeve AJ, et al. ANKTM1, a TRP-like channel
expressed in nociceptive neurons, is activated by cold tempera-
tures. Cell. 2003;112(6):819-829.
123. Bautista DM, Movahed P, Hinman A, et al. Pungent products from
garlic activate the sensory ion channel TRPA1. Proc Natl Acad Sci
USA. 2005;102(34):12248-12252.
124. Streng T, Axelsson HE, Hedlund P, et al. Distribution and function
of the hydrogen sulfide-sensitive TRPA1 ion channel in rat urinary
bladder. Eur Urol. 2008;53(2):391-400.
125. Jordt S-E, Bautista DM, Chuang H-H, et al. Mustard oils and can-
nabinoids excite sensory nerve fibres through the TRP channel
ANKTM1. Nature. 2004;427(6971):260-265.
126. Bandell M, Story GM, Hwang SW, et al. Noxious cold ion chan-
nel TRPA1 is activated by pungent compounds and bradykinin.
Neuron. 2004;41(6):849-857.
127. Baraldi PG, Preti D, Materazzi S, Geppetti P. Transient recep-
tor potential ankyrin 1 (TRPA1) channel as emerging target for
novel analgesics and anti-inflammatory agents. J Med Chem.
2010;53(14):5085-5107.
128. Holzer P. Transient receptor potential (TRP) channels as drug
targets for diseases of the digestive system. Pharmacol Ther.
2011;131(1):142-170.
129. Viana F. Chemosensory properties of the trigeminal system. ACS
Chem Neurosci. 2011;2(1):38-50.
130. Prescott L, Critchley J, Balali-Mood M, Pentland B. Effects of mic-
rosomal enzyme induction on paracetamol metabolism in man. Br
J Clin Pharmacol. 1981;12(2):149-153.
131. Dahlin DC, Miwa GT, Lu AYH, Nelson SD. N-acetyl-p-
benzoquinone imine: a cytochrome P-450-mediated oxidation
product of acetaminophen. Isotopenpraxis. 1984;20(1):1327-1331.
132. Hinson JA, Roberts DW, James LP. Mechanisms of acet-
aminophen-induced liver necrosis. Handb Exp Pharmacol.
2010;196:369-405.
133. Bhagwat SV, Leelavathi BC, Shankar SK, Boyd MR, Ravindranath
V. Cytochrome P450 and assocaited monooxygenase activities in
14401681, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1440-1681.13392 by Readcube (Labtiva Inc.), Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
PRZYBYŁA et al.
the rat and human spinal cord: Induction, immunological charac-
terization and immunocytochemical localization. Neuroscience.
1995;68(2):593-601.
134. Willingale HL, Gardiner NJ, McLymont N, Giblett S, Grubb BD.
Prostanoids synthesized by cyclo-oxygenase isoforms in rat spinal
cord and their contribution to the development of neuronal hyper-
excitability. Br J Pharmacol. 1997;122(8):1593-1604.
135. Pascoe GA, Calleman CJ, Baille TA. Identification of S-(2,5-
dihydroxyphenyl)-cysteine and S-(2,5-dihydroxyphenyl)-N-
acetyl-cysteine as urinary metabolites of acetaminophen in
the mouse. Evidence for p-benzoquinone as a reactive inter-
mediate in acetaminophen metabolism. Chem Biol Interact.
1988;68(1–2):85-98.
136. Shinoda S, Aoyama T, Aoyama Y, Tomioka S, Matsumoto Y, Ohe
Y. Pharmacokinetics/pharmacodynamics of acetaminophen an-
algesia in Japanese patients with chronic pain. Biol Pharm Bull.
2007;30(1):157-161.
137. Chen C, Krausz KW, Idle JR, Gonzalez FJ. Identification of novel
toxicity-associated metabolites by metabolomics and mass iso-
topomer analysis of acetaminophen metabolism in wild-type and
Cyp2e1-null mice. J Biol Chem. 2008;283(8):4543-4559.
138. Jancsó-Gábor A, Szolcsányi J, Jancsó N. Irreversible impairment of
thermoregulation induced by capsaicin and similar pungent sub-
stances in rats and guinea-pigs. J Physiol. 1970;206(3):495-507.
139. Jancsó-Gábor A, Szolcsányi J, Jancsó N. Stimulation and desensi-
tization of the hypothalamic heat-sensitive structures by capsaicin
in rats. J Physiol. 1970;208(2):449-459.
140. Miller MS, Brendel K, Buck SH, Burks TF. Dihydrocapsaicin-
induced hypothermia and substance P depletion. Eur J Pharmacol.
1982;83(3–4):289-292.
141. Woods AJ, Stock MJ, Gupta AN, Wong TTL, Andrews PLR.
Thermoregulatory effects of resiniferatoxin in the rat. Eur J
Pharmacol. 1994;264(2):125-133.
142. Liedtke W, Choe Y, Martí-Renom MA, et al. Vanilloid receptor-re-
lated osmotically activated channel (VR-OAC), a candidate verte-
brate osmoreceptor. Cell. 2000;103(3):525-535.
143. Strotmann R, Harteneck C, Nunnenmacher K, Schultz G, Plant TD.
OTRPC4, a nonselective cation channel that confers sensitivity to
extracellular osmolarity. Nat Cell Biol. 2000;2(10):695-702.
144. Vay L, Gu C, McNaughton PA. The thermo-TRP ion channel
family: properties and therapeutic implications. Br J Pharmacol.
2012;165(4):787-801.
145. Nakatsu Y, Nakagawa F, Higashi S, et al. Effect of acetaminophen
on osteoblastic differentiation and migration of MC3T3-E1 cells.
Pharmacol Rep. 2018;70(1):29-36.
146. Nakagawa F, Higashi S, Ando E, Ohsumi T, Watanabe S, Takeuchi
H. Modification of TRPV4 activity by acetaminophen. Heliyon.
2020;6(1):e03301.
147. Todaka H, Taniguchi J, Satoh JI, Mizuno A, Suzuki M. Warm tem-
perature-sensitive transient receptor potential vanilloid 4 (TRPV4)
plays an essential role in thermal hyperalgesia. J Biol Chem.
2004;279(34):35133-35138.
148. Huh D, Leslie DC, Matthews BD, et al. A human disease model
of drug toxicity-induced pulmonary edema in a lung-on-a-chip mi-
crodevice. Sci Transl Med. 2012;4(159):159ra147.
149. Darby WG, Grace MS, Baratchi S, McIntyre P. Modulation
of TRPV4 by diverse mechanisms. Int J Biochem Cell Biol.
2016;78:217-228.
150. Perez-Reyes E. Molecular physiology of low-voltage-activated
T-type calcium channels. Physiol Rev. 2003;83(1):117-161.
151. Bourinet E, Alloui A, Monteil A, et al. Silencing of the Cav3.2
T-type calcium channel gene in sensory neurons demonstrates its
major role in nociception. EMBO J. 2005;24(2):315-324.
152. Choi S, Na HS, Kim J, et al. Attenuated pain responses in mice lacking
Ca V 3.2 T-type channels. Genes Brain Behav. 2007;6(5):425-431.

PRZYBYŁA et al.
153. Becker AJ, Pitsch J, Sochivko D, et al. Transcriptional upregulation
of Cav3.2 mediates epileptogenesis in the pilocarpine model of ep-
ilepsy. J Neurosci. 2008;28(49):13341-13353.
154. Lee J, Kim D, Shin H-S. Lack of delta waves and sleep distur-
bances during non-rapid eye movement sleep in mice lack-
ing 1G-subunit of T-type calcium channels. Proc Natl Acad Sci.
2004;101(52):18195-18199.
155. Talley EM, Cribbs LL, Lee JH, Daud A, Perez-Reyes E, Bayliss DA.
Differential distribution of three members of a gene family encod-
ing low voltage-activated (T-type) calcium channels. J Neurosci.
1999;19(6):1895-1911.
156. Barbara G, Alloui A, Nargeot J, et al. T-type calcium channel inhibi-
tion underlies the analgesic effects of the endogenous lipoamino
acids. J Neurosci. 2009;29(42):13106-13114.
157. Kerckhove N, Mallet C, François A, et al. Cav3.2 calcium channels:
the key protagonist in the supraspinal effect of paracetamol. Pain.
2014;155(4):764-772.
158. De FC, Herrero JF, O’Brien JA, et al. Altered nociception, analge-
sia and aggression in mice lacking the receptor for substance P.
Nature. 1998;392(6674):394-397.
159. Inoue T, Mashimo T, Shibata M, Shibuta S, Yoshiya I. Rapid devel-
opment of nitric oxide-induced hyperalgesia depends on an alter-
nate to the cGMP-mediated pathway in the rat neuropathic pain
model. Brain Res. 1998;792(2):263-270.
160. Björkman R. Central antinociceptive effects of non-steroidal an-
ti-inflammatory drugs and paracetamol. Acta Anaesthesiol Scand.
1995;39:7-44.
161. Björkman R, Hallman KM, Hedner J, Hedner T, Henning M.
Acetaminophen blocks spinal hyperalgesia induced by NMDA and
substance P. Pain [Internet]. 1994;57(3):259-264.
162. Bujalska M. Effect of cyclooxygenase and no synthase inhibitors
administered centrally on antinociceptive action of acetamino-
phen (Part II). Pol J Pharmacol. 2003;55(6):1001-1011.
163. Ryu YS, Lee JH, Seok JH, et al. Acetaminophen inhibits iNOS gene
expression in RAW 264.7 macrophages: differential regulation
of NF-κB by acetaminophen and salicylates. Biochem Biophys Res
Commun. 2000;272(3):758-764.
164. Prado WA, Schiavon VF, Cunha FQ. Dual effect of local applica-
tion of nitric oxide donors in a model of incision pain in rats. Eur J
Pharmacol. 2002;441(1–2):57-65.
165. Smith WL, Malkowski MG. Interactions of fatty acids, nonste-
roidal anti-inflammatory drugs, and coxibs with the catalytic
and allosteric subunits of cyclooxygenases-1 and -2. J Biol Chem.
2019;294(5):1697-1705.
166. Deeb RS, Shen H, Gamss C, et al. Inducible nitric oxide synthase
mediates prostaglandin H2 synthase nitration and suppresses
eicosanoid production. Am J Pathol. 2006;168(1):349-362.
167. Deeb RS, Hao G, Gross SS, et al. Heme catalyzes tyrosine 385
nitration and inactivation of prostaglandin H2 synthase-1 by per-
oxynitrite. J Lipid Res. 2006;47(5):898-911.
168. Saliba SW, Bonifacino T, Serchov T, Bonanno G, de Oliveira
ACP, Fiebich BL. Neuroprotective effect of AM404 against
NMDA-induced hippocampal excitotoxicity. Front Cell Neurosci.
2019;13(December):1-10.
169. Ray S, Salzer I, Kronschläger MT, Boehm S. The paracetamol me-
tabolite N-acetylp-benzoquinone imine reduces excitability in
first- and second-order neurons of the pain pathway through ac-
tions on KV7 channels. Pain. 2019;160(4):954-964.
170. Van Der Horst J, Manville RW, Hayes K, Thomsen MB, Abbott
GW, Jepps TA. Acetaminophen (Paracetamol) metabolites in-
duce vasodilation and hypotension by activating Kv7 potassium
channels directly and indirectly. Arterioscler Thromb Vasc Biol.
2020;40(5):1207-1219.
171. Levy G, Garrettson LK, Soda DM. Letter: Evidence of placental
transfer of acetaminophen. Pediatrics. 1975;55(6):895.
|
14401681, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1440-1681.13392 by Readcube (Labtiva Inc.), Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
17
172. Kumpulainen E, Kokki H, Halonen T, Heikkinen M, Savolainen J,
Laisalmi M. Paracetamol (acetaminophen) penetrates readily into
the cerebrospinal fluid of children after intravenous administra-
tion. Pediatrics. 2007;119(4):766-771.
173. Bremer L, Goletzke J, Wiessner C, et al. Paracetamol medication
during pregnancy: insights on intake frequencies, dosages and
effects on hematopoietic stem cell populations in cord blood
from a longitudinal prospective pregnancy cohort. EBioMedicine.
2017;26:146-151.
174. Philippot G, Hallgren S, Gordh T, Fredriksson A, Fredriksson R,
Viberg H. A cannabinoid receptor type 1 (CB1R) agonist enhances
the developmental neurotoxicity of acetaminophen (paracetamol).
Toxicol Sci. 2018;166(1):203-212.
175. Thompson JMD, Waldie KE, Wall CR, Murphy R, Mitchell EA.
Associations between acetaminophen use during pregnancy and
ADHD symptoms measured at ages 7 and 11 years. PLoS One.
2014;9(9):e108210.
176. Avella-Garcia CB, Julvez J, Fortuny J, et al. Acetaminophen use in
pregnancy and neurodevelopment: attention function and autism
spectrum symptoms. Int J Epidemiol. 2016;45(6):1987-1996.
177. Stergiakouli E, Thapar A, Smith GD. Association of acetamin-
ophen use during pregnancy with behavioral problems in
childhood: evidence against confounding. JAMA Pediatr.
2016;170(10):964-970.
178. Eyers S, Weatherall M, Jefferies S, Beasley R. Paracetamol in preg-
nancy and the risk of wheezing in offspring: a systematic review
and meta-analysis. Clin Exp Allergy. 2011;41(4):482-489.
179. Blecharz-Klin K, Joniec-Maciejak I, Jawna K, et al. Effect of pre-
natal and early life paracetamol exposure on the level of neu-
rotransmitters in rats—Focus on the spinal cord. Int J Dev Neurosci.
2015;47(Part_B):133-139.
180. Blecharz-Klin K, Joniec-Maciejak I, Jawna-Zboińska K, et al.
Cerebellar level of neurotransmitters in rats exposed to parac-
etamol during development. Pharmacol Rep. 2016;68(6):1159-1164.
181. Blecharz-Klin K, Piechal A, Jawna-Zboińska K, et al. Paracetamol −
Effect of early exposure on neurotransmission, spatial memory and
motor performance in rats. Behav Brain Res. 2017;323:162-171.
182. Philippot G, Gordh T, Fredriksson A, Viberg H. Adult neurobehav-
ioral alterations in male and female mice following developmental
exposure to paracetamol (acetaminophen): characterization of a
critical period. J Appl Toxicol. 2017;37(10):1174-1181.
183. Aguado T, Monory K, Palazuelos J, et al. The endocannabi-
noid system drives neural progenitor proliferation. FASEB J.
2005;19(12):1704-1706.
184. Berghuis P, Dobszay MB, Wang X, et al. Endocannabinoids regulate
interneuron migration and morphogenesis by transactivating the
TrkB receptor. Proc Natl Acad Sci USA. 2005;102(52):19115-19120.
185. Johansson C. Neonatal exposure to paracetamol affects the lev-
els of important neuroproteins in developing mouse brain im-
portant neuroproteins in developing mouse brain. 2015. Uppsala
University, master thesis. https://www.diva-portal.org/smash/​
get/diva2​:81890​7/FULLT​E XT01.pdf
186. Lalert L, Ji-au W, Srikam S, et al. Alterations in synaptic plasticity
and oxidative stress following long-term paracetamol treatment in
rat brain. Neurotox Res. 2020;37(2):455-468.
187. Suemaru K, Yoshikawa M, Aso H, Watanabe M. TRPV1 mediates
the anticonvulsant effects of acetaminophen in mice. Epilepsy Res.
2018;145:153-159.
188. Pickering G, Macian N, Dubray C, Pereira B. Paracetamol sharp-
ens reflection and spatial memory: a double-blind randomized
controlled study in healthy volunteers. Drug Des Devel Ther.
2016;10:3969-3976.
189. McCrae JC, Morrison EE, MacIntyre IM, Dear JW, Webb DJ. Long-
term adverse effects of paracetamol - a review. Br J Clin Pharmacol.
2018;84(10):2218-2230.
 |
18
190. Rittchen S, Heinemann A. Therapeutic potential of hematopoi-
etic prostaglandin D2 synthase in allergic inflammation. Cells.
2019;8(6):619.
191. Wilson SJ, Roche AM, Kostetskaia E, Smyth EM. Dimerization of
the human receptors for prostacyclin and thromboxane facilitates
thromboxane receptor-mediated cAMP generation. J Biol Chem.
2004;279(51):53036-53047.
192. Jin RC, Voetsch B, Loscalzo J. Endogenous mechanisms of inhibi-
tion of platelet function. Microcirculation. 2005;12(3):247-258.
193. Idzko M, Hammad H, van Nimwegen M, et al. Inhaled iloprost sup-
presses the cardinal features of asthma via inhibition of airway
dendritic cell function. J Clin Invest. 2007;117(2):464-472.
194. Konturek SJ, Robert A. Cytoprotection of canine gastric mucosa
by prostacyclin: possible mediation by increased mucosal blood
flow. Digestion. 1982;25(3):155-163.
195. Botella A, Delvaux M, Fioramonti J, Frexinos J, Bueno L.
Stimulatory (EP1 and EP3) and inhibitory (EP2) prostaglandin E2
receptors in isolated ileal smooth muscle cells. Eur J Pharmacol.
1993;237(1):131-137.
196. Shahbazian A, Heinemann A, Peskar BA, Holzer P. Differential per-
istaltic motor effects of prostanoid (DP, EP, IP, TP) and leukotriene
receptor agonists in the guinea-pig isolated small intestine. Br J
Pharmacol. 2002;137(7):1047-1054.
197. Brzozowski T, Tarnawski A, Hollander D, Sekhon S, Krause WJ,
Gergely H. Comparison of prostaglandin and cimetidine in protec-
tion of isolated gastric glands against indomethacin injury. J Physiol
Pharmacol. 2005;56(SUPPL. 5):75-88.
198. Araki H, Ukawa H, Sugawa Y, Yagi K, Suzuki K, Takeuchi K. The
roles of prostaglandin E receptor subtypes in the cytoprotective
action of prostaglandin E2 in rat stomach. Aliment Pharmacol Ther
Suppl. 2000;14(1):116-124.
199. Kato S, Aihara E, Yoshii K, Takeuchi K. Dual action of prostaglan-
din E2 on gastric acid secretion through different EP-receptor
subtypes in the rat. Am J Physiol Gastrointest Liver Physiol.
2005;289:G64-G69.
200. Kato S, Aihara E, Yoshii K, Takeuchi K. Dual action of prostaglan-
din E2 on gastric acid secretion through different EP-receptor
subtypes in the rat. Am J Physiol Gastrointest Liver Physiol.
2005;289(1):G64-G69.
201. Audoly LP, Tilley SL, Goulet J, et al. Identification of specific EP
receptors responsible for the hemodynamic effects of PGE2. Am J
Physiol Hear Circ Physiol. 1999;277:H924-H930.
202. Foudi N, Kotelevets L, Louedec L, et al. Vasorelaxation induced
by prostaglandin E 2 in human pulmonary vein: Role of the EP 4
receptor subtype. Br J Pharmacol. 2008;154(8):1631-1639.
203. Kennedy CRJ, Zhang Y, Brandon S, et al. Salt-sensitive hyperten-
sion and reduced fertility in mice lacking the prostaglandin EP2
receptor. Nat Med. 1999;5(2):217-220.
204. Segi E, Sugimoto Y, Yamasaki A, et al. Patent ductus arteriosus
and neonatal death in prostaglandin receptor EP4-deficient mice.
Biochem Biophys Res Commun. 1998;246(1):7-12.
205. Sheller JR, Mitchell D, Meyrick B, Oates J, Breyer R. EP2 recep-
tor mediates bronchodilation by PGE2 in mice. J Appl Physiol.
2000;88(6):2214-2218.
206. Karim SMM, Hillier K, Trussell RR. The effects of prostaglandins
E2 and F2α administered by different routes on uterine activity
and the cardiovascular system in pregnant and non-pregnant
women. BJOG An Int J Obstet Gynaecol. 1971;78(2):172-179.
207. Tunaru S, Althoff TF, Nüsing RM, Diener M, Offermanns S. Castor
oil induces laxation and uterus contraction via ricinoleic acid ac-
tivating prostaglandin EP3 receptors. Proc Natl Acad Sci USA.
2012;109(23):9179-9184.
208. Kuriyama H, Suzuki H. Effects of prostaglandin E2 and oxytocin on
the electrical activity of hormone-treated and pregnant rat myo-
metria. J Physiol. 1976;260(2):335-349.
14401681, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1440-1681.13392 by Readcube (Labtiva Inc.), Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
PRZYBYŁA et al.
209. Fuchs AR, Ivell R, Balvers M, Chang SM, Fields MJ. Oxytocin
receptors in bovine cervix during pregnancy and parturition:
gene expression and cellular localization. Am J Obstet Gynecol.
1996;175(6):1654-1660.
210. Hib J, Ponzio RO, Vilar O. Effect of chronic treatment with prosta-
glandin E2 on male rat fertility. Andrologia. 1979;11(4):326-330.
211. Hedqvist P. Basic mechanisms of prostaglandin action on autonomic
neurotransmission. Annu Rev Pharmacol Toxicol. 1977;17(1):259-279.
212. Beiche F, Klein T, Nüsing R, Neuhuber W, Goppelt-Struebe
M. Localization of cyclooxygenase-2 and prostaglandin E2 re-
ceptor EP3 in the rat lumbar spinal cord. J Neuroimmunol.
1998;89(1–2):26-34.
213. Scammell TE, Elmquist JK, Griffin JD, Saper CB. Ventromedial pre-
optic prostaglandin E2 activates fever-producing autonomic path-
ways. J Neurosci. 1996;16(19):6246-6254.
214. Oka T. Division of psychosomatic medicine, department of neurol-
ogy, university of occupational and environmental health, Japan.
Neurosci Lett. 2004;2:3046-3057.
215. Lin CR, Amaya F, Barrett L, et al. Prostaglandin E2 receptor EP4
contributes to inflammatory pain hypersensitivity. J Pharmacol Exp
Ther. 2006;319(3):1096-1103.
216. Minami T, Nakano H, Kobayashi T, et al. Characterization of EP
receptor subtypes responsible for prostaglandin E2-induced pain
responses by use of EP1 and EP3 receptor knockout mice. Br J
Pharmacol. 2001;133(3):438-444.
217. Schweda F, Klar J, Narumiya S, Nüsing RM, Kurtz A. Stimulation
of renin release by prostaglandin E2 is mediated by EP2 and
EP4 receptors in mouse kidneys. Am J Physiol Ren Physiol.
2004;287:F427-F433.
218. Breyer MD, Zhang YH, Guan Y-F, Hao C-M, Hebert RL, Breyer RM.
Regulation of renal function by prostaglandin E receptors. Kidney
Int. 1998;54:S88-S94.
219. Roper RL, Phipps RP. Prostaglandin E2 and cAMP inhibit B lym-
phocyte activation and simultaneously promote IgE and IgG1 syn-
thesis. J Immunol. 1992;149(9):2984-2991.
220. Chouaib S, Welte K, Mertelsmann R, Dupont B. Prostaglandin E2
acts at two distinct pathways of T lymphocyte activation: inhibi-
tion of interleukin 2 production and down-regulation of transferrin
receptor expression. J Immunol. 1985;135(2):1172-1179.
221. Nataraj C, Thomas DW, Tilley SL, et al. Receptors for prostaglandin
E2 that regulate cellular immune responses in the mouse. J Clin
Invest. 2001;108(8):1229-1235.
222. Fedyk ER, Phipps RP. Prostaglandin E2 receptors of the EP2 and
EP4 subtypes regulate activation and differentiation of mouse
B lymphocytes to IgE-secreting cells. Proc Natl Acad Sci USA.
1996;93(20):10978-10983.
223. Turnbach ME, Seth Spraggins D, Randich A. Spinal administration
of prostaglandin E2 or prostaglandin F2α primarily produces me-
chanical hyperalgesia that is mediated by nociceptive specific spi-
nal dorsal horn neurons. Pain. 2002;97(1–2):33-45.
224. Coelho MM, Pelá IR, Rothwell NJ. Dexamethasone inhibits the py-
rogenic activity of prostaglandin F2α, but not prostaglandin E2.
Eur J Pharmacol. 1993;238(2–3):391-394.
225. Roberts JS, McCracken JA. Does prostaglandin F2α released from
the uterus by oxytocin mediate the oxytocic action of oxytocin?
Biol Reprod. 1976;15(4):457-463.
226. Banihani SA. Effect of paracetamol on semen quality. Andrologia.
2018;50(1):e12874.
227. Mathé AA, Strandberg K, Fredholm B. Antagonism of prostaglan-
din F2α induced bronchoconstriction and blood pressure changes
by polyphloretin phosphate in the guinea-pig and cat. J Pharm
Pharmacol. 1972;24(5):378-382.
228. Gardan B, Cracowski J-L, Sessa C, et al. Vasoconstrictor effects of Iso-
prostaglandin F 2(α) type-III (8-Iso- prostaglandin F 2(α)) on human
saphenous veins. J Cardiovasc Pharmacol. 2000;35(5):729-734.

PRZYBYŁA et al.
229. Kerstetter JR, Brubaker RF, Wilson LJ, Kullerstrand LJ.
Prostaglandin F2α-1-isopropylester lowers intraocular pres-
sure without decreasing aqueous humor flow. Am J Ophthalmol.
1988;105(1):30-34.
230. Bryan Smith J, Silver MJ, Ingerman CM, Kocsis JJ. Prostaglandin
D2 inhibits the aggregation of human platelets. Thromb Res.
1974;5(3):291-299.
231. Schuligoi R, Schmidt R, Geisslinger G, Kollroser M, Peskar BA,
Heinemann A. PGD2 metabolism in plasma: kinetics and rela-
tionship with bioactivity on DP1 and CRTH2 receptors. Biochem
Pharmacol. 2007;74(1):107-117.
232. Zhao H, Usui H, Ohinata K, Yoshikawa M. Met-Arg-Trp derived
from Rubisco lowers blood pressure via prostaglandin D2-
dependent vasorelaxation in spontaneously hypertensive rats.
Peptides. 2008;29(3):345-349.
233. Jarad N, Hui KP, Barnes N. Effects of a thromboxane receptor an-
tagonist on prostaglandin D2 and histamine induced bronchocon-
striction in man. Br J Clin Pharmacol. 1994;37(1):97-100.
234. Fajt ML, Gelhaus SL, Freeman B, et al. Prostaglandin D2 pathway
upregulation: relation to asthma severity, control, and TH2 inflam-
mation. J Allergy Clin Immunol. 2013;131(6):1504-1512.e12.
235. Monneret G, Gravel S, Diamond M, Rokach J, Powell WS.
Prostaglandin D2 is a potent chemoattractant for human eosino-
phils that acts via a novel DP receptor. Blood. 2001;98(6):1942-1948.
236. Oguma T, Asano K, Ishizaka A. Role of prostaglandin D2 and
its receptors in the pathophysiology of asthma. Allergol Int.
2008;57(4):307-312.
237. Shichijo M, Sugimoto H, Nagao K, et al. Chemoattractant recep-
tor-homologous molecule expressed on Th2 cells activation in
vivo increases blood leukocyte counts and its blockade abrogates
13,14-dihydro-15-ketoprostaglandin D2-induced eosinophilia in
rats. J Pharmacol Exp Ther. 2003;307(2):518-525.
238. Xue L, Gyles SL, Wettey FR, et al. Prostaglandin D 2 causes pref-
erential induction of proinflammatory th2 cytokine production
through an action on chemoattractant receptor-like molecule ex-
pressed on Th2 cells. J Immunol. 2005;175(10):6531-6536.
239. Matsuoka T, Hirata M, Tanaka H, et al. Prostaglandin D2 as a medi-
ator of allergic asthma. Science. 2000;287(5460):2013-2017.
240. Huang J-L, Gao P-S, Mathias RA, et al. Sequence variants of the
gene encoding chemoattractant receptor expressed on Th2 cells
(CRTH2) are associated with asthma and differentially influence
mRNA stability. Hum Mol Genet. 2004;13(21):2691-2697.
241. Lefer AM, Smith EF, Araki H, et al. Dissociation of vasoconstrictor
and platelet aggregatory activities of thromboxane by carbocyclic
thromboxane A2, a stable analog of thromboxane A2. Proc Natl
Acad Sci. 1980;77(3):1706-1710.
242. Moncada S, Amezcua JL. Prostacyclin, thromboxane A2 in-
teractions in haemostasis and thrombosis. Haemostasis.
1979;8(3–5):252-265.
243. Greenberg R, Antonaccio MJ, Steinbacher T. Thromboxane A2 me-
diated bronchoconstriction in the anesthetized guinea pig. Eur J
Pharmacol. 1982;80(1):19-27.
244. Machado GC, Maher CG, Ferreira PH, et al. Efficacy and safety of
paracetamol for spinal pain and osteoarthritis: systematic review
and meta-analysis of randomised placebo controlled trials. BMJ.
2015;350:h1225.
|
14401681, 2021, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/1440-1681.13392 by Readcube (Labtiva Inc.), Wiley Online Library on [31/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
19
245. Cranswick N, Coghlan D. Paracetamol efficacy and safety in chil-
dren: the first 40 years. Am J Ther. 2000;7(2):135-141.
246. Lee WM. Acetaminophen (APAP) hepatotoxicity—Isn’t it time for
APAP to go away? J Hepatol. 2017;67(6):1324-1331.
247. Bannwarth B. Gastrointestinal safety of paracetamol: is there any
cause for concern? Expert Opin Drug Saf. 2004;3(4):269-272.
248. Larson AM, Polson J, Fontana RJ, et al. Acetaminophen-induced
acute liver failure: results of a United States multicenter, prospec-
tive study. Hepatology. 2005;42(6):1364-1372.
249. Stricker BH, Meyboom RH, Lindquist M. Acute hypersensitivity
reactions to paracetamol. BMJ. 1985;291(6500):938-939.
250. Panchabhai TS, Gogtay NJ, Bavdekar SB. Paracetamol induced an-
gioedema. Indian J Med Sci. 2008;62:420-422.
251. Rumack BH. Acetaminophen. Pediatrics. 2007;1975:871-876.
252. Möller-Hartmann W, Siegers C-P. Nephrotoxicity of paracetamol
in the rat—mechanistic and therapeutic aspects. J Appl Toxicol.
1991;11(2):141-146.
253. Garcia Rodríguez LA, Hernández-Díaz S. The risk of upper gastro-
intestinal complications associated with nonsteroidal anti-inflam-
matory drugs, glucocorticoids, acetaminophen, and combinations
of these agents. Arthritis Res. 2001;3(2):98-101.
254. Trujillo C, Gago C, Ramos S. Stevens-Jonhson syndrome after ac-
etaminophen ingestion, confirmed by challenge test in an eleven-
year-old patient. Allergol Immunopathol. 2010;38(2):99-100.
255. Halevi A, Ben-Amitai D, Garty BZ. Toxic epidermal necrolysis
associated with acetaminophen ingestion. Ann Pharmacother.
2000;34(1):32-34.
256. Lacotte J, Perrin C, Mosquet B, Moulin M, Bazin C.
Agranulocytosis caused by paracetamol. A case report. Therapie.
1990;45(5):438-439.
257. Mehrotra TN, Gupta SK. Paracetamol-induced hemolytic anemia:
report of a case. Indian J Med Sci. 1973;27(7):548-549.
258. Graham GG, Scott KF, Day RO. Tolerability of paracetamol. Drug
Saf. 2005;28(3):227-240.
259. Tujios SR, Hynan LS, Vazquez MA, et al. Risk factors and outcomes
of acute kidney injury in patients with acute liver failure. Clin
Gastroenterol Hepatol. 2015;13(2):352-359.
260. Chalmers JP, West MJ, Wing LM, Bune AJ, Graham JR. Effects
of indomethacin, sulindac, naproxen, aspirin, and parac-
etamol in treated hypertensive patients. Clin Exp Hypertens.
1984;6(6):1077-1093.
261. Forman JP, Rimm EB, Curhan GC. Frequency of analgesic
use and risk of hypertension among men. Arch Intern Med.
2007;167(4):394-399.
262. Thornton JR, Losowsky MS. Severe thrombocytopenia after
paracetamol overdose. Gut. 1990;31(10):1159-1160.
How to cite this article: Przybyła GW, Szychowski KA, Gmiński
J. Paracetamol – An old drug with new mechanisms of action.
Clin Exp Pharmacol Physiol. 2021;48:3–19. https://doi.
org/10.1111/1440-1681.13392