Nitric Oxide 144 (2024) 40–46

Contents lists available at ScienceDirect

Nitric Oxide
journal homepage: www.elsevier.com/locate/yniox

Nitric oxide: A potential etiological agent for vaso-occlusive crises in sickle

cell disease
Parul Gupta , Ravindra Kumar *
ICMR-National Institute of Research in Tribal Health, India

A R T I C L E I N F O A B S T R A C T

Keywords: Nitric oxide (NO), a vasodilator contributes to the vaso-occlusive crisis associated with the sickle cell disease
Sickle cell disease (SCD). Vascular nitric oxide helps in vasodilation, controlled platelet aggregation, and preventing adhesion of
Vaso-occlusive crises sickled red blood cells to the endothelium. It decreases the expression of pro-inflammatory genes responsible for
Nitric oxide
atherogenesis associated with SCD. Haemolysis and activated endothelium in SCD patients reduce the
Vasodilation
Endothelium
bioavailability of NO which promotes the severity of sickle cell disease mainly causes vaso-occlusive crises.
Hemolysis Additionally, NO depletion can also contribute to the formation of thrombus, which can cause serious compli­
Clinical trials cations such as stroke, pulmonary embolism etc. Understanding the multifaceted role of NO provides valuable
insights into its therapeutic potential for managing SCD and preventing associated complications. Various
clinical trials and studies suggested the importance of artificially induced nitric oxide and its supplements in the
reduction of severity. Further research on the mechanisms of NO depletion in SCD is needed to develop more
effective treatment strategies and improve the management of this debilitating disease.

1. Introduction S, its kinetics and equilibrium, and disease modifiers such as increase
fetal hemoglobin (HbF) [15–18]. Subsequent studies have demonstrated
Sickle cell disease (SCD) is hemorheological disease caused by a the importance of adhesion of sickle RBCs to vascular endothelium,
single point mutation of beta globin gene (HBB: c.20A > T) located at leukocytes and the development of ischemia-reperfusion injury [8,
chromosome 11. This point mutation results in change of glutamic acid 19–22]. It has become increasingly apparent that inflammation and
to valine in the beta globin chain of hemoglobin [1–3]. Globally, more oxidative stress plays a critical role in both initiation and propagation of
than 3,00,000 babies are born each year with SCD [2,4]. It is a severe vaso-occlusion and finally in the pathophysiology of SCD [1,8,23,24].
multi-system hemoglobinopathy characterized by chronic hemolysis, Nitric oxide (NO), a potent vasodialator, is produced by the endo­
intermittent vaso-occlusive events and prone to infections. During thelial cells lining of blood vessels. It serves as an immunoregulator and
hypoxia, hemoglobin S (HbS) polymerizes causes blood flow restriction acts as the endothelium-derived relaxing factor (EDRF). The diminished
and cellular injury [1,2,5–7]. The most common clinical manifestation bioavailability of NO is particularly significant in the pathophysiology of
of SCD is a vaso-occlusive crisis which occurs due to restricted micro­ SCD [1,23,25]. Decreased NO bioavailability or degradation may lead to
circulation by sickled red blood cells (RBCs), causing ischemic organ vasoconstriction, endothelial injury, reactive oxygen species (ROS)
injury and intermittent pain [1,8–10]. Vaso-occlusive crisis in SCD oc­ generation, platelet activation, leukocyte adhesion, vaso-occlusion, and
curs through a series of events (a) polymerization of hemoglobin S (HbS) downstream ischemia, possibly contributing to the development of
(b) increased cell adhesion-mediated vaso-occlusion, (c) acute pain crises and SCD complications [Fig. 1] [19,26–33].
hemolysis-mediated endothelial dysfunction, and (d) activation of The mechanism of NO depletion in SCD is multifactorial and involves
sterile inflammation. All these cellular, and biophysical processes syn­ both the increased consumption and decreased production of NO. One of
ergize to promote acute and chronic pain followed by organ injury [5,7, the main reasons for NO depletion in SCD is the presence of free he­
11–14]. moglobin which can scavenge and neutralize NO. This process is known
Previous studies have provided key insights into both the structure as NO scavenging and is a major contributor to NO depletion in SCD [29,
and genetics of sickle hemoglobin, polymerization of deoxyhemoglobin 30,32,34–37]. Furthermore, the HbS is more prone to oxidation,

* Corresponding author. ICMR-National Institute of Research in Tribal Health, Nagpur Road, Garha, Jabalpur, Madhya Pradesh, 482003, India.
E-mail address: ravindra.kum@icmr.gov.in (R. Kumar).

https://doi.org/10.1016/j.niox.2024.01.008
Received 6 October 2023; Received in revised form 27 December 2023; Accepted 29 January 2024
Available online 4 February 2024
1089-8603/© 2024 Elsevier Inc. All rights reserved.
P. Gupta and R. Kumar Nitric Oxide 144 (2024) 40–46

resulting in the generation of ROS through heme-mediated oxidative

stress pathway [1,35,38–43]. These ROS reacts with NO and forms
peroxynitrite, a highly reactive molecule, that further depletes the NO
levels. Furthermore, ROS also impaired the endothelial cells and thereby
reducing their ability to produce NO. In addition, due to increased he­
molysis in SCD, there is an increase in enzyme arginase levels [1,35,42,
44,45]. The enzyme arginase breaks down the amino acid arginine
which is a precursor for NO synthesis. This dual mechanism of
heme-mediated oxidative stress and arginine depletion contributes to
the reduction of NO levels in SCD patients [29,30,35,42,46,47].
Another pathway involved in NO depletion in SCD is the activation of
the endothelin-1 (ET-1) pathway. ET-1 is a vasoconstrictor peptide that
is upregulated in SCD and has been shown to decrease NO production
and bioavailability [12,35]. ET-1 can directly inhibit the enzyme
responsible for NO synthesis, endothelial nitric oxide synthase (eNOS),
and also promote the production of ROS, further contributing to NO
depletion. In addition, ET-1 also activates the NF-κB pathway, which
plays a role in inflammation and oxidative stress and lead to further NO Fig. 2. Factors responsible for Nitric oxide depletion and reduced
depletion [2,22,39,42,43,48]. NF-κB is a transcription factor that regu­ bioavailability.
lates the expression of genes involved in inflammation and oxidative
stress. In SCD, NF-κB is activated due to presence of free heme and ROS, The depletion of NO in SCD has several implications on the patho­
leading to the expression of pro-inflammatory and pro-oxidant genes. physiology of the disease. In this review article, role of nitric oxide in
This chronic inflammation and oxidative stress can lead to further NO SCD pathophysiology and use of nitric oxide as potential therapeutic
depletion [24,49] (Fig. 2). option in management of SCD is discussed.
Apart from these pathways, other factors such as reduced levels of
tetrahydrobiopterin (BH4), a cofactor for eNOS, and increased levels of 2. Nitric oxide deficiency and endothelial dysfunction
asymmetric dimethylarginine (ADMA), an endogenous inhibitor of
eNOS, have also been implicated in NO depletion in SCD [26,28,50–56]. Endothelial dysfunction is a condition in which endothelial cells of

Fig. 1. During hypoxia, sickled red blood cells got polymerized and further causes hemolysis. Free heme released due to hemolysis scavenges Nitric oxide (NO) and
may responsible for vaso-constriction and finally vaso-occlusive crises. Inhaled Nitric oxide and L-arginine therapy provides required amount of NO which reduces
pain crises in sickle cell disease patients due to its vasodilatory effect.

41
P. Gupta and R. Kumar Nitric Oxide 144 (2024) 40–46

blood vessel lose their normal function and damaged. Chronic inflam­ through various interconnected mechanisms, including inflammation,
mation and endothelial dysfunction are prevalent in SCD [57]. NO oxidative stress, endothelial dysfunction, and the development of a
possesses anti-inflammatory properties and contributes to the regulation prothrombotic state. The procoagulant properties of RBCs with exposed
of endothelial function [26,31,57,58]. It plays a critical role in main­ PS lead to thrombotic events. Thrombosis and clot formation disrupt the
taining vascular health by regulating blood flow and preventing the blood flow, leading to local hypoxia. In response to hypoxia, the endo­
adhesion of sickle cells to endothelial surfaces. The endothelium releases thelial cells produce less NO. The release of phosphatidylserines and
NO, which combines with the heme group of hemoglobin and activates circulating free hemoglobin in the setting of haemolysis exacerbates NO
soluble guanylyl cyclase in smooth muscle, leading to an increase in depletion, leading to chronic vasoconstriction and platelet activation
intracellular cyclic GMP [59]. Cyclic GMP activates cGMP-dependent [32,76].
kinases that decrease intracellular smooth muscle calcium concentra­
tions, resulting in relaxation, vasodilation, and increased regional blood 5. Nitric oxide and platelet activation
flow [60]. The low level of NO contributes to endothelial dysfunction
which promotes elevated adhesion of sickle RBCs to endothelial cells Nitric oxide triggers a coordinated program of cellular events to
which further promotes inflammation and vasoconstrictive events [26, promote blood flow, primarily by inhibiting platelet aggregation,
57,61–63]. expression of cell adhesion molecules on endothelial cells, and secretion
Dysfunctional endothelial cells in SCD exhibit reduced expression of procoagulant proteins. Platelets are involved in clot formation, and
and activity of endothelial nitric oxide synthase (eNOS), which further increased activation of platelet plays a catalytic role in vasoconstriction
leads to reduced synthesis of NO [57,61,64,65]. Additionally, endo­ and vasculopathy in SCD [30,37,77]. In SCD, damaged blood vessels
thelial dysfunction has also been associated with the accumulation of exposes collagen and other adhesive molecules, leading to platelet
advanced glycation products. These products interfere with normal adhesion and aggregation, which can contribute to vaso-occlusion [6,
endothelial function and lead to diminished NO availability [66]. 37,77,78]. Nitric oxide inhibits the platelet adhesion and aggregation by
interfering with platelet activation pathways, such as reducing the
3. Nitric oxide and oxidative stress expression of platelet surface receptors involved in adhesion [19,22,
27–30,34,46,50,74]. Endothelial cells possess various receptors on their
In SCD patients, haemolysis promotes de-compartmentalization of surfaces that interact with platelets. One such receptor complex is the
hemoglobin to release free hemoglobin into the plasma which generates Glycoprotein Ib-IX-V Complex (GPIb-IX-V), which binds to von Wille­
oxidative stress [21,67]. Oxidative stress is responsible for the contin­ brand factor (vWF). This molecule is produced by endothelial cells and is
uous production of ROS which may lead to endothelial dysfunction and exposed at sites of vascular injury. The binding between GPIb-IX-V and
acute inflammation. Free hemoglobin scavenges nitric oxide, releases vWF is crucial for platelet adhesion to the subendothelial matrix that is
arginase to degrade L-arginine and also activates endothelial cells exposed during injury [79]. Another important receptor for platelets is
through Toll like receptor-4 (TLR-4) pathway to form more ROS [47]. the glycoprotein IIb/IIIa (GPIIb/IIIa) Integrin, also referred to as
Activated endothelial cells further promotes the production of ROS and integrin αIIbβ3. This receptor plays a critical role in platelet aggregation.
reduces nitric oxide bioavailability. High production of ROS exceeds the When platelets are activated, GPIIb/IIIa undergoes a change in its shape,
limit of available antioxidant system to normalize or balance. allowing it to bind to fibrinogen and other adhesive proteins [19,80].
Furthermore, several enzymes systems such as NADPH oxidase, This binding enables platelet-to- platelet interactions, leading to the
Xanthine oxidase, increased dimethyl arginase (ADMA) and dysfunc­ formation of a stable blood clot. Furthermore, the Glycoprotein VI
tional eNOS also produce ROS and thereby reduces the NO bioavail­ (GPVI) receptor triggers platelet activation and signalling pathways that
ability [39,42,43,45,68]. NADPH oxidase produces ROS in vascular enhance adhesion and aggregation [81]. Additionally, the selectin
endothelial cell which contributes to hemolysis, proinflammatory and (CD62P) on platelets interacts with P-selectin glycoprotein ligand-1
pro-thromobogenic responses associated with SCD [39,42,43,69]. (PSGL-1) on leukocytes, facilitating platelet-leukocyte interactions and
Regulator of NADPH oxidase such as protein kinase, Rac GTPase, TGFβ1 the formation of larger thrombi [82–85].
and endothelin-1, highly activated in SCD patients which further pro­ The tight regulation of the interactions between platelet surface re­
duces ROS via modulation of NADPH oxidase [1,39]. ceptors and their corresponding ligands is crucial in maintaining bal­
ance and preventing excessive bleeding. When these interactions
4. Nitric oxide and inflammation become dysregulated, it can result in bleeding disorders or thrombotic
conditions like deep vein thrombosis and arterial thrombosis [86,87].
The oxidized low-density lipoprotein (LDL) particles trigger various Consequently, comprehending the role of these receptors becomes
inflammatory and oxidative stress responses in the endothelial cells. imperative for the advancement of therapies that target platelet adhe­
Oxidized LDL also disrupts the normal signalling pathways in endothe­ sion and aggregation in different clinical scenarios.
lial cells by generating more intracellular ROS through the binding with
specific receptors such as lectin-like oxidized LDL receptor-1 (LOX-1). 6. Nitric oxide and leukocyte adhesion
Activation of LOX-1 by oxidized LDL leads to intracellular signalling
cascades such as production of ROS, activation of NF-kB and induction Several lines of evidence suggest that nitric oxide is an endogenous
of NADPH oxidase that results in the intracellular decreased level of NO inhibitor of leukocyte adhesion in venules: (1) nitric oxide synthase
[62,70–73] [28,74]. Overall, reduced NO levels lead to endothelial inhibitors induce recruitment of adherent leukocytes, (2) nitric oxide
dysfunction through multiple mechanisms, including impaired signal­ donors (nitroprusside, SIN -I) attenuate or prevent leukocyte adhesion
ling and reduced expression of nitric oxide synthase [47,57]. induced by different inflammatory stimuli, (3) superoxide, which reacts
Furthermore, chronic inflammation in SCD promotes the production with NO to render it biologically inactive, promotes leukocyte adher­
of pro-inflammatory cytokines such as tumour necrosis factor-α and ence [32,33]. Nitric oxide production and superoxide generation causes
Interleukin-1β to for the production of adhesion molecules and earliest recruitment of adherent leukocytes within postcapillary venules [33,
signs of endothelial dysfunction. Impaired endothelium, decreased 88].
endothelial release of both for agonist-mediated release of NO (e.g.,
vasorelaxation in response to endothelium-dependent vasodilators) and 7. Nitric oxide as a potential therapeutic agent for vaso-
for basal NO release (e.g., vasocontraction response to NOS inhibitors) occlusive crisis in SCD
[1,8]. Another important cause of NO breakdown is the release of
strongly procoagulant phosphatidylserine [75] from the RBC membrane The increased oxidative stress in SCD patients can result in a wide

42
P. Gupta and R. Kumar Nitric Oxide 144 (2024) 40–46

range of complications, including acute pain episodes, stroke, and organ infusion of NO was well-tolerated and resulted in a significant increase
damage. Currently, there is no cure for SCD, and treatment is focused on in NO levels and improvement in blood flow in patients with SCD [104].
managing the symptoms and preventing complications. However, in Subsequent trials have also demonstrated the efficacy of NO therapy in
recent years, there has been growing interest in the use of nitric oxide reducing pain episodes, promoting wound healing, and improving lung
(NO) therapy and its supplements as potential treatments for SCD [23, function in SCD patients [105].
77]. A randomized controlled trial compared the effects of inhaled NO
NO therapy involves the administration of exogenous NO or its de­ versus placebo in SCD patients with acute chest syndrome, a common
rivatives to supplement the naturally produced NO. Inhaled nitric oxide and potentially life-threatening complication of SCD [104]. The study
(iNO) is given as a form of treatment where nitric oxide gas is delivered found that inhaled NO significantly reduced the duration of hospitali­
directly into the lungs via inhalation [89]. zation and the need for mechanical ventilation in patients with acute
There have been several studies investigating the use of NO supple­ chest syndrome. This trial also showed that NO therapy was safe and
mentation in SCD, with mixed results. Previous studies showed that well-tolerated, with no significant side effects reported. Some clinical
inhaled NO improved blood flow and decreased the frequency of pain trials (NCT01393847, NCT00142051, NCT01033227) have been
crises in patients with SCD [74,77,78,89,90]. However, later studies did terminated early due to paucity of available participants whereas some
not find a significant difference in pain episodes between SCD patients clinical trials (NCT01568710, NCT00095472, NCT00094887,
who received inhaled NO and those who received a placebo [29,77,89, NCT00748423, NCT00001716) shows no improvement in time to crisis
91–93,102,104]. Additionally, some studies observed that NO supple­ resolution by using iNO in comparison to placebo. Primary outcomes of
mentation may have negative effects on lung function and may increase clinical trial (NCT00094887) shows difference in mean pain score on
the risk of infection in SCD patients. visual analog scale after the treatment of 16 hour with iNO [104].
Despite these mixed results, there is growing interest in the use of NO Furthermore, usage of narcotic is also reduced in these patients even
supplementation for SCD. The rationale behind using nitric oxide in SCD though no significant resolution in pain was observed due to iNO
is that it might improve oxygen delivery to tissues, reduce inflammation, therapy.
and inhibit the formation of sickle-shaped RBCs. By relaxing the smooth Additionally, L-arginine which is precursor of NO worked as
muscles lining blood vessels, nitric oxide prevents vaso-occlusive crises, powerful vasodilator with antiplatelet properties [75,98–100]. Low
a hallmark feature of SCD [23,77,94]. Furthermore, NO acts as an arginine bioavailability plays a pivotal role in the pathogenesis of SCD
anti-inflammatory agent by suppressing the expression of adhesion due to catabolism of arginine by arginase enzymes [101, 106]. It is the
molecules and pro-inflammatory cytokines, thereby mitigating tissue most common cause of an acquired arginine deficiency syndrome,
damage caused by chronic inflammation [27,28,57]. Nitric oxide indi­ frequently contributing to endothelial dysfunction and/or T-cell
rectly increases the production of HbF due to its role in the regulation of dysfunction, depending on the clinical scenario and disease state (ac­
blood flow, including blood flow to the bone marrow, where RBCs, quired amino deficiency) [101].
including fetal hemoglobin, are produced [95]. SCD related arginine deficiency is most remarkably associated with
While NO supplementation may hold promise for the treatment of elevated arginase activity that corelates to markers of haemolysis.
SCD, there are also limitations and challenges that must be considered. Clinical trial (NCT02536170) showed that L-arginine use for SCD could
One major limitation is the lack of standardization in dosing and de­ be beneficial, increase fetal hemoglobin and exert blood pressure-
livery methods of NO [96–101]. Additionally, the long-term effects and lowering and hepatoprotective properties [100,101,106] (Table-1).
potential adverse reactions of NO supplementation are still not fully During clinical trial (NCT0000412), arginine-butyrate has given to
understood. Furthermore, the cost of NO supplementation may be a twenty-three SCD patients having leg ulcer. Overall 70 % significant
barrier for many SCD patients. The cost of inhaled NO ($100/h/dose or healing were observed in leg ulcers in SCD patients [101]. Additionally,
approximately $500/VOC/patient [102] can be prohibitively expensive, NCT00056433 clinical trial has conducted on the co-administration of
making it inaccessible for those without adequate insurance coverage. arginine with hydroxyurea (HU). There was an increase level of nitrite
This raises concerns about the equitable access to this potential treat­ and fetal Hb in arginine-HU treatment group as compared to HU mon­
ment for all SCD patients, regardless of their socio-economic status. otherapy [75,96,107].
While there is some evidence to suggest that NO supplementation Overall, the balance of NO levels in SCD is critical, and researchers
may have benefits for the treatment of SCD, there are also limitations continue to study its role to better understand how it can be targeted for
and challenges that must be addressed. More research is needed to fully therapeutic interventions to manage the disease and its complications
understand the effects of NO supplementation on SCD and to determine [104]. Nitric oxide-based therapies, such iNO, L-Arginine and use of
the most effective dosing and delivery methods. Additionally, efforts nitric oxide donors are being explored as potential treatments to miti­
must be made to ensure that all SCD patients have access to this potential gate some of the vascular complications associated with SCD, including
treatment option. Despite these challenges, NO supplementation re­ platelet activation and vaso-occlusive crises [75,89,96,98–101,104].
mains a promising avenue for improving the management of SCD and These therapies aim to restore the balance of nitric oxide and improve
reducing the burden of this debilitating disease. iNO shows promise as a blood flow in individuals with SCD. Nitric oxide-based therapies have
treatment for sickle cell crises, but its use is not universally applicable to shown promising results in the treatment of SCD.
all patients. Furthermore, iNO therapy may not be readily available in It’s worth noting that the role of nitric oxide in SCD is complex and
all healthcare settings [78,89,93]. The response and duration of action not yet fully understood. Further research is needed to elucidate the
of iNO can vary among individuals, and additional research is needed to mechanisms underlying nitric oxide dysregulation in SCD and to
increase availability and make it cost effective. In some cases, the effects develop targeted therapies that can effectively modulate nitric oxide
of inhaled nitric oxide may be relatively short-lived, lasting for a few levels and improve outcomes for individuals with the condition.
hours. Therefore, it is not typically used as a long-term maintenance Several studies have shown that the use of antioxidants and NO
treatment for SCD but rather as a part of a broader management strategy donors can improve NO bioavailability and reduce oxidative stress in
during acute vaso-occlusive crises or to improve oxygenation in certain SCD. In addition, drugs that target the ET-1 pathway, such as endothelin
situations [29,77,91,92,103]. receptor antagonists, have shown promising results in reducing vaso­
constriction and improving blood flow in SCD. Moreover, recent studies
8. Clinical trials and research on nitric oxide in SCD treatment have also shown that targeting the NF-κB pathway can improve NO
bioavailability and reduce inflammation and oxidative stress in SCD.
Several clinical trials have been conducted to evaluate the efficacy of Additionally, investigating the combination of nitric oxide therapy with
NO therapy in SCD. One of the earliest trials showed that intravenous existing treatments, such as hydroxyurea, may lead to synergistic effects

43
P. Gupta and R. Kumar Nitric Oxide 144 (2024) 40–46

Table-1
Clinical trials of iNO and L-arginine.
S. NCT NUMBER STUDY STUDY INTERVENTIONS PHASES ENROLLMENT LOCATIONS
No STATUS RESULTS

1 NCT00142051 TERMINATED NO DRUG: nitric oxide|DRUG: oxygen PHASE2 18 Boston, United

States
2 NCT00352430 COMPLETED NO DRUG: Nitric Oxide/INP Pulse Delivery|DRUG: Nitric PHASE1 31 Maryland, United
Oxide/INO Pulse Delivery States
3 NCT00094887 COMPLETED YES DRUG: Nitric Oxide|DRUG: Placebo PHASE2 150 Alabama, United
States
4 NCT00095472 COMPLETED NO DRUG: L-NMMA|DRUG: Sodium Nitrite PHASE1 18 Maryland, United
States
5 NCT01393847 TERMINATED NO 12 Maryland, United
States
6 NCT01033227 TERMINATED YES DRUG: sodium nitrite injection, usp PHASE1| 5 California, United
PHASE2 States
7 NCT01089439 COMPLETED NO DRUG: Nitric oxide by inhalation INOMAX|DRUG: PHASE2 21 Paris, France
Placebo
8 NCT00001716 COMPLETED NO DRUG: Nitric Oxide|DRUG: Nitroglycerin PHASE2 58 Maryland, United
States
9 NCT00041574 TERMINATED NO DRUG: Inhaled Nitric Oxide PHASE2 7 United States
10 NCT00009581 COMPLETED NO DRUG: L-NMMA|DRUG: Acetylcholine PHASE2 65 Maryland, United
States
11 NCT00748423 COMPLETED NO DRUG: Nitric Oxide|DRUG: Placebo PHASE2| 100 France
PHASE3
12 NCT00023296 COMPLETED NO DRUG: Nitric Oxide|DEVICE: INO Pulse - NO Delivery PHASE1 59 Maryland, United
System States
13 NCT01142219 COMPLETED NO DRUG: l-arginine|DRUG: Placebo PHASE3 40 Brazil
14 NCT00513617 COMPLETED YES DRUG: Arginine|DRUG: Placebo PHASE2 128 Oakland, United
States
15 NCT00056433 COMPLETED NO DRUG: Hydroxyurea|DRUG: L-Arginine|DRUG: PHASE1 39 Oakland, United
Sildenafil States
16 NCT00029731 COMPLETED NO DRUG: Arginine hydrochloride PHASE2 30 Maryland, United
States
17 NCT01796678 COMPLETED NO DRUG: Arginine|DRUG: Placebo PHASE2 56 Oakland, United
States

and improved outcomes for SCD patients. Furthermore, exploring the with this debilitating disease. The development of more selective and
use of NO releasing nanoparticles to increase its bio-availability could targeted nitric oxide delivery systems could maximize its beneficial ef­
provide a long-term solution for maintaining nitric oxide levels in in­ fects on the vasculature. Furthermore, targeting the signaling pathways
dividuals with SCD. responsible for NO depletion in SCD may become potential therapeutic
Role of exercise in the bioavailability of nitric oxide in sickle strategy.
cell disease- Exercise has been shown to have numerous benefits for
individuals with SCD, including improved cardiovascular and respira­ Source of funding
tory function, decreased pain, and improved quality of life [108]. One of
the key mechanisms by which exercise benefits individuals with SCD is Nil.
through the production of NO. Exercise stimulates the release of sub­
stances such as adenosine triphosphate (ATP) and bradykinin, which in CRediT authorship contribution statement
turn stimulate the production of NO. Several studies have shown that
exercise can increase NO production in individuals with SCD [108,109]. Parul Gupta: Conceptualization, Writing – original draft. Ravindra
Acute exercise increased NO levels in individuals with SCD, leading to Kumar: Conceptualization, Resources, Supervision, Validation, Writing
improved blood flow and oxygen delivery to tissues [77,109]. The – review & editing.
combination of increased NO production and anti-inflammatory effects
of exercise can have a significant impact on the management of SCD. Declaration of competing interest
However, it is important to note that the benefits of exercise in SCD may
vary among individuals. However, further research is needed to fully None.
understand the complex interactions between NO, exercise, and SCD,
and to develop targeted exercise interventions that can optimize the Data availability
benefits for individuals with this condition.
No data was used for the research described in the article.
9. Conclusion
Acknowledgement
In conclusion, NO therapy and its supplements have shown prom­
ising results in improving blood flow and reducing the frequency of Authors are thankful to Director, ICMR-National Institute of
acute pain episodes in SCD patients. However, more research is needed Research in Tribal Health, Jabalpur for providing support and encour­
to establish their safety, efficacy, and optimal dosing. Standardization agement. PG is thankful to ICMR, New Delhi for her fellowship.
and regulation of NO supplements are also necessary to ensure their
quality and effectiveness. With further research and development, NO References
therapy and its supplements have the potential to become valuable
treatment options for SCD, improving the quality of life for those living [1] P. Sundd, M.T. Gladwin, E.M. Novelli, Pathophysiology of sickle cell disease, Ann.
Rev. Path. 14 (2019) 263–292.

44
P. Gupta and R. Kumar Nitric Oxide 144 (2024) 40–46

[2] V.M. Pinto, M. Balocco, S. Quintino, G.L. Forni, Sickle cell disease: a review for [34] M.T. Gladwin, J.H. Crawford, R.P. Patel, The biochemistry of nitric oxide, nitrite,
the internist, Intern. Emerg. Med. 14 (7) (2019) 1051–1064. and hemoglobin: role in blood flow regulation, Free Radic. Biol. Med. 36 (6)
[3] S.F. Ofori-Acquah, Sickle cell disease as a vascular disorder, Expert Rev. Hematol. (2004) 707–717.
13 (6) (2020) 645–653. [35] C.R. Morris, Mechanisms of vasculopathy in sickle cell disease and thalassemia,
[4] Global, Regional, and National Prevalence and Mortality Burden of Sickle Cell Hematology Am. Soc. Hematol. Educ. Program (2008) 177–185.
Disease, 2000-2021: a Systematic Analysis from the Global Burden of Disease [36] C. Donadee, N.J. Raat, T. Kanias, J. Tejero, J.S. Lee, E.E. Kelley, X. Zhao, C. Liu,
Study 2021, The Lancet Haematol, 2023. H. Reynolds, I. Azarov, S. Frizzell, E.M. Meyer, A.D. Donnenberg, L. Qu,
[5] M.A. Ali, A. Ahmad, H. Chaudry, W. Aiman, S. Aamir, M.Y. Anwar, A. Khan, D. Triulzi, D.B. Kim-Shapiro, M.T. Gladwin, Nitric oxide scavenging by red blood
Efficacy and safety of recently approved drugs for sickle cell disease: a review of cell microparticles and cell-free hemoglobin as a mechanism for the red cell
clinical trials, Exp. Hematol. 92 (2020) 11–18.e1. storage lesion, Circulation 124 (4) (2011) 465–476.
[6] M.H. Steinberg, Sickle cell anemia, the first molecular disease: overview of [37] J. Villagra, S. Shiva, L.A. Hunter, R.F. Machado, M.T. Gladwin, G.J. Kato, Platelet
molecular etiology, pathophysiology, and therapeutic approaches, Sci. World J. 8 activation in patients with sickle disease, hemolysis-associated pulmonary
(2008) 1295–1324. hypertension, and nitric oxide scavenging by cell-free hemoglobin, Blood 110 (6)
[7] D.C. Rees, T.N. Williams, M.T. Gladwin, Sickle-cell disease, Lancet 376 (9757) (2007) 2166–2172.
(2010) 2018–2031. [38] C. Sultana, Y. Shen, V. Rattan, C. Johnson, V.K. Kalra, Interaction of sickle
[8] N. Conran, J.D. Belcher, Inflammation in sickle cell disease, Clin. Hemorheol. erythrocytes with endothelial cells in the presence of endothelial cell conditioned
Microcirc. 68 (2–3) (2018) 263–299. medium induces oxidant stress leading to transendothelial migration of
[9] K. Takaoka, A.C. Cyril, S. Jinesh, R. Radhakrishnan, Mechanisms of pain in sickle monocytes, Blood 92 (10) (1998) 3924–3935.
cell disease, Br. J. Pain 15 (2) (2021) 213–220. [39] S. Voskou, M. Aslan, P. Fanis, M. Phylactides, M. Kleanthous, Oxidative stress in
[10] E.Y. Chiang, P.S. Frenette, Sickle cell vaso-occlusion, Hematol. Oncol. Clin. N. β-thalassaemia and sickle cell disease, Redox Biol. 6 (2015) 226–239.
Am. 19 (5) (2005) 771–784, v. [40] E. Nader, M. Romana, P. Connes, The red blood cell-inflammation vicious circle
[11] D.S. Darbari, V.A. Sheehan, S.K. Ballas, The vaso-occlusive pain crisis in sickle in sickle cell disease, Front. Immunol. 11 (2020) 454.
cell disease: definition, pathophysiology, and management, Eur. J. Haematol. 105 [41] P. Connes, T. Alexy, J. Detterich, M. Romana, M.D. Hardy-Dessources, S.K. Ballas,
(3) (2020) 237–246. The role of blood rheology in sickle cell disease, Blood Rev. 30 (2) (2016)
[12] L. Wang, C.K. Cheng, M. Yi, K.O. Lui, Y. Huang, Targeting endothelial dysfunction 111–118.
and inflammation, J. Mol. Cell. Cardiol. 168 (2022) 58–67. [42] E.N. Chirico, V. Pialoux, Role of oxidative stress in the pathogenesis of sickle cell
[13] V.A. Morikis, A.A. Hernandez, J.L. Magnani, M. Sperandio, S.I. Simon, Targeting disease, IUBMB Life 64 (1) (2012) 72–80.
neutrophil adhesive events to address vaso-occlusive crisis in sickle cell patients, [43] Q. Wang, R. Zennadi, The role of RBC oxidative stress in sickle cell disease: from
Front. Immunol. 12 (2021) 663886. the molecular basis to pathologic implications, Antioxidants 10 (10) (2021).
[14] J.E. Elion, M. Brun, M.H. Odièvre, C.L. Lapouméroulie, R. Krishnamoorthy, Vaso- [44] C.R. Morris, G.J. Kato, M. Poljakovic, X. Wang, W.C. Blackwelder, V. Sachdev, S.
occlusion in sickle cell anemia: role of interactions between blood cells and L. Hazen, E.P. Vichinsky, S.M. Morris Jr., M.T. Gladwin, Dysregulated arginine
endothelium, Hematol. J. 5 (2004) S195–S198. metabolism, hemolysis-associated pulmonary hypertension, and mortality in
[15] Y. Saunthararajah, J. DeSimone, Clinical studies with fetal hemoglobin- sickle cell disease, J. Am. Med. Assoc. 294 (1) (2005) 81–90.
enhancing agents in sickle cell disease, Semin. Hematol. 41 (4 Suppl 6) (2004) [45] R. Vona, N.M. Sposi, L. Mattia, L. Gambardella, E. Straface, D. Pietraforte, Sickle
11–16. cell disease: role of oxidative stress and antioxidant therapy, Antioxidants 10 (2)
[16] D. Lavelle, J.D. Engel, Y. Saunthararajah, Fetal hemoglobin induction by (2021).
epigenetic drugs, Semin. Hematol. 55 (2) (2018) 60–67. [46] C.D. Reiter, M.T. Gladwin, An emerging role for nitric oxide in sickle cell disease
[17] P. Allard, N. Alhaj, S. Lobitz, H. Cario, A. Jarisch, R. Grosse, L. Oevermann, vascular homeostasis and therapy, Curr. Opin. Hematol. 10 (2) (2003) 99–107.
D. Hakimeh, L. Tagliaferri, E. Kohne, A. Kopp-Schneider, A.E. Kulozik, J.B. Kunz, [47] E. Lubos, D.E. Handy, J. Loscalzo, Role of oxidative stress and nitric oxide in
Genetic modifiers of fetal hemoglobin affect the course of sickle cell disease in atherothrombosis, Front. Biosci. (2008) 5323–5344.
patients treated with hydroxyurea, Haematologica 107 (7) (2022) 1577–1588. [48] O.T. Gbotosho, M.G. Kapetanaki, G.J. Kato, The worst things in life are free: the
[18] D. Manwani, P.S. Frenette, Vaso-occlusion in sickle cell disease: pathophysiology role of free heme in sickle cell disease, Front. Immunol. 11 (2020) 561917.
and novel targeted therapies, Hematology, Am Soc Hematol. Education Program [49] R. Kollander, A. Solovey, L.C. Milbauer, F. Abdulla, R.J. Kelm Jr., R.P. Hebbel,
(2013) (2013) 362–369. Nuclear factor-kappa B (NFkappaB) component p50 in blood mononuclear cells
[19] J.D. Belcher, P.H. Marker, J.P. Weber, R.P. Hebbel, G.M. Vercellotti, Activated regulates endothelial tissue factor expression in sickle transgenic mice:
monocytes in sickle cell disease: potential role in the activation of vascular implications for the coagulopathy of sickle cell disease, Transl. Res. 155 (4)
endothelium and vaso-occlusion, Blood 96 (7) (2000) 2451–2459. (2010) 170–177.
[20] N. Conran, F.F. Costa, Hemoglobin disorders and endothelial cell interactions, [50] A. Solovey, R. Kollander, L.C. Milbauer, F. Abdulla, Y. Chen, R.J. Kelm Jr., R.
Clin. Biochem. 42 (18) (2009) 1824–1838. P. Hebbel, Endothelial nitric oxide synthase and nitric oxide regulate endothelial
[21] L.S. Torres, A. Hidalgo, Neutrophils as drivers of vascular injury in sickle cell tissue factor expression in vivo in the sickle transgenic mouse, Am. J. Hematol. 85
disease, Immunol. Rev. 314 (1) (2023) 302–312. (1) (2010) 41–45.
[22] D. Zhang, C. Xu, D. Manwani, P.S. Frenette, Neutrophils, platelets, and [51] R.P. Hebbel, G.M. Vercellotti, Multiple inducers of endothelial NOS (eNOS)
inflammatory pathways at the nexus of sickle cell disease pathophysiology, Blood dysfunction in sickle cell disease, Am. J. Hematol. 96 (11) (2021) 1505–1517.
127 (7) (2016) 801–809. [52] P. Gupta, R. Kumar, GTP cyclohydroxylase1 (GCH1): role in neurodegenerative
[23] A.K. Mack, G.J. Kato, Sickle cell disease and nitric oxide: a paradigm shift? Int. J. diseases, Gene 888 (2023) 147749.
Biochem. Cell Biol. 38 (8) (2006) 1237–1243. [53] J.K. Bendall, G. Douglas, E. McNeill, K.M. Channon, M.J. Crabtree,
[24] C.C. Hoppe, Inflammatory mediators of endothelial injury in sickle cell disease, Tetrahydrobiopterin in cardiovascular health and disease, Antioxidants Redox
Hematol. Oncol. Clin. N. Am. 28 (2) (2014) 265–286. Signal. (2014) 3040–3077.
[25] I. Belfer, V. Youngblood, D.S. Darbari, Z. Wang, L. Diaw, L. Freeman, K. Desai, [54] Z.F. Wang, J.-W. Chen, L. Tie, X.J. Li, Tetrahydrobiopterin synthesis and
M. Dizon, D. Allen, C. Cunnington, K.M. Channon, J. Milton, S.W. Hartley, biological function, Sheng Li Ke Xue Jin Zhan 46 (4) (2015) 259–264.
V. Nolan, G.J. Kato, M.H. Steinberg, D. Goldman, J.G.t. Taylor, A GCH1 [55] T. Eichwald, L.B. da Silva, A.C. Staats Pires, L. Niero, E. Schnorrenberger, C.
haplotype confers sex-specific susceptibility to pain crises and altered endothelial C. Filho, G. Espíndola, W.L. Huang, G.J. Guillemin, J.E. Abdenur, A. Latini,
function in adults with sickle cell anemia, Am. J. Hematol. 89 (2) (2014) Tetrahydrobiopterin: beyond its traditional role as a cofactor, Antioxidants 12 (5)
187–193. (2023).
[26] C.A. Meza, J.D. La Favor, D.H. Kim, R.C. Hickner, Endothelial dysfunction: is [56] E.R. Werner, N. Blau, B. Thöny, Tetrahydrobiopterin: biochemistry and
there a hyperglycemia-induced imbalance of NOX and NOS? Int. J. Mol. Sci. 20 pathophysiology, Biochem. J. 438 (3) (2011) 397–414.
(15) (2019). [57] A.R. Cyr, L.V. Huckaby, S.S. Shiva, B.S. Zuckerbraun, Nitric oxide and endothelial
[27] P. Vallance, A. Hingorani, Endothelial nitric oxide in humans in health and dysfunction, Crit. Care Clin. 36 (2) (2020) 307–321.
disease, Int. J. Exp. Pathol. 80 (6) (1999) 291–303. [58] Z.S. Katusic, A. Stelter, S. Milstien, Cytokines stimulate GTP cyclohydrolase I gene
[28] M. Tenopoulou, P.T. Doulias, Endothelial Nitric Oxide Synthase-Derived Nitric expression in cultured human umbilical vein endothelial cells, Arterioscler,
Oxide in the Regulation of Metabolism, vol. 9, 2020 F1000Res. Thromb. Vasc. Biol. 18 (1) (1998) 27–32.
[29] L. Hallmark, L.E. Almeida, S. Kamimura, M. Smith, Z.M. Quezado, Nitric oxide [59] B.K. Saha, S.L. Burns, The story of nitric oxide, sepsis and methylene blue: a
and sickle cell disease-Is there a painful connection? Exp. Biol. Med. 246 (3) comprehensive pathophysiologic review, Am. J. Med. Sci. 360 (4) (2020)
(2021) 332–341. 329–337.
[30] J. Loscalzo, Nitric oxide insufficiency, platelet activation, and arterial thrombosis, [60] N. Längst, J. Adler, O. Schweigert, F. Kleusberg, M. Cruz Santos, A. Knauer,
Circ. Res. 88 (8) (2001) 756–762. M. Sausbier, T. Zeller, P. Ruth, R. Lukowski, Cyclic GMP-dependent regulation of
[31] T.C. Buzinari, T.F. de Moraes, J.C. Conceição-Filho, E.C. Cárnio, L. Almeida- vascular tone and blood pressure involves cysteine-rich LIM-only protein 4
Lopes, H.C. Salgado, G.J. Rodrigues, Nitric oxide storage levels modulate (CRP4), Int. J. Mol. Sci. 22 (18) (2021).
vasodilation and the hypotensive effect induced by photobiomodulation using an [61] P. Poredos, A.V. Poredos, I. Gregoric, Endothelial dysfunction and its clinical
aluminum gallium arsenide (AlGaAs) diode laser (660 nm), Laser Med. Sci. 37 (6) implications, Angiology 72 (7) (2021) 604–615.
(2022) 2753–2762. [62] L. Cominacini, A. Rigoni, A.F. Pasini, U. Garbin, A. Davoli, M. Campagnola, A.
[32] M.J. Simmonds, J.A. Detterich, P. Connes, Nitric oxide, vasodilation and the red M. Pastorino, V. Lo Cascio, T. Sawamura, The binding of oxidized low density
blood cell, Biorheology 51 (2–3) (2014) 121–134. lipoprotein (ox-LDL) to ox-LDL receptor-1 reduces the intracellular concentration
[33] P. Kubes, M. Suzuki, D.N. Granger, Nitric oxide: an endogenous modulator of of nitric oxide in endothelial cells through an increased production of superoxide,
leukocyte adhesion, Proc. Natl. Acad. Sci. U.S.A. 88 (11) (1991) 4651–4655. J. Biol. Chem. 276 (17) (2001) 13750–13755.

45
P. Gupta and R. Kumar Nitric Oxide 144 (2024) 40–46

[63] H. Jiang, Y. Zhou, S.M. Nabavi, A. Sahebkar, P.J. Little, S. Xu, J. Weng, J. Ge, [89] T. Aboursheid, O. Albaroudi, F. Alahdab, Inhaled nitric oxide for treating pain
Mechanisms of oxidized LDL-mediated endothelial dysfunction and its crises in people with sickle cell disease, Cochrane Database Syst. Rev. 7 (7) (2022)
consequences for the development of atherosclerosis, Front. Cardiovasc. Med. 9 Cd011808.
(2022) 925923. [90] A. Piccin, C. Murphy, E. Eakins, M.B. Rondinelli, M. Daves, C. Vecchiato, D. Wolf,
[64] R. de Paula Martins, V. Glaser, A.S. Aguiar Jr., P.M. de Paula Ferreira, K. Ghisoni, C. Mc Mahon, O.P. Smith, Insight into the complex pathophysiology of sickle cell
D. da Luz Scheffer, L. Lanfumey, R. Raisman-Vozari, O. Corti, A.L. De Paul, R. anaemia and possible treatment, Eur. J. Haematol. 102 (4) (2019) 319–330.
A. da Silva, A. Latini, De novo tetrahydrobiopterin biosynthesis is impaired in the [91] F.T. Moreira, C.B. de Oliveira, C.M. Gomez, W.M. Bernardo, Is inhaled nitric
inflammed striatum of parkin((-/-)) mice, Cell Biol. Int. 42 (6) (2018) 725–733. oxide therapy more effective or safer than the conventional treatment for the
[65] S. Balta, Endothelial dysfunction and inflammatory markers of vascular disease, treatment of vaso-occlusive crises in sickle-cell anemia? Rev. Assoc. Med. Bras. 57
Curr. Vasc. Pharmacol. 19 (3) (2021) 243–249. (3) (1992) 253–254, 2011.
[66] S. de la Cruz-Ares, M.P. Cardelo, F.M. Gutiérrez-Mariscal, J.D. Torres-Peña, [92] M.T. Gladwin, A.N. Schechter, Nitric oxide therapy in sickle cell disease, Semin.
A. García-Rios, N. Katsiki, M.M. Malagón, J. López-Miranda, P. Pérez-Martínez, E. Hematol. 38 (4) (2001) 333–342.
M. Yubero-Serrano, Endothelial dysfunction and advanced glycation end products [93] S. Redaelli, A. Magliocca, R. Malhotra, G. Ristagno, G. Citerio, G. Bellani, L. Berra,
in patients with newly diagnosed versus established diabetes: from the E. Rezoagli, Nitric oxide: clinical applications in critically ill patients, Nitric Oxide
CORDIOPREV study, Nutrients 12 (1) (2020). 121 (2022) 20–33.
[67] I.M. Idris, E.A. Botchwey, H.I. Hyacinth, Sickle cell disease as an accelerated [94] B.S. Pace, A. Starlard-Davenport, A. Kutlar, Sickle cell disease: progress towards
aging syndrome, Exp. Biol. Med. 247 (4) (2022) 368–374. combination drug therapy, Br. J. Haematol. 194 (2) (2021) 240–251.
[68] Y. Wu, Y. Ding, T. Ramprasath, M.H. Zou, Oxidative stress, GTPCH1, and [95] R.T. Premont, J.D. Reynolds, R. Zhang, J.S. Stamler, Role of nitric oxide carried
endothelial nitric oxide synthase uncoupling in hypertension, Antioxidants Redox by hemoglobin in cardiovascular physiology: developments on a three-gas
Signal. 34 (9) (2021) 750–764. respiratory cycle, Circ. Res. 126 (1) (2020) 129–158.
[69] R. Bou-Fakhredin, L. De Franceschi, I. Motta, A.A. Eid, A.T. Taher, M. [96] R. Onalo, A. Cilliers, P. Cooper, C.R. Morris, Arginine therapy and
D. Cappellini, Redox balance in β-thalassemia and sickle cell disease: a love and cardiopulmonary hemodynamics in hospitalized children with sickle cell anemia:
hate relationship, Antioxidants 11 (5) (2022). a prospective, double-blinded, randomized placebo-controlled clinical trial, Am.
[70] A. Pirillo, G.D. Norata, A.L. Catapano, LOX-1, OxLDL, and atherosclerosis, J. Respir. Crit. Care Med. 206 (1) (2022) 70–80.
Mediat. Inflamm. 2013 (2013) 152786. [97] R.H. Böger, The pharmacodynamics of L-arginine, Alternative Ther. Health Med.
[71] A.J. Kattoor, A. Goel, J.L. Mehta, LOX-1: regulation, signaling and its role in 20 (3) (2014) 48–54.
atherosclerosis, Antioxidants 8 (7) (2019). [98] O. Tangphao, M. Grossmann, S. Chalon, B.B. Hoffman, T.F. Blaschke,
[72] A.J. Kattoor, S.H. Kanuri, J.L. Mehta, Role of ox-LDL and LOX-1 in atherogenesis, Pharmacokinetics of intravenous and oral L-arginine in normal volunteers, Br. J.
Curr. Med. Chem. 26 (9) (2019) 1693–1700. Clin. Pharmacol. 47 (3) (1999) 261–266.
[73] K. Tian, S. Ogura, P.J. Little, S.W. Xu, T. Sawamura, Targeting LOX-1 in [99] C.R. Morris, F.A. Kuypers, L. Lavrisha, M. Ansari, N. Sweeters, M. Stewart,
atherosclerosis and vasculopathy: current knowledge and future perspectives, G. Gildengorin, L. Neumayr, E.P. Vichinsky, A randomized, placebo-controlled
Ann. N. Y. Acad. Sci. 1443 (1) (2019) 34–53. trial of arginine therapy for the treatment of children with sickle cell disease
[74] M.A. Cinelli, H.T. Do, G.P. Miley, R.B. Silverman, Inducible nitric oxide synthase: hospitalized with vaso-occlusive pain episodes, Haematologica 98 (9) (2013)
regulation, structure, and inhibition, Med. Res. Rev. 40 (1) (2020) 158–189. 1375–1382.
[75] C.A. Rees, D.C. Brousseau, D.M. Cohen, A. Villella, C. Dampier, K. Brown, [100] G. Wu, C.J. Meininger, C.J. McNeal, F.W. Bazer, J.M. Rhoads, Role of L-arginine
A. Campbell, C.E. Chumpitazi, G. Airewele, T. Chang, C. Denton, A. Ellison, in nitric oxide synthesis and health in humans, Adv. Exp. Med. Biol. 1332 (2021)
A. Thompson, F. Ahmad, N. Bakshi, K.D. Coleman, S. Leibovich, D. Leake, 167–187.
D. Hatabah, H. Wilkinson, M. Robinson, T.C. Casper, E. Vichinsky, C.R. Morris, [101] N. Bakshi, C.R. Morris, The role of the arginine metabolome in pain: implications
Sickle Cell Disease Treatment with Arginine Therapy (STArT): study protocol for for sickle cell disease, J. Pain Res. 9 (2016) 167–175.
a phase 3 randomized controlled trial, Trials 24 (1) (2023) 538. [102] D.R. Todd Tzanetos, J.J. Housley, F.E. Barr, W.L. May, C.D. Landers,
[76] J.W. Weisel, R.I. Litvinov, Red blood cells: the forgotten player in hemostasis and Implementation of an inhaled nitric oxide protocol decreases direct cost
thrombosis, J. Thromb. Haemostasis 17 (2) (2019) 271–282. associated with its use, Respir. Care 60 (5) (2015) 644–650.
[77] D.B. Kim-Shapiro, M.T. Gladwin, Nitric oxide pathology and therapeutics in sickle [103] K. Abe, M. Nakayama, M. Yoshimura, S. Nakamura, T. Ito, M. Yamamuro,
cell disease, Clin. Hemorheol. Microcirc. 68 (2–3) (2018) 223–237. T. Sakamoto, Y. Miyamoto, Y. Yoshimasa, Y. Saito, K. Nakao, H. Yasue, H. Ogawa,
[78] C. Csonka, T. Páli, P. Bencsik, A. Görbe, P. Ferdinandy, T. Csont, Measurement of Increase in the transcriptional activity of the endothelial nitric oxide synthase
NO in biological samples, Br. J. Pharmacol. 172 (6) (2015) 1620–1632. gene with fluvastatin: a relation with the -786T>C polymorphism,
[79] S. Feghhi, A.D. Munday, W.W. Tooley, S. Rajsekar, A.M. Fura, J.D. Kulman, J. Pharmacogenetics Genom. 15 (5) (2005) 329–336.
A. López, N.J. Sniadecki, Glycoprotein Ib-IX-V complex transmits cytoskeletal [104] M.T. Gladwin, G.J. Kato, D. Weiner, O.C. Onyekwere, C. Dampier, L. Hsu, R.
forces that enhance platelet adhesion, Biophys. J. 111 (3) (2016) 601–608. W. Hagar, T. Howard, R. Nuss, M.M. Okam, C.K. Tremonti, B. Berman, A. Villella,
[80] M. Madan, S.D. Berkowitz, J.E. Tcheng, Glycoprotein IIb/IIIa integrin blockade, L. Krishnamurti, S. Lanzkron, O. Castro, V.R. Gordeuk, W.A. Coles, M. Peters-
Circulation 98 (23) (1998) 2629–2635. Lawrence, J. Nichols, M.K. Hall, M. Hildesheim, W.C. Blackwelder, J. Baldassarre,
[81] S.M. Jung, M. Moroi, Platelet glycoprotein VI, Adv. Exp. Med. Biol. 640 (2008) J.F. Casella, Nitric oxide for inhalation in the acute treatment of sickle cell pain
53–63. crisis: a randomized controlled trial, J. Am. Med. Assoc. 305 (9) (2011) 893–902.
[82] U. Klinkhardt, I. Dragutinovic, S. Harder, P-selectin (CD62p) and P-selectin [105] T. Aboursheid, O. Albaroudi, F. Alahdab, Inhaled nitric oxide for treating pain
glycoprotein ligand-1 (PSGL-1) polymorphisms: minor phenotypic differences in crises in people with sickle cell disease, Cochrane Database Syst. Rev. 7 (2022)
the formation of platelet-leukocyte aggregates and response to clopidogrel, Int. J. CD011808.
Clin. Pharmacol. Therapeut. 43 (6) (2005) 255–263. [106] B.D. Benites, S.T. Olalla-Saad, An update on arginine in sickle cell disease, Expert
[83] J.F. Théorêt, D. Yacoub, A. Hachem, M.A. Gillis, Y. Merhi, P-selectin ligation Rev. Hematol. 12 (4) (2019) 235–244.
induces platelet activation and enhances microaggregate and thrombus [107] C.R. Morris, Alterations of the arginine metabolome in sickle cell disease: a
formation, Thromb. Res. 128 (3) (2011) 243–250. growing rationale for arginine therapy, Hematol. Oncol. Clin. N. Am. 28 (2)
[84] T. Pouyani, B. Seed, PSGL-1 recognition of P-selectin is controlled by a tyrosine (2014) 301–321.
sulfation consensus at the PSGL-1 amino terminus, Cell 83 (2) (1995) 333–343. [108] D.A. Antonelli Rossi, J.A. De Araujo Junior, G.J. Luvizutto, R. Bazan, P.
[85] M.S. Patel, D. Miranda-Nieves, J. Chen, C.A. Haller, E.L. Chaikof, Targeting P- S. Salmazo, G.P. Modolo, J.C. Hueb, H.R.C. Nunes, N.K. Hokama, M.F. Minicucci,
selectin glycoprotein ligand-1/P-selectin interactions as a novel therapy for M.G. Roscani, S.G. Zanati Bazan, Effect of a physical exercise program on the
metabolic syndrome, Transl. Res. 183 (2017) 1–13. inflammatory response, cardiac functions, functional capacity, and quality of life
[86] M. Tomaiuolo, L.F. Brass, T.J. Stalker, Regulation of platelet activation and in patients with sickle cell disease, J. Clin. Med. 12 (12) (2023).
coagulation and its role in vascular injury and arterial thrombosis, Interv. Cardiol. [109] M. Grau, M. Jerke, E. Nader, A. Schenk, C. Renoux, B. Collins, T. Dietz, D.
Clin. 6 (1) (2017) 1–12. A. Bizjak, P. Joly, W. Bloch, P. Connes, A. Prokop, Effect of acute exercise on RBC
[87] R.C. Becker, T. Sexton, S.S. Smyth, Translational implications of platelets as deformability and RBC nitric oxide synthase signalling pathway in young sickle
vascular first responders, Circ. Res. 122 (3) (2018) 506–522. cell anaemia patients, Sci. Rep. 9 (1) (2019) 11813.
[88] A. Yildirim, J. Russell, L.S. Yan, E.Y. Senchenkova, D.N. Granger, Leukocyte-
dependent responses of the microvasculature to chronic angiotensin II exposure,
Hypertension 60 (6) (2012) 1503–1509.

46