Redox and apoptosis modulation by telmisartan, ertugliflozin, and omaveloxolone in a rat model of global cerebral ischemia/reperfusion injury

Redox and apoptosis modulation by telmisartan, ertugliflozin, and omaveloxolone in a rat model of global cerebral ischemia/ reperfusion injury Yasser J. H. Alyassery1, Ahsan F. Bairam2 1 Department of Pharmacy Sciences, Faculty of Pharmacy, University of Kufa, Najaf, Iraq 2 Department of Pharmacology and Toxicology, Faculty of Pharmacy, University of Kufa, Najaf, Iraq Corresponding author: Yasser J. H. Alyassery (Y[email protected]kufa.edu.iq; [email protected]) Received 18 August 2025♦ Accepted 28 October 2025♦ Published 7 November 2025 Citation: Alyassery YJH, Bairam AF (2025) Redox and apoptosis modulation by telmisartan, ertugliflozin, and omaveloxolone in a rat model of global cerebral ischemia/reperfusion injury. Pharmacia 72: 1–11. https://doi.org/10.3897/pharmacia.72.e169142 Abstract Ischemic stroke, accounting for 87% of all stroke cases, is a major global health issue associated with global cerebral ischemia. This study aimed to evaluate the neuroprotective effects of telmisartan, ertugliflozin, and omaveloxolone on cerebral ischemia–reperfusion injury. Forty-two rats were randomly assigned to seven groups. Their brain tissues were collected for infarct size assessment using triphenyltetrazolium chloride (TTC) staining and for ELISA analysis of oxidative and apoptotic markers, including superoxide dismutase (SOD), catalase (CAT), caspase-3, BCL2-associated protein X (BAX), B cell lymphoma-2 (BCL2), and the BCL2/BAX ratio. Pretreatment significantly reduced infarct area (P < 0.05), as determined by TTC staining. All three treatments significantly increased antioxidant enzyme levels, including SOD and CAT (P < 0.05). The treated groups showed a substantial decrease in caspase-3 levels, increased BCL2 expression, and a higher BCL2/BAX ratio (P < 0.05). Telmisartan, ertugliflozin, and omaveloxolone each produced neuroprotective benefits, preserving brain tissue largely through their antioxidant and anti-apoptotic actions. Keywords apoptosis, BCCAO, ertugliflozin, omaveloxolone, oxidative stress, stroke, telmisartan Introduction Stroke is the second greatest cause of mortality and the third leading cause of combined mortality and disability, as measured by disability-adjusted life-years lost (DALYs), among non-communicable disorders (NCDs) globally (Feigin et al. 2025). The majority of the global stroke burden (87.2% of deaths and 89.4% of DALYs) occurs in low-income and lower-middle-income countries. The worldwide cost of stroke is estimated at about US$890 billion (0.66% of global GDP) annually and is expected to almost double by 2050 (Feigin and Owolabi 2023). Ischemic stroke, accounting for 87% of all strokes, results from cerebral vessel obstruction by thrombi or emboli, leading to reduced oxygen and nutrient supply to neuronal cells (Ekpendu et al. 2025). Global ischemia refers to the condition in which the entire brain experiences reduced blood supply, falling below a crucial threshold (Li et al. 2018). Global cerebral ischemia (GCI) leads to reduced oxygen and nutrient delivery, causing an initial ischemic Copyright Alyassery YJH & Bairam AF. This is an open access article distributed under the terms of the Creative Commons Attribution License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Pharmacia 72: 1–11 DOI 10.3897/pharmacia.72.e169142 Research Article Alyassery YJH & Bairam AF: Neuroprotective roles of telmisartan, ertugliflozin, and omaveloxolone2 injury due to metabolic imbalance. Reperfusion, through thrombolysis or thrombectomy, restores blood flow but triggers inflammation, neurotransmitter release, and endothelial dysfunction, resulting in blood–brain barrier damage, edema, and neurological deficits (Campbell et al. 2019). Even with the brain’s natural antioxidant defenses, hypoxia occurring during cerebral ischemia–reperfusion injury (CIRI) results in the depletion of ATP and an increase in oxidative stress. Free radicals originate from the activity of Ca²⁺-dependent enzymes, the breakdown of phospholipids, and mitochondrial dysfunction. Following reperfusion, enzymes such as xanthine oxidase, phospholipase A2, and nitric oxide synthases increase radical production, which plays a role in excitotoxicity, lipid peroxidation, inflammation, and cell death (Anaya-Fernández et al. 2024). Excessive reactive oxygen species (ROS) inflict damage on cellular components, including proteins, DNA, RNA, and lipids. Following ischemia–reperfusion, mitochondria and NADPH oxidase (NOX) serve as significant sources of reactive oxygen species (ROS), with NOX producing free radicals through the transfer of electrons to molecular oxygen (Lin et al. 2016). Apoptosis and necrosis are evident in acute neurodegenerative conditions such as stroke (Chi et al. 2018). Apoptosis provides an essential system of programmed cell death, serving an important role in development, maintaining tissue homeostasis, and supporting immune function. Dysregulation of this system is linked to various diseases, especially neurodegenerative disorders (Dadsena et al. 2024). Ischemia and reperfusion activate various cell death pathways, in which hypoxic stress and ROS generation during reperfusion are crucial in both initiating and exacerbating apoptosis (Du et al. 2025). Recent studies focus on identifying effective neuroprotective drugs for ischemic stroke, given the lack of newly approved agents in this area. Although advancements have been made in acute interventions such as thrombolysis and thrombectomy, a notable deficiency persists in pharmacological alternatives that safeguard brain tissue and promote sustained recovery. Furthermore, the management of hypertension and diabetes is essential due to their significant contribution to stroke risk (Chen et al. 2021). Certain antihypertensive and antidiabetic drugs, such as telmisartan and ertugliflozin, demonstrate significant antioxidant and protective effects in addition to their primary functions. Nonetheless, the comprehensive neuroprotective potential and mechanisms in ischemic stroke have yet to be thoroughly investigated (Abdelhamid et al. 2021; Tsai et al. 2021). In 2023, the FDA approved omaveloxolone as a medication for Friedreich’s ataxia, functioning as an Nrf2 activator (Pilotto et al. 2024). This agent could potentially contribute to both the prevention and treatment of cerebral ischemia–reperfusion injury. This study aims to analyze the potential neuroprotective effects of telmisartan, ertugliflozin, and omaveloxolone in a global cerebral ischemia–reperfusion injury (CIRI) model, emphasizing their influence on redox balance and apoptotic pathways. Methods Ethical approval The Institutional Animal Care and Use Committees (IACUCs) and the Central Committee for Bioethics at the University of Kufa granted approval for this study (Approval No. 13191; May 18, 2025). All experimental procedures adhered to the National Institutes of Health (NIH) “Guide for the Care and Use of Laboratory Animals” and conformed to international standards regarding the ethical treatment of research animals. The study adheres to the ARRIVE guidelines, emphasizing the importance of transparency and reproducibility in animal research (Percie du Sert et al. 2020). Preparation of drugs The solubility and safety of the drugs were validated in alignment with the manufacturers’ specifications. Dosages were determined and adjusted relative to the body weight of the animals. Telmisartan and ertugliflozin were dissolved in DMSO to prepare stock solutions and stored at 4 °C, then diluted daily to 1 mg/ml and 5 mg/ml, respectively, in a 10:90 DMSO–corn oil mixture. Omaveloxolone was dissolved in DMSO to a final concentration of 10 mg/ml. Preparation of animals A total of 42 adult male Sprague–Dawley rats (210–245 g) were housed in polypropylene cages with corn cob bedding under controlled environmental conditions (25 ± 2 °C; 12 h light/dark cycle; 50–60% relative humidity). Animals had ad libitum access to standard laboratory chow and filtered water. The health status of the animals was monitored daily by veterinary staff, and cages were cleaned regularly to maintain hygienic conditions. Following a 15-day acclimatization period, the animals were randomly allocated into experimental groups. All experimental procedures were conducted at the Animal Research Center and the Pharmacology and Toxicology Laboratory, University of Kufa. Experimental protocol After the 2-week acclimatization phase, the rats were randomly assigned to seven experimental groups, each comprising six rats (Chandrashekhar et al. 2010; Lapi et al. 2016). • Group 1 (Sham): Rats were subjected to anesthesia and surgical exposure without occlusion of the bilateral common carotid arteries (BCCAO). • Group 2 (Control): Rats underwent anesthesia followed by bilateral common carotid artery occlusion (BCCAO) for 30 minutes and were then subjected to reperfusion for 1 hour. Pharmacia 72: 1–11 3 • Group 3 (Vehicle A): Rats received oral DMSO– corn oil (10:90) for 1 week before BCCAO and reperfusion. • Group 4 (Vehicle B): Rats were administered two intraperitoneal doses of DMSO prior to undergoing BCCAO and subsequent reperfusion. • Group 5 (Telmisartan): Rats received oral administration of telmisartan (3 mg/kg/day) in a DMSO– corn oil (10:90) solution for 1 week before BCCAO and reperfusion. • Group 6 (Ertugliflozin): Rats were administered oral ertugliflozin (20 mg/kg/day) in the same vehicle for 1 week before BCCAO and reperfusion. • Group 7 (Omaveloxolone): Rats received two intraperitoneal injections of omaveloxolone (10 mg/ kg) prior to bilateral carotid artery occlusion and reperfusion. The determination of pharmacological doses was based on prior research demonstrating effectiveness in regulating inflammatory and oxidative stress pathways without causing adverse effects. The telmisartan dosage (3 mg/ kg) was chosen for its advantageous bioavailability and established pleiotropic anti-inflammatory properties in preclinical models, particularly in the central nervous system (CNS), while avoiding hypotensive reactions that may hinder stroke management (Fouad et al. 2010; Haraguchi et al. 2010; Shindo et al. 2012; Sato et al. 2014; Alabbassi 2015; Sekar et al. 2018). The dosage of ertugliflozin (20 mg/kg) was selected based on previous findings demonstrating its protective, non-glycemic pleiotropic effects (Abd Uljaleel and Hassan 2023; Meesa and Yellu 2023). The chosen dosage of omaveloxolone (10 mg/kg) was based on recent studies validating its neuroprotective efficacy and its emerging therapeutic potential as an NRF2 activator for neurological diseases (Hu et al. 2022). Induction of cerebral ischemia All experimental groups, except the sham group, underwent bilateral common carotid artery occlusion (BCCAO) as previously described (Chandrashekhar et al. 2010; Lapi et al. 2016). Anesthesia was induced via intraperitoneal injection of ketamine (50 mg/kg) and xylazine (2–8 mg/ kg) (Li et al. 2021). The appropriate level of anesthesia was confirmed by the absence of pedal and corneal reflexes. During the procedure, animals were maintained at 37 ± 0.5 °C using a thermostatically regulated heating pad and an overhead light source. Each sedated rat was positioned supinely and immobilized on the surgical platform. A midline cervical incision was made between the neck and sternum to expose the trachea. The right and left common carotid arteries were carefully isolated lateral to the sternocleidomastoid muscles, with adjacent tissues gently separated and the vagus nerve protected. Bilateral blockage of the common carotid arteries was achieved using atraumatic vascular clamps (aneurysm clips) to induce cerebral ischemia (Singh et al. 2018). The reperfusion phase commenced with the removal of the clamps after the specified occlusion duration. To minimize animal suffering, preoperative monitoring included evaluation of breathing rate, mucosal coloration, and reflex responses. Body temperature was regularly assessed using a rectal probe to maintain normothermia. Brain tissue sample preparation Brains were meticulously extracted by dissecting the cranium posteriorly from the foramen magnum following euthanasia by decapitation. To maintain tissue integrity, the remaining midbrain and forebrain regions were bathed in ice-cold phosphate-buffered saline (PBS) and maintained on ice. The olfactory bulbs and cerebellum were excised. Subsequently, the skulls were coronally sectioned into predetermined segments. The initial segment was promptly subjected to 2,3,5-triphenyl-2H-tetrazolium chloride (TTC) staining to determine the infarct size. Until further biochemical analysis, the segment designated for enzyme-linked immunosorbent assay (ELISA) was weighed, washed with PBS, transferred into sterile Eppendorf tubes, flash-frozen on dry ice, and stored at –80 °C. Triphenyl-tetrazolium chloride (TTC) staining To evaluate cerebral infarction in rodents, TTC staining was employed due to its ability to distinguish between viable and infarcted tissue. Bright red staining is observed in respiring, viable regions, whereas infarcted regions remain unstained (white) (Buana et al. 2025; Domi et al. 2025). A 2% TTC solution was freshly prepared in normal saline and prewarmed to 37 °C. Coronal brain slices (2 mm thickness) were individually immersed in the TTC solution and incubated in the dark at 37 °C for 30 minutes. After incubation, the segments were fixed in 10% neutral-buffered formalin for 24 hours and subsequently transferred to saline for preservation (Dai et al. 2018). ImageJ software (National Institutes of Health, USA) was used to perform quantitative analysis of infarct size. The total infarct volume was determined by measuring the infarcted area of each slice, multiplying it by the thickness of the slice, and summing the results across all segments. Measurement of study biomarkers The levels of SOD and CAT were determined using enzyme-linked immunosorbent assay (ELISA) kits obtained from Bioassay Technology Laboratory, China, according to the manufacturer’s instructions. The levels of caspase-3, BCL2, and BAX were determined using ELISA kits obtained from Sunlong Biotech Co., Ltd., China, according to the manufacturer’s instructions. Alyassery YJH & Bairam AF: Neuroprotective roles of telmisartan, ertugliflozin, and omaveloxolone4 Statistical analysis All statistical analyses were performed using GraphPad Prism version 9.0.0 (GraphPad Software, USA) for Microsoft Windows. Data are expressed as mean ± standard deviation (SD). The normality of data distribution was assessed using the Shapiro–Wilk test. For data meeting the assumptions of normality, one-way analysis of variance (ANOVA) was performed, followed by Tukey’s honestly significant difference (HSD) post hoc test for multiple group comparisons. For data that did not conform to a normal distribution, the Kruskal–Wallis test was applied, followed by Dunn’s multiple comparisons test. Statistical significance was considered at P < 0.05. Results Brain infarction size determination This study demonstrated a significant increase (P < 0.05) in brain infarct area in the control group (Group 2) subjected to CIRI compared to the sham group (Group 1). No significant differences (P > 0.05) were observed in infarct size between the control and vehicle groups. Pretreatment with telmisartan, ertugliflozin, or omaveloxolone significantly reduced (P < 0.05) the brain infarct area compared to the control and vehicle groups (Fig. 1). Optical images of brain sections stained with TTC show that in the sham group, the tissue appears uniformly reddish, with no pale or white regions, indicating the absence of infarction. In the control group, large pale or white infarcted regions are visible, particularly in the cortex and striatum, indicating extensive cerebral ischemic injury. Vehicle A exhibits an infarction pattern comparable to that of the control group, with extensive unstained (white) regions and minimal protection, confirming that the vehicle has no effect on outcome. Vehicle B also shows substantial infarction, characterized by numerous pallid areas. The extent of injury appears similar to or slightly greater than that of the control group, emphasizing the importance of treatment intervention. Compared with the control and vehicle groups, the telmisartan group shows a marked reduction in infarct area. The predominantly red-stained regions indicate a strong neuroprotective effect, likely attributable to the drug’s antioxidant and anti-inflammatory actions. The ertugliflozin group shows smaller infarct regions than the control group, although some pale areas remain, suggesting moderate protection against ischemia-induced injury. In the omaveloxolone group, brain sections display reduced infarction compared with the control and vehicle groups, with greater preservation of viable red-stained tissue. This indicates substantial neuroprotection, though potentially less than that observed with telmisartan (Figs 2, 3). Oxidative stress biomarkers The levels of the antioxidant enzymes superoxide dismutase (SOD) and catalase (CAT) were significantly reduced (P < 0.05) in the control group compared with the sham group. No significant differences were observed between the control and vehicle-treated groups. Treatment with telmisartan, ertugliflozin, or omaveloxolone significantly increased (P < 0.05) brain SOD and CAT levels relative to the control and vehicle groups. However, no statistically significant differences were detected among the three treatment groups (P > 0.05), indicating that none of the agents exhibited superior antioxidant effects compared with the others (Figs 4, 5). Biomarkers for Apoptosis Caspase-3 levels in the control group were considerably higher (P < 0.05) than those of the sham group; however, no significant differences were observed between the vehicle and control groups. Compared with the control and vehicle groups, pretreatment with telmisartan, ertugliflozin, or omaveloxolone significantly (P < 0.05) decreased caspase-3 levels. There were no significant differences in caspase-3 levels among the groups treated with telmisartan, ertugliflozin, and omaveloxolone (Fig. 6). Similarly, BCL2 expression and the BCL2/BAX ratio were significantly lower (P < 0.05) in the control group compared with the sham group. BCL2 expression and the BCL2/BAX ratio were significantly higher (P < 0.05) in all treatment groups compared with the control and vehicle groups; however, no discernible differences were observed among the groups treated with telmisartan, ertugliflozin, and omaveloxolone (Figs 7–9). Analyses of the BAX levels showed no significant variations among the groups (P > 0.05) (Fig. 8). Figure 1. Measurement of brain infarct area with TTC. ImageJ software was utilized for analysis of the infarction area. Values represent mean percentage ± SD. Cont: Control, Veh A: Vehicle A (DMSO + corn oil PO); Veh B: Vehicle B (DMSO IP); Tel: Telmisartan; Ertu: Ertugliflozin; Omav: Omaveloxolone; ns: no significant difference. Pharmacia 72: 1–11 5 Figure 2. Optical images of brain sections stained with TTC showing infarct areas. White regions indicate infarcted (dead) tissue, whereas red regions denote viable (surviving) tissue. Cont: Control; Veh A: Vehicle A (DMSO + corn oil PO); Veh B: Vehicle B (DMSO IP); Tel: Telmisartan; Ertu: Ertugliflozin; Omav: Omaveloxolone. Discussion The current investigation demonstrated that pretreatment with telmisartan, ertugliflozin, and omaveloxolone significantly diminished brain infarction after cerebral ischemia– reperfusion injury (CIRI) in a rat model. TTC staining indicated that both the control and vehicle groups exhibited considerable cerebral infarction accompanied by edema, hemorrhage, and necrosis. In contrast, all three treatment groups demonstrated marked reductions in infarct size. The results align with previous studies indicating that bilateral common carotid artery occlusion (BCCAO) leads to consistent cerebral infarction, with the extent of damage being contingent upon the length of ischemia (Chandrashekhar et al. 2010; Handayani et al. 2018; Singh et al. 2018). The observed neuroprotection indicates that telmisartan, ertugliflozin, and omaveloxolone could reduce ischemia-induced brain injury, potentially via antioxidant and anti-apoptotic mechanisms. The current biochemical analyses substantiate this interpretation, revealing a restoration of antioxidant enzyme Alyassery YJH & Bairam AF: Neuroprotective roles of telmisartan, ertugliflozin, and omaveloxolone6 Figure 3. Monochromatic images of brain sections stained with TTC. ImageJ software was used to quantify the percentage of the white area corresponding to infarcted (dead) tissue. Figure 4. Brain tissue level of SOD (ng/ml). Values above each bar represent means ± SD. P-values are indicated along pairwise comparison lines. Cont: Control; Veh A: Vehicle A (DMSO + corn oil PO); Veh B: Vehicle B (DMSO IP); Tel: Telmisartan; Ertu: Ertugliflozin; Omav: Omaveloxolone. activity and changes in apoptotic biomarkers in the treated groups compared with the control and vehicle groups. When the body’s antioxidant defense systems are overwhelmed by the generation of reactive oxygen species (ROS), a condition known as oxidative stress ensues. To counteract this type of damage, the CAT and SOD enzymes collaborate (Ighodaro and Akinloye 2018). This study demonstrates that there is a significant decline in SOD and CAT levels in brain tissue homogenates in group 2 (control), group 3 (vehicle A), and group 4 (vehicle B) compared with group 1 (sham). In a physiologically normal setting (such as the sham group), antioxidant scavenging and ROS generation are in equilibrium. This equilibrium is greatly disrupted in ischemia–reperfusion (I/R) injury, which promotes oxidative damage. Due Figure 5. Brain tissue level of CAT (ng/ml). Values above each bar represent means ± SD. P-values are indicated along pairwise comparison lines. Cont: Control; Veh A: Vehicle A (DMSO + corn oil PO); Veh B: Vehicle B (DMSO IP); Tel: Telmisartan; Ertu: Ertugliflozin; Omav: Omaveloxolone. Pharmacia 72: 1–11 7 to the massive influx of free radicals, the antioxidant system becomes overwhelmed and thus overconsumes antioxidant enzymes (Zweier and Talukder 2006; Morrell 2008). These findings agree with previous studies (Barbhuiya et al. 2015; Lisha et al. 2019; Bhat and Kumar 2022). This study demonstrates that pretreatment of rat models of CIRI with telmisartan, ertugliflozin, or omaveloxolone enhances antioxidant defense in brain tissues, resulting in significant increases in SOD and CAT levels compared with their respective vehicle groups. The results for telmisartan align with earlier research (Gowda et al. 2022; Siddalingappa et al. 2023). Upon the binding of angiotensin II (Ang II) to angiotensin receptor type 1 (AT1R), there is an activation of the enzyme NADPH oxidase, which subsequently facilitates the production of ROS. Telmisartan directly reduces ROS production induced by Ang II through inhibition of AT1R. Given that NADPH oxidase contributes to oxidative stress across various organs, this mechanism is crucial (Nguyen Dinh Cat et al. 2013). Additionally, activation of PPAR-gamma by telmisartan may increase the production and activity of endogenous antioxidant enzymes such as SOD and CAT, which are crucial for neutralizing ROS and maintaining cellular redox balance (Villapol 2018). Similarly, pretreatment with ertugliflozin reinforces its antioxidant protective role within rat brains, aligning with the antioxidant effects of ertugliflozin reported in earlier studies (Croteau et al. 2021; Hassan et al. 2025). It is believed that SGLT2 inhibitors improve bioenergetics and mitochondrial function. The transition from carbohydrate to fatty acid and ketone body utilization enhances mitochondrial efficiency and reduces ROS production from the electron transport chain (Dabravolski et al. 2022). Recent research indicates that ertugliflozin activates the Nrf2/HO-1 pathway, which serves as a crucial regulator of the antioxidant defense system. The movement of Nrf2 into the nucleus and its subsequent binding to antioxidant response elements (AREs) facilitates the transcription of various antioxidant genes when activated (Ucar et al. 2021). Likewise, pretreatment with omaveloxolone reinforces its antioxidant protective function in rat brains. Other studies have demonstrated that omaveloxolone can restore SOD levels in chondrocytes subjected to oxidative stress induced by interleukin-1 beta (IL1B) in animal models (Jiang et al. 2022). Figure 6. Brain tissue level of caspase-3 (ng/ml). Values above each bar represent means ± SD. P-values are indicated along pairwise comparison lines. Cont: Control; Veh A: Vehicle A (DMSO + corn oil PO); Veh B: Vehicle B (DMSO IP); Tel: Telmisartan; Ertu: Ertugliflozin; Omav: Omaveloxolone. Figure 7. Brain tissue level of BCL2 (pg/ml). Values above each bar represent means ± SD. P-values are indicated along pairwise comparison lines. Cont: Control; Veh A: Vehicle A (DMSO + corn oil PO); Veh B: Vehicle B (DMSO IP); Tel: Telmisartan; Ertu: Ertugliflozin; Omav: Omaveloxolone. Figure 8. Brain tissue level of BAX (pg/ml). Values above each bar represent means ± SD. P-values are indicated along pairwise comparison lines. Cont: Control; Veh A: Vehicle A (DMSO + corn oil PO); Veh B: Vehicle B (DMSO IP); Tel: Telmisartan; Ertu: Ertugliflozin; Omav: Omaveloxolone. Figure 9. Brain tissue BCL2/BAX ratio. Values above each bar represent means ± SD. P-values are indicated along pairwise comparison lines. Cont: Control; Veh A: Vehicle A (DMSO + corn oil PO); Veh B: Vehicle B (DMSO IP); Tel: Telmisartan; Ertu: Ertugliflozin; Omav: Omaveloxolone. Alyassery YJH & Bairam AF: Neuroprotective roles of telmisartan, ertugliflozin, and omaveloxolone8 Omaveloxolone was also found to restore SOD levels in a study of hepatic ischemia–reperfusion injury (Hua et al. 2025). Under typical conditions, antioxidant responses are regulated by the cytoplasmic binding of Nrf2 to Keap1. Omaveloxolone binds to cysteine residues on Keap1, thereby preventing Nrf2 from interacting with it (Baird and Yamamoto 2020). Keap1 facilitates Nrf2 degradation. By activating Nrf2, omaveloxolone may enhance mitochondrial activity and biogenesis, boost cellular energy production, and decrease mitochondrial ROS (Zighan et al. 2022). Omaveloxolone has been shown to enhance mitochondrial resistance to oxidative stress and increase oxygen consumption (Pilotto et al. 2024). Caspase-3, BCL2, and BAX are all involved in apoptosis (Hardwick and Soane 2013). CIRI was found to activate apoptotic pathways in group 2 (control), group 3 (vehicle A), and group 4 (vehicle B) to a greater extent than in group 1 (sham). This activation resulted in a substantial increase in caspase-3 and a decrease in the ratio of BCL2 and BCL2/BAX. Caspase-3 levels increased in the hippocampus and cortex compared with the sham group at different time points following CIRI, while BCL2 levels decreased (Liu et al. 2013). Recent research has demonstrated that CIRI induction results in an increase in caspase-3 and a decrease in BCL2 compared with sham treatment. These findings were attributed to modification of the Nrf2 signaling pathway (Zeng et al. 2025). The BAX levels of the first four groups were comparable, suggesting that BAX does not significantly affect the CIRI model. BAX transcription and expression in mice were not influenced by BCCAO for 6 minutes (Wu et al. 2003). Compared with their vehicle groups, pretreatment with telmisartan, ertugliflozin, or omaveloxolone significantly reduced caspase-3 levels and increased BCL2 expression and the BCL2/BAX ratio. This corroborates the apoptosis-reducing properties of telmisartan. In rats with repeated cerebral ischemia, mice with hepatic ischemia–reperfusion injury, and rats with cardiac ischemic/hypoxic damage, caspase-3 levels were significantly reduced by telmisartan (Morsy et al. 2022; Trotta et al. 2019). Ertugliflozin also appears to offer protection against apoptosis. In animals with cardiac hypertrophy, ertugliflozin decreased caspase-3 (Moellmann et al. 2022). Ertugliflozin enhances cellular function and apoptosis resistance by increasing substrate usage and tissue adenosine triphosphate (ATP) levels. Moellmann et al. demonstrated that ertugliflozin may prevent inflammation-induced apoptosis by reducing inflammatory markers and modifying immune cell activity, such as macrophage polarization (Moellmann et al. 2022). Additionally, research indicates that omaveloxolone inhibits apoptosis. Previous studies have shown that omaveloxolone significantly increased BCL2 and decreased caspase-3 compared with the control group, thereby protecting against hepatic ischemia–reperfusion injury (Hua et al. 2025). Omaveloxolone activated Nrf2 and inhibited NF-κB p65 nuclear translocation, thereby protecting neonatal rodents from propofol-induced cognitive impairment by reducing caspase-3 levels (Zhang et al. 2021). Study limitations This study presents several limitations. The sample size was relatively small (n = 6 per group), potentially limiting statistical power and generalizability. Secondly, the study exclusively involved male rats, which restricts the ability to generalize findings to females, despite established sex differences in ischemic outcomes. The analysis concentrated mainly on oxidative stress and apoptotic markers, without assessing inflammatory mediators or long-term functional recovery. Finally, translation to human applications remains uncertain, as rodent ischemia–reperfusion models do not fully replicate the complexity of human stroke pathology. Conclusion This study illustrates that pretreatment with telmisartan, ertugliflozin, or omaveloxolone confers neuroprotection against cerebral ischemia–reperfusion injury in rats. The three agents produced a significant reduction in infarct size, restoration of antioxidant enzyme activity, and modulation of apoptotic markers. These findings suggest that their protective effects are primarily driven by mechanisms related to antioxidant activity and the inhibition of apoptosis. Telmisartan, ertugliflozin, and omaveloxolone demonstrated comparable efficacy; however, further research is needed to investigate dose optimization, sex-specific responses, long-term functional outcomes, and translational potential in human stroke. Additional information Conflict of interest The authors have declared that no competing interests exist. Ethical statements The authors declared that no clinical trials were used in the present study. The authors declared that no experiments on humans or human tissues were performed for the present study. The authors declared that no informed consent was obtained from the humans, donors or donors’ representatives participating in the study. Experiments on animals: The Institutional Animal Care and Use Committees (IACUCs) and the Central Committee for Bioethics at the University of Kufa granted approval for this study (Approval No. 13191; May 18, 2025). All experimental procedures adhered to the National Institutes of Health (NIH) Guide for the Care and Use of Laboratory Animals and conformed to international standards regarding the ethical treatment of research animals. The study adheres to the ARRIVE guidelines, emphasizing the importance of transparency and reproducibility in animal research (Percie du Sert et al. 2020). The authors declared that no commercially available immortalised human and animal cell lines were used in the present study. Pharmacia 72: 1–11 9 Use of AI No use of AI was reported. Funding The authors received no financial support for the research, authorship, or publication of this article. Author contributions Both authors contributed equally to this article. YJHA contributed to the main idea, study design, data collection, statistical analysis, and drafting of the manuscript. AFB contributed to the study design, critical revision, and supervision. Author ORCIDs Yasser J. H. 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