Nitric oxide (NO) is a widely distributed gasotransmitter binding to the heme of soluble guanylate cyclase
(sGC) to stimulate the formation of the second messenger cyclic GMP. In disease, two pathomechanisms
can occur, scavenging of NO by reactive oxygen species so that sGC is insufficiently stimulated, and
oxidative damage of sGC resulting in heme loss and a NO-insensitive apo-form of sGC. To address this
therapeutically, two pharmacological principles have entered the clinic or clinical development. sGC
stimulators (sGCs) allosterically sensitize sGC for lower NO levels to reach physiological cGMP levels again;
sGC activators (sGCa) bind to the empty heme pocket of apo-sGC to recover cGMP formation. Here we
show in vitro and in vivo that this dichotomic pharmacology of sGCs/sGC and sGCa/apo-sGC is wrong.
Instead apo-sGC is both activated by sGCa and allosterically modulated by sGC stimulators. The sGCs
binding site in sGC and apo-sGC, however, is redox sensitive explaining why it has been previously missed
in apo-sGC preparations generated for example by using heme oxidants such as
1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ). Moreover, sGCs synergised with sGCa on apo-sGC in a
supra-additive manner similar to the synergy between NO and sGCs on sGC. Our findings provide functional
evidence including ischemic stroke, where apo-sGC rather than sGC is detectable, for identical modulation of
sGC and apo-sGC by sGCs. This necessitates a revision of the dichotomic sGC/apo-sGC pharmacology and
expands the therapeutic potential of sGCs and sGCa both individually and in combination.