Enzymes are proteins which act as catalysts to facilitate the conversion of substrates into products. Enzyme classification has been developed by the Nomenclature Committee of the International Union of Biochemistry and Molecular Biology (NC-IUBMB), which arranges enzymes into six large families:EC 1.-.-.- OxidoreductasesEC 2.-.-.- Transferases (includes the protein kinases EC 2.7.-.-)EC 3.-.-.- HydrolasesEC 4.-.-.- LyasesEC 5.-.-.- IsomerasesEC 6.-.-.- LigasesEnzymes may also be grouped according to the physiological pathway or process in which they are involved. For example, L-arginine turnover, cyclic nucleotide turnover, eicosanoid turnover or chromatin modifying enzymes.The majority of drugs which act on enzymes act as inhibitors and most of these are competitive, in that they compete for binding with the enzyme's substrate- for example the majority of the original (first generation) kinase inhibitors bind to the ATP pocket of the enzyme. Some inhibitors are non-competitive, binding away from the substrate binding domain, competing for co-factor/co-enzyme binding, or causing an allosteric conformational change in the 3-dimensional protein structure that prevents substrate interaction. Yet other inhibitors are irreversible and these covalently bind to the enzyme, permanently inactivating catalytic function (these are also known as suicide inhibitors).The topics below highlight a cross-section of the clinical uses of enzyme inhibitors, from inflammation to cancer. Cyclooxygenase (COX) inhibitors Cyclooxygenase (COX) inhibitors are non-steroidal anti-inflammatory drugs (NSAIDs), used clinically to relieve fever and pain, such as those associated with headaches, colds, flu, and arthritis. NSAIDs are available by prescription and over-the-counter (OTC).COX inhibitors can act at one or both of the isozymes, COX-1 and COX-2.COX-1 is involved in the synthesis of prostaglandins which are responsible for maintenance and protection of the gastrointestinal tract, whilst COX-2 produces the pro-inflammatory prostaglandins responsible for causing inflammation and pain.Inhibitors differ in their relative specificities for COX-1 and COX-2, with examples such as aspirin, ibuprofen, naproxen and diclofenac being non-selective. Selective COX-2 inhibitors were developed to reduce the liability of gastrointestinal damage associated with COX-1 inhibition. Non-selective COX inhibitors are often prescribed with a proton pump inhibitor such as omeprazole to reduce the risk of causing gastrointestinal ulceration and bleeding. Meloxicam, valdecoxib, parecoxib and rofecoxib are examples of selective COX-2 inhibitors. However, some COX-2 selective inhibitors have been shown to cause an increased risk of heart attacks and strokes. Because of this risk all non-aspirin NSAID medications (prescription or OTC) must carry boxed warnings to alert patients to the potential danger associated with their use. The US FDA issued an updated safety warning in late 2015: FDA Drug Safety Communication: FDA strengthens warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes. NSAIDs and Cardiovascular Risk Explained Characteristics of NSAIDs and side effects Phosphodiesterase inhibitors Phosphodiesterases (PDEs) are enzymes responsible for the inactivation of the intracellular second messengers cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP). There are many subtypes of phosphodiesterases and many inhibitors which can be either non-specific, or selective in their inhibitory profile.Methylated xanthine derivatives act as nonselective PDE inhibitors. Examples include the natural product theophylline (aminophylline) which is used for its bronchodilatory effects and pentoxifylline. Xanthine derivatives can also act as nonselective adenosine receptor antagonists. Their combined action on phosphodiesterases and adenosine receptors likely underlies the anti-inflammatory action of pan-phosphodiesterase inhibitors.Selective phosphodiesterase inhibitorsPDE3 inhibitors: milrinone, enoximone, and inamrinone are cardiotonic agents used to treat congestive heart failure. Cilostazol (used to treat intermittent claudication) and anagrelide (used to treat essential thrombocythaemia) are also PDE3-selective inhibitors.PDE4 inhibitors: roflumilast and apremilast are used for their anti-inflammatory action, to treat asthma and chronic obstructive pulmonary disease (COPD), and psoriatic arthritis respectively. PDE4 inhibitors suppress the release of cytokines and other inflammatory signals to achieve an anti-inflammatory action.PDE5 inhibitors: sildenafil, tadalafil, vardenafil, and the newer drug avanafil selectively inhibit PDE5, a cGMP-selective phosphodiesterase expressed in the smooth muscle cells lining the blood vessels of the corpus cavernosum and other tissues. This set of drugs are used primarily to treat erectile dysfunction. Certain of these drugs also show efficacy in treating pulmonary arterial hypertension (PAH) and benign prostatic hyperplasia (BPH). Dihydrofolate reductase inhibitors Dihydrofolate reductase (DHFR) inhibitors reduce the production of folate (folic acid) required by rapidly dividing cells to make thymine for DNA synthesis.This antifolate activity is used as cancer chemotherapy because it reduces neoplastic cell proliferation. Methotrexate, pemetrexed and pralatrexate are antifolate drugs used in chemotherapy.Inhibitors selective for bacterial/microbial DHFR compared to host DHFR are used as as antimicrobial agents. Examples are the antimalarial drugs pyrimethamine and proguanil, and the antibiotic trimethoprim which is used in the treatment of urinary tract infections (UTIs), acute otitis media (AOM) caused by Streptococcus pneumoniae and Haemophilus influenzae and Pneumocystis jirovecii (formerly Pneumocystis carinii) pneumonia (PCP). Kinase inhibitors Protein and (lipid kinases) represent an important target class for treating human disorders, as their aberrant activity underlies a variety of pathologies, ranging from cancer, inflammatory diseases, diabetes, infectious diseases, and cardiovascular disorders.To date more than 35 small molecule protein kinase inhibitors have been approved for human use around the world. The majority of these are for oncology indications, but a growing number are targeting immune-related conditions such as rheumatoid arthritis (tofacitinib, a Janus kinase 3 inhibitor). Two earlier inhibitors, sirolimus and everolimus (mTOR inhibitors) are used as immunosuppressants to reduce rejection of transplanted organs. Subsequently everolimus has been approved for oncology use, for the treatment of progressive, well-differentiated non-functional, neuroendocrine tumors (NET) of gastrointestinal (GI) or lung origin, in patients with unresectable, locally advanced or metastatic disease.Approved kinase inhibitors (worldwide)INNTarget/sIndication/sYear first approvedfasudilROCK (ROCK1 & ROCK2)cerebral vasospasm1995- China & Japan onlysirolimusmTORkidney transplants1999imatinibABL, PDGFR (alpha & beta), KITCML, Ph+ B-ALL, CMML, HES, GIST2001gefitinibEGFRNSCLC2003erlotinibEGFRNSCLC, pancreatic cancer2004sorafenib VEGFR2, PDGFR (alpha & beta), KIT, FLT3, BRAFRCC, HCC2005sunitinib VEGFR1, VEGFR2 & VEGFR3, KIT, PDGFR (alpha & beta), RET, CSF1R, FLT3 RCC, imatinib resistant GIST2006dasatinib ABL, PDGFR (alpha & beta), KIT, SRC CML2007lapatinibEGFR, ERBB2BC2007nilotinib ABL, PDGFR (alpha & beta), KITCML2007everolimus mTORRCC, SEGA, transplantation 2009temsirolimusmTORRCC2009axitinibVEGFR1, VEGFR2 & VEGFR3, KIT, PDGFR (alpha & beta), RET, CSF1R, FLT3RCC2011ruxolitinibJAK2IMF with JAK2V617F2011 RET, VEGFR1 & VEGFR2, FGFRs, EGFR MTC2011vemurafenibBRAFm-Melanoma with BRAFV600E2011crizotinib MET, ALK NSCLC with ALK translocations2011tofacitinibJAK3RA2012pazopanibVEGFR1, VEGFR2 & VEGFR3, PDGFR (alpha & beta), KITRCC2012bosutinibABL CML resistant/ intolerant to therapy2012cabozantinibVEGFR2, PDGFR (alpha & beta), KIT, FLT3MTC2012ponatinibABLT315 resistant CML2012regorafenibVEGFR2, Tie2CRC, GIST2012afatinibEGFRNSCLC with EGFR activating mutations 2013dabrafenibBRAFm-Melanoma with BRAFV600E2013trametinib MEKsm-Melanoma with BRAFV600E2013ibrutinibBTKMCL2013nintedanibVEGFR1, VEGFR2 & VEGFR3, PDGFR (alpha & beta), FGFRsIPF2014idelalisib PI3Kδleukemia and lymphomas2014ceritinibALKNSCLC with ALK translocations2014alectinibALKALK-rearranged NSCLC2014- FDA 2015cobimetinibMEK1 & MEK2melanoma, BC, other solid tumours2015lenvatinibVEGFR1, VEGFR2 & VEGFR3progressive, differentiated thyroid cancer, advanced renal cell carcinoma (in combination with everolimus)2015palbociclibCDK4 & 6advanced (metastatic) BC2015radotinibBRC- ABL & PDGFR (alpha & beta)CML2015-S Korea onlyosimertinibmutant EGFR T790M +ve NSCLC2015brigatinibALK, EGFR ALK-rearranged metastatic NSCLC, resistant to crizotinib2017Disease abbreviations: BC (breast cancer), CMML (chronic myelomonocytic leukaemia), CML (chronic myeloid leukaemia), CRC (colorectal cancer), GIST (gastrointestinal cancer), HES (hypereosinophilic syndrome), IPF (idiopathic pulmonary fibrosis), MCL (Mantle cell lymphoma), MTC (medullary thyroid cancer), NSCLC (non-small cell lung cancer), Ph+ B-ALL (Philadelphia chromosome positive acute lymphoblastic leukemia), RA (rheumatoid arthritis), RCC (renal cell carcinoma), SEGA (subependymal giant cell astrocytoma)lipid kinases, protein kinases PMID: 25549667 PMID: 25630872 Drug metabolizing enzymes Cytochrome P450 enzymes are the main drug metabolising enzymes (xenobiotic inactivators) in humans, and these are the primary contributors to Phase I oxidative metabolism of drugs and other chemicals.The main families of CYP450 enzymes involved in drug metabolism are the monooxygenases of the CYP1, CYP2 and CYP3 families.CYP3A4 is the most common and most versatile CYP450 enzyme involved in drug metabolism. Most drugs undergo deactivation by CYP3A4, whilst others are bioactivated to form their active compounds. CYP3A4 is inhibited by grapefruit, pomegranate and other fruit juices so patients should be made aware of the consequences of ingesting these juices whilst taking susceptible drugs.Prescribers need to be aware of drug interactions with any of these enzymes that may alter responses to any other prescribed medications.Examples of specific CYP450 enzyme drug metabolism.Enzyme isoformDrugs metabolisedCYP1A2caffeinetheophyllinenicotinepazopanibCYP2A65-fluorouracilcoumarinbupropionCYP2B6propofolcyclophosphamideCYP2C8paclitaxelphenytoinwarfarindabrafenibpazopanibponatinibCYP2C9cabozantinib (minor contribution)NSAIDssulfonylureasCYP2C19omeprazoletricyclic antidepressantscodeinetofacitinib (minor contribution)CYP2D6some antipsychoticssome antiarrythmicssome beta-blockersCYP2E1paracetamolmidazolamtriazolamcyclosporin ACYP3A4 erythromycinHIV protease inhibitorscalcium channel blockers (e.g. diltiazem, nifedipine and verapamil)many chemotherapeutics (e.g. docetaxel, paclitaxel and doxorubicin)many protein kinase inhibitors (e.g. sorafenib, imatinib, sunitinib and gefitinib)PDE5 inhibitors (sildenafil and tadalafil) The Merck Manual - Drug Metabolism The Liver and Drug Metabolism Clinically relevant CYP450 substrates, inhibitors and inducers. Enzymes of epigenetic regulation Epigenetic control of genes can alter phenotype without altering genotype and the underlying DNA sequence. Epigenetic modifications such as acetylation, methylation, phosphorylation, and ubiquitination, alter the accessibility of DNA to transcription machinery and therefore influence gene expression. Specific epigenetic processes include imprinting, gene silencing, X chromosome inactivation and maternal effects. Epigenetic processes are responsible for many effects of teratogens, and are often associated with the development of cancer. Experimental studies are providing evidence of the influence of epigenetics in disease states, and are establishing a range of novel therapeutic targetsImportant epigenetic mechanisms include DNA methylation, histone modification, chromatin remodelling and non-coding RNA-associated gene silencing.The proteins that carry out these modifications are often described as being either "writers", "readers" or "erasers". Writer enzymes catalyze the addition of chemical groups onto either histone tails or the DNA itself, creating epigenetic marks. Eraser enzymes remove epigenetic marks providing plasticity in epigenetic regulation by facilitating epigenetic reprogramming of genes. DNA demethylation (methylation mark removal) is involved in many important disease mechanisms such as tumor progression. Readers can be enzymes or other proteins which contain structural domains which recognise specific epigenetic marks. See the table below.In this section we will provide information about DNA methylation and histone modification, including details of some of the enzymes which carry out DNA and histone modifications, implications for disease and pharmacological (drug) interventions at the level of epigenetic control.Epigenetic regulation: mechanisms and effectorsEpigenetic mechanismWriter enzymesReader domainsEraser enzymesDNA methylationHistone methyltransferasesmethyl-cpg binding domain proteinsDNA demethylation enzymes e.g. DNMT1Histone acetylationHistone acetyltransferases (HATs)bromodomain proteinstandem PHD finger proteinspleckstrin homology domain proteins e.g. PHIPHistone deacetylases (HDACs)Histone arginine methylationProtein arginine methyltransferases (PRMTs)tudor domain proteinsWD40 domain proteins e.g. WDR5Histone arginine demethylase JMJD6peptidyl arginine deiminases (putative)histone lysine methylationHistone lysine methyltransferaseschromodomain proteinstudor domain proteinsPHD finger domain proteinsMBT domain proteinsZF-CW proteinsWD40 domain proteinsPWWP domain proteinsHistone lysine demethylaseshistone phosphorylationkinases (e.g. JAK2, ATM/ATR, PKC, PKA, Haspin, Aurora Kinase B, RSK2, AMPK, MSK, MEK)chromoshadow domain proteins (phosphoTyrosine)14.3.3 proteins (phosphoSerine)inhibitor of apoptosis (IAP)/BIR domain proteinsBRCA1 C terminus (BRCT) domain proteinsprotein serine/threonine phosphatasesprotein tyrosine phosphataseshistone ubiquitinationubiquitin E2 conjugasesubiquitin E3 ligasesunknowndeubiquitinating enzymesDNA methylationCovalent addition of methyl (CH3) groups is performed by a family of enzymes called DNA methyltransferases (DNMTs), of which DNMT1, -3A and -3B are especially important for the establishment and maintenance of DNA methylation patterns. CH3 methylation marks are added to cytosine residues, and once in place project in to the major groove of DNA and inhibit transcription. Whilst DNMT1 seems to be required for maintaining established DNA methylation patterns, DNMT3A and -3B appear to mediate de novo DNA methylation patterns. In cancer cells DNMT1 and DNMT3B contribute to maintaining gene hypermethylation.Histone modificationsHistone proteins can be modified in many ways, including lysine acetylation, lysine and arginine methylation, serine and threonine phosphorylation, and lysine ubiquitination and sumoylation. The unstructured N-termini of histones ('histone tails') are particularly highly modified. Of particular pharmacological relevance are the histone deacetylases (HDACs), which catalyze the hydrolytic removal of acetyl groups from histone lysine residues. HDAC inhibitors have been developed to correct the imbalance in the equilibrium of histone acetylation that is associated with tumorigenesis and cancer progression. Vorinostat was the first HDAC inhibitor to receive regulatory approval (inhibits Class I, II and IV HDACs; approved for cutaneous T-cell lymphoma) and this has been followed by marketing authorisations for romidepsin (Class II HDAC inhibitor; approved to treat cutaneous T-cell lymphoma), belinostat (pan-HDAC inhibitor; approved for relapsed or refractory peripheral T-cell lymphoma) and panobinostat (pan-HDAC inhibitor; approved for multiple myeloma treatment). This article was published on 2025-01-28