Subject: Pharmacology Topic: ANS 1 Lecturer: Dr. Ma. Luisa M. Delacruz Date of Lecture: Aug. 3, 2011 Transcriptionist: Synapses!

, Neurons, NogNog Editors: Neurons, Synapses! Pages: 14

Yyeeeeelllllllllllooooooww! Go 2014! Before we start the discussion proper, let us have a brief introduction about the topic : ANS. It actually belongs to the 2 divisions of PNS (Peripheral Nervous System) together with the Somatic Nervous Sytstem. Somatic Nervous System supplies skeletal muscle during voluntary movement and conducts sensory information such as pain and touch. While ANS (Autonomic Nervous System), would be the coverage in our 5th evaluation, controls the cardiac, brain, smooth muscle contraction, and glandular secretion. And ANS has 2 major divisions, the Sympathetic (thoracolumbar) fight or flight response and Parasympathetic (craniosacral) rest and digest ...(Good to know: ANS has 3 divisions, but the 3rd division is just a minor and less talked about - the Enteric Nervous System) This transcription, it focused on the cholinergic agonist drugs ONLY. Don t be confused, if you encounter the words Parasympathomimetic or Cholinomimetic, they are all the same. Parasympatholytic is also known as anticholinergic. Adrenergic is also known as Sympathomimetic. Lastly, antiadrenergic is also known as Sympatholytic. Okay? Cholinergic agonist has 2 receptors, Muscarinic receptor(M1,M2,M3,M4,M5) and Nicotinic receptor(Nn,Nm) that will bind to Acetylcholine to mimic its action. RECEPTOR Primary Location M1 Nerves that supply gastric glands Gastric acid secretion M2 M3 Smooth muscle,glands Heart muscle
Bradycardia, (-)Dromotropism

M4 and M5

Nn( neural) Autonomic ganglia

Nm(muscle) Motor endplates

CNS contraction Stimulation Skeletal muscle contraction

Effect

Cholinergic agonists
1. Direct-acting Cholinergic agonists  Stimulates directly the cholinergic receptors. i. Choline ester y Acetylcholine (M, N)
2. Indirect-acting Cholinergic Agonist /Acethylcholinesterase Inhibitors  do not stimulates the receptors but can increase the concentration of Ach

in the cleft. a. Reversible Cholinesterase Inhibitors

i.Noncovalent Inhibitors y Tacrine y Edrophonium y Donezepil ii. Carbamate Inhibitors y Physostigmine y Neostigmine y Pyridostigmine y Ambenomium y Demecarium

y Betacholine / Urecholine (M) y Methacoline (M, N) y Carabachol (N, M)

ii. Cholinergic alkaloids y Pilocarpine (M) y Muscarine (M) y Nicotine (N) y Lobeline /Arecholine (N)

b. Irreversible Cholinesterase Inhibitors (organophosphate) y Diisofluorophosphate y Insecticides  Malathion  Parathion  Fenthion  Chlorpyrifos y Nerve gases  Sarin  Soman  Tabun y Echothiphate iodide

iii. Carbamate Insecticides  Propoxur  Carbaryl  Aldicarb

Therapeutic uses Glaucoma

Xerostoma

Gastrointestinal tract Bethanechol

Genitourinary tract Bethanechol Neostigmine

Myasthenia gravis For diagnosis: Edrophonium For treatment: Neostigmine, Pyridostigmine

Alzheimer s disease Tacrine Donezepil

Antidote for toxicity Physostigmine Neostigmine

Acute: Pilocarpine Pilocarpine Chronic:Isofluorophate Echothiophate

Neostigmine

Reminder: To make life easier, don t just memorize; you must also distinguish the characteristics that make them belong/differ from the group
Okay?

SY 2011-2012

Review:
Divisions of the Autonomic Nervous System Differences between the two divisions Steps in neurotransmission

A. Division of the ANS:

PARASYMPATHETIC Origin Length of preganglionic fibers Length of postganglionic fibers Terminal Ganglia (location of ganglia) Pre-Postganglionic ratio Discharge / Response 1: 1 Discreet or localized Craniosacral outflow: CN 3,4,9,10 and S2-S4 Long Short Near or in the wall of the target organ SYMPATHETIC Thoracolumbar outflow: T1 to L2 or L3 Short Long Paravertebral ganglia located on either side of the vertebral column; prevertebral ganglia located anterior to the vertebral column 1 : 20 Diffuse, continuous Can discharge as a unit Fight or Flight Prepares the body to cope with emergencies and intense physical activity

Function

Rest and Digest Conserve energy Maintenance of organ function : homeostasis

Others

Effectors distributed throughout the body Adjusts constantly to changing environment

Table 1.0

Table 1.0 and Figure 1.0

1. Synapses between neurons are made in the autonomic ganglia: a. Parasympathetic ganglia are located near the effector organ b. Sympathetic ganglia are located in the paravertebral chain 2. Preganglionic neurons have their cell bodies in CNS and synapse in the autonomic ganglia Preganglionic neurons of sympathetic nervous system originate in spinal cord segments T1-L3 or thoracolumbar region Preganglionic neurons of parasympathetic nervous system originate in the nuclei of cranial nerves and spinal cord segments S2-S3 or the cranio-sacral region 3. Post ganglionic neurons of both divisions have their cell bodies in the autonomic ganglia and synapse in effector organs (heart, blood vessels, sweat glands).

Figure 1.0

Figure 2.0
Illustrates that most organs in the body have dual innervations (innervated by both divisions of the ANS). For example, the vagal parasympathetic innervations slows the heart rate while the sympathetic innervations increases HR. Despite this, one system usually predominates in controlling the activity of a given organ.

B. Comparison of Sympathetic and Parasympathetic Systems Effector Organ

ANS DIVISION EYE (iris) PARASYMPATHETIC Pupillary constriction (circular smooth) HEART rate of contraction force of contraction rate of conduction Bronchi Sexual function Table 2.0 (-) chronotropic (-) inotropic (-) dromotropic Constriction Erection (+) chronotropic (+) inotropic (+) dromotropic Dilation Ejaculation

Response
SYMPATHETIC Pupillary dilatation (radial smooth)

Table 2.0 and Figure 3.0

Show the opposing effects of the sympathetic and parasympathetic systems except for sexual function (point and shoot) Erection (point)- parasympathetic Ejaculation (shoot)- sympathetic

Figure 3.0 CRASH COURSE: Physio101

C. Synapses
cell to cell interaction that connect neurons 2 types: chemical and electrical
Types of Synapses: 1. Chemical comprises the majority of synapses used for signal transmission in the CNS st the 1 neuron secretes at its nerve ending synapse a chemical substance (neurotransmitter or transmitter substance) transmitter substance acts on receptor proteins on the next neuron to excite, inhibit or modify its sensitivity 2. Electrical characterized by direct open fluid channels that conduct electricity from one cell to the next most consist of small protein tubular structures (gap junctions) that allow free movement of ions from the interior of one cell to the interior of the next

Figure 4.0
Neurons do not act in isolation they are connected via synapses.

Structure of chemical synapse:

Pre synaptic Post synaptic

Loewi s experiment
1921 Otto Loewi stimulate vagus nerve heart rate decreases Loewi hypothesized that stimulation of the vagus released a chemical (Figure 5.0) 1st proof of chemical mediation of nerve action 1926 Acetylcholine Figure 5.0

Figure 7.0 Junctional transmission

a) Storage and release of neurotransmitter Neurotransmitters are synthesized and stored in the synaptic vesicles in the pre-synaptic terminal AP conducted down the motor neuron depolarization of presynaptic terminal Ca2+ uptake release of neurotransmitters into the synaptic cleft by exocytosis b) Interaction with receptors Diffusion of the neurotransmitter to the postsynaptic membrane and binding to its receptors c) production of response eg. Muscle contaction

D. STEPS in Neurotransmission:
1. Axonal conduction (Figure 6.0) 2. Junctional transmission (Figure 7.0) a. storage and release of neurotransmitter b. interaction with receptors c. production of response 3. Destruction or dissipation of neurotransmitter through acetylcholinesterase (degrades acetylcholine acetyl CoA + choline)

CRASH COURSE : Neurophysio101

Communication between nerve cells, between nerve cells and effector organs occurs through the release of specific chemical signals called the NEUROTRANSMITTERS. This release as shown in Figures 7.0 and 8.0 is triggered by the arrival of the AP at the 2+ nerve ending leading to depolarization. Uptake of Ca initiates infusion of the synaptic vesicles with the presynaptic membrane and release of their contents.The neurotransmitters rapidly diffuse across the synaptic cleft (synapse) between neurons and combine with specific receptors on the postsynaptic (target) cell.

Figure 8.0 NEUROTRANSMITTERS of ANS:

Figure 6.0 Axonal Conduction

Generation of AP along the axon of the neuron

Adrenergic neurons release norepinephrine as the neurotransmitter Cholinergic neurons (the focus of this lecture) whether in the sympathetic or parasympathetic nervous system release acetylcholine (Ach) Nonadrenergic, noncholinergic neurons release subsatance P, vaso-active intestinal peptide (VIP) or nitric oxide (NO)

RECEPTORS
molecule on the surface or within a cell that recognizes and binds with specific molecules, producing a specific effect in the cell

Two types of receptors:

1. Presynaptic receptors a. Heteroreceptor heteros : different or another respond to neurotransmitters, neuromodulator and neurohormones released from neurons or cells in the other system may be inhibitory or excitatory examples:  Ach acting on M2 and M4 receptors stimulate release of NE from sympathetic neurons  NE acting on a2 receptors stimulate the release of Ach from parasympathetic neurons b. Autoreceptor auto : self or same located on or close to axon terminals of a neuron through which the neuron s own neurotransmitter can modify neurotransmitter synthesis and release examples:  Ach released from parasympathetic neurons interact with M2 or M4 receptors to enhance Ach release  NE released from sympathetic neurons interact with alpha2 receptors to inhibit release of NE (Figure 9.0)  Modulation of dopamine release (Figure 10)

Figure 10: Modulation of dopamine release 2. Postsynaptic receptor located in the outer membrane of the postsynaptic neuron interaction with neurotransmitter result in localized increase in ionic permeability or conductance of the membrane

Figure 11 : example of postsynaptic receptor

Figure 9.0

RECEPTOR INTERACTION
PRESYNAPTIC RECEPTORS Autoreceptors p inhibit or enhance release of neurotransmitter by the same neuron Heteroceptors p respond to neurotransmitter released by another neuron may be inhibitory or facilitatory POSTSYNAPTIC RECEPTORS Production of post junctional potential q o permeability to Na+ and Ca++ p EPSP o permeability to Cl p IPSP + o permeability to K p IPSP Figure 12: Ionic movements during postsynaptic potentials
Excitatory Postsynaptic Potentials (EPSPs)
inputs that depolarize the postsynaptic cell bringing it closer it closer to threshold and closer to firing an action potential + caused by opening of channels permeable to Na , similar to the Ach channels a) Influx of Na+ causes depolarization EPSPs

Inhibitory Postsynaptic Potentials (IPSPs)

Inputs that hyperpolarize the postsynaptic cell, moving it away from threshold and farther from firing an AP Caused by opening of Cl channels b) Efflux of K+ causes hyperpolarization IPSPs c) Influx of Cl- causes hyperpolarization IPSPs d) Influx of Ca2+ activates enzyme 5

I. CHOLINERGIC NEUROTRANSMISSION
A. STEPS 1. Axonal conduction 2. Junctional transmission a. storage and release of neurotransmitter b. interaction with receptors c. production of response 3. Destruction or dissipation of neurotransmitter through acetylcholinesterase

Figure 13 : Neurotransmission at cholinergic neurons:

STEP 1: SYNTHESIS of ACh choline transported from ECF into the cytoplasm of the cholinergic neuron acetyl CoA derived from mitochondria; produced by the Kreb s cycle and fatty acid oxidation choline + acetyl CoA acetylcholine (ACh) uptake of choline is the rate limiting step in the synthesis of Ach transport of choline is inhibited by hemicholinium STEP 2: STORAGE of ACh in vesicles in here ACh is protected from degradation STEP 3: RELEASE of ACh AP arriving at the nerve ending due to the action of voltage-sensitive Na+ channels opening of Ca2+ channels on the pre synaptic membrane Ca2+ influx increase in intracellular Ca2+ concentration promotes fusion of synaptic vesicles with cell membrane release of their contents into the synaptic space Blocked by botulinum toxin Spider venom causes release of ACh STEP 4: BINDING to the receptor Binds to:  Either of two postsynaptic cholinergic receptors : muscarinic and nicotinic  Presynaptic receptors in the membrane of the neuron that released the ACh leads to a biologic response within the cell:  initiation of nerve impulse in a postganglionic fiber  activation of specific enzymes in effector cells STEP 5: DEGRADATION of ACh Acetylcholinesterase rapidly hydrolizes acetylcholine in the synaptic cleft ACh choline + acetate STEP 6: RECYCLING of choline Recapturing of choline by Na+ coupled, high affinity uptake system that transports the molecule back to the neuron once again acetylated to acetylcholine stored until released by another AP

Cholinergic neurons use and release acetylcholine as a neurotransmitter neurotransmission involves 6 steps:  steps 1-4 : synthesis, storage, release and binding of Ach to a receptor  step 5 : degradation of ACh in the synaptic gap  step 6 : recycling of choline

B. Acetylcholine and its metabolites: Choline and acetate

C. Classification of ACETYLCHOLINETERASE: SPECIFIC True acetylcholinesterase Neurons Synaptic clefts Neuromuscular junction RBCs NONSPECIFIC Pseudo-butyryl ChE Glial cells Plasma Liver Other organs

D. Compounds that interfere with cholinergic transmission:

Inhibits ACh transport to the neuron terminal Inhibits ACh release Stimulates Ach release

Hemicholinum, Vesamicol Botulinum toxin Acetylcholine, latrotoxin Latrotoxin - from black widow spider

NN- autonomic ganglia/ adrenal medulla; CNS NM- motor end plate membrane c. Distribution of Nicotinic receptors Autonomic ganglia, adrenal medulla innervated by preganglionic cholinergic fibers Motor end plate on skeletal muscles innervated by somatic motor nerves Present in CNS

Agonist / Antagonist at receptor site Interferes with destruction of neurotransmitter

Acetylcholinesterase Inhibitor

E. Cholinergic Receptors: ACETYLCHOLINE Muscarinic Nicotinic Smooth muscles ANS ganglia Cardiac Muscles Neuromuscular junction Exo/endocrine glands CNS Glands / CNS 1. Muscarinic Receptors a. Nature of muscarinic receptors 90% of cholinergic receptors in the peripheral nervous system and brain slow either excitatory or inhibitory has 5 receptor subtypes : M1-M5 G-protein coupled receptor b. Distribution of muscarinic receptors Autonomic effector cells innervated by postganglionic parasympathetic nerves and a few cholinergic sympathetic fibers endothelial cells of blood vessels CNS : cortex, hippocampus, thalamus M1 (ganglionic) Brain(cortex, hippocamous), salivary glands, sympathetic ganglia Heart, hindbrain, smooth muscle Smooth muscle, salivary glands, brain Brain(forebrain, stratum) Brain(substantia nigra), eye

Figure 14 : Nicotinic Receptors

Binding of two ACh molecules elicits a conformational change that allows entry of Na+ ions depolarization of effector cell

II. PARASYMPATHOMIMETICS / CHOLINERGIC AGONISTS Drugs affecting the ANS which act on receptors that are activated by Ach Mimic the effects of acetycholine by binding directly to the cholinoreceptors Classification:

a. Directly Acting Cholinomimetics

1. Natural & synthetic choline esters  Acetylcholine  Methacholine (Acetyl-bmethyl choline)  Carbachol (Carbamyl choline)  Bethanecol (Carbamyl methyl choline) 2. Naturally-occuring cholinomimetics alkaloids     Muscarine Pilocarpine Arecoline Nicotine

M2 (effector cells)

M3

b.

M4

Indirectly Acting Cholinomimetics : Acetycholinesterase inhibitors / Anticholinesterases 2. Irreversible inhibitors Bind covalently to acetylcholinesterase Result: long-lasting increase in ACh at all sites where it is released

M5

2.

Nicotinic receptor a. Nature 10% of cholinergic receptor in PNS and brain Fast and excitatory Ligand-gated ion channels + activation increase permeability to Na

1. Reversible inhibitors Indirectly provide cholinergic axn by prolonging the lifetime of ACh produced endogenously Result: accumulation of ACh in the synaptic space      Edrophonium Tacrine Physostigmine Pyridostigmine Neostigmine

 Echothiophate

b. Subtypes of nicotinic receptors found at the neuromuscular junction

DIRECTLY ACTING PARASYMPATHOMIMETICS

I. Natural and Synthetic Choline Esters CHOLINE ESTERS a. Structure-activity relationship Presence of beta methyl group; less activity at nicotinic receptors  i.e. Methacholine, Bethanechol Carbamic acid esters are resisant to hydrolysis by Acetylcholinesterase  i.e. Bethanechol, Carbachol b. Pharmacokinetics Poorly absorbed in the GIT Hydrophilic : quaternary compounds are less lipid soluble poorly distributed in the CNS A. ACETYLCHOLINE first synthesized by Baeyer in 1867 very short duration of action rapidly hydrolyzed by Acetylcholinesterase and Plasma Butyrylcholinesterase no systemic therapeutic applications due to its multiplicity of actions orally inactive quaternary ammonium compound that can t penetrate membranes 1. MOA: (refer to Figure 15) a. M1 & M3 activation of Gq-PLC pathway hydrolysis of phosphoinositides mobilization of intracellular Ca2+ depolarization (stimulatatory) b. M2 & M4 activation of Gi and Go cAMP pathway inhibit adenyl cyclase regulate specific ion channel enhanced K+ conductance Hyperpolarization (inhibitory) b. Cardiovascular system hyperpolarization of SA node and atrial muscles dilatation of blood vessels effect on CO (?) = decrease in CO effect on BP (?) = decrease in BP by an indirect mechanism of action (-) chronotropic effect- decrease heart rate (-) inotropic effect  less dense cholinergic innervations of ventricles  more effect on atrial muscles. Minimal effect on stroke volume (-) dromotropic effect : decreased rate of conduction in SA and AV nodes effects on blood vessels:  M3 in endothelial cells Activation of GqPLC-IP3 pathway activation of endothelial NO synthase Release of Endothelium Derived Relaxing Factor (EDRF or Nitric Oxide) relaxation of smooth muscles vasodilatation  indirectly  inhibition of release of norepinephrine from adrenergic nerve endings mediated by acetylcholine nitric oxide mediated vasodilation (Refer to Figure 16)

Figure 16 : Nitric Oxide mediated vasodilatation

Ach activates M3 receptors found in the endothelial cells lining the smooth muscles of blood vessels production of NO from arginine NO diffuses to vascular smooth muscle cells NO stimulates protein kinase G production (cGMP) hyperpolarization smooth muscle relaxation vasodilation

Figure 15 : MOA of ACh

2. Pharmacologic actions due to Activation of MUSCARINIC receptors a. CNS all muscarinic receptor subtypes present M1 and M2 for cognitive functioning i.e. learning and memory M3, M4 and M5 no role in cognition blockade of M1 impairs learning and memory blockade of M2 facilitate cognitive functioning

effect on BP:  blood pressure is equal to the product of the cardiac output and total peripheral resistance : BP=CO X TPR  CO= Stroke volume (SV) X Heart rate (HR)  SV= venous return (EDV) X myocardial contractility (Fc)  Results to the decrease in TPR and HR c. Ocular predominance of M3 receptors on the constrictor pupillae and ciliary muscles contraction of constrictor pupillae muscle MIOSIS contraction of ciliary muscle ACCOMODATION

loss of accommodation power for far vision decrease intraocular pressure B. METACHOLINE (acetyl beta-methylcholine) d. Gastrointestinal tract increase tone and amplitude of contraction increase secretory activity of glands in the stomach and intestine DIARRHEA e. Genitourinary tract increase tone of detrusor muscle increase voiding pressure increase ureteral peristalsis relaxation of trigone and sphincter f. Respiratory increase secretion of tracheobronchial glands contraction of bronchial smooth muscles Other glands salivary, sweat, lacrimal, pancreatic glands Sexual function stimulate penile and clitoral arousal Receptor Specificity Muscarinic Nicotinic Acetylcholine   Methacholine   Carbachole   Bethanecol    Pilocarpine    Muscarine    has a methyl group at the second carbon of the acetylcholine molecule hydrolyzed by acetylcholinesterase at a slower rate predominantly muscarinic slightly nicotinic used as bronchoprovocative test to diagnose airway hyperactivity II. Naturally Occuring Cholinomimetics Alkaloids A. MUSCARINE from the poisonous mushroom, Amanita muscaria produces mycetism contains the alkaloid muscarine & amatoxins from which was derived the name muscarinic receptor B. PILOCARPINE chief alkaloid found in Pilocarpus jaborandi- an American shrub muscarinic receptor agonist tertiary amine (lipid soluble) not hydrolyzed by acetylcholinesterase primarily used in ophthalmology as a miotic agent potent stimulatory of secretion of exocrine glands C. ARECHOLINE chief alkaloid of Area catechu (betel nut) a muscarinic agonist acts at the nicotinic receptor used with leaves of Piper betel to produce euphoric effects D. NICOTINE From tobacco leaves ( Nicotina spp.) fatal dose of nicotine is approximately 40 mg, or 1 drop of the pure liquid equivalent to two regular cigarettes most of the nicotine in cigarettes is destroyed by burning or escapes via the "sidestream" smoke Acute toxicity: 1. CNS sitmulation  Convulsions  coma  respiratory arrest Susceptibility to acetylcholinesterase

g.

h.

3. Differences in Pharmacologic actions of directacting cholinergic agonist CVS Acetylcholine Metacholine Carbachole Bethanecol Muscarine Pilocarpine      + GIT      +++ GUT      +++ RT      EYE      + GLANDS      ++

4. Pharmacologic actions due to Activation of NICOTINIC receptors a. Autonomic ganglia parasympathetic and sympathetic adrenal medulla inc. EPINEPHRINE b. Neuromuscular junction Depolarization CONTRACTION c. CNS low dose STIMULATION high dose depression

5. Directly Acting Cholinergic Agonist (structureactivity relationship)

2.

Neuromuscular blockade  skeletal muscle paralysis

respiratory failure

VARIOUS STATES OF ACETYLCHOLINESTERASE

3. Hypertension and cardiac arrhythmias

1. 2. 3.

Chronic toxicity Addiction Increase risk for coronary artery disease Increase incidence of recurrences of peptic ulcer 4. Increase risk for malignancy
Clockwise: free AChE, acetylated AChE, carbamylated AChE, phosphorylated AChE

b.INDIRECT-ACTING CHOLINOMIMETICS
 Have their primary effect at the active site of the enzyme, although some also have direct actions at nicotinic receptors. The chief differences between members of the group are chemical and pharmacokinetic their pharmacodynamic properties are almost identical. Acetylcholinesterase Inhibitors (AntiAchE)

Ionic binding (reversible)

Covalent binding (Irreversible)

Pharmacokinetics of Acetylcholinesterase Inhibitors: compounds containing quartenary ammonium group do not penetrate the cell membranes readily absorbed poorly from the GIT does not penetrate CNS in moderate doses act preferentially at the neuromuscular junctions of skeletal muscles (both as Anti-AChE and direct agonists comparatively less effect at autonomic effector sites and ganglia compounds containing tertiary amines are more lipid soluble well absorbed after oral administration effects at both peripheral and central cholinergic sites may be sequestered in lipids for long periods of time lipid soluble organophosphates are well absorbed through the skin volatile agents are transferred readily across the alveolar membrane

When an enzyme binds to the ionic site the product is reversible, it will produce irreversible when it binds to covalent binding at the esteratic site.

A. Reversible Acetylcholinesterase Inhibitors  Prototype:PHYSOSTIGMINE i. . Noncovalent Inhibitors a) Edrophonium b)Tacrine c)Donepezil a. Edrophonium synthetic quaternary ammonium compound moderate affinity to AchE activity is limited to the peripheral nervous system synapses small volume of distribution, rapid renal elimination very short duration of action (10-20 min.) used for diagnosis of Myasthenia gravis (Tensilon Test)

Acetylcholinesterase Inhibitors (AntiAchE) Mode Of Action produce accumulation of Ach at the cholinergic nerve terminals Increase accumulation of Ach released by cholinergic impulse or spontaneously released from the nerve ending produce effects due to increase activation of cholinergic receptors throughout the CNS and peripheral nervous system ACTIVE CENTER OF ACETYLCHOLINESTERASE

Carbamyl and organophosphate inhibitors of AChE form covalent bonds at the esteratic site. Edrophonium(reversible) binds to the ionic binding site

Edrophonium is a shorting acting inhibitor of Acetylcholinesterase because it binds to the ionic(reversible) and not to the esteratic site of Ache.

b. Tacrine/Donepezil

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synthetic tertiary ammonium compound higher affinity to AchE readily cross the blood brain barrier to inhibit AChE in the CNS longer duration of action useful in patients with Alzheimer s disease ii. Carbamate Inhibitors a. b. c. d. e. f. Physostigmine Neostigmine Pyridostigmine Carbamylated Anticholinesterase Ambenonium Demecarium

(half-life for hydrolysis of the dimethylcarbamoyl enzyme is 15-30 minutes) in vivo, the duration of inhibition by the carbamoylating agents is 3-4 hours iii. Carbamate Insecticides i. Propoxur ii. Carbaryl iii. Aldicarb Carbamate Insecticides have similar cholinesterase inhibiting activity as organophosphate compounds and nerve agents. carbamate-cholinesterase bond does not age and spontaneously hydrolyzes with a half-life of 1-2 hours which inactivates the compound clinical recovery occur in several hours, and only rarely in >24 hours. in the past, patients were not treated with Pralidoxime but use in carbamate toxicity can reduce the clinical severity mixed poisoning with organophosphorus compounds and carbamates are common. CARBAMYLATION AND PHOSPHORYLATION OF AChE

CARBAMYL INHIBITORS OF ACETYLCHOLINESTERASE ENZYME These agents are esters of carbamic acid. The general formula is below.

Carbamate Esters covalent binding bind reversibly with the esteratic site increase relative conc. of Ach does not alter enzyme function a. Physostigmine an alkaloid obtained from Physostigma venenosum tertiary amine activates both muscarinic and nicotinic receptor can easily enter the CNS 2-4 hours duration of action
Carbamylation Phosphorylation

b. Neostigmine synthetic quaternary ammonium compound more polar do not pass thru the BBB directly stimulates Nicotinic Receptor at the motor end plate 2-4 hrs duration of action dual action reversible Achase inhibitor direct activation of nicotinic receptor at the motor end plate beneficial in Myasthenia Gravis antidote for toxicity to Non-depolarizing Neuromuscular blocker c. Pyridostigmine synthetic quaternary ammonium compound used for long term treatment of Myasthenia gravis longer duration of action (4-6 hrs) d. Carbamylated Anticholinesterase react covalently with the enzyme serine hydrolyzed by AchE much more slowly than Ach act as alternate substrate for Ach binding to the active center serine generates a carbamoylated enzyme which is more stable

The covalent bond of the carbamoylated enzyme is considerably more resistant to the second (hydration) process, and this step is correspondingly prolonged (on the order of 30 minutes to 6 hours). The third group consists of the organophosphates. These agents also undergo initial binding and hydrolysis by the enzyme, resulting in a phosphorylated active site. The covalent phosphorus-enzyme bond is extremely stable and hydrolyzes in water at a very slow rate (hundreds of hours).

B. Irreversible Acetylcholinesterase Inhibitors (Organophosphates)  Prototype: Isoflurophosphate a. Diisofluorophosphate (DFP) b. Insecticides i.Malathion ii. Parathion iii. Fenthion iv.Chlorpyrifos c. Nerve gases i. Sarin ii. Tabun iii. Soman d. Echothiophate iodide Organophosphate Inhibitors react covalently with the enzyme serine serve as true hemisubstrates the resultant conjugate with the active center serine phosphorylated or phosphonylated is extremely stable

11

return of AchE activity depends on the synthesis of new enzyme stability of the phosphorylated enzyme is enhanced through aging which results from the loss of one alkly group

ORGANOPHOSPHATE INHIBITORS OF ACETYLCHOLINESTERASE ENZYME

Basic structure of Organophosphate Inhibitors Phosphorylation of the esteratic site of AChE produces irreversible inhibition of the enzyme

Irreversible Acetylcholinesterase Inhibitors (Organophosphates) covalent binding cause inhibition of physiologic function of enzyme Phosphorylated enzyme complex undergo aging LOSS OF AN ALKYL GROUP FROM PHOSPHORYLATED AChE AGES THE ENZYME

After the initial binding-hydrolysis step, the phosphorylated enzyme complex may undergo a process called aging. This process apparently involves the breaking of one of the oxygen-phosphorus bonds of the inhibitor and further strengthens the phosphorus-enzyme bond. The rate of aging varies with the particular organophosphate compound.

Pharmacological Properties Organophosphates highly lipid soluble except Echothiophate effectively absorbed from all routes endogenous Ach stimulates all cholinergic receptors (peripheral and CNS)

a.

Diisofluorophosphate (DFP) produce virtually irreversible inactivation of AchE high lipid solubility low molecular weight volatile inhalation, transdermal and GIT absorption CNS penetration Insecticides Parathion/Malathion low volatility and stability in aqueous solutions widely used as insecticides employed for home, garden and agricultural use also use in suicide attempts or deliberate poisoning also used topically in the treatment of Pediculosis (lice infestations ) converted to active metabolites by CYPs

Therapeutic Uses of Cholinergic Agonists: 1. Glaucoma Acute: Pilocarpine Chronic: Isofluorophate Echothiophate PARASYMPATHETIC CONTROL OF ACCOMMODATION
Glaucoma is a disease characterized by increased intraocular pressure. Muscarinic stimulants and cholinesterase inhibitors reduce intraocular pressure by causing contraction of the ciliary body so as to facilitate outflow of aqueous humor and perhaps also by diminishing the rate of its secretion.

b.

2. Xerostomia usually 2 to head and neck radiation therapy or Sjgren s syndrome  Pilocapine

c. Nerve Gases most potent synthetic toxins known used in warfare and terrorism attacks

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3. Gastrointestinal tract Postoperative abdominal distension Gastric atony or gastroparesis adynamic ileus due to toxic states congenital megacolon  Bethanechol  Neostigmine 4. Genitourinary tract postoperative or postpartum urinary retention chronic hypotonic, myogenic, or neurogenic bladder partial sensory or motor paralysis of the bladder after spinal injury  Bethanechol  Neostigmine 5. Myasthenia gravis neuromuscular disease characterized by severe weakness and fatigability of skeletal muscles loss of nicotinic receptors due to autoimmune mechanisms use of acetylcholinesterase inhibitors to o Ach to stimulate limited receptors For Diagnosis: Edrophonium For Treatment: Neostigmine, Pyridostigmine

Nondepolarizing (Competitive) neuromuscular blockers  Physostigmine,  Neostigmine Other Use / Misuse of Organophosphates 1. Pesticides  Propoxur  Malathion  Parathion Chemical warfare  Sarin  Soman  Tabun Suicide

2.

3.

Clinical Signs of Intoxication (Organophosphate Poisoning) 1. Due muscarinic excess miosis, conjunctival congestion, blurring of vision dyspnea due to bronchoconstriction and increase bronchial secretion abdominal cramps, nausea, vomiting diarrhea increase sweating salivation involuntary defecation and urination penile erection 2. Due to Nicotinic excess involuntary twitching generalized spasms severe muscle weakness and paralysis respiratory failure 3. Due to CNS involvement confusion ataxia slurred speech generalized convulsions respiratory depression coma 4. Death arrhythmias respiratory depression Diagnosis of Organophosphate poisoning History of exposure Characteristic signs and symptoms Determination of Cholinesterase activity in RBC and plasma Treatment of OP poisoning a) Remove all sources of contamination b) Reduce absorption from the GIT with activated charcoal c) Support respiration d) Administer Atropine intravenously e) Administer Atropine until full atropinization is achieved f) Administer enzyme reactivator if aging has not occurred Enzyme Reactivators 1. Pralidoxime 2. Obidoxime

Distinguish myasthenic crisis vs. cholinergic crisis How ? Results and Interpretation ? Myasthenic Crisis vs Cholinergic Crisis Myasthenic crisis (extreme muscle weakness) occurs due to inadequate medication (insufficient Ach at NMJ). Cholinergic Crisis (extreme muscle weakness) caused by an overdose of a cholinesterase inhibitor (excessive cholinergic stimulation). 6. Alzheimer s disease a neurodegenerative disease believed to be associated with decrease functioning of the cholinergic system in the brain Treatment: Tacrine, Donezepil activation of postsynaptic M1 receptors in the CNS without concomitantly activating presynaptic M2 receptors that inhibit release of endogenous Ach Cholinergic Deficits in AD loss of the enzyme choline acetyltransferase reduced synthesis of the transmitter acetylcholine limbic and neocortical cholinergic deficits Acetylcholine receptors largely intact 7. Antidote for Toxicity to: Anticholinergic drugs Tricyclic antidepressants

1.

Pralidoxime

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2-PAM (2-pyridine aldoxime methyl chloride) belongs to a class of chemicals, called oximes that reverse the binding of cholinesterase inhibitors with acetylcholinesterase currently the only FDA approved oxime in the United States Obidoxime is the agent commonly used in Europe and other parts of the world attaches to the site where the cholinesterase inhibitor has attached to and blocked cholinesterase. then attaches to the cholinesterase inhibitor and removes it from cholinesterase, allowing the enzyme to work normally again. this is sometimes referred to as regeneration of cholinesterase. reverses the phosphorylation of cholinesterase improves neural synaptic transmission corrects muscle weakness and paralysis reserved for those who are symptomatic should be used early because the organophosphate-enzyme complex becomes irreversible after 24 to 36 hours. Contraindications to the Use of Cholinergic Agonists Hyperthyroidism Asthma Coronary insufficiency Acid Peptic Disease Organic obstruction in bladder in or GIT Botulinum toxin

A. MOA: inhibit the release of acetylcholine B. Actions:  Muscular paralysis  Death from respiratory failure c. Therapeutic uses  motor apasticity  blepharospas,strabismus  cervicaldystonia(spasmodic torticollis)  spasm of the vocal cords d. Cosmetic uses  Eyebrow furrows  Frontalis muscle hyperactivity  Latheral canthal wrinkles  Axillary and palmar hyperhydrosis References : ppt, Cor Christi tranx batch 2012, BRS Physio, Lipincott s : Pharma, Guyton,Katzung, Goodman And Gilman, and others
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