Contents

Preface vii

Acknowledgements viii

Abbreviations and acronyms 1x

General principles Drugs aHecting maior organ

1. What is pharmacology? 3
systems
2. How drugs oct: general principles 8 18. The heart 277
3. How drugs oct: molecular aspects 24 19. The vascular system 298
4. How drugs oct: cellular aspects-excitation, 20. Atherosclerosis and lipoprotein metabolism 321
contraction and secretion 54 21 . Hoemostosis and thrombosis 33 1
5. Cell proliferation and apoptosis 72 22 . The hoemopoietic system 347
6. Method and measurement in pharmacology 87 23. The respiratory system 356
7. Absorption and distribution of drugs 98 24. The kidney 368
8. Drug elimination and pharmacokinetics 113 25. The gastrointestinal tract 385
26. The endocrine pancreas and the control of blood
glucose 397
' '
27. Obesity 410
28. The pituitary and the adrenal cortex 420
2 ,.- A ,~ 29. The thyroid 437
30. The reproductive system 445
Chemical mediators 3 1. Bone metabolism 461

9. Chemical mediators and the autonomic nervous

system 131
10. Cholinergic transmission 144
11. Norodrenergic transmission 168
12. Other peripheral mediators: 5-hydroxytryptamine
and purines 189
13. local hormones, inflammation and immune
reactions 202
14. Anti-inflammatory and immunosuppressant
drugs 226
15. Connobinoids 248
16. Peptides and proteins as mediators 256
17. Nitric oxide 265

v
 CO N TE N TS

',E' TIC >r J

~
6
The nervous system Special topics
32. Chemical transmission and drug action in the 52 . Individual variation and drug interaction 739
central nervous system 473 53. Harmful effects of drugs 7 5 1
33 . Amino acid transmitters 479 54 . Lifestyle drugs and drugs in sport 765
34. Other transmitters and modulators 492 55. Biopharmaceuticals and gene therapy 770
35 . Neurodegenerative diseases 508 56. Drug discovery and development 781
36. General anaesthetic agents 523
37. Anxiolytic and hypnotic drugs 535
38. Antipsychotic drugs 545 Appendix 787
39. Antidepressant drugs 557
40. Antiepileptic drugs 575
41 . Analgesic drugs 588 Index 797
42. CNS stimulants and psychotomimetic drugs 610
43 . Drug addiction, dependence and abuse 619
44. Local anaesthetics and other drugs affecting
sodium channels 638

Drugs used in the treatment of

infections and cancer
45 . Drugs used in the treatment of infections and
cancer 647
46. Antibacterial drugs 661
47. Antiviral drugs 679
48 . Antifungal drugs 692
49. Antiprotozoal drugs 698
50. Antihelminthic drugs 712
51 . Cancer chemotherapy 71 8

vi
Abbreviations and acronyms

a-l\le-5-HT a-methyl 5-hydroxytrypamine Arg arginine

a-MSH a-melanocyte-stimulating hormone ARND alcohol-related neurodevelopmental disorder
12-S-HETE 12-S-hydroxyeicosatetraenoic acid ASCI ATP-sensitive Ca2+-inseositive
2-AG 2-arachidonoyl glycerol ASCOT Anglo-Scandinavian Cardiac Outcomes Trial
2-Mc-5-IIT 2-mcthyl-5-hydroxytrypamine ASlC acid-sensing ion channel
4S Scandinavian Simvastatin Survival Study AT angiotensin
5-CT 5-carboxamidotryptamine AT 1 angiotensin ll receptor subtype I
5-HIAA 5-hydroxyindoleacetic acid AT 2 angiotensin ll receptor subtype 2
5-HT 5-hydroxytryptamine [serotonin] AT Ill antithrombin Ill
8-0H-DPAT 8-hydroxy-2-(di-n-propylamino) tetraline ATP adenosine triphosphate
AA arachidonic acid AUC aren under the curve
AC adenylate cyclase AV atrioventricular
\ C \T acyl cocnqme A: cholesterol acyltransferase AZT 1ido\udine
AcCoA acetyl coenqme A BARK B-adrenoceptor kinase
\ CE angioten~in-converting enzyme BDNF brain-derived neurotrophic factor
ACh acetylcholine Bma\ binding capacity
AChE acetylcholinesterase BMT body mass index
ACTH adrenocorticotrophic hormone BMPR-2 bone morphogenetic protein receptor type 2
AD Al1heimer's di~ease BNP B-typc natriuretic peptide
ADH antidiuretic hormone BSE bovine spongiform encephalopathy
ADHD attention deficit-hyperactivity disorder RuChE butyrylcholinesterase
A0l\1A a~ymmetric dimethylarginine CaC calcium channel
ADME absorption, distribution, metabolism and CAD coronary artery disease
elimination [studies! cADPR cyclic ADP-ribose
ado-8 12 5'-deoxyadcnosylcobalamin CaM calmodulin
ADP adenosine diphosphate cAMP cyclic 3',5'-adenosine monophosphate
AFt activation funct ion I CAR constitutive androstane receptor
AF2 activation function 2 CARE Cholesterol and Recurrent Events [trial]
AGEPC acct y1-gl ycery1-ether-phosphorylchol i ne CAT choline acetyltransferase
.\GRP agouti-related protein CBG corticosteroid-binding globulin
Ah aromatic hydrocarbon CCK cholecystokinin
\IDS acquired immunodeficiency syndrome cdk cyclin-dependent kinase
AIF apoptotic initiating factor eDNA circular deoxyribonucleic acid
ALA b-amino laevulinic acid CETP chole1>teryl ester transfer protein
ALDH aldehyde dehydrogenase CFfR cyMic fibrosis transport [transmembrane
AMP adeno~ine monopho~pbate conductance) regulator
AMPA <.t-amino-5-hydroxy-3-methyl-4-isoxazole cGMP cyclic guanosine monophosphate
propionic acid CGRP calcitOnin gene-related peptide
A\F atrial natriuretic factor ChE choline~terase
A'IP atrial natriuretic peptide CHO Chinese hamster ovary [cell)
AP adapter protein CICR calcium-induced calcium release
Apaf-J apoptotic protease-activating factOr- I CIP cdk inhibitory proteins
APC antigen-presenting cell CJD Crcutlfeldt-Jakob disease
APP amyloid precursor protein CL total clearance of a drug
APTT activated partial thromboplastin time CNP C-natriuretic peptide
AR aldehyde reductase; androgen receptor CNS central nervous system ix
 ABBREVIATIONS AND ACRONYMS

co carbon monoxide FAA II fany acid amide hydrola~e

CoA coenqmeA FAD flavin adenine dinucleotide
COMT catechol-0-methyl transferase FAS fetal alcohol syndrome
COPO chronic obstructive pulmonary disease FOUMP fluorodeoxyuridine monophosphate
cox cyclo-oxygenase Fe 2+ ferrous iron
CREB cAMP response element-binding protein Fe 3+ ferric iron
C RF corticotrophin-releasing factor FeOJ+ ferric oxene
C RH corticotrophin-releasing hormone FEV 1 forced expiratory volume in 1 second
CRLR calcitonin receptor-like receptor FGF fibroblast growth factor
CSF cerebrospinal fluid; colony-stimulating factor FH2 dihydrofolate
c.. ~teady-state plasma concentration FH4 tetrahydrofolate
CTL cytotoxic T lymphocyte FKBP FK-binding protein
CTZ chemoreceptor trigger zone FLAP livc-lipoxygenase activating protein
CYP cytochrome P450 [system] FMN flavin mononucleotide
DAAO d-amino acid oxidase formyi-F"" formyl tetrahydrofolate
DAG diacylglycerol FSII fo il icle-stimulating hormone
OAGL diacylglycerol lipa~e FXR farnesoid [bile acid] receptor
OAT dopamine transporter G6PD glucose 6-phosphate dehydrogenase
DBH dopamine-~-hydroxylase GABA g<unma-aminobutyric acid
DOAH dimethylarginine dimethylamino hyd rolase GAO glutamic acid decarboxylase
OHFR dihydrofolate reductase GC guanylate cyclase
OHMA 3.4-dihydroxymandelic acid G-CSF granulocyte colony-stimulating factor
OHPEG 3,4-dihydroxyphenylglycol GOP guanosine dipho::.phate
orr diiodotyrosine GFR glomerular filtration rate
OMARO disease-modifying antirheumatic drug GH growth hormone
O~IPP dimethylphenylpipenuinium GHB y-hydroxybutyrate
DNA deoxyribonucleic acid G IIRF growth hormone-releasing factor
DO ll oxidiscd [hydroxylated] drug G HRH growth honnone-releasing hom10nc
DOPA dihydroxyphenylalanine GI gastrointestinal
DO PAC dihydroxyphenylacetic acid G IP ga~tric inhibitory polypeptide
OSI depolarisation-induced suppression of inhibition G IRK G-protein-sensitivc inward-rectifying
OTMP 2-deoxythymidylate potassium [channelj
DUMP 2-deoxyuridylate G IT ga~trointesti nal tract
EAA excitatory amino acid Gla y-carboxylated glutamic acid
EC 51/ED5o concentration/dose effecti ve in 50% of the GLP glucagon-like peptide
population Clu glutamic acid
ECG electrocardiogram C M-CSF granulocyte-macrophage colony-stimulating
ECM extracellular matrix factor
ECP eosinophi l cationic protein G nRH gonadotrophin-releasing hormone
ECT electroconvulsive therapy GP glycoprotein
EDHF endothelium-derived hyperpolarising factor GPCR G-protein--coupled receptor
EORF endothelium-derived relaxing factor CPL glycerophospholipid
EEG electroencephalography CR glucocorticoid receptor
EET epoxyeicosatetraenoic acid CRE glucocorticoid response element
EGF epidermal growth factor C RK GPCR kinase
EG-VEGF endocrine gland-derived vascular endothelial GSII glutathione
growth factor GSSG glutathione, oxidised
Ema maximal response that a drug can produce GTP guanosine triphosphate
EMBP eosinophil major basic protein GUSTO Global Use of Strategies to Open Occluded
Ei\IT endocannabinoid membrane transporter Coronary Arteries [trial]
ENaC epithelial sodium channel 1120 2 hydrogen peroxide
eNOS endothelial nitric oxide synthase [ OS-UI] HAART highly active iJ.ntiretroviral !herapy
epp endplate potential HCG human chorionic gonadotrophin
E PS extrapyramidal side effects HCI hydrochloric acid
eps p excitatory postsynaptic potential HDAC histone deacetylase
ER endoplasmic reticulum; (o)estrogen receptor IIOL high-density Iipoprotein
X
FA kinase focal adhesion kinase HDL-C high-density lipoprotein cholesterol
 ABBR EVIATI O N S AND A C RONYM S

HER2 human epidermal growlh factor LSD ly<>ergic acid died1ylamide

receptor 2 LT leukotriene
HERG human ~ther-a-go-go related gene LTP long-term potentiation
HETE hydroxyeicosatetraenoic acid LXR liver oxysterol receptor
hGH human growth hormone lyso-PAF lysoglyceryl-phosphorylcholine
HIT heparin-induced thrombocytopenia mAb monoclonal antibody
lUV human immunodeficiency virus MAC minimal alveolar concentration
HLA histocompatibility antigen mAChR muscarinic acetylcholine receptor
HMG-CoA 3-hydroxy-3-methylglutaryl-coenzyme A MAGL monoacyl glycerol lipase
HnRNA heterologous nuclear RNA MAO monoamine oxidase
HPA hypothalamic-pituitary-adrenal [axis] MAOI monoamine oxidase inhibitor
HPETE hydroperoxyeicosatetraenoic acid MAP mitogen-activated protein
HRT hormone replacement therapy MAPK mitogen-activated protein kinase
HSP heat shock protein MCP monocyte chemoattractant protein
HVA homovani ll ic acid M-CSF macrophage cotony-sti mulating factor
TAP inhibitor of apoptosis protein MOMA methytenedioxymethamphetamine l 'ecstasy' J
TC5j1 concentration causing 50% inhibition in the MeN A methylnoradrenaline
population methyi-FH4 meth y Itetrah ydrofolate
ICAM intercellular adhesion molecule MGiuR metabotropic glutamate receptor
ICE interleukin-1-converting enzyme MHC major histocompatibility complex
ICSH interstitial cell-stimulating hormone MHPEG 3-methoxy, 4-hydroxyphenylglycol
JDDM insulin-dependent diabetes mellitus MHPG 3-hydroxy-4-methoxyphenylglycol
Inoll' knOll'II as type I diabetes] MIT monoiodotyrosinc
IFN interferon MLCK myosin light-chain kinase
lg immunoglobulin MPTP 1-methyl-4-phenyl-1 ,2.3,5-tetrabydropyridine
TGF in~ulin-likc growth factor MR mineralocorticoid receptor
IL interleukin mRNA messenger ribonucleic acid
Int. inhibitors of kinases MRSA methicillin-resistant Staphylococcus aureus
iNOS inducible nitric oxide synlhase MSH melanocyte-stimulating hormone
INR international normalised ratio N20 nitrous oxide
IP inositol phosphate NA noradrenaline rnorepinephrine]
TP3 inositol trisphosphate NAAOP nicotinic acid dinucleotide phosphate
IP3R inositol trisphosphate receptor NaC voltage-gated sodium channel
w~ inositol tetraphosphate nAChR nicotinic acetylcholine receptor
ipsp inhibitory postsynaptic potential NAD nicotinamide adenine dinucleotide
IRS in~u li n receptor substrate NAOH nicotinamide adenine dinucleotide, reduced
lSI international sensitivity index NAOPH nicoti namide adenine dinucleotide phosphate,
ISIS lntcrnationaJ Study of Infarct Survival reduced
ISO isoprenali ne NANC non-noradrenergic non-cholinergic
JUPHAR International Union of Pharmacological NAPBQI N-acetyl-p-benzoquinooe imine
Sciences NAPE N-acyl-phosphatidylethanotamine
JRA juvenile rheumatoid arthritis NASA ational Aeronautics and Space
K\Ch pota~!>ium channel Administration
K\TP ATP-sensitive potassium [activator. channel] NAT N-acyl-transferase
KIP kina'e inhibitory protein NCX Na -Ca 2 exchange transporter
LA local anaesthetic NET norepinephrine transporter
LC locus coeruleus NF nuclear factor
LCAT lecithin choleMerol acyltransferase NFlCB nuclear factor kappa B
LDso do~e that is lethal in 50% of the population NGF nerve growth factor
LDL low-den~ity lipoprotein nGRE negative glucocorticoid response element
LDLC low-den~ity lipoprotein cholesterol NIOOM non-in!>ulin-dependent diabetes mellitus
LGC ligand-gated cation channel [now known as type 2 diabetes]
LH luteinising hormone NIS Natr symporter
LMWH low-molecular-weight heparin NK natural killer
L-NAME 1VC.-nitro-L-arginine methyl ester NM normetanephri ne
LNMMA N''-monomethyi-L-arginine NMDA N-mcthyl-D-aspartic acid
LQT long QT [channel, syndrome] nNOS neuronal nitric oxide synthase [NOS-I] xi
 ABBREVIATIONS AND ACRONYMS

NNT number needed to treat PPA OS pyridoxal-phospbate-6-azophenyl-2',

NO nitric oxide 4' -disulfonate
NOS nitric oxide synthase PPAR peroxisome proliferator-activated receptor
NPR natriuretic peptide receptor PR progesterone receptor: prolactin receptor
NPY neuropeptide Y PRF prolactin-releasing factor
NRM nucleus raphe magnus PRIF prolactin release-inhibiting factor
NRPG nucleus reticularis paragigantocellularis Pro-CCK procholecysLOkinin
NSAIO non-~teroidal anti-inflammatory drug pS picosiemens
OOQ I H-[ I,2.4 j-oxadiazole-[4,3-aj-quinoxalin- PT prothrombin time
l-one PTH parathyroid hormone
OPG osteoprotegerin PTZ pentylenetetrazol
oxLOL oxidised low-density lipoprotein PUFA polyunsaturated fatty acid
PA partial agonist: phosphatidic acid PUVA psoralen plus ultraviolet A
PABA p-aminobenwic acid QALY quality-adjusted life year
PAco2 partial pressure of carbon dioxide in arterial R&D research and development
blood RA rheumatoid arthritis
PAF platelet-activating factor RAMP receptor activity-modifying protein
PAG periaqueductal grey RANK receptor .activator of nuclear factor kappa B
PAH p-aminohippuric acid RANKL RANK ligand
PA l plasminogen activator inhibitor RANTES regulated on .activation normal I-cell ~xpressed
PAMP pathogen-associated molecular pattern and liecreted
PAOz partial pressure of oxygen in arterial blood RAR retinoic acid receptor
PAR protease-activated receptor Rb retinoblastoma
PARP poly-LADP-ribose]-polymerase REM rapid eye movement [sleep]
PC phosphorylcholine RGS regulator of G-protein signalling
PCPA p-chlorophenylalanine RIMA reversible inhibitor of the A-isoform of
PO Parkinson s disease monoamine oxidase
POE phosphodiesterase RNA ribonucleic acid
PDGF platelet-dependent growth factor RNAi ribonucleic acid interference
PDS pendrin; paroxysmal depolarising shift ROS reactive oxygen species
PE pho~phatidylethanolamine rRNA ribosomal ribonucleic acid
PECAM platelet endothelium cell adhesion RT I reverse transcriptase inhibitor
molecule RTK receptor tyrosine kinase
PEFR peak expiratory flow rate RXR retinoid X receptor
PEG polyethylene glycol RyR ryanodine receptor
PG pmstaglandin SA sinoatrial
PGE prostaglandin E SA H subarachnoid haemorrhage
PGI 2 prostacyclin rprostaglandin 12] SCF stem cell factor
PI phosphatidylinositol SCIO severe combined immunodeficiency
PIN protein inhibitor of nNOS SERCA sarcoplasmic/endoplasmic reticulum APTase
PIP2 phosphatidylinositol bisphosphate SERM selective (o) estrogen receptor modulator
PKA protein kinase A SERT serotonin transporter
PKC protein kinase C SG substantia gelatinosa
PKK cGMP-dependent protein kinase SH sulfhydryl [e.g. -SH group]
PL phospholipid siRNA small [short) interfering ribonucleic acid
PLA 2 phospholipase A 2 (see also sRNAi below)
PLC phospholipase C SLE systemic lupus erythematosus
PLC~ phospholipase c~ SNA P S-nitrosoacetylpenicillamine
PLO phospholipase D SNOG S-nitrosoglutathione
Plk Polo-like kinase SNRI serotonin/noradrenaline reuptake inhibitor
PLTP phospholipid transfer protein soc store-operated calcium channel
PMCA plasma membrane Ca2+-ATPase SOD superoxide dismutase
PMN polymodal nociceptor SP substance P
PNMT phenylethanolamine N-metbyl transferase SR sarcoplasmic reticulum
PNS peripheral nervous system sRNAi small ribonucleic acid interference
Po2 partial pressure of oxygen (see also siRNA above)
xii POMC prepro-opiomelanocortin SRS-A slow-reacting substance of anaphylaxis
 ABBREV I ATIONS AND ACRONYM S

SSRI selective serotonin reuptake inhibitor TRP transie nt receptor pote ntial [channel]
STX ~axitoxin TRPVJ tran ~ient receptor potential vanilloid
SLR sulfonylurea receptor receptor I
SVT ~upraventricu lar tachycardia T SH thyroid-stimulating hormone
SXR xenobiotic receptor ITX tel rodotox in
Tl triiodothyronine TX thromboxane
T4 thyroxine T XA 2 thromboxane A 2
TBG thyroxine-binding globulin TXSI TXA 2 synthesis inhibitor
TC tubocurarine UCP uncoupling protein
TCA tricyclic antidepressant UDP uridine diphosphate
TEA tetraeth yIammonium UDPGA uridine diphosphate g lucuronic acid
TF transcription factor UMP uridine monophosphate
TGF transforming growth factor vCJD variant CreutLfeldt-Jakob disease
Th T-helper [cell] Vd volume of diwibution
THC 6.9 -tetrahydrocannabinol VDCC voltage-dependent calcium channel
Thp T-helper precursor [cell] VDR vitamin D receptor
TIMI Thrombolysis in Myocardial Infarction [trial] VEGt< vascular e ndothelial growth factor
TIMJ>s tissue inhibitors of metalloproteinases VGCC voltage-gated calc ium channel
TLR Toll receptor VHeFT Vasodilator Heart Failure Trial
TNF tumour necrosis factor VTP vasoactive intestinal peptide
TNFR tumour necrosis factor receptor VLA very late antigen
tPA tissue pla~minogen activator VLDL very low-density lipoprotein
TR thyroid receptor VMA vanillylmandelic acid
TRAIL tumour occrosi!> factor-a- related f!poptosis- VMAT vc!.icular monoamine transporter
inducing ligand voce voltage-operated calcium channel
TRH thyrotrophin-relea!>ing hormone WHO World Health Organization
IR~A transfer ribonucleic acid WOSCOPS West of Scotland Coronary Prevention Study
GENERAL PRINCIPLES

What IS pharmacology?
Overview 3 parlance. the word drug is often associated with addictive,
What is drug? 3 mucotic or mind-altering substances-an unfortunate negative
Origins and antecedents 3 c hemical therapy. In this book, we focus mainly on drugs used
Pharmacoiogy in the 20th and
21 st centuries .4
-Alternative therapeutic principles 4
-The emergence of biotechnology 5
-Pharmacology today 6
OVERVIEW
In this introductory chapter, we explain how
pharmacology came into being and evolved as a
scientific discipline, and describe the present day
structure of the subject and its links to other
biomedical sciences. The structure that has
emerged forms the basis of the organisation of the
rest of the book. Readers in a hurry to get to the
hereand-now of pharmacology can safely skip
this chapter.
WHAT IS A DRUG?
For the purposes of this book. a dng can be defined a~ a
chl'lnical substance of knOII'Il structure, other than a nurriem or
an e.l.lelllial dietary ingrediefll. which, when administered to a
/iling organism. produces a biological effect.
A rcw points are worth noting. Drugs may be synthetic
chemicals. chemicals obtained from plants or animals, or
products of genetic engineering. A medicine is a chemical
preparation. which usually but not necessarily contains one or
more drugs. administered with the intention of producing a
th~rapculic effect. Medicines usually contain other substances
(C\Clpients. stabilisers. solvents, etc.) besides the active drug, to
make them more convenient to use. To count as a drug, the
substance must be administered a .. such, rather than released by
physiological mechanisms. Many subMances. such as insulin or
thyroxine, are endogenous hormones but are also drugs when
they are administered intentional ly. Many drugs arc not used in
medicines but are neverthclcs~ useful research tools. ln everyday
connotation that tends to bias opinion against any form of
for therapeutic purposes but also describe important examples of
drugs used as experimental tools. Although poisons fall strictly
within the definition of drugs, they arc not covered in this book.
ORIGINS AND ANTECEDENTS
Pharmacology can be defined a~ the study of the effects of drugs
on the function of living systems. As a science, it was born in the
mid-19th century, one of a host of new biomedical sciences based
on principles of experimentation rather than dogma that came
into being in that remarkable period. Long before that- indeed
from the dawn of civilisation-herbal remedies were widely
used, pharmacopoeias were written, and the apothecaries' trade
flourished, but nothing re!>Cmbling scientific principles wa~ applied
to therapeutics. Even Robert Boyle. who laid the scientific
foundations of chemistry in the middle of the 17th century, was
content. when dealing with therapeutics (A Collection of Choice
Remedies, 1692), to recomme nd concoctions of worms. dung,
urine, and the moss from a dead man's skull. The impetus for
pham1acology came from the need to improve the outcome of
therapeutic intervention by doctors, who were at that time skilled
at clinical observation and diagnosis but broadly ineffectual when
it came to treatment. ' Un til the late 19th century, knowledge of
the normal and abnonnal functioning of the body was too
rudimentary to provide even a rough basis for understanding drug
effects; at the same time, disease and death were regarded a~
~>emisacrcd subjects, appropriately dealt with by authoritarian,
rather than scientific, doctrines. Clinical practice often displayed
an obedience to amhority and ignored what appear to be easily
ascertainable facts. For example, cinchona bark was recognised
as a specific and effective treatment for malaria, and a sound
protocol for its use was laid down by Lind in 1765. In 1804,
however. Johnson declared it to be unsafe until the fever had
101iver Wendell Holmes, an eminent phy~ician, wrote in 1860: ... firmly
believe thai if the whole materia medica, a~ now used. could be unk 10 the
bottom of the sea, il would be atlthc better for mankind and the worse for
the fhhes.' (see Porter, t997). 3
 SECTION 1 GENERAL PRINCIPLES
sub~ided, and he recommended instead the use of Large doses of
calomel (mercurous ch loride) in the early stages-a murderous
piece of advice, which was slavishly followed for the next 40 years.
The motivation for understanding what drugs can and cannot
do came from clinical practice, but the science could be built
only on the basis of secure foundations in physiology, pathology
and chemistry. 1t was not until 1858 that Virchow proposed the
cell theory. The first u~e of a structural formula to describe a
chemical compound was in 1868. Bacteria as a cause of disease
were discovered by Pasteur in 1878. Previously, pharmacology
hardly had the legs to stand on, and we may wonder at the bold
vision of Rudolf Buchheim. who created the first pharmacology
institute (in his own house) in Estonia in 1847.
In its beginnings, before the advent of synthetic organic
chemistry, pharmacology concerned itself exclusively with
understanding the effects of natural substances, mainly plant
extracts-and a few (mainly toxic) chemicals such as mercury
and arsenic. An early development in chemistry was the purification
of active compounds from plants. Friedrich Sertilmer, a young
German apothecary, purified morphine from opium in 1805. Other
sub:.tances quickly followed, and, even though their structures
were unknown, these compounds showed that chemicals. not
magic or vital forces, were responsible for the effects that plant
extracts produced on living organisms. Early pharmacologists
focused most of their attention on such plant-derived drugs as
quinine, digitalis. atropine, ephedri ne, strychnine and others
(many of which arc still used today and will have become old
friends by the time you have finished reading this bool.). 2
PHARMACOLOGY IN THE 20TH AND
21ST CENTURIES
Beginning in the 20th century, the fresh wind of &ynthetic chemistry
began to revolutionise the pharmaceutical industry. and with it
the science of pharmacology. New synthetic drugs, such as
barbiturates and local anaesthetics, began to appear, and the era
of antimicrobial chemotherapy began with the discovery by Paul
Ehrlich in 1909 of arsenical compounds for treating syphilis.
Further breakthroughs came when the sulfo nam.idcs, the first
antibacterial drugs. were discovered by Gerhard Domagk in 1935,
and with the development of penicillin by Chain and Florey during
the Second World War, based on the earlier work of Fleming.
'A handful of ynlhetic subMances achieved pharmacological prominence
long before the era of synthetic chemistry began. Diethyl ether, firt
prepared a.~ 'sweet oil of vitriol' in the 16th century. and nitrom. oxide.
prepared by Humphre) Davy in 1799, 'Were used to liven up panics before
being introduced as anaesthetic agents in the mid-19th century (sec Ch. 36).
Amyl nitrite (see Ch. 18) was made in 1859 and can ci(Jim to be the first
r.uional therapeutic drug; iL\ therapeutic effect in angina was predicted on
the basis of its physiological effects-a true 'phannacologist's drug' and the
smelly forerunner of the nitrovasodilators that are widely u5ed today.
A~pirin (Ch. 14), the most widely used therapeutic drug in history, was first
\ynlhesised in 1853, with no therapeutic application in mind. It was
redto;covered in 1897 in the laboratorie\ of the Gennan company Bayer,
who were seel..ing a less toxic derivative of salicylic acid. Bayer
4 commercialised aspirin in 1899 and made a fortune.
These few well-known examples ~how how the growth of
synthetic chemistry, and the resurgence of natural product
chemistry, caused a dran1atic revitalisation of therapeutics in the
first half of the 20th century. Each new drug cl~~ that emerged
gave pharmacologbts a new challenge, and it was then that
pharmacology really established its identity and its status among
the biomedical sciences.
ln parallel with the exuberant proliferation of therapeutic
molecules--driven mainly by chemistry-which gave pharma-
cologists so much to think about, physiology was also making
rapid progress, panicularly in relation to chemical mediato~.
which are discu!.sed in depth elsewhere in this book. Many
hormo nes, neurotransmitters and intlammatory mediators were
disco\'ered in thic, period, and the realisation that chemical
communication plays a central role in almost e\'ery regulatory
mechanism that our bodies po~sess immediately eMablished a
large area of common ground between physiology and
pharmacology, for interactions between chemical sub~tances and
living syMems were exactly what pharmacologists had been
preoccupied with from the outset. The concept of 'receptors' for
chemical mediators, first proposed by Langley in 1905, was
quickly taken up by pharmacologists such as Clark, Gaddum,
Schild and others and is a constant theme in present day
pharmacology (as you will !>OOn discover as you plough through
the next two chapters). The receptor concept. and the
technologies developed from it, have had a massive impact on
drug discovery and therapeutics. Biochemistry also emerged as a
distinct science early in the 20th century. and the discovery of
enzymes and the delineation of biochemical pathways provided
yet another framework for understanding drug effects. The picture
of pharmacology that emerges from this brief glance at history
(Fig. 1.1) is of a subject evolved from ancient prescientific
therapeutics, involved in commerce from the 17th century onwards,
and which gained respectability by donning the trappings of
science as soon as this became possible in the mid-19th century.
Signs of its carpetbagger past ~till cling to phannacology, for the
pharmaceutical industry has become very big business and much
pharmacological research nowadays takes place in a commercial
environment, a rougher and more pragmatic place than the glades
of acadcmia. 3 No other biomedical 'ology' is so close to Mammon.
ALTERNATIVE THERAPEUTIC PRINCIPLES
Modern medicine relies heavily on drugs as the main tool
of therapeutics. Other therapeutic procedures such as surgery.
diet. exercise, etc. are also important, of course, Ul> i~ deliberate
'Some of our most ditinguished pharmacological pioneers made their
career;. in industry: for example, Henry Dale, who laid the foundations of
our knowledge of chem1cal rransmt~\ton and the autonomic nervous
system; George Hitchings and Gertrude Elion, who described the
antimet.abolite principle and produced the first effective anticancer drugs;
and James Black, who introduced the first ~-adrenoceptor and histamine
H2-receptor antagonists. It is no acctdent that tn this book, where we focu'
on the scientific principles of phannacology. most of our examples are
products of industry, not of nature.

Approximate dates
>3000 BC
-1600 AD
-1800 Chemistry
Natural
products
~ Pathology
. 1
Ch em1ca
strurre
- 1900
~~*
chemistry---------.
-1970
2000 Pharmacology
Fig. 1.1 The development of pharmacology.
non-intervention, but none is so widely applied as drug-
based therapcu tics.
Before the advent of science-based approaches, repeated attempts
were made to construct systems of therapeutics. many of which
produced even worse results than pure empiricism. One of these
was allopathy, espoused by James Gregory (1735-1821). The
favoured remedies included blood letting, emetics and purgatives,
which were used until the dominant symptoms of the disease
were suppressed. Many patients died from such treatment, and it
was in reaction against it that Hahnemann introduced the practice
of homreopathy in the early 19th century. The guiding principles
of homreopathy are:
like cures like THE EMERGENCE OF BIOTECHNOLOGY
activity can be enhanced by dilution.
The system rapidly drifted into absurdity: for example, Hahnemann
recommended the use of drugs at dilutions of I: l 0 60, equivalent
to one molecule in a sphere the size of the orbit of Neptune.
Many other systems of therapeutics have come and gone, and
the variety of dogmatic principles that they embodied have tended
to hinder rather than advance scientific progress. Currently,
therapeutic systems that have a basis which lies outside the domain
of science are actuaUy gaining ground under the general banner
of 'alternative' or 'complementary' medicine. Mostly, they reject
the 'medical model', which attributes disease to an underlying
derangement of normal function that can be defined in bio-
WHAT IS PHARMACOLOGY?
Therapeutics
Magical potions
Herbal remedies
Commerce
Apothecaries
Biomedical
sciences
Pharmaceu1ical
Pharmacoogy Phys1
.01ogy industry
//
~ . .
..------- B1ochem1stry
1
Synthetic
drugs
Molecular
~ biology ---.
+-- - - - - - Biopharmaceuticals
chemical or structural terms, detected by objective means, and
influenced beneficially by appropriate chemical or physical
interventions. They focus instead mainly on subjective malaise,
which may be disease-associated or not. Abandoning objectivity
in defining and measuring disease goes along with a similar
deparrure from scientific principles in assessing therapeutic efficacy
and risk, with the result that principles and practices can gain
acceptance without satisfying any of the criteria of validity that
would convince a critical scientist, and that are required by law
to be satisfied before a new drug can be introduced into therapy.
Public acceptance, alas, has little to do with demonstrable efficacy.
Since the 1980s, biotechnology has emerged as a major source of
new therapeutic agents in the form of antibodies, enzymes and
various regulatory proteins, including hormones, growth factors
and cytokines (see Buckel, 1996; Walsh, 2003). Although such
products (known as biopharmaceuticals) are generally produced
by genetic engineering rather than by synthetic chemistry, the
pharmacological principles are essentially the same as for
conventional drugs. Looking further ahead, gene- and cell-based
therapies (Ch. 55), although still in their infancy, will take thera-
peutics into a new domain. The principles governing the design,
delivery and control of functioning artificial genes introduced
into cells, or of engineered cells introduced into the body, are s
 SECTION 1 GENERAL PRINCIPLES

very different from those of drug-based therapeutics and will
require a different conceptual framework, which texts such as
this will increa!>ingly need to embrace if they are to stay abreast
of modem medical treatment.
PHARMACOLOGY TODAY
A with other biomedical disciplines, the boundaries of pharma-
cology are not sharply defined, nor are they constant. Its exponents
are, a~ befits pragmatists, ever ready to poach on the territory and
techniques of other disciplines. If it ever had a concepntal and
technical core that it could really call its own, this has now
dwindled almost to the point of extinction, and the subject is
defined by its purpose-to understand what drugs do to living
organisms, and more particularly how their effects can be applied
to therapeutics-rather than by its scientific coherence.
Figure 1.2 shows the structure of pharmacology as it appears
today. Within the main subject fall a number of compartments
(neuropharmacology, immunopharmacology, pharmacokinetics,
etc.), which arc convenient, if not watertight, subdivisions. These
topics fom1 the main subject matter of this book. Around the
edges arc ~everal interface disciplines, not covered in this book,
which form imponant two-way bridges between pharmacology
and other fields of biomedicine. Pharmacology tends to have
more of these than other disciplines. Recent arrivals on the fringe
are subjects such a~ pharmacogenomics, pharmacoepidemiology
and pharmacoeconomics.
Bioleclmology. Originally. this was the production of drugs
or other useful products by biological means (e.g. antibiotic
production from microorganisms or production of monoclonal
antibodies). Currently in the biomedical sphere, biotechnology
refers mainly to the usc of recombinant DNA technology for
a wide variety of purposes. including the manufacture of
therapeutic proteins, diagnostics, genotyping, production of
transgenic animals, etc. The many non-medical applicatiOn!.
include agriculture, forensics, environmental sciences, etc.
Pharmacogenetics. This is the tudy of genetic influences on
re~ponses to drug~. Originally, pharmacogenetics focused on
familia l idiosyncratic drug reactions, where affected individuals
show an abnormal-usually adverse--response to a class of drug
(sec Nebert & Weber, 1990). It now covers broader variations in
drug response, where the genetic basis is more complex.
Pharmacogenomics. This recent term overlaps with pharma-
cogenetics, describing the use of genetic information to guide the
choice of drug therapy on an individual basis. The underlying
principle i!> that differences between individuals in their rcspon\C
to therapeutic drugs can be predicted from their genetic make-up.
Examples that confirm lhi~ are steadily accumulating (see Ch. 51). n
So far, they mainly involve genetic polymorphism of drug-
metabolising enqmes or receptors (see Weinshilboum & Wang, D

f)

PSYCHOLOGY CLINICAL MEDICINE VETERINARY PHARMACY BIOTECHNOLOGY PATHOLOGY CHEMISTRY

THERAPEUTICS MEDICINE

Psycho- Clinical Veterinary Pharmaceutical Medicinal

Biopharmaceuticals Toxicology
pharmacology pharmacology pharmacology sciences chemistry

Pharmacokinetics/ Biochemical
drug metabolism pharmacology

Pharmacology
Molecular
Chemotherapy
pharmacology

Systems pharmacology

Neuro- Cardiovascular Gastrointestinal

pharmacology pharmacology pharmacology
lmmuno- Respiratory
pharmacology pharmacology

Pharmacogenetics Pharmacogenomics Pharmacoep1dem1ology Pharmacoeconomics

GENETICS GENOMICS CLINICAL EPIDEMIOLOGY HEALTH ECONOMICS

Fig. 1.2 Pharmacology today with its various subdivisions. Interface disciplines (brown boxes) link pharmacology to other
mainstream biomedical disciplines (green boxes).
6
 WHAT IS PHARMACOLOGY?

2004). Ultimately, linking specific gene variations with variations
in therapeutic or unwanted effects of a particular drug should
enable the tailoring of therapeutic c hoices on the basis of an
individual's genotype. The consequences for therapeutics will be
far-reaching.4
Plwrmacoepidemiology. This is the study of drug effects at
the population level (see Strom, 1994). Tt is concerned with the
'ariab1lity of drug effects between individuals in a population.
and between populations. lt is an increasingly important topic in
the eye~ of the regulatory authorities who decide whether or not
~An interesting recent example conccms a newly introduced anticancer
drug. gcfitinib. which i~ highly effective in treating lung cancer but work~
in only about I 0% of ca~c,. Re;ponders have mutations in the receptor
tym,ine kinu~e ('ec C h. 3) that i& the tnrget of this drug, and can be
identified in adva nce hy genotyping (see Ly nch ct al., 2004).
new drugs can be licensed for therapeutic use. Variability between
individuals o r populations has an adverse effect on the utility of
a drug, even though its mean effect level may be satisfactory.
Pharmacoepidemiological studies also take into account patient
compliance and other factors that apply when the drug is used
under real-life conditions.
Pharmacoeconomics. This branch of health economics aims
to quantify in economic terms the cost and benefit of drugs used
therapeutically. It arose from the concern of many governments
to provide for healthcare from tax revenues, raising questions of
what therapeutic procedures represent the best value for money.
This, of course, rahcs fierce controversy, because it ultimately
comes down to putting monetary value on health and longevity.
As with pharmacocpidemiology, regulatory authorities are increas-
ingly requiring economic analysis, as well as evidence of indi-
vidual be nefit, when making decis ions o n licensing. For more
information on this complex subject, see Dnunmond et al. ( 1997).

REFERENCES AND FURTHER READING

Bu.:Lrl P 1996 Recomhtnnnt protein' for lherapy. Trends
Ph.umacol 'kt 17 450-456 (T/umghtful "'ie..- of tile
Jl<llu\ tif. anJ pm.pt'cO for. protem-/xzsed thPropeuucs)
Om\, J 19981n quc't of tomorrow, llk."Cilcine>.
SJ'finger \'erlag. ;\ew Yod (An ~xull~nt acco11111 of the
ptnt. prr<tnt and futlm t>/ the drug diJcoe f) proass,
~mrllauung th~ groo.m~: role of biOtechnology)
Druounond \1 F. o Bncn B. 'itoddatt G I.
T1>rr.m.:c G W 1997 Method\ for the economic
tahuuon of hcahhcan: programme,. Oxford
Unl\er.tt) Pre" Oxford (Ctwtru~e of the geMral
pnnriplfl of t'WIIuming the economic costs and
b.nt[m of lt~ctlthtt~re. mclmlmg drug-based
thrraprutt.J
E>an' W E, Reiling M V 1999 Phannacogcnomics:
tmn,Jaetng funcuonnt genomic> into rational
therapeutics. Science :!86: ~87 SO I (A xmmli
oveni""' ofphamwcogmomics)
L)'nch T J, Bell 0 W, Sordella R et al. 2()().1 Acmaung
mutations m the ep1dennal gnl"1h factor receptor
underlying n:~porhi\ ene,s of non-o;mall-cell lung
cancer 10 gefitinib. N Engl J Med 350: 2129 21 W
(An imponam early exampl~ of a ~:mnic dnennm;mt
of theropemic l'ffictiC)' de(H!ndmg 011 mwmions ajJeOIII/1
the drug target-a huh pomter to o.hmn Ill mme)
Neben 0 W, Weber W W 1990 Pharmacogeneuc~. In
Prau W B. Taylor P (eds) Principles of drug actron.
3rd edn. Churchiii-Livingstone, New Yor~ (II tltllliltd
account ofgenetic factors thor affect rt'f{I(NIUI to tlmgr,
'ith ma11y examples from the P"!!""omic lllerlllurt')
Poner R t 997 The greatc't benefit to manl..ind. llarpcr-
Collins. London (A11 exullent a11d readohle account tif
thl' htrtnf) nf medicine, with good covero~:e of the
earl) de~elopmmt ofpharmacology and the
pharmacemical industf)')
Strom B L (ed) 2000 Phatmacoepidemiology. 3rd edn.
Wtley. Chichester (A multiamhar book coe ring all
IJJ(H!CIS of a n<'l<i)' emerged discipline, mcludm~
IJJ(H!OS ofpharmarot!cnnomic~)
Wahh G 2003 Btopbannaceuticals: biocbemt~Uy and
biotechnology. ChJcbe;tcr. Wiley (Gl)(){l mtroducton
uxtbooJ.. rnvering manJ OS(H!CIS of biotechflology
based therapeutics)
Wein;hllboum R. Wang L 2()().1 Phannacogenomics:
bench to bed>1de. Nat Rev Drug Discov 3: 739-748
(Discusses, with exam{Jies. tlte gro'ing imponance of
the corre/aJit111 between genetic make-up tmd Jl'Sptm<t'
10 therapeutic tlrugs)

7
 HoY~ drugs act:
general principles
Overview 8 of ac tio n of some drugs put them somehow out of reach of
The binding of drug molecules to cells 8 che mistry and phys ics and required the intervention of magical
-Protein targets for drug binding 9
-Drug receptors 9 ordinarily low doses a nd concentrations, low concentrations s till
-Drug specificity 10
-Receptor classification 10
-Drug-receptor interactions 10
-Partial agonists and the concept of efficacy 12
Drug antagonism 15
Desensitisation and tochyphylaxis 18
Quantitotive aspects of drug-receptor
interactions 20
The nature of drug effects 22
OVERVIEW
The emergence of pharmacology as a science came
when the emphasis shifted from describing what
drugs do to explaining how they work. In this
chapter, w e set out some general principles
underlying the interaction of drugs with living
systems (Ch. 3 goes into the molecular aspects in
more detail). The interaction between drugs and
cells is described, followed by a more detailed
examination of different types of drug-receptor
interaction. We are still far from the holy grail of
being able to predict the pharmacological effects of
a novel chemical substance, or to design ab initio a
chemical to produce a specified therapeutic effect;
nevertheless, we can identify some important general
principles, which is our purpose in this chapter.
THE BINDING OF DRUG MOLECULES
TO CELLS
To begin with, we s hould g ratefully acknowledge Paul Ehrlich
for insisting that drug action must be explicable in terms of con-
8 ventional chemical inte rac tio ns between drugs and tissues, and
p~
for dispelling the idea that the remarkable potency and specificity
'vital fo rces'. Althoug h many drugs produce effec ts in extra-
invo lve very large numbe rs of molecules. One drop of a solution
of a drug at only 1o - IOmol/! !>till contains about 10 10 drug molecules,
so there i1. no mystery in the fact that it may produce an obvious
pharmacological respo nse. Some bacterial toxins (e.g. diphtheria
toxin) act with !>uch precision that a s ing le molecule taken up by
a target cell is ~ufficient to kill it.
One of the basic tenets of pharmacology is that drug molecules
must exert \Orne chemical influence on one or more constituents
of cells in order to produce a phannacological response. In other
word!>, drug molecule!> must get so close to these constituelll cellular
molecules that the two interact chemically in s uch a way that the
function of the latter is altered. Of course, the molecules in the
organism vastly outnumber the drug molecules, and if the drug
molecules were merely distributed at random, the c hance of
interaction with any particular class of cellular molecule would
be negligible. Pharmacological effects, therefore, require, in general.
the no n-uniform distribution of the drug molecule within the
body or tissue, which is the same as saying that drug mo lecules
must be ' bound' to particular constituents of cells and tissues in
order to produce an effect. Ehrlich summed it up thus: 'Corpora non
agunf ni.~i jixara' (in this context, 'A drug will not work unless it
is bound'). 1
These critical binding s ites are often refe rred to as 'drug targets'
(an obvious allusion to Ehrlich's famous phrase 'magic bullets'
describing the potential of antimicrobial drugs). The mechanisms
by which the association of a drug molecule with its target leads
to a physiological re!.ponsc constitute the major thrust of pharma-
cological research. Most drug targets are protein molecules. Even
general anael>theticl> (l>ee Ch. 36), which were long thought to
produce their effects by an interaction with membrane lipid, now
appear to interact mainly with membrane proteins (see Franks &
Lieb, 1994 ). All rules need exceptions, and many antimicrobial
and anti tumour drug!> (Cbs 45 and 51), as well as mutagenic and
carcinogenic agent!> (Ch. 51), interact directly with DNA rather
'There arc. if one loolo..s hard enough. exceptions to Ehrlich's dictum-drugs REC
that act without being bound to any tissue constituent (e.g. osmotic
diuretic~. o~motic pu rgatives. antacids. and heavy meial chelming agents). Rccc:
Nonetheless, the principle remains true for the great majority. muni
 HOW DRUGS ACT: GENERAL PRINCIPLES

than protein: bio,pho~phonutes, used to treat osteoporosis (Ch. 31), activities of their cells and organs. Without them, we would be no
bind 10 calcium salts in the bone matrix, rendering it toxic to bcner than a bucketful of amoebae.
o-.teocla\1\, much like rat poison. Some fundamental properties of receptors are illustrated by
the action of ad renaline (epinephrine) on the heart. Adrenaline
firs1 binds to a receptor protein (the J3 adrenoceptor, see Ch. II)
PROTEIN TARGETS FOR DRUG BINDING that serves as a recognition site for adrenaline and other
catecholamines. When it binds to tbe receptor. a train of reactions
Four main kind~ of regulatory protein are commonly involved as
is initiated (see Ch. 3) leading to an increase in force and rate
primal) drug 1argets, namely:
of the heartbeat. Ln lhe absence of adrenaline, the receptor is
receptor~ functionally silent. This is true of most receptors for endogenous
cn1yme~ mediators (hormones, neurotransmitters, cytokines, etc.),
carrier molcculeo, (tran~porte rs) although there are now several examples (see Ch. 3) of receptors
~ity 1011 channels. that are 'conslitutively active'- lhat is, they exert a controlling
of influence even when no chemical mediator is present.
A few other types of protein arc known to function as drug
leal There is an important distinction between agonists, which
target\, and there cxbt many drugs witb sites of action that arc
tra- 'activate' the receptors, and amagonists, which may combine
not yet known. Furthermore, many drugs are known to bind (in
;till at the same site without causing activation, and block the effect
adt.li1ion to their primary targets) to plasma proteins (see Ch. 5),
ion of agonisls on that receptor. The distinction between agonists and
und to a variety of cel lular proteins, without producing any
!le~. antagonists only exists for receptors with this type of physiological
ob\ iou' phyo,iological effect. Nevertheless, the generalisation
K>US regulatory role; we cannot usefully speak of 'agonists' for the
that mo\t drugs act on one or other of the four types of protein
l!ria more general class of drug targets, such as the noradrenaline
li-.1~d ahO\e \Crve\ 3.\ a good \ tarting point.
by (norepinephrine) tranl>porter, the voltage-sensitive sodium channel
Funher discu%ion of the mechanisms by which such binding
or dihydrofolate reductase, or for entities such as lhe transferrin
lead, 10 cellular responses is given in Chapters 3-5.
ules receptor.
ents The characteri stics of pharmacological receptors, and the
ther DRUG RECEPTORS descriptors that are conventionally used for them, are described
in a review by eubig et al. (2003). The origins of the receptor
WHAT DO WE MEAN BY RECEPTORS?
concept and its pharmacological significance are discussed by
Y "' emphaw,cd in Chapter I. the concept of receptors is cenlml to Rang (2006).
pharmacolog). and the 1erm i> moM often used 10 describe lhe targe1
mnlecule' through which '>Oiuble physiological medi:11ors-hormones,
neurolran,mlllcf\, mnammatory media10rs. elc.-produce !heir effecl~.
uld F.\ample' 'uch n.' uco:tylchol ine recep1ors, cy1okine receptors, Meroid recep-
ral, lllf'. and gr~l~th hormone receptors abound in this book. and generally Targets for drug action
the the term fl!ttptor indicu1c~ a recogn ition molecule for a chemical medimor.
ulcs 'Receptor' i' 'omctime~ u~ed to denote any target molecule with which a A drug is a chemical applied to a
:s in dn1g molecule (i.e. u foreign compound rather than an endogenous physiological system that affects its function in a
mediator) ha~ to combine in order to elicit iiS specific effect. For example, specific way.
the volwgc-~ensi tive sodium channel i~ sometimes referred to as the
With few exceptions, d rugs act on target proteins,
'receptor' for locol anacsthetlcs (see Ch. 44). or the enzyme dihydrofolate
reduct;".; a' 1he 'receptor' for methotrexate (Ch.l 4). The term drug namely:
~ets' targtt" preferable in thi\ context. -receptors
lets' -enzymes
In the more gcncrul comcxl of cell biology, me tem1 receptor is used to
i\ffiS dc..cribe \ariou\ cell '>urfacc molecules (such as T-cell recep1ors, -carriers
eads 1ntegnn,. Toll reccptOI'\, etc.) involved in lhe immunological response 10 -ion channels.
rma- 1ore1gn protein., and 1he interaction of cells wilh each olhcr and wilh 1he The term recep tor is used in different ways. In
E,en t\lr.ICtllular matri,. The\C have many imponam roles in ceiJ growth and pharmacology, it describes protein molecules whose
mtgrJtion (-.o;c Ch.5l. and arc al\o emerging as drug uu-ge1;.. The~e
ht to functton is to recognise and respond to endogenous
reccp1or. diller from con,enuonal pharmacological recep1ors in thai they
now re'pvnd 10 protem' m1ached 10 cell ~urface:. or eJttracellular ~tructures. chemical signals. Other macromolecules with which
l~& rJther lhan to -oluble med.alof\. drugs interact to produce their effects are known as
pbial drug targets.
\".mou' c.micr pro1cin~ arc oltcn referred 10 as recep1ors, such as me /ow-
:and dtrull)' lif1<1prorem reaptor 1ha1 plays a key role in lipid membolism Specificity is reciprocal: individual classes of drug
ather tC'h.l9) and 1he rran'ifurill "c<'ptor mvolved in iron absorption (Ch.2 1). bind only to certain targets, and individual targets
n,~,e cnuuc, ha'e linlc in common "'ilh pharmacological recep1or~. recogn1se only certain classes of drug.
No drugs are completely specific in their actions. In
many cases, increasing the dose of a d rug will cause
RECEPTORS IN PHYSIOLOGICAL SYSTEMS
it to affect t argets other than t he principal one, and
Ill.). Receptors form a key part of the system of chemical com- this can lead to side effects.
municalion that all multicellular organisms use to coordinate the 9
 SECTION 1 GENERAL PRINCIPLES

DRUG SPECIFICITY
For a drug to be useful as either a therapeutic or a scientific tool,
it must act selectively on particular cells and tissues. In other words,
it must . how a high degree of binding site specificity. Conversely,
proteins that function as drug targets generally show a high
degree of ligand specificity; they will recognise only ligands of a
cenain prcci'ie type and ignore closely related molecules.
These principles of binding site and ligand specificity can be
clearly recognised in the actions of a mediator such as angiotensin
of major therapeuuc ~ignificance (Ch. 25). Two funber types of hiMamine rcc~
receptor (H , and H.) were recogni!.ed later. bintl
Receptor clru.>ification based on pharmacological re>pon~s continue, to the;
be a valuable and wtdely u-.ed approach. ewer experimental approaches
ha' e produced other criteria on which to base receptor clas.sificauon. The
direct mea,urcmcnt of ligand binding to receptors (see p.ll) ha> allowed
many new n."Ceptor ~ubtypes to be defined that could not easily be
distingui~hed by studie~ of drug effects. Molecular cloning (see Ch.3)
provtded a completely new basi' for classification at a much finer level of
detatl than can be reached through pharmacological analysio;. Finally.
analy~i' of the biochemical pathways that arc linked to receptor activation

(Ch. 19). This peptide acts strongly on vascular s mooth muscle,
and on the kidney tubule, but has very little effect on other kinds
of l>mooth muscle or on the intestinal e pithelium. Olher mediators
affect a quite different s pectrum of cells and tissues, the patte rn
in each case being determined by the specific pattern of expression
of the protein receptors for the various mediators. A small chemical
change, such as conve rsion of one of the amino acids in angiotensin
fro m L to o form, or removal of one amino acid from the chain,
can inactiva te the molecule altogether, because the receptor fails
to bind the altered fonn. The complementary specificity of ligands
and binding sites, which gives rise to the very exact molecular
recognition propenies of proteins. is central to explaining many
of the phenomena of phannacology. It is no exaggeration to say
that the ability of proteins to interact in a highly selective way
with o ther molecules-including other proteins-is lhe basis of
living machines. It\ relevance to the understanding of drug action
will be a recurring theme in this book.
Finally, it mu\1 be emphasised that no drug acts with complete
specificity. Thus tricyclic antidepressant drugs (Ch. 39) act by
blocking monoamine tramponers but are notorious for producing
side effects (e.g. dry mouth) related to their ability to block
various receptors. In gene ral , the lower the potency of a drug. and
the higher the dose needed, the more likely it is that sites of
action other than the primary one will assume significance. ln
clinical terms, this is ofte n associated with the appearance of
unwanted side effects, of which no drug is free.
S ince the 1970s, pharmacological research has succeeded in
identifying the protein targets of many different types of drug.
Drugs such as opiate analgesics (Ch. 41 ), cannabinoids (Ch. 15),
('>ee Ch.3) provide~ yet another basis for classification.
The rewlt of thh. data explo~ioo has been that receptor classification has
~uddeoly become very much more detai led, with a proliferation of receptor
subtype~ for all the main types o f ligand; more worryiogly. alternative
molecular and biochemical classifications began to spring up that wero::
incompat ible with the accepted pharmacologically defined receptor cla%e,.
Respond ing to this growing con fusion, the l11ternational Union of Pharma-
cologica l Sciences (IUPIIAR) convened expert working groups to produce
agreed receptor c la,sifications for the major types, taking into account the
pharmacological, molecular and biochemical information avai lable (see
http://www.iuphar.org). These wise people have a hard task; their con-
clu<,ions will be neither perfect nor final but are essential to ensure a
consi'>tCnt terminology. To the student, this may seem an arcane exercio;e oni~
in taxonomy, generating much detail but liulc illumination. There i' a rccc
danger that the tedious lisllt of drug names. actions and '>ide effects that
u~d to burden the ~ubJeCt will be replaced by exhausti\e tables of
receptors. lig:md'> :md tmn ..duction pathways. ln this book. we ha\"e tned
to avoid detatl for it\ own sake and include only such infom1ation on
receptor cla.\\tlication a.\ ~ems interesting in its own right or i\ helpful m
e\plaining the action\ of important drugs. A useful summar) of t..nown
receptor cla'>>es IS now publi\hed annually (Alexander et al.. 2006).
DRUG-RECEPTOR INTERACTIONS
Occupation of a receptor by a drug molecule may or may not
result in actil'ation of the receptor. By activation, we mean that
the receptor is affected by the bound molecule in suc h a way as
to elicit a tissue response. The molec ular mechanisms associated
,.
re
with recepto r activation arc discussed i11 Chapter 3. Binding and In
activation represent two dis tinct steps in the generation of the lig'
d

l
and benzodiaLcpine tranquillisers (Ch. 37), with actions that were nQ
Occupation Activation NC:
described in exhausti ve detail for many years. are now known to governed governed pr
target well-defined receptors, which have been fully characterised by by of
by gene-cloning techniques (<,ee Ch. 3). affinity efficacy ag

RECEPTOR CLASSIFICATION
Drug
A
(agonist)
+ R ----
141
k.,
ll
AR -:::: AR*
CL
RESPONSE
lig
n,
rea
B
T Where the acuon of a drug can be associated with a panicular ca
receptor. thi' provide\ a \aluablc means for classification and refinement
in drug de,ign. For C\amplc. pharmacological analys~ of the actions of Drug
hhtamine (\CC Ch. 13) showed that some of its effects (the H1 effects. B + BR NO RESPONSE
such a\ ~mooth mu-.cle contrnction) were strongly antagonised by the (antagon1st)
competitive hi\tamine antagoni\L\ then knoy. n. Black and his colleagues
<,ugge\ted 1n 1970 that the remaining actions of histamine, which included Fig. 2. 1 The distinction between drug binding and
its stimulant effect on ga~tric secretion. might represent a second class of receptor activation. The rate constants k ., k ., fl and CL,

l
hi\tamine receptor (112). Testing a number of hbtamine analogues, they
found that some were ~elective in producing H2 e ffects, with little H1
activity. By analysing which parts of the histam ine molecule conferred
this type of ~pecificity. they were able to develop selective antagonists.
10 which proved to be potent in blocking ga>tric acid secretion. a development
which apply to the binding and activation reactions,
respectively, are referred to in the text (pp. 15-20). Ligand A is
an agonist, because it leads to activation of the receptor (R),
whereas ligand B is an antagonist. )
 HOW DRUGS ACT: GENERAL PRINCIPLES

receptor-mediated response by an agonist (Fig. 2.1). If a drug
binds to the receptor without causing activation and thereby prevents
the agoni~t from binding, it is termed a receptor antagonist. The
tendency of a drug to bind to the receptors is governed by its
affinin. where~ the tendency for it, once bound, to activate the
receptor is denoted by its efficacy. These terms are defined more
preci~ly below (p. 12). Drugs of high potency will generally have
a high affinity for the receptors and thus occupy a significant
proportion of the receptors even at low concentrations. Agonists
will also possess high efficacy, whereas antagonists will, in the
simple~t ca~e. have zero efficacy. Drugs with intermediate levels
of efficacy, such that even when LOO% of the receptors are
occupied the tissue response is submaximal, are know n as parrial
agonists, to distinguish them from full agonists, the efficacy of
which is sufficient that they can elicit a maximal tissue response.
These concepts, even though we now see them as an oversimplified
description of events at the molecular level (see Ch. 3), provide a
useful basis for characterising drug effects.
We now discuss certain aspects in more detail, namely drug
binding, agonist concentration-effect curves, competitive antag-
onism, partial agonists and the nature of efficacy, and spare
receptors. Under!>tanding these concepts at a qualitative level is
sufficient for many purposes. but for more detailed analysis a
quantitative formulation is needed (see p. 20).
THE BINDING OF DRUGS TO RECEPTO RS
T The binding of drug~ to recepto~ can often be measured directly by
the use of drug molecule' labelled with one or more radioactive atoms
1
(u~ually H. 11C or m l). The main requirements are that the radioactive
ligand (which may be an agonist or antagonist) mu~t bind with high
affimty and specificity. and that it can be labelled to a sufficient specific
radioactivity to enable minute amounts of binding to be measured. The
usual procedure i~ to incubate samples of the tissue (or membrane
fragment\) with variou~ concentrations of radioactive drug until
equilibrium is reached. The tissue il, then removed, or the membrane
fragments separated by filtration or centrifugation. and dissolved in
scintillation nuid for mea~urement of its radioactive content.
ln such experiments, there is invariably a certai n amount of 'non-specific
binding' (i.e. drug taken up by wuctures other than receptors), wh ich
obscun.:s the speci fic componem and needs to be kept to a minimum. The
amount of non-specific binding is estimated by measuring the
radioactivity taken up in the presence of a saturating concentration of a
(non-radioactive) ligand that inhibils completely the binding of the
radioac1ive drug to the receptors, leaving behind the non-~pecific
component. This i~ then !>Ubtracted from the total binding to give an
e\timate of specific binding (Fig. 2.2). The binding cune (Fig. 2.28)

!A: :E
300 100
o;
c;
0
E
::::,
0 :.
E "'0
::::. c:
:::1
"'0
c:
:::1
.8
Fig. 2.2 Measurement of 0 ~
..c iij
receptor binding (p adrenoceptors iij 0
In cardiac cell membranes). The ;2 ~
Q)
ligand was r H]-cyanoplndolol, a a.
(/)
derivative of pindolol (see Ch. 11).
0
A] Measurements of total and
20 0 20
non-specific binding at equilibrium.
Non-specific binding Is measured in the Concentration (nmol/1)
presence of a saturating concentration
of a non-radioactive P-adrenoceptor
agonist, which prevents the radioactive
:9 [Q] Scatchard plot
ligand from binding to p adrenoceptors.
The difference between the two lines 100 150
represents specific bind1ng. o;
B Specific bind1ng plotted against E
::::, Bmax = 91 fmoVmg
concentration. The curve is a
0 c;
.E E
::::.
rectangular hyperbola (equation 2.5). "'0
c: .2:
.C. Specific binding plotted against :::1 Q)
0 Q)
concentration (log scale). The sigmoid ..c
curve is a logistic curve representing ~ ~c:
iij :::1
the logarithmic scaling of the 0
;o:; 0
(])
rectangular hyperbola plotted in '(3
Q)
panel B. a.
(/)
IQ1 Scatchard plot (equation 2.7,
0 0
p. 21). This gives a straight line from
0.001 100 0 100
which the binding parameters K and
, B.,., can be calculated. Concentration (nmol/1, log scale) Bound (fmol/mg)
11
 SECTION 1 GENERAL PRINCIPLES
defines 1he relation\hip between concentration and the amount of drug
bound (8). and in mo\t cases it ti~ well to the relationship predicted
theoretically (!,ce Fig. 2.12. below). allowing the affinity of lhe drug for
the receptor. to be estimated. a.'> well as the binding capacity (8...,.),
repre'>enting the dcn~ity of receptors in the tissue.
AU1orad1ograph) can abo be used to imestigate the distribution of
receplof\ in '>lnJCture~ ~uch a~ lhe brain. and direct labelling with ligand~
conlaining po~1tron-emiuing 1\otopes is now used to obtain image~ by
po..uron cmi~s1on tomography of receptor distribution in human'>. Thi'>
technique has been u<,ed, for e1.ample. to meal>ure lhe degree of dopamine
receptor blockade produced by antipsychotic drugs in the brains of
schi1ophrenic patient> (>ee Ch. 38). When combined wilh pharmacological
Mudic'>. binding meawrements have proved very valuable. It has, for
example. been confim1ed that the spare receptor hypolhesis (p. 15) for
muscarinic receptor in smooth muscle is correct: agonists are found to
bind. in general. with rather low affinity, and a maximal biological effect
occur at low receptor occupancy. It has also been shown, in skeletal
mu~clc and other !issues. that denervation leads lO an increase in lhe
number of recep1ors in the target cell. u finding that accounts. al least in
part, for lhe phenomenon of de nervation supersensirivity. More generally,
it appears thnt receptors lend to increase in number. usually over 1he
course of a few days. if the relevant hormone or transmitter is absent or
scarce. and to decrea~e in number if it is in excess. a process of adaptation
10 drug' or hormone' re .. ulting from continued administration (seep. 17).
Bindmg cunc~ with agoniSt\ are more difficult to interprcl !han those
wilh antagoni'>t\, becau<,e !hey often reveal an apparent heterogeneity
among receptor\. For example. agoni~l binding to muscarinic receptors
(Ch. 10) and abo to (3-adrenoceptors (Ch. ll) suggests at least t"o
population'> ofbmding site' wilh different affinities. This may be becauo,e
the receptOr\ can e~iSt either unattached or coupled wilhin the membrJne
to another macromolecule. the G-protein (see Ch. 3). which con.,ritules
part of the tran..ctuction syMem through "hich the receptor exens ils
regulatory effect. Antagoni\t binding does not show this comple:dty.
probably because antagonists. by their nature. do not lead to the
'>econdary event of Gprotein coupling. Agonist affinity bas proved to be
an clus1ve concept, a fact that has generated an algebraic paper-cha.~e in
1he pharmacolog1cullitcrature. with many enthusiastic followers.
Although binding can be measured directly, it is usually a bio-
logical response, such as a rise in blood pressure, contraction or
re laxation of a strip of smooth muscle in an organ bath, or the
activmion of an entyme, that we are interested in, and this is often
p lotted as a concemration-effect or dose-response curve, as in
Figure 2.3. Such curves allow us to estimate the maximal response
that the drug can produce (01.,). and the concentration or dose
needed to produce a 50% maximal response (EC 50 or ED50 ), par-
ameters that are u<,eful for comparing the potencies of different
drugs that produce qualitatively similar effects (see Ch. 4 ). Although
they look similar to the binding curves in Figure 2.2. concenlration
-effect curves cannot be used to measure the affinity of agonist
drug'> for their recepton.. because the physiological response prod-
uced i!t not. a-, a rule, directly proportional to occupancy. For an
integrated physiological response, such as a rise in arterial blood
pressure produced by adrenaline (epinephrine). many factors
interact. Adrenaline (see Ch. II) increases cardiac outpUl and
constricts some blood vessels while dilating others, and the change
in arterial pre!>sure it~clf evokes a reflex response that modifies
the primary response to the drug. The final effect will clearly not
be a direct measure of receptor occupancy in this instance, and
the same is true of most drug-induced effects.
In interpreting concentration-effect curves, it mus t be remem-
12 bered that the concenuution of the drug at the receptors may differ
from the known concentration in the organ bath. Agonists may be
subject to rapid enzymic degradation or uptake by cells as they
diffuse from the surface towards their site of action, and a steady
state can be reached in which the agonist concentration at the
receptor.-. is very much less than the concentration in the bath. In
the case of acetylcholine, for example. which is hydroly~ed by
cholinesterase present in most tissues (see Ch. 10), the con-
cenlration reaching the receptors can be less than I% of that in
the bath. and an even bigger difference has been found with
noradrenaline (norepinephrine). which is avidly taken up by
~ympathetic nerve terminals in many tissues (Ch. 11 ). Thus, even
if the concentration-effect curve, as in Figure 2.3, looks just like
a facsimile of the binding curve (Fig. 2.2C), it cannot be used
directly to determine the affinity of the agonist for the receptors.
PARTIAL AGONISTS AND THE CONCEPT
OF EFFICACY
So far, we have considered drugs either as agonists. which in some
way activate the receptor when they occupy it, or as antagonists,
which cause no activation. However, the ability of a drug molecule
to activate the receptor is actually a graded, rather than an aU-or-
nothing, property. lf a series of chemically related agonist drugs
acting on the same receptors is tested on a given biological
system. it is often found that the maximal response (the largest
re~pon c that can be produced by that drug in high concentration)
differ.-. from one drug to another. Some compounds (known as
full agonists) can produce a maximal response (the largest respon'>C
that the tissue is capable of giving). whereas others (panial agonists)
can produce only a submaximal response (Fig. 2.4). The difference
between full and partial agonists lies in the relationship between
receptor occupancy and response.
Figure 2.5 shows schematically the relationship between occu-
pancy and concentration for two drugs that have the same affinity
for receptors, producing 50% occupancy at a concentration of
100
~
E Acetylcholine
~ (frog rectus muscle)
3l 50
c:
~
Q)
a:
0
10-6
Concentration (moVI)
Fig. 2.3 Experimentally observed concentration-effec t
c urves. Although the lines, drawn according to the binding
equation 2.5, fit the points well, such curves do not give
correct estimates of the affinity of drugs for receptors. This is
because the relationship between receptor occupancy and
response is usually non-linear.
 HOW DRUGS ACT: GENERAL PRINCIPLES

occupancy is much smaller for the partial agonist. which cannot

100 produce a maximal response even at 100% occupancy. This can
be expressed quantitatively in terms of efficacy (e), a parameter
A=Me originally defined by Stephenson ( 1956) that describe. the strength
80 of the agonist-receptor complex in evoking a response of the tissue.
In the s imple scheme shown in Figure 2.1, efficacy describe~> the
x111 tendency of the drug-receptor complex to adopt the active (AR*),
E 60 rather than the reMing (AR) state. A drug with zero efficacy
::!!
e... (e = 0) has no tendency to cause receptor activation, and causes
G)
Ill
c
Et
no tissue response. A drug with maximal efficacy (e =
I) is a
8.
VI 40 full agonist. while partial agonists lie in between.
G)
a:
'f' Subsequently, it was appreciated that characteristic~ of the tissue {e.g.
the number of receptors that it posses~e~ and the nature of the coupling
20 between the receptor and the response: <,ee Ch.J), as well as of the drug
iPr
itSelf, were important, and the concept of inmmic efficac)' was developed
(~ee Jenkinson, 1996; Kcnakin, 1997). The rel ation~hip between

o~--. ;-_.--~_.--.-_.~.-_.~
10-6 10'5 10-4
Concentration (moVI)
Fig. 2.4 Partial agonists. Concentration-effect curves for
substituted methonium compounds on frog rectus abdominis
muscle. The compounds were members of the decamethonium
series (Ch. 7), RMe~N'(CH2l 10 WMe2 R. The maximum response
obtainable decreases (i.e. efficacy decreases) as the size of A
is lllcreased. With A = nPr or larger, the compounds cause no
response and are pure antagonists. (Results from Van Rossum
J M 1958 Pharmacodynamics of cholinometic and cholinolytic
drugs. St Catherine's Press, Bruges.)
occupancy and response can thus be represented:
In this equation.j(thc transducer function) and N.,. (the total number of
receptor~) are characteristic~ of the tissue: (the intrin'>ic efficacy) and
K;. (the equilibrium constant, ~ce p. 20) are characteri&uc~ of the agonist.
The importance of this formal representation is that it explain how
differences in the transducer function and the density of receptors in
different tissues can result in the \arne agoni,t, acting on the same recep-
tor, appearing as a full agonist in one tis;ue and Oil> a partial agonist in
another. By the same token, the relative potencies of two agonists may be
different in different tissue;. even though the receptor h the same.

For a more detailed discussion of drug-receptor imeracuons, sec Jenkmwn

1.0 ~-tmol/1. Drug a is a fu ll agonist, producing a maximal response
at about 0.2Jlmolll, the relationship between response and occu-
pancy being shown by the steep curve in B. Comparable plotS for
a partial agonist (b) arc shown as the shaJlow curves in A and B,
the essential difference being that the response at any given
(1996) and Kenakin (1997).
It would be nice to be able to explain what efficacy means in
physical terms, and to understand why one drug may be an agonist
while another, chemically very similar, is an antagonist. We are
beginning to understand the molecular events underlying receptor

@
1.0 100

Response
>.
(full agonist)
x<0 0
c
111
j
E Q.
::>
E
~ 0 ~
3lc 50 0.5 ~<0 3l 50
c c
~
G)
.Q
0
8.
Vl
G)
a: ~ a:
Part1al agonist

0 0
0.01 0.1 1.0 10.0 0 0.5 1.0
Concentration (~-tmoVI) Occupancy

Fig. 2.5 Theoret ical occupancy and response c urves for full and p artial agonists. rAJ The occupancy curve is for both drugs, the
response curves a and b are for full and partial agonist, respectively. !Dl The relationship between response and occupancy for full and
partial agonist, corresponding to the response curves in A. Note that curve a produces maximal response at about 20% occupancy,
while curve b produces only a submaximal response even at 100% occupancy. l3
 SECTION 1 GENERAL PRINCIPLES

activation (described in Ch. 3) but can still give no clear a nswer
to the question of why some ligands are agonist!. and some are
antagonists, although the simple theoretical two-state model
described below provides a useful !.tarting point.
Despite its uncertain theoretical status, efficacy is a concept
of great practical importance. Adrenali ne (epinephrine) and
propranolol have comparable affinities for the ~-adrenoceptor
but differ in efficacy. Woebetide the doctor- and the Mudent. for
that mauer-who confuses them. Efficacy matters!
CONSTITUTIVE RECEPTOR ACTIVATION AND
INVERSE AGONISTS
T Although we nre accustomed to lhmlung that receptors are activated
only when an agoni~t molecule i~ bound, there are examples (see De Ligt
et al .. 2000; Tcitler ct al., 2002) where an appreciable level of activation
may exist even when no ligand is pre\ent. These include receptors for
benzodiazepines (sec Ch. 37). ca nnabinoids (Ch. 15). serotonin (Ch. 12)
and several other mediators. Furthennore, receptor mutations occur-
either spontaneou\1), in some disea~ Mates or expenmentally created
(see Ch. 4}-that re\uh in appreciable activation in the ab\ence of any
ligand (constirutil't actil'arion). Resting activity may be too low to have
any effect under norma l conditions but become eviden t if receptors are
ovcrcxpressed, a phenomenon clearly demonstrated for P-adrcnoceptors
(~ee Bond et al .. 1995). a result that may prove to have major
The two-state receptor model
p:uhophysiologtcal tmplication~. Thus if, say, I <;f- of receptors are active
m lhe absence of any agonist, in a normal cell expre~~mg perhaps 10 000
receptors, only 100 will be acti\e. lncrea~ing !he expre~'ion level 10-fold
will result in 1000 active receptors, producing a significant effect. Under
the'e conditions, it may be possible for a ligand to reduce the level of
consti tutive activation; such dnags are known as illl'eru agonists (Fig.2.6;
see De Ligt et al., 2000) to distinguish lhem rrom simple competitive
antagoniM~. which do not by themselves affect the level of activation.
Inverse agoni\ts can be regarded as dntgs with negative efficacy. to
distinguish them from agoni\t\ (posithe efficacy) and competitive
antagonists (1-ero efficacy). New examples of constitutively active reccpto~
and inver~e agonists are emerging with increasing frequency (mainly
among G-protein-coupled receptors; sec Daefner & Landry, 2000; Seifert
& Wenzel-Seifert. 2002). Kenakin (2002) reported that over SO'l- of
G-protein receptor antagonists reponed in the literature are actually invcr.e
agonisu. when tested in systems 'howing constitutive receptor activauon.
However, most receptors-like cat<>-seem to have a ~Lrong preference
for the inactive ~tate, and for these there is no practical difference between
a competitive antagonist and an inverse agonist. It ha~ been suggested.
however. that inverse agoni~m at serotonin receptOr\ may be relevant for
antips)chouc drugs (see Ch. 38). but it remain~ to be seen whether lhc
in,erse agoni\t principle will prove to be generally important in therapeutiC\.
So far, nearly all the examples come from the family of G-protein-
coupled receptor~ (see Ch. 3, review by Costa & Cotecchia. 2005). anti it
is not clear whether similar phenomena occur with other receptor fami lies.
The two-Mate model described below explams nonnal and mve~
agonism in tenns of the relative affinuy of different ligands for the re'ting
and activated \tates of the receptor. Constitutive acuvation is a relatively
recent discovery. however, and may prove to be of greater phannacologic:tl
significance than is realised at presen t (see Milligan et :11.. 1995).
As illu~tratedin Figure 2.1. agonisL~ and antagonisL'> bolh bmd to
recepto~. but only agonisu. activate them. How can we expre~~ thi
difference in theoretical tenn~? The simplest ronnulation (see Fig. 2.1)
envisages that the occu pied receptor can switch from i" resting' (R) Mate

[B
"\
100 100
I
Antagonist in
presence of agonist
Agonist in presence
of antagonist 50

Constrtuttve level of
- - receptor activation
---- - ------ 1100
.!: .!:
Q) Q)
Ol Ol
c c
o:l
.s=
o:l
.s= Antagonist in presence
u u of inverse agonist
-504----------r---------.----------~ -50 -~~--------------------------------_J

10 10 10.v 1010

Ligand concentration (M) Antagonist concentration (M)

Fig. 2 .6 The interaction of a c ompetitive antagonist with normal and inverse agonists in a system that shows receptor
activation in the absence of any added ligands (constitutive activation). IAl The degree of receptor activation (vertical scale)
1ncreases in the presence of an agonist (open squares) and decreases In the presence of an inverse agonist (open circles). Addition of a
competitive antagonist shifts both curves to the right (closed symbols). 1m The antagonist on its own does not alter the level of
constitutive activity (open symbols), because it has equal affinity for the active and inactive states of the receptor. In the presence of an
agonist (closed squares) or an inverse agonist (closed circles), the antagonist restores the system towards the constitutive level of
act1v1ty. These data (reproduced with permission from Newman-Tancredi A et al. 1997 Br J Pharmacol120: 737-739) were obtained with
cloned human 5-hydroxytryptamine (5-HT) receptors expressed in a cell line. (Agonist, 5carboxamidotryptamine; inverse agonist,
\_spiperone; antagonist, WAY 100635; ligand concentration (M = mol/1); see Ch. 9 for information on 5-HT receptor pharmacology.) _)
14

to an ~CU\ated (R*l state, R being fawured by binding of an agoniJ.t but
not an antagonist molecule.
The tendency for the occupied receptor, AR, to conven to the activated
fonn, AR*. will depend on the equilibrium con~tant for this reaction, ~/a.
For u pure antagonist, ~a = 0, implying that there is no conven,ion to
the activated state, whereas for an agon i ~t. ~/a > 0 and will be different
for different drugs. Suppol>e thm for drug X. ~Ia is ~mall. ~o that only a
"mlll proponion of tbe occupied receptors will be activated even when
the receptor occupancy approache~ IOOo/r, whereas for drug Y, ~10. is large
nnd mo'>t of the occupied recepto~ will be activated. The conJ.tant ~/a i~.
therefore. a measure of efficacy (~e p. 12). A~ "'e now know. receptors
mal ,how constiruthe activation (i.e the R conformation can exiJ.t "'1thout
an; ligand being bound. ~o the added drug encounters an equilibrium
m1xture of Rand R* (Fig. 2.7). If it ha' a higher affinity for R than for
R, the drug will cause a shift of the equilibrium towards R (i.e. it will
promote activation and be cla~l>ed as an agonist). If its preference for R*
i' very large, nearly all the occupied receptors will adopt the R* confor-
mation and the drug will be a full ngoni~t (posi ti ve efficacy); if it shows
no preference, the prevailing R:R* equilibrium will not be disturbed and
the drug wil l be a competitive antagonist (zero efficacy), whereas if it
prefers R it will shift the equilibrium towards Rand be an inverse agoni!>t
!negative efficacy). We can therefore think of efficacy as a propcny
dct~rmtned b) the relathe affintly of a ligand for Rand R*. a formulation
Ln011 n a.~ the two-start' llypotltt'~i~. which is useful in that it put~ a
ph)'lcal interpretation on the othcrwi\e tn}'>terious meaning of efficacy.
A maJor problem with the two-Mate model is that, as we now know.
receptor<. are not actually restricted to r"'o distinct stares but have much
~rcater conformational nexibility. ~o that there is more than one inactive
and active conformation. The different conformations that they can adopt
may be preferentially stabili!.ed by different ligands, and may produce
different functional effects by activating different signal transducti on
p.lthways (see Cb. 3). Redefining efficacy for such a multistate model i'>
Inverse
Agonist
agonist
~>< ~
R R* RESPONSE
Aestmg \. / Activated
state
state "\
Antagonist
Fig. 2. 7 The two-state model. The receptor is shown in
two conformational states, 'resting' (R) and 'activated' W,
which exist in equilibrium. Normally, when no ligand is present,
the equilibrium lies far to the lett, and few receptors are found
In the R" state. For constitutively active receptors, an
appreciable proportion of receptors adopt the R conformation
1n the absence of any ligand. Agonists have higher affinity for
A' than for R, so shift the equilibrium towards A". The greater
the relative affinity for R' with respect to R, the greater the
efficacy of the agonist. An inverse agonist has higher affinity
for A than for A' and so shifts the equilibrium to the lett. A
'neutral' antagonist has equal affinity for R and A" so does not
by itself affect the conformational equilibrium but reduces by
competition the binding of other ligands. .
j tract may be reduced, or the rate of renal excretion may be
HOW DRUGS ACT: GENERAL PRINCIPLES
difficult, however. and will require a more complicated state transition
theory than that described here.
SPARE RECEPTORS
T Stephenson ( 1956), studying the actions of acetylcholine analogues in
isolated tissues. found that many fu ll agonists were capable of eliciting
maximal responses at very low occupancies. often less than ICff. This
means that the mechanism linking the response to receptor occupancy has
a ,ubMantiaJ reserve capacity. Such systems may be said to posse!>\ spare
receptors. or a receptor restrvt'. This IS common with drugs that elictt
,mooth muscle contracuon but les\ so for other types of receptor-
mediated response. such as <,eereuon, '>mooth muscle relaxation or card1ac
stimulation. where the effect IS more nearly proporuonal to receptor
occupancy. The exiMence of spare receptors does not in1ply any functtonal
subdivision of the receptor pool. but merely that the pool is larger than the
number needed to evoke a full re<,pom,e. This surplus of receptors over the
number actually needed might seem a wasteful biological arrangement. It
means, however, that a given number of agonist-receptor complexes.
corresponding to a given level of biological response, can be reached with
a lower concentration of hormone or neurotransmitter than wou ld be the
case if fewer receptors were provided. Economy of hormone or tmn'>miuer
..ecretion is thus achieved at the expense of providing more receptOfl>.
DRUG ANTAGONISM
Frequently. the effect of one drug is diminished or completely
abolished in the presence of another. One mechanism, competitive
antagonism, was discussed earlier; a more complete classification
includes the following mechanisms:
chemical antagm1ism
pharmacok.inetic antagoni11m
antagonism by receptor block
non-competitive antagonism. i.e. block of receptor-effector
linkage
physiological antagonism.
CHEMICAL ANTAGONISM
Chemical antagonism refer~ to the uncommon situation where
the two substances combine in solution; as a result, the effect of
the active drug is lost. Examples include the use of chelating
agents (e.g. dimercaprol) that bind to heavy metals and thus reduce
their toxicity. and the use of neutral ising antibodies against protein
mediators, such as cytokines and growth factors, a strategy recently
applied for therapeutic use (see Ch. 14).
PHARMACOKINETIC ANTAGONISM
Pharmaeokinetic antagonism describes the situation in which the
'antagonist' effectively reduces the concentration of the active
drug at its site of action. This can happen in various ways. The
rate of metabolic degradation of the active drug may be increased
(e.g. the reduction of the anticoagulant effect of warfarin
when an agent that accelerates it~ hepatic metaboli~m. such as
phenobarbital, is given; see Chs 8 and 52). Alternatively, the
rate of absorption of the active drug from the gastrointe tina!
increased. Interactions of I his sort can be important in the clinical
setting and are discussed in more detail in Chapter 52. 15
 SECTION 1 GENERAL PRINCIPLES

ANTAGONISM BY RECEPTOR BLOCK
Receptor block antagonism involves two important mechanisms:
reversible competitive antagonism
irreversible, or non-equilibrium, competitive antagonism.
Competitive antagonism
Competitive antagonism describes the common ~ituation
whereby a drug binds selectively to a particular type of receptor
without activating it, but in such a way as to prevent the binding
of the agonist. There is often ~ome similarity between the c hemical
structures of the agonist and antagonist molecules. The two drugs
compete with each other, because the receptor can bind only one
drug molecule at a time. At a given agonist concentration, the
agonist occupancy will be reduced in the presence of the antagonist.
However, because the two a re in competition, raising the ago nist
concentration can restore the agonist occupancy (and hence
the tissue response). The antagonism is therefore said to be
sunnountable, in contrJ~t to other types of antagoni!>m (see below)
where increas ing the agonist concentration fails to overcome the
blocking effect A simple theoretical analysis (see p. 21) predicts
that in the presence of a fixed concentration of the antagonist, the
log concentration-effect curve for the agonist wi ll be shifted to
the right. without any change in slope or maximum the hallmark
of competitive antagonism. The shift is expressed as a dose ratio
(the ratio by which the agonist concentration has to be increased
in the presence of the antagonist in order to restore a given level
of response). Theory predicts that the dose ratio increases linearly
with the concentration of the antagonist (see p. 21 ). These pre-
dictions are often bomc out in practice (see Fig. 2.8}, and examples
of competitive antagonism are very common in pharmacology.
The surmountabilit y of the block by the antagonist may be important

Agonlsts, antagonists and efficacy

Drugs acting on receptors may be agonists or
antagonists.
Agonists initiate changes in cell function, producing
effects of various types; antagonists bind to receptors
without initiating such changes.
Agonist potency depends on two parameters: affinity
(i.e. tendency to bind to receptors) and efficacy
(i.e. ability, once bound, to initiate changes that lead
to effects).
For antagonists, efficacy is zero.
Full agonists (which can produce maximal effects)
have high efficacy; partial agonists (which can
produce only submaximal effects) have
intermediate efficacy.
According to the two-state model, efficacy reflects the
relative affinity of the compound for the resting and
activated states of the receptor. Agonists show
selectivity for the activated state; antagonists show no
selectivity. This model, although helpful, fails to account
for the complexity of agonist action.
Inverse agonists show selectivity for the resting state of
the receptor, this being of significance only in unusual
situations where the receptors show constitutive activity.

A] liD
100 5

80 4
x
(!)
E ,...
~
K8 = 2.2 x 109 mol/1
~ 60 3
l!- I
.,
(I)
-=-
c: ~
.,8.
(I)
40 -J 2
a:
20

0 0 !---=f-~---.----.~-.-----1
1011 10 10 10'9 10-8 10'7 10"6 10-5 10"4 10"9 10-8 10"7 10-6
Isoprenaline concentration (moVI) Propranolol concentration (moVI)
Fig. 2.8 Competitive antagonism of isoprenaline by propranolol measured on isolated guinea pig atria. :Al Concentratio~ffect
curves at various propranolol concentrations (indicated on the curves). Note the progressive shift to the right without a change of
slope or maximum. B Schild plot (equation 2.10). The equilibrium constant (K) for propranolol is given by the abscissa! intercept
\. 2.2 x 1o-9 mol/1. (Results from Potter L T 1967 J Pharmacal 155: 91.)
16
'~--- --------------
 HOW DRUGS ACT: GENERAL PRINCIPLES

in practice, because it allows the functional effect of the agonist

Competitive nt.gonlsm
Reversible competitive antagonism is the
commonest and most important type of antagonism;
11 has two mam characteristics:
in the presence of the antagonist, the agonist log
concentration-effect curve is shifted to the right
w1thout change in slope or maximum, the extent
of the shift be1ng a measure of the dose ratio
the dose ratio mcreases linearly with antagonist
concentration; the slope of this line is a measure
of the affinity of the antagonist for the receptor.
Antagonist affinity, measured in this way, is widely
used as a basis for receptor classification.
to be restored by an increa~e in concentration. With other types
of antagonism (see below), the block is usually insurmountable.
The salient features of competitive antagonism are:
shift of the agoni'>t log concentration-effect curve to the
right, without change of slope or maximum
linear relation,hip between agonist dose ratio and antagonist
concentration
evidence of competition from binding studies.
Competitive antagoni!.m is the most direct mechanism by which one
dntg can reduce the effect of another (or of an endogenous
mediator), and !.everaJ examples are listed in Table 3.1; other mech-
anisms that are commonly encountered are discussed below.
The ch~1ract eris tics of reversible competitive antagonism
described above rencctthe fact that the rate of dissociation of the
antagonist molecu les is sufficiently high that a new equilibrium
is rapidly established on addition of the agonist. In effect, the agonist

A Reversible competitive antagonism

Antagonist
concentration

0 ~~~~-=~~~~~~-c~-,------------~-------
10'2 10

Agonist concentration

~ Irreversible competitive antagonism

~ Antagonist
c concentration
co
c.
::>
g 0.5
(ij
c
.Q
0
;t
10
0 L---~~~~~==============~1~oo~
10-2 10-1 10 102
Agonist concentration
Fig. 2.9 Hypothetical agonist concentration-occupancy curves in the presence of reversible and irreversible competitive
antagonists. The concentrations are normalised with respect to the equilibrium constants, K, (i.e. 1.0 corresponds to a concentration
equal to K and results in 50% occupancy). IAI Reversible competitive antagonism. (ID Irreversible competitive antagonism.
17
 SECTION 1 GENERAL PRIN CIPLES

is able to displace the antagonist molecules from the receptors,
although it cannot. of course, evict a bound antagonist molecule.
Displacement occurs because, by occupying a proportion of the
vacant receptors, the agonist reduces the rate of association of
the antagonist molecules; consequently, the rate of dissociation
temporarily exceeds that of association, and tbe O\'erall antagonist
occupancy falls.
irreversible, or non-equil ibrium, competitive antagonism occurs
when the antagonist dissociates very slowly, or not at all, from
the receptors, with the result that no change in the antagonist
occupancy takes place when the agonist is applied.2
The predicted effects of reversible and irreversible antagonists
are compared in Figure 2.9.
T In some cases (Fig. 2.1 OA ). the theoretical effect is accurately reproduced.
but the distinction between reversible and irreversible competitive
antagonism (or even non-competitive antagon ism: sec below) is not
always so clear. This is because of the phenomenon of spare receptors
(see p. 15): if the agonist occupancy required to produce a maximal
biological respon~ is vel) small (say I 'k of the total receptor pool). then
11 is possible 10 block irreversibly nearly 99% of the recepror~ withour
reducing the maximal response. The effect of a lesser degree of antagonist
occupancy will be to produce a parallel shift of the log concentration-
effect curve that IS indistingui~hable from rever.ible competitive antagonism
{Fig. 2.108 ). In fact, il was the finding thm an irre,ersible competitive
antagonist of hiMamine was able to reduce the sensitiviry of a smooth
muscle preparation to histami ne nearly I 00-fold withoul reducing the
maximal response that fiN gave rise to the ~pare receptor hypothesis.
Irreversible competitive antagonism occurs with drugs that possess
reactive groups that form covalent bonds with the receptor. These
are mainly used as experimental tools for investigating receptor
function, and few arc u ed clinically. Irreversible enLyme inhibitors
that act similarly are clinically used, however, and include drugs
such as aspirin (Ch. 14). omeprazole (Ch. 25) and monoamine
oxidase inhibitors (Ch. 39). m
Non-competitive antagonism
Non-competitive antagonism describes the situation where the
antagonist blocks at some point the chain of events that leads to
the production of a response by the agonist. For example, drugs
such as vera pamil and nifedipine prevem the influx of Ca2+
through the cell membrane (see Ch. 19) and thus block non-
specifically the contraction of smooth muscle produced by other
drugs. As a rule, the effect will be to reduce the slope and
maximum of the agonist log concentration-response curve as in
Figure 2.1 OB, although it is quite possible for some degree of
rightward shift to occur as well.
are'
PHYSIOLOGICAL ANTAGONISM oflcn
IS CO
Physiological amagonism is a term used loosely to describe the
f\!Sp!
interacLion of two drugs whose opposing actions in the body
thc d
tend to cancel each other. For example, histamine acts on
receptors of the parietal cells of the gastric mucosa to stimulate
acid secretion, whi le omcprazole blocks this effect by inhibiting
the proton pump; the two drugs can be said to act as
physiological antagonists.

DESENSITISATION AND TACHYPHYLAXIS

ln11s type of antagoni~m is sometimes called non-competiti1e. but that term
i~ best reserved for antagonism thai does not involve occupation of the Often, the effect of a drug graduall y diminishes when it is given
receptor site. continuously or repeatedly. Desensitisation and tachyphylaxis

~ [ID

100 Control 100

5min
15 min
xco xco
E E
~ ~
~ 30min ~
Q) Q)
50 - 50
"'c0 "'c
0
a. a.
60min
"'
Q)
a: "'
Q)
a:
120 min

60 min
0 0
1010 10-9 10-8 107 10~ 105 10-8 10-7 10-8 10-5 10-4 10-3
5-Hydroxytryptamine concentration (mol/1) Carbachol concentration (mol/1)

Fig. 2 .1 0 Effects of irreversible competitive antagonists o n agonist co ncentration-effect c urves. Rat stomach smooth
muscle responding to 5-hydroxytryptamine at various times after addition of methysergide (1 o-;
moVI). lru Rabbit stomach responding to
carbachol at various times after addition of dibenamine (10- 5 mol/l). (After: (A) Frankhuijsen A L, Bonta I L 1974 Eur J Pharrnacol 26: 220;
\ (B) Furchgott R F 1965 Adv Drug Res 3: 21.)
18
----------------------------------------------------------------------' add itt

Drug antagonism
Drug antagonism occurs by various
mechanisms:
chemical antagonism ~nteraction in solution)
pharmacokinetic antagonism (one drug affecting the
absorptton, metabolism or excretion of the other)
competitive antagonism (both drugs binding to the
same receptors); the antagonism may be reversible or
irreversible
non-competitive antagonism (the antagonist
interrupts receptor-effector linkage)
physiologtcal antagonism (two agents producing
opposing physiological effects).
are synonymou terms used to describe this phenomenon, which
often develop~ in the C0Uf1.e Of a few minutes. The tenn tolerance
i~ convemionall) u~ed to describe a more gradual decrea<>e in
rt!~ponsivene~s to a dntg. taking day~> or weeks to develop, but
the distinction i~ not a sharp one. The term refractorines.v is also
~ometimes used, mainly in relation to a loss of therapeutic
efficacy. Drug resistance is a term used to describe the loss
of cffecti,eness of antimicrobial or antitumour dntgs (sec
Cbs 45 and 51). Many diiierent mechanisms can give rise to this
type of phenomenon. They include:
change in receptors
loss of receptors
exhaustion of mediators
increased metabolic degradation of the drug
physiological adaptation
acti\C C\tnt~ion of drug from cells (mainly relevant in cancer
r.:hemotherapy; see Ch. 51).
CHANGE IN RECEPTORS
Among receptors directly coupled to ion channels. desensitisation
i' often raptd and pronounced. At the neuromuscular junction
(Fig. ~.II A), the desensitised state is cau<.ed by a conformational
change in the receptor. resulting in tight binding of the agonist
molecule without the opening of the ionic channel (see Changeux
ct al., 1987). Phosphorylation of intracellular regions of the receptor
protein is a second. slower mechanism by which ion channels
become desen~itised (see Swope et al., 1999).
Most G-protein-<:oupled receptOr'> (see Ch. 3) also !>how
de,ensitisation (see Fig. 2.11 B). Phosphorylation of the receptor
interferes with it'> ability to activate second messenger cascades,
although it can still bind the agonist molecule. The molecu lar
mechanisms of lhi~ 'uncoupling' arc described by Lefkowitz et
al. (1998) and considered further in Chapter 3. This type of desensi-
ti~ation usually take!. a few minutes to develop, and recovers at a
'imilar rate when the agonist is removed.
It will be rcali~ed that the two-state model in its simple form.
d1scussed earlier, needs to be further elaborated to incorporate
additional desensiti~ed' states of the receptor.
HOW DRUGS ACT: GENERAL PRINCIPLES
] SmV
111111 111 11 1 11 111 1 1 tl l lll ll ll!
~
100
ec 80
0
0
0 60
Q)
0>
nl
cQ) 40
E
Q)
a.
20
0
0 4 8 24 56 88
Time (h)
Fig. 2.11 Two kinds of receptor desensitisation.
00 Acetylcholine (ACh) at the frog motor endplate. Brief
depolarisations (upward deflections) are produced by short
pulses of ACh delivered from a micropipette. A lung pulse
(horizontal line) causes the response to decline with a time
course of about 20 seconds, owing to desensitisation, and it
recovers with a similar time course.
liD ~-Adrenoceptors of rat glioma cells in tissue culture.
Isoprenaline (1 !Jmol/1) was added at time zero, and the
adenylate cyclase response and ~-adrenoceptor density
measured at 1ntervals. During the early uncoupling phase,
the response {blue line) declines with no change in receptor
density (red line). Later, the response declines further
concomitantly with disappearance of receptors from the
membrane by internalisation. The green and orange lines
show the recovery of the response and receptor density after
the isoprenaline is washed out during the early or late phase.
(From: (A) Katz B, Thesleff S 1957 J Physiol138: 63;
(B) Perkins J P 1981 Trends Pharmacal Sci 2: 326.) )
LOSS OF RECEPTORS
Prolonged expo~ure to agonists often results in a gradual decrease
in the number of receptors expressed on the cell surface, as a result
of intemalisation of the receptors.1l1i.., is shown for ~adrenoceptors
in Figure 2.11 B and is a slower process than the uncoupling
described above. Tn studies on cell cu ltures. the number of ~
adrenoceptors can fall to about I 0% of normal in 8 hours in the
presence of a low concentration of isoprenaline, and recovery takes
several days. Similar changes have been described for other types
of receptor, including those for various peptides. The internalised
receptors are taken into the cell by endocytosis of patches of the
membrane. a process that also depends on receptor pho!tphorylation.
This type of adaptation is common for hormone receptors and has
obvious relevance to the effects produced when drugs arc given for 19
 extended periods. It is generally an unwanted complication when
drugs are used clinically, but it can be exploited. For example,
gonadotrophin-releasing hormone (see Ch. 30) is used to treat
endometriosis or prostatic cancer: given continuous ly, this hormone
paradoxically inhibits gonadotrophin release (in contrast to the
nomHll ~ti mulatory effect of the physiological secretion. which is
pu Isari le ).
EXHAUSTION OF MEDIATORS
In \Orne ca~es, desen s iti~ation
is associated with depletion of an
es~e nti al intermediate substance. Drugs such as amphetamine,
which acts by releasing amines from nerve terminals (see Chs II
and 32), show marked tachyphylaxis because the amine sto res
become depleted.
ALTERED DRUG METABOLISM
Tolerance to some drugs, for example barbiturates (Ch. 37) and
ethanol (Ch. 43), occurs partl y because repeated administratio n
of the ~arne dose produces a progressively lower plasma concen-
tration, because of increased metabolic degradation. The degree
of tolerance that results is generally modest, and in both of these
example~ other mechanisms contribute to the substantial tolerance
that actually occ u~. On the othe r hand, the pronounced tOlerance
to nitrovasodilators (see Chs 17 and 19) resuhs mainly from
decreased me tabolism. whjch reduces the release of the active
mediator, nitric oxide.
PHYSIOLOGICAL ADAPTATION
Dimi nution of a drug's effect may occur because it is nulli fied by
a homeostatic re!,pOnse. For example, the blood pressure-lowering
effect of thiazide ruurctics is limited because of a gradual acti vation
of the renin- angiotensin system (sec Ch. 19). Such ho meostatic
mechanisms arc very commo n, and if they occur slowly the result
will be a g raduall y developing tolerance. It is a common experie nce
that many s ide effects of drugs, suc h as nausea or s leepiness, te nd
to subside even though drug admjnistration is continued. We may
assume that :.orne kind of physiological adaptation is occurring,
presumably associated with altered gene expression resulting in
c hanges in the levels of various regulatory molecules, but little is
known about the mechanisms involved.
QUANTITATIVE ASPECTS OF
DRUG-RECEPTOR INTERACTIONS
Y Here we pre~nt wme a~pecL~ of so-called receptor theory, which is
ba..ed on applymg the Law of Ma.'s Action to the drug- receptor
interaction and "'hich ha~ \er.ed "'ell as a framework for interpreung a
large body of quantitative experimental data.
The binding reaction
Y The first step in drug action on specific receptors is the formation of a
reversible dnag receptor complex, the reactions bei ng governed by the
Law of Mass Action. Suppose that a piece of tissue, such as hean muscle
20 or Mnooth muscle, contai ns a total number of receptors, N10 1, for an
agonht such as adrenaline (epinephrine). When the ti%ue i\ expo,ed to
adrenaline at concentration x,. and allowed to come to equilibnum. a
cenam number. N ,... of the receptors "'ill become occupied. and the number
of \acant receptor-. will be reduced toN,"' - N,.. Nonnally, the number
of adrenaline molecules applied to the tissue in solution greatly exceed'
N,,.., \0 that the binding reaction does not appreciably reduce .\ ,... The
magnatude of the re.,ponse produced by the adrenaline will be related
(C\Cn if we do notl..no"' exactl} how) to the number of receptors occupied,
\0 it i\ u\cful to consider ''hat quantitative relationship is predicted
bct...,.ccn N, and 1,. The reaction can be represented by:
k
~
A + R ..,....--- AR
dnag + free receptor k., complex
(.I,.) (N,ot-NA) (N")
The Law of Muss Action (which states that the rate of a chemical reaction
is proportional to the prod uct of the concentrations of reactants) can be
applied to this reaction.
Rme of forward reaction = k. 1x,, (N,0, - N"} (2.1)
Rate of backward reaction = k 1N" (2.2)
At equilibrium, the two rates are eq ual:
(2.3)
The proponion of receptor~ occupied, or occupancy (pA). is N,.IN,,.
"hich i\ mdependcnt of N,,..
P, = x,. ( 2.4)
x,. + k tfk.,
IXIimng the equilibrium constant for the binding reaction. K, = J.. 1/J.. 1,
equation 2.4 can be "rinco:
(2.5)
Y Thi'> unportant result is l..no"'n as the Hill- Langmuir equation.-'
The equilibnum con\tant.' K,., is a characteristic of the drug and or
the receptor: it ha' the dimen;ions of concentration and is numerical!}
equal to the concentration of drug required to occupy 50% of the \i te> at
equilibrium. (Veri fy from equation 2.5 that when xA = KA. p,. = 0.5.)
The higher the affinity of the drug for the receptors, the lower wil l be
the val ue of K"' Equation 2.5 descri bes the relationship between occu-
pancy and dnag concentration, and it generates a characteristic curve known
a' u rectangular hyperbola, as sbown in Figure 2.1 2A. It is common in
pharmacological work to usc a logarithmic scale of concentration: thb
convem the hyperbola to a symmetrical sigmoid curve (Fig. 2.128}.
The '>ame approach is u;ed to analyse data from experi ments in which
drug binding is mea.sured di rectly (see p. 11, Fig. 2.2). In this case, the
re latiom.hip between the amount bound (8) and ligand concentration (xAJ
'>hould be:
(2.6)
'A. V. Hill fir'>t published it in 1909, \\hen he was still a medical smdcnt.
Langmur. a physical chemist working on gas adsorption. derived it
independently in 1916. Both ;ub~uently won Nobel prizes. Unti l recent!).
it was know n to phannacologisLs as the Langmuir equation. even though
Hill deserve., the credit.
1
' Theequil ibri um constant is sometimes called the dissociation constant.
Some authors prefer to use the reciprocal of K,., referred to as an affin ity
constant. in these expressions. which can cause confusion to the unwary.
 HO W DRUGS ACT: GENERAL PRINCIPLES

pham1acology, we muM con~ider (a) what happens when more than one
Binding of druga to receptora ligand i' pre,ent. and (b) how the tissue response is related to receptor
occupancy.
Binding of drugs to receptors necessarily
obeys the Law of Mass Action. Binding when more than one drug is present
At equilibrium, receptor occupancy is related to drug
T Suppo<.c thatt\~0 drug~. A and B. which bind to the ~arne receptor with
concentration by the Hill-Langmuir equation (2.7). equilibrium con~tant~ K,. ;md K8 respectively. are preoent at concentration\
The higher the affinity of the drug for the receptor, the ~~and 1 8 . If the two drug~ comp<>te (i.e. the receptor can accommodate
lower the concentration at which it produces a given onl) one at a time), then. by application of the same reasoning as for the
level of occupancy. one-drug \ituauon de\cribed above. the occupancy by drug A is given by:
The same principles apply when two or more drugs p "' x,lK, (2.8)
compete for the same receptors; each has the effect 11,/K + r,/K8 +1
of reducing the apparent affinity for the other. Comparing thi' rc~ult with equation 2.5 shows that adding drug B. a.\
expected. reduce the occupancy by drug A. Figure 2.9A show the
predicted bi nding cu rves for A in the presence of increaing concen-
trations of B, demonstrating the shift without any change of slope or
maximum th at characterise> the phannacological effect of a competitive
fA omagonil>t (f.ce Pig. 2.8). 'nle extent of the rightward shift, on a logari thmic
..calc. represent;, the r:ttio (rA, given by x,.'lxA where xA' is the increa>ed
g 1.0 concentration of A) by which the concentration of A must be increased to
overcome the competition by B. Rearranging 2.8 shows that
<11
c.
=> (2.9)
0.5
Thus r,. depend\ only on the concentration and equilibrium con~tant of
the competing drug B. not on the concentmtion or equilibrium constant
of A.
0'--------------' If A i~ an agoni\t, and B i~ a competitive antagonist, and we assume that
0 5 10
Concentration (linear scale) the respon\e of the tl\\ue w1ll be a functon of p,. (not necessaril} a linear
funcuon). then the value of r~ determined from the shift of the agomst
concentr:uion-effcct curve at different antagonist concentrations can be
B
uo;cd to C\llmate the equ1hbnum constant K8 for the antagonist. Such
pharmacological e\timate~ of r, are common!} termed a.t:onilt dol<'
~ 1.0
c rotior (more properly concentration ratios. although most pharmacol-
1'0
c. ogiw, U'>C the older. improper term). This simple and very useful equation
=>
(2.9) b ~nown a\ the Schild equation, after the pbarmacologht who firM
0.5 used it to annly~e drug antagonism.
iii
c
20 Equation 2.9 can be exprcM.ed logarithmically in the form:
~
u. 0 log (rA - I) : log x8 - log K8 (2. 10)
0.1 1.0 10 .0
Th u~ a plot of log (rA - I) agai nst log x8, usually called a Schild plot
Concen tration (log scale)
(a~ in Fig. 2.1\), ' hould give a straight line with unit slope and an abscis~nl
Fig. 2.12 Theoretical relationship between o ccupancy intercept cquttl to log K6 . Following the pH and pK notation, antagoni"
and ligand concentr ation. The relationship is plotted potency can be cxpre~~ed a; a pA 2 value: under conditions of competitive
according to equation 2.5. ~ Plotted with a linear antagonism. pA 2 : log Ku. Numerically. pA2 is defined as the
concentration scale, this curve is a rectangular hyperbola. negative logarithm of the molar concentration of antagonist required to
B Plotted with a log concentration scale, it is a symmetrical produce an agoni\t do\e ratio equal to 2. As with pH notation, its
sigmoid curve. principal advantage i'> that it produce\ simple numbers, a pA2 of 6.5 being
equivalent to a K 8 of 3.2 x 10 1 molll.
Thi' analy\1\ of competitive antagonism shows the following
characten,uc' of the do~ ratio r:

\\here 8_, ., the total number of binding sites in the preparation (often
e'pre"ed a' pmollmg of protein). To display the results in linear form.
equation 2.6 rna) be rearr.mged to:
(2.7)
A plot of Bll" against 8 {known as a Scatchard plot; Fig. 2.2C) ghes a
~tra1ght hoe from which both Brrw. and K,. can be estimated. Statistically,
thi\ procedure i\ not without problems. and it is now usual to estimate
the\C parameter;. from the untransformcd binding values by an iterative
non-linear curve-filling procedure.
To thi~ point, our analysis has considered the binding of one ligand to a
homoge neous population of receptors. To get closer to rea l-life
n depends on I) on the concentration and equilibrium con\tant of the
antagoni,t. and not on the ~i/e of re~pon~ that is chosen as a reference
point for the mea .. urement<,
it doe' not depend on the equilibrium constant for the agonist
it increa\C\ linearly" ith x 8 and the slope of a plot of (r,. - I) again\!
.t 8 is equal to IIK8 ; thb relationship, being independent of the
charncterbtic' of the agoniM. should be the same for aU agonists that
act on the ..ame population of receptor<>.
The~e predictions have been verified for many examples of competitive
ontagoni~m (Fig. 2.8).
In this secti on, we have avoided going into great detail and have
oversimplified the theory considerably. As we learn more about the actual 21
 SECTION 1 !I GENERAL PRINCIPLES

Drug effects
Drug + target

Drugs act mainly on cellular targets,

producing effects at different functional levels (e.g.
biochemical cellular, physiological and structuraQ.
The direct effect of the drug on lts target produces
acute responses at the biochemical cellular or
physiological levels.
Acute responses generally lead to delayed long-term
effects, such as desensitisation or down-regulation of
receptors, hypertrophy, atrophy or remodelling of
tissues, tolerance, dependence and addiction.
Long-term delayed responses result from changes in
gene expression, although the mechanisms by which
the acute effects bring this about are often uncertain.
Therapeutic effects may be based on acute
responses (e.g. the use of bronchodilator drugs to
treat asthma; Ch. 23) or delayed responses (e.g.
antidepressants; Ch. 39).
molecu lar details of l1ow receptors work to produce their biological
effect~ (~c Ch. 3), the ~hortcomings of thi\ theoretical treatment become
more obvious. Particular complication\ arise when v.c include the
involvement of G-protcm~ (see Ch. 3) in the reaction M:hcme. and when
we allow for the fact th at receptor 'activation' is not a s imple on off
switch. as the two-state model assumes, but may take different form ~. It
is as though the same receptor can tum on a tap or a light bulb, depending
on which agonbt does the talking. Ancmp!S by theoreticians to allov. for
such possibilities lead to M>me unwieldy algebra and fancy three-dimensional
graphics. but somehow the molecules always seem to remain one step
ahead. Despite its shortcom ings. the two-~tate model remains a useful
basis for developing quantitative model\ of drug action. The book by
Kenakin ( 1997) is recommended as an introduction. and his later review
(Kenakin. 2002) present\ a more elabor.ue theoretical approach.
THE NATURE OF DRUG EFFECTS
In discussing how dmgs act in this chapter, we have focused
mainly o n the consequences of receptor activation. Details of the
receptors and their linkage to effects at the cellular level are
described in Chapter 3. We now have a fairly good understanding
at this level. It is important, however, partic ularly when con-
sidering drugs in a therapeutic context. that the ir direct effects
on cellular function generally lead to secondary, delayed e ffects,
which arc often highly relevant in a clinical situation in relation
/~Rapid
Rapid
physiological Altered gene
Slow
responses expression
It
Slow
~ I
Delayed
responses
Fig. 2 .13 Early and late responses to drugs. Many drugs
act directly on their targets Qeft-hand arrow) to produce an
immediate physiological response. If this is maintained, it IS
likely to cause changes in gene expression that give rise to
delayed effects. Some drugs (right-hand arrow) have their
primary action on gene expression, producing delayed
physiological responses. Drugs can also wor1< by both
pathways. Note the bidirectional interaction between gene
expression and response.
to both the rapeutic efficacy and harmful effects (see Fig. 2.13).
For example, activation of a ~-adrenoceptor in the heart (sec Chs 3
and 18) causes rapid changes in the functioning of the hean muscle,
but abo '>lower (minutes to hours) changes in the functional state
of the receptors (e.g. desensitisation), and even slower (hours to
days) c hanges in gene expressio n that produce long-term changes
(e.g. hypertrophy) in cardiac stmctu re and function. Similarly, anti-
depressant drugs, which have immediate effects on transmitter
metabolism in the brai n (see Ch. 39) take weeks to produce thera-
peutic benefit Opiates (see Ch. 4 1) produce an immediate analgesic
effect but, after a time, tolerance and dependence ensue, and io
some cases long-term addiction. In these, and many othe r examples,
the nature of the intervening mechanism is unclear, although as a
general rule any long-term phenotypic change necessarily involves
alterations of gene expression. Drugs are often used to treat
chronic conditions. and understandi ng long-term as well as acute
drug effects is becoming increasingly important. Pharmacologists
have traditionally te nded to focus on short-term physiological
responses, which are much easier to study, rather than on delayed
effects. The focus is now clearly shifting.

REFERENCES AND FURTHER READING

G1!neral
Alexander SP, Muthie A. Petcl'l. JA 2006 Guide to
receptors and cltannels, 2nd ediloon. Br J Phannacol
147 (suppt J):SI
Chaogeux J P. Gtraudat J. Denm' M 1987 The
nicotinic acetylchotine receptor: molecular
22 architecture of " ligaod-regulalcd ion channel.
Trend~ Pharmacol Set 8: 459-465 (0111! of the
fir.H tlescriptioll.v of ll!Ct!ptor actio11 tJttM
m()/tcular lt!lle/)
Frankl. 'I P. Lieb W R 1994 Molecular and cellular
mecham;ms of general anaeslhesia Nature 367:
607 6 t4 (A m '"" of chtmging idtas about the sire
()faction of anaeJthetic drugs)
Jenkinson 0 II t996 Cta.~~icnl approachc. to the study of
drug-rcccplor interoction<. In: Foreman J C, Johan!><:n
T (ed!.) Textbook of receptor pharmacology. CRC
Press. BO<:a Raton (Good acco1mt ofphnrmDcologicol
onnlysiv of ~uptor-metliatttl tfftcrs)
Kcnakin T t997 Pharmacologtc nnalysb of
drug-receptor i nteract:ions, 3rd cdn. Lippincoll Raven.
 How drugs act:
molecular aspects
Overview 24
Targets for drug action 24
Receptor proteins 27
-Type l: ligand-gated ion channels 31
-Type 2: G-protein-coupled receptors 33
-Type 3: kinase-linked and related receptors 42
-Type 4: nuclear receptors 45
lon channels as drug targets 48
Control of receptor expression 51
Receptors and disease 52
OVERVIEW
In this chapter, we move from the general
principles of drug action outlined in Chapter 2 to
the molecules that are involved in recognising
chemical signals and translating them into cellular
responses. Molecular pharmacology has advanced
rapidly in recent years. This new knowledge is not
only changing our understanding of drug action, it
is also opening up many new therapeutic
possibilities, further discussed in other chapters.
First, we consider the types of torget proteins on
which drugs act. Next, we describe the main
families of receptors and ion channels that have
been revealed by cloning and structural studies.
Finally, we discuss the various forms of
receptor-eHector linkage (signal transduction
mechanisms) through which receptors are coupled
to the regulation of cell function. The relationship
between the molecular structure of a receptor and
its functional linkage to a particular type of
eHector system is a principal theme. In the next
two chapters, we see how these molecular events
alter important aspects of cell function-a useful
basis for understanding the eHects of drugs on
24 intact living organisms. We go into more detail
than is necessary for understanding today's
pharmacology at a basic level, intending that
students can, if they wish, skip or skim these
chapters without losing the thread; however, we
are confident that tomorrow's pharmacology will
rest solidly on the advances in cellular and
molecular biology that are discussed here.
TARGETS FOR DRUG ACTION
The protein targets for drug action on mammalian ceJJs (Fig. 3.1)
that are described in Lhi~ chapter can be broadly divided into:
receptors
io n channels
enzymes
carrier molecules (tran~porters).
The great majority of important drugs ac t o n one or other of
these types of protein, but there are exceptions. For example
colchicine (Ch. 14) interact!> with the structural protein rubufin,
while several immunosuppre~si ve drugs (e.g. ciclosporin,
Ch. 14) bind to cytosolic proteins known a'> immunophilins.
Therapeutic anti bodies that act by sequestering cytoJ..ines
(protein mediators involved in inflammatio n, see Ch. 14) are
also used. Targets for chemotherapeutic drugs (Chs 45 -5 1),
where the aim is to !>uppress invading microorganism!> or
cancer cells, include DNA and cell wall con!>tituents as well a~
other proteins.
Receptors
Receptor!> (Fig. 3.1 A) arc the sensing elements in the !>y<;tem of
chemical communications that coordinates the function of all
the different cells in the body, the chemical messengers being the
various ho rmones, trans mitters and other mediators discussed
in Section 2. Many therapeutically useful drugs act, either a~
agonists or antagonists, on receptors for known endogenous
medjators. Some example<; are given in Table 3.1. ln mo<.t ca\es.
the endogenous mediator wa~ discovered bcfore-Qften man}
years before-the recepto r was characterised pharmacologicall}
and biochemically, but there are examples of receptors for
synthetic drug molecules (e.g. benzodiazepines, Ch. 33: and
s ulfonylureas, Cb. 26) for which no endogenous mediator
has been identified. Receptors are discussed in more dctllil
below (p. 27).
 HOW DRUGS ACT: MOLECULAR ASPECTS

lon channels 1 (A RECEPTORS ton channel

Some ion channels (known as ligand-gated ion channels or /Direct opening/closing
ionotropic rcctpwn-) incorporate a receptor and open only when Enzyme
actJvabonlinhobobon
the receptor is occupied by an agonist: others (see p. 48) are
gated b) different mechanisms, toltage-gared ion channels (sec
Agonist r"C/1
"---J
_1. Transduction
mechanisms
ion channel
modulatJon
p. -l9) being panicularly important. ln general. drugs can affect DNA
transcnptoon
ion channel function by interacting either with the receptor site
of hgand-gated channels, or with other parts of the channel 0 No effect
Antagonost Endogenous mediators blocked
molecule. Tile interaction can be indirect, involving a G-protein
and other intermediaries (see below), or direct, where the drug
ihclf binds to the channel protein and alters its function. Tn the [.] ION CHANNELS
.,implcst ca'>c. exemplified by the action of local anaesthetics on Permeation
Blockers
the voltage-gated sodium channel (see Ch. 44). the drug molecule blocked
plug~ the channel physically (Fig. 3. 1B). blocking ion penneation.
Increased or
Examples of drugs that bi nd to accessory sites on the channel decreased
Modulators
protein and thereby affect channel gating include: opening probability
va,odilator drugs of the dihydropyridine type (see Ch. 19),
which inhibit the opening of L-type calcium c_hannels c] ENZYMES
(\CC Ch. 4).
bcn7odiazcpine tranq uillisers (see Ch. 37). These drugs
Inhibitor CJ Normal reaction
inhibited

bind to a region of the GABA receptor-chloride channel False -::::-, f- 0 Abnormal

complex (a ligand-gated channel; see above), this region substrate metabolite produced
bcmg di'>tinct from the GABA binding site. Most
bcn!Odtatepines facilitate the opening of the channel by the
~ ;;;;: 0
inhibitory neurotransmitter GABA (see Ch. 33), but some Pro-drug Active drug produced
imwse agonisl.l are known that have the opposite effect,
causmg :m-:iety rather than tranquillity. [0 TRANSPORTERS
Sulfon}lureas (see Ch. 26) used in treating diabetes. which
act on ATP-scnsitive potas~ium channels of pancreatic ~-cells Normal
transport
ant! thereby enhance insulin secretion.
A summary of the ditTerent ion channel families and their
function~
i\ given below (p. 50). or Transport
Inhibitor blocked
Enzymes
Many drugs arc targeted on enzymes (Fig. 3. 1C). examples being False Abnormal compound
given in Table 3.1. Often, the drug molecule is a substrate analogue substrate accumulated
that acts as a competitive inhibitor of the enzyme (e.g. captopr il,
acting on angiotensin-convening enzyme; Ch. 19); in other cases, AgonisVnormal substrate Q Abnormal product
the binding i~ irreversible and non-competitive (e.g. aspirin, G Antagonist/inhibitor 0 Pro-drug
acltng. on cyclo-oxygenase; Ch. 14). The inununophilin LO which \. Fig. 3 .1 Types of target for drug action. j
ctclosporin binds (!tee above) has enzymic activity as an isomerase
that catalyses the cis- trans isomerisation of proline residues in
- -
proteins, a reactton that is important in allowing expressed
protems to fold correctly. Inhibition of this enzymic activity is
one of the mcchani<,ms by which ciclosporin causes immu- uracil as an intermediate in purine biosynthesis but cannot be
no,upprcssion. Drug~ may also act as false substrates, where the converted into thymidylate. thus blocking DNA synthesis and
drug molecule undergoe!t chemical transformation to form an preventing cell division (Ch. 51).
abnormal product that subverts the normal metabolic pathway. It should also be mentioned that drugs may require enzymic
An example is the anticancer drug fluorouracil. which replaces degradation to convert them from an inactive form. the prodrug
(see Ch. 8), to an active form. Examples are given in Table 8.3.
Furthermore, as discussed in Chapter 53, drug toxicity often
results from the entymic conversion of the drug molecule to a
' ion channel\ an<.lthe electrical propenies they confer on cells are involved
in every human characteristic that dbtinguishes us from the stones in a
reactive metabolite. As far as the primary action of the drug is
field.' (Ann\trong C M 2003 Voltage-gated K channels concerned, this is an un wanted side reaction, but it is of major
hnp://www.stke.org). practical importance. 25
 SECTION 1 GENERAL PRINCIPLES

Table 3 . 1 Some examples of targets for drug action

Type of target Effectors Chapter(s) to refer to

Receptors Agonists Antagonists

Nicotmic ACh receptor Acetylcholine Tubocurarine 10
Nicotine a-Bungarotoxin

~-Adrenoceptor Noradrenaline (norepinephnne) Propranolol 11

Isoprenaline

Histamine (H 1 receptor) Histamine Mepyramine 18

Opiate ijt receptor) Morphine Naloxone 41

Dopamine (D2 receptor) Dopamine Chlorpromazine 35 and 38

Bromocriptine

Oestrogen receptor Ethinylestradiol Tamoxifen 30

Epidermal growth factor receptor Trastuzumab 55

lon channels Blockers Modulators

Voltage-gated sodium channels Local anaesthetics Veratridine 44
Tetrodotoxin

Renal tubule sodium channels Amiloride Aldosterone 24

Voltage-gated calcium channels Divalent cations (e.g. Cd2 ) D1hydropyridines 18 and 19

Opioids 41

ATP-sensihve potassium channels ATP Sulfonylureas 26

GABA-gated chloride channels Picrotoxin Benzodiazepines 33

Enzymes Inhibitors False substrates

Acetylcholinesterase Neostigmine 10

Cyclo-oxygenase Aspirin 14

Angiotensin-converting enzyme Captopril 19

HMG-CoA reductase Slmvastatin 20

Monoamine oxidase-A Iproniazid 39

Phosphodiesterase type V Sildenafil 30

Dthydrofolate reductase Trimethoprim 46

Methotrexate 14 and 51

Thymidine kinase Aciclovir 47

HIV protease Saquinavir 47

Carriers Inhibitors False substrates

Noradrenaline transporter Tricyclic anttdepressants - 39
Cocaine 11and53
Amphetamine 11 and 42
Methyldopa 19

Weak acid carrier (renal tubule) Probenecid 24

Na'/K'/2CI cotransporter (loop of Henle) Loop diuretics 24

Proton pump (gastric mucosa) Omeprazole 25

26

Tllble 3.1 (cont'd) Some examples of targets for drug action
Type of target Effectors
Others
1mmunoph11tns Ciclosporin
Tacrolimus
Tubuhn Colchicine
Taxol
HMG-CoA, 3-hydroxy-3-methylglutaryl-coenzyme A.
"These are representative examples and by no means a complete list. Other biochemical targets for drugs used in chemotherapy are
discussed in Chapters 44-51.
Carrier molecules
The tr3n-,port of ion~ and small organic molecules across cell
membrane\ generally requires a carrier protein, because the per-
meating molecule~ arc often too polar (i.e. insufficiently lipid-
-,oluble) to penerratc lipid membrane!> on their own. There are many
e\arnpJe., of \UCh carriers (Fig. 3.1 D). including those respon-
'ible for the transport of glucol.e and amino acids into cells, the
tr.ln'>port of ions and many organic molecules by the renal tubule,
the transport of Na and Ca 2 out of cells. and the uptake of
neurotransmitter precun,ors (such as choline) or of neurotrans-
mmcn, themsclvc-. (\uch as noradrenaline. 5-hydroxytryptamine
[5-HT). glutamate, and peptides) by nerve terminals. The amine
tran,portcl'll belong to a well-defined structural family. djstinct from
the corresponding receptOr<;. In most cases, the transport of organic
molecules is coupled to the transport of ions (usually Na), either
in the same direction (symport) or in the opposite direction
(antiport), a~ discussed in Chapter 24. The carrier proteins embody
a recogni tion site that makes them specific for a particular per-
meating species, and these recogn ition sites can also be targets
for drugs whose cfTcct is to block the transport system. Some
l!xumples arc given in Table 3.1.
RECEPTOR PROTEINS
ISOLATION AND CLONING OF RECEPTORS
In the 1970'>, pharmacology entered a new phase when receptors,
\\hich had until then been theoretical entities, began to emerge as
biochemtcal rcalitie\ following the development of receptor-
labelling technique~ (see Ch. 2), wruch made it possible to extract
and purify the receptor material. This approach was first used
successfully on the nicotinic acetylcholine receptor (see Ch. 7).
\\here ad\antage was taken of two natural curiosjties. The first was
that the electric organs of many fish, such as rays (Torpedo sp.)
anti electric eels (Electrophorus sp.) consjst of modified muscle
ti'>'IUC in which the acetylcholine-sensitive membrane is extremely
abundant, and these organs contain much larger amounts of
acetylcholine receptor than any other tissue. The second wa~ that
the vcnorn of snakes of the cobra family contains polypeptides
HOW DRUGS ACT: MOLECULAR ASPECTS
Chapter(s) to refer to
17
17
17
50
that bind with very high specificity to nicotinic acetylchol ine
receptors. These subMances, known a~ a-toxins, can be labelled
and used to assay the receptor content of tissues and tissue extracts.
The best t...nown i~ a-bungarotoxin, the mrun component of the
venom of the Malayan banded krrut (BungantS multicinctus).~
Treatment of muscle or electric tissue with non-ionic detergents
render<; the membrane-bound receptor protein soluble, and it can
then be purified by the technique of affiruty chromatography.
Similar approache~ have now been used to purify a great man)
hormone and neurotransmitter receptors, as well as ion channels.
carrier protein~. <Uld other IJnds of target molecules.
T Once receptor protein~ were isolated and purified. it wa~ po-.siblc to
analyse the ammo acid ~equence of a short stretch. allowing the
corre-.ponding ba~e ~equence of the mRNA to be deduced and full-length
DNA to be i\olmed. by conventional cloning methods, starting from a
eDNA libr.1ry obwi ned from a tis~ue ~ource rich in the receptor of intert:\t.
The lirM receptor clone were obtained in this way. but 'ub~cq ucmly
expression cloning and cloni ng ~trategies based on sequence homologies.
which do not require prior isolation and purification of the receptor
protein, were widely used, and now several hundred receptors of all four
structural fam ilies (~ee helow) have been cloned. Endogenous ligands for
many of thc~e 'receptor-like' molecules identified by gene cloning are ~o
far unknown. and they arc de;cribed as 'orphan receptors'.' Identifying
ligands for these presumed receptors is often difficult. However. there are
examples (e.g. the cannabinoid receptor: ;ec Ch. 15) where important
ligand ha\e hecn linked to hitherto orphan receptors, and it is likely that
thi'> pool of unclaimed receptors will yield many more receptors of
phy\iological and therapeutic ;ignificance.
Much information has been gruned by introducing the cloned
DNA encoding individual receptors into cell lines. producing
2
Nmurc has had the good sense to keep these heavily anned fishes and
~nakes wel l apart. Ironically enough. B. multicincws is now officially an
endangered ~pecic\, threatened by scienti;ts' demand for its venom.
Evolution for !>urvivaJ can go one Mep too far.
JAn oddly Dickcn>ian term that seems inappropriately condescending.
becam.e we can U\:.umc that these receptors play defined role~ in
physiological signalling their orphanhood' renects our ignorance, not
their sta!lls.
27
 SECTION 1 GENERAl PRIN CIPLES

1.Ligand-gated ion 2.G-protein-coupled 3.Kinase-linked 4.Nuclear receptors

channels receptors receptors
(ionotropic receptors) (metabotropic)

Ions Ions

o ~~;- A (f)~-~
y { \
Hyperpolarisation Change Second messengers
Protein
or
depolarisallon
'" "'"''"''"ly 1 phosphorylation

+
t Gene transcription
Ca 2+ release Protein Other
phosphorylation t
Protein synthesis

Cellular effects
1 i
Cellular effects
1 t
Cellular effects
Protein synthesis
t
Cellular effects

Time scale
Milliseconds Seconds Hours Hours
Examples
N1colln1c Muscarinic Cytokine receptors Oestrogen
ACh receptor ACh receptor receptor

Fig. 3.2 Types of receptor~ffector linkage. ACh, acetylcholine: E, enzyme; G, G-protein; A, receptor.

ce ll~ that cxpre~s the foreign receptors in a functional form. Such
engineered cells allow much more precise control of the expressed
receptors than is pos~ible with natural cells or intact tissues, and the
technique is widely used to study the binding and pharmacological
characteri~ti cs of cloned receptors.
The cloning of receptors revealed many molecu lar variants
(subtypes) of known receptors, which had not been evident from
pham1acological studies. Thi s produced some taxonomic confusion,
but in the long term molecular characteri sation of receptors is
essential. Barnard. one of the high priests of receptor cloning,
was undaunted by the proliferation of molecular subtypes among
receptors that pharmacologist-; had thought that they understood.
He quoted ThomaJ> Aquina.\: T ypes and shadows have their ending,
for the newer rite i~ here. The newer rite. Barnard confiden tly
as~ened, was molecular biology. Analysis of the human and other
mammalian genomcs suggests that many hundreds of receptor-
like gene'> arc present. of which only a minority so far have a
pham1acological identit). ow that most of the genes have been
clearly identified. and the full molecular inventory established, the
emphasis has shifted to characterising the receptors pharma-
cologically and determining their physiological functions.
opcr:.11ing within milliseconds. whereas other receptor-mediated
effects, ~uch as tho~e produced by thyroid hormone or variou'
steroid hormone~. occur over hours or days. There are also many
examples of intcrn1ediate timescales-<:atecholamines. for example,
usually act in a maucr of seconds, whereas many peptides take rather
longer to produce their effects. Not surprisingly, very different types
oflinkage between the receptor occupation and the ensuing response
arc invol ved. Based on molecular structure and the nature of thi~
linkage (the transduction mechanism), we can distinguish four
receptor types, or superfamilies (see Figs 3.2 and 3.3 and Table 3.2).
Type I: ligand-gated ion channels (also known as ionot ropic
recept ors).~ These are membrane proteins with a similar
~tructurc to other ion channeb. and incorporate a ligand-binding
(receptor) ~ite, u~ually in the extracellular domain. Typicall}.
these are the receptors on which fast neurotransmitters act.
Example~ include the nicotinic acetylcholine receptor (nAChR.
see Ch. 10): GABAA receptor (see Ch. 33): and glutamme
receptors of the NMDA. A MPA and kainate types (see Ch. 33).

TYPES OF RECEPTOR
Receptors elicit many different types of cellular effect. Some of
28 them arc very rapid. such as those involved in synaptic transmi ssion,
1
11crc. focu~ing on receptors, we consider ligand-gated ion channcb as an
example ol a receptor fam il y. O ther types of ion c han nels are described
later (p. 48); m:my of them are also drug targeL~. although not receptors i n
the slrict sem.c.
 HOW DRUGS ACT: MOLECULAR ASPE CTS

Type 1 c N - - - - - - - - - Binding domain

Ligand-gated

Jg~
ion channels
(ionotropic
receptors) x 4 or 5

Channel
lining

Type 2
Gprotein
coupled
receptors
(metabotropic Gprotein
receptors) coupling
Fig. 3 .3 General structure of
four receptor families. The domain
rectangular segments represent
hydrophobic ex-helical regions of the
c
protein compnsing approximately
20 amino acids, which fonm the
membrane-spanning domains of the
c] Binding domain
Type3
receptors. A Type 1: ligand-gated Kinase-linked
100 channels. Many ligand-gated ion
receptors
channels compnse four or five
subunits of the type shown, the
whole complex contaimng 16-20
membrane-spanning segments
surrounding a central ion channel.
Other structural types are shown in
F1g. 3.16. B Type 2: G- c
proteJrH:Oupled receptors. c . Type
3: kinase-linked receptors. Most
growth factor receptors incorporate Type4 c-'C- - - Binding domain
the llgandbJnding and enzymatic Nuclear ;::)

!:---
(kinase) domains in the same receptors DNA-binding domain
molecule, as shown, whereas
('zinc fingers')
cytokine receptors lack an
intracellular kinase domain but
link to cytosolic kinase molecules.
Other structural variants also exist.
o Type 4: nuclear receptors that N
control gene transcnption.

Type 2: G-protei n~oupl ed r eceptors (GPCRs). These are
abo known a~ m et abo tropic receptors or 7-transm embran e
-spanning (heptahelical ) r eceptors. They are membrane
receptor. that are coupled to intracellular effecror systems via
a G-protein (~ee below). T hey constitute the largest family.5
and include receptor.. for many hormones and slow transmitters.
fore:<amplc the muscarinic acetylcholine receptor (mAChR:
1-Jn~rc urc probably more than I 000 human GPCRs. compri sing rough ly
3' olthc genome. About h:1lf of these are bel ieved to be odorant receptors
Jll\Oived in ' mel I and ta\te ~en~ation~. the remainder bei ng recepwrs for
m kno\\n or un ~nown cndogennu~ mediators-ennugh to keep
phann:t~ulogi\1~ bu~y for l>Ollle Li me yet.
see Ch. 10). adrenergic receptors (see Ch. II ) and chemokine
receptors (sec Ch. 16).
Type 3: kjnase-lioked and r elated r eceptors. Thi s is a large
and heterogeneou~ gr oup of membrane receprors responding
mainly to protein mediator:.. T hey comprise an extracellular
ligand-binding domain linked to an imracellular domain by a
single transmembrane helix. In many cases. the intracellular
domain is enLymic in nature (with protein kinase or guanylyl
cyclase activity). Type 3 receptor:. include those for insulin and
for various cytokines and growth factors (see C hs 16 and 26):
the receptor for atri al natriuretic factor (ANF. C hs 18 and 19)
is the main example o f the g uany lyl cyclase type. The two
kind s arc very similar struc turally. even though their
transduc ti o n mechanism!> differ.
29
 SECTION 1 GEN ERAl PRIN CIPlES

Table 3.2 The four main types of receptor

Type 1: ligand-gated
ion channels
Type 2: G-protein-coupled
receptors
Type 3: receptor kinases Type 4: nuclear receptors '
1

Location Membrane Membrane Membrane Intracellular a

s.
Effector ion channel Channel or enzyme Protein kinases Gene transcription f.
4-
Coupling Direct G-protein Direct Via DNA
a
Examples Nicotinic acetylcholine Muscarinic acetylcholine Insulin, growth factors, Steroid receptors Yo
receptor, GABAA receptor receptor, adrenoceptors cytokine receptors Cl
sl
Structure Oligomeric assembly of Monomeric dimericor Single transmembrane Monomeric structure with t\.
subunits surrounding structure comprising seven helix linking extracellular separate receptor- and
01
central pore transmembrane helices receptor domain to DNA-binding domains
Intracellular kinase domain ac
T.
ar
re
e1
Type 4: nuclear receptors. These are receptors that regulate acetylcholine receptors respond to the same physiological ct-
gene transcription. The term nuclear receptors is something mediator and produce the same kind of synaptic response, so su
of a misnomer, because some are actuaUy located in the cytosol why many variants should have evolved is still a puzzle.
and migrate to the nuclear compartment when a ligand is 'Y Much of the sequence variation that accounts for receptor diversity
present. They include receptors for steroid hormones arises at the genomic level, i.e. different genes give rise to distinct
(see Ch. 28), thyroid hormone (Ch. 29), and other agents receptor subtypes. Additional variation arises from alternative mRNA
such as retinoic acid and vitamin D. splicing. which means that a single gene can give rise to more than one
receptor isoform. After translation from genomic DNA, the mRNA
normally contains non-coding regions (inmms) that are excised by
MOLECULAR STRUCTURE OF RECEPTORS mRNA splicing before the message is translated into protein. Depending
on the location of the splice sites. splicing can result in inclusion or
The molecular organisation of typical members of each of these deletion of one or more of the mRNA coding region~. giving rise to long
four receptor superfamilies is shown in Figure 3.3. Although or short forms of the protein. This is an imponant source of variation,
particularly for GPCRs (see Kilpatrick et al., 1999), which produce
individual receptors show considerable sequence variation in receptors with different binding characteristics and different signal
particular regions, and the lengths of the main intracellular transduction mechanisms. although its pharmacological relevance remain'
and extracellular domains also vary from one to another within to be clarified. Another process that can produce different receptors from
the same family, the overall structural patterns and associated the same gene is mRNA editing, whicb involves the mischievous
signal transduction pathways arc very consistent. The realisation substitution of one base in the mRNA for another, and hence a small
variation in the an1ino acid sequence of the receptor.
that just four receptor superfamilics provide a solid framework
for interpreting the complex welter of information about the Molecular heterogeneity of this ki nd is a feature of all kinds of
effects of a large proportion of the drugs that have been studied receptors-indeed of functional proteins in general. New receptor
has been one of the most refreshing developments in modem subtypes and isoforms are continually being discovered, and
pharmacology. regular updates of the catalogue arc available (Alexander et al.,
2004; JUPHAR Receptor Database and Channel Compendium).
Receptor heterogeneity and subtypes The problems of classification, nomenclature and taxonomy
Receptors within a given family generally occur in several molecular resulting from this flood of data have been mentioned earlier
varieties, or subtypes. with similar architecture but significant (p. 28). From the pham1acological viewpoint, where our concern
differences in their sequences, and often in their pharmacological is to understand individual drugs and what they do to living
properties.6 Nicotinic acetylcholine receptors are typical in this organisms, and to devise better ones, it is important that we keep
respect; distinct subtypes occur in different brain regions, and these molecular phrumacology in perspective. The 'newer rite' has proved
differ from the muscle receptor. Some of the known pharma- revelatory in many ways, but the sheer complexity of the ways in
cological differences (e.g. sensitivity to blocking agents) between whjch molecules behave means that we have a long way to go
muscle and brain acetylcholine receptors correlate with specific
sequence differences; however, as far as we know, all nicotinic
before reaching the reductionist Utopia that molecular biology
promises. When we do, this book wi ll get much shorter. Tn tbe
..
T
meantime, we try to pick out the general principles without getting h
$
too bogged down in detail.
a
6Receptors for 5-HT (see Ch. 12) are currently the champions with respect We will now describe the characteristics of each of the four c:
30 to diversity, with 14 cloned subtypes. receptor superfami lies.

TYPE 1: LIGAND-GATED ION CHANNELS
MOLECULAR STRUCTURE
The'e molecule~ have ~tructural features in common with other
ion channel~. described on p. 50 (see Ashcroft, 2000). The nicotinic
acetylcholine receptor (Fig. 3.3A), the first to be cloned, has been
'tudted in great detail (see Karlin, 1993). It is assembled from
four diflcrl!nt type!~ of :.ubunit, termed a. ~. y and S. each of M,
.t0-58 illa. The four subunits show marked sequence homology,
and analysi'> of the hydrophobicity profile, which determines
11 hi~:h section\ of the chain are likely to form membrane-spanning
a helices, sugge~ts that they arc inserted into the membrane as
shown in Figure 3.4. The pl!ntamcric structure (Otz, ~. y, o) possesses
two acetylcholine binding sites, each lying at the interface between
one of the two a subunits and its neighbour. Both must bind
act!tylcholine molecules in order for the receptor to be activated.
This receptor is sufficiently large to be seen in electron micrographs,
and Figure 3.4 shows its structure, based mainly on a high-
resolution electron diffraction ~tudy (Unwin 1993, 1995; M.iyazawa
et al., 2003). Each subunit spans the membrane four times, so the
channel comprbe~ no le~s than 20 membrane-spanning helices
surrounding a central pore.
Y ~ t"-O acctylcholinebinding sites lie on the extracellular pam of the
t\\o u 'ubumh. One of the u-;m,membrane helice~ (M:V from each of the
h1c 'ubumh fonm the hnmg of the ion channel (Fig. 3.4). The five M 1
hchcc' that fonn the pore are sharpl) kinked inwards halfway through the
mcmbrJn.:, fonnmg a con~tliction. When acetylcholine molecule~ bind.
---------- 1
Exterior
Cytosol
_______ __ _l
a-Helices forming gate
Fig. 3.4 Structure of the nicotinic acetylcholine receptor (a typical ligand-gated ion channel) in side view ~eft) and plan view (right).
The five receptor subunits (Ct2, ~. y, B) form a cluster surrounding a central transmembrane pore, the lining of which is formed by the M2
helical segments of each subunit. These contain a preponderance of negatively charged amino acids, which makes the pore cation
selective. There are two acetylcholine binding sites in the extracellular portion of the receptor, at the Interface between the et and the
adjoining subunits. When acetylcholine binds, the kinked et helices either straighten out or swing out of the way, thus opening the
channel pore. (Based on Unwin 1993, 1995.)
HOW DRUGS ACT: MOLECULAR ASPECTS
the Ct \ubunit\ twio,t, cau'>ing the kinked M 2 segments to swivel out or the
way, thu\ opening the channel (Mjyazawa et al, 2003).
The usc of \ite-directed mutagenesis. which enable.s shon regions, or single
re\idue,, of the amino acid !>C<)Uence to be altered. has shown (see Gal1i
& Changcux, 1994) that a mutation of a critical residue in the Mz helix
changes the channel from being cation-selective (hence excitatory 1n the
context of synaptic function) 10 being anion-selective(typical of receptors
for inhibitory tr.tn\mlller.. such a.s GABA). Other mutation~ affect
propcnie, ~uch a\ gating and dcscnsitisation of ligand-gated channel\.
Receptors for \Orne other f~t tran.,millers, such as the GABAA receptor
(Ch. 33),the 5-HT, receptor (Ch. t2) and the glycine receptor (Ch.33) are
built on the same pattern. and some show considerable sequence homology
with the nicotinic acetylcholine receptor; the number or subunits that go
to make up a functional receptor varies somewhat but is usually four or
five. However, other ligand-gated ion channels have a somewhat different
architecture, in which the pore is built from loops rather than tran~
mcmbranc helices (&ec p. 50), in common with many other (non ligand-
gated) ion channels. ATP receptors of the P2X type (sec Ch. 12) and
g lutamate receptors (see Ch. 33), whose structures are shown in
Figure 3.18, arc of this type.
THE GATING MECHANISM
Receptors of this type control the fastest synaptic events in the
nervous system, in which a neurot:r.msmitter acts on the postsynaptic
membrane of a nerve or muscle cell and transiently increases its
pt!nneability to particular ions. Most excitatory neurotransmitters,
such as accrylcholine at the neuromuscular junction (Ch. 10) or
gluramate in rhe central nervous system (Ch. 33), cause an increase
Pore - 0.7 nm diameter
6nm
2nm
31
 SEcnON 1 GENERAL PRINCIPLES

in Na+ and K+ permeability. Thi'> results in a net inward current of an agonist. there i\ a d) namtc equtlibrium between open nod closed ion
carried mainJy by Na+, which depolarise:, the cell and increa'>es channels. ln the \lead) \tate. the rate of opening balance' the rate of
closing, but from moment to moment the number of open channel' IHII
the probability that it will generate an action potential. The action
show ntndom nuctuations about the mean. By measuring the amplitude
of the transmitter reaches a peak in a fraction of a millisecond,
of these tluclltations. the conductance of a single ion chnnncl ~an be
and usuaJiy decays within a few mill iseconds. The sheer speed of calculated. and by mea~uringthcir frequency (u~ually in the form or a
this response implies that the coupling between the receptor and spectrum in which the noi ~c power of the signal i:. ploned a~ a function of
the ionic channel is a direct one, and the molecular structure of frequency) the average duration for which a single channel ~lay'> open
(mean open time) can be calculated. In the ca~e of acetylcholine acting at
the receptor-channel comp lex (see above) agrees with thi~. I n
the end plate, the channel cnnductance i;; about 20 pico\iemen' (l>S).
contrast to other receptor families (see below), no intem1cdiate which is equivalent to an intlux of about JO' ions per 'econd through a
biochemical steps are involved in the transduction process. ~inglc channel under nonnal phy;iological conditions. and the mean open
time is 1-2 millisecond,. Tite magmtude of the smgle channel conductance
'If A breakthrough by Katt and Miledi in 1972 made it po;~ible for the confirm' that permeation occur\ through a physical pore through the
liN ume to study the propcrtie., oltndividual ligand-gated channel b) membrane. becau<;e the ion tlo" " too large to be compatible 11 ith a earner
the U!.e of noise analysis. Studying the ;~clion of acet)lcholtnc at the mechanism. The channel conductance produced by different acetylcholine
motor endplate. they observed that \rn:tll r.tndom fluctuations of membrane LiJ...e agonists is the ~ame. whereas the mean channel lifetime 1ane,.
potenti~l were superimposed on the steady depolarisation produced by
ucetylcholinc (Fig.3.5). These tluctuations arise because. in the presence The simple scheme shown in Fig. 2.1 is a useful model for ion chan nel
gating. The conformation R", rcpre;enting the (Jpcn state of the ion
channel, is thought to be the ~ame for all agonists. accounting for the
finding that the channel conductance doe!. not vary. Kinetically, the mean
open time is determined mainly by the closing rate con\tant. a. and th1.,
ACh . . . varies from one drug to another. A~ e:~.plamed in Chapter 2. an agonl\t of
t., L~~ i4~ t!:l~,W,~ -i~ :=~~-!l:..if~
.\.:.' t .. :.:..
~, . . ,. . .,.~.: , ., . ! ~ --~;, ~""
high efficacy that activate' a l;trge proponion of the receptor\ that tt
occupies will be charactcri-,ed by ~a >> I. whereas for a drug olio\\
~
: ~ .!t~ f~ -~
~- !
! '"~.!;.:!: 1:4
lnA
[ ;
! .
! t : C,.I
. :
t \.:
.
efficacy fVa has a lo\\er value.
~1 'fOU- ,~I*" ;.,.. :..~:tw~ The patch clamp recording technique, devised by Neher und Sa~mann.
Control 1 allows the very small current nowing through a single ionic channel to be
L______)
mea,urcd directly (Fig. 3.6). and the resu lts have fully confirmed the
100 ms interpretation of channel propcrtiet- ba;ed on noise ann l yi~. Thi'
technique provides a view, unique in biology, of the physiological
behaviour of individual protein molecules in real time. and ha' given
B) many new insight'> into the gating reactions and pcrmcabtlit)
10-21 Cut-off frequency characteristics of both ligand-gated channel~ and 101tagegated channeh
42.5 Hz (see p. 49). Single-channeli\.'COrding ha\ sh01~ o that many agoni.,h cau..c
indi1idual channels to open to one or more of \everal di.,unct
conductance le\cb. In the ca-,e of glutamate-activated channeb. tl
appears that different agonl\h produce different receptor conformauon'

1023
(/)

t. . ~ .,....._
~"' til\..,~~ !lf'.~t ~ 0 Qi
c

I c
ItS
.c.

~ l~
0
10 100 c
~
Frequency (Hz)
'rl 0
Fig. 3.5 Acetylcholine-induced noise at the frog motor 0
endplate. A Records of membrane current recorded at high ~
~3pA ~~
gain under voltage clamp. The upper noise record was E
::J
2 z
recorded during the application of acetylcholine (ACh) from a
micropipette. The lower record was obtained in the absence of
10 ms trans
ACh, the blip in the middle being caused by the spontaneous
release of a packet of ACh from the motor nerve. The steady discu
(DC) component of the ACh signal has been removed by Fig . 3 .6 Single acetylcholine-operated ion channel s at varyi
electronic filtering, leaving the high-frequency noise signal. the frog motor endplate recorded by the patch clamp
are d
(] Power spectrum of ACh-induced noise recorded in a similar technique. The pipette, which was applied tightly to the
experiment to that shown above. The spectrum is calculated surface of the membrane, contained 1OJlmol/1 ACh. The
by Fourier analysis and fitted with a theoretical (Lorentzian} downward deflections show the currents flowing through single
curve that corresponds to the expected behaviour of a single ion channels in the small patch of membrane under the pipette
population of channels whose lifetime varies randomly. The tip. Towards the end of the record, two channels can be seen
cut-off frequency (at which the power is half of its limiting to open simultaneously. The conductance and mean lifetime of
low-frequency value) enables the mean channel lifetime to be these channels agrees well with ind1rect estimates from noise
calculated. (From: (A) Anderson C R, Stevens C F 1973 J Physiol I analysis (see Fig. 3.5). (Figure courtesy of D Colquhoun and )
235: 655; (B) Ogden DC et al. 1981 Nature 289: 596.) __) \ DC Ogden.)
32
------------------------------------

a\\t>Ci.ucu Wtth dtftcrent channel conductances (Jin et al., 2003).
D.;,cn,ni-ation of hgand-gated ion channel~ also imolves one or more
addtuonal agonl\tinuuced conformational Mates. These findings
n.x:.:,,itate 'orne claborJilon of the ~imple scheme of Fig. 2.1. in which
unl) a "ngk open 'tilt.:. R . ~ reprc-ented. and are an example of the wa)
m \1 hkh the J'tual bcha\iour of receptor. make' our theoretical model\
hul.. a hnle threadbare.
TYPE 2: GPROTEIN-(OUPLED RECEPTORS
The abundant GPCR family comprises many of the receptors that
n
arc familtar to pharmacologiM:-.. 1>uch as mAChRs. adrenocepLOrl>,
dopamine receptors. 5-HT receptors, opiate receptors, receptor:.
ner for many peptides, purine receptors and many others, including
the chemoreceptor<. involved in olfaction and pheromone detection,
and ai\O many 'orphans' (1.cc Pierce et al., 2002). For most of
neJ thc~c. quantitm ive pharmacologil:al studies w ith di fferent agonists
ra>n
und antagonists have revealed a variety of subtypes. M any
ihe
GPCR~ have been cloned. revealing a strikingly coherent pattern
of their molecular ~tructure.
Many ncurotran~mittcr~>. apart from peptides, can interact with
both GPCR, and with ligand-gated channels. allowing the same
molecule to produce a wide variety of effect<>. Individual peptide
hom10nc'l. on lhc other hand, generally act eitJ1er on GPCRs or
on J..ina,..:linJ..ed receptors (~ee below), but rarely on both, and
a 'imilar choo~ine~' applies to lhe many ligand:. that act on
7
nudear receptors.
The human genome includes genes encoding about -tOO GPCR <;
(c\duding odorant recep1or1>: ~cc Bcn-Shlomo et al.. 2003). GPCRs
con,titule the commonest '>ingle dru.s of targets for therapemic
drug,. and it is though! 1ha1 many promising therapeutic drug
targeh of thb 1ype remain to be identified. For a short review, see
Htll (2006).
MOLECULAR STRUCTURE
The tir~l GPCR to be fu lly characterised was the ~-adrenoccptor
((h. I I ). which was cloned in 1986. Subsequently, molecular
hiology caughl up very rapid ly with pharmacology. and most of
1he receptors that had been identified by their pharmacological
propcnic~ have now been cloned. What seemed revolutionary in
1986 i' now commonplace, and nowadays any aspiring receptor
ha~ to be doned before it is taken seriously.
G-prolcin-coupled receptor~ consist of a single polypeptide
chain of up to 1100 re~idues whose general anatomy is shown in
Figure 3.3B. Their characteristic structure comprises seven
tran,membrane o: helices. similar to those of lhe ion channels
di..cu,\Cd above. with an extracellular N-lerminal domain of
\af)ing lenglh. and an intracellular C-terminal domain. GPCRs
an: dh idcd into three di~tinct families (sec ScbwartL. 1996).
Example' of promi..:uity are incre<\\ing. however. Steroid hormones, nom1ally
lallhfult<l nuclear receptor~. m:lke the occasional pa.% at ion channels and
other target' t-ee ~ut ken\tcin el al .. 2000). and ~orne eicosanoids act on nuclear
rec~pt<lr' n' wellu~ GPCR>. Nature i~ 4uite open-minded, although such
example' an: ltahlc to make pharmacologists frown and students despair.
HO W DRUGS ACT: MOLECULAR AS PECTS
Ligand-gated lon channels
These are sometimes called ionot ropic
receptors.
They are involved mainly in fast synaptic
transmtssion.
There are several structural families, the commonest
betng heteromeric assemblies of four or five subunits,
with transmembrane helices arranged around a
central aqueous channel.
Ligand binding and channel opening occur on a
millisecond timescale.
Examples include the nicotinic acetylc holine, GABA
type A (GABAA), and 5-hydroxytrypt amine type 3 (5-
HT3) receptors.
There i'> con~idcrable sequence homology between the members
of one fami ly, but none between different families. They !.hare
the same seven-helix (heptahelical) structure, but differ in other
respect\, principally in the length of the extracellular N lcrminus
and the location of the agonist binding domain (Table 3.3). Family
A i~ by far the large'>t, comprising most monoamine, neuropeptide
and chemoJ..inc receptors. Family B includes recepto~ for .-.ome
other peplide\. '>UCh as calcitonin and glucagon (see Ch. 14).
Family C i'> the smallest. its main membeTh being the metabotropic
glutamate and GABA receptors (Ch. 33) and the Ca1-sensing
receptor~H (~ec Ch. 31 ).
The under~tanding of 1he function of receptors of this type
owes much 10 ~tudics of a closely related protein, rhodopsin,
which i~ re.,ponsible for transduclion in retinal rods. This protein
is abundant in the ret ina, and much easier to study than receptor
proteins (which are anything but abundant); it is built on an
identical plan to I hal shown in Figure 3.3 and also produces a
response in the rod (hyperpolarisation, associated with inhibition
of a Na conduclancc) lhrough a mechanism involving a G-protein
(sec below). The most obvious difference is that a photon, rather
lhan an agonist molecule. produces the response. In effecl,
rhodopsin can be regarded as incorporating its own inbuilt agonist
molecule, namely retilwl, which isomerises from the trans (inactive)
to the cis (aclive) form when it absorbs a photon.
Site-directed mutagene~i!. experiments show that the long third
cytopla~mic loop i'> the region of the molecule that couple:. to the
G-protein, because deletion or modification of this section results
in receptors that still bind ligands but cannot associate with
G-protein:-. or produce responses. Usually. a particular receptor
sub1ype couple'> 1>electively with a particular G-protein, and
' The Cal.,cn,ing receptor (~ee Conigrave et al.. 2000) i\ an unu'>ual GPCR
that i~ acuvmcd, not by conventional mediators. but by extracellular Ca 2 ' in
the range of I I0 mM un extremely low affinity in comparison with other
GPCR agoniM~. It is expres~eu by cell> of the parathyroid gland, and serves
to regu late the extracellular e;,~ concentration by controlling parathyroid
hormone ccretion (Ch. 31 ). This homeo>tatic mechanism is quite distinct
from the rncc.:h<m i\nh for regulating intracellular Ca2 discussed in Chapter4. 33
 SECTION 1 GENERAL PRINCIPLES
Table 3.3 G-proteln-coupled recept or families
Family Receptors"
A: rhodopsin family The largest group. Receptors for most amine
neurotransmitters, many neuropeptides,
purines, prostanoids, cannabinoids, etc.
8: secret1n/glucagon Receptors for peptide hormones, including
receptor family secretin, glucagon, calcitonin.
C: metabotrop1c glutamate Small group. Metabotropic glutamate
receptor/calcium sensor family receptors, GABAe receptors, Ca2
sensing receptors.
"A fourth distinct family Includes many receptors for pheromones but no pharmacological receptors.
For full lists, see http://www.iuphar-db.org.
swapping part!. of the cytoplasmic loop between different receptors
a lters their G-protein selectivity.
For small molecules, such as noradrenaline (norepinephrine), the
ligand-binding domain i:. buried in the cleft between the a-helical
segments within the membrane (Fig. 3.3B), similar to the slot
occupied by retinal in the rhodopsin molecule. Peptide ligands,
~uch ~ \ub-.tance P (Ch. 16) bind more superficially to the extra-
cellular lOOp'>. a\ '>hown in Figure 3.3B. By single-site mutagenesis
experiments. it is po~'>ible to map the ligand-binding domain of
these receptor... and the hope is that it may soon be possible to
design '>ynthetic ligand'> b~ed on knowledge of the receptor :.ite
\tructure- an important mibtone for the pharmaceutical industry.
which ha'> relied up to now mainly on the structure of endogenous
mediator~ ('>uch a., histamine) or plant alkaloids (such as morphine)
for ih chemical in~piration. 9 So far. GPCRs cannot be obtained in
crystalline form. so the powerful technique of X-ray crystallography
cannot yet be used to dcline the molecu lar structure of these
receptors in detail. Until then, designing new GPCR ligands will
remain a somewhat hit-or-miss business.
ALTERNATIVE MECHANISMS OF RECEPTOR
ACTIVATION
T Ahhough aclivation of GPCR~ i~ normally the consequence of agonist
binding. il can occur by other mechani~ms. Rhodopsin. mentioned earlier,
i<> ncli\ aled by hghHnduced cis-trans i'omerisation of pre bound retinal.
Ano1her C\ilmple i' 1ha1 of the pmteaseactil'Oted receptors (PARs), of
"hich four ha\c \ll far been 1dcntitied (see Vecgnolle et al.. 200 I). Many
pro1ea..c,. \uch a\ thromb10 (a protea-e involved in the blood-dolLing cas-
cade . ..ce Ch. 21 ), acll\ale PAR~ by 'mpping off the end of the extracellular
tenmnall;ul of the receptor (Fig. 3.7). The exposed N-tenninal residue~
then bmd to receptor domain' in the extracellular loops. functioning a~ a
'lelhcrcd agoni\t' Rcceplor, of thi!> type occur in many tb~ue\ (see
o,,of,l..:tya & Bunnell. 2004. Vergnolle. 20Q..l). and they appear to play a
role in innamma1ion and other re~ponse~ to ti~sue damage where tissue
protea<,e~ are re lea\ed. One of the family of PARs. PAR-2. is aclivmed by
9
Many lead compound~ i n recent year~ have come from screening huge
chemical libraric& (sec Ch. 56). No inspiralion i~ req LLired, just robust
34 assays, large computers and efficient robotics.
Structural features
Short extracellular (N terminal) tail. Ugand
b1nds to transmembrane helices (amines) or
to extracellular loops (peptides).
Intermediate extracellular tail incorporating
ligand-binding domain.
Long extracellular tail incorporating ligand
binding domain.
a pr01ca~c rel ea~ed from ma't cells, and is expressed on sensory neuron\.
11 i<> 1hough1 10 play a role in innammatory pain (see Ch. 41 ). One
con\equence of Ihi\ 1ype of activation is that the receptor can be ac1ivmed
only once. becauo,c the cleavage cannot be re,ersed. so continuous
re'ynlhc'i' of receptor prolein is neces~. Inactivation occurs by deo;en'>
usauon, imoh mg pho,phorylation (see below), after which lhe receptor
i' inlema.h,cd and degraded. to be replaced by newly synthe<>iscd prolcin
Sc' eraI human di\Ca\e \tale~ ha' c been described (see below) Ihal ~
a\\IX:iated ellher with \p<>ntancous receptor mutations that resuh 10
con\tllulhe acu' ali on of receptor~. or "ith the producuon of
autoanubo<hc~ d1rected again~t the extracellular domain of receplor,.
which mimic I he effec1 of agoniSL\.
G-proteins and their role
G-proteins comprise a family of membrane-resident proteins
whose function i.'. to recognise activated GPCRs and pass on the
message to the effector .'.ystems that generate a cellular response.
They represent the level of middle management in the organisational
hierarc hy, intervening between the receptors--choosy mandarins
alert tO the faintest wh iff of their preferred chemical-and the
effector e1u.ymes or ion channels-the blue collar brigade that
gets the job done without needing to know which hormone
authorised the process. They are the go-between proteins, but
were actually called G-proteins because of their interaction with
the guanine nucleotides, GTP and GDP. For more detailed
information on the structure and functions of G-proteins, see
review<; by OITermanns (2003) and Milligan and Kostenis (2006)
G-protein!> consist of three 1.ubunits: a, ~and-y (Fig. 3.8). Guanine
nucleotides bind to the a subunit. which bas enzymic accivit).
catalysing the conversion of GTP to GDP. The f3 and y subunit\
remain together as a ~'Y complex. All three subunits are anchored
to the membrane through a fauy acid chain, coupled to the G
protein through a reaction known as prenylarion. G-protein<.
appear to be freely diffusible in the plane of the membrane. so a
single pool of G-protein in a cell can interact with several
different receptors and effectors in an essentially promiscuou~
fashion. In the 'resting' stale (Fig. 3.8), the G-protein exists as an
unauached a~y trimer, with GDP occupying the site on the a
subunit. Whe n a GPCR is activated by an agonist molecule, a
conformational change occurs, involving the cytoplasmic domain
 HOW DRUGS ACT: MOLECULAR ASPECTS

~N
Cleavage by thrombin
/\..r'-N
Released N
fragment

Phosphorylation

p
DESENSITISED

Fig. 3. 7 Activation of the thrombin receptor by proteolytic cleavage of the N -terminal extracellular domain. Inactivation occurs
by phosphorylation. Recovery requires resynthesis of the receptor.

rro
flUS
i-
Resting state
Receptor Receptor occupied by agonist

............,.,.,P.""',---
Target
Target Target Target
,.
1
a
2 1 ......,......... a ~y 2
lnachve GOP Inactive Inactive GOP , Inactive
/., ',
~
1
GT P
!Ins
the
,~e.
Target proteins
~al GTP hydrolysed activated
rms Target Target Target
Target
the 2
1
_J
(l
2 l..__ 1 _.J, ~y ~
Jhat
Active GOP Active Active
one
+
but
~ilh

.led
..ee
Fig. 3 .8 The function of the G-protein. The G-protein consists of three subunits (ex, ~. J?, which are anchored to the membrane
It~).
through attached lipid residues. Coupling of the ex subunit to an agonist-occupied receptor causes the bound GOP to exchange with
Me Intracellular GTP; the a-GTP complex then dissociates from the receptor and from the ~y complex, and interacts with a target protein
ty. (target 1, wh1ch may be an enzyme, such as adeny!ate cyclase, or an ion channeQ. The ~y complex may also activate a target protein
lllits (target 2). The GTPase acllv1ty of the a subunit is increased when the target protein is bound, leading to hydrolysis of the bound GTP
to GOP. whereupon the ex subunit reunites with ~y.
Ired
I G-
ems
10a of the receptor (Fig. 3.38), causing it to acquire hjgh affinity for activation of the target (Fig. 3.8). It was originally thought that
ttal ~'(. A~'ociation of a~y with the receptor causes the bound GDP only the a subunit has a signalling function. the ~y complex
loUS to dts~ociate and to be replaced with GTP (GDP- GTP serving merely as a chaperone to keep the flighty a subunits out
~an exchange), which in tum causes dissociation of the G-protein of range of the various effector proteins that they might otherwise
1(!0. trimer, releasing o.-GTP and ~y subunits; these are the 'active' excite. However, the jYy complexes actually make assignations of
~.a forms of the G-protein, which diffuse in the membrane and can their own, and control effectors in much the same way as the a
associate with various enzymes and ion channels, causing subunits (see Clapham & Neer, 1997). In general, it appears that 35
nain
 SECTION 1 IJI GENERAL PRINCIPLES

Tble 3 .4 The main G-protein subtypes and their functions

Subtypes Associated receptors Main effectors Notes

Ga subunits
Ga., Many amine and other Stimulates adenylyl cyclase, causing Activated by cholera toxin, which
receptors (e.g. catecholamines, Increased cAMP formation. blocks GTPase activity, thus
histamine, serotonin) preventing inactivation.

Ga, As for Ga,., also opioid, Inhibits adenylyl cyclase, decreasing Blocked by pertussis tox1n, which
cannab1noid receptors cAMP formation. prevents dissociation of aj3y complex.

Ga., As for Gcx.. also opio1d, ?Limited effects of a subunit (effects Blocked by pertuss1s tox1n. Occurs
cannabino1d receptors mainly due to j3y subunits). ma1nly in nervous system.

Gexq Amine. peptide and Activates phospholipase C,

prostanoid receptors increasing production of second
messengers inositol trisphosphate
and diacylglycerol (see p. 38).

Gj3y subunits All GPCRs As for Ga subunits (see above). Also: Many Gj3y isoforms Identified, but et
activate potassium channels specific functions are not yet known.
inhibit voltage-gated calcium channels Gj3y -mediated effects probably
activate GPCR kinases (p. 40) reqUire higher levels of GPCR
activate mitogen-activated protein activation than Gamediated effects.
kinase cascade.
GPCR, G-proteincoupled receptor.
-rhis table lists only those isoforms of major pharmacological significance. Many more have been Identified, some of which play roles in
olfaction, taste, visual transduction and other physiological functions (see Offermanns, 2003).

higher concentrations of py complex than of a subunits are
needed, so py-mediated effect~ occur at higber levels of receptor
occupancy than a-mediated effect!>. Association of a subunits
with target enzymes can cause either activation or inhibation.
depending on which G protein in involved (see Table 3.4).
Signal ling is terminated when the hydrolysis of GTP to GOP
occurs through the GTPase activity of the a subunit. The
resulting a-GOP then dissociates from the effector, and reunites
with py, completing the cycle. Attachment of rhea subunit to an
effector molecule actually increases its GTPase activity. the
magnitude of thi increase being different for different types of
effector. Because GTP hydrolysis is the step that terminates the
ability of the a subunit to produce its effect. regulation of its
GTPase activity by the effector protein means that the activation
of the effector tends to be self-limiting. The mechanism results in
amplification because a single agonist-receptor complex can
activate several G-protein molecules in tum, and each of these
can remain associated with the effector enzyme for long enough
to produce many molecules of product. The product (see below)
i~> often a 'second messenger', and further ampl ification occurs
before the final cellular response is produced.
How is specificity achieved w that each kind of receptor produces
a distinct pattern of cellular responses? With a common pool of
promiscuous G-proteins linking the various receptors and effector
systems in a ceU, it might seem that all specificity would be l o~t.
but this is clearly not the case. For example, mAChRs and P-
adrenoceptors, both of wh ich occur in cardiac muscle cells. pro-
36 duce opposite functional effects (Chs I 0 and II ). The main reason
is molecular variation within the a subunits, of which more than
20 subtypes have been identified 0 (see Wess. 1998: Table 3.4). Four
main classes of G-protein (G,. G,. Go and Gq) arc of pharmaco-
logical importance. A'> "ummari!>ed in Table 3.4, they !.hov, ~elec
tivity with respect to both the receptors and the effecto~ with
which they couple, having l)pecific recognition domain~ in their
structure complementary to specific G-protein- binding domains
in the receptor and effector molecules. G~ and G; produce, respect-
ively. stimulation and inhibition of the enzyme adenylyl cyclase
(Fig. 3.9). The G-proteins can be thought of as the intramembranc
managers. bustling between receptors and effectors, controlling this
microcosm but communicaLing very little with the world out~idc.
The a subunits of these G-proteins differ in structure. One
functional difference that has been useful a~ an experimental tool
to distinguish which type of G-protein is involved in different
situations, concerns the action of two bacterial toxins, cholera
toxin and pertussis toxin (sec Table 3.4). These toxins, which an:
enzymes, catalyse a conjugation reaction (ADP ribosylation) on
the a subunit of G-protcins. Cholera toxin acts only on G,. and
it causes persistent activation. Many of the symptoms of cholera,
such as the excessive secretion of nuid from rhe gastrointeM inal
wA~ well as more than 20 known '>Ubi) pes of Ga. there arc 6 of G~ and 12
of Gy, providing, in them). about 1500 varianiS of the uimer. We r..now
liule about the role of different a, p. y '>Ubtypes. but it would be r.l'oh to
assume that the variation\ arc functionally irrelevant. By now, you will be
un;urprised (even if 'omcwlmt bemused) by such ;1 di!>play of molecular
heterogeneity, for it is the way of evolutinn.
 HOW DRUGS ACT: MOLECULAR ASPECTS

Inhibitory Target
receptor enzyme
Fig. 3.9 Bidirectional control
of a target enzyme, suc h as
adenylyl cyclase by G1 and G1
Heterogeneity of G-prote1ns allows
d1fferent receptors to exert opposite
effects on a target enzyme.

epithelium, arc due to the uncontro lled activatio n of ade ny ly l
cyclase that occun.. Pertu ~si s toxin specificall y blocks G, and 0 0
hy preve nting dissociation of the G -prote in trimer.
TARGETS FOR G-PROTEINS
The main target ~ for G-prote ins. through which GPCRs contro l
tlin'erent aspects of cell function (sec Milligan. 1995; Gudetmann
ct al., 1996: Nahorski, 2006: Table 3.4), are:
adenvlrl crcla\e, the e n1.yme respo nsible for cAMP formatio n
phospholipa.\ e C, the etvy me respo ns ible for inosito l
pho-.phate and diacy lg lycerol (DAG ) form ation
itm chtmntds, particularly calcium and potassium c hannels
Rlw NR/w ~ina!Je, a syMcm that controls the activity or
many stgnalhng pathways contro lli ng cell growth and
prohferauon. smooth muscle contraction. e tc.
The adenylyl cyclase/cAMP system
The di-.con:ry b) Sutherland and his colleagues of the role of
an c.\MP (cyclic 3'.5'-adenosine monophosphate) as an intracellular
lUr mediator demolished at a ~troke the barriers that existed between
to-
t'C-
ith Gproteln-coupled receptors
1eir
pns These are sometimes called metabotropic
ect- receptors.
~:~se Structures comprise seven membrane-spanning
1!11e a-helices, often linked as d imeric structures.
this One of the intracellular loops is larger than t he others
de. and interacts with the G- protein.
)ne 1 The G-protein is a membrane protein comprising
ool three subunits (ex, ~. "(), the a subunit possessing
rnt GTPase act1vity.
era 1 When the trimer binds to anagonist-occupied receptor,
are the <X subunit dissociates and is then free to activate
on an effector (a membrane enzyme or ion channel). In
md some cases, the ~Y subunit is the activator species.
:ra, 1 Activatton of the effector is terminated when the
nal bound GTP molecule is hydrolysed, which allows the
a subunit to recombine with py.
There are several types of G-protein, which interact
12 with different receptors and control different effectors.
1 Examples include muscarinic acetylcholine receptors ,
adrenoceptors, neuropeptide and c hemokine
receptors, and protease-act ivated receptors.
biochemistry and pharmacology, and introduced the concept of
second messengers in signal transd uction. cAMP is a nucleotide
synthesised within the cell fro m ATP by the actio n of a
membrane-bo und c nty mc. adeny ly l cyclase. It is produced
continuously and inactivated by hydro lysis to 5'-AMP. by the
action o f a fami ly or e nq mcs known as phosphodiesterases (PDEs).
Man y diffe re nt drugs, ho rmo nes and neurotrans mitters act on
GPC Rs and produce their effects by inc reasing or decreasing the
catal ytic ac ti vit y o f ade nylyl cyclase, thus raising or lowering
th e concentratio n of cAMP within the cell. There arc several
d iiTen.:nt mo lecular i~ofonns of the enzyme, some of which respond
<>electively toGa, or Ga, (see Si mo nds, 1999).
Cyclic AMP regulates many aspects of cellular function includ-
ing, for example, enzymes involved in energy metabolism, cell
d ivision and cell differentiation, ion transport, ion c hannels, and
the contractile prote ins in smooth muscle. These varied effects
are. however, all brought about by a common mechanism, namely
the activation of protein kinase:. by cAMP. Protein kina<>es regu late
the function or many different cell ular proteins by conrro lling pro-
tein pho!>phorylation (~ee p. 43). Figure 3.10 shows how increased
c AMP production in response to ~-adrenoceptor activation affects
e nzy mes invo lved in g lycoge n and fat metabolism in liver, fat
and muscle cells. The result is a coordinated response in wh ich
s tored energy in the fo rm o f g lycogen and fat is made available
as g lucose to fue l muscle contraction.
Other examples o f regulati on by cAMP-depe ndent pro tein
kin ases include the increased acti vity of voltage-activated calcium
channels in heatt muscle cells (see C h. 18). Phosphorylation of these
c hannels inc rea~es the a mount of Ca2+ enteri11g the cell durin g
the acti on pote ntia l, and thus increases the force of contractio n of
the heart.
In smooth muscle, cAMP-dependent protein kinase phos-
phorylates (the reby inacti vati ng) anothe r enzyme, myosi n- light-
chain "-ina e, which is req uired for contractio n. This accounts for
the smooth muscle re lax ation produced by many drugs that
increase cAMP production in smooth muscle (see Ch. 19).
As mentioned above, receptors li nked toG, rather than G, inhibit
adcny ly l cyclase. and thus reduce cAMP formation. Examples
include certain types of mAChR (e.g. the M 2 receptor of cardiac
muscle; see C h. I 0). <Xz-adrcnocep tors in smooth muscle
(Ch. I I). and opioid receptors (see C h. 41 ). Adeny ly l cyclase can
be acti vated direc tly by certain agents, includi ng forsko lin and
fluori de i on ~ . agents that are used experime ntall y to s tudy the
ro le of the cAMP syste m.
Cyclic AMP is hydro lysed w ithin cells by phosphodiesterases
(PDEs), an importan t and ubiquito us family of enzymes (see Beavo,
1995, for review). Many POE s ubty pes exist, of which some (e.g. 37
 SECTION 1 GENERAL PRINCIPLES

Increased lipolysis
Lipase (inact1ve)

~
-~ADP

Protein kinase

AC C ATP ~
inactive)
~ Glycogen synthase Reduced glycogen synthesis

\ ' cAMP -~--z(active)

pp
) Protein kinase
'- (active) /

G
Glycogen synthase
(inactive)_..,.

Agonist ) Phosphorylase Increased glycogen breakdown

kinase (inactive)
p

Phosphorylase
kinase (active) Glycogen

Phosphorylase a ~ATP
..._ (active) )
r - ADP

Glucose 1-phosphate

Fig. 3 . 1 0 Regulation of energy metabolism by cAM P. AC, adenylate cyclase.

PDE, and PDE4 ) are cAMP-selective, while others (e.g PDE5) are
cGMP-selecti ve. M o~>t are weakly inhibited by drugs such as
methylxanthines (e.g. theophylline and caffeine: see Chs 23 and
42). Rolipra m (used to treat asthma, Ch. 23) is selective for PDE4
expres!'>ed in innammatory cells; milrinone (used to treat heart
failure, Ch. 18) is . elective for PDE4 , which is expressed in heart
muscle: ildenafll (better known as Viagra, CIL 30) is selective for
PDEs. and consequently enhances the vasodilator effects of NO
and drugs that release NO, whose effects are mediated by cGMP
(see Ch. I 7). The similarity of some of the actions of these drugs
to those of catecholamines probably reflects their common property
of increasing the intracellular concentration of cAMP. Selective
inhibitors of the various PDEs are being developed, mainly to
treat cardiovascular and respiratory diseases (Chs 19 and 23).
The phospholipase C/ inositol phosphate
system
The phosphoinositide system, an important intracellular second
messenger system, was first discovered in the 1950s by Hokin
38
._.---- and Hokin, whose recondite interests centred on the mechanis m
of salt secretion by the nasal glands of seabirds. They found that
secretion was accompanied by increased turnover of a minor
class of membrane phospholipids known as plzosphoinositide.~
(collectively known as Pis; Fig. 3. 11 ). Subsequently, Michell and
Berridge found that many hormones that produce an increase in
free intracellular Ca 2+ concentration (which include, for example.
muscarinic agoni~ts and o..-adrenoceptor agonists acting on smooth
muscle and salivary glands. and vasopressin acting on liver cell~)
abo increase Pr turnover. Subsequently. it was found that one
particular member of the Pl family. namely phosphatidylinositol
(4,5) bi1>phosphate (PrP2). which has additional phosphate groups
attached to the inositol ring, plays a key role. PIP2 is the substrate
for a membrane-bound enzyme, phospholipase C~ (PLC~).
which pi its it into DAG and inositol ( 1.4,5) trisphosphate (TP1:
Fig. 3.12), both of which function as second messengers as
discus ed below. The activation of PLC~ by various agonists is
mediated through a G-protein (Gq, see Table 3.4). After cleavage
of PIP2 , the status quo is restored as shown in Figure 3. 12, DAG
being phosphorylated to form phosphatidic acid (PA), while the
IP 3 is dcphosphorylated and then recoupled with PA to form PIP2
 HOW DRUGS ACT: MOLECULAR ASPECTS

within the membrane. It binds to a specific site on the PKC

)> molecule, which migrates from the cytosol to the cell membrane
iil
0
;:r
in the presence of DAG, thereby becoming activated. There are
a: 10 different mammalian PKC subtypes. which have distinct
-:i 0
::;,
~ 0 cellular distributions and phosphorylate different proteins. Most
are activated by DAG and raised intracellular Ca 2. both of which
Q) Q)
0 0
a: a:
arc produced by activation of GPCRs. PKCs are also activated by
DAG
PA p horbol esters (highly irritant, tumour-promoting compounds
produced by certain plants}, which have been extremely useful in
0 0 studying the functions of PKC. One of the subtypes is activated
PIP2 , PLA2, by the lipid mediator arachidonic acid (see Ch. 13) generated by
c c c the action of pho:.pholipase A 2 on membrane phospholipids, so
0 PKC activation can also occur with agonists that activate this
PLC
p enzyme. The various PKC isoforms, like the tyrosine kinases
PLD discussed below (p. 43) act on many different functional proteins,
HO OH
6 2 such as ion channels. receptors, enzymes (including other
1(1 ,4,5)P 3
5 3 kjnascs) and cytoskeletal proteins. Kinases in general play a
p 4 OH central role in signal transduction, and control many different
p aspects of cell function. The DAG-PKC link provides a channel
whereby GPCRs can mobilise this army of control freaks.
Fig. 3.11 Structure of phosphatidylinositol
bisphosphate (PIPJ, sh owing sites of cl eavage by different lon channels as targets for G proteins
phospholipases to produce active mediators. Cleavage by
0-protein-<oupled receptors can control ion channel function
phospholipase A, (PLA,) yields arachidonic acid. Cleavage by
phospholipase C (PLC) yields inositol trisphosphate (1(1,4,5)P:J directly by mechanisms that do not involve second messengers such
and diacylglycerol (DAG). PA, phosphatidic acid; PLD, as cAMP or inositol pho~phates. This was first shown for cardiac
phospho~ pase 0 muscle, but it now appears that direct G-protein-<bannel interaction
may be quite general (see Wickham & Clapham. 1995). Early
examples came from :.tudies on potassium channel . In cardiac
Olk.'t agam 1 Lithium. an agent used in psychiatry (see Ch. 39) muscle, for example, mAChRs are known to enhance K+ per-
!litll:b this TCC}Chng pathway (see Fig. 3.12). meability (thu~ hypcrpolarising the cells and inhibiting electrical
activity: see Ch. 18). Similar mechanisms operate in neurons, where
Inositol phosphates and intracellular calcium many inhibitory drugs such m; opiate analgesics reduce excitability
lnosnol (I .4.5) trbphosphate is a water-soluble mediator that is by opening potassium channels (see Ch. 41). These actions arc
rck;Jscd mto the cytosol and act~ on a specific receptor-the fP3 produced by direct interaction between the l3y subunit of 0 0 and
receptor -which b a ligand-gated calcium channel present on the channe l, without the involvement of second messengers.
th~ membrane of the endopla~mic reticulum. The main role of
IP, tbcribcd in more detail in Chapter 4, is to control the The Rho/ Rho k inase system
1nd that rd~asc of Ca'+ from intrncellular stores. Because many dmg and "' Thi~ rcccnlly discovered !.ignal transduction pathway (see Bishop &
1 minor hormone effect~ involve intracellular Ca2+, thjs pathway is llall, 2000) i~ ~ctivaled by certain GPCRs (and aho by non-GPCR
ositide\ partkularly important. lP3 is converted inside the cell to the mechanisms). which couple 10 G-proteins of the G 12113 type. The free
nell and (1.\4,5) tctrapho~phate.IP4 , by a specific kinase. The exact role G-protcin a. subunit interJct!. with a guanosine nucleotide exchange
factor. which facililales GDP-GTP exchange at another GTPase,
rease in r>l IP4 remain' unclear (<,ec Irvine, 200 I), but there is evidence
Rho. Rho-GOP. the rc'ting fonn, is inactive, but when GDP-GTP
kample. thai it too I!I Jn\Oived in Ca 2+ signalling. One possibility is that it exchange occur~. Rho is activaled. and in tum activates Rho l.inase.
-,mooth faclht.llcs Ca' entry through the plasma membrane, thus avoiding Rho kin:t\e phO\phorylate' many ~ubs1rate proteins and control' a wide
er celb) dtpktwn of the intracellular store~ as a result of the action of IP3 . variety of cellular functions. including smooth muscle contraction and
hat one prolifcra1ion. angiogenesi\ and synaptic remodelling. B) enhancing
lino~Hol Diacylglycerol and protein kinase c hypoxia-mduced pulmonary artery vasooonstriction. acti\'ation of Rho
kina\e 1\ thought to be importanl in the pathogenesis of pulmonal')
rgroups DJac)lgl}cerol 1' produced a~ well as IP 3 whenever receptor- hypertension (sec Ch. 19). Specific Rho kinase inhibitor.. are m
ub~trate mduced PI hydrolysis occu~. The main effect of DAG is to dc\'Ciopmcm for a w1de range of clinical indications-an area to watch.
PLC~). &.:tll'ate a membrane-bound protein kinase, protein J.:inase C (PKC),
~te (IP,: The main postulated roles of GPCRs in controlling enzymes and
11h1lh catalyse' the phosphorylation of a variety of intracellular
ion channels arc summarised in Figure 3.13.
1ger.. as prot~m' bee Ni'>hituka, 1988; Walaas & Greengard, 1991 ). DAG,
tmists 1s unhke the 1nositol phosphates, is highly lipophilic and remains Desensitisation
;leavagc
"' As described in Chapter 2, desensitisation is a feature of all GPCRs.
2.DAG and the mechanisms underlying it have been extensively Mudied. Two
rhile the 11 \hcrnali~c ahb~viations for these medialors are Ptdlns (PI), Ptdlns (4,5)- main processes are involved ('ec Koenig & Edwardson. 1997; Krupnick
1m1 PIP2 & 13enovic, 1998; Fergu~on, 200 I):
39
P !PIP I. In\ (1,.1,5) P1 (IP3). and Ins ( I , 2, 4, 5)-P4 (lP4 ).
 SECTION 1 GENERAL PRINCIPLES

PI

~0
Kinases

Phospholipase C

Phosphatidic acid OAG

[
\. Kinase /

l
Activation o f
--~F=--~~ protein k inase C J
OH

Inositol
o ~
, 1-phosphatase.t Phosphatases

0 0 Release of
intracellular Ca2+
Inositol IP

1(1 ,4 ,S)P3

1 1
0

c\
? Ca2+ entry
through membrane

1(1,3,4)P3 1(1 ,3,4,S)P4

Fig. 3 .1 2 Th e phos phatidylinositol (PI} cycle. Receptor-mediated activation of phospholipase C results in the cleavage of
phosphatidylinositol b isphosphate (PIP2), forming diacylglycerol (DAG) (which activates protein kinase C) and inositol t risphosphate (IP:J

l
(which releases intracellular Ca2). The ro le of inositol tetraphosphate (IP4 ), which is formed from IP3 and o ther inositol phosphates, is
2
unclear, but it may facilitate Ca + entry th rough t he plasma membrane. IP3 is inactivated by dephosphorylat ion to inositol. DAG is
converted to phosphatidic acid, and these two p rod ucts are used to regenerate PI and PIP2 .

receptor pho.,phorylation
receptor intcrnali\ation (endocytosis).
The o,equcnce of GPCRs includes ccnain residues (serine and threonine).
mainly in the C-tcrminal C) toplasmic tail. which can be pho~phorylated
by kinao,c, ..uch a<, protein kma-e A CPKA), PKC, and specific membrane-
bound GPCR kina!>e!> CGRK\l.
internet ion with G-proteins and also target Lhe receptor for endocyto~i'.
producing a more profound and long-la~ting desensitisation. The fil'\t GRK
to be identified wa' the fl-adrcnoccptor kinase. BARK. but severJI other'
have since been discovered. and this rype of desensitbmion ..eem' tc
occur with mo\t GPCR,.

Phosphor)lation by PKA and PKC. which are activated by many GPCR.s,
general!} lead) to tmpaued coupling between the activated receptor and
the G-protein. \O the agonist effect ts reduced. These kinases are not very
..electi\e, \O receptor.. other than that for the desensitising agonist will
abo be affected. Thts effect. whereby one agonist can desensitise other
rccepmrs. i'> known a~ heterologous de>ensitisation, and is generally
weal.. and shon-la!>tmg (!>ee Fig. 3.14).
SOME RECENT DEVELOPMENTS
T Our knowledge of GPCR biolog) is expanding rapid!). Here we deo;crilJ(
\Orne recent de'elopments that may ha\e imponant implications for ph=
cology in the future (~>ee review by Pierce et al.. 2002). Those wishmg tu
'>tiel.. to the basic story of GPCR function can safely skip this section.

Phosphorylation by GRK' bee Krupnick & Benovic, 1998; Fig. 3.14) is

GPCR dime risation
receptor-specific to a greater or les\er degree. and affects mainly receptors T The conventional view that GPCRs exist and function as monomen.
10 their activated (i.e. agoni,t-bound) state, resulting in homologous proteins (in contrast to ion channels. which generally form multimcn,
desen.liti.llltion. The residue~ that IGRKs phosphorylate are different complexes: 'iCC p. 50) was first overturned by work on the GABA 0 receptor
from tho~e targeted by other kina~e,, and the phosphorylated receptor 1\vo 'ubtypc~> o f this GPCR el\ist. encoded by different genes. and the
40 '>Crve~ ll'> a binding ~i te for arreltitlS, intracellul ar proteins that block the functi onal receptor consists of a heterodimer of the two. It now seem>
 HOW DRUGS ACT: MOLECULAR ASPECTS

Receptors G-prote~f---------------,

Target
1
Guanylate Adenylyl
Phospholipase C
enzymes cyclase cyclase
' ,

Second
(\ (\
messengers cGMP cAMP - AA

1
t [Ca2..)1
1
Eicos anoids --- -- - -- - -,
I

Protein
klnases
1
PKG PKA
1 1
PKC
y
Released
as local

J l
hormones
I
~

Effectors Enzymes,
l
Contractile
l lon
transport proteins, etc. protetns channels

Fig. 3.13 G-protein and second messenger control of cellular effec tor system s. AA, arachidonic acid; DAG, diacylglycerol; IP3 ,
inosttol trisphosphate.

hkd} that mtht. tf not all. GPCRs exi\1 as oligomers (Angers et al .. 2002).
Withm the opioiu rcct:ptor family (~ee Ch. 4 1), Mabie and functional dimen.
''' K ami 0 r~~cptors have been found whose pharmacological properties
utller twm those ot either parent. More diverse GPCR combination~ have
also been toumJ. such as that between dopam ine (D!) and somatostati n
rc~cpwr~. on which both ligand act with increased potency. Roaming
even funhcr alicld in search of functional assignations. the dopami ne
receptor D, can couple directly wi th a ligand-gated ion channel, the GABAA
n:..:cpw, inhibiting the function of the latter without the intervention of
an} G prmcm (Ltu et al.. 2000). These interaction~ have so far been
studied mainly 111 t:ngineercd t:ell lineii, and their imponance in native
cells is unccnain. There i;, C\ idcnce. however (AbdAlla et al.. 200 I). that
Jun~tn>n<tl dnncnc complcxc' bemecn angiotensin (AT 1) and bradykinin
tBj) r~ceptors occur in human platelets and show greater sen~itivity to
angmten,in than pure Af 1 receptors. In pregnant women suffering from
h)penen\lon (pre-eclampuc toxaemia). the number of these dimers increases
<lue to increasc:d e'pre"ton of B. receptors. re~ulting-paradoxically- in
m<:rca'<--d SCn\IUHty to the 'a!>oconstrictor action of angiotensin. This is
the hrsttn,tancc ot the role of dimerisation in human disease.
It '' too carl} to 'a} \\hat tmpact this newly discovered versatility of
GPCR' in linlmg up "-llh other receptors to form functional combi-
nauon, "til ha~c on conventional pharmacology and therapeutics, but it
~uulu be considerable.
Constitutively active receptors
~ric
1tric 'f G protein coupled receptors may also be constitutively (i.e.
ptor. \pontancou,ly) active in the ab~>ence of any agonist (see Ch. 2. rev iew by
the Co,ta & Cotccchia. 2005). Th i' wa~ first ~>hown for the ~-adrenoceptor
ems 1\cc Ch. II). where mutations in the third intrace ll ular loop. or
simply o'erc11prcs~ion of the receptor. result in constitutive receptor
activat ion. There are now m:my e~tamples of native GPCRs that show
constitutive activity when expresed in vitro (see Teitler et aJ.. 2002). 111e
hiMaminc H 1 receptor also ~>hows constitutive activity in vivo, and thb
may prove to be a quite genera l phenomenon. It means that imer,e
agonist~. which suppress this ba~>al acti vi ty, may exert effects disti nct
from those of neutral antagonists. which block agonist effects without
affecting ha~al activity.
Agonist specificity
T It was thought that the linkage of a panicular GPCR to a particular
signal transduction pathway depends mainly on the structure of the
receptor. panicularly 111 the region of the third intracellular loop, which
confer;, ;,pecilicity for a panicular G-protein. from which the rest of the
'>ignal tr.ln\ducuon pathway follow,. This would imply. in line with the
tWlHt:ue model discu.,~cd in Chapter 2. that all agonists acting on a
panicular receptor Mabilise the same activated (R*) state and ;,hould
activate the \arne \lgnal tran,duction pathway. and produce the same type
of cellular rc;,pon,e. It i;, now dear that this is an o,ersimplitication. In
many ca\e\. for example with agoni~ts acting on opiate receptors, or with
inver;,c agoni~l'> on ~-adrcnoccpton.. the ceUular effects are qualitatively
different with diiTcrent ligand~. implying the existence of more than
one probably many R* Mates (sometimes referred to as agonis1
rrafficking or prorean agonism. ~ee Kenakin, 2002). How general this will
prove to be i' not yet clear. but it may have profound implications
indeed heretical w many pharmacologists. who are accustomed to think
of :lgonim in terms of their affin ity and efficacy, and nothing else. If
substan ti ated, it wi ll add a new dimension to the way in wh ich we th ink
about drug eftlcacy and spet:ificity. 41
 SECTION 1 GENERAL PRINCIPLES

mechanism that is thought to have a regulatol') function in man)

situations. RAMPs and RGS proteins arc two example' (see Pierce ct al
Agonist 2002) where protein-protein interaction~ influence the pharmacologk
beha' iour of the receptors in different ways.

Gprotein-independent signalling
T fn u~ing the term G-protein-<oupled receptor to de-.cribc the cla\S d
receptors characterised by their heptahelical ~tructurc. we are fol low1ng
Activation of conventional textbook dogma but neglecting the fact that G-proteins an
PKA, PKC, etc. not the only link between GPCR!> and the variou!> effector system~ thai
they regu late. The example of d1rect linkage between GPCR, and i01
A
Receptor
channcb wa~ mentioned abo, e. There are al'o many example\ where the
variOU\ 'adapter proteins' that link receptor' of the tyrosine kimt\e typo:
phosphorylation to thetr effectors (MX below) can al\0 intemct with GPCR\ (see 8rO<,tow'l
(non-specific) & Kimmel. 200 I), allowing the 'arne eiTector sy~tems to be regu lated h)
receptors of either type. In this context. the ~pecific receptor kioac;es till..

j \ are involved in de~nsiti!.ation (see above) may al\o contribute to signoli

transduction, because pho~phorylation of the C-tcrminal region of tb
GPCR produce' a recognition site for molecules of the ~ignaltransduction

...etc. pathway. analogous to the functioning of the kina'oe-linked receptor\ (set

below: review by Bockaen & Pin. 1999).

\I
In summary, the simple dogma that underpins much of our current
Arrestin understanding of GPCRs. namely,

I \ one GPCR gene-one GPCR protein-

Loss of Reduced
G-protein Endocytosis G-protein
coupling coupling
HOMOLOGOUS HETEROLOGOUS
Fig. 3.14 Desensitisation of G-protein-coupled
receptors (GPCRs). Homologous (agonist-specific)
desensitisation involves phosphorylation of the activated
receptor by a specific kinase (GPCR kinase, GRK). The
phosphorylated receptor (P-R) then binds to arrestin, causing
it to lose its ability to associate with a G-protein, and to
undergo endocytosis, which removes the receptor from the
membrane. Heterologous (cross-)desensitisation occurs as a
I result of phosphorylation of one type of receptor as a result of
activation of kinases by another.
l~an~KC, protein kinase A and C, respective!~ _ _ )
RAMPs and RGS proteins
T Receptor activity- modifying proteins (RAMPs) are a family of
membrane prote10;, that associate with GPCRs and alter their functional
characteristics. They were di..co,ercd in 1998 when it was found that the
functionally active receptor for the neuropepude calciwnin gene-related
peptide (CGRP) (\ee Ch. 13) con~i\ted of a complex of a GPCR-called
calcitonin receptor- like receptor (CRLR)-that by itself lacked activity,
with another membmne protein (RAMP I). More surprising!). CRLR
when coupled with another RAMP (RAMP2) showed a quite different
pham1acology, being activated by an unrelated peptide, adrenomedullin.
In other words. the agonist specificity is conferred by the associated
RAMP as well as by the GPCR it~elf. Whether this cype of modulation
occur' with other GPCR families b not yet known.
Regulators of G-protein \ignalling (RGS) proteins (see review by
Hollinger & Hepler, 2002) are a large and diverse fam ily of cellular
proteins that pos\ess a con~rved sequence that binds specifically to Gc:x
-.ubunits. They increase greatly the GTPase activity of the active GTP-Ga
comple)(, thus hastening the hydrolysi~ of GTP and inacuvaring the
42 comple~. They thus exen an inhibitory effect on G-protein \ignnl ling, a
one functional GPCR-one G-protein-one response
is beginning to show s igns of wear. In particular:
one gene, through alternative splicing, RNA editing, etc., can
give rise to more than one receptor protein
one GPCR protein can associate with others, or with other
proteins such as RAMPs, to produce more than one type of
functional receptor
different agoni~ts may affect the receptor in different ways
and elicit qualitatively different responses
the signal tran~duction pathway does not invariably require
G-proteins, and shows cross-talk with tyrosine kinase-linked
I receptors (see below).
I
G-protein-coupled receptors arc evidently versatile and Ihie
advcnrurous molecules around which much modem pharm.-
cology revolves, and nobody imagines that we have reached tht
end of the story.
TYPE 3: KINASE-LINKED AND RELATED
RECEPTORS
Thc~>e membrane receptors are quite different in structure ana
function from either the ligand-gated channels or the GPCRs
They mediate the actions of a wide variety of protein mediatol\
including growth factors and cytokincs (see Ch. 16). and honnono
such as insulin (sec Ch. 26) and leptin (Ch. 27), whose effects are
exerted mainly at the level of gene transcription. Most of theSt
receptor11 are large proteins consisting of a single chain of up 1
1000 residues. with a single membrane-spanning helical region
associated with a large extracellular ligand-binding domain, an~.
an intracellular domain of variable size and function. The basK
tructure is shown in Fig. 3.3C, but many varianL~ exist (sec belo\1>
Over I 00 such receptors have been cloned, and many stntctui'3l
variations exist. For more detail, sec reviews by Barbacid ( 1996
 HOW DRUGS ACT: MOLECULAR ASPECTS

IWIY activate, a cytosolic tyrosine kinase, such as Jak (the Janus

al.. Effectors controlled by G-proteins l.inasc) or other kinases. Ligands for these receptors include
.cal
cylokines such a~ interferons and colony-stimulating factors
Two key pathways are controlled by receptors involved in immunological responses.
vta G-proteins. Both can be acttvated or inhibited by Guanylyl cyclase- linked receptors. These are similar in
pharmacological ligands, depending on the nature of structure to RT~. but the enzymic moiety is guanylyl cyclase
the receptor and G-protein. and they exert their effects by stimulating cGMP formation.
tng Adenylyl cyclase/cAMP: The main example i!> the receptor for ANF (see Ch. 18).
are
adenylyl cyclase catalyses formation of the
1 thai
intracellular messenger cAMP
bon PROTEIN PHOSPHORYLATION AND KINASE
uhe - cAMP activates various protein kinases that
lype control cell function in many different ways by CASCADE MECHANISMS
IWski causing phosphorylation of various enzymes, One of the major principles to emerge from recent studies (sec
:d by
carriers and other proteins. Cohen, 2002) is that protein phosphorylation is a key mechanism
,!hal
ignal Phospholipase C/inositol trisphosphate for controlling the function of proteins (e.g. enzymes, ion channels,
f !he (IP~/diacylglycerol (DAG):
receptors, transport proteins) involved in regulating cellular pro-
elion catalyses the formation of two intracellular cesses. Phosphorylation and dephosphorylation are accomplished
(see messengers, IP3 and DAG, from membrane by kina1e.1 and plwsplwtases, respectively-enzymes of which
phospholipid several hundred subtypes are represented in the human genome-
Tent IP3 acts to increase free cytosolic Ca2 by which are themselves subject to regulation dependent on their
releasing Ca2 from intracellular compartments phosphorylation c;tatus. Much effort is currently being invested in
increased free Ca2' initiates many events, mapping the complex interactions between signalling molecules
Including contraction, secretion, enzyme that are involved in drug effect~ and pathophysiological processes
activation and membrane hyperpolarisation such as oncogenesis. neurodegeneration, inflammation and much
DAG activates protein kinase C, which controls else. Here we can present only a few pharmacologically relevant
many cellular functions by phosphorylating a a~pects of what has become an enormous subject.
tan variety of proteins. In many cases. ligand binding to the receptor leads to
Receptor-linked G-proteins also control: dimerisation. The association of the two intracellular kinase
phospholipase ~ (and thus the formation of domains allow~ a mutual autophosphorylation of intracellular
arachidonic actd and eicosanoids) tyrosine residue!> to occur. The phosphorylated tyrosine residues
ion channels (e.g. potassium and calcium channels, then serve a'> high-affinity docking sites for other intracellular
thus affecttng membrane excitability, transmitter proteins that form the next stage in the signal transduction cas-
release, contractility, etc.). cade. One important group of such 'adapter' proteins is known as
the SH2 domain proteins (standing for Src homology, because it
was first identified in the Src oncogene product). These possess a
highly conserved sequence of about 100 amino acids, fotm ing a
I hie ( 1995), and Schenk & Snaar-Jakelska ( 1999). They play a
and recognition ~> ite for the phosphotyrosine residues of the receptor.
major role in controlling cell division, growth, differentiation,
ma- Individual SH2 domain proteins, of which many are now known,
inllammation, ti~>sue repair, apoptosis and immune responses,
llhe bind selectively to particu lar receptors, so the pattern of events
di~cu~~cd further in Chapters 5 and 13.
triggered by particular growth factors is highly specific. The
The main type!. arc as follow.
mechanism is summarised in Figure 3.15.
Receptor rvro.~ine kina.\eS (RTKs). These receptors have the What happen!. when the SH2 domain protein binds to the
ba,ic \tructure shown in Fig. 3.15A, incorporating a tyrosine phosphorylated receptor varies greatly according to the receptor
kina-.e mOiety in the intracellular region. They include receptors that is involved; many SH2 domain proteins are enzymes, such as
and for many growth factors. such a~ epidermal growth factor and protein kinases or phospholipases. Some growth facLOrs activate
::Rs. nene gru\1 th factor. and also the group of Toll-like receptors a specific subtype of phospholipase C (PLCy), thereby causing
rs. that n.'Cognt-.e bacteriallipopolysaccarides and play an important phospholipid breakdown. IP3 formation and Ca2 release (see
'fleS role in the body'11 reaction to infection (see Ch. 13 and review above). Other SH2-containing proteins couple phosphotyrosine-
are by Cook c1 al., 20Q.l). The insulin receptor (see Ch. 26) also containing protein~ with a variety of other functional proteins,
bese belongs to 1he RTK cla~s. although it has a more complex including many that arc involved in the control of cell division
IP to d1menc structure. and differentiation. The end result is to activate or inhibit, by
non, Serine/threonine kinases. Thb smaller class is similar in phosphorylation, a variety of transcription factors that migrate to
and stntcture to RTKs but phosphorylate serine and/or threonine the nucleus and suppre~s or induce the expression of particular
~ic r~siducs rather than tyrosine. The main example is the genes. For more detail, see Pawson (2002). Nuclear factor knppa
pw). r~ccptor for transforming growth factor (TGF). B (NFKB) is a transcription factor that plays a key role in inflam-
tural Cytokine receptors. These receptors (Fig. 3.15B) lack intrinsic matory response!> (sec Ch. 13; Karin et aL, 2004). It is normally
~6), enzyme activity. When occupied, they associate with, and present in the cy tosol complexed with an inhibitor (lKB).
43
 SECTION 1 !II GENERAL PRINCIPLES

A Conformation
Growth change Tyrosine Phosphorylation
factor 0 Dimerisation autophosphorylation of Grb2

Receptor 0 0 0 0 Acllvation of Ras

domain - GDP/GTP exchange
Transmembrane
a helix MEMBRANE

A as
Tyrosine kinase
domain -
fGDP\

GTP ! Activation

Tyrosine Raf
residue
! Phosphorylation

Binding of SH2-domain
protein (Grb2)
KINASE
CASCADE
!
Mek

Phosphorylation

Map kinase

! Phosphorylation

Various transcription
factors

NUCLEUS
1
fe Cytoklne - 9 Conformation change Phosphorylation of receptor
Binding of Jak +Jak
0 0 0 0

MEMBRANE

Binding and Dimerisation

phosphorylation
of SH2-domain
protein (Stat)
of Stat

NUCLEUS

Fig. 3.15 Transduction mechanisms of kinase-linked receptors. The first step following agonist binding is dimerisation, which
eads to autophosphorylation of the intracellular domain of each receptor. SH2 domain proteins then bind to the phosphorylated receptor

44
land are themselves phosphorylated. Two well-characterised pathways are shown: [A] The growth factor (Ras/Raf/mitogen -activated
protein (MAP) kinase) pathway (see also Ch. 5); rnl the cytokine (Jak/Stat) pathway (see also Ch. 13). Several other pathways exist, and
hese phosphorylation cascades interact with components of G-protein systems.

Kinase-linked receptors
Receptors for various growth factors incorporate
tyrosine kinase in their intracellular domain.
Cytokine receptors have an intracellular domain that
binds and activates cytosolic kinases when t he
receptor is occupted.
The receptors all share a common architecture, with a
large extracellular ligand-binding domain connected
vta a single membrane-spanning helix to t he
tntracellular domain.
Signal transduction generally involves dimerisation of
receptors, followed by autophosphorylation of tyrosine
residues. The phosphotyrosine residues act as
acceptors for the SH2 domains of a variety of
intracellular proteins, thereby allowing control of many
cell functions.
They are involved mainly in events cont rolling cell
growth and differentiation, and act indirectly by
regulating gene transcription.
Two important pathways are:
the Ras/Raf/mttogen-activated protein (MAP)
kinase pathway, which is important in cell division,
growth and differentiation
the Jak/Stat pathway activated by many
cytokrnes, which controls the synthesis and
release of many inflammatory mediators.
A few hormone receptors (e.g. atrial natriuretic factor)
have a srmtlar architecture and are linked to guanylate
cyclase.
Pho~phorylati on of IKB occurs when a specific kinase (IKK) is
activated in response to various inflammatory cytokines and
GPCR agoniMs. This results in dissociation of IKB from NFKB
und migration of NFKB to the nucleus, where it switch es on a
wide variety of proinllammatory genes.
'f Thn well-defined ~ignal tran~duction pathways are summarised in
Figure 115. The RavRaf pathway (Fig. 3. 15A) mediate~ the effect of
man} growth factor' and mttogen>. Ras. wh ich is a proto-oncogene
product. function' ltke a G-protein. and conveys the signal (by GDP/GTP
exchange) from the SH2 domain protein, Grb, which is phosphorylated
b) the RTK Acuvauon of Ra\ in tum activates Raf. which is the
fiN ot a -.equcncc of three serine/threonine kinases. eacb of which
phlhphorylateo,, and acttvate~. the next m line. The la~t of these. mitogen-
aculated protein (\lAP) kma..e, pho~phol) lates one or more transcription
fa.:tor... that imthlte gene e\pre\sion. resulting in a variety of cellular
re'Jll'"-..!' mcludtng cell di1 1\ion. This three-tiered MAP kinase cascade
form, pan of many intracellular signalling pathways (see Garrington &
Jllhn,cm. 1999) tmolvcd in a 11 ide \ariety of disease processes. including
mahgnanc), mllammauon. neurodegeneration. atherosclerosis and much
ch.:. The l.inu..e\ fomt a large family, with different subtypes serving
'pc:ctlic role\. They are thought to represent ao imponant target for
future therapeutic drugs. Many cancer~ are associated wi th mutation~
tn the gene\ cod tng for proteins involved in this cascade, leadi ng to
3l:lilation of the cascade in the absence of the growth factor signal
t' cc Chs. 5 ond 51). For more detai ls, see reviews by Marshal l (1996),
Schenk & Smtar-Jakcbka ( 1999). and Chang & Karin (200 I).
HO W DRUGS ACT: MOLECULAR ASPECTS
A ~econd pathway, the Jak/Stat pathway (Fig. 3.15B) is involved in
re~pon\c~ to many cytol.incs. Dimerisation of these receptors occurs when
the cytol. tnc btnd>. and thb attracts a cytosolic tyrosine kinac;e unit (Jak)
to a~soci:ue with. and pho>phorylate. the receptor dimer. Jaks belong to a
famtly of protein,, dtfferent member> having specificity for different
cytokine receptor\. Among the targeLs for phosphorylation by Jak are a
family of tran\Cription factor> (SLats). These are SH2 domain protein'
that bind to the pho>photyro>toe group:. on the rcceptor-Jak comple~. and
arc thcmsehe> phosphorylated. Thus activated. Stat migrates to the
nucleu\ and activate\ gene e\pre'>-\ion (see lhle. 1995).
Recent ...,ork on ~ignal transduction pathway~ has produced a be...,ildering
profu\ion of molecu lar detail. oflen couched in a jargon that is apt to deter
the faint-heaned. Per>everance will be rewarded. however. for there is no
doubt thm imponant new drugs. particularly in the areas of innammation.
immunology and cancer. will come from the targeting of these prOteins
(sec Cohen. 2002). A recent breakthrough in the treatment of chronic
myeloid lcuk:temia was ach ieved with the introduction of the first spec ifi c
kinase inhibitor. ima tinib. a drug that inhibits a s pecific tyrosi ne kinase
involved in the pathogenesis o f the disease (see Ch. 5 1).
The membrane-bound form of guanylyl cyclase. the enzyme respon-
sible for generating the second messenger cGMP in response
to the binding of pcptides such as atrial natriuretic peptide (see
Chs 16 and 18), resembles lhe ty rosine kinase family and is
activated in a similar way by dirncrisation when the agonist is
bound (sec Lucas ct al.. 2000).
Figure 3. 16 illuwate:. the central role of protein kinases in
signal tran-.duction pathways in a highly simplified and schematic
way. Many, if not all, of the proteins involved. including lhe
receptors and the kina:.es themselves. are substrates for kinases.
so there are many mechani\ms for feedback and cross-talk between
the various signalling pathways. Given that there are over 500
protein kinases, and 11imilarly large numbers of receptors and
other signalling molecules, the network of interactions can look
bewilderingly complex. Dissecting out the details has become a
major theme in cell biology. For pharmacologists. the idea of a
simple connecti on between receptor and response, which guided
thinking throughout the 20th century, is undoubtedly crumbling,
although it wi ll take some time before the complexi ties of signal-
ling pathways arc assimilated into a new way of thinkin g about
drug action.
TYPE 4: NUCLEAR RECEPTORS
The founh type of receptors we will consider belong to the
nuclear receptor ft11nily. By lhe 1980s, it was clear that receptors
for steroid honnoncs such as oestrogen and the glucocorticoids
were present in the cytoplasm of cells and translocated into the
nucleus after binding with their steroid partner. Other hormones,
such as the thyroid hormone T 3 (Cb. 29) and the fat-soluble 'it-
amins D and A (retinoie acid) and their derivatives that regulate
growth and development. were found to act in a similar fashion.
Genome and protein sequence data revealed a close relationship
between these receptor:. and led to the recognition that they were
members of a much larger family of related proteins. As well as
the glucocorti coid and retinoic acid receptor whose ligands were
well characterised, the nuclear receptor family (as it became known)
included a great many orphan receptors-receptors with no known
well-defined li gand~>. The first of these to be described, in the
1990s, was RXR, a receptor cloned on the basis of its similarity
45
 SECTION 1 W GENERAL PRINCIPLES

nuc
GPCRs

~IP
cAMP
7 DAG
3"+
Ca 2 cGMP

~
Auto-

~ ~ ! phosphorylation

GRKs PKA PKC CaM PKG

klnases

l 1 1 ! l j
KINASE CASCADES

It
TARGET PROTEINS

Ion Transcription Contractile Secretory

Enzymes Receptors Transporters
channels factors proteins mechanisms

RESPONSES

Physiological Immune Malignant

Apoptosis
responses responses transformation

Fig. 3.16 Central role of kinase cascades in signal transduction. Kinase cascades (e.g. those shown in Fig. 3.15) are activated by
GPCRs, either directly or via different second messengers, by receptors that generate cGMP, or by kinase-linked receptors. The kinase
cascades regulate various target proteins, which in turn produce a wide variety of short- and long-term effects.
CaM kinase, Ca2 /calmodulin-dependent kinase; DAG, diacylglycerol; GC, guanylate cyclase; GRK, GPCR kinase; IP:~o inositol
trisphosphate; PKA, cAMP-dependent protein kinase; PKC, protein kinase C; PKG. cGMP-dependent protein kinase. )

Protein phosphorylation In signal
transduction
Many receptor-mediated events involve protein
phosphorylation, which controls the functional and
binding properties of intracellular proteins.
Receptor-linked tyrosine kinases, cyclic
nucleotide-activated tyrosine kinases, and
intracellular serine/threonine kinases comprise a
'kinase cascade' mechanism that leads to
amplification of receptor-mediated events.
There are many kinases, with differing substrate
specificities, allowing specificity in the pathways
activated by different hormones.
Desensitisation of G-protein-coupled receptors
occurs as a result of phosphorylation by specific
receptor kinases, causing the receptor to become
non-functional and to be internalised.
There is a large family of phosphatases that act to
reverse the effects of kinases.
46
with the vitamin A receptor and that was subseque ntly found tu
bind the vita min A deri vati ve 9-cis-retino ic acid. O ver the inter
vcning years, binding partners have been identified for man).
a ltho ugh by no means all, of these receptors. but some autho11
continue to use the te rminology 'orphan receptor' e ven when a
ligand has been identified or 'adopted' (as in the case ofRXR).Ii
is now clear that the re are at least 48 membe rs of the nuc lear
receptor famil y in the human genome. and while this represent\
a rathe r sma ll proportio n of all receptors (less than I 0% of the
tota l number of G PC Rs), the nuclear receptors are important drug
targets a nd play a vital ro le in endocrine signalling as well a1
metabolic regulation.
Today, it is conve nient to regard the entire nuclear receptor
fami ly as ligand-activated transcription factors that transduct
signa ls by modifying gene transcription. Unlike the recepton
described in the preceding sections of this chapter, the nuclea:
receptors arc not embedded in membranes but are present in th\
soluble phase of the cell. Some. such as the steroid receptOI\.
become mobile in the presence of their ligand and can trans local(
from the cytoplasm to the nucleus. while o thers such as the RXR
probably dwe ll mai nl y within the nuclear compartment. Man}
nuclear receptors act as lipid 1:oensors and are intimately i nvol v~
in the regulation of lipid metabo lism within the cell. In this wa)
they a rc c rucia l links between our die tary and metabolic statu,
and the expressio n of genes that regulate the metabo lism and
dispositio n of lipids. Pharmacologically, this e ntire famil y of
 HOW DRUGS ACT: MOLECULAR ASPECTS

nuclear receptors i., very important; they can recognise an extra- ~pccific tran~cription factors in a ligand-independent way and modifie~

ordinanly diver<;e group of substances. They regulate many drug
metabolic enzyme~ and tran~porters and are responsible for the
biologtcal effects of approximately I 0% of all prescription drugs.
There are abo many illnesses ac;sociated with malfunctioning of
the nuclear receptor system. including inflammation. cancer, dia-
bcte,, cardiova.,cular disease, obesity and reproductjve wsorders
(\O.:C: Murphy & Holder, 2000, and Kersten et al., 2000).
the binding or activity of the receptor itself. Alternative splicing of gene\
may yield ..everal receptor i~forms each with slightly different N-terminal
region\. The core domain of the receptor is highly conserved and consists
of the structure responsible for DNA recognition and binding. At the mol-
ecular le~el. this comprises two dnc fingus-cysreine (or cystine/histidine)
rich loops in the amino acid challl that are held in a particular confor-
mauon by 11nc aon\. The main function of this ponion of the molecule i~
to recogm..e and bind to the homwne response elements located in genes
that are ~en\itive to regulation by this family of receptors, but it pia), a
pan in regulating receptor dimerisation as well.

STRUCTURAL CONSIDERATIONS
T The nuclear recept(lr> ~hare a broadly similar structural design
compri\ed of lour modu le<, (see Fig. 3. 17 and Bourguet et al.. 2000, for
funhcr detail~). The N-tl'rminal domain displays the most heterogeneity.
It harbour\ the AFI (activation function I) site that binds to other cell-
A highly nexible hinf{e region in the molecule allows it to dimerisc with
other nuclear receptors and also to exhibit DNA binding in a variety of
configurations. Finally. the C-tenninal domain contains the ligand-binding
modu le and is >pccific to each class of receptor. A highly con~rved AF2
region i~ imponanJ in ligand-depcndem activation. Also located near the
C-terrninal are motifs that contain nuclear localisation signals and others

Zinc finger module 1 Zinc finger module 2

ld to
1ter-
L AF1

N-terminus Core DNA binding domain Hinge Ligand binding domain

AF2

C-terminal
~any, AF1 Co-activator region with "Zinc fingers" region AF2 Co-activator region extension
hors HSP binding
en a
t). [t
:lear
Types of nuclear receptor
ents RXR RXR
'the or
:!rug TR RXR PPAR RXR
Uas
J:llor
lnce
i
CLASS I
i
HYBRID CLASS
i
CLASS II
uors
present tn cytoplasm mainly endocrine present in nucleus
'lear
operale as homodimers operate as RXR heterodimers operate as heterodimers (except RXA)
the mainly endocnne ligands matnly lipid ligands
tors. high affinaty low afflnity
cate
lXR e.g. GR, MR. ER, PR e.g. TR, VDR e.g. PPAR, LXR, FXR, RXR
tany
tved Fig. 3.17 Nuclear receptors. A. Structure of a nuclear receptor, showing the different domains. The partial structure of the 'zinc
~ay. !angers' Is shown above using the single-letter amino acid code. Residues in yellow actually contact DNA. B. The two main classes of
nuclear receptors.
atus
ER, oestrogen receptor; FXR, farnesoid receptor; GR, glucocorticoid receptor; LXR, liver oxysterol receptor; MR, mineralocorticoid receptor,
and PPAR, peroxisome proliferator receptor; PR, prolactin receptor; RXR, retinoid receptor; TR, thyroid receptor; VDR, vitamin D receptor.
r of
47
 SECTION 1 GENERAL PRINCIPLES
that may, in the ca.\c of some receptor~. bind accessory heat shock and
other protein~.
CLASSIFICATION OF NUCLEAR RECEPTORS
The nuclear receptor superfamily consist of rwo main classes-
together with a third that shares some of the characteristics of
both (see Fig. 3. 17 and Novae & Henzel, 2004, for further details).
Class I consists largely of receptors for the steroid hom1ones,
including the glucocorticoid and mineralocorticoid receptors
(GRand MR. re!.pectively), as well as the oestrogen, progesterone
and androgen receptor~ (ER. PR, and AR, respectively). In the
absence of their ligand, these receptors are predominantly located
in the cytoplasm. complexed with heat shock and other proteins
and possibly reversibly attached to the cytoskeleton or other
structures. Fol lowing diffusion (or possibly transportation) of
their ligand partner into the cell and high-affinjty binding, these
n.:ccptors generally fonn homodimers and b'llnslocate to the nucleus,
where they can trtmsactivate or transrepress genes by binding to
'positive' or 'negative' hormone response elements (see Ch. 28).
Large number~ of genes can be regulated in lhjs way by a single
ligand. For example. it is estimated that the activated GR itself
can regulate up to I% of the genome either directly or indirectly.
Class I receptor!. generally recognise hormones that act in a
negative feedback fashion to control biological events (see Ch. 28
for more discussion on this topic).
Class II nuclear receptors function in a slightly different way.
Their ligands are generally lipids already present to some extent
within the cell. This group includes the peroxisome proliferator-
actimted receptor (PPAR) that recognises fauy acids; the fiver
oxysterof (LXR) receptor that recognises and acts as a cholesterol
sensor, the famesoid (bile acid) receptor (FXR). a xenobiotic
receplor (SXR: in rodents the PXR) that recognises a great many
foreign sub~tances, including therapeutic drugs, and the consti-
tutive andromme receptor (CAR). which not only recognises the
steroid androstane but also some drugs such as phenobarbita l
(see Ch. 40}. These latter receptors are akin to airport security guards
who a lert the bomb disposal squad when suspicious luggage is
found. They induce drug-metabolising enzymes such as CYP3A
(which is responsible for metabolising about 60% of all prescrip-
tion drugs: see Ch. 8 and Synold et a!., 200 I), and also bind some
prostaglandins and non-steroidal drugs, as well as the antidiabetic
thiazolidinedio nes (see Ch. 26) and fibrates (see Ch. 20). Unlike
the receptors in cla~s I. these receptors almost always operate as
heterodimerc; together with the retinoid receptor (RXR). They
tend to mediate po itive feedback effects (e.g. occupation of the
receptor amplific~ rather than inhibits a particular biological event).
When clas!> ll monomeric receptors bind to RXR. rwo types of
heterodimcr may be formed: a non-pennissive heterodimer, which
can be activated only by the RXR ligand itself, and the permissi1e
heterodimer. which can be activated either by retinoic acid itself
or by its partner's ligand.
A third group of nuclear receptors is really a subgroup of cla~s
II in the sense that they form obligate heterodimcrs with RXR,
but rather than sensing lipids, they too play a part in endocrine
signalling. The group includes the thyroid hormone receptor (TR),
48 the vitamin D receptor ( VDR) and the retinoic acid receptor (RAR).
CONTROL OF GENE TRANSCRIPTION
'Y llormone re~pon~e elementS are the short (four or five ba~e
~quence., {lf DNA to which the nuclear recepton. bind to modify
trnn\cription. They arc usually present symmetrically in pairc; or ha
fittl. although thc!>e may be arranged together in djfferent ways (e
simple repeat~ or inverted repeatS). Each nuclear receptor exhibit~
preference for a particular comensus sequence but because of the
homology. there i'> a clo!>e similarity between these !>equence.,.
In the nucleu~. the ligand-bound receptor recruits further
tncluding coactimtors or corepres:.ors to modify gene expre.,~ion throug
1h AFI and AF2 domains. Some of these coactivator., are en7}111(1
invohcd in chromatin remodelling ~uch a~ histone acetylase wh1ch.
together with other entyme... regulates the unravelling of the DNA ~
faci litate acce~., by polymerase enzymes and hence gene tran~cripuon
Corepre~~or complexes are recruited by some receptor;, and compri~e
IIi stone deacetyluse and other factor> that cause the chromatin to becorm
tightly packed. preventing further transcriptional activation. Some unligand.'li
class II receptON ~uch as TR and VDR are constitutively bound to the....
repre,sor complexe;, in the nucleus. thus 'silencing' the gene. The complcl
dissociate~ on Jjgand binding. permitting an activator complex to bind. Th<
case of CAR i& particularly interesting; like some types of G-protcm
de~cribed earlier in thb chapter. CAR also forms a constitutively acu1
complex that i'> tenninated when it binds its ligand.
The discussion here must be taken only as a broad guide to lht
action of this family of nuclear receptors. as many other types cl
interaction have also been discovered. For example, some mernlx>n
may bring about non-genomic actions by directly interacting ~it!
factors in the cytosol. or they may be covalently modified lr
pho!>phorylation or by protein-protein imeractions with othe~
transcrip<ion factors and their function altered as a result (c;c~
Falkenc;tein et aL 2000). In addjtion. there is good evidence f<J
separate membrane and other types of receptor that can billl
some steroid hormones such as oestrogen (see Walters & Ncmert
2004). Thi~ intricate network of receptor and their nuclear am.
cytosolic interactions serves as a subtle regulator of blood lipids
as well as transducing the effects of hormones that have arrivtx.
from distant tissues. Much remains to be discovered abouJ thi1
interesting <tnd complex fami ly of receptor proteins.
ION CHANNELS AS DRUG TARGETS
We have discussed ligand-gated ion channels as one of the fou
main types of drug receptor. There are many other !)'pes of i~
channel that represent important drug targets, even though the
arc not generally classified as receptors' because they are not u.
immediate target~ of fast neurotransmitters. 12
Here we discu~s the structure and function of ion channels
the molecular level: their role as regulators of cell function
described in Chapter 4.
12
1n truth. the dbtinction between ligand-gated channels and other ion cham~e
i., an arbitrary one. In grouping ligand-gated channels with other types of
receptor in this book. we are respecting the historical tradition establi.,hed
by Langley and other~. who fir~l defined receptors in the context of the acti!l
of acety lcholine m the neu~romuscular junction. The advance of molecuhu
biology may force u~ to recon~ider this semantic issue in the future. but for
now we make no upology for upholding the pharmacological tradition.
 HOW DRUGS ACT: MOLECULAR ASPECTS

Nuclear receptors
SELECTIVITY
p3ir,) Channels are generally either cation-selecti ve or anion-selective.
gene o A family of 48 soluble receptors that sense Cation-. elective channels may be selective for Na, Ca 2 or K,
lipid and hormonal signals and modulate gene or non-selective and permeable to all three. Anion channels are
transcription. mainly permeable to Cl-, although other types also occur. The
o Two main categories: effect of modulation of ion channels on cell function is discussed
those that are present in the cytoplasm, form in Chapter4.
reins homodimers in the presence of their partner, and
egh migrate to the nucleus. Their ligands are mainly
1)mes endocrine in nature (e.g. steroid hormones).
GATING
hieb. those that are generally constitutively present in
'A to
Voltage-gated channels
the nucleus and form heterodimers with the These channels open when the ceU membrane is depolarised. They
JpUon.
nprise retinoid X receptor. Their ligands are usually lipids form a very important group because they underlie the mechanism
ecome (e.g. the fatty acids). of membrane excitability (see Ch. 4). The most important channels
r.mded A third subgroup transduce mainly endocrine in thi s group are selective sodium, potassium or calcium channels.
I these
signals but function as heterodimers with retinoid Commonly, the channel opening (activation) induced by mem-
mplex
d The
X receptor (e.g. the thyroid hormone). brane depolarismion is short-lasting, even if the depolarisation is
rote ins o The liganded receptor complexes initiate changes in maintained. This is because, with some channels, the initial
active gene transcription by binding to hormone response activation of the channels is followed by a slower process of
elements in gene promoters and recruiting inactivation.
coactivator or corepressor factors. The role of voltage-gated channels in the generation of action
o the
o The receptor family is responsible for the pharmacology potentials and in controlling other cell functions is described in
le~ of
of approximately 10%, and the pharmacokinetics of Chapter4.
nbers
some 60%, of all prescription drugs.
with
id b} Ligand-gated channels
other These (see above) arc activated by binding of a chemical l igand
Jon' are unable to penetrate the lipid bilayer of the ceU membrane, to a ~ite on the channel molecule. Fast neurotransmitters, such as
hee
nnd can get aero ~ only with the help of membrane-spanning glutamate, acetylcholine, GABA and ATP (see Chs 10, 12, and 33)
'e for
protein'> in the form of channel!> or transporters. The concept of act in this way, binding to sites on the outside of the membrane.
bmd
ion channel'> wa'> developed more than 50 years ago on the basis The vani lloid receptor TRPV I mediates the pain-producing
llere,
of clectrophysiological Mudies on the mechanism of membrane effect of capsaicin on sensory nerves (see Ch. 41 ).
rand
c\Citatton (st:c below). Electrophysiology, particularly the voltage Some ligand-gated channels in the plasma membrane respond
ipids
rived
clamp technique (~occ Ch. 4) remains an essential tool for studying to intracellular rather than extracellular signals. the most important
the phy.,iological and pharmacological properties of ion channels. being the following.
I this
Since the mid-I 980s. when the first ion channels were cloned
by Numa in Japan, a highly productive collaboration between o Calcium-activated potassium channels, which occur in most
ch:ctrophy~i o l ogil>tS and molecular biologists has revealed many cells, and open, thus hyperpolarising the cell, when [Ca2+),

r detail\ about the structure and function of these complex molecules.

The U\C of tight-sen! ('patch clamp') recording, which allows the
beha,iour of individual channels to be studied in real time. has
four
been particularly valuable in distinguishing channels on the basis
ion
of their conductance and gating characteristics. A ccounts by Hille
they
(:~OOI).A,hcroft (2000), and Catterall (2000) give more information.
Hbe
Jon channel\ con.,ist of protein molecules designed to form
wat~r-filled pore' that span the membrane, and can switch between
:hat
open and clO'>Cd states. The rate and direction of ion movement
Jn is
through the pore is governed by the electrochemical gradient for
the ion in question. which is a function of its concentration on
either "de of the mcmbntne. and of the membrane potential. Ion
channel\ are characterised by:
l!lel~ their selectivity for particular ion species, determined by the
of '>17e of the pore and the nature of its lining
'ICd their gming properties (i.e. the nature of the stimulus that
ton
ular control'> the transition between open and closed states of the
1 for channel)
their molecular architecture.
o
increases.
ATP-sensitive potassium channels. which open when the
intracellular ATP concen tration falls because the cell is short
of nutrients. These channels, which are quite distinct from
tho~e mediating the excitatory effects of extracellular ATP,
occur in many nerve and muscle cells, and also in insulin-
secreting cell~ (see Ch. 26), where they are pan of the
mechani'>m linking insulin secretion to blood glucose
concentration.
Other example1> of chaoneh. that respond to intracellular ligands
include arachidonic acid-~ensi tive potassium channels and
DAG-sensitive calcium channels, whose functions are not well
understood.
Calcium release channels
These are present on the endoplasmic or sarcoplasmic reticulum
rather than the plasma membrane. The main ones, IP3 and ryanodine
receptors (sec Ch. 4) arc a special class of Ligand-gated calcium
channels that control the release of Ca2 from intracellular stores. 49
 SECTION 1 GENERAL PRINCIPLES

Store-operated calcium channels
When the intracellular Ca2 stores are de pleted, channels in the
plas ma membrane open to allow Ca2 entry. The mechanism by
which thi ~ linkage occun. is poorl y understood (see Barritt, I 999),
but ~tore-operated calcium channels (SOCs) are important in the
mechanism of action of many GPCRs that elicit Ca 2+ release. The
opening of SOCs allows [Cah], to remain elevated even when the
stores are running low. and also provides a route through which
the stores can be replenished (sec Ch. 4).
MOLECULAR ARCHITECTURE
T ton channels are !urge and elaborate molecules. Their characteristic
Mructurul moti f~ have bee n revealed a; knowledge of their sequence and
structure ha\ accumulated since the mid- 1980s. when the fiN ligand-gated
channel (the nicoti nic acet} !choline receptor) and the first voltage-gmc-d
<,odium channel '*Cre cloned. The main structural subtypes are shown io
Figure 3.18. All con~ist of several (often four) domains. which are \imilar
or identical to each other. orgalllied either as an oligomeric array of sepanut
subunll\. or as one large protem. Each subunit or domain contains a bundl<
of t\\O to \IX membrJne-\panning helices. Most ligand-gated chan~h
ha\e the ba,1c 'tructurc 'hown in Figure 3.18A. comprising a pentameri'
array of non-Identical ~ubunits. each consisting of four tran\membr.ult
helices. of which one-the M2 se1,oment-from each wbunit line~ the port
The large extracellular N-terminal region contains the ligand-hindi~
reg1on. Several exct:ption~ to thi\ simple design for ligand-gated channel
have emerged recently. They include (sec Fig. 3. 18) the glutamate ~ID\
receptor (Ch. 33). the purine P2x receptor (Ch. 12) and tht: vu nilloid
receptor (a channel that rc~ponds not only to cbemicab or the vani lloiJ
e t as~. but al~o to heat and protons; see Ch. 4 1). In these, as in many other

TYPICAL NMDA - TYPE

N N

LIGAND-GATED
CHANNELS
(4-5 subunits)

c
Examples: nAChR, GA BAA, Examples NMDA
5-HT3, IP3R, RyR

6T1P 2T1P 4T2P

POTASSIUM
CHANNELS
(4 subunits)
~~
N C N c
Examples: Voltage-gated Examples: Inward-rectifying Examples: Resting K+
K+ channels, TAP channels K' channels, P2XR, ASIC, channels
ENaC, degenerins

c
VOLTAGE-GATED
SODIUM AND
CALCIUM
CHANNELS

Fig. 3.18 Molecular architecture of ion channels. Red and blue rectangles represent membrane-spanning a. helices. Blue hairpins
are pore loop (P) domains, present in many channels, blue rectangles being the pore-forming regions of the membrane-spanning a. helices.
Cross-shaded rectangles represent the voltage-sensing regions of voltage-gated c hannels. The green symbol represents the inactivating
particle of voltage-gated sodium channels. Potassium channel nomenclature is based on the number of transmembrane helices (T) and
pore-form ing loops (P) in each subunit. Further information on ion channels is given in Chapter 4.
SO 5-HT3 , 5-hydroxytryptamine type 3 receptor; ASIC, acid-sensing ion channel; ENaC, epithelial sodium channel; GABAA. GABA type A
..,...----- receptor; IP3R, inositol trisphosphate receptor; nAChR, nicotinic acetylcholine receptor; Pl xR. purine P2x receptor; RyR, ryanodine receptor.
 HOW DRUGS ACT: MOlECUlAR ASPECTS

:.ted I) J'C'nl ~hanncl. the pori!-forming part of the molecule con~i'>ts of a

ated ha1rp111 lut>p- the pore (Pl loop-between two of the helice;,. ALTERED CHANNEL
in GATING BLOCK
\nllagc-gated channel' g~nerall) include one tr.msmembrane heli" that
ar
")!ll:iln' an allundan.:c of lla~ic (i.e. p<hili\ely charged) amino acid\. Tetrodotoxin
1111"3te \\ben 111<' membrane 1., dcpolano,ed. '\0 that the interior of the cell become~
C'ldle GPCR liga nds Saxitoxin
1.:" negau,c. lhl\ reg1on-the voltage ~cnsor-mo\'es slightly IO\\ard<; Conotoxins
mels
111<' utMr 'url,"e nf the membram:. wh1ch has the effect of opening the
(leric
channel. \fan) \nltagc-acll\aled channel' af,o ~h0\1 innctivation. which BLOCK OF
lrane
h:tppcn' \\hen an intracellular appendage of the channel protein mO\C:'> 10 INACTIVATION
pxe. plug the channel lrom the m~idc. Voltage-gated sodium nnd calcium
.Uing GPCRs Veratridine
,hannel' arc remMknble 111 that the whole stmcture \l-ith four si)(-helix
Batrachotoxin
~"' Jnmam' wn'i'" of ,1 'ingle huge protein molecule. the domains being

l
IIDA Scorpion toxins
!Inlet! h>gcthcr by intra..'l!llular loop' nf varying length. Pota~sium ch:mnel\ DDT, pyrethroids
illoid cump1 1\C the mo't numcrou> and heterogeneous class." Vohage-gated
tUoid
pot,1"1um channel' re~emble ~odium channels. e)(cept that they arc made
1Mer Second messengers
up nllour .,uhun1h rather than a .. ingle long chain. The class of potassium
channel' kn<l\1 n a' 'inward rectifier channeb because of their biophy8ical
propcruc' h,,, the lwo-hcl i~ Mructurc !>hown in Figure 3. 18C. wherea~
other' nrc cl.1"cd lh ' two pore domain' channel>. because each subunit
~ontain' 1wo P loops.
l
PKA
CHANNEL
BLOCK
The lilTIOU\ ;Jrchitectumlmoti f~ ~hown in Figure 3.18 only scrape the ~ur
Iace of the mokcul;rr diwr..ily of ion channeb. ln all cases. the individual
'uhunll' 'ume m \Cieral rnnlccular varieties. and these can unite in dif-
PKC
1
Phosphorylation
Local anaesthetics
Antiepileptic drugs
(e.g. phenytoin)
ferent wmhinauun' to fonn functional channel\ a~ hetero-oligomers (~
Antldysrhythmic drugs
tl1,1inct from hnrnn-oligomcf\ buill from identical subuniL~). Furthennore.
(e.g. disopyramide)
!he chlnnellonmng '>lmcture' de\Cribed are usually associated \I ilh other
m<mhranc protein,, whi~:h 'ignificaml) affect their functional propenie,.
For c\.1mpk. the ATP-gated pota,;ium channel exi,L<. in a;..ociation with Fig. 3 .19 Drug-bind ing domains of voltage-gated
lbe>uljt~mlrtrta Tl'fl'/lf<lr(SURI. and it is through litis linkage that variou~
sod ium c ha nne ls (see Ch. 44). The multiplicity of different
drug' undutling amid~abellc drug> of the ~ulfonylurea class. sec Ch. 26) binding Sties and effects appears to be typical of many ion
fl'Uiatc 111<' .:h.mnel (o,ee A'hcrofl & Gribble. 2000). Good progress is bemg channels. DOT, dichlorodiphenyltrichloroethane (dicophane, a
ma.k 111 undeNandmg the ret.uwn bel\\een mokcular structure and ion
well-known insectictde); GPCR, G-protein-coupfed receptor;
dunncl lun.:uon. but '' e \lilt ha\ c onI} a fragmemill') understanding of PKA, protetn kinase A; PKC, protein kinase C.
lhc: ph) ""lti)!IC.ll n1k of m<IO) of~ ch;mnels. Man) iruponant drug, excn
thm dtc.:h h) mlluencing channel function. either directly or indirectl}.

111/raa//ulor .li!IIWI~. particularly c and llllcleotides filCh O.f A I'P

PHARMACOLOGY OF ION CHANNELS
Y Many drug> and phy\lological mediators described in this book exen
thclrdfcch by uttering the behaviour of ion channels. Here we outline the
gcncrulmcchani~m' a' excrnplificd by the pharmacology of voltage-gated
'odium channel (Fig. :\.19). ton channel pharmacology is likely 10 be a
lcnilc MIUTCC ()!'future new drug~ (see Clare et al.. 2000).
Th~ gaung and permeation of both voltage-gated and ligand-gated ion
channel' i' modulated by many factors. including the following.
Li~und1 rlratl>i111i dir.crly IOI'Orious sires on the channel pn>rein. These
indudc man} neurotr;IO\tnine~. and al:;o a variety of drugs and toxin~
thai acl in diffcrem "'aY' for example by blocking the channel or by
~lfccung the gaung prtlCe\\. thereby either faciliwting or inhibiting the
upcnang of the channel.
lfc diuton cmJ <lnt~\ I hill ucf mdirect/_1: mailrly by acrimrion ofGPCRf.
lbt IJucr produce 1he1r effect~ mainl) by affecting the >talc of
ph<,.phor)lauun ul indi\ idual amino acid, located on the intrJcellular
ttgKm olth<' channel protem. A!. dc'>t:ribed above. thi, modulation im oi\C\
111<' pruduction ol 'ccond mc,'>Cnge~ that activate protein kina....:~. The
tlpcnmg of the channel may be facilitated or inhibited. depending on
\\h1ch rNduc' are pho,phorylated. Dmgs such as opioids (Ch. -tIl and
PadrentlCcpwr .tgoni''' (Ch. I I) affect calcium and potassium channel
ns fun.:uun m thi' "I). pmducing a wide variety of cellular effects.
s.
'l9
d type of control (sec review by Donaldson et al.. 1997) include the
~rhc human genome encodes mon: than 70 distinct potassium channel
IUblypc,-cilhcr a nightmare or a golden opportunity for the pharmacologist.
depending on one\ pcr~pcctivc.
and GTP (see Ch. 4 ). Many ion channels posseS> binding site> for these
intracellular mcdiaton:. lncrca~cd [Ca2+], opens certain types of pota;..~ium
chunncb. and inacti vate~ voltage-gated calcium channels. As described
in Chaplcr4. [Cal+]i i~ itself affected by the function of ion chan neb
and GPCR~. Drug; of the sulfonylurea class (see Ch. 26) act selectively
on ATP-gmcd potasium channels.
Figure .l19 summari;..c;.. Ihe main siLes ;md mecbanbms by which drugs
affect volwg.c-g;ucd >odium chru111eb. a typical example of Lhi~ type of
drug target.
CONTROL OF RECEPTOR EXPRESSION
Receptor protein~ are synthesised by the ceUs that express them,
and the level of expression is itself controlled, via the pathways
discus.,cd above. by receptor-mediated events. We can no longer
thin!.. of the receptors as the fixed clements in cellular control
systems, responding to changes in the concentration of ligands,
and initiating changes in the components of the signal transduction
pathway-they arc themselves subject to regulation. Short-tenn
regulation of receptor function generally occurs through desens-
itisation, as di&cussed above. Long-term regulation occurs through
an increase or decrease of receptor expression. Example!. of this
proliferation of various postsynaptic receptors after denervation
(see Ch. 9). the up-regulation of various G-protein-couplcd and 51
cytoJ...inc receptors in response to inflammation (see Ch. 13), and
 SECTION 1 GENERAL PRINCIPLES

the induction of growth factor receptors by certain tumour viruses
(sec Ch. 5). Long-tenn drug treatment invariably induces adaptive
respon se~. which, particularl y with drugs that act on the central
nervous system, are often the basis for therapeutic efficacy. They
may take the fonn of a ,ery slow onset of the therapeutic effect
(e.g. with amidepressant drugs; see Ch. 39), or the development
of dn1g dependence (Ch. 43). Although the details are not yet
clear. it i!> mo\t likely that change!> in receptor expression. secondary
to the immediate action of the drug, are involved-a kind
of secondary phannacology' whose importance is only now
becoming clearer. The same principles apply to drug targets other
than receptors (ion channels. enzymes, transporters, etc.) where
adaptive change!> in expression and function follow long-term
drug administration, re:.ulting, for example, in resistance to
certain anticancer drugs (Ch. 5 I).
RECEPTORS AND DISEASE
lncrea!.ing under~tanding of receptor function in molecular tenns
has revealed a number of disease states directly linked to receptor
malfunction. The principal mechanisms involved are:
autoantibodies directed against receptor proteins
mutation-. in genes encoding receptors and proteins involved
in signal transduction.
An example of the former is myasthen ia grmis (see Ch. 10), a
di!>ease of the neuromuscular j unction due to autoantibodie~ that
inactivate nicotinic acetylcholine receptors. Autoantibodic!> can
also mimic the efTect ~ of agonists. as in many cases of thyroid
hypersecretion. caused by activation of thyrotropin receptor-
Activating antibodies have also been discovered in patient~ \\.ith
severe hypertension (o:-adrenoceptors), cardiomyopathy (~
adrenoceptors), and certain fom1s of epilepsy and neurodegenerati\(
disorder (glutamate receptors).
Inherited mutations of genes encoding GPCRs account fo
variou'> d isea~e states (see Spiegel & Weinstein, 2004). Mutateo
va-,opressin and adrenocorticotrophic honnone receptors (set
Ch'> 24 and 28) can result in resistance to these hom10nes. Receptor
mutation!> can re:.ult in activation of effector mechanisms in the
absence of agonist. One of these involves the receptor f01
th yrotropin, producing continuous oversecretion of thyroid
hormone; another involves the receptor for luteinising honnonc
and results in precocious puberty. Adrenoceptor polymorphism1
arc common in humans, and recent studies suggest that certair.
mutations of the Pr adrenoceplor. although they do not directl)
cause disease, are associated with a reduced effi cacy of
~-adren oceptor agonists in treating asthma (Ch. 23) and a poo
prognosis in patient~ with cardiac failure (Ch. 18). Mutation., ic
G-proteins can also cause disease (see Farfel et al., 1999; Spiege
& Wein<,tein. 2004 ). For example, mutations of a particular Go
subunit cause one form of hypoparathyroidism. while mutatioll'
of a G ~ ~ubun i t result in hypertension.
Many cancers are associated with mutations of the gene~
encoding growth factor receptors. kinases and other prote1ns
involved in signal transduction (see Ch. 5).

REFERENCES AND FURTHER READING

Gi!ncrn l references
Alo, antkr S I' H, M:u hie /\, Pete!'\ J A 2004 Guide to
rt>ccptor< nnd channel, , Or J Ph,lrmacol 141
Supplcmcnl I (CmiiJlrelttWJil'e ca/11/ogue of
moftmlar aml!llrrmtllll'Oiogimi/JI'UJ!erties of k11own
rt'cepton also ll'tui\POrTl!l~ mul som' enzymes
llwaletl i11 i!llllll mm.wluaia11 )
BcnShlomo I. ll\u S Y. Rauch R el nl. 200J Signalling
rcccplomc: n pcnom1c and evolutionary perspective of
plasma membrane rcCCI>tor' mvolvL-d in ' ignal
lrnn,duction STKF 1\~b,ite: http:llwww.~tke.org
Donald,on I. h Hanley M R. Villabla.nca A C 1997
lnduc1ble n.-c~plol'\ Trend' Phannacol Sci 18: 171-181
(Empht/\i\1 I fl/ll<"rl\1'\ <lllllfrllflllflll'UfltOr l'.ffJI'I'SSiOII )
ILIPHAR receptor d.ual>.l...: and channel compendium.
http://""" mphar-db.ol'jl (Onlm~ wwlo~u~ tuul
ct~lm~ 11 h~""' for rr-tcptnr' 011d dwtml'b. Not '~'
compl~tl', lmt f>ltmnl'd Ill /"' Uf>dtllt!d ngular/y)
l...lutkt V. \dc:lmant G 1995 Lonc,on~e recep1ors. Curr
Bioi 5: 12-1 In 15htlrt m '"'' tif 'orphan. I'I'CI'ptors )
Wain:~' S I. Gn.-.:n~anl P 199t Protem pho-pborylation
and neuronallunctu>n . Pharmacal Rc\ -1~: 299- 3-19
( \a//nll ~('IIUCI/I'I'Iitw)
Recepi01"1
G-protcin~oupled receptors
AbdA lla S, Lothcr ~1 . El \1a'"CI) A. Quitterer U 200 1
lncrca..ed AT1 reeep1or hclcrodimcn. m prccclamp;iu
mediate enhanced angiolcn, in II rcsptln,hcncss. Nat
Mcd 7: I003- 1009 (/ Ire fmt ill.\Illlire of di.!lurhed
GPCR lutrltxlimnimticm i11 relation to lwmarr di.~~ase)
52 Anger'S, Salahpour A. Rouvicr M 2002 Dimeri w tion:
an cmcrging conccp1 for G protcmcouplcd rcccp10r
on1ogcny and function Annu Rev Phunnncol Toxicol
42: -109-135 (Re1iew of tire mrrrf>et'tNI l>l'iu11iour of
GPCRs in linkillfl /Oflether as ditlll'r.)
Bockncn J, Pin J P 1999 Mulcculur linkcring uf G
pro1ein-coupled rcccp1ors: nn coluli unury \Ucccs1.
EMBO J l 8: 1723- 1729 (Short l't'l'itu l'l/l't'ri11g .WIII/I'
11ewer aspens of GPCR fimctitm)
Coni&'Ta\ e A D. Qui nn S J, Brown E M 2000
Cooperathe multi-modol ,cnlln!\lllld lhcmpculic
implications of the extrncellulnr Ca'.,en,tng receptor.
Trend, Phannacol Scr 21: 40 t -107 (Slum aammt <if
tlte Ca'"tentin.~ ~t'epwr. an anmuo/m11 1\fll' of(;PCR)
Cos1a T. Cotecchia S 2005 ll i'loncal rc\lew: ncga111~
efficacy and the con\liruuvc acm tty of G pn)tctn -
coupled recep1ors. Trend, Phannacol S<~ 26: 618-62-1
(A dear and thau~lttfut l'l'm"' af 1dnu rdmmg w
consti1u1i\e recepwr actia tion tmtllfJ\'t'Mt- liRtUII\1\)
l'ergus0n SSG 2001 E\ohing con~ph 111 G protttn
coupled rec<!ptOr emiOC) to"' lhc rule in rc~cplor
desen>itization and signaling. Phorm..c:ol Re' 53: 1- 2-1
(Detailed account of tlte rt>l~ tif phmt>llllf') latit>n cif
receptors in fan and .1lon. dt'\t'fl\itl\lltum mt:t lwniWU )
Gudennann T. Kalkbrenner 1', Schul11 G 1996 01\ crMt>
and select/\ 1ty of rcccp1or G protein "!!nalhng Annu
Re\ Pharmacol Toxicol 36: 429-159 (/)II< 1111n lw"
selectivity is achined bellt.'ettr mon\. liRtmtf,,
receptors and i11terlmkm~ trmntluuion fllltlmll\'.\)
Hill S J 2006 Gprolein-coupled rcccptol'\: JX"'prc,cnl
:md future. Br J Pham1acol 147 (Suppl): 27 17 (Gt~od
introductory reiew)
Kcnakin T 2002 Efficacy m G-protein-couplcd rcccp10rs.
Na1 Rev Drug Di~cov I: I03 I I0 (Mai1111' thtt!Mic'al
discussio11 of lite implicatiom ()fagtlllill traf]itk.~J
Kilpatrick G. Dautzenberg F ~1. Mnnin G R. Egkn R M
1999 7TM receplors: 1he splicing on the cn~e. Trend!
Pharrnacol Sci 20: 294-301 (Re.iell' <if the importm"
of mRNA splicing as a source of mriation mnong
GPCRs-a solllfan reminder that clonill!: genes L1 111
thl' last II'Ord In defining receptor dier.rity)
Koenig J A, Edwardson J M 1997 Endocy1osis and
re9cling of G pro1eincoupled recepton<. Tfl!nd'
Phann01col Sci 18: 276-287 (1('ellem re1 tt'W of 1hc
wmpleA life cyde of a receptOr molecule)
Krupnick J G. Beoovic J L 1998 The role of receptor
km<L'"" and arrestin;. in G protein coupled receptor
regulation. Annu Rev Pbarmncol Toxicol 38 . 298-31
(Reuew on GPCR phosphory(ation. arrrmns and
Jc\CII\ili\UiiOII )
Lou F. Wan Q. Pri>tupa Z et al. 2000 Direct protem prua:
<'OUphng enable~ CllhS-t.alk bet\\een dopamine D;
y.;urunobul) ric acid A receptors. l"ature -103:
~7-1- 2SO. (7Jre Jim demonstr(Jtion of direct couplllfl
cif e1 GPCR 1111h an ion channtd. l.ooL. no Gpn>ttm:
M1lltgan G 1995 Srgnal 'orting b} G prolem hnl<-d
receplol'\. Adv Pharmxol 32: 1- 29 (Moll' on th~
ulntmtv problem)
O,>Or,l.aya V S. Bunnell N W 2()().1 Protenseacthatol
receptor\: conlribu1ion to ph} siolog} and dl....,;t.,.:
Phy'lol Rev 8-1: 579-621 !Re>in of currrnt
latf11rlnlge of fllltlwphysiologicol rolf of prc>tea<r
tl<'lil'<ltecl rec'eptnr.l)
P1ercc K L. Premon1 R T. Lcfkowill R J 2002 SC\CII
transmembmne receptors. Nat Rev Mol Cell Brol 3
639-650 (Useful general l'l'vlew ofGPCR.r. indudm
dcsnrsitisation mechanisms. siRna/transtlurtion
patlmuy.\ tuul dimt ri.WIIion)
 Hovv drugs act: cellular
aspects- excitation,
contraction and secretion
Overvie w 54 the storage and release of Ca2 by intracellular
organelles
Regulation of intracellular calcium levels 54 Ca2-dependent regulation of enzymes,
-Calcium entry mechanisms 55 contractile proteins and vesicle proteins.
-Calcium extrusion mechanisms 57
More de tailed coverage of the topics presented in
-Calcium release mechanisms 57
this chapter can be found in Nicholls et al. (2000),
-Calmodulin 58
Nestler et al. (200 1) and Levitan & Kaczmare k
Excitation 59 (2002).
-Channel function 60 Because [Ca2 ] ; plays such a key role in cell
function, a wide variety of drug eHects re sults from
Muscle contraction 64
interference with one or more of these
Re lease of chemical mediators 67 mechanisms. If love makes the human world go
t-- round, [Ca2 ] ; does the same for cells. Knowledge
Epithe lial ion transport 70
of the molecular and cellular details has expanded
remarkably in the past decade, and here we focus
on the aspects that help to explain drug eHects.

OVERVIEW
REGULATION OF INTRACELLULAR
The link between a drug interacting with a CALCIUM LEVELS
molecular target and its effect at the
Eve r s ince the famous accident by Sidney Ringer's technician
pathophysiological level, such as a change in blood
which showed that using tap wate r rathe r than distilled water ll
glucose concentration or the shrinkage of a
make up the bathing solution for isolated frog hearts would allo~
tumour, involves events at the cellular level.
the m to carry o n contracting, the role of Ca2+ as the most importa111
Whatever their specialised physiological function,
regulator o f cell functio n has never been in question. Many drug'
cells generally share much the same repertoire of
and phys io logical mechanisms o perate, directl y o r indirectly, hi
signalling mechanisms. In the next two chapters,
influe nc ing [Ca 2+j,. He re we consider the ma in ways in which;
we describe the parts of this repertoire that are of
is regulated, a nd later we describe some of the ways in wht<l
particular significance in understanding drug action
[Ca 2+], controls cell function. Details of the molecular componcn
at the cellular level. In this chapter, we describe
and drug targets arc presented in C hapter 3, and descriptions~
mechanisms that operate mainly over a short
drug e ffects o n integrated physiological function arc given n
timescale (milliseconds to hours), particularly
later chapters.
excitation, contraction and secretion, which account
The ' tudy of Ca2 regulatjon took a big step forward in t
for many physiological responses; Chapter 5 deals
1970s wi th the development o f fluorescent technique!. based c.
with the slower processes (generally days to
the Ca2 -~e n\itive photoprotein aequorin. and dyes such ~
months), including cell division, growth,
Fura-2, which, for the first tjme, allowed free [Ca2]; to b
diHerentiation and cell death, that determine the
continuoul.ly monitored in uving cells with a high level c
body's structure and constitution.
temporal and ~patia l reso lution.
The short-term regulation of cell function depends
Most of the Ca 2 in a resti ng cell is sequestered in organclk-;
mainly on the following components and
particularly the endoplasmic or sarcoplasmic reticulum (ER a
mechanisms, which regulate, or are regulated by,
S R) a nd the mitochondria, and the free [Ca2+], is kept to a len.
the free concentration of Ca2 in the cytosol, [Ca2 ];:
o-
level. abo ut I 7 M. The Ca2+ concentration in tissue fluid tCa21
ion channels and transporters in the plasma is abo ut 2.4 mM , so there is a large concentration gradielll
54 membrane favouring Ca 2+ entry. fC a2..l 1 is ke pt low (a) by the o peration o
 HO W DRUGS ACT: CELLU LAR ASPECTS - EXC ITATION, CONTRACTION AND SECRETION

tlcliH! tran~port mechanisms that eject cytosolic Ca 2 through the store-operated calcium channels (SOCs)
pla-.ma membrane :md pump it into the ER, and (b) by the Na-Ca 2 exchange (can operate in either direction; see
nom1ally IO"- Ca2 permeability of the plasma and ER membranes. Calcium extrusion mechanisms).
Regulauon of !Ca2 ], tmolves three main mechanisms:

control of ca~ entry VOLTAGE-GATED CALCIUM CHANNELS

control of C'a~ extru\ion
The pioneering work of Hodgkin and Huxley on the ionic basis
c\changc of Ca! between the cytosol and the intracellular
of the nerve action potential (sec below) identified voltage-
\lOre\ .
dependent Na and K + conductances as the main participants. II
The-.c mcchani'>ms are described in more detail below and was later found that some invertebrate nerve and muscle cells
arc 'ummari'>ed in Figure 4.1 (see reviews by Berridge et al., could produce action potentiab that depended on Ca2 + rather than
2()()(). 2003). Na, and improved voltage clamp methods revealed that vertebrate
cells also possess voltage-activated calcium channels capable of
allowing substantial amounts of Ca2 to enter the cell when the
CALCIUM ENTRY MECHANISMS membmnc is dcpolarised. These voltage-gated channels arc highly
selective for Ca2 (although they also conduct Ba2+ ions. which
There arc rour main routes by which Ca2+ enters cells across the
arc often used as a substitute in electrophysiological experiments),
in pla.,ma membrane:
and do not conduct Na' or K; they are ubiquitous in excitable
0), cells and allow Ca 2+ to enter the cell whenever the membrane is
\Oitagc-gatcd calcium channels
ligand-garcd calcium channels depolarised, for example by a conducted action potential.

Tom

~e
ded
<US

tcian,
tcr to
allow
ATP PMCA
~
mant
Jrugs
y. by GPCRs
ich it
,hich
nents
n~ of
~n in

Endoplasmic rettculum
n the
:don
Plasma membrane
h a<;
o be Fig. 4.1 Regulation of intracellular calcium. The main routes of transfer of Ca2 into, and out of, the cytosol and endoplasmic
reticulum are shown for a typical cell (see tex1 for details). Black arrows: routes into the cytosol. Blue arrows: routes out of the cytosol.
~I o f
Red arrows: regulatory mechanisms. Most of the channels and transporters have been characterised at the molecular level, but the
mechamsm by which store-operated calcium channels (SOCs) are linked to the state of the intracellular Ca2+ store is uncertain. Normally,
elles. [Ca2Jjts regulated to about 1(17 moVI in a 'resting' cell. Mitochondria (not shown) also function as Ca2 ' storage organelles but release
R or Ca2 only under pathological conditions, such as ischaemia (see tex1). There Is also evidence for an intracellular store (not shown)
tlow achvated by the second messenger nicotinic acid dinucleotide phosphate. GPCR, G-protein-coupled receptor; IP3 , inositol
a2+Jo,
tnsphosphate; IP3 R, inositol trisphosphate receptor; LGC, ligand-gated cation channel; NCX, Na-Ca2 exchange transporter; PMCA,
plasma membrane Ca2' -ATPase; RyR, ryanodine receptor; SERCA, sarcoplasmic/endoplasmic reticulum ATPase; VGCC, voltage-gated
dient calcium channel.
>n of 55
 SEcnON 1 GENERAL PRIN CIPLES

A combination of electrophy1>iological and pharmacological
criteria suggests that there are five distinct subtypes of voltage-
gated calcium channel!.: L, T, N. P and R. 1 The subtypes vary
with respect to their activation and inactivation kinetics, their voltage
threshold for acti vati on, their conductance. and their sensitivity
to blocking agents, a~ summari sed in Table 4. 1. T he molecular
basi ~ for this heterogeneity has been worked out in some detail.
The main pore-forming subunits (tenned al. see Fig. 3.4) occur
in at least 10 molecular subtype!., and they are associated w ith
other subunits (f3, y, b) that also exil>t in differem form s. D ifferent
com bi nations of these <;ubunits give ri se to the dif ferent
physiological subtypes. In general. L channels are particularly
important in regulating contraction of cardjac and smooth mu~ck
(see belov.. ), and N channeb (and also P/Q) are involved t
ncurotr ansmjner and hormone release, w hjJe T channels mcdiatt
Ca2+ entry into neuron-, and thereby control variou'> Ca;
dependent functi ons such as regulation of other channels. enzyme,.
etc. Clinically used drugs that act directly on these channel!
include the group of 'Ca2+ antagonists' consistin g of dihydro
pyridines (e.g. nifcdipine), ver apamil and diltiazcm (used for
their cardiovascular effect:.; see Chs 18 and 19), and aho
gabapentin and pregabalin (used to treat epilepsy and prun: \l't
Chs 40, 41 ). M any drugs affect calcium channel\ indirect!) b)
acting on G-protcin-coupled receptors (see Ch. 3: Triggle, 1999
A number of toxin~ act ~e lecti vel y on one or other type of calciurr
channel (Table 4. 1). and these are used as experi mental tool\.

1
A ~ i xrh (Q ) has also been fou nd, bul it~ propcnies so closely re~emblc
tho~e of P that they usu~ l ly gel lumped together. The terminology i' lc~s LIGAND-GATED CHANNELS
than poetic: L stund~ for long-la,ting: T stands for tramient; N !>tand' for
neither long-lasting nor tran\ient: anti P. Q and R carry on alphabeucally M ost Jjgand-gated cati on channel s (see Ch. 3) th at arc activated
from N, with 0 (of cour,cl omiued. by excitatory neurotran ~mi ttcrs are relatively non-selective. ana

Types and functions of calcium channels

Gated by: Main types Characteristics Location and function Drug effects

Voltage L High activation threshold. Plasma membrane of many cells. Blocked by dihydropyridines,
Slow inactivation. Main Ca2 ' source for contraction verapamil, diltiazem. Activated
in smooth and cardiac muscle. by BayK 8644.
N Low activation threshold. Main Ca2 source for transmitter Blocked by w-conotoxin (component
Slow inactivation. release by nerve terminals. of Conus snail venom).
T Low threshold. Fast Widely distnbuted. Important 1n Blocked by mibetradil.
1nact1vation. card1ac pacemaker and atria
(role 1n dysrhythmias).
P/ Q Low activation threshold. Nerve terminals. Transmitter Blocked by w-agatoxin (component
Slow inactivation. release. of funnel web spider venom).
A Low threshold. ?
Fast inactivation.

Inositol IP3 receptor Ligand-gated channel Located in endoplasmic/ Not directly targeted by drugs. Some
trisphosphate activated by IP3 . sarcoplasmic reticulum. experimental blocking agents known
Mediates Ca2 ' release (e.g. heparin, injected intracellularly).
produced by GPCR activation. Responds to GPCR agonists and
antagonists in many cells.

elf, sensitised Ryanod1ne Directly activated 111 striated Located in endoplasmic/ Activated by caffeine (high
by cyclicADP receptor muscle via dihydropyridine sarcoplasmic reticulum. concentrations). Blocked by ryanodine.
ribose receptor of T tubules. Mediates Ca2' -evoked Ca~ Mutations may lead to drug-induced
release in muscle. Also malignant hyperthermia.
activated by the second
messenger cyclic ADP ribose.

Store Store- Indirectly coupled to Located in plasma membrane. Activated indirectly by agents that
depletion operated endoplasmic/sarcoplasmic deplete intracellular stores (e.g.
channels reticulum Ca2' stores. GPCR agonists, thapsigargin). Not
directly targeted by drugs.

NAADP Act1vated by NAADP Located 111 lysosomes.

formed as second Functional role not clear.
messenger.

GPCR, G-protein-<:oupled receptor; NAADP, nicotinic acid dinucleotide phosphate.

56
 HOW DRU GS ACT: CELLULAR ASPECTS - EXCITATION, CONTRACTION AND SECRETION
ascle conJuct Ca~ ions as well a~ other cations. Most important in this
~in rc~pcct '' the glutamate receptor of the NMDA type (Cb. 33),
tliate 11hich ha' a particularly high penneability to Ca 2+ and is a major
contributor to Ca~ uptake by postsynaptic neurons (and also
~es, ghat celh) m the centml nervous system. Activation of this
nels receptor can rcadil) cau\e 'o much Ca2.. entry that the cell die~.
dro- maml) through acti\ation of Ca 2-dependent proteases but also
dfor b) triggering apopt0\1~ (\ee Ch. 5). Tbjs mccharusm, tenned
also f.lritoto.licir~. probabl) plays a part in various neurodegenerative
r. ~ee JiwJer... (\cc Ch. 35).
) by For man) years, there has been dispute about the existence
999). of 'receptor-operated chan neb' in smooth muscle, responding
llirectl) to mediator' such as adrcnaJjne (epinephrine), acetylcholine
and hi,taminc. Now it seems (sec Kuriyama et al.. 1998) that the
P2x receptor (sec Ch. 3), activated by ATP, is the o nly example
or a true ligand-gated channel in smooth m uscle, a nd this
COil\t itutes an important route or entry for Ca2 . Other mediators,
~a ted acting on G-protcin-coupled receptors, affect Ca2 en try
and inllirectly. mainly by regulating voltage-gated calcium channels
or pota.,,ium channels.
STORE-OPERATED CALCIUM CHANNELS
Thc'e arc channel' that occur in the plasma membrane and open
to allo11 Ca' cntf) when the ER stores are depleted. They are
Ji,tinct from other membrane calcium channels, and belong to
the large. recent!} di'>CO\ered group ofTRP (standing for 'transient
nx:eptor potential') chan neb. whjch have many different functions
('ee Clapham, 2003). SOCs remain somewhat mysterious,
becau'e 11 " unclear what lind of linkage couples them to the
ER (\t:t: Berridge. 1997: Barritt. 1999). Like the ER and SR
chanm:b. they can serve to amplify the rise in [Cah], resulting
lrom Ca' release from the stores. So far, only experimental
compounds are J..nown to block these channels, but efforts arc
being made to develop specific blocking agents for therapeutic
u~e a' rdaxanh of \mooth muscle.
CALCIUM EXTRUSION MECHANISMS
Active tran'po11 of Ca ' outwards across the plasma membrane,
and 1011ard' aero'>'> the membranes of the ER or SR. depends on
the actiVIt} of a Ca'-dependcnt ATPase, similar to the Na/K-
dcpendent ATPa\e that pumps Na+ out of the cell in exchange for
Jle.
li. Se\eral '>Ubtypcs of the Ca1-dependent ATPasc have been
dnncJ hut the physiological significance of this heterogeneity
remain' unclear. They ha\e not been implicated in pharmacological
re,pon..cs. 11 ith the exception that tbaps igargi n (derived from a
~kJu.:rranean plant. Tlwpsia garganica) specifically blocks the
ER pump. cam.ing loss of Ca2 from the ER. lt is a useful
experimental tool but ha\ no therapeutic significance.
Calcium i'> abo extruded from cells in exchange for a+, by
;\a'-Ca' exchange. The transporter that does this has been fully
char.tctt:riscd and cloned, and (as you would expect) comes in
'evcral molecular subtype~ whose functions remain to be worked
nut. The exchanger transfers three Na ions for one Ca2, and
therefore produce!> a net dcpolarising current when it is
extruding Cn2. The energy for Ca2 extrusion comes from the
electrochemical gradient for Na. not directly from ATP
hydroly'>iS. This means that a reduction in the Na concentration
gradient resulting from Na entry will reduce Ca1+ extrusion by
the exchanger, causing a ~econdary rise in [Ca1 ],. a mechanism
that is particularly important in cardiac muscle (sec Ch. 18). The
exchanger can actuaJJy function in reverse if [Na], rises
excessively, resulting in increased Ca 1+ entry into the cell (see
above). The effect of d igoxin on cardiac muscle (Ch. 18) is
produced in this way.
CALCIUM RELEASE MECHANISMS
There arc two main types of calcium channel in the ER and SR
membrane, which play an important part in controlling the
re lease of Ca~ from these stores.
The inositol trisphosphate receptor (IP 3R) is activated by
inositol trisphosphate (l P3), a second messenger produced by
the action of many ligands on G-protein-coupled receptors
(sec Ch. 3). IP1R is a ligand-gated ion channel, although its
molecular structure differs from that of ljgand-gated channels
in the plasma membrane. This is the main mechanism by
which activation of G-protein-coupled receptors causes an
increa~e in 1Ca1],.
The ryanodine receptor (RyR) is so called because it wa.,
fir;t identified through the specific blocking action of the
plant all.. aloid r yanodine. It is particularly important in
skeletal muscle, where there is direct coupling between the
RyR.., of the SR and the dihydropyridine receptors of the
T-tubub (see below); this coupling results in Ca 2 release
following the action potential in the muscle fibre. RyRs are
also present in other types of cell that lack T tubules; they
arc activated by a small rise in [Ca2 ], producing the effect
known as calcium-induced calcium release (CICR). which
serves to amplify the Ca 2 t signal produced by other
mechanisms such a~ opelling of calcium channels in the
plasma membrane. CICR means that release tends to be
regenerat ive, because an initial puff of Ca 2 releases more,
resu lting in localised 'sparks' or 'waves' of Ca 2 release
(sec Berridge, 1997).
The functions of IP3Rs and RyRs arc modulated by a variety
of other intracellular signals (sec Berridge et al., 2003), which
affect the magnitude and spatiotemporal patterning of Ca2+
signals. Fluorescence imaging techniques have revealed a
remarkable level of complexity of Ca2+ signals, and much
remain!. to be discovered about the importance of this patterning
in relation to phy<,iological and pharmacological mechanisms.
The Ca 2+ -;en~itivity of RyRs is increased by caffeine, causing
Ca2 rclea~e from the S R even at resting levels of [Ca2 ],. This is
used experimentally but rarely happens in humans. because the
other pharmacological effects of caffeine (see Ch. 42) occur at
much lower doses. The blocking effect of dantrolene, a compound
related to ryanodine, is used therapeutjcally to relieve muscle
spasm in the rare condition of malignant hyperthermia (sec
Ch. 36), which is associated with inherited abnormalities in the
RyR protei n. There are as yet few other examples of drugs that
directly affect these Ca 2 release mechanisms. 57
 SECTION 1 GENERAL PRINCIPLES
1.0
'-----'
s 0.8 1 min
.
0
E ea
2:
0.6
N
I'D Normal extracellular [Ca2 ]
~ tht: C}tt>toxicit} as,oei;tted with sc,ere metabolic di,turbance. Cell
iii
0.4 Zero extracellular [Ca2 j
2 involve' thi' mechani-,m. along with others that contribute to an
~ n'e in 1Ca2
e 0.2
0
Bradykinin 30 nmoVI
Fig. 4 .2 Increase in intracellular calcium concentration
in response to receptor activation. The records were
obtained from a single rat sensory neuron grown in tissue
culture. The cells were loaded with the fluorescent Ca2
indicator Fura-2, and the signal from a single cell monitored
with a fluorescence microscope. A brief exposure to the
peptide bradykinin, which causes excitation of sensory
neurons (see Ch. 41), causes a transient increase in [Ca2"], from
the resting value of about 150 nmoVI. When Ca2 is removed
from the extracellular solution, the bradykinin-induced increase
in [Ca2 '), is still present but is smaller and briefer. The response
1n the absence of extracellular Ca2 represents the release of
stored Intracellular Ca2 ' resulting from the intracellular
product1on of inositol trisphosphate. The difference between
this and the larger response when Ca2 ' is present extracellular1y
is believed to represent Ca2 entry through store-operated ion
channels in the cell membrane.
(Figure kindly provided by G M Burgess and A Forbes, Novartis
Institute for Medical Research.)
A typical [Ca 2' 1, signal resulting from activation of a 0-
protein-coupled receptor is shown in Figure 4.2. The response
produced in the absence of extracellular Ca2+ represents release
of intracellular Ca1. The larger and more prolonged response
when extracellular Ca 2 is present shows the contribution of
SOC-mediated Ca2 entry.
OTHER SECOND MESSENGERS
T 1\o intracellular metabolite~. cyclic ADPribose (cADPR: 'ee Gu<>e.
2000) and ni<'otinic acid dmucleoride plrospluue (NAADP: <>ee Chini &
De Toledo. 2002>. fonned from the ubiquitous coenzyme:. nicotinamide
adenme dinuclcmide (NAD) and NAD phosphate. al'>o affect Ca~
\lgnalting. cADPR act~ by mcre~ing the sensitivity of R}RS to Ca~-. thus
increa\ing the 'gain' of the CICR effect. NAADP release~ Ca from
2 ntcotlntc acid dinucleotide phosphate, also promote
l}'>o.,ome' by acuvaung channel<. not yet identified but e'idently distinct
from the IP,R and RyR .
The level\ of these me\M!ngen. in mammalian cells may be regulated
mainly in re~JXln\e 1<1 change~ in the metabolic status of the cell. although
the detai l\ are not yet clear. Abnorma l Ca2' signalling is involved in many
pmhophy~i ol ogical conditions. such as ischaemic cell death, endocrine
di~order' and cardiac dysrhythmias. where the roles of cADPR and
NAA DP, and their interaction wi th other mechanisms that regulate
58 [Ca'l" are the subject t>f much current work (see Berridge ct al .. 2003).
THE ROLE OF MITOCHONDRIA
T Under nonnal condition~. mitochondria accumulate Ca ' passi\CI}
a rc\uh of the intramilochondrial potential. wbich 1\ 'trongly
"llh rc,p..'Ct to the cyto,ol. This negativity i' maintained by
cxtru,ion of proton.,. and i' lo;,t-thus relea\ing 2
into the cy
the cell run' -,hon of ATP. for e~ample under conditions of hypcma
only happen' m c\tremb. and the resulting Ca~ relea-e contribute\
rc-,uhing from braan t\Chaemia or coronary i\Chaemia (see Ch\ t 8 and
I,.
CALMODULIN
Calcium exerts its control over ceU functions by virtue of 11
abi Iity to regulate the activity of many different proteins. includin
enzymes (parti cularly kinases and phosphatases). channel1
tran!.portcrs, transcription factors, synaptic vesicle proteins, 011(
many others. In most cases, a Ca2-bindjng protein serves as a
intermediate hetween Ca2 and the regulated functional protem
the best 1-.nown such binding protein being the ubiquito~
calmodulin. Thi., regulates at least 40 different function
proteins indeed a powerful fixer. Calmodulin i<; a dimer, \\i
Calcium regulation
Intracellular Ca2 concentration, (Ca2].. is
critically important as a regulator of cell function.
Intracellular Ca2 is determined by (a) Ca2 ' entry; (b)
Ca2 ' extrusion; and (c) Ca2 exchange between the
cytosol, endoplasmic reticulum (ER) and mitochondria.
Calcium entry occurs by various routes, including
voltage- and ligand-gated calcium channels and
Na-ca2 exchange.
Calcium extrusion depends mainly on an ATP- driven
Ca2 ' pump.
Calcium ions are stored by the ER or sarcoplasmic
reticulum (SR), from which they are released in
response to various stimuli.
Calcium ions are released from ERISA stores by (a)
the second messenger inositol trisphosphate acting
on inositol tnsphosphate receptors; or (b) increased
[Ca2], itself acting on ryanodine receptors, a
mechanism known as Ca2 -induced Ca2 release.
Other second messengers, cyclic ADP-ribose and
the release of Ca2 ' from Ca2 stores.
Depletion of ER/SR Ca2 stores promotes Ca2 ' entry
through the plasma membrane, via store-operated
channels.
Calcium ions affect many aspects of cell function by
binding to proteins such as calmodulin, which in turn
bind other proteins and regulate their function.
less
 HOW DRU GS ACT: CELLULAR ASPECTS - EXCITATION, CONTRACTION AND SECRETION
lour Ca1 binding '>ite,. When all are occupied. it undergoes a
confonnauonal change. expo!.ing a '!.ticky' hydrophobic domain
that lures many protein., into a.\sociation, thereby affecting
the1r functional propenie'>.
lk' to EXCITATION
.Ieath
ld35)
hcitabilit} descn~'> the ability of a cell to show a regenerative
hSiVC
all-or-nothtng electrical response to depolarisation of its
membrane. this membrane re-.ponse being known as an action
potential. It b a characteri!.tic of most neurons and muscle cells
(mduding striated, cardiac and smooth muscle), and of many
Jf its cndoaim: gland cells. In neurons and muscle celJs, the ability of
th~ action potential, once initiated, to propagate to all parts of
Jding
mels, the c\!11 membrane. and often to ~>pread to neighbouring cells,
.and explains the importance of membrane excitation in intra- and
~~~an
intercellular signalling. In the nervous system, and in striated
mu,de. action potential propagation is the mechanism responsible
)tein.
itous hlr communication over long dhtances at high speed, indispensable
for large. fast-moving creatures. ln cardiac and smooth muscle,
ion a!
With
u' 11dl a\ in 'omc central neurons. spontaneous rhythmic activity
llCCUrs.ln gland cells. the action potential, where it occurs. serves
to amplify the 'ignalthat cau'e" the cell to secrete. In each type
1>f ti,,uc. the propenies of the excitation process reflect the special
charac:t~n,IIC\ of the ion channels that underlie the process. The
mol(\:ular natur~ of ion channels, and their importance as drug
targch. is con,Jdered m Chapter 3: here we discuss the cellular
pnx:~''c' that depend primaril} on ion channel function. For
more detail. 'cc Hille (:!001 ).
THE 'RESTING' CELL
a. The rc,ting cell i' not resting at all but very busy controlling the
\late of ih interior, and it requires a continuous suppl.y of energy
w do ,o. In relation to the topics discussed in this chapter, the
following chaructcri!-tics arc especial ly Lmportant:
membrane potential
permeability of the plasma membrane to different ions
intr.tccllular ion concentrations, especially [Ca2];.
t'ndcr rc,ung conditions. all cells maintain a negative internal
potential bct\veen about -30 mV and -80 mV, depending on the
cdl t) pc. Til is ari-.es because (a) the membrane is relatively
tmpcm1eahlc to a. and (b) a+ ions are actively extruded from
lhe cell in exchange for K+ ions by an energy-dependent
tran,ponl!r. the a pump (or a-K ATPase). The re!.ult il> that
the mtmcellular K' concentration, LK+J,, is higher. and [Na], is
lo"er. than the respective extracellular concentrations. In many
celk other ion-.. particularly CI-. are also actively transported
and unequally di-.tributed acros'> the membrane. In many cases
(e.g. in m:urons). the membrane penneability to K+ is relatively
high. and the membrane potential settles at a value of -60 to
-80mY. clo~e to the equilibrium potential for K+ (Fig. 4.3). In
tn other cells (e.g. smooth muscle). anions play a larger part, and
the membrane potential is generally lower (-30 to -50 mV) and
bs dependent on K.
~
''
'
' CYTOSOL 'Resting'
ATP ',
'' potassium
''
' -4
Na
..
, channels
Intracellular Equif>brium potential Extracenular
Na 12mmolll - :!!l!'lY- 145mmolll
~- -- -- Ca2 K 150mmoVl -- :-~rr!Y----- - 2.4mmolll
ATP 0.1 f.imoVI __ :t120roV_-- - - 2mmoVI
5mmoVI - ---=-90m\L __ -- --125mmoVI
60mV
I
I I
I
.: / Na-ca2
I
.: e xchange
Na+
Fig. 4.3 Simplified diagram showing the ionic balance
of a typical 'resting' cell. The main transport mechanisms that
maintain the Ionic gradients across the plasma membrane are
the ATP-driven Na-K and Ca2 pumps and the Na-ca2
exchange transporter. The membrane is relatively permeable to
K+, because potassium channels are open at rest, but
impermeable to other cations. The unequal ion concentrations
on either side of the membrane grve rise to the 'equilibrium
potentials' shown. The resting membrane potential, typically
about -60 mV but differing between different cell types, is
determined by the equilibrium potentials and the permeabilities
of the various ions involved, and by the 'electrogenic' effect of
the transporters. For simplicity, anions and other ions, such as
protons. are not shown, although these play an important role
in many cell types.
ELECTRICAL AND IONIC EVENTS UNDERLYING
THE ACTION POTENTIAL
Our present undcrstunding of electrical excitability rests tirmly
on the work of Hodgkin, Huxley and Katz on squid axons,
published in 1949-52. Their experiments (see Katz, 1966)
revealed the existence of voltage-gated ion channels (sec above)
and showed that the action potential is generated by the interplay
of two proccsse~:
I. a rapid, transient increa.o;e in Na permeability that occurs
when the membrane b depolarised beyond about-50 mV
2. a slower, sustained increase in K+ permeability.
Because of the inequality of Na+ and K+ concentrations on the
two 1>ide!. of the membrane. an increase in Na+ permeability
causes an inward current of Na ions, whereas an incrca e in K+
permeability causes an outward current. The separate nature of
these two current!> can be most clearly demonstrated by the usc
of drugs blocking sodium and potassium channels, as shown in
Figure 4.4. During the physiological initiation or propagation of
a nerve impu lse, the first event is a small depolarisation of the
membrane, produced either by transmitter action or by the
approach of an action potential passing along the axon. This 59
 SECTION 1 GENERAL PRINCIPLES

~ Time (ms) c] Time (ms)

0 5 10 0 5 10 15 20

Fig. 4.4 Separation of sodium and

(0[
~
:;
0
~
..s
c
~
:;
10

0
potassium currents in the nerve (,) - 10 (,)

membrane. Voltage clamp records

from the node of Ranvier of a single - 10
frog nerve fibre. At time 0, the
membrane potential was stepped to a
depolarised level, ranging from -60 mV [_B [Q]
(lower trace in each series) to +60 mV
(upper trace In each series) in 15-mV
steps. [A] [C] Control records from two
fibres. B Effect of tetrodotoxin (ITX),
which abolishes Na' currents. IJ2J Effect
of tetraethylammonium (TEA), which TTX
abolishes K+ currents.
(From Hille B 1970 Prog Biophys 21: 1.)

open!> ~odium channels, allowing an inward current of Na+ ions

to now, which depolarisel> the membrane still further. The
process i'> thu-, a regenerative one. and the increase in Na+
permeability i-, enough to bring the membrane potential close to N"
E
E,a The increa'>ed a conductance is transient, because the 30
~
.c
channel-, inactivate rapidly and the membrane returns lO its E
resting ~late. .s
Q)
20
In many type~ of cell, including most nerve cells. repolarisation 0
c:
is a~si'>tcd by the opening of voltage-dependent potassium
<ll 10
u::J
channel!>. These function in much the same way as sodium '0
c:
chan neb, but their activation kineticl> are about 10 times slower 0
(,)
0
and they do not inactivate appreciably. This means that the
potas~ium channels open later th an the sodium channels, and 0 2 3 4
contribute to the rapid termination of the acti on potenti al. The Time (ms)
behaviour of the sodium and potassium channels duri ng an acti on Fig. 4 .5 Behaviour of sodium and potassium channels
potent ial is shown in Figure 4.5. during a conducted action potential. Rapid opening of
The foregoing nccount, based on Hodgkin & Huxley's work sodium channels occurs during the action potential upstroke.
Delayed opening of potassium channels, and inactivation of
50 years ago, involves only Na and potassium channels.
sodium channels, causes repolarisation. Em, membrane
Subsequently (sec llille. 2001 ), voltage-gated calcium channels potential 9N 9k, membrane conductance to Na+, K
(see Fig. 4.1) were discovered. These function in basically the
'>ame way as sodium channels; they contribute to action potential
generation in many cell\, particularly cardiac and smooth muscle
cell!>, but al'>o in neurons and secretory cells. Ca2+ entry through
voltage-gated calcium channels plays a key role in intracellular different cclb normally discharge action potentials also varit
signalling, tl'> de.,cribed above. greatly. from '>everal hundred Hertz for fast-conducting neuro11
down to about I Ht for cardiac muscle cells. T hese vel) pn.
nounccd functional variations reflect the different characteristJ.
CHANNEL FUNCTION
of the ion channeb expressed in different cell types.
The di.,charge patterns of excitable cells vary greatly. Skeletal Drugs that alter channel characteristics, either by interacu
muscle fibres arc quicsccm unles~ Mimulated by the arrival of a directly with the channel itself or i ndirectly through sec01
nerve impul\e at the neuromuscular junction. Cardiac muscle messenger~.. affect the function of many organ systems. includm,
fibres discharge spontaneously at a regular rate (see Ch. 18). the nervous. cardiovascular. endocrine. respiratory and reproductil
Neuron~> may be normally silent , or they may discharge syMems, and arc a frequent theme in this book. Here we describo:
spomaneously. either regularl y or in bursts; smooth muscle cells some of the key mechanisms invol ved in the regu lation o
60 show a similar variety of liring patterns. The f requency at which excitable cells.
 HOW DRUGS ACT: CELLULAR ASPECTS-EXCITATION, CONTRACTION AND SECRETION
In general. action potcntiab are initiated by membrane currents
that cau~c dcpolarisation of the cell. These currents may be
20 produced by synaptic activity. by an action potential approachi ng
;o
from another part of the cell. by a sensory stimulus. or by
'pontancou' pacenwker activity. The tendency of such currentl>
10 initiate an acuon potential is governed by the excitability of the
cell. 11hich depend~ mainly on the Mate of (a) the voltage-gated
'odium and/or calcium channels, and (b) the potassium channels
of the rc~ting membrane. Anything I hut increases the number of
available 'odium or calcium channels, or reduces their activation
threshold. v.ill tend to increase excitability. whereas increasing
th~ rNing K conductance reduces it. Agen~ that do the rcver,e,
b) blodtng channeb or interfering with their opening. will
-
haH! the oppo,ite effect. Some examples arc shown in
Figur.:' ~.6 and 4.7 and in Table 4.1.
USE DEPENDENCE AND VOLTAGE DEPENDENCE
T \oltag~gat~d channels can e~i\t in three functional \late' ('ig.4.8J:
tntm~ lthe d<hCd Mate that pre1ail\ at the nonnal resting potenti;ll).
a.:/II'Cll<~itthc o~n 'tate fa1oured b} bnef depolari-ation) and intiCIII'lllcd
tthe blt,.;~cd ,t.uc r~sulting from auap door hke occlusion of the chunnt.!l
b} a lloppy intract.!llular appendage of the channel protein). After the
action potential ha' pas~cd, many MKl ium channels are in the inactivmcd
,tate, after 1hc membrane potential return~ to its resting va lue. the
1nat:ti1~ted channel\ revert to the re\ting \tate and thus become uvailahle
for actllation unce more. In the meantime. the membrane is temporarll}
trjnuron. r:.1ch action potential cau...:' the channels to qcl.: through
the..c 'tate,. Th.: durmion of the refractOr) period. which determmco, the
D1t\imum lrequcnc) at which action potentials can occur. depend' on the
r.ue (lf rccovcl) from inactivation. Drug~ that block sodium channcb.
'uch as IlK:<~ I anac;thetics (Ch. 44), antidy,rhythmic drugs (Ch. 18) and
anticpileptic drug' (Ch. 40). commonly o,how a selective aflinity for one
or other uf thco,c functional \tate~ of the channel. and in their presence the
proponmn ,,(channel\ in the high-affinuy \tote is increlbed. Of particular
tmponan..:e are drugo, that bind most 'ttongly to the inacti\ated o,tate of the
<hanntl and thu' fa1our the adopuon of tht\ \late. thus prolongmg the
relract>l) ~nod and reducing the maximum frequency at which action
polenual' can be generated. Thi~ type of block b called w.e-dependem,
becau'e the btnding of ~uch drugs increa~e' as a function of the rate of
Is action potcnual di<.,charge. wbich governs the rate at wh ich inactivated-
and therefore drug-en~itivc--channel\ are generated. This is important
e. fur ")me antidyo,rh)thmlc drugs ('ee Ch. I!!) and for antiepileptic drug<.
tCh.401. bo!cau...: h1gh-frequency di~charge~ can be inhibited without
affe.:tmg C\Citabihty at nonnal fn.'qucncie~. Drug~ that readil} bloc~
,otJium channel' 10 the1r resting o,tate (e.g. local anaesthetic~. Ch. 44)
pre1cnt excllutmn :11 low as well as high frequencies.
:.1o\t \tKhum channel-blocking drugs arc c;lli onic at phy~iological pi I
Ulld are 1hcrcfore affected by the voltage gradient aero;,<., the cell
membrane. 'o that their blocking action i' favoured by depolari,ation.
1aries Tim phenumcnon. lulO\\ n as I'Oitagr depelldi!IICt'. is also of relevance to
rons. the :K:II<>n ot ;Jnlld)'rh) thmic and ant1cpilepuc drugs. bccauo;c the cell'
that urc the -eat of dy>rhythmia~ or \e11ure acti,'it) are generJII)
y pro-
"-'me\\ hat dcf><>l.lrht.!d and therefore more \lmngly blocked than 'healthy'
ristic:. cell' Similar cono,iderations apply abo to drug' that block pota.,.,ium or
calctum channels. but we know les' uhout the imporwnce of usc and
acting 1oltage dependence for the~e than we do for -,odium chan nels.
;econd
uding
luctivc
SODIUM CHANNELS
~ribc In most excitable cells. the regenerative inward current that initiates
ion of the action potential results from activation of voltage-gated sodium
channe l ~. The early voltage clamp studies by Hodgkin & I lux ley
on the squid giant axon, described above, revealed the e~~ential
functional properties of these channels. Later. advantage was
taken of' the potent and highly selective blocking action of
tetrodotoxin (TfX. see Ch.44) to label and purify the channel
protein. and '>Ubsequently to clone it. revealing the complex
structure shown in Figure 3.18. with four similar domains each
comprising ~ix membrane-spanning helices (reviewed by Catterall.
2000). One of these helice~. S4, contains several ba~ic amino
acids and forms the voltage senl.Or, and moves outward~. thus
opening the channel, when the membrane is dcpolarised. One of
the intracellular loops is designed to ~wing across and block the
channel when S4 is displaced. thu~ inactivating the channel.
It wa!. 1-..nown from phy~iological studicl> that the sodium chan-
nels of heart and ~keletal mu'>clC differ in various ways from those
of neuron.,. In particular. cardiac ~odium channeb arc relatively
insensitive 10 TTX. and slower in their kinetics (as arc those of
some sensory neurons), compared with most neuronal sodium
channels. Nine distinct molecular subtypes have so far been
identified, more than enough to e>..plain the functional divefl>ity.
Various experimental compound~ affect sodium channel gating
and inactivation. the most important being tetrodotoxin, a highly
potent and selective blocl-..ing agent (Ch.44}, and certain sub-
stances (e.g. batrachotoxin and veratridine) that prevent inacti-
vation and therefore cause sodium channels to remain open after
activation. Therapeutic agents that act by blocking sodium chan-
nels include local anaesthetic drugs (Ch.44). antiepileptic drugs
(Ch.40) and antidysrhythmic drugs (Ch.l8). The sodium channel-
blocking action., of these drug!. were in most case~ di!.covered
long after their clinical applications were recognised; many of
them lack 1-peciticity and produce a variety of unwanted side
effects. The usc of induced mutations in cloned sodium channels
cxpres<;ed in cell I incs is now revealing which regions of the very
large channel molecule are involved in the binding of particular
agents. and it is hoped that this information will allow more
specific drugs to be designed in the future. Certain inherited neuro-
logical disorders are associated with sodium channel mutations
(see Ashcroft, 2000).
POTASSIUM CHANNELS
Tn a typical resting cell (see above). the membrane i., selectively
permeable to K+. and the membrane potential (about -60 mY)
is somewhat positive to the K+ equilibrium (about - 90 mV).
This resting permeability comes about because potassium
channels arc open. Jf more powssium channels open, the
membrane hypcrpolarises and the cell is inhibited. wherea~ the
opposite happen<, if pomssium channels clol.e. A\ well as
affecting excitability in this way. potassium channel-. also play
an important role in regulating the duration of the action
potential and the temporal pattenri11g of action potential
discharges; altogether. these channels play a central role in
regulating cel l function. As mentioned in Chapter 3, the number
and variety of potassium channel .,ubtypes i~ extraordinary.
implying that evolution has been driven by the '>COpe for
biological advantage to be gained from subtle variation!. in
the functional properties of these channels. A recent resume
lists over 60 different pore-forming subunits. plus <mother 20 61
 SECTION 1 GEN ERAL PRINCIPLES

EXCITATION

r Inhibitory voltage-gated channels

Excitatory voltage-gated channels

Na+ 'Resting' channels

Tetrodotoxin
Local anaesthetics (Ch. 44)
GPCR ligands (some)
Antlepileptics (some, Ch. 40) Anaesthetics (some, Ch. 36)
Antldysrhy1hmics (some, Ch. 18)
GPCR ligands (some)
Depolarisation
BayK 8644 (some)
cAMP (some)
Ca 2+ Ca 2-gated channels
D1hydropynd1nes (some, Ch. 19)
w-Conotox1ns (some)
GPCR ligands (some)

Excitatory ligand-gated channels

NEUROTRANSMITTERS

OTHER LIGANDS

Low pH

Amiloride (some, Ch. 24)

Inhibitory ligand-gated channels
Capsaicin
GABA (Ch. 33)
Noxious heat
Vanllloids - - -- - - - -- - -...;..-*'-'
Bicuculline
(Ch. 41 ) Capsazepine
Picrotoxin

Glycine (Ch. 33)

INHIBITION
Fig . 4 .6 Jon channels associated with excitatory and inhibit ory mem brane effects, a nd some of the drugs and other ligands
that affect them. Channel openers are shown in green boxes, blocking agents and inhibitors in pink boxes. GPCR, G-protein-coupled
receptor.
\.,._

62
 HOW DRUGS ACT: CELLULAR ASPECTS-EXCITATION, CONTRACTION AND SECRETION
Membrane
depolarisation
+
Inward Na+
current
Fig. 4 .7 Sites of action of drugs
and toxins that affect channels
involved in action potential
generation. Many other mediators
affect these channels indirectly via
membrane receptors, through
phosphorylation or altered expression.
STX. sax1tox.n, TTX, tetrodotoxin.
or ' o auxiltary subunits. An impressive evolutionary display.
maybe, but hard going for most of us. Here we outline Lhe main
t)pe~ that arc known to be important pharmacologically. For
more details, and information on potassium channels and Lhe
variou~ urugs and toxins that affect them, see Shieh et al. (2000),
Gutman et al. (2003) and Jenkinson (2006).
T Pota~>ium channels fa ll into three main classes (Table 4.2),2 of which
tlw ' tructures are shown in Figure 3. 18.
llwgt-gared 11otaJ.1hmr channels, which possess six membrane-
'panning helicc~. one of which serves as the voltage sensor, causing the
hannel to open when the membrane is depolarised. Included in this
~tmup are channel\ of the lhaker fanlily. accounting for most of the
\\lltage-gatcd K currents familiar to electrophysiologists, and others
'uch 3\ Cal -ami'Oted potassium clwnnels and two subtypes that are
Important mthe heart. HERG and LQT c/wnnels. Disrurbance of these
P<ll;t\\IUm channel terminology is confusing. to put it mildly.
Ek;,"'ll>ph}''olog"" ha\e christened K+ currents prosaically on the basis of
thc1r tuncuonal propertie~ (IKv IKe. IKMP. 1""', etc.); geneticists have
nam<d g~ne' \Orne" hat fancifully according to the phenotypes associated
"'"h mutation\ (~haker. ether-a-go-go. etc.). while molecular biologists have
ntroduced a rational but unmemorable nomenclature on the basis of
se~u~nce data (KCNK, KCNQ, etc., with numerical suffixes). The rest of us
h.11e to make what we can of the unlovely jargon of labels such as HERG
t~~<hich-don't bh nk-Mands for Human Et her-a-go-go Related Gene),
nVJK, TREK and TASK.
Tetraethy lammonium
4-Am inopyridine
Slow + } - - - - - - - - - - - - l
conductance
Fast ~ +
Sodium channel
inactivation
Veratridine
Batra chotox in
Increased Na+ Scorpion toxin
conductance etc.
Outward K
current
channels, either by genetic mutation~ or by unwanted drug effects, is a
major factor in cau~ing cardiac dysrhyth mias, which can cause sudden
deat h (see Ch. 18). Many of these channels are blocked by drugs such
as tetraethylamm onium and 4-aminopyridine.
Inwardly rectifying potassium channels, so called because they allow
K ' to pa~' inwards much more readi ly than outwards (see review by
Reimann & Ashcroft, 1999). These have two membrane-spanning
helices and o si ngle pore-forming loop (P loop). These channels are
regulated by interaction with G-protcins (see Ch. 3) and mediate the
inhibitory effects of many agonists acting on G-protei n-coupled
receptor~. Certain types are important in the heart, particularly in
regulating the duration of the cardiac action potential (Ch. I 8); others
are the target for the action of sulfonylureas (antidiabetic drugs that
~timulate in!>ulin \ecretion by blocking them; see Ch. 26) and smooth
mu~cle relaxant drugs, such as cromakalim and diazoxide, which
open them (see Ch. 19).
1io-pore domain potassium clwmrels. with four helices and two P
loops (sec re' iew by Goldstein et al., 2001). These show oUiward
rectification and therefore exert a strong repolarising influence.
opposing any tendency to excitation. They may contribute to the
resting K conductance in many ceUs. and are susceptible to regulation
'ia G-proteins; certain ~ubtypes have been implicated in the action of
volatile anae~thetics such as halothane (Ch. 36).
Inherited abnormalities of potassium channels (channelopathies)
contribute to a rapidly growing number of cardiac, neurological
and other diseases. These include the long QT syndrome
associated wilh mutations in cardiac voltage-gated potassium
channels, causing episodes of ventricular arrest that can result in
sudden death. Certain familial types of deafness and epilepsy are 63
 SECTION 1 GENERAL PRIN CIPLES
Restmg Open Inactivated
Favoured by Na
depolansatJOn I
' depolarisation. This occurs in most neurons and
fast slow
~ lnachvating particle
Blocking
drug
A y' 8
Fig. 4.8 Resting, act ivated and inactivated states of
voltage-gated channels, exemplified by the sodium
channel. Membrane depolarisation causes a rapid transition
from the resting (closed) state to the open state. The
inactivating part1cle (part of the intracellular domain of the
channel protein) IS then able to block the channel. Blocking
drugs (e.g. local anaesthetics and antiepileptic drugs) often
show preference for one of the three channel states, and thus
affect the kinetic behaviour of the channels, with implications
for thelf clin1cal application.
a-.l>ociatcd with mut~t ionl> i n voltage-gated potassium channels.
Other genetic disorders-mostly very rare-involving potassium
channels arc described by A11hcroft (2000).
MUSCLE CONTRACTION
Effect ~ of drugs on the contractile machinery of smooth muscle
arc the basis of many therapeutic applications. for smooth muscle
is an important component of most physiological systems,
including blood vessels and the gastrointestinal and respi ratory
tracts. For many decadel>, ~mooth muscle pharmacol ogy with its
trademark technology the isolated organ bath-held the centre
of the pharmacological l>tage. and neither the subject nor the
technology -.how any sign of flagging. even though the stage has
become much more crowded. Cardiac muscle contractility is also
the target of important dng effect!>. whereas striated muscle
contractil ity io; only rarely affected by drugs.
Although in each case the basic molecular basis of contraction
is similar, namely an interaction between actin and myosin.
fue lled by AT P and initiated by an increase in [Ca 2+),. there are
di fferences between thCl>C three kinds of muscle that account for
their different rc~pon!. i vcncss to drugs and chemical mediators.
These differences (Fig. 4.9) involve (a) the linkage between
membrane events and increase in LCa2+);. and (b) the mechanism
64 by which [Ca2"' I, regulates contraction.
lon channels and electrical excitability
Exc itable cells generate an ali-or-nothing
action potential in response to membrane
muscle cells, and also in some gland cells. The iomc
basis and time course of the response varies
between tissues .
The regenerative response results from the
depolarising current associated with opening of
voltage-dependent cation channels (mainly Na and
Ca2 ). It is terminated by spontaneous closure of
these channels accompanied by opening of
potassium channels.
The sodium, calcium and potassium channels exist In
many molecular varieties, with specific functions in
different types of cell.
The membrane of the 'resting' cell is relatively
permeable to K ' but impermeable to Na+ and Ca2 .
Drugs or mediators that open potassium channels
reduce membrane excitability, and vice versa.
Inhibitors of sodium or calcium channel function have
the same effect.
Cardiac muscle cells, some neurons and some
smooth muscle cells generate spontaneous action
potentials whose amplitude, rate and rhythm is
affected by drugs that affect ion channel function.
SKELETAL MUSCLE
Skeletal muscle posses~es an array of transverse T wbule--
extcnding into the cell from the plasma membrane. The actioc
potential of the plasma membrane depends on voltagc-gatea
sodium channels. as in most nerve cells, and propagates rapid!)
from its site of origin, the motor endplale (see Ch. 10), to the re11
of the fibre. The T tubule membrane contains L-type calcium
channels, which re~pond to membrane depolarisation conducteG
passively along the T tubule when the plasma membrane i
invaded by an action potential. These calcium channel\ ar.
located extremely clo~e to ryanodine recep1ors (see Ch. 3) in t~
adjacent SR membrane. and acti vation of these RyRs caust
relea~e of Ca~ from the SR. There is evidence of direct couplin
between the calcium channels of the T tubule and the RyR'
the SR (a!> l.hown in Fig. 4.9): however. Ca~~ entry through tr
T-tubule channeb into the restricted zone between these channc
and asl>ociated RyRs may also contribute. Through this linl
depolarismion rapidly activates the RyRs. releasing a shon pur.
of Ca 2+ from the SR into the sarcoplasm. The Ca~ bind~o
1roponin. a protein that normally blocks the interaction betwec
actin and myosin. When Ca~+ bind!>, troponi n moves out of th:
way and allows the contrac ti lc machinery to operate. Ca2 relea.\(
is rapid and brief, and the muscle responds with a short- lastin
' twitch' response. This is a relatively fast and direct mechani1n:
compared with the arrangement in cardiac and smooth muse!,
 HOW DRUGS ACT: CELLUlAR ASPECTS -E XCITATION, CONTRACTION AND SECRETION
---
,...... 4.2 TYpes and functions of potassium channels

Structural class Functional subtypesb Functions Drug effects Notes

Voltage-gated Voltage-gated Action potential Blocked by tetraethyl- Subtypes in the heart include
(6T, 1P) potasstum channels repolarisation. Umits ammonium, 4-aminopyridine. HERG and LOT channels,
maximum firing Certain subtypes blocked whtch are involved In
frequency. by dendrotoxins (from congenital and drug-induced
mamba snake venom). dysrhythmias. Other subtypes
may be involved in inherited
forms of epilepsy.
ca~ -acltvated Inhibition following Certain subtypes blocked Important in many excitable
potassium channels stimuli that increase by apamin (from bee venom), tissues to limit repetitive
(Ca2 ] , and charybdotoxin (from discharges, also In
scorpion venom). secretory cells.

Inward recttfylng G-proteln-activated Mediate effects of many
in
(2T.1P) GPCRs that cause
inhibition by increasing
K' conductance.
AlP-sensitive Found in many cells.
Channels open when
(ATP] is low, causing
Inhibition. Important in
control of insulin
e secretion.
GPCR agonlsts and antagonists. Other inward-rectifying
No important direct interactions. potassium channels
Important in kidney.
Association of one subtype with
the sulfonylurea receptor results
in modulation by sulfonylureas
(e.g. glibenclamide), which close
channels, and by potasstum
channel openers (e.g. diazoxide,
pinacidil), which relax
smooth muscle.

Two-pore domatn Several subtypes Most are voltage-
(4T, 2P) identtfied (TWIK, tnsensitive; some are
TRAAK. TREK, normally open and
TASK. etc.) contribute to the 'resting'
K" conductance.
Modulated by GPCRs.
Certain subtypes are activated Recently discovered, so
by volatile anaesthetics (e.g. knowledge is fragmentary
halothane). No selective as yet.
blocking agents. Modulation
by GPCR agonists and
antagonists.

GPCR, G-protem-coupled receptor.

'Potassium channel structures (see Fig.3.17) are defined according to the number of transmembrane helices (T) and the number of pore-
buies formtng loops (P) In each a subuntt. Functional channels contatn several subunits (often four), which may be Identical or different, and
they are often assoctated with accessory (m subunits.
tction
bWtthin each functional subtype, several molecular variants have been identified, often restricted to particular cells and tissues. The
gated phystologtcal and pharmacological significance of this heterogeneity Is not yet understood.
pidly
crest
lcium
ucted h~c he low), and consequently less susceptible to phannacological to activate the contractile machinery directly. Instead. this initial
ne is modulation. The few examples of drugs that directly affect skeletal Ca1+ entry acts on RyRs (a different molecular type from those of
b are mu,clc contraelton arc shown in Table 4. I. skeletal muscle) to release Ca1+ from the SR, producing a
.n the secondary and much larger wave of Ca2+. Because the RyRs of
auJ>es cardiac muscle arc themselves activated by Ca1 +, the LCa 2+], wave
CARDIAC MUSCLE
pling is a regenerative. all-or-nothing event. The initial Ca1+ entry that
R~ of Cardia, mu,de bee review by Ben;. 2002) differs from skeletal trigger-, thi'> event is highly dependent on the action potential
h the mu-cic in ,e,eml important re~pect~. The nature of the cardiac duration. and on the functioning of the membrane L-type
nnels a.:uon potential. the ionic mechanisml. underlying its inherent channels. Some of the drugs that affect it are shown in Table 4.1.
link. rh) thmicit}. and the effect!> of drugs on the rate and rhythm of the With minor differencel>. the mechanism by which Ca2+ acti\-ates
puff heart are dco,cribcd in Chapter 18. Cardiac muscle cells lack T the contractile machinery is the same as in skeletal muscle.
d~ lO tubule,. and there is no direct coupling between the plasma
ween membrane and the SR. The cardiac action potential varies in its
SMOOTH MUSCLE
1f the conligurauon in different part'> of the heart, but commonly shows
lease J 'plateau' lasting ~>evera l hundred milliseconds following the The properties of smooth muscle vary considerably in different
L~ting tnttial rapiu depolarisation. The plasma membrane contains many organl., and the linl-.. between membrane events and contraction
1nism Ltype calcium channels. which open during this plateau and is less direct and less well understood than in other kinds of
uscle all011 Cal+ to enter the cell, although not in sufficient quantities rnuscle. The action potential of smoOth muscle is generally a 65
 SECTION 1 GENERAL PRINCIPLES

A Skeletal muscle B Cardiac muscle

A
Conducted action potential (slow)
Conducted action potential (fast)

NaC
RyR
L-type Cac PLASMA
MEMBRANE
1 NaC
Ca2
~ L-typeCaC

-
PLASMA
MEMBRANE

= =fa~~\
- - T-TUBULE
'~ /

~
t
Ca 2
~
Troponin Ca2 -troponin y
Ca2
~
Troponin Ca2-troponin

Fig. 4.9 Comparison of

excitation-contraction coupling in fAl striated
muscle, B] cardiac muscle and ~ smooth
muscle. Striated and cardiac muscle differ mainly
in the mechanism by which membrane C Smooth muscle
depolarisation 1s coupled to Ca2 release. In
striated muscle, the T-tubule membrane is coupled
Agonists
closely to the sarcoplasmic reticulum (SR) via the
Ligand-gated CaC
L-type CaC and the ryanodine receptor (RyR). In
GPCR ( 2
cardiac muscle, Ca2 entry via voltage-gated ) Ca L-type CaC
calcium channels initiates a regenerative release
through activation of the Ca2-sensit1ve RyRs. In
I ~ PLASMA

smooth muscle, contraction can be produced

'f I
MEMBRANE

either by Ca2 entry through voltage- or ligand- I

~
I
...
gated calcium channels, or by inositol
trisphosphate (IP:J-mediated Ca2 release from the
SR. The mechanism by which Ca2 activates
contraction is different, and operates more slowly,
in smooth muscle compared with in striated or
cardiac muscle. CaC, calcium channel; CaM,
Myosin
~Myosin-P
calmodulin; ER, endoplasmic reticulum; GPCR,
G-protein-coupled receptor; MLCK, myosin light-
chain kinase; NaC, voltage-gated sodium channel;
RyR, ryanodlne receptor. drugs

rather lazy and vague affair compared with the more military
behaviour of skeletal and cardiac muscle, and it propagates
through the tissue much more slowly and uncertainly. The action
potential is. in mo\t case~. generated by L-typc calcium channels
rather than by voltage-gated !>odium channels. and this is one
important route of Ca' entry. In addition, many smooth muscle
celb po~~es!> ligand-gated cation channels. which allow Ca!+
entry when they respond to transmitters. The best characterised
of the~e arc the recepto~ of the P!x L) pe (see Ch. 12). which
respond to ATP relea.\ed from autonomic nerves. Smooth muscle
cell<, also store Ca! in the ER. from which it can be released
when the IP1R is activated (see Ch. 3). TP3 is generated by
aclivation of many types of G-protein-coupled receptor. Thus, in
contrast to skeletal and cardiac muscle, Ca 2+ relea~e and
contraction can occur in smooth muscle when such receptors arc
activated wi1hout necessaril y involving depolarisation and Ca 2+
66 entry through the plasma membrane.
The contractile machinery of smooth muscle is activated whc
the myosin light elwin undergoes phosphorylation, causing it~
become de1ached from the actin filaments. This phosphorylatio
is cataly~ed by a kina~e. myolin light-elwin kinase (MLCA
which is activated when il binds to Ca 2+-calmodulin (seep. 58
A second enqme, myosin phosphatase. reverses the phc
phorylmion and causes relaxation. The activity of MLCK at.'
myosin pho~phatase thus exerts a balanced effect, promouc
contraction and rcla>..ation. respectively. Both enzymes are regula~c
by cyclic nucleotide~ (cAMP and cGMP: see Ch. 3). and mar
drug~ that cause smooth muscle contraction or relaxauo
medimed through G-protein-coupled receptors or throug
guanylate cyclase- linked receptors act in this way. Figure 4.1
summarise~ the main mechanisms by which drugs contr
smooth muscle contraction. The complexity of these conlr
mechanisms and interactions explains why pharmacologists halt
been en1ranccd for so long by smooth muscle. Many therapem they
 HOW DRUGS ACT: CELLULAR ASPECTS -EXCITATION , CONTRACTION AND SECRETION

CONTRACTION RELAXATION
Agonlsts Potassium-channel Agonists
Noradrenaline Adenosine
Histamine ~-Agonlsts
Angiotensin Prostagla nd ins
etc. et c.
E

I
I
+ I
I
I HYPER POLARISATION
I

Ca2 rele a s e - - - - - - ---

''
'' ~

-.
SMOOTH MUSCLE CELL

f
Fig. 4.10 Mechanisms controlling smooth muscle contraction and relaxation. 1. G-protein-coupled receptors for excitatory
agon1sts. ma1nly regulating inositol trisphosphate formation and calcium channel function. 2. Voltage-gated calcium channels. 3. Ligand-
gated cation channels (the P2X receptor for ATP is the main example). 4. Potassium channels. 5. G-protein-coupled receptors for
1nh b1tory agomsts, mainly regulating cAMP formation and potassium and calcium channel function. 6. Receptor for atrial natriuretic
peptide (ANP), coupled directly to guanylate cyclase (GC). 7. Soluble guanylate cyclase, activated by nitric oxide (NO). 8.
Phosphodiesterase (POE), the main route of inact ivation of cAMP and cGMP. AC, adenylate cyclase; PKA, protein kinase A; PKG,
prote1n kinase G: PLC, phospholipase C.

drug' work by contrac ting or relaxing smooth muscle, parti cu larl y a ll the conventional neurotransmitters and neuromodulators
tho\t: affecting the cardiovascular. respiratory and gastrointestinal (sec C hs 9 and 32). and many hormones. It also includes
'}stems. a' dbcus,ed in later chapters. where details of specific secreted proteins such as cytokines (Ch. 13) and various
drug' and their physiological effects are g iven. growth factors (Ch. 16).
"'hen Mediators that arc produced on demand and are released by
~it to diffusion or by membrane carriers. This group includes nitric
!arion RELEASE OF CHEMICAL MEDIATORS oxide (Ch. 17) and many lipid mediators (e.g. prosranoids,
[.CK). Ch. 13. and endocannabinoids. Ch. 15).3
\luh of pharmacology is based on interference with the body's
). 58).
O\\ n chenucal medtato~. particularly neurotransmitters, hormones
phos- Calcium ionc, play a key role in both cases, because a rise in
and mOammatO!) mediator'>. Here we di~uss some of the common
~and LCa 2+j, initiates exocytosis and is also the main activator of the
mechani,ms tmolved in the release of such mediators, and it will
10ting enqmc!> responsible for the synthesis of diffusible mediator!>.
come a' no o,urpri'>e that Ca2 plays a central role. Drugs and
ulated In addition to mediator> that are released from cells, some are
other agents that affect the various control mechanisms that regu-
many formed from precur~o~ in the plasma. two important examples
late [Ca~ t, \~ill therefore abo affect mediator release. and this
tation being kinin\ (Ch. 13) and angiotensin (Ch. 19), which are peptides
accounts for many of the physiological effects that they produce.
rough produced by protca~c-mediated cleavage of circulating proteins.
Chemical mediators that are relea~ed from cells fall into two
e4.10
main group~ (Fig. 4.1 I).
omrol
ontrol Mediators that arc preformed and packaged in storage
'have \esiclcs-sometimes called storage granules-from which 3
Carrier-med iated release can also occur with neurotrnnsminers that are stored
peutic they arc released by exocytosis. This large group com prises in vesicle~ but i~ quantilalively less ignificam than exocytosis (see Ch.9). 61
 SECTION 1 GENERAL PRIN CIPLES
Muscle contraction
Muscle contraction occurs in response to a
rise in [Ca 2 l1
In skeletal muscle, depolarisation causes rapid Ca2
release from the sarcoplasmic reticulum (SA); in
cardiac muscle, Ca2 enters through voltage-gated
channels, and this initial entry triggers further release
from the SR; in smooth muscle, the Ca2 signal is due
partly to Ca2' entry and partly to inositol
trisphosphate (IP3)-mediated release from the SR.
In smooth muscle, contraction can occur without
action potentials, for example when agonists at
G-protein- coupled receptors lead to IP3 formation.
Activation of the contractile machinery in smooth
muscle involves phosphorylation of the myosin light
chain, a mechanism that is regulated by a variety of
second messenger systems.
EXOCYTOSIS
Exocytosis, occurring in re~ponse to an increa~e of [Ca~],, is the
principal mechani'm of transmitter re lea<>e (see Fig. 4.11) in the
peripheral and central nervous systems. as well as in endocrine
cells and ma'>t celb. The secretion of enzymes and other proteins
by gastrointestinal and exocrine glands and by vascular endothelial
cclh i~ ul!>o ba.,ically similar. Exocytosis (see Burgoyne & Morgan.
2002) involves fusion between the membrane of synaptic vesicles
and the inner surface of the plasma membrane. The vesicles arc
prcloaded wit h stored transmitter, and release occurs in d iscrete
packets, or qum11a. each representing the conte nts of a single
vesicle. T he first evide nce for this (see Nic holls et a l., 2000)
came fro m the work of Kat;r and his colleagues in the I 950s, who
recorded spo ntnneous ' miniature endplate pote ntials' at the frog
neuro muscular j unctio n, and showed U1at each resulted from the
spontaneous re lease of a packet of the transmi tte r, acetylc ho line.
They abo showed that re lease evoked by nerve stimulation
occurred by the sync hronous release of several hundred such
quanta, and was highl y dependent o n the presence of Ca~'" in the
bathing solution. Uneq uivocal evidence that the qua nta
represented ve~icles relea.o,ing their contents by exocytosis came
from electron microscopic studies. in which the tissue was
rapidly fro;ren in mid- release, revealing vesicles in the process of
extrusion, and from e legant electrophysiological measuremems
showing that membrane capacitance (reflecting the area of the
pres) naptic membrane) increased in a stepwise way as each
vesicle fused. and then gradua lly returned as the vesicle
membrane wa1> recovered from the surface. There is a lso
biochemical evidence showing that. in addition to the transmitter,
o ther con~ t i tucnts of the vesicles arc released at the same ri me.
In nerve terminals specialised for fast synaptic transmission,
Ca2 enter!> through voltage-gated calc ium c hannels, mainly of
the N and P type (&ee above), and the synaptic vesicles are
68 "docked' at active zones-specialised regions of the presynaptic
CARRIER
MEDIATED
RELEASE
T T
'\Q-- _ ,'....-~
....
,';
; "
Pl
Synaptic
vesicle
cycle NO AA
t
..... --- ... ~
PG
, '\
: Endocytosis ,'
T
I
...... '
\
,'
'
I '
I
I DIFFUSION
I
~ ' EXOCYTOSIS y y
T
NO PG
Fig. 4.11 Role of exocytosis, carrier-mediated transport
and diffusion in med iator release. The main mechanism of
release of monoamme and peptide mediators is Ca2 -mediated
exocytosis, but carrier-mediated release from the cytosol also
occurs. T represents a typical amine transmitter, such as
noradrenaline (norepinephrine) or S-hydroxytryptam1ne. N1tric
oxide (NO) and prostaglandins (PGs) are released by diffusion
as soon as they are formed, from arginine (Arg) and
arachidonic acid (AA), respectively, through the action of
Ca2 ' -activated enzymes, nitric oxide synthase (NOS) and
phospholipase A;. (see Chs 16 and 17 for more details).
membra ne from whic h exocytosis occurs, s ituated close to tb.
re levant calc ium c hanne ls and opposite recepto r-rich zones ofth
postsynaptic membrane (sec Stanley, 1997). Elsewhere, whc
1>peed is Jess c ritical. Ca 2 may come from intracell ular ~tore~
described above, and the spatial o rganisation of active ;rone'
le% c lear. It i& common for secretory cells, including neuron'.
release more than one mediator (for example. a fast' transmit!.
such a' glutamate and a 'slow' traru.mitter such as a neuropcptiu.
from different vesicle pools (see Ch. 9). The fast trammit
vesicles are located close to active zones. while the slow transmiU
vesicles are fu rther away. Re lease of the fast transmitter, becat~A
of the tight spatial organisation. occurs as soon as the neighbounc
calcium channels open. before the Ca~ has a chance to diffi.
throughout the terminal. whereas release of the slo'" tran.,mit
require1> the Ca 2 to diffuse more widely. As a result. rele.
of fast tran<;mitters occurs impulse by impulse. even at I
stimulation frequcncie1>, whereas release of s low transmitter
builds up on ly at higher stimulation f reque nc ies. The rete.
rates of the two the refore de pe nd critically on the freque ncy a
patterning of liring of the presynaptic neuron (Fig. 4. 12). In no
excitable cells (e.g. most exocrine and e ndocrine glands), t~
 HO W DRUGS ACT: CEllUlAR ASPECTS-EXC ITATIO N , CON TRACTI O N A N D SE CRETIO N

Fig. 4.12 Time cou rse and

frequency dependence o f the

release of 'fast ' and 'slow'
transmitters. Fast transmitters
(e.g. glutamate) are stored in synaptic
V&S!Cies that are 'docked' close to Fast transmitter
voltage-gated calctum channels tn the (e.g. glutamate) Brief localised pulses Brief localised pulses
membrane of the nerve terminal, and
are released tn a short burst when the
membrane is depolarised (e.g. by an
actton potential). Slow transmitters
(e.g. neuropeptides) are stored tn Slow transmitter
separate vesicles further from the (e.g. neuropeptide) No release Slow diffuse build-up and decay
membrane. Release is slower,
because they must fi rst migrate to
the membrane, and occurs only
when [Ca'J, builds up sufficiently. Low frequency impulses High frequency impulses

,Ill\\ mcchani<,m predominates and is activated mainl y by Ca 2+
rdca-.c from intracellular store!>.
T Cakwm cau\C\ cxocylll'>i'> by binding to the vesicle-bound pr01ein
JlllllJItlltl~/11111. and tht' favour<. a~~ociation between a second vesicle-
bound prutctn. .1\llll(ltobrtTin. and a related protein. synaprota.xin. on the
mn~r ,urfa'e of the pla,ma membrane. Thi~ association brings the vesicle
~mbranc tnhl do-c appo~llton with the pla~ma membrane. cau'iing
ort
membrane fu,ion. Th" group ot protein~. known collectively as SNAREs.
:ed pia> a ~C) 1'\IIC Ill CXOC) tO\i~.
IJ Ha\lng undcrg<m.: c'oc) to~i~. the empty vesicle i~ recaptured by
cndoc>t<N' and return~ to the intenor of the terminal. \\here it fuses with
the larger cndo,nmal membrane. The endosome buds off ne\\ ve~icle,,
l'htch ta~e up tr;an,mittcr from the cyto~ol by means of specific transport
protem' and arc agam docked on the pre~ynaptic membrane. This
''lJUencc. whtch t)'pic;tlly take~ ~eventl minute~. is controlled by various
traltkkmg protein' t~s~octated with the plasma membrane and the
'''"b. a' well ''' cytosolic protein,. Further details about exocytm,i>
and vc,tclc recycling are given by Calakos & Scheller ( 1996). NeMier et
.tl. (20()1) anti Sildhof (2004). So far, there are few examples of drugs that
all cct tr:ln,lllittcr rclea\e by interacting with synaptic proteins, although
.o the the botulinum ncurol oxins (see Ch. I 0) produce their effecb by
pmtcnl)'tic cleavuge of SNARE proteins.
of the
o\here
re' a~
NON-VESICULAR RELEASE MECHANISMS
nes is
n,, tO II thi' neat and tidy picture of transmitter packets ready and
niuer \latting to pop obediently out of the cell in response to a puff of
plide) Ca~ 'eem~ a lillie too good to be true. rest assured that the
nitter ptlture i' not quite so '>imple. Acetylcholine, noradrenaline
mitter !norepinephrine) and other mediators can leak out of nerve endings
cause irom the C}to~olic compartment. independently of \'esicle fusion,
~t~ring b} uttli,ing carrier.. in the plasma membrane (Fig. 4.11 ). Drugs
iffuse 'uch a.\ amphetamine<,, which release amines from central and
nitter peripheral nmc terminals (see Chs 11 and 32), do so by displacing
:lease the endogcnou~ amine from storage vesicles into the cytosol,
t low
Jitters
:lease
tn~ ~e,idc comcnt' may not alway~ di~charge completely. Instead.
y and
'~'"b mny fuse tnw.icnll y with the cell membrane and release only pan
1 non- ofth~tr content'> (sec Burgoyne & Morgan, 2002) before becoming
J, the dt\Ctlnncctcd (termed J..i.ISwrd run exocytosis).
whence it escapes via the monoamine transporter in the plasma
membrane. a mechanism that does not depend on Ca 2+.
itric oxide (see C h. 17) and arachidonic acid metabolites
(e.g. prostaglandin!.; Ch. 19) arc two important examples of
mediators that are rclca~ed by diffusion across the membrane or
by carrier-mediated extrusion. rather than by exocytosis. The
mediator'> arc not \tored but escape from the ceU as soon as they
arc synthcsi~ed. In both cases, the synthetic enzyme is activated
by Ca 2 . and the moment-to-moment control of the rate of
synthesis depends on [Ca~1,. This kind of release is necessarily
slower than the ela<,sic exocytotic mechanism. but in the case of
nitric oxide is fast enough for it to function as a true transmitter
(see Ch. 17).
Mediator release
Most chemical mediators are packaged into
storage vesicles and released by exocytosis. Some
are synthesised on demand and released by diffusion
or the operation of membrane carriers.
Exocytosis occurs in response to increased [Ca2~], as
a result of a Ca2 ' -mediated interaction between
proteins of the synaptic vesicle and the plasma
membrane, causing the membranes to fuse.
After releasing their contents, vesicles are recycled
and reloaded with transmitter.
Many secretory cells contain more than one type of
vesicle, loaded with different mediators and secreted
independently.
Stored mediators (e.g. neurotransmitters) may be
released directly from the cytosol independently of
Ca2 and exocytosis by drugs that interact with
membrane transport mechanisms.
Non-stored mediators, such as prostanoids and nitric
oxtde, are released by increased [Ca2];, which
activates the enzymes responsible for their synthesis.
69
 SECTION 1 GENERAL PRINCIPLES

EPITHELIAL ION TRANSPORT

ENaC
Fluid-secreting epithelia include the renal tubule, saHvary glands,
ga'>trointe~tinal tract and airways epithelia. In each case. - --~ Na-

epithelial cell'> are arranged in sheets separating the interior

(blood-perfused) compartment from the exterior lumen
I
compartment. into which. or from which. secretion takes place. I
I

,,,
Fluid secretion involve!> two distinct mechanisms, which often I

coexist in the same cell and indeed interact with each other.
Greger (2000) and Ashcroft (2000) give more detailed accounts. - K'" ~ '~~ K.. - - -
The two mechanisms (Fig. 4.13) are concerned. respectively.
Potassium Potassium
with Na transport and Cl transport. channels channels
In the case of Na transport. secretion occurs because Na+
EXTRACELLULAR
enters the cell passively at one end and is pumped out actively at LUMEN
COMPARTMENT
the other, wi th water following passively. Critical to this
mechanism is a class of highly regulated epithelial sodium
channels (ENaCs) that allow Na entry.
Epithelial sodium channels (see De Ia Rosa et al., 2000) are
widely cxprcs~ed, not on ly in epithelial cells but also in neurons CI-- HC03 I
ATP
and other excitable cells, where their function is largely exchange I '
I '- - -- K+
unknown. They are regulated mainly by aldosterone. a hormone , ~ c~- -- I
I '
I
produced by the adrenal cortex that enhances Na reabsorption I
I
' '\
by the kidney (Ch. 24). Aldosterone, like other steroid hormones, I Potassium
\
\
exerts its effects by regulating gene expression (see Ch. 3). and ', channels
causes an increase in ENaC expression. thereby increasing the ~ - ~, ~ ~ - -- - - - -- Na
rate of Na and tluid transport. This takes a few hours. and '~ - -- --- --ci-
CFTR
aldosterone also affects E aC function through other more rapid Natcl
mechanisms. but the details arc not weU understood. ENaCs are co-transporter
selectively blocked by certain diuretic drugs, notably a miloride
EXTRACELLULAR
(see Ch. 24), a compound that is widely used to study the LUMEN
COMPARTMENT
functioning of ENaCs in other situations.
Chloride transport is particularly important in the airways and Fig. 4.13 M echanism s of epithelial ion transport. Such
gastrointestinal tract. In the airways, it is essential for tluid mechanisms are important in renal tubules (see Ch. 43 for
secretion, whereas in the colon it mediates fluid reabsorption, the more details) and also in many other situations, such as the
gastrointestinal and respiratory tracts. ~ Sodium transport. A
difference being due to the different arrangement of various
special type of epithelial sodium channel (ENaC) controls entry
transporters and channels with respect to the polarity of the cells. of Na' into the cell from the lumenal surface, the Na being
The simp!ificd diagram in Figure 4.13B represents the situation actively pumped out at the apical surface by the Na-K
in the pancreas. where secretion depends on o- transport. The exchange pump. K moves passively via potassium channels.
key molecule in o - transport is the cystic fibrosis transmembrane ~ Chloride transport. Cl- leaves the cell via a special
membrane channel, the cystic fibrosis transmembrane
conductance regulator (CFTR; see Hwang & Sheppard, 1999),
conductance regulator (CFTR), after entering the cell either
so named becau~e early studies on the inherited disorder cystic from the apical surface via the NaJcl- cotransporter, or at the
fibrosis ~howed it to be associated with impaired Cl lumenal surface via the ci-/HCo3- cotransporter.
conductance in the membrane of secretory epithelial cells, and
the CFTR gene. identified through painstaking genetic linkage
studies and isolated in 1989. was found to encode a Cl
conducting ion channel. Severe physiological consequences phosphorylation of channels and transporters. CFTR it~lf
follow from the impairment of secretion. particularly in the activated by cAMP. In the gastrointestinal tract, increased cA\f.
airways but al<>o in many other systems. such as sweat glands and formation causes a large increase in the rate of fluid secretion
pancreas. Genetic Mudies revealed mutations in the CFTR gene; effect that leads to the copious diarrhoea produced by chole
this knowledge has produced a tlood of research on the infection (sec Ch. 3) and also by inflammatory conditions
molecular mechanisms involved in cr transport, but as yet no which prostaglandin formation is increased (see Ch. 13
significant therapeutic advance. So far. no drugs are known that Activation of G-protein-coupled receptors, which cause relea..
interact specifically with CFTRs. of Ca2, also stimulates secretion, possibly also by activat1~
Both Na and Cl transport are regulated by intracellular CFTR. Many examples of therapeutic drugs that affect epitheli
messengers, notably by Ca2 and cAM P. the latter exerting its secretion by activating or blocking G-proteio-coupled receptor
70 effects by activating protein kinases and thereby causing appear in later chapters.
 HOW DRUGS ACT: CELLULAR ASPECTS- EXCITATIO N, CONTRACTION AND SECRETION

lplthela.l lon tnlnaport

Many epithelia (e.g. renal tubules, exocrine glands, Anion transport depends on a specific
and airways) are specialised to transport specific chloride channel (the cystic fibrosis transmembrane
tons. conductance regulator), mutations of which result in
Thts type of transport depends on a class of sodium cystic fibrosis.
channels known as epithelial sodium channels, which The activity of channels, pumps and exchange
allow Na entry mto the cell at one surface, coupled transporters is regulated by various second
to active extrusion of Na, or exchange for another messengers and nuclear receptors, which control the
10n. from the oppostte surface. transport of ions in specific ways.

LAR
:NT
REFERENCES AND FURTHER READING
r.~mral rerc rencc~
1\.11 8 1960 NNvc mu,clc and 'Yn<~psc. McGmw Hill.
'~" Y<>rk (1\ rlallir rl('fiWifl oftlr~ xmund-bnoking
tin tmph\lll>IIIRitlll nplriml'llt.\ that l'\Wbli.1hed the
n,,.,, of nrn r 11ntl mu1rl~ flm<'twn)
l.tl lJnl B. l':oomattk L K 2002 The neuron: cell and
lll(lkcul;u ~'"''"8} 'rd edn. Oford t:nive!blly Press.
''" '"r" Wrjul trtt/>t.,,~ NII'Uin~ "'" rhwm~/, tmtl
Sl1Wp/U' N< 1Jum1m1 U~ II d/ U~ 0(/r('r aSfJl'CIS of
MJ<ronol}UNtun 1
~ krl J, II)RWn S C \blcnt.a R C 2001 Molecular
IIOIIOphMnlliC<>IOg) McGra" I hll. 'ew Yorl.
ll.utUtnJ mt...lttn lntJ>t,.,t I
\>Cbolh J G. fu.:h' P A. ~bnon \ R. \\allacc: 8 G :!000
From ll<Un>n lu ~ram Sonau.:r. Sunderland (L.tcellMt.
'tU M-ntto ltttht~tAA. tJ/ nrunHdtnt:t)
ter
'lt<ond mh~ngcrs a nd calcium regula tioo
..AA
8J:nu G J 19'19 Re~ptor-a't"ated Ca' ooOow m
NT
umal cell' .1 >.lnCt) olpmhway' tarlorcd 10 mcel
J<ITercnl mtr,~edlular \n ' "gnalhng rcqU<rcmcnt;,.
n B~<~~:hcm J '17: 153 169 (Uuful twervit>w of
mrt ha'lt\111\ uwttl\ td m Ctl.. SiRtWIImR)
B<mJ c \1 J 1997 J:lcmcmary and global aspects of
A C!k1um "~nailing. J l'hy>iol499. 291 - 306 (RCliew of
try Ca'' \1~/Utllmq. emplwriin11 tilt \'orious intmcellular
mrdlcmimlf that (>rrnlutf 1[111/illl mul temporal
r1itlfntlll}.! '\{Hlrk.\ ', 'IHH't'\ ', ('/(',)
lkmdgc M J, Oouunnn M D. Llewellyn Roderick II
).
21XI' Cakium \lgnnlhng: dyn11mics. homeostasis and
11'm1><k l hn~. Nat Rev Mol ('ell llool 4: S 11 -529
Excitation a nd ion channel~
Ashcroft F M 2000 lon channels and di\ea\c. Acadcnuc
Press. San Diego (A 1'<'1)' tllrfu/ teftbclll~ thm tftsrribr
1lte physiology <if differem kimli of ian dwnnr/s, mod
refutes it to th<'ir moln:ulnr Hrurture: tht' lwo~
emphasises tilt' imJ)()rtanu of 'channe/t)fJlllhit~ ,
genetic channel defecl.f ass(J('iotrd 1wh dtrrare unrr.t)
Catterall W A 2000 Fmm oomc current' 10 mok-.:ular
mechanisms: the structure and function of ohage
gated sodoum channel\ Neuron 26: 13 25 CUufltl
re>il'l< arucle)
Clapham D E 2003 TRP channel' a.' cellular '><'n\01'.
Nature t26: 517-52-1 (Rl'\ll'\1 artidt> on lht> rt'ccmh
disco>'t'red multipurpos<' TRPfamtl~ of chamtdfl
De Ia Rosa D A. Cane-.<a C M. l"yfc G K. Lhang P :!000
Strucrure and regulation of nmiloride-scn\111\e 'odoum
channel\. Annu Re' Phy\IOI 62: 573 594 (Gtnero/
revin 011 thl' noture tmd flmt'IIOII of 'epilhelia/'
sodium chan11els)
Goldstein SA N. Bockenhauer D. Zilberberg N 200 I
Pota.>sium lea~ channel\ and the KCN K family nl
tw<>-P-domain ubunih. Nm Rc' Ncun"c' 2: I 75 184
(Review on the current swte of ~ntNied{!t' of a
re,ently di.wmered clan cif f'C/Itllsium t'htmnt'il)
Gutman G A et al 2003 IUPII AR compendium or
voltagegated ion channel~: pola<sium channel<,
Pharmacol Rev 55: 583 586
Hi lle B 200 I louie chanucls of excitable membranes.
Sinauer Associates. Sunderland (A rlear am/ detailed
account ofthe lxiSic [Jrinciple.t tif ion rlunmefl. with
emphasis on their biophysical pmpatie.f)
Tri!lplc I) J I999 1'hc phamacology of ion channels:
wilh particular reference 10 vollage-gmed Ca1 channch.
j:ur J Phnrmacol175: 111- 325 (Review focming
mainly on 1ariou~ typttl <if calcium chwmel bltK~t'r.\,
nootl\' of which are impar1a111 tlterapeulically)
Muscle contraction
Be"' D M 2001 Card1ac e.xcitalion-<omracuon coupling.
Nature 415: 198-205 (Short, M'elf.il/uslrated mi,....
artic/t>J
Kunyam;o H. Kuamura K.llohT.Inoue R 1998
Phy,tOiogtcal feature> of' i\Cer.ll 'mooth mu-cic cell,,
"llh 'JlL"'oal rcfcll!nce 10 recepw"' an<loon chilllnel,.
Ph)sool Re' 78: 811-920 CComprrhmsi1t> re\'ll'\1
ctrtide)
Secretion a nd exoc) tosis
Burgo)ne RD. Morgan A 2002 Secretory gmnule
exoc}tosis. Physiol Re' 83: 581~32 (Compreht>tuiw
reit'W of tht' mol<'cular machinen respansibl<' for
stc retory exoc:ytosis)
Calako' N. Scheller R H 1996 S)naptic vc><cle
biogcne"; docking and fu.ion: a molecular
descnption. Physiol Rev 76: 1-29
(~\ummtlfi.'ie,\ recent t.uh(mces in the undenumding of
the mecltcmism of exoc:) tosis)
Greger R 2000 The role of CFTR in the colon. Annu Rev
l'hy<iol62: 467-491 (A usefltl rP.<unu' of information
ahout CF'f'R t111d epithelia/.,ecretion, more gener~~l
than ill lille sugge>t.l)
II wang T-C. Sheppard D N 1999 Molecular
phannacology of 1he CPTR channel. Trend'

j
lkmdsc M J. L1pp P. Bootmnn M D 2000 The Jenkinson D II 2006 Po!llssium channels muhitJiicuy Pharmacol Sci 20: 448-453 (Ducription of
\tr,allhl) und uni\'CI'.aluy of calcoum signalling. and challenges. Br J Phnrmacol 147 CSuppl): 63- 71 approochu ain<Rd ot findillg thUafJl'ufic drugs oimed
\JI Re1 Cell \1ol Bu>l I II 21 Reimann F. A\hcroft F M 1999 Inwardly rectofyong at altcrmg tloe function of tloe
Ctuni f. 'I, De Tnkdo r 0 II 2002 l\ ocotonoc acod pOU$Sium channels. Curr Opon Cell Boo I II : 50' 508 CI-TR rhamwl)
a&runr donu.:leoudt pho,phatc: a new inU'aCellular (Re>tew dt'.<t:ribi11~ the .-ari()UI muh11ni1m\ by "huh Sian ley E E 1997 The calcium channel and lhe
sccood ffih"'ncr. Am J Ph)'ool Cell Physiol 292: lhl' inM'artf/~ rectifying J)()IOSfium chmUJ~I.r are organization of the presynaptic rransmmer release
Cll91 \II% ICumnt llatr cifi.Joc>MUd/1<' of modulalt'tf) face. Treod~ Neurosci 20: -104-409 (Discussu thl'
MM>P <h a ucm,J mcucll~l'r mm/1 td m Ca1 ' Shieh C.C. Coghlan M. Sull11an J P. C.opalakmhndn \1 mtcmph)siology ofesil'lllar l'l'il'ast')
:If is stgna!lmgl 2000 Potassium channels: molecular defects. do-ea~s Stldhof T C 2()().1 The synaptic vesicle cycle. Annu Re
Gwt A H :!iXlO Cycht ADPnbo..e. J Mol/lied 78: and therapeutic opponumloe<o. Pharmacol Rc1 52: 'lcunr.co 27: 509-.5-17 (Sununari<es reum admncer
;.\.\1P 26 15 rNrll~'>< amclt' da<l>tnl( lht' mil' of cADI'R. a 557- 593 ((A}mpre/u>n.riw revil'll of pclllmium r/oallnt'l m tht' 11ndtmtanding of >'t'Sicular reletut' at tht'
tn. an trcrntiYdn<mffrd lt>nd messcnllt'T s1mi/or 10 JP,) pathophJsiology tmtl phannacoiiii(J) nl()/ecular ll'>ef>
olera
1!> i n
13).
lease
ating
1elial
ptors
71
 Cell proliferation
and apoptosis

Overview 72
CELL PROLIFERATION

Cell proliferation 72 Cell proliferation is involved in many physio logical an,

-The cell cycle 72
- Interactions between cells, g rowth factors and the
extracellular matrix 76
Angiogenesis 77
Apoptosis and cell removal
-Pathways to apoptosis 78
Pathophysiological implications
-Therapeutic implications
pathological processes includi ng growth, healing, repair, hype
trophy, hyperplasia and the development of tumours.
genesis (Lhc development of new blood vessels) necessarily
during many of these processes.
Proliferating cells go through what is tem1cd the cell c_n,
77 during which the ceil replicates aJJ its components and then
itself into two idcmical daughter cells. Important componcnh
the ~ignalling pathways in proliferating cells are receptor tyro'
80
83
kinase\ or receptor-linked kinases. and the mitogen-acti\
kina~e ca\Cade (~>ee Ch. 3). In all ca<;es, the pathways e\
lead 10 tran~cription of the genes that control the cell cycle.

THE CELL CYCLE

The cell cycle is an ordered series of events consisting of
<;cquential phase~: G 1 S. G2 and M (see Fig. 5.1).

M is the phase of mitosis

OVERVIEW
In the postembryonic body, about 10 billion new
cells are ma nufactured daily through division of
existing cells-a prodigious output that must be
counterbalanced by the elimination of a similar
number of cells. A balance between cell generation
and cell removal is also critical during
embryogenesis and development. This chapter
covers the main elements involved in the processes
of cell proliferation and cell removal. We consider
the changes that occur within an individual cell
when, after stimulation by growth factors, it gears
up to divide into two daughter cells. We consider
the interaction of cells, growth factors and the
extracellular matrix in cell proliferation. We
consider the phenomenon of apoptosis-a
programmed series of events leading to cell
death-detailing the changes that occur in a cell
preparing to die and describing the intracellular
pathways that lead to its demise.
Last, the pathophysiological significance of the
events described is considered and their
implications for the potential development of
72 clinically useful drugs briefly discussed.
S is the phase of DNA .synthesis
&
G 1 is the ~ap between the mitosis that gave rise to the cell
and the S phase; during G,, the cell is preparing forD A
of
synthesis
G 2 is the gap between S phase and the mitosis that wi ll gil(
rise to two daughter cells; dULing G 2, the cell is preparing fa
the mitotic division into two daughter cells.
Cell division requires the com rolled timing of two critical
of the cell cycle: S phase (DNA replication) and M pha<;e (
Entry into each of these phases is carefully regulated, and
are thu~ two 'check points' 2 (restriction points) in the cycle:
at the ~tart of S and one at the start of M. DNA damage result,
the cycle being !>lopped at one or other of these. The integrit~
the check point~ is critical for the maintenance of genetic ~tab
(explained below), and failure of the check pointS to stop the
when it i~ appropriate to do so is a hallmark of cancer.
1
1n cells that are dividing continuously. G1 S and G2 compri'>e illlt'mltcJJt'.l!
the phase between one mitosis and the next.
2
Some authoritie~ have ch;11lenged the concept of celb simuhaneou;ly
being arrcMed at the check points and. on the basis of cell culture studie'
favour a continuum model in which arrest does not occur at a defined
in the cycle.
 CELL PROLIFERATION AND APOPTOS IS

forces and the negative regulatory forces. Apoptosis also has a

Check point 2 role in the control of cell number<; (see below).

POSITIVE REGULATORS OF THE CELL CYCLE

The cycle i~ initiated when a growth factor acts on a quiescent
cell. provol..ing it to divide. One of the main actions of a growth
factor ic; to 'itimulate production of the cell cycle regulators.
which are coded for by the delayed response genes (explained
below).
The main component11 of the control system that determines
progress through the cycle arc two families of proteins: cycfins3
and cycfin-dependent kinases (cdks). Recently, another family of
Check point 1 kinases- Polo-likc kinases (Plks)-have been shown to play an
I and Fig. 5.1 The main phases of the cell cycle of dividing cells. imponant role in the cell cycle (sec below).
1
1yper- The cdks phosphorylate various proteins (e.g. cnzymcs)-
.ngio- ac.:tivating some and inhibiting others- to coordinate their
'lCCUTS activities.
In the adult. most cell~ are not constantly dividing; most spend Sequential functioning of several different cdks activates the
ere/e. a varying amount of time in a quiescent phase outside the cycle processe!> that promote progress through the phases of the cycle.
isect<; a' 11 wc:re, in Ihe pha~e termed G 0 (Fig. 5.1 ). (Note that G 0 means Each cdk is inactive until it binds to a cyclin, the binding
ms of 'G nought'. not the word 'Go'.) Neurons and skeletal muscle enabling the cdk to pho~phorylate the protein(s) necessary for
rosine cell' 'f'\!nd all their lifetime in G0 ; bone marrow cells and the a particular Mep in the cycle. It is the cyclin that detcnnines
hated lming cdb of the ga~trointe~tinal tract divide daily. which protein(s) arc phosphorylated. After the phosphorylation
IUall) QUJN:Cnt cell\ can be activated into G1 by chemical stimuli event has taken place. the cyclin is degraded (Fig. 5.2) by the
u"tX'iatcd \\ ath damage; for example, a quiescent skin cell can be ubiquitin/protease system. This involves several enzymes (E1 E1
timulatcd b} a wound into dividing and repairing the lesion. The E, ) acting sequentially to add small molecules of ubiquitin to
1mpetu' for a cell to \tart off on the cell cycle (i.e. to move from the cyclin. with the resulting ubiquitin polymer acting as an
C~jj into G1J can be provided by several stimuli. tbe most impor- address label' that directs the cyclin to tbe proteasome where it
everal tant being growth factor action though G-protein-coupled is degraded.
r~ceptor,, \\h1ch can al\O stimulate cell proliferation. The action There are eight main groups of cyclins. Those important in the
of ligand' on G-protcin-coupled receptors (dealt with in Ch. 4) control of the cell cycle are cyclins A. B. D and E. Each cyclin
~:an al'o \llmulate the cell to embark on the cell cycle (Johnson is associated with and activates particular cdk(s). Cyclin A
& Walker. 1999; Cumming~ et al., 2004 ). activate!. cdks I and 2; cyclin B, cdk I; cyclin D, cdks 4 and
:II
Growth factors stimu late the production of signal transducers 6; and cyclin E, cdk 2. Precise timing of each activity is essen-
lA
of two type~: tial, and many cycle proteins are degraded after they have carried
out their functions. The actions of the cycl in/cdk complexes in
give positive regulators of the cell cycle that control the changes
the cell cycle are depicted in F igure 5.3.
ag for ncce,.,ary for cell division
ncgati'e regulators that control the positive regulators.
events The maintenance of normal cell numbers in tissues and organs 'The name cyclin' come' from lhe fact that these proteins undergo a cycle
itosis). rc4uirc' that there be a balance between the positive regulatory of ')'nlhe"' an<.J breaJ..<.Jown during each cell division.
I there
e: one
ult<; in
nt) of
ability
A 8 c
:cycle

.Juue-

Fig. 5.2 Schematic representation of the a ctivation of a cyc lin-de pe nde nt kinase. [A] An inactive cdk. E The inactive cdk is
1dies. activated by being bound to a cyclin; it can now phosphorylate a protein substrate (e.g. an enzyme). c After the phosphorylating event,
l point the cyclin is degraded.
73
 SECTION 1 GENERAL PRINCIPLES

Metaphase
K
Cell during G2 X Anaphase

G~ < ?
< ?

/
A.
Daughter cells

Go
Check point 1

Rb acts as a brake here, keeping

the cell in G 1 by inhibiting the genes
necessary for the entry into S
phase; phosphorylation by the cdks
releases the brake. The p53 Cell during G 1
protein stops the cycle here if there
has been DNA damage

Fig . 5.3 Schematic diagram of the cell cycle, showing the role of the cyclln/cyclin-d ependent kinase complexes. The
processes outlined in the cycle occur inside a oell such as the one shown in Figure 5.4. A quiescent cell Qn G0 phase), when stimulated
to divide by growth factors, is propelled into G1 phase and prepares for DNA synthesis. Progress through the cycle is determined by
sequential acllon of the cyclin/cdk complexes - depicted here by coloured arrows, the arrows being g1ven the names of the relevant
cyclins: D, E, A and B. The cdks (cyclin-dependent kinases) are given next to the relevant cyclins. The thickness of each arrow
represents the intensity of acllon of the cdk at that point in the cycle. The activity of the cdks IS regulated by cdk inhibitors. If there is
DNA damage, the products of the tumour suppressor gene p53 stop the cycle at check point 1, allowing for repair. If repair fails,
apoptosis (see Fig. 5.5) is initiated. The state of the chromosomes is shown schematcally in each G phase-as a single pair in G., and
each duplicated and forming two daughter chromatids in G2 Some changes that occur during mitosis (metaphase, anaphase) are shown
in a subsidiary circle. After the mitotic division, the daughter cells may enter G1 or G0 phase. Rb, retinoblastoma gene.

The activity of these cycl in/cdk complexes is modulated by Phase G 1

various negative regu latory forces (considered below), most of a. is the phase in which the cell is preparing for s pha~e m
which act at o ne or other of the two check points. sy nthc~ isi ng the messenger RNAs and proteins needed for Dt-.
replication. During a 1, the concentration of cyclin D incrca-.:
Cells in G0 and the cyclin D/cdk complex phosphorylates and activate~ tl
In quiescent an cell~. cyclin D is present in low concentration, necessary proteins.
and an important regulatory protein-the Rb protein 4-is In mid-a 1, the cyclin D/cdk complex phosphorylates the R
hypophosphorylated. protein, releasing tran!>cription factor E2F; this then activates tit
Hypophol>phorylated Rb holds the cell cycle in check at check genes for the components specified above that are essential ~
point I by inhibiting the expression of several proteins critical the next phase- D A synthesis-namely cyclin E and A. D\
for cell cycle progre~l>ion. The Rb protein accomplishes this by polymerase and so on.
binding to the E2F tram,cription factors. which control the The action of the cycLin E/cdk complex is necessaf} I
expression of the geneo, that code for cyclins E and A. for DNA tran'>ition from a, to S phase. i.e. past check poim I. Once p;
polymerase, for thymidine kinase. for dihydrofolate reductase. check point I. the processes that have been set in motion canrr
etc.- all Cl>SCntial for D A replication during S phase. be rever!>ed. and the cell is committed to continue with D~
Growth factor action on a cell in G0 propels it into G 1 phase. replication and mitosis.

5 phase
Cycl in Elcdk and cyclin A/cdk regulate progress through S pha
..,.he Rb pr01cin is coded for by the Rb gene. The Rb gene is so named phosphorylating and thus activating proteins/enzymes invoh
74
because rnu 1mion~ of this gene are associo1ed with retinoblastoma 1umours. in DNA synlhesis.
 CELL PROLIFERATION AND APOPTOSIS

G2 phase Anaphase. A specialised device, the mitotic apparatus,

In G, phase. the cell, which now has double the number of
chromo,omcs. mu~t duplicate all other cellular components for
allocation 10 the two daughter cells. Synthesis of the necessary
mc,~nger Rl\A., and protein~ occurs.
C)din Vcdk and cyclin 8/cdk complexes are active during
G~ pha'c and are nece\\ary for entry into M phase. i.e. for
p:t"mg check point 2. The presence of cyclin B/cdk complexes
mthe nucleu' j, required for mitosi' to commence.
Cnlike cyclin-. C. D and E, which are short-lived, cyclins A
and B remain \table throughout interphase but undergo
prot~uly'" by a ubiquitin-dependent pathway during mitosis.
Mitosis
~1ltos1s is a continuous process but can be considered to consist
of four stages.
Prophase. The duplicated chromosomes (which have up to
this point formed a tangled ma~s fil ling the nucleus)
condl.!n.,c, each now consisting of two daughter chromatids
Ohc original chromosome and a copy). These are released
mto the cytoplasm as the nuclear membrane disintegrates.
1ft wplwse. The chromosomes are aligned at the equator
('CC Fig. 5.3).
captures the chromosomes and draws them to opposite poles
of the dividing cell (see Fig. 5.3).
Telophase. A nuclear membrane forms round each set of
chromosome!>. Finally, the cytoplasm divides between the
two fonning daughter cells. Each daughter cell will be in G0
phase and will remain there unless stimulated into G 1 phase
a!> dc~cribcd above.
During metaphase, the cyclin A and 8 complexes phosphorylate
cytoskcletal proteins, histones, and possibly components of the
!.pindlc (the microtubule!. along which the chromatids arc pulled
during metaphase).
Polo-like kinoses
Polo-like kinases (Plks) are a family of kinases that arc involved
in the regulation of the cell cycle (Dai, 2005). There are rour
Plks in humans: Plks 1-4. l11 G" they are active in centrosome
dynamics and the DNA damage response; their action is import-
ant at the point where the cell enters the mitotic phase, they play
a part in spindle assembly, their action peaks cyclically during
anaphase- telophase, and they have a role in postmitotic function
when the cell passes into the G0 phase.

Extracellular
nd
matrix
>wn Growth factors ~ ~

Fig. 5.4 Simplified diagram of Growth factor

PLASMA MEMBRANE
the effect of growth factors on a receptors
cell in G0 The overall effect of
Aas I
growth factor action is the
Kina~ FA kinase
I
generation of the cell cycle I
I
transducers. A cell such as the one I
be by depicted will then embark on G 1 Kinase 2 I

phase of the cell cycle. Most growth Cytosolic

DNA Kinase 3
factor receptors have integral transducers
reases
tyros1ne k1nase (see Fig. 3.15). CYTOSOL
e~ the
These receptors dimerise (form
pa1rs), then phosphorylate each

. . . .! . . . .
heRb other's tyros111e residues. The early
.e~ lhe cytosolic transducers include
ial for protems that bind to the
phosphorylated tyrosine residues.
DNA Optllllum effect requires cooperation Nuclear
Wlth 1ntegnn action. lntegrins (which transducers
I
I) for have ct and ~ subunits) connect the I
I
e past extracellular matnx with intracellular I
:annot SIQnalhng pathways and also with I
___ II
the ce l's cytoskeleton (not shown
DNA here). G-protein-coupled receptors
Pos1!1ve regulators of Negative regulators of I
can also stimulate cell proliferation, I
the cell cycle: the cell cycle: I
because their intracellular pathways
cyclins p53 protein
can connect with the Raslkinase Cellcyjle
.~Jsducers
cycllndependent Rb protein
phase. cascade (not shown). AP, adapter
kinases (cdks) cdk inhibitors
prote1n; FA kinase, focal adhesion
lolved
k1nase; Rb, retinoblastoma.
75
-----------------------------------------------
 SECTION 1 GENERAL PRIN CIPLES
NEGATIVE REGULATORS OF THE CELL CYCLE
One of the main negative regulators has already been
mentioned the Rb protein that holds the cycle in check while it
i~ h) popho\phorylated.
Another negative regulatory mechanism is the action of the
inhibitor-. of the cdks. These bind to and inhibit the action of the
complexes, their main action being at check point I.
There arc two families of inhibitors:
the CI P family (~dk inhi bitory J!rOteins. also termed KIP or
hina~e inhibitory arotein~)-p2 1 , p27 and p57
the Ink fami ly (inh ibitor~ of kinases)-p16, p l 9, and p i S.
The action of p2 1 (explai ned below) serves as an example of the
role of a cyclin/cdk inhibitor. Protein p21 is under the control of
the p53 gene-a parti cularl y important negati ve regulator that
operates at check point I .
Inhibition of the cycle at check point 1
T he p53 gene has been called the 'guardian of the genome'. It
code~ for a protein transcription factor-the p53 protein. I n
normal healthy celb. the steady-~tate concentration of the p53
protein is low. But when there is D A damage, the protein
accumulate!> and activates the transcription of several genes. one
of which code~ for p21. Protein p21 inactivates cyclin/cdk com-
plexes, thus preventing Rb pho!>phorylation. which means that
the cycle i'> arre\ted at check point I. T his allows for D A
repair. If the repair is !>uccc!>sful. the cycle proceeds past check
point I into S phase. If the repair is unsucces ful. the p53 gene
trigger~ apoptosis-<ell ~uicide (see below).
Inhibition of the cycle at check point 2
T here i!> evidence thut DNA damage can result in the cycle being
Mopped m check point 2. but the mechanisms involved are less
clear than those at check point I . Inhibition of the accumulation
of cyclin B/cdk complex in the nucleus seems to be a factor.
For more detail on the control of the cell cycle, see Swanton
(2004).
INTERACTIONS BETWEEN CELLS, GROWTH
FACTORS AND THE EXTRACELLULAR
MATRIX
Duri ng cell proliferation. there is integrated interplay between
growth factor!>, cell\, the extracellular matrix, and the marrix
me ta ll oproteina<,e~. The extracellular matrix suppl ies the
supponing framework for the cells of the body and is secreted by
the cell~ t hcmsclvc~. It abo profoundly influences cell behaviour
through the cell's intcgrin!> (sec below). M atrix cxpres!>ion is
regulated by the action on the cell of growth factors and
cytokincs (~cc Chang & Werb. 200 I ; M cCawley & M atrisian,
200 I). T he activation status of some growth factors is, in tum,
determi ned by the matrix, because they are sequestered by inter-
action wi th matrix components and released by enzymes (e.g.
meta ll oprotei na ~cs. see below) secreted by the cells.
It is clear that the action of growth factors-which act through
76 receptor tyrosine kin ases or receptor-coupled kinases (see Ch. 3)
The cell cycle
The term cell cycle refers to the sequence
of events that take place within a cell as it
tools up for division.
The phases of the c ell cycle are:
G 1 - preparation for DNA synthesis
S - DNA synthesiS
G2 - preparation for division
mitosis-division into two daughter cells.
Growth factor action stimulates a quiescent cell - said
to be in G0 (G nought)-to divide, i.e. to start on G 1
phase.
In G0 phase, a hypophosphorylated protein, coded
for by the Rb gene, holds the cycle in check by
inhibiting expression of critical factors necessary for
DNA replication.
Progress through the cycle is controlled by specific
kinases (cyclin-dependent kinases, cdks) that are
activated by binding to proteins termed eye/ins.
Four main cyclin/ cdk complexes involving cyclins D.
E, A and B drive the cycle; the first complex, cyclin
0 /cdk, releases the Rb protein-mediated inhibition.
Vanous families of proteins act as cdk inhibitors.
Important is protein p21 , which is expressed when
DNA damage causes transcription of gene p53. The
p21 protein stops the cycle at check point 1.
i nitiating the cell cycle (~ee above}-is a fundamental parr of
these processes. There are numerous growth factors, i mporran
examples being fibrob last growth factor (FGF). epidermal growtl:
factor (EGF), platelet-dependent growth factor (PDGF}, vascuiJ'
endothelial growth factor (VEGF) and transforming gro"'th
factor (T GF-p). (But as pointed out above, there is also a role fo1
ligands acting on G-protein-coupled receptors in cell cycl~
initiation; sec also Ch. 3.)
The main components of the extracellular matri x arc as folio"'
Proreoglycans. These have a growth-regulating role, in pan
by fu nctioning as a reservoir of sequestrated growdl facto!'\
(as specified above). Some proteoglycans are associated \\ith
the cell surface, where they help to bind cells to the matrix
(K resse & Schonherr, 200 I).
Collagens. These arc the main proteins of the extracellular
matrix.
Adhe.\il'e proteins (e.g. fibronectin). These link the variou\
clements of the matrix together. and also form links bet\\Ct.
the cells and the matrix through integrins on the cells
(~ee below).
THE ROLE OF INTEGRINS
lntegrin s are transmembrane receptors, with a and Psubunits, th.
on interaction with the extracellu lar matrix elements outside th,

cell (e.g. 11bronectin) mediate various cell responses, such as
l~1o,kclctal rearrangement (not considered here) and coregulation
ot gro\\th factor function. Intracellular ~ignalling by both growth
factor receptors and integrins is important for optimal cell pro-
htcration <Fig. 5.4). l ntegrin stimulation activates an intracellular
tran,duction pathwa). which. through an adapter protein and an
en!) me (focal adhc.,ion kina\e). can activate the kinac;e cascade
that forms part of the growth factor signalling pathway (Fig. 5.4 ).
(ffi\,-talk between the integrin and growth factor pathways occur~
~) ,e,cral other means as wel l. Autophosphorylati on of growth
f,t~tor receptors (Ch. 3) i., enhanced by integrin activation, and
Jid mtegrin-mcdiated adhesion to the extracellular matrix (Fig. 5.4) not
onl} suppresses the concentrations of cdk inhibitors p2 1 and p27
rut IS rc4uinxl for the cxpre\sion of cyclins A <md D, and therefore
lor the progression of the cell cycle. Furthermore, iutegrin acti on
stimulutcs <~poptosi s-i nhibiti ng signals (sec below), further faci li-
tating growth factor action. Sec reviews by Schwart7 & Baron
( 1999). Dcdhar (2000), Eliceiri (200 I ), and Schwartz (200 I ).
THE ROLE OF MATRIX METALLOPROTEINASES
),
O.:grJdation of the extracellular matrix by metalloproteinases is
nw:"af) during the growth. repair and remodelling of tissues.
The.,c en1ymes are secreted a<, inactive precursors by local cells.
\\ hen grol\ th factors '>timulate a cell to enter the cell cycle. they
al-a 'ltimulate the secretion of metalloproteinases, which then
~ulptthc matri\ producing the local changes necessary for the
re.ulting mcrca"! in cell numbers. M etalloproteioases in tum
pl.t~ a part in relea.,ing growth factors from the matrix as
1hl:ribed abo1c and. in some cases (e.g. inlerleukin IL- l ~). in
prll\:e~'mg them from precursor to uctive form.
!U't of 'I he action of these cnqmcs is regulated by T IMPS (lissue
:>rtant inhtbitof\ of metallouroteinases), which are also secreted by
rowth local cell~.
;cular In addition to thl.! phy:,iological functi on outlined above,
rowth mctalloprotcinascs arc involved in the tissue destructi on that
le for o~cUI'\ in various disl.!ascs, such as rheumatoid arthriti s, osteo-
cycle arthritis. periodontitis. macular degeneration, and myocardi al
re,tcno\i~. They also have u critical role in the growth, invasion
Uows. and mcta\tasi' of tumours etc. See reviews by Chang & Wcrb
t21Xll ). McCawley & M atrisian (200 I ). Stcrnlicht & Werb
)art
(2!X)J ). Von Adrian & Engelhardt (2003) and Skiles et al. (2004).
Of'>
with
rix
ANGIOGENESIS
Jar
\ngiogcnc~i~. 11hich normally accompanies cell proliferation,
'' thc formatton of new capillaries from existing small blood
10)>
l e,-el,. Angiogenic Mimuli. in the context of ceU proliferation.
1\een
mclude the action of variou\ growth factors and cytokines, in
partkular VcGF. l'he '>equence of events is as follows.
I. VFGF tnduces nitric oxide and also the expression of
protcascs (e.g. rnctalloprotl.!inases). Nitric oxide (see Ch. 17)
cause~ local vasodilatation; and the protcascs degrade the
ts.that loc:tl basement membrane and the local matri x, and they also
de the mobilise further growth factors from the matrix.
CELL PROLIFERATION AND APO PTOSIS
Interactions between cells, growth
factors and the matrix
Cells are embedded in the extracellular
matrix (ECM), which is secreted by the cells
themselves.
The ECM profoundly influences the cells through the
cells' 1ntegrins; it also forms a store of growth factors
by sequestering them.
lntegrins are transmembrane receptors that on
interaction with elements of the ECM, cooperate w1th
growth factor signalling pathways (this is necessary
for optimum cell division) and also mediate
cytoskeletal adjustments within the cell.
On stimulation with growth factors, cells release
metalloproteinases that degrade the local matrix in
preparation for the increase in cell numbers.
Metalloproteinases release growth factors from the
ECM and can activate some that are present in
precursor form.
2. Endothelial cclb migrate out. forming a solid capillary sprout.
3. T he endothelial cells behind the leading cells are activated by
growth factor~ and start to di1ide.
4. A lumen form~ in the sprout.
5. Local fibrobla'tts, activated b) growth factors. proliferate and
lay down matrix around the capillary sprout.
6. A proccsl. of 'maturation occun. in which there is stabilisation
of the endothelial layer through cell to ceil binding by adherence
protei n ~ and integrin binding of the cells to the matrix.
APOPTOSIS AND CELL REMOVAL
Apoptosi~> is cell suicide by a built-in sclf-destwct mechanism
con1.isting of a geneti cally programmed sequence of biochemical
events. It is l hu)> unlike necrosi s, w hicb is disorgan ised
disintegration of damaged cells resulting in products that trigger
the innammatory respon~e.
Angiogenesis
Angiogenesis is the formation of new
capillaries from existing blood vessels, an important
stimulus being vascular endothelial growth factor
(VEGF). The sequence of events is as follows.
1. The basement membrane is degraded locally by
proteases.
2. Endothelial cells migrate out, forming a sprout.
3. Endothelial cells following the leading cells proliferate
under the influence of VEGF.
4. Matrix is laid down around the new capillary.
77
 SECTION 1 GENERAL PRINCIPLES
Apoptosis play' an essential role in embryogenesis, helping
!0 shape organs during development by eliminating cell-; that
have become redundant It is the mechanism that each day
unobtrusively removes I0 billion cells from the human body. It
is invohed in numerous physiological events: the shedding of the
intestinal lining, the death of time-expired neutrophils, and the
turnover of tissues as the newborn infant grows to marurity. h is
the basis for the development of self-tolerance in the immune
system (Ch. 13) and is implicated in the pathophysiology of many
conditions-from cancer (Ch. 51). where there is insufficient
apoptosis, to conditions in which there is disturbed or increased
apoptosis, 'uch a~ autoimmune diseases (Ch. 13). neurodegenerative
conditions (Ch. 35). cardiovascular diseases (Chs 19 and 20).
diseases of bone metabolism (Ch. 31), and AiDS (Ch. 47).
Apoptosi!> has a role in the monitoring of cancerous change
because it acts as a first- line defence against mutations-purging
cells with abnonnal DNA that could become malignant.
T Apopto~i~ i~ p:miculurly important in the regulation of the immune
respon~e and in the many conditions in which it is an underlying
component. There i' recent evidence that T cells have a negative
regulatory pathway controlled by "urface programmed cell death
receptOI"> <e.g. the PD-1 receptor). and that there is normally a balance
between the stimulatory path\\ays triggered by antigens and this negative
regulatory apopt0\1\-inducing pathway. The balance is important in the
maintenance of p.:ripher.tl toler.tnce. in that the receptor i~ up-regulated
on autoreactive T cclb (Okazaki et al .. 2002). A disturbance of thi'>
balance i~ -.een an autoimmune di~easc. in tbc 'exhaustion ofT cells in
chronic viral di'>C3\e\ '>UCh a'> I UV (see Ch. 47). and possibl} in tumour
e!>cape from immune de.,trucllon (Greenwald et al.. 2002: Zha
ct al.. 2004 ).
It is l.nown that apopto~is is a default response. i.e. that
cominuous active signalling by tissue-specific trophic factors,
cytokinc,, hormones. and cell-to-cell contact factors (adhesion
molecules. intcgrins. etc.) may be required for cell survival and
viabi lity, anu that the sclf-destntct mechanism is automatically
triggered un less it is actively and continuously inhibited by these
antiapoptotic factors. Different cell types require differing sets of
survival factors, which fu nction only locally. If a cell strays or is
dislodged from the area where its paracrine survival signals
operate, it will die.
Withdrawal of these cell survival factors-which has been
termed 'death by neglect'-is not the only pathway to apoptosis
(see Fig. 5.5). The death machinery can be activated by ligands
that stimulate death receptors ('death by design') and by DNA
damage. But it is generally accepted that cell proliferation
processes and apopto~i., are tightly connected (see below).
MORPHOLOGICAL CHANGES IN APOPTOSIS
As the cell dies it rounds up, the chromatin in the nucleus
condenses into dense masses and the cytoplasm shrinks. This is
followed by blebbing of the plasma membrane. and finally
transformation of the cell into a cluster of membrane-bound
entities constituting the corpse of tbe cell: this displays eat me'
signals-surface exposure of phosphatidylscrine and changes in
surface sugars. Macrophagcs recognise these signals and rapidly
phagocytose the remains. The fact that the remains are
18 membrane-bound is important, because release of the internal
con~tituent~ (entymel), mitochondrial components, D A frag-
ment~. etc.) into the cell's surroundings could trigger ar
unwanted innammatory reaction. An additional safeguard
against this is that macrophages that are engaged in the clearanc,
of the cell corpses release anti-inflammatory mediators such a'
TGF-~ and IL-10.
THE MAJOR PLAYERS IN APOPTOSIS
The repertoire of reactions in apoptosis is extremely comple\
and can vary not only between species but between cdl
types. Yet it could be, as some authorities have suggested, tha<
the pivotal rcaction(s) that lead to either cell survival or eel
death arc controlled by a single gene or combination of gene'
If so, the exciting possibility exists that these genes could
be attainable targets in the development of drugs for man)
proliferative diseases.
T Only a "implc outline of the apoptotic repertoire of reaction~ can bt
given here. Intriguingly. an increased understanding of the critical comr
point\ of apoptosis has resulted from comparison of the procc" m
mammal\ with that 111 the nematode Cae11orhabdiris e/e[ions. fh
nematode undergoe~ an unvarying procedure of apopto'>i' in which 13
cell, out of a total of t090 die during the development of the worm, \\hk1
thu<. c1 cntually consht> of JU~t 959 cells. It seems that some cnu.:al
control pomt~ fur cell death are not all that different in wonn
mammal hcc Damal & Kol">meyer, 2004.). More recently. an e\en mw.
lntere,ung and potentially lei') fruitful approach to dissecting out tlr
detail of the <lpoptotic pathways has been proposed: the u...e of ~etr
\ilcncng b) RNA antcrfcrcncc (R."'Ai) tcchnolog}. This pcmuh 'nJ
efficient and preci,iun 'ilencing of gene expre,sion and is being u-.ed
idenllf} anuapoptotic gene~ (Milner, 2004). For simple mer.iey.,
RNA 'ilcncing. 'ee Black & i'icwbury (2QO.t) and Zhang (2004).
The major players arc the caspases-a family of cy~teilll
protcascs present in the cell in inactive form. They do n
perform gencrali~cd proteolysis; they undertake delicme protei
surgery, selectively cleaving a specific set of target proteJO
(enzymes, structural components), inactivating some an~
activating others. A cascade of about nine different caspases takt
part in bringing about apoptosis, some functioning as initiaton by
that transmit the initial apoptotic signals, and some bc10
responsible for the fina l effector phase of cell death (Fig. 5.5).
The caspases are not the only executors of apoptotic change THE
Various pathways that result in apoptosis without the action
the ca~pase fraternity have been described. One invohe'
protein termed AIF (i!poptotic initiating factor) tbat is relea~
from the mitochondria, enters the nucleus and triggers cell suictdc
Note that not all caspases are death-mediating en7ymes; orr
have a role in the processing and activating of cytokines (e.
caspase 8 is active in processing the inflammatory cy10kin,
IL-l and JL-18).
PATHWAYS TO APOPTOSIS
There arc two main routes to cell death, one involvin.
stimulation of death receptors by external ligands, and o
arising within the cell and involving the mitochondria. Both thN
routes activate initiator caspases and both converge on a fin
common effector caspase pathway.
 CELL PROLIFERATION AND APOPTOSIS

trag-
Survival factors
~r an
guard
ranee Death
~~urvival Receptor for
factors
ch as domains

A PLASMA MEMBRANE

CYTOSOL

I
nplex DNA damage
cell +
, that
r cell p53 prot
enc~. Mitochondnon
~ould

many

;an be Death
vntrol Mitochondrial
receptor
!'\' 10 pathway
pathway
Thl'

r ,,. ... ...,..,. ,.

Caspase 9

~
h 131
...,h,ch
ritil:al
n ant.l lAPs -0-- Caspase 3 --<)-+ cleavage and Inactivation. ===?
more .....__,;~ of enzymes and structural
ut the consbtuents, fragmentabon
~ene
of genomiC DNA etc. APOPTOSIS

Fig. 5.5 Simplified diagram of the t w o main signalling pathways in apo ptosis. The death receptor pathway is activated when
death receptors such as members of the tumour necrosis factor (TNF) family are stimulated by specific death ligands. This recruits
adapter proteins that activate initiator caspases (e.g. caspase 8), which in turn activate effector caspases such as caspase 3. The
mitochondrial pathway is activated by diverse signals, one being DNA damage. In the presence of DNA damage that cannot be repaired,
tt!ine the p53 protein (see text and Figs 5.3 and 5.4) activates a subpathway that results in release of cytochrome c from the mitochondrion,

J
not with subsequent involvement of the apoptosome and activation of an initiator caspase, caspase 9. The apoptosome is a complex of
otein procaspase 9, cytochrome c and apoptotic-activating protease factor-1 (Apaf-1). Both these pathways converge on the effector
teins caspase (e.g. caspase 3), which brings about the demise of the cell. The survival factor subpathway (shown here faded) normally holds
apoptosis at bay by inhibiting the mitochondrion pathway through activation of the antiapoptotic factor Bcl-2. The receptor labelled 'R'
and
represents the respective receptors for trophic factors, growth factors, cell -to-cell contact factors (adhesion molecules, integrins), etc.
take Continuous stimulation of these receptors is necessary for cell survivaVproliferation. If this pathway is non-functional (as depicted here
1tor:; by being shown in grey), this antiapoptotic drive is withdrawn. lAP, inhibitor of apoptosis.
~eing ---
; ).
mgc. THE DEATH RECEPTOR PATHWAY them to get together in threes (trimcrise), and recruit an adapter
m of protein that complexes with the trimer by associating with the
es a Lurking in the plasma membrane of moM cell types are members death domains. The resulting complex activates caspase 8, an
ased or the tumour necrosis factor receptor (TNFR) superfamily, initiator caspase that in turn activates the effector caspases
cide. whtch function as death receptors (Fig. 5.5). Important ramily (Fig. 5.5).
.orne membe~ are TNFR-1 and CD95 (al-:a Fa!. or A po-l). but there
(e.g. are man) other\. ~ Each receptor has a 'death domain' in it!.
THE MITOCHONDRIAL PATHWAY
tine~ l)topl~mic tail. Stimulation of the receptors by an external ligand
,uch a!. tumour necrosis factor (TNF) itself or TRAIL1' causes This pathway can be called into action in two principal ways:
by DNA damage and by wilhdrawal of the action or cell survival
factors.
'There are two gene familie~. which include 28 receptor> and 18 Ligand\. PO-
\ing ''' adeath n:.:cptor that can be induced on actiHued T cells. as discu~!>Cd. DNA damage and the mitochondrial pathway
one In the presence of DNA damage that cannot be repaired, the
'1RAlL i> {Umour necro\i\ factor-a-relatct.ll!poptosis-inducing ligand of
hese coarse: \\bat et-.c' Sec Jan\!>en ct al. (2005) for t.lio,cu.,sion of a role of TRAIL p53 protein activates a subpathway involving the p21 protein
final PI).LI. a ligand for the PO-l receptor. is found on all haemopoietic cell\ (see above) and proapoptotic members of the Bcl-2 protein
Jlldmany other tbsucs, and on many tumours in mice (Latchman et al., 2004). family-Bid, Bax and Bak. In addition to these proapoptotic 79
 SECTION 1 GENERAL PRINCIPLES
Apoptosls
Apoptos1s is programmed cell death,
essential in embryogenesis and tissue
homeostasis; 1t is brought about principally by a
cascade of proteases-the caspases. Two sets of
initiator caspases converge on a set of effector
caspases.
There are two main pathways to activation of the
effector caspases: the death receptor pathway and
the mitochondrial pathway.
The death receptor pathway involves stimulation
of members of the tumour necrosis factor
receptor family; and the main initiator caspase is
caspase 8.
The mitochondrial pathway is activated by internal
factors such as DNA damage, which results in
transcription of gene p53. The p53 protein
activates a subpathway that results in release
from the mitochondrion of cytochrome c. This in
turn complexes with protein Apaf-1, and together
they activate initiator caspase 9.
In undamaged cells, survival factors (cytokines,
hormones, cell-to-cell contact factors) continuously
act1vate ant1apoptot1c mechanisms. Withdrawal of
survival factor stimulation causes cell death through
the m1tochondnal pathway.
The effector caspases (e.g. caspase 3) start a
pathway that results in cleavage of cell constituents,
DNA, cytoskeletal components, enzymes, etc. This
reduces the cell to a cluster of membrane-bound
entities that are eventually phagocytosed by
macrophages.
7
individual!., thi1. fami ly has antiapoptotic members. They meet
at the surface of mitochondria and compete with each other. The
proapoptotic branch of the family (e.g. Bax) promotes re lease
of cytochrome c from the mitochondria: the antiapoptotic
branch inhibits this. The released cytochrome c complexes with
a protein termed Apaf-1 (i!.poptotic nrotease-i!.Ctivating factor- I),
and the two then combine with procaspase 9 and activate it.
This latter entyme orchestrates the effector ca<>pase pathway.
The three-party compo~ite of cytochrome c. Apaf-1 and
procaspa'>e 9 is termed the apoptosome (sec Fig. 5.5).
Note that nitric oxide (sec Ch. I 7) is another mediator
that can have proapoptotic and antiapoptotic actions (Chung
et al., 2001 ).
7
Another br:akc on the cell death mechanisms is a family of caspase-
in hibiti ng proteins called. you will not be surprised to learn. lAPs
80 (inhibitor~ of apoptm is proteins).
Withdrawal of survival factors and the
mitochondrial pathway
In normal cell:., \urvival factors (specified above) conti
activme antiapoptotic mechanisms, and the withdra\~al
-.urvival factor~ can cause death in !>everal diffe rent \\
depending on the cell type. But a common mechanism 1'
tipping of the balance between Bcl-2 family members lead1
to los' of the Mimulation of antiapoptotic Bcl-2 protein
with re~ultant unopposed action of the proapoptotic
protein!. (~ee Fig. 5.5).
Cross-talk between the death receptor
pathway and the mitochondrial pathway
The two main pathways to cell death are connected
each o the r, in that ca:.pasc 8 in the death receptor pathwil
can ac tivate the proapoptotic Bcl-2 and thus activate lk
mitocho ndrial pathwuy.
THE EFFECTOR STAGE CASPASES
The effector stage caspases (e.g. caspase 3) clea\e
inactivate cell con~tituen ts such as the DNA repair en7)m;
protein kina~e C, and cytoskeletal components. A
i!> activated and cul<; genomic DNA between the nucleo,o!l'.
generating DNA fragmen~ of approximately I 80 ba~e pair..
THE FINAL STAGE: DISPOSAL OF THE REMAINS
When the effector ca:.pases have carried out their function'.
cell i\ reduced to a cluster of membrane-bound bodie'>. ~
containing a variety of organelles. This i~ the corpse of tht: c,
which. as described above. is phagocytosed by macrophage,.
PATHOPHYSIOLOGICAL IMPLICATIONS
OUTLINE
It has been briclly mentioned above that cell proliferation
apoptosit. arc involved in many physiological and
proce!.ses. These are:
the growth of tis:.ucs and o rgans in the embryo and later
during chi ldhood
the repleni~hment of lost or time-expired cells such a~
leucocyte~. gut epithel ium, and uterine endometrium
the development of immunological tolerance to ho~t
repair and healing after injury or inflammation
the hyperplasia (increase in cell number and in conneCII\e
tissue) associated with chronic inflammatory. hyper!.cnsitil
and autoimmune diseases (Ch. 13)
the growth, invasion and metastasis of tumours
regeneration of tissues.
The role of cell proliferation and apoptosis in
processes li sted is self evident and needs no
comment, and their invo lve ment in immune tolerance
discus!.ed brieny above. But the other processes need
comme nt.

REPAIR AND HEALING
DUSI} Repa1r tx:CUI'\ when there has been damage or loss of tissue; it
11 of 1' 3ho implicated in the resolution of the local inflammatory
"\\ays reacuon to a pathogen or chemical irritant. ln some instances.
damage or ti"ue lo'" can lead to regeneration. which is quite
'" a
lding J1llc:rc:nt to repa1r and i' con\idered separately beiO\\.
:lion. In rcpa1r and healing. there is an ordered series of events
Bcl-2 IR\Uhmg cell migration. angiogenesis. proliferation of connec-
11\ C: ti"uc cell\, synthesis of extracellular matrix and fina lly
rc:nllldc!lling all coordinated by the growth factors and
C)tllkines that are relevant for the particular tissue involved .
TGF-~ 1s a key cytokine in several of these processes. (There is
:d tO con"llerable overlap between the inflammatory reaction and
hway rcpuir in 1enns of the cells and mechanisms activated.)
: the
HYPERPLASIA
Hyperplasia (cell proli fe ration and matrix expansion) are
hallmarks of chron ic inflammatory. hypersensitivity and
and autOimmune disea~es such as rheumatoid arthritis (Ch. 13),
, mes. r-oria,is. chronic ulcers. chronic obstructive lung disease, the
IAase rnxc"~' underlying the bronchial hyperreactivity of chronic
)mes. u'1hma (Ch. 23). and glomerular nephritis. The cells that take
s. pan and the C\Cnts them,ehes are described in more detail in
Chapter 13 (p. 205).
Cell proliferation and apoptotic events are also implicated in
-.IS
athcro-.clero'i'. rc,tenosi\. and myocardial repair after infarction.
' the
each
THE GROWTH, INVASION AND METASTASIS
! cell.
OF TUMOURS
Onelloe'n 't need to be a rocket scientist to be aware that tumour
~elb proliferate, but what may not be so obvious is that perturba-
llllll\in the growth factor signalling pathways. the antiapoptotic
pathways, and the fun ction of the cell cycle controllers have an
Important role in the pathogenesis of malignancy. New under-
nand qanding of this is leading to novel approaches to the treatment of
)gical cancer. Sec below and in Chapter 51 (p. 7 18).
Rl'~l'llermion is di'> tinct from the processes above and needs to
Ill: con,1dercd in more detail.
REGENERATION
Rcg~ncrJiion after damage or tissue loss implies re!.litution
teim.
or replacement of the area !tO that it is identical to what was
there before.
ve
Man) animal' (e.g. amphibian~ and other lower orders) have
itiYity
an m1pre"I\C power 10 regenerate their tissues. even to regrow an
o~gan 'uch as a limb. The es~ential process is the activation of
~tern cdb primitive celb that are multipotent. i.e. they have the
Jll>lcntial 10 de\elop into any or most of the specialised cells in
1 two the Oody. Amphibian\ have a plenti fu l supply of these primitive
~ rthe r celb in their organs and. furthermore, many of their specialised
ce is cdb can dedifferentiate to become stem cells. These stem cells
unher then multiply and retrace the path ways that generated the organ
te.g. a limb) during fetal li fe, proliferating again and again and
CELL PROLIFE RATION AND APOPTOSIS
Repair, healing and regeneration
Repair and healing occur when there has
been damage or loss of tissue and are also
implicated in the resolution of the local inflammatory
reaction to a pathogen or chemical irritant. It involves
the act1vat1on and proliferation of connective tissue
cells, white blood cells and blood vessels.
Regeneration 1s the replacement of the tissue or
organ that has been damaged or lost. It involves the
activation of primitive st em cells that have the
potential to develop into any cell in t he body.
Regeneration of a tissue or organ is rare in m ammals.
If a mammal is injured or has its tissue removed,
repair processes-often with subseq uent scarring-
usually make good the damage.
It may be that repair (with rapid closure of the defect
after tissue loss) is an evolutionary trade-off in mammals
for the lost power of regeneration. But recent work
has suggested that it might be possible to activate in
mammals the original regenerative pathways-at
least to some extent and in some organs.
eventually differentiating into the various ccU types needed to
replace the mi'>'>ing part.
llowcvcr, during evolution. mammals in general have lost this
ability and now have regenerative capacity in only a few tis..,ue\.
Blood cell\, intestinal epithelium and the outer layers of the skin
are replaced continuously throughout life. Of the more discrete
organ1:.. there is a low degree of turnover and replacement of cells
in ~uch organ<, a' liver, kidney and bone. This is in essence
physiological renewal and is effected by local tissue-specific
stem cells.
Allnol.t alone, the liver has significant ability to replace itself
if much of it il. removed. It can regenerate to its original size in a
remarkably short time, provided that at least 25% has been left
intact. 8 And the mature parenchymal liver cells participate in this
process as well a!> all the other cellular components of the liver.
What underliel. the different regenerative abilities of mammals
and amphibians is that although stem cells are known to exist in
most tissues in adult mammal'>, they are very sparse in number,
the vast majority of cells in most tissues being irre1ersibly
differentiated. If a mammal is injured or itS tissue is removed.
repair processes-often with subsequent scarring- usually
make good the damage. It seems that rapid closure of the defect
after tissue los~ (which i~ much more speedily accomplished by
' There i<. an nccoum of li,cr regeneration in Greek myths. Promctheu~ stole
the \ccrel of tire from Zeu\ and ga~e it tO manl..ind. To punish him. Zeu\
had him -.had.led to a crag in the Cauca~us, and every day an eagle tore at
hi' nc,h and devoured much of hi~ liver. But during the night, it
regenerated and in the morn ing wa> whole agai n. The legend doesn't say
whether the requi,itc 25\lf wa; left after the eagle bad had its fill, and the
regenerat ion described i~ unphysiologically ;peedy-rat liver takes 2 week ~
or more 10 gel hack to the origi nal si1-e after 66% hepatectomy. 81
 SECTION 1 GENERAl PRINCIPlES
repair mechanism~) takes pnonty over regeneration. Until
recently. it was a<,~umed that this was an unalterable situation.
except for a few examples, some mentioned above.
But recent work ha'> ~uggested that it might be possible to
acti\'ate in mammal\ the original regenerative pathways-at
least to some extent and in some organs. Regeneration of a lost
limb as happens in amphibian~ is manifestly not possible in
human'>. but regeneration of limited areas of a tissue or of a small
part of an orgnn may well be feasible. For this to happen. it would
be neccssnry to encourage some stem cells to proliferate, develop
and differentiate at the relevant sites. Or-and this is a rather
more remote prospect in humans-to persuade some local
specialised cell~ to dedifferentiate. This can occur in some
mammals under special circumstances (see below). However,
it may be that repa ir is the Janus face of regeneration. repair
being a n evolutionary trade-off in mam mals for the lost power
of regeneration.
T Where arc the relevanl stem cclb that could be re~pons i ble for
regeneration proce,~es'! And what ~ort of stem celb are they? There arc
two po\sibilities:
'>ome ti,~ucs (e.g. bone marrow) in the postembryonic body have a
cohon of reserve pluripotent \tcm cells9 set aside during fetal life that
could seed other w.-,uc~ ;md. wnh the right signals. develop imo the
requi'>llC tis~ue\pecilic celh
..ome ussue'> contain ti\\UC\pecific stem celh developed during fetal life.
In the lir.t ca-.c. the adult stem cells ~ould have to be continuously ~elf
renew mg. \\ ith an unu.,ual liN mitotic di\ isioD-<lne daughter cell
maturing to de\elop into a ti~\ue-~pccific cell of one ~ort or another
when 1t reaches a panicular tbwc. 10 and one daughter cell remaining a>
a multipotent ~tem cell. The ti\\ue-~pecfic cells in a particular organ
~ould prc\umably be one \lep further along the differentiation pathway
and yet \till be "\ti!m cell~ undergoing. at mterval~. a second unusual
mitotic d1vision.
Thi' subject i\ too complex to cover here. but reviewb by Raff (2003) and
Rosentha l (2003) e<tch provide a fascinating discu~sion of this topic.
Suffice it to ~ay here that the possibility of making use of the body's own
pool of stem cells in the treatment of disease by using pharmacological
meam. (e.g. cytokincs) to coax them into regenerative service is being
vigorou~l y investigated.
Requisites for replacement of a portion of a
tissue or organ
What would need to happen if. after Joss, a portion of a tissue
such as, for example. the liver or the heart were to regenerate?
Replacement of the lo~t specialised parenchymal cells is a sine
qua non, and growth factor stimulation of the local tissue-
specific stem cells to start them off on the cell cycle and continue
to proliferate would be one of the first requirements for this. But
other e~sential proces<,es would be:
angiogenesi'> to supply the necessary blood vessels
activation of matrix metalloproteinases to replace the matrix
in which the new cells would need to be embedded
~eferrcd to as being pla.1tic in their development potential. or having plasticity.
10Not all authors ure convinced thnl there i~ plasticity of stem cells. i.e. that
any stem cell is pluripotent und c;m. on being transferred to or homing on a
82 pan icu lar organ, give rb.e to the 'pecilic parenchymal cells of that Qrgan.
interaction between matrix and integrins and fibronectin to
link the new elements together.
Concomitant replacement of components of the lost connecti1~
tissue (fibroblast'>, macrophages. etc.) would also be necessat)
ot all regenerative processes involve replacement of all the
elements in a tis!>uc. ln the case of regeneration of a pcripher.
nene after damage or cutting. the cell bodies in the spinal coro
are intact and it is the sensory axons that are replaced. Th1~ j,
a~-.ociated with the transport of retrograde injury signals fron:
the damage site to the dorsal root ganglion neurons. The-<
signals trigger the expres!>ion of genes controlling the regeneratile
process (Blesch & Tu~1ynski, 2004).
Is it possible to stimulate regeneration of
damaged tissue in humans?
T his is nn important question, because drugs that could awaken
the lost regenerative ubility could be of immense value in
numerous diseases.
To approach the question of whether it wou ld be possible to
stimulate regeneration pharmacologically, we need to consida
'>Orne of the tissue!> in which there is little or no regeneration afta
damage or loss. and consider to what extent the pathways are lo-1
and to what extent they are merely dormant but capable, with tb:
right stimulation. of being reactivated. The central nervous sy\te
and the myocardium are taken as examples here. but th
regenerative capacit) of other tissues and the role of stem ce b
therein arc abo under investigation.
The central nervous system
The adult central nervous system. unlike the peripheral ncno..
sy~tem. has virtually no capacity to regenerate. The rea..,ons arc
not fully understood. although there is some understanding o
the lethal events at the site of injury. Apoptosis of cells i,
certainly implicated. Thus there is evidence that in the spina'
cord, injury triggers increased expression of the death recepttl
CD95/Fas in the neurons and other cells at the damage site. anJ
also up-regulation of the na tural ligand for the CD95/Fas-whic
leads to apoptosis (Barthelemy & Henderson, 2004). Necro11
also occurs.
Regeneration after injury to the central nervous system
hampered by two main obstacles.
Inhibition by myelin-deril'ed factors. Three of these inhibiton
have been identified, the receptor for at least one of them b
been cloned, and small GTP kinases of the Rho family are
believed to be involved in the inhibitory action. (For fun~r
discussion. see Ch. 35.)
The del'elopmellt of a glial scar by the astrocytes.
In recent years. worl.. on these aspects in experimen
systems has resulted in significant advances in gening axoo;
to regrow. This is discussed further in Chapter 35 (see al
Filbin, 2003).
Heart muscle
The usua l assu mption is that cardiac muscle has no power b
regenerate. But in a particular strain of mouse, when part of tit scle
 CELL PROLIFERATION AND APOPTOSIS

0 heart i' damaged by freezing. repair processes do not start up; conditions with tissue damage or cell loss, such as myocardial
tn\tcad. the area is replaced by regeneration within a few months. infarction (Ch. 18), stroke. and spinal cord injury (Ch. 35)
The implication of this is that in this mouse strain, the genes that depletion ofT cells in HJV infection (Ch. 47)
clive din.--ct the mechanbms for repair of cardiac muscle have been osteoarthritis (Ch. 31)
.II). \\\itched off and thol>c that direct regeneration (silent in other haematological disease such as aplastic anaemia (Ch. 22).
lthe mouse stram\- and in humans) are activated.
1eral .\1ice are not the only mammals to be imbued with the Examples of defecrile apoprosis (Melnik:ova & Golden, 2004)
cord abtlit} to replace areas of the myocardium: there is regeneration include:
ll~ .... of hcan ti"ue in dogs after acute heart failure. Mitosis of
cancer evasion of the immune response and resistance to
!rom m)OC)te'> is seen in the normal human heart, and cell
cancer chemotherapy (Ch. 51)
'hese proliferation of myocytes immediately after infarction has
autoimmunc/intlammatory diseases such as myasthenia
mive been reponed. Indeed, the sequence of events described above
gravis, rheumatoid arthritil. (Chs 13 and 14), and bronchial
Iunder Requisites for replacement of a portion of a tissue
a!>thma (Ch. 23)
or organ) ha~ been shown to occur during the process of
viral infections with ineffective eradication of virus-infected
remodelling after myocardial infarction in rodents (Nian et
cells (Ch. 47).
al., 2004).
aken Potential apoptosis-modu lating compounds are being actively
1' Cytokines such ~~~ TNF-u and IL-6 ure produced after the ischaemic
e m investigated (sec Cummings et al., 2004; Melnikova & Golden,
inJury of myocanlial infarction and arc implicated in the immediate
e\cnts: cell death, recruitment of inflammatory cells, ru1d repair. Their 2004). Here we can only outline some of the more important
le to \ttllllimd presence has a role in remodelling--activation of matrix approaches.
sider metalloproteinasc;. angiogcne;is, the regulation of integrins and the
recruumcm of progenitor cells. TNF-a is able to self-amplify by targeting
after Promoters of apoptosis
the ll1ln-cription factor nuclear factor (NF) KB and initiating a positive
! lo-.t
fetdbad loop becau!>e NFKB activates the expression of cytoprotective
h the gene' that promote cell survival (Nian et al., 2004). The Bc/-2 family as a target for new drugs
'tern The Bcl-2 protein is oncogenic because it inhibits apoptosis and
the It '' not certain whether the myocytes that proliferate after an increases resistance to cancer chemotherapy; other antiapoptotic
cells 10\Uh to the heart are derived from local stem cells or from membe~ of the Bcl-2 family are Bcl-xt. and Mel- J. These arc all
'tem cell\ from other tissues that have homed to the heart current targets for anticancer drugs.
1~mersa & Nadai-Ginard, 2002).
T An anu..ense compound again;! Bcl-2 (oblimerson) is in phase m trial
Some researchers arc of the opinion that the sleeping for muluple myeloma and leukaemia. Investigations of antisense com-
"\'OUS regenerative pathways in humans could possibly be reawakened. pounds agamst Mcl-1 arc in progress (Melnikova & Golden. 2004).
" are !I this were possible, it would be of immense therapeutic benefit
1g of becau'e death of heart muscle underlies myocardial infarction Death receptors and their ligands as target for new drugs
lis is and other serious cardiac conditions. Death receptors for ligands such as TRAIL (see above) are
pinal expressed on cancer cells and undergo apoptosis when TRALL
eptor binds. Monoclonal antibodies to TRAIL are in phase J trial for
. anti THERAPEUTIC IMPLICATIONS cancer chemotherapy (Melnikova & Golden, 2004) and could
l'hich well become important in conditions in which tl1e immune
:rosis Con\idcrablc effort is being expended on finding compounds response might need to be enhanced (Janssen et al., 2005).
that will inhibit or modify the processes described in this T Viral infections are controlled largely by the action of cytotoxic
m is chapter. much work being aimed at developing new drugs T cell~ (~ee hg. 13.3). and the persistence and chronicity of viral
for cancer therapy. Theoretically. aJI the processes could infection~ (such as IIJV) is mainly due to exhaustion of T-ccll cytolytic
con,titutc targets for new drug development. Here we con- activity and cytokine production. A monoclonal antibody has been
)itor:-. \hown to block the interaction of the apoptosis-inducing PD-1 receptor
,entrJtc on those approaches that arc proving or are likely to
1 has and it., ligand and re\er.e thi~ exhaustion in mice with chronic
prmc fruitful. lymphocyuc choriomeningitis (Barber et al .. 2006). This approach-the
re
u<e of a blockjng antibody to the PD- 1 receptor and its tile 1S
her
mooted a' bemg a po1en11ally fruitful new a,enue to explore for the
APOPTOTIC MECHANISMS ueaLmem of HIV. hepatitis B and hepatitis C infection;-three chronic
\' outhned above, disrupted apoptosis is a factor in several infection., that affect > 500 million individuals worldwide-as well
as other chrome infection\ and <;Ome cancers that express the ligand for
ten tal di,ca\C\, and compounds that could modify it are being PD- I(Williruns & Bevan. 2006).
lXOOS IOten,iH:Iy investigated ( icholson, 2000; Reed, 2002;
also Melntkova & Golden, 2004). Indirect promoters of apoptosis
E~amples of over-exubertmr apoptosis with increase of Various compounds that act on the cell survival and proliferation
cell death (Mclnikova & Golden, 2004) include: pathways can induce cell death indirectly; see Cell cycle
regulator.\ as tarp,ersfor new drug development below.
;er to neurodegenerative diseases such as Alzheimer's, multiple A new indirect target is the proteasome, which is the part
of the ~clcrosis, and Parkinson's disease (Ch. 35) of the cel l's machinery for degradation of proteins-including 83
 SECTION 1 GENERAL PRINCIPLES

thO\C involve<.! in apoptosi~. A new drug, bonemozib, which Cyclin-dependent kinases

inhibit'> the protea...ome, is on the market for the treatment of
\elected cancers. It causes the build-up of Bax, an apoptotic
promoter protein of the Bcl-2 family that acts by inhibiting
antiapoptotic Bcl-2. Bonemozib is recognised as acting panly
by inhibiting NFKB action. 11
An endogenow.. caspa.o;e inhibitor. sunil'in. occurs in high
concentration in cenain tumours. its gene being one of the
mo~t cancer-~pecific genes in the genome. The possibility of
<.leveloping compounds that inhibit this inhibitor (lAPs) is
being pursued, the object being to free caspascs to induce
cancer cell suicide. Drugs based on antisense approaches to
survivin inhibition arc being considered for clinical trial
(Cumming~ et al., 2004).
Inhibitors of apoptosis
Apoptosis inhibitors s uch as the caspases are activated by
stimuli produced by damaged or diseased tissue. Several
caspase inhibitors are under investigation for usc in the
treatment of myocardial infarction, stroke. liver disease, organ
transplantation and sepsis. One, still only with a number for its
name, i1> in pha\e II trial.
Several small molecules that target the ATP-binding site~ o1
these kinases have been developed; examples are flavopirido
roscovitinc and UC -01 (7-hydroxystaurosporine). Flavopirid1
inhibits all the cdJ...s, causing arrest of the cell cycle; it al"
promotes apopto~is. has antiangiogenic ability and can indu,,
diiTercntiation. All three compounds are in early clinical trial (x-t
Scnderov.. ict, 2003: Swanton, 2004).
Some compound~ affect upstream pathways for cdk acti\atioo.
Examples are lovastatin and perifosine.
Proteasome-mediated degradation of cell cycle proteins
as a target
Bonezomib. a boronate compound, covalently binds th.
proteasome. Early results of a phase ill trial in melanorlll
patients have proved promising (Richardson et al., 2005).
The growth factor signalling pathway
Of the various component~ of the growth factor signalling patlma)
receptor tyrosine kinases, the Ra.'> protein and cytoplasmic k.ina~r
have been the ~ubject~ of most interest, and several new drup
have been developed. Their main use is in cancer therapy, i!llo.
detaib are given in Chapter 51 (p. 730) and Figure 51 .I.

ANGIOGENESIS AND METALLOPROTEINASES

A., outlined above, metalloproteinases and angiogenesis have
critical role<, in numerou~ bodily processes. some physiological
(e.g. growth. repair) and some pathological (e.g. tumour
growth. chronic inflammatory conditions), and disturbances of
these prOCC'>i>CS are implicated in many diseases. There has
been a con~iderable amount of work. done in the attempt to
find clinically useful inhibitor1>. but this bas not so far been
successful. At present, only one new drug bas been approved for
usc in cancer treatment: the antiangiogenesis compound
bcvacizumab, a monoclonal antibody that acts against YEGF.
CELL CYCLE REGULATORS AS TARGETS FOR
NEW DRUG DEVELOPMENT
The main cndogenou'> pol>itive regulators of the cell cycle are the
cdks. During the past decade, these have been cloned and small
molecule inhibitor~ ~ought (Senderowicz, 2003).
STEM CELLS AND THE REGENERATION
PATHWAYS AS TARGETS FOR NEW DRUGS
The potential use of embryonic stem cells in the treatment
human disease is a thorny and emotionally charged topic-and
beyond the remit of this book. But that endogenous adult
cells could have a therapeutic role in regeneration and repair i'
possibility for the future (see above). There is some experiment.:.
evidence that cytokincs and secreted proteins might be able
kick-start regeneration pathway!. (Bock-Marquette et al., 200:
Liberto et al., 2004 ). Retinoic acid. a biologically active mctaboli,
of vitamin A, has been shown to induce alveolar regeneration 1
rats and mice with experimental emphysema or with alv1XJ11
disrupted by various noxious treatments (Maden & Hind, 200.11
Many researchers in regenerative medicine are reasonabl
optimistic that it may eventually become possible to reawake
the lost regenerative pathways at least to some extent and '
'>Orne organs.

1
uclear factor t.B i' a trano,cription factor that. among multiple other actions, i' imol\ed in 1he imegration of many of the ~un ivai-signalling palh\\3}' h
alo,o inhibit\ acti\ation of ca.\pa~ 8 by up-regulating its inhibitor, I-LIP (o,ee Fig. 5.5).

REFERENCES AND FURTHER READING

t\poptost~ (jtenerall Chung H T, Pae H 0. Chm B M c1 nl. 2001 Nitnc oxide Biochim Biophys Acta t705: 53-6610tHHI rf!ie.
Ashkcnosi A 2002 Tnl)lcllng death and decoy receptor' a' a biorcgulmor of ,,ropto'" Oiochcm B1ophy' Res tliscussing-in the comext of tuuiwncer dntg
of the tumour necrosi' receptor supcrf,unity. Nat Rev Cornmun 282: I 075-1079 c/eve/oJJment-Bcf2 proteim. lAP.;. [!fOH thjw lt>N
Cancc12: -120-42'1 (I; lt'IIIJ>Iary rekw. Cummings J. Ward T. Ran,on M. Dive C 20().1 ApoptOSI' tyrosine k-inase inhibiwr.~. and ti.Htl)'.~ for apOJllmn
84 cmnprrlwtl\i\'l',' !(aod cliar.trwm) pathway targeted drugs- from the hcnch to I he chn ic. inducing dmgs)
a of
1ng
Method and measurement
1n pharmacology
It
3
nant
Overview 87
~--
Bioassay 87
the -General principles of bioassay 89
-Bioossays in humans 90
Animal models of disease
---------------------------4
91
Clinical trials 92
I Balancing benefit and risk 95
OVERVIEW
We emphasised in Chapters 2 and 3 that drugs,
being molecules, produce their effects by interacting
with other molecules. This interaction can lead to
eHects at all levels of biological organisation, from
molecules to human populations (Fig. 6 . 1). 1
In this chapter, we cover the principles of
metrication at the various organisational levels,
ranging from laboratory methods to clinical trials.
Assessment of drug action at the population level is
the concern of pharmacoepidemiology and
pharmacoeconomics (see Ch. 1 ), disciplines that are
beyond the scope of this book.
We consider first the general principles of
bioassay, and its extension to studies in human
beings; we describe the development of animal
models to bridge the predictive gap between
animal physiology and human disease; we next
discuss aspects of clinical trials used to evaluate
therapeutic efficacy in a clinical setting; finally, we
consider the principles of balancing benefit and
risk. Experimental design and statistical analysis
are central to the interpretation of all types of
pharmacological data. Kirkwood & Sterne (2003)
provide an excellent introduction.
C1n\ldCr the eftect of cocaine on organised crime, of organophosphate
n~l\e ga'c~ on the smbilily of dictatorships, or of anaesthetics on the
tmibility of surgical procedures for examples of molecular interactions
that affect the behaviour of populations and societies.
BIOASSAY
Methods for measuring drug effects are needed in order that we
may compare the properties of different substances, or the same
substance under different circumstances, requirements that are
met by the techniques of bioassay, defined as the estimation of
the concentration or potency of a substance by measurement of
the biological response that it produces.
USES OF BIOASSAY
The uses of bioassay are:
to measure the pharmacological activity of new or chemically
undefined substances
to inveMigate the function of endogenous mediators
to measure drug toxicity and unwanted effects.
'Y Bioas\ay play~ a key role in the developmem of new drugs. discussed
in Chapter 56.
In the p:t\t. bioa!>\ay wa~ often used to measure !he concemrarion of
drugs and other active substances in the blood or other body fluids, an
applicati on now superseded by analytical chemistry techniques.
Bioassay is usefu l in the study of new hormonal or other chemically
mediated control systems. Mediators in such systems are often first
recognised by the biological effects !hat they produce. The first clue may
be the finding thm a tb~ue extract or some o!her biological sample
produce\ an effect on an as~ay system. For example, !he ability of extracts
of the posterior lobe of the pituitary to produce a rise in blood pressure
and a contraction of the uterus was observed at the beginning of the 20th
century. These actions were developed as quantitative assay procedures,
and a 'tandard preparation of the extract was established by international
agreement in 1935. By use of these a~says. it was shown !hat mo distinct
peptide'>-l'OSOpll'nm and oxywcin-v. ere responsible, and !hey were
eventual!) identified and syn!hesised in 1953. Biological as'>ay had
already revealed much about the ~yn!hesis. ~10rage and relea.se of the
hormone\, and wa' e~senllal for their purification and identification.
No" aday\. 11 docs not take 50 years of laborious bioassays to identify
new hormones before they are chemically characterised. 2 but bioassay
still pia}~ a kC) role.
2
1n 1988. a Japanc~e group (Yanagisawa et al., 1988) described in a single
remarkable paper the bioa!>;ay. purification, chemical analysis and synthesis,
and DNA cloning of a new vosc ular peptide, endothelin (~ee Ch. 19). 87
 SECTION 1 GENERAL PRINCIP LES

Level of biological Test system Response measures Methods

organisation (examples) (example relating to
analgesia)
Population & society Socioeconomic Impact on health-care Pharmaco-
CJ
group costs. social costs,
disability costs,
economics,
pharmaco-
e
0
disease prevalence c:
11
epidemiology 0
CJ
G>
0
Fam1ly Patients' family Impact on relationships, Social "i3
0
members job prospects, suicide risk medicine CJ)

Patient Patients undergoing Pain relief, improvement Clinical trials

I
medical treatment of disability, etc.
iii
-~

Individual Human Normal healthy Subjective pain Intensity Clinical

=
u
1r\ ~""....
Experimental
subjects

Rat, mouse.
and th reshold

Behavioural responses to
pharmacology

am mal primate, etc. nox1ous and non-noxious

st1muli

Phys1ologtcal system CNS Reflex responses to

noxious stimuli Physiological

!i
T1ssue & organ Spinal cord Synaptic responses in
II)
"0

-
0
~

!i dorsal horn G>

E
...
>-
Cell Spinal cord
neurons
Membrane responses

Cellular
-...
0
I'll
0
.0

CN1r
I'll
..J

A
Transfected cell Second messenger
DRUG lines responses

Molecular
Molecule Substance P Binding studies on
(NK-1) receptor cloned receptor
expressed in cell lines

Fig. 6 . 1 l evels of biological organisation and types of pharmacological m easurem ent.

BIOLOGICAL TEST SYSTEMS

Nowaday~. an imponant u~e of bioassay is to provide information
that \\ ill predict the effect of the drug in the clinicaJ situation
(where the aim i~ to improve function in patients suffering from
the effcch of di~ea,e). The choice of laboratory test system~ (in
vitro and in vivo 'mode b.') that provide this predictive link is an
important a\pect of quantitative pharmacology. As our under-
standing of drug action at the molecular level advances (Ch. 3).
this knowledge. and the technologies underlying it, have greatly
extended the range of models that are available for measuring
dntg effects. By the 1960s. pharmacologists had become adept at
using isol:ued organs and laboratory animals (usually under
88 anaesthesia) for quantitative experiments, and had developed the
princ i pl e~ of bioa!>say to allow reliable measurements to be m
with these sometimes difficult and unpredictable test system'
Bioa-.says on different test systems may be run in parallel
reveal the profi le of activity of an unknown mediator. This 1
developed to an almost baroque splendour in the work of\
and his colleagues. wbo studied the generation and destructi0'1
endogenous active substances such as pro tanoids (see Ch.
by the technique of cascade superfusion (Fig. 6.2). ln this techn14
the sample ill run sequentially over a series of test preparati
chosen to differentiate between different active constituent'
the !.ample. The pattern of responses produced identifie, ~
active m::uerial , and the use of such assay systems for 'on Iii);
analysis of biological samples has been invaluable in stud)i

A
Water Jacket (38.C)
B Adr Nor Ang II BK PGs 5-HT ADH
V vf.------- J\. f\_ __ Rat stomach
Chick rectum
Rat colon
Rabbit rectum
Cat jejunum
Fig. 6.2 Parallel assay by the c ascad e superfusion
technique. A Blood IS pumped continuously from the test
an1mal over a succession of test organs, whose responses are
measured by a simple transducer system. ~ The response of
these organs to a variety of test substances (at 0.1-5 ng/mQ is
shown. Each active substance produces a distinct pattern of
responses. enabling unknown materials present in the blood to
be Identified and assayed. 5-HT, 5-hydroxytryptamine; AOH,
anltdturetic hormone; Adr, adrenaline (epinephrine); Ang II,
ang1otensm II; BK, bradykinin; Nor, noradrenaline
(norepinephrine); PG, prostaglandin. (From Vane J R 1969 Br J
Pharmacol 35: 209-242.)
the production and fate of shan-Lived mediators such as prostanoids
and th\! endothelium-derived relaxing factor (Ch. 14).
These 'traditional assay systems address drug action at the
ph) stologicalle\el roughly, the mid-range of the organisational
hterarch} shown in Fig. 6.1. Subsequent developments have
extended lhe range of a\'ailable models in both directions.
made tOI\anh the molecular and towards the clinical. The introduction
llS. of bmding a~'ay., (Ch. 3) in the 1970s was a significant step
llel to t011'3.rch analy'i' at the molecular level. More recently, the usc of
., wa.-. cell hne' engmccred to express specific human receptor subtypes
Vane has become wide.,pread as a screening tool for drug discovery
ion of (see Ch. 56). Indeed. the range of techniques for analysing drug
h. 13) effl!l:h at the molecular and cellular levels is now very impressive.
nique. Bndging the gap between effect~ at the physiological and the
ations th~rapeutic level~ has. however. proved much more difficult,
nts of ht.'Cau'e human il lness cannot. in many cases, be accurately
:s the r~produced in experimental animals. The use of transgenic animals
1 line to model human disea'e represents a real advance, and is discussed
tdying mmore detai l below.
METHOD AND MEASUREMENT IN PHARMACOLOGY
GENERAL PRINCIPLES OF BIOASSAY
THE USE OF STANDARDS
J H Bum wrote in 1950: 'Phannacologists today strain at the
king's arm, but they <,wallow the frog, rat and mouse. not to
mention the guinea pig and the pigeon: He w~ referring to the
fact that the 'king's arm had been long since abandoned as a
\tandard mea~ure of length. whereas drug activity continued to
be defined in term!> of dose needed to cause. say. vomiting of a
pigeon or cardiac arrest in a mouse. A plethora of 'pigeon units'.
'mouse units' and the like. which no two laboratories could agree
on, contaminated the literature. 3 Even if two Laboratories cannot
agree- because their pigeons differ-on the activity in pigeon
units of the same sample of an active substance. they should
nonetheless be able to agree thm preparation X is, say, 3.5 times
as active as st.a ndard preparation Yon the pigeon test. Biological
assays arc therefore designed to measure the relative potency of
two preparations. usually a standard and an unknown. The best
kind of standard is, of course. the pure substance, but it may be
necessary to establish standard preparations of various hormones,
natural products and antisera against which laboratory samples
can be calibrated. even though the standard preparations are not
chemically pure.
THE DESIGN OF BIOASSAYS
Given the aim of comparing the activity of two preparations. a
standard (S) and an unJ...nown (U) on a particular preparation. a
bioassay must provide an eMimate of the dose or concentration of
U that will produce the san1e biological effect as that of a known
dose or concentration of S. As Figure 6.3 shows. provided that
the log dose-effect curves for S and U are parallel, the ratio, M.
of equiactive doses will not depend on the magnitude of response
chosen. Thus M provides an estimate of the potency ratio of the
two preparations. A comparison of the magnitude of the effects
produced by equal doses of Sand U does not provide an esti mate
of M (sec Fig. 6.3).
The main problem with all types of bioa~say is that of biological
variation, and the design of bioassays is aimed at:
minimising variation
avoiding systematic errors resulting from variation
estimation of the limits of error of the assay result.
T Many diOercnt experimental dc>igns ha'e been proposed to m3ximi\C
the efficiency and rehabiluy of bioa<.,ays (see Laska & 111eisner. 1987).
Common!). compan,on~ are ba..ed on analy~i~ of do!>e-re!>pon-.e cu"e'.
from which the matching do\e!> of Sand U are calculated. Thi~ anal)'is
;., much \impler 1f the do,e-re,ponse curves are linear. v. hich can often
be aclue~ed by u"ng a log;mthmic dose ,caJe and resuicting observation'
3
M ore picturesque e,x:1mple' of ab;olute units of the kind that Bum would
have frowned (ln arc the PJ II and the mHclen. PHI, cited by Colquhoun
( 1971 ). stands for 'purity in heart index' and measures the ability of a virgin
pure-in-heart to tran.,form. under appropriate condjtions. a he-goat iruo a
youth of urpa~si ng beau ty. The mHelen b a unit of beauty. I mHclcn
being sufficicm to launch I ship. 89
 SECTION 1 GENERAL PRINCIPLES

QUANTAL AND GRADED RESPONSES

( 100
T An assay may be based on a graded response (e.g. change in blood
glucose concentration, contraction of a strip of smooth muscle, change ill
I iii the time taken for a rat to run a mate), or on a/l-or-nothing responses It~
xE<ll death. lo'>' of righting reflex. succco,~ in maze running withJO a '>lipularcd
time). With the latter. >Omettmes l..nown a.s a disconrimiOUl or qu~
E
respons~. the proportion of animal\ responding will mcrease with dw
~
~ ll1e ~hapc and slope of such a curve i., governed by the indi\ldual variti(
(I)
(/)
c between animals- the more uniform the population, the ~leeper the CUI\
0 and the more precise the assay. With graded responses, the steepnes1 a
0.
UJ
Ql the dm,e- response curve is a propcny of the test system ami ha~ nothin;
a: to do with biological variation. Quanta! responses can be used in esscmi:lll.
!he same way a\ graded respon\e\ for the purposes of bioa.\\ay. ulthoo..,
the appropnme statistical procedure\ are ~lightly different.

0 2 3
log 10 volume administered (J.d)
Fig. 6 .3 Co mparison of the potency of unknown and
standard by bioassay. Note that comparing the magnitude of
responses produced by the same dose (i.e. volume) of
standard and unknown gives no quantitative estimate of their
relative potency. (The differences, A 1 and Az, depend on the
dose chosen.) Comparison of equieffectlve doses of standard
and unknown gives a valid measure of their relative potencies.
Because the lines are parallel, the magnitude of the effect
chosen for the comparison is immaterial; I.e. log M is the
same at all points on the curves.
to !he midd le region of the log10 do;.e-effect curve, which is usual ly close
to a straight line (see Ch. 2). The usc of a logari thmic dose scale means
that !he curves for S and U wiU normally be parallel, and !he potency ratio
(M) is estimated from the horizontal di~tance between the two cur\'es
(Fig. 6.3). Assays of 1his 1ype are knO\vn a.s pam/lei line tiJJII)J, the
minimal design being !he 2 + 2 ~say. in which 1wo dose' of standard
(S 1 and S2) and two of unkno\\ o (U 1 and U2) are used. The do\es are
BIOASSAYS IN HUMANS
Studies involving human subjects fa ll into two distinct cmegorie1
The first. lwman pharmacology, focuses on using human subjec:L
(either healthy volunteers or patients) essentially as ex peri men
animals. for example to check whether mechanisms that open..
in other !>pecies also apply to humans, or to take advantage ofli..
much broader response capabilities of a person compared with,
rat. The scienti fic principles underlying such measurements an-
the same, but the ethical and safety issues are paramounl, ar..
ethical committees associated with all medical research ccntn
tightly control the rype of experiment that can be done.
T An example of an experiment to compare two analge~ic drug' (
Ch. 41) in human, is shown in Figure 6.4. Although many ani mall
have been devised (e.g. measuring I he effect of an analgc~ic drug on th:
Morphine Codeine

d'
~ /;
)~
chosen to give respon~s lying on the hnear pan of the log10 dose 6
- response curve, and nrc given repeated ly in randomised order. providing
an inherent mca~ure of the variabi lity of the test system. wh ich can be
used, by means of straightforward statiMical analysis, to estimate the
confidence limirr of the final result.

In practice, mo't bioassays will give re\uhs whose 5'k confidence limits
~ ~
Potency ratio = 1
3

lie within :!Oct. and many will do better than this. / 2

The 2 + 2 assay also detec1s whether or not the rwo log dose-effect
lines deviate ;.ignificantly from paralleli;.m. If the lines are not parallel, 2
which may be the cnse if the assay i~ u!ted to compare two drug' whose
mechanism of action is not the same. it is not possible to define the
relative potcncic~ of S and U unrunbiguou~ly in terms of a .,imple
ratio. The e~penmenter must then face up to the fact that there are
qualitative a~ well a'> quantitative differences between the two. so that 0
comparison requtre, measurement of more than a single dimen\ion of 8 16 30 60 120 240
potency. An example of this kind of difficulty is met when diuretic drugs
(Ch. 24) are compared. Some ('low ceiling') diuretics arc capable of
Dose (mg)
producing only a small diuretic effect, no maHer how much b given; Fig. 6 .4 Assay of morphine and c odeine as analgesics
others ('high ceiling') can produce a very intense diu resis (described in humans. Each of four patients (numbered 1- 4) was given,
as 'torrential' by authors with vivid imaginations). A compari'>on of on successive occasions in random order, four different
two ~uch drug'> requires not only a measure of the doses needed to treatments (high and low morphine, and high and low codeine
produce an equal low-level diuretic effect. but also a measure of the by intramuscular injection, and the subjective pain relief score
relative he1ghb of the ceilings. More generally. full and partial agoni'>l> calculated for each. The calculated regression lines gave a
at the 'rune receptor (see Ch. 2) will generate non-parallel log dose
- response curve. so the difference between 1hem cannot be expressed
I
~~t_ency ratio estimate of 13 for the two drugs. (After Houde
~ et al. 1965 In: Analgetics. Academic Press, New York.)
90 simply in termb of u potency raLio.
 METHOD AND MEASUREMENT IN PHARMACOLOGY
mean ume taken for group' of mice to JUmp off a surface heated to a
mlldl> painful temperature). they often fail to predict accurately the
blood subje<:tile relief of pain in human\. Figure 6.4 shows a compari!>on of
oge in morphme and codeine in humanJ., ba'><.'<l on u modified 2 + 2 design. Each
.l(e.g. of the four dose> wa!> given on different occa!>ions 10 each of the four
ulated >ttbject~. the order being mndomi ~cd and both subject and observer bei ng
Jantal unaware of the dose given. Subjecti ve pain relief was assessed by a
dose. tramed observer, and lhc resuIts showed morphine to be 13 times m. potent
1ation J\ todeine. This, of course, docs not prove it> >uperiority. but merely
cu rve 'ho''' that a smaller dose b needed to produce lhe same effect. Such a
e~~ of
rn<J,urem.:nt i>. however. an es>ential preliminary 10 assessing lhe relative
>thing therapeutic merit> of the t11.o drug.,, for an) comparison of other factor\,
DtiaJ J} such:., 'ide effects. duration of action. tolerance or dependence. needs to
10ugh be done on the basis of doses lhat arc equiacth e as analgesics.
The 'ccond type of human assay, the clinical trial, is designed
to measure therapeutic effecti veness, an important and highly
'P~cmliscd fonn of biological assay. The need to use patients for
l ries. ~xpctimcnta l purposes impose:. many restrictions. Below, we
1jects di,,u,, ' ome of the basic principles involved in clinical trial s; the
ental role of such tri al s in the course of drug development is described
erate in Chapter 56.
1f the
lith a
.., are ANIMAL MODELS OF DISEASE
, and
ntrcs Th~re are many examples where ~impl e intuitive models predict
with fair accuracy therapeutic effi cacy in humans. Ferrets, wh en
housed in swaying cages, respond by vomiting. and drugs that
s (see
I test.<> pr~vcnt this arc also found to relieve moti on sickness and other
Jn lhe
Bioassay is the measurement of potency of a
drug or unknown mediator from the magnitude of the
biological effect that it produces.
Bioassay normally involves comparison of the unknown
preparation with a standard. Estimates that are not
based on comparison with standards are usually
unreliable and vary from laboratory to laboratory.
Compansons are best made on the basis of
dose-response curves, which allow estimates of the
equiactive concentrattons of unknown and standard
to be used as a basis for the potency comparison.
Parallel line assays follow this principle.
The biological response may be quanta! (the
proportion of tests in which a given aU-or-nothing
effect is produced) or graded. Different statistical
procedures are appropnate in each case.
D1fferent approaches to metrication apply according
to the level of biological organisation at which the
drug effect needs to be measured. Approaches range
e) through molecular and chemical techniques, in vitro
e ischaemia) but ineffccti1e tn human\ (\troke victims). Similarly, recent
and in vivo animal studies, and clinical studies on
volunteers and patients, to measurement of effects at
the socioeconomic level.
types of nausea in humans. Irritant chemical s injected into rats'
paws cause them to become swollen and tender, and thi!. test
predicts very well the efficacy of drugs used for symptomatic
relief in inflammatory conditions such as rheumatoid arthriti ~ in
humans. As discussed elsewhere in thi s book, models for many
important disorders, such as epilepsy, diabetes, hypertension, and
gastri c ulceration, based on knowledge of the physiology of the
condition, are available, and have been used successfully to produce
new drugs. even though their success in predicting therapeutic
4
efficacy is f ar from perfect.
Generalising, we can say that an animal model ~hou ld ideally
resemble the human disease in the following ways:
I . similar pathophysiological phenotype (sometim es called face
validity)
2. similar causation (sometimes called construct validity)
3. similar response to treatment (sometimes call ed predictive
l'lllidiry).
In practice, there are many difficulties. and the shortcomings of
animal model s are one of the main roadblocks on the route from
basic medical science to improvemems in therapy. The difficulties
include the following.
M any diseases, particularly in psychiatry, are defined by
phenomena in humans that arc difficult or impossible to
observe in animals. whi ch rul es out criterion 1. As far as we
know, mania or delusions have no counterpart in rats, nor can
we recognise in them anything resembling a migraine attack
or suicidal behaviour. Pathophysiological similarity is al ~o
inapplicable to conditions such as depression or anxiety
disorders. where no clear brai n pathology has been defined.
The 'cause' (criterion 2) of many human diseases i~ complex
or unknown. For many degenerative diseases (e.g. A l1hei mer\
disease, osteoarthritis, Parkinson ~ disease), we need to
model the upstream (causative) factors rather th<m the
downstream (symptomatic) features of the disease, although
the latter are the basis of most of the simple physiological
models used hitherto.
Relying on response to treatm ent (criterion 3) as a test of
val idity carries the ri ~k that drugs acting by novel
mechani sm s could be missed, because the model will have
been selected on the basis of its responsiveness to known
drugs. With schi10phren ia (Ch. 38) for example, it is clear
that dopamine antagoni!>tS arc effective, and many of the
models used are designed to renect dopamine f unction in the
brain, rather than oth er potential mechanisms th at need to be
identified if drug discovery is to move on.
"There have been many example' ol drugs lhat ~ere high!) effecti'e in
experimental animals (e.g. in reducing brain damage following ccn:br.ll
~ ork on substance P antagoni\t~ (Ch. 16) showed lhem to be "ery effective
in ant mal tests for analgesia, bul I hey proved inaclive in humans. How
many errors in the opposite di rection may have occurred we shal l never
know, because sucb drug~ will not have been Jested in humans.
91
 SEcnON 1 GENERAL PRINCIPLES
GENETIC AND TRANSGENIC ANIMAL MODELS
owadays. genetic approaches arc increasingly used as an adjunct
to conventional physiological and pharmacological approaches
to d isease modelling.
By selective bre.eding, it is possible to obtain pure animal strains
with characteristics closely resembling certain human disea~es.
Genetic models of this kind include spontaneously hypertensive
rat'>, genetically obese mice, epilepsy-prone dogs and mice, rats
with deficient vasopressin secretion, and many other examples.
In most cases. the genes rc ... ponsible have not been idelllified.
More recently. deliberate genetic manipulation of the germ line
is increasingly used to generate transgenic animals as a means
of replicating human disea),c states in experimental animals, and
thereby providing animal models that are expected to be more
predictive of therapeutic drug e tTccls in humans (see reviews by
Rudolph & Moehler, 1999; 1ornell & Snaith, 2002). This versatile
technology, first reported in 1980, can be used in many different
ways. for example:
to inactivate individual gene\, or mutate them to pathological
forms
to introduce new (e.g. human) genes
to overexpress genes by inserting additional copies
to allow gene expression to be controlled by the experimenter.~
Currently, most transgenic technologies arc applicable in mice
but much more difficult in other mammals. 6
Exan1ples of such models include transgenic mice that
overexpress mutated forms of the amyloid precursor protein or
presenilins (see Yamada & Nabeshima, 2000). which are
important in the pathogenesis of AlLheimer's disease (see Ch. 35).
When they are a few month'> old. the!.e mice develop pathological
lesions and cognitive changes resembling Alzheimer's disea~e.
and provide very useful models with which to test possible new
therapeutic approaches to the disease. Another neurodcgenerative
condition, Parkinson's disea~e (Ch. 35) has been modelled in
transgenic mice that overcxpress synudein, a protein found in the
brain inclusions that are characteristic of the disease (sec Beal,
200 l ). Transgenic mice with mutations in tumour suppre%or
genes and oncogenes (!.ec Ch. 5) are widely used as models for
' With conventional transgenic technology. the genetic abnormality i'
expre~~ed throughout development, 'ometime;, proving lethal or cau,ing
major developmental abnom1alitie,. Conditional transgene~h b now pos,ible.
allo\\ ing the mutation to remain .. itcnt until triggered by the administration
of a chemical promoter (e.g. the tctrncychne analogue. doxycycline, tn the
mo~t "'ide!) used Cre-Lox conditional ')'h:m). This a'oids the complication'
of developmental effects and long-term adaptations. and may aiiO\\ adult
dt...ea..e to be modelled more accurJtcl).
~on the other hand. nemmodcs. fnut flte\ and tebrn fish-fast-multiplying
species whose genetics has been exten,ively \tudied. arc very amenable to
tran~genic approaches and, unlike mice, can be used in automated high-
92 throughput drug-screening as~ay' (sec Ch. 56}.
human cancers. Mice in which the gene for a particular aoe:no,li:IW
receptor subtype has been inactivated show distinct beha\
and cardiovascular abnormalities. such as increased '"''""""'"-
reduced response to noxious l>timuli. and raised blood
(Lcdcnt et al., 1997). The!.e findings serve to pinpoint
physiological ro le of this receptor, whose function was
unknown. and to suggest new ways in which agonists or an
for these receptors might be developed for therapeutic u~e
to reduce aggresshe behaviour or to treat hypertension).
mice can, however, be mil.leading in relation to human dio,e
For example, the gene defect responsible for causing cystic fibl
(a disease affecting mainly the lung1. in humans). when retti'O<IIucdl
in mice causes a di~order that mainly affects the inte~tine.
The use of tranl>gcnic animals in pharmacological rcscan;
increasing rapidly as the technology improves. For more
information, sec Offcrrnanns & Heio (2004).
CLINICAL TRIALS
A clinical trial is a method for comparing objecti-.el}. b)
prospective study. the rc!.ults of two or more therapeutic
For new drugs, this is carried out during phase TIT of
development (Ch. 56). lt is important to realise that, until :ttl
30 years ago, methods of treatment were chosen on the ba\11
cli nical impression a nd personal experience rather than oh11rt1r
testing. 7 Although many dntgs. with undoubted elti~clivcn:
remain in use without ever having been subjected to a """"'"n.-
clinical trial, any new dntg is now required to have been
this way before being licensed for general clinical u~c. 8
On the other hand, digitalis (l>CC Ch. I 8) was used for 200
to treat cardiac failure before a controlled trial showed it to
very limited value except in a particular type of patient.
A good account of the principles and organisation of
trials is given by Friedman et a l. ( 1996). A clinical trial aim
compare the response of a test group of patients receiving a
treatment (A) with that ora control group receiving an
'standard' treatment ( B). Treatment A might be a new drug
new combination of existing drugs, or any other kind ofthcmp:~/4~1
intervention, such a!> a '>Urgical operation, a diet, phy'>i
7
Not exclusively. Jame~ Lind conducted a controlled trial in 1753 on I~
mariners. which showed that ornnges and lemons offered protection a~ ,
scurvy. However, 40 years pa~~ed before the British Navy acted on hi1
advice. and a further century before the US Navy did.
8It is fashionable in some quarter~ to argue that to require evidence of
efficacy of therapeutic procedure~ in the fonn of a controlled trial run1
counter to the doctrine\ of 'holi,tic' medicine. Thb is a fund:uncnt311)
antiscicntific view. for 'cience ad' ances only by generating predicuon'
from hypothese~ and b) \UbJCCttng the predictions to cxpcrimcnul tN
Very few alternative' or complementat} medical procedure\, \Uch IS
homeopath). aromathcrnp). acupuncture or 'detox' . ha'e been ~o t~'tcd.
Standing up for the sctenttfic approach is the evidence-based medtcinc
mo,ement (sec Sackett et al .. 1996). which sets out ~trict criteria for
assessing therapeutic efficacy. ba~cd on random bed, controlled climcdl
trial~. and urge~ scepticism about therapeutic doctrines who~c effica9
not been so demonstrated.
 METHOD AND MEASUREMENT IN PHARMACOLOGY
osinc and 'o on. The \tandard against which it is judged (treatment B)
oural might he a currently used drug treatment or (if there is no cunently
,sion. a1ailable effecti1e treatment) a placebo or no treatment at all.
'\SUre The u'e of colllrols i~ crucial in clinical trials. Claims of
II the lherJpeutic cfticac) ba~ed on reports that. for example, 16 out
iherto of 20 paticnh rece11ing drug X got better within 2 weeks are of
onists no 1alue 11ithout a knowledge of how 20 patients receiving no
, (e.g. treatment. or a d1ffcrent treatment. would have fared. Usually. the
:genic controb arc provided by a separate group of patients from those
ease. recCI\mg the te\ttreatmcnt. but sometimes a cross-over design is
brosis ptMible in which the \arne patients are switched from test to control
Juced treatment or vice versa, and the results compared. Randomisalion
1\C,.,cnualto avoid bias in assigning individual patients to test or
reb is control group~. l ienee, the randomised coli/rolled clinical trial is
tailed no1~ regarded a., the essential tool for assessing clinical efficacy
ol new drugs.
Concern inevitably arises over the ethics of assigning patients
at random to an untreated control group when the doctor in
~harge believes the test Lrcauncnt to have advantages. However,
the rea~on for setting up a trial is that doubt exists in the minds
by a ul man) doctor<. that the treatment is efficacious, so for these
dures. d1lCtOI\ there is no ethical dilenuna. [f individual doctors are
1nical peMnall} con1inced that the treatment is beneficial, they should
about dearly avoid panicipating in a controlled trial. All would agree
J!>il> of on the principle of informed consen1,9 whereby each patient must
ective be told the nature and risk!> of the trial. and agree to participate
encss. on the ba'i' that he or she will be randomly and unknowingly
rolled a.'1igncd to either the te\t or the control group.
aed in t!nlikc the kmd of bioas.,ay discussed earlier. the clinical trial
doe' not nonnally give an) information about potency or the form
I year; of the do'c re~ponse curve, but merely compares the response
1be of produced by two stipulated therapeutic regimens. Additional
4UC,lions may be posed, such as the prevalence and severity of
linical
,tJe effects. or whether the treatment works better or worse in
ims to particular classes of patient. but only at the expense of added
a new complexity and numbers of patients, and most trials are kept as
tisting ' implc as possible. The investigator must decide in advance what
1g or a Ju\e to u~e and how often to give it, and the trial will reveal only
1peutic 11hethcr the chosen regimen performed better or worse than the
1erap) .ontroltreatmcnt. It will not say whether increasing or decreasing
the dm.e ~ould have improved the response; another trial would
be needed to ascenain that. The basic question posed by a clinical
tnsl1' thu' simpler than that addressed by most conventional
I~ bJ<Y.b'J}' However. the organisation of clinical trials, with the
l~ain~t
pwblcm of a101ding bias. is immea~urably more complicated, time-
j,
corhuming and cxpcm.ivc than that of any laboratory-based assay.
n~
I~ 'EI'(QIII" .:-.m toe contcntiou\. becau~e patients wbo are unconscious.
n> demented or mcnlall) ill <In: unable to gn:e such consent. yet no one would
...t. w to prcdudc trial' that might ofh:r improved Lhempie~ to these needy
lb PJUcm,. Clini~altriab '" children are particularly problematic but are
ted. oec-c,,JI) 11 the treatment of childhood di.,eases is to be placed on the same
1e t11Jcnc~ bJ,c a' i' judged appropriate for adults. There are many example~
~here~~pcncncc ha' >hown that children respond differently from adults.
:at nJ the~" now increa,ing prcs\urc on phannaceutical cornpanie~> to perform
;y have tn.ll> in ~hildrcn. dc,pitc the thfticulties of carrying out such S!Udies. The
'ame cllnccrn' npply to tria ls in elderly patients.
Animal models
Animal models of disease are important for
the discovery of new therapeutic agents. Animal
models generally reproduce imperfectly only certain
aspects of human disease states. Models of
psychiatric illness are particularly problematic.
Transgenic animals are produced by introducing
mutations 1nto the germ cells of animals (usually
mice). which allow new genes t o be introduced
('knock-ins') or existing genes t o be inactivated
('knockouts') or mutated in t he animals in a breeding
colony.
Insertion or deletion of certain genes sometimes
results In phenotypic changes resembling human
disease, and is an approach increasingly used to
develop d isease models for drug testing. M any such
models are now available.
The induced mutation operates throughout the
development and lifetime of the animal. and may be
lethal. The new technique of conditional mutagenesis
is an advance that allows the abnormal gene to be
switched on or off at a chosen time.
AVOIDANCE OF BIAS
There arc two main strategies that aim to minimise bias in clinical
trials. namely:
randomisation
the double-blind technique.
If two treatments, A and B, arc being compared on a series of
selected patients, the simplest form of randomisation is to allocate
each patient to A or B by reference to a series of random numbers.
One difficulty with simple randomisation. particularly if the groups
arc small, is that the two groups may turn out to be ill-matched
with respect to characteristics such as age. sex. or disease severity.
Stratified randomisation i~ often used to avoid the difficulty.
Thus the subjects might be divided into age categories, random
allocation 10 A or B being used within each category. It is possible
to treat two or more characteristics of the trial population in this
way, but the number of strata can quickly become large. and the
proce~~ i~ ~elf-defeating when the number of subjects in each
becomes too \mall. A.., well as avoiding error resulting from
imbalance of groups a~signed to A and B. stratification can also
allow more sophi~ticated conclusions to be reached. B might, for
example. prove to be better than A in a particular group of patients
even if it is not~>ignificantly better overall.
The douhle-hlind 1eclmique, which means that neither subject
nor investigator is aware at the time of the assessment which
treatment is being used, is intended to minimise subjective bias.
It has been repeated ly shown that, with the best will in the world,
subjects and investigators both contribute to bias if they know
which treatment i~ which. so the use of a double-blind technique 93
 SEcnON 1 GENERAL PRINCI PLES
is an important safeguard. It is not always possible. however. A
dietary regimen or a surgical operation, for example, can seldom
be disguised, and even with drugs, pharmacological effects may
reveal to patients what they arc taking and predispose them to report
accordingl y. 10 In general, however, the use of a double-blind
procedure, with precautions if neces~ary to disguise such clues as
the taste or appearance of the two drugs, is an important principle.
Maintaining the blind can be problematic. Ln an attempt to
determine whether melatonin is effective in countering jet lag, a
pharmacologiM selected a group of fellow pharmacologists
attending a cong ress in Australia, providing them with unlabelled
capsules of melatonin or placebo, with a jet lag questionnaire
to fill in when they arrived. Many of them (one of the author<;
included), with analytical resource~ easily to hand, opened the
capsules and consigned them to the bin on finding that they
contained placebo. Pharmacologists arc only human.
THE SIZE OF THE SAMPLE
Both ethical and financial considerations dictate that the trial
should involve the minimum number of subjects, and much
Matistical thought has gone into the problem of deciding in
advance how many subjects will be required to produce a useful
result. The results of a trial cannot, by their nature, be absolutely
conclusive. This is because it is based o n a sample of patients,
and there is always a chance that the sample was atypical of the
population from which it came. Two types of erroneous conclusion
are possible, referred to as type I and type 11 errors. A type I
error occurs if a difference is found between A and B when none
actually exists (false positive). A type TI error occurs if no difference
is found although A and 8 do actually differ (false negative). A
major factor that determines the size of sample needed is the
degree of certainty the investigator seeks in avoiding either type
of error. The probability of incurring a type I error is expressed
as the significance of the result. To say that A and B are different
at the 0.05 level of significance means that the probability of
obtaining a false positive result (i.e. incuiTing a type I error) is
less than I in 20. For most purposes, this level of significance is
considered acceptable as a basis for drawing conclusions.
The probability of avoiding a type IT error (i.e. failing to
detect a real diffe rence between A and 8) is termed the power of
the trial. We tend to regard type TI errors more leniently than type
l errors, and trials are often designed with a power of 0.8-0.9. To
increase the significance and the power of a trial requires more
patients. The second factor that determines the sample si7c
required i!> the magnitude of difference between A and 8 that is
1
0orhe distinction between a true pharmacological response anu a beneficial
clinical effect produced by the knowledge (ha..ed on the pham1acological
eftccts that the drug produCe\) that an acme drug is being administered h
not easy to draw. ond we should not expect a mere clinical trial to resolve
94 such a line ~emantic issue.
regarded as clinically significant. For example, to detect that.
given treatment reduces the mortality in a cenain condition b)
least I 0 percentage points, say from 50% (in the control group
to 40% (in the treated group), would require 850 subject\
assuming that we wanted to achieve a 0.05 level of significan,
and a power of 0.9. If we were content only to reveal a reduct~
by 20 percentage points (and very likely miss a reduction ~
I0 points), only 2 10 s ubject~ would be needed. Tn this exampk
missing a real I 0-point reduction in mortality could re~uh 1
abandonment of a treatment that would save I 00 lives for c1c
1000 patients treated-an extremely serious miqake from
point of view. T his simple example emphasises the need to
clinical benefit (whic h is often difficult to quantify) in parall
with statistical considerations (which are fairly straightforn.w:
in planning trials.
T A trial may give a ignificant result before Jhe planned oumb<!r
pa1iem~ have been cnroUed. so i1 i~ common for interim analyses
carried out (by an mdependem Jearn ~o that the trial team n:
unaware of the reo;ults). If this analy'i' gives a conclusive result,
it show~ that continuati on is un li ~e l y to give a conclusive re\uli.
trial can be terminated, thus reducing the number of !.ubjects 1e1t~d
one \Uch large-scale trial (Beta-blocker Heart Attack Trial
Group. 1982) of the value of long-term treatmelll with th
adrenoceptor-blockmg drug propmnolol (Ch. 18) following hean
the interim results \howed a significant reduction in mortality. v.h~eh
to the early termination of the trial. In sequential trials, the reuh>
computed case by case (each case being paired with a control) a~ the
proceed~. and the trial Mopped as soon as a re'uh (at a prede1c~l
level of ~tgnificance) 1~ achieved.
Variou~ 'hybrid' tri al designs, which have the advantage of sequc
tria ls in minimising the number of patients needed but do not
~trict pairing of ~ubjcc~. have b.:en de' i~ed (!>ee Friedman et al. I
CLINICAL OUTCOME MEASURES
The measurement of clinical outcome can
business. and is becoming increasingly so as society
more preoccupied with assessing the efficacy of thp,,.,,..,, .-
procedures in terms of improved quality of life, societal
economic benefit, rather than in terms of objective clinical
such as lowering of blood pressure, improved airways curtuuc;...:~~
or increased life expectancy. Various scales for a~sessing
related quality of life' have been devised and tested (see
et al., 1997; Walley & Haycocks, 1997), and the tendenc}
combine these with measures of life expectancy to arri'e ~
measure 'quality-adjubted life yean,' (QALYs) as an overall
of therapeutic efficacy, which attempts to combine both
time and relief from !-.uffering in assessing overall benefil
11
A'> may be imagined, trading off duration and quality of life rai..es
about which man) of U\ feel decidedly <;queamish. Not ~o economNs.
however. They approach the problem by a\king such que\ttons as: 'Ht
many yeu r' of life would you be prepared to sacrifice in order to live 1hr
rest of your life free of the disability you arc currently experiencing''()
even more disturbingly: 'If you could gamble on sun iving free of
for your normal lifespan. or (if you lo~ the gamble) dytng immediille
what odds would you accept?' Imagine bemg asked thi'> by your dO<.'
' Btll I unly wanted something for my ~ore throat ' you protest weakly.
 METH OD AN D MEASUREMENT IN PHARMACOLOGY

that a planning clinical trials, it i!\ necessary to decide the purpose of META-ANALYSIS
by at the trial in ad\'ance, and to define the outcome measures accordingly.
1' It i~ po''iblc. by the u\e of ~tatistical techniques. to combine the data
;roup) obtained in >everal indi\ idual trials (provided each ha.~ been conducted
1jects. according to a randomi<.ed design) in order to gain greater power and
FREQUENTIST AND BAYESIAN APPROACHES '>ignificancc. Tht\ procedure. ~:nown ~ mera-anclysis or oven'iew analnis,
cance
Jction " The con,emional approach to analysis of scientific data (including can be \Cry uwful in arriving at a conclusion on the basis of se\Cmll
chrucal mah <iua)t\ knO\\-n ~ 'frequenust' and is based on a null hypothesi~. published triab. of "'hich >orne claimed superiority of the test treatment
) n b)
for t\ample ot the form tretllment A is no more effecthe than treatment over the control while others did not. A5 an objective procedure, it is
mplc. B ReJection of the h) pothesis implies tbar A is more effective than B. cenaml) preferable to the 'take your pick' approach to conclusion forming
ult in Suppo-e that a trial \hOW\, on average. that patients treated with A live adopted by mo\t human being' when confronted with contradictory data.
eve!) l1111~<r than patient\ treated with B. Conventional frequentist statistics It ha, ltC\Cral drawback>, however (see Naylor. 1997). the main one being
:iety's ..Jdre,,e, the que;tton: /fA were acwally no more effecrive than 8. whar 'publication bias', because negative studies are generally considered less
;, thr pmbabilm (P) of obtaining 11te results tluu were acwally tJblllined intcrc'>ling, and are therefore less likely to be published, than positive
assess
m thr Ifill/? In other words, given that treatment A is no belter than B, \lud ic\. Double counting. cau~ed by the same data being incorpor.Jted into
:rrallel more th an one trial report. i' anmher problem.
ho11 ulten, had we repeated the trial ma ny times, would we have obtained
ward) r.:,ult, \uggeMing that A is better? If this probability is low (say Jess than
11.05), we reJeCt the null hypothesis and conclude thai A is most likely
better. II' P i\ larger. the re~ults could quite easily have been obtained
1ber of
llith\lut there being any true difference between A and B, and we cannot
THE ORGANISATION OF CLINICAL TRIALS
'to be
reject the nul l hypmhc;is.
emains The o rga nisation of large-scale clinical trials invol ving hundreds
It, or if II ~~~ ha\e no prior rem,on for thinking that A will be belter than B, the or thousands of patie nts at many different centres is a massive
ult, the trequ~ntiM approach i' perfectly appropriate, and it is the usual principle and expensive undertaking that makes up one of the major costs
,ted. ln 1>n 11hich trial' of un~nown drug~ are ba>ed. But often. in real life. there
of developing a new drug, and can easily go wrong.
~arch 11111 be j;ood rca,on, ba;cd on previous trials or clinical experience. to
the f\- bche'c that A i\ actually better than B. Using a Bayesian approach allow~ One large trial (Anturane Reinfarction Trial Research Group,
anacks, th1' to bc taken into account formally and explicitly by defining a prior 1978) involved 1620 patients at 26 research centres in the USA
ucb led pro/tal>ih1,1 for the effect of A. The data from the new trial. which can be a nd Canada, 98 collaborating researchers, and a formidable list
ults are >l!lJller than a COO\entional trial. are then statistically superimposed on of organilting committees. including two independent audit
lbe trial the pnor probabilit) cune to produce a posterior probabiliry curve. in
:rmined
committees to check that the work was being carried out in
tffect an update of the pnor probabilit) curve that takes account of the
ll(ll data The Ba)e,ian approach is controversial. depending as it does on
conformity with the strict protocols established. The conclusion
t\prt"'"!! the often \UbJCC:U\e prior assumption in e;~;plicit mathematical wa<, that the drug under test (sulfinpyrazone) reduced by almost
1uential
require term,, and the MaU\liCal <tnalysis is complex. Nevertheless. it can be one-half the mortality from repeat heart attacks in the 8-month
1996). argued that to ignore altllgether prior knowledge and experience when period after a fir~t anack, and could save many lives. The US
lnt(IJ'rellng ne11 data i' unJu,tified, and even unethical. and the Bayesian Food and Dntg Adminil>Ltation. however, refused to grant a
appnX~Ch j, wn'>l!<IUt:nt ly gaming acceptance, although most rrials are
'till bJ-ed 1ln lrequcnt"t principles.
licence for the usc of the drug, c riticising the trial as unreliable
and biased in several respects. Their independent analysis of
The princ1ple' underlying Bayesian approaches. which are being
lie a ted the data s howed the beneficial effect of the drug to be slight
maea"ngl)' upplicu to clinical trial~. are described by Spiegelhalter et al.
'Comes tl99<1) and Lilford & Braunholtz (2000). and insignificant. Further analysis and further trials, however,
tpeulic supported the ori ginal conclusion, but by then the efficacy of
al and aspirin in this condition had been established, so the use of
~ffects, PLACEBOS sultinpyra.wne never found favour.
tctance 'f \ placebo i' '' dummy medicine containing no active ingredient (or
health- ahcrnatively, a dummy >urgical procedure, diet. or other kind of
nmond thcrap.:utic intervention), which the patient believes is (or could be, in the BALANCING BENEFIT AND RISK
y is to ,om~xt of a controlled trial) the real thing. The 'placebo response' is
v.1J~I) bdie,ed to be a powerful therapeutic effect. producing a
THERAPEUTIC INDEX
:at the
tgmtkant bcnctkial effect in about one-third of patients. While many
leaSUJ'C Ehrlich recognised that a drug must be judged not only by its
c JnK"al trial\ include a placebo group that shows improvement, only a
urvival \1113ll mtnnnt} have compared this group with untreated control>. A useful propertiec,, but also by its toxic effects. and he expressed
tit. 11 In r.:.-ent >une) of the\e trial re\ult> (Hr6bjaruson & Grmsche. 200 I) the rherapetttic index of a drug in terms of the ratio between the
sbo<Aed that the placebo effect wa.' generally insignificant. except in the average minimum effective dose and the average maximum
.:ase of pam relief." here u "'~~mall but significant. The) concluded that tolerated dose in a group of subjects. i.e.
the popular belief in the >trength of the placebo effect is misplaced. and
probabl) reflect\ m pan the tendcnc} of many symptoms to improve Th . d Maximum non-toxic dose
i~sues ~ntJneou'l) and in pan the reporting bias of patient.~ v. ho want to erapeutlc 10 ex = Minimum effective dose
l\, plea-e the1r doctors. The ethical ca>e for using placebos as therapy, which
Ho"' ha> been the >UbJCCt ot much public discu>sion. may therefore be weaker Unfortunately, the variabi lity between individuals is not taken
e the than ha, been argued. The risk!. of placebo therapies should not be into account in this definition. Even if for a particular subject
~Or. undere,timnted. The U\e of active medicines may be delayed. The
the re is a large margin between the maximum tolerated dose and
habi lity n.:.;e,..:ll')i element of deception risks undermining the confidence of
p.lli~nt' tn the intcgrtty of doctors. A state of 'therapy dependence' may
minimum effective dose, individuals may vary widely in their
uely.
:tor. be pmJuccd in people who are not ill, because there is no way of sens itivity, so it is quite possible that the effective dose in some
y. u,\CI,ing whether n patient ~till needs' the plncebo. individuals wil l be toxic to others. 95
 SECTION 1 W GENERAL PRINCIPLES
Clinical trials
A clinical trial is a special type of bioassay
done to compare the clinical efficacy of a new drug
or procedure with that of a known drug or procedure
(or a placebo).
Generally, the aim is a straight comparison of unknown
(A) with standard (B) at a single dose level. The result
may be: '8 better than A', '8 worse than A', or 'No
difference detected'. Efficacy, not potency, is compared.
To avoid bias, clinical trials should be:
controlled (comparison of A with B, rather than
study of A alone)
randomised (assignment of subjects to A or B on
a random basis)
double-blind (neither subject nor assessor knows
whether A or 8 is being used)
Type I errors (concluding that A is better than 8 when
the difference is actually due to chance) and type II
errors (concluding that A is no better than 8 because
a real difference has escaped detection) can occur;
the likelihood of either kind of error gets less as the
sample size and number of end-point events is
increased.
Interim analysis of data, carried out by an independent
g roup, may be used as a basis for terminating a trial
prematurely if the data are already conclusive, or if a
clear result is unlikely to be reached.
All experiments on human subjects require approval
by an independent ethical committee.
Clinical trials require very careful planning and
execution, and are inevitably expensive.
Clinical outcome measures may comprise:
physiological measures (e.g. blood pressure, liver
function tests)
long-term outcome (e.g. survival)
subjective assessments (e.g. pain relief)
overall 'quality of life' measures
'quality-adjusted life years' (QALYs), which
combine survival with quality of life
Meta-analysis ts a statistical technique used to pool
the data from several independent trials.
An often-quoted definition that aims to take into account
individual variation is:
Therapeutic index= LD5ofEDso
where LD50 is the dose that is lethal in 50% of the population,
and ED50 is the dose that is effective' in 50%.
Thus defined, therapeutic index is intended to indicate the
margin of safety in use of a drug, by drawing attention to the
relationship between the effecti ve and toxic doses, but it has
obvious limitations and is therefore very rarely quoted as a
number. For many reasons, it is not a useful guide to the safety
96 of a drug in clinical usc.
LD50 does not reflect toxicity in the therapeutic setting.
which produces unwanted effects bU rarely death.
ED50 is often not definable, because it depends on what
measure of effectiveness is used. For example, the ED~o for (
aspirin used for a mild headache is much lower than for f,
aspirin as an antirheumatic drug. e
Some very important form~ of toxicity arc idiosyncratic (i.t
only a small proportion of individuals are susceptible; sec
Ch. 53). ln other cases. toxicity depends greatly on the
clinical state of the patient. Thus propranolol is dangerOU\
an asthmatic patient in doses that are harmless to a nonnal
individuaL More generally, we can say that wide indh.tdual
variation (see Ch. 52) in either rhe effective dose or the tox..
dose of a drug makes it inherently less predictable, and
therefore less safe, allhough thi s is not reflected in the
therapeutic index.
In conclusion. therapeutic index is of little value as a measure
the clinical usefulne1.s of a drug, It may have some relevance
a measure of the impunity with which an overdose ma) be g11
Thus one reason why the benLodiazepiues replaced barbitul'iL
as hypnotic drugs (see Ch. 37) i!> that their therapeutic inde\
much greater. and they are much less likely to kill when taken
accidental or deliberate overdose. Ironically. though, thalidorr
- probably the mo~t harmful drug ever marketed-'.\
promoted specifically on the basis of its exceptionally h1
therapeutic index.
Although therapeutic index expresses a valid general con.:t
by emphasising the balance between risk and benefit, its p~euJ
quantitative precision is misleading. and it provides no mea'
of the usefulness of a drug.
OTHER MEASURES OF BENEFIT AND RISK
Alternative ways of quantifying the benefits and risk!. of dn.,
in clinical use have received much attention. One use
approach is to estimate from clinical trial data the proportion
test and control patients who will experience (a) a defined b
of clinical benefit (e.g. survival beyond 2 years. pain relief lL
cenain predetermined level, slowing of cognitive decline b}
Determination of rtk and benefit
Therapeutic index (lethal dose for 50% of the
population d ivided by effective dose for 50%)
provides a very crude measure of the safety of any
drug as used in practice. Its main limitations are:
it is based on animal toxicity data, which may not
reflect forms of toxicity or adverse reactions that
are important clinically
it takes no account of idiosyncratic toxtc reactions.
More sophisticated measures of risk-benefit analysis
for drugs in clinical use are coming into use, and
include the number needed to treat (NNT) principle.
 METHOD AND MEASUREMENT IN PHARMACOLOGY

gl\cn amount), and (b) ad ve~e e ffecll> o f de fined degree. The~e
Nlmate~ of proportions o f patie nt!> showing benefic ial o r
harmful reactions can be expressed as number needed to treat
for t v,\T: i.e. the number of patients who need to be treated in order
lor one to show the given effec t, whether beneficial or adverse). For
~xample. in a recent study of pain re lief by anti depressa nt drugs
(i.e. compared with placebo, the finding~ were: for benefit (a defined
e bel of pain relief), NNT =
3; for mino r unwanted effects, NNT
=
3; for major adverse effects, NNT 22. Thus of 100 pati ents
J~ to treated \\ith the drug, on a' erage 33 will experience pain re lie f. 33
Ia! 111ll experience minor un wanted e ffects. and 4 or 5 wilJ experience
ual maJor adverse effecl~. infom1arion that is he lpful in g uiding
oxic
therapeutic choices. One advantage of this type o f a nalys is is that
it can take into account the underl ying disease severit) in
quantifying benefit. Thu-, if drug A halves the mortality of an
o ften fatal disease (reduc ing it from 50% to 25%, say), the NNT
to save one life is 4; if drug 8 halves the mortality o f a rare ly
fatal disease (reducing it from 5% to 2.5%, say), the NNT to save
one life is 40. Notwithstanding other considerations, drug A is
= judged to be more valuable than dru g B. eve n thoug h both
reduce mortaJity by a half. Furthermore, the clinic ia n must
reaJise that to save one life with dntg B. 40 patie nts must be
exposed to a risk o f ad vcr-.c e ffecll>. w hereas only 4 are expo~ed
for eac h life saved w ith drug A .

REFERENCES AND FURTHER READING

ure of C;tnrral references
Colqui>Un D 1971 Lectures on bio<tati<tic\. Oxford
nee as l mm'H) J>rr,,. Oxford (Standard tl'\1/)(l(lk)
gtven. llnmunon.J \1 ~.O'Brien B. Stoddan G l. Torr~n<-c G W
urate~ 19'!7 \kthocb for the econonuc e aluauon of health
wt rrogramme'. Oxford Un11e"rt) Pre". Q,ford
dex is
tllldu.tn ~I>Od e.rplanauon of the pmrnptef cif
ken in p~to:,.,.,.,,n<JIIImics)
omide Kub"OI'<i B R. Sterne J A C 2003 MC<Itcal \lllti\IIC,. 2nd
aln. Bla.:l,.d l. \1alden (CIMr rmrodttrtflr) tl'ttiHi<t~
-was
~ 11mn~ \llllilltcal principles <md ml'tlrotil)
I high l tlhtJ R J. Braunhohz D 2000 Who, afmid of Thomas
B.l)t <'1 J Eptdemiol Community llenlth 54:73 1- 739
ll~pl11m' tlrt smutiples of Bawsian mwlv.fi.f in a
oncept
non "111htrnat;col ~'ll)')
:.eudo- \1 le) T. Ha)c"OCh i\ 1997 PhannacoeconomrC\. ba;ic
ICasurc CtlllttJ'I' and tenninology. Br J Chn PhatmJcol 43:
}.1}-)4~ ct'~fitl tntrodllction lo mwl\11<'111 [lrmnples
111m ctt ~comm~ increa<in~/.1 lmp<>rllllll for
dl<roptlltlc poltn maJ.er1 ).
'~'""~ \1. Kunlura H. Kimura Setal. 198!1 A
IIO'ti !"~<DI asocoostnctor peptide produced by
1a ularcndc>thclial cells. Nature 332 41 1-1 15
r dntgs 1/ht jrwpapa d~scribin,g endotltelin 11 rt'lltt/f/..abll'
usefu l lull ch<lfcl<'lerisarion of on imfll>rllmt new metlittlor)
1ion o f lll~>a11ay
l ~. I M. Meh ner M J 1987 St31bt icnl mcthod> and
:d level
the I1J11lbcauon; of btoa-..ay. Annu Rev Pharmacol 27:
ief to a
lS5 \971(,.-fu/ references for tlto.rr concerrr~d with
IC by a 1 lllprmciples of ana de.1i,~n and anoh>isl
\llimll models
Bcal MF XIOI E'perimentnl model, of Pari.m\On\
distale ' t
R"' '\euro..ci 2: 325-332 <Rrwt'l< af the
noo , ppn>ai:hes 10 prodtlctngwlrd moddf fr~r
/\IT! "" '> di>east. including tmmgrnin: olthough
tire focur i1 orr rme disorcler. tlrt' flrillciple.< appiJ
generally)
Ledem C. Veaugoi' J.\1 , Schtffmann S Net al. 1997
Aggres<l\ene>\. h)poalgc"a and high blood pres>ure
in mice lacking the adcno-.me A receptor. Nature
388: 67~76 (wmpl~ of tire liSt' of a lrunsgt>nil'
modet1o stud) rrrl'ptnr funr 111111I
\Jaerki U, H!lrm A 1996 Trnn,~cmc technology:
principles. lm J E~p Pathul 77: 247-250
(Short mil'll' artir/e)
Offennann' S. He in L (cds) 2()().1 Tran\genic model>
in phannncology. llnndb Ex p Phurmacol 159 (A
compreheiiSil't' u riev nj rt'l'iew artides tlescribing
transgenic mo11re mndf'l\ 11.1ed to Mud\ differem
pharnracnlogica/ mechan11nu am/ drH!DU states}
Plueck A 1996 Condutonal mulagenesb in mice: the
CrelloxP recomhtnJuon ')'tem lnt J E~p Palhol 77:
269- 278 (All emu~ml/tt!clmoi<>RI for allo..-in~
genes lr> be IIWched nn or off durin!! the lift>limt>
ofall anima()
Polites H G 1996 Trnn,jlcmc model application> to
drug di,coer). lm J E'p P;uhol 77: 257- 262
(Useful gmaal ,.,., .;,~,)
Rudolph U. Mochlcr II 1999 Genetically modified
animals m llharmncological rc'c:trch: future trends.
Eur J Phannacol 375: 327 337 ((iood revii'W of uses
of transgenic nnimal1 ifl!tlwrmacr>logical research.
iiiCittding app/icotifm to di 1ea.1t models)
TorneU J. Snaith M 2002 Tran.genic >y>tems in drug
discovery: from target tdcnuhcauon to humanized
mice. Drug Oi..COI TodJ) 7. 463-170
Yamada K. 'labe,hrma T 2000 Animal modch of
Al7.heimer, di..ea'\C and e1aluatron of antr-dementia
drugs. Plwmacol Ther 88: 93 113
(Good Tel'il'l< ofmott~l! of Alz)remlers dts,ase.
includin~ tran!llflliC.I)
Clinicnllrlnls
AniUrJnc RctnfarciJon Trial Research Groupl978
Sulhnp) r:vone m lhe pre1eotion of canhac death after
myo.:ardtal mfarction. ~ Eltgl J Med 298 289-295
Ctampl~ of a la111.~<cale clinirattriat)
Betablockcr Hcan Attack Trial Research Group 19H2
A r.tndornr><=d trial of propranolol m p.ucnt' w!lh
acute myocardtJI infarc11on. I. Monnhl} te\Uih.
JAM;\ 247: 1707-1714 (A triDtthat 11ar
trrmmated earf. whm clear evirlenre <if bmejit
rmt!rl/ed)
Friedman L M. r urb<:rg C D. Oe Mets 0 L 1996
Fund:uncntal' of clinical trials. 3rd edn. Mo,by.
St Louis CStatulard te~tbook)
I lt<lhjnn,o;on A. Grot<.ehe P C 2001 Is the placebo
pow eric"1 An nnaly;is of clinical triah compJnng
placebo w11h no treatmcnL ~ Engl J ~led 344
1594-160 I (:\11 mrportalll sunl') of clintta/ mal flaw.
"hich 1h0\11. mntmr) /o l'Otnml>ll beliey. thm
plm l'l>nr 111 ~cnerul hem no significant 'ffut on
du11wl flll/n>me. except-to a small ttef!.ree- m parn
reltt'f trwls)
Naylor C D 1997 Meta-analysis and the meta
Cl'idcmtology of clmical re;,earch. Br Med J 315:
6 17- 6 19 (Tlrollglrtjrtl review on tire .>lrt'fll/th\ tuul
weak"""'' 1!{ meraarralysis)
Sackcll D 1., Ro;enburg W M C. MutrOray J A ct nl.
1996 l!vidcncebased medicine: what i1 is and what it
i~nt. Br Med J 312: 71 - 72 (8alonced acwunt of/he
IYllue r>f cvidcncc-hal.Cd medicine-an mrportant
fi'Unt trrnd m medlt:OIIhtnking)
Sptej!elhalter D J. \lyle> J P. Jones D R. Abrnm' K R
1999 An Introduction to Bayes~an method\ m health
tc.:hnolog) d''<!\>lllCDI. Br Med J 319:508- 512
<Short nmHnmllmwucatexplnnatirm tif tlr~ Btll~\lll/1
llflprtHit:lt to dtllo tmal)sisl

1Y

' not
hat

tions.
lysis

)le.
97
 Absorption and
distribution of drugs

long-distance distribution system. In contra.<,t, diffu\iOill..

Overview 98 characteri!>tics differ markedly between different drugs. It
Translocation of drug molecules 98 particular, ability to cross hydrophobic diffusion barrier~
-The movement of drug molecules across strongly influenced by lipid solubility. Aqueous diffusion is al>.
cell barriers 98 part of the overall mechanism of drug transport, because it 11
-Binding of drugs to plasma proteins 102 this process that delivers drug molecules to and from the nll
-Partition into body fat and other tissues 103 aqueous barriers. The rate of diffusion of a substance depen-:
mainly on its molecular size, the diffusion coefficient for srru..:
Drug disposition 104 molecules being inversely proportional to the square root
Drug absorption 104 molecular weight. Consequently, while large molecule!> diffu>~
- Routes of administration 104 more slowly than small ones, the variarion with molecu lar wcigl:'
- Distribution of drugs in the body 108 is modest. Many drugs fa ll within the molecular weight r.tng.
200-1000, and variations in aqueous diffusion rate have onI)
Special drug delivery systems 110 small effect on their overall pharmacokinetic behaviour. For roo
purposes. we can regard the body as a series of interconnectt
well-stirred compartments within each of which the dru
concentration is uniform. l t is movement beLween compartmenh
generally involving penetration of non-aq ueous diffmiu
barriers, that determines where, and for how long, a drug will~
OVERVIEW present in the body after it has been administered. The anal)'
of drug movements with the help of a simple compartmenu
In order to work, drugs need to achieve an
model is discussed in Chapter 8.
adequate concentration in their target tissues. The
two fundamental processes that determine the
concentration of a drug at any moment and in any THE MOVEMENT OF DRUG MOLECULES
region of the body are: ACROSS CELL BARRIERS
translocation of drug molecules Cell membranes form the barriers between aqueous corr
chemical transformation. partrnents in the body. A single layer of membrane !>eparat:.
the intracellular from the extracellular compartments. 1.
In this chapter, we discuss drug translocation and
epithelial barrier, such as the gastrointestinal mucosa or ren
the factors that determine absorption and
tubule, consists of a layer of cells tightly connected to ea:.
distribution. These are critically important for
other so that molecules must traverse at least two cell mcmbran:
choosing appropriate routes of administration, and
(inner and outer) to pass from one side to the other. Vasco
this aspect is emphasised. Chemical transformation
endothelium is more complicated, its anatomical disposiu.
by drug metabolism and other processes involved
and permeability varying from one tissue to another. G
in drug elimination are described in Chapter 8.
between endothelial cells are packed with a loose matrix
proteins that act as filters, retaining large molecules ru:
TRANSLOCATION OF DRUG MOLECULES letting smaller ones through. The cut-off of molecular si~
is not exact: water transfers rapidly whereas molecules c
Drug molecules move around the body in two ways: 80 000- 100 000 Da transfer very slowly. In some orgat
especially the central nervous system (CNS) and the placeli
bulk flow (i.e. in the bloodstream)
there are tight junctions between the cells, and the endothcli
diffusion (i.e. molecule by molecule, over short distances).
is encased in an impermeable layer of periendothelial ce
The chemical nature of a drug makes no difference to its transfer (pericytes). These features prevent potentially harm!
98 by bulk flow. The cardiovascular system provides a rapid molecules from leaking from the blood into these org<~;.
 ABSORPT ION AND DISTRIBUTION OF DRUGS

and have major pharmaeokinetic consequences for drug

dl,tribUtiOn. 1 Diffusion
Diffusion through
In other organ~ (e.g. the liver and spleen) endothelium is through aqueous
dt..continuous. allowing free passage between cells. In the liver. lipid channel Carrier
hcpatOC)tes form the barrier between intra- and extravac;cular 0 0 0
companment:. and take on several endothelial cell functions.
EXTRACELLULAR I
Fene-.trated endothelium oceurc; in endocrine glands, facilitating I I
y
y
tran,fer to the bloodstream of hormones or other molecules 0
through pore~ in the endothelium. Angiogenesis of fenestrated
endothelium is controlled by a specific endocrine gland-derived MEMBRANE 1iii :iiiiiiilt: lti11i 'H
\ii...CUiarendothelial growth factor (dubbed EG-VEGF). Endothelial
cells lining postcapillary venules have specialised functions relating
iilllllill ;
I I
I
0
I
ll
I
Jsional to leucocyte migration and inflammation: the sophistication of INTRACELLULAR
y y
gs. ln 1he mterccllular junction can be appreciated from the observation
iers is
is also
,c it is
1e non-
~epends
r small
that leucocyte migration can occur without any detectable leak of
1\atcr or small ions (see Ch. 13).
Thcr~ arc four main ways by which small molecules cross cell
m~rnbrancs (Fig. 7.I):

by diffusing directly through the lipid

l Fig. 7.1

pinocytosis.)
Routes by which solut es can traverse cell
membranes. (Molecules can also cross cellular barriers by

by dtiTusing through aqueous pores formed by special

root of
proteins ('aquaporin~') that traverse the lipid
diffuse temperature), and consequently diffuse readily across cell mem-
by combination with a transmembrane carrier protein that
weight branes. The number of molecules crossing the membrane per unit
bind\ a molecule on one side of the membrane then changes
t range area in unit time is determined by the permeabiliry coefficient, P.
conformation and relea:,es it on the other
only a and the concentration difference across the membrane. Permeant
b) pinOC}tO\i<,.
or most molecules must be pre!>ent within the membrane in -;ufficient
mected Of the~e routes. diffusion through lipid and carrier-mediated numbers and mu\t be mobile within the membrane if rapid
e drug tralllfiOrt arc panicularly important in relation to pharmacokinetic permeation ic; to occur. Thus two physicochemical factors contribute
tments. me~ham'm'. Diffusion through aquaporins (membrane glyco- toP. namely solubility in the membrane (which can be expressed
ffusion protein' that can be blocked by mercurial reagents such as para- as a partition coefficient for the substance distributed between the
will be hloromercurobentene sulfonate) is probably important in the membrane phase and the aqueous environment) and diffusivity,
malysis tran,ferof gase~ ~uch as carbon dioxide, but the pores are too small which is a measure of the mobility of molecules within the lipid
I mental tn dtameter (about 0.4 nm) to allow most drug molecules (which and is expressed as a diffusion coefficient. Among different drug
u~ually exceed 1 nm in diameter) to pass through. Consequently, molecules, the diffusion coefficient varies only slightly, as noted
drug distribution is not notably abnormal in patients with genetic above. so the most important variable is the partition coefficient
di,~asc~ affecting aquaporins. Pinocytosis involves invagination (Fig. 7.2). Consequently, there is a close correlation between
of pan of the cell membrane and the trapping within the cell of a lipid solubility and the permeability of the cell membrane to
'mall vesicle containing extracellular constituents. The vesicle differen t substances. For this reason, li pid solubility is one of the
s eom- contents can then be re lea~ed within the cell, or extruded from most important determinants of the pharrnacokinetic characteristics
:parates "'other .,ide. This mechanism appears to be important for the of a drug, and many properties-such as rate of absorption from
us. An tr.tn,pon of some macromolecules (e.g. insulin, which crosses the gut, penetration into the brain and other tissues, and lhe
)r renal ~11: blood {)rain banier by this process), but not for small molecules. extent of renal elimination--can be predicted from knowledge of
to each Diflu,ion through lipid and carrier-mediated transport will now a drug's lipid solubility.
nbranes 1>e di,cu\\ed in more detail.
iascular pH and ionisation
position One important complicating factor in relation to membrane
DIFFUSION THROUGH LIPID permeation b that many drugs are weak acids or bases, and
r. Gaps
atrix of :-.on-polar moleculel> (in which electrons are uniformly distributed) therefore cxi!>l in both unionised and ionised form, the ratio of
les and di,,ohe freely in membrane lipids (which are liquid at body the two forms varying with pH. For a weak base. the ionisation
Jar size reaction is
ules of
organs.
1laeenta. Th1' i' illu,trated by waan and spec1es differences. For example, collie dogs
l:x:k the rnuiL1drug re,bt<lnce gene (mdrl) and a P-glycoprmein that contributes and the dissociation constant pK, is given by the
)thelium
tmpon~ntl} to the blood- brain bnrrier ('ee p. I02), with important Henderson-Hasselbalch equation
ial cells ,on,cqucncc' for veterinary medicine because ivermectin (an anthelminthic
harmful [BWl
organs
drug. Ch. 50. p. 715) i' con,equcntly severely neurotoxic in the many
bre~tb with collie ancewy (sec Mealey et al., 200t; Neff et al., 2004).
pK" = pH + log1 0 [B] 99
 SECTION 1 GENERAL PRINCIPLES

pH partition and ion trapping

I AJ .----------,-.....------,

g
01
2
"0
0
Compartment 1
(extracellular)
Membrane Compartment 2
(intracellular)
Ionisation affects not only the rate at which drugs
membranes but also the steady-state distribution of drug molccu
between aqueous compartments, if a pH difference exislS
them. Figure 7.3 shows how a weak acid (e.g. aspirin. pK. l '
and a weak base (e.g. pethidine, pK, 8.6) would be distributcJ
equilibrium between three body compartments, name!} pl~r
(pH 7.4). alkaline urine (pH 8) and gastric juice (pH 3). \Vith-
.
~
each compartment, the ratio of ionised to unionised drug
c governed by the pK. of the drug and the pH of that compartmt
g It is as~umed that the unionised species can cross the membra .
8 and therefore reaches an cquaJ concentration in each comparrme
The ionised species is assumed not to cross at aJI. The rc,ub 1
that, at equilibrium, the totaJ (ionised + unionised) concentratil
High lipid solubility of the drug wi ll be different in the two compartments, with
acid ic drug being concentrated in the compartment wi th highpH
('ion trapping'), and vice versa. T he concentration gradients proo
Compartment 1 Membrane Compartment 2 uced by ion trappi ng can theoreticaJ ly be very large if then: j,
(extracellular) (intracellular)
E[ large pH difference between compartments. Thus aspirin would~
01 concentrated more than fourfold with respect to plasma in
2 alkaline renal tubule, and about 6000-fold in plasma with re'~
"0
0 to the acidic gastric contents. Such large gradients are, howe1.
c
.Q unlikely to be achieved in reaJity for two main reasons. FiN.
~
ca> attribution of total impenueability to the charged species "
realil.tic, and even a ~mall permeability will considerably 3IL
~em
0
c
8 uate the concentration difference that can be reached. Soo
c, _________ j lc.t
body compartments rarely approach equilibrium. Neither
gastric contents nor the renal tubular fluid stands still. and
Low lipid solubility resulting flux of drug molecules reduces the concen
Fig. 7.2 The importance of lipid solubility in membrane
gradients well below the theoretical equilibrium condition Th
permeation. and ~ Figures show the concentration profile pH partition mechanism nonetheJess correctly explains SO!Ik
in a lipid membrane separating two aqueous compartments. A the qualitative effects or pH changes in different body comp..;
lipid-soluble drug (A) is subject to a much larger transmembranje ments on the pharmacokinetics of weakJy acidic or basic dru
concentration gradient (6C,.,) than a lipid-insoluble drug (B). It particu larly in relation to renal excretion and to penetration ofUt
therefore diffuses more rapid ly, even though the aqueous
blood- brain barrier.
concentration gradient (C 1-C.J is the same in both cases.
pi I partition is not the main determinant of the site
absorption of drugs from the gastrointestinal tract. This is becau
the enormous absorptive s urface area of the villi and microvilli
the ileum compared with the much smaller surface area in lh
For a weak acid: stomach i!> of overriding importance. Thus absorption of an an
K. drug such as as pirin is promoted by drugs lhat accelerate ga.1t
AH ~A+ W emptying (e.g. m etoclopramide; see pp. 392-393) and retaro.
by drugs that s low gastric emptying (e.g. propantheline: ,
rAHl
pK. = pH + log10 [A-] p. 395), dc!>pite the fact that the acidic pH of the stomach c.
tents favours absorption of weak acids. VaJues of pK. for-.
In either ca~e. the ionised species. BH+ or A-. bas very low lipid common drugs are shown in Figure 7.4.
solubility and is virtually unable to permeate membranes except There are <;everal important consequences of pH partition.
where a specific transport mechanism exists. The lipid solubility
of the uncharged species. B or AH. depends on the chemical Urinary acidification accelerates excretion of weak basesw
nature of the drug: for many drugs, the uncharged species i<; retard<, that of weak acids.
sufficiently lipid-soluble to permit rapid membrane permeation, Urinary alkalinisation has the opposite effects: it reduce~
although there are exceptions (e.g. aminogJycosidc antibiotics; excretion or weak bases and increases excretion or weak oo
see Ch. 46) where even the uncharged molecule is insufficiently lncrca<;ing plasma pH (e.g. by administration of sodium
lipid-soluble to cross membranes appreciably. This is usually bicarbonate) causes weakly acidic drugs to be extracted fro
because of the occurrence of hydrogen-bonding groups (such as the CNS into the plasma. Conversely, reducing plasma pH
hyd roxyl in sugar moieties in ami noglycosides) that render the (e.g. by adm inis tration of a carbonic anhydrase inhibitor su.
100
......----- unc harged molecule hydrophilic. as acetazo la mide; see p. 375) causes weakJy acidic drugs t
 ABSORPTION AND DISTRIBUTION OF DRUGS

meate Gastric juice Plasma Urine

ecules pH3 pH 7.4 pH 8
tween
I 3.5): >400
tted a t
las rna
,\I thin Aspirin
rug is
Weak acid
uncnt. pK8 3.5
brane .
unent.
~ult i<>
c: U ndissociated
tration 0
acid
rith an ~ < 0.1 AH...____.._.....
gh pH c<ll
()
Fig. 7.3 Theoretical partition of
, prod- () ~----------------+-----------------~--------------~
:re is a a weak acid (aspirin) and a w eak
<ll
base (pethidine) between aqueous >
uld be
compartments (urine, plasm a a nd ~
in an gastric juice) according to the pH
Q)
a:
-espect difference between them .
wever. Numbers represent relative
rst. Lhe coocentrattons (total plasma Pethidine
concentration= 100). It is assumed
is not
that the uncharged species in each Weak base
auen- case can permeate the cellular pK8 8.6
oecond. battier separating the
Free

u
1er Lhe compartments, and therefore
100 Protonated base B
reaches the same concentration in
~~!\
md the
nration
1. The
ome of
all three. Variat1ons in the fractional
IOfllsation as a function of pH give
nse to the large total concentration
differences w1th respect to plasma. - L______!,_.______!....._-
D : "-6
30
/
)

Impart-
drugs.
1 of the

~ite of Bases Acids

>ecau se Weak
willi in Chloroqu lne -.......JtT.l~~rr'!:l',-'':;;"'i

1 in Lhe Desmethyllmipramlne Ascorbic acid

1 acidic Amphetam ine 11
gastric Atropine
Histam ine 10
etarded
ne: see 9
:b con- Phenytoin
lr some 8 Thiopental
Phenobarbital
Noradrenaline (norepinephrine) 7
ion.
Morphine 6
Sulphamethoxazole
.es and Ergometrine
5

:es 4
~acids.
Aspi ri n
Probenec id
m 3
Penicillins
-d from
2 Levodopa
tpH Fig. 7.4 pK1 values for some
.or suc h acidic and basic drugs.
Weak
101
11gs to
 SECTION 1 .. GENERAL PRINCIPLES
become concentrated in the CNS, increasing their
neurotoxicity. This has practical consequences in choosing a
means to alkalinise urine in treating aspirin overdose (see
p. 119): bicarbonate and acetazolamide each increase urine
pi I and hence increase salicylate elimination, but bicarbonate
reduce~ whereas acetazolamide increases distribution of
salicylate to the C S.
CARRIER-MEDIATED TRANSPORT
Many cell membranes possess specialised transport mechanisms
that regulate entry and exit of physiologically important
molecules, such as sugars, amino acids, neurotransmitters and
metal ions. Generally. such transport systems involve a carrier
molecule, i.e. a tran smembrane protein that binds one or more
molecules or ions, changes conformation. and releases them on
the other side of the membrane. Such systems may operate purely
passively, without any energy source; in this case, they merely
facilitate the process of transmembrane equilibration of the tran s-
ported species in the direction of its electrochemical gradient,
and the mechanism is called facilitated diffusion. Alternatively,
they may be coupled to the electrochemical gradient of Na+: in
this case, transport can occur against an electrochernicaJ gradient
and is called active transport. Carrier-mediated transport, because
it involves a binding step, shows the characteristic of saturation.
With simple diffusion. the rate of transport increases directly in
proportion to the concentration gradient, whereas with carrier-
mediated transport the carrier sites become saturated at high ligand
concentrations and the rate of transport does not increase beyond
this point. Furthermore, competitive inhibition of transport can
occur in the presence of a second ligand that binds the carrier.
Carriers of this type are ubiquitous, and many pharmacological
effects are the result of interference with them. Thus nerve
terminals have transport mechanisms for accumulating specific
neurotransmitters, and there are many examples of drugs that act
by inhibiting these tran sport mechanisms (see Chs 10, 11 and 32).
From a general phannacokinetic point of view, however, there
are only a few sites where carrier-mediated drug tran sport is
important, the main ones being:
the blood- brain barrier
the gastrointestinal tract
the renal tubule
the biliary tract
the placenta.
P-glycoprotein (the drug transporter responsible for multidrug
re~istance in neopla!>tic cells; p. 731) is present in ren al tubular
brush border membranes, in bile canaliculi. in astrocyte foot
processes in brain microvessels, and in the gastrointestinal tract.
It plays an important part in absorption. distribution and elimination
of many drugs. The characteristics of transport systems are
discussed later, when patterns of distribution and eliminati on in
the body as a whole arc considered more fully.
Tn addition to the processes so far described, which govern
the transport of drug molecules across the barriers between
different aqueous compartments, two additional factors have a
102
major influence on drug distribution and elimination. These arc:
binding to plasma proteins
partition into body fat and other tissues.
BINDING OF DRUGS TO PLASMA
PROTEINS
At therapeutic concentrations in plasma, many drugs exist maud~
in bound form. The fraction of drug that is free in aqueous soluua
can be as low as I %. the remainder being associated with pJa,m;
protein. It is the unbound drug that is pharmacologically acmt
The most important plasma protein in relation to drug binding
albumin. which binds many acidic drugs (e.g. warfarin (~<.
p. 338), non-steroidal anti-inflammatory drugs, sulfonamide
and a smaller number of basic drugs (e.g. tricyclic antidepressan
and chlorprom azine: sec p. 55 J). Other plasma protein
including ~-g lobulin and an acid glycoprotein that increases i
inflammatory disease, have also been implicated in the bindin,
of certain basic drugs, such as qui nine (see p. 706).
The amount of a drug that is bound to protein depends on thrtt
factors:
the concen tration of free drug
its affinity for the binding sites
the concentration of protein.
As a first approximation, the binding reaction can be regarll
as a simple association of the drug molecules with a fin
population of binding sites. exactly analogous to drug-recep!
binding (see Ch. 2).
Movement of drugs across cellular
barriers
To traverse cellular barriers (e.g. gastrointestinal
mucosa, renal tubule, blood-brain barrier, placenta),
drugs have to cross lipid membranes.
Drugs cross lipid membranes mainly (a) by passive
diffusional transfer and (b) by carrier-mediated transfer.
The main factor that determines the rate of passive
diffusional transfer across membranes is a drug's lipid
solubility. Molecular weight is less important.
Many drugs are weak acids or weak bases; their state
of ionisation varies with pH according to the
Henderson-Hasselbalch equation.
With weak acids or bases, only the uncharged
species (the protonated form for a weak acid, the
unprotonated form for a weak base) can diffuse
across lipid membranes; this gives rise to pH partitior
pH partition means that weak acids tend to
accumulate in compartments of relatively high pH,
whereas weak bases do the reverse.
Carrier-mediated transport (e.g. in the renal tubule,
blood-brain barrier, gastrointestinal epithelium) is
important for some d rugs that are chemically related
to endogenous substances.
 ABSORPTION AND DISTRIBUTION OF DRUGS

D + s DS so can cause hannful effects by displacing other drugs or, in

free binding complex premature babies. bilirubin (Ch. 52, p. 747). Much has been
drug site made of binding inter.1ctions of this kind as a source of untoward
drug interactions in clinical medicine, but this type of
The u~ual concentration of albumin in plasma is about 0.6 mmoVl competition is les~ important than was once thought (see Ch. 52).
(4g1100ml). With two sites per albumin molecule, the drug-
, main!) bindmg capacity of plasma albumin would therefore be about
solution PARTITION INTO BODY FAT AND OTHER
11 mmol/1. For moq drugs. the total plasma concentration required
plasma TISSUES
for a climcal effect is much less than 1.2 mmoVL so with usual
' active. therapeutic do,es the binding sites are far from saturated, and the Fat represents a large, non-polar compartment. In practice, this is
nding is concentration bound [DSJ varies nearly in direct proportion to important for only a few drugs, mainly because the effective
in [see the free concentration lDJ. Under these conditions, the fraction fat:water partition coefficient is relatively low for mo!.t drugs.
ami des) oound, IDSI!(IDJ + lDSJ), is independent of the drug concen- Morphine (see p. 596), for example, although quite lipid-soluble
ressants tmtion. However, some drugs, for example tolbutamide (Ch. 26) enough to cross the blood-brain barrier, has a lipid:water partition
roteins. and some sulfonamides (Ch. 46), work at plasma concentrations coefficient of only 0.4, so sequestration of the drug by body fat
!ases in at \\hich the binding to protein is approaching saturation (i.e. on is of little importance. T hiopental (p. 532), by comparison
binding the tlat part of the binding curve). This means that adding more (fat:watcr partition coefficient approximately 10), accumulates
drug to the pla~ma increases its free concentration disproportion- substanti al ly in body fat. This has important consequences that
on three ately. Doubling the dose of such a dmg can therefore more than limit its usefulness as an intravenous anaesthetic to short-term
uoublc the frl!e (pharmacologically active) concentration. This is initiation ('induction') of anaesthesia (Ch. 36).
lllu,trated in Figure 7.5. The ~:.econd factor that limits the accumulation of drugs in
Bmding sites on plasma albumin bind many different drugs, so body fat is its low blood supply-less than 2% of the cardiac
compctllion can occur between them. If two drugs (A and B) output. Consequently, drugs are delivered to body fat rather slowly,
compete m this way. admini!>tration of drug B can reduce the and the theoretical equilibrium distribution between fat and body
egarded protem bmdmg, and hence increase the free plasma concentration, water is approached slowly. For practical purposes. therefore,
a finite ol drug A. To do this. drug B needs to occupy an appreciable partition into body fat when drugs are given acutely is important
receptor lracuon of the bmding sites. Few therapeutic drugs affect the only for a few highly lipid-soluble drugs (e.g. general anae!.thetics:
hmdmg of other drugs because they occupy, at therapeutic Ch. 36). When lipid-soluble drugs arc given chronically, however,
rl.t,ma concentrations, only a tiny fraction of the available sites. accumulation in body fat is often significant (e.g. benzodiazepines:
Sulfonamide' (Ch. 46) are an exception, because they occupy Ch. 37). Furthennore, there are some environmental contaminants
JOOUt 50</r of the binding sites at therapeutic concentrations and ('xenobiotics'). such as insecticides. that are poorly metabolised.
If ingested regularly, 1.ucb xenobiotics accumulate slowly but
progressively in body fat.
Body fat is not the only tissue in which drugs can accumulate.
800 100
C hlor oquine- -an antimalarial drug (Ch. 49) used additionally to
ta), s
0 s0 treat rheumatoid arthritis (Ch. 14)-has a high affinity for melanin
E E
~ and is taken up by tissues such as retina that are rich in melanin
ve c I
.:;
0 600 I c granules, which may account for the retinopathy that can occur
0
1sfer. ~
I .;::;
I
~
ve c: I

g
I
'E
Q)
ilipid I 0
c
8 400
I
I
0
Q)
c I
I 50 0
Q)
Binding of drugs to plasma proteins
state c
.,
0 I
N I 0
I N

E I
I <0
3 Plasma albumin is most important; ~-globulin
>. I .0
and acid glycoprotein also bind some drugs.
c
Q) 200 I
I
Free >-
c
I CJ)
.t:
c. I .c Plasma album1n binds mainly acidic drugs
I a.
,, (approximately two molecules per albumin molecule).
'0
c CJ)
:1
__ .... , , ~ Basic drugs may be bound by ~-globulin and acid
trtion.
&:
glycoprotein.
200 400 600 800 Saturable binding sometimes leads to a non-linear
-!, Total phenylbutazone relation between dose and free (active) drug
concentration (f.lmoVI)
concentration.
fe, Fig. 7.5 Binding of phenylbutazone to plasma albumin. Extensive protein binding slows drug elimination
The graph shows the disproportionate increase in free (metabolism and/or glomerular filtration).
concentration as the total concentration increases, owing to
Competition between drugs for protein binding can
the bindlllg sites approaching saturation. (Data from Brodie 8,
Hogben C A M 1957 J Pharm Pharmacol 9: 345.) lead, rarely, to c linically important drug interactions.
103
 during prolonged treatment of patients with rheumatoid disease.
Tetracyclines (Ch. 46) accumulate slowly in bones and teeth,
because they have a high affinity for calcium, and should not be
used in children for this reason. Very high concentrations of
a miodaro ne (an antidysrhythmic drug: Ch. 18) accumulate in
li\er and lung. where they can cause adverse effects of (respectively)
hepatitb and interstitial fibrosis.
DRUG DISPOSITION
We will now con~ider how the physical processes described
above-diffusion, penetration of membranes, binding to plasma
protein, and partition into fat and other tissues-influence the
overall disposition of drug molecules in the body. Drug disposition
is divided into four stages:
absorption from the site of administration
distribution within the body
metabolism
excretion.
Absorption and distribution arc considered here. metabolism and
excretion in Chapter 8. The main routes of drug administration
and elimination are shown schematically in Figure 7.6.
DRUG ABSORPTION
ROUTES OF ADMINISTRATION
Absorption is defined as the passage of a drug from its site of
administration into the plasma. It is therefore important for all
routes of administration, except intravenous injection. There arc
instances, such a.~ inhalation of a bronchodilator aerosol to treat
asthma (Ch. 23), where absorption as just defined is not required
for the drug to act, but in most cases the drug must enter plasma
before reach ing its site of action.
The main routes of administratio n are:
oral
sublingual
rectal
application to other epithelial surfaces (e.g. skin. cornea,
vagina and nasal mucosa)
inhalation
injection
-subcutaneous
-intramuscular
- intravenous
-intrathecal.
ORAL ADMINISTRATION
Most drugs are taken by mouth and swallowed. Liule absorption
occurs until the drug enters the small intestine.
Drug absorption from the intestine
The mechanism of drug absorption is lbe same as for other
104
epithelial barriers, namely passive transfer at a rate determined
by the ionisation and lipid solubility of the drug molecule
Figure 7.7 shows the absorption of a series of weak acid~.
base'> as a function of pK. A'S expected, strong bases of pK, I
or higher are poorly absorbed, as are strong acids of pK.Ie~\
3, because they are fully ionised. The arrow poison curare
by South American Indians contained quaternary ammom~
compound.' that block neuromuscular transmission (Ch. 10). ~
strong ba~es are poorly absorbed from the gastrointestinal IIi
so the meat from animals killed in this way was safe to eat
There are a few instances where intestinal absorption depe
on carrier-mediated transport rather than simple lipid diffu,
Examples include levodopa. used in treating Parkinson's di~ea
(sec Ch. 35), which is taken up by the carrier that normal!
transports phenylalanine, and fluorouracil (Ch. 51), a cytoto\.
drug that is transported by the system that carries natu~
pyrimidines (thymine and uracil). Iron is absorbed via specih
carriers in the surface membranes of jejunal mucosa, and calciu
is absorbed by means of a vitamin D-dependent carrier sy\tem
Factors affecting gastrointestinal absorption
Typically, about 75% of a drug given orally is absorbed in 1-3
but numerous factors alter this, some physiological and 'orne
do with the formulation of the drug. The main factor<> are:
gastrointe'\tinal motility
splanchnic blood flow
particle ~i;e and formulation
physicochemical factors.
Ga,trointel>tinal motility has a large effect. Many disorder\ (l
migraine, diabetic neuropathy) cause gastric stasis and slo" d:'-
absorption. Drug treatment can also affect motility, either redu~o
(e.g. dmgt.that block muscarinic receptors: sec Ch. I0) or increa'
it (e.g. metoclopramide, an antiemetic used in migraine to facilit.
absorption of analgesic). Excessively rapid movement of!
contents (e.g. in some forms of diarrhoea) can impair absorpii~X
Conversely, a drug taken after a meal is often more slo"l
absorbed because its progress to the small intestine is deluyc
There are exceptions, however, and several drugs (e.g. nW1n"'" 111"
see p. 16) reach a higher plasma concentration if they are
after a meal, probably because food increases splanchnic
flow. Conversely, splanchnic blood flow is greatly reduced
hypovolaemia or heart failure, with a resultant reduction of
absorption.
Particle site and formulation have major effects on ab~orpr
In 1971, patient~ in a New York hospital were found to req
unusually large maintenance doses of digoxin (Ch. 18). 1,
Mudy on normal volunteers, it was found that standard
tablets from different manufacturers resulted in grossly di
pla~ma concentrations (Fig. 7.8), even though the digoxin
of the tablets was the same, because of differences in
size. Because digoxin is rather poorly absorbed, small d
in the pharmaceutical formulation can make a large difference
the extent of absorption.
Therapeutic drugs are formulated pharmaceutically to
desired absorption characteristics. Capsules may be de~igned
remain intact for some hours after ingestion in order to
absorption, or tablets may have a resistant coating to give
 ABSORPTION AND DISTRIBUTION OF DRUGS

:ules.
'and Administration Absorption and distribution Elimination
r. 10
,than ~ - - - - - - - - - - - - Bile ~ ----- -
used .' A ',
' I
nium , _ ~ Portal __ Liver _____ -:-" ~
These y 1 system Metabolites , ....__ _..
tract. Oral or rectal --- --~ Gut ---------- -~ ~
'
t I
. - - ,..
I
, ,,:!--------- -- -~ Faeces
I

:x:nd'> :...
t I I
, , ,'
I

Jsion. , , ,, ,,
Percutaneous - - Sk1n , ,
sease ~, ,
mally ,
ltoxic
arural Intravenous ----------------,., PLASMA - ,... Breast, sweat glands - -- Milk,
~-- sweat
ecific ......... : ......
Gcium ,' ,' ;f
~tern.
k '' ,' ,'
Intramuscular -- )too Muscle - ~ ,~, & I
Brain ,': ":' 1
n J
, ""T I I
,
I
, I y
hour;, ,~ ,',' Placenta
Intrathecal - - - - - - ~ CSF ,':
me to ,,
,, ,,
: ,; Fetus
Inhalation - - - - -- - -~
Expired
Lung - - - -- - - - - ------------- - - - - - - - - - - - - - - - air

Fig. 7.6 The main routes of drug administration and eliminat ion.

~(e.g.
drug
lucing
easing 'ame effect. In ~ome cases, a mixture of s low- and fast-release not only increase the dose interval but also reduce adverse effects
;iii tate p;tmcle~" included in a capsule to produce rapid blll sustained related to high peak plasma concentrations following administration
)f gut .tbo;orplion. More elaborate pharmaceutical systems include various of a conventional formulation (e.g. flushing following regular
-ptlon. mlldifictl release preparations (e.g. a long-acting form of oifedipine, nifedipine). Osmotically driven 'minipumps' can be implanted
;Jowly \C~ pp. ~95 296, that permits once-daily use). Such preparations expcrimcmally, and some oral extended-release preparations that
layed. are used clinically use the same principle, the tablet containing
molol; an osmotically active core and being bound by an impermeable
taken membrane with a precisely engineered pore to allow drug to exit
blood in solution, delivering drug at an approximately constant rate into
:ed by the bowel lumen. Such preparations may, however, cause problems
50
,f drug related to high local concentrations of drug in the intestine (an
osmotically released preparation of the anti-inflammatory drug
rption. indome tacin, Ch. 14, had to be withdrawn because it caused
-equire s mall bowel perforation). and are subject to variations in small
. In a bowel tranl.it time that occur during ageing and with disease .
igoxin Physicochemical factors (including some drug interactions;
fferem 5 Ch. 52) affect drug absorption. Tetracycline binds strongly to
:on tent Ca2+, and calcium-rich foods (especially milk) prevent its absorption
article 2 (Ch. 46). Bile acid- binding resins such as colest yramine (used
rences to treat diarrhoea caused by bile acids) bind several drugs, for
0 2 4 6 8 10 12
!nee to example wa rfarin (Ch. 2 1) and thyroxine (Ch. 29).
PKa
When drugs are administered by mouth. the intention is
Fig. 7.7 Absorption of drugs from the intestine, as a usually that they should be absorbed and cause a systemic effect,
roduce
function of pK., for acids and bases. Weak acids and bases
rned to bul there arc exceptions. Vancomycin (p. 674) is very poorly
are well absorbed; strong acids and bases are poorly absorbed. J
delay {Redrawn from Schanker L Setal. 1957 J Pharrnacol 120: 528l_} absorbed. and is administered orally to eradicate toxin-forming
ive the Clostridium dijficile from the gut lumen in patients with 105
 SECTION 1 GENERAL PRINCIPLES
l of healthy volunteer subjects may differ substantially from Itt
2 3 4 5
Hours
Fig. 7.8 Variation in oral absorption among different
formulations of digoxin. The four curves show the mean
plasma concentrations attained for the four preparations, each
of which was given on separate occasions to four subjects.
The large variation has caused the formu lation of digoxin
tablets to be standardised since this study was published.
(From Lindenbaum J et al. 1971 N Engl J Med 285: 1344.)
pseudomembranoul> colitis (an adverse effect of broad-spectrum
anri~ticl> caused by appearance of this organism in the bowel).
M esalaz ine (p. 395) is a fommlation of 5-arninosalicylic acid in
a pH-dependent acrylic coat that degrades in the terminal ileum
and proximal colon, and is used to treat inflammatory bowel
disease affecting this part of the gut. Olsalazine (p. 395) is a
prodrug consisting of a dimer of two molecules of 5-aminosalicylic
acid that is cleaved by colonic bacteria in the distal bowel and is
used to treat patients with distal colitis.
Bioavailability
To get from the lumen of the small intesti ne into the systemic
circulat io n, a drug must not only penetrate the intestinal mucosa,
it must also run the gauntlet of enzymes that may inactivate it in
gut wall and liver. The term bioavailability (F) is used to indicate
the fraction of an orally administered dose that reaches the
syMemic circulation as intact drug, taking into account both
ab~orption and local metabolic degradation. F is measured by
determining the plasma drug concentration versus time curves in
a group of subjects following oral and (on separate occasions)
intravenous administration (the fraction absorbed following an
intravenous dose is I by definition). The areas under the plasma
concentration time cunes (AUC) are used to estimate F as
AUC,....lAUC,,,""""" AUC is estimated using the trapezoidal which need to penetrate an insect's cuticle in order to work.
rule', by calculating the area under each pair of data points as a
trapezoid (i.e. a rectangle with a triangle on top). The areas of all
the trapctoids are ~ummed, and the area from the last point to
infinite time is estimated as clasllk. where clasl is the la!>t
measured concentration and k is the elimination rate constant of
the slowest elimination phase. Bioavailability is not a characteristic
solely of the drug preparation: variations in enzyme activity of
gut wall or liver, in gastric pH or intestinal motility all affect it.
Because of this. one cannot speak strictly of the bioavailability of
106 a particu lar preparation, but only of that preparation in a given
individual on a particular occasion, and F determined in a
value determined in patients with diseases of gastrointestinal
circulatory systems.
Even with these caveats. the concept is of limited u e beaux
it relate~ only to the total proportion of the drug that reache'
~y~temic circulation and neglects the rate of absorption. If a
i!> completely absorbed in 30 minutes, it will reach a much
peak pl~ma concentration (and have a more dramatic effect)
if it were absorbed more slowly. For these reasons, regul:u
authorities- which have to make decisions about the licensing
products that are 'generic equivalents' of patented products-
importance on cvide11Ce of bioequivalence, i.e. evidence that~
new product behaves sufficiently similarly to the existing one
be substituted for it without causing clinical problems.
SUBLINGUAL ADMINISTRATION
Absorption directly from the oral cavity is sometimes usel
(provided the drug does not taste too horrible) when a
response is required, particularly when the drug is either
at gastric pi I or rapidly metabolised by the liver. Glyceryl
is an example of a drug that is often given sublingually (Ch '
Drugs absorbed from the mouth pass directly into the sy,te
circulation without entering the portal system, and so
first-pass metabolism by enzymes in the gut wall and li,er.
RECTAL ADMI NISTRATION
Rectal administration is used for drugs that are required either
produce a local effect (e.g. anti-inflammatory drugs for u...:
ulcerative colitis) or to produce systemic effects. Absorpt
following rectal administration is often unreliable, but this root
can be useful in patients who are vomiting or are unable to tal
medication by mouth (e.g. postoperatively). It is used to admini~
diazcJ>am to chi ldren who arc in status epilepticus (Ch. 401,
whom it is difficult to establish intravenous access.
APPLICATION TO EPITHELIAL SURFACES
Cutaneous administration
Cutaneous administration is used when a local effect on the
i required (e.g. topically applied steroids). Appreciable
may nonetheless occur and lead to systemic effects.
Most drugs are absorbed very poorly through unbroken
However, a number of organophosphate insecticides (see Ch.
absorbed through skin. and accidental poisoning occurs in
workers.
T A ca~e i~ recounted of a 35-year-old floriM in 1932. 'While eng.ag!d._
doing a light electrical repair job at a work bench he sat down in
on the 'teat of which some "Nico-Fume liquid .. (a 40% soluuon
nicotine) had been ~pilled. He felt the solution wet through his cloth-
the ~kin over the left buttock, an area about the size of the palm ol
hand. He thought nothing further of it and continued at hi~ work for
15 minute~. when he was suddenly seized witb nausea and faintne<
and found him~elf in a drench ing sweat. On the way to hospital he
com.ciousncsft.' He survived, just. and then 4 days later: on
 AB SORPTION AND DISTRIBUTION OF DRUGS

group lfllm the ho,p1tal he wa\ gi' en the same clothes that he had worn when ammonium ion analogue of atropine. It is used as an inhaled
)ID the ht \\a' brought in. The clothe~ had been kept in a paper bag and were bronchodilator because its poor absorption minimises systemic
'ull damp\\ here they had been wet with the nicotine solution.' The ~equel adverse effects.
1nal or
\\a' prcdi,tabl~ He \Uf\ ived again but felt thereafter unable to enter a
grtcnhou...: where mcotine w~ being sprayed'. Transdcrmal dosage
ecause fomt' of nicotine are no'~ u..ed to reduce the withdrawal symptoms that ADMINISTRATION BY INJECTION
1es the aw11npan) \toppmg ~moking (Ch. 54).
a drug Imravenous injection is the fa~test and most certain route of drug
higher Tran-.dcrmal do. age forms. in which the drug is incorporated in administration. Bolu~ injection produces a very high concentration
:t) than a ,uc~-on patch applied to the ~kin. are used increasingly, and of drug, fi~t in the right heart and lungs and then in the systemic
Jlatory \C\erJI drugs-for example oestrogen for hormone replacement circulation. The peak concentration reaching the tissues depends
sing of (Ch. 30)-arc available in this form. Such patches produce a critically on the rate of injection. Administration by steady intra-
s-lay steady rate of drug delivery and avoid presystemic metabolism. venous infusion avoids the uncertainties of absorption from other
hat the Ho,,ever, the method is suitable only for lipid-soluble drugs and sites, whi le nvoiding high peak plasma concentrations cauc;ed
one to i' relatively expensive. by bolus injection. Drugs given intravenously include several
antibiotics, anaesthetics such as propofol (Ch. 36), and d iazepam
Nasal sprays for patients with status epilepticus (Ch. 40).
Some peptide hormone analogues, for example of antidiuretic Subcutaneous or intramuscular injection of drugs usually
hormone (Ch. 24) nnd of gonadotrophin-releasing honnone (see produces a faster effect than oral administration, but the rate of
useful Ch. 30). are given as nasal sprays, as is calcitonin (Ch. 31). absorption depends greatly on the site of injection and on local
t rapid Ab~orption i'> believed to take place through mucosa overlying blood flow. The rate-limiting factors in absorption from the
ll!>table na,al-aS\ociated lymphoid tissue. This is similar to mucosa injection site arc:
nitrate O\crlying Peyer\ patche!. in the small intestine, which is also
diffusion through the tissue
:h. I 8). UDU\UUII) penncablc.
removal by local blood flow.
''temic
escape Eye drops Ab!.orption from a site of injection is increased by increased
r \l.m) drug~ are applied as eye drops, relying on absorption blood flow. Hyaluronidase (an enzyme that breaks down the
through the epithelium of the conjunctival sac w produce their intercellular matrix, thereby increasing diffusion) also increases
eiTcXt\. Dc.,irable local effects within the eye can be achieved drug absorption from the site of injection. Conversely, absorption
1\tthout cau.,ing syMemic side effects; for example. dorzolamide i!. reduced in patients with circulatory failure ("shock') in whom
ither to '' a carbonic anhydrase inhibitor that is given as eye drops to tissue perfusion is reduced (Ch. 19).
use in lm\CT ocular pressure in patients with glaucoma. It achieves this
orption 1\tthout affecting the kidney (see Ch. 24), thus avoiding the Methods for delaying absorption
~route J(ldlhiS that is cau~ed by oral administration of acetazolamide. lt may be desirable to delay absorption. either to produce a local
to take Some ~y.,temic absorption from the eye occurs, however, and can effect or to prolong systemic action. For example, addition of
ninister rNth in unwanted effects (e.g. bronchospasm in asthmatic patients adrenaline (epin ephrine)-see p. 177-to a local anaesthetic
40), in u'ing timolol eye drops; see Table I0.4 on p. 153, for glaucoma). reduces absorption of the anaesthetic into the general circulation,
usefully prolonging the anaesthetic effect. Formulation of insulin
Administration by inhalation with protamine or zinc produces a long-acting form (see Ch. 26,
Inhalation is the route used for volatile and gaseous anaesthetics p. 404). Procaine penicillin (Ch. 46) is a poorly soluble salt of
(\cc Ch. 36). the lung serving as the route of both administration penicillin; when injected as an aqueous suspension, it is slowly
Jnd elimination. The rapid exchange resulting from the large absorbed and exerts a prolonged action. Esterification of steroid
he skin ,urface area and blood flow makes it possible to achieve rapid hormones (e.g. medroxyprogesterone acetate, testosterone
.orption adju,lmenh of pla.,ma concentration. The pharmacokinetic propionate; see Ch. 30) and antipsychotic drugs (e.g. nuphenazine
heha\lour of mhalation anaesthetics is discussed more fully in decanoate; Ch. 38) increases their solubility in oil and slows
~n skin. Chapter 36. Recently, the potential of the lung as a site of absorption their rate of absorption when they are injected in an oily solution.
:h. 10). of!l(ptide., and proteins has been appreciated, and inhaled human Another method used to achieve slow and continuou absorption
)rK, are m'ulin "now available for use in diabetes mellitus (see Ch. 26). of certain steroid hormones (e.g. estradiol: Ch. 30) is the
in fann Drug, used for their effects on the lung are also given subcutaneous implantation of solid pellets. The rate of absorption
b~ mhalation. u\ually as an aerosol. Glucocorticoids (e.g. is proportional to the surface area of the implant.
1gaged in
beclomelasone dipropiona te) and bronchodilators (e.g.
n a chair \lllbutamol; Ch. 23) are given in this way to achieve high local Intrathecal injection
n of free concentrations in the lung while minimising systemic side effects. Injection of a drug into the subarachnoid space via a lumbar punc-
lothes to Ho\\CW. drugs given by inhalation in this way are usually partly ture needle is used for some specialised purposes. Methotrexate
.m of hh ah,orbed into the circulation, and systemic side effects (e.g. tremor (Ch. 51) is administered in this way in the treatment of certain
for about
ntnes~ ...
following salbutamol) can occur. Chemical modification of a drug childhood lcukaemias to prevent relapse in the CNS. Regional
J] he lost ma} minimise such absorption. For example, ipratropium, a anaesthesia can be produced by intrathecal administration of a
jischarge muscarinic receptor antagonist (Chs I0 and 23), is a quaternary local anaesthetic such as bupivacaine (see Ch. 44); opiate 107
 SECTION 1 GENERAL PRINCIPLES

analge-.ic~ can also be u~ed in this way (Cb. 41). Baclofen

(a GABA analogue: Ch. 33) is used to treat disabling muscle
~pa'>ms. It ha~ been administered intratbecally to minimise its
advc~c effect\. Some antibiotics (e.g. aminoglycosides) cross
the blood bmin barrier very slowly, and in rare clinicall>ituations
where they are e~~ential (e.g. nervous system infections with
bacteria resbtant to olher antibiotics) can be given intrathecally
or directly into the cerebral ventricles via a reservoir.
DISTRIBUTION OF DRUGS IN THE BODY
BODY FLUID COMPARTMENTS
Body water is di!>tributed into four main compartments, as shown
in Figure 7.9. The total body water as a percentage of body
weight varies from 50 to 70%. being rather less in women than
in men.
Extracellular tluid comprises the blood plasma (about 4.5%
of body weight), interstitial tluid (16%) and lymph (1.2%).
Intracellular fluid (30-40%) is the sum of the fluid contents of
all cells in the body. Transcellular fluid (2.5%) includes the
cerebrospinal, intraocular, peritoneal. pleural and synovial fluids,
and dige'>tive secretions. The fetus may also be regarded as a
special type of tran~cellular compartment. Within each of these
aqueous compartments, drug molecules usually exist both in free
solution and in bound form: furthermore, drugs that are weal-.
acids or ba<;e~ will exbt as an equilibrium mixture of the charged
and uncharged form~. the position of the equilibrium depending
on the pH (see pp. 99-1 00).
The equilibrium pattern of distribution between the various
compartments will therefore depend on:
permeability acrosl. tis!>ue barriers
binding within compartments
Drug absorption and bloavallability
Drugs of very low lipid solubility, including
those that are strong acids or bases, are generally
poorly absorbed from the gut.
A few drugs (e.g. levodopa) are absorbed by carrier-
mediated transfer.
Absorption from the gut depends on many factors,
including:
gastrointestinal motility
gastrointestinal pH
particle size
physicochemical interaction with gut contents
(e.g. chemical interaction between calcium and
tetracycline antibiotics).
Bioavailability is the fraction of an ingested dose of a
drug that gains access to the systemic circulation. It
may be low because absorption is incomplete, or
because the drug is metabolised in the gut wall or
liver before reaching the systemic circulation.
Bioequivalence implies tha~ if one formulation of a
drug is substituted for another, no clinically untoward
consequences will ensue.
pi I partition
fat:water partition.
To enter the tran~:.cellular compartments from the extracellu
compartment, a drug must cross a cellular barrier, a panicul.r
important example in the context of pharmacokinetics being
blood- brain barrier.

Interstitial Intracellular
water water
-16% -35%

B BBB BBBBB B

I . .I... . ....I -- I
Plasma Transcellular
water water
-5% -2%

--- __________

' Bound drug molecules
Fig. 7.9 The main body fluid compartments,
expressed as a percentage of body weight. t e ee Free drug molecules
Drug molecules exist in bound or free form in BBB
each compartment, but only the free drug is able
108
1"''~----
l to move between the compartments. Fat -20%
 GENERAL PRINCIPLES

cannot easi ly enter cells because of th eir low lipid solubilit),.:

Drug distribution
they do not traverse the blood-brain or placental barriers free!

The major compartments are:

Distribution throughout the body water
plasma (5% of body weight)
Total body water represents about 0.55 1/kg. This approxun-.1!!
interstitial fluid (16%)
the distribution of relatively lipid-soluble drugs that readil} rn
intracellular fluid (35%)
cell membranes, such as phen)10in (Cb. 40) and ethanol (Ch ~
transcellular fluid (2%)
Binding of drug out!>ide the plasma compartmen t, or partitioo
fat (20%).
into body fat, increases Vd beyond total body water. Consequem
Volume of distribution (Vc:J is defined as the volume of
there are many drugs with Vd greater than the total body volur.-<
plasma that would contain the total body content of
such as m orphine (Ch. 41 ), tricyclic antidepressants (Ch 3
the drug at a concentration equal t o that in the
and h aloperidol (Ch. 38). Such drugs are not efficiently remo~<
plasma.
from the body by haemodialysis, which is therefore unhelpful
Lipid-insoluble drugs are mainly confin ed to plasma
managing overdose with such agents.
and interstitial fluids; most do not ent er the brain
following acute dosing.
Lipid-soluble d rugs reach all compartments and may SPECIAL DRUG DELIVERY SYSTEMS
accumulate in fat.
For drugs that accumulate outside the plasma Several approaches are being explored in an attempt to impro1
compartment (e.g. in fat or by being bound t o drug delivery. They include:
tissues), Vd may exceed total body volume.
biologically erodablc microspheres
prodrug!>
antibody-drug conjugates
packaging in liposomes
Drugs distributed in the extracellular coating implantable devices.
compartment
The total extracellular volume is about 0.2 1/kg. and this is the Biologically erodable microspheres
approximate V~ for many polar compounds. such as vecuronium Microspheres of biologically erodable polymers (see Yarde &1\.
(Ch. 10), gen tamicin and carb enicillin (Ch. 46). These drugs 2004) can be engineered to adhere to mucosal epithelium m

Table 7.1 Distribution volumes for some drugs compared with volume of body fluid compartments

Volume (1/kg body weight) Compartment Volume of distribution (Vd; 1/ kg body weight) Drug{s)

0.05 Plasma 0.05-0.1 Heparin

Insulin
0.1-Q.2 Warfarin
Sulfamethoxazole
Glibenclamide
Atenolol

0.2 Extracellular fluid 0.2-Q.4 Tubocurarine

0 .4-0.7 Theophylline

0.55 Total body water Ethanol

Neostigmine
Phenytoin
1-2 Methotrexate
Indomethacin
Paracetamol
Diazepam
Udocaine {lignocaine)
2-5 Glyceryl trinitrate
Morphine
Propranolol
Digoxin
Chlorpromazine
> 10 Nortriptyline
Imipramine
110
 ABSORPTION AND DISTRIBUTION OF DRUGS

, and ~ul. Such microspheres can be loaded with drugs. including
eely. high-molecular-weight substances, as a means of improving
absorption, which occurs both through mucosal absorptive
eptthclium and also through epithelium overlying Peyer's patches.
nates Tht~ approach ha'! yet to be used clinically, but microspheres
cross made from polyanhydride copolymers of fumaric and sebacic
43). acid' b) a technique known as phase inversion nanoencapsulation
ming ha\e been used to produce systemic absorption of insulin and of
mtly. pJa,mid 0;-lA following oral administration in rats. Because drug
umc, deli,ery is a critical problem in gene therapy (Ch.55), this is
). 39) potentially momentous!
tO\ed
ful in Prodrugs
Prodrugs arc inactive precursors that are metabolised to active
metabolites; they arc described in Chapter 8. Some of the examples
in clinical usc confer no obvious benefits and have been found to
be prodrugs only retrospectively, not having been designed with
this in mind. However, some do have advantages. For example,
JrOVe the cytOtoxic drug cyclophosphamide (sec Ch. 51) becomes active
onl) aft~r it has been metabolised in the liver; it can therefore be
tak~n orally without causing serious damage to the gastrointestinal
epithelium. Levodopa is absorbed from the gastrointestinal tract
and cro\\CS the blood-brain barrier via an amino acid transport
mechani m before conversion to active dopamine in nerve terminals
mthe basal ganglia (Ch. 35). Zidovudine is phosphorylated to its
ac111e tnsphosphate metabolite only in cells containing appropriate
re1ef\e transcnptase. hence conferring selective toxicity towards
Pack. celb tnfected with IIJV (Ch. 47). ValacicloYir and famcicloYir
n the are each eMcr prodrugs of prodrugs; respectively. of aciclovir
and of penciclovir. Their bioavailability is greater than that of
xiclom and penciclovir, each of which is converted into active
metabolite~ in virally infected cells (Ch. 47).
Other problem~ could theoretically be overcome by the use of
~uitablc prodrugs; for example, instability of drugs at gastric pH,
dtr~ct gastric irritation (aspirin was synthesised in the 19th
c~ntury in a deliberate attempt to produce a prodrug of salicylic
acid that would be tolerable when taken by mouth), failure of
drug to cross the blood-brain barrier and so on. Progress with
thts approach remains slow. however, and the optimistic prodrug
designer was warned as long ago as 1965: 'he will have to bear
in mind that an organism's normal reaction to a foreign substance
is to burn it up for food'.
Antibody-drug conjugates
One of the aims of cancer chemotherapy is to improve the
selectivity of cytotoxic drugs (see Ch. 51). One interesting
possibility is to attach the drug to an antibody directed against a
tumour-specific antigen, which will bind selectively to tumour
cells. Such approaches look promising in experimental animals.
but it is sti ll too early to say whether they will succeed in humans.
Packaging in liposomes
Liposomcs are minute vesicles produced by sonication of an
aqueous suspension of phospholipids. They can be filled with
non- lipid-soluble drugs or nucleic acids (Ch. 55), which are
retained until the liposome is disrupted. Liposomes are taken up
by reticuloendothelial cells. especially in the liver. They are also
concentrated in malignant tumours, and there is a possibility of
achieving selective delivery of drugs in this way. Amphoter icin.
an antifungal drug used to treat systemic mycoses (Ch. 48), is
available in a liposomal fonnulation that is less nephrotoxic and
bener tolerated than the conventional form, albeit considerably
more expensive. ln the future, it may be possible to direct drugs
or genes selectively to a specific target by incorporating antibody
molecules into liposomal membrane surfaces.
Coated implantable devices
Impregnated coatings have been developed that permit localised
drug delivery from implants. Examples include hormonal delivery
to the endometrium from intrauterine devices, and delivery of
antithrombotic and antiproliferative agents (drugs or radiophar-
maceuticals) to the coronary arteries from stents (devices inserted
via a catheter after a diseased coronary artery has been dilated
with a balloon). Stents reduce the occurrence of restenosis, but
this can still occur at the margin of the device. Coating stents
with drugs such as sirolimus (a potent immunosuppressant; sec
Ch. 14) embedded in a surface polymer prevents this important
clinical problem.

REFERENCES AND FURTHER READING

llru( dl\lrihulion Oncluding blood-brdin bu r rier) Bauer B, HlllU A ~ S, Fncl..er G. \1tller 0 S 2005 rol~ tifcarrier and rrctpiOr-~ioted tronsport I) <t~m<

Ahboa \ J ~2 ''ti'OC)tc~ndochchal mtemcuons and
b~mlln t>.mcr rcnncabohty. J Anal 200; 62~38
Th 1188 plotm>f\pt: de>~lop$ 11ndu tlr~ inj111~nce of
cutrontl< glw. atul COII$1SIS of morr complex ti~ht
J011CIIOtutlwn on mlru <<lplllan tndmlrdia. and a
lllll!lbtr oJ pt:<'ljl< tronlport 1111d mzym~ ry.Henu
lti&h "~"'"" moluular traffic across the endothelial
ti!J. rru~\{klfl<n ('hlll'l.l('/aisllc of the 888
pltLN llf mrl11de hmh upwke mrdumi.rmJ (e.g.
C/17 I~'"""" wmn Ll wnino acre/ tr<msponer)
alldrff/IL tnuo1por1er; (e.g. P-g/ycoprotein) ...
tn.l<'thtlwl rei/; all' mvolled in ixlt!r long- and ~hon
/trm chtnural cnmmunictuiou with neighbourinR
ali<, walt tloe prrila\cllftlf ttul feet of"'"'xytes
l~m~ 1>/ fi<Orliwlur imfiOrlllnce. ')
Modulation of P-glycoprocein cr-an\port fun~uon at the
blood-brain barrier. Ep Bol Med 230: 118-127
(Rtniews mechanum.r b) which P-gl_!coprotem actml)
can be modulated. inc/11di11~ direct i11lr1bllian b1
.(ptcific comperiron. 011d fimctwnal and
transcriptional modulation)
Cooper G J. Boron W F 1998 Effect of pCMBS on the
CO, penneabtln:y of Xmop1u OOC}te~ e<pre\,ing
aquaporin I or it~ CI89S mutMt. Am J Phy-.ol 275:
CI481-C1486 (Carbon clio ride awlificatiOII li<pends
011 trcuufer via a channel cttlled aquaporin I. rather
than free dij]iuion 0.1 thought prt>lioiiJI!)
de Boer A G, van der Sandt l C J, Gaillard P J 2003 The
role of drug transponers atlhe blood brain barrier.
Ann Rev Pharm:tcol Toxicol 43; 629--656 (Revit.'ws tire
rn the bl~rain barrier; these mclude P-glyroproteil~
multiliru~rrsistance proteins I 7. nucleoside
tramponers. organic ani011 transporters. and large
ammo acid transporters. the transfemn-1 and -Z
fl't'tpton. and the scovenger Tt.'Ceptors SB-Al and SB-8f)
Doan K M M. Humphreys J E. Web\ter L 0 et al. 2002
P:lsshe permeability and P-glycopro<ein-mediated
efllux differenuate cencral nervous system (CNS) and
non-CNS marketed drug,. J PET 303: 1029--1037
(Smdy on 48 CNS anc/45 nan-CNS drugs. comporing
permet1bility and P-glycoprotei11--medimed ejJiu.x
het~<l'ell compou11ds; concl11tles that for CNS delilef),
a drug should ideally hove an in l'ilro passive
permeabilitv > I 50 11mls and not be o good
Pglycopmrein substrate)
11 1
 !he

lm.
Drug elimination and
pharmacokinetics
!O

Overview 11 3 INTRODUCTION
Introduction 11 3 Drug eliminution ill the irreversible loss of dmg from the body. It
raJ
Drug metabolism 113 occurs by two processes: metabolism and excretion. Metabolism
JDNi\l -Phase I reactions 114 involves enzymic conversion of one chemical entity to another
~'>{llnal
-Phase II reactions 116 within the body, whereas excretion consists of elimination from
Jfflt"S -Induction of microsomal enzymes 116 the body of chemically unchanged drug or its metabolites. The
-First-pass (presystemic) metabolism 117 main routes by which dmgs and their metabolites leave the body are:
-Pharmacologically active drug metabolites 117 the kidney'>
Biliary excretion and enterohe patic the hepatohiliary <>y~tem
circulation 11 8 the lungs (important for volatile/gaseous anaesthetics).
n alld
md Renal excretion of drugs and drug Most drug'> leave the body in the urine. either unchanged or as
metabolites 118 polar metabolite!.. Some drugs are secreted into bile via the liver,
.,mux but mo!.t of these are then reabsorbed from the intestine. There
-Glomerular filtration 118
- Tubulor secretion 119 arc. however, in\tances (e.g. rifampicin: see Ch. ~. p. 675) \\here
-Diffusion across the renal tubule 119 faecal lo-.~ account'> for the elimination of a substantial fraction
ttltVIl
-Renol clearance 119 of unchanged drug in healthy individuals. and faecal elimination
EfllcaC) of dn1gs such a" digoxin that are normally excreted in urine
.1Iom. .~
Pharmacokinetics 120 (Ch. 18. p. 292) become!> progres1.ivcly more important in patient~
1; -Drug elimination expressed as clearance 121 with advancing renal failure. Excretion via the lungs occurs only
-Single-comportment model 121 with highly volatile or gaseous agents (e.g. general anaesthetics;
-More complicated kinetic models 123 Ch. 36). Small amounts of some drugs are also excreted in secretions
such as milk or sweal. Elimination by these routes is quantitatively
negligible compared with renal excretion, although excretion into
u;td to milk can sometimes be important because of effects on the baby
ltJIUrl
(e.g. ~>ee McNamara & Abbassi, 2004).
>trolled
::'i-51 Lipophi lie substances are not eliminated efficiently by the
on o11d kidney (~cc p. 119). Con!>equently, most lipophilic dmgs arc
<lat.d OVERVIEW metabolised to more polar products, which are then excreted
hot
in urine. Drug metabolism occurs predominantly in the liver.
r.t.~ Uft
In the first part of this chapter, we describe the
especially by the cytochrome P450 (CYP) system. Some P450
main pathways of drug metabolism, factors that
enzymes arc extrahepatic and play an important part in the
influence drug elimination by the kidney, and
biosynthe~is of 1>teroid hormones (Ch. 28) and eicosanoids (Ch. 13 ),
biliary excretion and enterohepatic recirculation of
but here we are concerned with cataboJjsm of dmgs by the hepatic
drugs. The second part presents a simple approach
P450 sy..,tem.
to quantitative pharmacokinetics, explaining how
drug clearance determines the steady-state plasma
concentration during constant-rate drug DRUG METABOLISM
administration and how the characteristics of
absorption and distribution (considered in Ch. 7), Animals have evolved complex systems that detoxify foreign
plus metabolism and excretion, determine the time chemicals, including carcinogens and toxins present in poisonou<;
course of drug concentration in the blood before plants. Drugs arc a ~pecial case of l>UCh foreign chemicals and,
and after steady state and how these vary with like plant alkaloids. they often exhibit distinct chirality (i.e. there
diHerent dosing regimens. 113
is more than one stereoisomer). which affects their overall
 SECTION 1 !I GENERAL PRINCIPLES
metabolism. Drug metabolism involves two kinds of reaction,
known as phase I and phase II. These often, although not
invariably, occur sequentially.
Phase I reaction<; are catabolic (e.g. oxidation, reduction or
hydrolysis), and the products are often more chemically reactive
and hence. paradoxically, sometimes more toxic or carcinogenic
than the parent drug. Phase IT reactions are synthetic ('anabolic')
and involve conjugation. which usually results in inactive products
(although there are exceptions, e.g. the active sulfate metabolite
of minoxidil, a potassium channel activator used to treat severe
hyperten!>ion; Ch. 19). Phase I reactions often introduce a reactive
group. such as hydroxyl. into the molecule, a process known as
'functionalisation'. This group then serves as the point of auack
for the conjugating system to attac h a substituent s uch as
glucuron ide (Fig. 8.1), explaining why phase I reactio ns so often
precede phase II reactions. Bo th phases decrease lipid solu bi lity,
thus increasi ng renal eli mination.
Phase I and phase 11 reactions take place mainl y in the liver,
although some drugs are metabolised in plasma (e.g. hydrolysis
of s uxa mcthonium by plasma cholinesterase; see Ch. 10), lung
(e.g. various prostanoids; see Ch. 13) or gut (e.g. tyram ine,
salbutamol; Chs 9 and 23). Many hepatic drug-metabolising
enzymes, including CYP enzymes, are embedded in the smooth
endoplasmic reticulum. They are often called 'microsomal' enzymes
because, on homogenisation and differential centrifugation, the
endoplasmic reticulum is broken into very small fragments that
sediment only after prolonged high-speed centrifugation in the
microsomal fraction. To reach these metabolising enzymes in
life, a drug must cro s the plasma membrane. Polar molecules do
this less readily than non-polar molecules except where there arc
specific transport mechanisms (Ch. 7), so intracellular metabolism
is in general les~ important for polar drugs than for Lipid-soluble
drugs, and the former tend to be excreted unchanged in the urine.
Conversely, non-polar d rugs can readily access intracellular
enzymes, but are elimi nated very inefficiently by the kidneys
because of passive tubular reabsorptio n (seep. I I 9).
I
Phas e 1
Drug
Oxidation
Hydroxylation
Dealkylation
Deamination
Hydrolysis
Example
COOH
60COCH,
I 6 I 0H
114 l Fig. 8.1 The two phas es
of drug metabolism.
Aspirin
Stereoselectivity
Many clinically important drugs, such as sotalol (Ch. 18), warfaM
(Ch. 21) and cyclophosphamide (Ch. 5 I). are mixtures of ~lcr
eoisomers. L11e components of which differ not only in
pharmacological effects but also in their metabolism, which m.:
follow completely distinct pathways. Several clinicall} import;;Jt
drug interactions involve stereospecific inhibition of metabo 1
of one drug by another (Ch. 52). In some cases, drug toxiclt)
mainly linked to one of the stereoisomers, not necessaril)
pharmacologically active one. Where practicable, regulat
authorities urge that new drugs should consist of pure stereoisomen
to avoid these compl ications. 1
PHASE I REACTIONS
THE P450 MONOOXYGENASE SYSTEM
Nature, classification and mechanism of P450
en%y-mes
Cytochrome P450 enzymes are haem proteins, comprisin<
large fami ly ('superfami ly') of related but distinct enzymes
referred to as CYP followed by a defining set of number.
leuer). These enzymes differ from one another in amino
sequence, in sensitivity to inhibitors and inducing agent\, anu
the specificity of the reactions that they catalyse (sec Coon, 21
for a review). Different members of the family have distinct.
often overlapping. substrate specificities. with some enz)
acting on the same substrates as each other but at different r.
Purification of P450 enzymes and complementary 0 A
fonn the basis of the current classification, which is ba~d
1No doubt a good idea: less happily, some in the industry have perceilt'll
commercial opportunity, and 'novel' entities that are actually juq the"
isomers of well-established and safe racemates have been l icen~ed and
aggrc~sive l y marketed.
l
Phase 2
It Denvative Conjugate
Conjugation
OH
COOH
0
6o c~ I
Salicylic acid Glucuronide
 DRUG ELIMINATION AND PHARMACOKINETICS

ammo acid sequence similarities. Seventy-four CYP gene families

.rfarin ha~t: been de~cribed, of which three main ones (CYPl, CYP2 Table 8.1 Examples of drugs that are substrates for
.C stcr- P450 isoenzymes
and CYP3) are involved in drug metabolism in human liver.
their .,ample~ of therapeutic drugs that are substrates for some important
hmay Isoenzyme P450 Drug(s)
N50 isoen1ymes are shown in Table 8.1. Drug oxidation by the
JOrtant monooxygenase P450 system requires drug (substrate, 'DH'), CYP1A2 Caffeme, paracetamol (-+ NAPQI; see
:JOlism N50 enzyme, molecular oxygen. NADPH and a flavoprotein p. XXX), tacrine, theophylline
city is I~ADPH-P450 reductase). The mechanism involves a complex
tl) the C)cle (Fig. 8.2), but the overall net effect of the reaction is quite CYP286 Cyclophosphamide, methadone
Jlatory 'ltmple, namely the addjtion of one atom of oxygen (from molecular
CYP2C8 Paclitaxel, repaglinide
;omers o'ygcn) to the drug to form a hydroxyl group (product, 'DOH'),
the other atom of oxygen being converted to water. CYP2C19 Omeprazole, phenytoin

l' The P450 cn1yme have unique spectral properties. and the reduced
CYP2C9 Ibuprofen, tolbutamide, warfarin
form; combine with carbon monoxide to fonn a pink compound (hence
'P') with absorption peaks near 450 om (range 447-452 nm). The first
CYP206 Codeine, debrisoquine, S-metoprolol
clue th31there nrc multiple forms of CYP came from the observation that
tremmcnl of rut~ with 3-methylcholanthrene, an inducing agent (see
CYP2E1 Alcohol, paracetamol
450 below). cuu,es n sh ift in the absorption maximum from 450 to 448 nm.

Cytochrome P450 en1ymes have unique redox properties that are CYP3A4, 5, 7 Ciclosporin, nifedipine, indinavir, simvastatin
sing a fundamental to their diverse functions. These relate to the variable spin
\late (high/low) of the haem iron, which lies in an octahedral complex (Adapted from http://medicine.iupui.edu/flockhart/table.htm.)
'i(each
with ~ix ligand~ and within which it can adopt either a pcnta or
;and a
he,acoordinate configuration. NADPH-P450 reductase supplies one or
o acid both electron\ needed for the oxidation. and restores the redox ~tate of the
and in P450. C)clic oxidation/reduction of haem iron occurs in conjunction with
.2005, 'ub,trate bmding and Ollygen activation. The ferric iron (Fe3 ) in free
ICt. but P450 i' maml) in a low-~pm form. After bmding DH, a conformational
change con\'en' the ferric Fe ' iron to the high-spin state. making it easier
uymes Product (DOH) Drug (DH)
to reduce Reducuon from Fe3' to Fe2' is achieved by a single electron.
t rates. wh~eh "relayed from NADPH (electron donor) to P450 via tbc flavoprotein
:Joning N:\DPH P450 rcductn~e. Molecular oxygen binds tbe reduced Fe2 ' -DH
\ed on complex to form a Fe2'0r DH complex. This then accepts a second
electn>n fmm NADPH- P450 reductase (or alternatively from cytochrome
b,) wnd a proton. to yield a peroxide complex: Fe2QOH- DH. Addition of
a \C\:ond proton cleaves the Fe 2'00H- DH complex to yield water and a

l
aved a feme oxcne (f7c0)1' drug complex: (Feoi- oH. (FeO)J.. extract~ a
:active hydrogen atom from DH to form a pair of transient free radicals: D and
nd Fel'OH. D acquire\ the bound OH radical to form hydroxylated drug
(DOH), which is rclea~ed from the complex with regeneration of P450 in
11' initial state.

P450 and biological variation

There are important variations in the expression and regulation
of P450 enzymes between species. For instance, the activation
pathways of certain dietary heterocyclic amincs (formed when
meat i~ cooked) to genotoxic products involves one member of
the P450 superfamily (CYP I A2) that is constitutively present in

IH
human' and rats (which develop colon tumours after treaonent
~otth such amines) but not in cynomolgus monkeys (wruch do
noo. Such ~peciel> differences have crucial implications for the
--
NADPH-P450 reductase

Cytochrome b 5

chotec of species to be used for toxicity and carcinogenicity
tNtng during the development of new drugs for use in humans.
Within human populatjons. there are major sources of
>H tntenndi\idual variatjon in P450 enzymes that are of great
tmponance in therapeutics. These include genetic polymorphisms:
for example, one variant of the gene CYP2D6 leads to poor or
C\tcnsi\e hydroxylation of debrisoquine. Environmental factors
(Ch. 52) arc also important. Enzyme inrubitors and inducers are
present in the diet and environment. For example. a component
of grapefruit juice inhibits drug metabolism (leading to potentially
Fig. 8 .2 The monooxygenase P450 cycle. P450 containing
ferric iron (Fe:~+) combines with a molecule of drug ('DH');
receives an electron from NADPH-P450 reductase, which
reduces the iron to Fe2; combines with molecular oxygen, a
proton and a second electron (either from NADPH-P450
reductase or from cytochrome b 5) to form an Fe200H-DH
complex. This combines with another proton to yield water and
a ferric oxene (Fe0)3+-DH complex. (FeO):~+ extracts a hydrogen
atom from DH, with the formation of a pair of short-lived free
radicals (see text), liberation from the complex of oxidised drug
('DOH'), and regeneration of P450 enzyme.
115
 SECTION 1 GENERAL PRINCIPLES
disastrous consequences, including cardiac dysrhythmias;
Ch. 52, p. 748), whereas Brussels sprouts and cigarette smoke
induce P450 enzymes. Components of StJohn's wort (used ro
treat depression in alternative medicine) induce CYP450
isoenzymes and P-glycoprotein, which is important in drug
distribution and excretion (see below. and Henderson et aJ.. 2002).
Inhibition of P450
Inhibitors of P450 differ in their selectivity towards different
i~oforms of the enzyme, and arc classified by their mechanism of
action. Some drugs compete for the active site but arc not themselves
substratcl. (e.g. quinidin e is a potent competitive inhibitor of
CYP2D6 but i1> not a substrate for it). Non-competitive inhibitor!>
include dntgs such as ketoconazole, which forms a tight complex
with the Fe l+ form of the haem iron of CYP3A4, causing reversible
non-competitive inhibition. So-called mechanism-based inhibitors
require oxidation by a P450 enzyme. Examples include gestodene
(CYP3A4) and diet hylca rbamazine (CYP2El)-see p. 450 and
p. 7 15, respectively. An oxidation product (e.g. a postulated
epoxide intermediate of gcstodene) binds covalently to the enzyme,
which then destroys itself ('suicide inhibition'). Many clinically
important interactions between drugs are the result of inhibition
of P450 entymc:. (see Ch. 52, p. 742).
OTHER PHASE I REACTIONS
Not all drug oxidation reactjons involve the P450 system. For
example, ethanol h. metabolised by a soluble cytoplasmic enzyme.
alcohol dehydrogenase. in addition to CYP2El. Other P450-
indcpendent enlymes involved in drug oxidation include
:camhine oxidase. which inactivates 6-mercaptopurine (Ch. 51),
and monoamine oxidase. which inactivates many biologically
acti ve amines (e.g. noradrenaline [norepinephrine], tyramine,
5-hydroxytryptamine; see Chs II and 12).
Reductive reactions arc much less common than oxidations, but
some arc important. For example, warfarin (Ch. 2 1) is inactivated
by convers io n of a ketone to a hydroxyl group by CYP2A6.
Hydrolytic reactions (e.g. of as pirin, Fig. 8.1; see Ch. 14) do
not involve hepatic microsomal e nzymes but occur in plasma and
in many tissues. Both ester and (less readily) amide bonds are
susceptible to hydroly!>is.
PHASE II REACTIONS
If a drug molecule has a suitable 'handle' (e.g. a hydroxyl, thiol
or amino group), either in the parent molecule or in a product
resultjng from ph~ r metabolism, it is susceptible to conjugation,
i.e. attachment of a ub~tituent group. This synthetic step is called
a phase n reaction. The resulting conjugate is almost always
pharmacologically inactive and less lipid-soluble than its
precursor, and is excreted in urine or bile.
The group~ most often involved arc glucuronyl (Fig. 8.3).
sulfate, methyl, acetyl and glycyl. The tripeptide glutathione
can conjugate drug metabolites via its sulfbydryl group, as in the
detoxification of pa racetamol (see Fig. 53.1, p. 755). Glucuronide
formation involves the formation of a high-energy phosphate
116
compound, uri dine diphosphate (UDP) glucuronic acid (UDPGA),
from which glucuronic acid is transferred to an electron-ncb
atom (N, 0 or S) on the substrate, forming an amide, ester or til!
bond. UDP glucuronyl transferase, which catalyses these reacuo .
has very broad substrate specificity embracing many drug~ ..
other foreign molecules. Several important endogenous substaJl(c
including bilirubin and adrenal corticosteroids, are conjugated"'
the same sy!>lem.
Acetylation and methylcllion reactions occur with acetyl-Co.
and S-adcnosyl methionine, respectively, acting as the dorx
compounds. Many of these conjugation reactions occur in lbe
liver, but other tissues, such as lung and kidney. are also involltd
INDUCTION OF MICROSOMAL ENZYMES
A number of drugs, such as rifampicin (Ch. 46), ethanol
(Ch. 43) and carbamazepin e (Ch. 40), increase the activity tt
microsomal oxidase and conjugating systems when administere~
repeatedly. Many carcinogenic chemicals (e.g. benzpyrene
3-methyl-cholanthrene) also have tlus effect, which can ['(
substantial; Figure 8.4 shows a nearly 10-fold increase in the rat:
of ben:rpyrene metabolism 2 days after a single dose. The effe~.
is referred to as induction, and is the result of increased synthn
and/or reduced breakdown of nucrosomal enzymes-sec rec~
reviews, for example Park et at. (1996) and Dickins (2004). ~
more detail.
Enzyme induction can increase drug toxicity and camr
genicity (Park et at.. 2005), because several pha e I metabolil,
arc toxic or carcinogenic: pa racetamol is an important exam.
of a dntg with a highly toxic metabolite (see Ch. 53).
The mechanbm of induction is incompletely understood tlt
is similar to that involved in the action of steroid and ol/IC!
hormones that bind to nuclear receptors (see Ch. 3). The m;
thoroughl y !>tudied inducing agents arc polycyclic aromall.
hydrocarbons. These bind to the ligand-binding domain of
soluble protein, termed the aromatic hydrocarbon (Ah) recepto
This complex is transported to the nucleus by an Ah receptUt
nuclear translocator and binds A11 receptor response elemenN 1
the DNA, thereby promoting transcription of the gene CYPIAJ
Tn addition to enhanced transcription, some inducing agent
(e.g. ethanol. which induces CYP2E1 in humans) also stabili~r
mRNA or P450 protein.
UDP-a -gluc uronide
Glucuronyl transfer UDP-glucuronyl transferase
G=:r Glucuronide
Drug-p-gluc uro nide conjugate
Fig . 8 .3 The glucuronide conjugation reaction.
 DRUG ELIMINATION AND PHARMACOKINETICS

n-rich
lf thiol 10 Table 8.2 Examples of drugs that undergo substantial
Q)

:tions. 2 first-pass elimination

iii
~~ and ! 8
:ances. E Asp1rin Metoprolol
~
ted by :8
Ill- Glyceryl trinitrate Morphine
-Q).._
0 6
1-CoA ec: lsosorbide din1trate Propranolol
~8
donor !g 4 0.4 11mol dose
in the E'i: Levodopa Salbutamol
....
c
olved. .8 Lidocaine Verapamil
0 2

s
Q
iii
a:
0
hanoi 0 2 3 4 5 6 inswnces, metabolites have pharmacological actions simi lar to
ity of
stered
yrene,
t
Benzpyrene administered
Days those of the parent compound (e.g. benzodiazepines, many of
which fom1 long-lived active metabolites that cause sedation to
persist after the parent drug has disappeared; Cb. 37). There are
an be also cases in which metabolites arc responsible for toxicity.
Fig. 8.4 Stimulation of hepatic metabolism of benzpyrene.
1e rate Hepatotoxicity of paracetam ol i s one example (see Ch. 53), and
Young rats were given benzpyrene (intraperitoneally) in the
effect doses shown, and the benzpyrene-metabolising activity of liver bladder toxicity of cyclophosphamide. which is caused by its
uhesis homogenates was measured at times up to 6 days. (From toxic metabolite acrolein (Cb. 51. p. 724), is another. Methanol
recent Cooney A H et al. 1957 J Bioi Chern 228: 753.) j and ethylene glycol both exert their toxic effects via metabolites
4), for -----~
formed by alcohol dehydrogenase. Poi soning with these agents
is treated with ethanol (or with a more potent inhibitor), which
.rcino- competes for the active site of the enzyme. Terfenadine. a non-
JOlites FIRSTPASS (PRESYSTEMIC) METABOLISM sedating antihistamine (p. 237-238). can. rarely, cau!>e l>erious
ample cardiac dysrhythmias by blocking cardiac potassium channels. Its
Some drug~ arc extracted so efficiently by the liver or gut wall
pharmacologically active metabolite (f exofenadine) blocks
that the amount reaching the systemic circulation is considerably
:xl but histamine H 1 receptors but not cardiac potassium channels, and
lc" than the amount absorbed. This is known as first-pass or
other has now largely replaced terfenadine in therapeutic use for this
pll'I'Utemic metabolism and reduces bioavailability (Ch. 7, p. 106)
:most
even when a drug is well absorbed from the gut. Presystemic
)rna tic
mctaboli~m i~ important for many therapeutic drugs (Table 8.2
1 of a
'how~ ~ome examples). and is a problem because:
;eptor. Drug metabolism
ceptor a much larger dose of the drug is needed when it is given
! nts in orally than when it is given by other routes Phase l reactions involve oxidation, reduction
'PIA I. marked individual variations occur in the extent of first-pass and hydrolysis. They:
agents metabolism of a given drug (see Ch. 52), resulting in usually form more chemically reactive products,
abilise unpr~dictabi lity when such drugs are taken oraUy. which can be pharmacologically act ive, toxic or
carcinogenic
often tnvolve a monooxygenase system in which
PHARMACOLOGICALLY ACTIVE DRUG
cytochrome P450 plays a key role.
METABOLITES
Phase II reactions involve conjugation (e.g.
In 'omc cases (see Table 8.3). a drug becomes pharmacologically glucuromdation) of a reactive group (often inserted
aC111e only after it ha!> been metabolised. For example, during phase I reaction) and usually lead to inactive
azathioprine. an immuno~upprcssant drug (Ch. 14), is metabolised and polar products that are readily excreted.
to mercaptopurine; and enalapril, an angiotensin-converting Some conjugated products are excreted via bile, are
ent)me inhibitor (Ch. 19). is hydrolysed to its active form reactivated in the intestine and then reabsorbed
enalaprilat. Such drugs. in which the parent compound lacks ('enterohepatic circulation').
IICIIIIt) of ih own. arc lnown as prodrugs. These are sometimes Induction of P450 enzymes can greatly accelerate
de,tgned deliberately to overcome problems of drug delivery hepatic drug metabolism. It can increase the toxicity
tCh 7). Metabolism can alter the pharmacological actions of a of drugs with toxic metabolites.
drug qualitatively. Aspirin inhibits some platelet functions and Presystemic metabolism in liver or gut wall reduces
h~' anti-inn:unmatory activity (Ch 21. pp. 34 I -342: Ch. 14, t he bioavailability of several drugs when t hey are
pp. 23-1-235). It is hydrolysed to salicylic acid (Fig. 8.1 ), which administered by mouth.
ha' anti-innammatory but not antiplatelet activity. rn other 117
 SECTION 1 GENERAL PRINCIPLES

Tllble 8.3 Some drugs that produce active or toxic metabolites

Inactive (prodrugs) Active drug Active metabolite Toxic metabolite See Chapter(s):

Azathioprine Mercaptopurine 14

Cortisone Hydrocortisone 28

Prednisone Prednisolone 28

Enalapril Enalaprilat 19

Zidovudine Zidovudine trisphosphate 47

Cyclophosphamide Phosphoramide mustard Acrolein 51

Diazepam ,. Nord iazepam Oxazepam 37

Morphine ,. Morphine 6-glucuronide 41

Halothane Trifluoroacetic acid 36

Methoxyflurane Fluoride 36

Paracetamol N-Acetyl-p- 14 and 53

benzoquinone imine

reason. Hepatic necrosis is a rare but sometimes fatal
complication of halotha ne anaesthesia. lt is caused by immune
sensitisation to new antigens formed by trifluoroacetylatioo of
liver protein (Ch. 53, p. 763). Disulfiram (see pp. 632-633)
inhibits CYP2E I and reduces substantially the formation of
tritluoroacctic acid during halothane anaesthesia, raising the
intriguing possibility that it could prevent halothane hepatitis
(Kharasch el al., 1996).
BILIARY EXCRETION AND
ENTEROHEPATIC CIRCULATION
Liver cells transfer various substances, including drugs. from
plasma to bile by means of transport systems similar to those of
the renal tubule and that involve P-glycoprotein (see Ch. 7).
Various hydrophilic drug conjugates (particularly glucuronides)
arc concentrated in bile and delivered to the intestine, where the
glucuronide is usually hydrolysed, releasing active drug once
more; free drug can then be reabsorbed and the cycle repeated
(enterohepatic circulation). The effect of this is to create a 'reservoir'
of recirculating dn1g that can amount to about 20% of total drug
in the body and prolongs drug action. Examples where this
is important include morphjne (Ch. 41) and ethinylestradiol
(Ch. 30). Several drugs arc excreted to an appreciable extent in
bile. Vecuronium (a non-depolarising muscle relaxant; Cb. 10)
is an example of a drug that is excreted mainly unchanged in
bile. Rifampicin (Ch. 46) is absorbed from the gut and slowly
deacetylated, retaining its biological activity. Both forms arc
118 secreted in the bile, but the deacetylated form is not reabsorbed,
so even1ually most of the drug leaves the body in this fonn
the faeces.
RENAL EXCRETION OF DRUGS AND
DRUG METABOLITES
Drugs differ greatly in the rate at which they are excreted bylh'
kidney, ranging from penicillin (Ch. 46), which is cleared frrr
the blood almost completely on a single transit through lh:
kidney, to diazepam (Ch. 37), which is cleared extremely slow I)
Most drugs fu ll between these extremes, and metnbolites w.
nearly always cleared more quickly than the parent drug. Thret
fundamental processes account for renal drug excreHon:
glomerular filtration
active rubular secretion
passive diffusion across tubular epithelium.
G LOMERULAR FILTRATION
Glomerular capillaries allow drug molecules of molecular weif
below about 20 000 to diffuse into the glomerular filtrate. Pla~r
albumin (molecular weight approximately 68 000) is alllll
completely impermeable, but most drugs-with the exception
macromolecules such as heparin (Ch. 21)-cross the bam
freely. If a drug binds appreciably to plasma alburrun, its conce1
tration in the filtrate will be less than the total plasma conccn1rati01.
If, like warfarin (Ch. 21 ), a drug is approximately 98% bounl
to albumin, the concentration in the filtrate is only 2% of that 1
plasma, and clearance by fi ltration is correspondi ngly reduced.
 DRU G ELIMINATION AND PHARMACOKINETICS

TUBULAR SECRETION Table 8 .4 Important drugs and related substances

actively secreted Into the proximal renal tubule
Lpto20~ of renal plasma flow is filtered through the glomerulus,
lea\ ing at lea\t 80% of delivered drug to pass on to the peri tubular
A cid s Base s
capillaric~ of the proximal tubule. Here. drug molecules are
tran,ferred to the tubular lumen by two independent and relatively p -Aminohippuric acid Amiloride
non,elective carrier c;ystems. One of these transports acidic drugs
l:t\ \\ell ac; variou~ endogenou acids. such as uric acid), while the Furosemtde (frusemide) Dopamine
01her handlec; organic bases. Some of the more important drugs
Glucuronic acid conjugates Histamine
that are transported by these two carrier systems are shown in
Table 8.4. The carrier:. can transport drug molecules against an Glyc1ne conjugates Mepacrine
electrochemical gradient, and can therefore reduce the plasma
concentration nearly to L.ero. Because at least 80% of the dmg lndometacin Morphine
delivered to the kidney is presented to the carrier, tubular secretion
Methotrexate Peth idine
is potentially the most effective mechanism of renal drug
elimination. Unlike glomerular filtration, carrier-mediated transport Penicillin Quaternary ammonium
can achieve maximal drug clearance even when most of the drug probenecid compounds
ts bound to plasma protein. 2 Penicillin (Ch. 46), for example,
although about 80% protein-bound and therefore cleared only Sulfate conjugates Quinine
,(O\\Iy by filtration, is almost completely removed by proximal
Thiazide diuret ics 5-Hydroxytryptamine (serotonin)
tubular ~ccrction, and it!> overall rate of elimination is very high.
\lany drug!> compete for the same transport system (Table 8.4), Uric acid Triamterene
kJdmg to drug imcrJctions. For example, probenecid (see p. 239)
\1-:t, de\ eloped originally to prolong the action of penicillin by
retarding its tubular secretion.
Many drug!>, being weak acids or weak bases, change their
ionisation with pH (see pp. 99-1 00), and this can markedly affect
DIFFUSION ACROSS THE RENAL TUBULE
min renal excretion. The ion-trapping effect means that a basic drug
\\ater is reabsorbed as fluid traverses the tubule, the volume of is more rapidly excreted in an acid urine, because the low pH
unne emerging being only about I% of that of the glomerular within the rubule favours ionisation and thus inhibits reabsorption.
nitrate. If the tubule is freely permeable to drug molecules, some Conversely, acidic drugs are most rapidly excreted if the urine
99~ of the fi ltered drug will be reabsorbed passively. Lipid- is alkaline (Fig. 8.5). Urinary alkalinisation is used to accelerate
'oluble dmgs arc therefore excreted poorly. whereas polar dmgs the excretion of salicylate in treating selected cases of aspir in
of low tubular permeability remain in the lumen and become overdose (p. I00).
y the
pmgressivcly concentrated as water is reabsorbed. Dmgs handled
from
10 this way include digoxin (p. 292) and aminoglycoside
1 the
antibiotics. These exemplify a relatively small but important group
RENAL CLEARANCE
)W[y.
of drugs (Table 8.5) that are not inactivated by metabolism, the El imination of drugs by the kidneys is best quantified by the
;; are
rate of rl!nal elimination being the main factor that determines renal clearance (CL,). This is defined as the volume of plasma
:brec
1heir duration of action. The~e drugs have to be used with special
c:rre mindividuals whose renal function may be impaired, including
1he elderly and patients with renal disease or any severe acute Elimination of drug by the kidney
illnN (Ch. 52. pp. 740-745).
Most drugs, unless highly bound to plasma
protein, cross the glomerular filter freely.
Many drugs, especially weak acids and weak bases,
are actively secreted into the renal tubule and thus
eight lkcJU,;e hhrauon tR\ olve~ t5o~motic movement of both water and solutes.
more rapidly excreted.
d iloo 1101 allect the free concentration of drug in the plasma. Thus the
asma Lipid-soluble drugs are passively reabsorbed by
cqwl brium bct\\een free and bound drug ts not disturbed. and there is no
Imost ~ndrn.:) for bound drug 10 dtssociate a5 blood traverses the glomerular
diffusion across the tubule, so are not efficiently
on of captllal). The ra1e of cleamnce of a drug by filtration is therefore reduced excreted in the urine.
arrier dlrt<:ll} '" proponton to 1he fraction that is bound. In the case of active Because of pH partition, weak acids are more rapidly
ncen- lubul.u 'e~retion, 1h i~ i) no1 so: secre1ion may be retarded very linle even excreted in alkaline urine, and vice versa.
ation. 1hoogh lhe llrug i~ mo;tly bound. Th is is because the carrier lfanspons drug
Several important drugs are removed predominantly
mole~:ule' unaccompanied by water. As free drug molecul es are taken from
K>und lhc pla;ma, therefore. lhe free pla~ma concentration falls, causing by renal excretion, and are liable to cause toxicity in
hat in Jil'ialion of bound drug from pl a,ma albumin. Consequently, effectively elderly persons and patients with renal disease.
ced. 10or, ol 1hc drug, bound and free, is available 10 the carrier. 11 9
 SECTION 1 GENERAL PRINCIPLES

i s termed pharmacokinetics ("what the body does to the dru.

Table 8 .5 Examples of drugs that are excreted largely to distinguish it from pharmacodynamics ('what the drug doe1
unchanged in the urine
the body', i.e. events consequent on interaction of the drug 1o1
its receptor or other primary site of action). The diMincuon
Percentage Drugs excreted
useful, although the words cause dismay to etymological purN
10Q-75 Furosemide (frusemide), gentamicin, Knowledge of pham1acoki netics is crucial for drug dcvclopm'
methotrexate, atenolol, digoxin both to make sense of preclinical toxicity testing and of who
animal pharmacology,3 and to decide on an appropriate d<h
75-50 Benzylpenicillin, cimetidine, regimen for pivotal phase rn
<;tudies of efficacy. Understandioi
oxytetracycline, neostigmine
the general principle. of pharmacokinetics is also imponant ~
-50 Propantheline, tubocurarine clinicians, who need to understand how dosage recommendaiMXS
in the product information provided with licensed drug' hm
been arrived at if they are to use the drug optimally and under
stand its limitations. In particular, clinicians dealing '>'ilh
containing the amount of substance that is removed by the kidney severely ill patient often need to individualise the dose reguner
in unit time. It is calcu lated from the plasma concentration. CP, depending on how rapid ly a therapeutic plasma concentratiOn I
th e urinary concentration, c. and the rate of flow of urine, Vu, by required, and whether the clearance of the drug is impairt
the equation: because of renal or l iver disease.

CL, = C.x v. (8.1) Scope

cp
CL, varies greatly for different drugs, from less than I mllmin to
the theoretical maximum set by the renal plasma tlow, which i<;
approximately 700 m1/min, measured by p-aminohippuric acid
(PAH) clearance (renal extraction of PAH approaches 100%).
ln this section, we explain how the total clearance of a
determines its steady-~tate pla!.ma concentration during continoo:;
administration. We then present a simple model in wh1ch 1lit
body is represented a~ a single well-stirred compartment, of \Oiulll
Vd, that describes the situation before steady state is reache<l
terms of elimination half life (1 112). Three dosing situatiom .1r

PHARMACOKINETICS
Definition and uses of pharmacokinetics
The relationship between the time course of drug concentrati ons
auained in different regions of the body during and after dolling
1
For example. do~~ u~d in experimemal animals often need to b.: mocb
greater than those in humans Con a 'per unit body weight' ba~i\), ballle
drug metaboli~m is commonly much more rapid in rodenb. IS

Phenobarbital (dog) ~ Amphetamine (human)

[a weak acid] [a weak base]
50 ,...----..---.----~----.
40 Psychological
l!! response
40
~ 20-
Alkaline urine
c pH 7.8-8.0
0
~
I 3o 2
Fig. 8.5 The effect of urinary pH Q)
s0
0
on drug excretion. Phenobarbital c E
::1.
clearance in the dog as a function of ~ 20
urine flow. Because phenobarbital Q)
0
0
is acidic, alkallnislng the urine 30 Urinary
increases clearance about fivefold.
fm Amphetamine excretion in
10- s0
excretion
E 15
humans. Acidifying the urine ::1.
increases the rate of renal elimination
0 ~----~----.---------~ 0
of amphetamine, reducing its plasma 0 2 4 6 8 0 2 3 4 5 6 7
concentration and its effect on the
Urine flow (mVmin) Days
subject's mental state. (Data from
Gunne & Anggard 1974 In:
Torrell T et al. (eds) Pharmacology - - Acidic urine (pH-5)
and pharmacokinetics. Plenum,
- - Alkaline urine (pH-7)
New York.)
120
 DRUG ELIMINATION AND PHARMACOKINETICS

;ug'), on-.idercd: continuous intravenous infusion, bolus dose admin-

x:s to .,,rauon and repeated administration. Finally, we consider some A)
with ,11uations where the ~imple model is inadequate, and either a
Css Css=XICL
on is 11\o-companment model or a model where clearance varies with
1rists. drug concentration ('non-linear kinetics ' ) is needed. More detailed
ment. account, are provided by Rowland & Tozer (1995) and B irken c
1hole 1~0021: Atkmson et al. (2002) describe an alternative approach.
osing
1ding 0
DRUG ELIMINATION EXPRESSED AS
1t for (Infusion) Y mg minl nme-
CLEARANCE
uions
have The O\crall clearance of a drug (CL) is the volume of plasma
fa]
ndcr- containing the total amount of drug that is removed from the
ith a body in unit time. It is the fundamental pharmacokinetic
;imcn paramc1cr 1hat relate!> the rate of elimination of a drug to its
ion is pla\ma concentralion (C):
aired c
Rate of drug elimination = C x CL (8.2)

Drug clearance can be determined in an individual subject

by mea~uring 1he plasma concentration of the drug (in units of,
drug -.a}. mg/1) at intervals during a constant-rate intravenous infusion
fBolus (0 mg) Time-

nuous l\3) X mg/h), until a steady state is approximated (Fig. 8.6A). At

C]
h the ''~3d)
\talc, the rate of input to the body is equal to the rate of
100
)lwne elimmauon, \O:
led in
X = Css x CL (8.3)
~~ Vd:CVC
: 0

ts arc
Rearranging thi~.

CL = X (8.4)
Css
JCh
use \\here Css i~ the plasma concentration at steady state, and CL
~' m unit\ of volume/time (1/h in the example given).
For many drugs. the clearance in an individual subject is the
'arne a1 different doses (at least within the range of doses used
lherapeu1ically- but sec the Saturation kinetics section below,
pp. 124-126, for exceptions), so knowing CL enables one to cal-
culate the dose rate needed to achieve a desired steady-state
pl~'ma concentration from equation 8.3.
fBolus (0 mg) Time-
Fig. 8 .6 Plasma drug concentration-time curves.
!AI During a constant intravenous infusion at rate X mg/min,
indicated by the horizontal bar, the plasma concentration (C)
increases from zero to a steady-state value (Css); when the
infusion is stopped, C declines to zero. lm Following an
intravenous bolus dose (0 mg), the plasma concentration rises
abruptly and then declines towards zero. ~ If the data from
panel B are plotted with C on a logarithmic scale, there Is a

J
Cl can also be estimated by measuring plasma concentrat ions linear portion during which the concentration declines
~~ 1n1ervals following a single intravenous bolus dose of, say, approximately exponentially. Extrapolation of this portion of the
Qmg (fig. 8.68). curve back to the ordinate at zero time gives an estimate of C0 ,
the concentration at zero time, and hence of Vd, the volume
Q of distribution.
(8.5)

J
CL = AUC

11hcre AUC is 1he area under the curve relating C to time (see
Ch. 7. p. 106. and Birkett, 2002. for a fuller account of AUC and the body to its concentration in plasma (see Ch. 7, p. 109). The
hoY il is e\timated). quantity of drug in the body when it is administered as a single

J
bolus is equal to the administered dose Q. The initial concentration.
C0 will therefore be given by:
SINGLE-COMPARTMENT MODEL
Con,der a highly s implified model of a human being, which Co = Q
7
con,i\ts of a single well-stirred compartment, of volume Vd
vd
idl,triblllion volume), into which a quantity of drug Q is introduced In practice, C0 is eMimated by extrapolating the linear portion

L
rapidly by intravenous injection. and from which it can escape
e1thcr by being mclabolised or by being excreted (Fig. 8.7). For
most drug~, V11 is an apparenl volume rather than the volume of
an anatomical compartment. It links the total amount of drug in
of a semi logarithmic plot of C against time back to its intercept
at time 0 (Fig. 8.6C). The concentration C, at a later time t will
depend on lhc rate of eliminalion of the drug (i.e. on its total
clearance, CL). Many drugs exhibit first-order kinetics where the 121
 SECTION 1 Ill GENERAL PRINCIPLES

~
Dose, a
(oral) --------->- s
10

0 8 (kef= 0.2/h)
E /

Absorption , f<abs .:.

I
c
.Q
..,' ~
6
Dose, a VolumeVd
c
Cl)
0
(intravenous) c
0
4
Single wellsbrred 0
compartment <II
I E
2-
a:"'
I I
<II
: kexc : kfnet
I I

t t 0
Excretion Metabolism 0 3.5 13.9 25 50

l
I
Fig. 8. 7 Single-compartment pharmacokinetic model.
Hours
This model is applicable If the plasma concentration falls r7 value
exponentially after drug administration (as in Fig. 8.6). for a
r? value
to'r b & b'

riD 10
Q)
rate of elimination is directJy proportional to drug concentration. (ij
Drug concentration then decays exponentially (Fig. 8.8), being ~
5
described by the equation: ~
s
0
(8.7) E 2
.:.
c
.Q ' .,
Taking logarithms: ~ ',.,
c ................
lnC(t) = lnC(01 - -CL., t (8.8)
g8 0.5 .,
''
vd <II
E
Plotting C, on a logarithmic scale against 1 (on a linear scale)
yields a straight line with slope CL/Vd. The inverse of this slope
"' 0.2 -
(CL/Vd) is the elimination rate constant ket The elimination half- 0 25 50
life, 1112, is an easily conceptualised parameter inversely related to Hours
ket Tt is the time taken for C, to decrease by 50%, and is equal to Fig. 8 .8 Predicted behaviour of single-compartment
ln2/ke1 (0.693/ke1). The plasma half-life is therefore determined by model following intravenous drug administration at time 0.
Vd and CL$. Drugs a and b differ only in their elimination rate constant, k.
When the single-compartment model is applicable, the drug Curve b shows the plasma concentration time course for a
smaller dose of b. Note that the half-life (t1n) (indicated by
concentration in plasma approaches the steady-state value ap- broken lines) does not depend on the dose. IAI Linear
proximately exponentially during a constant infusion (Fig. 8.6A). concentration scale. 1m Logarithmic concentration scale.
When the infusion is discontinued, the concentration falls
exponentially towards zero: after one half-life, the concentration
will have fallen to half the initial concentration; after two half-
live!>, it will have fallen to one-quarter the initial concentration;
after three half-lives, to one eighth; and so on. It is intuitively loading dose may be used (see below). The size of such a
obvious that the longer the half-life, the longer the drug will persist determined by the volume of distribution (equation 8.6).
in the body after dosing is discontinued. It is less obvious, but
nonetheless true, that during chronic drug administration the
longer the half-Life the Longer it will take for the drug to
EFFECT OF REPEATED DOSAGE
accumulate to it!> steady-state level: one balf-life to reach 50% of Drugs are usually given as repeated doses rather than
the steady-state value, two to reach 75%, three to reach 87.5%, injections or a constant infusion. Repeated injections
and so on. This is extremely helpful to a clinician deciding how dose Q) give a more complicated partern than the
to Mart treatment. If the drug in question has a half-life of approxi- exponential ri&e during intravenous infusion, but the principl
mately 24 hours, for example, it will take 3-5 days to approximate the same (Fig. 8.9). The concentration will rise to a mean
the steady-state concentration during a constant-rate infusion. If state concentration with an approximately exponential time
122 this is too slow in the face of the prevailing cl inical situation, a but will oscillate (through a range Q!Vd). The smaller and
 DRUG ELIMINATION AND PHARMACOKINETICS

15 c
~
Fig. 8.9 Predict ed behaviour of ~
single-compartment model with
g 10
continuous or Intermittent drug ~
administration. Smooth curve A
c
G)
0
shows the effect of continuous c
,nfus1on for 4 days; curve B the 8
<IS 5-
same total amount of drug given in E
a:"'
e1ght equal doses; and curve C the
same total amount of drug given in
"'
four equal doses. The drug has a
half-life of 17 hours and a volume of
d1stnbution of 20 litres. Note that in
each case a steady state is A. Infusion at 200 11mol/day
effectively reached after about
B. Injection 100 J..lmol twice daily
2 days (about three half-lives), and
that the mean concentration C Injection 200 11mol once daily
reached in the steady state is the 0 2 3
same for all three schedules. Days

frequent the doses, the more closely the situation approaches
that of a continuous infusion, and the smaller the swings in
concentration. The exact dosage schedule, however. does not
atlect the mean steady-state concentration, nor the rate at which
11 i' approached. In practice, a steady state is effectively achieved
alter three to five half-lives. Speedier attainment of the steady
,tate can be achieved by starting with a larger dose, as explained
Jbove. Such a loading dose is sometimes used when starting
treatment with a drug with a half-life that is long in the context
of the urgency of the clinical situation, as may be the case when
o. treating cardiac dysrhythmjas with drugs such as amiodarone or
digoxin (Ch. 18).
p. 100) approximates a constant-rate infusion. Once absorption is
complete, the plasma concentration declines with the same half-
time, irrespective of the rate of absorption.
T For the kind of pharmacokinetic model discussed here, the area under
the plasma concentration-time curve (AUC) is directly proportional to the
total amount of drug introduced into the plasma compartment, irrespective
of the rate at which it enters. Incomplete absorption, or destruction by
first-pass metabolism before the drug reaches tbe plasma compartment,
reduces AUC after or-dl administration (see Ch. 7. p. I 06). Changes in the
rate of absorption, however, do not affect AUC. Again, it is worth noting
that provided absorption is complete, tbe relation between the rate of
administration and the steady-state plasma concentration (equation 8.4)
is unaffected by kt>o although the size of the oscillation of plasma
concentration with each dose is reduced if absorption is slow.

J EFFECT OF VARIATION IN RATE OF ABSORPTION

If adrug is ab orbed slowly from the gut or from an injection site
mto the pla~ma, it is (in terms of a compartmental model) as
though 11 were being injected slowly into the bloodstream. For
the purpose of kinetic modelling, the transfer of drug from the
ose is te of adminbtration to the central compartment can be
repre-.cnted approximately by a rate constant, kabs (see Fig. 8.7).
Thi~ a'~umes that the rate of absorption is directly proportional,
at an} moment, to the amount of drug still unabsorbed, which is
at bN a rough approximation to reality. The effect of slow
;ingle a!hOrption on the time course of the rise and fall of the plasma
.ch of ronentrmion is shown in Figure 8. I 0. The curves show the effect
nooth of ~preading out the absorption of the san1c total amount of drug
pJe IS o1crdifferent times. In each case, the drug is absorbed completely,
eady- but the peak concentration appears later and is lower and less
ourse, 1harp if absorption is slow. In the limiting case, a dosage form
more !hat releases drug at a constant rate as it traverses the ileum (Ch. 7,
MORE COMPLICATED KINETIC MODELS
So far, we have considered a single-compartment pharma-
cokinetic model in which the rates of absorption, metabolism and
excretion are all assumed to be directly proportional to the con-
centration of drug in the compartment from which transfer is
occurring. This is a useful way to illustrate some basic principles
but is clearly a physiological oversimplification. The characteristics
of different partS of the body, such as brain, body fat and muscle,
are quite different in terms of their blood supply, partition coefficient
for dmgs, and the permeability of their capillaries to dmgs.
These differences, which the single-compartment model ignores,
can markedly affect the time courses of drug distribution and action,
and much theoretical work has gone into the mathematical
analysis of more complex models (see Rowland & Tozer, 1995;
Atkinson et al., 2002). They are beyond the scope of this book,
and perhaps also beyond the limit of what is actually useful, for
the experimental data on pharmacokinetic properties of drugs are 123
 SECTION 1 GENERAL PRINCIPLES

~ liD
s0
~ 10
~
c
E
..=,
:J c
...
>- t1 abs 0 20
~ ~
:e~ Oh
1h
E
Q)

c
.Q
3h
0
c
0
0

eE 5 6h Q)
: 10
Q) :;:.
0 .s::
c a.
0
8 c
IU
E
e
IU
en IU
IU
0::: E
en
0 IU
0 8 16 24 0::: 2 4 6 8
Hours Hours

Fig. 8.10 The effect of slow drug absorption on plasma drug concentration. ~ Predicted behaviour of single-compartment

model with drug absorbed at different rates from the gut or an injection site. The elimination half-time is 6 hours. The absorption half
times (t112 abs) are marked on the diagram. (Zero indicates instantaneous absorption, corresponding to intravenous administration.)
Note that the peak plasma concentration is reduced and delayed by slow absorption, and the duration of action is somewhat increased.
B Measurements of plasma aminophylline concentration in humans following equal oral and intravenous doses. (Data from Swintowsky
J V 1956 JAm Pharrn Assoc 49: 395.)


eldom accurate or reproducible enough to enable complex models in the case of a few drugs that distribute especially rapidly). Th
to be tested critically. effect of adding a second compartment to the model is to introduu
The two-compartment model, which introduces a separate a second exponential component into the predicted time coul"<
'peripheral' compartment to represent the tissues, in communication of the plasma concentration, so that it comprises a fast and a ,J
with the 'central' plasma compartment, more closely resembles phase. This pattern is often found experimentally, and i~ l1lll
the real situation without involving excessive complications. clearly revealed when the concentration data are plo1
semilogarithrnically (Fig. 8. 12). lf, as is often the case, the Iran
of drug between the central and peripheral compartmenl~
TWO-COMPARTMENT MODEL
relatively fast compared with the rate of elimination, then th~
The two-compartment model is a widely used approximation in phase (often called the a phase) can be taken to rcpre~ent
which the tissues are lumped together~ a peripheral compartment. redistribution of the drug (i.e. drug molecules passing fr
Drug molecules can enter and leave the peripheral compartment plasma to tissues, thereby rapidly lowering the plasma con~en
only via the central compartment (Fig. 8.1 1), whic h usually tration). The plasma concentration reached when the fast pha1~
represents the plasma (or plasma plus some extravascular space complete, bnt before any elimination has occurred, allow>
measure of the combined distribution volumes of 1he t~
compartments; the half-time for the slow phase (the ~ pha
provides an estimate of kc~. lf a drug is rapidly metabolised
a and fi phases are not well separated, and the calculation of
and kc~ is not straightforward. Problems also arise with drug' It
( Oral dose } - - - - -
very fat-soluble drugs) for which it is unrealistic to lump all
peripheral tissues together.
I
Absorption : kobs
I
I SATURATION KINETICS
Central
..,.. compartment
' k
k12- _,... p enp
- - --
compartment
. hera I
ln a few cases, such as etha nol, 1>heoytoin and salicylate.lh
(1) -c- - -21- - - (2) time course of disappearance of drug from the plasma doe,
follow the exponential or biexponeotial patterns shOI\O
Figures 8.8 and 8.12 but is initially linear (i.e. drug is rem01eJ
kexc a constant rate that i~ independent of plasma concentrationJ.lt
I
y y is often called zero-order kinetics to distinguish it from the u
Excretion Metabolism first-order kinetics that we have considered so far (these l

v.,.~__1
_2_4
lFig. 8.11 Two-compa rtment pharm acokinetic model. have their origin in chemical kinetic theory). Saturation kme
is a better tenn. Figure 8. 13 shows the example of ethanol. he
 DRUG ELIMINATION AND PHARMACOKINETICS

11118r1118coklnetlca 5~-------------.-------------.

Diazepam 105 p.mol orally

Total clearance (CL) of a drug is the
fundamental parameter describing its elimination: the
rate of elimination equals CL times plasma i
..:. 2
concentration. c:
.Q
CL determines steady-state plasma concentration ~
(C..): C = rate of drug administration/CL. c: 1.0
For many drugs, disappearance from the plasma ~
follows an approximately exponential time course.
8
E
Such drugs can be described by a model where t he [ 0.5
Q)
body is treated as a single well-stirred compartment :;j
'i5
of volume Vd. Vd is an apparent volume linking the co
amount of drug in the body at any time to the plasma E
concentration.
:a
a:
Elimination half-life (t112) is directly proportional to Vd
and Inversely proportional to CL.
With repeated dosage or sustained delivery of a drug, 0.1
0 12 24
ed. the plasma concentration approaches a steady value
Hours
;ky withtn three to five plasma half-lives.
Fig. 8 .12 Kinet ics of diazepam elimination in humans
In urgent situations, a loading dose may be needed to
following a single oral dose. The graph shows a
achieve therapeutic concentration rapidly. semilogarithmic plot of plasma concentration versus time. The
The loadtng dose needed to achieve a desired initial experimental data (black symbols) follow a curve that becomes
plasma concentration is determined by Vd. linear after about 8 hours (slow phase). Plotting the deviation of
). The
A two-compartment model is often needed. In this the early points (pink shaded area) from this line on the same
-oduce coordinates (red symbols) reveals the fast phase. This type of
::ourse
case. the kinetics are biexponential. The two
two-component decay is consistent with the two-compartment
~ siO\\
components roughly represent the processes of model (Fig. 8.11) and is obtained with many drugs. (Data from
most transfer between plasma and tissues (a phase) and Curry S H 1980 Drug disposition and pharmacokinetics.
lotted elimination from the plasma (13 phase). Blackwell, Oxford.)
ru1sfer Some drugs show non-exponential 'saturation'
'OIS is
kinetics, with important clinical consequences,
1e fast especially a disproportionate increase in steady-state
nt the plasma concentration when daily dose is increased.
I
from
mcen-
lasc 1s
ows a be \Cen that the rate of disappearance of ethanol from the plasma
20 Dose
e two 11 con~tant al about 4 mmol/1 per hour. irrespective of its plasma
concentration. The explanation for this is that the rate of oxidation
s0
administered
phase) E Dose
~d. the by the enzyme alcohol dehydrogenase reaches a maximum at low .sc: mol/kg)
1 of V ethanol concentrations, because of limited availability of the .Q
14.1
~s(e.g. cofactor NAD (see Ch. 43, p. 632, Fig. 43.6). ~
c:
all the Saturation kinetics has several important consequences (see ~
c: 10
Fig. 8.14). One is that the duration of action is more strongly 8
dcJl(ndem on dose than is the case with drugs that do not show :g
metabolic saturation. Another consequence is that the relationship 8
(ij
bet\\een do e and ~teady-state plasma concentration is steep and
te. the unpredictable, and it does not obey the proportionality rule ~
co
ICS not tmphclltn equation 8.4 for non-saturating drugs. The maximum
wn in rat~ of metabolism sets a lirrut to the rate at which the drug can
0 60 90 120
>Ved at be admimstered; if this rate is exceeded, the amount of drug in
Time after ingestion (minutes)
). Thts the body will, in principle, increase indefinitely and never reach
a,teady state (Fig. 8. 14). This does not actually happen, because Fig. 8.13 Saturating kinet ics of alcohol elimination in
! usual
humans. The blood alcohol concentration falls linearly rather
tem1s there is always some dependence of the rate of elimination on the than exponentially, and the rate of fall does not vary with dose.
inetics pla~ma concentration (usually because other, non-saturating (From Drew G C et al. 1958 Br Med J 2: 5103.)
125
. It can metabolic pathways or renal excretion contribute significantly at
 SECTION 1 GENERAL PRINCIPLES

A] Normal kinetics B] Saturating ki netics

150 150
..1Qj
s0 ~
E E
.:. .:.
c: 100 c: 100
.Q .Q
~ ~
c(I)
c
0
c: 2l
c:
0
0 8
ca ca
E
IJ)
E
IJ)
ca ca
a: a:
0 0
0 2 4 6 8 10 0 2 4 6 8 10
Days Days

- --------,
:_ _______ ..! Therapeutic range [iQ] Dose (units= 1-1mol/kg}

Fig. 8.14 Comparison of non-saturating and saturating kinetics for drugs given orally every 12 ho urs. The curves show an
imaginary drug, similar to the antiepileptic drug phenytoin at the lowest dose, but with linear kinetics. The curves for saturating kinetics
are calculated from the known phannacokinetic parameters of phenytoin (see Ch. 40). Note rl\l that no steady state is reached with
higher doses of phenytoin, and that a small increment in dose results after a time in a disproportionately large effect on plasma
concentration. With linear kinetics, the steady-state plasma concentration is directly proportional to dose. (Curves were calculated With
~e Sympak pharmacokinetic modelling program written by Dr J G Blackman, Univers_i_ t y_o_f_o_t_
ag_o_._>_ _ _ _ _ _ _ _ _ _ _....._~

high concentrations). Nevertheless, steady-state plasma concen-
trations of drugs of this ki nd vary widely and unpredictably with
dose. Similarly, variations in the rate of metabolism (e.g. through
enzyme induction) cau e disproportionately large changes in the
plasma concentration. These problems are well recognised for
drug&&uch as phenytoin, an anticonvulsant for which pi~~.>
concentration needs to be closely controlled to achieve an opu
clinical effect (see Ch. 40, p. 582, Fig. 40.3).
Clinical applications of pharmacokinetics are summarised
the clinical box.

Pharmacokinetics

Pharmacokinetic studies performed during drug
development underpin the standard dose regimens
approved by regulatory agencies.
Clinicians sometimes need to individualise dose
regimens to account for individual variation in a
particular patient (e.g. a neonate, a patient with
impaired and changing renal function, or a patient
taking drugs that interfere with drug metabolism;
see Ch. 52).
Drug effect (pharmacodynamics) is often used for such
individualisation, but there are drugs (including some
anticonvulsants, antidysrhythmics and antineoplastics)
where a therapeutic range of plasma concentrations
has been defined, and for which it is useful to adjust
the dose to achieve a concentration in this range.
Knowledge of kinetics enables rational dose
adjustment. For example:
the dose interval of a drug such as gentamicin
eliminated by renal excretion may need to be
126
markedly increased in a patient with renal
failure (Ch. 46, pp. 670-671)
- the dose increment needed to achieve a target plasma
concentration range of a drug such as phenytoin
with saturation kinetics (Ch. 40, p . 582, Fig. 40.3) is
much less than for a drug with linear kinetics.
Knowing the approximate t 112 of a drug can be very
useful, even if a therapeutic concentration is not known:
- in correctly interpreting adverse events that occur
some considerable time after starting regular treatmeo
(e.g. benzodiazepines; see Ch. 37, pp. 541-542)
- in deciding on the need or otherwise for an initial
loading dose when starting treatment with drugs such
as digoxin and amiodarone (Ch. 18, pp. 290 and 292)
The volume of distribution (V& of a drug determines the
size of loading dose needed. If Vd is large (as for many
tricyclic antidepressants), haemodialysis will not be an
effective way of increasing the rate of elimination in
treating overdose.
CHEMICAL MEDIATORS
 Chemical mediators
and the autonomic
nervous system
Overview 131
Historical aspects 13 1
~---------------~----------------------------~
1he peripheral nervous system 132
-Basic anatomy and physiology of the autonomic nervous
system 132
-Transmitters in the autonomic nervous system 135
Some general principles of chemical
lransmiu ian 136
- Dole's principle 136
- Denervotion supersensitivity 136
-Presynaptic modulation 137
- Postsynaptic modulation 138
- Transmitters other than acetylcholine and
noradrenaline 139
-Cotronsmission 140
-Termination of transmitter action 140
luic steps in neurochemical transmission: sites
af drug action 14 1
OVERVIEW
The network of che mical signals and a ssociate d
receptors by which ce lls in the body communicate
with one another provides many targets for drug
action, and has always bee n a focus of attention
for pharmacologists. Chemical transmission in the
peripheral nervous syste m, and the various ways
in which the proce ss can be pharmacologically
subverted, are discussed in this chapter. In addition
to neurotransmission, w e also consider briefly the
less clearly defined processes, collectively termed
neuromodulation, by which many mediators and
drugs exert control over the function of the nervous
system. The re lative anatomical and physiological
simplicity of the periphe ral ne rvous system has
mode it the proving ground for most of the important
discoveries about che mical transmission, a nd the
same general principle s apply to the central nervous
system (see Ch. 32). For more detail than is give n
here, see Broadley ( 1996), Brading ( 1999), and
Cooper et al. (2004).
HISTORICAL ASPECTS
, Swdies initiated on the peripheral nervous system have been central to
the understand ing and classification of many major types of drug action,
so il is wonh recounting a tittle history. Excellent accounts are given by
Bacq ( 1975) and Valcnstein (2005).
Experimental phy~iology became established as an approach to the
under<>tanding of the function of living organisms in the middle of the
t9th century. The peripheral nervous system, and particularly the autonomic
nervous system, received a great deal of anention. The fact that electrical
stimulation of nerve~ could elicit a whole variety of physiological effecL~
-from blanching of the ~kin to arrest of the hean-prescnted a real
challenge to comprehension. particularly of the way in which the signal
was passed from the nerve to the effecter tissue. In 1877, Du Bois-
Reymond wa~ the fi~t to put the altemati,e~ clearly: or known namral
proces..es that might pa~ on excitation. only two are, in my opinion. wonh
talking aJx)ut-either there exisL~ at the boundary of the contractile substance
a stimulatory secreuon ... or the phenomenon is electrical in nature'.
The Iauer v1ew wa~ generally favoured. In 1869. it had been shown
that an exogenou!> ~ub~tance, muscarine. could mimic the effects of
stimulating the vagu~ nerve, and that atropine could inhibit the actions
both of muscarine and of nerve stimulation. In 1905, Langley showed the
same for nicotine and curare acting at the neuromuscular junction.
Most physiologist~ imerpreted these phenomena as stimulation and
inhibi tion of the nerve e nding~. re,pectivety, rather than as evidence for
chemical transmission. Hence the suggestion ofT R Elliott, in 1904, that
J adrenaline (epinephrine) might act as a chemical transminer mediating
the actions of the sympathetic nervous system was coolly received, until
Langley, the Professor of Phy~iology at Cambridge and a powerful figure
at that time, suggested, a year later, that t.mnsmission to skeletal musc le
involved the secretion by the nerve tenn inals of a substance related
to nicotine.
One of the key observations for Elliott was that degeneralion of
sympathetic ncr\e terminals did not abolish the sensitivity of smooth muscle
preparations to adrenaline (which the electrical theory predicted) but actually
enhanced it. The hypothesis of chemical transmission was put to direct
test Ill 1907 by Dixon, who tried to show that vagus nerve stimulation
released from a dog~ hean into the blood a substance capable of
inhibiting another heart. The experiment failed, and the atmosphere of
scepticism prevailed.
It was not until I921. in Germany, that Loewi showed that stimulation
of the vagosympathet.ic trunk connected to an isolated and cannulated
frog's heart could cause the release imo the cannula of a substance
(' Vagusstoff') that. if the cannula fluid was transferred from the first hean
to a second. would mhibit the second hean. This is a classic and
much-quoted experiment that proved extremely difficult for even Loewi
to perform reproducibly. ln an autobiograpb.ical sketch, Loewi tells us
that the idea of chemical transmission arose in a discussion that he had
in t 903, but no way of testing it experimentally occurred to him until
he dreamed of the appropriate experiment one night in 1920. He wrote
some notes of this very imponant dre;1m in the middle of the nighl, bul 131
 SECTION 2 CHEMICAl MEDIATORS
in the morning could not read them. The dream obligingly returned the
next night and. takang no chance\. he went to the laboratory at 3 a.m.
and carried out the experiment ~ucce~sfully. Loewi"s experiment may be,
and wa.s, criticised on numerou~ grouncb (it coulcl for example, have
been pota.\\IUm rather than a neurotraosmiuer that was acting on the
recipient heart). but a ~cries of further experiments proved lum 10 be right.
H1~ findmgs can be ~ummarised as follow.
Sumulauon of the vagus caused the appearance in the perfu~ate of
the frog bean of a sub,tance capable of producing. in a second bean.
an mh1b1tOI)' effect re\embling vagus stimulation.
Stimulauon of the sympathetic nervous system caused the appearance
of a \Ub\tance capable of accelerating a second bean. By Ouorescence
meawrements. Loc" i concluded later that this substance was
adrenaline.
Atropine prevented the inhibitory action of the vagus on the bean but
did not prevent rclca'e of Vagusstoff. Atropine thus prevented the effects.
rather than the release. of the transmitter.
When YagussLOff was incubated with ground-up heart muscle, it became
inactivmed. This effect b now known to be due to enzymatic destruction
of acetylchol ine by cholinestera.~e.
Physostigmin e (eserine). which potentiated the effect of vagus
stimulmion on the bean. prevented destruction of Vagus~toff by heart
mu~cle, providing evidence that the potentiation is due to inhibition
of cholinestem~e. which normally destroy~ the tran~miuer sub,tance
acetylcholine.
A few yea~ later. in the early 1930~. Dale showed convincingly that
acetylcholine wa'> al\o the transmitter substance at the neuromuscular
JUnction of ~triated mu<.cle and at autonomic ganglia. One of the key~ 10
Dale, \ucce~~ lay m the u'e of very highly 'ensitive bioa~'ay,, especially
the leech dorsal mu<.cle, for me~uring acetylcholine release. Chemical
tran'>rni'>\ion at \}mpathellc ner.e terminals "~demonstrated at about
the 'arne ume ~ cholinergic transmission and by very similar methods.
Cannon and hi'> colleague' at Har,ard first showed unequi,ocally the
phenomenun or chem1cal tmnsmi,,ion at sympathetic ner.e endings, b)
experiment\ in '1vo in "hich tissues made supersensitive to adrenaline
by prior sympathetic denervation were shown to respond. after a delay.
to the transmitter released by stimulation of the sympathetic nerves to
other pan\ of the body. The chemical identity of the tran'>miuer,
tantalisingly like adren:aline but not identical to it, caused confu~ion for
many yeaN, unti l in 1946 von Euler showed it 10 be the non-methylated
derivative norndrenuline (norepinephrine).
THE PERIPHERAL NERVOUS SYSTEM
The peripheral nervous system consists of the following principal
elements:
autonomic nervou~ system, which includes the enteric
nervous sy!>tcm
somatic efferent nerves. innervating skeletal muscle
\Omatic and vbceral afferent nerves.
In this chapter, we focus on the autonomic nervous
syMcm, which for a long time occupied centre stage in the
pharmacology of chemical transmission. Aspects of the somatic
efferent system are considered in Chapter I0. Afferent nerves
(particularly the non-myelinated nerves subserving nociceptive
and other functions: see Ch. 41) also have important effector
functions in the periphery. mediated mainly by neuropeptides
(Ch. 16). Many afferent fibres are present in autonomic nerves
and arc anatomically part of the autonomic nervous system,
but it is the efferent pathways that are the main concern of
132 this chapter.
BASIC ANATOMY AND PHYSIOLOGY OF
THE AUTONOMIC NERVOUS SYSTEM
The autonomic nervous sy~tcm (see Appenzeller & Oribe.
consists of three main anatomical divisions: sympatheu
parasympathetic (see Fig. 9.1). and the enteric nervou<. ') '
con~is1ing of 1he intrinsic nerve plexuses of the gastroime
tract, which are closely interconnected with the sympalhet11.
parasympathetic systems.
The autonomic nervous system conveys all the output\
the central nervous system to the rest of the body, except fL
motor innervation of skeletal muscle. The enteric nervou~
has ~>Ufficient integrative capabilities to allow it to function
pendently of the central nervous system, but the sympatheti~
parasympathetic systems are agents of the central nervou~
and cannot function without it. The autonomic ncrvou~ syMc
largely outside the influence of voluntary control. The
processes that it regulates are:
contraction and relaxation of vascular and visceral smootll
muscle
all exocrine and certain endocrine secretions
the heartbeat
energy metabolism. particularly in liver and skeletal mu><
A degree of autonomic control also affects many other
including the kidney, immune system and somatosensol)
The main difference between the autonomic and the
efferent pathways is that the fonner consists of two neurons
in series. whereas in the latter a single motor neuron connec~
central nervous syMem to the skeletal muscle fibre (Fig. 9.2J
two neurons in the autonomic pathway are known.
as preganglionic and postganglionic. In the sympathetic nen
!>ystem, the intervening synapses lie in autonomic ganglia,
arc outside the central nervous system, and contain the
endings of preganglionic fibres and the cell bodies of po~;tga1ngli''''l
neurons. In parasympathetic pathways. the postganglionic
arc mai nly found in the target organs, discrete oarasvmlnatllltt<ll
ganglia (e.g. the ci liary ganglion) being found only in 1he
and neck.
The cell bodies of the sympathetic preganglionic neuron1
in the lateral horn of the grey matter of the thoracic
lumbar segments of the spinal cord, and the fibres leave
spinal cord in the spinal nerves as the thoracollm
sympathetic outflow. The preganglionic fibres synap~c in
parmertebral chains of sympathetic ganglia. lying on
side of the spinal column. These ganglia contain the cell
of the postganglionic sympathetic neurons, the axons of
rejoin the spinal nerve. Many of the postganglionic ~)
fibres reach their peripheral destinations via the branch~
the spinal nerves. Others. destined for abdominal and
viscera, have their cell bodies in a group of unpaired
ganglia in the abdominal cavity. The only exception
two-neuron arrangement is the innervation of the
medulla. The catecholamine-secreting cells of the
medulla arc, in effect, modified postganglionic
neurons, and the nerves supplying the gland are equivalcm
pregangl ionic fibres.
 CHEMICAL MEDIATORS AND TH E AUTONOMIC NERVOUS SYSTEM

Sympathetic Parasympathetic

Structures in
97) head and neck:
and
em. Eye
Blood vessels
mal
Salivary glands
and etc.

om
Lhe Heart
Lungs
Heart

Adrenal medulla Lung

Upper Gl tract

Nervi
erigentes

Liver
j Pelvic ganglia

5
Gl tract
~
. .: ~ Lowe' Gl
Bladder
"'d
le.
Bladder
Genitalia
.-- '
,

Fig. 9.1 Basic plan of the

mammalian auto no mic nervous Blood vessels Paravertebral
system. C, cerv1cal; Gl, Sweat glands sympathetic Preganglionic
gastrointestinal; L, lumbar; M, etc. Segmental chain
Postganglionic
medullary; S, sacral; T, thoracic. outflow (bilateral)

~
< ACh
(nic)
/ Skeletal muscle
Somatic efferent
system

...enw
>
en
en
ACh
--- ---<< (nic) et -- - -< N.A, - - : ' Blood vessels
etc.

~
:::;)

ie.,
0
>
a:
w
z

------<< ACh let --
(nic)
--
ACh
<(mus) Sweat glands
Sympathetic
system

~
..J ACh
c(
< (nic) Adrenal medulla
...z
a:
w
0
ACh .__ __

naJ
< (nic)
ACh
<(mus) 0 Salivary glands
etc.
Parasympathetic
system

nal
etic
Fig. 9.2 Acetylcholine and noradrenaline as tr ansmitters in the p eripheral nervous system. The main two types of acetylcholine
~ lO (ACh) receptor, nicotinic (nlc) and muscarinic (mus) (see Ch. 10), are indicated. NA, noradrenaline (norepinephrin e).
\..
133
 SECTION 2 . CHEMICAL MEDIATORS
The parasympathetic nerves emerge from two separate regions
of the central nervous system. The cranial outflow consists of
preganglionic fibres in certain cranial nerves, namely the
oculomotor nerve (carrying parasympathetic fibres destined for
the eye), the facial and glossopharyngeal nerves (carrying fibres
to the salivary glands and the nasopharynx), and the vagus nerve
(carrying fibres to the thoracic and abdominal viscera). The ganglia
lie scattered in close relation to the target organs; the postganglionic
neurons are very short compared with those of the sympathetic
system. Parasympathetic fibres destined for the pelvic and
abdominal viscera emerge as the sacral outflow from the spinal
cord in a bundle of nerves known as the nervi erigentes (because
stimulation of these nerves evokes genital erection-a fact of
some importance to those responsible for artificial insemination
of livestock). These fibres synapse in a group of scattered pelvic
ganglia, whence the short postganglionic fibres run to target
tissues such as the bladder, rectum and genitalia. The pelvic
ganglia carry both sympathetic and parasympathetic fibres , and
the two divisions are not anatomically distinct in this region.
The enteric nervous system (reviewed by Goyal & Hirano,
1996) consists of the neurons whose cell bodies lie in the intramural
plexuses in the wall of the intestine. It is estimated that there are
more cells in this system than in the spinal cord, and functionally
they do not fit simply into the sympathetic/parasympathetic
classification. Incoming nerves from both the sympathetic and
the parasympathetic systems terminate on enteric neurons, as
well as running directly to smooth muscle, glands and blood
vessels. Some enteric neurons function as mechanoreceptors or
chemoreceptors, providing local reflex pathways that can control
gastroimestinal function without external inputs. The enteric
nervous system is pharmacologically more complex than the sym-
pathetic or parasympathetic systems, involving many neuro-
peptide and other transmitters (such as 5-hydroxytryptamine,
nitric oxide and ATP).
1able 8.1 The main effects of the autonomic nervous system
Organ Sympathetic effect
Heart
Sinoatrial node Rate t
Atrial muscle Force t
Atrioventricular node Automaticity t ~1
Ventricular muscle Automaticity t ~1
Force t
Blood vessels
Arterioles
Coronary Constriction
Muscle Dilatation
Viscera, skin, brain Constriction
Erectile tissue Constriction
Salivary gland Constriction
134
In some places (e.g. in the visceral smooth muscle of rt
gut and bladder, and in the heart), the sympathetic and :
parasympathetic systems produce opposire effects, but there .1.
others where only one division of the autonomic system open.:es.
The sweat glands and most blood vessels, for example, b
only a sympathetic innervation, whereas the ciljary muscle oflk
eye has only a parasympathetic innervation. Bronchial ~mo
muscle has only a parasympathetic (constrictor) inne"..r
(although its tone is highly sensitive to circulating adrenaline
acting probably to inhibit the constrictor innervation rather tit:::
on the smooth muscle directly). Resistance arteries (see Ch JL
have a sympathetic vasoconstrictor innervation but no pa:
sympathetic innervation; instead, the constrictor tone i~ oppo!>t
by a background release of nitric oxide from the cndotheli
cells (sec Ch. 17). There are other examples, such as the saliva;
glands, where the two systems produce similar, rather th
opposing, effects.
It is therefore a mistake to think of the sympathetic art
parasympathetic systems simply as physiological opponem
Each serves its own physiological function and can be mn
or less active in a particular organ or tissue according to thent.:
of the moment. Cannon rightly emphasised the general role
the sympathetic system in evoking 'fight or flight' reactiOn\
an emergency, but emergencies are rare for most animail.
everyday life, the autonomic nervous system function~ ,
tinuously to control specific local functions, such as adjustmer:::
to postural changes, exercise or ambient temperature (see J
& McLachlan, 1992). The popular concept of a continuum 1
the extreme 'rest and digest' state (parasympathetic aculf.
sympathetic quiescent) to the extreme emergency fight or fl1,
state (sympathetic active, parasympathetic quiescem) is
oversimplification.
Table 9. 1 lists some of the more important autonom
responses in humans.
Adrenergic Parasympathetic effect Cholinergic
receptor type receptor type
~1 Rate l M2
~1 Force l M2
Conduction velocity l M2
Atrioventricular block M2
No effect M2
a No effect
~2 No effect
{.( No effect
a Dilatation Ml
0. Dilatation Mao
 CHEMICAL MEDIATORS AND THE AUTONOMIC NERVOUS SYSTEM

the
1 the Table 8.1 (cont'd) The main effects of the autonomic nervous system
~ are

ates. Organ Sympathetic effect Adrenergic Parasympathetic effect Cholinergic

have receptor type recept or type
fthe
Veins Constriction a No effect
ooth Dilatation ~2 No effect
ltion
1e- Viscera
than Bronchi
Smooth muscle No sympathetic innervation, Constriction M3
. 19) but dilated by circulating
>ara- adrenaline (epmephrine)
osed Glands No effect Secretion M3
elial Gastrointestinal tract
vary Smooth muscle Moti lity~ a, , a2, ~2 Motility t M3
Sphincters Constriction a2, ~2 Dilatation M3
than Glands No effect Secretion M3
Gastric acid secretion M,
and Bladder Relaxation 132 Contraction M3
!OlS. Sphincter contraction u, Sphincter relaxation M3
Uterus
nore
Pregnant Contraction a Variable
1eed Non-pregnant Relaxation ~
e of
iS in Male sex organs Ejaculation a Erection M3
. I n
Eye
::on -
Pupil Dilatation a Constriction M3
rents Ciliary muscle Relaxation (slight) 13 Contraction M3
iinig
'rom Skin
tiv e, Sweat glands Secretion (mainly cholinergic No effect
via M3 receptors)
ight
Pilomotor Piloerection u No effect
an
Salivary glands Secretion u,jl Secretion M3
mic
Lacrimal glands No effect Secretion M3

Kidney Renin secretion j3, No effect

Uver Glycogenolysis a , ~2 No effect

Gluconeogenesis

'The adrenergic and cholinergic receptor types shown are described more fully in Chapters 7 and 8. Transmitters other than
acetylcholine and noradrenaline (norepinephrine) contribute to many of these responses (see Table 9.2).
"Vasodilator effects of M3 receptors are due to nitric oxide release from endothelial cells (see Ch. 15).

All moto r nerve fibres leaving the central nervous system

TRANSMITTERS IN THE AUTONOMIC
NERVOUS SYSTEM
The two main neurotransmi tters that operate in the autonomic
')'tem are acetylcholine and nor adren aline, whose sites of action
are shown diagrammatically in Figure 9.2. This diagram also shows
the type of postsynaptic receptor w ith which the transmitters interact
31 lhe difTerenl sites (discussed more full y in Chs 10 and l 1). Som e
general rules apply.
release acety lcholine. w hich acts on nicotinic receptors
(although in autonomic ganglia a m inor component of excitation
is due to activatio n of m uscarinic receptor s; see Ch. I 0).
AU postganglionic parasympathetic fibres release acetylcholine,
which acts on muscarin ic recepto rs.
All postganglionic sympathetic fibres (with one importan t
exception) release nor adrenaline, which may act o n either
a- or ~-adrenoceptors (sec Ch . I I ). The exceptio n is the 135
 SEcnON 2 . CHEMI CAL MEDIATORS
Baalc anatomy of the autonomic
nervoua aptem
The autonomic nervous system comprises three
divisions: sympathetic, parasympathetic and enteric.
The basic (two-neuron) pattern of the sympathetic
and parasympathetic systems consists of a
preganglionic neuron with a cell body in the central
nervous system (CNS) and a postganglionic neuron
with cell body in an autonomic ganglion.
The parasympathetic system is connected to the
CNS via:
- cranial nerve outflow (Ill, VII, IX, X)
- sacral outflow.
Parasympathetic ganglia usually lie close to or within
the target organ.
Sympathetic outflow leaves the CNS in thoracic and
lumbar spinal roots. Sympathetic ganglia form two
paravertebral chains, plus some midline ganglia.
The enteric nervous system consists of neurons lying in
the intramural plexuses of the gastrointestinal tract. It
receives inputs from sympathetic and parasympathetic
systems, but can act on its own to control the motor
and secretory functions of the intestine.
Phplology of the autonomic
nervoua ayatem
The autonomic system controls smooth muscle
(visceral and vascular), exocrine (and some
endocrine) secretions, rate and force of the heart, and
certain metabolic processes (e.g. glucose utilisation).
Sympathetic and parasympathetic systems have
opposing actions in some situations (e.g. control of
heart rate, gastrointestinal smooth muscle), but not in
others (e.g. salivary glands, ciliary muscle).
Sympathetic activity increases in stress ('fight or
flight' response), whereas parasympathetic activity
predominates during satiation and repose. Both
systems exert a continuous physiological control of
specific organs under normal conditions, when the
body is at neither extreme.
sympathetic innervation of sweat glands, where transmission
is due to acetylcholine acting on muscarinic receptors. ln
some species, but not humans, vasodilatation in skeletal
muscle is produced by cholinergic sympathetic nerve fibres.
Acetylcholine and noradrenaline are the grandees among autonomic
transmitters, and arc central to understanding autonomic
pharmacology. However, many other chemical mediators are also
released by autonomic neurons (see below), and their functional
136 significance is gradually becoming clearer.
SOME GENERAL PRINCIPLES OF
CHEMICAL TRANSMISSION
The essential processes in chemica] transmission-the release o(
Su
mediators, and their interaction with receptors on target celh-
IS I
are described in Chapters 4 and 3, respectively. Here we con,idcr
log
some general characteristics of chemical transmission of paniculr
for
relevance to pharmacology. Many of these principles apply al~t
0
the central nervous system and are taken up again in Chapter3~
ca
the
DALE' S PRINCIPLE liD
sen
T Dale's pri nciple, advanced in 1934, states, in its modern form: ,
mature neuron relea~es the same transmitter (or transmitters) at all of,~ sy
~ynapscs'. Dale considered it unlikely that a single neuron could store a~.
release differem transmitter~ at different nerve terminals, and his 1ie.
was supported by phy&iological and neurochemical evidence. h is know~
for example, that the axons of motor neurons have branches that synap
on interncurons in the spinal cord. in addition to the main branch lh~
inncrvatc5 skeletal mu~cle fibres in the periphery. The transmitter atlx b
the central and the peripheral nerve endings is acetylcholine, m
accordance with Dale'~ principle. Recent work, however, ~ugge~ts thJI
there are situation~ where different transmitters are released lr1111
different terminals of the same neuron. Further. we now know that nm
neuron~ rcle~e more than one tran~miuer (see Corransmission, bd
and may change theti transmitter repertoire, for example during develop!'
or in re\pon-.e to IOJUry. Moreover (see Fig. 4.12). the balance of
cocl..tail of mediators released by a nerve terminal can ''aC)' with stimulci
conditiOn\, and tn response to presynaptic modulators. Dale's principl
was. of cou~. framed long before the~e compleJtities were dio;co\cnt,
and it has probably now outlived i!S usefulness, although punm '"
curiou\ly reluctant to let it go.
DENERVATION SUPERSENSITIVITY
[t is known, mainly from the work of Cannon on the sympatheti,
system, that if a nerve is cut and its terminals allowed to degener.ue
the structure supplied by it becomes supersensitive to the transmincr
substance released by the terminals. Thus skeletal muscle, which
normally responds to injected acetylcholine only if a large do~
is given directly into the arterial blood supply, will, after denervation.
respond by contracture to much smaJJer amounts. Other organ~.
such as salivary glands and blood vessels, show similar supersen'1
tiviry to acetylcholine and noradrenaline when the postganglionh
nerves degenerate, and there is evidence that pathways in t1x
central nervous system show the same phenomenon.
T Se' era I mechani~ms contribute to denervation supersensitivity, and die
extent and mechanism of the phenomenon varies from organ to ~n
Reponed mechani'm~ include the following.
Proliferation of receptors. This is panicularly marked in skeletal mll:idc.
in which the number of acetylcholine receptors increases 20.fold cr
more after denervation: the receptors. normally localised to the endpl311
region of the fibre~. spread over the whole surface. Elsewhere, mod
smaller increases in receptor number (about twofold) have often bm
reponed. but there are examples where no change occurs.
Loss of mecitamsms for transmitter removal. At noradrenergic synapx
the lo8~ of neuronal uptake of noradrenaline (see Ch. I I) com:rioote
substantiall y to denervation supersensitivity. At cholinergic syna~s .
partial loss of cholinesterase occurs (see Ch. 10).
Increased posrjunctiona/ responsiveness. In some cases, the postsynapt
cells become supersensitive without a corresponding increase in tht
 CHEMICAL MEDIATORS AND THE AUTONOMIC NERVOUS SYSTEM

number of receptor.. Thu.\ -.mooth mu~le cell~ become partly dcpolariscd no rad renaline acting on the parasympathetic nerve terminals. A
and hyperexcitable. and thh phenomenon contributes appreciably to similar situation of mutual pre!>ynaptic inhibition exists in the
their \Uper.en~itivuy. The mechani~m of this change and its imponance
heart, where noradrenaline inhibits acetylcholine release, as in
for other '>ynap\e' i\ not known.
the myenteric plexus, and acetylcholine also inhibits noradrenaline
Super.ensitivity can occur, but is less marked, when transmission release. These are examples of heterotropic interactions, where
s-
~ intcnupted by procc!.se!. other than nerve section. Pbarmaco- one neurotransmitter affects the release of another. Homorropic
der
logtcal blocl.. of ganglionic transmission, for example, if sustained interactions also occur, where the transminer. by binding to
Jlar
for a few days. causes some degree of supersensitivity of the target presynaptic autoreceptors. affects the nerve terminals from which
) !O
organs, and long-term blockade of postsynaptic receptors also it is being released. Thi~ type of autoinhibitory feedback acts
32.
cau..e~ rccepton. to proliferate, leaving the cell supersensitive when powerfully at noradrenergic nerve tenninals (see Starke et al., 1989).
lhe blocking agent is removed. Phenomena such as this are of One of the strongest pieces of evidence is that the amount of
imponance in the central nervous system, where such super- noradre naline rel ea~ed from tissues in response to repetitive
'ensitivity can cause ' rebound' effects when drugs that impair stimulation of sympathetic nerves is increased 10-fold or more
'A
~ynaptic transmission are given for some time and then stopped. in the presence of an antagonist that blocks the presynaptic
f iiS
and noradrenaline receptors (see Ch. ll). This suggests that the released
Jew noradre nal ine can inhibit further release by at least 90%. In the
wn, PRESYNAPTIC MODULATION
brain, acetylcholine release is modulated by a similar autoinhibitory
1pse n1c presynaptic te rminals that synthesise and release tran:.mittcr
lhat
feedback involving presynaptic muscarinic acetylcholine receptors.
10 rc~pon~c to electrical activity in the nerve fibre are often In both the no radre nergic and chol inergic systems, the
Xllh
in lhcm~elve~ sensitive to transmitter substances and to other presynaptic autorcceptors are pharmacologically di!>tinct from
ihat >Ub~tanccs that may be produced locally in tissues (for reviews the postsynaptic receptors (see Chs 10 and 11). and there arc
rom '<C Starke ct al., 1989; Fuder & Muscholl, 1995). Such presynaptic drugs that act selectively, as agonists o r antagonists, o n the pre-
lOSt
eiTem mo~t commonly act to inhibit transmitter release, but may or po~t~ynaptic receptors.
ow)
le!ll
enhance it. Figure 9.3 !>hows the inhibitory effect of adrenaline Cholinergic and noradrenergic nerve terminals respond not
the on the relea~e of acetylcholine (evoked by electrical stimulation) only to acetylcholine and noradrenaline, as described above, but
llus from the postganglionic parasympathetic nerve terminals of the also to other ~ubl>tanc~ that are released as cotransmitters, such
iple inte..tine. The release of noradrenaline from nearby sympathetic as ATP and neurope ptide Y (NPY). or derived from other
ied. nerve terminals can also inhibit release of acetylcholine. sources, including nitric oxide, prostaglandins. adenos ine.
:em
t\oradrcnergic and cholinergic nerve terminals often lie close do pamine. 5-hydroxytryptamine. GABA. o pioid peptides.
together in the myenteric plexus, so the opposing effects of the endocanna binoids and many other substances. The physiologi-
>)mpathetic and parasympathetic systems result not only from cal role and pharmacological signjficance of these various
the oppo~i te effect<. of the two transmitters on the smooth muscle interactions is still unclear (see review by Vizi. 200 1). but the
cell,, but also from the inhibition of acetylcholine release by description of the autonomic nervous system represented in
!UC
tte.
Figure 9.2 is undoubtedly oversimplified. Figure 9.4 shows some
of the main presynaptic interactions between autonomic ne uro ns,
tter
a nd summari!>es the many chemical influences that reg ulate
ich
)SC
transmi tter release from noradrenergic neurons.
on, Presynaptic receptors regulate transmitter release mainly by
ns, affecting Ca 2' e ntry into the nerve tenninal (sec Ch. 4). Most
Sl-
presynaptic receptors arc of the G-protein-coupled type (see Ch. 3),
'--' 15 min
'liC
which control the function of calcium channels and pota~sium chan-
:he nels either through second messengers that regulate the state of
phosphorylation of the c hannel proteins, or by a direct interaction
of G-proteins with the channels. Transmitter release is inhibited
the
when calcium channel opening is inhibited, or when potassium
an.
channel opening is increased (sec Ch. 4): in many cases, both mech-
anisms operate simultaneously. Presynaptic regulation by receptors
;le. linked directly to ion channels (ionotropic receptors; see Ch. 3)
or Slim. 0.4 Hz rather than toG-proteins also occurs (see Mac Dermott et al., 1999).
ate
lch
:en
Adrenaline
{ltmol/1)
-
0.5
1.0
D
1.0

0.5
Nicotinic acetylcholine receptors (nAChRs) are particularly
important in this respect. They facilitate the release of other trans-
Fig. 9.3 Inhibitory effect of adrenaline on acetylcholine mitters, such a\ glutamate (see Ch. 33). and most of the nAChRs
JeS.
res
a
llic
(ACh) release from pos tganglionic parasympathetic nerves
in the guinea pig ileum. The intramural nerves were stimulated
electrically where indicated, and the ACh released into the
bathing fluid determined by bioassay. Adrenaline strongly
inhibits ACh release. (From Vizi E S 1979 Prog Neurobiol 12: 181.}
J expressed in the central nervous system are located presynaptically.
Another example is the GABAA receptor, whose action is to
inhibit transmitter release (see Chs 4 and 33). Other ionotropic
receptors, such as those activated by ATP and 5-hydroxytryptamine
the (Ch. 12), may have similar effects on transmitter release. 137
 CHEMICAL MEDIATORS AND THE AUTONOMIC NERVOUS SYSTEM

mainly from a decrca1.c in K+ permeability. Conversely, the
inhibitory effect of various opiates is mainly due to increased
K permeability.
Benzodiazepine tranquillisers (Ch. 37) act directly on
receptors for GABA (see Ch. 33) to facilitate their inhibitory
effect. There is some evidence that drugs such as galantamine
act similarly on nAChRs to facilitate the excitatory effect of
acetylcholine in the brain. which may have relevance for the
u..e of such drug!. to treat dementia (see Ch. 35).
t'ieuropeptide Y, which is released as a cotransmirter with
nomdrcnaline at many sympathetic nerve endings and enhances
the vasoconstrictor effect of noradrenaline, thus greatly
faci litating tran~miS!>iOn (Fig. 9.5); the mechanism is not known.
The pre- and postsynap tic effects described above are often
described a!> neuromodulation, because the mediator acts to
increase or decrease the efficacy of synaptic transmission w ithout
participating directly as a transmitter. Many neuropeplides, for
example, affect membrane ion channels i n such a way as to
mcrease or decrease excitability and thus control the firing
pa!lem of the cell. Neuromodulation is loosely defined but, in
geneml. involves slower processes (taking seconds to days) than
neurotransmission (which occurs in milliseconds), and operates
through cascades of intracellular messengers (Ch. 3) rather than
directly on ligand-gated ion channels. Some aspects of this problem
of tcnninology are discussed in Chapter 16.
TRANSMITTERS OTHER THAN
ACETYLCHOLINE AND NORADRENALINE
As mentioned above, acetylcholine or noradrenalirte are not the
only autonomic transmitters. The rather grudging realisation that
this was ~>O dawned many years ago when it was noticed that
autonomic transmission in many organs could not be completely
blocked by drugs that abolish responses to these transmitters. The
dismal but tenacious term non-adrenergic non-cholinergic
(NANC) transmission was coined. Later, fluorescence and
immunocytochemical methods showed that neurons, including
autonomic neurons, contain many potenti al transmitters, often
several in the same cel l. Compounds believed to function as
NANC transmillers include ATP, vasoactive intestinal peptide
(VIP), NPY and nitric oxide (see Fig. 9.6 and Table 9.2), which
function at postganglionic nerve terminals, as well as substance
P, 5-hydroxytryptamine. GABA and dopamine, which play a

Fig. 9.5 Effect of neuropeptide Y Oi

:r:
(NPV) on noradrenergic E NA
transmission. Vasoconstriction . 60 1 Hz 10s
(upward deflection) of the rabbit ear ~
::>
artery occurs in response to injections lll
of noradrenaline (NA) or to a brief ~ 40
period of sympathetic nerve c
0
stimulation. Infusion of a low u;
::>
concentration of NPY greatly
Increases the response to both. (From
~
0..
20 -
L...J
Rand M J et al. 1987 Cardiovasc NPY 10nmol/l 1min
Pharmacol 1O(suppl 12): S33-S44.)

ted
Fig. 9.6 Noradrenaline/ATP cotransmission in the guinea pig vas deferens. Contractions of the tissue are shown in response to
a single electrical stimulus causing excitation of sympathetic nerve endings. With no blocking drugs present, a twin-peaked response is
produced (C). The early peak is selectively abolished by-tne ATP antagonist suramin (S), while the late peak is blocked by the a,-
adrenoceptor antagonist prazosin (P). The response is completely eliminated when both drugs are present. (Reproduced with permission
from von Kugelglen & Starke 1991 Trends Pharmacal Sci 12: 319- 324.)
139
 SECTION 2 . CHEMICAL MEDIATORS

Table 9 .2 Examples of non-noradrenergic non-cholinergic transmitters and cotransmitters in the peripheral nervous system

Transmitter Location Function

Non-peptides
ATP Postganglionic sympathetic neurons Fast depolarisation/contraction of smooth
(e.g. blood vessels, vas deferens) muscle cells

GABA, 5-hydroxytryptamlne Enteric neurons Peristaltic reflex

Dopamine Some sympathetic neurons (e.g. kidney) Vasodilatation

Nitric oxide Pelvic nerves Erection

Gastric nerves Gastric emptying

Peptides
Neuropeptide Y Postganglionic sympathetic neurons Facilitates constrictor action of noradrenaline;
(e.g. blood vessels) inhibits noradrenaline release

Vasoactive intestinal peptide Parasympathetic nerves to salivary glands Vasodilatation; cotransmitter with acetylcholine
NANG innervation of airways smooth muscle Bronchodilatation

Gonadotrophin-releasing hormone Sympathetic ganglia Slow depolarisation; cotransmitter with

acetylcholine

Substance P Sympathetic ganglia Slow depolarisation

Enteric neurons Cotransmitter with acetylcholine

Calcitonin gene-related peptide Non-myelinated sensory neurons Vasodilatation; vascular leakage; neurogenic
inflammation

NANG, non-noradrenergic non-cholinergic.

role in ganglionic transmJsson (see Lundberg, 1996, for a
comprehensive review).
COTRANSMISSION
It is probably the rule rather than the exception that neurons
release more than one transmitter or modulator (see Lundberg,
1996), each of which interacts with specific receptors and
produces effects, often both pre- and postsynaplicaliy. We arc
only just beginning to understand the functional implications of
this (see Kupfcrmann, 1991 ). The example of noradrenaline/ATP
cotransmission at the ~ympathetic nerve endings is shown in
Figure 9.6, and the best-studied examples and mechanisms are
summarised in Table 9.2 and Figures 9.7 and 9.8.
What, one might well ask, could be the functional advantage
of cotran~mi'>sion, compared with a single transmitter acting on
various different receptors? The possible advantages include the
following.
One constituent of the cocktail (e.g. a peptide) may be removed
or inactivated more slowly than the other (e.g. a monoamine).
and therefore reach targets fuithcr from the site of release
and produce longer-lasting effects. This appears to be the
case, for example, with acetylcholine and gonadotrophin-
140 releasing hormone in sympathetic ganglia (Jan & Jan, 1983).
The balance of the transmitters released may vary under
different conditions. At sympathetic nerve terminals, for
example, where noradrenaline and NPY arc stored in separate
vesicle!;, NPY is preferentially released at high stimulation
frequenc ies (see Stjarne, 1989), so that differential release of
one or OLher mediator may result from varying impulse pattern,
Differential effects of presynaptic modulators are also pos~ibk.
for exnrnple, activation of (3-adrenoceptors inhibits ATP
release while enhancing noradrenaline release from sympathe11,
nerve terminals (Gon~alves et al.. 1996).
TERMINATION OF TRANSMinER ACTION
Chemically transmiuing ~ynapses other than the peptidergic varid1
(Ch. 16) invariably incorporate a mechanism for dispo.. m_
rapidly of the relea ed transmitter. so that its action remains bnt
and localised. At cholinergic synapses (Ch. 10), the reiC<1'4:1
acetylcholine is inactivated very rapidly in the synaptic cleft~,
acetylcholinesteral.e. In most other cases (see Fig. 9.9). transmitl
action is terminated by active reuptake into the presynaptic ner.c
or into supporting cells such as glia. Such reuptake depend~ o
transporter protein~. each being specific for a particular transmittt:
(sec Nelson, 1998; Torres et aJ., 2003). They belong to a distin,,
family of membrane proteins, each possessing 12 transmembnm(
helices. Different members of the family show selectivity fo
 CHEMICAL MEDIATORS AND THE AUTONOMIC NERVOUS SYSTEM

Parasympathetic Sympathetic

Rapid
~~ ACh response ATP ~,

Fig. 9 . 7 The main

cotransmitters at postganglionic Intermediate
- ~ NO response NA -
parasympathetic and sympathetic
neurons. The different mediators
generally give rise to fast,
Intermediate and slow responses of ~ VIP
Slow
response
~ NPY .i.:"
the target organ. ACh, acetylcholine;
NA. noradrenaline; NO, nitric oxide;
NPY, neuropeptide Y; VIP, Tissue response
vasoactive intestinal peptide.

e
each of the main monoamine transmitters (e.g. the norepinephrine
transporter, NJ:.I, which transports noradrenaline: the serotonin
transporter, SERT. which transports 5-hydroxytryptamjne);
tran~porters for glutamate and GABA show greater diversity,
~mal subtypes of each having been described. Vesicular
/ramporters (Ch. 4), which load synaptic vesicles with transmitter
molecules, are closely related to the membrane transporters.
~1embrane transporter!. usually act as cotransporters of Na .., Cl-
:md tran\mitter molecules. and it is the inwardly directed 'downhill'
gradient for Na+ that provides the energy for the inward 'uphill'
mO\ement of the transmjuer. The simultaneous transport of ions
along with the transmitter means that the process generates a net
Transmitters of the autonomic
arate nervous system
Jn
;e or The principal transmitters are acetylcholine (ACh) and
ems. noradrenaline.
:.ible; Preganglionic neurons are cholinergic, and ganglionic
transmission occurs via nicotinic ACh receptors
lhetic (although excitatory muscarinic ACh receptors are
also present on postganglionic cells).
Postganglionic parasympathetic neurons are
cholinergic, acting on muscarinic receptors in target
organs.
lriecy Postganglionic sympathetiC neurons are mainly
:>sing noradrenergic, although a few are cholinergic (e.g.
brief sweat glands).
~ased Transmitters other than noradrenaline and
ft by acetylcholine (NANG transmitters) are also used
nitter extensively in the autonomic nervous system. The
terve. main ones are nitric oxide and vasoactive intestinal
Js on pept1de (parasympathetic), ATP and neuropeptide Y
nittcr (sympathetic). Others, such as 5-hydroxytryptamine,
,tinct GABA and dopamine, also play a role.
)rane Cotransmission is a general phenomenon.
y for
current across the membrane, which can be measured directly
and used to monitor the transport process. Very similar mechanisms
are responsible for other physiological transport processes, such
as glucose uptake (Ch. 26) and renal tubular transport of amino
acids. Because it is the electrochemical gradient for Na+ that
drive<, the inward transport of transmitter molecules, a reduction
of thi~ gradient can reduce or even reverse the flow of transmitter.
Thi is probably not important under normal conditions, but
when the nerve terminals are depolarised or abnormally loaded
with sodium (e.g. in ischaemic conditions) the resulting non-
ve~icular release of transmitter (and inhibition of the normal
synaptic reuptake mechanism) may play a significant role in
the effects of ischaernia on tissues such as heart and brain (see
Chs 18 and 35). Studies with transgenic 'knockout' mice (see
Torres et al., 2003) show that the store of releasable transrniner
is substantially depleted in animals lacking the membrane
transporter, showing that synthesis is unable to maintain the store
if the recapture mechanism is disabled.
As we shall see in s ubsequent chapters, both membrane and
vesicular transporters are targets for various drug effects, and
defining the physiological role and pharmacological properties of
these molecu les is the focus of much current research.
BASIC STEPS IN NEUROCHEMICAL
TRANSMISSION: SITES OF DRUG ACTION
Figure 9.9 summarises the main processes that occur in a classical
chemically transmitting synapse, and provides a useful basis for
understanding the actions of the many different classes of drug,
discussed in later chapters. that act by facilitating or blocking
neurochemical transmission.
All the steps shown in Figure 9.9 (except for transmitter diffusion,
step 8) can be influenced by drugs. For exan1ple, the enqmes
involved in synthesis or inactivation of the transmitter can be
inhibited, as can the transport systems responsible for the neuronal
and vesicular uptake of the transmitter or its precursor. The actions
of the great majority of drugs that act on the peripheral nervous
system (Chs I0 and I I) and the central nervous system fit into
this general scheme. 14 1
SECTION 2 . CHEMICAL MEDIATORS

~ Presynaptic Inhibition NERVE TERMINAL

Many noradrenergic and

cholinergic terminals
Transm1tter
m
Depolarisation~
precursor

\
' ',
- - ..a.. Precursor

B Heterotropic presynaptic Inhibition ~

Noradrenergic
--------- - -~ T
/cholinergic
nerve terminals
in the heart
T
,yo
I
Degradation T
I :@ products
I I
I I
I I
@] Postsynaptic synergism I I
I I
I I
I
I I
Noradrenaline/NPY in : : Y / __ _____ , . T
blood vessels ' ----
'--------- -----T
- -- ~12
- - ----
'----Inactivated ~
@
transmitter 10
l -----------
~-- ~

Noradrenaline/ATP in blood
vessels, vas deferens
ACh/GnRH in sympathetic
ganglia
ACh/SP in enteric ganglia
Fig. 9 .8 Cotransmission and neuromodulation-some
examples. IAl Presynaptic Inhibition. (ru Heterotropic
presynaptic inhibition. ~ Postsynaptic synergism. ACh,
acetylcholine; GnRH, gonadotrophin-releasing hormone
Outelnlsing hormone-releasing hormone); NPY, neuropeptide Y;
SP, substance P; VIP, vasoactive intestinal peptide.
T
NON-NEURONAL
T CELL
Fig. 9 .9 The main pro cesses involved in synthesis,
storage and release of amine and amino acid transmitters.
1, Uptake of precursors; 2, synthesis of transmitter; 3,
uptake/ transport of transmitter into vesicles; 4, degradation of
surplus transmitter; 5, depolarisation by propagated action
potential; 6, influx of Ca2 in response to depolarisation; 7,
release of transmitter by exocytosis; 8, diffusion to postsynaptiC
membrane; 9, Interaction with postsynaptic receptors; 10,
inactivation of transmitter; 11, reuptake of transmitter or
degradation products by nerve terminals; 12, uptake of
transmitter by non-neuronal cells; and 13, interaction with
presynaptic receptors. The transporters (11 and 12) can release
transmitter under certain conditions by working in reverse.
These processes are well characterised for many transmitters
(e.g. acetylcholine, monoamines, amino acids, ATP). Peptide
mediators (see Ch. 16) differ in that they may be synthesised
and packaged In the cell body rather than the terminals.

Neuromodul tlon nd presynaptic interactions

As well as functioning directly as neurotransmitters, Inhibitory presynaptiC autoreceptors occur on

chemical mediators may regulate:
- presynaptic transmitter release
- neuronal excitability.
Both are examples of neuromodulation and generally
involve second messenger regulation of membrane
ion channels.
Presynaptic receptors may inhibit or increase
transmitter release, the form er being more important.
noradrenergic and cholinergic neurons, causing each
transmitter to inhibit its own release (autoinhibitory
feedback).
Many endogenous mediators (e.g. GABA.
prostaglandins, opioid and other peptides). as well as
the transmitters themselves, exert presynaptic control
(mainly inhibitory) over autonomic transmitter release.
 Cholinergic transmission

100 000 times more active than choline in lowering the rabbit's bl,
Overview 144 pressure. The physiological role of ACh was not apparent at thut time.
it remained a pharmacological cu ri osity until Loewi and Dale and 1~
Muscarinic and nicotinic actions of colleagues discovered ih transmitter role in the 1930s.
acetylcholine 144
Analysing the pharmacological actions of ACh in 1914, OJ.
Acetylcholine receptors 145 distinguished two types of activily, which he designated a
-Nicotinic receptors 145 muscarinic and nicotinic. The muscarinic actions of ACh ;r.
-Muscarinic receptors 145 those that can be reproduced by the injection of muscarine,~
1--- ~ -~--

Physiology of cholinergic transmission 146 active principle of the poisonous mushroom Ama11ita muscaro
-Acetylcholine synthesis and release 147 and can be abolished by small doses of atropine. Muscaru
-Electrical events in transmission ot fast cholinergic action~ closely resemble the effects of parasympathetic stimulal!<

synopses 148
Effects of drugs on cholinergic transmission 149
-Drugs affecting muscarinic receptors 150
-Drugs affecting autonomic ganglia 155
-Neuromuscular-blocking drugs 157
-Drugs that oct presynaptically 161
-Drugs that enhance cholinergic transmission 162
OVERVIEW
This chapter is concerned mainly with cholinergic
transmission in the periphery, and the ways in
which drugs aHect it. Here we describe the diHerent
types of acetylcholine (ACh) receptors and their
functions, as well as the synthesis and release of
ACh. Drugs that act on ACh receptors, many of
which have clinical uses, are described in this
chapter. Cholinergic mechanisms in the central
nervous system (CNS) and their relevance to
dementia are discussed in Chapters 32 and 35.
MUSCARINIC AND NICOTINIC ACTIONS
OF ACETYLCHOLINE
'f' 'The di-,ctwery of the phannacologtcal action of ACh came. paradoxically.
from worl.. on adrenal gland~. extracu. of which were known to produce a
ri~e in blood pre~sure owing to thetr content of adrenaline (epinephrine).
In 1900, Reid Hum found that after adrenaline had been removed from
such extract\, they produced a fall in blood pressure instead of a rise. He
auributed the fall to the presence of choline. but later concluded that a
more potent derivative of choline must be responsible. With Taveau, he
144 tested a number of choline derivatives and discovered that ACh was some
as shown in Table 9.1. After the muscarinic effects have bet
blocked by atropine, larger doses of ACb produce another <,c,
effects, closely similar to those of nicotine. They include:
~timulation of all autonomic ganglia
Mimulation of voluntary muscle
secretion of adrenaline from the adrenal medulla.
The mu~carinic and nicotinic actions of ACh are demonstrat~d
Figure I0.1. Small and medium doses of ACh produce a tramJt
fall in blood pressure due to arteriolar vasodilatation and siOIIL
of the heart- muscarinic effects that are abolished by atropin~
large dose of ACh given after atropine produces nicotinic efftxb
an initial rise in blood pressure due to a stimulation of sympathell.
ganglia and consequent vasoconstriction, and a secondary n~
resulting from secretion or adrenaline.
Dale's pharmacological classification corresponds clo~ely 1
the main physiological functions of ACh in the body. The muscarin
actions corre!>pond to those of ACh released at postganglior
parasympathetic nerve endings, with two significant exceptior
Acetylcholine causes generalised vasodilatation. even thou,
most blood vessels have no parasympathetic innervation. Th
is an indirect effect: ACh (like many other mediators) acl\
va<;cular endothelial cells to release nitric oxide (see Ch. I"
which relaxes smooth muscle. The physiological function~
thb i!) uncertain. because ACh is not normally present in
circulating blood.
Acetylcholine evokes secretion from sweat glands, which .ue
innervated by cholinergic fibre!. of the sympathetic nervou,
system (l>ee Table 9.1 ).
The nicotinic actions correspond to those of ACh acting o
autonomic gang Iia of the sympathetic and parasympathetic systel1'
the motor end plate of voluntary muscle, and the secretory cellsol
the adrenal medulla.
 CHOLINERGIC TRANSMISSION

1 min
,--,
~ [ID

0>
I
E
.. 150
!!?
:::;)
IJ)
IJ)
!!?
a. 100

~
CD
lood
and 50
:heir

AC h ACh
1
Atropine ACh
1
ACh
>ale 2 1!9 50 119 2 m9 50 1!9 5m9
as Fig. 10.1 Dale's experiment showing that acetylcholine (ACh) produces two kind s of effect on the eat's blood pressure.
are Arterial pressure was recorded with a mercury manometer from a spinal cat. [A) ACh causes a fall in blood pressure due to vasodilatation.
the B A larger dose also produces bradycardia. Both ~ and [] are muscarinic effects. [Q; After atropine (muscarinic antagonist), the same
ria. dose of ACh has no effect. Dl Still under the influence of atropine, a much larger dose of ACh causes a rise in blood pressure (due to
stimulation of sympathetic ganglia), accompanied by tachycardia, followed by a secondary rise (due to release of adrenaline from
inic the adrenal gland). These effects result from its action on nicotinic receptors. (From Burn J H 1963 Autonomic pharmacology.
ion. Blackwell, Oxford.)
een
t of

cholinergic \)'napses in the CNS might be different again, the diversit)

ACETYLCHOLINE RECEPTORS
Although Dale himself dismissed the concept of receptors as
'ophistry rather than science, his classification provided the basis
din fordiqinguishing the two major classes of ACh receptor (see Ch. 3).
ient
ing
e. A NICOTINIC RECEPTORS
ICtS: Nicotinic ACh receptors (nAChRs) fall into three main classes,
etic the muscle, gang Iionic and CNS types, whose subunit composition
rise is ~ummarised in Table I 0. 1. Muscle receptors are confi ned to
the skeletal neuromuscular junction; ganglionk receptors are
v to re~ponsible for transmission at sympathetic and parasympathetic
inic ganglia; and CNS-type receptors mc widespread in the brain, a11d
~nic :rre heterogeneous with respect to their molecular composition
ms: and location (see Ch. 35).
Jgb T All nAChR~ are pcntameric structures that function as ligand-gated ion
1us channel<. (see Ch. 3). The five subunit~ that form the receptor~hannel
cnmple\ are sim1lar in \tructure. and so far 16 different members of the
on
famil} ha\e been identified and cloned. designated a (nine types). ~(four
7). types). y, 0 and E (one of each). The five subunits eacb po51>ess four
of membrane-spanning helical domains. and one of these helices (M 2) from
t-xh subunit define~ the central pore (see Ch. 3). nAChR subtypes generally
contain both a and ~subunit\, the exception being the homomeric (a7)s
'ubtype found mainly in the brain (Cb. 35). The adult muscle receptor has
are
the compo~1110n (<X I ),l~l)'E, while the main ganglionic subtype is
I~
!o.3),(j34),. The two binding sites for ACh (both of which need to be
occupied to cause the channel to open) reside at the interface berween the
extracellular domnin of each of the a subunits and itS neighbour. The
on
diver~ity of the nAChR fami ly (sec Hogg et al., 2003. for details), which
emerged from cloning studies in the 1980s, took pharmacologists
Is of somewhat by surpril>c. Although they knew that the neuromuscular and
ganglionic ~ynapscs differed pharmacologically. and suspected that
goes far beyond thh. and liS functional significance is not yet clear (for
reviewo; see McGehee & Role. 1995: Cordero-Erauskin et 31., 2000).
The different action of agonists and antagonists on ganglionic
and neuromuscular !>ynapses is of practical importance and mainly
renects the differences between the muscle and neuronal nAChRs
(Table I 0.1 ).
MUSCARINIC RECEPTORS
Muscarinic receptors (mAChRs) are typical G-protein-coupled
receptors (sec Ch. 3), and five molecular subtypes (M 1-M5) are
known (see Wcss. 1996). The odd-numbered members of the group
(M 1, M 3, M 5 ) couple with Gq to activate the inositol phosphate
pathway (Ch. 3), while the even-numbered receptors (M2, M4)
act through G, to inhibit adenylyl cyclase and thus reduce
intracellular cAMP (see Goyal. 1989).
Three ofthe~e (Mt, M2, M3) are well characterised (fable 10.2).
M 1 receptors ('neural') are found mainly on CJ Sand peripheral
neurons and on gastric parietal cells. They mediate excitatory
effects, for example the slow muscarinic excitation mediated by
ACh in sympathetic ganglia (Ch. 9) and central neurons. This
excitation i'> produced by a decrease in K+ conductance, which
causes membrane depolarisation. Deficiency of this kind of
ACh-mcdiated effect in the brain is possibly associated with
dementia ().ee Ch. 35), although transgenic M 1 receptor knockout
mice show only slight cognitive impairment (see Wess, 2004).
M 1 receptors are also involved in the increase of gastric acid
secretion fol lowing vagal stimulation (see Ch. 25).
M2 receptors ('cardiac') occur in the heart, and also on the
145
presynaptic terminals of peripheral and central neurons. They
SECTION 2 CHEMICAL MEDIATORS

Tllble 10.1 Nicotinic receptor subtypes

Musc le type Ganglion type CNS type Notes

Main molecular form (a1hj31& (adult form) (a3k (J34h (a4k(J32h (a7)s

Ma1n synaptic Skeletal Autonomic ganglia: Many brain regions: Many brain regions:
location neuromuscular mainly postsynaptic pre- and pre- and
junct1on: mainly postsynaptic postsynaptic
postsynaptic

Membrane response Excitatory Excitatory Pre- and Pre- and (a 7)5 receptor
Increased cation Increased cation postsynaptic postsynaptic produces large
permeability permeability excitation excitation Ca2 entry, evok1ng
(mainly Na, K) (mainly Na+, K) Increased cation Increased Ca2 transmitter release
permeability permeability
(mainly Na, K)

Agonlsts Acetylcholine Acetylcholine Nicotine Epibatidine (a.4l2 (J32b is

Carbachol Carbachol Eplbatidine Dimethylphenyl- brain ' nicotine
Succinylcholine Nicotine Acetylcholine piperazinium receptor'
Epibatidine Cytosine (see Ch. 34)
Dimethylphenyl-
piperazinium

Antagonists Tubocurarine Mecamylamine Mecamylamine a-Bungarotoxin

Pancuronium Trimetaphan Methylaconitine a-Conotoxin
Atracurium Hexamethonium Methylaconitine
Vecuronium a-Conotoxin
a -Bungarotoxin
a -Conotoxin

~is table shows only the main subtypes expressed in mammalian t1ssues. Several other subtypes are expressed in selected brain
regions, and also in the peripheral nervous system and in non-neuronal tissues. For further details, see Chapter 34 and reviews by
Lindstrom (2000), Cordero-Erausquin et al. (2000) and Dajas-Bailador & Wonnacott (2004).

exert inhi bitory effects, mainly by increasing K+conductance and
by inhibiting calcium channcb (see Ch. 4). M 2 receptor activation
is responsible for cholinergic inhibition of the heart, as well as
presynaptic inhibition in the CNS and periphery (Ch. 9). They are
also cocxprcssed with M3 receptors in visceral s mooth muscle,
and contribute to the smooth-muscle- stimulating effect of
mu ~carinic agonists in several organs.
M3 receptor~ ('glandular/smooth muscle') produce mai nl y
excitatory effect~. i.e. stimulation of glandular secretions (salivary,
bronchial, sweat, etc.) and contraction of visceral smooth muscle.
M 1 receptor!> also mediate relaxation of smooth muscle (mainl y
vascular), which results from the release of nitric oxide from
neighbouri ng endothelial cells (Ch. 17). M 1, M 2 and M3 receptors
occur also in specific locations in the C 1S (see Ch. 34). M~ and
M5 receptors arc largely confi ned to the CNS. and their functional
role is not well understood, although mice lacking these receptors
do show behavioural c h ange~ (Wess. 2004).
The pharmacological cla~sificat i on of these receptor types
relies on the limited selectivity of certai n agonists and antagonists
th at can distinguish between them. Most agonists are non-selective,
but two experimental compounds, McNA343 and oxotremorine,
are selective for M 1 receptors; carbachol is relatively inactive
on these receptors. Other M 1-selective agonists (e.g. xanomeline)
have recently been discovered and are in development as possible
treatments for de mentia. There is more selectivity amon4
antagonists. Although most of the classic muscarinic antagonl\l
(e.g. atropine, scopolamine) are non-selective, pirenzepine ~
selecti ve for M 1 receptors, and darifenacin for M3 rcccptoN
Gallamine, better known as a neuromuscular-blocking drur
(see p. 157), is also a selective, although weak, M2 recept(n
antagonist. Recently, toxins from the venom of the green mam~.
have been discovered to be highly selective mAChR antagoni,.
(!>ee Table 10.2), as well as various synthetic compounds w
some degree of selectivity (see Eglen et al., 1999, for mort
details). Compounds that have recently been approved forclimcJ
use are described below (p. 152).
PHYSIOLOGY OF CHOLINERGIC
TRANSMISSION
The physiology of cholinergic transmission is described in det~
by Nicholls et al. (200 I). The mai n ways in which drugs can affe,
cholinergic transmission arc shown in Figure 10.2.
T Acetylcholine is synthesised and stOred in many tissues that 1...
cholinergic innervation. such as the placenta and cornea. 0e>p1
speculation about po'sible regu latory and trophic functions (see rev1c.
by Wcsslc et al.. 1998), the role of non-neuronal acetylcholine ~
uncertain.
 CHOLINERGIC TRANSMISSION

Table 10.2 M uscarinic receptor subtypes

M , ('neural') M 2 ('cardiac') M 3 ('glandular/ M Ms

s m ooth muscle')

Man locations Autonomic ganglia Heart: atria Exocrine glands: CNS CNS: very localised
Glands: gastric, CNS: widely gastric, salivary, etc. express1on 1n
salivary. etc. distributed Smooth muscle. substantia nigra
Cerebral cortex gastrointestinal tract, eye, Salivary glands
airways, bladder Iris/ciliary muscle
Blood vessels: endothelium
CNS

Cellular response j IP3 , DAG .l.cAMP j iP3 .l. cAMP j IP3 Excitation
Depolarisation Inhibition Stimulation Inhibition
Excitation (slow epsp) .l. Ca2 conductance j[Ca2 ],
.l. K+ conductance j K conductance

Functional CNS excitation Cardiac inhibition Gastric, salivary Enhanced Not known
response (?memory) Neural inhibition secretion locomotion
Gastric secretion Central muscarinic Gastrointestinal smooth
effects (e.g. tremor, muscle contraction
hypothermia) Ocular accommodation
Vasodilatation

Agomsts (non- Acetylcholine AsM 1 AsM 1 AsM 1 AsM 1

selecttve. except Carbachol
those 1n italics) Oxotremorine
See also McNA343
Table 10.3 Talsaclidine

Antagonists Atropine Atropine Atropine Atroptne Atropine

(nonselecttve. Dicycloverine Dicycloverine Dicycloverine Dicycloverine Dicyclovenne
except those in Tolterodine Tolterodine Tolterodine Tolterodine Tolterodine
1tahcs) See also Oxybutynin Oxybutynin Oxybutynin Oxybutynin Oxybutynin
Table 10.5 lpratrop1um lpratropium lpratropium lpratropium lpratropium
Pirenzepine Gallamine Darifenacin Mamba toxin MT3
Mamba toxin MT7
mg
SIS
CNS, central nervous system; DAG, diacylglycerol; epsp, excitatory postsynaptic potential; IP3, inositol trisphosphate.
"This table shows only the predominant subtypes expressed in mammalian tissues. For further details, see Chapter 34 and reviews by
is Caulfield & Birdsall (1998) and Wess (2004).
~r:,.

:ug
tor
lba is present in the presynaptic nerve tenninals, and ACh is continually
ACETYLCHOLINE SYNTHESIS AND RELEASE
SIS being hydrolysed and re~ynthesised. Inhibition of the nerve tenninal
ith !\cetylcholine metabolism is well reviewed by Parsons et al. cholinestera\e cau~e~ the accumulation of 'surplus' ACh in the
ore (1993). ACh is 'ynthe~ised within the nerve tenninal from choline, cytosol, which is not available for release by nerve impulses
cal 1\htch i' taken up into the nerve terminal by a specific carrier (although it i., able to leak out via the choline carrier). Most of
Ch 9). 'imilar to that" hich operates for many transmitters. The the ACh ~ynthe'>i'>ed, however, is packaged into synaptic vesicles,
difference is that it tran~ports the precursor. choline, not ACh, so in which it'> concentration is very high (about I 00 mmoU I). and

r n ''not imponant in tcnninating the action of the transmitter. The

concentration of choline in the blood and body fluids is nonnaiJy
about 10 j.lmoUI, but in the immediate vicinity of cholinergic nerve
t.aiJ renninals it increases. probably to about 1 rnmoUl. when the
ect ~leased ACh is hydrolysed. and more than 50% of this choline is
nom1ally recaptured by the nerve terminab. Free choline within
th~ nerve tcm1inal i), aeetylated by a cytosoJic enzyme, choline
ack
acery/rransfemse (CA 7), which transfer~ the acetyl group from
pite
acetyl cocr11yme A. The rate-limiting process in ACh synthesis
ie""
e is appear' to be choline transport, the activity of which is regulated
according to the nlle til which ACh is being re leased. Cholinesterase
from which release occun. by exocytosis triggered by Ca 2+ entry
into the nerve terminal (sec Ch. 4).
Cholinergic vesicle:, accumulate ACh actively. by means of a
specific transponer (see Usdjn et al.. 1995: Liu & Edwards, 1997)
belonging to the family of amine transponers described in Chapter 9.
Accumulation of ACh is coupled to the large electrochemical
gradient for protons that exjstl> between intraceUular organelles
and the cytosol: it is blocked selectively by the experimental drug
vcsamicol (sec Parsons et aJ., 1993). FoUowing its release. the ACh
diffuses across the synaptic cleft to combine with receptors on
the postsynaptic cell. Some of it succumbs on the way to hydrolysis 147
 SECTION 2 . CHEMICAL MEDIATORS
Acetylcholine receptors
Main subdivision is into nicotinic (nAChR) and
muscarinic (mAChR) subtypes.
nAChRs are directly coupled to cation channels, and
mediate fast excitatory synaptic transmission at the
neuromuscular junction, autonomic ganglia, and
various sites in the central nervous system (CNS).
Muscle and neuronal nAChRs differ in their molecular
structure and pharmacology.
mAChRs and nAChRs occur presynaptically as well
as postsynaptically, and function to regulate
transmitter release.
mAChRs are G-protein-coupled receptors causing:
activation of phospholipase C (hence formation of
inositol trisphosphate and diacylglycerol as
second messengers)
inhibition of adenylyl cyclase
activation of potassium channels or inhibition of
calcium channels.
mAChRs mediate acetylcholine effects at postganglionic
parasympathetic synapses (mainly heart, smooth
muscle, glands), and contribute to ganglionic
excitation. They occur in many parts of the CNS.
Three main types of mAChR occur.
M 1 receptors ('neural') producing slow excitation
of ganglia. They are selectively blocked by
pirenzepine.
M 2 receptors ('cardiac') causing decrease in
cardiac rate and force of contraction (mainly of
atria). They are selectively blocked by gallamtne.
M2 receptors also mediate presynaptic inhibition.
M3 receptors ('glandular') causing secretion,
contraction of visceral smooth muscle, vascular
relaxation.
Two further molecular mAChR subtypes, M4 and M 5 ,
occur mainly in the CNS.
All mAChRs are activated by acetylcholine and
blocked by atropine. There are also subtype- selec tive
agonists and antagonists.
by acerylcholinestera!>e (AChE). an enzyme that is bound to the
basement membrane, which lies between the pre- and post!>ynuptic
membranes. At fast cholinergic synapses (e.g. the neuromuscular
and ganglionic sym1pses), but not at slow ones (smooth muscle,
gland cells. heart, etc.), the released ACh is hydrolysed very
rapidly (within 1 ms), so that it acts only very briefly.
T At the neuromu~cular junction. which is a highly specialised synap~c.
a ~ingle ner.e impulse relea'>Cs about 300 synaptic \C~icles (altogether
about three miUion ACh molecule~) from the nerve terminah ~uppl)ing
a single m~le fibre. "hich contain altogether about three million
synaptic vesicle<.. Approxtmately two million ACh molecule' comb10c
with receptors. of which !here are about 30 million on each muscle
fibre. the re~t being hydroly,cd without reaching a receptor. The ACh
molecules remain bound lo receptors for, on average. about 2m~. and arc
148 quickly hydrolysed after di~ociati ng. so that they cannot combine w ith
a second receptnr. The re~ult is that rransmiuer action 1' 'el) rdptd
very brief. \\hich t\ tmp<mant for a synap:.e that ha~ to tmllat~
muscular rc;pon\C\, and that may ha,e to rran;mit ;ignah fauhfu
high frequency. Mu.,clc cell-. are much larger than neuron' .tnd rcqt::
much more t.ynaptic currcm 10 generate an action potential. Thu' al
chemica l event~> happen 0 11 a larger ~cale than m a neuronal~>ynap,c.
number or Lra nsmil ter molecules i n a quantum. the numht!r ol qu,
released. and the number of receptors activated by each quan
are all I 0- 100 time~> greater. Our brains would be huge. but 111~ 1
clever. if their ~ynupo,e~ were built on the indu\trial \C<tle ol
neuromw,cular junction.
PRESYNAPTIC MODULATION
Acetylcholine relea. e is regulated by mediator~. mcluJ
ACh itself. acting on presynaptic receptor~. as discuo,o,ed
Chapter9. At postgangl ionic parasympathetic nerve cndm,
inhibitory M 2 receptors participate in autoinhibition of AC'h
release; other mediatorl>, such as noradrenaline, also inhibit th
release of ACh (~>ee Ch. 9). At the neuromusc ular junctinn. on the
other hand. pre~ynaptic nAChRs are believed to fac il itat~ \
release (see Prior et al.. 1995), a mechanism that may allow
synapse to function reliably during prolonged high frcq
activity. In the brain (\cere' iew by Dajas-Bailador & Wonn3C
2004). most of the nAChRo, are located presynaptically and~
to facilitate transmission by other mediators. such "' gluta1
and dopamine.
ELECTRICAL EVENTS IN TRANSMISSION AT
FAST CHOLINERGIC SYNAPSES
Acetylchol ine, acting on the postsynaptic membrane o
nicotinic (neuromuscular or ganglionic) synapo,e. cau'e' a I.
increase in it!> permeability to cations, particular!} to a- andK
and to a lesser extent Ca 2+. The resulting inflow of Na+dcpol3ru6
the postsynaptic membrane. This transmitter-mediated dcpo!
isation is called an endplate potential (epp) in a skeletal mux
fi bre, or a fast excitatory postsynaptic potential (ja.1t epsp) m
ganglionic synapse. ln a muscle fi bre, the localised epp \preau
to adjacent, electrically excitable parts of the muscle libr~: if
amplitude reaches the threshold for excitation. an action pot~nt
is initiated. which propagates to the rest of t.he fibre and c1ok
contraction (Ch. 4).
In a nerve cell. depolarisation of t.he soma or a dendntc b)
fast epsp causes a local current to now. Th i~ depolarise~ the \
hillock region of the cell. where, if the epsp is large enough
action potential is initiated. Figure 10.3 shows that tubocuroriDt
a drug that blockl> po~tsynaptic ACh receptors (see p. 158), rcdtl(
the amplitude of the fast ep!>p until it no longer initi ate~ an uct1
potentiaL although the cell is still capable of responding when
is stimulated antidromically. Most ganglion cells arc supplieJ
~everal presynaptic axons. and it requires simultaneous aCttl lt~
more than one to make the postganglionic cell fire. At the ne
muscular junction. only one nerve fibre supplies each mu..clc hlrt
Nevertheless, the amplitude of the epp is nonnally mor~ d
enough to initiate an action potential-indeed. tran~mi.,.,ion
occurs when the epp is reduced by 70-80%, and is '>aid to 'ho
a large margin of.\Clfety so that fluctuations in transmitter rele.
(e.g. during repetitive stimulation) do not affect transmission
 CHOLINERG I C TRANSMISSION

:uld
~edy
I) at
AcCoA) (Choline
tuire
the CAT ~ \
the CoA __ ACh ' ',
tanta ,- \

uum ACh ,' \

el) carrier"\ ,' , 1
\ I
the I
Fig. 10.2 Events and sites of I

drug action at a nicotinic +-- Empty 1:

cholinergic synapse. vesicle : ~
Acetylcholine (ACh) is shown I
I
acting postsynaptically on a ~ I I
I
l ing nicotinic receptor controlling a I
I
I in cation channel (e.g. at the I Choline carrier
I
neuromuscular or ganglionic
ngs. synapse), and also on a Exocytosts
\Ch presynaptic nicotine receptor that
the acts to facilitate ACh release Presynaptic
the during sustained synaptic activity. l
toxins,
The nerve term inal also contains l e .g . botulinum
\Ch l
acetylcholinesterase (not shown); l
the when this is inhibited, the amount
l
l l '
ncy l y II> l
of free ACh, and the rate of
;ott. leakage of ACh via the choline ',----------------------- ~ Choline
~rve carrier, is increased. Under Non-depolarislng 1 , AChE / +
1
1ate normal conditions, this leakage of blocking agents, Acetate
ACh is insigntficant. At muscarinic e.g. tubocurarine 1
cholinergic junctions (e.g. heart, I
I
smooth muscle, exocrine glands), Depolarising I
I
both postsynaptic and blocking agents, I
presynaptic Qnhibitory) receptors I e.g. neostigmine
e.g. suxamethonium
are of the muscarinic type.
AcCoA, acetyl coenzyme A;
AChE, acetylcholinesterase; CAT,
111111111111111111111111
!1!!11!111111!!11!!1!11!
' :111111111111111111111111
lll!ll!lll!lllllll!l!lll
choline acetyltransferase; CoA, Postsynaptic nicotinic
coenzyme A. ACh receptor
~cs

lar -
:cle
Transmission m the ganglionic synapse is more complex than at the thi s di1>charge cea~e~ and transmtsso n i s bloc ked . The loss
the
ncuronwscular j unction. A lthough the primary event at both is the epp or o f electrica l ex citabi lity at thi s time is shown by the fact th at
ads
fast cpsp produced by ACh acti ng on nAChRs, this is followed in the antidro m ic stimuli also fail to produce an ac tio n potential. T he
its ganglion by a 'lucce~sion of much slower postsynaptic responses.
tial main reason for the loss of electrical ex c itability during a peri od
comprii.ing the follow ing.
o f m aintained depo lari sati on is that the vol tage-sensitive sodium
~sa
A .fiOIV inhihirory (hl'flerpolarising) postsynaptic potential (sloo. ipsp)
channels (see C h. 4) becom e inactivated ( i.e. refractory) and no
lastillfl 2-5 !ecomiJ. Thh mainly refle.cts a muscarinic {M 2) receptor
longer able to open i n respo nse to a brief depolari sing st imulus.
the -mediated mcrca~c 111 K conductance. but other transmitters. such as
!ton dopamine and adcno~ine. abo contribute. A second type of effect is al~o seen in the experiment shown in
A 1/tn ep.1p, which laMJ for aholll 10 seconds. This is produced by Figure 10.4. After nicotine ha;, acted for sc,eral minutes. the cell panially
an
ACh acung on M 1 receptor<.. which close potassium channels. repolarise\ and it\ electrical excitability returns but. despite this.
ine. A late flow epsp. lasting for 1-2 min11tes. This is thought to be mediated trun\mi\,ion remains blocked. This type of secondary. non-depolari~ing
ICCS by a peptodc cotran~mmer. which may be substance Pin some ganglia. block occurs also at the neuromu.,cular junction if repeated do~e~ of the
ion and a gonadotroplun-rel~~~ng hollll()ne-like peptide in others (see Ch. 9). depolari~ing drug ~uccin) lcholine (sec below) are used. The main factor
nit Like the 'low epsp. 11 i' produced by a decrease in K- conductance. respon\1ble for the 'econdlll) block (known clinically as phase II block)
by appear<. to be receptor desell5itisation (see Ch. 2). This causes the
depolan\ing action of the blocking drug to subside. but transmission
yin
Jro-
DEPOLARISATION BLOCK remain\ blocked bccauo,e the receptor!. are desensitised to ACb.

bre. Depolarisation block occurs at c ho linerg ic synapses w hen the

han excitatory nAChRs are persi stently acti vated, and it results fro m EFFECTS OF DRUGS ON CHOLINERGIC
sti II a decrease in the elec tri cal excitability of the postsynaptic cell. TRANSMISSION
lOW Thi~ is shown in Fi gure I 0.4. Applicati o n of n icotine to a
ase ,ympathetic gang l io n causes a depolarisation of the cell, which A s shown in Fig ure I 0.2, drugs can influence cho linergic
transmission either by acting on postsynaptic ACh receptors as
149
at first initiate!> actio n po1enlial discharge. After a few seconds,
 SICnON 2 . CHEMICAL M ED I AT O RS
Control
30min
40 min
60 min
Fig. 10.3 Cholinergic transmission in an autonomic
ganglion cell. Records were obtained with an intracellular
microelectrode from a guinea pig parasympathetic ganglion
cell. The artefact at the beginning of each trace shows the
moment of stimulation of the preganglionic nerve. Tubocurarine
(TC), an acetylcholine antagonist, causes the epsp to become
smaller. In record C, it only just succeeds in triggering the
action potential, and in D it has fallen below the threshold.
Following complete block, antidromic stimulation (not shown)
will still produce an action potential (cf. depolarisation block,
Fig. 10.4). (From Blackman J G et al. 1969 J Physiol 201 : 723.)
agonists or antagonists (Tables 10.1 and I 0.2), or by affecting th e
release or destruction of endogenous ACh.
ln the rest of this chapter, we describe the following groups of
drugs, subdivided according to their physiological site of acti on:
muscarinic agonists
muscarinic antagonists
ganglion-stimulating drugs
ganglion-blocking drugs
neuromuscular-blocking drugs
anticholine terases and other drugs that enhance cholinergic
transmis~ion .
DRUGS AFFECTING MUSCARINIC
RECEPTORS
MUSCARINIC AGONISTS
Structure-activity relationships
Muscarinic agonists, as a group, are often referred to as
parasympathomimetic, because the main effects that they produce
in the w hole animal resemble th ose of parasympathetic
150 stimulati on. The structures of the most important compounds are
Cholinergic transmission
Acetylcholine (ACh) synthesis:
requires choline, which enters the neuron via
carrier- mediated transport
requires acetylation of choline, utilising acetyl
coenzyme A as source of acetyl groups, and
involves choline acetyl transferase, a cytosohc
enzyme found only in cholinergic neurons.
ACh is packaged into synaptic vesicles at high
concentration by carrier-mediated transport.
ACh release occurs by Ca2+-mediated exocytosis. At
the neuromuscular junction, one presynaptic nerve
impulse releases 100-500 vesicles.
At the neuromuscular junction, ACh act s on nicotinic
receptors to open cation channels, producing a rapid
depolarisation (endplate potential), which normally
initiates an action potential in the muscle fibre.
Transmission at other 'fast' cholinergic synapses
(e.g. ganglionic) is similar.
At 'fast' cholinergic synapses, ACh is hydrolysed
within about 1 ms by acetylcholinesterase, so a
presynaptic action potential produces only one
postsynaptic action potential.
Transmission mediated by muscarinic receptors is
much slower in its t1me course, and synaptic
structures are less clearly defined. In many situations,
ACh functions as a modulator rather than as a direct
transmitter.
Main mechanisms of pharmacological block:
inhibition of choline uptake, inhibition of ACh release.
block of postsynaptic receptors or ion channels,
persistent postsynaptic depolarisation.
given in Table I0.3. ACh itsel f and related choline ester' df.
agonists at both mAChRs and nAChRs. but act more potentI} Ul
mAChRs (see Fig. 10. 1). Only bethanechol and pilocarpillt
arc now used clinically.
The key fea tures of the ACh molecule that are important for
activity are the quaternary ammonium group, which bears a Jl<hl i1
charge, and the e~ter group. which bears a partial negati,e ch..r,
and is susceptible to rapid hydrolysis by cholinesterase. Van
of the choline ester structure (fable I0.3) have the effect of redu.:1
the susceptibility of the compound to hydrolysis by choline't~ra>.
and altering the relative activity on mAChRs and nAChR'>.
Car bachol and methacholine are used as experimental tOI.~
Bethanechol, which is a hybrid of these two molecule~. i'> \W~
to hydrolysis and selective for mAChRs, and is occasionall} u"
clinically. Pi locarpine is a partial agonist and shows SOI!k
selecti vity in stimulating secretion f rom sweat, salivary, lacrim..
and bronchial glands, and contracting iris smooth muscle (~a
below), w ith weak effects on gastrointestinal smooth muscle un.
the heart. to
 CHOLINERG I C TRANSMISSION

(a nitric oxide-mediated effect; see Ch. 17), and these two effects
combine to produce a sharp fall in arterial pressure (Fig. I 0.1 ).
A The mechanism of action of muscarinic agonists on t11e heart is
Microelectrode
discussed in Chapter 18.
0 A Smooth muscle. Smooth muscle other tllao vascular smooth
Stirn
muscle contmcts in response to muscarinic agonists. Peristallic
activity of the gastrointestinal tract is increased. which can
cause colid..y pain, and tlle bladder and bronchial smootll muscle
also contract.
\ Sweating, lacrimation, salivatum and bronchial secretion.
Cell body
Preganglontc Postganglionic These result from stimulation of exocrine glands. The combined
trunk trunk effect of bronchial secretion and constriction can interfere with
Ganglion
breathing.
Effects Oil the eye. Such effects are of some importance. The
para&ympatheti c nerves to the eye supply the constrictor pupillae
B Nicotine (50 J.tmol/1)
muscle, which runs circumferentially in tlle iris, and the ciliary

(a) Control 1 (b) 14 s (c) 18 s

mrtscle, which adjusts the curvature of the lens (Fig. 10.5). Con-
traction of the ciliary muscle in response to activation of mAChRs

50mV [
=tt~tt"
40ms 0 A 0 A 0 A
pulls the ci liary body forwards and inwards, tllu s relaxing the
tension on the suspensory ligament of the lens, allowing the lens
to bulge more and reducing its focal length. Thi s parasympathetic
reflex is thus necessary to accommodate the eye for near vision.
The constrictor pupillae is important not only for adjusting the
pupil in re. pon~e to changes in light intensity, but also in
(d) 1 min (e) 2 min (f) 6.5 min
regulating the intraocular pressure. Aqueous humour is secreted

0 A 0 A
=t 0 A
Fig. 10.4 Depolarisation block of ganglionic
transmission by nicotine. A System used for intracellular
recordtng from sympathetic ganglion cells of the frog, showing
the location of orthodromic (0) and antidromic (A) stimulating
(slim) electrodes. Stimulation at 0 excites the cell via the
cholinergic synapse, whereas stimulation at A excites it by
electrical propagation of the action potential. ~ The effect of
nicotine: (a) Control records. The membrane potential is -55 mV
(dotted line = 0 mV), and the cell responds to both 0 and A.
(b) Shortly after adding nicotine, the cell is slightly depolarised
are and spontaneously active, but still responsive to 0 and A.
on (c and d) The cell Is further depolarised, to -25 m\1, and
ine produces only a vestigial action potential. The fact that it does
not respond to A shows that it is electrically inexcitable. (e and
ij In the continued presence of nicotine, the cell repolarises
its and regains its responsiveness to A, but it is still unresponsive
ive to 0 because the ACh receptors are desensitised by nicotine.
rge (From Ginsborg 8 L, Guerrero S 1964 J Physiol172: 189.)
nts
ing
~e.
slowly and continuously by the cells of the epitllelium covering
tllc ciliary body, and it drains into the canal of Schlemm
(Fig. 10.5). which runs around tlle eye close to tlle outer margin
of the iris. The intraocular pressure is normally 10-15 mmHg
above atmospheric, which keeps the eye slightly distended.
Abnormally raised intraocular pressure (associated with glaucoma)
damages the eye and is one of the commonest preventable causes
of blindness. In acute glaucoma. drainage of aqueous humour
becomes impeded when the pupil is dilated. because folding of
the iris ti ssue occludes the drainage angle, causing the intraocular
pressure 10 ri se. Activation of the constrictor pupillae muscle
by muscarini c agonists in these ci rcumstances lowers the
intraocular pressure, although in a normal individual it has little
effect. The increased tension in the ciliary muscle produced
by these drugs may also play a part in improving drainage by
realigning the connective tissue trabecuJae through which the
canal of Schlemrn passes.
T In addition 10 the~e peripheral effects. muscarinic agonistS that are able
10 penetratethe blood brain barrier produce marked cenlr.ll effects due to
acthauon mainly ot M 1 receptol'\ in the brain. These include uemor,
hypothennia and increa...ed locomotor activiry, as well as impro' ed
cognition beeCh. 34). M 1-sclective agonbts (e.g. tacJirensine) are being
imcsugmed for po~~ible use in treating dementia (see Eglen et al.. 1999;
Ch.35).

))S. EHects of muscarinic agonists Clinical use

blc The main actions of muscarinic agonists are readily understood
ICd in term~ of the parasympathetic nervous system.
me Cardiovascular effects. These include cardiac slowing and a
nal decrea\e in cardiac output. The latter action is due mainly to a
.ee decreased force of contraction of the atria, because the ventricles
md have only a sparse parasympathetic innervation and a low sensitivity
to muscarinic agonists. Generalised vasodilatation also occurs
The main use of mu~carinic agonists is in treating glaucoma, by
local instillation in the form of eye drops. Pilocarpine is the mo~t
effective as, being a tertiary anunc. it can cross the conjunctival
membrane. I t is a Mable compound whose action lasts for about
I day. A variety of drugs with different mechanisms of action are
now available for the treatment of glaucoma, and are summarised
in Table I 0.4. 151
 SICTION2 .CHEM I C AL MEDIATORS

Table 1 0 .3 Muscarinic agonists

Drug Structure Receptor specificity Hydrolysis by Clinical uses

acetylcholinesterase

Muscarinic Nicotinic

0 CH,
)l_ 1$
HC ~-CH,
Acetylcholine tH3 +++ +++ +++ None

0 yH,
)l_~N~H3
Carbachol H,N tH, ++ +++ None

0 ~CH
lal
3

Methacholine H,
C)l_ N-CH3
tH, +++ + ++ None

0 ~CH
> I E9
3
H NA N-CH,
Bethanechol tH
3
+++ Bladder" and
gastrointestinal hypotonia
or

~cH3
H ~~H,
' tH3
Muscarine +++ None11

H,C
)::)'c(H'
0
Pilocarpine ++ Glaucoma

Q/ !!!!!!!

'{]
0
Oxotremorine ++ None

"Necessary first to ensure that bladder neck is not obstructed.

~>cause of mushroom poisoning.

Cornea
Dilator
muscle

act
Ciliary uri
muscle lllll
Fig. 10.5 The anterior hlu

l
chamber of the eye, showing the
pathway for secretion and Suspensory
drainage of the aqueous humour. ligaments
152
----------------------------
 CHOLINERGIC TRANSMISSION

Table 10.4 Drugs that lower intraocular pressure

Dru!( Mechanism Notes Reference

Pilocarpine Muscarinic agonist Widely used as eye drops This chapter

Ecothiopate Anticholinesterase Widely used as eye drops Can cause muscle This chapter
spasm and systemic effects.

Timolol, carteolol 13-Adrenoceptor Given as eye drops but may still cause systemic Chapter 11
antagonist side effects: bradycardia. bronchoconstnct1on.

Acetazolamide, Carbonic anhydrase Acetazolamide is given systemically. Side effects include diuresis, Chapter 24
dorzolamlde inhibitor loss of appetite, tingling, neutropenia. Dorzolamide is used as eye
drops. Side effects include bitter taste and burning sensation.

Clonidine, apraclonidine ~-Adrenoceptor agonist Used as eye drops Chapter 11

--~------~------------------------------------------
Latanoprost Prostaglandin analogue Can cause ocular pigmentation Chapter 13

"The most important drugs are shown in bold type.

Bcthancchol i'> very occa,ionally used to a~sist bladder emptying
or to \timulate ga ... trointestinal motility (see Table 10.3). It acts
mainly on M 1 recep10rs and has little effect on lhe heart. In
principle. a -.elective M~ agonist would be useful for treating
cardiac dy,rh)'thmias. but such drugs remain to be discovered.
MUSCARINIC ANTAGONISTS
\luo;carinic receptor antagonists (parasympatholytic drugs;
Table 10.5) are competitive antagonists whose chemical structures
u~ually comain ester and basic groups in lhe same relationship as
~Ch. butthcy have a buiJ...y aromatic group in place of the acetyl
group. The two naturally occurring compounds, atropine and
h}oscine (scopolamine) are a lkaloids found in solanaceous plants.
The deadly nightshade (Atropa belladonna) contains mainly
atropine. whereas the thorn apple (Datura stramonium) contains
mainly hyoscine. These arc tertiary ammonium compounds that
an: sufficiently lipid-soluble to be readily absorbed from lhe gut
or conjunctival ~ac and, importantly, to penetrate the blood-
brain barrier. The quaternary derivative of atropine, atropine
mcthonitra te, has pcripheruJ actions very similar to those of
alropine bur. because of its exclusion from the brain, lacks
cemral actions. Tiotro pium and ipratropium are also quaternary
deri\atives that are poorly absorbed from lhe lung. Given by
,, inhalation. they act on airways smooth muscle and are used
ro treat asthma and chronic obstructive pulmonary disease.
m although thi'> b unimportant in normal individuals. it can be
C)clopentola te and tropicamide are tertiary amines developed
for ophthalmic use and administered as eye drops. Pire nzepine
1' a relative!) selective M 1 receptor antagonist. Oxybuty nin,
tolterodinc and darife nacin (M3 -selective) are new drugs that
act on the bladder to inhibit micturition. and are used for treating
urinary incontinence. They produce unwanted effects typical of
muscarinic antagoniM1>. such as dry mouth, constipation and
blurred vbion, but these are les1. severe than wilh earlier drugs.
Effects of muscarinic antagonists
j All the muscarinic antagonists produce basically s imi lar
peripheral effects. although ~ome show a degree of selectivity,
for example for the heart or lhc gastrointestinal tract, reflecting
heterogeneity among mAChRs (seep. 145).
The main effects of atropine are as follow.
Inhibition of secretions. Salivary, lacrimal. bronchial and sweat
gland!. are inhibired by very low doses of atropine. producing an
uncomfortably dry mouth and skin. Ga~tric secretion is only slightly
reduced. Mucociliary clearance in the bronchi is inhibited, '-O that
re,idual ~ecretions tend to accumulate in the lungs. lprmropium
lacks thi<> effect.
Effects on heart rate. Atropine causes tachycardia through
block of cardiac mACh Rs. T he tachycardia is modest. up to
80-90 beats/min in humans. This is because there is no effect
on the sympathetic 1>ystem, but only inhibition of the existing
parasympathetic tone. Tachycardia is most pronounced in young
people, in whom vagal tOne at rest is highest; it is often absen t
in the e lderly. AI very low doses, atropine causes a paradoxical
bradycardia, possibly due to a central action. The response of
the heart to exercise is unaffected. Arterial blood pressure is
unaffecred, because most resistance vessels have no cholinergic
innervation.
Effects 0 11 the eye. The pupil is dilated (mydriasis) by atropine
administration. and becomes unresponsive to light. Relaxation of
lhe ciliary muscle causes paralysis of accommodation (cycloplegia).
so that near vision is impaired. Intraocular pressure may ril>e;
dangerou'> in patients suffering from narrow-angle glaucoma.
Effects 0 11 the gastroi11testi11al tract. Gastrointestinal motilit}
is inhibited by atropi ne, although this requires larger doses than
the other effects listed. and is not complete. This is because
excitatory transmiuers other than ACh are important in normal
function of the myenteric plexus (sec Ch. 9). Atropine is used in
pathological conditions in which there is increased gastrointestinal
motility; agents selective for M 3 receptors, which are being
developed, may be preferable. PircMepine, owing to its selectivity
for M 1 receptors, inh ibits gastric acid secretion in doses that do
not affec t other systems.
153
SECTION 2 . CHEMICAL MEDIATORS

Table 10.5 Muscarinic antagonists

Compound Phannacological properties Clinical uses Notes

Atropine Non-selective antagonist Adjunct for anaesthesia Belladonna alkaloid

Well absorbed orally (reduced secretions, bronchodilatatlon) Main side effects: urinary retenhoo.
CNS stimulant Anticholinesterase po1soning dry mouth, blurred vision
Bradycardia Dicycloverine (dicyclomine) 1s Stmila'
Gastrointestinal hyperrnottlity and used mainly as antispasmod c
(antispasmodic) agent

Hyoscine Similar to atropine As atropine Belladonna alkaloid (also known as

scopolamine)
CNS depressant Motion sickness Causes sedation; other side effects
as atropine

Atropine Similar to atropine but poorly Mainly for gastrointestinal hypermotility Quaternary ammonium derivative
methonitrate absorbed and lacks CNS effects Similar drugs include
Significant ganglion-blocking activity methscopolamine, propantheline

Tiotroplum Similar to atropine methonitrate By inhalation for asthma, bronchitis Quaternary ammonium compound
Does not inhibit mucociliary lpratropium similar
clearance from bronchi

Tropicamide Similar to atropine Ophthalmic use to produce mydriasis

May raise intraocular pressure and cycloplegia (as eye drops)
Short acting

Cyclopentolate Similar to tropicamide As tropicamide Qong acting)

Pirenzeptne Selective for M 1 receptors
Inhibits gastric secret1on by action
on ganglion cells
Little effect on smooth muscle
orCNS
Peptic ulcer Fewer side effects than other
muscarinic antagonists
Largely superseded by other
antiulcer drugs (see Ch. 25)

Darifenacin Select1ve for M3 receptors Urinary incontinence Few side effects

For chemical structures, see Hardman J G, Limbird L E, Gilman A G, Goodman-Gilman A et al. 2001 Goodman and Gilman's
pharmacological basis of therapeutics, 10th edn. McGraw-Hill, New York.

Effects 011 other smooth muscle. Bronchial, biliary and
urinary tract smooth muscle are all relaxed by atropine. Renex
bronchocon\triction (e.g. during anae&thesia) is prevented by
atropine. whereas bronchoconstriction caused by local mediators.
!ouch as histamine and leukotrienes (e.g. in asthma: Ch. 23) is
unaffected. Biliary and urinary tract smooth muscle are only
~lightly affected, probably because transmitters other than ACh
(see Ch. 6) are important in these organs; nevertheless. atropine
and similar drugs commonly precipitate urinary retention in
elderly men with prostatic enlargement.
Effects 011 the CNS. Atropine produces mainly excitatory
effects on the CNS. At low doses. this causes mild restlessness:
higher doses cause agitation and disorientation. In atropine
poisoning, which occur~> mainly in young children who eat
deadly nightshade berries, marked excitement and irritability
result in hyperactivity and a considerable rise in body
temperature, which i~> accenlllated by the loss of sweating.
These central effect1> are the result of blocking mAChRs in
the brain. and they arc opposed by anticholinestera~e dru~
such a<, physostigmjne. which i!. an effective antidote 1
atropine poisoning. Scopolamine in low doses causes marked
~edation. but ha.~ ~imilar effects in high dosage. Scopolamme
also ha~ a useful antiemetic effect and is used in treaun
motion l>ickne'>'>. Mu!.carinic antagonists also affect
cxtrap}ramidal system. reducing the involuntary mO\emt
and rigidity of patient!> \.,ith Parkinson's disea e (Ch 1;
and counteracting the extrapyramidal side effects of mam-
antip-.ychotic dn1g:. (Ch. 38).
Clinical use
The main u.,es of muscarinic antagonists are shown in Table 10 i
and the clinical box (p. 156). Apart from piren7epmc
(M 1-selective). currently u::.ed muscarinic antagonists show liule
subtype selectivity. M3-selective antagonists, which may be
U!>cful as smooth muscle relaxants, are in development, but none
has so far been approved for clinical use.
 CHOLINERGIC TRANSMISSION

DRUGS AFFECTING AUTONOMIC GANGLIA
GANGLION STIMULANTS
\IO\t nAChR agonbt~ affect both ganglionic and motor endplate
receptor\. but nicoti ne. lobeline and dimethylphenylpiperazinium
0\TPP) affect ganglia preferentially (Table 10.6).
Nicotine and lobeline are tertiary amines found in the leaves
of tobacco and lobelia plant!>, respectively. Nicoline belong~ in
pharmacological foii...Jore, as it was the substance on the tip of
Llngley\ paintbru'h cau~ing ~>timulation of muscle fibres when
applied to the endplate region, leading him to postulate in 1905
the existence of a 'receptive ~ubstance on the surface of the fibres
tCh. 9). DMPP is a synthetic compound that is selective for
ganglionic receptors.
Only nicotine is used clinically (to help people to stop smoking;
1CC Ch. 43); o th erwi se these drug~ are used only as experimental
tools. They cause complex peripheral responses associated with
generalised stimu lation of autonomic ganglia. The effects of
nicotine on the gastrointestinal tract and sweat glands are familiar
to neophyte smokers (see Ch. 43), although usually insufficient
to act a, an effective deterrent.
By interference with ACh release, as at the neuromuscular
junction (seep. 161 and Ch. 9). Botulinum toxin and
h emicholinium work in thh way.
By prolonged depolari~ation. Nicotine (see Fig. 10.4) can
block ganglia. after initial stimulation. in this way. as can
ACh itself if cholinesterase is inhibited so that it can exert a
continuing action on the postsynaptic membrane.
By interference with the postsynaptic action of ACh. The fe\"'
ganglion-blocking drugs of practical importance ac t by
blocking neuronal nAChRs or the associated ion channels.
T Fifty year~ ago. Paton and Zaimi~ investigated a series of linear
bi\quaternary compound~. Compounds with five or six carbon atom'>
(h exa methonium : T<~ble t0.6) in the methylene chain linking the mo
qumernary gmupo, produced ganglionic block. whereas compounds \\ith
nine or ten carbon atom\ (decamethonium) produced neuromuscular block. 1
Hexamethonium, although no longer used, deserves recognition as
the fin.t ciTcctivc anLihyperten~ive agent (see Ch. 19). The on ly ganglion-
blocking dnag currently in clinical usc is trimetapban (Thble t0.6: see
below).

GANGLION-BLOCKING DRUGS
Ganglion block b often used in experimental studies on the
autonomic nervous !.ystem but is of little clinical importance. It
can occur by several mechani'>ms.
1
Ba<;ed on their \tructurJl ~imilarit} to ACh. the!.e compound'> were
origanall} bchc\ed to act as compctimc antagonists. Ho'' e'er. the) are now
known to act mainly b)' blocling the ion channel rather than the receptor
.,ite il'>etf.

Table 10.1 Nicotine receptor agonists and antagonist s

Drug(s) Main site Type of action Notes

Agonists
Nicotine Autonomic ganglia Stimulation then block See Chapter 43
CNS Stimulation For CNS effects, see Chapter 43

Lobeline Autonomic ganglia Stimulation

)g~
Sensory nerve terminals Stimulation
lO
ted Eptbatldine Autonomic ganglia, CNS Stimulation Isolated from frog skin
lUll! Highly potent
No clinical uses
lng
Lhe Suxamethonium Neuromuscular junction Depolarisation block Used clinically as muscle relaxant
em
~5) Decamethonium Neuromuscular junction Depolarisation block No clinical use
Ill}
Antagonists
Hexamethonium Autonomic ganglia Transmission block No clinical use

Tnmetaphan Autonomic ganglia Transmission block Blood pressure-lowenng in surgery (rarely used)
0.5
ine Tubocurarine Neuromuscular junction Transmission block Now rarely used
Ule
Pancuronium Neuromuscular junction Transmission block Widely used as muscle relaxants in anaesthesia
be Atracurium
)llC Vecuronium
155
 SICTION2 .C H EMI C A L M EDIA TOR S
Clinical uses of muscari ni c antagonists
Cardiovascular
Treatment of sinus bradycardia (e.g. after myocardial
infarction; see Ch. 18): atropine.
Ophthalmic
To dilate the pupil: for example tropicamide or
cyclopentolate eye drops.
Neurological
Prevention of motion sickness: for example
hyoscine (orally or transdermally).
Parkinsonism (see Ch. 35), especially to counteract
movement disorders caused by antipsychotic drugs
(see Ch. 38): for example benzhexol, benztropine.
Respiratory
Asthma and chronic obstructive pulmonary disease
(see Ch. 23, clinical boxes): ipratropium or
tiotropium by inhalation.
Anaesthetic premedication
To dry secretions: for example atropine,
hyoscine. (Current anaesthetics are relatively
non-irritant, see Ch. 36, so this use is now less
important.)
Gastrointestinal
To facilitate endoscopy and gastrointestinal radiology
by relaxing gastrointestinal smooth muscle
(antispasmodic action; see Ch. 25): for example
hyoscine.
As an antispasmodic in irritable bowel syndrome or
colonic diverticular disease: for example
dicycloverine (dicyclomine).
To t reat peptic ulcer disease by suppressing gastric
acid secretion (see Ch. 25): for example pirenzepine
(M 1 -selective antagonist). This is used less since the
introduction of histamine H2 antagonists and proton
pump inhibitors.
EHects of ganglion-blocking drugs
The effects of ganglion-blocking drugs are numerous and
complex, as would be expected, because both di vi sion~ of
the autonomic nervous sy!.tem are blocked indiscriminately.
The description by Paton of 'hexamethonium man' cannot be
bettered:
"f' He is a pink-complexioned peNon. except when he has stood in a queue
for a long time. when he may get pale and faint. His handshake i~ warm
and dry. He is a placid and relaxed companion: for instance be may laugh
but he can't cry becau~ the tear.. cannot come. Your rudest Mo) wall not
make him blush. and lhe mo\t unplea\ant circumstances will fail to make
him tum pale. His collars and \OCk\ \Ia) \e) clean and sweet. He wear.
corse~ and may, if you meet him out, be rather fidgety {coNet\ to
compre5s his ~planchnic va~>cular pool. fidgety to keep the vcnou<o. return
going from his legs). He dii>likcs speaking much unless helped with
156 ~omcthing to moisten hii> dry mouth nnd Lhroat. He is long-sigh ted and
a
Drugs acti ng on muscarinic receptors
a
M uscarinic agonists
Important compounds include acetylcholine,
carbachol, methacholine, muscarine and pilocarpine.
They vary in muscarinic/nicotinic selectivity, and in
susceptibility to cholinesterase.
Main effects are bradycardia and vasodilatation
(endothelium-dependent), leading to fall in blood
pressure; contraction of visceral smooth muscle (gut,
bladder, bronchi, etc.); exocrine secretions, pupillary
constriction and ciliary muscle contraction, leading to
decrease of intraocular pressure.
Main use is in treatment of g laucoma (especially
pilocarpine).
Most agonists show little receptor subtype selectivity, ei
but more selective compounds are in development. re
M uscari nic antagonist s ac
Most important compounds are atropine, to
scopolamine, ipratrop1um and pirenzepine.
an
Main effects are inhibition of secretions; tachycardia.
th
pupillary dilatation and paralysis of accommodation,
111
relaxation of smooth muscle (gut, bronchi, biliary
lw
tract, bladder); inhibition of gastric acid secretion
(especially pirenzepine); central nervous system
effect s (mainly excitatory with atropine; depressant,
including amnesia, with scopolamine), including
antiemetic effect and antiparkinsonian effect.
N
ea~ily blinded by bright hght. The redne~>s of his eyeball~ ma} 'UW!I
irregular habit~ and in fact hi\ head is rather weak. But he alway' beha1 In
like a gentleman and never belchc;, or hiccups. He tend\ to gel cold 0111 'ct
keeps well wrapped up. But hi ~ health i~ good: he docs not have chilb!J
rat I
and Lhose diseases of modern dv ilitat ion. bypenension and r ertic ulc,
pa~s him by. He gets thin bccau;,c hib appetite is modeM; he never fee Cu
hunger pains and hi~> Momach never rumbles. He gets rather con,tip.,
~o that his intake of liqu id paraffin i'> high. As old age come., on. he~
suffer from retention of unne and impotence. but frequency. precapllaDCJ
and strangury will not wor) ham. One b uncertain how he "'ill end. t.1
perhaps if be i~ not careful. b} eating les\ and less and gelling colder
colder. he will bink into a ;,)mptomle.,<.. hypoglycaemic coma and dae,a
was proposed for lhe umvcrsc. a 'on of entropy dealh.
(From Paton W D M 1954 The principles of ganglion block. l..ccturNJG
the scientific ba.,i~ of medicine. vol. 2.)
In practice, the imponant effects are on the cardiovascular system
A marked fall in arterial blood pressure results mainly from bloc~
of sympathetic ganglia, which cau~es a1teriolar vasodilatation. Mu-
cardiovascular retlexe~ are blocked. In particular. the venocon,.
Lriction, wb.ich occurs nom1ally when a subject stands up, and \\hldl
is necessary to prevent the central venous pressure from falhn:
sharply, is reduced. Standing thu~ causes a sudden fall in cardU.
output and arterial pressure (postural hypotension) that can cau
fainting. Similarly, the vasodilatation of skeletal muscle dunn.
exercise is normally accompanied by vasoconstriction elsewhl!re
(e.g. splanchnic area) produced by sympathetic activity. If 1ha1

adju<.tment i~ prevented, the overall peripheral resistance fa lls
and the blood pre~\ure abo fall~ (po:.texercise hypotension).
Clinical use
Ganglion-blocking drug~. becau~e of their many side effects. are
chnicall) obc;olcte. witJ1 tlle exception of trimetaphan. a very short-
...:ting drug that can be adminiMered as an intravenous infusion
for certain types of anae~thetic procedure. Tilting of the operating
table results in controlled hypotension, used to minimise bleeding
during certain l-ind~ of surgery. Trimetaphan can also be u~ed to
lo11er blood pres... ure as an emergency procedure.
NEUROMUSCULAR-BLOCKING DRUGS
The pharmacology of neuromuscular function is well reviewed
by Bowman ( 1990). Drugs can block neuromuscular transmission
either by acting presynaptically to inhibit ACh synthesis or
release, or by acting po~ tsy napti cally, the latter being the site of
action of all the cli nically important drugs (except for botulinum
toxin; see below).
Clinically, neuromuscular block is used only as an adjunct to
anae-thcsia. when artificial venti lation is available; it i<; not a
therapeutic intervention. The drugs tllat are used all work by
interfering with the post~ynaptic action of ACh. They fal l into
1110 categoric<,:
non-depolari\ing blocking agentc, (the majority), which act by
blocl-ing ACh receptor" (and, in 5ome cases. also by blocl-ing
aon channel')
dcpolarising blocking agents. which are agonists at ACh
reccpto~.
NON-DEPOLARISING BLOCKING AGENTS
In 1856, Claude Bernard, in a famous experiment, showed that
~umre' causes paralysis by blocking neuromuscular transmission,
n;,
mther than by abolishing nerve conduction or muscle contracti lity.
er.
~b
Curan: is a mi xture of naturally occurring alkaloids found in
cd various South American plants and used as arrow poisons by
ill South American Indian,. The most important component is
tubocurari ne. the structure of which was elucidated in I935.
Tubocurarine is now rarely used in cli nical medicine. being
>uper-.eded by ~ynthetic drug!> with improved properties. The
mo>t important arc pa ncu ronium. vecuronium and atracur ium
1Tablc 10.7). which differ mainly in their duration of action.
pn
Gallamine wac, the fiN u<.,eful ~ynthetic successor to tubocurarine,
but has been re placed by compound~ with fewer side effects.
'll. The!>C substances arc all quaternary ammonium compounds,
:k 11hach means thai they are poorly absorbed and generally rapidly
hi mreted. They ai'>O fail to cross the placenta. which is important
..,_
an relation to their use in ob!>tetric anaesthesia. The low oral
r::h ab,orption of tubocurarine allowed it to be used safely in the
1g hunting of ani mal<, for food.
uc
se Mechanism of action
1g Non-depolarising blocking agents all act as competitive antagonists
re tsee Ch. 2) at the ACh receptors of the endplate. The amount of
li S ACh released by a nerve impulse normally exceeds by several-
CHOLINERGIC T RANSMISS I ON
fo ld what if. needed to elicit an action potential in the muscle
fibre. It is therefore neces~ary to block 70-80% of the receptor
site!. before tran!.mission actually fails. When this happens. it is
still po~'>ible to record a subthreshold epp in the muscle fibre
(Fig. 10.6). In any individual muscle fibre. transmission is all or
nothing. so graded degrees of block represent a varying proportion
of muscle fibre!-. failing to respond. ln this situation. where the
amplitude of cpp in all the fibres is close to threshold (just above
in some, just below in other5). small variations in tlle amount of
tran!.miuer released. or in the rate at which it is destroyed, will
have a large effect on the proportion of fibres contracting. so the
degree of block is liable to vary according to various physiological
circumstances (e.g. stimulation frequency. temperature, and
cholinesterase inhibition), which normally bave relatively little
effect on the efficiency of transmission.
Some non-dcpolarising blocking agents also appear to block
presynaptic autorcceptors, and thus inhibit the release of ACh
during repetitive stimulation of tlle motor nerve (see Prior et al.,
1995). This may play a part in causing the 'tetanic fade' seen witll
these drugs (sec p. 160).
Drugs acting on autonomic ganglia
Ganglion-stimulating drugs
Compounds include nicotine,
damethylphenylpiperazinium (DMPP).
Both sympathetic and parasympathetic ganglia are
stimulated, so effects are complex, including
tachycardia and increase of blood pressure; variable
effects on gastrointestinal motility and secretions;
increased bronchial, salivary and sweat secretions.
Additional effects result from stimulation of other
neuronal structures, including sensory and
noradrenergic nerve terminals.
Ganglion stimulation may be followed by
depolarisation block.
Nicotine also has important central nervous system
effects.
No therapeutic uses, except for nicotine to asstst
giving up smoking.
Ganglion-blocking drugs
Compounds include hexamethonium, trimetaphan,
tubocurarine (also nicotine; see above).
Block all autonomic ganglia and enteric ganglia. Main
effects: hypotension and loss of cardiovascular
reflexes, inhibition of secretions, gastrointestinal
paralysis, impaired micturition.
Clinically obsolete, except for occasional use of
trimetaphan to produce controlled hypotension in
anaesthesia.
157
 SECTION2 .CHEMICAL MEDIATORS

Ta ble 10.7 Characteristics of neuromuscular-blocking drugs

Drug Speed of onset Duration of action Main side effects Notes

Tubocurarine Slow (> 5 mtn) Long (1-2 h) Hypotension (ganglion block Plant alkaloid, now rarely used
plus histamine release) A lcuronium is a semisynthetic
Bronchoconstriclion derivative with similar properties
(histamine release) but fewer side effects

Pancuronium lntermedtate Long Slight tachycardia The first steroid-based compound

(2-3mtn) No hypotension Better side effect profile than tubocurarine
Widely used
Pipecuronium is similar

Vecuronium Intermediate Intermediate Few side effects Widely used

(30-40min) Occasionally causes prolonged paralysis,
probably owing to active metabolite
Rocuronium is similar, with faster onset

Atracurium Intermediate Intermediate Transient hypotension Unusual mechanism of elimination

(< 30 min) {histamine release) (spontaneous non-enzymic chemical
degradation in plasma); degradation
slowed by acidosis
Widely used
Doxacurium is chemically similar but stable
in plasma, giving it long duration of action
Cisatracurium is the pure isomeric
constituent of atracurium, similar but wtth
of
less histamine release

Mivacurium Fast (-2 min) Short (- 15 min) Transient hypotenston New drug, chemically similar to atracunum
(histamine release) but rapidly inactivated by plasma
cholinesterase (therefore longer acting tn
patients with liver disease or with genetic
cholinesterase deficiency (see p. 160)

Suxamethonium Fast Short (- 10 min) Bradycardia (muscarinic
agonist effect)
Cardiac dysrhythmlas
(increased plasma K+
concentration-avoid In
patients with burns or
severe trauma)
Raised intraocular pressure
(nicotinic agonist effect on
extraocular muscles)
Postoperative muscle pain
Acts by depolarisation of endplate (nicotintc
agonist effect)-the only drug of this type
still in use
Paralysis is preceded by transient
muscle fasciculations
Short duration of action owing to hydrolysiS
by plasma cholinesterase (prolonged action
in patients with liver disease or genetic
deficiency of plasma cholinesterase) oy
Used for brief procedures (e.g. tracheal
ut
Intubation, electroconvulsive shock therapy)
Rocuronium has similar speed of onset and
recovery, with fewer unwanted effects

"For chemical structures, see Hardman J G, Umbird L E, Gilman A G, Goodman-Gilman A et al. 2001 Goodman and Gilman's
pharmacological basis of therapeutics, 10th edn. McGraw-Hill, New York.

EHects of non-depolarising blocking drugs
The effects of no n-de polaris ing ne uromuscular-blocking agents
arc mainly due to motor paralysis, althoug h some of the drugs
also produce clinically sig nificant autonomic effects. The first
muscles to be affected are the extrins ic eye muscles (causing double
vision) and the small muscles of the face, limbs and pharynx
(causing difficulty in swallowing). Respiratory muscles are the
last to be affected and the first to recover. An experiment in 1947
158
in which a heroic volunteer wa~ fully curarised under artificial
an
de
ventilatio n e~tabli shed this orderly paralytic march. and shO\Icd to
that conscio usness and aware ness of pain were quite nom1al e1c
when paralysis was complete. The spec ial characteristics of no
depolaris ing block, and the ways in which it differs fror
de polarisation block, arc described on page 160.
Unwanted eHects
The main s ide e ffect of tubocurarine is a fall in arterial pressurt.
chicf1y due to gang lion block. An additional cause is the relcast
 CHOLINERGIC TRANSMISSION

jE Normal
Action Action
/ p otential / p otential
0
201
20
mV -40
-60
Fig. 10.6 The effect of
-80
tubocurarine on neuromuscular
transmission. A Microelectrode
record1ng at the endplate (left)
normally shows a complex response -40~
-60
to nerve stimulation, consisting of
an endplate potential (epp), from the 80
peak of which the action potential is Recording from endplate Recording away from endplate
initiated. The action potential is
distorted by the local Increase in
conductance produced by the
transmitter, Away from the endplate,
a simple propagated action potential
Is recorded, Bl Tubocurarine
reduces the epp amplitude, so that
no action potential is generated,

of histamine from ma!>t cells (see Ch. I 3), which can also give
n-.e to bronchospasm in c;ensitive individuals. This is unrelated to 100

n..\ChR'> but al<;o occurs with atracurium and mivacurium (as

11ell a.~ with some unrelated dmgs such as morphine, Ch. 4 I),
The other non-depolari1>ing blocking drugs lack these side 80
efl"ect\. and hence cause less hypotension. Gallamine, and to a
lesser extent pancuronium, block rnAChRs, particularly in the
heart, which re~ults in tachycardia.
60
Pharmacokinetic aspects
"lcuromuscular-blocking agents are used mainly in anaesthesia to
produce mu~cle relaxation. They are given intravenously but differ
40
in their rates of onset and recovery (Fig. I 0.7 and Table I 0.7).
Most of the non-depolarising blocking agents are metabolised
b) the liver or excreted unchanged in the urine, exceptions being
atracurium, which hydrolyses spontaneously in plasma, and 20
mhacurium, which, like succinylcholine, is hydrolysed by plasma
choline\tCrase. Their duration of action varies between about
IS minute\ and I 2 hours (Table J 0. 7). by which time the patient
regain' enough ~trength to cough and breathe properly, although 0
re'1dual weakness may persist for much longer. The route of 0 20 40 60 80
Time (min)
elimination i'> important, because many patients undergoing
dnaesthe~ia have impaired renal or hepatic function. which, Dimethyltubocurarine Fazadinium
oepending on the drug used, can enhance or prolong the paralysis Tubocuranne Gallamine
,ed to an important degree.
Pancuronium Alracurium
'CO Atracurium wa\ de'>igned to be chemically unstable at physio-
on- logical pH (spliuing into two inactive fragments by cleavage at Fig. 10.7 Rate of recovery from various non-
om one of the quaternary nitrogen atoms), although indefinitely depol arising neuromuscular-blocking drugs in humans.
'table when ~tored at an acid pH. It has a short duration of action, Drugs were given intravenously to patients undergoing surgery,
11hich is unaffected by renal or hepatic function. Because of the in doses just sufficient to cause 100% block of the tetanic
tension of the indirectly stimulated adductor pollicis muscle.
marked pH dependence of its degradation, however, its action
Recovery of tension was then followed as a function of time.
Jre, becomes considerably briefer during respiratory alkalosis caused (From Payne J P, Hughes R 1981 Br J Anaesth 53: 45.)
ase by hyperventilation, 159
 SEcnON2. CHEMICAL MEDIATORS
DEPOLARISING BLOCKING AGENTS
Thi~ cla~s
of neuromuscular-blocking drugs was discovered by
Paton and Zaimi'> in their study of the effect<; of symmetrical
bisquaternary ammonium compounds. One of these,
decamethonium, was found to cause paralysis without appreciable
ganglion-blod.ing activity. Several features of its action showed
it to be different from competitive blocking drugs such as
tubocurarine. In particular, it was found to produce a transient
twitching of skeletal muscle (fasciculation) before causing block,
and when it wa!> injected into chicks it caused a powerful extensor
spasm, 2 whereas tubocurarine simply caused flaccid paralysi1.. In
1951, Burns and Paton showed that its action was to cau~e a
maintained depolarisation at the endplate region of the mu&cle
fibre, which led to a loss of electrical excitability (sec p. 149),
and they coined the term depofarisation block. Fasciculation
occurs because the developing endplate depolarisation initially
causes a discharge of action potentials in the muscle fibre. This
subsides after a few seconds as the electrical excitability of the
endplate region of the fibre is lost.
Decamethonium itself was used clinically but has the
disadvantage of too long a duration of action. Suxamethonium
(Table 10.7) is closely related in structure to both decamethonium
and ACh (consi:.ting of two ACh molecules linked by their acetyl
groups). Its action is '>horter than that of decamethonium, because
it is quickly hydrolysed by pla1.ma cbolinesterdSc. Suxamethonium
and decamethonium act-like ACb-as agonists on the receptors
of the motor end plate. llowever. when given as drugs, they diffuse
relatively slowly to the endplate and remain there for long enough
that the depolarisation causes loss of electrical excitability. ACh,
in contrast, when released from the nerve, reaches the endplate in
very brief spurt!> and is rapidly hydrolysed in situ, so it never
causes sufficiently prolonged depolarisation to result in block. If
cholinesterase is inhibited. however (seep. 164), it is possible for
the circu lating ACh concentration to reach a level sufficient to
cause depolarisation block.
Comparison of non-depolarising and
depolarising blocking drugs
There arc several differences in the pattern of neuromuscular
block produced by depolarising and non-depolarising mechanisms.
Anticholine~terase drugs are very effective in overcoming the
blocl.ing action of competitive agents. This is because the
released ACh, protected from hydroly:.is, can diffuse further
within the <;ynaptic cleft. and so gains access to a wider area
of post~ynaptic membrane than it normally would. The chances
of an ACh molecule finding an unoccupied receptor before
being hydrolysed are thus increased. This diffusional effect
seems to be of more importance than a truly competitive
1
Birds possess a special type of skeletal muscle. rare in mammals. that has
many endplate~ scattered over the surface of each muscle fibre. A drug that
cau~c~ cndplatc de polarisation produces <1 widespre<~d depolarisation in such
mu~cle~. rc,ulting in a maintained contracture. In oormal skeletal muscle,
with only one endplate per fibre. end plate depolarisation i~ too localised to
160 cause con tracture on it~ own.
interaction, for it is unlikely that appreciable dissocwtion of
the antagonist can occur in the short time for which the \Q
i'> present. In contra~!. depolarisation block is unaffected. a
even increased, by anticholinesterase drugs.
The fa'>ciculations seen with suxan1ethonium (see Tabk 10
as a prelude to paralysis do not occur with compelili\e d
There appear:. to be a correlation between the amount of
fasciculation and the severity of the postoperative mu'l<:lc
pain that is often produced by succinylcholine.
Tewnic fade (a term used to describe the failure of mu-.cle
tension to be maintained during a brief period of nerve
stimulation at a frequency high enough to produce a fu,cd
tetanus) i)> increa~>ed by non-depolarising blocking drug,.
compared with normal muscle. This is probably due main!)
to the block of pre:-.ynaptic nAChRs. which normally scne t
sustain transmitter release during a tetanus (see Prior et al,
1995), and it docs not occur with depolarisation block. Th1,
forms the basis of a simple test used by anaesthetists to
discover which type of block is present. Electrodes are
applied lo the skin over a peripheral nerve, such as the uln
nerve, and mu..,cle contraction is observed during a short
period of tetanic stimulation.
Unwanted eHects and dangers of depolarising
drugs
Suxamcthonium. the only drug of this type in clinical u-e.
produce a number of important adverse effects (see Table IQ
Bradycardia. Thi ~ i!. preventable by atropine and is pro~
due to a direct muscarinic action.
Potassium release. The increase in cation permeabilit} oft
motor end plates cause!. a net loss of K+ from muscle, and thu,
small rise in pla!.ma K+ concentration. Tn normal individuah.L
is not important, but in cases of trauma, especially bum' c
injuries causing muscle denervation, it may be (Fig. 10.8). Th
is because dcnervation causes ACh receptors to spread to region
of the muscle fibre away from the end plates (see Ch. 9). so that
much large r area of membrane is sensitive to succinylcholilll
The resulting hyperkalae mia can be enough to cause ventricuJ,
dysrhythmia or even cardiac arrest.
Increased intraocular pressure. This results from contractu
of extraocular muscles applying pressure to the eyeball. It
particularly important to avoid this if the eyeball ha.~ been injured
Prolonged paralysis. The action of succinylcholine g11
intravenously normally lasts for less than 5 minutes, becau-e t1r
drug is hydrolysed by plasma cholinesterase. Its action is prolonged
by variou<, factors that reduce the activity of this enLyme:
Genetic variants in which plasma chounesterase is abnonru.l
(sec Ch. 52). Severe deficiency, enough to increase the durntioo
of action to 2 hours or more, occurs in only about I in 200l
individuals. Very rarely, the en.qme is completely absenl and
the paralysis lasts for many hours.
Anticholinesterase drugs. The use of organophosphates to treo
glaucoma (see Table I 0.4) can inhibit plasma cholinestera'e
and prolong the action of succinylcholine. Competing substr.rte'
for plasma c holinesterase (e.g. procaine. propanidid) can al\11
have this e iTeet.
 CHOLINERGIC TRANSMISSION

9 Neuromuscular-blocking drugs

8
T
Substances that block choline uptake: for
Paralysed example hemicholinium (not used clinically).
7)
gs. s 7 Substances that block acetylcholine release:

.
0
E am~noglycoside antibiotics, botulinum toxin .
.s 6 Drugs used to cause paralysis during anaesthesia are
~ as follows.
ro 5 Non-depolarising neuromuscular-blocking agents:
E
"'ro tubocurarine, pancuronium, atracurium,
a: 4
vecuronium. These act as competitive antagonists
at nicotinic acetylcholine receptors and differ
3
Sux mainly in duration of action.
Depolarising neuromuscular-blocking agents:
to 2
20 suxamethonium.
0 4 8 12 16
Important characteristics of non-depolarising and
s Minutes
depolarising blocking drugs:
Fig. 10.8 Effect of succinylcholine (Sux) o n plasma
non-depolarising block is reversible by
potassium concentration in humans. Blood was collected
from veins draining paralysed and non-paralysed limbs of anticholinesterase drugs, depolarising block is not
seven injured patients undergoing surgery. The injuries had depolarising block produces initial fasciculations
resulted in motor nerve degeneration, and hence denervation and often postoperative muscle pain
supersensitivity of the affected muscles. (From Tobey R E et al. suxamethonium is hydrolysed by plasma
1972 Anaesthesiology 37: 322.) cholinesterase and is normally very short-acting,
'9 but may cause long-lasting paralysis in a small
group of congenitally cholinesterase-deficient
an
individuals.
).
Main side effects: tubocurarine causes ganglion
Dl)
block, histamine release, hence hypotension.
bronchoconstriction; newer non-depolarising blocking
the drugs have fewer side effects; suxamethonium may
a ~eonates and patients with liver disease may have low plasma
cause bradycardia, cardiac dysrhythmias due to K
his cholinesterase activity and show prolonged paralysis with
release (especially in burned or injured patients).
~uccinylchol i ne.
or increased intraocular pressure, malignant
hi-, Ma/igna11t hyperthermia. This is a rare inherited condition. hyperthermia (rare).
ns due to a mutation of the Ca 2 release channel of the sarcoplasmic
t a reticulum (the ryanodine receptor, sec Ch. 4), which results in
ne. intcn~c muscle spasm lUld a dramatic rise in body temperature when
lar certain drugs arc given (sec Ch. 51). The most commonly implicated
drug' are suxamethonium and hal othane, although it can be DRUGS THAT INHIBIT ACETYLCHOLINE RELEASE
~re
precipitated by a variety of other drugs. The condition carries a
Acetylcholine release by a nerve impulse involves the entry of
is wy high mortality (about 65%) and is treated by administration Ca2+ into the nerve terminal; the increase in [Ca 2..], stimulates
:d. of dantrolcnc, a drug that inhibits muscle conttaction by preventing
cxocytosis and increases the rate of quantal release (Fig. I0.2).
en Ca~ relea-;e from the sarcopla.<omic reticulum.
Agents that inhibit Ca 2 + entry include Mg2 and various
he
aminoglycoside antibiotics (e.g. streptomycin and neomycin:
ed
DRUGS THAT ACT PRESYNAPTICALLY sec Ch. 46), which occa:.ionally produce muscle paralysis as an
unwanted side eiTect when used clinically.
DRUGS THAT INHIBIT ACETYLCHOLINE Two potent neurotoxins. namely botulinum toxin and ~
SYNTHESIS bungarotoxin. act specifically to inhibit ACh release. Botulinum
m
The ~teps in the '>ynthe~>is of ACh in the presynaptic nerve terminals toxin is a protein produced by the anaerobic bacillus Clostridium
ld arc shown in Figure 10.2. The rate-limiting process appears to be bowlinum, an organi~>m that can multiply in preserved food and
the transport of choline into the nerve terminal. H emicholinium can cause botulism. an extremely serious type of food poisoning.
at blocks this transport and thereby inhibits ACh synthesis. 1t is useful The potency of botulinum toxin is extraordinary, the minimum
a!> :m experimental tool but has no clinical applications. Its blocking lethal dose in a mouse being less than w-12 g-only a few million
effect on transmission develops slowly, as the existing stores of molecules. It belongs to the group of potent bacterial cxotoxins
so ACh become depleted. Vesamicol, which acts by blocking ACh that includes tetanus and diphtheria toxins. They possess two
161
transport into synaptic vesicles, has a similar effect. subunits, one of which binds to a membrane receptor and is
 SEcnON 2 . CHEMICAL MEDIATORS
re~ponsible for cellular ~pecificity. By this means, the toxin
enters the cell, where the other !>ubunit produces the toxic effect
(see Montecucco & Schiavo. 1995). Botulinum toxin contain~
~everal components (A- G). They are peptidases that cleave
'>pecific protein~ involved in exocytosis (synaptobre1ins.
symaxins. etc.-see Ch. 9). thereby producing a long-lasting
block of synaptic function. Each toAin component inactivates a
different functional protein- a remarkably coordinated attack
by a humble bacterium on a vital component of mammalian
physiology.
Botulinum poisoning causes progressive parasympathetic and
motor paralysis, with dry mouth. blurred vision and difficulty in
swallowing, followed by progressive respiratory paralysis.
Treatment with untitoxin is effecti ve only if g iven before
symptoms appear. for o nce the toxin is bound its action cannot be
reversed. Morta lity is high. and recovery takes several weeks.
Anticholinesterases and drugs that increase transmitter re lease
(sec p. 163) are ine ffective in restoring transmission. Among the
more spectacular o utbreaks of botulinum poisoning was an
incident on Loch Maree in Scotland in 1922, when all eight
members of a fishing party died after eating duck pate for their
lunch. Their ghillies, con,uming humbler fare no doubt. survived.
The innkeeper committed suicide.
Botulinum toxin. injected locally into mu des. is used to treat
a fonn of per<,i'>tent and disabling eyelid spasm (blepharol.pasm)
as well a., other type'> of local mu1>cle spasm. for example in
spasticity (sec T<,ui. 1996). Boto"< is abo fashionable as a wrinkle
remover, remO\ ing frown lines by paralysing the superficial muscles
that pucker the skin. Injections must be repeated every few momhs
to sustain the effect. For the same agent to figure as a beauty
treatment a., well as a weapon of biological warfare renects
strangely on the modern wo rld.
"' 1'\-llungarotO:\in i\ a protein contained in the venom of various snakes
of the cobra family, und hil~ a ;imilar action to b<>tulinum toxin. although
it~ active component i~ a phospholipase rather than a pcptida~c. The 'ame
venom\ abo contain a-bun ga rotoxi n (see p. 27). whic h blocks
po!.H.ynaptic ACit receptors. so these snakes evidently cover all
cvcmualitics a\ far as causing paralys is of their victims is concerned.
DRUGS THAT ENHANCE CHOLINERGIC
TRANSMISSION
Drugs that enhance cholinergic transmission act either by inhibiting
cholinesterase (the main group) or by increasing ACh release. ln
thi'> chapter, we focu~ on the peripheral actions of such drugs;
drug' affecting cholinergic transmission in the CNS. used to treat
senile dementia, are discussed in Chapter 35.
DISTRIBUTION AND FUNCTION OF
CHOLINESTERASE
There are two diMinct types of cholinesterase, namely
acetylcholinesterase and butyrylcholinesterase (BuChE), closely
related in molecular Mructure but differing in their distribution,
su bstrate specific ity and functions (see Cbatonnet & Lockridge.
1989). Both consist of g lobular cata lytic subunits. which constitute
162
the soluble forms fo und in plasma (B uChE) and cerebrospinal
fluid (AChE). Elsewhere. the catalytic units are linked to collager
like proteins or to glycolipids, through which they are tethereu
like a bunch of balloons. to the cell membrane or the ba..emet:
membrane at various c;ites, including cholinergic synapse\ I
al'>o. oddly. the erythrocyte membrane. where the function of he
enzyme is unknown).
The bound AChE at cholinergic synapses serves ro h}drol~
the released transmitter and temunate its action rapid!). SolubJ
AChE is al'>o present in cholinergic nerve terminals. "here
seems to have a role in regulating the free ACh concentrauua.
and from which it may be secreted: the function of the secre1td
enzyme is so far unclear. AChE is quite specific for ACh
closely re lated esters 1.uch as methacholine. Certain neuropepttdc~,
such as substance P (Ch. 16) are inactivated by AChE, but it1
not known whether this is of physiological significance. Overall
the re i!> poor corresponde nce between the dis tribution ur
chol inerg ic synapses and that of AChE. both in the brain and in
the periphery, and AChE most probably has functions otherthJ
dispo~a l of t\Ch, although the details remain unclear (see revic.
by Sorcq & Seidman, 200 1).
Butyrylcholine!>tem.se (or pseudocholinesterase) ha~ a wide\prc.il
distribution. being found in tissues such as liver, skin, brain .w
gastrointestinal \mooth muscle, as well as in soluble form in ihe
plasma. It is not particularly associated with cholinergic synaJ)'e\
and its phy~iological function is unclear. It has a broader ~ub>llld:
specificity than AChE. It hydrolyses the synthetic ~ub,u;
butyrylcholine more rapidly than ACh. as well as other e'Je
such a<, p rocaine. s uccinylcholine and p ropa n idid (a short-a.:
anaesthetic agent: 1>ec Ch. 36). T he plasma enzyme is import.~~
in rel:llion to the inactivation of the drugs listed above. Gene .
variants of BuChE occur (see Ch. 52). and these partly accou
for the variability in the duration of action of these drugs. Th.
very 1.hort duration of action of ACh given intravenously (It
Fig. I 0. 1) re~ults from its rapid hydrolysis in the plasma. Nonnal11
AChE a nd BuChE between them keep the plasma ACh at ru:
undelectably low level, so ACh (unlike noradrenaline) is stricll)
a ncurotran!>mit te r and not <I hormone.
Both AChE and BuChE belong to the class of serine hydrolase.
which includes many proteases, suc h as trypsin. The acti\e ,n,
of AChE comprises two distinct reg ions: an anionic site (glutamak
residue), which bind!. the basic (choline) moiety of ACh: and
esreratic site (h i ~tidine +serine). As with other serine hydrola~
the acidic (acetyl) group of the ~ubstrate is transferred to tJ
serine hydroxyl group. leaving (transiently) an acetylated enz~m:
molecule and a molecule of free choline. Spontaneous hydro!~
of the serine acetyl group occurs rapidly. and the overalltumO\tt
number of AChE i\ extremely high (over 10 000 molecule, d
ACh hydroly<,ed per second by a single acti\'e site).
DRUGS THAT INHIBIT CHOLINESTERASE
Peripherall y acting anticholinesterase drugs fall into three m...
group~ according to the nature of their interaction with the acU1.
1.ilc, which determines their duration of action. Most of the
inhibit AChE a nd BuChE about equally. Centrally actm,
anticholinesterases, developed for the treatment of dementia, ar,
discussed in C hapter 35.
 CHOLINERGIC TRANSMISSION

1- Short-acting anticholinesterases compounds of clinical importance, and physostigmine (c crine).

ti. The only important drug among the short-acting anticholinesterases a tertiary amine. which occurs naturally in the Cal abar bean.'
t "edrophonium (Table I0.8), a quaternary ammonium compound These drugs are all carbamyl. as opposed to acetyl, esters, and
ld that binds to the anionic site of the enzyme only. The ionic bond all possess basic groups that bind to tbe anioruc site. Transfer of
IC fom1ed is readjly reversible, and the action of the dmg is very brief. the carbamyl group to the serine hydroxyl group of the esteratic
h i~ used mrunly for diagnostic purposes, because improvement site occurs as with ACh, but the carbamylated enzyme i~> very
of muscle strength by an anticholinesterase is characteristic of much slower to hydrolyse (Fig. I 0.9), taking minutes rather than
le mya~thenia gravis (see p. 165) but docs not occur when muscle microseconds. The anticholinesterase drug is therefore hydrolysed.
it weakness is due to other causes.
n.
:d Medium-duration anticholinesterases 'Otherwise known a' the ordeal bean. In the Middle Ages, extracts of the..e
1d The medium-duration anticholinesterases (Table 10.8) include bean\ were used to determine the guilt or innocence of those accu~ed of
!S~ neostigmine and pyridostigmine, which are quaternary ammoruum crime or heresy. Death implied guah.
IS
11.
of
in
!ln
:w
Table 10.8 Anticholinester ase drugs
ud
d Drug Structure Duration Main site Notes
he of act ion of action

lte
1te
CH, CH
Edrophonium H~~Lf > Short NMJ Used mainly in diagnosis of myasthenia gravis
:::,... I tH, Too short acting for therapeutic use

CH,
Neostigmine H,C, ~I Medium NMJ Used intravenously to reverse competitive
H,c'Y N-CH, neuromuscular block
0 :::,... &, Used orally in treatment of myasthenia gravis
Visceral side effects
ec
l).
n
H,
H,C'Nn
0
o-ecfj
:::,...
1
ly I I p
Physostigmine CH3 CH3 Medium Used as eye drops in treatment of glaucoma

es.
itc
te
Pyridostigmine
HC....~o-(J-CH
H,<Y I
Medium NMJ Used orally in treatment of myasthenia gravis
Better absorbed than neostigmine and has
an 0 :::,... longer duration of action

he
ne Dyflos ~>--o'pto Long p Highly toxic organophosphate, with very
H,C>-O 'F prolonged action
~is H,c Has been used as eye drops for glaucoma
rer
of
H,c'-../o,P,o ?~
Ecothiopate HP,..'d 's,.........,_.'fcH, Long p Used as eye drops in treatment of glaucoma
CH3 Prolonged action; may cause systemic effects

lin Parath1on H,C'-../Oys Long Converted to active metabolite by replacement

\'e H,<Y" o 0--Q-No, of sulfur by oxygen
Used as insecticide but commonly causes
em poisoning in humans
ng
tre NMJ, neuromuscular junction; P, postganglionic parasympathetic junction.
163
 SECTION2 .CHEMICAL MEDIATOR S

Reversible anticholinesterase Irreversible anticholinesterase

Active enzyme

OPr
I
coo- Ho-r-oPr
J F Dyflos
A
'
' r
I
HO- P- OPr
Phosphorylated
enzyme
Histidin~:> Anionic
No spontaneous
hydrolysis
site coo-
Catalytic
site Serine Glutamate
J

Carbamyl transferred
to serine -OH

,I

p
coo- b

'
J ..
' a
p
'
: Reactivation
Phosphate
.. ,.... -............................. --:' ' transferred to -NOH
: Carbamyl-serine :
Enzyme OPr ~
: hydrolysed
:__ _____(slow)
'
_________ ,
reactivated PrQ- r- o-~~
OH I
~

Fig. 10.9 Action of anticholinesterase drugs. Reversible anticholinesterase (neostigmine): recovery of activity by hydrolysis of the
carbamylated enzyme takes many minutes. Irreversible anticholinesterase (dyflos): reactivation of phosphorylated enzyme by pralidoxime.

but at a negligible rate compared with ACh, and the slow recovery
of the carbamylatcd enzyme mean~ that the action of these drug-;
is quite long-lasting.
Irreversible anticholinesterases
Irreversible anticholinesterases (Table I 0.8) are pentavalent
phosphorus compounds containing a labile group such as nuoride
(in dyflos) or an organic group (in parat hion and ecothiopatc).
This group is released, leaving the serine hydroxyl group of the
enzyme phosphorylated (Fig. 10.9). Most of these organophosphate
compounds. of which there are many, developed as war gases and
pesticides as well as for clinical u~c: they interact only with the
esteratic site of the enzyme and have no cationic group. Ecothiopme
i~ an exception in having a quaternary nitrogen group designed to
bind also to the anionic site.
drugs. such as ecolhiopatc, slow hydrolysis occurs over the couroc
of a few days, so that their action is not strictly irrevcr.iblt
Dynos and parathion are volatile non-polar substance!) of ll'l)
high lipid solubility, and arc rapidly absorbed through muco
membranes and even through unbroken skin and insect cuudc
the use of these agents as war gases or insecticides relie~ on th
property. The lack of a specificity-conferring quaternary grour
means lhat most of these drugs block other serine hydrola-.e1
(e.g. trypsin, thrombin), although their pharmacologicnl effcct1
resu lt mainly from c ho linesterase inhibition.
Effects of anticholinesterase drugs
Cholinesterase inhibitors affect peripheral as well a~ centro!
cholinergic synapses. Ill
Some organophosphate compounds can produce, in addition .. \\

The inactive phosphorylated enzyme is usually very stable. severe form of neurotoxicity.
With drugs such as dynos. no appreciable hydrolysis occurs. and Effects 011 autonomic cholinergic sy11apses. These mainly ren~
recovery of enzymic activity depends on the synthesis of new enhancement of ACh activity at parasympathetic postgangliom,
164 ent.yme molecules, a process that may take weeks. With other synapses (i.e. increased secretions from salivary, lacrimal, bronchial
 CHOLINERGIC TRANSMISSION

:md ga~trointestinal glands: increased peristaltic activity: bro ncho- only pan ly understood, but it seems to result from inhibition of
constriction: bradycardia and hypotension: pupillary consuiction: an esterase (not cholinesterase itself) specific to myelin.
fi'ation of accommodation for near vis io n: fall in intraocular The main u~es of anticholincsterases are summarised in the
pn!,-.ure). Large do'>es can 'timulate. ru1d later block, autonomic clinical box.
ganglia, producing complex autonomic effects. The block, if it
occurs, i<> a depolarbmion block and is associated wi th a build-
CHOLINESTERASE REACTIVATION
up of ACh in the pla:.ma and body fl uids. Neostigmine and
p)rido~tigmine tend to affec t neuromuscular transmission more Spontaneous hydrolyl-.b of phosphorylated cholinesterase is
than the autonomic sy~tem. w hereas physostigmine and organo- extremely <;(ow, a fact that make~ poisoning with organophosphates
pho,phates . how the reverse pattern. T he reason is not clear, but very dangerous. Pralidoxime (Figs I 0.9 and I0. 10) reactivates
therapeutic usage ta l...es advantage o f this partial selectivi ty. the cntymc by bringing an oxime g roup into close proximity
Acute antic ho linesterase poisoni ng (e.g. from contact with with the phosphorylated esteratic site. T his group is a strong
in~ccticides or war gases) causes 11cvere bradycardia, hypotension nuc lcophile and lures the phosphate group away from the serine
and difficulty in breathing. Combined with a depo larising ne uro- hydroxy l gro up o f' the en;,yme. The effecti veness of pralidox ime
muscular block, and central e ffects (see be low), the result may be in reacti vating pl a~ma cho linesterase activity in a po isoned subject
fatal. is shown in Figure I0. 10. The main drawback to its use as an
Effects on the neuromuscular j unction. The twitch te nsion antidote to o rgano phosphate poisoning is that, within a few hours,
of a muscle stimulated via its moto r ne rve is inc reased by the phosphorylated enzy me undergoes a chemical change ('ageing')
anticholinesterases. owing to repetitive firing in the muscle fibre that rende rs it no lo nger !>Usceptible to reacti vation, so that
a~sociated wi th prolongation of the epp. Normally, the AC h is
h)drolysed so qu icldy that each stimulus initiates only one actio n
potential in the muscle fibre, but whe n AChE is inhibited th is is
Clinical uses of anticholinesterase drugs
convened to a '>hon train of action potentials in the muscle fibre.
and hence greater ten,ion. Much more important is the effect
To reverse the action of non-depolarising
produced when tran<,mis.,ion ha'> been blocked by a competitive
neuromuscular-blocking drugs at the end of an
blocking agent such a'> tubocurarine. In this ca<>e, add ition of an
operation (neostigmine).
anucholincMcrase can dramatically restore trans mission. 1f a large
To treat myasthenia gravis (neostigmine or
proponion of the receptor~ are blocked. the majority of ACh
pyridostigmine).
molecules will normally encounter. and be destroyed by. an AChE
As a test for myasthenia gravis and to distinguish
molecule before reaching a vacan t receptor; inhibiting AChE
weakness caused by anticholinesterase overdosage
gi1e~ the ACh mol ecu l e~ a greater chance of finding a vacam
('cholinergic crisis') from the weakness of myasthenia
r~ceptor before being destroyed. and thus inc rease the epp so that
itself ('myasthenic crisis'): edrophonium, a
it reaches thresho ld. In myasthenia gravis (see below ). transmi~~i on
short-acting drug given intravenously.
faib because there arc too few ACh recepto rs, and cholineste rase
Alzheimer's dieases (e.g. donepezil; see Ch. 35).
inhibition improves transmission j ust as it does in curari sed muscle.
Glaucoma (ecothiopate eye drops).
In large doses, :-.uch as can occur in poisoning, anticholinesterases
initiall y cause !witching o f muscles. This is because spontru1cous
ACh release can g ive rise to cpps that reach the firing threshold.
Later. paralysis may occur due to depo larisation block, whic h
c. i' as~oc iat cd wi th the build-up o f AC h in the plasma and tissue
ry lluids.
JS Effects on the CNS. Tertiary compounds, such a<> physostigmine,
and the non-polar organopho~phates penetrate the blood-brain
banicr freely and affect the brain. The result is an initial excitation, e
c0
100
1p \\hich can result in convuhion~. followed by depression, wh ich 0
0
can cau-,c unconscious ness and respiratory failure. These central ~
~
effects result mainly from the activation of rnAChRs, and are >
antagoni'>ed by atropine. The use of anticholi nesterascs to treat u
<
\Cnile dementia i<. di-,c ussed in C hapter 35. w
~
(.)
Neurotoxicity of organophosphates. Many organophosphates <
nl can cause a severe type of peripheral nerve demyelination. leading E
Ul
< 0
to progressive weaknes'i and l-.cnsory loss. This is not a problem 0::: I
0 30 60 90
a \\ith clinically u~ed a nticholinestcrases but occasiona lly occurs Time (min)
11 ith accidental poisoni ng with insecticides. ln 193 1, an estimated
Fig. 10.10 Reactivation of plasma cholinesterase (ChE)
Ct 20 000 Americans were affected , some fata lly. by contaminatio n in a volunteer subject by intravenous injection of
ic of fruit juice with an organophosphate insectic ide, and other similar pralidoxime. (Redrawn from Sim V M 1965 JAMA 192: 404.) )
outbreaks have been recorded. T he mechanism of this reaction is 165
tll
SlcnON 2 . C HE M I C AL MEDIATORS
A indi' idual,, who ~hO\\ muscle wcakncs~ and increa.\00 fatiguahilit} re'
Normal
Action
potential
J10mV
Tension
J 10kg
B]
Myasthenia
J 10 mV
Control
] 10 kg
After
neostigmine
Fig . 10.11 Neuromuscular transmission in a normal and
a myasthenic human subject. Electrical activity was recorded
with a needle electrode in the adductor pollicis muscle, in
response to ulnar nerve stimulation (3 Hz) at the wrist. IAl In a
normal subject, electrical and mechanical response is well
sustained. B In a myasthenic patient, transmission fails rapidly
when nerve is stimulated. Treatment with neostigmine improves
transmiSSIOn. (From Desmedt J E 1962 Bull Acad Roy Med
Belg VII 2: 213.)
pralidoxime must be given early in order to work. Pralidoxime
does not enter the brain, but related compounds have been developed
to treat the central effects of organophosphate poisoning.
Myasthenia gravis
T The neuromuscu lar junction j, a robust wucture that very rarely fai ls,
mya~theniagr:wi& being one of the very few disorders thm specifically
Chollneste,.se and anticholinesterase drugs
There are two main forms of cholinesterase:
acetylcholinesterase {AChE), which is mainly
membrane-bound, relatively specific for acetylcholine,
and responsible for raptd acetylcholine hydrolysis at
cholinergtc synapses; and butyrylcholinesterase
(BuChE) or pseudocholinesterase, which is relatively
non-selective and occurs in plasma and many tissues.
Both enzymes belong to the family of serine hydrolases.
Anticholinesterase drugs are of three main types:
short-acting (edrophonium); medium-acting
(neostigmine, physostigmine); irreversible
(organophosphates, dyflos, ecothiopate). They differ
in the nature of their chemical interact ion with the
act ive site of cholinesterase.
affect\ it bee LindMrom. 2000). This disea<.e affecu, about I 1n
fmm a failure of neuromu~ular transmission. The tendency for 1ro111'
10 fail during repeliti\e acthity can be seen in Figure 10.11 . t'unch
u result, 10 !he inability of muscle~ to produce sustained contr.~cn<-m.
which the characterhtic drooping eyelid~ of myasthenic patienh m
'ign. The ellecti\eness of anticholinesterase drugs in impnl' ing
\trcngth in mya\thenia was di~overed in 1931, long before the C3DSe
the di\C3.\C \\il\ J.n<l\\n.
The cau-.e of the transmission failure is an autoimrnune re,pon-.e
cau'e' a lo\\ of nAChR\ from the neuromuscular junction, fiN re'
in \ludic' \ho\\ing that the number of bungarotoxin-binding sne-> a: lit
endplates of myu"hcnic patients was reduced by about 70% c1>m~
with normal. It had been ;uspected !hat myasthenia had an immunulogd
ha\i~. becau ..e removal of the thymus gland was frequently of ilcll(
lmmuni ~ati on of nthbit~ with purified ACh receptor causes, after a dt
symptom; very 'imilar to those of human myasthenia gravis.'l11c prt~e
of antibody directed against' !he ACh recepwr protein can be detecttd
the ~crum of mya~lhenic patients. but the reason for the dcvclop111ent
the autoimmune rc~pon~ in human' i' still unknown (see Lindstrom.llll
The improvement of neuromu~cu l ar function by anticholin~,l~r
treallllCill ('hown in Fig. 10.11) can be dr.tmatic, but if !he disease~"""
too far. !he number of reccpto" remaining may become too few to prOOIII
an adequate cpp. and anticholine,tera\e drug!> willlh.:n cease to be elle.u
Alternative approachc\ to !he treatmem of myasthenia are 10 remo1e
culating anubody by plasma exchange. which is transiently cffecti,~.O!
a more pmlonged effect, to inhibit antibody production with <,tem<h e
prednisolone) or unmun<l,upp~t drug~ (e.g. azathioprine: s..-c Ot If
OTHER DRUGS THAT ENHANCE CHOLINERGIC
TRANSMISSION
T It v.a\ ob\ened many years ago !hat tetraethylammonium bt
!.no\\ n a\ a ganglion-blocking drug. could reverse !he neuromu-..:
blocking action of tubocurarine. and this was shown to be be~au<e
incrca\C\ the relea\e of tran'omitter evoked by nerve \limul
Subsequently. aminopyridines. 11hich bloc!. potaS,ium channel' (..ee CbA
and thu\ prolong th<.: action potential in !he presynaptic nene term1
were founu 10 act similarly and to be considerably more potent
..elective in their acti ons than tetraethylammonium. These drugs are'
5electivc for cholinergic nerves but increase the evoked release of m:m.
different tran~mittcrs, ~o have too many unwanted effect; to be u~elul m
treating neu romuscular di~orders.
Effects of anticholinesterase drugs are due
mainly to enhancement of cholinergic transmission at
cholinergic autonomic synapses and at the
neuromuscular junction. Anticholinesterases that cross
the blood-bratn bamer (e.g. physostigmine,
organophosphates) also have marked central nervous
system effects. Autonomic effects include bradycardia
hypotension, excessive secretions, bronchoconstriction.
gastrointestinal hypermotility, decrease of intraocular
pressure. Neuromuscular action causes muscle
fasciculation and increased twitch tension, and can
produce depolarisation block.
Ant icholinesterase poisoning may occur from exposure
to insecticides or nerve gases.
 Noradrenergic

transm1ss1on

Adrenaline (epinephrine), a hormone secreted by the

Overview 168
f--
Catecholamines 168
Classification of adrenoceptors 168
Physiology of noradrenergic transmission
-The noradrenergic neuron 171
1--
Drugs acting on noradrenergic transmission
-Drugs acting on adrenoceptors 176
--
Drugs that affect noradrenergic neurons 182
-Drugs that affect noradrenaline synthesis 182
-Drugs that affect noradrenaline storage 182
-Drugs that affect noradrenaline release 183
-Inhibitors of noradrenaline uptake 184
OVERVIEW
The peripheral noradrenergic neuron is an
important target for drug action, both as an object
for investigation in its own right and as a point of
attack for many clinically useful drugs. In this
chapter, we describe the physiology and function
of noradrenergic neurons and the properties of
adrenoceptors, and discuss the various classes of
drugs that affect them. For convenience, much of
the pharmacological information is summarised
later in the chapter.
CATECHOLAMINE$
Catecholamine~ are compounds containing a catechol moiety (a
ben7ene ring with two adjacent hydroxyl groups) and an amine side-
chain (Fig. 11.1 ). Pharmacologically. the most important ones are:
Noradren aline (n orepin ep h r i n e'). a transmitter released by
sympathetic nerve terminal!.
1
The conventional British names (e.g. adrenaline, noradrenaline) are
used, although the recommended International non-proprietary
168
names (riNNs) are now epinephrine and norepinephrine.
adrenal medulla
D op amine, the metabolic precursor of noradrenaline and
adrenaline, also a transmitter/ neuromodulator in the central
nervous sys tem
171 I soproter enol (previously isopren ali n e). a synthetic
derivative of noradrenaline. not present in the body.
176
CLASSIFICATION OF ADRENOCEPTORS
In 1896, Oliver and Schafer demonstrated that injection of extrac
of adrenal gland caused a rise in arterial pressure. Follm1 mg t1r
subsequent i'>olation of adren aline as the active principle. n ~
shown by Dale in 1913 that adrenaline causes two di~tinct ~1r
of effect. namt!ly vasoconstriction in certain vascular beds ("h
normally predominates and. together with its actions on the hc311
- sec below--causes the rise in arterial pressure) and vasodilau.
tion in others. Dale showed that the vasoconstrictor compone
disappeared if the animal was first injected with an eq;<t
dcrivative 2 (see p. 193), and noticed that adrenaline then caultd
a fall, instead of a rise, in arterial pressure. This result pamllel<.\
Dale's demonstration of the separate muscarinic and nicotin,
componen ts of the action of acety lcholine (see Ch. 10). H(
avoided interpreting it in terms o f different types of receptor. bill
later pharmncological work, beginning with that of Ahlqubtu
1948, showed clearly the existence of several subcla~sc> o
adrenoccptor. Ah lquist found that the rank order of the potencit
of variou~ catecholami nes. including adrenaline. n oradrenalint
and isoproterenol, fell into two distinct patterns, depending t
what re!>pon\e was being mea~urcd. He postulated the exi~tenct
of two kind' of receptor, a and B.
defined in terms of agom
potcncic~ a!. follow~:
u: noradrenaline > adrenaline > isoproterenol
~: i'oprotcrcnol > adrenaline > noradrenaline.
2
Dale was a new recruit in the laboratories of the Wellcome
pharmaceutical company, given the job of checking the potency o1
batches of adrenaline coming from the factory. He tested one batch
at the end of a day's experimentation on a cat that he had earl1er
injected with an ergot preparation. Because it produced a fall in
blood pressure rather than the expected rise, he had advised that
the whole expensive consignment should be rejected. Unknown to
him, he was given the same sample to test a few days later, and
reported it to be normal. How he explained this to Wellcome's
management is not recorded.
 NORADRENERGIC TRANSMISSION

It was then recognised that certain ergot alkaloids, which Dale

had studied, act as ~elective a-receptor antagonists, and that
Noradrenaline Dale's adrenaline reversal experiment reflected the unmasking of
the ~ effect\ of adrenaline by a-receptor blockade. Selective 13-
reccptor antagoni),t~ were not developed until 1955, when their
effect-; fully confirmed Ahlquist"s original classification and also
11uggc~ted the exi~tence of funher subdivi ions of both a and f3
Adrenaline reccpto~ . Subsequent studies with agonists and antagonists have
confirmed the exiMence of two maio a-receptor subtypes (a 1 and
a 2) and three ~-receptor subtypes (~" ~ 2 and ~3 ; Table 11.1 ).
All are typical G-protein-coupled receptors, and cloning hal>
revealed that a 1 and a 2 receptors each comprise three further sub-
Dopamine
classes, which arc expressed io different locations but whose func-
tions are, for the most part, !>till unclear (Bylund, 1994; l nsel, 1996).
Each of these receptor classes is associated with a specific

HOo-~:-CH2 - NH -i:' lsopmte<enol

second mcs~cnger system (Table I 1.1 ). T hus a 1 receptors are
coupled to phospholi pase C and produce their effects mainly by
the relea\e of intracellular Ca2; a 2 receptors are negatively coupled

J
HO CH3 to adenylyl cyclase, and reduce cAMP formation as well as
inhibiting calcium channels; and all three types of ~-receptor act
Fig. 11. 1 Structures of the major catecholamines.
by stimulation of adenylyl cycla<>e. The major effects that are

IS Table 11 . 1 Characteristics of adrenoceptors

"'
h Clt ~ ~I ~2 1\3
n
Tissues and effects
l-
Smooth muscle
lt Blood vessels Constrict ConstricVdilate Dilate
)I Bronchi Constrict Dilate
d Gastrointestinal tract Relax Relax (presynaptic effect) - Relax
(J Gastrointestinal sphincters Contract
Uterus Contract Relax
c.:
Bladder detrusor Relax
e Bladder sphincter Contract
)I Seminal tract Contract Relax
n Iris (radial muscle) Contract
~f Ciliary muscle Relax

~
Heart
e Rate Increase Increase
n Force of contraction Increase Increase
t!
,{ Skeletal muscle Tremor Thermogenesis
Increased muscle mass
and speed of contraction
Glycogenolysis

Uver Glycogenolysis Glycogenolysis

Fat Upolysis
Thermogenesis

Pancreatic islets Decrease insulin

secretion

Nerve terminals
Adrenergic Decrease release Increase release
Cholinergic Decrease release
169
 SECTION 2 . CHEMICAL MEDIATORS

Table 11.1 (cont'd) Characteristics of adrenoceptors

u, ~ ji, ~2 p3
Salivary gland K release Amylase
secretion

Platelets Aggregation

Mast cells Inhibition of histamine

release

Brain stem Inhibits sympathetic

outflow
Second messengers and Phospholipase C ~cAMP t cAMP t cAMP t cAMP
effectors activation ~ Calcium channels
t Inositol t Potassium channels
trisphosphate
t diacylglycerol
t Ca2

Agonist potency order NA ~ A ISO A> NA ISO ISO > NA > A ISO > A > NA ISO > NA = A

Select ive agonists Phenylephrine, Clonidine Dobutamine, Salbutamol, BRL 37344

xamoterol terbutaline,
methoxamine salmeterol,
formoterol
clenbuterol
Selecttve antagontsts Prazosin, Yohimbine, idazoxan Atenolol, Butoxamtne
doxazosin metoprolol

A, adrenaline; ISO, isoproterenol; NA, noradrenaline.

Mtnor component normally but may tncrease in heart rise.

produced by thcl.e receptors. and the main drugs that act on them.
are shown in Table I 1.1.
The distinction between ~ 1 - and f3 2-receptors is an important
one, for ~ 1 - recepto rs are found mainly in the heart, where they
are responsible for th e positive inotropic and chronotropic effects
of catecholamines (see Ch. 18). f3 2-receptors, on the other hand,
are responsible for causing smooth muscle rel axation in many
organs. The latt er is often a useful therapeutic effect, while the
former is more often harm ful; consequently. considerable efforts
have been made to fi nd selecti ve f3 2 agonists, which would relax
smooth muscle w ithout affectin g the heart. and selective f3 1
antagonists. which would exert a use fu l blocking effect on the
hean without at the same time blocking f3 2-receptors in bronchial
smooth muscle (sec Table I 1.1). It is important to realise that the
selectivity of these drugs is re lative rather than absolute. Thus
compounds used as selective f3 1-antagonists invariably have some
action on f3 2-rcccptor<; as well, which can cause unwanted effects
such as bronchoconstriction.
ln relation to vascular control. it is broadly true that a 1- and ~ 2-
receptors act mainly on the smooth muscle cells themsel ves, while
o.2-recepw rs act on presynaptic terminals, but different vascular
beds devi ate from thi s general rule. Both a- and f3-receptor
subtypes arc expressed in smooth muscle cells, nerve terminals
170
and endothelial cells, and their rol e in physiological regulation
and pharm acological responses of the cardiovascular sy~tcm ''
only partly understood (see Guimaraes & M oura, 2001 ).
Partial agonist eHects
T Several drugs that act on adrenoceptors have the characteristics of part1
agonisrs (see Ch. 2), i.e. they block receptors and thus antagoni-e 11't
action'> of fu ll agonists. but also have a weak agonisr effect of their(l\ir.
Examples include ergo!Ji minc (u1-receptors) and clonidine (a1-receptro
Some ~-adrenoceptor-blocking drugs (e.g. alprenolol, oxprenololl cau-c,
under rc\ling conditions. an increase of heart rate while at the same ti
opposing rhe tachycardia produced by sympathetic stimulation. Th1' Ill!
been interprered as a partial agonist effect. although there is evidtn.'t
that mechani'm~ other than ~-receptor activation may contribute row
taCh) cardia.
There are ~cveral additional factors thar mal..e 1}-adreno.:.:pca
pharmacology more complicated than it appears at first s1ghr. and I'\IT
ha\'e 1mphcation~ for the clinical usc of 13-adrenoceptor antagoni,l\:
The high degree of receptor specificity found for some compoo11<h
laboratory animal~ b seldom found in humans
A; well o; f3 1-receptors. f32-reccptors contribme to the cardioslimub
ciTech of catecholam ine;. Normally. the 131contribution predominates.
bul in failing heart; {~ee Ch. 18) f3 2-receptors become more irnpoiLlll
There i ~ evidence that 1)-ndrenoceptor agonists and partial agom
mny net not only through cA MP formation. but also through o1he1
signal transduction pathways {e.g. the mitogen-activated protein kina< l'O
pa1hway: see Ch. 3). and that the relative contribution of these signJh .Ill
 NORADRENERGIC TRANSMISS ION

ATP and ncuropcptidc Y (sec Ch. 12). Ruorescence histochemistry.

Classification of adrenoceptors
Main pharmacological classification into a and
~ subtypes, based originally on order of potency
among agonists, later on selective antagonists.
Adrenoceptor subtypes:
two main a-receptor subtypes, a 1 and ~. each
divided into three further subtypes
three ~-adrenoceptor subtypes ([3,, [32. fill
all belong to the superfamily of G-protein-coupled
receptors.
Second messengers:
ct 1-receptors activate phospholipase C, producing
inositol trisphosphate and diacylglycerol as
second messengers
a 2-receptors inhibit adenylate cyclase, decreasing
cAMP formation
all types of ~- receptor stimulate adenylyl cyclase.
The main effects of receptor activation are as follows.
,-receptors: vasoconstriction, relaxation of
gastrointestinal smooth muscle, salivary secretion
and hepatic glycogenolysis
u 2-receptors: inhibition of transmitter release
(including noradrenaline and acetylcholine release
from autonomic nerves), platelet aggregation,
contraction of vascular smooth muscle, inhibition
of insulin release
fl 1-receptors: increased cardiac rate and force
13z-receptors: bronchodilatation, vasodilatation,
relaxation of visceral smooth muscle, hepatic
glycogenolysis and muscle tremor
~3 -receptors: lipolysis.
in which fonnaldehyde treatment i:. used to convert eatecholamines
to nuore~cent qui none derivatives. shows that noradre naline is
prel.ent at high concemration in these varicosities. where it is !>lored
in large de nse-core ve!.icles. and re leased by exocytosis. ln most
periphera l tb:.ues. the ti,!.ue coment of noradre nali ne closely
parallels the den'>ity of the sympathetic innervation. With the
exception of the adrenal medulla. sympathetic nerve terminah
account for all the noradrenaline conte nt of peripheral tis:.ues.
Organs :.uch as the hean, spleen, vas deferens and some blood
vessels are part icularly rich in noradrenaline (5- 50 nmollg of
tissue) and have been wide ly used fo r studies of no radrene rgic
transmission. For deta iled info rmation o n noradre nerg ic neuro ns,
see Trendelenburg & We ine r ( 1988) and Cooper et al. ( 1996).
NORADRENALINE SYNTHESIS
The biosynthctic pathway for noradre naline synthes is is shown in
Figun.: 11 .2. The metabolic precursor fo r noradrenaline is L-tyrosine.
an aro matic amino acid that is present in the body fluids, and is
taken up by adrenerg ic neurons. Tyrosine hydro.rylase. a cytosolic
Tyrosine
Rate-lim1t1ng step Tyrosine hydroxylase
\.. /
COOH

HOo-CH,-~H - NH, DOPA

!al
dill'er!i fordiflcrcnl dmg~. Fun he1more,Lhe p:.uhways show di fferent levels
of con~t ilutive acti vmion. which is reduced by ligands tbat function as
inver~e agon i,l\. Cli nically u~cd ~-aclrcnoccptor antagon ists differ in
HO .# j, DOPA '"'"""~"" /

e re\pect of thc~oc propcnic~. and dmgs clas1.ified a.o; partial agoni ~ts may
actually activate one pathway whi le blocking the other (sec Baker et HOo -CH, -CH, - NH, Dopemlno
m.
). al.. 2003J.
The
10\er,e
po~\iblc
clinical significance of antagoni,~. panial agonist~ and
.1g0111\h i\ d1~CU\\Cd under the he:1ding~ of individual drug~ later
HO # ~~opamine ~-hydroxylas!t
in Lhi' chapter. fhc pharmacology of ergot derivati,es is discu~scd in OH

HOo-~ t H-CH2-NH2
Chapter 12.
Noradrenaline
or
8) PHYSIOLOGY OF NORADRENERGIC HO #
Phenylethanolamine
TRANSMISSION '- N-methyltransferase ./
in THE NORADRENERGIC NEURON
l.nt ~oradrc ncrgic neu ro ns in the pe ri phery are postganglionic Adrenaline
es. ~ympathct ic neuron'i whO\C cell bodies lie in sympathetic gang(ja.
They generally have lo ng axons that e nd in a series of varicosities
,trung along the branching termina l network. These varicosities Fig. 11 .2 Biosynthesis of catecholamines. DOPA,
contain numerous ~ynaptic vesicles. which are the sites of synthesis dihydroxyphenylalanine. 171
and release of no radre na line a nd of core leased mediators suc h as
 SECTION 2 C H E M I C A l M E D I AT 0 R S
en7yme that cataly\e~ the conversion of tyrosine to dihydroxy-
phenylalanine (dopa) is found only in catecholamine-containing
cell~. It i-, a mthcr selective enzyme; unlike other enzymes involved
in catecholamine metaboli~m. it does not accept indole derivative~
as '>Ub~tr.llc'>, and ~oil> not involved in 5-hydroxytryptamine (5-HT)
metaboli'>m. Thi'> fif'>t hydroxylation Mep is the main control point
for noradrenaline \ynthe'>i~. Tyro~ine hydroxylase is inhibited by
the end-product of the bio~ynthetic pathway. noradrenaline, and
this provide'> the mechanbm for the moment-to-moment regulation
of the rate of synthesi~: much slower regulation. taking hours or
days, occurs by change'> in the rate of production of the enzyme.
The tyrosine analogue a -methyltyrosine strongly inhibits
tyrosine hydroxylase and may be used experimentally to block
noradrenaline synthesis.
The next step, conversion of dopa to dopamine, is catalyscd
by dopa decMboxy/ase. a cytosolic enzyme that is by no means
confined to catecholam ine-synthesising cells. It is a relatively
non-specific cn;ymc, and catalyses the decarboxylation of various
other I.-aromatic amino acid~. such as L-histidinc and L-tryptophan,
which arc precursors in the synthesis of histamine (Ch. 13) and
5-HT (Ch. 12). respectively. Dopa decarboxylase activity is not rate-
limiting for noradrenaline synthesis. Although various factors,
including certain drug'>, affect the enzyme. it is not an effective
means of regulating noradrenaline synthe~is.
Dopamine-~hydmxylase (DBH) is also a relatively non-specific
en1yme. but i<; re'>tricted to catecholamine-synthesising cells. It is
located in synaptic ve..,icles. mainly in membrane-bound form. A
small amount of the en;yme i~ released from adrenergic nerve
terminal<. in company with noradrenaline, representing the
small proportion in a soluble form within the vesicle. Unlike
nomdrcnalinc, the released DBH i~ not subject to rapid degradation
or uptake, so its concentration in plasma and body fluids can be
used a' an index of overall sympathetic nerve activity.
Many drug!> inhibit DBH, including copper-chelating agents
and disulfira m (a drug used mainly for its effect on ethanol
metabolism: !ICC Chs 8 and 54). Such drugs can cause a partial
dep letion of noradrenaline stores and interference with
sympathet ic transmission.
Phenyletlwno/amine N-methyf transferase (PNMD catalyses
1he N-mcthylation of noradrenaline to adrenaline. The main location
of this cn1-ymc i~ in the adrenal medulla, which contains a popu-
lation of adrenaline-releasing (A) cells separate from the smaller
proportion of nomdrenaline-releasing (N) cells. The A cells, which
appear only afler birth, lie adjacent to the adrenal cortex. and the
production of PNMT i~ induced by an action of the steroid
hormones <>ccrcted by the adrenal cortex (see Ch. 28). PNMT is
also found in certain pam. of the brain. where adrenaline may
function as a transmitter. but little is known about its role.
oradrenaline turnover can be measured under steady-Mate
conditions by measuring the rate at which labelled noradrenaline
accumulates when a labelled precursor. such as tyrosine or dopa,
is adminbtercd. The turnover time is defined as the time taken for
an amount of noradrenaline equal to the total tissue content to be
degraded and rcsynthcsiscd. In peripheral tissues, the turnover
time is generall y about 5- 15 hours, but it becomes much shorter
if sympathetic nerve activity is increased. Under normal circum-
172 stances, Ihe rute of synthesis closely matches the rate of release,
so that the noradrenaline content of tissues is constanl regardk
of how fa~t it is being released.
NORADRENALINE STORAGE
Most of the noradrenaline in nerve terminals or chromaffin cdh
is contained in ve~icles: only a little is free in the C}IOpl
under normal circumstances. The concentration in the 'es1ck'n
vel) high (0.3-1.0 mol/1) and is maintained by the mtcul
monoamine transporter, which is similar to the amine tran~~
re<,ponsible for noradrenaline uptake into the nerve terminal. Ill
usc'> the transvesicular proton gradient as its driving force('<.
Liu & Edward~. 1997). Certain drugs. such as reserpine ('"
below; Table 11.2) block this transport and cause nerve termmal
to become depleted of their noradrenaline stores. The vesick
contain two major constituents besides noradrenaline, namch
ATP (about four molecules per molecule of noradrenaline) anJ
a protein called cltmmogranin A. These substances are rclca1cd
along with noradrenaline. and it is generally assumed that
revcr~>ible complex, depending partly on the opposite charge101
the molecule~ of noradrenaline and ATP, is formed within 1lr
vesicle. This would <>erve both to reduce the osmolarity of llr
vesicle content~ and abo to reduce the tendency of noradrenaline
to leak out of the vesicles within the nerve terminal.
ATP itself ha'> a transmitter function at adrenergic S}naP'CI
(sec Lundberg 1996: Ch. 12). being responsible for the [
excitmory synaptic potential and the rapid phase of contr.J(IIOII
produced by ~ympathetic nerve activity in many smooth mu...."'e
tissues.
an
NORADRENALINE RELEASE
The procc~ses linking the arrival of a nerve impulse m
noradrenergic nerve 1ermi nal to the release of noradrenaline art
basically the same as those at other chemically transmitting synapx'
(see Ch. 4). Depo l ~lrisation of the nerve terminal rnernbrdnc
opens calcium channels in the nerve terminal membrane. and the
resulting entry of Ca 2 ' promotes the fusion and discharge of
synaptic vesicles. A surprising feature of the release mechani\m
at the varicosities of noradrenergic nerves is thai the probabili11
of relea'>e, even of a single vesicle, when a nerve impulse arri1c1
at a varicosity, is very low (less than I in 50; see Cunnane. 198~
A single neuron pos.,esse~ many thousand varicosities. so o~
impulse leads to the discharge of a few hundred vesicles, scattert I
O\'er a wide area. Thi'> contra\ts sharply with the neuromu\cular
junction (Ch. 10). where the relea..\e probability at a single tennuu:
i'> high. and release of acetylcholine is sharply localised.
Regulation of noradrenaline release
Noradrenaline release is affected by a variety of substance' lhJ
act on presynaptic receptors (see Ch. 9). Many different type' of
nerve terminal (cholinergic, noradrenergic, dopaminergic, 5-HT
ergic, etc.) are :,ubject to this type of control, and many dilfere01
mediators (e.g. acetylcholine acting through muscarinic receptor,.
catecholamines acting through a- and ~-receptors, angioten110
II, prostaglandins. purine nuclcotides. neuropeptides, etc.) ~:an
act on presynaptic terminals. Presynaptic modulation rcprcscn11
 NORADRENERGIC TRANSMISSION

Table 11.2 Characteristics of noradrenaline (norepinephrine) transport systems

Uptake 1 Uptake 2 Vesicular-

Transport of NA (rat heart)

Us v_ (nmoVg per m1n) 1.2 100

K,. btmoVI) 0.3 250 - 0.2

Specificity NA > A > ISO A > NA > ISO NA = A = ISO

Ill(
Location Neuronal membrane Non-neuronal cell membrane (smooth Synaptic vesicle membrane
ee muscle, cardiac muscle, endothelium)
ee
tb Other substrates Methylnoradrenaline (+)-Noradrenaline Dopamine
Tyramine Dopamine 5-Hydroxytryptamine
e~
Adrenergic neuron- blocking 5-Hydroxytryptamine Guanethidine
Iy drugs (e.g. guanethidine) Histamine MPP+ (see Ch. 35)
1d
~d Inhibitors Cocaine Normetanephrine Reserpine
a Tricyclic antidepressants Steroid hormones (e.g. corticosterone) Tetrabenazine
(e.g. desipramine) Phenoxybenzamlne
>n
Phenoxybenzamine
1e Amphetamine
1e
lC A, adrenaline; ISO, isoprenaline; NA, noradrenaline.
-Transporters corresponding to uptake 1 and vesicular transporter have been cloned and termed noradrenaline transporter and
vesicular monoamine transporter, respectively (see review by Nelson 1998 J Neurochem 71: 1785-1803). The uptake 2 transporter has
not yet been 1dent1f1ed.

n
le

an important phy~io logical control mechanism throughout the

n~rvou s system.
a
Furthermore. noradrenaline. by acting on presynapti c
receptors, can regulate its own release. and also th at of
!S corcleased ATP (sec Ch. 9). This i s believed to occur
IC physiologically, so that released noradrenaline exerts a local
te inhibitory effect on the terminal s from which it came-the so-
>t called autoinhibitory feedback mechanism (Fig. I 1.3; see Starke
n et al.. 1989). Agonists or antagonists affecting these presynaptic
y receptors can have large effects on sympatheti c transmission.
The physiological significance of presynaptic autoinhibition in
). the sympathetic n ervou ~ <,y~tem is still somewhat contentious,
e and there is evidence that, in mo~t ti ssues, it is less influential
d than biochemical mea!>urement~ of transminer overflow would
lf 1mply. T hus, although blocking autoreceptors causes large
tl changes in noradrenaline meljloll'-the amount of noradrenaline
relca~ed into the bathing solution or the bloodstream \\ hen
~~mpathet ic nerves are !ttimulated-the associated changes in
the tissue rc~pon'>e are often rather small. This suggests that what
lt i~ meao,ured in overfl ow experi ments may not be the
i[ phy~iologically important component of transmitter release.
The inhibitory feedback mechanism operates through a 2
It recepton., which inhibit adenylatc cyclase and prevent the opening
1. of calcium channels. Sympathetic nerve terminals also possess
n ~-receptors, coupled to acti vation of adcnylyl cyclase. which
n cause an increased noradrenal ine release. Whether they have any
b phy~ i ol ogi ca l functi on is not yet cleru.
UPTAKE AND DEGRADATION OF
CATECHOLAMINE$
The acti on of released noradrenaline is terminated mainly by
reuptakc of the transmitter into noradrenergic nerve terminal s.
Some is also seque!>tercd by other cells in the vicinity. Circulating
adrenaline and noradrenaline are degraded enzymically, but much
more slow ly than acety lcholine (see Ch. I 0). where synaptically
located ace ty lcholinesterase inacti vates the transmitter in
milliseconds. T he two main catecholamine-metabolising enzymes
are located intrace llularl y, !tO uptake into cells necessarily precede.,
metabolic degradation.
Uptake of catecholamines
Radioactive noradrenaline injected into the bloodstream is
rapidly taken up into tbsues. Part of this uptake is by sympathetic
neuron., (for it di!>appcars when '>ympathetic nerves are caused to
degenerate). from which it can be released again by sympathetic
nerve stimulation. In a study of noradrenaline uptake by isolated
rat heart~. l ven,en identified two distinct uptake mechanisms.
each having the characteristics of a saturable active transport
system capable of accumulating catecholamines against a large
concentration gradient. T he..,e two mechanh ms, called uptake I
and uptake 2, correspond to neuronal and extraneuronal uptake,
respecti vely. About 75% of the noradrenaline released by
sympathetic neurons is recycled via uptake 1, the remainder being
captured by other cells in the vicinity via uptake 2. Thus uptake I
173
 SEcnON 2 . C HEMI CA L MEDIATO RS
Non~drenerglc transmission
Transmitter syntheSIS involves the following.
L-tyrosine is converted to dihydroxyphenylalanine
(d opa) by tyrosine hydroxylase (rate-limiting step).
Tyros1ne hydroxylase occurs only in
catecholaminergic neurons.
Dopa IS converted to dopamine by dopa
decarboxylase.
Dopamine is converted to noradrenaline by
dopamine ~- hydroxylase (DBH), located in
synaptic vesicles.
In the adrenal medulla, noradrenaline is converted
to adrenaline by phenylethanolamine N-methyl
transferase.
Transmitter storage: noradrenaline is stored at high
concentration in synaptic vesicles, together with ATP,
chromogranin and DBH, all of which are released by
exocytosis. Transport of noradrenaline into vesicles
occurs by a reserpine-sensitive transporter.
Noradrenaline content of cytosol is normally low due
to monoamine oxidase in nerve terminals.
Transm1tter release occurs normally by Ca2 -mediated
exocytosis from varicosities on the terminal network.
Non-exocytot1c release occurs in response to
indirectly acting sympathomimetic drugs (e.g.
amphetamine), which displace noradrenaline from
vesicles Noradrenaline escapes via uptake 1
(reverse transport).
Transmitter action is terminated mainly by
transporter-mediated reuptake of noradrenaline into
nerve terminals (uptake 1). Uptake 1 is blocked by
tricyclic antidepressant drugs and cocaine.
Noradrenaline release is controlled by autoinhibitory
feedback mediated by a 2 receptors.
Cotransmission occurs at many noradrenergic nerve
terminals, ATP and neuropeptide Y being frequently
coreleased with NA. ATP mediates the early phase of
smooth muscle contraction in response to
sympathetic nerve activity.
serve~ to cut short the action of the transmitter, and to recycle it,
whereas uptake 2 \erve~ mainly to limit its spread. Uptakes I and
2 arc associated with di'>tinct transporter molecules, which have
different kinetic propertie!t as well as different substrate and
inhibitor specificity, a'> ~ummarised in Table 11.2. Uptake I is a
high-affinity system. relatively l.elective for noradrenaline, with a
low maximum rate of uptake, and it is important in maintaining
relea~able store~ of noradrenaline. Uptake 2 has low affinity, and
tran~port~ adrenaline and isoproterenol as well as noradrenaline,
at a much higher maximum rate than uptake I. The effects of
several important drugs that act on noradrenergic neurons
depend on their nbi lity either to inhibit uptake 1 or to enter the
174 nerve terminal with it shelp (see Table 11.2).
( r
,
Calcium channels
~
~
~~-r
cAMP)
Adenylate
I
ATP lJ cyclase
Exocytosis
f
l ~ ~-Adrenoceptor
I ' I
y '............ //
ATP , ~ NA .;---'
''
'' \
POSTSYNAPTIC RECEPTORS
Fig. 11.3 Feedback control of noradrenaline release.
The presynaptic u 2 receptor inhibits adenylate cyclase,
thereby reducing intracellular cAMP. cAMP acts to promote
Ca2 ' influx in response to membrane depolarisation, and heN:e
to promote the release of noradrenaline and ATP.
Noradrenaline transporters belong to the fam ily of neur
tran~ mi ttcr trnn~porterproteins (NET. OAT, SERT, etc.) spec1~ .
for different amine tra nsmitters. described in Chapter 9: these nd
as cotrn nsporters of Na+, CJ- and the amine in question, u s ingth~
electrochemical gradient for Na+ as a dri ving force. Changc1 I"
this gradient can alter, or even reverse. the operation of uptake
with marked effects on the availability of the released transmit!:
at postsynaptic receptors. Uptake of noradrenaline from thecyto~
into the synaptic vessel is carried our by a different transport(
the l'esicufar monoamine transporter (VMA T).
Metabolic degradation of catecholamines
Endogenous and exogenous catecholamines are metabolised man::.
by two enzymes: monoamine oxidase (MAO) and catechol-0.
methyl transferase (COMn. MAO occurs within cells. bound~~:
the ~urfacc membrane of mitochondria. It is abundant 11
noradrcncrgic nerve terminals but is also present in man) other
places, such as liver and intestinal epithelium. MAO comens
catecholamines to their corresponding aldehydes, which, in the
periphery. arc rapidly metabolised by aldehyde dehydrogena'~ t
the corresponding carboxylic acid (3,4-dihydroxyphenylgi)Cl
being formed from noradrenaline; Fig. 11.4). MAO can also oxidi..
other monoamincs, important ones being dopamine and 5-Hr It
is inhibited by various drugs (see Table 11 .3). which are u~<.'il
 NORADRENERGIC TRANSMISSION

mainly for their effects on the central nervous system. where these
three amincs all have tran:.miuer functions (see Ch. 34). These
drug~ have important ~ide effects that are related to disrurbances
of peripheral adrenergic tran~mission. Within sympathetic neurons,
\lAO comroh the content of dopamine and noradrenaline, and the
releasable store of noradrenaline increases if the enzyme is inhibited.
\1AO and its inhibitor-, are discussed in more detail in Chapter 39.
The second major pathway for catecholamine metabolism
involves meth}lation of one of the catechol hydroxyl groups to
gl\e a mcthoxy dcrivati\'C. COMT is absent from noradrencrgic
neurons but present in the adrenal medulla and many other cells
and tissues. The final product formed by the ~equential action of
MAO and COMT is J-llydrvxy-4-methoxypheny/glycol (MHPG;
~ec Fig. 11.4). This is partly conjugated to sulfate or glucuronide
derivativcl>, which are excreted in the urine. but most of it is
converted to wmillylmcmde/ic (lcic/ (VMA: F ig. 11.4) and excreted
in the urine in this fom1. 3 In patients with tumours o f c hromaffin
%e amounts of MHPG and VMA excreted are often taken to reflect
noradrenaline release from sympathetic neurons and central
nervous system neurons, respectively, but this is now believed to be
unreliable (see Eisenhofer et al., 2004).
tissue that secrete these amines (a rare cause of high blood
pressure), the urinary excretion of VMA is markedly increased,
this being used a\ a diagnostic test for this condition.
In the periphery, neither MAO nor COMT is primarily
responsible for the tcnnination of tnmsmitter action. most of
rhc released noradrenaline being quickly recapiUred by
uptake I. Circulming catccholamines are usually inactivated by
a combination of uptake I. uptake 2 and COMT. the relative
importance of thc:.c processe~ varying according to the
agent concerned. Thus circulating noradrenaline is removed
mainly by uptake I, whereas adrenaline is more dependent
on uptake 2. l&oproterenol. on the other hand, is not a substrate
for uptaf..c I, and is removed by a combination of uptake 2
and COMT.
In the centr:.ll nervous system (see Ch. 32), MAO is more
important as a means of termi nating transmi tter action than it
is in the periphery, a nd MAO knockout mice show a greater
enhancement of noradrcncrgic transmission in the brain than
do NET knockouts, in which neuronal stores of noradrenaline
are much depleted (sec Gainetdinov & Caron, 2003). The
main excretory product of noradrenaline released in the brain
isMI IPG.

( OH l
CH30~COOH ~URINE

HoV VMA Major Metabolite

_)/ t
ADH COMT
( OH -- OH ~ r T oH ---.

t
. CH30~NH2 MAO _,_CH30~CHO HO~COOH
,.
HOV -NM ~ HO V .. ..NM ./ HO V DHMA
t t
aldehyde I ADH A

r
,cr- ---- ~ 7.: ~
~ OH NH,

NA
MAO- H O O C
~
OHICHO
HO~ NA
aldehyde

""'
CH,Ocr:OH CH20H
HO

. MHPEG
~~;;~~ URINE

Minor Metabolite
AR COMT

~ l OH ~
r HO~CH20H
HOV DHPEG

Fig. 11.4 The main pathways of no radrenaline meta bolism . The oxidative branch (catalysed by ADH) predominates, giving VMA
as the main urinary metabolite. The reductive branch (catalysed by AR) produces the less abundant metabolite, MHPEG, which is
conjugated to MHPEG sulfate before being excreted . ADH, aldehyde dehydrogenase; AR, aldehyde reductase; CNS, central nervous
system; COMT, catechol-0 -methyl transferase; DHMA, 3,4-dihydroxymandellc acid; DHPEG, 3,4-dihydroxyphenylglycol; MAO,
monoamine oxidase; MHPEG, 3-methoxy, 4-hyd roxyphenylglycol; NA, noradrenaline; NM, normetanephrine; VMA, vanillylmandelic acid.
175
 SECTION 2 C H E M I C A L M E D I AT 0 RS
DRUGS ACTING ON NORADRENERGIC
TRANSMISSION
Many clinically important drugs, particularly those used ro treat
cardiovascular. re::.piratory and psychiatric disorders (see Chs 18,
19. 23 and 39) act by affecting noradrcnergic neuron function.
The main drug targets are:
adrenoccptors
monoamine transporter::.
catccholaminc-mctabolising enzymes.
The propcrtic~ of the most important drugs that act on adrenergic
transmission arc !>ummarised in Table 11.3.
DRUGS ACTING ON ADRENOCEPTORS
The overall activity of these drugs is governed by their affinity,
efficacy and selectivity with respect to different types of
adrcnoccptor, and intensive research has been devoted to
developing drugs with the right properties for specific clinical
indication~. As a result. the pharmacopoeia is awash with
adrenoceptor ligand!>. Many clinical needs are mer, it turns out,
by drugs that relax -,mooth muscle in different organs of the
body:~ on the other hand, cardiac stimulation is generally unde-
sirable. Broadly speal..ing, ~-adrenoceptor agonist<> are useful as
bronchodilator-,, '' hile ~-adrenoceptor antagonists (often called
13-blocl..er-,) and a-adrenoceptor antagonists are used mainly in
cardiovascular indications, by virtue of their respective cardio-
dcprcssant and vasodilator effects.
ADRENOCEPTOR AGONIST$
Example~ of the main types of adrenoceptor agonist are given in
Table I I. I, and the characteristics of individual drugs arc
summarised in Table 11.3.
Actions
The major physiological effects mediated by different types of
adrcnoceptor arc ~ummarised in Table 11.1.
Smooth muscle
All types of ~mooth mu~cle, except that of the gastrointestinal
tract, contract in re~pon~e to stimulation of a 1-adrenoceprors.
through activation of the signal transduction mechanism
described in Chapter 4.
When a agonists arc given ::.y!>temically to experimental animal~
or humans. the mo::.t important action is on vascular smooth
muscle, particularly in the skin and splanchnic vascular beds.
which are strongly constricted. Large arteries and veins, as well
as arterioles. arc also constricted. resulting in decreased vascular
compliance, increased central venous pressure and increased
4
And conversely, contracting smooth muscle is usually bad news.
This bald statement must not be pressed too far, but the exceptions
(such as nasal decongestants and drugs acting on the eye) are
176 surprisingly few.
peripheral rcsi~tance, all of which contribute to an increa..e
systolic and dia~tolic arterial pressure and increased cardi.
work. Some vascular bed!> (e.g. cerebraL coronary and pulmonur
are relatively little affected.
In the whole animal, baroreceptor reflexes are activated b} tlr
rise in arterial pressure produced by a agonists, causing retb
bradycardia and inhibition of respiration.
Smooth muscle in the vas deferens, spleen capsule and C)e~
retractor muscles (or nictitating membrane. in some specie'
also stimulated by a agonists. and these organs are often us
for pharmacological studies.
The a-receptors involved in ~>mooth muscle contraction .:.
mainly a 1 in type. although vascular smooth muscle po~sc~'>C~ boc
a 1 and <.trrcceptors. lt appears that a 1-rcceptors lie close to th.
sites of release (and arc mainly responsible for neurally mediak..:
va!>oconstrict ion), while a 2-rcceptors Lie elsewhere on the muse.
fibre surface and are activa ted by circulating catecho l amine~.
Stimulation of f)-receptors causes relaxation of most kind1
smooth muscle by increasing cAMP formation (see Ch.~1
Additional ly. ~-receptor activation enhances Ca 2+ extrusion a.
intracellular Ca 2' binding, both effects acting to redu,
intracellular Ca 2' concentration.
Relaxation is usually produced by ~ 2-receptors, although lh:
receptor that is responsible for this effect in gastrointe-tm:
smooth muscle is not clearly 13 1 or l3 2 ln the vascular system. lit
mediated vasodilatation is (particularly in humans) m.
endothelium-dependent and mediated by nitric oxide rclca~e (~
Ch. 17). It occu~ in many vascular beds and is especiall} mar\.K
in <,kclctal muscle.
The powerful inhibitory effect of the sympathetic sy~tc:m
ga~trointestinal !>mOOth muscle is produced by both a and r
receptor<,, thb tiswe being unusual in that a-receptors c~u-.c
relaxation in most regions. Part of the effect is due to stimulau
of pre:-.ynaptic a 2-receptors (see below), which inhibit the rele..
of excitatory transmitters (e.g. acetylcholine) from intramur.
nerve:-., but there are also a-receptors on the muscle ceiJ,
stimulation or which hyperpolarises the cell (by increasing th,
membrane permeability to K+) and inhibits action potenb.1
discharge. The sphincters of the gastrointestinal tract are contracted
by a-receptor activation.
Bronchial smooth muscle is strongly dilated by activation o
~ 1-adrenoceptors, and selective B~ agonists are important 10 ~.
treatment of asthma (see Ch. 23). Uterine smooth muscle re~po.~~u
similarly, and thc~e drugs are also used to delay premarure Jabot
(Ch. 30).
a-Adrcnoccpto~ also mediate a long-lasting trophic responl(
\timulating smooth muscle proliferation in various tissues, fa
example in blood vessels and in the prostate gland, which 1' r4
pathological importance. Benign prostatic hyperplasia (see Ch. )I
is commonly treated with a-adrenoceptor antagonists (see d
clinical box on p. 179). cross-talk' between the a 1-adrenocepllf
and the growth factor signalling pathways (see Ch. 3) probab!}
accounts for this effect.
Nerve terminals
Presynaptic adrenoceptors are present on both cholinergic an,l
noradrcncrgic nerve terminals (sec Chs 4 and 9). The main effect
 N O RADRENERGIC TRANSMISSION

(u~-mcdiatcd} i'> inhibitory. but a weaker facilitatory action of~ the fibres, these effect~ combining to produce an instability in the
receptors on adrenergic nerve terminah has also been described. reflex control of muscle length. (3-Receptor antagonists are
sometimes used to control pathological tremor. The ~2 agoni,ts
Heart abo cause long-term changes in the expression of sarcoplasmic
Cah:cholamines. acting on (3 1-receptors, exert a powerful reticulum protein<, that control contraction kinetics. and thereby
he
,umulant effect on the heart (-.ee Ch. 18}. Both the heart rate
:x increase the rate and force of contraction of skeletal muscle (see
(chmnotmpic effect) and the force of contraction (inotropic Zhang et al.. 1996). C l enbuter ol. an 'anabolic drug used illicitly
tffect} are incrca\cd. re~ulting in a markedly increased cardiac by athlete<; to improve performance (see Ch. 54). is a ~ 2 agonist
output and cardiac oxygen con~umption. The cardiac efficiency that act<, in this way.
''
ed
(sec Ch. 18) i<, reduced. Catecholamines can also cause H istamine release by human and guinea pig lung tissue in
di'>rurbancc of the cardiac rhythm, culminating in ventricular response to anaphylactic challenge (see Ch. 13) is inhibited by
fibrillation. (Paradoxically. but importantly. adrenaline is also catecholamines. acting apparently on (32-recepton,.
u'ed to treat ventricular fibrillation arrest as well as other forms Lymphocytes and other cells of the immune system also express
th
of cardiac arre!.l-Ch. 18, Table 18. 1.) In normal hearts, the dose adrenoceptof'> (mainly ~-adrenoceptors). L ymphocyre proliferation,
'le
required to cause marked dysrhythmia is greater than that which lymphocyte-mediated cell killing, and production of many cytokines
ed
produces the chrono tropic and inotropic effects. but in ischaemic are inhibited by (3-adrenoceptor agonists. The physiological and
le
conditions dysrhythmias are produced much more readi ly. cl inical importance of these effects has not yet been established.
Figure I 1.5 show!. th e overall pattern o f cardiovascular responses For a review o f the effects of the sympathetic nervous system on
of
to catecholamine infusions in humans. ren ecting their actions on immune function, sec Elcnkov et al., 2000.
~ ).
~d
both the heart and vascular system.
Cardiac hypertrophy occurs in response to activation of a 1- Clinical use
::c
receptors, probably by a mechani~m similar to the hypertrophy The main clinical uses of adrenoceptor agonists are summarised
of ,.a\cular and prostatic smooth muscle. This may be important in the clinical box (p. 179).
1e
in the pathophy~iology of hypertension and cardiac failure
al
1-ce Ch. 18).
ADRENOCEPTOR ANTAGONISTS
ly Metabolism
The main drugs are lbted in Table 11.1. and further information
Catecholamines encourage the conversion of energy stores
ed is given in Table 11.3. In contrast to the situation with agonists,
(glycogen and fat) to freely available fuels (glucose and free fatty
most adrenoceptor antagonists are selective for a or ~-receptors.
acid-.), and cau'e an increa~c in the plasma concentration of the
m and many are abo subtype-selective.
latter '>Ub\tancc-,. The detailed biochemical mechanisms (see review
3- b) NonogaJ,.i, 2000} vary from species to species, but in most
e ca..,e~ the cffeeh on carbohydrate metabolism of liver and muscle
n !Fig. 11.6) arc mediated through (3 1-receptors (although hepatic
e glucose release can al~o be produced by a agonists), and the
al \timulation or lipolysis is produced by Brreceptors (see Table 11.1 ).
~.
Insulin secreti on is through arreceptors, an effect that further
'le Adrenoceptor agonlsts
contributes to the hyperglycaemia. Additionally, the production
a1 of leptin by adipose tis~ue (sec C h. 27) is inhibited. Adrenaline-
~d Noradrenaline and adrenaline show relatively
induced hypcrglycaemia in humans is blocked completely by a
little receptor selectivity.
combination of u and ~ antagonists but not by either on its own.
of Selective n 1 agonists include phenylephrine and
Selective ~,-receptor agonists (e.g. BRL 37344) have been
1e oxymetazoline.
developed a~ pos~ible treatment<> for obesi ty, but their action is
j.., Selective ct2 agonists include c lonidine and a -
too tran<,ient for them to be clinically useful.
ur m ethylnoradrenaline . They cause a fall in blood
Other effects pressure, partly by inhibition of noradrenaline release
e. Skeletal muscle is affected by adrenaline. acting on 131-recepton,. and partly by a central action. Methylnoradrenaline is
or although the effect i~ far less dramatic than that on the heart. The formed as a false transmitter from methyldopa,
of I\\ itch ten'>ion of fast-contracting fibres (white muscle) is increased developed as a hypotensive drug (now largely obsolete).
0) b) adrenaline, particularly if the muscle is fatigued, whereas the Selective 131 agonists include dobutamine. Increased
1e 1\\Hch of !.low (red) muscle is reduced. These effects depend on cardiac contracttlity may be useful clinically, but all ~~
or an action on the contractile proteins. rather than on the membrane, agonists can cause cardiac dysrhythmtas.
ly and the mechani~m i1. poorly underMood. In humans, adrenaline Selecttve ~2 agonists include salbutamol,
and other ~ 2 agonists cause a marked tremor, the shakines~ that t erbuta line and salmeterol, used mainly for their
accompanies fear, excitement or the excessive use of t32 agonists bronchodilator action in asthma.
(l!.g. salbutamol) in the treatment of asthma being examples of Selective lh agonists m ay be develop ed for the
ld thi~. It probably results from an increase in muscle spindle control of obesity.
177
et discharge, coupled with an effect on the contraction kinetics of
 SEtnON 2 . CHEMICAL MEDIATORS

200

Arterial
150
pressure
(mm Hg)
100

50
150
Heart rate
100 (beats/minute)
50

Peripheral
resistance
{arbitrary units) a

Adrenaline Noradrenaline Isoprenaline

a
Fig. 11.5 Schematic representation of the cardiovascular effects of intravenous infusions of adrenaline, noradrenaline and a
isoproterenol in humans. Noradrenaline (predominantly a agonist) causes vasoconstriction and increased systolic and diastolic \
pressure, with a reflex bradycardia. Isoproterenol $ agonist) is a vasodilator, but strongly increases cardiac force and rate. Mean artenaJ
{I
pressure falls. Adrenaline combines both actions.

LIVER MUSCLE
Glycogen Glycogen \\

h
e Glyctohgen
.., syn ase ,;
f 1,
Phosphorylase
.;
EB e Phosphorylase EB
1\..
Glucose-1-P
,;
Glucose1P

1j 11
Glucose6P Glucose --+ Glucose-6-P

Phosphatase
11 .... J

Glucose )

-- Bloodstream

FAT
Fatty acids

J,Lipase~()
Triglyceride ENERGY

Fig. 11.6 Regulation of energy metabolism by catecholamines. The main enzymic steps that are affected by ~-adrenoceptor

l
activation are indicated by + and - signs, denoting stimulation and inhibition, respectively. The overall effect is to mobilise glycogen and
fat stores to meet energy demands.
178

aAdrenoceptor antagonists
The main groups of a-adrenoceptor antagonists are:
non-selective a-receptor antagonists (e.g.
phenoxybenzamine. phentol amine)
u.-!.elective antagonist!. (e.g. prazosin. doxazosin, terazosin)
a~-sc lcctive antagonists (e.g. yohimbine. idazoxan)
ergot derivatives (e.g. ergotamine, dib)droergotamine).
This group of compounds has many actions in addition to
a-receptor block, and i~:. discussed in Chapter 12. Their action
on a-adrcnoccptors is of pharmacological interest (see
p. 168) but not u11ed th erapeutically.
Non-selective o.-adrenoceptor antagonists
Phenoxybenzaminc is not specific for a-receptors, and also
antagonises the act i on~ of acetylcholine, histamine and 5-HT. Tt
is long-last ing because it binds covalently to the receptor.
Phentol amine is more selective, but it binds reversibly and its
action is short - lasting. Ln humans, these drugs cause a fa ll in
arterial pressure (because of block of a-receptor-mediated
moconstriction) and postural hypotension. The cardiac output
and heart rate arc increased. This is a reflex response to the fall
in arterial pre sure, mediated through ~-receptors. The concomitant
block of a~-rcceptors tends to increase noradrenaline release,
1\hich ha<, the effect of enhancing the reflex tachycardia that
occuf'. with any blood p~sure-lowering agent. Phenoxybenzarnine
retain'> a niche (but vital) use in preparing patients with
phaeochromoc) toma for surgery: its irreversible antagonism and
the resultant depres.,ion in the maximum of the agonist dose
-response curve (cf. Ch 2. Fig. 2. 10) are desirable in a situation
\\here surgical manipulation of the tumour may release a large
bolus of pressor amine into the circulation.
Clinical uses of adrenoceptor agonists
Cardiovascular system:
cardiac arrest: adrenaline
- cardiogenic shock (see Ch. 19): dobutamine
(~ 1 agonist)
Anaphylaxis (acute hypersensitivity, see Ch. 13, and
Ch. 23): adrenaline.
Respiratory system:
asthma (Ch. 23): selective 132 -receptor agonists
(salbutamol, terbutaline, salmeterol, formoteroO
nasal decongestion: drops containing
xylometazoline or ephedrine for short-term use.
Miscellaneous indications:
adrenaline: with local anaesthetics to prolong
their action (see Ch. 44)
premature labour (salbutamol; see Ch. 30)
u 2 agonists (e.g . clonidine): to lower blood
pressure (Ch. 19) and intraocular pressure; as an
adjunct during drug withdrawal in addicts (Ch. 43;
Table 43.2); to reduce menopausal flushing; and to
reduce frequency of migraine attacks (Ch. 12).
NORADREN ERGIC TRANSMISSIO N
Labetalol and carvedilol are mixed a and ~-receptor
blocking drugs, although clinically they act predominantly on ~
receptor;. Much ha~ been made of the fact that they combine
both acti vities in one molecule. To a pharmacologist. accustomed
to puning specificity of action high on the list of pharmacological
saintly virtues. this may ~:.eem like a step backward!> rather than
forwards. Canedilol is used mainly to treat hypertension and
heart failure (see Ch~ 18 and I 9): labetalol is used to treat
hypertension in pregnancy.
Selective o. 1 antagonists
Prazosin was the first a 1-:.elective antagonist. Similar drugs with
longer half- lives (e.g. doxazosin. terazosin), which have the
advantage of allowing once-daily dosing, are now available. They
arc highly selective for a 1-adrenoceptors and cause vasodilatation
and fal l in arteria l pressure, but less tachycardia than occurs with
non-selecti ve a-receptor antagonists, presumably because they
do not increase noradrenaline release from sympathetic nerve
terminal ~. Some postural hypotension may occur.
The a 1-reccptor antagonists cause relaxation of the smooth
muscle of th e bladder neck and prostate capsule, and inhibit
hypertrophy of these ti ssues, and are therefore usefuJ in treating
urinary retention associated with benign prostatic hypertrophy.
Tamsulosin. an a 1A-rcceptor antagoni st. shows some selectivity
Clinical use s of tx-adrenoceptor
antagonists
Severe hypertension (see Ch. 19): a 1-selective
antagonists (e.g . doxazosin) in combination with
other drugs.
Benign prostatic hypertrophy (e.g. tamsulosin, a
selective a 1A-receptor antagonist).
Phaeochromocytoma: phenoxybenzamine
(irreversible antagonist) in preparation for surgery.
tx-Adrenoceptor antagonists
Drugs that block a, and a 2 adrenoceptors
(e.g. phenoxybenzamine and phentolamine) were
once used to produce vasodilatation in the treatment
of peripheral vascular disease, but this use is now
largely obsolete.
Selective et1 antagonists (e.g. prazosin, doxazosin,
terazosin) are used in treating hypertension. Postural
hypotension and impotence are unwanted effects.
Yohimbine is a selective a 2 antagonist. It is not used
clinically.
Tamsulosin is <x1A-selective and acts mainly on the
urogenital tract.
Some drugs (e.g. labetolol, carvedilol) block both a
and f3 adrenoceptors.
179
 SECnON2 .C HEMICAl MEDIATORS

for the bladder. and causes less hypotension than drugs such as
prazosin, which act on a 18-receptors to control vascular tone.
1t is believed that a 1A-receptors play a part in the pathological
hypertrophy not only of prostatic and vascular smooth muscle,
but also in the cardiac hypertrophy that occurs in hypertension,
and the use of selective a 1A-receptor antagonists to treat these
chronic condition!> is under investigation.
Selective a 2 antagonists
Yohimbine ic; a naturally occurring alkaloid: various synthetic
analogues have been made, such as idazoxan. T hese drugs are
used experimentally to analyse a-receptor subtypes. and yohimbine,
probably by virtue of its vasodilator effect, historically enjoyed
notoriety as an aphrodisiac, but they are not used therapeutically.
General clinical uses a nd unwanted effects of
a-odrenoceptor antagonists
T he main uses of a-adrenoceptor an tagonists are re lated to their
cardiovascular actions, and are summarised in the clinical box
(below). They have been tried for many purposes, but have on ly
limited therapeutic applications. In hypertension, non-selective
a-blocking drugs are unsatisfactory, because of their tendency to
produce tachycardia and cardiac dysrhythmias, and increased
gastrointestinal activity. Selective a 1-receptor antagonists
(especially the longer-acting compounds doxazosin and terazosin)
arc. however, useful. They do not affect cardiac function
appreciably. and po!>tural hypotension is less troublesome than
with pra.wsin or non-selective a-receptor antagonists. They have
a place in treating severe hypertension, where they arc added to
treatment with fif!>t- and second-line drugs, but are not used as
first-line agents (see Ch. 19). Unlike o ther antihypertensive
drugs. they cause a modest decrease in low-density lipoprotein
and an increac;e in high-density lipoprotein cholesterol (see Ch. 20
although the clinical importance of these ostensibly benefici
effects is uncertain. They are also used 10 control urinary retenuo::
in patients with benign prostatic hypertrophy.
Phaeochromocytoma is a catecholamine-secreting tumour <i
chromaffin tissue. which causes episodes of severe hyperten,IOO.
A combination of a- and ~-receptor antagonists is the most
effective way of controlling the blood pressure. The tumour 1113)
be surgically removable, and it is essential to block a- and~
receptors before surgery is begun, to avoid the effects of a sudden
release of catecholamines when the tumour is disturbed. A
combination of phenoxybenzamine and atenolol is effective f~
this purpose.
13-Adrenoceptor antagonists
The ~-adrenoeeptor antagonists are an important group of drug1.
They were first discovered in 1958, I0 years after Ahlquist had
postulated the existence of B-adrenoceptors. The first compounu
dichloroisoprotcrcnol, had fairly low potency and was a panial
agoni~t. Further development led to propranolol, which is muc
more potent and a pure antagonist that blocks B1- and ~
receptor. equally. T he potential clinical advantages of drugs 1111f
some partial agonist activity, and/or with selectivity for ~
receptors, led to the development of practolol (selective for 1
receptors but withdrawn because of its toxicity). oxprenolol -,
alprenolol (non-selective with considerable partial agonist actJ\U\
and a te nolol (~ 1 -sclective with no agonist activity). T\\.O ne\ltr
drugs are carvedilol (a non-selective ~-adrenoceptor antagomll
with additional o. 1-blocking activity) and nebjvolol (a f3 1 -~elecmt

Control First half Interval Second half

160

140

J}Y\J~l~\
'2
~iii
.8 120 -
(I)

e
~
(I)
:I: 100 l ...
l ~.J.~\
80
Oxprenolol 40 mg orally
~~!\.

60~----~---------------,~--------------~-----------------.~
0 30 60 90
Time (min)
Fig. 11.7 Heart rate recorded continuously in a spectator watching a live football match, showing the effect of the ~

180 l adrenoceptor antagonist oxprenolol. (From Taylor S H, Meeran M K 1973 In: Burley et al. (eds) New perspectives in beta-blockade.
CIBA Laboratories, Horsham.)

antagonist that also cau ...es vasodilatation through an endothelium-
dependent mechanbm). Both of these drugs have proven more
ll effoctive than conventional ~-adrenoceptor ant agonis~ in treating
n hean failure (see Ch. 18). The characteristics of the most important
compounds arc \C t out in Table I 1.3. Most 13-receptor amagonists
If are inactive on (3 1-receptors so do not affect lipolysis.
of exercise-induced hypoglycacmia. because the normal adrenaline-
Actions
) The pharmacological action!. of f3-receptor antagonist<; can be
deduced from Table 11.1. The effects produced in humans depend
on the degree of sympathetic activity and are slight in subjects at
re~t. The most important effects arc on the cardiovascular system
of and on bronchial smooth muscle (sec Chs 19 and 23).
In a subject at relit. propranolol causes little change in heart
rate, cardiac output or ~utcrial pressure. but reduces the effect of
exercise o r exciteme nt on these variables (Fig. 11.7). Drugs with
partial agonist activity. such as oxpre nolol, increase the heart rate
at rest but reduce it during exercise. Maximum exercise tolerance
I. is considerably reduced in normal subjects. partly because of
II the limitation of the cardiac re~ponse, and partly because the
h ~-mediated vasodilatation in skeletal muscle is reduced. Coronary
now is reduced. but relatively le% than the myocardial oxygen
con~umption. \O oxygenation of the myocardium is improved, an
effect of importance in the treatment of angina pectoris (see Ch. 18).
In normal subjects, the reduction of the force of contraction of
d the heart is of no importance, but it may have serious consequences
I. for patients with heart disea\e (see below).
r An important. and somewhat unexpected, effect of f3-receptor
.t antagonists is their antihypertensive action (see Cb. 19). Patients
e with hypertension (although not normotensive subjects) show a
grndual fall in arterial pressure that takes several days to develop
fully. The mechanism i~ complex and involves the following:
reduction in cardiac output
reduction of renin release from the juxtaglomerular cells of
the kidney
a central action, reduc ing sympathetic activity.
Carvcdilol and nebivolo l (sec above) arc particularly effective in
lowering blood pressure, because of their additional vasodilator
properties.
Bloclo.ade of the facilitatory effect of presynaptic f)-receptors
on noradrenaline rel ea~e (see Table 11.1 ) may also contribute to
the antihyperten-,ive effect. The antihypertensive effect of ~
receptor antagonists is clinically very useful. Because reflex
\asocon<,triction i'> pre e rved, postural and exercise-induced
h)potension (',ee Ch. 19) are less troublesome than with many
other antihypertensive drugs.
Many ~-receptor antagonists have an antidysrhythmic effect
on the heart, which is of clinical importance (see Ch. 18).
Airways resistance in normal subjects is only slightly increased
b} ~-receptor antagonists. and this is of no consequence. Tn
asthmatic subjects, however, non-selective 13-receptor antagonists
(such as propranolol) can cause severe bronchoconstriction,
which does not, of course, respond to the usual doses of drugs
such as salbutamol or ad re naline. This danger is less with ~~
selective antagonists, but none are so selective that this danger
can be ig nored.
NORADRENERGIC TRANSMISSION
Despite the involvement of ~-receptors in the hypcrglycacmic
actions of adrenaline, ~-receptor antagonists cause only minor
metabolic change!. in nonnal subjects. They do not affect the onset
of hypoglycaemia following an injection of insulin, but somewhat
delay the recovery of blood glucose concentration. In diabetic
patient.... the usc of f3-receptor antagonists increases the likelihood
induced release of glucose from the liver is diminished.
Clinical use
The main uses of f3-rcccptor antagonists are connected with their
effects on the cardiovascular system, and are discussed in
Chapters 18 and 19. They are as summarised in the clinical box
(p. 182).
The usc of f3 -receptor antagonists in cardiac fai lure deserves
spec ial me ntio n, as clinical opinion has undergone a U-turn in
recent yea rs. Patie nts with heart disease may rely on a degree of
sympathetic drive to the heart to maintain an adequate cardiac
output, and removal of this by blocking f3 receptors can exacerbate
cardiac failure, so using these drugs in patients with cardiac
failure was con~idered ill-advised. ln theory. drugs with partial
agonist activity (e.g. oxprenolol, alprenolol) offer an advantage
because they can, by their own action. maintain a degree of ~~
receptor activat ion, while at the same time blunting the cardiac
response to increa~cd l.ympathetic nerve activity or to circulating
adrenaline. Clinical trials. however. have not shown a clear
advantage of these drugs measurable as a reduced incidence of
cardiac failure.
Paradoxically. B-receptor antagonists are increasingly being
used in low doses to treat cardiac failure. although at the outset
there i~ a danger of exacerbating the problem. Several mechanism'>
may contribute. including inhibition of central sympathetic
outnow. direct vasod ilator effects (see review by Pfeffer &
Stevenson, 1996). and prevention of cardiac hypertrophy by
inte rfere nce with signalling pathways other than the major cAMP
pathway- a phenomenon s till poorly understood. Carvedilol is
often used for this purpose.
Unwanted effects
The main side effects of B-receptor antagonists result from their
receptor-blocking action.
Bronchoconstriction. This is of lillie importance in the absence
of airways disease. but in asthmatic patients the effect can be
dramatic and life-threatening. It is also of clinical importance in
patients "'ith other forms of obstructive lung disease (e.g. chronic
bronchitis, emphy~ema).
Cardiac depression. Cardiac depression can occur. leading to
signs of heart failure. particularly in elderl)' people. Patients
suffering from heart failure who are treared with B-receptor
antagonists (see above) often deteriorate in the first few weeks
before the beneficial effect develops.
Bradycardia. This ~ide effect can lead to life-threatening heart
block and can occur in patients with coronary disease, particularly
if they arc being treated with antiarrhythmic drugs that impair
cardiac conduction (sec Ch. 18).
llypoglycaemia. Glucose release in response to adrenaline is a
safety device that may be important to diabetic patie nts and to 181
 SECTION 2 . CHEMICAL MEDIATORS
Clinical uses of fladrenoceptor
antagonists
Cardiovascular (see Chs 18 and 19):
angina pectoris
myocardial infarction
dysrhythmias
heart failure
hypertension (no longer first choice; Ch. 19)
Other uses:
glaucoma (e.g. timolo l eye drops)
thyrotoxicosis (Ch. 29), as adjunct to definitive
treatment (e.g. preoperatively)
anxiety (Ch. 37), to control somatic symptoms
(e.g. palpitations, tremor)
migraine prophylaxis (Ch. 12)
benign essential tremor (a familial disorder).
fl-Adrenoceptor antagonists
Non-selective between f3 1 and 132
adrenoceptors: propranolo l, alpreno lol, oxp renolol.
131-selective: atenolol, nebivolol.
Alprenolo l and oxprenolol have partial agonist activity.
Many clinical uses (see clinical box).
Important hazards are bronchoconstriction, and
bradycardia and cardtac failure (possibly less with
parttal agontsts).
Side effects include cold extremities, insomnia,
depression, fattgue.
Some show rapid first-pass metabolism, hence poor
bioavailabllity.
other individuals prone to hypoglycaernic attacks. The sympathetic
response to hypoglycaemia produces symptoms (especially
tachycardia) that warn patients of the urgent need for carbohydrate
(usually in the form of a sugary drink). ~-Receptor antagonists
reduce these symptoms, so incipient bypoglycaemia is more likely
to go unnoticed by the patient. The use of f3-receptor antagonists
is generally to be avoided in patients with poorly controlled diabete~.
There is a theoretical advantage in U!>ing f3 1-selective agents, because
glucose release from the liver is controlled by 132-receptors.
Fatigue. This is probably due to reduced cardiac output and
reduced mu-;cle perfu'>ion in exercise. It is a frequent complaint
of patients taking f3 receptor- blocking drugs.
Cold extremities. These are presumably due to a loss of
13-rcceptor-mediated vasodilatation in cutaneous vessels, and
arc a common side effect. Theoretically, f3 1-selective drugs arc
less likely to produce this effect, but it is not clear that this is so
in practice.
Other side effects associated with 13-rcceptor antagonists are
182
not obviously the result of 13-receptor blockade. One is the
occurrence of bad dream<,, which occur mainly with highly hp1d
soluble drugs <,uch as propranolol, which enter the brain ea,il~
DRUGS THAT AFFECT NORADRENERGIC
NEURONS
Ernphasi!> in thi& chapter is placed on peripheral S)mpatht
transmbsion. The ~a me principles, however, are applicable tot
central nervou-, !>yMem (!>ce Ch. 34), where many of the dru.
mentioned here all.o act.
DRUGS THAT AFFECT NORADRENALINE
SYNTHESIS
Only a few clinically important drugs affect noradrenaline synthe>~
directly. Examples are oc-mcthy ltyrosine, which inhibits tyrosin.;
hydroxylase (used rarely to treat phaeochromacytoma), and
carbidopa, a hydrazi ne derivative of dopa, which inhibit\ uop;.
decarboxylase and is used in the treatment of parkin.-;oni\m hu
Ch. 35).
M ethy ldopa, a drug still used in the treatment of hypencn''
during pregnancy (sec Ch. 19) is taken up by noradrenergic neum
where it is converted to the false transmitter a -methylnoradrena o
This -.ub~tance i'> not deaminated within the neuron by ~lAO.
it accumulate'> and displaces noradrenaline from the S)nap
vesicles. <'L-Methylnoradrenaline is released in the same Y.a> as
noradrenaline, but i~ le~s active than noradrenaline on a 1-receptoo
and thus is lcs'> effective in causing vasoconstriction. On the
other hand. it is more active on presynaptic (a 2) receptOr'>.\Othe
autoinhibitory feedback mechanism operates more strong!) th
normal, thus reducing transmitter release below the normallc\d
Both of these effects (a!> well as a central effect, probably cau,(d
by the same cellular mechanism) contribute to the hypotcn,11
acti on. It produces side effects typical of centrally acun,
antiadrcnergie drugs (e.g. sedation), as well as carrying a ri'>l ol
immune haemolytic reactions and liver toxicity, so it is now little
used, except for hypertension in late pregnancy.
6-Hydroxydopamine (identical with dopamine except that 1
possesses an extra ring hydroxyl group) is a neurotoxin of th,
Trojan hor~e kind. It is taken up selectively by noradrenerg1,
nerve terminals, where it is converted to a reactive quinon-:
which destroys the nerve terminal, producing a chemll
sympathectomy'. The cell bodies survive, and eventually the
sympathetic innervation recovers. The drug is useful lot
experimental purposes but has no clinical uses. If injecttd
directly into the brain, it selectively destroys those n~n
terminals (i.e. dopaminergic, noradrenergic and adrenergic) tha
take it up, but it doe~ not reach the brain if given systemu:all
MPTP ( 1-rnethyl-4-phenyl- 1,2,3,5-tctrabydropyridine; see Ch 1i
is a rather simi lar selective neurotoxin.
DRUGS THAT AFFECT NORADRENALINE
STORAGE
Reserpin e is an alkaloid from the shrub Rauwolfia, which ha-
becn used in India for centuries for the treatment of mental di1

orders. Rc~crpinc. at very low concentration, blocks the transport of
noradrenaline and other amincs into synaptic vesicles, by blocking
the \C,icular monoamine transporter. Noradrenaline accumulates
JO'tead in the cytoplasm, where it is degraded by MAO. The
noradrenaline content of tisioues drops to a low level, and sym-
pathetic tran'>mi'>'>ion i.., blocked. Reserpine also causes depletion
of 5-HT and dopamine from neurons in the brain. in which these
amines arc tran\mitter-. (see Ch. 34). Reserpine is now used only
e\perimcntally. but wa\ at one time used as an antihypertensive
drug. Its central cfTccl\, e'>pecially depression, which probably result
from impairment of noradrenergic and 5-HT-mediated trans-
mi..,-.ion in the brain ('>ee Ch. 39) are a serious disadvantage.
DRUGS THAT AFFECT NORADRENALINE
RELEASE
s
e Drug'> can affect noradrcm1l inc release in four mai n ways:
by direct ly blocking release (noradrenergic neuron- blocking
a relationships
drugs)
e The most important drugs in the indirectly acting sympathomimetic
by evoking noradrenaline rclca~c in the absence of nerve
terminal depolarisation (indirectly acting sympathomimetic
drug-.)
by imeracting with prc.,ynaptic receptors that indirectly inhibit
or enhance dcpolarisation-evoked relea<oe (e.g. a 2 agonjsts,
0 These drugs have only weak actions on adrenoceptors. but
angiotcn'>in II. dopamine. and pro\taglandins). Effects mediated
c through u 1-adrenoceptor-. are discussed elsewhere in this
chapter: the other mechanic.,ms are probably more important
in the central than in the peripheral nervous system.
b) incrca\ing or decrea,ing available stores of noradrenaline
(e.g. reserpine. see above: MAO inhibitors. see Chapter 39).
NORADRENERGIC NEURON-BLOCKING DRUGS
e '\oradrenergic neuron- blocking drugs (e.g. guan ethidine) were
lin.t discovered in the mid-1950~> when a lternatives to ganglion-
f blocking drugs. for usc in the treatment of hypertension, were
e being sough1. The main effect of guanethidine is to inhibi t the
release of noradrenaline from sympathetic nerve term inals. ft has
it lillie effect on the adrenal medulla, and none on nerve terminals
c that release tran'>mitter1> other than noradrenaline. Drugs very
c.: similar to it include b r etylium, b etha n idine, and d eb risoqui n
e. (which is of interest mainly a~ a tool for studying drug
metaboli~m: ... ce Ch. 8).
If Actions
d Drug' of thi<. cia\\ reduce or abolish the response of tissues to
e 'ympathetic nerve .,timulation. but do not affect (or may potentiate)
:u the ciTech of circulating noradrenaline.
t The action of guanethidine on noradrenergic transmission i1>
i) complex (\ee Broadley. 1996). It i"> selectively accumulated by
noradrenergic nerve terminals, being a substrate for uptake 1. lts
initial blod.ing activity is due to block of impulse conduction in
the nerve terminab that selectively accumulate the drug. Its
action i., prevented by drugs, ~>uch as tricyclic antidepressants
(sec Ch. 39), which b lock uptake I.
Is Guanethidine b also concentrated in synaptic vesicles by means
,_ of the vesicular tran!-.porter, po~>sibly interfering with their abi lity
NORADRENERGIC TRANSMISSION
to undergo exocytosis. and also displacing noradrenaline. In this
way, it cau<.,es a gradual and long-la~ting depletion of noradrenaline
in sympathetic nerve endings. similar to the effect of reserpine.
Given in large do'>es. guanethidine causes structural damage to
noradrenergic neurons, which is probably due to the fact that the
tenninals accumulate the drug in rugh concenu-ation. It can
therefore be used experimentally a a selective neurotoxin.
Guanethidine, bethanidine and dcbrisoquin are no longer used
clinically, now that better antihypertensive drugs are available.
Although e:\tremely effective in lowering blood pressure, they
produce severe side effects associated with the loss of sympathetic
reflexes. The most troublesome are postural hypotension,
diarrhoea, nasal congestion and failure of ejaculation.
INDIRECTLY ACTING SYMPATHOMIMETIC
AMINES
M echanism of action and structure-activity
amine category are ty ram ine, amph etamine and ephedrine.
which arc \tructurally related to noradrenaline. Drugs that act
similarly and are used for l11eir central effects (see Ch. 42)
include m ethy lphenida t e and a to moxetin e.
sufficiently re.,cmble noradrenaline to be transported into nerve
terminals by uptake I. Once inside the nerve terminals. they arc
taken up into the vesicles by the vesicular monoamine transporter,
in exchange for noradrenaline, which escapes into the cytosol.
Some of the cytosolic noradrenaline is degraded by MAO, while
the re~t escapel. via uptake I. in exchange for the foreign
monoamine. to act on postsynaptic receptors (Fig. 11.8).
Exocytol>i~ is not involved in the release process, so their action~
do not require the presence of Ca 2 . They are not completely
specific in their actions, and act partly by a direct effect on
udrenoceptOr\, partly by inhibiting uptake 1 (thereby enhancing the
cfTect of the released noradrenaline), and partly by inhibiting MAO.
As would be expected, the effects of these drugs are strong ly
influenced by other drugs that modify noradrenergic transmission.
Thus reserpine or 6-hydroxydopanline abolishes their effects by
depleting the terminals of noradrenaline. MAO inhibitors, on
the other hand, Mrongly potentiate their effects by preventing
inactivation. within the terminals. of the transmitter displaced
from the ve~icle~. MAO inhibition particularly enhances the
action of ty r a mine. because this <>ubstance is itself a substrate for
MAO. Normally, dietary tyramine is destroyed by MAO in the
gut wall and liver before reaching the systemic circulation. When
MAO is inhibited this is prevented. and ingestion of tyramine-
rich foods !.UCh as fermented cheese (e.g. ripe Brie) can then
provoke a sudden and dangerous rise in blood pressure. Inhibitors
of uptake I, such as imipramine (see below), interfere with the
efTects of indirectly acting ~>ympatbomimetic amines by preventing
their uptake into the nerve temtinals.
These drugs, especially amphetamine, have important effects
on the central nervous system (see Ch. 39) that depend on their
abi lity to re lease not only noradrenaline, but also 5-HT and
dopamine from nerve terminals in the brain. A n important
183
 SECTION 2 . C H E M IC A L M EDI AT ORS
POSTSYNAPTIC RECEPTORS
Fig. 11.8 The mode of action of amphetamine, an
indirectly acting sympathomimetic amine. Amphetamine
enters the nerve terminal via the noradrenaline (NA) transporter
(uptake 1} and enters synapt1c vesicles via the vesicular
monoamine transporter (VMAT), in exchange for NA, which
accumulates 111 the cytosol. Some of the NA is degraded by
monoam1ne oxidase (MAO) within the nerve terminal and some
escapes, in exchange for amphetamine via the noradrenaline
transporter, to act on postsynaptic receptors. Amphetamine
also reduces NA reuptake via the transporter, so enhancing the
action of the released NA.
characteristic of the effects of indirectly acting sympathomimetic
amines is that marked tolerance develops. Repeated doses of
amphetamine or tyramine, for example, produce progressively
smaller pre~sor responses. This is probably caused by a depletion
of the releasable store of noradrenaline. A similar tolerance to the
central effect'> abo develops with repeated administration, which
partly accounts for the liability of amphetamine and related drugs
to cau<.e dependence.
Actions
The peripheral actions of the indirectly acting sympathomimetic
amines include bronchodilatat ion. raised arterial pressure,
peripheral va'>oconstriction. increased heart rate and force of
myocardial contraction. and inhibition of gut motility. They have
important central action~. which account for their signi ficanr
abuse potential and for their li mited therapeutic applications (sec
Chs 43 and 54). Aprut from ephedrine, which is still sometimes
used as a nasal decongestant because it has much less central
action, these drugs are no longer used for their peripheral
184 sympathomimetic effect!>.
Drugs acting on noradrenergic nerve
terminals
Drugs that inhibit noradrenaline synthesis include:
c:v-methyltyrosine: blocks tyrosine hydroxylase;
not used c linically
carbidopa: blocks dopa decarboxylase and is
used in treatment of parkinsonism (see Ch. 35);
not much effect on noradrenaline synthesis.
Methyldopa gives rise to false transmitter
(methylnoradrenaline), which is a potent ~ agonist,
thus causing powerful presynaptic inhibitory feedback
(also central actions). Rarely used as antihypertensive
agent.
Reserpine blocks carrier-mediated noradrenaline
accumulation in vesicles, thus depleting
noradrenaline stores and blocking transmission.
Effective in hypertension but may cause severe
depression. Clinically obsolete.
Noradrenergic neuron- blocking drugs (e.g .
guanethidine, bethanidine) are selectively
concentrated in terminals (uptake 1) and in vesicles
(vesicular transporter), and block transmitter release.
partly by loc al anaesthetic action. Effective in
hypertension but cause severe side effects (postural
hypotension, d iarrhoea, nasal congestion, etc.), so
now little used.
6-Hydroxydopamine is selectively neurotoxic for
noradrenergic neurons, because it is taken up and
converted to a toxic metabolite. Used experimentally
to eliminate noradrenergic neurons, not clinically.
Indirectly acting sympathomimetic amines (e.g.
amphetamine, ephedrine, tyramine) are
accumulated by uptake 1 and displace noradrenaline
from vesicles, allowing it to escape. Effect is much
enhanced by monoamine oxidase (MAO) inhibition,
which can lead to severe hypertension following
ingestion of tyramine-rich foods by patients treated
with MAO inhibitors.
Indirectly acting sympathomimetic agents are central
nervous system stimulants. M ethylphenidate and
atomoxetine are used to treat attention
deficit- hyperactivity d isorder.
Drugs that inhibit uptake 1 include cocaine and
tricyclic antidepressant drugs. Sympathetic effects
are enhanced by such drugs.
INHIBITORS OF NORADRENALINE UPTAKE
Neuronal reuptake of relea~ed noradrenaline (uptake I) is the 1110\t
important mechanism by which its action is brought to an end.
Many drugs inhibit this transport, and thereby enhance the elTech
of both sympathetic nerve activity and circulating noradrenaline.
 NORADRENERGIC TRANSMISSION

Uptake I is not responsible for clearing circulating adrenaline,
so lhc!>c drug~ do not affect responses to this amine.
The main clal.S of drugs whose primary action is inhibition of
uptake I are the tricyclic antidepressants (see Ch. 39), for
example desipramine. These drugs have their major effect on the
central nervous syaem but also cause tachycardia and cardiac
dysrhythmias, reflecting their peripheral effect on sympathetic
tranl>mj<.,ion. Cocajne, known mainly for its abuse liability (Ch. 43)
and local anaesthetic activity (Ch. 44). enhances sympathetic
transmission, causing tachycardia and increased arterial pressure.
It:. central effects of euphoria and excitement (Ch. 42) are probably
a manifestation of the same mechanism acting in the brain. It
'irongly potentiates the actions of noradrenaline in experimental
animals or in isolated tissues provided the sympathetic nerve
terminals arc intact.
Many drugs that act mainly on other steps in sympathetic
transmission also inhibit uptake 1 to some extent, presumably
because the carrier molecule has structural features in common
with other noradrenaline recognition sites, such as receptors and
dcgradative enzymes.
Extraneuronal uptake (uptake 2). which is important in clearing
circulating adrenaline from the bloodstream. is not affected
by most of the drugs that block uptake I. ll is inhibited by
phenoxybcnzamine, however, and also by various corticosteroids
(see Ch. 14). This action of corticosteroids may have some relevance
to their therapeutic effect in conditions such as asthma, but is
probably of minor importance.
The main sites of action of drugs that affect adrenergic
transmission are ~ummarised in Figure 11.9.

Noradrenergic varicos ity

MAO Inhibitors a-Methyltyrosine

Methyldopa
C MeNA ___ ,.. MeNA
NA ~
Jt--~-------------(e
I ',
)I I '
( Reserpine I ''
I
y '' MeNA
NA
' \
\
''
I

"f
NA
I

cx2-Adrenoceptor 1------< I
II ,,'-....J:::., ___...,( Uptake 1 inhibitors )
antagonists , ~

" __ ...
1

NA
~,."'
__

P-Adrenoceptor t-----....(
Adrenocep~~r-- -, Uptake 2 inhibitors
antagonists antagonists

I
I
I
)r

POSTSYNAPTIC CELL

Fig. 11 .9 Generalised diagram of a noradrenergic nerve terminal, showing sites of drug action. MAO, monoamine oxidase;
MeNA, methylnoradrenaline; NA, noradrenaline.
185
SECTION 2 II C H E M I C A l M E D I AT 0 R S

Teble 11.3 Summary of drugs that affect noradrenergic transmission

Type Drug" Main Uses/function Unwanted effects Pharmacokinetic Notes

action aspects

Sympathomimetic NorepmephnneO a.j3Agonist Not used clinically Hypertensoon, Poorty absorbed

(d~rectly achng) Transm1tter at vasoconstncbon, by mouth
postganglioniC tachycardia (or Rapid removal
sympathet1c reflex by !Issues
neurons, and in CNS bradycarcha), Metabolised by
Honnone of ventncular MAOandCOMT
adrenal medulla dysrhythm1as Plasma t, fl -2 min
EpinephnneO a/j!Agonist Asthma (emergency As norep1nephnne As norepinephrine See Chapter 23
treatment), Given i.m. or s.c.
anaphylactic shock,
cardiac arrest
Added to local
anaesthetic solutions
Main hormone of
adrenal medulla
Isoproterenol ~Agonist Asthma (obsolete) Tachycardia, Some tissue uptake, Now replaced by
(non-selective) Not an endogenous dysrhy1hmias followed by salbutamol in
substance inactivation (COMT) treatment of
Plasma t, fl - 2 h asthma (see Ch. 23)
Dobutamme ~,Agonist Cardiogenlc shock Oysrhythmlas Plasma t, 12 -2 min Chapter 18
(non-selective) G1ven i.v.
Salbutamol jl2 Agonist Asthma, premature Tachycardia, G1ven orally or Chapter23
labour dysrhy1hmias. by aerosol
tremor, Ma1nly excreted
penpheral unchanged
vasochlatatlon Plasma I '2 - 4 h
Salmeterol ~Agonist Asthma As salbutamol G1ven by aerosol Formoteroi 1S sunlar
long act1ng
Terbutahne ~ Agonist Asthma As salbutamol Poorly absorbed orally Chapter23
Delay of partuntion Given by aerosol
Ma1nly excreted
unchanged
Plasma 11 '2 -4 h
Clenbuterol j32 Agonist 'Anabolic' act1on to As salbutamol Active orally Illicit use 1n sport
1ncrease muscle long acting
strength
R1todnne ~Agonist Delay of partuntion As salbutamol Poorly absorbed Rarely used
by mouth; given i.v.
Phenylephrine u , Agonist Nasal HypertenSIOn, Given intranasally
decongestion reflex bradycardia Metabolised by MAO
Short plasma t ,,
Methoxamine a Agonist Nasal As phenylephnne Given intranasally
(non-selective) decongestion Plasma t ,12 - 1 h
Clonidine <t, Partial Hypertension, Drowsiness, Well absorbed orally See Chapter 18
agonist migraine orthostatic Excreted unchanged
hypotension, and as conjugate
oedema and weight Plasma 11'2 -12h
gain, rebound
hypertenSIOn

Sympathomimetic Tyram1ne NA release No chn1cal uses As norep1nephnne Normally destroyed Chapter39

(indirectly acting) Present 1n various by MAO 1ngut
foods Does not enter brain
Amphetamme NArelease, Used asCNS Hypertens1on. Well absorbed orally Chapter42
MAO stimulant in tachycardia, Penetrates freely Methylphenidate
mhibitor, narcolepsy, also 1nsomma 1nto brain and atomoxetl/le
uptake 1 (paradoxically) in Acute psychOSIS Excreted unchanged are Similar (used lot
inh1brtor. hyperactive ch11dren w1th overdose in urine CNS effects; see
CNS Appetrte Dependence Plasma 1112 - 12 h, Ch. 42)
stimulant suppressant depending on
Drug of abuse unne flow and pH
Ephednne NA release, Nasal As amphetamine Sim11ar to Contraindicated
~agonist, decongestion but less amphetamine if MAO inhibltOfS
weakCNS pronounced are g1ven
stimulant
 NORADRENERGIC TRANSM ISSION

T ble 11.3 l cont'd) Summary of drugs that affect noradrenergic transm1ssion

1YPe Drug" Main Uses/function Unwanted effects Pharmacokinetic Notes

action aspects

Adrenoceptor Phenoxybenzarmne a Antagonist Phaeochromocytoma Hypotens1011, Absorbed orally Action outlasts

antagonists (non-selectiVe. llush1ng, Plasma t 12 -12 h presence of drug
irreversible) tachycarda. nasal in plasma, because
Uptake 1 congestion, of covalent binding
1nh1brtor 1mpotence to receptor
Phentolamine (t Antagonist Rarely used As Usually given i. v. Tolazohne is similar
(non-select1ve), phenoxybenzam1ne Metabolised by liver
vasodilator Plasma t 11, -2 h
Prazos1n u 1 Antagonist Hypertension As Absorbed orally Doxazosin,
phenoxybenzamine Metabolised by liver terazosin are similar
Plasma t 112 -4 h but longer act1ng
See Chapter 19
Tamsulosin o. 1Antagonist Prostatic Failure of Absorbed orally Selective for cx,A
('uroselective') hyperplasia ejaculation Plasma t 112 -5 h adrenoceptor
Yohimbine a 2 Antagonist Not used clinically Excitement, Absorbed orally ldazoxan is similar
Claimed to be hypertension Metabolised by liver
aphrodisiac Plasma t 112 -4 h
Propranolol ~Antagonist Angina, Bronchoconstnction, Absorbed orally Timolol is similar
(non-selective) hypertension, cardiac latlure. cold Extensive l1rst- and used mainly
cardiac extremities, fatigue pass metabolism to treat glaucoma
dysrhythm1as. and depression. About 90% bound See Chapter 18
anxiety tremor, hypogtycaemla to plasma protem
glaucoma Plasma 1112 -4 h
Alprenolol ~Antagonist As propranolol As propranolol Absorbed orally Oxprenolol and
(non-selective) Metabohsed by liver pindolol are Similar
(partial agonist) Plasma t 112 -4 h See Chapter 18
Practolol ~.Antagonist Hypertens1on, As propranolol, also Absorbed orally Withdrawn from
ang1na, oculomucocutaneous Excreted unchanged climcal use
dysrhythm1as syndrome m unne
Plasma t u7 -4 h
Metoprolol ~ 1 Antagomst Angina, hypertension, As propranolol. Absorbed orally Atenolol IS
dysrhythmias less nsk of Ma1nly metabolised similar, with a
bronchoconstnchOn in hver longer half-life
Plasma t 112 -3 h See Chapter 18
Nebivolol II, Antagonist Hypertension Fatigue. headache Absorbed orally
Enhances nitric t,/2 - 10h
oxid&-med1ated
transmission
Butoxamlne fl2 Antagonist, No clinical uses
weak n agonist
Labetalol a/~ Antagonist Hypertension in Postural Absorbed orally Chapters
pregnancy hypotension, Conjugated In liver 18 and 19
brochoconstriction Plasma 1112 - 4 h
Carvedlloi a/~ Antagonist Heart failure As tor other Absorbed orally Additional
I\blockers t ,l'l -1 0 h actions may
Initial exacerbation contribute to
of heart fa1lure clinical benefit
Renal failure {Ch. 18)

Drugs affecting u-Methyl- Inhibits tyrosine Occasionally used 1n Hypotens1on.

NA synthesis p-tyros1ne hydroxylase phaeochromocytoma sedation
Carbidopa lnh1bits dopa Used as adjunct to Absorbed orally Chapter35
decarboxylase levodopa to prevent Does not enter
penpheral effects bratn
Methyldopa False HypertensiOn 1n HypotensiOn, Absorbed slowly Chapter 19
transmitter pregnancy drowsmess, by mouth
precursor diarrhoea, Excreted unchanged
Impotence, or as conJugate
hypersens11tv1ty Plasma t, 12 -6 h
reactions

187
 SECTION 2 . CHEMICAl MEDIATORS

Table 11.3 lc:ont'd) Summary o f drugs that affect noradrenergic transmission

Type Drug" Main Uses/function Unwanted effects Pharmacokinetic Notes

action aspects

Drugs affecting Reserpine Depletes NA HypertensiOn As methyldopa Poorly absorbed orally Antih ypertensiVe
NA release stores by (obsolete) Also depreSSion, Slowly metabolised effect develops
lllhibiting parkinsonism, Plasma t,12 - 100 h slowly and per51sts
vesicular gynaecomast1a Excreted in milk when drug iS
uptake of NA stopped
Guaneth1d1ne Inhibits NA HypertenSIOn As methyldopa Poorly absorbed orally Ac tion prevented by
release (obsolete) HypertensiOn on Mainly excreted uptake 1 1nh1bttors
Also causes first administration unchanged in urine Bethanid1ne and
NA d ep letion Plasma t ,12 - 1 00 h debrisoquin are
and c an similar
d amage NA
neurons
irreversib ly

Drugs affecting Imipramine Blocks Depression Atropine- like side Well absorbed orally Desip ramine
NA uptake uptake e ffects 95% bo und to and amitnptyhne
Also has Card iac plasm a protein are similar
atro pine-like dysrhythmias Converted to active See Chapter 39
action in overdose metabolite
(desmethylimipramine)
Plasma t 1n - 4 h
Cocame Local Rarely used local Hypertension, Well absorbed orally See Chapters
anaesthetic; anaesthetic excitement, or 1ntranasally 42 and 53
blocks M ajor drug of abuse c onvulsions.
uptake 1 dependence
CNS stimulant

COMT, catechol-0 - rnethyltransferase; MAO, monoamine o xidase; NA, noradrenaline.

For chem1cal structures. see Hardman J G , Umbird L E. Gilman A G . Goodman-Gilman A et a l 2001 Goodman and Gilman's pharmacological basts of
therapeutics, 10th edn. McGraw-Hill, New York.
"Note that norep1nephnne and eptnephnne are the recommended drug names for noradrenaline and adrenaline, respectively.

REFERENCES AND FURTHER READING

Gen~rnl Noradrenergic neurons Starke K. Gothen M . Kilbingcr H 1989 Moduluuon of

Broadley K J 1996 A uu>nomic phamu1cology. Taylor &
Franci, , London (Otwiled reA/book)
C'<x>pcr J R. Bhxlln FE. Roth R H 1996 The biochemical
ba'i' of neuropharmacology. Oxford University Press,
New York (Pn~llem 1tandard textbook)
Trcndelcnl>urg U. Wctner N 1988 Catecholanu ne;,.
Handbook of expert mental pharmacology, vol 90.
pan\ I and 2. Spnnger Verlag. Berlin (Massi~e
~ampliation of knnM 11-d~~ to <lote)
Ad renocc1>1ors
Baker J G. Hall I P. I h ll S J 2003 Agonist and inverse
agonl\t oK:hon' of Jl-blocker. at the human Jlr
adrcnoceptor pro' 1de e' ideoce for agonist-directed
~ignalling \lol Pll:mnacol64 1357-1369 (R<'cent
muli~t fiiOIHn~ tlwt /3-blodC'rs diff<"r in their obi/it)
to aoil'fltt' ami b/(1('/c < IMP ond mitogen-actimted
pmtt'm Amau Jxllhwan, JIQ~<ibly explaimng whJ
'""'" ,,... 1><-ttu thon other~ 111 trt'ating heart disease)
Gut m~rac' S. "'oura l) 2001 Va\Cular adrenoceptors: an
updntc. Pllnrmacol Rev 53: 3 19 356 (Review
deunhing the wmple.\ rolt':. of different
adT1'11nc-eptors i11 blood ''esse/s)
l n,el P A 1996 Adrenergic receptors-evolving conccp~s
and clinical implicnl ion,. New Engl J M cd 334:
58(}..585 (r:Xcellenr f'f!Vit'IV focusing 011
188 applications)
B ylund DB 1994 Nomenclatur.: of ndrcn<x:cptors.
Pharmacol Rev 46: 121 136 (/larimrali.wtitm of the
llLtontun_"'r' of adrenocepwr.\')
Cunnane T C 1984 The mechanism Clf nCllf'Otr:.n,n1iUcr
relca-.c from ;,ympathet>c nerve,, Trend' Neurosct 7:
248-253 (Pr>int.t out importtmt diff~rl'na~ btfll'etrr
odr<'ff<'fl/iC and c!rolinny,ic ll<'llfflll.f)
Elenkov I J, Wilder R I., C'hrou\0, G P. Vi11 n S 2000
'The ~yrnpathcuc ner.e an onte~r:Uf\C merface
bet\\een t"'o ~upel'\) 'tcm" the brarn and the 1mmune
S)Stem. Phanna.."'I Re1 52: 595-638 (Dttaikd
cmologu<' of t'jJ<'cts of catulwlmmnt'< und thr
sympathetic nenvu\ \\ ~tem (m the umnmae J)Jietn)
Gainetdino R R. Cnron M G 2()(JJ M onoamrne
transporter.: from gene, It> hcha10ur. Annu Re
Ph:mnacol Tox1col 43: 261 - 284 (Re\lt'" artidt
ftJcusinK "" t/r,. choracterwin t>/ tnm.S!(tmc mrct'
lacking \{leci}it mOIIO<Jmme trmr.lporttr>)
Liu Y. Edwards R H 1997 The role of ve\lculnr tr:rn,pon
protein\ 111 1ynaptic trJn'm"'iCln und neural
degeneration. A nnu Rev Neurosc>20 125-156 (Rt'>rt'IV
of TI'Cent ideas abowt!rt' fwrctiomrl mle nf ITIIIIS/I<Jrlfi'S)
L undberg J M 1996 Pharmacology of co-lt:tnl n>i, l ion 111
the autonomic nervous ~yMcm: mtcgrmi-..e n!)pccb on
amines, neuropeplides. adenosine tripho;phate. amino
acids and nitric oxide. Pharmacal Rev 48: I 14-192
(Cmn,>relre,.sive mul irrformmit Tl'1'it11')
transmitter release oy presynaptic auloreecp!Or...
Phy~iol Rev 69: 864-989 (C'ompre!retrtil'<'
review)
Miscellaneous topics
Ei>enhofer G. Kopin I J. GoJd,tern D S 2004
Catecholamine metabolism: a contemporary ''"""
implications for physiology and med>cine. PhJrrn:t.'!ll
Rev 56: 331-349 (Rnin. that dismiues a nUI!Ibcr II{
fillacits conct'ming tlr<' rowt's b) which rot<'< lk>l<
from different wurces art" metabolu"d and
acrt"ted)
Nonogalti K 2000 New in\ights into ') mpathcth:
n.-gula11on of glucose and fat metabolism
Diabetologia 43: 533-549 (R<'l'it'l< of tht complr<
odTI'nOCt'ptor-mtdiatt'd efft'ctr on tht' mnaholum cf
lier muscle and odi(>Qse tissue; up to dille, /1111 II/Jif
portimlorl) <'OS)' read)
Pfeffer M A, Ste,~nson L W 1996jl-adrenerg>c blo.:l.t!:
nnd su~hal in bean failure. New Engl J Med Jl4
1396-1397 (Sbows that fl-adrenergic bloc l ei'\ 1n low
do'c' can be beneficial in hean fai lure)
Zhang K-M, tlu P. Wang S-W el aJ. 1996 Sulbotaml
changes tbe molecular and mechanical propentc' ol
cuni nc skeletal muscle. J Physiol 496: 2 11-220
(Surprising jindin11 rhat salhwamol affectt mmrle
.fimctirm by non-receptor mechanisms)
 Other peripheral mediators:
5-hydroxytryptamine
and purines
Overview 189
5hydroxytryptamine 189
-Distribution, biosynthesis and degradation 189
-Pharmacological effects 190
-Classification of 5-HT receptors 191
-Drugs acting on 5-HT receptors 192
-Clinical conditions in which 5-HT ploys o role 195
Purines 198
-ATP as o neurotransmitter 198
-ADP and platelets 199
-Adenosine as o mediator 199
-Purine receptors 199
OVERVIEW
In this chapter, we discuss two types of mediator,
both of which play a role as neurotransmitters in
the brain and periphery and also function as local
hormones. S Hydroxytryptamine (SHT) has a
longer pharmacological history than purines
(nucleosides and nucleotides), and numerous drugs
in current use act wholly or partly on 5-HT
receptors, of which no fewer than 1 S subtypes
have been identified. Purine pharmacology is
currently a less well-exploited area, but this is
h
I changing and there is increasing interest in the
potential role of purinergic agents in the treatment
.s of thrombotic and respiratory disorders. In the case
of both mediators, the physiological significance-
and hence therapeutic relevance-of the various
receptor subtypes is still being unravelled. In our
discussion, therefore, we will focus on the more
secure hypotheses, recognising that the overall
picture is far from complete. Useful reviews include
Burnstock (2002) and Gershon (2004).
SHYDROXYTRYPTAMINE
Serotonin was the name given to an unknown vasoconstrictor
substance found in the serum after blood had clotted. lt was
identified chemica lly as 5-hydroxytryptamine in 1948 and shown
to originate from platelets. ft was subsequently found in the
gastrointestinal tract and central nervous system (CNS), and shown
to function both as a neurotransmitter and as a local hormone
in the peripheral va~cu lar system. This chapter deals with the
metabolism, distribution and possible physiological roles of
5-HT in the periphery, and with the different types of 5-HT
receptor and the drugs that act on them. Further information on
the role of 5-HT in the brain, and its relationship to psychiatric
disorders and the actions of psychotropic drugs. is presented in
Chapters 32, 38 and 39. The usc of drugs that modulate 5-HT in
the gut is dealt with in Chapter 25.
DISTRIBUTION, BIOSYNTHESIS AND
DEGRADATION
5-Hydroxytryptamine occurs in the highest concentrations in
three organ~.
In the wall of the imestine. Over 90% of the total amount in
the body i~ present in the entemchmmaffin cells in the gut
(endocrine cells with distinctive staining properties). These
arc cells derived from the neural crest and resemble those of
the adrenal medulla. They are interspersed with mucosal cells.
main ly in the stomach and smal l intestine. Some 5-HT also
occurs in nerve cells of the myenteric plexus, where it functions
as an excitatory neurotransmiuer (see Chs 9 and 25).
In blood. 5-HT i~ present in high concentrations in platelets,
which accumulate it from the plasma by an active transport
system and release it when they aggregate at sites of tissue
damage (see Ch. 21 ).
In the CNS. 5-IIT is a transmitter in the CNS and is present
in high concentration' in localised regions of the midbrain.
lt!> functional role is dio;cussed in Chapter 34.
Although 5-1IT is present in the diet. most of this is metabolised
before entering the blood~tream. Endogenous 5-HT arises from
a biosynthetic pathway similar to that which generates
noradrenaline (norepinephrine; see Ch. 11). except that the
precursor amino acid is tryptophan in tead of tyrosine
(Fig. 12.1 ). Tryptophan is converted to 5-hydroxytryptophan (in
chromaffin celb and neurons, but not in platelets) by the action of
tryptophan hydmxylase, an en~yme confined to 5-HT-producing
cells. The 5-hydroxytryptophan is then decarboxylated to 5-HT
by a ubiquitous amino acid decarboxylase that also participates
in the synthesis of catecholmnincs (Ch. I I) and histamine (Ch. 13). 189
 SECTION 2 . CHEMICAl MEDIATORS

Platelets (and neurons) possess a high-affinity 5-HT uptake

mechanism, and platelets become loaded with 5-HT as they pass
through the intestinal circulation, where the local concentration
is relatively high. The mechanisms of synthesis. storage, release
and reuptake of 5-HT are very similar to those of noradrenaline.
Many drugs affect both processes indiscriminately (see Ch. II),
but selective serotonin reuptake inhibitors have been developed Tryptophan hydroxylase
and arc important therapeutically as antidepressants (Ch. 39). 5-HT
is often !.tored in neurons and chromaffin ceUs as a cotransminer COOH
I
together with various peptide hormones, such as somatostatin,
HO~CH2?H
substance P or vasoactive intestinal polypeptide.
Degradation of 5-HT (Fig. 12.1) occurs mainly through oxidative ~N) NH2
5-Hydroxytryptophan H
deamination, catalysed by monoamine oxidase, followed by
oxidation to 5-ltydroxyindoleacetic acid (5-H/AA), the pathway L-Aromatic acid decarboxylase)
being the same as that of noradrenaline catabolism. 5-HlAA is '- (=dopa decarboxylase)
excreted in the urine and serves as an indicator of 5-HT production
in the body. This is used, for example, in the diagnosis of
HO~CH 2CH 2 NH2
carcinoid syndrome (sec below).
~N)
5-Hydroxytryptamine H
PHARMACOLOGICAL EFFECTS (serotonin)

The actions of 5-HT arc numerous and complex, and there is Monoamine oxidase
considerable species variation. This complexity reflects a
profu!.ion of 5-IIT receptor subtypes, which has been revealed in
recent year~ (see below). The main sites of action are as follows.
Gastrointestinal tract. 5-HT subserves complex and important
roles in the regulation of gastrointestinal function (see Gershon,
2004). Only about lOCK of 5-HT in the intestine is located in
neurons, where it acl'> as a neurotransmitter, while the remainder Aldehyde dehydrogenase
is located in the enterochromaffin cells, which act as sensors to
transduce information about the state of the gut. The 5-HT is
released from enterochromaffin cells into the lamina propria, HO~CH 2COOH
where it stimulates receptors located on enteric neurons. Acting ~N)

l
at 5-HT18 receptors, 5-HT initiates secretory and peristaltic 5-Hydroxyindoleacetic H
reflexes. Stimulation of presynaptic 5-HT4 receptors amplifies acid (5-HIAA)
neurotransmission in some enteric neurons, resulti og in increased Fig. 12.1 Biosynthesis and metabolism of 5-
hydroxytryptamine.
--------------------~
Distribution, biosynthesis and
degradation of a -hydroxytryptamine

Tissues rich in 5-HT are:
gastrointestinal tract (chromaffin cells and enteric
neurons)
platelets
central nervous system.
Metabolism closely parallels that of noradrenaline.
5-HT is formed from dietary tryptophan, which is
converted to 5-hydroxytryptophan by tryptophan
hydroxylase, then to 5-HT by a non-specific
decarboxylase.
5-HT is transported into cells by a specific transport
system.
Degradation occurs mainly by monoamine oxidase,
forming 5-hydroxyindoleacetic acid (5-HIAA), which is
excreted in urine.
190
prokinetic activity in the gut, and may also play a part in the
regulation of colonic motility. Stimulation of 5-HT3 receptor.
slows motility and mediates the neurotransmission involved in
sen<;ory perception of the gut by the CNS.
The importance of 5-HT in the gut is underlined by the:
widespread distribution of the serotonin uptake transporter. ~h1cb
rapidly and efficiently removes released 5-HT, limiting its acuon
Back-up tran!>porters have also been identified. Interesting!}
there is evidence for defects in this reuptake system in irritable
bowel syndrome (Ch. 25), which might explain the rather be~ll
dering symptoms of the disease.
Smooth muscle. ln many species (although only to a minor
extent in humans), smooth muscle (e.g. uterus and bronchial trw
is contracted by 5-HT.
Blood vessels. The effect of 5-HT on blood vessels depends on
various factors, including the size of the vessel, the species and
 OTHER PERIPHERAL MEDIATORS: 5-HYDROXYTRYPTAMI N E AN D PURINES
the prevailing sympathetic activity. Large vessels, both arteries
and \cins, arc usually constricted by 5-HT, although the sensitivity
\aries greatly. This is a direct action on vascular smooth muscle
cell~. mediated through 5-HT2A receptors (see below). Activation
of 5-HT1 receptors causel> con~triction of large intracranial
\O:sseh, dilatation of which contribute~ to headache (see below).
5-HT can abo cause va-.odilatation, partly by acting on endothelial
cells to release nitric oxide (!.ee Ch. 17) and partly by inhibiting
noradrenaline release from sympathetic nerve tenninals. If 5-HT
is injected intravenously, the blood pressure usually first ri ses,
O\\ ing to the constricti on of large vessels, and then falls, owing
to arteriolar dilatation.
Platelets. 5-HT causes platelet aggregation (see Ch. 21) by
acting on 5-HT 2A receptors, and the platelets that collect in the
vessel release furth er 5-HT. lf the endothelium is intact, 5-HT
release from adherent platelets causes vasodilatation, which helps
to sustain blood flow; if it is damaged (e.g. by atherosclerosis),
5-HT causes constriction and impairs blood flow further. These
effects of platelet-derived 5-HT are thought to be important in
vascular disease.
Nerve endings. 5-HT stimulates nociceptive (pain-mediating)
'ensory nerve endings. an effect mediated mainly by 5-HT1
r.:ceptors. l f injected into the skin. 5-HT causes pain; when given
'}'temically, it clicitl> a variety of autonomic reflexes through
stimulation of afferent fibres in the heart and lungs. which further
complicate the cardiovascular response. Nettle stings contain
5-HT among other mediators. 5-HT also inhibits transmitter
release from adrenergic neurons in the periphery.
Central nervous system. 5-HT excites some neurons and
inhibits others; it may al~o act presynaptically to inhibit transmitter
release from nerve terminals. Different receptor subtypes and
different membrane mechanisms mediate these effects (sec
Table 12. 1; Barnes & Sharp, J999; Branchek & Blackburn,
2000). The role of 5-HT in th e CNS is discussed in Chapter 34.
CLASSIFICATION OF 5-HT RECEPTORS
"' It wa' long ago reali~ed thm the actions of 5-HT are not all mediated
by receptor> of the Name type. and various pharmacological cla~sification~
have come and gone. The current ~yMem ( Hoyer et al., 1994) was agreed
after long deliberation at a ~ummit meeting of 5-HT aficionados and
delivered. with puff, of white smoke and much celebration, in 1992. It is
summari~ed in Table 12.1. Thb c lru.sification takes into account ~equence
data derhed from cloning, signal transduction mechanisms and
ph3IT!lacological 'iJeCifiCity. llleir diversity is astonishing. Currently.
there are 15 known receptor \ubtype\ (see Kroeze et al., 2002). lllese are
di,ided into ..even cl:tso;es (5-IIT, _7). one of \\hich (5-HT3 ) is a ligand-
gated 10n channel and the remainder G-prmein-coupled receptors
(GPCR\; see Ch. 3). The 'i~ GPCR families are funber subdivided into
13 receptor I)-pes ba~d on the1r sequence and phannacology. Mo~t
subtypes are found in all \pecie> ,o far e:r.:unined. but there are wme
c~cepuons (5 liT , 8 IS found in mouse but probably does nor exist in
humans) and the GPCR ~lructures are highly conserved. The most common
..econd me,..enger appcan. to be cAMP produced by activation of adenylate
cyclase. but some members (the 5-HT2 subtype) activate phospholipase
r C to generate phospholipid-derived second messengers (see Cb. 3).
Tron~gcnic mice lacking ~ome functional members of this receptor family
have been produced (sec for example Bonasera & Tecou. 2000). llle
functional dcticit~ in ~ouch animals are generally quite subtle. suggesting
that these receptors may ~erve to tune, rather than to enable, phys iological
respon\e~. Table 12.1 give!. an overview of the most imponant receptOr\.
Some of the more ~ignificant drug targets include the following.
5-IIT1 receptors. The~ occur mainly in the brain, the subtype~ being
distingui,hed on the basb of their regional distribution and their
pharmacological \pecilicity. They function mainly as inhibitory
presynaptic receptors and are linked to inhibition of adenylate C) clase.
The 5-HT 1A \Ubtype IS pancularly important in the bmin. in relation to
mood and behaviour (see Ch!. 37-39). The 5-HT10 subtype. which is
eltpressed 111 cerebro1.l blood ve\seb, is believed to be important in migraine
(see below) and i\ the target for ~umatriptan, an agonist used 10 treat
acute attacks. The cerebral ves-.els are unu~ual in that vasoconstriction is
mediated by 5 IIT1 receptors; in moSt vessels. 5-HT 2 receptors are
re~pon~iblc. The haple~s '5-I!Tac' receptor- actually the first to be cloned
has been officially declared non-exhtent, having been ignominiou\ly
rec lass ified a~ the 5- HT2c receptor when it was found to be linked to
inositol trisphosphate production rather than adenylate cyclase.
5-IIT2 receptors. The~e are particularly important in the periphery. The
effects of 5-I IT on smooth muscle and platelets, which have been known
for many years. are mediated by the 5-HTzA receptor, as are some of the
behavioural e ffect> of agent~ \uch as lysergic acid diethylamide (LSD;
see Table 12.1 nnd Ch. 42). 5-HT2 receptors are linked to phospholipase
C and thus stimulate inm.itol trisphosphate formation. The 5-HT2A
subtype is functionally the most important. the others having a much
more limited distribution and functional role. llle role of 5-HT1 receptors
in nonnal physiological proce~~s is probably a minor one. but it become~
more prominent in pathological conditions such as asthma and vascular
thrombo'>i'> (-.ee Ch\ 21 23).
Actions nd functions of
5-hydroxytrypblmlne
Important actions are:
increased gastrointestinal motility (direct excitation
of smooth muscle and indirect action via enteric
neurons)
contraction of other smooth muscle (bronchi,
uterus)
mixture of vascular constriction (direct and via
sympathetic innervation) and dilatation
(endothel iurn-dependent)
platelet aggregation
stimulation of peripheral nociceptive nerve
endings
excitation/inhibition of central nervous system
neurons.
Postulated physiological and pathophysiological roles
1nclude:
in periphery: peristalsis, vomiting, platelet
aggregation and haemostasis, inflammatory
mediator, sensitisation of nociceptors and
microvascular control
in CNS: many postulated functions, including
control of appetite, sleep, mood, hallucinations,
stereotyped behaviour, pain perception and
vomiting.
Clinical conditions associated with disturbed 5-
hydroxytryptamine function include migraine,
carcinoid syndrome, mood disorders and anxiety.
191
 SECTION 2 . CHEMICAl MEDIATORS

T ble 12. 1 The main 5-HT receptor subtypes

Receptor Location Main effects Second m essenger Agonists Antagonists

1A CNS Neuronal inhibition l cAMP 5-CT Spiperone

Behavioural effects: sleep, 8-0H-DPAT Methiothepin
feeding, thermoregulation, Buspirone (PA) Ergotamine (PA)
anxiety

1B CNS Presynaptic inhibition 1 cAMP 5-CT Methiothepin

Vascular smooth Behavioural effects Ergotamine (PA)
muscle Pulmonary vasoconstriction

10 CNS Cerebral vasoconstriction 1 cAMP 5- CT Methiothepin

Blood vessels Behavioural effects: Sumatriptan Ergotamine (PA)
locomotion

2A CNS Neuronal excitation t IPJ DAG a-Me-5-HT Ketanserin

PNS Behavioural effects LSD (CNS) Cyproheptadine
Smooth muscle Smooth muscle contraction LSD (periphery) Pizotifen (non-selective)
Platelets (gut, bronchi, etc.) Methysergide
Platelet aggregation
Vasoconstriction/vasodilatation

2B Gastric fundus Contraction t IP:IDAG u-Me-5-HT

2C CNS Cerebrospinal fluid secretion t IPJ DAG u-Me-5-HT Methysergide

Choroid plexus LSD

3 PNS Neuronal excitation (autonomic, None -ligand-gated 2-Me-5-HT Ondansetron

nOCICeptive neurons) cation channel Chlorophenyl- Tropisetron
CNS Emesis biguanide Granisetron
Behavioural effects: anxiety

4 PNS (GI tract) Neuronal excitation f cAMP 5-Methoxy- Various experimental

CNS Gl motility tryptamine compounds (e.g.
Metoclopramide GR113808, SB207266)
Tegaserod

5 CNS Not known Not known Not known Not known

6 CNS Not known Not known Not known Not known

7 CNS Not known t cAMP 5-CT Various 5-HT2

Gl tract LSD antagonists
Blood vessels No selective agonists No selective antagonists

2-Me-5-HT, 2-methyl-5-hydroxytrypamine; 5-CT, 5-carboxamidotryptamine; 8-0H-DPAT, 8-hydroxy-2-(di-n-propylamino) tetraJine; CNS,

central nervous system ; DAG, diacylglycerol; Gl, gastrointestinal; IP3 , inositol trisphosphate; LSD, lysergic acid diethylamide: PA, partial
agontst: PNS, penpheral nervous system; a -Me-5-HT, u -methyl 5-hydroxytrypamine.
' For further details, see Hoyer et al. (1994). The list of agonists and antagonists includes only the better known compounds. Many new
selective 5-HT receptor ligands, known only by code numbers, are being developed.

5- HTJ receptors. The..c occur mainly in the peripheral nervous system.
particularly on noc1cepti\e scnsol) neurons (see Ch. 41 J and on
autonomic and cntenc neurons, where 5-HT exerts a strong excitatol)
etTect. 5-HT lll>clf C\Olc~ pain when injected locally: when given
intr:J\enou~ly, 11 elicit~ a fine di~play of autonomic reflexe~. which result
from c~c 1tation of many type~ of vascular, pulmonary and cardiac sensory
nerve fibre\. 5-HT1 receptor~ also occur in the brain, panicularly in the
area po.1trema, a region of the medulla involved in the vomi ti ng reflex,
and selective 5 II r 1 antagoni~t> are used as antiemetic drugs (see Ch. 25).
5-IIT , receptor; arc exceptional in being directly linked to membrane
ion channcb (Ch. 3) t1nd cause excitation directly, without involvement
192 of any 'ccond mc;scngcr.
5-H T4 receptors. Th~ occur m the br:Jin, as well as in periphernl orr.ms
~uch a.'> the gru.trointe~llnaltraet. bladder and heart. Their main phy,io!ogiCi
role appears to be in the gastrOintestinal trnct. where they produce nelll'OO.ll
excitation and medi:lte the effect of 5-HT in stimulating perist.al~i\.
DRUGS ACTING ON S HT RECEPTORS
Table 12. 1 lists some of the agonists and antagonists for the different
receptor types. Many arc only partly selective. The improved
understanding of the location and function of the different
 OTHER PERIPHERAL MEDIATORS: 5-HYD ROXYTRYPTAMIN E AN D PURINES
5-Hydroxytryptamlne receptors
There are seven types {5-HT1_7), with further
subtypes of 5-HT, {A-F) and 5-HT2 {A-C). All are
G-prote~n-coupled receptors, except 5-HT3 , which 1s
a ligand-gated cation channel.
5-HT1 receptors occur mainly in central nervous
system {CNS) {all subtypes) and some blood vessels
{5-HT10 subtype). Effects, mediated through inhibition
of adenylate cyclase, are neural inhibition and
vasoconstriction. Specific agonists include
sumatriptan {used 1n migraine therapy) and buspirone
(used in anxiety). Ergotamine is a partial agonist.
Specific antagonists include spiperone and
methiothepin.
5-HT2 receptors occur in CNS and many peripheral
sites {especially blood vessels, platelets, autonomic
neurons). Neuronal and smooth muscle effects are
excitatory. Some blood vessels dilated as a result of
nitric oxide release from endothelial cells. 5-HT2
receptors act through the phospholipase C/inositol
trisphosphate pathway. Specific ligands include
lysergic acid diethylamide {LSD; agonist in CNS,
antagonist in periphery). Specific antagonists are
ketanserin, methysergide and cyproheptadine.
5-HT3 receptors occur in peripheral nervous system,
especially nociceptive afferent neurons and enteric
neurons, and in CNS. Effects are excitatory, mediated
through direct receptor-coupled ion channels.
Specific agonist is 2-methyi-5-HT. Specific
antagonists include ondansetron and tropisetron.
Antagonists are used mainly as antiemetic drugs but
may also be anxiolytic.
5-HT4 receptors occur mainly in the enteric nervous
system (also in CNS). Effects are excitatory, through
stimulation of adenylate cyclase, causing increased
gastrointestinal motility. Specific agonists include
metoclopramide {used to stimulate gastric emptying).
Little is known so far about the function and
pharmacology of 5-HTs-7 receptors.
receptor subtypes has. however. caused an upsurge of interest in
de\eloping compounds with improved receptor selectivity, and
useful new drug!> are likely to appear in the near future.
Important drugs that act on 5-HT receptors in the periphery
>
I mclude the following.
I
Selective 5-HT1A agoni~t!., !>Uch as 8-hydroxy-2-(di-n-
propylamino) tetra lin (Table 12.1 ). are potent hypotensive
agents, acting by a central mechanism, but are not used
clinically.
5-HT10 receptor agonists (e.g. sumatriptan) used for treating
migraine (sec below).
5-HT2 receptor antagonists (e.g. dihydroergotamine,
methysergidc, cyproheptadine, ketan serin, ketotiren,
pizotiren ) act mainly on 5-HT2 receptors but also block other
5-HT receptor<;, as well as a adrenoceptors and histamine
receptors (Ch. 14). Dihydroergotamine and methysergide
belong to the ergot family (see below) and are used mainly
for migraine prophylaxis. Other 5-HT2 antagonists are used
to control the symptoms of carcinoid tumours.
S-HT, receptor antagonists (e.g. ondansetron , granisetron,
tropisetron ) are used as antiemetic drugs (see Cbs 2S and S I),
particularly for controlling the severe nausea and vomiting
that occurs with many forms of cancer chemotherapy.
S-HT4 receptor agonists, which stimulate coordinated peristaltic
activity (known a:. a ' prokinetic action'), are used for treating
gastrointestinal disorders (see Ch. 2S). Metoclopr amide acts
in this way, although it also affects dopamine receptors. The
new drug tegaserod is more selective and is used to treat
irritable bowel syndrome.
S-l-IT is also important as a neurotransmitter in lhe CNS, and several
important antipsychotic and antidepressant drugs owe their actions
to effect~ on these pathways (see Chs 34, 38 and 39). LSD is a
relatively non-selective S-HT receptor agonist or partial agonist,
which acts centrally as a potent hallucinogen (see Ch. 42).
ERGOT ALKALOIDS
Ergot alkaloid~ con'>titute a hard-to-classify group of drugs that
have preoccupied pharmacologists for more than a century. Many
of them act on S-liT recepton., but not selectively. and their actions
arc complex and diver!>e.
T Ergot comam~ many active substances. and it was !he study of !heir
pham1acologic:1l propenies that led Dale to many imponam discoverie\
concerning acetylcholine, histamine and catecholamincs. Ergot alkaloids
occur naturally in a fungus (Claviceps purpurea) !hat infests cereal
crops. Epidemic;, of ergot poisoning have occurred. and still occur, when
contaminated grain is used for food. The symptoms produced include
mental disturbances and intensely painful peripheral vasoconstriction
leading 10 gangrene. This came to be known in the Middle Ages as
St Alllhony's fire, because it was believed that it could be cu red by a visit
to the Shrine of S1 Anthony (which happened to be in an ergot-free region
of France).
Ergot alkaloids arc complex molecules based on lysergic acid
(a naturally occurring tctracyclic alkaloid). The important
members of the group (Table 12.2) include various naturally
occurring and synthetic derivatives with different substituent
groups arranged around a basic nucleus. These compounds display
many different types of pharmacological action, and it is difficult
to discern any clear relationship between chemical structure and
pharmacological properties.
Actions
Most of the effects of ergot alkaloids appear to be mediated
through adrenoccptors. S-l-IT or dopamine receptors (Table 12.2),
although some effect& may be produced through other
mechanism!>. All alkaloid1. stimulate smooth muscle, some being
relatively selective for vascular smooth muscle while others act
mainly on the uterus. Ergotamine and dihydroergotamine are,
respectively, a partial agonist <md an antagonist at a adreno-
ceplors. Oromocriptine is an agonist on dopamine receptors, 193
 SEcnON 2 . CHEMI CA L MEDIATORS

T ble 12.2 Properties of ergot alkaloids

Drug 5- HT recept or a Adrenoceptor Dopamine Uterine Main uses Side effects etc.
receptor contraction

Ergotam1ne AntagonisVpartial Partial agonist Inactive ++ M1graine Emesis

agonist (5-HT1} (blood vessels} Vasoconstriction
Antagonist (avoid in peripheral
(other sites) vascular disease}
Avoid in pregnancy

Dihydroergotamine AntagonisVpartial Antagonist Inactive + Migraine (largely Less emesis than

agonist (5-HT1} obsolete} with ergotamine

Ergometrine AntagonisVpartial Weak antagonisV Weak +++ Prevention of

agonist (5-HT1} partial agonist postpartum
(weak} haemorrhage

Bromocriptine Inactive Weak antagonist AgonisVpartlal - Parkinson's disease Emesis

agonist (Ch. 35}
Endocrine disorders
(Ch. 28}

Methylsergide AntagonisVpartial - Carcinoid syndrome Retroperitoneal and

agonist (5-HT~ Migraine (prophylaxis} mediastinal fibrosis
Emesis

particularly in the CNS (Ch. 28). and methysergide is an antagoniM
at 5-HT2 receptors.
The main phannacologicaJ actions and uses of these drugs are
summari~ed in Table 12.2. As one would expect of drugs with so
many actions. their physiological effects are complex and rather
poorly understood. Ergotamine, dihydroergotamine and methy-
sergide are di~cussed here; further information on er gometrin e
and bromocriptine is given in Chapters 28, 30 and 35.
Vascular effects. When injected into an anaesthetised animal,
ergotamine activates a adrenoceptors, causi ng vasoconstrict ion
and a sustained rise in blood pressure. At the same time, ergolamine
reverses the pressor effect of adrenaline (epinephrine; see Ch. 9).
The vasoconstrictor effect of ergotamine is responsible for the
peripheral gangrene of St Anthony's ftre. and probably also for
some of the effects of er got on the CNS. Melhysergide and
dihydroergotamine have much less vasoconstrictor effect.
Methysergide is a potent 5-HT2 receptor antagonist, whereas
ergotamine and dihydroergotamine act selectively on 5-HT1
receptors. Allhough generally classified as antagonists. they show
partial agonist activity in some tissues. and this may account for
their activity in treating migraine attacks (see below).
Clinical use. The only use of ergotamine is in lhe treatment of
attacl0. of migraine unresponsive to simple aoaJgesics (see below).
M cthysergide is occasionally used for migraine prophylaxis, but
its main usc is in treating the symptoms of carcinoid tumours (see
below). All these drugs can be used orally or by injecti on.
Un wanted effects. Ergotamine often causes nausea and
vomiting, and it must be avoided in patients with peripheral
vascular disease bccnuse of its vasoconstrictor action. Methyscrgide
194
also causes nausea and vomiting, but its most serious side effect,
which considerably restricts its clinical usefulness, is retroperitoneal
and mediastinaJ fibrosis. which impairs lhe functioning of Ilk:
gastrointc!>linal tr1ct. kidneys. heart and lungs. The mechani'm
of this is unknown. but it is noteworlhy that simi lar tibroti.
reactions also occur in carcinoid syndrome (see below) in which
there is a high circulating level of 5-HT.
Ergot alkaloids
These active substances are produced by a
fungus that infects cereal crops; it is responsible for
occasional poisoning incidents. The most important
compounds are:
ergotamine, dihydroergotamine, used in migraine
ergometrine, used in obstetrics to prevent
postpartum haemorrhage
methysergide, used to treat carcinoid syndrome,
and occas1onally for migraine prophylaxis
bromocriptine, used in parkinsonism and
endocrine disorders.
Main sites of action are 5-HT receptors, dopamine
receptors and adrenoceptors (mixed agonist,
antagonist and partial agonist effects).
Unwanted effects include nausea and vomiting,
vasoconstriction (ergot alkaloids are contraindicated
in patients with peripheral vascular disease).
 OTHER PERIPHERAL MEDIATORS: 5-HYDROXYTRYPTAMINE AND PURINES
CLINICAL CONDITIONS IN WHICH 5-HT
PLAYS A ROLE
In this !>Cction, we discuss two situations in which the peripheral
actions of 5-HT are believed to be important. name ly migraine
and carcinoid syndrome. Further information may be found in
llouston & Vanhoutte ( 1986). The usc of 5-HT3 antagonists
in treating drug-induced emesis arc discussed in C hapter 25.
\1odulation of 5-HT-mediated transmission in the C S is an
tmportaot mechanism of action of antidepressant and ami psychotic
drugs (see Cbs 34, 38 and 39).
MIGRAINE AND ANTIMIGRAINE DRUGS
Migraine is a common and debilitating condition affecting
10 15% of people, although the causes are not well understood
(~ee Moskowitz, 1992; Edvinsson, 1999; Villalon et al., 2003). A
'textbook' migraine attack consists of an initial visual disturbance
(the aura), in which a nickering pallern, followed by a blind spot
(a 'scintillating scotoma'), progresses gradually across an area
of the visual field. This visual distu rbance is followed. about
30 minutes later. by a severe throbbing headache, starting
unilaterally, often accompanied by photophobia, nausea, vomiting
and prostration, which lasts for several hours. Jn fact, the visual
aura occurs o nl y in abou t 20% of migraine sufferers, although
many experience other kinds of premonitory sensation. Sometimes
auacks are precipitated by particu lar foods or by visual stimuli,
but more often they occur wi thout obvious cause.
n Pathophysiology
c Although controversy abounds and opinions vary. there are three
h fundamental views of the physiological mechanisms underlying
mtgrnine. linking it to primary events in blood vessels. the brain
or sensory nerves.
The classic 'vascular' theOI)', first proposed around 50 year:.
ago by Wolff, implicated an initial humorally mediated intracerebral
vasoconstriction causing the aura, followed by an extracerebral
vasodilatation causing the headache. This venerable hypothesis
has not. however. been generally supported by more recent blood
flow studies involving non-inva!>ive monitoring techniques in
patients with migraine (see review by Friberg, 1999). Jn episodes
of migraine with aura, there is indeed a biphasic change in
cerebral blood flow (Fig. 12.2), with a reduction of 20-30%
preceding the premonitory aura, followed by a highly variable
increase of similar magnitude. However. the headache usually
begins during the initial vasoconstrictor phase, and blood now
changes of similar magnitude caused by other factors do not
produce symptoms. The vasoconstriction starts posteriorly and
gradually spreads forwards over the hemisphere, implyi ng a
neural rather than a humoral cause. These changes occur only in
association with an aura and do not occur in the remaining 80%
of migraine sufferers. o con~istent blood flow changes are
associated with the headache phase itself.
The headache originates not in the brain itself. but in extra-
cerebral stntctures lying within the cranial cavity innervated by
nocicepti ve sensory nerve fibres of the trigeminal pathway, such
as the meninges and large arteries. The vascular theory attributes
~
~
~
150i
g
8 100
:0
~ 50
.0
!!? Headache
Q)
(.) 0 I
0 2 4 6 8 10 12
Hours
Fig. 12 .2 Cerebr al blood flow changes during migraine.
(After Olesen et al. 1990 Ann Neurol 28: 791-798.)
the headache to dilatation in these large mteries. While some
studies have shown a uni lateral widening of the middle cerebral
artery on the same side as the headache sensatio n, others have
shown no clear change. Ovemll, the evidence for arterial dilatation
as a cause of the headache is controversial (see Thomsen, 1997 ).
The 'brain' hypothesis (sec Lauriuen. 1987) links migraine to
the phenomenon of cortical spreading depression. This is a
dmmatic although poorly undcn.tood phenomenon, triggered in
experimental animaJs by local application of K+ to the cortex and
thought to occur in concussion. This causes an advancing wave
of profound neural inhibitio n, which progresses slowly over the
cortical surface at a rate of abo ut 2 mm/ min. ln the depressed
area, the ionic balance is gro~s l y disturbed, with an extremely
high extracellular K+ concentration, m1d the blood now is reduced.
There is ~trong evidence to sugge:.t that the aura phase of a migraine
attack is associated with a wave of spreading depression, although
what initiates it remains obscure. However. spreading depression
triggered in animal models does not lead to activation or
scnsitisation of trigeminal afferents (Ebersberger et al., 200 I). It
is now believed that the aum is associated with spreading depression,
but that this is not a necessary step in the pathogenesis of the
migraine attack itself.
The 'sensory nerve' hypothesis (see Moskowitz, 1992) proposes
that activation of trigeminal nerve terminals in the meninges and
extracranial vessels is the primary event in a migraine attac)...
This would cause pain directly and will also induce inflammatory
changes through the relca'>e of neuropeptides from the o,ensory
nerve terminals (neurogenic inflammation; see Chs 16 and 41 ).
This theory is supported by experiments showing that one '>uch
peptide (calcitonin gene-related peptide; see Ch. 16) is released
into the meningeal circulation during a migraine attack.
These theories arc summarised in Figure 12.3. Many varian ts
of these mechanis ms have been proposed. but it is noteworthy
that none can explain at the biochemical level what initiates a
migraine anack or define the underlying abnormality that
predisposes particular individuals to suffer such attac)..s. In . ome
rare types of familial migraine. inherited mutations affecting
calcium channels and Na-K+ ATPase have been found, suggesting
that abnormal membrane function may be responsible, but in
most forms of migraine there il. no clear genetic cause. Whether
one inclines to the view that migraine is a vascular disorder, a
type of spontaneous conc ussion, an inflammatory disease or just 195
 SECTION 2 . CHEMICAL MEDIATORS

PERIPHERAL MECHANISMS
Dilatation of

5-HT2
receptor

Sensitisation of
Fig. 12.3 Postulated
pathogenesis of migraine. The
initiating event is uncertain but may
r
Release of mediators /
be an abnormal neuronal discharge (prostaglandins, kinins, etc.)
Neuropeptide release
( NSAIOs ~
set off by emotional or biochemical
disturbances. This leads to localised / (CGRP,SP)
'spreading depression', which
causes the aura and may also lead Neuroinflammation
to sensitlsation of central pain
pathways. In migraine without aura,
the primary event Is excitation CENTRAL MECHANISMS
(cause unknown) of nociceptive
nerve terminals In the meningeal
Central pain
vessels, leading to the cycle of
sensitisation - - - .
neurogenic inflammation shown in
the upper part of the diagram. 5-HT,
5-hydroxytryptamine; CGRP, Unknown factors
calcitonin genEKelated peptide; NO,
nitric oxide; NSAIDs, non-steroidal
Spreading
anti-Inflammatory drugs; SP,
depression
substance P.

a bad headache, there are two important factors that implicate

5-HT in its pathogenesi!>.

There i.<. a sharp increase in the urinary excretion of the main

5-HT metabol ite, 5-l llAA. during the attack. The blood
concentration of 5-1-!T fal ls, probably because of depletion of
platelet 5-HT.
Many of the drugs that arc effective in treating migraine are
5-HT receptor agonists or antagonists. See Figure 12.3 and
the clinical box for further information.
Antimigraine drugs
The main drugs used to treat migraine are summarised in
Table 12.3, and their po!>tulated sites of action are shown in
Figure 12.3. It is important to distinguish between drugs used
therapeutically to treat acute attacks of migraine (appropriate
when the allacks are fairly infrequent) and drugs that arc used for
prophylaxis. Apart from 5-HT2 receptor antagonists. the drugs
used prophylactically are a mixed bag, and their mechanism of
action is poorly understood.
CARCINOID SYNDROME
Carcinoid l.yndromc (sec Creutzfeld & Stockmann, 1987) is a
rare disorder associated with malignant tumours of enterochromaffin
cells, which usually arise in the small intestine and mctastasise to
196
the liver. These tumours secrete a vari ety of chemical mediators:
Drugs used for migraine
Acute attack
Simple analgesics (e.g. aspirin, paracetamol; Ch. 14)
with or without metoclopramide (Ch. 25) t o hasten
absorption.
Ergotamine (5-HT10 receptor partial agonist).
Sumatriptan, zolmitriptan (5-HT10 agonists).
Prophylaxis
~-Adrenoceptor antagonists (e.g. propanolol,
m etoprolol; see Ch. 11 ).
Pizotifen (5- HT2 receptor antagonist).
Other 5- HT2 receptor antagonists:
cyproheptadine: also has antihistamine actions
- methysergide: rarely used because of risk of
retroperitoneal fibrosis.
Tricyclic antidepressants (e.g . amitriptyline; Ch. 39). 5
Clonidine, an a 2-adrenoceptor agonist (see Ch. 11).
Calcium antagonist s (e.g. dihydropyridines,
verapamil; see Ch. 18): headache is a side effect of
these drugs but, paradoxically, they may reduce
frequency of migraine attacks.
 OTHER PERIPHERAL MEDIATORS: 5-HYDROXYTRYPTAMI NE AND PURINES

Table 12.3 Antimigraine d rugs

Use Drug(s) M ode of action Side effects Pharmacokinetic aspects Notes

Acute Sumatriptan 5-HT10 receptor Coronary Poor1y absorbed by mouth, Effective in - 70% of
agonist vasoconstriction, hence delayed response migraine attacks, but
Constricts large dysrhythmias Can be g1ven subcutaneously short duration of action
arteries, inhibits Does not cross blood- is a drawback
trigeminal nerve brain barrier Contraindicated in patients
transmission Plasma half-life 1.5 h w1th coronary disease

Almotriptan As sumatriptan, Side effects less Improved bioavailability and Basically sumatriptan
Eletriptan with additional than with duration of act1on compared lookalikes, with improved
Frovatriptan actions on central sumatriptan with sumatriptan pharmacokinetics and
Naratriptan nervous system Able to cross blood- reduced card iac side
Rizatriptan brain barrier effects
Zolmltriptan

Acute Ergotamine 5-HT1 receptor Peripheral Poorly absorbed Effective, but use limited
partial agonist; vasoconstriction, Sometimes given by by side effects
also affects including coronary suppository, inhalation, etc.
a adrenoceptors vessels Duration of action 12-24 h
Vasoconstrictor Nausea, vomiting
Blocks trigeminal Contracts uterus
nerve transmission and may cause
fetal damage

Prophylaxis Methysergide
5-HT2 receptor Nausea, vomiting, Used orally Effective, but rarely used
antagonisVpartial diarrhoea owing to side effects and
agonist Rarely, but seriously, insidious toxicity
retroperitoneal or
mediastinal fibrosis

Prophylaxis Pizotifen 5-HT2 receptor Weight gain Used orally

antagonist Antimuscarinic
Also muscarinic side effects
acetylcholine
antagonist

Prophylaxis Cyproheptadine 5-HT2 receptor Sedation, weight Used orally Rarely used
antagonist gain
Also bloc ks
histamine rec eptors
and calc ium channels

Prophylaxis Propranolol and r~-adrenoceptor Fatigue Used orally Effective and wid ely used
similar drugs antagonists Bronchoconstriction for migraine
(e.g. metoprolol) Mechanism of
ant1migraine effect
not clear

Notes:
1. Aspirin-like or opiate analgesic drugs (see Ch. 41) are often used to treat acu1e migraine attacks.
2. Other drugs used for migra1ne prophylaxis include calcium channel blockers (e.g. mfedipine, see Ch. 19), antidepressants
(e.g. amitriptyline, see Ch. 39), valproate (see Ch. 40) and clonidine (Ch. 11 ). The1r efficacy is limited.

5-HT is the most important, but neuropeptides. such as substance
P (Ch. 16). and other agents, such as prostaglandins and bradykinin
(Ch. 13). arc also produced. The release of these substances into
the bloodstream resul ts in several unpleasant symptoms,
including flushing, diarrhoea, bronchoconstriction and hypotension,
which may cause dizziness or fainting. Stenosis of heart valves,
which can result in cardiac fai lure, also occurs. ll is reminiscent
of retroperitoneal and mediastinal fibrosis, which are adverse
effects of methy!>ergide (see above. p. 194). and hence is probably
related to an unknown action of 5-HT.
The syndrome is readi ly diagnosed by measuring the urinary
excretion of the main metabolite of 5-HT, 5-HIAA. Excretion in
the disease may increase 20-fold and is raised even during periods
when 01e tumour i~ asymptomatic. 5-HT2 antagonists, such as 197
 SECTION 2 . CHEMICAL MEDIATORS
cyproheptadine. are effective in controlling some of the symptom<>
of carcinoid syndrome. A complementary therapeutic approach is
to u~e octreotide (a long-acting analogue of somatostatin). which
suppresses hormone ~ecret ion from neuroendocrine. including
carcinoid, cells (see Ch. 28).
PURINES
Nucleosides (especially adenosine) and nucleotides (especially
ADP and ATP) produce a wide range of pharmacological effects
that are unrelated to their role in energy metabolism. lt was shown
in 1929 that adenosine injected into anaesthetised animals causes
bradycardia, hypotension, vasodilatation and inhibition of intestinal
movements. Since then, it ha~ become clear that purines participate
in many phyl>iological control mechanisms, including the regulation
of coronary now and myocardial function (Chs 18 and 19), platelet
aggregation and immune responses (Chs 13 and 2 1), and neuro-
transmission in both the central and peripheral nervous system
(Chs 9 and 34; for rev iew~. see Illes et a!., 2000; Cunha, 200 I).
Figure 12.4 summarises the mechanisms by which purine)) are
released and interconverted, and the main receptor types on
which they act.
The full complexity of purinergic control systems. and their
importance in many pathophysiological mechanisms. is only
now emerging, and there is no doubt that therapeutic agents
affecting the~e systems will a~sume growing significance.
ATP AS A NEUROTRANSMITTER
The idea that ~uch a worladay metabolite as ATP might be a
member of the neurotransmiller elite was resisted for a long time.
~ AMP
Fig. 12 .4 Purines as
mediators. ATP (and in platelets,
ADP) 1s stored in vesicles and
released by exocytosis. It is also ''
present in the cytosol of all cells,
from which large quantities may be ' ,
released by cellular damage.
Adenosine is present in the cytosol
of all cells, and is taken up and
released via a spectfic membrane
transporter. Released ATP and ADP
are rapidly converted to adenosine ltgand
l by the action of tissue gated ion
channels
nucleotidases.
198
-------------------------------------------------------
but it i'> now firmly established. ATP is a transmitter in the
periphery, both as a primary mediator and as a cotransmittcr in
noradrenergic nerve terminals (see Bumstock. 1985; Lundberg.
1996; Khakh, 200 I). The nucleotide is contained in synaptic
vesicle~ of both adrenergic and cholinergic neurons, and u
accoums for many of the actions produced by stimulation 01
autonomic nerve~ that are not caused by acetylcholine or
noradrenaline (see Ch. 9). These effects include the relaxation of
intestinal smooth mu1>cle evoked by sympathetic stimulation.
and contraction of the bladder produced by parasympatheth:
nerves. Burnstock and his colleagues have shown that ATP
is released On nerve Mimulation in a Ca2+-dcpcndcnt fashion,
and that exogenous ATP, in general, mimics the effects of nef\e
stimulation in various preparations. Furthcm1orc, the ATP
receptor antagonist suramin (a drug developed many yeaf\
ago for treating trypanosome infections) blocks these synaptic
responses. Recent work has also shown ATP to funct ion as a
conventionnl 'fast' transmitter in the CNS and in autonomtc
ganglia (see Kha!Jl, 200 I). ATP is present in all cells m
millimolar concentrations and is released, independently of
exocytosis, if the cells arc damaged (e.g. by ischaemia). ATP
released from cells is rapidly dcphosphorylated by a range o
tissue-specific nucleotidases, producing ADP and adeno .. mc
(Fig. 12.-t). both of which produce a wide variety of receptor-
mediated effects. Adenosine. produced following hydro!}'"
of ATP. exert~ presynaptic inhibitory effects on the release of
excitatory transmitters in the CNS and periphery.
The role of intracellular ATP in controlling membrane
pota-.sium channels. which is important in rhe control of '"ascular
smooth muscle (Ch. 19) and of insulin secretion (Ch. 26). ,,
quite dbtinct from its transmitter function.
Synt hesis
and release
Adenosine k1nase
Adenosine
ATP
.., Exocytos1s
ATP
I
I
I
I
: \_ Nucleolldases ) Extracellular
y l 1
ATP ~ ADP~ AMP~ Adenosine
~ conversions
!
P2x
l l
G-protein-coupled Receptors
receptors
 OTHER PERIPHERAL MEDIATORS: 5-HYDROXYTRYPTAMINE AND PURINES
e ADP AND PLATELETS
m antngoni~t selectivity. as well as molecular structure (for recent
rg. The secretory ve!>icles of blood platelets store both ATP and ADP
tic in high concentrations. and release them when the platelets arc
it activated (sec Chs 20 and 21 ). One of the many effects of ADP il>
of to promote platelet aggregation. ~o thh system provides positive
or feedback an important mechanism for controlling this process.
of as anel>ted by the thempeutic effectiveness of clopidogrel, which
n. \\Orks via amagoni-.m of platelet ADP receptors (Ch. 21, p. 342).
tic
TP
ADENOSINE AS A MEDIATOR
:m.
e Adenosine differs from ATP in that it is not stored by, and
TP released from, secretory vesicles. Rather, it exists free in the
ar-; cytosol of all celb and is transported in and out of cells mainly
~ic using a membrane transporter. Not much is known about the way
a in wh ich this is controlled. Adenosine in tissues comes partly
ic from this source and partly from extracellu lar hydrolysis of
in released ATP or ADP (Fig. 12.4).
of Adcno!>inc produces many pharmacological effects, both in
rP the periphery and in the CNS (sec Brundege & Dunwiddic, 1997;
of Cunha. 200 I). Based on its ability to inhibit cell function and
ne thus minimise the metabolic requirements of cells. one of its
r- functions may be a<, a protective agent released when tissue
integrity is threatened (e.g. by coronary or cerebral ischaemia;
'-l!e Ch!> 18 and 35). Under le!>s extreme conditions, variations in
adenosine release may play a role in controlling blood flow and
ne (through effect'> on the carotid bodies) respiration. matching
ar them to the metabolic needs of the tissues.
... Adenosine is del>troyed or taken up within a few seconds of
intravenous administration (as in the treatment of supraventricular
tachycardias; sec Ch. 18), but longer-lasting analogues have been
discovered that also show greater receptor selectivity. Adenosine
uptake is blocked by dipy rid a m ole , a vasodilator and anti platelet
drug (sec Ch. 2 1).
Another area of growing interest is asthma (see Adriaensen
and Timmcrmans, 2004). Adenosine has been identified as a
potentia l mediator of cytokine release from mast cells, of hyper-
reactivity of vagal and other airway neurons, and other actions
that may directly or indirectly contribute to the disease.
PURINE RECEPTORS
Receptor... for purines, like those for other mediators. have
undergone classification and reclassification several times, but a
rational !>Cherne ha<, now been agreed. There are two main types
(see Fredholm ct al., 1994).
P1 recepton (l>ubtype~ A 1 A 2 and A,). These are G PCRs that
respond to adenosine and are present in many different
ti~sues. They are linked to stimulation or inhibition of
adenylatc cyclase.
P1 receptors (subtypes Pzx and P 2y, each with several funher
subdivisions). These respond to ATP and/or ADP. P 2x
receptors are multimeric ionotropie receptors (sec Ch. 3).
whereas P2y receptors are GPCRs coupled to adenylate
cyclase or phosphoinositidc metabolism.
The'e \ubtypes are dif>tinguished on the basis of their agonist and
review-.. see von Ki.igelglen & Wetter. 2000: Fredholm ct al.,
200 I: Khakh. 200 I). Although there are many experimental
compound<; with varying degrees of receptor selectivity. there arc
so far few therapeutic agents that act on these receptors, and we
will confine this account to some functional aspects that rna}
give ri~c to therapeutic drugs in the future.
FUNCTIONAl ASPECTS
Adenosine receptors
The main effects of adenosine, and the receptors involved, are as
follow.
Vasodilatation, including coronary vessels (A 2). except in the
kidney, where A 1 receptors produce vasoconstriction.
Adenosine infusion causes a fall in blood pressure.
Inhibition of platelet aggregation (A 2).
Block of cardiac atrioventricular conduction (A 1) and
reduction of force of contraction.
Bronchoconstriction, especially in asthmatic subjects (A 1);
the antiasthmatic effect of m et hylxa n t hines may partly
reflect A 1 receptor antagonism.
Release of mediator.; from mast cells (A 3): this contribute!> to
bronchocon'>lriction.
Stimulation of nociceptive afferent neurons, especially in the
heart (A 2 ): adenosine release in response to ischaemia has
been !.uggested as a mechanism of anginal pain (Ch. 18).
Carotid body affcrents arc abo stimulated, causing reflex
hyperventilation.
Inhibition of transmitter release at many peripheral and
central synapses (A 1). ln the CNS. adenosine generally exerts
a pre and postsynaptic depressant action, reducing motor
activity, depre!>sing respiration, inducing sleep and reducing
anxiety, all of which effects are the opposite of those
produced by mcthylxanthines (Ch. 42).
Ncuroprotcction. in cerebral ischaemia, probably through
inhibi tion of glutamate release through A 1 receptors.
In general, the A 1 receptor has been characterised as a homeostatic'
receptor with protective functions in many tissues, whereas the
A2 receptor has more specific regulatory functions, especially in
the brain. where it i~ widely expressed.
P2 receptors and actions
P2 receptor<, rc~pond to various adenine nucleotides, generally
preferring ATP over ADP or AMP. The role of ATP as a fast
transmitter (sec above) involves Pzx receptors. of which seven
subtypes have been identified. These occur as a variety of mixed
(hctcromcric) assemblies (see Khakh, 200 I). Not all their functions
arc clear, but the following actions are generally agreed.
P2x 1 receptors arc expressed on various smooth muscle cells.
ATP is a cotran~mittcr released by sympathetic nerve (Ch. II),
and P2x 1 receptors are responsible for the initial contraction.
P 2x2 receptors are expressed in many brain regions and
mediate 'fast' transmission by ATP in the brain. 199
 SECTION 2 . CHEM ICAl MEDIATORS
P2x 1 receptors occur i n nociceptive afferent neurons and may
parti cipate in pai n associated with ATP released rhrough
ti s!>ue i nj ury.
P2x7 receptors are unusual in that activation causes a large
and non-selective increase in membrane permeability. They
are expre~~ed mainly by ceLls of the immune system, and
they control the release of certain cytokines.
T he other actions of ATP in mammals are mediated through some
eight subtypes of P2y receptors. These are GPCRs and are linked
to various second messenger systems. They occur in many
ti ssues, and the lack of :-electi ve antagonists makes it difficult to
define their functions individually, although the actions of ADP
on platelets and vascular endothelial ceLls are ascribed to the P2YI
subtype. Drugs acting selecti vely on P2 receptors have not yet
been developed for clinical purposes.
PHARMACOLOGICAL ASPECTS
Uses of adenosine
Because of its inhibitory effect on cardiac conduction, adenosine
may be used as an intravenous bolus injection to tenninatc
<.upraventricular tachycardia (Ch. 18). It is sa fer than altern ative
drugs such a~ (3-adrenoccptor antagonists or verapamil , because
Purines mediators
ATP functions as a neurotransmitter (or cotransmitter)
at peripheral neuroeffector junctions and central
synapses.
ATP is stored in vesicles and released by exocytosis.
Cytoplasmic ATP may be released when cells are
damaged. It also functions as an intracellular
mediator, inhibiting the opening of membrane
potassium channels.
ATP acts on two types of purinoceptor (P2), one of
which (P2x) is a ligand-gated ion channel responsible
for fast synaptic responses. The other (P2v) is coupled
to various second messengers. Suramin blocks the
P2x receptor.
Released ATP is rapidly converted to ADP and
adenosine.
ADP acts on platelets, causing aggregation. This is
important in thrombosis. It also acts on vascular and
other types of smooth muscle, as well as having
effects in the central nervous system (CNS).
200
of its short duration of action. Otherwise, adenosine is not used
therapeutically, although longer-lasting A 1receptor agonists might
prove useful in various conditions (e.g. hypertension, ischaem1c
hcan disease and stroke). Selective adenosine receptor antagom b
could also have advantages over t heophylline in the treatment of
asthma (sec Cb. 23).
Drugs acting on purine receptors
M ethy lxanthincs, especially analogues of theophy lline (Ch. 23),
are A 1/ A 2 receptor antagonists; however, they also incrca!>l:
cAMP by inhibiting phosphodiesterase, which contribute., to
their pharmacological ac6ons independently of adenosine receptor
antagonism. CNS stimulation by methylxanthines such as caffeine
(see Ch. 42) is partly a result of block of inhibitory A 1/A2 receptor'
Certain derivatives of theophylline arc claimed to show greater
selectivity for adenosine receptors over phosphodiesterase. p,
receptors are blocked by suramin and the experimental
compound PPADS.
Intensive efforts are underway to develop drugs with improved
receptor selectivity for therapeutic purposes. There are many
potential applications f or such compounds in different indication,.
including heart disease, stroke, pain and immunological disordm .
Probably, their time wi ll come.
Adenosine affects many cells and tissues,
including smooth muscle and nerve cells. It is not a
conventional transmitter but may be important as a
local hormone and 'homeostatic modulator'.
Adenosine acts through A 1, A2 and A3 receptors,
coupled to inhibition or stimulation of adenylate cyclase.
A 1 and A 2 receptors are blocked by xanthines such as
theophylline. The main effects of adenosine are:
hypotension (A0 and cardiac depression (A1)
inhibition of atrioventricular conduction
(antidysrhythmic effect, A 1)
inhibition of platelet aggregation (A0
bronchoconstriction (probably secondary to mast
cell activation, A3J
presynaptic inhibition in CNS (responsible for
neuroprotective effect, A 1).
Adenosine is very short acting and is sometimes used
for its antidysrhythmic effect.
New adenosine agonists and antagonists are in
development, ma1nly for treatment of ischaemic heart
disease and stroke.
 Local hormones,
inflammation and
1mmune react1ons
Overview 202
Introduction 202
The components of the acute inflammatory
reaction 203
-The innate immune response 203
-The adaptive immune response 207
-Systemic responses tn inflammation 211
-Unwanted inflammatory and immune responses 212
The outcome of the inflammatory response 212
Mediators of inflammation and immune
reactions 213
-Histamine 213
-Eicosanoids 215
-Platelet-activating Factor 219
-Bradykinin 220
-Nitric oxide 222
- Neuropeptides 222
-Cytokines 222
OVERVIEW
All living creatures are born into a universe that
poses a constant challenge to their physical well-
being and survival. Evolution, which has equipped
us with homeostatic systems that maintain a stable
internal environment in the face of changing
external temperatures and fluctuating supplies of
food and water, has also provided us with
mechanisms for combating the ever-present threat
of infection and for promoting healing and
restoration to normal function in the event of
injury. In mammals, this vital function is subserved
by the innate and acquired (or adaptive) immune
responses, working together with a variety of
mediators and mechanisms that give rise to what
202 we collectively term inflammation. Generally this
response acts to protect us, but occasionally it goes
awry, leading to a spectrum of inflammatory
diseases, and it is under these circumstances that
we need to resort to drug therapy to dampen or
abolish the inflammatory response.
This chapter deals with this inflammatory
response and its regulation. We outline the
principal features of the twin pillars of the
inflammatory reaction-the innate and the
adaptive components-and provide a detailed
description of the pathways involved in their
activation. We then describe the main chemical
mediators that control the responses, emphasising
their role in disease. This chapter should be read in
conjunction with the next, which explains in more
detail how anti-inflammatory drugs themselves
actually act.
Unfortunately for the reader, the inflammation
literature is rife with acronyms and abbreviations.
For this reason, a glossary is provided on p. 224.
INTRODUCTION
When faci ng invasion by disease-causing organisms (pathogen\),
mammals can call on a daunting arsenal of defensive responses,
the deployment of which constitutes the acute inflammatory/
immune reaction. When these defences are defective (as for
example in AIDS) or are suppressed by drugs, organisms that are
not normally pathogenic can cause opportunistic infection\,
sometimes with fatal consequences. Under other circumstance,,
the. e defensive re~ponses may be deployed inappropriately m
response to other sorts of injury. such as that caused by chemical,,
ultraviolet light or heat, against innocuous foreign substance'
(e.g. pollen) or against the tissues of the body itself (in autoimmune
conditions). When this happens, the inJlammation itself inflich
damage and may be responsible for the major symptoms of the
disease-either acutely in (for example) anaphylaxis. or chronicall)
in (for example) asthma, rheumatoid arthritis or atherosclerosi,.
The~e 'defcn~ive responses' are initiated and regulated by an arra)
of different mediators released from different cell types, and an
understanding of the effects, mechanisms of action and clinical
usc of drugs that affect the inflammatory and the immune response~
depends on an appreciation of the way in which these cells and
their mediators act and interact.
 LOCAL HO RMO N ES, INFLAMMATION AND IMMUNE REACTIONS
THE COMPONENTS OF THE ACUTE
INFLAMMATORY REACTION
The acute innammatory reaction has two components:
an innate. non-adaptive response. thought to have been
de\eloped early in evolution and presem in some form or
other in most multicellular organisms
the adapti1e immune response.
Some aspecb of the innate response are non-immunological.
for example the hi!>tamine-induced vascular changes to ultraviolet
damage, and some reactions of the neutrophil polymorphs. Other
aspects, particularly thol.e that occur in response to an invading
organism. form part of the overall immune response and are
referred to a~ the innme immune response. The innate response is
act ivated immed iately' after i nfec ti on or injury. A number of
multipurpose defences are automatically put in place, and the
adaptive immune response il> alerted. The innate response al so
has a role in preveming the adaptive response from targeting and
damaging host cells.
The adaptile immune response starts up only after a pathogen
has been reeogni!>ed by the innate system. It comprises a range of
exquisitely pathogen-specific responses, as well as boosting the
actions of the cells and mediators of the innate response. Several
back-up' systems e"bt, such that a pathogen can be neutralised
or killed in . everal way ....
In the discus. ion that follows. we concentrate on the local
manifestalions of the acute reaction to an invading organism. The
outline gi\en will. of necessity. be a very general one, but because
e\'eryone has experienced the innammatory response to a greater
or lesser degree during their lifetime, all will be broadly familiar
\\ ith the redness, swelling, heat and pain that are called the four
mrdinal signs of inflamnwtion (there is a fifth too: loss of
function). The changes occurring within the tissues at this time
can be divided into cellular and vascular events. M ediators are
generated both from plasma and from cells, and these, in tum.
modify and regulate the vascular and cellular reactions.
THE INNATE IMMUNE RESPONSE
The innate immune response has usually been rather airily
dismi!>scd by most immunologists as being an ancient throw-
back that merely provides a temporary holding operation until
the more effective ~pecific adaptive immune response gets going.
In fact, the innate response has a much more significant role in
host defence. An important initiating event in the innate immune
response is the recognition by pattern recognition. or Tol/, 2
'One unmunologi\t referred to the innate re~ponse as the organism's 'knee
w~' re~pon~eto infection. It i'> a good description.
-1'he<;e transmembrane receptor., were first identified in Drosophila and
believed to be involved in ~patial organisation of the developing embryo.
Later, it was appreciated that the receptor was also crucial to host defence.
The name, which loo~cly tran~lates from Gennan as 'G reat!' or 'Eu reka!',
has remained firm ly attached to the family.
The acute Inflammatory reaction
The 'acute inflammatory reaction' occurs in
tissues in response to a pathogen or other noxious
substance.
It usually has two components: an innate non-
adapttve response and an adaptive (acquired or
specific) immunolog tcal response.
These reactions are generally protective, but if
inappropriately d eployed they are deleterious.
The normal outcome of the response is healing w ith
or without scarring; alternatively, if injurious agent
persists, chronic inflammation.
Many of the diseases that require drug treatment
involve inflammation. Understanding t he action and
use of anti-inflammatory and immunosuppressive
drugs necessitates understanding t he inflammatory
reaction.
receptors on tir.~ue maerophages of specific pathogen-associated
molecular panems (PAMP!;) on the microorganism (see Medzhitov
& Janeway, 2000: Brown, 200 I). PAMPs are highly conserved
components that arc common to entire classes of pathogen (bacteria,
viru!>es and fungi). They are usually crucial structural components
of the pathogen that are critical for its survival and \'irulence.
Example~ of bacterial PAMPs are:
peptidoglycan. a con~tituent of the cell wall common to
virtually all bacteria (!>ee Ch. 45)
bacterial lipopolysaccharide. a constituent of the outer
membrane of al l Gram-negative bacteria.
Unlike the antigen receptors on T and B cells that are genemted
somatically as the T and B cells develop, endowi ng each
lymphocyte clone with a structurally unique receptor, Toll
receptors (TLRs) arc encoded in the host DNA and are expressed
on the surface of 'professional' antigen-presenting cells (APCs),
the dendritic cell!. and macrophages. Interaction of a PAMP with
TLRs triggers the dendritic cell or macrophage ro respond
immediately; imracellular signal pathways activate the production
of the main proinnanunatory cytokine!t (see below) tumour necro~is
factor (TNF)-CL and interlcukin (IL)-1. as well as other mediators
(such a~ prostaglandins and histan1ine) that act on the vascular
endothelial cells of the po~tcapillary venules, causing expression
of adhesion molecules on the intimal surface and an increase in
vascular permeability. This allows exudation, into the extravascular
space. of nuid containing the components of enzyme cascade!>
(Fig. 13.1) that give rise to more inflammatory mediators (e.g.
the chcmotaxin C5a).
White blood cell!> adhere to the endothelial cells through
interactions between their cell surface integrins (see below) and
adhesion molecu les on endothelial cells. This enables them to
migrate out of the vessels, attracted by chemotaxins generated by
the micro-organisms or as a resull of their interaction with tissues
(sec Fig. 13.2). Chcmokines released during TLR acti vation play 203
 SECTION 2 C H E M I C A L M E D I AT 0 RS

COMPLEMENT
Classical CASCADE Alternative
pathway pathway
.... ------ ~ Plasma fibrinogen - - - - - - + Fibnn
$ ~170~+ C
< /3

COAGULATION
CASCADE
Thrombin
---+ ..._..,_ _ _ _)~
~~

FIBRINOLYTIC Plasmin
CASCADE ---+ \....,_ _ _ _,
+
Neutral proteases from
'- phagocytic cells ./~
KININ
CASCADE ---+ ' Kallikrein .I

'C7-(Bffi"dy~ ~
- - - - - - - - - - - - - - - - - - - - - - - )> :~~~~~n (Vasodilator; Increases vascular (Releases histamine;
spasmogen)
permeability; spasmogen;
causes pain; generates
eicosanofds; stimulates @
endothelial NO synthesis) (Opsonin)
C3b

(Chemotaxtn; activates
phagocytic cells;
releases histamine)

(Lysis of bacteria)
Fig. 13.1 Four enzyme cascades are activated when plasma leaks out into the tissues as a result of the increased vascular
permeability of inflammation. Factors causing exudation are depicted in Figure 13.2. Med1ators generated are shown in red-bordered
boxes. Complement components are indicated by C1, C2, etc. When plasmin is formed, it tends to increase kinin formation and
decrease the coagulation cascade. (Adapted from Dale et al., 1994.)

an important part in this. (Cytokines and chemoki nes arc
considered on pp. 222-223.)
VASCULAR EVENTS AND THE MEDIATORS
DERIVED FROM PLASMA
The initial vascular event<> include dilatation of the small arterioles,
re~uhing in increased blood flow. This is foiJowed by a slowing
and eventually stasis of blood, and an increase in the permeability
of the po tcapillary venules with exudation of fluid. The val.o-
dilatation is brought about by mediators including hisramine,
prol.taglandin (PG) ~and PGI 2 (prostacyclin) produced by the
interaction of the microorganism with tissue. some of which act
together with cytokines to increase vascular permeability.
The fluid exudate contains the components for four proteolytic
enzyme cascadcl.: the complement system, the coagulation system,
the fibrinolytic l>ystem, and the kinin system (see Fig. 13.1 ). The
components of th ese cascades are proteases that are inactive in
their nalivc form but that are activated by proteolytic cleavage,
each activaled component then activating the next. The exudate
204 is carried by lymphatics to local lymph glands or lymphoid
tissue, where the products of the invading microorganism trigger
the adaptive phase of the response.
'111e complement system comprises nine major componenh.
designated C I to C9. Activation of the cascade is initiated by
substance~ derived from microorganisms. such as yeast cell wal11
or endotOxins. This pathway of activation is termed the
alternative pathway (Fig. 13.1) as opposed to the classic path a)
that i'> dealt with later. One of Lhe main events is the en1ymauc
splitting of C3. giving rise to various peptides, one of which, CJc
(termed an anaphylatoxin) stimulates mast cells to secrete funk
chemical mediator.. and can also directly stimulate smooth mu\Cic
while CJb (termed an opsonin) attaches to the surface of a micro-
organism, facilirating ingestion by white blood cells. C5a, generated
enqmatically from C5, also releases mediators from mast celh
and is a powerfully chemotactic attractant and activator of \\hitc
blood cells.
The final components in the sequence, complement-deri\ed
mediators (C5 to C9). attach to certain bacterial membranes, leading
to lysis. Complement can therefore mediate the destruction of
invading bacteria or damage multicellular parasites; however. il
may sometimes cause injury to the host. The principal enzymes
 LOCAL HORMONES, INFLAMMATION AND IMMUNE REACTIONS

( PAMPs on the pathogen

1. IL-1 andTNF-a act on ,_ IL-1 , tngger release from
endothelial cells, which ----- TNFa macrophages of IL-1
express adhesion molecules andTNF-a
2 Phagocytes Bacteria
adhere to , I , I
Chernotaxins CSa, LTB4 ,
endothelium ' -' IL-8, PAF, are
generated/released ...
3 Phagocytes
migrate towards , I

bacteria - , I
...and attract neutrophils

4. Phagocytosis of I Opsonins C3b, lgG

bacteria ,
-' l ' - mediate attachment to
neutrophils

5. Killing and digestion Bactericidal mechanisms:

of bacteria ( Granule enzymes
Toxic 0 2 products

Fig. 13.2 Simplified diagram of the initial events in a local acute inflammatory reaction. Recognition by tissue macrophages of
pathogen-associated molecular patterns (PAMPs) on the pathogen triggers release, from tissue macrophages, of the proinflammatory
cytokines interleukin (IL)-1 and tumour necrosis factor-a {TNF-a). These act on the endothelial cells of postcapillary venules, causing
exudation of fluid and expression of adhesion factors (e.g. selectins, integrins) to which counter-ligands on blood-borne neutrophils
adhere. Subsequent steps are listed in the figure. C5a and C3b, complement components; lgG, immunoglobulin G; LTB4 , leukotriene B.;
PAF, platelet-activating factor.

of the coagulation and fibrinolytic cascades. thrombin and
pla..\min, can abo activate the cascade by hydrolysing C3, as can
en7ymes released from white blood cells.
The coagulation system and tllefibrinolytic system are described
tn Chaptcr21. Factor XII is activated to Xlla (e.g. by collagen),
and the end product. fibrin. laid down during a host-patllogen
interaction may serve to limit the extent of the infection. Thrombin
i~ additionally involved in the activation of the kinin (Fig. 13.1 )
and, indirectly, the fibrinolytic systems (sec Ch. 21).
The kini11 system is another enzyme cascade relevant to
Inflammation. It yields several mediators, in particular bradykinin
(Fig. 13. 1 and sec below).
CELLULAR EVENTS
Of the cell!> involved in innammation. some (vascular endothelial
cells. mast cells and tissue macrophages) are normally present
~ it roll!> along the ~urface, stabilising its interaction with the
in tissues, while others (platelets and leucocytes) gain access
c endothelial cells. and enabling it to migrate out of the vessel
from the blood. The lcucocytes are actively motile cells and are
a (using a further adhe!>ion molecule termed PECAM. platelet
of two clas<,es.
tr
~. Polymorphonuclear cells (cells witll multilobcd nuclei. also
1- called granulocytes). which are further subdivided into
d newrophils. eosinophils and basophils according to the
staining properties of granules in their cy1oplasm. Some use
e the tenn to refer exclu!.ively to neutrophils.
Mononuclear cells (or cells with single-lobed nuclei), which
Ll arc subdivided into monocytes and lymphocytes.
g which acts as an opsonin that forms a link between neutrophil
f Mast cells
The mast cell membrane has receptors both for a special class of
s antibody, immunoglobulin (lg)E. as well as for the complement
component'> C3a and C5a. Ligands acting at these receptors
trigger mediator relea<,e, as does direct physical damage. One of
the main 1.ubstanccs released is histamine: others include heparin,
lcu kotriene~. PGD 2, platelet-activating factor (PAF). nerve
growth factor and some interleukins.
Polymorphonuclear leucocytes
Neutrophil polymorphs are the shock troops of inflammation.
and are the first of the blood leucocytes to enter an in named area
(Fig. 13.2). The whole process is cleverly choreographed: under
direct observation, the neutrophils may be seen first to roll along
the activated endothelium, then adhere and fina lly migrate out of
the blood vessel and into tlle extravascular space. This process is
regulated by the successive activation of different families of
adhesion molecules (selectins, intercellular adhesion molecule
LICA M] and integrins) on the inflamed endothelium that engage
corresponding COimter-ligands on the neutrophil, capturing it as
endothelium adhesion molecule). The neutrophil is attracted to
the invading pathogen by chemicals termed chemoraxins. some
of \>. hich (such as the tripeptide formyi-Met-Leu-Phe) arc
rclca~ed by the microorganism, whereas otllers, such as CSa. arc
produced locally or by local cells such as macrophages (e.g.
chcmokinc~ such as lL-8).
Neutrophils can engulf, kill and digest microorganisms.
Together with eosinophils, they have surface receptors for C3b,
and invading bacterium. (An even more effective link may be
made by antibody; see below.) Neutrophils kill microorganisms
by generating toxic oxygen products and other mechanisms, and 205
 SECTION 2 . CHEMICAl MEDIATORS
en7ymatic digestion then follows. if the neutrophil is inappropriately
activated, the toxic oxygen products and proteolytic enzymes
can cause damage to the host's own tissues. When neutrophib
have rclea.,cd their toxic chemicals. they undergo apoptosis and
must be cleared by macrophages. It is the live and apoptotic
neutrophil., that constitute 'pus.
Eosinophils have similar capacities to neutrophils but arc abo
armed '' ith a bauery of substances stored in their granules.
which. when released. kill multicellular parasites (e.g. helminths).
These include eosinophil cationic protein, a peroxidase, the
eosinophil major bmic protein and a neurotoxin. The eosinophil
is con ... idcred by many to be of primary importance in the
pathogenesis of the late phase of asthma where, it is suggested,
granule protein., cause damage to bronchiolar epithelium (Fig. 23.3).
Basophils arc very similar in many respects to mast cells. The
basophil content of the tissues is negligible-except in certain
parasitic infections and hypersensitivity reactions-and in health
they form only 0.5% of circulating white blood cells.
Monocytes/ macrophages
Monocytcs arrive in inflammatory lesions several hours after the
polymorph\. Adhe~ion to endothelium and migration into the
tissue follow a pattern similar to that of the ncutrophils (sec
above). although monocyte chemotaxis utilises additional
chemokine.,, ... uch a., MCP- 11 ('"hich. reasonably enough. stands
for monocyte chemoauractant protein- I) and RANTES (which
\Cry unreasonabl\' !>land!> for regulated on i!Ctivation normal I -
cell Xpres\cd and ~ecreted-immunological nomenclature ha-.
excelled it,clf here!).
Once in tiS\Ue!.. blood monocytes differentiate into macrophages
(literally 'big eaters. compared with neutrophils. originally called
microphagcs or 'liule eaters'). The resultant cell has a remarkable
range of abilities. being not only a jack of all trades hut also
ma.,tcr of many (see below). During innate reactions, macrophages
bind lipopolysaccharide and other PAMPs using specific cell
surface receptors. This stimulates the generation and release of
cytokincs and chcmokines that act on vascular endothelial cells.
auract other leucocytes to the area, and give rise to systemic
manifestations of the inflammatory response such as fever.
Macrophnges engulf tis!>uc debris and dead cells. as well a...
phagocyto!.ing and killing most (but unfortunately not all) micro-
organbm.... When ~timulatcd by glucocorticoids. they secrete
anncxin-1 (a potent anti-inflammatory polypeptide; see Ch. 28).
Vascular endothelial cells
Va\cular endothelial cclb (sec also Cbs 19 and 2 I). originally
considered a., p~si'e lining cells. are now known to play an
ucti\e pan in inflammation. Small aneriole endothelial cells secrete
nitric oxide ( 0). causing relaxation of the underlying smooth
Humon immunodeficiency viru;- 1 binds to the ~urface CD4 glycoprotein
1
on monocytc/macrophages but i; able to penetrate the cell only after
206 binding nl~o to MCP I and RANTES receptors.
muscle (~cc Ch. 17}, vasodilatation, and increased delivery of
pla.,ma and blood cells to the inflamed area. The endothelial cclb
of the po~tcapillary venule!> regulate plasma exudation and thu'
the delivery of pl~ma-dcrivcd mediators (sec Fig. 13.1 ). Va'>Cular
endothelial cells express several adhesion molecules (the ICAM
and '>elect in families: sec Fig. I3.2). a!> well as a ,aricty of receptor\
including tho.,e for histamine, acetylcholine and IL-l. In addition
to NO. the cell\ can '>ynthesise and release the "asodilator agent
PGI ,, the va<,ocon~trictor agent endothelin. plasminogen acti\'atOr
PAF and several cytolinel... Endothelial cells also participate in
the angiogenesis that occurs during innammawry resolution,
chronic innammation and cancer (see Chs 5 and 51).
Platelets
Platelets are involved primarily in coagulation and thrombotic
phenomena (see Ch. 21) but also play a part in inflammation.
They have low-affinity receptors for lgE, and are believed to
contribute to the first phase of asthma (Fig. 23.3). In addition to
generating thromboxane (TX) A2 and PAF, they can generm~
free radicals and prointlammatory cationic proteins. Platelet
derived growth factor contributes to the repair processes that
follow innammatory responses or damage to blood vessel~.
Neurons
In addition to relaying impulses to the central nenous S}\tcm
<C 'S), \Orne ;.,en;.,ory neurons release infiammatory neuropeptide'
when appropriately \timulated. These neurons are fine afferent'
(capsaicin-.,en'>itive C and AO fibres) with specific receptor\ at
their peripheral terminals. Kinins. 5-hydroxytryptamine and other
chemical mcdiatorl> generated during inflammation act on the"'
receptors. stimulating the release of neuropeptides such a\ th(
tachykinin., (neurokinin A. substance P) and calcitonin gene
related peptide (CGRP). The neuropeptides are considered
further in Chapter 16.
Natural killer cells
Natural killer (NK) cells arc a specialised type of lymphocyte. In
an unusual twist to the receptor concept, NK cells kill target'
(e.g. virus-infected or tumour cells) that lack ligands for inhibi((m
receptors on the NK cells themselves. The ligands in question are
the major histocompatibility complex (MHC) molecules, and an}
cell\ lacking these become a target for NK-cell attack, a mateg)
sometime\ culled the 'mother turkey strategy' .4 MHC protem,
arc expressed on the surface of most host cells and, in simple
terms. arc specific for that indi\'idual, enabling the NK cell' to
a'oid damaging host cells. NK cells ha\'e other functions: the)
are equipped with Fe receptors and. in the presence of antibod)
directed again\t a target cell, they can kill the cell by antib(}(l\~
dependem ce!ltt!ar crtotoxicity.
'Richard Daw kin-. in Rilw out of Eden. citing the zoologi~t Schlicdt.
explain~ that the 'rule ot thumb a mother turkey uses to recognise nest
robber' i' a dbmayingly bnt-.quc one: in the vicinity of the nest, anac~
anything thtll move~ unlc>\ it ma~e' a noi~c like a baby turkey' (quoted b)
KUrre & Wch.h. 1997).
 LOCAL HORMONES, IN FLAMMATI O N AN D IMMUNE REACTIONS
of MEDIATORS DERIVED FROM CELLS
lb
When innammatory cells arc !>timulated or damaged, another
major mediator family. the eicosanoids. are called into play.
~1any ami-innammatory drugs act. at least in part, by interfe ri ng
with '>ynthe\i'> of eico~anoids. O ther important innammatory
mediatOr\ deri\ed from cell\ are hi'>tamine, PAF. 10 , neuropeptides
and the cytol..ines.
or.
Ill
)ll .
THE ADAPTIVE IMMUNE RESPONSE
The adaptive immunological response is an immeasurably
more efficient defe ns ive manoeu vre and highly specific for the
invading pathogen. A simplified ve rsion will be g iven he re,
tic stressing onl y th ose aspects that are re levant for an understanding
1n. of dru g ac tion; fo r mo re d etailed coverage. see Janeway
to et at. (2004).
to T he key cells arc the lymphocytes. of whic h the re are three
main groups (see Fig. 13.3):
o 8 ce{{.\ , responsible for antibody production, i.e. the humoral
immune response
o T ce{{.\, which are important in the induction phase of the
immune rcspon.,e and in cell-mediated immune reactions
o NK cells. which arc specialised lym phoid cells that are
Ill
active in the non-immunological. innate response.
es
~l iraculou'>ly. T and B lymphoc) tes harbour antigen-specific
rcceptOrl> that recogn ise and react with virtually all foreign
protein<. and polyl>accharides that we are Likely to encounter
during our lifetime. The spccil1c immune re ponse occurs in
two phases:
I. Duri ng the induction phase. antigen is presemed 10 T cells
by large dendritic ce{{s, and th is is fo llowed by complex
interactions o f those T cells with 8 cells and othe r T cells.
On first contact with an a ntigen (foreign protein or
polysacchari de), the lymphocytes that have ' recognised' it
(by means o f s urface recepto rs speci fi e for that antigen)
undergo clmwl expansion, g iv ing rise to a mass of cells that
all have the capacity to recognise and respond to that
particu lar antigen. T hese cells arc eventually responsible fo r
the effector phase of the respon!>e.
2. During the effecror phase. these cells differentiate either
into pla.ww ce{{s or into memory ce{{s. The plasma cells
produce an tibodies (if they are B cells). or are involved in
cell-mediated immune re!>poru.es such as activating
macrophage'> o r killing viru~-infected host cells (if they are
T cell\). Other cell\ form an increased population of an tigen-
'>en!.itive memory cell\. Any subsequent exposure to the
antigen calls fonh a greatly enhanced response.
The receptor repertoi re on T and 8 cells is genera ted randoml y
and would recognise self' proteins as well as foreign antigens if
it were not that tolerance to self antigens is acquired during feta l
life by apoptotic de le tio n of T-cell c lones that recognise the
host's own tissues. Dendritic cells and macrophages involved in
the innate res ponse a lso have a role in preventing harmful immune
reactions against the host's own cells (sec below). A s implified
The Innate Immune response
The innate response occurs immediately on
injury or infection. It comprises vascular and cellular
elements. Mediators generated by cells or from
plasma mod1fy and regulate the magnitude of the
response.
Tissue macrophages, bearing Toll receptors,
recognise specific pathogen-associated molecular
patterns on the microorganism and release cytokines,
particularly interleukin (IL)-1 and tumour necrosis
factor (TNF)-n, as well as various chemokines.
IL-1 and TNF-u act on local postcapillary venular
endothelial cells, causing:
vasodilatation and fluid exudation
- expression of adhesion molecules on the cell
surfaces.
Exudate contains enzyme cascades that generate
bradykinin (from kininogen), and C5a and C3a (from
complement). Complement activation lyses bacteria.
C5a and C3a stimulate mast cells to release
histamine, wh1ch dilates local arterioles.
Tissue damage and cytokines release prostaglandin
(PG) 12 and PGE2 (vasodilators) and leukotriene (Ll)
84 (chemotaxin).
Cytokines st1mutate synthesis of vasodilator nitric
oxide, which increases vascular permeability.
Using adhesion molecules, leucocytes roll on, adhere
to and fmally migrate through vascular endothelium
towards the pathogen (attracted by chemokines,
IL-8, C5a, and LTB4) , where phagocytosis and killing
takes place.
outline o f the main interactions between ce lls and mediators i'>
give n in Figure 13.3.
THE INDUCTION PHASE
Antigenic molecules reach the local lymph nodes through the
lym phatics. A PCs ingeM and process the antigen and present it
on their \urface to:
uncommitted (naive) CD4 .. T-helper lymphocytes, termed
Th cell\. or T-helper precursor (T hp) cells. in association
wi th clas., II MHC molecules (see Fig. 13.4) and/or
naive Co s T lymphocytes in association wi th class I MHC
mol ecu l e\. ~
~he main rca~on thai b difficult to transplant organs such a~ kidney from
one pcr,on to another i~ that their re~pective M HC molecules are different.
Lymphocyte~ in the recipent wi ll react to non-self (al logeneic) MHC
molecule' in the donor ti,~ue. which is then likely to be rejected by a rapid
nnd powerful immunologica l reaction.
207
SECTION2 .CHEMICAL MEDIATORS

Induction phase Effector phase

Antigen presentation Clonal expansion and maturation

B ... p
---- ---~ ~ ANTIBODIES

IL-4~ y ~
~ T:2 4 ~ ... B ... p -------~ ~
'\~ v '
'\~/ ThO ,, l..______B_ ._
. ._M_B_ _ Antibody-mediated reactions j

\'
CD4

IL-2
ThO Th1 ... MT
Glucocorticoids 11
~.) I

Th1 m<-activating
cytokines
---~ (IL-2 and IFNy)
and other
Th1 cytokines

Tc
__ -~ Kill virally
infected cells
Tc

Immunosuppressants,
glucocorticoids
Cell-mediated
reactions
j
Fig. 13.3 Simplified diagram of the induction and effector phases of lymphocyte activation with the sites of action of
immunosuppressants. Antigen-presenting cells (APCs) ingest and process antigen () and present fragments () to naive, uncommitted
CD4 T cells in conjunction with major histocompatibility complex (MHC) class II molecules, or to naive CDS T cells in conjunction with
MHC class I molecules (), thus 'arming' them. The armed CD4' T cells synthesise and express interleukin (IL)-2 receptors and release
this cytokine, which stimulates the cells by autocrine action, causing generation and proliferation of T-helper zero (ThO) cells. Autocrine
cytokines (e.g. IL-4) cause proliferation of some ThO cells to give Th2 cells, which are responsible for the development of antibody-
mediated immune responses. These Th2 cells cooperate with and activate B cells to proliferate and give rise eventually to memory B
cells (MB) and plasma cells (P), which secrete antibodies. Other autocrine cytoklnes (e.g. IL-2) cause proliferation of ThO cells to give
Th1 cells, which secrete cytokines that activate macrophages (responsible for some cell-mediated immune reactions).
The armed cos T cells also synthesise and express IL-2 receptors and release IL-2, which stimulates the cells by aU1ocrine action to
proliferate and g1ve nse to cytotoxic T cells. These can kill virally infected cells. IL-2 secreted by CD4' cells also plays a part in
stimulating CDS' cells to proliferate. Note that the 'effector phase' depicted above relates to the 'protective' action of the immune
response. When the response is inappropriately deployed- as in chronic inflammatory conditions such as rheumatoid arthritis-the Th1
component of the immune response is dominant and the activated macrophages (m4P) release IL-1 and tumour necrosis factor-a, which
in turn trigger the release of the chemokines and inflammatory cytokines that play a major role in the pathology of the disease.
 LOCAL HORMONES, INFLAMMATION AND IMMUNE REACTIONS

B
Fig. 13.4 The activation of aT
cell by an antigen-presenting cell
(APC). A The activation process costimulatory signal
--------- -- -- ~
Involves three stages. (i) Interaction
between the complex of pathogen-
derived antigen () w1th peptide Qj
()
major histocompatibility complex
en
(MHC) class II and the antigen- Qj
specific receptor on the T cell. E~ ()
T <Do ~
B (ii) Interaction between the CD4 IJ)Il.
CD4 ~< ....
+
o.~
coreceptor on the T cell and an c 0
(.)
MHC molecule on the APC. (iii) A Q)
Ql
costimulatory signal from the APC c
to the T cell. The CD4 coreceptor, <
together with a T-cell chemokine
receptor, constitute the main binding
sites for the HIV virus (see Fig. 47.3).

CD4 and CDS arc coreceptors on T lymphocytes that cooperate
with the main antigen-specific receptors in antigen recognition.
Macrophages also carry surface CD4 proteins.
Activation of a T cell by an APC requires that severaJ signab
pa~s between the two cells (Fig. 13.4; see Medzhitov & Janeway,
2000). Researching the imeraction between the APC and the T cell
may enable u. to exploit these pathways in the treatment of HIY
infection and the therapy of immunologically mediated diseac;e.
After activation, the T cells acquire IL-2 receptors and
generate IL-2 il\elf. This cytokine has an autocrine action,
causing proliferation and giving rise to a clone ofT cells termed
ThO cells, which, in turn, give rise to two different subsets of
am1ed helper cell~ termed Til I and Th2 cells. The action of specific
interleukins determine!> whether Th I or Th2 cells develop; IL-12
favours progre% down the Th I, and IL-4 the Th2. pathway. Each
sub~et of Th cells then produces its own profile of cytokines,
which control a unique subset of immune responses. The Th I
pathway mainly controls macrophage- initiated cell-mediated
responses, and the Th2 pathway antibody-medjated responses.
The cyto kines serve as autocrine growth factors for their own
subset ofT cells and have cross-regulatory actions on the devel-
opment of the other subset.
The relationship of Th 1 and Th2 responses to
disease
The T-cell sub. et!> are emphasised here because the balance
between the function1. of the two sub~ets i important in
Immunopathology. Diseases in which Th I responses are
dominant include insulin-dependent diabetes mellitus (Ch. 26),
multiple sclerosi\. Helicobacter pylori-induced peptic ulcer
(Ch. 25), aplastic anaemja (Ch. 22) and rheumatoid arthritis (see
Ch. 14 ). Th I responses are aJso implicated in aJlograft rejection
(i.e. rejection of grafts between individuals of the same species),
although, interestingly, conversion of these Th I responses to Th2
responses at the maternal/fetal interface prevents rejection of the
fetus, which is a sort of foreign 'allograft'.
Th2 responses predominate in allergic conditions such as
asthma (Ch. 23). AIDS progression is associated with loss ofTh I
cello; and is facilitated by Th2 responses. Progression of some
diseases is associated with c hanges in the Th I/Th2 balance; for
example, in tuberculoid leprosy, Th I responses predominate, in
/epmmawus leprosy Th2 responses predominate.
Understanding the rclationsbjp between T-cell subsets, their
respective cytokine profiles and pathological conditions is
expected to highlight ways to manipulate the immune responses
for di<;casc prevention and treatment. There arc already many
experimental models in wruch modulation of the Th lffh2
balance with recombinant cytokines or cytokine an tagonists
alters the outcome of the disease.
Th 1 cells and cell-mediated events
Th I cells produce cytokines ( IL-2. TNF-~ and interferon
[rFNI-y), which:
activate macrophages such that tJ1cy phagocytose and kill
microo rganis ms (such as mycobacteria) that might otherwise
survive and grow intracellularly
stimulate CDS+ lymphocytes to release IL-2 that drives
proliferation and the subsequent maturation of the clone into
cytotoxic cells that kill virally infected host cells (Fig. 13.3)
inhibit Th2 cell functions (by IFN-y action).
Th2 ce lls and antibody-mediated events
Th2 cell\ produce cytokine<; (IL-4, transforming growth factor
[TGFJ-B. IL-l 0), which:
stimulate 8 cells to proliferate and mature into plasma cells
producing antibodies. particularly IgE, the antibody that fixes
to mast cells and. in the lung. to eosinophils
stimulate dijferentilllion and actimtion of eosinophils
inhibit Tit /-cell functions. i.e. the activation of inflammatory
cells and the cell-mediated reactions produced by Th l
cytokincs. For this reason, these cytokines are often thought
of as anti-innammatory.
The induc tio n of antibody-mediated res ponses varies with the
type of antigen. With most antigens. a cooperative process between 209
 SECTION 2 . CHEMICAL MEDIATORS
Th2 cell., and B cells is necessary to produce a response. B cells
can also present antigen to T cells that then release cytokines
that act on the B cell. The anti-inflammatory glucocorticoids
(sec Chs 14 and 28) and the immunosuppressive drug ciclospo ri n
(sec Ch. 14) affect the events at the stage of induction. The cytotoxic
immuno.,uppres\ivc drugs (sec Ch. 14) inhibit the proliferation of
both B and T celb. Eicosanoids are believed to play a part in
controlling these processes. For example. prostaglandins of the E
serie., inhibit lymphocyte proliferation. probably by inhibiting
the release of IL-2.
THE EFFECTOR PHASE
The effector phase may be antibody- or cell-mediated. The
antibody-me diated (humora l) response is effective in the
extracellular nuid, but antibodies cannot neutralise pathogens
within cells. Cell-med iated immune mechanisms hnve evolved to
deal with this problem.
The antibody-mediated (humoral) response
There arc fhe classes of antibody- IgG. IgM, IgE, IgA and
!gO-which differ from each other in certain structural respects
(sec Janeway et al., 2004). All are y-globulins (immunoglobulins)
and ge nerally have two functions:
to recogni\e and interact specifically with antigens, i.e.
protein\ or polysaccharides foreign to the host
to acti,ate one or more further components of the host's
defence sy\tems.
The amigen may form part of an invading organism (e.g. the coat
of a bacterium) or be released by such an organism (e.g. a bacterial
toxin), or it may be a substance introduced experimentally in the
laboratory to study the immune response (e.g. the injection of
egg a lbumin into the g uinea pig). An antibody is a Y-shaped
protein molecule in which the arms of theY (the Fab portions)
arc the recognitio n sites for specific antigens, and the stem of the
Y (the Fe portion) activates hos t defences. The B cells that arc
responsible for antibody production recognise foreign molecules
by mean!> of surface receptors that are essentially the
immunoglobulin that that B-cell clone will eventually produce.
Mammals possess a vast number of B-ceJJ clones that produce
different antibodies with recognition s ites for diffe re nt antigens.
As you might guess, the ability to make antibodies has huge
survival value; children born without this ability c;uffer repeated
infections such as pneumonia, skin infections and tonsillitis.
Before the days of antibiotics. they died in early childhood. and
even today they require regular replacement therapy with
immunoglobulin. Apart from their ability to neutralise pathogens,
antibodies can boo~t the effectiveness and specificity of the host's
defence reaction in several ways.
Antibodies and the complement sequence
Formation of the antigen-antibody complex exposes a binding
site for complement on the Fe domain. This activates the comp-
lement sequence a nd sets in train its attendant biological e ffects
(see Fig. 13. 1). This route to C3 activation (the classic pathway)
210
provides an especially selective way of activating complement in
respon<.c to a particular pathogen, because the antigcn-antibod)
reaction that initiates it is not only a highly specific recognition
event but also occur<> in close association with the pathogen
The lytic property of complement can be used therapeuticall}
monoclonal antibodies (mAbs) and complement together can be
u~ed to clean bone marrow of cancer cells as an adjunct to
chemotherapy or radiotherapy (see Ch. 51). Complemen1 l}~i' ''
a lso implicated in the action of antilymphocyte immunoglobulin.
Antibodies and the phagocytosis of bacteria
When antibodic:. arc attached to their antigens on micro-organism'
by their Fab portions, the Fe domain is exposed. Phagoc)tll
cells (neutrophi Is and macrophages) have receptors on their
mcmbranc11 for these projecting Fe portions. Antibodies thu>
fo rm a very specific link between microorganism and phagocyt~
that ill more effective than C3b as an opsonin in facilitating
phagocytosis (see Fig. 13.2).
Antibodies and cellular cytotoxicity
In some cases, for example with parasitic worms, the invader
may be too large to be ingested by phagocytes. Antibody molecule'
can form a lin!.. between parasite and the host's white celh (in
thil> case, eo<,inophils), which are then able to damage or kill th~
parasite by surface or extracellular actions. NK cells in conjunctiOn
with Fe receptors can also kill antibody-coated target cells tan
example of antibody-dependent cell-mediated cytoxicity).
Antibodies and most cells or basophils
Ma<,t celb and basophils have receptors for IgE, a particular form
of antibody that can attach ('fix') to their cell membranes. Whc:n
antigen reacts with this cell-fixed antibody, a whole panopl) of
pharmacologically active mediators is secreted. This \el)
complex reaction is found widely throughout the animal kingdom
and is unlikely to have been developed and retained during
evolution unless it offered clear survival val ue to the host. Ha\ ing
said that, its precise biological s ig nificance is not entire ly clear,
although it may be of importance in association with eosinophil
activity as a defence against parasitic worms. When inappropriate!}
triggered by substances not inherently damaging to the host, it i1
implicated in certain types of allergic reaction (see below) and
apparently contributes more to iUness than to survival in the
modern world.
The cell-mediated immune response
Both cytotoxic T cell!. (deri ved from CD8+ cells) and inflam-
matory (cytokine-rclcasing) Thl cells are involved in cell-mediated
rc<,ponsc~ (;.,ee Fig. 13.3). They enter inflammatory lesions 10 d
similar manner to neutrophils and macrophages, namely by imer
action between adhesion molecules on the endothelial cell and the
lymphocyte and attraction to the inflammatory site by chemolinc:'.
Cytotoxic T cells
Anncd cytotoxic T cells kill intracellular micro-organisms such
as vin1scs. When a virus infects a mammalian cell, there are t\\O
aspects to the resulting defe nsive response. The first step i'> the
expression on the cell surface of peptides derived from the
pathogen in association with MHC molecules. The second step i1
the recognition ofthc pcptidc-MHC complex by specific receptors
on cytotoxic (CD8+) T cells (Fig. 13.4 shows a s imilar process for
 LOCAL HORMONES, INFLAMMATION AND IMMUNE REACTIONS

d} a CD4+ T cell). The cytotoxic T cells then destroy virus-infected

on
The adaptive response
cells by programming them to undergo apoptosis. Cooperation
!n. with macrophage'> may be required for killing to occur.
1}: The adaptive (specific, acquired)
be Mocrophoge-octivoting CD4+ Th 1 cells immunological response boosts the effectiveness of
to Some pathogen\ (e.g. mycobacteria. listeria) have evohed the 1nnate responses. It has two phases, the
is strategies for sumving and multiplying within macrophages induction phase and the effector phase, the latter
in. after ingeqion. Anned CD4+ Thl cells release cyrokines that cons1stmg of (i) antibody-mediated and Oi) cell-
activate macrophages to kill these intracellular pathogens. Th I mediated components.
celb abo recruit macrophages by releasing cytokines that act on During the induction phase, naive T cells bearing
ns either the CD4 or the CDS coreceptors are presented
vascular endothelial cclb (e.g. TNF-a) and chemokines (e.g.
tic with antigen, triggering proliferation:
macrophage chemotacti c factor- !) that attract the macrophagcs
ei r COS-bearing T cells develop into cytotoxic T
to the site., of infection.
IUS cells that can kill virally infected cells
A complex of microorgani~m-derived peptidcs plus MHC
1te C04-bearing Th cells are stimulated by cytokines
molecules i~ expressed on the macrophage surface and is recognised
ng to develop into Th1 or Th2 cells
by cyto kinc-rc lcasing Th I cells, which then generate cytokincs
that enable the mac rophage to de ploy its killing mec hanisms. Th2 cells control antibody-mediated responses by
Activated macrophage!. (wi th or without intracellular pathogens) stimulating B cells to proliferate, giving rise to
arc factories for the production of chemical med iators, and can antibody-secreting plasma cells and memory cells
'er
les genera te and !.ecrete not o nl y many cytokincs but also toxic Th1 cells develop into cells that release cytokines
(i n oxygen mewbolites and neutral protea~es that kill extracellular that activate macrophages; these cells, along with
he organism'> (e.g. Pneumo(-ysti.l carinii and helminths). com- cytotoxic T cells, control cell-mediated
on plement components. eicosanoids. 0. a fibroblas t-stimulatin g responses.
an factor. pyrogens and the tissue factor' that initiates the extrinsic The effector phase depends on antibody- and cell-
pathway of the coagulation cascade (Ch . 21 ). as well as various mediated responses.
other coagulation factors. They are also important in the repair Antibodies provide:
proce.,ses that mu'>t occur for inflammation to resolve. Among more selective complement activation
i1U
the cytol..ines '>ecrctcd i'> lL-12. which has a positive feedback more effective pathogen phagocytosis
en more effective attachment to multicellular
effect. driving the development of further Thl cells. It i!>
of paras1tes, facilitating their destruction
primarily the cell-mediated reaction that is responsible for
ry direct neutralisation of some viruses and of some
allograft rejection.
1111 bactenal toxins
The specific cell-mediated or humoral immunological response
ng Cell-mediated reactions involve:
i~ superimposed on the non-\pecific vasc ular and cellular reactions
ng cos cytotoxic T cells that kill virus-infected cells
described previou~ly. making them not only markedly more
ar. cytokine-releasing co4 T cells that enable
effective but much more selective for partic ular pathogens. An
hi! macrophages to kill intracellular pathogens such
important as pect o f the specific immunologica l response is that
:ly as the tubercle bacillus
the clone of lymphocytes that arc programmed to respond to
is memory cells primed to react rapidly to a known
an antigen is greatl y expa nded after the first contact with the
nd antigen.
organism and now contains memory cells. These changes cause a
he Inappropriately deployed immune reactions are
greatly acce lerated and more effective response to subseq uent
antigen expo~urc. In r-ome cases. the response is so rapid and termed hypersensitivity reactions.
efficient that. after one exposure. the pathogen can never gain a Anti-inflammatory and immunosuppressive drugs are
foothold again. Immunisation procedures make use of this fact. used when the normally protective inflammatory
m- and/or tmmune responses escape control.
TI1e general event\ of the inflammatory and hypersensitivity
.ed
reaction-, 'pecified above vary in some tissues. For example, in
1 a
the aimay inflammation of a:.thma. eosinophils and neuro-
er-
peptides play a particularly :.ignificant role (see Ch. 23). ln CNS
he
mtlammation. there b le!>!. neutrophil infiltration and monocyte
e~.
mtlux is delayed. po~'>ibly becau!>e of lack of adhesion molecule
SYSTEMIC RESPONSES IN INFLAMMATION
e\pression on C S vascular endothelium and deficient generation
ch of chemotaxins. It ha~ long been known that some tissues-the In addition to the local change!> in an inflammatory area, there
o\'0 CNS parenchyma. the anterior chamber of the eye. and the are often general systemic manifel>tations of inflammatory
llc testi.,-arc prilileged sites. in that a foreign antigen introduced disea~e. including fever. an increase in blood leucocytes tenned
llc directly does not provol-..e an immune reaction. However, intro- leucocytosis (or newmphilia if the increase is in the neurrophils
I IS duction e lsewhere of an antigen already in the CNS pare nc hy ma only ). and the re lease from the liver of acute-phase proteins.
)rs wi ll tri gger the development of immune/inflammatory responses These inc lude C-rcactivc protein. a 2-macrogtobul in. fibrinogen.
for in the CNS. a 1-anLitrypsi n and some complement components. While the 2 11
 SICTION 2 CHEMICAL MEDIATORS
function of many of these components is still a mauer of
conjecture. they all seem to have antimicrobial actions. C-reactive
protein, for example, binds to some microorganisms, and the
re~ulting complex activates complement. Other proteins ~cavenge
iron (an cssemial nutrient for invading organisms) or block
protea~e'>, perhap protecting the host against the worst excesses
of the inflammatory response. Cortisol is also increased and
exerts an important counter-regulatory effect on the inflammatory
respon<,e (see Chs 14 and 28).
UNWANTED INFLAMMATORY AND
IMMUNE RESPONSES
The immune response ha~ to strike a delicate baJance. According
to one school of thought, an infection-proof immune system
would be a possibility but would come at a serious cost to the
host. With approximately I trillion potential antigenic sites in
the host, such a 'superimmune' system would be some 1000 times
more likely to allack the host itself, triggering autoimmune
diseal>c. In practice, therefore, it is not uncommon to find that
innocuous substances such as pollen. or the host's own tissues,
sometimes inadvertently activate the immune system; when this
occur~. anti-inflammatory or immunosuppressive therapy may
be required. Unwanted immune responses, termed allergic or
hypenemitil'ity reactions, have been classified into four types
(Janeway et al., 200-l ).
Type 1: immediate or anaphylactic
hypersensitivity
Type I llypenen.\itility (often known simply as 'allergy') occurs
in individuab who predominantly exhibit a Th2 rather than a Th I
response to antigen. In these individuals, substances that are not
inherently noxiOU!, (such as grass pollen, house dust mites, certain
foodstuffs or drugs. animal fur and so on) provoke the production
of antibodies of the lgE type. These fix on mast cells, in the lung,
and aJso to eosinophils. Subsequent contact with the material
causes the release of histamine, PAF, eicosanoids and cytok.ines.
The effects may be localised to the nose (hay fever), the
bronchial tree (the initial phase of asthma), the skin (urticaria) or
the gastrointestinal tract. Tn some cases. the reaction is more
generalised and produces anaphylactic shock, which can be severe
and life-threatening. Some important unwanted effects of drugs
include a11aphyla('(ic hyperse11sitility responses (sec Ch. 53).
Type II: antibody-dependent cytotoxic
hypersensitivity
Type II h\'persensirility occurs when the mechanisms outlined
above are directed against cells within the host that are (or appear
to be) foreign. For example, host cells altered by drugs are
sometime-. mistaken by the immune system for foreign proteins
and evoke antibody formation. The antigen-antibody reaction
triggers complement activation (and its sequelae) and may promote
attack by NK cells. Examples include alteration by drugs of
neutrophib, leading to agranulocytosis (see Ch. 53), or of platelets,
leading to thrombocytopenic purpura (Ch. 21 ). These class II
reaction!> are also implicated in some types of autoimmune
212 thyroidit is (e.g. Hashimoto's disease; see Ch. 29).
Type Ill: complex-mediated hypersensitivity
Type Ill hypersensitivity occurs when antibodies react with soluble
antigens. The antigen-antibody complexes can activate complement
or auach to maM cells and stimulate the release of mediators.
T An ex pen mental example of thi\ is the Anhus reaction that occur.. at" a
foreign protein is injected subcutaneously into a rabbit or guinea pig" uh
high circulating concentrations of antibody. Within 3-8 hour.., the area
become~ red and ;wollen because the antigen-antibody compte\e'
precipitate in \mall blood ve;,els and activate complement. Neutrophil'
are :mracted and acti\ated (by C5a) to generate toxic oxygen ~pecte\ and
to secrete cn1ymes.
Mast cells are also stimulated by C3a to release mediators. Damage
caused by this process is involved in serum sickness, cau~ed
when antigen persists in the blood after sensitisation causing a
severe reaction, as in the response to mouldy hay (known as
farmer's lung), and in certain types of autoimmune kidney and
arterial disease. Type rn hypersensitivity is also implicated in
lupus erythematosus (a chronic, autoimmtUle inflammatory disease).
Type IV: cell-mediated hypersensitivity
The prototype of type IV hypersensitivity (also known as delayed
hypersensitivity} is the wberculin reaction, a local inflammatol)
response seen when proteins derived from cultures of the tubercle
bacilluc; are injected into the skin of a person who has been sensitised
by a previous infection or immunisation. An 'inappropriate' cell-
mediated immune response is stimulated, accompanied b)
infiltration of mononuclear cells and the release of variou'
cytokines. Cell-mediated hypersensitivity is also the basis of the
reaction seen in some other infections (e.g. mumps and measle\).
as well as with mosquito and tick bites. It is also important m
the skin reactions to drugs or industrial chenticaJs (see Ch. 53),
where the chemical (termed a hapten) combines with protein~ in
the skin to fonn the 'foreign' substance that evokes the ceU-mcdiated
immune response (Fig. 13.3). Other examples of cell-mediated
hypersensitivity arc rheumatoid arthritis (Ch. 14), multiple
sclerosis and type I (insulin-dependent) diabetes (Ch. 26).
In essence, inappropriately deployed T-cell activity underlies all
types of hypersensitivity, initiating types I, II and lll, and being
involved in both the initiation and the effector phase in type IV.
These reactions are the basis of the clinically important group
of autoimmune diseases. immunosuppressive drugs (Ch. 14)
and/or glucocorticoids (Ch. 28) are routinely employed to treat
such di~orders.
THE OUTCOME OF THE INFLAMMATORY
RESPONSE
After outlining the specific immune response, we need to return
to a consideration of the locaJ acute inflammatory response that
occurs at the site of the host-pathogen interaction. It should no11
be clear that this comprises an innate, immunologically non
specific component together with a variable involvement of the
1.pecific immunological response (either humoraJ or cell-mediated).
The degree to which the latter is implicated depends on several
factors, such as the nature of the pathogen and the infected organ
or tissue.
 LOCAL HORMONES, INFLAMMATIO N AND IMMUNE REACTIONS
It is important not to lose sight of the fact that the inflammatory
response i~ a defence mechanism and not, ipso facto. a disease.
Its role is to restore normal strucrure and function to the infected
or damaged tissue and, in the vast majority of cases, this is what
happens. The healing and resolution phase of the inflammatory
response is an active process and does not simply 'happen in the
absence of further inflammation. This is an area that we are just
beginning to understand, but it is clear that it utilises its own unique
palette of mediators and cytokines (including various growth factors,
annellin-A I, lipoxin and IL-l 0) to terminate residual inflammation
and to promote remodelling and repair of damaged tissue.
In some case!>, healing will be complete, but if there has been
damage (death of cells, pus formation, ulceration) repair is usually
necessary and may result in scarring. Tf the pathogen persists, the
acute response is likely to transform into a chronic inflammatory
response. This is a slow, smou lderi ng reaction that can conti nue
indefinitely, destroying tissue and promoting local pro liferation
of cells and connective tissue. The principal cell types found in
areas of chronic inflammation are mononuclear ceUs and abnormal
macrophage-derived cells. During healing or chronic inflammation,
growth factors trigger angiogenesis and cause fibroblasts to lay
down fibrou1> tis~ue. Infection by some microorganisms, such as
syphilis, tuberculosis and leprosy, bears the characteristic hall-
marks of chronic inflammation from the start. The cellular and
mediator components of this type of inflammation are also seen
in many, if not most, chronic autoimmune and hypersensitivity
di~eases, and are important targets for drug action.
MEDIATORS OF INFLAMMATION AND
IMMUNE REACTIONS
Soluble mediators, many of which may be regarded as local
honnones, play a key (if sometimes mysterious) role in the
orchestration of the inflammatory response. A 'mediator' is
operationally defined as a substance that fulfils a set of criteria
generally modelled on the original suggestions of Sir Henry Dale
in 1933. A modified version, more applicable to the field today,
was considered by Dale ( 1994 ). The principal mediators of
pharmacological significance will be described below.
HISTAMINE
In a classic tudy, Sir Henry Dale and his colleagues demonstrated
that a local anaphylactic reaction (a type I or 'immediate hyper-
sen~itivity reaction'; see above) was caused by antigen-antibody
reactions in sensitised tissue, and found that histamine mimicked
this effect both in vitro and in vivo. The first generation of
antihistamine drugs was discovered by Bovet and colleagues. but
careful quantitative studies by Schild suggested that there were in
fact two types of histamine receptor in the body. Contemporary
antihistamine<, affected only one type, the H 1 receptors, and
were without action on the second group of H2 receptors, which
were important in gastric acid secretion. Utilising Schild's
classification. Black and his colleagues developed the second
generation of ami histamine drugs, the H2 receptor antagonists.
A third subtype of histamine receptor, the H3 receptor, was
cloned in 1999, and the H4 receptor in 200 I (Zhu et al., 200 I).
Synthesis and storage of histamine
Histamine i~ a basic amine formed from histidine by histidine
decarboxylase. It ic, found in most tissues but is present in high
concentration'> in the lungs and the skin, and in particularly high
concentration!> in the gastrointestinal tract. At the cellular level. it
i~ found largely in mast cells (approximately 0.1-0.2 pmoVccll)
and basophils (0.0 I pmoVcell), but non-mast cell histamine occurs
in 'histaminocytes' in the stomach and in histaminergic neurons
in the brain (see Ch. 34). In mast cells and basophils, histamine
i~ complexed in intracellular granules with an acidic protein and
a high-molecular-weight heparin tem1ed macroheparin.
Histamine re lease
Histamine is released from mast cells by exocytosis during
innammatory or allergic reactions. Sti muli include C3a and C5a
that interact with specific surface receptors, and the combi nation
of antigen with cel l-fixed lgE an tibodjes. ln common with many
secretory procc!>ses (Ch. 4), histamine release is initiated by a
rise in cytosolic Ca 2+. Various basic drugs, such as morphine and
tubocurarine, release histamine through a non-receptor action.
Agents that increase cAMP formation (e.g. ~-adrenoceptor
agonists; sec Ch. I I) inhibit histamine secretion. Replenishment
of secreted histamine by mast cells or basophils is a slow process,
which may take days or weeks, whereas n1mover of histamine in
the gaMric hiMaminocyte is very rapid. Histamine is metabolised
by histaminase and/or by the methylating enzyme imida:.ole
N-methyltransferase.
Actions
Histamine acts on specific receptors that may be distinguished by
means of selective antagonist drugs. Some details relating to the
four main types of histamine receptor, all of which are implicated
in the inflammatory response (see Gutzmer et al., 2005, for a
review), arc given in Tables 13. I and 13.2. Selective antagonists
at H 1, H2 and H 3 receptors include mepyramine, cimetidine and
thioperamidc, respectively. Selective agonists for H 2 and H 3
receptors arc, respectively, dimaprit and (R)-methylhistamine.
Histamine 11 1 antagonists are the principal antihistamines used
in the treatment of inflammation (notably rhinitis). Other clinjcal
uses of ~ubtype antagonists may be found in Chapters 14, 25 and 34.
Gastric secretion
Histamine ~timulates the secretion of gastric acid by action on H 2
receptors. In clinical terms, this is the most important action of
histamine. because it is implicated in the pathogenesis of peptic
ulcer. It is considered in detail in Chapter 25.
Smooth muscle effects
Hi!>tamine, acting on H 1 receptors, contracts the smooth muscle
of the ileum, bronchi, bronchioles and uterus. The effect on the
ileum i'> not as marked in humans as it is in the guinea pig (this
tissue remains the de facto standard preparation for histamine
bioa~say). Histamine reduces air flow in the first phase of bronchial
asthma (see Ch. 23 and Fig. 23.3).
Cardiovascular effects
Histamine d ilates human blood vessels by an action on H 1
receptors, the effect being partly e ndothelium-dependent in some 21 3
 SEcnON 2 . CHEMICAL MEDIATORS

Table 13.1 Details of some agonist drugs used to define the three types of histamine receptor

Drug Relative activity in vitro

H 1 receptors H2 receptors H3 receptors

(ileum contraction) (stimulation of atrial rate) (histamine release from brain tissue)
Histamine 100 100 100

Dimaprit < 0.0001 71 0.0008

(R)-u-Methylhistamine 0.49 1.02 1550

(Data derived from Black J Wet al. 1972 Nature 236: 385-390; Ganellin C A 1982 In: Ganellin C A, Parson ME [eds] Pharmacology of
histamine receptors. Wright, Bristol, pp.11-1 02; Arrang J M et al. 1987 Nature 327: 117-123; van der Werf J F, Timmerman H 1989 Trends
Pharmacal Scl10: 159-162.)

Table 13.2 Details of some antagonist drugs used to Hlatamlne

define the three types of histamine receptor
Drug Binding constant (K 8 ; moVI)
H,
Mepyramine 0.4 X 109
Cimetidine 4.5 X 10' 0.8 X 106
Thioperamide > 10' 4.3 X 109
(Data derived from Black J W et al. 1972 Nature 236: 385-390;
Ganellin C R 1982 In: Ganellin C A, Parson ME [eds)
Pharmacology of histamine receptors. Wright, Bristol, pp. 11-1 02;
Arrang J M et al. 1987 Nature 327: 117-123; van der Werf J F.
Timmerman H 1989 Trends Pharmacal Sci 10: 159-162.)
vascular beds. It also increases the rate and the qutput of the heart
by action on cardiac H2 receptors.
When injected intradermally, histamine causes a reddening of
the skin, accompanied by a weal with a surrounding flare. This i s
the triple response described by Sir Thomas Lewis over 50 years
ago. The reddening renects vasodilatation of the small arterioles
and precapillary sphincters, and the weal the increased permeability
of the postcapillary venulcs. These effects are mainly mediated
through activation of H 1 receptors. The flare is an axon reflex:
stimulation of sensory nerve fibres evokes antidromic impulses
through neighbouring branches of the same nerve, releasing
vasodilators such as CGRP (see Chs 14 and 16).
Histamine is a basic amine, stored in mast cell
and basophil granules, and secreted when C3a and
C5a interact with specific membrane receptors or when
antigen interacts with cell-fixed immunoglobulin E.
Histamine produces effects by acting on H, H2 or H3
(and possibly H 4) receptors on target cells.
The main actions in humans are:
stimulation of gastric secretion (H~
contraction of most smooth muscle, except blood
vessels (H 1)
cardiac stimulation (H 2)
vasodilatation (H,)
increased vascular permeability (H 1).
Injected intradermally, histamine causes the 'triple
response' : reddening (local vasodilatation), weal
(direct action on blood vessels) and flare (from an
'axon' reflex in sensory nerves releasing a peptide
mediator).
The main pathophysiological roles of histamine are:
as a stimulant of gastric acid secretion (treated
with H2 -receptor antagonists)
as a mediator of type I hypersensitivity reactions
such as urticaria and hay fever (treated with H 1-
receptor antagonists).
H3 receptors occur at presynaptic sites and inhibit
the release of a variety of neurotransmitters.

Itching
Itching occurs if histamine is injected into the skin or applied to
a blister base, because it stimulates sensory nerve endings by an
histamine H 1 antagonists do not have much clinical utility in the
H1-dependent mechanism.
acute inflammatory response per se, because other mediator~ are
Central nervous system effects more important. Histamine is, however, significant in type I
Histamine is a transmitter in the CNS (Ch. 34). hypersensitivity reactions such as allergic rhinitis and urticaria.
Despite the fact that histamine release is evidently capable of The usc of H 1 antagonists in these and other conditions is dealt
214 producing many of the innammatory signs and symptoms, w ith in Chapter 14.
 lOCAl HORMONES , INFLAMMATION AND IMMUNE REACTIONS

EICOSANOIDS
Unlike histamine, eicosanoids are not preformed in cells but are
generated from phospholipid precursors on demand. They are
implicated in the control of many physiological processes, and
are among the most important mediators and modulators of the
mflammatory reaction (Fig. 13.5).
Interest in eicosanoids arose in the 1930s after reports that
semen contained a lipid substance that contracted uterine smooth
muscle. The substance was believed to originate in the prostate,
and was saddled with the misnomer prostaglandin. Later, it became
clear that prostaglandin was not a single substance but a whole
family of compounds that could be generated from 20-carbon
unsaturated fatty acids by virtually all cells.
Structure and biosynthesis
In mammals, the main eicosanoid precursor is arachidonic acid
(5,8, II , 14-eicosatetraenoic acid), a 20-carbon unsaturated fatty
acid containing four double bonds (hence eicosa, referring to the
20 carbon atoms, and tetrae1wic, referring to the four double
bonds). Tn most cell types, arachidonic acid is esterified in the
phospholipid pool, and the concentration of the free acid is low.
The principal eicosanoid~ arc the prostaglandins. the rhromboxanes
and the leukotrienes, although other derivatives of arachidonate,
for example the lipoxins, are also produced. (The term
prostanoid will be used here to encompass both prostaglandins
and thromboxanes.)
In most instances, the initial and rate-limiting step in
eicosanoid synthesis is the liberation of aracbidonate, either in
a one-step process (Fig. 13.6) or a two-step process (Fig. 13.7),
from phospholipid-; by the enzyme phospholipase A 2 (Pl.A 2 ).
Several pecies exist, but the most important is probably the
highly regulated cytosolic Pl.A 2 This enzyme generates not only
arachidonic acid (and thus eicosanoids) but also lysoglyceryl-
phosphorylcholine (lyso-PAF), the precursor of platelet
activating factor, another inflammatory mediator (sec Figs 13.5
and 13. 10).
Cytosol ic PLA 2 is activated (and hence arachidonic acid
liberated) by phosphorylation. T his occurs i n response to signal
transduction events triggered by many stimuli, such as thrombin
action on platelets, C5a on neutrophils, bradykinin on fibroblasts,
and antigen- antibody reactions on mast cells. General cell damage
also triggers the activation process. The free arachidonic acid is
metabolised by several pathways, including the following.
Falty acid cyclo-oxygenase (COX). Two main isoform fonns,
COX- I and COX-2, tran:,fonn arachidonic acid to
prostaglandins and t11romboxanes.

Phospholipid
Glucoco rticoids
(induce annexin 1)

Arachidonate

12-Upoxygenase
~ ____, , cyclo-oxygenase, ~
'- 5-Lipoxygenas~

Glucocorticoids TXA2 SLipoxyg enase

inhibit synthase inhibitors (vasodilator;
induction Inhibitors (e.g. zlleutln) increases vascular
permeability;
12-HETE Llpoxlns PGI2 TXA 2 bronchoconstrictor:
(chemotaxin) A and B (vasodilator; (thrombotic; chemotaxin)
hyperalgesic; vasoconstrictor)
stops platelet
aggregation) Leukotriene
receptor
LTB 4 (chemotaxin) antagonists,
e.g .
PGF20 PGD2 PGE 2 zafirukast ,
(bronchoconstrictors; montelukast
(bronchoconstrictor; (inhibits platelet (vasodilator;
increase vascular
myometnal aggregation; hyperalges1c)
permeability)
contraction) vasodilator)

j
Fig. 13.5 Summary diagram of the inflammatory mediators derived from phospholipids, with an outline of their actions and
the sites of action of anti-inflammatory drugs. The arachidonate metabolites are eicosanoids. The glucocorticoids inhibit transcription
of the gene for cyclo-oxygenase-2, induced in inflammatory cells by inflammatory mediators. The effects of prostaglandin (PG) E:! depend
on which of the three receptors for this prostanoid are activated. HETE, hydroxyeicosatetraenoic acid; HPETE, hydroperoxyeicosatetraenoic
acid; LT, leukotriene; NSAID, non-steroidal anti-inflammatory drug; PAF, platelet-activating factor; PGI2 , prostacyclin; TX, thromboxane.
215
 SECTION 2 . CHEMICAL MEDIATORS

into every arachidonate molecule, forming the highly un~table

Carbon
( Phospholipase A1 / endopcroxide!> PGG1 and PGH2 . These are rapidly transfonned
atom
number by isomerase or symhase enzymes to PGE2, PGJ2, PGD 2, PGF~"
0 and TXA 2, which are the principal bioactive end products of th1,
II
A'-C ~ O-CH2 reaction. The mix of eicosanoids thus produced varie!> between
~ I \. Phospholipase D /
cell type!> depending on the particular endoperoxide isomerase~
or synthases present. In platelets, for example. TXA2 predominate\,
2
A -;~ 0-~H ~ ( whereas in vascular endothelium PGI2 is the main product
3 CH2-0 ~ P ~ 0 - A'' Macrophagcs, ncutrophils and mast ceUs synthesise a mixture
' Phospholipase A _, 2
) 6H of products. If eicosatrienoic acid (three double bonds) rather
than arachidonic acid is the substrate. the resulting prostanoid\
\. Phospholipase C ~ have only a single double bond, for example PGE,, while
eicosapentaenoic acid, which contains five double bonds, yields
Fig. 1 3 . 6 The structure of phospholipids and the sites
of action of phospholipases. Generally speaking, unsaturated
PGE1 . The latter substrate is significant because it is present in
fatty acids such as arachidonic acid are esterified at the C2 abundance in some fish oils and may, if present in sufficient
position, from which it can be removed by phospholipase A2 , amounts in the diet, come to represent a significant fraction of
but other metabolic routes are known (see Fig. 13.7). The cellular fatty acids. When this occurs, the production of the
numbering of the carbon atoms in the glycerol 'backbone' is proinflammatory PGE2 is diminished and, more significantly, the
given on the left. This figure shows 0-acyl residues on carbon
generation of TXA 2 as well. This may underlie the beneficial
atoms 1 and 2, but 0-alkyl residues can occur (see Fig. 13.1 0).
Different bases are found at C3. A' is choline, ethanolamine, anti-inflammatory and cardiovascular actions that are ascribed to
serine, inositol or hydrogen. diets rich in this type of marine product.

Catabolism of the prostanoids

This is a multistep process. After carrier-mediated uptake, mo~t
prostaglandins are rapidly inactivated by 'prostaglandin-specific'

"" r====
Phospholipids
enzymes. and the inactive products are further degraded b)
/
, Phospholipase D~ ;.Phospholipase C, general fatty acid-oxidising enzymes. The prostaglandin-specific

I
PhosphatidiC acid Diacylglycerol
IP/IP:!"IP3
cnqmes are present in high concentration in the lung, and 95r.
of infused PGE2, PGE, or PGF2a is inactivated on first passage.
The half-life of most prostaglandins in the circulation is less than
[ ':, DAG kinase : I I minute.
Pro!>taglandin 12 and TXA2 are slightly different. Both are
: hospholipase A2, \ DAG lipase 1 inherently unstable and decay rapidly (5 minutes and 30 seconds,
~ Arachidonate 7<:::::: Glycerol respectively) in biological fluids into inactive 6-keto-PGF1n and
TXB 2 Further metabolism occurs. but it is not really relevant to

l Fig. 1 3 .7 Alternative pathways for release of

arachldonate from phospholipids. DAG, diacylglycerol; IP,
inositol phosphate.
us here.

Lipoxvgena~el. Several ~ubtypes synthesise leukotrienes,
lipoxins or other compounds (Figs 13.5 and 13.8).
Chapter 14 deals in detail with the way inhibitors of these pathwa}S
(including non-'>teroidal anti-inflammatory drugs [NSAIDs] and
glucoconicoid'>) produce anti-inflammatory effects.
PROSTANOIDS
Cyclo-oxygenase-1 is present in most cells as a constitutive
enzyme that produces prostanoids that act as homeostatic regulaton.
(e.g. modulating vascular responses). whereas COX-2 is not nor-
mally present but it is strongly induced by inflammatory stimuli
and therefore bel ieved to be more relevant to inflammation
therapy (sec next chapter for a fu ll discussion of this point). Both
216 enzymes catalyse the incorporation of two molecules of oxygen
Prostanoid receptors
There are five main classes of prostanoid receptors (Coleman et
al.. 1993), all of which are typical G-protein-coupled receptor~.
They arc termed DP, FP, IP, EP and TP receptors, respectively,
depending on whether their ligands are PGD 2, PGF2u, PGl~.
PGE2 or TXA 2 Some have further subtypes; for exan1plc, the LP
receptors are ~ubdivided into three subgroups.
Actions of the prostanoids
The prostanoids affect most tissues and exert a bewildering
variety of effects.
PGD1 causes vasodilatation. inhibition of platelet
aggregation, relaxation of gastrointestinal and uterine muscle.
and modification of release of hypothalamic/pituitary
hormones. It has a bronchoconstrictor effect through an
action on TP receptors.
PGF2a causes myometrial contraction in humans (see
Ch. 30), luteolysis in some species (e.g. cattle) and
bronchoconstriction in other species (cats and dogs).
 LOCAL HORMONES, INFLAMMATION AN D IMMUN E REACTIO NS

, 15-lipoxygenaseJ Arachidonic acid "':12-lipoxygenase!

15-HPETE .' - - 12-HPETE

!
15-HETE
!
12-HETE
5-lipoxygenase

5-llpoxygenase inhibitors
(e.g. zileutin) 5-HPETE - - - -- - - - - --+ 5-HETE
Upoxins

~
AandB

L'"kotrioMC,
(Structure includes cysteine, Leukotriene E4
Leukotr Iene A4 glycine and (Structure includes cysteine)
Glutathione$- t . 'd)
'-transferase.I y-g1u amtc act

Glycine
y-glutamic
acid
, DipeptidaseJ

Leukotriene D4 Leukotriene F4
Leukotriene 6 4 (Structure tncludes (Structure includes cysteine
glycine and cystetne) and y-glutamic acid)

Fig. 13.8 The biosynthesis of leukotrienes from arachidonic acid. Compounds with biologtcal action are shown in grey boxes.
HETE, hydroxyeicosatetraenoic acid; HPETE, hydroperoxyeicosatetraenoic acid.

PG/2 causes vasodilatation, inhibition of platelet aggregation

(i>ee Ch. 21 ), renin release and natriuresis through effects on
tubular reabsorption of Na+.
TXA 2 causes vasoconstriction, platelet aggregation (see Ch. 21)
and bronchocon~otriction (more marked in guinea pig than in
humans).
PG2 has the follow ing actions:
-on EP 1 receptors, it causes contraction of bronchial and
gastrointestinal smooth muscle
-on EP2 receptors, it causes bronchodilatation,
vasodilatation, stimulation of intestinal fluid secretion. and
relaxation of gawointestinal &mooth muscle
-on EP1 receptor'>, it causes contraction of intestinal smooth
muscle, inhibition of gastric acid secretion (see Ch. 25),
increased gastric mucus secretion, inhibition of lipolysis.
inhibition of autonomic neurotransmitter release, and
stimulation of contraction of the pregnant human uterus
(Ch. 30).
The role of the prostanoids in inflammation
The inflammatory response is inevitably accompanied by the
release of pro!>tanoid<,. PGE:! predominates, although PGI2 is also
important. In areas of acute inflammation, PG. and PGT2 are
generated by the local tissues and blood vessels, while mast
cells release mainly PGD2 In chronic inflammation. cells of the
monocyte/macrophage series also release PGE2 and TXA 2 .
Together, the prostanoids exert a sort of yin-yang effect in
Mediators derived from phospholipids
The main phospholipid-derived mediators are
the eicosanoids (prostanoids and leukotrienes) and
platelet-activating factor (PAF).
The eicosanoids are synthesised from arachidonic
acid released directly from phospholipids by
phospholipase A2 , or by a two-step process involving
phospholipase C and diacylglycerol lipase.
Arachidonate is metabolised by cycle-oxygenase
(COX)-1 or COX-2 to prostanoids, or by
5-lipoxygenase to leukotrienes.
PAF tS derived from phospholipid precursors by
phospholipase Al, giving rise to lyso-PAF, which is
then acetylated to give PAF.
inflammation, stimulating some responses and decreasing other!>.
The most striking effects arc as follow.
[n their own right. PGE2 PG12 and PGD2 are powerful vaso-
dilators and synergise with other inflammatory vasodilators such
as histamine and bradyJ...inin. It is this combined dilator action on
precapillary anerioles that contributes to the redness and increased
blood fl ow in areas of acute in!1ammation. Prostanoids do not
directly increase the permeability of !he postcapillary vcnules,
but potentiate this effect or histamine and bradykinin. Similarly, 21 7
 SECTION 2 C H E M I C A l M E D I AT 0 R S
Prostanolds
The term prostanoids encompasses the
prostaglandins and the thromboxanes.
Cyc lo-oxygenases (COXs) oxidise arachidonate,
produc1ng the unstable intermediates prostaglandin
(PG) G2 and PGH 2
There are two ma1n COX isoforms: COX-1 , a
constitutive enzyme, and COX-2, which is often
induced by inflammatory stimuli.
PGI 2 (prostacyclin), predominantly from vascular
endothelium, acts on IP receptors, producing
vasodilatation and inhibition of platelet aggregation.
Thromboxane (TX) A 2 , predominantly from platelets,
acts on TP receptors, causing platelet aggregation
and vasoconstriction.
PGE2 is prominent in inflammatory responses and is a
mediator of fever. Main effects are:
EP1 receptors: contraction of bronchial and
gastrointestinal tract (Gil) smooth muscle
EP 2 receptors: relaxation of bronchial, vascular
and GIT smooth muscle
EP3 receptors: inhibition of gastric acid secretion,
1ncreased gastric mucus secretion, contraction of
pregnant uterus and of GIT smooth muscle,
inhibition of lipolysis and of autonomic
neurotransmitter release.
PGF2, acts on FP receptors, found in uterine (and
other) smooth muscle, and corpus luteum, producing
contract1on of the uterus and luteolysis (in some
species).
PGD2 is derived particularly from mast cells and acts
on DP receptors, causing vasodilatation and
inhibition of platelet aggregation. ) in lung, platelets, mast cells and whi te blood cells. The ma10
they do not themselves produce pain, but potentiate the effect
of bradykinin by sensitif.ing afferent C fibres (see Ch. 41) to the
effect!> of other noxiou~ stimuli. The anti-inflammatory effects of
the SA ID'> stem largely from their ability to block these action!.
of the prostaglandin\.
Pro\taglandins of the E series are also pyrogenic (i.e. they
induce feve r). lligh concentrations are found in cerebrospinal
nuid during infection, and there is evidence that the increase in
temperature (attributed to cytokines) is actually finally mediated
by the relea\e of PG~. NSAIDs exen antipyretic actions (Ch. 14)
by inhibiting PGE! '>ynthesi\ in the hypothalamus.
However. !)Omc prostaglandins have anti-inflammatory effects
under some circumMances. For example, PGE1 decreases
lysosomal entyme release and the generation of toxic oxygen
metabolites from neutrophi b, as well as the release of histamine
from mast cells. Several prostanoids are available for clinical use
218 (~ee clinical box).
Clinical uses of prostanoids
Gynaecological and obstetric (see Ch. 30)
term1nat1on of pregnancy: gemeprost or
misoprostol (a metabolically stable prostaglandin
(PG) E analogue)
induction of labour: dinoprostone or misoprost ol
postpartum haemorrhage: c arboprost.
Gastrointestinal
to prevent ulcers associated with non-steroidal
anti-inflammatory drug use: misoprostol (see
Ch.25).
Cardiovascular
t o maintain the patency of the ductus arteriosus
until surgical correction of the defect in babies
with certain congenital heart malformations:
a lprostadil (PGE 1)
to inhibit platelet aggregation (e.g. during
haemodialysis): epoprostenol (PG12l. especially if
heparin is contraindicated
primary pulmonary hypertension: epoprost enol
(Ch. 19).
Ophthalmic
- open-angle glaucoma: latanoprost eye drops.
LEUKOTRIENES
Leukotrienes (leuko because they are made by white cells, and
trienes because they contain a conjugated triene system of double
bond~) are synthe:-.ised from arachidonjc acid by l ipoxygena\C
ca talysed pathways. These soluble cytosolic enzymes are found
enzyme in thi s group is 5-/ipoxygenase. On cell activation, this
ent.ymc translocatcs to the nuclear membrane, where it associate\
with a cru cial accessory protein affectionately termed FLA P
(/jl'e-[ipoAygenase activating a rotein ). The 5-lipoxygena\C
incorporate:. a hydropcroxy group at CS in arachidonic acid
(Fig. 13.8), leading to the production of the unstable compound
leukotriene (L1) A 1 This may be converted enzymically to LTB,
and is ai'>O the precur~or of the cysteinyl-containing leukotricne,
LTC~. LTD4 , LT4 and LTF4 (also referred to as the suljidopeplldt
leukotrienel ). Mixture!. of these cysteinyl adducts c0nstitute
the vlow-reacting substance of anaphylaxis (SRS-A). a substance
-.hown man} yea(!) ago to be generated in guinea pig lung during
anaphylaxb. and believed to be important in asthma. LTB~ j,
produced mainly by neutrophils. and the cysteinyl-lcukotncne,
mainly by eosinophils. mast cells. basophils and macrophage'.
Lipoxins and other active products. some of which have anti
in narnmatory propertie:.. arc also produced from arachidonate b)
this pathway (Fig. 13.8).
Leukotriene B~ is metabolised by a unique membrane-bound
P450 enzyme in neutrophils, and then further oxidised to 2().
carboxy-LTB4 LTC, and LTD~ are metabolised to LTE4 which
i ~ excreted in the urine.
 LOCAL HORMONES, INFLAMMATION AND IMMUNE REACTION S
Actions and receptors of the leukotrienes
Receptors for the leukotrienes are termed /eukotriene receptors:
BLTifthe ligand is LTB 4 , and CysLTifthecysteinyl-leukotricnes.
LTB 4 act~ on specific LTB4 receptors as defined by selective
agonists and antagoniMs. The transduction mechanism utilises
ino!titol tri~pho~phate and increased cytosolic Ca 2+. LTB~ is a
potent chemotactic agent for neutrophils and macrophages (see
Fig. 13.2). On neutrophils. it also up-regulates membrane adhesion
molecule expres~ion. and increases the production of toxic oxygen
produCt!. and the release of granule enzymes. On macrophage!.
and lymphocytes. it stimulates proliferation and cytokine release.
Cysteinyl-lcukotrienes have important actions on the respiratory
and cardiovascular systems, and specific receptors for LTD4 have
been defined on the basis of numerous selective antagonists.
The respiratory system. Cysteinyl- leukotrienes arc potent
spasmogcns, causing dose-related contraction of human
bronchiolar muscle in vitro. LTE4 is less potent than LTC4
and LTD4, but its effect is much longer lasting. A ll cause an
increase in mucus secretion. Given by aerosol to human
volunteers. they reduce specific airway conductance and
maximum expiratory flow rate, the effect being more
protracted than that produced by histamine (fig. 13.9).
The cardimascular system. Small amounts of LTC4 or LTD4
given intravenously cause a rapid. short-lived fall in blood
pressure. and significant constriction of small coronary
resismncc vessels. Given subcutaneously. they are equipotent
with histamine in causing weal and flare. Given topically in
the no!tc, LTD~ increases nasal blood flow and increases local
vascular permeability.
The role of leukotrienes in inflammation
Leukotriene 6 4 is found in inflammatory exudates and tissues in
d many inflammatory conditions. including rheumatoid arthritis.
11
s
100
il ec
0 90
d 0
~
.~~..,
~
Q) 80
0
c be converted to either LTB4 or to a series of
'e ~:I
70
.e '0
c LTD4 and LTE4.
e 8 60
g "'>-
<a
,.., ~ 50
.... < production from macrophages and lymphocytes.
0
0 10 20 30 40 50
'
i- Time (min)
Fig . 1 3.9 The time course of action on specific airways
conductance of the cysteinyl-leukotrienes and histamine,
d in six normal subjects. Specific airways conductance was
measured in a constant volume wholebody plethysmograph,
)-
and the drugs were given by inhalation. (From Barnes P J,
h Piper P J, Costello J K 1984 Thorax 39: 500.)
psoriasi\ and ulcerative colitis. The cysteinyl-leukotriencs arc
present in the sputum of chronic bronchitis in amounts that arc
biologically active. On antigen challenge. they are released from
sample~ of human a thmatic lung in vitro, and into nasal lavage
fluid in subjects with allergic rhinitis. There is evidence that they
contribute to the underlying bronchjaJ hyperrcactivity in
a\thmatics, and it i~ thought that they are among the main
mediators of both the early and late phases of asthma (Fig. 23.2).
The CysLT-receptor antagonists zafirlukast and montel uk ast
arc now in use in the treatment of asthma (see Ch. 23). Cy~teinyl
lcukotricnes may mediate the cardiovascular changes of acute
anaphylaxis. Agents that inhibit 5-lipoxygenase are under devel-
opment as antiasthmatic agents (see Ch. 23) and anti-inflammatory
agents. One such drug, zileutoo. is available in some parts of the
world but has not won a definite place in therapy yet (see Larsson
et al., 2006).
LIPOXINS
Recent work has indicated that products of the 15-lipoxygenasc
enzyme termed lipoxins (Fig. 13.8) act on specific receptors on
polymorphonuclear leucocytes to oppose the action of LTB 4 ,
supplying what might be called 'stop signals' to inflammation.
Oddly, aspirin stimulates the synthesis of these sub tances, perhaps
contributing to its other anti-inflammatory effects (see Gilroy &
Perrelli, 2005; Serhan, 2005). Lipoxins utilise the same form) I
peptide G-protein-<:oupled receptor system as the anti-inflammatory
protein annexin-A I.
PLATELET-ACTIVATING FACTOR
Platelet-activating factor, also variously termed PAF-ace1her and
AGEPC (acery/-g/yceryl-erher-phosphorylcholine). is a biologically
active lipid that can produce effects at exceedingly low concen-
Leukotrlenes
5-Lipoxygenase oxidises arachidonate to give
5-hydroperoxyeicosatetraenoic acid (5-HPETE), which
is converted to leukotriene (LT) ~. This, in t urn, can
glutathione adducts, the cysteinyl-leukotrienes LTC 4,
LTB4, act1ng on spectfic receptors, causes adherence,
chemotaxis and activation of polymorphs and
monocytes, and sttmulates proliferation and cytokine
The cysteinyl-leukotrienes cause:
contraction of bronchial muscle
- vasodilatation in most vessels, but coronary
vasoconstriction.
LTB4 is an important mediator in all types of
infl ammation; the cyst einyl-l eukotrienes are of
particular importance in asthma.
219
 SECTION 2 II C H EM I C A l M ED I AT 0 RS

o-
tmtions (less than I 10 mol/1). The name is somewhat misleading,
because PAF has actions on a variety of different target cells, and
is believed to be an important mediator in both acute and chronic
allergic and innammatory phenomena. PAF is biosynthesised
from acyl-PAF in a two-step process (Fig. 13.10). The action of
PLA, on acyl-PAF produce~ lyso-PAF, which is then acetylated
to give PAF. PAF. in turn, can be deacetylated to the inactive
lyso-PAF (Fig. 13.11 ).
Sources of platelet-activating factor
Platelets stimulated with thrombin and most inflammatory cells
can release PAF under the right circumstances.
Actions and role in inflammation
By acting on specific receptor~. PAF is capable of producing
many of the signs and symptoms of inflammation. Injected
locally, it produces vasodilatation (and thus erythema), increased
vascular pcrmeubi lity and weal formation. Higher doses produce
hyperalgesia. It is a potent chemotaxin for neutrophils and
monocyte!.. and recruits eosinophils into the bronchial mucosa in
the late phase of asthma (Fig. 23.3). It can activate PLA 2 and
initiates eicosanoid synthe~is.
On platelets, PAF triggers arachidonate turnover and TXA
generation, producing shape change and the release of the
granule contents. This is important in haemostasis and thrombo~l\
(see Ch. 21 ). PAF has ::.pasmogenic effects on both bronchial and
ileal smooth muscle.
The anti-innammatory actions of the glucoconicoids rna> be
caused, at least in part, by inhibition of PAF synthesis (Fig. 13.5).
Competitive antago11ists of PAF and/or specific inhibitors of
lyso-PAF acetyltransferuse could well be useful anti-innammatol)
drugs and/or antiaMhmatic agents. The PAF antagonist lexipafant
is in clinical trial in the treatment of acute pancreatitis (see
Leveau et ul.. 2005).
BRADYKININ
Bradykinin and lysyl bradykini n (kallidin) are active pcptidcs
formed by proteolytic cleavage of circulating proteins termed
kininogens through a protease cascade pathway (Fig. 13.1 ).

Source and formation of bradykinin

An outline of the formation of bradykinin from high-molecular-
Carbon weight J..ininogen in plasma by the serine protease kalli~rein 1s
atom given in Figure 13.12. K ininogen is a plasma u-g1obulin that
number exists in both high (M, 1 J0 000) and low (Mr 70 000) molecular
weight forms. Kallikrein is derived from the inactive precuMr
0 prekallikrein by the action of Hageman factor (factor Xll: ~ee
II Ch. 21 and Fig. 13.1 ). Hageman factor is activated by contact
2
with negatively charged surfaces such as collagen, basement
0
II membrane. bacterial lipopolysaccharides, urate crystab and so
3 CH-0-P-0-R
2 I on. Hageman factor. preka1likrein and the kininogenl> leak om of
OH the vessels during innammation because of increased vascular
Fig. 1 3 .10 The structure of platelet-activating factor permeabil ity, and exposure to negatively charged surfaces promotes

l (PAF). A hexadecyl or octadecyl 0-alkyl residue is attached to

carbon atom 1 (cf. Fig. 13.6). Compounds containing either of
these moieties have PAF activity. R is choline.
the interaction or Hageman factor with prekallikrein. The activated
enzyme then cJ ips' bradykinin from its kininogen precursor
(Fig. 13. 13). Kallikrein can also activate the complement system
and can convert plasminogen to p la~min (see Fig. 13.1 and Ch. 21).

r
I '-Acy~"'''m'"
/ A c yi-PAF ~
~'A,J
l In add ition to plasma kall ikrein, there are other kinin
generating isoe1uymes found in pancreas. salivary glands. colon
and skin. These tissue kaflikreins act on both high- and 1011

Acyl Release of fatty acids

CoA A e.g. arachidonate
Platelet-activating factor
0
L oH + PAF IS released from activated inflammatory
Cpc PGs, LTs, HETEs
Lyso-PAF cells by phospholipase ~ and acts on specific
Acetyl --..,_ / ~ , - - Acetyl receptors in target cells.
group y ~ GoA Pharmacological actions include vasodilatation,

I. Acetyl hydr~ 71 transferase,

increased vascular permeability, chemotaxis and
activation of leucocytes (especially eosinophils),
activation and aggregation of platelets, and smooth
PAF

l
muscle contraction.
Fig. 1 3 .11 The synthesis and breakdown of platelet -
activating factor (PAF). HETE, hydroxyeicosatetraenoic acid; PAF is implicated in bronchial hyperresponsiveness
LT, leukotriene; PC, phosphorylcholine; PG, prostaglandin. and in the delayed p hase of asthma.
220
 LOCAL HORMONES, INFLAMMATION AND IMMUNE REACTIONS

II. Thus kininase U inactivates a vasodilator and activates a

Prekallikrein vasoconstrictor. Potentiation of bradykinin actions by ACE

H~~~~:n T +
~~~~~~~
factor
-{f}-
inhibitors may contribute to some side effecrs of these drugs (e.g.
cough; p. 309). Kinins are also metabolised by various less
specific peptidases, includjng a serum carboxypeptidase that
removes the C-terminal arginine. generating des-Arg9-bradykinin,
Negatively Kallikrein
charged surface ~ a specific agonist at one of the two main classes of bradykinin
receptor (see below).
HMWkininogen ____I_____ BRADYKININ
\ Kininases, -<>--! Actions and role of bradykinin in
inflammation
Inactive
pep tides Bradykinin causes vasodilatation and increased vascular
permeability. lts vasodilator action is partly a result of generation
Fig. 13.12 The generation and breakdown of
bradykinin. High-molecular-weight kininogen (HMW-kininogen) of PG12 (Fig. 13.5) and release of NO. lt is a potent pain-producing
probably acts both as a substrate for kallikrein and as a agent, and itS action is potentiated by the prostaglandms. Bradykinin
cofactor In the activation of prekallikrein. also has spasmogenic actions on intestinal, uterine and bronchial
smooth muscle (in some species). The contraction is slow and
sustained in comparison with that produced by histamjne (hence
brady, which means 'slow').
molecular-weight kininogens and generate mainly kallidin, a Although bradykinin reproduces many inflammatory signs
peptide with actions similar to those of bradykinin. and symptoms, its role in inflammation and allergy has not been
clearly defined, partly because its effects are often part of a
Metabolism and inactivation of bradykinin complex cascade of events triggered by other mediators.
Specific enzymes that inactivate bradykinin and related kinins llowever, excel.sive bradykinin production contributes to the
are caJied kininases (Figs 13. I 2 and 13.13). One of these, diarrhoea of gastrointestinal djsorders. and in allergic rhinitis it
kininase II, is a peptidyl dipeptidase that inactivates kinins by stimulates nasopharyngeal secretion. Bradykinin also contributes
removing the two C-tcrminal amino acids. This enzyme, which is to the clinical picture in pancreatitis. Physiologically, the release
bound to the luminal surface of endothelial cells, is identical to of bradykinin by tis~ue kallikrein may regulate blood flow to
angiotensin-comerting entyme (ACE; see Ch. 19). which cleaves certain exocrine glands, and influence secretions. It also
the two C-terminal residues from the inactive peptide angiotensin stimulates ion transport and fluid secretion by some epithelia,
I, converting it tO the active vasoconstrictor peptide angiotensin including intestine, airways and gall bladder.

Sites of cleavage for kinin form ation

Lys-bradyklnln
(kallidin) l
. - - - - - - - - - Bradykinin - - - - - - - - - -

1
l
[
H,N- Kininogen - Met- Lys- Arg- Pro- Pro- Gly- Phe- Ser- Pro- Phe- Arg- Kininogen - COOH
molecule -. .. l molecule
Kininas~ Kininase I ,

Sites of cleavage for inactivation

B2- receptor antagonist, Hoe 140: 0-Arg - Arg - Pro- Hyp- Gly- Thi - Ser- 0Tic- Oic- Arg
8 1- receptor antagonist, des-Arg Hoe 140: o-Arg- Arg- Pro- Hyp- Gly- Thi- Ser- o-Tic- Oic
Fig. 13 .13 Structure of bradykinin and some bradykinin antagonists. The sites of proteolytic cleavage of high-molecular-weight
kininogen by kallikrein kallidin involved in the formation of bradykinin are shown in the upper half of the figure; the sites of cleavage
associated with bradykinin inactivation are shown in the lower half. The 8 2-receptor antagonist icatibant (Hoe 140) has a pA 2 of 9, and

l the competitive 8 1-receptor antagonist des-Arg Hoe 140 has a pA2 of 8. The Hoe compounds contain unnatural amino acids: Thi, d-Tic
and Oic, which are analogues of phenylalanine and proline. 221
---
SECTION2 .CHEMICAL MEDIATORS
Bradykinin receptors
There are two bradykinin receptors, designated B 1 and B2 Both
are G-protein-coupled receptors and mediate very similar
effects. B 1 receptors are normally expressed at very low levels
but arc !.trongly induced in inflamed or damaged tissues by
cytokines such a\ I L- l. B 1 receptors respond to des-Arg9-
bradykinin but not to bradykinin it'ielf. A number of selective
peptide antagonists are l..nown. ft is likely that B 1 receptors play
a significant role in inflammation and hyperalgesia, and there ic;
recent interest in developing antagonists for use in cough and
neurological di~orders (see Chung, 2005; Rodi et al., 2005).
8 2 receptor& arc con~titutively present in many normal cells
and arc activated by bradykinin and kallidin, but not by des-Arg9 -
bradykinin. Peptide and non-peptide antagonists have been
developed, the best known being icati ban t. None are yet
avai lable for cl inical usc.
NITRIC OXIDE
Chapter 17 discusses NO in detail, and here we will consider
only it~ role in inflammation. Inducible NO synthase (i OS) is
the chief i!>ofom1 relevant to inflammation. and virtually all
inflammatory cell~ express the enzyme in response to cytokine
stimulation. iNOS is also present in the bronchial epithelium of
asthmatic ~ubjccts. in the mucosa of the colon in patients with
ulcerative colitis. and in synoviocytes in inflammatory joint
di~ease. 0 probably has a net proinflammatory effect: it increases
vascular permeability and prostaglandin production. and is a
potent va.,odilator. Some other properties may be seen as anti-
inflammatory: for example, endothelial NO inhibits adhesion
of neutrophils and platelets, and platelet aggregation. NO. or
Bradykinin
8K is a nonapeptide 'c lipped' from a plasma
a-globulin, kininogen , by kallikrein.
It is converted by kininase I to an octapeptide, 8K1-s
(des-Arg 9-8K), and inactivated by kininase II
(angiotensin-converting enzyme) in the lung.
Pharmacological actions:
vasodilatation (largely dependent on endothelial
cell nitric oxide and prostaglandin I:J
increased vascular permeability
stimulation of pain nerve endings
stimulation of epithelial ion transport and fluid
secretion in airways and gastrointestinal tract
contraction of intestinal and uterine smooth
muscle.
There are two main subtypes of 8 K receptors: 8 2 ,
which is constitutively present, and 8 1 , which is
induced in inflammation.
There are selective competitive antagonists for both
8 1 receptors (des-Arg Hoe 140; pA 2 :8) and 8 2
receptors (icatibant, pA 2 :9).
compounds derived from it, also hac; cytotoxic actions, killing
bacteria, fungi, viruses and metazoan parasites, so in this respect
NO enhance~ local defence mechanisms. However, produced in
excesl>, ic may abo harm host cell .
Inhibitors of iNOS are under investigation for treatment
of inflammatory conditions. Patients with septic shock ha\e
benefited from inhibitors of iNOS, and in experimental arthritis
iNOS inhibitors reduce disease activity. NSAIDs coupled ~ich
NO-releasing groups have fewer side effects than convenlional
NSATDs and greater anti-inflammatory efficacy (see Ch. 14).
NEUROPEPTIDES
Neuropcptidcs rel ca~.cd from sensory neurons cause newvgenic
inflammation (Maggi, 1996). The main peptides involved arc
substance P, neurokinin A and CGRP (sec Ch. 16). Substance P
and neurokini n A (members of the tachyk.inin fami ly) act on
mast cells, releasing histamine and other mediators, and producing
smooth muscle contraction and mucus secretion, wherea~ CORP
i<> a potent vasodilator. Neurogenic inflammation is implica1ed in
the pathogene~i~ of several inflammatory conditions, including
the delayed pha),e of asthma, allergic rhinitis, inflammatory
bowel disea~e and some types of arthritis.
CYTOKINES
Cytokine is an all-purpose functional term that is applied 10
protein or polypeptide mediators synthesised and released b}
cells of the immune system during inflammation. More than 100
cyto!..ines have been identified. and the superfamily is generall)
regarded a~ compri~>ing:
interleul..ins
chemokines
interferons
colony-s timulating factors
growrh facLOrs and TNFs.
Cytokines act locally by autocrine or paracrioe mechanisms. On
the target cell, they bind to and activate specific, high-affinity
recep1ors thnt, in moM cases, are up-regulated during inflammation.
Except for chemokines. which act on G-protein-<;oupled receptoT',
most cytokines act on kinase-linked receptors, regulating pho~
phorylation cascade<; that affect gene expression, such as the
Jak/Stat pathway (Ch. 3).
Tn addition to their own direct actions on ceUs, some cytokinc'
amplify inflammation by inducing formation of other intlammatOI)
mediators. Others can induce receptors for other cytokines on
their target cell. or engage in synergistic or antagonistic inler
actions with other cytokines. Cytokines have been likened to a
complex signalling language, with the final response of a particular
cell involved being determined by the strenglh and number of
different messages received concurrently at the cell surface.
Various systems for classifying cytokines can be found in the
literature, as can a multitude of diagrams depicting cornple~
networks of cytokines interacting with each other and with n
range of target cells. T he cytokine aficionado can find classi-
fication tables in Casciari et al. (J 996) and Janeway et al. (2004).
 LOCAL HORMONES, INFLAMMATION AND IMMUNE REACTIONS
g or by using the web links listed at the end of the chapter. A
comprehensive coverage of this area is beyond the scope of this
book but, for the purposes of this chapter, it is useful to divide
cytokines into two main groups:
tho!>e involved in the induction of the immune response,
described above and outlined in Figure 13.5
those proinflammatory and anti-inflammatory cytokines
involved in the effector phase of the immune/inflammatory
response, which we will consider below.
Proinjlammatory cytokines. These cytokines participate in
acute and chronic inflammatory reactions as well as repair and
resolution. The primary proinflammatory cytokines are TNF-a
and lL- 1; sec above (Fig. 13.2). The latter cytokine actually
e comprises a family of three cytokines consisting of two agonists,
p IL- l a, I L- 1~. and, surprisingly, an endogenous IL- l -receptor
antagonisl ( IL- l ra). Mixtures of these are released from
macrophages and many other cells during inflammation and can
initiate the synthesis and release of a cascade of secondary
cytokines, among which arc the chemokines (see below). Various
cytokine growth factors (e.g. platelet-derived growth factor,
fibrob last growth factor, vascul ar endothelial growth factor) are
crucial to the repair processes and are implicated in chronic
inflammation (sec Ch. 5).
The anti-inflammatory cytokines. These comprise those that
mhibit aspects of the inflammatory reaction, including TGF-~.
to JL-4, fL-10 and IL-13. They inhibit chemokine production, and
the anti-inflammatory interleukins can inhibit responses driven
by Th I celb, whose inappropriate activation is involved in the
pathogencsi!> of everal diseases.
CHEMOKINES
Chemokincs arc defined as chemoattractant cytokines that
con trol the migration of lcucocytes, functioning as traffic
coordinators during immune and inflammatory reactions. The
nomenclature (and the classification) i s a little confusing here,
because some non-cytokine mediators also control leucocy te
movement (C5a, LTB 4, f-Met-Leu-Phe, etc.; see Fig. 13.2).
Furthermore, many chemokines have other actions. f or example
causing mast cell degranulation or promoting angiogenesis.
More than 40 chemokines have been identified. and for those
of us who are not professional chemokinologists they can be
conveniently di'itinguished by considering whether key cysteine
residues in the polypeptide chain are adjacent (C-C chemokines)
or separated by another residue (C-X-C chemokines).
The C-X-C chemokines (main example TL-8: see Fig. 13.2) act
r- on neutrophils and arc predominantly involved in acute inflam-
a matory responses. The C-C chemokines (main examples M CP-1
ar and RANTES) act on monocytcs. eosinophils and other cells, and
of are involved predominantly in chronic inflammatory responses.
Chemokines act through G-protein-coupled receptors, and
c alteration or inappropriate expression of these is implicated in
~ multiple sclerosis, cancer, rheumatoid arthritis and some
a cardiovascular diseases (Gerard & Rollins, 2001 ). Some types
1- of virus (herpesvirus. cytomegaJovirus, poxvirus and members of
). the retrovirus fami ly) can exploit the chemokine system and
subvert the host's defences (Murphy, 200 I). Some produce
proteins that mimic host chemok ines or chemokine receptor!>.
some act as antagonists at chemokine receptors, and some
masquerade as growth or angiogenic factors. The AIDS-causing
HfV virus i. responsible for the most audacious exploitation of
the ho~t chemokinc system. Thh virus ha<; a protein (gp 120) in
its envelope that recognises and binds T-cell receptors for CD-l
and a chemokine coreceptor that allows it to penetrate the T cell
(see Ch. 47).
INTERFERONS
Interferons are con~>i dered in more detail below: the colony-
stimulating factors are considered in Chapter 22.
There arc three classes of interferon, termed JFN-a, !FN-{3 and
IFN-y. IFN-u is not a single substance but a family of approximately
20 proteins with similar activities.lFN-a and IFN-B have antiviral
activity, and IFN-a also has some antitumour action. Both
arc released from virus-infected cells and activate antiviral
mechani!>m~ in neighbouring cells. IFN-y has a role in induction
of Th I responses (Fig. 13.3; sec al so Abbas et al., 1996).
Clinical use of inte rferons
Interferon-a is used in the treatment of chronic hepatitis B and
C, and has some action against herpes :.oster and in the
prevention of the common cold. Antitumour action again~t some
lymphomas and solid tumour~ has been reported. A variety of
dose-related side effect~ may occur. IFN-~ is u~ed in some
patients with multiple ~clerosis, whereas IFN-y is used in chronic
granulomatous di11ease in conjunction with antibacterial drugs.
Cytoklnes
Cytokines are polypeptides released d uring
inflammation that regulate the action of inflammatory
and immune system cells.
The cytokine superfamily includes the interferons,
interleukins, tumour necrosis factor (TNF). growth
factors, chemokines and colony-stimulating factors.
Utilising both autocrine or paracrine mechanisms,
they exert complex effects on leucocytes, vascular
endothelial cells, mast cells, fibroblasts, haemopoietic
stem cells and osteoclasts, controlling proliferation,
differentiation and/ or activation.
lnterleukin (IL)-1 and TNF-a are important primary
inflammatory cytokines inducing the formation of
other cytokines.
Interferon (IFN)-u and IFN-~ have antiviral activity,
and IFN-a is used as an adjunct in the treatment of
viral infections. IFN-y has significant
immunoregulatory function and is used in the
treatment of multiple sclerosis.
223
 SECTION 2 C H E M I C A l M E D I AT 0 RS
GLOSSARY OF ABBREVIATIONS AND ACRONYMS
APC antigen-presenting cell
c
complement (as in C3a. CSa. C3b, etc.)
CO-l and CDS coreceptors in T lymphocytes for MHC
molecules classes IT and I. respectively
COX- I and COX-2 i. oforms of cyclo-oxygenases
ICAM intercellular adhesion molecule
rFN interferon (as in IFN-a, IFN-f3, IFN-y)
rL interleukin (as in IL- l, IL-2, etc.)
LT lcukotriene (as in LTB4 , LTC4 , LTD4 )
mAb monoclonal antibody
MCP- 1 monocyte chemoattractant protein- I
MHC major histocompatibility complex
REFERENCES AND FURTHER READING
The innate and adnp1h e I'CSI>Onses
Abba' A K. Murphy K M. Sher A 1996 Functional
d.veNty of helper lymphocyte\. Nature 383: 787-793
(Exullenr rt~in.: h~lpfil dwgronu: commendable
co~ raRe of Th I and Th2 c~IIJ (1JJ(/ thl'ir respecti1e
C,IIOkmt .<ubul\)
Adams D H, Lloyd A R 1997 Chemokme: leucocyte
recnnunem and acuvation cytokme,. Lancet 349:
490-495 (Comm~ndablt rrHt'l)
Akua S, Taleda K. Kal\ho T 2001 Toll-like receptors:
critical prote1ns hnkmg 1nnate and acqwred 1mmun11y.
I':at lmmunol 2 6 75 680 (A melt dt'scrrbtn/i the
reuptor> for PAM Ps shored bJ larg~ groups of micro
orgam.rm.s. S11mulat10n of theu re<eptor> by
componems of mcro-orgamsms actimll's 11111ate
immuniry and it a prtrt'quirit~ for triggering acquired
immunit). Us~fill dtafjrOlltf.)
Brown P 2001 Cinderella goes to the ball. Nature 4 10:
1018 1020.
Delves P J, Roin I M 2000 The immune YMCm. N Engl
J Med 343: 37-49, 108-1 17 (A good overvii!W of the
immune system-llminite.ltlxJok of major arras in
inummology; rolollrful tlrreedimeiiSimwl figures)
Gabay C. Kushner 1 1999 Acute phase proteins and other
systemic responses to inflammation. N Engl J Med
340: 448-454 (Lim the ocurephase protein.r (1JJ(/
omlmes th~ medtani.\nu rontmlling their symlwsis
and releast)
KWTC K. Wel\h R M 1997 Viral decoy vetoes killer cell.
Na10re 386: 446-447
Kay A B 200 I Allergic dl\ea!>CS and lhetr treatment.
N Engl J Med 344: 30 37, 109 113 <Coers atopy
(1JJ(/ Th2 ctlls, tht role af17t2 C,IUJ!cinl!.t m allergies,
lgE. tht' main f)pts of allerg,1. anti new theropeutic
approaches)
Mackay CR. Lan7<wecchla A. Sallu~to F 1999
Chemoattra<:tant receptor. and 1mmune responses.
1mmunologm 7 112-118 (Masterly shan rt'l'tt'l<
cowmng the m/~ of chemoarrractantl in OIThestrotin~t
immuM respons~s-both thl' rnnatt f'r'action and the
Thl (1JJ(/ Th2 I'I!Sponus)
Med1.h11ov R 2001 Toll-lile receptor. and innate
immunity. Nnt Rev lmmunol 1: 135-145 CE.tcellent
revi~w of the rol~ afTn/1-/ikt TI!Ceptors it1 (a) the
detectum ofmirmbittl inft'ctott. a11d (b) theactimtion
of innm~ ltOIItrdaptivt rt'.<ponl~.s. which in fllm lead
ro antif/eN.II>ecific tdaptile rro.rpo11s~s)
Medzhilov R, Janeway C 2000 Innate immunity. N Engl
224 J Med 343: 338 344 (0111> /lflltfilfg clear coverage of
NK natural killer lymphocyte
SAID
PAF
PAMP
PG
RANTES
Th
TLR
TN F-a
TNF-B
the -chanisms ini'OIIed in innlll~ immunity and itr
significana for the adaptil'~ immune respa11u)
Murphy P M 200 I Viral exploitatiOn nnd \ubveNon of
the immune system through chemokme m1m1cry. :-I at
1mmunol 2: 116-122 (Exull~nt de.1crrption of
iraVimmune SJ.ttem mteraction)
Panes J. Perry M, Granger D N 1999
Leucocyte-endothelial cell adhes1on: a,enue. for
therapeutic interven11on. Br J Phannacol 126: 537-5SO
(Bnef corerogt! of the prinnpal u/1 adhtrion
molecults and factors affectmg leiiCOC)t~ndotlttlial
adhesion p~cede.r considerotion ofpottnual
therapeutic tar.gers)
Parkin J. Cohen B 2001 An overview of the immune
system. Lancet357: 1777-1789 (A competent
straightforward rtin- cov~ring thl' rolt of tht'
immune system in recot~nisinf1, Tl!pt!llinR tmd
erodicating pathogens and i11 retrctiltg llf/trinst
molecules foreign to the body)
Romagnani S 1996 Shon analytical review: Th I and Th2
in human diseases. Clin lmmunol lmmunopa1hol 80:
225-23.5 (Admirable coverag~ of the pmhopltysiology
of Thl and Th2 responses)
Walker C. Zuany-Amorini C 2001 New trend\ in
immunotherapy to prevem atopic di ~e.1sc. Trends
Phannacol Sci 22: 84-91 (Discusres porentiol
therapies based on ret'l'ttl adl'(llll'ts in tltt
understanding of the immune mechanism.! ()f ultJpy)
Wills-Karp M. Santeliz J, Karp C L 2001 The germles~
theory of allergic di..ea.scs. Nat Rev 1mmunol J 69--75
(Discu.>St!.rthe hypotht'sirthat early chi/d/1()(1(/
infl!ctions inhibit the undt'rtC)' ro dntlop alltrgic
disease)
~1ainly mediators
A.rrang J M. Garbalg M, Schwanz J C 1983
AutoinhiblliOn of bram histamine release mediated by
a no\'el class (H,) of histam1ne recep1or. Nature 302:
832-834 (Seminal antde on the <'XISienu of H 1
receptors)
Casdari J J, Sato H et al. 1996 Tabo1ar lexicon of
cytokine structure and function. In: Chnbncr B A.
Longo D N (eds) Cancer chemotherapy and
biotherapy, 2nd edn. Lippincott Raven, Philadelphia.
pp. 787-793 (Useful cla.,sification brin11ing orrlu to ''
confusing field)
Coleman R A. Humphrey P A et al. 1993 Prostanoid
receptors: their function and clas\ification. In : Vane J,
O'Grady J (eds) Therapeutic applications of
non-steroidal anti-inflammatory drug
platelet-activating factor
pathogen-associated molecular pattern
prostaglandin (as in PGE:!, PG1 2, etc.)
regulated on activation normal T-cell
expressed and secreted
T-helper lymphocyte (occurs as Th I and
Th2)
Toll receptor
tumour necrosis factor-a
tumour necrosis factor-f3
proo;taglsndin;. Edward Arnold. London, pp. 15-36
(Useful coerage; iJJc/udes structures ofprosuuwids.
thdr aJJolog~Jes (1JJ(/ (JJJ/agonists-a t:lassificmitm th.u
bro~Jght forth order from chaos!)
Dale M M 1994 Summary of section on me(hatOI'>. In
Dale M M, Foreman J C. Fan T-P (eds) Textbool or
1mmunophannaeology. 3rd edn. B1aekwell Sc:ienufir.
Oxford, pp. 206-207 (Considers whkh -diators
mut dtjined cmeria)
Gerard C. RoWns B 2001 Cbemokines and disea...e. S31
1mmunol 2: IQS-115 (Discusses diseases assooartd
with inappropriau actiation of the chemo~mt
network, and discusses some theropeuric impllcanOttJ
dtscribes how viruses evade the immune responses h>
numicry of the chemokmes or their receptors)
Gutzmer R. Diestel C. Mommen S et nl. 2005 Hi,usmin.:
H.. receptor stimulation suppresses IL-12p70
production and mediates chemotaxis in human
monocyte-derived dendritic cells. J lmmunol 174:
5224. 5232
lloruk R 2001 Chemokine receptor>. Cytokine Growth
Fllctor Rev 12: 313-335 (Comprehl'nsive review
focusillfl 011 recent findings ilt chemokine receptor
research; describes the molecular. physiological and
biochemiral properties of each clremokine receptor)
Luster A D 1998 Mechanisms of disease: chemokine'
chemotactic cytokines !hat mediate inflammation 1\
Engl J Med 338: 436-445 (Excellent review:
olllsta11dmg diagrams)
Mackay C R 2001 Cbemokines: immunology's high
impact factors. Nas lmmunol2: 95-101 (Clear.
t/eyant roverage of the rolt of chemoldnu in
leuCOC)te~ndothelial interoction. control ofpnmary
1mmunt> responses and T/8 u/1 intuoction. T ulu
inflammatory diseases, and ira/ subersion of
tmmune t1'sponses)
Magg1 C A 1996 Pbatmacology of the efferent fuocuon
of pnmary sensory neurooes. In: Geppetti P. Holztt P
(eds) Neurogenic mfl311Uru1tioo. CRC Pre..s, London
(Worthwhile. Coers neurogemc inflammation, tM
release of JJeuropeptides from <ensory nerves. and
inflammatory mediators. Discussu agem> thlll inhthu
reletL\e and the phamacolcgical modulanon of
rt'Ceptor-mediated release.)
Mantovani A. Bussolino F. lntrona M 1997 Cytokme
regulation of endolhelial cell function: from molecular
level to the bedside. lmmunol Today 5: 231-239
(Patlwphy.siology of endothelial re/1-cytokine
interactions; detailt!d diagrt11ns)
 Anti-inflammatory and
immunosuppressant drugs
Overview 226
Non-steroidal anti-inflammatory drugs 226
-Pharmacological actions 226
-Mechanism of cycle-oxygenase inhibitory action 230
-Common unwonted effects 232
-Some important NSAIDs 234
-Agents selective for cyclo-oxygenase-2 236
Antagonists of histamine 237
Drugs used in gout 238
Antirheumatoid drugs 239
Immunosuppressant drugs 242
Anticytokine drugs 243
Possible future developments 245
OVERVIEW
This chapter deals with the drugs used to treat
inflammatory and immune disorders. While
generally associated with disorders such as
rheumatoid arthritis, it has become clear that
inappropriate inflammatory or immune reactions
form a significant component of many, if not most,
of the diseases encountered in the clinic, and
consequently anti-inflammatory drugs are extensively
employed in virtually all branches of medicine.
The three major groups of drugs are the non
steroidal anti-inflammatory drugs (NSAIDs); the
antirheumatoid drugs, which include the disease-
modifying antirheumatic drugs (DMARDs); and the
glucocorticoids. We describe the therapeutic effects,
mechanisms of action, and unwanted effects
common to all NSAIDs, and deal in a little more
detail with aspirin, paracetomol and drugs that are
selective for cyclo-oxygenase (COX)2. DMARDs
comprise a rather heterogeneous group of drugs
and include some important new agents. The
glucocorticoids are covered in Chapter 28, but their
immunosuppressive actions are discussed briefly in
226 this chapter. Also considered in this chapter are
immunosuppressant drugs used to prevent
rejection of organ transplants. Finally, we consider
drugs used to treat gout and (although they are
not strictly anti-inflammatory agents) the histamine
H 1 receptor antagonists used to treat certain acute
allergic conditions.
NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
The NSAIDs, sometimes called the aspirin-like drugs, are among
the mol>t widely used of all drugs. There are now more than 50
different NSAIDs on the global market: some of the more
imponant examples are listed in Table 14.1 and some structure\
in Figure 14.1. They provide symptomatic relief from pain and
swelling in chronic joint disease such as occurs in osteo- and
rheumatoid anhritis, and in more acute inflammatory conditions
such as spons injuries, fractures, sprains and other soft tissue
injuries. They also provide relief from postoperative, dental and
menstn.al pain, and from the pain of headaches and migraine. A~
.several NSAIDs are available over the coumer, they are often
taken without prescription for other types of minor aches and pains.
There arc many different formulations available, including tablet;,
injections and gels. Virtually all NSAIDs, particularly the 'classic'
NSAIDs, can have significant unwanted effects, especially in the
elderly. Newer agents have fewer adverse actions.
PHARMACOLOGICAL ACTIONS
All the NSALDs have actions very simjlar to those of aspirin, the
archetypal NSAID, which was introduced into clinjcaJ medicine
in Lhe 1890s. The three main therapeutic effects are:
an anti-inflammatory effect: modification of the
innammatory reaction
an analgesic effect: reduction of certain rypes of (especiall)
innammatory) pain
an amipyretic effect: lowering of body temperanrre when thi\
is raised in dil>ease (i.e. fever).
In addition, all the NSAIDs share, to a greater or lesser degree.
the same types of mechanjsm-based side effects. These include:
gastric irritation, which may range from simple discomfort
to ulcer formation
an effect on renal blood flow in the compromised kidney
 ANTI-INFLAMMATORY AND IMMUNOSUPPRESSANT DRUGS

Table 14.1 Comparison of some common non-steroidal anti-inflammatory drugs and coxibs

Usual indications

Drug Type RD Gout MS PO Dys H&M Comments

Aceclofenac Phenylacetate

Acemetacin Indole ester Ester of indometacin

Aspirin Salicylate Mainly cardiovascular usage

Celecoxib Coxib Fewer gastrointestinal effects

Dexketoprofen Propionate

Diclofenac Phenylacetate Moderate potency

Diflunlsal Salicylate

Etodolac Pyranocarboxylate Possibly fewer gastrointestinal effects

Etoricoxib Coxib

Fenbufen Propionate

Fenoprofen Propionate Prodrug activated in liver

Flurbiprofen Propionate

Ibuprofen Prop1onate Suitable for children

lndometacin Indole Suitable for moderate to severe disease

Ketoprofen Propionate Suitable for mild disease

Ketorolac Pyrrolizine

Mefenamic acid Fenamate Moderate activity

Meloxlcam Oxicam Possibly fewer gastrointestinal effects

Nabumetone Napthylalkenone Prodrug activated in liver

Naproxen Propionate

Parecoxib Coxib Prodrug activated in liver

Piroxicam Oxlcam

Sulindac lndene Prodrug

Tenoxicam Oxicam

naprofenic acid Propionate

Tolfenamic acid Fenamate

Dys, dysmenorrhoea; H&M, headache and migraine; MS. musculoskeletal disorders; PO, postoperative pain; RD, rheumatic diseases
(e.g. rheumatoid arthritis and osteoarthritis).
(From British Medical Association and Royal Pharmaceutical Society of Great Britain 2005 British National Formulary. BMA and RPSGB,
London.)

227
 SECTION2 .CHEMICAL MEDIATORS
OuP697 Meloxlcam
Nlmesulide Celecoxib
Paracetamol Phenacetin
Fig. 14. 1 Structures of some non-steroidal anti-inflammatory drugs (NSAIDs) and coxibs. Most 'classic' NSAIDs are carboxylic
, acids, but the coxibs contain 'bulky groups' that impede access to the hydrophobic channel in the cyclo-oxygenase-1 enzyme.
a tendency to prolong bleeding through inhibition of plare/et
Junction
controversially, it is argued that they may also all-but
especially COX-2 selective drugs-increase the likelihood of
thrombotic events &uch as myocardial infarction by inhibiting
prostaglandin (PG) 12 synthesis.
While there are differences between individual drugs, all these
effects arc generally thought to be related to the prim81) action
of the drugs- inhibition of the farty acid COX enzyme, and thus
inhibition of the production of prostaglandins and thromboxanes.
There are three known isoforms-COX-1. COX-2 and COX-3-
as well as some non-catalytic species (see Table 14.2). As it is not
yet cenain that COX-3 actually occurs in humans in a functional
form, we will confine the discussion mainly to a consideration of
COX-I and COX-2. While they are closely related (> 60o/c
sequence identity) and catalyse the same reaction. it is clear that
there are imponant differences between the expression and role
of these two isoforms. COX-I is a constitutive enzyme expressed
in most tissue!.. including blood platelets. It has a 'housekeeping'
ro le in the body, being involved in tissue homeostasis, and is
228 responsible for the production of prostaglandins involved in, for
Etodolac
Rofecoxib
Aspirin lndometacin
example, gastric cytoprotcction (see Ch. 25), platelet aggregation
(Ch. 2 1), renal blood tlow autoregulation (Ch. 24, p. 374) and the
initiation of parturition (Ch. 30).
In contrast, COX-2 is induced in inflan1111atory cells when
they arc activated, and the primary inflammatory cytokines-
intcrleukin (lL)-1 and tumour necrosis factor (TNF)-a (sec
Ch. 13)-are important in this regard. Thus the COX-2 i~ofonn
is re. ponsible for the production of the prostanoid mediator~ of
innammation (Vane & Botting, 2001), although there arc \orne
significant exceptions. For example. there is a considerable pool
of 'com.titutive' COX-2 present in the central nervous sy,tem
(CNS) and -.ome other tissues, although its function is not }et
completely clear.
Most 'traditional' NSAIDs are inhibitors of both isoenz)me'.
although they vary in the degree to which they inhibit each
isoform. It i!> believed that the anti-inflammatory action (and
probably moM analgesic actions) of the NSAlDs is relak'll
to their inhibition of COX-2. while their unwanted effects
particularly those affecting the gastrointestinal tract-are large!)
a result of their inhibition of COX-I. Compounds with a selecti\e
inhibitory action on COX-2 are now in cl inical use. but
expectations that these inhibitors would transform the treatment
 ANTI-INFLAMMATORY AND IMMUNOSUPPRESSANT DRUGS

Table 14.2 The cyclo-oxygenase family: a summary of p roperties

Gene Gene product Tissue expression Functions Inhibitors Comments

COX1 COX-1 Constitutively expressed Platelet aggregation, Most 'classic' NSAIDs, First COX to be
1n most t1ssues gastrointestinal protection, some selective inhibitors identified
some pain, production of
vascular prostacyclin

COX1 COX-3 Brain, heart and aorta; Pain perception Paracetamol, diclofenac, Few details presently
constitutive? ibuprofen, d1pyrone, known
phenacetin, antipyrine

COX1 pCOX-1a Brain ? n/a Not catalytically active

COX1 pCOX-1b Brain ? n/a Not catalytically active

COX2 COX-2 Induced In many tissues Inflammation, fever, some Many NSAIDs, COX-2-
by many stimuli, including pain, parturition and renal selective drugs such
growth factors, cytokines, function . Production of as the coxibs and others
oxidative stress, brain vascular prostacyclin?
hypoxia or seizures, and
other forms of injury or
stress; constitutively
present in brain, kidney
and elsewhere

COX2 COX-? J774 cells during ? Paracetamol Studied in only one

apoptosis system to date

COX, cyclo-oxygenase; n/a, not applicable; NSAID, non-steroidal anti-inflammatory drug.

p stands for partial; th1s refers to the fact that the protein is a truncated form.
(Modified from Bazan & Flower 2002.)

of innammatory conditions have received a setback because of
an increase in cardiovascu lar risk (see below). A broad scheme
for classifying the relalive selectivity for COX-112 of the
currently avai lable NSAfDs is given in Table 14.3.
There are few significant differences in pharmacological
actions among the currently used NSAlDs, but there are marked
m differences in toxicity and degree of patient tolerance. Aspirin,
pf however, has other qualitatively different pharmacological actions,
~e and paracetamol i<; an interesting exception to the general NSAID
~)I stereotype'. While it is an excellent analgesic and antipyretic,
JTl the anti-innammatory activity of paracetamol is very low and
et seems to be restricted to a few special cases (e.g. inflammation
following dental extraction: sec Skjelbred et al .. 1984). Paracetamol
has been shown to inhibit prostaglandin biosynthesis in some
experimental seuings (e.g. during fever) but not in others. It was
hoped that the discovery of COX-3A (Chandrasek.haran et al:
2002), an isoform found in dog brain and that seemed more
sensitive to paracctamol, might provide a neat explanation of this
anomaly, but it is too soon to teU whether this will be the case.
The main pharmacological actions and the common side
effects of the NSAJDs are outlined below, followed by a more
detailed coverage of aspirin and paracetamol, an outli ne of the
pharmacology of the selective COX-2 inhibitors, and finally the
clinical applications of the group as a whole.
ANTIPYRETIC EFFECT
Normal body temperature is regulated by a centre in the
hypothalamus that controls t11e balance between heat loss and
heat production. Fever occurs when there is a disturbance of this
hypothalamic 'thennostat, which leads to the set point of body
temperalUre being raised. NSAfDs 'reset" this them10stat. Once
there has been a return to the normal set point, the temperature-
regulating mechanisms (dilatation of superficial blood vessels,
sweating, etc.) then operate to reduce temperature. Nonnal body
temperature in humans is not affected by NSAIDs.
The NSAIDs exert their antipyretic action largely through
inhibition of prostaglandjn production in the hypothalamus.
During an inflammatory reaction. bacterial endotoxins cause the
release from macrophages of a pyrogen-IL-l (Ch. 13)-which
stimulates the generation, in the hypothalamus, of E-type
prostaglandins that elevate the temperature set point. COX-2
may have a role here, because it is induced by IL-l in vascular
endothelium in the hypothalrunus. There is some evidence that 229
 SEcnON 2 . CHEMICAl MEDIATORS
Table 14.3 Cyclo-oxygenase-inhibitory specificity of some common non-steroidal anti-inflammatory drugs and coxibs
Group Description
Highly COX-1-selective
II Very COX-1-selective
Ill Weakly COX-1-selective
IVa Non-selective; full inhibition of both enzymes
IVb Non-selective; incomplete inhibition of both enzymes
v Weakly COX-2-selective
VI Very COX-2-selective
VII Highly COX-2-selective
COX, cyclo-oxygenase.
"Rofecoxib has been withdrawn from use and is shown here as an illustration only.
(Based on data from Warner T 0, Mitchell J A 2004 FASEB J 18: 790-804.)
prostaglandins are not the only mediators of fever, hence
NSATDs may have an additional antipyretic effect by mechanisms
as yet unknown.
ANALGESIC EFFECT
The NSAIDs arc effective against mild or moderate pain,
especially that arising from inflammation or tissue damage. Two
sites of action have been identified. First, peripherally, they decrease
production of the prostaglandins that sensitise nociceptors to
inflammatory mediators such as bradykinin (see Chs 13 and 41)
and they arc therefore effective in arthritis, bursitis, pain of
muscular and vascular origin, toothache, dysmenorrhoea, the
pain of postpartum states and the pain of cancer metastases in
bone-all conditions that are associated with increased local
prostaglandin synthesis. In combination with opioids, they decrease
postoperative pain, and in some ca~es can reduce the requirement
for opioids by as much as one-third. Their ability to relieve
headache may be related to the abrogation of the vasodilator
effect of prostaglandins on the cerebral vasculature.
In addition to these peripheral effects. there is a second, less
well-characteri ed central action. possibly in the spinal cord.
Inflammatory lesions increa~e prostaglandin release within the
cord. causing facilitation of transmission from afferent pain
fibres tO relay neurons in the dorsal hom.
ANTI-INFLAMMATORY EFFECTS
Many mediators coordinate inflammatory and allergic reactions.
While some are produced in response to specific stimu li (e.g.
his tamine in allergic inflammation), there is considerable
230 redundancy, and each facet of the response-vasodilatation,
Selectivity ratio Examples
10Q-1000 Ketorolac
10-100 Flurbiprofen
1-10 lndometacin, aspirin, naproxen, ibuprofen
Fenoprofen
Salicylate
1-10 Diflunisal, piroxicam, meclofenamate,
sulindac, diclofenac, celecoxib
10-100 Valdecoxib, etoricoxib
100-1000 Rofecoxib8
increased vascular permeability, cell accumulation, etc.--can be
produced by everal eparate mechanisms.
The NSAIDs reduce mainly those components of the inflam-
matory and immune response in which prostaglandins, mainl}
derived from COX-2. play a significant part. These include:
I'GSOdifatatiOfl
oedema (by an indirect action: the vasodilatation facilitates
and potentiates the action of mediarors such as histamine that
increase the permeability of postcapillary vcnules-Ch. 13.
p. 204)
pain (see above), again potentiating other mediators, such as
bradykinin (see Ch. 4 1, Fig. 41.7).
The NSAIDs suppress the pain, swelling and increased blood
flow associated with inflammation but have little or no action on
the actual progress of the underlying chronic disease itself. As
a class, they are generally without effect on other aspect~ of
inflammation, such as leucocyte migration, lysosomal enzyme
release and toxic oxygen radical production, that contribute to
tissue damage in chronic inflammatory conditions such .~,
rheumatoid arthriti~. vasculitis and nephritis.
MECHANISM OF CYCLO-OXYGENASE
INHIBITORY ACTION
Vane and his colleagues established in 1971 that the main action'
of NSAIDs were bought about through inhibition of arachidonic
acid oxidation by the fatty acid COXs (see Fig. 14.2).
These are bifunctional enzymes, having two distinct catalytic
activities. The first. dioxygenase step incorporates two molecule'
of oxygen into the arachidonic (or other fatty acid substrate) chain at
C II and C 15, giving rise to the highly unstable endoperoxide
 ANTI-INFLAMMATORY AND IMMUNOSUPPRE SSANT DRUGS

Non-steroidal anti-Inflammatory drugs

The NSAIDs have three major pharmacologically
desirable actions, stemming from the suppression of
prostanoid synthesis in inflammatory cells through
inhibition of the cycle-oxygenase (COX)-2 isoform of the
arachidonic acid COX. They are as follow.
An anti-inflammatory action: the decrease in
prostaglandin E2 and prostacyclin reduces
vasodilatation and, indirectly, oedema. Accumulation
of inflammatory cells is not reduced.
An analgesic effect: decreased prostaglandin
generation means less sensitisation of nociceptive
nerve endings to inflammatory mediators such as
bradykinin and 5-hydroxytryptamine. Relief of
headache is probably a result of decreased
prostaglandin-mediated vasodilatation.
An antipyretic effect: interleukin-1 releases
prostaglandins in the central nervous system, where
they elevate the hypothalamic set point for temperature
control, thus causing fever. NSAIDs prevent this.
Some important examples are aspirin, ibuprofen,
naproxen, indometac1n, piroxicam and paracetamol.
Newer agents with more selective inhibition of COX-2
(and thus fewer adverse effects on the gastrointestinal
tract) include celecoxib and etoricoxib.

COX1 COX2

1-

y
'Side pocket'

- - - - - - Hydrophobic - - -
'tunnel'
ll

d
n
,s Intracellular membrane
>f
iC
.0 Br
lS

Bulky
S02CH3 --grouping
yHC02H
CH 3

COX1 inhibitor COX2 inhibitor

IS
Flurbiprofen DuP697
c
Fig. 14.2 Schematic diagram comparing the binding sites of cycle-oxygenase (COX)-1 and COX-2. The cartoon shows the
c differences in NSAID binding sites in the two isoforms. Note that the COX-2 binding site is characterised by a 'side pocket' that can
accommodate the bulky groups, such as the methylsulfonyl moiety of the prototype COX-2 inhibitor DuP697, which would impede its

~~
Iaccess to the COX-1 site. Other NSAIDs, such as flurbiprofen (shown here), can enter the active site of either enzyme. (After Luong et al.
~ 996 Nat Struct Bioi 3: 927-933.)
231
re
 SECTION 2 II C H EM I C A l M E D I AT 0 RS
intermediate PGG2 with a hydroperoxy gro up at CIS. A
second, peroxidase function of the enzyme converts this to PGH2
with a hydroxy group at Cl5 (see Ch. 13), which can then be
transformed in a cell-specific manner by separate isomerase,
reductase or synthase enzymes into other prostanoids. Both
COX-I and COX-2 are haem-containing enzymes (see Ch. 8,
p. ll4) that exist as homodimers in intracellular membranes.
Structurally, the isoforms are similar; both have a long
hydrophobic channel into which the arachidon ic or other
substrate fatty acids dock so that the oxygenation reaction can
proceed.
Most NSAIDs inhibit only the initial dioxygenation reaction.
They are generally 'competitive reversible' inhibitors, but there
are differences i11 their time courses. Generally, these dmgs
inhibit COX-1 rapidly, but the inhibition of COX-2 is more time-
dependent and the inhibition is often irreversible. To block the
enzymes, NSAIDs enter the hydrophobic channel, forming
hydrogen bonds with an arginine residue at position 120, thus
preventing substrate fatty acids from entering into the catalytic
domain. However, a single amino acid change (isoleucine to
valine at position 523) in the structure of the entrance of this
channel in COX-2 results in a bulky side pocket that is not found
in COX-l. This is irnp01tant in understanding why some dmgs,
especially those with bulky side groups, are more selective for
the COX-2 isofo1m (Fig. 14.2). Aspirin is, however, an anomaly.
It enters the active site and acetylates a serine at position 530,
uTeversibly inactivating COX-l. This is the basis for aspirin's
long-lasting effects on platelets (see below).
Other actions besides inhibition of COX may contribute to the
anti-inflammatory effects of some NSAIDs. Reactive oxygen
radicals produced by neutrophils and macrophages are implicated
in tissue damage in some conditions, and some NSAIDs (e.g.
s ulindac) have oxygen radical- scavengirig effects as well as
COX inhibitory activity, so may decrease tissue damage. Aspirin
also inhibits expression of the transcription factor nuclear factor
(NF) KB, which has a key role in the transcription of the genes
for i11flammatory mediators.
COMMON UNWANTED EFFECTS
Because prostaglandins are involved in gastric cytoprotection,
platelet aggregation, renal vascular autoregulation and induction
of labour, among other effects, it may be reasonably expected that
all NSATDs share, to some extent, a similar profile of mechanism-
dependent side effects. While this is true, Lhere may be other
additional unwanted effects peculiar to individual members of
the group.
Overall, the burden of unwanted side effects is high. Severe
gastrointestinal effects alone (perforations, ulcers or bleeding)
are said to result in the hospitalisation of over 100 000 people
per year in the USA. Some 15% of these patients may die from
this iatrogenic disease (Fries, 1998). These figures probably
reflect the fact that NSAIDs are used extensively in the elderly,
and often for extended periods of time. When the classic NSAlDs
are used in joint diseases (which usually necessitates fairly large
doses and long-continued use), there is a high incidence of
232 side effects-particularly in the gastrointestinal tract but also in
liver, kidney, spleen, blood and bone marrow. COX-2-selective
drugs have less gastrointestinal toxicity (see below).
GASTROINTESTINAL DISTURBANCES
Adverse gastroiritestinal events are the commonest unwanted
effects of the NSAlDs, and are believed to result mainly from
inhibition of gastric COX-1, which is responsible for the synthesis
of the prostaglandins that normally irihibit acid secretion and
protect the mucosa (see Fig. 25.2).
Common gastrointestinal side effects include gastric
discomfort, dyspepsia, diarrhoea (but sometimes constipation),
nausea and vomiting, and in some cases gastric bleeding and
ulceration. It has been estimated that 34-46% of users of
NSATDs will sustain some gastrointestinal damage that, while it
may be asymptomatic, carries a risk of serious haemorrhage
and/or perforation (Fries, 1983). The mechanism is dependent on
irihibition of COX in the gastric mucosa, and damage is seen
whether the drugs are given orally or systemically. However, in
some cases (aspirin being a good example) local damage to the
gastric mucosa caused directly by the dmg itself may compound
the damage. Figure 14.3 gives the relative risks of gastrointestinal
damage with some common NSAIDs. Oral administration of
prostaglandin analogues such as misoprostol (see Ch. 25) cao
diminish the gastric damage produced by these agents.
Based on extensive experimental evidence, it had been predicted
that COX-2-selective agents would provide good anti-inflammatory
and analgesic actions with less gastric damage, and some older
drugs (e.g. meloxicam) that were believed to be better tolerated
in the clinic turned out to have some COX-2 selectivity. Two
large prospective studies compared cclecoxib and rofecoxib with
standard comparator NSAIDs in patients with arthritis and showed
some benefit, although the results were not as clear-cut as bad
been hoped. Less encouraging, however, was an increase in the
incidence of serious cardiovascular illcidents seen in Lhese trials
(Boers, 2001; FitzGerald & Patrono, 2001). At the time, it was
not clear that this was connected with COX-2 inhibition, and
two 'coxibs', as they came to be called, were licensed in the USA
in 1998 (and in the UK shortly after), with many more in the
pipeline. Continuing uncertainty about the cardiovascular risk
led to the addition of warning labels on these drugs in 2002.
but the results from a long-term trial designed to assess the
anticancer activity of rofecoxib showed that the risk of cardio-
vascular events increased significantly after 18 months' treatment.
As a result of this, the dmg was voluntarily withdrawn in 2004.
When another coxib, valdecoxib, apparently showed similar
effects as well as serious skin reactions, this too was withdrawn.
At the time of writing, only celecoxib, parecoxib and etoricoxib
remain licensed in the UK (see below).
It seems that adverse cardiovascular pharmacology, especially
during prolonged use or ill patients with high cardiovascular risk,
may be a class effect of coxibs-indeed, this was anticipated in
a previous study (McAdam et al., 1999)-although the reason for
this is not entirely clear. It appears that while COX-1 was considered
to be the main source of the antiaggregating PGI2, some individuals
depend on COX-2 to synthesise this important regulator of
cardiovascular function. If this is disturbed, it may lead to an
 ANTI-INFLAMMATORY AND IMMUNOSUPPRESSANT DRUGS

Fenoprofen
Aspirin

Diclofenac
Sulindac
Diflunisal

Fig . 14.3 The ris k of
gastrointestina l complications
with va rious non-steroida l
Naproxen
anti-infla mmatory drugs. The risk lndometacin
is shown relative to ibuprofen Tolmetin
(relative risk = 1). Ibuprofen, given
tn a dose of 1200 mg daily, 1tself
Piroxicam
carries a risk double that of placebo. Ketoprofen
The lines represent 95% confidence Azapropazone
intervals. (From a figure by Hawkey,
2001; data derived from a
meta-analysis of 12 comparative 3 30
studies in Henry et a l., 1996.) Relative risk

increase in thrombotic epi!.odes including myocardial infarction
and \troke. Boers has concluded that, 'in patients who do not
require platelet inhibition, selective COX-2 inhibitors seem to be
a true advance and an attrJctive alternative to classic NSAIDs
combined with ga,troprotective l>trategies', but points out that
cardiologists and rheumatologists should routinely consider
ga~troprotection alongside cardioprotection. This episode has
proved a disappointing outcome for an apparently promising
thcmpcutic ~trategy, and at the time of writing it is not clear how
this area will develop-if at all-in the future. Some feel that the
reputation of these inhibitors has been irretrievably tarnished
(Melnikova, 2005), and that it i~ unlikely that the field will
recover: indeed. the cardiovascular side effects of the COX-I
inhibitor~ arc currently being re-examined in the light of the
COX-2 debate.
Other ideas have been proposed to explain the gasttic side
effects of NSAIDs. The administration of COX- I inhi bitors
themselves causes COX-2 induction and, on the basis of
experimental evidence, Wallace (2000) has argued that selective
inhibitors of either isoqmc will cause less gastric damage than
non-selective drugs.
SKIN REACTIONS
Rashes are common idiosyncratic unwanted effects of NSATDs,
particularly with mefenamic acid (I 0-15% frequency) and
sulindac (5-10~ frequency). They vary from mild erythematous,
urticarial and photo~ensitivity reactions to more serious and
potentially fatal disease~ including Stevens-Johnson syndrome
(1\hich is fortunately rare).
ADVERSE RENAL EFFECTS
Therapeutic dol:.cs of NSAJDs in healthy individuals pose little
threat to kidney function, but in susceptible patients they cause
acute renal insufficiency, which is reversible o n stopping the
drug (sec Ch. 53, p. 755. Table 53.1 ). T his occurs through the
inhibition of the bio!.ynlhe~is of those prostanoids (PG~ and PG1 2;
prostacyclin) involved in the maintenance of renal blood flow,
specifically in the PGE2-mediated compensatory vasodilatation
that occur.. in re~ponse to the action of nomdrenaline or angiotensin
II (~ee Ch. 24). Neonates and the elderly are especially at risk, as
arc patient~ with heart, liver or kidney disease (p. 745), or a
reduced circulating blood volume.
Chronic NSAID consumption. especially NSAID 'abuse', 1
can cause ana/gelic nephropathy characterised by chronic
nephritis and renal papillary necrosis (Ch. 24, p. 374).
P he nacetin, now withdrawn. was the main culprit; paracetarnol,
one of its major metabolites, is much less toxic. Regular usc of
prescribed doses of NSAlDs is less hazardous for the kidney in
this respect than is very heavy and prolonged use of over-the-
counter analgesics in a social context (e.g. Swiss workers
man ufacturing wa tches wou ld hand round analgesics in the same
way as shari ng sweets or cigarettes).
OTHER UNWANTED EFFECTS
Other, much less common. unwanted effects of NSAIDs include
CNS effects, bone marrow disturbances and liver disorders, the
last being more likely if there is already renal impairment. 2
Paracetamol overdose causes liver failure (see below). Approxi-
mately 5% of patients exposed to NSAIDs may experience
nspirin-sensitile nstlmw. The exact mechanism is unknown, but
1
So called becau.,c the a~ailabtlit} of NSAIDs in proprietary medicines over
the counter. often in combination with other substances. such as caffeine,
ha, tempted ~orne people to consume them. often in prodigious quantities,
for every conceivable malady.
2
An odd >ide effect of the NSAJD daclofenac came to light when a team of
>ciemi~t~ investigated the curiou'> decline in the population of several
species of vu ltures in the lndittn ~ubcontinent. Dead cattle fonn an
imponant part of the diet of the~c bird~. and some animals had been treated
wi th diclofenac.: for veterinary reasons. Apparently. residual amounts of the
drug in the carca>,e> proved un iquely toxic to this species. 233
 SECTION 2 C H EM I C A l M E D I AT 0 RS
inhibition of COX is implicated (see Ch. 23). Aspirin is the worst
offender, but there is cross-reaction with all other class members,
except possibly COX-2 inhibitors (see Ch. 23). All NSAIDs
(except COX-2 inhibitors) prevent platelet aggregation and
therefore may prolong bleeding. Again. aspirin is the main
problem in this regard (see below).
SOME IMPORTANT NSAIDS
Table 14.1 lim commonly used NSAIDs, and the clinical uses of
the NSAIDs are summarised in the clinical box. Here we discuss
only aspirin and paracetamol.
ASPIRIN
Aspirin (acetylsalicylic acid) was among the earliest drugs
synthesised, and is still one of the most commonly consumed
drugs worldwide. It is relatively insoluble, but its sodium and
calcium salts are readily soluble. A newer related drug is
dinunisal (Table 14. I ).
Aspirin in non-inflammatory conditions
A~pirin previously thought of as an old anti-inflammatory
worl,.horse- b now approaching the status of a wonder drug that
is of benefit not only in inflammation, but in an increasing
number of other conditions. These include:
cardiovascular disorders: through the antiplatelet action of
low-dose aspirin (Ch. 21)
colonic and rectal cancer: aspirin (and COX-2 inhibitors)
may reduce colorectal cancer-clinical trial results are
awaited
General unwanted effects of NSAIDs
Unwanted effects, many stemming from
inhibition of the constitutive housekeeping enzyme
cyclo-oxygenase (COX)-1 isoform of COX, are common,
particularly In the elderly, and include the following.
Dyspepsia, nausea and vomiting. Gastric damage
may occur in chronic users, with risk of haemorrhage.
The cause is suppression of gastroprotective
prostaglandins in the gastric mucosa.
Skin reactions. Mechanism unknown.
Reversible renal insufficiency. Seen mainly in
individuals with compromised renal function when the
compensatory prostaglandin E2-mediated
vasodilatation is inhibited.
'Analgesic-associated nephropathy'. This can occur
following long-continued high doses of NSAIDs (e.g.
paracetamol) and is often irreversible.
Liver disorders, bone marrow depression. Relatively
uncommon.
Bronchospasm. Seen in 'aspirin-sensitive' asthmatics.
234
Clinical uses of NSAIDs
For analgesia (e.g. headache, dysmenorrhoea,
backache, bony metastases, postoperative pain):
short-term use: aspirin, paracetamol or
ibuprofen
chronic pain: more potent, longer lasting drugs
(e.g. diflunisal, naproxen, piroxicam)
to reduce the requirement for narcotic analgesics
(e.g. ketorolac postoperatively).
For anti-inflammatory effects (e.g. rheumatoid
arthritis and related connective tissue disorders, gout
and soft tissue disorders).
Note that there is substantial individual variation In
c linical response to NSAIDs and considerable
unpredictable patient preference for one drug
rather than another.
To lower temperature (antipyretic): paracetamol.
Alzheimer's disease: again. clinical trial results are awaited
(Ch. 35)
radiation-induced diarrhoea.
Pharmacokinetic aspects
Aspirin, being a weak acid, is protonated in the acid environment
of the stomach, thus facilitating its passage across the muco,...
M ost absorption, however. occurs in the ileum. because of the
extensive surface area of the microvilli. Aspirin is rapid!}
(probably within 30 minutes) hydrolysed by esterases in the pla~m
and the tissues- particularly the liver-yielding salicylate. Thi'
compound itself has anti-inflammatory actions (indeed, it wa'
the ori ginal anti-intlammatory from which aspirin was derived);
the mechanism is not clearly understood, although it involve)
the COX system. Oral salicylate is no longer used for treating
intlammation, although it is a component of some topical
preparations. Approximately 25% of the salicylate is oxidised.
some is conjugated to give the glucuronide or sulfate before
excretion, and about 25% is excreted unchanged, the rate of
excretion being higher in alkaline urine (see Ch. 8).
The plasma half-life of aspirin will depend on the dose, but th(
duration of action is not directly related to the plasma half-life
because of the irreversible nature of the action of the acetylation
reaction by which it inhibits COX activity.
Unwanted effects
Salicylatcs may produce both local and systemic toxic effect\.
Aspirin shares many of the general unwanted effects of NSAJD,
outlined above. In addition, there are certain specific unwanted
effects that occur with aspirin and other salicylatcs.
Salicylism, characterised by tinnitus. vertigo, decreased
hearing, and sometimes also nausea and vomiting, occurs
with overdosage of any salicylate.
Reye's syndrome, a rare disorder of chi ldren that is
characterised by hepatic encephalopathy following an acute
 ANTI-INFLAMMATO RY AND IMMUNOSUPPRESSANT DRUGS
viral illness and a 20-40~ mortality. Since the withdrawal of
a!>pirin for paediatric u~e in the U K , the incidence of Reye's
syndrome has fallen dramatically.
Salicylate poisoning is a result of disturbances of the
acid-base and the electrolyrc balance that may be seen in patients
rreated with high do~es of salicylate-containing drugs and in
auempted suicide~. These drug'> can uncouple oxidative
phosphorylarion (mainly in skclewl muscle). leading to increased
o:~.ygen consumption and thus increased production of carbon
dioxide. Thi!. stimulates respiration. which is also stimulated by
a direcr action of rhe drugs on the respiratory centre. T he
resulting hypervenri larion causes a respiratory alkalosis that is
normally compensated by renal mechanisms involv ing increased
bicarbonate excretion. Larger doses can cause a depression of the
respiraLOry centre. w hich leads eventually to retention of carbon
dioxide and thu!. an increase in plasma carbon dioxide. Because
this is superi mposed on a reduction in plasma bicarbonate, an
uncompensated respiratory acidosis w ill occur. This may be
complicated by a mewlmlic acidosis, w hich resulls from the
accumulation of metabolites of pyruvic, lactic and acetoacetic
acids (an indirect consequence of interference with carbohydrate
metabolism). The acid load associated with the salicylate itself is
quantitatively trivial. Hyperpyrexia secondary to the increased
metabolic rare is abo likely to be present, and dehydration may
follow repeated \Omiting.
In the CNS, initial stimulation with excitemem is followed
eventually by coma and respiratory depression. Disturbances of
haemostasis can also occur. mainly as a result of depressed
platelet aggregation. Salicylate poisoning is a medical emergency:
it i~ more common. and more &erious. in children than i n adults.
The acid-ba~e disturbance seen in children is usually a metabol ic
acidosis. whereas thnt in adults b a respiratory alkalosis.
Some important interactions with other drugs
Aspirin causes a polentially h azardou~> increase in the effect of
war farin , partl y by displacing it from plasma proteins (Ch. 52)
and part ly because its effec t on platel ets interferes w ith
haemosratic mechanisms (see Ch. 2 1). Aspirin also interferes
wi th the effecr of uricosuric agents such as pr oben ecid and
sulfinpy razone, and because low doses of aspirin may, on their
own, reduce urare excretion, aspirin should not be used in gout.
PARACETAMOL
Paraceramol (called acetaminophen in the USA) is one of the
most commonly used non-narcotic analgesic-antipyretic agents,
and is a component of many over-the-counter proprietary prep-
ararion'>. I n ~;ome ways. rhe drug constitutes an anomaly: while
it ha-. excellent analgesic and antipyretic activity. which can be
traced 10 inhibition of C S proMaglandin synthesis. it has weak
anti-inflammatory activity (except i n some speci fic instances)
and does not share the ga.stric or platelet side effects of the other
NSATDs. For this reason, paracetamol is sometimes not classified
a~ an NSAID at all.
A potemial solu.tion to this puzzle was supplied by the obser-
vation thar a further COX isoform, COX-3 (an alternate spl ice
Aspirin
Aspirin (acetylsalicylic acid) is the oldest non-
steroid al anti-inflammatory drug. It acts by irreversibly
inactivating both cyc lo-oxygenase (COX)-1 and COX-2.
In addition to its anti-inflammatory actions, aspirin
inhibits platelet aggregation, and its main clinical
rmportance now is in the therapy of myocardial
infarction.
It is given orally and is rapidly absorbed; 75% is
metabolised in the liver.
Elimination follows first- order kinetics w ith low doses
(half- life 4 hours), and saturation kinetics with high
doses (half-life over 15 hours).
Unwanted effects:
w ith therapeutic doses: some gastric bleed ing
(usually slight and asympt omatic) is common
with large doses: dizziness, deafness and tinnitus
('salicylism'); compensated respiratory alkalosis
may occur
with toxic doses (e.g. from self-poisoning):
uncompensated respiratory acidosis with metabolic
acidosis may occur, particularly in children
aspirin has been linked with a postviral
encephalitis (Reye's syndrome) in children.
If g1ven concomitantly w ith warfarin, aspirin can
cause a potentially hazardous increase in the risk
of bleeding.
product of COX- I ) existed predominantl y in the CNS of some
species, and that paracetamol. as well as some orher drugs with
similar properti es (e.g. antipyr ine and dipyrone), were selecti ve
inhibitors of this enzyme (Chandrasekh aran et al. 2002). T his
elegant idea is still under inves tigation. Alternati ve explanations
for the ability of paracetamol selectively to inhibit COX in the
CNS alone have been provided by Ouellet & Percival (2001) and
Boutaud et al. (2002).
Pharmacokinetic aspects
Paracctamol i'> given orally and is well absorbed, with peak
plasma concentrations reached in 30-60 minutes. T he plasma
half-life of therapeutic doses is 2-4 hours. but with toxic doses it
may be c~tended to 4-8 hours. Paracetarnol is inactivated in rhe
liver, bl!ing conjugated to gi'e the glucuronide or sulfate.
Unwanted eHects
Wirh therapeutic dosel>. :.ide effects are few and uncommon,
ahhough allergic skin reactions sometimes occur. It is possible
that regular intake of large doses over a long period may cause
kidney damage.
Toxic dose~ ( 10- 15 graml>) cause potentially fatal hepatotoxicity.
T his occurs w hen the liver enzymes catalysing the normal conj u-
gation reaction!. arc saturated, causing the drug to be metabolised
instead by mixed funcri on ox idases. The resulting toxic
235
 SECTION 2 . CHEMICAL MEDIATORS
metabolite, N-acetyl-p-benzoquinone imine, is inactivated by
conjugation with glutathione, but when glutathione is depleted
the toxic intermediate accumulates and reacts with nucleophilic
constituents in the cell. This causes necrosis in the liver and also
in the kidney tubules.
The initial symptoms of acute paracetamol poisoning are
nausea and vomiting, the hepatotoxicity being a delayed mani-
fe tat ion that occurs 24-48 hours later. Further details of the toxic
effects of paracctamol are given in Chapter 53. If the patient is
seen sufficiently soon after ingestion, the liver damage can be
prevented by giving agents that increase glutathione formation in
the liver (acetylcysteine intravenously, or methionine orally). If
more than 12 hours have passed since the ingestion of a large
dose, the antidotes, which themselves can cause adverse effects
(nausea, allergic reactions}, are less likely to be useful. Regrettably,
ingestion of l arge amounts of paracetamol is a common method
of suicide.
AGENTS SELECTIVE FOR CYCLO-
OXYGENASE-2
Three coxibs, agents selective for COX-2, are currently available
for clinical usc in the UK: others may be available elsewhere.
Several have been withdrawn. and the overall licensing situation
is volatile. Current advice restricts the usc of coxibs to patients
for whom treatment with conventional SAIDs would pose a
high probability of serious gastrointestinal side effects, and coxibs
are prescribed only after an assessment of cardiovascular risk.
There is still a pos~ibility that gastrointestinal disturbances will
occur with these agents, perhaps because COX-2 has been
implicated in the healing of pre-existing ulcers. so inhibition
could delay recovery from earlier lesions.
Paracetamol has potent analgesic and
antipyretic actions but rather weaker anti-inflammatory
effects than other NSAIDs. It may act through inhibition
of a central nervous system- specific cyclo-oxygenase
(COX) isoform such as COX-3, although this is not yet
conclusive.
It is given orally and metabolised in the liver (half-life
2-4 hours).
Toxic doses cause nausea and vomiting, then, after
24-48 hours, potentially fatal liver damage by
saturating normal conjugating enzymes, causing the
drug to be converted by mixed function oxidases to
N-acetyl-p-benzoquinone imine. If not inactivated by
conjugation with glutathione, this compound reacts
with cell proteins and kills the cell.
Agents that increase g lutathione (intravenous
acetylcysteine or o ral methionine) can prevent liver
damage if given early.
236
CELECOXIB AND ETORICOXIB
Celecoxib and etoricoxib arc licensed in the UK for symptomatic
relief in the treatment of osteoarthritis and rheumatoid arthriti\.
Both are administered orally.
Pharmacokinetic properties
Both dnag have similar pharmacokinetic profiles. being 11ell
absorbed with peak plasma concentrations being achieved within
1- 3 hours. They are extensively (> 99%) metabolised in the
liver, and pla!>ma protein binding is high (> 90%).
Unwanted effects
Common unwanted effects may include headache, dizziness. sJ..m
rashes, and peripheral oedema caused by fluid retention. As with
all COX-2 inhibitors, consideration should be given to the possibility
of seri ous adverse cardiovascular events. Because of the potential
role of COX-2 in the healing of ulcers, the drugs should be
avoided. if possible, by patients with pre-existing disease.
PARECOXIB
Parecoxib is a prodrug of valdecoxib. The latter drug has no11
been withdrawn. but parecoxib is licensed for the shon-tenn
treatment of postoperative pain. It is given by intravenou~ or
intramu<;cular injection.
Pharmacokinetic properties
Following injection, parecoxib is rapidly and virtually completd)
(> 95%) converted into the active valdecoxib by enzymau.
hydrolysi!> in the liver. Maximum blood levels are achieved withm
approximately 30-60 minutes, depending on the route of admini,.
tration. Plasma protein binding is high. Elimination of the active
metabolite. valdecoxib, is through hepatic metabolism. Multiple
pathways arc utilised. About 70% of the total dose is excreted in
the urine, with an elimination half-l ife of approximately 8 hours.
Clinical uses of histamine H 1 receptor
antagonists
Allergic reactions (see Ch. 13):
non-sedating drugs (e.g. fexofenadine, cetirizine)
are used for allergic rhinitis (hay fever) and urticaria
topical preparations may be useful for insect bites
injectable formulations are useful as an adjunct to
adrenaline for severe drug hypersensitivities and
emergency treatment of anaphylaxis (see Ch. 23).
As antiemetics:
prevention of motion sickness
- other causes of nausea, especially labyrinthine
disorders.
For sedation:
some H, receptor antagonists (e.g. promethazine;
see Table 14.4) are fairly strong sedatives.
 ANTI-INFLAMMATORY AND IMMUNOSUPPRESSANT DRUGS

Unwanted eHects H1 RECEPTOR ANTAGONISTS (ANTIHISTAMINES)

The risk of precipitating cardi ovascular events should be
c Details of some characteristic H 1 receptor antagonists are shown
carefully considered prior to treatment with any COX-2 inhibitor.
Skin reactions, some of them serious, have been reponed with
the active metabolite valdecoxib, and patients shou ld be
monitored carefully. The drug should also be given with caution
to patients wilh impaired renal function, and renal failu re has
been reported in connecti on with this drug. Postoperative
anaemia may also occur.
ANTAGONISTS OF HISTAMINE
There are three groups: H 1, H 2 and H 3 receptor antagonists. The
fi rst group was introduced first by Bovet and his colleagues in the
1930s, at a time when histamine receptors had not been classified
(indeed, this was possible only because these agents were available).
For historical reasons then, the generi c term amihistamine
conventionally refers only to the 11 1 receptor antagonists that
affect various inflan1matory and allergic mechanisms, and it is
these drugs that are discussed in this section. The main clinical
effect of H 2 receptor antagonists is inhibition of gastri c secretion,
and this is discussed in Chaptcr25. Several H 3 receptor agonists
and antagonists arc now available, and the potential for their
clinical use (mainly in CNS conditions) is being explored.
in Table 14.4.
Pharmacological actions
Many of the pharmacological actions of the H 1 receptor antagonists
follow from the actions of histamine outlined in Chapter 13. In
vitro, for example, they decrease histamine-mediated contraction
of the smooth muscle of the bronchi, the intestine and the uterus.
They inhibit histan1ine-induced increases in vascular permeability
and bronchospasm in the guinea pig in vivo, but are unfonunately
of little value in allergic bronchospasm in humans. The clinical
uses of H 1 receptor antagonists are summarised in the clinical box.
Some H 1 receptor antagonists have pronounced effects in the
CNS. These are usually listed as 'side effects', but they may be
more clinically useful than the peripheral H 1 antagonist effects.
Some are fairly strong sedatives and may be used for thi s acti on
(e.g. di phenhydramine: sec Table 14.4). Several are antiemetic
and are used to prevent motion sickness (e.g. prom ethazine; !>ee
Ch. 25).
M any H 1 receptor antagonists (e.g. diphenhydramine) also
show significant antimuscarinic effects, although their affinity is
much lower for muscarinic than for histamine receptors. When
selective H 1 receptor antagonism is desired, untrammelled by

T ble 14.4 Comparison of some commonly used H1 receptor antagonists

Common uses

Type Drug H u R AE s Comments

Non-sedating Acrivastine
Cetirizine
Desloratidlne Metabolite of loratidlne
Fexofenadine Metabolite of terfenadine
Levocetrizine Isomer of cetrizine
Loratidine
Mizolastine May cause QT interval prolongatiOn

Sedating Alimemazine Used for premedication

Brompheniramine
Chlorpheniramine
Clemastine
Cyproheptadine Used also for migraine
Diphenhydramine Mainly used as a mild hypnotic
Doxylamine Mainly used as an Ingredient of proprietary decongestant and
other medicines
Hydroxyzine Also used to treat anxiety
Promethazine Also used for motion sickness
Triprolidine Mainly used as an ingredient of proprietary decongestant and
other medicines

AE, allergic emergency (e.g. anaphylactic shock); H, hay fever; A, rhin11is; S, sedation; U, urticaria and/or pruritis.
(From British Medical Association and Royal Pharmaceutical Society of Great Britain 2005 British National Formulary. BMA and RPSGB,
London.)
237
 SECTION2 .CHEMICAL MEDIATORS
CNS effect~. newer drugs-such as Cetirizine (Table 14.4)
which do not penetrate the blood-brain barrier-may be used.
Some norH.cdating a ntihistamines such as terfenadine, (now
withdrawn) can cause serious cardiac dysrhyrhmias (p. 117).
The risJ,. is extremely low but is increased if taken witb grapefruit
juice or agent'> that inhibit cytochrome P450 in the liver
(see Chs 8 and 52). Fexofenadine. the non-toxic, pharma-
cologically active metabolite of terfenadine, is now available
(see p. 117). Other, newer drugs that lack sedative action are
loratadine and mizolastine.
Several H 1 receptor antagonists show weak blockade at a 1
adrenoceptors (an example is the phenothiazine promethazine).
Cyprohepta dine is a 5-hydroxytryptamine antagonist as well as
an H 1 receptor antagonist.
Pharmacokinetic aspects
Most l 11 receptor antagonists are given orally, are well absorbed,
reach their peak effect in l-2 hours and are effective for 3-6 hours,
although there are exceptions. Most appear to be widely
distributed throughout the body, but some do not penetrate the
blood-brain barrier, for example the non-sedative drugs mentioned
above (see Table 14.4). They are metabolised in the liver and
excreted in the urine.
Unwanted eHects
What is defined as 'unwanted' will depend to a certain extent on
the purpose for which a drug is used. When used to treat
allergies. for example, the sedative C S effects arc generally
unwanted, but there arc other occasions (e.g. in small children
approaching bedtime) when such effects are more desirable. Even
under these circumstances, other CNS effects, such as dizziness,
tinnitus and fatigue. are unwelcome.
The peripheral anti muscari nic actions are always unwanted.
The commonest of these is dryness of the mouth. but blurred
visio n, constipation and retention of urine can also occur.
Unwanted effects that arc not mechanism-based are also seen;
gastrointestinal dis turbances are fairly common, while allergic
dermatitis can foll ow topical application.
DRUGS USED IN GOUT
Gout is a metabolic disease in which plasma urate concentration
is rai!>Cd because of overproduction (sometimes linked to indulgence
in alcoholic beverages, especially beer. or purine-rich foods such
as offal, or increased cell turnover as in haematological
malignancies, particularly when treated with cytotoxic drugs;
Ch. 51) or impaired excretion of uric acid. It is characterised by
very painful intermittent attacks of acute arthritis produced by
the deposition of crystals of sodium urate (a product of purine
metabolism) in the synovial tissue of joints and elsewhere. An
inflammatory response is evoked. involving activation of the
kinin, complement and plasmin systems (see Cb. 13 and Fig. 13. 1),
generation of lipoxygenase products s uch as leukotriene B4
(Fig. 13.5), and local accumulation of neutrophil granulocytes.
These engulf the crystals by phagocytosis, releasing tissue-
238 damaging toxic oxygen metabolites and subsequently causing
lysis of the cells with release of proteolytic enzymes. Urate
crystals also induce the production of IL- l and possibly other
cytokincs too.
Drugs used to treat gout may act in the following ways:
by inhibiting uric acid synthesis: allopurinol (this is the
main prophylactic drug)
by increa-,ing uric acid excretion (uricosuric agents:
probenecid, sulfinpyrazone)
by inhibiting leucocyte migration into the joint (colchicine)
by a general anti-inflammatory and analgesic effect (NSAfD~).
ALLOPURINOL
Allo purinol is an analogue of hypoxanthine and reduces the
synthesis of uric acid by competitive inhibition of xamhi11e
oxidase (Fig. 14.4). Some inhibition of de novo purine synthesis
also occurs. Allopurinol is converted to alloxanthine by xanthine
oxidase, and this metaboUtc, which remains in the tissue for a
considerable time, is an effective non-competitive inhibitor of the
enzyme. The pharmacological action of allopurinol is largely due
to alloxanthinc.
Allopurinol reduces the concentratio n of the relatively
insoluble urates and uric acid in tissues. plasma and urine, while
increasing the concentration of their more soluble precursors, the
xanthines and hypoxantbines. The deposition of urate crystals rn
tissues (tophi) is reversed, and the formation of renal stones .,
inhibited. Allopurinol is the drug of choice in the long-tenn
treatment of gout, but it is ineffective in the treatment of an acute
attack and may even exacerbate the inflammation.
Pharmacokinetic aspects
Allopurinol is given o rally and is well absorbed in the
gastrointestinal tract. Its half-life is 2-3 hours; it is converted to
alloxanthine (Fig. 14.4), which has a half-Life of 18-30 hours.
Allo purino l
, Xanthine oxidase / l
Hypoxanthine
Xanthine oxidase
Alloxanthine Xanthine
' X'"thtoe """''" ;l
( Uric acid )
l
Fig. 14.4 Inhibition of uric acid synthesis by allopurinol.
(See text for details.)
 ANTI-INFLAMMATORY AND IMMUNOSUPPRESSANT DRUGS
Renal excretio n is a balance between glomerular filtration and
probenec id-sensitive tubular reabsorpti on.
Unwanted eHects
These a re few. Gastro intestinal disturbances and allerg ic
reactions (mainly ra~hes) can occur but usually disappear if the
drug is stopped. Pote ntia ll y fatal skin diseases (Stevens- Johnson
syndrome and toxic epidermal necrolysis-a horrible disorde r
where skin peels away in sheets as if scalded) are rare but
devastating. Rcchallc nge is never justified. Acute attacks of gout
occur commonly during the early stages of therapy (possibly as a
result of physicoche mical changes in the surfaces of urate crystals
as these start to redissolve), so treatme nt is neve r initiated during
an acute attack and is usually initiated accompanied by an NSATD.
Drug interactions
Allopurino l inc reases the effect of me r c a pto purine, an
antimetabolite used in cancer che motherapy (Ch. 51), and also
that of azathioprine (an immunosuppressant used to prevent trans-
plant rejection; see below), which is metabolised to mercaptopurine.
Allopurino l also e nha nces the e ffect o f another anticancer drug,
cyclop hospha m id e (Ch. 5 1). The effect of warfarin is increased
because its metabo lism i!> inhibited.
URICOSURIC AGENTS
Uricosuric drugs increase uric acid excretio n by a direct action
on the renal tubule. Exa mples are probenecid and sulfinpyrazone.
They remain useful as prophylaxis for patients with severe
recurrent gout who have severe adverse reactions to allo purino l.
Sulfinpyratone has NS AID activity; treatment wi th uricosuri c
drugs is initiateu with a n SATD, as for allopurinol.
COLCHICINE
Colchic ine is an alkaloid extrac ted from the autumn crocus. It
has a specific e ffect in gouty arthritis and can be used both to
preve nt and to relieve acute attacks. It prevents migration of
ncutro phils into the j oint, appare ntly by binding: ,to tubulin,
resulting in the de po lymeris atio n o f the microtubules and
reduced cell mo tility. Co lchic ine-treated neutrophils develop a
'drunke n walk'. Colchic ine may also preve nt the productio n of a
putative infla mmatory g lycoprotein by neutropruls that have
phagocytosed urate crystal s, and o ther mec hanisms may also be
important in bringing about its effects.
Pharmacokinetic aspects
Colchicine is g iven o ra lly, is well absorbed. and reaches peak
concentrations in about I hour. It is excre ted partly in the
gastrointestinal tract and partly in the urine.
Unwanted eHects
The acute unwanted effects o f colchicine are largely gastrointestinal:
nausea , vomiting and abdominal pain. Seve re diarrboea3 may be
3Because the therapeutic margin is so small, i t used to be said by
rheummologistS that ' patients mu&t run before they can walk' .
a proble m, and with large doses may be associated with
gal>tro intestinal haemo rrhage and kidney damage. Pro lo nged
treatme nt can, rarely. cau~e blood dyscrasias. rashes or periphera l
ne uropathy.
ANTIRHEUMATOID DRUGS
Arthritic disease is o ne o f the commonest c hronic inflammatory
conditio ns in developed countries, and rheumatoid arthritis is a
common cause o r disability. One in three patients with rheumatoid
arthriti!> is like ly to become severely disabled. The joint changes,
which probably re present an autoimmune reaction, comprise
inflammatio n, pro liferation of the synovium, and e rosion o f
carti lage and bone. The primary inflammatory cytokines, IL- l
and TNF-a , have a major role in pathogenesis (Ch. 13).
The drugs most frequently used in therapy are the DMARDs
and the NSA!Ds. Unlike the NSAJDs, which reduce the symptoms,
but not the progress, of t~e disea&e, the former g roup may halt o r
reverse the underlying disease itself. Such claims may be more
optimi ~ti c than real, but nevertheless these drugs are useful in the
treatment o f discrete groups o f patients. So me immunosuppressants
(e.g. azathioprine, ciclospori n; see below and Ch. 51 ) are a lso
used, as are the g lucoco r ticoids (covered in Ch. 28). Newer
agents, with more specific actio ns, arc the anticytokine drugs.
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS
The term DMARD is a latex concept that c an be stretched to
cover a hete ro logous g roup of agent with unrelated che mical
stntctures and d iffere nt mechanisms of action. Included in th i!>
category are metho trexate. s ulfasalazine, gold com pounds.
penicillamine a nd chloro quine (see Table 14.5).
The antirhe umatoid action of most of these agents was usually
discovered through a mixture of serendipity and clinical intuition.
When the dntgs we re introduced, nothing was known about the ir
mechanism of action in these conditions, and decades of in vitro
experiments have generally resulted in further bewildennent rather
than understanding. DMARDs generally improve symptoms and
can reduce disease activity in rheumato id arthritis, as measured
by reductio n in number o f swo llen and tender joints, pain score,
disability score, artic ular index on radio logy. and serum concen-
Drugs used In gout
To treat an acute attack:
non-steroidal anti-inflammatory drugs have anti-
inflammatory action and reduce pain
colchicine reduces leucocyte migration into joints.
For prophylaxis:
- allopurinol inhibits uric acid synthesis
- probenecid increases uric acid excretion.
Drugs used for prophylaxis must not be started until
the acute attack has resolved.
239
 SECTION 2 . CHEMICAL MEDIATORS

Table 14.5 Comparison of some common 'disease-modifying' and immunosuppressive drugs

Indications

Drug Type RA JRA SLE Severity Comments

Sodium aurothiomalate Gold complex

Auranofin Gold complex

Penicillamine Penicillin metabolite Severe

Chloroquine Antimalarial Moderate

Hydroxychloroquine Antimalarial Moderate Useful for some skin disorders

sulfate

Mepacrine Antimalarial Moderate

Methotrexate lmmunomodulator Moderate to severe Also used in Crohn's disease, psoriasis

and cancer treatment

Azathioprine lmmunomodulator Also used in transplant rejection

Ciclosporin lmmunomodulator Severe Used when other therapies fail; some skin
diseases; transplant rejection

Cyclophosphamide lmmunomodulator Severe

Leflunamide lmmunomodulator Moderate to severe Also used In psoriatic arthritis

Adaiimumab Cytokine inhibitor Moderate to severe Used when other drugs inadequate; often
combined with methotrexate

Anakinra Cytokine inhibitor Moderate to severe Used when other drugs inadequate; often
combined with methotrexate

Etanercept Cytokine inhibitor Used when other drugs inadequate; often

combined with methotrexate

lnfliximab Cytokine inhibitor Used when other drugs inadequate; often

combined with methotrexate; used in
psoriasis

Sulfasalazine NSAID Also used in ulcerative colitis

JRA, juvenile rheumatoid arthritis; NSAID, non-steroidal anti-inflammatory drug; RA, rheumatoid arthritis; SLE, systemic lupus
erythematosus.
(From Brit ish Medical Association and Royal Pharmaceutical Society of Great Britain 2005 British National Formulary. BMA and RPSGB,
London.)

tration of acute-phase proteins and of rheumatoid factor (an
immunoglobulin [lg] M antibody against host TgG). However,
whether they actually halt the long-term progress of the disease
is hotly debated.
The DMARDs were often referred to as second-line drugs,
with the implication that they are only resorted to when other
therapies (e.g. NSAIDs) failed. Today, however, DMARD therapy
may be initiated as soon as a definite diagnos is has been reached.
Their clinical effects are usually slow (months) in onset, and it is
usual to provide NSAID 'cover' during this induction phase. If
240 therapy is successful (and the success rate is not invariably hig h),
concomitant NSAID (or glucocorticoid) therapy can generally be
dramatically reduced. Some DMARDs have a place in the
treatment of other chronic inflammatory diseases, whereas others
(e.g. penicillamine) are not thought to have a general anti-
inflammatory action. Putative mechanis ms of action of
DMARDs are reviewed by Bondeson (1997).
SULFASALAZINE
Sulfasalazine, a common first-choice DMARD in the UK,
produces remission in active rheumatoid arthritis and is also used
 ANTI-INFLAMMATORY AND IMMUNOSUPPRESSANT DRUGS
for chronic inflammatory bowel disease. It may act by scavenging
the toxic oxygen metabolites produced by neutrophils. The drug
is a combination of sulfonamide (sulfapyridine) with a salicylate.
It is split into its component parts by bacteria in the colon, the 5-
aminosalicylic acid being the putative radical scavenger. Tt is
poorly absorbed after oral administration. The common side effect~
are gastrointe tina! disturbances, malaise and headache. Skin
reactions and leucopenia can occur but are reversible on stopping
the drug. The absorption of folic acid is sometimes impaired; this
can be countered by giving folic acid supplemenrs. A reversible
decrease in sperm count has also been reported. As with other
sulfonamides, blood dyscrasial> and anaphylactic-type reactions
may occur in a few patients.
GOLD COMPOUNDS
Gold is ad ministered in the form of organic complexes:
sodium aurothiomalatc and auraoofin are the two most
common preparations. The effect of gold compounds develops
~lowly, the maximum action occurring after 3-4 months. Pain
and joint swelling subside, and the progression of bone and joint
damage diminishes. The mechanism of action is not clear, but
auranofin, although not au rothiomaJate, inhibits the induction of
TL-1 and TN F-a.
Phormocokinetic aspects
Sodium aurothiomalate is given by deep intramuscular injection;
auranofin is given orally. Peak plasma concentrations of the
former dmg are reached in 2- 6 hours. The compotmds gradually
become concentrated in the tissues, not only in synovial cells in
joints but also in liver cells. kidney tubules. the adrenal cortex
and macrophage~ throughout the body. The gold complexes
remain in the tissues for some lime after treatment is stopped.
Excretion is mostly renal, but some is eliminated in the
gastrointestinal tract. The half-life is 7 days initially but increases
with treatment, so the drug is usually given first at weekly, then
at monthl y intervals.
Unwonted eHects
Unwanted effects with aurothiomalate are seen in about one-third
of patients treated, and serious toxic effects in about! patient in I 0.
Unwanted effects with auranofin are less frequent and less
severe. Important unwanted effects include skin rashes (which
can be severe), mouth ulcers, non-specific flu-like symptoms,
proteinuria, thromboctyopenia and blood dyscrasias. Enceph-
alopathy, peripheral neuropathy and hepatitis can occur. If therapy
is stopped when the early symptoms appear, the incidence of
serious toxic effects is relatively low.
PENICILLAMINE
Penicillamine is dimethylcysteine: it is one of the substances
produced by hydrolysis of penicillin and appears in the urine
after treatment with that drug. The D isomer is used in the
therapy of rheumatoid disease. About 75% of patients with
rheumatoid arthritis respond to penicillan1ine. ln responders.
therapeutic effects are seen within weeks but do not reach a
plateau for several months. Penicillamine is thought to modify
rheumatoid disease partly by decreasing the immune response,
TL-1 generation, and/or partly by an effect on collagen synthesis,
preventing the maturation of newly synthesised collagen.
However, the precise mechanism of action is still a matter of
conjecture. The drug has a highly reactive thiol group and also
has metal-chelating properties, which are put to good use in the
treatment of Wilson's disease (pathological copper deposition
causing neurodegencration) or heavy metal poisoning.
Phormocokinetic aspects
Penici II ami ne ilo given orally, and only half the dose administered
is absorbed. It reaches peak plasma concentrations in 1-2 hours
and is excreted in the urine. Dosage is s tarted low and increased
only graduall y to minimise unwanted effects.
Unwonted eHects
Unwanted effects occur in about 40% of patients treated and
may necessitate cessation of therapy. Anorexia, fever, nausea and
vomiting, and disturbances of taste (the last related to the chelation
of zinc) are seen but often disappear with continued treatment.
Proteinuria occurs in 20% of patients. Rashes and stomatitis are
the most common unwanted effects and may resolve if the
dosage is lowered, as may dose-related thrombocytopenia. Other
bone marrow disorders (leucopenia, aplastic anaemia) are
absolute indications for stopping therapy, as are the various
autoimm une conditions (e.g. thyroiditis, myasthenia gravis) that
sometimes supervene. Because penicillamine is a metal chelator,
it should not be given with gold compounds.
HYDROXYCHLOROQUINE
Hydroxychloroquine and chloroquine are 4-aminoquinoline
drugs used mainly in the prevention and treatment of malaria
(Ch. 49), but they arc also used as DMARDs. Chloroquine is
usuall y reserved for cases where other treatments have failed.
They are also used in patients with systemic or discoid lupus
erythematosus, but are contraindicated in patients with psoriatic
arthropathy because they make the skin lesions worse. Mepacrine
is also sometimes used in discoid lupus. Pharmacological
effects do not appear until a momh or more after the drug is
started, and only about half the patients treated respond. The
pharmacokinetic aspects and unwanted effects of chloroquine
are dealt with in Chapter 49; screening for ocular toxicity is
particularly important.
METHOTREXATE
Methotrexate is a folic acid antagonist with cytotoxic and
immunosuppressant activity (see below and Chs 45 and 51) and
potent antirheumatoid action. It is commonly a first-choice
DMARD. Tt has a more rapid onset of action than other
DMARDs, but treatment has to be closely monitored because of
blood dyscrasia~ (some fatal) and liver cirrhosis. More than 50%
of patients continue with it for 5 years or more, whereas about
half stop other DMARDs within 2 years because of unwanted
effects and lack of efficacy. 241
 SECTION 2 C H E M I C A L M E D I AT 0 RS
Antlrheumatold drugs
These comprise non-steroidal anti-inflammatory
drugs (see key points box on p. 234), disease-modifying
antirheumatic drugs (DMARDs) and anticytokine agents.
DMARDs:
include sulfasalazine, m ethotrexate (a folate
antagonist), gold compounds, chloroquine
(an antimalarial), penicillamine and azathioprine
(an immunosuppressant)
are slow-acting drugs and can improve symptoms
and reduce the inflammatory process
retard progress of the disease but do not halt it
entirely.
Anticytokine agents (e.g. infliximab, etanercept) are
used In Crohn's disease {Ch. 25, p. 396) and psoriatic
arthropathy, as well as in rheumatoid arthritis.
IMMUNOSUPPRESSANT DRUGS
Immunosuppressants are used in the therapy of autoimmune
disea~e and to prevent and/or treat transplant rejection. Because
they impair immune responses. they carry the hazard of a decreased
respon-.e to infections and may facilitate the emergence of malignant
cell lines. However. the relationship between these adverse effects
and potenc) in preventing graft rejection varies with different
drugs. The clinical u!.e of immunosuppressants is summarised in
the clinical box.
Most of thel.e drug!> act during the induction phase of the
immunological responl>c (:.cc Ch. 13), reducing lymphocyte
Clinical uses of Immunosuppressants
Immunosuppressants are used:
to suppress rejection of transplanted organs and
tissues (kidneys, bone marrow, heart, liver, etc.)
to suppress graft-versus-host disease in bone
marrow transplantation
to treat conditions with an autoimmune
component in their pathogenesis, including
idiopathic thrombocytopenic purpura, some
forms of haemolytic anaemia, some forms of
glomerulonephritis, myasthenia gravis , systemic
lupus erythematosus, rheumatoid arthritis,
psoriasis, and ulcerative colitis.
Therapy of autoimmune disease often involves a
combination of glucocorticoid and cytotoxic agents.
For transplantation of organs or bone marrow,
ciclosporin is usually combined with a glucocorticoid,
a cytotoxic drug or an antilymphocyte immunoglobulin.
242
proliferation, although others also inhibit aspects of the effector
phase. They can be roughly characterised as:
drugs that inhibit lL-2 production or action (e.g. ciclosporin.
tacrolim us)
drug!. that inhibit cytokine gene expression (e.g. the
corticos teroids)
drugs that inhibit purine or pyrimidine synthesi:. (e.g.
a7athioprine, m ycophenolate m ofetil)
drugs that block the T-cell surface molecules involved in
signalling (e.g. monoclonal antibody-based agents).
CICLOSPORIN
Ciclosporin is a compound first found in fungus. It consists of
a cyclic peptide of II ami no acid residues ( including some not
found in animals) with potent immu nosuppressive activity but no
ciTcct on the acute innammatory reaction per se. lts unusual activity,
wh ic h, unl ike most earlier immunosuppressants, docs not involve
cytotoxicity. wa~ discovered in 1972 and was crucial for the devel-
opment of transplant ~urgery (for a detailed review. see Borel
ct al., 1996). The drug has numerous actions on several cell type>,
in general. the actions of relevance to immunosuppression arc:
decrea<,ed clonal proliferation ofT cells. primarily by
inhibiting lL-2 :.ynthe!.is and possibly also by decreac;ing
cxprcs.,ion of lL-2 receptor<>
reduced induction. and clonal proliferation. of cytotoxic T
cells from CDS+ precur.or T cells
reduced function of the effector T celJs that arc respon~iblc
for cell-mediated responses (e.g. decreased delayed-type
hypersen~itivity)
some reduction ofT cell-dependent B-cell responses.
The main action is a relatively selective inhibitory effect on lL-2
gene tran~cription, although a ~imi lar effect on irlterfcron (IFN)-
y and lL-3 has also been reported. Nommlly, interaction of
antigen with o T-he lper (Th) cell receptor results in increased
intrace ll ular Ca 2 (Chs 2 a nd 13). which in turn stimulates a
phosphata!>e, calcineurin: this ac tivates various transcription
factors that initiate lL-2 transcription. Ciclosporin binds 10
cyclophi/in, a cytosolic protein member of the immunophilinJ Ia
group of proteins that act as intracellular receptors for \uch
drug~). The drug- immunophilin complex binds to and inhibi~>
calcincurin. thereby preventing activation of Th cells and
production of IL-2 (Ch. 13).
Pharmacokinetic aspects
Ciclosporin is poorly ab~orbed by mouth but can be given or.lll}
in a more readil) absorbed fonnulation. or given by intravcnou'
infusion. After oral administration. peak plasma concentration'
are usually attained in about ~ hours. The plasma half-life i'
approximately 24 hours. Metabolism occur~ in the liver, anJ
most of the metabolites arc excreted in the bile. Ciclosporin
accumulates in most tissues at concentrations three to four times
that seen in the plasma. Some of the drug remain~ in
lymphomyeloicl tissue and remains in fat depots for some time
after administratio n has stopped.
 ANTI-INFLAMMATORY AND IMMUNOSUPPRESSANT DRUGS

Unwanted eHects AZATHIOPRINE

The commonest and most ~erious unwanted effect of ciclosporin
is nephrotoxicity, which is thought to be unconnected with
calcineurin inhibition. It may be a limiting factor in the use of
the drug in some patients (~ec also Ch. 52). Hepatotoxicity and
hypertension can also occur. Less important unwanted efTects
include anorexia, lethargy. hin.utism. tremor. paraesthesia (tingling
sensation). gum hypertrophy (especially when coprescribed
with calcium antagoniMs for byperteru.ion: Cb. 18) and gastro-
intestinal diMurbances. Ciclosporin bas no depressant effects on
the bone marrow.
TACROLIMUS
A7athioprine interferes with purine synthesis and is cytotoxic. It
is widely U'>ed for immunosuppression, particularly for control of
amoimmune diseases !.uch as rheumatoid arthritis and ro prevent
tissue rejection in transplant surgery. This drug is metabolised
to give mercaptopurine. a purine analogue that inhibits DNA
synthesis (see Ch. 51). Both cell-mediated and antibody-mediated
immune reaction!> are depressed by this drug, because it inhibits
clonal proliferation during the induction phase of the immune
response (see Ch. 13) by a cytotoxic action o n dividing cells. As
is the case wi th mercaptopurine itself. the main unwanted effect
is depression of the bone marrow. Other toxic effects are nausea
a nd vomiting. skin eruptions and a mild hepatotoxicity.

Tacrolimus is a macrolide antibiotic of fungal origin with a very

simi lar mechanis m of action lo ciclosporin, but considerably MYCOPHENOLATE MOFETIL
more potency. The main difference is that the intemal receptor
Mycophenolate mofetil is a semisynthetic derivative of a fungal
for this drug is not cyclophilin but a different immunophilin
antibiotic. In the body, it is converted to mycophenolic acid,
termed FKBP (.K.-I2inding fl1Vtein, so-called because tacrolimus
which restrains proliferation of both T and B lymphocytes and
was initially tem1cd FK506). The tacrolimus- FKBP complex
reduces the production of cytotoxic T cells by inhibiting inosine
inhibit~ calcineurin with the effects described above.
mo1wplwsplwre dehydrogenase, an e nzyme crucial for de nmo
Pimecrolimus (used topically for atopic eczema) and sirolimus
purine biosynthe~i'> in both T and B cells (other cells can generate
(used to prevent organ rejection after transplantation. and also in
purines through another pathway). so the drug has a fairly
coming on <;tents to pre,ent restenosis: Ch. 7. p. Ill ) have similar
selective action. It b mainly used to curtail transplant rejection.
properties.
Mycophcnolate mofetil is gi,en orally and is well absorbed.
Magnesium and aluminium hydroxides impair absorption. and
Pharmacokinetic aspects
colestyramine reduces plasma concentrations. The metabolite
Tacrolimus can be given orally. by intravenous injection or as
mycophenolic acid undergoes enterohepatic cycling and is
an ointment for topical use in inflammatory disease of the
eliminated by the t..idney as the inactive glucuronide. Unwanted
skin. It is 99% metabolised by the liver and bas a half-life of
gastrointestinal effect~ are common.
approximately 7 hour~.

Unwanted eHects LEFLUNOMIDE

The unwanted effects of tacrolimus are similar to those of
ciclosporin but are more severe. The incidence of nephrotoxicity
and neurotoxicity is highe r, but that of hirsutism is lower.
Gastrointestinal disturbances and metabolic disturbances
(hyperglycaemia) can occur. Thrombocytopenia and hyper-
lipidaemia have been reported but respond to reducing the
dosage.
GLUCOCORTICOID$
Immunosuppression by glucocorticoids involves both their
effects on the immune response and their anti-inflammatory
actions. The~e arc de cribed in Chapter 28. and the sites of action
of the agents on cell-mediated immune reactions are indicated in
Figure 14.5. Glucocorticoids are immunosuppressant chiefly
because. like ciclosporin. they restrain the clonal proliferation of
Th cells. through decreasing transcription of the gene for IL-2.
However, they also decrease the transcription of many other
cytokine genes (including those for TNF-a. IFN-y. IL- l and
many other interleukins) in both the induction and effector
phases of the immune response. These effects on transcription
are mediated through inhibitio n of the action of transcription
factors, such as ac ti vator prolein- 1 and NFKB.
LeOunomide ha:-. a relatively specific inhibitory effect on activated
T cells. It gives rise to a metabolite that inhibits de novo synthesis
of pyrimidines by inhibiting dihydroorotate dehyd1vgenase. It is
orally active and well absorbed from the gastrointestinal tract. It
has a long pla<,ma half-life, and the active metabolite undergoes
e nterohcpatic circulation. Unwanted effects include diarrhoea,
alopecia, raised liver enzymes and indeed a risk of hepatic
failure. The long half-life increases the risk of cumulative toxicity.
ANTICYTOKINE DRUGS
The drugs in this section probably represent the greatest
conceptual breaJ..through in the treaunent of severe chronic
inflammation for many years (see Maini. 2005). Using these
agents. treatment can. for the first time. be aimed at specific
aspects of the di~ease processel. in rheumatoid arthritis. The
dmgs arc 'biopharrnaceuticals'. that is to say. they are recombinant
e ngineered antibodies and other proteins (see Ch. 55). As such.
they arc difficult and expensive to produce, and this limits their
usc. In the UK. their usc (on the National Health Service) is
restricted to patients who do not res pond adequately to other
DMARD therapy. 243
 SECTION2 .CHEM ICAl MEDIATORS

Immunosuppressants;
meth otrexate
Glucocorticoids
l
T
CD4 ...

Release of other
inflammatory
cytokines and
chemokines

/
Influx of
inflammatory cells

Fig. 14.5 A schematic diagram

+
/
Erosion of cartilage and bone
of the cells and mediators involved
JOINT DAMAGE
in the pathogenesis of rheumatoid
joint d amage, indicating the sites
of action of antirheumatoid drugs.
The antHumour necrosis factor
(TN F) agents are etanercept,
adalimumab and infliximab, and the DMARDS: Mechanism of

l anti-inter1eukin (IL)-1 drug is anakinra. Sulfasalazlne, penicillamine, gold compounds, action:

DMARD, disease-modifying chloroquine not clearly known
antirheumatic drug.
---------------------------------------------
Immunosuppressants

Clonal proliferation of T-helper cells can be decreased
through inhibition of transcription of interleukin (IL)-2:
ciclosporin, tacrolimus and glucocorticoids act in this
way.
Ctclosporin and tacrolimus are given orally or
intravenously; common adverse effect is
nephrotoxicity.
For glucocorticoids, see pp. 242-243.
DNA synthesis is inhibited by:
-azathioprine, through its active metabolite
mercaptopurine
- mycophenolate mofetil, through inhibition of d e novo
punne synthesis.
T-cell stgnal transduction events are blocked by
basiliximab and daclizumab, which are monoclonal
antibodies against the a chain of the IL-2 receptor.

The drugs currently available are inniximab and adalimumab
(chimeric mou1:1elhuman monoclonal antibodies against TNF-a),
etanercept (a TNF receptor fused to the Fe domain of a human
IgG molecule) and anakinra (an IL-l antagonist). InDix..imab,
24 4 adalimumab and etenercept bind TNF and inhibit its effects
(Fig. 14.5). Etanercept and anak.inra function as antagonists.
although etanercept can also bind another cytokine, lymphotoxin
-a, which may be of relevance for the treatment of juvenile
arthritis because this cytokine is found in inflamed tissue~ in
this condition.
 ANTI-INFLAMMATORY AND IMMUNOSUPPRESSANT DRUGS

Related compounds include basiliximab and daclizumab,
monoclonal antibodies against the a chain of the IL-2 receptor.
They exert an immunosuppressant action by blocking this
receptor on Th cells (see Ch. 13). They are given by intravenous
infusion and can cause seriouc; hypersensitivity reactions.
Pharmacokinetic a spects
Etanercept i!> given \ubcutaneously twice a week. Infliximab
is used in conjunction with methotrexate therapy and is given
intravenously every 6 8 weeks. Adalimumab is given by sub-
cutaneous injection in alternate weeks. Anakinra is given daily by
subcutaneous injection.
Unwanted eH ects
Cytokines have an important part to play in the regulation of
host defence systems, so one might predict that an ticytoki ne
therapy- like any treatment that interferes with immune function
-may precipitate latent disease or encourage opportunistic
infections. With ctancrccpt, unwanted effects have in general
been minimal and consist mainly of reactions at the injection
site, although there have been reports of blood dyscrasias
and demyelinating CNS disorders. Anakinra is similarly well
tolerated. Infliximab and adalimumab have been associated
with recurrence of tuberculosi~. and there is evidence that
long-tern1 usc can cause the development of autoantibodies.
Despite misgivings. it seems that prolonged inhibition of
T F action doc'> not substantially increase infections or
malignancies.
POSSIBLE FUTURE DEVELOPMENTS
At the time of writing, it would seem that the whole area of anti-
inflammatory dntg development :.tands at a crossroads. The
mainstay treatments for inflammation (e.g. the NSAIDs and
the glucocorticoids) are rather 'old' drugs-aspirin, it will be
remembered, being synthesised in the fi nal years of the 19th
century and the glucocorticoids having been discovered in the
late 1940s. Compared with the innovation in some other therapeutic
areas. such as the treatment of hypertension, for example, the
field seems somewhat impoverished.
A major blow to the NSAlD area (and indeed to the pharma-
ceutical indu-,try in general) has been the recent controversy
surrounding the adverse cardiovascular side effects of the COX-
2 inhibitors and the withdrawal of several prominent members of
this class. The emerging evidence that traditional SAIDs may
also have s imilar cardiovascular side effects has cast a pall over
our existing therapie)>. At the time of writing. it is too early to say
exactly how thi'> awkward !>ituation will be resolved.
One of the few innovation~ in the beleaguered SAID area has
been the design and synthesis of nitric oxide (NO)-NSA!Ds-
conventional NSAID~ that have NO-donating groups attached to
them by eMer linkage!.. The ability of these dntgs to release NO
following hydroly11is in plasma and tissue fluid is associated with
a decreased ri!tk of ulcerogenic events and an improved anti-
inflammatory profile, presumably due to the beneficial effects of
low concentrations of NO (sec Ch. 17). Some of these drug~ are
currently in cl inical trial.
Other techniques for manipu lati ng or inhibiting the production
of arachidonic acid metabolites, such as inhibiting phospholipase
A 2 or preventing the generation or action of lipoxygenase
products, have yet to realise their apparent potential, except in
the ca!.e of the leukotrienc receptor antagonist mootelukas t (see
Ch. 23), which has a minor role in the treatment of asthma.
Elsewhere. a lot of attention has been given to inhibitors of
leucocyte trafficking, on the premise that this would achieve a
comprehensive anti-inflammatory action. The rationale for
these developments has arisen from the detailed researches into
the integrins, selectim. and other adhesion molecules that are
involved in the targeting. capture and transmigration of blood-
borne leucocyte<, a!t they enter an area of inflammation. Sever.1l
putative compounds have utilised a monoclonal antibody
strategy. One of these. efaJuzimab. which binds the CDJ Ia
adhc!>ion molecule. has been approved in some countries for
the treatment of psoriasi~.
Another adhesion molecule that has been targeted is very
late antigen (VLA)-4. Natalizumab antagonizes this adhesion
molecu le. It prevents lymphocytes from targeting the plaques in
mu ltiple sclerosis, but is used therapeutically only in the rapidly
evolvi ng severe relapsi ng-remiltiJlg form of this disease because
it can, rarely, precipitate a lethal viral encephalopathy.
The journal Currem Opinion in Phannacology has several
compendium issues devoted to recent advances in anti-inflammatory
therapy for those who wish to research this field in more derail.

REFERENCES AND FURTHER READING

Seminal or original papers
Chandra-.ekharan NV e1 nl 2002 COX-3. a
C)Ciooxygennoel variam mhrbrlctl by acetaminophen
and olher anall!c"c/.mlrpyretrc drug;: cloning.
lotru~tun:, and expre"ion Proc Nail Acad Sci USA 99:
1392(>..1393 1 (A ntu COX tw:vme ;., dt.\cnbed:
COX.J. In hunwm. tire COXJ mRNA is eJ.presstd
most aiNmdanrly in urebral cone\ wrd heart. It i1
se/uti>elJ mhibited b1 analgtriclmrtt/>)rt'tlf' drug>
such as paracetamal and i.! inhibitn/1" ;omt' mher
NSA/Ds.)
Vane J R 1971 Inhibition of pro,wglandm 'Ynlhesi, o' u
mecbani;m of action for a.'prrin-like drul!' Nal New
Bioi 231: 232-239 (Dtfiniti e. remilutlartidr)
C) clo-ox) genase pharmacology
BaLan 'I G 2001 COX-2 as a mullifunclional neuron.1l
motlulalor. Nm Med 7: 41+-415 (Succinct trnllment uj
P<JJ>iblt rolt of COXZ in the CNS: u.\eful dia~rarrul
BMon N G. Flower R J 2002 Upid signals 10 pain
control. NaiUre 420: 135-138. (Succinct artid<'
t'Ofllfllflllifl!1 (m the di.vC<fl'ery of COX-3)

245
 Cannabinoids

et al.. 1992). This led to the purification of arachi-

Overview 248 donylerllanolamide, an eicosanoid mediator (~ee Ch. 13), the:
Endocannabinoids 248 structure of which is ~hown in Figure 15.1. Thi\ was chri'ltcned
- Biosynthesis of endocannabinoids 249 anandamide. 1 Anandnmide not on ly displaced labelled
- Termination of the endocannabinoid signal 249 carmabinoid from synaptosomal membranes in the binding assay.
but also inhibited electrically evoked twitches of mouse \as
Cannabinoid receptors 250 deferens, a bioassay for psychotropic cannabinoids (Fig. 15.2). A
Physiological mechanisms 251 few years later, a second endocannabinoid, 2-arachidonoyl
glycerol (2-AG), was identified, and more recently three further
Plant-derived cannabinoids and their endocannabinoid candidates with distinct CB 1/CB 2 (see below)
pharmacological eHects 252 receptOr selectivities have been added to the list (Table 15.1).
Synthetic ligands 253 Endocannabinoids are made 'on demand' like o ther eicosanoi~

Pathological involve ment 253

Clinical applications 254

OVERVIEW
Modern pharmacological interest in cannabinoids
dates from the discovery that 6 9 -tetrahydrocannabinol
(THC) is the active principle of cannabis, and took
oH with the discovery of specific cannabinoid 69-Tetrahydrocannabinol (THC)
receptors-termed CB receptors-and endogenous
ligands (endocannabinoids), together with
mechanisms for their synthesis and elimination.
Drugs that act on this endocannabinoid system
have considerable therapeutic potential. Here we
consider endocannabinoids, cannabinoid receptors,
physiological functions, plant-derived cannabinoids,
Anandamlde
synthetic ligands, pathological mechanisms and
potential clinical applications, which are revisited in
Ch. 27. More detailed information is given in reviews C-OH
0 I
by DiMarzo et al. (2004), DePetrocellis et al. (2004)
and Howlett et al. (2004). The pharmacology of /c
0 C-OH
cannabinoids in the central nervous system (CNS) is
discussed in Chapters 34, 42 and 43.
2 Arachldonoyl Glycerol (2 AG)
ENDOCANNABINOIDS I Fig. 15 .1 Structures of 6 9 -tetrahydrocannabinol and
~ndocannabinoids.
The discovery of specific cannabinoid receptors led to a search
for endogenou~ mediaton.. The first success was chalked up by
a team that screened fractions of extracted pig brain for ability
248 to displace a radiolabelled eannabinoid receptor ligand (Devane 1
From a Sun~kril word meaning 'bliss'+ amide.
 CANNABINOIDS

I rA ]]
100 110

90 100

90
80
~
:::e 80
70 e..
~

:::e ~ 70
e.. c
;; 60 . 60
~ ~
::> .c
:c 50 50
0
Ol
:!
c 0 40
'5 40 c
c .Q
05 :5 30
30 :c
..s 20
20
10
10 0

0
1 10 100 1000 10000 10 100 1000 10000
Anandamide (nM) Anandamide (nM)

Fig. 1 5.2 Anandamide as an endocannabinoid. Anandamide is an endogenous cannabinoid. ~ Competitive inhibition of tritiated
HU-243 (a cannabino1d receptor ligand) binding to synaptosomal membranes from rat brain by natural anandamide. lru Inhibition of vas
deferens twitch response (a bioassay for cannabinoids) by natural anandamide. Note the similanty between the binding and bioactivity.
(Redrawn from Devane et al. 1992.)

other membrane pho~pholipid!>. and known as NAPE-PLD. NAPE-PLD

Tbl 15. 1 Definite and possible endocannabinoids is a 7inc metallohydrola!>e that is stimulated by Ca 2' and also by polyamines.
Selective tnhibitors for NAPE-PLD are being sought. The precursors are
Endocannabinoid Selectivity produced by an as-yet-uncharacterised but Ca2 -sensitive transacyluse
thai trnn~fer; an acyl group from the sn- l position of phospholipids to the
Definite endocannabinoids nitrogen atom of phosphatidylethanolam ine.
Anandamlde CB, > CB2 2-AG is also produced by hydrolysis of precursors derived from
phospholipid metabolism. The key enzymes are two recently cloned sn-1-
2-Arachidonoyl glycerol CB, = CB2 selective diacylglycerol lipases (DAGL-a and DAGL-j3), which belong to
the family of serine lipases. Both these enzymes, like NAPE-PLD, are
Ca 2 '-~ensitive, consistent with intracellular Ca 2 acting as the
Less well-established
endocannabinoid candidates physiological stimulus to endocannabinoid synthesis. The DAGLs are
Virhodamine located in axon\ and presynaptic axon terminals during development, but
poMsynaptically in dendrites and cell bodies of adult neurons. con~i~tent
Noladin CB, C~
with a role for 2-AG in neurite growth. and with a role as a retrograde
mediator (<.ee below) in adult brain.
Lmle 1\ known a.<, yet about the biosynthesis of the more recent
N-Arachidonoyl dopamine CB, C~
endoc:annabmo1d candidate5 noladin. virhodamine and N-amchidonoyl
dopamine. pi !-dependent non~ntymatic intcrcooversioo of vihrodamine
and anandamidc i\ one po~sibility. and could result in a switch between
CB,- and CB -med1ated re~ponse~ (see Table 15.1 ).
(e.g. prostaglandins and leukotrienes; see Ch. 13), rather than
being presynthe!>ised and stored for release when needed.
TERMINATION OF THE
ENDOCANNABINOID SIGNAL
BIOSYNTHESIS OF ENDOCANNABINOIDS
Endocannabinoids are rapidly taken up from the extracellular
Biosynthesis of anandamidc and of 2-AG is summarised in space. Being lipid-soluble, they diffuse through plasma
Figure 15.3. membranes down a concentration gradient. There is also
T Anandamidc is formed by a diMinct phospholi pa.~e D (PLD) selective plausible but indirect evidence for a saturable, temperature-
for N-acyl-phosphatidylcthanolamine (NAPE) but with low affini ty for dependent, fac ilitated transport mechanism for anandamide and 249
 SECTION 2 . CHEMICAL MEDIATORS

~ PLC

2At \ 0
Sn-1-acyl-2 ~
GPL

arachidonoyl glycerol
Pre synaptic
neuron ....
~
~)
w NAPE-PLD
Post synaptic
neuron

0
---' GPL
/ /\ NAPE~P+E
V \ NAT

l
CBI
Receptor Anandamlde '-----"
FAAH ~-__..-'------'

E+A

Fig. 15.3 Biosynthesis and inactivation of endocannabinoids. 2-AG, 2-arachidonoyl glycerol; A, arachidonic acid; DAGL,
diacylglycerol lipase; E, ethanolamine; EMT, endocannabinoid membrane transporter; FAAH, fatty acid amide hydrolase; GPL,
glycerophospholipid; MAGL, monoacyl glycerol lipase; NAPE, N-acyl-phosphatidylethanolamine; NAPE-PLD, N-acyl
phosphatidylethanolamine-specific phopholipase D; NAT, N-acyl-transferase; PE, phosphatidylethanolamtne; PLC, phospholipase C.

2-AG dubbed the 'endocannabinoid membrane transporter. This CANNABINOID RECEPTORS

has yet to be isolated and cloned. but selective uptake inhibitors
(e.g. UCM-707) have been developed. Pathways of endo-
cannabinoid metabolism are summarised in Figure 15.3. The key
enzyme for anandamide is a microsomal enzyme known as fa tty
acid amide hydrolase (FAAH). FAAH has been crystallised and
is a serine hydrolase. It converts anandamide to arachidonic acid
plus ethanolamine and also hydrolyses 2-AG. yielding arachidonic
acid and glycerol. Expression of its gene is up-regulated by leptin
and progesterone, and down-regulated by oestrogen and
glucocorticoids.
The phenotype of FAAH 'knockout" mice gives some clues to
endocannabinoid physiology; such mice have an increased brain
content of anandamide and an increased pain threshold. Selective
inhibitOr'> of FAAH have analgesic and anxiolytic properties in
mice (see Ch. 37, p. 537. for an explanation of how drugs are
tested for anxiolytic properties in rodents). In contrast to
anandamide. brain content of 2-AG is not increased in FAAH
knockout animals, indicating that another route of metabolism of
2-AG, for example via monoacylglycerol lipase (MAGL), an
enzyme that i coexpressed with presynaptic CB 1 receptors in the
hippocampus, is liJ..ely to be important. Other possible routes of
metabolism include esterification, acylation and oxidation by
cyclo-oxygenase-2 to prostaglandin ethanolarnides ('prostamides'),
250 or by 12- or 15-1ipoxygenase (see Ch. 13).
Cannabinoids. being highly lipid-soluble, were originall}
thought to act in a similar way to general anaesthetics. However,
in 1988, saturable high-affinity binding of a tritiated cannabinoid
was demonstrated in membranes prepared from homogcniscd
rat brain. This led to the identificarion of specific cannabinoid
receptors in brain. These are now termed CB 1 receptors to
distinguish them from the C8 2 receptors subsequently identified
in peripheral tis~ues. Cannabinoid receptors are typical membcl\
of the family of G-protein-coupled receptors (Ch. 3. p. 29). CB
receptor; are linked via G110 to inhibition of adenylate cycla<>e and
of voltage-operated calcium channels. and to activation of
G-protein- sensitive inv.ard-rectif) ing potassium (GIRK) channel,,
causing hyperpolarisation (Fig. 15.4). These effects are \imilar
to those mediated by opioid receptors (Ch. 41. p. 598). CB
receptors are located in the plasma membrane of ner"e endmg'
and inhibit tran'>mitter release from presynaptic terminals. "htw
is caused by depolarisation and Ca 2 entry (Ch. 4, pp. 67-68). CB
receptors also influence gene expression. both directly b)
activating mitogen-activated protein kinase, and indirectly O)
reducing the activity of protein kinase A as a result of reduced
adcnylate cyclase activity (see Ch. 3).
The CB 1 receptors are among the most numerous receptor> in
the brain. their abundance being comparable with receptor~ for

Fig. 15.4 C ellular act ions
of cannabinoids. CB 1 receptor
activation inhibits
neurotransmitter release via
inhibition of Ca2 entry and
hyperpolarisation due to
activation of potassium
channels. It also alters gene
expression. GIRK: G-
protein-responslve potassium
channel; MAPK: mitogen-
activated protetn kinase; PKA:
protein kinase A; VOC, voltage-
operated calcium channel.
glutamate and GABA. the main central excitatory and inhibitory
neurotran!>mitters (Ch. 33). They are not homogeneously dis-
tributed. being concentrated in the hippocampus (relevant to
effects of cannabinoids on memory). cerebellum (relevant to loss
of coordination). hypothalamus (important in control of appetite;
see Ch. 27 and below), substantia nigra, mesolimbic dopamine
pathways that have been implicated in psychological 'reward'
(Ch. 43, p. 621 ), and in association areas of cerebral cortex.
There is a relative paucity of CB 1 receptors in the brain stem,
perhaps explaining the lack of serious respiratory or cardio-
vascular toxicity of the cannabinoids. At a cellular level, CB 1
receptors arc local ised presynaptically. and inhibit transmitter
release as explained above. Like opioids, they can, however,
increase the activity of some neuronal pathways by inhibiting
inhibitory connections, including GABA-ergic interneurons in
the hippocampus and amygdala.
In addition to their well-recognised location in the CNS, CB 1
receptor~ are also expressed in peripheral tissues, including on
endothelial cells and adipocytes. Cannabinoids promote lipogenel.is
through activation of CB 1 receptors, an action that could contribute
to their effect on body weight (Cola et al., 2003).
The peripheral cannabinoid receptor (CB2 subtype) has only
approximately 45% amino acid homology with CB 1 and is
located mainly in lymphoid til.sue (spleen, tonsils and thymus as
well a!. circulating lymphocytes. monocytes and tissue mast
cells). CB 2 receptors are also present on microglia-immune
cells in the CNS (Ch. 32, p. 475). The localisation of CB 2
receptors on cells of the immune system was unexpected, but
it may account for inhibitory effects of cannabis on immune
function. CB 2 receptors differ in their responsiveness to cannabinoid
ligands from CB 1 receptors (see Table l5.J ). They are linked via
G;10 to adenylate cyclase, G IRK channels and mitogen-activated
CANNABINOIOS
Altered gene
~ expression
~ voc
Adenylate
Cyclase
~
' .... \
Cannabinoid
protein kina.'e l.imilarly to CB 1, but not to voltage-operated
calcium channels (which are not expressed in immune cells). So
far, rather little is known about their function. They are present
in atherosclerotic lesions (see Cb. 20), and CB 2 agonists have
antiatherosclerotic effects (Steffens et al., 2005).
Some endocannabinoids turned out, surprisingly,2 to activate
vanilloid receptors. ionotropic receptors that stimulate
nociceptive nerve endings (see Ch. 41. p. 593). Other as-yet-
unidentified G-protein-couplcd receptors are also implicated,
because cannabinoids exhibit analgesic actions and activate
G-proteins in the brain of CB 1 knockout mice despite the absence
of CB 1 receptors.
PHYSIOLOGICAL MECHANISMS
Stimuli that release endocannabinoids, leading to activation of
CB 1 receptors and the linkage to downstream events including
behavioural or psychological effects. are very incompletely
defined. l ncreawd intracellular Ca2+ concentration is probably
an important cellular trigger because, as mentioned above,
Ca2 activates NAPE-PL D and other enzymes involved in
endocannabinoid biosynthesis.
Activation of CB receptors is implicated in a phenomenon
known as depolarisation-induced suppression of inhibition (DSf).
DSI occurs in hippocampal pyramidal cells; when these are
depolarised by an excitatory input, this suppresses the GABA-
2
Surpri~ing because capsai cin. the active principle of chilli peppers. cause~
intense burning pain. wherea~ the endocannabinoid anandamide is associated
with pleasure. or even bliss ... so perhaps not so surprising after all! 251
 IICTION2 .CHEMICAL MEDIATORS
mediated inhibitory input to the pyramidal cells, implying a
retrograde flow of information from the depolarised pyramidal
cell to inhibitory axon~ terminating on it. Such a reverse flow of
information from po!>t- to presynaptic cell is a feature of other
instanCe!> of neuronal plasticity, such as 'wind-up' in nociceptive
pathways (p. 591, Fig. 41.3) and long-term potentiation in
the hippocampu\ (p. 486. Fig. 33.7). where nitric oxide is
implicated a~ an excitatory reverse messenger diffusing from
depolarbed hippocampal neurons to a glutamate-releasing
excitatory axon terminal. DSI is blocked by the CB 1 antagonist
rimonabant. The presynaptic location of CB 1 receptors and
cellular distributions of the DAGL and MAGL enzymes
(Fig. 15.3) fit nicely with the idea that the endocannabinoid 2-AG
could be a 'retrograde' mcs~cngcr in DS I (see Fig. 34.9, p. 506).
NeuromodulaLOry actions of endocannabinoids could influence
a wide range of physiological activities, including nociception,
cardiovascular, respiratory and gastrointestinal f unction.
Hypothalamic horm one interactions could influence food intake
and reproductive function. Effects of endocannabinoids on food
intake are of particular interest. because of the importance of
obesity (Ch. 27) and the potential of CB receptor antagonists in
treating this (see below).
PLANT-DERIVED CANNABINOIDS AND
THEIR PHARMACOLOGICAL EFFECTS
Cannabis sarila, the hemp plant. has been used for its
p),ychoactive propertic~ for thousands of years (Ch. 54). It!>
medicinal Ul>C was advocated in antiquity, but serious intere~t
resurfaced only with the identification of THC, see Figure 15.1,
as the main p!>ychoactive component in 1964. Cannabis extracts
contain numerous related compounds. called cannabinoids, most
of which arc in~olublc in water. The most abundant cannabinoids
are THC, its precursor cannabidiol, and cannabinol, a breakdown
product formed spontaneously from THC. Cannabidiol and
cannabinol lack the p~ychoactive properties of THC, but can
exhibit anticonvulsant acti vity and induce hepatic drug metabolism
(see Ch. 8, p. 11 6).
PHARMACOLOGICAL EFFECTS
~9-Tetrahydrocannabinol acts mainly on the CNS, producing a
mixture of psychotomimetic and depressant effects, together
with various centrally mediated peripheral autonomic effects.
The main ~ubjective effects in humans consist of the foJJowing:
Sensations of relaxation and well-being. similar to the effect
of ethanol but without the accompanying recklessness and
aggression. (Insensitivity to ri~k is an important feature of
alcohol-often a factor in road accidents. Cannabis users are
less accident-prone. even though their motor performance is
similarly impaired.)
Feelings of sharpened l.ensory awareness. with sounds and
sights seeming more intense and fantastic.
These effects arc similar to. but usually less pronounced than,
those produced by psychotomimetic drugs such as lyser gic acid
252 diethylamide (L SD ; sec Ch. 42). Subjects report that time passes
The endocannablnold system
Cannab1noid receptors (CBh CB:J are G-
protein-coupled (G11o).
Activation of CB1 inhibits adenylate cyclase and
calc1um channels, and activates potassium channels,
inhibiting synaptic transmission.
The peripheral receptor (CB2) is expressed mainly in
cells of the immune system.
Selective agonists and antagonists have been
developed.
Endogenous ligands for CB receptors are known as
endocannabinoids. They are eicosanoid mediators
(see Ch. 13).
The best-established endocannabinoids are
anandamide and 2-arachidonoy/ glycerol (2-AG). They
act as 'retrograde' mediators passing informat ion
from postsynaptic to presynaptic neurons.
The main enzyme that inactivates anandamide is fatty
acid amide hydrolase (FAAH).
A putative 'endocannabinoid membrane transporter'
may transport cannabinoids from postsynaptic
neurons, where they are synthesised, to the synaptic
cleft, where they access CB1 receptors, and into
presynaptic terminals, where 2-AG is metabolised.
FAAH 'knockout' mice have an increased brain
content of anandamide and an increased pain
threshold; selective inhibitors of FAAH have analgesic
and anxiolytic properties, implicating
endocannabinoids in nociception and anxiety.
Rimonabant, an antagonist at CB1 receptors, causes
sustained weight loss and may promote abstinence
from tobacco.
extremely slowly. The alarming sensations and paranoid delusion'
that often occur with LSD arc seldom experienced after cannabis.
There is, however, evidence that chronic use is associated with
an increased incidence of schizophrenia and mood disorder
(Henquet et al., 2005).
Central effect!> that can be directly mea<>ured in human and
animal studie~ include:
impairment of short-term memory and simple learning
tasks-subjective feel ings of confidence and heightened
creativity are not reflected in actual performance
impairment of motor coordination (e.g. driving perfonnance)
catalepsy-the retention of fixed unnatural postures
hypothermia
analgcl>ia
antiemetic action
increased appetite.
The main peripheral effects of cannabis are:
tachycardia, which can be prevented by drugs that block
sympathetic transmission

vasodilatation, which is panicularly ma rked o n the scle ral
and conjuncti val vessels, producing a bloodshot appearance
characteri~t ic of cannabis smokers
reduction of int raocular pressure
bronchodilatation.
TOLERANCE AND DEPENDENCE
Tole rance to cannabis. and physical dependence. occur onl y to a
minor degree a nd mainl y in heavy users. The abstinence symptoms
are similar to those of e thanol or opiate withdrawal. namely
nausea, agitation, irri tability, confu~ ion . tachycardia and sweating,
but are relatively mild and do not result in a compulsive urge
to take the drug. Psychological de pe ndence does occur with
cannabis, but it is less compelling than with the major drugs of
addiction (Ch. 43), and it is arg uable whether cannabis should
be classified as addictive (see reviews by Abood & Martin, 1992:
Maldonado & Rodriguez de Fo nseca. 2002).
PHARMACOKINETIC AND ANALYTICAL ASPECTS
The effect of cannabis, taken by smoki ng, ta kes about I ho ur to
develop fu lly and la\ts for 2-3 hours. A small fraction of THC is
convened to 11-llydroxy-THC, which is more active than THC
itself and probably contribute<> to the pharmacological effect of
smoking cannabis, but mo'>t is converted to inactive metabolites
that arc <,ubjcct to conjugation and e nterohepatic recirculation.
Being highly lipophi lic. THC and its metabolites are sequestered
in body fat, and excretion continues for several days after a single
dose. Radioimmunoa\say ofTHC is bedevilled by cross-reactivity,
and accu ra te identification and q uantification of THC in
biological fl uidl>, impon ant for medico-legal reasons. depends o n
mass spectro metry.
ADVERSE EFFECTS
In overdose, THC is relatively safe, producing drowsiness and
confusion but not life-threate ning respiratory or cardiovascular
depression. In this respect, it is safer than most abused sub-
stances, particularl y opiates and ethanol. Even in low doses, THC
and synthetic deri vatives such as na bilone (see below) produce
euphoria and d rowsiness, sometimes accompanied by sensory
distonion and hallucinations. These effects. together with legal
restrictions on the use of cannabis. have precluded the wide-
spread therapeutic usc of cannabinoids.
ln rodents. Tl IC produces teratogenic and mutagenic effects,
and an increa'>cd incidence of chromosome breaks in circulating
white cells has been reponed in humans. Such breaks are,
however. by no mean!. unique to cannabis. and epidemiological
studies have not shown an increased risk of fetal malfonnation or
cancer among cannabis users.
SYNTHETIC LIGANDS
Cannabinoid receptor agonists were developed in the 1970s in
the hope that Lhey would prove useful non-opioid/non-NSATD
CANNABINOl OS
Cannabis
Main active constituent is !l9-
tetrahydrocannabinol (THC); a pharmacologically
active 11 -hydroxy metabolite is also important.
Actions on the central nervous system include both
depressant and psychotomimetic effects.
Subjective experiences include euphoria and a feeling
of relaxation, with sharpened sensory awareness.
Objective tests show impairment of learning, memory
and motor performance, including impaired driving
ability.
THC also shows analgesic and antiemetic activity, as
well as causing catalepsy and hypothermia in animal
tests.
Peripheral actions include vasodilatation, reduction of
intraocular pressure, and bronchodilatation.
Cannabinoids are less liable than opiates, nicotine or
alcohol to cause dependence but may have long-
term psychological effects.
analgesics (cf. Chs 4 I and 14, respectively. for limitations of
opioid'> and NSAIDs). but adverse effects. panicularly sedation
and memory impairment. were problematic. everthelcss. one
such drug, na bilone. i!. sometimes used clinically for nausea
and vomiting caused by cytotoxic chemotherapy if this is unrespon-
sive to conventional antiemetics (Ch. 25. pp. 39 1-392). The cloning
of CB ~ receptor~. and their absence from healthy brain, led to the
synthesis of CB2-i>elective agonists in the hope that these would
lack the C S-related adverse effects of plant cannabinoids. Several
such drugs arc being invc1:1tigated for possible use in inflammatory
and neuro pathic pain. See Howlett (2004) fo r a review of effi cacy
in CB 1-mediated signal transductio n and a discussion of synthetic
analogues with a ra nge of agonist selectivities.
The fi rst selecti ve CB 1 receptor antagonist, rimona bant, also
has inverse agonist pro pcnies in some systems and shows con-
siderable therapeutic promi~e (see below). It is in advanced clinical
trials for the indications of obesity and tobacco dependence.
Synthetic inhi bitors of endocannabinoid uptake and/or metabolism
(see above) have !.hown potentially useful effects in animal
models of pain. epi lcp1:1y. multiple sclerosis, Parkinson's disease,
anxiety and diarrhoea.
PATHOLOGICAL INVOLVEMENT
There i'> evidence, both from experimental animals and from human
ti s~ue, that cndocannabi noid signalling is abnonnal in various
neurodegcncrativc diseases (sec Ch. 35). Other diseases where
abnormalities of cannabinoid signalling have been reponed in
human tissue as well as expe rimental models include hypotensive
shock (both hacmorrhagic and septic; see Ch. l 9, pp.3 15-3 16).
advanced cirrhosis of the liver (where there is evidence that vaso-
dilatatio n is mediated by c ndocannabinoids acting on vasc ular CB 1 253
 SECnON 2 .CHEMICAL MEDIATORS

receptors-see Batkai e t al ., 200 I), miscarriage (see Maccarro nc

et al., 2CX>0) and malignant disease (see Gal ve-R operh e t al., 0
Oi
2000). It secm c; like ly that in som e disorders. e ndocannabino id ~
Q)
activity is a compensatory mechanis m Limiting the progrcl>sion of ,!;;; 2
Q)
disease or occurre nce of symptoms, whereas in othe rs it m ay be IJ)

' too much of a good thing and actually contribme to disease "'
.0
-4
E
progression. Conscquenlly. there may be a place in therapeutics ,g
for drugs that pote ntiate or inhibit the cannabinoid system; see Q)
01 6
c
DiMarzo et al. (2(}().l) for a fuller discussio n.
"'
.c
0
.E 8
.!2l

CL.NICAL APPLICATIONS ~ 10
0 12 24 36 52
C linical uses o f drugs that act on the cannabinoid sys tem remain Weeks
contro ve rsial, but in bo th the UK and the USA cannabinoids have
been used as antie mcti cs and to encourage weight gain in patie nts Placebo
with chro nic disease such as HJV-AIDS and malignancy. A & Rimonabant Smg
substantial randomised controlled trial of TH C in patients with & Rimonabant 20mg
multiple sclerosis found no objective evidence of bene fit o n
spastic ity but improved mobility (see a lso Ch. 4 3, p. 6 36). Fig. 15.5 Change from baseline in body weight in a
Ad verse events were ge nemlly mild at the doses used-see U K double-blind, placebo-controlled trial of rimonabant versus
placebo in 1507 overweight patients. (Redrawn from Van
MS Research G roup (2003). Other po te ntial c linical uses arc Gaal et al., 2005.)
give n in the clinical box.
The C B 1 receptor antagonist rimo nabant, combined w ith a
reduced calo ric diet, caused a dose-re lated weight loss
(of approxi mately o ne sto ne at the hig her dose) afte r 12 mo nths' blocking the actions of a tonically active c ndocannabin01d
treatment in one placebo-contro lled trial (see F ig. 15.5, a nd see sy"em. Long-term psychological effects in clinical triah will
abo C h. 27). Advcfl>C effects at doses used in re ported c linical be care full y analysed for evidence of anhedonia (i.e. los' of
tri als have been relati vely mild and consist of sympto ms such pleasure) and othe r sympto ms of depression o r psychologica
as nausea and d iarrhoea. w hich mig ht be anticipated fro m disturbance.

Potential and actual clinical uses of cannablnold agonlata and antagonists

Cannabinoid agonists and antagonists are undergoing - Tourette's syndrome (to reduce tics- rapid
evaluation for a wide range of possible indications, involuntary movements that are a feature of this
including the following. disorder)
Agonists: - Parkinson's disease (to reduce involuntary
glaucoma (to reduce pressure in the eye) movements caused as an adverse effect of
nausea/vomiting associated with cancer L-dopa; see Ch. 35, p. 520).
chemotherapy Antagonists:
to reduce weight loss in patients with cancer or -obesity
AIDS - tobacco dependence
neuropathic pain -drug addiction
head injury -alcoholism.

REFERENCES AND FURTHER READING

urther ~ading
OcPetrocelh\ I~ Casco M G. DiMarzo V 2()().l The
cndocannahinmd 'Y'lcm: a general view and latest
addlliOn\. Br J Phnm1ncol 14 1: 765 774 (Reiew.<the
late.ft 'adduimu ' to the endtx:amwbilwid,ystem,
2 54 mcltuling trewer endocilllfrobitwid callllidates)
DiMarzo V, Bifulco M. DePctroccll " l. 2()().1 The
endocannnbinoid system and it\ therapeutic
e~ploi talion Nat Rev Drug Discov 3: 77 1- 784
(Reviews the system. nr itwolvemtm in Jllllholot~ital
cmrditiom mrd potl'lllial for therttpetl/i('
drugs)
Freund T F, Katona I, Piomelli D 2003 Role of
cndogcnou\ cnnnnbinoids in synapuc ;ignaling
Physiol Rev 83: 1017-1066 (fhejinegrain
anatomical distribution of the tll'Limlutl ctmnabwoid
receptor CB1 IS described. and possible fim('tionr of
endoramwbinoids as retrogrcu/{ synaptic .vigtwl
 Peptides and proteins
as mediators

non-peptide~. One reason for thb apparently irrational disl ike h thm. at
Overview 256 one ti me, mo~t drugs were natural (mainly plant) products. Very few were
-Historical aspects 256 pcptidcs or acted through what we now recognise as peptide signalling
system~. A second reason b that the methodology required to stud}
General principles of peptide pharmacology 256 pcpti dcs is of more recent origin. The development of high-performance
-Structure of peptides 256 liquid chrmnatography and solid-phase pepti de sy nthesis, and the u~ nf
antibod ic~ for rad ioimmunoassay and immunocytochemistry, as well a>
-Types of peptide mediator 257
the usc of molecular biology, have fac ilitated the development of the area.
Biosynthesis and regulation of peptides 259 In 1953, du Vigneaud made history. and earned a Nobel Prize, by
-Peptide precursors 259 determining the o,tructure and carrying out the synthesis of o:~:ytocin. the
-Diversity within peptide families 260 first pepude mediator to be characterised and the first to be produced
-Peptide trafficking and secretion 261 commercially for dmaca l u~e. The structure~ of many other mediato~. f11f
r-- -
Peptide antagonists
- 262
example \ub-.tance P. bradykinin and angimensin, ''hich had ~n
idcnutied a' peptide~ io the 1930~. remained unsohed for many yem
While nil are ~mall peptide~ of II residues or fewer, determination of
Proteins and peptides as drugs 262 thcar ~tructure. and their total chemical synthesb, was a Herculean elTon.
r--- - - - ---

The \tructure of bmdykimn was not elucidated until 1960. ~hile that of
Concluding remarks 262 \Ub,tance P wa.\ published in 1970.

By contr.t\t. the u~ of contemporary techniques enabled cndothehn

OVERVIEW
Much of today's pharmacology is based on
signalling molecules that are of low molecular
weight and non-peptide in nature. Since the 1970s,
it has emerged that peptides and proteins are at
least as important, maybe more so, as signalling
molecules. Yet the pharmacological manipulation
of peptide signalling is still far less advanced than
that of, say, the cholinergic, adrenergic or
5 -hydroxytryptamine systems (Chs 1 o-12).
Pharmacology, one could say, has some catching
up to do. In this chapter, we give an overview of
the main characteristics of peptides and proteins as
mediators and as drugs, bringing out the contrasts
between these and nonpeptides, and we evaluate
the present and possible future use of peptides as
therapeutic agents. For reviews, with more detail
than can be provided here, see Buckel ( 1996),
Cooper et al. (1996}, Hokfelt et al. (2000) and
Nestler et al. (2001 ).
HISTORICAL ASPECTS
T De~ pite the fact that some peptide mediators were discovered early in
the hiMory of our disc ipline (e.g. subMance P was discovered in the
256 1930s), pharmacology has historically harboured a strong bias towards
(a much larger peptide) to be fully characterised, synthesised and cloned
with an about a year. the complete information being published in a singk
paper ( Yanagisawa et a!.. 1988). Protein mediators. such as cytokine'
(Ch. 131 and growth factor~ (Ch. 22). containing 50 or more residue' are
Mi ll very dif!icult to synthesi\e chemically, and maj or advance' mu~t rei}
large ly on molecular biology. The use of recombinant proteins as thcmpcuu'
agcnt\- a development driven mai nly by the emergent biotechnolog}
industry- is napidly gaining ground (see Ch. 55). Whereas the discov~r)
of new 's mn ll molecule" mediators has vinually dried up, the discovery nr
new protein and peptide mediators continues apace. Htikfelt et al. (2000)
list 13 ncuropcpti dcs that have been discovered since 1990.
GENERAL PRINCIPLES OF PEPTIDE
PHARMACOLOGY
STRUCTURE OF PEPTIDES
Peptide and protein mediators vary from 3 to about 200 amino
acid residue\ in <>il e (Fig. 16. 1), the arbitrary dividing line between
peptides and proteins being about 50 residues. For convenience.
in thb chapter, we use the term peptide to cover both classes.
Specific residues in peptides generally undergo post-translational
modification!., l>uch as C-terminal amidation, glycosylmion.
acetylation, carboxylation, su/fation or phosphorylation. The)
also may contain intramolecular disulfide bonds, such that the
molecule adopt!. a partial ly cyclic conformation, or may comprise
two or more separate chains linked by disulfide bonds.
lL is difficult to determine the conformation of peptides in
solution because they are so flexible, and peptides of less than
about 40 residues have proved impossible tO crystal!ise, precluding
 PEPTIDES AND PROTEINS AS MEDIATORS

nevertheless led in recent years to the discovery of many non-

peptide antagonisL~-although few agonists-for peptide receptors
Biologically Active Peptides (see below; Betancur et al., 1997).
2

TRH TYPES OF PEPTIDE MEDIATOR

Peptide mediators that are secreted by cells and act on surface
receptors of the . arne or other celJs can be very broadly divided
5 Enkephahns into four groups:
Vasopressin
_ _ / Angiotensrn II Oxytocin
Bradykinin
neurotransmillers and neuroendocrine mediators (discussed
further in thi~ chapter)
hormones from non-neural sources: these comprise (a)
10 Substance P plasma-derived peptides, notably angiotensin (Ch. 19) and
-AiphaMSH [Somatostatin bradykinin (Ch. 13), and (b) s ubstances such as insulin
II)
"0
Bombesin
'(3 (Ch. 26) cndothclin (Ch. 19), atrial natriuretic peptide
<1l
0 (Ch. 19) and lepti n (Ch. 27)
c 20 Secretin
.E Glucagon growth factors: produced by many different cells and tissues
<1l
0 Cholecystokinin that control cell growth and differentiation (see Ch. 22)
Q; Calcitonin mediators of rile immune system (cytoki11es and chemokines;
.0
E [ Neuropeptide Y see Ch. 13).
:l
z CGRP
50 Insulin Some important examples of peptide and protein mediators are
~hown in Figure 16. J.

~-Lrpotrophin Role of molecular biology

100

F- Nerve growth factor

Chemokines
- - - - - - Leptin
T Becau~e peptide 'tructures are represented directly in the genome.
molecular b1olog) ha\ been the key to most of the recent advances in
l..nowledge. It b used 10 many ways. a.~ in the following examples.

200 ~~:
GH
Prolactin
Most cytokines
Fig. 16.1 Some typical peptide med iators. ACTH,
adrenocorticotrophic hormone; Alpha-MSH, (l-melanocyte
stimulating hormone; CGRP, calcitonin gene-related peptide;
CRH, corticotrophin-releasing hormone; FSH, follicle-
stimulating hormone; GH, growth hormone; GHRH, growth
hormone-releasing hormone; GnAH, gonadotrophin-releasing
hormone; LH, luteinlsing hormone; TRH, thyrotrophin-releasing
hormone; TSH, thyroid-stimulating hormone; VIP, vasoactive
intestinal peptide.
the use of X-ray diffraction methods to study their conformation
(although some other techniques. such as nuclear magnetic
resonance, have proved helpful). Larger proteins adopt more
restricted conformations, but because of their size they generally
interact with multiple sites on the receptor. To envisage peptides
fitting into a receptor l.ite in a precise 'lock and key' mode is
to imagine that you can unlock your front door with a length of
cooked spaghetti. Such problems have greatly impeded the
rational design of non-peptide analogues (peptidomimetics) that
mimic the action of peptides at their receptors. The use of random
screening methods has (somewhat to the chagrin of the rationalists)
Cloning of the gene~ mcoding peptide precursors has shown how
several active peptides can arise from a single precursor protein.
Calcitonin gene related peptide (CGRP) was discovered in this way.
Cloning of the gi'III'S encoding peptide receptors has revealed that
nearly all belong either to the class of G-protein-coupled r.:ceptors or
the tyro;,ine kina;,e- linkcd receptors (see Ch. 3). Very few peptides act
on ligand-gated channels.
Severn I new pepride mediators have been discovered by screening for
lignndv of 'orphon receptor~, (see Civelli et al., 200 I). Searching in an
ex tract of brain peptides for possible ligands for an opioid
receptor-like orpha11 (called ORLI) Jed to the idemification of the
novel neuropcptidc nociceptin (Meu nier et al., 1995). When the gene
encoding nociceptin w:1s cloned. it was found also to encode another
pcptide,nociswtin. which had the opposi te effects on pain transmi%ion
and acted on yet another receptor (see Okuda-Asbit.aka & Ito, 2000).
The di\CO\ cry of orexins (peptides involved in appetite and obesity; sec
Ch. 27) aro~c through ~imilar molecular orienteering.
The control of precur.or ~ynthesi~ can be srudied indirectly by measuring
mRNA, for ~hich highly 'en~itive and specific assays have been
de~cloped. The techmque of in situ hybridisation enables the location
and abundance of the mRNA to be mapped at micrzy.,copic resoiUiion.
TrallSI/I!IIic animals wnh pepude or receptor genes deleted or
O\erexpres!iCd provide valuable clues to the functions of novel
pcpudes. Anllstllft' oligonucleotides (see abo Cb. 55, p. 779) can also
be u~ed to Mlence ~uch genes.
PEPTIDE$ IN THE NERVOUS SYSTEM:
COMPARISON WITH CONVENTIONAL
TRANSMITIERS
The abundance of neuropeptides in the brain and elsewhere
became evident in the 1970-SOs, and new examples are still 257
 SICTION 2 CHEMICAL MED I ATORS

emerging. In mo!>l respects, neuropeptide-mediated transmission
resemble!. transmission by 'conventional" non-peptide mediators;
the mechanisms for peptide storage and release (summarised in
Fig. 16.2), and the receptor mechanisms through which their
eiTects are produced, are essentially the same in both cases. One
diiTcrcncc is that the vesicles are loaded with peptide precursors
in the cell body, the active peptides being generated within the
vesicles as they move to the nerve terminals. Following exocytosis.
the vc~>icles cannot be reloaded in situ but must instead be replaced
with new prcloadcd veskles. Transmitter turnover is therefore
less rapid than with conventional meruators, and recapture of the
released transmitter does not occur.
As with other chemical mediators, the effects of peptides may
be excitatory or inhibitory, pre- or postsynaptic, and exerted over
short or long distances from the site of release. There arc, however,
certain monopolies of function between peptide and non-peptide
mediators. For example, pepti des do not activate ligand-gated ion
channels, and therefore do not function as fast neurotransmitters
in the manner of non-peptides such as acetylcholine, glutamate.
glycine or GABA (see Chs lO and 32). Instead, they serve (as do
many non-peptides) mainly as neuromodulators, by acti\'atJng
G-protein-<:oupled receptors. In contrast. the ligands for tyro~ine
kinase l inked receptors are all peptides or proteins.
Tn summary, the similarities in function between peptide and
non-peptide mediator:. are more striking than the diiTcrence,.
The main diiTerence sterns from the fact that peptides, being gen~
products, represent variations on a single theme-a linear string
of amino acido,. Such sequences are much more susceptible
to evolutionary change than are the structures of non-peptide
mediators, and the number of known peptide mediators no11
greatly exceeds that of non-peptides. As I versen pointed out in
1983: 'almost overn ight. the number of putative transmi tter~ in
the mammalian nervous system has jumped from the ten or so
monoamine and amino acid candidates to more than 40'. Since
then, no new monoamine transmitters have appeared, but there
arc at lea~L another 60 peptides.

SYNTHESIS

_Rough endoplasmic
---:::::::::=::=:::::/ reticulum

Smooth endoplasmiC
reticulum

~~; ~J) _______ Transport

Fig. 16.2 Cellular mechanisms ~ vesicle
for peptide synthesis and release.
Proteins synthesised by ribosomes
are threaded through the membrane
of the rough endoplasmic reticulum,
from where they are conveyed in SORTING
transport vesicles to the Golgi
apparatus. Here, they are sorted
and packaged into secretory
vesicles. Processing (cleavage,
glycosylation, amidation, sulfation,
etc.) occurs within the transport and
secretory vesicles, and the products PROCESSING
are released from the cell by Cleavage, amidation,
exocytosis. Constitutive secretion sulfat1on. etc. I
y
(e.g. of plasma proteins and clotting
factors by liver cells) occurs
continuously, and little material is ~ I
stored in secretory vesicles. Y ~ Secretory vesicles
Regulated secretion (e.g. of
neuropeptides or cytokines) occurs Cell membrane
in response to increased intracellular ~ I
/
Ca2 or other intracellular signals,
and material is typically stored in
SECRETION
~ ~~
significant amounts in secretory Regulated secretion Continuous secretion
vesicles awaiting release. (e.g. neurotransmitter release) (e.g. clotting factors)
258

The role of peptide!> a~ cotran~mitters is discussed in Chapter 9.
Two well-documented examples (reviewed by Lundberg, 1996)
are the parasympathetic nerves innervating the salivary glands
(\~here the secretory rc:-.pon~e is produced by acetylcholine and
the ,asodilatation partly by msoacti1e imestinal peptide) and the
sympathetic inncn.ation to many tissues. which releases the
,asocon'>trictor neuropeptide Y in addition to noradrenaline
(norepi nephrinc ).
The di!.tinction between neuropeptides and peripherally acting
honnones i'> useful but not absolute. Thus insulin, angiotensin.
atrial natriuretic peptide and oxytocin are best known as
hormones that arc formed, released and act in the pe riphery. They
arc. however, abo found in the brain, although their role there is
uncertain. Similarly, e ndothclin was first discovered in blood
vessel~ but i~ now known to occur extensively in the brain as well.
MULTIPLE PHYSIOLOGICAL ROLES OF PEPTIDES
T In common wi th muny non-peptide mediators. such as noradre naline,
dopamine. 5 hydroxytrypwmine or acetylcholine, the same peptides may
function a~ mediator' in '>everal ditTerent organs. and intriguingly often
appear to '>ub~r. e '>omc coordinated phy~iological function. For example.
angioten,in ac:h on the celt- of the h) pothalamus to release antidiurc:tic
hormone (va\Opre\\111). which in tum causes water retention. Angiotensin
also acts el~" her.: 111 the brain to promote drinking behaviour and to
increa..e bkK>d prC'>'>ure by acuvauon of the sympathetic system: in
addJtion. it rclea'>C'> aldO'>terone. "hich cause~ ~alt and water retention
and act'> directly to constrict blood 'e<.'>els. Each of these effects play~ a
part in the O\crall re'>pon'>e of the body to water deprivation and reduced
circulaung volume. There are other examples of what appears to be an
orche'>tr.ued function<tl response produced by the various actions of a
'ingle mediator. but there are many more examples where the multiple
etTech \CCm ju'>l to be-multiple effects.
So far. the 'tream of ne'~ information about neuropcptides since the
197(}, h<h led to few usefu l gcnerali\ations about their functional role.
and ~urprisingly few new drug;- with the exception of anti byperten,ive
dntgs acting on the reni n ang iotensin system (see Ch. 19). For whatever
reason. peptide phannacology has proved to be something of a graveyard
for drug discovery projects. For example, substance P antagonists were
confidently expected to be ef'f'ecti ve analgesic drugs based on copious
data from animal studies, but proved to have no analgesic activity in
humans, although one such drug, aprepitant. has beeo found 10 have
a role in pre,enting vomiting caused by cisplatin-based cytotoxic
chemotherapy (Ch. 51). They al\o have unexpected anxiolytic properties.
BIOSYNTHESIS AND REGULATION
OF PEPTIDES
Peptide '>lructurc i'>, of course. directly coded in the genome. in
a manner that the structure of (say) acetylcholine is not. so
intracellular manufacture is simpler. Peptide synthesis (Fig. 16.3)
begins with the manufacture of a precursor protein in which the
peptide sequence i~ embedded, along with specific proteolytic
enzyme'> that exci.,e the active peptide. a process of sculpture
rather than synthe!.i.,. The precursor protein is packaged into
vesicles at the point of synthesis, and the active peptide is formed
in situ ready for release (Fig. 16.2). Thus there is no need for
specialised biosynthetic pathways. or for uptake or recapturing
mechanisms, such as arc important for the synthesis and release
of non-pe ptide mediators.
PEPTIDES AND PROTEINS AS MEDIATORS
Structure and function of
peptide mediators
Size varies from three to several hundred amino acid
residues. Conventionally, molecules of fewer than
50 residues are called peptides, larger molecules
being proteins.
Neural and endocnne mediators range in size from
3 to over 200 residues. Cytokines, chemokines and
growth factors are generally larger than 100 residues.
Most known peptide mediators come from the
nervous system and endocrine organs. However,
some are found in the plasma, and many occur at
other sites (e.g. vascular endothelium, heart, cells of
the immune system). The same peptide may occur in
several places and serve different functions.
Small peptides and chemokines act mainly on
G-protein-coupled receptors, and act through the same
second messenger systems as those used by other
mediators. Cytokines and growth factors generally act
through tyrosine kinase-linked membrane receptors.
Peptides frequently function in the nervous system as
cotransmitters with other peptides or with non-
peptide transmitters.
The number of known peptide mediators now greatly
exceeds that of non-peptides.
PEPTIDE PRECURSORS
The precursor protein, or prepmlwrmone. usually I 00-250 residues
in length, consists of an N-terrninal signal sequence (peptide),
followed by a variable stretch of unknown function, and a peptide-
containing regio n in which several copies of active peptide
fragments m:.~y be contained. Often, several different peptides are
found within one precursor, but sometimes there is only one in
multiple copie!t. An extreme example occurs in the invertebrate
Aplysia. in which the precursor contains 28 copies of the same
short peptide. The signal peptide, which is strongly hydrophobic,
facilitates insertion of the protein into the e ndoplasmic reticulum
and is then cleaved off at an early stage, yielding the prohormone.
The active peptides are usually demarcated within the
prohom1onc sequence by pairs of basic amino acids (Lys-Lys or
Lys-Arg). which are cleavage point., for the trypsin-like proteases
that release the peptide~. Thi~ endoproteolytic clea,age generally
occurs in the Golgi apparatus or the secretory vesicles. The enzymes
responsible arc known a., prolwrmone convenases, of which two
subtypes (PC I and PC2) have been studied in detail (see Cullinan
ct al., 1991 ). Scrutiny of the prohormone sequence often reveals
likely cleavage points that demarcate unknown peptides. In some
cases (e.g. CGRP: see below), new peptide mediarors have been
discovered in this way, but there are many examples where no
Function has yet been assigned. Whether these peptides are, like
strangers at a funeral , waiting to declare their purpose or merely
func tio nless relics, remains a mystery. There are also large
259
 SECTION 2 . CHEMICAL MEDIATORS

Gene Exons lntrons

s

mANA Poly-A tail

ter~;nal
Preprohormone
(protein) --~____......___ ,__'1-----'' termtnal
C
Fig. 16.3 Synthesis of a
peptide mediator. The coding -i----'---'--..J..
P-ai_rs__,of basic residues

[-.-
regions of the gene (exons) are demarcating active peptides
transcribed and spliced to give rise Cleavage of signal peptide
to mANA, segments of which (blue)
are translated to produce
Prohormone J
preprohormones. Cleavage of the
Endoproteolytic cleavage ~
N-terminal signal peptide produces
the prohormone, from which
- Amidation,
endopeptldases excise peptide
Secreted t sulfation, etc.

i...
fragments. These may be active as
such, or they may undergo further
peptides ---------< -
{ Further cleavage
post-translational processing
(amidation etc.).

stretches of the prohormone sequence of unknown function lying
between the active peptide fragmenrs.
The abundance of mRNA coding for particular preprohormones,
which reflects the level of gene expression. is very sensitive to
physiological conditions, and this type of transcriptional control
is one of the main mechanisms by which peptide expression and
release are regulated over the medium to long term. Inflammation,
for example. increases the expression, and hence the release, of
various cytokincs by immune cells (see Ch. 13). Sensory neurons
rc~pond to peripheral inflammation by increased expression of
tachykinins. which is important in the genesis of inflammatol)
pain (sec Ch. 41 ).
DIVERSITY WITHIN PEPTIDE FAMILIES
T Peptide-. commonly occur in families with similar or related ~equence
and action-. Opioid peptides (see Ch. 41) provide a good example of tilt
representation of such a family at the genomic level. Opioid peptides.
defined a~ peptide~ with opiate-like pharmacological effects. are coded by

(
Fig. 16.4 Opioid precursors.
Structures of the three opioid
precursor proteins, showing the
location of op1oid and other peptides
within the sequence. These
embedded peptides are bounded by
pairs of basic amino acids, which
form points of attack for enzymatic
cleavage. The signal peptide
sequence is shown in green. ~-END,
jl-endorphin; ACTH,
adrenocorticotrophic hormone; DYN,
dynorphin; L, leucine enkephalin; M,
methionine enkephalin; MSH,
melanocyte-stimulating hormone;
___ 6_0
2 ..:. ~EO, neoendorphln.

three di,tinct gene'> who~e products are, respectively, prepro-
opiomelanoeortin (POMC), p!Y'proenf>pha/in and preprodynorphin. Each
of theo,e precur.or. contain!. the sequenceJ, of a number of opioid peptides
(Fig. 16.4). Hughe~ and Ko~terhu, who discovered the enkephalins in
1975. noticed that the o,equence of ml!tenkephalin i~ contained within
that of a pituita!) hormone. ji-)jpotrophin. About this time. three other
peptide' with morphme-tike action~ were disco\ered. a-. ji- andy-endorphin.
\1-hich al~o \1-Cre contamed wnhin the ~-lipotrophin molecule. It wa~ then
found that the enkephahn'> actuall) come from the other gene products,
p~nAeplwlin and prodynorphin. POMC itself serving as a ~ource of
adrenoconicotrophic honnone (ACfH). melanocyte-stimulating hormones
and ~-endorphin. but not or erikephal in~.
The e'pre\\ion of the precu~or protein~ varie~ grea!ly in different tissues
and brain areas. For example. POMC and its peptide products are found
mainly in the pituitary and hypothalamus. whereas endorphin, met
enkephalin, leu-en kephalin and dynorphin are more widely distributed. In
the spinal cord, dynorphin occurs mai nly in intemeurons, whi le the
cnkephal in~ arc fou nd mainly in long descending pathways from the
midbrai n to the dor~al horn. Opioid peptide!> are also produced by many
non-neuronal cells. including endocrine and exocrine glands and cells of
the immune system, a~ well as in brain area~ distinct from those involved
in nociception. and corre~pondi ngl y they play a regulatory role in many
different physiological syMem~. as renected in the rather complex
pharmacological propenie~ of opiate drug~.
Dhe"ity of mcmbe~ of a peptide family can also arise by gene splicing
or dunng pall-translational proceuing of the prohormone.
Gene splicing as a source of peptide diversity
'f' Gene'> contain codmg region~ (exon~) interspersed with non-coding
regions Cintron,). and when the gene is transcribed RNA (hnRNA-
heterologous nuclear RNA) i'> '>pi iced to remove the introns and some of
the e~on'>. formmg the final mRJ A that i~ translated. Control of the
~plicing process allow~ a measure of cellular control over the peptide~
that are produced. Good examples of this are calcitonin/CORP and
~ubstance P/neuro~inin A.
The calci tonin gene codes for culcitonin itself (Ch. 31) and al~o for
a completely dissimilar pepti de. CO RP. Alternative splicing allows cells
to produce either pmralcitonin (expres~ed in thyroid cells) or pro-CGRP
(expre;sed in many neurons) from the same gene. Substance P and
neurokinin A arc two clo~el y related tachykinins belonging to the same
family. and are encoded on the same gene. Alternative splicing results in
the production of two precu r~or proteins: one of these includes both
pcptidcs, the other includes only substance P. The ratio of the two varies
widely between ti'>'>UCS, which correspondingly produce either one or
both pepti des. The control of the splicing process is not weU underMood.
Post-translational modifications as a source of
peptide diversity
'f' Many peptides, wch a'> tachykinins and peptides related toACTH (see
Ch. 28), mu'>l undergo enzymatic amidation at the C-terminus to acquire
full biological actinty. Ti'>'>UC'> rna) also generate peptides of val)ing
length from the <arne primary sequence by the action of specific peptidascs
that cut the chain at different point~. For example. procholecystokinin
(pro-CCK) contain'> the sequence~ of at least five CCK-Iike peptides
ranging in length from 4 to 58 amino acid re~idues, all with the same
C-terminal sequence. CCK itself (33 residues) is the main peptide
produced by the imesune. whereas the brain produces mainly CCK-8.
The opio1d precu~or. prodynorphin, similarly gives rise to several pcptides
with a common terminal sequence. the proponions or which vary in different
tis~ue~ and in d1fferent neurons in the brain. Ln some case~ (e.g. the
innamm::uory mediator bmdy ~i nin; Ch. 13), peptide cleavage occurring
after release generate~ a new active peptide (des-Arg9-bradykinin), which
acts on a different receptor, both pcptidcs contributing differently to the
inflammatory response.
PEPTIDES AND PROTEINS AS MEDIATORS
PEPTIDE TRAFFICKING AND SECRETION
The ba!.iC mechanisms by which peptides are synthesised,
packaged into vesicles. processed and secreted are summarised
in Figure 16.2 (see review by Perone et al .. 1997). Two secretory
pathways exist, for constitutive and regulated secretion,
respectively. Constitutively secreted proteins (e.g. plasma proteins,
some cloning factors) are not stored in appreciable amounts, and
secretion is coupled to l>ynthesis. Regulated secretion is, as with
many hormones and transmitters, controlled mainly by
intracellular Ca2+ (l>ee Ch. 4), and peptides awaiting release are
stored in cytoplas mic vesicles. Specific protein-protein
interactions appear to be responsible for the sorting of different
proteins into different vesicles, and for their selective release.
Identification of the specific ' trafficking' proteins involved in
particular secretory pathways may yield novel drug targets for
the selective control of secretion, but the prospect is still some
way off, and conventional receptor-based pharmacology will be
the basis for shorter term therapeutic developments.
Bloayntheala and ntleaH of peptldea
The genettcally coded preprohormone is a
large protein comprising a signal sequence (involved
in transfer of the protein across the membrane) and
the prohormone, containing the embedded
sequences of one or more active peptides.
The active peptides are produced intracellularly by
selective enzymic cleavage, centred on pairs of
adjacent Arg or Lys residues. In most cases, the
active peptides are stored (often in vesicles) in a
releasable form.
A single precursor gene may give rise to several
peptides by selective mANA splicing before
translation, by selective cleavage of the prohormone,
or by post-translational modification.
Peptides and proteins are located in intracellular
vesicles, which are budded off from the endoplasmic
reticulum and Golgi apparatus.
After sorting and post-translational processing of the
peptide products, the vesicles differentiate into secretory
vestcles, whtch discharge their contents by exocytosis.
With constitutive release (e.g. plasma proteins,
clotting factors), secretory vesicles are discharged as
soon as they are formed, and secretion is continuous.
With regulated release (neuropeptides and endocrine
peptides), exocytosis is controlled by intracellular
Ca2 , as with release of conventional transmitters.
There are many examples of closely related peptides,
presumably produced by divergent evolution from a
single gene, with different locations and physiological
functions.
261
 SECTION 2 C H EM I C A L M E D I AT 0 RS
PEPTIDE ANTAGONISTS
Although selective antagoni!>ts are available for the great
majority of non-peptide receptors, only a few peptide antagonists
are so far in clinical uc;e, although their therapeutic potential
is con,iderable (sec Betancur et al.. 1997). Substitution into
endogenou~ peptide~ of unnatural amino acids, such as o-amino
acid'>. ~omctime!> produces excellent antagonists. This strategy
was successful in the case of substance P, angiotensin and
bradykinin. llowcver. for reasons discussed below. such peptide
antagonists arc of liulc usc therapeutically. so effort has been
channelled instead into discovering non-peptides that bind to
peptide receptors. In a few cases, 'peptoids' have been produced
by modifying the peptide backbone, while retaining as far as
possible the disposition of the side-chain groups that are
responsib le for binding to the receptor. Such compounds have
been developed as antagonists for several peptide receptors (e.g.
CCK and ncuropcptide Y). In other cases, random screening of
large compound libraries has succeeded where rational approaches
failed, resulting in highly potent and selective antagonists, some
of which arc in use, or under development, as therapeutic agents.
The most important peptide receptor antagonists in clinical use,
all of them non-peptidcs, are:
naloxone. na ltrcxonc (1..1-0pioid receptors): used to
antagonise opiate effect!> (see Ch. 41)
losar tan . valsartan, ibresartan, etc. (angiotensin AT1
recepton.): u\ed a\ antihypertensive drugs (see Ch. 19)
boscnta n (endothelin ET 1/ET2 receptors).
Antagonists for many other peptides. including bradykinin,
substance P. CGRP, corticotrophin-releasing factor. neuropeptidc
Y, neurotcnsin. oxytocin, antidiuretic hormone and somatostatin,
have been discovered but. with some notable exceptions (e.g. the
oxytocin antagonist atosibao; see Ch. 30), have not yet been
developed for clinical usc. Details can be found in Alexander et
a l. (2006) and in the review by Betancur et al. (1997).
Few, if any, agonists at peptide receptors have been discovered
by random l>Crccning, and morphine-like compounds are probably
the most important clinical examples of non-peptide agonists at
peptide receptor~. It i& becoming increasingly clear, however,
that some peptide receptors are 'promiscuous'. in that they can
bind both peptide and non-peptide ligands. A recent example is
that of the FPR family of G-protein-coupled receptors, some of
which recogni'>e both the bacterial tripeptide}MLP and also the
anti-innammatory lipid lipoxin A 4 Binding of the rwo ligand!>
probably occun. at different receptor domains. Understanding
of \\-hat make~ non-peptides chemicaJly recognisable by peptide
receptors remain<; elu\ive. much to the frustration of medicinal
chemist<, who would dearly like to be able to design such
compound!> de novo. There remain many peptide mediators
for which no antagoni~ts are known, but strenuous efforts are
being made to fill this gap in the hope of developing new
therapeutic agents.
Not !>Urpri\ingly, it has proved easier to find synthetic
compounds that block receptors for small peptidcs (e.g. most
262 neuropcptidcs), which have only a few points of attachment, than
for large peptides and proteins (e.g. cytokines and gro,qh
factors), which interact with the receptor at many points. ThN
receptors arc not ca<;ily fooled by small molecules. and effon~
to target them therapeutically rely on protein-based approache~
(~ce below).
PROTEINS AND PEPTIDES AS DRUGS
Many proteins, including antibodies, decoy receptors, cytokine,,
cnqmcs and clotting factors, are registered for use as therapeuuc
agents in specific conditions; they are mainly given by injection
but occa\ionally by other routes (see Table 16.1 ). Many of the
protein!> currently in therapeutic use are functional human
proteins prepared by recombinant technology, which are used to
supplement the action of endogenous mediators. Although their
preparation requires advanced technology, such proteins arc
relatively straightforward to develop as drugs, because they rnrely
cause toxicity and have a more predictable therapeutic effect
than synthetic drugs. 'Designer proteins' -genetically
engineered variants of natural proteins-for specific purposes are
already a reaJity. Examples include 'humanised antibodies' and
fusion proteins consisting of an antibody (targeted, for example.
at a tumour antigen) or a peptide (e.g. bombesin or somatostatm.
which bind to receptors on tumour cells) linked to a toxin (such
as ricin or diphtheria toxin) to kill the target cells (see Ch.51).
Many ingenious ideas arc being explored. and some prophet.,
anticipate the dawn of a new era of therapeutics, as the hegemon)
of small-molecule therapeutics begins to fade. Pharmacologi\h,
needles\ to l.ay, are somewhat sceptical. but nobody can afford
to ignore the potential of biotechnology-based therapeutic' m
the future. A full discussion of this exciting area is pro,ided
in Chapter 55.
Smaller peptides are u&cd therapeutically mainly when ther~
is simply no viable alternative (e.g. insulin and its designer
variants, Ch. 26) but, in general, peptides make bad drugs. There
arc several reasons for this.
Most must be administered by injection or nasal spray,
because they arc poorly absorbed or metabolised in the gut.
(An important exception is ciclosporin, discussed inCh. 14,
which contains so many unnatural amino acids that no
peptidase will touch it.)
They are expensive to manufacture.
They u~ually have a short biological half-life because of
hydroly\iS by plasma and tissue peptidases. although there
are exception., to this.
They do not penetrate the blood-brain barrier.
A list of some important therapeutic proteins and peptidcs i'
given in Table 16.1.
CONCLUDING REMARKS
The physiology and pharmacology of peptides-particularly
ncuropcptides has stimulated a large amount of research since
the early 1980s, and the now of data continues unabated. With
more than a dozen major fami lies of peptides, and a host of
 PEPTIDES AND PROTEINS AS ME DIATORS

minor player~. it is beyond the scope of this boo k to cover them
individually or in de tail. Instead, we will introduce informatio n
on peptide pharmacology wherever it has relevance to the
physiology and pharmacology under di!>cussio n. Examples are
bradykinin (Ch. 13) and monoclo nal antibodies (Chs 14 and 55)
m infla mmation; e ndo the lins and a ngio ten!>in in cardiova~cula r
regulation (Ch. 19): tachykinins in asthma (Ch. 23): tac hykinins
and o pio id pe ptides in nociceptio n (Ch. 41 ); and leptin,
neuropeptidc Y and orexins in o bes ity (Ch. 27). Useful general
accounts of peptide pharmaco logy include Sherman e t al. ( 1989),
Hokfe lt e t al. (1 99 1, 2000), Cooper et al. (1 996) and e!.Lier
et al. (200 I ).

Peptldes and proteins as drugs

Despite the large number of known peptide mediators,
only a few peptides, mostly close analogues of
endogenous mediators, are currently useful as drugs.
In most cases, peptides make poor drugs, because:
they are poorly absorbed when given orally
they have a short duration of action because of
rapid degradation in vivo
they do not cross the blood-brain barrier
they are expensive and difficult to manufacture.
Peptide antagonists were slow to be discovered, but
many are now available for experimental purposes
and in development as therapeutic agents.
Important peptide antagonists used clinically
include naloxone, losartan and bosentan.
Protein-based therapeutic agents are limited in number
and include hormones (e.g. insulin, growth hormone),
clotting factors, cytokines, antibodies and enzymes. In
many cases, these are produced using recombinant
technology.
'Designer proteins' prepared by recombinant techniques
are expected to play an increas1ng therapeutic role 1n
the future.

Table 16.1 Some peptide and protein drugs

Drug Use Route

Peptides
CaptopriVenalaprll (peptide-related) Hypertension, heart failure (Ch. 19) Oral

Antidiuretic honnone, desmopressin and lypressin D1abetes insipidus (Ch. 24) Intranasal, injection

Oxytocin Induction of labour (Ch. 30) Injection

Gonadotrophin-releasing hormone analogues Infertility, suppression of ovulation (Ch. 30), Intranasal, injection
(e.g. buserelin) prostate and breast tumours

Adrenocorticotrophic honnone Diagnosis of adrenal insufficiency (Ch. 28) Injection

Thyroid-stimulating hormone/thyrotrophin-releas~ng honnone Diagnosis of thyroid disease (Ch. 29) Injection

Calcitonin Paget's disease of bone (Ch. 31} Intranasal, injection

Insulin Diabetes (Ch. 26) Injection

Somatostatin, octreotlde Acromegaly, gastrointestinal tract tumours Intranasal, injection

(Ch. 25)

Growth hormone Dwarfism (Ch. 28) Injection

Ciclosporin Immunosuppression (Ch. 13) Oral

F(ab) fragment Digoxin overdose Injection

Prot eins
Streptokinase, t1ssue plasminogen activator Thromboembolism (Ch. 21} Injection

Asparaginase Tumour chemotherapy (Ch. 51) Injection

263
SECTION 2 C H E M I C A l M E D I AT 0 RS
Table 18.1 (cont'd) Some peptide and protein drugs
Drug
ONAase
Glucocerebrosidase
Proteins
Interferons
Erythropoietin, granulocyte colony-stimulating factor, etc.
Clotting factors
Monoclonal antibodies (e.g. anti-tumour necrosis factor-a)
Antibodies, vaccines, etc.
Enfurvitide
REFERENCES AND FURTHER READING
Ale~311der S P. \la1h1e A. Peter.. J A (eds) 2006 Gwde 10
reccplor. and channel\, 211<1 edn. Br J Ph<mnacol
147(suppl 3): Sl - 5168 (Cmnprrhmm~ wrunary of
rrupton, mdudm~ pepllde rrupton. and compomtds
thtll IICt l>fl tht'nl)
Bet311cur C. An1 \1. Rchlene W 1997 Nonpeptide
antagon"r; of neuropepride receptor... Trends
Pharrnacol Sc1 I!!: 372- 386 (Descflbes sucuss in
jindifl!llltmptprule tmw,qot~isrs-for <long rime
elusil'-<mtltheir fXI.I.Iihle rlrrrapeutic mes)
Bri\tow A F 1991 The currenr statu' of therapeutic
pepridc, and prolein~. In: Hider R C. Barlow 0 (eds)
Polypeptide and protean drugs. t:!lli> Horwood,
Chiche\lcr (Reiew article)
Bruckdorfer T, Marder 0. Albcricio F 2()().j From
producrion of pcptide> in milligram amounts for
research to multi-tons q unn1i1 ies for drugs of rhe
future. Curr Phnrrn Biorechnol 5: 29-43 (Deals wirh
the rat~ridullhl~ redmlcal pmblems in scaling up rhe
nmil~.fi.1of f>rf>lidc dmg.r, and gie.\ rlze l'xample of
~nfunllide, rhe ami-AID; dmg that wa.1 rM jim
p~ptidt ro hr pmduud m mulmon amoums: 11 is a
rrmarkahlc flO') , l''l'tll if rou urr IUJt a cheuucal
tnRmrerinf( xuk)
Buckel P 1996 Recombma01 pi'Oiem\ for therapy. Trend,
Phnnnacol S.:r 17 450-456 (Good account of
rhtntpelllic pmttim)
Cielli 0. '101hacker H-P. Sruto Yet at. 2001 Noel
n.:uf'Oiran\mlllcr. a\ narural hgand~ of orphan
Use
Cystic fibrosis (Ch. 23)
Gaucher's disease
Tumour chemotherapy (Chs 13 and 51),
multiple sclerosis (Ch. 35)
Anaemia (Ch. 22)
Clotting disorders (Ch. 21)
Inflammatory diseases (Ch. 13)
Infectious diseases
HIV infection (Ch. 47)
G-protein-coupled rooeptor.. Trench /lleul'lhei 24
230-237 (DescriMs hoM "~" peprule methuum ha~
Men discmered by scrumng orplto11
receplorJ)
Cooper JR. Bloom FE. R01h R ~I 1996 B1oc:henucal
basis of neurophannacology. Q,ford Unl\eNI) Pre".
New Yorl. (x,ellem <llllldtlrd texrhtHik)
Cullinan WE. Day N C. Schafer M K cr al. 1991
Neuroanatomical 311d functional studoes of pepudc
precur..or-proces,ing enzyme~. Enzyme 45: 285- 300
(Revieu: of en:..vme mecJumi\m,t imwltnl in
neuropeptide processil!g)
HClkfelt T I 99 I Neuropeplides in perspective: 1he 1,,,, ten
years. Neuron 7: 867- 879 (F..~rrllenr "''1'11'iew by a
neuropeptide pioneer)
Hokfelt T, Broberger C. Xu Z-Q 0 et nl. 2000
Ncuropeptides-:m overview. Neurophnm1ncology 39:
1337-1356 (xul/em .wmmW')' oj'deelopmtrllf t1trhe
millennium)
Lundberg J M 1996 Phannacology of co-lr:tn\mi,,ion in
the auronomic ne.-ous 'Y'ICnl: inrcgrarhc ll\pect' on
amines. neuropepudes, adenos1nc Lripho~pharc. anuno
acids and nitric oxide. Phannacol Re 48
114-192
\llcunter J-C. Mollercau C. Toll L et at. I'195 holatton
and strucrure of the endogenou<, agOnhl of opio1d
receptor-like ORLI receplor 'laturr 377: 532- 535
(Dest:riMs the difC(J>UJ of on (l(lll>idflk~ peprull'
ligand for a hitherto 'orphart ' reupiiJr)
Route
Inhalation
Injection
Injection
Injection
Injection
Injection
Injection or oral
Injection
\hleJew'kt G J 2001 Peptides as receptor lig311d dru~
and the.r relarionship to G<OUpled signal
lr311sduction. Expert Opin (0\estig Drugs 10:
1063-1073 Wse/ttiJ1enera/ mit'K ofpeptide
thuupeutit:.l, dealing "ith many inue.\ inc/udin( 1~
tulvamages mtd disad>atllages of pep11des Ill dru~
multheir potemial use in mrricm1cer
thertpy)
Nestler E J, Hyman S E. Malcnka R C 2001 Molecul;tr
neuropharmacology. McGmw-Hill, New York IGt~>il
motlern textbook)
Ol..uda-Ashitaka E. Ito S 2000 Nocisrarin : a novel
neuropeptide encoded by the gene for the
nociceplin/orphanin FQ precursors. Pepl ides 21:
1101-1109
Perone M J, Windeau S, Ca>tro M G 1997 1nrraccllu1Jr
trafficking of prohom1ones and proneuropeplides: cell
type-specific soning and targeting. Exp Phy~iol 82:
609-628 (Excellent reo'iew of mechanisms by whirh
cells manage to avoid getting their mOrt)
neuropeptides confused)
Sherrn311 T G, Akil H. WaL'>On S J 1989 The molecular
b1ology of neuropepudes. Disc Neuro-.ct 6: I 58
(Gmeral ,.,., it"K)
Yanagt~wa M. Kurihara H. Kimura Setal. 1988A
no1cl porcnl va>oconstriclor peptide produced b)
-ascular endothelial eel b. 'larure 332: 411-415
(The discou>o ofendotheli~ rrnttJrliabl~ """de
forrt')
 Nitric oxide

(Fig. 17.1) i!. NO (Fig. 17.2). NO is the endogenous activator of

Overview 265 soluble guanylate cyclase, leading to the formation of cyclic
Introduction 265 GMP (cGMP), an important 'second messenger' (Ch. 3) in many
--------------------------~ celts, including nerves, smooth muscle, monocytes and platelets.
Biosynthesis of nitric oxide and its control 266 Nitrogen and oxygen are neighbours in the periodic table, and
Degradation and carriage of nitric oxide 268 NO shares several properties with 0 2, in particular a high affinity
for haem and other iron-sulfur groups. This is important for
Effects of nitric oxide 269 activation of guanylate cyclase, which contains a haem group,
--------------------~ and for the inactivation of NO by haemoglobin (see below).
Therapeutic approaches 270
-Nitric oxide 270 The role of 0 in specific settings is described in other
-Nitric oxide donors 271 chapters: the endothelium in Chapter 19, the autonomic nervous
-Inhibition of nitric oxtde synthesis 271 system in Chapter 9, as a chemical transmitter and mediator of
-Potentiation of nitric oxide 272 excitotoxicity in the central nervous system (CNS) in Chapters
32-35, and in the innate mediator-derived reactions of acute
Clinical conditions in which nitric oxide may play inflammation and the immune response in Chapter 13. Therapeutic
a part 272 uses of organic nitrates and of nitroprusside (NO donors) are
described in Chapters 18 and 19.

OVERVIEW
Nitric oxide (NO) is a ubiquitous mediator with Unrubbed
diverse functions. It is generated from Larginine
by nitric oxide synthase (NOS), an enzyme that
occurs in endothelial, neuronal and inducible
rch-8
j 7
isoforms. In this chapter, we concentrate on Smin
general aspects of NO, especially its biosynthesis,
degradation and effects. We touch on recent NA -7.7
evidence that it can act as a circulating as well as
a local mediator, and conclude with a brief
consideration of the therapeutic potential of drugs Rubbed
that act on the Larginine/NO pathway. ~
ACh -8 -7 -6 wl

~
INTRODUCTION
itric oxide, a free radical gas. is formed in the atmosphere 1'
NA -7.7
during lightning Morms. Less dramatically. but with far-reaching w
biological consequences, it is also formed in an enzyme-catalysed
reaction between molecular oxygen and L-arginine. The
convergence of several tines of research led to the realisarion Fig. 17.1 Endothelium-derived relaxing factor.
that 0 is a key signalling molecule in the cardiovascular and Acetylcholine (ACh) relaxes a strip of rabbit aorta precontracted
nervous systems. and that it has a role in host defence. with noradrenaline (NA) if the endothelium is intact ('unrubbed':
j
l
upper panel), but not if it has been removed by gentle rubbing
A physiological function of NO was discovered in the 'rubbed': lower panel). The numbers are logarithms of molar
vasculature when it was shown that the endothelium-derived concentrations of drugs. (From Furchgott & Zawadzki, 1980.)
relaxing factor described by Furchgott & Zawadzki ( 1980)
265
 SECTION 2 . CHEMICAL MEDIATORS

A B

Hb+ACh

I I I I
3 10 30 100 O.o7 0.22 0.67
'-y----J '---v------'
~
c EDRF from BK nmol/1 TC NO nmol
l
-e0
II)
.0
<( 10 min

0.1

I I I
0 3 10 30 100 0.07 0.22 0.67
400 425 450 400 425 450
' - - - - - v - - ' '--..r-----'
Wavelength (nm) EDRF from BK nmol/1 TC NO nmol

Fig. 17.2 Endothelium-derived relaxing factor (EO AF) is c losely related to nitric oxide (NO). A EDRF released from aortic
endothelial cells (EC) by acetylcholine (ACh) (right-hand panel) has the same effect on the absorption spectrum of deoxyhaemoglobin
(Hb) as does authentic NO (left panel). 18' EDRF is released from a column of cultured endothelial cells by bradykinin (BK 3-100 nmol)
applied through the column of cells (TC) and relaxes a de-endothelialised precontracted bioassay strip, as does authentic NO (upper
trace). C A chemical assay of NO based on chemiluminescence shows that s1milar concentrations of NO are present in the EDRF
released from the column of cells as in equiactive authentic NO solutions. (From: A lgnarro et al. 1987 Circ Res 61: 866-879; (lW and
C) Palmer et al. 1987 Nature 327: 524-526.)

BIOSYNTHESIS OF NITRIC OXIDE AND
ITS CONTROL
Nitric oxide synthase ent.ymes are central to the control of NO
biosynthesis. There are three known isoforms: an inducible form
(iNOS or NOS- II ; expressed in macrophages and Kupffer cells,
neutrophils, fibroblasts, vascular smooth muscle and endothelial
cells in respon~e to pathological ~timuli such as invading
microorganisms) and two so-called constitutive forms, which are
present under physiological conditions in endothelium (eNOS
or OS-I II ) and in neurons (nNOS or NOS-I). eNOS is not
restricted to endothelium. It is also present in cardiac myocytes,
renal mesangial cells, o~teoblru.~ and osteoclasiS. airway epithelium
and, in !.mall amounts, platelet<;. The constitutive enzymes generate
small amount~ of 0. whereas iNOS produces much greater
amount~ both because of its high activity and because of the large
amount!. in which it i!> present, at least in pathological states
a!>sociatcd with cytokine release. '
11 is po~~ible that -.ome of the NO made in healthy animals under basal
1
condition~ is derived from the action of iN OS. just as the inducible form of
cycle-oxygenase is active under basal conditions (Ch. 13}--whether this is
becau~e there is hOme iNOS expressed even when there is no pathology, or
becau~e there i~ always enough 'pathology'. for example gut microtlora. 10
266 induce it. i\ u mool point.
T All three NOS isoenzymes are dimers. They are structurally Wld
functionally complex. bearing simllariries to the cytochrome P450 ent.yme'
(described in Ch. 8. p. 114) that are so imponant in drug metaboli,m.
Each isoform contains iron proloporphyrin IX (haem}, flavin adenine
dinucleotide (FAD). flavin mononucleotide (FMN) and retrahydrobiop1erin
( H4 13) as bound prosthetic groups. They also bind !-arginine. reduced
nicotinamide aden ine d inucleotide phosphate (NADPH) and calcium
-calmodu lin. These prosthetic groups and ligands control the a~sembly of
the en7yme into the active dimer. Calcium-calmodulin regulates elewon
tran~fer within the molecule.
Both nNOS and iN OS are ~oluble cytosolic enzymes, and eNOS
is dually acylated by N- myri~toylation and cysteine palmitoylation:
thc~c post-tran!>lational modifications lead to its association with
membranes in the Golgi apparatus and in caveolae, speciali'>ed
cholesterol-rich microdomain!> in the plasma membrane deri\ed
from the Golgi apparatu~>. In the caveolae. e OS is associated
with ca1eolin. a transmembrane protein involved in signal
transduction. A~sociation of eNOS with caveolin is reversible.
dissociation from caveolin activating the enzyme. Oxidised low
density lipoprotein (oxLDL) displaces eNOS from caveolae by
binding to endothelial cell CD36 receptors. This depletes the
cavcolac of cholesterol, disturbing eNOS function.
T The nitrogen atom in NO is derived from the terminal guanidine groop
of L-arginine. NOS enzymes are functionally 'bimodal'. in that they
combine oxygenase and reductase activities associaied with di\lin<:t
struclum l domains. The oxygenase domain contains haem. while the
 NITRIC OXIDE

reducta\e domatn bind\ calcium-<almodu)jn. FMN, FAD and NADPII.
NOS en1yme., are the only flavohaem enzymes tha! use H,B as a redox
cofactor The cry.,tal structure of the NOS berne (oxygena;e) domain in
iNOS and eNOS has revealed hoY. !-arginine. heme and H4B bind in the
acthe .. ue. By analogy Y.ith cytochrome ?450, it is believed that the
fla' in'> accept electron' fmm NADPH and transfer them to the haem iron,
Y.hich bmds otygen and cataly..e' the Mepwise oxidation of L-arginine.
via a hydro,yl-argmmc intermediate. to NO and ciLrulline. ln pathological
state,. the en1yme can undergo \tructural change leading to electron
tran,fer bet"ecn substrate\, enL}'rne cofactors and producll> becoming
uncoupled'. \O thm electrons are tran'>fcrred to molecular o:-.ygcn,
leading to the sy ntheSts of 'upero,ide anion rather than NO. This is
important. a' superoxidc anion i'> a reactive oxygen specie'> and react\
with NO to form a to,ic product (peroxynitrite anion. seep. 268 below).
L-Arginine is usually pre~ent in excess in endothelial cell
cytoplasm, so the rate of production of NO is determined by
the <lCtivity of the enzyme rather than by substrate availabi lity.
Nevertheless, very high doses of L-arginine can restore
endothelial NO biosynthesis in some pathological state~ (e.g.
hyperchole~terolaemia; ~ee below) in which endothelial function
is impaired. Po'>sible explanations for this paradox include:
compartmentation: i.e. existence of a distinct pool of
ubstrate in a cell compartment with access lO the synthase
en7yme, which can become depleted despite apparently
plentiful total cytoplasmic arginine concenrrations
competition with endogenous inhibitors of NOS such as
asymmetric dimethylarginine (ADMA: see below),
which is elevated in plasma from patients with
hyperchole!.terolaemia
reassembly/reactivation of enzyme in which transfer of
electrons has become uncoupled (rom L-arginine
relative deplelion of arginine, which can inhibit NOS activity
by inhibiting Lranslation of iNOS mRNA.

Receptors
(acetylcholine, bradykinin,
0' substance P, etc.) Mechanical shear stress
~ 100
c a
Q
iii 80
3
~
u; [Ca2+]i
60

t
(I)
(/)
<
0 40
>.
u Calmodulin ---'----.-Ca2+-calmodulin

NOS ~
(I)

12>. 20
c ENDOTHELIAL
n. <
::1
CELL NOS
e (!) 0 (active) (inactive)
'- ~

X
in
:d +
m
of
'[ 60
b Citrulline + NO Arginine
,D ~

GC ~GC
c 50
~0
s :[
40
n; (/)
iii 30
lh (I)
.c
d c:>. SMOOTH
(/)
20 MUSCLE
:d Q)
CELL
:d :E 10
al
2
5 0 ( cGMP GTP
e.
0.1 0.2 0.3 0.4 0.5 1.6
Free Ca2 concentration (J.tmol/1)
'----.....____~:;;;_;;,-~,:__,
RELAXATION

Fig. 17.3 Control of constitutive nitric oxide synthase (NOS) by calcium-calmodulin. ~1 Dependence on Ca of nitric oxide (NO)
2

and citrulline synthesis from L-arginine by rat brain synaptosomal cytosol. Rates of synthesis of NO from L-arginine were determined by
~p
stimulation of guanylate cyclase (GC) (a) or by synthesis of [3H)-citrulline from L-[3H)-arginine (b). lm Regulation of GC in smooth muscle
ey by NO formed in adjacent endothelium. Akt is a protein kinase that phosphorylates NOS, making it more sensitive to
ICI calcium-calmodulin. (From: (A) Knowles R Get al. 1989 Proc Natl Acad Sci USA 86: 5159-5162.) 267
he
 SECTION 2 . CHEMICAL MEDIATORS
The activi ty of constitutive isoforms of NOS is controlled by
intracellular calcium-calmodulin (Fig. 17.3). Control is exerted
in two ways:
many endothelium-dependent agonists (e.g. acetylcholine,
bradykinin, sub!.tance P) increase the cytoplasmic
concentration of calcium ion~. [Ca2] ,; the consequent
increase in calcium-calmodulin activates e OS or nNOS
phosphorylation of specific residues on eNOS renders it more
or less active at a given concentration of
calcium-calmodulin: this can alter NO synthesis in the
ab~ence of any change in [Ca2],.
The main physiological stimulus controlling endothelial NO
synthesis in re~ i stance vessels is probably shear stress. This is
sensed by e ndothelial mechanoreceptors and transduced via a
serine-threonine protein kinase called Akt or p!Vtein kinase B.
Agonists that increase cAMP in endothel ial cells (e.g. p2
ago nists) a lso increase eNOS activity, but via protein kinase
A- mediated pho~phorylation, 2 whereas protein kinase C reduces
eNOS acti vi ty by phosphorylating residues in the calmodulin-
binding domain, thereby reducing the binding of calmodulin.
Insulin increases eNOS activity via tyrosine kinase activation
(and a lso increases the expression of nNOS in diabetic mice).
In contrast to constitutive NOS isoforms, the activity of iN OS
is independent of rca 2],. Although iNOS contains a binding site
for calcium-calmodulin, the very high affinity of this site for its
ligand mean~ that i OS is activated even at the low values of
[Ca 2 ], present under resting conditions. The eruyme is induced
by bacterial li popolysaccharide and/or cytokjnes synthesised in
response to lipopolysaccharide. notably interferon-y, the antiviral
effect of which can be explained by this action. Tumour necrosis
factor-a and interleukin-1 do no t alone induce iNOS, but they
each syncrgise with interferon-y in this regard (see Ch. 13).
Induc tion of iNOS is inhibited by glucocorticoids and by several
cytoki nes, including transforming growth factor-p. There are
important species differe nces in the induc ibility of iNOS, which
is less readi ly induced in human than in mouse cells.
DEGRADATION AND CARRIAGE OF
NITRIC OXIDE
Nitric oxide reacts with oxygen to fonn 20 4 , which combines
with water to produce a mixture of nitric and nitrous acid~.
Nitrite ions are oxidised to nitrate by oxyhaemoglobin. These
reactions are !.ummarised as follow.
2NO + 0 2 -+ N 20 4
N204 + Hp -+ N0 3- + N0 2- + 2W
N02- + HbO -+ N0 3- + Hb
Low conccnLrations of NO arc relatively stable in air because the
reaction ~hown in equation l7 . 1 is second order. Consequently,
~he ~z agonbt~. which have endothelium-dependent as well as
268 endothelium-independent relaxing effects, work partly i n this way.
Nitric oxide: synthesis, inactivation and
carriage
Nitric oxide (NO) is synthesised from L-arginine and
molecular 0 2 by nitric oxide synthase (NOS).
NOS exists in three isoforms: inducible, and
constitutive endothelial and neuronal forms
(respectively iNOS, eNOS and nNOS). NOSs are
dimeric flavoproteins, contain tetrahydrobiopterin and
have homology with cytochrome P450. The
constitutive enzymes are activated by
calcium-calmodulin. Sensitivity to
calcium-calmodulin is controlled by phosphorylation
of specific residues on the enzymes.
iNOS is induced in macrophages and other cells by
lnterferon-y.
nNOS is present in the central nervous system (see
Chs 32-35) and in non-noradrenergic non-cholinergic
nerves (see Ch. 9).
eNOS is present in platelets and other cells in
addition to endothelium.
NO is inactivated by combination with the haem of
haemoglobin or by oxidation t o nitrite and nitrate,
which are excreted in urine.
NO is unstable but can react reversibly with cysteine
residues (e.g. in globin or albumin) to form stable
nitrosothiols; as a result, red cells can act as an
0 2 -regulated source of NO. NO released in this way
escapes inactivation by haem by being exported via
cysteine residues in the anion exchange protein in red
cell membranes.
s mall amounts of NO produced in the lung escape degradation
and can be detected in exhaJcd air. In contrast, NO reacts very
rapid ly with even low concentrations of superoxide anion (0, 1
to produce peroxynitrite anion (ONoo-), which is responsible
for some of its toxic effects.
Endothelium-derived NO acts locally o n underlying vascular
smooth muscle or on adherent monocytes or platelets. The potential
for action at a distance is neatly demonstrated by Rhodni111
proltxu.\, a blood-sucking insect that produces a saliva"
vasodilator/platelet inhibitor with the properties of a nitr;
(17.1) vasodilator. This consists of a mixture of nitrosylared
haemoprotein!., which bind NO in the salivary glands of the
( 17.2)
insect but release it in the tissues of its prey. The consequent
( 17.3) vasodilatation and inhibition of platelet activation presumabl)
facilitates extraction of the bug's meal in liquid fonn. A strong.
but still controversial, case has been made that NO can also act
a t a dbtance in the mammalian circulation via reversibk
interactions with haemoglobin. Here we describe this proposal
o nly in broad outline; readers who require a more detailed
account arc directed to reviews by Singel & Stamler (2005) and,
for a sceptical view, Schechter & Gladwyn (2003).

Haem has an affinity for NO> I 0 000 times greater than for
oxygen. In the absence of oxygen. NO bound to haem is relatively
stable, but in the presence of oxygen NO is converted to nitrate
and the haem iron oxidised to methaemoglobin. Distinc t from
this inactivation reaction, a specific cysteine residue in globin
combines reversibly with 0 under phy~iological conditions.
The re~ulting S-nitrosylated haemoglobin is believed to be involved
in various NO-related activities, including the control of vascular
resistance, blood pressure and respiration. Key features of the
propo!>ed mechani!>m include the following.
Nitrosylation of haemoglobin is reversible.
It depends on the state of oxygenation of the haemoglobin,
which consequently takes up NO in the lungs and releases it
in tissues, in concert with release of oxygen. Haemoglobin
acts as an 0 2 sensor and could regulate vascular tone (and
hence tissue perfusion) in response to the local partial
pres~ure of 0 2 by releasing NO in this way. This mechanism
is impaired in sickle cell disease (a common inherited
di~order caused by a molecular variant of haemoglobin).
NO is not relca~ed into the cytoplasm of erythrocytes (where
it would promptly be inactivated by haem), but is transported
out of the red cells via cysteine residues in the haemoglobin-
binding cytoplasmic domain of an anion exchanger called AE 1.3
S-nitrosylated albumin also constitutes a source of circu lating
NO bioactivity. An alternative view is that nitrite anion,
rather than nirrosylated protein, is the main intravascular NO
storage molecule (see Kim-Shapiro et al., 2006).
1
AEI i~ responsible for the exchange of chloride and b1carbonare ions
acro~sthe cell membrane. the Hamburger shifl' beloved of red cell
physiologists. It i s rhc most abundam protein in red cell membranes.
Table 17.1 Postulated roles of endogenous nitric oxide
Syste m Phys iological role
Ca rdiovascular
Endothelium/vascular Control of blood pressure and
smooth muscle regional blood flow
Platelets Limitation of adhesion/aggregation
Hos t defence
Macrophages, Defence against viruses, bacteria,
neutrophils, leucocytes fungi, protozoa, parasites
Nervous sys te m
Central Neurotransmiss1on, long-term
potentiation, plasticity
(memory, appetite, nociception)
Peripheral Neurotransmission (e.g. gastric
emptying, penile erection)
N ITRIC OXIDE
EFFECTS OF NITRIC OXIDE
Nitric oxide reacts with various metals, thiols and oxygen
species, thereby modifying proteins, DNA and lipids. One of its
most important biochemical effects (sec Ch. 3) is activation of
soluble guanylate cyc/(1.\e. a heterodimcr present as distinct
isoenzymes in vascular and nervous tis~ue. Guanylate cyclase
synthesises the second messenger cGMP. NO activates the
enzyme by combining with its haem group. and many physiological
effects of low concentrations of NO are mediated by cGMP.
These effects arc prevented by inhibitors of guanylate cyclase
(e.g. I H-1 1,2,4]-oxadiazole-r4,3-aj-quinoxalin- l-one, ODQ),
which are useful investigational tools. NO activates soluble
guanylate cyclase in intact celb (neurons and platelets)
extremely rapidly, and activation is followed by desensitisation
to a steady-state level. This contrasts with its effect on the
isolated enzyme, which is slower but more sustained. Guanylate
cyclase contains another regulatory site, which is NO-
independent. This is activated by several investigational drugs
(e.g. BAY 41-2272 and YC-1) that potentiate NO and have
therapeutic promise.
Effects of cGMP are terminated by pho!>phodiestera e enzymes.
S ildeoafil and tadalafil are inhibitors of phosphodie~terasc type
V that arc used to treat erectile dysfunction, because they
potentiate NO actions in the corpora cavemosa of the penis
by this mechanism (sec Ch. 30. p. 458). 0 also combines
with haem groups in other biologically important proteins (e.g.
cytochrome c oxidase, where it competes with oxygen,
contributing to the control of cellular respiration). Cytotoxic and
/or cytoprotective effect.'> of higher concentrations of NO relate to
its chemistry as a free radical (see Ch. 35). Some physiological
and pathological effects of NO are s hown in Table 17. I.
Pat hological role
Excess production Inadequate production or action
Hypotension (septic shock) Atherogenesis, thrombosis (e.g.
m hypercholesterolaemia,
diabetes mellitus)
Excitotoxicity (Ch. 35) (e.g.
ischaemic stroke, Huntington's
disease, AIDS dementia)
Hypertrophic pyloric stenosis,
erectile dysfunction
269
 SEcnON 2 CHEMICAL MEDIATORS
BIOCHEMICAL AND CELLULAR ASPECTS
Pharmacological effect~ of 0 can be studied with NO gas
dissolved in deoxygenated ~alt solution. More conveniently, but
less directly. variou~ donon. of NO, such as nitroprusside.
S-nitro.wacetylpenicillamine (SNAP) or S -nitrosoglwathione
(SNOG) have been u~ed ~ ~urrogates. This has pitfalls; for
example, a\corbic acid potentiate~ SNAP but inhibits responses
to authentic o.~
Nitric oxide can activate guanylate cyclase in the same cells
that produce it, giving ri!>e to autocrine effects, for example on
the barrier function of the endothelium. NO also diffuses from it!>
site of !>ynthcsis and activates guanylate cyclase in neighbouring
cells. The resulting increase in cGMP affects protein kinase G,
cyclic nucleotide phosphodiesterases, ion channels and possibly
other proteins. This inhibits the rca~+l,-induced smooth muscle
contraction and platelet aggregation that occur in response to
agonists. NO also hyperpolariscs vascular smooth muscle, as a
consequence of potassium channel activation. NO inhibits
monocyte adhesion and migration. adJ1esion and aggregation of
platelet~. and ~mooth muscle and fibroblast proliferation. These
cellular effect\ probably underlie the antiatberosclerotic action of
NO (see Ch. 20, p. 321 ).
Large amounts of 0 (released following induction of NOS or
excessive stimulation of NMDA receptors in the brain; sec
pp. 510-512) cau!>e cytotoxic effects (either directly or via
peroxynitrite anions). These contribute to host defence, but also
to the neuronal destruction that occurs when there is
overstimulation of NMDA receptors by glutamate (see Chs 33
and 35). Paradoxically. NO is also cytoprotective under some
circumstances (\Ce Ch. 35).
VASCULAR EFFECTS (SEE ALSO CH. 19, P. 306)
The endothelial I.-arginine/NO pathway is tonically active in
resistance vessels, reducing peripheral vascular resistance and
hence systemic blood prcssuJe. Mutant mice that lack the gene
coding for eNOS arc hypertensive, consistent with a role for
0 bio~ynthcsis in the physiological control of blood pressure.
[ncrea~cd endothelial 0 generation may contribute to the
generalised vasodilatation that occurs during pregnancy.
NEURONAL EFFECTS (SEE CH. 9, P. 139,
TABLE 9.2 AND FIG. 9.7, AND CH. 34, P. 504)
Nitric oxide i'> a non-noradrenergic non-cholinergic ( A C)
neurotransmitter in many tissues (Ch. 9). and is important in tllc
upper airway'>. gastrointe!.tinal tract and control of penile erection
(Chs 23. 25 and 30). It is implicated in the control of neuronal
development and of synaptic plasticity in the CNS (Chs 32 and 34).
Mice carrying a mutation disrupting tlle gene coding nNOS have
grossly di\tended !.lomachs similar to those seen human
hypertrophic pyloric !>Ienos is (a disorder characterised by pyloric
"A~corbic acid rcl ea~es NO from SNAP but accelerates NO degradaLion in
270 solution. which could exp lain lhi~ divergence.
hypertrophy causing gastric outflow obstruction, which occur... m
approximately I in 150 male infants and is corrected surgicall) J.
n OS knockout mice rcsiM stroke damage caused by middle
cerebral artery ligation but are aggressive and over.;e~ed
(characteristics that may not be unambiguously disadvantageou'.
at least in the con1ext of natural selection !).
HOST DEFENCE (SEE CH. 13, P. 221)
Cytotoxic and/or cyto'>tatic effects of NO arc implicated m
prim iti ve non-'>pecific host defence mechanisms again\!
numerous pathogens, including viruses. bacteria, fungi, proto10a
and parasites, and against tumour cells. The importance of thb i\
evidenced by the susceptibility to Leishmania major (to which
wild-type mice are highly resistant) of mice lacking iNOS
M echanisms whereby NO damages invading pathogens include
nitrosylation of nucleic acids and combination with haem
containing ent.ymes, such as the mitochondrial enzymes involved
in cel l re!.piration.
THERAPEUTIC APPROACHES
NITRIC OXIDE
Inhalation of high concentrations of NO (a~ occurred \\hen
cylinder.. of nitrous oxide, N 10, for anaesthesia were accidentall)
contaminated) causes acute pulmonary oedema and methacrno-
globinacmia. but concentrations below 50 ppm (pans per mliltonl
are not toxic. NO (5-300 ppm) inhibits bronchoconsrriction
(at lea~t in guinea pigs). but the main action of inhaled NO i'
pulmonary vasodilatation. inspired NO acts preferentiall} on
ven tilated al veoli, and could therefore be therapeutically u-.eful
in respiratory distress syndrome. This condition has a high
mortality and is caused by diverse insults (e.g. infection). It i'
Actions of nitric oxide
Nitric oxide (NO) acts by:
combining with haem in guanylate cyclase,
activating the enzyme, increasing cGMP and
thereby lowering [Ca2+]1
combining with haem groups in other proteins
(e.g. cytochrome c oxidase)
combin1ng with superoxide anion to yield the
cytotoxic peroxynitrite anion
nitrosation of proteins, lipids and nucleic acids.
Effects of NO tnclude:
vasodilatation, Inhibition of platelet and monocyte
adhesion and aggregation, inhibition of smooth
muscle proliferation, protection against atheroma
synaptic effects in the peripheral and central
nervous system (see Chs 9 and 32-35)
host defence and cytotoxic effects on pathogens
(see Ch. 13)
cytoprotection.
 NITRIC OXIDE

characteri~ed by intrapulmonary 'shunting' (i.e. pulmonary

arterial blood entering the pulmonary vein without passing
through capillaric:. in contact with ventilated alveoli), resulting
in arterial hypoxacmia. and by acute pulmonary arterial
hypencn'>ion. Inhaled NO dilate~ blood \'essels in ventilated
alveoli (which arc expo~ed to the inspired gas) and thus reduces
'>hunting. NO is u'>ed in intensive care units to reduce pulmonary
h) pcnen~ion and to improve oxygen delivery in patients with
n.:spiratory diMre.,., syndrome. but it is not known whether this
imprO\CS long-term '>Urvival in these severely ill patients. E thy l
nitrite gas ha., been inve.,tigated in newborns (who arc at much
t------~ Citrulline
increa ed risk of respiratory di!>tress syndrome because of their
immature lungs) as a potentially less toxic alternative. ' DDAH ~

NITRIC OXIDE DONORS

Nitrovasodilators have been used therapeutically for over a
century. The common mode of action of these drugs is as a
source of 0 (Chs 18 and 19). There is interest in the potential
for selectivity of nitrova&ocli lators; for instance. gl yceryl
trinitrate is more potent on vascular smooth muscle than on
platelet!>, whereas SNOG !>electively inhibits platelet function.
L-arginine NOS /
+ - --=-=..:;.._____,., NO+ Citrulline
02
Fig. 17.4 Effect of a symmetric dimethylarginine
(ADMA). DDAH, dimethylarginine dimethylamino hydrolase;
NO, nitric oxide; NOS, nitric oxide synthase.

INHIBITION OF NITRIC OXIDE SYNTHESIS

Drugs can inhibit NO '>ynthesis or action by several mechanisms. 110
Arginine analogues compete with arginine for NOS. Several such
ec
100
compound'>, for example N'-monomcthyi-L-arginine (L-NMMA) 8
0 90
and JV'i-nitro-L-arginine methyl ester (L-NAME). have proved of
~ 80
great mlue as experimental tool&. One such compound, ADMA. ~
0
is approximately equipotent with L-NMMA. Jt is present in <;::;
70
human plasma and is excreted in urine. Its plasma concentration 8
:0 60
correlates with vascular mortality in patients receiving
E
haemodialysi~ for chronic renal failure, and is increased in iii 50
~
people with hypercholeMerolaemia (see p. 266, above). In 0
u. 40
addition to urinary excretion, ADMA is a lso eliminated by DNMA lNMA
metabolism to citru lline and methylami ne by dimethylarginine L-Arg
dimerhylamino hydrolase (DDAH), an enzyme that exists in two
isoforms, each with a functional ly essential reactive cysteine
residue in the active site that is subject to control by nitrosylation.
Inhibition of DDAH by NO causes feedback inhibition of the 0 20 40 60 80 100
L-arginine/NO pathway by allowing cytoplasmic accumulation Minutes after cannulation
of AD MA. Conversely, activation of DDAH could potentiate the Fig. 17. 5 Bas al blood flow in the human forearm is
L-argininc/NO pathway see Figure 17 .4. influenced by nitric oxide (NO) biosynthesis. Forearm blood
lnfw,ion of a low do'>e of t.-NMMA into the brachial artery flow is expressed as a percentage of the flow in the non-
cannulated control arm (which does not change). Brachial
cau<>es local va~oconwiction (Fig. 17.5), owing to inhibition of
artery infusion of the o-isomer of the arginine analogue
the basal production of NO in resi~tancc vessels of the infused ~-monomethyiL-arginine (o-NMA) has no effect, while the
arm, without inOucncing blood pressure or causing other systemic L-isomer (L-NMA) causes vasoconstriction. L-Arginine (L-Arg)
effects. whereac; intravenous L-NMMA causes vasoconstriction accelerates recovery from such vasoconstriction (dashed line).
in renal, mesenteric, cerebral and striated muscle resistance (From Valiance et al. 1989 lancet ii: 997-1000.)
vessels. increase~ blood pressure and causes reflex bradycardia.
There is therapeutic interest in selective inhibitors of different
isoforms of OS. Drugs for long-tenn treatment should not has been implicated (e.g. asthma). 7-Nitroindazole inhibits nNOS
inhibit eNOS, to avoid adverse cardiovascular effects. Selective and, following intraperitoneal administration to mice, inhibits
in hibitors of iNOS versus the two constitutive forms have been nociception wi thout ahering anerial blood pressure: this selectivity
described (e.g. N-iminocthyl-L-Iysine). and have potential for the apparent ly results from an incompletely understood phannac-
treatment of innammatory and other conditio ns in whic h iNOS okinetic effect relating to access of the drug to NOS in brain. 271
 SECTION 2 C HEMICAL MEDIATORS
An endogenous protein inhibitor of n OS (termed PIN) works
by an entirely diiTereot mechanism, namely destabilising the
NOS dimer.
POTENTIATION OF NITRIC OXIDE
Several means whereby the L-arginine/NO pathway could be
enhanced are under investigation. Some of these rely on existing
drugs of proven value in other contexts. The bope (as yet unproven)
is that, by potentiating NO. they will prevent atherosclerosis or
its thrombotic complications or have other beneficial effects
attributed to NO. Possibilities include:
selecti ve NO donors as 'replacement' therapy (see above)
dietary supplementation with L-argi nine (see above)
antioxidants (to reduce concentrations of reactive oxygen
species and hence stabili se NO; Ch. 20)
drugs that restore endothelial f unction in patients with
metabolic risk factors for vascular disease (e.g. angiotensin-
converti ng enzyme inhibitors, statins, insulin, oestrogens;
Chs 19, 20, 26 and 30)
~ 2 -adre noceptor agonists and related drugs (e.g. nebivolol , a
~ 1 -adrenoceptor antagonist that is metabolised to an active
metabolite that activates the L-arginine/NO pathway)
phosphodiesterase type V inhibitors (e.g. sildenafil ; see
above and Ch. 30).
CLINICAL CONDITIONS IN WHICH NITRIC
OXIDE MAY PLAY A PART
The wide distribution of OS enzymes and diverse actions of
NO suggest that abnormalities in the L-arginine/NO pathway
could be importnnt in disease. Either increased or reduced
production could play a part, and hypotheses abound. Evidence
is harder to come by but has been sought usi ng various indirect
approaches, including:
analysing nitrate and/or cGMP in urine: these are bedevilled,
respectively, by dietary nitrate and by membrane-bound
guany late cyclase (which is stimulated by natriuretic
peptides; see Ch. 18)
Inhibition of the L-arglnlne/nitric oxide
pathway
Glucocorticoids inhibit biosynthesis of inducible (but
not constitutive) nitric oxide synthase (NOS).
Synthetic arginine analogues (e.g. L-NMMA, L-NAME;
see text) compete with arginine and are useful
experimental tools.
Endogenous NOS inhibitors include ADMA (see text)
and PIN (a protein t hat inhibits NOS dimerisation).
lsoform-selective inhibitors have therapeutic
potential.
272
a con~iderab le refinement is to administer l 15N]-argininc and
use ma~s ~pectrometry to measure the enrichment of 15N O\er
naturally abundant [ 14N]-nitrate in urine
measuring NO in exhaled air
measuring eiTectl> of NOS inhibitors (e.g. L-NMMA)
comparing responses to endothelium-dependent agoni~t~ (e.g.
acetylcholine) and endothelium-independent agonists (e.g.
nitropru~side)
measuring responses to increased blood flow ("flow-mediated
dilatation'), which are largely mediated by NO
studying histochemical appearances and pharmacological
respon1>es in vitro of ti ssue obtained at operation (e.g.
coronary artery surgery).
All these methods have limitations, and tbe dust is far from
settled. Nevertheless, it seems clear that the L-arginine/NO pathwa}
is indeed a player in the pathogenesis of severn! important
diseases, opening the way to new therapeutic approaches. Som~
pathological roles of excessive or reduced NO production are
summarised in Table 17.I. We touch only briefly on these cl i nic~!
conditions, and would cau tion the reader that not all of lhN
exciting pos<.ibilities are likely to withstand the test of rime!
Sepsis can cause multiple organ failure. Whereas NO benefit-
host defence by killing invading organisms, excessive NO cau-.e,
harmful hypotension. Disappointingly, however, L-NM\iA
worsened !>Urvival in one controUed clinical trial. Chronic lo~..
grade endotoxaemia occurs in patients with hepatic cirrho'''
Systemic vasodilatation is typical in such patients. Unnal)
excretion of cGMP i~ increased. and vasodilatation rna} be a
consequence of induction of NOS leading to increased t\0
synthesis. Nitrosative stress and nitration of proteins in aim~
epithelium may contribute to steroid resistance in asthma, and
the ineffectiveness of glucocorticoids in chronic obstructile
pulmonary disease (see Ch. 23, pp. 365- 366).
Nitric oxide biosynthesis i s reduced in patients with
llypercholesterolaemia and some other disorders that predispose
to atheromatous vascular disease, i ncluding cigarette srnokmg
and diabetes mellitus. In hypercholesterolaemia, evidence or
Nitric oxide In pathophysiology
Nitric oxide (NO) is synthesised under
physiological and pathological circumstances.
Either reduced or increased NO production can
contribute to disease.
Underproduction of neuronal NO is reported in babes
with hypertrophic pyloric stenosis. Endothelial NO
production is reduced in patients with
hypercholesterolaemia and some ot her risk factors for
atherosclerosis, and this may contribute to
atherogenesis.
Overproduction of NO may be important in
neurodegenerative diseases (see Ch. 35) and in septic
shock.
 NITRIC OXIDE

blunted NO relea1>c in forearm and coronary vascular beds is
suppo rted by evidence that this can be corrected by lowering
plas ma cholesterol (with a statin; sec Ch. 20) or by suppleme n-
tation with L-argininc.
Endothelial dysfunction in diabetic patients with erectile
dysfunction occurs in tissue from the corpora cavemosum of the
penis, as evide nced by blunted relaxation to ace tylcholine despite
preserved responses to nitro prusside (Fig. 17.6 ). Vasoconstric tor
response~ to intra-arterial L-NMMA are reduced in fo ream1
vasculan1re of insulin-dependent diabetics, especially in patients
r- 0 Established cli nical uses of drugs that intlue nce the
10
with traces of albumin in their urine (' microalbuminuria': early
evidence of glome rular endothelial dysfunctjon), suggesting that
basal NO synthesis may be reduced throughout their circulation.
It is thought that failure to increase endogenous NO biosynthesis
normally during pregnancy contributes tO eclampsia. This is a
hypcrtcn1>ive disorder that accounts for many maternal deaths
and in whic h the normal vasodilatatio n seen in healthy pregnancy
is lost.
Exccs!>ive NMDA receptor acti vatio n inc reases NO synthesis,
which contributes to several forms of neurological damage
(sec Ch. 35). nNOS i ~ absent in pyloric tissue from babies with
idiopathic hype rtrophic pyloric stcnosis. 5
L-arginine/NO syste m are summarised in the clinical box.

20
c
0 Nitric oxide In therapeutics
~ 30
1il /
Non-diabetic
~ 40 Nitric oxide (NO) donors (e.g. nitroprusside
-a; and organic nitrovasodilators) are well established
E
;;: 50 (see Ch. 19, clinical box, p. 31 0).
<1l
E Type V phosphodiesterase inhibitors (e.g. sildenafil,
0 60
c tadalaf il) potentiate the action of NO. They are used:
Q)
e 70 to treat erectile dysfunction (Ch. 30)
~ - other possible uses (e.g. pulmonary hypertension,
80
gastric stasis) are being investigated.
90 Inhaled NO is used in adult and neonatal respiratory
distress syndrome.
100 Inhibition of NO biosynthesis (e.g. by L-NMMA; see
-9 -8 -7 -6 -5 -4 text) is being investigated in disorders where there is
Acetylcholine concentration (log mol/1) overproduction of NO (e.g. inflammation and
Fig. 17.6 Impaired endothelium -mediated relaxation of neurodegenerative disease). Disappointingly, L-NMMA
penile smooth muscle from d iab etic men with erectile increases mortality in one such condition (sepsis).
dysfunction. Mean (:: SE) relaxation responses to
acetylcholine in corpora cavernosa tissue (obtained at the time
of performing surgical implants to treat impotence) from 16
I diabetic men and 22 non-diabetic subjects. (Data from Saenz
\_de Tejada et al. 1989 N Engl J Med 320: 1025-1030.) ' Arc such individuals 'nNOS gene knockout humans"/ What of their
~ubsequcm development?

REFERENCES AND FURTHER READING

Biochemical aspect~
Aldenon W K. Cooper(' I'" Kno-.le; R G 2001 Nitric
o~1de '> nlha..c.: ,uuc:IUre. funcuon and inhibition.
BlllChem J 357 593-615
Bellamy T C. Wood J. Good--.n 0 A. Ganhwalle J 2000
Rapod desen~11izauon of !he mine o"de n:c:cptor.
-.oluble guanylyl C)Cia..e. undcrhc\ di\CNI) of
cellular cGMP re\ptm...:,_ Proc Nail Acad Sci lJSA 97:
2928-2933 (In it< 1111/Ur<ll rmirrmmelll. soluble
[llltm\ltlle 1ydll\l' ht-hae, ffllll'h morr /oAe a
11eumtro11Jmlll<r rt'fe{>tor tlwn htul bu11 l'T{H'Cted
from pn:riou< m:;~mologiml <tlldlct. rarml
de\m\lflltllion ;, /iAe/.1 w bt: lfnJ>Qrttmt wuler
phwo/0/ll<a/ WflliltiOIIS)
Davis K L, Manin F.. Turko I V. Murad F 200 I Novel
eiTcch of nllric oxide. Annu Rev Phannacol Toxicol
4 1: 203 236 (R,.iew.\ 111111 -;GMPmediwed effects of
NO, i11duding modijiwtion1 ofiJIVItiiiS. li!Jids and
nucleic t1citls)
Fleming L Busse R 2003 \1olecular mcchanbm'
involved in the regulation of lhc endothelial notric
oxide synthase. Am J Ph) "ol 284 R I R 12
Fulton D. Fontana J, Sowa G e1 al 2002 Locahtall<ln of
endolhelial nitric-o~ide ~yntha-.c pho-phorylaled on
>erine 1179 and notric o~ide in Golg1 and pla~ma
membrane defines the e11i~1ence of '"o pool' of .K:tl\e
enzyme. J Bioi Chem 277: 4277~284 (Actiated.
phosphorylatt!d eNOS rrside.1 in cmeo/i11-rnriched
plasmalemma and Go/gi membrcml'.; both po<Jis Ill\'
VcGF-regulated to !Jnx./ucl' NO)
Hess D T. Matsumoto A. Kim S 0 et al 2005 Prmein S-
nitrosylation: purvie" and paran\CICI'I. Nature Re'
Mol Cell Biol6: 150-166
Jaffrey S R, SnyderS 1996 PIN: on n>\ociatcd prolcin
inh.ibi10r of neuronal nilric oxide 'Ynlha\e. Science
274: 774-777 (Works by tlestahilisin!l the nNOS dlmer)
Kim-Shapiro D B, Schcch1cr A N. Gladwin M T 2006
Unraveli ng the reactions of nitric ox ide. 111tritc. nnd
hemoglobin in physiology and !herapeulic>.
Anenoscler Thromb Vase Bioi 26: 697- 705 (Rmnu
reantnidl'IICl' thot nitrite anion may bl' thl! mam
mtrm-a>cutar NO soorage 1110/uute: cf Singe/ &
Stamler. 2005. below)
Krumenncl.cr J. HanaiY K A. .\Iurad F 2001 R~gula1ion
of nrlnc oxid~ and soluble guanylyl cyclase. Bram Re'
Bull 62: 505-515
lee: J. Ryu H. Ferrante R J e1 al. 2003 Tran\lauonal
control of mducible nitric Ollide S) nthase ex pre" ron
by argirnnc can eJtplain the arginine pnrado~. Proc
Natl Acad Sci USA 100: 484~848 (Inhibition of
NOS activity by arginme depletion in stimulated
ll.ltro<yte c11/tures occurs via inhibition of trans/arion
of iNOS mRNA. and provides oM explanorion for the
'a'8mine paradox' while indicating a distinct
mechanism b which substmte cwr regulate the
activit) of its asso,icoted
em:yme)
273
DRUGS AFFECTING MAJOR
ORGAN SYSTEMS

Overview 277
Introduction 277
Physiology of cardiac function 277
-Cardiac rate and rhythm 277
-Cardiac contraction 280
-Myocardial oxygen consumption and coronary
blood flow 282
-Autonomic transmitters 283
-Cardiac natriuretic peptides 285
------------------~
lschaemic heart disease 285
Drugs that aHect cardiac function 286
-Antidysrhythmic drugs 286
-Drugs that increase myocardial contraction 290
-Antianginal drugs 292
OVERVIEW
In this chapter, we review briefly the physiology of
cardiac function in terms of electrophysiology, of
contraction, of oxygen consumption and coronary
blood flow, and of autonomic control. This provides
a basis for understanding eHects of drugs on the
heart and their place in treating cardiac disease.
The main drugs considered are antidysrhythmic
drugs, drugs that increase the force of contraction
of the heart (especially digoxin), and antianginal
drugs. The commonest forms of heart disease are
caused by atheroma in the coronary arteries, and
thrombosis on ruptured atheromatous plaques;
drugs to treat and prevent these are considered in
Chapters 20 and 21. Heart failure is mainly
treated indirectly by drugs that work on vascular
smooth muscle, discussed in Chapter 19, by
diuretics (Ch. 24) and Padrenoceptor antagonists
(Ch. 11 ).
INTRODUCTION
In this chapter, we consider effects of dmgs on the heart under
three main headings:
The heart
rate and rhythm
myocardial contraction
metabolism and blood tlow.
The effects of drugs on these aspects of cardiac function are not,
of course, independent of each other. For example, if a drug
affects the electrical properties of the myocardial cell membrane,
it is likely ro innucnce both cardiac rhythm and myocardial
contraction. Similarly, a drug that affects contraction will
inevitably alter metabolism and blood flow as well. Nevertheless,
from a therapeutic point of view, these three classes of effect
represent di'>tinct clinical objectives in relation to the treatment,
respectively, of cardiac dysrhythmias. cardiac failure and
coronary insufficiency (as occurs during angina pectoris or
myocardial infarction).
PHYSIOLOGY OF CARDIAC FUNCTION
CARDIAC RATE AND RHYTHM
The chambers of the heart normally contract in a coordinated
manner, pumping blood efficiently by a route determined by the
valves. Coordination of contraction is achieved by a specialised
conducting ~ystcm. Phy:;iological sinus rhythm is characterised
by impulses arising in the si noatrial (SA) node and conducted in
sequence through the atria, the atrioventricular (AV) node,
bundle of His, Purkinje fibres and ventricles. Cardiac cells owe
their electrical excitability to voltage-sensitive plasma membrane
channels selective for various ions, including Na+, K+ and Ca 2,
the ~tructure and function of which are described in Chapter 4.
Electrophysiological features of cardiac muscle that distinguish
it from other excitable tissues include:
pacemaker activity
absence of fast Na+ current in SA and AV nodes, where slow
in\\ard Ca 2 current initiates action potentials
long action potential ('plateau') and refractory period
innux of Ca1+ during the plateau.
Thus several of the special features of cardiac rhythm relate to
Ca 1 current'>. The heart contains intracellular calcium channels
(i.e. the large ryanodine receptors and smaller inositol
trisphosphate-activated calcium channels described in Chapter 4
and important in myocardial contraction) and I'Oitage-dependent
calcium channel!> in the plasma membrane, which are important
in controlling cardiac rate and rhythm. The main type of voltage-
dependent calci um c hnnnel in adult working myocardium is the 277
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
L-type channel, which is also important in vascular smooth
muscle; L-typc channels are important in specialised conducting
regions as well as in working myocardium.
The action potential of an idealised cardiac muscle cell is
shown in Figure 18.1 A and is divided into five phases: 0 (fast
depolarisation), I (partial repolarisation), 2 (plateau), 3
(repolarisation) and 4 (pacemaker).
T Ionic mechanasm\ underlying these phase> can be summarised as
follow~.
Phase 0, rapid dt'polarisation. occurs wben the membrane potential
reache'> a critical firing thre~hold (about -60 mV), at which the inward
current of Nn nowing through the voltage-dependent sodium channels
becomes large enough to produce a regenerative ('all or nothing)
depolarisation. This mechan ism is the same as that responsible for action
potential generation in neurons (see Ch. 4). Activation of sodium channels
by membrane depolarisation is transient. and if the membrane remains
dcpolarised for more than a few milliseconds, they close again (inactivation).
They arc therefore c l o~ed du ring the plateau of the action potential and
remain unavailable for the initiation of another action potential unti l the
membrane repolari~es.
Pho.se I, partial t"t'polarisotion. occurs as the Na current is inactivated.
There may also be a tran<oient voltage-sen~itive outward current.
Phase 2. the plateau, results from an inward Ca2 current. Calcium
channcb '>how a pattern of voltage-<,ensitive activation and inactivation
qualitatively similar to sodium channels. but with a much slower time
cour-e. The plateau i\ assiMed by a special property of the cardiac muscle
membrane known as an ward-going rectification. which means that the K
conductance falls to a low level when the membrane is depolarised.
Becau~e of tht'>. there i'> little tendency for outward K current to restore
the resting membrane potential during the plateau. so a relathely small
inward Ca' ' current suffices to maintain the plateau.
Pltasl' 3. rtpolarisatton. occurs as tbe Ca2" current inactivates and a
delayed outwardly rectifying K' current (analogous to but much slower
than the K' current that cause~ repolarisation in nerve fibres; Ch. 4)
activate\, cau\ing outward K' current. Thi~ b augmented by another K
current. which is activated by high intracellular Ca2 concentration~.
!Ca21,. during the plateau. and sometimes also by other K~ currents.
including one through cha nnels activated by acetylcholine (see below)
and anmher that is activated by arachidonic acid. which is libera1ed under
pathological conditions ~>uch as myocard ial infarction.
Plwse 4, the pacemaker potellfial, is a gradual depolarisation during
dia~tole. Pacemaker activity i ~ normally found only in nodal and conducting
tissue. The pacemaker potential is caused by a combination of increasing
inward currents and declining outward currents during diastole. It is
u\ually mo\1 rapid in cells of the SA node. whicb therefore acts a.~
pacemaker for the whole heart. Celb in the SA node have a greater
background conductance to Na' than do atrial or ventricular myocytes,
leading to a greater background inward currenl ln addition, inactivation
of voltage-dependent calcium channels wears off during dia.Stole, resulting
10 increasmg mward Caz current during late diastole. Activation of
T-type calcaum channeb during late diastole contributes to pacemaker
activity in the SA node. The negative membrane potential early in diastole
activates a cauon channel that is permeable to Na and K. giving rise to
another inward current, called 111 An inhibitor of this current. habradinc,
slows the heart and b u~d therapeutically (see below, p. 292).
'f' for funny', because it is unu~ual for cati on channels to be activated by
1 provide a useful starting point for understanding how
hyperpolari~ation; electrophysiologists are renowned for a peculiar sen~e of
278 humour!
Several voltage- and time-dependent outward currents play a part as "'ell:
delayed rectifier K current (IK), which is activated during the acuon
potential, ~ turned ofT by the negative membrane potential earl) in
dia~tole. Current from the electrogenic NatK pump abo contribute, to
the outward current during the pacemaker potential.
Figure 18.1 B shows the action potential configuration in
different parts of the heart. Phase 0 is absent in the nodal
regions, where the conduction velocity is correspondingly slo\1
(- 5 cm/s) compared with other regions such as the PurkinJc
fibres (conduction velocity - 200 cm/s). which propagate the
action potential rapidly to the ventricles. Regions that lack a ra~t
inward current have a much longer refractory period than fast-
conducting regions. This is becau e recovery of the slow inward
current following ill> inactivation during the action potential take,
a considerable time (a few hundred milliseconds), and the
refractory period outlasts the action potential. With fast-conducting
fibres, recovery from inactivation of the Na+ c urrent is quick, and
the cell becomes excitable again as soon as it is repolarised.
The orderly pattern of sinus rhythm can become disrupted
either by heart disease or by the action of drugs or circulating
hormones, and an important therapeutic use of drugs is to restore
a normal cardiac rhythm where it has become disturbed. The
commone. t cause of cardiac dysrhythmia is ischaemic hean
disease. and many deaths following myocardial infarction re'ult
from \Cntricular fibrillation rather than directly from contracule
failure. For a more detailed coverage, 'from cell to bed,ide',
readers are referred to an authoritative textbook such a!> that of
Zipes & Jalife (2004).
DISTURBANCES OF CARDIAC RHYTHM
Clinically. dysrhythmial> are classified according to:
the site of origin of the abnormality- atrial, junctional or
ventricular
whether the rate is increased (tachycardia) or decreased
(bradycardia).
They may cause palpitations (awareness of the heartbeat) or
symptoms from cerebral hypoperfusion (feeling faint or losing
con~ciousness). Their diagnosis depends on the surface electro-
cardiogram (ECG), and details are beyond the scope of thi'
book- sec Braunwald & Opie (2001 ). The commonest t)pe'
of tachyarrhythmia are atrial fibrillation, where the heartbeat 1\
completely irregular, and supraventricular tachycardia (SVfl.
'"here the heartbeat is rapid but regular. Occasional ectopic beat'
(ventricular as well as supraventricular) are common. Sustain(()
ventricular tachyarrhythmias are much Jess common but much
more serious; they include ventricular tachycardia and ventricular
fibrillation. where the electrical activity in the ventricle, i)
completely chaotic and cardiac output ceases. Bradyarrhythmtii\
include various kinds of heart block (e.g. at the AV or SA node>
and complete cessation of electrical activity ('asystolic arre.,t').lt
is often unclear which of the various mechanisms discussed
below are rel>ponsiblc. These cellular mechanisms neverthcle"
antidy:.rhythmic drugs work. Four basic phenomena underlie
disturbances of cardiac rhythm:
 THE HEART

50~------------------------------.

>
.s
]! 0
'E
Q)

8.
Q)
c
~
.c -50
E
Q)
::!

100

0 0.5 1.0
Time (sec)

SA node

1
Atrium

1
AV node
Fig. 18.1 The cardiac action
potential. A Phases of the action
1
Purkinje fi bre

~
potential: 0, rapid depolarisation;
1, partial repolarisation; 2, plateau;
3, repolarlsatlon; 4, pacemaker Ventricle
depolarisatlon. The lower panel
shows the accompanying changes
in membrane conductance for Na,
K and Ca2. [ij] Conduction of the
impulse through the heart, with the
corresponding electrocardiogram
(ECG) trace. Note that the longest
delay occurs at the atrioventricular
(AV) node, where the action
potential has a characteristically
slow waveform. SA, sinoatrial.
(Adapted from: (A) Noble 0 1975
The initiation of the heartbeat. 0 0.2 0.4 0.6
Oxford University Press, Oxford.) Time (sec)

delayed after-depolarisation
abnormal action potentiaJs (Fig. 18.2). After-depolarisation is the
re-entry result of a net inward current, known as the transient inward current.
ectopic pacemaker activity A rise in iCa2+], activates Na+/Ca2+ exchange. This transfers one
heart block.
Ca2+ out of the cell in exchange for entry of three Na+. resulting
The main cause of delayed ajier-depolarisation is abnormally in a net innux of one positive charge and hence membrane
279
raised [Ca 2+],, which triggers inward current and hence a train of depolarisation. Additionally. Ca2+ opens non-selective cation
 SECTION 3 . DRU GS AFFECTING MAJOR ORGAN SYSTEMS
( Normal
1 sec
...-----.
'
81 82 83
Fig. 18.2 After-depolarisation in cardiac muscle
recorded from a dog c oronary sinus in the presence of
noradrenaline (norepinephrine). The first stimulus (81) causes
an action potential followed by a small after-depolarisation. As
the interval 82-83 is decreased, the after-depolarisation gets
larger (t) until It triggers an indefinite train of action potentials
\ (:j:). (Adapted from Wit A L, Cranefield P F 1977 Circ Res 41 : 435.)
channeb in the plas ma membrane, causing depolarisation
analogou!> to the endplate potential at the neuromuscular junction
(Ch. 10). Con.,equently. hypercalcaemia can delay repolarisation.
This is recognised clinically from prolongation of the QT interval
in the ECG. Hypokalaemia also prolongs the QT interval (via an
effect on the gating of cardiac delayed rectifier potassium
channels). Many drug~. including ones whose principal effect~
are on other systems, delay cardiac repolarisation as a result of
effects on electrolyte concentrations or from binding to
potassium or other cardiac channels (see Roden, 2004). This
increases Ca2 entry during the prolonged action poten6al,
leading to aftcr-depolarisation. Prolongation of the QT interval,
which carries a risk of causing dangerous ventricular dysrhythmias,
is a concern in drug development (see section below, Class Ill
drugs, and sec C h. 53).
In normal cardiac rhythm, the conducted impulse dies out after
it has activated the vcnuiclcs because it is surrounded by refractory
tissue, which it has just traversed. Re-entry (Fig. 18.3) describes
the situation in which the impulse re-cxcites regions of the
myocardium after the refractory period has subsided, causing
continuous circulation of action potentials. It can result from
anatomical anomalies or. more commonly, from myocardial
damage. Re-entry underlies many types of dysrhythmia, the pattern
depending on the ~ite of the re-entrant circuit, which may be in
the atria, ventricles or nodal tissue. A simple ring of tissue can
give rise to a re-entrant rhythm if a transient or unidirectional
conduction blocl.. is present. Normally. an impulse originating at
any point in the ring will propagate in both directions and die out
when the two impubes meet, but if a damaged area causes either
a transient block (so that one impulse is blocked but the second
can get through; Fig. 18.3) or a unidirectional block, continuous
circulation of the impul1.e can occur. This is known as circus
movement and was first demonstrated experimentally on rings of
280 jellyfish tissue many years ago.
Damaged
Anterograde Circus
impulse movement
blocked
Fig. 18 .3 Generation of a re-entrant rhythm by a
damag ed area of myocardium. The damaged area (brown)
conducts in one direction only. This disturbs the normal pattern
of conduction and permits continuous circulation of the
impulse to occur.
Although the physiological pacemaker resides in the SA node,
other cardiac tissues can take on pacemaker activity. This pro\tdc:,
a safety mechanism in the event of failure of the SA node but can
also trigger tachyarrhythmias. Ectopic pacemaker actil'it\' i'
encouraged by sympathetic activity and by partial depolarisauon.
which may occur during ischaemia. Catecholamines, acting on
~ 1 adrcnoceptors (sec below), increase the rate of depolarisatton
during phase IV and can cause normally quiescent parts of thl:
heart to take on a spontaneous rhythm. Several tachyarrhythmia'
(e.g. paroxysmal atrial fibrillation) can be triggered b}
c ircumstances associated with increased sympathetic activity.
Pain (e.g. during myocardial infarction) increases sympathetic
d ischarge and re leases adrenaline (epinephrine) from the adrenal
gland. Partial de polarisation resulting from ischaemic damage
also causes abnormal pacemaker activity.
Heart hlock results from fibrosis of, or ischaemic damage to,
the conduc ting system (often in the AV node). ln complete hean
block, the atria and ventricles beat independently of one another,
the ventricles beating at a slow rate determined by whate\er
pacemaker picks up distal to the block. Sporadic complete failure
of AV conduction causes sudden periods of unconseiou\nc''
(Stoke~ Adam!> atLacks) and is treated by implanting an anificial
pacemaker.
CARDIAC CONTRACTION
Cardiac output is the product of heart rate and mean left
ventricular stroke volume (i.e. the volume of blood ejected from
the ventricle with each heartbeat). Heart rate is controlled b)
the autonomic nervous system (Chs I 0 and II, and see belo11.
pp. 283-285). Stroke volume is determined by a combination of
factors, including some intrinsic to the heart itself and other
hacmodynamic factors extrinsic to the heart. Intrinsic facto~
regulate myocardial contracti lity via fCa2+l; and ATP, and arc
 THE HEART

caused by ischaemic preconditioning, and blockade of adenosine

Dysrhythmias arise because of:
delayed after-depolarisation, which triggers
ectopic beats
re-entry, resulting from partial conduction block
ectopic pacemaker activity
heart block.
Delayed after- depolarisation is caused by an inward
current associated with abnormally raised intracellular
Ca2~.
Re-entry is facilitated when parts of the myocardium
are depolarised as a result of dtsease.
Ectopic pacemaker activity is encouraged by
sympathetic activity.
Heart block results from disease in the conducting
system, especially the atrioventricular node.
Clinically, dysrhythmias are divided:
according to their site of origin (supraventricular
and ventricular)
according to whether the heart rate is increased
or decreased (tachycardia or bradycardia).
receptors prevents the protective effect of preconditioning (see
Saurin et aJ., 2000; Linden, 200 l). There is considerable interest
in developing strategies to min.im.ise harmful effects of ischaemia
while maximising preconditioning.
VENTRICULAR FUNCTION CURVES AND HEART
FAILURE
The force of contraction of the heart is determined partly by its
intrinsic contractility (which, as described above, depends on
[Ca 2+], and availability of ATP), and partly by extrinsic
haemodynamic factors that affect end-diastolic volume and
hence the resting length of the muscle fibres. The end-diastolic
volume is determined by the end-diastolic pressure, and its effect
on stroke work is expressed in the Frank-Starling law of the
heart, which reflects an inherent property of the contractile
system. The Frank-Starling law can be represented as a
ventricular function curve (Fig. 18.4). The area enclosed by the
pressure-volume curve during the cardiac cycle provides a
measure of ventricular stroke work. It is approximated by the
product of stroke volume and mean arterial pressure. As Starling
showed, factors extrinsic to the heart affect its performance in
various ways, two patterns of response to increased load being
particularly important.

Increased cardiac filling pressure (preload), whether caused

<;ensitive to various drugs and pathological processes. Extrinsic
by increased blood volume or by venoconstriction. increases
circulatory factors include the elasticity and contractile state of
arteries and veins, and the volume and viscosity of the blood,
which together determine cardiac load (preload and afterload).
Drugs that inrluence these circulatory factors are of paramount
importance in treating patients with heart failure. They are
covered in Chapter 19.

MYOCARDIAL CONTRACTILITY AND VIABILITY

The contractile machinery of myocardial striated muscle is
basically the same as that of voluntary striated muscle (Ch. 4). Il
involves binding of Ca2+ to troponin C; this changes the con-
formation of the troponin complex. permining cross-bridging of
myosin to actin and initiating contraction.
Many effects of drugs on cardiac contractility can be explained
in terms of actions on [Ca 2+]i, via effects on calcium channels in
plasma membrane or sarcoplasmic reticulum, or on the Na+/K+
pump, which indirectly influences the Na/Ca2+ pump (see below,
pp. 291-292). Other factors that affect the force of contraction
are the availability of oxygen and a ~ource of metabolic energy
such as free fatty acids. Myocardial stunning-<:ootractile 4
dysfunction that persists after ischaemia and reperfusion despite End diastolic pressure (kPa)
restoration of blood flow and absence of cardiac necrosis- is
Fig. 18.4 Ventricular function curves in the dog.
incompletely understood but can be clinically important. Its Infusion of physiological saline increases blood volume and
converse is known as ischaemic preconditioning; this means an hence end-diastolic pressure. This increases stroke work
improved ability to withstand ischaemia following previous ('extrinsic' control) by increasing the force of contraction of the
ischaemic episode~. This potentially beneficial state could also heart. This relationship is called the Starling curve.
Noradrenaline has a direct action on the heart ('intrinsic'
be clinically important. There is some evidence that it is
control), increasing the slope of the Starling curve. (Redrawn
mediated by adenosine (see Ch. 2), which accumulates as ATP is from Sarnoff S J et al. 1960 Circ Res 8: 11 08.)
depleted. Exogenous adenosine affords protection similar to that
 SECTION 3 DRUGS AFFECTING MAJOR ORGAN SYSTEMS

ventricular end-diastolic volume. This increases stroke

volume and hence cardiac output and mean arterial pressure. Myocardial contraction
Cardiac work and cardiac oxygen consumption both increase.
Arterial and arteriolar vasoconstriction increases afterload. Controlling factors are:
End-diastolic volume and hence stroke work are initially - intrinsic myocardial contractility
unchanged, but con<>tant stroke work in the face of increased - extrinSIC circulatory factors.
vascular resistance causes reduced stroke volume and hence Myocardial contractility depends critically on
increased end-diastolic volume. This in turn increases stroke intracellular Ca2, and hence on:
work, until a steady state is re-established with increased -Ca2 ' entry across the cell membrane
end-diastolic volume and the same cardiac output as before. -Ca2 storage in the sarcoplasmic reticulum.
As with increa ed preload, cardiac work and cardiac oxygen The main factors controlling Ca2 entry are:
consumption both increase. - activity of voltage-gated calcium channels
- intracellular Na, which affects Ca2tNa exchange,
Normal ventricular filling pressure is only a few centimetres of Catecholamines, cardiac glycosides, and other
water, on Lhe steep part of the ventricular function curve, so a mediators and drugs influence these factors.
large increase in woke work can be achieved with only a s mall Extrinsic control of cardiac contraction is through the
increase in filling pressure. The Starling mechanism plays little dependence of stroke work on the end-diastolic
part in controlling cardiac output in healthy subjects (e.g. during volume, expressed in the Frank-starling law.
exercise), because c hanges in contractility, mainly as a result of Cardiac work is affected independently by afterload
c hanges in sympathetic activity, achieve the necessary regulation (i.e. peripheral resistance and arterial compliance) and
wi tho ut any increase in ve ntricular filling pressure (Fig. 18.4). In preload (i.e. central venous pressure).
contrast, the denervated heart in patients who have received a
heart transplant relies on the Starling mechanism to increase
cardiac output during exercise.
In heart failure, the cardiac output is insufficient to meet the
circulatory needs of the body, initially only when these are
Physical factors
During systole, the pressure exerted by the myocardium on
increased during exercise but ultimately, as disease progresses,
vessels that pass through it equals or exceeds the perfusion
also at re~t. It has many causes, most commonly ischaemic heart
pres~ure, so coronary flow occurs only during diastole. Diastoll:
disease. In patients with heart fai lure (see Ch. 19), the heart may
is shortened more than systole during tachycardia. reducing 1he
be unable to deliver as much blood as the tissues require, even
period available for myocardial perfusion. During diastole, the
when its contractility is increased by sympathetic activity. Under
effective perfusion pressure is equal to the difference between the
these conditions, the basal (i.e. at rest) ventricular function curve
aortic and ventricular pressures (Fig. 18.5). If diastolic aortic
is greatly depressed, and there is insufficient reserve, in the sense
pressure falls or diastolic ventric ular pressure increase,.
of extra contractility that can be achieved by sympathetic
perfusion pressure falls and so (unless other control mechanism'
activity, to e nable cardiac output to be maintained during
can compe nsate) does coronary blood flow. Stenosis of the aortic
exercise without a large increase in central venous pressure
(Fig. 18.4). Oedema of peripheral tissues (causing swelling of the
legs) and the lungs (causing breathless ness) is an important
consequence of cardiac failure. It is caused by the increased
venous pressure, and retention of Na (see Ch. 19). 20 Systole Diastole Systole

MYOCARDIAL OXYGEN CONSUMPTION

AND CORONARY BLOOD FLOW
Relative to it~ large metabolic needs, the heart is one of the most
poorly perfused ti~sues in the body. Coronary flow is, under
nonnal circumstances, closely related to myocardial oxygen
consumption, and both change over a nearly 10-fold range
between conditions of rest and maximal exercise. 0

PHYSIOLOGICAL FACTORS 0.5 s

Fig. 18 .5 Mecha nical factors affecting coro nary blood
The main phyl>iological factors that regulate coronary flow are: flow. The 'window' for coronary flow may be encroached
physical factors on by: (1) shortening diastole, when heart rate increases;
(2) increased ventricular end-diastolic pressure; and
vascular control by metabolites (3) reduced diastolic arterial pressure.
2 82 neural and humoral control.

valve reduce~ aortic pre~~ure but increases left ventricular
pre!>Sure up. tream of the narrowed valve, and often causes
ischaemic che!>t pain (angina) even in the absence of coronary
artery di!>ease.
Vascular control by metabolites/ mediators
Vascular control by metabolites is tbe most important mechanism
b} which coronary flow is regulated. A reduction in arterial
partial pressure of oxygen (Po!) causes marked vasodilatation of
coronary vessels in situ but has little effect on isolated strips of
coronary artery. Thi~ suggests that it is a change in tbc pattern of
metabolites produced by the myocardial cells, rather than the
change in Po 2 per sc, that controls the state of lbe coronary
vessels, a popular candidate for the dilator metabolite being
adenosine (sec Ch. 12).
Neural and humoral control
Coronary vessels have a dense sympathetic innervation, but
sympathetic nerves (like circulating catecholamines) exert only a
small direct effect on the coronary circulation. Large coronary
vessels possess a-adrcnoceptors that mediate vasoconstriction,
whereas smaller vessels have ~ 2 -adrenoceptors that have a dilator
effect. Coronary vessels are also innervated by purinergic,
pcptidergic and nitrergic nerves. Normally, neural and endocrine
effects on coronary vasculature are overshadowed by lbe vascular
response to altered mechanical and metabolic activity.
AUTONOMIC TRANSMITTERS
Many aspects of autonomic pharmacology have been discussed
in Chapter!> 9-11; here. we mention only aspects that particularly
concern the heart.
Coronary flow, Ischaemia and infarction
The heart has a smaller blood supply in
relation to its oxygen consumption than most organs.
Coronary flow is controlled mainly by:
physical factors, including transmural pressure
during systole
vasodilator metabolites.
Autonomic innervation is less important.
Coronary 1schaem1a IS usually the result of
atherosclerosis and causes angina. Sudden
ischaemia is usually caused by thrombosis and may
result in cardiac infarction.
Coronary spasm sometimes causes angina (variant
angina).
Cellular Ca2 overload results from ischaemia and
may be responsible for:
cell death
- dysrhythmlas.
THE HEART
AUTONOMIC CONTROL OF THE HEART
The sympathetic and parasympathetic systems each exert a tonic
effect on the heart at rest. They influence each of the aspects of
cardiac function that have been discussed above, namely rate and
rhythm, myocardial contraction. and myocardial metabolism and
blood flow.
Sympathetic system
The main effects of sympathetic activity on the heart are:
increased force of conuaclion (positive inotropic effect;
Fig. 18.6)
increased heart rate (positive chronotropic effect; Fig. 18.7)
increased automaticity
repolarisation and restoration of function following
general ised cardi:Jc depolarisation
reduced cardiac efficiency (i.e. oxygen consumption is
increased more than cardiac work).
These effects all result from activation of ~ 1 - adrenoceptors. The
~ 1 effects of catecholamines on the heart, although complex,
probably all occur through increased intracellular cAMP (see Ch. 3).
cAMP activates protein kinase A, which phosphorylates sites on
the a, subunit!> of calcium channels. Tbis increa~e~ the
probability that the channels will open. increasing inward Ca 2
current and hence force of cardiac contraction (Fig. 18.6).
Activation of ~ 1 -adrenoceptors also increases the Ca 2+ sensiti\ ity
of the contractile machinery, possibly by phosphorylating troponin
C; furthermore, it facilitates Ca2"' capture by the sarcopla<;mic
reticulum. thereby increa:.ing the amount of Ca2+ available for
release by the action potential. The net result of catecholamine
action is to elevate and steepen the ventricular function curve
(Fig. 18.4). The increase in heart rate results from an increased
slope of the pacemaker potential (Figs 18.1 and 18.7). Increased
Ca2+ entry also increases automaticity because of the effect of
lCa 2+J; on the transient inward current, which can result in a train
of action potentials following a single stimulus (Fig. 18.2).
Activation of ~ 1 -adrcnoceptors repol arises damaged or
hypoxic myocardium by stimulating the Na+/K+ pump. This can
....____c_ ontroQ ( Isoprenaline 2.5 nmoVI
::~"~2=K=(o2mN
1s
Fig. 1 8.6 The calcium transient in frog cardiac muscle.
A group of cells was injected with the phosphorescent Ca2
indicator aequorin, which allows (Ca2 ], to be monitored
optically. Isoprenaline causes a large increase in the tension
l
and in the [Ca2], transient caused by an electrical stimulus (.A).
(From Allen D G, Blinks J R 1978 Nature 273: 509.) )
283
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

restore function if asystole has occurred following myocardial

A infarction, and adrenaline is one of the most imponant drug'
10 sec used during cardiac arrest.
NA
-~Control
The reduction of cardiac efficiency by catecholamincs i,
imponant because it means that the oxygen requirement of the
I Action myocardium increases. This limjts the use of~ agonists such a'
potential adrenaline and dobutamine for circulatory shock (Ch. 19)
400ms
Myocardial infarction activates the sympathetic nervous sy\tc:m
c 0 (Fig. 18.8), wruch bas the undesirable effect of increasing the
10 sec oxygen needs of the damaged myocardium.
- ---<

f'tc::~ol Parasympathetic system

I ~Ch Action
potential
Vagal stimulation 400ms
Fig. 18.7 Autonomic regulation of the heartbeat. A and
B. Effects of sympathetic stimulation and noradrenaline (NA). C
and D. Effects of parasympathetic stimulation and
acetylcholine (ACh). Sympathetic stimulation (A) increases the
slope of the pacemaker potential and increases heart rate,
whereas parasympathetic stimulation (C) abolishes the
pacemaker potential, hyperpolarises the membrane and
temporarily stops the heart (frog sinus venosus). NA (B)
prolongs the action potential, while ACh (D) shortens it (frog
atrium). (From: (A and C) Hutter 0 F, Trautwein W 1956 J Gen
Physiol 39: 715; (B) Reuter H 1974 J Physiol242: 429; (D) Giles
W R, NobleS J 1976 J Physiol261: 103.)
Parasympathetic activity produces effects that are, in general,
opposite to those of sympathetic activation. H owever. in contra't
to sympat hetic activity, the parasympathetic nervous system ha\
lillie effect on contractil ity, its mai n effects being on rate and
rhythm, namely:
cardiac slowing and reduced automaticity
inhibition of AV conduction.
These effects result from occupation of muscarinic (M 2)
acetylcholine receptors, which arc abundant in nodal and atrial
tissue but sparse in the ventricles. These receptors are negativel}
coupled to adenylate cyclase and thus reduce cAMP formauon,
acting to inhibit the slow Ca2 current, in opposition to ~
adrenoceptors. M 2 receptors also open a potassium channel
(called KAC'h ). T he resulting increase in K permeability produce'

Thrombolytic drugs
Aspirin
Oxygen

p8__ Myocardial
ischaemia
Nitrates

t Sympathetic ----+ t cardiac work

activity +Cardiac efficiency

(
Dysrhythmias

+ATP
Receptor activation (e.g. TN Fa)
+ton pumps
ICE-related protease activation
t[Ca 2"li PARP-inactivation
Protease act1vation
DNA fragmentation
Membrane damage

Necrosis ~ptosis
Cell
Death

Fig. 18.8 Effects of myocardial ischaemia. This leads to cell death by one of two pathways: necrosis or apoptosis. ICE,
284 \ interleukin-1-converting enzyme; PARP, poly-[ADP-ribose)-polymerase; TNF-q, tumour necrosis factor-a.
~'1',----

a hyperpolarising current that opposes the inward pacemaker
current, slowing the heart and reducing automaticity (see Fig. 18.7).
Vagal activity b often increased during myocardial infarction,
both in association with "agal afferent stimulation and as a side
effect of opioid~ u~ed to control the pain. and parasympathetic
effects are important in predisposing to acute dysrhythmias.
Vagal stimulation decreases the force of contraction of the
atria associmed with marked shortening of the action potential
(Fig. 18.7). Increased K+ permeability and reduced Ca2+ current
both contribute to conduction block at the AV node, where
propagation depend~ on the Ca 2 current. Shortening the atrial
action potential reduces the refractory period, which can lead to
re-entrant arrhythmias. Coronary vessels lack cholinergic
innervatio n; consequently, the parasympathetic nervous system
has little effect o n coronary artery tone (see Ch. 10).2
CARDIAC NATRIURETIC PEPTIDES
Atrial cells have a !.pecialised endocrine function in relation to
the cardiovascular system. They contain secre tory granules, and
store and release atrial natriuretic peptide (ANP). This has
powerful effect<, on the kidney and vascular system. Release of
ANP occurs during vol ume overload in response to stretching of
the atria. Saline infuc;ion is sufficient to evoke ANP release. Two
related natriuretic peptides (B and C) are found, respectively, in
\'entricular muscle and vascular endothelium. The plasma con-
centration of B-type natriuretic hormone (BNP) is predictably
increased in patients with heart failure and is increasingly used as
an aid to diagnosil..
The main effects of natriuretic peptides are to increase Na and
\\ater excretion by the kidney; relax vascular smooth muscle
(except efferent arterioles of renal glomeruli; see below);
increase vascular permeability; and inhibit the release and/or
actions of several hormones and mediators, including aldosterone,
angiotensin IT, c ndothe lin and antidiuretic hom10ne. They exert
their effects by combining with membrane receptors (natriuretic
peptide receptors, NPRs, which exis t in at least two subtypes,
designated A and 8 ). 3
Both NPR-A and NPR-B incorporate a catalytic guanylate
cyclase moiety (see C h. 3). Binding of one of the natriuretic
peptides to either receptor leads to intracellular generation of
cGMP. This is the same respon!.e as that produced by organic
nitrates (see later) and endothelium-derived nitric oxide (Ch. 17),
which, however, achieve this by interacting with soluble rather
than membrane-bound guanylate cyclase. Renal glomerular
'The Creator h:~-.. howe,er. thoughtfully provided coronary endothelium
\\ith muscarinic receptor.. linked to nitric oxide synthesis (see Cbs 17 and
19), presum:~bt:r for the delectation of va.<,cular pharmacologists.
'The nomenclnturc of natriuretic peptides and their receptors is peculiarly
obtuse. The peptide~ are named 'A' for atrial. 'B' for brain-despi te being
pre:.ent mainly in cardiac ventricle- and 'C' for A. B, C ...: NPRs are named
NPR-A. which preferentially binds ANP: NPR-B, which binds C natriuretic
peptide preferentially: and NPR-C for 'clearance' receptor. because until
recently clearance via cellular uptake and degradation by lysosomal
enzymes was the only dclinitc known function or this binding site.
THE HEART
Autonomic control of the heart
Sympathetic activity, acting through ~ 1
adrenoceptors, increases heart rate, contractility and
automaticity, but reduces cardiac efficiency (in
relation to oxygen consumption).
The ~~ adrenoceptors act by increasing cAMP
formation, which increases Ca2 currents.
Parasympathetic activity, acting through muscarinic
M2 receptors, causes cardiac slowing, decreased
force of contraction (atria only), and inhibition of
atrioventricular conduction.
M2 receptors inhibit cAMP formation and also open
potassium channels, causing hyperpolarisation.
afferent arterioles are dilated by ANP but efferent arterioles are
constricted, so filtration pressure is increased, leading to
increased g lomerular filtration and enhanced Na+ excretion.
Elsewhere, natriuretic peptidcs cause vasorelaxation and reduce
blood pressure. Their therapeutic potential is considered in
Chapter 19.
ISCHAEMIC HEART DISEASE
Atheromatous deposits are ubiquitous in the coronary arteries of
adults living in developed countries. They are asymptomatic for
most of the natural history of the disease (see Cb. 20), but can
progress insidiously, culminating in acute myocardial infarction
and its complications, including dysrhythmia and heart failure.
Details of ischemic heart disease are beyond the scope of this
book, a nd up-to-date accounts (e.g. Braunwald, 2005) are
avai lable for those seeking pathological and clinical information.
Here, we merely set the scene for understanding the place of
drugs that uffcct cardiac function in treating this most common
form of heart disease.
lmp011ant conseque nces of coronary atherosclerosis include:
angina (ischaemic c hest pain)
myocardial infarction.
ANGINA
Angina occurs when the oxygen supply to the myocardium is
insufficient for ih needs. The pain bas a characteristic
distribution in the chest. arm and neck, and is brought on by
exertion, cold or excitement A similar type of pain occurs in
skeletal muscle when it i~ made to contract while its blood supply
is interrupted. and Lewis showed many years ago that chemical
fact6rs released by ischaemic muscle are responsible. Possible
cin"didatcs include K, H+ and adenosine (Ch. 12), all of which
stimulate nociceptors (see Ch. 41 ). It is possible lhal the same
mediator that causes coronary vasodilatation is responsible. at
hig her concentration. for initiating pain.
Three kinds of angina are recognised clinically: stable,
unstable and variant 285
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
Stable angina. Thi~ i~ predictable chest pain on exertion. h i!.
produced by an increased demand on the heart and is caused by
a fixed narrowing of the coronary vessels, almost always by
atheroma. Symptomatic therapy is directed at altering cardiac
worl.. with organic nitrates, 13-adrenoceptor antagonis~ and/or
calcium antagoni L~ (as described below), together with treatment
of the underlying atheromatous diseac;e. usually including a statin
(Ch. 20), and prophylaxis against thrombosis with an antiplatelet
drug, usually aspir in (Cb. 21 ).
Unstable angina. This is characterised by pain that occurs
with less and less exertion. cuJminating in pain at rest. The
pathology is sirnil<tr to that involved in myocardial infarction,
namely platelet- fibrin thrombus associated with a ruptured
atheromatous plaque. but without complete occlusion of the
vessel. The risk of infarction is substantial, and the main aim of
therapy is to reduce this. Aspirin approximately halves the risk of
myocardial infarction in this setting, and hepar in and platelet
glycoprotein receptor a ntagonists add to this benefit {Ch. 21 ).
Variant angina. This is uncommon. It occurs at rest and is
caused by coronary artery spasm, again usually in association
with atheromatous disease. Therapy is with coronary artery
va~odilators (e.g. organic nitrates, calcium antagonists).
MYOCARDIAL INFARCTION
Myocardial infarction occurs when a coronary artery hac; been
blocked by thrombus. This may be fatal and is a common cause
of death, usually as a result of mechanical failure of the ventricle
or from dysrhythmia. Cardiac myocytes rely on aerobic
mctaboli,m. If the supply of oxygen remains below a critical
value, a sequence of events leading to cell death (by necrosis or
apoptosis) cn~ucs (sec Ch. 5 for a fuller account of apoptosis).
The sequences leading from vascuhtr occlusion to cell death via
the two pathways arc illustrated in Figure 18.8. The relative
importance of necrosis and apoptosis in myocardia] cell death in
clinically distinct seuings is unknown, but it has been suggested
that apoptosis may be an adaptive process in hypoperfused reg ions,
sacrificing some jeopardised myocytes but thereby avoiding the
disturbance of membrane function and risk of qysrhythmia
inherent in necrosis. Consequently, it is currently unknown if
pharmacological approaches to promote or inhibit this pathway
could be clinically beneficial.
Prevention of irreversible ischaemic damage following an
episode of coronary thrombosis is an important therapeutic aim.
The main po~~ibilities among existing therapeutic drugs, sho\.\n
in Figure 18.8, are:
thrombolytic and antiplatelet drugs (aspirin and clopidogrel)
to open the blocked artery and prevent their reocclusion (1>ee
Ch. 21)
oxygen
opioid~ to prevent pain and reduce excessive sympathetic
activity
~-adrcnoceptor antagonists
angioten!>in-converting enzyme (ACE) inhibitors (see Ch. 19).
The Iauer two classes of drug reduce cardiac work and thereby
286 the metabolic needs of the heart. The 1~-adrenoceptor antagonists
have an important benefit during chronic treatment in reducing
dysrhythmic deaths, and are widely used in patients with uNable
angina; they increase the risk of cardiogenic shocl.. if gi,cn
during acute infarction to patients with signs of heart failure. but
are started as ~oon as is haemodynamically prudent (COMMIT
Collaborative Group. 2005). Several clinical trials ha\e
demonwated that ACE inhibitors improve survival if gi\en to
patients shortly after myocardial infarction, especially if there IS
even a modest degree of myocardial dysfunction. It is possible
(sec Ch. 19 for a discussion of the differences bemeen
angiotcn!>in receptor antagonists-sanans-and ACE inhibitor')
that sartan~ could prove similarly beneficial.
Despite several encouraging small trials of organic nitraJI'l, u
large randomiscd controlled trial (the Fourth International Stud>
of Infarct Survival, lSlS-4. 1994) showed that these drugs do not
improve outcome in patients with myocardial infarction,
although they are useful in preventing or treating anginal pain
(see below). Calcium antagonists. which reduce cardiac work
(via arteriolar vasodilatation and afterload reduction) and block
Ca 2 entry into cardiac myocytes, have been disappointing. and
several clinical trials of short-acting dihydropyridine~ (e.g.
nifedipine) were halted when adverse trends were C\ident
Trimctazidinc. a 3-ketoacyi-CoA thiolase inhibitor. is belie\ed
to protect the heart from ischaemia by switching cardiac
metabolism from fatty acid to glucose oxidation, but its place (if
any) in therapeutics is yet to be established (sec Manilli. 2(kH;
and Lee ct al., 2004).
DRUGS THAT AFFECT CARDIAC
FUNCTION
Drug!> that have a major action on the heart can be divided mto
three groups.
Drugs that affect myocardial cells directly. These include:
- autonomic neurotransmitters and related drugs
- antidysrhythmic drugs
- cardiac glycosides and other inotropic drugs
- miscellaneous drugs and hormones; these are dealt with
elsewhere (e.g. doxorubicin, Ch. 51; thyroxine, Ch. 29;
glucagon, Ch. 26).
Drugs that aj](!CI cardiac function indirectly. These have
actions el!>ewhere in the vascular system. Some antianginal
drugl> (e.g. nitrates) fall into this category. as do most drug,
that are u~ed to treat heart failure (e.g. diuretics and ACE
inhibitor,).
Calcium antagonists. These affect cardiac function b) a
direct action on myocardial cells and also indirectly b)
relaxing arterioles.
ANTIDYSRHYTHMIC DRUGS
A classification of antidysrhythrnic drugs based on their
clectrophysiological effects was proposed by Vaughan William'
in 1970. It provides a good starting point for discus,ing
mechanisms, although many useful drugs do not fit neatly mto
this classification (Table 18.1 ). Furthermore, emergenc}
 THE HEART

treatment of serious dysrhythmias is usually by physical meanl>

e (e.g. pacing or electrical cardioversion by applying a direct Pacemaker
1 current shock to the chest or via an implanted device) rather than potential
l drugs. (phase 4)
r There are four classes (see Table 18.2).
Class 1: drugs that block voltage-sensitive sodium channels.
They are subdivided: la, lb and lc (see below).
Class II: ~-adrenoceptor antagonists.
Class Ill: drugs that substantially prolong the cardiac action
pOiential.
Cla.~s IV: calcium antagonists.
The pha~e of the action potential on which each of these classes Plateau
of drug have their main effect is shown in Figure 18.9. (phase 2)

T
Repolarisation
Table 18.1 Antidysrhythmic drugs unclassified in the (phase 3)
Vaughan Williams system
Fig. 18.9 Effects of antidysrhythmic drugs on the
Drug Use different phases (as defined in Fig. 18.1) of the cardiac
action potential.
Atropine Sinus bradycardia

Adrenaline (epinephrine) Cardiac arrest

Isoprenaline Heart block M ECHANISMS OF ACTION

Digoxin Rapid atrial fibrillation Class I drugs
Class I drugs block sodium channels, just as local anael>thetics
Adenosine Supraventricular tachycardia
do, by binding to sites in the a subunit (see Chs 4 and 44 ).
Calcium chloride Ventricular tachycardia due to Because th.is inhibits action potential propagation in many
hyperkalaemia excitable cells. it has been referred to as 'membrane-~tabili~ing'
activity. a phrase best avoided now that the ionic mechanism is
Magnesium chloride Ventricular fibnllation, digoxin toxicity understood. Their characteristic effect on the action potential is
to reduce the maximum rate of depolarisation during phase 0.
The reason for further subdivision of these drugs into classes
Ia, [b and lc is that the earliest examples, quinidine and
procaina mide (class la), have different effects from many of the
more recently developed dng~. even though all share the same
Table 18.2 Summary of antidysrhythmic drugs ba'>ic mechanism of action. A partial explanation for these
(Vaughan Williams classification)
functional differences comes from elec!rophysiological ~tudies
of the characteristics of the sodium channel block produced by
Class Example(s) Mechanism
different class I drugs.
Ia Disopyramide Sodium channel block The central concept is of use-dependem channel block. It is
(intermediate dissociation) this characteristic that enables all class I drugs to block the
hig h-frequency excitation of the myocardium that occurs in
lb Lidocaine Sodium channel block tachyarrhythmias, without preventing the heart from beating
(fast dissociation)
at nom1al frequencies. Sodium c hannels exist in three distinct
lc Flecainide Sodium channel block functional states: resting. open and refractory (see Ch. 4). Channels
(slow dissociation) switch rapidly from resting to open in response to depolari'>ation;
this is known a<> activation. Maintained dcpolarisation. as in
II Propranolol ~-Adrenoceptor antagonism ischaemic muscle. causes channels to change more slowly from
Amiodarone, sotalol Potassium channel block
open to refractory (inacti vatio n), and the membrane must then be
Ill
rcpolarised for a time to re~tore the c hannel to the resting Mate
IV Verapamil Calcium channel block before it can be activated again. Class I drugs bind to c hannels
most strongly when they are in either the open or the refractory 287
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
state, less strongly to channels in the resting state. Their action
therefore shows the property of 'use dependence' (i.e. the more
frequently the channels are activated, the greater the degree of
block produced).
Class Tb drugs, for example lidocaine. associate and
dissociate rapidly within the timeframe of the nonnal heartbeat.
The drug binds to open channels during phase 0 of the action
potential (affecting the rate of rise very little, but leaving many of
the channels blocked by the time the action potential reaches its
peak). Dissociation occurs in time for the next action potential,
provided the cardiac rhythm is normal. A premature beat.
however, will be aborted because the channels are still blocked.
Furthermore, class lb drugs bind selectively to refractory
channels and thus block preferentially when the cells are
depolarised, for example in ischaemia.
Class lc drugs, such as Oecainide and encainide, associate
and dissociate much more slowly, thus reaching a steady-state
level of block that does not vary appreciably during the cardiac
cycle; they also show only a marginal preference for refractory
channels, so are not specific for damaged myocardium. Therefore
they cause a rather general reduction in excitability and do not
discriminate particularly against occasional prematuJe beats. as
class Tb drugs do, but will suppress re-entrant rhythms that
depend on unidirectional or intermittent conduction pathways
operating at a low margin of safety (e.g. some forms of
paroxysmal atrial fibrillation). They markedly inhibit conduction
through the His-Purkinje system.
Class Ia, the oldest group (e.g. qu inidine, procainamide,
djsopyramide), lies midway i11 its properties between Ib and Ic
but, in addition, prolongs repolarisation, albeit less markedly
than class ill drugs (see below).
Class II drugs
Class ll drugs comprise the ~- adrenoceptor antagonists (e.g.
propranolol).
Adrenaline can cause dysrhythmias by its effects on the
pacemaker potential and on the slow inward Ca 2+ current
(see above). Ventricular dysrhythrnias following myocardial
infarction are partly the result of increased sympathetic activity
(see Fig. 18.8), providing a rationale for using ~-adrenoceptor
antagonists in this setting. AV conduction depends critically on
sympathetic activity; (3-adrenoceptor antagonists increase the
refractory period of the AV node and can therefore prevent
recurrent attacks of SVT. The ~-adrenoceptor antagonists are
also used to prevent paroxysmal attacks of atrial fibrillation when
tllese occur in the setting of sympathetic activation.
Class Ill drugs
The class ITJ category was originally based on the unusual
behaviour of a single drug, amiodarone (see below), although
others with similar properties (e.g. sotalol) have since been
described. Both amiodarone and sotalol have more than one
mechanism of antidysrhythrnic action. The special feature that
defines them as class ill drugs is that they substantially prolong
the cardiac action potential. The mechanism of this effect is not
fully understood, but it involves blocking some of the potassium
288 channels illvolved in cardiac repolarisation, including the outward
(delayed) rectifier. Action potential prolongation increases the
refractory period, accouuti11g for powerful and varied ami-
dysrhythmic activity. for example by interrupting re-entrant
tachycardias and suppressing ectopic activity. However, all drugs
that prolong the cardiac action potential (detected clinically a\
prolonged QT interval on the ECG; see above) can paradoxically
also have proarrbythrnic effects, notably a polymorphic fom1 of
ventricular tachycardia called (somewhat wbimsicaUy) torsade
de pointes (because the appearance of the ECG trace is said to be
reminiscent of tins ballet sequence). This occurs particularly in
patients taking other drugs that can prolong QT, including several
antipsychotic drugs; those with disturbances of electrolytes
involved in repolarisation (e.g. hypokalaenlia. hypercalcaemia);
or individuals with hereditary prolonged QT (Ward- Romano
syndrome). 4 The mechanism of the dysrhythmia is not fully
understood; possibilities include increased dispersion of
repolarisation (i.e. lack of spatial homogeneity) and increased
Ca2+ entry durllig the prolonged action potential, leading to
increased aftcr-depolarisation.
Class IV drugs
Class IV agents act by blocking voltage-sensitive calcium
channels. Class IV drugs in therapeutic use as an6dysrhythmic
drugs (e.g. vera pamil) act on L-type channels. Class IV drugs
slow conduction in the SA and AV nodes where action potential
propagation depends on slow illward Ca2+ current, slowing lhe
heart and terminating SVT by causing partial AV block. They
shorten the plateau of the action potential and reduce the force of
contraction. Reduced Ca2+ entry reduces after-depolarisation and
thus suppresses premature ectopic beats.
DETAILS OF INDIVIDUAL DRUGS
Quinidine, procainamide and disopyramide
(class Ia)
Quinidine and procainamide are pharmacologicaUy similar.
They are now mainly of historical interest. Disopyramide
resembles quinidine, including in its marked atropine-like
effects, which result in blurred vision, dry mouth, constipation
and urinary retention. It bas more negative inotropic action than
quinidine but is less likely to cause hypersensitivity reactions.
Lidocaine (class lb)
Lidocaine, also well-known as a local anaesthetic (see Ch. 44) t>
given by intravenous infusion to treat and prevent ventricttlar
dysrhythmias in the immediate aftermath of myocardial infarction.
Tt is almost completely extracted from the portal circulation by
4
A 3-year-old girl began to have blackouts, which decreased in frequency
with age. Her ECG showed a prolonged QT interval. When 18 years of age.
she lost consciousness running for a bus. When she was 19, she became
quite emotional as a participant in a live television audience and died sudden!~.
The molecular ba~is of tltis rare inherited disorder is now known. It is
caused by a mutation in either the gene coding for a particular potassium
channel-called HERG-or another gene, SCN5A , which codes for the
sodium channel and disruption of which results in a loss of inactivation of
the Na' currem (see Welsh & Hoshi, 1995, for a commentary).

hepatic first-pass metabolism (Ch. 8), and so cannot usefully be
admini~tercd orally. Its plasma half-life i~ normally about
2 hours. but its elimination is slowed if hepatic blood now is
reduced, for example by reduced cardiac output following
myocardial infarction or by drugs that reduce cardiac
contractility (e.g. p-adrenoceptor antagonists). Dosage must be
reduced accordingly to prevent accumulation and toxicity.
Indeed. its clearance has been used to estimate hepatic blood
now, analogous to the use of para-aminohippurate clearance to
measure renal blood now.
The adverse effects of lidocaine are mainly due to its actions
on the central nervous system and include drowsiness,
di~orientation and convulsions. Because of its relatively short
half-life, the plasma concentration can be adjusted frurly rapidly
by varying the infusion rate.
Phenytoin (class lb)
Phenytoin is an antiepileptic drug (Ch. 40); it has anti-
dy~rhythmic actions on the heart, but its clinical use for this
indication is obsolete.
Flecainide and encainide (class lc)
Flecai nide and encainide suppress ventricular ectopic beats.
They are long acting and reduce the frequency of ventricular
ectopic beats when administered orally. However. in clinical
trials, they increase the incidence of sudden death associated
with ventricular fibri llation after myocardial infarction, so they
are no longer used in this setting. This counter-intuitive result
had a profound impact on the way clinicians and drug regulators
view the use of seemingly reasonable intermediate end points (in
thi case. reduction of frequency of ventricular ectopic beats) as
C\'idence of efficacy in clinical trials. Currently. the main use of
necainide is in prophylaxis again!>! paroxysmal atrial fibrillation.
rlAdrenoceptor antagonists (class II)
The most important P-adrenoccptor antagonists are described in
Chapter 11. Their clinical usc for rhythm disorders is shown in
Clinical uses of class I
antJctprhythmic drugs
Cla ss Ia (e.g. dis o pyramide)
ventricular dysrhythmias
- prevention of recurrent paroxysmal atrial
fibri llation triggered by vagal overactivity.
Cla s s lb (e.g. intravenous lidoca ine)
treatment and prevention of ventricular
tachycardia and fibrillation during and immediately
after myocardial infarction.
Class lc
to prevent paroxysmal atrial fibrillation (flecainide)
recurrent tachyarrhythmias associated with
abnormal conducting pathways (e.g.
Wolff-Parkinson-White syndrome).
THE HEART
Clinical use s of cla ss II antidysrhythmic
drugs (e.g. propranolol, tlmolol)
To reduce mortality following myocardial infarction.
To prevent recurrence of tachyarrhythmias (e.g.
paroxysmal atrial fibri llation) provoked by increased
sympathetic activity.
the clinical box. Propranolol. like several other drugs of this
type. has some class I action in addition to blocking ~
adrenoceptors. This may contribute to its antidysrhythrnic
effects, although probably not very much, because an isomer
with little p antagonist activity has little antidysrhythmic
activity, despite similar activity as a class T agent.
Adverse effects arc described in Chapter 11, the most
important being worsening bronchospasm in patients with
asthma. a negative inotropic effect. bradycardia and fatigue. II
was hoped that the use of ~ 1 -!.clective drugs (e.g. metoprolol,
atenolol) would reduce the risk of bronchospasm, but their
selectivity is insufficient to achieve this goal in clinical practice.
although the once-a-day convenience of several such dngs has
led to their widespread usc in patients without lung disease.
Amiodarone and sotalol (class Ill)
Arniodar one is highly effective at suppressing dysrhythmias (see
the clinical box). Like other drugs that interfere with cardiac
repolarisation, it is important to monitor plasma electrolyte
concentrations during its use to avoid precipitating 10rsadcs de
pointes. Unfortunately, it has several peculiarities in addition to
its mrun pharmacological action on potassium channels, that
complicate its use. It is extensively bound in tissues, has a long
elimination half-life ( 10-100 days) and accumulates in the body
during repeated dosi ng (sec p. 104). For this reason, a loading
dose is used, and for life-threatening dysrhythmias this is given
intravenously via a central vein (it causes phlebitis if given into
a peripheral vessel). Adverse effects are numerous and important:
they include photosensiti\e siJn rashes and a slate-grey/bluish
discoloration of the skin: thyroid abnormalities (hypo- and hyper-,
connected with its high iodine content): pulmonary fibrosi . which
is slo"' in onset but may be irreversible: corneal deposits: and
neurological and gastrointestinal disturbances, including hepatitis.
Sotalol is a non-selective f3-adrcnoccptor antagonist, this
activity residing in the L isomer. Unlike other 13 antagonists, it
prolongs the cardiac action potential and the QT interval by
delaying the slow outward K+ current. This class Ill activity is
present in both L and o isomers. Racemic sotalol (the form
prescribed) appears to be '>Omewhat less effective than amiodaronc
in preventing chronic malignant ventricular tachyarrhythmias. lt
shares the ability of amiodaronc to cau:,e torsades de pointcs but
lacks its other adverse effects: it is valuable in patients in whom
f3-adrenoceptor antagonists arc not contmindicated. As with
amiodarone, close monitoring of plasma electrolytes is imponant
during its usc. 289
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
Clinical uses of class Ill
antldysrhythmlc drugs
Amiodaro ne: tachycardia associated with the
Wolff-Parkinson-White syndrome. It is also effective
in many other supraventricular and ventricular
tachyarrhythmias but has serious adverse effects.
(Racemic) sot alol combines class Ill with class II
actions. It is used in paroxysmal supraventricular
dysrhythmias and suppresses ventricular ectopic
beats and short runs of ventricular tachycardia.
Verapamil and diltiazem (class IV)
Verapamil is given by mouth. (Intravenous preparations are
available but are dangerous and almost never needed.) lt has a
plasma half-life of 6-8 hours and is subject to quite extensive
firM-pass metabolism, which is more marked for lhe isomer lhat
is responsible for its cardiac effects. A slow-release preparation
is available for once-daily use, but it is less effective when used
for prevention of dy~rhythmia than the regular preparation
bccau~e the bioavailability of the cardioactive isomer is reduced
through the presentation of a steady low concentration to the
drug-metabolising enzymes in the liver. If verapamil is added to
djgoxin in patients with poorly controlled atrial fibrillation, lhe
dose of digoxin should be reduced and plasma digoxin
concentration checked after a few days. because verapamil both
displaces digoxin from tissue-binding sites and reduces its renal
elimination, hence predi:.posing to digoxin accumulation and
toxicity (sec Ch. 52).
Verapamil is contraindicated in patients with Wolff-
Parkinson White syndrome, and is ineffective and dangerous in
ventricular dysrhythmias. Adverse effects of verapamil and
diltiazcm arc described below in the section on calcium channel
antagonists.
Diltiazem is si milar to verapamil but has relatively more
smooth muscle relaxing effect and produces less bradycardia.
Adenosine (unclassified in the Vaughan
Williams classification)
Adenosine is produced endogenously and is an important
chemical mediator (Ch. 12) with effects on breathing, on cardiac
muscle and afferent nerves, and on platelets. in addition to the
effect!. on cardiac conducting tissue that underlie i ts therapeutic
u~c. The A receptor is responsible for its effect on the AV node.
The!>e receptors arc linked to the same cardiac potassium channel
(KAC'lt) that is activated by acetylcholine. and adenosine
hyperpolarises cardiac conducting tissue and slows the rate of
rise of the pacemaker potential accordingly. It is used
intravenously to terminate SVT if this rhythm persists despite
manoeuvres such as carotid artery massage designed to increase
vagal tone. It has largely replaced verapamil for this purpose,
because it is safer owing to its effect being short-lived. This is a
consequence of its pharmacokinetics: it is taken up via a specific
290 nucleoside transporter by red blood cells and is metabolised by
Clinical uses of class IV
antldysrhythmlc drugs
Verapamil is the main drug. It is used:
to prevent recurrence of paroxysmal
supraventricular tachycardia (SV7)
to reduce the ventricular rate in patients with atrial
fibrillation, provided they do not have
Wolff-Parkinson-White or a related disorder.
Verapamil was previously given intravenously to
terminate SVT; it is now seldom used for this because
adenosine is safer.
enzymes on the lumenal surface of vascular endothelium.
Consequently, the effects of a bolus dose of adenosine last only
20-30 seconds. Once SVT has terminated, the patient usuall}
remains in sinus rhythm, even though adenosine is no longer
present in plasma, but the unwanted effects resolve very rapid!).
These include chest pain. shortness of breath, dizziness and
nausea. Theophylline and other xanthine alkaloids blod
adenosine receptors and inhibit lhe actions of intravenou'
adenosine, whereas dipyridamole (a vasodilator and anti platelet
drug; see below and Ch. 21) blocks the nucleoside uptake
mechanism, potentiating adenosine and prolonging its ad,crse
effects. Both these interactions are clinically important.
DRUGS THAT INCREASE MYOCARDIAL
CONTRACTION
CARDIAC GLYCOSIDES
Cardiac glycosidel! come from foxgloves (Digitalis spp.) and
related plants. Withering ( 1775) wrote on the use of the foxglove:
' it has a power over the motion of Lhe heart to a degree yet
unobserved in any other medicine...' There is evidence in
mammals of an endogenous digitalis-like factor closely similar to
another cardiac glycoside, ouabain, and this is of potenual
physiological and pathological significance (see Schoner, 20021.
Chemistry
T Foxglove~ contain !.everal cardiac glycosides with similar act1oo
Digo\in 1\ the mO\t 1mportant therapeutically. Ouabain is similar IIIII
~honer acting. The ba,ic chemical structure of glycosides con\hh of
three components: a sugar moiety. a steroid and a lactone. The 'liP1
mo1ety conMSt~ of unu~ual 1-4 linked monosaccharides. The lactone fUll
i' e\-.ential for activit). and substituted lactones can retain biologlal
activity even when the Merotd moiet) is removed.
Actions and adverse eHects
The main action!> of glycosides are on the heart, but some ofthetr
adverse effects are extracardiac, including nausea, vomiting,
diarrhoea and confusion. The cardiac effects are:
cardiac slowing and reduced rate of conduction through the
AV node
i ncreascd force of contraction

------~.~.~--~~--------------------------
disturbances of rhythm, especially:
-block of AV conduction
-increased ectopic pacemaker acti vi ty.
Adverse effects are common and can be severe. One of the main
drawbacks of glycosides in clinical use is the narrow margin
between effectiveness and toxicity.
Mechanism
The main mechanisms of action of cardiac glycosides are
increased vagal activity and inhibition of the Na+fK.+ pump.
Cardiac glycosides bind to a site on the extracellular aspect of the
a subunit of the NaJK+ ATPase (which is an af3 heterodimer),
and arc useful experime ntal tools for studying this important
transport system.
Rate and rhythm
Cardiac glycosides s low AV conduc tion by increasing vagal
outnow via central nervous syste m activity. Their beneficial
effect in established rapid atrial fibrillation results partly from
this. If ventricular rate is excessively rapid, the time available for
diastolic filling is inadequate. Increasing the refractory period of
the AV node reduces ventricular rate. The atrial dysrhythmia is
unaffected, but the pumping efficiency of the heart improves
owing to improved ventricular filling. SVT can be terminated by
cardiac glycosides, which slow AV conduction. although other
drugs are usually employed for this indication (see below).
Larger doses of glycosides disturb sinus rhythm. Tbis can
occur at pla~ma concentrations of digoxin within. o r only slightly
above. the therapeutic range. Slowing of AV conduction can
progress to AV bloc!.. Glyco~ides can also cause ectopic beats.
Because Na;K+ exchange is electrogenic. inhibition of the pump
by glycosides causes depolarisation. predisposing to
disturbances of cardiac rhythm. Furthermore, the increased
[Ca 2 I, causes increased after-depolarisation. leading first to
coupled beats (bigeminy), in which a normal ventricular beat is
fol lowed by an ectopic beat; this is followed by ventricular
tachycardia and eventually by ventricular fibrillation.
Force of contraction
Glycosides cause a large increase in twitch tension in isolated
preparations of cardiac muscle. Unlike catccholamines, they do
not accelerate relaxation (compare Fig. 18.6 with Fig. 18.10).
Increased tension i!. caused by an increased fCa 2+]1 transient
(Fig. 18.10). The action potential is only slightly affected and
the slow inward current liule changed, so the increased
[Ca 2+], transient probably reflects a greater release of Ca 2+ from
intracellular stores. The most likely mechanism is as follows
(see also Ch. 4).
I. Glycosides inhibit the NaJK+ pump.
2. Inc reased [Nal, slows extrusion of Ca2+ via the Na/ca 2
exchange transporter. Increasing [Na], reduces the inwardly
directed gradient for Na+; the smaller this gradient. the
slower is extrus io n of Ca 2+ by Na/ca2+ exchange.
3. Inc reased 1Ca2+1 1 is stored in the sarcoplasmic reticulum, and
thus increases the amount of Ca2+ released by each action
potential.
THE HEART
L Control J[ Acetylstrophanthidin o 75 j.lmoVI J
Tension ~ f \ _ [o.2mN
Fig. 18.10 Effect of a cardiac glycoside
(acetylstrophanthidin) on the Ca2 transient and tension
produced by frog cardiac muscle. The effect was recorded as
\ In Figure 18.6. (From Allen D G, Blinks J A 1978 Nature 273: 509.)
The effect of extracellular potassium
Effects of cardiac glycosides are increased if plasma [K+J
decreases, because of reduced competition at the K+-binding site
on the Na'IK' ATPase. This is clinically important, because
diuretics (Ch. 24) are often used to treat heart failure, and most
of them decrea~e plasma [K+], thereby increasing the risk of
glycoside-induced dysrhythmia.
Pharmacokinetic aspects
Digoxin is administered by mouth or, in urgent situations,
intravenously. It is a very polar molecule; elimination is mainly
by renal excretion and involves ?-glycoprotein (p. 102). leading
to clinically significant interactions with other drugs used to rreat
heart failure. such as spironolactone, and with antidysrhythmic
drugs such a verapamil and amiodarone. Elimination half-time
is approximately 36 hours in patients with normal renal function.
but considerably longer in elderly patients and those with overt
renal failure, in whom reduced doses are needed. A loading dose
is used in urgent s ituations. The therapeutic range of plasma
concentrations, below which digoxin is unlikely to be effective
and above which the risk of toxicity increases substantially, is
fairly well defined ( 1- 2.6 nmol/1). Determination of plasma digoxin
conce ntration is useful when lack of efficacy or toxicity is suspected.
Clinical use
Clinical uses of digoxin arc summarised in the clinical box.
OTHER DRUGS THAT INCREASE MYOCARDIAL
CONTRACTILITY
Certain ~ 1 -adrenoceptor agonists. for example dobutamine, are
used to treat acute but potentially reversible heart failure (e.g.
following cardiac surgery or in some cases of cardiogenic or
septic shock) on the basis of their positive inotropic action.
Dobutamine, for reasons that are not well understood, produces
less tachycardia than other ~~ agonists. ll is administered
intravenously. Glucagon also increases myocardial contractility
by increasing synthesis of cA1\1P, and has been used in patients
with acute cardiac dysfunction owing to overdosage of ~
adrenoceptor antagonists (see the glucagon clinical box on p. 402).
Inhibitors of the heart-specific subtype (type Ill) of
phosphodieste rase, the enzyme responsible for the intracellular 291
 SECTION 3 DRUGS AFFECTING MAJOR ORGAN SYSTEMS
CllniCIII uses of cardiac glycosides
(e.g. digoxin)
To slow ventricular rate in rapid persistent atrial
fibrillation.
Treatment of heart failure in patients who remain
symptomatic despite optimal use of diuretics and
angiotensrn-converting enzyme inhibitors (Ch. 19).
degradation of cAMP, increase myocardial contractility.
Consequently, like ~-adrenoceptor agonists, they increase
intracellu lar cAMP but cause dysrhythmias for the same reason.
Compounds in this group include amrioone and milrinone,
which arc c hemically and pharmacologically very similar. They
improve haemodynamic indices in patients with heart failure
but paradoxica lly worsen survival. presumably because of
dysrhythmias. This dichotomy has had a sobering effect on
clinicians a nd drug regulatory authorities.
ANTIANGINAL DRUGS
The mechanism of anginal pain is discussed above (p. 285).
Angina is managed by using drugs that improve perfusion of the
myocardium or reduce its metabolic demand. or both. Two of the
main groups of drugs, organic nitrates and calcium amagonists,
are vasodilators and produce both these effects. The third group,
{3-adrenoceptor amagonists, slow heart rate and hence reduce
metabolic demand. Organic nitrates and calcium antagonists are
described below. The B-adrenoceptor antagonists are covered in
Chapter II , except for their antidysrhythmic actions, which are
described above. Very recently, ivabradioe, which slows the
heart by inhibiting the sinus node 11 current (see above, p. 278)
has been introduced as an alternati ve to ~ -adrenoceptor
antagonists in patients in whom these are not tolerated or arc
contraindicated.
ORGANIC NITRATES
The ability of organic nitrates (see also Chs I 7 and 19) to relieve
angina was discovered by Lauder Brunton, a distinguished British
physician, in I 867. He had found that angina could be partly
relieved by bleeding, and also knew that amyl nitrite, which had
been synthesised 10 years earlier, caused flushing and tachycardia,
with a fall in blood pressure, when its vapour was inhaled. He
thought that the effect of bleeding resulted from hypotension,
and found that amyl nitrite inhalation worked much better. Amyl
nitrite has now been replaced by glyceryl trinitrate (nitroglycerin). 5
Efforts to increase the duration of action of glyceryl trinitrate
sNobel discovered how to ~tahil i'e nitroglycerin with kieselguhr, enabling
him to exploit its explosive propenies in dynamite. the manufacture of which
292 earned him the fortu ne with which he endowed the eponymous prizes.
have led to the synthesis of several related organic nitrates, of
which the most important is isosorbide mononitrate.
Actions
Organic nitrates relax vascular and some other (e.g. oesophageal
and biliary) smooth muscles. They cause marked vcnorela."<auon.
with a consequent reduction in central venous pressure (reduced
preload). In healthy subjects. this reduces stroke volume. Venou'
pooling occurl> o n standing and can cause postural hypotensiOn
and diuiness. Therapeutic doses have less effect on small
resistance arteries than on veins, but there is a marked effect on
larger mu~cular arteriel>. This reduces pulse wave reflection from
arterial branches (as appreciated in the 19th century by Murrell
but neglected for many years thereafter), and consequently
reduces central (aortic) pressure and cardiac afterload (see Ch. 19
for mo re detail on the role of these factors in determining cardiac
wo rk). The direct effect on coronary artery tone oppose'
coronary artery spasm in variant angina. With larger dose\.
resista nce arteries and arterioles dilate, and arterial pressure falls.
Nevertheless, coronary flow is increased as a result of coronary
vasodilatation. Myocardial oxygen consumption is reduced
because of the reductions in both cardiac preload and afterload.
This, together with the increased coronary blood flow, causes a
large increa1.e in the oxygen content of coronary sinus blood.
Studies in experimental animals have shown that glyceryl trinitrate
diverts blood from normal to ischaemic areas of myocardtum.
The mechanism involves dilatation of collateral vesseb that
bypa!>S narrowed coronary artery segments (Fig. 18. I I).
T It i' mtereMmg to compare this effect with that of other va\odilatlli"S,
notably dip)ridamole. which dilate arterioles but not collateral,
Dipyridamole is at least a'> effective as nitrates in increasing cororta)
flow in normal ~ubjects but actually worsens angina. This is probabl~
becau~e arterioles in an ischaemic region are fuUy dilated by ~
i ~chaemia. and drug-induced dilatation of the anerioles in normal an:"'
hns the effect of divening blood away from the ischaemic are<~l
(Pig. 18. 1t ). producing what is termed a vascular steal. This effect 11
exploited in 3 pharmacological 'sU'ess' test for coronary arterial di..ea;e.
in which dipyridamole is administered ioU'avcnously to patien t~ in whom
this diagno~i~ is su~pected but who cannot exercise, wh ile monitorin~
myocardial perfusion and the ECG.
In summary, the antianginal action of nitrates involves:
reduced cardiac oxygen consumption. secondary to reduced
cardiac preload and afterload
redistribution of coronary flow towards ischaemic areas via
collaterals
relief of coronary sp<ll>m.
In addition to iLc; effects on smooth muscle, nitric oxide increa-e,
the rate of relaxation of cardiac muscle (dubbed a 'lusiotropic'
action). It is probable that organic nitrates mimic this action. \\hich
could be important in patients with impaired diastolic function a
common accompaniment of hypertension and of heart failure.
Mechanism of action
Organic nitrates arc metabolised with release of nitric oxide. At
concentra tions achieved during therapeutic use, this invol\es nn
entymic step and possibly a reaction with tissue sulfhydf)l
(- SH) groups. Niuic oxide activates soluble guanylate cyclase
 THE HEART

!>.of

~ Control (no drug) in a patient with CAD

ageal
tion. Atheromatous
/plaque
uced
Effect of mlrate
c
IOOUS Effect of dipyridamole
1sion
mall Collateral
t:t on Normal
arteriolar tone
l
from
)rrell
ently Collateral

u
not dilated
h.19
rdiac
\
aoses
oses,
falls.

u
Blood flow to Blood flow to
mary normal area of lschaemlc area of
IUCed myocardium myocardium
load.
ses a
ood. Blood flow to Blood flow to Blood flow to
itratc 1schaem1C area normal area ischaemic area
INCREASED INCREASED REDUCED
ium.
that
Fig. 18.11 Comparison of the effects of organic nitrates and an arteriolar vasodi lator (dipyridamole) on the coronary
circulation. A Control. lm Nitrates dilate the collateral vessel, thus allowing more blood through to the underperfused region (mostly by
~uors. d1version from the adequately perfused area). Dipyridamole dilates arterioles, increasing flow through the normal area at the expense of
terah. the 1schaemic area (in which the arterioles are anyway fully dilated). CAD, coronary artery disease.
onary
bably
1he
area~

area!>
ect b
'ease. (see Ch. 17), increasi ng formatio n of cGMP, which activates
vhom
protein ki nase G and leads to a cascade of effects in smooth
oring
muscle culminating in dephosphorylatio n of myosin light c hains
and sequestration of intracellular Ca2+, with consequent relaxation.
ed Tolerance and unwanted effects
Repeated admini!>tration of nitrates to smooth muscle preparations
in vitro results in diminished relaxation, possibly partly because
ia
of depletion of free -SH groups, aJthough attempts to prevent
tolerance by agents that restore tissue -SH groups have not been
clinically u eful. Tolerance to the antianginal effect of nitrates
~es doe~ not occur to a clinically important extent with ordinary
lpic' formulations of short-acting drugs (e.g. glyceryl trinitrate), but
hich does occur with longer-acting drugs (e.g. isosorbide mononitrate)
,>n. a or when glyceryl trinitrate is administered by prolonged
'1!. intravenou~ inful>ion or by frequent application of slow-release
transdermal patches (see below).
The main adverse effects of nitrates are a direct consequence
:. At of their main pharmacological actions, and include postural
s an hypoten~ion and headache. This was the cause of ' Monday
rdryl morning sickness' among workers in explosives factories. Tolerance
:lase to these effects develops quite q uickly but wears off after a brief
nitrate-free inlerval (which is why the symptoms appeared on
Mondays and not later in the week). Formation of methaemoglobin,
an oxidatio n product of haemoglobin that is ineffective as an
oxygen carrier, seldom occurs when nitrates are used clinically
but is induced deliberately with amyl nitrite in the treatment of
cyanide poisoning, because methaemoglobin binds cyanide ions.
Pharmacokinetic and pharmaceutical aspects
Glyceryl trinitrate is rapidly inactivated by hepatic metabolism.
IL is well absorbed from the mouth and is taken as a tablet under
the tongue or nl> a sublingual spray, producing its effects within a
few minutes. lf swallowed, it is ineffective because of first-pass
metabolism. Given sublinguaHy. the trinitrate is converted to di-
and mononitrate~. It<; effective duration of action is apprmtimatel}
30 minutes. It is quite well absorbed through the skin. and a more
sustained effect can be achieved by applying it as a transdermal
patch. Once a bottle of the tablets has been opened, its shelf life
is quite short because the volatile active substance evaporates;
spray preparations avoid this problem.
Isosorbide mononitrate is longer acting than glyceryl trinitrate
(half-life approximately 4 hours) but has similar pharmacological
ac tio ns. It is swallowed rather than taken sublingually, and is 293
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
taken twice a day for prophylaxis (usually in the morning and at
lunch, to allow a nitrate-free period during the night, when
patients arc not exerting themselves. to avoid tolerance). Tt is also
available in !>low-release form for once-daily use in the morning.
Clinical use
The clinical use of organic nitrates is summarised in the
clinical box.
POTASSIUM CHANNEL ACTIVATORS
Nicorandil combines activation of the potassium K An> channel
(see Chs 4 and 26) with nitrovasodilator (nitric oxide donor)
actions. It is both an arterial and a venous dilator, and causes the
expected unwanted effects of headache. flushing and dizziness. It
is used for patients who remain symptomatic despite optimal
management wi th other drugs. often while they await surgery or
angioplasty.
~-ADRENOCEPTOR ANTAGONISTS
~-Adrenoceptor antagonists (sec Ch. II) are important 111
prophylaxis of angina, and in treating patients with unstable
angina. They work for these indications by reducing cardiac oxygen
consumption. In addition. they reduce the risk of death following
myocardial infarction, probably via their antidysrbythmic action.
Their effects on coronary vessels are of minor importance, although
these drugs arc avoided in variant angina because of the theoretical
risk that they will increase coronary spasm. Their very diverse
clinical uses are !.ummarised in the clinical box on p. I 82.
CALCIUM ANTAGONISTS
The term calcium antagonists is often used for drugs that block
cellular entry or Ca 2+ through calcium channels rather than its
intracellular actions (Ch. 4). Some authors use the term Ca2+
entry blockers to make this distinction clearer. Therapeutically
important calcium antagor1ists act on L-type channels. L -type
calcium antagoniMs comprise three chemically distinct classes:
phenylalkylamines (e.g. verapamiJ), dihydropyridines (e.g.
nifedipine, amlodipinc) and benzothiazepines (e.g. diltiazem).
M echanism of action: types of calcium channel
The properties of voltage-gated calcium channels have been
studied in great detail by voltage-clamp and patch clamp
techniques (see Ch. 2). Drugs of each of the three chemical
classe!> mentioned above all bind the a 1 subunit of the cardiac
L-typc calcium channel but at distinct sites. which interact
allosterically with each other and with the gating machinery of
the channel to prevent it!> opening (see below), thus reducing
Ca2 entry. Many calcium antagonists show properties of use
dependence (i.e. they block more effectively in those cells in
which the calcium channels are most active; see the discussion of
class I antidysrhythmic drugs above). For the same reason, they
also show voltage-dependent blocking actions, blocking more
strongly when the membrane is depolarised, causing calcium
294 channel opening and inactivation.
Organic nitrates
Important compounds include glyceryl
trinitrate and longer-acting isosorb ide mononitrate.
These drugs are powerful vasodilators, acting on
veins to reduce cardiac preload and reducing artenal
wave reflection to reduce afterload.
Act via nitric oxide, to which they are metabolised
Nitric oxide strmulates cGMP fonnation and hence
activates protein kinase G, affecting both contractile
proteins (myosin light chains) and Ca2 + regulation.
Tolerance occurs experimentally and is important
clinically with frequent use of long-acting drugs or
sustained-release preparations.
Effectiveness in angina results partly from reduced
cardiac load and partly from dilatation of collateral
coronary vessels, causing more effective distribution
of coronary flow. Dilatation of constricted coronary
vessels is particularly beneficial in variant angina.
Serious unwanted effects are uncommon; headache
and postural hypotension may occur initially.
Overdose can, rarely, cause methaemoglobinaemia.
Clinical uses of organic nitrates
Stable angina:
prevention (e.g. daily isosorbide mononitrate, or
glyceryl trinitrate sublingually immediately before
exertion)
treatment (sublingual glyceryl trinitrate).
Unstable angina: intravenous glyceryl trinitrate
Acute heart failure: intravenous glyceryl trinitrate
Chronic heart failure: isosorbide mononitrate, with
hydralazine in patients of African origin (Ch. 19).
Uses related to relaxation of other smooth muscles
(e.g. uterine, biliary) are being investigated.
T Dihydropyridine;, affect calcium channel function in a complex 1\l).
not Mmply by ph)'\ical plugging of the pore. This became clear \\hen
\Orne dihydrop)ridinc~. exemplified by BAY K 8644. were found kl
bind to I he \arne \lte but to act in the converse way; that i~.to promo1ethe
opening or ~oltage-gated calcium channels. Thus BAY K 864-1 pmlum
effects oppo"te 10 those of the clinical!) used dihydropyridines. namely
an increase m the force of cardiac contraction. and constriction of blood
ve~..eb: it b competitively antagoni<;ed by nifedipine. Studies on the
re<,pon.,e of ~mgle calcium channels to a ~tep depolarisation of the
membrane \uggest that channels can exist in one of three distinct ~l.llc>,
termed 'mode~ (Fig. 18.12). When a channel is in mode 0. it doe, n~
open in re~pon'>e to dcpolari>ation: in mode 1. depolarisation produce, a
low opening probability, and each opening is brief. In mode 2.
depolari,mion produces a very high opening probability. and single
openings are prolonged. Under normal condi tions, about 70% of the
channels at any one moment exist in mode I. with only I% or les' 10
mode 2; each channel swirches randomly and quite slowly belween the

Mode ModeO
A-Depolarising- A A-Depolarising-
step
Opening probability Zero
Favoured by DHP antagonists
% of time normally
<1%
spent in this mode
Fig. 18.1 2 Mode behaviour of ca lcium channels. The traces are patch clamp recordings (see Ch. 2) of the opening of single
calcium channels (downward deflections) in a patch of membrane from a cardiac muscle cell. A depolaristng step is imposed close to
the start of each trace, causing an increase in the opening probability of the channel. When the channel is in mode 1 (centre), this
causes a few brief openings to occur; in mode 2 (right), the channel stays open for most of the time during the depolarising step; in
mode 0 (left), it fails to open at all. Under normal conditions, the channel spends most of its time In modes 1 and 2, and only rarely
enters mode 0. (Redrawn from Hess et al. 1984 Nature 311: 538-544.)
three modes. Dihydrop) ridine\ of the antagonbt type bind \Ciecti\cly to
channeb in mode 0. thus favounng thl\ non-opening state, wherea'>
agoni\ts bind selectively to channel\ in mode 2 (Fig. 18.12). Thi\ type of
two-directional modulation rc~cmble~ the phenomenon ~een with the
GABAibenzodiazepine interaction (Ch. 37). and invites speculation about
po~sible endogenous dihydropyridine-like mediator(s) with a regulatory
effect on Ca 2 entry.
Mibcfradil i~ distinctive in that it block~ T- a~ well as L-typc channel' at
therapeutic concentrations, but it \\a; withdrawn from therapeutic u~e
lx.'Cau>e it caused ad,ef\e drug interaction~ by interfering with drug
metabolism.
Pharmacological eH ects
The main effects of calcium antagonists, as used therapeutically,
are on cardiac and smooth muscle. Vera pamil preferentially
affects the heart, whereas most of the dihydropyridines (e.g.
nifcd ipinc) exert a greater effect on smooth muscle than on the
heart. Diltiazem is intermediate in its actions.
Cardiac actions
The antidysrhythmic effect!> of vcr a pamil and diltiazcm have
been discussed above. Calcium amagonists can cause AV blod..
and cardiac slowing by their actions on conducting tissues, but
this is offset by a reflex increase in sympathetic activity
secondary to their vasodilator action. For example, nifcdipinc
typically causes reflex tachycardia: diltiazem causes little or no
change in heart rate and vcra pa mil s lows the heart rate. Calcium
antagonists also have a negative inotropic effect. which results
from the inhibition of the slow inward current during the action
potential plateau. Despite thi!>, the cardiac output usually !>Lays
constant or increases because of the reduction in peripheral
resi~tance. Again. there are clinically important differences
between the different classes of drug. with verapamil having the
mo!>t marked negative inotropic action. and therefore being
contraindicated in heart failure. as are most other calcium
antagonists, although amlodipinc does not worsen cardiovascular
mortality in patients with severe chronic heart failure.
THE HEART
Mode1 Mode2
~ I
1 ,1 .............. - Channel closed
~ Channetopen
A A-Depolarising-!
step step
Low High
DHP agonlsts
-70% -30%
Vascular smooth muscle
Calcium antagonists cause generalised arteriaUarteriolar dilatation.
thereby reducing blood pressure, but do not much affect the
veins. They affect all vascu lar beds, although regional effects
vary considerably between different drugs. They cause coronary
vasodilatation and are used in patients with coronary artery spa~m
(variant angina). Other types of smooth muscle (e.g. biliary tract.
urinary tract and uterus) are also relaxed by calcium antagonists.
but these effects arc less important therapeutically than their
actions on vascular smooth mu..,cle, although they do cause adverse
effects (see below).
Protection of ischaemic tissues
There are theoretical reasons (see Fig. 18.8) why calcium
antagonists might exett a cywprotective effect in ischacrnic tissues
and thus be of use in treating heart attack and stroke (see Ch. 35).
However, randomised clinieaJ trials have been disappointing,
with little or no evidence or beneficial (or harmful) effects of
calcium antagonists on cardiovascular morbidity or mortality in
patient groups other than patients with hypertension, in whom
calcium antagonists have beneficial effects comparable \\ ith
those of other drugs that lower blood pressure to similar extent'>.
Nimodipine has some selectivity for cerebral vasculature and is
sometimes used in the hope of reducing cerebral vasospasm
following subarachnoid haemorrhage.
Pharmacokinetics
Calcium antagonists in clinical use are all well absorbed from the
ga!.trointestinal tract, and are given by mouth except for some
special indications. such a~ following subarachnoid haemorrhage.
for which intravenou~ preparations are available. They are
extensively metabolised. Pharmacokinetic differences bet\\een
different drugs and different pharmaceutical preparation~ are
clinically important, because they determine the dose interval
and also the intensity of some of Lhe unwanted effects, such as
headache and flushing (sec below). Amlodipine has a long 295
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

elimination half-life and is given once daily, whereas nifedipine,
diltiazem and verapamil have shorter elimination half-lives and
arc either given more frequently or are formulated in various
slow-release preparations to permit once-daily dosing.
Unwanted effects
Most of the unwanted effects of calcium antagonists are
extension of their main pharmacological actions. Short-acting
dihydropyridinel> cause flushing and headache because of their
vasodilator action, and in chronic use dihydropyridines often
cause anlde l>Welling related to arteriolar dilatation and increased
permeability of postcapillary venules. Verapamil can cau'c
constipation, probably because of effects on calcium channeb in
gastrointestinal nerves or smooth muscle. Effects on catdJac
rhythm (e.g. heart block) and force of contraction (e.g. won.ening
heart failure) are discussed above.
Apart from these predictable effects, calcium channel antagom~l'.
as a class. appear rather free from idiosyncratic adverse effect>.
Clinical uses
The main clinical uses of calcium antagonists are summari~ed in
the clinical box below.

Calcium antagonists

Block Ca 2 entry by preventing opening of voltage-gated L-type calcium channels.

There are three main L-type antagonists, typified by verapamil, diltiazem and dihydropyridines (e.g. nifedipine).
Mainly affect heart and smooth muscle, inhibiting the Ca2+ entry caused by depolarisation in these tissues.
Selectivity between heart and smooth muscle varies: verapamll is relatively cardioselective, nifedipine is relatively
smooth muscle-selective, and diltiazem is intermediate.
Vasodilator effect (mainly dihydropyridines) is mainly on resistance vessels, reducing atterload. Calcium antagonists
dilate coronary vessels, which is important in variant angina.
Effects on heart (verapamil, diltiazem): antidysrhythmic action (mainly atrial tachycardias), because of impaired
atrioventricular conduction; reduced contractility.
Clinical uses:
antidysrhythmic (mainly verapamil)
- ang1na (e.g. diltiazem)
- hypertension (mainly dihydropyridines).
Unwanted effects 1nclude headache, constipation (verapamil) and ankle oedema (dihydropyridines). There is a risk of
causing cardiac failure or heart block, especially with verapamil.

Clinical uses of calcium antagonists

Dysrhythmias (verapamil):
to slow ventricular rate in rapid atrial fibrillation
- to prevent recurrence of supraventricular tachycardia (SV7) (intravenous administration of verapamil to terminate
SVT attacks has been replaced by use of adenosine).
Hypertension: usually a dihydropyridine drug (e.g. amlodipine or slow-release nifedipine; Ch. 19).
To prevent angina (e.g. dihydropyridine or diltiazem).

REFERENCES AND FURTHER READING

Funber reading
Braun\Ooald E 2005 Cnrdoology: bow did we gel here,
\Ooben: an: "-C l<Xb) and when: are we going" Can J
Cardiol 21 1015 1017
Braun"'aid t. Op1e t H 200 I Drug> for the hean.
Saunder.. Phola.Jelphoa
Vaughan Wilham\ EM 1989 CJn,>Oficmoon of
anuarrhythmic a.;uon,. In: V,lUghan William' E M
(ed) Anunrrhythmoc drug>. I land book of experimental
pharmacology. vol. 89. Springer Verlag. Berlin (For a
tlijj'l'rt!lll ap1>mac!J Jte Circularioro 1994, 84: 1848)
Zipc, D. Jalifc J 200-1 Cardiac clectropby,iology: from
cell to bed\ ide, 41h cdn. Snundcrs. Philadelphia
296 (Compnhtn\il'l! te.\lbook)
Specific aspects
Physiological and pathoph) siological aspects
Jngwall J S 2oot Transgenesos and cardonc energe1ics:
new insights into cnrdinc metnbohsm J \1ol Cell
Cnrdiol37: 61~23
Linden J 2001 Molecular npprooch 10 ndenO\onc
receptors: receplor-mediaoed onechan"m' Of II!UC
protec1ioo. Annu Rev Phannacol Toxicol 41 775 -787
(Adenosine in cardiac: i.\'dwenuc:prectmdttwmng)
Opie L H 1999 Cardiac metabolism in i.chemic hean
disease. Arch Mal Coeur Vniss 92: 175.5-1760
Rockman H A. Koch W J, Lefkowil? R J 2002 Scven-
transmembrane-sp;mning reccp1ors und heart function.
Na1Ure4 15: 206 2 12
Saurin AT. Rakhol R D, Mather M S 2000Thcrap<c c
potential of oscbaemic precooditioning. Br J Chn
Pharmacol 50: 87-97 (Adenosine ere.)
Schoner W 2002 Endogenous cardiac glycosi~. tll(Vo
class of slerood hormones. Eur J Biocbem 269:
2440-2448
Trochu J N. Boubour J B. Kale) G. Hintze T H 2<m
Role of endolhelium-denved nil ric o~ode m the
regulnuon of cardtac oxygen melllbolism-
implications in health and disease. Circ Res
87: II 08-1117 (Emlunres rile role of nitric oxidr
ill the collfml of mirocloontlrial respiration. wull
:.pecial emplwsis 011 irs effect on cardiac
merabalism)
 The vascular system
Overview 298
-
Vascular structure and function 298
Control of vascular smooth muscle tone 299
-The vascular endothelium 299
-The renin-angiotensin system 303
Vasoactive drugs 305
-Vasoconstrictor drugs 305
-Vasodilator drugs 305
r--
Clinical uses of vasoactive drugs 310
-Systemic hypertens1on 311
-Cardiac failure 312
-Shock and hypotens1ve stoles 314
-Penpherol vascular disease 316
-Reynaud's disease 316
-Pulmonary hypertension 316
OVERVIEW
This chapter is concerned with the pharmacology of
blood vessels. The walls of arteries, arterioles,
venules and veins contain smooth muscle whose
contractile state is controlled by circulating hormones
and by mediators released locally from sympathetic
nerve terminals (Ch. 9) ond endothelial cells. These
work mainly by regulating Ca 2 in vascular smooth
muscle cells, as described in Chapter 4. In the present
chapter, we first consider the control of vascular
smooth muscle by the endothelium and by the
renin-angiotensin system, followed by the actions
of vasoconstrictor and vasodilator drugs. Finally,
we briefly consider clinical uses of vasoactive
drugs in some important diseases, namely
hypertension (pulmonary as well as systemic),
heart failure, shock, peripheral vascular disease
and Raynaud's disease. The use of vasoactive
298 drugs to treat angina is covered in Chapter 18.
VASCULAR STRUCTURE AND FUNCTION
Blood is ejected with each heartbeat from the left ventricle into
the aorta. whence it flows rapidly to the organs via large conduit
arteries. Successive branching leads via muscular arteries to arteri-
oles (endothelium surrounded by a layer of smooth muscle only
one cell thick) and capillaries. where gas and nutrient exchang~'
occur. Capi llaries coalesce to form postcapillary venules. \enub
and progressively larger veins leading. via the vena cava, to the
right heart. Deoxygenated blood ejected from the right ventncle
travels through the pulmonary artery, pulmonary capillarie\ and
pulmonary veins back to the left atrium. ' Small mul.cular anerie
and arterioles are the main resistance vessels, while vein' are
capacity vessels that contain a large fraction of the total blood
volume. In terms of cardiac function. therefore, arterie, and
arterioles regulate the afterload, while veins and pulmona!)
vessel!. regulate the preload of the ventricles.
Viscoelastic properties of large arteries determine artenal
compliance (i.e. the degree to which the volume of the artenal
system increases as the pressure increases). This is an important
factor in a circulatory system that is driven by an intcm1ittent
pump such as the heart. Blood ejected from the lefl ventricle i'
accommodated, in the ftrst instance, by distension of the aorta.
which absorbs the pulsations and delivers a relatively steady Oow
to the tissues. The g reater the compliance of the aorta, the more
effectively are nuctuations damped out,2 and the smaller the oM:d-
lations of anerial pressure with each heartbeat (i.e. the difference
between the sy&tolic and diastolic pressure, known as the 'puh~
pressure). Renection of the pressure wave from branch point\'"
the vascular tree also sustains arterial pressure during diastole. In
young people, this helps to preserve a steady perfusion of \ita!
organ-., -.uch as the J.Jdney. during diastole. However, exce\\1\e
renection can pathologically augment aortic systolic pre,,ure
' William Harve) (ph)~ician to King Charles I) inferred the circulation ot
the blood on the ba"' of ~uperbly elegant quantitative experiment, tong
before the in\cntion of the micro~cope enabled visual coofimtation of the
tiny ve~sets he had predicted. Thi~ intellectual triumph did his med1cat
~tanding no good at alt. and Aubrey wrote that 'he felt mightily in hi~
practice, and wa\ regarded by the vulgar as crack-brained'. Plus ~a
change ...
2
This cu~hioning action i called the windkesser effect The same principle
wac, u~etlto deliver a steady rather than intennirtent flow from old-
fashioned fire pump~.

This results from stiffening of the aorta due to loss of elastin
during agei ng, especially in people with hypertension. Elastin is
replaced by inelastic collagen. Cardiac work (see Ch. 18) can be
reduced by increasing arterial compliance or by reducing arterial
''ave reflection. even if the cardiac output and mean arterial press-
ure are unchanged. Over around 55 years of age. pulse pressure
and aortic stiffness are important risk factors for cardiac disease.
Actions of drugs on the vascular system can be broken down
into effects on:
total systemic ('peripheral') vascular resistance, which is one
of the main determinants of arterial pressure and is relevant
to the treatment of hypertension
the resistance of individual vascular beds, which determines
the local distribution of blood flow to and within different
organs; such effects arc relevant to the drug treatment of
angina (Ch. 18), Raynaud 's phenomenon, pulmonary
hypertension and circulatory s hock
aortic compliance and pulse wave reflection, which are
relevant to the treatment of cardiac failure and angina
venous tone and blood volume (the 'fullness' of the
circulation). which together determine the central venous
pressure and arc relevant to the treatment of cardiac failure
and angina; diuretics (which reduce blood volume) are
discussed in Chapter 24
atheroma (Ch. 20) and thrombosis (Ch. 2 1).
CONTROL OF VASCULAR SMOOTH
MUSCLE TONE
Like other muscle cells. vascular smooth muscle contracts when
[Ca 2+], rises. but the coupling between [Ca2+], and contraction is
less tight than in striated or cardiac muscle (Ch. 4). Vasoconstrictors
and vasodi lators act by increasing or reducing [Ca2+],, and/or
by altering the sensitivity of the contractile machinery to [Ca2+J,.
Figure 4.10 (p. 67) summarises cellular mechanisms that are
involved in the control of smooth muscle contraction and
relaxation.
THE VASCULAR ENDOTHELIUM
A new chapter in our unden.tanding of vascular control opened with
the discovery that vascular endothelium acts not only as a passive
barrier between plasma and extracellular fluid. but also as a source
of numerous potent mediators. These actively control the contraction
of the underlying smooth muscle as weU as influencing platelet
and mononuclear cell function: the roles of the endothelium in
haemostasis and thrombosis are discussed in Chapter 21. Several
distinct classes of mediator are involved (Fig. 19.1).
Prostanoids (1.ee Ch. 13). The discovery by Bunting,
Gryglewski, Moncada & Vane ( 1976) of prostaglandin (PG)
11 (also known as prostacyclin) ushered in this era. This
mediator, acting on I prostanoid receptors (Ch. 13), relaxes
smooth muscle and inhibits platelet aggregation by activating
adenylatc cyclase. Endothelial cells from rnicrovessels
synthesise PGE2 , which is a direct vasodilator and also
THE VASCULAR SYSTEM
Vascular smooth muscle
Vascular smooth muscle is controlled by
mediators secreted by sympathetic nerves (Chs 9 and
11) and vascular endothelium, and by circulating
hormones.
Smooth muscle cell contraction is initiated by a rise
in [Ca2 ],. which activates myosin light-chain kinase,
causing phosphorylation of myosin, or by
sensitisation of the myofilaments to Ca2 by inhibition
of myosin phosphatase (see Ch. 4).
Agents cause contraction via one or more
mechanism:
release of intracellular Ca2+ via inositol
trisphosphate
depolarising the membrane, opening voltage-
gated calcium channels and causing Ca2 entry
increasing sensitivity to Ca2+ via actions on
myosin light-chain kinase and/or myosin
phosphatase (Ch. 4, Fig. 4.9)
Agents cause relaxation by:
inhibiting Ca2 entry through voltage-gated
calcium channels either directly (e.g. nifedipine)
or indirectly by hyperpolarising the membrane
(e.g. potassium channel activators such as
cromakalim)
increasing intracellular cAMP or cGMP; cAMP
inactivates myosin light-chain kinase and
facilitates Ca2 efflux, cGMP opposes agonist-
induced increases in (Ca2 ],.
inhibits noradrenaline (norepinephrine) release from
sympathetic nerve terminals, while lacking the effect of PGI2
on platelets. Prostaglandi n endoperoxide intermediates
(PGG 2 PGH2) are endothelium-derived contracting factors
acting via thromboxane (T prostanoid) receptors.
Nitric oxide (NO) (sec Ch. 17). Endothelium-derived relaxing
factor (EDRF) was discovered by Furchgott and Zawadzki in
1980, and identified as NO by the groups of Moncada and of
lgnarro (sec Fig. 17.2, p. 266). These discoveries enormously
expanded our understanding of the role of the endothelium.
NO activates guanylate cyclase. It is released continuously in
rc~i<,tance vessel<;, giving rise to vasodilator tone and
contributing to the physiological control of blood pressure.
As well as causing vascular relaxation. it inhibits vascular
smooth mu1.cle cell proliferation. inhibits platelet adhesion
and aggregation. and inhibits monocyte adhesion and
migration; consequently, it may protect blood vessels from
atherosclerosis and thrombo1.is (see Chs 20 and 21).
Peptide.\. The endothelium secretes several vasoactive peptides.
C-natriuretic peptide (Ch. 18, p. 285) and adrenomedulin
(a vasodi lator peptide originally discovered in an adrenal
tumour- phaeochromocytoma-but expressed in many
tissues, including vascular endothelium) are vasodilators 299
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

Various Shear Agonists

(thrombin, stress (ACh, BK, 5-HT, etc.)
All Al IL-1,
endotoxin) !
~
~ [Ca2..] 1

~EN"'6~:'."LIAL
ET-1 GAP JUNCTION
-electrotonic
spread of
endothelial
NO GNP PG~ EDHF hyperpolarisation
?EET
?K

AT1 NPR IP

/ VASCULAR
SMOOTH
MUSCLE

Fig. 1 9.1 Endothelium- derived mediators. The schematic shows some of the more important endothelium-derived contracting and
relaxing mediators; many (if not aiQ of the vasoconstrictors also cause smooth muscle mitogenesis, while vasodilators commonly mhibtt
mitogenesis. 5-HT, 5-hydroxytryptamine; A, angiotensin; ACE, ang1otens1n-converting enzyme; ACh, acetylcholine; AT1 , angiotensin AT1
receptor; BK, bradykinin; GNP, C-natriuretic peptide; DAG, diacylglycerol; EDHF, endothelium-derived hyperpolarising factor; EET,
epoxyeicosatetraenoic acid; ET-1, endothelin-1; ETAI(B) endothelium A (and B) receptors; Gq, G-prote1n; IL-1, interleukin-1; IP, I
prostanoid receptor; IP3, inosinoi 1,4,5-trisphosphate; i<tR, inward rectifying potassium channel; NatK ATPase, electrogenic pump; NPR,
natriuretic peptide receptor; PG, prostaglandin; TP, T prostanoid receptor.

working, respectively. through cGMP and cAMP. Angiotensin
If, formed by angiolensin-converling enc;yme (ACE) on the
surface of endothelia l cells (see below), and endolhelin are
potent endothelium-derived vasoconstrictor peptides.
Endothelium-derived hyperpolarising factor(s) (EDHFs).
Endothelium-dependent dilatation in response to several
mediators (including acetylcholine and bradykinin) persists
in some vessels despite complete inhibition of prostaglandin
and NO synthe~is. Such relaxation is accompanied by
endothelium-dependent hyperpolarisation of vascular smooth
muscle, and is abolished by an unusual combination of Ca 2-
dependent potassium channel-blocking toxins (apamin plus
charybdotoxin). but not by these toxins individually. Such
hyperpolarising/relaxant responses are caused by EDHFs
distinct from prostanoids and N0.3 EDHF becomes
progre!.sively important. compared with NO, in progressively
smaller arteries. Its chemical identity (or identities) remains
elusive, but there are currently three main contenders, which
3
Confusingly, P01 2 ond NO do e<~ch byperpolarise vascular smooth muscle.
300 and thi~ can contribute 10 their re lallant effects.
are not necessarily mutually exclusive. These are (i)
epoxyeicosanoids synthesised from arachidonic acid by an
isoform of cytochrome P450; (ii) electrotonic spread of
hyperpolarisation from endothelium to vascular smooth
muscle by gap junctions; and (iii) K+ released from
endothelium, which paradoxically hyperpolarises vascular
smooth muscle by activating inwardly rectifying potassium
channels (which can be blocked by barium ions) and an
electrogenic atK pump (which can be blocked by
ouabain or other cardiac glycosides; p. 291 ).
ln addition to secreting this array of vasoactive mediator.., en<Jo.
thelial cclb express several enzymes and transpon mechanisrru.oo
their pla!.ma membranes that act on circulating hormone!> and drt
important targets of drug action. ACE is a particularly imponant
example (see below).
Many endothelium-derived mediators are mutually antagonbuc,
conjuring an image of opposing rugby football players swaymg
back and forth in a serum: in moments of exasperation, on~
sometimes wonders whether aU this makes sense or whctherthe
designer simply could not make up his mind! An important
distinction ill made between mechanisms that are tonically active

in resistance vessels under basal condition~. as is the case with the
noradrenergic neJ1'0IIS system (Ch. J J). 0 (Ch. 17). and possibly
endorhelin, and tho'>e that operate mainly in response to injury,
inflammation, etc., as with PGI 2 Some of Lhe latter group may be
functionally redundant, perhaps representing vestiges of mechan-
tsms that were important to our evolutionary forebears. or they
rna) simply be taJ...ing a breather on the touchline and are ready
to rejoin the fray if called on by the occurrence of some vascular
insult. Evidence for ~uch a 'back-up role comes, for example,
from mice that lacJ... the 1 prostanoid receptor for PGI2, and that
have a normal blood pre!.sure and do not develop spontaneous
thrombol>il>. but are more susceptible to vasoconstrictor and
thrombotic stimuli than their wild-type litter mates (Murata et al.,
1997). Such redundancy complicates interpretation of experiments
using mutant gene 'knockout' animals. For example. whereas
acetylcholine relaxes arterioles (from muscle) of wild-type mice
mainly by re leasing NO. it also relaxes vessels from 'eNOS
knockout' mice (which lack the gene for the endothel ial NO
synthase, eNOS) by releasing EDHF in place of NO.
The endothelium in angiogenesis
As touched on in Chapter 7 (pp. 98-99), the barrier function of
\'ascular endothelium differs markedly in different organs. and its
development during angiogenesis is controlled by several growth
factors, including non-specific ones such as vascular endothelial
gro\\ th factor (VEGF) and tissue-specific factors such as endo-
crine gland VEGF. These are involved in repair processes but
aho in pathological l>ituations. including tumour growth and
neovascularisation in the eye (an important cause of blindness in
patients with diabetes mellitus). These factors and their receptors
are potentially fruitful targets for drug development and new
therapies (including gene therapies; Cb. 55, p. 773).
ENDOTHELIN
Discovery, biosynthesis and secretion
Hickey ct al. described a vasoconstrictor factor produced by cultured
endothelial cells in 1985. This was identified as cndothelin, a 21-
residue peptide. by Yanagisawa et al. (1988), who achieved the
isolation. analysi!> and cloning of the gene for this peptide in an
impres!lively short space of time.
T Three gene' encode different 'equcnccs (ET- 1. ET-2 and ET-3), each
with a di\tincti\'e '\hepherd\ crool..' \tructurc produced by two internal
d1\ulfide bonds. Thco.e I\Ofom1s arc differently expressed in organ~ such
a~ brnin and adrenal glands (Table 19. I ). \uggCJ>ti ng Lhat endothelins ha' e
function' beyond the cardiovascular system. and this is supponed by
ob..ervauons of m1ce 111 "'luch Lhe gene coding for ET-1 is disrupted (see
below ). 1:.1- 1 1s the onl) endothelin pre~nt in endothelial cells, and is
also c'pre,sed 111 many other ussue~. hs synthesi~ and acuons are
~ummari~cd schcmaucally in Figure 19.2. ET-2 is much le~s widely
distributed: 11 IS present in ~idney and inteMine. ET-3 is present in brnin,
lung. mtesune and adrenal gland. ET- 1 is synthesised from a 212-residue
precun.or molecule (prcpro-1:.1). which is processed to 'big ET-1' and
finally cleaved by an endmhe lin-conven.ing enzyme to yield ET- 1.
Cleavage occun. not at the u\ual Lys-Arg or Arg-Arg position, but at a
Trp-Val pair, implying a very atypical endopeptidase. The convening
enl}'me i~ a metalloprotca~e and is inhibited by phospboramidon. Big
ET-1 i~ converted to ET- 1 intraccllularly and also on Lhe surface of
endothelial and smooth mu~clc cells.
THE VASCULAR SYSTEM
Table 19.1 Distribution of endothelins and endothelin
receptors in various tissues"
Tissues Endothelin Endothelin receptor
1 2 3 ETA ETa
Vascular tissue
Endothelium ++++ +
Smooth muscle + ++
+++
Bra1n +++ + +
Kidney ++ ++ + + ++
Intestines + + +++ + +++
Adrenal gland + +++ + ++
"Levels of expression of endothelins or the receptor mRNA
and/or Immunoreactive endothelins: ++++, highest; +++, high;
++, moderate; +, low.
(Adapted from: Masaki T 1993 Endocr Rev 14: 256-268.)
Stimuli to endothelin synthesis include many noxious vasocon-
!>trictor mediators released by trauma or inflammation, including
activated platelet , endotoxin. thrombin, various cytokines and
growth factors, angiotensin II. antidiuretic hormone (ADH)
(arginine-va~opres'>in). adrenaline (epinephrine), insulin, hypoxia
and low shear stress. Inhibitors of ET synthesis include NO.
natriuretic pcptidcs. PGE2 PG12 heparin and high shear stress. It
was originally believed that ET-1 is generated entirely de novo
and not stored intraccllularly. but secretion of ET-1 can occur
more rapidly (e.g. in response to stretch) than would be expected
if it were alway~> freshly synthesised, and there is evidence that
preformed ET- 1 can be stored in endothelial cells, although
probably not in granules. Release mechanisms of such stored ET-
1 arc poorly understood. ET-1 concentration i.n plasma is low
(< 5 pmol/1) compared with concentrations that activate endot.helin
receptors, but concentra tions in the extracellular space between
endothelium and vascular smooth muscle are presumably much
higher, and endothelin receptor antagonists (see below) cause
vasodilatation when infused directly into the brachial artery, con-
sistent with tonic ET-1-mediatcd vasoconstrictor activity in resist-
ance vasculature. ET-1 has an elimination half life of< 5 minutes,
despite a much longer duration of action. and clearance occurs
mainly in the lung and J...idneys.
Endothelin receptors and responses
There are two types of endothelin receptor, designated ETA and
ET 8 (Table 19.2). both of which are G-protein-coupled (Ch. 3).
The predominant overall response is vasoconstriction.
T Endothelin l preferentially activate!. ETA receptors. Messenger RNA
for the ETA receptor;, expre~'>Cd in many human tissues. including vascular
smooth mw,cle. heart. lung and kidney. It is not expressed in endothelium.
ETA-mediated responses include vasoconstriction, bronchoconstriction
and aldostt>rolle secretion. ETA receptors arc coupled to phospholipa~e
C, which !>timu late.\ NafH exchange, protein kinase C and mitogenesis,
as well as causing va~oconstriclionthrough inositol trisphosphate-media!cd
301
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

Stimulation Inhibition

Adrenaline Thrombin Shear stress

Angiotensin II Glucose PGI 2
Vasopressin Oxidised LDL NO
Insulin Hypoxia Natriuretic peptides (A, B, C)
Cortisol Ciclosporin
IL-1

Prepro-ET-1

BIG ET-1

~
ET-1

ET-1 Clearance
(lungs, kidneys)

Fig. 19.2 Endothelin-1 (ET-1) Signal transduction Effects

synthesis and actions. Tyrosine kinase/MAPK
The schematic shows some of the
Gene expression } { f Blood pressure
Phospholipase A2 , C, D Vasospasm

~
more important actions only. IL-1,
Inositol trisphosphate /Mitogenesis - Smooth muscle proliferation
nterleukin-1; LDL, low-density
ipoproteln ; NO, nitric oxide; PGI 2, Ca2 } Activation of hypothalamic-
prostaglandin 12 Protein kinase C Contraction pituitary axis
-------------------------

Ca1 release (Ch. 3). There are several selective ETA-receptor amagon""
including BQ- 123 (n cyclic pentapeptide) and several orally active non
peptide drug' (e.g. bosentan. a mixed ETA/ET8 antagonist u!>ed in tre ung
pulmonary anerial hypertension-see below). ET8 receptors are actillc.
to a >imilar extent by each of the Lhree endothelin isofonns, but sarafoto\in
Table 19.2 Endothelin receptors S6c (a 21-re\idue peptide that shares the shepherd's crook suucture of tl-
endothelin~ and wru. i~lated from the venom of the burrowing ~'P' h a
..electil'e :~goni~t and hru. pro"ed useful as :1 pharmacological tool for <;QJdymg
Receptor Affinity Pharmacological response the ET8 recep10r. Me,..enger RNA for the ET8 recep1or i~ mrunl} e~fn\sal
111 brain (c~pecJall} cerebral cortex and cerebellum), with modentt
ETA ET-1 = ET-2 > ET-3 Vasoconstriction, expression in aorta. heart. lung. kidney and adrenals. In coniJ':bt ro the
bronchoconstriction, ETA receptor. it i~ highly expressed in endothelium. where 11 may lnt!WC
stimulation of l'a.wdilawrion by stimulating NO :10d PGI 2 production. but 11 j, al;o
aldosterone secretion present in vascular smooth muscle. where it initiates vasoconstriction lu.e
the ET" receptor.
ET-1 ET-2 ET-3 Vasodilatation, inhibition
of ex vivo platelet
aggregation Functions of endothelin
Endothelin- 1 is a paracrine mediator rather than a circulating
(From: Masaki T 1993 Endocr Rev 14: 256-268.) hormone, although it stimulates secretion of several hormone'
302 (see below). Administration of an ETA-receptor antagonist or of
 THE VASCULAR SYSTEM

phosphoramidon into the brachial artery increases forearm blood

tlow, suggesting that ET-1 may contribute to vasoconstrictor tone
and the control of peripheral vascular resistance (Haynes &
( Ro 46-2005 (mg/kg)
Webb, 1994). Endothelin!> have several other possible function&.
0 3
including roles in: 0
release of various hom1ones, including atrial natriuretic
peptide, aldosterone, adrenaline. and hypothalamic and 10
pituitary hormones
thyroglobulin synthesis (the concentration of ET-1 in thyroid
follicle~ is extremely high)
~ 20

control of uteroplacental blood flow (ET-1 is present in very 8

:0 30
high concentrations in amniotic fluid) (ij
c:
renal and cerebral vasospasm (Fig. 19.3) Q)
0::
development of the cardiorespiratory systems (the ET-1 gene
40~------------------------~
has been disrupted experimentally; pharyngeal arch tissues
develop abnormally in such mice and homozygotes die of
respiratory fai lure at birth).

THE RENIN-ANGIOTENSIN SYSTEM 3l 0

co
2?
The renin- angiotensin system synergises with the sympathetic
~ r
nervous system. for example by increasing the release of e SAH
noradrenaline from sympathetic nerve terminals. It stimulates
aldosterone &ecretion and plays a central role in the control of ~
Na excretion and fluid volume, as well as of vascular tone.
8 25
:0
Renin i~ a proteolytic enzyme that is secreted by the
~
jtLttaglomerular apparatus (see p. 370. Fig. 24.2). The control of .0
2?
renin secretion (Fig. 19.4) i:. only partly understood. It is secreted in (I)
(.)
re~ponse to various phy'iiological stimuli. including a fall in Na
concen tration in the distal tubule and a fall in renal perfusion Baseline 30 60 90 120
pressure. The Na concentration in the distal tubule is sensed by Time after SAH (min)
the macula densa (a specialised part of the distal tubule apposed
to the juxtaglomerular apparatus). Renal sympathetic nerve activity,
1}-adrenoceptor agoniMs and PG! 2 all stimulate renin secretion
directly, whereas angiotensin ll causes feedback inhibition. Atrial c;;
I
natriuretic peptide (Ch. 18, p. 285) also inhibits renin secretion . E
E
s2? - 10
:::l
~
The role of the endothelium In controlling 2?
a. -20
vacular mooth mucle (ij
~
t:
Endothelial cells release vasoactive mediators co -30
c:
co
tncluding prostaglandtn 12 and nitric oxide (NO) (I)
~
(vasodilators), and endothelin (vasoconstrictor).
Many vasodilators (e.g. acetylcholine and bradykinin) 0 2 3 4 5 6 7 8
act via endothelial NO production. The NO derives Time (h)
from arginine and is produced when [Ca2], increases
Fig. 19 .3 In vivo effects of a pot ent non-peptide
in the endothelial cell, or the sensitivity of endothelial endothelin-1 ETA- and ET8 -receptor antagonist, Ro 46-
NO synthase to Ca2 is increased (see Fig. 17.3, p. 267). 2005, in three animal m odels. [AI Prevention by Ro 46-2005
NO relaxes smooth muscle by increasing cGMP of postischaem1c renal vasoconstriction in rats. E Prevention
formation. by Ro 46-2005 of the decrease in cerebral blood flow after
subarachnoid haemorrhage (SAH) in rats treated with placebo
Endothelin is a potent and long-acting vasoconstrictor
(blue) or with Ro 46-2005 (red). [Q] Effect of orally administered

peptide released from endothelial cells by many
chemical and physical factors. It is not confined to
blood vessels, and it has several fu nctional roles.
l
Ro 46-2005 on mean arterial pressure in sodium-depleted
squirrel monkeys treated with placebo (blue) or increasing
doses of antagonist (red: <4 < t ). (From Clozel M et al. 1993
Nature 365: 759--761.) 303
 SECTION 3 DRUGS AFFECTING MAJOR ORGAN SYSTEMS

Renin is cleared rapidly from plasma. It acts on angiotensinogcn

Renal perfusion (a plasma globulin made in the liver), splitting off a decapcplide,
~ pressure ~ angiOtensin I, from the N-tenninal end of the protein.

t
Angiotensin I has no appreciable activity per se, but is con\ened
Renal by ACE to an octapeptide. angiotensin II. which is a potent
sympathetic Glomerular vasocon!>trictor. Angiotensin II is a substrate for enz) me'
nerve actiVIty ~ filtration
(aminopeptidase A and N) that remove single amino acid resid\Jc!\,
giving ri!>e. rc!>pcctively. to angiotensin fiJ and angiotensin 1\'
Atrial natriuretic
peptide
Renin release -<>- ~-Agonists
PGI
(Fig. 19.5). These had been regarded as of little importance. but
2 it i~ now known that angiotensin lll stimulates aldosterone
secretion and i~ involved in thirst. Angiotensin IV also hn'
Angiotensinogen distinct actions. probably via its own receptor, including relea-c
of plasminogen activator inhibitor-! from the endothelium (Ch. 21 ).
Angiotensin T Receptors for angiotensin IV have a distinctive distribution,
including the hypothalamus.

!~
Angiotensin II
Angiotensin-converti ng enzyme is a membrane-bound enzyme
on the surface of endothelial cells, and is particu larly abundant in
the lung, whic.;h has a vast surface area of vascular endothelium.~
! Angiotensin 11
The common isoform of ACE is also present in other va~cular
tissues, including heart, brain, striated muscle and kidney, and I\
AT, subtype not restricted to endothelial cells.5 Consequently, local formation
receptor
r,....._ __ __ r_e_cr~, antagonists
of angiotensin ll can occur in different vascular beds, and it pro-
vides local control independent of blood-borne angiotensin II.
ACE inactivates bradykinin (see Ch.l3-Fig.l3.13 and p.221)
and se' eral other peptides. This may contribute to tbe pharma<:o-
Vascular growth: Vasoconstriction: Salt retention. logical actions of ACE inhibitors. as discussed below. The main
1 Hyperplasia 1. D1rect 1. Aldosterone action~ of angioten in ll are mediated viaAT1 and/ or AT2 receptO"o.
2 Hypertrophy 2 Via increased secretion which belong to the family of G-protein-<:oupled receptol\.
noradrenaline 2. Tubular Na
release from reabsorption Effects mediated by AT1 receptors include:
sympathetic
nerves generali\ed vasocon~triction. especially marked in efferent
arteriole~ or the kidney
Fig. 19 .4 Control of renin release and formation, and increa!>ed relea~e of noradrenaline from sympathetic nerve
action of angiotensin II. Sites of action of drugs that inhibit terminals, reinforcing vasoconstriction and increasing the rate
1 the cascade are shown. ACE, angiotensin-converting enzyme;
\ AT1 , angiotensin II receptor subtype 1. and force of contraction or the heart
stimulation of proximal tubular reabsorption of Na+
secretion of aldosterone from the adrenal cortex (see Ch. 28)
cell growth in the heart and in attcries.6
The AT 2 receptors have also been cloned. They are expn.:~~cd
during feta l life and in distinct brain regions in adults. Studie>of
mice in which the gene for the AT2 receptor has been disrupted
suggest that it may be involved in growth. development and

I C-terminal
etc. v
Nterminal
exploratory behaviour. Cardiovascular effects of AT2 receptol'l
(inhibition of cell growth and lowering of blood pressure) appear
to be relative!} :.ubtle and oppose those of AT1 receptors.
The renin-angioten!>in-aldosterone pathway is imponant m the
pathogenesis of heart failure. and several very important cla~-e~ of
therapeutic drug act by inhibiting it at various points (see bel011)

'-------- ..-------'
Angiotensin 11
N

4
Approximutely that of a football field.
\----------------~----------------'
Angiotens111 I ' A differem i\oform of ACE i> abo present in testis. and male mice laclmg
~ - --------------v-----------------J this ACE have markedly reduced fertility.
Angiotensinogen
l>fhese effects are initiated by the G-protein-coupled AT 1 reccp10r acting
Fig. 19.5 Formation of angiotensins I-IV from the N- via the bamc intrnccllu lar tyroinc pho5phorylation pathways as are used b}
terminal of the precursor protein angiotensinogen. cytokincs, for example the Jak/Stat pathway (Ch. 3; Marrero et al. 1995
304 Nature 375: 247- 250).

VASOACTIVE DRUGS
Drugs can affect vascular ~mooth muscle by acting either directly
on smooth mu<,cle cell!.. or indirectly, for example on endothelial
cells, on ~ympathetic nerve terminals or on the central nervous
system (CNS) (Table 19.3). Another type of indirect action is
exemplified by ACE inhibitor~. Mechanisms of directly acting
vasocon~trictors and vasodilators are summarised in Figure 4.10
(p. 67). Many indirectly acting drugs are discussed in other
chapter~ (see Table 19.3). We concentrate here on agents that are
not covered elsewhere.
VASOCONSTRICTOR DRUGS
The a 1-adrenoccptor agonists and drugs that release noradrenaline
from sympathetic nerve terminals or inhibit its reuptake
(sympathomimetic amines) cause vasoconstriction and are discussed
in Chapter II . Some eicosanoids (e.g. thromboxane A2 ; see Chs 13
and 21) and several peptides, notably endothelin, angiotensin and
ADH, are also predominantly vasoconstrictor. Sumatriptan and
ergot alkaloids acting on certain 5-hydroxytryptamine receptors
(5-HT2 and 5-HT 11.>) also cause vasoconstriction (Ch. 12).
ANGIOTENSIN II
The physiological role of the renin-angiotensin system is
described above. Angiotenl.in n is roughly 40 times as potent as
noradrenaline in raising blood pressure. Like a 1-adrenoceptor
agonists, it constricts mainly cutaneous. splanchnic and renal
vasculature, with less effect on blood flow to brain and skeletal
muscle. It has no routine clinical uses, its therapeutic importance
lying in the fact that other drugs (e.g. captop ril and losartan;
see below) affect the cardiovascular system by reducing its
production or action.
ANTIDIURETIC HORMONE
Antidiuretic hormone (also known as vasopressin) is a posterior
pituitary peptide hormone (Ch. 28, pp. 425-426). It is important
for its antidiuretic action on the kidney (Ch. 24, p. 372) but is
abo a powerful vasoconstrictor in skin and some other vascular
beds. Its effects are initiated by two distinct receptors (V 1 and
V2). Water retention b mediated through V2 receptors, occurs at
low plasma concentrations of ADH, and involves activation of
adenylate cyclase in renal collecting ducts. Vasoconstriction is
mediated through V 1 receptors. requires higher concentrations
of ADH, and involves activation of phospholipase C (see Ch. 3).
ADH causes generalised vasoconstriction, including the coeliac,
mesenteric and coronary vessels. It also affects other (e.g. gastro-
intestinal and uterine) ~mooth muscle and causes abdominal
cramps for this reason. It is sometimes used to treat patients with
bleeding oesophageal varicc~ and portal hypertension before
more definitive treatment. although many gastroenterologists
prefer to use octreotide (unlicensed indication; see Ch. 28-also
Ch. 26 and Ch. 5 1) for this. It may also have a place in treating
hypotensive shock (sec below, p. 3 16).
ENDOTHELIN
Endothelins arc discussed above in the context of their
physiological roles: a~ explained, they have vasodilator and vaso-
constrictor actions. but vasoconstriction predominates. Intravenous
administration causes transient vasodilatation followed by pro-
found and very long-lived vac;oconstriction. The endothclins are
even more potent vasoconstrictors than angiotensin IT. As yet.
they have no clinical uses and their pharmacological importance,
like that of angiotensin IT, will probably lie in drugs that affect
the cardiovascular sy~tem by reducing their production or actions.
VASODILATOR DRUGS
Many vasodilators are clinically important, being used to treat
common conditions including hypertension. cardiac failure and
angina pectoris.
DIRECTLY ACTING VASODILATORS
Targets on which drugs act to relax vascular smooth muscle
include plasma membrane voltage-dependent calcium channels,
sarcoplasmic reticulum channels (Ca2 release or reuptake), and
entyme!oo that determine Ca2 sensitivity of the contractile proteins
(see Fig. 4.1 0, p. 67). A pyridine drug. Y27632, causes \'aso-
rela'<ation by inhibiting a Rho-associated protein kinase, thereby
selecti vely inhibiting smooth muscle contraction by inhibiting
Ca 2 ~en.,iti'>ation.
Calcium antagonists
L-type calcium antagonists are discussed in Chapter 18 (pp. 294-
296). They cause generalised arterial vasodilatation, although
individual agents exhibit distinct patterns of regional potency.
Dihydropyridines (e.g. nifedipine) act preferentially on vascular
smooth muscle, whereas vcrapamil acts also on the heart;
diltiazem is intermediate in specificity. Consequently, rapid acting
dihydropyridines usually produce reflex tachycardia as a result of
Vsoconstrlctor substances
The main groups are sympathomimetic
amines (direct and indirect; Ch. 11 ), certain
eicosano1ds (especially thromboxane A2 ; Ch. 13),
peptides (angiotensin II, antidiuretic hormone [ADH)
and endothelin; Ch. 16) and a group of miscellaneous
drugs (e.g. ergot alkaloids; Ch. 12).
Clinical uses include local applications (e.g. nasal
decongestion, coadministration with local
anaesthetics). Sympathomimetic amines and ADH are
used in circulatory shock. Adrenaline is life-saving in
anaphylactic shock and in cardiac arrest. ADH may
be used to stop bleeding from oesophageal varices
in patients with portal hypertension caused by liver
disease.
305
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
Table 19.3 Classification of vasoactive drugs th at act indirectly
Site Mechanism
Vasoc onstrictors
Sympathellc nerves Noradrenaline (norepinephrine) release
Blocks noradrenaline reuptake
Endothelium Endothelin release
Vasodilators
Sympathetic nerves Inhibits noradrenaline release
Endothelium Nitric oxide release
Central nervous system Vasomotor inhibition
Enzymes Angiotensin-converting enzyme
Inhibition
lowering the blood pressure, whereas verapamil and diltiazem do
not because, although they also lower blood pressure, they slow
the cardiac pacemaker by their direct action on the heart.
Drugs that activate potassium channe ls (see
also Ch. 18, pp. 294-295)
Some drugs (e.g. cromakalim and minoxidil) relax smooth muscle
by !.electively increasing the membrane permeability to K+ by
KAT!' channel activation. This hyperpolarises the cells and switches
off voltage-dependent calcium channels. Patch clamp recording
(see Fig. 19.6 and p. 32) demonstrated that these drugs open a
high-conductance potassium channel. This discovery coincided
with studies demonstrating the existence of ATP-sensitive
potassium channels in various cells. In cardiac muscle and panc-
reatic islet insulin-secreting B cells, for example, intracellular
ATP closes these potassium channels, thus causing depolarisation. 7
Potassium channel activators work by antagonising the action of
intracellular ATP on these channels (Fig. 19.6), thus opening them
and causing hypcrpolarisation and relaxation.
Minoxidil is a very potent and long-acting vasodilator, used as
a drug of lal>t resort in treating severe hypertension unresponsive
to other drugs. It causes hirsutism (its active metabolite is acrually
used as a rub-on cream to treat baldness). This is unacceptable
to most women. It also causes marked salt and water retention,
and is usually prescribed with a loop diuretic. It cause!. reflex
tachycardia, and a ~-adrenoceptor antagonist is used to prevent
thi!>. Crom a ka lim and its active isomer Jemakalim are also KATP
channel activators. Nicorandil (Ch. 18. p. 294) combines KAT!'
channel activation with NO donor activity. and is used in refractory
angina. Levosimendan combines K..xrp channel activation with
scnsitisation of the cardiac contractile mechanism to Ca 2 by
7
This mechani~m form~ an imponantlink between the metabolic srare of
the cell and mcmbr;me function. and ~ulfonylurea drugs cause insulin
secretion by mimicking the action of ATP on these channels (see Ch. 26).
Conversely, ~orne potassium ch;mnel activators increase blood glucose by
306 inhibiting in~u l in secretion from the pancrem.
Examples Chapter(s) for further details
Tyramtne 11
Cocaine 11
Angiotensin II On part) This chapter
Prostaglandin E2, guanethidine 9, 11 and 13
Acetylcholine, substance P 17
Anaesthetics 36
Captopril This chapter
binding troponin (Ch. 18, p. 281 ), and is used in decompensated
heart failure (see below, p. 314).
Drugs that act v ia cyclic nucleotide s
Cyclase activation
Many drugs relax vascular smooth muscle by increasing th~
cellular concentration of either cGMP or cAMP. For exampl~.
0, nitrates and the natriuretic peptides act through cGMP (~ee
Chs 17 and 18); BAY4 I-2272, a pyrazolopyridine, activates solubk
guanylate cyclase via an NO-independent site (see Ch. 17, p. 269).
The /32 agonists, adenosine and PG/2 increase cytoplasmic cAMP
(sec Chs I 1- 13). Dopamine has mixed vasodilator and vasocon
stricter actions. It selectively dilates renal vessels, where it increa..-.e\
cAMP by activating adcnylate cyclase. It is the precursor of
noradrenaline (Ch. I 1), and is also a transmitter in its own right
in the brain (Ch. 34) and probably also in the periphery (Ch. 9).
The proposal that dopamine might serve a role as a peripheral
transmillcr came from observations that stimulation of sympathetic
nerves to the kidney causes vasodilatation that is not affected by
adrenoccptor antagoni!.ts, but is blocked by dopamine receptor
antagonists such as halope ridol. Dopamine. when adrniniMered
as an intravenous infusion, produces a mixture of cardiovascuiOJI
effect.~ resulting from agonist actions on a and ~ adrenoceptol'\,
as well as on dopamine receptors. Blood pressure increa\C>
o;Iightly, but the main effects are vasodilatation in the renal
circulation and increased cardiac output. Dopamine was \~1dd)
U!>ed in intensive care units in patients in whom renal failure
associated with decreased renal perfusion appeared immin~nt:
despite its beneficial effect on renal baemodynamics, it doe~ not
however, improve survival in these circumstances and thi~ uo,e '
ob!.olctc. Nesiritide, a recombinant form of human B-t)pe
natriuretic peptide (BNP) (see Ch. I 8, p. 285), has been appro1ed
in the USA for the treatment of acutely decompensated heart
failure, but a pooled analysis of randomised controlled trial~ ha1
suggested that it too may increase mortality (Sackner-Bemstein
e t al., 2005).

Fig. 19.6 ATP-sensitive potassium cha nnels. Patch clamp (see Ch. 3) record from insulin-secreting pancreatic 8 oell: sapomn
permeabilised the cell, with loss of intracellular ATP, causing the channels to open (upward deflection) until they were inhibited by ATP.
Addition of diazoxide, a vasodilator drug (which also inhibits insulin secretion; see text) reopens the channels. In smooth muscle, this
causes hyperpolarisation and relaxation. (Redrawn from Dunne et al. 1990 Br J Pharmacal 99: 169.)
Nitroprusside (nitroferricyanide) is a powerful vasodilator with
liule effect outside the vascular !>yl>tem. It reacts with tissue
sulfhydryl group!. under physiological conditions to yield NO.
Unlike the organic nitrates, which preferentially dilate capaci-
tance vessels and muscular arteries, it acts equally on arterial and
venous smooth muscle. Tts clinical usefulness is limited because it
must be given intravenously. In solution, particularly when exposed
to light, nitroprusside hydrolyses with formation of cyanide. The
intravenous solution must therefore be made up freshly from dry
powder and protected from light (usually by covering the con-
tainer with foil). Nitroprusside is rapidly convened to thiocyanate
in the body, its plas ma half-life being only a few minutes, so it
must be given as a continuous infusion with careful monitoring to
avoid hypoten~ion. Prolonged use causes thiocyanate accumulation
and toxicity (weakness, nausea and inhibition of thyroid func-
tion): consequently, nitroprusside is useful only for shon-term
treatment (usually up to 72 hours maximum). It is used in
intensive care units for hypenensive emergencies, to produce
controlled hypotension during surgery, and to reduce cardiac
work during the reversible cardiac dysfunction that occurs after
cardiopulmonary bypass surgery.
Phosphodiesterase inhibition
Phosphodiesterases (POEs; see Ch. 3) include at least 14 distinct
isoeozymes. Methylxanthines (e.g. theophylline) and pa paverine
are non-selective POE inhibitors (and have other actions too).
Melhylxanthines exen their main effects on bronchial smooth
muscle and on the CNS, and are discussed in Chapters 23 and 42.
In addition to inhibiting POE, some methylxanthines arc also purine
receptor antagonists. They are not used clinically as vasodilators.
Papaverine is chemically related to morphine, and indeed is
produced by opium poppies (sec Ch. 41, p. 596). Pharmacologi-
cally, it is quite unlike morphine, however, its main action being
to relax smooth muscle in blood vessels and elsewhere. Its
mechanism is poorly understood but seems to involve a combi-
nation of PDE inhibition and block of calcium channels. Selective
PDE type m inhibitors (e.g. milrinone, amrinone) increase cyto-
plasmic cAMP in cardiac muscle. They have a positive inotropic
effect but, despite short-term hacmodynamic improvement,
THE VASCULAR SYSTEM
0.5 mmol/1 ATP
100 ~-tmoVI Diazoxide
!spA
V.sodlletor drugs
Vasodilators act:
to increase local tissue blood flow
- to reduce arterial pressure
- to reduce central venous pressure.
Net effect is a reduction of cardiac preload {reduced
filling pressure) and atterload (reduced vascular
resistance), hence reduction of cardiac work.
Main uses are:
antihypertensive therapy (e.g. AT 1 antagonists,
calcium antagonists and a 1 antagonists)
treatment/prophylaxis of angina (e.g. calcium
antagonists, nitrates)
treatment of cardiac failure {e.g. angiotensin-
converting enzyme inhibitors, AT1 antagonists).
increase mortality in heart failure, possibly by causing dysrhythmias
(p. 292). Cilostazol, a related drug, improves symptom!> in patients
with peripheral vascular disease (see below). Dipyridamole can
provoke angina (p. 293) and is used to prevent stroke (p. 342).
Selective POE type V inhibitors (e.g. sildenafil) inhibit the break-
down of cGMP. Penile erection is caused by increased activity in
nitrergic nerves in the pelvis. These release NO, which activates
guanylate cyclase in smooth muscle in tbe corpora cavemosa.
Taken by mouth about an hour before sexual stimulation, sildenafil
increases penile erection by potentiating this pathway. It has
revolutionised treatment of erectile dysfunction (see Ch. 30) and
has therapeutic potential via potentiation of other NO-mediated
activities (Ch. 17), including pulmonary hypertension (see below).
VASODILATORS WITH UNKNOWN MECHANISM
OF ACTION
Hydralazine
Hydralazine acts mainly on arteries and arterioles, causing a fall
in blood pressure accompanied by reflex tachycardia and an 307
 SECTION 3 DRUGS AFFECTING MAJOR ORGAN SYSTEMS
increased cardiac output. ll interferes with the action of inositol
trisphosphate on Ca 2 release from the sarcoplasmic reticulum.
Ils original clinical u\e was in hypertension. It is still used for
short-tcnn treatment of severe hypertension in pregnancy but
can cau!>e an immune disorder resembling systemic lupus
erythemato.w\,8 'o alternative agents are now usually preferred
for long-term treatment of hypertension. Recent evidence has,
however, suggested that it has a place in treating heart failure in
patient\ of African origin (l.ee below).
Ethanol
Ethanol (sec Ch. 43) dilates cutaneous vessels. causing the familiar
dnmkard's flush. Several general anaesthetics (e.g. proporol)
cause vasodilatation as an unwanted effect (Ch. 36).
INDIRECTLY ACTING VASODILATOR DRUGS
The two mai n groups of indirectly acting vasodi lator drugs are
inhibitor<; of:
sympathetic vasoconstriction
the renin-angiotensin system.
The central control of ~ympathetically mediated vasoconstriction
is believed to involve not only a 2 adrenoceptors but also another
class of receptor, termed the imida:.oline 11 receptor, present in
the brain stem in the rostral ventrolateral medulla. Drugs can
inhibit the sympathetic pathway at any point from the C S to the
peripheral sympathetic nerve tenninal (see Cb. I 1). ln addition,
many vasodilator~ (e.g. acetylcholine. bradykinin. substance P)
exert some or all of their effects by stimulating biosynthesis of
vasodilator prostaglandins or of NO (or of both) by vascular
endothelium (sec above and Ch. 17), thereby causing functional
antagonism of the constrictor tone caused by sympathetic nerves
and angiotensin 11. Endothelia receptor antagonists including
bosenta n lower systemic and pu lmonary arterial pressure.
We concentrate here on the ren in-angiotensin-aldosterone
system. This can be inhibited at several points:
renin release: P-adrenoceptor antagonists inhibit reni n release
(although their other actions can result in a small increase in
peripheral vascular resistance)
renin activity: renin inhibitors
ACE: ACE inhibitors
angiotensin II type I (AT 1) receptors: AT 1-receptor
antagonists
aldosterone receptors: aldosterone receptor anragonisL<>.
All o;uch drugs can increase plasma K+ concentration by reducing
aldosterone secretion or action.
Renin inhibitors
Orally active renin inhibitors (e.g. enalkiren ) reduce plasma
renin activity, but their effects on blood pressure in patients with
hypertension have been disappointing.
3
An autoimmune tli~ea~e affecting one or more tissues, including joints, skin
308 and pleural membranes. It is characterised by antibodies directed against DNA.
Angiotensin-converting enzyme inhibitors
Several specific ACE inhibitors have been developed. the fiN of
which wa'> captopr il (Fig. 19.7). ACE cleaves the C-tenntnal
pair of amino acids from peptide substrates. Its acti\e -.ite
containc; a zinc atom. The development of captopril \\aS one ot
the first exan1ples of successful drug design based on a chemical
knowledge of the target molecule. Various small peptide\ h..d
been found to be weal.. inhibitors of the enzyme,9 but these \\en:
unsuitable as drugs becau'>e of their low potency and poor oml
absorption. Captopril was designed to combine the steric propente'
of such peptide antagonists in a non-peptide molecule. It contatn,
a sulfhydryl group appropriately placed to bind the Line mom.
coupled to a proline residue that binds the site on Lhe enqrnc thJt
normally accommodates the terminal leucine of angioten~in I
(Fig. 19.7). Several ACE inhibitors. differing in duration of
action and tissue d istribution. arc used clinically, including
ena lapril. lisinopril. rarnipriJ. perindopril and t ra ndolapril.
Pharmacological eHects
Captopril is a powerful inhibitor of the effects of angioten~in I tn
the whole animal. It causes only a small fall in arterial pres,urc
in normal animals or human subjects who are consuming the
amount of salt contained in a usual western diet, but a much
larger fall in hypertensive patients, particularly those in \\hom
renin c,ecretion is enhanced (e.g. in patients receiving diuretic,).
ACE inhibitors affect capacitance and resistance vessels, and redlk.-e
cardiac load as well as arterial pressure. They do not affect cardtac
contractility. so cardiac output normally increases. The) act pref
ercntially on angioten&in-sensitive vascular beds. which include
those of the t...idney, heart and brain. This selectivit) rna) be
important in ~uMaining adequate perfusion of these vital organ,
in the face of reduced perfusion pressure. Critical renal arttT)
stenosis 11l represents an exception to this. where ACE inhibition
resu lts in a ft~ ll of glomerular fi ltration rate (sec below).
Clinical uses
Clinical uses of ACE inhibitors are summarised in the clinical box.
Clinical uses of angiotensin-converting
enzyme Inhibitors
Hypertension.
Cardiac failure.
Following myocardial infarction (especially when there
is ventricular dysfunction).
In people at high risk of ischaemic heart disease.
Diabetic nephropathy.
Progressive renal insufficiency.
11nc lead compound wa~ a nonapeptide derived from the venom of
Bmlrmps jacumca-a South American snake. It was originally
charactcri ~cd as n bradykinin-potentiating peptide, an indire~:t effect of
inhibiting ACE, which inactivate; bradykinin (see Ch. 13).
lf)Scverc narrowing of the renal artery, for example that caused by atheroma
(Ch. 20).

~ ~IMio~
r
A]
Fig . 1 9 . 7 The active site of angiotensin-converting enzyme. ~ Binding of angiotensin I. 8 Binding of the inhibitor captopril,
which is an analogue of the term1nal dipeptide of angiotensin I.
Unwonted effects
Captopri l was initially used in doses that. in retrospect, were
excessive. In these large doses, it caused rashes, taste disturbance,
neutropenia and heavy proteinuria. Th is pattern of adverse
effect~ also occur~ during treatment with pe nicillamjne (Ch. 14),
which also contains a sulfhydryl group, and it has been argued
that these effects are attributable to this chemical feature of the
molecule rather than to ACE inhibition as such. Other ACE
inhibitors that do not possess a sulfhydryl group do not cause
these effects. In contrru,t, adver:.e effects that are directly related
to ACE inhibition are common to all drugs of this class. These
include hypotension, especially after the first dose and especially
in patients with heart failure who have been treated with loop
diuretics, in whom the renin- angiotensin system is highly
activated. A dry cough, possibly the result of accumulation of
bradykinin (Ch. 16), is the commonest persistent adverse effect.
Patients with severe bilateral renal artery stenosis predictably
develop renal failure if treated with ACE inhibitors, because
glomerular filtration in the face of low afferent arteriolar pressure
is maintained by angiotensin n, which constricts the efferent
arteriole; hyperkalaemia may be severe owing to reduced
aldosterone secretion. Such renal failure is reversible provided
that it is recognised prompt ly and the ACE inhibitor stopped.
THE VASCULAR SYSTEM
s1tes
C-terminal of Captoprll
angiotensin I
( \ ~
Angiotensin II receptor subtype 1 antagonists
(sartans)
Losar ta n , cnndesarta n, valsartan and irbesarta n (sartans)
arc non-peptide, orally active AT 1 receptor antagonists. The~e
differ predictably from ACE inhibitors in their pharmacological
properties (Fig. 19.8) but behave rather similarly to ACE
inhibitors in clinical practice, apart from not causing cough-
consistent with the 'bradykinin accumulation' explanation of this
side effect, mentioned above. ACE is not the only enzyme capable
of fonning angiotensin II, chymase (which is not inhibited by
ACE inhibitors) providjng one alternative route. It is not known
if alternative pathways of angiotensin II formation are imponant
in vivo, but if so, then AT1 receptor antagonists could be more
effective than ACE inhibitors in such situations. It is not known
whether any of the beneficial effectc; of ACE inhibiwrs are
bradykinin/NO-mediated, so it is unwise to assume that AT 1
receptor antagonists will necessarily share all the therapeutic
properties of ACE inhibitors. Experience with valsartan
and candesarta n (a longer-acting drug) in patients with
heart fai lure has, however, been positive, as bas experience
with irbesa r ta n , in limiting the progression of diabetic
nephropa thy. 309
 SECTION 3 DRUGS AFFE CTING MAJOR ORGAN SYSTEMS

A, "'Ypes of vasodilator drug

_J Placebo Directly acting vasodilators

20 I Enalapril Calcium antagonists (e.g. nifedipine, diltiazem,
.A Losartan verapamil): block Ca2 entry in response to
~
~ 0 depolarisation. Common adverse effects include ankle

~
swelling and (especially with verapamil) constipation.
- 20 KArP channel activators (e.g. minoxidil): open
.!:
Q)
Cl
membrane potassium channels, causing
c: -40
ctl
.s:;
hyperpolarisation. Ankle swelling and increased hair
(.) growth are common.
- 60
Drugs that increase cytoplasmic cyclic nucleotide
- 80 concentrations by:
increasing adenylyl cyclase activity, for example
prostacyclin (epoprostenol), ~2 -adrenoceptor
10 1 102 10 3
agonists, ad enosine
Angiotensin ll (pmol/min) increasing guanylyl cyclase activity: nitrates (e.g.
glyceryl trinitrate, nitroprusside)
inhibiting phosphodiesterase activity (e.g. sildenafiQ.
600
I Placebo Indirectly acting vasodilators
D Enalapril ,....., Drugs that interfere with the sympathetic nervous
.A Losartan system (e.g. a 1-adrenoceptor antagonists). Postural
400 hypotension is a common adverse effect.
Drugs that block the renin-angiotensin system:
renin inhibitors (e.g. enalkiren)
angiotensin-converting enzyme inhibitors (e.g.
enalapril); dry cough may be troublesome
AT, receptor antagonists (e.g. losartan).
Drugs or mediators that stimulate endothelial NO
release (e.g. acetylcholine, bradykinin).
Drugs that block the endothelin system:
- endothelin synthesis (e.g. phosphoramidon)
101 102 - endothelin action (e.g. bosentan).
Bradykinin (pmol/min)
Vasodilators whose mechanism is uncertain
Fig. 19.8 Comparison of effects of angiotensin-converting
enzyme inhibition and angiotensin receptor blockade in the Miscellaneous drugs including alcohol, propofol
human forearm vasc ulature. @ Effect of brachial artery (Ch. 36) and hydralazine.
infusion of angiotensin II on forearm blood flow after oral
administration of placebo, enalapril (1 0 mg) or losartan (1 00 mg).
B Effect of brachial artery infusion of bradykinin, as in A. (From
Cockcroft J R et al. 1993 J Cardiovasc Pharmacal 22: 579-584.)

Clinical uses of angiotensin II subtype 1

receptor antagonists (sartans)
CLINICAL USES OF VASOACTIVE DRUGS
The AT, antagonists are extremely well tolerated.
It is beyond the scope of this book to provide a detailed account
Their uses include the following.
of the clinical use!> of vasoactive drugs. but it is nonetheless
Hypertension, especially in:
useful to con ider briefly the treatment of certain important
young patients (who have higher renin than older
di!.ordcrs. The conditions that will be discussed are:
ones)
systemic hypertension hypertensive diabetic patients
cardiac failure hypertension complicated by left ventricular
shock hypertrophy.
peripheral vascular disease Heart fai lure
Raynaud's disease Diabetic nephropathy.
310 pulmonary hypertension.

SYSTEMIC HYPERTENSION
Systemic hypcrtem,ion i~ a common disorder that, if not effectively
treated, re!>ult~ in a greatly increased probability of coronary
thrombosis, strokel> and renal failure. Until about 1950, there was
no effective treatment, and the development of antihypertensive
drugs, which restore healthy life expectancy. has been a major
therapeutic success story.
There are a few recognisable and surgically treatable causes
of hypertension. such a-, phaeochromocytoma. 11 s teroid-secreting
tumours of the adrenal cortex, renal artery stenosis and so on, but
most cases involve no obvious cause and are grouped as essential
hypertension (so-called because it w~ originally, albeit incorrectly,
thought that the raised blood pressure was 'essential' to maintain
adequate tissue perfusion). Increased cardiac output may be an
early feature, but by the time it is diagnosed (commonly in
middle li fe) there is usually increased peripheral resistance and
the cardiac output is normal. Blood pressure control is intimately
related to the kidneys, as demonstrated by transplantation exper-
iments in which kidneys are transplanted from or to animals with
genetic hypertension, or to humans requiring renal transplantation:
hypertcn!>ion 'goes with' the kidney from a hypertensive donor,
and donating a J...idney from a normotensive to a hypertensive
corrects hypertension in the recipient (see also Ch. 24 ). Persistently
raised arterial pressure leads to hypertrophy of Lhe left ventricle
and remodelling of resistance arteries. with narrowing of the
lumen. The raised peripheral vascular resistance calls into play
various physiological responses involving the cardiovascular
system, nervous y~tem and kidney. Such vicious circles provide
targets for pharmacological attack.
Figure 19.9 summarises physiological mechanisms that control
arterial blood pressure and shows sites at which antihypertensive
drugs act. The main systems include the sympathetic nervous
system, the renin-angiotensin-tlidosterone system and tonically
active endothelium- derived au/acoids (NO and probably ET- 1;
see above). Remodelling of resistance arteries in response to the
raised pressure reduce!\ the ratio of lumen diameter to wall thickness
and increases the peripheral v~cu lar resistance. The role of cellular
growth factors (including angiotensin IT) and inhibitors of growth
(e.g. NO) in the evolution of these structural changes is of great
interest to vascular biologists. and is potentially of importance to
the therapeutic use of drugs suc h as ACE inhibitors.
Contrary to the earlier view that hypertension was 'essential'
to sustain life, reducing arterial blood pressure greatly improves
the prognosis of patients with hypertension. Controlling hyper-
tension (whic h is asymptomatic) without producing unacceptable
side effect'> b therefore an important clinical need, which is. in
general. well catered for by modern drugs. Treatment involves
non-pharmacological measures (e.g. increased exercise. reduced
dietary salt and saturated fat with increased frujt and fibre. weight
and alcohol reduction) followed by the staged introduction of
drugs, Marting with tho~>e of proven benefit and least likely to
produce side effect~. Some of the drugs that were used to lower
11
Catecholamine-~ecreting tumours or chromaffin tis~ue. usually the adrenal
medu lla (Ch. II).
blood pressure in the early days of antihypertensive therapy,
including ganglion blockers, adrenergic neuron blockers and
reserpine (see Ch. II ), produced a fearsome array of adverse
effects and are now ob5olete. The preferred regimem have changed
progressi\'ely as better-tolerated drugs have become available.
One rational ~trategy with some evidence to support it, and
recommended by the current British Hypertension Society
guidelines. is to start treatment with either an ACE inhibitor or an
AT 1 antagonist in patients who are likely to have normal or raised
plasma renin (i.e. younger white people), and with either a
thiat.ide diuretic or a calcium antagonist in older people and
people of African origin (who are more likely to have low plasma
re nin). If the target blood pressure is not achieved but the drug is
well tolerated, then a drug of the other group is added. lt is best
not to increase the dose of any one drug excessively, as this often
causes adverse e ffects and engages homeostatic control
mechanisms (e.g. re nin release by a diuretic) that limit efficacy.
~-Adrenoceptor antagonists are less well tolerated than
ACE inhibitors o r AT 1 antagonists, and the evidence supporting
their ro utine use is less strong than for other classes of
antihypertensive drugs. They are useful for hypertensive patients
with some addi tional indication for ~ blockade, such as angina
or heart failure.
Addition of a third or fourth drug (e.g. to sartan/diuretic or
sartan/calcium antagoni ~t combination) is often needed, and a
long-acting 0:1 antagonist (Ch. ll, p. 180) such as doxazosin
is one option in this setting. The o:1 antagonists additionally
improve symptoms of prostatism,12 enabling one to kill two birds
with one stone in older men with the common disorder of benign
prostatic hypertrophy, albeit at the expense of some postural
hypotension, which is the main unwanted effect of these agents.
Doxazosin is used once daily and has a mild but theoretically
desirable ciTect on plasma lipids (reduci ng the ratio of low-
to high-density lipo proteins; see Ch. 20). S pironolac tone
(a competitive antagonist of aldo1:.terone; Ch. 24, p. 379) has
staged something of a come back in treating severe hyperte nsion,
with the realisa1ion that this is often associated with an excess of
circ ulating aldoslerone relative to renin. Careful monitoring of
plasma K+ concentration is required. because spironolactone
inhibits urinary K+ excretion as well as causing oestrogen-related
adverse effects (see p. 379). but it is usually well tolerated
in low doses. Methyldopa (p. 184) is now used mainly for
hypertension during pregnancy because of the lack of
documented adver,e effects on the baby (in contrast to ACE
inhibitor<., sartam, and l>tandard ~-adrenoceptor antagonists, which
are contramdicated during pregnancy). Oonidine (a centrally acting
o:2 agonist; clinical box. p. 179) is now seldom used. Moxonjdine.
a centrally acting agonist at imidazoline 11 receptors that causes
less drowsines-. than o:2 agonists. is licensed for mild or moderate
hypertension, but there is little evidence from clinical end-point
trials to support its usc. Minoxidil. combined with a diuretic and
~-adrcnoccptor antagonist, is sometimes effective where other
12 Difficulty ~turting the stream, poor ~trcam , terminal dribbling, and
needing to get up often in the night to pass urine-all depressingly common
in ageing men.
311
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

Baroreceptor
discharge
Moxonldlne
Clonidlne
Methyldopa Ganglion-
blocking
drugs

...,..f----1 Endothelial Blood volum e

autacoids:

Peripheral
NO
ET-1 Cardiac i
resistance output

Arterial
pressure

Al l AI Angiotensinogen
I

~ -------------- -
Fig. 19.9 Diagram showing the m ain m echanisms involved in arterial blood pressure regulation (black lines), and the sites of
action of antihypertensive drugs (hatched boxes+ orange lines). ACE, angiotensin-converting enzyme; AI, angiotensin I; All, angiotensin
II; ET-1, endothelin-1; NA. noradrenaline; NO, nitric oxide.

drugs have fai led in ~evere hypertension resistant to other drug!..
Fenoldopam, a selective dopamine D 1 receptor agonist, is
approved in the USA for the short-term management in hospital
of severe hypertension. Its effect is similar in magnitude to that
of intravenous nitropr usside, but it lacks thiocyanate-a<>sociated
toxicity and is slower in onset and offset.
Commonly used antihypertensive drugs and their common
adverse effects are summarised in Table 19.4.
demands of the body during exerci!>e (and ultimately also at re-tl.
It may be cau~ed by disease of the myocardium itself Cmo t
commonly ischaemic heart disease). or by circulatory factoo
such as volume overload (e.g. leaky valves, or arteriovenous shunts
caused by congenital defects) 13 or pressure overload (e.g. stellO\ed-
narrowed valves, arterial or pulmonary hypertension). Some of
these underlying causes are surgically correctable, and in son~
either the underlying disease (e.g. hyperthyroidism; Ch. 29). or

CARDIAC FAILURE
The underlying abnormality in cardiac failure (see also Ch. 18)
3 12 is a cardiac o utput that is inadequate to meet the metabolic
11
So-called ' hole in the heart" babies have a defect in the atrial or
ventricu lar septum. lead ing to shunting of blood from high- to low-pres\we
parts of I he circulution.

Tble 19.4 Common antihypertensive drugs and their adverse effects
Drug Adverse effect s
Postural hypotension
Thiazide diuretics" (e.g. bendroflumethiazide)
Angiotensin-converting enzyme inhib1tors
(e.g. ramipril, lisinopril)
AT 1 antagonists (e.g. losartan, candesartan)
Ca2 antagonists (e.g. nifedipine, amlodipine)
~-Adrenoceptor antagonistsc (e.g. metoprolol)
tt,-Adrenoceptor antagonistsc (e.g. doxazosin) ++
1
1ndicates that the adverse effect occurs in special circumstances only (e.g. postural hypotension occurs with a thiazide diuretic only 1f
the patient is dehydrated for some other reason or is taking some additional drug.)
"See Chapter 24.
<see Chapter 11.
an aggravating factor such as anaemia (Ch. 22) or atrial fibrillation
(Ch. 18), is treatable with drugs. Here, we focus on drugs used to
treat hean failure irrespective of the underlying cause. When
cardiac output is insufficient to meet metabolic demand, an
increase in fluid volume occurs. partly because increased venous
pressure causes increased formation of tissue fluid, and partly
because reduced renal blood flow activates the renin-angiotensin-
aldol>terone system, causing Na+ and water retention. irrespective
of the cause, the outlook for adu lts with cardiac failure is grim:
50% of those with the most severe grade are dead in 6 months,
and of those with 'mild/moderate' disease 50% are dead in 5
years. Non-drug measures, including dietary salt restriction, are
important. but drugs arc needed to improve symptoms of
oedema. fatigue and breathlessness. and to improve prognosis.
A highly simplified diagram of the sequence of events is
\hown in Figure 19.1 0. A common theme is that several of the
feedbacks that are activated are 'counter-regulatory'-i.c. they
make the situation worse not better. This occurs because the body
fails to distinguish the haemodynamic state of heart failure from
haemorrhage, in which release of vasoconstrictors such as
angiotensin ll and ADH would be appropriate. 14 ACE inhibitors
and AT~o ~-adrenoceptor and aldosterone antagonists interrupt
these counter-regulatory neurohormonal mechanisms and have
each been 1.bown to prolong life in heart failure. although prognosis
remain~ poor despite optimal management.
Natural selection presumably favoured mechanisms that would benefit
young bunter gatherers at risk of haemorrhage: middle-aged or elderly
people at high risk of hean fai lure arc past their reproductive prime.
THE VASCULAR SYSTEM
Impotence Other
++ Urinary frequency, gout, glucose intolerance,
K .1, Na J..
First-dose hypotension, dry cough, reversible
renal dysfunction in patients with bilateral
renal artery stenosis, fetal toxicity
Reversible renal dysfunction in patients with
bilateral renal artery stenosis, fetal tox1city
:t Ankle oedema
+ Bronchospasm. fatigue, cold hands/feet,
bradycardia
First-dose hypotension
Drugs used to treat heart failure act in various complementary
ways to do the following.
Increase natriuresis. Diuretics, especially loop diuretics
(Ch. 24), are important in incre~ing salt and water excretion,
e1.pecially if there is pulmonary oedema. In chronic heart failure,
drugs that have been shown to improve prognosis were all
studied in patients treated with diuretics.
Inhibit the renin-angiotensin-aldosterone system. The
renin-angiotensin-aldosterone system is inappropriately activated
in patients with cardiac fai lure, especially when they arc treated
with diuretics. The ~-adrcnoceptor antagonists inhibit renin
secretion and arc used in clinically stable patients with chronic
heart failure (see below). ACE inhibitors and AT1 antagonists
block the fonnation of angiotensin ll and inhibit its action,
respectively. thereby reducing vascular resistance, improving
tissue perfusion and reducing cardiac afterload. They also cause
natriuresis by inhibiting secretion of aldosterone and by reducing
the direct stimulatory effect of angiotensin II on reabsorption of
Na+ and HC03- in the early part of the proximal convoluted
tubule. Most important of all, they prolong life. The question
of whether ACE inhibitors and AT 1 antagonists can usefully be
combined is being evaluated. Angiotensin ll is not the only
stimulus to aldosterone secretion, and during chronic treatment
with ACE inhibitors, circulating aldosterone concentrations
return towards pretreatment value!> (a phenomenon known a..,
'aldosterone escape'). This provided a rationale for studying the
eiJect of combining spironolactone (an aldosterone antagonist
sec Cb. 24) with ACE inhibitor trcaLmenL, and this further reduces
mortality. Eplereoone is a recently licensed aldosterone antagonist
with less oestrogen-like adverse effects than sprironolactonc; il 313
 SECTION 3 DRUGS AFFECTING MAJOR ORGAN SYSTEMS
( Pathological factors
t
Tissue
perfusion
! blood
Renal
flow
~ Retrospective analysis of this trial suggested that the benefit wa\
L
+ restricted to black patients, and a prospective study in African-
Renin release
~ treatment indicated that addition of hydralazine and isosorbide
Formation of
angiotensin II
~ Drug Administration. but people of African origin are genetically
Release of
aldosterone
~ +
Na+twater
( Diuretics~ retention
~ inhibitor. Digoxin does not reduce mortality in heart failure
O edema
Fig. 19.10 Simplified scheme showing the pathogenesis
l
of heart failure, and the sites of action of some of the
drugs used to treat it. The symptoms of heart failure are
produced by reduced tissue perfusion, oedema and increased
central venous pressure. ACE, angiotensin-converting enzyme.
too has been shown to improve survival in patients with heart
failure when added to conventional therapy. Patients with
impaired renal function were excluded from these trials, and
careful monitoring of plasma K+ concentration is important when
they are treated with an ACE inhibitor or an AT1 antagonist in
combination with an aldosterone antagonist.
Antagonise f3 adrenoceptors. Heart failure is accompanied by
potentially harmful activation of the sympathetic nervous system
as well as of the renin-angiotensin system. providing a rationale
for u~ing ~-adrenoceptor antagonists for this disorder. Most
clinicians have been very wary of this approach because of the
negative inotropic action of these drugs, but wben started in low
doses that are increased ~lowly, metoprolol. carvedilol and
bisoprolol have each been shown convincingly to improve
survival when added to other treatment in clinically stable
patients with chronic heart failure.
Inhibit ADH. ADH, also known as vasopressin (above. p. 305;
Ch. 24, p. 372; and Ch. 28 pp. 425-426), is released inappropriately
314 in heart failure and may contribute to the hyponatraemia that is
common in severe heart failure. 15 Tolvaptan is an orally active
non-peptide selective V2 receptor antagonist that has sh011n
promise in patients with heart failure and hyponatraemia. It~
effect (if any) on mortality is unknown, and it is not yet licen-ed
for general use.
Relax vascular smooth muscle. Glyceryl trinitrate (Ch. 18,
pp. 292-294) 1\ infused intravenously to treat acute cardiac
failure. It., venodilator effect reduces venous pressure, and 11~
effects on arterial compliance and wave reflection reduce cardiac
work. The combination of hydralazine (to reduce afterload)
with a long-acting organic nitrate (to reduce preload) in patienb
with chronic heart failure improved survival in a randomised
controlled trial known as VHeFf (Vasodilator Heart Failure Trial).
American patients with severe heart fai lure receiving standard
dinitrate caused a substantial (and significant) reduction in
mortality. This evidence has been accepted by the US Food and
very heterogeneous, and it is unknown what other groups will
benefit from such treatment.
Increase the force ofcardiac contraction. Cardiac glyco~ide'
(Ch. 18, pp. 291-292) are used either in patients with heart failure
who also have chronic rapid atrial fibrillation. or in patients who
remain <,ymptomatic despite treatment with diuretic and ACE
patients in sinus rhythm who are otherwise optimally treated. but
does improve ymptoms and reduce the need for hospital admission.
In contrast, POE inhibitors (e.g. amrinone. milrinone; see Ch. 18,
p. 292) increase cardiac output acutely but increase mortality in
heart failure, probably through cardiac dysrhytbmias. Dobutamine
(a ~ 1 -selective adrenoceptor agonist; see Ch. 18, p. 291) is used
intravenously when a rapid response is needed in the short teml,
for example following heart surgery. Levosimendan, a positive
inotropc with additional vasodilator properties attributed, respect-
ively, to scnsitisation of cardiac muscle to [Ca2+], and activation
of KATP in vascular smooth muscle (p. 306), is showing promise in
the treatment of severe heart fai lure and circulatory shock (below).
SHOCK AND HYPOTENSIVE STATES
Shock is a medical emergency characterised by inadequate per-
fusion of vital organs. usually because of a very low arterial blood
prc<,<,ure. This leads to anaerobic metabolism and hence
to increased lactate production. Mortality is extremely high. e\t:n
with optimal treatment in an intensive care unit. Shock can be
cau<,ed by variou!. insults. including haemorrhage. bums, bactenal
infections, anaphylaxis (Ch. 13) and myocardial infarction
(Fig. 19.1 I). Reduced effective circulating blood volume
(hypovolacmia) may be cau!>ed either directly by bleeding or b)
15
Jnappropriatc ,ecrction of ADH causes hyponatraemia because the kidne~
fa il\ lO excrc1c water while continuing to excrete sodium ions, while drinking.
which is largely determined by habit in addition to thirst, continues. '111i1
lead~ to rcd uc1ion of the plasma sodium concentration as a result of dilution.
 THE VASCULAR SYSTEM

movement of Ouid from the plasma to the gut lumen or ti~sues.

ive
Drugs used in chronic heart fa ilure The physiological (homeostatic) response to this i!> complex:
.\0
vasodilatation in a vital organ (e.g. brain, heart or kidney) favours
lls
Loop diuretics, for example furosemide perfusion of that organ, but at the expense of a further reduction
ed
(Ch. 24, pp. 375-377). in blood pressure. which leads to red uced perfusion of olher organ!..
Angiotensin-converting enzyme inhibitors (e.g. Ideally, there is a balance between vasoconstriction in non-essential
8,
captopril, enalapril). vascu lar beds and vasodilatation in vital ones. The dividing line
ac
Angiotensin II subtype 1 receptor antagonists (e.g. between the norma l physiological response to blood loss and
its
valsartan, candesartan). c linical shock is lhat in shock tissue hypoxia produces ~econdary
ac
~-adrenoceptor antagonists (e.g. metoprolol, effects that magnify rather than correct the primary diMurbance.
td)
bisoprolol, carvediloQ, introduced in low dose in Therefore patients with established shock have profound and
Hs
stable patients. inappropriate vasodilatation in non-essential organs, and this i'>
ed
Aldosterone receptor antagonists (e.g. difficult to correct with vasoconstrictor drugs. The relea~e of
~).
spironolactone, Ch. 24, p. 379; and eplerenone). mediators (e.g. histamine, 5-hydroxytryptaminc. bradykinin,
Digoxin (see Ch. 18, pp. 291-292), especially for heart prostaglandins, cytok.ines including interleukins and tumour
>IJ-
failure associated with established rapid atrial necrosis factor, NO, ond undo ubtedly many mo re as-yet-
.rd fibrillation. It is also indicated in patients who remain unidentified substances) that c ause capillary dilatation and
de
symptomatic despite optimal treatment. leakiness is the opposite of what is required to improve function
in
Organic nitrates (e.g. isosorbide mononitrate) reduce in this setting. Mediators promoting vasodilatation in shock
od
preload, and hydralazine reduces afterload. Used in converge on two main mechanisms:
ly
combination, these prolong life in African-Americans.
'111
activation of ATP-!.en'>itive potassium channels in va~cular
smooth muscle by reduced cytoplasmic ATP and increased
es
lactate and protons
re
'10
:E
re
ut
Ill.
8.
m
~e
Haemorrhage

Myocardial damage
]f.- ---. ,. +circulating volume

l
+Cardiac output
l
.d
....
e
:t-
Adrenaline

+Renal blood flow

1
+Arterial pressure
)0
in

Renal failure Renin release

1
Vasoconstriction
Adrenaline

Prostacyclln
(epoprostenol)
r-
id
:e
. . - - - - - Tissue hypoxia
1 Acidosis
:n
DEATH

~-1---------
)C

at ~

i ~~:~H.:::y
Arteriolar and
Release of mediators -----+

Fig. 19.11 Simplified sche me

s howing the pathogenesis of
hypovolaemic s hoc k. Adrenaline Bacterial Burns,

l
Allergen
causes vasodilation in some vascular endotoxin traumaj
beds, vasoconstriction in others. 315
I.
 SECTION 3 . DRUGS AFFECTING MAJOR OR G AN SYSTEMS
increased synthesis of NO, which activates myosin light-
chain phosphata~e and activates Kc. channels.
A third key mechanism seems to be a relative deficiency of ADH,
which il> ~>ecrctcd acutely in response to haemorrhage but sub-
sequently declinel.. probably because of depletion from the
neurohypophysil> (see Ch. 28, pp. 425-426).
Patients with -;hock are not a homogeneous population.
making it hard to perfonn valid clinical trials, and in contr~t to
hypertension and heart failure there is very little evidence to
support treatment wategic!. based on hard clinical end points
(such as improved . urvival). Hypoperfusion leads to multiple
organ failure, and intensive therapy specialists spend much effort
supporting the circulations of such patients with cocktails of
vasoactive drugs designed to optimise flow to vital organs. Trials
of antagonists designed to block or neutralise endotoxin,
interleukins, tumour necrosis factor and the inducible form of
NO synthase have so far been disappointing. Volume replacement
is of benefit if there is hypovolaemia; antibiotics are essential if
there is per~istent infection; adrenaline can be life-saving in
anaphylaxis; a preparation of recombinant activated protein C,
drotrecogin alpha (activated ) (see Ch 21, p. 334) improves
mortality in severe septic shock with multiple organ failure and
is licensed for thi'l indication; ADH may be effective in increasing
blood pressure even when there is resistance to adrenaline;
corticosteroid~ ~uppresl> the formation of 0 and of prostaglandins
but are not of proven benefit once shock is established;
epo p roste nol (PGI 2) may be useful in patients with inappropriate
platelet act ivation (e.g. meningococcal sepsis); positive
inotropcs, including ad rena line and dobotamine. may help in
individual patients.
PERIPHERAL VASCULAR DISEASE
When atheroma involves peripheral arteries, the commonest
symptom is pain in the legs on walking (claudication), followed
by pain at rest, and in severe cases gangrene of the feet or legs.
Treatment is often surgical (s urgical reconstruction or an1putation)
or by angiopfasty (disruption of atheroma by inflation of a
balloon !>urrounding the tip of a catheter). Other vascular beds
(e.g. coronary. cerebral and renal) are often a lso affected by
atheromatous dbease in patients with peripheral vascular disease.
Drug treatment includes antiplatelet drugs (e.g. aspirin,
clopidogrel; see Ch. 21 ), a statio (e.g. simvastatin: see Ch. 20)
and an ACE inhibitor (e.g. ramipril; see above). These reduce
the excess risk of ischaemic coronary and cerebra] events.
Additionally, sever.ll placebo-controlled studies have demonstrated
that cilostazol, a type Ill POE inhibitor (see above, p. 307),
improves pain-free and maximum walking distance in such
patients, but its effect on mortaJiry is unknown.
RAYNAUD'S DISEASE
Inappropriate vasoconstriction of small arteries and arterioles
gives rise to Raynaud's phenomenon (blanching of the fingers
during vasoconstriction, followed by blueness owing to
316 deoxygenation of the static blood and red ness from reactive
hyperaemia following return of blood flow). This can be mild,
but if ~evere cau~es ulceration and gangrene of the fingers. It can
occur in isolation (Raynaud's disease) or in association with a
number of other diseases, including several so-called connecti\e
tissue disea~es (e.g. systemic sclerosis, systemic lupu'
erythematosu<>). Treatment of Raynaud's phenomenon invohe,
Mopping '>moking and avoiding the cold: ~-adrenoceptor
antagoni'>L'> are contraindicated. Vasodilators (e.g. nifedipine,
see Ch. 18, pp. 295-296) are of some benefit in severe ca<;es, hut
treatment is difficult.
PULMONARY HYPERTENSION
After birth, pulmonary vascular resistance is much lower than
systemic vascular resistance, and systolic pulmonary artery pressure
in adults is normally approximately 20 mmHg. 16
Pulmonary artery pressure is much less easy to measure than
is systemic pressure, requiring cardiac catheterisation. lf pulmonary
artery pressure is raised. this usually causes some leak of the
tricuspid valve, allowing regurgitation of blood from the right
ventricle to the right atrium. This phenomenon, detectable b}
ultra!.onography, can be used to estimate the pulmonary artel')
pressure indirectly. Because of the difficulty in measuring
pulmonary artery pressure, only severe and symptomatic
pulmonary hypertension usuaJiy gets diagnosed. Such pulmon:lr)
hyperten. ion may be idiopathic (i.e. of unknown cause. analogou'
to essential hypertension in the systemic circulation), or associated
with some other disease. Increased pulmonary pressure can re~uh
from an increased cardiac output (such as occurs for example 10
patients with hepatic cirrhosis-where vasodilatation rna}
accompany intermillent subclinical exposure to bacterial
endotoxin-or in patients with congenital connections between
the systemic and pulmonary circulations that lead to increa~
flow of blood in the low-pressure pulmonary circuit a' a
consequence of 'shunting' of blood from high to low pressure).
Alternatively, vasoconstriction and/or structural narrowing of the
pulmonary resista nce arteries increase p ul monary arterial
pressure, even if now (cardiac output) is maintained con~tant. In
some situations, both increased cardiac output and increa,ed
pulmonary vascular re~istancc are present. A clinical classification
has been proposed by the World Health OrganiLation (sec
http://www. who. int/card iovascu Iar_diseases/en/).
In contrast to ~ystemic hypertension. pulmonary hypertensiOn
a~sociated with other di~cascs is much more common than
idiopathic pulmonar) hyperten!>ion. which is a rare. severe and
progressive disease. Onset of idiopathic pulmonary bypcrten,JOn
is usually in the thirties, with progressive shortness of breath and
fatigue. Women arc affected more commonly than men
Approximately 10% of patients have Raynaud's phenomenon
16 1n fetal life, pulmonary va;.cular resi~tance is high: failure to adapt
appropriately at birth i associated with prematurity, lack of pulmonary
urfuclant, and hypoxacmia. The resulting pulmonary hypertension is
treated by paediatric inrensivists with measures including replacement of
surfactant and venti latory support, sometimes including inhaled NO-
&ce Ch. 17, pp. 270-271.
 THE VASCULAR SYSTEM

a. (see above). Endothelial dysfunction (see above) p. 299. Ch. 20 Drug treatment
tn p. 321. and Cb. 21 pp. 333-334 i1. implicated in its aetiology. Drugs used in treating pulmonary arterial hypertension are
a Familial primary pulmonary hypertension is caused by mutations shown in the ctinical box. It follows from the above discussion
e in the gene coding for a receptor related to transfom1ing growth that treatment is often that of the underlying disease. In addition
JS factor-~ called bone morphogenetic protein receptor type 2 to anticoaguLation and inhaled oxygen, digoxin (Ch. 18) and
~s (BMPR-2). diuretics (Ch. 24) can provide symptomatic improvement.
Drugs (e.g. anorexic drugs including dexfenflura mine) and Recently, several direct and indirect vasodilators have been
e: toxins (e.g. monocrotaline) can cause pulmonary hypertension. shown to have useful clinical effects, including improved
Ut Occlusion of the pulmonary arteries. for example with recurrent exercise tolerance and slowing of disease progre,!>ion.
pulmonary emboli (Ch. 2 1. p. 335). causes pulmonary hyper- Continuous intravenous e poprostenoi (see Ch. 13). inhaled
tension. Pulmonary emboli or thrombi fonned in siru as a result ilopros t (a stable analogue of prostacyclin. ~ometime~
of endothelial dysfunction (Ch. 21. pp. 333-334) commonly administered by inhalation of a mist of nebulised solution. in
accompany pulmonary hypcrten~ion-both the idiopathic form the same way as for ~everal of the drugs used to treat asthma.
Ill and when associated with other pmhologies. Consequently. anti- Ch. 23), subcutaneous tre prostinil and oral bosentan (see
e coagulation (see Ch. 2 1) is an important part of treatment. Aggre- above, pp. 301-303) arc all used clinically. The choice of drug is
gates of sickled red cells in patients with sickLe cell anaemia influe nced by the stage of the disease (usually classified using a
Ill (Ch. 22) can occlude small pu lmonary arteries duri ng sickling system modified from that used in heart failure-the New York
crises and increase pulmonary artery pressure. exacerbated by Heart Association-World Ilealth Organization classification
te the increased cardiac output associated with chronic anaemia. where I is very mild and IV severe). Oral treatment (e.g. bosentan)
ht Increased pulmonary va~cular resistance may. alternatively. is used for the less severe and parenteral (subcutancou!> trepro!>tinil,
I}' re~ult from vasoconstriction ancVor strucrural changes in the intravenous epoprostenol) for the more severe. Survival may
fY walls of pulmonary resistance arteries. Many of the diseases (e.g. be improved by epoprostenol (~ee Fig. 19.12). Inhaled 0 is
lg \y&~emic sclerosis) associated with Raynaud's phenomenon
ic mentioned in che section above are also associated with pulmonary
'iY hypertension. and there are cal>e reports where pulmonary hyper-
Drugs used In pulmonary hypertension
IS tension was observed in discrete episodes. presumably as a resu lt
cl of vasoconstriction occurring in the pulmonary circu latio n rather
It than (or as well as) in the skin of the fingers. Vasoconstriction O ral anticoagulants (Ch. 2 1).
n may precede cellular proliferation and medial hypertrophy in the Diuretics (Ch. 24).
pulmonary vasculature. Treatment with vasodilators such as the Oxygen.
calcium antagonist nifedipine is of some use. but vasodilators Digoxin (Ch. 18).
n that al o have an antiproliferative ac tion (e.g. epoproste noi. drugs Calcium channel blockers (Ch. 18).
id that potentiate NO. or drug~ that antagonise endothclin) are more Epoprostenol (Ch. 13).
a promising-see below. Prostanoid analogues (iloprost, treprostinil. beraprost).
Several diseases affect che pu lmonary vasculature directly (e.g. Bosentan.
sarcoidosis, histiocytosis X and schistosomiasis 11 ) and can cause P hosphodiesterase V inhibitor (sildenafil).
pulmonary hypertension. In addition. pulmonary vessels are un ique
in constricting in response to hypoxia; physiologically, this
enables the lung to match poorly ventilated areas with reduced
n perfusion. but when hypoxia is generalised it causes pulmonary
e hypertension. 18 Consequently. any lung disease that cau!>es
hypoxaemia of sufficient severity will be complicated by pulmonary .8
'iii
n hypertension. even if the pulmonary vasculature is not directly >
~
ill involved. and oxygen treatment i~ indicated to correct this. The ::l
1/) .6
d mechanism of pulmonary hypoxic vasoconstriction remain& .~ IV epoprostenol
n elusive, but both an increase in l Ca2+ji and increased sensitivity 1ii .4
::;
d to Ca 2+, possibly mediated by Rho kinase (see above, p. 305) E
::l
1. have been implicated. () .2 His torical control
n p < 0.0001 (CoxManlellog-rank test)
0
1"Re,pecthely. a granulommou~ disea'e with histological fearures related to 0 12 24 36 48 60 72 84 96 108 120
lho..e of tuberculosis. infiltration of' arious thsues with aboonnal (Monlhs)
h1~Uocytes. and an infection with a para~ite that is endemic in the ile della
and has a life cycle shared berwecn humans and ~nail~see Ch. 50. p. 713. Fig. 19.12 Surviva l in primary pulmonary hypertension.
Survival in 178 patients treated with intravenous epoprostenol
1
~Giover and Newson were commissioned by cattle ranchers to Mudy high versus a historical control group of 135 patients matched for
mountain diesease in cattle in Colorado in 1913. leading to the recognition disease severity. (Adapted from Sitbon 0 et al. 2002 Prog
th<tt chronic hypoxia cau~e pulmonary hypcnension, medial hypertrophy of \_Cardiovasc Dis 45:115.)
the ~malt pu lmonary arteries, and right ventricu lar hypertrophy.
317
 SECTION 3 DRUGS AFFECTING MAJOR ORGAN SYSTEMS
mentioned above in the context of pulmonary hypertensive crises,
for example in the newborn. POE V inhibitors (e.g. sildenafil)
potentiate the action of NO by blocking the metabolism of cGMP
(Ch. 17, p. 269) and show promise in idiopathic pulmonary
hypertension.
Clini cal disorders for which vasoactive drugs are important
Systemic hypertension:
secondary to underlying disease (e.g. renal or
endocrine)
primary 'essential' hypertension, an important risk
factor for atheromatous disease (Ch. 20).
Treatment reduces the excess risk of stroke or
myocardial infarction, the main classes of drugs
being A, angiotensin-converting enzyme (ACE)
inhibitors or AT1 receptor antagonists; 8, P-
adrenoceptor antagonists; C, calcium antagonists;
and D, diuretics.
Cardiac failure. Several diseases (most commonly
ischaemic heart disease) impair the ability of the heart
to deliver an output adequate to metabolic needs.
Symptoms of oedema can be improved with diuretics.
Life expectancy is reduced but can be improved by
treatment of haemodynamically stable patients with:
ACE inhibitors and/or AT1 receptor antagonists
P-adrenoceptor antagonists (e.g. carvedilol,
bisoprolol)
REFERENCES AND FURTHER READING
Vascular aruclure unci fuucllon, control of v~ular
smoolh mu..clc lone
Guimar~cs S, Mourn D 200 I VaM:ul:u adnmoceptors: an
u)'ldnlc. Phnnn:tcol Rev 53: 319- 356 (Functional
pU.~WI'tl"')
Quayle J M, NeJ,on M T, S1anden N B 1997 ATP-
M:n\111\C and inwardly rccufying pol~\ium channels
in 'moo1h muscle. Phy\iol Rev 71: 1165 1232
CR~rirw1 thru J>ll/ltl\imn rhwmr/1. both of .. hirh Ort'
mtporlatJt m mntmllml( th~ mntroc/1/~ .flat/! of
mscular (nJOOih mtddr)
Stasch J Pel al. 2001 NO-indepcndem regulalory site on
soluble guanyla1c cycl~ . Nature 410: 212-415 CAn
arlflatorofthtf filt. RAI 41-2242. tl'iaus WJ.SC'ular
lnWI>tlt mu1dr. inhihllf fllotcll'ltJtl(rr~atil)n and iii>U!TT
h/{1()(/ pll'.ISurt Ill lhl! J{IOfl/ll/li'OiiJ/) h)pl'rll'fiSiW! rot)
Ueha1a M hh11AI-i T. Sa1oh II e1 al. 1997 Calcium
o;en,ni1auoo of 'mooth muscle medtaled by a Rho-
:h\Oetawd pro1em l..masc m hypertensiOn. NaiUre 389:
990-994 (A p)ntlinl' tlui>'lltn" Y-27632, selectiv~ly
mlubm flnOOtl truud~ tontractwn b1 mhtbllmg Ca1
semiII wti1111 'Ill thl' Rho-a\\lldtud protl'm kinase
pothwa_ \, and Jowu1 b/0()(/ prt'l.lurt' in several
1'.\pl'rimenral m0</e/1 of hy{ll'nensiotl)
Wurd J P T, Knock G A. Snetkov V A. Aaronson P I
2004 Pmtcin kina.\C\ in YlhCulur smooLb muscle
lone- role in the ru lmonary vuscululurc an<) hypoxic
318 pu lmonary vo~ocotl\tricl ion. Phannacol Ther 104:
Unwanted effects
Adverse effects of the pro!.taglandin analogues relate mainly
to systemic vasodilatation (e.g. flushing, hypotension, syncope:):
bosenta n causes dose-related increases in liver transamin:l'-e':
unwanted effects of sildenafil are on page 459.
-aldosterone antagonists (e.g. spironolactone).
Shock. Several diseases (e.g. overwhelming bacterial
infections, Ch. 46; anaphylactic reactions, Ch. 23) lead
to inappropriate vasodilatation, hypotension and
reduced tissue perfusion with raised circulating
concentrations of lactic acid. Pressors (e.g. adrenaline)
are used.
Peripheral vascular disease. Atheromatous plaques in
the arteries of the legs are often associated with
atheroma in other vascular territories. Statins (Ch. 20)
and antiplatelet drugs (Ch. 21) are important.
Raynaud's disease. Inappropriate vasoconstriction in
small arteries in the hands causes blanching of the
fingers followed by blueness and pain. Nifedipine or
other vasodilators are used.
Pulmonary hypertension, which can be:
-idiopathic (a rare disorder): epoprostenol, iloprost,
bosentan and sildenafil are of benefit in selected
patients
-associated with hypoxic lung disease.
207- 23 1 (Conclude.< tlwtthl' stronJleste\ideiiC'<' for I luang A, Sun D, Smith C J e1al. 2000 In eNOS ~nockt101
dirt!ct imo/vemem ofprotein kiltmes in the me('/wnisms mice skeletal muscle aneriolar dilation 10 ace1ylcholu~
0/ hy{JOXif' pu/mmwry \'0\'0CIJIJSirittiOJJ ('()11('~1'11\ II is mediated by EDHF. Am J Physiol 278: H762-H76S
central role for Rho kmau i11 Ca 2 sensiti.\tllion) (Where NO is ab.1ent, DHF compcn.sotc.s)
Angiogenesis
Vascular endothelium (see Ch. 17 for furl her rending
C'armclicl P, Jain R K 2000 Angiogene,is in cancer and
on nil ric oxide)
olher dir,easc. Namre 407: 249- 257 (Nn~ approocht1
Prostacyclin ro trt!atmem of cancer 011d other diseases, na a
BuntingS. Gryglewsld R, Moncada S, Vane JR 1976 gro ..ingnumbu ofpro- and antiangilll(enir
Anerial walls generate from pi'0'>13!llandm lnt!lecules; -~~~also (in same issut') Yancoptmln1 G n
endopcroJCJde\ a >Ub>lanCe lpro,lllglandtn XI -..h1ch er al. 2000 Vascular specific growth fac1ors and blood
relaxes slrip> of mesen1eric and celt a.: anene' and ,c,..el formallon. pp. 242- 248)
inhibils plaJ.elcl aggregaltOn. Pr<hlaglandtn' 12:
Endothelin
897-913 ( Cia.wc)
Bagnall A J. Webb D J 2000 1be eodotbehn sy,lem
Murata T. Ushikubi F. ~lal<uoka T e1 al 1997 Ahered
phyMol~). ln: Vallance P J T. \\ebb D J (e<b) \ascullr
pain perception :md inflamm.110l) response tn nucc
endothelium in buman physiology :md palhopb} ,ic>log)
lacking pros1acyclin receplot "'nmre 388: 678-682 (I
Harnood Academic. Singapore. pp. 31-W
prostanoid rt'Uptor-dt'ficimt miu an- l'inbk
Hayne\ W G. Webb D J 1994 Comnbulon of eodogcnocn
reprodutth~ and nomtotcnriH; ho~ewr. th~1r
generation of endotbelinl 10 basal nscular 1one.
susceptibifitl to thrombost.s 1.1 inc"n1~d ... tit~ rt'.SIIIIJ
l.anccl 344: 852-854 (Demonstrated a comributuNJ m
establi.rh that proHacycfm ir 1111 rufnfletlllll<
humans of ~tufogmous nuforhelinl 10 ~riphtml
anlithrombotic agent)
asc11iar to11e by loco/ inrraorlerio/ admmisrronon of
EndotbeUum-der ived hyperpolarislng foetor pho.~plwramidon and tm ETA antagonist)
BusseR, Edward~ G, Felc1ou M c1 nl. 2002 F.DHF: Hickey K A. Rubnnyi G, Paul R J. Highmilh R F 19~5
bringing the concepts 1ogether. Trends Phnrmucol Sci Characleri7.ation of a coronary vasocons1ric1or
23: 374-380 (Consensu.s on EDHF? Potassium ion.s produced by cultured endothelial cells. Am J Ph)Ml>l
are imporumt) 248(p11rl l): C55()...(:556 (Key di.scovery)

Ked7iel"ko R M. Yonag"a"a M 2001 Endothelin sy>tem:
me double-edged '"onion health and dJ>ease. Annu
Rev Phannacol Toxocol 41: 851.S76 (R<'n~ by on<'
of th<' dnro1rf'f'n of cmlothdin)
Kirchenga'l M. Lu7 M 2005 Endothchn receptor
..magon"h-<hnocal realme, and future directions. J
Canlio,a-.c Pharm.1.:ol 5: 182-191 (Cntirally ll'>i~u
clim<'OI dt111J on ~mllllh<'lm n:reJ>IOr antagomsm m
mnlit)\aJt'lllar mdocatimu u~mmttht' bat'kground of
l"'<'cllno('Q/ rrt<'arrh)
Yanag"a"a M, Kunhara II. Komura Setal 1988 A
no'cl potent ,a,ocon,tnclor pepude produced b}
\a\Cular endothelial cell\ Nmure n2: 411-415 (Tour
dt'fon:<')
Renin-angioten~ln S) stem
Bum ocr M. Stunner II R 2000 Angoo1cn"n II receptor
amagono\ls. Lnnccl 355. 637 645 (Reoies this class
ofdmRS)
Cai II, Gricndling K K, l larri,on D G 2003 The vascular
NAD(I')H oxidthCS u' therapeutic wgcts in
ctordoovnsculor disca\cs. Trend> l'harmacol Sci 24:
47 1-178 (RNU'tile ti.W!Ien ;pede; l>rt>duced following
tmgil>lt'll\m llmeditottd \/llllulmitm of NAD( P)H
oxida.\e5 lignnltilrou/lh pathways :.ucil liS mitogc11
actioatt!d protrin killliW\, 1,1n1.1111e kinaus mul
transcri111imo f~~tum. mulleat! to lnflmmrwticm.
lnpertmpln. rtmt><lellm!l, ami anp,iogenC.\iS. Studie> in
mire dejtciemm NA!>(P)H otltla.\~ .111/mnits show that
rt'aUil'<' trr.{lt'n tp<'t'l<'>/>n.>dtl<'t'd bv tlre<t: t><itiase.r
amtributr ltJ canlimaswlur di lf'tJU.I mdudmg
atherosdnrnir trnd hl/'<!rttfLiimt.)
He..n Outcome' J're,enuon E\aluauon S111dy
ln'c,ugatOf\ 2000 Effccl\ ot an angootcn\ln
cOtl\enong en1ymc onhobol<>r. rnmopril. on
cardoo,a.-.cular e1en1' on hoghml. palien~. N Engl J
Med :\.12: 145-153 (Ramtpril;i~mficllntly Iowen
rates of death. mw:><:trnlwl mft~rttion and >troAe in a
t~ide ran11r tJf hrRit-nd. !'<lltrnt.s)
Hem L, B;~f\h G S. Pruu R E et al. 1995 Beha\loural and
cardo<>'"-'cular effect> of di,rupling the angootensin 11
type2 receptor gene on mote. "imure 377: 744-747
('{he AT, rtrtpwr plan" role m tire CNS and in
carrltomrrular fmrwom tlrtll till' medwted by the
renin anxmtCfl\111 \V\tem.' l'cllllf for t/wu~htfor
din/clans inl'littl'tlto prt.lcribe AC ittlubitors and
AT1 rece1Jior ttllfiii/OIIiSIIIIIIertltalll(ectbly.)
lchil..i T. Labosl.y P A. Shoota C ct al. 1995 Effects on
blond pre~surc und cxplormory hehuviour of mice
lacking nngiolcn,in lltype2 receptor. Ntllurc 377:
748-750 (Anxioten<itJ II attil'tlles AT1 ami AT2 which
lrm<' muttwlly coufiiUtlctillt,r lraemodynamic effects;
AT, regulate! CNS fimctiOill, Including behaviour)
Walanabe T, Barker T A. Berk B C 2005 Angooten;in 11
and the cndotheli um-<hvcr'c "&nah and effects.
H)penensoon 45: 16J 169 (Rtl'il'l<'S the
t?nill-<111f1iotennn n11rm rn th<' ~ndOihe/ium ba:.ed 011
the dil eru .fiRIIall und effi'w mt'diatt'd by multipl~
angiottnfin I and tlnJ:WitfiStn 1/..tfemed ptptides,
multiple Ulll/10/tnSIIImetabolifiiiR en:,)mtl. multiple
l'l'l'l'pton, and afcultJr bt'd>M<'ific mtmctllulnr
fifllltlll)
\'asoacth e drugs
\'asoeon~trictor drug.~
Antidiuretic honnone
Holme' C I " Ru,...:ll J A 2()().1 V~opresson Scmin
Rc,por Cnt Care \1ed 25. 705 711 ('A defidenc) of
aJoprrnm r.o ftf in wme 1hod. s/11/t'S tmd
replacemmt of fill) 1wlogiwllnels of msopre.>.llfl ctm
rer/01'1' tl~tultlf 1011e. Vusopres1in is thet?fore
emerf!,/111( nr a rati01111l therctpyfor Vli.\Otlilatory
.thock.' Revi<'W.f rmimwle, evidence mod u!lcertainties
for usin11 a.orJrenw ;, shod.)
Vasodilator d rugs (see Cb. 18 for furt her reading on
calcium a ntagonist.<.)
Indirect
Chan C K S, Burl.:e S L. Zhu H el al. 2005 lmodaz.oline
receptors associated .,.llh n<>rndrcnergoc terrnonal' on
the roslnll 'enuolm.eral medulla tnetloa1c the
hypotensh-e repon<oe> of lfl<)xonidone but no1
clonidine. 1\euro.,ctence 132:991-1007 (1/"
h~potensir and bnul\canlic actiom if notJMmidm~
but not cion/dine "" tn<'tliated thnm~h imidll~olmt
receptors and dep~nd on norrulrtn<'rgic CNS
pathways; nonulren~f!liC mner\'atit>ll mll\' M
associat~d with imida:olme rtceptor protrtn)
Weber M A 2001 Vasopeptidtl\c inh1hitor,, Lant:el 358;
l525-1532 (Rt"''ittwr thi Ill'><' dlll< trf drlll(,for
example OrrUJ{Jtltrilm, thm inhibits hmh nemrol
endopeptidtiSe and AC; omnpatriltt i 1 moll' eflc(tii'C
tlrar other tlntihypenensivr dm!l,\ tmd ellwurttt,riiiR i11
irellrt failurt. The frequem) of wogttJtJetltma 'rtmmll >
to be established', as do efleN 011 rlmimll'lttf 110/nt.v.)
Cli nical uses
Hypertension
Murphy M B, Mumly C, Shoncn G D 2001
Fenoldopam-a ;elective peripheral dopamine
receptor agom>t for Lreatmem o l <oC\'Crc hypcrtcn,ion.
N Engl J Med 345: 1548-1557 (Sitmlttr rflel'lilenc;~
as that of 11itroprussid~ bm 11 ithtJitlthit>t,\'lllltlte
tOxicity or instabilil)' in /if!. Ill. htm ,.,.,., 11 t.t .tloM't!r m
on<et and oflutthtlll nurormnsitle)
Chronic heart failure
Backgrowrd readi11g
J~sup \1 . Brozena S. 2003 Heart failure. 1\ Engl J \1ed
.348: 2007-2018
References
AZizi M. Menard J 2004 Combined blocl.aJc of the
renin-angiotensin sy~tem wilh angoorcnson-coO\enong
enzyme inhibitor\ and nngioten"n ll1ype 1 receptor
antagonist>. Circulation 109: 2492-2499 (Dilt'U.!\e.!
rationale)
de LemO> J A, McGuire 0 K. Oramcr M II 2003 Btype
natnuretic peptide in canliova>eulnr di,ense. Lancet
362: 316-322 (8NP i1 lin imtror/llllt tlitti/IW.flit- /Otll
and possible therapemic tl//1'111 in heart failuf'f'.
Reviews the physiology cif th~ 11111riuretlr peptide
system, measumnent tif cln:ulallnli CIIIIC'flllrlllitmr tif
BNP ... to cfill/llltl.le heart failure ami a.vsnr fii'OI/IIII.vil
in patients with rardit1c abnomwfitie1, all(/ u.ve tif
recombinwll human BNP- nesirititle- mrd
Raynuud 's disease and pulmonary hypertension
vasopeptidtlse inhibirors wrremlteurt fiolluf'f'.)
Gbeorghiadc M. G:mi~ W A. O'Connor C M c1 al. 2004
EITecL~ of tohaplilll, a vasopre,.,in antagonist, in patient'
hospitalized with wor.cning hean failure-a randomi1ro
controlled triaL JAMA 291: 1963-1971 (/IJIIaptmr +
sUJndanl therapy hal prom IS<' for htart failull')
McMurray J J V 2005 Vai-HeFf: do .mgoOlen\lnreccplor
TaJ>I.forcc on Ooagnosis and Treaunent of Pulmon3r}
blockers benefit hean failure pauenb already n:cc"'"ll
ACE inhibitor thcrapy'l ~at Clio Prac1 Cardon, a...:
~1ed 2: 128-129
MERITHF Study Group 1999 Effe.:t of metoprolol
CRIXL in chrome hcan failure Metoprolol ('R/XL
RandomiLed lmel"'enuoo Trial in Conl!e'u'c I lean
Failure (MERITHFI. Lnnccl 35J: 2001-2007
(Random/sed trialm 3991 P<llimfl atltluion of
metoprololto Standonl optimum rrearmnu
substantially impm>ed sun ivai; ue alw
tU:companying eduoriale11titled Benefit of ~ blocl.e~
for bean failure: proven on 1999 b) N Sharpe ftJr
references to other fJ blocker!h~tlrt fit/lure tritlls)
Sackoer-Bemstein J D, Kowal,~i M, Fox M, Aaron,on K
2005 Shon tcrm ris~ of death after treatment with
ncsiritidc for decompen~ated hcan failure a pooled
THE VASCULAR SYSTEM
analy.os of mndomi1<Xi controlled trials. JAMA 293:
1900-1905 ( 'Nesiritide-i.e. BNP-ntal' be a!Hocimcd
11 ith 011 increased risk of deatlt after tf'f'atmrnt far
atltl<'iy deroni(J<'mated liMn failull'. Th<' poHrbilrty of
an ITU:rerued risJ. of death should bt' imtlfigmed ill a
large.Ktlk tulequauly powtll'd. controlled rrial
/Kfoll' routine u.<t of nniririd<' for acutely
det:Otn!'<'II.SOI<'d ht'art failure.')
Ta) lor A L. Zoc.,che S, Yancy C el al. 2004 Combonauoo
of iwwrbidc dmotnue and bydralanne on bla<:b worn
heart Crulure. N Engl J Med 351: 2049-2057 (Addmon
of a fixed dose of ososorbide dinitmte plus h)dralo::int'
w <ttuulanltherctp.\ for heart failure includinR
nt'urolromoonal blocun mcll'ased sunhal among
black pat/ems with tUivanced heart failure)
Topol E J 2005 Ncsiritide-not verified. N Engl J Mcd
353: 113 116 (Critical perspecti~l')
S hock
J.'urther readi11g
Landry 0 W. Oli ver J A 200 I Mechani>ms of oisca.c:
lhc pathugcne,is of vasodilalOry shoe~. N Engl J Med
345: 588-595 (Revoew.v mechanisms IJ/'OIIIOiillll
inappmprillle \'tl..odilation in shock, includill/1
artil'lltion of ATP-smsitive poUMsium rlwmuds,
incrrased swthesis of NO tuul depletion ofADH)
Rtferei/U~
Au\trahan and New Zealand lnten~ive Care Society
Clinical Tnal' Group 2000 Low-<lo;e dopamonc in
patoenh with early renal dy,funclion. a plocebo-
controlled randomized trial Lance1 356: 2139-2143
<No clinirally lignificant protection; see also
tiC'CtJmpan) m,~ eduorial. Renaklose dopamine: "oil
the me<-.age no" gel through'~)
Bernard G R et al 200 I Efficacy and <afet) of
m:ombinant human acti-ated protein C for '<!\ere
-cp'" N Engl J Med 344: 699-709 (COIIftnUOUS
rntnnmous infusion of actilated protem C. a ottmun
K-deMntienJ amicoagulant that prvmolt'.! fibrmol\515,
mhibot\ thrombosis 01od is anninflammJJWf'.\,
111111/fiwntly f'f'duced ris~ of tleatlo tit 28 dtns, from
30.8 /t) 24.7%)
Peripheral vascular disease
Hiatt W R 2001 Medical treatment of peripheral nncrinl
<Ji,ca,<;c and claudication. N Engl J Mcd 344:
1608-162 L (Discusses risk factor modificatioll,
summarises evitlerorf' fur efficacy of ciloswwl, und
describes mtimwle for several investlfltlt/onal dmgs,
for e.wmple tlmpionyllevocamititw)
Further reading
Rich S. McLaughlin V V 2005 Cbapler 67. In: Zipes 0
J>, Lobby P. Bonow R 0, Braunwald E (eds)
BrawJwald'> hean disease, 7th Mo. El<evier,
PhJ!adelphia, pp. 1807-1842
Anerial H)penension of the European Sociel)l of
Canliolog) 2()().1 Guideline, on diagnosis and
treaunent of pulmonary anerial bypenen'lon. Eur
Hean J 25: 2243-2278
R<'ftrenus
Abe K. Sbunoka"a H. Monl.a.,.a Ketal 2()().1 Long
term ueaunent with a Rho-kinase inhibotor ompro'e'
monocrotalonc-onducoo fatal pulmonru') h) perten"oo
in rats. Core Res 94: 385-393 ('The Rho
kmwe-medillled pathK'a,l' is irrvolvetl ill the
fllllhogenesis of pulmOIIllf)' hypenension. nogxe>ting
tlotllthos molecule could be a no1el thempeuti<' lllf!let
for this fatal tlt>onler.')
Badescb DB, Abmun S H, Ahearn G S et al. 2()().1
Medical therapy for pulmonary an erial hypcncnsion-
319
 Atherosclerosis and
lipoprotein metabolism
Overview 321
Atherogenesis 321
-Prevention of atheromatous disease 322
Lipoprotein transport in the blood 323
-Dyslipidaemia 324
Lipid-lowering drugs 325
-Statins: HMG-CoA reductase inhibitors 325
-Fibrates 326
-Drugs that inh1bit cholesterol absorption 327
-Nicotinic acid derivatives 328
-Fish oil derivatives 329
OVERVIEW
Atheromatous disease is ubiquitous and underlies
the commonest causes of death (myocardial
infarction caused by thrombosis-Chapter 21-
which occurs on ruptured atheromatous plaque)
and disability (stroke, heart failure) in industrial
societies. Hypertension is one of the most
important risk factors for atheroma, and is
discussed in Chapter 19. Here, we consider other
risk factors, especially dyslipidaemia, 1 which, like
hypertension, is amenable to drug therapy. We
describe briefly the processes of atherogenesis and
of lipid tronsport as a basis for understanding the
actions of lipid-lowering drugs. Important agents
(statins, fibrates, cholesterol absorption inhibitors,
nicotinic acid derivatives, fish oil derivatives) are
described, with emphasis on the statins, which
reduce the incidence of arterial disease and
prolong life.
1
The term dy.11ipidaemia is preferred to hyper/ipidaemia because a /ow
plasma concentration of high density lipoprotein cholesterol is believed to
be harmful and i~ a novel therapeutic targel.
ATHEROGENESIS
Atheroma is a .focal disease of the intima of large and medium-
s ized arteries. Lesions evolve over decades, during most of which
time they arc clinically silent. the occurrence of symptoms signal-
ling advanced disease. Presymptomatic lesions are often difficult
to detect non-invasively. although ultrasound is useful in relatively
static and l>upcrficial arteries (e.g. the carotids), and associated
changes such as reduced aortic compliance and arterial calcium
deposition can be detected by measuring. respectively, aortic pulse
wave velocity and coronary artery calcification. Until recently,
there have been no good subprimate models, but transgenic mice
(see Ch. 6) deficient in apolipoproteins or receptors that play key
rolel> in lipoprotein metabolism have transformed this scene.
evertheless, most of our current understanding of atherogenesis
comes from human epidemiology and pathology. and from
clinical investigations.
Epidemiological studies have identified numerous risk factors
for atheromatous disease. Some of these cannot be altered (e.g. a
family history of ischaemic heart disease). but others are modi-
fiable (see Table 20.1) and are potential targets for therapeutic
drugs. Clinical trials have shown that improving risk factors can
reduce the consequences of atheromatous disease. For example,
drugs that reduce the concentration of low-density lipoprotein
cholesterol (LDL-C) in plasma reduce the incidence of myocar-
dial infarction. Many risk factors cause e ndothelial dysfunction
(sec Ch. 19, pp. 299-30 I), evidenced by reduced vasodilator
responses to acetylcholine or to increased blood flow (so-called
now-mediated dilatation', a response that is inhibited by drugs
that block nitric oxide, NO, synthesis; Ch. 17, pp. 271-272).
Healthy endothelium produces NO and other mediators that
protect again~! atheroma. so it is likely that the adverse effects o n
endothelium of many metabolic risk factors are a common path-
way to atherogenesis.
Atherogenesis involves the following.
I. Endothelial dysfunction. with altered prostaglandin (PG) 12
(prostacyclin: Ch. 13) and 0 (Ch. 17) biosynthesis.
2. Injury of dysfunctional endothelium leads to expression of
adhesion molecules. Thi~> encourages monocyte attachment
and migration of monocytes from the lumen into the intima.
Lesions have a predilection for regions of disturbed flow
s uch as the origins of aortic branches.
3. Low-density lipoprotein (LDL) particles are transported into
the vessel wall. Endothelial cells and monocytes/macrophages 3
__2_1_ _
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
Table 20.1 Modifiable risk factors for
atheromatous disease
Raised low-density hpoprote1n cholesterol
Reduced high-density lipoprotein cholesterol
Hypertension (Ch. 19)
Diabetes mellitus (Ch. 26)
Cigarette smoking (Ch. 54)
Obes1ty (Ch. 27)
Physical inactivity
Raised C-reactive protein
Raised coagulation factors (e.g. factor VII, fibrinogen)
Raised homocysteine
Raised lipoprotein(a)b
strongly associated with atheromatous disease but unknown
if this is causal.
bPotentially modifiable but strongly genetically determined:
nicotinic acid does lower lipoprotein(a).
generate free radicals that oxidise LDL (oxLDL ), resulting in
lipid peroxidation.
4. The oxLDL is taken up by macrophages via 'scavenger
receptors. Such macrophagcs arc caJled foam cells because of
their 'foamy' histological appearance, resulting from
accumulation of cytoplasmic lipid. Uptake of oxLDL
activates macrophages and releases proinilammatory
cytokincs. Foam cells are pathognomonic of atheroma.
Macrophage chemotaxi s is inhibited by
rerrahydmcannahinol, and CB 2 receptor agonists have
potential as antiatherosclerotic drugs (see Ch. 15).
5. Subendothelial collections of foam ce!Js and T lymphocytes
form fatty streak~.
6. Cholesterol can be mobilised from tbe artery walJ and
transponed in plasma in the form of high-density lipoprotein
chole!>terol (HDL-C).
7. Activated platelets. macrophages and endothelial cells release
cytokines and growth factors. causing proliferation of smooth
muscle and deposition of connective tissue component<>. This
inflammatory fibroproliferative response leads to a dense
fibrous cap overlying a lipid-rich core. the whole structure
comprising the atheromatous plaque.
8. A plaque can rupture. forming a substrate for thrombosis
(see Ch. 2 1, Figs 2 1.1 and 2 1.10). The presence of large
numbers of macrophages predisposes to plaque rupture,
whereas vascular smooth muscle and matrix proteins stabi lise
322 the plaque.
Atheromatous disease
Atheroma is a focal disease of large and
medium-sized arteries. Atheromatous plaques are
almost universally present in members of
economically developed countries, progress
insidiously over many decades. and underlie the
commonest causes of death (myocardial infarction)
and disability (e.g. stroke) in these countries.
Fatty streaks are the earliest structurally apparent
lesion and progress to fibrous and/or fatty plaques.
Symptoms depend on the vascular bed and occur
only when blood flow through the vessel is reduced
below that needed to meet the metabolic demands of
tissues downstream from the obstruction.
Important modifiable risk factors include hypertension
(Ch. 19), dyslipidaemia (this chapter) and smoking
(Ch.43).
The pathophysiology is of chronic inflammation fn
response to injury. Endothelial dysfunction leads to
loss of protective mechanisms,
monocyte/macrophage and T-cell migration, uptake
of low-density lipoprotein (LDL) cholesterol and its
oxidation, uptake of oxidised LDL by macrophages,
smooth muscle cell migration and proliferation, and
deposition of collagen.
Plaque rupture leads to platelet activation and
thrombosis (Ch. 21).
PREVENTION OF ATHEROMATOUS DISEASE
Drug treatment is often justified, to supplement healthy habits.
Treatment of hypertension (Ch. I 9) and, to a lesser exten1.
diabetes mellitus (Ch. 26) reduces the incidence of symptomatic
atheromatous disease, and antithrombotic drugs (Ch. 2 1) reduce
arterial thrombosis. Reducing LDL-C is highly effective and b
the main subject of this present chapter, but several other steps m
atherogenesis are also potential targets for phannacological attack.
Angiorensin-cotwerring enzyme inhibitors (Cb. 19) improve end<r
thelia) function and prolong life in patients with atheromatous
di ease. Other drugs that also increase NO biosynthesis or 3\ail
ability are under inve~tigation. Moderate alcohol consumption
increa!>es HDL-C, and epidemiological evidence fa\ours mod
crate alcohol consumption in older pcople. 2
T Regular exercise abo mcrca~s circulating HDL-C; drug ueauncntiO
increa..c HDL-C 1\ le,~ established than drugs thmlo\\er LDL-C. lln'31l5t
until recent!) ~uch drug~ (e.g.jibrates and nicotinic acid derimllm ->
below) ha\C had only modeM effects on HDL-C. accompanied b} effe..'!S
on LDL-C and triglyceridcs that complicate interpretation of chnial
trials. However. in subject~ with low HDL-C. inhibition of chole,wnl
ester tram,fer protein (CETP; see below) with torcetrapib mar~tJiy
2
'Sinful, ginful. rum-soaked men. survive for lhree score year~ and ten'-or
longer. we rather hope...

increases IIDLC (Brou~~eau et al., 2004). Torcetrapib is being developed
in combination with a Malin. ApoA-1 Milano is a variant of apolipoprotcin
A-1 identified in tndivtdual., in rural Italy with very low le' els of HDL
but low anerial di-e:~..e pre,alence. lnfu<,ion of recombinant ApoA-1
Milano-pho!>phohpid comple'e~ produces rapid regression of
athero\Ciero'' tn animal model~. and administered intravenously caused
regre~sion of atherosclero~i~ tn pauents with acute coronary S) ndrome
(Ni'>sen et al., 2003).
Amio.\idams (e.g. vuamtn C and vitamin E) are of interest. both because
of evidence th:tt the) improve endothelial function in patients with
increa..ed oxtdant !>Ire'' and because of epidemiological evidence that a
diet rich in antioxidant~ b ~soci:tted with reduced risk of coronary artery
disease. Results from chnical triab have been negative. however, and
'everal :~ntiox Jdant'> reduce HDL-C. Oestrogen, used to prevent
'>ymptom.. of the mcnopau~c (Ch. 30) and to prevent postmenopau.,al
osteoporosis, has antioxidant properties and exens other vascular effects
that could be benefic ial. Epidem iological evidence suggested that women
who usc such hormone replacemen t are at reduced risk of atheromatous
disease, hut contro ll ed trials show ~ignificant adverse effects on
cardiovascular mon:~lity (Ch. 30 and see commentary by Dubey et at.,
2004). Drug treatment to lower C-reacti ve protein has been mooted, but
it i~ pos~iblc that elevated C-reaclive protein is a marker of vascular
inflammation rather than playing an active pan in disease progression.
Other anti-inflammatory mea.\ures are being investigated: for example, an
acyl coen1ymc A: cholesterol acyltransferase (ACAT) inhibitor.
a\asimibe. reduce\ circulating tumour necrosis factor-a levels in
hyperchole\lerolaemic \UbjecL'> without much effect on plasma lipids, and
impro~e' re!>i'>tancc \C\\el endothelial function (Kharbanda eta!., 2005).
but it may not improve coron:~ry atherosclerosis (Tardif et al .. 2004).
Other novel therapie~ in development were revie" ed recently
(Wieobtcl..t, 200-' ).
Pla~ma homocy~teine can be lowered by supplementing the diet with folic
acid, and it "ill be interc\ting to sec whether countries such as the USA,
which have tntroduced folate supplemenb to pre,ent congenital neural
rube defect~ (see Ch. 53. p. 759). experience a reduced incidence of
atheromatous di~ea'>e.
In contrast to thi!> somewhat unclear (albeit exciting) picture, drugs
that lower plasma LDL-C are of proven benefit in preventing
coronary a.nery di),ease. To understand how such drugs work, it
i!> necessary to address how lipids are handled in the body.
LIPOPROTEIN TRANSPORT IN
THE BLOOD
Lipids and cho le~terol are transported through the bloodstream
as macromolecular complexes of lipid and protein known as
lipoproteins. These consist of a central core of hydrophobic lipid
(including triglyceridcs and cholesteryl esters) encased in a hydro-
philic coat of polar phospholipid, free cholesterol and apolipo-
protein. There are four main clac;ses of lipoprotein. differing in the
relative proportion of the core lipids and in the type of apoprotein.
They also differ in site and density, and this latter property. as
meru.ured by ultracentrifugation, is the basis for their classi-
fication into:
HDL-C particles
LDL-C particles
very low-density lipoprotein (VLDL) particles
chylomicrons.
Each class of lipoprotein has a specific role in lipid transport, and
there arc different pathways for exogenous and for endogenous
ATH EROSCLEROSIS AND LIPOPROTEIN METABOLISM
lipids, as well as a path way for reverse cholesterol transport
(Fig. 20.1 ). The pathways are distinguished by the main apoproteins
(apoB-48, apoB-1 00 and apoA 1. respectively) that are ligand~
for the key receptors. ln the exogenous pathway, cholesterol and
triglycerides absorbed from the ileum are transported as
chylomicrons (diameter 100-1000 nm), in lymph and then blood.
to capillaries in mu~cle and adipose tissue. Here. triglyceridcs are
hydrolysed by lipoprotein lipac;e, and the tissues take up the
resulting free fatty acids and glycerol. The chylomicron remnants
(diameter 30-50 nm). still containing their fuU complement of
cholesteryl e~ ters, pass to the liver, bind to receptors on hcpato-
cytes and undergo endocytosis. Cholesterol liberated in hepato-
cytes is stored, oxidised to bile acids, secreted unaltered in bile,
or can enter the endogenous pathway.
In the endogenous pathway, cholesterol and newly synthesised
triglyceridcs are transported from the liver as VLDL (diameter
30-80 nm) to muscle and adipose tissue, where triglyceride is
hydrolysed to fatty acids and glycerol; these enter the tissues as
described above. During this process, the lipoprotein particles
become smaller (diameter 20-30 nm) but retain a full complement
of cholcstcryl esters. Consequently, they increase in density to
intermediatc-den~ity cholesterol and ultimately LDL-C particles.
LDL-C provides the source of cholesterol for incorporation into
cell membrane~ and for synthesis of steroids (see Chs 28 and 30)
but is also key in atherogenesis, as described above. Cells take up
LDL-C by endocyto)ois via LDL receptors that recognise LDL
apolipoproteins. Some drugs (notably statins: see below) reduce
circulating LDL-C by inhibiting endogenous cholesterol synthesis
and stimulating the synthesil> of hepatic LDL receptors. Cholesterol
can rerum to plasma from the tissues in HDL particles (diameter
7-20 nm). Chole!>terol is esterified with long-chain fatty acids in
HDL particles. and the resulting cholesteryl esters are transferred
to VLDL or LDL particles by a transfer protein present in the
plasma and known as cholesteryl ester transfer protein (CETP).
Lipoprotcin(a), or Lp(a), is a species of LDL that is strongly
associated with atherosclerosis and is localised in atherosclerotic
lesions. Lp(a) cont<tins a unique apoprotein, apo(a), with stntctural
similarities to plasminogen (Ch. 21, p. 344). Lp(a) competes with
and inhibits the binding of pla~minogen to its receptors on the
endothelial cell. Plasminogen is normally the substrate for
plasminogen activator, which is secreted by and bound to endo-
thelial cells. generating the fibrinolytic enzyme plasmin (see
Fig. 21.1 0). The effect of the binding of Lp(a) is that Jess plasmin
is generated, fibrinolysis is inhibited and thrombosis promoted.
There i~ currently much interest in four lipid transfer proteins
that have been implicated in atherogenesis. ACAT (acyl coenzyme
A: cholesterol acyltran!>fera~e), which is expressed in two forms,
cataly!>eS the intracellular synthesis of cholesteryl ester in macro-
phage!>, adrenal cortex, gut and liver. LCAT (lecithin cholesterol
acyltransferase) catalyses cholesteryl ester synthesis in HDL
particlcl>. CETP and PLTP (phospholipid transfer protein) are
involved in transfer of cholesterol between different classes of
lipoprotein particle in plasma. Tamoxifen. used in the treatment
and prevention of breast cancer (Ch. 51, p. 729; also discussed in
Ch. 30 on p. 449), was recently discovered to be a potent ACAT
inhibitor (De Medina et al., 2004). So far, the most promising
therapeutic approach has been inhibition of CETP: torcetra pib 323
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

Exogenous pathway

HEPATOCYTE

Statlns decrease '--__,.~ HMG CoA - HMG CoA

synthesis of C reductase )
MVA

Statlns, resin s, "Coated pit"

/...
c~ / ------------
BILE DUCT
~

fib~:.~.':~ ------.. /. / :/ \ "':~i~~- m-u--m -- ---~ -- - ..~ addo

,'' ~---.....,. LDL PORTALVEIN
/ receptors
I
I I Fat +C
I I
I I
in diet
LIVER
I
I

' I
I
I
I

!
Fatty acids
I
I
+
#- Chylomicron Glycerol
VLDL remnant +
' c
' CE__ - -- ~ TG > CE CE > JG
''
, \ . -- INTESTINE
,' ' \
\
' \ ChylomiCrons
/ CE '
HOL , .... --- .......... LDL t Faecal
elimination of
TG > CE
CE CE
,.. , bile acids
'II
I
I

I / Lipoprotein lipase ',

I

( I }0 [( I I
I
I
y
I
I
n
y
I
I
'

I l[ -=;
,/ I

I
I
y
VA~CULAR E~DOTHE~~M J
C from cell Uptake Free fatty Free latty PERIPHERAL TISSUES
turnover oiC acids acids (FAT, MUSCLE)

Fig. 20.1 Schematic diagram of cholesterol transport in the tissues, with sites of action of the main drugs affecting
lipoprotein metabolism. ACoA, acetyl-coenzyme A; C, cholesterol; CE, cholesteryl ester; HDL, high-density lipoprotein; HMG-CoA
reductase, 3-hydroxy-3-methylglutaryl-coenzyme A reductase; LOL, low-density lipoprotein; MVA. mevalonate; TG, triglyceride; VLDL,
very low-density lipoprotein.

(mentioned above) increases HD L-C and is in a late stage of diet and genetics (often but not always polygenic). The} are
development. class ified, according to which lipoprotein particle is raised. mto
six phenotypes (the Frederickson classification; Table 20.2). An
especially great risk of ischaemic heart disease occurs in a sub'cl
DYSLIPIDAEMIA
of primary type na hyperlipoproteinaemia caused by single-gene
The normal range of plasma total cholesterol concentration defects of LDL receptors: this is known as familial hyper
varies in different populations (e.g. in the UK 25-30% of middle- choleslerolaemia, and the sentm cholesterol concentration in
aged people have sentm cholesterol concentrations > 6.5 mmol/1, affected adults is typically > 8 mmol/1 in heterozygotes and
in contrast to a much lower prevale nce in China). There are 12 25 mmol/1 in homozygotcs. Study of familial hyper
smooth gradations of increased cardiovascular risk with increased cholesterolaemia enabled Brown & Goldstei n ( 1986) to define
LDL-C and with reduced H DL-C. Dyslipidaemia may be primary the LDL receptor pathway of c holeste rol homeostasis (for which
324 or secondary. The primary forms are due to a combination of they shared a Nobel Prize).
 ATHEROSCLEROSIS AND LI POPROTEI N METABOLISM

T ble 20.2 Frederickson/World Health Organization classification of hyperlipoproteinaemia

Type Lipoprotein elevated Cholesterol Triglycerides Atherosclerosis risk Drug treatment

Chylomicrons + +++ NE None

IIa LDL ++ NE High Statin ezellmibe

lib LDL + VLDL ++ ++ High Fibrates, statin, nicotinic acid

Ill fWLDL ++ ++ Moderate Fibrates

IV VLDL + ++ Moderate Fibrates

v Chylomicrons + VLDL + ++ NE Fibrate, niacin, fish oil and

statin combinations

+, increased concentration; LDL, low-density lipoprotein; NE, not elevated; VLDL, very low-density lipoprotein; ~VLDL, a qualitatively
abnormal form of VLDL identified by its pattern on electrophoresis.

Secondary forms of dyslipidaemia arc a consequence of other

conditions. such a!> diabetes mell itus, alcoholism, nephrotic syn-
drome. chronic renal failure, hypothyroidism, liver disease and
administration of drugs, for example isotretinoin (an i!>omer of
vitamin A given by mouth as well as topically in the treatment
of \evere acne), tamoxifen (Mikhailidis ct al., 1997, and see
above), ciclosporio (Cb. 14) and protease inhibitors used to treat
infection with human immunodeficiency virus (Ch. 47).
LIPID-LOWERING DRUGS
Several drugs decrease plasma LDL-C. Drug therapy is used in
addition to dietary measures and correction of other modifiable
cardiovascular risk factors. The selection of patients to be treated
with drugs remains controversial. not least for reasons of cost: the
benefit is greatest for those who are at greatest risk, including those
with symptomatic atherosclerotic disease (referred to as secondary
pre1ention) and those with several cardiova!>cular risk factors, as
well as those with the highest plasma concentrations of cholesterol.
The main agents used clinically are:
statins: 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA)
reductase inhibitors
fibrates
inhibitors of cholesterol absorption
nicotinic acid or its deri vati ves
e LDL particles.
fish oil derivatives.
0
Fish oil lowers plasma triglyceride concentration but can
increase plasma cholesterol.
e six phenotypes (the Frederickson classification). The
- STATINS: HMGCoA REDUCTASE
n
INHIBITORS
rl
- The rate-limiting enzyme in cholesterol synthesis is HMG-CoA
e reductase. which catalyses the conversion of HMG-CoA to
h mevalonic acid (see Fig. 20. 1). Simvastatin. lovastatin and pra-
vastatin are specific, reversible, competitive II MG-CoA reductase
Lipoprotein metabolism
and dysllpldaemla
Lipids, including cholesterol and triglycerides, are
transported in the plasma as lipoproteins, of which
there are four classes.
Chylomicrons transport triglycerides and
cholesterol from the gastrointestinal tract to the
tissues, where triglyceride Is split by lipoprotein
lipase, releasing free fatty acids and glycerol.
These are taken up in muscle and adipose tissue.
Chylomicron remnants are taken up in the liver,
where cholesterol is stored, secreted in bile,
oxid1sed to bile acids or converted into
very low density lipoproteins (VLDL), wh1ch
transport cholesterol and newly synthesised
triglycerides to the tissues, where triglycerides are
removed as before, leaving
low-density lipoprotein (LOL) particles with a large
component of cholesterol; some LDL cholesterol
is taken up by the tissues and some by the liver,
by endocytosis via specific LDL receptors.
High-density lipoprotein (HOL) particles adsorb
cholesterol derived from cell breakdown in tissues
(including arteries) and transfer it to VLDL and
Hyperlipidaemias can be primary, or secondary to a
disease (e.g. hypothyroidism). They are classified
according to which lipoprotein particle is raised into
higher the LDL cholesterol, and the lower the HDL
cholesterol, the higher the risk of ischaemic heart
disease.
325
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
inhibitOr\ with K, values of approximately I nmoiJl. Atorvasta tin
and rosuvasta tin arc long-lasting inhibitors. Decreased hepatic
cholesterol synthesi~ up-regulates LDL receptor synthesis,
increasing LDL-C clearance from plasma into liver cells. The
main biochemical effect of statins is therefore to reduce plasma
LDL-C. There b also some reduction in plasma triglyceride and
increase in HDL-C. Several large randomised placebo-conrrolled
trials of the effects of llMG-CoA reductase inhibitors on morbidity
and mortality have been positive.
.., The Scandinavian Smmwatin Survival Swdy (4S) recruited patients
with i\chaemic hean d:.ease and plasma cholesterol of 5.5-8.0 mmol/1;
simva,tatin lowered serum LDL-C by 35% and death by 30% (Fig. 20.2).
This wa~ accounted for by a 42% reduction in death from coronary
disease over the median follow-up period of 5.4 years. Other large trials
have confirmed reduced mortality both in patients with estnbli~hed
i~chuemic hear1 di&ea5e (e.g. the Clwle!>tetvlanrl Recurrent Event.~. CARE.
Trial) :md in hc;t lthy people ;~t ri:,k of coronary djsease, with a wide range
of pla,ma cholesterol value~> and other risk factOrs. and treated with
different Matin~ (e.g. the West of Scotlanrl Coronal)' Prevemion Study
[WOSCOPS], the Heart Protection Study and the AngloScarulinal'ian
Cardiac Otttroml'.l' Trial rASC07l). Intensive lowering of LDL-C with
morva\tatin 80 mg had " greater effect on event rate than did a I0-mg
dose in a recent r.llldomi.,ed compari~cm, but with a greater incidence of
abnormally rai<>ed plru.ma tran'>llminase activity (LaRosa et al., 2005). In
..econdary prevention trial~ of stntins. cardiovascular event rate is
approximately linearly related to the achieved plasma LDL-C over a
concentration range from approx111Jatel) 1.8 to 4.9 mmol/1. and the event
mte fall\ on the 5arne line in placebo and statin-treated patientS.
Other actions of statins
Products of the mevalonate pathway prenylate or farnesylate
several imponant membrane-bound enzymes (e.g. endothelial
NO synthase; see Ch. 17). These fatty groups serve a!> anchors,
localising the en;yme in organelles such as caveoli and Golgi
apparatus. Consequently, there is currently great interest in
actions of statin~ that are unrelated, or indirectly related, to their
effect on plasma LDL-C (sometimes referred to as pleiotropic
0.95
-~
lV 0.90
~
&. - - Simvastatin
0.85 --Placebo
0.80
P= 0.0003
0.00 ...L..-"'T""-"'T""_ _ _ _ _ _ _____J
0 2 3 4 5 6
Years since randomisation
I
Fig. 20.2 Survival in patients with coronary heart disease
and serum c holesterol 5.5-8.0 mmol/ 1treated either with
placebo o r with s imvas tatin. The relative risk of death in the
~imvastati n group was 0. 70 (95% confidence intervals
~.58-0.85). (Based on 4S study 1994 Lancet 344: 1383-1389.)
J ' Ccrivastatin. a potent ~latin introduced at relatively rugh dose, was
326
effects). Some of these actions are undesirable (e.g. HMG-CoA
reductase guide!> migrating primordial genn cells, and stalin U'>l:
is contraindicated during pregnancy), but some otTer thempeutic
promise. for example in Alzheimer's disease (Sparks et al.. 2005J
and prevention of prostate cancer (Shannon et al.. 2005). Su.:h
actions include:
improved endothelial function
reduced vascular inflammation
reduced platelet aggregability
increased neovascularisation of ischaemic tissue
increased circulating endothelial progenitor cells
stabilisation of atherosclerotic plaque
antithrombotic actions
enhanced fibrinolysis
inh ibition of germ cell migration during development
immune suppression
protection against sepsis.
The extenl to which these effects contribute to the antiathero
matous actions of statins is unknown.
Pharmacokinetics
Shon-acting \Latins are given by mouth at night to reduce peak
cholesterol !>ynthe~is in the early morning. They arc 11cU
absorbed and extracted by the liver, !.heir site of action, and are
subject to extensive presystemic metabolism via cytochrome P450
and glucuronidation pathways. Simvastatin is an inactive lactone
prod rug; it is metabolised in the liver to its active fonn. the corre-
sponding ~-hydroxy fatty acid.
Adverse eHects
Statins are well tolerated; mild unwanted effects include myalgia.
gastrointestinal di~turbance, raised concentrations of liver enLyme~
in plasma, insomnia and rash. More serious adverse effect~ are rare
but include severe myositis (rhabdomyolysis) and angio-oedema.
Myositis is a class effect of stalins, occurs also with other lipid-
lowering drugs (especially fibrates) and is dose-related.' It i\
commoner in patients with small lean body mass or uncorrected
hypothyroidism.
Clinical uses
See the clinical box.
FIBRATES
Sever-al fibric acid derivatives (fibrates) are available, includin!-
bezafibrate. ciprofibrate, gemfibroz.il. fenofibrate and clofibmte
These cau~e a marked reduction in circulating VLDL. and hl!net
triglyceride, with a modest (approximately 10%) reduction m
LDL-C and an approximately 10% increase in HDL-C. In one
study, gemfibrolil reduced coronary bean disease by approximate!)
one-third compared with placebo in middle-aged men with primru;
withdrawn because of severe myositis occurring pamcularly in patient-
treated with gcmfibrozil---{]iscu&sed later in the chapter.

A such paLienL~ and also in alcoholic individuals, who are predisposed
Clinical uses of HMG-CoA
reductase Inhibitors (statins,
e.g. slmvastatln. atorvastatin)
Secondary prevention of myocardial infarction and
stroke in patients who have symptomatic
atherosclerotiC disease (e.g. angina, transient
ischaemic attacks, or following myocardial infarction
or stroke).
Primary prevention of arterial disease in patients who
are at high risk because of elevated serum cholesterol
concentration, especially if there are other risk factors
for atherosclerosis. Tables (available for example in
the British National Formulary) are used to target
treatment to those at greatest risk.
Atorvastatin lowers serum cholestero l in patients
w ith homozygous fami lial hypercholestero laemia.
In severe drug-resistant dyslipidaemia (e.g.
o-
heterozygous familial hypercholesterolaemia),
ezetimibe is combined with statin treatment.
:II
e hyperlipoproteinaemia. An HDL-C intervention trial performed
-o by the US Veteran s Affairs Department in some 2500 men with
ne coronary hean disease and low HDL-C together with low LDL-C
showed that gemfibrotil increased HDL-C and reduced coronary
disease and stroke. Event rate!> were linked to changes in HDL-C
but not to triglycerides or to LDL-C, suggesting that increasing
HDL-C with a fibrate reduces vascular risk.
fa, The mechanism of aclion of fibrates is complex (see Fig. 20.1 ).
es They are agonists for a subset of l ipid-controlled gene regulatory
re elements (PPARs4 ), PPARo, which are members of the super-
a. family of nuclear receptors (Ch. 3); in humans, the main effects
iJ- are to increase transcription of the genes for lipoprotein lipase,
IS apoA I and apoA5. They increase hepatic L DL-C uptake. In addition
~d to effects on lipoproteins, fibrates reduce plasma C-reactive protein
and fibrinogen, improve glucose tolerance, and inhibit vascular
smooth muscle innammation by i nhibiting the expression of the
transcription factor nuclear factor KB (see Ch. 28, p. 428). As
with the pleiotropic effects of stalins (see above), there is great
interest in these actions. although again it is unknown if they are
clinically important.
g Adverse eH ects
e. Myositis is unusual but can be severe (rlzabdomyolysis). with
;e myoglobinuria and acute renal failure. I t occurs particularly in
in patients with renal impairment. because of reduced protein binding
te and impaired dmg elimination. Fibrates should be avoided in
I)
'Y
4
Standing for neroxi~ome nrolifcrator-J!ctivated receptors-don'! a~k!
(Peroxisome~ arc organelles that arc not present in human cells. so
sornelhing of a misnomer!) Th iazolidined ione drugs used in treating
diabetes act on related PPARy receptors ; see Chapter 26.
ATH EROSC LEROSIS AND LIPOPROTEIN METABOLISM
to hypertriglyceridaemia but are at risk of rhabdomyolysis. 5
Myositb can abo be caused (rarely) by statins (see above), and
the combined use of fibrates with this class of drugs is therefore
generally inadvisable (although it is sometimes undertaken by
specialists). Gastrointestinal symptoms. pmritus and rash are more
common than with Matins. Clofi brate predisposes to gallstones,
and its use is therefore limited to patients who have had a
cholecystectomy (i.e. removal of the gall bladder).
Clinical u se
Sec the clinical box.
DRUGS THAT INHIBIT CHOLESTEROL
ABSORPTION
Historical ly, bile acid-binding resins were the only agents avail-
able to reduce cholesterol absorption and were among the few
means to lower plasma cholesterol. Decreased absorption of exo-
genous cholesterol and increased metabolism of endogenous
cholesterol into bile acids in the liver lead to increased expression
of LDL receptors on hepatocytes, and hence to increased clear-
ance of LDL-C from the blood and a reduced concentration of
LDL-C in plasma. Such resins (see below) reduce the incidence
of myocardial infarction, but their effect is modest and they are
bulky, unpalatable and cause diarrhoea. With the introduction of
statins, their role in treating dyslipidaemia was relegated largely to
additional treatment in patients with severe disease (e.g. familial
hypercholesterolaemia).
'f' Sub~equently, plant sterols and Manols have been marketed; the\e are
isolated from wood pulp and used to make margarines or yoghun.\. They
mode'>tly reduce pla.,ma cholesterol and are tastier than resins. 6 Their
Clinical uses of flbrates
(e.g. gemflbrozll, fenoflbrate)
Mixed dyslipidaemia (i.e. raised serum triglyceride as
well as cholesterol), provided this is not caused by
excessive alcohol consumption. Fenofibrate is
uricosuric, which may be useful where
hyperuricaemia coexists with mixed dyslipidaemia.
In patients with low high-density lipoprotein and high
risk of atheromatous disease (often type 2 diabetic
patients; see Ch. 26).
Combined with other lipid-lowering drugs in patients
with severe treatment-resistant dyslipidaemia. This
may, however, increase the risk of rhabdomyolysis.
'For .,everal reason\, including a tendency to lie immobile for prolonged
periods followed by gcnerali5ed convulsions-'rum fits'-and del irium
tremcn~.
l><fhis is not. however, say ing much. 327
 SECTION 3 DRUGS AFFECTING MAJOR ORGAN SYSTEMS
mecham~m i\ unclear: ~ito;tanol in the gut lumen competes with
cholesterol for an cnterocyte cholesterol uptake receptor called NPC ILl, 7
and sitosterol interferes with cholesterol transfer within the enterocyte.
Stano! supplement~ "-O~o homozygous sirosrerolaemia. a rare autosomal
rece\\ive dt..ea\e characteri..ed by increased intestinal absorption of plant
..reroJ,. ckcrea\Cd hepauc excretion into bile and raised plasma phyrostcrols.
tuberous xanrhom<b (potato-like accumulations of lipid-rich material in
tendons) and :nhero~lerosis.
EZETIMIBE
Ezetimibe is one of a group of azetidinone choleste rol absorp-
tion inhibitors, and i!. indicated as an adjunct to diet and statins
in hypercholesterolaemia. It specifically inhibits absorption of
cholesterol (and of plant s tanols) from the duodenum by blocking
NPC 1Ll in the brush border of enterocytes, without affecting the
absorptio n of fat-solub le vitamins, triglycerides or bile acids. It
is truly a drug in the sense defined in Chapter 2 (p. 8). in conLrast
to resins, which act by combining with bile acids rather than by
binding to receptors; ezctimibc is consequently very much more
convenient to take because of its high potency (a daily dose of
I 0 mg compared with a dose of resin of up to 36 g of
colcstyra mine--a differe nce of 3600-fold), and represents a
very real advance as a substitute for resins as supplementary
treatment to statins in patients with severe dyslipidaemia. Its
mechanism b dbtinct from that of phytosterol and phytostanol
esters, which interfere with the micellar presentation of sterols to
the cell 1.urface.
Pharmacokinetic aspects
Ezetimibe is administered by mouth and is absorbed into intes-
tinal epithelial cellr., where it localises to the brush border, which
is its presumed site of action. lt is also extensively (> 80%)
metabolised to eLetimibe-glucuronide, which is pharmacologically
active. Total ('parent' plus glucuronide) ezetimibe concentrations
reach a maximum 1-2 hours after administration, followed by
entcrohcpatic recycling and !.low elimination. The terminal half-
life is approximately 22 hours. It enters milk (al least in animal
studies) and, in conLras t to resins, is therefore contraindicated for
women who nrc breast feeding.
Adverse eHects
Ezctimibe is generally well tolerated but can cause diarrhoea,
abdominal pain or headache; rash and angio-oedema have
been reported.
Clinical use
See clinical box.
BILE ACID-BINDING RESINS
Colestyra mine and colestipol are anion exchange resins. Taken
by mouth, they seque!>ter bile acids in the intestine and prevent their
reabsorption and enterohepatic recirculation (Fig. 20. 1). The con-
centration of HDL-C is unchanged, and they cause an unwanted
328 7
Por Niemann- Pick C 1-like protein- I
increase in Lriglycerides. The American Lipid Research Clinic\'
trial of middle-aged men with primary hypercholesterolacmia
showed that addition of a resin to dietary treatment caused a mean
13% fall in plasma cholesterol and a 20-25% fall in coronary
hean disease over 7 years .
Unwanted eHects
Because resins are not absorbed, systemic toxicity is 10\~ but
gastrointestinal symptoms-especially diarrhoea-are common and
dose-related. Resins are bulky and unappetising. They interfere
with the absorption of fat-soluble vitamins, and of drugs such a'
chlorothiazide (Chs 19 and 24), digoxin (Ch. 18) and warfarin
(Ch. 2 1), which should therefore be taken at least I hour before
or 4-6 hours after the resin.
Clinical use
They have been superseded by ezetimibe in treating
dyslipidae mia in adu lts; for other uses, see the clinical box.
NICOTINIC ACID DERIVATIVES
Nicotinic acid is a vitamin, and as such is essential for man~
imponant metabolic processes. Quite separately from this, it ha,
been used in gram quantities as a lipid-lowering agent. Nicotinamide
inhibits hepatic triglyceride production and VLDL secretion(~
Fig. 20.1 ), with reductions in triglyceride and LDL-C includmg
Lp(a), and increnr.e in HDL-C. The mechanism is poorl) under
stood but is believed to be initiated by an effect on lipolysis \ia a
G-protein-coupled orphan receptor called HM74A and prt'<nt
in adipocyte membranes (see review by Karpe & Frayn. 200H It
also influences hepatic diacylglycerol transferase. Long-term
administration to survivors of myocardial infarction reduced
rnonality in the Coronary Drug Project trial. but unwanted ctTcch
limit its clinical usc. A modified-release preparation is better lol
crated, with preserved lipid etTects, marginal adverse effecl\ on
glycaemia nnd liver function, and efficacy on intermediate {angio-
graphic and ultrasound) end points; it is a real, if modest, advance.
Clinical use of drugs that reduce
cholesterol absorption: ezetlmibe or bile
acid-binding resins (e.g. colestyramlne)
As an addition to a statin when response has been
inadequate (ezetimibe).
For hypercholesterolaemia when a statin is
contraindicated.
Uses unrelated to atherosclerosis, including:
pruritus in patients with partial biliary obstruction
(bile acid-binding resin)
bile acid diarrhoea, for example caused by
diabetic neuropathy (bile acid- binding resin).
 ATHEROSC LERO SIS AND LIPOPROTEIN METABOLISM

Druga In clpllpldaemla Clinical uaea of nicotinic acid

The main drugs used in patients with
dyslipidaemias are:
HMG-CoA reductase Inhibitors (statins, e.g.
simvasta1in): inhibit synthesis of cholesterol,
1ncreas1ng expression of low-density lipoprotein (LDL)
receptors on hepatocytes and hence LDL cholesterol
(LDL-C) uptake. Adverse effects include myalgias (rarely,
severe muscle damage) and raised liver enzymes.
Fibrates (e.g. gemfibrozil): activate PPARa receptors,
increase activity of lipoprotein lipase, decrease
hepatic very low-density lipoprotein producti on, and
enhance clearance of LDL-C by the liver. They
markedly lower serum triglycerides, and modestly
increase high-density lipoprotein cholesterol. Adverse
effects include muscle damage.
Agents that interfere with cholesterol absorption,
usually as an adjunct to diet plus statin:
ezetimibe
- stanol-enriched foods
- bile acid- binding resins (e.g. colestyramine).
Modified-release nicotinic acid. Flushing is the main
adverse effect.
Fish oil derivatives- omega-3-acid ethyl esters.
Adverse eHects
Adverse effect~ include Oushing, palpitations and gastrointestinal
dislllrbancc~. Fl u~hing b associated with production of PGD 2
(Ch. 13) and i-; reduced by taking the dose 30 minutes after aspirin.
High doses can disturb liver function, impair glucose tolerance,
and precipitate gout by increasing circulating urate concentration.
FISH OIL DERIVATIVES
Omega-3 marine triglyccridcs reduce plasma triglyceride concen-
trations but increase cholesterol. Plasma triglyceride concentratio ns
derivative are:
as adjunct to a statin and diet in dyslipidaemia,
especially when associated with low HDL-C and
raised triglycerides
when a statin is contraindicated.
arc less strongly associated with coronary artery disease than is
c holesterol, but there is e pidemiological evidence that eating fish
regularl y does reduce ischaemic heart disease, and dietary sup-
plementa tion with n-3 polyunsaturated fatty acids (PUFA) improves
survival in patientS who have recently had a myocardial infarction
(GTSS I-Prevenzione Inves tigators. 1999). The mechanis m may
be the pote nt antiarrh ythmic effects of PUFA (reviewed by Leaf
et al., 2003). The mechanism of action of fi sh oil o n plas ma
triglyceride concentrations is unknown. Fish oil is rich in PUFA,
including cicosapcntaenoic and docosahexaenoic acid, and it has
other potentially important effects including inhibition of platelet
fu nction, prolongation of bleeding ti me, anti-inflammatory effects
and reduction of pla.~ma fibrinogen. Eicosapentaenoic acid sub-
stitutes fo r arachidonic acid in cell membranes and gives rise to
3-series prostaglandi ns and thromboxanes (that is, prostanoids with
th ree double bondc; in their side-chains rather than the usual two),
and 5-~eries leukOLrienes. This probably accounts for their effects
on haemostasi~. because thromboxane A3 is much less active as
a platelet-aggregating agent than is lhromboxane A2 whereas
PGI 1 is simiJar in potency to PGI2 as an inhibitor of platelet function.
The alteration in leukotricnc biosynthesis probably underlies the
ami-innammatory effects of fish oil. Fish oil is contraindicated in
patie nts with type Ila hypcrlipoproteinaemia because of the
inc rease in LDL-C that it causes. A pre paration of omega 3-acid
ethyl esters is licensed in the UK for prevention of recurre nt
events aft er myocardial infarction in addition to treatment of
hypc rtriglyceridae mia; it causes less inc rease in LDL-C and
fewer problems wi th fishy odour, weight gain and dyspe ps ia than
the older fish oil preparatio ns.

REFERENCES AND FURTHER READING

Atherosclero<;b
Brown M S. Gold\letn J L 1986 A receptor-mediated
pathiU) for chole,terol ho~t:l.>l\. Sctence 232:
34-47 (C/awc from tht'ft' N~l Pri;t' "mnt'n; '""
also Goltlsr~ill J l . Bm1111 M S /990 R~gu/01ron of th~
mnalt>llalt' fXllh>~a.\ Ntllllrt 343 425-130)
(}.J\Ies M J. Woolf~ 1993 Athero-.cleroo,b: whatts it
and why doe~ 11 occur? Br Hcan J 69: S1 S II
( Rni~w offXIIIIO/tlfl)'lfl<lllltll(<ll~\1 1)
Gin" C K. Wimum J L 2001 Atherosclerosis. The Road
Ahead Cell 104: 503-S 16
~l cCully K S 1996 Homoc:y,tcutc and vn-.cular di~ea>e.
Nat Mcd 2: 386 389 (Dht'll.\\es ther1111eutic promise
of inc,etlled diewry folllle wtd vitamin 8 0 )
}.1iles LA. Aess G M. Levm E G ct ul. 1989 A potential
basis for the thmmbotic ri'k' ll'\Cx:intcd with
lipoprotein(a). Nature 339: 301- 303 (Su a/10
com~nt: Scon J 1989 fhromb<gt-nei lm~~d to
ath~rogenesis at /rut? Aaturt 341: 22-33)
Ross R 1999 Alheroscero,is-an inflamm:~tOI) dt-.ea.-.e
' Eogl J Med 340: I t5-126
Stein 0. Stein Y 2005 Lipid tron,fer protem' (LTPJ and
alhero~teroo,i:.. Athero,clerosis 178: 217-230
(Revi~wsfour lipid transfer proteuu-ACAT. CrfP.
LCAT and PLTP-and the tht'rapeutic fXIIt'ntwl of
modulating them)
Lipoprotein metabolism and dysllpid aemlas
Gervois P. Torra I P. Fruchart J C. Stuch B 2000
Regulation of li pid and lipoprotcut metabolism by
PPAR activator<>. Clin Chem Lab Med 38: 3 I I
(Review)
Stalins
Almog Y. Shefer A. :"o11ek V et al. 2004 Pnor Stalin
thcntpy " ..._'>Oeiated with a decrea.~ rote of seere
~P>i\. Circulauon 110: 8~85 (Statin thuap) "as
aJ!I<Kialetf with a ~duud rate ofsnert upsts and
111/ensrv~ cart umr admission-a role for stotins in th'
prrvenllon of sepns ?)
LaRo~a J C et at. for the Treating to New Targets (TNT)
ln,estigator.; 2005lntensive Upid Jo,..ering wilh
atorva>tntin in parienll> with stable coronary dio;ease. N
Fngl J Med 352: 1425-1435 (Intensive lif>ldIOI>erlllfl
therapy atorvostatin 80 mg doily in coronary hean
tlisease patie11ts prol'ided significam cli11ical benefit
beyo11tlthat afforded by 10 mg: this O<'curretl with 11
fl'elller incidence of elewJted aminotra/lsferase
leels)
329
 Haemostasis and
thrombosis

Platelet activation leads to the formation of a haemostatic plug,

Overview 331
Introduction 331
r---~-
Blood coagulation 332
-Coagulation cascade 332
-Vascular endothelium in haemostasis and
thrombosis 333
Drugs that act on the coagulation cascade
-Coagulation defects 334
-Thrombosis 335
Platelet adhesion and activation 339
-Antiplatelet drugs 340
Fibrinolysis (thrombolysis) 344
-Fibrinolytic drugs 344
-Antifibrinolytic and haemostatic drugs 345
OVERVIEW
This chapter summarises the main features of
blood coagulation, platelet function and
fibrinolysis. These processes underlie haemostasis
and thrombosis, and provide a basis for
understanding haemorrhagic disorders (e.g.
haemophilia) and thrombotic diseases both of
arteries (e.g. thrombotic stroke, myocardial
infarction) and of veins (e.g. deep vein thrombosis).
Drugs that act on the coagulation cascade, on
platelets and on fibrinolysis are considered.
Anticoagulants, antiplatelet drugs and fibrinolytic
drugs are especially important clinically because of
the prevalence of thrombotic disease, and are
emphasised for this reason.
INTRODUCTION
Haemostasis is the arrest of blood loss from damaged blood
vessels and is essential to life. A wound causes vasoconstriction,
accompanied by:
adhesion and activation of platelets
fibrin formation.
which stops the bleeding and is subsequently reinforced by fibrin.
The relative importance of each process depends on the type of
vessel (arterial, venous or capillary) that bas been injured.
Thrombosis is the pathological formation of a 'haemostatic'
plug within the vasculature in the absence of bleeding. Over a
century ago, Rudolph Virchow defined l.hree predisposing factors,
still known as Yirchow's triad. This comprises injury to the vessel
334 wall-for example when an atheromatous plaque ruptures or
becomes eroded: altered blood flow-for example in the left atrial
appendage of the hean during atrial fibrillation, or in the veins of
the legs while sitting cramped up on a long journey; and abnonnal
coagulabiliry of the blood-as occurs, for example, in the later
stages of pregnancy or during treatment with certain oral contra-
ceptives (see Ch. 30). Increased coagulability of the blood can be
inherited and is referred to as thrombophilia. A thrombus, which
forms in vivo, <;hould be distinguished from a clot, which forms
in static blood in vitro. Clots are amorphous. consisting of a diffuse
fibrin me hwork in which red and white blood cells are trapped
indiscriminately. By contrast. arterial and venous lhrombi each
have a distinct structure.
An arteria/thrombus (see Fig. 2l.l) is composed of so-called
white thrombus consisting mainly of platelets and Jeucocytes
in a fibrin mesh. It is usually associated with atherosclerosis. It
interrupt~ blood flow, causing ischaemia or death (infarction) of
the tissue beyond. Venous thrombus is composed of 'red thrombus'
and consists of a small white head and a large jelly-like red tail,
s imilar in composition to a blood clot, which streams away in
the now. Thrombus can break away, forming an embolus; this
may lodge in the lungs or. if it comes from the left heart or a
carotid artery, in the brain or other organs, causing death or other
disaster.
Drug therapy to promote haemostasis is rarely necessary, being
required only when thi~ essential process is defective (e.g. coagu-
lation factors in haemophilia or following excessive anticoagulant
therapy). or when it proves difficult to staunch haemorrhage fol-
lowing surgery or for menorrhagia (e.g. antifibrinolytic and haemo-
static drugs: see below). Drug therapy to treat or prevent thrombosis
or thromboembolism. by comparison, is extensively used because
such discase1. are common as well as serious. Drugs affect hae-
mostasis and thrombosis in three distinct ways, by affecting:
blood coagulation (fibrin formation)
platelet function
fibrin removal (fibrinolysis). 331
 SECTION 3 DRUGS AFFECTING MAJOR ORGAN SYSTEM S

Rupture of atherosclerotic
plaque in artery

[ )
Adhes1on, activation and In vivo pathway Contact
aggregation of platelets~ (tissue factor and pathway factors
factor VIla) (XII & XI)

1
Secretion of preform ed
mediators (e.g. ADP) and
synthesis of mediators
(e.g.TXA 2, PAF)
Thrombin +-- - - - - - _ _ , : : , - - II

1
Further aggregation
of platelets
- - - - - - ----(+}----:---:----:-- Fiboo~--_,;::!.__ _ _ _ _ _ __.,. Fibrin

PLATELET REACTIONS BLOOD COAGULATION

l
Fig. 21 .1 The main events in the formation of an arterial thrombus. Exposure of acidic phospholipids during platelet activation
provides a surface on which factors IXa and VIla interact with factor X; factor Xa then interacts with factor II, as illustrated in more
detail in Figure 21.4. Activation of factor XII also initiates the fibrinolytic pathway, which is shown in Figure 21.1 0. (A similar series of
events occurs when there is vascular damage, leading to haemostasls.) PAF, platelet-activating factor; TXA!, thromboxane ~

BLOOD COAGULATION this accelerating enzyme cascade has to be controlled by inhibl

------~-----~~-----~
COAGULATION CASCADE
Blood coagulation means the conversion of fluid blood to a solid
gel or clot. The main event is the conversion by thrombin of
soluble fibrinogen to insoluble ~trands of fibrin. the last step in a
complex entyme cascade. The components (called factors) arc
present in blood :l!. inactive precursors (zymogens) of proteolytic
enzymes and cofacto~. They are activated by proteolysis. the
active forms being designated by the suffix 'a. Factors XTTa, Xla,
Xa. TXa and thrombin (Tla) are all serine proteases. Activation of
a sm:lll amount of one f:~ctor catalyses the formation of larger
amounts of the next factor, which catalyses the formation of still
larger amounts of the next. and so on; consequently, the cascade
provides a mechanism of amplification. 1 As might be expected,
'Coagulation of 100 ml of blood requires 0.2 mg of factor VIII, 2 mg of
332 factor X. 15 mg of prothrombin and 250 mg of fibri nogen.
tors. becaw.e otherwise all the blood in the body would solidif}
within minutes of the initiation of haemostasis. One of the mo't
important inhibitors is amithrombin Ill, which neutralises all the
serine proteases in the ca~cade. Vascular endothelium also actilel)
limits thrombus extension (see below).
There are two main pathways of fibrin formation (Fig. ~1.21.
one traditionally tenned 'intrinsic' (because all the component\ are
present in the blood) and the other 'extrinsic' (because some com-
ponents come from outside the blood). The extrinsic path\\a) is
especially important in controUing blood coagulation and can
accurately be called the in vivo pathway. The intrinsic path\\11)
(better called the contact pathway) is activated when shed blood
comes into contact with an artificial surface such as glass.
T The in vivo (extrin;ic) pathway is initiated by 'tissue factor'. Th~> ''
the cellular receptor for factor V11, which. in the presence of Ca
undergoes an active site transition. This results in rapid autocatnl}lic
activmion of factor VII to Vlla. The tissue factor-V[[a complex activate\
factors IX nnd X. Acidic phospholipids function as surface caml,1>11.

Haemostaala and thromboala
Haemostasis is the arrest of blood loss from
damaged vessels and is essential to survival. The
main phenomena are:
- platelet adheston and activation
- blood coagulation (fibrin formation).
ThromboSIS is a pathologtcal condition resulting from
inappropriate activation of haemostatic mechanisms:
venous thrombosis is usually associated with
stasis of blood; a venous thrombus has a small
platelet component and a large component of
fibrin
arterial thrombosis is usually associat ed with
atherosclerosis, and the thrombus has a large
platelet component.
A portion of a thrombus may break away, travel as an
embolus and lodge downstream, causing ischaemia
and infarction.
They are pro~ 1dcd during plmclet activation. which exposes acidic
pho~phohp1d\ (e\pecmlly pho~phaUd) I<>Crinc ), and these activate various
clottmg factor<.. clo\CI) JU'tafl(l\lllg them in functional complexe\.
Platelet' aho contribute by 'ecreting coagulation factors. including factor
Va and fibrinogen . Coagulauon is sustained by further generation of
factor Xa by !Xa Vllla....Ca 2- phospholipid complex. This is needed
becau~e the ti~MlC factor- VIIa complex i~ rapidly inactivated in pl~ma
by tb~ue factOr pathway inhibitor and by untithrombin m. Factor Xa, in
the pre,ence of Ca 2 , pho,pholipid and factor Va. activates prothrombin
to thrombin. the main cntymc of the cascade. The contact (intrinsic)
pathway comme nces when factor XII (Hageman factor) adheres to a
negatively churgctl ~urface and converges with the in vivo pathway at the
stage of factor X activntion (see Fig. 2 1.2). The proximal part of this
pal11way i ~ not crucial for blood coagulation in vivo. The two pathways
arc not entirely ~cparate even before they converge. and various positive
feedbacks promote coagulation.
The role of thrombin
Thrombin (factor lfa) cleaves fibrinogen, producing fragments
that polymeri~>e to form fibrin. It also activates factor xm.
a fibri -
ooligase. which ~trengthcnc, fibrin-to-fibrin links, thereby stabilising
the coagulum. In addition to coagulation, thrombin also causes
platelet aggregation, stimulates cell proliferation and modulates
smooth muscle contraction. Paradoxically, it can inhibit as well
as promote coagulation (see below). Effects of thrombin on platelets
and smooth muscle are initialed by interaction with specific
protease-activated receptors (PARs), which belong to the super-
family of G-protein-<:oupled receptors. PARs initiate cellular
responses that contribute not only to hacmostasis and thrombosis,
but abo to innammation and perhaps angiogenesis. The signal
transduction mechanism is unusual: receptor activation requires
proteolysis by thrombin of the extracellular N-terminal domain
of the receptor, revealing a new N-terminal sequence that acts as
a 'tethered agonist' (sec ri g. 3.7. p. 35).
HAEMOSTASIS AND THROMBOSIS
VASCULAR ENDOTHELIUM IN
HAEMOSTASIS AND THROMBOSIS
Vascular endothelium. the container of the circulating blood. can
change from a non-thrombogenic to a thrombogenic structure in
rcspon!tc to different demands. Normally, i t provides a non-
thrombogenic <;urfacc by vinuc of surface heparan sulfate, a
glycosaminoglycan related to heparin, which is, like heparin, a
cofactor for antithrombin ill. Endothelium thus plays an essential
role in preventing intravascular platelet activation and coagulation.
However, it also plays an active pan in haemostasis, synthesising
and storing 1>everal l..ey haemostatic components; von Willebrand
factOr, 2 tissue factor and plasminogen activator inhibitor (PAl)- I
are particularly important. PA 1- 1 is secreted in response to
angiotensin IV, receptors for which are present on endothelial
cells, providing a link between the renin-angiotensin system (see
Ch. 19) and thrombosis. These prothromboticfaczors are invol ved,
Blood coagulation (fibrin formation)
The clotting system consists of a cascade of
proteolytic enzymes and cofactors.
Inactive precursors are activated in series, each
gtving nse to more of the next.
The last enzyme, thrombin, derived from prothrombin
(II}, converts soluble fibrinogen (I) to an insoluble
meshwork of fibrin in which blood cells are trapped,
forming the clot.
There are two pathways in the cascade:
the extrinsic pathway, which operates in vivo
- the intrinsic or contact pathway, which operates in
vitro.
Both pathways result in activation of factor X, which
then converts prothrombin to thrombin.
Calcium ions and a negatively charged phospholipid
(PL) are essential for three steps, namely the actions of:
factor IXa on X
- factor VIla on X
- factor Xa on II.
PL is provided by activated platelets adhering to the
damaged vessel.
Some factors promote coagulation by binding to PL
and a senne protease factor; for example, factor Va
in the activation of II by Xa, or VIlla in the activation of
X by IXa.
Blood coagulation is controlled by:
enzyme inhibitors (e.g. antithrombin Ill}
- fibrinolysis.
2Von Willebrand factor is a glycoprotein that is missing in a hereditary
haemorrhagic di~order called von Willebrand's disease. It is synthesi!>ed by
vascular cndothcliul cel l ~ (the presence of immunoreactive von Wi llebrand
factor is an ide ntifying featu re or these cells in culture) and is also present
in platelet.
333
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

Extrinsic pathway Intrinsic pathway

Tissue damage

Tissue factor
VIla
PL
Ca2 +

Platelets

Fig. 2 1.2 The coagulation

cascade: sites of action of
anticoagulant drugs. Oral ~~ ~)
Ca2+ XIII
anticoagulants interfere with post-
translational y-carbOxylation of
factors II, VII, IX and X (shown in II (Prothrombin)----L-- lito (ThomWo)- - "''
blue boxes); see Figure 21.4.

l
Heparins activate antithrombin Ill.
ATIII, antithrombin Ill; LMWHs, low-
molecular-weight heparins; PL,
negatively charged phospholipid
supplied by activated platelets. Ab"oogeo FiMo Isoow"'"' '""'

respectively, in platelet adhesion and in coagulation and clot stabil-

isation. However, the endothelium is also implicated in thrombus
limitation. Thus it generates prostaglandin (PC) 12 (prostacyclin;
Ch. 13) and nitric oxide (NO; Ch. 17); converts the platelet
agonist ADP to adenosine, which inhibits platelet function
(Ch. 12); synthesises tissue plasminoge11 activator (IPA; see below);
and expresses thrombomodulin, a receptor for thrombin. After
combination with thrombomodulin, thrombin activates protein C,
a vitamin K-dependent anticoagulant. Activated protein C, helped
by its cofactor protein S, inactivates factors Va and Vlla. This is
known to be physiologically important, because a naturally occur-
ring mutation of the gene coding for factor V (factor V Lei den),
which confers resistance to activated protein C, resuJts in the
commonest recogni!>ed form of inherited thrombophilia. A synthetic
form of activated protein C. drotrecogin aJpha (activated), is
licensed for the treatment of severe septic shock with multiple
organ failure (Ch. 19).
Endotoxin and cytokines, including tumour necrosis factor. tilt
the balance of prolhrombotic and anti thrombotic endothelial func-
tions towards thrombosi& by causing loss of heparan and expression
of tissue factor, and impair endothelial NO function. If other mech-
anisms limiting coagulation are also faulty or become exhausted,
disseminated intravascular coagulation can result. This is a
serious complication of sepsis and of certain malignancies, and
334 the main treatment is to correct the underlying disease.
DRUGS THAT ACT ON THE
COAGULATION CASCADE
Drugs are used to modify the cascade either when there is a
defect in coagulation or when there is unwanted coagulation.
COAGULATION DEFECTS
Genetically determined deficiencies of clotting factors arc rare.
Examples are classic haemophilia, caused by lack of factor VIII.
and an even rarer form ofhaemophilia (haemophilia B orChri,t
rna!> disease) caused by lack of factor IX (also called Christma.,
factor). Missing factors can be supplied by giving fresh pl:!!>ma
or concentrated preparations of factor VUJ or factor IX. In
the past, these have transmitted viral infections including HI\
and hepatiti B and C (Ch. 47). Pure forms of several human
factors arc now available. synthesised by recombinant technolog).
but are difficult to manufacture because of the need for
posHran!>lational modification in mammalian cells, and they are
expensive.
Acquired clotting defects are more common than heredital'}
ones. These include liver disease, vitamin K deficiency (universal
in neonates) and excessive oral anticoagulant therapy, each of
which may require treatment with vitamin K.
 HAEMOSTASIS AND THROMBOSIS

VITAMIN K
Vitamin K (for Koagulation in German) is a fat-soluble vitamin 0
occurring naturally in plants (Fig. 2 1.3). It is essential for the
formation of clotting factors 11, V U, lX and X. These are all
glycoprotein~ with several -rcarboxygltlfamic acid (Gia) residues. y- Vitamin K
(natural vitamin)
Carboxylation occur. after the synthesi s of the chain, and the
carboxylase enzyme requires vi tamin K as a cofactor. The role of
the vitamin ic; clarified by considering the interaction of factors X a
and prothrombin (factor II) with Ca2+ and phospholipid. as
0
shown in Figure 2 1.4. Binding does not occur i n the absence of
y-carboxylation. The reduced form of vitamin K is an essential
cofactor in the car boxylation of glutamate residues (Fig. 2 1.5).
Similar considerations apply to the proteolytic activation of factor ONa
X by TXa and by V Ila (sec Fig. 2 1.2).
There are several other vitamin K-dependent Gla proteins,
including proteins C and S (see above) and osteocalcin in bone.
The effect of Lhe vitamin on osteoporosis is under investigation.

Administration and pharmacokinetic aspects Warfarin

(vitamin K antagonist)
Natural vitamin K (phytomenadione) may be given orally or by
injection. l f given by mouth, it requires bile salts for absorption,
and this occurs by a saturable energy-requiring process in the Fig . 21 .3 Vitamin K and warfarin. Warfarin, a vitamin K
antagonist, is an oral anticoagulant. It competes with vitamin K
proximal small intestine. A synthetic preparation, menadiol
(note the similarity 1n their structures) for the reductase enzyme
sodium phosphate, is also available. I t is water-soluble and does that activates vitamin K (see Fig. 21.5).
not require bile salts for its absorption. This synthetic compound \......
takes longer to act than phytomeoadione. There is very little storage
of vitamin K in the body. It is metabolised to more polar substances
that are excreted in the urine and the bile.
injectable anticoagulants (heparin and newer thrombi n
inhibitors)
Clinical uses
oral anticoagulants (warf arin and rel ated compounds).
Clinical uses of vitamin K are summ arised in the clinical box.
Heparins act immediately, whereas oral anticoagulants take
several days to exert their effect. Consequently, patients with
THROMBOSIS
venous thrombosis are treated immediately with an injectable
Thrombotic and thromboembolic disease is common and has severe anticoagulant , which is continued until the effect of warfarin has
consequences, including myocardial infarction, stroke, deep vein become established.
thrombosis and pulmonary embolus. The main drugs used for
platelet-rich ' white' thrombi are the <Ultiplatelet drugs (notably
aspirin ) and fi brinolytic drugs, which arc considered below. The
main drugs used to prevent or treat 'red' thrombus are: Clinic al use of ant icoagulants

Heparin (often as low- m olecu lar-weight

Clinical use of vitamin K
Treatment and/ or prevention of bleeding:
from excessive oral anticoagulation (e.g. by
warfa rin)
in babies: to prevent haemorrhagic disease of the
newborn.
For vitamin K deficiencies in adults:
sprue, coeliac disease, steatorrhoea
- lack of bile (e.g. with obstructive jaundice).
hep arin) is used acutely. Wa rfarin is used for
prolonged therapy. Anticoagulants are used to
prevent:
- deep vem thrombosis (e.g. perioperatively)
extension of established deep vein thrombosis
pulmonary embolus
thrombosis and embolisation in patients with atrial
fibrillation (Ch.18)
thrombosis on prosthetic heart valves
clotting in extracorporeal circulations (e.g. during
haemodialysis)
myocardial infarction in patients with unstable
angina.
335
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

INJECTABLE ANTICOAGULANTS
0 2 + C02 + Glutamic acid y-Carboxyglutamic acid
res1dues
Heparin (including low-molecular-weight
heparins) r (in II, VII, IX, X)
residues
(in II, VII, IX, X)

Heparin wac; discovered in 1916 by a second-year medical

student at Johns Hopl..in'> Hospital. He was attempting to extract
thromboplastic (i.e. coagulant) substances from various tissues
during a vacation project, but found instead a powerful anticoa-
gulant activity. 1 This wac, named heparin, because it was first
Vitamin K reduced form Vitamin K oxidised form
extracted from Iiver. (hydroquinone) (epoxide)

Vitamin ~
l leparin is not a single substance but a family of sulfated glyco-
saminoglycans (mucopolysaccharides). It is present together with
/ vitamin K
hi~taminc in the granules of mast cells. Commercial preparations ~eductas~ Vi t~minK \. reductase 1
are extracted from beef lung or hog intestine and, because prep- (qu1none) ('----"""
arations differ in potency, assayed biologically against an agreed

lr ~ ~
Fig. 21.5 M echanism of vitamin K and of warfarin. Alter
the peptide chains in clotting factors II, VII, IX and X have
been synthesised, reduced vitamin K (the hydroquinone) acts
(/) as a cofactor in the conversion of glutamic acid (Giu) to y-
II I
(/)
Xa carboxyglutamic acid (Gia). During this reaction, the reduced
form of vitamin K is converted to the epoxide, which in turn is
reduced to the quinone and then the hydroquinone.

international !>tandard: doses are specified in units of activity rather

lWJlli llUllU
I I I I I I
than of mass.
Heparin fragments (e.g. enoxaparin, dalteparin) or a synthetic
Ca2+ 'ca2 11 pcntasaccharide (fondaparinux), referred to as low-molecular-
I I I I I
I I I I I I I I I I
...!..!..!...!.!~-!.------ - - 1!... -- ~ '- '-'-'----- weight heparins (LMWHs), are used increasingly in place ol
unfractionated heparin.

Mechanism
Acidic phospholipid Heparin inhibits coagulaUon, both in vivo and in vitro, by activating
antithrombin Ill (see above). Antithrom bin ill in hi bits th rombin
* and other serine proteases by binding to the active serine ~ile.
Enzymic sites
l y-Carboxyglutamic
acid residues Heparin modifies this interaction by binding, via a unique pcntasac
charide sequence, to antithrombin m, changing its conformation
Activation _.r- Site of cleavage of
and accelerating its rate of action.
peptides II byXa
Thrombin is con~iderably more sensitive to the inhibitory effe~t
of the heparin antithrombin Ill complex than is factor X. To
Fig. 21.4 Activation of prothro mbin (factor II) by factor
Xa. The complex of factor Va with a negatively charged
inhibit thrombin, it is necessary for heparin to bind to the enz)me
phospholipid surface (supplied by aggregating platelets) forms as well a, to antithrombin Jll; to inhibit factor X, it is nece>'JJ)
a binding s1te for factor Xa and prothrombin (II), which have only for heparin to bind to antithrombin ill (Fig. 21.6). Anti
peptide chains (shown schematically) that are similar to one thrombin Il l deficiency is very rare but can cause thrombophilia
another. Platelets thus serve as a locahsing focus. Calcium ions and resistance to heparin therapy.
are essent1al for binding. Xa activates prothrombin, liberating
thrombin (shown in grey). (Modified from Jackson C M 1978 Br
The LMWHs increase the action of antithrombin Ill on fador
J Haematol 39: 1.) Xa but not it!> action on thrombin, because the molecules are too
small to bind to both enzyme and inhibitor, essential for inhibition
of thrombin but not for that of factor Xa (Fig. 21.6).

Yrhis kind of good fonunc aho favoured Vane and his colleague~ in their
di~covcry of PG1 2 (Ch~ 13 and 19), where they were looking for one kind of
biological activity and found another. More specific chemical assays (Ch. 6),
336 for all their Mreng1hs, cannot throw up this kind of unexpec1ed discovery.
Administration and pharmacokinetic aspects
Heparin is not absorbed from the gut because of its charge and
large size, and it is therefore g iven intravenously or suhcuta
neously (i ntramuscular injections would cause haematomas).

I

Heparin
Heparin
Fig. 21.6 Action of heparins. The schematic shows
interactions of heparins, antithrombin Ill (AT Ill) and clotting
factors. To increase the inactivation of thrombin (lla) by AT Ill,
heparin needs to interact with both substances (top), but to
speed up its effect on factor Xa it need only interact with AT
Ill (middle). Low-molecular-weight heparins (LMW Hep)
increase the action of AT Ill on factor Xa (bottom), but cannot
increase the action of AT Ill on thrombin because they cannot
bind both simultaneously. (Modified from Hirsh J , Levine M
1992 Blood 79: 1-17.)
T Arter intra,enou\ lnJCCtion of a bolu5 dose. there is a phase of rapid
elimination followed by a more gradual disappearance owing both to
\aturable proce~~c' (involving binding to s ites on endothelial cells and
macrophage\) and ~lower tir~t-order processes including renal excretion.
A~ a resu lt , once the do\e exceed' the ~aturating concentration. a gr.:ater
proportion b dealt with by thc;e s lower processes. and the apparent half-
life incrca~cs with incre:J;ing dose (sutumtion kinetics: see Ch. 8).
Heparin acts immediately following intravenous administration,
but the onset is delayed by up to 60 minutes when it is given
subcutaneou:.ly. The elimination half-life is approximately
40-90 minutes . In urgent situations, it is therefore usual to start
treatment with a bolus intravenous dose, followed by a constant-
rate infusion. The activated partial thromboplastin time (APTT),
or some other in vitro clotting test. is measured and the dose of
unfractionated heparin adjusted to achieve a value within a target
range (e.g. 1.5- 2.5 time!. control ).
Low-molecular-weight heparins are given subcutaneously.
They have a longer elimination half- life than unfractionated
heparin, and this is independent of dose (first-order kinetics), so
the effects are more predictable and dosing less frequent (once or
twice a day). LMWll!. do not prolong the A PTT; unlike unfrnc-
tionated heparin, the effect of a standard dose is sufficiently predict-
able that monitoring i~ not required routinely. They are eliminated
mainly by renal excretion, and unfractionated heparin is preferred
in renal failure. In general, they are at least as safe and effective
as unfractionated heparin and are more convenient to use, because
patients can be taught to inject themselves at home and there is
generall y no need for blood tests and dose adjustment.
HAEMOSTASIS AND THROMBOSIS
Unwanted effects
Haemorrhage. The main hazard is haemorrhage, which is
treated by stopping therapy and, if necessary, giving protamin e
sulfate. This heparin antagonist is a strongly basic protein that
forms an inactive complex with heparin; it is given intravenou~ly.
The dose i~ estimated from the dose of heparin that has been
admini'>tered recently. and it is important not to give too much, as
this can itself cau~e bleeding. ff necessary. an in vitro neutralisation
test is performed on a sample of blood from the patient to provide
a more preci'>e indication of the required dose.
Thrombosis. Thi~ is an uncommon but serious adverse effect
of heparin and. a!> with warfarin necrosis (see below), may be
misattributed to the natural history of the disease for which heparin
is being administered. Paradoxically, it is associated with heparin-
induced 1hromhocytopenia (/i/7). A transitory early decrease in
platelet numbers is not uncommon, and is not clinically important.
More serious thrombocytopenia occurring 2-14 days after the stan
or th erapy is uncommon and is caused by lgM or JgG antibodies
against complexes of heparin and platelet factor 4. Circulating
immune complexes bind to Fe receptors (see Ch. 13) on circulating
platelet<.. thereby activating them and releasing more platelet factor
4 and causing thrombocytopenia. Antibody also binds to platelet
factor 4 complexed with glycosarninoglycans on the surface of
endothelial cells, leading to immune injury of the vessel wall.
thrombosis and dis::.eminated intravascular coagulation. LMWHs
are less liable than standard heparin to activate platelets to release
platelet factor 4, and they bind le::.s a' idly to platelet factor 4. Con-
sequently, LMWHs arc less likely than uofrnctionated heparin to
cause thrombocytopenia and thrombosis. If antibodies to
heparin- platelet factor 4 complexes have formed, however, it is
to be expected that LMWHs could trigger these immunologically
mediated adverse effects. Management of patients with thrombo-
embolic disease who develop HIT is therefore usually with either
d a naparoid or with a direct thrombin inhibitor (see below).
Danaparoid is a low-molecular-weight heparinoid consisting of
a mixture of heparan, dermatan and chondroitin sulfates, with well-
established antithro mbotic activity.
Osteoporosis with spontaneous fractures has been reported
with long-term (6 months or more) treatment with heparin
(usually during pregnancy, when warfarin is contraindicated or
problematic-~ee below). Its explanation is unknown.
Hypoaldosterouism (with consequent hyperkalaemia) has
been described.
Hypersensitivity reactions are rare with heparin but more
common with protamine. (Protamine sensitivity al o occurs in
patient., treated with protamine zinc insulin: seep. 404. Protamine is
extracted from fish roe. and sensitivity to protamine occurs in
some people with fish allergy.)
ANTITHROMBIN Ill-INDEPENDENT
ANTICOAGULANTS
Hirudin!> arc direct thrombin inhibitors derived from the anticoagu-
lant present in 1.aliva from the medicinal leech. Hirudin itself has
been synthesised by recombinant DNA techniques, but clinical
trials, including Global Use of Strategies to Open Occluded
Coronary Arteries (GUST0)-2 and Thrombolysis in Myocardial
337
 SECTION 3 DRUGS AFFECTING MAJOR ORGAN SYSTEMS
Infarction (TIMI)-9, have been somewhat disappointing.
Lepirudin is a related polypeptide that binds irreversibly both to
the fibrin-binding and catalytic sites on thrombin. Argatroban is
a synthetic low-molecular-weight inhibitor that binds irreversibly
to the catalytic site alone. Each of these agents is effective for
preventing and treating thrombosis in HIT. Lepirudin can itself
provoke antibody synthesis. Melagatran is a related inhibitor that
can be administered subcutaneously. A prodrug form of melagatran,
ximelaga tra n, is an orally active direct thrombin inhibitor. It can
be administered in a standard dose twice daily. In large clinical
trials, it has proved to be similarly effective as warfarin in pre-
venting stroke in patients with atrial fibrillation, and it may well
be safer than warfarin. Disappointingly, it caused abnormal liver
function in around 6% of patients, and its licensing has been
delayed in consequence. Bivalirudin, another hirudin analogue,
is used by cardiologists in selected patients undergoing percu-
taneous coronary interventions.
'Y Various other approaches are being explored. These include several
naturally occurring anticoagulants (tissue factor pathway inhibitor,
thrombomodulin and protein C) synthe~ised by recombinant technology.
A particularly ingenious approach is the development of thrombin
agoni \t'> that are ~elective for the anticoagulant properties of thrombin.
One '>UCh modified thrombin, differing by a single amino acid
subsmution, has ~ubstrate specificity for protein C. It produce\
anticoagulation in monkeys without prolonging bleeding times,
sugge\ling that 11 may be less likely than standard anticoagulants to cause
bleeding (Gibbs. 1995; Pineda et al2004).
VITAMIN K ANTAGONISTS: WARFARIN
'Y Oral anticoagulant~ were discovered as an indirect result of a change
in agricultural policy in North America in the 1920s. Sweet clover was
substituted for corn in cattle feed. and an epidemic of deaths of cattle
from haemorrhage ensued. This turned out to be caused by
bishydrorycoumarin in spoiled sweet clover, and it led to the discovery of
wa rfarin (named for the .Wisconsin Alumni Research foundation). One
of the first uses to which this was put was as a rat poison. but for the past
50 years it has been the standard anticoagu lant for the treatmen t and
prevention of thromboembolic disease.
Warfarin (Fig. 21.3) is the most important oral anticoagulant;
alternatives with a simi lar mechanism of action, for example
phenindione, arc now used only in rare patients who experience
idiosyncratic adverse reactions to warfarin. Warfarin and other
vitamin K antagonists require frequent blood tests to iodividu-
ali!.e dose, and arc consequently inconvenient as well as having
a low margin of safety; hopes that the oral direct thrombin
inhibitor ximelagatran (see above) would replace warfarin for
some at Jeac;t of it!. many indications have been put on hold ac; a
result of hepatotoxicity.
Mechanism of action
Vitamin K antagonists act only in vivo and have no effect on
clotting if added to blood in vitro. They interfere with the post-
translational y-carboxylation of glutamic acid residues in clotting
factors II, VIT, IX and X. They do this by inhibiting enzymic
reduction of vitamin K to its active bydroquinonc form
(Fig. 2 1.5). Inhibition is competitive (reflecting the structural
similarity between warfarin and vitamin K, Fig. 21 .3). Their effect
338 takes several days to develop because of the time taken for
degradation of preformed carboxylated clotting factors. Their
onset of action thus depends on the elimination half-live~ of
the relevant factors. Factor vn, with a half-life of 6 hour,, i'
affected first, then IX. X and II, with half-lives of 24, 40 and
60 hours, respectively.
Administration and pharmacokinetic aspects
Warfarin is absorbed rapidly and completely from the gut after
oral administration. It has a small distribution volume, being
strongly bound to plasma albumin (see Ch. 7). The peak concen-
tration in the blood occurs within an hour of ingestion, but
because of the mechanism of action this does not coincide with the
peak pharmacological effect, which occurs about 48 hours later.
The effect on prothrombin time (PT. see below) of a single dose
starts after approximately 12-16 hours and lasts 4-5 days.
Warfarin is metabolised by the hepatic mixed function oxidase
P450 system, and its half-life is very variable, being of the order
of 40 hours in many individuals.
Warfarin crosses the placenta and is not given in the fir\t
months of pregnancy because it is teratogenic, nor in the later
stages because it can cause intracranial haemorrhage in the baby
during delivery. It appears in milk during lactation. This could
theoretically be important because newborn infants are natural!)
deficient in vitamin K. However, infants are routinely prescribed
vitamin K to prevent baemorrhagic disease (see above), so warfarin
treatment of the mother does not generally pose a risk to the
breal>t-fed infant.
The therapeutic use of warfarin requires a careful balance bet
ween giving too little, leaving unwanted coagulation unchecked. and
giving too much, thereby causing haemorrhage. Therapy is com
plicated not only because the effect of each dose is maximal some
2 days after its administration, but also because numerous medical
and environmental conditions modify sensitivity to warfarin,
including interactions with other drugs (see Ch. 52). The effect of
warfarin is monitored by measuring PT, which is expressed as an
international normalised ratio (INR).
'Y The PT is the time taken for clotting of citrated plasma after the
add ition of Ca1 and ~tandardised reference thromboplastin; it 11
expressed us the ratio (PT ratio) of the PT of the patient to the PT of a
pool of pl a~ma from healthy subjects on no medication. Because of the
variability of thromboplaslins, different results are obtained in different
laborntorie~. To Mandardise PT measurements internationally. each
thrombopla;tin is ~~igned an international sensitivity index (lSI), and the
patient's PTi~expre'>'>ed as an INR. where INR = (PTratio)151 Thisklnd
of nonnalisation procedure shocks puris~ but provide~ ~imilar !'e'Uits
when a pattent mo"e' from. say. Birmingham to Baltimore, pennitun~
warfarin dose adju~tment independent of laboratory. Pra~matc
haematologtsts argue that the proof of the pudding is in the eating'
The do e of warfarin is usually adjusted to give an INR of 2-4.
the precise target depending on the clinical situation. The
duration of treatment also varies, but for several indication~
(e.g. to prevent thromboembolism in chronic atrial fibrillauon)
treatment is long term.
Factors that potentiate oral anticoagulants
Various diseases and drugs potentiate warfarin, increasing the
risk of haemorrhage.

Disease
Liver disease interfere~ with the synthesis of clotting factors;
condition. in which there is a high metabolic rate, such as fever
and thyrotoxicosi,, increase the effect of anticoagulants by
increasing degradation of clotting factors.
Drugs (see also Chs 8 and 52)
Many drug'> potentiate warfarin.
Agents that inhibit hepatic drug metabolism. Exan1ples
include cimetidine. imip ra m ine. co-trimoxazole. chJoramphe-
nicol. cipronoxacin. m etro nidazole. amiodar one and many
antifungal azote.,. Stereoselective effects (warfarin is a racemate.
and its isomers arc metabolised differently from one another) are
described in Chapter 52.
Drugs that inhibit platelet f unction. Aspirin increases the
risk of bleeding if give n during warfarin therapy, although this
combinatio n can be used safely with careful mon itoring (e.g.
Turpic, 1993). Other non-steroidal anti-inflammatory drugs
(NSAIDs) also increase the risk of bleeding, partly by their effect
on platelet thromboxanc synthesis (Ch. 14) and. in the case of
~orne NSAIDs. also by inhibiting warfarin metabolism as above.
Some antibiotic.,, includi11g moxalactam and carbenicillin, inhibit
platelet function.
Drugs that displace warfarin from binding sites on plasma
albumin. Some of the SAID!. and chloral hydra te, for example,
result in a tran,ient increa\e in the concenlration of free warfarin
in plasma. Thi., mechani'>m '>eldom causes clinically imponant
effects. unle!ts accompanied in addition by inhibition of warfarin
metabolism. a' with phen) lbutazone (Ch. 52).
Drugs that inhibit reduction of vitamin K. Such dmgs
include the cephalosporins.
Drugs that decrease the availability of vitamin K. Broad-
spectrum antibiotics and some wlfonamides (see Ch. 46) depress
the intestinal nora that normally synthesise vitamin K2 (a form
of vitamin K made by gut bacteria); this bas little effect unless
there is concurrent dietary deficiency.
Factors that lessen the effe ct of oral
anticoagulants
Physiological state/disease
There is a decrea~ed rel.ponse to warfarin in conditions (e.g.
preRJWncy) where there is increa ed coagulation factor synthesis.
Similarly. the effect of oral anticoagulants is lessened in
hypothyroidism, which ill associated with reduced degradation of
coagulmion factors.
Drugs (see also Chs 8 and 52)
Several drug'> reduce the effectiveness of warfarin; this leads to
increased doses being used to achieve the target INR. If the dose
of warfarin is not reduced when the interacting drug is discon-
tinued. this can result in over-anticoagulation and haemo rrhage.
Vitamin K. This vitamin is a component of some parenteral
feeds and vitamin preparations.
Drugs that induce hepatic P450 enzymes. Enzyme induction
(e.g. by rifa mpicin, carbamazepine, barbiturates, griseofulvin)
increase!> the rate of degradation of warfarin. Induction may wane
HAEMOSTASIS AND THROMBOS IS
only s lowly after the inducing drug is discontinued, making it
difficult to adjust the dose appropriately.
Drugs that reduce absorption. Drugs that bind warfarin in the
gut, for example colestyramine, reduce its absorption.
Unwanted effects
Haemorrhage (c'>pecially into the bowel or the brain) is the main
hau:trd. Depending on the urgency of the situation, treatment may
con'>i\1 of withholding warfarin (for minor problems). adminis-
tration of vitamin K. or fresh plasma or coagulation factor con-
centrates (for life-threatening bleeding). OraJ anticoagulants arc
teratogenic. Hepatotoxicity occurs but is uncommon. Necrosis of
soft tissues (e.g. breast or buttock) owing to thrombosis in venules
occurs shonly after staning treatment and is attributed to inhibition
of biosynthesis of protein C. which has a sboner elimination half-
life than do the vitamin K-dependent coagu lation factors; this
results in a procoagulant state soon after starting lreatment. This is
a rare but serious adverse effect Treatment with bepari11 is usually
staned before warfarin, avoiding this problem except in individ ual!.
experiencing lilT as an adverse effect of heparin (see above).
Clinical use
The clinical use of anticoagulants is summarised in the box on
page 335.
PLATELET ADHESION AND ACTIVATION
Platelets maintain the integrity of the circulation: a low platelet
count result'> in thrombocytopenic purpura. 4
When plateletl> are activated, they undergo a sequence of reac-
tion!. that are esl.ential for haemostasis, important for the healing
of damaged blood vessels, and play a pan in inflarnmation (see
Ch. 13). The~e reactions. several of which are redundant (in the
sense that if o ne pathway of activation is blocked another is
available) and several autocatalytic, include:
adhesion fol lowing vascular damage (via von Wille brand
facto r bridging between subendothelial macromolecules and
glycoprotein (GP) lb receptors on the platelet s urface)5
shape change (from smooth discs to spiny spheres with
protruding p~eudopodia)
secretion of the gran ule contents (including platelet agonists,
such as ADP and 5-hydroxytryptamine, and coagulation factors
and growth factors, such as platelet-derived growth factor)
biosynthesis of labile mediators such as platelet-activating
factor and thromboxane (TX) A 2 (see Fig. 21.7)
agRregation, which i~ promoted by various agonists,
including collagen, thrombin, ADP, 5-hydroxytryptamine and
TXA 2 acting on specific receptors on the platelet surface:
activation by agonists leads to expression of GPIIb/Illa
Purpura mean' tl purple rash cau~ed by multiple spontaneous bleeding
poims in the skin. When thh b cau!>ed by reduced circulating plateletS,
bleeding can occur imo other organ~. including the gut and brain.
'Various platelet membrane glycoproteins are receptors or binding sites for
adhesive protein> Mach a.~ von Willebrand factor or fibrinogen. 339
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
Drugs affecting blood coagulation
Procoagulant drugs: vitamin K
Reduced vitamin K is a cofactor in the post-
translational y-carboxylation of glutamic acid (Giu)
residues in each of factors II, VII, IX and X. The
y-carboxylated glutamic acid (Gla) residues are
essential for the interaction of these factors with Ca2
and negatively charged phospholipid.
Injectable anticoagulants (e.g. heparin, low-
molecular-weight heparins)
Potentiate antithrombin Ill, a natural inhibitor that
inactivates Xa and thrombin.
Act both In vivo and in vitro.
Anticoagulant activity results from a unique
pentasaccharide sequence with high affinity for
antithrombin Il l.
Heparin therapy is monitored via activated partial
thromboplastin time, and dose individualised.
Low-molecular-weight heparins have the same effect
on factor X as heparin but less effect on thrombin;
therapeutic efficacy is similar to heparin but monitoring
and dose individualisation are not needed. Patients
can administer them subcutaneously at home.
Oral anticoagulants (e.g. warfarin)
lnhibtt the reduction of vitamin K, thus inhibiting the
y-carboxylation of Glu in II, VII, IX and X.
Act only in vivo, and their effect is delayed until
preformed clotting factors are depleted.
Many factors modify their action; drug interactions
are especially important.
There is wide variation in response; their effect is
monitored by measuring the international normalised
ratio (INA) and the dose individualised accordingly.
,/
receptors that bind fibrinogen, and this links adjacent
platelets, sticking them together (aggregation)
expo.mre of acidic phospholipid on the platelet surface,
promoting thrombin formation (and hence further platelet
activation via thrombin receptors and fibrin formation via
cleavage of fibrinogen; see above).
These processes are e '>ential for haemostasis but may be inappro-
priately triggered if the artery wall is diseased. most commonly
with atherosclerosis, resulting in thrombosis (Fig. 2 1.7).
ANTIPLATELET DRUGS
Platelets play ~uch a critical role in thromboembolic disease that
it is no surprise that antiplatelet drugs are of great therapeutic
value. Clinical triab of aspirin radically altered clinical practice,
and more recently drugs that inhibit ADP and GPTTb/IITa have also
been found to be therapeutical ly useful. Sites of action of antiplatelet
340 drugs arc shown in Figure 2 1.7.
Platelet function
Healthy vascular endothelium prevents
platelet adhesion.
Platelets adhere to diseased or damaged areas and
become activated, i.e. they change shape, expostng
negatively charged phospholipids and glycoprotein
(GP) lib/lila receptors, and synthesise and/or release
various mediators, for example thromboxane A2 and
ADP. which activate other platelets, causing
aggregation.
Aggregation entails fibrinogen binding to GPIIb/llla
receptors on adjacent platelets.
Activated platelets constitute a focus for fibrin
formation.
Chemotactic factors and growth factors necessary for
repair, but also implicated in atherogenesis, are
released during platelet activation.
Antlplatelet drugs
Aspirin inhibits cycle-oxygenase irreversibly.
The balance between prostaglandin (PG) 12 (an
inhibitor of aggregation generated by vascular
endothelium) and thromboxane (a stimulant of
aggregation generated by platelets) is thus altered,
because the endothelium can synthesise more
enzyme but platelets cannot. Aspirin is very
important clinically.
Clopidogrel is a prodrug. Given by mouth, it inhibits
platelet responses to ADP. Its actions are additive
with aspirin.
Antagonists of GPIIb/ llla receptors include a
monoclonal antibody (abciximab) and several
oligopeptides (e.g. tirofiban). They inhibit diverse
agonists, for example ADP and thromboxane (TX) A2,
because different pathways of activation converge on
GPIIb/llla receptors. They are used intravenously for
short-term treatment.
Dipyridamole is a phosphodiesterase inhibitor. It is
used in addition to aspirin.
Epoprostenol (synthetic PG12l is chemically unstable.
Given as an intravenous infusion, it acts on I
Prostanoid (IP) phosphate receptors on vascular
smooth muscle and platelets (Ch. 15}, stimulating
adenylate cyclase and thereby causing vasodilatation
and inhibiting aggregation caused by any pathway
(e.g. ADP and ~).
Agents that inhibit T~ synthesis or block TXA2
receptors, or have both actions, are available but are
not used clinically.
 HAEMOSTASIS AND THROMBOSIS

Ruptured atherosclerotic plaque )

1
Adhesion of platelets to
thrombogenic surface

!
Activation of platelets
Exposure of
------------~ acidic
p hospholipids

AA generation
1
Coagulation
processes

~
Production of cyclic
endoperoxides
1
Thrombin

TXA2
synthesis
Inhibitors

Release of ADP etc. ~ Synthesis of TXft.:! Direct thrombin

inhibitors
TXA2 -
(e.g . hirudin)
Tlclopldlne receptor
Clopldogrel antagonists
Expression of GP
lib/lila receptors

Antagonists of GP

!---<- >---t

Linkage of adjacent platelets

lib/lila receptors (e.g.
abclxlmab, tirofiban)
'-------~--~-J

by fibrinogen binding to
GP lib/lila receptors

!
AGGREGATION of Epoprostenol, NO
platelets

Fig. 21 .7 Platelet activation. Events involved in platelet adhesion and aggregation are shown, with the sites of action of drugs and
endogenous mediators. AA, arachidonic acid; ADP, adenosine bisphosphate; GP, glycoprotein; NO, nitric oxide; ~. thromboxane ~
"--- _./

is relatively selective for platelets because of presystemic

ASPIRIN
Aspirin (see Ch. 14, pp. 234-235) alters the balance between
TXA2 , which promotes aggregation. and PGI2, which inhibits it.
Aspirin inactivates cycle-oxygenase (COX)-acting mainly on
the constitutive form COX- 1-by irreversibly acetylating a serine
residue in its active l>ite. This reduces both TXA2 synthesis in
platelets and PG 12 synthesis in endothelium. Oral administration
elimination (sec p. 117). Furthermore. vascular endothelial cells
can synthesise new enzyme via regeneration of COX-I
and via COX-2, whereas platelets (which comain only COX-I
and have no nuclei) cannot. After administration of aspirin,
TXA2 synthesis does not recover until the affected cohort of
platelets is replaced in 7-10 days. Consequently, low doses of
aspirin given once every 24 or 48 hours decrease the synthesis 341
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

of TXA 1 without drastically reducing PGI2 synthesis. Clinical
trials have demon~trated the efficacy of aspirin in several clinical
setting!> (e.g. Fig. 21.8). with similar efficacy over a dose range
of 50- 1500 mg per day, all of which doses nearly completely
aboli!.h platelet thromboxane biosynthesis (see the clinical box
on p. 343). Adve~ effecLc; of aspirin. mainly on the gastrointestinal
tract (pp. 232-234), are. however. clearly dose-related. so a low
dose (often 75 mg once daily) is usually recommended for
thromboprophylaxis. Treatment failure can occur despite taling
a-.pirin, and there i' currently interest in the possibility that some
patients exhibit a syndrome of 'aspirin resistance'. although
the mechanism and pos~iblc importance of this remains
controversial (sec Sande~on et al.. 2005, for a review). Other
non-steroidal drugs (e.g. sulfinpyrazone, for which there is sup-
portive trial evidence) may have similar antilhrombotic effects
to aspirin, but they differ from aspitin in several potentially
important ways (notably in being revers ible rather than
irreversible inhibitOr!. of COX), so it is unwise to assume this in
the absence of clinical trials.
DIPYRIDAMOLE
The value of dipyrida mole-a phosphodiesterase inhibitor (sec
Ch. 19. p. 307)-ha~ been clarified by the European Stroke
Pre.,ention Study 2 in patients with a history of ischaemic stroke or
transient cerebral io;chaemic attack. This showed that a modified-
relea.,e form of dipyridamole reduced the risk of stroke and
Placebo Infusion
and placebo
tablets-.........
500
Cll
~
death in \uch pat ienL~ by around 15%-a similar effect to that of
a~pirin (25 mg twice daily). 6 The beneficial effects of a~ptrin
and dipyridamole were additive. Headache was the commone't
adverse effect of dipyridamole: unlike aspirin, it caused no
exce!.s risk of bleeding.
THIENOPYRIDINE DERIVATIVES
Ticlopidine inhibiL'> ADP-dependent aggregation. IL\ action 1~ ,JO\I
in onset, taking 3 7 days to reach maximal effect, and it worl'
through an active metabolite that blocks platelet P~v 1 ~ receptof\
(sec Ch. 12, p. 199). It~ efficacy in reducing stroke is simtlar to
that of aspirin, but idiosyncratic unwanted effects, including
severe blood dyscrasia~ (e~pecially neutropenia), have limited it>
long-term u~e.
C lopidogrel is structurally related to ticlopidine and also
inhibits ADP-induced aggregation through an active metabolite.
Like ticlopidine, it can cause rash or diarrhoea, but ncutropcnta
is no more common than with aspirin. Clopidogrel wa~ ~light!)
more effective than a~pirin in reducing a composite outcome of
ischacmic ~troke, myocardial infarction or vascular death in on~
large trial. Because ADP antagonists inhibit a separate pathwa} ot
platelet activation than that which is inhibited by aspirin. theirefTcc'
add to those of aspirin. Clinical trials of adding clopidogrel o
aspirin in patients with acute coronary syndromes7 (see Fig. 21.9)
and (in a megatrial of O\'er 45 000 patients) in patients \\ith au e
myocardial infarction (COMMIT CoUaborathe Group. 2005) h;11e
confirmed that combined treatment reduces mortality. Pretreatment
with clopidogrel and aspirin followed by long-term therap) h
also effective in patients with ischaemic heart disease undcrgomg
percutaneous coronary interventions.
GLYCOPROTEIN liB/lilA RECEPTOR
ANTAGONISTS
AntagoniMs of the GPilb/Ula receptor have the theoretical attntc
tion that they inhibit all pathways of platelet activation (because

----
Q)
400 these all converge on activation of GPllbfllla receptors). A
'0
~ hybrid murine human monoclonal antibody Fab fragment directed
~~ 300
against the GPilblll la receptor. which rejoices in the catchy litt l~
name of abciximab. is licensed for use in highrisk patient\
0 undergoing coronary angioplasty, as an adjunct to heparin and
Streptokinase infusion
jJ and aspirin tablets a~pirin. It reduces the risk of restenosis at the expense of an
c: 200 increased risk of bleeding. lmmunogenicity limits its u c 10 1
~ ~ingle administration.
~
'5 Tirofiban and eptifibatide are cyclic peptides based on the
100 Arg-Giy-Asp ('RGD') sequence that is common to ligand' for
u

0 ~---r--------------------------~
0 7 14 21 28 35
Days from start of trial
"Thi' d<hC rcgancn of a~pirin L\ unconventional. being somewhat lo"er
Fig. 21.8 Efficacy of aspirin and streptokinase for than the 75 mg once daily commonly used in thromboprophylaxi,.

l
myocardial infarction. The curves show cumulative vascular
mortality in patients treated with placebo, aspirin alone,
streptokinase atone or a combined aspirin-streptokinase
regimen. (ISIS-2 trial 1988 Lancet ii: 35G-360.)
342
7
Acute coronary ~yndrome'> include unstable angina (p. 286) and
myocardial infarction that hm, not extended through the wall of the hean.
The clinical picture i~ similar to transmuml infarction, but there is no ST
segment elevation on the dectrocardiogram.
 HAEMOSTASIS AND THROMBOSIS

0.14

0.12

Q)

~ 0.10
"0
'-
!0
N 0.08
!0
..c
Q)
>
~ 0.06
'S
E
Fig. 21.9 Effect of adding ::J 0.04
()
clopidogrel to aspirin. The curves
show cumulative hazard rates for
major vascular events in patients 0.02
with acute coronary syndromes
treated either with placebo + aspirin 0.00
or clopidogrel + aspirin. (Modified
0 3 6 9 12
from CURE lnveslgators 2001 N
Engl J Med 345: 494-502.) Months of follow-up
r
r
GPil bll lla receptor... Given intravenously, these agents reduce early Clinical use of antiplatelet drugs
events in acute coronary ~yndrome~ when given as an adjunct to The clinical use of anti platelet drugs is summarised in the clinical
aspirin and a heparin preparation. but long-term oral therapy with box below.
GPII bfllla receptor antagonists i~ not effective and may be harmful.
Unsurprisingly, they increase the risk of bleeding.

OTHER ANTIPLATELET DRUGS Clinical uses of antlplatelet drugs

Epoprostenol (PGI,) may be administered imo blood entering

The main drug is aspirin. Other drugs with
the dialy~is circuit to prevent thrombosis during haemodialysis,
distinct actions (e.g. dipyridamole, clopidogrel) can
especially in patients in whom heparin is contraindicated. It is also
have additive effects, or be used in patients who are
used in ~evcre pulmonary hypertension (Ch. 19. pp. 316-318) and
intolerant of aspirin. Uses of antiplatelet drugs relate
circulatory shock. It i1. unstab le under physiological conditions
mainly to arterial thrombosis and include:
and has a half-life of around 3 minutes, so it is adm inistered by
acute myocardial infarction
an intravenous infusio n pump. Adverse effects related to its
high risk of myocardial infarction, including a
vasodilator action include nushing, headache and hypotension.
history of myocardial infarction, angina or
T Thrombo.mne Azlw:epror ('TP') onragonisrs (e.g. GR32191) are intermittent claudication (see Ch. 19)
unlikely to be more eiTcctivc than low-dose aspirin but could have fewer
following coronary artery bypass grafting
adver<>c effect\. TXA 2 ~ynrhesis inhibitors ('TXSl'. e.g. daz.oxiben, an
analogue of imidaLolc) increase PGI~ synthesis. as a consequence of
unstable coronary syndromes (clopidogrel is
divcr,ion of endopcroxide intem1ediates from TXA1 synthesis to PGI~ added to aspirin)
symhe;io,, a' well a~ reducing TXA~ production. However. they only following coronary artery angioplasty and/or
weakly mh1b11 platelet function in vitro. probably because pro.,taglandin stenting (tntravenous glycoprotein lib/lila
cndnp.!rOxldC' (e.g. PGH 2 ) arc agonist;, at thromboxanc receptor<>.
antagonists, e.g. abciximab, are used in some
Compound' that ha\e both TXA~ ;,ynthetase inhibition as well a' TXA~
receptor-blod.mg aciiHty offer a better pos,ibilit) of selccti\Cl) inhibiting
pattents in addition to aspirin)
thromboxanc o,ynthe'" while mcrea.,ing PGI~ S)nthesis. and drug' with trans1ent cerebral ischaemic attack ('ministrokes')
thi' combination of Jct1v1tie' (e.g. ridogrel) arc in development. or thrombotic stroke, to prevent recurrence
{dipyridamole can be added to aspirin)
atrial fibrillation, if oral anticoagulation is
contraindicated.
Other antiplatelet drugs (e.g. epoprostenol [PGI:J;
see Ch. 13) have specialised clinical applications (e.g.
"The UK National l n~titute for Clinical Excellence belied su;.picions that it
was actually an in\tl tute for rationing the use of expen;ive drugs by
In haemodialysis or haemofiltration, Ch. 24, or in
endor~ing GP II b/llla antagonist in ucute coronary syndromes when a pulmonary hypertension, Ch. 19).
pcn;utancou~ invention i desirable but has to be delayed.
343
 SECTION 3 . DRU GS AFFECTING MAJOR ORGAN SYSTE MS

inactivmed by plasmin inhibitors. including PAI-l (see abo'e and Ch.l9.

FIBRINOLYSIS (THROMBOLYSIS) p. 304), which protect us from digesting ourselves from within.

When the coagulation system is activated, Lhe fibrinolytic system
is also c;et in motion via ~everal endogenous plasminogen
activators, including tPA. urokinase-type plasminogen activator,
kallikrein and neutrophil elastase. tPA is inhibited by a structurally
related lipoprotein, lipoprotein(a), increased concentrations of
which constitute an independent risk factor for myocardial infarction
(Ch. 20, p. 323). Plasminogen is deposited on the fibrin strands
within a thrombus. Plasminogen activators are serine proteases
and are un~table in circulating blood. They diffuse into thrombus
and cleave plasminogen to release plasmin (see F ig. 21. I 0).
T Pla~min is trypsin -like. acting on Arg-Lys bonds. and thus digests not
only fibrin but fibrinogen; factor~ II. V and VIU; and many other protein~.
It is formed locally and acts on the fibrin meshwork, generating fibrin
degradation product!. and lysing the cloL ll~ action is localised to the clot,
because pla8minogcn activators are ell'ective mainly on plasminogen
adsorbed to fibrin: any plasmin that escapes into the circulation is
Drugs affect t11is system by increasing or inhibiting fibrinolysis
(fibrinolytic and antifibrinolytic drugs. respectively).
FIBRINOLYTIC DRUGS
Figure 21.10 summarises the interaction of Lhe fibrinolytic
system with the coagulation cascade and platelet activation, and
the action of drugs that modify this. Several fibrinolytic (throm-
bolytic) drugl> are used clinically. principally to reopen the occluded
coronary artery in patients with acute myocardial infarction, less
commonly in patients with life-threatening venous thrombosis or
pulmonary embolism.
Strep tok i nase is a protein extracted from cultures of strepto-
cocci. It activates plasminogen. I nfused intravenously, it reduces
mortality in acute myocardial infarction, and this beneficial effect
is additive with aspirin (Fig. 21 .8). Its action is blocked by anti-

ATHEROSCLEROTIC PLAQUE
_ Plaque rupture

Platelet Activation of
adhesion clotting factors,
{ activation tissue factor, Xlla,
aggregation Xa,lla etc.

l
FIBRIN forms the
framework of the

THROMBUS________.

ANTIFIBRINOLYTIC
AGENTS
~ Fibrin
degradation
Tranexamic acid products

- - - VASCULAR
ENDOTHELIAL
CELLS
FIBRINOLYTIC
AGENTS
Anistreplase Plasminogen Proactivators in
Alteplase acttvator plasma and
Reteplase A tissues
Streptokinase
Urokinase

Fig. 21 .10 Fibrinolytic system. The schematic shows interactions with coagulation and platelet pathways and sites of action of
drugs that modify these systems. LMHs, low-molecular-weight heparins. For more details of platelet activation and the coagulation
:- ------
344
cascade, refer to Figures 21.1, 21.2 and 21. 7. _______________________________________________________________ /

bodies, which appear about 4 days or more after the initial dose.
At least I year must elap e before it is used again.
A ltepl ase and d uteplase are. respectively, single- and double-
chain recombinant tPA. They are more active on fibrin-bound
plasminogen than on plasma plasminogen, and are therefore said
to be 'clot-selective'. Recombinant tPA is not antigenic, and can
be used in patients likely to have antibodies to streptokinase.
Because of their short half-lives, they must be given as intra-
venous infusions. Reteplase is similar but has a longer elimin-
ation half-life, allowing for bolus administration and making for
simplicity of admini!>lration. ft is available for clinical use in
myocardial infarction.
Unwanted eHects and contraindications
The main ha1,ard of all fibrinolytic agents is bleeding, including
gastrointestinal haemorrhage and stroke. If serious, this can be
treated with trancxamic acid (see below), fresh plasma or
coagulation factors. Streptokinase can cause allergic reactions
and low-grade fever. Streptokinase causes a burst of plasmin
formation, generating kinins (see Ch. 13), and can cause hypo-
tension by this mechanism.
Contraindications to the use of these agents are active internal
bleeding, haemorrhagic cerebrovascular disease, bleeding diath-
eses, pregnancy, uncontrolled hypertension. invasive procedures
in which haemostasis i'> important, and recent trauma-including
vigorous cardiopulmonary resuscitation.
Which fibrinolytic agent is best?
Several large placebo-controlled studies in patients with myo-
cardial infarction have l.hown convincingly that fibrinolytic drugs
reduce mortality if given within 12 hours of the onset of symp-
toms. and that the sooner they are administered the better is the
result. Much has been written as to which drug is best, but an
authoritative review (Collins et al., 1997) concluded that:
... the choice of fibrinolytic drug makes little difference to the
overall probability of stroke-free survival, because the regimens
that dissolve coronary thrombi more rapidly produce greater
ri sks of cerebral haemorrhage... it is ... important that any
uncertainties about which fibrinolytic regimen or dose of
aspirin to usc do not engender uncertainty about whether to use
fibrinolytic and antiplatelet therapies routinely.
The important thing is to open up the thrombosed coronary artery
as swiflly as possible. lf facilities are available to do this mech-
anically (percutaneous coronary intervention), this is at least as
good as using a lytic drug.
Clinical use
The clinical use of fibrinolytic agents is summarised in the
clinical box.
REFERENCES AND FURTHER READING
Blood coagulation und anticoagulants Clouse L H. Camp PC 1987 The rcgulnuon of
Bates SM. Wcit7 J I 2003 Emerging ;'"t icoagulant hemostasis: the protein C 'YMCm. N Engl J Med 3 14:
drugs. AneriosclcrThmmb Vase Biol 23: 1491-1500 1298-1304
HAEMOSTASIS AND THROMBOSIS
ANTIFIBRINOLYTIC AND HAEMOSTATIC
DRUGS
Tranexamic acid inhibits plasminogen activation and thus
prevents fibrinolysis. It can be given orally or by intravenous
injection. It is u:.ed to treat various conditions in which there is
bleeding or risk of bleeding. such as haemorrhage following
prostatectomy or dental extraction. in menorrhagia (excessive
menstrual blood loss) and for life-threatening bleeding following
thrombolytic drug administration. lt is also used in patients with
the rare disorder of hereditary angio-oedema.
A protinin inhibits proteolytic enzymes and is used for
hyperplasminaemia caused by fibrinolytic drug overdose and in
patients at risk of major blood loss during cardiac surgery.
Fibrinolysis and drugs modifying
fibrinolysis
A fibrinolytic cascade is initiated concomitantly with
the coagulation cascade, resulting in the formation
within the coagulum of plasmin, which digests fibrin.
Various agents promote the formation of plasmin from
its precursor plasminogen, for example streptokinase,
and tissue plasminogen activators (tPAs) such as
a lteplase, duteplase and reteplase. Most are
infused; reteplase can be given as a bolus injection.
Some drugs (e.g. tranexamic acid, aprotinin) inhibit
fibrinolysis.
Clinical uses of fibrinolytic drugs
The main drugs are streptokinase and tissue
plasminogen ac tivat ors (tPAs), for example
t enect eplase.
The main use is in acute myocardial infarction, with
ST segment elevation on the ECG within 12 hours of
onset (the earlier the better!)
Other uses include:
acute thrombotic stroke within 3 hours of onset
(tPA), in selected patients
clearing thrombosed shunts and cannulae
acute arterial thromboembolism
life-threatening deep vein thrombosis and pulmonary
embolism (streptokinase, given promptly).
Coughlm S R 2000 Thrombin signalling und protea,e
uctivarcd receptors. Nature 407: 258-264 (Review.>
celllllar acrioas ofrllrombill via PARs: .let' al>o Brass
345
 The haemopoietic system
Overview 347
The haemopoietic system 347
-Types of anaemia 347
Haematinic agents 348
-Iron 348
-Folic acid and vitamin B12 350
Haemopoietic growth factors 352
-Erythropoietin 353
-Colony-stimulating factors 354
OVERVIEW
In this chapter, we summarise the different kinds of
anaemia and cover the main haematinic agents
used to treat them, namely iron, folic acid and
vitamin 8 12 We also cover erythropoietin, a
growth factor specific for red blood cells used to
treat anaemia of chronic disease, and several other
haemopoietic factors, known as colony-stimulating
factors (CSFs), which are used to increase numbers
of circulating white blood cells.
THE HAEMOPOIETIC SYSTEM
The main components of the hacmopoictic system are the blood,
bone marrow, lymph nodes and thymus, with the spleen, liver and
kidneys as important accessory organs. Blood consists of formed
elements (red and white blood cells and platelets) and plasma. It
has diverse functions, including key roles in host defence (Ch. 13)
and haemostasis (Ch. 21 ). This pre ent chapter deals mainly with
red cells, which have the principal function of carrying oxygen.
Their oxygen-carrying power depends on their haemoglobin
content. The most important site of formation of red blood cells in
adults is the bone marrow, whereas the spleen acts as their grave-
yard. Red cell loss in healthy adults is precisely balanced by pro-
duction of new cells. The liver stores vitamin B 12 and is involved
in the process of breakdown of the haemoglobin liberated when
red blood cells are destroyed. The kidney manufactures erythro-
poietin. Cells from various organs synthesise and release CSFs,
which regulate the production of leucocytes and platelets. The
function of platelets is discussed in Chapter 21, and that of
leucocytes in Chapter 13. Drugs used in the chemotherapy of
leukemias, a very important part of oncology, are described in
Chapter 5 1.
TYPES OF ANAEMIA
Anaemia is defined as a reduced concentration of haemoglobin in
the blood. It may give rise to fatigue but, especially if it is chronic,
is often l>Urprisingly asymptomatic. The conunonest cause is blood
loss related to menstruation and child bearing, but there are several
different types of anaemia and several different diagnostic levels.
Determining indices of red cell siL.e and haemoglobin content and
microscopical examination of a stained blood smear of blood allow
characterisation into:
hypochromic, microcytic anaemia (small red cells with low
haemoglobin: caused by iron deficiency)
macrocytic anaemia (large red cell , few in number)
normochromic normocytic anaemia (fewer normal-sized red
cells. each with a normal haemoglobin content)
mixed pictures.
Further evaluation may include determination of concentrations
of ferritin, iron, vitamin 8 12 <md folic acid in serum (haematinics),
and microscopic examination of smears of bone marrow. This leads
to more precise diagnostic groupings of anaemias into:
defi ciency of nutrients necessary for haemopoiesis, most
importantly:
- iron
-folic acid and vitamin 8 12
-pyridoxine, vitamin C.
depression of the bone marrow, caused by:
-toxin!. (e.g. drug~ U\Cd in chemotherapy)
-radiation therapy
--diseases of the bone marrow of unknown origin (e.g.
idiopathic aplastic anaemia, leukaemias)
- reduced production of, or responsiveness to, erythropoietin
(e.g. chronic renal fai lure, rheumatoid arthritis, AIDS).
excessive destruction of red blood cells (i.e. haemolytic
anaemia); this has many causes, including
haemoglobinopathies (such as sickle cell anaemia), adverse
reactions to drugs, and inappropriate immune reactions.
It is important tO note that the use of haematinic agents is often
only an adjunct to treatment of the underlying cause of the 347
 SECTION 3 DRUGS AFFECTING MAJOR ORGAN SYSTEMS

anaemia-for example surgery for colon cancer (a common cause haem group can carry one oxygen molecule, which is bound
of iron deficiency) or anthelminthic drugs for patients with hook- reversibly to Fe 2+ and to a histidine residue in the globin chain.
worm (a frequent cause of anaemia in parts of Africa and Asia; This reversible binding is the basis of oxygen transport.
Ch. 50). Sometimes treatment consists of stopping an offending
drug, for example a non-steroidal anti-inflammatory drug that Iron turnover and balance
causes blood loss from the stomach (Ch. 14). Both the normal phy~iological turnover of iron and plumnacokinetic
factors affecting iron when it is given therapeutically will be deah
with here. The normal daily requirement for iron is approximate()
HAEMATINIC AGENTS 5 mg for men, and IS mg for growing children and for
menstruating women. A pregnant woman needs between 2 and
IRON
I 0 times this amount because of the demands of the fetus and
lron is a transition metal with two important properties relevant increased requirements of the mother. 1 The average diet in Western
to its biological role: Europe provides 15-20 mg of iron daily, mostly in meat. Iron in
meat is generally present as haem, and about 20-40% of haem
ability to exist in several oxidation states
iron is available for absorption.
abi lity to form stable coordination complexes.
'9' Humans are adapted to absorb iron in the form of haem. It is thought
The body of a 70-kg man contains abo ut 4 g of iron, 65% of that one reason why modern humm1s have problems in maintaining tron
which circu lates in the blood as haemoglobin. About one-half of balance (there are an e~timated 500 million people with iron deficienc)' in
the remainder is stored in the liver, spleen and bone marrow. chiefly the world) i~ that the change from hunting to grain cultivation 10000
as ferritin and haemosideri11. The iron in these molecules is avail- years ago led to cereab, which have a relatively small amount ol
utilisable iron. being sub~tituted for meat in the diet.
able for haemoglobin synthesis. The rest, which is not available
for haemoglobin synthesis, is present in myoglobin, cytochromes Non-haem iron in food is mainly in the ferric state, and this need'
and various enzymes. to be converted to ferrous iron for absorption. Ferric iron, and to
The distribution of iron in an average adult man is shown in a lesser extent ferrous iron, has low solubility at the neulrnl pH
Table 22.1. The corresponding values for a woman would be about of the intestine; however, in the stomach iron dissolves and bind,
55% of these. Because most of the iron in the body is either part to mucoprotein. ln the presence of ascorbic acid. fructose and
of--or destined to be part of-haemoglobin. the most obvious various amino acids. iron is detached from the carrier. formmg
clinical result of iron deficiency is anaemia. and the only indica- soluble low-molecular-weight complexes that enable it to remain
tion for therapy with iron is for treatment or prophylaxis of iron in soluble form in the intestine. Ascorbic acid stimulates iron
deficiency anaemia. absorption partly by forming soluble iron-ascorbate chelate'> and
Haemoglobin is made up of four protein chain subunits partly by reducing ferric iron to the more soluble ferrous form.
(globins), each of which contains one haem moiety. Haem consists Tetracycline form& an insoluble iron chelate, resulting m
of a tetrapyrrole porphyrin ring containing ferrous (Fe2+) iron. Each impaired uptake of both substances.
The amount of iron in the diet and the various factors affecting
its availability are thus important determinants in absorption, but
the regulation of iron absorption is a function of the intestinal
Table 22.1 The distribution of iron in the body of a
healthy 70-kg man mucosa, intluenced by the body's iron stores. Because there is no
mechanism whereby iron excretion is regulated, the absorptive
Protein Tissue Iron c onte nt mechanism has a central role in iron balance as it is the sole
(mg) mechanism by which body iron is controlled.
The site of iron absorption is the duodenum and upper jejunum.
Haemoglobin Erythrocytes 2600 and absorption is a two-stage process involving first a rapid
uptake across the brush border and then transfer into the plasma
Myoglobin Muscle 400
from the interior of the epithelial cells. The second stage, ~htch
Enzymes (cytochromes, Liver and other 25 is rate limiting. is energy-dependent. Haem iron in the diet i~
catalase, guanylate tissues ab!>orbed as intact haem, and the iron is released in the muco,aJ
cyclase, etc.) cell by the action of haem oxida e. Non-haem iron is absorbed in
the ferrou'> state. Within the cell. ferrous iron is oxidised to ferri;:
Transferrin Plasma and 8
extracellular fluid iron. which is bound to an intracellular carrier, a transferrin-like
protein; the iron is then either held in storage in the mucosal cell
Ferritin and haemosiderin Liver 410 as ferritin (if body stores of iron are high) or passed on to th.:
Spleen 48 plasma (if iron stores are low).
Bone marrow 300

(Data from Jacobs A, Worwood M 1982 Chapter 5. In: Hardisty

A M, Weatherall D J (eds] Blood and its disorders. Blackwell 1
Ench pregnancy co-.ts' the mother 680 mg of iron, equivalent to 1300 ml
Scientific, Oxford.) of blood. owing to the demands of the fetus. plus requirements of the
348 expanded blood volume nnd blood loss at delivery.
 Iron is carried in the plasma bound to transferrin, a ~-globulin
with two binding ~ites for ferric iron, which is normally only
30% saturated. Pla~ma contain~ 4 mg of iron at any one time, bur
the daily turnover i~ about 30 mg (Fig. 22.1 ). Most of the iron
that enters the pla!.ma is derived from mononuclear phagocytcs,
following the degradation of time-expired erythrocytes. Intestinal
absorption and mobilisation of iron from storage depots contrib-
ute only ~mall amounts. Most of the iron that leaves the plasma
each day i used for haemoglobin synthesis by red cell precur-
sors. These cells have receptors that bind transferrin molecules,
releasing them after the iron has been taken up.
Iron is stored in two forms: soluble ferritin and insoluble
haemosiderin. Ferritin is found in all cells, the mononuclear pha-
gocytes of liver, spleen and bone marrow containing especially
high concentrations. lt is also present in plasma. The precursor of
ferritin. apoferritin, is a large protein of molecular weight
450 000, composed of 24 identical polypeptide subunits that
enclose a cavity in which up to 4500 iron molecules can be
stored. Apoferritin takes up ferrous iron, oxidises it and deposits
the ferric iron in its core. ln this form, it constitutes ferritin, the
primary storage form of iron, from which the iron is most readily
available. The lifespan of this iron-laden protein is only a few
days. llaemo:;.iderin is a degraded form of ferritin in which the
iron core~ of several ferritin molecules have aggregated, fol-
lowing partial disintegration of the outer protein shells.
The ferritin in plasma has virtually no iron associated with it.
It i~ in equilibrium with the <;torage ferritin in cells. and its con-
cemralion in plasma provide~ an e:;.timate of total body iron stores.
The body has no means of actively excreting iron. Small
amounts leave the body through desquamation (peeling off) of
mucosal cells containing ferritin, and even smaller amounts leave
in the bile. sweat and urine. A total of about 1 mg is lost daily.
Iron balance is therefore critically dependent on the active absorp-
Absorption
1-2 mg daily
t caused by conditions other than ingestion of iron salts, for
Plasma
(4 mg)
~f 5mg
30mg Tissues 30mg
(150 mg)
t Clinical uses of Iron salts
Loss
1-2 mgdaily
r Bone marrow:
6mg Stores in mnp
in rbc precursors (1000 mg)
(150 mg)
Hb 1n rbc
(3000 mg)
Fig. 22.1 Distribution of iron in the body. The quantities
by the arrows indicate the usual amounts transferred each day.
, haemoglobin; mnp, mononuclear phagocytes; rbc, red
od cells.
tion mechanism in the intestinal mucosa. This absorption is
influenced by the iron stores in the body. but the precise
mechanbm of this control is still a matrer of debate; the amount
of ferritin in the intestinal mucosa may be important, as may the
balance between ferri tin and the transferrin-like carrier molecule
in these cells. The daily movement of iron in the body is
illustrated in Figure 22.1.
The clinical use of iron is given in the clinical box.
Administration
Iron is usually given oralJy but may be given parenterally in
special circumstances.
Several different preparations of ferrous iron salts are available
for oral administration. The main one is ferrous s ulfate, which
has an elemental iron content of 200 ~.tg/mg. Others arc ferrous
succinate, ferrous gluconate and ferrous fumarate. These arc all
absorbed to a comparable extent.
Pare nteral iron may be necessary in individuals who are not
able to absorb oral iron because of malabsorption syndromes, or
as a result of surgical procedures or inflammatory conditions
involving the gastrointestinal tract. lt is also used for patients
who do not tolerate oral preparations. and patients with chronic
renal failure receiving treatment with erythropoietin (see below).
The preparations used are iron-dextran or iron-s ucrose. iron-
dextran can be given by deep intramuscular injection or slow
intravenous infusion: iron-sucrose is given by slow intravenous
infusion. A small initial dose is given because of the risk of
anaphylactoid reaction.
Unwanted effects
The unwanted effects of oral iron administration are dose-related
and include nau~ea, abdominal cramps and diarrhoea. Parenteral
iron can cause anaphylactoid reactions (cf. p. 212).
Acwe iron toxicity, usually seen in young children who have
swallowed attractively coloured iron tablets in mistake for sweets,
occurs after ingestion of large quantities of iron salts. This can
result in severe nccrotising gastritis with vomiting, haemorrhage
and diarrhoea, followed by circulatory collapse.
Chronic iron toxicity or iron overload is virtually always
example chronic haemolytic anaemias such as the thalassaemias
(a large group of genetic disorders of globin chain synthesis) or
repeated blood transfusions.
To treat iron deficiency anaemia, which can be
caused by:
chronic blood loss (e.g. with menorrhagia,
hookworm, colon cancer)
increased demand (e.g. in pregnancy and early
infancy)
inadequate dietary intake (uncommon in
developed countries)
inadequate absorption (e.g. following gastrectomy).
349
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
T he treatment of acute and chronic iron toxici ty involves the
use of iron chelators such as desferrioxamine. This is not
absorbed from the gut but is nonetheless given intragastrically
followi ng acute overdose (to bind iron in the bowel lumen and
prevent its absorption) as well as intramuscularly and, if necessary,
intravenously. In severe poisoning, it is given by slow intravenous
i nfusion. Desferrioxamine forms a complex with ferric iron and,
unlike unbound iron, this is excreted in the urine. Deferiprone,
an orally ab!.orbed iron chelator. is an alternative treatment for
iron overload in patient!. with thalassaemia major who are unable
to take desferrioxamine. Agranulocytosis and other blood dys-
crasias are serious potential adverse effects.
FOLIC ACID AND VITAMIN 8 12
Vitamin B 12 and foli c acid are essential constituents of the
human diet, being necessary for DNA synthesis and consequently
for cell proliferation. T heir biochemical actions are interdependent
(sec below), and treatment of vitamin 8 12 deficiency with folic
acid corrects some, but not all, of the f eatures of v itamin 8 12
deficiency. Deficiency of either vitamin 8 12 or folic acid affects
tissues wi th a rapid cell turnover, particularly bone marrow, but
vitamin 8 12 deficiency also causes important disorders of nerves,
which arc not corrected (or may even be made worse) by treat-
ment w ith folic acid. Deficiency of ei ther vitamin causes megalo-
blastic lwemopoiesis, in which there is disordered erythroblast
differentiation and defective erythropoiesis in the bone marrow.
Large abnormal erythrocyte precursors appear in the marrow.
Iron
Iron is important for the synthesis of
haemoglobin, myoglobin, cytochromes and other
enzymes.
Ferric iron (Fe3 ) must be converted to ferrous iron
(Fe2 ) for absorption in the gastrointestinal tract.
Absorption involves active transport into mucosal
cells in jejunum and upper ileum, from where it can
be transported into the plasma and/or stored
intracellularly as ferritin.
Total body iron is controlled exclusively by
absorption; in iron deficiency, more is transported into
plasma than is stored as ferritin in jejunal mucosa.
Iron loss occurs mainly by sloughing of ferritin-
containing mucosal cells.
Iron rn plasma is bound to transferrin, and most is
used for erythropoiesis. Some is stored as ferritin in
other t issues. Iron from time-expired erythrocytes
enters the plasma for reuse.
The main therapeutic preparation is ferrous sulfate;
iron-sucrose can be given as an intravenous infusion.
Unwanted effects include gastrointestinal
disturbances. Severe toxic effects occur if large
doses are ingested; these can be countered by
desferrioxamine, an iron chelator.
350
each w ith a high RNA:DNA ratio as a result of decreased DNA
synthesis. The circulating erythrocytes (macrocytes) are large
fragile cells, often distorted in shape. Mjld leucopenia and
thrombocytopenia usually accompany the anaemja, and the nuclei
of polymorphonuclear leucocytes are abnormal (hypersegmented).
eurological disorders caused by deficiency of vitamin B1:
include peripheral neuropathy and dementia. as well as subacutt
combined2 degenemtion of the spinal cord.
Folic acid deficiency is caused by dietary insufficienC}.
especially in seuings of increased demand (e.g. during pregnanC).
or because of chronic haemolysis in patients with haemoglobino-
pathies). Vitamin 8 12 defi ciency, however, is usually caused by
decreased absorption, caused either by a lack of intrinsic factor
(sec below ) or by conditions that interfere with its absorpti on in
the terminal ileum, for example resection of diseased ileum in
patients with Crohn's disease (a chronic inflammatory bowel
disease that can affect this part of the gut) . Intrinsic factor is a
glycoprotein secreted by the stomach and is essential for vitamm
B 12 absorption. It is lacking i n patients with pernicious anaemia
and in individuals who have had total gastrectomjes. In pem1
cious anaemia, there is atrophic gastritis caused by autoimmune
i nj ury of the stomach, and antibodies to gastric parietal cell ~ ar~
often present in the plasma of such patients.
FOLIC ACID
Folic acid (pleroylglutamic acid) consists of a pteridine ring,
para-aminobenzoic acid and glutamic acid. Some aspects of folate
structure and metabolism are dealt with in Chapters 45 and 51.
because several important antibacteri al and anticancer drug~ are
antimctabol ites that interfere with folate synthesis in micro-
organisms. Liver and green vegetables are rich sources of folate.
ln healthy non-pregnant adults, the daily requirement is about
200 ~tg daily, but this is increased duri ng pregnancy.
Actions
Dihydrofolate (FH 2) and tetrahydrofolate (FH4) act. as carriers
and donors of methy l groups (!-carbon transfers) in a number of
important metabolic path ways. For example, FH4 is essential for
DNA synthesis because of its role as cofactor in the synthesis of
purines and pyrimidines. It is also necessary for reactions invol\ed
in amino acid metabolism. The active FH4 form is maintained by
dihydrofolate reductase. This important enzyme reduces dicta!)
folic acid to FH 4 and regenerates F~ from FH2 (see Fig~ 22.2
and 22.3). Folate antagoni<>LS (e.g. trimetboprim, methotrexate
are imponant antibacterial and anticancer drugs, and work b)
inhibiting dihydrofolate reductase (see also Chs 46, 49 and 51).
M ethotrexate is al so used as a disease modifying drug for
rheumatoid arthritis (p. 241) and for treating severe form~ of
psoriasis-a common skin disorder characterised by scaly lesion'
Tctrahydrofolate is especially important for the conversion of
dcoxyuridylatc monophosphate to deoxythy midy late monopho,.
phate. This is rate-limjting in mammalian DNA synthesis and i'
1
'Combi ned' because the lateral as well as l.he dorsal columns are involved,
g ivi ng ri ~e to motor as well as sensory symptoms.
 THE HAEMOPOEITIC SYSTEM

NA~PH
W NADP-
NA~PH
W NAOp-
l
_(NXH

.: I N: CH,
l i --c~"r<H
I A
' DHFR I
l i --c~+H
I. H ' DHFA I . H
Fig. 22.2 Folate reduction.
Reductton from folate (F), to
dihydrofolate (FH2), to
I
NH
N C~I NH
N HJ
H c~
I
tetrahydrofolate (FH4 ) by --., N~--
dihydrofolate reductase (DHFR).

Unwanted eHe cts

Unwanted effects do not occur even with large doses of folic
acid-except possibly in the presence of vitamin B 12 deficiency,
because if the vitamin deficiency is treated with folic acid, the
blood picture may improve and give the appearance of cure while
the neurological lesions get worse. ll is therefore important to
determine whether a megaloblastic anaemia is caused by a folate
or a vitamin 8 12 deficiency. This could have been import.am in

H20 3 P
_,o0l)CH, the setring of supplementation of bread with folate, which is used
in the USA as a public health measure to reduce the number of
neural tube defect~. There is a theoretical risk of precipitating
neuropathy in the small group of people with undiagnosed
0
pernicious anaemia by such measures, but such problems have
DTMP not been noted.
HO H

Fig. 22.3 The synthesis of 2-deoxythymidylate (DTMP).

DTMP is syntheSISed by the transfer of a methyl group from
tetrahydrofolate (FH 4) to 2-deoxyuridylate (DUMP), the FH4
being oxidlsed to dihydrofolate (FH:J in the process. __} Clinical uses of folic acid and
hydroxocobalamin

catalysed by thymidylate :.ynthetase, with FH 4 acting as methyl
donor (Fig. 22.3).
Pharmacokinetic aspe cts
Folates in food are in the form of polyglutamates. These are
converted to monoglutamates before absorption, and are trans-
ported in blood as ~uch. They are converted back into polyglu-
tamates, which are considerably more active than monoglutamates,
in the ti~sue~. Therapeutically, folic acid is given orally (or. in
exceptional circumstances. parenterally) and is absorbed in lhe
ileum. Methyi-FH~ is the form in which folate is usually carried
in blood and which enters cells. It is functionally inactive until it
is demelhylated in a vitamin 8 12-<lcpendent reaction (see below).
This is because (unlike FH 2, FH4 and formyl-FH4) methyi-FH~ is
a poor substrate for polyglutamate fom1ation. This has relevance
for the effect of vitamin B 12 deficiency on folate metabolism, as
is explained below. Folate is taken up into hepatocytes and bone
marrow cells by active tran~port. Within the cells. folic acid is
reduced and formylated before being converted to the active
polyglutamate form. Folink acid, a synthetic FH4 , is converted
much more rapidly to the polyglutamate forrn.
Folic acid
Treatment of megaloblastic anaemia resulting from
folat e deficiency, which can be caused by:
poor diet (common in alcoholic individuals)
- malabsorption syndromes
- drugs (e.g. phenytoin).
Treatment or prevention of toxicity from
methotrexate, a folate antagonist (see Ch. 51).
Prophylactically in individuals at hazard from
developing folate deficiency, for example:
pregnant women and before conception
(espec1ally if there is a risk of birth defects)
premature infants
patients with severe chronic haemolytic anaemias,
including haemoglobinopathies (e.g. sickle
cell anaemia).
Hydroxocobalamin (vitamin B 1:J
Treatment of pernicious anaemia and other causes of
vitamin 812 deficiency.
Prophylactically after surgical operations that remove
the site of production of intrinsic factor (the stomach)
or of vitamin 8 12 absorption (the terminal ileum).
351
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEM S
Clinical use
The clinical use of folic acid is given in the box opposite (p. 35 1).
VITAMIN B12
Vitamin 8 12 is a complex cobalamin compound. The vi tamin
B t ~ used medically is hydroxocobalamin. The principal dietary
sources of vitamin Bt 2 are meat (particularly liver), eggs and dairy
products. All cobalamins, dietary and therapeutic, must be converted
to methylcobalamin (methyl-S 12) or 5'-deoxyadenosylcobalamin
(ado-Bd for activity in the body. The average daily diet in
Western Europe contains 5-25 f,Ag of vitamin B 12 , and the daily
requirement is 2-3~-tg. Absorption requires intrinsic factor
(p. 350), which forms a one-to-one complex with vit<mlin B 12 A
healthy stomach secretes a large excess of intrinsic factor, but this
is not true in patientl> with add isonian pernicious anaemia (an
autoimmune disorder where the lining of the stomach atrophies),
or fo llowing to tal gastrectom y. Vitamin B 12, complexed with
intrinsic factor, is absorbed by active transport.
Vitamin 8 12 is carried in the plasma by binding proteins called
1ranscobalamins. The vitamin is stored mainly in the liver, the
total amou nt in the body being about 4 mg. This store is so large
compared with the daily requirement, that if v itamin B 12
absorption i~ stopped ~uddenly-as after a total gastrectomy-it
takes 2-4 year~ for evidence of deficiency to become manifest.
Actions
Vitamin 8 12 b required for two main biochemical reactions
in humans:
the conversion of metbyi-Fll4 to FI-14
isomerisation of methylmalonyi-CoA to s uccinyl-CoA.
The conversion of methyi-FH4 to FH4
The role of vitam in B 12 in folate coenzyme synthes is is
illustrated in Figure 22.4. lt is through these mechanisms that the
me tabo lic activities of vitamin 8 12 and folic acid are linked and
implicated in the synthesis of DNA. Jt is also through this
pathway that fo late/vitamin B 12 treatment can lower plasma
homocysteine concentration. Because increased homocysteine
concentrations may have undesirable vascular effects (Ch. 20,
Table 20. 1, p. 322), this ha~ potential therapeutic and public
health implications.
T The reaction In\ oh e~
conversion of both methyi-FH, to FH4 and
homOC)'tteine to methtonine. The enzyme that accomplishes this i~
homocy~teine methionine melhyllransferase: Lhe reaction requires
\itamin Bp a<, cofactor and methyi-FH.. as melhyl donor. Methyi-FH4
donate~ the methyl group to B 12, the cofactor. The meth) I group is then
uansferred to homocysteine to form methionine (Fig. 22.4). This vitamin
B1r<Jepcndent reaction generates active FH.. from inactive methyi-FH4
and comen~ homocyMeme to methionine.
Vitamin 8 1, deficiency thu'> uaps folate in the inactive methyi-FH4 form.
thereby depleting the folate polyglutamate coenzymes needed for DNA
'>ynthe\i<o (see ubove).
Vitamin 8 12 -dependent methionine synthesis also affects the synthesis
of folate polyglutnmme coenzymes by an additional mechanism. The
preferred ~oub;,trate for polyglutamate synthesis is formyi-FH.,, and the
conver-.ion of FH4 to formyi-FH4 requires a formate donor >uch as
352 methionine.
Methyl FH 4
I
I PLASMA
'e
y CYTOSOL
Methyl FH4
B,;--\~
!
FH, - - --;-- _ . Formyl
FH4
!
Folate
polyglutamate
formation
Fig. 22.4 The role of vitamin 8 12 in the synthesis of
folate polyglutamate. Methyltetrahydrofolate (Methyl FH 4)
enters cells by active transport. The methyl group is transferred
to homocysteine to form methionine via vitamin 8 12, which IS
bound to the apoenzyme homocysteine-methionine
methyltransferase. (Vitamin 8 12 is shown as '8 12' and as
'methyl 8 12 ', but the enzyme is not shown.) Methionine is
important in the donation of formate (shown by the curved red
arrow) for the conversion of tetrahydrofolate (FH 4) to formyl
tetrahydrofolate (formyl FH.J, which is the preferred substrate
for the formation of folate polyglutamates. J
------
lsomerisafion of methylmalonyf-CoA to succinyi-CoA
This isomerisation reaction is part of a ro ute by which propionate
is converted to succinate. Through this pathway, cholesterol, odd-
chain fatty acids, ~orne amino acids and thymine can be used for
g luconeogenesis o r for energy production via the tricarboxylic
acid cycle. Coenzyme B 12 (ado-B 12) is an essential cofactor, so
methylmalonyl-CoA accumulates in vitamin 8 12 deficiency. This
distorts the pattern of fa tty acid synthesis in neural tissue and
may be the basis of neuropathy in v itamin B 12 deficiency.
Administration and pharmacokinetic aspects
When vitamin 8 12 is used therapeutically (as hydroxocobalamin),
it is almost always given by injection because, as explained above,
vitamin 8 12 deficiency is a result of malabsorption. Plasma
transport and distribution of therapeutically administered vitamm
8 12 arc described above.
Patients with pernicious anaemia require lifelong thcrap)
Unwanted effects do not occur. Clinical use of vitamin B 2 ~~
summarised in the box.
HAEMOPOIETIC GROWTH FACTORS
Every 60 seconds, a human being must generate about 120
million granulocytes and 150 million erythrocytes, as well a~
nume rous mo no nuclear cells and platelets. The cells responsible
for th is re markable productivity are derived from a relatively

VItamin 8 12 and folic acid
Both vitamin 8 12 and folic acid are needed for
DNA synthesis. Deficiencies particularly affect
erythropoiesis, causing macrocytic megaloblastic
anaemia.
Folic acid
Folic acid consists of a pteridine ring, p-aminobenzoic
acid and a glutamate residue.
There is active uptake into cells and reduction to
tetrahydrofolate (FH4 ) by dihydrofolate reductase;
extra glutamates are then added.
Folate polyglutamate is a cofactor (a carrier of
1-carbon units) in the synthesis of purines and
pyrimidines (especially thymidylate).
Vitamin 8 12 (hydroxocobalamin)
Vitamin 8 12 needs an intrinsic factor (a glycoprotein)
secreted by gastric parietal cells for absorption in
terminal ileum. It is stored in the liver.
It is required for:
conversion of methyi-FH4 (inactive form of FH 4) to
active formyi-FH 4 , which, after polyglutamation, is
a cofactor in the synthesis of purines and
pyrimidines (see above)
isomensation of methylmalonyi-CoA to succinyi-
CoA.
Defictency occurs most often in pernicious anaemia,
which results from malabsorption caused by lack of
intrinsic factor from the stomach. It causes
neurological disease as well as anaemia.
Vitamin 8 12 is given by injection to treat pernicious
anaemia.
small number of self-renewing, pluripotent stem cells laid down
duri ng embryogenesis. Main tenance of haemopoiesis necessitates
a balance between self-renewal on the one hand, and differen-
tiation into the various types of blood cell on the other. The factors
involved in controlling this balance are the haemopoietic growth
factors, which direct the division and maturation of the progeny
of Lhe!.e cells down eight possible lines of development (Fig. 22.5).
These cytokine growth factors are bigWy potent glycoproteins,
acting at concentrations of 10"12-10-10 mol/l. They are present in
plasma at very low concentrations under basal conditions, but on
stimulation their concentrations can increase within hours by
1000-fold or more. Erythropoietin regulates the red cell line, and
the signal for its production is blood loss and/or low tissue
oxygen tension. CSFs regulate the myeloid divisions of the white
cell line, and the main .stimulus for their production is infection
(see also Ch. 13).
The genes for several haemopoietic factors have been cloned,
and recombinant erythropoietin (epoetin), recombinant granulo-
cyte CSF (filgrastim, lenograstim) and granulocyte-macrophage
THE HAEMOPOEITIC SYSTEM
Haemopoletlc growth factors
Erythropoietin
Regulates red cell production.
Is given intravenously, subcutaneously,
intraperitoneally.
Can cause transient flu-like symptoms, hypertension,
iron deficiency and increased blood viscosity.
Is available as epoietin.
Granulocyte colony-stimulating factor
Stimulates neutrophil progenitors.
Is available as filgrastim, pegfilgrastim or
lenograstim; it Is given parenterally.
CSP (molgrasmostim) are used clinically; thrombopoietin is in
development. Some of the other haemopoietic growth factors
(e.g. interleukin-1. interleukin-2 and various other cytokines) are
covered in Chapter 13.
ERYTHROPOIETIN
Erythropoietin i\ produced in juxtatubular cells in the kidney and
alc;o in macrophages; its action is to stimulate committed
erythroid progenitor cells to proliferate and generate erythrocytes
(Fig. 22.5). Two forms of recombinant human erythropoietin,
epoetin alfa and epoetin beta, are available. These are clinically
indistinguishable and are referred lO here simply as epoetin.
Oarbopoietin, a hyperglycosylated form of epoetin, has a longer
half-life and can be administered less frequently.
The clinical use of epoietin is given in the box below.
Pharmacokinetic aspects
Epoetin and darbopoietin can be given intravenously or subcu-
taneously, the response being greatest after subcutaneous injection
and fastest after intravenous injection.
Clinical uses of epoletln
Anaemia of chronic renal failure.
Anaemia during chemotherapy for cancer.
Prevention of the anaemia that occurs in premature
infants.
To increase the yield of autologous blood before
blood donation.
Anaemia of AIDS (exacerbated by zidovudine).
Anaemia of chronic inflammatory conditions such as
rheumatoid arthritis (investigational).
353
 SECTION 3 DRUGS AFFECTING MAJOR ORGAN SYSTEMS

Committed
progenitor
cells
Erythropoietin GM-CSF IL-3
}------'----'----------------~ Erythrocytes

IL-3 GM-CSF Thrombopo1etin

Megakaryocyte - Platelets
_ _ __...J

GM-CSF IL-3 M-CSF

Monocyte- Monocytes
GM-CSF
granulocyte
precursor GM-CSF G-CSF IL-3
-=:.:.:.:....::..:::..:_.....:::.....=-=.:.._.:..:..:::__~: Neutrophils

GM-CSF IL-3 IL-5

r---------------------------------~I E~-

IL-3
} - - - - - - - - - - - - - - - - - - - - - - - - - + , Basophils

~----------------------------~ 8~~

lnterleukins 1,2,4,6,7
r-------.....;..;.;...;;.;;;.;......;..;.;....:.;;;;.:....:..;;.:.._ __.I T~

Fig. 2 2 .5 Haemopoietlc growth factors in blood cell differentiation. The factors shown in bold are in clinical use under different
names (see text). Most T cells generated in the thymus die by apoptosis; those that emerge are either CD4 or CDS T cells. The colours
used for the mature blood cells reflect how they appear in common staining preparations (and after which some are named). CSF,
colony-stimulating factor; G-CSF, granulocyte CSF; GM-CSF, granulocyte-macrophage CSF; IL-1, interleukin-1; IL-3, interleukin-3 or
multi-CSF; M-CSF, macrophage CSF; SCF, stem cell factor. (See also Ch. 13.)
\.__

Unwanted effects Actions

Transient influenza-like symptoms are common. Hypertension is Granulocyte CSF acts only on the neutrophil line (Fig. 22.5}-
also common and can cause encephalopathy with headache, increasing the proliferation and maturation of neutrophils.
disorientation and sometimes convulsions. Iron deficiency can be stimu lating their release from bone marrow storage pools and
induced because more iron is required for the enhanced erythro- enhancing their function.
poiesis. Blood viscosity increases as the haematocrit (i.e. the The clinical use of granulocyte CSFs is given in the box.
fraction of the blood that is occupied by red blood cells) rises,
increasing Ihe risk of thrombosis, especially during dialysis. There
have been rare reports of pure red cell aplasia, possibly connected
with development of antibodies directed against erythropoietin.

Clinical uses of the

COLONY-STIMULATING FACTORS
colony-stimulating factors
The CSFs are so-called because they stimulate the formation of
maturing colonies of leucocytes in semisolid medium in vitro. Colony-stimulating factors are used in specialist
CSFs arc classified as cytokines (sec Ch. 13). They not only stimu- centres:
late particular committed progenitor cells to proliferate (Fig. 22.5) to reduce the severity/duration of neutropenia
bUI also cause irreversible differentiation. The responding precursor Induced by cytotoxic drugs during:
cells have membrane receptors for specific CSFs and may express anticancer chemotherapy
receptors for more than one factor, thus permitting collaborative intensive chemotherapy necessitating autologous
interaction'> between factors. bone marrow rescue
Granulocyte CSF i~ produced mainly by monocytes, fibro- following bone marrow transplant.
blasts and endothelial cell!., and controls primarily the to harvest progenitor cells.
development of neutrophils. Recombinant forms (filgrastim, to expand the number of harvested progenitor cells
which is not g lycosylatcd, and glycosylated lenograstim) are ex vivo before reinfusing them.
used therapeutically. Pegfilgrastim is a derivative of filgrastim for persistent neutropenia in advanced HIV infection.
conjugated with polyethylene glycol (pegylated) w ith a in aplastic anaemia.
354 prolonged duration of action.
 THE HAEMOPOEITIC SYSTEM

Pharmacokinetic aspects and unwanted eHects

Filgrastim and lenograstim are given either subcutaneously or
by intravenous infusion. Pegfilgrastim is administered subcu-
taneously. Gastrointe!>linal eiTects. fever. bone pain, myalgia and
rash are recognised adverse eiTects: less common effects include
pulmonary infiltrates and enlargement of liver or spleen.
THROMBOPOIETIN
Thrombopoietin Mimulates proliferation of the progenitor cells
of the platelet lineage and &trikingly increases platelet production.
Recombinant thrombopoictin is being tested cJjnically.

REFERENCES AND FURTHER READING

Generul
Clar~e R, Armitage J 2000 Viwmin ;upplement and
cardJOvno;culnr ri,k: rcvtew of the mndomited 1r1als of
homocysteine-lowering itamm wpplcmcrm. Semrn
Thromb Hcrno\1 26: 14 1-348
Fishman S M. Chri>Uan P. WcM K P 2000 The role of
vitamin~ in the prevent ion und control of anaemia.
Public Health Nutr 3: 125- 150
Goodenough L r. Mon~ T G. Andriole 0 L 1997
Erythropoier in therapy. N Eng I J Med 336: 933 938
Hocl1er D 1997 Hacrnopoicuc growth factors-not
whether. but when and where. N En[tl J Med 336:
1822- 1824 (f:di/lin~ tditnrial wmmr/11)
Kurzrock R 2005 Thrombopotetic factol'\ rn chronic
bone marrow failure 'llltC\ the platelet problem
tevhlled. Clrn Cancer Re' II : l.l61 1167 (S/cM
P"'II"Hl
Le\ln J 1997 Thromhoporcun-<:hnicall) realised? 1'\
Engl J Med 336. ~34-1 '6 (A utt'ful t'dllorial)
~irner S D 1997 Platelet \Umulatmg agenl\-offthe
launch pad. Nat Med 3. 154-155 !Throml>t>pot~ttc
gro>"h fartafl pm1 ~ u~frlm dmicoltrialsl
Sph ~ J L 1993 Rccombrnant Ct) thropoteun. Annu Rev
Me<l-14: 241-253
Iron a nd iron deficiency
Andrew' N C 1999 Di>order~ of iron mewboli ~m N Engl
J Med 341: 1986-1995
Finch CA. Hueber S H 1982 Pe,..;pcctives in iron
metabolism. N Engl J Med 306: 1520-1528 (Good
backgmwul article on iron)
Frewin R. Henson A, Provar1 D 1997 ABC of cl inical
haemalology: iron deficiency anaemia. Br Med J 3 14:
360-363
Hoflbrand A V. Herbert V 1999 Nutrit ional anemia,.
Semin Hematol 36(suppl 7): 13-23
Lieu P T, Hei,kala M, Peterson I' A. Yang Y 2()()1 The
roles of iron in health and di~a~. \1ol A'pee" Med
22: l-87
Pro'-an D. Weatherall D 2000 Red cell~ 11 ncqurrcd
anaemias and poi)C)thaemia. Lancet 355: 1260 1268
Toh B-H. ,.an Oriel I R. Glee<nn P A 1997 PerlllciOU>
anaemia..~ Engl J \1e<l 337: 1-141 1-148
(lmmunoporhogent!.liS <1pemiciouf mwemia;
t'.rcellenr jigu"s)
Folic acid and >itamin Bl2and their deficiencies
Bono L D et al. 2005 lntemauonal retro,p..'CII\C cohort
study of neural tube defect~ in relation 10 fohc acid
rccommendauons: are the recommendations l!oorking?
Br Med J 330: 571-573 (Nor as well as mi11ht bt'
hoped)
Ref\urn H 2001 Folate. vitamin 8 12 and homocysteine in
relmion to birth defects and pregnancy outcome. Br J
Nutr 85(suppl 2): S I09-S 113
Steinberg S 8 1984 Mechanisms of folate homeostasis.
Am J Physiol 246: G319--G324 (Good background
<rride on folate)
Wald N J, Bower C 1994 Folic acid, pernicious anaemia,
and prevemion of neural tube defect~. Lancet 343: 307
Colon)-slimulating factors
Dale DC 1995 Where now for colony-Mimulatiog
factors? Lancet 346: 135-136
1.1e\Chke G J. Buf[!~ A W t992 Granulocyte colony-
'umulating factor and granulocylcOlliCrophage
colony-~timulating factor. N Engl J Med 327: 1-35.
99 106 (\1\Jnh... hile. comp"hl'nsi\e mi,....s)
Petro' W P 1996 Colon)~Umulating factors. In: Chabner
B A. Longo D L (edsl Cancer chcmOiherap) and
brOiherapy. 2nd edn. Lippincou-Ra\en. Pbrladelphia,
pp. 639-654 (COl't'r:f mechanism ofaction. biolo~:ical
rffeciJ and clinical phamtacology)

355
 The respiratory system

and vagal aiTerents from the lungs. Various chemical factors affect
Overview 356 the respiratory centre, including the partial pressure of carbon
The regulation of respiration 356 dioxide in arterial blood (PAco2) by an action on medullary chemo
-Regulation of musculature, blood vessels and g lands of receptors, and of oxygen (PAo2) by an action on the chemo
the airwoys 356 receptors in the carotid bodies.
Some voluntary control can be superimposed on the automauc
Pulmonary disease and its treatment 357
regulation of breathing, implying connections between the cortex
-Bronchial asthma 357
and the motor neurons innervating the muscles of respiration
- Drugs used to treat asthma 361
Bulbar poliomyelitis and certain lesions in the brain stem result
-Severe acute asthma (status osthmoticus) 364
in loss of the automatic regulation of respiration wilhoutlo~'i of
- Allergic emergencies 364
voluntary rcgulation. 1
-Chronic obstructive pulmonary disease 365
-Surfoctonts 366
-Cough 366 REGULATION OF MUSCULATURE, BLOOD
-Drugs used for cough 366 VESSELS AND GLANDS OF THE AIRWAYS
Efferent pathways controlling the airways include cholinergK'
parasympathetic nerves and non-noradrenergic non-cholinergic
(NANC) inhibitory nerves. Inflammatory mediators (~ee Ch. IJ)
and NANC bronchoconstrictor mediators also have a role m
OVERVIEW diseased airways. The afferent pat.hways include three different
types of sensory receptor, described below.
In this chapter, we cover some basic aspects of the
The tone of bronchial muscle influences the airways resistance.
physiology of the respiratory system as a prelude
wh ich is also affected by the state of the mucosa and activity of
to pulmonary diseases and drugs used in their
the glands in patients with asthma and bronchitis. Airway reSISt
treatment. We devote most of the chapter to
ancc can be measured indirectly by instruments that record the
asthma, dealing first with factors involved in its
volume or flow of forced expiration. FEV 1 is the forced expira-
pathogenesis and then the moin drugs used in its
tory volume in I second. The peak expiratory flow rate (PEFRi
treatment-the bronchodilators and anti-inflammatory
is the maximal flow (expressed a~ !/min) after a full inhalation.
agents. We address chronic obstructive pulmonary
this is simpler to measure at the bedside than FEV1 which ll
disease (COPD). There are short sections on allergic
follows closely.
emergencies, surfactants and the treatment of
cough. Other important pulmonary diseases, such
as bacterial infections (e.g. tuberculosis and acute EFFERENT PATHWAYS
pneumonias) ond malignancies, are addressed in
Autonomic innervation
Chapters 46 and 51 , respectively, or are not yet
The autonomic innervation of human airways is reviewed b) \3D
amenable to drug treatment (e.g. occupational and
der Velden & Hulsmann (1999).
interstitial lung diseases). Antihistamines, important
Parasympathetic innervaJion. Parasympathetic innervation of
in treatment of hay fever, are covered in Chapter 13.
bronchial smooth muscle predominates. Parasympathetic ganglia
Pulmonary hypertension is covered in Chapter 19.
are embedded in the walls of the bronchi and bronchioles, and the

THE REGULATION OF RESPIRATION

Respiration is controlled by spontaneous rhythmic discharges
from the respiratory centre in the medulla, modulated by input
356 from pontine and higher central nervous system (CNS) centres
1
Referred to as Oodine~ curse. Ondine was a water nymph who fell in lol(
with a mortnl. When he was unfaithful to her. the king of the water nymph'
put a curse on him- that he must s1ay awake in order to breathe. When
exhuu~tion final ly supervened and he feU asleep, he djed.

postganglionic fibres innervate airway smooth muscle, vascular
smooth muscle and glands. Three types of muscarinic (M) receptors
are present (see Ch. 10, Table 10.2). M 3 receptors are pharma-
cologically the most important. They are found on bronchial
smooth muscle and glands, and mediate bronchoconstriction and
mucus secretion. M 1 receptors are localised in ganglia and on
post ynaptic cells, and faci litate nicotinic neurotransmission,
whereas M2 receptors are inhibitory autoreceptors mediating
negative feedback on acetylcholine release by postganglionic
cholinergic nerves. Stimulation of the vagus causes bronchocon-
striction- mainly in the larger airways. The possible clinical rel-
evance of the heterogeneity of muscarinic receptors in the
airways is discussed below (on p. 363).
Sympath etic innervation. Sympathetic nerves innervate
tracheobronchial blood vessels and glands, but not human airway
smooth muscle. B-Adrenoceptors arc, however, abundantly
expressed on human airway smooth muscle (as well as mast cells,
epithelium, glands and alveoli) and ~ agonists relax bronchial
smooth muscle, inhibit mediator release from mast cells, and
increase mucociliary clearance (see below). In humans, virtually
all the j3-adrenoceptors in the airways are of the (31 variety.
Non-noradrenergic non-cholinergic nerves. Inhibitory NANC
nerves, releasing 1'asoacti1e intestinal peptide (Ch. 9, Table 9.2)
and nitric oxide (NO; Ch. 17, p. 270), are important neural
bronchodilator pathways in human airways. ExcitatOt)' NANC
ner.es are at o present in human airways. In animal models, they
cause an inflammatory response consisting ofbronchoconstriction.
mucus secretion, increased vascular permeability, cough and
vasodilatation. Neuropcptides released from excitatory NANC
nerves initiate this neurogenic injlammaiion (see p. 222) and
influence the recruitment, proliferation and activation of
inflammatory cells that can, in tum, modulate neuronal function.
The main excitatory neuropeptides in the lung are the tachykinins
substance P and neuroki11in A- see Chapter 41, p. 596.
SENSORY RECEPTORS AND AFFERENT
PATHWAYS
Slowly adapting stretch receptors control respiration via the
respiratory centre. Unmyelinated sensory C fibres and rapidly
adapti ng irritant receptors associated with myelinated vagal
fibres are al&o important.
Physical or chemical stimuli, acting on irritant receptors on
myelinated fibres in the upper airways and/or C-fibre receptors
in the lower airways, cause coughing, bronchoconstriction and
mucus secretion. Such stimuli include cold air and irritants such
as ammonia, sulfur dioxide, cigarette smoke and the experi-
mental tool cap~aicin (Ch. 41, p. 593), as well as endogenous
inflammatory mediators.
PULMONARY DISEASE AND ITS
TREATMENT
Common symptoms of pulmonary disease include shortness of
breath, wheeze, chest pain, and cough with or without sputum pro-
duction or haemoptysis-blood in the sputum. Ideally, treatment
THE RESPIRATORY SYSTEM
Regulation of airway muscle, blood
veuels and glands
Afferent pathways
Irritant receptors and C fibres respond to exogenous
chemicals, inflammatory mediators and physical
stimuli (e.g. cold air).
Efferent pathways
Parasympathetic nerves cause bronchoconstriction
and mucus secretion through M3 receptors.
Sympathetic nerves innervate blood vessels and
glands, but not airway smooth muscle.
~ 2 -adrenoceptor agonists relax airway smooth
muscle. This is pharmacologically important.
Inhibitory non-noradrenergic non-cholinergic (NANG)
nerves relax airway smooth muscle by releasing nitric
oxide and vasoactive intestinal peptide.
Excitatory NANC nerves cause neuroinflammation by
releasing tachykinins: substance P and neurokinin A.
is of the underlying disease, but sometimes symptomatic treat-
ment. for example of cough, is all that is possible. The lung is
an important target organ of many diseases addressed elsewhere
in this book, including infections (Chs 46-50), malignancy
(Ch. 5 1), and occupational and rheumatological diseases; drugs
(e.g. amiodarone, p. 290; m ethotrexate. p. 241) can adversely
affect the pulmonary interstitium. Heart failure leads to pul-
monary oedema (Ch. 19). Thromboembolic disease (Ch. 2 1) and
pulmonary hypertension (Ch. 19) affect the pulmonary circulation.
ln this present chapter, we concentrate on two important diseases
of the airways: asthma and COPD.
BRONCHIAL ASTHMA
Asthma is the commonest chronic disease in children in econ-
omically developed countries, and is also common in adults. It is
increasing in prevalence and severity. It is an inflammatory con-
dition in which there is recurrent reversible airways obstruction
in response to irritant stimuli that are too weak to affect non-
asthmatic subjects. The obstruction usually causes wheeze and
merits drug treatment, although the natural history of asthma
includes spontaneous remissions. 2 Reversibility of air.vays
obstruction in asthma contrasts with COPD, where the obstruc-
tion is either not reversible or at best incompletely reversible, by
bronchodilators.
2
William O~ler, 19th century doyen of American and British clinicians,
wrote thai 'the n~thm atic pants imo old age'-this at a time when lhe mos1
effective drug that he could offer was to smoke stramonium cigarettes, a
herbal remedy the anti muscarinic effects of which were offset by direct
irritm ion from the smoke.
357
 SEcnON 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

CHARACTERISTICS OF ASTHMA (
Asthmatic patients experience intermittent attacks of wheezing,
shortnc~!. of breath-with difficulty especially in breathing ow, Diluent
and sometime!> cough. A!. explained above, acme attacks arc
revcr~iblc, but the underlying pathological disorder can progress
l 2.5
2.0
in older patients to a chronic state superficially resembling COPD.
Acute severe asthma (also known as status asthmaricus) is not
~
u. 1.5
easily reversed and causes hypoxaemia. Hospitalisation is necess- Early phase: Late phase.
ary, as the condition. which can be fatal. requires prompt and 1.0 bronchospasm inflammation
energetic treatment. 0 2 3 4 5 6 7 8
Asthma is characterised by: Hours

inflammation of the airways
bronchial hyper-reactivity
reversible airways obstruction.
The term bronchial h)1Jer-reactivity (or hyper-responsiveness)
refers to abnormal sensitivity to a wide range of stimuli, such as
irritant chemicals. cold air, and stimulant drugs, all of which can
result in bronchoconstriction. In allergic asthma, these features
may be initiated by sensitisation to allergen(s). but once estab-
lished asthma attacks can be triggered by various stimuli such as
viral infection, exerci'>e (in which the stimulus may be cold air
and/or drying of the airways). and atmospheric pollutants such as
sulfur dioxide. Immunological descnsitisation to allergens such
as pollen or dust mites is popular in some countries but is not
superior to conventional inhaled drug treatment.
The pathogenesis of asthma involves both genetic and environ-
mental factors, and the asthmatic attack itself consists, in many
subjects. of two main phases: an immediate and a late (or
delayed) phase (sec Fig. 23.1 ).
Fig. 23.1 Two phases of asthma demonstrated by the
changes in forced expiratory volume In 1 second (FEV1)
after Inhalation of grass pollen In an allergic subject. (From
Cockcroft D W 1983 Lancet ii: 253.)
Numerous cells and mediators play a part in the pathogcnc:.i>
of asthma, and the full details of the complex events involved are
still a matter of debate (Walter & Holtzman, 2005). The following
simplified account i!> intended to provide a basis for und~r
standing the rational use of drugs in the treatment of a~thma.
PATHOGENESIS OF ASTHMA
A!>thmatics ha,e activated T cells, with a Th2 profile of cytokine
production ('ee Ch. 13 and Fig. 13.3), in their bronchial muco,a.
How these cells are activated is not fully understood, but aller-
gens (Fig. 23.2) are one mechanism. The Th2 cytokine!. that are
released do the following.

Th1

c6 - ThO' t
Th2 --$-- B
B p

---4> lgE
antibodies

1~-4
p
J B ..

( G!ucocortlcolds }-0 { \~
IL-5
IL-13

~
Eosinophlls

Fig. 23.2 The part played by T lymphocytes in allergic asthma. In genetically susceptible individuals, allergen (green circle)
interacts with dendritic cells and CD4+T cells, leading to the development of ThO helper lymphocytes, which give rise to a clone of
helper Th2 lymphocytes. These then (i) generate a cytokine environment that switches B cells/plasma cells to the production and
release of lgE; (ii) generate cytokines, such as interleukin (IL)-5, which promote differentiation and activation of eosinophils; and (iiQ
cytokines (e.g. IL-4 and IL-13) that induce expression of lgE receptors. Glucocorticoids Inhibit the action of the cytokines specified. APC,
antigen-presenting dendritic cell; B, B cell; P, plasma cell; Th, T-helper cell.
358

Asthma
Asthma 1s def1ned as recurrent reversible
airway obstruction, with attacks of wheeze, shortness
of breath and often nocturnal cough. Severe attacks
cause hypoxaemia and are life-threatening.
Essential features include:
airways inflammation, which causes
bronchial hyper-responsiveness, which in turn
results in
recurrent reversible airway obstruction.
Pathogenesis involves exposure of genetically
disposed individuals to allergens; activation of Th2
lymphocytes and cytokine generation promote:
differentiation and activation of eosinophils
lgE production and release
expression of lgE receptors on mast cells and
eosinophils.
Important mediators include leukotriene 8 4 and
cysteinyl leukotrienes (C4 and 0 4); interleukins IL-4,
IL-5, IL-13; and tissue-damaging eosinophil proteins.
Antiasthmatic drugs include:
- bronchodilators
- anti-inflammatory agents.
Treatment is mon1tored by measuring forced
expiratory volume in 1 second (FEV1) or peak
expiratory flow rate and, in acute severe disease,
oxygen saturation and arterial blood gases.
Attract other inflammatory granulocytes, especially
eosinophils, to the mucosal surface. lnterleukin (TL)-5 and
granulocyte-macrophage colony-stimulating factor prime
eosinophils to produce cys tcinyl leukotrienes, and to release
granule proteins that damage the epithelium. This damage is
one cause of bronchial hyper-responsiveness.
Promote l gE synthesis and responsiveness in some asthmatics
(IL-4 and IL-13 ;&witch' B cells to TgE synthesis and cause
expression of l gE receptors on mast cells and eosinophils;
they also enhance adhesion of eosinophils to endothelium).
Some asthmatics, in addition to these mechanisms, are also
atopic-i.e. they make all ergen-specific I gE that binds to mast
cells in the airways. inhaled allergen cross-links TgE molecules
on mast cells. triggering degranulation with release of histamine
and leukotriene 8 4 both of which are powerful bronchocon-
strictors to which asthmatics are especially sensitive because of
their airways hyper-responsiveness. This provides a mechanism
for acute exacerbation of asthma in atopic individuals exposed
to allergen. The effectiveness of om alizumab (an anti-lgE anti-
body; see below, p. 364) serves to emphasise the importance
of lgE in the pathogenesis of asthma as well as in other allergic
diseases. Noxious gases (e.g. sulfur dioxide, ozone) and airway
dehydration can also cause mast cell degranulation.
THE RESPIRATORY SYSTEM
Clinician~ often refer to atopic or 'extrinsic' asthma and non-
atopic or 'intrinsic' asthma; we prefer the terms allergic and
11011-a/lergic.
The immediate phase of the asthmatic attack
In allergic a~thma, the immediate phase (i.e. the initial response
to allergen provocation) occurs abruptly and is mainly caused
by spasm of the bronchial smooth muscle. Allergen interaction
with ma~t cell fixed lgE causes release of several spasmogens:
histamine, leukotriene 8 4 (Ch. 13) and prostaglandin (PG) 0 2 .
Other mediators released include IL-4, IL-5, IL-13, macrophage
inflammatory protein- La and tumour necrosis factor (TNF)-a.
Various chemotaxins and chemokines (see Ch. 13) attract
leucocytes-particularly eosinophils and mononuclear cells-
into the area. setting the stage for the delayed phase (Fig. 23.3).
The late phase
The late phase or delayed response (see Figs 23.1 and 23.3) may
be nocturnal. It is, in essence, a progressing inflammatory
reaction, initiation of which occurred during the first phase, the
influx of Th2 lymphocytes being of particular importance. The
inflammatory celb include activated eosinophils. These release
cysteinyl leukotrienes; interleukins IL-3, IL-5 and TL-8; and the
toxic proteins. eosinophil cationic protein, major basic protein
and eosinophil-derived neurotoxin. These play an important part
in the events of the late phase, the toxic proteins causing damage
and loss of epithelium (see for example Larche et al., 2003; Kay.
2005). Other putative mediators of the inflammatory process in
the delayed pha-.e are adenosine (acting on the A 1 receptor; see
Ch. 12). induced NO (see Ch. 17) and the neuropeptides (see
Chs 13 and 16).
Growth factors released from inflammatory cells act on smooth
muscle cells, causing hypertrophy and hyperplasia, and the smooth
muscle can itself release proinflan1matory mediators and autocrine
growth factors (Chs 5 and I 3). Figure 23.4 shows schematically
the changes that take place in the bronchioles. Epithelial cell Joss
means that irritant receptors and C fibres are more accessible to
irritant stimuli-an important mechanism of bronchial hyper-
reactivity.
' Aspirin-sensitive' asthma
Non-steroidal anti -inflammatory drugs (NSA IDs). especially
aspi rin, can precipitate asthma in sensitive individuals. Such
aspirin-sensitile asthma is relatively uncommon ( < I 0% of
asthmatic subjects). and is often associated with nasal polyps.
Individuals sensiuvc to one SAID are usually also sensitive to
other chemically unrelated cyclo-oxygenase (COX) inhibitors,
including sometimes par acetamol. but not highly selective
COX-2 inhibitor- (Ch. 14, pp. 236-237). Abnormal leukotriene
(Ch. 13) production and sensitivity are implicated. Patients with
aspirin-!>ensitive asthma produce more cysteinyl leukotriene and
have greater airway hyper-responsiveness to inhaled cysteinyl
Jcukotrienes than aspirin-tolerant asthmatics. Such airway
hyper-responsiveness reflects elevated expression of cysteinyl
leukotriene receptors on inflammatory cells, and this is down-
regulated by aspi rin desensitisation (Sousa et a!., 2002). In
addition, aspirin and similar drugs directly activate eosinophils 359
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

Immediate phase Late phase

Eliciting agent: Infiltration of
allergen or cytokine-releasing Th2 cells,
non-specific st1mulus and monocytes, and activation
of inflammatory cells,
particularly eosinophils
I
,----1-----,
I \

Mast cells,
*
Mediators e.g.
t
EMBP,ECP
mononuclear cells cysLTs,

t
_____ lI ___ _ neuropeptides?,
NO?, adenosine?
I/ 'I
'i/ v
Spasmogens Epithelial
cysLTs, Chemotaxins,
damage
Chemokines
H, PGD2

Bronchospasm
Airway
I
hyper-reactiVIty

Fig. 23.3 Immediate and late

phases of asthma, with the
actions of the main drugs. CysLTs,
cysteinyl leukotrienes Oeukotrienes
Reversed by
132-adrenoceptor
antagonists,
CysLT-receptor Bronchospasm,
I
C4 and OJ; ECP, eosinophil cationic antagonists and wheezing,
protein; EMBP, eosinophil major theophylline coughing
basic protein; H, histamine; iNO,
induced nitric oxide. For more detail
of the Th2-derived cytokines and
chemokines, see Chapter 13, Inhibited by glucocorticoids
~e 221, and Figure 13.4.

Mucosa - -

Infiltration of /
inflammatory cells,
(mononuclear 0
cells, eosinophils,
etc.) Mucus plug wllh
eosinophils and
Fig. 23.4 Schematic diagram desquamated
of a cross-section of a bronchiole, Hypertrophied epithelial cells
showing changes that occur with smooth muscle
severe chronic asthma. The
individual elements depicted are Mononuclear cell Mast cell
not, of course, drawn to scale. Oedema
360 .J

and mast cells in these patients through I gE-independcnt
mechanisms.
DRUGS USED TO TREAT ASTHMA
There are two categories of antiasthma drugs: bronchodilators
and anti-inflammatory agents. Bronchodilators reverse the
broncho~pasm of the immediate phase: anLi-inflammatory agents
inhibit or prevent the inflammatory components of both phases
(Fig. 23.3). These two categories are not mutually exclusive:
some drug~ classified as bronchodilators also have some anti-
intlammatory effect.
How best to use these drugs to treat asthma is complex. A
guideline (see British Thoracic Society, updated in 2004) specifies
five therapeutic steps for adults and children with chronic asthma.
Very mild disease may be controlled with short-acting broncho-
dilator alone (step I ), but if patients need thi s more than once a
day a regular inhaled corticos teroid should be added (step 2). If
the asthma remains uncontrolled, the next step is to add a long-
acting bronchodilator (salmeterol or formoterol); this minimises
the need for increased doses of inhaled corticosteroid (step 3).
Theophylline and leukotriene amagonists, such as montelukast,
also exert a corticosteroid-sparing effect. but this is less reliable.
One or other is added in for patients with more severe asthma
who remain symptomatic and/or the dose of inhaled cortico-
steroid increased to the maximum recommended (step 4). ff the
patient's condition is still poorly controlled, it may be necessary
to add a regular oral corticosteroid (e.g. prednisolone)-step 5.
Corticosteroid~ are the mainstay of therapy because they are the
only asthma drugs that potently inhibit T-cell activation, and thus
the intlammatory response, in the asthmatic airways. Crornoglicate
(see below) has only a weak effect and is now seldom used.
BRONCHODILATOR$
The main dngs used as bronchodilators are f3z-adrenoceptor
agonists; others include xanthines, cysteinylleukotriene receptor
antagonists and muscarini c receptor antagonists.
jl-Adrenoceptor agonists
The f3 2-adrenoceptor agonists are dealt with in detail in
Chapter I I . Their primary effect in asthma is to dilate the bronchi
by a direct action on the ~ 2 adrenoceptors on the smooth muscle.
Being physiological antagonists of bronchoconstrictors (see Ch. 2,
p. 17), they relax bronchial muscle whatever the spasmogens
involved. They al<>o inhibit mediator release from mast cells and
TNF-a release from monocytes, and increase mucus clearance
by an action on cilia.
The ~ 2 -adrenoceptor agonists are usually given by inhalation
of aerosol, powder or nebulised solution, but some may be given
orally or by injection. A metered-dose inhaler is used for aerosol
preparations.
Two categories of ~radrcnoceptor agonists are used in asthma.
Short-acting agent, : sal butam ol and ter butaline. These are
given by inhalation: the maximum effect occurs within
30 minutes and the duration of action is 3-5 hours; they are
usually used on an 'as needed' basis to control symptoms.
THE RESPIRATORY SYSTEM
Antla.th..,. drugs: bronchodllators
f32-Adrenoceptor agonists (e.g. salbutamol)
are first-line drugs (for details, see Ch. 11).
They act as physiological antagonists of the
spasmogenic mediators but have little or no effect
on the bronchial hyper-reactivity.
Salbutamol is given by inhalation; its effects start
immediately and last 3-5 hours, and it can also be
given by intravenous infusion in status asthmaticus.
Salmeterol or formoterol are given regularly by
inhalation; their duration of action is 8-12 hours.
Theophylline (often formulated as am ino phy lline) is
a third-line drug for asthma. Theophylline:
is a methylxanthine
Inhibits phosphodiesterase and blocks adenosine
receptors
has a narrow therapeutic window: unwanted
effects include cardiac dysrhythmia, seizures and
gastrointestinal disturbances
is given intravenously (by slow infusion) for status
asthmaticus, or orally (as a sustained-release
preparation) as add-on therapy to inhaled
corticosteroids and long-acting f32 agonists (step 4)
is metabolised in the liver by P450; liver
dysfunction and viral infections increase its
plasma concentration and half-life (normally
approximately 12 hours)
1nteracts Importantly with other drugs; some (e.g.
some antibiotics) increase the half-life of
theophylline, others (e.g. anticonvulsants)
decrease it.
Cysteinyl leukotriene receptor antagonists (e.g.
m ontelukast ) are third-line drugs for asthma. They:
competitively antagonise cysteinyl leukotrienes at
CysLT1 receptors
are used mainly as add-on therapy to inhaled
corticosteroids and long-acting ~2 agonists (step 4).
Longer-acting agents: e.g. salmeterol and formoterol. These
are given by inhalation. and the duration of action is
8-12 hours. They are not used 'as needed' but are given
regularly, twice daily, a<> adjunctive therapy in patients whose
asthma is inadequately controlled by glucocorticoids.
Unwonted effects
The unwanted effects of ~2 -adrenoceptor agonists result from
systemic absorption and are given in Chapter 11. fn the context
of their usc in a~thma. the commonest adverse effect is tremor,
other unwanted effects including tachycardia and cardiac
dysrhythmia.
Clinical uses
Cli nical uses are summarised in the clinical box. 361
 SECTION 3 . DRU GS AFFECTING MAJOR O RGAN SYSTEMS
Clinical use of P2 -adrenoceptor agonlsts
as bronchodllators
Short-actng drugs (salbutamol or terbutaline, usually
by inhalation) to prevent or treat wheeze in patients
with reversible obstructive airways disease.
Long-acting drugs (salmeterol, formoterol) to
prevent bronchospasm (e.g. at night or with exercise)
in patients requiring long-term bronchodilator therapy.
Xanthine drugs
There are three pharmacologically active, naturally occurring
methylxanthines: theophylline, rheobromine and caffeine (see also
Ch. 19, p. 307, and Ch.42). T heophylHne (1,3-dimethylxanthine),
which is also used as theophylline ethylenediamine (known as
a minophylline), is the main therapeutic drug of this class.
Theophylline has a bronchodilator action, although it is more likely
to cause side effects (tachycardia, agitation, seizures) than the ~2-
adrenoceptor agonists and ha!. a less favourable risk:benefit ratio.
Actions
Antiasthmatic. Methylxanthines have long been used as
bronchodilators. 1
Centra/nervous system. Methylxanthines stimulate the CNS,
increasing alertnesl. (see Ch. 42). They can cause tremor and
nervou~ness. and can interfere with s leep and have a stimulant
action on respiration. This may be useful in patients with COPD
and reduced rc piration evidenced by a tendency to retain C0 2
(see below).
Cardiovascu lar. Mcthylxantbines stimulate the hean (see
Ch. 18), having positive chronotropic and inotropic actions, while
relax ing vascular smooth muscle (Ch. 19). They cause gener-
alised vasodilatation but constric t cerebral blood vessels.
Kidney. Mcthylxanthines are weak diuretics, although this
effect is not the rape utically useful.
Mechanisms of action
The ways in which the xanthine drugs produce effects in asthma
are still unclear.
The relaxant effect on smooth muscle has been attributed to
inhibition of the phosphodie~terase (POE) isoenzymes, with result-
ant increase in cAMP and/or cGMP (see Fig. 4.10. p. 67). However.
the concentrations necessary to inhibit the isolated enzymes exceed
the therapeutic range of plasma concentrations.
Competitive antagonism of adenosine at adenosine A 1 and A 2
receptors (Ch. 12) may contribute, but the POE inhibitor
enprofylline, which is a potent bronchodilator, is not an
adenosine antagonist.
Type rv PDE is implicated in inflammatory cells (see below),
and non-specific methylxanthines may have some anti-
inflammatory effect. (Rofl umilas t, a type IV PDE inhibitor, is
mentioned below in the context of COPD.)
1
0ver 200 years ago. William Wilhering recommended 'coffee made very
362 strong' as a remedy for asthma.
Unwanted effects
When theophylline is used in asthma, its other effects (CI\S.
cardiova cular, gastrointestinal and diuretic) are unwanted s1de
effects. Funherrnore, the the rapeutic plasma concentration range
is 30-100 j.lmoVI, and adverse effects are common with concen
trations greater than II 0 ~tmolfl; thus, there is a relative!} naiTO\\
therapeutic window. Mea~urements of its concentration in plasma
are useful for optimising dosage of aminophylline. Serious car
diova~cular and CNS effects can occur when the plasma concen
tration exceeds 200 j.lmol/1. The most serious cardiovascular
effect is dy. rhythmia, which can be fatal. Seizures can occur w1th
theophyll inc concentrations at or slightly above the upper limit of
the therapeutic range, and can be fatal in patients with impaired
respiration due to severe asthma.
Pharmacokinetic aspects
Methylxanthines are give n orally in sustained-release prep-
arations. Aminophylline can also be given by slow i ntravcnou~
injec tio n of a loading dose followed by intravenous infusion.
Theophylline is well absorbed from the gastrointestinaltra~t.
It is metabolised by the P450 system in the liver, and the elimin
ation half-life is about 8 hours in adults but varies widely tn
different subjects.
The half-life of theophylline is increac;ed in liver disea-e.
cardiac failure and viral infections, and is decreased in heal)
cigarette smokers and drinkers (ac; a result of enzyme induction I.
Theophylline i' innuenced by many unwanted drug interaction'.
its plasma concentration is decreased by drugs that induce P-150
enzymes (including r ifampicin. phenobarbital, phenytoin and
carba mazepine- ce Cbs 46 and 40. also Ch. 8, p. 116. and
Ch. 52, p. 747, for more on induction of microsomal enzyme\).
The concentration is increased by drugs that inhibit P450 entyme\
such as erythr omycin, cJar ithromycin, ciprofloxacin, diltiazem
and flu conazole (sec Chs 46, 19 and 48, also Ch. 52, p. 747, for
more on enzyme inhibition). This is important in view of the
narrow therapeutic window; antibiotics such as clarithromycin
arc often s tarted when asthmatics are hospitalised because of a
severe attack precipitated by a chest infection, and if the dose or
theophylline is unalte red severe toxicity can result.
The clinical use of theophylline is summarised in the box.
Muscarinic receptor antagonists
Muscarinic receptor antagonists are dealt with in detrul m
Chapter I 0. The main compound used as a bronchodilator ~
iprat ropium. Tiot ropium is also available; it is a longer-acting
Clinical use of theophylline
As a second-line drug, in addition to steroids,
in patients whose asthma does not respond
adequately to ~2-adrenoceptor agonists.
Intravenously (as aminophylline, a combination of
theophylline with ethylenediamine to increase its
solubility in water) in acute severe asthma.

drug used in maintenance treatment of COPD (sec below).
lpratropium i~ <,eldom u!>ed on a regular basis in astluna but can
be useful for cough caused by irritant stimuli in suc h patients.
lpra t ropium i-, a quaternary derivative of N-isopropylatropine.
II doe\ not discriminate between muscarinic receptor subtype!.
(\ee Ch. 10). and it is po!.!.iblc that its blockade of M 2 auto-
receptors on the cholinergic nerves increases acetylcholine
release and reduce., the effectiveness of its antagonism at the Ml
receptors on the smooth muscle. lt is not particularly eiTective
agai n-.t a llergen challenge. but it inhibits the augmentation of
mucus secretion that occur:- in asthma and may increase the
mucociliary c learance of bronchial secretion!>. It has no effect o n
the late inflammatory pha~e of a:.thma.
It is given by acro~>ol inhalation. As a quaternary nitrogen com-
pound, it is highl y polar and is not wdl absorbed into the c ircu-
lation (Ch. 7. p. 99), and thus does not have much action at
muscarinic receptors other than those in the bronchi. The maxi-
mum e ffect occurs after approximately 30 minutes and persists
for 3 5 hours. lt has few unwanted effects and is, in general, safe
and well to lerated. ll can be used with ~2 -adrenoceptor agonists.
Sec the c linical box for c linical uses.
Cysteiny l le ukotriene rece ptor antagonists
All the cy\teinyl leukotricnes (LTC4 , LTD4 and LTE~) act on the
same high-affinity cystcinyl lcukotriene receptor termed CysLT1
(see Chs 13 and 14). Two receptors have been cloned, CysLT
and Cy-.LT2 and both are expressed in respiratory mucosa and
infiltra1ing inflammatory cells. but the functional significance of
each is unclear. The Jukast' drugs (montelukast and zafirlukast)
antagonise only CysLT 1
Pharmacological actions
Lukasts reduce acute reactions to aspirin in sensitive patients, but
have not been ~o.hown to be particularly effective for aspirin-
sensitive a~ thma (see above, p. 359) in the clinic. They inhibit
exercise-induced asthma and decrease both early and late
responses to inhaled allergen. They relax the airways in mild
asthma but arc less e ffective than salbutamol. Their action is
additive with ~ 1 -adrenoceptor agonists. They also reduce sputum
eosinophi lia, but so far there is no clear evidence that they
modify the underlying inflammatory process in chronic asthma.
Clinical use of Inhaled muscarinic
receptor antagonists (e.g. lpratropium)
For asthma, as an adjunct to ~-adrenoceptor
antagonists and steroids.
For some patients with chronic obstructive pulmonary
disease, especially long-acting drugs (e.g. tiotropium).
For bronchospasm precipitated by f32-adrenoceptor
antagonists.
For clinical uses of muscarinic receptor anta gonists
in other organ systems see clinical box in Chapter 1 0
(p. 156).
THE RESPIRATORY SYSTEM
Unwonted effects
These are few, consisting mainly of headache and gastrointestinal
disturbances. They have. rarely, been associated with the emerg-
ence of Churg-Strauss syndrome.4 but the consensus is that this
is because of withdrawal of concomitant conicosteroid therapy
that had masked this dhease.
Phormocokinetic aspects
Both drugs are given orally, montelukast once daily. zafir lukast
twice.
Clinical use
They arc used in combination with an inhaled corticosteroid,
u~uall y aL step 3, when regular lo ng-acting f32 agonists arc inad-
equately effective.
H istamine H 1-receptor antagonists
Althoug h mast cell mediators play a part in the inunediate phase
of allergic asthma (Fig. 23.3) and in some types of exercise-induced
asthma, hi ~ t am inc H1-rcccpto r antagonists have no routine place
in therapy, a lthough they may be modestly effective in mild atopic
a<,thma, c'>pecially when this is precipitated by acute histamine
relcar>e in patient~ with concomitant allergy such as severe hay fever.
ANTI-INFLAMMATORY AGENTS
The main drugs used for their anti-inflammatory action in asthma
arc the glucocorticoids.
Glucocorticoid s
Glucoconicoids arc dealt with in detail in Chapter 28. They are
not bronchodilators, but pn:vent the progression of chronic asthma
and are effecti ve in acu te severe asthma (see be low). 5
Actions and mechanism
The basis of the anti-inflammatory action of glucocorticoids is
discussed o n page 428. An impottant action. of relevance for
asthma, is that they dec rea.<;e formation of cytokines (Fig. 13.3),
in particular the Th2 cylokines that recmit and activate eosinophils
and arc responsible fo r promoting the production of lgE and the
expression of lgE receptors (p. 358 and Ch. 13). Glucocorticoids
a lso inhibit the generation of the vasodilators PGE2 and PGI2 by
inhibiting induction of COX-2 (Fig. 13.5). By inducing annexin I~
(p. 428). they could inhibit production of lcukotrienes and platelet-
acti vating factor. although there is currently no direct evidence
that the release of thi:. protein is involved in the antiasthma
effects of glucocorticoids.
-'Tit" uncommon but \e\ ere \yndrome L\ characterised by systemic
va-.culiti'>. eo'>mophllia. and a hi'>IOJ') of asthma. sinusitis and rhinitis.
'In 1900. Soli~-Cohcn reponed that dried bovine adrenals had amia\lhma
acttvity. lie noted thm the extract dtd not >-ene acutely 'to cut shon the
paroxy'>m' but wa.s u.,cful in melting recurrence of paroxysm~. Mi.,taken
for the fir,! rcpon on the effect of adrenaline. his astule observation wa<,
probably the tir~L on the efficacy of Mcroids in asthma.
bPrcviou,ly known a~ /ipocortin-1 the nomenclature was changed in order
to comply with the hucst genomics data, which indicate then: are
approximately 30 member~ of this family! 363
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
Corticosteroids inhibit the a llergen-induced influx of eosino-
phils into the lung. Glucocorticoids up-regulate ~ adrenoceptor ,
decrease microva~cular pem1eability, and indirectly reduce mediator
release from eosinophils by inhibiting the production of cytok:ines
(e.g. TL-5 and granulocyte- macrophage colony-stimulating factor)
that activate eosinophils. Reduced synthesis of IL-3 (the cytokine
that regulates mast cell production) may explain why long-term
steroid treatment eventually reduces the number of mast cells in
the respiratory mucosa, and hence suppresses the early-phase
response to allergens and exercise.
Glucocorticoid resistance. Glucocorticoids are sometimes
ineffective, even in high doses, for reasons that are incompletely
under~tood (see for example review by Adcock & Ito, 2004). Many
individual mechanisms could contribute to this. The phenomenon
has been linked to the number of glucocorticoid receptors, but in
some situations other mechanisms arc clearly in play-for
example reduced act ivity of histo ne deacetylase (HDAC) may be
important in cigarette r.mokers (see below, p. 365).
The main compo unds used are beclometasone, budesonide,
fl uticasone, mometasonc and ciclesonide. These are given by
inhalation with a metered-dose or dry powder inhaler, the full
effect on bronchial hyper-responsiveness being attained only
after weeks or months of therapy.
Unwonted effects
Serious unwanted effects are uncommon with inhaled steroids.
Oropharyngeal candidiasis (thrush; Ch. 48) can occur (T lympho-
cytes are important in protection against fungal infection), as can
sore throat and croaky voice, but use of 'spacing' devices, which
decrease oropharyngeal deposition of the drug and increase air-
way deposition, reduces these problems. Regular high doses can
produce some adrenal suppression. particularly in children, and
necessitate carrying a 'steroid card' (Ch . 28). This is less likely
with flu ticasone, mometasone and ciclesonide, as these drugs
arc poorly absorbed from the gastrointestinal tract and undergo
almost complete presystemic metabolism. The unwanted effects
of oral g lucocorticoids are given in Chapter 28, page 433 and
Figure 28.7.
Cromoglicate and nedocromil
These drugs are now hardly used for the treatment of asthma.
Although very safe, they have only weak anti-inflammatory
effects and short duration of action. They can be used topically
for allergic conjunctivitis or rh.initi~. They are not bronchodilators,
having no direct effects on smooth muscle. nor do they inhibit the
actions of any of the known smooth muscle stimulants. Given
prophylactically, they reduce both the immediate and late-phase
asthmatic responses and reduce bronchial hyper-reactivity.
Mechanism
Their mechanism of action is not fully understood. Cromoglicate
is a mast cell stabiliser', preventing histamine release from mast
cells. However, this b not the basis of its action in asthma,
because compounds have been produced that are more potent than
cromoglicate nt inhibiting mast cell histamine release but arc
ineffective agai ns t asthma.
Cromogl icatc depresses the exaggerated neuronal reflexes that
364 are triggered by stimulatio n of the 'irritant receptors'; it suppresses
Clinical use of glucocortlcolds In asthma
Patients who require regular bronchodilators
should be considered for glucocorticoid treatment
(e.g. with inhaled beclometasone).
More severely affected patients are treated with high-
potency inhaled drugs (e.g. budesonide).
Patients with acute exacerbations of asthma may
require intravenous hydocortisone and oral
prednisolone.
A 'rescue course' of oral prednisolone may be
needed at any stage of severity if the clinical
condition is deteriorating rapidly.
Prolonged treatment with oral prednisolone, in
addition to inhaled bronchodilators and steroids, is
needed by a few severely asthmatic patients.
the response of sensory C fibres to capsaicin and may inhibit the
release ofT-cell cytokines. Various other effects on the inflammatol)
cells and mediators involved in asthma have been described.
Anti-lgE treatment
Oma lizuma b is a humanised monoclonal anti-IgE antibody It i'
effective in patients with allergic asthma a<; well as in allergic
rhinitis. It is of considerable theoretical interest (see above, p. 359.
and review by Holgate et al.. 2005). but it is very expensi\e and
its place in therapeutics is still unclear.
SEVERE ACUTE ASTHMA (STATUS
ASTHMATIC US}
Severe acute as thma is a medical emergency requiring hospitalis
ation. Treatmem includes oxygen (in high concentration, usuall)
2: 60% ), inhalatio n of s a lbutamol g iven by nebuliser, and intra
venous hydrocortisone followed by a course of oral prednisolone.
Additional measures occasionally used include nebulised ipra
tropium . intravenous sa lbutamol or aminophylline, and anti biot ic~
(if bacterial infection is present). Monitoring is by PEFR or
FEV1, and by measurement of arterial blood gases and oxygen
saturation. Oxygen saturation can be measured continuously and
non-invasively by means of an oximeter clipped over a finger.
ALLERGIC EMERGENCIES
Anaphylfllis (Ch. 19) and angio-oedema are emergencies imoh-
ing acute airways obstruction: adrenaline (epinephrine) is poten
tially life-saving. It is administered intramuscularly (or occasional!)
intravenously, as in anaphylaxis occurring in association \lith
general anaesthesia). Patients at risk of acute anaphylaxis, for
example from food or insect sting allergy, may self-admini"er
intramuscular adrenaline using a spring-loaded syringe. Oxygen.
an antihistamine such as chlorpbenamine, and hydrocortisone
are a lso indicated.
Angio-oedcma is the intermittent occurrence of focal swelling
of tho s kin or intra-abdo minal organs caused by plasma leakage

Antlaathma drugs: anti-Inflammatory
agents
Glucocorticoids (for details see Ch. 28)
These reduce the Inflammatory component in chronic
asthma and are life-saving in status asthmaticus
(acute severe asthma).
They do not prevent the immediate response to
allergen or other challenges.
The mechan1sm of act1on involves decreased formation
of cytokines, particularly those generated by Th2
lymphocytes (see key points box on p. 359), decreased
activation of eosinophils and other inflammatory cells.
They are given by inhalation (e.g. beclometaso ne);
systemic unwanted effects are uncommon at
moderate doses, but oral thrush and voice problems
can occur. Systemic effects can occur with high
doses but are less likely with m ometasone because
of its presystemic metabolism. In deteriorating
asthma, an oral glucocorticoid (e.g. prednisolone) or
intravenous hydrocortisone is also given.
~--/
from capillaries. Most often. it is mild and idiopathic'. but it can
occur as part of acute allergic reactions. when it is generally
accompanied by urticaria-'hives'--caused by histamine release
from mast cells. If the larynx is involved. it is life-threatening;
swelling in the peritoneal cavity can be very painful and mimic a
surgical emergency. It can be caused by drugs, especially
angiotensin-converting en~yme inhibitors-perhaps because they
block the inactivation of peptides such as bradykinin (Ch. 19)-
and by as pirin and related drugs in patients who are aspirin-
sensiti ve (!>cc above, p. 359, and Ch. 14, p. 233). The hereditary
form is associated with lack of C I esterase inhibitor-C I
esterase is an enzyme that degrades the complement component
C l (see Ch. 13, Fig. 13. 1). Trancxamic acid (Ch. 2 1, p. 345) or
danazol (Ch. 30, p. 453) may be used to prevent attacks in
patients with hereditary angionewvtic oedema, and administration
of C I esterase inhibitor or fresh plasma can terminate acute attacks.
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
Chronic obstructive pulmonary disease is a major global health
problem. Cigarette smoking is the main cause. and is increasing
in the developing world a!> a result of targeting by the tObacco
industry. Air pollution. also aetiologically important, is also increas-
ing, and there is a huge unmet need for effective drugs. Despite this.
COPD has received relatively little attention compared with asthma.
Clinical features. The clinical picture starts with attacks of
morning cough during the winter, and progresses to chronic
cough with intermittent exacerbations, often initiated by a cold,
when the sputum becomes purulent ('chronic bronchitis'). There
is progressive breathles~ness. Some patients have a reversible
component of airflow obstruction identifiable by an improved
FEV1 following a dose of bronchodilator. Pulmonary hypertension
THE RESPIRATORY SYSTEM
(Ch. l9) is a late complication, causing symptoms of heart failure
(cor pulmonale). Exacerbations may be complicated by type I or
type 2 respiratory failure (i.e. reduced PAo2 alone or with increased
PAco 2, respectively) requiring hospitalisation and intensive care.
Tracheostomy and artificial ventilation. while prolonging survival,
may serve only to return the patient to a miserable life.
Pathogenesis. There is small airways fibrosis, resulting in
obstruction, and/or destruction of alveoli and of elastin fibres in
the lung parenchyma. The Iauer features are hallmarks of emphy-
sema.' thought to be caused by proteases, including elastase,
released during the inflammatory response. Small airways obstmc-
tion and emphysema vary independently of one another. The
explanation for this variation is unknown. It is emphysema that
causes respiratory fai lure, because it destroys the alveoli, impairing
gas transfer. There is chronic inflammation, predominantl y in
small airways and lung parenchyma, characterised by increased
numbers of macrophagcs. ncutrophils, and T lymphocytes. The
inflammatory mediators have not been as clearly defined as in
asthma. Lipid mediators, inflammatory peptides, reactive oxygen
and nitrogen species. chemokines, cytokines and growth factors
arc all implicated (Barnes, 2004).
Pri11ciples of treatment. Stopping smoking (Ch. 43) slows the
progreM, of COPD. Patients should be immunised against
influen7a and Pneumococcus, because superimposed infections
with these organisms are potentially lethal. Glucocorticoids are
generally ineffective, in contra<;t to asthma, but a trial of gluco-
corticoid treatment is worthwhile because asthma may coexist
with COPD and have been overlooked. This contrast with asthma
is puzzling. because in both diseases multiple inflammatory genes
arc activated. which might be expected to be turned off by gluco-
corticoids. Inflammatory gene activation results from acetylation
of nuclear histoncs around which DNA is wound. Acetylation
opens up the chromatin structure. allowing gene transcription and
synthesis of inflammatory proteins to proceed. HDAC is a key
molecule in suppressing production of pro inflammatory cytokinc:..
Corticosteroids recruit HDAC to activated genes, reversing
acetylation and switching off inflammatory gene transcription
(Barnes ct al., 2004). There is a link between the severity of
COPD (but not of asthma) and reduced HDAC activity in long
tissue (Ito cl al., 2005); furthennore, HDAC activity is inhibited
by smoking-related oxidative stress. which may explain the lack
of effectiveness of glucoconicoids in COPD.
Long-acting bronchodilators have been a worthwhile if modest
advance in the treatment of COPD. but do not deal with the
underlying inflammation. No currently licensed treatments reduce
the progression of COPD or suppress the inflammation in !.mall
airways and lung parenchyma. Several new treatments that target
the inflammatory process are in clinical deve1opment (Barnes &
Stockley, 2005). Some, such a<> chernokine antagonists. are directed
again">! the influx of inflammatory cells into the airways and lung
parenchyma, whereas others target inflammatory cytokincs such
as TNF-a. POE IV inhibitors (e.g. roDumilast: Rabe et al., 2005)
7
Emphysema is a pathologica l condi ti on someti mes associated wi th COPD,
in which lung parenchyma i> destroyed and replaced by air spaces that
coalesce to form bu//al'- blister-like air-fi lled spaces in tbc lung tissue. 365
 SECTION 3 . DRUGS AFFECTING MAJOR OR GAN SYSTEMS

show some promi.,e. Other drugs that inhibit cell signalling (see
Chs 3 and 5) include inhibitors of p38 mitogen-activated protein
kina~e. nuclear factor KB and pbosphoinositide-3 kinase-y. More
pecific approaches arc to give antioxidants, inhibitors of inducible
0 '>ynthase and leukotriene 8 4 antagonists. Other treatments have
the potential to combat mucus hypersecretion. and there is a search
for -.erine proteina~e and matrix metalloproteinase inhibitors to
prevent lung destruction and the development of emphysema.
Specific aspects of treatment. Short- and long-acting inhaled
bronchodilator., can provide useful palliation in patients with a
reversible component. The main short-acting drugs arc ipratro-
pium (see p. 363) and salbutamol (p. 36 1); long-acting drugs
inc lude tiotropium (p. 362) and salmeterol or formoterol (p. 36 1).
T heophylline (p. 362) can be given by mouth but is of uncertain
benefit. Its respiratory stimu lant effect may be useful for patients
who tend to re tain C0 2 Other respiratory stimulants (e.g. doxa-
pra m ; sec Ch. 42) arc sometimes used briefly in acute respiratory
fai lure (e.g. postoperatively) but have largely been replaced by
ventilatory support (intermittent positive-pressure ventilation).
Long-term oxygen therapy administered at home pro longs life
in patient\ wi th severe disease and hypoxaemia (at least if they
refrain from 'moking-an oxygen fire is not a pleasant way to
go. especially for one's neighbours!).
Acute exacerbations. Acute exacerbations of COPD are treated
with inhaled 0 1 in a concentration (initially, at least) of only 24%
0 2, i.e. only ju'>t above atmospheric 0 2 concentration (approxi-
mate!) 20%). The need for caution is because of the risl. of
precipitating col retention as a consequence of terminating the
hypoxic d rive to respiration. Blood gases and tissue oxygen
saturation arc monitored. and in!>pired 0 2 subsequently adjusted
accordingly. Broad-spectrum antibiotics (e.g. cefuroximc: Ch. 46)
including activity again:,t 1-faemophilus injluen;:.ae are used if
there is evidence of infection. Inhaled bronchodilators may
provide some symptomatic improvement.
A system ically active g lucocorticoid (intravenous hydro-
cortisone or oral prednisolone) is also administered routinely,
although efficacy is modest. inhaled steroids do not influence the
prog ressive decline in lung function in patients with COPD, but
do improve the quality of life, probably as a result of a modest
reduction in ho,pital ad missions.
SURFACTANTS
Pulmonary l.urfactants arc not true drugs in Ehrlich s sense (Ch. 2,
p. 8). acting a'> a result of their physicochemical properties within
the airways rather than by binding to specific receptors. They are
effective in the prophylaxis and management of respiratory di'trc''
syndrome in newborn babies. especially if premature. Example,
include beractant and poractant a lpha , which are deri,ati\c~ol
the physiologically produced pulmonary surfactant protein that i'
important in preventing collapse of the alveoli. They are ad mini,.
tcred directly into the tracheobronchial tree via the endotracheal
tube. (The mothen. of premature infants are sometimes treated \\tth
glucocorticoids before birth in an attempt to accelerate maturation
of the fetal lung and minimise incidence of this disorder.)
COUGH
Cough is a protective rellex that removes foreign material and
secretions from the bronchi and bronchioles. lt is a very common
adverse e ffect of angiOiensin-converting enzyme inhibitors, in
wh ic h case the treatmen t is usual ly to substiiUte an alternmi~c
dru g, notably an angiotensin receptor antagonist, less likely lll
cause this adverse effect (Ch. 19, p. 309). It can be triggered b)
inflammation in the respiratory tract, for example by undiagnosed
a!.thma or chronic reflux with a~pi rati on, or by neopla<;ia. In thN
cases. cough suppressant (antitussant) drugs are sometimes u,eful.
for example for the dry painful cough associated with bronchial
carcinoma, where opioids are invaluable. Antitussive drug~ are to
be avoided in ca<,es of chronic pulmonary infection, as they can
cause undesirable thicl.ening and retention of sputum. and m
asthma because of the risk of respiratory depression.
DRUGS USED FOR COUGH
Antitussive drugs act by an ill-defined effect in the brain stem
depre~singan even more poorly defined cough centre'. All optotd
narcotic analgesics (see Ch. 41) have antitussive actions in do'c'
below those required for pain relief. Those used a., cough
suppressants are me mbers of the group with minimal analgest'
actions and addictive properties. New opioid analogues that
suppress cough by inhibiting release of excitatory neuropeptide'
throu gh an action on ~l receptors (see Table 4 1. 1) on sen,ory
nerves in the bronchi are being assessed.
Codeine (methylmorphine) is a weak opioid (see Ch. 41 ) \\tth
considerably less addiction liability than the main opioids, and.,
a mild cough supprcssant. lt decreases secretions in the bronchiole'.
which thicken~ sputum, and inhibits ciliary activity. Constipation
is common (~ee Chs 25 and 41 ). Dextromethorphan and
pholcodine arc believed to have fewer adverse effects.

REFERENCES AND FURTHER READING

Buck~:round mnterinl
Ert> K J 199<) Atnp1c d"ordc"'; a d~fault pathway in the
ab,ence of mfc~tion hnmunol Tod.1y 20: 317- 322
(Diwmlfl tltt- hyrmtlte\1\ that the derline of infectious
"'-""'"' in tilt deve/optd world multi tlcc'Otml for
an inaeaw in ttltlpk dhan/er:.. :.tres.1ing tile role
366 of 1hr Til ll)'fll' mwtWil' rl'spnll~<' tn infection m
inhibiting the dl!velopmnll t>/ Ulll(>y: uuju/
diagrams)
Kirstein S L. ln;el P 1\ 200* Autonomic ncrvou' '}>lcm
phanmlcogcnomic;: a progrc" report l'hunn;~cot Rev
56: 3 1- 52 (RI'I'il'WI l'l'l"l'nl idt'/11 rt'!fOnfilll{
plwrmacogetwmin of cO!IIfJlJJJ(nt.\ oftht! <Wtonoulic
nenous system)
Small K M. McGra"' D W. Liggeu S B 2()(11
Pharmacology and physiology of human ndtell(rgiC
receptor polymorpbisms. Annu Rev Pharmacol
Toxicol 43: 38 1-H l (Reviews th~ conseqttetttt uf
atlrtmergic rereptor polymorphism\ in tPnnt of
Jtgnalling. lruman phy.~io!tJgy andtliseaw~. tmd
response to therapy)
 The kidney
Overview 368
Outline of renal function 368
The structure and function of the nephron 368
-Tubular function 370
-Acid-base balance 373
-Potassium balance 373
-Excretion of organic molecules 374
-Natriuretic peptides 374
-Prostaglandins and renal function 374
._____
Drugs acting on the kidney 375
-Diuretics 375
Drugs that alter the pH of the urine 380
1--
Drugs that alter the excretion of organic
molecules 381
Drugs used in renal failure 382
- Hyperphosphataemia 382
-Hyperkalaemia 382
Drugs used in urinary tract disorders 383
OVERVIEW
The main drugs that work by altering renal
function-the diuretics-are crucial for the
management of cardiovascular disease (Chs 18 and
19). The kidneys are the main organ by which
drugs and their metabolites are eliminated from
the body (Ch. 8), and so when they fail dosing
regimens of many drugs must be adapted.
Furthermore, they are a target for various kinds of
drug toxicity (Ch. 53). In the present chapter, we
set the scene for describing drugs that aHect renal
function with a brief outline of renal physiology
based on the functional unit of the kidney-the
nephron. Subsequent emphasis is on diuretics-
drugs that increase the excretion of No ions and
water. We also consider briefly other drugs that
are used in treating renal failure and urinary tract
368 disorders. Antihypertensive drugs (commonly
indicated in kidney disease) are covered in
Chapter 19, immunosuppressant drugs (eHective in
several of the diseases that can cause renal failure,
and crucial for maintaining the health of patients
who have received a kidney transplant) in
Chapter 14, and antibacterial drugs (used to treat
renal and urinary tract infections) in Chapter 46.
OUTLINE OF RENAL FUNCTION
The main function of the lcidney is to maintain the constanq of
the 'interior environment' by eliminating waste products and b}
regulating the volume, electrolyte content and pH of the e."<tra
cellular fluid in the face of varying dietary intake and Vat)ing
environmental (e.g. climatic) demands.
The kidneys receive about a quarter of the cardiac outpm.
From the several hundred litres of plasma that flow through them
each day, they filter (in a 70-kg human) approximately 1201itre~
per day, II times the total extraceUular fluid volume. This filtrate
is similar to plasma apart from the absence of protein. A~ it
passes through the renal tubule, about 99% of the filtered water.
and much of the fi ltered sodium ions, are reabsorbed, and ~orne
substances arc secreted into it from the blood. Evenrually.
approximately 1.5 litres is voided as urine per 24 hours under
usual conditions (Table 24.1 ).
Each kidney consists of an outer cortex, an inner medulla and
a hollow pelvis, which empties into the ureter. The functional
unit is the nephron, of which there are approximately 1.4 x I()"
in each kidney (approximately half this number in people with
hypertension: Keller et al., 2003), with considerable variation
between individuab and an age-related decline.
THE STRUCTURE AND FUNCTION OF THE
NEPHRON
Each nephron consists of a glomentlus. proximal mbu/e-
comprising convoluted and straight segments, loop of Henle.
distal convoluted tubule and collecting duct-Figure 24.1. The
glomerulus comprises a tuft of capillaries projecting into a dilated
end of the renal tubule. Most nephrons lie largely or entirely 1n
the cortex. The remaining 12%, called the juxtamedullary
nephrons, have their glomeruli and convoluted tubules next to the
junction of the medulla and cortex. and their loops of Henle pa\s
deep into the medulla. l'n juxtamedullary nephrons, part of the
 THE KIDNEY

thick ascending limb of the loop of H enle (as weU as the thin pan
Tble 24.1 Reabsorption of fluid and solute in of the loop) lies in the medulla; the pan of the medulla containing
the kidneya
the thick ascending limb is known as the outer stripe of the medulla,
as opposed tO the inner stripe, which contains thin segments only
Filtered/ Excreted/ Percent age
(the difference i1. visible to the naked eye).
day dayb reabsorbed

Na' (mmol) 25000 150 99+

THE BLOOD SUPPLY TO THE NEPHRON
K (mmol) 600 90 93+ Nephrons possess the special characteristic of having two capillary
beds in series with each other (see Fig. 24. 1). The afferent arteriole
Cl"(mmol) 18000 150 99+
of each cortical nephron branches to form the glomerulus; glom-
HC03 (mmol) 4900 0 100 erular capillaries coalesce into the efferent arteriole, which, in
turn, branches to form a second capillary network in the cortex,
Total solute (mosmol) 54000 700 87 around the convoluted tubules and loops of Henle, before con-
verging on venules and thence on renal veins. By contrast,
H20 (lltres) 180 - 1.5 99+
efferent arterioles of ju.xtamedullary nephrons lead to vessel
"Typical values for a healthy young adult: renal blood flow, loops that pass deep into the medu lla with the thin loops of
1200 ml/mln (20-25% of cardiac output); renal plasma flow, Henle. These loops are called vasa recta and play a key role in
660 ml/mln; glomerular filtration rate, 125 ml/min. counter-current exchange (sec p. 373).
1>-fhese are typical figures for an individual eating a western
diet. The kidney excretes more or less of each of these
substances to maintain the constancy of the internal milieu, so THE JUXTAGLOMERULAR APPARATUS
on a low-sodium diet (for instance in the Yanomami Indians of
the upper Amazon basin), NaCI excretion may be reduced to A conjunction of afferent arteriole. efferent arteriole and distal
below 10 mmol/day! At the other extreme, individuals liv1ng in convoluted tubule ncar the glomerulus forms the juxtaglomerular
some fishing communities in Japan eat (and therefore excrete)
appamtul> (Fig. 24.2). At this site, there are specialised cells in
several hundred mmol/day.
both the afferent arteriole and in the tubule. The Iauer, termed

Bowman's capsule Glomerulus

Distal tubule

\~
Proximal tubule

/. ~tubule
Collecting

)(
w
ti
0
Peritubular capillaries
()

Arcuate
( artery
,.. __
I
I
I
I
I \ Arcuate
I
vein

I
I
I
I

: Vasa recta Loop of Henle Collecting duct

U
lg. 24.1 Simplified diagram of a juxtamedullary neph ron and its blood supply. The tubules and the blood vessels are shown
eparately for clarity. In the kidney, the peritubular capillary network surrounds the convoluted tubules, and the distal convoluted tubule
asses close to the glomerulus, between the afferent and efferent arterioles. (This last Is shown in more detail in Fig. 24.2.)
369
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
Distal tubule
Fig. 24.2 The juxtaglomerular apparatus. The cutaway
sections show the granular renin-containing cells round the
afferent arteriole, and the macula densa cells in the distal
convoluted tubule. The inset shows the general relationships j instance!> of a111iport systems-that is, ones in which sub~tancc~
l between the structures. DT, distal tubule; G, glomerulus.
(Modified from Sullivan & Grantham, 1982.)
mamla densa cells, re~pond to changes in the rate of flow and the
composition of tubule fluid, and they control renin release from
the specialised granular renin-containing cells in the afferent
arteriole (Ch. 19). Other mediators also influence renin secretion,
including ~2 agoni!.ts. vasodilator prostaglandins and feedback
inhibition from angiotensin II acting on AT1 receptors (see
Fig. 19.4). The role of tile juxtaglomerular apparatus in the
control of Na balance b dealt with below. and its cardiovascular
role ic; con!.idered in Chapter 19.
GLOMERULAR FILTRATION
Fluid il> driven from 1he capillaries into tile tubular capsule
(Bowman\ capsule) by hydrodynamic force opposed by the
oncotic pressure of the plasma proteins to whic h tile g lomerular
capi llaries arc impermeable. All the low-molecular-weight
constituents of plasma appear in the filtrate, while albumin and
larger proteins arc retained in the blood.
TUBULAR FUNCTION
The apex (lumenal surface) of each tubular cell is surrounded by
a tight junction. as in all cpitilelia. This is a specialised region of
membrane that separates tile intercellular space from the lumen
(see Figs 24.7- 24.10. below). The movement of ions and water
aero<,~ the epithelium can occur through cells (the t:ransccllular
pathway) and betll'een cell'> through tile tight junctions (tile
paracellular pathway).
THE PROXIMAL CONVOLUTED TUBULE
The epithelium of the proximal convoluted tubule is 'leaJ.:y', i.e.
the tight junction~ in the proximal tubule are not so 'tight' after
all, being permeable to ions and water, and permitting passive
flow in either direction. This prevents the build-up of large con-
cenlratio n gradients; thu!>, although approximately 60-70% of
3 70 Na reabsorptio n occurs in lhe proximal tubule, tilis lransfer is
accompanied by passive absorption of water so that fluid leaving
the proximal tubule remains approximately isotonic to the filtro1te
entering Bowman\ capsule.
Some of the transport processes in the proximal tubule are
\hown in Figure!> 24.3-24.5. The most important mechani~m for
Na entry into proximal tubular cells from lhe filtrate occur\ by
Narw exchange (Fig. 24.5). Intracellular carbonic anhydrase 1\
essential for production of W for secretion into the lumen. Na is
reabsorbed in exchange for H+. and transported out of the cell'
into the interstitium and thence into the blood by a Na fK
ATPase (sodium pump) in the basolateral membrane. This is the
main active transport mechanism of the nephron in tenns of
energy consumption. BoU1 Na+rH+ and Na+rK+ exchange arc
arc exchanged with cuch other in opposite directions across a
membrane, in distinction from symporters, where coupled
transport takes place in the same direction (see below).
Bicarbonate i!. normally completely reabsorbed in the proximal
tubule. This is achieved by combination with protons, yielding
carbonic acid, which dissociates to form carbon dioxide and
water- a reaction cataly~ed by carbonic anhydrase present in the
lumenal brush border of the proximal tubule cells (Fig. 24.5)-
followed by pa!.!.ive reabsorption of the dissolved carbon dioxide
The selective removal of sodium bicarbonate. with accompanying
water. in the early proximal tubule causes a secondary rise in the
concentration of chloride ions. Diffusion of chloride down it-.
concentration gradient via tile paracellular shunt leads. in tum. to
a lumen positive potential difference that favours reabsorption of
sodium. The other mechanism involved in movement "ia tht:
paracellular route b that sodium ions are secreted by NafK
Na+, Cl-,
glucose, HC03-.
amino acids,
water (isosmotic)
Fig. 24.3 Transport processes in the proximal
convoluted tubule. The main driving force for the absorption
of solutes and water from the lumen is the NatK ATPase in
the basolateral membrane of the tubule cells. Many drugs are
secreted into the proximal tubule (see Ch. 8). (Redrawn from
Burg, 1985.)
 THE KIDNEY

Na+ 145, 100% Na 30, 10%

c1- 115, 100% Cl 30, 10%

~
Fig. 24.4 Schematic showing
the absorption of sod ium and
chloride in the nephron and the y DT
main sites of action of drugs. Na"' Na' Cl
Cells are depicted as an orange
border round the yellow tubular
lumen. Mechanisms of ion
absorpt1on at the apical margin of
the tubule cell: (1) Natw exchange;
INTERSTITIA
(2) NatK'/2CI- cotransport; (3)
Na'/CI- cotransport, (4) Na' entry Osmotic diuretics
through sodium channels. Sodium modify filtrate
is pumped out of the cells into the content
interstitium by the Na'tK ATPase in
the basolateral margin of the tubular
cells (not shown). The numbers in
Na' 145,35%
the boxes give the concentration of
Cl- 115, 40%
ions as mlllimoles per litre of filtrate,
and the percentage of filtered ions
still remaining in the tubular fluid at
the sites specified. CT, collecting
tubule; DT, distal tubule; PCT,
proximal convoluted tubule; TAL,
Na... 0 .1-2%
thick ascending loop. (Data from
c1- 0.1- 2%
Greger, 2000.)

Proximal tubule

BASOLATERAL
/ 1 MEMBRANE

ZONA OCCLUDENS

~
-:;::. Na - - --- --- ---- ,.. Na'
;'if p
.,. /
~ .,.'
Na'..... .,."
___. .A.
NaHC03 -- -------- A
-- -
Fig. 24.5 Renal mec hanism of Hco3- - - ------ ~ Hco -
3
bicarbonate ion reabsorption in /
the proximal convoluted tubule, H2C03

-~~~-.....Jt a~~:~:e.~
showing the action of ca rbonic
anhydrase inhibitors. Sodium ions
are absorbed and H' secreted at
H2 0 + C02 ~- - - -- -- - - - - C02
the lumenal surface by an antiport
mechanism (A). The primary active
transport mechanism is the Na' LUMEN Metabolism
t I BLOOD
pump (P). The diagram Is simplified:
the sodium pump exchanges 3Na'
for 2 K. (Adapted from Hendry &
Ellory 1988 Trends Pharmacol Sci 9:
1059-1067.)
371
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEM S
ATPa~e into the lateral intercellular space, slightly ratstng irs
o~molality bccau\e of its 3:2 stoichiometry. This leads to osmotic
movement of water across the tight junction. in tum causing
sodium reab.,orption by convection (solvent drag).
Many organic acids and bases are actively secreted into the
tubule from the blood by specific transporters (see below.
Fig. 24.3 and Ch. 8).
After passage through the proximal tubule. tubular fluid (now
30-40% of the original volume of the filtrate) passes on to the
loop of Henle.
THE LOOP OF HENLE
The loop of Henle consists of a descending and an ascending
portion (Figs 24. 1 and 24.4), the ascending portion having both
thick and thin segments. Up to 30% of filtered a+ is reabsorbed
by this part of the nephron, which enables the kidney to excrete
urine that is either more or less concentrared than plasma, and
hence to regulate the osmotic balance of the body as a whole.
The descending limb is permeable to water, which exits passively
becau<,c the interstitial fluid of the medulla is kept hypertonic by
the counter-current concentrating system (p. 373).1njuxtamedullary
nephrons with long loops. there is extensive movement of water
out of the tubule 'iO that the fluid eventually reaching the tip of
the loop has a high osmolality-normally approximately
1200 mosmollkg. but up to 1500 mosmol/kg under conditions of
dehydration--compared with plasma and extracellular fluid.
which i'> approximately 300 mo~mol/kg. 1 The hypertonic milieu of
medulla. through which the collecting dueL<> of all nephron'\ pa~.,
on the way to the renal pelvis. is important in providing a
mcchani'>m by which the osmolarity of the urine is controlled
(see below).
The ascemling limb has very low permeability ro water. i.e. the
tight junctions really are 'tight'. enabling the build-up of a
substantia l concentration gradiem across the wall of the tubule. It
is here, in the thick a~cending Limb of the loop of Henle, that
20-30% of fihcrcd Na+ is reabsorbed. There is active reabsorption
of NaCl. unaccompanied by water, reducing the osmolarity of
the tubular lluid and making the interstitial fluid of the medulla
hypertonic. Jon~ move into the cell across the apical membrane
by a Na+JK+/2 Cr symporter (sec p. 370 above for the distinction
between '>ymport and antiport systems). The energy for this is
derived from the electrochemical gradient for a produced by
the Na;K" ATPase in the basolateral membrane. Chloride exits
the cell into the circulation. partly by diffusion through chloride
channel., and partly by a symport mechanism with K'". Most of
the K+ taken into the cell by the NaJK+/2cr cotransponer returns
to the lumen through apical potassium channeb. but some K+ is
reabsorbed. along with Mg2 and Ca2+.
Reabsorption of salt from the thick ascending limb is not
balanced by reabsorption of water. so tubular fluid is h)poronic
with respect to pla'>ma as it leaves the thick a cending limb and
'These figures arc for humunb; 'omc other species. notably the desert rat,
372 c;m do much better, with urine o~mol a l it i es up to 5000 mosmol/kg.
enter> the distal convoluted tubule (Fig. 24.4). The thick ascending
limb is therefore sometimes referred to as the 'diluting segment',
THE DISTAL TUBULE
In the early distal tubule. aCI reabsorption. coupled with imper-
meability of the :onula ocdudens to water, further dilutes the
tubular fluid. Transport is driven by a+/K+ ATPase in the ba'o-
lateral membrane. This lo,vers cytoplasmic Na concentration.
and consequently a enters tbe cell from the lumen dm\n il\
concentration gradient, accompanied by Cl-, by means of an
clcctroncutral a+/CJ carrier (Fig. 24.8).
The excretion of Cal il> regulated in this part of the nephron.
parathormone and calcitriol both increasing Cal+ reabsorption
(sec Ch. 31 ).
THE COLLECTING TUBULE AND
COLLECTING DUCT
Distal convoluted tubules empty into collecting tubules. which
coale'>CC to form collecting ducts (Fig. 24.1 ). Collecting tubule'
include principal cells, which reabsorb Na+ and secrete K. and
two populations of intercalated cells. a and ~which secrete acid
and ba'>c, respectively.
The tight junctions in thi:. portion of the nephron are tmper
mcablc to water and ions. The mo\'ement of ions and water m thl\
'>cgment is under independent hormonal control: absorption of
aCI by aldosteiVIU! (Ch. 19). and absorption of water b} allfl
diuretic hormone (ADH). all>o tenned msopressin (Ch. 28).
Aldosterone enhances Na+ reabsorption and promote., K
excretion. It promote~ a+ reabsorption by:
a rapid effect. stimulating Na+fH+ exchange by an action on
memhrane aldosterone reccptors 2
a delayed effect, via nuclear receptors (see Chs 3 and 28),
directi ng the ))ynthesi)) of a l>pecific protein mediator that
activates sodium channels in the apical membrane
long-term effects, by increasing the number of basolatcral
Na+ pumps.
Antidiuretic hormone is secreted by the posterior pituitary (Ch. 28t
and binds V2 receptors in the basolateral membrane!>. increasing
expression of aquaporin (water channels: see Ch. 7) in the apiwl
membranes. This renders this part of the nephron penneable to
water, allowing passive reabsorption of water as the collecting
duct traverses the hypcrosmotic region of the medulla, and hence
the excretion of concentrated urine. Con\'ersely. in the ab-..:ncc
of ADH collecting duct epithelium i!> impermeable to \\ater. '>0
hypotonic fluid that lca,es the di!>tal tubule remaini> hypotonic ;l\
it passes down the collecring ducts. leading to rhe excrctton of
eli/we urine.
Ethanol (sec p. 629) inhibits the secretion of ADH. cau,mg a
water diuresis (possibly familiar to some of our readers) ;h a ~ind
~A mcchuni~rn di~tinct from regulation of gene transcripLion, which;, the
normal rran\duction mcchunism for steroid hormones (Chs 3 and 2g).

------------------------------------
of transient diabetes ill$ipidus-a disorder in which patients
excrete large volume~ of dilute urine because of failure to secrete
ADH (pp. 425-426). Several drugs inhibit the action of ADH:
lithi um (u!.ed in p~ychiatric disorders: see Cb. 38). demeclocycline
(a tetracycline u~ed not as an antibiotic-Chapter 46--but rather
to treat condition,. \uch as some lung cancers. associated with
inappropriate secretion of ADH), colchicine (Ch. 14) and l'inca
alkaloids (Ch. 51). All the~e drugs can cause acquired forms of
11ephrogenic diabete.\ imipidus-i.e. diabetes insipidus caused
not by a failure to secrete ADH but by a failure of the renal
collecting ducts to respond to its action. Nephrogenic diabetes
insipidus can also be caused by two genetic disorders (mutations
of the Y 2 receptor in the rare X-linked variety. and mutations of
aquaporin-2 in the even rarer autosomal recessive variety).
THE MEDULLARY COUNTER-CURRENT MULTIPLIER
AND EXCHANGER
The loops of Henle of the juxtamedullary oephrons function as
counter-curren t multipliers, and the vasa recta as counter-current
exchangers. NaCI is actively reabsorbed in the thick ascending
limb. causing hypertonicity of the interstitium. In the descending
limb. water moves out and the tubular fluid becomes progress-
i\'ely more concentrated as it approaches the bend. The resulting
osmotic gradient range:. from botonicity (300 mosmoVI) at the
conical boundary to~ 1500 mosmoVI in the deepest part of the
renal papilla. This gradient is the key consequence of the counter-
current multiplier sy\tem. the main principle being that small
horizontal osmotic gradients stack up to produce a large vertical
gradient. Urea contributes to the gradient because it is more
slowly reabsorbed than water and may be added to fluid in the
descending limb, so its concentration rises along the nephron
until it reaches the collecting tubules. where it dilluses out into
the interstitium. It is thus 'trapped' in the inner medulla.
T he vertical osmotic gradient would be rapidly dissipated if
solute in the medu llary interstitium were carried away by brisk
blood now. This docs not happen because the vasa recta function
as passive COrtll/er-current exchangers: water effectively 'short-
circuits' the deepest parts of the vasa recta by leaving these
vessels a~ they descend into the medulla, re-entering them as they
ascend and exit the medulla, and thus preserving the
concentration gradient built up in the medullary interstitium by
the active counter-current multiplier.
ACID-BASE BALANCE
The kidney~ (together with the lungs: Ch. 23. p. 356) regulate the
W concentration of body Ouids. Acid or alkaline urine can be
excreted according to need. the usual requjrement being to form
acid urine to eliminate phosphoric and sulfuric acids generated
during the metabolism of nucleic acids. and sulfur-containing
amino acid~ con~umed in the diet. Consequently. metabolic acidosis
is a common accompaniment of renal failu re. Carbonic anhydrase
is essential for acid base control both because of its lumenal and
cellular roles in the proximal tubule (sec above), and because
intracellular carbonic anhydrase is essential for distal tubular
urine acidification.
THE KIDNEY
Renal tubular function
Protein-free filtrate enters via Bowman's
capsule.
Na'/K ATPase in the basolateral membrane is the
main acttve transporter. It provides the gradients for
passive transporters in the apical membranes.
6D-70% of the filtered Na and > 90% of HC03 is
absorbed in the proximal tubule.
Carbonic anhydrase is key for NaHC03 reabsorption
and distal tubular urine acidification.
The thick ascending limb of Henle's loop is
impermeable to water; 20-30% of the fi ltered NaCI is
actively reabsorbed in this segment.
Ions are reabsorbed from tubular fluid by a
Na'/K'/2 Cl- cotransporter in the apical membranes
of the thick ascending limb.
NaJK/2 Cl cotransport is inhibited by loop
diuretics.
Filtrate is diluted as it traverses the thick ascending
limb as ions are reabsorbed, so that it is hypotonic
when it leaves.
The tubular counter-current multiplier actively
generates a concentration gradient-small horizontal
differences 1n solute concentration between tubular
fluid and interstitium are multiplied vertically. The
deeper 1n the medulla, the more concentrated is the
interstitial fluid.
Medullary hypertonicity is preserved passively by
counter-current exchange in the vasa recta.
Na'/CI- cotransport (inhibited by thiazide diuretics)
reabsorbs 5-10% of filtered Na in the distal tubule.
K ' is secreted into tubular fluid in the distal tubule
and the collecting tubules and collecting ducts.
In the absence of antidiuretic hormone (ADH), collecting
tubule and collecting duct have low permeability to
salt and water. ADH increases water permeability.
Na is reabsorbed from collecting duct through
epithelial sodium channels.
These are stimulated by aldosterone and inhibited by
amiloride. K'" or W is secreted into the tubule in
exchange for Na in this distal region.
POTASSIUM BALANCE
Extracellular K-critically important for excitable tissue function;
see Chapter 4, page 63-64-is tightly controlled through
regulation of K+ excretion by the kidney. Urinary K+ excretion
matches dietary intake, usually approximately 50-100 mmol in
24 hours in western countries. M ost diuretics cause K+ loss (see
below). This causes potentially important dmg interactions (see
Ch. 52, p. 746) if they are coadministered with cardiac f(lycosides
or class l/1 a11tidysrltythmic drugs (whose toxjcity is increased
by low plasma K+; see Ch. 19). 373
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
Pota!>sium ions are transported into collecting duct-and
collecting tubule-cells from blood and interstitial fluid by Na/K
ATPasc in the ba~olateral membrane. and leak into the lumen
through a K-!>elective ion channel. la passes from tubular fluid
through !>odium channel~ in the apical membrane down the
electrocbcmical gradient created by the Na/K+ ATPase; a lumen-
negative potential difference across the cell results, increasing the
driving force for K+ secretion into the lumen. Thus K+ secretion is
coupled to Na reabsorption.
Con~equently. K+ is lost when:
more a reaches the collecting duct. as occurs with any
diuretic acting proximal to the collecting duct
Na reabsorption in the collecting duct is increased directly
(e.g. in hyperaldosteronism).
K" is retai ned when:
a reabsorption in the collecting duct is decreased, for
example by amiloridc or triamtcrenc, which block the
sodium channel in this part of the nephron, or
spironolactone or eplerenone, which antagonise aldosterone
(sec p. 379).
EXCRETION OF ORGANIC MOLECULES
There arc distinct mechanisms (see Ch. 8, Table 8.4) for secreting
organic anions and cations into the proximal tubular lumen.
Secreted anions include ~everal important drugs. for example
thia:ides, furosemide, salicylate (Ch. 14). and most penicillins
and cephalosporins (Ch. 46). Similarly, several secreted organic
cations are important drugs. for example triamterene. amiloride,
atropine (Ch. I0), morphine (Ch. 41) and quinine (Ch. 49). Both
anion and cation trun!>port mechanisms arc, like other renal ion
transport processes. indirectly powered by active transport of a
and K, the energy being derived from Na+/K+ ATPase in the
basolateral membrane.
Organic anions are exchanged with a-ketoglutarate by an anti-
port (sec p. 370 above for an explanation of antiportlsymport) in
the basolatcral membrane, and diffuse passively into the tubular
lumen (Fig. 24.3).
Organic cations diffuse into the cell from the interstitium and are
then actively transported into the tubular lumen in exchange for H.
NATRIURETIC PEPTIDE$
Endogenous A, B and C natriuretic peptides (AtW. BNP and CNP;
see Ch. 18, p. 285. and Ch. 19. p. 306) are involved in the
regulation of Na excretion. They are released from the heart in
respon~e to stretch (A and 8), from endothelium (C) and from
brain (8). They activate the particulate form of guanylate cyclase
(Ch. 3. p. 29), and cau!.e natriuresb both by renal haemodynamjc
effects (increasing glomerular capillary pressure by dilating
afferent and constricting efferent arterioles) and by direct tubular
actions. The tubular actions include the inhibition of angiotensin
IT-stimulated Na and water reabsorption in the proximal convol-
uted tubule, and of the action of ADH in promoting water
374 reabsorption in the collecting tubule.
Within the kidney, the post-translational processing of Ai~P
prohormone differs from that in other tissues, resulting in an
additional four amino acids being added to the amino terminu~ of
A P to yield a related peptide. urodilatin, that promotes 'a
excretion by acting on receptors on the lumenal side of the
collecting duct cells (Vesely. 2003).
PROSTAGLANDINS AND RENAL FUNCTION
Prostaglandins (see Ch. 13) generated in the kidney modulate ih
haemodynamic and excretory functions. The main renal pro~tag
landins in humans are vasodilator and natriuretic, namely pro-
staglandin (PG) E2 in the medulla and PGI 2 (prostacyclin) in
glomeruli. Factors that stimulate their synthesis include ischaemia,
angiotensin II , ADH and bradykinin.
Influence on haemodynamics
Prostaglandin biosynthesis is low under basal condition~. !low-
ever, when vasoconstrictors (e.g. angiotensin II, noradrenaline
rnorepinephrine]) are released, PGE 2 and PGI 2 modulate thetr
effects on the kidney by causing compensatory vasodilatation.
Influence on the renal control of NaCI and
water
The influence of renal prostaglandins on salt balance and haemo-
dynamics can be inferred from the effects of drugs that inhibit
prostaglandin synthesis. Non-steroidal anti-inflammatory drug'
(NSAID~. which inhibit prostaglandjn production; see Ch 1-t)
have little or no effect on renal function in healthy people. but
predictably cau~e acute renal failure in clinical condition' in
which renal blood Oow depends on vasodilator prostaglandm
biosynthc!>is. These include cirrhosis of the liver, heart failure.
nephrotic syndrome, glomerulonephritis and extracellular mlume
contraction (see Ch. 53. Table 53.1 and pp. 754-755). Volume
contraction st imulates the renin- angiotensin- aldosterone ~ystcm.
and the rise in angiotensin [) causes glomemlar prostaglandin
synthesis (sec above) without which glomeru lar blood now and
glomerular filtration rate would be compromised due to the
unopposed vasoconstrictor action of angiotensin IT on the afferent
and efferent arterioles. NSAIDs consequently cause renal failure
in states of extracellular volume contraction (Cuzzolin et al., 2001).
NSAIDs increase blood pressure in patients treated for h)per-
tension by impairing vasodilatation and salt excretion. They
exacerbate \alt and water retention in patients with heart failurt'
(see Ch. 19. pp. 313-314). partly by this same direct mechanism.3
'Additionally. NSAlD~ make many of the diuretics used to treat hean
failure less effective by competing witb them for the weak acid secretory
mechanism mentioned above; loop diuretics and thiazides act from \\ ilhin
the lumen by inhibiting exchange mechanisms-see later in this chaptcr-
~o blocking their secreti on into the lumen reduces their effectivenes~ by
reducing their concentration at their site or action.
 THE KIDNEY

Urinary loss of bicarbonate depletes extracellular bicarbonate,

DRUGS ACTING ON THE KIDNEY
DIURETICS
Diuretic!> increa\e the excretion of Na and water. They decrease
the reabsorption of a and (usually) Cl- from the filtrate,
increased water loss being secondary to the increased excretion
of NaCI (natriuresis). This can be achieved by:
a direct action on the cells of the nephron
indirectly, by modifying the content of the filtrate.
Because a very large proportion of salt (NaCI) and water
that passe~ into the tubule in the glomerulus is reabsorbed
(Table 24.1 ), a small decrease in reabsorption can cause a
marked increase in Na excretion. A summary diagram of the
mechanisms and sites of action of various diuretics is given
in Figure 24.4.
Note that the diuretics that have a direct action on the cells of
the nephron (with the exception of s pironolactone) act from
within the tubular lumen and reach their sites of action by being
secreted into the proximal tubule.
DIURETICS ACTING DIRECTLY ON CELLS OF THE
NEPHRON
Drug!> that cau~e NaCI los!> by an action on cells must obviously
affect those pans of the nephron where solute reabsorption
occurs. Most Na ab~orption occurs in the proximal tubule
(see above. p. 370), ~o it may seem surprising that carbonic
anhydrase inhibitors- the only class of diuretic drugs that acts
on the proximal tubule- are not particularly potent. This is
because they inhibit NaHC0 3 rather than NaCl absorption.
and HC0 1 normally has only approximately one-quarter the
abundance of Cl in the glomerular filtrate, and because of the
important sodium-reabsorbing sites further down the nephron,
which increase in activity in the face of mild volume contraction,
attenuating the effect of diuretics acting proximal to them.
Plasma HC0 3- concentration declines during chronic usc of
these drugs because of the increased urinary excretion of HC03-
and the diuretic effect of carbonic anhydrase inhibitors is con-
~cqucntly <;elf-limiting.
Their mechanism of action is shown in Figure 24.5.
Loop d iuretics
Loop diuretic~ arc the most powerful diuretics. capable of causing
the excretion of 15- 25% of filtered a+ (see Fig. 24.6 for com-
parison with a thiatide). Their action is often described-in a
phrase that conjures up a rather uncomfortable picture-as causing
'torrential urine now'. The main example is furosemide;
bumctanide i& an alternative agent. These drugs act on the thick
ascending limb, inhibiting the NafKJ2CJ- carrier in the lumenal
membrane (see above and Figs 24.4 and 24.7) by combining with
its Cl binding site.
Loop diuretics also have incompletely understood vascular
actions. Intravenous administration of furosemide to patients with
pulmonary oedema caused by acute heart failure (see Ch. 19,
p. 3 13) causes a therapeutically useful vasodilator effect before
the onset of the diuretic effect. Possible mechanisms that have
been invoked include decreased vascular responsiveness to vaso-
constrictors such as angiotensin IJ and noradrenaline; increased
formation of vasodilating prostaglandins (see above, p. 374);
decreased production of the endogenous ouabain-like natriuretic
honnonc (NatK ATPa<;e inhibitor: see Ch. 18, p. 291 ), which has
vasoconstrictor properties: and potassium channel-opening
effech in resistance arteries (see Greger et al.. 2005).
Loop diuretics increa\e the delivery of Na+ to the distal
nephron. causing loss of Wand K. Because Cl- but not HC03 is
14
12
:2
Ill
10
~0
0)

(see below), further limiting the diuretic potency of carbonic ~

w
8
anhydrase inhibitors. Instead, the main therapeutically useful .s
Q)
diuretics act on the:
.c 6
thick ascending loop of Henle .s
early distal tubule E
::::J 4
collecting tubules and dueLS. ~
C/)

For a more detailed review of the actions and clinical uses of the 2
diuretics, see Greger et aJ. (2005).

0
Diuretics acting on the proximal tubule
0.01 0.1 1.0 10 100
Carbonic anhydrase inhibitors- for example acetazolamide
Dose (mglkg)
(Fig. 24.5)---incrcasc excretion of bicarbonate with accompanying
a, K+ and water, resulting in an increased flow of an alkaline Fig. 24.6 Dose-response curves for furosemide
(frusemide) and hydrochlorothiazide, showing differences
urine and metabolic acidosis. These agents, although not now
in potency and maximum effect 'ceiling'. Note that these
used as diuretics, arc still used in the treatment of glaucoma doses are not used clinically. (Adapted from Timmerman R J et
to reduce the formatio n of aqueous humour, and also in some al. 1964 Curr Ther Res 6: 88.) 375
unusual types of infantile epilepsy.
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

Ascending limb of Henle's loop

'-1
BASOLATERAL
MEMBRANE

LUMEN I
I
\ p BLOOD
\
\
\
I
I
I

/"
--- -- ....

'' I
'
Loop diuretics
e.g. furosemide

Fig. 24.7 lon tra nsport in the thic k ascending lim b of Henle's loop , showing the s ite of action of l oop d iuretics. The sodium
pump (P) is the mam primary active transport mechanism, and Na , K and c1- enter by a cotransport system (C1 ). Chloride leaves the
cell both through basolateral chloride channels and by an electroneutral K/CI cotransport system (C~. Some K. returns to the lumen
via potassium channels in the apical membrane, and some Na is absorbed paracellularty through the zonula occludens. The diagram
is Simplified: the sodium pump exchanges 3 Na for 2 K. (Based on Greger, 2000.)

lost in the urine, the plasma concentration of HC03- increases as

In nephrotic syndrvme,4 loop diuretics become bound to albumin
plasma volume is reduced- a fo1m of metabolic alkalosis therefore
in the tubular fluid, and consequently are not available to act on the
referred to as 'contraction a lkalosis'.
Na+fK+/2Cl- carrier- another cause of diuretic resistance. Mol
Loop diuretics increase excretion of Ca2+ and Mgl+ and decrease
ecular variation in the Na ../K../2Cl- carrier may also be imponant
excretion of uric acid.
in some cases of diuretic resistance (Shankar & Bratcr, 2003).
Pharmacokinetic aspects The fraction not excreted in tl1e urine is metabolised, mainly in
Loop diuretic!> are normally readily absorbed from the liver bumeta nide by cytochrome P450 pathways and ruro-
gamointe~tinal tract, and arc usually given by mouth. They may semide being glucuronidated. The plasma balf-li\"es are about
also be given intravenou:.ly in urgent situations (e.g. acute pul- 90 minutes (longer in renal failure), and the duration of acuon
monary oedema) or when intel.tioal absorption is impaired. for 3-6 hours. The clinical use of loop diuretics is given in the box.
example as a result of reduced intestinal perfusion in patients
with chronic congesti~e heart failure. who can become resistant
to the action of orally adminiMercd diuretics. Given orally, they
act within I hour; given intravenously. they produce a peak effect
within 30 minutes. Loop diuretics are strongly bound to plasma
protein, and so do not pass directly into the glomerular filtrate.
They reach their site of action- the lumenal membrane of the 4
Seventl disea,es that damage renal glomeruli impair !.heir ability to retain
cells of the thick ascending limb--by being secreted in the
pl a~maalbumin. cau~ing mus;ivc loss of albumin in the urine and u reduced
prox imal convoluted tubule by the organic acid transport conccntratiun of albumin in I he plasma. which can in turn cause peripheral
376
mechanism; the fraction th ul> secreted is excreted in the urine. oedema. This conMcllmion is referred to as nephroric syndrome.

Clinical uses of loop diuretics
(e.g. furosemide)
Loop diuretics are used (cautiously!), in conjunction
with dietary salt restriction and often with other
classes of diuretic, in the treatment of salt and water
overload assoctated with:
acute pulmonary oedema
chronic heart failure
cirrhosis of the liver complicated by ascites
nephrotiC syndrome
renal failure.
Treatment of hypertension complicated by renal
impairment (thiazides are preferred if renal function is
preserved).
Treatment of hypercalcaemia after replacement of
plasma volume with intravenous NaCI solution.
Unwonted effects
Unwanted effects directly related to the renal action of loop
diuretic~ arc common.~ Exce!.~ive Na+ loss and diuresis arc com-
mon, especially in elderly patien~. and can cause hypoi'O!aemia
and h.\110ten~ion. Potassium lo1.s. resulting in low plasma K
(hypoka/aemia). and metabolic a lkalosis are common.
Hypokalacmia increases the effects and toxicity of several dmgs
(e.g. digoxi n , p. 292. and t) pe Ill antidysrhythmic drugs.
pp. 288-289), !10 thil> i~ potentially a clinically importanr source
of drug interaction (Ch. 52. p. 746). If necessary. hypokalaemia
can be averted or treated by concomitant use of K+-sparing
diuretic!. (sec below), &ometimes with supplementary pOLassium
replacement. llypomagne.1aemia is less often recognised but can
also be c linicall y important. llyperuricaemia is common and can
precipitate ac ute gout (sec Ch. 14. pp. 238-239).
Unwanted c ffectl> unrelated to the renal actions of the drugs
arc infreque nt. They include predictable reactions related to the
main action of these drug~. and unpredictable idiosy ncratic
reactio ns (see C h. 52, pp. 754-755). Dose-related hearing loss
(compounded by concomitant use of other ototoxic drugs such as
aminoglycosidc an tibiotics) is explained by the main action of
loop diuretics: Na+/K+/2 Cl cotransport is important in the
basolateral membrane of the stria vascularis in the inner ear, and
babie~ with ~ome fonm of Banter's syndrome (mentioned earlier)
have associated deafness. lt occurs only at much higher doses
than usually needed to produce diuresis. because renal secretion
of loop diuretic'> concentrate~ them at their site of action in the
nephron. a~ explained above.
~such unwanted effect\ an: re-enacted in extreme form in Banter's
~ymJrome type I. a ran: auto~omaJ reces,ive single gene disorder of the
Na'/K'/2 Cl tran~portcr. who~c featu res include polyhydramnio,-caused
by fetal po lyuria- and. po>UlataJiy, renal salt loss, low blood pressu re.
hypo~a l acm ic metabolic alka losis und hypcrcalciuria.
THE KIDNEY
Idiosyncratic a llergic reactions (e.g. rashes, bone marrow
dcprc.,~ion}are uncommon.
Diuretics acting on the distal tubule
Diuretic~ ac ting on the diMal tubule include thia:.ides and related
drug~. Widely u~ed thiazides include bendroflumethiazide
(bendronuwide) and h ydrochlo rothiazid e. Chemically distinct
drug!. '-"ith '>imilar actions include chlor talidone, inda pamide
and mctolazone.
Thiatide~ arc less powerful than loop diuretics (Fig. 24.6) but
arc preferred in treating uncompUcated hypertension (Ch. 19).
They arc better tolerated than loop diuretics. and in clinical trial\
have been shown to reduce risks of stroke and heart attack associ-
ated with hyperte nsion. fn the largest trial (ALLHAT 2002),
chlortalidone performed as well as newer antihypertensive drug!>
(a n angiotensin-converting enzy me [ACE] inhibitor and a cal-
cium antagonbt). They bind to the Cl- s ite of the distal LLibular
Na+Jcl- cotransport system, inhibiting its action (Figs 24.4 and
24.8) a nd causing natriuresis with loss of sodium and c hloride
ions. The re~ulting contraction in blood volume stimulates renin
~ecrction, leading to angiotensin formation and aldosterone
secretion (Ch. 19, ~ee Figs 19.4 and 19.9). This homeostatic
mechani'>m limits the effect of the diuretic on the blood pressure.
re~ulting in an in vivo dose- hypotensive response relation~hip
wit11 only a \Cry gentle gradient during chronic dosing. Potal>sium
loss (by mechani~ms explained on p. 374) can be important, as
can los'> of Mg2 Excretion of uric acid is decreased, and hypo-
chloraemic alkalosi!> can occur. Effects of thiazides on Na. K.
H+ and Mg 2 balance are thul> qualitati,ely similar to those of
loop diuretics. but ~maller in magnitude. ln contrast to loop
diuretics, however, thia:tides reduce Ca2 excretion. This could
favour thiazidcs over loop diuretics in terms of bone metabolism
during long-term use in older patients (Re id et al., 2000: Rejnmark
e t al.. 2003; Schoofs et al.. 2003). The mec hanism underlying
hypocalc iuria caused by thiazide diuretics may be e nhanced
passive Ca 2 trans port in the proximal tubule rather than active
Ca2 transport in the distal tubule (Nijenhuis e t al., 2 005).
Alt houg h milder than loop diuretics when used alone. coadmin-
istration of thiaz ide with loop diuretics has a synergistic effect.
because the loop diuretic delivers a greater fraction o f the filtered
load of Na to the site of action of the thiazide in the distal tubule.
Thi:uide diuretics have an incompletely understood vasodilator
action and can cause hyperglycaemia. When used in the treat-
ment of hypertension (Ch. 19). the initial fall in blood pressure
result'> from the decrea\ed blood volume caused by diuresis, but
the later phase is al..,o related to an action on vascular smooth
muscle. Note that d iazoxide. a non-diuretic thiazide. has powerful
vac;odilator effects cau'>ed by activation of KATP c hannels impli-
cated in the control of membrane potential in vascular !.mooth
muscle and in in.,ulin secretion (Ch. 4. p. 64). It markedly increases
blood sugar, an effect opposite to that of chemically related
~>u l fonylurea~ such as glibenclamide that inhibit KArP channels
and are used to treat diabetes (see Ch. 26). lndapamide is said to
lower blood pressure with less metabolic disturbance than related
drugs, possibly because it is marketed at a lower equivalent dose.
Thia:tide diuretics have a paradoxical effect in diabetes
ins ipidus, where they reduce the volume of urine by inte1fering 377
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

Distal tubule

BASOLATERAL
~ MEMBRANE

Filtrate
hypo-osmotic
Na \
~ ' .......... __ ....t___ _ _ ...
Fig. 24.8 Salt transport in th e I
distal convoluted tubule, showing LUMEN
I p
BLOOD
the site of action of thiazide
diuretics. The sodium pump (P) In
the basolateral membrane is the
primary active transport mechanism. Th iazides
Sod ium and chloride Ions enter by
an electroneu tral cotransp ort carrier ...
(C,). Some c1 is transported out of '
''
the cell by a K/CI cotransport '' I
carrier (C2); some leaves the cell I
through chloride channels. Some K ~ ,-"
is transported out of the cell by the c 1--
cotransport carrier (C~. and some
passes back into the tubule lumen
through potassium channels. The
diagram is simplified: the sodium
pump exchanges 3 Na for 2 K.
(Based on Greger, 2000.)

with the production of hypotonic fluid in the distal tubule, and
hence reduce the ability of the kidney to secrete hypotonic urine
(i.e. they reduce free water clearance).
Phormocokinetic aspects
ThiaL.ides and related drugs are effective orally, being well
absorbed from the gastrointestinal tract. All are excreted in the urine,
mainly by lUbular secretion (see p. 374), for which they compete
with uric acid. With the shorter-acting drugs such as bendroflu-
methiazide, the maximum effect is at about 4-6 hours and duration
is 8- 12 hours. Chlortalidone has a longer duration of action.
The clinical usc of thiazide diuretics is given in Lhe clinical box.
Clinical uaea of thiazide diuretics (e.g.
bendroflumethlazlde)
Hypertension.
Mild heart failure (loop diuretics are usually preferred).
Severe resis tant oedema (metolazone, especially, is
used, together with loop diuretics).
To prevent recurrent stone formation in idiopathic
hypercalciuria.
Nephrogenic diabetes insipidus.
378
Un wonted effects
Mild unwanted effectl> are common. These re-enact the feature~
of Gire/man 's syndrome, a rare monogenetic disorder due to an
inactivating mutation in the thiazide-sensitive Natcr cotransponer
in the distal tubule. The clinical features are milder than Barner\
syndrome (which affects the NatK +/2 Cr cotransporter-see
above), but as in Bartter's syndrome include renal salt loss, low
blood pressure and hypokalacmic metabolic alkalosis; bypocalciuria
is a feature, in contrast to Bartter's syndrome, and hypomagne
saemia is characteristic. In patients treated with thiazides, symptoms
are usually limited to the inconvenience of a mildly increased fre-
quency of micturition. Hypocalciuria may be beneficial as regards
bone metabolism (see above) and stone formation. Hyponatraemia
is potentially serious, especiaUy in the elderly. Hypokolaemia
can be a cau1.e of adverse drug interaction (see above under loop
diuretics) and can precipitate encephalopathy in patiems \\ith
severe liver disea1>e.
The commonest unwanted effect not ob,iously related to the
main renal actions of the thiazides is erectile dysfunction. Thi~
emerged in an analysis of reasons given by patients for with-
drawing from blinded treatment in Lhe Medical Research Council
mild hypertension trial, where (to Lhe surprise of the investigators)
it was significantly worse than placebo and ~-adrenoceptor antag-
onists. Thiazide-associated erecti le dysfunction is reversible; it is
less common with the low doses used in current practice but
remains a problem. Other dose-related problems include hyper-
uricaemia precipitating gout and hyperglycaemia (which does
not, however, contrai ndicate their use in low dose in patients with

diabetes mellitus: Ch. 26, pp. 402-403). idiosyncratic reactions
(e.g. rashes, blood dyscra~ias. pancreatitis and acute pulmonary
oedema) are rare but can be serious.
Aldosterone antagonists
S pironolactone and its recently marketed analogue eplerenone
(see Weinberger. 2004, for a review) have very limited diuretic
action when u~ed smgly, because distal a-/K- exchange-the
site on which they act-accounts for reabsorption of only 2CK of
filtered Na+. They do, however. have marked antihypertensive
effects (Ch. 19), prolong \Urvival in selected patients with heart
failure (Ch. 19), and can prevent hypokalaemia when combined
with loop diuretics or with thia7ides. They compete with aldosterone
(p. 372) for its intracellular receptors (see Ch. 28), thereby
inhibiting distal Na+ retention and K+ secretion (see Figs 24.4 and
24.9). Eplerenone differs from spironolactone by replacement of
a 17-a-thioacetyl group with a carbomethoxy group.
Pharmacokinetic aspects
Spironolactone i~ well absorbed from the gut. Its plasma half-life
is only I 0 minute~. but its active metabolite, canrenone, has a
plasma half-life of 16 hours. The action of spironolactone is largely
attributable to canrcnone. Con~istenr with this, its onset of action
is sloY.. taJ...ing several days to develop. Eplerenone has a shorter
elimination half-life than canrenone and has no active metabolites.
It is administered by mouth once daily.
Unwanted effects
Aldosterone antagonists predispo<;e to hyperkalaemia, which is
potentially fatal. Potassium supplements must not be coprescribed,
and close monitoring of plasma creatinine and electrolytes is needed
if these drugs are used for patients with impaired renal function.
especially if other drug~ that can increase plasma potassium, such
as ACE inhibi10rs, angiotensin recep10r antagonists (sanans)
(Ch. 19) or {3-adrenoteptor antagonists (Ch. 18) are also
prescribed-as they often arc for patients with herut failure
(Ch. 19). Gastrointest ina I upset is quite common. Actions of
spironolactonc/canrenonc on progesterone and androgen receptors
in tist.ues other than the kidney can result in gynaecomastia.
menstrual disorders and testicular atrophy. Eplerenone has lower
affinity for these receptor~. and such oestrogen-like side effects
arc lcs:. common with licensed do~cs of this drug.
The clinical u~c of potassium-sparing diuretics is given in the
clinical box.
Triamterene and amiloride
Like aldo!>tcrone antagonists, triamterene and amiloride have
only limited diuretic efficacy, because they also act in the distal
nephron. where only a ~mall fraction of a+ reabsorption occurs.
They act on the collecting tubules and collecting ducts. inhibiting
Na reabsorption by blocking lumenal sodium channels (see
Ch. 4) a11d decreasing K excretion (see Figs 24.4 and 24.9).
They can be given with K-Jo:.ing diuretics (e.g. loop diuretics,
thiaLides) in order to maintain potassium balance.
Pharmacokinetic aspects
Tria mterene is well absorbed in the gastrointestinal tract. Its
onset of action is within 2 hours. and its duration of action
THE KIDNEY
Clinical uses of potassium-sparing
diuretics (e.g. amlloride, spironolactone)
With K -losing (i.e. loop or thiazide) diuretics to
prevent K loss, where hypokalaemia is especially
hazardous (e.g. patients requiring digoxin or
amiodarone; see Ch. 18).
Spironolactone or eplerenone is used:
'" heart failure, where either of these improves
survival (see Ch.19)
in primary hyperaldosteronism (Conn's syndrome)
in resistant essential hypertension (especially low-
renin hypertension)
in secondary hyperaldosteronism caused by
hepatic cirrhosis complicated by ascites.
J2-16 hours. It i~ partly metabolised in the liver and partly
excreted unchanged in the urine. Amiloridc is less well absorbed
and ha., a slower onset, with a peak action at 6 hours and duration
of about 24 hours. Most of the drug is excreted unchanged in
the urine.
Unwanted effects
The main unwanted effect. hyperkalaemia. is related to the
pharmacological action of these drugs and can be dangerous.
especially in patients with renal impairment or receiving other drugs
that can increase plasma K+ (see above). Gastrointestinal disturb-
ances have been reported but are infrequent. Triamterene has been
identified in kidney stones, but its aetiological role is uncertain.
Idiosyncratic reactions, for example rashes, are uncommon.
The clinical usc of triamtcrcnc and amiloride is given in the
box on potassium-sparing diuretics.
DIURETICS THAT ACT INDIRECTLY BY
MODIFYING THE CONTENT OF THE FILTRATE
Osmotic diuretics
Osmotic diuretics are pharmacologically inert substances (e.g.
mannitol) that are filtered in the glomerulus but not reabsorbed
by the nephron (see Fig. 24.4).6 To cause a diuresis. they must
constitute an appreciable fraction of the osmolarity of tubular fluid.
Within the nephron, their main effect is exerted on those parts of
the nephron that arc freely permeable to water: the proximal
tubule, descending limb of the loop. and (in the presence of ADH:
6 Jn hyperglycacmia, gluco~e act~ as an osmotic diuretic once plasma
glucose exceed;, I he renal reabsorptive threshold {usually approximately
12 mmol/1), accou111ing for the cardinal symptom of polyu ria in diabetes
mellitus: sec Chapter26.
379
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

Collecting tubule

ADH (vasopressin) Aldoste rone

increases the
Fig. 2 4 .9 Act ions of hormones n u mber
and drugs on the c ollecting
tubule. The cells are impermeable
to water in the absence of Amilo r ide
antidiuretic hormone (ADH), and to
Triamterene
Na in the absence of aldosterone. p
Aldosterone acts on a nuclear
receptor within the tubule cell and
on membrane receptors (see Aldostero n e
p. 372). Chloride Ions exit the tubule
through the paracellular pathway.
Potassium Ions are added to the
filtrate, as Is H' (not shown). The
LUMEN BLOOD
Na pump (P) in the basolateral
membrane is the main source of
energy for ion movement. The
diagram is simplified: the sodium
pump exchanges 3 Na for 2 K.
(Adapted from Greger, 2000.)

see above) the collecting LUbules. Passive water reabsorption is

reduced by the presence of non-reabsorbable solute within the
tubule; consequently a larger volume of fluid remains wi thin the
proximal tubule. This has the secondary effect of reducing Na
reabsorptio n.
Therefore the mai n effect of osmotic diuretics is to increase
the amount of water excreted, with a smaller increase in Na
excretion. They are not useful in treating conditions such as heart
failure associated with Na retention but have much more limited
therape utic indications, including emergency treatment of
acutely raised intracranial or intraocular pressure. Such treatment
has nothing to do with the kidney, but relies on the increase in
plasma osmolarity by solute~ that do not e nter the brain or eye;
this results in extraction of water from these compartments.
In acute renal failure. which can occur as a result of haem-
orrhage, injury or ~ystemic infection~. the glomerular filtration
rate is reduced. and absorption of 'aCJ and water in the proximal
tubule become~ almo~t complete. so that more distal pans of the
nephron vinually 'dry up'. and urine flow ceases. Protein is
deposited in the tubules and may impede the flow of fluid. Osmotic
diuretic~ (e.g. mannitol in a dose of 12- 15 g) can limit these effects,
at least if given in the earliest stages, albeit while increasing
intravascular volume and risking left ventricular failure.
Osmotic diuretics are given intravenously.
Unll'anted effects include transient expansion of the extra-
cellular fluid volume (with a risk of causing left ventricular fa il ure)
380 and hyponatraemia. 1-leadache, nausea and vomiti ng can occur.
DRUGS THAT ALTER THE PH OF THE
URINE
It is possible, by Lhe use of pharmacological agents, to produce
urinary pH values ranging from approximately 5 to 8.5.
AGENTS THAT INCREASE URINARY PH
Carbonic anhydrase inhibitors alkalinise urine by blocking b1Cat
bonate reabsorption (see above). Citrate (given by mouth as a
mixture of sodium and potassium salts) is metabolised vw the
Krebs cycle with generation of bicarbonate, which is excreted
to give an alkaline urine. This may have some antibacterial
effect!., a!. well as improving dysuria (a common symptom ol
bladder infection. consi!.ting of a burning sensation ~hile
pas~ing urine). Additionally. some citrate is excreted in the urine
as ~uch and inhibits urinary stone formation. Alkalinisation i~
important in preventing cenain weak acid drugs with limited
aqueous !.Olubility, for example sulfonamides (now seldom u'ed
as antibacterial dmgs but important in treating Pneumocystis
infection with high-dose co-tr imoxazole-Ch. 49, p. 71 0---and
in using sulfasalazine in the management of inflammatot)
bowel disease- p. 395, and as a disease-modifying anti-
rheumatoid drug- p. 239-240), from crystallising in the urine; it
also decreases Lhe formation of uric acid and cystine stone\ by
favouring the charged anionic form that is more water-soluble
(Ch. 7, p. I 00).

Diuretics
Normally, < 1 % of filtered Na is excreted.
Diuretics increase the excretion of salt (NaCI or
NaHCO:J and water.
Loop diuretics, thiazides and K. -sparing diuretics are
the main therapeutiC drugs.
Loop diuretics (e.g. furosemide) cause copious urine
production. They inhibit the Na+/K./2 Cl-
cotransporter in the thick ascending loop of Henle.
They are used to treat heart failure and other
diseases complicated by salt and water retention.
Hypovolaemia and hypokalaemia are important
unwanted effects.
Thiazides (e.g. bendroflumethiazide) are less potent
than loop diuretics. They inhibit the Natcl-
cotransporter in the distal convoluted tubule. They
are used to treat hypertension. Erectile dysfunction is
an important adverse effect. Hypokalaemia and other
metabolic effects can occur.
Potassium-sparing diuretics:
act in the distal nephron and collecting tubules;
they are very weak diuretics but effective in some
forms of hypertension and heart failure, and they
can prevent hypokalaemia caused by loop
diuret1cs or thiazides
spironolactone and eplerenone compete with
aldosterone for its receptor
amiloride and triamterene act by blocking the
sodium channels controlled by aldosterone's
protein mediator.
Alkalinising the urin e increases the excretion of drugs that are
weak acids (e.g. salicylates and some barbiturates). Sodium bicar-
bonate is sometimes used to treat salicylate overdose (Ch. 8).
Note that Na+ overload is dangerous in cardiac failure, and that
overload with either Na+ or K+ i~ harmful in renal insufficiency.
AGENTS THAT DECREASE URINARY PH
Urinary pH can be decreased with ammonium chloride, but this
is now rarely, if ever, U!>ed clinically except in a specialised test
for renal tubular acidosis.
DRUGS THAT ALTER THE EXCRETION OF
ORGANIC MOLECULES
Uric acid metaboli!>m and excretion is relevant in the treatment of
gout, and a few points about its excretion are made here.
Uric acid i!. derived from the catabolism of purines. and is
present in plasma mainly as ionised urate. In humans, it passes
freely into the glomen1lar filtrate, and most is then reabsorbed in
the proximal tubule wh ile a s mall amount is secreted into the
THE KIDNEY
tubule by the anion-secreting mechanism (see p. 374). The net
result is excretion of approximately 8-12% of filtered urate. The
secretory mechanism is generally inhibited by low doses of drugs
that affect uric acid excretion (see below), whereas higher doses are
needed to block reabsorption. Such drugs therefore tend to cause
retention of uric acid at low doses, while promoting its excretion
at higher doses. ormal plasma urate concentration is approxi-
mately 0.24 mmoVI. In some individuals, the plasma concentration
is high, predisposing to gout. In this disorder, urate crystals are
deposited in joints and !.Oft tissues,' resulting in acute arthritis
and chalky tophi characteristic of tJ1is condition. Drugs that increase
the e limination of urate (uricosuric agents, e.g. p roben ecid and
s ulfinpyr azon e ) may be useful in such patients, although these
have largely been supplanted by a llopurinol, which inhibits
urate sy nthe1>is (C h. 14, pp. 238-239).
Prob en ecid inhibits the reabsorption of urate in the proximal
tubule, increasing its excrerion. It has the opposite effect on
penicillin, inhibiting irs secretion into the tubules and raising its
plasma concentrati o n. Given orally, probenecid is well absorbed
in the gastrointestinal tract, maximal concentrations in the plasma
occurring in about 3 hours. Approximately 90% is bound to
plm.ma albumin. Free drug passes into the glomerular filtrate but
more is actively secreted into the proximal tubule, whence it may
diffuse back because of its high lipid solubility (see also Ch. 8).
Sulfinpy r azon e i~ a congener of phen ylb u tazon e (see Ch. 14)
with a powerful inhibitory effect on uric acid reabsorption in the
proximal tubule. It is absorbed from the gastrointestinal tract, is
highly protein-bound in the pla~ma and is secreted into the
proximal tubule.
The main effect of uricosuric drugs is to block urate reab-
sorption and lower plasma urate concentration. Both probenecid
and sulfinpyra7one inhibit the secretion as weU as the reabsorp-
tion of urate and, if given in subtherapeutic doses, can actually
increase plasma urate concentrations.
Usual th erapeutic doses of salicylates, in contrast. selectively
inhibit urate secretion, increasing blood urate concentration. They
exacerbate gouty arl'hritis and antagonise the effects of more
powerful uri cosuri c agents. (But note that salicylates become uri-
cosuric th emselves at the very high doses used in the past to treat
rheumatoid arthritis.)
Some inorganic agents inhibit secretion of other drugs by the
acid carrier system. Thus probenicid, as specified above, inhibits
penicillin excretion, and at one time was used to enhance the
action of penicillin anribiotics (e.g. in single-dose treatment of
gonorrhoea). It is currently licensed in the UK to prevent nephro-
toxicity cauo;ed by cidofovir (Ch. 47), an antiviral drug used to
treat cytomegallovirus retiniris in AIDS patients for whom other
antiviral drugs are inappropriate. It is given with probenecid to
prevent its concentration within the tubular lumen, and
intravenous hydration, without which it causes tubular toxicity.
7
The di~tribu1ion i& de1ermined by body temperature: crystals come out of
solution in cool extrcmilics such as the joinLs of the big toe-the clru,sic ~i1e
for acute gout-and the pinna of the ear, a common site for gouty tophi.
381
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

mobility but otherwise cause surprisingly few symptoms. Con-

DRUGS USED IN RENAL FAILURE junctival calcification CM cause conjunctivitis ('uraemic red eye')
Calcification of the aortic valve cM cause steno~is. Acme
A huge ~pectrum of congenital and acquired diseac;es damage the
calciphvla.\is is a ~yndrome characterised by abrupt meta~tmic
kidney\. Despite their diversity, these lead ultimately to common
calcification in 1>ubcutaneous tissues and small vessels. leading
end points of acute or chronic renal failure. The management of
to e.xtcn~i\e \Oft ti'>~ue necrosis. Hyperphosphataernia is the maJor
these states depends crucially on various forms of artificial dialysis
trigger for the On\et of hyperparathyroidism in early chronic renal
or filtration. and on renal transplantation. Dialysis depends on
failure. and lead\ to renal osteodystrophy.
anticoagulation with heparin (Ch. 21) and/or epoprostenol
(Ch. 13), and transpiMtation on immunosuppession (Ch. 14). The'>C
Phosphate binders
are outside the scope of this book-interested readers should
These effects of hyperphosphataemia have led to the widespread
consult a nephrology textbook such as the Oxford Textbook of
use of phosphate-binding preparations in renal failure: approxi-
Nephrolo[?y (3rd edition, 2005). Hypertension is both a cause and
mately half of patients on chronic haemodialysis are treated with
a consequence of renal impairment. so its treatment with anti-
such drugs. The Mtacid aluminium hydroxide (Ch. 25. p. 388)
hyperrensil>e drugs (Ch. 19) is extremely important in the context
binds phosphate in the gastrointestinal tract. reducing it; absorp
of renal disease. ACE inhibitors and angiotensin IT antagonists
tion, but may increase plasma aluminium in dialysis patie nt~.
arc used as rcnoprotective agents to prevent progression of chronic
T here is huge sensitivity to this in the nephrology community.
renal impairment in proteinuric patients, where their benefi t is
because before Kerr identified the cause in Newcastle, the u~c of
over and above their effects on blood prcssuJe (see Brunner, 1992,
alum 3!. a water purifier in municipal water supplies led to a
and clinical boxes on ACE inhibitors ru1d sartans i11 Ch. 19). The
horrible and untreatable neurodegenerative condition known a~
excess mortality in patients with chronic renal disease is attri-
'dialysis dementia', and abo to a panicularly painful and refrac-
butable largely to cardiovascular diseac;e, and aggressive mMage-
tory form of bone disease. Calcium-containing phosphate-
ment of dyslipidaemia (Ch. 20) is of great importance. lmmuno-
binding agents (e.g. calcium carbonate) are widely used. The}
Htppressam drug' arc effective in halting the progression of some
are contraindicated in hypercalcaemia or hypercalciuria but until
systemic di\eases (e.g. Wegener's granulomatosis) that can cause
recently ha\'c been believed to be otherwise safe. HO\~e,er.
renal failure. They are covered in Chapter 14. Erythropoietin
calcium salt'> may predispose to tissue calcification (including of
(Ch. 22, pp. 353-354) is used to treat the anaemia of chronic renal
artery \\.all~). and calcium-containing phosphate binder\ rna~
failure. Vitamin D preparations (calcitr iol or alphacalcidol) used
actually contribute to the very higb death rates from cardiO\a'-
to treat the osteodystrophy of chronic renal failure are covered in
cular disease in dialysi~ patients (Goldsmith et al., 2004).
Chapter 31 (p. 468). Amibacterial drugs are crucial in treating renal
An anion erdwnge resin, sevelamer. lowers plasma phosphate.
and urinary tract infections, and are dealt with in Chapter 46.
This i' not abl>orbed and has an additional effect in lowering loll-
Dosing regimens of many drugs must be adapted to prevent
density lipoprotein cholesterol. It is given in gram doses by mouth
accumulation and toxicity in patients with renal failure, as
three times a day with meals. Its adverse effects are gaSLrointe~
described in detai l in clinical texts (see Carmichael. 2005). Here
tinal di~turbance, and it is contraindicated in bowel obstruction.
we cover brieny preparations used to treat or prevent two other
In a 2-year randomised &tudy of haemodialysis patient~. calcium
common and important aspects of chrorric renal fai lure, namely
carbonate was a~sociated with greater progression of arterial cal
ltyperpltosphataemia and hyperka/aemia.
cification than sevelamer (Asmus et al., 2005), and if early report'
of posit ive results on cardiovascular mortality in a randomi\cd
controlled trial of sevelamer (Dialysis Clinical Outcomes Revisited)
HYPERPHOSPHATAEMIA
arc borne out. thi!. may prove to be of considerable importance.
Phosphate metaboli~m i~ closely linked with that of calcium and
is discus. ed in Chapter 31 (pp. 463-464). Phosphate, at concen-
HYPERKALAEMIA
trations commonly occurring in chronic renal insufficiency, causes
va~cular smooth mu~cle cell differentiation into osteobla~t-like Severe hypert...alaemia is life-threatening. lt is common!~
eel)<.. able to '>U\tain mineralisation. Molecular identification of a\sociatcd with pota<,sium ion retention because of renal failure,
phosphate transporters, transporter regulators. and genes associated especially if there is concomitant hypoaldosteronism (e.g in
with familial and acquired hypo- and hyperphosphataernias has Addison'<; disease: Ch. 28. p. 427) or more common!) becau-.e
transformed current understanding of phosphate homeostasis. of drugs that interfere with renin secretion (e.g. ~-adrenocep10r
Hyperphosphataemia (plasma phosphate concentration > antagonists: Ch. II, p. 180). or with Mgiotensin n formation or
1.45 mmolll) is common in renal failure. It may be asymptomatic, action (i.e. ACE inhibitors and Mgiotensin receptor antagoni-.h:
but an acute increa~e in pla\ma phosphate causes symptoms by Ch. 19. pp. 308-31 0). or blockade of distal tubular potassium ion
causing acute hypocalcaemia. ln chronic hyperphosphataemia, excretion (above. p. 379).
hypocalcaemia is corrected by compensatory mechanisms, but Prompt treatment is indicated if the plasma K+ concentration i,
calcium phosphate precipitates in tissues if the calcium phosphate > 6.5 mmol/1. Cardiac toxicity is counteracted directly by admin-
concentration product (Ca x P) exceeds a threshold of approxi- istering calcium g/uconate intravenously (Table 18.1, p. 287).
mately 5.6 (when the concentration of each ion is expressed in and by measures that shift K+ into the intracellular compartment,
382 mmol/1). Large calcium phosphate deposits around joi nts limit for example glucose plus insulin (Ch. 26, cljnical box on p. 405).
 THE KIDNEY

Salbutamol (albute rol ), administered intravenously or by inha-
lation, abo cau~cl. cellular K+ uptake and is used for this
indication (e.g. Murdoch et al .. 1991 ); it acts synergistically with
insulin. l ntravenoul. !>O<Hum bicarbonate is also often rec-
ommended. and moves potassium into cells. Removal of exces!.ive
potassium from the body can be achieved by carion exchange
resins such as sodium or calcium polystyrene s ulfonate admin-
istered by mouth (in combination with sorbitol to prevent severe
constipation) o r a!> an enema. Dialysis is often needed.
DRUGS USED IN URINARY TRACT
DISORDERS
Bed wetting (enure~is) is normal in very young children and
persists in around 5% of children aged JO. Disordered micturition
is also extre mely common in adults of either sex, and becomes
more so with advancing age. Associated structural problems (e.g.
prostatic hypertrophy, uterine prolapse) may warrant surgical
intervention. and urinary infection--<:urable with antibiotics-
may have been overlooked. However. many ca-;es of incontinence
(socially devastating) are functional, and should in principle be
amenable to drugs acting on urinary tract smooth muscle or on
the nerves controlling thi~. Currently available treatment is,
however. disappointing. perhaps because it is not easy to prevem
incontinence without causing urinary retention.
Nocturnal cnuresi:. in children aged 10 or more may warrant
desmopressin (oral or nasal: Ch. 28. p. ~26) combined \\ith
restricting nuid intake, in addition to practical measures such as
an enuresis alarm. Tricyclic antidepressants such as a mitrypt) line
(Ch. 39) arc sometimes used for up to 3 months, but adver'e
effects including behaviour disturbance can occur, and relapse is
common after stopping treatment.
Symptoms from benign prostatic hypertrophy may be
improved by a 1-adrenoceptor antagonists. for example doxazosin
and tamsulosin (Ch. I I, p. 179), or by a S-a-reductase inhibitor
suc h as finastcridc (Ch. 30, p. 453).
Incontinence in adu lts and caused by neurogenic detru~or
muscle instability is mannged by conservative measures such as
pelvic fl oor exercises combined with muscarinic receptor antago-
nists (Ch. 10. p. 153) such as oxybutinin, tolterodine, propivc-
rine or trospium. butt he dose is limited by their adverse effect\.

REFERENCES AND FURTHER READING

Ph)~io logkala>pect \ (molecular/cellular)
Agre P 201).1 i\qu~ponn "~ter channel> INobellcx:turcl.
1\ngc,.anJtc Chemoe-lntemational Ed111on 43:
427g.....j2'1()
Bcoi.hon E B. llumphre>' M II 2001 Re!!ulation of renal
tubular ~-.:retoon ol oq:anoc compounJ,_ Kodne) lnt
59: 17-3() !Relit~" tht lituollln! '"' ph_uwlogtcal and
l>harmmo/t>l/.l<'tli ll\flr<l\ tif onum 1111tl cation
trtlnf(l<>n, am/ tliltll\\t'\ fouon b<!lit!l't!tlto "'-~ulolt!
I hill
Burg M G 1985 Renal hanJhnj; ol ,o(]oum. chloride.
water, amino acllh ami gluco,c. ln. Brenner B M,
Rector F C (cd') The kidney. 1rd cdn. Saunder~.
l'hi ladclrl11a, PI' 145 175
Gamba (j 2005 Molccui;Jr phy'>iology und
pathophy,iology of clccti'Oneutrul cution-chlolide
cotrun,poncl'\. Phy,iol Rev 85: 423-493
(Compr<!ht111io~ nte\1 ofrht moln111ar hiolt>gy.
(llllrtWII relmum.lhtll\, ami phlsiolof:ical
.Hfll<'lllrt'
ami pllllmphi'II<Jio~iC'IIItvle\ of <'liCit totramportu)
Greger R 2000 Ph~'mlng~ of '><Khum transpon. Am J
MeJ Sci J 19: 51 62 IOuWalltlitt/l<lflicfe. Corers nor
onll Va lrtlll\fl<lrl hur ulw. IJricfl_\', rluu of K. H-.
C/, fiCO,, Ct/'. \Ill:+ mtd .\OIIU' ocyamc substance
i11 l'adt of/Itt mum pom <if lite ~~tplmm. DiKu1us
ll'!llllawn fawm. f'<ltlmpiiiiWI"K',-al a.1puu and
plwnntlmlt.~ttaii"'""Pin I
Rell> R f. Elh'<>n 0 H 21KKI lll~mmahan distal tubule:
phy\lolog}. p;tthoph) 'tOlO!!> and molcx:ular anatomy.
Ph)'tol Rc !10. 277-313 <Compl"f'hmsirt' mi..,.J
Sulhan L P. Grantham J J 19821he ph)'lolog) of the
l.dnc). 2nJ edn Lea & ft>btgcr. PhilaJdphia
Pathological a'pects
Keller G. Z1mmer G. Mnll G ct al. 2003 Nephron
numhcl'\ on paucnt' "'oth pnmary h}pertcn,ion. N
Engl J 1\ted 348 I0 I I08 lAKed 35 59 + mmched
twrmc>tell\ll'e commll. 111/ oj 11lttn11 died 111 rrxul
accide111s: tftflmll llu>rr>ltOIIfl'll))
Vc,cly 0 L 2003 Nutnurclic peptides and acute ren3l
failure. Am J Phy,iol Renal Phy,iol285: Fl67 F177
(Rcoiew)
Drug;; and therapeutic aspect;
Oiurelics
Brruer 0 C 2000 Pharmacolog) of doun:ll<' Arn J 1\ted
Sci 319: 38-50 (Phannttnl<l\nttmi< 1. <lu11wl
phllmwcalog) ami ad1us1' effect\ af tlllln'/11'\ I
Greger R. Lang F. Sebdoa K. Hctdlaml A 2005 Acuon
and clinical uc of dtur~lic,, 1n: Oa..,on A M et al.
(eds) Oxford lcxtbool. of chnocal nephrology. 3rd cdn.
Oxford Unovcr.uy Pn:". Oxford. pp. 2619 2~8
I Succinct awhoritarie accom11 oj 1 tlllflttr
medumisms: )/f'OilR on dinirtliU\t'.\')
Reid I R, Ames R W ct nl. 2()()() llydmchlomthia11dc
reduces loss of conical hone tn norrnul
postmenopausal women: :1 randomized controlled tri<tl .
Am J Med 109: 362 370 (Thiu:;idto may /)( tm1ul iu
prevell/iOII bu/1101 IJ'I'(I/fTII'n/ of1)().<(1111'110()(111.\llf
nsteoporo,t\: ,,ee also. in the .\tlmt inue, St:Jm,tien A.
PI' 429-130)
Rejnmark L ct al. 2003 Oo..c-<!tTcx:t rclat ion' of l<~>fl
and Lhi:u.ide-diuretic\ on calcium homco,tJ,is: a
randomized. double-blinded Lmin,quarc multiple
cross-over study tn (XN mcnopau,al o,teopentc
women. Eur J Chn ln'c't 13 41 -50 1nre <ff<cll <if a
loop diuretic, hutiWI a thia:itle, 1111 calcmm
homecma<is " " "'"'""wl/1 lwnnf~tltn l>morl
Sc.booh M W C J et al. 21XI3 Thoa11dc dJUrell.:' and the
nsl. for hip frocture. Ann lntem \1c:d 139: -17~82
(Rouerdam smdv: thitttid<" dillll'lit 1 l>n>I<Tictl UR<IIIIII
hip fractu". /ml pmleWtm tlt111Jif'<:lln ajta lilt'
discontinued)
Sbankar S S. Brotcr 0 C 2003 Loop diun:ti.:': from the
Na K 2 Cltran,poner to chnocal u,c. ,\m J Ph>"ol
Renal Ph>sool28-l: FII -F21 IRI'Iil'll<
pltomJocoldnetir.t and plmnnilcOll\nt.mm\ tJf loop
diuretics in health tmtl itt etlemntml't tltu~rtlerl: the
awltor< it)pothr<i<t tlwtalteml e.1pref\it11t or attl\111'
of the No'IK'/2Cr traJJS(>Orter po.nihl_y llct'lilllll\ j(Jr
rediiCt!tf tfillrt!lir l"f'IJIOII.ViVI'IIt!.\',f)
Weinberger M H 2004 Eplercnonc .1 new 'clccuve
aldosterone receptor :onwgoni" . Drug' Today 40:
48 1-485 (Reoirw)
Ca,.IPO, (see also Diuretics section, aho1e)
rumu> H Get aJ 2005 Tv.o )ear compari>On of
"'' elamcr and calc own carbonate effect' on
canlooascular calcificauon and bone dcn-.t}. K<phn>l
01al Tran,plant 20: 1653-1661 (u;s pro~r,toum <>/
mK11Iar calt-ification K'ith St!ll'lamer)
C'o1.1ohno M. Brancaccio D. Galhem 1\.1. Skuopoi,L] E
2005 Pathogenesis of 11\SCu\ar calciticauon in chrono~
kidney dio;ease. Kidne) lnt 68: 429-136 !Rel'ieM
ltypuphosplwtemia and h}J><:n:alcemia as mtlrpelltlrnt
risk fllcWr\ for higher illcideTJce of amlimm< ulur
t'\'t>flls in pmienh uith clutmic_ J:.idne\, disea:rt':
... hyperplro,,phalemiu accelerare.s rite {IYOJ{TI'.Uimt of
.w('(mdary hyperparathvroidism witll the conu)miumt
/)(me lo.<s. IHJssihly linked 10 oasrulur calclllm
{Jhasllhate precipiwrio11')
Gold>milh D. Ritz E. Covic A 2004 Vascular
c:olcification: a >liff challenge for the nephrologi, t
does preventing hone disea,e cau,e aneriat dio;ea,c'!
Kidney lnt66: 1315-1333 (Potential tlan.~rrofulill.~
mh iw11 mlt..s as phosphate M11tlen IIIJ>OIIelllo "''''
chmmr rellalfaillll"f')
Antih~ pert"nsiws and renal proJection
AU.HAT Officers and Coordioaton. for the ALLHAT
C'ollaborau,e Research Group. "The Antoh>penen'""
and I opodLo-.enng Treaunem 10 J>re,enl Heart Attacl
Trial 2002 !\1ajor ouiCOIUC> on hgh-ri'l b)penen,l\c
p.1Ucnl' mnJonuzc:d 10 angiotensio-conwrtong enl) me
i mhhnor or calcium channel blocler ' doureuc: the
Ant1hypertensi'e and Lipid-Lo,.enng Treatment to
Pn:1ent llean Attack Trial CALLH~n. JAMA ~8~.
2981-2997 (M<ISsi>e trial: su aha Alfl<'l L J far
~tluonal comment: 'Thl! i!nlil'l fmm AWlAT-
thitt~ide diure/lcS a" tlte pl"f'}'errttf initialth~rup' for
11\pt"rll'llliOII' JAMA 288: 3039-3042)
Brunner H R 1992 ACE intubitor. in renal do..ca..e.
Kidney lm 42: -163--179 (E.ffeCIS b<!yomltftmr
allributabfe ro lowering blood prtn-ure)
Nijenhui~ T et al. 2005 Enhanced pa.-.'>i\e Cn'
rcub,orpoion and reduced Mg,. channel abundance
explains thiazide-induced hypocalciuriu and
383
 The gastrointestinal tract
Overview 385
The innervation and hormones of the
gastrointestinal tract 385
-Neuronal control 385
-Hormonal control 385
Gastric secretion 386
-The regulation of acid secretion by parietal cells
-Drugs used to inhibit or neutralise gastric acid
secretion 387
-Treatment of Helicobocter pylori infection 390
-Drugs that protect the mucosa 390
Vomiting 390
-Antiemetic drugs 391
----------------------~
The motility of the gastrointestinal tract 393
-Purgatives 393
-Drugs that increase gastrointestinal motility 394
-Antidiorrhoeol agents 394
-Antimotility and spasmolytic agents 394
Drugs for chronic bowel disease 395
Drugs aHecting the biliary system 396
OVERVIEW
In addition to its main function of digestion and
absorption of food, the gastrointestinal tract is one
of the major endocrine systems in the body and
has its own integrative neuronal network, the
enteric nervous system (see Ch. 9), which contains
almost the same number of neurons as the spinal
cord. It is also the site of many common
pathologies, ranging from simple dyspepsia to
complex autoimmune conditions such as Crahn's
disease. Medicines for treating these
gastrointestinal disorders comprise some 8% of all
prescriptions. In this chapter, we briefly review the
physiological control of gastrointestinal function
and then discuss the pharmacological
characteristics of drugs aHecting gastric secretion
and motility.
THE INNERVATION AND HORMONES OF
THE GASTROINTESTINAL TRACT
The blood vessels and the glands (exocrine, endocrine and
paracrinc) that comprise the gastrointestinal tract are under both
neuronal and hormonal control.
386
NEURONAL CONTROL
There arc two principal intramural plexuses in the tract: the
myenteric plexus (Auerbach's plexus) between the outer, longi-
tudinal and the middle. circular muscle layers. and the submucous
plexus (Meis~ner's plexus) on the lumenal side of the circular
muscle layer. These plexuses arc interconnected. and their ganglion
cellc: receive preganglionic parasympathetic fibres from the vagus.
which are mostly cholinergic and excitatory. although a few are
inhibitory. Incoming sympathetic fibres are Largely postgangli-
onic, and these, in addition to innervating blood vessels. smooth
muscle and some glandular cells directly, may terminate in these
plexuses, where they inhibit acetylcholine secretion (see Ch. 9).
The neurons within the plexuses constitute the enteric nervous
system and secrete not only acetylcholine and noradrenaline
(norepinephrine). but also 5-hydroxytryptamine, purines, nitric
oxide and a variety of pharmacological ly active peptides (see
Chs I 0-12, 16 and 17). The enteric plexus also contruns sensory
neurons, which respond to mecharucal and chemical stimuli.
HORMONAL CONTROL
The hormones of the gastrointestinal tract include both endocrine
and paracrine secretions. The endocrine secretions (i.e. substances
released into the bloodstream) are mainly peptidic in nature and
are synthesised by endocrine cells in the mucosa. Important
examples include gastrin and cholecystokinin. The paracrine
secretions include many regulatory peptidcs released from special
cells found throughout the wall of the tract. These hormones act
on nearby cells. and in the stomach the most important of these
is histamine. Some of these paracrine factors also function as
neurotransmitters.
Orally administered drugs arc absorbed in the gastrointestinal
tract (Ch. 7). The main functions of the gastrointestinal tract that are
important from the viewpoint of pharmacological intervention are:
gastric secretion
vomiting (emesis) 385
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
the motility of the bowel and the expulsion of the faeces
the formation and excretion of bile.
GASTRIC SECRETION
The ~tomach secretes about 2.5 litres of gastric juice daily. The
principal exocrine secretions are proeruymes such as prorennin
and pepsinogen elaborated by the chiefor peptic cells, and hydro-
chloric acid (HCI) and intrinsic factor (sec Ch. 22) secreted by
the parietal or o.\yfllic cells. Mucus-secreting cells abound among
the surface cells of the gastric mucosa. Bicarbonate ions arc also
secreted and arc trapped in the mucus. creating a gel-like pro-
tective barrier that maintains the mucosal surface at a pH of 6-7
in the face of a much more acidic environment (pH 1-2) in the
lumen. Alcohol and bile can disrupt this layer. Locally produced
'cytoprotcctive' prostaglandins stimulate the secretion of both
mucus and bicarbonate.
Disturbances in these secretory and protective mechanisms are
thought to be involved in the pathogenesis of peptic ulcer, and
the therapy of this condition includes drugs that modify each of
these factors.
THE REGULATION OF ACID SECRETION BY
PARIETAL CELLS
The regulation of acid secretion by parietal cells is especially
important in the pathogenesis of peptic ulcer. and constitutes a
particular target for drug action. The secretion of the parietal
cells is an isotonic solution of HCI ( 150 mmol/1) with a pH less
than I, the concentration of hydrogen ions being more than a
million times higher than that of the plasma. The Cl- is actively
transported into canaliculi in the cells that communicate with the
lumen of the gastric glands and thus with the stomach itself. This
Cl secretion i~ accompanied by K+, which is then exchanged for
W from within the cell by a K+/1-1+ ATPase (Fig. 25.1). Carbon ic
anhydrase catalyses the combination of carbon diox ide and water
to give carbonic acid, which dissociates into H and bicarbonate Acetylcholine
ions. The Iauer exchanges across the basal membrane of the parietnJ
cell for Cl- . The principal stimuli acting on the parietal cells are:
gastrin (a Mimulatory hormone)
acetylcholine (a stimulatory neurotransmitter)
histamine (a stimulatory local hormone)
prostaglandins E2 and f 2 (local hormones that inhibit acid
~ecrction).
Figure 25.2 summarise!> the actions of these chemical mediators.
Gastrin
Gastrin is a peptide hormone synthesised in endocrine cells of the
mucosa of the gastric antrum and duodenum. and secreted into the
portal blood. Its main action i11 stimulation of the secretion of acid
by the parietal cells, but there i11 controversy about the precise mech-
anism of stimulatory action (discussed below). Gastrin receptors on
the parietal cells have been demonstrated using the radioactively
labelled hom1one. These receptors are blocked by the experimental
386 drug proglumide (Fig. 25.2), which in hi bits gastrin action.
Cl --------~ CI - - ---~CI
, __ ~ c
--- -- -
A '-4
,-- - K K
;: ~'
HC03- HC03 ' --- ~ --
~
p
l --- ---
1:
~
' '-4
H2C03 H+ w
Cort><m;o
PLASMA anhydrase.;~ LUMEN
PARIETAL
C02 H20
CELL
Fig. 25.1 A schematic illustra tion of the s ecretion of
hydrochloric acid by the gastric parietal cell. Secretion
involves a proton pump (P), which is an W/K ATPase, a symport
carrier (C) forK and Cl-. and an antiport (A), which exchanges
Cl- and HC03 . An additional NaJH antiport situated at the
interface with the plasma may also have a role (not shown).
Ga~trin also indirectly increases pepsinogen secretion, stimu-
late~ blood now and increa~es gastric motility. Release of thi'
hormone is controlled both by neuronal transmitters and blood-
borne mediators, as well as the chemistry of the stomach content'
Amino ~tcids and small peptides directly stimulate the ga'>trin-
secreting cells, as do milk and solutions of calcium salts, explaining
why it is inappropriate to use calciurn-contaiuing salts as antacid\.
Acetylcholine is released from (e.g. vagal) neurons and stimu-
lates specific muscarinic receptors Oil the surface of the parietal
cells and on the surface of histamine-containing cells (see Ch. I01.
Histamine
Hbtaminc is discussed in Chapter 13, and only those aspecb
of its pharmacology relevant to gastric secretion will be dealt \\Jth
here. Within the stomach, mast cells (or histamine-containing
celb similar to mast cells) lying close to the parietal cell relcN
a steady basal release of histamine, which is further increa!>ed b}
gastrin and acetylcholine. The hormone acts Oil parietal cell H
receptor:-., which are re:.ponsive to histamine concentrations that
are below the threshold required for vascular H2 receptor activation.
The coordinated role of acetylcholine,
histamine and gastrin in regulating acid
secretion
The exact mechanism of ac tion of the Lbree secretagogucs on the
parietal cell is not entirely clear. A general scheme is given in
 THE GASTROINTESTINAL TRACT

secretion follow<; after the synergistic stimulation of H~ receptors

Secretion of ga trtc acid, mucu
and bicarbonate
The control of the gastrointestinal tract is through
nervous and humoral mechanisms.
Ac1d is secreted from gastric parietal cells by a
proton pump (K./H ATPase).
The three endogenous secretagogues for acid are
histamine, acetylcholine and gastrin.
Prostaglandins E2 and 12 inhibit acid, stimulate
mucus and bicarbonate secretion, and dilate
mucosal blood vessels.
The genesis of peptic ulcers involves:
infection of the gastric mucosa with Helicobacter
pylori.
an imbalance between the mucosal-damaging
(acid, pepsin) and the mucosal-protecting agents
(mucus, bicarbonate, prostaglandins E2 and l2,
and nitric oxide).
(which increa~e~ cAM P), and M 2 and gastrin receptors (which
increase cyto!>olic Ca 2 ). Arguing against this is the observation
that cimetidine (an H 2 receptor antagonist) can block the action
of all !>timuli under ~ome circumstances. This was accoumed for
in tenn~ of potentiati ng interactions at the postreceptor level.
According to the alternative. two-ceU hypothesis. which has more
explanatory power, gastrin and acetylcholine act on parietal cells
but also on a second cell type that then releases histamine that
further ~timulates the parietal cells.
This problem has been thoroughly investigated in seveml specie~
and discussed in depth by S hank ley et al. ( 1992). Some inter- and
even inrraspecie::. :.peciftcity was observed in the histamine depen-
dence of the ga&tri n response. Their overall conclusion is that
both models can operate s ide by side; that hista mine released by
muscarinic sti mulation or gastrin may integrate the local secretory
and circ ulatory re!.ponses to tbesc hormones; and that interac-
tions between histamine, acctycholine and gastrin regulate H+
secretion by the parietal cell itself.

DRUGS USED TO INHIBIT OR NEUTRALISE

Figure 25.2, which ~ummarbcs the two main theories: the 'single-
cell' or penni~~ion' hypolhe!>i!>, and the 'two-celr or transmission'
hypothesis. According to the former concept, the parietal cell
itself has H! receptors for histamine and muscarinic M2 recep-
tors for acetylcholine, a!> well as receptor!> for gastrin itself. Acid
GASTRIC ACID SECRETION
The principal clinical indications for reducing acid secretion are
peptic ulceration (both duodenal and gastric), reflux oesophagitis
(in which gastric juice causes damage to the oesophagu::.) and the

CHOLINERGIC BLOOD VESSEL

NERVE
MR 'MC' GR

} / j \
Fig. 25.2 Schematic diagram ACh Histamine Gastrin

~\ IV _ ~
showing t he one-cell and two-cell
hypotheses of the act ion of 2
0
secretagogues on the acid-
secreting gastric parietal cell, )A ,--
anta:-nR G Proglumlde

7 MR.- -t--
illustrating t he site of action of

~
drugs influencing acid secretion.
Acelylcholine and gastnn act either
directly on their receptors (the one-
cell hypothesis) or partly directly and
PARIETAL
partly indirectly by releasing
histam1ne (the two-cell hypothesis).
~I CELL

r-~
AA, arachidonic ac1d; ACh,
acelylchohne; C, symport carrier for
K" and Cl ; GR, gastrin receptor;
H2R, histamine H2 receptor; Hist,
H
... K
\
I
Cl-
I I
I
histamine; 'MC', mast cell-like c,
histamine-secret1ng cell; MR,
muscarinic receptor; NSAIDs, non- K
..
I
I

~
Cl-
steroidal anti-inflammatory drugs; P,
proton pump (WtK ATPase); PGE2 ,

l prostaglandin E2 ; PGR,
prostaglandin E2 receptor.
387
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
Zollinger-1/ison ~yndrome (a rare condition that is caused by a
gastrin-producing tumour).
The reason why peptic ulcers develop is not fully understood,
although infection of the stomach mucosa with Helicobacrer
pylorit-a Gram-negative bacillus that causes chronic gastritis-
is now generally considered to be a major cause. especially of duo-
denal ulcer. Treatment of H. pylori infection is discussed below.
Prostaglandin!> (mainly Ez and T2). synthesised in the gastric
mucosa mainly by cyclo-oxygenase-1, stimulate mucus and bicar-
bonate secretion. decrease acid secretion and cause vasodilatation,
all of which serve to protect the stomach against damage. This
probably explains the ability of many non-specific non-steroidal
anti-innammatory drugs (NSAlDs: inhibitors of prostaglandin
formation; sec Ch. 14) to cause gastric bleeding and erosions.
More selective cyclo-oxygenase-2 inhibitors such as celecoxib and
rofecoxib appear to cause less stomach damage (but see Ch. 14
for a discussion of this issue).
Therapy of peptic ulcer and renux oesophagitis aims to decrease
the secretion of gastric acid with H2 receptor antagonists or proton
pump inhibitors, and/or to neutralise secreted acid with antacids
(see Huang & Hunt, 2001 ). These treatments are often coupled
with measures to eradicate H. pylori (sec Hom, 2000).
ANTACIDS
Antacid!> arc the simplest of all the therapies for treating the
symptoms of excessive ga<;tric acid secretion. They directly neu-
tralise acid, thus raising the gastric pH: this also has the effect of
inhibiting the activity of peptic enzymes. which practically
cea'>es at pH 5. Given in sufficient quantity for long enough, they
can produce healing of duodenal ulcers but are less effective for
gastric ulcers.
Most antacids in common use are salts of magnesium and
aluminium. Magnesium salts cause diarrhoea and aluminium salts
constipation, so mixtures of these two can. happily, be used to
preserve normal bowel function. Some preparations of these s ub-
s tances (e.g. magnesium trisilicate mixture and some proprietary
aluminium preparations) contain high concentrations of sodium
and should not be given to patients on a sodium-restricted diet.
umerous antacid preparations are available; a few of the more
significant arc given below.
Magn esium hydroxide is an insoluble powder that forms
magnesium chloride in the stomach. It does not produce systemic
alkalosis, because Mg2+ is poorly absorbed from the gut. Another
salt, m agnesium tr isilicate, is an insoluble powder that reacts
slowly with the gastric juice. forming magnesium chloride and
colloidal silica. This agent has a prolonged antacid effect. and it
aJso adsorb pep:.in.
Aluminium hyd roxide gel forms aluminium chloride in the
stomach: when this reaches the intestine, the chloride is released
and is reab:.orbcd. Aluminium hydroxide raises the pH of the
gastric juice to about 4, and also adsorbs pepsin. Its action is
1Helicobactor pylori infection in the stomach has been classified as a class I
388 (definite) carcinogen for ga~tri c cancer.
gradual, and its effect continues for several hours. 2 Colloidal alu-
minium hydroxide combines with phosphates in the gastrointes-
tinal tract. and the increased excretion of phosphate in the faece\
that occurs re~ults in decreased excretion of phosphate via the
lidney. This effect has been used in treating patients with chronic
renal failure (see Ch. 24, p. 382).
T Sodium bicarbonate acts rapid!} and is said to raise the pH of ga,ui<:
ju1ce to about 7.4. Carbon dioxide is liberated, and this cau~s eructalll>n
(belching). The carbon diox1de stimulates gastrin secretion and can r.:,ult
in a ~oecondary ri'e in acid secretion. Because some sodium bicarbonate
is absorbed in the intestine, large doses or frequent administration ol thl\
antacid can cause alkalo~is. the onset of which can be insidiou,. To B\Oid
thi\ po;,ibility. ~odium bicarbonate should nor be prescribed for long
term treatment, nor should it be given to patients who arc on a ~Othum
restricted diet.
Alginatcs or simeticone arc sometimes combined with an tacids.
The former are believed to increase the viscosity and ad herence
of mucus to the oesophageal mucosa, forming a protective barrier
(sec also below), whereas the latter is a surface active compound
that, by preventing 'foanning', can relieve bloating and natulence.
The clinical use of antacids is given in the box below.
HISTAMINE H2 RECEPTOR ANTAGO NISTS
The hi:.taminc H2 receptor antagonists competitively inhibit hi'
tamine actions at all H2 receptors, bur their main clinical u'e j,
Clinical uae of agents affecting
gaatrlc acidity
Histamine H2 receptor antagonists (e.g. ranitidine):
- peptic ulcer
- reflux oesophagitis.
Proton pump inhibitors (e.g. omeprazole,
Jansoprasole):
peptic ulcer
reflux oesophagitis
as one component of therapy for Helicobacter
pylori infection
Zollinger-EIIison syndrome (a rare condition
caused by gastrin-secreting tumours)
Antacids (e.g. magnesium trisilicate, aluminium
hydroxide, alginates):
dyspepsia
- symptomatic relief in peptic ulcer or (alginate)
oesophageal reflux.
Bismuth chelate:
- as one component of therapy for H. pylori infection
2
Thcre wa\ a sugge~tion-no longer widely believed-that if aluminium was
absorbed, it could trigger Al;heimer's disease. In fact, aluminium is nor
absorbed to any significant extent during administration of aluminium
hydroxide, but some perhaps overly cautious practitioners may prefer to U>e
other antacids.
 THE GASTROINTESTINAL TRACT

as inhibitors of gastric acid secretion. They can inhibit histamine-,
gastrin- and acetylcholine-stimulated acid secretion; pepsin
secretion also falls with the reduction in volume of gastric juice.
These agents not only decrease both basal and food-stimulated
acid ~ecretion by 90% or more. but numerous clinical trials indi-
cate that they also promote healing of duodenal ulcers. However.
relapses are likel) to follow after cessation of treatment.
The drugs used are cimetidine, ranitid ine (sometimes in com-
bination with bi~muth; ~ee below), nizatidine and famotidine.
The efTect of cimetidine on ga~tric secretion in human subjects is
shown in Figure 25.3. The clinical use of H 2 receptor antagonists
is given in the clinical box on page 388.
Pharmacokinetic aspects and
unwanted eHects
The drugs are generally given o rally and are well absorbed,
although preparatio ns for intramuscular and intravenous use are
also available (except famotidine). Dosage regimens vary
depending on the conditio n under treatment. Low-dosage over-
the-counter formulations of cimetidine, ranitidine and famotidine
arc available to the general public for short-term uses, without
prescription. from pharmacies.
Unwanted effects arc rare. Diarrhoea. dizziness. muscle pains,
alopecia, transient rashes and hypergastrinaemia have been
reponed. Cimetidine sometimes causes gynaecomastia in men
and, rarely, a decrease in sexual function. This is probably caused
by a modest affinity for androgen receptors. Cimetidine also inhibits
cytochrome P450, and can retard the metabolism (and thus poten-
tiate the action) of a range of drugs including oral anticoagulants
and tricyclic antidepre:.sants. It can cause confusion in the elderly.
PROTON PUMP INHIBITORS
The first proton pump inhibitor was the substituted benzimidazole
omeprazole, which irreversibly inhibits the H+/K+ ATPase (the
proto n pump), the terminal !.tep in the acid secretory pathway
(see Figs 25. I and 25.2). Both basal and stimulated gastric acid
secre tion (Fig. 25.4) is reduced. The drug is a weak base, and
accumulates in the acid e nvironme nt of the canaliculi of the
stimulated parietal cell where it is activated. This preferential
accumulation means that it has a specific effect on these cells.
Other proton pump inhibitors include esomepra1..ole (the (S)
isomer of omeprazolc), lansoprazole, pantoprazole and
rabeprazole. The clinical use of these inhibitors is given in the
clinical box on page 388.

Pharmacokinetic aspects and

unwanted eHects
c 4 Clmetldlne Oral adminiMration is the most common route of administration.
e
~plaoo~T~
II)
although some injectable preparations are available. Omepra70le
~ 3 is given orally, but as it degrades rapidly at low pH it is adminis-
w tered as capsules containing enteric-coated granules. It is absorbed
__
c: and, from the blood, passes into the parietal cells and then into the
.Q 2 canaliculi. Increased doses give disproportionately higher increases
~
al
(/)
in plasma concentration (possibly because its inhibitory effect on
'0 acid secretion improves its own bioavailabil iry). Although its
o
< '
~J:/_~
30 60 120 150 180 210

c
e 4 Clmetldlne
II)
or placebo 100
:::

!"""I'!~
-or
0
3
.!!!
c.
2..
c: 2
.Q 50
~

::1 t::f.-~
al
(/)
c:
IC50 -so nmoVI
'iii
c.
~~~'~~~~~~~
Q)
0. 0 10-7
30 60 120 150 180 210 10-9 10 8
Time (min) Omeprazole concentration (moVI)
Fig. 25 .3 The effect of cimetidine on betazole- Fig. 25.4 The inhibitory action of omeprazole on acid
stimulated gastric acid and pe ps in s ecre tion in huma ns. secre tion from isolated human gastric glands stimulated by
Either cimetidine or a placebo was given orally 60 minutes prior 50 ~mol/1 his tamine. Acid secretion was measured by the
to a s ubcutaneous injection (1.5 mg/kg) of betazole, a relatively accumulation of a radlolabelled weak base, aminopyrine (AP),
specific histamine H2 receptor agonist that stimulates gastric in the secretory channels. The data represent the mean and
acid secretion. (Modified from Binder H J , Donaldson A M
1978 Gastroenterology 74: 371-375.)
I~tandard error of measurements from eight patients. (Adapted
~rom Lindberg Petal. 1987 Trends Pharmacal Sci 8: 399-402.)
389
 SECTION 3 DRUGS AFFE CTING MAJOR OR GAN SYSTEMS
half-life is about I hour. a l.ingle daily dose affecS acid secretion
for 2-3 days, because it accumulates in the canaliculi and inhibits
WfK ATPase irreversibly. With daily dosage, there is an increas-
ing antisecretory effect for up to 5 days, afler which a plateau
is reached.
Unwanted effects of tnis clasl> of drugs are uncommon. They may
include headache, diarrhoea (both sometimes severe) and rashe!).
Dizziness, somnolence. mental confusion, impotence, gynae-
comastia, and pain in mu~cle~ and joints have been reported.
Proton pump inhibitors should be used with caution in patient:.
with liver disease. or in women who are pregnant or brea't
feeding. The use of these drug~ may mask the symptom<,
of ga~tric cancer.
TREATMENT OF HELICOBACTER PYLORI
INFECTION
llelicobacter pylori infection has been implicated as a causative
factor in the production of gastric and. more particularly. duodenal
ulcers, as well as a risl. factor for gastric cancer. Indeed. some
\\-Ould argue that infectioul. gastroduodenitis is actually the chief
clinical entiry with ulcers. and gastric cancer its prominent sequela.
Certainly, eradkation of H. pylori infection promotes rapid and
long-term healing of ulcers, and it i' routine practice to test for
the organism in patients presenting with suggestive symptoms. If
the test is positive, then the organism can generally be eradicated
with a 1- or 2-week regimen of 'triple therapy' . A further test can
be u~ed to confirm eradication.
Triple therapy usually comprises a proton pump inhibitor in
combination with the antibacterials amoxicillin and metronidazole
or cla rithromycin. although other combinations are also used.
Sometimes. particularly in the ca..e of the 2-week regimen. bismuth-
containing preparations are added. The antibiotics are covered in
Chapter 46, and bismuth chelate!> are considered below. While
elimination of the bacillu!. can produce long-term remi~~ion of
ulcers, reinfection with the organi!>m can occur.
DRUGS THAT PROTECT THE MUCOSA
Some agents, termed cytoprotecti1e, are said to enhance endogen-
ou~ mucosal protection mechanism\> (see above) and/or to provide
a physical barrier over the surface of the ulcer.
Bismuth chelate
Bism uth chelate (colloidal bi<,muth subcitrate, tripotasl.ium
dicitratobismuthate) is used in combination regimens to trent
H. pylori. lt has toxic effects o n the bacillus, and may also
prevent its adherence to the mucosa or inhibit its bacterial
proteolytic enzymes. Tl b a lso believed to have other mucosa-
protecting actions, including coating of the ulcer base, adsorbing
pepsin, enhancing local prostaglandin synthesis and stimulating
bicarbonate secretion. The !.mall amount of bismuth that is
actually absorbed is excreted in the urine. If renal excretion ill
impaired, the raised pla~ma concentrations of bismuth can re~uh
in encephalopathy.
Unwanted effects include nausea and vomiting, and blackening
390 of the tongue and faeces.
Sucralfate
S ucralfate is a complex of aluminium hydroxide and \Uifatcd
l.ucrose, which relea!.es aluminium in the presence of acid
The residual complex carries a strong negative charge and bmd~
to cationic groups in proteins, glycoproteins, etc. It can form
complex gels with mucus, an action that is thought to decrease
the degradation of mucus by pepsin and to limit the diffu\ion of
H+. Sucralfate can also inhibit the action of pepsin and stimulate
!.ecretion of mucus. bicarbonate and prostaglandin\ from the
gastric mucosa. All these actions contribute to ih mu~o,a
protecting action.
Sucralfate is given orally, and in the acid environment of the
stomach the polymcri~ed product forms a viscous pa!>lc: about
30% is still present in the stomach 3 hours after administration. It
reduces the absorption of a number of other drugl.. including
nuoroquinolone antibiotiC!., theo phylline, tetra cycline, digoxin
and a mitri ptyline. Because it requires an acid environment for
activation, antacids given concurrently or prior to its administration
will reduce its efficacy.
Unwamed effects are few, the mo~t common being con\tipation.
which occurs in up to 15<k of patients treated. Less common cfi~'Ct'
include dry mouth, nau-,ea, vomiting, headache and ra~hc~. It
-,hould be used with caution in pregnancy, when brea~t feeding,
or in patients for whom enteral feeding is in progresl..
Misoprostol
Pros taglandins of the E and 1 series have a generally protccti1c
action in the gastrointestinal tract, and a deficiency in endogcnou'
prostaglandin production (after ingestion of a NSAID. for example)
may contribute to ulcer formation. M is oprostol is a stable ana
Iogue of prostaglandin E 1 It is given orally and is used to pro-
mote the healing of ulcer\ or to prevent the gastric damage that
can occur with chronic U!.e of NSAIDs. ft exerts a direct action
on the parietal cell (Fig. 25.2), inhibiting the basal ~ecreuon of
gastric acid as well as the stimulation of production seen in
response to food, histamine, pentagastrin and caffeine. It abo
increases mucosal blood now and augments the secretion of
mucus and bicarbonate.
Unwamed effect:} include diarrhoea and abdominal cramp~:
uterine contractions can abo occur, so the drug ~hould not b.!
given during pregnancy (unles~ deliberately to induce a therapeutic
abortion; see Ch. 30). Pro~taglandin!> and NSAID~ are discu"cd
fully in Chapters 13 and 14.
VOMITING
The act of vomiting is a physical event that results in the forceful
evacuation of gastric contents through the mouth. lt is often
preceded by nausea (a feeling of 'quealiness' or of impending
vomiting), and may be accompanied by retching (repetitive con-
traction of the abdominal muscles with or without actual di\-
charge of vomit). Vomiting can be a valuable (indeed life-~a' in g)
physiological response to the ingestion of a toxic ~ubstancc
(e.g. alcohol). but it is also an unwanted side effect of man>
clinically used drugs. notably thol.e used for cancer chemothcmp}
as well as opioids, general anaesthetics and digoXcin. Vomiting also
occurs in motion sickness and during early pregnancy, and also
 THE GASTROINTESTINAL TRACT

accompanic~ numerous disease '> tates (e.g. migraine) as well as

bacterial and viral infection!>. The reflex mechanism of vomiting

Emetic stimuli include:

THE REFLEX MECHANISM OF VOMITING chemtcals or drugs in blood or intestine
Vomiting i-, rcgularcd cemrally by the l'omiting centre and the - neuronal input from gastrointestinal tract, labyrinth
chemoreceptor trigger :.one (C7Z). both of which lie in the and central nervous system (CNS).
medulla. The CTZ i-. ~cnsitive to chemical stimuli and is the main Pathways and mediators include:
site of action of many emetic and antiemetic drugs. The blood-brain impulses from chemoreceptor trigger zone and
barrier in the neighbourhood or the crzis relatively permeable. vanous other CNS centres relayed to the vomiting
allowing circulating mediators to act directly on this centre. The centre
CTZ also regulates motion sickness, a condition caused by con- chemical transmitters such as histamine,
llicting spatial signals arising from the vestibular apparatus and acetylcholine, dopamine and 5-hydroxytryptamine,
the eye. Impulses from the CTZ pass to those areas of the brain acting on H 1, muscarinic, 0 2 and 5-HT3 receptors,
stem- known collecti vely as the vomiting centre-that control and respectively.
integrate the visceral and somatic functions involved in vomiting. Antiemetic drugs include:
An outline of the pathways involved in the control of vomiti ng H1 receptor antagonists (e.g. cyclizine)
is given in Figure 25.5 and reviewed in detail by Hornby (200 I). muscarinic antagonists (e.g. hyoscine)
The main neurotran ~ mitter<; are acetylcholine, histamine, 5- 5-HT3 receptor antagonists (e.g. ondansetron)
hydroxytryptaminc and dopamine, and receptors for these trans- 0 2 receptor antagonists (e.g. metoclopramide)
mitters have been demonstrated in the relevant areas (see cannabinoids (e.g. nabilone)
Chs 10-13 and 34). It has been hypothesised that enkephalins neurokinin-1 antagonists (e.g. aprepitant).
(see Ch. I 6) arc also implicated in the mediation of vomiting, Main side effects of principal antiemetics include:
acting po~sibly at b (CTZ) or f.l (vomiting centre) opioid receptors. drowsiness and antiparasympathetic effects
Substance P (<,cc Ch. 13) acti ng at neurokinin-] receptors in the {hyosctne, nabilone > cinnarizine)
crz. and endocannabinoid~ (Ch. 15). may also be invohed. dystonic reactions (thiethylperazine >
metoclopramide)
general CNS disturbances (nabilone)
ANTIEMETIC DRUGS headache, gastrointestinal tract upsets
Several antiemetic agents are available. and these are generally (ondansetron).
used for specific conditions. a lthough there may be some overlap.
Such drug!> arc of panicular imponance as an adjunct to cancer
chemotherapy, where the nausea and vomiting produced by many
cytotoxics (see Ch. 5 1) can be almoM unendurable. 3 In using drugs
to treat the morning sic I-. ness of pregnancy, the problem of pote n- Clinical use of antiemetic drugs
tial damage to the fetus has always to be borne in mind. In
general. all drugs should be avoided during the first 3 months of Histamine H 1 receptor antagonists (see also
pregnancy, if possible. Details of the main categories of anti emetics clinical box in Ch. 14, p. 236):
arc given below, and the ir main clinical uses are summarised in cyclizine: motion sickness
the box. cinnarizine: motion sickness, vestibular disorders
(e.g. Meniere's disease)
Receptor antagonists promethazine: severe morning sickness of
Many H 1 (~ee Ch. 14). mu~carinic (sec Ch. 10) and 5-HT3 (sec pregnancy.
Ch. I 2) receptor antagonil>tl> exhibit clinically useful antiemetic Muscarinic receptor antagonists:
activity. Of the H1 antagoni!.ts, cinnarizine. cyclizi ne, meclizine - hyoscine: motion sickness.
and promethazine arc the most commonly employed; they are Dopamine 0 2 receptor antagonists:
effective again't mlu'>ea and vomiting arising from many causes, phenothiazines (e.g. prochlorperazine): vomiting
including motion \ickness and the pre ence of irritants in the caused by uraemia, radiation, viral gastroenteritis,
stomach. None arc very effective against substances that act directly severe morning sickness of pregnancy
on the CTZ. Promethatine has proven of particular benefit for metoclopramide: vomiting caused by uraemia,
morning ~icl-.nes~ of pregnancy. and ha~ been used by NASA to radiation, gastrointestinal disorders, cytotoxic drugs.
5-Hydroxytryptamine 5-HT3 receptor antagonists
(e.g. ondansetron): cytotoxic drugs or radiation,
postoperative vomiting.
' It wa~ reported that a young. medically qualified patient being Lreated by Cannabinoids (e.g. nabilone): cytotoxic drugs
combinmion chemotherapy for ~arcoma st~ted that 'the severity of vomjting (see Ch. 15).
at time;. made the thought of death seem like u welcome relief'. 391
 SECTION 3 . DRU GS AFFECTING MAJOR ORGAN SYSTEMS

Stimulus Input Output

Pain, repulsive :
Sensory aHerents
sights and smells, .......--. Higher centres :----~
and CNS pathways
emotional factors

H 1-receptor
antagonist s, Dopamine antagonists,

'---....;;-...___,.,
muscarinic receptor
antagonists :
5-HT 3 antagonists

l
I
Motion sickness~
Labyrinth ~
Nerves to
Vestibular nuclei : CTZ Vomiting somatic and
(H1 and mACh receptors)~ (D2 and 5-HT 3 centre
:: ~~~~ (mACh receptors)
-----+- visceral
receptors

Endogenous ~
:
1
Blood _ _ _ _ _ _ _ ___,_____
,--------T------'
t t
toxins drugs ....,_,._ r .
' Release of emetogemc
agents (5-HT, prostanoids,
I Muscarinic receptor
Nucleus of the antagonists
free radicals) solitary tract

Stimuli from L Visceral

afferents
(mACh and H 1 receptors)
t
pharyn x and -+-- -
stomach (5-HT3 receptors?)
H 1-receptor
antagonists
5-HT3
antagonists

Fig. 25.!5 Schematic diagram of the factors involved in the control of vomiting, with the prob able sites of action of antiemetic
drugs. The cerebellum may function as a second relay or gating mechanism 1n the link between labyrinth and chemoreceptor trigger
zone (CTZ; not shown). 5-HT3, 5-hydroxytryptamine type 3; ACh, acetylcholine; 0 2, dopamine 0 2 ; H, histamine H1; M, muscarinic.
(Based partly on a diagram from Borison H Let al. 1981 J Clin Pharmacal 21: 235-295.)

treat space motion sickness. Drowsiness and sedation, while poss-
ibly contributing to their clinical efficacy, are the chief unwanted
effects.
Muscarinic antagonists are also good general purpose anti-
emetics. Hyoscine (SCOJ>olamine) is the most widely used example.
Tt is employed principally for prophylaxis and treatment of motion
sickness, and may be administered orally or as a transdermal patch.
Dry mouth and blurred vision are the most common unwanted
effects. Drowsiness also occurs, but the drug has less sedative
action than the antihistamines.
Selective 5-HT1 receptor antagonists, including ondansetron,
granisetron , tropisetron and dolasetron , are of particular value
in preventing and treating postoperative nausea and vomiting, or
that caused by radiation therapy or administration of cytotoxic
drugs such as cisplatin. The primary site of action of these drugs
is the crz. They may be given orally or by injection (sometimes
helpful if nau~ea is already present).
Unwanted effects such as headache and gastrointestinal upsets
arc relatively uncommon.
Antipsychotic drugs
Phenothiazines are dealt with in Chapter 38, and only those aspects
392 relevant to the control of vomiting will be considered here. Anti-
psychotic phcnothiazines, such as chlorpromazine, perphenazine,
prochlorpcrazine and trifluoperazine, are effective antiemetic~
commonly used for treating the more severe manifestations of
these disorders, particu larly the nausea and vomiting associated
with cancer, radiation therapy, cytotoxics, opioids, anaesthetic!> and
other drugs. They can be administered orally, intravenously or by
suppository. They act mainly as antagonists of the dopamine 0 2
receptors in the CTZ (see Fig. 25.5) but may also block histamine
and muscarinic receptors.
Unwamed effects are relatively frequent and include sedation
(especially chlorpromazine). hypotension, and extrapyramidal
symptoml> including dystonias and tardive dyskinesia (Ch. 38).
Other anti psychotics, such as haloperidol and levomepromazine
(Ch. 38), abo act as D2 antagonists in the crz and can be used
for acute chemotherapy-induced emesis.
Metoclopramide and domperidone
Metoclopramide is a 0 2 receptor antagonist (Fig. 25.5), closely
related to the phenothiazine group, that acts centrally on the crz
and also has a peripheral action on the gastrointestinal tract itself,
increasing the motility of the oesophagus, stomach and intestine.
This not only adds to the antiemetic effect but explains its usc in
the treatment of gastro-ocsophagcal reflux (see below), and hepatic

and biliary disorders. As metoclopramide also blocks dopamine
receptors (see Ch. 37) elsewhere in the central nervous system
(CNS). it produces a number of unwanted effects including
di orders of mo\'ement (more common in children and young
adults). fatigue, motor restlessness, spasmodic torticollis (invol-
untary twisting of the neck) and occulogyric crises (involuntary
upward eye movements). It stimulates prolactin release (see
Ch. 28), causing galactorrhoea a nd disorders of menstruation.
Dompe rido ne i a similar drug often used to treat vomiting
due to cytotoxic therapy as well as gastrointestinal symptoms.
Unlike metoclopramide. it does not readily pene trate the
blood-brain barrier and is consequently less prone to produce
central side effects. Both drugs are given orally. have plasma
half-lives of 4-5 hours and are excreted in the urine.
Cannabinoids
Anecdotal evidence original ly suggested the poss ibility of us ing
cannabinoids as antiemetics (see Pertwee, 2001). Since that time,
synthetic cannabi nol derivatives such as na bilone have been
found to decrease vomiting caused by agents that stimulate the
CTZ, and are sometimes effecti ve where other drugs have failed
(see Ch. 15, p. 253). The antiemetic effect is antagonised by
naloxone, which implies that opioid receptors may be important
in the mechani~m of action. Nabilone is given orally: it is well
absorbed from the gastrointestinal tract and is metabolised in
many tissues. It ~ plasma half-life is approximately 120 minutes.
and its metabolites are excreted in the urine and faeces.
Unll'anted effects are common. especially drowsiness. dizzi-
ness and dry mouth. Mood changes and postural hypotension are
also fairly frequent. Some patients experience hallucinations and
psychotic reactions. resembling the effect of other cannabinoids
(see Ch. 15).
Steroids and neurokinin antagonists
High-dose glucocorticoids (particularly dexamethasone; see
Chs 14 and 28) can also control emesis, especially when th is is
caused by cytoto.xics such as cisplatin. The mechanism of action
is not clear. Dexame thasone can be used alone but is frequently
deployed in combinatio n with a phe nothiazine, ondansetron or
the neurokinin- ! antagonbt a prepitant (Ch. 16). The rationale for
investigating the last of these for this indication was based on the
idea that. because substance P causes vomiting when injected
intravenously and is also found both in gastrointestinal vagal
afferent nerves and in the vomiting centre itself. neurokinin-!
antagonists could be effective antiemetics.
THE MOTILITY OF THE
GASTROINTESTINAL TRACT
Drugs that alter the motility of the gastrointestinal tract include:
purgatives. which accelerate the passage of food through the
intestine
agents that increase the moti lity of the gastrointestinal
smooth muscle without causing purgation
antidiarrhoeal drugs, which decrease motility
antispasmodic drugs, whic h decrease s mooth muscle tone.
THE GASTROINTESTINAL TRACT
PURGATIVES
The transi t of food through the intestine may be hastened by
several different types of drugs. including laxatives, faecal
softeners and stimulam purgatiles. These agents may be used to
relieve constipation or to clear the bowel prior to surgery or
examination.
Bulk and osmotic laxatives
The bulk laxatives include methylcellolose and certain plant
extracts such as s terc ulia, aga r , bran and is paghula husk . These
agents are polysaccharide polymers that arc not broken down by
the normal proce~ses of digestion in the upper part of the gastro-
intestinal tract. They form a bulky hydrated mass in the gut lumen
promoting peristalsis and improving faecal consistency. They may
take several days to work but have no serious unwanted effects.
The oslltO/ic laxatives consist of poorly absorbed solutes-the
saline purgatives- and lactulose. The main salts in use are mag-
nesium sulfate and magne5ium hydroxide. By producing an osmork
load, these agents trap increased volumes of fluid in the lumen of
the bowel. accelerating the transfer of the gut contents through
the small intestine. This results in an abnormally large volume
entering the colo n, causing distension and purgation within about
an hour. Abdominal cramps can occur. The amount of magnesium
absorbed afte r an oral dose is u ually too s mall to have adverse
systemic effect'>. but these salts should be avoided in small
children and in patients with poor renal function. in whom they
can cause heart block. neuromuscular block or CNS depression.
While isotonic or hypotonic solutions of saline purgatives cause
purgation, hypertonic solutions can cause vomiting. Sometimes,
other sodium salts of phos phate and citrate are given rectally,
by s uppository, to relieve constipation.
Lactulose i~ a ~emisynthetic disaccharide offructose and galac-
tose. It is poorly absorbed and produces an effect s imilar to that
of the other osmotic laxatives. lt takes 2-3 days to act. Unwa111ed
effects, seen with high doses, include flatulence. cramps, diar-
rhoea and elec trolyte disturba nce. Tolerance can develop.
Another agent, mac rogols, which consists of inert ethylene
glycol polymers, ac ts in the same way.
Faecal softeners
Doc usate sodium is a surface-active compound that acts in the
gastrointestinal tract in a manner similar to a detergent and pro-
duces softer faece~. It is also a weak stimulant laxative. Other agents
that achieve the \ame effect include arachis oil, which is given
a~ an enema, and liq uid paraffin. although this is now seldom used.
Stimulant laxatives
The stimulant laxative drugs act mainly by increasing eleccrolyte
and hence water secretion by the mucosa. and also by increasing
peristalsis- possibly by stimulating enteric nerves. Abdominal
cramping may be experienced as a side effect with almost any of
these drugs.
Bisacod yl may be given by mouth but is often given by
suppository. In the latter case, it s timulates the rectal mucosa,
inducing defecation in 15-30 minutes. Glycerol suppositories act
in the same man ner. Sodium picosulfate and docusate sodium 393
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
have similar action~. The former i~ given orally and is often used
in preparation for inte~tinal ~urgery or colonoscopy.
Senna and da nt ron are anthroquinone laxatives. The active
principle (after hydroly:.is of glycosidic linkages in the case of
the plant extract, ~enna) directly stimulates the myenteric plexus,
resulting in increased peristal~is and thus defecation. Another
member of the family i'> dantron. As this drug is a skin irritant and
may be carcinogenic, it i<> generally used only in the terminally ill.
Laxatives of any type should not be used when there is
obstruction of the bowel. Overuse can lead to an atonic colon
where the natural propul~>ive activity is diminished. In these cir-
cumstances. the only way to achieve defecation is to take further
amounts of laxatives, so a sort of dependency arises.
DRUGS THAT INCREASE
GASTROINTESTINAL MOTILITY
Domperidone b primarily used as an antiemetic (as described
above), but it also increases gastrointestinal motility (although
the mcchani!>m is unknown). Clinically. it increases lower oeso-
phageal sphincter pressure (thus inhibiting gastro-oesophageal
reflux). increases ga~tric emptying and enhances duodenal peri-
stalsis. It is useful in disorders of gastric emptying and in chronic
gastric reflux.
Metoclopramide (also an antiemetic; see above) stimulates gas-
tric motility, cau..ing a marked acceleration of gastric emptying.
It is useful in gastro-oesophageal reflux and in disorders of gastric
emptying. but is ineffective in paralytic ileus.
Now \\-ithdrawn (because it precipitated fatal cardiac arrhyth-
mias). cisapride stimulate!> acetylcholine release in Lhe myenteric
plexu~ in the upper ga~trointcstinal tract through a 5-HT4
receptor-mediated efTcct. Thi& raises oesophageal sphincter pressure
and increase!> gut motility. The drug was used for treating reflux
ocsophagitis and in disorders of gastric emptying.
ANTIDIARRHOEAL AGENTS
Diarrhoea is the frequent passage of liquid faeces, and this is
generally accompanied by abdominal cramps and sometimes nausea
and vomiting. It may be viewed as a physiological mechanism
for rapidly ridding the gut of poisonous or irritating substances.
There are numerou~ causes, including underlying disease, infec-
tion, toxins and even anxiety. It may also arise as a side effect of
drug or radiation therapy. Repercussions range from mild di<;-
comfort and inconvenience to a medical emergency requiring
hospitalisation and parenteral fluid and electrolyte replacement
therapy. Globally. acute diarrhoeal disease is one of the principal
cause!> of death in malnourished infants. especially in developing
countries where medical care is less accessible.
During an episode of diarrhoea. there is an increase in the motility
of the gastrointestinal tract. accompanied by an increased secretion
coupled with a decreased absorption of fluid. which leads to a
loss of electrolytes (particularly Na+) and water. Cholera toxins
and some other bacterial toxins produce a profound increase in
electrolyte and fluid secretion by irreversibly activating the
g uanine nucleot ide regulatory proteins that couple the surface
394 receptors of the mucosal cells to adenylate cyclase (see C h. 3).
There arc three approaches to the treatment of severe acute
diarrhoea:
maintenance of 11uid and electrolyte balance
u~e of anti-infective agents
use of spasmolytic or other amidiarrhoeal agents.
The maintenance of 11uid and electrolyte balance by mean!> of oral
rehydration is the fi~t priority. and wider application of this cheap
and <;imple remedy could save the lives of many infants in the
developing world. Many patients require no other treatment. In
the ileum, as in parts of the nephron, Lhere is cotransport of Na
and glucose across the epithelial cell. The presence of glucose (and
some amino acids) therefore enhances Na absorption and thu\
water uptake. Preparations of sodium chloride and glucose for oral
rehydration are available in powder form, ready to be disso lved
in water before use.
Many gastrointestinal infections are viral in origin, and
because those tha t are bacterial generally resolve fairly rapidly,
the usc of anti-infective agents is usually neither necessary nor
usefu l. Other cases may require more aggressive therapy, howe\cr.
Campylobacter sp. is the commonest strain of bacterial organi\m
causing gastroenteritis in tbe UK, and severe infections may
require erythromycin or ciprofloxacin (Ch. 46). The most common
bacterial organi~ms encountered by travellers include Escherichia
coli, Salmonella and Shigella, as well a~ protozoa such as
Giardia and C01>tosporidium spp. Chemotherapy may be nece~'
ary in treating these and other more serious infections.
Other types of antidiarrhoeal drug that mitigate the symptoms of
the condition include spasmolytic or antimotility agents, adsorb-
ent!., and agent~ that modify fluid and electrolyte transport. The,e
arc dealt with below.
Traveller's diarrhoea
More than 3 million people cross international borders each year.
Many travel hopefully, but some 20-50% come back ill, having
e ncountered enterotoxin-producing E. coli (the most common
cause) or other organisms. Most infections arc mild and self-
limiting, requ iring only oral replacement of fluid and salt. as
detai led above. General pri nciples for the treatment of traveller\
diarrhoea arc detailed by Gorbach (1987). who flippantly (although
accurately) observed that 'travel broadens the mind and loosen~
the bowels'. Up-to-date information on the condition, including
the prevalence of infectious organisms around Lhe globe as well
as recommended treatment guidelines, is issued in Lhe UK by the
National Travel Health 1etwork and Centre (see web links in the
reference list).
ANTIMOTILITY AND SPASMOLYTIC AGENTS
The main pharmacological agents that decrease motility are opiate'
(details inCh. 41) and muscarinic receptor antagonists (detaib in
Ch. I0). Agents in this latter group are seldom employed as primary
therapy for diarrhoea because of Lhcir actions on other systems,
but small doses of a tropine are used, combined with diphcnoxy-
late (sec below). The action of mo r phine, the archetypal opiate,
on the alimentary tract is complex; it increases the tone and
rhythmic contractions of the intes tine but d.iminishes propulsive

activity. The pyloric, ileocolic and anal sphincters are contracted,
and the tone of the large intel>tine is markedly increased. Its
overall effect is con~tipating.
The main opiatel> u ed for the symptomatic relief of diarrhoea
arc codeine (a morphine congener). diphenoxylate and Iope ra-
mide (both pethid ine congeners that do not readily penetrate the
blood-brain barrier and are used only for their actions in the gut).
All may have unwanted effect<; including constipation. abdominal
cramps, drow iness and diuiness. Paralytic ileus can also occur.
They should not be Ul!ed in young(< 4 years of age) children.
Loperamide is the drug of first choice for traveller's diarrhoea
and is a component of !.cvcral proprietary antidiarrhoeal medicines.
It has a re lative ly selective action on the gastrointestinal tract and
undergoes significant entcrohcpatic cycling. It reduces the fre-
quency of abdo minal cramps, decreases the passage of faeces
and shorte ns the duration of the illness.
Diphe noxylatc a lso lacks morphine-like activity in the CNS,
although large doses (25-fold higher) produce typical opioid
effects. Preparatio ns of diphenoxylate usually contain atropine as
well. Codeine and lopcramide have anti secretory actions in addition
to their effects on intestinal motility. Cannabinoid receptor agonist~
also reduce gu t motility in animall>, most probably by decreasing
acetylcholine release from enteric nerves. There have been anec-
dotal reportS of a beneficial effect of cannabis against dysentery
and cholera.
Drugs that reduce spasm in the gut are also of value in irritable
bowel syndrome and diverticular disease. Muscarinic receptor
antagonists are dealt with in Chapter 10. They decrease spasm
by inhibiting parasympathetic activity. Agents available include
atropine, hyoscine, pro pa ntheline and d icycloverine. The last
named is thought to have some additional direct relaxant action
on smooth muscle. Mebeverine, a derivative of reserpine, has a
direct relaxant action on gastrointestinal smooth muscle.
Unwanted effects arc few.
Adsorbents
Adsorbent agents arc used exte nsively in the symptomatic treat
ment of diarrhoea, altho ug h properly controlled trials proving
efficacy have not been carried o ut. The main preparations used
contain kao lin, pectin, chalk, charcoal, methyl cellulose and
activated attapulgitc (magnesium alumini um silicate). It has been
suggested that the e agents may act by adsorbing micro-
organisms or toxins, by altering the intestinal flora or by coating
and protecting the intestinal mucosa, but there is no hard evi-
dence for this. They arc often given as mixtures with other drugs
(e.g. kaolin a nd morphine rnixLUre BP).
DRUGS FOR CHRONIC BOWEL DISEASE
This category comprises irritable bowel syndrome. ulcerative
colitis and Crohn s disease. The first of these is characterised by
bouts of diarrhoea, constipation or abdominal pain. Approximately
one-third of patients fall prey to each of these manifestations.
The aetio logy of the disease is uncertain, but psychological
factors may play a part. Treatment is symptomatic, with
lopcramide or a laxative. Ulcerative colitis and Crohn's disease
THE GASTROINTESTINAL TRACT
Drugs and gastrointestinal tract motility
Purgatives include:
bulk laxatives (e.g. ispaghula husk, first choice for
slow action)
osmotic laxatives (e.g. lactulose)
faecal softeners (e.g. docusate)
stimulant purgatives (e.g. senna).
Drugs that can increase motility without purgation:
- domperidone, used in disorders of gastric
emptying.
Drugs used to treat diarrhoea:
oral rehydration with isotonic solutions of NaCI plus
glucose or starch-based cereal (important in infants)
antimotility agents, for example loperamide
(unwanted effects: drowsiness and nausea)
absorbents (e.g. magnesium aluminium silicate).
are inflammatory disorders, the latter being a granulomatous
condition especially affecting the terminal ileum and the colon.
Again, both conditions have uncertain aetiology. The following
agents are used.
Glucocorticoids
Glucoconicoids are potent anti-inflammatory agents and are dealt
with fully in Chapters 14 and 28. The drugs of choice are pred
nisolone or budesoojde, given orally or locally into the bowel by
suppository or enema.
Aminosalicylates
While glucoconicoids arc useful for the acute attacks of inflam-
matory bowel diseases, they are not the ideal for the long-term
treatment (because of their s ide effects). Maintenance of remission
in both ulccrmive colitis and Crohn's is generally achieved
us ing the aminosalicylatcs, although they are less useful in the
latte r conditio n.
Sulfasalaz:ine
SulfasalaLine is a combination of the sulfonamide s ulfa pyridine
with 5 -a minosalicylic a cid. The latter fom1s the active moiety
when it is released in the colon. Its mechanism of action is
obscure. It may reduce inflammation by scavenging free radicals,
by inhibiting proMaglandin and leukotriene production, and/or by
decreasing neutrophil chemotaxis and superoxide generation. Its
unwanted effects are diarrhoea. salicylate sensitivity and inter-
stitial nephriti . 5-aminosalicylic acid is not absorbed but the
sulfapyridine moiety, which seems to be therapeutically inert in
this instance, is ab!.orbed, and its unwanted effects are those
associated with the sulfo namides (see Ch. 46).
ewer compounds in this class, which presumably share a
simi Jar mechanism of action, include m esalazine (5-arninosalicylic
acid itself), olsalazine (two molecules of 5-aminosalicylic acid
linked by a diazo bond, which is hydrolysed by colonic bacteria)
and ba lsalazide (4-aminosalicylic acid). 395
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

Other drugs 'radiolucent choleste rol gallstones. The principal agen t is

The immuno!.uppre!>~ants azathioprine and 6-mercaptopurine
(see Ch. 14) are also ~ometimes used in patients with seYere
disease. Recently, the cytokine inhibitor infliximab (see Ch. 14)
has been used with success for the treatment of innarnmatory
bowe l diseases. The drug is expensive, and in the UK its use is
restricted to severe Crohn s disease that is unresponsive to g luco-
corticoid'> or irnmunomodulators. The antiallergy drug sodium
cromoglicate is sometimes used for treating gastrointestinal
sy mptom~ associated with food allergies.
DRUGS AFFECTING THE BILIARY SYSTEM
Drugs used to treat cholesterol cholelithiasis
The commonest pathological condition of the biliary tract is
chole~>tcrol c/wlelirhiasis, i.e. the formati on of gall s tone~ with
high chole~terol content. Surgery is generally the preferred option,
bur there are orally active drugs that di-,solve non-calcified
ursodeoxycho\k acid, a minor con~tituenl of human bile (but
the main bile acid in the bear. hence urso). Diarrhoea i~ the main
unwanted effect.
Drugs aHecting biliary spasm
Biliary colic, the pain produced by the pa'>sage of galbtones
through the bile duct. can be very intense, and immediate relief
may be required. Morphine relie\'es the pain effecti\cl). but ll
may have an undesirable local effect because it constricts the
sphincter of Oddi and raises the press ure in the bile duct.
Buprenorphine ma y be preferable. Pethidine has similar
actions, although it relaxes other <,mooth mu!..cle. for example
that of the ureter. Atropine is commonly employed to relie\e
biliary spasm because it has antispa<,modic action and may be
used in conjunction with morphine. The nitrates (sec Ch. 17) can
produce a marked fal l of intrabiliary pressure and may be used to
relieve biliary spa<>rn.

REFERENCES AND FURTHER READING

Seminal und cia sic paper
Bloc~ J \\ . Duncan\\" AM. Dur;ant C Jet al. 1972
Dcliniuon and antagomsm of hi'I.Jmine H~-n.-cep1on.
Nature 236: 385-390 (SmwWifJ<Iptr outlining the
f1IW111lllt'Oiogicalllf1pmach 111 inhibition flj acid
secrrrwn 1hmugh ai1IOROni.wn tJI on alternatil'l'
hiMmnm~ rcnptor)
lnnenation and honnones of the ga>trointesti:naltruct
Han,en M 8 20o.l The emen~ ncr"lU' system II:
gamoiniC\Ilnat fuoctions. Phannacol Toxicol 92:
249-257 (Small review on the mle of the ell/eric
nrnou.v \ \'Mem in the rmutnl af ~a.ttrointestinal
mmtlil\, Lnrt'tory liCtil'ill'. bltx><l fln"' and inunmre
Sllllllf: ~IJ.\_\ to l't'Od)
Sanger G J 200t 'leurolinm -.;K and 'K, recepto,... a'
mrgeh for drug' to treat ga,lmrntc,llnal motilit)
di;ortlcr,andpain. BrJ Phurmacoll-11: 1303 Dl2.
( Usejn/ tie"' that deal willt Ihe present tmd
pm~ntial jmurt us~s of JU'Iirr)~tnilt antagoni\1\ in
ga.urotm~\lmal physiology and fkllhaltJ/IY)
Spiller R ~00~ Serotooergic modulatong drug' (or
funcuonall!""roint~tonal di\C3\C\. 8r J Clio
Phannacol ~4: 11-20 (An ~\ce/1('111 mul "eliSil\
dil/ellihl~ artide descnbin11 flu lme:.tlhinking on lire
u<e of ~-lmlro.\ylryptamine tll(tmi:.t:. and mllag<mi\1\
in 1:01trointcstinal fimclirm; urful dtagrllm<)
Van Oudcnho'e L. Dcm)ltcnaere K. Tack J. Aziz Q
200t Ccntrnl ner.ous S}'tem inH>hement in
funcuon.ll !!">lrorntestinat d1\0nler... Be~! Pract Re'
Cl1 n G:l\trocntcrol 18: 663-68() !Small mi<"<llrat
focu<t'f on/Ire mle of the CNS 11.1 reealed by
ima~:in~ \/tidies-in regu/(}(illlllfO:>troimeslinal
fimC/iiJn, <1/:.o discuss~\ thf relotwnsltip beMPI'II
P'.'rlua1ru dtsorrhn and !llllfromt~rlinal dimnlu:. )
Gastric secretion
Shanllcy N P. \\chh N J, Btacl J W 1992. Histamonc
dependence of pcotagastnnMimulated acid secretion
in rat\. Yale J Bioi Med 65:6 13- 6 19 (Pllper that
cri1icafll ewmm.-; the on<'cellmrd 1\W<ell
h\jl<llhne\ oj gltlfric acid \I'UI'twn l
Drugs in ~:a~lric disorders
Axon A, Forman D 1997 HeliwhaotJ g!l>lruduodcnili<:
a seriou ~ on fccllt>U\ disease. Br Mcd J 3 14: 1430-1431
(dimria/,mllmelll)
Bateman D ' 1997 Proton-pump rnh1h11<>r.: three of a
kind' Lan.:c! 3-19. 1637-1638 (f.Jitt>ri<l/ COfllfll<'lllllry)
Bl:1>er M J 1996 The bacteria hch1nd ulcer.. Sci Am Feb:
92-97 CStmple coera11e. ery gnntl tlw~:ramJ)
Blaser M J 1998 Helicobafter pylr>rl and ga.,tric disen,c.
Br Med J ,16: 1507- 15 10 (Sucrrmf t<'l'iew; emplrn~i1
011 fi<lllf'l' tlr tlopmems)
Hom J H 1000 The proton-pump inh1b110r.: ~unilanue,
and ditTercn<.-.:\ Chn Ther 22: 266-280 CE.tu//~111
o'enien)
Huang J Q. ltunt R H 2001 Phannncotog1cal and
pharmacodynamic essent ials of I t.-rcccplor
antagoni~h and proton pump inhibitor. for the
practi"n~ phy'>ician. Baillierc' Be'! Pmc1 Res Chn
Ga.,uoenterol 15: 355-370
Klotz U 2000 The role of :unillO'oahc) late< at the
beginninr, of the new millenmum 111 the treatment of
chronic innnmmmory bowel cl1~a\e . Eur J Chn
PhamlOCOI 56: 353- 362
Pcnwce R G 2001 Cannabinoids nnd the gastrointestinal
traCL Gut -18: t\59-867
Rau'" E A J. \an der Hul\t R \\ M 199b Tik:
management of H p)lori infecuon Br Med J 316:
162-161 (l:d<lorwl.-ommenwrJ)
Yeoman' N D. Tulassy Z ct al. 199& A comparison of
omcpm1ole with ranitidine for ulcer. a'<ocialed with
non"erordol :tnliinnammatol) drug,,/\ Engl J Med
338: 719- 726
\ 'om iring
American GMn>enlerological A"oc1atton 2001
Technical rcvtcw on natL,ca and vomiung.
Gastroemcmlogy I~0: 263-286
He,keth P J ~00 I Potcnual role of the ;\ K, n.'<:cptor
antagonists in <hclll<>therap) indu<ed nau""<a and
vomiting. Suppnn Care Cancer 9.
350-354
llomby P J 2001 Ccmral ncurocircu11ry :"'omucd ~>ilh
emesis. Am J \<ted I I I: 106S-t 12S tCIIIIIfJrdlfiiSll't
rt'Lie" ofnmral cofllrol ofmmitin.~)
Tnuner ~I R. Moore R ct at. 1997 A quanlllah\c
'ystematic rc1 rev. of ondansetron rn tn!alment of
eslabli,hed (lO'IOperau'e nau'ca and 10nuung. Br
Med J 3 14: 1088- 1092
Yule\ 8 J. Miller A D. Luco1 J B 1998 Phy,itlo~ical
ba,is and phan11acology of motion 'ic~nc": an
update. Br:un Re' Bull 5: 395-406 !Gt><lfi account nj
lhl! mt!dllllllim.f omdrrl\mg motion ltcAntn and tU
lrecument)
Motility of the gu; lrointestinat tract
De (_a, Casas C. AdJchi J, Dupon1 H 1999 Tm,ellen,"
diarrhoea. Aliment Pharmacol Thcr 11; I 373-1378
(Reil'l<' arllc/t')
Gorbach S L I 987 Bacterial diarrhoea and II' treauneot.
Lancet II: 1371! 1382
lluizinga J D. Thunebcrg L ct al. 1997 lnteNtllal cell-
of Cajal as tnrgcl\ for pharmacological intcl"lcntion m
gawointeslinnl mmnr di>order,. Trend' Ph.trmacol Scr
18:393-401
1 he biliar) S) stem
Bate>O M C 1<197 Otic acid re.-.e.~n:h and apphcation'
Lancet 349 5 6
Useful web resources
hnp://www.nalhnoc.org (Thi.; i.\ the Wl'.far tlw UK
Health Pmteoirm A.t:ency\ Narimwl Tntl'l'l Health
Vtno-orl. and Cmm_ Theft' aft' nw ct>m(kmtnts 10 tht
.life. 011<' for lm fk"Pf>lt atod antfi~r lk<~llh Jrofnstonal.
Click on tlu lmtcr mul ncnigme m tht Tro,etter.;
diarrhoea arud~ for c:ur"trt infonmllum t.md
advice.)

396
 The endocrine pancreas
and the control of
blood glucose
Overview 397
f--
Pancreatic islet hormones 397
-Insulin 397
-Glucagon 401
-Somatostatin 402
-Amylin (islet amyloid polypeptide) 402
Control of blood glucose 402
Diabetes mellitus 402
-Treatment of diabetes mellitus 403
OVERVIEW
Insulin is the main hormone controlling intermediary
metabolism. Its most obvious acute eHect is to lower
blood glucose. Reduced (or absent) secretion of
insulin, often coupled with reduced sensitivity to its
action (insulin resistance), causes diabetes mellitus,
the prevalence of which is rapidly increasing to
epidemic proportions. The consequences of
diabetes are dire-especially complications of
atherosclerosis, kidney failure and blindness.
In this chapter, we describe pancreatic hormones,
emphasising insulin and the control of blood
glucose. The second part of the chapter is devoted
to diabetes mellitus and its treatment with drugs-
insulins and the orally active hypoglycaemic
agents. Oral hypoglycaemic drugs include
biguanides, a-glucosidase inhibitors, sulfonylureas
and other drugs that stimulate insulin secretion,
and the thiazolidinediones.
PANCREATIC ISLET HORMONES
The islet<, of Langerhans contain four main cell ypes, all of
which secrete peptide hormones: B (or~) cells secrete insulin. A
cells secrete ~:tucagon, D cells secrete somatostmin and PP cells
secrete pancreatic polypeptide (the function of which is
unknown). The core of each i1.let contains mainly the predomi-
nant B cells surrounded by a mantle of A cells interspersed with
D cells or PP cells (sec Fig. 26. 1). In addition to insulin, B cells
1.ccrctc a peptide known all islet amyloid polypeptide or amy/in.
which delays gastric emptying and opposes insulin by stimu-
l<lting glycogen brc<tkdown in striated muscle. G lucagon a lso
opposes insulin. increasing blood glucose and stimulating protein
breakdown in muscle. Somatostat in inhibits secretion of insulin
and of glucagon. It is widely distributed outside the pancreas and
is also released from the hypothalamus. inhibiting the release of
growth hormone from the pituitary (p. 422).
INSULIN
Insulin was the fir:.t protein for which an an1ino acid sequence
wa~ determined (by Sanger\ group in Cambridge in 1955). It
consists of two peptide chains (A and B. of 21 and 30 amino acid
residues. respectively).
SYNTHESIS AND SECRETION
Like other peptide hormones (see Ch. 16), insulin is synthe!>i1>ed
as a precursor (preproinsulin) in the rough endoplasmic reticulum.
Preproinsulin is transported to the Golgi apparatus, where it under-
goes proteolytic cleavage first to proinsulin and then to insulin
plus a fragment of uncertain function called C-peptide. 1 Insul in
and C-pcptide are stored in granules in B cells, and are normally
cosecreted by exocytosis in equimolar amounts together with
smaller and variable amounts of proinsulin. The main factor con-
trolling the synthesis and secretion of insulin is the blood glucose
concentration (Fig. 26.1 ). B cells respond both to the absolute
glucose concentration and to the rate of change of blood glucose.
Other stimu li to insulin release include amino acids {particularly
arginine and leucine), fatty acids, the parasympathetic nervous
system. peptide hormones for the gut (see below) and drugs that
act on \11/[ony/urea receptors.
There is a !>teady basal release of insulin and also a response
to an increase in blood glucose. This response has two phases:
an initial rap id pha~e reflecting release of stored hormone. and
a slower. delayed phase reflecting both continued release of
stored hormone and new synthesis (Fig. 26.2). The response is
abnormal in diabetes mellitus. as discussed later.
ATP-sensitive potas~ium channels (KATP; Ch. 4, pp. 63-64)
determine the re~ting membrane potential in B cells. Glucose
'Not to be ccmfu~cd with C-reactive peptide. wh ich is an acute pha;e
rcacwm used cl ini cal ly a~> a marker of inflammation (Ch. 13). 397
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

INTESTINE
Digested food

''
''
D
' \
\
l
\
I
I
I
I
Glucose Fatty ac1ds I
I I
I I
I I
I I I
I I I I
I
' I I
I
GIT hormones
'I I I I

$ $ <)
I I I
I I I
I
I I
I /
I /
I Parasympathetic
I ''
~ nerves
.J.. (on muscarinic
Somatostatin G receptors)
/
B cell

Fig. 26.1 Factors regulating

... -
insulin secretion. Blood glucose is
the most important factor. Drugs Sympathetic nerves and
PANCREATIC adrenaline
used to stimulate insulin secretion
ISLET (on a:zadrenoceptors)
are shown in yellow boxes.
Glucagon potentiates insulin release
but opposes some of its peripheral J
actions and increases blood
_____
glucose. GIT, gastrointestinal tract.
[
_
Insulin
_____.,

enters B cells via a membrane transporter called Glut-2, and its

1st phase 2nd phase subsequent metabolism via glucokinase (the rate-limiting enzyme
~---------- - . that acts as the 'glucose sensor' linking insulin secretion to extra-
cellular glucose) and glycolysis increases intracellular ATP. Thi~
80
blocks K ATP channels, causing membrane depolarisation and
opening or vollage-dcpeudcnt calcium channels, leading to Ca 2
innux. The resulling increase in cytoplasmic Ca2 triggers insulin
secretion, bul only in the presence of amplifying messengers
Basal including diacylglycerol, non-esterified arachidonic acid (which
level
20 ~====~~=-------_2T1~yp~e~1~d~ia~b=et~e~
s facilitates further Ca 2 entry), and 12-lipoxygenase products of
arachidonic acid (mainly 12-S-hydroxyeicosacetraenoic acid or
12-S-HI:.TE; !>ee Ch. 13). Phospholipases are commonly activated
0 15 30 45 60 75
by Ca 2. but free arachidonic acid i!> liberated in B cells by an
Insulin(/)
ATP-sensitive Ca 2-insensitive (ASCI) phospholipase A 1.
Glucose
Consequently, in B cells, Ca 2 entry and arachidonic acid pro-
Fig. 26.2 Schematic diagram of the two-phase release
duction are both driven by ATP. linking cellular energy status to
of insulin in response to a constant glucose infusion. The
first phase is missing in type 2 (non-Insulin-dependent) insulin !>ecretion.
diabetes mellitus, and both are missing in type 1 Qnsulin- T Many gastrointe~tinal honnones intluence insulin secretion. including
dependent) diabetes mellitus. The first phase is also produced gavtrin, St'(:rttin. cholecystokinin. gastric inhibitory polypeptide (GIPJ.
by amino acids, sulfonylureas, glucagon and gastrointestinal glucagon-like peptide (GLPJ and GLP 1 (the amide of a fragment ofGLPJ,
tract hormones. (Data from Pfeifer et al. 1981 Am J Med 70: all of which Mimulate insulin secretion. They are released by eating. Thi>
~588.) explains why oral gluco~e cause:. &>reater insulin release than doe~ the
same amount of glucose admini~Lered intravenously. These hormones (in
particular GlP nnd GLP1) provide an anticipatory signal from the
gastrointe~tinal 1ruc1 to the islets, and offer some novel prospects for
398 treating diabetes.
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

INSULIN RECEPTOR
Glucose

CELL MEMBRANE

p p

p p

I
I
y
Endocytosis of Beta subunit Ras ------.. Actions on DNA
insulin-receptor tyrosine kinase complex and RNA
complex activation

IRS

! SH2 domain proteins

j
RecrUitment of Effects on
glucose Effects on kinases and phosphatases and thus: +--- synthesis of
transporters key enzymes
Alteration in the pattern of phosphorylallon
of key enzymes (e.g. MAP kinase and
protein phosphatase 1)

Increased formation Increased Increased Decreased formation of Growth and

of glycogen, protein uptake of utilisation of glucose from glycogen, gene
and fat glucose glucose fat and protein expression

L------J.-!-~J
Decreased blood glucose

Fig . 26.3 Insulin signalling pathways . I, insulin; Glut-4, an insulin-sensitive glucose transporter present in muscle and fat cells; IRS.
insulin receptor substrate (several forms: 1-4).

Other metabolic eHects of insulin long-term eHects of insulin

Other metabolic effect!> of insulin include transport inro cells of
K,1 Ca2+, nucleosides and inorganic phosphate.
'This action is exploited in the emergency treatment of hyperkalaemia by
400 intravenous gluco5c with in~ulin (see Ch. 24, p. 382).
In addition to it~ rapid effects on metabolism. exerted via altered
activity of enzymes and transport proteins. imulin has long-temt
actions via altered entyme synthesis. 1t is an important anaboli~
hormone during fetal development. It stimulates cell proliferation
and is implicated in somatic and visceral growth and development.
T Mitogenic action; of im.ulin are of great concern in the development
of in~ulin analogues. because these are intended for long-term use and
 THE ENDOCRINE PANCREAS AND THE CONTROL OF BLOOD GLUCOSE
b<!cau'e mammal) tumour.. develop m rat\ gt' en one long-acting in,uhn
analogue kno"n a_<, B 10-a~p imuljn.
MECHANISM OF ACTION
ln~ulin binds to a specific receptor on the !.urfacc of its target
cel ls. The receptor is a large transmembrane glycoprotein com-
plex belonging to the kinase-linked type 3 receptor superfamily
(Ch. 3. pp. 43-46) and consisting of two a and two ~ subunit~
(Fig. 26.3). Occupied receptors aggregate imo clusters. which are
:.ub~equcnt l y internalised in vesicles. resulting in down-
regulation. Internalised insulin is dcgmded in lysosomes. but the
receptor~ arc recycled to the pJa ...ma membrane.
T lltc 'ignal transduction mechani'm' that link receptor binding to the
biological eiTecL~ of insu li n arc compte,.. Re~:eptor autophosphorylation
- the fir,t ~tep in signal transd uction is a con ~cquence of djmerisation.
al lowi ng each receptor to phm,phorylate the other, as e,xplained in
Chapter 3.
lnwlin receptor subsLrale (IRS) prote in \ undergo rapid tyrosine
pho,phol) lation specificall)' in re'>p<ln'>e to insulin and in~ulin- l ike
gro" th fa..:tor-1 but not to other gmwth factor.... The best chamcteri..ed
\Ubstratc i\ rRS-1 . which cont.Un!> :!2 tyro\inc re,idues that are potential
pho,phol) lation 'ite~. It imer.tct> wtth protem\ that cont:Un a so-called
SH:! domam (..ee Cb. 3. Fig. 3.15). therehy pa~~ing on the insulin '>ignal.
Knod.out mice lacking lRS-1 are hyporC\J)(m~ive to insulin (in~ulin
re'>t\lant) but do not become diabetic because of robust 8 -ce ll
compensation with increa\ed insulin ~ccrction. By contrast. mice lacking
IRS-2 fai l to compen~ate and develop overt diabetes, implicati ng the IRS-
2 gene as a candidate for human type 2 diabetes (IRS protein~ are
reviewed by Lee & White. 2004). Acti valion of phosphatidylino:-.itol 3-
l..ina\e by interaction of its SH2 domain with phosphorylated lRS ha'>
">e\eral tmponant effects. including recruitment of insulin-sensitive
gluco\e transponc~ (Giut-4) from the Golgi apparatu~ to the plasma
mcmbrJne m muscle and fat cell\
The longer-tenn actions of msuhn entail effect\ on 01'\A and Rl'\A.
mediated panty at least by the Ra~ '>ignalling complex. Ra.<. i~ a protein
that regulates ceiJ gro,vth and cycle'> hetween an actjve GTP-bound fonn
and an inactive GOP-bound form (~ec Ch'> 3 and 51). Insu lin shifts the
eq uilibrium in favour of the acti ve form. and initiates a phosphorylation
ca~cadc that resu lts in activati on of mitogen-activated protei n kina;e.
which in turn activates severa l nuch:ar tra nscription factOrs. leadj ng to the
exprc'>'>ion of genes that are involved bot h w ith cell growth and with
intcnncdiary metabolism. Regulation nf the mte of mRNA transcription
by tnsulin provides an imponant mean\ of modulating enzyme activity.
Insulin for treatment of diabetes mellitus is considered below.
GLUCAGON
Glucagon is a single-chain polypeptide of 2 1 amino acid residues.
SYNTHESIS AND SECRETION
Glucagon is synthesised mainly in the A cell of the i lets. but
also in the upper gastrointestinal tract. It has considerable struc-
tuml homology with other gru.trointe~tinal tract hormones. including
.\ecretin, msoacti1e imestinal peptide and GIP (see Ch. 25).
One of the main physiological Mimuli to glucagon secretion is
the concentration of amino acids. in particular L-arginine. in plasma.
Therefore an increase in secretion follows ingestion of a high-
protein meal, but compared with insulin there is relatively little
change in plasma glucagon concentrations throughout the day.
Endocrine pancreas and blood glucose
Islets of Langerhans secrete insulin from 8
(or B) cells, glucagon from A cells and somatostatin
from D cells.
Many factors stimulate insulin secretion, but the main
one is blood glucose.
Insulin has essential metabolic actions as a fuel
storage hormone and also affects cell growth and
differentiation. It decreases blood glucose by:
increasing glucose uptake into muscle and fat via
Glut-4
increasing glycogen synthesis
decreasing gluconeogenesis
decreasing glycogen breakdown.
Glucagon is a fuel-mobilising hormone, stimulating
gluconeogenesis and glycogenolysis, also lipolysis
and proteolysis. It increases blood sugar and also
increases the force of contraction of the heart.
Diabetes mellitus is a chronic metabolic disorder in
whtch there is hyperglycaemia. There are two matn
types:
type 1 (insulin-dependent) diabetes, with an
absolute deficiency of insulin
type 2 (non-insulin-dependent) diabetes, with a
relative deficiency of insulin associated with
reduced sensitivity to its action (insulin resistance).
Glucagon secretion is stimulated by low and inhibited by high
concentrations of glucose and fauy acid!> in the plasma. Sym-
pathetic nerve activity and circulating adrenaline Mimulate glu-
cagon release via ~ adrenoceptor!.. Parasympathetic nerve activity
also increases secretion, whcrea~ somatostatin. release<.l from D
cells adj acent to the glucagon-secreting A cells in the periphery
or the islets. inhibits glucagon re lea!-e.~
ACTIONS
Glucagon increases blood glucose and causes breakdown of fat
and protein. It acts on specific G-protein-coupled receptors to
stimulate adenylate cyclase, and con ...equently its actions are some-
what ~imilar to ~ adrenoceptor- mediated actions of adrenaline.
Un like adrenaline, however, its metabolic effects are more pro-
nouncc<.l than its cardiovascular actions. Glucagon is proportionately
more active on liver, while the metabolic actions of adrenaline
arc more pronounced on muscle and fat. Glucagon stimulates
glycogen breakdown and gluconeogenesis, and inhibits glycogen
'>ynthcsis and glucose oxidation. It~ metabolic actions on target
tissues are thus the opposite of thO'>C of insulin. Glucagon incrcal>Cs
"Octreotide. a somatostatin analogue (~cc p. 422). i ~ u~ to treat tht:
'yndrome (which includes relatively mild hyperglycaemia but profound
mu~c le ~:ataboli sm) caused by ra re g lucagon-secreting tumours.
401
 SECTION 3 . DRUGS AFFE CTING MAJOR ORGAN SYSTEMS
the rate and force of contraction of the heart, although less
markedly than adrenaline.
Clinical uses of glucagon are summarised in lhe box.
SOMATOSTATIN
Somato~tatin is secreted by the D cells of lhe islets. h is also
generated in the hypothalamus. where it acts to inhibit the release
of growth hormone (sec Ch. 28). In the islet, it inhibits release of
insulin and of glucagon. Oc treotide is a long-acting analogue of
somatostatin (see above). It inhibits release of a number of hor-
mones, and is used clinically to relieve symptoms from several
uncommon gastroenteropancreatic endocrine tumours, and for
treatment of acromegaly 5 (the endocrine disorder caused by a
functioning lllmour of cells that secrete growth hormone from the
anterior pituitary; see Ch. 28).
AMYLIN (ISLET AMYLOID POLYPEPTIDE)
T The tcnn amvloid rcfe11> to amorphous protein deposits in different
ti~sues that occur in a variety of diseases, including several
ncurodegenerative condition~ (see Ch. 35). Amyloid deposits occur in the
pancrea\ of patient\ with diabetes mellitus, although it is not known if
this i~ functionally mponant. The major component of pancreatic
amyloid s a 37 amino acid residue peptide known as islet amyloid
pol) peptide or amylln. Thi~ is stored with insulin in secretory granules in
8 cell\ and 1\ co~ecreted with in~ulin. Amylin delays gastric emptying.
Supraphy\iological concentrations sumulate the breakdown of glycogen
to lactate m stnnted muscle. Amylin also inhibits insulin secretion
(Fig. 26.1 ). It is structurall) related to calcitonin (see Ch. 31) and has
wea].. calcitonin-liJ..e action~ on calcium metabolism and osteoclast
activity. It is aho about 50% identical with calcitonin gene-related
peptide (CGRP; ~ee Ch. 16). and large intravenous doses cause
vasodilatation. presumably by an action on CGRP receptors. Whether
amylin has a role in the physiological control of glucose metabolism is
controversial. but there is intereM in the therapeutic potential of amylin
agonbt\ (\uCh :u, l>r a mlintid e, an analogue with three proline
substitutions that reduce its tendency to aggregate into insoluble fibrils}-
scc Schmitz et al. (2004) for a review.
Clinical uaea of glucagon
Glucagon can be given intramuscularly or
subcutaneously as well as intravenously.
Treatment of hypoglycaemia in unconscious patients
(who cannot drink); unlike intravenous glucose, it
can be administered by non-medical personnel
(e.g. spouses or ambulance crew). It is useful if
obtaining intravenous access is difficult.
Treatment of acute cardiac failure precipitated by
~-adrenoceptor antagonists.
lOctreotide is u~ed either short term before surgery on the pituitary tumour,
or while waiting for radiotherapy of the tumour to take effect, or if other
402 treatments have been ineffective.
CONTROL OF BLOOD GLUCOSE
Glucose is the obligatory source of energy for the brain, and physi-
ological control of blood glucose reflects the need to maintain
adequate fuel supplies in the face of intermiueot food intake and
variable metabolic demands. More fuel is made available b}
feeding than is immediately required. and excess calories are
stored as glycogen or fat. During fasting, these energy store~
need to be mobilised in a regulated manner. The most important
regulatory hormone is insulin, lhe actions of which are described
above. Increased blood sugar stimulates insulin secretion, whereas
reduced blood sugar reduces insulin secretion. Hypoglycaemia,
caused by excessive insulin, not only reduces insulin secretion
but also elicits secretion of an array of 'counter-regulatory' hor-
mones, including glucagon, adrenaline, glucocorticoid.~ and
growth hormone, all of which increase blood glucose. Their main
effects on glucose uptake and carbohydrate metabolism arc
summarised and contrasted with those of insulin in Table 26.2.
DIABETES MELLITUS
Diabetes mellitus is a chronic metabolic disorder characterised
by a high blood glucose concentration-hyperglycacmia (fasting
plasma glucose> 7.0 mmoVl. or plasma glucose > ll.l mmoUI
2 hours after a meal )-caused by insulin deficiency, often combined
with insulin resistance. Hyperglycaemia occurs because of
uncomrolled hepatic glucose output and reduced uptake of glucose
by skeletal muscle with reduced glycogen synthesis. When the
renal thre~hold for glucose reabsorption is exceeded, glucose
spills over imo the urine (glycosuria) and causes an osmotic
diuresis (polyuria), which, in turn, results in dehydration, thirl>t
and increased drinking {polydipsia). Insulin deficiency causes
wasting through increased breakdown and reduced synthesis of
proteins. Diabetic ketoacidosis is an acute emergency. It develops
in the absence of insuli n because of accelerated breakdown of fat
to acetyi-CoA, which, in the absence of aerobic carbohydrate
metabolism, is converted to acetoacetate and ~-hydroxybutyrate
(which cause acidosis) and acetone (a ketone).
Various complications develop as a consequence of the metabolic
derangements in diabetes, often over many years. Many of these
are the result of disea~e of blood vessels, either large (macrovascular
disea e) or small (microangiopathy). Dysfunction of vascular
endothelium ( ee Ch. 20, p. 321) is an early and critical event in
the development of vascular complications. Oxygen-derived free
radicals, protein kinase C and non-enzymic products of glucose
and albumin (called ad1anced glycation end products) have been
implicated. MacrVI'Oscular disease consists of accelerated atheroma
(Ch. 21) and its thrombotic complications (Ch. 22), which are
commoner and more severe in diabetic patients. Microarzgioparh~
is a dbtinctive feature of diabetes mellitus and particularly
affects the retina, kidney and peripheral nerves. Diabetes mellitus
is the commonest cause of chronic renal failure, which itself
represents a huge and rapidly increasing problem, the costs of
which to society as well as to individual patients are staggering.
Coexistent hypertension promotes progressive renal damage, and
treatment of hypertension slows the progression of diabetic
 THE ENDOCRINE PAN CREAS AND THE CONTROL OF BLOOD GLUCOSE

T ble 26.2 The effect o f hormon es o n blood glucose

Hormon e M ai n actions M ain stimulus for se c retio n M ain effect

Main regu latory hormone

Insulin t Glucose uptake

t Glycogen synthesis
Acute rise in blood glucose glucose ~ Blood glucose
~ Glycogenolysis

Gluconeogenesis

Main c ounter-regulatory hormones

Glucagon t Glycogenolysis
t Glyconeogenesis
Hypoglycaemia {i.e. b lood glucose
Adrenaline (epinephrine) t Glycogenolysis < 3 m mol/1}, (e.g. with exercise, ' t Blood glucose
stress, high protein meals), etc.
Glucocorticoids ! Glucose uptake
t Gluconeogenesis
l Glucose uptake and utilisation

Growth hormone + Glucose uptake

nephropathy and reduces myocardial infarction. Angiolensin-
comerting enzyme inhibitors or angiolensin receptor anlagonists
(Ch. 19) are more effective in pre ve nting diabetic nephropathy
than other antihypertensive drug~. perhaps because they prevent
fibropro liferative actions of angiote nsin n and aldostero ne.
Diabetic ne uropathy is a~~oci ated wi th accumulation of
o~motica lly active metabolites of glucose, produced by the actio n
( vpe 2 diabetes is accompanied both by i nsulin resistance (which
precedes overt disease) and by impaired insulin secretion. each of which
are importa nt in its pathogene:.is. Such patient\ are oft en obe:,e nnd
usuall y present in adult l ife, the incidence rising progressively w ith age
as B-cell function decline!.. Treatment i~ i nitially dietary. although ornl
hypoglycaemic drugs u!.ually become ncces'>ary. and about one-third of
patient!. ultimately require iru.ulin. Pro-.pecuve studies have demon.,trnted
a relentle:.s deterioration m diabeuc control~ over the ye~.

of aldo~e reductase, but aldose reductase inhibitors have been
disappoi nting as therapeutic drug\ (\ee C hung & Chung, 2005,
for a rev iew).
There are two main types of diabe tes me llitus:
type I diabetes (previously kno wn as insulin-dependent
diabe tes mellitus -IDDM-or juve nile-onset diabetes)
type 2 diabetes (previo usly known a1> no n- insulin-depe ndent
diabetes me llitus-NTDDM-or matu rity-onset diabetes).
In type I d iabetes, there is an absolute deficiency of insulin
resulti ng from autoimmune destruction of B cells. Without
i n~u lin treatment, such patie nts will ultimate ly die with diabetic
ketoacidosis.
't" fype I diabetic patients arc m.uall y young (children or adolesce nt~)
and not obese when they first develop symptoms. There is an inherited
predisposition, with a 10-fold increased incidence i n first-degree relati ves
of an index case. and ~trong a&sociation> w ith particular histocompatibi lity
antigen~ (HLA types). Studie~ ot' identical twi ns have shown that
genetically predisposed indi\ iduab mu'>t additionally be exposed to an
envtronmental factor such as 'ira! infection (e.g. with coxsackievirus or
echo' tnt\). Viral infection may damage pancremic B cells and e:>.po.,e
anugens thm initiate a self-perpetuating autoimmune process. The patient
becomes ovenly diabetic only when more than 90'l of the B cells have
been destroyed. Thi s natural hi\tOry provide!. a tantalising prospect of
intervening in the prediabetic Mage. and a variety of strategies have been
mooted, i ncluding i.mmunosuppre~>,ion. early i n ~ulin therapy. antioxidants,
nicotinamide and many others. but so fnr these have di ~appoimed.
Insulin secretion in the two main forms of diabetes is shown
sche matically in Fig ure 26.2. contras ted with the no rmal
response.
There are many other less commo n forms of diabetes mellitus
in addition to the two main o nes described above, and
hype rg lycaemia can also be a c linically important adverse effect
of several drugs, including g lucocorticoids (Ch. 28). high doses
of thiazide diuretics (Ch. 24) and several of the protease
inhibito rs used to tre at HlV infectio n (Ch. 47).
TREATMENT OF DIABETES MELLITUS
Insulin is essential fo r the treatment of type 1 diabetes. Fo r many
years, it was assumed, as an act of faith , that normalising plasma
glucose would prevent diabetic complications. The Diabetes
Control and Complications Trial (American Diabetes Associatio n,
1993) showed that this faith was we ll placed: type I diabetic
patie nts were randomly allocated to intens ive or conventional
management. Mean fa~ting blood glucose concentration was
6 DiabeLic control is not easily e~ti mated by determination of blood gl ucose.
becaU'.e Lhi ~ i s so variable. Instead. gl ycated haemoglobin (haemoglobi n
A 1c) is rnea!our~d . This provides an integrated measure o f control over the
lifespan of the red cell: approximately 120 day~.
403
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
2.8 mmol/1 lower in the intensively treated group. who had a
l.ub~tantial reduction in the occurrence and progression of retino-
pathy, nephropathy and neuropathy over a period of 4-9 years.
These benefit<, outweighed a threefold increase in severe
hypoglycaemic attad.~ and mode 1 excess weight gain.
The UK Prospective Diabetes Study showed that lowering
blood pressure markedly improves outcome in type 2 diabetes
(sec above). Optimal control of blood glucose was not achieved
even in intensively treated patient!.. Beuer metabolic control did
improve outcome, but the magnitude of the benefit was
di~appointing and Matistically significant only for microvascular
complications. Consequently, realistic goals in type 2 diabetic
patients arc usually less ambitious than in younger type 1
patients. Diet is the cornerstone (albeit one with a tendency to
crumble), combined with increased exercise. Oral agents arc
used to control symptoms from hyperglycaemia, as wel l as to
limit microvascular complkations. Dietary measures and statins
to prevent atheromatous disease (Ch. 20) are crucial. Details of
dietary management and treatment for specific diabetic
complications are beyond the scope of this book.
INSULIN TREATMENT
Effects of insulin and its mechanism of action are described
above (pp. 399-401 ). Here we describe phannacok.inetic aspects
and adverse effect..... both of which are central to its therapeutic
use. Insulin for clinical use was once either porcine or bovine but
is now almost entirely human (made by recombinant DNA
technology). Porcine and bovine insulins differ from human
insulin in their amino acid sequence, and are liable to elicit an
immune response, a problem that is avoided by the use of recom-
binant human insulin. Although recombinant insulin is more
consistent in quality than insulins extracted from pancreases of
fresh ly slaughtered animals, doses are still quantified in terms of
units of activity, with which doctors and patients are familiar,
rather than of mass.
Pharmacokinetic aspects and insulin
preparations
Insulin is destroyed in the gastrointestinal tract, and must be
given parcntcrally- ullually subcutaneously, but intravenously or
occa~ionally intramuscularly in emergencies. lntraperitoneal insulin
is used in diabetic patients with end-stage renal failure treated by
ambulatory peritoneal dialysis. Pulmonary absorption of insulin
occur!., and inhalation of an aerosol is a promising route of admin-
istration, e~pecially for type 2 patients. Other new approaches
include incorporation of insulin into biodegradable polymer
microsphere.,, and its encapsulation with a lectin in a glucose-
permeable membrane? Once absorbed. insulin has an elimination
half-life or approximately I0 minutes. It is inactivated enzymicaJiy
in the liver and kidney, and 10% is excreted in the urine. Renal
impairment reduces insulin requirement.
7
Th is could. in theory. provide variable release of insulin control led by the
prevailing glucose concentration, because glucose and glycosylated insulin
404 compete for binding ~ i tc~ on the lectin.
One of the main problems in using insulin is to avoid wide
nuctuations in pla~ma concentration and thus in blood glucose.
Different formulations vary in the timing of their peak effect and
duration of action. Soluble insulin produces a rapid and shon-
lived effect. Longer-acting preparations are made by precipitating
insulin with protamine or zinc. thus forming finely di\ ided
amorphous solid or relatively insoluble crystals, which are
injected as a suspen~ion from which insulin is slowly absorbed.
These preparations include isophane insulin and amorphous or
crystalline insulin tine su~pensions. Mixtures of different forms
in fixed proponions are available. Ins ulin lispro is an insulin
l
analogue in which a lysine and a proline residue are 'switched'.
It acts more rapidly but for a shorter time than natural insulin,
enabling patients to inject themselves immediately before the
start of a mc:1l. Insulin glargioe is another modified insulin
analogue, designed with the opposite intention, namely to
provide a constant basal insulin supply and mimic physiological
postabsorptive basal insulin secretion. Insulin glargine, which is
a clear solution, forms a microprecipitate at the physiological pll
of subeutaneoul. til.sue, and absorption from the subcutaneous
-.ite of injection is prolonged. Used in conjunction with short-
acting insulin, it lowers po!>tabsorptive plasma glucose.
Various dosage regimens are used. Type I patients commonly
inject a combination of shon- and intermediate-acting insulin~
twice daily, before breakfast and before the evening meal. lmpro\ed
control of blood glucose can be achieved with multiple daily
injections of shon-acting insulins with meals, and a longer-acting
insulin at night. insulin pumps are used in hospital and some-
time~. by specialists, in outpatients. The most sophisticated
form~ of pump regulate the dose by means of a sensor that
continuou~ly measures blood glucose. but these are not routine!)
available.
Unwanted eHects
The main undesirable effect of insulin is hypoglycaemia. Thi'
is common and, if very severe, can cause brain damage. In one
large clinical trial, intensive insulin therapy resulted in a
threefold increase in severe hypoglycaemia compared with u~ual
care. The treatment of hypoglycaemia is to take a sweet drink or
snack or, if the patient is unconscious. to give intravenous glucose
or intramu~cular glucagon (see above). Rebound hypcrglycacmia
('Somogyi effect') can follow insulin-induced hypoglycacmia,
becau!>e of the releru.e of counter-regulatory hormones (see above).
Thi., can cause hypcrglycaemia before breakfast followmg an
unrccogni~ed hypoglycaemic attack during sleep in the earl)
hours or the morning. lt is essential to appreciate this possib1ht)
to avoid the mistake or increasing (rather than reducing) the
evening dose of insulin in this situation.
Allergy to human in&ulin is unusual but can occur. It rna) take
the form of local or !>yMemic reactions. Insulin resistance a~ a
con~equence of antibody fom1ation is rare.
Clinical u.,es of in~ulin are summarised in the box.
ORAL HYPOGLYCAEMIC AGENTS
The main oral hypoglycaemic agents (sec the box on p. 408)
arc metformin (a biguanidc), sulfonylureas and other dmg~ that
 THE ENDOCRINE PAN C REA S AND THE CONTRO L OF BLOOD GLUCOSE
Clinical uses of Insulin
Patients with type 1 diabetes require long-
term insulin:
an intermediate-acting preparation (e.g. isophane
insulin) is often combined with soluble insulin
taken before meals.
Soluble insulin is used (intravenously) in emergency
treatment of hyperglycaemic emergencies (e.g.
diabetic ketoacidosis).
Many patients with type 2 diabetes ultimately need
insulin.
Short-term treatment of patients with type 2 diabetes
or impaired glucose tolerance during intercurrent
events (e.g. operations, infections, myocardial
infarc tion).
During pregnancy, for gestational diabetes not
controlled by diet alone.
Emergency treatment of hyperkalaemia: insulin is
given with glucose to lower extracellular K+ via
redistribution into cells.
act on the !>ulfony lurea receptor, and glitawnes. Acarbose is an
a-gluco~idase inhibitor.
Biguanides
Metfo rmin is the o nl y drug of th is class presently available in
the UK.
Actions and mechanism
Biguanidcs lower blood glucose by mec hanisms that are complex
and incomple tely unde rstood. They increase glucose uptake and
utilisation in ske letal muscle (the re by reduc ing insulin resistance)
and redu ce he patic g lucose produc tio n (gluconeogenesis).
Metformin, while preventing hyperg lycaemia. does not cause
hypoglycacmia. Tt a lso reduces low-density and very low-density
lipoproteins (LDL a nd VLDL, respect ively).
Phormocokinetic aspects
Metformin ha~ a half- life of about 3 ho urs and is excreted
unchanged in the urine.
Unwonted effects
The commonest un wanted effects of metfonnin are dose-related
gastrointestinal disturbances (e.g. anorexia. diarrhoea. nausea),
wh ich are u ~uall y but not always transient. L actic acidosis is a
rare but potentially fata l toxic effect, and me tfo rmin should not
be given to patients wi th renal or he patic disease. hypoxic
pulmonary disease, heart failure or shock. Such patie nts are
predisposed to lac tic acidosis because o f re duced drug
eliminatio n or reduced tissue oxygenation. It s hould also be
avoided in other s ituatio ns that predis pose to lactic acidosis, and
is contra indicated in pregnancy. Long-term use may interfere
with absorptio n o f vita min 8 12
Clinical use
Merformi n is u\ed to treat patients with type 2 diabetes. It does
not sti mulate appetite (rather the reverse: see above!) and is
consequently the d ru g of first c hoice in the majority of type 2
patie nt<; who are obese and who fai l treatment with diet a lone. It
can be combined wi th ~u lfonyl ureas. glitazones or insulin.
Sulfanylureas
The sulfonylureas we re developed following the chance obser-
vation that a sul fonam ide derivative (used to treat typhoid ) caused
hypoglycac mia. Numerous sul fonylureas are available. T he fi rst
used therape uticall y were tolbutamide and cWorpropamid e.
Chlo rpro pa mide has a lo ng duration of ac tion and a substa ntial
frac tion is excreted in the urine. Consequently, it can cause severe
hypoglycaernia, e!>pecially in elderly patients in whom renal func-
tion declines inevitably but ins idious ly (Ch. 24). It causes llush-
ing after alcoho l because o f a disulfiram- like e ffect (Ch. 4 3), and
has an action like that of antidiure tic hormone on the distal
ne phron, g iving rise to hyponatraemia and water intoxicatio n.
Williams ( 1994) comme nts that ' time honoured but idiosync ratic
c hlorpropamide sho uld now be laid to rest'-a sentime nt with
which we concur. Tolbutamide, however, remai ns useful. So-called
second-generation sulfonylureas (e.g. g libenclamide, g lipizide;
sec Table 26.3) are more potent (on a milligram basis), but their
maximum hypoglycaemic effect is no greater and control of
blood g lucose no better than with tolbutamide. These drugs a ll
contain the !>ulfonylurea moiety and act in the same way, but
different sub titutiom. result in diffe re nces in pharmacokinetics
and hence in duration of action (see Table 26.3).
Mechanism of action
The princ ipal action of ~ulfonylureas is on B cells (Fig. 26. 1),
stimulating insulin secretion (the equivalent o f phase I in Fig. 26.2)
and thus reduc ing plas ma g lucose. Hig h-affinity recepto rs for
sulfony lurcas a re present o n the K ATP c hanne ls (Ch. 4. p. 64) in
B-ccll plasma membr.mes, and the binding of various sulfonylureas
para llels the ir potency in stimulating insulin re lease. Block by
sulfo ny lurea drugs o f K~rr channe l activation causes depo laris-
ution, Ca2+ entry and insulin secretion. (Compare this with the
physio logical contro l of insulio scretion, see p. 398 above.)
Phormocokinetic ospects
Sulfonylureas are well absorbed after o ral administration. and
most reach peak plasma concentratio ns within 2~ hours. The
duration of action varie~ (Tab le 26.3). All bind strong ly to plasma
albumin and are implicated in interactions with other drugs (e.g.
salicylates and ~ulfonamides) that compete for these binding
sites (see below and C h. 52). Most sulfonylureas (or their active
metabolites) are excreted in the urine. so their action is increased
in the e lderly and in patients with renal disease.
Most sulfony lu reas cross the placenta and enter breast milk; a'>
a result, u e of sulfonylureas is contraindicated in pregnancy and
in breast feeding w hen d iet and, if necessary. insulin are used.
Unwonted effects
The sulfony lurcas arc usuall y we ll to lerated. Unwanted e ffects
are s pecified in Table 26.3. T he commonest adverse effect is
hy poglycac mia, w hich c an be seve re and prolonged. Its 405
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

Table 26.3 Oral hypoglycaemic sulfonylurea d rugs

Drug Relative Duration of action Phannacokinetic aspectsb General comments

potencr- and (half-life) (hours)

Tolbutamide 6-12(4) Some converted 1n hver to weakly A safe drug; least likely to cause
active hydroxytolbutamide; some hypoglycaemia.
carboxylated to inactive compound. May decrease iodide uptake by thyro1d.
Renal excretion. Contraindicated in liver failure.

Glibenclamide 150 18-24 (10) Some is oxidised in the liver to May cause hypoglycaemia.
moderately active products and is The active metabolite accumulates in
excreted in urine; 50% is excreted renal failure.
unchanged in the faeces.

Glipizide 100 16-24 (7) Peak plasma levels in 1 hour. May cause hypoglycaemia.
Most Is metabolised in the liver to Has diuretic action. Only inactive
inactive products, which are excreted products accumulate in renal failure.
in urine; 12% is excreted in faeces.

'Relative to tolbutamide.
bAll are highly protein-bound (90-95%).
"Termed gllburfde in USA.

incidence is related to the potency and duration of action of the
agent, the highel>t incidence occurring with chlorpropamide and
glibenclamide and the lowest with tolbutamide. Glibenclamide is
best avoided in the elderly and in patients with even mild renal
impairment becau~e of the risk of hypoglycaemia, becau~e
several of it~ metabolites are excreted in urine and are moderately
active. Sulfonylureas stimulate appetite (probably via their
effects on insulin secretion and blood glucose) and often cause
weight gain. This is a major concern in obese diabetic patients.
About 3% of patients experience gastrointestinal upsets. Allergic
skin rashes can occur, and bone marrow damage (Ch. 53),
although very rare, can be severe.
During and for a few days after acute myocardial infarction,
insulin must be ~ubstituted for sulfonylurea treatment. This is
associated with a sub~tantial reduction in short-term mortality,
although it remain!. unclear if this is due to a specifically
beneficial effect of insulin or to a detrimental effect of sulfonylurea
drugs in this setting, or both. Another vexing question is whether
prolonged therapy with oral hypoglycaemic drugs has adverse
effects on the cardiovascular system. A study in the USA in the
1970s found that after 4-5 years of treatment, there was an
increase in cardiova cular deaths in the group treated with oral
drugs compared with the groups treated with insulin or placebo.
Blockade of KATI' in heart and vascular tissue could theoretically
have adverse effects, but evidence for an adverse cardiovascular
effect is unclear.
Drug interactions
Several drugs augment the hypoglycaemic effect of the
sulfonylureas. Non-steroidal anti-intlan1matory drugs, coumarins,
406 some uricosuric drugs (e.g. sulfinpyrazone), alcohol, monoamine
oxidase inhibitors, l.Ome antibacterial drugs (including
s ulfonamides, trimethoprim and chloramphenicol) and ~orne
imidawle antifungal drugs have all been reported to produce
severe hypoglycaemia when given with a sulfonylurea. The prob-
able basi!> of most of these interactions is competition for metab-
olising enzymes. but interference with plasma protein binding or
with excretion may play some part.
Agents that decrea.~e the action of sulfonylureas on blood
glucose include high doses of thiazide diuretics and corticosteroid~.
Clinical use
Sulfonylurcas require functional B cells, so they arc useful in the
early stages of type 2 diabetes. They can be combined with
metformin or with thiazolidinediones.
Other drugs that stimulate insulin secretion
Several drugs that lack the sulfonylurea moiety but stimulate
insulin secretion have recently been developed. These include
repaglinide and oateglinide. These act. like the sulfonylurea!.,
by blocking the sulfonylurea receptor on KATP channels in
pancreatic B celb. Thus nateglinide, which is structurally
derived from o-phenylalanine ('the first of a new class of insulin
secretion enhancers' according to one piece of promotional
literature), competes with glibcnclamide for specific binding
sites on B cells. Like sulfonylureas, it inhibits tlux of radioactive
rubidium ions (which traverse KATP channels) from B celb
loaded with this isotope and blocks these channels in patch clamp
experiments. It is much less potent than most sulfonylureas (with
the exception of tolbutamide), and has rapid onset and offset
kinetics. These features, coupled with rapid absorption (time to
maximal plasma concentration approximately 55 minutes after
 THE ENDOCRINE PAN C REAS AND THE CONTROL OF BLOOD GLUCOSE
an oral dose) and elimination (half-life approximately 3 hours),
lead to short duration of action and a low risk of hypoglycaemia. 8
These drug~ are adminhtered shortly before a meal to reduce the
postprandial gluco~e ri!>e in type 2 diabetic patients whose
condition is inadequately controlled with diet and exercise. A
potential advantage is that they may cause less weight gain than
conventional sulfonylureas. Later in the course of the disease,
they can be combined with other oral agents such as metformin
or thiazolidinediones. Unlike glibenclamide, these drugs are
relatively selective for KATP channels on B cells versus KATP
channels in vascular smooth muscle.
Thia:zolidinediones (glita:zones)
The thiazolidinedione~> (or glitazones) were developed following
the chance observation that a clofibrate analogue, ciglitazone,
which was being screened for ctTccts on lipids, unexpectedly
lowered blood glucose. Ciglita.wne caused liver toxicity, as did
troglitazone, but there are only rare reports of hepatotoxicity
with currently marketed thiazolidinediones (rosiglitazone and
pioglitazone).
Effects
The effect of thiacolidinediones on blood glucose is slow in
onset, the maximum effect being achieved after only 1-2 months
of treatment. Thi.volidinediones reduce hepatic glucose output
and increa e glucose uptake into muscle. enhancing the
effectiveness of endogenous in1.ulin and reducing the amount of
exogenous insulin needed to maintain a given level of blood
glucose by approximately 30%. The reduction in blood glucose
is often accompanied by reductions in circulating insulin and free
fatty acids. Triglycerides may decline, while LDL and high-
den~ity lipoprotein (HDL) are either unchanged or slightly
increased, with little alteration in LDL:HDL ratio. The
proportion of small dense LDL particles (believed to be the mo~t
atherogenic; Ch. 20) is reduced. Weight gain of 1-4 kg is
common, usually :.tabi lising in 6-12 months. Some of this is
attributable to nuid retention: there is an increase in plasma
volume of up to 500 ml, with a concomitant reduction in haemo-
globin concentration caused by haemodilution; there is also an
increase in extravascular Ouid, and increased deposition of
subcutaneous (as opposed to visceral) fat.
Mechanism of action
Thiazolidinediones bind to a nuclear receptor called the peroxisome
proliferator-actii'CIIed receptor-y (PPARy), which is complexed
with retinoid X receptor (RXR; see Ch. 3).9 PPARy occurs mainly
hlt is 1ronic that these receml) introduced and aggressively marketed drugs
share many of the propertle~ of tolbutamine. the oldest, least expensive
and least fa<.hionable of the <,ulfonylurea~. Perhaps diabetologists should
tum some of their inve>tigativc effort to Mudying how best to use this
Cinderella drug!
9
Compare with librate> (to which thiazolidinediones are structurally
rcl:ucd), which bind to PPARu (see Ch. 20).
in adipose tissue, but also in muscle and liver. It causes differ-
entiation of adipocytes (thi~> contributes to the unwanted effect of
weight gain), increa!>es lipogenesis and enhances uptake of fatty
acids and glucose. It also promotes amiloride-sensitive sodium
ion reabsorption in renal collecting ducts, explaining the adverse
effect of fluid retention (Guan et al .. 2005). Endogenous agonists
of PPARy include unsaturated fatty acids and various derivatives
of these, including prostaglandin J2 Thiazolidinediones are exogen-
ous agonil>t~>, which cause the PPARy-RXR complex to bind to
DNA, promoting transcription of several genes with products
that are important in insulin signalling. These include lipoprotein
lipase, fauy acid transporter protein, adipocyte fatty acid-binding
protein, G lut-4, phosphoenolpyruvate carboxykinase, malic
enzyme and others. It remains something of a mystery that
glucose homeostn!>is should be so responsive to drugs that bind
to receptors found mainly in fat cells; it has been suggested that
the explanation may lie in resetti ng of the glucose-fatty acid
(Randle) cycle by the reduction in circulating free fatty acids.
Phormocokinetic aspects
Both rosiglitatone and pioglitazonc are rapidly and nearly
completely absorbed, with time to peak plasma concentration of
less than 2 hour<>. Both are highly (> 99%) bound to plasma pro-
teins, both are subject to hepatic metabolism and both have a short
(< 7 hours) elimination half-life for the parent drug, but sub-
stantially longer (up to 150 hours for rosiglitazone, up to 24 hours
for pioglitazone) for the metabolites. Rosiglitazone is metab-
olised by CYP2C8 to weakly active metabolites. pioglita7one
mainly by a CYP2C isozyme and CYP3A4 to active metabolites.
The metabolites of rosiglitazone are eliminated mainly in urine,
and those of pioglita.tone mainly in bile.
Unwonted effects
The seriou~ hepatotoxicity of ciglitazone and troglitazone was
not encountered during clinical trials of rosiglitazone or pioglita-
zone, and reports of liver dysfunction since their general release
have been rure. Regu lar blood te&ts of liver function are currently
recommended. One (unproven) hypothesis is that the hepato-
toxicity of troglita7one is caused by quinone metabolites of its a-
tocopherol side-chain, which are not formed from the newer
thiazolidinediones. The commonest unwanted effects of rosigli-
tazone and pioglitazone are weight gain and fluid retention (see
above). Fluid retention i[) a substantial concern, because it can
precipitate or wor!.en heart failure, which contraindicate!.. their
use. Symptoms of uncertain cause, including headache, fatigue
and gastrointestinal disturbances. have also been reported.
Thiazolidinediones are contraindicated in pregnant or breast-
feeding women and in children. It is theoretically possible that
these drugs could cause ovulation to resume in women who are
anovulatory because of insulin resistance (e.g. with polycystic
ovary syndrome).
Interactions
Thiatolidinediones are additive with other oral hypoglycaemic
drugs. In Europe, both rosiglitazonc and pioglitazone are contra-
indicated for usc with insulin because of concern that these com-
binations increase the risk of heart failure, although in the USA
thiaz.ol idinediones arc widely used in combination with insulin. 407
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
Clinical use
Because insulin re~iMance is one important component of the
pathogenesis of type 2 diabetes. and has been implicated in the
excess cardiova cular mortality that accompanies lhe common
metabolic syndrome' (visceral obesity, hypertension. dyslipi-
daemia. insulin resbtance, etc.), there is a good rationale for
glituones in type 2 diabetes. This probably explains their wide-
spread adoption into clinical practice. especially in lhe USA.
There is, however, as yet no evidence that this optimism is justified
in terms of improved clinical outcomes (see for example Gale,
2001). Clinical trial evidence to date is from short-term studies
and supports their use in combination with metformin or with a
sulfonylurea in patients whose condition is inadequately con-
trolled on one of these drugs and are unsuited to addition of the
other. It is hoped that evidence to support wider and more useful
applications (e.g. as monotherapy or as triple therapy with both
metformin and a sulfonylurea) will soon be forthcoming. Poten-
tial clinical uses unrelated to diabetes, including fatty liver and
atheromatous disease, arc under investigation.
a-Glucosidase inhibitors
Acar bosc, an inhibitor of intestinal a-glucosidase, is used in
type 2 patients whose diabetes is i nadequately controlled by diet
with or without other agent~. It delays carbohydrate absorption.
reducing the postprandial increase in blood glucose. The com-
monest adverse effects arc related to its main action and consist
of flatulence. loo~c stools or diarrhoea. and abdomnal pain and
bloating. Like mctformin. it may be particularly helpful in obese
type 2 patient~. and it can be coadministered with metfonnin.
Potential new antidiabetic drugs
Several agents arc currently being studied, including a~
adrenoccptor antagonists and inhibitors of fany acid oxidation.
Lipolysis in fat cells is con trolled by adrenoceptors of the p3
subtype (see Ch. I I). The possibility of using selective 133 agonists,
currently in development, in lhe treatment of obese patients with
Clinical uses of oral hypoglycaemic drugs
Type 2 diabetes mellitus, to reduce symptoms
from hyperglycemia (e.g. thirst, excessive urination).
('Tight' control of blood glucose has only a small
effect on vascular complications in this setting.)
Metformin is preferred for obese patients unless
contraindicated by factor(s) that predispose to lactic
acidosis (renal or liver failure, heart failure, hypoxaemia).
Acarbose (a-glucosidase inhibitor) reduces
carbohydrate absorption; it causes flatulence and
diarrhoea.
Drugs that act on the sulfonylurea receptor (e.g.
tolbutamide, glibenclamide) are well tolerated but
often promote weight gain.
Thiazolidinediones are used in patients unable to
tolerate metformin/sulfonylurea combinations or where
either of these classes of drugs is contra-indicated.
408
type 2 diabetes is being investigated (see Ch. 27). There is interest
in inhibitors of protein ltinase C, for example ruboxistaurin
(LY33353 1), an inhibitor specific for the 13 isoform of PKC,
because of evidence implicating activation of this pathway in the
development of vascular diabetic complications (Aiello, 2005).
Drugs In diabetes
Insulin
Human insulin is made by recombinant DNA
technology. For routine use, it is given subcutaneously
(by intravenous infusion in emergencies).
Different formulations of insulin differ in their duration
of action:
fast- and short-acting soluble insulin: peak action
after subcutaneous dose 2-4 hours and duration
6-8 hours; it is the only formulation that can be
given intravenously
intermediate-acting insulin (e.g. isophane insulin)
long-acting forms (e.g. insulin zinc suspension).
The ma1n unwanted effect is hypoglycaemia.
Altering the amino acid sequence ('designer' insulins,
e.g. lispro and glargine) can usefully alter insulin
kinetics.
Oral hypoglycaemic drugs
These are used in type 2 diabetes.
8iguanides (e.g. metformin):
have complex peripheral actions in the presence
of residual insulin, increasing glucose uptake in
striated muscle and inhibiting hepatic glucose
output and intestinal glucose absorption
cause anorexia and encourage weight loss
can be combined with sulfonylureas.
Sulfonylureas and other drugs that stimulate insulin
secretion (e.g. tolbutamide, glibenclamide,
nateglinide):
can cause hypoglycaemia (which stimulates
appetite and leads to weight gain)
are effective only if 8 cells are functional
block ATP-sensitive potassium channels in 8 cells
are well tolerated but promote weight gain.
Thiazolidinediones (e.g. rosiglitazone, pioglitazone)
increase insulin sensitivity and lower blood
glucose in type 2 diabetes
can cause weight gain and oedema
are peroxisome proliferator-activated receptor-y
(a nuclear receptor) agonists.
a-Glucosidase inhibitor: acarbose
reduces carbohydrate absorption
- causes flatulence and diarrhoea.
 Obesity
Overview 410
Background 410
-Definition of obesity 410
The homeostatic mechanisms controlling energy
balance 411
-The role of leptin in body weight regulation 411
-Integration of information and effect on energy
balance 411
-Regulation of food intake and energy expenditure
Obesity as a health problem 414
-The pothophys1ology of human obesity 415
Pharmacological approaches to the problem of
obesity 416
-Sibutramine 417
-Orlistat 417
-Psychotropic drug therapy in obesity 418
New approaches to obesity therapy 418
OVERVIEW
Obesity is a growing health issue around the world
and is reaching epidemic proportions in some
nations. The problem is not restricted to the
inhabitants of the aHiuent countries, to the adult
population, or to any one socioeconomic class.
Body fat represents stored energy, and obesity
occurs when the homeostatic mechanisms
controlling energy balance become disordered or
overwhelmed. In this chapter, we explore first the
endogenous regulation of appetite and body mass,
and then consider the main health implications of
obesity and its pathophysiology. W e conclude with
a discussion of the two drugs currently licensed for
the treatment of obesity, and glance at the future
410 of pharmacological treatment of this condition.
BACKGROUND
Survival requires a continuous provision of energy to maintain
homeostasis even when the supply of food is intermittent. Evol-
ution has furni shed a mechanism for storing any excess energy
latent in food~luffs in adipose tissue as energy-dense trig lyceride~.
such that the!>e can be easily mobilised when food is absent or
less abundant. This mechanism. controlled by the so-called thrifty
genes, was an obvious asset to our hunter-gatherer ancc~tor,.
412 However, in many societies a combination of sedentary lifestyle.
genetic ' usceptibi lity, cultural influences and unrestricted acces\
to an ample ~uppl y of calorie-dense foods is leading to a global
epidemic of obesity, or 'globesity' as it sometimes called.
DEFINITION OF OBESITY
Tfthe 'ideal weight' of an individual is that which maximises life
expectancy. 'obesity' may be defined as an illness where the
health (and hence life expectancy) is adversely affected by exce~s
body fat. 1 But at what point does an individual become 'obese'?
The generally accepted benchmark. as proposed by the World
Health Organil ation expert committee, is the body mass index
( BM[). The BMJ is calculated by dividing the body mass (in kg)
by the square of the height (in metres). Although it is not a
perfect index (e.g. it does not distinguish between fat and lean
mass), the BM I is generally well correlated with other measure-
ments of body fat, and it is widely employed in obesity studies.
While there arc problems in defining a healthy' weight for a par-
ticular population. it is generally agreed that people with a BMI
of< 18.5 kg/m 2 ~hould be classified as 'underweight', and those
with a BMl of 18.5- 24.9 kg/m2 are regarded as of acceptable' or
'normal' weight. A BMI in the range of25.0-29.9 kglm 2 signifie~
'grade I overweight'. If the BMI is between 30.0 and 39.9 kg/m2
the patient b deemed to be obese or grade 2 overweight' . \\hile
those with a BMI of > 40 kg/m2 are said to be 'grade 3 0\cr-
weight ' or morbidly obese.
As the BMl obviously depends on the overall energy balance.
another, operational, definition of obesity would be that it i~ a
multifactOrial disorder of energy balance in which caloric intake
1
'Pcr~on~ w ho are natura lly very fat arc apt to die earl ier than those who arc
!.lender' observed ll ippocrates.

over the long tem1 exceed~ energy output, resulting in an abnor-
mally high BMI.
THE HOMEOSTATIC MECHANISMS
CONTROLLING ENERGY BALANCE
A common view. and one that is implicitly encouraged by authors
of numerous dieting booh as well as the enormously lucrative
dieting industry in general. i~ that o~ity is simply the result of
bad diet or wi lful overeating (hyperphagia). Tn truth, however,
the situation i~ more complex. Many people exposed to the san1e
dietary choices fail to become obese. and the failure rate in such
diets is high (probably 90%), with most eventually returning to
their original starting weight, suggesting the operation of some
intrinsic homeo:-.tatic system that strives to maintain a particular
set weight. This mechanism is normally exceptjonaUy precise,
and it has been calculated that it is capable of regulating e nergy
balance to 0.17% per decade (Weigle, 1994). A truly remarkable
feat considering the day-to-day variations in food intake.
Studies of obesity in monozygotic and dizygotic twins have
established a ~trong genetic innuence on the susceptibility to the
disease. and studies of rare mutations in mice (and more recently
in humans) have led to the discovery and elucidation of the
neuroendocrine pathway<> that match food intake with energy
expenditure, and to the concept that it is. in fact, disorders of
trus system that arc re~ponsible for the onset and maintenance
of the dil>ea<;c.
THE ROLE OF LEPTIN IN BODY WEIGHT
REGULATION
At the beginning of the 20th century. it was observed that patients
with damage to the hypothalamus tended to gain weight. ln the
1940s, it was also !.hown that discrete lesions in the hypothalamus
of rodents caused them to become obese. As early as 1953, Kennedy
proposed, on the basis of experiments on rats, that a hormone
released from adipose tissue acted on the hypothalamus to regu-
late body fat and food intake, thus setting the stage for future
discoveries in this area.
It was well established that mice can become obese as a result
of mutations in certain genes. At least five of these have now
been identified- including the ob (obesity), tub (tubby),fat and
db (diabetes) genes. Mice that arc homozygous for mutant fom1s
of these genes-o/J/ob mice and db/db mice-eat excessively
and have low energy expenditure, become grossly faL, and have
numerou~ metabolic and other abnormalities. Weight gain in an
ob/ob mouse is !.uppressed if its circulation is linked to that of a
normal mouse, implying that the obesity is caused by lack of a
blood-borne factor.
An important breakthrough came in 1994, when Friedman and
his colleagues (!tee Zhang et al.. 1994) cloned the ob gene and
idcntHied its protein product-/epti11 (the word is derived from
the Greek lepws, meaning thin). When recombinant leptin was
administered to obloh mice, it strikingly reduced food intake and
body weight. It had a s imilar effect when injected directly into
the lateral or the third ventricle, implying that it acted on the
OBESITY
regions of the brain that control food intake and energy balance.
Recombinant leptin ha~ sinular effects in humans (see Fig. 27.1 ).
Lcptin mR A is expressed in adipocytes; its synthesis is
increased by glucocorticoids. insulin and the oestrogens, and it is
reduced by ~-adrenoceptor agonists. In humans, the concentmtion
of leptin in the circulation varies according to the fat stores and
BMT in normal <;ubjects: the release is pulsatile and inversely
related to hydrocortisone levels. Leptin enters the central nervous
system (CNS) by a saturable transport mechanism. in amounts pro-
portional to the pla-;ma level. It acts on hypothalamic nuclei that
express specific leptin receptors. Insulin also plays an important
part in regulating energy balance. It strongly stimulates leptin
expression in fat cells. But its role as a fat sensor is more complex
(sec below, pp. 412-413). and it is accepted that leptin has the
more critical role.
Today, the adipocyte is regarded not only as a storage depot for
fat, but also as an important staging post on the energy informa-
tion highway. These cells secrete a host of other cytokioes and
other autocrine, paracrine and endocrine meruators. leading some
authorities to consider that adipose tissue is a dispersed endocrine
organ (Ahima & Flier, 2000a; Frlihbeck et al., 200 I).
INTEGRATION OF INFORMATION AND
EFFECT ON ENERGY BALANCE
Leptin 's main targets in the hypothalamus are two groups of
neurons in the arcuate nucleus. These have opposing actions, and
energy homeostasis depends, in the first instance, on the balance
between the~e action~. In one group, the peptides neuropeptide Y
(NPY) and aJ:ollfi-related peptide are colocalised. The other group
contains the protein prepro-opiomelanocortin (POMC) and
rclca!>es o.-melanocyte-stimulatillg hormone (a-MSH), which is a
proteolytic product of POMC cleavage. Both groups of neurons
express 11pecific leptin receptors.
Falling leptin levels activate the first group of neurons, resulting
in increased food intake (an orexigenic effect), and synthesis and
storage of fat (anabolism). as well as decreased energy expenditure.
Conversely, rising leptin levels activate the second group of neurons,
producing the opposite anorexigenic and catabolic effect. The
signal transduction mechanisms triggered by leptin receptor
activation arc thought to involve the Jak!Stat pathway (Ch. 3) and
activation of an ATP-sensitive potassium channel. Orexigenic
neurons project into the para ventricular nucleus, and anorexigenic
neurons into the lateral hypothalamk area. Interestingly, these two
areas had previou!>ly been identified. using lesioning techniques,
as 'hunger' and ~atiety' centres.
The integration of the infonnation on fat stores (adiposity signals)
with other nutritional information is very complex. Leptin, although
apparently a crucial coordinator, is only one part of the process.
Insulin receptors also occur on both groups of hypothalamic
neurons, and it is thought that leptin and insulin act in concert at
thi1. important regulatory !lite.
Some of the exi11ting information on energy balance and the
control of body weight and fat depots is shown in Figure 27.2
(see also Friedman, 1997).
T Numcrou~ factors other !han !hose included in the figure are involved
in regu lating food int<Jke and energy e)(penditure, including orexigenic
411
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

B
100
98th percentile start of leptin
100 therapy 95
- 50th percentile
- 2nd percentile '-.....
90
90
85
Oi
80 c
.:E
Cl
80
a;
~
70 75 -

70
60
65
cOi
.:E
Cl
50 60
~ 0 1 2 3 4 5 7 8 9 10 11 12
Months of Treatment
40
[c_
2
Oi 0
"--t: ....~ ..- " ~~an
30 c
IJ) -2
IJ)
<0
E mass
20 >- 6 ......
~
!: 10 weight ---.
-..._ Fat
10 Q)
01
c -14
<0
.c
(.)

0 ~------~---~~--~ 18
0 2 3 4 5 6 7 8 9 10 0 2 4 6 8 10 12
Age (years) Months of Treatment
Fig. 27.1 The effect of recombinant leptin on body weight in a 9-year-old severely obese child deficient in endogenous leptin
because of a frame shift mutation in the leptin gene. Although of normal birth weight, the child began gaining weight at 4 months and
was constantly demanding food. When treatment was initiated, the child weighed 94.4 kg. Weight loss began after 2 weeks' treatment,

l
and her eating pattern returned to normal. She had lost 15.6 kg of body fat after 1 year of treatment. (Data and figure adapted from,
Farooqi et al. 1999 N Engl J Med 341: 879-884.)

faclor<, <,uch as melanin-concentrating hormone. orexins A and B,
galanin, GABA. growth hormone-releasing hormone and ghrelin, as well
a.\ anorexigenic faclor<> \uch as corticotrophin-releasing hormone. the
'cocaine and a.mphctruninc-regulared tran~cript', neuroten~in , tumour
necrosis factor (TNI)-a. interleukin- 1fl, 5-hydroxytryptamine. glucagon-
like peptide~. bombe~in. ciJjary neurotrophic factor and the sariety facwr
cholecy<,~okmm. (For more details. see Ahima & Osei. 200 1.) It wiU come
a<, no wrpri-.e to learn that many of these are being targeted to produce
nO\CI antiObc\it) drug\ (\ee below).
REGULATION O F FOOD INTAKE AND
ENERGY EXPENDITURE
Food intake b of coun,e modified by a multitude of physiological,
psychological, financial and social factors, and so lhe long-term
regulation of energy balance by adiposity signals such as leptin
and insulin must of necessity occur against a background of day-
to-day variations in meal size, frequency and content. Food intake
412
appears to be modu lated by feedback loops in which signals from
the gastrointestinal tract are transmitted to the CNS. apparently
converging on the nucleus tractus solitarius. Some of these -.1gnal'
arise from vagal and other spinal affercnts originating in the ga'tro-
inte'>tinal tract. Another important endocrine afferent signal "
cholecystokinin-a peptide secreted by the duodenum m
re<,ponse to the process of eating and digestion of (espcciall)
fatty) foodstuffs. Cholecystokinin acts locally on cholecy\tokmm
A receptor.. in the gastrointestinal tract to stimulate vagal affcrents
and may. in its capacity as a neurotransmitter. also act on chol~
cystokinin B receptors in the brain in order to funcuon as a
satiety factor. Studies in rodents show how lhese short-term \3llct)
signals are integrated into the overall context of the body's encrg)
economy by regulation of meal size. for example. the ~timu
lation of food intake by NPY is largely attributable to larger mc31
siLes, whereas treatment with leptin leads to a reduction in meal
sie rather than frequency.
As mentioned above, insulin also has a significant role in the
control of energy metabolism. ll stimulates leptin release from fat
 OBESITY

Normal fat stores

Starvation:~
Decreased fat stores
Overfeeding:
Increased fat stores
Weight loss Weight gain
Fig. 27.2 The role of leptin,

~
insulin and hypothalamic peptides
in the regulation of energy
balance and fat stores. The
primary level of hypothalamic
control is vested in two groups of
neurons, with opposing actions, in
the arcuate nucleus. Both groups
!
+ Lept1nlinsulin
Arcuate nucleus of
the hypothalamus
t Leptin/insulin
express leptin receptors. In one
group, the peptides neuropeptide Y
I \ I I \~
(NPY) and agouti-related protein
(AGRP) are colocalised, the other ~RP ~ ~GAP
contains the protein prepro- neuron ~euron

opiomelanocortin (POMC), which

releases a-melanocyte-stimulating
hormone (a-MSH). Activation of the
t NPYflAGRP ~SH
t
tNPY/AGRP
t
t a-MSH

l
first group by fall in leptin levels
results in increased food intake and
decreased energy expenditure.
Increased leptin levels following
+Action of
t Food intake /anorexigenic + F0 od . 1 k /
tActi~nof
anorexigeniC
overfeeding activates the second pathways In a e pathways
group and has the opposite effect. +Energy expend1ture t Energy expenditure
a-MSH acts on melanocortin-4
receptors, an action that is inhibited
t
\
Size and number of fat cells
\
~ Size and number of fat cells
by AGRP. Insulin receptors also
occur in both groups. Leptin and Weight "" ~ / Wolghtt=
insulin act in concert on the
hypothalamic neurons, but leptin is
the main regulating factor. Many
other factors are involved in
regulating food intake and energy
expenditure-see text. Normal fat stores

cells, and it decreases food inLake by affecting the actions of PY
in the CNS (see Fig. 27.2). However. insulin may also. in 1>0mc
circumstances, increase food intake. prel.umably indirectly, by an
effect on blood glucose. Thus patients with type 2 diabetes mellitus
usually gain weight when treated with insulin or sulfonylureas-
an effect that is of clinical importance (sec Ch. 26).
Monoamines such as noradrenaline (norepinephrine), serotonin
and dopamine also play a role in the modulation of satiety signa b.
oradrenaline is colocaliscd with NPY in ~me neurons and greatly
potentiates its hyperphagic action. Deficit of dopamine impair<;
feeding behaviour, as do agonists at the 51 1T 2c receptor; antag-
onists at this receptor have the reverse effect.
Balancing food intake is the energy expenditure required to
maintain metabolism, physical activity and thennogenesis (heat
production). The metabolic aspects of energy expenditure include,
among other things, cardiorespiratory work and the actions of a
multitude of enzymes. Physical activity increases all these. as well
all increasing energy expenditure by the skeletal muscles. Lowering
the environmental temperature (e.g. exposure to cold) or feed ing
also stimulates thermogenesis. and the reverse is also true. The
often dramatic (20-40% increase) thermogenic effects of feeding
may provide a partial protection against developing obesity.
The sympathetic nervous system (sometimes in concert with
thyroid hormone) plays a significant part in the regulation of energy
expenditure in cardiovascular and skeletal muscle function during
physical activity, as well as in the thermogenic response of
adipose tissue and the response to cold. Both 'white' and 'brown
(the colour is apparently caused by the high density of mito-
chondria) fat cells (but especially the latter) have a major role in
thermogenesis. Brown fat, which is densely innervated by the
sympathetic nervous system, is abundant in rodents and human
infants, althoug h in human adults these cells are generally to be
found more interspersed with white fat cells. Because of their
abundant mitochondria. they are remarkable heat generators. pro-
ducing more heat and less ATP than white fat cells. The ba is for
this, as determined in mice. is the presence of mitochondrial
uncoupling proteins (UCP). Three isoforms, UCP-1, -2 and -3, are
known a nd have different distributions, although all are found in 413
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

!A Type 2 diabetes
Energy balance

6 - - Cholelithiasis
Hypenens100
Energy balance depends on food intake, energy
5 storage in fat, and energy expenditure. In most
- - Coronary hean dsease

""'~ 4 individuals, the process is tightly regulated by a

homeostatic system that integrates inputs from a
-~ number of internal sensors and external factors.
1U 3
G)
a: Important components of the system include the
2 following.
Hormones that signal the level of fat stores (e.g. leptin).
Increasing fat storage leads to raised plasma lepbn
0 release from adipocytes, which signals through neuronal
s 21 22 23 24 25 26 27 28 29 30
pathways in the central nervous system (CNS).
Body mass index
liD Hypothalamic neurons with leptin receptors sense
6 ~ increased body fat and release a -melanocyte-
stimulating hormone, which activates systems that
5 decrease food intake and increase energy
.>< expenditure. Decreased leptin causes the release
c: 4
<f)

~
:;
from other neurons of neuropeptide Y and agouti-
3 related protein, which have the opposite effect.
"'
G)
a: Along with leptin, insulin has a critical role in energy
2
homeostasis, but many other factors also play a part:
other hormones, cytokines, autonomic transmitters,
other CNS neuropeptide transmitters, and a variety of
o-L.,--.-,......----~--"T--,-------l
S 21 22 23 24 25 26 27 28 29 30 other mediators released from adipose tissue (which
Body mass index is now regarded as an endocrine organ).

Fig. 2 7.3 The relation between body mass index and

the relative risk of the d iseases specified. !A! The figures for
women, initially 3Q-55 years of age, who were followed for
18 years. B The figures for men, initially 40-65 years of age,
who were followed up for 10 years. (Adapted from Kopelman P
G 2000 Nature 404: 635-643; data from Willet W C, Dietz W H,
Colditz G A 1999 N EngI J Med 341: 427-433.)
brown fat. These proteins ' uncouple' oxidative phosphorylation,
so that mitochondria continue oxidative metabolism but produce
much les!> ATP. thus promoting net e11ergy loss as heat. As one
might anticipate, exposure to cold or leptin administration increases
both the activity and (after prolonged stimulation) the amount of
UCP- 1 in brown fat. Noradrenaline, acting on j3 adrenoceptors
(mainly B1 ) in brown fat, increases the activity of the peroxisome
proliferator-activated receptor-y (PPARy) transcription factor,
which, together with its coactivator PPARy coactivator (PGC)-1,
activates the gene for UCP-1. The expression of j33 adrenoceptors
is decreased in genetically obese mice.
OBESITY AS A HEALTH PROBLEM
Obesity is a growing and costly global health problem. According
to the World Hea.lth Organization, there are more than l billion
overweight adults, approximately one-third of whom are obese
according to the criteria outlined above. National obesity levels
vary enormously, being less than 5% in China, Japan and parts of
414 Afri ca, to a staggering 75% in parts of Samoa. Obesity levels in
the USA, Europe and the UK (among others) have increased thr~-e
fold ~ince 1980, with figures of 31% being quoted for the USA
and about 25% for many other industrialised nations (Padwal e1
al., 2003). The disease is not confined to adults: some 22 million
children under 5 years old are estimated to be overweight. In
the USA, the number of overweight children has doubled, ami
the number of overweight adolescents has trebled, since 1980.
Ironically, obesity often coexists with malnutrition in man)
developing countries. All socioeconomic classes arc affected. In
the poore~t countries, it is the top socioeconomic classes in \\hom
obesity is prevalent, but in the West it is usually the reverse
While obe~ity itself is rarely fatal. it brings with it th~ n'k
of increased susceptibility to a host of metabolic and other disonlcrs,
the most important of which are type 2 diabetes, cardiO\a~ular
conditions, cancers (particularl y hormone-dependent). and
re~piratory and digestive problems. as well a' osteoarthnus
Increasingly, !>OCial stigma is suffered by obese indh iduab,
leading to a sen~e of psychological isolation. One commentator
( Kopelman, 2000) has remarked that obesity ... is beginning to
replace under-nutrition and infectious disease!> as the most
significant comributor to ill health'. The total costs of obe,it)
related illness are hard to estimate. Figures in the range of2-7'!
of the total healthcarc budget are often given but are probably an
underestimate.
The risk of developing type 2 diabetes (which represcnh 8Yl
of all cases of the disease) rises sharply with increasing BMI. At

one time, thi~ disease was found mainly in the adult population,
but it is increa~ingly ~een in obese children, often striking even
before the on~et of puberty. The World Health Organization
repons that 90q. of those diagnosed with the disease are obese.
In a study of the disease in women. the risk of developing diabetes
\\a\ closely correlated with BMI, incre~ing fivefold when the
BMI was 25 kglm 2, to 93-fold when the BMI was 35 kglm 2 or
above (Coldill et al., 1995). Through several mechanisms. the
elevated pla~ma fauy acids. characteristic of the obese individual.
lead to inappropriate secretion of in~ulin and down-regulation of
in~ulin receptors. Eventually. when the system can no longer
compensate. in~ulin resiMance supervenes (see Ch. 26 for further
details of in~ulin actions).
Cardiovascular disease is also increased in the obese individual,
partly because of the increased oxygen demand secondary to the
extra ti~suc mass, and the increase in cardiac output that is
necessary to accommodate this. Secondary structural alterations
in the heart. coupled with other vascular changes including an
increased peripheral resistance, may lead eventually to heart failure.
The increased thoracic and abdominal adipose tissue reduces lung
volume and makes respiration difficult. This is especially the
case when the patient is lying down and the mass of abdominal
fat presses down on the peritoneal cavity, displacing other organs,
v.hich further reduce the diaphragm and other respiratory muscles.
Thi~ itself can cause '>erious sleep disorders secondary to changes
in blood ga'>es.
Olx!se subjects have an increased risk of colon. breast. prostate,
gall bladder, ovarian and uterine cancer. Numerous other disorders
are associated \\-ith excess body weight. including osteoarthritis,
h}peruricaemia and male hypogonadism. Gross obesity (BMI
over 40 l,.g/m 2) i associated with a 12-fold increase in mortality
in the group aged 25-35 years compared with those in this age
group with a BMI of20-25 kglm 2
THE PATHOPHYSIOLOGY OF HUMAN
OBESITY
In most adult subjects, body fat and body weight remain more or
less constant over many years. even decades, in the face of very
large variations in food intake and energy expenditure-amounting
to about a million calories per year. The steady-stale body weight
and BMl of an individual is, as has been stressed above, the result
of the integration of multiple interacting factors. and perturbations-
either in the direction of increa~e or decrea e-are resisted by
homeostatic mechanisms. How. then. does obesity occur? Why is
it '>0 difficult for the obese to lose weight and maintain the
lower \\-eight?
The main determinant is manifestly a disturbance of the homeo-
static mechanisms that control energy balance, but genetic endow-
ment underlies this disturbance. Other factors, such as food intake
and lack of physical activity, contribute. and there are, of course,
social, cultural and psychological aspects. We will deal below
with the imbalance of homeostatic mechanisms and genetic
endowment. and then briefly mention the role of food intake and
physical activity. The role of social. cultural and psychological
aspects we will leave (with a profound sigh of relief) to the
psychosociologists.
OBESITY
OBESITY AS A DISORDER OF THE
HOMEOSTATIC CONTROL OF ENERGY
BALANCE
Becau<;e the homeostatic control of energy balance is extremely
complex, it is not easy to determine what goes wrong in obesity.
When the leptin \LOry unfolded. it was thought that alterations in
leptin kinetics might provide a simple explanation. There is a
considerable interindividuaJ variation in sensitivity to leptin, and
some individual'> seem to produce insufficient amounts of this
hormone. Paradoxically, however, plasma leptin is often higher
in obese individuals, compared with non-obese subjects, not lower
as might be expected (Fig. 27.2). The reason for this is that resist-
ance to leptin rather than insufficient hormone is more prevalent
in obesity. Such rcsiMance could be caused by defects in leptin
synthesis, in its carriage in the circulation, in its transpo rt into the
CNS, in lcptin receptors in the hypothalamus (as occurs in db/db
mice) or in postreceplor signalling. There is some evidence that
the action of a member of the family of suppressors of cytokine
signalling, SOCS-3, may underlie or contribute to leptin resistance.
Dysfunction of mediators other than leplin could be implicated
in obesity. For example, TNF-a, another cytokine that can relay
information from fat tissue to brain, is increased in the adipose
tisc,ue of insulin-resistant obese individuals. Another pathophysi-
ological alteration in obesity is a reduced insulin sensitivity of
muscle and fat. and decre~ed ~3 adrenoceptor function in brown
adipose tissue (see above) may also occur; alternatively, UCP-2.
one of the proteins that uncouple oxidative phosphorylation in
adipocytes, could be dysfunctional in obese individuals.
A further '>uggestion is that alterations in the function of
specific nuclear receptors, such as PPARa. ~ and y, may play a
role in obc~ity. These receptors regulate gene expression of
enzymes a1>sociated with lipid and glucose homeostasis, and they
also promote the genesis of adipose tissue. PPARy is expressed
preferentially in fat cel ls and syncrgises with another transcription
factor, C/EBPa, to convert precursor cells to fat cells (see
Spiegelman & Flier, 1996). The gene for UCP (see above) in
white fat cells also has regulatory sites that respond to PPARa
and C/EBPa. A new class of agents, the rhiazoladinediones, bind
to and activate PPARy (see Ch. 26). One of these, troglitazone,
is licensed in the UK for treatment of type 2 diabetes. The
pathophysiology of obesity could involve disturbance(s) in any
of the multitude of other factors involved in energy balance.
GENETIC FACTORS AND OBESITY
Analyses of large-scale (> 100 000) studies in human monozygotic
and ditygotic twin pairs indicate that 50-90% of the variance of
BMI can be anributed to genetic factors. and suggest a relatively
minor role for erwironmental factors (Barsh et al.. 2000). This
conclu'>ion may seem surprising. but feeding studies using lab-
oratory rodent<, where food intake is held constant have demon-
strated the importance of genetic background to body weight
regulation, and this is especially true for high-fat diets. The pre-
vai ling viewpoint is that su1.cept ibility to obesity is largely deter-
mined by genetic factors, while environmental factors detem1ine
the expression of lhe disease. 4
__1_5_ _
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
The discovery that spontaneous mutations arising in single
genes (e.g. the oblob genotype) produced obese phenotype in
mice led to a ~earch for equivalent genes in humans. A recent
review (Perus~e et al., 2005) reported over 170 human obesity cases
that could be traced to single gene mutations in lO different genes.
Leptin receptor or POMC mutations are sometimes observed, but
MC4R mutations. however. seem to be more pre\alent (3-5%) in
obese patients (e.g. see Barsh et al .. 2000). In general, however,
human obesity '>hould be regarded as a polygenic disorder
involving the interaction of many genes. At the time of writing,
> 600 genes, marker:. and chromosomal regions are under
investigation for linkage to human obesity (Perusse et al., 2005),
and all information is annually updated on the Obesity Gene Map
Database (http//obesitygene.pbrc.edu).
Other genes that appear to be involved include the ~3 adreno-
ceptor and the glucocorticoid receptor. Decreased function of the
~ 3 adrenoceptor gene could be associated with impairment of
lipolysis in while fat or with thenuogenesis in brown fat. A
mutation of this gene has been found to be associated with
abdominal obesity, insulin resistance and early-onset type 2
diabetes in some subjects and a markedly increased propensity to
gain weight in a separate group of morbidly obese subjects.
Alterations in the function of the glucocorticoid receptor could
be associated with obesity through the permissive effect of gluco-
corticoids on several aspects of fat metabolism and energy balance.
FOOD INTAKE AND OBESITY
As Spiegelman & Flier (1996) point out, 'one need not be a
rocket scientist to notice that increased food intake tends to be
associated with obel.ity'. A typical obese subject will usually have
gained 20 kg over a decade or so. This means that there has been
a daily ex cells of energy input over output of 30-40 kcal initially,
increasing gradually to maintain the increased body weight.
The type of food eaten, as well as the quantity, can disturb
energy homeostasis. Fat is an energy-dense foodstuff, and it may
be that the mechanisms regulating appetite react more rapid ly to
carbohydrate and protein than to fat-too slowly to stop an indi-
vidual consuming too much high-fat food before th e satiety sys-
tems come into play.
Obese individuals diet to lose weight. However, when a subject
reduces calorie intake. shifts into negative energy balance and
lo!>es weight, the resting metabolic rate decreases, and there is a
concomitant reduction in energy expenditure. Thus an individual
who was previou~ly obese and is now of normal weight generally
needs fewe r calories to maintain that weight than an individual
who has never been obese. The decrease in energy expenditure
appears to be largely caused by an alteration in the conversion
efficiency of chemical energy to mechanical work in the skeletal
muscles. This adaptation to the caloric reduction contributes to
the difficulty of maintaining weight loss by diet.
PHYSICAL EXERCISE AND OBESITY
It used to be said that the only exercise effective in combating
obesity was pushing one's chair back from the table. It is now
416 recognised that physical activity-i.e. increased energy
expenditure-hal> a much more pos1t1ve role in reducing fat
storage and adjusting energy balance in the obese, particularly if
associated with modification of the diet. An inadvertent, narural
population study provides an example. Many years ago, a tribe of
Pima Indians split into two groups. One group settled in M ex1co
and con tinued to live simply at subsistence level. eating frugall)
and spending most of the week in hard physical labour. They are
generally lean and have a low incidence of type 2 diabetes. The
other group moved to the USA-an environment v.ith easy acce\'
to calorie-rich food and less need for hard physical worJ.... The)
are, on average. 57 lbs (26 kg) heavier than the Mexican group
and have a high incidence of early-onset type 2 diabetes.
PHARMACOLOGICAL APPROACHES TO
THE PROBLEM OF OBESITY
The first weapons in the fight against obesity arc diet and
exercise. Unfortunately, these often fail or show only short-term
efficacy, leaving only heroic surgical techniques (such as gastric
stapl ing or bypass) or drug therapy as a viable alternative.
The attempt to control appetite with drugs has had a long and
largely undistinguished history. Many types of 'anorectic' (e.g.
Obesity
Obesity is a multifactorial disorder of energy
balance, in which long-term calorie intake exceeds
energy output.
It is characterised by an excessive body mass index
(BMI; weight in kg divided by the square of height in m).
A subject with a BMI of 20-25 kg/m 2 is considered as
having a healthy body weight, one with a BMI of
25-30 kg/m 2 as overweight, and one w ith a BMl >
30 kg/m2 as obese.
Obesity is a growing problem in most rich nations;
the incidence-at present approximately 30% in the
USA and 15-20% in Europe-is increasing.
A BMI > 30 kg/m 2 significantly increases the risk of
type 2 diabetes, hypercholesterolaemia, hypertension,
ischaemic heart disease, gallstones and some cancers.
The causes of obesity may include:
deficiencies in the genesis of and/or the response
to leptin or other adiposity signals
defects in the hypothalamic neuronal systems
responding to leptin or other adiposity signals
defects in the systems controlling energy
expenditure (e.g. reduced sympathetic activity),
decreased metabolic expenditure of energy, or
decreased thermogenesis caused by a reduction
in ~3 adrenoceptor-mediated tone and/or
dysfunction of the proteins that uncouple
oxidative phosphorylation
an important genetic contribution.
 OBESITY

appetite l>Upprcs!.ant) agent:. have been tested in the past. including
the uncoupling agent ONP. amphetamines and fe nfluramine.
However. these arc no longer used. and the only t\vo drugs
currently licensed in the UK for the treatment of obesity are
sibutramine and orlistat. The two agents work in totally different
ways. with sibutramine acting on the C S to suppress appetite (a
true anorectic effect), while orlistat acts wilhin the gastrointestinal
tract to prevent fat ab'>orption. either should be given without
other concomitant dietary and other therapy (e.g. exercise). A5 might
be imagined. the que t for funher effective antiobesity agents is
the subject of a prodigious effon by the pharmaceutical industry.
SIBUTRAMINE
Sibutramine, originally intended as an an tidepressaot, has shown
promise in the trea tment of obesity. T he drug inhibits the re up-
take of serotonin and noradrenali ne at the hypothalamic sites that
regu late food inmke. Its main effects are to reduce food intake
and cause dose-dependent weight loss (see Fig. 27.4), the weight
loss being associated with a decrease in obesity-related risk
factors. Sibutramine enhances satiety and is reported to produce
a reduction in waist circumference (i.e. a reduction in visceral fat),
a decrease in plasma triglyccridcs and very low-density lipo-
proteins, but an increase in high-density lipoproteins. In addition,
beneficial effects on hyperinsulinaemia and the rate of glucose
metaboli m arc 1.aid to occur. There is some evidence that the
weight loss is associated with higher energy expenditure, possibly
through an incrca. e in thermogenesis mediated by the sympath-
etic nervous system.
A recent meta-analysis of three long-tem1 treatment studies
utilising sibutramine in comparison with placebo (Padwal et al.,
2003) concluded that there wa~ a 4.6% loss of weight after I year's
treatment with the drug. There wa~ a lso a higher ( 15%) increase
in patients who lost more than 10% of their body mass among
those taking the drug.
In the UK, the drug is licensed for use in periods up to a year,
and the National Institute for Health and Clinical Excellence has
advised that it should not be given to people who have not
already tried conscientiously to lose weight by other means.
Pharmacokinetic aspects
Sibutramine is given orally, is well absorbed and undergoes
extensive first-pass metabolism. The metabolites are responsible
for the pharmacological actions. Steady-state blood levels of the
metabolites occur within 4 days. The active metabolites are inac-
tivated in the liver, and 85% of the inactive residues arc excreted
in the urine and faeces.
Unwanted effects
S ibutramine increases heart rate and blood pressure. Regu lar
monitoring of these parameters is essential, and the drug is con-
traindicated if cardiovascular disease is present or if the systolic
or dia~tolic pressure is raised by I 0 mmHg or more. Other unwanted
effects include dry mouth, constipation and insomnia Interactions
with drugs that are metabolised by one of the P450 isoenzymes
can occur.
ORLISTAT
Orli1.tat reacts with serine residues at the active sites of gastric
and pancreatic lipases. irreversibly inhibiting the enzymes and
thereby preventing the breakdown of dietary fat to fany acids and
glycerols. It therefore causes a dose-related decrease in fat absorp-
tion and a corresponding increase in faecal fat excretion that
plateau~ at some 30% of dietary fat. Given with a low-calorie diet
in obese individuals, it produces a modest but consistent loss of

( 104
102
~

100 Placebo
Cl
~ 98
E01
"G) 96
3:
>- 94
'8
co 92
90
88
I
0 2 4 6 8 10 12 14 16 18 20 22 24
Month
Weight loss Weight maintenance
Fig . 27.4 The res ults of a c linical trial of the efficacy of sibutramine in maintaining weight loss. Patients selected for the trial
had a body mass index of 3o-45 kg/m? and were put on to an initial 6-month treatment programme including oral sibutramine, an

l
individualised 600 kcal/day dietary deficit programme, and activity and behavioural advice. The results are shown in the 'weight loss'
section of the graph. (Only patients who had lost 5% of their body weight are represented; 467 of the 499 who completed the 6-month
programme.) These responders were then entered into a randomised, placebo-controlled, double-blind parallel group trial to evaluate the
effect of s ibutramine on weight maintenance. (Figure adapted from James et a t. 2000 Lancet v: 21 19-2125.)
417
 SECTION 3 . DRUGS AFFECTING MAJ OR O RG AN SYSTEMS

weight compared with in placebo-treated control subjects. In a
recent meta-analysis of II long-term placebo-controlled trials
encompassing over 6000 patients, orlistat was found to produce
a 2.9% greater reduction in body weight than in the control group,
and 12% more patients lol>t I 0% or more of their body weight
compared with the con trols (Padwal et al., 2003).
Orlistat is also reported to be effective in patients suffering
from type 2 diabetes and other complications of obesity, to
reduce leptin levels and blood pressure. to protect against weight
loss-induced changes in biliary '>ecretion, to delay gastric emptying
and gastric secretion, to improve several important metabolic
paran1eters. and not to interfere with the releal>e or action of
thyroid !md other important hormones (Curr!m & Scou. 2004). It
does not induce changes in energy expendinrre.
Pharmacokinetic aspects
Virtually all (97%) of orl istat is excreted in the faeces (83%
unchanged). with only negligible amounts of the drug or its
metabolites being absorbed.
Unwanted eHects
Abdominal cramps, narus with discharge !md faecal incontinence
C!m occur, as can intestinal borborygmi (rumbling) and oily sponing.
Surprisingly. in view of the possibility of these antisocial effects
occurring, the drug is well tolerated. Supplementary therapy with
faHoluble vitamins may be needed. and there has been a report
of decreased absorption of contraceptive pills.
No significant drug interactions have been noted, except in the
case of ciclosporin (see Ch. 14), where reduced absorption of the
latter drug has been reponed.
PSYCHOTROPIC DRUG THERAPY IN
OBESITY
While they cannot be regarded as specific therapies, a common
cli nical finding is lhat some subgroups of obese patients, such as
those with concomitant depres1.ion. respond well to mood-
altering drugs such as the selective serotonin uptake inhibllol\
(see Ch. 39). A discussion of this whole area is beyond the \cope
of this chapter, and the reader i~ referred to Appolinario et al.
(2004) for further information.
NEW APPROACHES TO OBESITY
THERAPY
Rare cases of leptin deficiency in patients have been '>UCCe~,fully
treated by long-term treatment with the hormone. but thi' i\ an
unusual intervention and unlikely to be of more than limited
use in the future. Many other approaches arc being piloted: in
fact, a recent review of the area estimated that there were more
than 150 novel agents under development (Kaplan, 2005). Some
of these aim to exploit the action or production of neuroendocrine
satiety signals such as cholecystokini n to produce appetite
suppression, while others aim to alter the C S levels of neuro-
transrniuers such as NPY or melanocortins, which transduce
changes in humoral adiposity signals such as leptin (Halford.
200 I). The tractability of the MC4 receptor it<;e(f as a drug target.
coupled with the observation that defects in MC4 signalling arc
prevalent in obesity, ha~ attracted much intcrc~t from the
pharmaceutical industry.
Another approach enti rely has originated from research in the
carlllabinoid field (sec Ch. 15 ror further detai ls). From the clinical
(and indeed, anecdotal) observation that marijuana and 6."-
tetrahydrocannabinol can stimulate appetite has arisen the notion
that cannabinoid receptors, especially the CB 1 receptor. may b.:
involved in the control of energy ba!Mce (see Di Marzo 8:.
Matias, 2005; Vicker~ & Kennett. 2005). A selecti\C CB 1 anta-
goni::.l. rimonabant , has been developed (Ch. 15) and i' current!)
undergoing phase Ill clinical trial!> for a variety of indicallom.
including smoking cessation, obesity and metabolic ~yndromc
(Boyd eta!., 2005).

Clinical uses of antiobesity drugs

The main treatment of obesity is a suitable diet and
increased exercise.
Orlistat, which causes fat malabsorption, is
considered for severely obese individuals, especially
with additional cardiovascular risk factors (e.g.
diabetes mellitus, hypertension).
Many centrally acting appetite suppressants
have been w1thdrawn because of addiction, pulmonary
hypertension or other serious adverse effects.
Sibutramine is one possible adjunctive treatment of
severely obese individuals.

REFERENCES AND FURTHER READING

llod) "eight regulation
Ahuna R S. Flier J S 20<Xla Adapo-.c t"'uc a> an endocrine
organ. Trends Endocrinol Mctnb II. 327- 332
(Succmct tmicle on th~ nrw irwr>f atlq>ose tlrsue)
Ahimn R S. Aier J S 2000b Le(ltin. Annu Rev Phy,iol
418 62: .\ 13-437 (Compreltetuile revirw <if leptitJ: its
e.:preuion. awma m lt.\(HJih<llatmu. role;,, merg_1
homt'ostmif mul t>tlter 11ctions)
Ahima R S. O'c' S 2001 Molecular regulation of eating
behaviour. new '""ght; and prospect~ for future
strategic,. Trcmh Mol Med 7: 205- 213 (Praiseworthv
short ,.,.;;w; etcellem jigures cmd useful rabies <!f rltt
mt:(lwwn ln\O[,ed ill snmulatitm unJ mhth1twn 1
jitdmg behavioltr)
l'riedrnan J M 1997 The alphabet of "eight control
Nature 385: 119-120
rrOhbed, G. G6mez-Amllrosi et al. 2001 The ndapvcyk
a model for integration of endocrine and mct,abolc
 The pituitary and the
adrenal cortex
Overview 420
The pituitary 420
-Anterior pituitary (adenohypophysis) 420
- Hypothalamic hormones 421
-Anterior pituitary hormones 422
-Posterior pituitary (neurohypophysis) 425
The adrenal cortex 427
-Adrenal steroids 427
New directions in glucocorticoid therapy 435
OVERVIEW
The pituitary and adrenal glands are major sites
for the synthesis and release of hormones that
profoundly aHect the biochemistry and physiology
of almost all cells, and which are crucial to the
understanding of the actions of many anti
inflammatory and other drugs. The pituitary itself
is controlled by hormones released from the
hypothalamus and, in turn, the hypothalamic
-pituitary axis orchestrates the activity of the
adrenal (and other endocrine) glands. In the first
part of this chapter, we examine the control of
pituitary function by hypothalamic hormones and
review the physiological roles and clinical uses of
both anterior and posterior pituitary hormones.
The second part of the chapter concentrates on the
actions of adrenal hormones and, in particular, the
anti-inflammatory eHect of glucocorticoids. This
should be read in conjunction with the relevant
sections of Chapters 3 and 14.
THE PITUITARY
The pituitary gland comprises three different structures arising
from two different embryological precursors. The anterior pituitary
and the intermediate lobe are derived from the endoderm of the
buccal cavity, while the posterior pituitary is derived from neural
420 ectoderm. The main parts of d1e gland, the anterior and posterior
lobes, receive independent neuronal input from the hypothalamus,
with which they have an intimate functional relationship.
ANTERIOR PITUITARY (ADENOHYPOPHYSIS)
The a nterior pituitary (adenohypophysis) secretes a number of
hormones crucial for normal physiological function. Within this
tissue are specialised cells such as corticotrophs, lactotrophs
(mammotrophs). .10matotrophs, thy1vtrophs and gonadotrophs,
which secrete hormones that regulate different endocrine organs
of the body (Table 28.1 ). Interspersed among these are other cell
typcl>, including the follicu/ostel/ate cells that exert a nurturing
and regulatory innuence on the hormone-secreting endocrine cell,.
Secretion from the anterior pituitary is largely regulated by
factorsol- in effect hormones-that are derived from the h)po-
thalamu-. and that reach the pituitary through the bloodstream.
Blood ves-,eb to the hypothalamus divide in its tissue to form a
meshwork of capillaries, the primary plexus (Fig. 28.1), \.\-hich
drains into the hypophyseal portal vessels. These pas~ through
the pituitary stalk to feed a secondary plexus of capillaries in the
anterior pituitary. Peptidergic neurons in the hypothalamus secrete
a variety of releasing or inhjbitory hormones directly into the
capillaries of dle primary plexus (Table 28.1 and Fig. 28.1 ). Most
of these regulate the secretion of hormones from the anterior
lobe, although the me lanocyte-stimulating hormones (MSHs) arc
secreted main ly from the intermediate lobe.
Negative feedback pathways between the hormones of the
hypothalamus, dle anterior pituitary and the peripheral endocrine
g lands regu late the release of stimulatory hormones and integrate
the functions of individual components of the endocrine sy\tem
into a functional whole. In long negative feedback path\~3)\,
hormonel> secreted from the peripheral glands exert regulatOI)
actions on both the hypothalamus and the anterior pituitary. The
mediatofl> of the short negati1e feedback pathways are antenor
pituitary hormones that act directly on the hypothalamus.
The peptidergic neurons in dle hypothalamus are themsehe'
innuenccd by odler centres within the central nervous sy,tem
(CNS). This action is mediated through pathways that release
dopamine, noradrenaline (norepinephrine), 5 -hydroxytryplamine
1
The word 'factor' wa\ originally coined at a time wben their structure and
function were not known. The~e are blood-borne messengers, and :L~ such
nrc c learly hormones. Nevertheless, the term factor, however irrational.
lingers on.
 THE PITUITARY AND THE ADRENAL CORTEX

Table 28.1 Hormones secreted by the hypothalamus and the anterior pituitary

Hypothalamic factor/hormone Hormone affected in anterior Main effects of anterior pituitary hormone
(and related drugs) pituitary (and related drugs)

Corticotrophin-releasing factor Adrenocorticotrophic hormone Stimulates secretion of adrenal cort1cal hormones (mainly
(corticotrophin, tetracosactide) glucocorticoids); maintains integrity of adrenal cortex

Thyrotrophin -releas1ng hormone Thyroid-stimulating hormone Stimulates synthesis and secretion of thyroid hormones, thyrox~ne
(TRH, protirelin) (thyrotrophin) and triiodothyronine; ma1ntains integrity of thyroid gland

Growth hormone-releasing factor Growth hormone Regulates growth, partly directly, partly through evoking the
(somatotrophin) release of somatomedins from the liver and elsewhere; increases
protein synthesis,lncreases blood glucose, stimulates lipolysis

Growth hormone release-inhibiting Growth hormone As above

factor (somatostatin, octreotide)

Gonadotrophin-releasing hormone
(GnRH, somatorelin, sermorelin)
Follicle-stimulating hormone
(FSH; see Ch. 30)
Luteinising hormone (LH) or
interstitial cell-stimulating
hormone (see Ch. 30)
Stimulates the growth of the ovum and the Graafian follicle
in the female, and gametogenesis in the male; with LH,
stimulates the secretion of oestrogen throughout the
menstrual cycle and progesterone in the second half
Stimulates ovulation and the development of the corpus luteum;
with FSH, stimulates secretion of oestrogen and progesterone
in menstrual cycle; in male, regulates testosterone secretion

Prolactin release-inhibit1ng factor Prolactin Together with other hormones, prolactin, promotes development
(probably dopamine) of mammary tissue dunng pregnancy; stimulates milk production
in the postpartum period

Prolactin-releasing factor Prolactin As above

Melanocyte-stimulating hormone a-, ~- and y-MSH Promotes formation of melanin, which causes darkening of skin;
(MSH) releasing factor MSH is anti-inflammatory and helps to regulate feeding

MSH release-inhibiting factor u-, ~-and y-MSH As above

and the opioid peptides, the last of these being found in very high
density in the hypothalamus (see Ch. 16). Hypothalamic control
of the anterior pituitary is also exerted through the wberohypo-
physeal dopaminergic pathway, the neurons of which lie in close
Hypothalamic- apposition to the primary capillary plexus (see Ch. 32). Dopamine
hypophyseal secreted directly into the hypophyseal portal circulation reaches
tract the anterior pituitary in the blood.
Artery_ Intermediate
-;;;;~-~
lobe
Long portal vessels HYPOTHALAMIC HORMONES
~-- POSTERIOR
PITUITARY The secretion of anterior pituitary hormones is regulated by some
Secondary (neurohypophysis) six sets of releasing factors that originate in the hypothalamus.
capillary plexus
The. e are listed in Table 28.1 and are described in more detail
below. Some arc used clinically for diagnosis or treatment, whereas
ANTERIOR Venous
PITUITARY outflow others are useful research tools. Many of these releasing factor
Venous outflow hormones all.O function as neurotransmitters or neuromodulators
Fig. 28.1 Schematic d iagram of vascular and neuronal elsewhere in Lhe CNS (Ch. 32).
relationships between the hypothalamus, the posterior
pituitary and the anterior pituitary. The main portal vessels to
the anterior pituitary lie in the pituitary stalk and arise from the GROWTH HORMONE-RELEASING FACTOR
primary plexus in the hypothalamus, but some (the short portal (SOMATORE LIN)

l vessels) arise from the vascular bed in the posterior pituitary

(not shown). Growth hormone- releas ing factor (GHRF) is a peptide with
40-44 ami no acid residues. An analogue, sermorello, has been 421
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
introduced as a diagnostic test for growth hormone secretion. The
main action of GIIRF is summarised in Figure 28.2. Given intra-
venously, subcutaneoul>ly or intranasally (generally the former),
it causes secretion of growth hormone within minutes and peak
concentrations in 60 minutes. The action is selective for the
somatotroph'> in the anterior pituitary, and no other pituitary
hormone~ are affected. Utmanted effects are rare.
SOMATOSTATIN
Somato~tatin il-l a peptide of 14 amino acid residues. Tt inhibits
the release of growth hormone and thyroid-stimulating hormone
(TSH, thyrotrophin) from the anterior pituitary (Fig. 28.2), and
insuli n and glucagon from the pancreas; it also decreases the release
of most gastrointestinal hormones. and reduces gastric acid a nd
pancreat ic secretion.
O ctreotide is a long-acting analogue of somatostatin (sec a lso
Ch. 26 and Ch. 51). It is U!>ed for the treatment of tumours secreting
vasoactive intcMinal peptide, carcinoid tumours (Ch. 12), gluca-
gonomas and various pitllitary adenomas. It also has a place in the
therapy of acromegaly (a condition in which there is oversccretion
of growth hormone in an adu It) and of bleeding oesophageal varices.
Octre01ide is generally given subcutaneously. The peak action is
at 2 houn., and the <,uppressant effect lasts for up to 8 hours.
Unwamed effect!. include pain at the injection site and gastro-
intestinal disturbances. Gallstones and postprandial hypergly-
caemia have also been reported. and acute hepatitis has occurred
in a few cases.
( Hypothalamus
Ante rior pituitary
+ The main hormones of the anterior pituil<lry are li\tc.:d in
Somatropin I Table 28.1. The gonadotrophins are dealt with in Chapter 30.
v and TSH in Chapter 29. The remainder are dealt with belo\\
Growth
hormone
Liver
+ '
+
IGF-1 ==========:__)
~ developmental problems (see below).
Growth of peripheral tissue
Fig. 28.2 Control of growth hormone secretion and its
a ctions. Drugs are shown in yellow boxes. GHRF, growth
hormone-releasing factor; IGF-1, insulin-like growth factor-1.
422
Lanreotide has similar effects but is also used in the treatment
of thyroid tumours.
THYROTROPHIN-RELEASING HORMONE
(PROTIRELIN)
Thyrotrophin-releasing hormone (TRH) from the hypothalamu'
releases TSH from the anterior pituitary. Protirelin is a syntht:tic
TSH used for the diagnosi~ of thyroid disorders (~ee Ch. ~9).
Given intravenously in normal subjects. it causes an incrca-.c in
plasma TSJ 1 concentration, whereas in patients with hypa-
thyroidism there is a b lunted response because the raised blooJ
thyroxine concentration has a negative feedback effect on the
anterior pi tuitary. The opposite occurs with hypolhyroidi,m.
where there i~ an intrinsic defect in the thyroid itself.
CORTICOTROPHIN-RELEASING FACTOR
Corticotrophin-releasing factor (CRF) is a peptide that rc l ca'c~
adrenocorticotrophic hormone (ACTH, corticotrophin) and~
endorphin from the anterior pituitary. CRF acts synergi\ticall)
with antidiuretic hormone (ADH; arginine-vasopressin), and lxnh
its action and its release are inhibited by glucocorticoid.\ ('-t!l!
Fig. 28.4, below). Synthetic preparations have been used to te't
the ability of the pituitary to secrete ACTH. and to assess '~hether
ACT! I deficiency is caused by a pituitary or a hypothalamic defect.
It has also been used to evaluate hypothalamic pituitary funcuon
after therapy for Cushing's syndrome (see Fig. 28.7, belo" ).
GONADOTROPHIN-RELEASING HORMONE
Gonadotrophin- (or luteinising hormone-) releasing hom1onc 1\
a dccapeptide that releases bothfollicle-stimu/ating lwmume and
luteini.ving hormone. It is also available as a preparation called
gonadorelin. Its primary clinical uti lity is in the treatment of
inferti lity. and its actions are described in Chapter 30.
ANTERIOR PITUITARY HORMONES
GROWTH HORMONE (SOMATOTROPHIN)
Growth hormone is ~ecreted by the somatotropb cells and ., the
mo 1 abundant pituitary hormone. Secretion is high in the
newborn, decreasing at 4 years to an intermediate level. \\hich i'
then maintained until after puberty. after which there is a further
decline. Several recombinant preparations of growth hormone. or
somatropin. are available for treating growth defects and other
Regulation of secretion
Secretion of growth hormone is regulated by the action of h) pt)-
tha lamic GHRF modulated by somatostatin, as described abmc
and o utl ined in Figure 28.2. One of the mediators of growt h

hom1one action. insulin-liJ.e growth factor (IGF)-1. which is
relea<,ed from the liver (see below), has an inhibitory effect on
growth hormone secretion by ~timulating somatostatin release
from the hypothalamu~.
Growth hormone rclca!>c, like other anterior pituitary secre-
tion!., il> pubatile. and its plasma concentration may fluctuate
10- to 100-fold. The!>e surges occur repeatedly during the day
and night. and renect the dynamics of hypothalamic control.
Deep l>lecp is a potent stimulus to growth hormone secretion,
particularly in children.
Actions
The main effect of growth hormone (and its analogues) is to
stimu late normal growth and, in doi ng this, it affects many
tissues, acting in conj unction with other hormones secreted from
the thyroid, the gonads a nd the adrenal cortex. Tt stimu lates
hepatic production of the IGFs-also termed somatomedins-
which mediate most of its anabolic actions. Receptors for lGF- 1
(the principal mediator) exist on many cell types, including liver
cells and fat cell~.
Growth hormone stimulates the uptake of anlino acids and
protein synthe'>is. especially in skeletal muscle. IGF- 1 mediates
many ofthe<,e anabolic effects, acting on skeletal muscle and also
on the cartilage at the epiphy'>es of long bones. thus influencing
bone grO\Hh.
Disorders of production and clinical use
DeficienC} of growth hormone results in pituitary dwarfism. In
this condition, which may result from lack of GHRF or a failure
of IGF generation or action, the normal proportions of the body
are maintained. Growth hormone is used therapeutically in
patients (often children) with growth hormone deficiency and
with the short stature associated with Turner's syndrome. It may
also be used to correct chronic renal insufficiency in children.
Satisfactory linear growth can be achieved by giving somatropin
.,ubcutaneously, six to seven times per week, and therapy is most
successful when started earl y. Humans arc insensitive to growth
hormone of o ther species. so human growth hormone must be
used clinical ly. This used to be obtained from human cadavers,
leading to the spread of Creutzfeldt-Jacob disease, a prion-
mediated ncurodegenerative disorder (Ch. 35). Human growth
hormone i~ now prepared by recombinant DNA technology,
which avoid~ the risk of prion contamination.
An exces'>ive production of growth hormone in children results
in gigantism. An cxcel.sive production in adults, wruch is usually
the result of a benign pituitary tumour, results in acromegaly, in
which there is enlargement mainly of facial structures and of the
hands and feet. The dopamine agonist bro mocriptine and
ocrreotide may mitigate the condition, but effective treatment
demands removal or irradiation of the tumour.
PROLACTIN
Prolactin is secreted from the anterior pituitary by lactotroph
(mammotroph) cells. These are abundant in the gland and increase
in number during pregnancy, probably under the influence of
oestrogen.
THE PITU ITARY AND THE ADRENAL CORTEX
Regulation of secretion
Prolactin secretion is under tonic inhibitory control by the
hypothalamus (Fig. 28.3 and Table 28.1 ). the inhibitory mediator
being dopamine (acting on D2 receptors on the lactotrophs). The
main stimulus for release is suckling; in rats, both the smell and
the sounds of hungry pups are also effective triggers. Neural
renexe~ from the brca:.t may stimulate the secretion from the
hypothalamus of prolactin-releasing factor(s). possible candidates
for which include TRH and oxytocin. Oestrogens increase both
prolactin secretion and the proliferation of lactotrophs through
release. from a subset of lactotrophs. of the neuropeptide galanin.
Dopamine antagonists (used main ly as antipsychotic drugs; see
Ch. 38) arc potent stimulants of prolactin release, whereas
agonists such as bromocriptine (see below and also Chs 12. 35
and 38) suppress prolactin release. Bromocriptine is a lso used in
parki nsonism.
Actions
There are at least three specific receptor subtypes that bind
prolactin, and these are not only found in the mammary gland but
are widely distributed throughout the body, including the brain,
ovary, heart and lungs. The main function of prolactin in women
is the control of milk production. At parturition. when tl1e blood
level of oestrogen falls. the prolactin concentration rises and
lactation is initiated. Maintenance of lactation depends on suckling,
which Mimulates a rene~ secretion of prolactin by neural path-
ways, causing a I 0- to I 00-fold increase within 30 minutes.
Together with other hormones. prolactin is responsible for the
proliferation and differentiation of mammary tissue during preg-
nancy. It inhibits gonadotrophin release and/or the response of
the ovaries to these trophic hormones. This is one of the reasons
- - - - -- Hypothalamus ---- - - - -
~,
~-~_ _ _ _ _, ..............6:...
?PRF PRIF
?TRH
+ +
Anterior p!tuitary
'II
I
v
Suckling
reflex t
Prolactin - - - - - - - - - '
l. ._____ Mamma~y glands
Fig. 28.3 Control of prolactin secretion. Drugs are shownj
in yellow boxes. PRF, prolactin-releasing factor; PRIF, prolactin
release-inhibiting factor; TRH, thyrotrophin-releasing hormone.
423
 SECTION 3 DRUGS AFFECTING MAJOR ORGAN SYSTEMS

why ovulation docs not usually occur during breast feeding, and \
it is believed to constitute a natural contraceptive mechanism.
r------- Hypothalamus ~-- ----- ~
T According to one rather appealing hypothesis, the high postpartum I
I
I
I
concentration of prolactin reflect~ irs biological function as a parental' I

hormone. Cenainly broodiness and nest-building activity can be induced v I

I
I
CRF
in btrds, mtce and rabbtll> by prol:tctin injections. It is rather attraCtive to
e
ADH~<b
thmk that it mtght have a ~tmilar action in humans, although this is
conjectural. Prolactin abo exerts other, apparently unrelated, actions.

~~
includmg \llmulaung nutogene~i' in I} mphocytes. There is some evidence I
Long negative Short negative
that it may play a part in regulating immune responses.
feedback loop feedback loop
I
Anterior pitUitary I
Modification of prolactin secretion I
I
I
I
Prolactin itself i~ not used clinically. Bromocriptine, which stimu- I

lates dopamine receptors, is used to decrease excessive pro lac ti n

v
secretion (e.g. that results from prolactinomas). It is well absorbed ACtT~ ///'

---~enin-angiotensin
orally, and peak concentrations occur after 2 hours. Unwanted
reactions include nausea and vomiting. Dizziness, constipatio n -- -
and postural hypotens ion may also occur. Cabergoline is a related
compound wi th similar effects, and quinagolide, havi ng actio ns ,-----__ / \ ________,,% system
I \
simi lar to those of ergot-derived dopamine agonists, may also be I
\
I
I
\ I
used fo r hyperprolactinaemia. \
\ I
I

'' /
' \
\ I
I/
/

I \

ADRENOCORTICOTROPHIC HORMONE / Adrenal \

~~,
,"'" cortex ''........... ~
Ad renoconicotrophic hormone (corticotrophin) is the anterior
Glucocorticoids Mineralocorticotds
pituitary secretion that controls the synthesis and release of the
glucoconicoids of the adrenal conex (see Table 28.1 and p. 427). It Exogenous Exogenous
is a polypeptide hormone with 39 amino acid residues derived gluc ocorticoids mineralocorticoids
from the precursor pro-opiomclanocortin by sequential proteolytic (e.g . prednisolone) (e.g. fludrocortisone)
processing. Detail of the regulation of ACTH secretion is shown +
in Figure 28.4.
T Thb hormone occupies (together with cortisone) an important place in Peripheral actions Peripheral acttons
the history of inflammation therapy because of the work of Hench and his (metabolic, anti- on salt and water
colleagues in the 1940s. who first observed that both substances had anti- Inflammatory, metabolism
inflammatory effect~ in patients with rheumatoid disease. The effect of
immunosuppressive)
ACTH wa~ thought to be <,ccondary to stimulation of the adrena l cortex Fig. 28.4 Regulation of synthesis and secretion of
bu t, imeresti ngly, the hormone also has anti-inflammatory actions in its adrenal corticosteroids. The long negative feedback loop Is
own righ t, through activation of macrophage (melanocortin) MC 1 more important than the s hort loop {dashed lines).
receptors (Gelli ng et al.. 2002). Adrenocorticotrophic hormone (ACTH, corticotrophin) has only
a minimal effect on minera locorticoid production. Drugs are
Adrenocorticotrophic hormo ne itself is not often used in therapy
s hown In yellow boxes. ADH, antidiuretic hormone
today, because its action is less predictable than that of the corti- (vasopressin); CRF, corticotrophin-releasing factor.
costeroids and it may provokes antibody formation. Tetracosactide,
a synthetic polypeptide that consists of the first 24 N-tenninal
residues of human ACTH, has the same drawbacks but is now

widely used in it!> stead for assessing the competency of the

adrenal conex (see below).
The concentration of ACfH in the blood is reduced by gluco-
conicoids, forming the basis of the dexamethasone suppression
Clinical use of bromocriptine
test (see p. 433).
To prevent lactation
Actions
To treat galactorrhoea (i.e. non-puerperal lactation in
Tetracol>actide and ACfH have two actions on the adrenal conex.
either sex), owing to excessive prolactin secretion.
To treat prolactin-secreting pituitary tumours Stimulation of the synthesis and release of g lucoconicoids.
(prolactinomas). This action occurs within minutes of injection, and the main
In the treatment of parkinsonism (Ch. 35) and of bio logical actio ns are those of the steroids re leased.
acromegaly. A trophic action on adrenal cortical cells, and regulation of
424 the levels of key mitochondrial steroidogenic enzy mes. The

los' of this effect accounts for the adrenal atrophy that result!>
from chronic glucocorticoid admi ni ~trati on (see p. 429),
which suppresses ACTH secretion.
The main use of tetracosactide is in the diagnosis of adrcnaJ
conical insufficiency. The drug is given intramuscularly, and the
concentration of hyd rocortisone in the plas ma is measured by
radioimmunoassay.
MELANOCYTE-STIMULATING HORMONE
The MSH peptides. a-, ~- and y-MS H, arc peptide hormone~
with structural similarity to ACfH and are derived from the same
precur:;or. Together, these peptides are referred to as melanocortins,
because their first recognised action was to stimulate the produc-
tion of mehmin by specialised s kin cells called melanocytes. As
such, they play an imp011ant part in determining hair coloration,
skin colour and reaction to ultraviolet light.
Melanocyte-stimulating hormone acts o n melanocortin
receptors, of which five (MC 1_5) have been cloned. These arc G-
protein-coupled receptors that activate cAMP synthesis. Melanin
formation is under the control of the MC 1 receptor, and excessive
u-MS H production can provoke abnormal proliferation of
melanocytcs and may predispo~e to melanoma.
'f" Mclanoconin& exhibi1 numerous other biological effects. For exnmple,
u-MS II inhibits cytokine (interleuldn [ILl Ipand tumour necrosis fnctor-
u [TNF]) relense. reduces neutrophi l infiltration, and exhibits anti
inflammatory and antipyretic activi ty. Levels of a-MSH are increased in
synovial fluid of patients with rheumatoid anhritis. MC1 and MC1 receptors
mcdinte the immunomodulatory effect of MSH. Agonists at these receprors
wirh polemial anti-inflammatory activit) are being sought.
y-Melanoc) te-srimulating hormone tncrea~es blood pressure. heart rate
and cerebral blood flow follo\\ing tntracerebrovemricular or intravenoul>
injection. These effects are likely mediated by !he MC4 receptor. Central
injection of a-MSH also cau;c\ change-. in animal behaviour. such a!>
increa~ed grooming and sexual activity a~ well :L~ reduced feeding.
Two naturally occurring ligandb for melanocortin receptors (agouri
.signalling protein and agouti-related peptide, together called the agouri)
have been discovered in human tissues. These are proteins th:H
competitively antagonise the effect of MSH at mclanocortin receptors.
Their preci~c role in the body i; not known.
Adrenocorticotrophic hormone
(corticotrophin) and the adrenal steroids
Adrenocorticotrophic hormone (ACTH) stimulates
synthesis and release of glucocorticoids (e.g.
hydrocortisone), and also some androgens, from the
adrenal cortex.
Corticotrophin-releasing factor from the
hypothalamus regulates ACTH release, and is
regulated in turn by neural factors and negative
feedback effects of plasma glucocorticoids.
Mineralocorticoid (e.g. aldosterone) release from the
adrenal cortex is controlled by the renin-angiotensin
system.
THE PITUITARY AND THE ADRENAL CORTEX
The anterior pituitary gland
and hypothalamus
The anterior pituitary gland secretes hormones that
regulate:
the release of glucocorticoids from adrenal cortex
the release of thyroid hormones
ovulation in the female and spermatogenesis in
the male, and the release of sex hormones
growth
mammary gland structure and function.
Each anterior pituitary hormone is regulated by a
specific hypothalamic releasing factor. Feedback
mechanisms govern the release of these factors.
Substances available for clinical use include:
growth hormone-releasing factor (sermorelin) and
analogues of growth hormone (somatrem,
somatropin)
thyrotrophin-releasing factor (protirelin) and
thyroid-stimulating hormone {thyrotrophin; used to
test thyroid function)
octreotide and lanreotide, analogues of
somatostatin, which inhibit growth hormone release
corticotrophin-releasing factor, used in diagnosis
gonadotrophin-releasing factor.
POSTERIOR PITUITARY (NEUROHYPOPHYSIS)
The posterior pituitary gland con~ists largely of the terminals of
nerve cells that lie in the supraoptic and paraventricular nuclei
of the hypothalamu&. Their axons form the hypothalamic-
hypophyseal tract, and the fibres tenninate in dilated nerve endings
in close association with capillaries in the posterior pituitary gland
(Fig. 28.1 ). Peptides, synthesised in the hypothalamic nuclei,
pa:.s down these axons into the posterior pituitary, where they arc
stored and eventually secreted into the bloodstream.
The two main hormones of the posterior pituitary are oxytocin
(which contracts the smooth muscle of the uterus; see Cb. 30) and
ADH (aJso called vasopressin; see Chs 19 and 24). Several ~imilar
peptides have been synthesi. ed that vary in their antidiuretic,
vasopressor and oxytocic (uterine stimu lant) properties.
ANTIDIURETIC HORMONE
Regulation of secretion and physiological role
Amidiuretic hormone released from the posterior pituitary has a
crucial role in the control of the water content of the body
through its action on the cells of the distal part of the nephron and
the collecting tubules in the kidney (sec Ch. 24 ). The hypothalamic
nuclei that control fluid balance lie close to the nuclei that
synthesise and secrete ADH.
One of the maio stimuli to ADH release is an increase in
plas ma osmolality (which produces a sensation of thirst). A 425
 SECTION 3 DRUGS AFFECTING MAJOR ORGAN SYSTEMS
decrease in circulating blood volume (hypovolaemia) i~ another,
and here the stimuli arise from baroreceptors in the cardiovascular
system or from angiotensin release. Diabetes insipidus is a
condition in which large volumes of dilute urine are produced
because ADH secretion is reduced or absent, or because of a
reduced sensitivity of Lbe kidney to the hormone.
Antidiuretic hormone receptors
There are three classes of receptor for ADH: V" V 2 and V 3 . V 2
receptors, which are coupled to adenylate cyclase, mediate its
main physiological actions in the kidney, whereas the V 1 and V 3
receptors are coupled to the pho~pholipase C/inositol trbphos-
phate system.
Actions
Renal actions
Antidiuretic hormone binds to V 2 receptors in the basolateraJ
membrane of the cells of the distal tubule and collecting ducts of
the nephron. Its main effect in the collecting duct is to increase
the rate of insertion of water channels into the lumenal mem-
brane, thus increasing the permeability of the membrane to water
(see Ch. 24). It also activates urea transporters and transiently
increases Na 1 absorption, particularly in the distal tubule.
Several drugs affect the action of ADH. Non-steroidal anti-
inflammatory drugs and carbamazepine increase, and lithium,
colchicine and vioca alkaloids decrease, ADH effects. The
effects of the last two agents are l.econdary to their action on the
microtubules required for translocation of water channels.
Demeclocycline counteracts the action of ADH and can be us~d
to treat patients with hyponatraemia (and thus water retention)
caused by excessive secretion of AD! l.
Other non-renal actions
Antidiuretic hormone causes contraction of smooth muscle, par-
ticularly in the cardiovascular system, by acting on V 1 receptors
(see Ch. 19). The affinity of these receptors for A DH is lower
than that of the V 2 receptors, and smooth muscle effects are seen
only with doses larger than those affecting the kidney. ADH also
stimulate., blood platelet aggregation and mobilisation of
coagulation factors. ln the CNS, ADH acts as a neuromodulator
and neurotransmitter. When released into the pituitary 'portal
circulation'. it promotes the release of ACTH from the anterior
pituitary by an action on V 3 receptors (Fig. 28.4).
Pharmacokinetic aspects
Antidiuretic honnone, as well as various analogues, is used clini-
cally either for the treatment of diabetes insipidus or as a va-;o-
coru.trictor. The analogues have been developed to (a) increase
the duration of action and (b) shift the potency between V 1 and
V 2 receptors.
TI1e main substances used arc vasopressin (ADH itself: short
duration of action, weak selectivity for V 2 receptor!>, given by
subcutaneous or intramuscular injection. or by intravenous
infusion), desmopressin (increased duration of action, Y 2-selective
and usually given as a nasal spray), terlipressin (increased dur-
ation of action, low but protracted vasopressor action and
426 minimal antidiuretic properties) and fclypressin (short duration
of action, vasoconstrictor effect is used with local anaesthetics
such a!> prilocaine to prolong its action; see Ch. 44).
Vasopressin is rapidly eliminated, with a plasma half-life of 10
minutes and a short duration of action. Metaboli'>m is by ti ssue
peptida~es , and 33% is removed by the kidney. Desmopressin is
less subject to degradation by peptidases. and its pla.,ma half-life
is 75 minutes.
~ Variou~ ~ynthetic non-peptide agonist~ and antagoni<.t~ ol ADH have
been synthc>ised and are u!.etl us experimental tools. Several oral ly active
V 1 receptor antagonis iS arc under study for the trcauncnt of
dysmenorrhoea ( for a review of ADH receptor amagonists and their
po<,<.ible clinical uses. sec Thibon mer et al . 200 I ).
Unwanted effects
There arc few unwanted effects if Lhe antidiuretic peptide:. are
administered intranac;ally in therapeutic doses, although intra-
venous vasopressin may cause spasm of the coronary arteries,
with resultant angina.
OXYTOCIN
Oxytocin is discussed in Chapter 30.
Posterior pituitary
The posterior pituitary secretes:
oxytocin (see Ch. 30)
antidiuretic hormone (vasopressin), which acts on
v2receptors in the d istal kidney tubule to
increase water reabsorption and, in higher
concentrations, on V 1 receptors to cause
vasoconstriction. It also stimulates
adrenocorticotrophic hormone secretion.
Substances available for c linical use are vasopressin
and the analogues desmopressin and terlipressin.
Clinical use of antidiuretic hormone
(vasopressin) and analogues
Diabetes insipidus: lypressin, desmopressin.
Initial treatment of bleeding oesophageal varices:
vasopressin, tertipressin, lypressin. (Octreotide-a
somatostatin analogue-is also used, but direct inJection
of sclerosant via an endoscope is the main treatment.)
Prophylaxis against bleeding in haemophilia (e.g.
before tooth extraction): vasopressin, desmopressin
(by increasing the concentration of factor VIII).
Felypressin is used as a vasoconstrictor with local
anaesthetics (see Ch. 44).
Desmopressin is used for persistent nocturnal
enuresis in older children and adults.

THE ADRENAL CORTEX
ADRENAL STEROIDS
The adrenal gland., are !>ituated above the kidneys, and for this
reason they are sometimes referred to as the suprarenal glands. At
a gross level, the gland comprises two components: the medulla,
which secretes catecholamines (see Ch. 9). and the cortex, which
secrete~ adrenal \teroids. The Iauer structure, which concerns us
in this section. may be divided further on a histological basis into
three concentric zones: the ~ona glomerulosa (the outermost layer)
that elaborates mineralocorticoids, the ;:.onafasciculata that elab-
orates glucocorticoids, and the innermost -;.ona reticularis. While
the principal adrenal steroids are those with mineralocorticoid
and glucocorticoid activity, some sex steroids (mainly androgens)
arc abo secreted by the gland but will not be considered further
in this chapter.
The mincralocorticoids regulate water and electrolyte balance,
and the main endogenous hormone is aldosterone. The gluco-
corricoids have widespread actions on intermediate metabolism,
affecting carbohydrate and protein metabolism, a~ well as a potent
regulatory effect on our endogenous 'defence reactions such as
the innate and acquired immune response. The adrenal secretes a
mixture of glucocorticoid\, but the main hormone in humans is
hydrocortisone (also. confusingly. called cortisol). but in rodents
corticosterone predominate!.. The mineralocorticoid and gluco-
corticoid actions are not completely separated in naturally
occurring Meroid~. ~ome glucocorticoids having quite substantial
effect~ on water and electrolyte balance. In fact. hydrocortisone
and aldosterone arc cquiactive on mineralocorticoid recepLOrs,
but, in mineralocorticoid-sensitive tissues such as the kidney. the
action of II {3-hydmxysteroid dehydrogenase converts hydro-
cortisone to an inactive metabolite cortisone/ thereby protecting
the receptor from inappropriate activation. With the exception of
replacement therapy (sec below), glucocorticoids are most com-
monly employed for their anti-inflammatory and immunosup-
pressive properties. Under these circumstances, all their
metabolic and other actions are seen as unwanted side effects.
Synthetic steroids have been developed in which it bas been
possible to separate, to some degree, the glucocorticoid from the
mineralocorticoid actions (sec Table 28.2), but it has not been
possible to separate the anti-inflammatory actions from the other
actions or the glucocorticoids.
The adrenal gland is essential to life, and animals deprived of
these gland~ arc able to survive only under rigorously controlled
conditions. In humans. a deficiency in corticosteroid production,
termed Addison'.\ disease, is characterised by muscular weak-
ness, low blood pressure. depression. anorexia, loss of weight
and hypoglycaemia. Addison's disease may have an autoimmune
aetiology. or it may result from destruction of the gland by
2
0ddly. it was cortisone that wm, originally demonstrated to have potent
anri-innammatory activity in the classic studies by Hench and his colleagues
in 1949. The reason for thi:. apparent anomaly i:, that an isofonn of 1 t f3-
hydroxyqeroid dehydrogenase pre<,cnt in some tissues can transfom1 this
steroid back into coni sol (i.e. hydrOCOith,onc), thus restoring biological activity.
THE PITUITARY AND THE ADRENAL CORTEX
chronic innammatory conditions such as tuberculosis. Because
of the negative feedback effects that glucocorticoids exert on
ACTH release. a decreased production of endogenous corticoids
also occurs when glucocorticoids are given therapeutically for
prolonged periods. This can result in deficiency when treatment
is discontinued. and is the reason why glucocorticoid therapy is
usually tapered off to allow recovery of anterior pituitary function.
When corticosteroids are produced in excess, the clinical
picture depend~ on which of the steroids predominates. Excessive
glucocorticoid activity results in Cushing's syndrome. the mani-
festations of which are outlined in Figure 28.7. This can be caused
by hypersecretion from the adrenal glands or by prolonged
therapeutic glucocorticoid regimens. An excessive production of
mincralocorticoids results in disturbances ofNa+ and K+ balance.
This may occur with hyperactivity of the adrenals or tumours of
the glands (primary hyperaldosteronism. or Conn's syndrome, an
uncommon but important cause of hypertension; see Ch. 19), or
with excessive renin- angiotensin action such as occurs in kidney
disca~e. cirrhosis of the liver or congestive cardiac failure
(secondary hyperaldosteronism).
GLUCOCORTICOIDS
Synthesis and release
Adrenal steroid., are !>ynthe~ised and released as required, under
the innuence of circulating ACTH secreted from the anterior
pituitary gland (see p. 424 and Fig. 28.4). ACTH secretion is
(positively) regulated by CRF released from the hypothalanllls and
vasopressin from the posterior gland, and (negatively) by blood
glucocorticoids. The release of CRF, in rum, is inhibited by the
level of glucocorticoids in the blood, and is influenced by input
from the CNS. This functional hypothalamic-pituitary-adrenal
unit is referred to as the HPA axi~.
Glucocorticoids are alway!> present in the blood, but in health y
human!> there is a well-defined circadian rhythm in the secretion,
with the blood concentration being highest early in the morning,
gradually diminishing throughout the day and reaching a low
point in the evening or night. Opioid peptides also exercise a
tonic inhibitory control on the secretion of CRF, and psycho-
logical factors can affect the release of vasopressin and CRF. as
can stimu li such as excessive heat or cold, injury or infections.
This is the principal mechanism whereby the HPA axis is
activated in response to a threatening environment.
The precursor of glucocorticoids is cholesterol (Fig. 28.5). The
initial step, the conversion of cholesterol to pregnenolone, is the
rate-limiting step and is itself regulated by ACTH. Some of the
reactions in the biosynthetic pathway can be inhibited by drugs.
Metyr apone prevent:. the f3-hydroxylation at C II, and thus the
formation of hydrocortisone and corticosterone. Synthesis is
blocked at the I 1-deoxycorticosteroid stage. and as these sub-
stances have no negative feedback effects on the hypothalamus
and pituitary, there b a marked increase in ACTH in the blood.
Metyrapone can therefore be used to test ACTH production. and
may also be used to treat patients with Cushing's syndrome.
Trilostane (also of use in Cushing's syndrome and primary
hyperaldosteronism) blocks an earlier step in the pathway- the
3~-dehydrogcnase. 427
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
Glucocorticoid
Common drugs used include hydrocortisone,
prednisolone and dexamethasone.
Metabolic actions
Carbohydrates: decreased uptake and utilisation of
glucose accompanied by increased gluconeogenesis;
th1s causes a tendency to hyperglycaemia.
Proteins: increased catabolism, reduced anabolism.
Lipids: a permissive effect on lipolytic hormones and
a redistributiOn of fat, as observed in Cushing's
syndrome.
Regulatory actions
Hypothalamus and anterior pituitary gland: a negative
feedback action resulting in reduced release of
endogenous glucocorticoids.
Cardiovascular system: reduced vasodilatation,
decreased fluid exudation.
Musculoskeletal: decreasing osteoblast and
increas1ng osteoclast activity.
Inflammation and immunity:
acute mflammation: decreased influx and activity
of leucocytes
chronic inflammation: decreased activity of
mononuclear cells, decreased angiogenesis, less
fibrosis
lymphoid tissues: decreased clonal expansion of T
and B cells, and decreased action of cytokine-
secreting T cells.
Mediators:
decreased production and action of cytokines,
including interleukins, tumour necrosis factor-a and
granulocyte macrophage colony-stimulating factor
reduced generation of eicosanoids
decreased generation of lgG
decrease in complement components in the blood
increased release of anti-inflammatory factors
such as interleukin-1 0 and annexin 1.
Overall effects: reduction in the activity of the innate
and acquired immune systems, but also decreased
healing and diminution in the protective aspects of
the inflammatory response.
Am inoglutethimide inhibits the initial step in the biosynthetic
pathway and has the same overall effect as metyrapone. Keto-
conazole, an antifungal age nt (Ch. 48). used in higher doses also
inhibits steroidogenesis and may be of value in the specialised
treatment of Cushing's syndrome.
Mechanism of action
The glucocorticoid effects relevant to this discussion are initiated
by interaction of the drugs with specific intracellular glucocor-
428 ticoid receptors belonging to the nuclear receptor supelfami/y
(although there may be other binding proteins or sites: sec
Nonnan et al., 2004). This superfamily (see Ch. 3 for structural
details) also includes the receptors for mineralocorticoids. the
sex steroids. thyroid hom10nes. vitamin D3 and retinoic acid.
After entering cells (probably by passive diffusion), the gluco-
corticoids bind to specific receptors in the cytoplasm. Two receptors
have been described, termed GRa and GR/3 (highly homologous
but lacking part of the C terminal). Although it may modulate
signalling through the GRa receptor under some circumstances.
GRt3 docs not appear to function as a glucocorticoid receptor in
vivo and will not be discussed further. GRa has been cloned and
contai ns 777 amino acid residues. It has a high affinity for gluco-
corticoids and is found in virtually all tissues at a density of
between 3000 and 30 000 copies per cell, the number varying
be tween different tissues.
Tn its ' resting', unliganded state, the receptor dwells in the
cytoplas m as part of a complex of proteins that include hear
shock proteins (HSPs) 56 and 90. After binding the steroid, the
receptor dissociates from the HSPs and undergoes a conforma-
tional c hange that exposes a DNA-binding domain (see Figs 28.6
a nd 3.3). Subsequent events have yet to be fully delineated; in the
best characteri~ed example, steroid-receptor complexes fonn
homodimers (and possibly heterodimers with the mineralocor-
ticoid receptor too). then translocate to the nucleus possibly u~ing
the cytoskeleton. Here. they bind to positive or negative gluco-
corticoid response clements present in the promoters of target
genes. thus bringing about corresponding changes (induction or
repression) in transcription. The receptor is eventually recycled
in an ATP-dependent process and combined again with HSPl> in
the cytoplasm to complete the cycle.
Several molecular mechanisms by which changes in gene tran-
scription are accomplished have been identified, and these are
shown in Figure 28.6. Regulation, particularly repression. is
generally achieved in conce rt with various transcription factor~.
such asAP I and nuclear factor KB. Induction stimulates the fresh
format ion of specific mRNAs, which then direc t the synthesis of
specific proteins. lt is estimated that approximately I% of nuclear
genes can be regulated by glucocorticoids using such pathway~.
In addition to these ' nuclear' events, it has become evident in
recent years that the liganded receptor itself, in either a monomeric
or a dimeric form, may trigger signal transduction events while
still in the cytosolic compartment. One of these effects, gem1anc
to the anti-inflammatory profile of these drugs, is the rel ea~c.
following phosphorylation, of the protein annexin-I (forrnerlj
/ipocortin). whic h has potent effects on leucocyte trafficking and
other biological actions. The significance of such 'receptOr-
mediated, non-genomic' action~ is that they can happen rapid!}
(within a few minutes), as they do not entail changes in rnRNN
protein synthel.is that occur over a longer timeframe.
Actions
General metabolic and systemic effects
The main metabolic effects are on carbohydrate and protein metab-
olis m. The honnone!> and their synthetic congeners cause both a
decrease in the uptake and utilisa6on of glucose and an increa~e
in gluconeogenesis, resulting in a tendency to hyperglycaemia
 THE PITUITARY AND THE ADRENAL CORTEX

Table 28.2 Comparison of the main corticosteroid agents used for systemic therapy (using hydrocortisone as a standard)

Compound Relative affinity Approximate relative Duration of Comments

for g lucocorticoid potency in clinical use action after
receptorsD oral doseb

Anti- Sodium
inflammatory retaining
Hydrocortisone 1 1 Short Drug of choice for replacement therapy
(cortisol)

Cortisone 0.01 0.8 0.8 Short Cheap; inactive until converted to hydrocortisone;
not used as anti-inflammatory because of
mineralocorticoid effects

Corticosterone 0.85 0.3 15 Short

Prednisolone 2.2 4 0.8 Intermediate Drug of choice for systemic anti-inflammatory and
immunosuppressive effects

Prednisone 0.05 4 0.8 Intermediate Inactive until converted to prednisolone

Methylprednisolone 11.9 5 Minimal Intermediate Anti-inflammatory and immunosuppressive

Triamcinolone 1.9 5 None Intermediate Relatively more toxic than others

Dexamethasone 7.1 30 Minimal Long Anti-inflammatory and immunosuppressive, used

especially where water retention is undesirable
(e.g. cerebral oedema); drug of choice for
suppression of adrenocorticotrophic hormone
production

Betamethasone 5.4 30 Negligible Long Anti-inflammatory and immunosuppressive, used

especially when water retention is undesirable

Deoxycortone 0.19 Negligible 50

Fludrocortisone 3.5 15 150 Short Drug of choice for mineralocorticoid effects

Aldosterone 0.38 None 500 Endogenous mineralocorticoid

8
Human fetal lung cells.
bDuration of action (half-lives in hours): short, 8-12; intermediate, 12- 36; long, 36--72.
(Data for relative affinity obtained from Baxter J D, Rousseau G G (eds) 1979 Glucocorticoid hormone action. Monographs on
endocrinology, vol12. Springer-Verlag, Berlin.)

(see Ch. 26). There is a concomitant increase in glycogen storage,
which may be a result of insulin secretion in response to the
increase in blood sugar. Overall, there is decreased protein
synthesis and increased protein breakdown, particularly in muscle,
and this can lead to wasting. Glucocorticoids also have a 'permiss-
ive' effect on the cAMP-dependent lipolytic response to cat-
echolamiJles and other hormones. Such hormones cause lipase
activation through a cAMP-dependent kinase, the synthesis
of which requires the presence of glucocorticoids (see below).
Large doses of glucocorticoids given over a long period result
in the redistribution of body fat characteristic of Cushing's
syndrome (Fig. 28.7).
Glucocorticoid& tend to produce a negative calcium balance by
decreasing Ca2+ absorption in the gastrointesti nal tract and
increasing its excretion by the kidney. This may result in osteo-
porosis (see below). ln non-physiological concentrations, the
glucocorticoids have some mineralocorticoid actions (see below),
causing Na+ retention and K+ loss-possibly by swamping the
protective ll ~-hydroxysteroid dehydrogenase and acting at
mineralocorticoid receptors.
N egative feedback e ffects on the anterior pituitary and
hypothalamus
Both endogenous and exogenous glucocorticoids have a negative
feedback effect on the secretion of CRF and ACTH (see
Fig. 28.4). Administration of exogenous glucocorticoids depresses
the secretion of CRF and ACTH, thus inhibiting the secretion of
endogenous glucocorticoid& and potentially causing atrophy of 429
 1'0
~
(.) (X)
0

2l \
"'g
Ill

Mineralocorticoid pathway Glucocorticoid pathway Sex hormone pathway 0

Cholesterol
22
CH3
z
:>!
\ w
,.
27 C=O D D

0

ff
l 17-a-hydrox .... ;;Q

ACTH
"'" ~
: Aminoglutethimide J
0 ct)X>
Pregnenolone
HO
17-a-Hydroxypregnenolone
0 ct)X>
Dehydroepandrosterone
c
G)
(/')

,,
)>

3-~-dehy. ~l
Angiotensin II ()
CH3 CH3
-1
-i
\. \ \ .Jl zG)
( rrllostaner::e:==:;, C=O \. 3-il-dohy. C= O \. 3-jl-dohy.
0

\ 17-a-hydrox.~ ~
2::
0
;;u
o 0
Progesterone
17-a-Hyldroxyproges:~:::
;;Q
G)

21-~-hydrox .Jl CH 20H )>

\. . \
C=O \..._21-~-hydrox.~ ' c=o z
(/')
-<
(/)
'" 17-a-hydrox. ~ --l
m
~
(/')

11-Deoxycorbcosterone 11-Deoxycortsol
D

0 a-nvaro CH2 0H
\
\. ~-~-hydrox. ~1 CH 20H
\
C=O {Metyrapone~ C=O

, 17-a-hydrox.
1

0 .....
I
Aldosterone 0
OriiCOS! Bro"n Hydrocortisone (cortisol)

Fig. 28.5 Biosynthesis of corticosteroids and adrenal androgens. Drugs are shown in yellow boxes adjacent to their sites of action; note that they have selective actions on
different cortical cell types. Glucocorticoids are produced by cells of the zona fasciculata , and their synthesis is stimulated by adrenocorticotrophic hormone (ACTH); aldosterone is
produced by cells of the zona glomerulosa, and its synthesis is stimulated by angiotensin II. Metyrapone inhibits glucocorticoid synthesis, aminoglutethimide inhibits both
glucocorticoid and sex hormone synthesis, and trilostane blocks synthesis of all three types of adrenal steroid. Further details of sex steroid biosynthesis are given in Figure 30.3.
\.__11-~-hydrox. , 11 -~-hydroxylase; 17-B-hydrox., 17-~-hydroxylase; 21-B-hydrox., 21 -fi-hydroxylase; 3-B-dhy., 3-(i-dehydrogenase.
-----
 THE PITUITARY AND THE ADRENAL CORTEX

GRE

GRa.GRa.

Fos Jun TM

L91

Fig. 28.6 Molecular mechanism of action of glucocorticoids. The schematic figure shows three possible ways by which the
liganded glucocorticoid receptor can control gene expression following translocation to the nucleus. [Al Basic transactivation mechanism.
Here, the transcriptional machinery (TM) is presumed to be operating at a low level. The liganded glucocorticoid receptor (GR) d1mer
binds to one or more 'positive' glucocorticoid response elements (GREs) within the promoter sequence (shaded zone) and up-regulates
transcription. [JJ] Basic transrepression mechanism. The transcriptional machinery is constitutively driven by transcription factors (TF).
In binding to the 'negative' GRE (nGRE), the receptor complex displaces these factors and expression falls. IQJ Fos/Jun mechanism.
Transcription is driven at a high level by Fos/Jun transcription factors binding to their AP-1 regulatory site. This effect Is reduced in the
presence of the GR. ol Nuclear factor ~rB mechanism. The transcription factors P65 and P50 bind to the NF11.B site, promoting gene
expression. This is prevented by the presence of the GR, which binds the transcription factors, preventing their action (this may occur in
1 ~=cytoplasm also). For further details of the structure of GR, see Chapter 3. (Modified from Oakley R H, Cidlowski JAin Gor1ding N J,
"-=wer R J (eds) 2001 Glucocorticoids. Birkhauser Veri.)

Lhe adrenal cortex. If therapy is prolonged. it may take many
months to return to normal function when the drugs arc stopped.
Anti-inflammatory and immunosuppressive effects
Endogenous glucocorticoids maintain a low-level anti-inflammatory
tonus that can be readily demol15trated by observing the
heightened response of adrenalectorniscd animals to even mild
inflammatory stimuli. A failure of appropriate secretion in response
to injury or infection may underlie certain chronic inflammatory
pathologies. Glucocorticoids are the anti-inflammatory drugs par
excellence, and w hen given therapeutically have powerful anti-
inflammatory and immunosuppressive effects. They inhibit both
the early and the late manifestations of inf1ammation, i.e. not only
the initial redness, heat, pain and swelling, but also the later stages
of wound heating and repair, and the proliferative reactions seen
in chronic inflammation (Ch. 13). They reverse virtual ly all types
of intlammatory reaction, whether caused by invading pathogens.
by chemical or physical stimuli. or by inappropriately deployed
immune responses !>uch as are seen in hypersensitivity or auto-
immune disease. When used clinically to suppress graft rejection,
glucocorticoids suppress the initiation and generation of an immune
response mounted against this new ' invader' more efficiently than
an established response in which clonal proliferation has already
occurred. Given that the glucocorticoids are able to modify the
expression of so many genes, and that the extent and direction
of regulat ion varies between tissues and even at different times 431
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

--(Be"~";"'"'" ";" I
decreased generation of many cytok:ines, including IL- l , IL-
Euphoria
2, IL-3, IL -4, LL-5, l L -6, lL-8, tumour necrosis factor-a, cell
(though sometimes
depression or psychotic adhesion factors and granulocyte macrophage colony-
symptoms, and emot1onal stimulating factor, secondary to inhibition of gene
lability) hypertension) transcription
reduction in the concentration of complement components in
(Cataracts)
the pla~ma
Moon face, with red decreased generation of induced nitric oxide
(Hypertension) (plethoric) cheeks decreased histamine release from basophils
decreased l gG production
_...-Increased increased synthesis of anti-inflammatory factors such as
Thinning abdominal fat
of skin IL- 10, IL- l -soluble receptor and annexin-1 .
---+:..-<-- (Avascular necrosis
Thin arms of femoral head) Tnnammati on is an important protecti ve response designed to
and legs: ensure the survival of an infected or injured host. Tt therefore strikes
muscle wasting '\- -++--- Easy bruising
many as odd I hat we should not only have potent anti-inflammatory
horm ones circulating constantly in the blood, but that these should
be dramati cally increased during such threatening episodes. A
H--- - Poor wound useful explanatory paradigm is that of Munck et al. ( 1984);
Also: healing according to thi s idea, the anti-inflammatory and immunosup-
Osteoporosis
Tendency to hyperglycaemia pressive actions may play a crucial counter-regulatory role, in
Negative nitrogen balance that they prevent excessive activati on of inflammation and other
Increased appetite powerful defence reactions, which rnigbt, if unchecked, them-
Increased suscepttbility to Infection selvcl> threaten homeostasis. Certai nly. this view is borne out by
Obesity
experimental work with adrenalectomised animals. While these
Fig. 28.7 Cushing's syndrome. This is caused by drugs arc of great value in treating conditions characterised by
excessive exposure to glucocorticoids, and may be caused by
disease (e.g. an adrenocorticotrophic hormone-secreting
tumour) or by prolonged administration of glucocorticoid drugs
(iatrogenic Cushing's). Italicised effects are particularly
common. Less frequent effects, related to dose and duration of
therapy, are shown in parentheses. (Adapted from Baxter JD, Mechanism of action of
Rousseau GG (eels) 1979 Glucocorticoid hormone action. the glucocortlcolda
\,__Monographs on endocrinology, vol 12. Springer-Verlag, Berlin.)

Glucocorticoids bind intracellular receptors that then

during disease. you will not be surpri sed to Jearn that their anti-
inflammatory effects are fearsomely complex. Some prominent
acti ons may be highlighted, but these should not be considered a
complete list.
Actions on inflammatory cells i nclude:
decreased egress of neutrophils from blood vessels and
reduced activation of neutrophils and macrophages secondary
to decreased transcription of the genes for cell adhesion
factors and cytokines
decreased activation ofT-helper cells and reduced clonal
proliferation ofT cells, secondary to decreased transcription
of genes for IL -2 and its receptor (see bel ow)
decrea ed fibrobla~t function. less production of collagen and
glycosaminoglycans. and thus reduced healing and repair
reduced activity of osteoblasts but increased activation of
osteoclasts and therefore a tendency to develop osteoporosis.
Action on the mediators of inflammatory and immune
responses include:
decreased production of prostanoids owing to decreased
432 expression of cyclo-oxygenase-2
dimerise, migrate to the nucleus, and interact with
DNA t o modify gene transcript ion, ind ucing synthesis
of some proteins and inhibiting synthesis of others.
Metabolic actions: most mediator proteins are
enzymes, for example cAMP-depend ent kinase, but
not all actions on genes are known.
Anti-inflammatory and immunosuppressive actions:
known actions include:
inhibition of transcription of the genes for cyclo-
oxygenase-2, cytokines and interleukins, cell
adhesion molecules, and the inducible form of
mtric oxide synthase
block of vitamin 0 3-mediated induction of the
osteocalcin gene in osteoblasts, and modification
of transcription of the collagenase genes
increased synthesis and release of annexin-1 ,
which has potent anti-inflammatory effects on
cells and mediator release, and may also mediate
negative feedback at the level of the
hypothalamus and anterior pit uitary gland.
Some rapid non-genomic effects of glucocorticoids
have also been observed.

hypcJ;ensiti\ ity and unwanted inflammation, they carry the hazard
that they arc able to suppress the same defence reactions that
provide protection to infection and promote healing.
Unwanted eHects
Unwanted effects are likely to occur with large doses or pro-
longed admini'>tration rather than replacement therapy. Possible
unwanted effect~ include suppression of the response to infection
or injul)': an opportunistic infection can be potentially very serious
unless quickly treated with antimicrobial agents along with an
increase in the do~e of '>teroid. Wound healing may be impaired,
and peptic ulccrmion may abo occur.
Sudden withdrawal of the drugs after prolonged therapy may
result in acute adrenal insuffic ie ncy throug h suppression of the
patient's capacity to synthesise corticosteroids? Careful procedures
for phased withdrawal should be followed. Recovery of full
adrenal function usually lakes about 2 months, a lthough it can
take 18 months or more.
When the drugs are used in anti- inf1ammatory and immuno-
suppressive therapy, the metabolic actions and the effects on water
and electrolyte balance and on organ systems are considered
unwanted side effech, and Cushing's syndrome may occur (see
Fig. 28.7). Osteoporosis, with the attendant hazard of fractures,
i~ probably one of the main limitations to long-term gluco-
corticoid therapy. The~ drugs innuence bone density by regulation
of calcium and phosphate metabolism and through effects on
collagen turnover. Given over a long term, gJucocorticoids reduce
the function of osteoblasts (which lay down bone matrix) and
incre:t'>e the activity of osteoclasts (which digest bone matrix).
An effect on the blood supply to bone can result in avascular
necrosis of the head of the femur (see Ch. 31).
The tendency to hyperglycaemia that occurs with exogenous
glucocorticoids may develop into actual diabetes. Another limita-
) tion is the development of muscle wasting and weakness. Jn
children, the inhibitory metabolic (particularly those on protein
metabolism) and hormo nal effects may result in inhibition of
growth if drug treatment is continued for more than 6 months or
so, even if fairly low doses are used.
Reports of central effects are quite common; some patients
experience euphoria, but others may become depressed or develop
psychotic symptoms. In fact. the circadian secretion of hydro-
cortisone may be disturbed in some depressed patients, and the
dexamerhaso11e suppressio11 resr can be used to identify these
indi\'iduals. Other toxic effect.<> that have been reported include
glaucoma, raised intracranial pressure, hypercoagulability of the
J blood. fever and disorder~ of menstruation. and an increased
incidence of cataracts. Oral thrush (candidiasis. a fungal infec-
tion; sec Ch. 48) frequently occurs when glucocorticoids are
taken by inhalation. because of suppression of local anti-infective
mechanisms.
'Patient> on long-term glucocorticoid theraphy are advised to carry a card
r
stating, 11m a patient on STEROID TREATMENT which must not be
' SlOpped :tbruptly'.
THE PITUITARY AND THE ADRENAL CORTEX
Pharmacokinetic aspects
Glucocorticoids may be administered by a variety of routes.
Most arc active when given orally, and all can be given sys-
temically, either intramuscularly or intravenously. Most may also
be given topically-injected intra-articularly, given by aerosol
into the re~piratory tract, administered as drops into the eye or
the nose, or applied in creams or ointments to the skin. Topical
administration diminishes the likelihood of systemic toxic effects
unless large quantities are used. When prolonged use of systemic
g lucocorticoids is necessary, therapy on alternate days may
decrease the unwanted effects. Inhaled or intranasal glucocorti-
coids are listed in Table 28.3.
Endogeno us g lucocorticoids are transported in the plasma
bound to corticostero id-binding globulin (CBG) and to albumin.
CBG accounts for about 77% of bound hydrocortisone, but many
synthetic g lucocorticoids are not bound at all. Albumin has a
lower affin ity for hydrocortisone but binds both natural and
synthetic stero ids. Both CBG-bound and albumin-bound steroids
arc biologically inactive.
As small lipophi lic molecules, g lucocorticoids probably e nter
their target cells by simple diffusion. Hydrocortisone has a plasma
half-life of 90 minutes, although its main biological effects have
2-8 hours' latency. Biological inactivation. which occurs in liver
cells and el-;ewhere, b initiated by reduction of the C4-C5
double bond. Cortisone and prednisone are inactive umil con-
ve rted in vivo to hydrocortisone and prednisolone, respectively.
The clinical ul>e of the glucocorticoids is given in the clinical
box. Dexamethasone can be used to test HPA axis function in the
dexamethasone suppression test. A low dose, usually given at night,
should suppress the hypothalamus and pituitary, and resuh in
reduced ACfH secretion and hydrocortisone output, as measured
in the pla~ma about 9 hours later. Failure of suppression implies
hypersecre tio n of ACTH o r of glucocorticoids (Cushing's
syndrome).
MINERALOCORTICOIDS
The main endogenous mineralocorticoid is aldosterone. Its chief
action is to increase Na+ reabsorption by the distal tubules in the
Ta ble 28.3 Inhaled or intranasal glucocorticoids
Compound Approximate potency"
Beclomethasone 0.59
Budesonide 0.78
Flunisolide 2
Fluticasone
Mometasone
Triamcinolone 0.45
"Fiuticasone = 1.
433
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
kidney, with concomitant increased excretion of K+ and H+ (see
Ch. 24). An excessive secretion of mineralocorticoidc;, as in Conn's
syndrome, causes marked Na and water retention, with a resultant
increase in the volume of extracel lular nuid, hy pokalaemia, alka-
losis and hypertension. A decreased ~ecretion, as in Addison's
disease, cau es net Na loss, which is relatively more pronounced
than water loss. The o~motic pressure of the extracellular fluid is
thus reduced, resulting in a shift of fl uid i nto the intracellu lar
Clinical use of glucocorticoids
Replacement therapy for patients with adrenal
failure (Addison's disease).
Anti-inflammatory/immunosuppressive therapy
(see also Ch. 14):
in asthma (Ch. 23; clinical box on p. 364)
topically in various inflammatory conditions of
skin, eye, ear or nose (e.g. eczema, allergic
conjunctivitis or rhinitis)
hypersensitivity states (e.g. severe allergic reactions)
in miscellaneous diseases with autoimmune and
inflammatory components (e.g. rheumatoid
arthritis and other 'connective tissue' diseases,
inflammatory bowel diseases, some forms of
haemolytic anaemia. idiopathic thrombocytopenic
purpura)
to prevent graft-versus-host disease following
organ or bone marrow transplantation.
In neoplastic disease (Ch. 51}:
in combination with cytotoxic drugs in treatment
of specific malignancies (e.g. Hodgkin's disease,
acute lymphocytic leukaemia)
to reduce cerebral oedema in patients with
metastatic or primary brain tumours
(dexamethasone)
Pharmacokinetics and unwanted actions
of the glucocortlcolds
Administration can be oral, topical or parenteral.
The drugs are transported in t he blood by
corticosteroid-binding globulin and enter cells by
diffusion. They are metabolised 1n the liver.
Unwanted effects are seen mainly after prolonged
systemic use as anti-inflammatory or
immunosuppressive agents but not usually with
replacement therapy. The most important are:
suppression of response to infection
suppression of endogenous glucocorticoid synthesis
metabolic actions (see above)
osteoporosis
iatrogenic Cushing's syndrome (see Fig. 28 .7).
434
compartment and a marked decrease in extracellular fluid volume.
There is a concomitant decrease in the excretion of K~. re~ulung
in hyperkalaemia.
Regulation of aldosterone synthesis and
release
The regulation of the synthesis and relea~e of aldosterone il>
complex. Control depends mai nly on the electrolyte composition
of the plasma and on the angiotensin II sy~tem (Fig. 28.4 and
Chs 19 and 24). Low plasma Na or high pla!>ma K+ concentrations
affect the ::.ona gfomerulosa cells of the adrenal directly, stimulating
aldosterone release. Depletion of body Na also activates the ren in-
angiotensin system (sec Fig. 19.4). one of the effects of angio-
tensin II is to increase the synthc~is and relea!>e of aldo~terone.
M echanism of action
Like other steroid hormones, aldosterone acts through specific
intracellular receptor-, of the nuclear receptor family. Unlike the
glucocorticoid receptor. which occurs in most tisl>ues. the mm
erafocorticoid recepror is largely restricted to a few tissues, ~uch
as the kidney and the transporting epithelia of the colon and bladder.
Cells containing mineralocorticoid receptOfl> also contain the
II ~-hydroxysteroid dehydrogena~e enzyme (see above), which
converts glucocorticoids into metabolites wi th low affinity for
the mineralocorticoid receptors, thus ensuring that the cells
are affected only by bona fide mineralocorticoid hormone.
Interestingly. this en7yme is inhibited by carbenoxolone (used
to treat ulcer s: see Ch. 25) and liquorice. I f thjs inhibition is
marked, it allows corticosterone to act on the mineralocorticoid
receptor. producing a syndrome '>imilar to Conn's syndrome
(primary hyperaldosteronism).
As with the glucocorticoid~. the interaction of aldoMeronc
w ith its receptor initiates transcription and trans lation of specific
proteins, resulting in an increase in the number of sodium chan-
nels in the apical membrane of the cell, and subsequently an
i ncrea~e in the number of NatK ATPase molecule~ in the
basolaleral membrane (see Fig. 24.9). The ensuing increased K
excretion into the tubule results from an influx of K+ into the ceU
by the action of the basal NatK ATPa~e. coupled with an
increased efflux of K+ through apical potassium channels. In
additi on to the genomic effects, there is evidence for a rapid non-
genomic effect of aldosterone on Na influx, through an action
on the Na-H+ exchanger in the apical membrane.
Clinical use of mineralocorticoids
and antagonists
The main clinical u!oe of mineralocorticoids is in replacement
therapy. The most commonly used drug i., fludrocortisooe
(Table 28.2 and Fig. 28.4), which can be taken orally. Spirono
l actone is a competitive antagonist of aldosterone. and it also
prevents the mineralocorticoid effects of other adrenal steroids
on the renal tubule (Ch. 24). Side effects include gynaecoma~tia
and impotence, because spironolactone also has some blocking
action on androgen and progesterone receptors. It is used in
conjunction with other diuretic~ in the treatment of oedema.
Epler enone has a similar indication and mechanism of action,
although fewer side effects.
 THE PITUITARY AND THE ADRENAL CORTEX

drugs that were topically applied (e.g. by inhalation for asthmaticl.)

Mlneralocorticolds
Fludrocortisone is given orally to produce a
mineralocorticoid effect. This drug:
Increases Na reabsorption in distal tubules and
increases K' and W efflux into the tubules
acts on intracellular receptors that modulate DNA
transcription, causing synthesis of protein mediators
is used together with a glucocorticoid in
replacement therapy.
NEW DIRECTIONS IN GLUCOCORTICOID
THERAPY
Glucocorticoids are so effective that any further development in
anti-intlammatories would scarcely be required iJ it wasn't for one
thing the side effects. While these are ~eldom a problem with
toptcal administration or short ( 1-2 weeks) courses of oral therapy,
the) ~c,crely limit the usc of these agents in chronic disease.
The Holy Grail would be a glucocorticoid possessing the anti-
inflammatory but not the unwanted metabolic or other effecL<>. For
many years, the pharmaceutical industry pursued simple strategies
based on the development of structural analogues of hydrocortisone.
While this yielded many new active and interesting compounds
(several of which are in clinical use today), they never achieved
separation of these actions. An alternative idea was to develop
and that were preferably metabolically unstable, such that any
leakage from the site of topical administration caused minimal
systemic effects. While these ideas bore fruit, it still was not an
ideal solution.
Recently, investigators have taken another tack. As glucocor-
ticoids function as anti-inflamrnatories largely by down-regulating
genes (e.g. cytokines) that promote the inflammatory response,
and many of the side effects are caused by over-expression of
metabolic and other genes (causing. for example. diabetes), and
because these effects are brought about through different pathways,
researchers have sought steroids that may have one set of actions
without the other. At the time of writing, modest successes have
been achieved with these 'dissociated' steroids (see Schackc et
al., 2002; Schacke & Rehwinkel , 2004), but it is too early to tell
whether they will really make a difference in the clinic.
Another approach has been to focus on the actual mechanism
of receptor activation. It is clear that not all glucocorticoids bind
to the receptor in the same way, and the dynamics of the resulting
liganded complex may vary (Adcock., 2003). This could alter the
ability of the steroid-receptor complex to initiate transcriptional
and other changes in a way that could be beneficial to the profile
of the drug.
Yet another idea has been to manipulate the histone deacetylase
enzymes that are responsible for facilitating the transcriptional
regulation of get1es follow ing nuclear receptor binding to response
elements (Hayashi et al., 2004). One current notion is that there
may be a specific isoform of this enzyme that deals with gene up-
regu lation, and that if this could be inhibited, it would lessen the
possibility of those unwanted effects.

REFERENCES AND FURTHER READING

The hypothalamus and pituitary
Btmhaumcr ~~ 2000 Vasopressin receptors. Trend~
Endocrinol Metab tl : 406-4 10
('Jar~ R G. Robinson C A F 1996 Up and down the
gi'O\Io th hormone cascade. Cytolme Growth Factor
R~ I 65-80 (A mi~ COINin~ tht' t tl.\t'tJtit' thlll
nmmL< rht' priman rr~ulators of gro.. th tmJ
nuwl>tlmn. namely J~rowth honnoflt' and tht' mrulm
liLt .tnm th facron l
Drolet G. Ri'N S 2001 Contcotropm.rele;hmg honnone
and 1t' receptors: an e\'a]uation at the trano,cnpuon
lc,cJn 'tvO. Peptides 22: 76t-767
Freeman M E. Kanyicsla B, Lernnt A, N3gy G 2000
J>rolacun: >tructure. function and regulation of
secretion. Physiol Re. 80: 1524-t585 (Cmnprehen.rile
mle11 of pmlllctin and itS rerepmrs}
Jurgen,cn J 0 L. Christiansen J S 1993 Growth hormone
therapy. Lancet3-ll: t247-t248
l.Jmbc:n' S W J. \an der Lety A-Jet al. t996 Octn.'Oitde.
N Engt J '1.1ed 334: 2-t()-254 (A IT"'t'W COI'fftn.~
'"'""rosrawt rruptors. somatosratm ataalogu~r. and
trrtl/ment of rumours e.xprrssin.~ soma/OJttl/111
TrctpiOT.\ "llh OCII'f'Oiide)
Okilda S. Kopchick J J 200 I Btologtcat effect\ of growth
hormone and ats antagonisL Trend\ Mol Mcd 7
126132
llubonmcr M. Coles P, Thibonnier A et at. 2001 The
ba~ic ond clinical pharmacology of nonpept ide
vasopre~sin receptor antagonists. Annu Rev Phannacol
41: 175-202 (Autlroriroril~ llccomll ofADll receprors
and tire set1rch for ne11 tt/1/a,~onivtsl
Vance M L 1994 ltypopituitari\m. N Engl J Med 330:
1651 - 1662 (Re>~en' of cauft.t. clinicttlfearul'f'S and
lromwne rrpluummt rlrerap\' of hlpopituitarism)
\Vtkberg J E S. Mucemece R. Mandnl..a t et al. :!000
1\ew a~pects on the lll(]anoconin~ and their receptor;.
Pharmacol Re\ 42: 393-420 (Dnailed m-it'\< of the
aned brologucttl role of mtlllnocomns and their
recepwrs)
Gelling S J, Christian H C, Rower R J. Perrctu M 2002
ACTH and lhe adrenal corlico<;teroids
Mechanism of actlon
Adcock t M 2003 Glucoconicoids: new mechanisms and
future agents. Curr Allcagy Asthma Rep 3: 249-257
(Excellent revien of udi'Dnce,v in glucocorticoid
pharmacology)
Ba'll C. Hay>tett J P t992 The cellular acuon of
aldosterone in target epithcha Kidne) lnt 42: 250-264
(A derailed""'"" rO\uing the aldosrero11e receptor
and rrgulation of gm<' etpiTI 11011. aldosrero11e action
on electrog<'nic and ell'ctn.memrol Na' transpon, atuf
on I<' and 11' .terretwn)
Borski R J 2000 Nongemlmte membrane actions of
glucoconicoids an 'enebr:ne~. Trend\ Endocrinol
Metab II; 427-436 (A tlloughrpm.,king acNJLmt nf
the non-gemJini<' effect.! of [1/ur()rorticoids)
Falkcn;tcin e. Tillmann H C. Christ M et al . 2000
Mu ltiple actions of steroid hom1ones-a focu> on
rapid. nongenomic effect;. Pbarmacol Rev 52:
513-556
Fundcr J W 1997 Gtucoconicoid and mioeraloconacoid
receptol'i btotog) and clinical relevance. Annu Re'
Med 48c 23t-240 <Satccmcrrniew ofgluCCKOrtrcotd
mul mmtraiO<orticord l'l'Ct!pton. dijferrnu.1 m
giU<t><omcmd receptor- and mmeroloconacmd
~r~ptor..mt'diated transcription and response.!, and
strmid ft.!>i\ltmCI')
Acuvmion of rnclanoconin type 3 recepto ru. a
molecular mo:chanism for adrenoconicotropic
homlonc efficacy in gouty anhritis. Arthritis Rheum
46: 2765 2775 (Original poper rllat demmutmte.v rhat
ACT/1/wr intrinsic mui-injlamnuuory actiofll thm tt~
indertemlenr of the adrena is)
Hayru.hi R. Wada H. Ito K. Adcock t \1 20()4 Effects of
glucocontcoids on gene transcription. Eur J Ph31Tllacol
SOO: 5 I 62 (Good basic rniro ofglucocortrcoltf
actton. t'a.n ro rrtuf)
'lonnan A W, \liz~icki M T, Nonnan D P 2004 Sterotd
honnone raptd acuons, membrane receptol'i and a
confonnatumal en>emble modeL Nat Rev Drug
Di-cov 3: 27-41 (Fairly adanced ~admg b111
conruin.! man) useful table.r and excellmt dlagmm.r;
well worth tllf t'fforr if this subject interesrs you}
435
 The thyroid
Overview 437
f--
Synthesis, storage and secretion of thyroid
hormones 437
Regulation of thyroid function 438
Actions of the thyroid hormones 439
Transport and metabolism 440
1---
Abnormalities of thyroid function 440
Drugs used in diseases of the thyroid 441
- Hyperthyrotdism 441
-Hypothyroidism 443
OVERVIEW
Diseases of the thyroid gland are prevalent, and in
this chapter we deal with drug therapy used to
mitigate these disorders. We set the scene by
briefly outlining the structure, regulation and
physiology of the thyroid, and highlight the most
common abnormalities of thyroid function. We then
go on to consider the drugs that replace the thyroid
hormones when these cease to function
adequately, and the drugs that decrease thyroid
function when this is excessive.
SYNTHESIS, STORAGE AND SECRETION
OF THYROID HORMONES
The thyroid gland secre tes three main hormones: thyroxine (T4 ),
Iriiodothyronine (T1) a nd calcitonin. T 4 and T 3 are critically
important for normal growth a nd development and for energy
metabolism. Calcitonin is involved in the control of plasma Ca 2
and i~ dealt with in Chapter 31. The term thyroid hormone will
be used here solely to refer to T 4 and T 1 .
The functional unit of the thyroid is the follicle or acinus. Each
follicle consists of a single layer of epithelial cells around a
cavity. the follicle lumen. which is filled with a thick colloid con-
taining thyroglobulin. Thyroglobulin is a large glycoprotein. each
molecule of which contain!> about 11 5 tyrosine residues. It is
synthesised. glycosylated and then secreted into the lumen of the
follicle, where iodination of the tyrosine residues occurs. Sur-
roundi ng the follicles is a dense capillary network, and the rate of
blood now through the gland is very high in comparison with other
tissues. The main steps in the synthesis, sto rage and secretion of
thyroid hormone (Fig. 29.1) are as follow:
uptake of plasma iodide by the follicle cells
oxidation of iodide and iodinatio n of tyrosine residues of
thyroglobulin
secretion of thyroid hormone.
Uptake of plasma iodide by the follicle cells
Iodide uptake is an ene rgy-dependent process occurring against a
gradie nt, which is no rmally about 25: I. Iodide is captured from
the blood and moved to the lumen by two transporters: the Na/l-
symporter (NIS) located at the basolateral surface of the thyrocytes
(the energy being provided by the NaJK+ ATPase), and pendrin 1
(PDS), an net- porter in the apical membranes (Nilsson, 200 I;
Yoshida et al., 2004). Numerous mutations have been discovered
in the NTS and PDS genes, and these contribute to thyroid disease
in some patients.
Oxidation of iodide and iodination of tyrosine
residues
The oxidation of iodide and its incorporation into thyroglobulin
(termed the organification of iodide) is catalysed by thyroperoxi-
dase. an e nzyme situated at the inner surface of the cell at the
interface with the colloid. The reactio n requires the presence of
hydrogen peroxide (1-1 20 2) as an oxidising agent. The process is
very rapid: labelled iodide ct 25 I) is found in the lume n within 40
seconds of inrravcnous injection. Iodination occurs after the tyro-
sine has been incorporated imo thyroglobulin. The process believed
to occur is shown in Figure 29.2.
Tyrosine residues are iodinated first at position 3 o n the ring,
forming monoiodotyrosine (MID and then, in some molecules,
on position 5 as well. form ing diiodotyrosine (DID. While stiiJ
incorporated into thyroglobulin. these molecules are then coupled
in pairs, either MIT with DITto form T1 or two DIT molecules
to form T4 (Fig. 29.3). The mechanism for coupling is believed to
1
So called becau!>e 11 ~implicated in the pathophysiology of Pendreds
syndrome. named after the eponymous English physician who first
tle~cribcd this fonn of ftsmilial goitre.
437
 SECTION 3 DRUGS AFFECTING MAJOR ORGAN SYSTEMS

Thioureylenes and
excess I-

r-- ~ I --:,------- ...

NPS C ,, Thyroperoxidase C PDS Uptake of
Fig. 29.1 Diagram of thyroid 1- iodide
hormone synthesis and secretion, ,<' + H20 2 }
TSH /
with the sites of action of drugs ,/'
stimulates I
used tn the treatment of thyroid transcription
I

dtsorders. Iodide in the blood is

I
I
T T
of the gene I
I
Iodination
transported by the carriers NSI and for this
I T TG T - - - - - - T T
MIT } and coupling
pendrin (PDS) through the follicular carrier MIT T MIT
DIT Protein T
cell and into the colloid-rich lumen, I

where it is incorporated into ~I synthesis

I
\
thyroglobulin under the influence \
\
of the thyroperoxidase enzyme \ T Endocytosis
\ T and secretion
(see text for details). The hormones \
\J<,;_ ~
are produced by processing of the p
\ : :=:- _ ..( __ _ - T4 *- 1~
endocytosed thyroglobulin and I

exported into the blood. DIT, j(. T3 '' ).\

dliodotyroslne; L, lysosome; MIT,
monoiodotyrosine; P, pseudopod;
T, tyrosine; T3 , triiodothyronine; T4 ,
Scavenger
route
L r
Colloid
thyroxine; TG, thyroglobulin; TSH,
thyroid-stimulating hormone PLASMA FOLLICLE CELL FOLLICLE LUMEN
(thyrotrophin).
'-

Secretion of thyroid hormone

_ -e OH
1 The thyroglobuUn molecule is taken up imo the follicle cell by

Thy,.,.,L.. H,O,~
endocytosis (Fig. 29.1 ). The endocytotic vesicles then fuse with
lysosomes, and proteolytic enzymes act on thyroglobulin,

/
releasing T 4 and T 3 to be secreted into the plasma. The surplus
MTT and DIT, which are released at the same time, are scavenged
OH OH / C by the cell, where the iodide is removed enzymatically and reused.
H2N/H"'-..COOH

c
-~~

H2N /H "'-..COOH
c

H2N / H "'-..COOH
Monoiodotyrosine
Tyrosine Tyrosine radical
Fig. 29.2 Iodination of tyrosyl residues by the
thyroperoxidase-H20 2 complex. This probably involves two
sites on the enzyme, one of which removes an electron from
iodide to give the free radical I"; another removes an electron
from tyrosine to give the tyrosyl radical (shown by orange dot).
Monoiodotyrosine results from the addition of the two radicals.
involve a peroxidase system similar to that involved in iodina-
tion. About one-fifth of the tyrosine residues in thyroglobulin arc
iodinated in this way.
The iodinated thyroglobulin of the thyroid forms a large store
of thyroid hormone with a relatively slow turnover. This is in
contrast to some other endocrine secretions (e.g. the hormones of
the adrenal cortex), whjch are not stored but synthesjsed and
438 re leased as required.
REGULATION OF THYROID FUNCTION
Thyrotrophin-releasing hormone (TRH), released from the
hypothalamus in response to various stimuli, releases thyroid-
stimulating hormone (TSH; thyrotrophin) from the anterior
pituitary (Fig. 29.4), as does the synthetic tripeptide protirelin
(pyroglutamyl-histidyl-prolinc amide), which is used in this way
for diagnostic purposes (sec p. 439). TSH acts on receptors on
the membrane of thyroid follicle cells through a mechanism that
involves cAMP and phosphatidylinositol 3-k:inase. It controls all
aspects of thyroid hormone synthesis, including:
the uptake of iodjde by folljcle cells, by stimulating
transcription of the iodjde transporter genes; this is the main
mechanism by which it regulates thyroid function
the synthesis and secretion of thyroglobulin
the generation of H 20 2 and the iodination of tyrosine
the endocytosis and proteolysis of thyroglobulin
the actual secretion of T 3 and T 4
the blood flow through the gland.
Thyroid-stimulating hormone also bas a trophic action on the
thyroid cells; it stimulates the transcription of the genes for thyro-
globulin and thyroperoxidase, as wel l as the 1- transporters.

:.
 THE THYROID

Monoiodotyrosine Oiiodotyrosine Thyroxine (T4 ) Triiodothyronine (T3)

lYI
OH OH OH

lyYI HI
y CH2
y CH2
y 0
Fig. 29.3 Iodinated tyrosine ,
I
_...c,
''N,.. H "c
,
I
_...c,
' N ,.. H 'C''
. ly.yl
9
residues. Two molecules of
H II H II
iodinated tyrosine are combined to 0 0
produce either thyroxine (T4 ; two
molecules of dliodotyrosine) or
CH2
triiodothyronine (T3 ; one molecule
each of monolodotyrosine and I
c
dllodotyroslne). Monolodotyrosine H2N / H '--co OH
and diiodotyrosine are linked by a
peptide bond as in thyroglobulin.

actions of T 4 and T RH (and probably also somatostatin) on the

Cold Trauma Stress pituitary, although even high concentrations of thyroid hormone
"\~{ do not totally inhibit TSH secretion.
Hypothalamus The other main factor influencing thyroid function is the
plasma iodide concentration. About l 00 nmol ofT4 is synthesised
!
Somatostatin
! daily, necessitating uptake by the gland of approximately 500 nmol
of iodide each day (equivalent to about 70 mg of iodine). A
reduced iodine intake, with reduced plasma iodide concentration,

+
Anterior pituitary
Fig. 29.4 Regulation of thyroid hormone secretion.
Iodide<n is essential for thyroid hormone synthesis, but
excess of endogenous or exogenous iodide (30 times the daily
requirement of iodine) actually inhibits the increased thyroid
hormone production, which occurs in thyrotoxicosis. Protirelin
as well as recombmant thyrotrophin-releasing hormone (TSH)
is sometimes used to st1mulate the system for diagnostic
purposes, as is the admimstration of 13 11 (see text for details).
T3, triiodothyronine; T4 , thyroxine.
'-
The production of TSH is also regulated by a negative feed-
back effect of thyroid hormones on the anterior pituitary gland,
T3 being more active than T 4 in this respect. T he peptide soma-
tostatin (see p. 421) also reduces basal T SH release. The control
of the secretion of TSH thus depends on a bal ance between the
will result in a decrease of hormone production and an increase
in TSH secretion. An increased plasma iodide has the opposite
effect, although this may be modified by other factors (see below).
The overall feedback mechanism responds to changes of iodide
slowly over fairly long periods of days or weeks, because there is
a large reserve capacity for the binding and uptake of iodide in
the thyroid. The size and vasculari ty of the thyroid arc reduced
by an increase in plasma iodide. Diets defici ent in iodine eventu-
ally result in a continuous excessive compensatory secretion of
TSH, and eventually in an increase in vascularity and (sometimes
gross) hypertrophy of t11e gland. 'Derbyshire neck' was the name
given to this condition in a part of the UK where sources of
dietary iodine were once scarce.
ACTIONS OF THE THYROID HORMONES
The physiological actions of the thyroid hormones fall into two
categories: tho e affecting metabolism and those affecting growth
and development.
EFFECTS O N METABOLISM
The thyroid hormones produce a general increase in the
metabolism of carbohydrates, fats and proteins, and regulate
these processes in most tissues, T 3 being three to five times more
active than T 4 in this respect (Fig. 29.5). A lthough the thyroid
hormones directly control the activity of some of the enzymes of
439
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTE MS
+5
Q)
~ protein synthesis.
Q -5
:8(1)
a; 15
E
~
(1)
- 25
IXl
-35
0 4 8 12 16 20
Days after injection
Fig. 29.5 The effect of equimolar doses of
triiodothyronine (T3l and thyroxine (T4 ) on basal metabolic
rate in a hypothyroid s ubject. Note that this figure is meant
only to illustrate overall differences in effect; thyroxine is not
given clinically in a single bolus dose as here, but in regular
daily doses so that the effect builds up to a plateau. The
apparent differences in potency really represent differences in
kinetics, reflecting the prehormone role of T4 (From Blackburn
C Metal. 1954 J Clin Invest 33: 819.)
carbohydrate metabolism. most effects are brought about in
conjunction with other hormones, such as insulin, glucagon, the
glucoconicoids and the catecholamines. There is an increase in
oxygen consumption and heat production, which is manifested as
an increase in the measured basal metabolic rate. This reflects
action of these hormones on tissues such as heart, kidney, liver
and muscle, although not on others. such as the gonads, brain or
spleen. The calorigenic action is important as part of the response
to a cold environment. Administration of thyroid hormone results
in augmented cardiac rate and output, and increased tendency to
dysrhythmias such as atrial fibrillation.
EFFECTS ON GROWTH AND DEVELOPMENT
The thyroid hormones have a critical effect on growth, partly by
a direct action on cells, and also indirectly by influencing growth
hormone production and potentiating its effects on its target tissues.
The hormones are imponant for a normal response to parathor-
monc and calcitonin as well as for skeletal development; tl1ey are
also essential for normal growth and maturation of the central
nervous system.
MECHANISM OF ACTION
While there is some evidence for non-genomic actions (sec
Bassett et al., 2003; Lazar. 2003), these hormone act mrunly
through a mechanism dependent on occupation of a member of
the nuclear receptor family. TR (Ch. 3 and Fig. 3.17). Two distinct
genes, TRo. and TR~. code for several receptor isoforms that
have distinct functions. T 4 may be regarded as a prohormone,
because when it enters the cell. it is first convened to T 3 , which
then binds with high affinity to a member of the TR family. This
interaction is likely to take place in the nucleus, where TR
isoforms generally act as a repressor of target genes. When T 3 is
440 bound, the receptors change conformation, the corepressor complex
-
is released and a coactivator complex is recruited, which then
activates transcription-resuJting in generation of mRNA and
TRANSPORT AND METABOLISM
Both hormones are transported in the blood bound mainly to
thyroxine-binding globulin (TBG). Plasma concentrations of these
hormones can be measured by radioimmunoassay, and normally
fall into the range I X 10"7 mol/1 (T4) and 2 X 10"9 mol/) for TJ.
Both arc eventually metabolised in their target tissues by deio-
dination, deaminatjon, decarboxylation, and conjugation with
glucuronic and !:>ulfuric acids. The liver is a major site of meta-
bolism. and the free and conjugated fonns are excreted partly in
the bile and partly in the urine. The metaboUc clearance of T 3 is
20 limes faster than that ofT4 (wllich is about 6 days). The long
half-l ife of T 4 is a consequence of its strong binding to TBG.
Abnormalities in the metabolism of these hormones may occur
naturally or be induced by drugs or heavy metals, and this may
give rise to a variety of (uncommon) clinical conditions such as
the 'low T 3 syndrome'.
ABNORMALITIES OF THYROID FUNCTION
Thyroid disorders are among the most common endocrine dis-
eases, and subclinical thyroid disease is particularly prevalent in
the middle-aged and elderly. They are accompanied by many
extrathyroidaJ symptoms, particularly in the heart and skin. One
cause of organ dysfunction is thyroid cancer. Depending on
where it is located, tills can affect all aspects of glandular
function including iodide uptake, TSH expression and
thyroglobulin synthesis. Many other thyroid disorders have an
autoimmune basis; the ultimate reason for this is not clear,
although it may be linked to polymorphisms in the PDS, TNF-a
or other genes. Regardless of causation, there are two principal
manifestations of the disease.
HYPERTHYROIDISM (THYROTOXICOSIS)
In thyrotoxicosis, there is excessive activity of the thyroid
hormones, resulting in a high metabolic rate, an increase in !>kin
temperature and sweating, and a marked sensitivity to heat.
Nervousness, tremor, tachycardia. heat sensitivity and increased
appetite a ...sociated with loss of weight occur. There are several
types of hyperthyroidism. but only two are common: diffuse
toxic goitre (abo called Grmes' disease or exophthalmic goitre)
and toxic nodular goitre.
Diffuse toxic goitre is an organ-specific auwimmune disease
caused by thyroid-stimulating immunoglobulins directed at the
TSH receptor. Constitutively active mutations of the TRH receptor
may also be involved. As is indicated by the name, patients with
exophthalmic goitre have protrusion of the eyeballs. The patho-
genesis of this condition is not fully understood, but it is thought
to be caused by the presence of TSH receptor-like proteins in
orbital tissues. There is also an enhanced sensitivity to cate-
cholamines. Toxic nodular goitre is caused by a benign neoplasm

or adenoma. and may develop in patients with long-standing
simple goitre (~ee below). This condition does not usuaJJy have
concomitant exophthalmos. The antidysrhythmic drug amiodarone
(Ch. 18) i~ rich in iodine and can cause either hyperthyroidism or
hypothyroidism. Some other iodine-containing drugs. such as
iopanoic acid and its congeners. which are used as imaging
agents u\ed to vi,ualise the gall bladder. may also interfere with
th}roid function but may have some clinical utility in treating
h) perthyroidism.
SIMPLE, NON-TOXIC GOITRE
A dietary deficiency of iodine, if prolonged, causes a rise in
plasma TRH and eventual ly an increase in the size of the gland.
Thi~ condition is known as simple or non-toxic goitre. Another
cause is ingestion of goitrogens (e.g. from cassava root) . The
enlarged thyroid usually mru1ages to produce normal an1ounts of
thyroid hormone. although if the iodine deficiency is very severe,
hypothyroidi~-om may ~upervene.
HYPOTHYROIDISM
A decrea~cd acti vity of the thyroid results in hypothyroidism. and
in severe cases lll):medema. Once again. this disease is immuno-
logical in origin, and the manifestations include low metabolic
rate. slow speech. deep hoarse voice, lethargy, bradycardia, sen-
sitivity to cold, and mental impairment. Patients also develop a
characteristic thickening of the skin (caused by the subcutaneous
deposition of glycosaminoglycans). which gives myxoedema its
name. Hashimoto's thyroiditis. a chronic autoimmune disease in
which there is an immune reaction against thyroglobulin or some
other component of thyroid tissue. can lead to hypothyroidism
and myxocdema. Therapy of thyroid tumours with radioiodine
(see below) is another cause of hypothyroidism.
Thyroid deficiency during development, caused by congenital
absence or incomplete development of the thyroid, which is the
most prevalent endocrine disorder i n the newborn (1 in
3000-4000 births) causes cretinism , characterised by gross retar-
dation of growth and mental deficiency. Pendred's syndrome, an
autosomal recessive disorder caused by mutations in the PDS
tran~porter gene, may cause goitre as well as deafness and other
&ymptoms (see Hadj Kacem et al., 2003).
DRUGS USED IN DISEASES OF THE
THYROID
HYPERTHYROIDISM
Hyperthyroidism may be treated pharmacologically or surgically.
In general, surgery is used only when there are mechanical
problems resuhing from compression of the trachea, and it is
usual to remove only part of the organ. Although the condition of
hyperthyroidi-.m can be controlled with antithyroid drugs, the
disea~c is not cured', because the drugs do not alter the under-
lying autoimmune mechanisms. Furthermore, there is little evi-
dence that these drugs affect the course of the exophthal mos
associated with Graves' disease.
THE TH YROID
The thyroid
Thyroid hormones, triiodothyronine (T:J and
thyroxine (T4 ) , are synthesised by iodination of
tyrosine residues on thyroglobulin within the lumen of
the thyroid follicle.
Hormone synthesis and secretion are regulated by
thyroid-stimulating hormone (thyrotrophin) and
influenced by plasma iodide.
There is a large pool of T4 in the body; it has a low
turnover rate and is found mainly in the circulation.
There is a small pool of T3 in the body; it has a fast
turnover rate and is found mainly intracellularly.
Within cells, the T4 is converted to T3 , which interacts
with a nuclear receptor to regulat e gene transcription.
T3 and T 4 actions:
stimulation of metabolism, causing increased
oxygen consumption and increased metabolic rate
regulation of growth and development.
Abnormalities of thyroid function include:
hyperthyroidism (thyrotoxicosis); either diffuse
toxic goitre or toxic nodular goitre
hypothyroidism; in adults this causes myxoedema,
in infants cretinism
simple non-toxic goitre caused by dietary iodine
defiCiency, usually with normal thyroid function.
RADIOIODINE
Radioiodine is a firM-line treatment for byperthyroidi m (particu-
larly in the USA). The isotope used is 131 1 (usually as the sodium
salt}, and the dose generally 5- 15 millicuries. Given orally, it is
taken up and processed by the thyroid in the same way as the
stable form of iodide, eventually becoming incorporated into
thyroglobulin. The isotope emits both ~ radiation and y rays.
The y rays pass through the tissue without causing damage, but
the ~ particles have a very short range; they are absorbed by the
ti ssue and exert a powerful cytotoxic action that is restricted to
the cells of the thyroid follicles, resulting in significant destruction
of the tissue. 111 1 has a half-life of 8 days, so by 2 months its
radioactivity has effectively disappeared. lt is given as one single
dose, but its cy totoxic effect on the gland is delayed for 1- 2
months and docs not reach its maximum for a further 2 months.
Hypothyroidism will eventually occur after treatment with
radioiodine, particularly in patients with Graves' disease, but is
easily managed by replacement therapy with T 4 Radioiodine is
best avoided in children and also in pregnant patients because of
potential damage to the fetus. There is a theoretical risk of thyroid
cancer following the treatment.
The uptake of 131 1 and other isotopes of iodine may also be
used diagnostically as a test of thyroid function. A rracer dose of
the isotope is given orally or intravenously, and the amount accumu-
lated by the thyroid is measured by a y-scintillation counter
placed over the gland. Another use for this drug is the treatment
of thyroid cancer. 441
 SECTION 3 . DRUGS AFFE CTING MAJOR O RGAN SYSTEMS
THIOUREYLENES
The thioureylene group of drugs comprises carbimazole,
methimazole and p ropylthiouracil. Chemically, they are related
to thiourea, and the thiocarbamide (S-C-N) group is essential for
antithyroid activity.
Mechanism of action
Thioureylenes decrease the output of thyroid hormones from the
gland, and cause a gradual reduction in the signs and symptoms
of thyrotOxicosis, the basal metabolic rate and pulse rate
returning to normal over a period of 3-4 weeks. Their mode of
action i~ not completely understood, but there is evidence that
they inhibit the iodination of tyrosyl residues in thyroglobulin
(see Figs 29.1 and 29.2). It is thought that they inhibit the
thyroperoxidase-catalysed oxidation reactions by acti ng as sub-
strates for the postulated peroxidase-iodinium complex, thus
competitively inhibiting the interaction with tyrosine. Propyl-
thiouracil has the additional effect of reducing the deiodination
of T4 to T3 in peripheral tissues.
Pharmacokinetic aspects
Thioureylene!. are given orally. Carbimazole is rapidly converted
to methimazole, which is distributed throughout the body water
and has a plasma half-life of 6-15 hours. An average dose of
carbima7ole produces more than 90% inhibition of thyroid incor-
poration of iodine within 12 hours. The clinical response to this
and other antithyroid drugs. however. may take several weeks
(Fig. 29.6). This is not only because T~ has a long half-life, but
also because the thyroid may have large stores of hormone,
which need tO be depleted before the drug's action can be fully
manifest. Propylthiouracil is thought to act somewhat more
rapidly because of its additional effect as an inhibitor of the
peripheral conversion ofT4 to T 3.
+40
+30
'#- +20
a:
:E
ll) +10
0 through inhibition of thyroperoxidase, thus reducing
- 10
I
0 4 8 12 16 20
Weeks
lg. 29.6 Time course of fall of basal metabolic rate
BMR) during treatment with an antithyroid drug,
carbimazole. The curve is exponential, corresponding to a
U
dally decrease in BMR of 3.4% (From Furth E 0 et al. 1963 J
Clin Endocrinol Metab 23:1130.)
442
Both methimuole and propylthiouracil cross the placenta and
also appear in the milk, but tbi effect is less pronounced with
propylthiouracil. because it is more strongly bound to plasma
protein. After degradation, the metabolites are excreted in the urine,
propylthiouracil being excreted more rapidly than methimazole.
The thiourcylenes may be concentrated in the thyroid.
Unwanted eHe cts
The most important unwanted effect is granulocytopenia (see
Ch. 22). This is relatively rare. having an incidence of 0. 1 - 1.2~ .
and is reversible on cessation of treatment. Rashes are more
common (2-25%), and other symptoms. such as headaches,
nausea, jaundice and pain in the joints, can occur.
IODINE/IODIDE
Iodine is converted in vivo to iodide (r), which temporarily
inhibits the release of thyroid hormones. When high doses of
iodine arc given to thyrotoxic patients, the symptoms subside
within 1-2 days. There is inhibition of the secretion of thyroid
hormones and. over a period of 10-14days. a marked reduction
in vascularity of the gland. which becomes smaller and firmer.
Iodine is often given orally in a solution with potassium iodide
('Lugol's iodine'). With continuous administration, itS effect
reaches maximum within 10-15 days and then decreases. The
mechanism of action is not entirely clear; it may inhibit iodina-
tion of thyroglobulin. possibly by reducing the HP2 generation
that is necessary for this process.
The main uses of iodine/iodide are for the preparation of
hyperthyroid subjects for surgical resection of the gland. and 3!.
part of the treatment of severe thyrotoxic crisis (thyroid storm).
Allergic reactions can occur; these include angio-oedema. rashes.
drug fever, lacrimation, conjunctivitis, pain in the salivary glands
and a cold-like syndrome.
Drugs In thyroid disease
Drugs for hyperthyroidism
Radioiodine , given orally, is selectively taken up
by thyroid and damages cells; it emits short-range
13 radiation, which affects only thyroid follicle cells.
Hypothyroidism will eventually occur.
Thioureylenes (e.g. propylthiouracil) decrease the
synthesis of thyroid hormones; the mechanism IS
iodinat1on of thyroglobulin. They are given orally.
Iodine, given orally in high doses, transiently reduces
thyroid hormone secretion and decreases vascularity
of the gland.
Drugs for hypothyroidism
Thyroxine has a ll the actions of endogenous
thyroxine; it is given orally.
Liothyronine has all the actions of endogenous
triiodothyro nine; it is given intravenously.
 THE THYROID

OTHER DRUGS USED precipitating angina pectori,, cardiac dysrhytbmias or even cardiac
failure. The effects of le~~ ~evere overdose arc more in~idious;
The {J-adrenoc:eptor alltagoni.ltS, for example propranolol (Ch. II), the patient feels well but bone resorption is increased, leading to
arc not antithyroid agents m; such, but they are useful for decreasing osteoporosis.
many of the signs and ~ymptom~ of hyperthyroidjsm- the The use of drugs acting o n the th yroid is summarised in the
tachycardia, dysrhylhmias, tremor and agi tation. They are used clinical box.
during the preparation of thyrotoxic patients for surgery. as well
a~ in most hyperthyroid patients during the initial treatment period
while the thioureylenes or radioiodine take effect, and as part Clinical use of drugs acting on
of the treatment of acute hyperthyroid crisis. Guanethidine. a the thyroid
noradrenergic-blocking agent (Ch. II), is used in eye drops to
ameliorate the exophthalmos of hyperthyroidism (which is not Radioiodine
relieved b} antithyroid drugs); it aw. by relaxing the sympathe- Hyperthyroidism (Graves' disease, multinodular toxic
tically innervated smooth mu\cle that causes eyelid retraction. goitre).
Glucocorticoids (e.g. prednisolone) or surgical decompression Relapse of hyperthyroidism after failed medical or
may be needed to mitigate severe cxophthalmia in Graves' disease. surgical treatment.
Some other drugs (e.g. cho lecystographic agents) or pesticides/
environmental contaminant (e.g. polychlorinated biphenyls) may Carbimazole or propylthiouracil
interfere with the normal production of thyroid hormones. Hyperthyroidism (diffuse toxic goitre); at least 1 year
of treatment is needed.
Preliminary to surgery for toxic goitre.
HYPOTHYROIDISM Part of the treatment of thyrotd storm (very severe
hyperthyroidism); propylthiouracil is preferred. The
There arc no drugs that specifically augment the synthesis or
~-adrenoceptor antagonists (e.g. propranolol) are
relea<,e of thyroid hormones. The only effective treatment for
also used.
hypothyroidism, unless it is caused by iodine deficiency (which is
treated with iodide; see above), is to administer the thyroid Thyroid hormones and iodine
hormones themselves as replacement therapy. T hyroxine and Thyroxine (T4) is the standard replacement therapy
triiodothyronine (liothyronine) arc avai !able and are given orally. for hypothyroidism.
Thyroxine a~ the sodium salt in doses of 50- 100 microgram~/day Liothyronine (T3l is the treatment of choice for
i' the u\ual first-line drug of choice. Liothyronine has a faster myxoedema coma.
onset but a shorter duration of action, and is generally reserved Iodine dissolved in aqueous potassium iodide
for acute emergencies such a:. the rare condition of myxoedema ('Lugol's iodine') is used short-term to control
coma. where these properties are an advantage. thyrotoxicosis preoperatively. It reduces the
Unwamed effects may occur with overdose, and in addition to vascularity of the gland.
the ~igns and symptoms of hypcnhyroidism there is a risk of

REFERENCES AND FURTHER READING

Ba,...:n J H D. Hat\ey C B. Wilham' G R 2003
\frchani'ms of lhyroid honnonc rcccp1or 't>e<:ilic
nudear and ex1ra nuclear actions. Mol Cell hmlocrinol
213: 1- 11 (An excellent aiUl camprehen<hl' reiew
Jrt1li111: 11/1 the actions of thymid hormtm'\ throu~:h
tlw 1mdfar rec:~ptor mechanism O\' weJI t:M other
artion.r through Gprotein-coupled rece{ltorf ttnd
ntha path\..OYS)
llra~aM. Cooper D S 2001 Clinical rcicv. 129. Oral
chnle<),lographic agents and !he thyro1tl. J Chn
Endocnnol .\1e~nb 86: t853-t860 tDucuiUl till' ~J/I'ct
~>/ 1m0~111~ O~t'ntS on th)roid fimuil>n)
Bra~a-Ba..ana M. Rmgel M D 2003 Clinocal re"e" 158.
lk)ond rad101odJne: a review of potenual new
therapeUiic approaches for lhyro1d cancer. J Chn
~.ndocrinol Metab 88: 1947- 1960 (l)acus<l'< somt'
nt'w !trategit's that might be ILsed 10 mmmlthvroid
mrritwma)
Frnn~hn J A 1995 The managcmcnl of hypenhyrotdism.
:-l Eng! J Med 330: 1731- 1738 (An l!xceltent mi~ of
tiU! drng trPatmrnt of Jnwnh1 nlitfi.lm)
Hadj Kacem H. Rebat A, KnOcl 1\ el al. 2003. PDS is a
new ~usccpliblluy gene 10 aUioimmune thyroid
diseases: a\octalion and linknge study. J Clin
Endocriool Metab 88: 2274 2280 (Interesting anicle
on rhe PDS trtmsporrer fHYitcill and in contribution 10
diSffJSI' SIUCeptibi/it,\")
Knhaly G J. Dllmann W H 2005 Thyrotd honnone
aclioo in !he hean. 1-.ntlocr Rev 26: 704-728
(A ,.,.,.., imef't'stm!( rein ft>tusing on the caniiac
actimu of thyroid hannonl'.t: muth hwonca/ detail)
Kelly G S 2000 Peripheral metaboli\m of lhyroid
honnones: a revtew. Ahem \1ed Rev 5: 306-333
(11ris ll'Vicw fomst's 1111tht mil' cif wripherol
nU!tabo/ism 111 th1roid harmOnl' action)
Lazar M A 2003 Thyroid hormone ac1ion: a binding
contract. J Clin lnvc'l 11 2: 497-499 (A shon ond
accessible article dell/in~: with thP main nuclear
rucpwr mediated t'ff<'cts of thyroid homwnl'.\ tJj ""It
wme mh~r pountial medumi.Jnu l1/ action)
tlf
Lua/\1' J H 1997 Hypenhyroidism. Lance1 349:
339-343 (A .s('mitwr' rol'rri11g a.etiology. cltmcal
fNuare.Y. pmhophy.siology. diag11osis omltflatment)
Lind,:1y R S 1997 Hypothyroidism. Lancet349:
413-417 (A '.veminor' emphasising lite management
of hYfllllltvmitliwl)
NiepomniS7C7e II, Amad R H 2001 Skin d1sorder' and
1hyro1tl dl\ea<.es. J Endocrinollnve>l 24: 62S 61R
(Anmhu rni,.... af thl' t'XJrath~roidal ~ffutj a11d thl'lr
linJ. to mritJUf ,un fN1thologi~s)
'lilwm M 200t Iodide handling by !he lh> ro1d ~fltlhelial
cell. Exp Chn Endocrinol Diabetes t09. 13-17 W!~ful
and rt!ad<lhlt' mit'k' of iodide hand/m~ by tilt' th\ mid
gltmdl
P;~~hl.e R, Ludgme M 1997 The thyi'Olropm rccep1or
and il ' di\enst's. N Engl J Med 337: 1675 1679
(Rtiewo~ ll.lf'I'I"I.V of1SH biology and diseaje)
443
 The reproductive system

Overview 445 hormones interact to control reproduction, 1 and

many drugs, including agents used to prevent or
Endocrine control of reproduction and drugs that assist conception, work by influencing negative
influence this 445 feedback mechanisms. Oestrogen replacement
-Neurohormonal control of the female reproductive therapy prevents postmenopausal bone loss as
system 445 well as treating symptoms of oestrogen deficiency,
-Behavioural effects of sex hormones 447 benefits that are oHset by eHects on the breast and
-Oestrogens 447 endometrium, and by an increase in
-Antioestrogens 449 thromboembolism. There is a separate section on
-Progestogens 449 drugs that alter the contractile state of the uterus,
-Antiprogestogens 450 which are important in obstetrics: drugs that
-Postmenopausal hormone replacement therapy 450 stimulate uterine contraction-'oxytocic' drugs-are
-Neurohormonal control of the mole reproductive used to induce labour or abortion and to prevent
system 451 postpartum haemorrhage, whereas uterine
-Androgens 451 relaxants are used, much less eHectively, to delay
-Anabolic steroids 452 labour. There is a section on drugs for erectile
-Antiandrogens 452 dysfunction, which have made a remarkable
-Gonadotrophin-releasing hormone: ogonists and transition from below-the-counter charlatanry to
antagonists 453 medical orthodoxy.
-Gonadotrophins and analogues 454

Drugs used for contraception 454

ENDOCRINE CONTROL OF
-Oral con traceptives 454
REPRODUCTION AND DRUGS THAT
-Other drug regimens used for contraception 455 INFLUENCE THIS
The uterus 456
-Drugs that stimulate the uterus 456 Hormonal control of the reproductive systems in men and women
-Drugs that inhibit uterine contraction 458 involves sex !.tcroids from the gonads, hypothalamic peptides,
and glycoprotein gonadotrophins from the anterior pituitary.
Erectile dysfunction 458

NEUROHORMONAL CONTROL OF THE

OVERVIEW
Drugs that aHect reproduction (both by preventing
conception and more recently for treating
infertility) have had profound consequences for
individuals and for society. In this chapter, we
describe the endocrine control of the female and
male reproductive systems, because this forms the
basis for understanding many important drugs.
The principle of negative feedback, which is
stressed, is central to understanding how
FEMALE REPRODUCTIVE SYSTEM
At puberty, an increased output of the hormones of the hypo-
thalamus and anterior pituitary stimulates secretion of oestrogenic
sex steroids. These are responsible for the maturation of the
reproductive organs and the development of the secondary sexual
characteristics, and also for a phase of accelerated growth followed
by clo ure of the epiphyses of the long bones. Sex steroids are
thereafter involved in the regulation of the cyclic change~;
'Recognition that negative feedback is central to endocrine control wa> a
profound insight, made in 1930 by Dorothy Price. a laboratory as;istant in
the Univcr,ily of Chicago experimenting on effects of te>tosterone in rat~.
She referred to it us 'reciprocal influence'. 445
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

expressed in the menstrual cycle. and are important in pregnancy.

A '>implified outline of the inter-relationship of these substances
A
in the physiological control of the menstrual cycle is given in
Figures 30. 1 and 30.2.
The men<,trual cycle begins with menstnwtion, which lasts for
3-6 day~. during which the superficial layer of uterine endo-
metrium is shed. The endometrium regenerates during the follicular
phase of the cycle after menstrual flow has stopped. A releasing B
factor, the gonadotrophin-releasing honnone (GnRH), is secreted
from pcptidergic neurons in the hypothalamus in a pulsatile fashion,
the frequency being about one burst of discharges per hour.
GnRH stimulates the anterior pituitary to release gonadotrophic
hormones (Fig. 30.1 )-follicle-stimulating hormone (FSH) and
luteinising hormone (LH). These act on the ovaries (Fig. 30.2A) [C]
to promote development of small groups of follicles, each of 1800
LH
which contain s an ovum. One follicle develops faster than the 1500
others and forms th e Graafian follicle (Figs 30. 1 and 30.2E), and
1200
the rest degenerate. The ripening Graafian follicle consists of
thecal and granulosa cells surrounding a fluid-filled centre, within t.s 900
which lies an ovum. Ocstrogens are produced by the granulosa 600
cells stimulated by FSH. from androgen precursor molecules 300
derived from thecal celb !>limulated by LH. Oestrogens are 0 llllilliill~~fliiriiiiia.J
D
respom.ible for the proliferative phase of endometrial regeneration,
28
which occurs from day S or 6 until mid-cycle (Fig. 30.2B,F). Progesterone
During this pha'>e. the endometrium increases in thickness and 20

10

~ ['-_Hy_po_t_h~1-
,1. .am_u_s~ E Ovulation
v
GnRH

~ F

0 7
Day of menstrual cycle
Fig. 30.2 Plasma concentrations of ovarian hormones
and gonadotrophins in women during normal menstrual
cycles. Values are the mean :1: standard deviation of 40
women. The shaded areas indicate the entire range of
observations. Day 1 is the onset of menstruation. E and F
show diagrammatically the changes in the ovarian follicle and
the endometrium during the cycle. Ovulation on day 14 of the
menstrual cycle occurs with the mid-cycle peak of luteimsing
'
'' hormone (LH), represented by the vertical dashed line. A,
' \
arterioles; FSH, follicle-stimulating hormone; V, venules. (After
7' van de W~ele R L, Dyrenfurth 11974 Pharmacal Rev 25: 189-217.)
Progesterone - - - " '

I Act on reproductive tract and other tissues

Fig. 3 0 .1 Hormonal control of the female reproductive
vascularity, and at the peak of oestrogen secretion there is a pro-
system. The Graafian follicle (GF) is shown developing on the lific cervical secretion of mucus of pH 8-9, rich in protein and

l
left, then involuting to form the corpus luteum (CL) on the right,
after the ovum () has been released. FSH, follicle-stimulating
hormone; GnRH, gonadotrophin-releasing hormone; LH,
lutelnising hormone.
446
carbohydrate. which facilitates entry of spermatozoa. Oestrogen has
a negative feedback effect on the anterior pituitary, decreasing
gonadotrophin release during chronic administration of oestrogen
as or.ll contraception (see below). In contrast, the high cndogenou~

oc~trl)gen secretion just before mid-cycle sensitises LH-releasing
cell<. of the pituitary to the action of the GnRH and causes the
mid-cycle surge of LH secretion (Fig. 30.2C). This. in tum, causes
rapid swelling and rupture of the Graafian follicle, resulting in
O\'Ulation. If fenilisation occurs, the fertilised ovum passes down
the falloptan tube~ to the uterus, starting to divide as it goes.
Stimulated by Lll, cells of the ruptured follicle proliferate and
develop tnto the corpus luteum. which secretes progesterone.
Proge~teronc act!>. in turn. on oestrogen-primed endometrium,
-.timulating the secretory phase of the cycle, which renders the
endometrium ~u itable for the implantation of a fertilised ovum.
During thi'> phase, cervical mucus becomes more viscous, less
alkaline, less copi ou~ and in general less welcoming for sperm.
Progesterone exert~ negative feedback on hypothalamus and
pituitary, dcc rca~ ing the rcleusc of LH. It also has a thermogenic
effect, causing a rise in body temperature of about 0.5C at
ovulation, which is maintained until the end of the cycle.
If implantation of the ovum does not occur, progesterone
secretion stops. triggering menstruation. If implantation does
occur, the corpus luteum continues to secrete progesterone, which,
by ih effect on the hypothalamus and anterior pituitary, prevems
further ovulation. The chorion (an antecedent of the placenta)
't.'Cretes human chorionic gonadotrophin (HCG), which maintains
the lining of the womb during pregnancy. For reasons that are not
ph}siologically obviou~. HCG has an additional pharmacological
action in stimulating ovulation. As pregnancy proceeds. the placenta
dc\'clops further hormonal functions and secretes a gamut of
hormone variants (often with post-translational modifications),
including gonadotrophins as well as progesterone and oestrogens.
Proge~terone o;ecreted during pregnancy controls the development
of the secretory alveoli in the mammary gland, while oestrogen
~timulates the lactiferous ducts. After parturition, oestrogens, along
with prolactin (see Ch. 28. pp. 423-424), are responsible for
stimulating and maintaining lactation. whereas high doses of
exogenous oestrogen suppre!>S this.
Ocstrogcns arc dealt with below, progestogens (progesterone-
like drugs) on page 449, androgens on page 451, and the
gonadotrophins on page 454.
BEHAVIOURAL EFFECTS OF SEX
HORMONES
A~ well as controlling the menstrual cycle, sex steroids affect
'exual behaviour. Two types of control are recognised: organis-
auonal and actil'tltional. The former refers to the fact that sexual
differentiation of the brain can be permanently altered by the
pre,cncc or ab~ence of ex steroids at key stages in development.
In rats, adminbtration of androgens to females within a few
day~ of birth re<,ults in long-term virilisation of behaviour. Con-
\ersely, neonatal castration of male rats causes them to develop
behaviourally as female!>. Brain development in the absence of
\CX steroid\ follows female lines. but is switched to the male pattern
by exposure of the hypothalamus to androgen at a key stage of
development. Similar but less complete behavioural virilisation
of female offspring has been demonstrated following androgen
administration in non-human primates, and probably also occurs
in humans if pregnant women are exposed to excessive androgen.
THE REPRODUCTIVE SYSTEM
Hormonal control of the female
The menstrual cycle starts with menstruation.
Gonadotrophin-releasing hormone, released from the
hypothalamus, acts on the anterior pituitary to release
follicle-stimulating hormone (FSH) and luteinising
hormone (LH).
FSH and LH stimulate follicle development in the ovary.
FSH is the main hormone stimulating oestrogen
release. LH stimulates ovulation at mid-cycle and is
the main hormone controlling subsequent
progesterone secretion from the corpus luteum.
Oestrogen controls the proliferative phase of the
endometrium and has negative feedback effects on
the anterior pituitary. Progesterone controls the later
secretory phase, and has negative feedback effects
on both hypothalamus and anterior pituitary.
If a fertilised ovum is implanted, the corpus luteum
continues to secrete progesterone.
After implantation, human chorionic gonadotrophin
from the chorion becomes important, and later in
pregnancy progesterone and other hormones are
secreted by the placenta.
The activational effect of sex steroids refers to their ability to
modify sexual behaviour after brain development is complete. In
general, oestrogens and androgens increase sexual activity in the
appropriate sex. Oxytocin, which is important during parturition
(see below), also has roles in mating and parenting behaviours, its
action in the central nervou!> system being regulated by oestrogen
(see Ch. 28).
OESTROGENS
Ocstrogcns arc synthesised by the ovary and placenta, and in small
amounts by the testis and adrenal cortex. As for other steroids,
the starting sub"ance for oestrogen synthesis is cholesterol. The
immediate precursors to the oestrogens are androgenic
substances-androstenedione or testosterone (Fig. 30.3 ). There
arc three main endogenous oestrogens in humans: oestradiol,
oestrone and oestriol (Fig. 30.3). Oestradiol is the most potent
and is the principal oestrogen secreted by the ovary. At the
beginning of the menstrual cycle, the plasma concentration is
0.2 nmol/1, rising to -2.2 nmolll in mid-cycle.
Actions
Oe~trogcn acts in concert with progesterone. and induces synthesis
of progesterone receptors in uterus. vagina, anterior pituitary and
hypothalamus. Conversely, progesterone decreases oestrogen
receptor exprc!>sion in the reproductive tract. Prolactin (sec Ch. 28)
also influences oestrogen action by increasing the numbers of
oestrogen receptors in the mammary gland, but has no effect on
oestrogen receptor expression in the uterus. 447
 SECTION 3 DRUGS AFFECTING MAJOR ORGAN SYSTEMS

Cholesterol - - - ~ Progesterone Oestriol

......

-.... y
... Androstenedione "
Aromatase
/
r
Oestrone

Fig. 3 0 .3 The biosynth etic

pathway for the androgens and
oestrogens, with sites of drug
action. (See also Fig. 28.5.)

l
Finasteride is used in benign
prostatic hyperplasia, and Dihydrotestosterone Testosterone --------L------~ Oestradiol
anastrazole to treat breast cancer in \.. Sa-Reductase / , Aromatase /
postmenopausal women.
-------------------

Effects of exogenous oestrogen depend on the state of sexual Preparations

maturity when the oestrogen is administered:
in primary hypogonadism: oestrogen stimulates development
of secondary sexual characteristics and accelerates growth
in adults with primary amenorrhoea: oestrogen, given
cyclically with a progestogen, induces an artificial cycle
in sexually mature women: oestrogen (with a progestogen) i~
contraceptive
at or after the menopause: oestrogen replacement prevents
menopausal symptonu. and bone loss.
Oestrogens have several metabolic actions, including mineralo-
corticoid (retention of salt and water) and mild anabolic actions.
They increase plasma concentrations of high-density lipoproteins,
a potentially beneficial effect (Ch. 20) that may contribute to the
relatively low risk of atheromatous disease in premenopausal
women compared with men of lhe same age. Oestrogens increase
the coagulability of blood. and increase the risk of thromboem-
bolism. This effect is dose-related.
Mechanism of action
As with other steroids, oestrogen binds to type 4 nuclear receptors
(Ch. 3, pp. 46-48). There are at least two types of oestrogen
receptor, termed ERa and ER/3. the roles of which are currently
being investigated using mice in which the gene coding one or
other of these has been 'knocked out' (Ch. 6, p. 92). Binding is
followed by interaction of the resultant complexes wilh nuclear
sites and subsequent genomic effects--either gene transcription
(i.e. DNA-directed RNA and protein synthesis) or gene repression
(inhibition of transcription). More details are given in Chapters 3
and 28. In addition to these 'classic' intracellular receptors, some
oe~trogen effects, in particular its rapid vascular actions, may be
initiated by interaction with membrane receptors (e.g. Chen et al.,
1999). Acute vasodilatation caused by 17-~-oestradiol is
mediated by nitric oxide. and a plant-derived (phyto-) oestrogen
called genistein (which is selective for ER~, as well as having
quite distinct effects from inhibition of protein kinase C) is as
potent as 17-~-ocstradiol in this regard. Oestrogen receptor
modulators (receptor-selective oestrogen agonists or antagonists)
448 are mentioned briefly immediately below this section.
Many preparations (oral, transdermal, intramuscular, implantable
and topical) of oestrogens arc available for a wide range of indi-
cations. These preparations include natural (e.g. estradiol, estriol)
and synthetic (e.g. mestranol, ethinylestradjoJ, stilbestrol)
oestrogcns. Ocstrogcns arc presented either as single agents or
combined wilh progestogen.
The clinical use of oestrogens and antioestrogens is given in
lhe box.
Pharmacokinetic aspects
Natural as well as synthetic oestrogens are well absorbed in the
gastrointestinal tract. but after absorption the natural oestrogens
arc rapidly metabolised in the liver, whereas synthetic oestrogens
arc degraded less rapidly. There is a variable amount of entero-
hepalic cycling, which forms the basis for drug interaction, because
broad-~pectrum antibiotic use alters bowel flora and can thereby
render oral contraception ineffective (Ch. 52). Most oestrogens
are readily absorbed from skin and mucous membranes. They
may be given topically in the vagina as creams or pessaries for
local ellect. In the plasma. natural oestrogens are bound to albumin
Clinical use of oestrogen
and antloeatrogena
Oestrogens
Replacement therapy:
primary ovarian failure (e.g. Turner's syndrome)
- secondary ovarian failure (menopause) for flushing,
vaginal dryness and to preserve bone mass.
Contraception.
Prostate and breast cancer (these uses have largely
been superseded by other hormonal manipulations;
see Ch. 51)
Antioest rogens
To treat oestrogen-sensitive breast cancer (tamoxifen).
To induce ovulation (clomiphene) in treating infertility.

and to a ~ex steroid-binding globulin. Natural oestrogens arc
excreted in the urine as glucuronides and sulfates.
Unwanted eHects
Unwanted effects of oestrogens include tenderness in the breasts,
nausea, vomiting, anorexia, retention of salt and water with
resultant oedema, and increased risk of thromboembolism. More
details of the unwanted effects of oral contraceptives are given on
page 455.
Used intermiuently for postmenopausal replacement therapy,
oestrogens cau~e menstruation-like bleeding. Oestrogen causes
endometrial hyperplasia unless given cyclically with a progestogen.
When administered to mal es, oestrogens result in feminisation.
Oestrogen administration to pregnant women can cause genital
abnormalities in their offspring. Carcinoma of the vagina was more
common in young women whose mothers were given stilbestrol
in early pregnancy in a misguided attempt to prevent miscarriage
(see Ch. 53).
Clinical use
Clinical uses of oestrogens arc given in the box on page 448.
In addition, see the section below {pp. 450-451) on postmenopausal
hormone replacement therapy (HRT).
OESTROGEN RECEPTOR MODULATOR
Raloiliene, a selective oestrogen receptor modulator', has anti-
oestrogenic effects on breast and uterus but oestrogenic effects
on bone. lipid metabolism and blood coagulation. It is used
for prevention and treatment of postmenopausal osteoporosis
(Ch. 3 1, p. 467) and reduces the incidence of oestrogen
receptor-positive breast cancer, although its role in therapy of
breast cancer is undefined. Unlike oestrogen, it does not prevent
menopausal flushes.
ANTIOESTROGENS
Antioestrogens compete with natural oestrogens for receptors in
target organs. Tamoxifen has antiocstrogenic action on mammary
tissue but oestrogenic actions on plasma lipids, endometrium and
bone. Tt produces mild oestrogen-like adverse effects consistent
with partial agonist activity. The tamoxifen-oestrogen receptor
complex does not readily dissociate, so there is interference with
the recycling of receptors.
Tamoxifen up-regulates transforming growth factor-~, decreased
function of which is a'>sociated with the progression of malig-
nancy, and which has a role in controlling the balance between
bone-producing osteoblasts and bone-resorbing osteocla~ts (Ch. 31 ).
Tamoxifen is discussed further in Chapter 51.
Clomiphene inhibits oestrogen binding in the anterior pituitary,
so preventing the normal modulation by negative feedback and
causing increased secretion of GnRH and gonadotrophins. This
results in a marked stimulation and enlargement of the ovaries
and increased oestrogen secretion. The main effect of their
antioestrogen acti on in th e pituitary is that they induce ovulation.
It is used in treating infertility caused by lack of ovulation. Twins
are common, but multiple pregnancy is unusual.
THE REPRODUCTIVE SYSTEM
PROGESTOGENS
The natural progestational hormone (progestogen) is progesterone
(see Figs 30.2 and 30.3). This is secreted by the corpus luteum in
the second part of the menstrual cycle. and by the placenta during
pregnancy. Small amounts are also secreted by testis and adrenal
cortex.
Mechanism of action
Progestogens act, as do other steroid hormones, on nuclear
receptors. The density of progesterone receptors is controlled by
oestrogens (see above).
Preparations
There arc two main groups of progestogens.
The naturally occurring hom10ne and its derivatives (e.g.
hydroxyprogester onc. mcdr oxyprogesterone,
dyhydrogester one). Progesterone itself is virtually inactive
orall y, because after absorption it is metabolised in the liver,
and hepati c extraction is nearly complete. Other preparations
arc available for oral administration, intramuscular injection,
or administration via the vagina or rectum.
Oestrogen and antloeatrogena
The endogenous oestrogens are oestradiol
(the most potent), oestrone and oestriol; there are
numerous exogenous synthetic forms (e.g.
ethinylestradiol).
M echanism of action involves interaction with nuclear
receptors (termed ERa or ERt3) in target tissues,
resulting in modification of gene transcription.
Their pharmacological effects depend on the sexual
maturity of the recipient:
before puberty, they stimulate development of
secondary sexual characteristics
given cyclically in the female adult, they induce an
artificial menstrual cycle and are used for
contraception
given at or after the menopause, they prevent
menopausal symptoms and protect against
osteoporosis, but increase thromboembolism.
Antioestrogens are competitive antagonists or partial
agonists. Tamoxifen is used in oestrogen-dependent
breast cancer. Clomiphene induces ovulation by
inhibiting the negative feedback effects on the
hypothalamus and anterior pituitary.
Selective drugs that are oestrogen agonists in some
tissues but antagonists in others are being
developed. Raloxifene (one such drug) is used to
treat and prevent osteoporosis.
449
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
Testosterone derivatives (e.g. norethisterone, norgestrel and
ethynodiol) can be given orally. The first two have some
androgenic activity and are metabolised to give oestrogenic
product~. Newer proge~togens used in contraception include
desogestrel and gestod ene; they may have less adver~e
effect~ on lipid~ than ethynodiol and may be considered for
women who experience side effects such as acne. depression
or breakthrough bleeding with the older drugs. However,
these newer drug~ have been associated with higher risks of
venous thromboembolic disease (see below).
Actions
The pharmacological actions of the progestogens are in essence
the same as the physiological actions of progesterone described
above. Specific effects relevant to contraception are detailed
on pages 454-456.
Pharmacokinetic aspects
Injected progesterone is bound to albumin, not to the sex
steroid binding globulin. Some is stored in adipose tissue. Tt is
metaboli~ed in the liver. and the products, pregnanolone and
pregnanediol, are conjugated with glucuronic acid and excreted
in the urine.
Unwanted eHects
Unwanted effects of progeMogens include weak androgenic action'>.
Other unwanted efTecL<; include acne, fluid retention, weight
change. depre\'>ion. change in Libido. breast discomfort. premen-
strual ~oymptom~. irregular menstrual cycles and breakthrough
bleeding. There is an increased incidence of thromboembolism.
Clinical use
Clinical u~es are <,ummarised in the box on this page.
Progeatogena and antlprogestogens
The endogenous hormone is progesterone.
Examples of synthetic drugs are the progesterone
derivative medroxyprogesterone and the
testosterone derivative norethist erone.
Mechanism of action involves intracellular
receptor/altered gene expression, as for other steroid
hormones. Oestrogen stimulates synthesis of
progesterone receptors, whereas progesterone
inhibits synthesis of oestrogen receptors.
Main therapeutic uses are in oral contraception and
oestrogen replacement regimens, and to treat
endometriosis.
The antiprogestogen mifepristone, in combination
with prostaglandin analogues, is an effective medical
_____
-, 450
alternative to surgical termination of early pregnancy.
Clinical use of progestogens
and antlprogestogens
Progestogens
Contraception:
with oestrogen in combined oral contraceptive pill
as progesterone-only contraceptive pill
as injectable or implantable progesterone-only
contraception
as part of an intrauterine contraceptive system.
Combined with oestrogen for oestrogen replacement
therapy in women with an intact uterus, to prevent
endometrial hyperplasia and carcinoma.
For endometriosis.
In endometrial carcinoma; use in breast and renal
cancer has declined.
Poorly validated uses have included various
menstrual disorders.
Antiprogestogens
Medical termination of pregnancy: mifepristone
(partial agonist) combined with a prostaglandin
(e.g. gemeprost).
ANTIPROGESTOGENS
M ifcpristone i\ a partial agonist at progesterone receptor<;. It
sen~iti\es the uterus to the action of prostaglandins. It is gi\'cn
orally and has a pla..ma half-life of2l hours. Mi fepri~tone is used,
in combination with a prostaglandin (e.g. gemeprost: see below).
as a medical alternative to surgical termination of pregnancy (see
cl inical box).
POSTMENOPAUSAL HORMONE
REPLACEMENT THERAPY
At the menopause, whether natural or surgically induced, ovarian
function decreases and oestrogen levels fall. There is a long his-
tory of disagreement regarding the pros and cons of hormone
replacement therapy ( HRT) in this context. with the prevailing
wisdom undergoing several revisions over the years (see Davi~ et
al., 2005). Short-term HRT has some clear-cut benefits:
improvement of \ymptoms caused by reduced oestrogen, for
example hot flushes and 'aginal dryness
prevention and treatment of osteoporosis, but other drugs arc
often preferable for this (Ch. 31).
Oe~Lrogen replacement does not reduce the risk of coronary heart
disease. despite earlier hope~. nor is there evidence that it reduce\
age-related decline in cognitive function (indeed. some trials sugge.,t
the reverse). Drawbacks include:
cyclical withdrawal bleeding
adverse effects related to progestogen (see above)
increa!>ed risk of endometrial cancer if oestrogen is given
unopposed by progestogen

increa,ed ri\1.. of brea!.t cancer, related to the duration of HRT
use and di,appearing within 5 years of stopping; in women
using combined HRT for 5 years, brea~t cancer is diagnosed
m about 4 e\tra ca'e' 111 1000 (British Medical Association
and Ro>al Pharmaceutical Society of Great Britain, 2005)
increased ri\k of venou' thromboembolism (risk approximately
doubled in \~omen U!>ing combined HRT for 5 years).
ONmgen' used in HRT can be given orally (conjugated estrogens,
~'tradiol, estriol), vaginally (estriol). by transdem1al patch
(Nradiol) or by ~ub<.:utancou!> implant (estradiol). T ibolon e is
marketed for the short-term treatment of symptoms of oestrogen
deficiency. It has oe~trogenic. progestogenic and weak androgenic
activity, and can be used continuously without cyclical progester-
one (avoiding the inconvenience of withdrawal bleeding).
NEUROHORMONAL CONTROL OF THE
MALE REPRODUCTIVE SYSTEM
A~ in the female, endocrine secretions from the hypothalamus,
anterior pituitary and gonads control the male reproductive system.
A ~implificd outline of the inter-relationship of these factors is
ghen in Figure 30.4. GnRH controls the secretion of gonado-
trophms by the anterior pituitary. This secretion is not cyclical as
10 rnen ... tmating women; in both l>exes, it is pulsatile ( ee below).
FSH 1s re ... pon\ible for the integrity of the seminiferous tubules.
and after pubcrt) i'> important in gametogenesis through an action
Gypothala~ - - - - ---....
I subMance. Dehydroepiandrosterone and androstenedione are
~ important intermediatel>. They are released from the gonads and
GnRH
cr
Sertoli
cell
Gametogenesis
mthe
seminiferous
tubules Dihydrotestosterone
/i-~
Secondary sex organs
Fig. 30. 4 Hormonal control of the male reproductive
system. FSH, follicle-stimulating hormone; GnRH,
gonadotrophin-releasing hormone; ICSH, interstitial
cell-stimulating hormone.
THE REPRODUCTIVE SYSTEM
on Sertoli cells, which nourish and support developing spermatozoa.
L H, which in the male i\ abo called interstitial cell-stimulating
hormone ([CSH), \timulates the interstitial cells (Leydig cells) to
secrete androgenl> in particular testosterone. LH/ICSH secretion
begin\ at puberty, and the consequent secretion of testosterone
causes maturation of the reproductive organs and development of
secondary sexual characteri!>tics. Thereafter. the primary function
of te<;tosterone is the maintenance of spermatogenesis and hence
fertility-an action mediated by Sertoli cells. Testosterone is also
important in the maturation of spermatozoa as they pass through
the epididymis and vas deferens. A further action is a feedback
effect on the anterior pituitary. modulating its sensitivity to
GnRII and thus influencing secretion of LH/ICSH. Testosterone
has marked anabo lic effects, causing development of the muscu-
lature and increased bone growth, resulting in a rapid increase in
height (the pubertal grow th spurt) at puberty, followed by closure
of the epiphyses of the long bones.
Secretion of testosterone is mainly controlled by LHIICSH,
but FSH also plays a part, possibly by releasing a factor similar
to GnRH from the Sertoli cells (which are its primary target). The
interstitial cel l ~ that synthesise testosterone also have receptors
for prolactin, which may influence testosterone production by
increasing the number of receptors for LHIICSH.
ANDROGENS
Testosterone is the main natural androgen. It is synthesised mainly
by the interstitial celb of the testb. and in smaller amounts by the
ovarie\ and adrenal cortex. Adrenal production of androgens is
under the control of adrenocorticotrophic hormone (cortico-
trophin). As for other steroid hormones, cholesterol is the starting
the adrenal cortex. and converted to testosterone in the liver
(see Fig. 30.3).
Actions
In general, the effects of exogenous androgens are the same as
those of testosterone, and depend on the age and sex of the
recipient. If administered to boys at the age of puberty, there is
rapid development of secondary sexual characteristics, maturation
of the reproductive organs and a marked increase in muscular
~trength. Height increases more gradually. The anabolic effects
can be accompanied by retention of salt and water. The skin
thicken\ and may darken, and sebaceous glands become more
active (which can re!>ult in acne). There is growth of hair on the
face and on pubic and axillar) regions. The vocal cords hyper-
trophy, resulting in a lower pitch to the voice. Androgens cause
a feeling of well-being and an increase in physical vigour, and
may increase libido. Whether they are responsible for sexual
behaviour as s uch is controversial. as is their contribution to
aggressive behaviour.
If given to prepubertal males, the individuals concerned do not
reach their full predicted height because of premature closure of
the epiphyses of the long bones.
Administration of 'male' doses to women results in masculin-
isation, but lower doses (e.g. 300 1.1.g/day testosterone patches) 451
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
re~tore plasma testosterone to normal female concentrations
and improve sexual dysfunction in women following ovari-
ectomy, without adverse effects (Shifren eta!., 2000; Braunstein
et al.. 2005).
Mechanism of action
In most target cells, testo terone works through an active meta-
bolite. dihydrotestosremne. to which it is converted locally by a
Sa-reductase enzyme. In contrast, testosterone itself causes viri-
lisation of the genital tract in the male embryo and regulates
LH/lCSH production in anterior pituitary cells. Testosterone and
dihydrotestosterone modify gene transcription by interacting
with intracellular receptors.
Preparations
Testosterone itself can be given by subcutaneous implantation or
by transdermal patches. Various esters (e.g. enanthatc and pro-
prionate) are given by intramuscular depot injection. Testosterone
undecanoate and mesterolone can be given orally.
Pharmacokinetic aspects
If given orally, testosterone is rapidl y metabolised in the liver. H
is therefore usually injected. Virtually all testosterone in th.e
circulation is bound to plasma protein-mainly to the sex steroid-
binding globulin. The elimination half-life of free testosterone is
short (I 0-20 minutes). It is inactivated in the liver by conversion
to androstenedione (sec Fig. 30.3). This has weak androgenic
activity in its own right and can be reconverted to testosterone,
although approximately 90% of testosterone is eliminated as
metabolites rather than the parent compound. Synthetic androgens
are less rapidly metabolised, and some are excreted in the urine
unchanged.
Unwanted eHects
Unwanted effects of androgens include eventual decrease of
gonadotrophin release, with resultant infertility, and salt and
water retention leading to oedema. Adenocarcinoma of the
liver has been reported. Androgens impair growth in children
(via premature fusion of epiphyses), cause acne. and lead to
masculinisation in girls. Adverse effects of testosterone replace-
ment and monitoring for these are reviewed by Rhoden &
Morgentaler (2004).
Clinical use
The clinical use of androgens is given in the box.
ANABOLIC STEROIDS
Androgens can be modified chemically to alter the balance of
anabolic and other effects. Such anabolic steroids' (e.g. nandro-
lonc) increase protein synthesis and muscle development, but
clinical use (e.g. in debilitating disease) has been disappointing.
They are used in the therapy of aplastic anaemia, and (notori-
ously) abused by some athletes. Unwanted effects are described
above. under Androgens. In addition, cholestatic jaundice. liver
tumours and increased ri. k of coronary heart disease are recog-
452 nised adverse effects of high-dose anabolic steroids.
Androgens and the hormonal control of
the male reproductive system
Gonadotrophin-releasing hormone from the
hypothalamus acts on the ant erior pituitary to release
both follicle-stimu lating hormone, which stimulates
gametogenesis, and luteinising hormone (also called
interstitial cell-stimulating hormone), which stimulates
androgen secretion.
The endogenous hormone is testosterone;
intramuscular depot injections of testosterone esters
are used for replacement therapy.
Mechanism of action is via intracellular receptors.
Effects depend on age/sex, and include development
of male secondary sexual characteristics in
prepubertal boys and masculinisation in women.
Clinical use of androgens and
antlandrogens
Androgens (t estosterone preparations) as hormone
replacement in:
male hypogonadism due to pituitary or testicular
disease (e.g. 2.5 mg/day patches)
hyposexuality following ovariectomy (e.g.
300 J..Lg/day patches).
Antiandrogens (e.g. flutamide, cyproterone) are used
as part of the treatment of prostatic cancer.
5a.-Reductase inhibitors (e.g. finast eride} are used in
benign prostatic hypertrophy.
ANTIANDROGENS
Both oestrogens and progestogens have antiandrogen activity.
oestrogens mainly by inhibiting gonadotrophin secretion and
progestogens by competing with androgens in target organs.
Cyproterone is a derivative of progesterone and has weak pro-
gestational activity. It is a partial agonist at androgen receptors,
competing with dihydrotestosterone for receptors in androgen-
sensitive target tissue~. Through its effect in the hypothalamus. it
depresses the synthesis of gonadotrophins. It is used as an adjunct
in the treatment of prostatic cancer during initiation of GnRH
treatment (see below). It is also used in the therapy of precocious
puberty in males. and of masculinisation and acne in women. It
also has a central nervous system effect, decreasing libido, and
has been used to treat hypersexuality in male sexual offenders.2
2
As with the oestrogen~. very different doses are u~d for these differem
condition\. for example 2 mg/day for acne, I 00 mglday for hypersexual it),
and 300 mglday for prostatic cancer.
 THE REPRO DUCTIVE SYSTEM

Fluta mide is a non-steroidal antiandrogcn used with GnRH in
the treatment of prostate cancer.
Drugs can have antiandrogen action by inhibiting synthetic
enzymes. Finas tcridc inhibits the enzyme (Sa-reductase) lhat
con\crts testosterone to dihydrotestosterone (Fig. 30.3), which
h;h greater affinity than testosterone for androgen receptors in
the prostate gland. Finasteride is well absorbed after oral admin-
istration, has a half-life of about 7 hours, and is excreted in the
urine and faeces. ll is used to treat benign prostatic hyperplasia,
although a 1-adrenoceptor antagonists. ter azosin or tamsulosin
(Ch. II, p. 179), are more effective (working by the entirely
different mechanism of relaxing smooth muscle in the capsule of
the prostate gland). Surgery is the preferred option (especially
by 'urgcons).
GONADOTROPHIN-RELEASING HORMONE:
AGONISTS AND ANTAGONISTS
Gonadotrophin-releasing hormone (GnRH) is a decapeptide lhat
controb the secretion of FSH and LH by the anterior pituitary.
Secretion of GnRH is controlled by neural input from other parts
of the brain. and through negative feedback by the sex steroids
(Fig~ 30.1 and 30.5). Exogenous androgens. OCf>trogens and pro-
gc\togcns all inhibit GnRH secretion, but only progestogens exert
this effect at doses that do not have marked hormonal actions on
peripheral tissues. presumably because progesterone receptors in
the reproductive tract are sparse unless they have been induced
by previous exposure to oestrogen. Danazol (sec below) is a syn-
thetic steroid that inhibits release of GnRH and, consequently, of
gonadotrophins (FSH and LH). Clomiphene is an oestrogen
antagoni~t that stimulates gonadotrophin release by inhibiting the
negati\e feedback effects of endogenous oestrogen; it is used to
treat infertility (see above and Pig. 30.5).
(
GnRH
agonists
Hypothalamus
Synthetic GnRH is termed gonadorelin. Numerous analogues
of GnRH, both agonists and antagonists, have been synthesised.
Buserelin, leuprorelin, goserelin and nafarelin are agonists, lhe
last being 200 times more potent than endogenous GnRH.
Pharmacokinetics and clinical use
Gonadotrophin-releasing hormone agonists, given by subcuta-
neous infusion in pulses to mimic physiological secretion of
GnRH, stimulate gonadotrophin release (Pig. 30.5) and induce
ovulation. They are absorbed intact following nasal admin-
iwation (Ch. 7). Continuous use, by nasal spray or as depot
preparations, Sti mulates gonadotrophi n release transiently, but
then paradoxically inhibits gonadotrophin release (Fig. 30.5)
because of down-regulation (desensitisation) of GnRH receptors
in the pituitary. GnRH analogues are given in this fashion to
cause gonadal suppression in various sex hormone-dependent
conditions, including prostate and breast cancers, endometriosis
(endometrial tissue outside the uterine cavity) and large uterine
fibroids. Continuous, non-pulsatile administration inhibits
spermatogenesis and ovulation, raising the possibility (which is
under investigation) lhat GnRH analogues could be useful as
contraceptives. GoRH agonists arc used by specialists in
inferrility treatment, not to stimulate ovulation (which is
achieved using gonadotrophin preparations) but to suppress the
pituitary before administration of FSH or HCG (sec below). It
was originally hoped that GnRH antagonists would be useful for
contraception, but this has not been reali ed.
Unwante d eHects of GnRH analogues
Unwanted effects of GnRH agonists in women, for example
flushing. vaginal dryness and bone loss, result from hypo-
oestrogenism. The initial stimulation of gonadotrophin secretion
on starting treatment can cause transient worsening of pain from
bone metastases in men with prostate cancer, so treatment is started
only after lhc patient has received an androgen receptor anta-
gonist such as flutamide (see above and Ch. 5 1).

v
I
I
I
I
I
PrR h WV\1\

I
DAN AZOL
Actions and pharmacokinetics
I GnRH Oestrogen Danazol inhibits gonadotrophin secretion (especially the mid-
Continuous
I
~
I
WV\1\
cycle surge), and consequently reduces oestrogen synthesis in the
Pulsatile ovary (Fig. 30.5). In men, it reduces androgen synthesis and

t GnAHA
spermatogenesis. It has androgenic activity. It is orally active and
metabolised in the liver.

f
Clinical uses
Ante rior pituitary Danazol is used in sex hormone~ependent conditions including
I I
endometriosis, breast dysplasia and gynaecomastia. An additional
v v specialist use is to reduce auacks of swelling in hereditary angie-
FSH LH
Clomiphene oedema (Ch. 23, p. 365).
GnRH
antagonists Cyclofenil
Unwante d e Hects
Fig. 30.5 Regulation of gonadotrophin (follicle- Unwanted effects are common, and include gastrointestinal
stimulating hormone, FSH; luteinising hormone, LH) release
disturbances, weight gain, nuid retention, dizziness, menopausal
from the anterio r pituitary. GnRHR, GnRH receptor; PrR,
progestogen receptor. ) symptoms, muscle cramps and headache. Danazol ha~ a virilising
action in females. 453
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
GONADOTROPHINS AND ANALOGUES
Gonadotrophins (FSH , LH and HCG ) are glycoprotcins produced
and secreted by the anterior pituitary (see Ch. 28) or chorion and
placenta. Large amount!. of gonadotrophins arc present in the
urine of women following the menopause, in whom oestrogen no
longer exert~ feedback inhibition on the pituitary, which con-
sequently secretes large amounts of FS H and LH. 3 The chorion
and placenta secrete HCG.
Preparations
Gonadotrophins are extracted from urine of pregnant (HCG) or
postmenopausal women (human menopausal gonadotrophin,
which contains a mixture of FSI I and L H). Recombinant FSH
(foUitrophi n) is abo available.
Pharmacokinetics and clinical use
Gonadotrophin preparations are given by injection. They are
used to treat infertility caused by lack of ovulation as a result of
hypopituitarism. or following failure of treatment with clomiphene;
they are also used by ~pecialists to induce ovulation to enable
eggs to be collected~ for in vitro fertilisation and reimplantation
into the uterine cavity in women whose infertility is caused by
mechanical obstruction of their fallopian tubes. For this use,
gonadotrophin is usually administered after endogenous secretion
of FSH and LH has been suppressed using a continuously admin-
istered GnRH agonist (see above). Gonadotrophins arc also
sometimes used in men with infertility caused by a Low sperm
count as a result of hypogonadouophic hypogonadism (a disorder
that is sometimes accompanied by lifelong anosmia, i.e. lack of
sense of smell). (Gonadotrophins do not, of course. work for
patients whose low sperm count is the result of primary testicular
failure.) HCG has been used to stimulate testosterone synthesis
in boys with delayed puberty, but tc~tosterone is w,ually preferred.
DRUGS USED FOR CONTRACEPTION
ORAL CONTRACEPTIVES
There arc two main types of oral contraceptives:
combinations of an oestrogen with a progestogen (the
combined pill)
progestogen alone (the progestogen-only pill).
The combined pill
The combined oral contraceptive pill is extremely effective, at
least in the absence of intercurrent illness and of treatment with
potentially interacting drugs (see below). The oestrogen in most
'This forms the basis for the ~tandard blood test, estimation of plasma
LHJFSH concentration\. to confirm whether a woman i~ po~tmenopau~al.
"The eggs are harYested u~ing laparo><:Op). a technique "'hereby a flexible
fibre-optic in.,trument is 1nsened under annc~tbesia juo,t belo\\ the umbilicus.
454
the ovaries inspected at the predicted time of ovulmion, and egg> retrieved.
Gonadotrophin-releasing hormone
and gonadotrophins
Gonadotrophin-releasing hormone is a decapeptide;
gonad o relin tS the synthetic form. Nafarelin is a
potent analogue.
Given in pulsatile fashion, they stimulate
gonadotrophin release; given continuously, t hey
inhibit it.
The gonadotrophins, follicle-stimulating hormone and
luteinising hormone, are glycoproteins.
Preparations of gonadotrophins (e.g. chorionic
gonadotrophin) are used to treat infertility caused by
lack of ovulation.
Danazo l is a modified progestogen that inhibits
gonadotrophin production by an action on the
hypothalamus and anterior pit uitary.
combined preparation!> (second-generation pills) 5 is ethi nylcstra-
diol , although a few preparations contain mestranol instead. The
progestogen may be norethister one, levonorgestrel , ethynodjol ,
or- in ' third-generation' pills-desogest r el or gestodene, which
are more potent, have less androgenic action and cause less change
in lipoprotein metabolism, but which probably cause a greater
ri sk of thromboembolism than do second-generation preparations.
The oestrogen content is generally 20-50 lAg of ethinylcslradiol
or it'> equivalent, and a preparation is choo,en with the lowest
oestrogen and progestogen content that ic, well tolerated and
gives good cycle control in the individual woman. This combined
pil l is taken for 2 1 consecutive days followed by 7 pill- free days,
which causes a wi thdrawal bleed. Nonnal cycles of menstruation
u!.ually commence fairly soon after discontinuing treatment. and
permanent loss of fertility (which may be a res~lt of early meno-
pause rather than a long-term consequence of the contraceptive
pill) is rare.
The mode of action is as follows:
oestrogen inhibits secretion of FSH via negati ve feedback on
the anterior pituitary. and thu~ suppresses development of the
ovarian follicle
progestogen inhibits secretion of LH and thus prevents
ovulation; it also makes the cervical mucus less suitable for
the passage of sperm
oestrogen and progestogen act in concert to alter the
endometrium in such a way a~ to discourage implantation.
They may also interfere with the coordinated contractions of
cervix, uterus and fallopian tubes that facilitate fertilisation and
implantation.
~e first-generation pll~. containing more than 50 IA8 of oestrogen. Y.ere
shown in the 1970, to be as~ociated with an increu-.cd risk of deep vein
thrombo~is and pulmonary embolism.

Potential unwanted and beneficial effects of
the combined pill
More than 200 million women worldwide have used this method
\ince the 1960~. and in general the combined pill con1.titutes a
,afe and effective method of contraception. There are distinct health
benefit<; from taking the pill (see below). and serious adver.,e efTects
are rare. Howe\er. minor unwanted efTect!> constitute drawbac(..s
to it~ use. and several important que~tions need to be considered.
Common adverse effects
The common effects are:
weight gain. O\'ving to Ouid retention or an anabolic effect. or
both
mild nausea. nushing. dizziness, depression or irritability
~kin changes (e.g. acne and/or an increase in pigmentation)
amenorrhoea of variable duration on cessation of taking the pill.
Questions that need to be considered
Is there a11 i11creased risk of cardiovascular disease (venous
thromboembolism, myocardial infarctio n, stroke)? With
'econd-generation pills (oestrogen content less than 50 ~lg). the
risk of thromboembolism is small (incidence approximately I 5 per
100 000 users per year. compared with 5 per I00 000 non-pregnant
non-users per year or 60 per 100 000 pregnancies). The risk is
greateM in subgroups with additional factors, such as smoking
(which increases ric;k substantially) and long-continued use of
the pill. especially in women over 35 years of age. For prepara-
tion' containing the third-generation progestogens desogestrel or
gestodene. the incidence of thromboembolic disease is approxi-
mately 25 per I00 000 users per year, which is still a small absol-
ute risk that b substantially less than that caused by a pregnancy.
In general. as ~tated by Baird & Glasier ( 1993). 'the evidence
'uggests that after risk factors (e.g. smoking, hypertension. and
obesity) have been identified. combined oral contraceptive~ arc
,afe for most women for most of their reproductive lives.
Is there an increase in the risk of cancer ? One large epi-
demiologicall'.tudy suggests that there may be a duration-related
increase in the risk of breast cancer, the risk being 0.5 excc1.s
cancers per 10000 women aged lt'rl 9. and 4.7 excess cancer\ per
10000 women at age 25- 29. The cancers were less advanced in
pill users. and thu!> potentially more treatable (see Hemrninki, 1996).
Does the pill increase blood pressure? A marked increase in
arterial blood pressure occurs in a small percentage of women
~hortly after starting the combined oral contraceptive pill. This is
a>sociated with increased circulating angiotensinogcn. and dis-
appears when treatment is stopped. Blood pressure is therefore
monitored carefully when oral contraceptive treatment is started.
and an alternative method substituted if necessary.
Is there an impainnent in glucose tolerance? Older progestogen
preparations impaired glucose tolerance, but this is not a problem
with the newer compounds.
Beneficial effects
The combined pill markedly decreases men!>trual symptom~ o,uch
a\ irregular periods and intermenstrual bleeding. Iron deficiency
anaemia and premenstrual tension are reduced, as are benign
breast disease. uterine libroids and functional cysts of the ovaries.
THE REPRODUCTIVE SYSTEM
Unwan ted pregnancy. carrying a maternal mortality ranging from
I in I 0 000 in developed countries to I in 150 in Africa, is avoided.
The progestogen-only pill
The drugs used in progestogen-only pills include norethis tcrone,
levonorgcstrel or eth ynodiol. The pill is taken daily without
interruption. The mode of action is primarily on the cervical
mucus. which is made inhospitable to sperm. The progestogen
probably also hinders implantation through its effect on the
endometrium and on the motility and secretions of the fallopian
tubes (sec above).
Potential beneficial and unwanted effects of the
progestogen-only pill
Progestogen-only contraceptive'> offer a suitable alternative to
the combined pill for some women in whom oestrogen i'> contra-
indicated. and are suitable for women whose blood pressure
increases unacceptably during treatment with oestrogen. However,
their contraceptive effect is less reliable than that of the combina-
tion pill, and mi\sing a dose may result in conception. Di'>turb-
ances of menstruation (especially irregular bleedjng) are common.
Only a small proportion of women usc this form of contraception.
so long-term safety data are less reliable than for the combined pill.
Pharmacokinetics of oral contraceptives: drug
interactions
Combined and progestogen-only oml contraceptives are metab-
olised by hepatic cytochrome P450 enzymes. Because the mini-
mum effective dose of oestrogen is used (in order to avoid excess
risk of thromboembolism), any increase in its clearance may
result in contraceptive failure. and indeed enzyme-inducing
drugs can have this effect not only for combined but also for
progesterone-only pills. Such drugs include (par excellence)
rifampicin and rifa butin. as well as carbamazepine, phenytoin,
griseoful vi n and others. Enterohepatic recycling of oewogen is
mentioned above (p. 448). Broad-spectrum antibiotics such as
amoxicillin can disturb this by altering the intestinal nora, and
cause failure of the combined pi ll. This does not occur with
progesterone-only pills.
OTHER DRUG REGIMENS USED FOR
CONTRACEPTION
POSTCOITAL (EMERGENCY) CONTRACEPTION
Oral admini!>lration of levooorgestrcl, alone or combined with
oestrogen. is effective if taken within 72 hours of unprotected
intercourse. repeated 12 hours later. Nausea and vomiting are
common (and the pills may then be lost: replacement tablets can
be taken with an antiemetic such as domperidone). Insertion of
an intrauterine device is more effective than hormonal methods,
and work& up to 5 days after intercourse.
LONG-ACTING PROGESTOGEN-ONLY
CONTRACEPTION
Medroxyprogesterone can be given intramuscularly as a contra-
ceptive. This is effective and safe. However, menstmal irregularities 455
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
Or11l contraceptives
The combined pill
The combined pill contains an oestrogen and a
progestogen. It IS taken for 21 consecutive days out
of 28.
Mode of action: the oestrogen inhibits follicle-
stimulating hormone release and therefore follicle
development; the progestogen inhibits luteinising
hormone release and therefore ovulation, and makes
cervical mucus inhospitable for sperm; together, they
render the endometrium unsuitable for implantation.
Drawbacks: weight gain, nausea, mood changes and
skin pigmentation can occur.
Serious unwanted effects are rare. A small proportion
of women develop reversible hypertension; there is
evidence both for and against an increased risk of
breast cancer. There is a small increased risk of
thromboembolism with third-generation pills.
There are several beneficial effects, not least the
avoidance of unwanted pregnancy, which itself
carries risks to health.
The progestogen-only pill
The progestogen-only pill is taken continuously. It
differs from the combined pill in that the
contraceptive effect is less reliable and is mainly a
result of the alteration of cervical mucus. Irregular
bleeding is common.
are common, and infertility may persist for many months after
cessation of treatment.
Levonorgestrel implanted subcutaneously in non-biodegradable
capsu les is used by approximately 3 million women worldwide.
This route of administration bypasses the liver, thus avoidi ng
first-pass metabolism. The tubes release their progestogen content
slowly over 5 years. Irregular bleeding and headache are common.
A levonorgestrel-impregnated intrauterine device has contra-
ceptive action for 3- 5 years.
THE UTERUS
The physiological and pharmacological responses of the uterus
vary at different stages of the menstrual cycle and during pregnancy.
THE MOTILITY OF THE UTERUS
Uterine muscle contracts rhythmically both in vitro and in vivo,
the contractions originating in the muscle itself. Myometrial cells
in the fundus act as pacemakers and give rise to conducted action
pote ntials. The elcctrophysiological activity of these pacemaker
456 cells is regulated by the sex hormones.
The non-pregnant human uterus contracts spontaneously but
weakly during the first part of the cycle, and more strongly during
the luteal phase and during menstruation. Uteri ne movements are
depressed in early pregnancy because oe trogen, potentiated b}
progesterone, hyperpolarises myometrial cells. This supprc\'>C\
~pontaneous contractions. Towards the end of gestation, howe' er.
contractions recommence; these increase in force and frequenC).
and become fully coordinated during parturition. The nene
supply to the uterus includes both excitatory and inhibitOr}
sympathetic components: adrenaline, acting on 1:\2-adrenoceptor<;,
inhibits uterine contraction, whereas noradrenaline, acting on Ct
ad renoceptor~. stimulates contraction.
DRUGS THAT STIMULATE THE UTERUS
Drugs that stimulate the pregnant uterus and are imponant in
obstetrics include oxytocin, ergometrine and prosmglandins.
OXYTOCIN
As explained in Chapter 28, the neurohypophyseal hormone
oxytocin (an octapeptide) regulates myometrial activity. Oxytocin
release is stimulated by cervical dilatation, and by suckling, but
its role in parturition is incompletely understood. Oxytocin for
clinical u e is prepared synthetically.
Actions
On the uterus. Oxytocin contracts the uterus. Oestrogen induce~
oxytocin receptor synthesis and, consequently, the uterus a1 term
i~ highly . ensitive to this hormone. Given by slow inrravcnOU\
infusion to induce labour, oxytocin causes regular coordinated
contractionl> that travel from fundus to cervix. Both amplitude
and frequency of these contractions are related to dose, the uterus
relaxing completely between contractions during low-dose
infusion. Larger doses further increase the frequency of the con-
tractions, and the re is incomplete relaxation between them. Still
higher doses cause sustained contractions that interfere with
blood !low through the placenta and cause fetal distress or death.
Other actions.6 Oxytocin contracts myoepithelial cells in the
mammary gland, which causes ' milk let-down'-the expression
of milk from the alveoli and ducts. It also has a vasodilator action.
A weak antidiuretic action can result in water retention, which
can be problematic in patients with cardiac or renal disea!>e, or
preeclampsia.7
Clinical use
The clinical use of oxytocin is given in the box on page 457.
60xyrocin receptor~ are found not only in the uterus but also in the brain,
panicul arly in the limbic system. Animal experiments have shown that
oxytocin is important in mating and parenting behaviottr.
7
Eclam p~ i a i~ a pathological condi tion (invol ving. among other things, high
blood pressure, swelling and seizures) that occurs in pregnant women.

Clinical uses of drugs acting on
the uterus
Myometrial stimulants (oxytocics)
Oxytocin is used to induce or augment labour when
the uterine muscle is not functioning adequately. It
can also be used to treat postpartum haemorrhage.
Ergometrine can be used to treat postpartum
haemorrhage. Carbopro st can be used if patients do
not respond to ergometrine.
A preparation containing both oxytocin and
ergometrine is used for the management of the third
stage of labour; the two agents together can also be
used, prior to surgery, to control bleeding due to
incomplete abortion.
Dinoprostone given by the extra-amniotic route is
used for late (second trimester) therapeutic abortion;
given as vaginal gel, it is used for cervical ripening
and tnduction of labour.
Gemeprost, given as vaginal pessary following
mifepristone, is used as a medical alternative to
surgical termination of pregnancy (up to 63 days of
gestation).
Myometrial relaxant s
The ~-adrenoceptor agonists (e.g. rito drine) are used
to delay preterm labour.
Atosiban (oxytocin antagonist) also delays preterm
labour.
Pharmacokinetic aspects
Oxytocin can be given by int:ravenous injection or intramuscularly,
but is moM often given by intravenous infusion. It is inacti vated
in the tiver and kidneys, and by c irculating placental oxytocinase.
Unwanted eHects of oxytocin
Lnwaotcd effects of oxytocin include dose-re lated hypotension
(arising from its vasodilator actio n). with a~sociated reflex tachy-
cardia. Its antidiuretic hormone-like effect o n water excretion by
the kidney causes water re tention and. unless water intake is
curtailed. consequent hyponatraemia.
ERGOMETRINE
Ergot (Claviceps purpurea) is a fungus that grows o n rye a nd
contains a surprising variety of pharmacologically active sub-
~tances (sec Ch. 12). Ergot poisoning, which was once common,
was oflen associated wi th abortion. In 1935, ergometrine was
isolated and was recog nised as the oxytocic princ iple in ergot.
Actions
Ergometrine contracts the human uterus. This action depends
partly on the contractile state of the o rgan. On a contracted uterus
(the normal state following de livery), ergometrine has re lati vely
THE REPRODUCTIVE SYSTEM
little e ffect. However, if the uterus is inappropriate ly relaxed,
ergometri ne initiates strong contraction, thus reducing bleeding
from the placental bed (the raw surface from which the placenta
has detached). Ergometrine also has a moderate degree of vaso-
con~trictor actio n per se.
The mechanis m of actio n of ergometri ne on smooth muscle is
not understood. lt is possible that it acts partly on a adrcnoceptors,
like the related alkaloid ergotamine (see Ch. 9), and partly on
5-hydroxytryptamine receptors.
The clinical use of ergometrine is given in the box o n this page.
Pharmacokinetic aspects and unwanted
eHects
Ergometrine can be given orally, intramuscularly or intravenously.
It has a very rapid onset of action and its effect lasts for 3-6 hours.
Ergo me trine can produce vomiting, probably by an effect on
dopamine D 2 recepto rs in the c he moreceptor trigger zone (see
Fig. 25.5). Vasoconstriction with an increase in blood pressure
associated with nausea, blurred vision and headache can occur,
as can vasospasm of the coronary arteries, resulting in angina.
PROSTAGLANDINS
Endogenous prostaglandins
Prostaglandins are discussed in detail in Chapter 13. The endo-
me trium and myo metrium ha ve subs ta ntial prostagla ndi n-
synthesil)ing capac ity, particularly in the second, proliferati ve phase
of the menstrual cycle. Prostaglandi n (PG) F2( l is generated in
large amou nts. and has been implicated in the ischaemic necrosis
of the endometrium that precedes men~tru ation (although it has
relatively linle vasoconstrictor action on many human blood vessels,
in contras t to some other mammalian species). Vasodi lator
prostaglandins, PG~ and PG12 (prostacyclin), are also gene rated
by the uterus.
In addition to their vasoactive properties, the E and F
prostagla ndins contract the non-pregnant as well as the pregnant
uterus. The sensitivity of uterine muscle to prostaglandins increases
during gestation. Their ro le in partu rition is not fully understood,
but al> cyclo-oxygenase inhibitors can delay labour (see below),
they probably play some part in this.
Prostaglandins a lso play a part in two of the main disorders of
menstruation: dysmenorrh oea (painful menstruatio n) and menor-
rhagia (excessive blood loss). Dysmenorrhoea is associated with
increal)ed production of PG~ and PGF2(l: non-steroidal anli-
inftammatory dmgs, which inhibit prostaglandin biosynthesis
(see C h. 14), are used to treat dysmenorrhoea. Menorrhagia. in
the absence of uterine patho logy, may be caused by a combina-
tion of increased vasodilatation and reduced haemostasis. Increased
generation by the uterus of PGI 2 (which inhibits platelet aggre-
gation) could impair haemostasis as well as causing vasodila-
tation. Non-steroidal anti-inflammatory d rugs (e.g. mefenamic
acid ) are used to treat menorrhagia as well as dysmenorrhoea.
Prostaglandin preparations
Prostaglandins of the E and F series pro mote coordinated con-
tractions of the body of the pregnant uterus, while relaxing the
cervix. E and F prostaglandins reliably cause abortion in earl y and 457
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
middle pregnancy, unlike oxytocin. which generally docs not cause
expulsion of the uterine contents at this stage. The prostaglandins
used in obstetrics are dinoprostone (PG~. carboprost ( 15-methyl
PGF2...) and gemeprost or misoprostol (PGE1 analogues). Dino-
prostone can be given intravaginally as a gel or as tablets, or by
the extra-amniotic route as a solution. Carboprost is given by deep
intramuscular injection. Gemeprost or misoprostol arc given
intravaginaUy.
Unwanted effects
Unwanted effecL<; include uterine pain. nausea and vomiting. which
occur in about 50% of patients when the drugs arc used as aborti-
facients. Dinoprost may cause cardiovascular collapse if it escapes
into the circulation after intra-amniotic injection. Phlebitis can
occur at the site of intravcnou~o. infusion. When combined with
mifepristone, a progestogen antagonist (see p. 450) that sensitises
the uterus to prostaglandins, lower doses of the prostaglandins
(e.g. misoprostol) can be used to terminate pregnancy and side
effects are reduced.
Clinical use
The clinical use of pro!>taglandin analogues is given on page 457.
DRUGS THAT INHIBIT UTERINE
CONTRACTION
Selective ~2 -adrcnoceptor agonists, such as ritodrine or salbu-
tamol. inhibit spontaneous or oxytocin-induced contractions of
the pregnant uterus. These uterine relaxants are used in <;elected
patients to prevent premature labour occurring between 22 and
33 weeks of gestation in otherwise uncomplicated pregnancie!i.
They can delay delivery by 48 hours. time that can be u ed to
administer glucocorticoid therapy to the mother so a!> to mature
the lungs of the baby and reduce neonatal respiratory distress.
and to optimise logistics such as making sure the baby is born in
a facility wi th neonatal intensive care. It has been difficult to
Drugs acting on the uterus
At parturition, oxytocin causes regular
coordinated uterine contractions, each followed by
relaxation; ergometrine, an ergot alkaloid, causes
uterine contractions with an increase in basal tone.
Atosiban, an antagonist of oxytocin, delays labour.
Prostaglandin (PG) analogues, for example
dinoprostone (PGE2) and dinoprost (PGF2,J, contract
the pregnant uterus but relax the cervix. Cyclo-
oxygenase inhibitors inhibit PG synthesis and delay
labour. They also alleviate symptoms of
dysmenorrhoea and menorrhagia.
The ~2-adrenoceptor agonists (e.g. ritodrine) inhibit
spontaneous and oxytocin-induced contractions of
the pregnant uterus.
458
demonstrate that any of the drugs used ro delay labour improve
the outcome for the baby. Risk!. to the mother, especially pulmonaJ)
oedema. increase after 48 hours, and myometrial response is
reduced, so prolonged treatment is avoided. Cyclo-oxygenase
inhibitors (e.g. indometacio) inhibit labour, but their use could
cause problems in the baby, including renal dysfunction and
delayed closure of the ductus arteriosus, both of which arc
innuenced by endogenous prostaglandins.
An oxytocin receptor antagonist. atosiban, provides an alter-
native to a ~ 2-adrenoceptor agonist. 11 is given ac; an intravenous
bolus followed by an intravenous infusion for not more than 48
hours. Adverse effect'> include symptoms of vasodilation, nausea,
vomiting, and hyperglycaemia.
ERECTILE DYSFUNCTION
Erectile function depend.;; on complex interactions between
physiological and p!>ychological factors. Erection is cau~ed b)
vasorelaxation in the arteries and arterioles supplying the erectile
tissue. This increases penile blood flow. Relaxation of tmbecular
smooth muscle causes filling of the sinusoids. This compresses
the plexuses of l>Ubtunical venules between the trabeculae and the
tunica albuginea, occluding venous outflow and causing erection.
During sexual intercourse, reflex contraction of the ischiocaver-
nosus muscles compresses the base of the corpora cavcmosa,
and the intracavernosal pressure c<m reach several hundred milli-
metres of mercury during this phase of rigid erection. Innervation
of the penis includes autonomic and somatic nerves. Nitric oxide
is probably the main mediator of erection and is relea~ed both
from nitrergic nerves and from endothelium (Ch. 17; Fig. 17.6).
Erectile function is adversely affected by several therapeutic
drugs (including many antipsychotic, antidepres<;ant and antihy-
pertensive agents). but in long-term randomiscd controlled trials
an appreciable percentage of men who discontinue treatment
because of erectile dysfunction had been receiving placebo, and
psychiatric and vascular disease can themselves cause sexual
dysfunction. Furthermore, erectile dysfunction is common in
middle-aged and older men, even if they have no psychiatric or
cardiovascular problems. There are several organic causes. including
hypogonadism (sec above). hyperprolactinaemia (~ee Ch. 28).
arterial disease and various causes of neuropathy (most common!}
diabetes). but often no organic cause is identified. or the problem
is a result of a combination of organic and psychological factOTh.
notably anxiety relating to sexual perfonnance, which can establi~h
a vicious circle.
Over the centuries, there has been a huge trade in parts of
various creatures that have the misfortune to bear some fancied
resemblance to human genitalia, in the pathetic belief that con-
suming these will restore virility or act as an aphrodisiac {i.e. a
drug that stimulates libido). Alcohol (Ch. 43) 'provokes the
desire but takes away the performance', and cannabi\ (Ch. 15)
can also release inhibitions and probably docs the same.
Yohimbine (an a 2 antagonist: Ch. II) may have ~ome positive
effect in this regard, but even with meta-analysis the number
of subjects randomised is not very impressive. and efficaq
somewhat unconvincing. Apomorphine (a dopamine agonist;

Ch. 35) causes erections in human~ as well as in rodents when
injected subcutaneously, but it is a powerful emetic, an effect
that is usually regarded as socially unacceptable in this context.
Dc~pite this rather obvious disadvantage, a sublingual preparation
ts licensed for erectile dysfunction. 8 Nausea is said to sub~ide
'' 11h continued use-but really!
The generally negative picture picked up somewhat when it
was found that injecting vasodilator drug!. directly into the corpora
cavemosa causes penile erection. Papaver ine (Ch. 19). if neces~ary
'hith the addition of phentolamine, was used in this way. The
route of admini~tration is not acceptable to most men. but diabetics
in particular are often not needle-~hy, and this approach wa~ a
real boon to many such patients. PGE 1 (alprostadil) is often
combined with other vasodilators when given intracavemosally.
It can also be given tran~urethrally as an alternative (albeit still a
somewhat unromantic one) to injection. Adverse effects of all
these drugs include priapism, which is no joke. Treatment consists
of a~piration of blood (using sterile technique) and. if necessary,
cautious intraca,ernosal administration of a vasoconstrictor such
a~ phen) lephrine. lntracavemosal and transurethral preparation<>
are still available, but orally active phosphodiesterase inhibitors
are now generally the drugs of choice.
PHOSPHODIESTERASE TYPE V INHIBITORS
Sildenafil, the firM selective phosphodiesterase type V inhibitor
('ee also Ch) 17 and 19), was found incidentally to influence
erecule function. Tadalafil and vardenafil are also phosphodi-
esterase type V inhibitors licensed to treat erectile dysfunction.
Tadalafil i1. longer acting than sildenafi l. In contrast to intra-
cavemosal va,odilators, phosphodiesterase type V inhibitors arc
not sufficient to cau~e erection independent of sexual desire, but
enhance the erectile response to sexual stimulation. They have
transfonned the treatment of erectile dysfunction.
1
lrooically so, becau~c apomorphine wa~ used as aversion Lherapy' in a
ml'!!uided attempl 10 cure' homosexualil) b) condirioning individual'> 10
a'-ociale homoerouc \llmuli with nausea and vomiLing, during the nol SO
'ery-far-olftimc when homosexualily wa!> classified a.~ a psychiatric
dt-.ease ('only apomorphine cures'-Willianl Burroughs, Naked Lm1ch.
Grove Pre>s. 1966).
THE REPRODUCTIVE SYSTEM
Mechanism of action
Phosphodiesterase V is the isoform that inactivates cGMP.
Nitrergic nerves release nitric oxide (or a related nitrosothiol),
which diffuses into smooth muscle cells, where it activate~ guanylate
cyclase. The resulting increase in cytoplasmic cGMP mediate~
vasodilation via activation of protein kinase G (Ch. 17). Con-
sequently, inhibition of phosphodiesterase V potentiates the effect
on penile vascular smooth muscle of endothelium-derived nitric
oxide and of nitrergic nerves that arc activated by sexual stimu-
lation. Other vascular beds are also affected, suggesting other
possible uses, notably in pulmonary hypertension (Ch. 19. p. 317).
Pharmacokinetic aspects and drug interactions
Peak plasma concentrations of sildenafil occur approximately
30-120 minutes after an oral dose and are delayed by eating, so
it is taken an hour or more before sexual activity. lt is given as a
single dose as needed. l t is metabolised by the 3A4 isoenzyme of
cytochrome P450, which is induced by carbamazepine. rifam-
picin and barbiturates. and inhibited by cimetidine. macrolide
antibiotics. antifungal imidazoline~. some antiviral drugs (such
as ritonavir) and also by grapefruit juice (Ch. 8). These drugs can
potentially interact with sildenafil in consequence. Tadalafi l ha~
a longer half-life than sildenafil, so can be taken longer before
sexual activity. A clinically important pharmacodynamic interac-
tion occurs with organic nitrates, which work through increasing
cGMP (Ch. 17) and are therefore markedly potentiated by
sildenafil. Consequently, concurrent nitrate use, including use of
nicorandil, contraindicates the use of any phosphodic~terase
type V inhibitor.
Unwanted eHects
Many of the unwanted effects of phosphodiesterase type V
inhibitor::. are caused by vasodilation in other vascular beds; these
effects include hypotension, flushing and headache. Visual dis-
turbances have occasionally been reported and are of concern
because sildenafil has some action on phosphodiesterase VI.
which is present in reti na and important in vision. The manu-
facturers advise that sildenafil l>hould not be used in patient~ with
hereditary retinal degenerative diseases (such as retiniti~ pigmcn-
tosa) because of the theoretical ri~k posed by this. Vardenafil is
more selective for the type V isolyme than is sildenafil (reviewed
by Doggrcll, 2005). but is also contraindicated in patients with
hereditary retinal disorders.
459
 Bone metabolism
Overview 461
r-
Bone structure and composition 461
Bone remodelling 462
-The action of cells and cytokines 462
-The turnover of bone minerals 463
-Hormones involved in bone metabolism and
remodelling 464
Disorders of bone 466
Drugs used in bone disorders 467
-Bisphosphonates 467
-Oestrogens and related compounds 467
-Parathyroid hormone 467
-Strontium ronelate 468
-Vitamin D preparations 468
-Calcitonin 468
-Coburn salts 469
-Colcimimetic compounds 469
Potential new therapies 469
OVERVIEW
The human skeleton undergoes a continuous
process of remodelling throughout life-some bone
being resorbed and new bone being laid down.
With advancing age, there is an increasing possibility
of structural deterioration and decreased bone
mass (osteoporosis). This constitutes a major health
problem throughout the world, and there are, in
addition, various other conditions that can lead to
pathological changes in bone that require therapy.
In the past decade, there have been significant
advances in the understanding of bone biology,
which have led to new drugs and may yet lead to
further new drugs. In this chapter, we consider first
the processes involved in bone remodelling and
then go on to describe the pharmacological agents
used to treat disorders of bone.
BONE STRUCTURE AND COMPOSITION
The human skeleton consists of 80% cortical bone and 20%
trabecular bone. Cortical bone is the dense, compact outer part,
and trabecular bone the inner meshwork. The former predominates
in the shafts of long bones, the laner in the vertebrae, the epiphyses
of long bones and the iliac crest. Trabecular bone. having a large
surface area. is metabolically more active and more affected by
factors that lead to bone los!. (see below).
The main minerals in bone are calcium and phosphates. More
than 99% of the calcium in the body is in the skeleton, mostly as
crystalline hydroxyapatite but some as non-crystalline phosphates
and carbonates; together, these make up half the bone mass.
The main cells in bone homeostasis are osteoblasts, osteoclasis
and osteocytes.
Osteoblasts, which are derived from precursor cells in the
bone marrow and the periosteum, secrete important
components of the extracellular matrix-the osteoid,
particularly the collagen. They also have a role in the
activation of osteoclasiS (see below).
Osteoclasts are multinucleated bone-resorbing cells derived
from precursor cells of the macrophage/monocyte Lineage.
Osteocytes are derived from the osteoblasts, which, during
the formation of new bone, become embedded in the bony
matrix and differentiate into osteocytes. These cells form a
connected cellular network that, along with the nerve fibres
in bone, is thought to have a role in the response to
mechanical loading.
Other cells of importance are monocytes/macrophages,
lymphocytes and vascular endothelial cells; these secrete
cytokines and other mediators necessary for bone
remodelling (see below).
The organic matrix of bone is termed osteoid (as mentioned
above), the principal component of which is collagen. But there
are also other components such as proteoglycans, osteocalcin and
various phosphoproteins, one of which. osteonectin. binds to
both calcium and collagen and thus links these two major
constituents of bone matrix.
Calcium phosphate crystals in the form of hydroxyapatite
lCa 10(PO~MOH) 2] are depo ited in the osteoid, converting it into
hard bone matrix.
Bone plays a major role in overall calcium homeostasis in the
body (see below). 461
 SECTION 3 . DRUGS AFFECTING MAJO R O RGAN SYSTEMS

BONE REMODELLING
The process of remodelling involves the following:
the activity of two main cell types: osteoblasts that secrete
new bone matrix and osteoclasts that break it down (Fig. 31.1 ).
the action~ of a variety of cytokines; see Figs 31.1 and 31.2
lhe turnover of bone minerals-particularly calcium and
phosphate
the actions of several hormones: parathyroid hormone (PTH),
the vitamin D family, oestrogens, growth hormone, steroids,
calcitonin and various cytokines.
Diet, drugs and physical factors (exercise, loading) also affect
remodelling. Bone loss-of 0.5-1% per year-!.tarts in the 35-40
age group in both sexes. The rate accelerates by as much as 10-told
during the menopause in women (or with castration in men), and
lhen gradually settles at 1-3% per year. The loss during lhe
menopause is due to increased osteoclast activity (see below) and
affects mainly trabecular bone; the later loss in both sexes with
increasing age is due to decreased osteoblast numbers (see
below) and affects mainly cortical bone.
THE ACTION OF CELLS AND CYTOKINES
A cycle of remodelling starts with recruitment of the cells lhat
give rise to osteoclast precursors, and their differentiation to mature
multinuceated osteoclasts by cytokines (Fig. 31.1 ). The o~teoclasts
adhere to an area of trabecular bone, developing a ruffled border
at the attachment site. They move along the bone. digging a pit
by secreting hydrogen ions and proteolytic enzymes. Thi~ process
gradually liberates cytokines such as insulin-like growth factor
(IGF)- 1 and transforming growth factor (TGF)-~. which have
been embedded in the osteoid (Fig. 31.1); these in tum recruit

----------- - - - - ---
OC precursor cell ------@ @ ------ OB precursor cell
...
~ Recruitment of
PTH~
OC precursors

OBaction~

0
- IGF

0 0
0

I 0
0

TGF-~
Osteocyte - @

Quiescent bone Bone resorption Bone formation

I such
Fig. 3 1.1 The bone-remodelling cycle and the action of hormones, cytok ines and d rugs. Quiescent trabecular bone. Cytokines
as insulin-like growth factor (IGF) and transforming growth factor (TGF)-~.
shown as dots, are embedded in the bone matrix. Bone
I resorption. Osteoclast (OC) precursor cells, recruited by cytokines and hormones, are activated by osteoblasts (OBs) to form mobile
I multinuclear OCs (see Fig. 31.2) that move along the bone surface, resorbing bone and releasing the embedded cytokines. Bone
formation. The released cytokines recruit OBs, which lay down osteoid and embed cytokines IGF and TGF-~ in it. Some OBs also
I become embedded, forming terminal osteocytes. The osteoid then becomes mineralised, and lining cells cover the area (not shown).

- .
...-_
1 Oestrogens cause apoptosis (programmed cell death) of OCs. Note that pharmacological concentrations of glucocorticoids have the

! effects specified above, but physiological concentrations are required for OB differentiation. BPs, embedded bisphosphonates-these
\_are ingested by OCs when bone is resorbed (not shown): IL, interleukin; PTH, parathyroid hormone.
)I
.
462
------ --------------~
 BONE METABOLISM

Osteoblast Multinucleated osteoclast

resorbing bone
Calcitriol.
PTH, lls M-CSF

Molecules~
ofOPG '

1'

( r-OPG J
Fig. 31.2 Schematic diagram of the role of the osteoblast and cytokines in the differentiation and activation of the os teoclast
and the action of anti resorptive drugs. The osteoblast is s timulated by calcitriol, parathyroid hormone (PTH) and interleukins (lls) to
express a surface ligand, the RANK ligand (RANKL). RANKL expression is increased by various interleukins, parathormone, tumour
necrosis factor (TNF)-tt, prostaglandin E2 and glucocorticoids. RANKL interacts with a receptor on the osteoclast-an osteoclast
differentiation and activation receptor termed RANK (receptor S!.Ctivator of nuclear factor )Sappa B). This, with macrophage colony-
stimulating factor (M-CSF) released by the osteoblast, causes differentiation and activation of the osteoclast progenitors to form mature
osteoclasis (not shown). Fusion of osteoclasis occurs to give giant multinucleated bone-resorbing cells, which are polarised with a
ruffled border on the bone-resorbing side (shown). Bisphosphonates inhibit bone resorption by osteoclasis. Anti-RANKL antibodies (e.g.
denosumab) b1nd RANKL and prevent the RANK- RANKL interaction. The osteoblast also releases 'decoy' molecules of osteoprotegerin
(OPG), which can bind RANKL and prevent activation of the RANK receptor. Recombinant OPG (r-OPG)-which has this effect-is in
cl1mcal trial. Stromal cells may also function in the manner shown above for osteoblasts. _)

and activate succes. ive teams of ostcoblasts that have been stimu-
lated 10 develop from precursor cells and are awaiting the call to
duty (sec Fig. 31.1 and below). The osteoblasts invade the site,
~ynthesising and secreting the organic matrix of bone, the osteoid,
and secreting IGF- 1 and TGF-fJ (which become embedded in the
oMeoid; see above). Some osteoblasts become embedded in the
osteoid, forming terminal osteocytes; others interact with and
activate o~teoclast precursors-and we are back to the beginning
of the cycle.
Cytokines involved in bone remodelli ng other than !GF-1 and
TGF-~ include other members of the TGF-B fami ly, such as the
bone morphogenic proteins, a range of interleukins, prostaglandins,
various hormones, and me mbers of the tumour necrosis factor
family. A member of this last family-a ligand for a receptor on
the osteoclast precursor cell- is of particular importance. The
receptor is termed (wait for it-biological terminology has fallen
0\Cr it!> own feet here) RANK, which stands for receptor i!Clivator
of nuclear factor kappa B (NFtcB)-NFKB being the principal
transduction factor involved in osteoclast differentiation and acti-
vation. And the ligand is termed, unsurprisingly, RANK ligand
CRANKL).
The stromal cell and the osteoblast synthesise and release a
molecule termed osteoprotegerin (OPG), identical with RANK,
which functions as a decoy receptor. In a sibling-undermining
process by the two cells (osteoblast/stromal cell and osteoclast
precursor), OPG can bind to RANKL 1 (generated by the very cell
RANKL is al~o sometimes confusingly termed OPG ligand.
1
that OPG itself i'> generated by) and inhibit RANKL's binding to
its intended receptor. RANK. on the osteoclast precursor cell
(Fig. 31.2). (See l lofbauer & Schoppe!. 2004; Roodman, 2004:
Theoleyre et al.. 2004: Kostenuik, 2005.)
The ratio of RANKL to OPG is critical in the formation and
activity of osteoclasts.
THE TURNOVER OF BONE MINERALS
The main bone minerals are calc ium and phosphates.
CALCIUM METABOLISM
The daily turnover of bone minerals during remodelling involves
about 700 mg of calcium. Calcium has numerous roles in phy-
siological functioning. Intracellular Ca2+ constitutes only a small
proportion of body calcium, but it has a major role in cellular
function (~ee Ch. 3). An influx of Ca~+ with increase of Ca 2+ in
the cytosol is part of the signal transduction mechanism of many
cells, so the concentration of Ca1 in the extracellular fluid and
the plasma needs to be controlled with great precision. The con-
centration of Ca2 in the cytoplasm of cells is about 100 nmoVI.
whereas in the plasma it is about 2.5 mmolll. The plasma Ca1+
concentration is regulated by complex interactions between PTH
and various forms of vitamin D (Figs 31.3 and 31.4): calcitonin
also plays a part.
Calcium absorption in the intestine involves a Ca2+-binding
protein whose synthesis is regulated by calcitriol (see Fig. 3 1.3
and below). It is probable that the overall calcium content of the
body is regulated largely by this absorption mechanism, because 463
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS

urinary Ca2.. excretion normally remains more or less constant.
However, with high blood Ca2+ concentrations, urinary excretion
increases, and with low blood concentrations urinary excretion
can be reduced by PTH and calcitriol. both of which enhance
Ca2 reabsorption in the renal tubules (Fig. 31.3).
PHOSPHATE METABOLISM
Phosphates are important constituents of bone, and are also
critically important in the structure and function of all the cells of
the body. They play a significant part in enzymic reac!ions in the
cell; they have roles as intracellular buffers and in the excretion
of hydrogen ions in the kidney.
Phosphate absorption is an energy-requiring process regulated
by calcitriol (see below). Phosphate deposition in bone, as hydrox-
yapatite, depends on the plasma concentration of PTH, which,
with calcitriol, tends to mobilise both Ca2+ and phosphate from
the bone matrix. Phosphate is excreted by the kidney; here PTH
inhibits reabsorption and thus increases excretion.
HORMONES INVOLVED IN BONE
METABOLISM AND REMODELLING
T he main hormone<, involved in bone metabolism and
remodelling are PTH, members of the vitamin D family.
oestrogens and calcitonin. Glucocorticoids and thyroid hormone~
also affect bone.
PARATHYROID HORMONE
Parathyroid hormone. which consists of a single-chain polypeptide
of 84 amino acids, is an important physiological regulator of Ca 2
metabolism. It maintains the plasma Ca2 concentration by
mobilising Ca 2+ from bone, by promoting its reabsorption by the
kidney, and in particular by stimulating the synthesi of calcitriol.
'Over-replacement of thyroxine in hypolhyr01di\m resuhs in o\tcoporo~s:
;ce Roberts & Laden;on (2004).

A rise in the plasma calcium

concentration act1vates the
Activates the calcium-sensing receptor
( Cinacalcet Jcalcium-sensing
receptor and
on parathyroid cells
which decreases:
decreases:

A fall in the plasma

calcium concentration
causes:
Secret1on of parathormone
from the parathyroid
which causes:
/
Conversion of
calcifediol to calcitriol
which causes:

Decreased excretion of Increased calcium Mobilisation of

calcium by the kidney absorption in the calcium from bone
which causes: intestine which causes: which causes:

Fig. 31.3 The main factors involved in maintaining the concentration of Ca2 in the plasma and the action of drugs. The
calcium receptor on the parathyroid cell is a G-protein-coupled receptor. Calcifedlol and calcitriol are metabolites of vitamin 0 3 and
constitute the 'hormones' 25-hydroxy-vitamin 0 3 and 1,25-dihydroxy-vitamin 0 3, respectively. Endogenous calcitonin, secreted by the

~
hyroid, inhibits Ca2 mobilisation from bone and decreases its resorption in the kidney, thus reducing blood Ca2 . Calcitonin is also used
therapeutically in osteoporosis.
464
----- - ---- --------------------------------------------------------------------------~
 BONE METABOLISM

which in turn increases Ca 2+ absorption from the intestine and
\ynergiscs with PTH in mobilising bone Ca2+ (Figs. 31.3 and
31.4). PTH promote~ pho~phate excretion, and thus its net effect
i' to increa~e the concentration of Ca2 + in the plasma and lower
that of phosphate.
The mobili'>ation of Ca2+ from bone by PTH is mediated, at
least in pan. b) 'timulation of the recruitmem and activation of
o,tcodasts. Pathological oversecretion of PTH (hyperparathy-
roidism) inhibit~ o~teobla~t activity (not shown in Fig. 31.1 ). But
g1vcn therapeutically in a low intenniuent dose, PTH and frag-
ment~ of PTH paradoxically stimulate osteoblast activity and
enhance hone formation (see below).
Parathyroid hormone is synlhesised in the cells of the para-
thyroid glands and stored in vesicles. The principal factor controlling
~ecretion is the concentration of ionised calcium in tbe plasma,
low pl a~ma Ca 2+stimulating secretion, high plasma Ca2+ decreasing
it by binding to and activating a Ca2 +-sensing G-protein-coupled
surface receptor (Fig. 3 1.3). (See Stewart, 2004.)
VITAMIN D
Vitamm D is a prehormone that is converted in lhe body into a
number of biologically active metabolites that function as true
hormones, circulating in the blood and regulating the activities of
various cell types (see Reichel et al., 1989). Their main action is
the maintenance of plasma Ca 2+ by increasing Ca 2+ absorption in
the intestine, mobilising Ca 2+ from bone and decreasing its renal
excretion (sec Fig. 31.3). Vitamin Dis really a family of hormones
(see below) which act on receptors belonging to the superfamily
of steroid hormone nuclear receptors (see p. 428 top of right
column and p. 45 for details). In humans. lhere are two sources
of vitamin D:
dietary ergocalciferol (D 2) . derived from ergosterol in plants
cholecalciferol (0 3) generated in the skin from
7-dehydrocholesterol by the action of ultraviolet irradiation,
the 7-dehydrocholesterol having been formed from
cholesterol in the wall of the intestine.
Cholecalciferol (vitamin 0 3) is converted to 25-hydroxy-vitamin
0 3 (calcifediol) in the liver, and this is converted to a series
of other metabolites of varying activity in tbe kidney, the most
potent of which is I ,25-dihydroxy-vitamin 0 3 (calcitriol) (see
Fig. 3 1.4).
The synthesis of calcitriol from calcifediol is regulated by
PTH, and is also influenced by the phosphate concentration in
the plasma and by the caJcitriol concentration itself through a
negative feedback mechanism (Fig. 31 .4). Receptors for calcitriol
have been identified in vinually every tissue except liver, and it

Skin

UV ~-choloste<ol I
I
I
-~
I
I
I
I

I
I Exogenous
Vit D3 (cholecalciferol) -~' ergocalciferol
(Vit 0 2)
I
I
I
' Kidney
'f
25(0H)D3
( Alfacalcldol '-4'~--t,.~
. f'!J I- --,.;--- Decreased
Exogenous blood P04-
calcifediol - Parathyroid
hormone
+ Decreased
1,25(0Hh03 \ ,;'blood calcium
(calcitriol) \

( \,,, Pam<hymid
Fig. 31 .4 Summary of the
actions of the vitamin 0
endocrine system and the action
Calcilriol
n Increased
blood calcium
of drugs. Exogenous ergocalciferol, in blood
vrtam10 (Vit) 0 2 (formed in plants by
ultraviolet, UV, light), is converted to
the corresponding 02 metabolites in
hver and kidney, as Is the 02
analogue dihydrotachysterol (not Biological actions:
t Exogenous
calcitriol

shown). Alfacalcidol (1 a- Intracellular actions: Calcium and

hydroxycholecalciferol) is 25- cell differentiation, phosphate
hydroxylated to calcitriol In the liver. activation of OBs homeostasis
OB, osteoblast. 465
 SECTION 3 . DRUGS AFFECTING MAJOR ORGAN SYSTEMS
i\ now considered that calcitriol may be important in the func-
tioning of many cel l types.
The main actions of calcitriol are the stimulation of absorption
of Ca2+ and phosphate in the intestine, and the mobilisation of
Ca 2+ from bone, but it also increases Ca 2+ reabsorption in the
kidney tubules (Fig. 31.3). Its effect on bone involve promotion
of maturation of osteoclasts and indirect stimulation of their
activity (Figs 3 1.1 and 3 1.3). It decreases collagen synthesis by
osteoblasts, and its effect on these cells is by the classic steroid
pathway, involving intracellular receptors and an effect on the
DNA. However. the effect on bone i'> complex and is clearly not
confined to mobilising Ca 2+. because in clinical vitamin D
deficiency (sec below), in which the mineralisation of bone is
impaired. administration of vitamin D restores bone formation.
One explanation may lie in the fact that calcitriol stimulates
sylllhesis of osteocalcin, the vitamin K-dcpcndent, Ca2+-binding
protein of bone matrix.
OESTROGEN$
During reproductive life in the female, oestrogens have an
important role in maintenance of bone integrity. They inhibit the
cytokines that recruit osteoclasts, and oppose the bone-resorbing,
Ca2+-mobilising action of PTH. Withdrawal of oestrogen, as
happens at the menopause, can lead to osteoporosis.
CALCITONIN
Calcitonin is a hormone secreted by the specialised 'C' cells
found in the thyroid follicles.
The main action of calcitonin is on bone; it inhibits bone
resorption by binding to a specific receptor on osteoclasts,
inhibiting their action. In the kidney, it decreases the reabsorption
of both Ca2+ and phosphate in the proximal tubules. Its overall
effect is to decrease the plasma Ca2+ concentra tion. See Figures
3 1.3 and 31.4.
Secretion is determined mainly by the plasma Ca 2+ concen-
tration.
GLUCOCORTICOID$
Physiological concentrations of glucocorticoids are required for
osteoblast differentiation. Excessive pharmacological concentra-
tions inhibit bone formation by inhibiting osteoblast differenti ation
and activity, and may stimulate osteoclast action-leading to
osteoporosis. This larter effect is also evident when pathological
concentrations of endogenous glucocorticoids are present, as in
Cushing's syndrome (see Fig. 28.7).
DISORDERS OF BONE
DISORDERS OF THE STRUCTURE OF BONE
The reduction of bone mass with distortion of the microarchitec-
lure is termed osteoporosis; a reduction in the mineral content is
termed osreopenia. Osteoporotic bone can fracture easily after
4_6_6
...r-_ _ _
minimal trauma-and frequently docs. The commonest causes of
osteoporosis are postmcnopau~al deficiency of oestrogen and
age-related deterioration in bone homeo~tasis. It is calculated
that , in Englnnd and Wales, one in two women and one in five
men over the age of 50 will have a fracture due to osteoporO\is
(Van Swa et al., 200 I ), while in the USA a 50-year-old woman is
estimated to have a 40% lifetime risl.. of an osteoporotic fracture
(Strcwler, 2005). But osteoporosis can also occur secondary to
conditions such as rheumatoid arthritis, and can result from other
factors, such as excessive thyroxine or glucocorticoid adminis-
tration. Up to half the patients on long-term oral glucocorticoid
therapy can suffer fracture~ due to excessive bone loss. Becau~e
life expectancy has increased significantly in the developed world.
osteoporosis is now regarded as being of epidemic proportion\.
and bas become an important public health problem. Drugs that
prevent its development are being actively sought. The treatment
of osteoporosis involves either antiresorptive (anticatabolic) drug~
(e.g. the bisphosphonates. raloxifene) or anabolic drugs that
stimulate bone fonml!ion (PTH, teriparatide) (see Rigg!. & Parfitt,
2005). ewer compounds (e.g. strontium ranelate; see below)
have both actions.
Other diseases of bone requiring drug therapy arc osteomalacia
and rickets (the juvenile form of osteomalacia), in which there
are defects in bone mineralisation due to vitamin D deficiency.
and Paget's disease, in which there is distortion of the processes
of bone resorption and remodelling.
DISORDERS OF BONE MINERAL METABOLISM
H ypocalcaemia occurs with hypoparathyroidism, vitamin D
deficiencies, congenital rickets and some kidney diseases; hyper
calcaemia with hyperparathyroidism and some malignancies.
also sarcoidosis.
Bone remodelling
Bone is conttnuously remodelled throughout
life. The events of the remodelling cycle are as follow:
osteoc/asts, having been activated by osteoblasts,
resorb bone by digging pits in trabecular bone.
Into these pits the bone-forming osteob/asts
secrete osteoid (bone matrix), which consists
mainly of collagen but also contains osteocalcin,
osteonectin, phosphoproteins and the cytokines
insulin growth factor (IGF) and transforming
growth factor (TGF)-13
the osteoid is then mineralised, i.e. complex calcium
phosphate crystals (hydroxyapatites) are deposited.
Bone metabolism and mineralisation involve the
action of parathyroid hormone, the vitamin 0 family,
calcitonin and various cytokines (e.g. 1GF, the TGF-~
family and interleukins). Declining physiological levels
of oestrogens and therapeutic levels of glucocorticoids
can result in bone resorption not balanced by bone
formation-leading to osteoporosis.

Pho~phate deficiency and bypophospbataemia can occur in
nutritional deficiency states (e.g. in alcoholic individuals and
patient~ rece1\ ing parenteral nutrition).
H) perphosphataemia is a conunon problem in patientS with
renal failure, and is treated with phosphate-bonding compounds
~uch a~ the anion exchange resin sevelamer (Cb. 25).
DRUGS USED IN BONE DISORDERS
BISPHOSPHONATES
BP.pho~phonatc~ are entyme-resistant analogues of pyrophos-
phate that inhibit bone resorption by an action mainly on the
o~tcoclaM~. After administration, they are bound to bone min-
erals in the matrix and are released slowly as bone is resorbed
by the ostc<>clasts, which are thus exposed to high concentrations
or the drugs.
The main bi~phol.phonates available for clinical use are
alcndronate and r ised ronate. Others are disodium pamidronate
and sodium clodron:.ne. A newer compound, zoledronic acid, which
j, g1\Cil only once in a '>ingle intravenous infusion, is now used for
malignancy and is in clinical trial for Paget's disease and
o'tcoporosis.
Mechanism of action
In term' of thc1r molecular mechanism of action, the bisphos-
phonate\ can be grouped into two classes.
The \lmplc compounds that are very similar to
p)ropho~phatc arc incorporated into ATP analogues that
accumulate within the osteoclasts and promote their apoptosis.
The potent, nitrogen-containing bisphosphonates-such as
alendronatc and ibandronate-interfere with the formation of
the mflled border at the attachment site of the cell to bone,
pn:\cnting bone resorption (see Fig. 31.2).
? 1l1e rutrogen-corHaining bbphosphonates appear to inhibit famesyl
dipho>phate ~yntha~e. an cntymc in the mcvalonate pathway. Inhibition
olthis enzyme prevents the synthesis of certain lipids rhar are essential
lor the activity of smull GTPase signalling proteins necessary in the
lomMtion of the ruffied border (Rogers, 2003; Strewler, 2005).
It j, now known that bisphosphonates are incorporated into the
bone matrix and ingested by osteoclasis when these resorb bone.
Pharmacokinetic aspects
Bl,pho,phonate~ are usually given orally and are poorly absorbed.
Th<!) ma} be given intravenously in malignancy. About 50% of a
do-e accumulates at sites of bone mineralisation, where it remains,
potentiall} for months or years, until the bone is resorbed. The
fr.:c drug 1\ excreted unchanged by the kidney.
Ab~orption b impaired by food, particularly milk, so the drugs
mu,tl:l\! tal.;en on an empty stomach.
Ummnted effectJ include ga!.lrointestinal disrurbances, which
can be severe. and occasionally bone pain. Peptic ulcers have
occurred. Alendronate can cau!>e oesophagitis.
Di-.odium ctidronate can increase the risk of fractures due to
reduced calcification of bone; this is less likely if it is given
cyclically.
BONE METABOLISM
Clinical uses of blsphosphonates
(e.g. alendronate, pamldronate)
Paget's disease of bone.
Hypercalcaemia caused by malignant disease.
Prevention or treatment of postmenopausal
osteoporosis (as an alternative or addition to
oestrogens).
Prevention or treatment of glucocorticoid-induced
osteoporosis.
They are under investigation for the treatment of
cancer metastases in bone.
OESTROGENS AND RELATED COMPOUNDS
The decline in oestrogen levels is a major factor in postmeno-
pausal osteoporosis, and there is evidence that giving hom1one
replacement therapy (HRT; ~ee Ch. 30) can ameliorate this con-
dition. But HRT has actions on many systems, and newer non-
hormonal agents have now been developed that exhibit agonist
actions on some tissues and antagonist actions on others. These
arc termed selectile oestrogen receptor modulators (SERMS).
Raloxifenc is a SERM that has agonist activity on bone and the
cardiovascular system. and antagonist activity on mammary
tissue and the uterus.
RALOXIFENE
Actions and mechanism of action
Raloxifcne produces a dose-dependent increase in osteoblast
activity and reduction in osteoclast action.
It is well absorbed in the gastrointestinal tract, and undergoes
extensive first-pass metabolism in the liver to give lhe glucuronide.
(Colestyramine, given with it, reduces lhe enterohepatic cycling
of raloxifcnc by 60%.)
Thus bioavailability is only about 2%. ft is widely distributed
in the tissues, and is converted to an active metabolite in liver,
lungs, bone, spleen, uterus and kidneys. Its half-life averages
32 hours. It is excreted mainly in the faeces.
Unwanted eH ects
Hot flu!>hes and leg cramps are common. In a recent clinical trial,
raloxifcne was found to be associated with venous thrombo-
embolism; however, other authorities state that there is less risk
of this adverse effect in younger patients.
PARATHYROID HORMONE
Until recently, there had been little or no clinical use for PTH as
such, but then it was realised that PTH and fragmentS of PTH
paradoxically stimulate osteoblast activity and enhance bone for-
mation, and they arc now considered to be important compounds
in the treatment of osteoporosis (see below). The main compound 46 7
 SECTION 3 DRUGS AFFECTING MAJOR ORGAN SYSTEMS
used i~ teriparatide-the peptide fragment ( 1- 34) of recombinant
parathormonc.
Actions and mechanism of action
Tcriparatide ha!> anabolic effects on bone. It increase!> bone mass,
structural integ rity and bone strength by increasing the number of
o~teob lasts and by activating those o~teobl asts already in bone. It
also reduces oMeoblast apoptosis.
It acts o n the G-protein--dependcnt PTH receptor- ! in the
membrane of target cells. and its effects arc mediated through
adenylate cycla~e. pho!.pholipase!> A, C and D. and increases in
intracellular Ca 2+ and cyclic AMP.
(See Brixe n et al., 2004: Cappuzzo & Delafuente, 2004;
Dobnig, 2004: Quattrocchi & Kourla~. 2004.)
Pharmacokinetic aspects
Given subcutaneously once daily, peak concentrations occur after
30 minutes. The serum distribution half-life is 10 minutes after
intravenous injection and I bour after subcutaneous injection.
Unwanted effects
Teriparatide ill well tolerated. a nd serious adverse effects are
few. ausea, dizziness, headache and arthralgias can occur.
Mild hypercalcaemia, transient orthostatic hypotension, nausea.
ditLiness, headache and leg cramp\ have been reported.
Clinical use
The clinical u<,e of teriparatide is given on page 466. Note that
there is comroversy as to whether or not this drug should be
given seque ntially or in combination with one of the bisphos-
phonates ( Heaney & Recker, 2005); however, a bispho~phonate
!.hould be gi\'en at the end of a courl>e of teriparatide to prevent
tcriparatide withdrawal bone loss.
STRONTIUM RANELATE
This compound, newly introduced for treatme nt of osteoporosis,
is composed of two atoms of strontium combined with organic
ranelic acid, the latter being a carrier for the active strontium
component. It inhibits bone reso rption and also stimulates bone
formation. In recent trials. it has been shown to be effecti ve in
prc\'cnting vertebral and non-vertebral fracture~ in older women
(see Fogelman & Blake, 2005).
The precise mechani.,m of action is not clear. Strontium is
similar to calcium as regards its absorption in the gastrointestinal
tract. its incorporation into bone and its renal elimination. Strontium
atoms are adsorbed on to the hydroxyapatite crystals, but eventually
they exchange for calcium in the bone minerals and remain in the
bone for many years.
The drug is well tolerated; a low incidence of nausea and
diarrhoea is reported.
VITAMIN D PREPARATIONS
Vitamin D preparation'> are used in the treatment of vitamin D
deficiencies, bone problems associated with renal failure. and
468 hypoparathyroidism-acute hypoparathyroidbm neces~ itating
the use of intravenous calcium and injectable vitamin 0
preparations.
The main vitamin D preparation used clinically is ergocalciferol;
also available for clinical use are alfacalcidol and calcitriol. All
can be given orally and are well absorbed from the intestine.
Vitamin D preparations are fat-soluble, and bile salts are necess-
ary for absorption. Injectable forms of calciferol are available.
ewer vi tamin D analogue'> with le<,s potential to cau~e
hypercalcaemia are the vitamin D sterols 19-nor-paracalcitol
and doxcrcalciferol (Salusky, 2005).
Pharmacokinetic aspects
Given orally, vitamin D is bound to a specific a-globulin in
the blood. The plasma half-life is about 22 hours, but vitamin 0
can be found in the fat for many month'>. The main route of
elimination is in the faeces.
The clinical use of vitamin D preparatio ns is given in the
box on thi ~ page.
Unwanted effects
Excessive intake of vitamin D causes hypercalcaemia, the mani-
festations of which include constipation. depression, weakne~~
and fati gue. There is a reduced ability to concentrate the urine,
resulting in polyuria and polydipsia. If hypercalcaemia persists.
calcium \a Its arc deposited in the kidney and urine, causing renal
failure and kidney ~tOnes.
Some anticonvulsant drugs (e.g. phe nytoin ; see Ch.40)
increase the requirement for vitamin D.
CALCITONIN
The main preparation available for clinical use (sec the clinical
box on p. 469) is salcatonin (synthetic salmon calciwnin).
Synthetic human calcitonin is now also available. Calcitonin is
given by subcutaneous or intramuscular injection. and there rna)
be a local inflammatory action at the injection site. It can also be
given intranasally. Its plasma half-life is 4-12 minutes, but ih
action lasts for several hours.
Unwamed effects include nausea and vomiting. Facial flushing
may occur, as may a tingling sensatio n in the hands and an
unpleasant taste in the mouth.
The clinical uses of calcitonin are given on page 466.
Clinical uses of vitamin D
Deficiency states: prevention and treatment of
rickets, osteomalacia and vitamin D deficiency owing
to malabsorption and liver disease (ergocalciferoO.
Hypocalcaemia caused by hypoparathyroidism
(ergocalciferol).
Osteodystrophy of chronic renal failure, which is the
consequence of decreased calcitriol generation
(calcitriol or alphacalcidol).
Plasma Ca2 levels should be monitored during
therapy with vitamin D.

CALCIUM SALTS
Calcium salts used therapeutically include calcium gJuconate and
calcium lactate, given orally. Calcium gluconate is also used for
imravcnou~ injection in emergency treatment of hyperkalaemia
(Ch. 24); intramu cular injection is not used, because it causes
local necrosis.
Calcium carbonate, an antacid, is poorly absorbed in the gut,
but there is concern about systemic absorption and the potential
to cause arterial calcification. An oral preparation of hydroxya-
patite is available.
Unwanted effects: oral calcium salts can cause gastroimestinal
disturbance. Intravenous administrati on requires care, especially
in patients on cardiac glycosides (see Ch. 18).
The clinical use of the calcium salts is given on this page.
CALCIMIMETIC COMPOUNDS
Calcimimctics enhance the sensitivity of the parathyroid Ca2+-
~ensing receptor to the concentration of blood Ca2+. The effect is
to decrease the secretion of PTH and reduce the serum Ca 2+
concentration. There are two types of calcimimetics.
T}pe I are agonbts, and include inorganic and organic
pol)cations.
Type IT are allosteric activators that activate the receptor by
altering its conformation. One such compound is cinacalcet,
Y.hich is in clinical trial for the treatment of
h)perparathyroidism (Nemeth et al.. 2004: Peacock et al., 2005).
POTENTIAL NEW THERAPIES
NEW DRUGS FOR OSTEOPOROSIS
There i\ growing interest in the possible value of anabolic
compounds that stimulate bone formation-for use al one or in
combination with the antiresorptive drugs (see Rosen &
Bile.c:ekian, 200 1). Teriparatidc, the first anabolic compound
licensed for osteoporosis, is already available for use. A new
antiresorptive compound, an anti-RANKL antibody named
denosurnnb. is now available; this specifically blocks RANKL
Clinical UMS of calcltonln/salcatonln
Hypercalcaemia (e.g. associated with
neoplasia).
Paget's disease of bone (to relieve pain and reduce
neurological complications).
Postmenopausal and corticosteroid-induced
osteoporosis (with other agents).
BONE METABOLISM
binding to RAN K and is in phase Ill trial (Bekker et al. 2004;
Kostenuik, 2005).
Other potential anabolic agents being considered for future
development are IGF-1 and insulin-like growth hormone (see
Fig. 31.1) and the statins. These last commonly given to reduce
blood chole terol (Ch. 20). have been shown to increase the gene
expression of bone morphogenic protein-2, and to increase bone
formation in vitro. Thiazides (Ch. 24) have a small effect in
slowing bone loss and might be of value in combination therapy.
Possible new anti resorptive agents on the horizon include agents
related to OPG-a physiological inhibitor of bone resorption.
POTENTIAL NEW THERAPIES FOR
BONE DISEASES
Recombinant OPG has been tried in juvenile Paget's disease, with
promising results (Cundy ct al., 2005; Deftos, 2005).
Clinical uses of calcium salts
Dietary deficiency.
Hypocalcaemia caused by hypoparathyroidism or
malabsorption (intravenous for acute tetany).
Calcium carbonate is an antacid; it is poorly
absorbed and binds phosphate in the gut. It is used
to treat hyperphosphataemia (Ch. 24, p . 382).
Prevention and treatment of osteoporosis (often with
oestrogen, bisphosphonate, vitamin D or calcitonin).
Cardiac dysrhythmias caused by severe
hyperkalaemia (intravenous; see Ch. 18).
Parathyroid, vitamin D and bone mineral
homeoatasla
The vitamin D family are true hormones; precursors
are converted to calcifediol in the liver, then to the
main hormone, calcitriol, in kidney.
Calcitriol increases plasma Ca2 by mobilising it from
bone, increasing its absorption in the intestine and
decreasing its excretion by the kidney.
Parathyroid hormone (PTH) increases blood Ca2 by
increasing calcitriol synthesis, mobilising Ca2 from
bone and reducing renal Ca2 excretion. (But,
paradoxically, small doses of PTH given intermittently
increase bone formation.)
Calcitonin (secreted from the thyroid) reduces Ca2
resorption from bone by inhibiting osteoclast activity.
469
THE NERVOUS SYSTEM
 Chemical transmission and
drug action in the central
nervous system
Overview 473
Introduction 473
Chemical signalling in the nervous system 47 4
Targets for drug action 475
Drug action in the central nervous system 476
The classification of psychotropic drugs 477
OVERVIEW
Brain function is the single most important aspect
of physiology that defines the diHerence between
humans and other species. Disorders of brain
function, whether primary or secondary to
malfunction of other systems, are a major concern
of human society, and a field in which
pharmacological intervention plays a key role. In
this chapter, we introduce some basic principles of
neuropharmacology that underlie much of the
material in the rest of this section.
INTRODUCTION
Tilere are two reasons why understanding the action of drugs on
the central nervous system (CNS) presents a particularly
challenging problem. The first is that centrally acting drugs are of
~pecial ~ignificancc to humankind. Not only are they of major
therapeutic importance. 1 but they are also the drugs that humans
mo't commonly administer to tllemselves for non-medical reasons
(e.g. alcohol, tea and coffee. cannabis. nicotine. opiates, ampheta-
mi~ and so on). The second reason is tllat tlle CNS is functionally
far more complex than any otller system in the body, and this
1
1n Bntam in 2003, 118 million prescription~ (about 20% or all
prNnptions), costing 1.3 billion, were for CNS drugs as defined by the
Bnu'h Jllntional Formulary. This amounted to nearly two per person across
lhe whole population.
makes the under!>tanding of dntg effects very much more difficult.
The relationship between the behaviour of individual cells and
that of the organ as a whole is far less direct in the brain than, for
example, in the heart or kidney. In these latter organs, a detailed
underl>tanding of how a drug affects the cells gives us a fairly
clear idea of what effect it will produce on the organ (and on the
animal) a~ a whole. In the brain, this is simply not true. Thus we
may know that a drug mimics the action of 5-hydroxytryptamine
in it<; effect on nerve cells, and we know empirically that ~uch
drugs often cau~e hallucination~. However, other drugs that enhance
the action of 5-hydroxytryptamine, such as amidepressanl<; (Ch. 39)
affect mood and behaviour in a quite different way. Currently, the
link between a drug's action at the biochemical and cellular level
and its effects on high-level brain function remain largely mys-
terious. Functional brain imaging is beginning to reveal relation-
ships between brain activity in ~pecific regions and mental function.
and thil> tool i~ being used increasingly to probe drug effects.
Neverthele~~. the fairly gros~ (millimetre scale) re!tolution
currently achievable with imaging methods is far from being able
to reveal events at the level of individual neurons and synapses.
Despite l>U\tained progress in understanding the cellular and
biochemical effects produced by centrally acting drugs, and the
increasing use of brain imaging to study brain function and drug
effects, the gulf between our understanding of drug action at the
cellu lar level and at the functional and behavioural level remains,
for the most part, very wide. Attempts to bridge it seem, at times,
like throwing candy tloss into the Grand Canyon.
A few bridge-headr. have nonetheless been established. some
more firmly than others. Thus t11e relationship between dopami-
nergic pathways in the extrapyramidal system and the effects of
drugs in alleviating or exacerbating the symptoms of Parkinson's
disease (see Ch. 35) i<; clear-cut. Also reasonably firm is the link
between the functions of noradrenaline (norepinephrine) and 5-
hydroxytryptamine in certain parts of the brain and tlle symp-
toms of depre ion (sec Ch. 39). and that between GABA and
anxiety (Ch. 37). Less well elttablished is tlle connection between
hyperactivity in dopaminergic pathways and schizophrenia (see
Ch. 38). On the other hand. attempts to relate the condition of
epilep~y to an identifiable cellular disturbance (sec Ch. 40) have
been very disappointing, even though the abnormal neuronal
discharge pauern in epilepsy seems. on the face of it, a much
simpler kind of disturbance than. for example. the altered mood
of a depressed patient. Many CNS drugs are used to treat psy-
chiatric disorders that arc defined according to tlleir symptoma-
tology rather than on the basis or causative factors or clinical signs 473
 SECTION 4 . THE NERVOUS SYSTEM

and investigations. What is called 'schizophrenia' or ' depression '

on the basis of particular symptoms is likely to consist of several CHEMICAL SIGNALUNG IN THE
distinct disorders caused by different mechanisms and NERVOUS SYSTEM
responding to drugs in different ways. Much effort is going into
The brain (like every other organ in the body!) is basically a
pinning down the biological basis of psychiatric disorders-a
chemical machine; it controls the main functions of a higher
necessary tep to improve the design of berter drugs for clinical
animal across timescales ranging from milliseconds (e.g. returning a
use- but the ta!>k is daunting and progress is slow.
I 00 mph tennis serve) to years (e.g. remembering how to ride a
In this chapter, we outline the general principles governing the
bicycle). 2 The chemical signalling mechanisms cover a corre-
action of drugs on the CNS. M ost neuroactive drugs work by
spondingly wide dynamic range, as summarised, in a very general
interfering with the chemical signals that underlie brain function,
way. in Figure 32.1. Currently, we understand much about drug
and the next two chapters discuss the major CNS transmitter
effects on events at the fast end of the spectrum- synaptic
systems and the ways in which drugs affect them. In Chapter 35,
transmission and neuromodulation-but much less about long-
we focus on neurodegenerative diseases, and the remaining
term adaptive processes, although it is quite evident th at the latter
chapters in this section deal with the main classes of neuroactive
arc of great importance for the neurological and psychiatric
drugs that are currently in use.
disord ers that are susceptible to drug treatment.
B ackground information will be found i n neurobiology text-
books such as Kandel et al. (2000), and in texts on neuropharma-
cology such as N estler et al. (200 I) and Cooper et at. (2004). For 2Memory of the basic facts of phannacology seems to come somewhere in
exhausti ve coverage, see Davis et al. (2002). the middle of Lhis range (skewed towards the short end).

Timescale Process Chemical mediators Molecular mechanisms

ms Impulse conduction None V-gated ion channels

Transmitter release Exocytosis (Ch. 4)

Fast synaptic transmission Fast transmitters Ligand-gated ion channels (Ch. 3)

(e.g. glutamate, GABA, ACh)

Slow synaptic transmission Slow transmitters

s (e.g. monoamines, peptides, ACh) G-proteincoupled receptors (Ch. 3)
linked to ion channels, ca2\

Neuromodulation Slow transmitters+ others (e.g. NO,
arachidonic acid metabolites)
J1 second messengers
Soluble guanylate cyclase (Ch. 17)

mln
. -

Synaptic plasticity

Delayed pharmacological Many neuroactive drugs

(e.g. antidepressants, Ch. 39) Receptor up/down-regulation
effects
h ? Altered gene expression
(

Pharmacological tolerance Many neuroactive drugs (Ch. 43)

11J------
(e.g. opiolds, benzodiazepines)

day
St-mt "modollt"g 1 Chemok1nes

1 Cytokines
Growth factors
Kinase-linked receptors
controlling gene expression

~
? Adhes1on molecules
;
month/year
Degeneration,
regeneration and repair
J ? Steroids

(very limited in CNS)

FJg. 32.1 . Chemical signall!ng in th~ n~rvous syst em . Knowledge of the mediators and mechanisms becomes sparser as we move

l
from the r~p1d events of synapt1c transmiSSion to the slower ones involving remodelling and alterations of gene expression. ACh,
acetylcholine; CNS, central nervous system; NO, nitric oxide.
474
 C HEMI CAL TRANSMISSION AND DRUG ACTION IN THE CENTRAL NERVOUS SYSTEM

The original concept of ocurotransnussJOn envisaged a
sub~tance released by one neuron and acting rapidly, briefly and
at ~hon range on the membrane of an adjacent (postsynaptic)
neuron. causing excitation or inhibition. The principles outlined
in Chapter 9 apply to the central as well as the peripheral nervous
~}stem. It 1\ now clear that chemical mediators within the brain
can produce l>IO\\ and long-lal>ting effects: that they can act rather
diffuse!). at a con~iderable distance from their site of release; and
that the) can produce diverse effects, for example on transmitter
S} nthesis. on the expression of neurotransmitter receptors and on
neuronal morphology. in addition to affecting the ionic conduc-
tance of the po~tsynaptic cell membrane. This form of signalling
has been termed non-synaptic communication (see ViL.i, 2000).
The term newvmodufator is often used to denote a mediator. the
action~ of which do not conform to the original neurotransmitter
concept. The term is not clearly defined, and it covers not only the
dirfu,e ly acting neuropeptide mediators, but also mediators such
as nitric oxide and arachidonic acid metabolites, which are not
stored and released like conventional neurotransmitters, and may
come from non-neuronal cells, particularly glia, as weU as neurons.
In general. neuromodulation relate!> to synaptic plasticity, including
shon-tem1 physiological events such as the regulation of pre-
~)naptic transmiuer relea<;e or postsynaptic excitability. Longer
term ne11rotrophic effects are involved in regulating the growth
and morphology of neurons. as well as their functional pro-
pentes. Table 32.1 summarises the types of chemical mediator
that operate in the C S.
Glial cells. panicularly astrocytcs. which are the main non-
neuronal celb in the C S and outnumber neurons by 10 to 1,
abo play an important signalling role. Once thought of mainly as
housekeeping cells, whose function was merely to look after the
fa~tidiou~ neurons, they are increasingly seen as 'inexcitable
neurons' with a major communications role to play (see Bezzi &
Volterra, 2001; Fields & Stevens-Graham, 2002), albeit on a
slower timescale than that of neuronal communication. These
cells expre!>s a range of receptors and transporters similar to
tho~c present in neurons. and also release a wide variety of
mediators, including glutamate. lipid mediators and growth factors.
They respond to chemical signals from neurons, and also from
neighbouring astrocytes and microglial cells (the CNS equivalent
of macrophages. which function much like inflammatory cells in
peripheral tissues). Electrical coupling between astrocytes causes
them often to respond in concert in a particular brain region, thus
controlling the chemical environment in which the neurons
operate. Although they do not conduct action potentials, and do not
send signals to other parts of the body, astrocytes are otherwise
very similar to neurons and play a crucial communication role
within the brain. Because they are difficult to study in situ, how-
ever, our knowledge of how they function, and how they respond
to drugs, is still fragmentary. It is an area to watch closely.
TARGETS FOR DRUG ACTION
To recapitulate what was discussed in Chapters 2 and 3, neuro-
active drugs act on one of four types of target proteins, namely
ion channels, receptors. enzymes and transport proteins. Of the four
main receptor farnilies-ionotropic receptors. G-protein~oup1ed
receptor~. kinase-linked receptors and nuclear receptor~
current drugs target mainly the first two.
In the la!>t two or three decades. knowledge about these targets
in the C S has accumulated rapidly, particularly as foliO\\ s.
As well a'> 40 or more small-molecule and peptide mediators,
the importance of other 'non-classical' mediators- nitric
oxide, eicosanoids, growth factors. etc.-has become
apparent (see Baraiiano et aL 2001).
Considerable molecular diversity of known receptor
molecules and ion channels (see Ch. 3) has been revealed.

Table 32.1 Types of chemical mediators in the central nervous system

Mediator type Examples Targets Main functional role

Conventional small- Glutamate, GABA, acetylcholine, Ugand-gated ion channels Fast synaptic neurotransmission
molecule mediators dopamine, 5-hydroxytryptamine, etc. G-protein~oupled receptors Neuromodulation

Neuropeptides Substance P. neuropeptide Y, G-protein~oupled receptors Neuromodulation

corticotrophin-releasing factor, etc.

Lipid mediators Prostaglandins, endocannabinoids G-prote1n-<:oupled receptors Neuromodulation

N1tricoxide Guanylate cyclase Neuromodulation

Neurotroph1ns, Nerve growth factor, brain-derived Kinase-linked receptors Neuronal growth, survival and
cytokines neurotrophic factor, interleukin-1 functional plasticity

Steroids Androgens, oestrogens Nuclear receptors (also membrane Functional plasticity

receptors)

'Most central nervous system pharmacology is currently centred on small-molecule mediators and, less commonly, neuropeptides.
Other mediator types have yet to be targeted for therapeutic purposes.
475
 SECTION 4 . THE NERVOUS SYSTEM
Chemical transmission In the central
nervous system
The basic processes of synaptic transmission in the
central nervous system are essentially similar to those
operating in the periphery (Ch. 9).
Glial cells, particularly astrocytes, participate actively
in chemical signalling, functioning essentially as
'inexcitable neurons'.
The terms neurotransmitter, neuromodulator and
neurotrophic factor refer to chemical mediators that
operate over different timescales. In general:
neurotransmitters are released by presynaptic
terminals and produce rapid excitatory or
inhibitory responses in postsynaptic neurons
neuromodulators are released by neurons and by
astrocytes, and produce slower pre- or
postsynaptic responses
neurotrophic factors are released mainly by non-
neuronal cells and act on tyrosine kinase-linked
receptors that regulate gene expression and
control neuronal growth and phenotypic
charactenstics
fast neurotransmitters (e.g. glutamate, GABA)
operate through ligand-gated ion channels
slow neurotransmitters and neuromodulators (e.g.
dopamtne, neuropeptides, prostanoids) operate
mainly through G-protein-coupled receptors.
The same agent (e.g. glutamate, 5-hydroxytryptamine,
acetylcholine) may act through both ligand-gated
channels and G-protein-coupled receptors and
function as both neurotransmitter and neuromodulator.
Many chemical mediators, including glutamate, nitric
oxide and arachidonic acid metabolites, are produced
by glia as well as neurons.
Many mediators (e.g. cytokines, chemokines, growth
factors, steroids) control long-term changes in the
brain (e.g. synaptic plasticity and remodelling), mainly
by affecting gene transcription.
All the receptors and channels are expressed in at least three
or four (often more) subtypes. with quite characteristic
distribution~ in different brain areas. In most cases, we have
little clear idea of what this diversity means at a functional
level, although the study of transgenic 'gene knockouts' is
beginning to provide some clues. From the pharmacological
standpoint. the molecular diversity of such targets raises the
possibility that drugs with improved selectivity of action-
blocking one kind of sodium channel without affecting
others, for example-may be discovered. So far, however, the
potential of th ese new approaches in terms or improved drugs
for neuro logical and psychiatric diseases remains largely
476 unrealised. llope, however (and certainly hype), springs eternal.
The pathophysiology of oeurodegeneration in conditions
~uch as Altheimer's disease and stroke is beginning to be
understood (see Ch. 35). and progress is being made in
understanding the mechanisms underlying drug dependence
(see Ch. 43). These advances are suggesting new strategic~
for treating these disabling conditions. Other area!. of brain
research (e.g. the neurobiology of epilepsy, schizophrenia
and depressive illnesses) are advancing less rapidly, but there
is still progress to report.
DRUG ACTION IN THE CENTRAL
NERVOUS SYSTEM
/\s we have already emphasised, the molecular and cellular
mechanisms underlying dntg action in the CNS and in the
pe riphery are essentially similar. Understanding how drugs anect
brain function is, however, made difficult by several factors. One
is the complexit y of neuronal interconnections in the brain- the
wiring diagram. Figure 32.2 illustrates in a schematic way the kind
of interconnections that typically exist for, say, a noradrcncrgic
neuron in the locus coeruleus (see Ch. 34), shown as neuron I
in the diagram, releasing transmitter a at its terminals. Relea~e
of a affects neuron 2 (which releases transmitter b ), and also
affect\ neuron I by direct feedback and, indirectly, by affecting
presynaptic inputs impinging on neuron I. The firing pattern of
neuron 2 also affects the system. partly through interneuronal
connections (neuron 3, releasing transmitter c). Even at this
grossly oversimplified level. the effects on the system of blocking
or enhancing the release or actions of one or other of the tran\-
miuers are difficult to predict, and will depend greatly on the
relative stre ngth of th e vario us excitatory and inhibitory synaptic
connections, and on external inputs (x andy in the diagram). Added
to this complexity at the level of neuronal interconn ections is the
influence o r the g lial cells, mentioned above. A further important
complicating factor is that a range of secondary, adaptive responses
is generally set in train by any drug-induced perturbation of the
system. Typically, an increase in transmitter release, or interference
with transmitter reuptakc. is countered by inhibition of tran~
mitter sy nthesis, enhanced transporter expression or decreased
receptor ex pressiotl. These changes, which involve altered gene
expression, generall y take time (hours. days or weeks) to develop
and arc not evident in acute pharmacological experiments.
In the clinical ~ituation. the effects of psychotropic drugs often
take weeks to develop. so it is likely that they reflect the adaptive
rcspon!>es rather than the immediate pharmacodynamic effects of
the drug. This is well documented for antidepressant drugs (Ch. 39)
and some antipsychotic drugs (Ch. 38). The development of
dependence on drugs such as opiates, benzodiazepines and ps}-
chostimulants is similarly gradual (Ch. 43). Thus one has to take
into accoun t not only the primary interaction of the drug with tts
target, but also the secondary response of the brain to thi'>
primary effect: it is often the secondary response, rather than the
primary effect. which leads to clinical benefit.
A furthe r important factor in CNS pharmacology is the exist-
ence of the blood-brain barrier (sec Ch. 4), penetration of which
req uires mo lecules to traverse the vascular endothelial cclb
 C HEMI CAL TRANSMISSION AND DRUG ACTION IN THE CENTRAL NERVOUS SYSTEM

b
3

Fig. 32.2 Simplified scheme of neuronal interconnections in the central nervous system. Neurons 1, 2 and 3 are shown
releasing transmitters a, b and c, respectively, which may be excitatory or inhibitory. Boutons of neuron 1 terminate on neuron 2, but
also on neuron 1 itself, and on presynaptic terminals of other neurons that make synaptic connections with neuron 1. Neuron 2 also
feeds back on neuron 1 via interneuron 3. Transmitters (x and y) released by other neurons are also shown impinging on neuron 1. Even

____ J
with such a simple network, the effects of drug-induced interference with specific transmitter systems can be difficult to predict.
_...

rather than going between them. ln general, only small non-polar

molecules can diffuse passively across cell membranes. Some
neuroacti\e drugs penetrate the blood-brain barrier in !his way.
but man) do so via tran-.porter!>, which either facilitate entry into
the brain or dimini'>h it by pumping !he compound from the
endothelial cclltnterior back into the bloodstream. Drugs !hat gain
ent!) in thi'> way include L-dopa (Ch. 35). valproate (Ch. 40) and
vanou'> ~cdative histamine antagonists (Ch. 14). Drugs that are
excluded include many antibacterial and anticancer drugs !hat are
substrates for the P-glycoprotein transporter (see Cbs 4 and 45).
Sc\cr.tl'>uch transporters have been identified. and their importance
in relation to drug action in the brain is becoming increasingly
apparent (see review by Tarnai & T suji, 2000).
THE CLASSIFICATION OF PSYCHOTROPIC
DRUGS
P~ychotropic drug'> are defined as those !hat affect mood and
beha\ iour. Because these indices of brain function are difficult to
define and measure, !here is no consistent basis for classifying
P')chotropic drugs. Instead. we find a confusing melee of tenns
relating to chemical '>tructure (benzodiazepines. butyropheoooes,
etc.). biochemical target (monoamine ox idase inhibitors.
serotonin reuptake inhibitors. opiates. etc.). behavioural effect
(hallucinogens. ps)chomotor stimulants) or clinical use (anti-
depressants. antips)chotic agents. antiepileptic drugs, etc.),
togc:ther with a number of indefinable rogue categories (atypical
antipsychotic drugs, nootropic drugs) thrown in for good
mea~ure.
However, grumbling about terminology is fruitless. The
following classification is based on that suggested in 1967 by the
World Health Organization; although flawed, it provides a basis
for the material presented later (Chs 37-43).
Drug action In the central
The basic types of drug target (ion channels,
receptors, enzymes and transporter proteins)
described tn Chapter 3 apply in the central nervous
system, as elsewhere.
Most of these targets occur in several different
molecular isoforms, the functional significance of
which is, in most cases, unclear.
Many of the currently available neuroactive drugs are
relatively non-specific, affecting several different
targets, the principal ones being receptors, ion
channels and transporters.
The relationship between the pharmacological profile
and the therapeutic effect of neuroactive drugs is
often unclear.
Slowly-developing secondary responses to the primary
interaction of the drug with its target are often important
(e.g. the delayed efficacy of antidepressant drugs,
and tolerance and dependence with opiates).
Anaesthetic agents
Definition: dntg!> used to produce surgical anaesthesia
Examples: halothane, propofol
See Chapter 36
Anxiolytics and sedatives
Synonyms: hypnotics. sedatives, minor tranquillisers
Definition: drugs that cause sleep and reduce anxiety
Examples: barbiturates, bcnzodiazepines
Sec Chapter 37 4 77
 SECTION 4 . THE NERVOUS SYSTEM

Antipsychotic drugs (particularly visual hallucinations) and of behaviour in ways

Synonwns: neuroleptic 3 drugs, amischizophrenic drugs, major
tranquillisers
Definition: drugs that are effective in relieving the symptoms
of schizophrenic illness
ramples: clozapine, chlorpromazine. haloperidol
See Chapter 38
Antide pressant drugs
Definition: drugs that alleviate the symptoms of depressive
illne~s
Examples: monoamine oxida1.e inhibitors, tricyclic
antidepressants, selective serotonin reuptake inhibitors
Sec Chapter 39
Analgesic drugs
Definilion: drugs used clinically for controlling pain
Examples: opiates, carbamaLe pine
See Chapter 4 I
Psychomotor s timulants
Synonym: psychostimulants
Definition: drugs that cause wakefulness and euphoria
Examples: an1phetamine, cocaine and caffeine
See Chapter 42
Psychotomimetic drugs
Synonyms: hallucinogens, psychodysleptics 3
Definilion: drugs that cause disturbance of perception
YJnese '>lntnge terms nrc the remnant~ o f a classification proposed by Javel
in 1903. who distingui.,hcd p~ycholeptic' (depressants of mental function),
pS)Choanaleptics (~timulanll. of mental function) and psycbodysleptics
(drugs that produce dt\turbed mental funclion). The term neurolepttc
(literal ly ' nerve seizing') was coined 50 years later to cle~cribe
chlorpromtuinc-like drugs (sec Ch. 38). It gained favour, preswnably by
vinue of it\ brevity rather than its literal meaning.
that cannot be ~imply characterised a!> sedative or stimulant
effects
Examples: lysergic acid diethylamide, mescaline and
phencyclidine
See Chapter 43
Cognition enhancers
Synonyms: nootropic drugs
Definition: drugs that improve memory and cognitive
performance
Examples: acetylcholinesterase inhibitor::. (e.g. donepezil.
galantamine. rivastigmine (Ch. 10), NMDA receptor
antagonists (e.g. memantine, Ch. 33), piracetam (improves
cognitive function in animal teste;, but not proven in humans).
This is something of a wbhful category, in that several
classes of drugs that improve learning and memory in animal
tests have not been shown to do so in humans.
Some drugs defy classification in this scheme, for example lithium
(see Ch. 39), which is used in the treatment of manic-depressive
psychosis, and ketamine (sec Cb. 36), which is classed as a
dissociative anae~thetic but produces psychotropic effects rather
similar to those produced by phencyclidine.
rn practice, the use of drugs in psychiatric illness frequently cuts
across the specific therapeutic categories listed above. For example,
it is common for antipsychotic drugs to be used as rranquiJiisers'
to control extremely anxious or unruly patienLs. or to treat severe
depression. Antidepressant drugs arc often used to treat neuro-
pathic pain (Ch. 41), and certain psychostimulants are of proven
efficacy for treating hyperactive children. The simple-minded
phannacologist, confronted with the realities of clinical practice,
may find this confusing. Here we will adhere to the conventional
pharmacological categories, but it needs to be emphasised that in
clinical use these distinctions arc often disregarded.

REFERENCES AND FURTHER READING

Barai13nO 0 E. Ferris CD, SnyderS H 2001 Atyprcal
ncurolmc"cngcrs. Trend' Ncurosci 24: 99-106 (Short
trendy rtr..w 011 some emrbli tired mediator.r. !UI"h as
nuric o~ule, and some .rpuulatie: ones. such a.\
carbon fll(>nll.tide and n-fenneJ
Beur P. V<lltcrra A 2001 A neuron-glia \ignalhng
networl.. m the acti'e brnm. Curr Opm Neurobiol II:
387-394 (G()(x/ ;/um m ilw MlfJhasishrll tire
intercmmmmication between glial cells and nturons-
11 topic rti/1 poorly undentooJ but ofgro" rn11
importanu)
Cooper J R. Bloom F E. Roth R H 2~ Biochemical
ba;i; of neuropharmacology. Oxford University Press,
New York (Excellent 11nd IY!olioble arrormt fo<using
on basrc ruther than diniml W.fH!CIS)
Davr; K L. Charney D. Coyle J T, Nemeroff C (ed')
2002 Neuropsychopharmacology: the lifih genemuon
of progress. LippincotL Williams & Wilkins,
Phrladelphia (A 2000-page: monster with t!xullmr and
authoritotie ani< les on ba.src and clmical aspects)
De Doer A G. van der Sandt I C J, G:ullard P J 2003 The
role of drug tran>poners at the hlood-bruin bamer.
i\rrnu Rev Pharmncol Toxicol 43: 626-629
(Comprelremie rt'l'i~ of the moluular trature of
blood-brain barrier transporten and their
pharmacological ti~mjicanct)
Field> R D. Stecn\Grnham B 2002 New insight\ into
neuron-glia communication. Science 298: 556 562
Knodel E, Schwam J H, Jesse II T M 2000 Princ1ples of
neural science. 4tll cdn. Elo;evier, New York (Excel/em
and tfmtrltd standort! tett on neurobioiOfil) lrrtle
empha <is on pharnwwii>J())
Nestler P. J, Hyman S E. Malcnka R C 2001 Molecular
neurophannacology. McGmw-Hill. New York (Good
modem tl'llbook)
Tarruu I. T\UJI A 2000 Tr.ln,poner-medrated penneauon
of drug\ aero tbc hlood- bnun barrier. J Phann Sci
89: I~72 1388 (Good review of the role of tran.rpon
tni'C'hllllWIIS 111 detenninin~ transfer oj1lriiRS and
enda~;en1tut molecules into and ou1 of thl' bram)
Vizi E S 2000 Role of h1gll aflinil) receptvr. and
membrane transpone" rn nonsynapuc comrnunicauoo
:md drug action in the central nervou' ~yMem. Pbarm
Rev 52: 63- 89 (Comw~henJie rel'ie" of
Mun>mt><iulmory muhannm; in the CNSl

-,-.......,._ _4_7_8
 Amino acid transmiHers
Overview 479
r--
Excitatory amino acids 479
-Excitatory amino acids os C NS transmitters 479
-Metabolism and release of a mino acids 480
Glutamate 480
-Glutamate receptor subtypes 480
-Functional role of glutamate receptors 484
-Drugs acting on glutamate receptors 485
r--
yAminobutyric acid 487
-Synthesrs storage and function 487
-GABA receptors: structure and pharmacology 488
-Drugs acting on GABA receptors 488
Glycine 490
Concluding re marks 490
OVERVIEW
In this chapter, we discuss the major
neurotransmitters in the central nervous system
{CNS), namely the excitatory transmitter,
glutamate, and the inhibitory transmitters, GABA
and glycine. It is an area in which scientific interest
has been intense in recent years, producing a
prolific literature and, for many of us, a stiff
measure of information overload. Unravelling
some of the complexities of amino acid receptors
and signalling mechanisms has thrown
considerable light on their role in brain function
and their likely involvement in CNS disease. Drugs
that target specific receptors and transporters have
been developed, but translating this knowledge
into drugs for therapeutic use has been very slow
going. Here, we present the pharmacological
principles and include recent references for those
seeking more detail.
EXCITATORY AMINO ACIDS
EXCITATORY AMINO ACIDS AS CNS
TRANSMinERS
L-glutamate is the principal and ubiquitous excitatory transmiuer
in the CNS (sec Cotman et al., 1995, for general review). Aspartate
plays a similar role in certain brain regions, and possibly also
homocysteate, but this is controversial. The realisation of gluta-
mate's importance came slowly (see Watkins & Jane, 2006). By
the 1950s (in the wordl> of Kmjevic, one of the glutamate pioneers,
the em of Prehil>tory'). work on the peripheral nervous system
had highlighted the transmitter roles of acetylcholine and
catecholamines. and <ll> the bmin also contained these substances.
there seemed little reason to look further. The presence of
'Y-aminobutyric acid (GABA: see below) in the brain, and its
powerful inhibitory effect on neurons. were discovered in the
1950s, and it~ transmitter role was postulated. At the same time,
work by Curti!;~ group in Canberra showed !hal glutamate and
various other acidic amino acids produced a strong excitatory
effect, but it seemed inconceivable that such workaday metabo-
lites could actually be transmitters. Through the 1960s (the 'Dark
Ages'), GABA and excitatory amino acids (EAAs) were thought,
even by their discoverers. to be mere pharmacological curiosities.
In the 1970s (the 'Renaissance'). the humblest amino acid, glycine,
was established as an itthibitory transmitter in the spinal cord,
g iving the lie to the idea that transmjtters had to be exotic
molecules, too beautiful for any role but to sink into the arms of
a receptor. Once glycine had been accepted, the rest quickly
followed (the 'Baroque era', an apt phrase to describe the intricate
detail that has since been added to the basic discovery). A major
advance was the disco,ery of EAA antagonists. based on the
work of Watkins in Brh.tol, which enabled the physiological role
of glutamate to be established unequivocally, and also led to the
realisation that EAA receptors are heterogeneous.
To do ju'>tice to the wealth of discovery in this field in the past
two decades is beyond the range of this book: for recent reviews
giving more detail, see Conn & Pin (1997), Dingledine et at. (1999)
and Javitt (2{)()..l). Here we concentrate on pharmacological aspects.
Disappointingly, hardly any therapeutic drugs have yet been
introduced on the basis of EAA mechanisms, 1 despite the many
1
Mcmnnt inc, an NMDA antagonist. is licensed for the treatment of
moderate to ~cvcrc Al1hcimer'~ disea>c (Ch. 35) bu t is no magic wand!
4 79
 SECTION 4 . THE NERVOUS SYSTEM

potential applications that exist. The 'Industrial Revolution' seems
to be running late.
METABOLISM AND RELEASE OF AMINO
ACIDS
Glutamate is widely and fairly uniformly distributed in the CNS,
where its concentration is much higher than in other tissues. It has
an important me tabolic role, the metabolic and neurotransmitter
pool!. being linked b)' transaminase enzymes that catalyse the
interconversion of glutamate and a-oxoglutarate (Fig. 33.1).
Glutamate in the CNS comes main ly from either glucose, via the
Krebs cycle, or glulllmine, which is synthesised by glial cells and
taken up by the neurons; very lillie comes from the periphery.
The interconnection between the pathways for the synthesis of
EAAs a nd inhibitory amino acids (GABA and glycine). shown in
Figure 33.1, makes it difficult to usc experimental manipulations
of tran~miuer synthesis to study the functional role of individual
amino acids, because disturbance of any one step will affect both
excitatory and inhibitory mediators.
ln common with other transmitters, glutamate is stored in
synaptic vesicles and released by Ca 2+-depcndent exocytosis:
specific transporter proteins account for its uptake by neurons
and other cells, and for its accumulation by synaptic vesicles (see
Ch. 9). Released glutamate is taken up by cells in exchange for
a (cf. monoamine transporters-Ch. 9). and transported into
synaptic vesicles, by a different transporter driven by the proton
gradient across the vesicle membrane. l n contrast to the s ituation
with monoamine synthesis and transport (Chs ll and 34), few
drugs (none in clinical use) arc known that interfere specifically
with glutamate metabolism.
The action of glutamate is terminated mainly by carrier-mediated
reuptat...e into the nerve terminals and neighbo uring astrocytes
(Fig. 33.2). This transport can, under some circumstances (e.g.
dcpolarisation by increased cxtr<tcellular K+). operate in reverse
and constitute a source of glutamate relea~c (see Takahashi eta!.,
1997), a process that may occur under pathological condjtiom
~uch as brain ischaemia (sec Ch. 35). Glutamate taken up by astro-
cyte<, is converted to glutamine and recycled. via transporters. bad.
to the neurons, which convert the glutamine back to glutamate.
Glutamine, which lacks the pharmacological activity of glutamate,
thus serves a~ a pool of inactive transmiuer under the regulatory
control of the astrocytes. which act a~ ball boys, returning the
ammunition in harmless form in order to rearm the neurons.
Glutamate uptake is coupled to Na~ entry, and several tran~
portcrs have been cloned and characteri.,cd in detail (see Shigeri
et al.. 2004).
GLUTAMATE
GLUTAMATE RECEPTOR SUBTYPES
On the basis of ~tudies with ~electi ve agonists and antagonists
(Fig. 33.3), four main subtypes of EAA receptors can be dis-
tinguished. namely NMDA , Ai\lPA . kaina te and metabotropic
receptors (Table 33.l), all of which have been cloned and
studied in great detail (see Conn & Pin, 1997; Dingledine et al..
1999). The first three arc ionotropic receptors, named according
to their specific agonists. 2 The channel consim of four <,ubunits.
~A MPA and kaina1e receptors ar.: pharmacologically simil ar and are often
lumped toge1her a\ AMPA!kainatl' or non-NMDA receptors.

Glyoxylate

Succ1n1c

sem;a~G~\
TRICARBOXYLIC Succinate.......,__ __ _ ___.
ACID
Fig. 33.1 Metabolis m of CYCLE
tra ns mitte r ami no acids in the
brain. Transmitter substances are As pa rtate Txaloaceta~t_e_ _
marked with green boxes. GABA-T,
GABA transaminase; GAD, glutamic
~cid decarboxylase.
\.Transaminase )
-,.,- 480
----
 AMINO ACID TRANSMITTERS

NEURON ASTROCYTE

GlnT GlnT
--------- ---\
l
Gin~

I
\.. Glutaminase J

EAAT
Glu ~ -- - --------
'' Gin

VGiot~ ' I
I
I
I Glutamine
synthase
Glu I
...._ ~

Fig. 33.2 Transport of I

I
glutamate (Giu) and glutamine I
Glu
I
(Gin) by neurons and astrocytes.
Released glutamate is captured
partly by neurons and partly by
j I
I
I
I
I
J..I
I

astrocy1es, which convert most of it Glu ' EAAT

'

l
to glutamine. EAAT, excitatory amino '
'
acid transporter; GlnT, glutamine , ,,'
transporter, VGiuT, vesicular
glutamate transporter. Glu :::::-----------

EXCITATORY INHIBITORY

COOH
COOH

H,N~COOH ~
COOH

H,N~COOH
TAANSMITIERS
NH 2 H2N~OOH
Glutamate Aspartate GABA Glycine

OH

~l
COOH

~
COOH
H 2P0 3

H,N~COOH
COOH

'N~COOH
SYNTHETIC OH toCI
ANALOGUES
)dCOOH
H H 2N COOH H NH 2 NH2
NMDA AMPA Kainate AP-4 Musc1mol Baclofen

Flg. 33.3 Structures of agonists acting on glutamate, GABA and glycine receptors. The receptor specificity of these compounds
1s shown in Tables 33.1 and 33.2. AP-4, 3-amino-4-phosphonopentanoic ac1d. AMPA, a amino-3-hydroxy-5-methylisoxazole-4-propianic
acid; NMOA, N-methyl-0-asparatic acid.

each Y.ith the 'pore loop' !>tructure shown in Figure 3.18. NMDA
receptor.. arc U\~embled from two types of subunit. NR 1 and NR2
each of which can exist in different isoforms and splice variants,
gi\ing rise to many different receptor isoforms in the brain,
whose significance is not yet understood-a scenario by now
familiar to our readers. The subunits comprising AMPA and kainate
receptors, termed GluR 1 7 and KA 12 , are closely related to, but
distinct from. NR ~>ubunits. AMPA receptors consist of combina-
tions of GluR 1 4 3 AMPA receptors lacking the GluR2 subunit
'AMPA receptor subunil'o arc also !.ubject to other kinds of variation,
namely alternative \plicing, giving rise to the engagingly namedj7ip and
j10fl vuri:mt,, um.l RNA ed iting at the single amino acid level. both of which
contribute yet more functl()nal diven,ity to this motley family. 481
 SECTION 4 . THE NERVOUS SYSTEM

Table 33.1 Properties of excitatory amino acid receptors

NMDA AMPA Kainate M etabotropic

Subunit Tetramers consisting of NR 1 and Tetramers consisting of Tetramers consisting Dimeric G-

composition NR2 subunits GluR1-4 subunits (variants of GluRs-7 subunits protein-coupled
associated with alternative plus KA 12 receptors
splicing and RNA editing)

Receptor site Modulatory site

(glycine)
Endogenous Glutamate Glycine Glutamate Glutamate Glutamate
agonist(s) Aspartate 0-Serine

Other NMDA Cycloserine AMPA Kainate D-AP4

agonist(s)' Quisqualate Domoate ACPD

Antagonist(s) AP-5, AP-7 7-Chloro- NBQX NBQX MCPG

CGS 19755 kynurenic acid CNQX LY 377770
(selfotel) ACEA 1021 LY 293558
CPP HA-466
LY 235959

Other Polyamines (e.g. spermine, Cyclothiazide

modulators spermidine) Anlracetam
Mg2 , Zn2 Ampakinesb
Piracetam

Channel Dizocilpine (MK801) Not applicable

blockers Phencyclidine
Ketamine
Remacemide
Memantine
Mg2

Effector Ligand-gated cation channel Ligand-gated cat1on channel Ligand-gated cation G-protein--<:oupled
mechanism (slow kinetics, high Ca?. (fast kinet1cs; channels channel (fast kinetics, Qnositol trisphosphate
permeability) possessing GluR 2 subunits low Ca2 permeability) formation and release
show low Ca2' permeability) of Ca2')

Location Postsynaptic (also glial) Postsynaptic Pre- and postsynaptic Pre- and postsynaptic
Wide distribution

Function Slow epsp Fast epsp Fast epsp Synaptic modulation

Synaptic plasticity (long-term Wide distribution ? Presynaptic inhibition Excitotoxicity
potentiation, long-term depression) Limited distribution
Excitotoxicity

ACPD, 1-aminocyclopentane-1,3-dicarboxylic ac1d; AP-5, 2-amino-5-phosphonopentanoic acid; AP-7, 2-amino-7-phosphonoheptanoic

acid; CNQX, 6-cyano-7 -nitroquinoxaline-2,3-dione; CPP, 3-(2-carboxypirazin-4-yl)-propyl-1-phosphonlc acid; epsp, excitatory
postsynaptic potential; MCPG, CL-methyl-4-carboxyphenylglycine; NBQX, 2,3-dihydro-6-nitro-7-sulfamoyl-benzoquinoxaline. (Other
structures are shown in Figure 33.3.)
structures of experimental compounds can be found in Brauner-Osborne et al. (J Med Chern 43: 2609-2645, 2002).
0
Ampakine is a term invented to describe a number of compounds that appear to enhance the action of AMPA receptor agonists.

have much higher permeability to Ca 2+ than the other~. which has
important functional consequences (see Ch. 4). The metabotropic
receptor:. are G-protcin-coupled receptors linked to intracellular
second messenger systems (see Ch. 3; Conn & Pin, J 997), and
comprise eight subtypes in three main classes (Table 33. 1). They
arc unusual in showing no sequence homology with other G-
protein-coupled receptors. They posses~ a very large extracellular
"'-....._ _4_8_2 N-terminal tail (class C ; see Table 3.2). which contains the
glutamate-binding site, in contraM to most amine receptors
(class A), in which the agonist binding site is buried among the
transmembrane helices (Ch. 3).
Binding studies show that glutamate receptors are most abundant
in the cortex. basal ganglia and ~ensory pathways. NMDA and
AMPA receptors are generally colocalised, but kainate receptor~
have a much more restricted distribution. Expression of the
many different receptor subtypes in the brain also shows diMinct
 AMINO ACID TRANSMITTERS

regional differences. but we have hardly begun to understand the
,ignificance of thi\ extreme organisational complexity.
SPECIAL FEATURES OF NMDA RECEPTORS
The N\IDA rcccpto~ and their associated channels have been
\tudied m more detail than the other types and show special
pharmacological properties, summarised in Figure 33.4. which
arc po~tulated to play a role in pathophysiological mechanisms.
They are highly permeable to Ca2, as weU as to other
cations, so activation of MDA receptors is particularly
effective in promoting Ca2+ entry.
They are readily blocked by Mi'". and this block shows
marked 'oltage dependence. It occurs at physiological Mg2
concentration~ when the cell is normally polarised, but
disappear~ if the cell i!> depolarised.
Activation of NMDA receptors requires glycine as well as
glutamate (Fig. 33.5). The binding site for glycine is distinct

RECEPTOR MODULATORY RECEPTOR

SITE SITES SITE

\
Channel-blocking Channel-blocking
drugs drugs
I
I
I

I
y
NMDA receptor GABAA receptor
Fig. 33.4 Main sites of drug action on NMDA and GABAA receptors. Both receptors are multimeric ligand-gated ion channels.
Drugs can act as agonists or antagonists at the neurotransmitter receptor site or at modulatory sites associated with the receptor. They
can also act to block the ion channel at one or more distinct sites. In the case of the GABAA receptor, the mechanism by which 'channel
modulators' (e.g. ethanol, anaesthetic agents) facilitate channel opening is uncertain; they may affect both ligand binding and channel
sites. The location of the different binding sites shown in the figure is largely imaginary, although study of mutated receptors is beginning
to reveal where they actually reside. Examples of the different drug classes are given in Tables 33.1 and 33.2.

lAJ
NMDA
rru Glu
NMOA Gly + Gly Glu + Gly
--.__...;--

-55
1100 pA ~
c D
Quis Kal
Quis + Gly Kai +Giy

~--w-
u-u
Fig. 33.5 Facilitation of NMDA by glycine. Recordings from mouse brain neurons in culture (whole-cell patch clamp technique).
Downward deflections represent inward current through excitatory amino acid-activated ion channels. 1A1 NMDA (10 l!mol/1) or glycine
(1 )lmol/1) applied separately had little or no effect, but together produced a response. B The response to glutamate (10 f.!mol/ 1, Glu) was
strongly potentiated by glycine (1 f.!mol/1, Gly). C and D. Responses of AMPA and kainate receptors to quisqualate (Quis) and kainate
(Ka1) were unaffected by glycine. (From Johnson J W, Ascher P 1987 Nature 325: 529-531.)
483
 SECTION 4 . THE NERVOUS SYSTEM

from the glutamate-binding site, and both have to be

occupied for the channel to open. This discovery caused a
Control APV
stir, because glycine had hitherto been recognised a~ an o.5mVL
inhibitory transmitter (sec below). so to find it facilitating J Before J Before 1oms
excitation ran counter to the prevailing doctrine. The
concentration of glycine required depends on the subunit ~ Vc:-
composition of the NMDA receptor; for some NMDA e- 250
receptor subtypes, physiological variation of the glycine
concentration may serve as a regulatory mechanism, whereas ~ 200
others arc fully activated at all physiological glycine -8
2
concentrations. Competitive antagonists at the glycine site a 1so
E APV
(see Table 33.1) indirectly inhibit the action of glutamate. "' 100
l7;
Recently (see Miller, 2004). a surprising molecule, 4 namely .,a.
o-serine, has been found to activate the NMDA receptor via L- Condittonlng tratn
the glycine site and to be released from astrocytes. 0 15 30 45 60
Certain well-koown anaesthetic and psychotomimetic agents, Mtnutes
such as ketamine (Ch. 36) and phencyclidine (Ch. 42). are
selective blocking agents for NMDA-operated channels. The Control CNQX (5j.tmolll)
CNQX (5~tmofl1)
APV (SOj.tmol/1)
experimental compound dizocilpine (codename MK801)
shares this property.
Certain endogenous polyamines (e.g. s permine, s permidine)
-~ _f".- - -
act on a different accessory site to facilitate channel opening.
2omv[_
The experimental drugs ifenprodil and cliprodil block their
50ms
action.
Fig. 33.6 Effects of excitatory amino acid receptor
antagonists on synaptic transmission. ~ APV (NMDA
FUNCTIONAL ROLE OF GLUTAMATE
antagonist) prevents long-term potentiation (LTP) in the rat
RECEPTORS hippocampus without affecting the fast excitatory postsynaptic
potential (epsp). Top records show the extracellularly recorded
The AMPA receptors, and in certain brain regions kainate
fast epsp (downward deflection) before, and 50 minutes after, a
receptors (sec Bleakman & Lodge, 1998). serve to mediate fast conditioning train of stimuli (1 00 Hz for 2 s). The presence of
excitatory synaptic transmission in the eNS-absolutely essential LTP in the control preparation is indicated by the increase in
for our brains to function. Kainate receptors also have a epsp amplitude. In the presence of APV (50 ~tmol/1), the normal
presynaptic role (see Huenner. 2003). AMPA receptors occur on epsp is unchanged, but LTP does not occur. Lower trace
shows epsp amplitude as a function of time. The conditiomng
astrocytes as well as on neurons, and these cells (see Ch. 32) play
train produces a short-lasting increase in epsp amplitude,
an important role in communication in the brain. NMDA receptors which still occurs in the presence of APV, but the long-lasting
(which often coexist with AMPA receptors) contribute a slow effect is prevented. [81 Block of fast and slow components of
component to the excitatory synaptic potential (Fig. 33.6). the epsp by CNOX (6-cyano-7-nltroquinoxaline-2,3-dione; AMPA
magnitude of which varies in different pathways. Metabotropic receptor antagonist) and APV (NMDA receptor antagonist). The
epsp (upward deflection) in a hippocampal neuron recorded
glutamate receptors are linked either to inositol trisphosphate
with intracellular electrode is partly blocked by CNQX (5 11mol/1),
production and release of intracellular Cal+. or to inhibition of leaving behind a slow component, which is blocked by APV
adcnylyl cyclase (see Ch. 3). They arc located both pre- and (50 )lmOVI). (From: (A) Malinow R, Madison 0, Tsien R W 1988
postsynaptically, like other glutamate receptors. and also occur Nature 335: 821; (B) Andreasen M, Lambert J D. Jensen M S
on astrocytes. Their effects on transmission are modulatory rather , 1989 J Physiol 414: 317-336.)
than direct, compri!>ing mainly postsynaptic excitatory effects
(by inhibition of potassium channeb) and presynaptic inhibition
(by inhibition of calcium channels).
In general, it appears that NMDA and metabotropic receptors blocked, brain function shut'> down entire!); nevertheless, tbc}
play a particular role in long-term adaptive and pathological too are involved in synaptic plasticity.
changes in the brain, and are of particular interest as potential Two aspects of glutamate receptor function are of particular
drug targets. AMPA/kainatc receptors, 011 the other hand, are mainly pathophysiological importance, namely synaptic plasticity.
responsible for fast excitatory transmission. and if they are fully discussed here, and excitotoxicity (discussed in Ch. 35).

SYNAPTIC PLASTICITY AND LONG-TERM

POTENTIATION
4
Surpri'>ing. becau!te it i'> the 'wrong' enantiomer for amino acids of higher
- ...____.,___
4_8_4
organ t\m>. Nevcrthcle>'t, vertebrate> pos<,e;,<, spectfic enzymes and Synaptic plasticity is a general tenn to describe long-term changes
transporters for this o amino acid. wbich is abundant in the brain. in synaptic connectivity and efficacy, either following physiological

alterations in neuronal activity (as in learning and memory), or
n:;,ulting from pathological disturbances (as in epilepsy, chronic
pain or drug dependence). Synaptic plasticity underlies much of
\\hat \~e call 'brain function'. and understanding it has been a Holy
Grail for neurobiologhts for decades. Needless to say, no single
mechanl'm ts re~pon~ible; however. one significant and much-
'tudied~ component i\ long-term potemiarion (LTP). a phenomenon
in \\hich glutamate and NMDA receptors play a central role.
Longtcrm potentiation (see Malenka & Nicoll. 1999; Bennett,
20001 is a long-lasting (hours in vitro, days or weeks in vivo)
enhancement of synaptic transmission that occurs at various CNS
..ynapse~ following a short (conditioning) burst of high-frequency
prcs}naptic stimulation. Its counterpart is long-term depression,
\\hich is produced by a longer train of stimuli at lower frequency.
These phenomena have been studied in great detail in the hippo-
campus (Fig. 33.6). which plays a central role in learni ng and
memory. It has been argued that ' learning', in the synaptic sense,
can occur if ~ynaptic strength is enhanced following simultaneous
activity in both pre- and postsynaptic neurons. LTP shows this
charactcri\tic; it docs not occur if presynaptic activity fails to excite
the po~t'>ynaptic neuron, or if the latter is activated independently.
tor in<,tancc by a different presynaptic input. Thus LTP initiation
imohc~ hoth the pre!>ynaptic and postsynaptic components. and
11 re,ults from enhanced activation of AMPA receptors at EAA
')nap'e'. The facilitatory process also appears to involve both
pre and po\1\)'naptic elements (although the small-print argument
rumbb on ahout whether increased transmitter release does or
doe' not occur in LTP): the response of postsynaptic AMPA
receptors to glutamate i'> increased, and so (probably) is glutamate
release. Increased cxpres<,ion and trafficking of AMPA receptors
to S)napuc \itcs al. o occurs. The following experimental results
ha\e led to the model ~hown in Figure 33.7, in wh.ich activation
of 1\fMDA receptors and metabotropic glutamate receptors
indtrccrly sethitiscs AMPA receptors.
NMDA antagonists prevent LTP, without affecting normal,
non-potentiated transmission (which depends on AMPA
receptors). Disruption of the NMDA receptor gene has the
\ame effect.
LTP occur\ only if the postsynaptic cell is depolarised at the
time when the conditioning burst of stimulation is delivered.
Blocking AMPA receptors prevents this, and prevents LTP.
Antagoni.,ts at metabotropic glutamate receptors reduce the
duration of LTP; LTP is also impaired in transgenic mice
lacking the mGiuR t receptor.
Ca' entry into the post:.ynaptic cell is required, and there is
c\tdcnce that activation of protein kinase C (see Ch. 3),
rc\ulting in pho.,phorylation of AMPA receptors. is involved
in the mechanbm of potentiation.
LTP i" reduced by agents that block the synthesis or effects
of nitric oxide or arachidonic acid. One or both of these
medtator:. may be the hitherto elusive 'retrograde messenger'
through which events in the postsynaptic cell are able to
s 'A recent review notcu that over 3000 papers on LTP were published during
tl the 1990.,, nearly one per <.lay. Which i~ a lot!
AMINO ACID TRANSMITTERS
influence the presynaptic nerve terminal. Anandamide, released
by the po\t'>ynaptic cciJ, may also play a role by reducing the
release of GABA from inhibitory nerve endings (see Ch. 15).
T Two 'pecial propcnie\ of the NMDA receptor and channel underlie its
in\'OI\'emem 10 LTP. namely voltage-dependent channel block by Mg~
and ih high Ca~ permeabillt). At normal membrane potemiab. the
NMOA chanll<!l i' blocked by Mt: a ~ustained postsynaptic depolari\ation
produced by glutamme acting repeated!) on AMPA receptors, howe\er,
removes the Mg 2 bloc!... and NMDA receptor activation then allows Ca~
to enter the cell. The metabotropic EAA receptor also contribute\ to the
increase 10 [Ca 2'),. This ri~e in [Ca~l, in the postsynaptic cell activate
prote1n kina-;es. phm.pholipase~ and rtitric ox.ide synthase, which act
jointly (by mechanhm~ that arc not yet fully understood) to facilitate
tran~mi~'ion via AMPA receptors. Initially. during the induction phase of
LTP. pho;phorylmion of AMPA receptors increases their responsiveness
to glutamate. Later. during the maimenance phase, more AMPA receptors
arc recru ited to the postsynaptic membrane as a result of altered receptor
trafficking; later still. various other med iators and signalling pathways arc
activmcu. causing structu ra l changes and leading to a pcrmanem increase
in the number of ~yn aptic contacts.
Although LTP i'> well eMablhhed as a synaptic phenomenon, it~ rela.ion~hip
to learning anu memory remain~ controversial (although the evidence i.,
~ug.ge\uvc). For example. NMDA receptor antagonists applied to the
hippocampu~ impair learning in raL\; al~o. 'satumtion' ofLTP by electrical
\timulntion of the h1ppocampus bas been found to impair the ability of
rats to learn ho" to navigate a m;ue. Furthermore. LTP-Iike changes ha\'e
been detected after learning has taken place. Thus there is hope that drugs
capable of enhancmg. LTP may improve learning and memOJ).
Long-term potentiation i;, ju\l one manifeMation of synaptic plasticit}.
whereby neuronal connections re~pond to change~ in the activity of the
ner\OU\ sy\tem. Other phenomena. including shon-tenn potentiation and
long term depre\\ion. aho occur. and the} too appear to invohe
glutamntc reccpto~ ('ce Malenil.a & Nicoll. 1993}. LTP and long-tenn
depre\\ion :tre not confined to hippocampal regions involved in learning
and memof). but occur throughout the CNS. Glutamate receptors play a
central role in al l c:1ses so far studied. but other mediatoN, such a~
endocannabinoiu,, may also be mvolved (see Malenka & Bear. 2~).
DRUGS ACTING ON GLUTAMATE
RECEPTORS
ANTAGONISTS
Much effort, based on the work of Watkins and h.is colleagues.
has gone into the search for selective glutamate antagonists, partly
to provide tool!. for better understanding the physiological roles
of the different types of EAA receptor. and partly as potential
therapeutic agent<, with which to treat, for example, epilepsy,
psychiatric and neurodegenerative disorders.
The main type'> of EAA antagonists are shown in Table 33.1.
They are selective for the main receptor types but generally not for
specific l>Ubtype~. Many of these compounds, although very useful
al> experimental tools in \itro. are unable to penetrate the blood-
brain barrier, so they are not effective when given systemically.
NMDA reccpton.. a<> discussed above. require glycine as well
as MDA to activate them, so blocking of the glycine site is an
alternative way to produce antagonism. Kynurenic acid and the
more potent analogue 7-chloro-kynurenic acid act in this way,
as do various compounds currently in development.
Another l>ite of block is the channel itself, where various
substances act, for example ketamioe and phencyclidine.
Dizocilpine. remacemide and memantine are more recent 485
 SECTION 4 . THE NERVOUS SYSTEM

- - - - - - - - - -- -- ------ ------
rAJ Normal tran sm iss ion (ru After conditioning t ra in
AMPA receptors only activated AMPA, NMDA, metabotropic receptors activated
Increased [Ca 2],
Activation of PKC and NOS

Retrograde message

- ----"' -- -- -
Ca2I
- --,
:

y
Na
I
Na+ Na+
I
I, e Mg 2 I
y
II

' Met

' ~
y
+
;t~: PI IP3 DAG

Depolarlsation Depolarlsatlon _)
{brief) (sustained)

~
Phosphorylation of
AMPA channels
Arg NO

Long-term <:=:==J Altered gene

changes expression

Fig. 33.7 M echanism s of lo ng-term potentiation . !Al With infrequent synaptic activity, glutamate activates mainly AMPA receptors.
There is insufficient glutamate to activate metabotropic receptors, and NMDA receptor channels are blocked by Mg2 . B After a
conditioning train of stimuli, enough glutamate is released to activate metabotropic receptors, and NMDA channels are unblocked by the
sustained depolarisation. The resulting increase in (Ca2 ] , activates various enzymes, including the following.
Protein kinase C (PKC) phosphorylates various proteins, including AMPA receptors (causing facilitation of transmitter action) and other
signal transduction molecules controlling gene transcription (not shown) in the postsynaptic cell.
Nitric oxide synthase (NOS). Release of nitric oxide (NO) facilitates glutamate release (retrograde signalling, otherwise known as NO
turning back).
Phospholipase A2 (not shown) catalyses the formation of arachidonic acid (Ch. 13), a retrograde messenger that increases presynaptic
glutamate release.
A phospholipase (NAPE-PLD, not shown) that catalyses production of the endocannabinoid, anandamide (Ch. 15). Anandam1de appears
to act on GABAergic inhibitory nerve terminals, enhancing transmission by suppressing GABA release. A, AMPA receptor; DAG,
diacylglycerol; G, glutamate; IP3 , inositol (1 ,4,5) triphosphate; Met, metabotropic receptor; N, NMDA receptor; PI, phosphatidylinositol.

examples. These agents are lipid-soluble and thus able to cross
the blood-brain barrier.
The potential therapcmic interest in glutamate antagonists lies
mainly in the reduction of brain damage following strokes and
head injury (Ch. 35), as weU a~ in the treatment of epilepsy (Ch. 40)
and of Alzheimer's disease (Ch. 35). They have also been con-
sidered for indications, such as drug dependence (Ch. 43) and
schizophrenia (Ch. 38), where the rationale is less clear. Trials
with NMDA antagonists and channel blockers have so far proved
disappointing, and a serious drawback of these agents is their
486 tendency to cause hallucinatory and other disturbances (also a
feature of phencyclidine; Ch. 42). Only two NMDA receptor
antagonists, ketamine (anaesthesia and analgesia; see Chs 36 and
41) and memantine (Alzheimer's disease; Ch. 35) are in clinical
usc. Glycine site antagonists may have fewer unwanted effech,
and experimental compounds have been tested in cijnical trial\
for conditions such as stroke and epi lepsy (see Jansen &
Dannhan, 2003); the results have been inconclusive. AMPA
receptor antagonists seem unpromising as therapeutic agenL'i.
because the available agent~ (as might be expected) produce
overall CNS depression, including respiratory depression and
motor incoordination, with liule margin of safety. Only if ~ubtyp.:

-.elcctivity can be achieved i~ this approach likely to succeed.
Again't thb unpromi~ing background, antagonists at metabotropic
Excitatory amino acids
receptor\ may offer the bc~t hope (see Nicoletti et al., 1996), but
'uch compound'> are not yet available for clinical use.
0\erall. the promi\e foreseen for glutamate receptor ligands
in the clinic ha\ \imply not, so far, been fulfilled. The problem
may be that glutamate i.., \Uch a ubiquitous and multifunctional
mediator-invohcd. it seems. in almost every aspect of brain
functton-that attempting to improve specific malfunction by
flooding the brain with a compound that affects the glutamate
'}'tem Ill some way is just too crude a strategy.
AGONISTS AND POSITIVE MODULATORS
Various agonist~ at EAA receptors that are used experimentally
arc ~hown in Table 33. 1. From the clinical perspective, interest
centres on the theory that positive AMPA receptor modulators,
\~hich act by reducing receptor descnsitisation, may improve
memory and cognitive performance. Cycloth iazide, a compound
related to thiazide diuretics (Ch. 24), acts in this way but is
toxic: drug~ \uch a~ pir acctam and aniracetam. which are used
m dementia (not routinely, at least in the UK) (Ch. 35) also
~n,iti\e AMPA receptors. although it is not certain that this
accounts for their pl>ychotropic effects. Other so-called
ampakines are in development as possible drugs for improving
co~niti\e performance.
yAMINOBUTYRIC ACID
GABA 1s the main inhibitory transmitter in the brain. Tn the
spinal cord and brain stem, glycine is also important.
SYNTHESIS, STORAGE AND FUNCTION
GABA occurs in brain ti ssue but not in other mammalian tissues,
~xccpt in trace amounts. It is particularly abundant (about
10 ).lmol/g tissue) in the nigrostriatal system, but occurs at lower
concentrations (2-S ).l.moVg) throughout the grey matter.
GABA is formed from glutamate (Fig. 33. 1) by the action of
~lummic acid decarboxylase (GAD), an enzyme found only in
GABA-synthesi ing neurons in the brain. lmmunohistochemical
labelhng of GAD is used to map the GABA pathways in the
bram. GABA is destroyed by a transamination reaction in which
the ammo group is transferred to a-oxoglutaric acid (to yield
glutamate), with the production of succinic semialdehyde and then
>Uccinic acid. Thi~ reaction is catalysed by GABA transaminase,
!r
\\hich h inhibited by vigabatrine. a compound used to treat
jj
epileps) (Ch.40). GABAergic neurons and astrocytes take up
u Specific agonists and antagonists are known.
GABA \Ia spcc1fic transporter:., and it is this, rather than GABA
tran-ammase, which removes the GABA after it has been released.
GABA transport is inhibited by guvacine and nipecotic acid.
~
GABA functions as an inhibitory transmitter in many different
l\
1).
CNS pathways. About 20% of CNS neurons are GABAergic:
te most are ~hort interneurons, but long GABAergic tracts run to
the cerebellum and striatum. The widespread distribution of
d 487
GABA, und the fact that virtually all neurons are sensitive to its
le
AMINO ACID TRANSMITTERS
Excitatory amino acids (EAAs), namely
glutamate, aspartate, and possibly homocysteate, are
the main fast excitatory transmitters in the central
nervous system.
Glutamate is formed mainly from the Krebs cycle
intermediate a-oxoglutarate by the action of GABA
transaminase.
There are four main EAA receptor subtypes:
NMDA
AMPA
kainate
metabotropic.
NMDA, AMPA and kainate receptors are ionotropic
receptors regulating cation channels; metabotropic
receptors are G-protein-coupled receptors and act
through intracellular second messengers. There are
many molecular subtypes within each class.
The channels controlled by NMDA receptors are
highly permeable to Ca2 and are blocked by Mg2.
AMPA and kainate receptors are involved in fast
excitatory transmission; NMDA receptors mediate
slower excitatory responses and, through their effect
in controlling Ca2 entry, play a more complex role in
controlling synaptic plasticity (e.g. long-term
potentiation).
Competitive NMDA receptor antagonists include AP-5
(2-amino-5-phosphonopentanoic acid) and CPP (3-(2-
carboxypirazin-4-yl)-propyl-1-phosphonic acid); the
NMDA-operated ion channel is blocked by
dizocilpine, as well as by the psychotomimetic drugs
ketamine and phencyclidine.
CNQX (6-cyano-7-nitroquinoxaline-2,3-dione) is a
selective AMPA receptor antagonist.
NMDA receptors require low concentrations of
glycine as a coagonist, In addition to glutamate;
7-chlorokynurenate blocks this action of glycine.
NMDA receptor activation is increased by
endogenous polyamines, such as spermine, acting on
a modulatory site that is blocked by ifenprodil.
The entry of excessive amounts of Ca2+ produced by
NMDA receptor activation can result in cell death-
excitotoxicity (see Ch. 35).
Metabotropic receptors are dimeric G-protein-coupled
receptors linked to inositol trisphosphate formation and
intracellular Ca2 release. They play a part in glutamate-
mediated synaptic plasticity and excitotoxicity.
EAA receptor antagonists have yet to be developed
for clinical use.
 SECTION 4 . THE NERVOUS SYSTEM
inhibitory effect, suggests that its function is ubiquitous in the
brain. GABA serves as a transmitter at about 30% of all the
synapse in the CNS.
GABA RECEPTORS: STRUCTURE AND
PHARMACOLOGY
GABA acts on two distinct types of receptor, one (the GABA,.,
receptor) being a ligand-gated channel. the other (GABA 8 ) being
a G-protein-coupled receptor.6 GABAA receptors (see Barnard,
2000) belong to the same structural class as nicotinic acetylcholine
receptors (sec Fig. 3.18). They are pentamers, most of them
composed of three different subunits (a. ~. y), each of which can
exist in three to six molecular subtypes. There arc a great many
possible permutaUons. of which one (a 1 ~2y~ is by far the most
abundant overall, although dozens of other functional variants arc
expressed in specific regions-a familiar pattern of heterogeneity
typical of neurotransmitter receptors. We so far have only a
rudimentary under~>tanding of their functional roles (see Mody &
Pearce, 2004 ).
GABA 11 receptors located postsynaptically mediate fast
postsynaptic inhibition, the channel being selectively permeable
to Cl . GABA 11 receptors located perisynaptically are responsible
for slow inhibitory effects produced by GABA diffusing further
from its <>ite of release. Thus GABA produces inhibition by
acting both a<; a fast 'point-to-point' transmitter and as an action-
at-a-distance' neuromodulator. It is possible that different
GABAA receptor subtypes are involved in these two modes.
Because the equilibrium membrane potential foro- is usually
negative to the resting potential. increasing Cl- permeability
hyperpolarise~ the cell. thereby reducing its excitability. 7
GABA 8 receptor~ (see Settler et al., 2004) are located pre- and
pomynaptically, and they are typical G-protein-coupled
receptors, but unusual in that the functional receptor is a dimer
consisting of two different subunits (see Ch. 3). Apart from minor
splice variants, only a single isoform is known-also unusual
among G-protein-coupled receptors. GABA 8 receptors exert
their effects by inhibiting voltage-gated calcium channels (thus
reducing transmitter release) and by opening potassium channels
(thus reducing postsynaptic excitability), these actions resulting
from inhibition of adenylyl cyclase.
It is believed that glutamate and GABA, and their receptors,
evolved very early, so these receptors probably represent the
venerable aristocrats from which upstarts such as the neuropeptide
receptors evolved much later.
6
A third clas~. GABI\c. has recent!) been proposed (see Bonnann. 2000).
Closely re~embhng GABAAreceptors in their structure and function,
GABAc receptor.. are con~tructed from a different family of subunits
(tenned p). and ha\e \lightl) different phannacological propenie\. Their
functional \tgnificance remains unknown.
7
During early bmin development (in which GABA plays an important role).
and abo in some regions of the adult brain. GABA has an exciunory rather
than an inhibitory effect, because the intracellular cr concentration is
rclalivcly high, so that the equilibrium potential is positive to the resting
488
----
._,--~~-..-
membrane potential.
DRUGS ACTING ON GABA RECEPTORS
GABAA RECEPTORS
GABAA receptors resemble NMDA receptors in that drugs may
act at \everal different sites (Fig. 33.4: see Johns10n. 1996)
These include:
the GABA-binding site
!>everal modulatory sites
the ion channel.
There is growing evidence that the different receptor subtype~
differ in their pharmacological properties but, with the exception
of bentodiatepine~ (see below), the picture is far from clear.
GABAA receptors arc the target for several important centrally
acting drugs, notably benzodiazepines, barbiturates and
ne urosteroids (sec below). General anaesthetics (Ch. 36) also
act on GABAA receptors. as well as on other targets. The main
agonists. antagonists and modulatory substances that act on
GABA receptors are shown in Table 33.2.
Muscimol, derived from a hallucinogenic mushroom.
re~embles GABA chemically and is a powerful GABAA receptor
agonist. A synthetic analogue, gaboxadol (previously known as
TH IP from its chemkal structure) is a partial agonist in
development as a hypnotic drug (Cb. 37). Bicuculline, a
naturally occurring convulsant compound, is a specific antagoni\t
that blocks the fast inhibitory synaptic potential in mo~t CNS
synapses. Gabazin e, a synthetic GABA analogue, is similar
These compounds are useful experimental tools but have no
therapeutic u~>es.
Benzodiazepines, which have powerful sedative and
anxiolytic effects (see Ch. 37), selectively potentiate the effech
of GABA on GABAA receptors. They bind with high affinity to
an accessory ~>ite (the 'benzodiazepine receptor') on the GABA~
receptor, in such a way that the binding of GABA is facilitated
and its agonist effect is enhanced. Studies on recombinant
GABAA receptors have shown that a small region of they subunit
confers benzodiazepine sensitivity, and mutations in this region
affect the level of constitutive activity (see Ch. 2) at this site, and
its sensitivity to benzodiazepines.8 Association with particular a
subunits is also required. Thus not all GABAA receptors are
affected by benzodiazepines. Sedative benzodiazcpines, uch
as diazepam , are agonist~ (enhancing the action of GABA).
whereas convulsant analogues, such as flumazenil (Ch. 37) are
antagonbt!-. or inverse agonists.
Modulators that also enhance the action of GABA, but who<.c
site of action is less weJJ defined than that of benzodiazepine~
(shown as 'channel modulators' in Fig. 33.4). include other C'\S
depressants such as barbiturates (see Ch. 37), anaesthetic agent~
(Ch. 36) and neurosteroids. Neurosteroids (see Lambert et al ..
2003) are compounds that are related to steroid hormones but
"lntere!>tingly. there is evidence from transgenic animal~. in which <.pccific
GABA" receptor !.ubuniL~ were knocked out. that the anxiolytic and
~cdativc effects of benzodiazepines are separable in terms of their molecular
wrgcts (sec Rudolph ct al., 200 1), a discovery with imponam implication~
for the development of improved anxiolytic drugs .
 AMINO ACID TRANSMITTERS

'hble 33.2 Properties of inhibitory amino acid receptors

GABAA GABA9 Glycine

Receptor site Modulatory site Modulatory site

(benzodiazepine) (others)
Endogenous GABA ?Diazepam-binding Various neurosteroids GABA Glycine
agonlst(s) inhibitor (e.g. progesterone ~-Alanine
metabolites) Taurine

Other agomst(s) Muscimol Anxiolytic Barbiturates Baclofen

!. Gaboxadol benzodiazepines Steroid anaesthetics
(THIP", (e.g. diazepam) (e.g. alphaxolone)
partial agonist)

Antagonist(s) Bicuculline Flumazenil Phaclofen Strychnine

J Gabazine CGP 35348 and others
~
Channel blocker Picrotoxin Not applicable

Effector Ligand-gated chloride channel G-protein-coupled receptor; Ligand-gated

mechanism(s) inhibition of adenylyl cyclase chloride channel

Location Widespread; ma1nly GABAergic interneurons Pre- and postsynaptic Postsynaptic

Widespread Mainly in brain
stem and spinal cord

Funct1on Postsynaptic inhibition {fast ipsp) Presynaptic inhibition Postsynaptic

{decreased Ca2 entry) inhibition (fast ipsp)
Postsynaptic Inhibition
(increased K+ permeability)

1psp, inhibitory postsynaptic potential.

"THIP is an abbreviation of the chemical name of gaboxadol.

that act (hke benzodiazepines) to enhance acti vation of GA B AA
rcccptol'> a.~ well as on conventional intracellular steroid receptors.
Interestingly, they include metabolites o f progesterone and
androgens that are fonned in the nervous system, and are believed
to have a physiological role. Synthetic ncurosteroids include
alphaxolone, developed as an anaestheti c agent (Ch. 36). Another
putati\e endogenous modulator of G ABA-mediatcd transmission
i' a IJ~:ptide. diazepam binding inhibitor, which occurs in the
brain and elsewhere but whose physiological role is unclear.
Picrotoxin (Ch. 42) is a convulsant that acts by blocking the
chlonde channel associated wi th the GABAA receptor, thu.
bkdmg the postsyn aptic inhibitory effect o f GABA. It has no
lhcmpeutic uses.
of the G ABA 8 receptor. for w hich baclofen is a selective agonist
(see B owery, 1993). Baclo fen is used to treat spasticity and
related motor disorders (Ch. 37).
Competitive antagonists for the GABA 13 receptor include a
number of experimental compounds (e.g. saclofen and more potent
compounds with improved brai n penetration, such as CGP 35348).
Tests in animal s have shown that these com pounds produce only
slight effects on C NS fu nction (in contrast to the powerful
convulsant effects of GABAA antagonists). The main effect
observed. paradoxically, was an antiepileptic action, l>pecifi cally
in an animal model of absence seizures (see C h. 37), together
w ith enhanced cogni tive performance. Whether such compounds
w ill prove to have therapeutic uses remains to be seen.

GABA8 RECEPTORS y-HYDROXYBUTYRATE

When the importance of GA BA as an inhibitory transmitter was
rc:cogni~ed, it was thought that a GABA-like substance might
prmc: to be effective in controll ing epilepsy and other convulsive
,tate:': because GABA itself fails to penetrate the blood-brain
barrier, more Lipophilic GA B A analogues were sought, one
ol which, baclofen. was introduced in 1972. U nlike G ABA,
baclofcn has little pos tsynaptic inhibitory effect, and its ac ti ons
Hrc not blocked by bicucullinc. These findings led to the recognition
T y-Hydroxybutyrate (see Wong et al.. 2004) occurs naturally in the brain
as a side product of GABA \}nthe\i\. As a synthetic drug from 1960
onwards, it has found fa,our with bodybuilders. based on it~ abili ty to
C\Oke the relea1oe of grov. th hormone, and with party-goe~. based on ~~~
euphoric and disinhibitOI) effect>. In common with many abu,cd drug\
(see Ch. 43). it activate.\ 'reward pathways' in the brain. and its usc b now
illegal in most countrie!.. The phannacological properties of GHB are not
well understood, although it b believed to activate GABA8 receptor.,
partly through conversion to GABA, and may also bind 10 >pecific GHB
receptor sites, of which lillie is known.
489
 SECTION 4 . THE NERVOUS SYSTEM

GLYCINE Inhibitory amino acids: GABA and glycine

T Glycine is pre~ent in panicularly high concentration (511JlloVg) in the

grey matter of the \pinal cord. Applied ionopboreticaiJy to motor neuron.,
or mterneuron\, it produces an inhibitory hyperpolarisation that i'
indi~tingui.,hablc from the inhibitory synaptic response. Strychn ine (sec
Ch. 42). a convulsant poison that acts mainly on the spinal cord, blocks
both the synaptic mhibitOI) response and the response to glycine. Thi~.
together with drrect measurements of glycine release in response to nerve
\Umulation, provrde~ ~trong evidence for its physiological transmiuer
role. ~-Alanine has pharmacological effects and a pattern of distribution
ve11 similar to those of glycine, but its action is not blocked by strychnine.
The tnhibitory effect of glycine is quite distinct from its role in faci litating
activat ion ol NMDA receptors (see p. 483).
The glyci ne receptor (sec Laube e t al., 2002) resembles the GA BA"
receptor; it is a rnu ltirncric ligand-gated chloride channel, of whi ch a
number of subtype~ have been identified by c\onin11, and mutations of the
receptor have been identified in some inherited neurological di sorders
associated with m u~cle ~pasrn an d re nex hyperexcitability. There arc no
therapeutic drugs that act spccilically by modifying glycinergic transmi;~ion.
although it turns out that many of the compounds (such as benzodiazepines
and anaest hetic agents) that enhance GABAA receptor activation act
\imilarly on glycine receptors. Teta nus toxin, a bacterial toxi n re~embling
botulinum toxin (Ch. 10), acts selectively to prevent glycine release from
mhrbrtory intemeurons rn the spinal cord, causing exces\ive reflex
hypcrc;~.citability and violent mu~cle spasnts (lockjaw).
CONCLUDING REMARKS
The study of amino acids and their receptors in the brain has been
one of the most active fields of research in the past two decades.
and the amount of information available is prodigious. These
signalling systems have been speculatively implicated in almost
every kind of neurological and psychiatric disorder, and the
pharmaceutical industry has put a great deal of effort into
identifying specific ligands-agonists, antagonists, modulators.
en;.yme inhibitors, transport inhibitors--desi gned to innuence
them. However, despite a large number of pharmacologically
unimpeachable compounds having emerged. and many clinical
trials having been undertaken, there have been no major therapeutic
breakthrough1.. The optimistic view is that a better understanding
of the particular fun ctions of the many molecular subtypes of
these targets, and the design of more subtype-specific ligands,
will lead to future breakthroughs. Expectations have, however,
undoubtedly dimmed in recent years.
GABA ts the main inhibitory transmitter in the
brain.
It is present fairly uniformly throughout the brain;
there is very little in peripheral tissues.
GABA is formed from glutamate by the action of
glutamic acid decarboxylase. Its action is terminated
mainly by reuptake, but also by deamination,
catalysed by GABA transaminase.
There are two types of GABA receptor: GABAA and
GABAe.
GABAA receptors, which occur mainly
postsynaptically, are directly coupled to chloride
channels, the opening of which reduces membrane
excitability. Muscimol is a specific GABAA agonist,
and the convulsant bicuculline is an antagonist.
Other drugs that interact with GABAA receptors and
channels include:
benzodiazepine tranquillisers, which act at an
accessory binding site t o facilitate the action of
GABA
convulsants such as picrotoxin, which block the
anion channel
neurosteroids, including endogenous
progesterone metabolites, and other CNS
depressants, such as barbiturates and some
general anaesthetic agents, which facilitate the
action of GABA.
GABAe receptors are G-protein-coupled receptors
linked to inhibition of cAMP formation. They cause
pre- and postsynaptic inhibition by inhibiting calcium
channel opening and increasing K conductance.
Baclofen is a GABA8 receptor agonist used t o treat
spasticity. GABAe antagonists are not yet in clinical use.
Glycine is an inhibitory transmitter mainly in the spinal
cord, acting on its own receptor, structurally and
functionally similar to the GABAA recept or.
The convulsant drug strychnine is a competitive
glycine antagonist. Tetanus toxin acts mainly by
interfering with glycine release.

REFERENCES AND FURTHER READING

f.'\cltator) a mino acids
Blealman D. LodgeD 1998 Neuropharmacolog} of
AMPA and k.1tnare receptor\. Neurophannacolog}' 37:
187 2~ (Rl'l'""' gimtg molecular cmd fimcllonal
lftjomwrwrt Oil rlrnl' rtaprors )
Conn P J, Pin J. p 1997 Pharmacolog) und functions of
metllbotroprc glutamate receptor;. Annu Rev
Phamacol l7: 205 217
Cotman C W, Kahle J S, MillerS Bet al. 1995
490
- , ____ .,.----- Excitatory amino acid lr<m~mi~sion. In: Bloom FE.
Kupfer D J (eds) p,ychophannacology: a founh
generauon of progn:'' Ra en Pre\\, 1\c"' Vorl., pp.
75-85
Dmgledrne R. Borge., K, Bowre D. Trayncli' S I' 1999
The glutamate receptor ion channel ~. Pharmncol Rev
51: 8-6 1 ( Comprelretrstve reie11 fot 1Wil8 Oil
molecular aspeers. wirlr ucrion on poremial
rlterapemic applicarion.f)
Hueuner J E 2003 K<tinatc receptor; and ~ynaptic
transmission. Prog Ncurobiol 70: 387-407. (Review of
rhe role ofpre and postsynaptic kainare receprofl ar
CNS synapses)
Jansen M. Dannhan G 2003 Antagonist> and agonists ar
the glycine sire or rhe NMDA receptor for therapeuttc
applications. Eur J Med Chem 38: 661-670 ( Updart
ollejfons ro develop glycine sire ligmuJsfor
clinical use)
Javin DC 2004 Glutamate as a therapeutic target in
psychiatric dhorders. Mol Psychiatry 9: 984-997
(Summa ry of gluramOIP receptor \ubt)1W<, wirlt
 Other transmitters
and modulators

about the ability of drugs to influence these

Overview 492 systems. Many of the drugs that are discussed in
Introduction 492 later chapters owe their eHects to mechanisms that
are related to these mediators. Amine mediators
Noradrenaline 493 diHer from the amino acid transmitters discussed in
-Noradrenergic pathways in the CNS 493 Chapter 33 in being localised to small populations
-Functional aspects 493 of neurons with cell bodies in the brain stem and
Dopamine 494 basal forebrain, which project diHusely to cortical
-Dopaminergic pathways in the CNS 494 and other areas. These amine-containing neurons
-Dopamine receptors 494 function as ' modulatory aerosols', and they are
-Functional aspects 497 broadly associated with high-level behaviours
r- (e.g. the stereotypic behaviour associated with
5-Hydroxytryptamine 498 enhanced dopamine activity; see below), rother
-5-HT pathways in the CNS 498 than with localised synaptic excitation or
-5-HT receptors in the CNS 498 inhibition. 1 More recently, some ' atypical' chemical
-Functional aspects 499 mediators, such as nitric oxide (NO; Ch. 17) and
-Acetylcholine 500 endocannabinoids (Ch. 1 5) have come on the
-Cholinergic pathways in the CNS 501 scene, and they are discussed at the end of the
-Acetylcholine receptors 501 chapter. The other major class of CNS mediators,
-Functional aspects 501 the neuropeptides, are described in Chapter 16,
and information on specific neuropeptides appears
Purines 502 in later chapters in this section.
Histamine 503
r--
Other CNS mediators 503
INTRODUCTION
-Melatonin 503
-Nitric oxide 503 Although we know much about the many different mediators,
-Lipid mediators 505 their cognate receptors, and signalling mechanisms at the
A final message 505 cellular level, when describing their effects on brain function
we fall back on relatjvely crude terms-psychopharmacologbts
wi ll be at our throats for so underrating the sophistication of
their mca~urements-such as 'motor coordination', arousal',
'cognitive impairment' and 'exploratory behaviour'. The gap
OVERVIEW between these two levels of understanding (the Grand Canyon
referred to in Ch. 32) still frustrates the best effons to link drug
The principal ' amine' transmitters in the central action at the molecular level to drug actjon at the therapeutic
nervous system (CNS), namely noradrenaline level. Modem approaches, such as the use of transgenic animal
dopamine, 5-hydroxytryptamine (5-HT, serotonin) technology (see Ch. 6) and non-invasive imaging techniques. are
and acetylcholine (ACh), are described in this helping to forge links, but there is still a long way to go.
chapter, with briefer coverage of other mediators,
including histamine, melatonin and purines. The
monoamines were the first CNS transmitters to be 1
They are, if you like. voices from lhe nether regions, which make you
identified, and during the 1960s a combination of happy or sad. <,lecpy or alert. cautious or adventurou~. energeti c or lazy.
neurochemistry and neuropharmacology led to nit hough you do not quite know why- very much the stu ff of menta l
492 many important discoveries about their role, and illness.

~ore detail on the content of this chapter can be found in
Davis et al. {2002) and Cooper et al. (2003).
NORADRENALINE
The basic processes responsible for the synthesis, storage,
relc:ase and reuptake of noradrenaline are the same in the brain
a' in the periphery {Ch. II), and the same types of adrenoceptor
are also found in pre- and po tsynaptic locations in the brain.
NORADRENERGIC PATHWAYS IN THE CNS
Although the transmitter role of noradrenaline in the brain
wa., ~uspected in the 1950s, detailed analysis of its neuronal
di~tribution became possible on ly when the fluo rescence
technique, based on the formation of a fluorescent derivative
of catecholamines when tissues are exposed to formaldehyde,
was devised by Falck and Hillarp. Detailed maps of the pathway
of noradrenergic, dopaminergic and serotonergic neurons in
laboratory animals were produced and later confirmed in
human brain!>. The cell bodies of noradrenergic neurons occur
tn small cluster., in the pons and medulla, and they send
exten~ively branching axons to many other parts of the brain
and spmal cord (Fig. 34.1). The most prominent cluster is the
locus comtleus (LC), located in the pons. Although it contains
onI) about I 0 000 neurons in humans, the axons, running in a
dt~rete medial forebrain bundle, give rise to many millions
of noradrenergic nerve terminals throughout the cortex, hippo-
NORADRENALINE
Fig. 34.1 Noradrenaline pathways in the brain. The
location of the main groups of cell bodies and fibre tracts is in
solid colour. Light-shaded areas show the location of
noradrenergic terminals. Am, amygdaloid nucleus; C,
cerebellum; Hip, hippocampus; Hyp, hypothalamus; LC, locus
coeruleus; MFB, medial forebrain bundle; NTS, nucleus of the
tractus solltarius (vagal sensory nucleus); RF, brain stem
reticular formation; Sep, septum; SN, substantia nigra; Str,
corpus striatum; Th, thalamus.
OTHER TRANSMITTERS AND MODULATORS
campus and cerebellum. These nerve terminals do not form
distinct synaptic contacts but appear to release transmitter
diffusely-justifying the aerosol analogy. The LC is involved in
the descending control of pain pathways (Ch. 41, Fig. 4 I .5).
Other noradrenergic neurons lie close to the LC in the pons
and medulla, and project to the hypothalamus, hippocampus and
other parts of the forebrain, as well as to the cerebellum and
spinal cord. A small cluster of adrenergic neurons, which release
adrenaline rather than noradrenaline. lies more ventrally in the
brain stem, projecting mainly to the pons, medulla and
hypothalamus. Rather little is known about them, but they are
believed to be important in cardiovascular control.
FUNCTIONAL ASPECTS
Noradrenali ne applied to individual neurons usually causes
inhibition, and in most cases this is produced by activation
of f)-adrenoceptors linked to cAMP accumulation. In some
situations, however, noradrenaline has an excitatory effect,
which is mediated by either a- or ~-adrenoceptors and involves
other signal transduction pathways (see Chs 3 and 4). See
Ashton-Jones (2002) for a recent review.
Arousal and mood
Attention has focused mainly on the LC, which is the source
of most of the noradrenaline released in the brain, and from
which neuronal activity can be measured by implanted elec-
trodes. LC neuron'> are silent during sleep, and their activity
increases with behavioural arousal. Wake-up' stimuli of an
unfamiliar or threatening kind excite these neurons much
more effectively than familiar stimuli. Amphetamine-like drugs,
which release catecholamines in the brain, increase wakefulness,
alertness and exploratory activity (although, in this case, firing
of LC neurons is actually reduced, by feedback mechanisms;
see Ch. 42).
There is a close relationship between mood and state of
arousal; depressed individuals are usually lethargic and
unresponsive to external stimuli. The catecholamine hypothesis
of affective disorders (see Ch. 39) suggested that depression
results from a functional deficiency of noradrenaline in certain
parts of the brain, while mania results from an excess. This
remains controversial, and subsequent findings suggest that
5-HT may be more important than noradrenaline in relation
to mood.
Blood pressure regulation
The role of central, as well as peripheral. noradrenergic synapses
in blood pressure control is shown by the action of hypotensive
dmgs such as clonidine and methyldopa (see Chs II and 19),
which decrease the discharge of sympathetic nerves emerging
from the C S. They cause hypotension when injected locally
into the medulla or fourth ventricle. in much smaller amounts
than are required when the drugs are given systemically.
Noradrenaline and other aradrenoceptor agonists have the
same effect when injected locally. Noradrenergic synapses in
the medulla probably form part of the baroreceptor reflex
pathway, because stimu lation or antagonism of a 2 -adrenoceptors 493
 SECTION 4 . THE NERVOUS SYSTEM
in this part of the brain has a powerful effect on the activity
of baroreceptor reflexes.
Ascending noradrenergic fibres run to the hypothalamus, and
descending fibres run to the lateral hom region of the ~>pinal
cord, acting to increase sympathetic discharge in the periphery. It
has been suggested that these regulatory neurons may release
adrenaline rather than noradrenaline. Some catecholamine-
containing cells in the brain stem contain phenylethanolamine
N-methyl transferase (the enzyme that converts noradrenaline to
adrenaline; see Ch. I I ), and inhibition of this enLyme interferes
with the baroreceptor reflex.
DOPAMINE
Dopamine is particularly important in relation to neuropharma-
cology, because it is involved in several common disorders of
brain function, notably Parkinson's disease, schizophrenia and
attention deficit disorder, as well as in drug dependence and
certain endocrine disorders. Many of the drugs used clinically to
treat these conditions work by influencing dopamine transmission.
The distribution of dopamine in the brain is more restricted
than that of noradrenaline. Dopamine is most abundant in
the corpus striawm, a part of the extrapyramidal motor !>ystem
concerned with the coordination of movement (see Ch. 35),
and high concentrations also occur in certain parts of the
limbic system and hypothalamus (where its release into the
pituitary blood supply inhibits secretion of prolactin; Ch. 28).
The synthesis of dopamine follows the same route as that of
noradrenaline (see Fig. 11.2), namely conversion of tyrosine to
dopa (the rate-limiting step), followed by decarboxylation
to form dopamine. Dopaminergic neurons lack dopamine
~-hydroxylase, and thus do not produce noradrenaline.
Dopamine is largely recaptured, following its release from
nerve terminals, by a specific dopamine transporter, one of the
large family of monoamine transporters (see Ch. 4). Jt is metab-
olised by monoamine oxidase and catechol-0 -methyl transferase
(Fig. 34.2), the main products being dihydroxyphenylacetic acid
(DOPAC) and homovanil lic acid (HVA, the methoxy derivative
of DOPAC). The brain content of HYA is often used as an index
of dopamine rurnover. Drugs that cause the release of dopamine
increase HYA, often without changing the concentration of
dopamine. OOPAC and HYA. and their sulfate conjugates, are
excreted in the urine, which provides an index of dopamine
release in human subjects.
6-bydr oxydopamine, which selectively destroys dopaminergic
nerve terminals, is commonly used as a research tool. Jt is taken
up by the dopamine transporter and converted to a reactive
metabolite that causes oxidative cytotoxicity.
DOPAMINERGIC PATHWAYS IN THE CNS
Dopaminergic neurons form three main systems (Fig. 34.3).
The nigrostriatal path way. accounting for about 75% of the
dopamine in the brain, consists of cell bodies in the substantia
nigra whose axons terminate in the corpus striatum. These
494 fibres run in the medial fo rebrain bundle along with other
Noradrenaline In the CNS
Mechanisms for synthesis, storage, release
and reuptake of noradrenaline in the central nervous
syst em (CNS) are essentially the same as in the
periphery, as are the receptors (Ch. 11).
Noradrenergic cell bodies occur in discrete clusters,
mainly in the pons and medulla, one important such
cell group being the locus coeruleus.
Noradrenergic pathways, running mainly in the medial
forebrain bundle and descending spinal tracts,
terminate diffusely in the cortex, hippocampus,
hypothalamus, cerebellum and spinal cord.
The actions of noradrenaline are mainly inhibitory
(~-receptors), but some are excitat ory (a- or
~-receptors).
Noradrenergic transmission is believed to be
important in:
the 'arousal' system, controlling wakefulness and
alertness
blood pressure regulation
control of mood (functional deficiency contributing
to depression).
Psychotropic drugs that act partly or mainly on
noradrenergic transmission in the CNS include
antidepressants, cocaine and amphetamine. Some
antihypertensive drugs (e.g. clonidine, methyldopa)
act mainly on noradrenergic transmission in the CNS.
monoamine-containing fibres. The abundance of dopamine-
containing neurons in the human striatum can be appreciated
from the image shown in Figure 34.4, which was obtained b)
injecting a dopa derivative containing radi oactive fluorine,
and scanning for radioactivity 3 hours later by positron
emission tomography.
The mesolimbic/mcsocortical pathways, whose cell bodies
occur in groups in the midbrain and whose fibres project,
also via the medial forebrain bundle, to parts of the limbic
system, especially the nucleus accumbens and the amygdalo1d
nucleus and to the frontal cortex.
The tuber ohyp ophyseal syst em is a group of short neurons
running from the ventral hypothalamus to the median eminence
and piruitary gland, the secretions of which they regulate.
The function s of these systems are discussed below. There are
also many local dopaminergic intemeurons in other brain regions
and in the retina.
DOPAMINE RECEPTORS
Two types of receptor. 0 1 and 0 2 (linked, respectively, to
activation and inhibition of adenylyl cyclase), were originall)
distinguished on pharmacological and biochemical grounds. Gene
cloning revealed further subgroups, 0 1 to 0 5 (for review, see Missale
et al, 1998). The original 0 1 family now includes D 1 and 0 5, while
 OTHER TRANSMITTERS AND MODULATORS

Dopamine 3-Methoxydopamine

", COMT j

MAO MAO

HOo~CH2CHO , COMT , CH30o~ CH2CHO

HO ~ --~~--~~-- HO ~

Aldehyde Aldehyde
~ehydrogenas, ~ehydrogenas;;

Fig. 34.2 The main pathways

for dopamine metabolism in the
brain. COMT, catechol-0-methyl
transferase; MAO, monoamine Dlhydroxyphenylacetlc acid Homovanillic acid
oxidase. (DOPAC) (HVA)

Nigrostriatal
pathway

DOPAMINE
Mesolimbic
pathway
Fig. 34.3 Dopamine pathways in the brain, drawn as in
Figure 34.1. The pituitary gland (P) is shown, innervated with
dopamlnerglc fibres from the hypothalamus. Ac, nucleus
~umbens; other abbreviations as in Figure 34.1.

!he D~ family, which is pharmacologically more important in the

~S. consists of 0 2, 0 3 and 0 4 (see Table34.1). Splice variants,
leading to long and short fonns of 0 2, and genetic polymorphisms,
panicularly of D~ (see below), have subsequently been identified.
T All belong to the family of G-protein-coupled transmembrane
receptor~ dc.,cribed in Chapter 3. and their signal transduction
mechan1sm., linked vin adenylyl cyclase and/or phospholipid hydrolysis
to the control of potassium and calcium channels, arachidonic acid
relea\e, etc.- are similar to those of other such receptors. A key
component in the ~igno l tran~duction pathway is the protein DARPP-32
(32-kDa dopamine- und cA MP-regulated phosphoprotein; see Girauil &
Greengard, 2004). When intracellular cA MP is increased through
Fig. 34.4 Dopamine in the basal ganglia of a human
subject. The subject was injected with 5-fluoro-dopa labelled
with the positron-emitting isotope 18F, which was localised
3 hours later by the technique of positron emission tomography.
The isotope is accumulated (white areas) by the dopa uptake
system of the neurons of the basal ganglia, and to a smaller
extent In the frontal cortex. It is also seen in the scalp and
j
temporalis muscles. (From GarnettE Setal. Nature 305: 137.)
495
 SECTION 4 . THE NERVOUS SYSTEM

Tble 34.1 Dopamine receptors

Functional role 0 1 type 0 2 type

01 Ds 02 03 o.
Distribution
Cortex Arousal, mood +++ ++ +
Umbic system Emotion, stereotypic behaviour +++ + ++ + +
Striatum Motor control +++ + ++ + +
Ventral Prolactin secretion ++ +
hypothalamus and anterior
pttuttary

Agonists
Dopamine + (low potency) + (high potency)
Apomorphine PA (low potency) + (high potency)
Bromocriptlne PA (low potency) + (high potency)

Antagonists
Chlorpromazine + + +++ +++ +
Haloperidol ++ + +++ +++ +++
Splperone +++ +++ +++
Sulplride +++ ++
Clozapine + + + + ++
Ariprazole ++ +
(PA)

Signal Increase cAMP Decrease cAMP and/or

transduction increase inositol trisphosphate

Effect Mainly Pre- and postsynaptic

postsynaptic inhibition
inhibition Stimulation/inhibition of
hormone release

PA, partial agonist.

activation of 0 1 receptors, and protein kinase A, DARPP-32 is

pho~phory l atetl (Fig. 34.5). Phosphorylated DARPP-32 acts as an
inhibitor of protein phosphatascs such as protein phosphatase-! and
cuJcineurin, thus acting in concert with protein kinases and favouring 02
protein phosphorylation-effectively an amplifying mechanism. receptor

I
Activation of 0 2 receptors opposes the effect of 0 1 receptor activntion.

Dopamine receptors are expressed in the brain in distinct but

overlapping areas. 0 1 receptors are the most abundant and widc- cAMP
~pread in areas receiving a dopaminergic innervation (namely the
~triarum, limbic system, thalamus and hypothalamus; Fig. 34.3),
al. are 0 2 receptors. which also occur in the pituitary gland. 0 3
f
PKA

~spho-
receptors occur in the limbic system but not in the striatum.
Because dopamine antagonists used as antipsychotic drugs (Ch. 38) Protem
owe their actions to effects in the mesolimbic system but often DARPP-32 DARPP-32 ---<:!)-+ Phosphatase-!

~
cause motor side effects by blocking receptors in the striatum,
there is interest in targeting the D3 and 0 4 receptors as a means
of avoiding these side effects. The D4 receptor is much more weakly Calcineunn
expres!>ed. mainly in the cortex and limbic systems, but is a focus
of interest because of its possible relationship to the mechanism
of schizophrenia (Ch. 38) and dmg dependence (Ch. 43). ca2+
$
Fig. 34.5 The role of the neuron-specific phosphoprotein
T The D. receptor di~plays an unexpected polymorphism in humans, DARPP-32 In signalling by dopamine receptors (see text).
with a varying number (from 2 to LO) of L6 amino acid repeat sequences PKA, protein kinase A. )
496 being expressed in the third intracellular loop. which participates in --------------------------~

Gprotein couplmg (Ch. 3). However. neither this polymorphism nor the
longl,hon \plice variant> in the 0 1 receptor arc associated with
'igniticanl change~ in receptor function. Expectations that 0 4 receptor
pol}morphl'm might be related 10 the occurrence of schizophrenia in
human' lli:rt di-.appomted after !ieveral ~tudie~ failed to find any correlation.
There !IU) be a connccuon w1th auention deficit hyperactivity disorder
(-.ee laro~Ji et al.. 2ron
Dopamine, like many other transmitters and modulators, acts
pre~)naptically as well as postsynaptically. Presynaptic D3 receptors
occur main I) on dopaminergic neurons, for example those in the
'triatum and hmbic system, where they act to inhibit dopamine
~)nthc'>is and release. Dopamine antagonists, by blocking these
receptors, increase dopamine synthesis and release, and cause
accumulation of dopamine metabolites in these parts of the brain.
They abo cause an increase in lhe rate of firing of dopaminergic
neurons (sec Cooper et al., 2003), probably by blocking a neuronal
feedback pathway.
Dopamine receptors also mediate various effects in the periphery
(mediated by 0 1 receptors), notably renal vasodilatation and
increased myocardial contractility (dopamine itself has been used
chnically in the treatment of circulatory shock; see Ch. 19).
although its efficacy and safety are questionable.
FUNCTIONAL ASPECTS
The functions of doparninergic pathways divide broadly into:
motor control (nigrostriatal system)
beh:wioural effect\ (mesolimbic and mesocortical systems)
endocrine control (tuberohypophyseal system).
Dopamine and motor systems
LngeNcdt showed, in 1968, that bilateral ablation of the substantia
nigra in rats, which destroys the nigrostriatal neurons, causes
profound catalepsy, the animals becoming so inactive that they
die of Marvation unless artificially fed. Unilateral lesions produced
by 6 hydroxydopamine injection caused the animal to tum in
circles towards the lesioned side, because of an imbalance of
dopamine action in the corpus !>lriarurn between the two sides
of the bruin. Conversely. unilateral injection of apomorphine
(a dopamine receptor agonist) into the striatum causes circling
a~my from the injected ~ide. If apomorphine is given systemically
to nonnal rat~. it cau~es, a~ one would expect, no asymmetrical
pauem of locomotion, but if given systemically to animals with
unilateral le,ions of the '>ubstantia nigra made days or weeks
~arlier. apomorphine causes circling away from the Jesioncd
''de. Thi\ i' becau'e denervation supersensitiviry (see Ch. 9) on
one 'ide. following the destruction of dopaminergic terminals,
re'ult-. in an a!>ymmetric response to apomorphine. In these
ammal\, administration of drugs that act by releasing dopamine
(~.g amphetamine) causes turning towards the lesioned side,
becau~e the doparninergic nerve terminals are present only on the
nom1al ~ide. This 'turning model' has been extremely useful in
tme~tigating the action of drugs on dopaminergic neurons and
dopamine receptors.
Parkinson's disease (Ch. 35) is a disorder of motor control,
associated with a deficiency of dopamine in the nigrosrriatal
pathway.
OTHER TRANSMITTERS AND MODULATORS
Many antipsychotic drugs (see Ch. 38) arc D2 receptor
antagonists, whose major side effect is to cause movement
disorders, probably associated with block of D2 receptors in the
nigro~triatal pathway.
Transgenic mice lacking D2 receptors show greatly reduced
spontaneous movement, resembling Parkinson's disease.
Behavioural eHects
Administration of amphetamine to rats. which releases both
dopamine and noradrenaline, causes a cessation of normal ratty'
behaviour (exploration and grooming), and the appearance of
repeated 'stereotyped' behaviour (rearing, gnawing and so on)
unrelated to external stimuli. These effects are prevented by
dopamine antagonists and by destruction of dopamine-containing
cell bodies in lhe midbrain, but not by drugs that inhibit the
noradrenergic system. These amphetamine-induced motor disturb-
ances in rats probably reflect hyperactivity in the nigrostriatal
dopaminergic system.
Amphetamine also causes a general increase in motor activity,
which can be measured, for example, by counting electronically
the frequency at which a rat crosses from one part of its enclosure
to another. Thi~ effect, in contrast to stereotypy, appears to be
related to the mesolimbic and mesocortical dopaminergic
pathways. There is some evidence (see Ch. 38) that schizophrenia
in humans is as ociated with dopaminergic hyperactivity. Chronic
administration of amphetamine to a few rats in a large colony
produces various types of abnormal social interaction, including
withdrawal and aggressive behaviour. but it is difficult to quanrify
such effects or to e tablish their relationship to schizophrenia in
humans.
Amphetamine, cocaine (which acts by inhibiting the dopamine
transporter: Ch. 9) and also other addictive drugs (Ch. 43)
activate mesocortical dopaminergic 'reward' pathways, which
play a key role in drug dependence. The main receptor involved
appears to be D1o and transgenic mice lacking D 1 receptors
behave as though generally demotivated, with reduced food
intake and insensitivity to amphetamine and cocaine (see
Sibley, 1999).
Neuroendocrine function
The tuberohypophyseal dopaminergic pathway (see Fig. 34.3) is
involved in the control of prolactin secretion. The hypothalamus
secretes various mediators (mostly small peptides; see Ch. 28),
which conrrolthe secretion of different hormones from the pituitary
gland. One of these mediators, which has an inhjbitory effect on
prolactin release, is dopamine. This system is of clinical importance.
Many antipsychotic drugs (see Ch. 38), by blocking D 2 receptors,
increase prolactin secretjon and can cause breast development
and lactation. even in males. Bromocriptine, a dopamine receptor
agonist derived from ergot. is used clinically to suppress prolactin
secretion by tumours of the pituitary gland.
Growth hormone production is increased in normal subjects
by dopamine, but bromocripline paradoxically inhibirs the
excessive secretion re&ponsible for acromegaly (probably
because it de~>ensitise!> dopamine receptors, in contrast to the
physiological release of dopamine, which is pulsatile) and has a
useful therapeutic effect, provided it is given before excessive 497
 SECTION 4 THE NERVOUS SYSTEM
Do.,.mlne In the CNS
Dopamine is a neurotransmitter as well as
being the precursor for noradrenaline. It is degraded
in a similar fashion to noradrenaline, giving rise mainly
to dihydroxyphenylacetic acid and homovanillic acid,
which are excreted in the urine.
There are three main dopaminergic pathways:
nigrostriatal pathway, important in motor control
mesolimbic/ mesocorttcal pathways, running from
groups of cells in the midbrain to parts of the
limbic system, especially the nucleus accumbens,
and to the cortex; they are involved in emotion
and drug-induced reward systems
tuberohypophyseal neurons running from the
hypothalamus t o the pituitary gland, whose
secretions they regulate.
There are five dopamine receptor subtypes. 0 1 and
D5 receptors are linked to stimulation of adenylyl
cyclase. D2, D3 and D4 receptors are linked to
inhibition of adenylyl cyclase. Most known functions
of dopamine appear to be mediated mainly by
receptors of the D2 family.
Receptors of the D2 family may be implicated in
schizophrenia. The D4 receptor shows marked
polymorphism in humans, but no clear relationship
with disease has been established.
Parkinson's disease is associated with a deficiency of
nigrostriatal dopaminergic neurons.
Behavioural effects of an excess of dopamine activity
consist of stereotyped behaviour patterns and can be
produced by dopamine-releasing agents (e.g.
amphetamine) and dopamine agonists (e.g.
apomorphine).
Hormone release from the anterior pituitary gland is
regulated by dopamine, especially prolactin release
(inhibited) and growth hormone release (stimulated).
Dopamine acts on the chemoreceptor tngger zone to
cause nausea and vomiting.
growth has taken place. I t is now rarely used, as other agents are
more effective (see Ch. 28).
Vomiting
Pharmacological evidence strongly suggests that dopaminergic
neurons have a role in the production of nausea and vomiting.
Thus nearl y aiJ dopamine receptor agonists (e.g. bromocriptine)
and other drugs that increase dopan:tine release in the brain
(e.g. l evodopa; Ch. 35) cause nausea and vomiting as side
effects, whi le many dopamine antagonists (e.g. phenothiazi nes,
metoclopramide; Ch. 25) have antiemetic acti vity. D2 receptors
occur in the area of the medulla (chemoreceptor trigger Lone)
associated with the initiation of vomiting (Ch. 25), and are assumed
498 to mediate this effect.
5-HYDROXYTRYPTAMINE
The occurrence and functions of 5-HT i n the periphery are
described in Chapter 12. Interest in 5-HT as a possible CNS
transmitter dates from 1953, when Gaddum found that lysergic
acid diethyl amide (LSD), a drug known to be a powerful hal-
lucinogen (see Ch. 42), acted as a 5-HT antagonist on peripheral
tissues. and suggested that its central effects might also be related
to this action. The presence of 5-HT in the brain was demon-
strated a few years later. Even though brain accounts for onl}
about l % of the total body content, 5-HT is an important CNS
transmitter (sec Cooper et al., 2003).
In its fo rmation, storage and release, 5-HT resembles
noradrenaline (see Fig. 12.1 ). Its precursor is tryptophan, an amino
acid derived from dietary protein, the pla!.ma content of which
varies considerably according to food intake and time of day.
Tryptophan is actively taken up into neurons, converted by
tryptophan hydroxylase to 5-hydr oxytryptophan, and then
decarboxylated by a non-speci fic amino acid decarboxylase to
5-HT. Tryptophan hydroxylase can be selectively and incversibly
inhibited by p -chJorophcnylal anine (PCPA). Avai lability of
tryptophan and the activity of tryptophan hydroxylase are
thought to be the main factors that regulate 5-HT synthesis. The
decarboxylase is very simi lar, if not identical , to dopa
decarboxylase, and does not play any role in regulating 5-HT
synthesis. Following release. 5-HT is largely recovered b}
neuronal uptake. this mechanism being inhibited by many of
the same drugs (e.g. tricyclic antidepressants) that inhibit
catecholamine uptake. The carrier is not identical, however,
and inhibitors show varying degrees of specificity between the
two. Selecti ve serotonin rcuptake i nhibitors (see Ch. 39)
constitute an important group of antidepressant drugs. 5-HT i~
degraded almost entirely by monoamine oxidase (Fig. 12.1).
which convertS it to 5-hydroxyindole acetaldehyde, most of which
is dehydrogenated to form 5-hydroxyindole acetic acid, which i~
excreted in the urine.
5-HT PATHWAYS IN THE CNS
The distribution of 5-HT-containing neurons (Fig. 34.6) resembles
that of noradrcnergic neurons. The cell bodies are grouped in the
pons and upper medulla. close to the midli ne (raphe), and are
often referred to as raphe nuclei. The rostrally siruated nuclet
project, via the medial forebrain bundle, to many pans of the cortex.
hippocampus, basal ganglia, limbic system and hypothalamus.
The caudally situated cells project to the cerebellum, meduiJa
and spinal cord.
5 -HT RECEPTORS IN THE CNS
The majn 5-HT receptor types are shown in Table 12.1. All are
G-protein~oupled receptors except for 5-HT 1, which is a ligand-
gated cation channel. All are expressed in the CNS, and their
functional roles have been extensively analysed. Wi th 14
identified subtypes, and a large number of pharmacological tools
of relativel y low specifici ty, assigning clear-cut functions to
5-HT receptors is not simple. A detailed account of our present

s
SEROTONIN
Raphe nuclei
y
Fig. 34.6 5-Hydroxytryptamine pathways in the brain,
n drawn as in Figure 34.1. Abbreviations as in Figure 34.1.
0
'tate of knowledge is gi,en by Barnes & Sharp (1999). Knowledge
3h<lUt the nC\\Cr members of the family (5-HT5_7 receptors) is
ummamcd in recent reviews by Woolley et al. (2004) and
Hedlund & Sutcliffe (2005).
Certam generalisations can be made.
~-HT 1 receptors are predominantly inhibitory in their effects.
'-HT 1 ~ n:ceptors are expressed as autoreceptors by the 5-HT
neurons in the raphe nuclei, and their autoinhibitory effect
tends to limit the rate of firing of these cells. They are also
11 idcly distributed in the limbic system. and are believed to
be the main target of drugs used to treat anxiety and
).
depression (see Ch~ 37 and 39). 5-HT 18 and 5-HT10 receptors
h 5-HT 2A receptors and depress the firing of brain-stem 5-HT
arc found mainly as presynaptic inhibitory receptors in the
IS
ba~al ganglia. Agonists acting on peripheral 5-HT 10
receptors are used to treat migraine (see Ch. 12).
5 HT, receptors (mostly 5-HT2A in the brain) exert an
excitatory postsynaptic effect, and are abundant in the cortex
and limbic system. They are believed to be the target of
es
\'3rious hallucinogenic drugs (see Ch. 42). The use of 5-HT2
1e
re receptor antagonists such as methysergide in treating
ei migraine is discussed in Chapter 12.
x. 5-HT, receptor., are found chiefly in the area postrema
[~. (a rcg1on of the medulla involved in vomiting: see Ch. 25)
Ia and other pans of the brain stem. extending to the dorsal
hom of the ~pinal cord. They are also presem in certain pans
of the corte'<. a-. well as in the peripheral nervous system.
The) are excitatory ionotropic receptors. and specific
antagoni~h (e.g. o ndansetron ; see Cbs 12 and 25) are used
re to treat nausea and vomiting. They may also have anxiolytic
d- allcch. but thb is les~ clear.
rir 5-IITJ receptors are important in the gastrointestinal tract
l4 (M.'e Ch~ 12 and 25), and are also expressed in the brain,
lis particularly in the striatum. They exert a presynaptic facilit.atory
to effect, particularly on ACh release, thus enhancing cognitive
nl performance.
OTHER TRANSMITTERS AND MODULATORS
5-HT6 receptor~ occur only in the CNS, particularly in the
hippocampus, cortex and limbic system. They are considered
potential targets for drugs to improve cognition or relieve
symptoms of schizophrenia, although no such drugs are yet
available.
5-HT7 receptors occur in the hippocampus. cortex, thalamus
and hypothalamus, and also in blood vessels and the
gastrointestinal tract. Likely CNS functions include
thermoregulation and endocrine regulation, as weU as
suspected involvement in mood, cognitive flmction, and
sleep. Selective antagonists are being developed for clinical
usc in a variety of potential indications.
FUNCTIONAL ASPECTS
The precise localismion of 5-l lT neurons in the brain stem has
allowed their electrical activity to be studied in detail and
correlated with behavioural and other effects produced by drugs
thought to affect 5-HT-mediated transmission. 5-HT cells show
an unusual, highly regular, slow discharge pattern, ru1d are strongly
inhibited by 5-HT1 receptor agonist<>, suggesting a local inhibitory
feedbad. mechanism.
In vertebrates. certain physiological and behavioural functions
relate particularly to 5-HT pathways (see Barnes & Sharp. 1999).
namely:
hallucinations and behavioural changes
sleep, wakefulness and mood
feeding behaviour
control of sensory transmission (especially pain pathways;
see Ch. 41 ).
Hallucinatory effects
Many hallucinogenic drugs (e.g. LSD, Ch. 42) are agonists at
neurons. These neurons exert an inhibitory influence on cortical
neurons, and it is suggested that a loss of cortical inhibition
underlies the hal lucinogenic effect, as well as certain behavioural
effects in experimental animals, such as the wet dog shakes' that
occur in rats when the 5-HT precursor 5-bydroxyt:ryptophan is
administered. Many antipsychotic drugs (Cb. 38) are antagonists
at 5-HT2A receptors in addition to blocking dopamine 0 2 receptors.
Sleep, wakefulness and mood
Lesions of the raphe nuclei. or depletion of 5-HT by PCPA admin-
istration. abolish s leep in experimental animals, whereas
microinjcction of 5-HT at specific points in the brain stem induces
sleep. Attempts to cure insomnia in humans by giving 5-HT pre-
cur<;ors (tryptophan or 5-hydroxytryptophan) have. however.
proved unsuccessful. There is evidence that 5-HT, as well as
noradrenaline, may be involved in the control of mood (see Ch. 39),
and the usc of tryptophan to enhance 5-HT synthesis has been
tried in depression, with equivocal results.
Feeding and appetite
In experimental animals. 5-HT 1A agonists such as 8-hydroxy-2-
(di-n-propylamino)tctralin (8-0H-DPAT) cause hyperphagia, 499
 SECTION 4 . THE NERVOUS SYSTEM
leading to obesity. Antagonil>lS acting on 5-HT2 receptors, including
several antip)ychotic drugs used clinically, also increase appetite
and cau~c weight grun. On the other hand. antjdepressant drug
that inhibit 5-I IT uptake (~crotonill reuptake inhibitors; see Ch. 39)
cau~e lO!.!> of appetite.
Sensory transmission
After le!.iOn!) of the raphe nuclei or administration of PCPA, animals
~how exaggerated re:.ponses to many fonns of sensory stimulus.
They are startled much more easily. and also quickly develop
avoidance respon~es to stimuli that would not normally bother
them. lt appear~ that the nonnal ability to rusregard irrelevant fonns
of sensory input requires intact 5-HT pathways. The 'sensory
enhancement' produced by hallucinogenic dmgs may be partly due
to loss of this gatekeeper function of 5-HT. 5-HT also exerts an
inhibitory effect on trans mission in the pain pathway, both in the
spinal cord and in the brain, and there is a synergistic effect between
5-llT and analgesics such as morphine (see Ch. 38). Thus depletion
of 5-llT by PCPA, or selective lesions to the descending 5-HT-
containing neurons that run to the dorsal hom. antagonise the
analgesic effect of morphjue. while inhibitors of 5-HT uptake have
the opposite effect.
Other possible roles
Other putative role!. of 5-HT include various autonomic and endo-
crine function<,, -.uch as the regulation of body temperarure, blood
pre. sure and \exual function. Further information can be found
in Atmitia & Whitaker-A7..mitia (1995) and Cooper et al. (2003).
Several cla\Se'> of drugs used clinically influence 5-HT-mediatcd
transmission. They include:
serotonin reuptake inhibitors. such as flnoxetine, used as
an tidepressants (Ch. 39)
5-IIT 10 receptor agonbts, such as sumatri pta n (Ch. 12), used
to trent migraine
buspirone, a 5-HT 1A receptor agonist used in treating
anxiety (Ch. 37)
5- HT~ receptor antagonists, such as ondansetro n, used as
antie metic agents (see Ch. 25), which are also active in animal
models or anxiety
antipsychotic drugs (e.g. clozapioe. Ch. 38). which owe their
efficacy partly to an action on 5-HT receptors.
Effort~ arc being made to identify drugs that selectively target
other 5-HT receptor subtype~ in the hope of discovering
improved drugs for usc in different CNS indications. As a result,
many code-numbered compounds have been characterised
experimentally. but very few have been registered for clinical use
in recent yean..
ACETYLCHOLINE
There arc numerous cholinergic neurons in the CNS, and the basic
processes by which ACh is synthesised, stored and released arc
the same as in the periphery (see Ch. 10). Various biochemical
markers have been used to locate cholinergic neurons in the
-~
500 brain, the most useful being choline acetyltransfe rase, the
.-
enzyme responsible for ACh synthesis, and the transporters that
capture choline and package ACh. whjch can be labelled by
immunonuore~cence. Biochemical studies on ACh precurso"
and metabolites are generally more difficult than corresponding
~tudie. on other amine transmitters. because the relevant substances.
choline and acetate, are involved in many processes other than
ACh metabolism.
5-Hydroxytryptamlne In the CNS
The processes of synthesis, storage, release,
reuptake and degradation of 5-hydroxytryptamine (5-H1)
in the brain are very similar to events in the periphery
(Ch. 12).
Availability of tryptophan is the main factor regulating
synthesis.
Urinary excretion of 5-hydroxyindole acetic acid
provides a measure of 5-HT turnover.
5-HT neurons are concentrated in the midline raphe
nuclei in the pons and medulla, projecting diffusely to
the cortex, limbic system, hypothalamus and spinal
cord, similar to the noradrenergic projections.
Functions associated with 5-HT pathways include:
various behavioural responses (e.g. hallucinatory
behaviour, 'wet dog shakes')
feeding behaviour
control of mood and emotion
control of sleep/wakefulness
control of sensory pathways, including nociception
control of body temperature
vomiting.
5-HT can exert inhibitory or excitatory effects on
individual neurons, acting either presynaptically or
postsynaptically.
The main receptor subtypes (see Table 12.1) in the
CNS are 5-HT1A, 5-HT18, 5-HT10, 5-HT2 and 5-HT3
Associations of behavioural and physiological
functions with these receptors have been partly
worked out. Other receptor types (5-HT4-7) also occur
in the central nervous system, but less is known
about their function.
Drugs acting selectively on 5-HT receptors or
transporters include:
'triptans' (e.g. sumatriptan), 5-HT10 agonists used
to treat migraine (See Ch. 12)
5-HT2 antagonists (e.g. ketanserin) used for
migraine prophylaxis (see Ch. 12)
selective serotonin uptake inhibitors (e.g. fluoxetine)
used to treat depression (see Ch. 39)
ondansetron, 5-HT3 antagonist, used to treat
chemotherapy-induced em esis (see Ch. 12).

.t
CHOLINERGIC PATHWAYS IN THE CNS
Acetylcholine is very widely distributed in the brain, occurring in
all pan~ of the forebrain (including the cortex). midbrain and brain
.. \tern, although there is little in the cerebellum. Some of the main
n cholinergic pathways in the brain arc shown in Figure 34.7.
Cholinergic neurons in the forebrain and brain stem send diffuse
projecuons to many part~ of the cortex and hippocampus-a
panem 'tmilar to that of the amine pathways described above.
The-e neurons lie in a discrete area of the basal forebrain,
fonmng the magnoce/lular forebrain nuclei (so called because
the cell bodies are con!.picuously large). Degeneration of one
ol thc,e. the nucleus basalis of Meynerr, which projects mainly
to the cortex, is associated with Alzheimer's disease (Ch. 35).
-\nothcr cluster, the septohippocampal nucleus, provides the
main cholinergic input to the hippocampus, and is involved
in memory. In addition, there are-in contrast to the monoamine
pathways-many local cholinergic interneurons. particularly in
the corpus striatum. these being important in relation to Parkinson'&
dt,ea'e and Huntington's chorea (Ch. 35).
ACETYLCHOLINE RECEPTORS
Acetylcholine has mainly excitatory effects, which are mediated
b) various subtypes of either nicotinic (ionotropic) or muscarinic
(0-protein~oupled) receptors (sec Ch. I 0). Some muscarinic ACh
receptors (mAChRs) are inhibitory.
The mAChRs in the brain arc predominantly of the M1 class
(i.e. M1 M 1 and M 5 subtypes; see Ch. 10). and the central actions
of mu-.carinic antagonists and amicholinesterases depend on block
and 'timulation of these receptors. re~pecrively. mAChRs act
pre,ynapticall} to inhibit ACh relea~e from cholinergic neuron!>,
and mu,carinic antagonists, by blocking this inhibition, markedly
in~rea'c ACh release. Many of the behavioural effects a<>sociated
\\ 11h cholinergic pathways seem to be produced by ACh acting on
mAChRs.
Striatal
ACETYLCHOLINE
Fig. 34.7 Acetylcholine pathways In the brain, drawn as
In Figure 34.1. Abbreviations as In Figure 34.1.
OTHER TRANSMITTERS AND MODULATORS
Nicotinic ACh receptors (nAChRs) are also widespread in the
brain but much sparser than mAChRs. They are typical pentameric
ionotropic receptors (Ch. 3; ~ce Hogg et al., 2003), assembled
from a and ~ subunits. each of which come in several isofom1s
(Table 10.1). The main ones occurring in the brain arc the
heteropentameric a4 ~ 2 subtype (occurring mainly in the cortex)
and the homomeric a 7 subtype (mainly in the hippocampus).
Other isoforms occur at lower densities in many brain region~.
For the most part, nAChRs are located presynaptically and act to
facilitate the release of other transmitters, such as glutamate and
dopamine, although in a few '>ituations they function postsynap-
tically to mediate fast excitatory tran~mis!>ion, as in the periphery.
icotine (see Ch. 43) exert'> its central effects by agonist action
on nAChRs of the a4 ~2 subtype.
Many of the drugs that block nAChRs (e.g. tubocurarine; see
Ch. I 0) do not cross the blood-brain barrier, and even those that
do (e.g. mecamylamine) produce only modest CNS effects. Variou~
nAChR knockout mou~c strains have been produced and studied.
Deletion of the various CNS-spccific nAChR subtypes generally
has rather little effect. although ~ome cognitive impairment can
be detected.
FUNCTIONAL ASPECTS
The functional roles of cholinergic pathways have been deduced
mainly from studies of the action of drugs that mirn.ic. accentuate
or block the actions of ACh, and recently from studies of transgenic
animals in which particular nAChRs were deleted or mutated
(sec Cordero-Erausquin et al.. 2000; Hogg et al., 2003).
The main function'> a!>cribed to cholinergic pathway'> are
related to arousal. learning and memory. and motor control.
Electroencephalography (EEG) recording can be used to monitor
the state of arousal in human., or in experimental animals. A drowsy,
inattentive state is a<>sociated with a large-amplirude, low-frequency
EEG record. which switches to a low-amplitude, high-frequency
pattern on arousal by any sensory stimulus. Administration of
physostigmine (an anticholinesterase that crosses the blood- brain
barrier) produces EEG arousal, whereas atropine has the opposite
effect. It is presumed that the cholinergic projection from the ventral
forebrain to the cortex mediate~ this response. The relation~hip of
this response to beha,iour is confusing, however. for physo~tigmine
in humans causes a Mate of lethargy and anxiety. and in rat!> it
depresses exploratory activity, wherea~ atropine often cau!>C~ excite-
ment and agitation in human~ and increases exploratory activity
in rats, effects opposite to what one might expect. In contra~t to
atropine, hyoscine causes sedation in human~ and animals; the
reason for the difference is not known.
T There is evidence thm cholinergic pathways, in particular the
septohippocampal p:tthway. are in,olved in learning and ~hon-term
memory (see Hagan & Morrb. 1988). For eMmple (Fig. 34.8), mtce may
be trained to execute a maze-running manoeune in response to a buuer.
and many will remember the correct re'>ponse '~hen reteMed 7 da>' later.
Intracerebral injection ol a mu~arinic agonist. arecoline. 1mmed1atel}
after the training session reduce' the percentage of animal~ that forget the
correct response when rele\ted. whereas an injection of the mu.,cann1c
antagonist hyoscine ha'> the oppm.ite effect. In the experiment ~hown
in Figure 34.8, a deliberate bin~ wn~ introduced, in that the mice \elected
for the arecoline test were particularly dim (the fast learner~ having been 501
 SECTION 4 . THE NERVOUS SYSTEM

Acetylcholine In the CNS

100 Arecoline Hyoscine
(nmol) (nmol)
Synthesis, storage and release of acetylcholine
80 ,!? $ (ACh) in the central nervous system (CNS) are
....-
~ essentially the same as in the periphery (Ch. 10).
C)
c: ACh is widely distributed in the CNS, important
;:: 60
Q)
~ ..! pathways being:
.2 40 ~ '
~ basal forebrain (magnocellular) nuclei, which send
<fl. ~ c0 .JL a diffuse projection to most forebrain structures,

rT
20 ~ including the cortex
c0 ~ septohippocampal projection
u short interneurons in the striatum and nucleus
0
Fig. 34.8 Effect of arecoline and hyoscine on learning.
Mice were trained to perform a behavioural feat in order to avoid
an electric shock, and tested for their ability to remember it
7 days later. Mice in the group that performed least well (left)
were given the cholinergic agonist arecoline by
intracerebroventricular Injection; at low doses, their
performance Improved markedly, but at higher doses their
performance declined. Animals in the group that performed
best in the initial test were given the muscarinic receptor
antagonist hyoscine, which caused a deterioration of their
performance. (From Flood J F. Landry D W, Jarvik M E et al.
1981 Brain Res 215: 177-185.)
C\cluded). and the trainmg was brief, so that lhe forgeuing r:uc in !he comml
group "'a.' about 70'7c: an optimal dose of arecoline reduced this to about
15%. The M:Opolamine test was done on the cleverest mice (the no hopers
bcang excluded), and the training was more thorough. so the forgening
rate in the control group was only about 20%. and this wa.~ increased by
scopolamine. More recently, synthetic muscarinic agonists have been
shown partially to restore learning and memory deficits induced in
experimental :utimals by lesions of the septohippocarnpal cholinergic
pathway. Scopolamine also impairs memory in human ~ubjects and causes
amne~ia when used as prcanaesthetic medication. M1 mAChR knockout
mice, however, !>how only slight impairment of learning and memory (see
We\s, 2004).
Nicotine increases alertnes and also enhances learning and memory, as
can various synthetic agonists at neuronal nAChRs. Conversely. CNS-
active nAChR antagonists such as mecamylamine cause detectable.
although shght. ampairment of learning and memory. Tran~genic mice
with disruption of brain nAChR~ arc only slightly impaired in spatial
learning ta~k,. In conclu'>ion. both nAChRs and mAChRs may play a role
in learning and memory. while nACbRs also mediate beha\ ioural arousal.
Receptor knockout mice are surprisingly JinJe affected, suggesting that
altematl\e mcchani!.m' may be able to compensate for the IO'>'> of ACh
receptor 'ignalling.
TrJn'>gemc mtce that overe)(press acetylcholinesterase (and hence ~how
impaired cholinergic trans1UThsion) beha\e nomtally but develop a leamang
tlelicit after a few month' (Beeri eta!.. 1995). The interpretation b not ~imple.
ho\1.-C\Cr. becau-.e the~ mice also respond poorly to muscarinic and nicOtinic
agontsls. 'uggeMing that more complex secondary effects were produced.
Involvement of neuronal nAChRs in pain transmission 1\ suggested by
the recent finding that epibatidine, a compound extracted from frog skin,
which b a selective agonist at these receptors. ha> powerful ana lge1>ic
propertie' in animals (Ch. 41 ), as does nicotine itself.
The 'ignificance of cholinergic neurons in neurodegenerative cond itions
502 such <h dementia and Parkinson's disease is discussed in Chapter 35.
- ~--""".~----
-
accumbens.
Certain neurodegenerative diseases, especially
dementia and Parkinson's disease (see Ch. 35), are
associated with abnormalities in cholinergic pathways.
Both nicotinic and muscarinic ACh receptors occur in
the CNS. The former mediate the central effects of
nicotine. Nicotinic receptors are mainly located
presynaptically; there are few examples of transmission
mediated by postsynaptic nicotinic receptors.
Muscarinic receptors appear to mediate the main
behavioural effects associated with ACh, namely effects
on arousal and on learning and short-term memory.
Muscarinic antagonists (e.g. hyoscine) cause
amnesia.
Acetylcholinesterase released from neurons may have
functional effects distinct from its effects on cholinergic
transmission.
Acetylcholine;~erase may have. in addition to its primary role of di'>posing
quickly of rclcaed ACh, various trophic functions-not necessarily related
to its enzymic activity-in the regu lation of neuronal growth and >YD~Jl'e
formation (see Soreq & Sediman, 200 1). about which we know very little
at present.
PURINES
Both adenosine and ATP act as transmitters and/or modulator'\ m
the CNS (for review, see Dunwiddie & Masino. 2001; Robemon
et al., 200 I) as they do in the periphery (Ch. 12). Mapping the
pathways is difficult. because purinergic neurons are not eastl}
identifiable histochemically, but it is likely that adenosine sene'
as a very widespread neuromodulator. while ATP has more spectfic
!>ynaptic functions as a fast transmitter and as a local modulator.
Adenosine is produced intracellularly from ATP (see Fig. 12.4)
It ill not packaged into vesicles but is released mainly by carrier-
mediated transport. Because the intracellular concentration of ATP
(several mM) greatly exceeds that of adenosine, conversion of a
small proportion of ATP results in a large increase in adenosine.
ATP is packaged into vesicles and released by exocytosis as a
conventional transmilter, but can also leak out of cells in large
amounts under conditions of tissue damage. ln high concentrations,

ATP can act as an excitotoxin (like glutamate, see Ch. 33) and cause
further neuronal damage. ll is also quickly convened to adenosine
(Fig. 12.4). which exerts a protective effect. These special charac-
teri,tiC\ of adenO\ine metabolism suggest that it serves mainly as
a ...Uety mechanism. protecting the neurons from damage when their
'iabilit) is threatened, for example by ischaemia or seizure activity.
As discussed in Chapter 12. adenosine produces its effects
through G-protein-coupled receptor, (A 1 A2A. A28 and A3), while
~TP acts on P2 receptors, PD. being ligand-gated cation channels.
Pn being G-protein-coupled. P2y receptors produce mainly
inhibitory effects, while the P2X receptors are excitatory. producing
both pre- and postsynaptic effects in much tbe same way as
nAChRs. All these receptors arc more or less widely distributed
in the brain.
The overall effect of adenosine. or of various A receptor
agonists, is inhibitory, leading to effects such as drowsiness, motor
incoordination, analgesia and anticonvulsant activity. Xanthines,
such as caffeine (Ch. 42), which are antagonists at A2 receptors,
produce arousal and alertnel>s. Many synthetic adenosine agonists
have been developed, because such drugs could be useful in treating
conditions !>uch as epilepsy, pain and sleep disorders. A further
po'sible u~e is in neuroprotection. because the inhibitory effect of
adeno~ine on neuronal excitability and glutamate release is able, in
c:xpcrimental models. to protect the brain against ischaernic damage
(-ee Ch. 35). No such drugs are yet available for clinical use.
Lmle is J..nown about the function of ATP as a chernicaJ
mediator in the brain. Because it is quickly metabolised to ADP
and adenosine, it.s pharmacologicaJ actions are difficuJt to unravel.
and there are few selective agonists or antagonists for ATP receptors.
It may play a role in nociception. because ATP is released by
u-,.,ue damage and causes pain by stimulating unmyelinated afferent
nerve terminals. which express P2x receptors.
HISTAMINE
'f Histamine i ~ present in the brain in much smaller amounts than in
other tissues. such as skin and lung, but undoubtedly serves a
neurotram.miuer role (see Brown et al.. 200 I). The cell bodies of
hi\Lammergic neurons, which al>o synthesise and release a variety of
\lther tran<,miuc~. are re~tricted to a small pan of the hypothalamus, and
thear axons run to virtually all parts of the brain-an 'aerosol'
a!Tllngement 'limilar to that of other monoamines. Unusually, no uptake
mechani\m for hi"amine i' pre<,ent. iLs action being terminated instead
by en1ymac methylation.
Hl\tamine acts on three t) pes of receptor (H 1_ 3; Ch. 13). all of which are
G-protem-coupled re<:eptor. and occur in most brain regions. H1 receptors
are mainly located po~L\ynaptically and cause excitation: H2 and H3
receptor. are anhibitory. re~pectively post- and presynaptic. H3 receptor\
being inhabilOI') autorecepton. on histamine-releasing neurons.
Like other monoamine ll'!Ulsmiuers. histamine is in'olved in many different
CNS function<.. Hiqamine release follows a djstinct circadian panem, the
neuron' being acth e by day and silent by night. H1 receptors in the cortex
and reticular activating system contribute to arousal and wakefulness. and
H1 receptor antagoni\t\ produce \edation {see Ch. 13). Other functions
ascribed to histamine include control of food and water intake, and
thermoregulation. but the~e arc less well characterised. Antihistan1ines
are widely used to control nausea tmd vomi ting. for example in motion
~ickness and midd le car disorders. suggesting a role for histamine in these
rellexcs.
OTHER TRANSMITTERS AND MODULATORS
OTHER CNS MEDIATORS
We now move from the familiar neuropharmacological territory
of the cJa<.~ic' monoamines to some of the frontier towns. bordering
on the Wild West Useful drugs are stiJI few and far between in
thi~ area, and if applied pharmacology is your main concern. you
can safely sJ..ip the next pan and wait a few years for law and
order to be established.
MELATONIN
T Melatonin (reviewed by Brnzinski. 1997) is something of a myMery.
It i;,~ynthc>i~ed cxclu;ively in the pineal, an endocrine gland that plays
a role in establishing circadian rhythms. The gland contains two
cn1.ymes. not found ebewhere. which convert 5-HT by acetylation and
0 -mcthylmion to melatonin, its hom1onal product. Melatoni n secretion
(in all an imals. whether diurnal or nocturnal in tl1eir habits) is high at
night and low by day. Thi> rhythm is controlled by input from the retina,
via a noradrenergic rctinohypothalamic tract that terminates in the supra-
chiasmatic nucleu~ in the hypothalamu;,, a structure often tem1ed !he
'biological clock', which generates the circadian rhythm. The >upra-
chim.matic nucleus controls the pineal, not directly. but via sympathetic
fibre;, <,upplying the gland. This retinal conrrol system serves to inhibit
melatonin \CCrction when !he light intensity is high. It dne;, not iL..elf
genernte the circadian rhythm. but rnther 'enrrain.s it to !he light-dark
cycle. Circadian rhythm,, including the rhythmic secretion of melatonin.
continue C\Cn in the absence of light-dark cues, but u>ually with a
pcnodicU) rnther longer than 24 houn..
Melatonin receptor. (a_., you Will have guessed) are widespread, and come
in different type;,. 1l1e main ones are typical G-protei~oupled receptor,,
found maanly an the brain and retina but also in peripheral ti~<.ue~. AnOiher
type has been adentified a.'> one of the previou;, 'orphan receptors' (sec Ch. 3),
a member of the rctinoic acid intrnccllular receptor family that regulate;,
gene tran\cription. We currently know very little about the phy'>iological
proce,;.e;, that nrc controlled by melatonin. allhough there i'> intense
research activity in this area.
The use of melatonin for medicinal purposes has become something of an
'alternative medicine' fad. allhough there are few properly controlled trials of
its efficacy. Given omlly, melatonin i ~ well absorbed but quickly metaboli~ed,
il!, pla;ma half-life being a few minutes. It has been promoted a~ a means
of controlling jet lag, or of improving the performance of night shift worker.>,
ba~ed on its ability to reset the ci rcadian clock, and controlled Mudie'
have conlim1ed lhm melatonin given in !he evening can alleviate the eiTect"
of jet lag. A "ingle do~e appear; to have the effect of resynchronising the
phy;iological "ecre10ry cycle, although it is not clear how this occurs. II
cau..e' \leepinc!>\, and there i' some disagreement about whether ib action."
are di\lingui\hable from tl1ose of con,entional hypnotic drugs {see Ch. 37).
Claim\ that melatonin produces olhcr effects {e.g. on mood and immune
function) ha\e yet to be confirmed. Synthetic agonistl> and antagoni'>h
have been produced and are being te>ted in a range of indications. main I)
sleep disorden..
NITRIC OXIDE
Nitric oxide as a peripheral mediator is discussed in Chapter 17.
Its significance as an important chemical mediator in the nervous
system became apparent only about IS years ago, and demanded
a considerable readjustment of our views about neurotransmission
and neuromodulation (for review, see Dawson & Snyder, 1994).
The main defining criteria for transmitter substances-namely
that neurons should possess machinery for synthesising and sroring
the substance, that it should be released from neurons by exocytosis, 503
 SECTION 4 THE NERVOUS SYSTEM
Other transmitters and modulators
Purines
ATP functions as a neurotransmitter, being stored in
ves1cles and released by exocytosis. It acts, via
ionotropic receptors, as a fast excitatory transmitter
in certain pathways and, via metabotropic receptors,
as a neuromodulator.
Cytosolic ATP is present at relatively high concentration
and can be released directly if neuronal viability is
compromised (e.g. in stroke). Excessive release may
be neurotoxic.
Released ATP is rapidly converted to ADP, AMP and
adenosine.
Adenosine is not stored in vesicles but is released by
carrier mechanisms or generated from released ATP,
mainly under pathological conditions.
Adenosine exerts mainly inhibitory effects, through A 1
and A2 receptors, resulting in sedative, anticonvulsant
and neuroprotective effects, and acting as a safety
mechanism.
Methylxanthines (e.g. caffeine) are antagonists at A'l
receptors and increase wakefulness.
Histamine
Histamine fulfils the criteria for a neurotransmitter.
Histaminergic neurons originate in a small area of the
hypothalamus and have a widespread distribution.
H" H2 and H3 receptors are widespread in the brain.
H 1 and H3 receptors are mainly excitatory; H2
receptors are inhibitory.
The functions of histamine are not well understood,
the main clues being that histaminergic neurons are
active during waking hours, and H1 receptor
antagonists are strongly sedative.
H1 receptor antagonists are antiemetic.
Melatonin
Melatonin is synthesised from 5-hydroxytryptamine,
mainly in the pineal gland, from which it is released
as a circulating hormone.
Secretion is controlled by light intensity, being low by
day and high by night. Fibres from the retina run to
the suprachiasmatic nucleus ('biological clock'),
that it should interact with specific membrane receptors, and that
there should be mechanisms for it<; inactivation-do not apply to
NO. Moreover, it i!> an inorganic toxic gas, not at all like the kind
of molecule we are used to. The mediator function of NO, and
probably also carbon monoxide (CO), is now well established,
however (sec Bredt & Snyder, J992; Vincent, 1995; Barafiano et
al., 200 I ). NO diffuses rapidly through cell membranes, and
its action is not highly localised. Its half-life depends greatly
on the chemical environment, ranging from seconds in blood
504 to several minutes in normal tissues. The rate of inactivation of
which controls the pineal gland via its
sympathetic innervation.
Melatonin acts on several types of receptor in the bra1n
and penphery. G1ven orally, it causes sedation and also
'resets' the biological clock, being used for this purpose
to counter Jet lag.
Other claimed actions of melatonin (e.g. on mood and
immune function) are controversial.
Nitric oxide (see Ch. 17)
Neuronal nitric oxide synthase (nNOS) is present in
many central nervous system neurons, and nitric oxide
(NO) production is increased by mechanisms (e.g.
transmitter action) that raise intracellular Ca2 .
NO affects neuronal function by increasing cGMP
formation, producing both inhibitory and excitatory
effects on neurons.
In larger amounts, NO forms peroxynitrite, which
contributes to neurotoxicity.
Inhibition of nNOS reduces long-term potentiation and
long-term depression, probably because NO functions
as a retrograde messenger. Inhibition of nNOS also
protects against ischaemic brain damage in animal
models.
Carbon monoxide shares many properties with NO and
may also be a neural mediator.
Lipid mediators
Arachidonic acid is produced in neurons by receptor-
mediated hydrolysis of phospholipid. It is converted to
various eicosanoids and to anandamide.
Arachidonic acid itself, as well as its active products,
can produce rapid and slow effects by regulation of ion
channels and protein kinase cascades. Such effects can
occur in the donor cell or in adjacent cells and nerve
terminals.
Anandamide is an endogenous activator of cannabinoid
receptors (Ch. 15) and also of the vanilloid receptor
(Ch.41).
The functional role of lipid mediators in the central
nervous system is still poorly understood.
NO (sec Ch. 17, reaction 17.1) increases disproportionately with
NO concentration, so low levels of 0 are relatively stable. The
pre ence of superoxide, with which NO reacts (see below).
shortens it\ hal f-life considerably.
Nitric oxide in the nervous system is produced mainly by
the constitutive neuronal form of nitric oxide synthase (nNOS;
see Ch. 17), which can be detected either histochemically or by
immunolabclling. This enzyme is present in roughly 2% of neur-
ons, both short intemeurons and long-tract neurons, in virtually
all brain areas, with prutieular concentrations in th~ccrebellum

and hippocampus. It occurs in cell bodies and dendrites. as well
a~ in axon terminals, sugge~tin g (because NO is not stored, but
relca\ed as it is made) that the release of 0 is not restricted to
comentional neurotransmitter release sites. nNOS is calmodulin-
dependent and is activated by a rise in intracellular Ca 2+
concentration, which can occur by many mechanisms, including
action potential conduction and neurotransmitter action. Many
'lUdics have shown that NO production is increased by activation
of S) naptic pathways, or by other events, such as brain ischaemia
(\CI! Ch. 35).
'litric oxide exerts its effects in two main ways.
By activation of soluble guanylate cyclase, leading to the
production of cGMP, leading to various phosphorylation
cascades (Ch. 3). This 'physiological' control mechanism
operates at low NO concentrations of about 0. I [.I.M.
By reacting with the superoxide free radical to generate
pcroxynitrite. a highly toxic anion that acts by oxidising
various intracellular proteins. This requires concentration~ of
I 10 ftM, which are achieved in brain ischaemia.
There is good evidence that NO plays a role in long-term
potentiation and depression (~ Ch. 33), because these phenomena
are reduced or prevented by NOS inhibitors and are absent in
tran\gcnic mice in which the nNOS gene has been disrupted.
Ba~ed on the same kind of evidence, NO is also believed to
play an important part in the mechanisms by which ischaemia
cau~es neuronal death (see Ch. 35). There is also speculation that
it may be involved in other processes, including neurodegeneration
m Parkinson's disease. senile dementia and amyotrophic lateral
-.clerosis, and the local control of blood now linked to neuronal
a'ti' it). If substantiated. the~e theoriel. will open up major new
therapeutic possibilities in some hitherto intractable disease areas.
T Carbon monoxide is best known a, a poi.,onou~ gas present in ,chicle
e~hau\t, which binds strongly to haemoglobin. causing tissue anoxia.
Ho\\ever, it is also fom1ed endogenously and has many feature~ in
common with NO (see Verma et al., 1993; l3arJiiano et al.. 2001). Neuron~
and other cells contain a CO-generating enzyme. haem oxygenase, and
CO. like NO, activates guanylate cycla~e.
The rote of CO as a CNS mediator is not well established. but there
" 'orne evidence that it plays a role in the cerebellum and also in
olfa.:tol") neurons. where cGMP-sensitivc ion channels are imolved 1n the
uan..duction process.
l"ndoubtedl}. further function~ of NO and CO in the brain remain to be
1denulied. and novel therapeutic approaches may come from targeting
the d11Terem step; in the synthetic and ~ignal transduction pathways
for these ourprising mediator,. We may have to endure the ponderou~
1\himsy of many 'NO' puns. but it should be wonh it in the end.
LIPID MEDIATORS
T The formation of arachidonic acid. and its conversion to eicosanoids
tmamly prostaglandins. leukotnenes and hydroxyeicosatetraenoic acids
(HETEs); see Ch. 13) and to the endogenous cannnbinoid receptor ligand
anandamide (see Cb. 15) are kno"'n to take place in the CNS. They
doubtle,., play an imponant role. although our knowledge in tbh area ts
'till fragmentary (for reviews. see Piomelli. 1995; Piomelli et al.. 2000).
p:111ly because there are few selecuve mhibitors that can be used to probe
the various steps in the rather lengthy biochemical pathways through
which the mediators are formed and cxen their effects. Figure 34.9
\hows a schematic view of the different possibilities, but it should be
OTHER TRANSMITTERS AND MODU LATORS
reali~ed that evidence~ to the functional imponance of these path"' a}"'
IS >till \Cry limited.
Phospholipid clea\age. leadmg to arachidonic acid production. occur\ in
neurons in re&ponse to receptor activation by many different mediator~.
including neurotransmitlers. The arachidonic acid so formed can act
directly as an imracelluh1r me~senger. controlling both ion channels and
various parts of the protein kina'e cascade (sec Ch. 3). producing both
rapid and delayed effect~ on neuronal fu nction. Arachidonic acid can
also be metabolised to anandamide and to eicosanoids, some of wh1ch
(principally the HETEs) can also act as intracellular me~sengers acting
in the same cell. Eicosanoid., can also exert an autocrine effect via
membrane receptors expre\..ed by the cell. Both arachidonic ac1d it..elf
and it\ products escape readily from the cell of origin and can all"ect
neighbouring structure!>. including presynaptic terrmnal~ (retrograde
'ignalling) and adjacent celb (paracrine signalling). by act1ng on
receptors or by acting directly as intracellular messengers. Theoretically,
the possibilities arc numerou,, hut there are so far only a few in\tanccs
where this system is known to play tt significant role. These include our
old friend long-term potentiation (Ch. 33), one component of which is
prevented by inhibition of phospholipase A1 , where arach idonic acid
is believed to serve a.\ a retrograde messenger causing facilitmion of
transmitter release by the presynaptic nerve terminal. A second well
\ludied system is the Aplysia ..ensory neuron. \\here the effects of various
inhibitory mediator,. acting on membrane receptors. are exened through
the intracellular action' of arachidonic acid and its products.
One ~urprio;e in thi\ field ha\ been the di~ovcry that anandamide, be<, ide'
being an agonist at cannab1noid receptors. also activate; vanilloid
receptors (see Cb. 41 ), which arc invol~ed in the response of peripheral
~ensory nerve terminab to painful stimuli. What role, if any. annndnmidc
has in pain Lransmis~ion remains to be seen.
A FINAL MESSAGE
In the last two chapters. we have taken a long and tortuous tour
through tbe brain and its chemistry, with two questions at the
back of our minds: What mediators and what receptors play a key
role in what brain functions? How does the information relate
to existing and future drugs that aim to correct malfunctions?
Despite the efforts of a huge anny of researchers deploying an
arsenal of powerful new techniques, the answers to these questions
seem to remain as elusive as ever. Although transgenic tech-
niques allow specific gene products (i.e. proteins) to be modi fled
in a much more precise and controllable way than can be achieved
pharmacologically. behavioural analysis of transgenic animals
has failed to clear the air very much. The array of potential CNS
targets-comprising multiple receptor subtypes, many with the
added complexity of heteromeric assemblies. splice variant~, etc.,
along with regulatory mechanisms that control their expression
and localisation-continues to grow in complexity. Speculation
about the best target to aim at in order to ameliorate the effect of
a particular brain malfunction, such as stroke or schizophrenia,
has become less focused, even if better informed, than it was two
decades ago. In the ensuing chapters in this section, we shall find
that most of the therapeutic successes have come from chance
discoveries that were followed up empirically: few have followed
a logical, mechanism-based route to success. The optimistic view
is that this is changing, and that future therapeutic discoveries
will depend less on luck and more on molecular logic. But the
revolution is slow in coming. One of the key problems, perhaps,
is that the brain puts cells, organel les and molecules exactly sos
 SECTION 4 . THE NERVOUS SYSTEM

Autocrine
Transmitters signalling
Modulators
PRESYNAPTIC
TERMINAL

Paracrine
OTHER CELLS
lon channels, signalling
(NEURONS, GLIA)
kinases, etc.

D
Functional
effects

Fig. 34.9 Postulated modes of signalling by lipid mediators. Arachidonic acid (AA) is formed by receptor-mediated cleavage of
membrane phospholipid. It can act directly as an intracellular messenger on ion channels or components of different kinase cascades,
producmg various long- and short-term effects. It can also be converted to eicosanoids (prostaglandins, leukotrienes or
hydroxyeicosatetraenoic acids [HETEsD or to anandamide (Ana). HETEs can also act directly as intracellular messengers. All these
mediators diffuse out of the cell, and exert effects on presynaptic terminals and neighbouring cells, acting either on extracellular
receptors or intracellularly. There are examples of most of these modes of signalling but only limited information about their functional
significance in the nervous system. Eic, eicosanoids; PL, membrane phospholipid.

where they are needed. and uses the same molecules to perform Ch. 56), but we lack delivery systems able to target them ana-
different functions in different locations. Drug discovery ~dentists tomically even to macroscopic brain regions, let alone to ;,pecific
arc getting quite good at devising molecule-specific ligands (see cells and subcellular structures.

REFERENCES AND FURTHER READING

Cenen1l references
Coop.:r J R. Bloom FE. Roth R H 2003 Biochemical
ba-., of neuropharmacology. Oxford University Press,
New Vorl.. (Clear and well" rilletl tutbook giting
11101'1' tlttailed infomwtian on nwnv topics col'ered in
tllrtc'ilaptu)
Da'" K L. Charney D, Coyle J T, :-<emeroff C (eds)
2002 'leui'Op'>ychophannacology: the fifth generation
of progre'~ Llppmcon. W1lhams & Willms.
Pluladtlph1a (A 2000pa.~t monsur "ith exullem and
uuthtmtatll e artides on bas1c and clinical aspects)
Nestler E J. H) manS E. Malenka R C 2001 Molecular
neurophannacolog). McGra,.. H,ll. ~ew Yorl..
((jliOd mtNI~m tertboak)
Noradrt>nnline
A\hton-Joncs G 2002 Nomdrenahne. ln: Davis K L.
Chame) D. Coyle J T. Nemeroff C (eds) 2002
Neurop\ychophannacology: the fifth generation of
prugre". l.ippinwtt, Willinm' & Will.tns, Philadelphia
Oopumlnc
Girauh J A, Grceng:ml f' 2004 The neurobiology of
dopamine 'ignalling. Arch Neurol 61: 641-644
506 (Short nview llrtrcle)
Missale C, Nash S R, Robin~on S Wet ul 1998 Doparmnc
receptors: from structure 10 function. Phy\iol Rev 78:
19S-225 CComprehen<ll'e retieK article)
Seeman P. Van Tolll II M 1994 Dopamine receptor
phannacology. Trend, Phannacol Sc 15 264-270
(lntmducrory mie artic/t')
Sibley DR 1999 'I:'< in\ighh mto dopanunefl!tC receptor
function u"ng anu'<!n-.c and geneucally altered
anrmals. Annu Re' Ph:um.1eol To"col 19: 313 '\41
Svennin!!s>On 1'. '\i'h' A, l'i'(lne G et al 2004 DARPP
32: an mtcgr.uor of ncurotran\mi~SIOn Annu Re'
Phannacol Toxicol 44 . 269-296 (Rmt'\0 <rrticle
Jeuribmg th<' nmluple roles of tills cflln{l<ment of thl'
dopamint .H~nalling path,..ay)
Tarazi F I. Zhang K. Balde,..urinr R J 2004 Dopamme D,
receptors: be)ond ..chi7ophrenia J Reccpt Sgnal
Transduct 24: 131 147 COmnirtr< l111k btotwut~ D,
receptor polymorph11nr atUI ;c/ri~ophreflla, s11ggesting
possible link with attemion deficit hlptractiwil\
disonler, imp11lsMry anti Coflnitive function)
5-Hydroxytryptnmine
Azmilia E C. Whiwl..cr Atrnitin PM 1995 Anatomy, cell
biology and pla~ticrty of the sero1oncrgic system. In:
Bloom FE, Kupfer D J (eds) Ps)'chophannacolog)': a
fourth generation of progres\. Raven Press. Ne" Vorl
(General rel'ie.. aniclt')
Barnes N M. Sharp T 1999 A review of centrdi5HT
receptors and their function. Neurophannacolog) 'R:
1083-1152 (Detailt>d rompilarion of dalllll'llllm.~ ttl
distribution. pharmacoiOJO' and funuitm of 5-HT
tl'<:t'ptors in the CNS: useful ilrfonnation soun-1' 1>111
not particular/)- illuminann~)
Hedluoo P B. Sutcliffe J G 2004 Functional. molecul.v
and pharmacological advances in 5-HT, recepcor
research. Treods Pharmacol Sci 25: 481-486 (Rn 1nu
curll'nt understanding of role of5HT ~'~''"'P"'"
includmg data from receptor /cnl~C'Wut mrul
WooUey M L. Marsden CA. Fone K C 2004 5-HT
receptors. Curr Drug Targets CNS :-<eurol Dt..onl '
59-79 (Gellt>raltl'vie article focming 011 the mum
poss1ble cliniclll applications of 5-HT6 rtl'tpror
t~gonist.v and antagonists)
Acetylcholine
Beeri R. Andres C. LevLehman E et al. 1995 Tran,gemc
expres~ion of human a.cetylcholinestemse induce'
progressive cognitive deterioration in mice. Curr Brol
 Neurodegenerative
diseases

incidence and social impact of neurodegenerative

Overview 508 brain disorders in ageing populations has resulted
f--
Protein misfolding and aggregation in chronic in a massive research eHort in recent years.
neurodegenerative diseases 508 In this chapter, we focus mainly on three common
neurodegenerative conditions: Alzheimer's disease
Mechanisms of neuronal death 509 (AD), PD and ischaemic brain damage (stroke). AD
- Excitotoxicity 510 and PO are the commonest examples of a group of
-Apoptosis 512 chronic, slowly developing conditions that include
-Oxidative stress 512 various prion diseases (e.g. Creutxfeldt-Jakob
lschaemic brain damage 512 disease, CJD, see below). They have a common
-Alzheimer's disease 514
aetiology in that they are caused by the aggregation
of misfolded variants of normal physiological proteins
-Pathogenesis of Alzheimer's disease 514 (see reviews by Forman et al., 2004; Mallucci &
-Therapeutic approaches 515 Collinge, 2005). This new understanding has
Parkinson's disease 517 suggested a range of potential new therapeutic
-Features of Parkinson's disease 517 strategies in this important area. To date, though,
-Pathogenesis of Parkinson's disease 517 the available therapeutic interventions are aimed
-Drug treatment of Parkinson's disease 519 at compensating for, rather than preventing or
reversing, the neuronal loss.
Huntington's disease 521 Stroke, which is also a common disorder of
Neurodegenerative prion diseases 521 enormous socioeconomic importance, results from
acute ischaemic brain damage, quite diHerent from
the aetiology of chronic neurodegenerative
diseases, requiring diHerent but equally
challenging therapeutic approaches.
OVERVIEW The main topics discussed are:
mechanisms responsible for neuronal death,
As a rule, dead neurons in the adult central focusing on protein aggregation (e.g. amyloidosis),
nervous system (CNS) are not replaced, 1 nor can excitotoxicity, oxidative stress and apoptosis
their terminals regenerate when their axons are pharmacological approaches to neuroprotection,
interrupted. Therefore any pathological process
based on the above mechanisms
causing neuronal death generally has irreversible pharmacological approaches to compensation for
consequences. At first sight, this appears to be very neuronal loss (applicable mainly to AD and PO).
unpromising territory for pharmacological
intervention, and indeed drug therapy is currently
very limited, except in the case of Parkinson's PROTEIN MISFOLDING AND
disease (PO) (see below). Nevertheless, the AGGREGATION IN CHRONIC
NEURODEGENERATIVE DISEASES
11ti-. rccogni~>ed that ne"" neurons arc formed from progenitor cells in certain Misfolding means the adoption of abnormal conformations, b)
region'> of the adult brain, C\CO in primate~. Whether this occur\ in the certain normally expressed proteins such that they tend to form
cortex. and whether it play~ any role in learning and memory. i'> :t matter of large in~oluble aggregates (Fig. 35.1 ). The conversion of the linear
di,putc (~cc Gros~. 2000: Rakic. 2002). Certainly, it play& liule if any role
amino acid chain produced by the ribosome into a functional
in brain repair. However. teaming how to harness the inherent abi lity of
neuronal progcnitorb hlem cell~) to form new neurons is seen as an obviou~ protein requires it to be folded correctly into a compact confor-
508 approach to treating neurodegenerative disorders. mation w ith specific amino acids correctly located on its surface.

Mutations
External factors
Native
~
protein
l m
I
Molecular
chaperones
Fig. 35.1 Protein misfolding: a
process involved In m any c hronic
neurodegenerative diseases.
Th1~ complicated stepwise sequence can easily go wrong and lead
to nmfolded v;~rian t ~ that are unable to find a way back to the
correct nati\e' conformation. The misfoldcd molecules arc non-
funcuonal with re~pcct to the normal function of the protein, but
,an noncthele.,., make mischief within the cell. The misfolding
olh:n mean., that hydrophobic residues that would normally be
buril:d m the core of the protein are exposed on its surface. which
gi\e' the molecule., a strong tendency to aggregate. initially
a' oligomer,, and then a.-. insoluble microscopic aggregates
(l1g. 35.1 ). The} al\o tend to <,ticJ... to cell membranes. The tend-
enq to adopt 'uch conformations may be favoured by specific
mutation\ of the protein in question. or by infection with prions
(\CC beiO\\ ).
\1,,folded conformations can be generated spontaneously at a
low rate throughout life, so that aggregates accumulate gradually
11ith age. In the nervous system. the aggregates often form
di,tinct ~tructures, generally known as amyloid deposits, that arc
v1~ible under th e microscope and are characteristic of
ncurodegcncr:uivc disease. Although the mechanisms arc not
clear. ~uch aggregates, or the misfolded protein precursors, lead
to neuronal death. Examples of neurodegenerative diseases
that are cau~cd by such protein misfolding and aggrcga6on arc
'ho11 n in T;~ble 35.1.
The bmin pos'>esses a variety of protective mechanisms that
hmit the accumulation of such protein aggregates. The main ones
are the production of 'chaperone' proteins, which bind to newly
'}nthe,ised or misfolded proteins and encourage them to fold
COI'rel:tl}. and the 'ubiquitination' reaction. which prepares proteins
ior destruction '' ithin the cell. Accumulation of protein deposits
occurs\\ hen these protecti-.e mechanisms are unable ro cope. For
rc11ews of the~e mechanisms. see Stefani & Dobson (2003) and
Selkoe (2~).
MECHANISMS OF NEURONAL DEATH
Acute injury to cells causes them to undergo necrosis. recognised
pathologically by cel l swelli ng. vacuolisati on and lysis. and
associated with Ca 2 overl oad of the cells and membrane damage
(sec below). Necrotic cells typically spill their contents into the
NEURODEGENERATIVE DISEASES
Misfolded Oligomer Insoluble
protein
I IIIII
aggregate
/
Cellular d1sposa1 Intracellular
mechanisms depos1ts
~/
NEUROTOXICITY
Protein mlsfoldlng
Many chronic neurodegenerative diseases
involve the misfolding of normal or mutated forms of
physiological proteins. Examples include Alzheimer's
disease, Parkinson's disease, amyotrophic lateral
sclerosis and many less common diseases.
Misfolded proteins are normally removed by
intracellular degradation pathways, which may be
altered in neurodegenerative disorders.
Misfolded proteins tend to aggregate, initially as
soluble oltgomers, later as large insoluble aggregates
that accumulate intracellularly or extracellularly as
microscopic deposits, which are stable and resistant
to proteolysis.
Misfolded proteins often present hydrophobic surface
residues that promote aggregation and association
w ith membranes.
The mechanisms responsible for neuronal death are
unclear, but there is evidence that both the soluble
aggregates and the microscopic deposits may be
neurotoxic.
surrounding tissue. evoking an inflammatory response. Cells can
also die by apoptosis or programmed cell death (see Cb. 5). a slower
process that is essential for many processes throughout l ife.
including development. immune regulation and tissue remodelling.
Apopto~is. as well a., necrol.i~. occurs in many neurodegenerative
disorders (including acute conditions such as stroke and head injury;
for re,iew. sec Jellingcr. 200 1). The distinction between necrosis
and apoptosi'> as processes leading to neurodegeneration is not
absolute, for challenges such as excitotoxicity and oxidative stress
may be enough tO kill cells directly by necrosis or, if less intense,
may induce them to undergo apoptosis. Both processes therefore
represent possible targets for putative neuroprotective drug therapy.
Pharmacological interference with the apoptotic pathway may
become possible in the future, but for the present most effons 509
 SECTION 4 . THE NERVOUS SYSTEM

Table 35.1 Examples of neurodeg enerative d iseases associat ed w ith p rotein misfolding and aggregation

Disease Protein Charact erist ic pathology Notes

Alzhe1mer's disease (\-Amyloid (A(\} Amyloid plaques A(\ mutations occur in rare familial forms of Alzheimer's
disease

Tau Neurofibrillary tangles Implicated in other pathologies ('tauopathies'} as well

as Alzheimer's disease

Park1nson's disease <t-Synuclein Lewy bodies u-Synuclein mutat1ons occur in some types of familial
Parkinson's disease

Creutzfeldt-Jakob Prion protein Insoluble aggregates Transmitted by infection with prion protein in its
disease of prion protein misfolded state

Huntington's disease Huntingtin No gross lesions One of several genetic 'polyglutamine repeat' disorders

Amyotrophic lateral Superoxide loss of motor neurons Mutated superoxlde dismutase tends to form
scleros1s dismutase aggregates; loss of enzyme function increases
(motor neuron disease) susceptibility to oxidative stress

"Protein aggregation disorders are often collectively known as amyloidoses and commonly affect organs other than the brain.

are di rected at the processes involved in cell necrosis, and at
compensating pharmacologically for the neuronal loss.
EXCITOTOXICITY
Despite its ubiquitous role as a neurotran~mitter. glutam ate
is highly toxic to neurons, a phenomenon dubbed excitOtoxicity
(see Ch. 33). A low concentration of glutamate applied to neurons
in culture kills the cells, and the finding in the 1970s that glutamate
given orally produces neurodegeneration in vivo caused consider-
able alarm because of the widespread use of glutamate as a 'tru,te-
enhancing' food additive. The 'Chinese restaurant syndrome'- an
acute attack of neck MilTness and chest pain-i~ well known. but so
far the possibility of more serious neurotoxicity is only hypothetical.
Local injection of kaink acid is used experimentally to produce
neurotoxic lesions. It acts by excitation of local glutamate-releasing
neurons, and the release of glutamate, acting on NMDA and also
metabotropic receptors (Ch. 33), leads to neuronal death.
Calcium overload is the essential factor in excitotoxicity. The
mechanisms by which thjs occurs and lead!> to cell death are as
follows (Fig. 35.2).
Glutamate activates NMDA, AMPA and metabotropic receptors
(sites I. 2 and 3). Activation of AMPA receptors depolarises
the cell. which unblocks the NMDA channels (see Ch. 33),
permitting Ca 2+ entry. Depolarisation also opens voltage-
activated calcium channels (site 4). releasing more glutamate.
Metabotropic receptors cause the relea<;e of intracellular Ca 2
from the endoplasmic reticulum. Na+ entry further contributes
to Ca2 entry by Mimulating Ca2+/Na+ exchange (site 5).
Depolarisation inhibits or reverses glutamate uptake (site 6),
thus increasing the extracellular glutamate concentration.
The mechanisms that normally operate to counteract the rise
in [Ca2...)i include the Ca2 efflux pump (site 7) and, indirectly.
510 the Na pump (site 8).
The mitochondria and endoplasmic reticulum act as capaciou\
!>inks for Ca 2+ and normally keep [Ca 21, under control.
Loading of the mitochondrial stores beyond a certain point.
however, disrupts mitochondrial function, reducing ATP
synthesis, thus reducing the energy available for the membr.tne
pumps and for Ca2+ accumulation by the endoplasmic
reticulum. Formation of reactive oxygen specie~ is also
enhanced. This represents the danger point at which positive
feedback exaggerates the process.
Raised [Ca 2+]. affects many processe1., the chief ones relevant
to neurotoxicity being:
-increased glutamate release
-activation of proteases (calpains) and lipa!->es. causing
membrane d<m1age
-activation of nitric oxide !>ynthase; while low concentration'
of nitric oxide are neuroprotective, high concentrations in the
presence of reactive oxygen species generate peroxynitrite and
hydroxyl free radicals, which damage many important
biomolecules. including membrane lipids, protein'> and DNA
-increased arachidonic acid release, which increases free
radical production and also inhibits glutamate uptake
(site 6).
Glutamate and Ca2+ are arguably the two most ubiquitou' chemical
signals, extracellular and intracellular, respectively, underlying
brain fu nction, so it is disconcerting that such cytotoxic mayhem
can be unleashed when they get out of control. Both are stored in
dangerous amounts in subcellular organelles. like hand grenade'
in an ammunition store. Defence again~t excitotoxicity is clear!)
essential if our brains arc to have any chance of staying alive.
Mitochondrial energy metabolism provides one line of defence
(see above), and impaired mitochondrial function, by rendering
neurons vulnerable to excitotoxic damage, may be a factor in variou,
neurodegcnerative condition1., including PD.
 NEURODEGENERATIVE DISEASES

--------.
-''- -- ~---- --- e e e
---- -----------------
GLUTAMATE

NMDA Calcium
-- .... _

-- ,e ,, receptor channel '

''
\ antagonists inhibitors ''
''
' ''
''
\

''
I
7 ''
I
I
,
, .., 'II
I
I
I y
I
I Ca2+
''
I
y I I
I ''
I 3 '' I I I
I

I \

''
---r-----
,
I

'' '' I
1 I

' '' '

'

---------)
AA
----------1
release
NO
Membrane~ Inactive
damage products
~ Proteases

VILLAINS HEROES
I
I
I
I
I

I
I
I
I
I
I
\
\
\
Glutamate
\
release
'' inhibitors
''

.
I
'' I I
I I
' ' y I y I
,,
,,_ y y
"""------ - - -- ~

Fig. 35.2 Mechanisms of excitotoxicity. Membrane receptors, ion channels and transporters, identified by numbers 1-8, are
dtscussed in the text. Possible sites of action of neuroprotective drugs (not yet of proven clinical value) are highlighted. Mechanisms on
the left (villains) are those that favour cell death, while those on the right {heroes) are protective. See text for details. AA, arachidonic acid;
ER, endoplasmic reticulum; Glu, glutamate uptake; IP3 , inositol trisphosphate; M, MGiuR, metabotropic glutamate receptor; NO, nitric
oxide; ROS, reactive oxygen species; SOD, superoxide dismutase; VDCC, voltage-dependent calcium channel.

511
 SECTION 4 THE NERVOUS SYSTEM
The role of cxcitoto.xicity in ischaemic brain damage is wel l
c1>tablished (see below), and it i~ also believed to be a factor in
other neurodegencrative diseasc1>. such as those discussed below
(~ee Lipton & Rosenberg, 1994).
T There arc ~cvcral examples ul ncurodegencrativc conditions cau,ed by
environmental toxins acting as ugoni!>t!> on glutamme receptors. Domoic
ucid i!. a gluwmate analogue produced by mu'>SCI'>. which wa.~ identified
a~ the cau-;e of an epidemic of <;evere menial and neurological deterio-
ration in a group of Newfoundlander.. in 1987. On the !\land of Guam. a
\)ndromc combining !he features of dcmemia, paralysis and PO wa'
traced to an cxcitotoxic an1ino ac id, ~-metbylamino-ulanine, in the !.Ceds
of a local plant. Discouraging the consumption of thc'c seeds has largely
eliminated the disea\e.
APOPTOSIS
Apoptosis can be initiated by various cell surface signals (see Ch. 5).
The cell is systematically dismantled, and the shrunken remnants arc
removed by macrophages without causing inOammation. Apoptotic
cells can be identified by a ~taining technique that detects the
characteristic DNA breaks. Many different signalling pathway~
can resu lt in apoptosis, but in a ll cases the fina l pathway resulting
in cell death i~ the activation of a family of protcases (caspase.1).
which inactivate various intracellular proteins. Neural apoptosi~
is nonnally prevented by neuronal growth factor!.. including ncf\c
growth factor and brain-derived neurotrophic factor, secreted
proteins tha t arc required for the survival of different populations
of neurons in the C S. These growth factors regu late the expression
of the two gene products Bax and Bcl-2, Bax being proapoptotic
and Bcl-2 being antiapoptotic ('>ee Ch. 5). Blocking apopto'>is by
interfering at specific point'> on these pathways represents an
attractive strategy for developing neuroprotcctive drugs, but one
that has yet to bear fruit.
OXIDATIVE STRESS
The brain hal- high energy needs. which are met almost entirely
by mitochondrial oxidative phosphorylation, generating ATP at
the same time a~ reducing molecular 0 1 to H 20. Under certain
conditions. highly reactive oxygen <.pecics, for example oxygen
and hydroxyl free radicals and HP2 rna) be generated as side
products of thi!. procc:.s (see Coyle & Puttfarken. 1993). Oxidative
~tress is the result of excessive production of these reactive species.
They can ai'>O be produced as a by-product of other biochemical
pathways. including nitric oxide '>ynthesi!. and arachidonic acid
metabolism (which are implicated in excitotoxicity: see abo\e).
as well as the mixed function oxidase system (see Ch. 8).
Unchecked, reactive oxygen radical& attack many key molecules.
including en7ymcs, membrane lipids and DNA. Not surprisingly.
defence mechani'>ms are provided, in the form of enzymes such
a_., superoxide dismwase (SOD) and catalase, a-. well as antioxidants
such as ascorbic acid, glutathione and a-tocopherol (vitamin E),
which normally keep these reactive species in check. Some
cytokines, especially tumour necrosis factor (TNF-a), which is
produced in conditions of brain ischaemia or inflammation
(Ch. 13), exert a protective effect, partly by increa_c;ing the expression
of SOD. Tran~genic animals lacking TNF receptors show enhanced
-
-...
512
--~---
susceptibil ity to brain ischaemia. Mutations of the gene encoding
SOD (Fig. 35.2) are associated with a progressive form of motor
neuron di!>case known as amyotrophic lateral sclerosis, a fatal
paralytic di..ease resulting from progressi'e degeneration of motor
neurons. and transgenic mice expressing mutated SOD develop
a similar condilion. 2 Accumulation of aggregates of misfolded
mutated SOD (see above) may also contribute to neurodegeneration.
Tt is possible that accumulated or inherited mutations in cn;yme'
such as those of the mitochondrial respiratory chain lead to a
congenital or age-related increase in ltu~ceptibility to oxida111e
stress, which is manifest in different kinds of inhented
neurodcgcnerative disorder~ (such as Huntington s disease), and
in age-related neurodcgcneration.
Several po~siblc targeh for therapeutic intervention with
neuroprotcctive dmglt are shown in Figure 35.2. Disappointing!}
intense effort to find effective drugs for a range of neurodegencraUit
disorder~ in which excitotoxicity is bel ieved to play a part ha'
had very limited success. Riluzole, a compound that inhibits both
the release and the post<.ynaptic action of glutamate, retard\ tc
some degree the deterioration of patients with amyotrophic late~
sclerosis. Memantine, a compound first de~cribed 40 year~ ago
is a weak NMDA receptor antagonist that produces slight improl~
ment in moderate- to-severe cases of AD. and was recent!)
approved for clinical usc.
ISCHAEMIC BRAIN DAMAGE
After heart disease and cancer. stroke~ are the commonest cau'-1:
of death in Europe and North America. and the 70% that are noo-
fatal are the commonest cause of disability. Approximately 85
of strokes are ischaemic, ultually due to thrombosis of a major
cerebral artery. The remainder are haemorrhagic, due to rupture
of a cerebral artery.
PATHOPHYSIOLOGY
Interruption of blood supply to the brain initiates the cascade of
neuronal events shown in Figure 35.2, which lead in turn to later
consequence!.. including cerebral oedema and inflammation, 1\hkh
can also contribute to brain damage (see Dimagl et al .. 1999). Furthtr
damage can occur following reperfusion, because of the production
of reactive oxygen species when the oxygenation is re~tored
Reperfusion injury may be an important component in '>tro~e
patienh. These secondary processes often take hours to develo.
providing a window of opportunity for therapeutic intencntion
The lesion produced by occlusion of a major cerebral artery COil\!\~
of a central core in which the neurons quickly undergo irre-
versible necrosis. surrounded by a penumbra of compromi'led
tissue in which inflammation and apoptotic cell death de,elop
over a period of several hour!.. It is assumed that neuroproteCll\(
therapies. given within a few hours, might inhibit this sc<:ontlary'
penumbral damage.
'Surprhingl). the SOD mutation responsible b more. rather tban le'>'. a.:uvc
than the normal enzyme. The mechanism by which 1t causes
neurodegcncrmion is nm clear.

lacltotollicity and oxidative stress
Excitatory amino acids (e.g. glutamate) can
cause neuronal deat h.
Excitotoxicity is associated mainly with activation of
NMDA receptors, but other types of excitatory amino
actd receptors also contribute.
Excitotoxicity results from a sustained rise in
Intracellular Ca2+ concentration (Ca2 overload).
Excitotoxicity can occur under pathological
conditions (e.g. cerebral ischaemia, epilepsy) in which
excessive glutamate release occurs. It can also occur
when chemicals such as kainic acid are administered.
Raised intracellular Ca2" causes cell deat h by various
mechanisms, including activation of proteases,
formation of free radicals , and lipid peroxidation.
Formation of nitric oxide and arachidonic acid are
also involved.
Various mechanisms act normally to protect neurons
against excitotoxicity, the main ones be1ng Ca ~
2
transport systems, mitochondrial function and the
production of free radical scavengers.
Oxidative stress refers to conditions (e.g . hypoxia) in
which the protective mechanisms are compromised,
reactive oxygen species accumulate, and neurons
become more susceptible to excitotoxic dam age.
Excitotoxicity due to environmental chemicals may
contribute to some neurodegenerative disorders.
Measures designed to reduce excitotoxicity include
the use of glutamate antagonists, calcium
channel-blocking drugs and free radical scavengers;
none are yet proven for chn1cal use.
Glutamate excitotoxicity plays a critical role in brain ischaemia.
J,~hacmia causes depolarisati on of neuron),, and the release of
large amounts of glutamate. Ca!+ accumulation occurs. partly as
are,uJt of glutamate acting on MDA receptor~. for both Ca + entry
2 followed by more gradual (hours) degeneration of cells
and cell death following cerebral i~haemia are inhibited by drug!.
thai hlod.. 'MDA receptors or channel\ (sec 01. 33). 'itric oxide i~
nl'iO produced in amounts much greater than result from normal
!k:unmal activity (i.e. to levels that arc toxic rather than modulatory).
THERAPEUTIC APPROACHES
1 he only dmg CUITCntly approved for treating strokes is rccom-
hmant lissue plasminogen acti vator (tl'A). given intravenously.
llhl~h helps to restore blood now by dispersing the thrombus
~~ Ch. 21). It gives significant, but ~ l ight, functi onal benefit lO
patient' 11ho survive. To be effective. itmu'>t be given within about
\ hour.. of the thrombotic epi'>ode. Abo. it should not be given
m the 15~ of cases where the caul.C i~ haemorrhage rather than
lhromb<his. Because this can be determined only by brain scanning.
tPA j, actually given to only 1- 2% of stroke victims.
A preferable approach would be to u~c neuroprotecti ve agents
aimed at rescuing cells in the penumbral region of the lesion,
NEURODEGENERATIYE DISEASES
which are otherwise l ikely to die. In animal models involving
cerebral artery occlusion. many drug~ targeted at the mechani!>m'
!>hown in Figure 35.2 (not to mention many others that have
been tested on the basi s of more far-n ung theories) act in thi~
wny to reduce the size of the infarct. These include glutamate
antagonists. calcium and sodium channel inhibitors, free radical
scavengers, an ti-inflammatory drugs. protease inhibitors and others.
It \ecms that almost anything worh . A ltogether. Green et at.
(2003) reported that more than 37 such agents had been tc!>ted in
more than 114 cli nical triab . and all had failed to show efficacy.
The dispiriting list of failures include\ calcium and sodi um channel
blockers (e.g. nimodipine, fosphcny toin), MDA receptor
antagonists (selfotel , eliprodil, dcxt rom eth orpban), drugs that
inhibit glutamate release (adenosine analogues, lobeluzole),
dru gs that enhance GABA effects (e.g. chlormethiazole), and
various free radical scavengers (e.g. tirilazad). Green et al (2003)
argue, reasonably enough. that the animal models in use fail to
replicate the clinical situation, and urge the use of more rigorou1.
experimental protocols to make animal models more predictive.
but a c;uccess rate of tero among 37 compounds suggests that the
model'> are more deeply na\1-ed.
Controlled clinicaltriah on 'ltroke patients are problematic and
very expensive. partly becau:-.e of the large variability of outcome
in terms of functional recovery. which means that l arge groups of
patients (typically several hundred) need to be observed for ~everaJ
months. T he need to start therapy w ithin hours of the attack is an
additional problem.
Stroke tTeatment is certainly not- so far at least- one of
pharmacology's success storie:-., and medical hopes re~t more
on prevention (e.g. by controlling blood pressure,3 taking aspir in
and preventing atherosclc ro'i~) than on treatment.
Stroke
Associated w ith intracerebral thrombosis or
haemorrhage (less common), resu lting in rapid death
of neurons by necrosis in the centre of the lesion,
in penumbra due to excitotoxicity and inflammation.
Spontaneous functional recovery occurs to a highly
variable degree.
Although many types of drug that interfere wtth
excitotoxicity (see Protein misfolding box) are able to
reduce infarct size in experimental animals, none of
these have so far proved efficacious in humans.
Tissue plasminogen activator, which d isperses blood
clots, is beneficial if it is given within 3 hours.
None of the many neuroprotective drugs that are
effective in animal models are efficacious in the
clinical trials.
' It i~ no1 obviou~ why hypcrten~ion .,hould predi,pose LO thrombotic a'
oppo,cd 10 haemorrhagic wo~c. yel ' ludic., have ~hown that nonnali\lng
513
blood pressure e ffectively el imi nates the increased risk of woke.
 SECTION 4 . THE NERVOUS SYSTEM
ALZHEIMER' S DISEASE
Loss of cognitive ability with age is considered to be a normal
process who~e rate and extent is very variable. AD was originally
defined as presenile dememia. but it now appears that the same
pathology underlies the dementia irrespective of the age of onset.
AD refer-. to dementia that docs not bave an antecedent cause,
such as \troke. brain trauma or alcohol. Its prevalence ri~es
sharply with age. from about 5% at 65 to 9091: or more at 95.
Until recently. age-related dementia was considered to result
from the Meady loss of neurons that normally goes on throughout
life, possibly accelerated by a failing blood supply associated
with atherosclerosis. Studies over the past three decades have,
however, revealed specific genetic and molecular mechanisms
underlying AD (reviewed by Selkoe, 1997; Bossy-Wetzel ct al.,
2004 ), which have opened potential new therapeutic oppor-
tunities (see Yamada & Nabeshima, 2000).
PATHOGENESIS OF ALZHEIMER' S DISEASE
Al7heimer's di,ease is associated with brain shrinkage and localised
loss of neurons, mainly in the hippocampus and basal forebrain.
The loss of cholinergic neurons in the hippocampus and frontal
cortex is a feature of the disease, and is thought to underlie the
cognitive deficit and loss of short-term memory that occur in AD.
Two microscopic features are characteristic of the disease. namely
extracellular amrloid plaques. consisting of amorphous extracellular
depo,ih of (3-amyloid protein (known as A~). and intraneuronal
neurofibrillary tangles. comprising filaments of a phosphorylated
form of a microtubule-associated protein (Tau). Both of these
deposits are protein aggregates that result from misfolding of native
proteins, as discussed above. They appear also in normal brains,
although in smaller numbers. The early appearance of amyloid
deposits presnges the development of AD, although symptoms
may not develop for many years. Altered processing of amyloid
protein from its precursor (amyloid precursor protein, APP; see
Bossy-Wett.el et al., 2004) is now recognised as the key lo the
pnthogcnesis of AD. This conclusion is based on several lines of
evidence, particularly the genetic analysis of certain, relatively rare,
types of familial AD, in which mutations of the APP gene, or of
other genes that control amyloid processing, have been discovered.
The APP gene resides on chromosome 21, which is duplicated in
Down's -,yndrome, in which early AD-like dementia occur~ in
as~ociation with overexpreS!>ion of APP.
T Amylod depo~it~ con~bt of aggregates of Af3 (Fig. 35.3) containing 40
or 42 rc~due\. AjWO i!. produced nonnall:r in small amount\, v. hercas
AjW2 is O\Crproduced lb a resuh of lhe genetic mutations mentioned above.
Both proteins aggregate to form amyloid plaques. but Af3-t2 shows a
'>IIOngcr tendency than Af340 to dow. and appears to be the main culprit in
amyloid fom1ation. AjWO and 42 are produced by proteolytic cleavage of
a much l:1rger (770 amino acid) APP. a membrane protein normally
c,.,pressed by many cell,, including CNS neurons. The protea~e~ that cut
out lhc Af3 -.cqucoce arc knov. n as secrera.1e.'>. Normally, asecreuue acts to
re lease the large extracellular domain as soluble APP, which serves
variou!o poorly underblood trophic functions. Formation of Aj3 involves
cleavage m two different points, including one in the intramembrane
domain of APP. by {3- and y-secrerases (Fig. 35.3). ')'Secretase is a clumsy
- 514
.. ..: ...:,_-'. .~--- cntymc- actuall y a large intramembrane complex of several protei ns-
that Jach precision and cuts APP at different poin~ in lhe transmembrJJl(
domain. generating Af3 fragments of different lenglhs, including A!Wi
and 42. Mutauons in !his region of the APP gene affect lhe preferred
cleavage point, tending to favour formation of AjW2. Mutations of 1M
unrelated presenili11 genes result in increased activity of "fSI'Cf'l'taU,
becau..e the pi'I'Sellilitl proteins form pan of lhe ')'~ecreta'e compk\
The-.e ditlerent AD-related mutation;. increase lhe ratio of Af342:Af3-W
'~hch can be detected in plasma. serving as a marker for familial AD
Mutation~ in anolher gene. !hat for the tipid transpon protein ApoE4. al"
pred.-po\e to AD. probably because of expres~ion of abnormal ApoF~
proteins that facilitate the aggregation of Af3.
It is uncenain e~acdy how A~ accumulation causes neurodegeneration.
and whether the damage i~ done by soluble A~ monomers or oligomcl"\.
or by amyloid plaques. There is some evidence !hat the cell~ die b)
apopto~b. although an inflammatory response is also evident. Exprcssi!>n
of Altheimer mutations in transgenic animals cause~ plaque formation
and ncurodegeneration, and also increases the su~ceptibility of CNS
neuron~ to other challenges. such as ischaemia, excitotoxicity and
oxidative strcs~. and this increased vul nerability may be the cause 111
the progressive neurodegeneration in AD. These transgenic modeb will
be of great value in testing potential drug therapies aimed at rctan.ling
the ncurodegencrativc process.
The other main player on the biochemical stage i' Tau, the protein 11f
which the neurofibrillary tangles are composed (Fig. 35.3 ). Thetr wle
in neurodegeneration i~ unclear, allhough similar 'tauopathics occur 10
many ncurodcgcncrativc conditions (see Lee et a! .. 200 I). Tau is a nonnal
con\utuent ot neurons. being a~ociated wilh intracellular mcrotubule'-
ln AD and other tauopalhies. it becomes abnormally phosphol)lated and
i~ dep<hited intrnccUularly as paired helical jilamems wilh a characteri'uc
mcro~opc appearance. When the cells die, these filaments aggregate as
e"racellular neurofibrillary tangles. It is possible. but not proven. thou
Tau phosphorylallon is enhanced by lhe presence of A~ plaque,. Whether
hyperpho,phol) lation and intracellular deposition of Tau harm~ the ce
is not cenain. although it is known that Tau phosphorylation impair. la\1
axonal tran~pon. a proce~s that depends on microtubule~.
Alzheimer's disease
Alzheimer's disease (AD) is a common age-
related dementia distinct from vascular dementia
associated with brain infarction.
The main pathological features of AD comprise amyloid
plaques, neurofibrillary tangles and a loss of neurons
(particularly cholinergic neurons of the basal forebrain).
Amyloid plaques consist of aggregates of the A~
fragment of amyloid precursor protein (APP), a normal
neuronal membrane protein, produced by the action
of ~- and y-secretases. AD is associated wtth
excessive A~ formation, resulting in neurotoxicity.
Familial AD (rare) results from mutations in the APP
gene, or in presenilin genes (involved in y-secretase
function), both of which cause increased A~ formation.
Neurofibrillary tangles comprise intracellular
aggregates of a highly phosphorylated form of a
normal neuronal protein (Tau). The relationship of
these structures to neurodegeneration is not known.
Loss of cholinergic neurons is believed to account for
much of the learning and memory deficit in AD.
 NEURODEGENERATIVE DISEASES

fA] Structure of APP [!!] Processing of APP

...-----.
APP and presenilin mutations
Cleavage increase Af340 and Af342 formation
by secretases
PHYSIOLOGICAL I
_j_ AMYLOIDOGENIC
~ a y
PATHWAY
..
PATHWAY '\

:..
~

Sites of
amyloidogenic ~cr-.
: Af\ 40/42 I
,, ~42
mutations .. y _ _ _ ApoE4 mutations
. sAPP enhance aggregation
Aggregation

~---- sAPP -----+

1
Growth factor
function
'-<---t
TauP
~ Tau

l~ .
AMYLOID

PLAQUlES r= Paired helical

flla1ents
NEUROFIBRILLARY
TANGLES

: NEURONAL DEATH ,
--- --- --- -- ----- -- -- - ---- ------ -------J
Fig. 35.3 Pa1hogenesis of A lzheimer's di sease. rA Structure of amyloid precursor protein (APP), showing origin of secreted APP
(sAPP) and Afl amyloid protein. The regions involved in amyloidogenic mutations discovered in some cases of familial Alzheimer's disease are
shown flanking the Afl sequence. APP cleavage involves three proteases: secretases a, j3 and y. aSecretase produces soluble APP,
whereas fl- and y-secretases generate Afl amyloid protein. y-Secretase can cut at different points, generating Afl peptides of varying
lengths, including ~0 and ~42, the latter having a high tendency to aggregate as amyloid plaques. ~ Processing of APP. The main
'physJOiogical' pathway gives rise to sAPP. which exerts a number of trophic functions. Cleavage of APP at different sites gives rise to AI\.
the predomtnant form normally being A~O. which is weakly amyloidogenic. Mutations in APP or presenilins increase the proportion of
APP, which is degraded via the amyloidogenic pathway, and also increase the proportion converted to the much more strongly
amyloidogenic form Afl42. Aggregation of Afl is favoured by mutations in the apoE4 gene.

Loss of choline rgic ne urons THERAPEUTIC APPROACHES

Although changes in many transmitter systems have been observed,
mainly from measurements on post-monem AD brain tissue. a
relati,ely selective loss of cholinergic neurons in the basal forebrain
nuclei (Cb. 34) is characteristic. This discovery, made in 1976,
1mplied that pharmacological approaches to restoring cholinergic
funcuon migbt be fea~ible. leading to the use of cholinesterase
inhtbitors to treat AD (sec below).
Choline acetyl transferase activity, acetylcholine content. and
ac~tylcholinestcrasc nnd choline transport in the cortex and hippo-
~:ampu~ are all reduced considerably in AD but not in other
di.;orders. such a~ depression or schizophrenia. Muscarinic receptor
lktNl). determined by binding studies. is not affectecl but nicotinic
receptors. particularly in the cortex, are reduced. The reason for
1he -.elective loss of cholinergic neurons resulting from Af3
lormatioo is not known.
Recent advances in understanding the process of neurodegencration
in AD have yet to result in therapies able to retard it. Currently,
cholinesterase inhibitors (see Ch.l 0) and me man tine (see above)
are the only drugs approved for treating AD. although many
drugs have been claimed to improve cognitive performance and
several new approaches are being explored (see Citron, 2004).
Choline ste rase inhibitors
Tacrine. the first drug approved for treating AD, was investigated
on the basis that enhancement of cholinergic transmission might
compensate for the cholinergic deficit. Trials showed modest
improvements in tests of memory and cognition in about 40% of
AD patients, but no improvement in other functional measures that
affect quality of life. Tacrine has to be given four times daily and 515
SECTION 4 . THE NERVOUS SYSTEM

produces cho linergi c side effects such as nausea and abdo minal
cramp~. as w ell as hepatotoxicity in some patien ts, so it i s far fro m
an ideal drug. L ater compounds, w hich also have limited e f ficacy
but arc m ore e ffective than tacrine in improv ing qu ali ty o f life,
i ncl ude d on ep ezil, r i vastigmine and galantamine (Table 35.2).
The~e drug~ produce a m easurable. although slig ht, improvem ent
AD patients. but this may be too sm all to
o f cogn i tive func tio n i n
be si g nifica nt in terms of everyday life.
There i s !>Orne evidence from l aboratory studies that c ho lin-
estera~e inhibiton. may act somehow to reduce the fo rmati on or
neuroto xic ity o f Af3, and therefore retard the progressi on o f AD as
w ell as producing ~ymptomatic benefit. Clinical trials, ho w ever,
have sh o wn o nl y a l)mall improvement in cognitive functi on, with
no e ffect o n disease progression.
Other drugs aimed at improv ing cholinergic function that arc
bei ng investigated include other cholinesterase inh ibitors and
a variety o f muscarinic and nicotinic receptor agoni sts, none of
whic h l ook promising on the basi s of early cl inical resu l ts.
Other drugs
'Y Oih)'droer gotamuine was used for many year; to treat dementia. It
act\ a\ a cerebml vasodilator. but trial!. showed it to produce l ittle if any
cogniti\e improvement. 'Nootropic' drugs such as piracctam and
aniracelam tmprove memory in animal tests, po,sibly b) enhancing
glutamate releou.e. but are probably ineffective in AD.
Inhibiting neurodegeneration
'Y For mo\t of the dt\order., dbcussed in this chapter. including AD.
the lloly Grail. which so far eludes us. would be a drug that retard\
neurodegt:nt:ration. Now that we have several well-characterised targets.
wch "' A~ formation by the f3- and y-secreta!>es, and Af3 neurotoxicity.
togt:ther with a range of transgenic animal models of AD on w hich
compound; can be tested. the prospecl> cen ainly look brighter than
they did a decade ago. Particular developments are wonh mentiomn
(~ee Selkoe& Schenk. 2003. and Citron. 2004. for more details).
l nhtbtto~ of 1}- and y-!>ecretase have been identified and are undergomg
clinical triab. Unfonunately. y-secretase plays a role in other 'ignalling
pathway' be\tde~ AI} fom1ation. so inhibitors are like!} to produce un\\Olllt<-d
a!> well a.' beneficial effec~.
An tngen1ou' ne"' approach was taken by Schenk et al. ( 1999). "ho
immum'>Cd AD tran~genic mice with AP protein. and found that thi' 11<1!
onl) prevented but also re\ersed plaque fonnation. Initial trial' m hum.m'
had to be tcnninatcd because of neuroinflammatory complication\. but
work on developing bencr immunisation strategies is continuing.
Epidemiological studies reveal that some non-steroidal anti-inflammatul)
drug~ CNSAIDs: see Ch. 14) used routinely to treat anhri ti s reduce the
likelihood of developing AD. Ibuprofen and in domctacin ha\e thi'
effect. although other NSATDs. such as llSpirin , do not, nor do ant1
inflammatory steroids !>uch as prednisolone. Recent wort.. (see De Stroopcr
& Ktinig. 2001 ) suggests that NSMDs may reduce A f~42 formation h}
regulating y-secretase, an effect unrelated to cyclo-oxygcnase i nhibition,
by which NSAI D:.. reduce inflammation. Tt may therefore be po'\ihlc h>
fi nd compounds that target y-secretase selecti vely withou t inhibui n~
cyc lo-oxygena>e. thus avoiding the side effects associated with current
NSAI D>. Di>appointingly. cli nical trials with various NSAl Ds have so far
f:ailed to show any effect on cognitive perfom1ance or disease progression
in AD patient' (\CC Towni>end & Pratico. 2005).
A~ plaque> bind copper and zinc, and removal of these metal 10~
promote\ di,;,oluuon of the plaques. The amocb1c1dal drug clioquinol t
a mctal-chclating agent that causes regression of amyloid dcp<hit'
animal models of AD. and showed some benefit in innial climcal trials.
Clioqumol H!>elf has known toxic effects in humans. ~hich preclude us
routine clinical U>e. but less toxic metal-chelating agent\ are un.ler
in..-e.,llgatllln.
Shonage of growth factor~ (panicularly nerve growth factor) rna)
contnbute to the loss of forebrain cholinergic neuron\ in AD. Admmi\tcnng
growth factor.. into the brain i> not realistic for routine thcrap). but
alternative approachei>. such as implanting cells engineered to ..ccretc n<ne
growth factor. arc under investigation.

Table 35.2 Cholinesterase inhibitors used in the treatment of Alzheimer's disease

Drug Type of inhibition Duration of action Main side effects Notes

Tacrlne Short acting, reversible - 6 h Few cholinergic side The first anticholinesterase shown
Affects both AChE and effects to be effective in Alzheimer's disease
BuChE Can cause hepatotoxicity Monitoring for hepatotoxicity needed

Donepeztl Short-acting, reversible - 24 h Slight cholinergic side

AChE-selective effects

Aivastigmine Slowly reversible - 8 h Cholinergic s1de effects Gradual dose escalation to m1nim1se
Affects both AChE and that tend to subside wtth side effects
BuChE continuing treatment

Galantamine Reversible, non-selective - 8 h Few side effects Dual mechanism of action postulated
Also enhances nicotinic
acetylcholine receptor
activation by allosteric
mechanism

AChE, acetylcholinesterase; BuChE, butyryl cholinesterase.

' Similar level of limited clinical benefit for all d rugs. No clinical evidence for retardation of disease process, although animal tests
suggest diminution of Al3 and plaque formation by a mechanism not related to cholinesterase inhibition.

Current!). the only drug!> approved for the treatment of AD are variou'
choline,terJ-.e inhibito~ (Table 35.2) and memantjne. an NMDA receptor
antagom't bclie,cd to ~>.or!.. by inhibaung glutamate-induced excitotoxicity.
It ha, only maid <;ide eftech. and clinacal trial~ data show it to produce a
'hght but <;agnificant improvement an cognitive function in moderate-to-
-.e,ere AD
PARKINSON' S DISEASE
FEATURES OF PARKINSON'S DISEASE
Parkin~on's disease i~ a progressive disorder of movement that
occu~ mainly in the elderly. The chief symptoms are:
tremor at rest, u~ually starting in the hands ('pill-rolling'
tremor), which tends to diminish during voluntary activity
muscle rigidity, detectable as an increased resistance in
passive limb movement
~upprcssion of voluntary movements (hypokinesis), due partly
to muscle rigidity and partly to an inherent inertia of the
motor system. which means that motor activity is difficult to
\lop a~ well as to initiate.
Par~insonian patients walk with a characteristic sbuffljng gait.
The) find it hard to '>tart. and once in progress they cannot quickly
'top or change direction. PO is commonly associated with dementia,
probabl) becau ..e the degenerative process is not confined to the
ba,al ganglia but also affects other parts of the brain.
Pa~in.,on 's disease often occurs with no obvious underlying
cau-,e, but it may be the result of cerebral ischaemia. viral
ell\."\:phaliti~ or other types of pathological damage. The symptoms
~.an abo be drug-induced, the main drugs involved being those
that reduce the amount of dopamine in the brain (e.g. r eserpine;
~e Ch. II) or block dopamine receptors (e.g. antipsychotic drugs
,uch as chlorprom azi ne; &ce Ch. 38). There are rare instances of
early-onset PO that runs in families, and several gene mutations
have been identified, the mo~t important being synuclein and parkin.
Study of these gene mutations has given some clues about the
mechanism underlying the neurodegenerative process (see below).
NEUROCHEMICAL CHANGES
Parkm..on\ disease affect<; the basal g:mglia, and its neurochemical
(lngin \\U~ discovered in 1960 by Hornykiewicz. who showed that
:he dopamine content of the \Ub~tantia nigra and corpus striatum
1-ee Ch. 34) in po\t-mortem brains of PO patients was extremely
ltm (usually less than I Oo/c of normal), associated with a loss of
dopammcrgic neuron'> in the \ubstantia nigra and degeneration
of nenc terminaJ... in the striatum. Other monoamines. such as
noradrenaline and 5-hydroxytryptamine. were much less affected
th3n dopamine. Later !.tudie~ (e.g. with positron emission
wmography scanning tO reveal dopamine transport in the
,triarum) have ~hown a lo:,' of dopamine over several years, with
')mptom'> of PO appearing only when the striatal dopamine conrent
ha.' fallen to 20-40% of normal. Lesion~ of the nigrostriatal tract or
chemically induced depletion of dopamine in experimental animals
abo pro<.luce symptoms of PD. The symptom most clearly related
to dopamine deficiency is hypokinesia, which occurs immediately
and invariably in lcsioned animals. Rigidity and lremor involve
NEURODEGENERATIVE DISEASES
Clinical use of drugs in dementia
Acetylcholinesterase inhibitors and NMDA
antagonists detectably improve cognitive impairment
in clinical trials but have significant adverse effects
and are of limited use clinically.
Efficacy is monitored periodically in individual
patients, and administration continued only if the
drugs are believed to be working and their effect in
slowing functional and behavioural deterioration is
judged to outweigh adverse effects.
A cetylcholin est erase inhibitors:
examples include donepezil, galantamine,
rivastig mine
used in mild to moderate Alzheimer's disease.
NMDA receptor anta go nists:
for example m em antine (see Ch. 33, p. 485)
- used in moderate to severe Alzheimer's disease.
more complex neurochemical disturbances of other transmitters
(particularly acetylcholine, noradrenaline. 5-hydroxytrypramine
and GABA) as well as dopamine. In experimental lesions, two
secondary consequences follow damage to the nigrostriatal tract,
namely a hyperactivity of the remaining dopan1inergic neurons,
which show an increased rate of transmitter turnover, and an
increa<;e in the number of dopamine receptors, which produces
a Mate of denervation hypersensitivity (see Ch. 9). The striatum
cxpres~es mainly 0 1 (excitatory) and D 2 (inhibitory) receptors
(see Ch. 34), but fewer D, and 0 4 receptors. A simplified diagram
of the neuronal circuitry involved, and the pathways primarily
affected in PO and lluntington 's disease, is shown in Figure 35.4.
Cholinergic interneurons of the corpus striatum (not shown
in Fig. 35.4) arc also involved in PO and Huntington's disease.
Acetylcholine release from the striatum is strongly inhibited by
dopamine, and it is suggested that hyperactivity of these cholinergic
neurons contributes to the '>ymptoms of PD. The opposite happens
in Huntington's dil.ease, and in both conditions therapies aimed
at redressing the balance between the dopaminergic and cholinergic
neurons are, up to a point. beneficial.
PATHOGENESIS OF PARKINSON' S DISEASE
Parkinson's disease is believed to be caused mainly by environ-
mental factors, although the rare types of hereditary PO have
provided some valuable clues about the mechanism. As with other
neurodegencrative disorders, the damage is caused by protein
misfolding and aggregation, aided and abetted by three familiar
villains, namely excitotoxicity. oxidative stress and apoptosis
(see Lotharius & Brundin, 2002; Vila & Przedhorski, 2004).
Aspects of the pathogenesis and animal models of PD are
described by Bcal (200 1).
517
 SECTION 4 . THE NERVOUS SYSTEM

Motor cortex

Corpus striatum
Huntington's
disease

Fig. 35.4 Simplified diagram of

the organisation of the
extrapyramidal motor system and
the defects that occur in
Park inson's disease (PO) and
Huntington's disease. Normally, PO
activity in nigrostriatal dopamine
Thalamus
neurons causes excitation of
striatonigral neurons and inhibition
of striatal neurons that project to the
globus pallidus. In either case,
because of the different pathways
involved, the activity of GABAergic PC PR
neurons in the substantia nigra is
suppressed, releasing the restraint
on the thalamus and cortex, causing Substantia
motor stimulation. In PO, the nigra
dopaminergic pathway from the

~-
substantia nigra (pars compacta) to
the striatum is impaired. In
~ Dopaminergic neuron STN = Subthalamic nucleus
Huntington's disease, the GABAergic
PR =Substantia nigra (pars reticulata
striatopallldal pathway is impaired,
PC = Substantia nigra (pars compacta)
producing effects opposite to the
changes in PD. PC, substantia nigra
(pars compacta); PR, substantia
.--.e---< GABA-ergic neuron

nigra (pars reticulata); STN,

subthalamic nucleus. ~ Glutamatergic neuron

Neurotoxins ox idation of dopamine gives rise to potentially toxic metabolite,.

New light was thrown on the possible aetiology of PD by a
chance event. ln 1982, a group of young drug addicts in California
suddenly developed an exceptionally severe form of PD (known
as the ' fro;.-cn addict' syndrome), and the cause was traced to
the compound 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine
(MPTP), which was a contaminant in a preparation used as a
heroin ~ubstitute (see Langston, 1985). MPTP causes irreversible
deslnlction of nigrostriatal dopaminergic neurons in various species,
and produces a PO-like state in primates. MPTP acts by being
convened to a toxic metabolite. MPp+. by the enzyme monoamine
oxidase (MAO, specifically by the MAO-B subtype: see Ch. 39).
MPP+ is taken up by the dopamine transpon system. and lhus act~
selectively on dopaminergic neurons: it inhibitc; mitochondrial
oxidation reactions, producing oxidative stress (see above). MPTP
Whclher or not the action of MPTP reflects lhe natural pathogene"'
of PO, the MPTP model is a very useful experimental tool for
testing possible therapies.
Various herbicides, such as rotenone, that selectively inhibu
mitochondrial function cause a PO-like syndrome in animal\,
suggesting lhat environmental toxins could be a factor in human
PO, because impaired mjtochondrial function is a feature of th~
disease in humans.
Molecular aspects
Parkinwn, di~ea,e. as well as se,eral other neurodegenerati\'t
diwrdcr.., i~ :l!.~ociatcd with Lhe de' clopment of intracellular prllt(m
aggregate~ known as uwy bodies in ,arious parts of Lhe brain. The)
con~l\t large!) of a-syouclein. a synaptic protein prescm in large amounts

appean. to be !.elective in destroying nigrostriatal neurons and doc!>
not affect dopaminergic neurons elsewbere-lhe reason for this
is unknown. Selegiline, a elective MAO-B inhjbitor (see below),
prevents MPTP-induced ne uro toxicity by blocking its conversion
to MPp+, Selegiline is also used in treating PO (see below): as well
as inhibiting dopamine breakdown. it might also work by blod.. ing
the metabolic activation of a putative endogenous, or environmental,
MPTP-Iike substance, which is involved in the causation of PD.
--..-..:.,._..,..
. ...........
518
- -- - It is possible that dopamine itself could be the culpri t, because
in normal br.rin~. Mutations occur in rare types of hereditary PO (~ abmt
and 1t i' believed that ~uch mutations render the protein resistant 10
degrJdation within cells. caw.ing it to pile up in Lewy bodie\. It i'o po"'bk
(~ Lolhariw. & Brundin. 2002) that the normal function of CH)nuclem IS
related to ~ ynaptic \esicle recycling. and that the mutated form lo~,e, !his
functionality. with the result that vesicular storage of dopamine i'> impaired
Thi' may lead to an increase in cytosolic dopamine, degradation of -whid
produCe'> reactive oxygen ~pecies and hence neurotoxicity. Con~i,tent with
the u-,ynuclein hypothesi~. the other mutation associated with PO (parkin)
also involves a protein that participates in the in tr.:tcelluh1r degradation of
rogue proteins. Other gene mutations that have been identified a\ n;k

ta.:h>r. f~>r carl)'tlO\Cl PO code for proteins involved in mitochondrial
fun,tion. making cell' more ~u\Ceptible to oxidative stress.
Thu,. a p1crure 'imilar to AD pathogenesis is slowly emerging. Mi~folded
u-,ynuclein. fa(llitat~'tl by gcncuc mutauo~ or po~sibly by environmental
factor.. l'llnld' up m the cell a~ a result of impaired protein degradation
(re,ulung Irom defec:ti' e parkin) m the form of Le"''Y bodies. which. by
unlno~n me,ham\m\, compromise cell survival. If o:tidati,e stre"~ i'
u,.;rea-ed. a' a rc\ult of j,chacmia. mitochondrial poisons or mutations of
cenam mitt><:hondrial proteins. the re~uh is cell death.
DRUG TREATMENT OF PARKINSON'S
DISEASE
De..pitc pa~t optimism. none of th e dmgs used to treat PD affect
the progres\ion of the disease. For general reviews of current and
future approaches. sec Hagan et al. (1997) and Olanow (2004).
Currently, the main drugs u~ed are levodopa and various dopamine
agonists. Of less importance are:
\1AO-B inhibitors (e.g. sel egiline)
drug\ that release dopamine (e.g. am antadine)
mu..carinic acetylcholine receptor antagonists (e.g. bcnztropine).
LEVODOPA
lt\odopa is the fir-.t-line treatment for PO and is combined with
a penpheral dopa decarboxyla~e inhibitor. either carbidopa or
bensera7ide. which reduces the dose needed by about 10-fold and
dimmt,hes the peripheral \ide effect~. It i s well absorbed from
Lhl! 'mall inte\ttne, a proces!> that relies on active transport. although
much of it i' inactivated by MAO in the wall of the intestine. The
pJa,ma half-life is short (about 2 hours). Conversion O dopamine
in the periphery. which would otherwise account for about 95%
Parkinson's dleeaee
Degenerative disease of the basal ganglia
causing tremor at rest , muscle rigidity hypokinesia,
often with dementia.
Associated with aggregation of a-synuclein (a protein
normally involved in vesicle recycling) in the form of
characteristic Lewy bodies.
Often idiopathic but may follow stroke or virus
infection, can be drug-induced (neuroleptic drugs).
Rare familial forms also occur, associated with
various gene mutations, including a-synuclein.
Associated with early degeneration of dopaminergic
nigrostnatal neurons, followed by more general
neurodegenerallon.
Can be induced by 1-methyl-4-phenyl- 1 ,2,3,6-
tetrahydropyridine (MPTP), a neurotoxin affect ing
dopamine neurons. Similar environmental
neurotoxins, as well as genetic factors, may be
involved in human Parkinson's d isease.
NEURODEGENERATIVE DISEASES
of the levodopa do<.e and cause troublesome side effects. is largely
prevented by the decarboxylase inhibitor. Decarboxylation occurs
rapidly within the brain, because the decarboxylase inhibitors do
not penetrate the blood-brain barrier. It i~ not certain whether the
effect depend'> on an increa~ed release of dopamine from the few
!>urviving dopaminergic neurons or on a 'flooding' of the synapse
with exogenous dopamine. Because synthetic dopamine agonists
(see below) are equally effective. the laner explanation is more
likely, and animal studies suggest that levodopa can act even
when no dopaminergic nerve terminals are present. On the other
hand, the therapeutic effectivene~s of levodopa decreases as the
disease advances, so part of i~ action may rely on the presence of
functional dopaminergic neurons. Combination of levodopa plus
dopa decarboxylase inhibitor with entacapone. an inhibitor of
catechol-0-mcthyl transferase (COMT; see Cb. II ) to inhibit its
degradation, is used in patients troubl ed by 'end of dose' motor
fluctuati ons.
Therapeutic effectiveness and unwanted
effects of levodopa
About 80% of patients show initial improvement with levodopa,
particularly of rigidity and hypokinesia, and about20% are restored
virtually to normal motor function. As time progresses, the effec-
tiveness of levodopa gradually declines (Fig. 35.5). In a typical study
.._.... Levodopa + benserazide + selegiline
o--o Bromocriptine
..._.. Levodopa + benserazide
4
~ 3
8
(/)
2
~
:0
<0
(/)
'6
.E 0
&
c
-1
<0
c3 -2
-3~--------~--~------------~
0 12 24 36 48 60 72
Number of months sinoe entry
Fig. 35.5 Comparison of levodopalbenserazide,
levodopalbenser azide/selegiline and bromocriptine on
pro gression of Parkinson's d isease symptom s. Patients
(249-271 in each treatment group) were assessed on a
standard disability rating score. Before treatment, the average
rate of decline was 0.7 units/year. All three treatments produced
improvement over the initial rating for 2-3 years, but the effect
declined, either because of refractoriness to the drugs, or
disease progression. Bromocriptine appeared slightly less
effective than levodopa regimens, and there was a higher drop-
out rate due to side effects In this group. (Parkinson's Disease )
Research Group 1993 Br Med J 307: 469-472.) .
519
 SECTION 4 . THE NERVOUS SYSTEM
of 100 patienL<> treated with levodopa for 5 years, only 34 were
bener than they had been at the beginning of the trial. 32 patients
having died and 21 having withdrawn from the trial. It is likely
that the loss of effectiveness of levodopa mainly reflects the
natural progreSl>ion of the disease, but receptor down-regulation
and other compensatory mechanisms may also contribute. There
is no evidence that levodopa can actually accelerate the
neurodegenerative process through overproduction of dopamine,
as was suspected on theoretical grounds (see above). Overall,
levodopa increases the life expectancy of PO patients, probably
as a result of improved motor function, although some symptoms
(e.g. dysphagia, cognitive decline) are not improved.
Unwanted effects
There arc two main types of unwanted effect.
Involuntary writhing movements (dyskinesia}, which do not
appear initially but develop in the majority of patients within
2 years of starting levodopa therapy. These movements usually
affect the face and limbs, and can become very severe. They
occur at the time of the peak therapeutic effect, and the margin
between the beneficial and the dyskinetic effect becomes
progre~!tively narrower. Levodopa is short acting, and the
fluctuating plasma concentration of the drug may favour the
development of dyskinesias, as longer-acting dopamine
agonist may be less problematic in this regard.
Rapid fluctuations in clinical state, where hypokinesia and
rigidity may suddenly worsen for anything from a few minutes
to a few hou~. and then improve again. This 'on-off effect'
b not seen in untreated PO patients or with other anti-PO drugs.
The 'off effect' can be so sudden that the patient stops while
walking and feels rooted to the spot. or is unable to rise from
a chair in which he or she had sat down normally a few
moments earlier. As with the dyskinesias, the problem seems
to reflect the nuctuating plasma concentration of levodopa,
and it is suggested that as the disease advances, the abili ty of
neurons to store dopamine is lost, so the therapeutic benefit
of levodopa depends increasingly on the continuous formation
of extraneuronal dopamine, which requires a continuous supply
of levodopa. The use of sustained-release preparations, or
coadministration of COMT inhibitors such as entacaponc
(see above), may be used to counteract the fluctuations in
plasma concentration of levodopa.
In addition to these slowly developing side effects, levodopa
produces several acute effect.<>, which are experienced by most
patients at fir:.t but tend to disappear after a few weeks. The main
ones are as follow.
au ea and anorexia. Domperidone. a dopamine antagonist
1
that works in the chemoreceptor trigger zone (where the
blood-brain barrier is leaky) but does not gain access to the
basal ganglia, may be useful in preventing this effect.
Hypotension: postural hypotension is a problem in a few
patients.
Psychological effects. Levodopa, by increasing dopamine
activity in the brain, can produce a schizophrenia-like syndrome
(sec Ch. 38) wi th delusions and hallucinations. More commonly,
in about 20% of patients, it causes confusion, disorientation,
insomnia or nightmares.
SELEGILINE
Sclegiline is a MAO inhibitor that is selective for MAO-B. \\>hich
predominates in dopamine-containing regions of the C S. h
therefore lacks the unwanted peripheral effects of non-selective
MAO inhibitors used to treat depression (Ch. 37) and. in contrast
to them, does not provoke the 'cheese reaction' or interact so
frequently with other drugs. Inhibition of MA0-8 protect\
dopamine from intraneuronal degradation and was initially used
as an adjunct to levodopa. Long-term trials showed that the
combination of ~elegiline and levodopa was more effective than
levodopa alone in relieving symptoms and prolonging life. Recog
nition of the role of MAO-B in neurotoxicity (see above) suggested
that selegiline might be neuroprotective rather than merely enhanc
ing the action of levodopa, but clinical studies do not suppon
this. A large-scale trial (Fig. 35.5) showed no difference when
sclcgilinc wa~ added to levodopalbenserazide treatment.
OTHER DRUGS USED IN PARKINSON'S DISEASE
Dopamine receptor agonists
Bromocriptioe, derived from the ergot alkaloids (see Ch. 12), i'
a potent agoni~t at dopamine (Ov receptors in the C S. 11
inhibits the release of prolactin from the anterior pituitary gland.
and was firM introduced for the treatment of galactorrhoea an
gynaecomastia (Ch. 28), but is effective also in PO (Fig. 35.51
Its duration of action is longer (plasma half-life 6-8 hours) than
that of levodopa, so that it does not need to be given so frequent!).
Tt wa~ hoped that bromocriptine might be effective in patient>
who had become refractory to levodopa through loss of
dopaminergic neurons, but this has not been clearly established
The main side effects of bromocriptine are nausea and vomiting,
and (rarely but seriously) peritoneal fibrosis, as seen with other
ergot derivatives (see Ch. 12). Newer dopamine receptor agon i ~t'
include lis uride, pergolide, ropinirole, cabe rgoline and
pra mipexole. They are longer acting than levodopa and need to
be given only once or twice daily, with less tendency to cau~~
dyskincsias and on-off effects. Their main side effects are
confu<>ion and occasionally delusions, and sleep disturbance,.
Pramipexole may have antioxidant effects, as well as a protccthc
effect on mitochondria. Whether these potentially ncuroprotccll\c
propertie~ are \ignificant clinically remains to be disCO\ereG
Clinical trials have shown linle difference between these drug'.
Amantadine
'9' Amantadine w~ introduced ~ an antiviral drug and di\CO\enxl b)
accident in 1969 to be beneficial in PD. Many possible mechanism\ for IIi
action have been ~ugge~ted based on neurochemical evidence of increa.;al
dopamine relea...c. inhibition of amine uptake. or a direct action on dopammc
receptors. M<>!.t author~ now suggest. although not with much conviction.ths
increased dopamine release is primarily responsible for the clinical eff~,
Amantadine is les~ effective than levodopa or bromocriptine. and its actJua
declines with time. It~ ~ide effects are considerably less severe. although
qualitmivcly similar to those of levodopa.

Drugs used In Parkinson's disease
Drugs act by counteracting deficiency of dopamine in
basal ganglia or by blocking muscarinic receptors.
None of the available drugs affect the underlying
neurodegeneration.
Drugs include:
levodopa {dopamine precursor; Ch. 11), given
with an inhibitor of peripheral dopa decarboxylase
(e.g. carbidopa) to minimise side effects; sometimes
a catechol-0-methyltransferase inhibitor
Acetylcholine antagonists
l' For more than a century, until levodopa was discovered, atropine and
rdatcd drug~ ''ere the main ronn or treatment for PD. Muscarinic
awylcholinc receptor\ c~ert an inhibitory effect on dopaminergic nerve
termmal\, wpprc,<.km of which compen!>ate for a lack of dopamine. The
'i<k! cllt' ol mu..carinic antagonists-dry mouth. constipation. impaired
'''i<>n. unnat) retention are troublesome, ru1d they are now rarely u~ed,
e\lept to treat parkm\Onian 'Ymptom' in patients receiving anti~ychotic
drug' (\\hich arc dopam10e antagoni\~ and thu!> nullify the effect of
L..k-.pa >oCC Ch 381.
NEURAL TRANSPLANTATION
l' P..~rkm'>tm\ d1-ea-.e 1\ the lir~t neurodegenerative disease for which
fll'llr.ll tran,plantation wa' attempted 111 1982. amid much publicit}.
\Jnilth tran\plantauon approachc' ha\c tx.-cn tried. based on the injection of
'-"'""-IJIL-.1 fetal cell' directly into the 'triatum. Trials in patients with PD
(,.._-e Bjorklund & Lindvall. 2000: Barker & Rosser. 2001) have mainly
illlllllcd injection of midbrmn neurons from aborted human feruses. It
h:h bt..:n \hown that \uch tran-.plant~ are able to survive and esrabl i~h
')"'puc connection' hlll, de~pite report' of miracle cures. controlled
,lUdiC\ 'o far have ~hown little clinical benefit. Some patients have gone on
tu de~elop ..criou' dy~ki nesi<l'>. po~sibl y due to dopam ine overproduction.
!he u'c of fetal material i~. of cour~e. fmught with difficulties (usually
cell' from five or more fctu\es are needed ror one transplant). Hopes for the
fu1Ure rc\1 mainly on the pos<.ibility of developing preparations of
1mmorwlised neuronal precur.>or cells that can be multi plied in culture,
Jnd that will dill'ercntinte into functional postmirotic neurons after
lfan,plammion. I lfons are continuing to develop tr.msplantation as a means
~~ treJUng other condition\, \uch a\ Huntington~ disease, stroke and
ep1lep') a' well a\ PD. but the field remains highly controversial (see
BJ<>t'llund & l.mdvall. 2000: Barker & Rosser. 200 I).
HUNTINGTON' S DISEASE
l' Huntmgton\ di..ea.<oe 1\ an mherited (auto:.omal dominant) disorder
rt-oulong 111 progressi' c brain degeneration. starting in adulthood and
c;~u,mg rapid dctcriorauon and death. As "ell as dementia. it causes
IC\en! mlllor \) mptom, in the rorm of involuntary writhing movements.
l'hl<-h 3fC highl) di\nbhng. It is rhc commonest of a group of so-called
tnnudeoude repeat neurodegenerative diseases. asM>Ciared with the
cwan'lon of the number of repeats of the CAG sequence in specific
g<n<,, and hence the number (50 or more) of consecutive glutamine
re,idues in the expressed protein (see Gusella & MacDonald. 2000). The
brgN the number of repems. the earlier the appearance of symptoms. The
protein coded by the Hunti ngton's disease gene, lumtingtin. interacts with
1arious regulatory protei ns, including one of the caspases (see above), wh ich
panicipates in excitotoxicity and apoptosi~. Some or these inLeractions are
NEURODEGENERATIVE DISEASES
(e.g. entacapone) is also given, especially to
patients with 'end of dose' motor fluctuations
- bromocriptine {dopamine agonist; Ch. 28)
- selegiline (monoamine oxidase B inhibitor)
- amantadine (which may enhance dopamine release)
- benzatropine (muscarinic receptor antagonist used for
parkinsonism caused by antipsychotic drugs).
Neurotransplantation, still in an experimental phase,
may be effective but results are variable.
enhanced by the poly-Gin repeat in the mutru1t protein. and this may
account for the neuromil los~. which affects mainly the cortex and the
~triatum. rc~u lting in progres;,ive dementia and severe involuntary jerky
(choreiform) movement~. 1l1c mutru1t protein is also prone to misfolding
and aggregation, a~ described above. Studies on post-mortem brains
showed that the dopamine content of the striatum was normal or slightly
increa'>Cd, while there was a 75% reduction in the activiry of glutamic acid
decarboxylnu, the en1yme rcspom.ible for GABA ~ynthesis (Ch. 34). h is
believed that the lo\\ of GA BAmcdiated inhibition in the basal ganglia
produce' il hyper;lcti\ily of dopaminergic synapses, so the syndrome b in
wme \en<oes a mimlr image of PD (Fig. 35.4). The effecLs of drugs that
influence dopaminerg1c tran\mis\ion are correspondingly the opposite of
those that arc ob,en ed 111 PD. dopamine antagonists being effecthe in
reducing the involunl:lf) movements. while drugs such as levodopa and
bromocriptine make them worse. Drugs used to alleviate the mo1or
symptoms include dopamme antagoms~. such as chlorpromazine (Ch. 38).
and the GABA agonl\t baclofen (Ch. 33). These do not affect dementia
or retard the course of the d1sease. and it b possible mat drugs that inhibit
excitotoxiciry. or po~~ibly neuml transplantation procedures when these
become available (~ee above). may prove useful.
NEURODEGENERATIVE PRION DISEASES
'Y A group ol human and aninJ<i l diseases associated with a characteristic
type of neu rodege nerat ion, known as spongiform encephalopathy
because of the v;~cuolated appeara nce of the affected brain, ha~ recently
been the focu~ of i nten~e research activ ity (see Collinge, 200 I ; Prusincr,
200 I). A key feature of the!.e di!.eases is that they are transm issible
through an infective agent. although not, in general, across species. The
recent upsurge of imere\t has been spurred mainly by the discovery that
the bovine fom1 of the di<oea\e, bovine spongiform encephalopathy
<BSE), i\ tran\mi~\ible to human\. Different human forms of spongiform
encephalopathy include CJD (" hich is unrelated to BSE) and the new
variant fom1 (\C'JD). a.\ yet very rare. \\<hich results from eating, or
close comact with. infected beef or human tissue. Another human form
IS k11ru, a ncurodegenemt1ve di,ease affecting cannibalistic tribes in
Papua Ne\\ Gu10ea. These d1<oea.<oes cause a progressi\e. and sometimes
rapid. dementia and IO\\ of motor coordination. for which no therapies
currently exl\t. Scrapie. a common disease of domestic sheep. is another
eAample. and it may have been the practice of feeding sheep offal to
domestic cattle that initiated an epidemic of SSE in Britain during the
1980s, leading to the appearance of vCJD in humans in the mid-1990s.
Although the BSE epidemic has been controlled. there is concern that
more human Ca\CS may develop in its wake. because the incubation
period known to be long is uncertain.
Prion disem.e\ are examples of protein misfolding diseases (see above)
in wh ich the prion protein adopt~ a misfolded conformation that forms
insoluble aggregate~. The infectiow. agent responsible for transm issible
spongiform cncephalopmhics such a~ vCJD is, unusually, a protei n, known 521
 SECTION 4 . THE NERVOUS SYSTEM

a~ a prion. The protein involved (PrJ>') is a nonnal cytosolic con<.titucn t
of the brain and other tbsue ... who\e functions are not known. As a result
of altered glyco,ylation. the protein can become misfolded, fonning the
in"<>luble PrP"' fonn. v.hich has the ability to recruit nonnal PrpC molecules
to the mi\folded PrP"'. thus Maning a chain reaction. PrF-the infective
agent accumulate~ and aggregates as insoluble fibrib. and i\ re'pon-.ible for
the progrcwve neurodegcneration. In support of !his unusual fonn of
infecti\ tly, 1t ha'> been '>hov.n !hat injection of PrF into nonnal mtce
cau-cs \p<lntufonn encephalopalhy. whereas PrP knockout mtce. v.hich
are otherwi\C fairly normal, are resistant because they lack the \Ub\trate
for the autocatalyuc generation of PrP"'<. Fortunate!). the infection doe-.
not ea\ily cross between species. because !here are difference, between
the PrP gene\ of different species. It is possible !hat a mutation of the PrJ>
gene in either sheep or cattle produced the variant fonn that became
infccuve rn humans.
Thb cham of e'en!\ bears some similarity to !hat of AD. in that the brain
accumulate\ an abnonnal fonn of a normally expressed protein.
There is a~ yet no kno~n treatment for lhi~ type of encephalopathy. but
labomtol') e\penment~ ~uggest !hat two very familiar drug~. namel)
quinacrine (an antimalarial drug) and chlorpromazine (a wideI} u..OO anU
psychotic drug: Ch. 38). can inhibit PrP"'< aggregation in mou.\C model\. BOlli
are under imesugauon for treating human CJD. Other possible ~tratege'.
none yet teMed in patients. are discu~sed b) Mallucci & Collinge (20051

REFERENCES AND FURTHER READING

l>atho~:~ne;,i<,
Bos\y-Ww.cl E. Schwurzenbacher R. Lipton SA 2004
Molecular pathway\ t(l noumdcgcncration. Nat Med
IO(,uppl ): S2 S9 (Rel'itw ofmolel'lllar mecho11isms
tmder/yinf( ariou\ chi'Onic nettrodegenerative
di>l'll\t'S, mdudlllflthou di:.cussed 111 the chapter)
Coyle J T, Puufarkcn P 1993 Oxidau'e >tre.'' glutamate
and neurodcpencrati\ o dl\onlcl'\. Science 262:
689 -695 (Gt>od """" arttcle)
Forman '-1 S. Troj3n0\' 'k' J G. Lee V '-1 Y 2004
"'curodegeneratl\ e dt>ea-e>. a decade of discoveries
f"l'e' the \\3) for therapeutic breakthrough !':at Med
10: 1055-1063 <Gmeral mw on pothoge11esis of
lll'Urod~Rr1trrati\.t. di'leO'it'S - not
mu<h on tht'rapeutic
appmachr~. de1pi1e the wle)
Gu-.ella J r. MacDonald M E 2000 Molecular genetics:
unma,kmg pol) Jlutanune tngger. '"
neurodcgencmu'e dl>ea:.e. Kat Re' Neurosci I:
I09-115 I Gflltrttl fl'\'tew on trinucleotide repeat
tllfortferr tmd """ tht' brrrin dt~magt is produced)
Jellingcr K A 200 I ('ell death nx.'ChanMrb in
ncumdegcncmuon. J C'cll Mol Med 5: 1-17 (Useful
ll'View arlide t'O~ermg acule ru well clJ chronic
dlfortlerr ltading to 11eumdese,cmtio11)
Lee V M -Y, Goeden M . TtoJanow>ki J Q 2001
Neurodegcnerutivc cuuopatltic>. Annu Rev Nourosci
24: 1121 1159 (Del/tiled rel'ie,.. of tlu tmcataill role
of Tm pmt~in< illneurtxlegeneratiall)
Sclkoe I) J 2004 C'c ll biology or protein misfoldlng: the
e'nrnple<> of AILhcimcr's and Parkinson's diseases. Nat
Cell Biol6: 1054-106 1 (GoOf/ rr>in article by one of
tht pitmtrfl 111 llitlltif.ymg the amyloid h)pothesis)
Stefani M. Doh>on C \1 2003 Protem aggregation and
apgrcgacc toxtctty: new tn\lght<> into protein folding,
mi,foldm~ di..C.l'>C' and btologteal evolutJon. J Mol
Med 81: 678 699 (f-lu/lent miewanide on protein
mi ifol</m~ a.\ th~ wtdu/.1 /fiR cause of chronic
"""rode!ltllerame diSta:.e)
Yamada K. al>c,htma T 2000 Ammal rnodch of
Al1hem1Cr'' d1'<!<!>e and ealuatioo of anti-dementia
drug' Pha~T~~aCol Thcr Sl!: 93-113 (Describe.<
path<>lt>fl.\ ofAI), lrttJUJ(tnic tJnd other ammo/ models.
atld therapeutic approatht'S)
Alzheimer's disease
Citron M 2004 Stratcsic' for d>C:t.\C modfication m
J\lthcimcr'' th...:a.\C. Nat Re 1\eurosci 5: 677-685
(A re\'ie"- 1/tllrrttl/v oplllnistic-<Jf the status of new
thuapeutlt rrrUitl/ie fnr rretttinli AD)
Schenk D ct al. 1999 lmmunitnlion with amyloid-bcw
attenuates Al7hcimcr-di,case- like pathology in the
PDAPP mouse. Nature 400' l7l 177 (Re1>0rt of tm
ingenious e~perimem thlll muld h01e im(llil'ttlt/JIL\for
AD treotmellt in humttll<)
Selkoe D J 1997 Al7hcuner~ dto;ca-.c: genot)pes.
phenor~pe and treatment\. Science 275: 630-631
(Shon bm informame .<11n11nary of r;ocrm adwmre
Al:;heim~r 1/ennic.<)
Selkoe D J. Schenk D 2003 Abheuner'' dt-.ea..c:
molecular unde~tandtng pn:dtct' am)IOidl>a...ed
th~rapeuuc,. Annu Re' Phannacol Toxtcol 43:
545-58-1 (Compr;ohemne ,....,..,. antclt')
Parkinson's disea>e
Beat F W 200 I b.pt.'nmental model' of l'.ul.imon\
disease. Nat Re\ Neuro;c1 2' 325 332 W<efitltnirw
article couing many arpecll tif PO ('<tthtl/>!ellt.lis)
Hagan J J. ~1tddlemi" D N. Sharpe PC. Po\le G H
1997 Parkinson\ d-;ea,e pro,pech for tmprtwcd
therap). Trends Phannncol Sci 18: 1 ~6 163
(Excellent revin <1} currmttrend\)
Lang\lon W J 1985 MP'fP and Pari.ID\Oil '> dtsta>e.
Trends Neurosci 8: 79-83 (Remlahle accoum of the
MPTP story b) tts dircoverer)
Lipton SA, Rosenberg P A 1994 llxcitmory amino acids
as a final common pathway for ncurol\lgic disorders.
New Eng! J Med 330: 6ll 622 (Hetll'w Pmplmsi1i11g
central role of gluumwre /11 lll'trrtltlef1rneratitm)
Lotbanus J. Brundin t>2002 Pathogene,;, of Parkin;on~
disease: do1>amine. esicles and a-synuclcin Nul Rev
Neurosci 3: 833~ 842. (Reiew of PI) IHJthaxene.,;,,
emplwsiinx tlw P"'"hle mil'~( dopamine it:.e/f ar a
/tke/y Stllt/'Ct' of III'UrtJtOXiC mttabo/11/!S)
Olanow C \V 2004 The o;ciemilic ba'i' for the current
treatment of Parkin\on', d1..ca...:. Annu Re1 Med 55:
~ 1-60 (Detoiled miew of currell/ PD thtrupewio.
based tm kntl~>"letl~l' tifi><IIhophpwlogy)
Vila M. Przedhor.ki S 2004 Genetic clue\ to the
pathogene'i' of Pa~'""'"'' dt-.ea....:. Nat Med
lO(,uppl): S58-S62 (AccOulltof the \'tlrtcluS mttwtwru
associated ...ith PD. and ho" tilt') ma\ cmunrnttl' to
pothogent'sis)
Stroke
Dimagl U. ladecola C. \1o,lc\\ttz \1 A 1999
Pathobiology of io;chaemtc \t ro~e : nn integmted vic\\,
Trend> Neurosci :!2: 391- 397 (Useful rewew llf
mechanisms under/linJt lltL<rr>ll<tl dt~ma,qe i11 stmkt)
Green A R, Odcrgren T, Ashwood T 2003 Animal
models of 'lroke: do they have value for dtscovenn~
ncuroprotecrive agents? Trend> Pharmacal Sci 24:
402-108 (Article suggesring reasons why dru11 efJictln
in tJJiimal models does not predict \lll'rer< in the
clit1ic)
111 Prion diseases
Collinge J 200 I Prioo disea,;,e, of human; and anuliJI'
the1r causes and molecular basis. Annu Re' "'eu/'O'CI
24: 519-550 (Useful ~ni~ anic/e)
Prusmer S B 2001 Neurodegenerau'~ dt-.ea...e and pti<IG$
ev. Engl J ~1ed 344: 1544-1551 CGtneml "''""
aniclt by the tliscoveru ofprioi!S)
Therapeutic strategies
Barlcr R A. Rosser A E 200 I Neural tr.ln,plantauon
therapies for Parldn~n~ and Hunungton' d-.ea"''
Drug Dt.cov Toda) 6: 575-582 (ltifonnath~ mtd
balnnud rel'ien amcle 011 a controlersialtopu)
Bjor~lund A. Lind,all 0 2000 Cell replacement
therapies for central ne.-ous system dl\Orde" Nat
Neurosci 3: 537-544 (Upbnu review by pioneer~ m
the field of neuraltran.splcmtmion)
Citron M 2004 Strategies for disease modificnuon tn
Alzheimer's disease. Nat Rev Neurosei 5: 677-685
(A revie~~generally optimistic-cf the SWillS oj llfll
therapeutic strategies for trelllill!1 AD)
De Strooper B, Konig G 2001 An inflammatory drug
prospect. Nature 414: 159-160 ( lliformmie
commentary 011 publirmimJ hy lVeggen n tJ!. in thl
.lame issue, describing effects of NSAID< 011 A PP
clemage)
Gro<>s C G 2000 Neurogenesis in the nduh brain: death
of a dogma. Nat Rev Neurosei 1: 67-73
Mallucci G, Collinge J 2005 RatJonal targeung for 1'""11
therapeutics. Nat Rev Neurosei 6: 23- 34 (RetJiilfu
miew ofpossible approaches to treiJ/illf( pnon
dtSeaw!.<; a \'1'1')' difficult pmb/em """ 110/hlnl/ reallv
insight)et)
Ra!Jc P 2002 curogenc.is '" the adult primate conn
an ealuation of the evidence. Nat Re Keuro-c l
65-71
To\\lbeod K P. Pratico D 2005 o,cltherapeuuc
opponuruti~ for AILheimer'' dtsease: focu, on
non\leroidal antiinOammatO!} drugs. FASEB J 19
1592-160 I (Discussio11 ofpossiblt druR 10'1/ttr fir
treatment ofAD. includin11 animlll sttulit.\ t1nd rltniclll
I ria/., dtlta- largely negatie..fO far)

522
 General anaesthetic
agents
Overview 523
Introduction 523
Mechanism of action of anaesthetic drugs
-lipid theory 524
-Effects on ion channels 524
EHects of anaesthetics on the nervous
system 525
1---
Effects on the cardiovascular and respiratory
systems 525
~ -
Inhalation anaesthetics 526
-Pharmacokinetic aspects 526
-The solubility of anaesthetics 527
-Induction and recovery 528
-Metabolism and toxicity of inhalation anaesthetics
Individual inhalation anaesthetics 529
-Halothane 529
-Nitrous oxide 530
-EnRurone 530
-lsoRurone, desflurane and sevoflurane 530
Intravenous anaesthetics agents 531
-Thiopental 531
-Etomidate 532
-Propofol 533
-Other induction agents 533
OVERVIEW
General anaesthetics are used to render patients
unaware of, and unres ponsive to, painful
stimulation during s urgical procedures. They are
given systemically and exe rt their main effects on
the central nervous system (CNS), in contrast to
local anaesthetics (see Ch. 44), which work by
blocking conduction of impulses in peripheral
sensory nerves. Although we now take them for
granted, gene ral anaesthetics are the drugs that
paved the way for modern surgery. Without them,
much of modern medicine would be impossible.
In this chapter, w e describe the pharmacology of
the main agents in current use, which fall into two
main groups: inhalation agents and intravenous
agents. Detailed information on the clinical
524 pharmacology and use of anaesthetic agents can
be found in specialised textbooks (e .g . Evers &
Maze, 2004).
INTRODUCTION
Many drugs, including, for example, ethanol and morphine, can
produce a state of insensibility and obliviousness to pain but
are not used as anaesthetics. For a drug to be useful as an
anaesthetic, it must be readily controllable, so that induction and
recovery are rapid, allowi ng the level of anaesthesia to be
529 adjusted as required during the coun.e of the operation. For thb
reason, it was only when inhalation anaesthetics were first
discovered, in 1846, that most surgical operations became a
practical possibil ity. Until that time, surgeons relied on being
able tO operate on s truggling patients at lightning &peed, and
most operations were amputations. inhalation is still the
commonest route of adminiMration for anaesthetics, although
induction is usually carried out with intravenous agents.
T The usc of nitrous oxide to relieve the pain of su rgery was suggested
by Humphrey Davy in 1800. He was the first person to make nitrous
oxide, and he tested its effects on several people, including himself and
the Prime Min i~tcr. noting that it caused euphoria, analgesia and loss
of consciousness. The u!.e of nitrous oxide, billed as 'laughing gas',
became a popular fairground entertainment and came to the notice of
an American dcnttM. Horace Wells, who had a tooth extracted under
its influence, white he himself squeezed the inhalation bag. Ether also
first gained pubhcny in a dbreputable way. through the spread of ether
frolics'. at which it wa' u-.ed to produce euphoria among the gueMs
(explo'>ion\. too. one mtght have thought). William Morton, also a denti~t
and a srudem at Han ard Medical School. used it successfully to extract
a tooth 111 1846 and then \ugge~ted to Warren. the illustrious chief surgeon
at Ma\~achu\ell~ Geneml Ho~pital. that he should administer it for one
of Warren's operation\. Warren grudgingly agreed. and on 16 October
t 8-16 a large audience W:b gathered m the main operating theatre:' after
'orne preliminary fumbling. Morton~ demonstration was a spectacular
success. Gentlemen. thts i!> no humbug was the most gracious comment
that Warren could bring htm~elf to make to the assembled audience.
A more wordy appreciation came later from Ol iver Wendell Holmes
1
Now preserved a~ the ether dome. a museum piece at Massachusetts
Gcncro l llospital. 523
 SECTION 4 . THE NERVOUS SYSTEM
( 1847), the ncurologist-poet-philo~opher who first coined the \l-Ord
anacsthe~ia :
'The knife is ..earching for disease, the pulleys are draggmg back
di\located limb'>-Naturc herself is working out the primal curse whtch
doomed the tenderest of her creature~ 10 the sharpest of her trial~. but
the fierce e:memit) of 'uffering has been steeped in the water.. of
forgetfulne'' and the deepest furrow in the knotted brow of agony has
been \moothed forever:
Monon '>Ub~equently ~ank into an endless and bitter di~pute over the
patent right'>, and contributed nothing more to medical science. In the
~arne year. Jamc!> Simpson. professor of obsteuics in Glasgow, u~ed
chloroform to relieve the pain of childbirth. bringing on himself fierce
denunciation from the clergy, one of whom wrote:
'Chloroform is a decoy of Satan, apparently offering itself to hie;.~
women: but in the end it will harden society and rob God of the deep,
carne~t cries which ari!>e in time of trouble. for help.'
Opposition was effectively silenced in 1853, when Queen Victoria gave
birth to her seventh chi ld under the influence of chloroform , und the
procedure became known a~ anaestlu?sie a Ia reine.
MECHANISM OF ACTION OF
ANAESTHETIC DRUGS
Unlike mo~t drug~. inhalation anaesthetics, which include sub-
~tance~ a!> diverse a!> halothane. nitrous oxide and xenon,
belong to no recognisable chemical class. The shape and elec-
tronic configuration of the molecule is relatively unimportant,
and the phannacological action seems to require only that the
molecule has certain physicochemical properties. Early theorie'>,
particularly the lipid theory (see below), were therefore based
on rather general physicochemical ideas. Because we now know
much more about lhe functional components of cell membranes-
the principal structures affected by anaesthetic drugs-the
empha~is has shifted towards identifying specific protein targets.
Accounts of the different theories of anaesthesia are given by
Halsey (1989), Little (1996) and Franks & Lieb ( 1994).
LIPID THEORY
Overton and Meyer, at the turn of the 20th century, showed a
close correlation between anaesthetic potency and lipid solubility
in a diverse group of simple and unreactive organic compounds
that were te!>ted for their ability to immobilise tadpoles. This led
to a bold theory. formulated by Meyer in 1937: Narco~i~ com-
mences when any chemically indifferent substance has attained
a certain molar concentration in the lipids of the cell'.
The relationship between anaesthetic activity and lipid
solubility has been repeatedly confirmed. Anaesthetic potency in
humans is usually expressed as lhe minimal ail'eo/ar concemration
(MAC) required to abolish the response to surgical incision in
50% of subjects. Figure 36.1 shows the correlation between
MAC (inversely proportional to potency) and lipid solubility.
expressed a.; oil:water partition coefficient, for a wide range
of inhalation anaesthetics. The Overton-Meyer studies did not
suggest any particular mechanism. but revealed an impressive
correlation, for which any theory of anaesthesia needs to account.
-.~;.-
524
.... _-~.------- Oil:water partition was assumed to predict partition into
50
carbon tertrafluoride
10
Sutturhexafluonde ,
Nitrous oxide
Xenon
"E
.
Cyclopropane (.)
<(
Fturoxene 0.1 :E
Ether
Halothane
Chloroform 0.01
Methoxyflurane
, - - . -----...,.-J
'----~r--.___--..., 0.001
5000 1000 100 10 0.1
011/gas partrlion coefficient (37C)
Fig. 36.1 Correlation of anaesthetic potency with
oil:gas partition coefficient. Anaesthetic potency in humans
is expressed as minimum alveolar partial pressure (MAC)
required to produce surgical anaesthesia. There is a close
correlation with lipid solubility, expressed as the oil:gas
partition coefficient. (From: Halsey, 1989.)
membrane lipids, consistent with the suggestion that anaesthe''
result~ from an alteration of membrane function.
How the simple introduction of inert. foreign molecules tnt1
the lipid bilayer could cause a functional disturbance i~ ncr
explained by the lipid theory. Two possible mechanisms. namel}
I'OhtiiU! expansion and increased membrane fluidity, ha\e been
suggested and tested experimentally, but both are now largel>
di~credited (see Halsey, 1989; Little, 1996), and anention hJ
swung from lipid1> to proteins. the correlation of potency \\tth
lipid solubility being explained by the effect of lipid ~olubi lity on
the concentration of anaesthetic adjacent to its supposed protein
target in the hydrophobic region of neuronal cell membrane~.
EFFECTS ON ION CHANNELS
Following early studies that showed that anaesthetics can btnd
to various proteins as well as lipids, it was found that anaeslhet1c1
affect many ligand-gated ion channels (see Franks & Lieb 1994.
Rudolph & Antkowiak, 2004). Many anaesthetic agents are able
at concentrations reached during anaesthesia, to inhibit the func
tion of excitatory receptors. such as the ionotropic glutamatt
acetylcholine or 5-hydroxytryptamine receptors, as well ~
enhancing the function of inhibitory receptors such a!> GAB.\
and glycine. The GABAA receptor is the sole target fo
benLodiatepines (see Ch. 37) and also appears to be a majo
target for intravenous anaesthetics. such as thiopental, propofol
and etomidate (see below). that act at a site on the receptor
different from the benzodiazepine binding site. Studie~ o
experimentally mutated receptors (see Rudolph & Antko.... iak,
2004) have confirmed this and succeeded in identifying th
specific 'modulatory sites' through which the anaesthetic drug'
exert their effects on c hannel function. The 'two-pore domain
potassium channel known as TREK (see Ch. 4) is another
specifically anaesthetic-sensitive channel. It is activated. thu'

reducing membrane excitability, by low concentrations of
1olatile anaesthetic~ (see Franks & Lieb, 1999).
In summa!). general anaesthetics inhibit excitatory channels
(e~peciall) glutamate receptors) and facilitate inhibitory channels
(p;micularly GABA ., but al~o glycine and certain potassium
channels). and the~e interactions are targeted at specific
h~drophobic domains of the channel proteins. This is probably
a ~riou~ overl>implification: al> Little (1996) emphasises. indi-
lidual anaesthetics differ in their actions and affect cellular
function in several different ways, so a unitary theory is unlikely
to bt: .,ufficient, but it does provide a useful starting point.
EFFECTS OF ANAESTHETICS ON THE
NERVOUS SYSTEM
-\t the cellular level, the effect of anaesthetics is mainly to inhibit
synaptic transmission, any effects on axonal conduction probably
being relatively unimportant.
Inhibition of synaptic transmission could be due to reduction
(lf tram.mitter release, inhibition of the action of the transmitter,
or reduction of the excitability of the postsynaptic cell. Although
311 three effects have been described. most studies suggest that
reduced tmnsmitter release and reduced postsynaptic response
are the main factor'>. Reduced acetylcholine release occurs at
p.:ripheral S}nap..,es, and reduced sensitivity to excitatory
transmitter.. (due to inhibition of ligand-gated ion channels: see
abmc) occuf" at both peripheral and central synapses.
Inhibitory ...ynaptic tran~mission is usually potentiated by general
anaNhetic~. particularly barbiturates, volatile anaesthetics having
~tmtlar butles-. strong action~ (see Rudolph & Antkowiak, 2004).
The anaesthetic state comprisel> several components. including
unconsciou... ness. loss of renexes (muscle relaxation) and anal-
gesia. Much effort has gone into identifying the brain regions on
whtch anae~thetics act to produce these effects. The most sensi-
tive region\ appear to be the midbrain reticular formation and
thalamic sensory relay nuclei, inhibition of which results in
unconsciousness and analgesia, respectively. Some anaesthetics
cause inhibition at spinal level, producing a loss of reflex
responses to painful stimuli, although, in practice, neuromuscular-
blocking drugs (Ch. I0) are U!>ed to produce muscle relaxation
r.uher than relying on the anae!>thetic alone. Anaesthetics. even
tn IOI\ concentrations, cau!>e short-tenn amnesia, i.e. experiences
occurring during the influence of the drug are not recalled later,
~en though the \ubject was responsive at the time. 1 It is likely
that interference with hippocampal function produces this effect,
lxcau'e the hippocampus is involved in short-term memory. and
C(nam htppocampal synapses are highly susceptible to inhibition
b) anae\thctics.
:\s the anael.thetic concentration is increased, all brain func-
bono, are affected, including motor control and reflex activity,
The benzodiazepine lluni traL.cpam. Rohypnol, has achieved a na~ry
nJtoriel) because its amnesia-producing and traoquillising effect led to its
u..e a~ a rapists' aid along with compounds such as kctaminc (Ch. 43) and
y-hydroxy butyric acid.
GENERAL ANAESTHETIC AGENTS
Theories of anaesthesia
Many simple, unreactive compounds produce
narcotic effects, the extreme example being the inert
gas xenon.
Anaesthetic potency is closely correlated with lipid
solubility (Overton-Meyer correlation), not with
chemtcal structure.
Earlier theories of anaesthesia postulate interaction
with the lipid membrane bilayer. Recent work favours
interaction with ligand-gated membrane ion channels.
Most anaesthetics enhance the activity of inhibitory
GABAA receptors, and many inhibit activation of
excitatory receptors such as glutamate and nicotinic
acetylcholine receptors.
respiration and autonomic regulation. Therefore it is not possible
to identify a critical 'target site' in the brain responsible for all
the phenomena of anaesthesia.
High concemrations of any general anaesthetic affect all parts
of the CNS, causing complete shut-down and. in the absence
of artificial respiration. death from respiratory failure. The margin
between surgical anaesthesia and potentially fatal respiratory
and circulatory depression i~ quite narrow. requiring careful
monitoring by the anaesthetist and rapid adjustment of the level
of anael.thesia, as required.
EFFECTS ON THE CARDIOVASCULAR AND
RESPIRATORY SYSTEMS
All anaesthetics decrease cardiac contractility, but their effects
on cardiac output and blood pressure vary because of con-
comitant actions on the sympathetic nervous system and vascular
smooth muscle. Nitrous oxide increases sympathetic djscharge
and plasma noradrenaline concentration, and if used alone
increases heatt rate and blood pressure. Halothane and other
halogenated anaesthetics have the opposite effect.
Many anaesthetic~. el>pecially halothane, cause ventricular
extrasystoles. The mechanism involves scnsitisation to adrenaline.
Electrocardiogram monitoring shows that extrasystolic beat<;
occur very commonly in patients under halothane anaesthesia,
with no harm coming to the patient. If catecholamine secretion is
excessive, however (par excellence in phaeochromocytoma; see
Ch. II), there i., a risk of precipitating ventricular fibrillation.
With the exception of nitrous oxide and ketamine. all
anaesthetics depress respiration markedly and increase arterial
Pco 2 Nitrous oxide has much less effect. mainly because its low
potency prevents very deep anaesthesia from being produced
with this drug (~ee below). Some inhalation anaesthetics. particu-
larly desflurane among agents commonly used nowadays, are
pungent and liable to cause laryngospasm and bronchospasm, so
desnurane is not used for inducing anaesthesia but only for
maintaining it. 525
 SECTION 4 . THE NERVOUS SYSTEM
Pharmacological effects of
anaesthetic agents
Anaesthesia involves three main neurophysiological
changes: unconsciousness, loss of response to
painful stimulation and loss of reflexes.
At supra-anaesthetic doses, all anaesthetic agents
can cause death by loss of cardiovascular reflexes
and respiratory paralysis.
At the cellular level, anaesthetic agents affect
synaptic transmission rather than axonal conduction.
The release of excitatory transmitters and the
response of the postsynaptic receptors are both
inhibited. GABA-mediated inhibitory transmission is
enhanced by most anaesthetics.
Although all parts of the nervous system are affected
by anaesthetic agents, the main targets appear to be
the thalamus, cortex and hippocampus.
Most anaesthetic agents (with exceptions, such as
ketamme and benzodiazepines) produce similar
neurophysiological effects and differ mainly in respect
of their pharmacokinetic properties and toxicity.
Most anaesthetic agents cause cardiovascular
depression by effects on the myocardium and blood
vessels, as well as on the nervous system.
Halogenated anaesthetic agents are likely to cause
cardiac dysrhythmias, accentuated by circulating
catecholamines.
INHALATION ANAESTHETICS
We next consider the pharmacological properties of general
anaesthetics; it should be remembered that these are rarely used
alone. The anaesthetic state consists of three main components,
namely loss of con.1ciousness, analgesia and muscle relaxation.
In practice, these effects are produced with a combination of
drugs. A common approach for a major surgical operation would
be to produce unconsciousness rapidly with an intravenous
induction agent (e.g. propofol); to maintain unconsciousness
and produce analgesia with one or more inhalation agents (e.g.
nitr ous oxide and hal othane). which might be supplemented
with an intravenous analgesic agent (e.g. an opiate; see Ch. 41 );
and to produce muscle paralysis with a neuromuscular-blocking
drug (e.g. atracurium; see Cb. 10). Such a procedure results
in much faster induction and recovery. avoiding long (and
hazardous) period~ of semiconsciousness, and it enables surgery to
be carried out with relatively little impairment of homeostatic
reflexes.
Most inhalation anaesthetics that were once widely used, such
as ether, chloroform. tr ichloroethyl ene, cyclopropane and
methoxyflurane, have now been replaced in clinical practice,
particularly by the 'flurane' series (enflurane, isotlurane,
sevotlurane, deslluraoe), which have improved pharmacokinetic
526 properties, fewer side effects and are non-flammable. Of the
Clinical uses of general anaesthetics
Intravenous anaesthetics are used for:
induction of anaesthesia (e.g. thiopental,
etomidate)
maintenance of anaesthesia throughout surgery
('total intravenous anaesthesia', e.g. propofol
given in combination with muscle relaxants and
analgesics).
lnhalational anaesthetics (gases or volatile liquids) are
used for maintenance of anaesthesia. Points to note
are that:
volatile liquids (e.g. halothane, sevoflurane) are
vaporised with air, oxygen or oxygen-nitrous
oxide mixtures as the carrier gas
halothane hepat otoxicity (see Ch. 53) occurs
more often after repeated exposure
all inhalational anaesthetics can trigger malignant
hyperthermia In susceptible individuals (Ch. 10).
older agents. nitrous oxide is still used widely (especiall} u:
obstetric practice), and halothane occasionally.
Anaesthetics, like many other CNS depressantl>, are poteP.
tially addictive (see Ch. 43).
PHARMACOKINETIC ASPECTS
An imponant characteristic of an inhalation anaesthetic is til.
speed at which the arterial blood concentration, which govern<
the pharmacological effect, follows changes in the concentrauon
of the drug in the inspired air. Ideally, the blood concentration
should follow as quickly as possible, so that the depth of anaesthesr.
can be controlled rapidly. In particular, the blood concentratio~
shou ld fall to a subanacsthctic level rapidly when administration
is stopped, so that tbc patient recovers consciousness with minimJJ
delay. A prolonged semicomatose state, in which respiraton
reflexes are weak or absent, is particularly hazardous.
The lungs are the only quantitatively important route b
which inhalation anaesthetics enter and leave the body. Metaboli.
degradation of anaesthetics (see below), although important 1
relation to their toxicity. is generally insignificam in determinin.
their duration of action. Anaesthetics are all small, lipid-solub
molecules that readily cross alveolar membranes. It is thcrefo.
the rates of delivery of drug to and from the lungs, via (respecthely
the inspired air and bloodstream. that determine the 0\en.
kinetic behaviour of an anaesthetic. The reason that anaestheu,,
vary in their kinetic behaviour is that their relative solubilitie\
blood. and in body fat. vary between one drug and another.
The main factors that determine the speed of induction and
recovery can be summarised as follow.
Properties of the anaesthetic:
-blood:gas prutition coefficient (i.e. solubility in blood)
- oil:gas partition coefficient (i.e. solubiliry in fat).
 GENERAL ANAESTHETIC AGENTS

Phy~iologi cal factor<;: The blood:gas partition coefficient is the main factor that
-aheolar ventilation rate determines the rate of induction and recovery of an inhalation
---<ardiac output. anaesthetic, and the lower the blood:gas parti6oo coeffi ci ent the
faster is induc tion and recovery.
The oi/:gas partition coefficiellf. a measure of fat solubility,
THE SOLUBILITY OF ANAESTHETICS
determines the potency of an anaesthetic (as already discussed)
Anac\thetics can be regarded physicochemically as ideal gases: and also innuence the kineti cs of its distribution in the body,
tht:lr solubility in different media is expressed as partition the main effect being that high lipid solubiliry delays recovery
coefficiems, defined as the ratio o f the concentration of the agent from anaesthesia. Values of blood:gas and oil:gas panition
m two ph ase~ at equilibrium. coe ffi cients for some anaesthetics are gi ven in Table 36. 1.

Tlble 36.1 Characteristics of inhalation anaesthetics

Drug Partition coefficient Minimum alveolar Induction/ Main adverse Notes

Blood:gas Oil:gas concentration recovery effect(s) and
(% v/v) disadvantage(s)

Ether 12.0 65 1.9 Slow Respiratory irritation Now obsolete, except

Nausea and vomiting where modern facilities
Explosion risk are lacking

Halothane 2.4 220 0.8 Medium Hypotension In common use but

Cardiac arrhythmias declining in favour
Hepatotoxicity (with of newer agents
repeated use) Significant metabolism
Malignant to trifluoracetate
hyperthermia (rare)

N"1trous oxide 0.5 1.4 100" Fast Few adverse effects Good analgesic effect
Risk of anaemia Low potency precludes
(w1th prolonged or use as sole anaesthetic
repeated use) agent- normally
Accumulation in combined with other
gaseous cavities inhalation agents

Enflurane 1.9 98 0.7 Medium Risk of convulsions Widely used

(slight) Similar
Malignant characteristics to
hyperthermia (rare) halothane, with
less risk of
hepatic toxicity

softurane 1.4 91 1.2 Medium Few adverse effects Widely used as

Possible risk of alternative to
coronary ischemia halothane
in susceptible
patients

Desfturane 0.4 23 6.1 Fast Respiratory tract Used for day case
irntation, cough, surgery because of fast
bronchospasm onset and recovery
(comparable with
nitrous oxide)

Sevofturane 0.6 53 2.1 Fast Few reported Recently introduced

Theoretical risk of Similar to desflurane
renal toxicity owing
to fluoride

'Theoretical value based on experiments under hyperbaric conditions.

527
SECTION 4 . THE NERVOUS SYSTEM

absorbed via the l ungs in order to achieve a given panial pre~~ure

INDUCTION AND RECOVERY
Cerebral blood now is a substantial fraction of cardiac output,
and the blood- brain barrier is freely penneable to anaesthetics.
1,0 the concentration of anaesthetic in the brain closely tracks that
in the arterial blood. The kinetics of transfer of anaesthetic between
the inspired air and the arterial blood therefore determine the
kinetics of the pharmacological effect.
If an anaesthetic is added to the inspired air at a concentration
that. nt equilibrium, will produce surgical anaesthesia, the rate
at which this equilibrium is approached depends mainly on the
blood:ga1-. partition coefficient. Contrary to what one might
intuitively !>uppose, the lower the solubility in blood, the faster
is the process of equilibration. T his is because less drug has to be
in the blood. Thus a single lungful of air containing a Joy.
solubility agent will bring the partial pressure io the blood clo~er
to that of the inspired air than is the case for a high-solubilit~
agent. and a smaller number of breaths (i.e. a shoner time) \\i
be needed to reach equilibrium. The same principle applic' m
reverse for wash out of the drug. recovery being faster with ..
low-solubility agent. Figure 36.2 shows the much fa<,ter
equilibration for nitrous oxide. a low-solubility agent. than for
ether. a high !>Oiubility agent.
The transfer of anae~thetic between blood and tissues aho
affects the kinetics of equilibration. Figure 36.3 shows a very
~,imple model of the circulation, in which two tissue com-
partments arc included. Body fat has a low blood flow and

~ ~

'2 100 100

0
e'E 90 90
CD '2
0
c 80 .Q 80
Fig. 36.2 Rate of equilibration 8 ~
of inhalat ion anaesthetics in '0
70 'E 70
! CD
humans. The curves show alveolar a.
V>
0
c
concentration (which closely reflects . 60
0
0 60
arterial blood concentration) as a 0 :u
function of t1me during induction 0CD
~ 50
.2
50
and recovery. The initial rate of c <II
0
equilibration reflects solubility in 40 (ij 40
""!.'! :.;::;
blood. There is also a slow phase of 'E :s
c~
equilibration, most marked with 30 0 30
highly lipid-soluble drugs (ether and 0 ~
~
0
halothane), owing to the slow :u 20 20
transfer between blood and fat (Fig. 0
CD
36.3). A Induction. cJ Recovery. > 10 10
<t

l
(From Papper EM, Kitz R (eds) 1963
Uptake and distribution of 0- 0
anaesthetic agents. McGraw-Hill, 0 10 20 30 40 50 0 10 20 30 40 50
New York.) Minutes Minutes

Alveolar ventilation

Cardiac output

Fig. 36.3 Factors affecting the

rate of equilibration of inhalation
anaesthetics in the body. The body
Slow perfusion

e Fast perfusion

l'
Large partition coefficient Small partition coefficient
is represented as two Slow equilibration e Rapid equilibration
compartments. Lean tissues,
including the brain, have a large
blood flow and low partition
Lean
coefficient for anaesthetics, and FAT
tissues
therefore equilibrate rapidly with the
blood. Fat tissues have a small
blood flow and large partition
coefficient, and therefore equilibrate
slowly, acting as a reservoir of drug
during the recovery phase.

e often a high anae~thetic solubility (see Table 36.1 ), and
con,titute' about 20~ of the volume of a representative man.
r Therefore. for a drug ~uch as hal othane. which is about l 00
) ume' more soluble m fat than in water. the amount present in
I fat after complete equilibration would be roughly 95% of the
n total amount in the body. Because of the low blood flow to
D adipose tissue. it take~ many hour<. for the drug to enter and leave
r the fat. which re~uhs in a pronounced slow phase of equilibration
r following the rapid phase associated with the blood-gas
e\changes (F1g. 36.2). The more fat-soluble the anaesthetic and
the fatter the patient. the more pronounced this slow phase
becomes.
Of the physiological factors affecting the rate of equilibration
!.1 of inhalation anaesthetics. alveolar ventilation is the most
1mportant. The greater the ventilation rate, the faster is cquili-
brntion, particu larly for drugs that have high blood:gas partition
coefficients. Respiratory depressant drugs, such as morphine
f\ee Ch. 4 1), can thus retard recovery from anaesthesia.
Reco\ery from anaesthesia involves the same processes as
mduction but in reverse (Fig. 36.2). the rapid phase of recovery
bcmg followed by a slow 'hangover'. If anaesthesia with a highly
faholuble drug has been maintained for a long time. so that the
fat ha, had time to accumulate a substantial amount of the
anae~thetic. this hangO\'er can become very pronounced and the
patient rna) remain drowsy for some hours. Because of these
kinetic factors, the \earch for improved inhalation anaesthetics
ha' focused on agents with low blood and tissue solubility.
~1!\\er drugs, '"hich l>how kinetic properties similar to those of
nitrous oxide but have higher potency. include sevoflorane and
desnurane (Table 36.1 ).
METABOLISM AND TOXICITY OF
INHALATION ANAESTHETICS
\1etabolism. although not quantitatively important as a route of
elimi nation of in halation anaesthetics. can generate toxic metab-
olites. Chloroform (now obsolete) causes hepatotoxicity associated
1\llh free rad ical formation in liver cells. Methoxyfluran e, a
halogenated ether, is no longer used because about 50% is
metabolised to fluoride and oxalate, which cause renal toxicity.
Enflurane and sevoflurane also generate fluoride. but at much
ltl\\cr (non-toxic) concentrations (Table 36.1 ). Halothane is the
onl> \Oiatile anaesthetic in current use that undergoes sub tantial
metabolism, about 30'! being converted to bromide. trifluoroacetic
acid and other metabolites that are implicated in rare instances
ofhw tOXICity (see below).
The problem of toxicity of low concentrations of anaesthetics
mhaled 0\er long periods by operating theatre staff causes much
concern, following the demonstration that such chronic low-level
e\po\ure (and associated metabolite formation) leads to liver
toxicit) in experimental animals. Epidemiological sn.dies of
operating theatre ~taff have shown increased incidence of liver
d1,ea~e and of certain types of leukaemia. and of spontaneous
abonion and congenital malformations. compared with control
groups not exposed to anaesthetic agents. A Ithough causation has
not been clearly establil.hed, strict measures are used to minimise
the escape of anaesthetics into the air of operating theatres.
GENERAL ANAESTHETIC AGENTS
INDIVIDUAL INHALATION ANAESTHETICS
The inhalation anac!>thetics currently used in developed countries
are halotha ne. nitrous oxide, enflura ne and isoflur ane. E ther .
now largely obsolete. is still used in some parts of the world. It
is explosive and highly irritant. and commonly causes postoperative
nausea and respir:.Hory complications. Methoxyflurane (see
above) is no longer used because of its renal toxicity. Desflurane
and sevoflurane have gained popularity because they overcome
many of the problems of the earlier drugs. The newer compounds
arc all halogen -sub~tituted hydrocarbons of very similar spot
the difference' structure. After 50 years of this kind of musical
chairs chemistry, there is a sense that we may have reached the
end of the line with sevotlurane. Xenon , an inert gas shown
many years ago to have anaesthetic prope1ties, is making some-
th ing of a comeback in the clinic because-not surprisingly for
an inert gas-it lacks toxicity, but its relatively low potency and
high cost arc disadvantages.
HALOTHANE
Halothane is a widely used inhalation anaesthetic, but its use is
now declining in favour of isofluranc and other drugs (see below).
It is non-e\plo-,ive and non-irritant: induction and recovery
arc relatively fa-,t; and it is highly potent and can easily produce
respiratory and cardio\'ascular failure. so the concentration
admini\lercd need'> to be controlled accurately. Even in normal
anaesthetic concentrations. halothane causes a fall in blood pressure.
partly due to myocardial depression and partly to vasodilatation.
Pharmacoklnetlc properties of
Inhalation anaesthetics
Rapid induction and recovery are important
properti es of an anaesthetic agent, allowing flexible
contro l over the depth of anaesthesia.
Speed of induction and recovery are det ermined by
two properties of the anaesthetic: solubility in blood
(blood:gas partition coefficient) and solubility in fat
(lipid solubility).
Agents with low blood:gas partition coefficients
produce rapid induction and recovery (e.g. nitrous
oxide, desflurane); agents with high blood:gas
partition coefficients show slow induction and
recovery (e.g. halothane).
Agents with high lipid solubility (e.g. halothane)
accumulate gradually in body fat and may produce a
prolonged 'hangover' if used for a long operation.
Some halogenated anaesthetics (especially halothane
and methoxyflurane) are metabolised. This is not very
important in determining their duration of action, but
contributes to toxicity (e.g. renal toxicity associated
with fluoride production with methoxyflurane- no
longer used).
529
 SECTION 4 . THE NERVOUS SYSTEM
Halothane is not analgesic and has a relaxant effect on the uterus,
which limits its usefulness for obstetric purposes.
Adverse eHects
In common with many halogenated anaesthetics, halothane
sensitises the heart to adrenaline, predisposing to cardiac
dysrhythmia. This may be important, notably in operations for
phaeochromocytoma (see Ch. II and above). Two rare but serious
adverse reactions associated with halothane are hepatotoxicity
and malignam hyperthermia.
Halothane hepatitis. One major study of 850 000 anaesthetic
administrations identified nine deaths from otherwise unexplained
liver failure. Seven of the nine patients bad received halothane.
Subsequent reports suggest that hepatotoxicity is associated
with repeated administration of halothane. A study of 62 cases of
unexplained serious liver disease in the UK showed that 66%
were associated with repeated halothane administration.
consistent with an immune mechanism. Halothane metabolism
yields trifluoroacetic acid (see above), which reacts covalently
with protein, especially in liver cells where halothane metabolism
occurs. Fluoroacetylated Liver proteins are believed lo initiate an
immune response (Ch. 53).
Malignant hyperthermia. This is caused by heat production in
skeletal muscle, due to excessive release of Ca2+ from the
sarcoplasmic reticulum. The result is muscle contracture, acidosis,
increased metabolism, and an associated dramatic rise in body
temperature that can be fatal unless treated promptly. Triggers
include other halogenated anaesthetics and neuromuscular-
blocking drugs (see Cb. 10), as well as halothane. Susceptibility
has a genetic basis, being associated with mutations in the gene
encoding the ryanodine receptor, which controls Ca2+ release
from the sarcoplasmic reticulum (Ch. 4). Why such mutations
induce sensitivity of the channel to anaesthetics and other drugs
is not clear. Malignant hyperthermia is treated with dantrolene,
a muscle relaxant drug that blocks these calcium channels.
NITROUS OXIDE
Nitrous oxide (N 20, not to be confused with nitric oxide, NO) is
an odourless gas with many advantageous feamres for anaesthesia,
and is in widespread use. Tt is rapid in action because of its low
blood:gas partition coefficient (Table 36.1 ). and is an effective
analgesic in concentrations too low to cause unconsciousness. It
is used in this way to reduce pain during childbirth. Its potency
is low; even at 80% in the inspired gas mixture, nitrous oxide
does not produce surgical anaesthesia. It is not therefore used on
its own as an anaesthetic, but is very often used (as 70% nitrous
oxide in oxygen) as an adjunct to volatile anaesthetics, allowing
them to be used at lower concentrations. During recovery from
nitrous oxide anaesthesia, the transfer of the gas from the blood
into the alveoli can be sufficient to reduce, by dilution, the
alveolar partial pressure of oxygen, producing transient hypoxia
(known as diffusional hypoxia). This is important for patients
with respiratory disease.
Given for brief periods, nitrous oxide is devoid of any serious
toxic effects, but prolonged exposure(> 6 hours) causes inactivation
530 of methionine symhase, an enzyme required for DNA and protein
synthesis, resulting in bone marrow depression that may cau~e
anaemia and leucopenia, so its use should be avoided in patients
with anaemia related to vitamin 8 12 deficiency. Bone marro,.
depression does not occur with brief exposure to nitrous oxide.
but prolonged or repeated use should be avoided. Nitrous oxid~
'sniffers' are subject to this danger.
Nitrous oxide tends to enter gaseous cavities in the body, causing
them to expand. This can be dangerous if a pneumothorax or
vascular air embolus is present, or if the intestine is obstructed.
Prolonged exposure to very low concentrations of nitrou'
oxide, far below the level causing anaesthesia, may affect protein
and DNA synthesis very markedly, and nitrous oxide has been
suspected to be a cause of the increased frequency of abortion
and fetal abnormality among operating theatre staff.
ENFLURANE
Entlurane is a halogenated ether similar to halothane in its
potency and moderate speed of induction. Tt was introduced a\
an alternative to methoxyflurane, its advantages being that ar
therapeutic levels it produces less fluoride (and hence less renal
toxicity) than methoxyl1urane and is less fat-soluble so that
onset and recovery are faster. Its main drawback is that it can
cause seizures, either during induction or following recovel)'
from anaesthesia. In this connection, it is interesting that a related
substance, the fluorine-substituted diethyl-ether hexafluoroether.
is a powerful convulsant agent, although the mechanism is not
understood. Enflurane can induce malignant hype1thennia.
ISOFLURANE, DESFLURANE AND
SEVOFLURANE
lsoflurane is now the most widely used volatile anaesthetic. It i1
broadly similar to enflurane, but is not appreciably metabolised
and lacks the proconvulsive property of enflurane. Tt is expensi~e
to manufacture because of the difficulty in separating isomer;
formed during synthesis. Tt can cause hypotension and is '
powerful coronary vasodilator. This can exacerbate cardia\
ischaemia in patients with coronary disease, because of the
'steal' phenomenon (see Ch. 18).
Destluranc is chemically similar to isoflurane, but its lower
solubility in blood and fat means that induction and recovery are
faster, so it is increasingly used as an anaesthetic for day ca\e
surgery. It is not appreciably metabolised. It is less potent thac
the drugs described above, the MAC being about 6%. At tlle
concentrations used for induction (about I 0%), destlurane cause,
some respiratory tract irritation, which can lead to coughing
and bronchospasm.
Sevotlurane resembles desflurane but is more potent anrl
does not cause respiratory irritation. It is partially (about 3~1
metabolised, and detectable levels of fluoride are produced.
although this does not appear to be sufficient to cause toxicit)
Like other halogenated anaesthetics, sevoflurane can cause
malignant hyperthermia in genetically susceptible individuals.
Many inhalation anaesthetics have been introduced and
gradually superseded, mainly because of their inflammable nature
or because of toxicity. They include chloroform (hepatotoxicil)
 GENERAL ANAESTHETIC AGENTS
--~~~----------------------

and cardiac dysrhythmia'>), djethyl ether (explosi ve and ru ghly

tmtant to the re~pi ratory tract, leading to postoperative compli- Individual Inhalation anaesthetics
cation~). ' in)l ether (explosi, e), cyclopropane (explosive. strongly
dcpn:~'ant to respiration, and hypotensive), trichloroethyl ene
The main agents in current use in developed
(chc:micall) unstable, no special advantages). and methoxyflurane countries are halothane, nitrous oxide, isoflurane,
(,Jo" recm Cl) and renal toxicity). enflurane, desflurane and sevoflurane. Ether is largely
Further information is available in many excellent textbooks obsolete.
of anaesthesia (e.g. M i ller. 1999). As a rare but serious hazard, inhalation anaesthetics
(espectally halothane) can cause malignant
s hyperthermia.
Halothane:
INTRAVENOUS ANAESTHETIC AGENTS
n widely used agent
E1en the fastest-acting inhalation anaesthetics, such as nHrous potent, non-explosive and non-irritant, hypotensive;
O\ide. takt: a few minutes to act and cause a period of excitement may cause dysrhythmias; about 30% metabolised
befon: anac~thcsi a is produced. Intravenous anaesthetics act 'hangover' likely, due to high lipid solubility
much more rapid ly, rroducing unconsciousness in about risk of liver damage if used repeatedly.
2(heconds, as soon as the drug reaches the brain from its site Nitrous oxide:
!> of injection. These drugs (e.g. thiopental, etomidate, propofol; low potency, therefore must be combined with
s 'ce hc:low) arc nonnally U!>ed for induction of anaesthesia. They other agents
It arc preferred by patient ~ because injecti on generally lacks the rapid mduction and recovery
il menacing quality associated with a f ace mask in an apprehensive good analgesic properties
lt indi\idual. risk of bone marrow depression with prolonged
n Other drugs used a-. intravenous induction agents include administration
cenam bcn?Odiat cpine., (see Ch. 37), such as mazepam and accumulates in gaseous cavities.
)
d midazolam, \\hich act rather less rapidly than the drugs Listed Enflurane :
r. al1o\e. Although intra-.enou!. anaesthetics on their own arc halogenated anaesthetic similar to halothane
)I generall) unsatisfactory for producing maintained anaesthesia Jess metabolism than halothane, therefore less
~cau'e their elimination from the body is relatively slow risk of toxicity
compan:c.l 1\ith that of i nhalation agents. propofol can be used faster mductton and recovery than halothane
m thi' \\a), and the duration of action of ketamioe is sufficient (less accumulation in fat)
that it cnn be used for short operations without the need for an some risk of epilepsy-like seizures.
mh.tlation agent. lsoflurane:
is The combined usc of droperidol, a dopamine antagonist related similar to enflurane but lacks epileptogenic
1d to antip~yc hotic drugs (Ch. 38), and an opiate analgesic such property
e a' fentanyl (Ch. 4 1) can produce a state of deep sedation and may precipitate myocardial ischaemia in patients
rs analgesia (known as neumleplanalgesia) in which the patient with coronary disease
a remain~ responsive to simple commands and questions, but does irritant to respiratory tract.
lC nut respond to painful stimuli or retain any memory of the Desflurane:
me pmctdure. This is used for minor procedures such as endoscopy. similar to isoflurane but with faster onset and
The properties of the main intravenous anaesthetics arc recovery
er ,ummarised in Table 36.2. Propanidid and aJthesin were respiratory irritant, so liable to cause coughing
re 1\ithdra\\ n becau'e of allergic reactions including hypotension and laryngospasm
and bronchoconwiction. useful for day case surgery.
Sevoflurane:
- stmtlar to desflurane, with lack of respiratory
THIOPENTAL irritation.
Thiopental (Ch. 37) is the only remaining barbiturate used as Ether:
an anaesthetic. It hal> very high lipid solubility, and thi s accounts obsolete except where modern facilities are not
1d for the speed and tran~i ence of its effect w hen it is injected available
~) mtra1 cnousl) (sec below). T he free acid is insoluble in water, so easy to administer and control
d. thtopcntal i<. given as the sodium salt. This solution is srrongly slow onset and recovery, with postoperative
.). alkaline and i' un, table. 1.0 the drug must be dissolved nausea and vomtttng
se immediately before it is used. analgesic and muscle relaxant properties
highly explosive
nd Pharmacokinetic aspects irritant to respiratory tract.
tre On intravenous injection, thiopental causes unconsciousness within
ty about 20 seconds and lasts for 5- 10 minutes. The anaesthetic
531
 SECTION 4 THE NERVOUS SYSTEM

Ta ble 36.2 Properties of intravenous anaesthet ic agents

Drug Speed of induction and recovery M ain unwanted effect(s) Notes

Thiopental Fast (cumulation occurs, giving Cardiovascular and resp1ratory Widely used as induction agent for
slow recovery) depression routine purposes
'Hangover'

Etomidate Fast onset, fairly fast recovery Excitatory effects dunng Less cardiovascular and respiratory
induct1on and recovery depression than with thiopental
Adrenocortical suppression Causes pain at injection site

Propofol Fast onset. very fast recovery Cardiovascular and respiratory Rapidly metabolised
depression Possible to use as continuous infusion
Causes pain at injection site

Ketamlne Slow onset, after-effects common Psychotomimetic effects Prod uces good analgesia and amnesia
during recovery following recovery
Postoperative nausea, vomiting
and salivation
Raised intracranial pressure

Midazolam Slower than other agents Little respiratory or cardiovascular

depression

efTect clo-,cly paralleb the concentration of thiopental in the
blood reaching the brain, because its high lipid solubility allow~
it to cro-.-, the blood-brain barrier without noticeable delay.
The blood concentration of thiopental declines rapidly. by
about 80% within I 2 minutes. following the initial peal. after
intravenous injection. because the drug is redistributed. first to
tissues with a large blood flow (liver. kidneys, brain, etc.) and
more slowly to muscle. Uptake into body fat, although favoured
by the high lipid solubility of thiopental, occurs only slowly,
because of the low blood tlow to this tissue. After several hours,
however, most of the thiopental present in the body will have
accumu lated in body fat. the rest having been metabolised.
Recovery from the anaesthetic effect occurs within about 5
minutes. governed entirely by redistribution of the drug to well-
perfused ti<,sucs: very little is metabolised in this time. After
the initial rapid decline. the blood concentration drops more
-.lowly. over <,everal hours. as the drug is taken up by body fat
and metabolised. Consequently. thiopental produces a long-lasting
hangover: furthermore. repeated intravenous doses cause
progres'>ively longer periodc; of anaesthesia. because the plateau
in blood concentration becomes progressively more elevated a'>
more drug accumulates in the body. For this reason, thiopental
is not used to maintain l:!urgical anaesthesia but only as an
induction agent.
Thiopental binds to plasma albumin (roughly 85% of the
blood content normally being bound). The fraction bound is less
in stale\ of malnutrition, liver disease or renal disease, which
affect the concentration and drug-binding properties of plasma
albumin, and this can appreciably reduce the dose needed for
-
532
-_..,._...t~>.;.-:-.....~--- induclion or ana<.:sthesia.
Actions and side e Hects
The actions of thiopental on the nervous system are very similar
to thol:!e of inhalation anaesthetics. although it hru. no analge'i'
efTecl and can cause profound respiratory depres!-.ion even ir.
amounts that fail to abolish reflex responses to painful stimuli
Its long after-effect. associated with a slowly declining plasmJ
concentration. means that drowsiness and some degree of
respiratory depression persist for some hours.
Accidental injection of thiopental around, rather than inlo, the
vein, or into an artery, can cause local tissue necrosis and ulcer
arion or !>evere arterial spasm that can result in gangrene.
Immediate injection of procaine, through the same needle. i'
the recommended procedure if this accident occurs. The risk is ~mall
now that lower concentrations of thiopental are used for intravenou1
injection. Thiopental, like other barbiturates, can precipitale an
allack of pmphyria in susceptible individuals (sec Ch. 53).
ETOMIDATE
Etomidatc has gained favour over thiopental on account of the
larger margin between the anaesthetic dose and the dose needeJ
to produce respiratory and cardiovascular depression. It i'> al\11
more rapidly metabolised than thiopental. and thus less likel}
to cause a prolonged hangover. 1n other respects, etomidate i'
very !.imilar to thiopental. although it appears more likely to
cause involuntary movements during induction. postoperali\t
nau~ea and vomiting. and pain at the injection ~ite. Etomidate.
particularly with prolonged use, suppresses the production ol
adrenal sleroids, an effect that has been associated with an
increase in mortality in severely ill patients. II shou ld therefore

not he u~ed in patient\ with adrenal insufficiency. Tt is preferable
to thiopentaltn pat ient~ at risk of circulatory failure.
PROPOFOL
Proporor. imroduced in 1983. is al\o similar in its properties to
thiopental. but it has the advantage of being very rapidly
metabolised and therefore giving rapid recovery without any
hango\er effect. This enables it to be used as a continuous
mfu~1on to maintain ~urgica l anaesthesia without the need for
an~ tnhalation agent. Propofol lacks lhe tendency to cause
involuntary movement and adrenocorti cal suppression seen with
~tonmlatc. ll is particularly useful for day case surgery.
OTHER INDUCTION AGENTS
KETAMINE
'f Ketaminc closely rc~cmblc~. both chemically and pharmacologica lly.
llhenc}clidinc, wh ich i\ a ~tree! drug' wilh a pronounced e ffecl on
'~n,or) pcrccptit)O (sec Ch. 43). Both dng~ produce a -, imilar
aruc,lhesia- li~c state and profound an alge~ia, bu1 keramine produces
.:onsitkrJbl} lc'' euphoria and o.,ensory distortion than phencyclidine
anJ j, thus nmrc useful 111 anae\thesia. Both drugs are belie,ed to act
b) blcxkmg aCII\allon of one t)'pc ol excitatory amino acid receptor (the
~\ID \ receptor; sec Ch. 33 ).
G1'tn intrJ\Cnou'l}. l..etamine take~ effect more slowly (2- 5 minutes)
than thiop.:ntal. and produce~ a dtfterent effect. known ~ 'dis~ociati\ e
IUIJcsthe,ia'. in \\ hich there i~ a marked ~nsory IO\S and analgesia. as
,.dJ a' amnc,ia and paral)sis of mo\ement. \\ithout actual loo;s of
coo...:itJU,ne\\. During 10duction and recovery. involunlary movemem'
anJ p.!~uhar \Cn\OI) e>.pcnence' often occur. Ketamine does not act
, impl) as a dcpre\\ant. and it produce~ cardimascu lar and respiratory
ditch qunc different from tho~ of mo\1 anaesthetics. Blood pressure
and hcan rate are U\ually increa~ed. and respiration is lU)a]Jected by
d fCd i\C anaco.,thctic do'e~. Ketamine. unli ke other in travenous
an;lcsthctic drug,, increases intracranial pres~ure. so it ~hould not be
gi\en 10 pat 1Cill'> with rai~ed int rncran ial pre,,ure or at risk o f cerebral
i...:hacmw. The mo in dra wback of ketarnine. despite the safety assoc iated
with a lad of overall deprc,sant acti vity, is that hallucinations, and
sometime\ deliri um and irrati onal behav iour. are common during
recovery. These after-effect\ limit the usefulness of ketamine but are
>aid to toe lcs~ marked in ch ildren.3 therefore ketam ine. o ften in
conjunction wit h a bcntodiut epine, is sometimes still used for minor
procedure' in paediotric<,.
MIDAZOLAM
~hdazolam. a bent odia; epine (Ch. 37). i s slower in the onset
3Jld oH\ct of ih acLion than the drugs discussed above but. li ke
~ cauuon:lf) note: man) ad~ersc en eel\ are claimed to be less marked in
cblldren. p.!rhap., because the> cannm 'erbali~e their experiences. Until
r~ctntl). mu-cic relaJtants alone were used ~ ithout anaesthesia during
c-anlJac \Utgery in neonate\. The habies d1d not complain of pain. but their
, culanng atecholamincs reached e:nrcmc levels.
GENERAL ANAESTHETIC AGENTS
kctamine. doc~ noL cau~e re'piralory or cardiovascular depres~ion.
It is oflen u'ed a\ a preoperative sedati ve and during procedure!.
such as endoscopy. where full anaesthesia is not required.
Intravenous anaesthetic agents
Most commonly used for induction of
anaesthesia, followed by inhalation agent. Propofol is
also used to maintain anaesthesia during surgery.
Thiopental, et omidate and propofol are most
commonly used; all act within 20- 30 seconds if given
intravenously.
Thiopental:
barbiturate with very high lipid solubility
rapid action due to rapid transfer across blood- brain
barrier; short duration (about 5 minutes) due to
redistribution, mainly t o muscle
slowly metabolised and liable to accumulate in
body fat, therefore may cause prolonged effect if
given repeatedly
no analgesic effect
narrow margin between anaesthetic dose and
dose causing cardiovascular depression
risk of severe vasospasm if accidentally injected
into artery.
Etomidate:
simtlar to thtopental but more quickly metabolised
less risk of cardiovascular depression
may cause involuntary movements during induction
possible risk of adrenocortical suppression.
Propofol:
rapidly metabolised
- very rapid recovery; no cumulative effect
- useful for day case surgery.
Ketam ine:
analogue of phencyclidine, with similar properties
action differs from other agents, probably related
to effect on NMDA-type glutamate recept ors
onset of effect is relatively slow (2-5 minutes)
produces 'dissociative' anaesthesia, in which
pat1ent may remain conscious although amnesic
and insensitive to pain
h1gh tncidence of dysphoria, hallucinations, etc.
during recovery; used mainly for minor procedures
in children
raises intracranial pressure.
533
 Anxiolytic and hypnotic
Overview 535
-
The nature of anxiety and measurement of
anxiolytic activity 535
-Animal models of anxiety 536
-Tests on humans 536
f---
Classification of anxiolytic and hypnotic
drugs 536
- ACTIVITY
Benzodiazepines 536
-Chem1stry and structure-activity relationships
-Mechanism of action 537
-Pharmacological effects and uses 538
-Pharmacokinetic aspects 540
-Unwanted effects 540
Benzodiazepine antagonists 542
luspirone 543
Barbiturates 543
....__.
Other potential anxiolytic drugs 543
OVERVIEW
In this chapter, we discuss the nature of anxiety
and the drugs used to treat it (anxiolytic drugs), as
well as drugs used to treat insomnia (hypnotic
drugs). Although the clinical objectives are
different, there is some overlap between these two
groups, reflecting the fact that anxiolytic drugs
commonly cause a degree of sedation and
drowsiness. There are, however, many sedative
and hypnotic drugs that lack specific anxiolytic
effeds. In high doses, all these drugs cause
unconsciousness and eventually death from
respiratory and cardiovascular depression.
Benzodiazepines form the most important group,
although anxiolytic and hypnotic drugs from an
earlier era are still in use. In recent years, a
number of drugs acting on 5-hydroxytryptamine
(SHT) receptors in the brain, which do not have
drugs
strong sedative activity, have been introduced as
anxiolytic agents. Possible new approaches, based
on neuropeptide mediators, are also discussed
briefly.
THE NATURE OF ANXIETY AND
MEASUREMENT OF ANXIOLYTIC
537 The normal fear respom,e to threatening stimuli comprises
several component~. including defensive behaviours, autonomic
reflexes, arou\al and alertness, corticosteroid secretion and nega-
tive emotions. ln atniety states, these reactions occur in an
anticipatory manner, independently of external events. The dis-
tinction between a 'pathological and a 'normal' state of anxiety is
not clear-cut but reprel.ents the point at which the symptoms
interfere with normal productive activities. Despite (or perhaps
because of) this loose distinction. anxiolytic drugs were until
recently among the most widely used drugs in general practice.
They have fallen out of favour as their uncertain benefit and
definite risks have become evident.
Anxiety disorders as recognised clinically include:
generalised anxiety disorder (an ongoing state of excessive
anxiety lacking any clear reason or focus)
panic disorder (sudden attacks of overwhelming fear occur in
J association with marked somatic symptoms, such as
sweating, tachycardia, chest pains, trembling and choking).
Such auacks can be induced even in normal individuals by
infusion of sodium lactate, and the condition appears to have
a genetic component)
phobias (!>trong fear~ of specific objects or situations. e.g.
snakes, open spaces, flying. social interactions)
post-traumatic stress disorder (anxiety triggered by recall of
past ~tressful experiences)
obsessi1e compulsive disorder (compulsive ritualistic
behaviour driven by irrational anxiety, e.g. fear of
contamination).
ll should be stressed that the treaunent of such disorders generally
involves psychological approaches as well as drug treatment.
Furthermore, other types of drug, particularly antidepressants
(Ch. 39) and sometimes antipsychotic drugs (Ch. 38), are often
used to treat anxiety disorders, in addition to the anxiolytic drugs
described here. 535
 SECTION 4 . THE NERVOUS SYSTEM

ANIMAL MODELS OF ANXIETY puni,hment wa' in operation. although the -.ubjects reported no change
in the painfulne~~ of the electric ~hock. Subtler forms of tormem anJ
"' In addition to the ~ubje<:llve (emotional) component of human anxiety. reward are not hard to imagine.
there are mea,urable behaviouml and phy~iologtcal effech that aho
occur in e'perimemal animal~. In biological term~. anxiety induce~ a
particular lorm ol beha' ioural inhibition thai occurs in re,pon~ to CLASSIFICATION OF ANXIOLYTIC AND
nmcl em ironmental event\ that are non-rewarding Iunder condnion'
HYPNOTIC DRUGS
"here reward t\ e'pected). threatening or painful. In animal\, thi\
beha\ iouml inhibition may take the form of immobtlity or ~uppre~~ion
ol;~ heha' tt>ural re,pono.,e \Uch a~ bar pressing to obtain food {see below).
The main groups of drugs (see review by Argyropoulos ct al
To UC\t!lop ne'' amiol) tic drugs. it is important to have animalte\l\ that 2000) arc as follows.
gi'e .1 good gutdc to efficacy in humans. and much ingenuity h"' gone
into dc,clopmg and validating buch tests.
Denzod iazepines. This is the most important gro up, u'cd as
anxiolytic <md hypnotic agents.
For example. a rm placed in "n unfamiliar environment normally re-.pond,
Bus pirone. This 5-HT 1A recepto r agonist is anxiolytic but
by remaining tmmobile a lt hough alert (behavioural suppres<>ion) for a
time, which may represen t an;>.iety' prod uced by the wangc cmiron
no t appreciably sedative.
ment. Thi' immobility i~ reduced if anx iolyric drugs arc administered. ~-Adrenoccplor antagonists (e.g. propranolol; Ch. I I).
The 'dcvmcd cro~; maze is a widely used test model. Two arm; of These arc used to treat some forms of a nxiety, particularl y
the ra i ~cd horitontal cross are c losed in. and the others arc open. whe re physical sympto ms such as sweating, tremor and
Normal ly. rat' 'pend rno'l of the ir Li me in the closed arms and avoid tachycardia are troublesome. Their effcclivencs!t depends on
the ope n arm' (afraid. possibly, of falling off). Admini~tration of
anxiolytic drugs increases the time spent in the ope n anm and aJ!,o
block of pe riphe ral sympathe tic responses rather than on an}
lnCrC;hc;, the actl\ ity of the rats a> judged by the frequenc) of cro,,ing central effects. They are sometimes used by actors and
the imcr-o::ction. m u sician~ to reduce the symptoms of stage fright, but their

Conflict h.:'t' can abo be u~ed. For example. a rat trained to pre~~ a b<tr
use by snooker players to mi nimise tre mor is banned as
rcpc;lledl) to obt;un a food pellet normally achie'e' a high and con,i\lcnt unsport~man l i ke.
re'pon~ mte. A conflict element i~ then introduced: at imen al~. indicated Zolpidem . Thi!> hypnotic acts similarl y to benzodiazepinc~.
hy an audtiOI') 'ignal. bar pre,,ing results in an occasional puni,hment' although chemically di))tinct. but lacks appreciable anxioi}UC
111 the form of an electric ,hock in addition to the reward of a food pellet.
activity.
ormall). the mt cease; pre,sing the bar (behavioural inhibition!. and
thu;, a\ oid' the 'hock. "htle the signal i~ ~ounding. The eiTect of an
Barbiturates. These are now largely obsolete. super..eded b)
anxiol)tic drug " to relie\e thi;, 'uppressiH~ effect, ;,o that the rat' bentodtuepincs. Their use is now confined 10 anaesthesia
continue bar pre\\ing for reward despite the 'puni~hment'. Other t)Jl<!' (Ch. 36) and the treatment of epilepsy (Ch. 40).
ol P')chotropic drug are not effective, nor are analge;,ic drug;,, Other Mi-.cellaneou<. other drugs (e.g. chloraJ hydrate.
cvtdence conlim1s that an>.iolytic drug~ affect the level of behavioural
meproba ma te and methaquaJone). They are no longer
inhibit ton produced by the 'conflict ~ituation. rather than -.imply rai\ing
the pain thre,hold.
recommended, but therapeutic habits die hard and they are
occasionally used. Sedative antihistamines (see Ch. 13). ~ud
In other tc;,ts. aggressive behaviour is produced experimentally by lc:-ion~
as di phe nhydra mine, are sometimes used as sleeping pilb.
of the midbra in 'eptum. or by hous ing mice in individ ual cages and then
introducing u ;,trangcr. Anx iolytic drugs reduce the amount of aggn:s,ivc particu larly for wakeful c hildren. They are included in
behaviour displayed. They also increase the amou nt of social' interacti on various over-the-counter preparatio ns intended to improve
occurri ng between pairs o f rats placed in an unfamiliar environment, this c hildren\ s leep patterns.
be ing a 'itu:tti on in wh ich soc ial interaction is greatly decrca~ed in
control animal ~. In many o f these test!>. the response is an incrca;,e in
behuvioura l activity, \O it i;, dear that the anxiolytic drugs are prod uc ing
BENZODIAZEPINES
o.,omcthing more than a non-specific sedation.

The first ben1odiazepine, chlordiazepoxide, was synthesised b)

TESTS ON HUMANS accident in 1961, the un usual seven-membered ring having been

"' Variou' \Ubjccti\e 'an>.iety scale' tests have heen devi,ed based on
\tandard paucnt que~uonnaire~. The~>e have confirmed the efficacy of
man} an~iol)tic drug,. but placebo treatment often al~o produces high!}
Measurement of anxiotytic activity
''gmlicant tc'>JXm,es.

Other h!,ts rely on mea~urement of the somatic and autonomic ellecl\

a"octated with an\tet). An example is the gal,anic skin respon~. in
"h1ch the electrical conducti\ it) of the skin is used as a rnea,ure of "~cat
production. Any no~cl sttmulus. whether pleasant or unplea,ant. cau\e~
a rc,ponse. 11tb fom1~ the basi.!. of the lie detector te~t. If an innocuous
\timulus i' repeated at tntervals. the magnitude of the respon~ dccrea'c'
(habituation). The rate of habituation is less in anxiou' patient\ than
in normal \Ubjecls, and i~ increased by anxiolytic drugs.
A human ver~ion of the confl ict test described above involves the
~ub!>li tution of rnone) for food pellets. and the usc of graded e lectric
~hocks U\ puni,hmcnt. As with rats, administration of d ia?Cpam i ncrease~
536 the rate or button pressi ng for money during the peri od , when the
Behavioural tests in animals are based on
measurements of the behavioural inhibition
(considered to reflect 'anxiety') in response to conflict
or novelty.
Human tests for anxiolytic drugs employ psychiatric
rating scales or measures of autonomic responses
such as the galvanic skin response.
Tests such as these can distinguish between
anxiolytic drugs (benzodiazepines, buspirone, etc.)
and sedatives (e.g. barbiturates).
 ANXIOLYTIC AND HYPNOTIC DRUGS

ca.ues of anxiolytic and hypnotic drugs

Benzodiazepines: the most important class,
used for treating both anxiety states and insomnia.
Buspirone: a 5-HT,A receptor agonis t w ith anxiolytic
activity but little sedation, although o th er side effects.
~-Ad renoceptor antagonists: used m ainly to reduce
phystcal symptoms of anxiety (tremor, palpit ations,
etc.); no effect on affective component.
Miscellaneous other agents (e.g. methaqualone, chloral
hydrate) are still used occasionally to treat insomnia
(benzodiazep ines are preferable 1n most cases).
Barbiturates: no w largely obsolete as
anxiolytic/sedative agen ts.
produced as a result of a reaction that went wrong in the labora-
lone' of Hoffman-la Roche. Its unexpected pharmacological
octi1it) Wil!> recognised in a routine screening procedure, and
b.:n11xliazepmcs quite soon became the most widely prescribed
drug' in the pharmacopoeia.
CHEMISTRY AND STRUCTURE-ACTIVITY
RELATIONSHIPS
The basic chemical sm1cturc of bcnwdiazepines consiM'> of a
seven-membered ring fused to an aromatic ring. with four main
subslituent groups that can be modified without loss of activi ly.
Thousands of compounds have been made and tested, and aboul
20 are available for clinical u!>e, the most important ones being
li~ted in Table 37.1. They arc basically similar in their pharma-
cological actions, although '>Orne degree of selectivity has been
reported. For example. ~orne, \uch a.'> clo oazepam. ~ho\\ ami-
com ulsant activity with les~ marJ...ed <iedative effects. From a clinical
point of view. differences in pharmacokinctic behaviour among
different benzodiazepines (see below) are more important than
differences in profile of activity. Drugs witb a similar slntcture
have been discovered rhal specifically antagonise the effect~ of
the bcnzodiazepines, for example flumaL:cnil (see below).
MECHANISM OF ACTION
Ben7odiazepioes (once thought to be acting as non--.pecific
depressants') act selectively on GABAA receptors (Ol. 33).

Tlble 37.1 Characteristics of benzodiazepines in humans

Orug(s) Half-life of parent Active metabolite Half-life of Overall duration of Main use(s)
compound {h) metabolite (h) action

Triazolam, 2-4 Hydroxylated 2 Ultrashort(< 6 h) Hypnotic

midazolam derivative Midazolam used
as intravenous
anaesthetic

Zolptdenf 2 No Ultrashort(- 4 h) Hypnotic

Lorazepam, 8- 12 No Short (12-18 h) Anxiolytic, hypnotic

oxazepam,
temazepam,
lormetazepam

Alprazolam 6-12 Hydroxylated 6 Medium (24 h) Anxiolytic,

derivative antidepressant

Ntrazepam 16-40 No Medium Hypnotic, anxiolytic

Otazepam, 20-40 Nordazepam 60 Long (24-48 h) Anxiolytic, muscle

chlordtazepoxide relaxant
Diazepam used
intravenously as
anticonvulsant

Flurazepam Desmethyl- 60 Long Anxiolytic

flurazepam

Ctonazepam 50 No Long Anticonvulsant,

anxiolytic
(especially manta)

-Triazolam has been withdrawn from use in the UK on account of side effects.
bZolpidem is not a benzodiazepine but acts at the same site. Zopiclone is similar.
537
SECTION 4 . THE NERVOUS SYSTEM
which mediate fast inhibitory synaptic transmission throughout
the central nervous system (C S). Benzodiazepines enhance the
rc'>ponse to GABA by faci litating the opening of GABA-
activated chloride channels (Fig. 37.1 ). They bind specifically to
a regulatory site of the receptor. distinct from the GABA-binding
.,ite, and act allo terically to increase the affinity of GABA for
the receptor. Single-channel recordings show an increase in the
frequency of channel opening by a given concentration of
GABA. but no change in the conductance or mean open time,
consistent with an effect on GABA binding rather than the
channel-gating mechanism. Benzodiazcpines do not affect
receptors for other amino acids, such as glycine or glutamate
(Fig. 37 . I).
T The GABAA receptor is a ligand-gated ion channel (~ee Ch. 3)
con~bting of a pelllameric a.\~embly of different subunits, the ma in one
being u. j3 and y, eoch of which occurs in three or more isoforms. The
pot~n ti:l l number of combinations b therefore huge, but three
combinatiom, predominate in the adult brain. namely (t 1 f{ 2y~. n 2j~ 1y, und
et,~ ,y 2 The various combinatiom, occur in different parts of the brain, and
linking thi~ diver~ily with physiological function and pharmacological
'pecificity prc.,ent~ a difficult. although familiar, problem (sec Whiting,
2003). Progre~., ha' recently been made. however, in understanding the
effect\ of bcntodtiVepine., at the molc:cular le,el (see Rudolph et al.,
2001 ; Rudolph & Mohler. 2QO.t). which may point the way to no,el drug.,
"ith more 'pecilic action'>. Sen\itivity to benzodiazepine;, requires the
pre,cncc of hoth <l and ~ \Ubunits. and mutation of a 'ingle amtno acid
(hi,tidine 101) tn the <t \Ubunit eliminates benLodia.1epine '>en,itivit).
Thi' h:.., been u\ed in an mgemous series of e..:perimems on tran,genic
mice n \\htch tht\ residue has been mutated in different a '>ubunit~. 1l1c
animal\" ere then tt!Med to determine "'hich benzodiazepine effect~ "'ere
GABA
~10mV
Con Diazepam Con 1 s
Glu GABA Glu GABA
~~
~
Gly GABA Gly GABA
Control Chlordiazepoxide
Fig. 37.1 Potentiating effect of benzodiazepines and
chlordiazepoxide on the action of GABA. Drugs were applied
by ionophoresis to mouse spinal cord neurons grown in tissue
culture, from micropipettes placed close to the cells. The
membrane was hyperpolarised to -90 mV, and the cells were
loaded with Cl from the record ing microelectrode, so inhibitory
amino acids (GABA and glycine, Gly), as well as excitatory
ones (glutamate, Glu), caused depolarising responses. The
potentiating effect of diazepam is restricted to GABA responses,
glutamate and glycine responses being unaffected. Con, control.
clirninmcd in thc5e different mutants. with the interesting rc\ult that
mutation of the most widely expres~ed variant eli minated the <.edati'e and
amne~ia-productng action<; of ben7odiazepines. as "'ell as dimim,hmg
the anticonvul\ant effect. whereas mutation of a , (eAprcS\ed mainl) m
the hmbtc sy!>lem) eliminated the anxiolytic effect but left the 'edatt\l:
efle.:t unaltered. The conclu,ions from this kind of \IUd) suggest that
GABA~ receptor.. containing the a \Ubunit account for 'edatJ\-e
amne,ic and anticonvulsant effects of benzodiazepines. \\.berea~ thole
contatning the u 2 !>ubunit account for the amtiol) tic and muscle rcla'anr
elfects. Thi' 'ugge'" the possibility of developmg no,el drugs 1101
more \electtve effects than e~isting benzodiazepines. "'hich are oo:-
selective wtth respect to different a subun it~ (see Whiting. 2003). To this
end. un eAperimentnl a 1-5elective benzodiazepine, L 838-117, has b<(n
discovered. which ha5 anxiolytic but not sedative actions in laboratory
an tmals. a~ predicted from the transgenic animal data. Whether or notth11
will hold true in humans rt!mains to be seen.
Pcdphcral bcnzodiazepine-binding sites, not associated with
GABA receptors, arc known to exist in many tissues, but their
function and pharmacological significance are unknown.
PHARMACOLOGICAL EFFECTS AND USES
The main effects of benlOdiazepines are:
reduction of anxiety and aggression
\edation and induction of sleep
reduction of muscle tone and coordination
anticonvubant effect
anterograde amnesia.
Reduction of anxiety and aggression
Bentodia?epine!> show anxiolytic effects in animal test,, a'
described above. and also exert a marked 'taming' ene,~
allowing animals to be handled more easily. 1 If given to the
dominant member of a pair of animals (e.g. mice or monkc)"
housed in the same cage, benzodiazepines reduce the numbcro
attack!> by the dominant individual and increase the number of
attacks made on him. With the possible exception of'alprazolam
(Table 37. 1), benzodia7epines do not have antidepressant effects.
Ben7.0dia7.epines may paradoxicaJJy produce an inc rea~e m
irritability and aggression in some individuals. This appears to be
particularly pronounced with the ultrashort-acting drug triazolum
(and led to its withdrawal in the UK and some other countrie'
and i~ generally more common with short-acting compound,. ll
ic; probably a manifestation of the benzodiazepine withdr.~v.ol
syndrome. which occurs with all these drugs (see below) butt
more acute with drugs whose action wears off rapidly.
BenLodiatepines are used mainly for treating acute anxt~!J
~tates. but their use is declining in favour of antidepressants (Ch 39
coupled with behavioural therapies in more severe cases.
The use of benzodiazepines as anxiolytic agents is re\ iewed
by Shader & Greenblatt (1993).
1
This depends on the ~pecies. Cats actually become more excitable, a~ a
colleague or one of the uuthors discovered to his cost when allempting to
scdmc u tiger in the Baltimore zoo.

Sedation and induction of sleep
BenLlXhaJepines decrease the time taken to get to sleep. and
mcreasc the total duration of sleep. although the latter effect
occuf\ only in subjects who normally sleep for less than about 6
hou r~ each night. Both effects tend to decline when
bentodia;epines are taken regularly for 1-2 weeks.
On the basis of electroencephalography measurements. several
bds of \Jeep can be recognised. Of particular psychological
tmportance are rapid eye movement (REM) sleep. which is
a"octatcc.l \\ ith dreaming. and slow-wave sleep. which
rorre,ponds to the deepest level of \leep \\hen the metabolic rate
and adrenal steroid secretion are at their lowe~! and the secretion
of gro"'th hormone is at ilS highest (see Ch. 28). Most hypnotic
drugs reduce the proportion of REM sleep, although
bentodiazepines affect it Jess than other hypnotics, and zolpidem
('~c below) least of all. Artificial interruption of REM sleep
cau 'c~ irritabi lity and anxiety. even if the tOtal amount of sleep is
not reduced. and the lost REM sleep b made up for at the end of
,u~:h an e'periment by a rebound increase. The same rebound in
RE.\1 ,leep is ~een at the end of a period of administration of
benlOdiazeptne~ or other hypnotics. lt is therefore assumed that
RF.\1 ,lcep has a function, and that the relatively slight reduction
ofRLM '>leep by benzodiazepines is a point in their favour.
The proportion of slow-wave sleep i<; significantly reduced
b\ bcntodiazepines, although growth hormone secretion is
unanectcd.
Hgurc 37.2 shows the improvement of subjective ratings o f
,kcp quality produced by a ben1.0diazepine, and the rebound
decrea'e at the end of a 32-week period of drug treatment. It is
notable that, although tolerance to objective effects such as
reduced ~lcep latency occurs within a few days. this is not obvi-
ou' in the subjective ratings.
Although long-term use of benzodiazepines as sleeping pills
1, undesirable, owing to tolerance, dependence and "hangover'
etlccts, occasional use (e.g. by shift worker~. plane travellers, etc.)
IS cffeCti\C.
Reduction of muscle tone and coordination
Ben1odi:ucpines reduce muscle tone by a central action that is
md~penc.lent of their sedative effect. Cats are particularly sensi-
UIC to thi\ action, and some benwdiatepines (e.g. clonazepam,
Ounilra7epam) reduce decerebrate rigidity in doses that are
n u~h \lnallcr than those needed to produce behavioural effeclS.
In other \pecies, the difference is les!> clear. Coordination can be
te-ted by measuring the length of time for which mice can stay
on a slowly rotating horizontal plastic rod. or the time taken for
them to escape from confinement by climbing up the inside of
utuhular chimney. Performance in these acrobatic tricks is impaired
b~ ben7odiazepines and other sedatives, but it is not clear that
~icular drugs show selectivity in this respect in species other
than the cat. Studies in humans have failed to show differences
bet11een benzodiazepines.
lnaeascd muscle tone is a common feature of anxiety states
mhuman~ and may conrribute to the aches and pains, including
headache, which often trouble anxious patients. The relaxant
effect of benzodiazepines may therefore be clinically useful. A
reduction of muscle tone appears to be possible without
ANXIOLYTIC AND HYPNOTIC DRUGS
Lormetazepam
ro('
Nitrazepam
i[ ~f'
u;
Treatment (32 weeks)
Fig. 3 7.2 Effects of long-term benzodiazepine
treatment on sleep quality. A group of 100 poor sleepers
were given, under double-blind conditions, lormetazepam
5 mg, nitrazepam 2 mg or placebo nightly for 24 weeks, the
test period being preceded and followed by 4 weeks of
placebo treatment. They were asked to assess, on a subjective
rating scale, the quality of sleep during each night, and the
results are expressed as a 5-day rolling average of these
scores. The improvement in sleep quality was maintained
during the 24-week test period, and was followed by a
' rebound' worsening of sleep when the test period ended.
(From Oswald I et al. 1982 Br Med J 284: 86o-864.)
appreciable loss of coordination. Other clinical uses of muscle
relaxants are discussed in Chapter 40.
Anticonvulsant eHects
All the benzodiazepines have anticonvul!>ant activity in exper-
imental animal tests. They are highly effective against chemically
induced convulsions caused by pentylenetetrazol. bicuculline
and similar drugs (see Chs 40 and 42) but less so against
electrically induced convulsions. Bcntodiazepines do not affect
strychnine-induced convulsions in experimental animals. This
is because strychnine causes convulsions by blocking inhibitory
glycine receptors (see Ch. 42). whereas bicuculline and several
other chemical convulsant agents act on GABAA receptors
(Ch. 30). Benzodiazepincs enhance the action of GABA but
not glycine, so the sclectiYity of their anticonvulsant action is
explicable. Clonazepam (see above), because of its selectiYe
anticonvulsant action, is used to treat epilepsy (Ch. 40). a) b
diazepam. which is given intravenously to control life-
threatening seizures in status cpilepticul>.
Anterograde amnesia
Benzodiazcpines obliterate memory of events experienced while
under their influence, an effect not seen with other CNS depress-
ants. Minor surgical procedures can thus be performed without
leaving unpleasant memories.
IS THERE AN ENDOGENOUS BENZODIAZEPINE-
LIKE MEDIATOR?
T Whether there are endogenou~ ligands for the bentodiatepine
539
receptors. whose function i!. to regu late the action of GABA. is Mill
 SECTION 4 . THE NERVOUS SYSTEM

uncertain. The main candidate is a 10-kDa peptide, dia7epam-binding

inhibitor. isolated from rJt brain. This peptide binds st:rongly to the Benzodiazepine GABA
benlodiaepine-btnding site of the GABA~ receptor. and has the opposite (agonist)
effect to ben1odiucpines. i.e. it inhibits chloride channel opening by
GABA. and ~hen injected into the brain has an anxiogenic and
proconvul\ant ellect. Other pos,ible endogenous modulatOI'> of GA8A~
receptor\ include \tcroid metabolites (see Ch. 33). There is also evidence
that benzodta~cpmes themselves may occur natural!} in the brain. At
pre,cnt. there i\ no general agreement on the identit} and function of
cndogenou' ligands.

BENZODIAZEPINE INVERSE AGONISTS AND

ANTAGONISTS
T The term imerse agoni.lt (Ch. 2) is applied to drugs that bind
to benJ.odia1.epine receptors and exert the opposite effect to that of
conventional bcntodia1.epincs. producing signs of increased anxiety and
convulo,ion'>. Dia~epam-binding inhibitor is an example, and some
I~ Confo rmational
~ 1 eq uilibrium
hen1.odin~epi ne analogue\ act similarly. li is possible (see Fig. 37.3) to
explain these complexities in terms of t.he two-state model discus~cd
in Chapter 2. by pm.tulating that the benzodiazcpine receptor exists in
rwo di!>tinct conformations. only one of which (A) can bind a GABA
molecule and open the chloride channel. The other conformation (8)
cannot bind GABA. Normally. with no benzodiaz.epine receptor ligand
prc~cnt, there i'> an equilibrium between these mo conformationo,:
LJO
l t ~-Carbolines (inverse agonist)
..en~iti\ tty to GABA i\ pre~cnt but submaximal. Benzodiatepine agoni\1'>
(e.g. dialCpam) are po~tulated to bind preferentially to conformation A.
thu'> ~hthing the equilibrium in favour of A and enhancing GABA
..en,itl\ ity. Jn,erse agoni~ts bind selectively to 8 and have lhe oppo'>itc:
effect Competiti,e antagonist~ such as llum azenil (~ee below) bind
equall) to A and B. and consequently do not disturb the conformational
Fig. 37.3 Model of benzodiazepine/GABA recepto r
cqutlibrium but antagonise the effect of both agonisL~ and in' erse
Inte ractio n. Benzodiazepine agonists (e.g. diazepam) and
agoni\t\ Some of the molecular variants of t.he GABA, receptor
antagonists (e.g. flumazenil) are believed to bind to a site on
(\Cc above) seem to \hO\\ different relative affinities for agoni\1\.
the GABA receptor distinct from the GABA-binding site. A
antagont\1'> and inverse agonists. and it is possible that !his renee!\
conformational equilibrium exists between states in which the
difference~ tn the equilibrium between the A and 8 states as a function
benzodiazepine receptor exists in its agonist-binding
of the \ubunit composition of the receptor.
conformation (above), and in its antagonist-binding
conformation (below). In the latter state, the GABA receptor
PHARMACOKINETIC ASPECTS
Bcnwdia;.cpines are well absorbed when given orally. usually
giving a peak plasma concentration in about I hour. Some (e.g.
l has a much reduced affinity for GABA; consequently, the
chloride channel remains closed.

o xazepam, lorazepam) are absorbed more slowly. T hey bind

strongly to plasma protein, and their high lipid solubi li ty causes
many of them to accumulate gradually in body fat. They arc bcnLodiuepine~. which may be used regularly as hypnotics or
agent~ for many years. tend> to increase wilh age, and it is common I
normally given by mouth but can be given intravenously (e.g.
drow~ine~> and confusion to develop insidiously for thts rea\on. 2
diazep a m in status cpilepticus, midazolam in anaesthesia).
Intramuscular injection often results in slow absorption.
Bentodia7epine~ are all metabolised and eventually excreted UNWANTED EFFECTS
as glucuronide conjugates in the urine. They vary greatly in
These may be divided into:
duration of action and can be roughly divided into shon-, medium-
and long-acting compounds (Table 37.1). Several arc convened tox.ic effects resulting from acute overdosage
to active metabolites !>uch as N-desmethyldiazepam (nordazepam), unwanted effects occurring during normal therapeutic uc;e
which has a half-life of about 60 hours. and which accounts for tolerance and dependence.
the tendency of many ben7odiazepines to produce cumulative
effect'> and long hangovers when they are given repeatedly.
The shon-acting compounds are those that are metabolised
directly by conjugation with glucuronide. The main pathways arc
shown in Figure 37.4. Figure 37.5 shows the gradual build-up
1 At the age of 91. the grandmother of one of t.he authors was grO\\ ing
and slow disappearance of nordazepam from the plasma of a
increa~ingly forgetful and mildly dotty, having been taking nitratepam lor
human subject given diat epam daily for IS days. in~omnia regularly for years. To the author's lasting shame, it took a cnnn
T Advancing age affects the rate of oxidative react ions more general practitioner to diagnose the problem. Cancellation of the
540 than that of conjugation reactions. Thus the effect of the long-acting prc:,cription produced u dramatic improvement.
 ANXIOLYTIC AND HYPNOTIC DRUGS

MEDAZE~ ~--------+

CHLORDIAZEPOXIDE

CHLORAZEPATE

Ii
i LUORAZEPA
~m;&ii Mil-1-----------------------------------+ Glucuronide

F"eg. 37.4 The metabolism of TAfAZOLAir

benzodiazepines. The N-demethylated
metabolite nordazepam is formed from
a number of benzodlazepines, and is
Important because it Is biologically
active and has a very long half-life.
Compounds with pharmacological
activity are shown. Drugs available for
clinical use are shown in shaded boxes. Triazolam withdrawn in UK

Fig. 37.5 Pharmacokinetics
of diazepam in humans.
s
Ig
A Conce<ltrallons of diazepam
0
and nordazepam following a single E
oral or intravenous dose. Note the ~ 0.1
... --:------. i
very slow disappearance of both
substances after the first
g
c:

l'!
,
Nordazepam
~
c +'
~
~
20 hours. B Accumulation of "'c:
<.> 0.1
noroazepam during 2 weeks' daily
adm1nstrat1on of diazepam, and
80.o1
..." Oral
E
8.
slow decline (half-life about ~
3 days) after cessation of Intravenous "'
:;j
'E Diazepam 35 11mol/day
0
diazepam administration. (Data 0.001 z 0.01
from Kaplan SA et al. 1973 0 5 10 15 20 25 30 48 0 4 8 12 16 20 24
J Pharmacal Sci 62: 1789.) Time (hours) Time (days)

Acute toxicity Side eHects during therapeutic use

Ben1odiazepines in acute overdose are considerably less
dangerous than other anxiolyti c/hypnotic drugs. Because such
agenh are often used in attempted suicide, this is an important
3(hantage. In overdo~e. bcnzodiazepines cause prolonged sleep.
111thout -.erious depression or respiration or cardiovascular
fun.:tion. However, in the presence of other CNS depressants.
panJcularly alcohol, benl0dia7epines can cause severe. even life-
lhrealening. respiratory depression. The availability of an
effecti1e antagonist, flumazcnil, means that the effects of an
acute Ol'erdose can be counteracted.3 which is not possible for
mo\t CKS deprcs antl>.
In practice. patients nrc usually left to sleep it oiJ. because there is a risk of
1eizure' ~~<ith llumat.enil; however. tlumazenil may be useful diagnostically
10 rule out coma of other cau~es.
The main side effects of benzodiazepines are drowsiness,
confusion, amnesia and impaired coordination, which consider-
ably affects manual skills such as driving performance.
B enzodia7epines enhance the depressant effect of other drugs,
including alcohol, in a more than additive way. The long and
unpredictable duration of action of many benzodiazepines is
important in relation to side effectl>. Long-acting drugs such as
nitra7epam are no longer used as hypnotics, and even shorter-
acting compounds such as lorazepam can produce a substantial
day-after impairment of job performance and driving skill.
Tolerance and dependence
Tolerance (i.e. a gradual escalation of dose needed to produce
the required effect) occurs with all benzodiazepines, as does
dependence, which is their main drawback. They share these
properties with other hypnotics and sedatives. Tolerance is less
marked than it is with barbiturates, which produce pharmacokinetic
tolerance because o f induc tion of hepatic drug-metabolising
541
 SECTION 4 . THE NERVOUS SYSTEM
en;yme~ (Ch. 8}-this does not occur with benzodia.zepincs. Such
tolcmncc ru. docs occur appears to represent a change at the
receptor level. but the mechanism is not well understood.
The ~Jeep-induc ing effect shows relatively little tolerance
(Fig. 37.2).ln a Mudy with intravenous diazepam given to nonnal
subjects. it~ euphoric effect was not pre ent in those taking oral
diatepam daily. It i<. not clear v.. hether rolerance to the anxiolytic
effect ic, <,ignificant.
BentodiaLepines produce dependence. and this is a major
problem. In human subjects and patients, sropping benzodia7epine
treatment after weeks or months causes an increase in symptoms
of anxiety. together with tremor and dizziness. Although
animals ~how only a weak tendency to self-administration of
bcnt.od i;.wepincl>, withdrawal after chronic administration
causes physical symptoms similar to those that follow opiate
withdrawal (sec Ch. 43), namely nervousness, ucmor, loss of
appetite and sometimes convulsions.4 The withdrawal syndrome,
in both animals and humans. is slower in onset than with
barbiturate!>, probably because of the long plasma half-life
of mo'>t benlOdiaLcpinc!>. Short-acting benzodiazepines cause
more abrupt withdrawal effects. With triazolam, a very short-
acting drug and no longer in use, the withdrawal effect
occurred within a few hours, even after a single dose, producing
early-morning insomnia and daytime anxiety when the drug
wa<, u<,cd a.<, a hypnotic.
The phy,ical and psychological withdrawal symptoms make
it difficult for patiems to give up taking benzodiazepines. but
addiction (i.e. severe psychological dependence thai outlasts
the phy.,ical withdrawal syndrome). which occurs with many
drugs of abuse (Ch. 43). is not a major problem.
BENZODIAZEPINE ANTAGONISTS
Competiti ve antagonists of benzodiazepines were first dis-
covered in 198 1. The best-known compound is t1umazenil. This
compound was originally reported to lack effects on behaviour
or on drug-induced convulsions when given on its own. although
it was later found to posse~s some 'anx.iogenic' and pro-
convu lsant activity. Flumazenil can be used to reverse the
effect of ben1.0diazepine overdosage (normaiJy used only if
re~piration is ~everely depressed), or to reverse the effect of
bcntodiatepine!) <,uch as m idazolam used for minor surgical
procedure'>. Flumatenil acts quickly and effectively when given
by injection. but its action lasts for only about 2 hour-.. so
drov\ sines\ tends to return. It is often used in treating comatose
patients suspected of having overdosed w1th benzodiatepine~
even before the diagnosis is confirmed on the basis of a blood
sample. Convulsions may rarely occur in patients treated with
"Withdrawal ~ymp1oms can be more severe. A relative of one of the author~.
udvi~ed to Mop laking beniOdiatepine:, after 20 years, su ffered h311ucinalion~
__ 542
.......,.- - - - and one day lore down all the cu rtains, conv inced !hat they were on fire.
Benzodlazepines
Act by binding to a specific regulatory site on
the GABAA receptor, thus enhancing the inhibitory
effect of GABA. Subtypes of the GABAA receptor
ex1st 1n dtfferent regions of the brain and dtffer 1n their
functional effects.
Anxiolytic benzodiazepines are agonists at this
regulatory site. Other benzodiazepines (e.g.
flumazenil) are antagonists and prevent the actions of
the anxiolytic benzodiazepines. A further class of
inverse agonists is recognised, which reduce the
effectiveness of GABA and are anxiogenic; they are
not used clinically.
Anxiolytic effects are mediated by GABAA receptors
containing the u 2 subunit, while sedation occurs
through those with the u 1 subunit.
Endogenous ligands for the benzodiazepine-binding
site are believed to exist. They include peptide and
steroid molecules, but their physiological function is
not yet understood.
Benzodiazepines cause:
reduction of anxiety and aggression
sedation, leading to improvement of insomnia
muscle relaxation and loss of motor coordination
suppression of convulsions (antiepileptic effect)
anterograde amnesia.
Differences in the pharmacological profile of different
benzodiazepines are minor; clonazepam appears to
have more anticonvulsant action in relation to its
other effects.
Benzodiazepines are active orally and differ mainly tn
respect of their duration of action. Short-acting
agents (e.g. lorazepam and temazepam, half-lives
8-12 hours) are metabolised to inactive compounds
and are used mainly as sleeping pills. Some long-
acting agents (e.g. diazepam and chlordiazepoxide)
are converted to a long-lasting active metabolite
(nordazepam).
Some are used intravenously, for example diazepam
in status epilepticus, midazolam in anaesthesia.
Zolpidem is a short-acting drug that is not a
benzodiazepine but acts similarly and is used as a
hypnotic.
Benzodiazep1nes are relatively safe in overdose. The1r
main disadvantages are interaction with alcohol, long
lasting 'hangover' effects, withdrawal symptoms and
the development of dependence.
numaLenil, and thi!> is more common in patients
tricyclic antidepressants (Ch. 39). Reports that
improves the mental state of patients with severe liver
(hepatic encephalopathy) and alcohol intox.ication have not
confirmed in conuoiJed uials.

BUSPIRONE
Bll!lpirone I'> a partial agoni~t at 5-HT 1" receptors (Ch. 12)
311d i~ U\Cd to treat variou~ anxiety disorders. It also binds to
dopamine receptor-,, but 11 b likely that its 5-HT-related actions
are important in relation to anxiet) suppression. because
related compound\ (e.g. ipsapirone and gepirone. neither of
11h1ch are approved for clinical u~e. which are highly specific
for 5HT 1\ receptor'; \CC Traber & Glaser. 1987) show similar
an"ol}tic acti\ ity in e.xpcrimental animals. 5-HT 1A receptors are
inhib1tory autorcceptor' that reduce the release of 5-HT and
other mediator~. They also inhibit the activity of noradrenergic
IOCU\ cocnrleus neurons (Ch. 34) and thus interfere with arousal
r~actmns. llowcvcr, bu~>pirone takes days or weeks to produce
1ts effect in humans, suggesting a more complex indirect
mcchani~m of action. Buspironc is ineffective in contJolling
panic attack\ or severe anxiety Mates.
Bu,pirone has side eiTccts quite different from those of
henzodia7epines. It doe~ not cause sedation or motor incoor-
dinatum. nor have withdrawal effects been reponed. Its main
'1dc cffech are nau~ea, diuincss. headache and restlessness.
11h1ch generally '>cem to be less troublesome than the side effects
ofhc:n70dla7epinc\.
BARBITURATES
The ,Jeep-mducing propertie' of barbiturates were discovered
earl~ in the 20th centuf). and hundreds of compounds \\ere
mJde and te~tcd. Until the 1960s, they formed the largest group
o h)pnollc'> and 1.edatives in clinical use. Barbiturates all have
d~pre,.,ant activity on the CNS, producing effects similar to
tho'e of inhalation anae~thetics. They cause death from respir-
atOI) and cardiovascu lar depression if given in large doses,
11h1ch bone of the main reasons that they are now lirtle used
a'> anxiolytic and hypnotic agents. Pentobarbital and similar
t)pical barbiturates with durations of action of 6-12 hours are
,till \cry occasionally used as ~> leeping pills and anxiolytic
drug,, but they are less safe than benzodiazcpines. Pentobarbital
"olkn u'>ed a' an anaesthetic for laboratory animals.
Barbiturates that remain in clinical use include pheno-
barbital. '>till occa,ionally used to treat epilepsy (see Ch. 40),
and thiopental. which is widely used as an intravenous
anac~thetic agent (see Ch. 36).
1-HTta agonlsts as anxlolytic drugs
Busp1rone is a potent (although non-selective)
agonist at 5-HT lA receptors.
Anx1olytic effects take days or weeks to develop.
Side effects appear less troublesome than with
e benzodiazepines; they include dizziness, nausea,
headache, but not sedation or loss of coordination.
ANXIOLYTIC AND HYPNOTIC DRUGS
Barbilllrate\ share with benzodiazepines the ability to enhance
the action of GABA, but they bind to a different site on the
GABA, receptor/chloride channel. and their action is less specific.
As well as being dangerous in overdose, barbiturates induce
a high degree of tolerance and dependence. They also strongly
induce the o,ynthel.is of hepatic cytochrome P450 and conjugating
enzymes. and thu\ increa\e the rate of metabolic degradation
of many other drugs. giving rise to a number of potentially
troublesome drug interactions (Ch. 52). Because of enzyme
induction. barbiturates are also dangerous to patients suffering
from the metabolic disea\e porphyria.
OTHER POTENTIAL ANXIOLYTIC DRUGS
Selective serotonin reuptake inhibitors (see Cb. 39) such a~
fluoxetine, paroxetinc and ser traline are used to treat certain
anxiety disorders, including obsessive compulsive disorder and
panic. Their action in this context appears to be independent of
their antidepre%ant eflects.
T Bc\1de' the GABAA and 5-HT 1,.. receptor mechanisms discU\\ed
above. many o1her lran\millel'\ and rcccpton. have been implicated in
anxicly and panic di\ordcr.. (~ee Sandford et at.. 2000). particularly
noradrenaline. and neuropeptide~ 'uch a\ cholecystokinin (CCK) and
..ubsrance P. Am.iol)tic drug'> aimed at these targets are in developmem.
but none are \O tar a\a1lablc for clinical use. Variou~ drug~ thai enhance
the effects of GABA. de, eloped primaril) ;c, antiepileptic drug' (see Ch.
40). ma) 1\o be cllectl\c m treating amtiet) di~order.. (see Nemcroll.
2003). They include ga ba~ntin. 'igabatrin. tiagabine and valproate.
5-HT, receptor antagom\IS wch as ondansetron (Ch. 12) shoow
anxiol) uc activil} in am mal model' but have not proved efficaciou\ in
controlled hum:m trial\. A' mentioned earlier. 5-HT uptake inhibi1or...
such a' nuoxelinc. and m1xed 5-HT/noradrenaline up1ake inhibitor...
which are U\Cd as antidepressant drugs (Ch. 39). also show efficacy in
anxicly di~order,.
Barbiturates
Non-selective central nervous system
depressants that produce effects ranging from
sedat1on and reduction of anxiety to unconsciousness
and death from respiratory and cardiovascular
failure-therefore dangerous in overdose.
Act partly by enhancing action of GABA, but less
specific than benzodiazepines.
Mainly used in anaesthesia and treatment of epilepsy;
use as sedative/hypnotic agents is no longer
recommended.
Potent inducers of hepatic drug-metabolising
enzymes, especially cytochrome P450 system, so
liable to cause drug interactions. Also precipitate
attacks of acute porphyria in susceptible individuals.
Tolerance and dependence occur.
543
 SECTION 4 . THE NERVOUS SYSTEM

Antagonists of lhc ncuropcptidc CCK (see Cb. 16) have been tested emotion. ha\ been considered as a possible meilimor of panic ana.-l-,
a~ anxiolytie drug~. CCK, which is expressed in many areas of the but non-peptide CCK antagonists have proved ineffective in chmcal
bratn stem and midbrain that are involved in arousal, mood and trials.

Clinical use of drugs as anxiolytics

Many anxiolytic drugs (e.g. benzodiazepines) are Buspirone (5-HT1A agonist; p. 544) has a
also hypnotic. These should be used only for short- different pattern of adverse effects from
term (< 4 weeks) relief of severe and disabling benzodiazepines and much lower abuse potential. Its
anxiety. effect is slow in onset (> 2 weeks).

Clinical use of hypnotics ('sleeping tablets')

The cause of insomnia should be established before
administering hypnotic drugs. Common causes
include alcohol or other drug misuse (see Ch. 43) and
physical or psychiatric disorder (especially depression).
Tricyclic antidepressants (Ch. 39) cause drowsiness,
so can kill two birds with one stone if taken at night by
depressed patients with sleep disturbance.
Optimal treatment of chronic insomnia is often by
changing behaviour (e.g. increasing exercise, staying
awake during the day) rather than with drugs.
Most hypnotics act on specific modulatory sites on
GABAA receptors (Ch. 33, Fig. 33.4) and cause
dependence; they should be used only for short
periods (< 4 weeks) and for severe insomnia. They
can be useful for a few nights when transient
factors such as admission to hospital, jet lag or an
impending procedure cause insomnia
Hypnotic drugs include:
- benzodiazepines (e.g. temazepam, nitrazepam) and
related drugs (e.g. zolpidem, zopiclone, which also
work on the benzodiazepine receptor)
-chloral and triclofos, which were used formerly in
children, but this is seldom justified
-sedating antihistamines (e.g. promethazine), which
cause drowsiness (see Ch. 14, and clinical box on
p. 236) and are on general sale for occasional
insomnia. They can impair performance the day after
they are used.

REFERENCES AND FURTHER READING

t\rgyropoulo' S V, Sandford J J, Null D J 2000 The
I)>}Chobiology of unxmlylic drugs. Part 2:
pbnnnacologicalm:mments of anxiety. Phannacol
Thcr H8: 211 227 CGr11rmll'l'virw article 011 r/inicallx
u.~td tm.. iolttic drug!)
Nemeroll C B 2003 The role of GABA m the
pathoph)'iology and treatment of anxiety di\Ordcl'\.
P')Chophamtacol Bull J7: 133 146 (R~iew artide
tli\CII\\inlltlrl' fkllentwl nfariou.~ GABA~nhant:ing
drUf/.1 11.\ Ull.UUI\tio)
Rudolph U. Cre,tano F. \1ohler H 2001 GABAA receptor
'ubtH''" d"...:<tmg the: or pharmacologocal functions.
Trends P harmacol Sci 22: 188 194 (De.vai/Je,, retell/
II'Ork with tr(uogenic mice expres.ing 11111/Uted GABA.
receptors, suggesting that atlxioll'lic and ll'llat/\'1'
(U'tiunr of ben;;odinupine\ may be Ufklrtthle)
Rudolph U. Mohler II 2004 Analy~is of GABAA receptor
function and di;section of the pham1acolo~,ty of
bentodiat.epine' and general anae,thcuc' through
mouse genetic,. Annu Rev Phannacol Toxicol 44.
475-498 (Dewiletl ,..,,.,..,. of l'~temire tlatu rt'latinll. 111
GABA . rt'Ceptor mutatiotu 111 trt1111.qenic- miu)
Sandford J J. Argyropoolo, S V. l':uu 0 J 2000 The
fh}Choboology ofanxoOI)IIC drug,. Pan I. ba.-oc
neurobiology. Phannacol Ther 88: 197-212 (E.rpi<JtOJ
bmit1 mechanisms thought 10 underlie actions of
anxiolytic drugs)
Shader R I. Greenblau D J 1993 Use of ben7odia7ep
in anxiety disorders. New Engl J Med 328: 1398-1
Traber J. GlaserT 1987 5-HT,. receptor-related
anxiol}tics. Trends Pharmacal Sci 8: 432-437
Whiting P 2003 GABA A receptor >ub!ypes on the l'a::
a paradigm for CNS drug discO\ ery Drug Do"""'
Toda) 8: 445-450 ( Uuful summaryof the exttnslrt
data rrlating to GABA rrceptor subtyper m rrlatioll
w bet~::odia::epine and anaesthetic t>lrannu<bi(t(>)

----,-____
544
 Antipsychotic drugs
Overview 545
The nature of schizophre nia 545
-Aetiology and pathogenesis of schizophrenia 546
Antipsychotic drugs 548
-Classification of antipsychotic drugs 548
-General properties of antipsychotic drugs 551
-Mechanism of action 551
-Pharmacological effects of antipsychotic drugs 552
-Phormocokinetic aspects 554
-Cim1col use and clinical efficacy 554
OVERVIEW
In this chapter, we focus on schizophrenia and the
drugs used to treat it. We start by describing the
illness and what is known of its pathogenesis,
including the various neurochemical hypotheses
and their relation to the actions of the main types
of antipsychotic drugs that are in use or in
development.
Psychotic illnesses include various disorders, but
W5
the term antipsychotic drugs-previously known as
neuroleptic drugs, antischizophrenic drugs or major
un
tranquillisers-conventionally refers to those used
to treat schizophrenia, one of the most common
and debilitating forms of mental illness.
" Pharmacologically, they are characterised as
dopamine receptor antagonists, although many
of them also act on other targets, particularly
Hydroxytryptamine (S-HT) receptors, which may
contribute to their clinical efficacy. Existing drugs
have many drawbacks in terms of their efficacy
and side effects. Gradual improvements are being
achieved as new drugs are developed, but radical
new approaches will probably have to wait until
we have a better understanding of the biological
nature of the disease, which is still poorly
understood. 1
THE NATURE OF SCHIZOPHRENIA
Schizophrenia (see Lewis & Licbennan, 2000) affects about 1%
of the population. Tt is one of the most important forms of
psychiatric illness, because it affects young people. is often chronic
and is usually highly disabling. There is a strong hereditary factor
in its aetiology. and evidence '>uggestive of a fundamental
biological disorder (see below). The main clinical feature!> of the
disease are as follow.
Positive symptoms:
--delusions (often paranoid in nature)
- hallucinations, usually in the form of voices which are
often exhortatory in their message
- thought disorder, comprising wild trains of thought,
garbled sentences and irrational conclusions, sometimes
associated with the feeling that thoughts are inserted or
withdrawn by an outside agency
- abnormal behaviour-., \uch a-. \tereotyped movement~ and
occasionally aggres!>ive behaviour!>.
Negative symptoms:
- withdrawal from social contacts
- flattening of emotional responses.
In addition, deficits in cognitive function (e.g. attention, memory)
arc often present, 2 together with anxiety and depression. leading
to suicide in about I0% of Cal>e\. The clinical phenotype varies
greatly. particularly with respect to the balance between negative
and positive sympto~m. and this may have a bearing on the
1
1n this respect. the study of 'chi1ophrcnia lags some years behind that of
Alzheimer's disease (Ch. 35). \\here under~tandiog of the pathogene;b ha~
progressed rapidly to the p01nt ~here promi,ing new drug targets can be
identified. On the other hand. pragmati~l\ can argue that drug> again>!
Al7heimer's disease are \O far ont) margmally effective. w herea; current
anups)chotic drugs deliver great henelil\, even though we do not quite
know how they work.
2Kraepelin. who tim described the condition, used the tcml deme11tw
praecox (premature dementia) 10 de>cribe the cognitive impairment
545
ns~ociated with schi.wphre nia.
 SECTION 4 . THE NERVOUS SYSTEM
efficacy of antipsychotic dmgs in individual cases. Schizophrenia
can present dramatically, usually in young people, with predomi-
namly positive feature!> such as hallucination!., delusions and
uncontrollable beha,iour, or more insidiously in older patient!.
with negative feature!. such as flat mood and social withdrawal.
The latter may be more debilitated than those with a florid
presentation. and the prognosis is generally worse.
'f' A char.l<:tcmtic feature of ~chizophrenia is a defect in ,electi\e
attention Wherea~ a nonnal indi\idual quickly accommodates tO ~timuli
of n t;Jmtlmr or incon\Cquential nature. and respond; only to '>timuli that
are une~p.:ct.:d or Mgnlficant. the ability of schizophrenic patient'> w
di~criminate between significant and insignificant stimuli 'eem' tO be
impaired. Thu-.. the ticking of a clock may command as much anent ion
a.. the wonh of a companion; a chance thought. which a normal per~on
wou ld di\mi~' a~ incon;equential, may become an inesistible imperative.
'Latent inhibition' is a fonn of behavioural te.ting in animals, which can
be u~cd u, a model for this type of ~ensory habituation. If a nll i1. expo'cd
to a 'conditioned \t imu iLL'- (such as a bell). followed by an 'unconditioned'
stimulu~ (e.g. u foot hock) that it can avoid (e.g. by pressing a bar). it will
quicl..l) learn to press the bar a~ ~oon a-. it hears the bell-the conditioned
re\p<I11\C. But if it has previously heard the bell several times without any
en,uing foot ~hock. it wil l learn the conditioned respon;e le% quickly.
having learned to dt,regard the bell. Latent inhibition is a mem;urc of the
inhtbitor} effect of pre-exposure to the conditioned \limu)u., on acqui.,i-
tion of the conditioned respon..e. It is often impaired in schitophrenic
wbJCCh and in animal\ treated "ith amphetaoune or p~ychotomimctic
drug, \uch a' 1)\Crgtc acid diethylamide <LSD). and is re.. torcd by man}
anttp,ychotic drugs.
Schizophrenia can follow a relapsing and remitting course, or be
chronic and progre!>~ive. particularly in cases with a later onset.
Chronic ~chitophrenia used to account for most of the patient!> in
long-stay p<,ychiatric hospitals: following the closure of many of
thcl>e in the UK, it now accounts for many of society's outca\ts.
AETIOLOGY AND PATHOGENESIS OF
SCHIZOPHRENIA
GENETIC AND ENVIRONMENTAL FACTORS
The cause of schizophrenia remains unclear but involves a
combination of genetic and environmental factors (see Lewis &
Lieberman, 2000). The disease shows a strong, but incomplete,
hereditary tendency. ln first-degree relatives, the risk is about
10K, but even in monozygotic twins, one of whom has
schit.ophrenia, the probability of tbe other being affected i\ only
about 50%. pointing towards the likely importance of environ-
mental factor\. Genetic linkage studies have identified a number
of \U~ceptibility genes (see Harrison & Owen. 2003), but it is
clear that no single gene is responsible. There arc significant
as~ociations between polymorphisms in indi,'idual gene~ and the
likelihood of an individual developing schizophrenia, but many
are quite \\eak, and there appears to be no single gene that has an
overriding influence.
'f' The tirM. and mo" robust. association found wa\ with the gene for
111'11/'ef.llllml. a gene involved with ~yn:~ptic development and pl;l',ticity.
"1th effect'> on NMDA receptor expression. Transgenic mice that
undcrexprcs~ neuregulin-1 show a phenotype resembling human
'chitophrcnia in certain respect>. This discovery wa:. followed by the
identification of about eight other susceptibility genes, several of which
were invo lved in one way or another with glutamate-mediated
546
.,...,.t"'f_..,._~,\"'---- tran-.mis.. ion. 1ltcy include the gene for d-amino acid oxida~e (DAAOJ,
the cnl)'me re~ponsible for making o-serioe, an aiJo.,teric modulator
~MDA receptors (see Cb. 33). and G72. an activator of DAAO. -\
the other genes involved some are thought to affect monoamine tmn
'ion. Ap.lll from focusing auention on glutamate (see Moghaddam. ~
and confirming the likely involvement of amine~ 'uch as dopa
genetic '>tudies have not so far pointed to an} specific neunlChe
abnonnaht} underlying the '>Chizophrenic phenot}pe.
Some environmental influences early in development ha'e be.:
identified a\ po!.sible predisposing factors, particularly materr.
virus infection~. This and other evidence suggem tb
::.chitophrenia is associated with a neurodevelopmental di,orda
affecting mainly the cerebral cortex and occurring in the fiN ft
months of prenatal development (see Harrison. 1997). This vie~
is supported by brain-imaging studies showing cortical atroph)
with en largement of the cerebral ventricles. These structuro
changes arc present in schizophrenic patients presenting for th'
first time, and are probably no t progressive, suggesting that the~
represent an early irreversible aberratio n in brain deve loprncn
rather than a gradual ncurodegeneration. Studies of po~t-mone
schit.ophrenic brains show evidence of misplaced cortic
neurons with abnormal morphology. Tt appears to be through
combination of such genetic and developmental factor' \\ :
social and environmental factors that schizophrenia becollk
manife~t in particular individuals. One of the environmen
factors now thought to play a significant role is consumption of
cannabii> (sec Ch. 42).
NEUROCHEMICAL THEORIES
Current ideas about the neurochemical mechanisms in schiLOo
phrenia came mainly from analysing the effects of antip!.ychd~~;
and prop!>ychotic drugs-from pharmacology rmher than from
neurochemistry. Instead of neurochemical theory providing the ba''
for rational drug treatment, the opposite occurred: dmgs found b1
chance to be effective have provided the main clues about t~
nature of the disorder. Indeed, an intensive search tor ncurochcmil".J
abnormalities in schizophrenia proved fmstrating for many yea!\
no biochemical markers being found either in post-mortem bmin
material or in o th er &amples from ljving patients. More reccntl1
(sec below), imaging studies have succeeded in detcctin~
neurochemical abnormalities.
The main neurochemical theories centre on dopamine o~ll(j
glutamate. although other mediators, particularly 5-HT, are al<
receiving attention (!>ee Mortimer. 2004).
Dopamine theory
The dopamine theory was proposed by Carlson-awarded 1
obcl PrUe in 2()()().-{>n the basis of indirect pharmacologJ,
C\ idcnce in humans and experimental animals. Amphetamine
relca\cs dopamine in the brain and can produce in human'
behavioural ~yndrome indistinguishable from an acute schill}
phrenic episode-very familiar to doctors who treat drug u\el"l
In animals. dopamine release causes a specific pattern o
stereotyped behaviour that resembles the repetitive behaviours
sometimes seen in schizophrenic patients. Potent 0 2-reccpto
agonists (e.g. a p omorphine and bromocr iptine; Ch. 341
produce similar effects in animals, and these drugs, like
 ANTIPSYCHOTIC DRUGS

r of ampht!laminc. exacerbate the ~ymptoms of schizophrenic during 'JXmtaneou., remt"ion~--<:lcar evidence linking dopamine release
patient\. Funhcnnore, dopamine antagonist~ and drugs Lhat to the ;.ympwmatology.
block neuronal dopamine storage (e.g. reserpine) are effective An increase in dopamine receptor density in schizophrenia has been
m controlling the po~i tive symptoms of schizophrenia. and in reported in .,orne \tUdJe,. but not consi'lently, and the interpretation i;.
(Xl:\enting amphetamine-induced behavioural changes. There is complicated by the fact that antipsychotic drug treaLment i~ known to
increase dopamine receptor expres,on.
a '1100g correlation bct\vccn clinical antipsychotic potency and
:en actl\it} 111 blod..ing 0~-recepto~ (Fig. 38.1). and receptor- The D.-rcce!J(or ha.., alw attrxted attention on account of the high degree
unaging \ludic'> have shown that clinical efficacy of of geneuc polymorphi'm that it show' in buman subjects, and because
nal some of the newer anup;.)'chotic drugs {e.g. clozapine; see bclo\\) mm
hat anup,)chotic drugs il> consistently achieved when Drreceptor
out to have a high uflinit) for this ret.-eptor 'ubtype. Genetic studies have,
der occupanc) reaches about 80%.-' however. failed to ~how any relationship bc!Ween schit.ophrenia and D.-
CW receptor polymorphi.,m. Moreover. a specific 0 4 -roceptor amagonist proved
T There 1\ M C(m\i\tent biochemical evidence for excessive dopamine
ew ineffective in clinical triab.
'}mhc\1\ or rclca\C in \chitophrenia. Furthermore. the production of
by. prolactin, which might be expected to be abnormally low if dopaminergic Another variant of the dopamine hypothesis {see Abi-Dargham &
tral trJJNllh~ion wa' f:tcilicatcd. b normal in schizophrenic patients. One Larucllc. 2005) ~ugge~t~ thm ~chizophreoia reflects an imbalance
Mli~ulty in interpret ing such Mudies is that nearly all schizophrenic patients betwee n exees~ivc activation of Drreceptors in subcortical regions
Lhc
arc treated with drugs that nre known to affect dopamine metabolism, (causing po~itive symptoms) and deficient activation of cortical 0 1-
~ey
wherca\ the nOIHChit:ophrcnic control group are not Even where it has reccptor~ (causing negati ve symptoms). 11 is fair to say that, although
ent ~n pos.,ible to allow for this facto1, however. most findings have proved dopamine i~ undoubtedly involved, the detail~ remain far from clear.
em ncgallle. The hc;.t evidence for mcrea~ed dopamine release in schizophrenic
cal pauenl\ come;. from imaging ;.tudie.-. (Luruelle et al .. 1999). A radioligand
imagmg tcchmquc was used to meru.ure binding of a specific antagonist Glutamate theory
1 a
1rnclopride) to 0 1-reccptor;. in the ;.triatum. Injection of amphetamine Another transmitter implicated in Lhe pathophysiology of
ilh .au...:d dopamine relea~e and lbu dhplaccment of mclopride. measured as schizophrenia is-you will not be surprised to !cam-glutamate
lCS a red~uon uf the \l)_mal inten\11). Thi;. reduction wa' greater by a factor of
(sec GoIT & Coyle. 200 I; Moghaddam. 2003). NMDA receptor
tal 2 (l( more in ~hitophrenic ;.ubjecl.\ compared with in control subjects.
mpl)mg a greater amphetanune-induced relea;.e of dopamine. The effect an tagonist~ ~uch as phencyclidine, ketarn ine and dizocilpine
of
,.-a., great~'! m '-Chitophrenic indi,idual' during acute auacks, and absent (Ch. 33) produce p~ychotic symptoms (e.g. hallucinations.
thought disorder) in humans. and reduced glutamate concen-
trations and glutamate receptor densities have been reponed in
po~t- mortem schiwphrenic brains-one of the few fairly
~ Jre. ho\\e\er. e.~ception;. to thb 'unple rule. Up to one-third of
consistent findings.
~ehilophreni.:patient'> tail to repond C\CD when D! receptor blockade
:o-
e1'etd' 90'l, and clotapine bee Table 38.1) can be effective at much lower .., Although M:hitophrenia i~ difficult to diagnose in a mouse. transgenic
tic k\th ot hh~<:~ . mice in which NMDA receptor expression is reduced (not aboli;hed,
>m
sis
by
he! 7
1 0- .--------.----------,-----------c-----------~--------~
~al
rs. 4 Promazine
tin Trazodone Chlorpromazine
Jy Clozapine
ng Thioridazine
10-a Mollndone
Prochlorperazine
nd s
0
Moperone
.. Tnfluperaztne
0
Th1othixene
2"'
Haloperidol
10-9 Droperidol
a Fluphenazne
Ptmozide
:al Fig. 38.1 Correlation between -- Trifluperidol
ne the clinical potency and affinity
for dopamine 0 2 receptors among Benperidol
a
antipsychotic drugs. Clinical
o- potency is expressed as the daily 1Q- 10
r.s. dose used in treating schizophrenia, Spiroperidol
of and bmding activity is expressed as /
rs
or
cl-)
the concentration needed to
produce 50% inhibition of
haloperidol binding. (From Seeman
Petal. 1976 Nature 361: 717.)
0.1 10 100
Average clinical dose (mg/day)
1000 J
te
-------- 547
 SECTION 4 . THE NERVOUS SYSTEM
becau~e this i~ fatal) show stereotypic behaviours and reduced ~ocial
interaction that are suggesthe of schizophrenia and that respond to
antip\ychotic drug~-cvidence that supports the glutamate hypothe~i,.
According to thi~ \ ie\\, glutamate and dopamine exen excitatory and
inhtbnory effecl\. respectively. on GABAergic striatal neuron\. "'hich
proJect to the thalamus and constitute a sensory gate' (see below). Too
little glutamate. or too much dopamine, disables the gate, allowing
uninhtbned sensory input to reach the corteJt. It is also suggested that
abnormal glutamate function- specificall) reduced NMDA-receptor
activauon-could account for the cognitive deficit that is increa,ingly
recogntsed a\ a central feature of schizophrenia. responsible in pan for
the negative S} mptom' of the disorder. One possibilit) is therefore that
exces\ dopamme receptor activation is mainly responsible for positive
symptoms. deficient NMDA-receptor activation for the negat ive
symptoms. Although undoubtedly roo simple, this idea is dri ving current
efforts to develop novel anlipsychotic drugs that increase NMDA-rcccptor
activati on.
Other theories
Other transmi tters that may be important include 5-HT and
noradrenaline (norepinephrine). The idea that 5-HT dysfunction
could be invol ved in schizophrenia was based on the fact that
LSD (see Ch. 42) produces schizophrenia-like symptoms, and
has drifted in and out of favour many times (see Busatto &
Kerwin, 1997).
M any effective antipsychotic drugs, in addition to blocking
dopamine receptors (see below), also act as 5-H T-receptor
antagonists. 5-HT modul ates dopamine pathways, so the two
theories are not incompatible. M any 'atypical' antipsychotic
drugs (see below) produce fewer extrapyramidal side effects than
dopamine-selective compounds, and combi ne wi th 5-IIT 2A-
receptors. Whether 5-HT2A-rcceptor blockade accounts directly for
their antipsychotic effect<>. or merel y reduces undesirable side
effect~ associated with 0 2-receptor antagonists. remains
controverl> ial.
In conclusion. the dopamine hyperactivity theory of schit.o-
phrenia remains attractive. It is undoubtedly an oversimpli-
fication, and relates only to the positive symptoms, but it provides
the best framework for understanding the action of antipsychotic
drugs, although effects on 5-HT and other receptors may
contribute significantly to the clinical profile of !.Orne of the
newer drugl:>. The glutamate hypothesi s is. however, gaining
ground, and there are reasonable hopes that it will lead to the next
generation of antipsychotic drugs (see Javitt, 2004).
ANTIPSYCHOTIC DRUGS
CLASSIFICATION OF ANTIPSYCHOTIC
DRUGS
M ore than 20 different antipsychotic drug!. are available for
clinical use, but with certain exceptions the differences between
them are minor.
A distinction i<> drawn between the drugs that were originally
developed (e.g. chlorpromazine, haloperidol and many similar
compounds), often referred to as first-generation or typical
antipsychotic drugs, and more recently developed agents (e.g.
clozapinc, risperidone), which are termed atypical antipsychotic
548 drugs. The term atypical is widely used but not clearly defined,
The nature of schizophrenia
Psychotic illness characterised by delusions,
hallucinations and thought disorder (positive
symptoms), together with social withdrawal, flattening
of emotional responses, and cognitive impa~nnent
(negative symptoms).
Acute episodes (mainly positive symptoms) frequently
recur and may develop into chronic schizophrenia,
with predominantly negative symptoms.
Incidence is about 1% of population, with a
significant hereditary component. Genetic linkage
studies suggest involvement of various genes
associated with dopaminergic and glutamatergic
transmission, but no single 'schizophrenia gene'.
Pharmacological evidence is generally consistent with
dopamine overactivity/glutamate underactivity
hypothesis, supported by biochemical fi ndings and
imaging studies, and there is also evidence for
involvement of 5-hydroxytryptamine.
and experts argue endlessly about what it actually means
Remington. 2003). M ost often. it refers to the di
tendency of the newer compounds to cause unwanted motor
effects (see below). but it is also used to describe "n''""'"'Mi
wi th a different pharmacological profile from fi
compound!.: several of these newer compounds improve!
negati ve as well as the positive symptoms. In practice,
it often serves-not very usefully- to distinguish the large
of similar first-generation dopamine antagoni!.tS from the
diverse group of newer compounds described below.
Table 38. 1 summari ses the m ain drugs that are in clinical
Classification of antipsychotic drugs
Main categories are:
first-generation ('typical') antipsychotics (e.g.
chlorpromazine, haloperidol, fluphenazine,
flupentixol, clopentixol)
second-generation ('atypical') antipsychotics
(e.g. clozapine, risperi done, s ertindole,
quetiapine, amisulpride, aripiprazole, zot epine'
Distinction between typical and atypical groups is not
clearly defined but rests on:
receptor profile
incidence of extrapyramidal side effects (less in
atypical group)
efficacy (specifically of clozapine) in 'treatment-
resistant' group of patients
efficacy against negative symptoms.
 ~ ~.a~~g~ft[~

Table 38.1 Characte..-istics of antipsychotic drugs

Drug Receptor affinity Main side effects Notes

01 Dz cx adr HI mACh 5 HT2 EPS Sed Hypo Other

First generation
Chlorpromazine ++ +++ +++ ++ ++ ++ ++ ++ ++ Increased prolactin (gynaecomastia) Phenothiazine class
Hypothermia Fluphenazine, trifluperazine are similar but:
Anticholinergic effects do not cause jaundice
Hypersensitivity reactions cause less hypotension
Obstructive jaundice cause more EPS
Fluphenazine available as depot preparation

Thioridazine + ++ +++ + ++ ++ + ++ ++ As chlorpromazine but does not Phenothiazine class

cause jaundice First drug with lower EPS tendency
Withdrawn because of cardiac side effects

Haloperidol + +++ ++ - + +++ - ++ As chlorpromazine but does not Butyrophenone c lass

cause jaundice Widely used antipsychotic drug
Fewer anticholinergic side effects Strong EPS tendency

Flupentixol ++ +++ ++ ++ - +++ ++ + + Increased prolactin (gynaecomastia) Clopentixol is similar

Restlessness Available as depot preparations

Second generation
(atypical)
Sulpiride - +++ - - - - + + - Increased prolactin (gynaecomastia) Benzamide class
Selective D/ 0 3 antagonist
Less EPS than haloperidol
Poorly absorbed
Amisulpride and pimozide (long acting) are
similar

Clozapine ++ ++ ++ ++ ++ +++ - ++ + Risk of agranulocytosis (-1 %): Oibenzodiazepine class )>

regular blood counts required Potent antagonist at 0 4 -receptors z
-l
Seizures No EPS
Sedation Shows efficacy in 'treatment-resistant' patients -c
(/)
Salivation Effective against negative and positive symptoms -<
()
Anticholinergic side effects Olanzapine is similar, without risk of
I
Weight gain agranulocytosis, but questionable efficacy in I
0
treatment-resistant patients I -l
()
0
;:110
c
G)
(/)

Ul -
.1:11
-o w
co
"
.~
,.

Ul
Ul
0

"'g
m

0
z


-i
I
m
Table 38.1 (cont'd) Characteristics of antipsychotic drugs
z
m
:;>0
Drug Receptor affinity Main side effects Notes <
D, D2 a adr H, mACh 5-HT2 EPS Sed Hypo Other 0
c(/)
Risperidone - ++ ++ ++ ++ +++ + ++ + Weight gain Significant risk of EPS (/)

EPS at high doses ?Effective against negative symptoms -<

(/)
Hypotension Potent on 0 4 receptors -i
m
~
Sertindole - ++ ++ - - +++ + + ++ Ventricular arrhythmias (ECG Long plasma half-life (-3 days)
checks advisable) ?Effective against negative symptoms
Weight gain
Nasal congestion

Quetiapine - + +++ - + + + ++ ++ Tachycardia Novel type acting mainly on a adrenoceptors

Agitation Not yet fully evaluated
Dry mouth
Weight gain

Aripiprazole - +++ + + - ++ - + - - Recently approved drug

(PA) Long acting (plasma half-life - 3 days)
Unusual 0 2 PA profile may account for paucity
of side effects
No effect on prolactin secretion
No weight gain

Zotepine ++ ++ + + + + - + - Weight gain

Hypotension
Cardiac dysrhythmias

5-HT2 , 5-hydroxytryptamine type 2 receptor; adr, adrenoceptor; 0 1, 0 2 , 0 3 , 0 4 , dopamine types 1, 2, 3 and 4 receptor, respectively; ECG, electrocardiograph; EPS, extrapyramidal side
effects; H 1, histamine type 1 receptor; Hypo, hypotension; mACh, muscarinic acetylcholine receptor; PA, partial agonist; Sed, sedation.

-;-t;.~"'-;;:;-"'Q ::I !T ::::I ;:;- ;:T f"":!ll n;;np "Q r;;; llllll ;;:> ':' c:Tnnr-:-. V> ...l """F,....,- ,I"" .- :- r"''l ..., M ,...,, - ..,., r.
 ANTIPSYCHOTIC DRUGS

unwanted motor effects, acts on both !>Cts of dopamine neurons.

GENERAL PROPERTIES OF ANTIPSYCHOTIC
DRUGS
The therapeutic activity of the prototype drug, chlorprom azi ne.
m -.chizophrenic patients was discovered through the acute
ob"f\ation!> of a French surgeon. Laborit. in I 947. He tested
lanOU\ substance~. including promethazine, for their ability to
Jile\Jate ~igns of ~tress in patients undergoing surgery, and
nmcluded thai promethazine had a calming effect that was
different from mere sedation. Elaboration of the phenothiazine
'tructure led to chlorpromazine. the antip~ychotic effect of which
II.L, demonstrated. at Laborit's instigation, by Delay and Dcniker
m 1953. This drug was unique in controlling the symptoms of
~)chotic patients without excessively sedating them. The
dinical efficacy of phenothiazine~ was discovered long before
their mechani~m was guessed at ( let alone understood).
Pharmacological investigation showed that phenothiazines block
I11Jil) different mediators. including hi.ltamine, catecholamines.
erylclwline and 5-HT. and this multiplicity of actions led to
the trade name Largactil for chlorproma7ine. lt is now clear
see Fig. 38.1) that antagonism of dopamine is the main
determinant of antipsychotic action.
MECHANISM OF ACTION
whereas clozapine and other drugs (see Table 38. I) that have
much less tendency to cause adverse motor effects affect mainly
the ventral tegmental neurons.
Antipsychotic drugs, like many neuroactive compounds, take
several weeks to take effect even though their receptor-blocking
action is immediate. 4 When antipsychotic drugs are administered
chronically, the increase in activity of dopaminergic neurons is
transient and gives way after about 3 weeks to inhibition (Fig. 38.2),
at which time both the biochemical and electrophysiological
markers of activity decline.
Another delayed effect of chronic administration of antipsy-
chotic drugs is proliferation of dopamine receptors, detectable
as an increase in haloperidol binding (see Seeman. 1987), with
a pharmacological supersensitivity to dopamine reminiscent of
the phenomenon of denervation supcrsensitivity (Ch. 9). The
mechanism(s) of these delayed effects and their relationships to
the clinical respon~e are poorly understood.
Antipsychotic drugs show varying patterns of selectivity in
their receptor-blocking effects (Table 38.1 ), some having high
affinity for S-IIT2 and/or Orreceptor~ . The connection between
their receptor specificity and their functional and therapeutic
effects, despite a wealth of fine argument, remains hidden. Were
it understood, we might not have to resort to words like 'atypical'
to hide our uncenainty.

DOPAMINE RECEPTORS AND DOPAMINERGIC

NEURONS
The classification of dopamine receptors in the central nervous
')'tcm is discussed in Chapter 34 (see Table 34.1 ). There arc
hve 'ubtypes, which fall into two functional classes: the 0 1 type,
comprising D and 0 5 and the 0 2 type. comprising 0 2 Dl and
ec
~

140
0
D. Antipsychotic drugs owe their therapeutic effects mainly to u
~ 120
~
blockade of D2-receptors. As stated abo\-e, antipsychotic elfecL'i "0
rtqutre about 80% block of 0 2-receptors. In experimental animals, ~
2 100
anlagonism at 0 2-receptors is reflected in inhibition of c
::l
0 80 Nigrostriatal neurons
amphetamine-induced stereotypic behaviour, and of 0
c
(])
apomorphine-induced turning behaviour, in animals with !!! 60
nilateral striatal lesions (see Ch. 34). These in vivo effects are Q)
0
paralleled. in vitro. by inhibition of binding of a radioactive D2 -~ 40
anl3gonist (e.g. s piroperidol) to brain membrane fragments. The 0
a!
0 20
fiN-generation compounds show some preference for 0 2 over Mesolimbic neurons
(0
01-receptors, whereas some of the newer agents (e.g. s ulpirid c, .D 0
E c 0 2 3 4 5 6 7 8
amisulpride, remoxipride) are highly selective for 0 2-rcccptors. ::l
z
Clozapine is relatively non-selective between 0 1- and 0 2-, but Weeks of haloperidol treatment
b~ h1gh affinity for D4 Fig. 38.2 Effect of chronic haloperidol treatment on the
In animal tes~. all antipsychotic drugs initially increase and activity of dopaminergic neurons in the rat brain. In both
later decrease the electrical activity of midbrain dopaminergic regions, the activity of dopaminergic neurons, recorded with
microelectrodes from anaesthetised animals, initially increases
1~urons in the substantia nigra and ventral tegmentum, and also
and then declines, reaching a steady level after 3 weeks. (From
the release of dopamine in regions contain ing dopamincrgic White F J, Wang A Y 1983 Life Sci 32: 983.)
nerve terminals (see 0' Donnell & Grace, l 996). These changes arc
pu'sibly associated with changes in dopamine receptor expression
see later). Effects on the mesolimbic/mesoconical dopamine
(llth\\ays are believed to correlate with antipsychotic effects,
11hereas effects on the nigrostriatal pathways are responsible for
!he unwanted motor effects produced by antipsychotic drugs 4-fheir sedating effect i~ also immediate, allowing them to be used in acute
(\l!c below). Thus ha loperidol, a first-generation dmg with marked behavioural emergencies. 551
 SECTION 4 . THE NERVOUS SYSTEM
Mechanism of action of
antipsychotic drugs
All antipsychotic drugs are antagonists at dopamine
0 2 -receptors, but most also block other monoamine
receptors, especially 5-HT2 . Clozapine also blocks
0 4-receptors.
Antipsychotic potency generally runs parallel to
activity on 0 2-receptors, but other activities may
determine side effect profile.
Imaging studies suggest that therapeutic effect
requires about 80% occupancy of 0 2 -receptors.
Antipsychotics take days or weeks to work, suggesting
that secondary effects (e.g. increase in number of
D2-receptors in limbic structure) may be more
important than direct effect of 0 2-receptor block.
PHARMACOLOGICAL EFFECTS OF
ANTIPSYCHOTIC DRUGS
BEHAVIOURAL EFFECTS
Antip ychotic drugs produce many behavioural effects in
experimental animals (see Ogren, 1996), but no single test
distingui hes them clearly from other types of psychotropic dnrg.
Antipsychotic drugs reduce spontaneous motor activity and in
larger doses cause catalepsy. a state in which the animal remains
immobile even when placed in an unnatural position. Inhibition
of the hyperactivity induced by amphetamine parallels antipsy-
chotic actions of these drugs, whereas their tendency to induce
catalepsy parallels extrapyramidal symptoms (see below). Antipsy-
chotic effects probably reflect 0 2-receptor antagonism in the
mesocorticaVmesolimbic pathway, while extrapyramidal actions
relate to dopamine inhibition in the striatonigral pathways.
T Olher te~l~ reveal effecl~ distinct from motor inhibition. For example, in
a conditioned avoidance model, a rat may be trained to respond to a
conditioned stimulus, ~uch a~ a buzzer, by remaining immobile and
thereby avoiding a painful shock; chlorpromazine impairs perfonnance
in thi~ tc>t, a~ well as in tests lhat demand active motor responses. In
dO'-C\ too <,mall to reduce spontaneous motor activity. chlorproma7ine
reduces <oocial interactions (grooming, mating. fighting, etc.) and al~o
impair. pcrfonnancc in discriminant tests (e.g. requiring lhe animal to
respond differently to red and green lights).
All first-generation antipsychotic drugs inhibit amphetamine-induced
behavioural change~. reflecting their action on Drreceptors. Some
atypical drug~ have less activity on 0 2-receptors and are Jess active in
~uch model~. and also 10 lhe catalepsy model. They are, however, as
efficacious a.~ the older drugs in conditioned avoidance tests. Both classic
and atypical drug~. moreover, reduce lhe hyperactivity caused b}
phencyclidine (a glutamate antagonist: Cb. 33). which cause~
a schizophrenia-like syndrome in humans. Conditioned avoidance and
phencyclidine tests in animals are therefore used as guides to
antip~ychotic activity in humans.
In humans, antipsychotic drugs produce a state of apathy and
reduced initiative. The recipie nt displays few emotions, is slow to
552 respond to external stimuli and tends to drowse off. The subject
-Vf,-.. ....- - - -
is, however, easily aroused and can respond to questions accurate!)
with no marked loss of intellectual function. Aggressive tendencre
are strongly inhibited. Effects differ from those of hypnotic and
anxiolytic drugs, which also cause drowsiness and confusion bu:
with euphoria rather than apathy.
Many antipsychotic drugs are antiemetic (see Ch. 24}, reflecull'.
antagonism at dopamine, muscarinic, histamine and possib
5-HT receptors.
UNWANTED EFFECTS
Extrapyramidal motor disturbances and
tardive dyskinesia
Antipsychotic drugs produce two main kinds of motor
disturbance in humans: acute dystonias and Jardive dyskinesia1.
collectively termed extrapyramidal side effects. These all rcsuh
directly or indirectly from 0 2-receptor blockade. Extrapyramid~
side effects constitute one of the main disadvantages of fir~l
generatio n antipsychotic drugs. The term atypical was originall1
applied to some of the newer compounds that show much le1
tendency to produce extrapyramidal side effects.
Acute dystonias are involuntary movements (restlessness, mu-..;lf
spasms, protruding tongue, fixed upward gaze, torticollis, t.
involuntary spasm of neck muscles resulting in ruming oft:
head, etc.), often accompanied by symptoms of Parkin<;()!
disea c (Ch. 35). They occur commonly in the first few weeks,
often declining with time, and are reversible on stopping dru.
treatment. The timing is consistent with block of the doparninerp:
nigrostriatal pathway, and the relative selectivity of atypict!
antipsychotic drugs for the mesolimbic/mesocortical path\\~
could account for the diminished risk of acute dystonias 111
these drugs. Concomitant block of muscarinic acctylcholir.
receptors may also mitigate the motor effects of dopamu~:
receptor antagonists, because these two receptor systems oppo
one another (Ch. 35).
Tardive dyskinesia (sec Klawans et al., 1988) develops after
months or years (hence 'tardive') in 20-40% of patients rrealt\1
with first-generation antipsychotic drugs, and is one of lhc mar
problems of antipsychotic d1erapy.lts seriousness lies in the factlhll
it is a disabling and often irreversible condition, which often gdl
worse when antipsychotic therapy is stopped and is resistant
treatment. The syndrome consists of involunta.ry
often of the face and tongue, but also of the trunk and
which can be severely disabling. lt resembles that seen
prolonged treatment of Parkinson's disease with le"odopa.
incidence depends greatly on drug, dose and age (be
commonest in patients over 50).
T There are several lheorie~ about the mechanism of tardi\'e d)'
(~ Ca!>ey, 1995). One is lhat it is associated wilh a gradual tncrea:
the number of Dz-receptors in the striatum. which is less marked ci:!
treatment wilh the atypical lhan wilh the first generation of anU(h).:il:li:.
drugs. Another possibility is that chronic block of inhibitory w--
receptor~ enhances catecholamine and/or glutamate release 10
srriawm, leading to excitotoxic neurodegeneration (Ch. 35). The rea.
why atypical antipsychotic drugs (e.g. clozapine, olanzapine, sertindolr
are better in lhi regard is not clear. One possible explanation (see
& Seeman, 2001) lies in differences in lhe rate at which cornpotitr.l!l
dissociate from Drrcccptors. With a rapidly dissociating compound,
 ANTIPSYCHOTIC DRUGS

s
Antipsychotic-Induced
110tor disturbances
d c: 400
.Q
MaJOr problem of antipsychotic drug treatment. ~
c 320
g Two main types of disturbance occur: ~
c:
y - acute, reversible dystonias and Parkinson- like o~
240
symptoms
~E
:=0
0 c:
- slowly developing tardive dyskinesia, often <a~ 160
irreversrble.
e
0.
E 80
Acute symptoms comprise involuntary movements, 2Q)
tremor and rigidity, and are probably the direct (f)
0
consequence of block of nigrostriatal dopamine
receptors. Injection of fluphenazine
lr decanoate (225mg)
Tardive dyskinesia comprises mainly involunt ary
s.
ll
aJ
movements of face and limbs, appearing after
months or years of antipsychotic treatment. It may be
2000
l
l- associated with proliferation of dopamine receptors
(possibly presynaptic) in corpus striatum. Treatment is 0
y
generally unsuccessful. 0 30 60 90 120 150 180
Incidence of acute dystonias and tardive dyskinesia is Days
less wrth atypical anti psychotics, and particularly low Fig. 38.3 Effects of antipsychotic drugs on prolactin
e
wrth clozapine, aripiprazole and zotepine. This may secretion in a schizophrenic patient . When daily dosage with
e.
reflect relatively strong muscarinic receptor block with chlorpromazine was replaced with a depot injection of
e fluphenazine, the plasma prolactin initally dropped, because of
these drugs, or a degree of selectivity for the
s the delay in absorption, and then returned to a high level.
mesolrmbic, as opposed to the nigrostriatal,
s. (From Meltzer H Yet al. 1978 In: Upton et al. (eds)
dopamrne pathways. Psychopharmacology. A generation in progress. Raven Press,
g
c New York.)
il
bnel -.urge of dopamine can effectively O\ercome the block by
compeution (Ch. 2), wherea.\ with a ~lowly dissociating compound the
le\d of block tllke' a long Lime to rc~pond to the presence of endogenous
e d<1pa111inc. and i'> in practice non-compeLiLive. Adverse motor e!Iects may
1e be avoided if fractiona l receptor occupation falls during physiological Other unwanted eHects
.e 'urge' ol dopamine- an attractive kinetic explanation that remains to be Sedation, which tends to decrease with continued use, occurs
cuntim1ed. Cloznpinc ha.\ relatively high afnnity for D 1 and 0 4compared with many antipsychotic drugs. Antihistamine (H 1) activity is
11illh 0 1 receptors, and also has marked antimuscarinic activity.
a property of phenothiazines and contributes to their sedative and
Appreciable affinity for muscarinic receptors is shared by some other
td antip'>)'Chotic drugs, such as thiori dazlne.5 This pharmacological property
antiemetic properties (Ch. 25), but not to their antipsychotic
n C<1Uid counteract its adverse motor effecb (cf. the use of benztropine action.
at tn reduce ex trapyramidal effects of antipsychotic drugs). Phenothiazines and, to a variable extent, other antipsychotic
ts drugs, block a variety of receptors, particularly acetylcholine
,o Endocrine eHects (muscarinic), histamine (H 1), noradrenaline (a) and 5-HT

"s. Dopamine. released in the median eminence by neurons of the

tuheroh)pophyseal pathway (see Chs 27 and 33), acts physio-
(Table 38.1 ).
Blocking muscarinic receptors produces a variety of peripheral
logical!) to inhibit prolactin secretion via D 2-receptors. Blocking effects, including blurring of vision and increased intraocular
te D.-receptor.. by antipsychotic drugs can therefore increase the pressure, dry mouth and eyes, constipation and urinary retention
g pla,ma prolactin concentration (Fig. 38.3). resulting in breast (see Ch. 10). It may, however, also be beneficial in relation
S'o\tlling. pa10 and lactation, which can occur in men as well as to extrapyramidal side effects. Acetylcholine opposes dopamine
m \\Omen. As can be seen from Figure 38.3. the effect is in the basal ganglia (see Ch. 35), and it is possible that the
Ia '11310tatned during chronic antipsychotic administration, without relative lack of extrapyramidal side effects with clozapine
in
an} habituation. Ot.her less pronounced endocrine changes have and t hioridazine is due to !.heir high antimuscarinic potency
ag
lC
aho been reponed. including a decrease of growth honnone (see above).
lC secretion, but these. unlike the prolactin response, are believed Blocking a-adrenoceptors causes orthostatic hypotension
)e to be unimportant clinically. (see Ch. 19) but does not seem to be important for their
>n antipsychotic action.
eJ
Weight gain is a common and troublesome side effect, particu-
ur
;b 'NO\Io 11illhdrawn. bccaU',e of a tendency to cause ventricular dysrbythmias larly associated with some of the atypical drugs, and probably
a by bloc~ing curdiac potas;ium channels (sec Cb. 18). related to 5-IIT antagonism. 553
 SECTION 4 . THE NERVOUS SYSTEM
Unwented effects of entlpsychotJc drugs
Important side effects common to most drugs
are extrapyramidal motor disturbances (see
Antipsychotic-induced motor disturbances box) and
endocrine disturbances (increased prolactin release);
these are secondary to dopamine receptor block.
Sedation, hypotension and weight gain are also
common.
Obstructive Jaundice sometimes occurs with
phenothiazines.
Other side effects (dry mouth, blurred vision,
hypotension, etc.) are due to block of other receptors,
particularly a-adrenoceptors and muscarinic
acetylcholine receptors.
Some antipsychotic drugs cause agranulocytosis as a
rare and serious idiosyncratic reaction. With
clozapine, leucopenia is common and requires routine
monitoring.
Antipsychotic malignant syndrome is a rare but
potentially dangerous idiosyncratic reaction.
Various idio!>yncratic and hypersensitivity reactions can occur,
the most important being the following.
Jaundice, which occur:. with older phenothiazines such a~
chlorpromazine. The jaundice is usually mild. associated
with elevated serum alkaline phosphatase activity (an
'obstructive' pattern), and disappears quickly when the drug is
stopped or substituted by a chemically unrelated antipsychmic.
Leucopenia and agranulocytosis arc rare but potentially fata l,
and occur in the first few weeks of treatment. The incidence
of leucopenia (usually reversible) is Jess than 1 in 10 000 for
most antipsyc hotic drugs, but much higher ( 1-2%) with
clozapinc, whose usc therefore requires regular monitoring of
blood cell counts. Provided the drug is stopped at the first
sign of leucopenia or anaemia, the effect is revers ible.
Ola nzapine appears to be free of this disadvantage.
Urticarial skin reactions are common but usually mild.
Exce!>sive \ensitivity to ultraviolet light may also occur.
Antipsychotic malignant syndrome is a rare but serious
complication similar to the malignant hyperthermia
syndrome seen with certain anaesthetics (see Ch. 36). Muscle
rigidity i!> accompanied by a rapid rise in body temperature
and memal confusion. It is usually reversible. but death from
renal or cardiovascular failure occurs in 10-20% of cases.
PHARMACOKINETIC ASPE~TS
Chlorprom azi ne. in common with many other phenothiazine~.
is erratically absorbed after oral administration. Figure 38.4
shows the wide range of variation of the peak plasma concen-
tratio n as a function of dosage in 14 patients. Among four
patients treated at the hig h dosage level of 6--8 mg/kg, the
554
..,,-...---- variation in peak plas ma concentration was nearly 90-fold; two
1000 -
~
.s
c
800 ; ~ effects
Q
~
c 600
c~
8 400 .
nl
E
Vl
nl
0. 200
....
.:.!
nl No response
If /
0 I
5 10
Dose (mg/kg twice daily)
Fig . 38.4 Individual variation in the relation between
dose and plasma concent ration of chlorpro mazine in a
group of schizophrenic patients. (Data from Curry S H et al.
1970 Arch Gen Psychiatry 22: 289.)
showed marked ~ide effects, one wac; well controlled and 011(
showed no clinical response.
The relationship between the plasma concentration and the
clinical effect of antipsychotic drugs is highly variable, and the
do!>age ha~ to be adjusted on a trial-and-error basis. This is ~
even more difficult by the fact that at least 40% of <>chizophren~e
patient~ fail to take drug& as prescribed. It il> remarkably fonunate
that the acute toxicity of antipsychotic drugs is slight, given the
unpredictability of the clinical response.
The plasma half-life of most antipsychotic drugs is 15-
hours. clearance depending entirely on hepatic transformation ~
a combinatio n of oxidative and conjugative reactions.
Most antipsychotic drugs can be given orally or by intr4
muscular injectio n o nce or twice a day. Slow-release (depoli
preparations of many are available, in which the active drug 11
esterified wi th heptanoic or decanoic acid and dissolved in oil
Given as an intramuscular injection, the dmg acts for 2-4 wceh
but initially may produce acute side effects. These preparation~
arc widely used to minimise compliance problems.
CLINICAL USE AND CLINICAL EFFICACY
The major use of antipsychotic drugs is in the treatment '
schi:ophrenia and acl/fe behmioural emergencies, but the) ..n
abo widely u~ed a~ adjunc t therapy in the treatment of
illnesses, such as psychotic depression and mania. Some rJ
the newer antipsychotic drugs (e.g. sul piride) have been clannt
to have specific antidepressant actions. Phenothiazines Jr..
related dmgs are also useful as antiemetics (see Ch. 25). Mu)(
uses include the treatment of Huntington's chorea (mainly
haloperidol; sec Ch. 35).
The c linical efficacy of antipsychotic drugs in enablin,
schizophre nic patients to lead more normal lives has bee~
demonstrated in many controlled trials. The in-patient populatior
(mninly chro nic schizophrenics) of mental hospitals decline~
sharply in the 1950s and 1960s. The efficacy of the nclll)
 ANTIPSYCHOTIC DRUGS

mtroduccd antipsychotic drugs was a significant enabling factor.
a' well .J.\ the changing public and profe~sional atlitude5 toward\
ho,pitall~ation of the mentally ill.
r\ntip,ychotic drug!>. apart from their \ide effects. have two
main 'honcoming~.
The) are effective in only about 70% of schiLophrenic patients:
for an} ~inglc drug, the succe~s rate is lower. The remaining
3011 are cla~sed as 'treatment-resistant' and present a major
thc:t.tpcutic problem. The rea~on for the difference between
rc:,pon\ive and unresponsive patients is unknown at present.
although there i~ some evidence (not conclusive) that
pol}morpht\m within the family of dopamine and 5-11T
receptors may be involved (sec Basile et al.. 2002).
\\ lc the) comrolthe positive symptoms (thought di-.order,
hallucination\, delu~ions, etc.) effectively, they are ineffective
in reliC\ iog the negative symptoms (emotional nattening,
"-JCial isolation).
The newer atypical ami psychotic drug~> may overcome these !>hort-
comings to some degree, !>howing efficacy in treatment-re!>btant
patients and improving negati ve a!> well as positive symptoms.
However, a recent meta-analysis (Geddes et al.. 2000) suggests
that whiJe these newer drugs reduce the ri~k of adverse motor
effects, they are not significantly better in terms of efficacy or
other \ide effects. The older drugs. Geddes et al. sugge<;t, may have
gained a bad nam e for cau~-.ing troublesome side effects because
of the common practice of overdosing beyond the u\cful
therapeutic range. Following a detailed review of the available
clinical evidence. the ational Institute for Clinical Excellence
(2002) recommend the u!>e of atypical antipsychotic drugs as
first-line treatment for newly diagnosed schilophrcnic patients,
because of the low level of motor side effech that they produce.
although- apart from the use of clozapine for treatment-
resistant schizophrenia- there is no evidence that they are more
effective than first-generation drug~ in controlling ~ymptoms.

Clinical uses of antipsychotic drugs

Behavioural emergencies (e.g. violent patients with a compliance w ith oral treatm ent is a problem.
range of psychopathologies including mania, toxic Flupentixol has antidepressant properties distinct
oeurium, schizophrenia and others): from its antipsychotic action.
classic antipsychotic drugs (e.g. chlorpromazine, Atypical antipsychotic drugs (e.g. amisulpride,
haloperidol) can rapidly control hyperactive olanzapine, risperidone) are used if extrapyramidal
psychotic states symptoms are troublesome, if symptom control is
note that the intramuscular dose is lower than the inadequate, or for newly diagnosed patients.
oral dose of the same drug because of Clozapine can cause agranocytosis but is distinctively
presystemic metabolism. effective against 'negative' features of schizophrenia.
Schizophrenia It is reserved for patients whose condition remains
Many chronic schizophrenic patients are treated inadequately controlled despite previous use of two
with first generation antipsychotic drugs. Depot or more antipsychotic drugs, of which at least one is
Injections (e.g. flupentixol decanoate) may be atypical. Blood count is monitored weekly for the first
useful for maintenance treatment when 18 weeks, and less frequently thereafter.

REFERENCES AND FURTHER READING J

~1\e\h or schi1ophrenia
l!li...uoG ~. Kerwin R W 1997 Pcr,pectivc> on the role
I sentunci')!IC rncchanl\rm in the pharmacolog) of
..~l't11ia_ J P..)chopl\annacol II:~ 12 IAsent<
rl1t r iJcr11 r implicdtlnfl 5-H7 111 ll'f/1 '"' tlopamine in
1hrartum of <mtipnc lwtic drill/f)
Dl' ( <>)le J T 1UOI1be emerging mlc of
' m the pathoph)sioiOj!) and trCatment of
<Chlzophrcn1,1, Am J p,ychiatry 158: 1367 1377
"' d rnifl<' articlt on flllllwph\'liology. although
rr,nn:ng 10 mit illtr(tllmenl iJ ptl'naalllrr)
l!mism P J 1997 Sch11ophrenw: a lli>ordcr of
Jc1elop01~nt. Curr Opin Neurobiol 7: 285 289
..Rmt-KJ f"TSUa"iuJ\ the endcm~ fa\'Ollrmr.:
.,.,I rarl) bmm Jnelopmtm <IS r!rr bam of
~rhophrtnia)
ltirrual PJ. Owen M J 2003 Gene' for sch1topllrema'!
Rt>:tm 6n4Jng' ;md thc1r pathophy,iologi,~l
1mp Jea11<n' Loncct361: 417-419 (Recemlr dentijwd
><lu:ophrt'm<Hn<ocilllcd genes pmm to pas>iblr
im.olvem~lll (}! gluwmatt! tnmsmininn)
Laruclle M. Ab1 Dargham A, Gil Ret al. 1999 l11<0rea.o;ed
dopamme unn,mi,~ion m -.chizophrenia: relatJOn,hip
to illness phu-.cs. Bioi P>)'Chiatry 46: 56-7:! !The first
direct evidel!l'l' for iiU'rt!a\ed tlopamme fim<ti<m as a
Cl/ll.!t of S\IIIJ>Imns i11 <clu:ophrmiul
Lew" 0 A, Licbeman J A 2000 Catchmg up on
.chi1ophrcniu: natural history and neurobiology.
'fcuron 28: 325-334 CU<eful rel'it'l lWntiUITIImg
prt!<mt undullandin!l, rif tile nal111't' of
>clti-:,ophren/11)
Moghaddam B 2003 Brinring order to the glutumate
ch.J(h in l>Chuophrenia. '\curon 40: l\61-864 (Rt'li""l
l!lltle11ce from recent genetic find mg.< . m[lgeMinll the
tlhnormaliti in ~lutanul/e trallJmi\ \itJIJ nun p((l\' tl
1
:.
~ role in nht:ophrenilll
Mortm~er A M 2004 No'cl antipsychoucs m
'thil(lphretuu. Expen Opin lnve"1g Dmgs I3:
315 329 (A mi1lrading 111/e for a Tl'>'irw dealing
mainl.v \l-ith curtt!nl ideas ahmuthe ttturochemku/
abnnntrultti~'i umlt'rlyinR 1chi:.ophrrnw)
Seeman P 1987 Dopamine receptors and the dopamme
hypothesis of schi7.ophreniu. Synap;e 1 133- 152
(Comi11fing 11111111 it/ely qumnl renn> tif role of
tlapmnine Tt'Cepwr.r in schi:ophTt'ma)
Antipsychotic dru g~
AbtDargham A. Larue lie M 2005 Mech3tl"lll> of a~uon
of '>Ccond gencr.111011 3/ltip,ychotic dnllJ.' in
schiLophrenia: 111\igh~ from brain imaging studic>.
Eur p,ychiatl') 20. 15-27 IRrnews Tt't'tlll nitlenu
fawmrin.~ tmhlllllnce bet11un conicdl and ;ubmrttcal
tlopwnine tron.\miulon m 11hhophmria)
Basile V S. Maselli' M. Potkm S G. Kenncd) J L 2002
Phann...:ogenomiC\ m scht10phrenia: the quest for
indiv11lualiLcd therapy. Hum Mol Genet II:
2517 2530 ( Re itw of inrtmclusive tlitlerrc~ for 555
 Antidepressant drugs
Overview 557
The nature of de pression 557
Theories of depression 558
-The monoamine theory 558
-Animal models of depression 560
Antidepressant drugs 560
-Types of antidepressant drug 560
-Measurement of antidepressant activity 561
-Mechanism of action of antidepressant drugs 562
- Tncyclic antidepressant drugs 562
-Selective 5-hydroxytryptamine uptake inhibitors 566
-Monoamine oxidase inhibitors 566
-future antidepressant drugs 568
Electroconvulsive therapy 569
~
Clinical eHectiveness of antidepressant
treatments 569
Mood-stabilising drugs 569
-lith1um 569
OVERVIEW
Depression is an extremely common psychiatric
condition, about which a variety of neurochemical
theories exist, and for which a corresponding
variety of diHerent types of drug are used in
treatment. It is a field in which therapeutic
empiricism has led the way, with mechanistic
understanding tending to lag behind, part of the
difficulty being that animal models cannot address
the mood change that defines the human condition.
In this chapter, we discuss the current
understanding of the nature of the disorder, and
describe the major drugs that are used to treat it.
Agood summary of our present state of
knowledge is given by Wong & Licinio (2001)
THE NATURE OF DEPRESSION
Depression is the most common of the affective disorders
(defined as disorders of mood rather than disturbances of thought
or cognition); it may range from a vcty mild condition, bordering
on normality, tO severe (psychotic) depression accompanied by
hallucinations and delusions. Worldwide, depression is a major
cause of disability and premature death. Jn addition to the
significant ;uicidc ri~k. depre;sed individuals are more likely to
die from other cau-,es, such a~ heart disease or cancer.
The symptom~ of dcpres;ion include emotional and biological
components.
Emotional '>ymptoms:
- misery. apathy and pes'>imism
-low self-esteem: feelings of guilt. inadequacy and ugliness
-indecisivenes\, loss of motivation.
Biological -.ymptoms:
-retardation of thought and action
-los!. of libido
-sleep disturbance and loss of appetite.
There are two distinct types of depressive syndrome, namely
unipolar depression, in which the mood swings are always in
the same direction, and bipolar aj]'ective disorder, in which
depression alternates with mania. Mania is in most respects
exactly the opposite, with excessive exuberance, enthusiasm
and self-confidence. accompanied by impulsive actions, these
signs often being combined with irritability. impatience and
aggression, and <,ometime-; with grandiose delusions of the
Napoleonic kind. As with depression. the mood and actions
are inappropriate to the circum!>tances.
Unipolar depres'>ion i-. commonly (about 75% of cases) non-
familial, clearly a\\Ociated with stressful life events, and
accompanied by symptoms of anxiety and agitation; this type is
sometime., termed reactile depression. Other cases (about 25%,
sometimes termed endogenous depression) show a familial
pattern. unrelated to external stresses. and with a somewhat
different symptomatology. This distinction is made clinically. but
there ill little evidence that antidepre~sant drugs show significant
selectivity between these conditions.
Bipolar deprcs1.ion. which usually appears in early adult life, is
less common and resuiL~ in oscillating depression and mania over
a period of a few week~. There is a strong hereditary tendency,
but no specific susceptibility genes have been identified either by 557
 SECTION 4 . THE NERVOUS SYSTEM

genetic linkage studies of affected families, or by comparison of reasonable ~uppon, there are several examples of drug~ th uri
affected and non-affected individuals. might have been predicted to improve or worsen depre ..,il. in
'>ymptom.... but fail to do so convincingly. It has to be rccogm...: llu
that the ba'b for predicting tbe effects of drugs on mood i,, m
THEORIES OF DEPRESSION be..,t., very !>imple-minded. Thus supplying a transmitter precuM eli
---~~~~~

THE MONOAMINE THEORY
The main biochemical theory of depression is the 11wnoamine
hypothesis, propo!>ed by Schildkraut in 1965, which states that
depre~sion i\ caused by a functional deficit of monoamine
tran\miuers at certain ~ite~ in the brain, while mania results from
a functional exce!>~- For reviews of the evolving status of the
theory. ~ce Baker & Dewhurst ( 1985). Maes & Meltzer ( 1995)
nnd Manj i et nl. (200 I).
The monoamine hypothel>is grew originally our of associations
between the clinical effects of various drugs that cause or
allevime symptoms of depression <md their known neuro-
chemical effect~ on monoaminergic transmission in the brain.
Initially, the hypothesis was formulated in terms of noradrenaline
(norepinephrine), but sub~equent work showed that most of tJ1e
observations were equally consistent with 5-bydroxytryptamine
(5-HT) being the key mediator. This phannacological evidence,
which is ~ummari'>ed below, gives general support to the
monoamine hypothe~i'>. although there are seYeral anomalies.
Auempts to obtain more direct evidence, by studying monoamine
metaboli'>m in depre!>sed patient~ or by measuring changes in the
number of monoamine receptors in post-mortem brain tissue.
have tended to give inconsistent and equivocal results, and the
interpretation of these studies is often problematic. because the
changes described are not specific to depression. Similarly. inve~
tigation by functional test\ of the activity of known monoaminergic
pathways (e.g. those controlling pituitary hormone release) in
depressed patients have abo given equivocal results.
PHARMACOLOGICAL EVIDENCE
Table 39. 1 summarises the main pharmacological evidence
supporting the monoamine hypothesis. Although it provides
Table 39.1 Pharmacological evidence supporting the monoamine hypothesis of depression
Drug(s) Principal action
will not nece ...sarily increase the release of transminer unln ret
availabilit) of the precursor is rate-limiting. Similarly, a drug ths th
release.., monoamine~ from normal nerve terminals may farl
do ..,o if the nerve terminals are functionally defective. The
pharmacological evidence does not enable a clear distincu
to be drawn between the noradrenaline and 5-HT theorie' d.
depression. Clinically. it seems that inhibitors of noradrcnalir.:
rcuptake and of 5-HT reuptake are equally effective a
antidepressant~> (see below), although individual patients ma1
respond beuer to one or the other.
Any theory of depression has to take account of the fact th.
the direct biochemical effects of antidepressant drugs appe;u
very rapidly, whereas their antidepressant effects take weeks ((
develop. A similar ~ituation exists in relation to antipsychotr
drugs (Ch. 38) and some anxiolytic drugs (Ch. 37), sugge\tll.
that the ...econdary, adaptive changes in the brain, rather than tl
primary drug effect, are responsible for the clinical impro\'e!Th:
Rather than thinking of the monoamine deficiency as cau,rng
direct changel> in the activity of putative 'happy' or sad' neuroos
in the brain. we should think of the monoarnines as rcgulatoo
of longer-tem1 trophic effects. whose time course is paralleled
by mood changes (see below. p. 559).
BIOCHEMICAL STUDIES
Many Mudie~ have sought to test the amine hypothesis by lookllJt
for biochemical abnormalities in cerebrospinal fluid, blood or uri~
or in post-mortem brain tissue. from depressed or manic patient'
They have included studies of monoamine metabolites. receptOI'l
ent..ymes and tran!>porters, largely with negative results. The maJCi
metabolites of noradrenaline and 5-HT, respectively. are 3-metho.~)
4-hydroxyphenylglycol (M HPG) and 5-hydroxyindoleacetic acru
(5-IIIAA). These appear in the cerebrospinal lluid, blood an<
Effe<:t in depressed patients

Tricyclic antidepressants Block NA and 5-HT reuptake Mood t

Wr
Monoamrne oxrdase (MAO) inhibitors Increase stores of NA and 5-HT Mood t
Reserprne Inhibits NA and 5-HT storage Mood~

a-Methyltyrosine Inhibits NA synthes1s Mood Hcalming of manic patients)

Methyldopa Inhibits NA synthesis Mood~

Electroconvulsive therapy ?Increases central nervous system Mood t

responses to NA and 5-HT

Tryptophan (5-hydroxytryptophan) Increases 5-HT synthesis Mood ? t in some studies

558
-,~----

ll!llle(>ee Chs 11. 12 and 34). There are two fundmnental problems
rrbung changes in the concentration of these metabolites in body
fluid~ to changes in transmitter function in the brain. One is that
HI many ~ccondary factors can affect their concentration, such as
or et. tran~port between cerebrospinal fluid. blood and urine; or
!tlea,c of monoamines from non-cerebral sites. The second is
at 11W many patients receive drug treatment, which affect~ the
to m~wbolitc concentrations marked ly.
'he Studtes of urinary MHPG excretion in normal and depressed
on .ltlJCCt~ have shown convincingly that the level is reduced in
of ~polar depressive patients, and i~ lower during the depressive
11e d:.m during the manic phase. In unipolar depression, however,
~IHPG excretion. although highly variable between patients. is
R) 001 'iniftcantly lower than in control subject!>. so support for
the :nonoamine theory i~ at best equivocal. Plasma noradrenaline
at actually Lends to be higher in depressed than in normal subjects,
ar po,,ihly because it renects peripheral sympathetic activity. which
to mcrea!lts \\itb the anxiety that often accompanies depression. It
IC n'hows a cyclic variation in bipolar depressive patients.
g Result\ pertaining to altered 5-HT metabolism arc also highly
lC 1mable (~ee Maes & Meltzer, 1995). Studies of 5-HTAA in
,mbro-,pinal fluid and urine have generally failed to find any
-lear correlation with depression. Low levels of 5-HIAA occur
mthl! brain and cerebrospinal fluid of suicide victims but may
!'< a~~iated with violent behaviour rather th<U1 with depression.
\lore con~istent changes have been reported in the plasma
.:oocentmuon of L-tryptophan (the precursor of 5-HT). Although
the resting levels are not significantly different in depressed
panenL\, the rise in plasma L-tryptophan following an intravenous
-oral dose is reduced, implying lower 'L-tryptophan availability'.
Olhl!r evidence in support of the monoamine theory is that
J.ent' k.nown to block noradrenaline or 5-HT synthesis consist-
en~y revcn;e the therapeutic effects of antidepressant drugs that
.w:t ,eJectively on these two tran<,miner systems (sec below).
In \Ummary, there is considerable circumstantial evidence to
'upport the monoamine hypothesis, although there are ~orne
mcon\i\tencies, of which the most obvious are the following.
~either amphetamine nor cocaine has antidepressant actions.
de-pue their ability to enhance monoamine transmission.
Some clinically effective antidepressants seem to lack any
action\ that could enhance monoamine tran~mission.
The biochemical changes associated with depression have. in
'e\erJI ~tudies. been identical with changes observed in
mamc patient!>.
1\nh improved neuroimaging methods for 1.tudying neuro-
:ran,muter function in the living human brain, as described
Chapter 38, some of the gaps and incon~i~tencies may be
~solved.
NEUROENDOCRINE MECHANISMS
\anou:. attempts have been made to test for a functional deficit
ol monoamine pathways in depression. Hypothalamic neurons
cuntrolling pituitary function receive noradrenergic and 5-HT
~h. which control the discharge of these cells. Hypothalamic
celh relca~e corticotrophin-releasing hormone (CRR), which
ANTIDEPRESSANT DRUGS
stimulates pituitary cells to 1.ecrete adrenocorticotrophic hormone
(ACTH). leading in rum to cortisol secretion. The plao;ma cortisol
concentration is usually high in depressed patients. and it fails to
respond with the notmal fall when a synthetic steroid. such ao;
dexamethasone. is given. This formed the basis of a clinical test
the de.rametha:.om! suppression rest (also u!>ed in the diagnosis of
Cu~hings syndrome; see Ch. 28). Other hormones in plasma are
also aiTccted, for example growth hormone concentration i~ reduced
and prolactin is increa~ed. In general, these changes are consistent
with deficient monoamine tran\mission, but they are not specific to
depressive syndromes.
Cotticotrophin-rcleasing hormone is widely distributed in the
brain and bas behavioural effects that arc distinct from its
endocrine function~. Injected into the brain of experimental
animals, CRH mimics some eiTects of depression in humans,
such as diminished activity, loss of appetite, and increased signs
of anxiety. Furthermore. CRH concentrations in the brain and
cerebrospinal nuid of depre~sed patients arc increased. Therefore
CR II hyperfunction, as well as monoamine hypofunction, may
be associated with depression (see Holsbocr, 1999).
NEUROPLASTICITY AND TROPHIC EFFECTS
'Y Recently (!.ee reviews by Duman, 2004; Charney & Manji, 2004) a
new idea ha~ emerged. namely that major dcpre!>~ion is as\ocioted with
11etmmal los; i11 rite hippocampus ami prtfmmal corte.\. ;md that
anttdcpres:.am thempi~ of dift"erem kin<b act b) inhibinng or actually
reversing thi!. lo,., by stimulating neurogene,i'>. lllis surprbmg idea is
'upported by various lines of evidence.
Imaging and po'>t-mortem Mudie' sbow shrinl-..age of the hippocampus
and prefrontal cortex of depre~sed patien~. \\ ith 1~ of neurons and
glia. Functional imaging re\eal~ reduced neuronal activuy in these
regions.
In animals, the arne effect is produced by chronic stre~~ of various
kincb. or b) administration of glucoconicoid\. mimicking the increased
cortisol \ecretion in human depression. h'cesshe glucocorticoid
'>ecretion in humans (Cu~hing\ ;yndrome; ,ee Ch. 28) often causes
depression.
Antidepressant drugs, or other treatment' '>Uch as electroconvulsions
(see below). promote neurogenesis in these regions. and (a'> m humans)
restore funcuonal acti' ity. Preventing htppocampal neurogcnesi\
prevents the bchaviour.U eflcct~ of antidepre\!.anL~ in rat~ (SantareJJi
ct al., 2003).
5-HT. whose action is enhanced by many amidepressanh (see below).
promotes ncurogenesis during dc\elopment. thi\ effect being mediated
by bmin-deri,cd neurotrophiC factor (801'\F). Antidepre,,ants also
tncrea.~e BDNF production.
'Y Figure 39.1 ~ummarises the possible mechanisms involved. TJ
~hould be stre~..cd that theM: h)pothescs are far from pro,cn. bot the
diagram emphasises the \\ay in which the licld ha.~ moved on \ince
1
Ncurogenesis (~ee Ch. 35)-the formation of ne\\ neurons from \tem ceJJ
precui""\Or.-occur. to n significam degree in the adult hippocampu'>. and
po~'ibly elsewhere in the brain. contradicting the old dogma that it occurs
only during brain development. 559
 SECTION 4 . THE NERVOUS SYSTEM
the fonnulat ion of the monoamine hypothesis. suggesti ng a range of
pos~iblc target\ for the next generation of antidepressant drugs. 2
For now, although it clear ly needs to be modified and elaborated,
Schildkraut\ basic hypothesis remains the best basis for under-
~tand ing the action\ of current antidepressant drugs.
ANIMAL MODELS OF DEPRESSION
T Progre" in unravelling the neurochemical mechanisms is. a.s in so
man} area.\ of p~ychophannacology, limited by the lack of good animal
models of the clinical condition. Tilere is no known animal condition
corresponding to the inherited condition of depression in human\, but
variou~ procedu re~ have hcen descri bed that produce in animals
behavioural \late' (withdrawal from social inreraction, loss of appetite,
reduced motor activity, etc.) typical of human depression (sec review by
Porsoh. 1985). For example, the delivery of repeated inescapable pai nful
stimuli lend~ to a Slate of ' learned hel plessness'. in which even when the
animal is free to escape it fails to do so. Mother- infant separation in
monkeys, and adminiwation of amine-depleting drugs such as reserpine,
also produce '> tales thtll superficittlly resem ble human depression. As well
a\ being inherentl y distastefu l, these experiments often req uire elaborate
and expen\ive experimental protocols. and the similarity of
these \tate\ to human depre\\ion is questionable. However. the learned
he lple;,\nC\\ \late and the effect of mother-infant separation can be
reve~d by tricyclic antidepre~sanl!. (TCAs) and increased by small
doses of a -methyl-p t)rosine (which inhibih noradrenaline .,ynthe\i\),
\Ugge~ting a ba. . ic \imilarity to depre;,.,ive illness in humans.
ANTIDEPRESSANT DRUGS
TYPES OF ANTIDEPRESSANT DRUG
A ntidepressant drug~ fall into the following categories
(Table 39.2).
Inhibitors of monoami ne uptake:
- non-selecti ve (noradrenaline/serotonin) uptake inhibitors;
the&e inc lude tricyclic antidepressants (TCAs) (e.g.
imipramine, amitriptyline) and more recent antidepressants
such as venlafaxine (somewhat selective for serotonin,
although less so than selecti ve serotonin uptake inhibitors)
and duloxetine, which have fewer side effects than TCAs.
- selecti ve serotonin reuptake inhibitors (SSRTs) (e.g.
fluoxetine, flu voxaminc, paroxetine and sertraline).
-selecti ve noradrenaline uptake inhibitors (e.g. maprotiline,
r eboxetine).
2
Cynic.. ma)' feel that the\e mechani\m~. in which glutamate. neurotrophic
factors. monoamine;, and Meroid' all interact to control neuronal death,
survival nnd plasticity. arc bemg invoked just as enthusiastically to account
for almost every neurological and psychiatric dbordcr that you can think of.
from ~troke and Parkin\on\ di\ea\e to schi10phrenia. 'A re we missi ng
something,' they may feel, 'or are all the.,e di~eases basically the same? If
so, why are their effect ;o ditTerent'? Is this j ust a scienti fic bandwagon, or
docs this mechan istic convergence point to some fundamental princi ples of
neural organisation?' We do not have the answers. of course, but it is a field
560 worth watching.
Monoamine theory of depression
The monoamine theory, proposed in 1965,
suggests that depression results from functionally
deficient monoaminergic (noradrenaline and/or
5-hydroxytryptamine) transmission in the central
nervous system.
The theory was based on the ability of known
antidepressant drugs (tricyclic antidepressants and
monoamme oxidase inhibitors) to facilitate
monoaminergic transmission, and of drugs such as
reserpine to cause depression.
Biochemical studies on depressed patients do not
clearly support the monoamine hypothesis in its
simple form.
An abnormally weak response of plasma cortisol to
exogenous steroid {dexamethasone suppression test)
is common in depression and may reflect defective
monoamine transmission in the hypothalamus.
Recent evidence suggests that depression may be
associated with neurodegeneration and reduced
neurogenesis in the hippocampus.
Although the monoamine hypothesis in its simple
form is insufficient as an explanation of depression,
pharmacological manipulation of monoamine
transmission remains the most successful therapeutic
approach.
Current approaches focus on other mediators (e.g.
corticotrophin-releasing hormone), signal transduction
pathways, growth factors, etc., but theories remain
imprecise.
Monoamine oxidase (MAO) inhibitors (MAOls):
- irreversible, non-competitive inhibitors (e.g. phenelzine,
tranylcypromine), which are non-selective with respcctlo
the MAO-A and -B subtypes (see below)
- reversible, MAO-A-selective inhibitors (e.g. moclobemidel
Miscellaneous (atypical) receptor-blocking compounds
whose antidepressant actions are poorly understood (e.g.
mianserin, trazodooe, mirtazapine). The herbal prcparauc
St John's won. whose main active ingredient is hyperforin.
has similar clinical efficacy to most of the prescribed
antidepressant!>. It is a weak uptake inhibitor but also has
other actions.'
'Although re latively free of acute side effects, hyperforio activates
cytochrome P450. resulting in loss of efficacy. with serious consequen.;c
of several imponnnt drugs. includi ng ciclosporin. oral contraceptives, '~llil
ant i-II IV and anticancer drug,, and oral anticoagul ants-underl ining th(
principle that herbal remedi es need to be used with the same degree of
informed caution as any other drug.
 ANTIDEPRESSANT DRUGS

STRESS (!) .. Glutamate NA 5HT BDNF

~ ~ ~ ~
CAF u2 5HT1A TrkB
Hypothalamus
release receptors receptors receptors

~ I ~ /'\. / I
ACTH
Pituitary
release

~ Adrenal cortex
Cortisol Beneficial gene
release
+ transcription response

f><t
Neural apoptos1s Neurogenesis
Hippocampus
Prefrontal cortex

'/ DEPRESSIVE
SYMPTOMS

Fig. 39.1 Simplified diagram showing mechanisms believed to be involved in the pathophysiology of depression. The main
prodepressive pathways 1nvolve the hypothalamic-pituitary-adrenal axis, which is activated by stress and 1n turn enhances the
excitotoxic action of glutamate, mediated by NMDA receptors (see Ch. 33), and switches on the expression of genes that promote
neural apoptosis in the hippocampus and prefrontal cortex. The antidepressive pathways involve the monoamines noradrenaline (NA)
and 5-hydroxytryptamine (5-Hl), which act on G-protein-coupled receptors, and the brain-derived neurotrophic factor (BON F), which
acts on a k1nase-linked receptor (TrkB), switching on genes that protect neurons against apoptosis and also promote neurogenesis. For
further detail, see Charney & Manji (2004). ACTH, adrenocorticotrophic hormone; CRF, corticotrophin-releasing factor.

Table 39.4 summarises the main features of these types of drug.
Relent updates (Bosker et al., 2004; Pacher & Kecsemeti, 2004)
proVIde more detail. Mention should also be made of
el~ctroconvul~ive therapy (ECT), which is effective and usually
0 "more rapidly than antidepressant drugs (see later section).
MEASUREMENT OF ANTIDEPRESSANT
ACTIVITY
T The clinical effectivenes of the lirst MAOI and TCA drugs was
Ji...:overed by chance when these drug~ were given to patient.~ for other
rt '"II' lpronia:tid. the fiN MAOI. was originally used to treat
1 loterculo'1' be1ng chem1cally related to isoniazid (~ee Ch. 46);
imipramine. the first TCA. resemble;, chlorpromazine (sec Ch. 38) and
"a.' first tried a~ an antipsychotic dn1g. Lmer. the monoamine hypOLhesis
ol dcpre,,ion produced a biochemical rationale for their antidepres\ant
._'tlOil>. and hence ways of te\ting new compound.\ :l\ a preliminary to
chmcal Lnals. The resu lts of sucb biochemical tew. are succcs,ful in
pR'dicting clinical efficacy for conventional TCA~ and MAOJs. but fail to
preJct efficacy with many newer antidepressant drug\. Variou~
l'eha1iowal tC\l\ have ~ been used (..ee above), although !here i'> no
1mal model that satisfactorily resembles depressive illness in humans.
Sume of tl1e most useful tests are the following.
lhrmtiatu~tr of noratll?naline effect.\ i11 the penplrel). Stimulation of
')mpatheuc nerves or administration of noradrenaline causes
contraction of ~mooth muscle, wllich i~ enhanced if 1he noradrenaline
reuptake mechani\m of lhe nel"\e terminal is blocked (..ee Ch. II).
This tc\t gives po<,ithe result\ with monoamine uptake inllibitol"\
but doe~ not reveal MAOI or atypic3l antidepressant activity.
Potentiatioll of tile central effects of amplletami11e. Amphetamine
work~ partly by rclea>ing noradrenaline in the brain. and it' action\
are enhanced both by MAOb and by uptake inhibitors. Some atypical
antideprc.sams 3lso give a positive rcsponM!, making it u useful test for
predicting activity in humans.
Amagonism of reserpi11e-inducetl depression. Reserpine depletes the
bram of both noradrenaline and 5-HT. causmg variou' measurable
effecb (hypothem1ia. bradycardia, reduced mOtor activity, etc.) that are
reduced by antideprc~sam drug~. This test oho revea!J, activity among
the atypical antidepressant~.
Block of amine upt;lke in vitm. Among TCA~. !here 1\ a fairly good
correlation between antidepres~ant activity and potency in inhibiting
noradrenaline or 5-IIT uptake, but MAOis and many other antidepres~
ants ha'e no effect.
A general point that ha.\ to be borne in mind when using in vitro tesll. to
assess potential antidepressants b that many drugs (particularly TCA~)
are metabolised to pharmacologically active ;ub<,tanccs in vivo. and it ;..,
often unclear whether the parent drug or the metabolite is actually
respon'>ible for the clinical effect.
Clinically. the etrect of antidepressant drug i~ usually mea~urcd by a
subjective rating scale such a<, the 17-item Hamilton Rari11g Scale
Clinical depression takes man) forms, and the symptom' \ary between
patienL\ and over time. Quantitation is !herefore difficult. and the many
clinical trial ~ of antidcpressanll. have generally ~hown rather weak effccL'>. 561
 SECTION 4 . THE NERVOUS SYSTEM
Main types are:
monoamine uptake inhibitors (tricyclic
antidepressants, selective serotonin reuptake
inhibitors and others)
monoamine oxidase (MAO) inhibitors
miscellaneous ('atypical') antidepressants, mainly
non-selective receptor antagonists (e.g.
trazodone, m1rtazepine).
Tricyclic antidepressants and selective serotonin
reuptake inhibitors act by inhibiting uptake of
noradrenaline and/or 5-HT by monoaminergic nerve
terminals, thus acutely facilitating transmission.
MAO inhibitors inhibit one or both forms of brain
MAO, thus increasing the cytosolic stores of
noradrenaline and 5-HT in nerve terminals. Inhibition
of type A MAO correlates with antidepressant
activity. Most are non-selective; moclobemide is
specific for MAO-A.
Mode of action of 'atypical' antidepressants is poorly
understood.
All types of antidepressant drug take at least 2 weeks
to produce any beneficial effects, even though their
pharmacological effects are produced immediately,
indicating that secondary adaptive changes are
important.
The most cons1stent adaptive change seen with
different types of antidepressant drugs is down-
regulation of tl and a - adrenoceptors, as well as
5-HT2 receptors. How this is related to therapeutic
effect is not clear.
Recent evidence suggests that antidepressants may
act by increasing neurogenesis in the hippocampus.
after allowance for quite large placebo response;. There i ~ also a high
degree of individ ual vuri<tti on. wilh 3~0% of patients failing to show
any improvement. (Xl\<,ibly due to genetic factors (sec below).
MECHANISM OF ACTION OF
ANTIDEPRESSANT DRUGS
In the ab-.cnce of a l>imple mechanistic theory to account for
antidepressant action (see above). it is u eful to look for
phannacological effect\ that the various drugs have in common,
concentrating more on Lllc slow adaptive changes that follow a
-.imilar time cour.e to the therapeutic effect. This approach has
led to the d iscovery that certain monoamine receptors, in
particular ~ 1 and a 2-adrenocep tors. are consistently down-
regulated fo llowing chronic antidepressant rreatment. This can
be demonstrated in experimental animals as a reduction in the
number o f bind ing sites, as well as by a reduction in the
functio na l response to agonists (e.g. sti m ulation of cAMP
fo rm atio n by ~ -ad rc n occ ptor agonis ts). R ecepto r d own-
...,,...____ _
562 regulatio n probably also occurs in humans, because endocrine
respon~e~ to clonidine, tm a 2-adrenoceptor agonist. are redlKd!
by long-tem1 antidepressant treatment. Other receptors have dl
been ~tudied; a 1-adrenoceptors are not consistently affected, b
5-IIT ,-receptor~ are also down-regulated.
How t he~e fi ndi ngs re late to the monoamine hypothe'i'
unclear. Lo~., of f3-adrenoceptors as a factor in allc\iauot
depression docs not fit comfortably with theory, becau..c ~
adrenoceptor antagoni!.ts are not antidepressant, although it i-. !It
most consistent c hange reported. Impaired presynaptic inhibit100
secondary to down-regulation of uradrenoceptors might. l
is argued. faci litate monoamine re lease and thus faci l it~
transmi1.sion. Con~btent with this possibility i~ the fact that 'iCMn!
newer antidep res~ant drugs, suc h as mirtazapine (Table 39.4
arc antagonists at vari ous inhibitory presynaptic receptor"
inc luding a 2-adrenoceptors.
As described a bove, several antidepressant drugs appear h
pro mo te n et~~ogenes i s in the hippocan1pus, a mechanism th3i
could account for the slow development of the therape utic effect
TRICYCLIC ANTIDEPRESSANT DRUGS
Tricyclic antidepresstmts are l>lill widely used. They are, ho\\Cil'l;
far from ideal in practice. and it was the need for drug~ that u.:
more quickly and reliably, produce fewer side effect~ and are
les'> ha7ardou'> in overdose that led to the introduction of nelltr
5-HT reuptake inhibitor<. and other antidepressants.
Chemical aspects
Tricyclic antidepressant~are closely related in srrucrure to !It
phenothiaJine~ (Ch. 38) and were initially synLilesised (in 19-19
as potential antipsychotic dntgs. Imipramine was found to be ci
no use in schi1.0phrenia but effective in depression. so related
compounds, such as clomipramine. were synthesised. They difftr
from phenothiazi ncs principa lly in the incorporation of an extra
atom into the central ring (Fig. 39.2), which twists the structure
so that the mo lecule is no longer planar as in phe nothiazine~.
S imilar changes to Llle structure of thioxanthenc-typc anlip')
c hotic dru gs resulted in dru gs such as amitripty line. All LhCIC
compounds arc tertiary amines, with two methyl groups attached
Testing of antidepressant d"'gs
Animal models of depression include:
learned helplessness model
- reversal of reserpine-induced behavioural syndrome
- mother- infant separation in primates.
None is a good model for human depressive illness,
but they are the best available for testing new drugs.
Biochemical and pharmacological measures include
inhibition of monoamine uptake, receptor-blocking
activity, enhancement of peripheral noradrenergic
transmission.
Clinical testing of antidepressant drugs necessitates
allowance for large placebo effects.
uccd adrenoceptor!.. Most TCAs inhibit noradrenaline and 5-HT
abo uptake by brain synaptosomes to a similar degree (Fig. 39.4) but
Olbenzazeplnes
hut have much less effect on dopamine uptake. It has been suggested
that improvement of emotional symptoms reflects mainly an
I~ j, enhancement of 5-HT-mcdiated transmission, whereas relief of
tting biological symptoms re~ults from facilitation of noradrenergic
- f\- transmission. Interpretation is made difficult by the fact that
; the the major metabolites of TCAs have considerable pharmacological
Drug
it lOll activity (in some cases greater than that of the parent drug)
t. it /CH3 and often differ from the parent drug in respect of their
Imipramine - CH 2CH2 CH2 N noradrenaline/5-HT selectivity (Table 39.2).
\ ln addition to their effects on amine upt.ake, most TCAs affect
rne CH3
1.4), one or more types of neurotransmilter receptor, including
(lf-;,
Desipramine - CH 2CH2CH2 NHCH3 muscarinic acetylcholine receptors, histamine receptors and
5-HT receptors. The antimuscarinic effects of TCAs do not
t to contribute to thei r antidepressant effects but arc responsible
Clomipramine
that for various troublesome side effects (see below).
CCI,
Actions and unwanted eHects
Olbenzcycloheptenes in non-depressed human subjects, TCAs cause sedation,
confusion and motor incoordination. These effects occur also
in depressed patients in the first few days of treatment, but tend
to wear off in 1- 2 weeks as the antidepressant effect develops.
~trc In experimental animals, TCAs produce sedation, but they are
'-'CI able to reverse the depressant effect of reserpine treatment. TCAs
Drug are also used to treat neuropathic pain (see Ch. 41 ).

lH3 Unwanted eHects with normal clinical dosage

Amitriptyline =CHCH2CH2N Tricyclic antidepressants produce a number of troublesome side
the \ effects, mainly due to interference with autonomic control.
9) CH3
Atropine-like effects include dry mouth, blurred vision,
ol Nortriptyline = CHCH2CH2NHCH3 constipation and urinary retention. These effects arc strong with
cd amitriptyline and much weaker with desipramine. Po~tural
Fer hypotension occurs with TCAs. This may seem anomalous for
Fig. 39.2 Chemical structures of tricyclic
drugs that enhance noradrenergic transmission, and possibly
lr~
antidepressants.
results from an effect on adrenergic transmis!.ion in the
medullary vasomotor centre. The other common side effect is
y- sedation (see above), and the long duration of action means that
o;c
daytime performance is often affected by drowsiness and
d
difficulty in concentrating.
Tricyclic antidepressants, particularly in overdose, may cause
ventricular dysrhytlunias associated with prolongation of the QT
10 the ba~ic nitrogen atom. They arc quite rapidly demethylated
interval (see Ch. 18). Usual therapeutic doses of TCAs increase
tn 1 ivo (Fig. 39.3) to the corresponding secondary amines
the risk of sudden cardiac death slightly but significantly.
desipramine, nortriptyline, etc.). which are themselves active
.md may be administered as drugs in their own right Other Interactions with other drugs
lricyclic derivatives with slightly modified bridge structures include Tricyclic antidepressants are particularly likely to cause adverse
doxepin The pharmacological differences between these drugl> effects when given in conjunction with other drugs (see Ch. 52).
are not \ery great and relate mainly to their side effects, which They rely on hepatic microsomal metabolism for elimination,
are discussed below. and this may be inhibited by competing drugs (e.g. antipsychotic
drugs and some steroids).
Mechanism of action Tricyclic antidepressants potentiate the effects of alcohol and
As discu\'>Cd above, the main immediate effect of TCAs is to aneMhetic agents, for reasons that are not well understood, and
,,od; the uptake of amines by nerve terminal!., by competition deathl> have occurred as a result of this, when severe respiratory
for the binding site of the amine transporter (Ch. 11). Synthesis depression has followed a bout of drinking. TCAs also interfere
of amine~. storage in synaptic vesicles, and release are not with the action of various antihypertensive drugs (see Ch. 19), with
Jirectl) affected, although some TCAs appear to increase potentially dangerous consequences, so their use in hypertensive
transmitter release indjrectly by blocking presynaptic a r patients requires close monitoring. 563
 SECTION 4 . THE NERVOUS SYSTEM

lminodibenzyl lmtpramtne Imipramine N-oxide

C):b-- cDJ --.C):b c~

H I
CH 2CH 2CH2N(CH:J2 '" / CH 2CH2 CH2N-O
Demethylatio/ CH3

,-- Hydroxylation ---., ~

..__ ~ 'l../--NV Desmethylimipramtne

I
CH2CH2CH2NHCH3

2-Hydroxyiminodibenzyl
\
2-Hydroxyimipramine 2-Hydroxydesmethylimipramine

~OH ~OH ~OH

Fig. 39.3 Metabolism of 'l../--NV 'l../--NV 'l../--NV
H I I
imipramine, which is typical of CH2CH2CH 2N(CH3)2 CH 2CH2CH 2NHCH
that of other tricyclic
antidepressants. The hydroxylating
enzyme, CYP206, is subject to
genetic polymorphism, which may
1 Co"Jgotlo" l
Glucuronide Glucuronide
account for individual variation in
response to tricyclic antidepressants
(see Ch. 52). Hydroxylatton catalysed by CYP206

Acute toxicity
Tricyclic antidepressants are dangerous in overdose, and were
at one time commonly used for suicide attempts. which wa~
an important factor prompting the introduction of !>afer
antidepressants. The main effects are on lhe central nervou!>
1000
~ Reboxetine
'>Y'>tem and the heart. The initial effect of TCA overdo~agc is
cause excitemellf and delirium. which may be accompani~'ll
comttfsions. This is followed by coma and respiratory
la!>ting for some days. Atropine-like effects arc
including flushing, dry mouth and skin. mydriasis, and i
of gut and bladder. Anticholinestemse drugs have been U'>~'ll
counter atropine-like effects but are no longer
Cardiac dysrhythmias (sec above) are common, and
death (rare) may occur from ventricular fibri llation.

r - 100
Maprotiline

Desipramine
~ Reboxetine NA-selective
Table 39.2 Inhibition of neuronal noradrenaline and
c:
.Q
:B
:E
.!:
Q)
.:.:.
10 -
+- Protriptyline
Nortriptyline
uptake by tricyclic antidepressants and their metabolites

Drug/metabolite NA uptake 5-HT uptake

g
a. Amitriptyline lmtpramine +++ ++
:J
1- lmtpramine Non-selective
J:
.;, Desmethylimipramine (DMI) ++++ +
<( Clomipramine
z 0.1 Hydroxy-OMI +++
Q
iii
a: Venlafaxine Clomipramine (CMI) ++ +++
Paroxetine
0.01 Fluvoxamine 5-HT-selective Desmethyi-CMI +++ +
Sertraline
Fluoxetine Amitriptyline (AMI) ++
++
Citalopram
0 .001 Nortrip tyline (desmethyi-AMI) +++ ++

.,.,., / .. 564 l Fig. 39.4 Selectivity of inhibition of noradrenaline and 5-

hydroxytryptamine uptake by various antidepressants. Hydroxynortriptyline ++ ++

Pharmacokinetic aspects
Tricyclic antidcpressarHs are all rapidly absorbed when given
orally and bind strongly 10 plasma albumin, most being 90-95%
bound at therapeutic plasma concentration11. They also bind to
t\Lralal>Cular tissues, which accounts for their generally very
large distribution volumes (usually 10-50 1/kg; see Ch. 7) and
l011 rates of elimination. Extravascular sequestration, together
11rth \trong binding to plasma albwnin, means that haemodialysis
"ineffective as a means of increasing drug elimination.
Tricyclic antidepressants are metabolised in the liver by two
m:un routes (Fig. 39.2). namely N-demethylation. whereby tertiary
amme> are converted to secondary amines (e.g. imipramine to
de~methjlimipramine, amitriptyline to nortriptyline). and ring
h1droxylation. Both the desmethyl and the hydroxylated
melabolites commonly retain biological activity (see Table 39.2).
During prolonged treatment with TCAs, the plasma concen-
tration of these metabolites is usually comparable with that of
th~ parent drug. although there is wide variation between
mJ11 1duals. Lnacuvation of the drugs occurs by glucuronide
conjugation of the hydroxylated metabolites. the glucuronides
lll:mg excreted in the urine.
The 01erall half-times for elimination ofTCAs are generally long,
mnging from 10 to 20 hours for imipramine and desipramine
to about 80 hours for protriptyline. They are even longer in
elder!} patients. Therefore gradual accumulation is possible,
leading to slowly developing side effects. The relationship between
pla,ma concentrauons and the therapeutic effect is not simple.
to Indeed, a study on nortriptyline (Fig. 39.5) showed that too high a
by pl:hma concentration actually reduces the antidepressant effect,
ion ;md there is a narrow 'therapeutic window'.
ed,
ion Other non-selective uptake inhibitors
to ll'her rela1ively non-selective amine uptake inhibitors
d. ..ero~onin/noradrenaline reuptake inhibitors, or 'SNRis' 4 ) include
kn 1enlafaxine and duloxeti n e (see Table 39.4).
l!? 6
0 for neuropathic pain (e.g. postherpetic and other
~
c: 4
0
~
.Q 2
a;
~ 0
0 200 400 600
Plasma nortriptyline concentration (nmol/1)
Fig. 39.5 'Therapeutic window' for nortriptyline. The
anbdepressant effect, determined from subjective rating scales,
s opt1mal at plasma concentrations between 200 nmoVI and
.;oo rmoVl, and declines at higher levels. ____ _)
'Don't be misled by a marketing term for a Jcs~> selective drug than an SSR I.
ANTIDEPRESSANT DRUGS
Tricyclic antidepressants
Tricyclic antidepressants are chemically
related to phenothiazines, and some have similar
non-select1ve receptor-blocking actions.
Important examples are imipramine, amitriptyline and
clomipram1ne.
Most are long-acting, and they are often converted to
active metabolites.
Important side effects: sedation (H, block); postural
hypotension (a-adrenoceptor block); dry mouth,
blurred vision, constipation (muscarinic block);
occasionally mania and convulsions. Risk of
ventricular dysrhythmias due to HERG channel block.
Dangerous in acute overdose: confusion and mania,
cardiac dysrhythmias.
Liable to interact with other drugs (e.g. alcohol,
anaesthetics, hypotensive drugs and non-steroidal
anti-inflammatory drugs; should not be given with
monoamine oxidase inhibitors).
Clinical uses of tricyclic antidepressants
and related drugs
Tricyclic antidepressants (e.g. amitryptyline,
imipramine) and related drugs (e.g. trazodone) are
used:
for moderate to severe endogenous depression ,
especially with psychomotor features such as
insomnia (a sedating drug such as amitriptyline is
used) or poor appetite; t razodone has less
marked antimuscarinic effects
for panic and related disorders (e.g.
c lo mipramine for obsessional and phobic states)
forms of neuralgia; see Ch. 41)
short-term treatment of nocturnal enuresis in older
children (Ch. 24).
Points to note are as follow.
Onset of action is slow: treatment should be for at
least 4-6 weeks before concluding that an
individual drug is ineffective. If there is a partial
response, treatment should be continued for
several more weeks before increasing the dose.
Treatment should continue for at least 4 months
following remission. Withdrawal is tapered over
several weeks.
Tricyclic antidepressants cause severe
cardiotoxicity (dysrhythmia) in overdose; suic1de
risk should be assessed before prescribing.
565
 SECTION 4 . THE NERVOUS SYSTEM
SELECTIVE 5-HYDROXYTRYPTAMINE
UPTAKE INHIBITORS
Drugs of this type (often termed selective serotonin reuptake
inhibitors or SSR/s) include fl uoxetine, Ouvoxami ne. paroxetine,
citalopram and sertraline (M!e Table 39.4). They arc the most
commonly prescribed group of antidepressants. As well as show-
ing selectivity with respect to 5-IIT over noradrenaline uptake,
they arc less likely than TCA!> to cause anticholinergic side
effects and are less dangerous in overdose. ln contrast to MAOls
(sec below), they do not cau\C 'cheese reactions'. They are as
effective a~ TCAs and MAOh in treati11g depression of moderate
degree, but probably less effective than TCAs in treating severe
depression. ll1ey arc at o u-.ed to treat a particular type of anxiety
di!.order known as obsesshe compufsil'e disorder (see Ch. 37).
Pharmacokinetic aspects
The SSRls are well absorbed, and most bave plasma half-lives of
15-24 hour-. (fluoxetine is longer acting: 24-96 hours). ll1e delay
of 2-4 week\ before the therapeutic effect develops is similar to
that seen with other antidepressant~. Paroxetine and fl uoxetine are
not used in combination with TCAs, whose hepatic metabolism
they inhibit, for fear of increasing TCA tollicity.
Unwanted effects
Common '>ide effects are nau'>ea. anorexia, insomnia, loss of
libido and fai lure of orgasm.
ln combination with MAOis. SSRJs can cause a '!>erotonin
syndrome' characterised by tremor, hyperthennia and cardio-
vasmfar co((apse, from which deaths have occurred.
There have been reports of increased aggression, and
occasionally violence, in patients treated with fluoxetinc. but
these ha"c not been confirmed by controlled studies. The use of
SSRTs is not recommended for treating depression in children
under 18, in whom efficacy i~ doubtful and adver\e effects,
including excitement, insomnia and aggression in the first few
weeks of treatment, may occur. The possibility of increased
suicidal ideation is a concern in this age group.
Despite the apparent advantages of 5-HT uptake inhibitors
over TCA\ in terms of side efTeCL\, the combined result. of many
trials ~how no overall difference in tenus of patient acceptability
(Song ct al.. 1993).
5-HT uptake inhibitors arc used in a variety of psychiatric
disorders, as well as in depression, including anxiety disorders,
panic attacks and obsessive compul!,ive disorder.
MONOAMINE OXIDASE INHIBITORS
Monoamine oxidase inhibitors (MAOIs) were among the first dmgs
to be introduced clinically as antidepressants but were largely
superseded by tricyclic and other types of antidepressants, whose
clinical efficacies were considered better and whose side effectS
are generally less than those of MAOh. The main examples are
phenelzine. tranylcypromine and iproniazid. These drugs cause
irreversible inhibition of the enLyme and do not di!.tinguish
between the two main isozymes (!.ee below). Recently, the discovery
- S66 of reversible inhibitors that show isozyme selectivity has reki ndled
"'"'"-----
Selective serotonin reuptake
Inhibitors (SSRis)
Examples include fluoxetine, fluvoxamine, paroxetine,
sertraline, citalopram. Venlafoxine is a less selective
5-HT uptake inhibitor.
Antidepressant actions are similar in efficacy and time
course to those of TCA.
Acute toxicity (especially cardiotoxicity) is less than
that of MAOI or TCA, so overdose risk is reduced.
Side effects include nausea, insomnia and sexual
dysfunction. SSRI are less sedating and have less
antimuscarinic side effects than the older TCAs.
No food reactions, but dangerous 'serotonin reaction
(hyperthermia, muscle rigidity, cardiovascular
collapse) can occur if given with MAOI.
Currently the most commonly prescribed
antidepressants; also used for some other psychiatric
indications. Venlafaxine is licensed to treat generalized
anxiety disorder as well as depressive illness.
There is concern about the use of SSRI in children
and aolescent s, due to reports of an increase in
suicidal thoughts on starting treatment.
Other monoamine uptake Inhibitors
Group of noradrenaline-selective (e.g.
reboxetine) or non-selective (e.g. venlafaxine,
duloxetine) inhibitors.
Generally similar to tricyclic antidepressants but lack
maJor receptor-blockrng actions, so fewer srde effects.
Less risk of cardiac effects, so safer in overdose than
tricyclic antidepressants.
intere!>t in this class or drug. A lthough several studies have sho\1
a reduction in platelet MAO activiry in certain group> '
depressed patients, there b no clear evidence that aboonn..
MAO activity is involved in the pathogenesis of depression.
M onoamine oxidase (sec Ch. 11 ) is found in nearly all tissue,
and exists in two simi lar molecular form~ coded by separate
gene~ (sec Table 39.3). M AO-A has a substrate preference ~
5-HT and is the main target for the antidcpre'>sant MAOI'
MAO-B has a substrate preference for phenylethylamine, aoc
both enzymes act on noradrenaline and dopamine. Type B is
selectively inhibited by sclcgiline, which is used in the treatmel1
of parkinsonism (see Ch. 35). Disruption of the MAO-A gent
in mice causes increased brain accumulation of 5-HT and. to.
le~~cr extent, noradrenaline, along with aggre<;sive bebavia..;
(Shih ct aJ., 1999). A family has been reported with an inherite~;
mutation leading to loss of MAO-A activity, whose memberl
showed mental retardation and violent behaviour patterns. Mo-t
antidepressant MAOls act on both forms of MAO. but clinical
 ANTIDEPRESSANT DRUGS

changes occur in peripheral ti,,uel> such as heart, liver and

Tillie 39.3 Substrates and inhibitors for type A and type intestine, and increase!> in the plasma concentrations of the~e
8 monoamine oxidase
amines are also detectable. Although these increases in tissue
amine content are largely due to accumulation within neurons,
Type A Type B
' transmitter release in response to nerve activity is not increased.
Preferred Noradrenaline Phenylethylamine In contrast to the effect of TCAs, MA01s do not increase the

~
substrates 5-Hydroxytryptamine Benzylamine response of peripheral organ~. such as the heart and blood
vesl.els, to sympathetic nerve !>limulation. The main effect of MAO Is
Non-specific Dopamine Dopamine is to increase the cytopla!>mic concentration of monoamine~ in
substrates Tyramine Tyramine
nerve terminals, without greatly affecting the vesicular stores that
SpecifiC Inhibitors Clorg1line Selegiline fom1 the pool that is releac;able by nerve <;timulation. The incre<L'>ed
Moclobemide cytoplasmic pool results in an increased rate of !.pontaneou'
leakage or monoamincs, and also an increased release by indirectly
Non-spec1fic Pargyline Pargyline acting sympathomimetic amines ~uch a~ amphetamine and
nh,bitors Tranylcypromine Tranylcypromine
tyramine (see Ch. ll). This occurs because these aminel. work
lsocarboxaz1d lsocarboxazid
by displacing noradrenal ine from the vesicles into the nerve
terminal cytoplasm. from which it may either leak out and
produce a response, or be degraded by MAO (sec Fig. I 1.8).
Inhibition of MAO increase~ the proportion that escapes and thus
'tud1c' with subtype-specific inhibitors have shown clearly that
enhances the response. Tyramine thu'> causes a much greater rise
anlldepre\,ant activity. as well ao, the main side effects of
in blood pressure in MAOI-treated animals than in control'>. Thi'>
~L-\01,, 1s associated with MAO- A inhibition. MAO is located
mechanism is important in relation to the cheese reaction produced
mtracellularly, mostly ac;sociated with mitochondria, and has
by MA01s in humans (see later c;ection).
t\10 main functions.
ln normal human subjecL~. MAOls cause an immediate increa~e
Within nerve terminals, MAO regulates the free inlraneuronal in motor activity. and euphoria and excitement develop over the
concentration of noradrenaline or 5-IIT, and hence the course of a few days. This is in contrast to TCAs, which cause
r~lcasable stores of these transmitters. It is not Lnvolved in only sedatiou and confu~>ion when given to non~deprcs~ed
the Inactivation of relea~ed tran1-.mittcr. The biochemical role 1-ubject~. MAOls (like TCAs) arc also effective in reversing the
of ~1AO in noradrenergic nerves and the effect of MA01 on behavioural effects of reserpine treatment. The effects of MAOI~
tran,miuer metabolism are discussed in Chapter 11. on amine metabolism develop rapidly. and the effect of a '>ingle
~lAO i~ important in the inactivation of endogenous and dose lac;ts for several day<.,. There is a clear discrepancy, a'> v. ith
mgc,ted amines that would otherwise produce unwanted TCA<>, between the rapid biochemical response and the delayed
eltcct\. An example is tyramine. an ingested amine that is a antidepressant effect.
'uh.,trate for both MAO-A and MAO-B, and is important in The mechanisms underlying the antidepressant effect~ of
producing some clinically important adverse interactions of MAOls are not well under~tood, but MAOls cause a delayed
MAO!s with foods and other drug!> (see below). down-regulation of ~-adrenoceptor~ and 5-HT2-rcceptors similar
to that produced by TCAs.
Chemical aspects
\!1moamine oxidase inhibitors arc substrate analogues with a Unwanted effects and toxicity
wn phen} leth) !amine-like structure. and most comain a reactive Many of the unwanted effect'> of MA01s result directly from
of group (e.g. hydrazine, propargylamine, cyclopropylamine) that MAO inhibition, but some are produced by other mechani'>mS.
nal enable., the inhibitor to bind covalently to the enzyme. resulting llypoteusion is a common ~ide effect; indeed. pargyline was
m a non-competiti,e and long-la~ting inhibition. Recovery of at one time used as an antihypcnensivc drug. One possible
e~. \lAO activity after inhibition take!. several weeks with most explanation for this effect the oppo<.,ile of what might have been
me drug~. but is quicker after tranylcy promine, which forms a expected-is that amines such as dopamine or octopamine
or k'' \table bond with the enL.ymc. Moclobemide acts a~ a accumulate within peripheral sympathetic nerve terminals and
lis. 1\'Vcr~iblc competitive inhibitor. displace noradrenaline from the ~>torage vesicles, thus reducing
Llld \1onoamine oxidase inhibitors arc not particularly specific in noradrenaline release associnted with sympathetic activity.
IS !he1r actions, and inhibit a variety of other enzymes as well a~ Excessive central stimulation may cause tremors. excitement.
ent \1\0. including many en;ymes involved in the metabolism of in<.,omnia and, in overdose, convul<;ion~.
ne OOier drugs. This is responsible for o,ome of the many clinically Increased appetite, leading to weight gain. can be so extreme
)a unportant drug interactions a~sociated with MA01s. as to require the drug to be discontinued.
)Ur Atropine-like side effect!> (dry mouth, blurred vision, urinary
cd Pharmacological effects retention, etc.) are common with MAOis, although they are less
~fS \lonoamine oxidase inhibitors cause a rapid and sustained of a problem than with TCAs.
st maeasc in the 5-HT, noradrenaline and dopamine content of the MAOis of the bydmzine type (e.g. phenelzine and iproniazid)
~a] bram, 5-1IT being affected most a nd dopamine least. Similar produce, very rarely (less than I in I0 000), severe hepatotoxicity, S67
 SECTION 4 . THE NERVOUS SYSTEM
Other antidepressant drugs
Heterogeneous group including trazodone,
mirtazapine and bupropion.
No common mechanism of action. Act mainly as non-
selective antagonists at presynaptic receptors,
possibly enhanc1ng amine release.
Delay in therapeutic response is similar to that with
tricyclic antidepressants and monoamine oxidase
inhibitors. Mirtazapine may act more rapidly.
Unwanted effects and acute toxicity vary but are
generally less than with tricyclic antidepressants.
Monoamine oxidase inhibitors (MAOI)
Main examples are phenelzine, tranylcypromine,
isocarboxazid (irreversible, long-acting, non-selective
between MAO-A and B) and moclobemide (reversible,
short-acting, MAO-A-selective).
Long acting MAOI:
o Main side effects: postural hypotension (sympathetic
block); atropine-like effects (as with TCA); weight
gain; CNS stimulation, causing restlessness,
insomniahepatotoxicity and neurotoxicity (rare).
o Acute overdose causes CNS stimulation,
sometimes convulsions.
o 'Cheese reaction', ie. severe hypertensive
response to tyramine-containing foods (e.g.
cheese, beer, wine, well-hung game, yeast or soy
extracts. Such reactions can occur up to 2 weeks
after treatment is discontinued.
Interaction with other amines (e.g. ephedrine in
over the counter decongestants, clomipramine
and other TCAs) and some other drugs (e.g.
pethidine) are also potentially lethal.
Moclobemide is used for major depression and
social phobia. Cheese reaction and other drug
interactions less severe and shorter-lasting than with
long-lasting MAOis.
MAOI are used much less than other antidepressants
because of their adverse effects and serious
interactions.
They are indicated for major depression in patients
who have not responded to other drugs.
which seems to be due to the hydra7ine moiety of the molecule.
Their use in patients with liver disease is therefore unwise.
Interaction with other drugs and foods
Interaction with other drugs and foods is the most serious
problem with MAOTs and is the maio factor that caused their
568 clinical u!>e to decline. The special advantage claimed for the new
reversible MAOTs. such as moclobemidc. is that these imeracuoos
arc reduced.
The cheese reaction is a direct consequence of MAO inhib1tioo
and occurs when normally innocuous amines (mainly tyramin:
produced during fermentation are ingested. Tyramine is normaih
metabolised by MAO in the g ut wall and liver, and little dicta~
tyramine reaches the systemic circulation. MAO inhibill<
allows tyramine to be absorbed, and also enhances its S\111-
pathomimetic effect. as discussed above. The result is a~uk
hypertension. giving rise to a severe throbbing headache ar
occasionally even to intracranial haemorrhage. Although m.. ,
foods contain some tyramine, it appears that at least lO mg of
tyramine needs to be ingested to produce such a response, and
the main danger i-. from ripe cheeses and from concentrated }e.&
products such as Marmitc. Administration of indirectly acun.
sympathomimetic amines (e.g. ephedrine, a mphetamine) abo
causes severe hypertension in patients receiving MAOls; dirt\:d1
acting agents such as noradrenaline (used for example
conjunction with local anaesthetics; see Ch. 44) arc no:
hazardous. Moclobcmide, a specific MAO-A inhibitor, docs nut
cause the cheese reaction, probably because tyramine can ~till bt
metabolised by MAO-B.
Hype rte ns ive episodes have been reported in patients gi\~n
TCAs and MAOis simultaneously. The probable explanation ,
that inhibition of noradrenaline reuptake further enhances d
cardiovascular response to dietary tyramine, thus accentuatinE
the c heese reaction. This com hi nation of drugs can also produc,
excitement and hyperactivity.
Monoamine oxidase inhibitors can interact with pcthidint
(see Ch. 41) to cause severe hyperpyrexia, with restle~snc"
coma and hypotension. The mechani'>m is uncertain. but it ,
likely that an abnormal pethidine metabolite is produced bee~
of inhibition of dcmcthylation.
A comparison of the main characteristics of MAOTs and otht1
antidepressant drugs is given in Table 39.4.
FUTURE ANTIDEPRESSANT DRUGS
Uncertainty about the biochemical pathogenesis of depres'1
raises the poss ibi lity of finding new antidepressants acting on
other (non-amine-related) targets. Many different approach<:
have been taken, and several compounds are in development (
Pacher & Kecsemeti, 2004). They include antagonists
oeuropeptides- including CRH and substance P-a~ well a
compounds active on NMDA. acetylcholine and histam1
receptors, and compounds that act on the signal transducti
pat11ways responsible for neurogenesis, neural plasticity and
apoptosis. The aim is to satisfy the following criteria:
fewer side effects (e.g. sedation and anticholinergic effects)
lower toxicity in overdose
rapid action
greater efficacy (i.e. more complete relief of symptoms)
efficacy in patients non-responsive to TCAs or MAOis.
So far, although many compounds have ~hown some efficac}
clinical trials, none appear better than the existing drugs \\
respect to these criteria.

ELECTROCONVULSIVE THERAPY (ECT)
A iauh: line of rea~oning. namely that schizophrenia and
tptlep') \\ere belieH!d to be mutuaUy exclusive, led to the use
f mduced com uiSion~ a.\ therapy for psychological disorders in
!he 1930..; although useless in schizophrenia. its efficacy in
tre.lllng C\Cre dcpre!>sion has been repeatedly confirmed. ECT
human' mvolvcs stimulation through electrodes placed on
!her ,jJe of the head, with the patient lightly anaesthetised.
paral)'cd "11h a short-acting neuromuscular-blocking drug
c~ 'u~-cmylcholine; Ch. I 0) so as to avoid physical injury,
and artificmll) ventilated. More recently, a technique involving
:m..:ranial magnetic ~timulation , which does not require these
pr~caution!>, has been introduced. Controlled trials have shown
ECT to be at least as effective as antidepressant drugs, with
f'i'J'llnsc rates ranging between 60% and 80%; it appears to be
the most effective treatment for severe suicidal depression. The
mam dtsadvantagc of ECT is that it often causes confusion
J memory lo'>s la\ling for days or weeks.
The effect of ECf on experimental animals bas been carefully
al)'cd to see if it provides clues as to the mode of action of
anudcpre<.,:\llt drugs. but the clues it gives are enigmatic. 5-HT
. the''' and uptake are unaltered, and noradrenaline uptake is
on i'
IOOle\lhat increa-.ed (in contrast to the effect ofTCAs). Decreased
"' the
adrenoceptor responsiveness. both biochemical and behavioural,
mting
t\'tlll\ "tth both ECT and long-tenn administration of anti-
uce
~-.ant drugs. but changes in 5-HT-mediated responses tend to
gom oppo,itc directions (sec Macs & Meltzer. 1995).
idine
ne~!>.
it i\ CUNICAL EFFECTIVENESS OF
'3U\C
ANTIDEPRESSANT TREATMENTS
The owall cl inical efficacy of antidepressants has been
N.tblhhcd in many well-controlled clinical trials, although the
J~grcc of improvement i!> limited. 5 Moreover, it is clear that a
IUhstantial proportion of patients recover spontaneously, and that
Jtl-lOtt of patients fail to improve with drug treatmems.
:ssion ~!though antidepressants produce significant benefit in patients
~g on "th modcmtc or severe depression, their efficacy in mild cases
ache' bJs not bt:cn clearly demonstrated. ControUed trials show there
t (o;ee ~little to choo-.c in terms of overall efficacy between any of the
ts of mug' currently in U!>e, although clinical experience suggests that
ell as l!ldi\iJual patients may. for unknown reasons, respond better to
mine ~drug than to another.
tction
and Pharmacogenetic factors
't' n.e mdi\tdual \Uriation in re~ponse to antidepressants ma) be panly
due to genettc factoJ'., n~ well as to heterogeneity of the clinical condition.
it!>)
T~"O ~eneuc filctor.. have recetved panicular anention. namely:
PIJ~ro rt\Jl(lO\CSare pnrticularly evident in antidepressant trials, patient~
cy in "<tnc influenced by the altitude of the prescriber, who is in tum influenced
with h) daum for the late~t in a long line of dntgs. A nightmare for hospital
ltlf!nulary commiuccsl
ANTIDEPRESSANT DRUGS
polymorphi'>m of the cytochrome P450 gene. especially CYP2D6 (see
Kin::hheiner et al., 2004) which is rt!l>ponsible for hydroxylation ofTCAs
polymorphi'm of mono:unine tr.m~poner genes (see Glan & Reus, 2003).
Up to 104 of white people possess a dysfunctional CYP2D6 gene. and
con\equcntly may be ~u~eptible to ~ide effects of TCAs and variou\
other dru~h (..ce Ch. 51) that are metabolised by this route. The opposite
eft'ect. cnuc;ed b) duplic;~tion of the gene, i!. common in Eru.tem European
and F.a\t African population~. and may account for a lnck of clinical
efficac) in \Oille mdividuab. There is some evidence to suggest that
re<.pon,ivcnc" to SSRI~ i' related to polymorphism of one of the
serotonin tran'>porter gene<.. but thi' remain~ controversial.
Although gcnotyping may prove to be a useful approach in the future
to individuali,ing antidepre\sant thempy. itS pmctical realisation is <;Ome
way off.
Suicide and antide pressants
,. Vnrious anecdotal reports. and ;,ome defini ti ve studies, have suggested
that antidepressants may increase the risk of 'suicidality' in depressed
patients (sec Licinio & Wong. 2005). The term stdcidaliry encompasses
suicidal thoughts and planning as well as unsuccessful attempts; acuml
suicide, although one of the major causes of death in you ng people, is
much rarer than suicidality. Clinical trials to determine the relmion,hip
between antidepre~sants and suicidality arc djfficult, because of t.he
clear a\\ociation between depre~sion and suicide. and have given variable
results. with \omc \tudies 'uggesting that suicidality may be increased
during the first few weeks of antidepressant treatment, although not
thereafter. and 'ome ~howing n small increase in the risk of nctual suicide
(;,ec Cipriam et al., 2005). There is no evidence to suggest that SSRJs
carr) an) greater ri\1.. than other antidepressants. Although inconclusive.
the<.e data ha\C cau;,ed the regulatory authorities to issue warning~ about
the u-.e of anudcpressant~. Their caution has been reinforced by detailed
reappmi,al of triab data. ~uggesting that tbe clinical efficacy of anti-
deprC\\llnh b weal..er than previou~ly thought and significant ont} in
ca~es of 'e~ere deprc~~ion. ll1i\ bacl..lash of opinion regarding the u&e
of antidepressant~ ha~ sparked much controversy, with many clinicians
arguing that. even if the ~uicide risk is real. for many patients the benefit,
greatly outweigh the risks.
MOOD-STABILISING DRUGS
These drugs arc used to control the mood swings characteristic
of manic-depressive (bipolar) illness. Lithium is most
commonly u~ed, but recently anticpileptic drugs such as
car bamazepine, valproate and gabapentin (Ch. 40). which
have fewer side effects than lithium, have also proved
efficacious.
Used prophylactically in bipolar depression. mood-stabilising
drugs prevent the !>wing!> of mood and thus reduce both the
depressive and the manic phases of the illness. They arc given
over long period'>, and their beneficial effects take 3-4 weeks to
develop. Given in an acute attack. they are effective only in
reducing mania. not during the depressive phase (although
lithium is sometimes used as an adjunct to antidepressants in
severe cases of unipolar depression).
LITHIUM
The psychotropic effect of lithium was discovered in 1949 by
Cade, who had predicted that urate salts should prevent the
induction by uraemia of a hyperexcitability state in guinea pigs.
lie found lithium urate to produce an effect, quickly discovered 569
 SECTION 4 . THE NERVOUS SYSTEM

Table 39.4 'TYpes of antidepressant drugs and their characteristics

Type and examples Actlon(s) Unwanted effects Risk of overdose Pharmacokinetics Notes

MONOAMINE UPTAKE INHIBITORS

TCA group Inhibition of NN5- Sedation Ventricular 'First-generation'
HT reuptake Anticholinergic effects dysrhythmias antidepressants, still
(dry mouth, constipation, High risk in very widely used,
blurred vision, urinary combination with although newer
retention, etc.) CNS depressants compounds generally
Postural hypotension have fewer s1de
Seizures effects and lower ns.~
Impotence with overdose
Interaction w1th CNS
depressants (especially
alcohol, MAO inhibitors)

Imipramine Non-selective As above As above t1124-18h;

converted to
desipramine

Desipramine NA-select1ve As above As above t1f212-24h

Amitriptyline Non-selective As above As above t 112 12-24 h; Widely used, also for
converted to neuropathiC pa1n
nortriptyline (Ch. 41)

Nortriptyline NA-selective As above As above Long t 112 (24-96 h) Long duration, less
(slight) sedative

Clomipramine Non-selective As above As above t,/2 18-24 h Also used for anxiety
disorders

Other non-selective
uptake inhibitors
Venlafaxine Weak non- As SSRis (see below) Safe in overdose Short t '-~ (-5 h) Claimed to act more
selective NN5-HT Withdrawal effects rapidly than other
uptake inhibitor common and antidepressants, and
Also non-selective troublesome if doses to work better in
receptor-blocking are missed 'treatment-resistant'
effects patients
Usually classed as
non-selective NA/5-
HT uptake blocker,
although in vitro data
show selectiv1ty for
5-HT

St John's wort (active Weak non- Few side effects Risk of drug t,<2-12h Freely available as
principle: hyperforin) selective NN5-HT reported interactions due to crude herbal
uptake 1nhibitor enhanced drug preparation
Also non- metabolism (e.g. Similar efficacy to
selective loss of efficacy of other antidepressants.
receptor-blocking ciclosporin, with fewer acute side
effects antidiabetic effects but risk of
drugs etc) serious drug
interactions (see text)

Duloxetine Potent non- Fewer side effects than t,/2 -14 h Also used to treat
selective NN5-HT venlafaxine urinary incontinence
uptake Inhibitor Sedation, dizziness, (see Ch. 25) and for
No action on nausea anxiety disorders
monoamine Sexual dysfunction
receptors

~, ...... 570
 ANTIDEPRESSANT DRUGS

bble 31.4 (c ont'd) Types of antidepressant d rugs and their characteristics

Type and examples Action(s) Unwanted effects Risk of overdose Pharmacokinetics Notes

Boprop1oo Weak inhibitor of Headache, dry mouth, Seizures at high t112 - 12h Plasma half-life - 20 h
dopamine and NA agitation, insomnia doses Used mainly in
uptake depression associated
Mechanism with anxiety
poorly understood Slow-release
formulation used to
treat nicotine
dependence (Ch. 43)

SSRis All highly selective Nausea, diarrhoea, Low risk in

for 5-HT agitation, insomnia, overdose but must
anorgasmia not be used
Inhibit metabolism of in combination with
other drugs, so risk of MAO inhibitors
interactions

Fluoxetine As above As above As above Long t 112 (24-96 h)

Fluvoxam1ne As above As above As above t, 12 18-24 h Less nausea than with

other SSRis

Paroxellne As above As above As above t,/2 18-24 h Withdrawal reaction

Crtalopram As above As above As above t,/2 24-36 h Escitalopram is active

S isomer of
citalopram
Fewer side effects
reported

Sertrahne As above As above As above t,2 24-36 h

NAselective
uptake inhibitors
Mapro!llme Selective NA As TCAs; no significant As TCAs Long 1112- 40 h No significant
uptake inhibitor advantages advantages over
TCAs

Reboxetine Selective NA Dizziness Safe in overdose t,/2 - 12 h Safer and fewer side
uptake inhibitor Insomnia (low risk of cardiac effects than TCAs
Anticholinergic effects dysrhythmia)

MAO INHIBITORS
Inhibit MAO-A
r- and/or MAOB
Earlier compounds
have long duration
of action due to
covalent binding
~.
to enzyme
;I
Phenelzme Non-selective 'Cheese reaction' to Many interactions ''12 1-2 h
tyramine- containing (TCAs, opioids, Long duration of
foods (see text) sympathomimetic action due to
Anticholinergic side drugs)- risk of Irreversible b1nding
effects severe
Hypotension hypertension due
Insomnia to cheese reaction
Weight gain
Uver damage (rare)

57 1
SECTION 4 . THE NERVOUS SYSTEM

Types of antidepressant drugs and their characteristics

Type and examples Action(s) Unwanted effects Risk of overdose Pharmacokinetics Notes

Tranylcypromine Non-selective As phenelzine As phenelzine t,.? 1-2 h

Long duration of
action due to
trreversible binding

lsocarboxazid Non-selective As phenelzine As phenelzine Long t t.? -36 h

Moclobemtde MAO-A-selective Nausea Interactions less t,/2 1-2 h Safer alternative to
Short acting Insomnia, agitation severe than with earlier MAO inhibitors
other MAO
inhibitors; no cheese
reactions reported

MISCELLANEOUS ANTIDEPRESSANTS
Trazodone Weak 5-HT uptake Sedation Safe in overdose t 112 6-12h Nefazodone and
inhibitor Hypotension mianserin are similar
Also blocks Cardiac dysrhythmias
5-HT2 and H1
receptors
(enhances
NA/5-HT release)

Mirtazapine Blocks n 2 , 5-HT2 Dry mouth No serious drug t112 2Q-40 h Claimed to have
and 5-HT3 Sedation interactions faster onset of action
receptors Weight gain than other
antidepressants

that it was due to lithium rather than urate, and went on to show
that lithium produced a rapid improvement in a group of manic
paticnt1>. Adoption of lithium for prophylaxis of mania was
delayed in the USA by earlier American experience of lithium as
an over-the-counter salt substitute for patients recommended a
low sail diet becau1>e of heart failure. in whom it caused severe
toxicity.
Other drugs (e.g. antipsychotics) are equally effective in
trenting acute mania; Lhey acl more quickly and are considerably
safer, so the clinical use of lithium is mainly confined to
prophylactic control of manic-depressive illness.
Pharmacological effects and mechanism
of a ction
Lithium is clinicaJiy effective at a plasma concentration of
0.5-1 mmoVl. and above 1.5 mmoVl it produces a variety of toxic
effect~. l>O the therapeutic window is narrow. In normaJ subjccll>.
I mmoVllithium in plasma has no appreciable psychotropic effects.
It docs. however. produce many detectable biochemicaJ changes.
and it i<; Mill unclear how these may be related to its therapeutic
effect.
Lithium is a monovalent cation that can mimic the role of a+
in excitable tissues. being able to permeate the voltage-gated Na+
channel~ that are responsible for action potentiaJ generation (sec
Ch. 4). It is. however, not pumped out by the Na+/K+ ATPase,
and therefore tends to accumulate inside excitable cells, leading to
a partial loss o f intracellular K+, and depolarisation of the cell.
The biochemicaJ effects of lithium are complex, and it inhibits
many ervymes that participate in signal transduction pathY.a}
Its therapeutic actions are generally ascribed to two mechani'n
(11ce Phiel & Klein, 200 1).
Inhibition of inositol monophosphatase, which blocks the
phosphat idyl inosito l (PT) pathway (see Ch. 3) at the point
where inositol phosphate is hydrolysed to free inositol,
resulting in dep letion of PI. This prevents agonist-stimulated
inositol trbphosphatc formation through various PI-linked
receptors, and therefore blocks many receptor-mediated effecb
Inhibition of glycogen synthase kinase, which phosphorylate
a number of key enz.ymes involved in pathways leading to
apopto~is and amyloid formation (see Phiel & Klein, 2001 J.
Lithium aJ~o inhibits hormone-induced cAMP production illl:
blocks other cellular responses (e.g. the response of renal tububr
cells to antidiuretic hormone, and of the thyroid to th}roic
stimulating hormone: see Chs 24 and 29, respectively). Thi'
not, however. a pronounced effect in the brain.
The cellular selectivity of lithium appears to depend on
selective uptake, reflecting the activity of sodium channel\
different cells. This could explain its relatively selective acti
in the brain and kidney, even though many other tissues u'~
the same second messengers. Notwithstanding such insights. 0111
ignorance of the nature of the disturbance underlying the mooo
swings in bipolar depression leaves us groping for links between
the biochemical and prophylactic effects of lithium.
 ANTIDEPRESSANT DRUGS

Pharmacokinetic aspects and toxicity Thyroid enlargement, sometimes associated with

Lithium i~ given by mouth as the carbonate salt and is excreted hypothyroid ism.
b) !he kidney. About half of an oral dose is excreted within about Weight gain.
12 boUTS-the remainder, which presumably represents hthium
Acute lithium toxicity results in various neurological effects,
lilin up by cells. is excreted over the next 1-2 weekl.. This
progressing from confusion and motor impairment to coma,
1~ ~low phase means thaL with regular dosage, lithium accumu-
convulsions and death if the plasma concentration reaches
~ ~lowly over 2 weeks or more before a steady state is
~ached. The narrow therapeutic window (approximately 0.5-
3-5 mmol/1.
1.5 mmoVI) means that monitoring of the plasma concentration is
e,1ential. Na+ depletion reduces the rate of excretion by
tncreasing the reabsorption of lithium by the proximal tubule,
and ums increa\e:, the likelihood of toxicity. Diuretics that act Clinical use of mood-stabilising drugs
dl,talto the proximal tubule (Ch. 24) also have this effect, and
renal disease also predisposes to lithium toxicity. Lithium (as the carbonate) is the main drug.
The main toxic effects that may occur during treatment arc It is used:
a1 follows. in prophylaxis and treatment of mania, and in the
prophylaxis of bipolar or unipolar disorder (manic
o 1\ausca. vomiting and diarrhoea. depression or recurrent depression).
o Tremor. Points to note include:
o Renal effect!.: polyuri a (with resulting thirst) resulting from there is a narrow therapeutic window and long
inhibition of the action of antidiuretic hormone. At the same duration of action
time. there is some a+ retention associated with increased acute toxic effects include cerebellar effects,
aldosterone secretion. With prolonged treatment, serious nephrogenic diabetes insipidus (see Ch. 24) and
renal tubular damage may occur, making it essential to renal failure
monitor renal function regularly in lithium-treated patients. dose must be adjusted according to the plasma
concentration
elimination is via the kidney and is reduced by
llood-stablllslng drugs proximal tubular reabsorption. Diuretics increase
the activity of the reabsorptive mechanism and
1 Inorganic ion taken orally as lithium carbonate. hence can precipitate lithium toxicity
1 Mechanism of action is not understood. The main thyroid disorders and mild cognitive impairment
biochemical possibilities are: occur during chronic use.
- 1nterference with inositol trisphosphate formation Carbamazepine and valp roic acid (sodium channel
- 1nh1b1tion of kinases. blockers with antiepileptic, Ch. 40, and analgesic
1 Alternative drugs (e.g. carbamazepine, valproate, action, Ch. 41) are used, respectively, for the
gabapentin) are gaining favour for treatment of prophylaxis and treatment of manic episodes in
mania, because of better side effect and safety profile. patients with bipolar disorder unresponsive to lithium.
ed

REFERENCES AND FURTHER READING

Pllhogtnesis or depreMi>e illness
BJ.:rG 8 [)e,..hur~l ~ G 1985 Biochemical lhcone' of
all'o:llcdJ-cnJcto, ln ONhul'\t W G, Baker G B (e<hl
l'1larmaoolberap) of alleclt\'e disorders. Croom Helm.
BW.Iwn (Useful l'l'llt'\l of ~arliu hypoth~u.l
rr 1wm~ monoamin~ dllturbtmc~' to 11!()()(/ di;ortlen)
Ch:tn1e~ DS, Manji J\.1 K 2004 Lfe stres;, gene;, and
its d<pres,ion: multiple pathways lead to increased risk
tn .md new opponunitic' for intervention.
ion haj'J/v."'"'Mke.org (l)etmled re>iew of currmt
liN!mtw!dmR if th<' {'llthophvsiology ofdepressron.
~ ...e noDiasinn~ the rok t>/ n~urol plasticif)' tleuroJ:melil
ur noptOiis)
10d lb= RS 2001 Depre"oon: ca<oe of neuronal hfc and
d<..lh' Bioi p,ychiatry 56: 14(}-145 (RI!I'i<'II'J ewlena
en
~gtJtmg tlulllleurmwllou in the hippocampuJ /llod
pr<Jronral conex rest It,\ in tlepressive symplom.r. ami
tlrar antideprt'S\tmll arr itrdirec1/y to pmmme
n~umgenesif)
Maes M. Meltz<:r H Y 19951be serotonm h)pothe~o\ of
maJOr depresion. In Bloom FE. Kupfer D J (~'d\)
Psychophannacology: the founh gcncr.ltion of progre,s.
Raven Pres,, New York (Reut'\l' showing lro" emp!oa.\i.\
loas shifted rcmortl> tloe invohement of 5HT. mtlrer
tloan noradremoline, in tloe aetiology of tlepression )
Manji H K. Drevets W C. Charney D S 2001 The
cellular ncuroboology of depres,ion. Nat Med 7:
541-547 (Spet:ulmi f'l'>iew of the po.uiblt
nredu111isms mul role t>/tleurode~:mero/IOII ami
~~europlruticoty m tlq>f't'<.lil'e dirordet'$, allempting 11>
IIIOI'l' beyond tlrr mon01urome tioMry)
Porsolt R D 1985 Animal models of afTcctiYe d~>order>.
In: Dewhurst W G. Baker G B (eds) Phannacothcrnpy
o f affective disorder~. Croom Helm, Beckenluun
(Useful re1 '"" <if""'"'"' models. still mom!! >lllitl
despite dille)
Santarelli L. Saxe 111. Gro'-' C el al. 2003 Requorement
of luppocan>J"iil neurogenesis fOf' the heha'looral
effects of antidepre"anls. Science 30 l : 805 1!09
(Study in rots .\ttggrrltn8 tloat gro" tlo of nnv
lrippocampol neumm is responsible for anritlrpres.mnt
effects: commetllmy in a me issue of Science.
fl. 757)
Shih J C. Chen K. Rodd M J 1999 Monoamonc o~ ida-.e:
from genes 10 behaviour. Annu Rev Neurmc1 22.
197-217 (Rn1n1 t>frt'UIII,.Ori on trun<~rrnocmtu
,.it/1 MAO mututilln or delnion)
Wong M-L. Locmoo J 200 I Research and trenuncnt
approache> to dcpre>'iOn. Nat Rev Neuro\Co 2:
343- 351 (.1C<'IIe111 ,lummal}' of th~ current
somewhat pat('h.\'-Stme of knowledge llhom the
573
 Antiepileptic drugs
Overview 575
1M nature of epilepsy 575
-Types of epilepsy 576
-Neural mechanisms and animal models of epilepsy 577
Mechanism of action of antiepileptic drugs 578
Antiepileptic drugs 579
-Phenytom 580
-Corbomazepine 581
-Volproote 581
-Ethosuximide 581
-Phenobarbital 582
-Benzodiazepines 583
-Newer anliepileplic drugs 583
-Other uses of anliepileplic drugs 584
[ Muscle spasm and muscle re laxants 584
OVERVIEW
Epilepsy is a very common disorder, characterised
by seirures, which take various forms and result
from episodic neuronal discharges, the form of the
seizure depending on the part of the brain affected.
Epilepsy affects 0.5-1% of the population. Often,
there is no recognisable cause, although it may
develop after brain damage, such as trauma,
infedion or tumour growth, or other kinds of
neurological disease, including various inherited
neurological syndromes. Epilepsy is treated mainly
with drugs, although brain surgery may be used
for a very few suitable severe cases. Current
antiepileptic drugs are effective in controlling seizures
in about 70% of cases, but their use is often limited
by side effects. In addition to their use in patients
with epilepsy, antiepileptic drugs are used to treat
or prevent convulsions caused by other brain
diseases, for example trauma (including following
neurosurgery), infection (as an adjunct to antibiotics),
broin tumours and following cerebral infarction.
Far this reason, they are sometimes termed
anticonvu/sonts rather than antiepileptics. A separate
important use discussed in Chapter 41 is in
treating neuropathic pain. Many new antiepileptic
drugs have been developed in the past 1 5-20 years
-one of the most active areas of drug development-
in attempts to improve their efficacy and side effect
profile. Improvements have been steady rather
than spectacular, and epilepsy remains a difficult
problem, despite the fact that controlling
reverberative neuronal discharges would seem, on
the face of it, to be a much simpler problem than
controlling those aspects of brain function that
determine emotions, mood and cognitive function.
In this chapter, we describe the nature of epilepsy,
the neurobiological mechanisms underlying it, and
the animal models that can be used to study it. We
then proceed to describe the various classes of
drugs that are used to treat it, the mechanisms by
which they work and their pharmacological
characteristics. More information on the topics
covered here is given by Eadie & Vajda ( 1999) and
Levy et al. (2002).
Centrally acting muscle relaxants are discussed
briefly at the end of the chapter.
THE NATURE OF EPILEPSY
The characteristic event in epilepsy is the seizure, which is
associated with the episodic high-frequency discharge of
impulses by a group of neuron~ in the brain. What stans as a
local abnonnal discharge may then !>pread to other areas of the
brain. The site of the primary discharge and the extent of its
spread determine the symptoms that are produced, which range
from a brief lapse of anention to a full convulsive fit lasting for
several minutes, as well as odd sensations or behaviours. The
particular symptoms produced depend on the function of rhe
region of the brain that is affected. Thus involvement of the
motor cortex causes convul~ions; involvement of the hypothala-
mus causes peripheral autonomic discharge, and involvement of
the reticular formation in the upper brain stem leads to loss of
con:.ciousness.
Abnormal electrical activity during and following a seiture
can be detected by electroencephalography (EEG) recording
from electrodes distributed over the surface of the scalp. Various
types of seizure can be recot,'1lised on the basis of the natme and
distribution of the abnormal discharge (Fig. 40.1). 575
 SECTION 4 . THE NERVOUS SYSTEM

'i] Normal [B Generalised seizure (grand mal)

- tonic-clonic type
j,
=~t t:r-t:'L -----------
1 3 4
--~--~-----------------F
T - -4.~~ ~
Fig. 40.1
Electroencephalography (EEG)
records In epilepsy. ~ Normal EEG
~--_. ....,.
~~~~~~~--0
~-. ..,
~------------~------------- ..._._ -'fi/1 "--\l'-,-.......Jr "'--"'-''-''-"
-~~~ ~i~~ ~--
~ ~,1.:.~ 1~\Nrt ~
recorded from frontal (F), temporal (T)
and occipttal (0) sites on both sides,
as shown in the inset diagram. The a
rhythm (1 0/s) can be seen in the
occipital region . {DJ Sections of EEG
recorded during a generalised @] Generalised seizure (petit mal) [OJ Partial seizure
tonic-clonic (grand mal) seizure: 1, - absence seizure type
normal record; 2, onset of tonic
phase; 3, clonic phase; 4,
postconvulsive coma. I.QJ Generalised
absence seizure (petit mal) showing
sudden brief episode of 3/s 'spike
and wave' discharge. [QJ Partial
seizure with synchronous abnormal
discharges in left frontal and
temporal regtons. (From Eliassen
S G et al. 1978 Neurological
pathophysiology, 2nd edn. Oxford
Untverstty Press, New York.)

TYPES OF EPILEPSY
The clinical classificatio n of e pilepsy define!> two major
categories, namely partial and generalised seizures, although
there is some overlap and many varieties of each. Either form
is classified as simple (if consciousness is not lost) or complex
(if consciousness is lost).
PARTIAL SEIZURES
Partial sciwres are those in which the discharge begins locally
and often remains localised. The symptoms depend on the brain
region or regions involved, and include involuntary muscle
contractions, abnormal sensory experiences or autonomic
discharge, or effects on mood and behaviour, often termed
psychomotor epilepsy. The EEG discharge in this type of
epi lep~y i~ normally confined to one hemisphere (Fig. 40.1 0).
Partial sei.wres can often be attributed to local cerebral lesions,
and their incidence increases with age. In complex partial
seizures, loss of consciousness may occur at the outset of the
attack, or somewhat later. when the discharge has spread from itc;
site of origin to regions of the brain stem reticular formation.
An epileptic focu~ in the motor cortex results in attacks,
sometimes called jacksonian epilepsy, 1 consisting of repetiti ve
jerking of a particular muscle group, beginning on one side of
1
After Hughling~ Jack~on. a distinguished t 9th century Yorksh ire
ncurologbt who published his oul~tanding work in the Annals of rhe Wesr
576 Ridinll Lunatic Asylum.
the body. often in the thumb. big toe or angle of the mouth, \\ht
\pread~> and may involve much of the body within about
minute~> before dying out. The patient loses voluntary control rl.
the affected parts of the body but does not necessarily IO"x
conl.CiOu!.ness. In psychomotor epilepsy, which is ofte
associated with a focus in the temporal lobe, the attack m~.
cons ist of s tereotyped purposive movements such as rubbing <r
palling move ments, or much more complex behaviour such"'
dressing, walking or hair combing. The seizure usual ly la~ts 111
a few minutes, after which the patient recovers wi th m
recol lection of the event. The behaviour during the seizure can be
bizarre and accompanied by a strong emotional response.
GENERALISED SEIZURES
Generalised seizures involve the whole brain, including the reticular
system, thus producing abnormal electrical activity
both hemispheres. fmmediate loss of consciousness is characten\lti:
of generalised seizures. Two important categories are tonic-<IOt
sei:ures (grand mal. Fig. 40.1B) and absence sei:ures (petit m:.
Fig. 40.1 C). A tonic-clonic seizure consists of an initial Mroo.
contraction of the whole musculature. causing a rigid e).ten ...
spasm and an involuntary cry. Re piration stops, and defecati~
micturition and salivation often occur. This tonic phase la~b ~
about I minute, during which the face is suffused and
blue (an important clinical distinction from syncope, the
disorder from which fits must be distinguished, where the face
ashen pale), and is followed by a series of violent, synchronou
jerks that gradually die out in 2-4 minutes. The patient Sta)'
unconscious for a few more minutes and then gradually rccovel\
 feeling ill and confused. i njury may occur during the convulsive
ept~t)(k The I:.EG shows generalised continuous high-frequency
BCUI II} in the tonic phase and an intenniuent di scharge in the
lome rha-.c.
Ab,encc o,ei1ures occur in children: they are much Jess
dramauc but may occur more frequently (many seizures each
dJ}l than tonic-clonic \eitures. The patient abruptJy ceases
v.h:ue\'er hi! or 'he was doing. ometimes stopping speaking in
mxJ.-entcncc. and \tare~ vacantly for a few seconds, with linle
or no motor disturbance. Patients are unaware of their
surroundtng'> and recover abruptl y w ith no after-effects. The
EF.G pattern show~> a characteri stic rhythmic discharge during
lhe pcnod of the seizure (Fig. 40.1 C). The rhythmicity appears
111 Ill! due to oscillatory feedback between the cortex and the
thalamus, the special properti es of the thalamic neurons being
d~pcndcnt on the calcium channels that they express (see
1\illoughhy, 1999). The pattern differs from that of partial
'wure,, where a high-frequency asynchronous discharge
'preads out from a local focus. Accordi ngly (see below), the
drug' u'cd 'pccifically to treat absence seizur es act mainly by
bkdmg calcium channels, whereas drugs effective against other
l)pc' of epilepsy act mainly by blocking sodium channels or
enhanctng GABA-mediated inhibition.
:\ panicularly \e\ere k ind of epi lepsy, Lennox-Gastaut
:ndmme. occurs in children and is associated with progressive
mental retardation, pos~ibly a ren ection of excitotoxic neuro-
J!g~ocmtion (-.ec Ch. 35). About one-third of cases of epilepsy
.ue famtlial, and a few \peci fic gene defects accounting for
we fonm of the di\order have been identified (see Steinlein,
I of 2~\. Most of these encode neuronal ion channels closely
osc m10lled in controlling action potential generation (see Ch. 4),
ten 1U1:h il\ voltage-gated sodium and potassium channels, GABAA
nay receptor\ and nicotinic acety lcholine receptors. Other genes of
or unlml\\n function may also be involved,2 and it is clear that
as ~~:uure' can be the end result of many kinds of disorder at the
for cllular level. Therefore- a familiar theme in central nervous
no ')stem dmgs- antiepileptic drugs aim to inhjbit the abnormal
1 be nturonnl discharge rather than to correct the underlying cause.
With optimal drug therapy, epilepsy is controlled completely
mabout 75% of patients, but about 10% (50 000 in Britain)
contmuc to have seit.ures al intervals o f I month or less, w hich
~t"' ercl} di~rupt\ their life and work . There is therefore a need to
~ Jar 1IDpro1c the efficacy of therapy.
OUt Sra1111 epilepricus refer1. to continuous uninterrupted seizures,
:;tic rtqutnng emergency medical trealment
'n ic
ial.
mg NEURAL MECHANISMS AND ANIMAL
sor MODELS OF EPILEPSY
on. Th! underlying neuronal abnonnaliry in epilepsy is poorly understood.
for In gellt'1':11. excitation will natumlly tend to ~pread throughout a network
'tes
!lin
1 is
In on~ type. the mutation turned out to be in a ubiquitous e ndogenous
IUS
pM~a,einhibitor. cystati n B. prcv iou ~l y un>uspcctcd of any connection
tys ~nhneuronal function. Comment of an expert in epilepsy genetics, quoted
1rs, mSde11u: ' floy, what a ~urpri sing thing!'
of interconnected neuron' but is nonnally prevented from doing >o by
inhibitor} mechani\m'-. Thu' epileprogenesis can arise if excitatory
tran~mh\10n h facilitated or inhibitory tranSmission is reduced. In cenain
n.>sp..>cts, cpileptogcnc~i!. ~mbl~ long-term potentiation (Ch. 33), nod
~im1lar type~ of u!>e-dcpcndcnt synaptic plasticiry may be in,olved (see
Kulmann et al., 2000). Becau!>C detailed studies are difficult to carry out on
epileptic pauent~. man) d11ferent noimal models of epilepsy ha,e been
invesug:ucd (',ec Sarki\lan, 200 I). These include a variet} of genetic
\troin~ that \hO~ cpilcp~y-likc characteristics (e.g. mice that con~ulse
briefly m response to certain sounds. baboons that show photically
induced sei1ures. and beag!~ with no inherited abnonnaliry that clo..ely
re,embles human epilepsy). Recently, several tran~genic mouse ~trains
have been n:p<lrted that show '>pontaneous seizures. The) include
knockout mutations of various ion chnoncls. receptors and other synaptic
proteins. It 1\ too early to say whether these will be useful as models of
human epi lepsy. Local cortical damage (e.g. by applyi ng alumin ium
oxide paste or cryMals of a cobalt >all) re~ults in focal epilepsy. Local
application of penicillin crystals has a si mil ar effect, probably by
interfering with inhibitory !.ynaptic transmission. Convulsant dmgs such
a~ pentylenetetrazol (PTZ : see Ch. 42) are often used, particularly in
1he testi ng of untiepileptic agents, and seizure caused by electrical
stimulation of the whole bru in arc used for the same purpose. It has been
found empirically that drugs that inhibit PTZ-induced convulsions and
Nature of epllepy
Epilepsy affects about 0.5% of the population.
The characteristic event is the seizure, which may be
associated with convulsions but often takes other forms.
The seizure is caused by an asynchronous high-
frequency discharge of a group of neurons, starting
locally and spreading to a varying extent to affect
other parts of the brain. In absence seizures, the
discharge is regular and oscillatory.
Partial seizures affect localised brain regions, and the
attack may involve mainly motor, sensory or
behavioural phenomena. Unconsciousness occurs
when the reticular formation is involved. Generalised
seizures affect the whole brain.
Two common forms of epilepsy are the tonic-clonic
fit (grand mal) and the absence seizure (petit mal).
Status epilepticus is a life-threatening condition in
which seizure activity is uninterrupted.
Many animal models have been devised, including
electrically and chemically induced generalised
seizures, production of local chemical damage, and
kindling. These provide good prediction of
antiepileptic drug effects in humans.
The neurochemical basis of the abnormal d ischarge is
not well understood. It may be associated with
enhanced excitatory amino acid transmission,
impaired inhibitory transmission, or abnormal
electrical properties of the affected cells. Several
susceptibility genes, mainly encoding neuronal ion
channels, have been identified.
Repeated epileptic discharge can cause neuronal
death (excitotoxicity).
Current drug therapy is effective in 7D-80% of patients.
577
 SECTION 4 . THE NERVOUS SYSTEM
rai'>e 1he thre\hold for production of electrically induced seizures are
generally effective again\t ab'>ence sei1ure~. wherea~ those thai reduce
the dural ion and 'pread of electrically induced convubion~ are effective
in focal1ypes of epilep\y ~uch ~ tonic-clonic seit.ures.
The ki11111ing model may approximate the human condition more closely
lh<m direcll) e\oked 'e11ure models. Low-intensity electrical stimulation
of ccna1n rcg1on' of the hmb1c S) \tern. wch ~ the amygdala, "ith
implanted electrode\ nonnall) produces no seizure respon..c. If a brief
period of '''mulauon 1~ repeated dail) for several days. however, the
re~pon'e gradually increa\C~ umil very low levels of stimulmion will
evoke u full 'ei1ure. and eventually seizures begin to occur
spontaneou\1). Once produced. 1he kindled state persbts indefinitely.
Thio; change b prevented by NMDA recep1or amagoniMs. and may
involve proces\e~ \imilar 10 those that cause long-term potenl iation
of synaptic trnn,mi~'ion in 1he hippocampus (see Ch. 33 ). Ln human
focal cpilcp,ic,, surgica l removal of a damaged region of cortex of1en
fails IO cure the condition, m, !hough 1he abnormal discharge from 1he
region of primary damage had somehow produced a seconda ry
hypcrexcilabi lily elsewhere in the brain. Furthermore. prophylac1ic
1reatmen1 with an1iepilep1ic drugs for 2 years following severe head
injury reduce~ 1hc ~ub.,equent incidence of posl-lraumalic epilep~y. wh ich
~uggesl\ lhat a phenomenon ~imilar to kindling may underlie this form
of epilep~y.
The kainat~ model emails a single injection of the glutamate receptor
agoni'l kainic acid IIllO the amygdaloid nucleus of a rat Afler tran\iem
inteno;e ~1imula1ion. ~pontaneou' !>eiure~ begin to occur 2-4 weeh larer.
and then conunue ndelinilely. It i~ believed that excitotoxic damage to
inhibi1ory neuron\ i' re\pon"ble, ~..ocialed wilh ~rruc1ural remodelling
of excilatory '> naptic connection\. changes that rna) also be a factor
m human ep11Cp\IC\.
\leu ron' from "hich the epileptic discharge originates di~pla) an unu\ual
1ype of electrical behaviour 1enned 1he paroxysmal depolarising .1hift
(PDS). dunng wh1ch the membrane potenlial sudden!) decre~e, by
about 30m V and remains de polarised for up to a few seconds before
relurnmg to nonnal. A burst of action potentials often accompanies 1hi'
depoluri'>:lllon (rig. 40.2). This event probably results from the
~~_M__M__]so l Other mechanisms include inhibition of glutamate release anJ
500 ms mv
'--""k__X
1s
Fig. 40.2 'Paroxysmal depolarising shift' (PDS)
compared with experimental activation of glutamate
receptors of the NMDA type. A PDS recorded with an
intracellular microelectrode from cortical neurons of
anaesthetised cats. Seizure activity was induced by topical
application of penicillin. ~ Intracellular recording from caudate
nucleus of anaesthetised cat. The glutamate analogue NMDA
was applied by ionophoresis from a nearby micropipette. Note
the periodic waves of depolarisation, associated with a burst of
action potentials, which closely resemble the PDS. (From: (A)
578
-;.---- l Matsumoto H, Marsan C A 1964 Exp Neural 9: 286; (B)
Herrllng P Let al. 1983 J Physiol339: 207.)
abnormally exagicra1cd and prolonged action of an exci1ow
lran\miuer. Aclivarion of NMDA receptors (see Ch. 33) produ.
'pl:ueau-\haped' depolarising responses very similar to lhe PDS. a\ 11
a\ ini1ia1ing 'ei1ure acth lly. Thh membrane response occur.. be..:aw
of the \Oitage-dependenl blocking ac1ion of ~1g1 on channel\ op.:rnttd
by \IMOA receptor.. (see Ch. 33). Glutamate mus1 undoublediJ
pan1c1pale 111 1he epileptic discharge. but efforts to de,elop glmarn:~t
anlagoni\1\ a\ ant1epilep11c drugs have mel with little succes~- It i\ k0011
Ihat repealed 'ei1ure acti\ ily can lead 10 neuronal degeneration. Pl"'bly
due 10 C'CIIOIOXiCIIY (Ch. 35 ).
Studic' on experimenlal epilep~) in the kindling or kainate modeb h.n
re~ealed u detici1 111 variou\ biochemical marker~ of GABA-medird
inhibi1ory lrammi~;ion. and an inc~e of markers associmetl "
glulamate-medmed exciralion (see Jarrott. 1999). Human s1Ud1e' lmc
'hown le~., con~iMent change'>. allhough Mudies on brain ;ampk
removed at operation \uggesr thm the epileptic focu'> comain., mon
glurammc than normal: the GABA content is no1 affec1ed. Pola,\ium-
Mimulalcd gluwmatc release is also increased in the epileptic loc~
compared with in normal tissue.
Rcccm ~llldie~ (~ee Binder el al.. 200 1) suggest 1.hm IWIImlrophi'
parlicularly hr11in-deri ved nenrot roph.ic factor (BDNF). may pia) 1
role in cpilcptogcncsi'>. BDNF, which acts on a membrane reccpll'
1yrosinc kina;c (Ch. 3). enhances membrane excitabili1y and al
\limulalc'> ~ynapse formation. Production and release of BDNF
increa\ed 111 1hc kindling models. and there is also evidence for
in\OI\cmenl in human epilep~y. Specific blocking agenls repre..cm
JXl''iblc future \tratcgy for treating epilepsy but remain 10 be idenuficd
MECHANISM OF ACTION OF
ANTIEPILEPTIC DRUGS
Three main mechanisms appear to be important in the action 11
antiepilcptic drug~ (sec Meldrum. 1996; Rogawsk.i & Loschcr
2004a):
enhancement of GABA action
inhibition of sodium channel function
inhibition of calcium channel function.
block of glutamate receptors. Many of the cutTen t antiepilcptic
drugs were developed empirically on the basis of activity i
animal models. Their mechanism of action at lhe cellular level
is not ful ly understood. As with drugs used to treat cardi ...
dysrhythmia!> (Ch. 18). the aim is to prevent lhe paroxysm.!
discharge without affecting nom1al tranSmission. It is clear ()-
properties l>UCh as use-dependence and voltage-dependence~
channel-blocking drugs (see Cb. 4) are important in achie,in
lhis selectivity, but our understanding remains fragmentary.
Enhance me nt of GABA action
Several antiepileptic drugs (e.g. phenobarbital :ml
benzodiazepincs) enhance the activation of GABAA receptor;
thus facilitating the GABA-mediated opening of chloria,
channels (see Chs 3 and 37). 3 Vigabatrin (see below) acts b
inhibiting lhe enLyme GABA transamina<;e, which is respon,ibl.
J Absence sei1ure~. paradoxically, are ofteo exacerbated by drugs thai
enhance GA BA activity (see Manning et aL, 2003) aod beuer treated by
drug~ uc1ing by differcnl mechan i!.mN.
 ANTIEPILEPTIC DRUGS

for ma~tivating GABA, and tiagabine inhibits GABA uptake;

beth thereb} enhance the action of GA BA as an inhibitory trans- Mechanism of action of antleplleptJc
mtta Gabapentin (~ee below) was designed as an agonist at drugs
G-\BA, receptor~. but ironically w~ found to be an effective
anuepilepllc drug de~pite ha' ing little or no effect on GABA Current antiepileptic drugs are thought to act mainly
rune recepiOI\ or on the tran,poner; it has high affinity for a particular by three ma1n mechamsms:
ubunit (<t;O) of voltage-gated calcium channels (see Ch. 4), but reducing electrical excitability of cell membranes,
'llk.>cham\m of action remain!> uncertain (see M acdonald, !999). mainly through use-dependent block of sodium
channels
Inhibition of sodium channel function enhancing GABA-mediated synaptic inhibition;
S:wal of the mo~t important antiepileptic drugs (e.g. this may be achieved by an enhanced
phen)toin. carbam azepine. valproate, l am otrigine) affect postsynaptic action of GABA, by inhibiting GABA
mernhrane excitabil ity by an action on voltage-dependent transaminase, or by drugs with direct GABA
,rJium channe l~ (sec Ch. 4), which carry the inward membrane agonist properties
.urrcm neccs'ary for the generation of an action potential. Their inhibiting T-type calcium channels (important in
hloc~mg action shows the property of usc-dependence (see Ch. controlling absence seizures).
4l: 10 other words. they block preferentially the excitation of cells Newer drugs act by other mechanisms yet to be
in>. :hJt <11\! liring repetitively, and the higher the frequency of firing, elucidated.
yu Drugs that block glutamate receptors are effective in
the greater the block produced. This characteristi c, which is
lvr animal models but are unsuitable for clinical use.
.,
'"'
rehant to the ability of drugs to block the high-frequency
d1...:hargi! that occurs in an epileptic fit without unduly interfering
ib "1th the low frequency firing of neurons in the normal state,
~~ a
art.IC\ from the ability of blocking drugs to discriminate between
etl. it also acts by inhibiting excitatory synaptic responses, although
~lium channeb in their rcMing. open and inactivated states.
little is known about the mechanism.
Dqx!lari\allon of a neuron (~uch a~ occurs in the PDS described
Phenytoin ha'> been ~tudied in great detail. It not only causes
Jbtllel increa'>C\ the proportion of the sodium channels in the
usc-dependent block of ~odium channels (see above) but also
.nxll\ated '>tate. Anticpileptic drug:. bind preferentially to
affects other aspects of membrane function, including calcium
ch:mnef, 111 th1s '>tate. prevcming them from returning to the
channel!> and po~t-tetanic potentiation, as well as intracellular
of rNang -.tate. and thus reducing the number of functional
protein pho,phorylation by calmodulin-activated kinases, which
er, cr.mncb available tO generate action potentials.
could abo interfere with membrane excitability and synaptic
function.
Inhibition of calcium channels
ewer anti epileptic drug!> such as Jevetiraeetam and
~mal anticpilcptic drugs have minor effects on calcium
zonisamide act by mechanisms that are as yet poorly under-
,hanneb (sec Table 40.1 ), but only ethosuximide specifically
stood, although they have weak effects on several of the targets
block' the T-type calcium channel , activation of which is
discussed above.~
d belimd to play a role in the rhythmic discharge associated with
One theme, which has become familiar in earlier chapters
Itic ~b,encc sci7ures (Khosravani et al., 2004). G abapeotin acts
in th e central nervous system section of thi s book, is that
in on L-typc calcium channels by binding to the o.2 subunit o antagonists at excitatory amino acid receptors have not, despite
>.'e] "l'e below), but whether this is important for its antiepileptic
showing efficacy in animal models, proved useful in the clinic,
iac propc11ic~ b uncertain.
because the margin between the desired anticonvulsant effect and
tlal
unacceptable side effects, such as loss of motor coordination,
hat Other mechanisms
is too narrow.
of Tie action of many antiepileptic drugs remains poorly
ng unde~tood (~ee Meldrum. 1996: Macdonald. 1999; Levy et al.,
2002). Phenobarbital i.., a barbiturate (see Ch. 37) that has a ANTIEPILEPTIC DRUGS
grtJter antiepileptic effect and relatively less sedative action
:han other barbiturates. aJthough its GABA-potentiating action The term antiepileptic i~ used synonymously with anriconwdsant
nd ,jmilar. However. phenobarbital is as effective against to describe drugs that are used to treat epilepsy (which does not
electrically induced convulsions as it is against PTZ-induced necessarily cau~ convulsions) as well as non-epileptic convu l~ive
rom ul~ion., in rats or mice, whereas benzodiazepines. which disorders.
XI 'imilarly on GABA-mediated transmission. are without
eltt~:t on electricallyinduced convulsions. Phenobarbital reduce!>
tile electrical activity of neurons within a chemically induced
epilept1c focus wi thin the cortex, whereas diazepam (a
"The highly complex action~ of current anliepileptic drugs are apt !O make
benzodiazepine) docs not suppress the focal activity but prevents
discouraging reading for tho>e engaged in trying to develop new drugs on
1tlrom spreading. The action of phenobarbital cannot therefore simple rational principle~. Serendipity, not science. appears tO be the path to
be due solely to its interaction with GABA, and it i s likely that therapeutic success. 579
 SECTION 4 . THE NERVOUS SYSTEM

Antiepileptic drug!> are f-ully effec6ve in controlling seizures
in 50-80% of patient~. although unwanted effects arc common
(see below). Patients with e pilepsy usually need to take drugs
continuously for many years, so avoidance of side effects is
particularly important. This also explains why some drugs that are
largely obsolete because of their adverse effects are still quite widely
used even though they are not drugs of choice for newly diagnosed
patients. There is clearly a need for more specific and effective
drugs, and several new drugs have been recently introduced for
clinical use. Long-esrablished antiepileptic drugs (see Table 40.1)
include phenytoin . carba m azepine. valproate, ethos uximjde
and phenoba rbital, together with various benzodiazepines. such
as diazepa m , clonazcpam and clobazam. Newer drugs include
vigaba trin, gahapcntin , la motriginc, fclbamate, tiagabine,
topirama tc, lcvctiracctam and zonisamide. The length of this list
reflect~ the etTorts being made to improve on the far from ideal
prope11ics of the earlier drugs. In general, the newer drugs are less
likely tO interact pharmacokinctically with other drugs (see Ch. 52)
and have fewer adverse effects. although their efficacy in controlling
seizures is no greater. The selection of drugs from this large
available menu depends o n many clinical factors and is covered
in specialised textbooks.
PHENYTOIN
Phenytoin is the mo<ot important member of the hydantoin group
of compound\, which are structurally related to the barbiturdtcs. l t
is highly effective in reducing the intensity and duration of
electrically induced convulsions in mice, al though ineffective
against PTZ-induced convulsions. Despite its many side effects
and unpredictable pharmacokinetic behaviour, phenytoin is
widely used. being effective agai nst various forms of partiaJ and
generalised seizures, although not against absence seizures,
which may even get worse.
Pharmacokinetic aspe cts
Phenytoin has certain phannacok.inctic peculiarities that need
to be taken into account when it is used clinjcally. It is well
absorbed when given orall y. and about 80-90% of the pla'm
conte nt is bound to albumin. Other drugs, such as salicylate'
phenylbutamne and valproate, inhibit this binding competiti\t
(see Ch. 52). This increases the free phenytoin conccntrati
but also increases hepatic clearance of phenytoin. so m:ry
enhance or reduce the effect of the phenytoin in an unpredictable
way. Phenytoin is metabolised by the hepatic mixed functi
ox ida. e system and excreted mainly as gluc uronide. It caux
enzyme induction, and thus increases the rate of metaboli'r
of other drugs (e.g. oral anticoagulants). The metabolism 0'
phenytoin itself can be either e nhanced o r competiti\el)
inhibited by various o ther drugs that share the same hepati,
enzymes. Phenobarbital produces both effects, and becau~e
competitive inhibition is immediate whereas induction takes
time, it initially enhances and later reduces the pharmacological
activity of phenytoin. Ethanol has a similar dual effect.
The me tabolis m of phe nytoin shows the characteristic of
saturation (see Ch. 8), which means that over the therapeutic
plasma concentratio n range the rate of inactivation does nol
increase in proportion to the plasma concentratio n. The
consequences of this are as follow.
The plasma half-life (approximately 20 hours) increases as
the dose is increased.
The steady-state mean plasma concenr:ration, achieved when
a patient is given a constant daily dose, varies
disproportionately with the dose. Figure 40.3 shows that, in
one patient, increasing the dose by 50% caused the stead>-
statc plasma concentration to increase more than fourfold.
The range of plasma concentration over which phenytoin 11
effective without causing excessive unwanted effects is quite
narrow (approximately 40-100 !AffiOl!l). The very steep relation-
ship be tween dose and plasma concentration. and the man}
interacti ng factors, mean that there is considerable individual
variation in the plasma concentration achieved with a given
dose. A radioimmunoassay for phenytoin in plasma is available.
and its usc has helped considerably in achieving an optimal
therape utic effect. The past tendency was to add further dntgs in

150

s0
E
Fig. 40.3 No n-linear relations hip ~
between daily dose of phenytoin 5 100 -----------
:;::;
and steady-sta te plasma ~
concentration in five individual cCD
huma n s ubjects. Although the 0 Therapeutic
c
therapeutic range is quite broad 0 range
(4Q-100 1-1moVI), the daily dose
required varies greatly between
e
0
so
individuals, and for any one individual a:"'"'
the dose has to be adjusted rather
precisely to keep within the
acceptable plasma concentration
range. (Redrawn from Richens A, 2 3 4
Dunlop A 1975 Lancet 2: 247.) Daily dose (mmol) )
580
- -- ---- up
1la!>ma rue' where a single drug failed to give adequate control. It is
t Late~. 0011 recognised that much of Lhe unpredictability can be ascribed
itively 1n phannacokinetic variability, and regular monitoring of plasma
sation ~:onccntration has reduced the use of polypharmacy.
ma}
,ctable Unwanted eHects
rJCUOn Std~ effects of phenytoin begin to appear at plasma concen-
:auscs tration~ exceeding I 00 ~A-mol/1 and may be severe above about
!Oiism I~Oitmol/1. The milder side effects include vertigo, ataxia.
;m of headache and nystagmus, but not sedation. At higher plasma
tivel) c n,entrations. marked confusion with intellectual deterioration
epmic t~~:cun.; a paradoxical increase in seizure frequency is a particular
cause Udp for the unwary prescriber. These effects occur acutely and
takes are quickly rever.ible. Hyperplasia of the gums oflen develops
)gical _r;uluall), 3!> does hirsutism and coarsening of the features.
which probably resu lt from increased androgen secretion.
.ic of \legaloblastic anaemia, associated with a disorder of folate
>eutic mct.tbolism, sometimes occurs. and can be corrected by giving
"not fohc ac1d (Ch. 22). Hypersensitivity reactions, mainly rashes.
The are quite common. Phenytoin has also been implicated as a cause
111 the increased incidence of fetal malformations in children
hom to epileptic mothers. particularly the occurrence of cleft
p3latc, associated with the formation of an epoxide metabolite.
S~1cre idiosyncratic reactions, including hepatitis, skin reactions
hen
.tnd neoplastic lymphocyte disorders, occur in a small proportion
of pauents.
in
.y-
j, CARBAMAZEPINE
1in i' urbamazepine, one of the most widely uc;ed antiepileptic drugs.
quite . chemically derived from the tricyclic antidepressant drugs (see
nion- [h, 39) and was found in a routine screening test 10 inhibit
11any dectrically-evoked seizures in m ice. Pharmacologically and
Ju,tl chntcally. its actions resemble those of phenytoin, although it
~i\Cn ~Jrs to be particularly effective in treating complex partial
ahlc, r.c:~~urcs (e.g. psychomotor epilepsy). It is also used to treat other
tima l conditions, suc h as neuropathic pain (Ch. 41) and manic-
gs in cpre-;sive illnes~ (Ch. 39).
Pharmacokinetic aspects
Carbamazepine is well absorbed. Tts plasma half-life is about
10 hour~ when it is given as a single dose, but it is a strong
mducmg agent. and the plasma half-Life shortens to about 15
'II.AJrs \.\hen it il> given repeatedly. A slow-release preparation
11 uiCd for patients who experience transient s ide effects coinciding
~ th plasma concentration peaks following oral dosing (see
~loll)
Unwanted eHects
Carbamazepine produces a variety of unwanted effects ranging
1rom drowsines~. dizziness and ataxia to more severe mental
ld motor di~turbances. It can also cause water retention (and
1cncc hyponatraemia; Ch. 28) and a variety of gastrointesti nal
and cardiovascular side effects. The incidence and severity of
theiC effects is relatively low, however, compared with other
tJUg,. Treatment is usually started with a low dose, which is built
up gradually to avoid dose-related toxicity. Severe bone marrow
depression. causing neutropenia. and other severe forms of
hypersensitivity reaction can occur but are very rare.
Carbarnazcpine is a powerful inducer of hepatic microsomal
enzymes, and thus acce lerates the metabolism of many other
drugs, such as phenytoin. oral contraceptives, warfarin and
corticosteroids. Tn general, it is inadvisable to combine it with
other antiepileptic drugs. O zcarb azepin c, introduced recently.
is a prodrug that is metabolised to a compound closely
resembling carbamazcpine, with similar actions but less
tendency to induce drug-metabolising enzymes.
VALPROATE
Valproate is a simple monocarboxylic acid, chemically unrelated
to any other class of antiepileptic drug, and in 1963 it was
discovered qu ite accidentally to have anticonvulsant propertie!>
in mice. It inhibits most kinds of experimentally induced
convulsions and is effective in many kinds of epilepsy. being
particularly useful in certain types of infantile epilepsy, where
its low toxicity and lack of sedative acrion are important, and
in adolescentl> in whom grand mal and petit mal coexist. because
valproate (unlike most antiepileptic drugs) is effective against
both. Like carbamazepinc. valproate is also used in psychiatric
conditions such as bipolar depressive ill ness (Ch. 39).
Mechanism of action
Valproate works by several mechani~ms, of which the details
remain uncertain (see Macdonald, 1999). It causes a significant
increase in the GABA content of the brain and is a weak inhibitor
of two enzyme systems that inactivate GABA. namely GABA
transamina~e and succinic semialdehyde dehydrogenase, but in
vitro studies suggest that these effects would be very slight at
cl inical dosage. Other more potent inhibitors of these enzymes
(e.g. vigab a trin; see below) also increase GABA content and
have an anticonvulsant effect in experimental animals. There is
some evidence that it enhances the action of GABA by a
postsynaptic action, but no clear evidence that it affects inhibitory
synaptic responses. It also inhibits sodium channels. but less so
than phenytoin.
Valproate is well absorbed orally and excreted, mainly as the
g lucuronide. in the urine, the plasma ha lf-life being about 15 hours.
Unwanted eHects
Compared with most antiepileptic drugs, valproate is relatively
free of unwanted effects. It causes thinning and curling of the hair in
about I 0% of patients. The most serious side effect is hepatotoxicity.
An increase in serum glutamic oxaloacetic transaminase, which
signals liver damage of some degree, commonly occurs, but
proven cases of valproatc-induced hepatitis are rare. The few
cases of fatal hepatitis in valproate-trcated patients may well
have been caused by other factors. Valproate is teratogenic,
causing spina bifida and other neural tube defects.
ETHOSUXIMIDE
Ethosuximide, which belongs to the succinimidc clac;s, is another
d111g developed empirically by modifying the barbituric acid ring 581
 SECTION 4 . THE NERVOUS SYSTEM
structure. Pharmacologically and clinically, however, it is different
from the drugs so far discussed. in that it is active against PTZ-
induced convulsion~ in animals and against absence seizures in
humans, with little or no effect on other types of epilepsy. It
supplanted tr i methadi one, the first drug found lObe effective in
absence seizures, which had major side effects. Ethosuximide is
used clinically for its selective effect on absence seizures.
The mechanism of action of ethosuximide and trimethadione
appcan, to differ from that of other antiepileptic drugs. The main
effect described is inhibition of T-type calcium channels, which
may play a role in generating the 3/second firing rhythm in
thalamic relay neurons that is characteristic of absence seizures.
Ethosuximide is well absorbed, aod metabolised and excreted
much like phenobarbital, with a plasma hal f-life of about
50 hours. It~ mai n side effects are nausea and anorexi a,
sometimes lethargy and diu iness, and it is said to precipitate
tonic-clonic seizures in susceptible patients. Very rarely, it can
cause severe hypersensitivity reactions.
PHENOBARBITAL
T Phenobarbital w~ one of the fiTht barbiturates to be de eloped. and it'>
anticpileptic propenie~ were recognised in 1912. ln its action against
experimentally tnduced convuhion~ and clinical fonns of epilepsy, it
clo~cly rc~emblc> phcnytom; it affects the duration and intensity of
artifictally induced l>Ciure~. rather than tbe seizure threshold. and is (like
phenytoin) meflecu'e in treating absence seizures. Primidnne, now rarely
uo,ed, act' by bemg metabolised to phenobarbital. It often causes
hyp.:r.en\lti\ ity reaction>. The clinical u~ of pheoobarbital are vinually
the \3me as th<he of phenytoin. although phenytoin is preferred becalll>C of
the ab.,ence of ~edation.
Pharmacokinetic aspects
'f' Phenobarbital i'> well ab~orbed, and about 50% of the drug in the blood
i~ bound to pl~ma albumin. It is eliminated slowly from the plasma (half-
life. 50-140 hour~). About 25% is excreted unchanged in the urine.
Becau~c phenobarbital j, a weak acid. it> ionisation and hence renal
elimi nat ion arc incrca>cd if the uri ne is made al kali ne (see Ch. 8). The
remain ing 75% b mctaboli;cd, mainly by oxidation and conj ugation. by
the hepatic microsomal enzyme;. Phenobarbi tal is a powerful inducer of
liver P450 Cnlymcs, and it lowers the plasma concentration of several
other drugs (e.g. steroid>. oral contraceptive. warfarin, tricyc lic
antideprcs~nnL-.) to an extent that is cli nically imponanL
Unwanted eHects
'f' The mam unwanted effect of phenobart>ital is sedation, which often
occurs at pl~ma concentrations within the therapeutic range for seizure
control. Thi'> t'> a ">eriow. dmwback. because the drug may have to be used
for year. on end. Some degree of tolerance to tbe sedati'e effect seems
to occur. but ob)CCU\e lel>t' of cognition and motor performance show
impainncnt C\en after long-tenn treatment Other unwanted efTcctl> that
may occur "'ith clinical d<Nlge include megaloblastic anaemia (similar to
tfult cau-.ed by phenytoin). mild h)'pl!rsensitivity reactions and osteomalacia.
Li~c other barbitumte\ bee Ch. 52). it mw.t not be given to patient; with
porphyna. In overdo\c, phenobarbital produces coma and respiratory and
circulatory fai lure, a~ do all barbiturates.
Clinical use
T Phe nobarbital i' now ~cldom used in adu lt; because of sedation. For
some year~. it wa!> widely used in children, including as prophylaxis
582 following febrile convulsions in infancy, but it can cause behavioural
The maJor antleplleptic drugs
The main drugs in current use are phenytoin,
c arbamazepine, valproate and ethosuximide.
Phenytoin:
acts mainly by use-dependent block of sodium
channels
effective in many forms of epilepsy, but not
absence seizures
metabolism shows saturation kinetics, therefore
plasma concentration can vary widely; monitoring
is therefore needed
drug interactions are common
main unwanted effects are confusion, gum
hyperplasia, skin rashes, anaemia, teratogenesis
widely used in treatment of epilepsy; also used as
antidysrhythmic agent (Ch. 18).
Carbamazepine:
derivative of tricyclic antidepressants
similar profile to that of phenytoin but with fewer
unwanted effects
effective in most forms of epilepsy (except
absence seizures); particularly effective in
psychomotor epilepsy; also useful in trigeminal
neuralgia
strong inducing agent, therefore many drug
interactions
low incidence of unwanted effects, principally
sedation, ataxia, mental disturbances, water
retention.
Valproate:
chemically unrelated to other antiepileptic drugs
mechanism of action not clear; weak inhibition of
GABA transaminase, some effect on sodium
channels
relatively few unwanted effects: baldness,
teratogenicity, liver damage (rare, but serious).
Ethosuximide:
the main drug used to treat absence seizures;
may exacerbate other forms
acts by blocking T-type calcium channels
relatively few unwanted effects, mainly nausea
and anorexia.
Secondary drugs include:
phenobarbital: highly sedative
- various benzodiazepines (e.g. clonazepam);
diazepam used in treating status epilepticus.
Newer agents that are becoming widely used
because of their improved side effect profile include
vigab atrin, lam otrigine, felbam ate, gabapentin,
pregabalin, tiagabine, topiramate and zonisamide.

dhturllance' and hypcrkine,ia. and is now seldom used at all in newly
diag!IO\etl paticm,.
BENZODIAZEPINES
Dimpam, given intravcnoul>ly or rectally. is used to treat status
t rpricus. a life-threatening condition in which epileptic
sttzure, occur almo~t without a break. Its advantage in this
tuauon is that it acts very rapidly compared with other
antteptleptic dnags. With most ben.wdiatepines (see Ch. 37). the
sedati\C effect i11 too pronounced for them to be used for
matntenance therapy. Clonazcpam and the related compound
dobazam arc claimed to be relatively selective as antiepilcptic
drug,. Sedation i~ the main side effect of these compounds, and
Jnaddcd problem may he the withdrawal syndrome, which results
tn an exacerbation of sei1.ures if the drug is stopped abruptly.
NEWER ANTIEPILEPTIC DRUGS
f,ralx>ut 25 years, from the mid-1960s. the inventiveness of the
pharmaceutical industry in producing improved anliepilcptic
drug' dried up. Around 1985. the muse returned, and a spate of
llC\I drug' was developed over the next 10-15 years (see Eadie
~Vajda. 1999).
VIGABATRIN
\igabalrin, the fiN 'designer dnag' in the epilepsy field. is a
lln)l,ubstituted analogue of GABA that was designed as an
tnhtbitor of the GABA-mctabolising enzyme GABA
tr.lllsammase. Yigabatrin is extremely l>pecific for this enzyme
and 11ork' by forming an irreversible covalent bond. In animal
'tuJic.,, vigabatrin increases the GABA content of the brain and
Jl'o increases the sti mu lation-cvoked release of GABA,
nnplying that GABA transaminase inhibition can increase the
releasable pool of GABA and effectively enhance inhibitory
transmission. In humans, vigabatrin increases the content of
GABA in the cerebrospinal fluid. Although its plasma half-life
" 'hort, it produces a long-lasting effect because the enzyme
J> blocked irrevcr!>ibly, and the drug can be given by mouth
once da1ly. Evidence of neurotoxicity was found in animals but
ha' not been found in humans. removing one of the main
quNion mark~ hanging over this drug.
The main drawback of vigabatrin is the occurrence of depression,
3lld occasionally p\ychotic di<.,turbances. in a minority of patients;
othcrn i-.e, it i., relatively free from side effects.
\1gabatnn has been reported to be effective in a substantial
proporuon of patients resistant to the established drugs, and may
n:pre,ent an important therapeutic advance.
lAMOTRIGINE
Lamotngine. ahhough chemically unrelated. resembles phenytoin
Jnd carbamazepine in its pharmacological effects, acting on
>odium channels and inhibiting the release of excitatory amino
actds. It appears that. despite its similar mechanism of action,
lamotriginc has a broader therapeutic profile than the earlier
ANTIEPILEPTIC DRUGS
dnags, with significant efficacy against absence seizures (and is
also used to treat unrelated psychiatric disorders). Its main side
effccL'> arc nausea. dizLines!. and ataxia, and hypersensitivity
reactions (mainly mild ra~hes, but occasionally more severe). IL~
plasma half-life i~ about 24 houn., with no particular pharma-
cokinctic anomalie'>, and it is taken orally.
FELBAMATE
Fclbamate i., an analogue of an obsolete anxiolytic drug,
meprobamate. It is active in many animal seizure models and
has a broader clinical spectrum than earlier antiepileplic drugs,
but its mechanism of action at the cellular level is uncertain. ll
has only a weak effect on sodium channels and little effect on
GABA, but causes some block of the NMDA receptor channel
(Ch. 33). Its acute side effects arc mild, mainly nausea, irritabi lity
and insomnia, but it occasionally causes severe reactions resulting
in aplastic anaemia or hepatitis. For this reason, its recommended
use is limited to a form of intractable epilepsy in children (Lennox-
Gastaut syndrome) that is unresponsive to other drugs. lts plasma
half-life is about 24 hours, and it can enhance the plasma
concentration of other antiepileptic drugs given concomitantly.
GABAPENTIN
Gabapemin was designed a!> a simple analogue of GABA that
would be sufficiently lipid-soluble to penetrate the blood-brain
barrier. It n1mcd out to be an effective anticonvulsant in several
animal models but, !>Urprisingly, not by acting on GABA receptors.
Its main site of action appears to be on T-rype calcium channel
function, by binding to a particular channel subunit (a2o). and it
inhibit!. the release of various neurotransmitters and modulators,
but the details remain unclear. The side effects of gabapentin
(main ly sedation and ataxia) are less severe than with many
antiepi leptic drug!>. The absorption of gabapentin from tbc intestine
depends on the amino acid carrier system and shows the property
of saturability, which means that increasing the dose does not
proportionately increase the amount absorbed. This makes
gabapentin relatively safe and free of side effects associated with
overdosing. Its plasma half-life is about 6 hours, requiring dosing
two to three times daily. lt is excreted unchanged in the urine and
is free of interactions with other drugs. It bas limited efficacy
when used on its own, so is used mainly as add-on therapy. It is
also used as an analgesic to treat neuropathic pain (Ch. 4 I). A
recently introduced follow-up drug. pregabalin, is more potent
than gabapcntin but otherwise very similar. These dnags are
excreted unchanged in the urine, and so must be used with care
in patients whose renal function is impaired.
TIAGABINE
Tiagabinc, an analogue of GABA that is able to penetrate the
blood-brain barrier, acts by inhibiting the reuptake of GABA by
neuron~ and glia, and was the product of rational dmg design. It
enhances the extracellular GABA concentration, as measured in
microdialysis experiments. and also potentiates and prolongs
GABA-mcdiatcd synaptic responses in the brain. It has a short 583
 SECTION 4 . THE NERVOUS SYSTEM
plasma half-life, and its main side effects are drowsiness and
confusion. The clinical u~efulness of tiagabine has not yet been
fully assessed.
TOPIRAMATE
Topiramate is a recently introduced drug that, mechanistically,
appears to do a little of everything, blocking sodium channels,
enhancing the action of GABA, blocking AMPA receptors and,
for good measure, weakly inhibiting carbonic anhydrase. Its
spectrum of action resembles that of phenytoin, and it is claimed
to produce less ~>everc side effects, as well as being devoid of
the phannacokinetie properties that cause trouble with phenytoin.
Tts main drawback is that (like many antiepileptic drugs) it is
teratogenic in animals. so it should not be used in women of
c hi ld-bearing age. Currently, it is recommended for use as add-
on therapy in refractory cases of epilepsy.
LEVETIRACETAM
Levetiracetam wa!> developed as an analogue of piracetam , a
drug used to improve cogniti ve function (see Ch. 35), and
discovered by accident to have antiepileptic activity in animal
model!.. Unu~uaUy. it lacks activity in conventional models such
as electro~hock and PTZ tel>ts. but is effective in the kindling
model. It has little or no effect on known targets (ion channels
and GABA-related mechanisms). and its mechanism of action
is unl>.nown. It is excreted unchanged in the urine.
ZONISAMIDE
Zonisamide is a 11ulfonaroide compound originally inte nded as
an antibacterial drug and found accidcntaJJy to have antiepileptic
properties. It is believed to act by blocking sodium channels but
may well have other effect~. ft is free of major unwanted effects,
although it causes drowsiness, and of serious interaction with
other drugs. It tends to suppress appetite and cause weight loss,
and is sometimes used for this purpose. Zoillsamide has a long
plasma half- life of 60-80 ho urs, and is partly excreted unchanged
and partly converted to a glucuronide metabolite.
OTHER USES OF ANTIEPILEPTIC DRUGS
Antiepileptic drug!> have proved to have mucb wider clinical
applications than was originally envisaged, and clinical trials have
shown many of them to be effective in the following conditions:
cardiac dysrhythmiru. (e.g. phenytoin-not used clinically,
however; Ch. 18)
bipolar disorder (valproate, carbamazepine,
oxcarbazepine, la mo tr igine. topira m a te; Ch. 39)
migraine prophylaxis (valproate, gabapentin)
anxiety disorders (gaba pentin; Ch. 37)
neuropathic pain (gabape ntin. carbamazepine, la motr igine;
Ch.4 1).
This surpris ing multiplicity of clinical indications may reflect the
584 fact that similar neurobiological mechanisms, involving synaptic
Clinical uses of antiepileptic drugs
Tonic-clonic (grand mal) seizures:
carbamazepine (preferred because of a relatively
favourable effectiveness:risk ratio), phenytoin,
valproate
use of a single drug is preferred, when possible,
to avoid pharmacokinetic interactions
newer agents include vigabatrin, lamotrigine,
f elbamate, gabapentin.
Partial (focalj seizures: c arbamazepine. valproate;
alternatives are c lonazepam or phenytoin.
Absence seizures (petit mal): ethosuximide or
valproate
valproate is used when absence seizures coexist
with tonic-clonic seizures, because most other
drugs used for tonic-clonic seizures can worsen
absence seizures.
Myoclonic seizures: diazepam intravenously or (in
absence of accessible veins) rectally.
Neuropathic pain: for example carbamazepine,
gabapentin (see Ch. 41).
To stabilise mood in mono- or bipolar affective
disorder (as an alternative to lithium): for example
c arbamazepine, valproate (see Ch. 39).
plasticity and increased excitability of interconnected populatiom
of neurons, underlie each of these disorders (see Rogawsl>.i &
Loscher. 2004b).
MUSCLE SPASM AND MUSCLE
RELAXANTS
Many diseases of the brain and spinal cord produce an increase in
muscle tone, which can be painful and disabling. Spasticity resulting
from birth injury or cerebf'dl vascular disease, ru1d the paralysi~
produced by spinal cord lesions, are examples. Local injury or
innammation, a~ in arthritis, can have d1e same effect, and chrome
back pain is also often associated with local muscle spasm.
Certain centrally acting drugs are available that have the effect
of reducing the background tone of the muscle without serious!}
affecting iL~ ability to contract transiently under voluntary control
The distinction between voluntary movements and 'backgrouna
LOne' ill not clear-cut. and the selectivity of those drugs is n01
complete. Po!>tural control, for example, is usually jeopardi~ed
by centrally acting muscle relaxants. Furthermore. drug~ that
affect motor control generally produce rather widespread effecb
on the central nervous 11ystem, and drowsiness and confusion tum
out to be very common side effects of these agents. The mam
groups of drugs that have been used to control muscle tone are:
me phenesin and related drugs
baclofe n
bcnzodiazcpines (sec Ch. 37)
 ANTIEPILEPTIC DRUGS

Tlble 40.1 Properties of the m ain antiepileptic drugs

Drug Site of acti on M ain uses M ain unwanted effect(s) Pharm acokinetics
v Sodium GABAA Calcium Other
I channel receptor channel

Pllenyto1n ++ All types except Ataxia, vertigo Half-life -24 h

absence seizures Gum hypertrophy Saturation kinetics,
Hirsutism therefore
Megaloblastic anaemia unpredictable plasma
Fetal malformation levels
Hypersensitivity reactions Plasma monitoring
often required

Carbamazep1ne" ++ All types except Sedation, ataxia Half-life 12-18 h

absence seizures Blurred vision (longer initially)
Especially temporal Water retention Strong induction of
lobe epilepsy Hypersensitivity reactions microsomal enzymes,
(Also used in Leucopenia, liver failure therefore risk of drug
trigeminal neuralgia) (rare) interactions
Most widely used
antiepileptic drug

Valproate + ?+ GABA Most types, including Generally less than w1th Half-life 12-15 h
trans- absence seizures other drugs
aminase Nausea
inhibition Hair loss
Weight gain
Fetal malformations

Ethosuximideb ++ Absence seizures Nausea, anorexia Long plasma half-life

May exacerbate Mood changes (-60 h)
tonic-clonic seizures Headache

)OS
Phenobarbltal0 7+ + All types except Sedation, depression Long plasma half-life
& absence seizures (> 60h)
Strong induct1on of
microsomal enzymes,
therefore risk of drug
interactions (e.g. w1th
phenytoin)

Benzodiazepines ++ All types Sedation See Chapter 37

In
(e.g. clonazepam, Diazepam used Withdrawal syndrome
ng clobazam, intravenously to (see Ch. 37)
j., daazepam) control status
or epilepticus
tic
V~gabatrin GABA All types Sedation Short plasma half-
trans- Appears to be Behavioural and mood life, but enzyme
aminase effective in patients changes (occasionally inhibition is long-
inhibition resistant to other psychosis) lasting
drugs Visual field defects

Lamotrigine ++ 7+ Inhibits All types Dizziness Plasma half-life

Ol
gluta- Sedation 24-36h
!d mate Skin rashes
release
ts
Gabapentin" ?+ Partial seizures Few side effects, mainly Plasma half-life 6-9 h
n
sedation
n

585
 SECTION 4 . THE NERVOUS SYSTEM

Table 40.1 (cont'd) Properties of the main antiepileptic drugs

Drug Site of action Main uses Main unwanted effect(s) Pharmacokinetics

Sodium GABAA Calcium Other
channel receptor channel

Felbamate ?NMDA Used mainly for Few acute side effects Plasma half-life - 20 h
receptor severe (Lennox- but can cause aplastic Excreted unchanged
block Gastaut syndrome) anaemia and liver
because of risk of damage as rare
idiosyncratic reaction idiosyncratic reaction

Tiagabine Inhibits Partial seizures Sedation Plasma half-life - 7 h

GABA Hepatic metabolism
uptake

Topiramate ?+ ?+ ?+ M ech- As phenytoin Sedation Plasma half-life - 20 h

anism Fewer pharmacokinetic Excreted unchanged
unknown interactions than
phenytoin
Fetal malformation

Levetiracetam Mech Partial seizures Sedation (slight) Plasma half-life - 7 h

an ism Excreted unchanged
unknown

Zonisamide + Partial seizures Sedation (slight) Plasma half-life -70 h

Appetite suppression and Excreted partly
weight loss unchanged and
partly as glucuron ide

oxcarbazepine, recently introduced, is similar; claimed to have fewer side effects.

1>frimethadione is similar to ethosuximide in that it acts selectively against absence seizures. Its greater toxicity (especially the risk of
severe hypersensitivity reactions) means that ethosuximide has largely replaced it in c linical use.
cPrimidone is pharmacologically sim ilar to phenobarbital and is converted to phenobarbital in the body. It has no c lear advantages and
is more liable to produce hypersensitivity reactions, so is now rarely used.

botulinum toxin (see Ch. 10); injected into a muscle, this
neurotoxin causes long-lasting paralysis confined to the site of
injection, and its use to treat local muscle spasm is increasing
dantrolene (sec C b. 4).
MEPHENESIN
M ephenesin is an ruomatic ether that acts mainly on the spinal
cord, caus ing a selective inhibition o f polysynaptic excitation
o f motor neuro ns. Thus it strong ly inhibits the polysynaptic
flexor withdrawal retlex w ithout affecting the tendon jerk reflex,
w hic h is monosynap ti c, and it abo lishes decerebrate rigidity. Its
mechanism o f ac ti o n at the cellular le vel is unknown.
Mephenesin is little used clinically, although it is sometimes
given as an intraveno us injection to reduce acute muscle spasm
resulting from injury.
BACLOFEN
Baclofen (see Ch. 33) is a cbloropheny l de rivati ve of GABA
586 originally prepared as a lipophilic GABA-Iike agent in order
"'"~---
to assist penetration o f the blood- brain barrier, wb.ich is
impe rmeable to GABA itself . Baclofen is a selective agonist at
presynaptic GABA 8 receptors (see Ch. 33). The antispastic
action of baclofcn is exerted mainl y on the spinal cord, where
it inhibits both monosynaptic and polysynaptic acti va tion of
motor neurons. It is effective whe n given by mouth, and is used
in the treatment of spasti city associated with multiple sclerosi1
or spinal injury. However. it is ineffective in cerebral spasticity
caused by birth injUly
Baclofe n pro duces various unwa nted e ffects, p articular!)
drowsiness, moto r incoordination and nausea, and it may also
have behavimLral effects. It is not useful in epile psy.
CANNABIS
Anecdotal evide nce suggests that smoking cannabis (Ch. 43)
relieves the painful muscle s pasms associated with multiple
sclerosis. A full-scale controlled trial of tetrahydrocannabinol
(see Ch. 15), however, showed no significant effect on muscle
spasm, tremor, bladder control or disability, although the patients
re ported subjecti ve improvements (Zajicek et a l., 2003).
 Analgesic drugs
Overview 588
Neural mechanisms of pain 588
-Nociceptive afferent neurons 588
-Modulation in the nociceptive pathway 589
-Neuropathic pain 592
-Pain and nociception 592
-Chemical signalling in the nociceptive pathway 593
-Transmitters and modulators in the nociceptive
pathway 596
~ though we all know what we mean by it. Typically, it is a direcl
Analgesic drugs 596
-Morphine-like drugs 596
-Other opiate analgesics 604
-Opiaad antagonasts 605
-Paracetamol 605
-Other analgesic drugs 607
New approaches 607
OVERVIEW
Pain is a disabling accompaniment of many
medical conditions, and pain control is one of the
most important therapeutic priorities.
In this chapter, we discuss the neural mechanisms
responsible for different types of pain, and the
various drugs that are used to reduce it. The
'classic' analgesic drugs, notably opiates and non-
steroidal anti-inflammatory drugs (NSAIDs;
described inCh. 14}, have their origins in natural
products that have been used for centuries. The
original compounds, typified by morphine and
aspirin, are still in widespread use, but many
synthetic compounds that act by the same
mechanisms have been developed. Opiate
analgesics a re described in this chapter. Next, we
consider various other drug classes, such as
antidepressants and antiepileptic drugs, which
clinical experience has shown to be effective in
588 certain types of pain. Finally, looking into the
future, many potential new drug targets have
emerged over the past decade or so as our
knowledge of the neural mechanisms underlying
pain has advanced. We describe briefly some of
these new approaches at the end of the chapter.
NEURAL MECHANISMS OF PAIN
Pain is a subjective experience, hard to define exactly, even
response to an untoward event associated with tissue damage.
~uch as injury, inflammation or cancer, but severe pain can ari..e
independently of any obvious predisposing cause (e.g. trigemanal
neuralgia), or pc~iM long after the precipitating injury has healed
(e.g. phantom limb pain). It can also occur as a consequence of
brain or nerve injury (e.g. following a stroke or herpes infectionl
Painful conditions of the latter kind. not directly tinked to ti\\uc
injury, are very common and a major cause of disability and
diSLre1.S. and in general they respond less well to conventional
a na lgesic drugl> than do conditions where lhe immediate cause is
clear. In these cases, we need to thin k of pa in in te rms of di 'i
ordered neural function, comparable with schizophrenia or epilep'}
rather than simply as a ' no rmal' response to tissue injury. There-
fo re it is useful to disting uish two compone nts, e ithe r or both of
w hic h may be involved in patho logica l pain states:
the peripheral nocicepti ve affere nt neuro n, which is activated
by noxious sti mu li
the central mec hanisms by which lhe afferent input generate>
a pain sensation.
Good accou nt!> of the neural basis of pain can be found m
McMahon & Kolt7enburg (2006).
NOCICEPTIVE AFFERENT NEURONS
Under normal conditions. pain is associated with impulse acti\it)
in small-diameter primary afferent fibres of peripheral nerve~
(see Raja et al., 1999). These nerves have sensory endings in
peripheral tis!>ues and arc activated by stim uli of various kind,
(mechanical, thermal. chemical: Julius & Basbaum, 200 I; Julius
& McCleskey, 2006). They are disting uished fro m other sort>
o f mechanical and therm al receptors by the ir higher threshold.
because they are norm all y acti vated o nly by s timuli of noxiou1
inte nsity-suffic ient to cause some degree of tissue damage.

Rn.'tl ding\ of activity in single afferent fibres in human subjects
ha1e shown thai stimuli sufficient 10 excite these small afferent
fihre' also evoke a painful sensation. Many of these fibres are
nonm}clinatcd C fibres with low conduction velocities
< 1mM: this group is known as C polymodalnociceptors. Others
are fine myelinated (A6) fibres, which conduct more rapid ly but
re,pond to ~imilar peripheml stimuli. Although there are some
pl'tle., diiTcrences, the majority of the C fibres are associated
1111h polymodal nociceptive endings. Afferents from muscle and
li,cera abo convey nociceptive information. In the nerves from
thN tissue,, the small myelinated Ab fibres are connected to
h1gh-threshold mechanorcceptors, while the non-myelinated
Clibrcs arc connected to polymodal nociceptors, as in the skin.
bperiments on human subjects, in which recording or stimu-
laung electrodes are applied to cutaneous sensory nerves, have
1holln that activity in the Ao fibres causes a sensation of sharp,
11dl-localised pain. whereas C fibre activity causes a dull.
diiiu-.e, burning pain.
With many pathological conditions, tissue injury is the
immediate cause of the pain and results in the local release of a
m~t} of chemicals that act on the nerve terminals. either
..:111atmg them directly or enhancing their sensitivity to other
form~ of :.timulation. The pharmacological properties of
c.
1 ll:iceptive nerve terminals are discussed in more detail below.
c The cell bodies of spinal nociceptive afferent fibres lie in
nl J1Nl root ganglia; fibres enter the spinal cord via the dorsal
root\, ending in the grey matter of the dorsal hom (Fig. 41.1 ).
Mo'l of the nociceptive afferents terminate in the superficial
e~ion of the dorsal hom, the C fibres and some Ao fibres
te mnervating cell bodies in laminae J and IT, while other A fibres
d xnetrale deeper into the dorsal hom (lamina V). Cells in laminae I
and\' give rise 10 the main projection pathways from the dorsal
hom 10 the thalamus.
The non-myelinated afferent neurons contain several neuro-
pepudes (~ee Ch. 16), panicularly substance P and calcitonin
gcntrrelated peptide (CG RP). These are released as mediators at
f hoth the central and the peripheral terminals, and play an
Important role in the pathology of pain.
Fig. 41.1 The termination of
afferent fibres in the six lam inae of
the dorsal horn of the spinal cord.
ANALGESIC DRUGS
MODULATION IN THE NOCICEPTIVE
PATHWAY
Acute pain is generally well accounted for in terms of
nociception- an excessive noxious stimulus giving rise to an
intense and unpleasant sensation. In contrast, most chronic pain
states 1 are associated with aberrations of the normal physiological
pathway. giving ri!>e to hyperalgesia (an increased amount of
pain associated with a mi ld noxious stimulus), allodynit1 (pain
evoked by a non-noxious stimulus) or :;pontaneou~ pain without
any precipitating Mimulus. An analogy ill with an old radio set
that play~ uncontrollably loudly (hyperalgesia), receives two
stations at once (allodynia), or produces random shrieks and
whistles (spontaneou~ pain spasms). These distonions in the
transmission line are beginning to be understood in terms of
various types of positive and negative modu lation in the
nociceptive pathway. discussed in more detail below. Some of the
main mechanisms are summarised in Figure 41.2.
HYPERALGESIA AND ALLODYNIA
T Anyone who has suffered a burn or spmincd ankle ha& experienced
hyperalgesia and al lodynia Hyperalgesia involves both ~ensi tisation of
peripheral nociceptive nerve terminals and cemral facilitation of
t:ransml\,ion at the le1 el of the dor;al horn and thalamu,~hanges
defined by the term neuroplasriciry. The peripheral component is due
to the acJion of mediators ~uch u; bradykinin and prostaglandins acti ng
on 1he nerve tenninals (see below). The central component reflect~
1
Defined a~ pain that ourla~ts the precipitating ti\\UC injury. Many clinical
pain state' fall into thi\ category. The dissociation of pain from noxious
input is mo;t evident in 'phantom limb' pain. which occur; after
amputation' and may be very severe. The pain i; u;ually not relieved by
local anac;thetic injections, implying that electrical activity in afferent
fibres i~ not an essentJal component. At the other e>.treme. no,.ious input
with no pam. there arc many well-documented reports of mywc~ and
; howmen who ;ubject themselves to horrifying ordeals with knives, burning
embers. nai l'> and hooks (undoubtedly cauing masstve afferent input)
~ithout apparently suffering pain.
---- -- ----l Mechanoreceptor AP-fibres
Nociceptor
}...,.,.,
C-fibres
589
 SECTION 4 . THE NERVOUS SYSTEM

DESCENDING ~
INHIBITORY + Opiates
PATHWAYS

l
NOCICEPTIVE PATHWAY
NOFOriO; r
EXCITATION OF
NOXIOUS
- - ' - - TRANSMISSION
STIMULUS
NEURON

b MEDIATOR
RELEASE
K, 5-HT, PGs, etc.)

_____' . .______ Inflammation _ _ _ ___,

~
Fig. 4 1.2 Summary of modulatory mec hanisms in the nociceptive pathway. 5-HT, 5-hydroxytryptamine; BK, bradykinin; CGRP,
calcitontn gene-related peptide; NA, noradrenaline; NGF, nerve growth factor; NO, nitric oxide; NSAID, non-steroidal anti-inflammatory
drug; PG, prostaglandin; SP, substance P.

facilitation of synaptic transmission. This has been well studied in the
dor~al horn (~ee Yak~h. 1999). The ~ynaptic responses of dorsal hom
neurons to nociceptive inputs di~play the phenomenon of 'wind-up'-i.e.
the synaptic poten tial ~ ~tead ily increase in amplitude with each
srimulus when repeated Mimuli are delivered at physio logical
frequencies (~ee Fig. 4 1.3 ). This activ ity-dependent facilitation of
lransm i s~ion has features in common with the phenomenon of long-term
potentiation in rhe hippocampus, described in Chapter 33. and the
chemical mechani~ms underlying it may also be si mi lar (see Ji et at..
2003). In the do.-.nl hom. the fac ilitation is blocked by NMDA recepror
an tagonists, also by antagonists of subMance P. a slow ellcitatory tran~
mitter relea..ed by nociceptive afferent neurons (see above), and by
inhibitor, of nitric oxide \ynthe~is. Substance P produces a slow
depolan\tng re<,pon\c 111 the po~~ynaptic cell, which builds up during
repetithe '>timulation, and i\ believed to enhance NMDA receptor-medimed
rran.,mi~'ion. Thi\ re\ult., in Ca~ inflult and acrhation of nitric oxide
S}ntha~ (<ee Ch. 17). the released nitric oxide acting to facilirarc
tran\mi\\ion h> mechani'm' thar haYe yer to be elucidated. Substance
P and CGRP relea~cd from primai} afferent neurons also act in the
periphery, promoting inflammation by their effects on blood \'CSl>Ch
and cell\ of the rmmune ~ystem (Ch. 13). This mechanism. known as
neurogenic inflammation. amplifies and sustains the inflammatory
reacrion and the accompanymg actiYation of nociceptive afferenr fibres.
Ccmral faci litarion b an important component of pathological hyper-
alge~ia (e.g. that awJC iated with inflammatory responses: see Fig. 4 I .2).
The mediator~ rc'>ponstble for central faci liration include sub~tance
P and CGRP, !1.'> well a~ many others (sec Ji et al., 2003). For eltample,
nerve growth factor (NGF). a cytokine-likc mediator produced by
peripheral tissue~. particularly in inflammation, acts specifically on
nociceptive afferen t neurons, increasi ng their electrical eltcitability,
590 chemosensitivity and peptide content, and also promoting the formation
of synaptic contact\. Increased NGF production may be an imp<>ru
mechani\m by which nociceptiYe transmission becomes facilitareJ b)
tis!>ue damage, leading to hyperalge.,ia (>ee McMahon, 1996). lncrea~
gene expression in sen.'>ory neurons is induced by NGF and othc.
inflammarory mediator>; the up-regulated genes include those en~odm
va rious neuropeptide precttrsors, receptors and channels, and have lht
overal l ciTcct of fitcilitating transmission at the first synaptic relay in tht
dor~a l horn. Brain-derived neumtmphic factor released from primaT\
afferent nerve tcmlinals activates pathways leading to sen~itisation,
glutamate receptor~. and hence synaptic facili tation. in the dorsal hom.
Exci tati on of nociceptive ~ensory neurons depends, as in other neuron
(\cc Ch. 4), on voltage-gated sodium channels. Certain sodium channd
subtype\ are found in these neurons but not elsewhere, and there i' t>.ld
evidence (\ee Lai et al.. 2004: Chahine el al .. 2005) that increa-d
expre~sion of rhe~ channeb underlie~ the ~ensitisation ro external \Umuli
that occur, 111 inflammatory pain and hyperalgesia. Consisrem wuh this
hypothco,io, ~ the fact that man} antiepileptic and antidysrhythmic dJ'ui
which act by blocr..ing \Odium channels (see Chs 18 and 40) al\0 find
clinical application !1.'> analgc'>ics.
THE SUBSTANTIA GELATINOSA AND THE GATE
CONTROL THEORY
Cells of lamina U of the dorsal horn (the substantia gelati1101a.
SG) arc mainly short inhibitory intemeurons projecting to lamtnJ
I and lamina V, and they regulate transmission at the fiN
synapse of the nociceptive pathway, between the primary afferenr
fibre!. and the spinothalamic tract transmission neurons. Thi'
gatekeeper function gave rise to the term gate control theory,
 ANALGESIC DRUGS

SINGLE STIMULUS REPETITIVE STIMULATION

Control
Control NMDA receptor antagonist
NMDA receptor antagonist

------------~ ~-
L
Substance P
antagonist
Control 0.5 mV

Substance P 1.0 s
antagonist

Fig. 41.3 Effect of g lutam ate and substance P antagonist on noci ceptive tr ansmission in the rat spinal cord . The rat paw was
nflamed by ultraviolet irradiation 2 days before the experiment, a procedure that induces hyperalgesia and spinal cord facilitation. The
synaptic response was recorded from the ventral root, in response to stimulation of C fibres in the dorsal root with single stimuli (left) or
repetJttve stimuli (right). The effects of the NMDA receptor antagonist o-AP-5 (see Ch. 33) and the substance P antagonist RP 67580
selective for neurokinin type 2, NK2, receptors) are shown. The slow component of the synaptic response is reduced by both
antagontsts Qett-hand traces), as is the 'wind-up' in response to repetitive stimulation (right-hand traces). These effects are much less
pronounced 1n the normal animal. Thus both glutamate, acting on NMDA receptors, and substance P. acting on NK2 receptors, are
Involved In nociceptive transmission, and their contribution increases as a result of inflammatory hyperalgesia. (Records kindly provided
by L Urban and S W Thompson.)

propo>ed by Wall and Melzack in 1965. According to this view
!1ummari~cd in Fig. 41.4). the SG cells respond both to the
activity of afferent fibres entering the cord (thus allowing the
am1-al of tmpulses via one group of afferent fibres to regulme
the lnlll~tnl\\ion of impubes via another pathway) and to the
a.:tivtty of de\Cending pathway (see below). The SG is rich in
~oth opioid peptides and opioid recepto rs, and may be an
tmportant \ite of action for morphine- like drugs (see later
~ertion). For a more detailed account of dorsal horn circuitry, see
f~eld' et al. (2006). Similar gate' mechanisms also operate in
the thalamu-..
From the spinothalamic tracts. the projection fibres form
'111apses. mainly in the ventral and medial part~ of the thalamus,
111th cell\ \\hO\e axons run to the somatosensory cortex. In the
me(ba] thalamus in particular, many cells rel>pond specifically
d to noxJOU~ Munuli in the periphery, and lesions in this area cause
analgesia. Functional imaging studies in conscious subjects (sec
Shnilllcr & Ploner, 2000) suggest that the affective component
. f pam ~n,ation (i.e. its unpleasantness) involves a specific region
of the ctngulate cortex, distinct from the somatosensor y cortex.
DESCENDING INHIBITORY CONTROLS
~'mentioned above, descending pathways (Fig. 41.5) constitute
one of the gating mechanisms that control impulse transmission
mthe dorsal hom (see MiUan, 2002). A key part of this descend-
mg y~tem is the periaqueducral grey (PAC) area of the
midbrain, a small area of grey matter surroundillg the central
canal. In 1969, Reynolds found that e lectrical stimulatio n of this
brain area in the rat caused analgesia sufficiently inten-.e that
abdominal surgery could be perfonned without anaesthesia and
without eliciting any marked response. on-painful sensations
were unaffected. The PAC receives inputs from many other brain
regions, including the hypothalamus. cortex and thalan1us, and is
the main pathway through which cortical and other inputs act to
control the nociceptive gate in the dorsal horn.
The PAG projects first to an area of the medulla clo:.e to the
midline, known as the nucleus raphe magnus (NRM). and thence
via the dorsolateral funiculus of the spinal cord to the dorsal horn.
Two important transmitters in this pathway are 5-hydroxytryptamine
and enkephalin, which act directly or via intemeurons to inhibit
the discharge of spinothalamic neurons (Fig. 41.5).
The descending inhibitory pathway is probably an important
site of action for opioid analgesics (see below). Both PAG and
SG are particularly rich in enkephalin-containing neurons, and
opioid antagonists such as naloxone (see later section) can
prevent electrically induced analgesia, which would sugge:.t that
opioid peptides may function as transmiuers in this system. The
physiolog ical role of opioid pcptides in regulating pain trans-
mission has been controversial, mainly because under normal
conditions naloxone has relatively little effect on pain threshold.
Under pathological conditions, however. when stress is present,
naloxone causes hyperalgesia, implying that the opioid system
is active. 591
 SECTION 4 . THE NERVOUS SYSTEM

Gate control
Tran smission system

:~:~:.../
Descending
inhibitory
pathways HYPOTHALAMUS
..........
.I
'

Nociceptive
afferents
(CIAO)

- Noradrenaline
...
. .............'
- - - - -- - - - " ' -- - Mechanoreoeptors
(Aj3)

Fig . 41 .4 Schematic diagram of the gate control

syst em. This system regulates the passage of impulses from
the peripheral afferent fibres to the thalamus via transmission
neurons originating in the dorsal horn. Neurons in the
substantia gelatinosa (SG) of the dorsal horn act to inhibit the Fig. 4 1.5 The descending control system, showing the
transmission pathway. Inhibitory interneurons are activated by main sites of action of opioids on pain transmission.
descending inhibitory neurons or by non-nocicept1ve afferent Opioids excite neurons in the periaqueductal grey matter (PAG)
input. They are inhibited by nociceptive C-fibre input, so the and in the nucleus reticularis paragigantocellularis (NRPG),
persistent C-fibre activity facilitates excitation of the which in turn project to the rostroventral medulla, which
transmission cells by either nociceptive or non-nociceptive includes the nucleus raphe magnus (NRM). From the NRM, 5-
inputs. This autofacilitation causes successive bursts of activity
in the nociceptive afferents to become increasingly effective in
activating transmission neurons. Details of the interneuronal
hways are not shown. (From Melzack R. Wall P D 1982 The
allenge of pain. Penguin, Harmondsworth.)
J hydroxytryptamine (5-HT)- and enkephalin-containing neurons
run to the substantia gelatinosa of the dorsal horn, and exert
an inhibitory influence on transmission. Opio1ds also act
directly on the dorsal horn, as well as on the peripheral
terminals of nociceptive afferent neurons. The locus coeruleus
- - - --- --- (LC) sends noradrenergic neurons to the dorsal horn, which
also inhibit transmission. The pathways shown in this diagram
represent a considerable oversimplification but depict the
There is also a noradrenergic pathway from the locus coeruleus general organisation of the supraspinal control mechanisms.
(see Ch. 34), which has a similar inhibitory effect on tran s- Shaded boxes represent areas rich in opiold peptides. (For
more detailed Information, see Fields & Basbaum, 1994.) DLF,
mission in the dorsal hom (Fig. 4 1.5). The use of tricyclic
dorsolateral funiculus.
antidepre~sants to control pain (sec below) probably depends
on thi s pathway.

under normal conditions. Thus physiological stimuli that

NEUROPATHIC PAIN
Neurological disease affecting the sensory pathway can produce
severe chronic pain-term ed neuropathic pain- unrelated to any
peripheral ti ssue injury. This occur<; with central nervous system
(CNS) disorders such as stroke and multiple 'clerosis, or with
conditions associated with peripheral nerve damage, such as
mechanical injury, diabetic neuropathy or herpes zoster infection
(shingles). The pathophysiological mechanisms underlying this
kind of pain are poorly understood, although spontaneous
activity in damaged sensory neuron~. due to overexpression or
redistributi on of voltage-gated sodium channels (see above), is
thought to be a factor (see Chahine et at., 2005). The sympathetic
nervous system also plays a pan, because damaged sensory
neurons can express C1 adrenoccptOrl> and develop a sensitivity
592 to noradrenaline (norepinephrine) that they do not possess
sympathetic respon~es can produce severe pain, a phenomeoc
described clinically as sympathetically mediated pain. Neuro
pathic pain, which appears to be a component of many types
of clinical pain (including common conditions such a~ ban
pain and cancer pain. as well as amputation pain). is general
difficuiL to control with conventional analgesic drugs.
new drug targets are discussed below.
PAIN AND NOCICEPTION
1' As emphasised above, the perception of noxious stimuli (tc!'IM
nociception by Sherrington) is not the same thing as pain. which ~;
~ubjecti\ e experience and include~ a strong emotional (affect<
component. The amount of pain that a pantcular stimulu\
depends on many factors other than the ~timulus itselr. A Mabb .
scn;ation in 1hc chest will cause much more pain if it occun

lloclulatlon of pain transmission
Transmission in the dorsal horn is subject to
vanous modulatory influences, constituting the ' gate
control' mechanism.
Descending pathways from the midbrain and brain
stem exert a strong inhibitory effect on dorsal horn
transm1ssion. Electrical stimulation of the midbrain
periaqueductal grey area causes analgesia through
thrs mechanism.
The descending inhibition is mediated mainly by
enkephalins, 5-hydroxytryptamine, noradrenaline and
adenosine. Optoids cause analgesia partly by activating
these descending pathways, partly by inhibiting
transmission in the dorsal horn, and partly by inhibiting
excitation of sensory nerve terminals in the periphery.
Repetitive C-fibre activity facilitates transmission
through the dorsal horn ('wind-up') by mechanisms
tnvolving activation of NMDA and substance
P receptors.
e 'puntaneou'l> in a m1ddleaged man than if it is due to a 2year-old
polmj! hun 1n the rib\ "'1th a '>harp Mick. The nociccpti,e component may
G) be mu<h the 'arne. but the affective component is quite different. Animal
tt''' ot an:llgC!.IC drug' common!) me;c.ure nociception and invohe
tNmg the reaction of an animal to a mildly painful stimulus. often
me<hanical or thennal. Such me;c.urcs include the tail flick test
s mca,uring the ume taken for a r.u to withdraY. its tail when a standard
rJdiJIIt heat \tlmulu~ i\ applied) or the paw pressure test (measuring the
1\lthdm"al thre\hold when a normal or inflamed paw is pinched with
m.:rea,ing force). Simi lar tc~ts can be u~ed on human subjects. who
s ''mply 10d1cate when a stimulu~ begin> to feel painful. but the pain in
the'e crcu1mtance' l ack~ the affect ive component. Clinically.
'pontaneou' pain :md allodynia of neu ropathic origin is coming to be
t~Xogni,ed II' particularly important, bu t this is more difficult to model
m ~nim:il ' tudics. lt b recognised cli nically that many ana lges ics,
particulnrl y those of the morphine type. can greatly reduce the distress
a\\OCI3tCd with pai n even though the patient reports no great change
in the intcn,ity of the actua l sensa tion. It is much more difficult to devise
tNs that measure thi s affecti ve component. and important to realise that
II may be <II !caM a~ &igniticant a; Lhe antinociceptive component in the
a.:uon of thc'c drug,. There is often a poor correlation between the
~divHy of analge,ic drugs in animal tests (which mainly assess
'\'Oke
antinociccpti\C acuvity) and their clinical effectiveness.
en on
~ uro-
ypes CHEMICAL SIGNALLING IN THE
bad: NOCICEPTIVE PATHWAY
rally
CHEMOSENSITIVITY OF NOCICEPTIVE NERVE
ntial
ENDINGS
In il o't ca~e~. !>timulation of nociceptive endings in the periphery
t' chemical in origin. Excessive mechanical or thermal stimuli
can obviously cause acute pain, but the persistence of such pain
nncd atrer the stimulus has been removed. or the pain resulting from
1ha mtlarnmatory or ischaemic changes in lissues, generally retlects
:live)
an altered chemical environment of the pain afferents. The field
Juces
'!bing wa~ opened up in the 1960s by Keele and Armstrong, who devel-
ccun. oped a simple method for measuring the pain-producing effect of
various substances that act on cutaneous nerve endjngs. They
produced smal l bl isters on the forearm of human subjects, and
applied chemicals to the blister base. recording the degree of pain
that the subjects reported. Since then, electrical recording from
sensory nerves and studies of the membrane responses of neurons
in culture. coupled with molecular biology techlliques to identify
receptors and signal transduction pathways in nociceptive neurons,
have produced a wealth of new information. and the humble
nociceptive neuron has bathed in a Limelight that more aristocratic
neurons might envy. The current state of knowledge is reviewed
by M cM ahon et al. (2006) and summarised in Figure 4 1.6.
The main groups of substances that stimulate pain endings in
th e skin are discussed below.
The vanilloid receptor (TRPVl)
T Capsaicin, the substa nce in cbiJlj peppers that gives them their
pungency, selectively exc ites nociceptive nerve terminals. causing intense
pain if injected into the skin or applied to sensi tive structures such as
the cornca.1 It produce~ this effect by binding to a rccepLDr expressed by
nociceptive afferen t neurons. The receptor, originally known as the
vani lloid receptor becau~c many capsaicin-like compounds are based on
the ~tructure of 'anillic acid. is a typical ligand-gated cation channel
known as the tra/1.\ieut ll'Ceptor poteutialmnilloid receptor I (TRPV 1)
(sec Ch. 3). Agonl\t\ such as capsaicin open the channel. which i'
pern1cable to ~a. Ca~ and other cation~. causing depolarisation and
initiation of action potentials. TRPV I respond~ not only to cap~aicin-like
agoni\1\ but alw to other stimuli. including temperature~ in exce'>s
of about 45 C (the thre~hold for pain) and proton concentrations in Lhe
micromolar range (pll 5.5 and below). \lohich also cause pain. The
receptor thu'> ha\ unu\ual 'pol) modal' characteristics that closely march
tho\C of nociceptive neurons. and it is believed to play a central role
in nociccption (\ee Wang & Woolf. 2005). TRPVI is, like many other
ionotropic receptor,, modu lated by phosphorylation, and several of the
pain-producing -.uiNances that act through G-protein-coupled receptor<;
(e.g. brod,tkinin; >CC below) work by ;ensitising TRPV I. A search for
endogcnou~ ligand'> for TRPV I revealed. surprisingly. that anandamide
(u lipid mediator previou;ly identified as an agoniM at cannabinoid
receptor\; \CC Ch. 43) is also a TRPV l agonist, although less potent than
capsaicin. Other endogenous lipid mediators, collectively known as
endo\anilloids (van dcr Stell & Di Mart.o. 2004) have since been
identified, bu t their role in nociception is not cu rren tly known.
Confirming the role of TRPV I in nociception. it ha~ been found that
TRPV I knockout mice show reduced responsiveness to noxious heat and
a l ~o fai l to ,how thennul hyperalge;ia in response to inflammation. The
Iauer ob~ervati on is interesting, because TRPV I expression is known to
be increa\ed by inOammation (sec Wang & Woolf, 2005), and th1!.
may be a key mechanbm by which primary hyperalgesia is produced.
The TRPV I channel\ may repre;eot tbe common pathway through
which many pain-producing mediators exert their excitatory effects on
nociceptor.., and are considered to be a possible target for future analgesic
drugs (sec Krau\e et al . 2005).
Capsaicin and related irritant substances
T Cap~aicin is a potent TRPV I agonist that selectively stimulates
nocicepti\'e nerve ending~. as described above. Similar substances exist
in other pungent plant~ (ginger. black pepper, etc.). but none are as potent
as capsaicin. Resiniferatoxin, a compound produced by some plants
2
Anyone who htL~ rubbed thei r eyes after cutting up chilli pepper~ will know
this. 593
 SECTION 4 . THE NERVOUS SYSTEM

V-gated
Na channel K channels

PKC ~ prJ
I

B2 '''"PIO< - Prostanoid [tJlrU other inhibitory

j ap,:::: j~~=
receptor

1 Prostaglandins Norepmephrine

Fig . 41 .6 Channels, receptors and transduction mechanisms of nociceptive afferent terminals. Only the main channels and
receptors are shown. Ligand-gated channels include acid-sensitive ion channels (ASICs), AlP-sensitive channels (P2x receptors) and the
capsaicin-sensitive channel (TRPV1 ), which is also sensitive to protons and to temperature. Various facilitatory and inhibitory G
protein-coupled receptors (GPCRs) are shown, which regulate channel function through various second messenger systems. Growth
factors such as nerve growth factor (NGF) act via kinase-linked receptors (TrkA) to control ion channel function and gene expression. 82
receptor, bradykinin type 2 receptor; PKA, protein kinase A; PKC, protein kinase C.

of the Euphorbia family. who...e \ap causes painful skin irrirarion. is so far
rhe most porenr agonisr l.nown.
There are several inrercsting fearure~ of !he action of capsaicin.
The large influx of Ca2+ inro nerve terminals rhar it produce' re~ult~ in
peptide release (main ly substance P and CGRP), causing intense
vascular and other physiological responses. The Ca2 influx muy be
enough to cause nerve terminal degenera6on, which takes days or
weeks lo recover. Aucmpts to use topically applied capsaicin 10 relieve
painful skin conditions have had some ~uccess. bur !he iniria l ~trong
irritant effecr is a major disadvantage.
Capsaicin applied to the bladder causes degenerarion of primary
afferem nerve terminals, and has been used to treat incontinence
associated wilh bladder hyperreactivir) in stroke or \pmal mjury
patien~. C-fibre afferents 10 the bladder serve a local reflex function.
which promotes emptying when the bladder is distended, the reflex
being exaggerared when central control is lost.
Given ro neonatal animal!., capsaicin causes an irreversible loss of
polymodal nociceptors, becau&e the cell bodies (nor just the terminals)
are killed. The anima l~ grow up with greatly reduced responses to
painful stimu li. This ha~ been used as an experimental procedure for
investigating the role of the~e neurons.
Unlike mammals, bird~ do not respond to capsaicin, because avian
TRPV 1 differs from mammalian TRPV I. Consequently, birds eat chilli
peppers and distribure thetr seeds. while mammal~ (orher rhan
humans-the only mn~och1\lic mammal) avoid !hem.
Kin ins
The most active substances are bradykinin and kallidin (sec
Cb. 13), two closely related peptides produced under conditions
594 of tissue injury by the proteolytic cleavage of the active kinins
from a precursor protein contained in the plasma (reviewed b}
Dray & Perkins. 1993). Bradykinin is a potent pain-produc10g
substance, acting panly by release of prostaglandins. wluch
strongly enhance the direct action of bradykinin on the nem
terminals (Fig. 41.7). Bradykinin acts by combining w1tt
specific G-protein-<:oupled receptors, of which there are I\\O
subtypes, B 1 and 8 2 . In nociceptive neurons, B2-receptors are
coupled to activation of a specific isoform of protein kina~e
C (PKCE), which phosphorylatcs TRPV I and facilitates opening
of the TRPV I channel.
Bradykinin acts on B2-receptors but is convened in tissues b)
removal of a terminal arginine residue to des-Arg9 bradykinin.
which acts selectively on B 1-receptors. B2 and B 1-receptOf\ art
both involved in the pathogenesis of pain and inflammation B
receptors are unusual in that they are normally expressed at vel)
low levels, but their expression is strongly up-regulated in inflamed
tissues (see Calixto et al., 2004). Transgenic knockout anima),
lacking either type of receptor show reduced innammatol')
hyperalgesia. Specific competitive antagonists for both 8 1 and B
receptors are known, including peptides such as the B2 antagonl\1
icatibant (Ch. 13 ), as weU as non-peptides. These show analg~,
and anti-inflammatory properties. and may prove suitable ft
clinical usc as analgesics (sec Marceau & Regoli, 2004).
Prostaglandins
Prostaglandins do not themselves cause pain, but they strongl)
enhance the pain-producing effect of other agents such as 5
 ANALGESIC DRUGS

40 ]5omv
U)

:gj
CD
~ 20
c.
.E
0
t
Brad. Brad.
261-lg 26!tg 5min

Fig. 41 .7 Response of a nociceptive afferent neuron to bradykinin (Brad.) and prostaglandin. Recordings were made from a
noclceptiv? afferent fibre supplying a .muscle, and drugs were injected into the arterial supply. Upper records: single- fibre recordings
showng dscharge caused by bradykmln alone (left), and by bradykinin following Injection of prostaglandin (right). Lower trace:
ratemeter recording of single-fibre discharge, showing long-lasting enhancement of response to bradykinin after an injection of
prostaglandin E2 (PGE2). Prostaglandin itself did not evoke a discharge. (From MensaS 1981 Brain Res 225: 95.)

hydroxytryptamine or bradykinin (Fig. 41.7). Prostaglandins of

lhe E and F ~cries are released in inflammation (Ch. 13) and
also during ti.,~ue ischaemia. They sensitise nerve terminals to
Other agents panty by inhibiting potassium channels and partly
e b) facthtating-through ~econd messenger-mediated phos-
phol')lation reaction~ (~ee Ch. 3)-the cation channels opened
b) noxtous agent'>. It i~ of intere~t that bradykinin itself causes
pro,taglandin relea~e. and Lhus bas a powerful self-sensitising'
etln:t on nociceptive afferents. Other eicosanoids, including
P'O'WC)'clin, leukouienes and the unstable hydroxyeicosatetraenoic
ac1d (HETE) derivatives (Ch. 13). may also be imponant (see
Samad et al., 2002). The analgesic effects of NSAlDs (Ch. 14)
:ing r~'ult from inhibition of prostaglandin synthesis.
tich
:rve Other peripheral mediators
vith \'anou' metabolites and substances arc released from damaged
two or i~chacmic cells, or inflamed tissues, including ATP, protons
are !produced by lactic acid), 5-hydroxytryptamine. histamine and
13SC K'. many of which affect nociceptive nerve terminals.
aing ATP excites nociceptive nerve terminals by acting on P2x3
receptors, a form of ligand-gated ion cban11el that is selectively
'by exprc\,cd by these neurons. Down-regulation of P2x 3 receptors,
1in, b} antisense D A technology. reduces infiallllllatory pain. 3
are Antagoni\ts at this receptor may be developed for clinical use.
B, \TP and other purine mediators. such as adenosine, also play a
ery role in the dor...al hom, and other types of purinoceptor may also
ned re 1arg..:ted b} analgesic drug!> in the future (see Liu & Salter, 2005).
1als lo11 pH excites nociceptive afferent neurons partly by opening
ory proton-acttl'ated cation channels (acid-sensitive ion channels)
B~ nd panl) b) facilitation ofTRPVJ (see above).
nist 5-H)di'OX}tryptamine causes excitation. but studies wilh antagon-
!~ic ,r~ 'uggeM that it play!> at most a minor role. Histamine is also
for
Mechanlama of pain and noclception
Nociception is the mechanism whereby
noxious peripheral stimuli are transmitted to the
central nervous system. Pain is a subjective
experience not always associated with nociception.
Polymodal nociceptors (PMNs) are the main type of
peripheral sensory neuron that responds to noxious
stimuli. The majority are non-myelinated C fibres
whose endings respond to thermal, mechanical and
chemical stimuli.
Chemical stimuli acting on PMNs to cause pain
include bradykinin, protons, ATP and vanilloids (e.g.
capsaicin). PMNs are sensitised by prostaglandins,
which explains the analgesic effect of aspirin-like
drugs, particularly in the presence of inflammation.
The vanilloid receptor TRPV1 (transient receptor
potential vanilloid receptor 1) responds to noxious
heat as well as capsaicin-like agonists. The lipid
mediator anandamide is an agonist at vanilloid
receptors, as well as being an endogenous
cannabinoid receptor agonist.
Nociceptive fibres terminate in the superficial layers
of the dorsal horn, forming synaptic connections with
transmission neurons running to the thalamus.
PMN neurons release glutamate (fast transmitter) and
various peptides (especially substance P) that act as
slow transmitters. Peptides are also released
peripherally and contribute to neurogenic inflammation.
Neuropathic pain, associated with damage to
neurons of the nociceptive pathway rather than an
excessive peripheral stimulus, is frequently a
component of chronic pain states and may respond
poorly to opioid analgesics.

g ly P." knockout mice are. in contrast. fairly normal in this respect.

5- nre,umubly because other mechanism take over. 595
 SECTION 4 . THE NERVOUS SYSTEM

active but causes itching rather than actual pain. Both these Noradrenaline is the transmitter of the inhibitory pathway
substances arc released locally in inflammation (see Ch. 13). from the locu'> coeruleus to the dorsal horn, and possibly aho
Opioid peptide!> relea!>ed peripherally inhibit nociceptor in other antinociceptive pathways.
excitability, as do cannabinoids. These agents act through G- Adeno-,ine play!> a dual role in regulating nociceptive
protein~oupled receptors that are negatively coupled to adenylate transmission, activation of A 1 receptors causing analgesia, b}
cycla~e. and hence their effects oppose those of prostaglandin!.. acting on both peripheral nerve terminals and dorsal hom
The physiological significance of these mediators in the periph- neurons, while activation of A 2 receptors in the periphel)
ery is uncertain. doe~ the reverse (see Liu & Salter. 2005). There is e\idence
In summary, pain endings can be activated or sensitised by a for descending inhibitory purinergic pathways acting on pain
wide variety of endogenous mediators. the receptors for which tran'lmission through A 1 receptors.
arc often up- or down-regulated under pathophysiological con-
ditions. Neuroplasticity plays an important role in persistent pain
states, irrespective of their primary cause: not surpris ingly, the ANALGESIC DRUGS
signalling pathways have much in common with, and are at least
MORPHINE-LIKE DRUGS
as complex as, those involved in other neuroplastic ity-based
CNS pathologies discussed in emlier chapters. The strategies for The te rm opioid applies to any substance, whether endogcnou>
deve loping the next wave of analgesic drugs therefore follow or synthetic, that produces morphine-like effects that are blocked
similar lines.~ by antagonists <,uch as naloxone. The older term, opiate, is
restricted to synthetic morphine-like drugs with non-peptidk
strucwrcs. The field is reviewed thoroughly by Herz ( 1993).
TRANSMITTERS AND MODULATORS IN THE Opium is an extract of the juice of the poppy Papaw
NOCICEPTIVE PATHWAY somnifemm, which ha~ been tt~ed for social and medicinal puflX>"'
for thousands of year~ as an agent to produce euphoria, analge,Ja
The family of opioid pcptides (see Ch. 16) plays a key role in
and sleep, and to pre,ent diarrhoea. Tt was introduced in Britam
nociceptive transmission: its role in descending inhibitory
at the end of the 17th century, usually taken orally a~ tincture
controls is summarised in Figure 41.5. Opiate analgesics (see
of laudanum, addiction to which acquired a certain social cachet
below) act on the various receptor!> for these peptides.
during the next 200 years. The sjtuation changed when t~
Another peptide family thought to play a key role is the
hypodermic 11yringe and needle were invented in the mid-19th
tachykinin family (see Ch. 16), of which substance Pis the bcst-
century, and opiate dependence began to take on a more sini\t(r
I.nown member. Substance P is expressed by nociceptive afferen t
significance.
neurons and released at their peripheral and central terminals. In
the periphery, it produce!. !\orne of the features of neurogenic
inflammation (sec above), and in the dorsal horn it may be CHEMICAL ASPECTS
invo lved in wind-up and central sensitisation. In animal models,
Opium contains many alkaloids related to morphine. The structure
subst<tnce P antagonistl> are effective analgesic drugs, but clinical
of morphine (Fig. 41.8) was determined in 1902, and since then
trials have failed to confirm this in humans, so the high hopes for
many semisynthetic compounds (produced by chemical modifi
developing a new type of analgesic for clinical use have been
cation of morphine) and fully synthetic opiates have been studied
dashed. The reason for this fai lure is not clear, but it may imply
In addition 10 morphine- like compounds, opium also contain~
that substance P is less important as a pain mediator in humans
papaverine, a smooth muscle re laxant (see Ch. 19).
than in rats.
The mai n groups of drugs that arc discussed in this section are
Other mediators include the following.
as fo llow.
Glutamate (see Ch. 33) is released from primary afferent
Morphine analogues. These are compounds closely related in
neurons and, acting on AMPA receptors, is responsible for
structure to morphine and often synthesised from it. They
fast synaptic transmjssion at the first synapse in the dorsal
may be agonists (e.g. morphine, diamorphine [heroin] and
hom. The re is abo a ~lower NMDA receptor-mediated
codeine), partial agonists (e.g. nalorphine and levallorphan
re~pon<>c, which i'> important in relation to the wind-up
or antagoni'>ts (e.g. naloxone ).
phenomenon (see Fig. 41.3).
Synthetic derivative~ with strucrures unrelated to morphine:
GABA (see Ch. 33) is released by !'.pinal cord intemeurons
- phenylpiperidine series (e.g. pethidine and fentanyl)
and inhibit'> tran~miller release by primary afferent terminals
- methadone series (e.g. methadone and dextropropoxyphellf
in the dorsal hom.
-bcnzomorphan series (e.g. pentazocine and cyclazocine)
5-Hydroxytryptamine is the transmitter of inhibitory neurons
-semisynthetic thebaine derivatives (e.g. etorphine all\
running from NRM to the dorsal horn.
buprenorphine).

Me ntion should also be made of loperamide. an opiate that doe

not e nte r the brain and therefore lacks analgesic activity. Likt
4
And, sceptics may argue. face similar obstacles in relation to specificity othe r opiates (see be low), it inhibits peristalsis, and it is used to
596 and unwanted effect~. contro l diarrhoea (sec Ch. 25).
 --------- '
also I I \
I CH2
CH3 _; NCH2 - HC/I
I II ' CH2 I

b) N
Cyclazocine

ce
1ain
OH
HO

Morphine Pentazocine

lous CH 3
ked I
N
. is

~
idic

1rer
o-.c!>
e'ia I
0
tain I
CH2
ure I
::het CH3
the
9th Pethidine Fentanyl

stcr

urc
hen
li fi-
ied.
tin'>

are

Ill Fig. 41.8 Structures of some

opiate analgesics. Methadone Sufentanil
d
ln)

Morphine analogues sought. It is chemically unlike morphine. although iLc; pharma-

\1orphine is a phenanthrene derivative with two planar rings
and two aliphatic ring wuctures, which occupy a plane roughly
ne)
~~ right angles to the rest of the molecule (Fig. 41.8). Variants
)
of the morphine molecule have been produced by substitution
md
Jt one or both of the hydroxyl groups or at the nitrogen atom.
)CS Synthetic derivatives
ike Plrenylpiperidine series. Pethidine (known as meperidine in the
to LSA), the first fu lly synthetic morphine-like drug, was dis-
covered accidentally when new atropine-like drugs were being
cological actions arc very similar. Fentanyl and sufentanil (the
latter not u. ed in the UK) are more potent and shorter-acting
derivatives that are used intravenously. or for chronic pain via
patches applied to the skin, to treat severe pain or as an adjunct
to anaesthesia.
Methadone eries. Methadone, although its structural formula
bears no obvious chemical relationship to that of morphine,
assumes a s imilar conformation in solution and was designed
by reference to the common three-dimensional structural
features of morphine and pethidine (Fig. 41.8). Tt is longer 597
 SECTION 4 . THE NERVOUS SYSTEM

acting than morphine but otherwise very similar to it. Dcxtro-
propoxyphcnc is very similar and was used clinically for treating
mild or moderate pain (no longer recommended on account of
cardiotoxiciry).
Benzomorphan series. The most important members of this
clas~ arc penta10cine and cycla.wcine (Fig. 41.8). These drugl>
differ from morphine in their receptor-binding profile (see
below), and so have somewhat different actions and side effects.
Cychvocinc is not used in the U K, and the use of pentazocine is
declining.
Thebaine derivatives. Etorphine is a highly potent morphine-
like drug used mainly in veterinary practice. Buprenorphine
resembles morphine but is a partial agonist (see below);
therefore. although very potent, its maximal effect is less than
that of morphine, and it antagonises the effect of other opiates.
OPIOID RECEPTORS
The discovery of endogenous opiod peptides (eokephalins, see
Ch. 16) by llughcs and Kostcrlitz in 1972 was quickly followed
by the discovery by Snyder and his coUegues of specific binding
sites in the brain, and the identification of these as specific opioid
receptors, the existence of which had been proposed much earlier
to account for the actions of drugs that antagonised the effects of
morphine. Various pharmacological observations implied that
subsequent pharmacological studies, later confirmed by receptor
cloning, is that three types of opioid receptor, termed ll band K"
(all of them typical G-protein-<:oupled receptors; see Ch. 3)
mediate the main pharmacological effects of opiates. a'
summarised in Table 41.1. 6 There is pharmacological evident
for further subdivi-;ions of each of these three subtypes; it "
possible that splice variants and receptor dimerisation (see Ch. 31
can account for this pharmacological diversity. Studies on ttl<
characteristics of transgenic mouse strains lacking each of th<
three main 11ubtypes (see Law et al., 2000) show that the maJa-
pharmacological effects of morphine, including analgesia, are
mediated by the ~t-receptor.
The interaction of various opioid drugs and peptides with Lh~
various receptor types is summarised in Table 41.2. In addition
to endogenous peptides and drugs in clinical use, some agent1
that arc used as experimental tools for distinguishing the differ
ent receptor subtypes are also shown.
Ta ble 41 .1 Functional effects associated with the main
types of opioid recept or
JL I) K

more than one type of receptor was involved, the original

suggestion of multiple receptor types arising from in vivo studies Analges1a
Supraspinal +++
of the spectrum of actions (analgesi~ sedation, pupillary
Spinal ++ ++ +
constriction, bradycardia. etc.) produced by different drugs. It Peripheral ++ +T
was al~o found that some opiates, but not all. were able to relieve
wi thdrawal symptoms in morphine-dependent animals, and this Respiratory depression +++ ++
was interpreted in terms of distinct receptor subtypes. The
conclusion (see Dhawan et al., 1996) from these and many Pupil constriction ++ +
Reduced gastrointestinal motility ++ ++ +

Euphoria +++

Dysphoria +++
Oplold enelgealca
Sedation ++ ++

Opioid drugs include: Physical dependence +++ +

phenanthrene derivatives structurally related to
morphine
synthetic compounds with a variety of dissimilar
structures but similar pharmacological effects.
Important morphine-like agonists include diamorphine
sA founh subtype, <J, wa.' al\o poMulated in order to account for the
and codeine; other structurally related compounds
'dysphoric' effect~ (anxiety, hallucinations. bad dreams, etc.) produced b)
are partial agomsts (e.g. nalorphine and levallorphan) some opiates. "TheM: are. however, not true op1oid receptors. becau.-.e man~
or antagonists (e.g. naloxone). other types of psychotropic drug also interact with them, and their
The main groups of synthetic analogues are the biological role remain~ unclear (see Walker et al . 1990). Of the opiate
piperidines (e.g. pethidine and fentanyl), the drugs. only bcnfomorphans. such as pentaLocine and cycl:vocine. bmd
appreciably to o receptor,. which is consistent with their known
methadone-like drugs, the benzomorphans
psychotomimetic propcnies.
(e.g. pentazocine) and the thebaine derivatives
l>fhe opiod ~yMcrn is unusual among mediator system directed by G-
(e.g. buprenorphine).
protein-couplcd rccepton>, in that there are many (20 or more) opioid
Opioid analgesics may be given orally, by injection, or
pcplides bul on ly three receptors. In contrast, 5-bydroxytryptamine, for
intrathecally to produce analgesia. example, is a single mediator interacting witb many (about 14) receptor~.
598 which i ~ the more common pal tern.
 ANALGESIC DRUGS

Oplold receptors Table 41.2 Selectivity of opioid drugs and peptides for
receptor subtypes
11-Receptors are thought to be responsible for
most of the analgesic effects of opioids, and for some fL li K

major unwanted effects {e.g. respiratory depression,

Endogenous peptides
euphoria, sedation and dependence). Most of the ~-Endorphin ++-!- +++ +++
analgesic opioids are ~~-receptor agonists. Leu-enkephalin + +++
ll-Receptors are probably more important in the Met-enkephalin ++ +++
periphery but may also contribute to analgesia. Dynorphin ++ + +++

c ~-Receptors contribute to analgesia at the spinal

Opiate drugs
level and may elicit sedation and dysphoria, but Pure agonists
c produce relatively few unwanted effects and do not Morphine, codeine, oxymorphone, +++ + +
n contribute to dependence. Some analgesics are dextropropoxyphene
relatively 11.-selective. Methadone +++
a-Receptors are not true opioid receptors but are the Meperidine ++ + +
Etorph1ne, bremazocine +++ +++ +++
site of action of certain psychotomimet ic drugs, with Fentanyl, sufentanil +++ +
which some opioids interact.
All opioid receptors are linked through G-proteins to Partial/mixed agonists
Inhibition of adenylate cyclase. They also facilitate Pentazocine, ketocyclazocine + + ++
Nalbuphlne + + (++)
opening of potassium channels {causing
Nalorphine ++ ++
hyperpolarisation) and inhibit opening of calcium Buprenorphine (-.-. ++
channels {inhibiting transmitter release). These
membrane effects are not linked to the decrease in Antagonists
cAMP formation. Naloxone +++ + ++
Funct1onal heterodimers, formed by combination of Naltrexone +++ + +++

different types of opioid receptor, m ay occur and give

Research tools (receptor-
nse to further pharmacological diversity. selective)
DAMGO' +++
DPDPE' ++
U50488 ++-o-
CTOP' +++
Naltrindole, diprenorphine +++
AGONIST$ AND ANTAGONISTS Nor-binaltorphimine + + +++

Opiates vary not only in their receptor specil:icity but aJso in their
ctficaq at the different types of receptor. Thus l-Ome agents act
a' agonists on one type of receptor, and antagonists or partial
goni~b at another. producing a very complicated pharmaco-
lo.ical picture. Some of this complexity may reflect the
e\i'tence of receptor heterodimers whose functi onal properties
Jiffer from those of the wei !-studied monomeric opiate receptors.
',\g,lni<.t-directed trafficking' (see Ch. 3), whereby different ligands
JCUng on the same receptor can elicit different cellular responses.
may abo account for some of the complexity. Current under-
'tanding of why different opiates have different actions is far
trom complete.
Partial agonists and mixed agonist-anwgonisrs. l11esc drugs,
Three main pharmacological ca tegories arc recognised
(fable 4 1.2).
Pure agoniHs. This group includes most of the typical
morphine-like dmgs. They all have high affinity for !.l
receptors and generaJiy lower affinity for() and K sites.
Some drugs of this type. notably codeine. methadone and
dextropropoxyphene, are sometimes referred to as weak
agonists because their maximal effects, both analgesic and
unwanted. are less than those of morphine. and they do not
cau'e dependence. Whether they are tmly partial agonists is
not established.
Note: Blue + symbols represent agonists activity; partial
agonists in parentheses
Black + symbols denote antagonist activity.
- symbols represent weak or no activity.
8
0AMGO, DPDPE and CTOP are synthetic opioid-like peptides,
more receptor-selective than endogenous opioids.
bU50488 is a synthetic opiate.
typified by nalorphine and pentazocine, combine a degree of
agonht and antagonist activity on dilTcrent receptor,.
aJorphine, for example. is an agonist when tel>ted on guinea
pig ileum, but it also inhibits competiti vely the effect of
morphine on this tissue (consi!>tent with a partial agonist
profile; !>Ce Ch. 2). In vivo, it \hows a similar mixture of
agonist and antagonist actions. Penuuoeine and cyclazocine,
on the other hand, are antagonists at ~t-rcceptors but partial
agonists on band K-receptors. Most of the dmgs in this
group tend to cause dysphoria rather than euphoria, probably
by acting on the K'-rceeptor. 599
 SECTION 4 . THE NERVOUS SYSTEM
Amagonists. These drugs produce very little effect when
given on their own but block the effects of opiates. The most
imponant examples are naloxone and naltrexone.
MECHANISM OF ACTION OF OPIATES
The opiates have probably been studied more intensively than
any other group of drugs in the cffon to understand their power-
ful effects in molecular. biochemical and physiological terms,
and to usc this understanding to develop opiate drugs as
analgesics with significant advantages over morphine. While the
receptor biology is well worked out (see Waldhoer et al.. 2004).
the physiological pathways that are regulated by opiates. which
underlie their analgesic and other actions, are only partly under-
stood. Even so. morphine-described by Osler as 'God 's own
medicine' -rcmains the standard against which any new analgesic
is assessed. For a review on the neuropharmacology of opiates,
sec Yaksh ( 1997).
Cellular actions
Opioid receptors belong to the family of G-protein-coupled
receptors, and all three receptor subtypes inhibit adenylyl cyclase.
so reducing the intracellular cAMP content (see Dhawan et al.,
1996). secondarily affecting protein phosphorylation pathways
and hence cell function. They also exert effects on ion c h<mnels
through a direct G-protein coupling to the channel. By these
mean!>, opiates promote the opening of potassium channels and
inhibit the opening of voltage-gated calcium channels. which
are the main effects seen at the membrane level. These membrane
effects reduce both neuronal excitability (because the increased
K+ conductance causes hyperpolarisation of the membrane) and
transminer release (due to inhibition of Ca2+ entry). The overall
effect is therefore inhibitory at the cellular level. Nonetheless,
opiates increase activity in some neuro nal pathways (see be low)
by suppressing the firing of ir1hibitory interneurons. At the cellu-
lar level, all three receptor s ubtypes mediate very similar effects,
although the heterogeneous distribution of the receptors means
that particular neuro ns and pathways are affected selectively by
different agonists.
EHects on the nociceptive pathway
Opioid receptors are widely distributed in the brain. and their
relationship to the nociceptive pathway is summarised in
Figure 41.5. Opiates are effective as analgesics when given
intrathecally in minute doses. implying that a central action can
account for their analgesic effect. Injection of morphine into the
PAG region cau~es marked analgesia, which can be prevented by
surgical interruption of the descending pathway to NRM or by
blocking 5-hydroxytryptamine synthesis pharmacologically with
p-chlorophenylalanine. This latter procedure blocks the 5-
hydroxytryptamine pathway running from NRJvl to the dorsal
hom. Moreover. systemic morphine is rendered less effective in
suppressing nociceptive spinal reflexes by transection of the
spinal cord in the neck, and the firing of neurons associated with
the descending inhibitory pathways is increased by morphine,
confirming that there is a s i&'llificant supraspinal component of
600 the overall effect.
At the spinal level, morphine inhibits transmission of nocicep-
tive impul<;es through the dorsal hom and suppresses nocicepure
spinal reflexes. even in patients with spinal cord transection It
can inhibit relea!>e of ~ubstance P from primary afferem ter
minals in the do~al hom neurons. but does not appear to do~
in rats when given systemically in analgesic doses, implying th3!
an action on primary afferent terminals may not be imponantm
producing its therapeutic effect.
There is abo evidence (see Sawynok, 2003) that opiates inhibu
the discharge of nociceptive afferent terminals in the periphel).
panicularly under conditions of inflammation. in which the
expression of opioid receptors by sensory neurons is increa-.eJ.
Injection of morphine into the knee joint following surger} tu
the j o int provides effective analgesia, undermining the age-oiJ
belief that opiate analgesia is exclus ively a central phenomenon.
PHARMACOLOGICAL ACTIONS
Morphine is typical of many opiate analgesics and will be ta~en
as the reference compound.
The most important effects of morphine arc on the CNS ana
the ga~trointestina ltract , although numerous effects of lesser sig
nificance on many other systems have been described.
EHects on the central nervous system
Analgesia
Morphine is effective in most kinds of acute and chronic pair
although opiates in general are less useful in neuropathic p;un
syndromes (such as phantom limb and other types of deaf
ferentation pain, and trigeminal neuralgia) than in pain aS\01:
ated with tissue injury, inflammation or tumour growth.
As well as being antinociceptive, morphine also reduces tht
affective component of pain. This reflects its supraspinal action.
possibly at the level of the limbic system, which is probabl)
involved in the euphoria-producing effect. Drugs such as nalorphin,
and pent:u.ocine share the antinociceptive actions of morphine
but have much less effec t on the psychological response to pain.
Euphoria
Morphine causes a powerful sense of contentment and well
being. This is an important component of its analgesic effec~
because the agitation and anxiety associated with a painful rll
ness or injury are thereby reduced. If morphine or diamorphine
(heroin) is given intravenously, the result is a sudden 'ruo;h
likened to an 'abdominal orgasm'. The euphoria produced b}
morphine depends considerably on the circumstances. In patient>
who arc distressed it is pronounced. but in patients who becomt
accustomed to chronic pain. morphine causes analgesia ll'itl-
linle or no euphoria. Some patients repon restlessness rather th11.
euphoria under these circumstances.
Euphoria appears to be mediated through ~ receptors, and to
be balanced by the dy:.phoria associated with K-receptor actr
vat ion (sec Table 41. J). Thus, different opiate drugs vary greatl)
in the amount of euphoria that they produce. it does not occur
with codeine or with pe ntazocine to any marked extent, and
nalorphine, in doses sufficient to cause analgesia. produces
dysphoria.

cp- Respiratory depression
1\e Rt,plraiOI) depre~'>ion, resulting in increased arterial Pco,,
occu~ 1\ith a nonnal analgesic dose of morphine or related com-
pound~. Analgesia and respiratory depression are both mediated
b) llrcceptors. and the balance between them is therefore the
S31Tll' for most opiates. The depre!>sant effect i'> associated with
adtaca~c in the sensitivity of the respiratory centre to Pco2
\Mons in Lhe medul lary respiratory centre itself do not appear
it In b.: d1rectly depressed, but opiates applied to the ventral !>urfacc
ry. f the medulla in the region where C0 2 chemosensitivity is
he mn1mal have a powerful depres~ant effect on respiration.
d. Re'>pirmory depression by opiates is not accompanied by
to J<pr~'"on of the medullary centres controlling cardiovascular
!ld ll<:llon (in contra'>t to the action of anaesthetics and other
10. ~eneral depressants). This means that respiratory depression
produc~d by opiates is much better tolerated than a similar
de~rec of depression caused by. say. a barbiturate. Nonetheless.
re'p1ra1ory depression is the mo!>t troublesome unwanted effect
.n of thN drugs and, unlike that due to general CNS depressant
dn1g,, it occurs at therapeutic doses. Tt is the commonest cause
ttl of tk;Hh in acute opiate poisoning.
g-
Depression of cough reflex
Cough 'uppression. <,urprisingly, does not correla te closely with
!he analgesic and respiratory depressant actions of op iate~>, and
1t' mechanism at the receptor level is unclear. In general,
mcrea\mg substitution on the phenolic hydroxyl group of mor-
phine Jncreases antitussive relative to analgesic activity. Thus
codeine suppres~es cough in subanalgesic doses and is often
u-.ed in cough medicines (see Ch. 23). Pholcodine is even
more \Cicctive. although these agent~ cau!.e constipation as an
uOI\antcd effect.
Nausea and vomiting
~au,ca and vomiting occur in up to 40%- of patients to whom
morphme is given, and do not seem to be separable from the
analgc~ic effect among a range of opiate analgesics. The site of
action is Lhe area postrcma (chemoreceptor trigger zone), a region
of the medulla \\here chemical stimuli of many kind\ may
tmllalc vomiting ('ee Ch. 25). 7 ausea and vomiting following
morphtne injection are usually transient and disappear w ith
repeah!c.l administration.
Pupillary constriction
Pupillary constriction is caused by 1J. and K receptor- mediated
~timulntion of the oculomotor nucleus. Pinpoint pupils arc an
mponant diagnoMic feature in opiate poisoning, 8 because most
other causes of coma and respiratory depression produce pupil-
1M) dilatation.
T1e ~h~mically related compound apomorphine is more strongly emetic
lh.m morphine. through it ~ action a; a dopamine agonist; despite its name. it
,, m...:me on opioid receptors. 11 was a1 one time used as a conditioned
1\ti'IOR therap) for lreating variou\ kinds of unwanled behaviour.
~exception i~ pethidme, which causes pupillary dilatation becau>oe it
Nrock' mu~carinic receplors.
ANALGESIC DRUGS
EHects on the gastrointestinal tract
Morphine increases tone and reduces motility in many parts of
the gastrointestinal system, resulting in constipation, which may
be severe and very troublesome to the patient. The resulting
delay in gastric emptying can considerably retard the absorption
of other drug!). Pressure in the biliary tract increases because
of contraction of the gall bladder and constriction of the biliary
sphincter. Opiates should be avoided in patients suffering from
biliary colic due to gallstones. in whom pain may be increa ed
rather than relieved. The ri'>e in intrabiliary pressure can cause
a transient increase in the concentration of amylase and lipase in
the plasma.
The action of morphine on visceral smooth muscle is probably
mediated mainly through the intramural nerve plexu~es, because
the increase in tone is reduced or abolished by atropine. It is partly
med iated by a central action of morphine. because intraventr icular
injection of morphine inhibits propulsive gastrointeMinal move-
ments. The local effect of morphine and other opiates on neurons of
the myenteric plexus is inl1ibitory, associated with hyperpolarisation
resu lting from an i ncreased K + conductance. The receptors
involved in these effects are of the IJ.. K and b type, with much
variation between different preparations and different species.
Other actions of opiates
Morphine releases histamine from mast cells by an action unrelated
to opioid receptors. This release of histamine can cause local
effects, such a~ urticaria and itching at the site of the injection,
or systemic effccL~. namely bronchoconstriction and hypotension.
The bronchoconstrictor effect can have serious consequences for
Actions of morphine
The main pharmacological effects are:
analgesia
euphoria and sedation
respiratory depression and suppression of cough
nausea and vomiting
pupillary constriction
reduced gastrointestinal motility, causing
constipation
histamine release, causing bronchoconstriction
and hypotension.
The most troublesome unwanted effects are
constipation and respiratory depression.
Morphine may be given by injection (intravenous or
intramuscular) or by mouth, often as slow-release
tablets.
Acute overdosage with morphine produces coma and
respiratory depression.
Morphine is met abolised to morphine-6-glucuronide,
which is more potent as an analgesic.
Morphine and morphine-S-glucuronide are the active
metabolites of diamorphine and codeine.
601
 SECTION 4 . THE NERVOUS SYSTEM
aslhmatic patients. to whom morphine should not be given.
Pethidjne does not produce this effec1.
Hypotension and bradycardia occur with large doses of most
opiates. due to an action on the medulla. With morphine and similar
drugs, histamine release may contribute to the hypotension.
Effects on smooth muscle otber than that of the gastrointestinal
tract and bronchi are slight, although spasms of the ureters. bladder
and uterus sometimes occur. The Straub tail reaction, an improb-
able phenomenon beloved of pharmacologists, consists of a rais-
ing and stiffening of the tail of rats or mice given opiate drug~.
and is due to spasm of a muscle at the base of the tail. It was
through this effect that the analgesic action or pethidine
was discovered.
Opiates abo exert complex immunosuppressant effects, which
may be important as a linl.. between the nervous 1>ystem and
immune function (see Vallejo et al., 2004). The pharmacological
significance of this is not yet clear, but there is evidence in
humans that the immune system is depressed by long-term opiate
abuse. leading to increased susceptibility to infections.
TOLERANCE AND DEPENDENCE
Tolerance to opiates (i.e. an increase in the dose needed to
produce a given pharmacological effect) develops within a few
days and is readily demonstrated. Physical dependence refers to
a state in which withdrawal of the drug causes adverse physio-
logical effect!>, i.e. the abstinence syndrome. These phenomena
occur to some degree whenever opiates are administered for
more than a few days. They must not be confused with addjction
(see Ch. 43), in which physical dependence is mucb more
pronounced and psychological dependence (or craving') is the
main driving force. Addiction is rare in patients receiving opiates
to control pain. The opiate withdrawal syndrome can be repro-
duced in experimental animals and appear~ to be closely related
to tolerance.
Tolerance
Tolerance can be detected within 12-24 hour'> of morphine
administration. Figure 41.9 shows the increase in the equianalgesic
dose of morphine (measured by the hotplate test) that occurred
when a s low-release pellet of morphine wa~ implanted
subcutaneously in mice. The pellet was removed 8 hours before
the test, to allow morphine absorbed from it to be eliminated
before the test was carried out. Within 3 days. the equianalgesic
dose increased about fivefold. Sensitivity ren1rned to normal
withjn about 3 days of removing the pellet. Tolerance extend!>
to most of the pharmacological effect\ of morphine, including
analgesia. emesis, euphoria and respiratory depression, but affectl.
the consti paling and pupi 1-constricti ng ac tions much less.
Therefore addict<; may take 50 times the normal analgesic dose
of morphine with relati\ely little respiratory depression but
marked constipation and pupillary constriction.
The cellular mechanisms responsible for tolerance arc dis-
cussed in Chapter 43. Cenain possibilities can be excluded. such
as increased metabolic degradation. reduced affinity of opiates for
their receptor'>, down-regulation of opioid receptors and inhibition
602 of the release of endogenous opioids. Tolerance is a general
40
c;;
s0
E Morphine
2:
Jw 40
Q)
c
:ca.
0
~
0 12 24 36 48 60 72
nme after morphine implantation (hours)
Fig. 41.9 Development o f morphine tolerance in mice.
The median effective dose (ED50) for analgesia (hotplate test)
produced by subcutaneous injection of a test dose of morphine
(orange line) was measured at intervals after implantation of a
slow-release pellet of morphine, the pellet be1ng removed
8 hours before the assay in order to allow the circulating
morphine concentration to fall to zero before the test dose was
given. The ED50 increases about fivefold after 72 hours.
Simultaneously, the dose of naloxone needed to precipitate
withdrawal symptoms (green line) decreases very markedly.
(From Way E Let al. 1969 J Pharmacol Exp Ther 167: 1.)
'-...._
phenomenon of opioid receptor ligands. irre'>pectivc of \\hiC
type of receptor they act on. Cross-tolerance occurs between dru~'
acting at the same receptor, but not between opiates that act on
different receptors. in clinical settings. the opiate dose requ1re1!
for effective pain relief may increase as a result of de\'elopm~
tolerance, but it does not constitute a major problem.
Physical dependence
Physical dependence is characterised by a clear-cut ab~tinencr
syndrome. In experimental animab (e.g. rats), abmpt withdr:maJ
of morphine after chronic administration for a few days cau\el
an increased irritability. loss of weight and a variety of abnonnJ
behaviour patterns. ~uch as body shakes. writhing. jumping all'
signs of aggression. These reactions decrease after a few days. bo
abnormal irritability and aggression persist for many week~. Th,
signs of physical dependence are much less intense if the opiate
is withdrawn gradually. Humans often experience an abstinenc<
syndrome when opiates are withdrawn after being used for pam
relief over days or weeks. with symptoms of restlessness, runn)
nose, diarrhoea, shivering and pi loerection.9 The intensity of the
abstinence syndrome varies greatly. and dependence rare!) pro-
gresses to addiction, in wruch psychological dependence (i.e
craving for the drug) is the predominant feature.
Many physiological changes have been described in relation
to the abstinence syndrome. For example, spinal reflex h) per
excitability occurs in morphine-depcndem animals and can bt
produced by chronic intrathecal as well as systemic administration
9
Causing goo~e pimples. This is the origm of the phrase 'cold turke) u-.ed
to describe the effect of morphine withdrawal.
 ANALGESIC DRUGS

of morphine. The noradrenergic pathways emanating from the Codeine is well ab orbed and nonnally given by mouth. Most
~u' coerulcus (see above) may also play an important role in morphine-like drug!> undergo considerable first-pass metabolism,
cau,ing the abstinence syndrome. and the aradrenoceptor and are therefore markedly less potent when taken orally than
o; 3rom't clonidine (Ch. I I, p. 170) is sometimes used to alleviate
s
0
when injected.
ll ln ammal model\, and abo in humans. the abstinence syn- The plasma half-life of most morphine analogues is ~ hour,.
[
drome i~ reduced b) giving NMDA receptor amagonists (e.g. Hepatic metabolis m is the main mode of inactivation. usually by
:il Ldamine: 'ce Ch. 33). 10 The rate of firing of locus coeruleus
0 conjugation with glucuronide. This occurs at the 3- and 6-0H
w
CD II(Uron~ I\ reduced by opiates and increased during the absti- groups. and these glucuronides constitute a considerable fraction
c
0 nence\) ndrome. Similar changes affect dopamioergic neurons in of the drug in the bloodstream. Morphine-6-glucuronide is. sur-
~
(ij ~ 1emral tegmental area that project to the nucleus accumbens. prisingly. more active as an analgesic than morphine itself, and
z Thc'e cell\ receive input fro m opioid-containing neuro ns and contribute~ 1.ubstantially to the pharmacological effect. Morphine-3-
etm,ti tutc the 'reward path way' responsible for the stro ng glucuronide has been claimed to antagonise the analgesic effect
r~mforcing effect of opiates (see Ch. 43). of morphine, but the significance of this expe rimental fi nding is
uncertain. Morphine glucuronides are excreted in the urine, so
the dose need ~ to be reduced in cases of re nal failure. Gluc u-
PHARMACOKINETIC ASPECTS
ronides also reach the gut via biliary excretion, where they a re
1116
Table 41.3 summarises the pharmacok.inelic properties of the hydrolysed, most of the morphine being reabsorbed (enteroheparic
a
mam opiate analgesics. The absorptio n of morphine congeners circ ulatio n). Because of low conj ugating capacity in neonates,
b) mouth i~ variable. Mo rph ine itself is slowly and erratically morphine-li ke drugs have a muc h longer duratio n of action;
as 6h;,omed. and is commonl y give n by intravenous or intra- because even a small degree of respiratory depression can be
mu-cular injection to treat acute severe pain: oral morphine is. hazardous, morphine congeners should not be used in the neonatal
0011e1er. often used in treating chronic pain, and s low-release period. nor used as analgesics duri ng childbirth. Pethidine (see
preparations are available to increase its duration of action. below) is a safer alternative for this purpose.
Analoguel. that have no free hydroxyl group in the 3-position
(i.e. diamorphine, codeine) are metabolised to morphine, which
accounts for all or part of their pharmacological activity. Morphine
Tolerance nd dependence produce very effective analgesia when administered intra-
thecally. and i!. often used in this way by anaesthetists, the
.1 on Tolerance develops rapidly, accompanied by advantage being that the edative and respiratory depressant
)ired physical Withdrawal syndrome. effects are reduced. although not completely avoided.
ping The mechanism of tolerance may involve adaptive Fo r the treatment of chronic or postoperative pain. opiates are
up-regulation of adenylyl cyclase. It is not being increasingly used 'on demand' (patient-controlled analgesia).
pharmacokinetic in origin, and receptor down- The patie nts are provided with an infusion pump that they
regulation is not a major factor. control, the maximum possible rate of administration being
encc Dependence is satisfied by wreceptor agonists, and limited to avoid acute toxicity. Contrary to fears, patie nts show
~wal the withdrawal syndrome is precipitated by p- little te ndency to usc excessively large doses and become depe n-
llSCS receptor antagonists. de nt; instead, the dose is adjusted to achieve analgesia without
m1al Dependence comprises two components: (i) physical excessive sedatio n, and is reduced as the pain subsides. Being in
and dependence, associated with the withdrawal control of their own analgesia, the patie nts' anxiety and distress
but syndrome and lasting for a few days; and (ii) is reduced, and a nalgesic consum ption actually tends to decrease .
The psychological dependence, associated with craving
)iate and lasting for months or years. Psychological
encc dependence rarely occurs in patients being given
UNWANTED EFFECTS
pain opoids as analgesics. The main unwanted effects of morphine and related drugs are
DO) Weak, long-acting ~-receptor agonists such as listed in Table 41.3.
' the methadone may be used to relieve withdrawal Acute overdo age with morphine results in coma and respir-
pro- symptoms. atory depression, wi th characteristically constricted pupils. It is
(i.e. Certan opioid analgesics, such as codeine, treated by giving naloxone intravenously. This also serves as a
pentazoc1ne, buprenorphine and tramadol, are much diagno!.tic test, for fai lure to respond to naloxone suggests a
tion less likely to cause physical or psychological cause other than opiate poisoning for the comatose state. 11 There
per- dependence. is a danger of precipitating a severe withdrawal syndrome with
1 be naloxone, becau~e opiate poisoning occurs mainly in addicts.
tion

'The opialc drug dextromethorphan has NMDA receptor blocking aclivity

11
,, well a! being a ~t-opioi d receptor agon ist. and appears to be less liable For unknown reason. naloxone may be ineffecti ve in reversi ng the effects
~an other opiates 10 induce physical dependence. of weak' opiates such as buprcnorphine or dextropropoxyphene. 603
 SECTION 4 . THE NERVOUS SYSTEM
Individual variability
T Individual~vary by as much as I0-fold in their sensi tivi ty 10 opioid
analge~ics.Thi-. i' due to differences in the plasma concentrmion needed
to produce a gtven effect. and therefore reflect pham1acodynamic rather
than pharmacokinetic variability. It may be related to polymorphi'm of
the ~H>pioid receptor gene (see Ikeda et al .. 2005). Genotyping could in
principle be U>ed to identify opiotd-rc\btam individual\. but this
approach ha~ not yet been te,ted in practice.
OTHER OPIATE ANALGESICS
Oiamorphine (heroin) is the diacetyl derivative of morphine. A
strong smell of 'inegar commonly provides the lead to illicit
heroin producers, at least in fiction. ln the body, it is rapidly
deacetylatcd 10 morphine, and its effects are indistinguishable
following oral administration. llowever, because of its greater
lipid solubility, it crosses the blood brain barrier more rapidly
than morphine and gives a greater rush when injected intra-
venously. It is said to be less emetic than morphine, but the
evidence for this is slight. It is still available in Britain for u e as
an analgesic, although it is banned in many countries. lh only
advantage over morphine is its greater solubility. which allows
smaller volumes to be given orally. subcutaneously or intra-
Lhecally.ll exctts the same respimtory depressant effect as morphine.
and if given intravenously is more likely to cause dependence.
Codeine (3-methylmorphine) is more reliably absorbed by
mouth than morphine. but has only 20'k or less of the analgesic
potency. Furthermore, its analgesic efTect does not increase
appreciably at higher dose lcvcb. ft is therefore used mainly as
an oral analgesic for mild types of pain (headache, backache,
etc.). Unlike morphine, it causes little or no euphoria and is
rarely addictive, <.o is available freely without prescription. It is
often combined with paracetamol in proprietary analgesic
preparations. In relation to its analgc~ic effect. codeine produces
the same degree of respiratory depression as morphine, but the
limited response even at high doses means that it is seldom a
problem in practice. It does, however, cause constipation.
Codeine ha~ marked antitussive activity and is often used in cough
mixtures (see Ch. 23). Dihydrocod e ine is pharmacologically
very similar, having no substantial advantages or disadvantages
over codeine. About 10% of the population is resistant to the
analgesic effect of codeine. because they lack the demethylating
enzyme that converts it to morphine.
Pethidine (meperidine) is very similar to morphine in its
pharmacological effects. except that it tends to cause restlessness
mther than sedation. and it has an additional antimuscarinic
action that may cause dry mouth and blurring of vision as side
effects. It produces a very similar euphoric effect and is equally
liable to cause dependence. Its duration of action is similar to
that of morphine, but the route of metabolic degradation is
different. Pethidine is partly N-dcmcthylated in the liver to
norpetbidine, which has a hallucinogenic and convulsant elTect.
This becomes '>ignificant with large oral doses of pethidine.
producing an overdose syndrome rather different from that of
morphine. Pethidine is preferred to morphine for analgesia
during labour, because it does not reduce the force of uterine
604 contraction. Pethidine is only slowly e liminated in the neonate,
and naloxone may be needed to reverse respiratory dcpres~iO"
in the baby. (Morphine is even more problematic in this regard.
because the conjugation reactions on which the excretion of
morphine, but not of pethidine, depends are deficient in the nell
born). Severe reactions. consisting of excitement, hyperthel1lll:
and convulsions. have been reported when pethidine is gi1en 10
patients receiving monoamine oxidase inhibitors. Thi) \eern-. 10
be due to inhibition of an alternative metabolic pathway, leadm.
to increased norpethidine formation, but the detai Is arc not known.
Fentanyl and s ufentanil arc highly potent phenylpipcridine
derivatives, with actions similar to those of morphine but 111th
a more rapid onset and shorter dumtion of action, panicularl)
sufentanil. Their main use i~ in anaesthesia, and the} rna) lx
given intrathecally. They are also used in patient-controlled
infusion systems. where a short duration of action i., advan
tageou~>. and in severe chronic pain, when they arc ndm i ni~tereJ
via patches applied to the skin.
Etorphine is a morphine analogue of remarkable potenc.
more than 1000 times that of morphine, but otherwise \el)
similar in its actions. Its high potency confers no pamcubr
clinical advantage. but it is used to immobilise wild anima], f(l(
trapping and research purposes, because the required dose. em
for an elephant, is s mall enough to be incorporared into a dan
or pellet.
M ethadone is also pharmacologically similar to morphine.
the main difference being that it~ duration of action i., con,id~
ably longer (plasma half-life > 24 hours). and it i' claimed 111
have lcs~ sedative action. The increased duration !leem~ to OCl'll
because the drug is bound in the extravascular compartment and
slowly re leased. One consequence is that the physical abstinence
syndrome is less acute than with morphine or o ther shon-actmg
drugs. although the psychological dependence is no les., prr
nounced. Methadone is widely u'ed as a means of treating mo
phine and diamorphine addiction. ln the presence of methadont
an injection of morphine docs not cause the normal euphori.
and the lack or a physical abstinence syndrome make~ it possible
to wean addicts from morphine or diamorphine by giving regula:
oral doses of methadone- an improvement if not a curc.' 2
Pentazocine is a mixed agoni'>t antagonist (sec earlier <;eelloo
with analgesic properties similar to those of morphine. Howc1cr,
it causes marked dy!>phoria, with nightmares and hallucinaUolll,
rather than euphoria, and is now rarely used.
Buprenorphine is a partial agonist on !-1- receptors. It i~ b
liable to cause dysphoria than pentazocine but more liable to
cause respiratory depression. It has a long duration of action.lb
abuse liability is probably less than that of morphine.
Meptazinol is a recently introduced opiate of unu'Uli
chemical structure. It can be given orally or by injection and b.
a duration of action shorter than that of morphine. It seem~ to bl:
relative ly free of morphine-like side effects, cau1.ing neitk
euphoria nor dysphoria, nor severe respiratory depression. I
does, however. produce nausea. sedation and dizziness. and bJ.
1
~he bene fill> come mainly from removing the risks of se lf-injection and
the need to linnnce the drug habit through crime.

sion ~tropine-like side effects. Because of its short duration of action
gan.l, ;d lad. of respiratory depression, it may have advantages for
n of ~~~tm: analge~ia.
cw-
Tramadol is widely used as an analgesic for postoperative
m1i.1
PJIR. h i~ a weak agonist at 1!-opioid receptors, and also a weak
n to
mhihitor of noradrenaline reuptake. lt is effective as an analgesic
hto
and .1ppears to have a better side effect profile than most opiates,
iling
although psychiatric reactions have been reported. It is given by
wn.
Dlllllth or by intramuscular or intravenous injection for moderate
ilmc
ttl I.C\~rc pain.
"'ith
arl)
be OPIOID ANTAGONISTS
lllcd
.m- ' alorphine is closely related in structure to morphine, was the
!rcd fiN \p!!Cific antagonist to be discovered, and provided the first
clear C\idencc in favour of a specific receptor for morphine.
l'ei.~OIIIOn of which led to the sucee~sfu l search for endogenous
mcdtators. Nalorphine has, in fact, a more compl icated action
than that of a simple competitive antagonist (Table 41.2). ln low
dv'~' tt is a competiti ve antagonist and bloch most actions of
morphine in whole animals or isolated tissues. Higher doses.
art boll~\ cr. arc analgesic and mimic the effects of morphine. These
etlw~ probably refl ect an antagonist action on !!-receptors,
nc. o
.:oupled with a partial agonist action on and K-receptors. the
lcr- btlcr causing dysphoria, which makes it unsuitable for use as an
to analgesic. Nalorphine can itself produce physical dependence,
ur b.lt can al~o precipitate a withdrawal '>yndrome in morphine or
nd d1amorphine addicts. Nalorphine now has few clinical uses.
cc 'lalo-xone was the first pure opioid antagoniM. w ith affinity for
ing I hrel! opioid receptors. It blocks the actions of endogenous
TO 1>pioid pt:ptides as well as those of morphine- like drugs, and has
or- been extensively used a'> an experimental tool to determine the
he, ph}"nlogical role of these pcptides, particularly in pain tran s-
ia, mt"ion.
lc Gl\cn on its own, naloxone produces very little effect in nom1al
lar 1ubjects but produces a rapid reversal of the effects of morphine
nJ other opiates, including partial agonists such as pentazocine
snd nalorphine. It has linle effect on pain threshold under nonmtl
conditions but causes hyperalgesia under conditions of stress
ntlammation, when endogenous opioids are produced. This
&.:cur,, for example, in patients undergoing dental surgery. or in
.~mmab subjected to physical stress. Naloxone also inhibits
~>.~puncture analgesia, which is known to be associated with
the release of opioid peptides. Anal gesia produced by PAG
'1mulation is also prevented.
The main clinical uses of naloxone are to treat respiratory
~\'ion caused by opiate overdosage, and occasionally to reverse
r..e ellect of opiate analgesic1>, used during labour, on the respir-
auon of the newborn baby. It is usually given intravenously, and
efiws are produced immediately. It is rapidly metabolised
by the liver. and its effect laMs only 2-4 hours, which is con-
llderably shorter than that of m ost morphine-like drugs.
Therefore it may have to be given repeatedly.
Naloxone has no important unwanted effects of its own but
nm:ip1tates withdrawal symptoms in addicts. It can be used to
detect opiate addiction.
ANALGESIC DRUGS
N aJtrcxone is very similar to naloxone but with the advantage
of a much longer duration of action (half-life about 10 hours). It
may be of value in addicts who have been ' detoxified', because
it nullifies the effect of a dose of opiate should the patient's
resolve fail. lts u~c in other condi tions, :.uch as alcoholi~m and
septic shock, is being investigated. although the role of opioid
peptides in these conditions is con troversial.
Specific antagonists at 1-l b and K-receptors arc available for
experimental usc (Table 41.2) but not yet for clinical purposes.
PARACETAMOL
The NSAIDs (covered in detail in Ch. 14) arc widely used to
treat painful inflammatory conditions. Paracetamol (known as
acetaminophen in rhe USA) deserves special mention. It was
first synthesised more than a century ago, and since th e 1950s
ha~; (alongside a'>pirin) been the most widely u~;cd over-the-
counter remedy for minor aches and pains. Paracctamol differs
from other NSAJDs in producing analgesic and antipyretic cfTccts
while lacl,ing anti-inflammatory effect~. It also lack\ the tendency
of other NSAID~ to cause gastric ulceration and bleeding. The
reason for the difference between paracetamol and other NSAIDs
is unclear. Biochemical tc~ts showed it to be only a weak cyclo-
oxygenasc (COX) inhibitor. with some selectivity for brain COX.
M ore recently, it was claimed to act on a novel COX variant
(COX-3), which turned out to be a splice variant of the main
COX isoform COX-I (sec Ch. 14). There is ~ti ll uncertainty
about the role of COX -3 in human'>, and disagreement about its
significance as a target for paracctamol (see Graham & Scott,
2003: Davies et at, 2004).
Paracetamol i ~ well absorbed by mouth, and its plasma half-
life is about 3 hours. It is metabolised by hydroxylation, conjugated
mainly al> glucuronide, and excreted in the urine. In therapeutic
Opioid antagonists
Pure antagonists include naloxone (short
acting) and naltrexone (long acting). They block ~t. b
and K-receptors more or less equally. Selective
antagonists are available as experimental tools.
Other drugs, such as nalorphine and pentazocine,
produce a mixture of agonist and antagonist effects.
Naloxone does not affect pain threshold normally but
b locks stress-induced analgesia and can exacerbate
clinical pain.
Naloxone rapid ly reverses opioid-induced analgesia
and respiratory depression, and is used mainly to
t reat opioid overdose or to improve breathing in
newborn babies affected by opioids given to the
mother.
Naloxone precipitates withdrawal symptoms in
morphine-dependent patients or animals.
Pentazocine may also do this.
605
 SECTION 4 . THE NERVOUS SYSTEM

Table 41.3 Characteristics of the main opioid analgesic drugs

Drug Use(s) Route(s) of Pharmacokinetic Main adverse effects Notes

administration aspects

Morphine Widely used for Oral, including Half-life 3-4 h Sedation Tolerance and
acute and chronic sustained-release Converted to active Respiratory withdrawal effects
pain form metabolite depression not common when
lnjectione (morphine Constipation used for analgesia
Intrathecal 6-glucuronide) Nausea and vomiting
Itching (histamine
release)
Tolerance and
dependence
Euphoria

Diamorphlne Acute and chronic Oral Acts more rapidly As morphine Not available in all
pain Injection than morphine countries
because of rapid Considered
brain penetration (irrationally) to be
Metabolised to analgesic of last
morphine resort.
Also known as hei'O!Il

Hydromorphone Acute and chrome Oral Half-hfe 2-4 h As morphine but Levorphanol is
pain Injection No active allegedly less sedative similar, with longer
metabolites duration of action

Methadone Chronic pain Oral Long half-life As morphine but Slow recovery resuhs
Maintenance of Injection (> 24 h) little euphoric effect in attenuated
addicts Slow onset Accumulation may withdrawal syndrome
occur because of
long half-life

Pethidine Acute pain Oral Half-life 2-4 h As morphine, Known as

Intramuscular Active metabolite anticholinergic effects meperidine in USA
injection (norpethidine) may Risk of excitement Interacts wtth
account for and convulsions monoamine oxidase
sttmulant effects inhibitors (Ch. 39)

Buprenorphine Acute and chronic Sublingual Half-life about 12 h As morphine but Useful in chronic
pain Injection Slow onset less pronounced pain with patient-
Intrathecal Inactive orally Respiratory depression controlled injection
because of first- not reversed by systems
pass metabolism naloxone (therefore
not suitable for
obstetric use)

Pentazocine Mainly acute patn Oral Half-life 2-4 h Psychotomtmettc Nalbuphtne is stmtlar
lnjectton effects (dysphoria)
Irritation at injection
site.
May precipitate
morphine withdrawal
syndrome
(wantagonist effect)

Fentanyl Acute pain Intravenous Half-life 1-2 h As morphine High potency allows
Anaesthesta Epidermal transdermal
Transdermal patch administration
Sufentanil ts similar
Remifentanil is
similar with more
rapid onset and
recovery

~~
606
 Tillie 41.3 (cont'd) Characteristics of the main oplold analgesic drugs

Drug Use(s) Route(s) of Pharmacokinetic Main adverse effects Notes

administration aspects

Codeine Mild pain Oral Acts as prodrug Mainly constipation Effective only in
Metabolised to No dependence mild pain
morphine and liability Also used to
other active suppress cough
opioids Oihydrocodeine
is similar

Dextropropoxyphene Mild pain Mainly oral Half-life - 4 h Respiratory depression Similar to codeine
Active metabolite May cause convulsions No longer
(norpropoxyphene) (possibly by action recommended
with half-life - 24 h of norpropoxyphene)

Tramadol Acute (mainly Oral Well absorbed Dizziness Metabolite of

postoperative) and Intravenous Half-life ~ h May cause trazodone (Ch. 39)
chronic pam convulsions Mechanism of action
No respiratory uncertain
depression Weak agonist at
opioid receptors
Also inhibits
noradrenaline uptake

'lnjecllons may by given Intravenously, intramuscularly or subcutaneously for most drugs.

du,es, it has few adve rse effects. However, in overdose

r J.:ctamol causes severe Liver damage. which is commo nly Othe r analgesic drugs
. al hee Chs 14 and 53), and the d rug is ofte n used in aue mpted
~~iddc. Paracetamol resembles non-steroidal anti-
inflammatory drugs and is effective as an analgesic,
but it lacks anti-inflammatory activity. It may act by
OTHER ANALGESIC DRUGS inhibiting cyclo-oxygenase (COX)-3, a splice variant
,. Se, eral other drugs ore used as analgesics. panicularly to treat of COX-1, but probably has other effects as well. In
neur(lp;lthic pain 'tate~. which re~pond poorly to conventional analgesic overdose, it causes hepatotoxicity.
11tug' and po-.e a major chnical problem. Various antidepressants (e.g. amitriptyline), as well as
Thi, group includes the following. antiepileptic drugs (e.g. carbamazepine, gabapentin),
are used mainly to treat neuropathic pain.
Tricyclic tmtitlepressants. panicularly imipram ine and amitript) line
tCh 39). These drug~ act centrally by inhibiting noradrenaline Other drugs occasionally used include the NMDA
reuptake and are high ly effective in relieving neuropathic pain in some, receptor antagonist ketamine and the local
but not all, cases. Their action is independent of their antidepressant anaesthetic drug lignocaine (lidocaine).
t lfecll>. and selective serotonin reuptake inhibitor~ are n01 effective.
~ntitpiltptic drugs (Ch. 40). Carbamazepine. gabapeotin and
oc-casionally phenytoin are somelimcs effecti ve in neuropathic pai n.
Carbama1.epine and phenytoin act on voltagegated sodium channels.
The target for gabapentin is !he uzb subunit of the L-type calcium
channel (see Ch. 3).
NEW APPROACHES
Ketamine, a dissociative anaesthetic (Ch. 36) !hat works by blocking
T As in other fields of neuropharmacology, increasing knowledge of the
NMDA receptor channels, has analge!>ic properties probably directed
various chemical mediators and >ignalling p;~thways responsible for p;~i n
at the wind up phenomenon in !he dorsal hom (Fig. 41.3). Given sensation '>Uggesb many new approaches to !he conrrol of pain. Currently.
muathecally. its effecl\ on memory and cognitive function are largely opiate~ and NSAID> are !he mainline treatment,, with various other drugs
a\oided.
listed above-all discovered by acc idem rather rhan by de,ign-being
Intravenous lignocaine (lidoca ine), a local anae,thetic drug (Ch. 44)
used for special purposes. Nevertheless. pain lrcatment i ~ currently far
with a shon plasma half life. can give long-lasting relief in neuropathic
from perfect. and several new approaches are being explored.
pam state~. h probably acts by blocking spootaneou'> discharge\ from
damaged \ensory nerve tenminals, but !he reawn for its pe~istem Enkephalinase inh ibuors such a\ thiorphan act by inh ibiting the
analge>ic effect is 1101 clear. metabolic degrad<lt ion of endogenous opioid peptides. and have bee n 607
 SECTION 4 . THE NERVOUS SYSTEM
Clinical uses of analgesic drugs (1)
Analgestcs are used to treat and prevent pain,
for example:
pre- and postoperatively
common painful conditions including headache,
dysmenorrhoea, labour, trauma, bums
many medical and surgical emergencies (e.g.
myocardial infarction and renal colic)
terminal disease (especially metatastic cancer).
Opioid analgesics are used in some non-painful
conditions, for example acute heart failure (because
of their haemodynamic effects) and terminal chronic
heart failure (to relieve distress).
The choice and route of administration of analgesic
drugs depends on the nature and duration of the
pain.
A progressive approach is often used, starting with
non-steroidal anti- inflammatory drugs (NSAIDs),
supplemented first by weak opioid analgesics and
then by strong opioids.
In general, severe acute pain is treated with strQng
opioids (e.g . morphine, fentanyl) given by injection.
Mild inflammatory pain (e.g. sprains, mild arthralgia) is
treated with NSAIDs (e.g . ibuprofen) or by
paracetamol supplemented by weak opioids (e.g.
codeine, dextropropoxyphene). Severe pain (e.g.
cancer pain) is treated w ith strong opioid given orally,
intrathecally, epidurally or by subcutaneous injection.
Patient-controlled infusion systems are useful
postoperatively.
Chronic neuropathic pain is often unresponsive to
opioids and is treated with tricyclic antidepressants
(e.g. amitriptyline) or anticonvulsants (e.g.
carbamazeplne, gabapent in).
~h0\1 n to produce analgc>ia. together with other morphine-like effect\,
without cau\ing dependence.
The variou~ ion channel> that play a role in nocicepti\'e nerve~ (Fig.
-11.6) may repre..ent u..eful drug targets. They include the TRPV I
r~..-ceptor. for wh1ch antagoni>t~ hae been identified (sec Krause ct al..
2005). and cenain Mldium channel subtypes that are specific for these
nene termmal\ (see L:u et al.. 2004).
Variou\ neuropeptide\. ...uch a!- .. omatostatin (see Ch. 28) and
calcitonin (see Ch. 29). produce powerful analgesia when applied
mtr.uhecally. and there are clinical rcpons suggesting that they may
hac 'imllar effect\ when used systemically to treat endocrine
di ...ordcr...
G lut:unatc antag(mi\t\ acting on NM DA or AMPA receptor~ !.how
ona lgc~ic activit) in animal models. but it has not yet been possible to
obtain thb effect in humans without unacceptable side effects.
AntagoniM~ m the metabotropic glutamate receptor mGiuR5 are
currentl y in development and have fewer side effects.
Adenosi ne analogue~ and adenosine ki nase inhibitor' could mimic or
608 enhance the inhibitory effect of adenosine on nocicepti ve pathways.
Clinical use of analgesic drugs (2)
Non-steroidal anti-inflammatory drugs (see
clinical box on p. 234) including paracetamol are
useful for musculoskeletal and dental pain and for
dysmenorrhoea. They reduce opioid requirements in
acute (e.g. postoperative) and chronic (e.g. bone
metastasis) pain.
Weak opioids (e.g. codeine) combined with
paracetamol are useful in moderately severe pain if
non-opioids are not sufficient. Tramadol (a weak
opioid with additional action on 5-hydroxytryptamine
and noradrenaline uptake; p. 606) is an alternative.
Strong opioids (e.g. m o rphine) are used for severe
pain, particularly of visceral origin.
Note that:
the intravenous route provides rapid relief from
pain and distress
the intravenous dose is much lower than the oral
dose because of presystemic metabolism
morphine is given orally as a solution or as
'immediate-release' tablets every 4 hours
dose is titrated; when the daily requirement is
apparent, the preparation is changed to a
modified-release formulation to allow once- or
twtce-daily dosing
transdermal administration (e.g. patches of
fentanyl) is an alternative
adverse effects (nausea, constipation) are
anticipated and treated preemptively
addiction is not an issue in the setting of terminal
care
intravenous morphine has a distinct use for acute
left ventricular failure (Chs 18 and 19).
Neuropathic pain responds to drugs that interfere
w ith amine uptake (e.g. amitriptyline; p. 562) or block
sodium channels (e.g. gabapentin or
carbamazepine; p. 583).
Subanaesthetic doses of nitrous oxide (Ch. 36, p. 531)
are analgesic, and self-administration of a mixture of
nitrous oxide with oxygen is widely used during
labour, for painful dressing changes and in ambulances
AgonJM\ at mcouruc acetylcholine receptors. blbed on epibatidint
alkaloid from frog ~kin. which is a potent nicotinic agoni't
une'tpectedl) a potent analgesic a., well). rna) be analg~
Dcmative" with fewer side efTecb are under investigation.
Agoni't' at cannabinoid receptors, including tetr ahydrocannabi111
(Ch. 15) have '>trong analgesic effects in animal models, suppone..
anecdotal rcpons from dope smokers. Cannabinoid receptor. ha1~
inhibitory effect on nociceptive afferent termi nals. and al~o on dm
horn tmn\m i%ion. Formal trials are in progress to assess the chm,
value o f ' uch compounds.
For more informalion on new approaches, see Sawynok (200!
and Ahmad & Dray (2004).

We \hould recall that analgesia was. for the best part of a
century. a therapeutic need addressed only by opiates and
'IS\10,, and the only new drugs to be developed as analgesic~
n recent years have been lookalike:. in these two families. As
uften happens. clinical observation rather than pharmacological
n1eniiH!ncss ha~ expanded the range by discovering, for
REFERENCES AND FURTHER READING
C...ral
l1eld> HL Ba,baum A I 1994 Centro! nen.ou~ ~)''tern
mechJmsn" of pain modulauon. In: Wall P D.
lki1.K~ R (eds) Te\tbook of pain Churchill
lnlllf,tOII<. EdJnbtlfl!h
idd.' II L BJ,baum A I. Hcanricber M M 2006 Centro!
1mot~<~ 'Y~tem mcchnni\m~ or pJin mudulntion. In:
II.~IJI,,.., S B. KoltLcnl>urg M (cd') Wall &
~l<lz.o ~ , lttbool. of pam. 5th edn EJ<oe,ier.
EJanhur~h. pp. 125 142 (Detailtd llCl'OI/111 of amra/
p":hwan t/1111 inlubit or e11hance trmwllission in the
.Wnalhbm)
R G :!I lib \nal~e''" drug' in de,clopmenL ln
\1,\IJb"n S B. Kolucnburg M (cd'l Wall &
M'l1ack'> IC\tbook ol JXLin. 5th edn. Elsevier.
Edioburgh pp. 541-552 (8a/onc~<ltlrwum of ,.,,rent
""'""""'" ta dt'ldt~plltll el anaiR~ru dn<gl
Jtiliu, IJ. ~kCie,key E W 2006 Cellu l.tr :md molecular
propenb of primary nffcrcnt neuron,, ln: McMahon
SB. "olucnbtlrg C\1 (ed,) Wall(,. Mel1~1ck's te~tbook
d p.nn. 5th tdn. EI\C\ICr. Edinl>urgh. pp. 35-IN
D<~ml>rr rereptor.t. 11111 chamtei> 1111d sigllliiiiiiR
mtchdlli\m.'i of nociC('J"ive neti/V/1.~)
~L\Iahoo S B. Kolucnbtlrg M (eU\) 2CXl6 \\'all &
MdDCl. , lt'lhook of paon. 5th edn l!l<,e,;er.
Edmhu~h (i.Jif~e mll(tltllllhor IT'fe~>'llcr book)
\hllan ~~ J 2002 Qc,ccnding control llf pain. Prog
\ !IJI\>btt>l66: 355-174 (Ct)fn{lff'lunmt' re>~('>t llmde
""~ mhtlmory 111111 farilirawr;a muhanism\ i11
~"'"'dum/)
R1 S N. \1cyer R A, Ringkamp M, Campbell J N 1999
Ch.pl.-r I In: WaU PD. Melzack R (edsl 1999
Tettt>.'lll. of pam .tth edn Churclull Liing>tone.
I:Jmi'<ll'8h. pp. 11- 57 (Goad g<neral acw~tm of
P< rrphtml nociceptor funrtions)
Sl'i)nol. J 2003 Toptcal and peripbcrully acting
IIWft'"' Pllarmacol Rc 55: 1-20 (Rt'l'it'M' of'''"
~tumtmiH medumi.suu b~ H hich drufr~ interfere with
/lil(l<tplll'r muhani>m 111 tlte puipltrr;a)
~ilnuler ~. Ploner ~1 2000 curoph)"olog) and
fun..~llll I ncuroanatom) of pam perception. J Clin
\curophy,iol17: 592 603 (Revi~l\ .fjimling. tlf
tltumimal(m~ studie.f of pain i" humans. slwwinR that
lilt ll]Jt< 111~ componmt of pain llll'l>l~s bram "~:inns
Wol!k 1fmm rh~ maJor ;mnatosmwr;a parlnmn l
h\-Jt T I 1999 Spinal 'Y.tems and r uin proccs,ing:
de\elc'(lmCnl of novel analgesic drug' with
n,.dtam,tocall) dehned models. Trends Pharmacol Sci
~. 3~ U7 <Good !I<'Mml mint art1cle 011 r>i11al
ccmlmedrmrifms-more p,eneraf tlum its title
lU,~(l/1)
loa channels
Clwhme ~I. Zwne R. Vi.taynragavan K, O~amuru Y 2005
Re~IJoon <lf 'lla,. channel> in \en'>()() neuron' Trend.
I'II:Jnno..,>l Sci 26: 4% ~2 CDi.so<ft<'r rol~ of f'rlllllarion
ANALGESIC DRUGS
example. the efficacy of tricyclic antidepressants in pain
treatment. The long list of new possibilities under investigation
sugge~ts that the tide of inventiveness may bave resumed after
a long gap, but it is too early to say whether it will lead to beuer
therapies (see HiU. 2006). Morphine is. as expected of 'God's
own medicine', very hard to beat!
~>f ~xpre:.sum and gatml( t'harartaillin of'OIW~<" Mc\labon S B. Kohunbtlrg M (oxf,l \\all &
fiiiiPd s(J(/tum chmme/1 111 flllllwgrneti.s ofpCiin) Melzack' tc"book of pnin. 5th cdn Fl<oevier.
Clapham 0 E 2003 TRP channeb a$ cellular scrN>r,. Edinburgh, pp. 49-72 (l(e1ie" of lill't1l'tiolls oj'man1
'llarure 426: 517-524 {ll!riplter.rl mrtlimorJ mr 11(1('iceptirt nnw tt'nnrmt/.1)
Juliu> D. Ba.,baum A I 2CXll Molecular mechanNlh ot Samad T A. '>aptr.tein A. Woolf C J 2002 Prol.urnord'
nocicepuon. Nature 413; 203- 210 CRel'in aniclt nnd paon: unravelli ng mechanisms and reveahng
focusing nwinlv on re<'t'ptors ami dumnels imo/'t.'t d in
1
lhcrapeutic turgets. Tremh Mol Med 8: 390-396
tlrtivatiott o/Mnson nen:et by no.\imu .stitmtli} (u... j'ur ,..,.,.... artie/~)
Krouse J E. Chenard B L, Conright 0 N :!005 Tr:t!NeOl
Opiates
receptor potential ion channels a; t.trgcts for the
Dhllwan B N, Cesselin F, Rughubir R cl al. 1996
discovery of flllin thempcutics. Curr Opin lnve;tig
Classificatron of opi01d receptor\. Ph.armacol Rc' 48:
Drug., 6: 48 57 (A /oo!. oh<"nd to tilt- fllJSsibilillc.\ aj
567-592 (lite last 11 on/ 1111 opimd ff'uptor
t/('>tdopm~ trrmsienJ l't'ctptnr pol~lllial thamrd
drrrsificatiou, from tlrt 111/t'mationa/ Union oj
ligtmd.r a.\ analgesic drrt~s)
Plurrmamlof!V Illhf'mnmiuee elllnl\trd ll'illt the Ill\~)
Lai J, Poncca I'.,Humer J C. Gold M S 2004 Vollagc
llcndersoo G. \ilcKnight A 1 1997 The orphan optoid
gated sodrum channel' and hyperatgc~ia. Annu Rc'
n.-ceptor and '" end<!i!COOth lrgand
Pharmacol To,icol44. 171-197 (l'llfrt/ mit'M' tlrtic/1'
nocicepunfurphanin !'Q Trends Phamlacol Sci l K
on biology of .<odium clwnne/s irr rt!lation to /XIIII
293-300 (Review anide 1/lllllllltritirrs wltatll'e ~"""'
mPrlumism.\' )
1100111 the nrwly distoo..-tf apioitf flt'fllid~ am/11
'an der Stell 1\1. Di MarLO V 2004 l:ndo,aoillod,
naptor)
Putati\C cndogeOOU!o hg;md' of tr:IO\ICnt receptor
Hcr7 A (ed) 1993 Opioids. llandb fup l' harmacol HJ.I
potential vunrlloid I channel<. Eur J B10chem 27 1:
( /Jefirritile nmrpendi1111111f nl'iews tm all aspects nf
1827- ll!34
opwid plumnncologyl
Wang H. Woolf C J 2005 !"din TRP>. Neuron 46: 9 12
~~~'CI3 K. Ide S. Han Wet al. 2005 HO\\ tndl'idual
( Utl'ful rn rew of l'llrrrnt l.llo1edRI' ubout tht' mil' of
'cnsitivuy to nptates can he predicted hy gene
trmuirnJ tl!cepwr polt'lltiaJ clwnne/.f i11 pllill)
analysis. Trends Pbnrmacol Sci 26: 31 1- 317 (Fm'IHI'.f
an {JQ/.mrorpltt\m ofpnpiaid ll?C'I'fi/Or ~me 111 u <tillS<'
Chemical mediators and receptors
of mdiridmli .arimion)
Ahmad S. Drdy A 2()0.11\'o'd Gprotetn-<:oopled receptOC\
Lnw P Y. Won!! Y H. Loh II H 2000 Molecular
n' pain tnrgcts. Curr Orin lnveM ig Dnags 5: 67 70
mechani'"'~ and regula!ion of opOi(l rt'Cepwr
(A look 111 j111ure possibilities for 111111/.~ic tim.~.\)
,;goaling. Annu Re- Pharmacal To\KOI 40: 389-110
Cah.<~o J B. ~leddro- R. f'emand'" E S 2004 Kmrn 8 1
ValleJO R. de Lcon-Ca>a;ola 0. Benyamtn R 2004
receptol'\: ~cy G-protcm-couplcd receptors and thctr
Opioid therapy and immunosuppre\\ion: n rc' icw. Am
role in mllammmory and painful proccs;es Br J
J Thcr I I: 351-365
Phannacol 141: 803-8 1R (Re1ie" t'fll{llrasisin!ltlre
Waldhoer \1, Banleu S F. Whistler J I 2004 Opultd
mil' of mdunhlr 8 1 ret l'ptors 111 mritms condllltm.
recepto~. Annu Re' Bu..:bem 73: 953 990
mcluding mflwrrmatof'\' IIJiin)
(Compreh'11.\H't' re,iew artlrfe with fil.\'tWi.tion of
Dray A. Perkin' M 1993 Bmclykinin 110d inllammntory
meclumi.\ltrl underhirr.~ 10/rrana and tlepellderrn.')
pain. Trend' Neuro;ci 16: 99-1().1
Wal~er J M. 80\\en W D. Wal~cr F 0 et al 1990 SiEma
1 RR. Kohno T. C\loore K A. \\'oolf C J 2003 Centrul
receptors: boology and function. Phannacol Rev 42:
\Cnsiti>atron and LTP: do pain and memory shan:
355-402
' imilar mechanisms? Tn:nds Neuroci 25: 696-705
Yak~h T L 1997 Pharmacolog) and mcchnni>ms ol
(Review tho! mrphasru.\ the medumirtic parallel!
opiOtd analt:e,ic XII\ rl) Acta Anae,lbc>iol Scand .II;
hc-MI'I!/1 J)(llll and memt>f'\'l
94-111 CRI'Iii"W of firclrllu relminK 111 rir~s uf
Lru X J, Sah~r M W 2005 Purines and pain mechani\ms:
action oud reuptor specifwity of mlfil!le>ic effrct
recent developments. Curr Opin IJwe" iS Drugs 6: (o5-75
ofopioid>)
\ilnrceau F. Rc~oli 0 2CX).I Bradykman receptor hgand-=
tberapeullc per;pecu'e'. 1\'at Re' Drug Disco' 3 l>aracetamol
!\45-852 Davie> N M. Good R L, Roupe K A el nl. 2004
McMahon S 13 1996 NG r a' a mediator of inflarnmmory C'yclooxygcna,c-3: axiom. dogma. anomaly or 'Piice
pain. Philo- Trun; R Soc Lond 351 431-440 (Rtl'il'w error?-not n' cas) 3lo I. 2, 3. J Phann Phann Sci 7:
of nid~lln' mrplicatinl: SGF tu a lllt'dtatQr of 217-226 (Update 011 tlu rmifrrsm~ ml~ofCOX .ll!f 11
iliflammaiOf)' pain nmllryperalge.ritt, i11cludirrg >tlltfles wrge1 for f>llrncetamo/1
of a nmel flpe of NGF i11lribiwr) Grnhnm G G. Scou K F 2003 Mcchani"t" of action of
McMahon S B. Benncu 0 H L. Be\ an S J 2006 parucet:unol and related analgesics.
lnOammatol') mediatol'\ ~nd modulator. of pam. In: lnOammophannacology II; 401-l!J
609
 CNS stimulants and
psychotomimetic drugs
Overview 610
Convulsants and respiratory stimulants 610
Psychomotor stimulants 611
-Amphetamines and related drugs 611
-Coca me 614
Methylxanthines 615
Psychotomimetic drugs 616
- LSD, psilocybin and mescaline 617
-MDMA 617
-Phencyclidine 618
OVERVIEW
In this chapter, we describe drugs that have a
predominantly stimulant eHect on the central
nervous system (CNS); these fall into three broad
categories:
convulsants and respiratory stimulants
psychomotor stimulants
psychotomimetic drugs, also known as
hallucinogens.
Drugs in the first category have relatively little
eHect on mental function and appear to act mainly
on the brain stem and spinal cord, producing
exaggerated reflex excitability, an increase in
activity of the respiratory and vasomotor centres
and, with higher dosage, convulsions.
Drugs in the second category have a marked
eHect on mental function and behaviour, producing
excitement and euphoria, reduced sensation of
fatigue, and an increase in motor activity.
Drugs in the third category mainly aHect thought
patterns and perception, distorting cognition in a
complex way and producing eHects that
superficially resemble psychotic illness.
Table 42. 1 summarises the classification of the
610 drugs that are discussed in this chapter.
Several of these drugs have no clinical uses but
are recognised as drugs of abuse on the strength
of their tendency to produce dependence. This
aspect is discussed in Chapter 43.
CONVULSANT$ AND RESPIRATORY
STIMULANTS
Convulsants and respiratory Mimulants (sometime~ called
ana/eptics) are a chemically diverse group of sub~tancc1> whose
mechanisms of action are, with some exceptions. not well under-
stood. Such drugs were once used to treat patients in tenninJ
coma or with severe respiratory fa ilure. but their u. e ha1> huge!.
been replaced by mechanical means of assisting ventilauon.
Although temporary restoration of function could ~ometimes l\
achieved, mortality was not reduced, and the treatment carried t
considerable risk of causing convulsions, which left the patient
more deeply comatose than before. There remains a very limiteG
clinical use for respiratory stimulants in treating acute vcntilatOI"I IIC'i
failure (sec Ch. 23). doxapram (Table 42.1) being mo'>t common!
used. because it carries less rbk of causing com ul!.ion' th.
earlier compounds.
Also included in this group are various compounds, such a,
strychnine, picrotoxin and pentylenetetrazol (PTZ), which are
of interest as experimental tools but have no clinical uo,es.
Strychnine is an alkaloid found in the seeds of an Indian tree
which has been used for centuries as a poison (mainly \CrtJJ:;..
but also human; it is much favoured in detective stories of a cert.:l
genre). It is a powerful convulsant and acts throughout the CNS
but particularly on the spinal cord, causing violent extensor spasm;
that arc triggered by minor sensory stimuli, the head being thr011r
back and the face fixed, we are told, in a hideous grin. The-.e
effects result from blocking receptors for glycine, which is the l1lillll
inhibitory transmitter acting on motor neurons. The action ~
strychnine superficially resembles that of tetanus toxjn, a protc
neurotoxin produced by the anaerobic bacterium C/ostridiumtetar
which blocks the release of glycine from inhibitory interneuron1
This is very si milar to the action of botulinum toxin (see Ch. 10
which is produced by another bacterium of the Clostridiw
genus and causes paralysis by blocking acetylcholine relea~.l:
small doses. strychnine causes a measurable improvement
visual and auditory acuity; it was until quite recently included
various 'tonics' on the basis that C S stimulation should restor.
both the weary brain and the debilitated body.
 CNS STIMULANTS AND PSYCHOTOMIMETIC DRUGS

BicucuJiine, also a plant alkaloid, resemble~ strychnine in its

etlws but acts by blocking receptors for GABA rather than
gly~me. lt.s action is confined to GA8AA recepton., which control
Cl permeability. and it does not affect GABA 8 receptors (see
Ch. 33). It\ main effect\ are on the brain rather than the spinal
cord, and it is a usefu l experimental tool for studying GABA-
mcdiated trml\mission; it has no clinical uses.
Picrotoxin (obtained from the fhhberry) al~o blocks the action
>I GABA on chloride channels, although not competitively. The
pl.!llt'~ name renects the native practice of incapacitating fish by
lhro\liog berrie~ into the water. Picrotoxin, like bicuculline.
... u,e> convulsions and has no clinical uses.
Pentylenetetrazol acts similarly, although its precise mech-
. ,,m is unknown. Inhibition of PTZ-induccd convulsions by
Jntlepilcptic drugs (sec Ch. 40) correlates quite well with their
effectiveness ngainst absence seizures, and PTZ has occasionally
"'-en u>ed diagnostically in humans, because it can precipitate the
pteal EEG pattern of ab-.ence seizure~ in susceptible patient'>.
Ooxapram is similar to the above drugs but has a bigger margin
nhafety between respiratory stimu lation and convulsions. [t also
CJ "es nausea. coughing and restlessness. which limit its
leu ~fulne~s. It is rapidly eliminated, and it is occasionally used as
ose an mtravenous infusion in patients with acute respiratory failure.
Jcr-
nal
I) PSYCHOMOTOR STIMULANTS
011.
AMPHETAMINES AND RELATED DRUGS
be
il \mphetamine and its active dextroisomer dextroamphetamine,
ent lllgether with methamphetamine and methylphenidate, com-
eu p-ea group of drugs with very similar pharmacological proper-
ry be' ('ee Fig. 42.1 ). which includes street drugs' ~uch as
ly
Ill
Convulsants and respiratory stimulants
This is a diverse group of drugs that have little
clinical use, although several are useful as
experimental tools.
Certain short-acting respiratory stimulants (e.g.
doxapram) can be used in acute respiratory failure.
Strychnine is a convulsant poison that acts mainly
on the spinal cord by blocking receptors for the
inhibitory transmitter glycine.
Picrotoxin and bicuculline act as GABAA
antagonists; bicuculline blocks the GABAA receptor
site, whereas picrotoxin appears to block the ion
channel.
Pentylenetetrazol (PTZ) works by an unknown
mechanism. PTZ-induced convulsions provide an
animal model for testing antiepileptic drugs, giving
good correlation with effectiveness in preventing
absence seizures.
metbylenedioxymethampheta mine (MDMA or 'ecstasy'; see
below). Fennuramine, although chemically similar, has slightly
different pharmacological effects. All these drugs act by releas-
ing monoamines from nerve terminals in the brain (sec Seiden et
al.. 1993; Green et al.. 2003). They are substrates for the neuronal
uptake transporters for noradrenaline (norepinephrine), serotonin
and dopamine, and cause release of these mediators, as described
in Chapter 34. producing the acute effects described below. With
prolonged use, they are neurotoxic, causing degeneration of

Tlble 42. 1 Centra l nervous system stimulants and psychotomimetic drugs

tre
Category Example(s) Mode(s) of action Clinical s ignificance

Convulsants and respiratory

stimulants (analeptics)
~esptratory stimulant
Ooxapram Not known Short-acting respiratory
stimulant sometimes g1ven by
intravenous infusion to treat
acute respiratory failure

Mscellaneous convulsants Strychnine Antagonist of glycine No clinical uses

Main action is to increase reflex
excitability of spinal cord
Bicuculline Competitive antagonist of No clin1cal uses
GABA
Picrotoxin Non-competitive antagonist of Clinical use as respiratory
GABA stimulant (now obsolete)
Risk of convulsions
Pentylenetetrazol Not known No clin1cat use
Convulsant activity in
experimental animals provides a
n useful model for testing
anliepileptic drugs (see Ch. 40)
6 11
 SECTION 4 . THE NERVOUS SYSTEM

Table 4 2.1 (cont'd) Central nervous system stimulants and psychotomimetic drugs

Category Example(s) Mode(s) of action Clinical signif icance

Psychomotor stimulants Amphetamine and related Release of catecholamines Methylphenidate and

compounds (e.g.
dexamphetamine,
methylamphetamine,
methylphenidate, fenfluramine)
Cocaine
Methylxanthines (e.g.
caffeine, theophylline)
Inhibition of catecholamine
uptake
Inhibition of catecholamine
uptake
Local anaesthetic
Inhibition of phosphodiesterase
Antagonism of adenosine Az
receptors (relevance of these
actions to central effects is not
clear)
dexamphetamine used to treat
ADHD in children; otherwise
very limited clinical use
Some agents used occasional.,
as appetite suppressants
Risk of dependence,
sympathomimetic side effects
and pulmonary hypertension
Mainly important as drugs of
abuse
Important as drug of abuse
Risk of fetal d amage
Occasionally used for
nasopharyngeal and ophthalmic
anaesthesia (see Ch. 44)
Clinical uses unrelated to
stimulant activity, although
caffeine is included in various
'tonics'
Theophylline used for aclion
on cardiac and bronchial muscle
(Chs 18, 23)
Constituents of beverages

Psychotomimetic drugs LSD Agonist at 5-HT2A receptors No clinical use

(hallucinogens) (see Ch. 11) Important as drug of abuse
MDMA Releases 5-HT and blocks No clinical use
reuptake Important as drug of abuse
Mescaline Not known
Chemically similar to
amphetamine
Psilocybin Chemically related to 5-HT;
probably acts on 5-HT
receptors
Phencyclidine Chemically similar to ketamine Originally proposed as an
(see Ch. 36) anaesthetic, now important as
Blocks NMDA receptor-operated drug of abuse and as a model
ion channels (see Ch. 33) for schizophrenia
Also blocks a receptors (Ch. 41)

5-HT, 5-hydroxytryptamine; ADHD, attention deficit hyperactivity disorder; LSD, lysergic acid diethylamide; MDMA,
methylenedloxymethamphetamine.

amine-containi ng nen e tem1inals and eventually cell death. This
effec1 is probabl y due 10 the accumulation o f reactive metabolites
of the paren1 compounds w ithin the nerve terminals. It has been
well documented in experimental animals. and is believed to
occur also in humans, possibly accounting for long-term adverse
psychological ef fects in habitual users of amphetamine
deri vatives.
Further information on the pharmacology, uses and dangers o f
amphetamines can be found in the monograph by Iversen (2006).
Pharmacological eHects
612 The main central effects of amphetamine-like drugs are:
locomo10r stimulati on
euphoria and excitemenl
stereotyped behaviour
anorexia.
In addition. amphetamines have peripheral sympathomime
acti ons, producing a rbe in blood pressure and inhibition
gastrointestinal motility.
In experimental animals, amphetamines cause increa'c
alertness and locomotor ac tivity, and increased grooming: illc
also increase aggressive behaviour. On the other hand, systemat1.
exploration o f novel objects by unrestrained rats is reduced b
amphetamine. The animals run around more but appear le
 CNS STIMULANTS AND PSYCHOTOMIMETIC DRUGS
CH3
0 CH2CHNHCH 3
Amphetamine Methamphetamine
CH3
< D 'CH 2CHNHCH3
Methylenedioxymethamphetamine
(MOMA, 'ecstasy')
CH3
I erentially affect 5-hydroxytryptamine (5-IIT) release.
Y CH,CHNHCH,CH,
CF3
Fenlluramine Methylphenidate
Fig. 42. 1 Structures of amphetamine-like d rugs.
.rtenU\e to their surroundings. Studies of conditioned responses
1uggest that amphetamines increase the overall rate of
re'ponding without affecting the training process markedl y.
Thu1, in a fixed interval schedule where a reward for lever
pre>,ing t'> forthcoming only after a fixed interval (say
10 minutes) following tl1e last reward, trained animals nonnally
press the lever very infrequently in the first few minutes afler
the reward. and increase the rate towards the end of the
10-minute interval when another reward is due. The effect of
:unphctamine is to increase the rate of unrewarded response~ at
he beginning of the 10-minute interval wi thout affecting (or
even reducing) the rate towards the end of the period. The e ffects
of amphetamine on more sophisticated types of conditioned
respon~e. for example those involving discriminative tasks, are
not clear-cut. and there is no clear evidence that either the rate
~f learning of such task:. or the final level of performance that
can be achieved is affected by the drug. Put crude ly,
:unphetaminc makes the animals busier rather than brighte r.
With large doses of amphetamines, stereotyped behaviour
t\ UU"S. This consistS of repeated actions, such as licking. gnawing.
re3Jlllg or repeated movements of the head and limbs. These
Jctilities are generall y inappropriate to the e nvironment, and
11ilh increasing doses of amphetamine they take over more and
:nore of the behaviour of the a nimal. These behavioural effects
~ e1idently produced by the release of catecho lamines in the
c brain. because pretreatment with 6-hydroxydopamine. which
depletes the brain of both noradrenaline and dopamine,
abolishe!. the effect of ampheta mine, as does pretreatment with
u-methyltyrosine, an inhibitor of catecholamine biosynthesis
-ee Ch. II). Similarly, tricyclic a ntidepressants and monoamine
oxidase inhibitors (see Ch. 39) potentiate the effects of
amphetamine, presumably by blocking amine rcuptake or metab-
olism. Interestingly, reserpine, which inhibits vesicular s torage
of catccholamines (sec C h. 11). does not block the be havioural
effect~ of amphetamine. This is probably because amphetamine
releru es cytosolic rather than vesicular catecholamines (see
Ch. II). The behavioural effects of amphetamine are probably
due mainly to release of dopamine rather than noradre naline. The
evidence for this is that destruction of the central noradrenergic
bundle does not affect locomotor !>timulation produced by
amphetamine, whereas destruction of the dopaminc-comaining
nucleus accumbens (see Ch. 34) or administration of antipsychotic
drugs that antagonise dopamine (see Ch. 38) inhibits this response.
Amphetamine-like drugs cause marked anorexia, but with
continued administration this effect wears off in a few days and
food intake returns to normal. The effect is most marked with
fennura mi ne and its o isomer dexfe nnura mine, which pref-
In humans. amphetami ne causes e uphoria: with intravenous
injection, this can be so intense as to be described a1> 'orgasmic'.
Subjects become confident, hyperactive and talkative, and sex
drive is said LO be enhanced. Fatigue, both physical and mental,
is reduced by amphetamine, and many studies have shown improve-
ment of both mental and physical performance in faLigu ed, although
not in well-rested, subjects. Mental performance is improved for
simple tedious tasks much more than for difficult tasks, and
amphetamines have been used to improve the performance of
soldiers, military pilots and others who need to remain alert
under extremely fatig uing conditions. lt has also been in vogue
as a means of helping students to concentrate before and during
examinations, but the improvement caused by reduction of
fatigue can be offset by the mistakes of overconfidence. 1 The use
of amphetamines in sport is described in C hapter 54.
Tolerance and dependence
If amphetamine is taken repeatedly over the course of a few days.
which occurs when users seek to maintain the euphoric ' high' that
a s ing le dose produces. a state of 'amphetamine psychosis' can
develop, which closely resembles an acute schizophre nic attack
(see Ch. 38), with halluc inations accompanied by paranoid
symptoms and aggressive behaviour. At the same time, repetitive
stereotyped behaviour may develop (e.g. polishing shoes or
stringing beads). The close s imilarity of this condition to
schitophrcnia, and the effectiveness of antipsychotic dru gs in
control ling it. is cons istent with the dopamine theory of
schizophre nia discussed in Chapter 38. When the drug is stopped
after a few days. there is usually a period of deep sleep, and
on awakening the subject feels lethargic, depressed, anxious
(sometimes even suic idal) and hungry. Even a s ingle dose of
amphetamine, insuffic ie nt to cause psychotic symptoms, usually
leaves the subject later feeling tired and depressed. These after-
effects may be the result of depletion of the normal stores of
1
Pay heed 10 the awful warning of the medical \ludent who. it 1\ c;aid.
having taken copious amount;, of dextroamphetamine. left the examination
ball in confident mood, having spent 3 hours writing his name over and
over again.
613
 SECTION 4 . THE NERVOUS SYSTEM
noradrenaline and dopamine. but the evidence for thi s is not
clear-cut. A state of amphetamine dependence can be produced
in experimental animals-thus rats quickly learn to press a lever
in order to obtain a dose of amphetamine, and also become
inactive and irritable in the withdrawal phase. These effects do
not occur with fenOuramine.
Tolerance develops rapidly to the peripheral sympathomimetic
and anorexic effectS of amphetamine, but more slowly to the
other effects (locomotor stimulation and stereotyped behaviour).
Dependence on amphetamine appears to be a consequence of the
unpleasant after-effect that it produces and to the insistent memory
of euphoria, which leads to a desire for a repeat dose. There is no
clear-cut physical withdmwal syndrome such as occurs with opiates.
It is estimated that only about 5% of users progress to full depen-
dence, the usual pattern being that the dose is increased as
tolerance develops, and then uncontrolled 'binges' occur in which
the user takes the drug repeatedly over a period of a day or more,
remaining continuously intoxicated. Large doses may be con-
sumed in such binges, with a high risk of acute toxicity, and the
demand for the drug di!>placcs all other considerations.
Experimental animals, given unlimited access to amphetamine,
take it in such large amounts that they die from the cardio-
vascular effect.~ within a few days. Given limited amounts, they
too de\'elop a binge pattern of dependence.
Pharmacokinetic aspects
Amphetamine is readily ab::.orbed from the gastrointestinal tract
and freely penetrates the blood-brain barrier. It does this more
readily than other indirectly acting sympathomimetic amines
such as ephedr ine or ty ramine (Ch. II), which probably explains
why it produces more marked central effects than those drugs.
Amphetamine is mainly excreted unchanged in the urine, and
the rate of excretion is increased when the urine is made more
acidic (sec Ch. 8). The plasma half-life of amphetamine varies
from about 5 hours to 20-30 hours, depending on urine flow and
urinary pH.
Clinical use and unwanted eHects
The main usc of amphetamines is in the treatment of attention
dejicit- hyperactil'ity disorder (ADHD), particularly in children,
methy lphenidate being the drug most commonly used, at doses
lower than those causing euphoria and other side effects. ADHD
is a common condition in children whose incessant overactivity
and very limited attention span disrupt their education and social
development. The efficacy of amphetamines has been confirmed
in many controlled trials. Disorders of dopamine pathways are
suspected to underlie ADHD symptomatol ogy. but the mech-
anism of action of amphetamines is unclear.
Narcolepsy is a di~abling condition. probably a form of epilepsy,
in which the patient uddenly and unpredictably falls asleep at
frequent intervals during the day. Amphetamine is helpful but
not completely effective.
As appetite suppressants in humans, for use in treating obesity,
amphetamine derivatives proved relatively ineffective and have
been largely abandoned because of their tendency to cause
pulmonary hypertension, which can be so severe as to necessitate
614 heart- lung transplantation.
The limited clinical usefulness of amphetamine is offset b)
many unwanted effects, including hypertension, insomnia, anoreXI3.
tremors, risk of exacerbating schiLophrenia, and risk of dependeoct
Sudden deaths have occurred in ecstasy users, even aft~r
single, moderate dose. The drug can induce a condiuoc
resembling heat troke. associated with muscle damage and rena
failure, and also causes inappropriate secretion of antidturea:
hormone, leading to thirst, over-hydration and hyponatrnelllli
('water intoxication'). Cerebral haemorrhage has also !Jeff
reported after amphetamine use, possibly the result of acute!
raised blood pressure. There is evidence that habitual U\e
amphetamines is associated with long-tem1 psychological effo:L
of many kinds, including psychotic symptoms, anxiet)
depression and cognitive impairment, although interpretation I'
made difficult by th e fact that drug users generally rake man)
different substances, and the association may reflect increa1cd
drug usc by psychologically disturbed individuals rather than th.
psychological after-effects of the drug. Taken in conjunction 111d
animal data, however, the human data suggest that amphelanlin~
can cause long-term damage.
COCAINE
Cocaine (see reviews by Gawin & Ellinwood, 1988; Johan on&
Fischman, 1989) b found in the leaves of a South Amenl.
shrub, coca. These leaves are used for their stimulant properu,
by natives of South America. particularly those in mountainc..
areas, who use it to reduce fatigue during work at high altitu~~.
Considerable mystical significance was attached to the powel\
cocaine to boost the flagging human spirit. and Freud tested
extensively on hi~ patients and his family. publishing an influentL
Amphetamines
The main effects are:
increased motor act ivity
euphoria and excitement
anorexia
with prolonged administration, stereotyped and
psychotic behaviour.
Effects are due mainly to release of catecholamines,
especially noradrenaline and dopamine.
Stimulant effect lasts for a few hours and is followed
by depression and anxiety.
Tolerance to the stimulant effects develops rapidly,
although peripheral sympathomimetic effects may
persist.
Amphetamines may be useful in treating narcolepsy,
and also (paradoxically) to control hyperkinetic children
They are no longer used as appet ite suppressants
because of the risk of pulmonary hypertension.
Amphetamine psychosis, which closely resembles
schizophrenia, can develop after prolonged use.
Their main importance is in drug abuse.

byih ~nograph in 1884 advocating its use as a psychostimulant.2
xi a. Freud\ ophthalmologist colleague, Koller, obtained supplies of
lhe drug and drscovcred its local anaesthetic action (Ch. 44). but
lhe P'}chor,timulant effects of cocaine have not proved to be
dmrcall) u,cful. On the other hand. they led to it becoming a
.-rde,pread drug of abu<,e in we!>tem countries. The mechanisms
mltn:atment of cocaine abuse are discussed in Chapter 43.
Pharmacological eHects
l ocame inhibits catecholamine uptake by the noradrenaline and
;e of rlopamim: transporters (see Ch. 11), thereby enhancing the
/teet-. [(npheral effects of sympathetic nerve activity and producing
.iety, J marked psychomotor stimulant effect. The lauer produces
on is euphoria, garnrlousncss, increased motor activity and a magni-
nany n-:ation of pleasure, similar to the effects of amphetamine. Its
'ased dfecb resemble those of amphetamines, although it has less
n the tendency to produce stereotyped behaviour, delusions, halluci-
with OJtions and paranoia. With excessive dosage, tremors and con-
lines .ulsions, followed by ret:.piratory and vasomotor depression, may
c~:.:ur. The peripheral !>ympathomimetic actions lead to tachycardia.
ll>OCOn,lriclion and an increase in blood pressure. Body
rrmperaturc may increase, owing to the increased motor activity
coupled "'ith reduced heat loss. Like amphetamine, cocaine
n& ;rocfuce~ no clear-cut physical dependence syndrome but tends
'can IOC'JU'I! depre sion and dysphoria, coupled with craving for the
IC:' drug hee Ch. 43), following the initial stimulant effect.
nous \\tthdra\\ al of cocaine after administration for a few days causes
udc:. a marked deterioration of motor performance and learned
s of rcha\iour. which arc re~tored by resuming dosage with the drug.
:d it There i' thus a considerable degree of psychological dependence.
The pauem of dependence, evolving from occasional use through
escalating do~age 10 compulsive binges, is identical to that seen
"11h amphetamines.
The duration of action of cocaine (about 30 minutes when
~ilen intravenously) is much shorter than that of amphetamine.
Pharmacokinetic aspects
Cocaine is readily absorbed by many routes. For many years,
illicrt 'upplic~ consisted of the hydrochloride salt, which could
toe gil en by nasal inhalation or intravenously. The latter route
produces an intense and immediate euphoria, whereas nasal
rnhalation produces a less dramatic sensation and also tends to
cau'e atrophy and necrosis of the nasal mucosa and septum.
Cocamc use increased dramatically when the freebase form
crack') became available as a street drug. Unlike the salt, this
;:an be 'moked, giving an effect nearly as rapid as that of
mtra\enous adrnini~tration. with less inconvenience and social
tigma. The social. economic and even political consequences
ofthr' 'mall change in formulation have been far-reaching.
In the 186().., a Corsican phnrmacist. Mariani, devised cocaine-conUlining
be1tr.~ges. Vin Manan1and The Mariani, wh ich were sold very successfully
l\ ronics. Imitator\ ~oon moved in, and The Mariani became the foreru nner
of Coca Colu. In 1903, cocaine wa~ removed from Coca Cola because of its
growing a\\Ocintion with addicrion and criminality (see Courtwrighr, 2001,
ror a lively account).
CNS STIMULANTS AND PSYCHOTOMIMETIC DRUGS
A cocaine metabolite i~ deposited in hair, and analysis of its
content along the hair shaft allows the pattern of cocaine con-
sumption to be monitored. a technique that has revealed a much
higher incidence of cocaine use than was voluntarily reported.
Cocaine expo~ure in utero can be estimated from analysis of the
hair of neonate!>.
Cocaine i~ Mill occasionally used topically as a local anaes-
thetic. mainly in ophthalmology and minor nose and throat surgery.
but ha~ no other clinical uses. It is a valuable pham1acological
tool for the study of catecholamine release and reuptakc, because
of its relatively specific action in blocking noradrenaline and
dopamine uptake.
Adverse eHects
Toxic effects occur commonly in cocaine abusers. The main
acute dangers arc serious ca1diovascular events (cardiac
dysrhythmias, aortic dissection, and myocardial or cerebral
infarction or haemorrhage). Progressive myocardial damage
can lead to heart fai lure, even in the absence of a history of acute
cardiac effect<;.
Cocaine can severely impair brain development in utero (sec
Volpe, 1992). The brain size is significantly reduced in babies
exposed to cocaine in pregnancy, and neurological and limb
malformations are increased. The incidence of ischaemic and
haemorrhagic brain lesions. and of sudden infant death, is also
higher in cocaine-exposed babies. Interpretation of the data is
difficult because many cocaine abusers also take other illicit
drugs that may affect fetal development. but the probability is
that cocaine is highly detrimental.
Dependence, the main psychological adverse effect of
amphetamines and cocaine, has potentially severe effects on
quality of life (Ch. 43).
METHYLXANTHINES
Various beverages, particularly tea. coffee and cocoa, contain
methylxanthines, 10 which they owe their mild central stimulant
effects. The main compounds responsible are caffeine and
theophylline. The nuts of the cola plant also contain caffeine,
which is present in cola-flavoured soft drinks. However, the
most important sources, by far. are coffee and tea, which account
Cocaine
Cocaine acts by inhibiting catecholamine
uptake (especially dopamine) by nerve terminals.
Behavioural effects of cocaine are very similar to
those of amphetamines, although psychotomimetic
effects are rarer. Duration of action is shorter.
Cocaine used in pregnancy impairs fetal development
and may produce fetal malformations.
As drugs of abuse, amphetamines and cocaine
produce strong psychological dependence and carry
a high risk of severe adverse reactions.
615
 SECTION 4 . THE NERVOUS SYSTEM
for more than 90% of caffeine consumption. A cup of instant
coffee or ~trong tea contains 50-70 mg of caffeine. while filter
coffee contain~> about twice as much. Among adults in tea- and
coffee-drinking countries. the average daily caffeine consump-
tion is about 200 mg. Further information oo the pharmacology
and toxicology of caffeine is presented by Fredholm et al. ( 1999).
Pharmacological eHects
Methylxanthines have the following major pharmacological actions:
CNS stimulation
diuresi~ (see Ch. 24)
stimulation of cardiac muscle (see Ch. 18)
relaxation of smooth muscle. especially bronchial muscle
(sec Ch. 23).
The latter two etTects resemble those of j3-adrenoceptor stim ulation
(see Ch. I I). This is thought to be because metbylxanthincs
(especially theophylline) inhibit phosphodiesterase, which is
responsible for the intracellular metabolism of cAMP (Ch. 3).
They thus increase intracellular cAMP and produce effects that
mimic those of mediators that stimulate adenylyl cyclase.
Methylxanthine~ also antagonise many of the effects of adenosine,
acting on both A 1 and A2 receptors (see Ch. 12). Transgenic mice
lacking fu nctionnl A 2 receptors are abnormally active and
aggressive, and fnil to !)how increased motor activity in response
to caffeine (Ledent et al., 1997). suggesting that antagonism at A2
receptors accounts for pan, at least, of its CNS stimulant action.
The concentration of caffeine reached in plasma and brain after
two or three cups of strong coffee-about 100 J.(M-is sufficient
to produce appreciable adenosine receptor block and a small
degree of phosphodiesterase inhibition. The diuretic effect
probably results from vasodilatation of the afferent glomerular
arteriole, causing an increased glomerular filtration rate.
Caffeine and theophylline have very similar stimulant effects
on the CNS. I Iuman subjects experience a reduction of fatigue,
with improved concentration and a clearer flow of thought. This
is confirmed by objective studies, which have shown that caffeine
reduces reaction time and produces an increase in the speed at
which simple calculations can be performed (although without
much improvement in accuracy). Performance at motor tasks,
such as typing and simulated driving. is also improved, particularly
in fatigued subjects. Mental tasks. such as syllable learning,
associa tion test~ and so on. are abo facilitated by moderate doses
(up to abou t 200 mg of caffeine. or about three cups of coffee)
but impaired by larger doses. Insomnia is common. By comparison
with amphetamine~. methylxanthines produce less locomotor
stimulation and do not induce euphoria, stereotyped behaviour
patterns or a psychotic state, but their effects on fatigue and
mental function are similar.
Tolerance and habituation develop to a small extent. but much
Jess than with amphetamines, and withdrawal effects are slight.
Caffeine does not lead to self-adminis tration in animals, and it
cannot be classified as a dependence-producing drug.
Clinical use and unwanted eHects
There arc few clinical uses for caffeine. It is included with aspirin
616 in some preparations for treating headaches and other aches and
pains, and with ergotamine in some antimigraine preparation
the object being to produce a mildly agreeable sense of alertne"
1l1eophylline b used mainly as a bronchodilator in treating -.e1~
asthmatic attacks (see Ch. 23). Caffeine has few unwanted ~lt.
effects and is c;afe even in very large doses. In vitro tests ,hcJ
that it has mutagenic ac tivity, and large doses are teratogemc
animals. However, epidemiological studies have shown llli
evidence of carcinogenic or teratogenic effects of tea or coft~
drinking in human!..
PSYCHOTOMIMETIC DRUGS
Psychotomimetic drugs (also referred to as psychedelic o
hallucinogenic drugs) affect thought, perception and mOtll.l
without causing marked psychomotor stimulation or depres~iun
(see review by Nichols, 2004). Thoughts and perceptions ten~
to become distorted and dreamlike, rather than being mere!)
sharpened or dulled, and the change in mood is likewise more
complex than a simple shift in the direction of euphoria ('II
depression. Importantly, psychotomimetic drugs do not cau.;e
dependence or addiction. even though their psychological cffec:.
overlap those of highly addictive major psychostimulanh sill.
as cocaine and amphetamines.
P~ychotomimetic drugs fall broadly into two groups.
Drugs that act on 5-HT transporters or receptors. These
include lysergic acid diethylamide (LSD), psilocybin and
mescaline, which arc agonists at 5-HT2 receptors (sec Ch. I~
and M OMA (ecstasy; see above). which acts mainly by
inhibiting 5-HT uptake. MDMA also acts on many other
reccpto~ and transporters (see Green et al., 2003), and ha'
powerful psychostimulant effects typical of amphetamine~..
well as psychotomimetic effects.
Antagonists at NMDA-type glutamate receptors
(e.g. phencyclidine).
Methylxanthlnes
Caffeine and theophylline produce
psychomotor stimulant effects.
Average caffeine consumption from beverages is
about 200 mg/day.
Main psychological effects are reduced fatigue and
improved mental performance, without euphoria.
Even large doses do not cause stereotyped behaviour
or psychotomimetic effects.
Methylxanthines act mainly by antagonism at A2
purine receptors, and partly by inhibiting
phosphodiesterase, thus producing effects similar to
those of P-adrenoceptor agonists.
Peripheral actions are exerted mainly on heart,
smooth muscle and kidney.
Theophylline is used clinically as a bronchodilator;
caffeine is not used c linically.
 CNS STIMULANTS AND PSYCHOTOMIMETIC DRUGS
ions, LSD, PSILOCYBIN AND MESCALINE
!le\S.
~\ere
LSD I' an exceptionally potent psychotomimetic drug capable
... ide ofproducang strong effect~ in humans in do!>e!> less lhan I f.Ag/kg.
ho\\ It 1' a chemical derivative of lysergic acid, which occurs in the
ic in ~ereal fungus ergot (see Ch. 12), and was fir~t synthesised by
no Hoffman in 1943. H offman deliberately swallowed about
ffce ~51lug of LSD and wrote 30 years later of the experience: 'the
face' of tho'>e around me appeared as grote!>que coloured ma.'>h
marked motoric unrest, alternating with paralysis ... heavy
feeling in the head. limbs and entire body, as if they were filled
"ith lead ... c lear recognition of my condition, in which state
I I(Jmettmes observed. in the manner of an independent obl>erver.
lhat I 'houted half insanely'. These effects lasted for a few
ltour'l. after which Hoffman fell asleep, 'and awoke next morning
feeling perfectly well'. Apart from these dramatic psychological
effect>. LSD has few physiological effects. Mescaline , which is
.kri\ed from a Mexican cactus and ha~ been known as a
tore b:tlluctnogenic agent for many centuries. wa'> made famou~ by
or :\ldou~ Huxley in The Doors of Perception. It is chemically
related to ;~mphetam ine and acts as an inhibitor of monoamine
transport, in addition to its agonist action o n 5HT2 receptors.
1>\iloqbin i~ obtained from a fungus and has very l>imilar
propente' to LSD. The p<,ychotomimetic effects of all three
drug, are the same.
Pharmacological eHects
[be main effects of lhe!>e drugs are on mental function, most
!JOL!bl) an alteration of perception in such a way that sights and
\OOJld' appear distorted and fantastic. Hallucinations visual,
.iUdttory, tactile or olfactory also occur, and sensory modalities
as may become confused, so that sounds are perceived as visions.
Thought processes tend to become illogical and disconnected.
lllt 'ubject\ retain insight into the fact that their disturbance is
drug-mduced. and generally find lhe experience exhilarating.
<kcasionally, LSD produces a syndrome that is extremely dis-
lurbing to the subject (the 'bad trip'), in which the hallucinatory
e'perience takes on a menacing quality and may be accompanied
b) paranotd delusions. This sometimes goel> so far as to produce
homicide or suicide attempts, and in many respects the ~tate has
teature~ in common with acute schizophrenic illness. Further-
more. na~hbacks ' of the hallucinatory experience have been
reported week' or months later.
LSD act' on various 5-HT-receptor subtype<> (see Ch. 12), and
:n the CNS it is believed to work mainly as a 5-HT :!A-receptor
gomst (see Nichols, 2004). It inhibit!> the firing of 5-1IT-
containing neurons in the raphe nuclei (see Ch. 34), apparently
b) acung as an agonist on the inhibitory autoreceptors of these
.ell.,. The action of mescaline is apparently different, however,
3Dd e~crted mainly on noradrenergic neurons. ft is still quite
unclear how changes in cell firing rates might be related to the
p;ychotomimetic action of these drugs.
The main effects of psychotomimetic drugs are subjective, so
11 1> not surprising lhat animal tests lhat reliably predict psycho-
tomimettc activity in humans have not been devised. Attempt<> to
measure changes in perception by behavioural conditioning studies
have given variable resu lts, but some authors have claimed that
effects consistent with increased sensory 'generalisation' (i.e. a
tendency to respond similarly to any sensory stimulus) can be
detected in lhis way. One of lhe more bizarre te~~ involves
spide~. whose normal elegantly symmetrical webs become jumbled
and erratic if the animals arc treated with LSD.
Dependence and adverse eHects
Psychotomimetic agents (except for phencyclidine; see below)
are not self-administered by experimental animals. Indeed, in
contrast to most of the drugs that arc widely abused by humans.
they have aversive rather than reinJorcing properties in behavioural
tests. Tolerance to their effects develop~ quite quick.ly.
There is no physical withdrawaJ syndrome in animals or
humans.
There has been much concern over reports that LSD and
other psychotomjmetic drugs, as wel l as causing potentially
dangerous bad trips, can lead to more persistent mental disorder
(see Abraham & Aldridge, 1993). There are recorded instances
in which altered perception and hallucinations have la.\tcd for up
to 3 weeks following a single dose of LSD, and of precipitation
of attacks in schizophrenic patients. Furthermore, it is possible
that LSD may occasionally initiate long-lasting schizophrenia,
although conclusive evidence is lacking. This possibility, coupled
wilh the fact that the occasional bad trip can result in severe
injury through violent behaviour, means that LSD and other
psychotomimetics must be regarded as highly dangerous drugs,
far removed from the image of peaceful 'experience enhancers'
that the hippy subculture3 of the 1960s so enthusiastically
espoused.
MDMA
MDMA is an amphetamine derivative with complex effects on
monoamine function ('>ce Green et al.. 2003; Morton, 2005;
Iversen 2006). It inhibit~ monoamine transporters, principally the
5-HT transpot1er, and also releases 5-HT, the net effect being a
large increase in free 5-HT in certain brain regions, followed
by depletion. Similar but smaller changes occur in relation to
dopamine and noradrenaline. Simplistically, the effects on 5-HT
function determine the psychotomimetic effects, while dopamine
and noradrenaline changes account for the initiaJ euphoria and
later rebou nd dysphoria. MDMA is widely used as a 'party drug'
becau~e of the euphoria. loss of inhibitions and energy surge
that it induces. Although not addictive, MDMA carries l>erious
risks, both acute and long term .
Sudden illness and death can occur even after small doses
of MDMA. The syndrome appears to result from acute
hyperthermia, resulting in damage to skeletal muscle and renal
failure. This may reflect an action of MDMA on mitochondrial
function, exacerbated by energetic dancing and high ambient
temperature. It appears that certain individuals may be particu-
larly !)USCeptible to this danger.
'You may recall the Beatles' lyric Lucy in tire Sky with Diamonds, aho the
phra~e 'Drop our; tune in; turn on' coined by Tim01hy Leary. whose ashes
were sent into orbi t in 1997.
617
 SECTION 4 . THE NERVOUS SYSTEM

The after-effects of MDMA persi t for a few days and comprise

depression, anxiety, irritability and increased aggression-the Psychotomimetic drugs
'midweek blues. There is also evidence of lo ng-term deleterious
effects on me mory and cognitive function in heavy MDMA The main types are:
users. in animal studies, MDMA can cause degeneration of 5-HT lysergic acid diethylamide {LSD), psilocybin and
and dopamine neurons, but whelher this occurs in humans is mescaline {actions related to 5-hydroxytryptamme
uncertain. In summary. recreational usc of MDMA cannot be {5-Hl) and catecholamines)
cons idered safe. methylenedioxymethamphetamine {MDMA,
'ecstasy')
phencyclidine.
PHENCYCLIDINE Their main effect is to cause sensory distortion of a
Phencyclidine was originally intended as an intravenous anaesthetic fantastic and hallucinatory nature.
agent, but was found to produce in many patients a period of LSD is exceptionally potent, producing a long-lasting
disorientation and hallucinations following recovery of conscious- sense of dissociation and disordered thought,
ness. Ketamine (see Ch. 36), a close analogue of phencyclidine. sometimes with frightening hallucinations and
is better as an anaesthetic, all hough it too can cause symptoms of delusions, which can lead to violence. Hallucinatory
disorientation. Phencyclidine is now of interest mainly as a drug episodes can recur after a long interval.
of abuse ('Angel du t', now declining in popularity). LSD and phencyclidine precipitate schizophrenic
attacks in susceptible patients, and LSD may cause
Pharmacological effects long-lasting psychopathological changes.
The effects of phencyclidine resemble those of other psycho- LSD appears to act as an agonist at 5-HT2-receptors,
tomimetic drugs (see Johnson & Jones, 1990) but also include and suppresses electrical activity in 5-HT raphe
analgesia, which was one of Lhe reasons for its introduction as neurons, an action that appears to correlate with
an anaesthetic agent. It can also cause stereotyped motor psychotomimetic activity.
behaviour, like amphetamine. It has the same reported tendency MDMA is an amphetamine analogue that has
as LSD to cause occasional bad trips and to lead to recurrent powerful psychostimulant as well as psychotomimetiC
psychotic episodes. Its main pharmacological effect is to block effects.
the NMDA receptor channel (see Ch. 33), but it is also an MDMA can cause an acute hyperthermic reaction,
antagoniM at o-receptors, which are activated by various opioids sometimes fatal. It also has severe long-term
of the ben.lOmorphan type (Ch. 41 ). It is believed that the NMDA psychological effects, similar to LSD.
channel-blocking ac tion is primarily responsible for the Psychotomimetic drugs do not cause physical
psychotomimetic effects, which mimic, both be haviourally and dependence and tend to be aversive, rather than
biochemically, the manifestations of human schizophrenia reinforcing, in animal models.
(Morris et al., 2005). Phencyclidine is known to exacerbate Phencyclidine acts by blocking the glutamate-activated
symptoms in stabilised schizophrenic patients, but it is not NMDA receptor channel, and also blocks u-receptors.
known whether habitual use can cause the disorder to develop.

REFERENCES AND FURTHER READING

General reference
Courtwright D T 2001 Forces of habit: drugs and the
making of the modem world. Harvard University
PreM;. Cambridge (A /ioe/y hiftorical account of hohit-
formmg dn1~s)
P>) chostimulants
~rcdholm B B. Bauog K, Holmes J et al. 1999 Acuon;, of
caffeine in the hmon with special reference to facton.
lhat contribute to its widespread u;,e. Pharmacal Rev
51: 83-133 (Compfl'hensie r~ouw article cmuin.~
phannacological. ~ha>~Ourtll aTUI mcial aspuu)
Ga"' in F H. Elhnwood E H 1988 Cocrune and other
Mimulants. N Engl J Med 3 18: 11 73- 1182
l'ersen LL 2006 Speed, Ecstasy. ritaJin. The science of
runphelaminc,. Oxford UniveNty Press. (Amlwmarn<'
book on all a1pts of th<' pro{'<'rties. use and abu" of
amphetamme.!.)
Johanson C-E. Fi,chman M W 1989 The phamtacology
618 of cocaine related to its abuse. Pharmacol Rev 4t: 3 ~7
l..edcnt C et al 1997 Aggrel\eness, hypoolge>ta and
high blood pressure in moce lacking the ndeno~ine A 21
receptor. Nature 388: 674.-678 (Study of rmns11enic
mirt!. .ohowi11g loss of.<timulanr effect.r of rtifleiriR in
miu lackmg A, rueptors}
Nehlig A. Daal J-L. Debry G 1992 Cafftone and the
central nervous sy;tem: mechanistru. of acuon,
biochemical. metaooloc and psycho,timulnnt effects.
Brain Res Rev 17: 139- 170
Seiden L S. Sabol K E. Rocaunc G A 1993
Amphetamine: effect' on catechol am one ')\terns and
beha oor. Annu Re Phann:~eol Toucol 33: 639-677
Volpe J J 1992 Effect of cocnme on the fetus. N Engl J
Med 327: 399-107
Psychotomimetics
Abr:tham H D. Aldridge A M 1993 Ad,er.e cono;equences
of l)..ergtc acid dteth) lamode. Addiction 88: 1327-1334
Green A R. Meehan A 0. El!Jou J M et nl. 2003 The
pharmacology and cli nical phannacology of 3,4-
melhytenedoo') melhamphetamone (MDMA.
'Ec;tasy'). Phrum Re 55: 463-508
Johnson K M, Jones S M 1990 Neurophannacolo~}ol
phencyclidine: bnic mechanisnh w1d tbempeutoc
potential. Annu Re Pbarmacol Toxicol 30: 707 'Ill
Moms B J. Cochr.ln S \1. Pran J A 2005 PCP from
phannacotogy to modelling -.ch11ophrenia. CUJT
Pharmacol 5: 101-106 (Rel'ii'H'llf'lltwtg thm N.lllll
cluumel h/mk by phencyclidine closely mod1'1.1 /uw!Ql
schi~ophmria)
Monon J 2005 f'..c,tas): pharmacotog) and neumu
Curr Opon Ph.mnacol 5: 79 86 (l/s~ful shon m'ln'
focusing oro ad1erse effen tJf MDMA)
Nochols D E 2004 Hallucinogens. Phannacol Ther 101
t31-181 ( Comwehensie fl'liew article focu.lin~ ,,,
5HT1!1 rt'Ct'pWr.\ OS tht' IO'flt'l of psyc/tO/OIIIimnlf
drugs)
 Drug addiction,
e
dependence and abuse
IOverview 619
~
The nature of drug addiction 620
-Reward pathways 621
-Biochemical mechanisms 621
-Pharmacological approaches to treating drug
oddtction 622
Nicotine and tobacco 622
-Pharmacological effects of smoking 623
-Phormacokinetic aspects 625
-Tolerance and dependence 626
-Harmful effects of smoking 626
Ethanol 628
-Pharmacological effects of ethanol 629
-Pharmacokinetic aspects 631
-Tolerance and dependence 633
Cannabis 63.4
-Chemical aspects 63.4
-Phormacological effects 63.4
-Tolerance and dependence 635
-Pharmacokinetic aspects 635
-Adverse effects 635
! -Clinical use of cannabis: o controversial topic
OVERVIEW
In earlier chapters, we have discussed several
drugs (e.g. benzodiazepines, opiates,
<>I
psychostimulants) that can cause dependence.
There are also many drugs that human beings
consume because they choose to, and not because
they are advised to by doctors. Society in general
disapproves, because in most cases there is a
social cost; for certain drugs, this is judged to
outweigh the individual benefit, and their use is
banned in many countries. In western societies, the
three most commonty used non-therapeutic drugs
are caffeine, nicotine and ethanol, all of which are
legally and freely available. Many other drugs are
widely used although their manufacture, sale and
consumption has been declared illegal in most
western countries-but very big business,
nevertheless 1 -except when it is under the direction
of the medical profession. A list of the more
important ones is given in Table 43. 1. Other
' lifestyle' and 'sport' drugs are discussed in
Chapter 54.
The reasons why particular drugs should come to
be used in a way that constitutes a problem to
society are complex and largely outside the scope
of this book. The drug and its pharmacological
activity are only the starting point, although drug
taking is clearly seen by society in a quite diHerent
light from other forms of addictive self-gratification,
such as opera going, football or sex. At first sight,
the ' drugs of abuse' form an extremely
heterogeneous pharmacological group; we can find
little in common at the molecular and cellular level
between say, morphine, cocaine and barbiturates.
What links them is that people find their eHect
pleasurable (hedonic) and tend to want to repeat
it, an action that reflects the eHect-common to all
dependence-producing drugs-of activating
mesolimbic dopaminergic neurons (see below). This
hedonic effect becomes a problem when:
636
the want becomes so insistent that it dominates
the lifestyle of the individual and damages his or
her quality of life
the habit itself causes actual harm to the
individual or the community.
Examples of the latter are the mental incapacity
and liver damage caused by ethanol, the many
diseases associated with smoking, the high risk of
infection (especially with HIV), the serious risk of
overdosage with most narcotics, and the criminal
behaviour resorted to when addicts need to
finance their habit.
In this chapter, we discuss some general aspects
of drug dependence and drug abuse, and describe
the pharmacology of three important drugs that
1
Giobally. accordmg to UK e\tJmate,. annual \ate . . of illegal drug~ \\ere
about $800 bilhon in the late 1990s. accounting for 8% of all international
619
trade, similar to oil 'u les and rollghly three times thm of prescription drugs.
 SECTION 4 . THE NERVOUS SYSTEM

have no place in therapy but are consumed in
large amounts, namely nicotine, ethanol and
can nabis. Other drugs with abuse potential are
described elsewhere in this boo k (see Table 43.1 ).
For further information on various aspects of drug
abuse, see Friedman et al. (1996), Karch (1997),
Hyman & Malenka (2001) and Winger et al. (2004).
not addictive, so it io; important to di<>tinguish this type of commonl,
observed 'rebound' phenomenon from true dependence.
The common feature of the various types of psychoactive drug
that are addictive is that all produce a rewarding effect. Jn animal
studies, where this cannot be inferred directly, it is manife~t
positive reinforcement (i.e. an increase in the probability of OO;m
renee of any behaviour that results in the drug being administered ~trc

Thus, with all dependence-producing drugs, ~pontaneous self

THE NATURE OF DRUG ADDICTION
Several related terms arc used, sometimes interchangeably, to
describe the consequences of continued administration of hedonic
drugs. Dntg dependence and the older tenn dntg addiction describe
the human condition in which drug taking becomes compulsive,
taking precedence over other needs, often with serious adverse
consequences. This generally implies a state of physical, as well as
psychological, dependence (see below). Drug dependence can be
viewed as a reversible pharmacological phenomenon. readily
induced in animals, whereas addiction is a chronic, relapsing human
condition, as distinct from an acute illness that can be cured by
abMinence. Drug abuse and substance abuse are more general
terms. meaning any recurrent use of substances that are illegal
or that cause harm to the individua l. including drugs in sport.
Tolerance- the decrease in pharmacological effect on repeated
administration of the drug-often accompanies the state of depen-
dence. and it i~ possible that related mechanism-. account for
both phenomena (see below). Withdrawal syndrome or abstinence
syndrome describes the adverse effects, both physical and
psychological and lasting for a few days or weeks, of stopping
taking a drug. Several psychotropic drugs. including antidepressant
and antipsychotic agents, produce withdrawal symptoms but are
administration can be induced in animal studies. Coupled 11-it'
the direct rewarding effect of the drug, there is usual!) aho a
process of habiwation, or adaptation, when the drug is gi1~
repeated ly or continuously, s uch that cessation of the drug has <II
aversil'e effect. negative reinforcement, from which the subject Il-l
attempt to escape by self-administration of the drug. The ph)''"'
withdrawal syndrome, associated with the state of physical dcpc
dence, is one manifestation of this type of habituation; the intcll\11)
and nature of physical withdrawal ~ymptoms varies from onccJa,,
of drug to another, being particularly marked with opioids. It i' k
important in sustaining drug-seeking behaviour than psychologt..
habituation, which is associated with a craving that is not rclat~
to physical symptoms. A degree of physical dependence is comnn
when patients receive opioid analgesics in hospital for several <L.
but this mreJy leads to addiction. On the other hand. addicts 1\ho ..
nursed through and recover fully from the physical abstincn,,
syndrome are still extremely likely to revert to drug taking l.tk
Therefore physical dependence is not the major factor in Jon~
tenn dmg dependence. In addition to the positive and negat
reinforcement associated with drug administration and withdraii-J
conditioning plays a significant part in ~ustaining dru.
dependence (see Weiss. 2005). When a particular environment
location. or the sight of a syringe or cigarette, becomes associ. ,
with the pleasurable experience of drug taking, the anteccJ.:

Table 43.1 The main drugs of abuse

Type Examples Dependence liability Chapter in which discussed

Narcotic analgesics Morphine Very strong 41

Diamorphine Very s trong 41

General central nervous Ethanol Strong This chapter

system depressants Barbiturates Strong 37
Methaqualone Moderate 37
Glutethimide Moderate 37
Anaesthetics Moderate 36
Solvents Strong

Anxiolytic drugs Benzod1azepines Moderate 37

Psychomotor stimulants Amphetamines Strong 42

Cocaine Very strong 42
Caffeine Weak 42
Nicotine Very strong This chapter

Psychotomimetic agents Lysergic acid diethylamide Weak or absent 42

Mescaline Weak or absent 42
Phencyclidine Moderate 42
Cannabis Weak Th1s chapter
620
 DRUG ADDICTION, DEPENDENCE AND ABUSE

!lunulu' iL-elf evokes the response. as with Pavlov's dogs. The same
appens in rever~e. o that the antecedents of not taking the
g... drug become aver<;ive. Thil. kind of conditioning is generally
amal roore per'i'tent and lel>S eal>ily extinguished than unconditioned
mnforcemenl. and probably accounts for the high relapse rate of
'lw.med' addictl>. The psychological factors in drug dependence
are di-cu'>sed by Koob ( 1996) and l>ummarised in Figure 43.1.
T ~mmal modeh of drug dependence rely mainly on self-adminiwarion
prtl(JCOI\, in ~hich a do'e of the drug is given in response to a behaviour
,u,h a' bar prc,,ing. Some drug\, for example ethanol. are spontaneously
iven ~lfadmmi\lercd by laborotory animals: others. for example cocaine.
are -.:It-administered only after dependence has been induced by previous
lllmml\tration of the drug. flu man~. of course, self-administer drugs such
l'ethanol without ncce,sarily becoming addicted. To model the compulsive
n;uurc of add iction more accurate ly. extensions to the self-administration
parad1gm may be employed (sec Deroche-Gamonet et al., 2004). Rats treated
for nshon time wi th 'non-addictive' doses of cocai ne will self-administer
the drug by bar prcs~ing but Mop bar pressing when a signal is shown to
1ndicate thm the drug injector is disconnected. or if the dmg injection is
accompanied by punishment in the form of a foot shock. With more
mten;e 'addictive pretreatment. bar pressing persists at a high rate under
a ted ihN condition,. Modeb of this son arc considered more likely to repl icate
mon the >Huation of addiction in humans. as a ba~is for testing therapeutic
. )S. Jf'!'rOache,, but in human~ drug dependence represents a srable change in
lnin funcnon ~u~tained by proce\~ that are more complex and long lasting
th.111 the neurobiological change~ ~o far studied in experimental animals.
REWARD PATHWAYS
T \nuall} all dependence-producing drug~ so far tested. including
op!Oid,, nicounc, amphetamillCl>. ethanol and cocaine. activate the rl'warrl
~al'-lhe me\ohmbtc dopaminergic patbwa} (see Ch. 34). which
ltor run,,' 1a the medial forebroin bundle. from the ventral tegmental area of
the mtdbrain (A 10 cell group in rats) to the nucleus accumbcns and
:.ned
limbic regton (see NcMier. 2001 ). Even though their primary sites of
i.knt a11on arc generally cbe"' here in the brain. all the;e drugs increase the
relea'e of dopam1ne in the nucleus accumbens. as shown by microdialysis
and other techntque' (~ Spanagel & Weiss, 1999). Some stimulate firing
of AIO celh. whe~ others, wch a~ amphetamine and cocaine. release
dopamine or prevent its reuptake (sec Ch. II). Their hedonic effect re,ull',
from activation of th1~ pathwa}. rot her than from a subjective appreciation
of the diver...e other effects (such as alertness or disinhibition) that the drugs
produce. Chem1cal or surg1cal interruption of this dopaminergic path~ay
impair~ drug-\eektng behaviours in many experimental situauon\.
Deletion of D, receptOr\ in a tmn,genic mouse strain eliminated the
re"' ard propcnics of morphine adnuni,tration without eliminating other
opiate effects, and it did not prevent the occurrence of physical withdra\\ al
\)mptoms 10 morphine-dependent animals (Maldonado et al.. 1997).
!>ugge..,ting that the dopaminergic pathway is responsible for the po<,itive
reward but not for the negative withdrawal effects. However, Drrcceptor
antagonists (antipsychotic drugs: sec Ch. 38) have not been succes~ful in
treating addiction. and more recent evidence (see Heidbreder & Hagan.
2005) suggeM'> that 0 1-reccplors play an important role. Other mediators,
particularly 5-hydroxytryptamine. glutamate and GABA, have al ~o been
implicated in the conditioning mechanisms that reinforce drug-seeking
behaviour. and a variety of phannacological strategies based on blocking
these pathways are being explored (sec Heidbreder & Hagan, 2005). In
th i ~ regard, the field of drug add iction resembles many of the topics
discussed in other chapters dealing wi th centra l nervous system (CNS)
drugs. where many of lhe same mediators appear to be involved. and
many of the same pharmacological strategies have been propo;ed to treat
addiction. ~o far with limited success (see below).
BIOCHEMICAL MECHANISMS
T The cellular mechanisms in1ohed in habituation to the effects of drug\
\uch as op101d~ and cocaine have been studied in some detail (see 1\e~tler.
200-' ). Both cla\-,c\ of drug produce. on chronic administrarion, an increase
in the acmuy of adenylyl cyclase in bmin regions such as the nucleus
accumbens. which compensates for their acute inhibitory effect on cAMP
formauon and produces a rebound increase in cAMP when the drug i'
terminated (Fig. 43.2). Chronic opioid treatment increases the amount not
only of adcnylyl cyclase itM:If. but also of other components of the
signalling pathway. including the G-proteins and various protein kinases.
This incrca\C in cAMP aiTect' many cellular functions through the
increa~cd activity of various cAMP-dependent protein kinases, which

.. . . .,r"'"' "
Cues associated with drug withdrawal Cues associated with drug taking
social situation social situation
, non-availability of drug etc. purchase of drug
,

I
I
I
,' '
,,
j
Drug withdrawal Drug administration
''
'
''
''
I

r
I ' \
~
NegatNe conditioning Positive conditioning
Negative Positive
\ reinforcement reinforcement I
\ I

'
''
'
''
'
'4 Delayed Immediate "' '
~ABSTINENCE Long-lasting (days) Brief (hours) REWARD Antagonists
~ SYNDROME Response modifiers
Increases wtth Decreases
repetition with repetition

Fig. 43.1 Psychological factors involved in drug dependence. _ _ _j 621

 SECTION 4 . THE NERVOUS SYSTEM

acting on pre~ynaptic A 1-recep10rs, acts to inhibit glutamate rele4~t

e>.citatory ~ynap~e~. and thu\ counteracts the neuronal hypere"iW>Cll
Morphine that occur~ during drug withdrawal, suggesting the possibilit) - IIN
400 clinically proven-that adenosine agonists might pro,e useful in tm!JlC
drug dependence.
(ij
E 300 Adenylyl Family \ludie' ~ho" clearly that ~usceptibility to addiction is an m~
0c: cyclase chamcteri~tic. and many candid:ue genes have been reported, \\lth
0 200 expression particular locu~ on gene~ invohed in transmitter metabolism. re.:tpUt_
,o
0 etc. (\ee Mayer & llollt, 2005). The general conclusion is that uriJIIIS
many dillerent gene~ each make a small contribution to the 01
100
suscepllbiltt) ol an individual to addiction- a familiar o,cenmo
provide\ few pointer~ for therapeutic interYention. Polymorphhms
cthanol-metabolbing genes (~e below) are the best example of gcn~
Time - - - - -- -.. directly affect the tendency to abuse a drug.
Fig. 43.2 Biochemical mechanism postulated to explain
morphine tolerance and dependence. Morphine inhibits
adenylyl cyclase, thus reduc ing cAMP formation (green line). A PHARMACOLOGICAL APPROACHES TO
secondary rise In adenyl yl cyclase expression occ urs (red line), TREATING DRUG ADDICTION
so that cAM P prod uction recovers in the presence of morphine
(i.e. tolerance develops). On cessation of morphine treatment, From th e di scussio n above, it wiU be clear that drug addicti,
excessive cAM P production occurs, causing withdrawal invol ves many psycho!>ocial and some genetic fac tors, as well
symptoms, until the high level of adenylyl cyclase expression neuropharmacological mechanisms, so drug treatment is onl) IJ
returns to normal. Later work has shown that other elements in
the cAMP signalling pathway, in addition to adenylyl cyclase
itself, are similarly affected by chronic drug exposure, in vivo
as well as 1n vitro. (From Sharma S K et al. 1975 Proc Natl
Acad Sci USA 72: 3092.)
J component of the therapeutic approaches that are used.
The main pharmacological approaches (see O'Brien. 19'r
H eidbreder & H agan, 2005) are summarised in Table 43.2.

NICOTINE AND TOBACCO

control the acti\ ity of ion channeb (making the cells more excitable),
'" \\CII ao, \anou~ cnLyme~ and rran~cription factors. One particular
tran~ription factor. cAMP reo,ponse element- binding protein (CREB).
"hich io, up-regulated m the nucleus accumbens by prolonged
adminro,trauon of opratc\ or cocaine. play~ a key role in regulating various
component' of cAMP ~ignalting pathways. and transgenic animals lacking
CREB show reduced withdraw:1l symptoms (see Chao & Nestler, 2004).
The'c changes (o,ee rig. 43.3) probably account for the relatively short-term
(days to weeks) phenomena or tolerance and dependence. but the long-
tenn proce\sCs rc~ponsiblc for craving and relapse-the major issues in
human addiction arc very poorly underMood at the neurochemical level.
Adeno>ine, which i~ an impo11ant CNS mediator (see Ch. 12), has also been
implicated in drug dependence. Withdrawal of opiates, cocai ne or alcohol
resu lts in incrca>cd adcnm,ine production. due partly to the conversion of
high Jc,cl~ of cAMP to adenosine (see Hack & Christie, 2003). Adenosine,
Tobacco growing, chewing and smoking was indigenous througta:
the American !>Ubcontinent and Australia ar the time that E~
exploren. first vbited these places. Smoking spread through Eul\l'f
during the 16th century. coming to England mainly a~ a re,ult
its enthusiastic espousal by R aleigh at the court of Elizabeth
James I strongly disapproved of both R al eigh and tobacco.
initiated the firM antismoking campaign in the earl y 17th cent~.
with the !>upport of' the Royal College of Physicians. Parliamt
responded by imposi ng a substanti aJ duty on tobacco, there
setting up the d i lem ma (fro m w hich we show no sign of bci1.
able to escape) of g iv ing the State an economic interest in th
continua tion of smoking at the sam e time that i ts official expe
advisers were issuing emphatic warnings about its dangers.

( Drug-taking Drug withdrawal

Days-weeks Months-years
Acute _ _ _ _....:...._
State produced: Acute _ __:___ __ _.., Chrome ___,~

drugged state drugged state abstinence abstinence

Effect: Reward Tolerance, dependence Withdrawal syndrome Craving

Mechanism: Act1vat1on of mesolimb1c Adapt1ve changes in receptors. Uncompensated adaptive Not known
OA pathway transporters, 2nd messengers, changes (e.g. ~DA.
? Other reward etc. (e.g. tadenylyl cyclase, DA t glutamate)
pathways t transporter)

Fig. 43.3 Cellular and physiological mechanisms involved In drug dependence showing the relationship between the
immediate and delayed effects of drug-taking and drug withdrawal. DA, dopamine.
622
 DRUG ADDICTION , DEPENDENCE AND ABUSE

Tillie 43.2 Pharmacological approaches to treating d rug dependence

Mechanism Example(s)

Subs! tullon to alleviate Withdrawal Methadone used short term to blunt opiate Withdrawal
symptoms Benzodiazepines to blunt alcohol Withdrawal
2Adrenoceptor agonists (e.g. clonidine, lofexJdJne) to diminish withdrawal symptoms
----------------------------------
long-term substitution Methadone substitution for opiate addiction
Nicotine patches or chewing gum

:, that Block1ng response Naltrexone to block opiate effects

Mecamylamine to block nicotine effects
Immunisation against cocaine and nicotine to produce circulating antibody (not yet proven)

Avers1ve therapies Disulfiram to induce unpleasant response to ethanol

Modification of craving Bupropion (antidepressant)

:tion Naltrexone (blocks opiate receptors-also of value in treating other addictions)
11 as Clonidine (a~-adrenoceptor agonist)
Acamprosate (NMDA receptor antagonist) used to treat alcoholism
one

997;

Unulthe latter half of the 19th century, tobacco was smoked

mp1pe,, and by men. Cigarette manufacture began at the end of
tbt 19th centul). and now cigarettes account for 98% of tobacco
coo..umption. The trend in cigarette consumption in the 20th century
sho\\11 in figure 43.4. From a peak in the early 1970s, cigarette
rort-umption m the UK dropped by about 50%, the main factors
l:l:mg increa.-.cd price. adven.e publicity. restrictions on advenising,
tot .mJ the compulsory publication of health warnings. Filter cigarette!.
h I. 11hich gi\c a somewhat lower delivery of tar and nicotine than
and stmJard cigarcucs) and ' low-tar' cigarettes (which are also low in
Uf) Ol'Oimc ) cons ti1u1e an increasing proportion of the total. 2 The
1!111 pmptlrtion of cigarette smokers in the UK is currently about 27%,
by Hh lillie difference between men and women, and has remained
Jlth1s level since the early 1990s. About I 0% of children aged
10-15 arc regular smokers. Curren tly, there are about 1.1 billion
'moker' in the world ( 18% of the popu lation), and the number in
ile1eloping countries is increasing rapidly. Five trillion (5 x 10 12)
,Jgarettes arc sold each year, about 5000 per smoker.
fur reviews on nicotine and smoking, see Balfour & Fagerstrom
1996) and Benowit7 ( 1996).
PHARMACOLOGICAL EFFECTS OF
SMOKING
i~ the only phannacologically active substance in tobacco
1
\llXJOJlt!
smok apart from carcinogenic tan. and carbon monoxide (see
Drug dependence
Dependence is defined as a compulsive
craving that develops as a result of repeated
administration of the drug.
Dependence occurs with a wide range of
psychotropic drugs, acting by many different
mechanisms.
The common feature of dependence-producing drugs
is that they have a positive reinforcing action
('reward') associated with activation of the
mesolimbic dopaminergic pathway.
Dependence is often associated with (i) tolerance to
the drug, which can arise by various biochemical
mechanisms; (ii) a physical abstinence syndrome,
which varies in type and intensity for different classes
of drug; (iii} psychological dependence (craving},
which may be associated with the tolerance-
producing btochemical changes.
Psychological dependence, which usually outlasts the
physical withdrawal syndrome, is the major factor
leading to relapse among treated addicts.
Although genetic factors contribute to drug-seeking
behaviour, no specific genes have yet been identified.

below). The acute effect/> of smoking can be mimicked by injection

~lOOker. adapl by smoldng more low-wr cigarettes so as to maintain their
IJI(oune consumption. of nicotine and are blocked by mecamylamine. an antagonist at
neuronal nicotinic acetylcholine receptors (nAChRs) (see Ch. 10).
rn'm the plant Nicotiano. named after Jean Nicot. French ambassador to
Portugal. who pre~cnted ~ccds to the French king in 1560. having been
Jl(l\uaded of the medical value of smol-.ing tobacco leaves by natives of EHects on the central nervous system
S<>uth America. Smo~ing wa~ believed to protect against illness, particularly The central c ffccl!> of nico1inc arc complex and cannot be summed
1he plag11c. up overall simply in terms of slimuJation or inhibitio n. At the 623
 SECTION 4 . THE NERVOUS SYSTEM
Clinical use of drugs in substance
dependence
Tobacco dependence:
short-term nicotine is the drug of choice as
adjunct to behavioural therapy in smokers
committed to giving up
bupropion is also effective but lowers seizure
threshold, so is contraindicated in people with risk
factors for seizures.
Alcohol dependence:
long-acting benzodiazepines (e.g.
c hlordiaze poxide) can be used t o reduce
withdrawal symptoms and the risk of seizures;
they should be tapered over 1-2 weeks and then
discontinued because of their abuse potential
dis ulfiram is used as an adjunct to behavioural
therapy in suitably motivated alcoholics after
detoxification; it is contraindicated for patients in
whom a hypotensive acetaldehyde-induced
reaction (p. 632) would be dangerous (e.g. those
with coronary or cerebral vascular disease)
acamprosate can help to maintain abstinence; it
IS started as soon as abstinence has been
achieved and maintained if relapse occurs, and it
is continued for 1 year.
Opioid dependence:
opioid agonists or partial agonists (e.g.,
respectively, methado ne and buprenorphine)
administered orally or sublingually may be
substituted for injectable narcotics, many of
whose harmful effects are attributable to the route
of administration
naltrexone, a long-acting opioid antagonist, is
used as an adjunct to help prevent relapse in
detoxifi ed addicts (opioid-free for at least 1 week)
lofexidine, an u 2 agonist (ct. c lonidine; Ch. 11) is
used short term (usually up to 10 days) to
ameliorate symptoms of opioid withdrawal, and is
then tapered over a further 2-4 days.
cellular level, nicotine acts on nAChRs of the a4 ~ 2 subtype (see
Ch. 3-l), which are widely expressed in the brain, particularly in
the corte:< and hippocampus, and are believed to play a role in
cognitive function, as well as in the ventraltegmemal area, from
which dopaminergic neurons project to the nucleus accumbens
(the reward pathway, 1>ee above). These receptors are ligand-gated
cation channels located both pre- and postsynaptically, causing,
respectively, enhanced tran!>mitter release and neuronal excitation
(sec Wonnacott et al., 2005). As well as activating the receptors,
nicotine also causes de11ensitisation, which may be an important
component of it~ effects, because the effects of a dose of nicotine
are diminished in animals after sustained exposure to the drug.
624 Chronic nicotine administration leads to a substantial increase in
~ 140
~
c: 120
g
\
Q.
E 100
::>
8"'
<II
80
::
!!! 60
co
Cl>
u
::t: 40
::>
(ij
::> 20
c:
c:
< 0
1900 1910 1920 1930 1940 1950 1960 1970 1980 1~
Fig. 4 3 .4 Cigarette c onsumption in the UK, 1900-1994.
Numbers 1, 2 and 3 refer to publication of Royal College of
Physicians reports on smoking and health. Since 1980, the
drop In consumption has closely followed price increases.
Since 1994, cigarette consumption has levelled off. (Data from
Ashton H, Stepney R 1982 Smoking psychology and
pharmacology. Tavistock Publications, London; Townsend 1996
Price and consumption of tobacco. Br Med Bull 52: 132-142.)
Tobacco smoking
Cigarette consumption in the UK is now
declimng after reaching a peak in the mid-1970s.
The worldwide prevalence of smoking is now about
18% of the adult population, each smoker using on
average 5000 cigarettes per year.
Nicotine is the only pharmacologically active agent ~
t obacco, apart from carcinogenic tars and carbon
monoxide.
The amount of nicotine absorbed from an average
cigarette is about 1-1.5 mg, which causes the plasma
nicotine concentration to reach 130-200 nmol/1.
These values depend greatly on the type of c igarette
and on the extent of inhalation of the smoke.
the number of nAChRs (an effect opposite to that produced
sustained adminiwation of most receptor agonists), which r.
represent an adaptive response to prolonged receptor desensiti\Jll
It is likely that the O\'erall effect of nicotine reflects a baL
between activation of nAChRs. causing neuronal excitation.
desenl.itisation. causing synaptic block.
Pig.
At the spinal level, nicotine inhibits spinal reflexes, cau'
skeletal muscle relaxation that can be measured by elecc
myography. This may be due to stimulation of the inhibit
Renshaw cells in the ventral horn of the spinal cord. The htgl
level functioning of the brain, as reflected in the subjective ~c
of alertness or by the electroencephalography (EEG) pattern,c
be affected in either direction by nicotine, according to dose
circumstances. Smokers report that smoking wakes them up 11ft
 DRUG ADDICTION, DEPENDENCE AND ABUSE

~) are drowsy and calms them down when they are tense. and
fiG recordings broadly bear this out. 1t also seems that small
iJse, of nicotine tend to cause arousal. whereas large doses do
!be re\crse. Test~ of motor and sen<;ory perfom1ance (e.g. reaction
me measurements or' igilance tests) in humans generally show
rrmement after smoking. and nicotine enhances learning in
, Some elabomte tests have been conducted to see. for example.
lletherthe effect of nicotine on performance and aggression varies
:~.:.ording to the amount of stress. In one such test. the subject
fiN has to name the colours of a series of squares (low stress).
:\!then ha\ to name the colours in which the names of other
u11011ll are v.'litten (high stress). The diiTerence between the scores,
n:lk'l:ting the extent by which performance is affected by stress, was
J1min i~hed by smoking. Some tests border on nasty- mindedness,
~u~h as one in which subjects played a complicated logical game
11itb a computer that ini tia ll y played fair and then began to cheat
r.mdom ly, causing stress and aggressio n in the su bjects and a
dtdine in the ir perfonnance. Smoking. it was reported, did not
educe the anger but did reduce the decline in perfonnance.
~icotine and other agoniMs such as epibatidine (Ch. 41) have
gmficant analgesic activity.
Peripheral eHects
Tie peripheral effech of small doses of nicotine result from
\lllllulation of autonomic ganglia (see Ch. 10) and of peripheral
~en-ol) receptors. mainly in the heart and lungs. Stimulation of
lbe-ie receptors elicit!> various autonomic retlex responses, causing
txh}cardJa. mcrcased cardiac output and increased arterial pressure.
mluwon of ga~trointe~tinal motility. and sweating. When people
1111\'ke for the fir~t time, they u~ually experience nausea and
1om~ume\ vomit, probably becau~e of stimulation of sensory
.~eptors in the stomach. All these effects decline with repeated
JNgc. although the cemral effects remain. Secretion of adrenaline
JJ1J noradrenaline from the adrenal medulla contributes to the
,ardiovaseular effects, and release of antidiuretic hormone from
the posterior pituitary cause~ a decrease in urine flow. The plasma
concentration of free fatty acids is increased. probably owing to
sympathetic stimulation and adrenaline secretion.
Smokers weigh, on average. about 4 kg less than non-smokers,
mainly becau e of reduced food intake; giving up smoking usually
causes weight gain associated with increased food intake.
PHARMACOKINETIC ASPECTS
An average cigarette contains about 0.8 g of tobacco and 9-17 mg
of nicotine, of which about 10% is normally absorbed by the smoker.
This fraction varies greatly with the habits of the smoker and the
type of cigarette.
Nicotine in cigarette smoke is rapidly absorbed from the lungs
but poorly from the mouth and nasopharynx. Therefore inhalation is
requi red to give appreciable absorption of nicotine, each puff
de li veli ng a distinct bolus of drug to the CNS. P ipe or cigar smoke
is less acidic than cigarette smoke. and the nicotine tends to be
absorbed from the mouth and nasopharynx rather than the lungs.
Absorption is considerably slower than from inhaled cigarette
smoke, resulting in a later and longer lasting peak in the plasma
nicotine concentration (Fig. 43.5). An average cigarette, smoked
over 10 minutes. causes the plasma nicotine concentration to rise
to 15-30 ng/ml (I 00-200 nmoVI). falling to about half within I0
minutes and then more slowly over the next 1-2 hours. The rapid
decline results mainly from redistribution between the blood and
other tissues; the slower decline is due to hepatic metabolism,
mainly by oxidation to an inactive ketone metabolite, cotinine. This
has a long pla\ma half-life, and measurement of plasma cotinine
concentration provides a lll.eful measure of smoking behaviour.
A nicmine patch applied for 24 hours causes the plasma concen-
tration to ri~e to 75 150 nmol/1 over 6 hours and to remain fairly
constant for about 20 hours. Administration by nasal spray or
chewing gum resu lts in a time course intermediate between that
of smoking and the nicotine patch.

200
s0 Cigarette
E
.s
c
0
~
cQ)
0
c
0
0 100
Cl)
c
~
Fig. 43.5 Nicotine
c:0
concentration in plasma during l
smoking. The subjects were E
en
l
habitual smokers who smoked a a:
c~garette, cigar or pipe according to
their usual habit. (From Bowman W
C, Rand M 1980 Chapter 4. In: 0
Textbook of pharmacology. 0 20 40 60 80 100
Blackwell, Oxford.) Minutes after commencement of smoking
625
 SECTION 4 . THE NERVOUS SYSTEM
TOLERANCE AND DEPENDENCE
As with other dependence-producing drugs, three separate but
related processes-tolerance, physical dependence and psy-
chological dependence-contribute to the overall state of depen-
dence. in which tal.ing the drug becomes compulsive.
The effect'> of nicotine associated with peri pheral ganglionic
stimulation show rapid tolerance, perhap5 as a result of de~ensi
tisation of nAChRs by nicotine. With large doses of nicotine. this
deseusitisation produces a block of ganglionic transmission rather
than stimulation (see Ch. 10). Tolerance to the central effects of
nicotine (e.g. in the arousal response) is much less than in the
periphery. The increase in the number of nicotinic receptors in
the brain produced by chronic nicotine administration in animals
(see above) also occurs in heavy smokers. Because the cellular
effects of nicotine arc diminished, it is possiblc that the additional
binding sites represent desensitised rather than functional receptors.
The addictiveness of smoking is due solely to nicotine. Rats
choose to drink diiULe nicotine solution in preference to water if
given a choice. and in a situation in which lever pressing causes
an injection of nicotine to be delivered. they quickly learn to ~elf
administer it. Similarly, monkeys who have been trained to smoke.
by providing a reward in response to smoking behaviour, will
continue to do so spontaneously (i.e. unrewarded) if the smoking
medium contains nicotine, but not if nicotine-free tobacco is offered
instead. Like other addictive drugs (see above). nicotine causes
excitation of the mesolimbic rC\\.ard pathway and increased
dopamine release in the nucleus accumbcn~. Transgenic mice lack-
ing the ~2 subunit of the acetylcholine receptor lose the rewarding
effect of nicotine and its dopamine-releasing effect, confirming
the role of tl1is nAChR subtype and mesolimbic dopamine release in
t11e response to nicotine. In contrast to normal mice, the mutant mice
could not be induced to self-administer nicotine. e\'en though they
did so with cocaine. Further evidence implicating brain nAChRs
in the addictive property of nicotine come~ from experiments with
mecamylamine, an antagonist at nAChRs. If monkeys arc habitu-
ated to tobacco smoking so that they choose to puff 1.moke in
preference to air. administration of mecamylamine causes them
to switch to puffi ng air instead of smoke.
A physical withdrawal syndrome occurs in both human~ and
experimental animals accustomed to regular nicotine administration.
Its main features arc increased irritabil ity. impaired performance
of psychomotor tasks, aggressiveness and sleep disturbance. The
withdrawal syndrome is much less severe than that produced by
opiates, and it can be alleviated not only by nicotine but also by
amphetamine, a fi nding consistent with the postulated role of
dopamine in the reward pathway. The nicotine withdrawal S) ndrome
lasts for 2-3 weeks, although the craving for cigareues persists for
much longer than this: relapses during attempts to give up cigarette
smoking occur most commonly at a time when the physical
withdrawal syndrome has long since subsided.
HARMFUL EFFECTS OF SMOKING
The life expectancy of smokers is shorter than that of non-smokers.
For example, in a 1971 study of British doctors, the proportion of
626 heavy smokers dying between the ages of 35 and 65 was estimated
th
Pharmacology of nicotine '),l
c,
At a cellular level, nicotine acts on nicotinic I (I
acetylcholine receptors (nAChRs), mainly of the <14 ~ co
subtype, to cause neuronal excitation. Its central 20
effects are blocked by receptor antagonists such as
mecamylamine.
At the behavioural level, nicotine produces a mixture
of inhibitory and excitatory effects.
Nicotine shows reinforcing properties, associated
with increased activity in the mesolimbic
dopaminergic pathway, and self-administration can
be elicited in animal studies. ca
Electroencephalography changes show an arousal II/I
response, and subjects report increased alertness in
accompanied by a reduction of anxiety and tension. thl
Learning, particularly under stress, is facilitated by Cll
nicot1ne.
Peripheral effects of nicotine are due mainly to
ganglionic stimulation: tachycardia, increased blood
pressure and reduced gastrointestinal motility.
Tolerance develops rapidly to these effects. pr
Nicotine is metabolised, mainly in the liver, within IO
1-2 hours. The inactive metabolite, cotinine, has a
long plasma half-life and can be used as a measure is
of smoking habits. l/{l
Nicotine gives rise to tolerance, physical dependence the
and psychological dependence (craving), and is th)
highly addictive. Attempts at long-term cessation pet
succeed in only about 20% of cases. (h)
Nicotine replacement therapy (chewing gum or skin
patch preparations) improves the chances of giving
up smok1ng but only when combined with active
counselling.
ll
(in
25
to be 40%, compared with 15% for non-smokers. For a ree.
am
analysis, sec Peto et al. ( 1996). Smoking is, by a large margin, lh
biggest preventable cause of death, responsible for about I in Par
adult deaths worldwide. Apart from AIDS, smoking is the on nlln- ~
major cause of death that is increasing rapidly. Tn 1990. smob;
was responsible for I 0% (3 mi llion out of 30 million) of dea
worldwide; by 2030, this is expected to increase to 17o/r ( 10 millt.
out of 60 million), mainly due to the growth of smoking in AsL.
Africa and Lat in America (Peto et al., 1999).
The main health risks are as follow.
Cancer, particularly of the lung and upper respiratory traer
but also of the oesophagus, pancreas and bladder. Smokin.
20 cigarettes per day is estimated to increase the ri-,1. of lu
cancer about 10-fold. About 90% of lung cancers are cauo<..
by smoking. Pipe and cigar smoking carry much l es~ risk

than cigarene smoking, although the risk is stiiJ appreciable.
Tar. rather than nicotine. is responsible for the cancer risk.
Coronary heart disease and other forms of peripheral
ra~cular disease. The mortal ity among men aged 55-64 from
coronary thrombosis is about 60% greater in men who smoke
20 cigarettes per day than in non-smokers. Although the
increase in risk is less than it i!> for lung cancer, the actual
number of excess death1> associated with smoking is larger.
because coronary heart disease b '>0 common. Other kinds of
\a..cular disease (e.g. stroke. intermittent claudication and
diabetic gangrene) are also !.trongly 1>moking-related. Many
'ltudie~ have suggested that nicotine is mainly responsible for
the adverse effect of smoking on the incidence of
cardiovascular disease. Another factor may be carbon
IIUIIJOxide (see below). Surprisingly, there is no clear increase
in ischaemic heart disease in pipe and cigar smokers, even
though similar blood nicotine and carboxyhaemoglobin
concentrations are reached, suggesting that nicotine and
carbon monoxide may not be the only causative factors.
Chronic bronchitis. Chronic bronchitis is much more
common in smokers than in non-smokers. Nonetheless. in
contrast to lung cancer, chronic bronchitis has declined in
pre\'alence over the past 50 year!>. This is generally attri buted
to cleaner air and other social changes, and smoking now
appcan to be the most important remaining cause. Its effect
i ~ probably due to tar and other irritants rather than nicotine.
llannful effects in pregnancy. Smoking, particularly during
the latter half of pregnancy, significantly reduces birth weight
(by about 8% in women who smoke 25 or more cigarettes
per day during pregnancy) and increases perinatal mortality
tby an estimated 28% in babies born to mothers who smoke
in the last half of pregnancy). There is evidence that children
bom to smoking mothers remain behind, in both physical and
mental development, for at least 7 years. By I I years of age,
the difference is no longer significant. These effects of
~moking, although measurable, arc much smaller than the
effects of other factors, such as social class and birth order.
Various other complications of pregnancy are also more
common in women who smoke. including spontaneous
abortion (increased 30-70% by !>moki ng). premature delivery
(mcrea.,ed about 40%) and placenta praevia (increased
25 90%). Nicotine is excreted in breast milk in sufficient
ent
amounts to cause tachycardia in the infant.
the
10 Parkinson's disease is approximately twice as common in
nly non-~mokers as in smokers. It is possible that this reflects a
ing protective effect of nicotine. but it could be that common genetic
ths or environmental factors underlie smoking behaviour and sus-
jon ceptibility to Parkinson's disease. Symptoms from inflammatory
>ia. ho~rel disease may be reduced by cigarette smoking. Earlier
reports that Alzheimer's disease is less common in smokers have
not been confirmed.
The agents probably responsible for the harmful effects are as
folio~.
Tar and irritallfs, such as nitrogen dioxide and formaldehyde.
Cigarette smoke tar contains many known carcinogenic
hydrocarbons, as well as tumour promoters, which account
DRUG ADDICTION , DEPENDENCE AND ABUSE
for the high cancer ri!.J... It i!. likely that the variou'> irritant
substance are also responsible for the increase in bronchiti!>
and emphysema.
Nicotine probably accounts for retarded fetal development
because of its vasoconstrictor properties.
Carbon monoxide. The average carbon monoxide content of
cigarette smoke is about 3%. Carbon monoxide has a high
affin ity for haemoglobin, and the average carboxyhaemoglobin
content in the blood of cigarette ~mokers is about 2.51k
(compared with 0.4% for non-'>moking urban dwellers). In
very heavy smokers, up to 15q, of haemoglobin may be
carboxylated, a level that affects feta l development in rats.
This factor may also contribute to the increased incidence of
heart and vascular disease. Fetal haemoglobin has a higher
affinity for carbon monox ide than adult haemoglobin. and the
proportion of carboxyhaemoglobin is higher in fetal than in
maternal blood.
Increased oxidative stress may be responsible for atherogenesi.\'
(Ch. 20) and chronic obstructive lung disease (Ch. 23).
Low-tar cigarettes gi'e a lower yield of bOLh tar and nicotine than
standard cigarettes. However. it has been shown that smoken puff
harder, inhale more, and smoke more cigarettes when low-tar
brands are substituted for standard brands. The end result may be
a slightly reduced intake of tar and nicotine but an increase in
carbon monoxide intake, with no net gain in terms of safety.
PHARMACOLOGICAL APPROACHES TO
TREATMENT OF NICOTINE DEPENDENCE
Most smokers would like to quit. but few succeed.~ The most
successful smoking cure clinics. u!.ing a combination of p\ycho-
logical and pharmacological treatments, achieve a succe!.s rate of
Harmful effects of smoking
Smoking accounts for about 10% of deaths
worldwide, mainly due to:
cancer, especially lung cancer, of which about
90% of cases are smoking-related; carcinogenic
tars are responsible
ischaemic heart disease; both nicotine and carbon
monoxide may be responsible
-chronic bronchitis; tars are mainly responsible.
Smoking in pregnancy reduces birth weight and
retards childhood development. It also increases
abortion rate and perinatal mortality. Nicotine and
possibly carbon monoxide are responsible.
The incidence of Parkinson's disease is lower in
smokers than in non-smokers.
4
Freud tried unsucces;full y to give up cigars for 45 years before dyi ng of
ca ncer of the mouth at the age of 83.
627
 SECTION 4 . THE NERVOUS SYSTEM
about 25%, measured a~ the percentage of patients still abstinent
after I year. The two main pharmacological treatments (sec
George & O'Malley, 2004) are nicotine replacem ent therapy
and bupro pio n (also used to treat depression: see Table 39.2).
icotine replacement therapy is used mainly to assist smokers
to quit by relic' ing the p!.ychological and physical withdrawal
syndrome. Because nicotine is relatively shon-acting and not well
absorbed from the gastrointestinal tract. it is given either in the
form of chewing gum. u~ed several times daily. or as a tnmsdcrmal
patch that is replaced daily. These preparations cause various side
effects, particularly nausea and gastrointestinal cramps. cough,
insomnia and muscle pain~. There is a risk that nicotine may cause
coronary spasm in patients with herut disease. Traosdermal patches
often cause local irritation and itching. The conclusion of many
double-blind trials of nicotine against placebo is that these prep-
arations, combined with professional counselling and supportive
therapy, roughly double the chances of successfully breaking the
smoking habit, but the success rate measured as abstinence I year
after ceasing treatment is still only about 25%. Nicotine on its own.
without counselling and \upport, is no more effective than placebo,
so its u~e a~ an over-the-counter smoking remedy has little justifi-
cation. Although of limited value as an aid w abstinence. the
long-tenn u~ of nicotine can significandy reduce cigarette con-
sumption by smokers. In Sweden. the use of smokeless tobacco' is
encouraged and smoking-related death rate is much lower than
elsewhere in Europe or 1 onh America.
The identification of the aJ~ 2 nAChR subtype as the putative
'nicotine receptor' in the brain may allow selective agonists to be
developed as nicotine !>ubstitutcs ""'ith fewer side effects, but this
remains theoretical at present.
Bupropion (Ch. 39). in recent trials, appears to be as effective
as nicotine replacement therapy. even in non-depressed patients.
and ha~ fewer side effects. However. bupropion lowers the
seizure threshold so shou ld not be prescribed if there are other
risk factors for seitures (including other dmgs that lower seizure
thre!lhold). It is also contraindicated if there is a history of eating
disorders or of bipolar mood disorder. and is used only with
caution in patients with liver or renal disease. Because of these
problems, nicotine remains the pharmacological treatment of
choice in mo~t ca~e~.
Bupropion may act by increa~ing dopamine activity in the
nuclew, accumben~. It is a weak blocker of dopan1ine and
noradrenaline uptake, but it i'> not clear that this accounts for its
efficacy in treating nicotine dependence. It is usually given as a
slow-rclca<,e formulation.
Many other drugs have been tested clinically and shown to be
useful in some ca.,es. They include the following.
Clonidine, an a 2-adrenoceptor agonist (see Ch. II). which
reduces the withdrawal effect!> of several dependence-
producing drugs. including opioids and cocaine. as well as
nicotinc.1 Clonidine may be given orally or as a transdcrmal
~h also reduce~ po<,tmcnopau;a l flushing. which may represent a
628 physiological oc~trogcn withdrawal re:.ponse.
patch. and is about as effective as nicotine substitution in
assisting abstinence. The side effects of clonidine
(hypotension, dry mouth. drowsiness) are troublesome.
however. and it is not widely used.
T ricyclic a ntidepressants, selective serotonin reuptake
inhibitors and mo noamine oxidase inhibitors. u~ed mam
as antidcpre~\ants (Ch. 39). The rationale may be that
dcpres!>ivc epbodes. which often lead to resumption of
smoJ...ing, are prevented.
Mecamyla mine, which antagonises the effects of nicottne.
not promising. Small doses actually increase smoking.
presumably because the antagonism can be overcome by
increa.,ing the amount of nicotine. Larger doses of
mecamylamine, which abolish the effects of nicotine more
effectively, have many autonomic side effects (see Ch. 10),
and compliance is poor. The rationale is questionable
because, a lthoug h mecamylamine reduces the reward effect
of nicotine, it does not affect the craving associated with
abstinence.
A new approach to the treatment of drug dependence. '0 far
applied mainly to nicotine and cocaine, is the development
vaccines (see Bunce et al.. 2003) consisting of the drug mokcu
complcxcd to a protein. Antibodie!> produced in respon""<:
injection of the complex also bind the free drug, there'
preventing it from reaching the brain. This strategy is effeclt\e
animal model!> involving self-administration, and clinical trial
humans arc in progrc!>s.
ETHANOL
Judged on a molar basis, the consumption of elhanol far exceo
that of any other dmg. The ethanol content of various drink" ran1,
from about 2.5% (weak beer) to about 55% (strong spirit~). a
the size of the normal mea!>ure is such that a single drink usuall
contains about 8- l2 g (0. 17-0.26 moles) of ethanol. It is byn
means unusual to consume 1-2 moles at a sitting. equivalent h
about 0.5 kg of most other drugs. l ts low pharmacological poten(.
is reflected in the range of plasma concentrations needed to prod111.
pham1acological effects: minimal effects occur at about I0 mmn
(46 mg/1 00 ml), and I 0 time& this concentration may be leth
The average per capita ethanol consumption in European countne<
is about I 0 litre~year (expre!>~ed as pure ethanol), a figure tit:
ha~ changed little over the past 20 years, the main change ha11
been a growing consumption of wine in preference to beer
For practical purposes, ethanol intake is often expres<;ed
term~ of unit'>. One unit is equal to 8 g (I 0 mJ) of ethanol. and
the amount contained in half a pint of normal strength lx'er,
mca~ure of !>pirits or one small glao;s of wine. Based on the he;
risk~ described below, the current official recommendation 11
maximum of 21 units/week for men and 14 units/week for womct
It b estimated that in the UK, about 33% of men and 131J'
women exceed these levels. The annual tax revenue from dn
amount!> to about 7 bi II ion. whereas the health cost is estimat'
at 3 billion. and the social cost undoubtedly greater. Government
in rno!>l developed countries arc attempting to curb alcooo
consumption.

PHARMACOLOGICAL EFFECTS OF ETHANOL
EHects on the central nervous system
T'le main effect<; of ethanol arc on the CNS (see review by Chamess
ttal.. 1989), where its depressant actions resemble those of volatile
aM,thetic~ (Ch. 36). At a cellular level. the effect of ethanol
b pure!) dcprc.,.,ant, although it increases neuronal activi!)'-
pre,umabl) by di'>inhibition- in l>Omc parts of the CNS. notably
mthe mc'>olimbic dopaminergic neurons that are involved in the
1\ reward pathway described above. The main theories of ethanol
action (sec reviews by Liule, 1991; Lovinger. 1997; Tabakoff &
Huffman, 1996) are:
o enhancement of GABA-mcdiated inhibition, similar to the
action of bcnzodiazepines (sec Ch. 37)
o inhibition of Cah entry through voltage-gated calcium channels
o mhibition of NMDA receptor function
o inhibition of adenosine transport.
Fthanol enhances the action of GABA acting on GABAA receptors
10 a 'imilar way to benzodiazepincs (sec Ch. 37). Its effect is,
far
bllllever, \maller and lesc, consistent than that of benzodiazepincs,
of
l!l1d no clear effect on inhibitory synaptic transmission in the CNS
ulc
h;t, lx-en demonwatcd for ethanol. The beruodiazepine antagonist
to
numazenil ('>ce Ch. 37) reverses the central depressant actions of
eb)
ethanol, but thi-. appear' to re,ult from physiological antagonism
rather than from a direct pharmacological interaction. The use of
rlumazcnil to rcvcr\e ethanol intoxication and treat dependence
Ill' not found favour for several reasons. Because flumazenil is
.m 10\l!f\C agonist (see Ch. 2) at ben7odiazepine receptors. it carries
101~ of causing -.ei7ures, and it could cause an increase in et:hanol
CllO\Umption and thus increase long-term toxic manifestations.
~d., Ethanol inhibih tran-.mitter release in response to nerve terminal
gc" .!.:polarisation by inhibiting the opening of voltage-sensitive calcium
md channels in neurons.
ully The excitatory effects of glutamate arc inhibited by ethanol at
no concentrations that produce CNS depressant effects in vivo. NMDA
,t to receptor activation is inhibited at lower ethanol concentrations
!ncy than are required to affect AMPA receptors (see Ch. 34). Other
Jucc effect~ produced by ethanol include an enhancement of the
nol/1 mitatory effects produced by activation of nAChRs and 5-HT3
,hal. ri.'Ceptors. The relative importance of these various effects in the
trie" 01erall effect'> of ethanol on C S function is not clear at present.
that The depressant effects of ethanol on neuronal function resemble
1ing tho'e of adenosine acting on A 1-receptors (see Ch. 12). Ethanol
11etll culture systems increases extracellular adenosine by inhibiting
::l in ~eno,me uptake, and there is some evidence that inhibition of
id j-, !be adeno'>ine tr..tnsporter may account for some of irs CNS effecL<>
one \lelendeL & Kalivas, 2004).
alth Endogenous opioids also play a role in the CNS effects of ethanol,
IS a ~':lU\C both human and animal studies show that the opioid recep-
nen. :or antagonist na ltrexone reduces the reward associated with
~ of ethanol.
rink The effects of acute ethanol intoxication in humans are well
lltcd known and include 11lu rred speech, motor incoordination, increased
ent" ~elf-confidence and euphoria. The effect on mood varies among
)hoi Individuals, most becoming louder and more outgoing, but some
becoming morose and withdrawn. At higher levels of intoxication,
DRUG ADDICTION, DEPENDENCE AND ABUSE
the mood tends to become highly labile. with euphoria and melan-
choly, aggression and submi~sion. often occurring successively. The
association between alcohol and violence is well documented.
Intellectual and motor performance and sensory discrimination
sho11 uniform impairment by ethanol. but subjects are generally
unable to judge this for themselves. For example. bus dri1ers were
asked to drive through a gap that they selected as the minimum
for their bus to pass through: ethanol caused them not only to hit
the barrier' more often at any given gap l>etting. but also to set the
gap to a narrower dimension, often narrower than the bus.
Much effort ha~ gone into measuring the effect of ethanol on
driving performance in real life. as opposed to artificial tests under
experimental conditions. In an American study of city drivers, it
was found that the probability of being involved in an accident was
unaffected at blood ethano l concentrations up to 50 mg/ 100 ml
(I 0.9 mmol/1); by 80 mg/1 00 ml ( 17.4 mmol/1), the probability was
increased about fourfold, and by 150 mg/100 mJ (32.6 mmol/1)
about 25-fold. In the UK, driving with a blood ethanol concen-
tration greater than 80 mg/100 ml constitutes a legal offence.
The rclation~hip between pla~ma ethanol concentration and
effect is highly variable. A given concentration produces a larger
effect when the concentration is rising than when it is steady or
falling. A subMantial degree of tissue tolerance develops in habitual
drinker\, with the re~ult that a higher plasma ethanol concen-
tmtion i'> needed to produce a given effect (see below). In one study,
gro'>!> intoxication' (a~~es~ed by a battery of tests that measured
speech. gait and so on) occurred in 30% of subjects between
50 and I 00 mgt I00 ml and in 90% of subjects with more than
150 mg/100 mi. Coma generally occurs at about 400 mg/100 ml,
and death from re'>piratory failure is likely at leveb exceeding
500 mg/100 mi.
In addition to the acute effects of ethanol on the nervous system,
chronic administration also causes irreversible neurological effects
(see Harper & Matsumoto, 2005). These may be due to ethanol
itself, or to metabolites such as acetaldehyde or fatty acid esters.
The majority of heavy drinkers develop irreversible dementia and
motor impairment associated with thinning of the cerebral cortex
(apparent as ventricular en largement) detectable by brain-
imaging techniques. Degeneration in the cerebellum and other
specific brain regions can also occur, as well as peripheral
neuropathy. Some of these changes are not due to ethanol itself
but to accompanying thiamine deficiency, which is common in
alcoholics.
Ethanol significantly enhances-sometimes to a dangerous
extent the CNS depres\ant effecL<> of many other drugs, including
benzodiazepines, antidepressants. antipsychotic drugs and opiate\.
EHects on other systems
The main acute cardiovascular effect of ethanol is to produce
cutaneou\ va.,odilatation. central in origin, which causes a warm
feeling but actually increa~es heat loss. Paradoxically, there is a
positive correlation between ethanol consumption and hypertension,
possibly bccau;,c ethanol withdrawal causes increased sympathetic
activity. The beneficial effect of moderate drinking on cardio-
vascular function is discussed below.
Ethano l increa!>es salivary and gastric secretion. This is partly
a retlex effect produced by the taste and irritant action of ethanol. 629
 SECTION 4 . THE NERVOUS SYSTEM
However, heavy consumption of spiri~ causes damage directly to
the ga!>tric mucosa, caw.ing chronic gastritis. Both this and the
incrca~ed acid ~ecretion are factors in the high incidence of gastric
bleeding in alcoholic\.
Ethanol produce~ a variety of endocrine effec~. In panieular,
it increa..es the output of adrenal Meroid hormones by stimulating
the anterior pituitary gland to ~rete adrenocorticoll'Ophic hom1one.
However, the increase in plasma hydrocortisone usually seen in
alcoholics (producing a 'pseudo-Cushing's syndrome'; Ch. 28) is
due partly to inhibition by ethanol of hydrocortisone metabolism
in the liver.
Diure!>i'> is a familiar effect of ethanol. It is caused by inhibition
of antidiuretic hormone secretion, and tolerance develops rapidly,
so that the diurcsi~> is not sustained. There is a similar inhibition
of oxytocin secretion, which can delay parturition. Attempts have
been made to use this effect in premature labour, but the dose
needed is large enough to cause obvious drunkenness in the mother.
If the baby is born prematurely despite the ethanol, it too may be
intoxicated at birth, sufficiently for respiration to be depressed.
The procedure evidently has serious disadvantages.
Chronic male alcoholics are often impotent and show signs of
feminisation. This is associated with impaired testicular steroid
symhesi<., but induction of hepatic microsomal enzymes by ethanol,
and hence an increa~ed rate of testosterone inactivation. also
contribute<..
EHects of ethanol on the liver
Together with brain damage, liver damage is the most serious
long-term con\equence of excessive ethanol consumption (see
Lieber, 1995). In the \equence of effects. increased fat accumulation
(fauy liver) progresse!. to hepatitis (i.e. inflan1mation of the liver)
and eventually to irrever!.ible hepatic necrosis and fibrosis. Diver-
sion of portal blood fl ow around the fibrotic liver often causes
oesophageal varices to develop, which can bleed suddenly and
cata:,trophically. Increased fat accumulation in the liver occurs,
in rats or in humans, after u single large dose of ethanol. The
mechanism is complex, the main fuctors being:
increased release of fatty acids from adipose tissue, which is
the result of increased stress, causing sympathetic discharge
impaired fatty acid oxidation, because of the metabolic load
imposed by the ethanol itself.
With chronic ethanol con~umption, many other factors contribute
to the liver damage. One is malnutrition, for alcoholic individuals
may sati-.fy much of their calorie requirement from ethanol itself.
Three hundred granlS of ethanol (equivalent to one bottle of whisky)
provide!. about 2000 kcal but, unlike a normal diet. it provides no
vitamins. amino acids or fatty acids. Thiamine deficiency is an
important factor in causing chronic neurological dan1age (see
above). The hepatic changes occurring in alcoholics are partly due
to chronic malnutrition but mainly to the cellular toxicity of ethanol,
which promote!> inflammatory changes in the liver.
The overall incidence of chronic liver disease is a function of
cumulative ethanol consumption over many years. Therefore
overall consumption, expressed as g/kg of body weight per day
multiplied by years of drinking, provides an accurate predictor
630 of the incidence of cirrhosis. An increase in the plasma
concentration of the liver enzyme y-glutamyl transpcptida~ IS
provides an index of liver damage, although not specific to ethanv
EHects on lipid metabolism, platelet function
and atherosclerosis
Moderate drinking reduces mortality associated with coronJI)
heart di\ease. the maximum effect- about 30% reduction L
mortality overall-being achieved at a level of 2-3 unitvu..
(sec Grocnbaek et al., 1994). The effect is much more pronOU!ll.'t<
(> SO% reduction) in men with high plasma concentration\ d
l ow-dcn ~ity lipoprotein cholesterol (sec Ch. 20). 6 Most e'iden,,
suggeMs that ethanol. rather th:m any speci fie beverage, such 61
red wine, is the essential factor.
Two mechanisms have been proposed. The first involves the
effect of ethanol on the plasma lipoproteins that are the carrier
molecules for cholesterol and other lipids in the bloodstream
(see Ch. 20). Epidemiological studies, as well as studies on
volunteers, have shown that ethanol, in daily doses too small
to produce obvious CNS effects, can over the course of a fe~
wecl,s increase plasma high-density lipoprotein concentrauo
thus exerting a protective effect against atheroma formation.
Ethanol may also protect against iscbaemic heart di3Ca\e b)
inhibiting platelet aggregation. This effect occurs at ethanol concen-
trations in the range achieved by normal drinking in hum:m
(I 0-20 mmoVl) and probably re:.ults from inhibition of arachidonit
acid formation from phospholipid. In humans, the magnitudeof
the effect depends critically on dietary fat intake, and it is not yet
clear how important it is clinically.
The eHect of ethanol on fetal development
The adverse effect of ethanol consumption during pregnane) oa
fetal development wa& demonstrated in the early 1970s, when the
term fetal alcohol syndrome (FAS) was coined.
The features of full FAS include:
abnormal facial development, with wide-set eyes, short
palpebral fissures and small cheekbones
reduced cranial circumference
retarded growth
mental retardation and behavioural abnormalities, often taking
the form of hyperactivity and difficulty with social integration
other anatomical abnormalities, which may be major or minor
(e.g. congenital cardiac abnormalities, malformation of the
eyes and ears).
A lesser degree of impairment. termed alcohol-relm
neurode1e/opmenta/ disorder (ARND), results in beha\iour:
problems, and cognitive and motor deficits. often associated \lilh
reduced brain size. Full FAS occurs in about 3 per 1000 111~
births and affects about 30% of children born w alcoholic motht
Tt is rare with mothers who drink less than about 5 units/da}. aoo
most common in 'binge drinkers' who sporadically consume mlli.
larger amounts. resulting in high peak levels of ethanol. AR\D
lrfhis beneficial effect of moderate drinking outweighs the ri sk of adver~e
effect~ (e.g. acciden t~. cancers, liver damage) only in men over 45 and
women over 55.

~about three times as common. Although there is no clearly
dehned ,afe thre~hold, there is no evidence that amounts Jess than
about 2 unillJday are hannful. There is no critical period during
pt'g11ill1Cy \\hen ethanol con!-.umption is likely to lead to FAS,
ahhough one '>tudy '>ugge~L'> that FAS incidence correlates most
strong!} wuh ethanol consumption very early in pregnancy, even
before pregnancy is recogni!>ed. implying that not only pregnant
v.01111:n. but abo \\.Omen who are likely to become pregnant. must
be ;}(hi..ed not to drink heavily. Experiments on rats and mice
~ugge't that the effect on facial development may be produced
hce \Cl} early in pregnancy (up to 4 weeks in humans). while the effect
a!\ llll ~rain development is produced rather later (up to I 0 weeks).
Other adve~e effect!. of chronic ethanol consumption include
the ga,tritis, associated with increased acid secretion and the direct
rier antant effect of ethanol; immunosuppression, leading to increased
mcidencc of infections such as pneumonia; and increased cancer
mk. particularly of the mouth, larynx and oesophagus.
on.
ltfecta of ethanol
b)
en- Ethanol consumption is generally expressed in
... units of 10 ml (8 g) of pure ethanol. Per capita
mic consumption in Europe is about 10 Vyear.
of Ethanol acts as a general central nervous system
)l!t depressant, similar to volatile anaesthetic agents,
producing the familiar effects of acute intoxication.
Several cellular mechanisms are postulated: inhibition
of calcium channel opening, enhancement of GABA
on action, and inhibitory action at NMDA-type glutamate
the receptors.
Effective plasma concentrations:
threshold effects: about 40 mg/1 00 ml (5 mmol/1)
- severe intoxication: about 150 mg/1 00 ml
- death from respiratory failure: about 500 mg/1 00 mi.
Main peripheral effects are self- limiting diuresis
(reduced antidiuretic hormone secretion), cutaneous
vasodilatation, and delayed labour (reduced oxytocin
secretion).
Neurological degeneration occurs in heavy drinkers,
r
caus1ng dementia and peripheral neuropathies.
Long-term ethanol consumption causes liver disease,
progressing to cirrhosis and liver failure.
ted Moderate ethanol consumption has a protective
)ral effect against ischaemic heart disease.
ith Excessive consumption in pregnancy causes
live impaired fetal development, associated with small
ers. size, abnormal facial development and other physical
and abnormalities, and mental retardation.
uch Tolerance, physical dependence and psychological
ND dependence all occur with ethanol.
Drugs used to treat alcohol dependence include
diSUlfiram (aldehyde dehydrogenase inhibitor),
naltrexone (opiate antagonist) and acamprosat e
e
(NMDA receptor antagonist).
DRUG ADDICTION, DEPENDENCE AND ABUSE
PHARMACOKINETIC ASPECTS
Metabolism of ethanol
Ethanol i., rapidly absorbed. an appreciable amount being
absorbed from the stomach. A substantial fraction is cleared by
first-pass hepatic metabolism. Hepatic metabolism of ethanol
shows saturation 1-.inetic<, (see Ch. 8) at quite low ethanol
concentrations, o the fraction of ethanol removed decreases as
the concentration reaching the liver increases. Thus. if ethanol
absorption i. rapid and portal vein concentration is high, most of
the ethanol escapes into the systemic circulation. whereas with
slow absorption more is removed by first-pass metabolism. This
is one reason why drinking ethanol on an empty stomach
produces a much greater pharmacological effect. Ethanol is
quickly distributed throughout the body water, the rate of its
redistribution depending mainly on the blood flow to individual
ti ssues, as with volatile anaesthetics (see Ch. 36).
Ethanol is about 90% metabolised. 5-10% being excreted
unchanged in expired air and in urine. This fraction is not
phamlacokinctically significant but provides the basis for estimating
blood ethanol concentration from measurements on breath or
urine. The rmio of ethanol concentrations in blood and alveolar
air, mea~ured at the end of deep expiration, is relatively constant,
80 mg/100 ml of ethanol in blood producing 35 !Lg/100 ml in
expired air, this being the basi~ of the breathalyser test. The concen-
tration in urine is more variable and provides a le s accurate measure
of blood concentration.
Ethanol metabolism occurs alrno!>t entirely in the liver, and mainly
by a pathway involving successive oxidations, first to acetaldehyde
and then to acetic acid (Fig. 43.6). Since ethanol is often consumed
in large quantities (compared with most drugs), l-2 moles daily
being by no means unusual. it constillltes a substantial load on
the hepatic oxidative systems. The oxidation of 2 moles of ethanol
consumes about I .5 kg or the cofactor nicotinamide adenine
dinucleotide (NAD+). Availability ofNAD+ limits the rate of ethanol
oxidation to about 8 g/hour in a normal adult, independently of
ethanol concentration (Fig. 43.7), causing the process to show
saturating kinetics (Ch. 8). ll also leads to competition between
the ethanol and other metabolic substrates for the available NAD+
supplies, which may be a factor in ethanol-induced liver damage
(see Ch. 53). The intermediate metabolite, acetaldehyde, is a reactive
and toxic compound, and this may also contribute to the
hepatotoxicity. A small degree of esterification of ethanol with
various fatty acids abo occurs in the tissues, and these esters may
also contribute to long-term toxicity.
Alcohol dehydrogenase is a soluble cytoplasmic entyme.
confined mainly to liver cells. which oxidises ethanol at the same
time as reducing NAD.. to NADH (Fig. 43.6). Ethanol metabolism
causes the ratio of AD to 'ADH to fall. and this has other
metabolic con equences (e.g. increased lactate and slowing down
of the Kreb~ cycle). The limitation on ethanol metabolism imposed
by the limited rate of NAD+ regeneration has led to a11empts to
find a 'sobering up' agent that works by regenerating NAD+ from
NADH. One such agent is fructose, which is reduced by an
NADH-requiring enzyme. Ln large doses. it causes a measurable
increase in the rate of ethanol metabolism, but not enough to
have a useful effect on the rate of return to sobriety. 631
 SECTION 4 . THE NERVOUS SYSTEM

NAD'

Aldehyde oxidase
/

MAINLY EXTRA-HEPATIC

Fig. 43.6 Metabolism of

ethanol. NAD, nicotinamide adenine
dinucleotide.

Nearly all the acetaldehyde produced is converted to acewte

100~----r-----~---------,
~ acetaldehyde concentration of20-50 J.lmol/1 after an intoxicaun.
E
.sc
Q has little or no effect. but the concentration may become muc
~c
g 50
8 as d isulfiram . In the presence of disulfiram, which produces no
g marked effect when given alone. ethanol consumption is follo\\cu
"'
J:
Qi
8ffi
4 8 12 16
Hours
Fig. 4 3.7 Zero-order kinetics of ethanol elimination in
rats. Rats were given ethanol orally (1 04 mmol/kg) either as a
single dose or as four divided doses. The single dose results in
a much higher and more sustained blood ethanol
concentration than the same quantity given as divided doses.
Note that, after the single dose, ethanol concentration declines
linearly, the rate of decline being similar after a small or large
dose, because of the saturation phenomenon. (From Kalant H
et al. 1975 Biochem Pharmacol24: 431.)
Normally. only a small amount of ethanol is metabolised by
the microsomal mixed function oxidase system (see Ch. 8), but
induction of this sy:.tem occur:; in alcoholics. Ethanol can affect
the metabolism of other drugs that are metabolised by the mixed
function oxidase system (e.g. phenobarbitone, warfari n and
steroids), with an inilial inhibitory effect produced by com-
632 petition, followed by enh<mcement due to enzyme induction.
in the liver by aldehyde dehydrogenase (Fig. 43.6). Normall).
only a little acetaldehyde escapes from the liver. giving a blool
dose of ethanol in humans. The circulating acetaldehyde u~ual
larger under certain circumstances and produce toxic ctlc~t>
This occurs if aldehyde dehydrogenase is inhibited by drugs SUl~
p
u
by a severe reaction comprising flushing, tachycardia, hyper II
ventilation. and con1>idcrable panic and distress, which is due It n
excessive acetaldehyde accumulation in the bloodstream. Th1
II
reaction is extremely unpleasant but not harmful, and disu lfirJOI
can be used as aversion therapy to discourage people from taking
ethanol. Some other drugs (e.g. metronid azole; sec Ch.46
"
p
produce similar reactions to ethanol. IJllcrestingly, a Chinese herb.
p
medicine. used traditionally to cure alcoholics, contains daid7in
d
a specific inhibitor of aldehyde dehydrogenase. In hamqer (I
(which spontaneously consume alcohol in amounts that \\OU h
defeat even the hardest two-legged drinker. while remaining. 0
far as one can tell in a hamster. completely sober), daidLin marl.edh
inhibit'> alcohol con~umption.
TO
Genetic factors Tole
In 50% of A~ian people. an inactive genetic variant of one ofltt both
aldehyde dehydrogcn~e isoforms (ALDH-2) is expressed: thN to tl
individuals experience a disulfiram-like reaction after alcoht cnnt
and the incidence of alcoholism in this group is extreme!) lo duct
(sec Tanaka et al., 1997: Tyndale. 2003).
M etabolism and toxicity of methanol
T Methanol i~ mctabolbed in the same way as ethanol but prod111
formuldchydc i n~tead of acetaldehyde from the first oxidation 11

Metabolism of ethanol
Ethanol 1s metabolised mainly by the liver, first
by alcohol dehydrogenase to acetaldehyde, then by
aldehyde dehydrogenase to acetate. About 25% of
the acetaldehyde is metabolised extrahepatically.
Small amounts of ethanol are excreted in urine and
expired air. Hepatic metabolism shows saturation
kinetics, mainly because of limited availability of
nicotinamide adenine dinucleotide (NAD+). Maximal
rate of ethanol metabolism is about 1 0 ml/hour. Thus
plasma concentration falls linearly rather than
exponentially.
Acetaldehyde may produce toxic effects. Inhibition of
aldehyde dehydrogenase by disulfiram accentuates
nausea, etc., caused by acetaldehyd e, and can be
used in aversion therapy.
Methanol is similarly metabolised to formic acid,
which is toxic, especially to retina.
Asian people show a high rate of genetic
polymorphism of alcohol and aldehyde
dehydrogenase, assoc1ated with alcoholism and
alcohol intolerance, respectively.
!!>.
h Fom1aldehyde io, more rcacti\e than acetaldehyde and reacts rapidly with
protemo,. cauMng the macuv:nion of enzymes involved in the tricarboxylic
0 'delirium tremens' develops. in which the patient becomes confused.
actd cycle. It b convened to another toxic metabolite. fom1ic acid. This.
id unhb.e acetic acid. cannot be ut i l i~cd i n the tricarboxylic acid cycle and i~
r- hable to cuu ~e ti!.o,uc damage. Conver,ion of alcohols to aldehydes occurs
,o not only in the l iver bu t also i n the reti na. catalysed by the dehydrogenase
re>pon>iblc for reti nol- retinal conversion. Formnti on of fonnaldehyde in
is
the retina :u.:cnunt o, for one o f the muin toxic effects of methanol. namel y
m A lcohol dependence ('alcohol ism') is common (4-5% of the
blindne'' wh ich can occur nftcr i ngc~tion of a, little as I 0 g. Form ic acid
g pmduction and derangeme nt of the tricarboxy lic ac id cyc le also produce
>) >~:>ere ac itlo~ i ~. M ethanol io, U\Cd o~ an i ndusrrial sol vent and also to
uduhcrute i ndu~trial ethanol i n order to make it unfit to drink. M ethanol
po1,onmg i' quite common. and it i~ tremed by admi ni;tration of large
dl~ of ethanol. which (ICb to retard methanol metabolism by competition
or alcohol dchydrogcna,c. Thio, is often done in conjunction with
haemodial)\i\ to rcmO\C unch:tngcd methanol. which has a small volume
of Ul\tnbution.
TOLERANCE AND DEPENDENCE
Tolerance to the effec t ~ of ethanol can be demonstrated in
both humans and experimental animal s, to the extent of a two-
to threefold reduction in potency occurring over 1-3 weeks of
.:ontmuing ethanol administration. A small component of this is
due to the more rapid elimination of ethanol. The maj or component
I> li,sue tolerance, which accounts for a roughly twofold decrease
mpotency and which can be observed in vitro (e.g. by measuring
the inhibitory effect of ethanol on transmitter release from
~)naptosomes) as well a~ in vivo. The mechanism of this tolerance
~ 633
11 not known for certain (sec Little, 199 1). Ethanol tolerance is
DRUG ADDICTION, DEPENDENCE AND ABUSE
associated with tolerance to many <macsthctic agents, and alcoholics
arc often di ffic ult to anac~thcti sc with dmgs such as halothane.
Chronic ethanol administration produces various changes in
C S neuron ~. which tend to oppose the acute cellular effects
that it produces hce above). There is a small reduction in the
den!>ity of GABA, receptor.., and a proliferation of vol tage-gated
calcium channels and 1 MDA receptors. T he effect on calci um
channel s has received part icular attention (see Chames:. et al..
1989). The acute effect of ethanol (~ee above) is to reduce Ca 2
entry through voltage-gated calcium channel s. and thus to reduce
transmitter release. During chronic exposure to ethanol, Ca2+
entry recover~ owing to a proliferation of calcium channels, ru1d
when ethanol i~ withdrawn depolarisation-evoked Ca2+ entry and
tran smitter release arc increased above normal, which is possibly
associated with the physical withdrawal symptoms. Consistent
with thi s explanation, calcium channel- blocking dmgs of the
dihydropyridine type (sec Ch. 19) reduce the effects of cth<mol
withdrawal in experimental animals (see Little, 1991).
A well-defined physical abstinence syndrome devel ops in
response to ethanol withdrawal. A s with most other dependence-
producing drugs. this is probably important as a short-term factor
in sustaining the drug habit. but other (mainly psychological)
factors are more important in the longer term. The physical
abstinence syndrome usually subsides in a few days, but the
craving for ethanol and the tendency to relapse last for very much
longer.
The phy.,ical abstinence syndrome in humans. in severe form.
developl> after about 8 hours. l n d1e first stage, the main symptoms
are tremor, nau\ca, c;wcating, fever. and sometimes hallucinations.
These last for about 24 hours. This phase may be f ollowed by
seizures ('rum fi ts'). Over the next few days, the condition of
agitated and often aggressive, and may suffer much more severe
hallucinations. A similar syndrome of central and autonomic
hyperacti vity can be produced in experimental animals by ethanol
withdrawal.
population) and. as with smoking, difficul t to treat effectively.
The main pharmacological approaches (sec Zemig ct al.. 1997:
Table 43.2) are the following.
To alleviate the acute abstinence syndrome during 'drying
out'. benzodiazepines (sec Ch. 37) are effective: clonidine
and propr anolol arc also useful. Clonidine (aradrenoceptor
agonist) is believed to act by inhibiting the exaggerated
transmitter release that occurs during withdrawal, while
propranolol (~-ndrenoceptor antagonist) blocks some of the
effects of excessive sympathetic activity.
To render alcohol consumption unpleasant. disulfiram
(sec above).
To reduce alcohol-induced reward, naltrexone (see above) is
effecti ve.
To reduce craving, acamprosat e is used. This taurine
analogue is a weak antagonist at NMDA receptors, and may
work by interfering in some way with synaptic plasticity.
Seventl clinical trial s have shown it to improve the success
rate in achieving alcohol abstinence, with few unwan ted effects.
 SECTION 4 . THE NERVOUS SYSTEM
CANNABIS
Extracts of the hemp plant. Cannabis satim. which grows freely
in temperate and tropical regions. contain the active substance
6 9 -tetrahydrocannabinol (THC; Fig. 43.8). Marijuana is the name
given to the dried leaves and flower heads. prepared as a smoking
mixture; ha~hi'>h is the extracted resin. For centuries. these sub-
stances have been used for various medicinal purposes and as
intoxicant preparations. Marijuana was brought to North America
by immigrants. mainly in the 19th century. and began to be regarded
as a social problem in the early years of the 20th century; it was
banned during the 1930'>. ft s use increased dramatically in the
1 960~. and recent figures suggest that about 15% of the adult
population in America and Western Europe have taken cannabis
at some time, with a much higher proportion (close to 50%) among
teenagers and young adults. A good scientific account is given by
Iversen & Snyder (2000).
CHEMICAL ASPECTS
Cannabis extract~ contain numerous related compounds. called
cannabinoid-., most of which arc insoluble in water. The most
abundant cannabinoids are THC, its precuror cannabidiol and
cannabinol. which is formed spontaneously from THC. THC is
the most active pharmacologically and also the most abundant.
constituting roughly I- lOCK by weight of marijuana and hashish
preparations. A metabolite, I 1-hydroxy-THC, is more active than
THC i!'>elf and probably contributes to the pharmacological
effect. Radioimmunoassays have been developed for cannabinoids,
but they lad. sufficient chemical specificity to be able to distinguish
TIIC from numerous other cannabinoids found in crude extracts,
and from the various metabolites that are formed in vivo. Therefore
the assay of pharmacologically active THC in biological fluids
still presents a problem.
Cannabinol Anandamide
(inactive) (endogenous agonist)
Fig. 4 3 .8 Structure of cannabinoids. Anandamide is an
arachidonic acid derivative that is present in the brain and
, believed to be an endogenous agonist tor cannabinoid receptors.
634
PHARMACOLOGICAL EFFECTS As
6 9 -Tetrahydrocannabinol acts on cannabinoid CB 1-receptoo
(Ch. 15), which are widely distributed in the brain, producing
mixture of psychOLomimetic and depressant effects (see lwM
2003). together\\ ith variou~ centrally mediated peripheral ..ut
nomic effects. CB 1-receptors are typical G-protcin-coupl
receptors (see Ch.3 ). linked to inhibition of adenylyl cycla\l!.llr
receptors are abo coupled to potassium channel activation
calcium channel inhibition. and thereby exert an inhibit<X)
effect on transmitter release. These cellular effects closely re'l!mbl:
those of opioids. CB 1-reccptors arc abundant in the hippocampu
(memory impairment), cerebellum and substantia nigra (molt
disturbance), and mesolimbic dopamine pathways (reward),
well as in the cortex.
The main s ubjective effects in humans consist of:
a fee ling of relaxation and well-being, similar to the effect of
ethanol but without the accompanying aggression
a feeling of sharpened sensory awareness, with sounds and
sights seeming more intense and fantastic.
These effects are similar to but usually less pronounced than lh<R
produced by p!.ychotomimetic drugs such as LSD (!.ee CU1
Subject!. report that time passes extremely slowly. The frighten
sensation~ and paranoid delusions that often occur with L~D
occur rarely and only after high doses of cannabis.
Central effects that can be directly measured in human 11M
animal studies include:
impairment of 11hort-term memory and simple learning
tasks-subjective feelings of confidence and heightened
creativity are not retlected in actual performance
impairment of motor coordination (e.g. driving perfonnanw
catal ep~y-the retention of fixed unnatural postures, seen
with large doses of cannabis in animals
analge!>ia
antiemetic action
increased appetite.
The rna in peripheral effects of cannabis arc:
tachycardia, which can be prevented by drugs that block
sympathetic transmission
vasodi latation. which is particularly marked on the scleral
and conjunctival ve%els, producing a bloodshot appearance
characteristic of cannabis smokers
reduction of intraocular pres:sure
bronchodilatation.
A potent CB 1-receptor antagonist. SRI41716A. produces ellc..
opposite to those of cannabinoid agonists. namely increa...;
locomotor activity and improved short-term memory, as Y.Clltl
enhanced tran~mitter release in peripheral tissues. implying a~
of tonic activation of CB 1-receptors under physiological conditilXli
The effects of cannabis on intraocular pressure, bronchial sm\'~t
muscle, pain perception and the vomiting reflex are of potent1
therapeulic value. and certain cannabinoid derivatives, for exampl
na bilonc. have been developed as therapeutic agents. The pro
nounced central effects produced by these compounds, includin,
their possible add ictive properties (see below), limit their usefulne"

\' UJCI\! i~ lillie evidence for 1-ubtypes of the CB1-receptor-which
:night offer the possibility of developing ligand\ with more selective
:xnual effecl\-lherapeutic developments on this front are
1g a currently \tailed.
sen. A 'econd cannabinoid receptor subtype, CB2. occurs mainly
mcells of the immune system, controlling cell migration and
cytof..i nc release. Its importance as a factor in the effects ofTHC
and other cannabinoid.<. i ~ not clear.
OJ]
1ble TOLERANCE AND DEPENDENCE
pus Tolerance to cannabis, and physical dependence, occur to only a
)tor mmor degree and maioly in heavy users. The abstinence .<.ymptom~
3re 'imilar to those of ethanol or opiate withdrawal. namely nausea.
agllation, initability, confu~ion, tachycardia, sweating, etc., but are
relauvely mild and do not result in a compulsive urge to take the
tlrug. Psychological dependence, accompanied by craving. does.
of
ho\\e\er. occur to some extent with cannabis, although it is
m-ufficicnt to classify cannabis as truly addictive. Self-admin-
>tration doe' not occur in animal models, although the CB1-reccptor
Jntagonist rimonabant given after treatment with cannabis for a
sc
fewdays induces a withdrawal syndrome in rats similar to opiate
2 ).
'I.Ithdra\\ al.
mg
so
PHARMACOKINETIC ASPECTS
The effec t of cannabis. taken by smoking or by intravenous
injection, takes about I hour to develop fu lly and lasts for 2-3
hours. 1\ small fraction is convened to 11-hydroxy-THC. which
,more active than THC it\clf, but most is convened to inactive
metabolites. II is partly conjugated and undergoes enterohcpatic
recirculation. Being highJy lipophilic, TliC and its metabolites
Jre seque~tcred in body fat, and excretion continues for several
d:l)' after a single dose.
ADVERSE EFFECTS
In overdose. TIIC is relatively safe, producing drowsiness and con-
flliion but not respiratory or cardiovascular effects that threaten life.
In this re~pect, it il> safer than most abused ~ub\tances, particularly
~tatcs and ethanol. Even in low doses, THC and synthetic deriva-
h\C~ such as nabilone produce euphoria and drowsiness, sometimes
JCcompanied by sensory distortion and hallucinations. The risJ.. of
rood accident~ i~ significantly increac;ed by recent use of cannabi<>.
In rodent~. THC produce!> teratogenic and mutagenic effects,
and an increased incidence of chromosome breaks in circulating
ts white cells has been reported in humans. Such breaks arc,
ho\\ever. by no means unique to cannabis, and epidemiological
..tudies have not shown any increased risk of fetaJ malformation
or cancer among cannabis u~ers.
Cenain endocrine effects occur in humans, notably a decrease
mplasma testosterone and a reduction of sperm count. One &~ udy
'howed a reduction of more than 50% in both plasma testosterone
and sperm count in subjects smoking 10 or more marijuana cigarenes
per 1\'eek.
Recently, major concern has arisen about the risk of long-tenn
neurological and psychological disturbances resulting from
DRUG ADDICTION , DEPENDENCE AND ABUSE
Cannabis
Main active constituent is 6 9-
tetrahydrocannabinol (THC), although
pharmacologically active metabolites may be
important.
Actions on central nervous system (CNS) include
both depressant and psychotomimetic effects.
Subjectively, subjects experience euphoria and a
feeling of relaxation, with sharpened sensory
awareness.
Objective tests show impairment of learning, memory
and motor performance.
THC also shows analgesic and antiemetic activity, as
well as causing catalepsy and hypothermia in animal
tests.
Peripheral actions include vasodilatation, reduction of
tntraocular pressure, and bronchodilatation.
Cannabinoid receptors belong to the G-
protein-coupled receptor family, linked to inhibition of
adenylyl cyclase and effects on calcium and
potassium channel function, causing inhibition of
synaptic transmission. The brain receptor (CB 1) differs
from the peripheral receptor (CB2), which is
expressed mainly in cells of the immune system.
Selective agonists and antagonists have been
developed.
Anandamide, an arachidonic acid derivative, is an
endogenous ligand for the CNS cannabinoid
receptor; its function has not yet been ascertained.
Cannabinoids are less liable than opiates, nicotine or
alcohol to cause dependence but may have long-
term psychological effects.
Nabilone, a THC analogue, has been developed for
its antiemetic property.
Although cannabinoids are not available for clinical
use, trials are in progress for symptomatic treatment
of multiple sclerosis and AIDS.
cannabis use. Epidemiological studies have suggested an
association between heavy cannabi'> usc and poor cognitive
function (see Kalant, 2004), but thi~ doc!> not necessari ly imply
causation, and there is little direct evidence that cannabis can
cause ncurodegeneration or irreversible cognitive impairment
(see Iversen, 2005). The possibility that cannabis can cause
psychotic illness has received much attention following reports
that cannabis smoking during adole\ccnce increased the
likelihood of schizophrenia more than sixfold (see A r~cnault ct
al., 2004). The issue is highly controversial, but it il> generally
believed that cannabis use du ri ng adolescence can cause
psychosi~ to become manifest in 'prepsychotic' individuals
earlier than it otherwise would. and that it can make the
symptoms worse. 1t has been estimated that elimination of
cannabis use in under- I5s would reduce the incidence of
 SECTION 4 . THE NERVOUS SYSTEM

schizophrenia by 8% (see Arsenault et al., 2004). Whelher
cannabis can induce psychosis in individuals who would not
otherwise have become ill remains unclear.
The long-running argument over the legalisation of cannabis
centres mainly o n the seriousness of these adverse effects.
Opponents o f legalisation argue lhat it would be folly to change
the law in favour o f the use by lhe public at large of a substance
that could tum out to have serious toxic effects. Proponents of
a change argue that the present law is clearly ineffective and
encourages crime. and that cannabis undoubtedly carries less
health ril. k than either ethanol or tobacco.
CLINICAL USE OF CANNABIS: A
CONTROVERSIAL TOPIC
Anecdotal evidence s uggests that smoking cannabis may be
efficacio us in a numbe r o f conditions, particularly the following:
relief of pain and muscle spasms associated with multiple sclerosis;
relief of other types of chronic neuropathic pain, including AIDS-
related pain; improvement of appetite and prevention of wasting
in AIDS; and relief of chemotherapy-induced nausea. Current
cannabis products cannot be prescribed for medical use in m
countries. 7 There is strong pressure from patient groups to pre~~
ahead with licens ing THC for clinical use, and clinical triah
in progress in a number of indications. The results so far ha\e bcai
equivocal, and neilher THC nor synthetic cannabinoids ha\e ~
approved for clinical use in Europe or the USA. Cannabi<; appm
to have a sig nificant but limited effect in reducing spasticit}
pain associated wilh multiple sclerosis, without producing map
adve rse effects, and s imilar results have been reported in other
neuropalhic pain states (see Iversen, 2005). Trials are also undef\1
in o ther conditions, including bead injury, Tourette's S)ndromc
and anorexia. Whether crumabinoids will prove to be a therap!:u~.
panacea o r a f1op remains unclear, and passions arc high on bo~
sides of the argument.
7
Dronabinol (purifi ed T I!C. as distinct from the plant extract. which
contain~
other active ~ub;tances) i~ approved io lhe USA for u-eating
chemotherapy-induced vomiting and to ;rimulate appetite in AIDS pauc~r.

REFERENCES AND FURTHER READING

General
Bunce C J. Loudon PT. Al.er. C ct al 2003
De\elopmem of 'acrone~ to help !real drug
dependence. Curr Opon Mol Thcr 5: 58-63
Chao J. Nc-tlcr li J 2()()..1 Mok..:ular ncurobiolog) of
addocllon Annu Rc Mcd 55 113 132 W~efid review
tlrtlc/t' /1_1 lttul111g >i'itlltilt> 111 adtlictwrr rr>~arclt)
Derochc-Gamonct V, Belin D. Pinua P V 2()().1 Evidence
for nddict ion-hkc b.:havoour in the rat Science 305:
1014-1017 (Set' al;o 'ommmtar') b.' Robir~son, ibitl.
95 1 -953, Expcrimcmnl Wtllc~y for distingubhing
between scl fudon ini ~lration and ilddiction-like
b.:haviour in rm>
Friedman L. Fleming N P, Robert' D I I, ltyman S E
1996 Source book of bUb,tance al>use and addiction.
William> & Wilkin~. Baltimore (Useful source of
factutol irrfomwtitm)
Hack S P. Chri,tie M J 2003 Adaptalionb in adenosine
,;~nailing on drug dependence: thempeutic
unplicauon,, Cnt Rev \lcurobiol 15: 235-274
lleodbredcr C A. Ilagan J J 2005 'locl phannacologocal
approache~ for the treatment of drug addicuon and
craving. Curr Opon Phannacol 5: 107-118 <D~scn~s
the IIUntt'mrH th~nr~trcolllnttl'.~lf'S, bast'd mainh' on
mUIII>cllnlll~ phtJf'IIUit'OIIIJI), fiJr tl't!atmg addiction)
Hyman S E. \lalenka R C 200 I Addiction and lbe brain:
til<! neuroboology ol compul,u>n and ol' pen.i>tcnce.
1':nt Re ~euro-.co 2: 695- 705 CRnot'l>.f longtemr
chmr~n 111 the hrmn rL\\tKrut~d ..-uh uddiction.
~mphasism~ !eJtllfH'niiiJII~III ultenttiOtu 111 g~nt'
expnsrwn)
Kan":h S B (cd) 1997 Drug abu..e handbook. CRC "=:>.
Boca Raton
Koob G f' 1996 Dnog nddicllon the yon and yang of
hedonic homco'tu"' Neuron 16: 893 -896
Maldonado R. Saiardi A, V;therde 0 el al. 1997 Absence
of opiate rewording eH<:ct\ in mice lacl.ing dopamine
0 , receptor">. Nature 388: 586-589 (Use of transgenic
tminwlr ro tltmnmtrrtll' role of d/J!'(rmiroe receptors in
636 mwTYI fii1JfJertit,, of opitlle.>)
Mayer P. Hollt V 2005 Geneuc di'po"uon to addictive
dborder;-currentl.nowlcdge and future pcr.pti\c,.
Curr Opin Phannncol 5: 4-8 ( De1rri~.> the 1 urrr:nt
incotlclusi>~ 111rdusra11din[1 of the .~m~tic basis of
addiction)
~estler E J 2001 Molecular b<N\ ollong-term pla,locoly
underlying addiction. Nat Rev llleuro,ci 2: 119 128
(Good revr~w am ell' fonWnJI on lonRterm dwngtl 111
gene expression assoc:iatetlwlllr tlru11 tletJI'IIdence)
Nesller E J 2004 Molecular mcchani>m> of drug
addiction. Neuropharmacology 47(~uppl t): 24-32
O'BrienC I' 1997 A r..ongcofrc~carch bnscd
pharmacotherapies for addict ion. Science 278: 66 70
(Usefitl ovel1'iew ofiJirurmamloRimla!>lmuulre>'IIJ
treatmenr)
Spanagel R. Weiss F t 999 The dopamine hypothesi~ of
reward: pa.\t and current rc..carch. Trend\ Ncuru'ci 22:
52 1-527 (Sumr~wrise> eidenre forarti1utio11 of Groenbae~ J\.1 et at. 1994 Influence of sex. age. bod~
mesolimbic dopaminl' pathways III 11 /tlc/IJr 111 drug
de{H'ndmce)
Weis~ r 2005 Neurobiology of era' ong. condolooned
reward and relap!>C. Curr Opm Phannacol 5. 9 19
(R~I'it'l<' of recent Jtudies On the III'IIITJhia/111(\ of
addiction, focusin!l noainll- 011 animal ltU>dels)
Winger G, Woo<l\ J H. llofrnann r G 2004 A h.llldboo~
on drug and alcohol abu~. 4th edn. Oford l:nl\er..ll)
Pres~. New Yon (Siron and infomoati_, t~rtbot1l em
biomedical aspectJ)
.xi cotine
Balfour D J K. Fagerstrom K 0 1996 Phamlacology or
nicotine and il.'> lhcrapculic u-.c on ~omok ong ce,\.Uoon
and neurodegeneratie dowrder.. Pharmacol1l1cr 72:
51-8 t (Review "!the pharmacology of nicotine mot/ its
usejt1lness as rrpltocemmtthuapy)
Benowi11. N L 1993 Nicotine rcplaccmcm thcrapy. l)rug>
45: 157-170
Benowitz N L 1996 Pharmacology of oucotine: addiction
and therapeutics. Annu Rev Phannncol 36: 597-613
(General reiew ortirlr illrlrulilll: iliformmirm 011
p01elllia/Jherapeollic ll.fes of nitotilre othu th.m
rt!duction of smoking)
George T P. O'Malley S S 2()().1 Current phanruc~iop:l
treatments for nic01ine dependence. Trends Pll.umxi
Sco 25: 42-48
Peto R. Chen Z..M. Borebam J 1999 Tobacco-tlk!
growong epidemic. NaJ Mod 3: I 5- I 7
Peto R. Lopez A D, Boreham Jet at. 1996 Momht)
from ;,molcing worldwide. Br Med Bull 52: 12-21
Wonnacc>ll S, Sidhpura N. Balfour D J K 2005 No~oor<:
from molecular mechanisms 10 behaviour. Curr Opo
Phurnwcol 5: 53-59 (Useful review 011 the a<uu unJ
longterm CNS effects of nicotine)
Ethanol
Charness M E. Simon R P. Greenberg D A t989 EtrunJ
and the nervous sy~tem. EngJ J Med 32 1: 442-4.~
rna index and smoking on alcohol inlllke and rnoru!ll!
Br Med J 308: 302-306 (Large-seal~ Danish s:udl
sho><-iiiJII'f!duced corona')' monaliry at moduutt
leels of drinking, ><-ith incrrase at hiRh ltwls)
Hruper C, Matsumoto I 2005 Ethanol and bram tLnu;t.
Curr Opin Pbannacol 5: 73-78 (DescriMs d~lmn~~~~~
effecl\ oflonl(term alcohol abu.re on brainftm<IJOI
Keung W-M. Vallee B L 1993 Daidzin and daodum
uppress free-choice elbanol intake by Syrian goldcl
brumter.. Proc Nail Acad Sci USA 90: 100011-10012
Loeber C S 1995 Med1cal disorde~ of alcoholi'm \
Engl J Med 333: 1058-1065 (Rt'l'it'l<-focuson~ 011
t!lhan{)lrnduced liver dam11gt! rn re/11twn w tl/umd
metabolism)
Liule H J 199 I Mechanisms that may underloe tlk!
behavioural effects of ethanol. Prog Neurobiol 36
171-194
Lovinger 0 M 1997 Alcohol~ and neurotransmlltel'
gmcd ion channcb: past pre~nl and future. 1\aun)n
Schmicdebergs Arch Phannacol 356: 267-282
(Review corticle arguing that alcoh(}l efft!cll depnod '
i11teraction with sy11aptic ion channels)
 Local anaesthetics and
other drugs aHecting
sodium channels
in this category that arc clinically useful are the local anaesthetic'
Overview 638 vari ous anticpilcptic drugs (see Cb. 40) and class I antidysrhythmK
1--
Local anaesthetics 638 drugs (sec C h. 18).

Other drugs that affect sodium channels 642 History

-Tetrodotoxin ond saxitoxin 642 Coca leaves have been c hewed for their psyc hotropic effects for
- Agents that affect sodium channel gating 644 tho usands o f years (see Ch. 4 2) by South Ame rican Indi an ~. wh.
kne w abo ut the numbing e ffect they produced on the mouth
and to ng ue. Cocaine was isolated in 1860 and proposed a' 1
local anae~theti c for surg ical procedures. Sigmund Freud, 1\~
tried un ~ucces!tfully to make use of its psychic energi\lr.
OVERVIEW power, gave !>ome cocaine to his ophthalmologist friend in Vie~~ 3,
Carl Ko ller, who reported in 1884 that reversible corneal anaesthe-~a
As described in Chapter 4 , the property of electrical
could be prod uced by dr opping cocaine into the eye. The .~
excitability is what enables the membranes of
was rapidly take n up, and within a few years cocaine anaesthc
nerve and muscle cells to generate propagated
was introduced into dentistry and general surgery. A S)ntheuc
action potentials, which are essential for
substitute, procaine. was discovered in 1905. and man) 0100
communication in the nervous system and for the
useful com pounds were late r developed.
initiation of mechanical activity in striated and
cardiac muscle. Electrical excitabiJity depends mainly
Chemical aspects
on voltage-gated sodium channels, which open
Local anaesthetic molecules consist of an aromatic part linked
transiently when the membrane is depolarised.
by an este r or amide bo nd to a basic side-chain (Fig. 44. 1). The)
Also important are the voltage-dependent potassium
arc weak bases, with pK. values mainly in the range 8-9, so thl
channels and calcium channels, which function
they are main ly, but not complete ly. ionised at physiologcal
similarly, although they serve quite different
pi!. This is important in relation to the ir ability to penetrate the
physiological functions and are affected by
nerve sheath and axon membrane; quaternary derivatives, whi(h
different classes of drugs (Chs 4 , 18 and 19). Here
arc fully io nised irrespective o f pH. are ineffective as local
w e discuss local anaesthetics, which act mainly by
anaesthetics. Benzocaine, an atypical local anaesthetic, ha, nu
blocking sodium channels, and mention briefly
ba!>ic g roup.
other drugs that affect sodium channel function.
The presence of the e1>ter o r amide bond in local anaestheu.
There are, broadly speaking, two ways in which
mo lecules i ~ important because of its susceptibility to metaboh,
channel function may be modified, namely block of
hydro lysis. The el.ter-contai ning compounds are usually inacti\atoo
the channels and modification of gating behaviour.
in the pla~ma and t is~ues (mainly liver) by non-specific e~tera~>t
Either mechanism can cause an increase or a
Amide~ are more stable. and these anaesthetics generall) hit\.
decrease of electrical excitability. Thus blocking
lo nge r pl a~> m a half- lives.
sodium channels reduces excitability, whereas
block of potassium channels tends to increase it.
Mechanism of action
Similarly, an agent that affects sodium channel
Local anaesthetics block the initiation and propagation of acuoc
gating so as to increase channel opening will tend
pote ntia ls by preventing the voltage-depende nt increase in 1\J
to increase excitability, and vice versa.
conduc tance (see Fig. 4.5). Although they exert a variety of nor
specific e ffects on me mbrane function, the ir main action i\ ll
LOCAL ANAESTHETICS block sodium chrumcls, whic h they do by physically pluggmt
the tra nsmembrane pore , interacting with residues of the St
Alth oug h many drug~ block voltage-sens itive sodium channels transmembrane helic al domain of the channel protein (<;ec
638 and inhibit the generation of the action potential, the only dru gs Stric hartz & Ritc hie, 1987; Ragsdale et al., 1994; Hille, 200 1).
 LOCAL ANAESTHETICS AND OTHER DRUGS AFFECTING SODIUM CHANNELS

L ocal anaesthetics

Ester
or Bas1c amme
Aromatic region
amide Side-chain
bond

Procaine

cs.
lllJC
Cocaine

for Tetracaine
0
vho (amethocaine)
ruth
s a
~ ho
n g'
ana. Cinchocaine
_sia (dibucaine)
i:lea
e!>ta

etic

o-
her CH3 0 CH CH
2 3
II I Lidocaine
NH-C - CH N
2 \ (lignocaine)
- CH3 CHzCH3

ed
cy
hat
yH NHCH 2CH2CH3 Priloca ine

cal CH3

the
ich
!Cal
no
Bupivacaine

~tic Fig. 44.1 Struc tures of local

,lie anaesthetics. The general structure
ted of lOcal anaesthetic molecules
consists of aromatic group ~eft), Benzocaine
ester or amide group (shaded) and
!l\C
amana group (right).

'f' Local ana.:\thetic activity i~ \trongl) pH-dependent, being increased at
alkaline pH (i.e. when the proport1on of ionised molecules is low) and
reduced at ac1d pH. Thb I'> bccau~e the compound needs to penetrate the
~n ncr.e \heath and the axon membrane to reach the inner end of the sodium
to .:hJnnel (where the local anae\thetic-binding site resides). Because the
ng 10nl\ed form i'> not membrane-pcrmcant. penetration is very poor at acid
pH. Once inside the axon, it i~ the ionised form of the local anaesthetic
S6 molecule that binds to the channel (Fig. 44.2). Th is pH dependence can
>ee be clinically important, hccau'>c inflamed tissues arc often acidic and
). lhu' somcwhtll rcsisram 10 local anaesthetic agents.
Further analysi' of local anae~thetic action (see Stricharo & Ritchie, 1987)
has ~hown that man) drugs exhibit the property of 'use-dependent' block
of \O<hum channel\, a.\ \\ell ~ a!Tecting. to some extent. the gating of
the channel>. U'>e dependence means that the more the channeb arc
opened. the gremer the block become~. It is a prominent feature of the
action of many cia's I untidysrhythmic drugs (Ch. 18) and anticpileptic
drugs (Ch. 40). and occul) because the blocking molecule enters the
channe l much more readily when the channel is open than when it is
closed. With quaternary local anaesthetics work ing from the inside or the
mcmhrunc, the channels nllli>l be cycled through their open slate a few
639
 SECTION 4 . THE NERVOUS SYSTEM
Exterior
Fig. 44.2 Interaction of local
anaesthetics w ith so dium
channels. The blocking site within
the channel can be reached via the
open channel gate on the inner
surface of the membrane by the
charged species BW (hydrophilic
pathway), or directly from the
membrane by the uncharged
species B (hydrophilic pathway).
'---
times before the blocking effect appean.. With tertiary local anaesthetics,
on the other hnnd. block can develop e\'eo if the channels are not open,
nnd it i\ likely that lhe blockmg molecule (uncharged) can reach the channel
either dtrectly from the mcmbrnne phase or via the open gate (Fig. 44.2).
The relanvc imponance of these two blocking pathways-the hydrophobic
pathway vtn the membrane, and the hydrophilic pathway via the inner
mouth of the channel-varie~ according to the lipid solubility of the drug,
and the degree of u\edependence varies correspondingly.
As discus~cd in Chapter 4, the channel can exist in three functiona l
states: resting, open and inactivated. Many local anaesthetics bind moM
strongly 10 the innctivaled stale of the channel. Therefore, at any given
membrane potential, the equil ibrium between resting and inactivated
channels wi ll, in the presence of a local anaesthetic, be shifted in favour
of the inactivated stale, and thi~ factor contributes to the overall blocking
effect. The pa%age of a tra in of action potentials causes the chan nels to
cycle through the open and inactivated states, both of which are more
likely to bind local anaesthetic molecules than the resting state; thus both
mechanism~ contribute 10 use-dependence.
In general, local anaesthetics block conduction in small-diameter
nerve fibres more readily than in large fibres. Because nociceptive
impulses are carried by Ab and C fibres (Ch. 41), pain sensation
is blocked more readily than other sensory modalities (touch,
proprioception, etc.). Motor axons, being large in diameter, are also
relatively resi~t ant. The differences in sensitivity among different
nerve fibres. although easily measured experimentally, are not
of much practical importance, and it is not possible to produce
a block of pain sensation without affecti ng other sensory
modalities.
Local anaesthetics, as their name implies, are mainly used to
prod uce local nerve block. In concentrations too low to cause
nerve block, however, they arc able to suppress the spontaneous
discharge in sensory neurons that is believed to be responsible for
640 neuropathic pain (sec Ch. 4 1). Lidocaine (lignocaine; see below)
Axonal
Menbrane Interior
B I ,. B ----+----- B
Channel open
Hydrophilic pathway
(use-dependent)
BW Channel shut
I
B---t-------B ---+-- --- 6
can be used intravenously to control neuropathic pain, and o,o~
antidysrhythmic drugs (e.g. mexiJetine, tocainide, necainidr.
see Ch. 18) can be used orally (see Lai et al., 2004). although n
licensed for this indication.
Action of local anaesthetics
Local anaesthetics block action potential
generation by blocking sodium channels.
Local anaesthetics are amphiphilic molecules with a
hydrophobic aromatic group and a basic amine group.
Local anaesthetics probably act in their cationic form
but must reach their site of action by penetrating the
nerve sheath and axonal membrane as unionised
species; they therefore have to be weak bases.
Many local anaesthetics show use-dependence
(depth of block increases with action potential
frequency). This arises:
because anaesthetic molecules gain access to the
channel more readily when the channel is open
because anaesthetic molecules have higher
affinity for inactivated than for resting channels.
Use-dependence is mainly of importance in relation
to antidysrhythmic and antiepileptic effects of sodium
channel blockers.
Local anaesthetics block conduction in the following
order: small myelinated axons, non-myelinated axons,
large myelinated axons. Nociceptive and sympathetic
transmission is thus blocked first.
 LOCAL ANAESTHETICS AND OTHER DRUGS AFFECTING SODIUM CHAN N ELS

The properties o f individual l ocal anaesthetic drugs are
1ummari~ed in Table 44. 1.
Unwanted eHects
The main unwanted effects of local anaestheti cs involve the
.~ntral nervous system (CNS) and the cardiovascular system , and
rhey constitute the main source o f hazard when local anaestheti cs
Jre u-ed clin ically. Most local anaestheti cs produce a mixture of
Jepressant and stimulant effec ts on the CNS. D epressant effects
predominate at low plasma concentr ations, giving w ay to stimu -
lation at higher concentrations, resulting in restlessness. tremor and
li.ll11eUmes convulsions, accompanied by subjective effects ranging
from confusion to ex treme agitation. Further increasing the dose
produces profound C S depression. The main threat to life comes
from respiratory depression in this phase. The only local anaesthetic
'Mih markedly different CNS effects is cocaine (see Ch. 42), which
produce~ euphori a at do~cs well below those that cause other
CNS effects. This relates to it~ specific effect on monoamine uptake
(see Ch. 42), an effect not shared by other local anaestheti cs.
Procaine is particularly liable to produce unwanted central effects.
and has been superseded in clinical use by agents such as lidocaine
(lignocaine) and prilocaine, whose central effects are much
less pronounced. Studies with bupivacaine (Table 44. 1), a widely
used long-acting local anaesthetic prepared a~ a racemic mixture
o f two optic al isomers, sugge!>ted that its CNS and cardiac
effects were mainly due to the S(+) isomer. The R(-) isomer
(l evobupivacaine) proved to have a better margin of safety and
hal> now been introduced .
The adverse cardiovascu lar effects of local anaesthetics are due
mainly to myocardial depression, conduc tion block and vaso-
dilatation. Reduction o f myocardial contractility probably results
indirectl y from an inhibition of the Na+ current in cardiac muscle
(see Ch. 18). The res ulting decrease o f [N a+], in tum reduces
intracellular Ca2+ stores (see Ch. 4), and thi s reduces the force

Tlble 44.1 Properties of local anaesthetics

Drug Onset Duration Tissue Plasma Main unwanted Notes

penetration half-life (h) effects

Cocaine Medium Medium Good -1 Cardiovascular and CNS effects Rarely used, only as spray
owing to block of amine uptake for upper respiratory tract

Procaine MediUm Short Poor <1 CNS: restlessness, shivering, The first synthetic agent
anxiety, occasionally convulsions No longer used
followed by respiratory depression
Cardiovascular system: bradycardia
and decreased cardiac output;
vasodilatation, which can cause
cardiovascular collapse

Udocaine Rapid Medium Good -2 As procaine but less tendency to Widely used for local
IQnocame) cause CNS effects anaesthesia
Also used intravenously for
treating ventricular
dysrhythmias (Ch. 18)
Mepivaca1ne is similar

Tetracaine Rapkl Medium Moderate -1 As lidocaine Used mainly for spinal and
(amethocaine) corneal anaesthesia

Bup1vacaine Slow Long Moderate -2 As lidocaine but greater Widely used because of
cardlotoxicity long duration of action
Ropivacatne is stmilar, wrth
less cardiotoxicity
Levobuprvaca1ne, recently
introduced, causes less
cardiotoxicity and CNS
depression than the
racemate, bupivacaine

Prilocaine Medium Medium Moderate -2 No vasodilator activity Widely used; not for
Can cause methaemoglobinaemia obstetric analges1a
because of risk of neonatal
methaemoglob1naemia

CNS, central nervous system.

641
 SECTION 4 . THE NERVOUS SYSTEM
of contraction. Interference with atrioventricular conduction can
result in partial or complete heart block, as well as other types of
dy'>rhythmia.
Va~odilatation. mainly affecting arterioles, is due partly to a
direct effect on vascular smooth muscle, and partly to inhibition
of the !.yrnpathetic nervous system. The combined myocardial
depre!>\ion and va\odilatation leads to a fall in blood pressure,
which may be 1.udden and life-threatening. Cocaine is an exception
in re~pect of it\ cardiovascular effects. because of its ability to
inhibit noradrenaline reuptake (sec Ch. II ). This enhances sym-
pathetic activity. leading to tachycardia. increased cardiac output,
vasoconstriction and increased arterial pressure.
Although local anaesthetics are usually administered in such
a way as to minimise their spread to other parts of the body,
they arc ultimately ab1-.orbed into the systemic circu lation. They
may also be injected into veins or arteries by accident. The most
dangerous unwanted effects result from actions on the central
nervou ~ and cardiovascular systems discussed above, namely
restlcssnes~ and convulsions followed by respiratOry depression,
and hypotcn<oion. or even cardiac arrest. Hypersensitivity reactions
sometimes occur with local anaesthetics, usually in the form of
allergic dermatitis but rarely as an acute anaphylactic reaction.
Other unwanted effects that are specific to particular drugs
include muco<,a) irritation (cocaine) and methaemoglobinaemia
(which occurs after large doses of prilocaine, because of the
production of a toxic metabolite).
Pharmacokinetic aspects
Local anae-.thetiC\ vary a good deal in the rapidity with which
they penetrate tis<,ue\. and thi!. affects the rate at which they cause
nerve block when injected into tissues. and the rate of onset of. and
Unwanted effects and pharmacokinetics
of local anaesthetics
Local anaesthetics are either esters or amides. Esters
are rapidly hydrolysed by plasma cholinesterase, and
amides are metabolised in the liver. Plasma half-lives
are generally short, about 1-2 hours.
Unwanted effects are due mainly to escape of local
anaesthetics into systemic circulation.
Matn unwanted effects are:
central nervous system effects, agitation, confusion,
tremors progressing to convulsions and
respiratory depression
cardiovascular effects, namely myocardial
depression and vasodilatation, leading to fall in
blood pressure
occasional hypersensitivity reactions.
Local anaesthetics vary in the rapidity with which they
penetrate tissues, and in their duration of action.
Lidocaine (lignocaine) penetrates tissues readily and
is suitable for surface application; bupivacaine has a
particularly long duration of action.
642
recovery from. anaesthesia (Table 44.1 ). It also affects their u-.c~
ne~s a!> l>urface anaesthetics for application to mucous membr.u
Mmt of the ester-linked local anaesthetics (e.g. telracaint
arc hydroly~cd by plasma cholinesterase, so their pla~ma hall
i~ relatively short. Procaine-now rarely used-is hydrol}'d
p-aminobcntoic acid. a folate precursor that interfere~ \\ith lhe
antibacterial effect of sulfonamides (see Ch. 46). The amide-linLzd
drug11 (e.g. lidocaine [lignocaine] and prilocaine) are metaboh\01
mainly in the liver, u~ually by N-dealkylation rather than cli!'JI
of the amide bond. and the metabolites are often pharmacologiCal.i
active.
Benzocaine is an unu~ua ll ocal anaesthetic of very low solubili
which is used a~ a dry powder to dress painful skin ulcer~. or
throat lozenge!.. The drug is slowly released and produce~ ion_
lasting surface anaeMhe~ ia.
The routes o f administration. uses and main adverse cffect\o
local anaesthetics are summarised in Table44.2.
Most local anncsthetics have a direct vasodilator nction, \\htt
increa~es the rate at which they are absorbed into the system .
circulation, thus increasing their potential toxicity and reduct .
their local anaesthetic action. Adrenaline (epinephrine) i\ ohc
added to local anaesthetic solutions injected locally in order t
cause vasoconMriction. although care is needed to avoid adrenal e
induced cardiova~cular changes.
Future d irections
Blocking 'pecilic sodium channel subtypes is seen as a promi'
therapeutic \trategy for a variety of clinical condition<;. incluJi
epilep~y. neurodegenerative diseases, stroke. neuropathic pain
myopathies.
Currently available local anaesthetic agents do not di~tingUI b
between different sodium channel subtypes (see Lai et al.. 2!KJ.I
and con1.equently produce a variety of unwanted effects 11hr
given systemically. It is expected that, with a beuer undcrstandin~
of the role of specific sodium channel subtypes in diiTcrcnl
pathophysiological situations, it may be possible to de1clop
selecti ve blocking agents for use in different clinical situation;
There is much activity in this area, but progress is !.low, as it 11
proving difficult to identify blocking agents that are highly sclcctil\
for different sodium channel subtypes.
Mo!>t local anae!.lhetic~ act for 2-3 hours when injected localh
which is often insufficient for pain relief. To increase the dur.ni~
of action. special formulations consisting of local anae\thcttCI
encapsulated in lipid vesicles (liposomes) are being developed
slow-relca-.e preparation-..
OTHER DRUGS THAT AFFECT SODIUM
CHANNELS
TETRODOTOXIN AND SAXITOXIN
T We \hOuld not be >Urpri\ed that nature, rather than med.:
chem1Mry. h:l\ provided the moM potent and selective agents that bh(l
\Odium dwnnel\ llf excit:~ble tis~ue~. Tetrodotoxin (TIX) is prcxluced b
:1 marine bacterium and accumu late~ in the tissues of a poisonou' P.~<:J
fi~h. the puffer fi-.h. Ml called becau~e when nlam1ed it intl a1es itself to
almost ;phcrical \pi ny ball. It i ~ evidently a species highly preoccupied 1\iU
defence. but the Japane!.c arc not ea.s il y put off and the puffer hsh 11
 LOCAL ANAESTHETICS AND OTHER DRUGS AFFECTING SODIUM CHANNELS

Tillie 44.2 Methods of administration, uses and adverse e ffect s of local anesth etics

Method Uses Drug(s) Notes and adver se e ffects

Surtace anaesthesta Nose, mouth, bronchial tree Udocaine, tetracaine. Risk of systemic toxicity when high
(usually 1n spray form), cornea, (amethocaine), dibucaine, concentrations and large areas are
urinary tract benzocaine involved
Not effective for skin"

Infiltration anaesthesia Direct injection into tissues to Most Adrenaline or felypressin often added
reach nerve branches and as vasoconstrictors (not with fingers or
term inals toes, for fear of causing ischaemic
lit), Used in minor surgery tissue damage)
Suitable for only small areas, otherwise
ng- serious risk of systemic toxicity

Intravenous regional LA injected intravenously distal
s of anaesthesia to a pressure cuff to arrest blood
flow; remains effective until the
circulation is restored
Used for limb surgery
Mainly lidocaine, prilocaine Risk of systemic toxicity when cuff is
released prematurely; risk is small if
cuff remains inflated for at least
20 minutes

Nerve block anaesthesia
LA is injected close to nerve
trunks (e.g. brachial plexus,
intercostal or dental nerves) to
produce a loss of sensation
peripherally
Used for surgery, dentistry,
analges1a
Most Less LA needed than for infiltration
anaesthesia
Accurate placement of the needle is
important
Onset of anaesthesia may be slow
Duration of anaesthesia may be
increased by addition of
vasoconstrictor

Sptnal anaesthesia
LA injected into the
subarachnoid space (contai ning
cerebrospinal fluid) to act on
spinal roots and spinal cord
Glucose sometimes added so
that spread of LA can be limited
by tilting patient
Used for surgery to abdomen,
pelvis or leg, mainly when
general anesthesia cannot be used
Mainly lidocaine Main risks are bradycardia and
hypotension (owing to sympathetic
block), respiratory depression (owing to
effects on phrenic nerve or respiratory
center); avoided by minimising cranial
spread
Postoperative urinary retention
(block of pelvic autonomic outflow)
is common

Epidural anaesthesia~> LA injected into epidural space, Mainly lidocaine, bupivacalne Unwanted effects similar to those of
blocking spinal roots spinal anaesthesia but less probable,
ive Uses as for spinal anesthesia; because longitudinal spread of LA is
also for painless childbirth reduced
Postoperative urinary retention
lly. common
ion
LA. local anaesthetic.
'Surface anaesthesia does not work well on the skin, although a non-crystalline mixture of lidocaine and prilocaine (eutectic mixture of
local anaesthetics or EMLA) has been developed for application to the skin, producing complete anaesthesia in about 1 hour.
omtrathecal or epidural administration of LA in combination with an opiate (see Ch. 41) produces more effective analgesia than can be
achteved wtth the opiate alone. Only a small concentration of LA is needed, insufficient to produce appreciable loss of sensation or other
SKle effects. The mechanism of this synergism is unknown, but the procedure is provtng useful 1n pain treatment.

regarded by them a\ a \pec1al deltc:tcy partly because oflhe mild tingling

nal -en,ation that follow\ eallng it~ tlc~h. To ~ervc it in public restaurants,
~k ho\1 ever. the chef mu\t be regi~tered ~ ~ufficiently skilled in removing the
h) tn\te organ\ (c~pccially l iver and ovarie~) so a~ to make the flesh safe
Itil' 10 e:tl. (The ahernauve ' trategy, of fanning puffer fish so that they do not
accumulate the toxi n and then adding a safe do;e of TTX--obtained, say,
lth fmm Sigm:l-~u ftic ient to provide the tingling ensal ion, has never caught
i~ on, whether l'o r cu ltural or gastronomic rea;ons one can only gues~.)
Accidental TTX poboning i; quite common. nonetheless. Historical reconh.
of long ..ea voyage\ often contained reference to attacks of severe weakness,
progre>,ing to complete paraly' " and death, caused by eating puffer fhh.
Saxitoxin (ST X) i' produced by a marine micro-organism that ~ometimes
prol iferate' i n very large number~ and even colours the sea. giving the
red tide' phenomenon. At such ti mes, marine shellfish can accumulate
the toxin and become poi sonous to humans.
643
 SECTION 4 . THE NERVOUS SYSTEM

These toxins, unlike con\entional local anaesthetics, act exclusively
from the outSide of the membrane. Both are complex molecules, beari ng
a positively charged guanidinium moiety. The guanidinium ton i ~ able to
pem1eate voltage-~ensi ti ve \odium channels. and thi~ part of the 1TX or
STX molecule lodges in the channel, while the re~t of the molecu le blocks
its outer mouth. In contrast to the local anaesthetics, there is no interaction
between the gating and block mg reaction~ wllh 1TX or STX-1heir
a\sociation and dl\soctation are independent of whether the channel is
open or closed. Some \Oitage-\ensitive \Odium channels arc insen~itive to
1TX. notably tho~e of cardiac muscle and nociceptive peripheral ~em,ory
neurons, the latter being of interest as a posstble target for novel analgesic
agents (see Ch. 41 ).
Clinical use of local anaesthetics
Both 1TX and STX are unsuitable for clinical u\e a\ local anaesthetics,
being expensive to obcain from their exotic !.OliJ'Ce~ and poor at penetrating
ti\sue\ becau\C of their very low lipid solubility. They have. however.
been importa nt ll\ experimental tools for the i'>olation and cloning of
sodi um channels (see Ch. 4).
AGENTS THAT AFFECT SODIUM CHANNEL
GATING
T Variou;, substances, rno;,tly complex and ornate molecule~. are known
that modify 'odium channel gating in such a way a~ to increase the
probability of opening of the channels (&ee Hille, 200 I). They include
various tox ins, mainly from frog skin (e.g. batrachotoxin). sc01pion or <,ea
anemone venoms; plant alkaloids such as ,eratridine; and insecticides ~uch
as DOT and the pyrcthrins. They facilitate sodiwn channel activation so that
sodium channels open at the nonnal resting potential: they also inhtbit
inactivation. so that the channel' fail to close if the membrane remains
depolarised. The membrane thu;, becomes hyperexcitable, and the action
potential is prolonged. Spontaneous discharges occur at first, but the :di
eventually become pem1anently depolarised and inexcitable. Alllhett
substances affect the hean, producing extrasystoles and other dysrllylhm
culminating in fibrillation: they also cause ~pontaneous di\Charge. tn nen:
and mu\cle, leadi ng to twitching and convulston\. The vel) htgb
solubility of substances like DDT makes them effective as ino,ecticido,
the) arc readily abwrbed through the integument. Drug\ io this eli!!'' r.
useful a;, expcrimeotal tools for studying ~odium channeh but h.t\~
clinical USe8.
Local anaesthetics may be infiltrated into soft
tissue (e.g. of gums) or to block a nerve or nerve plexus.
Coadministration of a vasoconstrictor (e.g.
adrenaline) prolongs the local effect.
Lipid-soluble drugs (e.g. lidocaine [lignocaine)) are
absorbed from mucous membranes and are used as
surface anaesthetics.
Bupivacaine has a slow onset but long duration. It is
often used for epidural blockade (e.g. to provide
continuous epidural blockade during labour) and
spinal anaesthesia. Its isomer levobupivacaine is
less cardiotoxic if it is inadvertently administered into
a blood vessel.

REFERENCES AND FURTHER READING

lhlle B 2001 Ionic channel~ or excitable membmncs.
Sinauer, Sunderland (E\ulltnl, clearly -..nlltn textbool
for thou wall/ing mo" tluJn th~ basi~ mintmum)
Lru J. Porreca F, Hunter J C. Gold M S 2004 Voltage-
gated sodtum clulnnels and hyperalge"a. Annu Re'
Pharmacal 44. 371-397 (Reie>< summariting rhe role
ofpanicu/ar sodium channel subi.\'Pe.f in rite
pmhogenesi.l ofpain. anti rhl' uu tif /O('a/ nnai'Siht'll('
and anrid}srh)rhmi~ drugs in ~onrrolling neuroparllic
JHJin)
Ragsdale 0 R. McPhee J C, Scheuer T. Cauerall W A
1994 Molecular detenninants of ~tate-dependent block
or Na channel; by local aneMhetics. Sctence 265:
1724-1728 ( Uu of Slltdi"ued mutarions II/ rh~
sndium chOJtnl'l ro show rhar IIleal anae\lltetu.v
residues ;, rhe S6 rmnsmembrone <lomam)
Slrichart1 G R. Rotchte J M 1987 ~action of loc..J
anaesthetic' on ton channels or excitable lis,ucs.
llandb Exp Phnnnacol 8 1: 21 - 52(Excel/entrntn
acrionr of /IJ('a/ anaeuheiiU-(>Ihtr anirlts 1n tilt
rami' oluml' coter more rlimcal alpecrJ)

644
cdls
!:he~e
~uas.

~c

hpld
~tor
arl'
re no

DRUGS USED IN THE

TREATMENT OF
INFECTIONS AND CANCER

~Ito

of
 Drugs used in the
treatment of infections
and cancer
Overview 647
Background 647
The molecular basis of chemotherapy 647
-Biochemical reactions as potential targets 649
-The formed structures of the cell as potential
targets 655
Resistance to antibacterial drugs 655
-Genetic determinants of antibiotic resistance 656
-Biochemical mechanisms of resistance to
antibiotics 657
-Current status of antibiotic resistance in bacteria 658
OVERVIEW
Chemotherapy is the term originally used to
describe the use of drugs that are ' selectively toxic'
to invading micro-organisms while having minimal
effects on the host. The term also embraces the use
of drugs that target tumours and in fact has now
come to be associated specifically with that branch
of pharmacology. In this chapter, we use the term
to cover both usages, although, in the public mind
at least, chemotherapy is specifically associated
with those types of anticancer drugs that cause
side effects such as loss of hair, nausea and
vomiting.
All living organisms are prey to infection.
Humans, being no exception to this rule, are
susceptible to diseases caused by viruses, bacteria,
protozoa, fungi and helminths. The use of
chemotherapeutic agents dates back to the work of
Ehrlich and others and to the development of
arsenical drugs such as salvarsan for the treatment
of syphilis. 1 The successful development of such
agents during the past 80 years, particularly the
'antibiotic revolution', constitutes one of the most
\1ercury-containing compou nd' were also once used for treating syphil is.
Ooe mght with Yenu~. u lifeti me wilh Mercury' wus a saying of Lhat time.
important therapeutic advances in the entire
history of medicine.
Clearly, the feasibility of selective toxicity
depends on the ability to exploit such biochemical
differences as may exist between the infecting
organism (or indeed cance r cells, our internal
' invaders' ) and the host. The bulk of the chapters
in this section of the book describe the drugs used
to combat infections, but in this introductory
chapter we consider, very broadly, the nature of
these biochemical differences and outline the
molecular targets of drug action.
Unhappily, our success in developing drugs to
attack these invaders has been paralleled by their
own success in counteracting the effects of the
drugs, resulting in the emergence of drug resistance.
And at present, the invaders-particularly some
bacteria-seem close to getting the upper hand.
This is a very important problem, and we will
devote some space to the mechanisms of resistance
and the means by which it is spread.
BACKGROUND
The term chemotherapy was coined by Ehrlic h himself at the
beginning of the 20th century to describe the use of synthe tic
chemicals to de!.troy infective agents. In recent years, the definiti on
of tl1e term ha~ been broadened to include a ntibiotics-substances
produced by some mic ro-organisms (or by pharmaceutical
chemists) that kill or inhibit the growth of other micro-organisms.
He re, we broaden it ~till further to include agents that kill or
inhibit the growth of cancer cells.
THE MOLECULAR BASIS OF
CHEMOTHERAPY
Chemotherapeutic agents then. are che micals that are intended to
be toxic for the pathogenic organism (or cancer cells) but innocuous
to the host. Before discussing the molecular basis of such selective
toxicity, we need to defin e what we mean by infectious o rganism.
The word ' microbe' is generall y used to describe bacteria, viruses
and fun gi, and the word ' para!.ite' to describe protozoa and hel-
minths. However, we are concerned only with those organisms
that cause disease, and the immune response of the human host 647
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANC ER

makes no distinction between the above categories, which are of
purely semantic convenience. We will use the term pathogens to
describe these invade~. It is important to remember that many
micro-organisms share our body space (e.g. the gut) without
causing disease (these are called commensals), although these may
become pathogenic under adverse circumstances (i.e if the host
is immunocompromised).
Living organisms are classified as either prokaryote!>, cells
without nuclei (the bacteria), or eukaryotes, cells with nuclei (e.g.
protozoa, fungi. helminths). In a separate category are the viruses,
which arc not real ly cells at all because they do not have their
own biochemical machinery for generating energy or for any
sort of !>ynthesis. Viru!>es need to utilise the metabolic machinery
of the host cell, and they thus present a particular kind of problem
for chemotherapeutic attack. There remain those mysterious protein-
aceous agents, the prions (see Ch. 35), which cause disease but
resist all attempts at classification, and for which there is no known
amjdote at present.
In yet another category still are cancer cells-host cells that have
somehow escaped from the nonnal regulatory mechanisms that limit
cell division. Cancer cells are clearly more s imilar to normal host
cells than are any of the pathogenic invaders, and this makes the
problem of implementing selective toxicity especially difficult.
evertheless. major advances have been made. mainly following
in the wake of the pioneering work of George Hitchings and
Gertrude Elion. whose 'rational drug design' approach led to the
development of many important 'antimetabolite' drugs. including
anti leukaemia agents.
Virtually all creatures, host and parasite alike, have the same
basic blueprint-DNA (an exception being the RNA viruses)--so
some biochemical processes are common to most, if not all,
organisms. Finding agents that affect pathogens or cancers but n01
other human celll. necessitates finding either qualitative or quan
titative biochemical differences between them.
Bacteria cause most infectious dbeases, and Figure 45.1 sbo\11
in simplified diagrammatic fonn the main structure!. and function>
of a 'generalised' bacterial cell. Surrounding d1e cell is the cell wall.
which characteristically contain!. peptidoglycan in all fonns of
bacteria except mycoplasma. Peptidoglycan is unique to prokaryOO;
cells and has no counterpart in eukaryotes. Within the cell 'Wall11
the plasma membrane, which, similar to that of eukaryotic cell>.
consists of a phospholipid bilayer and proteins. Tt functions ru; a
selectively penneablc membrane with specific transport mechanisllll
for various nutrients. However, in bacteria the plasma membrane an
does not contain any sterols, and this may alter the penetration 0!
some chemicals.
The function of the cell wall is to support the underlying
plasma membrane, which is subject to an internal osmotic pressure
of about 5 atmospheres in Gram-negative organi!.m!>, and abol.
20 atmospheres in Gram-positive organisms (see below). Th.
plasma membrane and cell wall together comprise the bacteria.
envelope.
Within the plasma membrane is the cytoplasm. As in eukaryoti
cells, this contains soluble ent.ymes and other proteins. th,
ribosomes involved in protein synthesis. and the small-molecuk
intennediates involved in metabolism, as well a~ inorganic ion'
However, unlike the eukaryotic cell, the bacterial cell has no nucleu':
instead, the genetic material, in the form of a s ingle cllromosomt
comaining all the genetic information. ties in the cytoplasm \\ill
no surrounding nuclear membrane. In further contrast to eukat)ob.
cells, there are no mitochondria-cellular energy i~ generaled bj
enzyme systems located in the p la!.ma membrane.

re;

Ribosom es

I
Fig. 4 5 .1 Diagram of the Cell wall Cell membrane DNA (chromosome)
structure and metabolism of a
'typical' bacterial cell. A Schematic
representation of a bacterial cell.
B Flow diagram showing the ~ PO 3-
I 4
synthesis of the main types of
macromolecule of a bacterial cell.
Class I reactions result in the
Hexosamines- Peptidoglycan
synthesis of the precursor molecules <ll
c
VI
c
necessary for class II reactions, 0 Q
which result in the synthesis of the Precursor
co
u 0
co Proteins
molecules-- !!! Aminoac1ds !!!
constituent molecules; these are
then assembled into
&ATP
~ ~
=
VI
-<ll RNA
macromolecules by class Ill , VI
co "'<0
reactions. (Modified from , J
I
(3
Nucleotides 0 DNA
J I
Mandelstam J, McQuillen K, Dawes I
I (eds) 1982 Biochemistry of I
I I I
bacterial growth. Blackwell I J I

" -Scientific, Oxford.) Glucose NH4+ so42

648
 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
Ot Some bacteria have additional components such as a capsule
and/or one or more flagella, butthe only additional structure with
relevance for chemotherapy i~ the outer membrane outside the cell
~all. The nature of this structure is important for aXonomic reasons,
'lS :b it enables bacteria to be classified according to whether they
ll. take up Gram\ stain ('Gram-positive') or not ('Gram-negative';
of for more detai l!., see Ch. 46). In Gram-negative bacteria, this
jc membrane may prevent penetration of antibacterial agents, and
IS it also prevent1> cru.y access of lyso<;yme (a microbiocidal enzyme
Is, found in white blood cells, tears and other tissue tluid~ that breaks
a down peptidoglycan).
ns The biochemical reactions that are potential targets for
e antibacterial drugs are shown in Figure 45. I. There are three groups.
of
Class 1: the utilisation of glucose or some alternative carbon
source for the generati on of energy (ATP) and synthesis of
1g
simple carbon compounds used as precursors i n the next class
re
of reactions.
ut
Class II: the utili ~ati o n of th ese precursors in an energy-
he
dependent synthesis of all the amino acids, nucleotides,
ial
phospholipids, amino sugars, carbohydrates and growth
factors required by the cell for survival and growth.
tic
Class 11/: assembly of small molecules into macromolecules-
he
protein~. RNA, DNA, polysaccharides and peptidoglycan.
ale
l S. Other potcntialtarge~ are the formed structures. for example the
JS. cell membrane, or in higher organisms (e.g. fungi and cancer cells)
ne the microwbules or other specific tissues (e.g. muscle tissue in
ith helminths). In considering these targets, empha5is will be placed
tic on bacteria, but reference will also be made to protozoa, helminths,
by fungi, cancer cells and, where possible, viruses as well. The
clmificmion that follows is clearl y not rigid; a drug may affect
more than one class of reactions or more than one subgroup of
reactions within a class.
The molecular basis of chemotherapy
Chemotherapeutic drugs should be toxic to
invading organisms and innocuous to the host. Such
selective toxicity depends on the discovery of
biochemical differences between the pathogen and
the host that can be appropriately exploited.
Three general classes of biochemical reaction are
potential targets for chemotherapy of bacteria.
Class 1: reactions that utilise glucose and other
carbon sources are used to produce ATP and
simple carbon compounds.
Class II: pathways utilising energy and class I
compounds to make small molecules (e.g. amino
acids and nucleotides).
Class Ill: pathways that convert small molecules
into macromolecules such as proteins, nucleic
acids and peptidoglycan.
BIOCHEMICAL REACTIONS AS POTENTIAL
TARGETS
CLASS I REACTIONS
Class I reactiOn!> are not promising targets for two reasons.
First, bacterial and human cells use similar mechanisms (the
Embden- Meyerhof pathway and the tricarboxylic acid cycle) to
obtain energy from gluco c. Second. even if glucose oxidation
was blocked, many other compounds (amino acids, lactate, etc.)
could be utilised by bacteria as an alternative energy source.
CLASS II REACTIONS
Class II reactions are better targets because some pathways exist
in parasitic but not in human cells. For instance, human cells lack
the abi lity, possessed by bacteria, to synthesise the so-called
'essential' mnino acids as well as certain growth factors (termed
vitamins in human physiology). Differences such as these represent
a potential target. Another opportunity occurs when a pathway is
identi cal in both bacteria and humans but exhibits a differential
sensitivity to drugs.
Folate
Folate biosynthesis is an example of a metabolic pathway found
in bacteria but not in humans. Folate is required forD A synthesis
in both bacteria and in human~ (see Chs 22 and 46). Humans cannot
synthesise folate and must obtain it from the diet, and specific
uptake mechanisms have evolved to transport it into cells. By
contrast, most species of bacteria. as well as the asexual forms of
malarial protot.oa, lack the necessary transport mechanisms and
cannot make use of preformed folate but must synthesise their
own de novo. This i~ a prime example of a difference that has proved
to be extremely useful for chemotherapy. Sulfonamides contain
the sulfanilamide moiety-a strucntral analogue of p-aminobentA>ic
acid (PABA), which is essential in the synthesis of folate (see
Figs 22.2 and 46.1 ). Sulfonamides compete with PABA for the
enzyme invol ved in folate synthesi s, and thu s inhibit th e
metabolism of the bacteria. They are consequently bacteriostatic
not bactericidaP (i.e. they suppress division of the cells but do
not kill them), and are therefore only really effective in the presence
of adequate host defences (which are discussed in Ch. 13).
The utilisation of folate, in the form of tetrahydrofolate, as a
cofactor in thymidylate synthesis (see Figs 22.3 and 46.2) is a good
example of a patl1way where human and bacterial enzymes exhibit
a differential sem.iti vity to chemicals (Table 45.1). Although the
pathway is virtually identical i n micro-organisms and humans,
one of the key enqmes, dihydrofolate reductase, which reduces
dihydrofolate to tctrahydrofolate (Fig. 22.2), is many times more
sensitive to the folate antagonist trimet hoprim in bacteria than
in humans. In some malarial protozoa. this enzyme is somewhat
less sensilive than Lhc bacterial entyme to trimethoprim but more
2
Whether a drug is bactericidal rather than bacteriostatic is detem1ined on a
strict technical criterion. but in practice it can be difficult to differentiate the
two actions du ring therapy.
649
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CA N CER
Table 45.1 Specificity of inhibitors of dihydrofolate
reductase
Inhibitor ICso (~tmoVI) for dihydrofolate reductase
Human Protozoal Bacterial
Trimethoprim 260 0.07 0.005
Pyrimethamine 0.7 0.0005 2.5
Methotrexate 0.001 -0.1" Inactive
"Tested on Plasmodium berghei, a rodent malaria.
sensitive to pyrimethamine and proguani.l, which arc used as
antimalarial agents (Ch. 49). The relative IC50 values (the concen-
tration causing 50% inhibition) for bacterial, malarial, protozoal
and mammalian eni'ymes are given in Table 45. 1. The human
enzyme, by comparison, is very sensitive to the effect of the folate
analogue methotrexate (Table 45.1 ). which is used in cancer
chemotherapy (~ee Ch. 51). Methotrexate is inactive in bacteria
because, being very '>imilar in structure to folate, it requires active
uptake by cells. Trimethoprim and pyrimethamine enter the cells
by diffusion.
The U'>e of '>equential blockade with a combination of two
drugs that affect the same pathway at different points, for example
sulfonamide'> and the folate antagonists (Fig. 46.2). may be more
:,uccessful than the usc of either alone (e.g. in the treatment of
Pneumocysris carinii pneumonia), and lower concentrations are
effective when the two are used together. Thus pyrimethamine
and a sulfonamide (sulfadoxine) are used to treat fa/ciparum
malaria (p. 702). An antibacterial formulation that contains both
a sulfonamide and trimethoprim is co-trimoxazole (p. 664); once
widely used, this combination has become progressively less
effective because of the development of sulfonam ide resistance.
Pyrimidine and purine analogues
The pyrimidine analogue Lluorouracil, which is used in cancer
chemotherapy (Ch. 5 1), is converted to a fraudulent nucleotide that
interferes with thymidylate synthesis. Other cancer chemotherapy
agents that give rise to fraudulent nucleotides are the purine
analogues mercaptopurine and thioguanine. Flucytosine, an
antifungal drug (Ch. 48), is deaminated to fluorouracil within fungal
cells but to a much les..er extent in human cells. conferring a degree
of selectivity.
CLASS Ill REACTIONS
As cells cannot take up their own unique macromolecules from
the environment. cia\~ fll reactions are particularly good targets
for selective toxicity, and there are distinct differences between
mammalian cells and para!>itic cells in the class Ill pathways.
The synthesis of peptidoglycan
The cell wall of bacteria contains peptidoglycan, a substance that
650 docs not occur in eukaryotes. It is the equivalent of a non-stretchable
string bag enclosing the whole bacterium. ln some bacteria (the
Gram-negative organisms), this bag consists of a single thickn~'\
but for other'> (Gram-positive organisms) there may be as man}
as 40 layers of peptidoglycan. Each layer consists of mul11j:1e
backbones of amino )Ugars-altemating N-acerylglucosamine cUI!
N-acetylmuramic acid re~idues (Fig. 45.2)-tbe latter having ,floo
peptide ~ide-chain~ that are cross-linked to form a polymeric latll\.'t
which i~ wong enough to resist the high internal osmotic pre"lllt
and may con.,titute up to 10-15% of the dry weight of the cell
The cross-links differ in different species. In staphylococci. lhC)
consiM of five glycine residues.
To build up this very large insoluble peptidoglycan layer on
the out:, ide of the cell membrane, the bacterial cell bas the problem
of how to tran!>port the hydrophilic cytoplasmic 'bui lding block'
through the hydrophobic cell membrane structure. This i~ accom
plishcd by lin king them to a very large lipid carrier, containing
55 carbon atoms, which 'tows' them across the membrane. The
process of peptidoglycan synthesis is outlined in Figure 45J.
First, N-acetylmuramic acid, attached to uridine diphosphak
(UDP) and a pentapeptide. is transferred to the C55 lipid carrier
in the membrane, with the release of uridine monophosphat~
This is followed by a reaction with UDP-N-acetylglucosamme
resulting in the formation of a disaccharide pentapcptide
complex auached to the carrier. This complex is the ba.'1'
building bloct.. of the peptidoglycan. Tn Staphylococcus aureus
the five glycine re:,idues arc attached to the peptide chain at thi'
stage. The building block is now transponed to the outside of the
cell and added to the growing end of the peptidoglycan. the
Tetrapeptide
_ _...,._ _ _ _ _ _ _:----------._ side-chain
1}-Lactams prevent the Peptide crosshnl<s
cross-linking peptides
from binding to the
tetrapeptide
side-chains
Fig. 45.2 Schematic diagram of a single layer of
peptidoglycan from a bacterial cell (e.g. Staphylococcus
aureus), showing the site of action of the ~-lactam
antibiotics. In S. aureus, the peptide cross-links consist of
five glycine residues. Gram-positive bacteria have several
layers of peptidoglycan. (NAMA, N-acetylmuramic acid; NAG,
N-acetylglucosamine: more detail in Figure 45.3).
 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER

the
Glycine (gly) residues
in}
pie
md
I Amino acids of the peptide
side-chain on muramic acid

1on (gly)s
UDP
ce, Pi ~::::liS!

ure A
I
ell. Inside
IC}
-C55 1ipid
~"''"'
M ------ C55 lipid
on
zm
A.
I
ks'
CELL MEMBRANE
m-
ng
'he Outside
.3
He
ier
lc.
....
1C. -
de
~ic
~.\, PLactam a ntibiotics, e .g .
~i<, pen icillin s
he cephalos po r in s
mon ob act ams
he
carbapenems

Fig. 45.3 Schematic d iagram of the biosynthesis of peptidog lyca n in a bacterial cell (e.g. Staphylococcus aureus), w ith the
sites of action of various antibiotics. The hydrophilic disacchande-pentapeptide is transferred across the lipid cell membrane attached
to a large lipid (CSS lipid) by a pyrophosphate bridge (-P-P-). On the outside, it is enzymically attached to the 'acceptor' (the growtng
peptidoglycan layer). The final reaction is a transpeptidation, in which the loose end of the (gly)5 chain is attached to a peptide side-chain
of an M in the acceptor and during which the terminal amino acid (alanine) is lost. The lipid is regenerated by loss of a phosphate group
(Pi) before functioning again as a carrier. G, N-acetylglucosamine; M, N-acetytmuramic acid; UDP, uridine diphosphate; UMP, uridine
monophosphate.

acceptor'. with the relea~e of the C55 li pid. which still has two
phosphates attached. The lipid carrier then loses one phosphate
group and thus becomes available for another cycle. Cross-
linking between the peptide side-chain~ of the sugar residue& in
the peptidoglycan layer then occurs, the hydrolytic removal of the
tcnninal alanine supplying the requisite e nergy.
This synthes is of peptidoglycan is a vulne rable step and can be
blocked at several points by antibiotics (Fig. 45.3 and Ch. 46).
C}closerine, which is a structural analogue of D-alaninc. prevent~
the addition of the two terminal a lanine residues to the initial
!npcptide side-chain on N-acetylmuramic acid by competitive
mhibition. Vancomycin inhibit!> the release of the building
block unit from the carrier, thu!> preventing its addition to the
growing end of the peptidoglycan. Bacitra cin interferes with the
regencmtion of the lipid carrier by blocking its dephosphorylation.
Penicillins, cepha losporins and other ~-lactams inhibit the final
Lmn~peptidation by fonning covale nt bonds with penicillin-binding
proteins that have transpeptida~e and carboxypeptidase activitie~.
thus preventing fonnation of the cro~l>-links.
Protein synthesis
Protein synthesis takes place in the ribosomes. Eukaryotic and
prokaryotic ribosomes are different, and this provides the ba::.is
for the selective antimic rob ial action of some antibiotics. T he
bacterial ribosome consists of a 50S subunit and a 30S subunit
(Fig. 45.4), whereas in the mammalian ribosome the subunit!> are
60S and 40S. The other elements involved in peptide ~ynthesis
are messenger RI~A (mR A), ~hich forms the template for
protein synthesis. and transfer RNA (tRNA). which specifically
transfers the individual amino acids to the ribo!.ome. The
ribosome has three binding sites for tRNA, termed the A, P and
E sites.
A simplified version of protein synthesis in bacteria is shown
in Fig ure 45.4. To initiate trans latio n, mRNA, transcribed from 65 1
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER

A The elements 1nvolved in protein

syntheSIS are shown: a ribosome (with
Anticodon .fJ)
3 b1nding Sites for transfer RNA (lANA):
the P, A and E sites), messenger RNA
(mANA) and lANA. The different mANA
\....~
~..,...........__
- lANA
Co mpetition with tRNA
codons (tnplets of 3 nucleotldes which for the A site, e.g.
code for spec1flc am1no ac1ds) are tetracyclines; selectivity
represented by dots, dashes and 50S subunit largely through selective
stra1ght or wavy lines and are shown in of nbosome uptake by active
different colours. A lANA w1th the transport into
growmg peptide cha1n (consisting so far prokaryotic cells
of Met -Leu Trp: MLT) IS m the P site.
bound by codon:ant1codon recognition 30S subunit
(i.e. by complementary base-pairing).
The Incoming lANA carries valine (V),
covalently linked.

[J The incoming lANA binds to the A site

by complementary base-pairing.
Abnormal
. - - - - . codon:anticodon leads to
misreading of the
message, e.g.
aminoglycosides,
gentamycin, amikacin, etc.

Inhibition of
C Transpeptidation occurs, 1.e. the
transpeptidation, e.g.
pephde chain on the lANA 1n the
P s1te is transferred to the lANA chloramphenicol
on the A s1te The pept1de chain
Premature termination of
attached to the tRNA m the A site
peptide chain, e.g.
now consists of Met- Leu- Trp-Val
(MLTV). The lANA in the P s1te puromycin , which
has been 'diSCharged', i.e. has lost resembles the amino acid
its peptide. end of tRNA (it also affects
mammalian cells; used as
an experimental tool)

o] The discharged tRNA is now

transferred from the P site to the Inhibition of
E site; the tRNA with the growing translocation,
peptide chain is translocated e.g. erythromycin
from the A site to the P site and (also spectinomycin,
the ribosome moves on one fusidic acid)
codon, relat1ve to the messenger.

E The !RNA from which the

peptide chain has been removed
is ejected. A new tANA, w1th
am1no ac1d (M) attached and
with the relevant anticodon, now
moves into the A s1te, and the
whole process is repeated.

Fig. 45.4 Schematic diagram of bacterial prot ein synthesis, indicating the points at whi ch antibiotics inhibit the process.

652
 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
the DJ\A template (see below), is attached to the 30S subunit of the
nbosome. The 50S subunit then binds to the 30S subunit to fonn
. 7051 -.ubunit, which move!> along the mRNA such that successive
oodons of the me-;\enger pas'> along the ribosome from the A
JXl'IIIOn to the P po~ition. Antibiotics may affect protein synthesis
at any one of these Mages (Fig. 45.4 and Ch. 46).
Nucleic acid synthesis
The nucleic acid\ of the cell are D A and RNA. There are three
!)pes of RNA: mR A, tRNA and ribosomal RNA (rRNA). The
la.st of the~e is an integral part of the ribosome and is necessary
tor it~ assembly as well a~ for facilitating mRNA binding. The
ossembled ribosome al!>o exhibits peptidyl transfera~e activity.
DNA i~ the template for the synthesis of both D NA and RN A.
It cxi~t~ in the cell as a double helix, each !>U"and of which is a linear
polymer of nucleotides. Each nucleotide consists of a base Iinked
to a' ugar (deoxyribose) and a phosphate. There are two purine bases.
adenine (A) and guanine (0). and two pyrimidine bases, cytosine
!C) and thymine (T). Single-strand DNA comprises alternating sugar
.00 phosphate groups with the bao;es attached (Fig. 45.5). Specific
h}drogen bonding between G and C and between A and Ton each
'trand (i.e. complementary ba!>e pairing) is the basis of the double-
\lr.llldcd helical structure of DNA. The DNA helix. is itself further
mk.>d. In the test tube, the coil has I 0 base pairs per turn. In vivo, the
coil is um~ound by about I tum in 20. forming a negative supercoil.
lmtiation of DNA c,ynthe~is requires first the activity of a
protem that causes separation of the strands. The replication
proce" inserts a positive ~upcrcoil. which is relaxed by DNA
I
Vo\-A=T
';---!
D 0 p
p 0 ;-{
'(-\-c-G-\~)\
';---! 0 p
p 0 ;-{
'(-\-G-c-\~)\
0 ';---! 0 p
0 Deoxynbose
p 0 ;-{
P Phosphate p- T=A-\~)\I 0 p
Fig. 45.5 Struct ure of DNA. Each strand of DNA consists
of a sugar-phosphate backbone with purine or pyrimidine
bases attached. The purines are adenine (A) or guanine (G) and
the pyrimidines are cytosine (C) or thymine (T). The sugar is
deoxyribose. Complementanty between the two strands of
DNA Is maintained by hydrogen bonds (either two or three)
between bases.
'You query whether JOS + 50S = 70S'! Yes il does. because we are
talkmg about Svedbl!l'flllllits. which rnea~ure sed imen tati on rate not mas>.
gyrase (also called topoisomerase II; Fig. 45.6). During the
synthesis of DNA. nucleotide units--each consisting of a base
linked to a sugar and three phosphate groups-are added by base
pairing with the complementary residues on the template. Con-
densmion occurs by elimination of two phosphate groups. catalysed
by DNA polwnerase.
RNA cxi-;t~ only in ~ingle-~tranded form. Tbc sugar moiety here
is riboc,e, and the ribonucleotides contain the bases adenine. guanine,
cytosine and uracil (U).
It is po~l.iblc to interfere with nucleic acid synthc~is in five
different ways:
by inhibiting the synthesis of the nucleotides
by altering the base-pairing properties of the template
by inhibiti ng either DNA or RNA polymerase
by inhibiti ng DNA gyrasc
by a direct effect on D A itself.
Chromosome
A
-Cell wall
8
Qulnolones , DNA gyrase ;
c
chromosome.
Eachtoopis
independently
supercoiled
Fig. 45.6 Schematic diagram of the action of DNA
gyrase: the site of action for quinolone antibacterials.
[A Conventional diagram used to depict a bacterial cell and
chromosome (e.g. Escherichia colt). Note that the E. coli
chromosome is 1300 mm long and is contained in a cell
envelope of 2 ~1m x 1 J.lm; this is approximately equivalent
to a 50-m length of cotton folded into a matchbox.
lW Chromosome folded around RNA core, and then
(C supercoiled by DNA gyrase (topoisomerase It). Quinolone
and antibacterials interfere with the action of this enzyme.
(Modified from Smith J T 1985 In: Greenwood D, O'Grady F
(eds) Scientific basis of antimicrobial therapy. Cambridge
University Press, Cambridge, p. 69.)
653
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER

Inhibition of the synthesis of the nucleotides
This can be accomplished by an effect on the metabolic pathways
that generate nucleotide precursors. Examples of agents that have
such an effect have been described under class IT reacti ons.
Alteration of the bose-pairing properties of the template
Agents that intercalate in the DNA have this effect. Examples
include acridines (p rofl avine and acrifl avine). which are used
topi cally as antiseptics. The acridines double the distance
berween adjacent base pairs and cause a frameshift mutation
(Fig. 45.7), whereas some purine and pyrimidine analogues
cause base mispairing.
Inhibition of either DNA or RNA polymerase
Dactinom ycin (actinomycin D ) binds to the guanine re~1duv
in DNA and blocks the movement of RNA polymerase. th
preventing tran1.cription and inhibiting protein synthesis. The dnr;
i-. used in cancer chemotherapy in humans (Ch. 5 I) and also a
experimental tool, but it is not useful as an antibacterial age~
Dir
Specific inhibitors of bacterial RNA polymerase that act by binding
Alk
to this enzyme in prokaryotic but not in eukaryotic cells incluu.
pre'
rifamycin and rifampi cin, which arc particularly useful fort.reaun~
can
Mycobacterium tuberculosis (which causes tubcrculo,i'>: 't
nil
C h. 46). Aciclovir (an analogue of guanine) i~ phosphorylated m
anti
cells infected with herpes virus, the initial phosphorylation being
anti
by a virus-specific kinase to give the aciclovir trisphosphate. \\hldl
lrce

r-
has an inhibitory action on the DNA polymerase of the herpes \iru

--- ----- --- ---- - (Ch. 47 and Fig. 45.8).

RNA retroviruses have a reverse /ranscriptase (viral TH
ucu uuu cuu ucu... \
~
mANA AUU GUU R A-dependent DNA polymerase) that copies the viral R.\\
normal) Ser Phe Leu lie Val Ser
into DNA that integrates into the host cell genome as a provirus
r
mANA ucu UUG ucu UAU UGU uuc... Various agents (zidovudine, didanosine) arc phosphorylated b1
(mutant) Ser Leu Ser Tyr Cys Phe cellular enzymes to the trisphosphate forms, which compete \\lib
the host cell precursors essen ti al for the formation by the 1iral
Fig. 45.7 An example of the effect on RNA and protein reverse transcriptase of proviral D A.
synthesis of a frameshift mutation in DNA. A frameshift
Cytarabi n e (cytosine arabinoside) is used in cancer chemo
mutation is one that involves a deletion of a base or an
insertion of an extra base. In the above example, an extra therapy (Ch. 51). Its trisphosphate derivative is a potent inh1b11
cytosine has been Inserted In the DNA template, with the resu lt o f DNA polymerase in mammalian cells. Foscarnet inhibits \ lral
that when mANA is formed it has an additional guanine (G), as RNA polymerase by attaching to the pyrophosphate-binding 'lte
indicated in orange. The effect is to alter that codon and all the
succeeding ones (shown in blue), so that a completely different Inhibition of DNA gyrose
protein is synthesised, as indicated by the different amino
rigure 45.6 is a simplified scheme showing the action of 0:':.1
acids (Leu instead of Phe, Ser instead of Leu, etc.). A, adenine;
C, cytosine; U, uracil. gyrase. The fluoroquinolones (cinoxacin, ciproOoxacin, nalidixic
'-- acid and norfloxacin ) act by inhibiting DNA gyrase. and the-<

Incoming
deoxyribonucleoside _ .JSr
trisphosphate ~~\
~ ~ ...... ,' c
'
S - P- S - ~
''
1 I ""~'--------
Fig. 45.8 Schemati c diagram of
G A
DNA replication, showing some
Ill II --,I
antibiotics that inhibit it by act ion C T G A T
on DNA polymerase. Nucleotides I I I I I Template
are added, one at a time, by base - 5 - P - S -P- S - P - S -P ~ S - I
I
pairing to an exposed template --1
strand, and are then covalently Rifampicin and
rifamycin Inhibit the

l
joined together in a reaction
catalysed by DNA polymerase. The bacterial enzyme;

' "'!"-
units that pair with the aciclovir inhibits the DNA polymerase
complementary residues in the herpes virus enzyme;
template consist of a base linked to cy1arabine Inhibits the
a sugar and three phosphate human enzyme
groups. Condensation occurs with S - P- S
the elimination of two phosphates. I I
The elements added to the template G A C
are shown 1n darker colours and bold Ill II Ill
type. A, adenine; C, cytosine; G, C T G A
guanine; P, phosphate; S, sugar; T, I I I I
-s- p- s- p- s- p- s ---
654 ~ymi~
 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
chemotherapeutic agents arc used particularly in infections with
~UC'i Gram-negative organisms (Ch. 46). These drugs arc selecti ve for the
um-. bacterial enzyme because it i!. structurally different from the mam-
jrug malian enzyme. Some anticancer agents, for example doxorubicin,
an act on the mammalian topoisomerase II.
Direct effects on DNA itself
ing
Alkylating agents fom1 covalent bonds with bases in the DNA and
Jude
prevent replication. Compounds with this action are used only in
tmg
c:mcer chemotherapy and include nitrogen mustard derivatives and
~cc
nurosourcas (Ch. 51). M itomycin also binds covalently to DNA. No
din
antibacterial agents work by these mechanisms. Bleomycin, an
!ing
anticancer drug, cau~es fragmentation of the DNA strands following
ich free radicul format ion (Ch. 5 1).
lfU'>
iraI THE FORMED STRUCTURES OF THE CELL AS
"JA POTENTIAL TARGETS
. ,, THE MEMBRANE
I b)
\ith The plasma membrane of bacterial cells is similar to that in mam-
ira I malian cells in that it consist!. of a phospholipid bilayer in which
protein~ arc embedded, but it can be more easily disrupted in certain
110- bacteria and fungi.
ltOr Polymixins arc cationic peptide antibiotics, containing both
iraI h}drophilic and lipophilic groups, which have a selecti ve effect
lite. on bacterial cell membranes. They act as detergents, disrupting
NA Biochemical reactions as potential
ixic targets for chemotherapy
esc
Class I reactions are poor targets.
Class II reactions are better targets:
folate synthesis in bacteria is inhibited by
sulfonamides
folate utilisation is inhibited by folate antagonists,
for example trimethoprim (bacteria), pyrimet hamine
(malarial parasite), methotrexate (cancer cells)
pyrimidine analogues (e.g. fluorouracil) and purine
analogues (e.g. mercaptopurine) give rise to
fraudulent nucleotides and are used to treat cancer.
Class Ill reactions are important targets:
peptidoglycan synthesis in bacteria can be
selectively inhibited by ~-lactam antibiotics (e.g.
penicillin)
bacterial protein synthesis can be selectively
inhibited by antibiotics that prevent binding of tRNA
(e.g. tetracyclines), promote misreading of mANA
(e.g. aminoglycosides), inhibit transpeptidation
(e.g. chloramphenicol) or inhibit translocation of
tRNA from A site to P site (e.g. erythromycin).
nucleic acid synthesis can be inhibited by altering
base pairing of DNA template (e.g . the antiv1ral
vidarabine), by inhibiting DNA polymerase (e.g. the
antivirals aciclovir and foscarnet) or by inhibiting
DNA gyrase (e.g. the antibacterial ciprofloxacin).
the phospholipid components of the membrane structme, thus
killing the cell.
Unlike mammalian and bacterial cells, fungal cell membranes
have large amounts of ergosterol. This facilitate~ the attachment
of polyene antibiotics (e.g. nystatin and amphoter i cin; Ch. 48),
which act a-. ionophores and cau!>e leakage of cation\.
Azoles such as i t r aconazol e kill funga l cells by inhibiting
ergosterol synthesis. thereby disrupting the function of membrane-
associated entymes. The azoles also affect Gram-po\itive
bacteri a, their selectivity being associated with the presence of
high levels of free fatty acids in the membrane of susceptible
organisms (Ch. 48).
INTRACELLULAR ORGANELLES
Microtubules and/ or microfilaments
The benzimidazoles (e.g. albendazol e) exert their antihelminthic
action by binding selecti vely to parasite tubulin and preventing
microtubule formation (Ch. 50). The vi11ca alkaloids vinblastine
and vincr isti ne are anticancer agents that disrupt the functioning
of microtubules during cell divi~ion (Ch. 51).
Food vacuoles
The erythrocytic fom1 of th e malaria plasmodium feeds on host
haemoglobin. which is digested by proteases in the parasite food
vacuole, the final product, haem, being detoxified by polymeris-
ation. Chloroquine exerts its antimal arial action by inhibiting
plasmodial haem polymerase (Ch. 49).
MUSCLE FIBRES
Some antihelminthic drugs have a selective action on helminth
muscle cells (Ch. 50). Pi per azine acts as an agonist on parasite-
specific chloride channels gated by GABA in nematode muscle.
hyperpolarising the mu!>cle fibre membrane and paralysing the
worm; avermectins increase Cl- permeability in helminth
muscle-possibly by a similar mechanism. Pyrantcl (now ~eldom
used) and levamisole act as agonists at nematode acetylcholine
nicotinic receptors on muscle, causing contraction followed by
paralysis (Ch. 50).
RESISTANCE TO ANTIBACTERIAL DRUGS
Since the 1940s, the development of effective and safe drugs to
deal with bacterial and other infections has revolutionised medical
treatmenL and the morbidity and mortality associated with these
diseases has been dramatically reduced. Unfortunately, the develop-
ment of effective antibacterial drugs has been accompanied by the
emergence of drug-resistant organisms. This is not unexpected,
because the short generation time of many bacterial species aiTords
an1ple opportunity for evolutionary adaptation. The phenomenon
of resistance imposes serious constrain~ on the options available
for the medical treatment of many bacterial infections. Resistance
to chemotherapeutic agents can also develop in protozoa, in multi-
cellular para<>ites (see Foley & Tilley, 1997; Martin & Robertson,
2000; St Gcorgiev, 2000) and in populations of malignant cells
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
Formed structures of the cell that are
targets for chemotherapy
The plasma membrane is affected by:
amphotericin, which acts as an ionophore in
fungal cells
azoles, which inhibit fungal membrane ergosterol
synthesis.
Microtubule function is disrupted by:
- vinca alkaloids (anticancer drugs)
- benzimidazoles (antihelminthics).
Muscle fibres are affected by:
avermectins {antihelminthics), which increase Cl-
permeability
pyrantel (antihelminthic), which stimulates
nematode nicotinic receptors, eventually causing
muscle paralysis.
(discu~\ed in Ch. 51). Here, however. we will confine discussion
mainly to the mcchanhms of re~il>tance in bacteria.
Amibiotic rc!>il.tance in bacteria spreads in three ways:
by transfer of bacteria between people
by tran~fer of re. iMancc gene!> between bacteria (usually on
plasmids)
by tran~fer of re~iMancc gene!> between genetic elements
within bacteria. on transposons.
Under!.tanding the mechanisms involved in antibiotic resistance
is cmcial for the ~ensible clinical use of existing medicines and
in the design of new anti bacterial drugs. One by-product of the
studies of resistance in bacteria was the development of plasmid-
based techniques for DNA cloning. leacting to the use of bacteria
to produce recombinant proteins for therapeutic use (sec Ch. 55).
GENETIC DETERMINANTS OF ANTIBIOTIC
RESISTANCE
CHROMOSOMAL DETERMINANTS: MUTATIONS
The spontaneour. mutation rate in bacterial populations for any
particular gene ill very low. and the probability is that approxi-
mately only I cell in 10 million will. on division, give rise to a
daughter cell containing a mutation in that gene. However, as there
arc likely to be very many more cells than this over the course of
an infection, the probability of a mutation causing a change from
drug sen~itivity to dmg resistance can be quite high with some
species of bacteria and with some drugs. Fortunately, in most cases,
a few mutant!> are not l>Ufficient to produce resistance as. despite
the selective advantage that the resistant mutants possess. the drastic
reduction of the population by the antibiotic usually enables the
host's natural defences (sec Ch. 13) to prevail. However, this may
not occur if the primary infection is caused by a dnlg-resistant strain.
Resistance resulting from chromosomal mutation is important
in 1.0mc instances, notably infections with methicillin-resistant
656 S. a11reus (MRSA; see below) and in tuberculosis, but this type
of resi~tancc is of limited clinical relevance, possibly because 1M
mutants often have reduced pathogenicity.
EXTRACHROMOSOMAL DETERMINANTS:
PLASMIDS
In addition to the chromosome itself, many species of bactell3
contain extrachromosomal genetic elements called plasmid1th
exist free in the cytoplasm. These are also genetic element\ th
can replicate independently. Stmcturally, they are clo~ed loop'
D A that may comprise a single gene or as many as 500 or mn
more. Only a few pla1.mid copies may exist in the cell but oft,n
multiple copies are present. and there may also be more than unc
type of plasmid in each bacterial cell. Plasmids that carry gen~,
for resistance to antibiotics (r genes) are referred to as R p/a.smic/1
Much of' the drug resistance encountered in clinical medicine i1
plasmid-determined. It is not known how these genes arose.
THE TRANSFER OF RESISTANCE GENES
BETWEEN GENETIC ELEMENTS WITHIN THE
BACTERIUM
Transposons
Some ~trctche~ of DNA are readily transferred (transposed) from
one plasmid to another and al~o from plasmid to chromo><>me
or 'ice versa. This is because integration of these egmenl\
DNA, which are called transposons. into the acceptor D 'A c..
occur independently of the normal mechanism of homologo
genetic recombination. Unlike plasmids. transposons are notable
to replicate independently. although some may replicate dunn.
the proce!>s of integration (Fig. 45.9), resulting in a copy tn both
the donor and the acceptor DNA molecules. Transposons m3)
carry one or more resistance genes (see below) and can 'hitchhil~
on a plasmid to a new species of bacterium. Even if the plasmtu
is unable to replicate in the new host. the transposon may integmte
[Aj
0
0
Fig . 45.9 An example of the transfer and replication of a
transposon (which may carry genes coding for resistance
to antibiotics) . .A Two plasmids, a and b, with plasmid b
containing a transposon (shown in brown). ~ An enzyme
encoded by the transposon cuts DNA of both donor plasmid
and target plasmid a to form a cointegrate. During this
process, the transposon replicates. ~ An enzyme encoded by
the transposon resolves the cointegrate. [Q] Both plasmids now
contain the transposon DNA.
1
 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
into the new ho~t 's chromosome or into its indigenous plasmid'>.
Thi!> probably accounts for the widespread distribution of certain
of the resistance genes o n different R plasmids and among
unrelated bacteria.
Gene cassettes and integrons
ia Pla.\mids and trampo~ons do not complete the rally of mechani\ms
at that natural selection ha!> provided to confound the hopes of the
at microbiologislfchemothcrapist. Resistance-in fact, mu/tidrug
of resistance--can also be spread by another mobile eleme nt, the
!n ~ene cassette. which consists of a resiMance gene attached to a
m 'mall recognition site. Several cassette~ may be packaged together
lC in a mu/ticassel/e array, which can. in turn. be integrated into a
es larger mobile DNA unit termed an integron. The integron (which
~. may be located on a transposon) contains a gene for an entyme.
is integrase (recombinasc), which insert~ the casscne(s) at unique sites
on the intcgron. Thi~ sy~tem-transposonlintegron/multiresi stancc
cmette array-allows particularly rapid and efficient transfer of
multidrug resistance between genetic clements both within and
between bacteria.
THE TRANSFER OF RESISTANCE GENES
BETWEEN BACTERIA
m
,,.
e The transfer of rel>istancc genes between bacteria of the same and
mdeed of different species is of fundamental importance in the
m 'pread of antibiotic resistance. The most important mechanism in
this context i~ conjugation. Other gene transfer mechanisms,
lc transduction and tramformarion. are of little impo rtance in
lg 'preading resistance genes.
..y Conjugation
Conjugation involve!> cell-to-cell contact during which chromosomal
d or cxtrachrorno!>omal D A is transferred from one bacterium to
IC another, and is the main mechanism for the spread of resistance.
The ability to conjugate is e ncoded in conjugative plasmids; the~>e
are plasmids that contain transfer genes. which, in coliform bacteria,
code for the production by the host bacterium of prote inaceous
,urface tubules. termed sex pili, that connect the two cells. The
conjugative plasmid then passes across from one bacterial cell to
.mother (generally of the same specie:.). Many Gram-negative and
'ome Gram-positive bacteria can conjugate. Some promiKuous
plasmids can cross the species barrier, accepting one host as readily
a~ another. Man y R plas mids are conjugative. Non-conjugative
pla... mids. if they coexist in a donor' cell with conjugative plasmid,,
can hitch-hike from one bacterium to the other with the conjugmive
plasmids. The transfer of resistance by conjugation is significant
m populations of bacteria that are nonnally found at high densities,
a~ in the gut.
Tronsduction
Transduction b a process by which plasmid DNA is enclo:.ed
in a bacterial virus (or phage) and transferred to another
bacterium of the same species. lt is a relatively ineffective mean<;
of transfer of genetic material but is clinically important in the
transmission of resistance genes between strains of staphylococci
and of streptococci.
Transformation
A few species of bacteria can, under natural conditions, undergo
transformation by taking up DNA from the environment and
incorporating it into the genome by nom1al homologous recombi-
nation. Transformation is probably not of importance clinically.
BIOCHEMICAL MECHANISMS OF
RESISTANCE TO ANTIBIOTICS
THE PRODUCTION OF AN ENZYME THAT
INACTIVATES THE DRUG
Inactivation of p-lactam antibiotics
The most important example of resi.,tance caused by inactivation
is that of the {3-!actam a/1/ihiotic.\. The enzymes concerned arc
{3-/actamases, which cleave the fHactam ring of penici llins and
cepha losporins (see Ch. 46). Cross-resistance between the two
classes of antibiotic is not complete. because some ~-lactamases
have a preference for penicillins and some for cephalosporins.
T Stapfrrlomcci are the principal hacteria producing ~-lactamao..e, and
the gene~ coding for the enzymes are on plu'>mids that can be tmn~ferred
by mmsduction. In '>taphylococci. the cnt.yme is inducible (i.e. it~
synthe~b i' not expressed in the ab~ence of the drug), and minute.
subilthibitory concentrations of antibiotic~ derepress the gene and rc~ult
in a 50- to !!0 fold increase in e~pre.,son. The entyme passe'> through the
bacterial envelope and inactivate~ antibiotic molecules in the surrounding
medium. The grn\e clinical problem po'ed b) l'e\.htant Maphylococci
secreting 13-lactamase \\.as tackled by de\eloping 'emi,ynthetic
penicillin'> buch as methicillin) and new 13-lactam antibiotic' (the
Resistance to antibiotics
Resistance in bacterial populations can be
spread from person to person by bacteria, from
bacterium to bacterium by plasmids, from plasmid to
plasmid (or chromosome) by transposons.
Plasmids are extrachromosomal genetic elements
that can replicate independently and can carry genes
coding for resistance to antibiotics (r genes).
The main method of transfer of r genes from one
bacterium to another is by conjugative plasmids. The
bacterium forms a connecting tube with other
bacteria through which the plasmids pass.
A less common method of transfer is by transduction,
i.e. the transmission by a bactenal virus (phage) of a
plasmid bearing an r gene into another bacterium.
Transposons are stretches of DNA that can be
transposed from one plasmid to another, from a
plasmid to a chromosome or vice versa. A plasmid
containing an r gene-bearing transposon may code
for enzymes that cause the plasmid to be integrated
with another. Following their separation, this
transposon replicates so that both plasmids then
contain the r gene.
657
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
monobactams and carbapeoems). and cephalo&porins (~uch as
cephamandole). that are le~~ ~u~eptible to inactivation. The growing
problem of MRSA ~ di~u~'ed below.
Gram-negative organisms can also produce (3-lactamases. and
this i'> a significant factor in their resistance to the semisynthetic
broad-spectrum ~-lactam antibiotics. In these organisms. the
enZ) me. may be coded by either chromosomal or plasmid genes.
In the former case. the cruymes may be inducible, but in the latter
they are produced conl>titutivcly. When this occurs, the enzyme
does not inactivate the drug in the surrounding medium but instead
remains attached to the cell wall. preventing access of the drug to
membrane-associated target sites. Many of these (3-lactarnases are
encoded by transposons, some of which may also carry resistance
determinants to several other antibiotics.
Inactivation of chloramphenicol
Chloramphe nicol is inactivated by chloramphenicol
acetyltransfera.ve, an enzyme produced by resistant strains of
both Gram-positive and Gram-negative organisms, the resistance
gene being pla~mid-bome. ln Gram-negative bacteria, the enzyme
is produced con~titutively. resulting in levels of resistance fivefold
higher than in Gram-positive bacteria. in which the enzyme is
inducible.
Inactivation of aminoglycosides
Aminoglycosides arc inactivated by phosphorylation, adenylation
or acetylation. and the requisite eruymes are found in both Gram-
negative and Gram-pol>itive organbms. The resistance genes arc
carried on plasmid'>, and several are found on transposons.
ALTERATION OF DRUG-SENSITIVE OR DRUG-
BINDING SITE
The aminoglycoside-binding site on the 30S s ubunit of the
ribosome may be altered by chromosomal mutation. A plasmid-
mediated alteration of the binding site protein on the 50S subunit
also underlies resistance to erythromycin, and decreased binding
of nuoroquinolones because of a point mutation in DNA gyrase
A ha~ recently been described. An altered DNA-dependent RNA
polymerase determined by a chromosomal mutation is reported
to be the ba!>is for rifampicin re~istance.
In addition to acquiring resistance to ~-lactams susceptible to
~-lactamase, some strains of S. aureus have even become
resistant to some antibiotics that are not significantly inactivated
by ~-lactamase (e.g. methicillin). because they express an
additional f3-lactam- binding protein coded for by a mutated
chromosomal gene.
DECREASED DRUG ACCUMULATION IN THE
BACTERIUM
An important example of decreased drug accumulation is the
plasmid-mediated resistance to tetracyclines encountered in borh
Gram-positive and Gram-negative bacteria. In this case. resistance
genes in the plasmid code for inducible proteins in the bacterial
membrane, which promote energy-dependent efflux of the tetra-
658 cycl ines. and hence resistance. This type of resistance is common
and has greatly reduced the therapeutic value of the tetracyclinr'
in human and veterinary medicine. Resistance of S. aure11.1 I
erythromycin and the other macrolides, and to fluoroquinolone'
is also brought about by energy-dependent efflux.
There i'> al'>O recent evidence of plasmid-determined inhibitioc
of porin '>ynthel>il>. which could affect those hydroph1h,
antibiotic\ that enter the bacterium through these water-filkd
chan neb in the outer membrane. Altered permeability as a re~ult
of chromo'>omal mutations involving the polysaccharide com-
ponents of the outer membrane of Gram-negative organi.,ms ffiJ)
confer enhanced resistance to ampicillin. Mutations affectin~
envelope components have been reported to affect the accumu
lation of aminoglycosides, (3-lactams, chloramphenicol, peptide
antibiotics and tetracycline.
THE DEVELOPMENT OF A PATHWAY THAT
BYPASSES THE REACTION INHIBITED BY THE
ANTIBIOTIC
Resistance to trimethoprim is the result of plasmid-directed
synthesis of a dihydrofolate reductase with low or zero affinit) lor
trimethoprim. It is transferred by transduction and may be spreaJ
by transpo~on'>.
Sulfonamide re!.istance in many bacteria is plasmid-mediated aru
result~ from the production of a form of dihydJvpceroate S)7lllleta..
with a low affinity for sulfonamides but no change in affinit} for
PABA. Bacteria causing serioul> infections have been found 1
carry pla<;mids with rc:.istance genes to both sulfonamides ar..
rrimethoprim.
s
CURRENT STATUS OF ANTIBIOTIC
RESISTANCE IN BACTERIA
The most disturbing development of resistance has been in
staphylococci, one of the commonest causes of hospital bloodstream
infections, many strains of which are now resistant to almo~t nil
current ly avai lable antibiotics. In addition to resistance to ~orne
Biochemical mechanisms of resistance
to antibiotics
The principal mechanisms are as follow.
Production of enzymes that inactivate the drug: for
example B-lactamases, which inactivate penicillin.
acetyltransferases, which inactivate
chloramphenicol; kinases and other enzymes,
which inactivate aminoglycosides.
Alteration of the drug-binding sites: this occurs
with aminoglycosides, erythromycin, penicillin.
Reduction of drug uptake by the bacterium: for
example tetracyclines.
Alteration of enzyme pathways: for example
dihydrofolate reductase becomes insensitive to
trimethoprim.
 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
es ~-lacLams through production of 13-lacLamase and the production
to of an additional B-lactam-binding protein that also renders them
~~. resistant to methicil lin, S. aureus may also manifest resistance to
other antibioticl> a!> follows:
)11
to streptomycin (because of chromosomally determined
IC
alterations of target site)
~d
to aminoglycosides in general (because of altered target site
lit
and plasmid-determined inactivating enzymes)
n-
to chloramphenicol and the macro! ides (because of plasmid-
ty
detemtined enzymes)
lg
to trimethoprim (because of transpol>on-cncoded drug-re~istant
11-
dihydrofolate reductase)
le
to sulfonamide~ (because of chromol>omally detennined
increased production of PABA)
to rifampicin (because of chromosomally and plasmid-
determined increases in efflux of the drug)
to fusidic acid (because of chromosomally determined
decreased affinity of the target site or a plasmid-encoded
decreased penneability to the drug)
id
to quinolones. for example cipronoxacin and norfloxacin
1r
(because of chromosomally determined reduced uptake).
d rime of writing) is linezolid, a relatively new oxazolidinone
Infections with MRSA have become a major problem, particu-
d larly in hospital&. where they can spread rapidly among elderly
and/or seriously ill patient~. and patients with burns or wound\.
If In a number of hospitals, surgical wards have been closed becau~e
0 of the high rates of infection among patients. Until recently, the
d glycopeptide vancomycin was the antibiotic of last resort against
MRSA but, ominously, strains of MRSA showing decreased
su~ceptibil ity to this drug were isolated from hospitalised patients
m the USA and Japan in 1997.4 MRSA infections are ri&ing:
Bax et al. (2000) report prevalence in US hospitals as rising from
11-13% in 1985/6to 26% in 1998.
n The fact that vancomycin resistance seems to have de\'eloped
n 'pontaneously could have major clinical implications-and not
II only for nosocomial (those contracted in hospital) MRSA infections.
e II had been thought that antibiotic-resistant bacteria were dangerous
only 10 seriously ill, hospitalised patients, in thai the genetic burden
of multiple resistance genes would lead to reduced virulence.
Di~tressingly, however, there is now evidence that the spectrum
and frequency of disease produced by methicillin-susceptible
and methiciUin-resistant staphylococci are similar.
In the past few years, emerococci have been rapidly developing
resistance to many chemotherapeutic agents and have emerged as
the second most common nosocomial pathogen. Non-pathogenic
enterococci are ubiquitous in the intestine. have intrinsic resistance
to many antibacterial drugs, and can readily become resistant to
other agents by taking up plasmids and transposons carrying the
relevant resistance genes. Such re::.istance is easily transferred to
invading pathogenic enterococci.
'Noble et al. have tran~ferred vancomycin resis1ance from enterococci to
\Uphylococci. lf th1~ occured in a clinical cnvtronment, i1 wouJd be
di,:L\II'Ou~. Some microbiologisiS have sugge\ted thai Noble and his team
lhould be autoclaved.
Enterococci, already multiresistant, have recently developed
resistance to vancomycin. This is npparently achieved by ~ubsti
tution of o-A ia-D-Aia with o-A ia-D-Iactate in the peptide chain
attached to N-ncetylglucosamine-N-acetylmuramic acid (G-M)
during the first steps of peptidoglycan synthesis (!.ee rig. 45.3
and Ch. 46). Thi~ is becoming a major problem in ho,pitalised
patients, and in the USA vancomycin resisitance ha~ increa~ed
from 0.5% to 18% in less than a decade (Bax e1 aJ., 2000). A particu-
lar concem is the possibility of transfer of vancomycin resistance
from enterococci to staphylococci. because they can coexist in
the same patient.
Many other pathogens are developing or have developed resist-
ance to commonly used drugs. Thi~ list includes P:;eudomonas
aerugino.w, Streptococcus pyogenes. Streptococcus pneumoniae,
Neisseria meningitidis, N. gonorrhoeae, 1/aemophifius injluenzae
and H. durreyi, as well as Mycobacterium, CampyfohtlCIN and
Bacremide:, ~pecies. Some strains of M. lttberculosis are now
able to evade every antibiotic in the clinician's armamentarium,
and tuberculo~is. once easily treatable. is now reponed to be
causing more deaths worldwide than malaria and AJDS together.
The only antibiotic that seems to defy resistance (at lea~t at the
drug with a novel mechanism of action (see Zurenko ct al., 200 I,
and Ch. 46).
Prescriber<; and consumers must aho bear a re!>ponsibility
for the burgeoning problem of re.,i,tance. lndiscriminate usc of
antibiotics in human and veterinary medicine, and their use in
animal foodstuffs. has undoubtedly encouraged the growth of
resistant ~trains. Some governmental and regulatory bodies (e.g.
the European Union) have devised political and social measures
to curb such excesses. and these have been at least partly successful
(reviewed by Bax et al.. 2000).
The issue around declining antibiotic efficacy is. however, not
solely to do with bacterial countennea~ures. The fact il> that there
has been a declining interest in the pharmaceutical industry in
researching novel antibiotics. Historically, the area hns been
one of the mainstays of the industry, but most of the drugs
available today arc the result of incremental change& in the
structures of a relatively small number of ba..,ic molecular
structures. such as the f3-lactam nucleus. By common con~ent.
the days when it was possible to discover new and effective drugs
in this way arc long gone.
Hubris has also played a part. In I967, the US Surgeon
General effectively announced thai infectious diseases had been
vanquished, and that the researchers should tum their attention to
chronic di:.eases instead. As a result. many pharmaceutical
companies scaled down their efforts in the area, and only in the
pa.<;t few years ha' activity been resumed as the pressing need
for novel compounds has been recognised (see Sax et al.. 2000;
BaHett & Barrett, 2003).
However. nature has endowed micro-organisms with fiendish ly
effective adaptive mechanisms for outwitting our be<,ttherapcutic
strategies. and so far several have been effortlessly keeping pace
with our attempts to eradicate them. This challenging l>ituation
has been reviewed in depth by Shlaes (2003) and Barrett &
Barrell (2003).
659
SECTIONS DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER

Multldrug resistance

Many pathogenic bacteria have developed resistance
to the commonly used antibiotics. Examples include:
some strains of staphylococci and enterococci
that are resistant to virtually all current antibiotics,
the resistance being transferred by transposons
and/ or plasmids; such organisms can cause
serious and virtually untreatable nosocomial infections
some strains of Mycobacterium tuberculosis that have
become resistant to most antituberculosis agents.

REFERENCES AND FURTHER READING

General rending
Amye S 0 B 2001 Mngic bullet>. lost hori zon>: the rise
and fall of anlihiot ic\. Tuylor & Francis, l.ondon
(Thou~lllflf'flmAillfl boo~ hr 11 bat-terioiogist 11 ith
widr e.lprrienrt in bnuerial J"l!liMtma anti 8Cnetics:
he opim.< 111111 11nln tile pmiJlemof wllt!Jiotic
re<islonu i< .wled m tlte nt'.\1 5 year.l, ,..e are going
to slip further imo I he abn:. of uncontrollable
infectinn')
Bu'h K, "laciclaF "1 2000 'lc-. npproache' 111 the
treatmem of h3~tcnal tnfecuon,, Curr Optn Chem B1ol
-1 -IH-419 (Cnnc t<t tlisn1111cm of nt~ nlllibactt'rinl
a)1tIJI.\ 111 phar II t>r plwu II/ trial t)r alf'l'atly
OJ>proleti)
Croft S I 19<)7 Th.: current \tatu' of anupanNtc
chem01her:1p). Pan.,llolog) 114 S1 S 15
<Cmnpr.hrnnr l'ti\O'tJ~t' if r11rf'l'nt Jr11~1ft>r
pro1o~t>ttl. W<'<'i<lml 11n<l ltl'lmintlt mfrctiotU, "ith
n111li11t of appma<'hr In f'<'Htblt flllllre a~ellls)
Knocller LA. Celh J. f'mla) B B 2001 Pathogenoc
triclel): deception of ho,t cell p1UC"o;e>. Mol Cell
B1ol 2: 578 ~S!I (Dw 11\.11'1 bctctnwl ploys 10 s11bert
or hlotJ. m>mml hml al/u/ur r>m<~, e.{. mull irking
1ile liRaml\ for hflll ct/1 f'l!tepl<>rl or 11gnal/111g
pmlmun. U.1t}11lli11 uj ewmple;.)
\1anm R J. Rohcn,on A P 2000 Electrophy~iological
mesugation of anthcltnlllliC rcSt,lancc. Para;itology
120(,uppl): S87 S9-l (U.~t~ J>tlt<il clomp techmque to
.\ltldy itm C'hmurrl\ in rt'.\'i\ftmlllnd nmll'('5isltmr
nemauu.le li.\we)
Recchia G D. llall R M 1995 Gene cas>elles: a new class
of mobile clement. Microbiology 14 1: 30 15-3027
(Detoiletlrmuafl<' of/Ius ltllusualmechanism)
Shlac, D M 2001 The uhandonmcn1 of nnli bac~eriak
why and wherefore? Curr Opin Pharmacol 3: 470-473
(A .~(1(1(1 rnirw thlll eJ.pl11inf tltt rea1011.1 11ndalying
the 1"1.'\i\/mue (lmhlm1 allfl lhr rr:g,(ulrlry and other
hunl/e{ lila/ null/ br oercoml' befort.' ,,.,.
anul>al'lnialr (IJI~ttr 1111 to/he murkl't: almost
af'<'Callpur m 1011<')
Tan Y T, Tilleu D J, McKay I A 2000 Molecular
strategies for overcoming antibiotic rcsi~1ancc in
bacteria. Mol Mcd Today 6: 309 314 ($url'i11r1 articll'
reviewing strmegies m np/oit adl'imre.! in moleculw
biology 10 develop new ami/JiotiCI 1hat mrrromr
re.~iswnce: useful glo.uary of rele1ant temts)
Zasloff M 2002 Antimicrobial peptide-; of muluecllular
organisms. Nature 415: 389-395 (71tOIIflhiJiroi'Okill~
article abom 1/U' po1e111 hroutls~ctrw!l muimirmhial
peplides possessed by bmlt animal! and p/m!l.r, 11 lt11'h
are used 10 fend off a ,.;de ron)1e of microbes: 1/1.1
sugges1ed thai nplnilil!l( 111tre mi~h1/>e nne tlltlll ('r 10
the problem of amihtolk t'l'fiJiant e)
Zurenko 0 E. Gibson J K. Shinaba.rger D I et al 200 I
Oxatolidinone;: a new cia" of anu""'teri31,. Curr
Opin Pharm3COI I: 470-476 (A ml'tif htJ~ 11
Drug resistan ce
Barrell C T, Barren J F 2003 Anuhxtcnal\. arc the nc-.
entries enough to deal "ith the emef1!mg re,i,tance
problem? Curr Opm Biotechnol 14 621 626 ((}ond
general reiew "'ilh some wmr>ellm.~ l'-wmple! anti a
mwul-up of new tfntg cwuliduu.<)
Sax R. Mullan N. Vemoef J 2000 The millennium
bugs-the need for and development of new
antibacterials. lnl J Anlimicrob Agent\ 16: 5 1 59
(Excellent rt!View of 1/te problem of relilllmu anti
some of the new nfiellls in the t>lf>elme)
Courvalin P. Tricu-CoUI 200 I Min imiting poiCntinl
resistance: the molecular view. Cli n lnfect Dis 33:
SI38-S I46 (Reviews 1/te potential COilttibut/OJt of
molecular biology to prel'elltlnfltlte .<pl'('atl of resislant
bacteria)
Foley M. Tilley L 1997 Quinoline amimalarial':
mechanisms of action nnd resistance. lnt J Parn,ilol
27: 231-240 (Good. short revinv: u<efu/
diagranL\)
Hawkey P M 1998 The origins and molecular bao;i, of
antibiotic resisUlllce. Br Med J 7159: 657-{)59
(Succinc/ oenie~~ of l"'.'siswnCl'; uuful, .fllnplt
diagrams: 1/iis is o11e of 12 papers on resiswnct m1/u
iss11e of the joumal)
Jonc1> M E, Peters Ectal. 1997 Widespread occum:"''
of integrons causing multiple antibiotic resis1ance 1n
bacteria. Lancct 349: 1742-1743
Levy S B 1998a Ami bacterial resisumce: bacleria on the
defence. Br Med J 7 159: 6 12-{) J3 (Resi.<1a11ce .<m
from thr poim of view of the baclerium; thi! is ontD}
lPl'f'll editorial arliclt.< on dte subjec/ nf !l'<i<llln"'"'
rlti.r I!..\ Itt' of the JOumal)
Levy S B 1998b The challenge of antibiOiic re>i<Llnt.-e
Sci Am \1arch: 32-39 (Simple, clear rerin. b) WI
l'.lpert in I he field: excel/em diagrams)
Michel \1, Gutman L 19<)7 Mcthkillin-re'"tant
Swph) lncoccw. allf'l'US and vancomycinreo.i\L1!\I
enterococci: therapeutic realities and pos>ibibun
Lnncet349: 1901-1906 (Good mil'K amc/t; wq,J
dial(rom: su~xests schemes for medical ma/111~~
of mfuumu cmued by resiswm organisnu)
l'oble W C 1992 FEMS Microbiol Leu 72: 195-19~
St Gcof1!ic V 2000 \Jcmbmne transporte"' and
ant1fungal drug resistance. Curr Drug Taf1!ets I.
184-261 (Discusses arious aspects of mulndru~
resistance in tliseasecausing fimgi in 1he l'Onltll of
tar8eted drug del'elopnU'III)
van flclkum A 2000 Molecular epidemiology of
methicillinresistant Swphylococcus aureus wain.'
'tale of uiTair> and tomorrow's possibilitie,. M1crob
Drug Resist 6: 173-187
Walsh C 2000 Molecular mechanisms that confer
unlibaelerial drug resistance. Nature 406: 775 781
(e.xcellem review amlining the mechanismI ofaaron
of umi!Jit>lic,, and 1/U' resiswnce f>loy.r of !Jacleria.
l'l'l)' good diagronr)
Woodford N 2005 Biological counter;trikc: amihi04ic
resistance mechanisms of Grampositive cocci. ChQ
Microbiol Infect 3: 2-21 (A useful rl'fl'rl'ltet 1hat
classtfies amibi01ic resis1ance as OIU' of rhe maJor
p1tblic health conums of the 2/s/ cemury and
tlistusus dm~ lreatmenl for resiWUII Slnltn.<)
 Antibacterial drugs

are also highlighted, but it must be understood

Overview 661 that most of these pathogens can produce a
rir
Introduction 66 1 spectrum of illness.

Antimicrobial agents that interfere with the

synthesis or action of folate 663 INTRODUCTION
-Sulfonamides 663
- Trimethoprim 664 Many organisms (see Table 46.1) can be classified as being either

I~lactam antibiotics 665

-Penicillin 665
-Cephalosporins and cephamycins
-Other ~lactam antibiotics 668
Antimicrobial agents aHecting bacterial protein
synthesis 668
-Tetracyclines 668
-Chloramphenicol 669
-Aminoglycosides 670
-Macrolides 671
-Streptogramins 671
-Uncosamides 672
-Oxalazidonones 672
-Fusidic acid 672
Gram-positive or Gram-negati1e depending on whether or not they
stain with Gram's stain. 1 This is not merely a taXonomic device,
as it reflects several fundamental differences in (for example) the
666 structure of their cell walls, and thi!> in turn has implications for
the action of antibiotics.
The cell wall of Gram-positive organisms is a relatively simple
structure, 15-50 nm thick. ll comprises about 50% peptidoglycan
(see Ch. 45), 40-45% acidic polymer (which results in the cel l
surface being highly polar and carrying a negative charge) and
5-10% proteins and polysaccharides. The strongly polar polymer
layer influences the penetration of ionised molecules and favours
the penetration into the cell of positively charged compounds such
as streptomycin.
The cell wall of Gram-negative organisms is much more complex.
From the plasma membrane outwards, it consists of the following:

Antimicrobial agents aHecting
topoisomerase 672
-Fiuoroquinolones 672
1 Miscellaneous antibacterial agents 674
IAntimycobacterial agents 675
-Drugs used to treat tuberculosis 675
-Drugs used to treat leprosy 676
>
1 Possible new antibacterial drugs 677
OVERVIEW
A detailed classification of the bacteria of medical
importance is beyond the scope of this book, but a
short list of common clinically important micro-
organisms is given in Table 46.1, together with the
principal chemotherapeutic agents in use and a
general indication of their antibacterial actions.
Characteristic diseases caused by these organisms
a peripfasmic space containing enzymes and other components
a peptidoglycan layer 2 nm in thickness, forming 5% of the
cell wall mass, that is often linked to outwardly projecting
lipoprotein molecules
an outer membrane consiMing of a lipid bilayer, similar in
~ome respects to the plasma membrane, that contains protein
molecules and (on its inner aspect) lipoproteins linked to the
peptidoglycan. Other proteins form transmembrane water-fiUed
channels, termed porins, through which hydrophilic antibiotics
can move freely.
complex polysaccharides forming important components of
the outer surface. These differ between strains of bacteria and
are the main determinants of the antigenicity. The complex
polysaccharides constitute the source of endotoxin, which, in
vivo, trigger various aspect~ of the inflammatory reaction by
activating complement, causing fever, etc. (see Ch. 13).
Difficulty in penetrating this complex outer layer is probably the
reason why some antibiotics are less active against Gram-negative
Named after the eponymou~ Danih physician who devised the technique.
1 661
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
Table 48.1 General choice of antibiotics against common o r important micro-organisms
Micro-organism(s)"
Gram-positive cocci
Staphylococcus (boils, Infection
of wounds, etc.)
Non-~lactamaseproducing
~-lactamase-produc1ng
Methicillin-resistant
Methicillin/vancomycin-resistant
Streptococcus, haemolytic types
(septic infections, e.g. bacteraemia,
scarlet fever, toxic shock syndrome)
Enterococcus (endocarditis)
Pneumococcus (pneumonia)
Gram-negative c occi
Morasella catarrhs/is (sinusitis)
Neisseria gonorrhoeae (gonorrhoea)
Neisseria menlngitidts (meningitis)
Gram-positive rods
Corynebacterium (diphtheria)
Clostridium (tetanus, gangrene)
Usteria monocytogenes
(rare cause of meningitis and
generalised infection 1n neonates)
Gram-negative rods
Enterobacteriaceae (coliform organisms)
Eschenchia coli, Enterobacter, Klebsiella
Infections of urinary tract
Septicaemia
Shigella (dysentery)
Salmonella (typhoid, paratyphoid)
Haemophifus inffuenzae
(infections of the respiratory tract, ear,
sinuses: meningitis)
Bordetella pertussis (whooping cough)
Pasteurella multocida
(wound infections, abscess)
Vibrio cholerae (cholera)
Legtonella pneumophila
(pneumonia, legionnaires disease)
Helicobacter pylori
(associated with peptic ulcer)
Pseudomonas aeruginosa
Unnary tract infection
Other infections (of burns etc.)
Brucella (brucellosis)
Bacteroides fragilis
Oropharyngeal infection
Gastromtestinal infection
Gram-negative anaerobic rods
(other than B. fragllis)
Campylobacter (diarrhoea)
Spirochaetes
Treponema (syphilis, yaws)
662
First-choice antibiotic(s)
Benzylpenicillin (penicillin G)
or phenoxymethylpenicillin (penicillin V)
A ~-lactamasErresistant penicillin
(e.g. flucloxacillin)
Vancomycin gentamicin nfampicin
(rifampin)
Quinupristin/dalfopristin or linezolid
Benzylpenicillin or phenoxymethylpeniclllln
an aminoglycoside
Benzylpenicillin + gentamicin
Benzylpenicillin or phenoxymethylpeniclllln
or ampicillin, or a macrolide
Amoxicillin + c lavulanic acid
Amoxicillin + c lavulanic acid, or ceftriaxone
Benzylpenicillin
A macrolide
Benzylpenicillin
Amoxicillin an aminoglycoside
An oral cephalosporin, or a quinolone
An aminoglycoside (intravenous) or cefuroxime
A q uinolone
A q uinolone or ceftriaxone
Ampicillin or cefuroxime
A macrolide
Amoxicillin + c lavulanic acid
A tetracycline
A macrolide rifampicin
Metronidazole + amoxicillin + ranitidine<~
(2-week regimen)
Aquinolone
Antipseudomonal penicillins ... tobramycin
Doxycycline + rifampicin
Benzylpenicillin
Metronidazole, clindamycin
Benzylpenicillin or metronidazole
A macrolide or a quinolone
Benzylpenicillin
Sec ond-choice antibiotic(s)
A cephalosporin or vancomycin
A cephalosporin or vancomycin, or a
macrolide, or a quinolone
Cotrimoxazole, or ciprofloxacin, or a
macrolide fusidic acid, or rifampicin
A cephalosporin, or a macrolide,
or vancomycin.
Vancomycin
A cephalosporin
Ciproxafloxacin
Cefotaxime, or a quinolone
Chloramphenicol, or cefotaxime, or
minocycline
Benzylpenicillin
A tetracycline, or a cephalosporin
Erythromycin an aminoglycoside
Extended-spectrum penicillin
lmipenem or a quinolone
Ampicillin or trimethoprim
Amoxicillin or chloramphenicol or
trimethoprim
Cefuroxime (not for meningitis) or
chloramphenicol
Ampicillin
Ampicillin
A quinolone
Clarithromycin + metronidazole
Ant1pseudomonal penicillins
lm1penem an aminoglycos1de, or
ceftazidime
Metronidazole or clindamycin
lm1penem
A cephalosporin or clindamycin
A tetracycline or gentamicin
A macrolide or ceftriaxone
 ANTIBACTERIAL DRUGS

T1ble 46.1 (continued) General choice of antibiotics against common or important micro-organisms

Micro-organlsm(s)l> First-choice antiblotic(s)c Second-choice antibiotic(s)c

Borrelia recurrentis (relapsing fever) A tetracycline Benzylpenicillin

Bonelia burgdorferi (Lyme disease) A tetracycline
Leptospira (Wail's disease) Benzylpenicillin A tetracycline
Rickettsiae A tetracycline A quinolone
a
(typhus, tick-bite fever, fever, etc.)
Other organisms
Mycoplasma pneumonlae A tetracycline or a macrolide Ciprofloxacin
Chlamydia (trachoma, A tetracycline
psittacosis, urogenital infections)
Actinomyces (abscesses) Benzylpenicillin A tetracycline
Pneumocyst1s (pneumonia, Co-trimoxazole (high dose) Pentamidine or atovaquone or
especially in AIDS patients) trimetrexate
Nocardia (lung disease, brain abscess) Co-trimoxazole

'This table is not meant to be a definitive guide for clinical treatment but a general indication of the main antimicrobial actions and thus
of the overall usefulness of commonly used antibiotics. For a more comprehensive list, see Laurence et al. (1997).
"Only the marn drseases caused by each organism are mentioned (in parentheses).
':t signifies that an agent is to be used with or without another agent; rf agents are to be used concomitantly, a plus sign only is used.
'An antiulcer drug, not an antibiotic (see Ch. 25).
'Not in the same syringe.

than Gram-positive bacteria. Thi& is the basis of the extraordinary
ntibiotic resistance exhibited by Pseudomonas aerugino.m, a
ra!hogen that can cau~c life-threatening infections in neutropenic
patient~ and tho~e with bums and wounds.
The cell wall lipopolysaccharide is also a major barrier to pen-
etration. Antibiotics affected include benzylpenicillin (peniciUin G),
methicillin. the macrolides, rifampicin (rifampin), fusidic acid,
lancomycin. bacitracin and novobiocin.
ANTIMICROBIAL AGENTS THAT
INTERFERE WITH THE SYNTHESIS OR
ACTION OF FOLATE
SULFONAMIDES
In a landmark discovery in the 1930s. Domagk demonstrated that
11 ~as possible for a drug to influence the course of a bacterial
mfection. The agent was prontosil, a dye that proved to be an
inactive prodrug but which is metabolised in vivo to give the active
product, sulfanila mide (Fig. 46. J ). Many sulfonamides have been
developed since, and some are still useful drugs although their
Importance has declined in the face of increasing resistance.
F.'amples include sulfadiazine (Fig. 46.1 ), sulfadimidine (short
3\:ung). sulfame thoxazole (intermediate acting), sulfameto-
p)razine (long acting), s ulfas alazioe (poorly absorbed in the
gastrointestinal tract: sec also Chs 14 and 25) and sulfamethoxazole
tin combination with trimetboprim as co-trimoxazole). In the
UK. only sulfamethoxazole, sulfadiazine and trimethoprim are
u'ed clinically.
Mechanism of action
Sulfanilamide is a structural analogue of p-aminobenzoic acid
{PABA; see Fig. 46.1 ), which is an essential precursor in the
synthesis of folic acid in bacteria. As explained in Chapter 45,
folate is required for the synthesis of the precursors of DNA and
RNA both in bacteria and in mammal-;, but whereas bacteria
need to synthesise folic acid, manunals can obtain it from dietary
sources. Sulfonamides compete with PABA for the enzyme
dihydropteroate ~)n rherase, and the effect of the su lfonamide
may be overcome by adding excess PABA. This is why some
local anaesthetics. which are PABA esters (such as procaine: see
Ch. 44). can antagonise the antibacterial effect of these agents.
The action of a sulfonamide is to inhibit growth of the bacteria,
not to kilf them; that is to say, it is bacteriostatic rather than
bactericidal. The action is vitiated in the presence of pus or
products of tissue breakdown, because lhese contain thymidine
and purines. which bacteria utilise directly, bypassing the require-
ment for folic acid. Resistance to the drugs, which is common, is
plasmid-mediated (see Ch. 45) and results from the synthesis of
a bacterial e nzyme insensitive to the drug.
Pharmacokinetic aspects
Most sulfonamidcs are readily absorbed in the gastroinlel>tinal tract
and reach maximum concentrations in the plasma in 4-6 hours.
They are U'>ually not given topicall} because of the risk of
sensitisation or allergic reactions.
The drugs pass into inflammatory exudates and cross both
placental and blood-brain barriers. They are metabolised mainly
in the liver, the major product being an acetylated derivative that
lacks antibacterial action.
Unwanted eHects
Mild to moderate side effects include nausea and vomiting,
headache and mental depression. Cyanosis caused by
methaemoglobinaemia may occur but is a lot less alarming than
it looks. Serious adverse effects necessitating cessation of therapy 663
 SECTION 5 DRUGS USED IN THE TREATMENT O F INFECTIONS AND CANCER

,,----- Pteridine ring---- -- ,-- p-Aminobenzoic- -~v' -Glutamic acid--

: : acid (PABA) : :
I I I I

Folic acid

H
,N
-Q!-so,NH-{J
Sulfanilamide Sulfadiazine
Fig. 46.1 Structures of two
representative sulfonamides and
trimethoprim. The structures
illustrate the relationship between the
sulfonamides and the p-aminobenzoic
acid moiety in folic acid (orange box),
as well as the possible relationship
between the antifolate drugs and
the pteridine moiety (orange).
Co-trimoxazole Is a mixture of
sulfamethoxazole and trimelhoprim. Trimethoprim (dihydrofolate reductase inhibitor)
\...____

include hepatitis. hypersensitivity reactions (rashes, fever,
anaphylactoid reactions), bone marrow depression and crystalluria.
This la~t efrect results from the precipitation of acetylated
metabolites in the urine.
TRIMETHOPRIM
Mechanism of action
Trimetho pri m is c he mically related to the antimalarial drug
pyrimet ha mine (Fig. 49.3), bo th being folate antagonists. Struc-
turally (Fig. 46. 1), it resembles the pteridine moiety of folate and
the similarity is close enough to fool the bacterial dihydrofolate
reductase, which is many times more sensitive to trimethoprim
than the equivalent e nzyme in humans (Table45. 1).
Trimclhoprim is active against most common bacterial pathogen,.
a nd it too is bacteriostatic. It is sometimes given as a mixture
with sulfamethoxazole in a combination called co-trimoxazole
( rig. 46. 1). Because sulfo namides inhibit the same bacterial
metabolic path way, but upstream from dihydrofolate reducta~.
they can pote ntiate the actio n of trimethopri m (see Fig. 46.2).
ln the UK, its usc is generally restricted to the treatment of
Pneumocystis carinii pneumonia, toxoplasmosis and nocardia~~~-

Clinical uses of sulfonamides Pharmacokinetic aspects

Combined with trimeUloprim (co-trimoxazole)
for Pneumocystis carinii.
Combined with pyrimethamine for drug-resistant
malaria (Table 49.1), and for toxoplasmosis.
In inflammatory bowel disease: sulfasalazine
(sulfapyridine-aminosalicylate combination) is used
(see Ch. 14, clinical box on p. 242).
For infected burns (silver sulfadiazine given topically).
For some sexually transmitted infections (e.g.
trachoma, chlamydia, chancroid).
For respiratory infections: use now confined to a few
special problems (e.g. infection with Nocardia).
For acute urinary tract infection (now seldom used).
664
Trimelhoprim is given orally. It is fully absorbed from the ga~trolll
testinal tract and widely distributed throughout the tissues ana
body nuids. lt reaches high concentrations in the lungs ano
kidneys, and fairly high concentrations in the cerebrospinal fluid
(CSF). When given with sulfamethoxazole, about balfthedoseof
each i~ excreted within 24 hours. Because trimethoprim b a
weak base. it~ elimination by the kidney increases with decreasin~
urinary pH.
Unwanted effects
Unwanted effects of trimethoprim include nausea, vormtmg.
blood disorders and skin rashes. Folate deficiency, with rc5ultant
megaloblastic anaemia (see Ch. 22)-a toxrc effect related to the
pharmacological action of lrimethoprim-can be prevented b)
givi ng fo linic acid.

PABA
D1hydropteroate ~
synthetase ~ he called pe nicillin. This substance wa::. subsequently extracted
Folate
Tetrahydrofolate
l
Synthesis of
thymldylate etc.
!
DNA
Fig. 46.2 The action of s ulfonamides and trimethoprim
on bacterial fo late synthesis. See Figure 22.2 for more detail
of tetrahydrofolate synthesis, and Table 45.1 for comparisons
of antifolate drugs. PABA, p-aminobenzoic acid.
Clinical uses of trlmethoprim/
co-trimoxazole
For urinary tract and respiratory infections:
trimethoprim, used on its own, is usually preferred.
For infection with Pneumocystis carinii, which causes
pneumonia in patients with AIDS: co-trimoxazole is
used in high dose.
Antimicrobial agents that Interfere with
the synthesis or action of folate
Sulfonamides are bacteriostatic; they act by
interfering with folate synthesis and thus with
nucleotide synthesis. Unwanted effects include
crystalluria and hypersensitivities.
Trimethoprim is bacteriostatic. It acts by antagonising
folate.
Co-trimoxazole 1s a mixture of trimethoprim with
sulfamethoxazole, which affects bacterial nucleotide
synthesis at two po1nts 1n the pathway.
~ -LACTAM ANTIBIOTICS
PENICILLIN
In 1928, Alexander Fleming. working at St Mary's Hospital in
l{)ndon, observed that a culture plate on which staphylococci were
being grown had become contaminated with a mould of the genus
ANTIBACTERIAL DRUGS
Penicillium, and that bacterial growth in the vicinity of the mould
had been inhibited. He isolated the mould in pure culture and
demonstrated that it produced an antibacterial substance, which
and its antibacterial effect!> analysed by Florey, Chain and their
colleague<, at Oxford in 1940. They showed that it had powerful
chemotherapeutic properties in infected mice, and that it wa<,
non-toxic.
The remarkable antibacterial effects of penicillin in human~
were clearly demonstrated in 1941. A small amount of penicillin,
extracted laboriously from crude cultures in the laboraLOrie::. of the
Dunn School of Pathology in Oxford. was given to a policeman
who had staphylococcal and l>treptococcal septicaemia with multiple
abscesses, and osteomyelitis with discharging sinuses. He was in
great pain and wns desperately ill, and although sulfonamides were
available, they would have had no ciTect in the presence of pus. Intra-
venous injections of penici ll in were g iven to the policeman eve1y
3 hours. All the patient's urine was collected, and each day the
bulk of the excreted penicillin was extracted and reused. After
5 days, the patient's condition was vastly improved; his temperature
was normal, he was eating well, and there was obvious resolution
of the abscesses. Furthem1ore, there seemed to be no toxic effects
of the drug. Unfortunately. when the supply of penicillin was
finally exhau~ted hi~ condition gradually deteriorated and he died
a month later.
Although thi~ wa:, the fin,t evidence of the dramatic antibacterial
effect of penicillin when given systemically in humans, topical
penicillin had actuall) been u!.>ed with success in five patients with
eye infections I 0 yearo, previou.o,ly by Paine. a graduate of St Mary's
who had obtained some penicillin mould from Fleming.
While the penicillins are extremely effective antibiotics and are
very widely used, they may be destroyed by bacterial arnidases
and ~-lactamases (penicillinases) (see Fig. 46.3).
Mechanisms of action
All ~-J actam antibiotics interfere with the synthesis of the
bacterial cell wall peptidoglycan (see Ch. 45, Fig. 45.3). After
attachment to penitillin-bindi11g proteins on bacteria (there may
be seven or more type~ in different organisms), they inhibit the
transpeptidation cnL.yme that cross-links the peptide chains attached
to the backbone of the peptidoglycan.
The final bactericidal event is the inactivation of an inhibitor of
autolytic en1ymcs in the cell wall, leading to lysis of the bacterium.
Some organisms. referred to as 'tolerant', have defective autolytic
enzymes and are inhibited but not lyl:>ed in the presence of the
drug. Re~istancc to penicillin may result from a number of different
causes and is discussed in detail in Chapter 45.
Types of penicillin and their antimicrobial
activity
The first penicillins were the naturally occurring ben7ylpenicillin
and its congeners, including phenoxymethylpenicillin. Benzyl-
penicillin is active againM a wide range of organisms and is the
drug of first choice for many infections (see Table 46.1 and the
clinical box). Its main drawbacks are poor absorption in the
gastrointestinal tract (which means it must be given by injection)
and its susceptibility to bacterial ~-l actamases. 665
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER

( 0
II H s CH3
R 1 -C+N~ /::.~CH3
J B ~
Amidase / N COOH
0
Fig. 4 6 .3 Basic structures of f}-Lactamase _,}
four groups of ~-lactam

antibiotics and clavulanic acid. Penicillin nucleus Cephalosporin nucleus
The structures illustrate the ~-lactam
ring (marked B) and the sites of
action of bacterial enzymes that
inactivate these antibiotics (A,
thiazolidine ring). Various
substituents are added at R1, R2
and R3 to produce agents with
different properties. In
carbapenems, the stereochemical
configuration of the part of the ~ Monobactam nucleus Carbapenem nucleus
lactam ring shown shaded in orange (tl-lactamase resistant) (high resistance to ~-lactamases)
here is different from the
corresponding part of the penicillin ,- ------------- ----------------~
I
and cephalosporin molecules; this is I

probably the basis of the ~

lactamase resistance of the
carbapenems. The ~-lactam ring of 0
clavulanic acid is thought to bind
strongly to 13-lactamase, meanwhile
protecting other 13-lactams from the Clavulanic acid
enzyme. (inh1bits many ~-lactamases)

Various scmi~ynthctic penicillins have been prepared by adding
different side-chains to the penicillin nucleus (at Rl in Fig. 46.3). In
this way, P-lactamase-rel.istant peniciiJjns (e.g. flucloxacillin)
and broad-spectrum penicillins (e.g. ampicillin. pivampicillin
and amoxicillin) have been produced. Extended-spectrum
penicillins (e.g. ticarcilin ) with an tipseudomonal activity have
also been developed and have gone some way to overcoming
the problem of serious infections caused by P. aeruginosa.
Amoxicill in is sometimes combined with P-lactamase inhibitor
clavula n ic acid as co-amoxiclav.
Pharmacokinetic aspects
When given orally, different penicillins are absorbed to differing
degree!> depending on their stability in acid and their adsorption
to foodstuffs in the gut. Penicillins can be given by intramuscular
or intravcnou!. injection. but intrathecal administration is
inadvisable. panicularly in the case of benzylpenicillin. as it can
cause con\'ulsions.
The penicillins :1re widely distributed in body fluids. passing
into joints; into pleural and pericardia! cavities: into bile, saliva and
milk; and across the placenta. Being lipid-insoluble. they do not
enter mammalian cell!> and do not. therefore. cross the blood-brrun
barrier unless the meninges are inflan1cd, in which case they readily
reach therapeutically effective concentrations in the CSF as well.
Elimination of mo~t penicillins occurs rapidly and is mainly renal,
90o/c being through tubular secretion. The relatively short plasma
half-life is a potential problem in the clinical use of benzylpenicillin,
666 although because penicillin works by preventing cell wall synthesis
in di\'iding organi~m!:>, intermittent rather than continuous expo'ure
to the drug can be an advantage.
Clinical use of the penicillins
Penicillins, often combined with other antibiotics. are cruc1all1
important in antibacterial chemotherapy. They are the drug' of
choice for many infections. A list of clinical uses is given in Ilk
clinical box and also in Table 46.1.
Unwanted effects
Penici II ins are relatively free from direct toxic effects (other than
their proconvulsant effect when given intrathecally). The matn
unwanted effects are hypersensitivity reactions caused by tht
degradation products of penicillin, which combine with hOSI
protein and become antigenic. Skin rashes and fever are coi11JllQll;
a delayed type of serum '>ickness occurs infrequently. Much nm
serious is acute anaphylactic shock. which although fonunatel}
very rare, may in some cases be fatal. When given orall}
penicillins. panicularly the broad-spectrum type, alter the bacter
nora in the gut. This can be associated with gasrroimesun:
disturbances and in some cases with suprainfection by othri
penicillin-insensitive, micro-organisms.
CEPHALOSPORIN$ AND CEPHAMYCINS
Cephalosporins N and C, whjch are chemically related k>
penicillin, and cephalosporin P, a steroidal antibiotic that resembk'
fusidic acid (sec below), were first isolated from Cephalosporirm. ar..:
 ANTIBACTERIAL DRUGS

Mechanism of action
Clinical use s of the penicillins
The mechanism of action of these agents i s similar to that of the
penicillins: interference w ith bacterial peptidoglycan synthesi!. after
Penicillins are given by mouth or, in more
binding to the 1}-lactam-binding proteins. This is described in detail
severe infect ions, intravenously, and often in
in Chapter 45 and illuJ>Lrated in Figure 45.3. Resistance to this group
comb1nat1on with other antibiotics.
of drugs has i ncrcased because of plasmid-encoded or chromosomal
Uses are for sensitive organisms and may (but may
1}-lactamasc. Nearly all Gram-negative bacteria have a chromosomal
not: individual sensitivity testing is often appropriate
gene coding for a ~-lactarnase that is more acti ve in hydrolysing
depending on local conditions - see below) include:
cephalosporins than penicillins. and in several organisms a single
bacterial meningitis (e.g. c aused by Neisseria
mutation can result in high-level constitutive production of this
meningitidis, Streptococcus p neumoniae):
cn;ymc. Rc~istancc also occurs when there is decreased penerration
benzylpenicillin, high doses intravenously
of the drug as a result of alterations to outer membrane proteins. or
bone and joint infecti ons {e.g. with
mutations of the binding-site proteins.
Staphylococcus aureus): fluc loxacillin
skin and soft tissue infections {e.g . with Strep.
pyogenes or Staph. aureus): benzylpenicillin, Pharmacokinetic aspects
flucloxacillin; animal bites: co-amoxiclav Some cephalosporins may be given orally (see Table 46.2), but most
pharyngitis (fro m Strep. pyogenes): are given parenterally, intramuscularly (which may be painful) or
phenoxylmethylpenic illin intravenously. After absorption, they are widely distributed in the
otitis media {organisms commonly inc lude Strep. body and some, such as cefotaxime, cefuroxime and ceftriaxone,
pyogenes, Haemophilus influenzae): amox icillin cross the blood- brain barrier. Excreti on is mostly via the kidney,
bronchitis {mixed infections common): amoxic illin largely by tubular secretion, but40% of ceflriaxone i s elj minated
pneumonia: amoxicillin in the bile.
urinary tract infections (e.g. with Escherichia coli):
amoxicillin Clinical use
gonorrhea: amoxic illin {plus probenecid) Some clinical uses of the cephalosporins are given in Table 46.2
syphilis: procaine benzylpenic illin and in the clinical box.
endocarditis (e.g. with Strep. viridans or
Enterococcus faecalis)
Unwanted eHects
ure serious infections with Pseudomonas aeruginosa:
Hypersensitivity reactions, very imiJar to those seen with penicillin.
ticarc illin, piperacillin.
may occur, and there may be some cross-sensitivity: about 10% of
This list is not exhaustive. Treatment with penicillins is
penicillin-sen!>itive individual:. will have allergi c reactions to
sometimes started emp irically, if t he likely causative
cephalo!>porins. Nephrotoxicity has been reported (especially with
organism is one th ought to be susceptible to
111) cefrad ine), as has drug-induced alcohol intolerance. Diarrhoea can
of penicillin, while awaiting the results of laboratory tests occur with oral cephalosporins and cefoperazone.
the to identify the organism and determine its antibiotic
susceptibility.

han
1ain
the
lO!'.t fungus. The cephamycins arc ~-lactarn antibiotics produced by Clinical uses of the cephalosporin&
1on: Su-epromrces organi!.ms. and they arc closel y related to the
ore cephalo~porins. Cephalosporins are used to treat infections
[eJ) Semi,ynthetic broad-spectrum cephalosporins have been caused by sensitive organisms. As with other
Ill y. nroduced by addition. to the cephalosporin C nucleus. of different antibiotics, patterns of sensitivity vary geographically,
rial ''<It-chains at R I and/or R2 (see Fig. 46.3). These agents arc and treatment is often started empirically. Many
mal Jicr-soluble and relati vely aci d-stable. They vary in sus- different kinds of infection may be treated, including:
her. ceptibility to ~- lactama!>es. There are now a very large number of septicaemia {e.g. cefuroxime, cefotaxime)
cephalosporins and cephamycins available for clinical use. pneumonia caused by susceptible organisms
Original members of the group such as cefradine. cef al exin fmd meningitis (e.g. c eftriax one, cefotaxime)
cefradoxil have largely been replaced with 'second-generation' biliary tract infection
drugs such as cefuroxime, ccfalcor and ccfproziJ, or 'third- urinary tract infection (especially in pregnancy or
to generation' drugs such as cc fotax ime, ceftazidime and in patients unresponsive to other d rugs)
Jlcs ceftri axone. The acti ons and properties or some of these drugs sinusitis {e.g. cefadroxil).
tll/11 are described in Table 46.2. 667
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER

Table 46.2 Cephalosporins and cephamycins

Categories, w ith exa mple(s) Important properties Similar drug(s)

Oral drugs
Cefalexin (t 112 1 h) An example of the first-generation
compounds that have reasonable activity
against Gram-positive organisms and
modest activity against Gram-negative
organisms
Cefachlor (t 112 0.8 h) IS a second-generation
compound with greater potency against Gram-
negative organisms, but it can cause unwanted
cutaneous lesions

Parenteral drugs
Cefuroxime (t112 1.5 h)
An example of the second-generation
compounds that show only moderate
activity against most Gram-positive
organisms but reasonable potency
against Gram-negative organisms
Cephamandole, cefoxitin (t112 of both -1 h), good
activity against Gram-negative organisms, resistant
to P-lactamase from Gram- negative rods, good
potency against Bacteroides fragilis, bowel flora

Cefotaxlme (t 112 1 h)
An example of the third-generation
compounds, which are less active against
Gram-positive bacteria than those of the
second generation but more active against
Gram- negative bacteria. Has some activity
against pseudomonads.
Ceftizoxlme (t112 1.5 h); ceftriaxone (t 112 8.5 h),
exc reted largely in the bile; cefperazone (t112 2 h),
excreted mainly in the bile, can cause decrease
of vitamin K-dependent clotting factors.

OTHER ~- LACTAM ANTIBIOTICS
CARBAPENEMS AND MONOBACTAMS
Carbapenems and monobactams (see Fig. 46.3) were developed to
deal with ~-lactamase-producing Gram-negative organism:.
resistant to penici ll in~.
CARBAPENEMS
lmipcnem. an exam ple of a carbapenem, acts in the same way as
the other ~- l actams (see Fig. 46.3). It has a very broad spectrum of
antimicrobial activity, being active against many aerobic and
anaerobic Gram-positive and Gram-negative organisms. However,
many of the ' methicillin-resistant' staph ylococci (see p. 656)
are less suscepti ble, and resistant strains of P. aeruginosa have
emerged during therapy. lmipenem was originally resistant to all
~- l actamases, but some organisms now have chromosomal genes
that code for imipenem-hydrolysing !3-lactamases. It is sometimes
given together with cilastatin , which inhibits its inactivation by
renal cntymes. Meropenem is J.imilar but is not metabolised by
the kidney. Ertapenem ha.\ a broad spectrum of antibacterial actions
but is licen!.ed only for a limited range of indications.
Unwanted effects arc generally similar to those seen with other
~-lactams, nausea and vomiting being the most frequently seen.
Neurotoxicity can occur with high pla~ma concentrations.
MONOBACTAMS
The main monobactam is aztreonam, a simple monocyclic ~
lactam with a complex substituent at R3 (see Fig. 46.3), which is
resistant to most ~- l actama.~es. It is given parenterally and has
a plasma half-li fe of 2 hours. Aztreonam has an unusual
668 spectrum of activity and is effective only against Gram-negative
aerobic rods ~uch as p~eudomonads. Neisseria meningitidis and
Haemophilus influen-;.ae. It has no action against Gram-p<l\itlle
organisms or anaerobes.
Unwawed e.Dects arc. in general. similar to those of other
j3-lactam antibiotics. but this agent does not necessaril) cro'>Hea:t
immunologically with penicillin and its products, and sodoe'!kX
usually cause allergic reactions in penicillin-sensitive individual-.
ANTIMICROBIAL AGENTS AFFECTING
BACTERIAL PROTEIN SYNTHESIS
TETRACYCLINES
Tetracyclines arc broad-spectrum antibiotics. The group includes
tetracycline, oxytetracycline, demeclocycline, lymecycline,
doxycycline and minocyclinc.
Mechanism of action M
Following uptake into l.usceptibJe organisms by active transpon.
tetracyclines act by inhibiting protein synthesis. This action li
described in detail in Chapter 45 (see Fig. 45.4). The tetrac;cli!lel
arc regarded as bacterio\tatic. not bactericidal.
Antibacterial spectrum
The spectrum of antimicrobial activity of the tetracyclines is \c:' gene
wide and includes Gram-positive and Gram-negative bacteri: res is
Mycoplasma, Rickettsia, Chlamydia spp.. spirochaetes and ~om: tetra
protozoa (e.g. amoebae). Minocycline is also effective agains
N. eningitidi.l and has been used to eradicate this organism fm Pha
the nasopharynx of carriers. However. widespread resistance u 'Jhe.:
these agents has decreased their usefulness (see p. 658
Resistance is tran~milted mainly by plasmids and, because the gene~
controll ing resista nce to tetracyciLnes are closely associated witb

PLactam antibiotics
Bactericidal by interference with peptidoglycan
synthesis.
Penicillins
The first choice for many infections.
Benzylpenicillin:
given by injection, short half-life and is destroyed
by P-lactamases
spectrum: Gram-positive and Gram-negative
cocci and some Gram-negative bacteria
many staphylococci are now resistant.
~-Lactamase-resistant penicillins (e.g. flucloxacillin):
given orally
- spectrum: as for benzylpenicillin
- many staphylococci are now resistant.
Broad-spectrum penicillins (e.g. amoxicillin):
given orally; they are destroyed by P-lactamases
spectrum: as for benzylpenicillin (although less
potent); they are also active against Gram-
negative bacteria.
Extended-spectrum penicillins (e.g. ticarcillin):
gtven orally; they are susceptible to ~-lactamases
- spectrum: as for broad-spectrum penicillins; they
are also active against pseudomonads.
Unwanted effects of penicillins: mainly hypersensitivities
A combination of clavulanic acid plus amoxicillin or
ticarcillin is effective against many P-lactamase-
producing organisms.
Cephalosporins and cepham ycins
Second choice for many infections.
Oral drugs (e.g. cefachlor) are used in urinary infections.
Parenteral drugs (e.g. cefuroxime, which is active
against Staphylococcus aureus, Haemophilus
influenzae, Enterobacteriaceae).
Unwanted effects: mainly hypersensitivities.
Carbapenem s
lmipenem is used with cilastin, which blocks its
breakdown in the kidney.
lmipenem is a broad-spectrum antibiotic.
Monobactams
Aztreonam is active only against Gram-negative
IS
aerobic bacteria and is resistant to most
~-lactamases.
~~nes for resistance to other antibiotics, organisms may develop
C\i\tance ro many drugs simuhaneously. The clinical use of the
rtracyclines is given in the clinical box.
Pharmacokinetic aspects
Thetetracyclines are generally given orally but can also be admin-
1\tered parenterally. The absorption of most preparations from
the gut is irregular and incomplete but may be improved in the
h Jbsence of food. Because tetracyclines chelate metal ions (calcium,
ANTIBACTERIAL DRUGS
Clinical uses of tetracyclines
The usefulness of tetracyclines has declined
because of widespread drug resistance. Most
members of the group are microbiologically similar;
doxycycline is given once daily and may be used in
patients with renal impairment. Uses (sometimes in
combination with other antibiotics) include:
rickettsial and chlamydia/ infections, brucellosis,
anthrax and Lyme disease
as useful second choice, for example in patients
with allergies, for several infections (see Table
46.1), including mycoplasma and leptospira
mixed respiratory tract infections (e.g.
exacerbations of chronic bronchitis)
acne
inappropriate secretion of antidiuretic hormone
(e.g. by some malignant lung tumours), causing
hyponataemia: dem eclocycline inhibits the action
of this hormone (Ch. 28, p. 426).
magnesium, iron, aluminium), forming non-absorbable com-
plexes, absorption is decreased in the presence of milk, certain
antacids and iron preparations. Minocycline and doxycycline are
virtually completely absorbed.
Unwanted eHects
The commonest unwanted effects arc gastrointestinal disturbances
caused initially by direct irritation and later by modification
of the gut flora. Vitamin B complex deficiency can occur, as
can suprainfection. Because they chelate Ca2+, tetracyclines arc
deposited in growing bones and teeth, causing staining and
sometimes dental hypoplasia and bone deformities. They should
therefore not be given to children, pregnant women or nursing
mothers. Another hazard to pregnant women is hepatotoxicity.
Phototoxicity (sensitisation to sunlight) has also been seen. particu-
larly with demeclocycline. Minocycline can produce dose-related
ve tibular disturbances (dizziness and nausea). High doses of
tetracyclines can decrease protein synthesis in host cells- an
antianabolic effect that may result in renal damage. Long-tcrrn
therapy can cause disturbances of the bone marrow.
CHLORAMPHENICOL
Chloramphenicol was originally isolated from cultures of
Streptomyces. The drug binds to the same site of the 50S subunit
of the bacterial ribosome as erythromycin and clindamycin,
and acts to inhibit bacterial protein synthesis as descri bed in
Chapter 45 (see Fig. 45.4). The clinical use of chloramphenicol
is given in the box.
Antibacterial spectrum
Chloramphenicol has a wide spectrum of antimicrobial activity,
including Gram-negative and Gram-positive organisms and rickett- 669
 SECTION 5 DRUGS USED IN THE TREATMENT O F IN FECTIONS AN D CAN CER
Clinical uses of chloramphenicol
Chloramphenicol should be reserved for
serious 1nfect1ons in which the benefit of the drug
outweighs its uncommon but serious haematological
toxicity. Such uses may include:
infections caused by Haemophilus influenzae
resistant to other drugs
meningitis in patients in whom penicillin cannot be
used.
It is also safe and effective in bacterial conjunctivitis
(given topically).
It is effective in typhoid fever, but ciprofloxacin or
amoxicillin and co-trimoxazole are similarly effective
and less toxic.
Other possible uses are given in Table 46.1.
siae. lt is bacteriostatic for most organisms but kills H. injTuen::.ae.
Resistance, caused by the production of chloramphenicol
acetyltran.iferase (seep. 658), is plasmid-mediated.
Pharmacokinetic aspects
Given orally, chloramphenicol is rapidly and completely
absorbed and rcache'> its maximum concentration in the plasma
within 2 hour\; it can al<.o be given parenterally. The drug is
widely distributed throughout the tissues and body fluids
including the CSF. where its concentration may reach 60% of
that in the blood. In the plasma. it is 30-50% protein-bound. and
its half-life i., approximately 2 hours. About 10% is excreted
unchanged in the urine, and the remainder is inactivated in the
liver.
Unwanted eHects
The most important unwanted effect of chloramphenicol is
severe. idiosyncratic depression of the bone marrow, resulting in
pancytopenia (a decrease in aJI blood cell elements)-an effect
that, although rare, can occur even with very low doses in some
individuals. Chloramphenicol should also be used with great care
in newboms, because inadequate inactivation and excretion of the
drug (sec Ch. 52) can result in the 'grey baby syndrome'-vomiting,
diarrhoe~ flaccidity, low temperature and an ashen-grey colour-
which carricl> 40Ck mortality. If its use is essential, plasma concen-
trations '>hould be monitored and the dose adjusted accordingly.
Hypersensitivity reactions can occur with the drug. as can gastroin-
te tinal disturbances secondary to alteration of the intestinal
microbial nora.
AMINOGLYCOSIDES
The aminoglycosidcs arc a group of antibiotics of complex
chemical structure, resembling each other in antimicrobial
activity, pharmacokinetic characteristics and toxicity. The main
agents are genta micin, streptomycin, amikacin, tobram ycin ,
670 netilmicin and neomycin.
Mechanism of action
Aminoglycosides inhibit bacterial protein synthesis (see Ch 45
Their penetration through the cell membrane of the bacteriu
depends partly on oxygen-dependent active transpon by 1
polyamine carrier system, and they have minimal action agai
anaerobic organi<;ms. Chloramphenicol blocks this transpon S)~tc:m
The effect of the aminoglycosides is bactericidal and is enhaoca!
by agent~ that interfere with ceU wall synthesis. Some clinical uses
of the aminoglycosides are given in Table 46.1.
Resistance
Resistance to aminoglycosides is becoming a problem. It occur~
through several different mechanisms, the most important being
inactivation by microbial enL.ymes, of which nine or more ar~
known. Amikacin was purposefully designed as a poor substrmc
for these enzymes, but some organisms have developed enzyme-
that inactivate this agent as well. Resistance as a rcsull of failurt
of penetration can be largely overcome by the concomitant use of IIlli
Cllll
penicillin and/or vancomycin.
Ill hi
Antibacterial spectrum of1
The aminoglyco!.ides are effective against many aerobic Grclr"
negative and some Gram-positive organisms (see Table 46.1 ). The
are most widely used against Gram-negative enteric organi~IU}
and in sepsis. They may be given together with a penicillin m ror
streptococcocal infections cau!>ed by Listeria sp. and P. aeru~lllllS/l gen
(see Table 46.1 ). Gentamicin is the aminoglycoside most commoolj ma
used. although tobramycin i'> the preferred member of this group
for P. aemginosa infections. Amikacin has the widest amimicrob
spectrum and, along with netilmicin. can be effective in infecuons
with organisms resistant to gentamicin and tobramycin.
Pharmacokinetic aspects
The aminoglycosides are polycations and therefore highly polar.
They arc not absorbed from the gastrointestinal tract and are usual!) trat
given intramuscularly or intravenously. They cross the placenta ba~
but do not cross the blood-brain bruTicr, penetrate into the vitreou~ the
humour of the eye or into most other secretions or body fluid\ of
although high concentrations can be attained in joint and pleural
fluids. The plasma half-life is 2-3 hours. Elimination is virtual!)
entirely by glomerular filtration in the kidney, 50-60% of a do-e
being excreted unchanged within 24 hours. If renal function i1
impaired. accumulation occurs rapidly, with a resultant increa"
in those toxic effects (such as ototoxicity and nephrotoxicity. t
below) that are dose-related.
Unwanted eHects
Seriou!., do!.e-related toxic effects, which may increase as treauncol
proceeds, can occur with the aminoglycosides, the main hazards
being ototoxicity and nephrotoxicity.
The ototoxicity involves progressive damage to, and eventual!)
destruction of. the sen~ory cells in the cocWea and vestibular org-...
of the car. The re!>ult, usually irreversible. may manifest as vertig11
ataxia and loss of balance in the case of vestibular damage, and aud1
tory disturbances or deafness in the ca~e of cocWear damage. An)
aminoglycosidc may produce both types of effect, but streptomycin
and gentamicin arc more likely to interfere with vestibular function.

whereas neomycin and amikacin mostly affect hearing. Nctilmicin
5). i' IN ototoxic than other aminoglycosides and is preferred when
l1l
prolonged usc is necessary. Ototoxicity is potentiated by the con-
a comitant use of other ototoxic drugs (e.g. loop diuretics; Ch. 24).
bt
The nephrotoxicity consisll. of damage to the kidney tubules. and
n. can be reversed if the usc of the dmgs is stopped. Nephrotoxicity
d 'more likely to occur in patients with pre-exi'>ting renal disea~e
Tin conditions in which urine volume is reduced, and concomitant
use of other nephrotoxic agents (e.g. cephalosporins) increases the
n,L.. 1 ote rhat as the elimination of these drugs is almost entirely
renal. their nephrotoxic action can impair their own excretion, and
a vicious cycle may develop. Plasma concentrations should be moni-
g ored regularly. S pectinomycin i~ related to the aminoglycosides
rc in structure, but its use is confined to the treatment of gonorrhoea
mpatients allergic to penicillin, or in those whose infections are
cau~ed by penicillin-resistant gonococci.
A rare but serious toxic reaction is paralysis caused by neuro-
mu-cular blockade. This is usually seen only if the agents are given
concurrently with neuromuscular-blocking agents. It results from
mhibiuon of the Ca2+ uptake necessary for the cxocytotic release
of acetylcholine (see Ch. I 0).
MACROLIDES
For40 years. erythromycin was the only macrolide antibiotic in
general clinical use. (The term macrolide relates 10 the structure-a
many-membered lactone ring to which one or more deoxy sugars
.ue attached.) Several additional macrolide and related antibiotics
are now available, the two most important of which arc
darithromycin and azithromycin. Spiramycin and telthromycin
.lfe also macrolides but are of minor utility.
Mechanism of action
The macroJjdcs inhibit bacterial protein synthesis by an effect on
tran~location (fig. 45.4). Their action may be bactericidal or
bacterio~tatic, the effect depending on the concentration and on
the type of micro-organism. The drugs bind to rhe same 50S subunit
of the bacterial ribosome as chloramphenicol and clindamycin,
.md the three drugs may compete if given concurrently. The clinical
u'e of the macrolides i:, given in Table 46.1.
Antimicrobial spectrum
The antimicrobial spectrum of erythromycin is very similar to that
of penicillin. and it has proved to be a safe and effective alternative
for penicillin-sensitive patients. Erythromycin is effective against
Grnrnpositive bacteria and spirochaete.<; but not against mo~t Gram-
negative organi~ms, exceptions being N. gonorrhoeae and, to a
lesser extent, H. influen::.tle. Mycoplasma pneumoniae, Legionel/a
'P and some chlamydia! organisms arc also ~usceptible (sec
Table 46. 1). Re~istance can occur and results from a plasmid-
controlled alteration of the binding site for erythromycin on the
bacterial ribosome (Fig. 45.4).
ALithromycin is les'> active against Gram-positive bacteria
than erythromycin but is considerably more effective against
H. influenzae and may be more active against Legionella. It has
excellent action again~t Toxoplasma gondii, killing the cym.
Clarithromycin is as active, and its metabolite is twice as active,
ANTIBACTERIAL DRUGS
against H. injluen:,ae as erythromycin. It is also effective against
M1cobacterium alium-imercellulare (which can infect immu-
nologically compromised individuals and elderly patients with
chronic lung disease), and it may also be useful in leprosy and
against Heficobacrer pylori (see Ch. 25). Both the~c macrolides
arc also effective in Lyme disease.
Pharmacokinetic aspects
The macrolides are administered orally, azithromycin and
clarithromycin being more acid-stable than erythromycin.
Erythromycin can also be given parenterally, a lthough intra-
venous injections can be followed by localthrombophlebiw. All
three diffuse readily into most tissues but do not eros!. the
blood-brain barrier, and there is poor penetration into syno' ial
fluid. The plasma half-life of erythromycin is about 90 minutes;
that of clarithromycin is three times longer, and that of
azithromycin 8-16 times longer. Macrolides enter and indeed
arc concentrated within phagocytes-atithromycin concen-
trations in phagocyte lysosomes can be 40 times higher than in
the blood-and they can enhance intracellular phagocyte killing
of bacteria.
Erythromycin is partly inactivated in the liver; aLithromycin
is more resi~tant to inactivation, and clarithromycin is converted
to an active metabolite. Their effects on the P450 cytochrome
sy'>tem can affect the bioavailability of other drug., (see Ch. 52).
The major route of elimination is in the bile.
Unwanted eHects
Gastrointestinal disturbances are common and unpleasant but
not seriou'>. With erythromycin, the following have also been
reported: hypersensitivity reactions such as skin rashes and fever,
transient hearing disturbances and, rarely, following treatment
for longer than 2 week!.. cholestatic jaundice. Opportunistic
infections of the gastroi ntestinal tract or vagina can occur.
STREPTOGRAMINS
Quinupristin and dalfopristin are member, of the streptograrnin
fami ly of compounds isolated from Streptomyces pristinaespiralis.
These agents are characterised by a cyclic peptide structure.
They act by inhibiting bacterial protein synthesis. Individually,
quinupristin and da lfopristin exhibit only very modest bacterio-
static acti' ity, but combined together as an intravenous injection
they are active against many Gram-positive bacteria.
Mechanism of action
Coadministration of quinupristin-dalfopristin (3 parts to 7 parts.
weight for weight) is an effective approach to the treatment of
serious infections, usually where no other antibacterial is suitable.
For example, the combination is effective again~t methicillin-
sensitive Staphylococcus aureus and is also active against
vancomycin-resistant Enterococcus faeciwn. The mechanism of
action is to inhibit protein formation by binding to the 50S subunit
of the bacterial ribosome. Dalfopristin changes the structure
of the ribosome t.o as to promote the binding of quinupristin,
which probably explains the improved effectiveness of the drugs
when administered together. 671
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
Pharmacokinetic aspects
BOLh quinupri~tin and dalfopri~tin are broken down in the liver
and mu~t therefore be given as an intravenous infusion. The half-
life of each compound is 1-2 hours.
Unwanted eHects
Unwanted effect~ include inflammation and pain at the infu~ion
site. arthralgia. myalgia and nausea, vomiting and diarrhoea. To
date. resi~tance to quinupristin and dalfopristine does not seem to
be a major problem.
LINCOSAMIDES
Clindamycin is active againl:.l Gram-positive cocci, including many
penici llin-resistant Maphylococci and many anaerobic bacteria such
as Bacremides species. its mechanism of action involves inhibition
of protein synthesis through an action simiJar to that of the macrolides
and chloramphenicol (Fig. 45.4). In addition to its use in infections
caused by Bacteroides organisms, it is used to treat staphylococcal
infections of bone!> and joints. It is also given topically, as eye
drops. for staphylococcal conjunctivitis.
Pharmacokinetics
Clindamycin may be given orally or parenterally and i widely
distributed in ti~'>ue~ (including bone) and body fluids. although
it docs not cross the blood-brain barrier. There is active uptake
into leucocyte~. The half-life is 21 hours; some of the drug is
metaboli\ed in the liver. and the metabolites. which are active.
are excreted in the bile and the urine.
Unwanted eHects
Unwanted effects consist mainJy of gastrointestinal disturbances.
and a potentially lethal condition, pseudomembranous co/iris.
may develop. Thi~> is an acute inflammation of the colon caused
by a nccrotising toxin produced by a clindamycin-resistant
organism, Clostridium d(ffirile, which may form part of the
normal faecal tlora. 2 Vancomycin, given orally, 1md metronidazole
(sec below) arc effective in the treatmen t of this condi tion.
OXALAZIDONONES
Hailed a~ the first truly new class of antibacterial agents to reach
the marketplace in . everal decades' (Zurenko et al., 2001 ). the
oxalizidonones boa't a novel mechanism of action on bacterial
protein synthe~is: inhibition of N-fonnylmethionyl-tRNA binding
to the 70S ribosome. Linezolid is the first member of this new
antibiotic family to be introduced. It is active against a wide
variety of Gram-positive bacteria and is particularly useful for the
treatment of drug-resistant bacteria such as methicillin-resistant
Staph. au reus. penicillin-resistant Streptococcus pneumoniae and
vancomycin-resistant enterococci. The drug i& also effective against
some anaerobes. ~uch as C. difficile. Most common Gram-negative
organisms are not sul.ceptiblc to the drug. Linezolid can be used
672 2
This may also occur with snme penici ll ins and ccphal osporins.
to treat pneumonia, septicaemia, and skin and soft tissue infection
The drug i~ u~ually restricted to serious bacterial infecuo
where other antibiotics have failed.
It i~ encouraging to report that, so far, there have been ft
reports of lineLOlid resistance, although there is a risk thi~ m:..
develop if patients receive inadequate doses for exten~<
period,.
Pharmacokinetics
Line?Oiid can be given ora!Jy or by intravenous infusion m
serious infections. After oral administration, peak pla'ma
concentrations are achieved quickly. and the drug has a halfli:
of 5-7 hours. Metabolism is through oxidation of the morpholir..
ring structure.
Unwanted eHects
Unwanted effects include thrombocytopenia, diarrhoea. nau,e.
and, rarely, ra~h and diLZincss. Linezolid is a non-selective inhibit
of monoamine oxidase. and appropriate precautions need to be
observed (sec Ch. 37).
FUSIDIC ACID
Fusidic acid is a narrow-spectrum steroid antibiotic active maml
against Gram-positive bacteria. It acts by inhibiting bacteriaJ protem
synthesi-. (Fig. 45.4 ). As the sodium salt. the drug is well absorbed
from the gut and is distributed widely in the tissues. Some IS
excreted in the bile and some metabolised.
Unll'allted effect:. such a~ ga~trointestinal disturbances arc fair!)
common. Skin eruptions and jaundice can occur. It is also U'ol'd
topically for staphylococcal conjunctivitis.
ANTIMICROBIAL AGENTS AFFECTING
TOPOISOMERASE
FLUOROQUINOLONES
The fluoroquinolones include the broad-spectrum agent~
ciprofloxacin, le vofl oxaci n, oflo xacin, norfloxa cin and
moxinoxacin. a~ well as a narrow-spectrum drug used in uri nar~
tract infcctions- naJidixic acid (the first quinolone and n(
fluorinated). The~e agents inhibit topoisomerase Tl (a bactenOL
DNA gyra~c). the eruymc that produces a negative supercoil in DN.~
and thu'> permit~ transcription or replication (see Fig. 46.4).
Antibacterial spectrum and clinical use
Ciprofloxacin i~> the most commonly used fluoroquinolone and
will be described as the type agent. It is a broad-spectru
antibiotic effective against both Gram-positive and Gram-
negative organi'>ms. It has excellent activity again~t tl.
Enterobacteriaceae (the enteric Gram-negative bacilli). includin.
many organism~ resiMant to penicillins. cephalosporin-; an
aminoglycoside!>. and it is also effective against H. injluen:ae
penicillinase-producing N. gonorrhoeae, Campylobacrer sp. an"
pscudomonads. Of the Gram-positive organisms, streptocOI:u
and pneumococci are only wcakJy inh ibited, and there is a higb nt A
inc idence of staphylococcal resistance. Ciprofloxacin should b.: hllll
 ANTIBACTERIAL DRUGS

lS.
Antimicrobial agents affecting bacterial
n~
protein synthesis
0
w
Tetracyclines (e.g. minocycline). These are orally F
~ .... II COOH
ay iT ( "
active, bacteriostatic, broad-spectrum antibiotics.

(5
cd
Resistance is increasing. Gastrointestinal disorders
are common. They chelate calcium and are deposited
in growing bone. They are contraindicated in children
and pregnant women. N
tn
Chloramphenicol. This is an orally active, Ciprofloxacin
na
fc bacteriostatic, broad-spectrum antibiotic. Serious
toxic effects are possible, including bone marrow
ne
depression, 'grey baby syndrome'. It should be
reserved for life-threatening infections.
Aminoglycosides (e.g. gentamicin). These are given
by injection. They are bactericidal, broad-spectrum
antibiotics (but with low activity against anaerobes,
streptococci and pneumococci). Resistance is
Increasing. The main unwanted effects are dose-
related nephrotoxicity and ototoxicity. Serum levels
should be monitored. (Streptomycin IS an
antituberculosis aminoglycoside.)
Macro/ides (e.g. erythromycin). Can be given orally
and parenterally. They are bactericidal/bacteriostatic. Fig. 46.4 A simplified diagram of the m echanism of
actio n of the fluoro quinolones. [A An example of a quinolone
The antibacterial spectrum is the same as for
(the qulnolone moiety is shown In orange). (PJ Schematic diagram
penicillin. Erythromycin can cause jaundice. Newer of (left) the double helix and (right) the double helix in
IS
agents are clarithromycin and azithromycin. supercoiled form (see also Fig. 45.6.). In essence, the DNA
Clindamycin. Can be given orally and parenterally. It gyrase unwinds the RNA-induced positive supercoil (not shown)
can cause pseudomembranous colitis. and introduces a negative supercoil.
Quinupristin/dalfopristin. Given by intravenous
1nfus1on as a combination. Considerably less active
when administered separately. Active against several
strains of drug-resistant bacteria. Clinical uses of the fluoroquinolones
Fusidic acid. This is a narrow-spectrum antibiotic that
acts by inhibiting protein synthesis. It penetrates bone. Complicated urinary tract infections
Unwanted effect s include gastrointestinal disorders. (norfloxacin , ofloxacin).
Linezolid. Given orally or by intravenous injection. Pseudomonas aeruginosa respiratory infections in
Active against several strains of drug-resistant bacteria. patients with cystic fibrosis .
Invasive external otitis ('malignant otitis') caused by
P. aeruginosa.
Chronic Gram-negative bacillary osteomyelitis.
a1oidcd in methi cillin-resistant '>taphylococcal i nfections. Eradication of Salmonella typhi in carriers.
Clin1cally, the fluoroquinolones arc best used for infections with Gonorrhoea (norfloxacin, ofloxacin).
facultative and aerobic Gram-negative rod'> and cocci .3 Resistant Bacterial prostatitis (norfloxacin).
1trai n~ of Staph. aureus and P. aeruginosa have emerged. Cervicitis (ofloxacin).
further detai ls of the clinical use of the fluoroquinolones are Anthrax.
gi1en in the box.

Pharmacokine tic a spects

\\hen c.:ipmnoxacin was introduced, clinical pharmacologist; and Given orally, the fluoroquinol one~ are well absorbed The hal f-life
mlcmholog~ts <;en<;ibly sugge'>led that it \hould be re~n ed for organi<>m~
of ciprofloxacin and norfloxacin is 3 hours, and that of ofl oxacin
alread> resi<.tam to mher drugs \O a\ 10 prc\cnt emergence of resi<;tancc.
is 5 hours. The drugs accumulate in several tissues. particularl y
Ho11.evcr, by 1989 it was already e;,timatcd that it wa!, prescribed for I in 44
of Americans, so it would seem that the hor~c had not only left the stable in the kidney, prostate and lung. All quinolones are concentrated
in phagocytes. Most fail tO cross the blood- brain barrier, but 673
1>u1 had bolted off into the blue!
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
onoxacin penetrates the CSF and attains 40% of its serum concen-
tration!>. Aluminium and magne!>ium antacids interfere with the
absorption of the quinolone!>. Elimination of ciprofloxacin and
nornoxacin is partly by hepatic metabolism by P450 enzymes
(which they can inhibit. giving rise to interactions with other drugs:
see below) and partly by renal excretion. Ofloxacin is excreted in
the urine.
Unwanted eHects
Unwanted effect!> arc infrequent, u!.ually mild, and disappear
when the drugl> are withdrawn. The most frequent manifestations
are gastrointc~tinal disorders and skin rashes. Arthropathy has
been reported in young individuals. Central nervous system
symptoms- headache and diuiness-have occurred, as have,
less frequently, convulsions associated with central nervous
system pathology or concurrent use of theophylline or a non-
steroidal anti-innammatory drug.
There i1> a clinically important interaction between ciprofloxacin
and this drug (through inhibition of P450 enzymes). which
can lead to theophylline toxicity in asthmatics treated with the
nuoroquinolones. The topic is discussed further in Chapter 23.
MISCELLANEOUS ANTIBACTERIAL
AGENTS
Vancomycin i' a glycopeptide antibiotic, and tcicoplanin is similar
but longer la\ling. Vancomycin is bactericidal (except against
streptococci) and acts by inhibiting cell wall synthesis (see
Fig. 45.3). It i!> effective mainly again!>t Gram-positive bacteria
and has been used against methicillin-resistant staphylococci.
Vancomycin is not absorbed from the gut and is only given by the
oral route for treatment of gastrointestinal infection with C. difficile.
For parenteral use, it i!> given intravenously and has a plasma
half-life of about 8 hours.
Antimicrobial agents affecting DNA
topolsomerase II
The fluoroquinolones interfere with the supercoiling of
DNA.
Ciprofloxacin has a wide antibacterial spectrum,
being especially active against Gram-negative enteric
coliform organisms, including many organisms
resistant to penicillins, cephalosporins and
aminoglycosides; it is also effective against
Haemophilus influenzae, penicillinase-producing
Neisseria gonorrhoeae, Campylobacter sp. and
pseudomonads. There is a high incidence of
staphylococcal resistance. It is active orally, with a
half life of 4.5 hours.
Unwanted effects include gastrointestinal tract
upsets, hypersensitivity reactions and, rarely, central
nervous system disturbances.
674
The clinical u e of vancomycin is limited main!}
p!>cudomembranous colitis (see clindarnycin. p. 669) and tk
Lrcatmcnt of some multiresistant staphylococcal infection~ It
also valuable in severe staphylococcal infections in patients all~
both to penicillins and cephalosporins. and in some fonn,
endocarditi!>.
both
Unwanted effect.\ include fever, rashes and local phleb1tl\
after
the site of injection. Ototoxicity and nephrotoxicity can oo.
prod
and hypersensitivity reactions are occasionally seen.
Nitrofurantoin i!> a synthetic compound active against a ran~
of Gram-positive and Gram-negative organisms. The develop!Th:
of resistance in susceptible organisms is rare. and there i'
cross-resistance. Its mechanism of action is not known. h is gilt
orally and is rapidly and totally absorbed from the gastrointe~tin;.
tract and just as rapidly excreted by the kidney. The clinicaluscot
nitrofurantoin is confined to the treatment of urinary tract infcction1.
Unwanted e.ffects such as gastrointestinal disturbances ar~
relatively common, and hypersensitivity reactions involving the,~,,
and the bone marrow (e.g. leucopenia) can occur. Hepatotoxicir
and peripheral neuropathy have also been reported.
The polymixin antibiotic:, in use are polymixin B and coli~tio
(polymixin E). They have cationic detergent properties and e\a:
their antibacterial action by disrupting the cell membm
phospholipids (Ch. 45). They have a selective. rapidly bactenc!d.11
action on Gram-negative bacilli. especially pseudomonad-, ani
colifonn organism!>. They are not absorbed from the gru.troint~llml
tract. Clinical use of these drugs is limited by their toxicity ~
below) and is confined largely to gut sterilisation and topicallll'l
mcnt of car, eye or skin infections caused by susceptible organNm.
Unwamed effects may be serious and include neuroto,idt
and nephrotoxicity.
Metronidazole was introduced as an antiprotozoal agent(<
Ch. 49). but it is also active against anaerobic bacteria such .
Bacteroides, Clostridia sp. and some streptococci. lt is effe"11c
in the therapy of pseudomembranous colitis, a clostridial infectJN
sometimes associated with antibiotic therapy (see above). and i'
important in the treatment of serious anaerobic infections (e.g.
sepsis secondary to bowel disease).
Miscellaneous antibacterial agents
Glycopeptide antibiotics (e.g. vancomycin).
Vancomycin is bactericidal, acting by inhibiting cell
IS~
wall synthesis. It is used intravenously for
multiresistant staphylococcal infections and orally for
pseudomembranous colitis. Unwanted effects include
ototoxicity and nephrotoxicity. ca
Potymixins (e.g. colistin). They are bactericidal, acting
by disrupting bacterial cell membranes. They are highly
neurotoxic and nephrotoxic, and are only used topically.

to
the ANTIMYCOBACTERIAL AGENTS
t is
The main mycobacterial infections in humans are tuberculosis
rgJc
md leprosy-typically chronic infections caused by Mycobacterium
. of
tuherculosif and M. leprae, respectively. A particular problem with
hoth these organisms is that they can survive inside macrophages
S at
1her phagocytosis, unless these cells are activated' by cytokines
cur.
pnxluccd by T-helper 1 lymphocytes (see Ch. 13).
hge
lent DRUGS USED TO TREAT TUBERCULOSIS
no
For centurie . tuberculosis was a major killer disease. but the
en
mtroduction in the I 960s of rifampicin and ethambutol
inal
r~\olutionised therapy, and tuberculosis came to be regarded as
e of
an ea~ily treatable condition. Regrettably, this is so no longer-
;ms.
the causative mycobacterium has returned to haunt us with a
are
1engennce. and strains with increased virulence or exhibiting
multidrug resistance strains are now common (Bloom & Small.
1998). Tuberculosis is again a major threat; the World Health
Organization estimates that one-third of the world's population
, currently infected with the bacillus and that I billion people
111!1 be newly infected in the period 2000-20. resulting in
35 milhon more deaths ( 1.75 million deaths in 2003). Africa
hears the brunt of the disease. partly because of an ominous
s}n~rgy between mycobacteria (e.g. M. tuberculosis, M. avium-
intercellulare) and HlV. About 15% of HIV-associated deaths in
the continent are caused by tuberculosis. The disease is out of
at-
ctlntrol in many countries. <md it is now the world's leading cause
J11s.
,,f death from a single agent.
cit)
Our counter-attack is led by the first-line drugs isoniazid.
nfamp1cin. rifabutin. ethambutol and pyrazinamide. Some
~ond-line drugs available are capreomycin, cycloserin e.
>U"eptomycin (rarely used now in the UK), clarithromycin and
cprofloxacin. These are used to treat infections likely to be
csi>tant to first-line drugs, or when the first-line agents have to
I~
be abandoned because of unwanted reactions.
'e.g.
To decrease the probability of the emergence of resistant
organisms, compound drug therapy is a frequent strategy. This
.ummonly involves:
an mitial phase of treatment (about 2 months) with a
combination of isoniazid. rifampicin and pyrazinamide
!plus ethambutol if the organism i<; suspected to be re!>istant)
a -econd. continuation phase (about 4 months) of therapy
11ith isoniazid and rifampicin; longer-tem1 treatment is needed
for patients with meningitis, bone/joint involvement or drug-
resistant infection.
ISONIAZID
Th~ antibacterial activity of isoni:uid is limited to mycobacteria.
It h3lh the growth of resting organisms (e.g. is bacteriostatic) but
can kill dividing bacteria. It passes freely into mammalian cells
!lld ''thus effective against intracellular organisms. The mechanism
,fits action is not clear. There is evidence t11at it inhibits the
>)llthesis of mycolic acids. important constituents of the cell wall
pi!Culiar to mycobacteria. It is also reported to combine with an
ANTIBACTERIAL DRUGS
entyme that is uniquely found in isoniazid-sensitive strain. of
mycobacteria, disrupting cellular metabolism. Resistance to the
drug, caused by reduced penetration into the bacterium, may be
encountered, but cross-resistance with other tuberculostatic drugs
docs not occur.
Pharmacokinetic aspects
Isoniazid is readily absorbed from the gastrointestinal tract and is
widely distributed throughout the tissues and body fluids. including
the CSF. An important point i~ that it penetrates well into
caseou~ tuberculous lesions (i.e. necrotic lesions with a cheese-
like consistency). Metaboli~m. which involves largely acetylation,
depends on genetic facton; that determine whether a person is a
slow or rapid acetylator of the drug (see Chs 8 and 52), with slow
inactivators enjoying a better therapeutic response. The half-life
in slow inactivator:. is 3 hours and in rapid inactivators, 1 hour.
Isoniazid is excreted in the urine partly as unchanged drug and
partly in the acetylated or otherwise inactivated form.
Unwanted eHects
Unwanted effects depend on the dosage and occur in about 5%
of individuals. the commonest being allergic skin eruption<;. A
variety of other adverse reactions have been reported, including
fever, hepatotoxicity, haematological changes, arthritic symptoms
and vasculitis. Adverse effects involving the central or peripheral
nervous systems arc largely consequences of a deficiency of
pyridoxine and are common in malnourished patients unless pre-
vented by administration of this substance. Pyridoxal-hydrazone
formation occurs mainly in slow acctylators. Isoniazid may cause
haemolytic anaemia in individual!. with glucose 6-phosphate
dehydrogenase deficiency. and it decreases the metabolism of the
antiepileptic agents phenytoin. ethosuximide and carbamazepine.
resulting in an increase in the plasma concentration and toxicity
of these drugs.
RIFAMPICIN
Rifampicin acts by binding to, and inhibiting. DNA-dependent
RNA polymerase in prokaryotic but not in eukaryotic cells (Ch. 45).
It is one of the most active antituberculosi~ agents known. and is
also effective against mo~t Gram-positive bacteria as well as
many Gram-negative specie<;. It enters phagocytic cells and can
therefore kill intracellular micro-organisms including the
tubercle bacillus. Resi~tance can develop rapidly in a one-step
process and is thought to be caused by chemical modification of
microbial DNA-dependent RNA polymerase, resulting from a
chromosomal mutation (sec Ch. 45).
Pharmacokinetic aspects
Rifampicin is given orally and is widely distributed in the tissues
and body fluids. giving an orange tinge to saliva. sputum. tears
and sweat. In the CSF. it reaches I0-40% of its serum concentration.
It is excreted partly in the urine and partly in the bile, some of it
undergoing enterohepatic cycling. 1l1e metabolite retains anti-
bacterial activity but is less well absorbed from the gastrointestinal
tract. The half-life is 1-5 hours, becoming shorter during treatment
because of induction of hepatic microsomal enzymes. 675
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
Unwanted eHects
Unwanted effects are relatively infrequent. The commonest are
skin eruptions, fever and gastrointestinal disturbances. Liver
damage with jaundice has been reported and has proved fatal in
a very small proportion of patients. and liver function should be
assessed before treatment is :.tarted. Rifampicin causes induction
of hepatic metaboli:.ing enzymes, resulting in an increase in the
degradation of war farin, glucocorticoids, narcotic analgesics,
oral antidiabetic drugs, dapsone and oestrogens, the last effect
leading to failure of oral contraceptives.
ETHAMBUTOL
Ethambutol has no effect on organisms other than mycobacteria.
It is taken up by the bacteria and exerts a bacteriostatic effect after
a period of 24 hours, although the mcchallism by wruch this
occurs is unknown. Resistance emerges rapidly if the drug is used
alone. Ethambutol is given orally and is well absorbed, reaching
therapeutic concentrations in the plasma within 4 hours; it can
also reach therapeutic concentrations in the CSF in tuberculous
meningitis. In the blood, it is taken up by erythrocytes and slowly
released. Ethambutol is partly metabolised and is excreted in
the urine. The half-life i!> 3-4 hours.
Unwanted eHects
Un~anted effects are uncommon, the most important being optic
neuritis, which is dose-related and is more likely to occur if renal
function is decreased. It results in visual disturbances marufesting
initially as red-green colour blindness progressing to a decreased
visual acuity. Colour vil.ion should be monitored during prolonged
treatment
PYRAZINAMIDE
Pyrazinamide is inactive at neutral pH but tuberculostatic at acid pH.
It is effective against the intracellular orgallisms in macrophages
because, after phagocytosis, the organisms are contained in
phagolysosomes where the p H is low. Resistance develops rather
readily, but cro~s-re1>istance with isoniazid does not occur. The drug
is well absorbed after oral administration and is widely distributed,
penetrating well into the meninges. It is excreted through the
kidney, mainly by glomerular filtration.
Unwanted eHects
Unwanted effects include gout. which is associated with high
concentrations of plasma urates. Gastrointestinal upsets, malaise
and fever have al o been reported. Historically high doses of this
drug were used, and serious hepatic damage was a possibility;
this is now less likely with lower dose/shorter course regimens
but, nevertheless, liver function should be assessed before
treatment.
CAPREOMYCIN
Capreomycin is a peptide antibiotic given by intramuscular
injection. There is some cross-reaction with the aminoglycoside
676 kana m ycin .
Unll'anted e.ffects include kidney damage and injury to the ei~
nerve, with consequent deafness and ataxia. The drug shouldM
be given at the -;a me time as streptomycin or other drugs th3t
damage the eighth nerve.
CYCLOSERINE
Cycloserine is a broad-!>pectrum antibiotic that inhibits the growth
many bacteria, including coli forms and mycobacteria. ft i~ V.!t.:t
soluble and destroyed at acid pH. It acts by competitively inh1b1t
bacterial cell wall synthesis. lt docs this by preventing the formatJa:
of o-alaninc and the o-Aia-o-Ala dipeptide that is added to 1!-.i
initial tripeptide :.ide-chain on N-acetylmuramic acid, i.~.
prevents completion of the major building block of peptidogl)'
(sec Fig. 45.3). After oml administration, it is rapidly absorb.:,
and reaches peak conccnuations within 4 hours. It is distribuk,
throughout the tissues and body fluids, and reaches concentrmioo
in the CSF equivalent to those in the blood. Most of the drug 1
eliminated in active form in the urine, but approximately 35~
metabolised.
Cycloserine has unwanted effects mainly on the central nenou;
system. A wide variety of disturbances may occur. ranging from
headache and irritability to depression, convulsions and P')Ch<n:
states. Its use is limited to tuberculosis that is resistant to other dru.
DRUGS USED TO TREAT LEPROSY
Leprosy is one of the most ancient diseases known to manlinl
and has been mentioned in texL<> dating back to 600 BC. It is a chru
disfiguring illnes~ with a long latency, and historically suffereflih:o
been ostracised and forced to live apart from their commu111t1.
although. in fact, the disease is not particularly contagious. o~
viewed as incurable, the introduction in the 1940s of dapsoo
and subsequently rifampicin and clofazimine in the 196().
completely changed our perspective on leprosy. It is now con~id~ro:
relatively easy to diagnose and to cure, and the global figure~ sho
that the prevalence rates for the disea<>e have dropped by 90% sincr
1985, und that the disease has been eliminated from I08 out of 12~
countries where it wa~ considered to be a major health problem
Today, !>Orne 650 000 new cases arc reported each year (200.
figures). The bulk of these (70%) are in the Indian subconunen
Multidrug treatment regimen~ initiated by the World HecJ
Organi7ation in 1982 are now the mainstay of trcatmt
Paucibacillary lepro~y. leprosy characterised by one to five nu
patches, is mainly tuberruloitf in type and is treated for 6 mood:;
with dapsone and rifampicin. Multibaci/lary leprosy. characten~
by more than five numb skin patches, is mainly lepromatous
DAI
type and is treated for at least 2 years with rifampicin, daJ>"one Dap
and clofazimine. The effect of therapy with minocycline or lbt its 0
tluoroquinolones is being investigated. ofb
.uuJ
()
thro
"The ba~b of the dilference between tuberculoid and lepromatou; di~;ea;e
appear~ to be thai the T cell~ from patients with the former vigorously
produce intcrfcron-y. which enable~ macrophages to kill intracellular
microbe~. whcrea~ in the latter case the immune response is dominated b)
intcrlcuki n-4, which blocks the action of interferon-"{. See Chapter 13.
 ANTIBACTERIAL DRUGS

treat dermatitis herpetiform is, a chronic bliste ring skin conditio n

Antituberculosis drugs associated wi th coeliac d i ~ease.

To avoid the emergence of resistant organisms,

Unwanted eHects
compound therapy is used (e.g. three drugs initially,
Unwanted effects occur fairly freq uently and include haemolysis
followed by a two-drug regimen later).
of red cells (usually not severe enough to lead to frank anaemia),
First-line drugs
methaemoglobinaemia, anorexia, nausea and vomiting, fever,
lsomaz1d kills act1vely growing mycobacteria within
allergic dermatitis and neuropathy. Lepra reactions (an exacerbation
host cells; mechanism of action unknown. Given
of lepromatous lesions) can occur, and a potentially fatal syndrome
orally, it penetrates necrotic lesions, also the
resembling infectiou mononucleosis has occasionally been seen.
cerebrospinal fluid (CSF). 'Slow acetylators'
(genetically determined) respond well. It has low
toxicity. Pyridoxine deficiency increases risk of RIFAMPICIN
neurotoxicity. No cross-resistance with other agents.
Rifampicin is discussed under Drugs used to treat tuberculosis.
Rifampicin (rifampin) is a potent, orally active drug
that inhibits mycobacterial RNA polymerase. It
s penetrates CSF. Unwanted effects are infrequent (but CLOFAZIMINE
s serious liver damage has occurred}. It induces
Clofazimine is a dye of complex structure. Its mechanism of action
hepatic drug-metabolising enzymes. Resistance can
against leprosy bacilli may involve an action on DNA. It also has
develop rapidly.
anti-inflammatory activi ty and is useful in patients in whom dapsone
Ethambutol inhibits growth of mycobacteria by an
causes inflammatory s ide effects.
unknown mechanism. It is given orally and can
Clofazimine is given orally and accumulates in the body, being
penetrate CSF. Unwanted effects are uncommon, but
sequestered in the mononuclear phagocyte system. The plasma
optic neuritis can occur. Resistance can emerge
half-life may be as long as 8 weeks. The antileprotic effect is
rap1dly.
delayed and is usually not evident for 6-7 weeks.
Pyrazinamide is tuberculostatic against intracellular
mycobacteria by an unknown mechanism. Given
orally, it penetrates CSF. Resistance can develop Unwanted eH ects
rapidly. Unwanted effects include increased plasma Unwanted effect!> may be related to the fact that clofazimine is a
urate and liver toxicity with high doses. dye. The slo.in and urine can develop a reddish colour and the
Second-line drugs lesions a blue-black discoloration. Dose-related nausea, giddiness,
Capreomycin is given intramuscularly. Unwanted headache and gastrointesti nal distu rbances can also occur.
effects include damage to kidney and to eighth nerve.
Cycloserine is a broad-spectrum agent. It inhibits an
early stage of peptidoglycan synthesis. Given orally, it
POSSIBLE NEW ANTIBACTERIAL DRUGS
penetrates the CSF. Unwanted effects affect mostly The reader is referred to the notes at the conclusion of Chapter 45.
central nervous system.
Streptomycin , an aminoglycoside antibiotic, acts by
inhibiting bacterial protein synthesis. It is given
Intramuscularly. Unwanted effects are ototoxicity
(mainly vestibular) and nephrotoxicity.
Antlleprosy drugs

For tuberc uloid leprosy: dapsone and

DAPSONE
Dapsone is chemically related to the sulfonamides and, because
lh action is antagonised by PABA. probably acts through inhibition
of bacterial folate synthesis. Resistance to the drug is increasing,
and treatment with combinations of drugs is now recommended.
Dapsone is given orally; it is well absorbed and widely distributed
through the body water and in all tissues. The plasma half-life is
~-!--48 hours, but some dapsone persists in certain tissues (liver,
kidney, and to some extent skin and muscle) for much longer
periods. There is enterohepatic recycling of the drug, but some is
acetylated a nd excreted in the urine. Dapsone is also used to
rifampicin (rifampin).
Dapsone is sulfonamide-like and may inhibit folate
synthesis. It is given orally. Unwanted effects are fairly
frequent, a few are senous. Resistance is increasing.
Rifampicin (see Antituberculosis drugs box).
For lepromatous leprosy: dapsone, rifampicin and
clofazimine.
Clofazimine is a dye that is given orally and can
accumulate by sequestering in macrophages. Action
is delayed for 6-7 weeks, and its half-life is 8 weeks.
Unwanted effects include red skin and urine,
sometimes gastrointesinal disturbances.
677
 Antiviral drugs
I Overview 679
Background information about viruses 679
-An outline of virus structure 679
-Examples of pathogenic viruses 679
-Virus function and life history 680
The host-virus interaction 680
-Host defences against viruses 680
-Viral ploys to circumvent host defences 681
HIV and AIDS 681
Antiviral drugs 684
-Combination therapy for HIV 689
-Prospects for new antiviral drugs 689
OVERVIEW
This chapter deals with drugs used to treat
infections caused by viruses. We give first some
necessary information about viruses: a simple
outline of virus structure, a list of the main
pathogenic viruses and a brief summary of the life
history of an infectious virus. We then continue
with a consideration of the host-virus interaction:
the defences deployed by the human host against
viruses and the strategies employed by viruses to
evade these measures. We then describe the
various types of antiviral drugs and their
mechanisms of action, with particular reference to
the treatment of AIDS, an infection caused by the
human immunodeficiency virus (HIV).
BACKGROUND INFORMATION ABOUT
VIRUSES
AN OUTLINE OF VIRUS STRUCTURE
l1ruses are s mall (usually in the range 20-30 nm) infecti ve
Jgents that arc incapable of reproduction outside their host ceUs.
The free-living (e.g. outside its host) virus particle is termed a
rion, and consists of segments of nucleic acid (either RNA or
D~A) enclosed in a protein coat comprised of synm1etrical
repeating s truclllral units and called a capsid (Fig. 47. 1). The
viral coat, togethe r with the nucleic acid core, is termed the
nucleocapsid. Some viruses have, in addition, a further external
lipoprotein envelope, whic h may be decorated with antigen ic
viral glycoproteins o r phospholipids acquired from its host when
the nucleocapsid buds thro ug h the me mbranes of the infected
cell. Certain viruses also contain enzymes that initiate their
re plication in the host cell.
Viruses arc generally characterised eithe r a~ DNA or RNA
viruses depending on the nature of their nucleic acid conte nt.
These two broad categories arc conventio nall y s ubdivided into
some six subclasses, which clru.sify viruses according to whether
they contai n single- or double-stranded nucleic acids and how
this functions during replication.
EXAMPLES OF PATHOGENIC VIRUSES
Vimses can infec t virtually ali living o rganisms. Hum ans are no
exceptio n, and such infections are commo n.
T Some impona nt example~ of the disease~ they cause arc as follow.
DNA vim~ev: poxvi ruse (-.mall pox). herpe~v iruses (chickenpox,
shingles. cold sores. glandu lar fever), adcnoviruses (sore throat,
conjuncti vi tis) and papillomaviruses (wart1;).
RNA viruses: orthornyxov iru ~es (influenza), paramyxoviruses
(measles. mumps, rcspirutory tract infections), rubella virus (German
measles), rhabdov iru~es (r:1bies), picornaviruses (colds. meningitis,
poliomyel itis), rctrovirue~ (acquired immunodefi ciency syndrome
[A IDS]. T-cell leukaemia). arcnaviruses (meningitis. Lassa fever).
~ Lipopmto;o e"""~
~77~, ,--....,-- Nucleic acid }
-- : core Nucleocapsid
~ Coat (capsid)
' '''
.
Capsomere
(lhe morphological
protein units
of the coat)
Fig. 4 7.1 Schematic diagram of the components of a
virus particle or virion.
679
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER

hepadnaviru<.e~ (~erum hepatitis) and arboviruses (anhropodbome Replication in DNA viruses

encephaliti~ and variou; febrile illne~ses. e.g. )ellow fever).
Viral DNA enter the host cell nucleus. where transcription tnlt
mRNA occur!. catalysed by the host cell RNA polymer.t'<'
VIRUS FUNCTION AND LIFE HISTORY Translation of the mRNA into virus-specific proteins then tak~
place. Some of these proteins are enzymes that then synthe,t>t
As viruses have no metabolic machinery of their own, they have more viral DNA, as well as proteins comprising the viral coat <IBl
to attach to and penetrate a living host cell-animal, plant or envelope. After a'\sembly of coat proteins around the viral D~.\.
bacterial-and use the victim's own metabolic processes to complete virions are released by budding or after host celll}~i'
replicate. The first Mep in this process is facilitated by polypep-
tide binding sites on the envelope or capsid, interacting with Replication in RNA viruses
receptors on the host cell. These 'receptors' are normal Enzymes within the virion synthesise its mR
membrane constituenL~-receptors for cytokines, neurotransmitters RNA template, or sometimes the viral RNA serves as its 011
or hormones, ion channels, integral membrane glycoproteins, mRNA. This is translated by the host cell into various enz}me,
etc. Some examples of host cell receptors utilised by particular including RNA polymerase (which directs the synthesis of more
viruses are listed in Table 47.1. viral RNA), and also into structural proteins of the virion.
Following attachment, the receptor-vims complex enters the Assembly and release of virions occurs as explained above. With
cell (often by receptor-mediated endocytosis), during which time these viruses, the host ceU nucleus is usually not involved in 1irdi
the virus coat may be removed by host cell enzymes (often replication, although some RNA viruses (e.g. orthomyxoviru~e't
lysosomal in nature). Some bypass this route. Once in the host replicate exclusively within the host nuclear compartment.
cell, the nucleic acid of the virus then uses the host cell's
machinery for synthesising nucleic acids and proteins that are Replication in retroviruses
assembled into new virus particles. The actual way in which this The virion in retroviruses' contains a reverse transcriptase enzyme
occurs varies between DNA and RNA viruses. (virus RNA-<Iependent DNA polymerase), which make~ a OK~
copy of the viral RNA. This DNA copy is integrated into the
genome of the host cell, and it is then termed a prol'irus. Th.
proviru~ DNA i!> transcribed into both new viral genome R.\~
Table 47. 1 Some host cell structures that can function
as receptors for viruses as well as mRNA for translation in the host into viral protein
and the completed viruses are released by budding. Man} retn>- ns
Host cell structure Virus(es) viruses can replicate without killing the host cell. dct
The ability of several viruses to remain dormant within. and b: of
Helper T-lymphocytes CD4 HIV (causing AIDS) replicated together with, the host genome is responsible for the to
glycoprotein periodic nature of some viral diseases, such as those caused b)
herpes fahiafis (cold sores) or the varicella zoster (chickenpo1
CCRS receptor for chemokines HlV (causing AIDS)
MCP-1 and RANTES and shingles) virus, which recur when viral replication i'
reactivated by some factor (or when the immune system i1
CXCR4 chemokine receptor for HIV (causing AIDS) compromised in some way). Some RNA retroviruses can
cytokine SDF-1 transform normal cells into malignant cells. gl'l
S\:h
Acetylcholine receptor on Rabies virus
skeletal muscle a~ t
THE HOST-VIRUS INTERACTION rcc
8-lymphocyte complement C3d Glandular fever virus c.tu
receptor HOST DEFENCES AGAINST VIRUSES
S\\i
The first defence is the simple barrier function of intact ~ktn the
T-lymphocyte interleukin-2 T-cell leukaemia viruses
receptor which most viruses are unable to penetrate. However. broken tllll.
skin (e.g. at sites of wounds or insect bites) and muco.
~-Adrenoceptors Infantile diarrhoea virus membranes are more vulnerable to viral artack. Should the ltM
gain entry to the body, then the host can deploy both the iniiJl(
MHC molecules Adenovirus (causing sore
and subsequently the adaptive immune response (Ch. 13). 1'he
throat and conjunctivitis)
T-cell leukaemia viruses infected cell presents, on its surface, viral peptides complextd
with major histocompatibility complex (MHC) class l molecules
MCP-1, monocyte chemoattractant protein-1; MHC, major This complex is recognised by T lymphocytes. which then ktll
histocompatibility complex; RANTES, regulated on activation, the infected cell (Fig. 47.2). This may be accomplished by th<.
normal T-een-expressed and secreted; SDF-1, stromal VI
release of lytic proteins (such as perforins, granzymes) or b)
cell-derived factor-1. DE
'For more detail on complement, interleukin-2, the CD4
glycoprotein on helper T lymphocytes, MHC molecules, etc.,
see Chapter 13. For SOF-1, see Chapter 22. 1
A virus that can synthc~i;e DNA from an RNA template- the reverse of
680 the normal ~iruation.
 ANTIVIRAL DRUGS

Subversion of the immune response

l into Viruses can inhibit the action of the cytokines, such a~
Virus-tnfected host cell
!rase. interleukin-1, TNF-a. and the antiviral interferons (TFNs; sec
takes p. 223), that normally coordinate the innate and adaptive immune
responses. Following infection. for example, some poxviruse'>
Fas receptor MHC-1
lt and product
express proteins !hat mimic the extracellular ligand-binding
;:>"l.\. domains of cytokine receptors. These pseudoreceptors bind
Fas ligand
ysts. cytokines, preventing them from reaching their natural receptors
Lytic
on cells of the immune system and thu\ moderating
Vtral peptide enzymes the normal immune re~ponse to virus-infected cells. Other
viml viruses that can i11terferc with cytokine signalling include
own human cytomegalovirus, Epstein-Barr virus, herpesvirus and
me~. CDS+ killer T cell adenovirus.
more
non. Evasion of immune detection and attack by
Fig. 47.2 The m echanism s w hereby a c os T cell kill s a
With virus-infected host cell. The virus-infected host cell killer cells
viral expresses a complex of virus peptides plus major Once within host cells, viruses may also escape immune
use') htslocompatibility complex class I product (MC H-1) on its detection and evade lethal attack by cytotoxic lymphocytes and
surface. This is recognised by the cos T cell, which then
NK cells in various ways, such as the following.
releases lytic enzymes into the virus-infected cell and also
expresses a Fas ligand. This triggers apoptosis In the infected fnterference with the surface protein marken on the infected
cell by stimulating its Fas 'death receptor'.
t)mC cells essemial for killa cell attack. Some viru!>es inhibit
DNA generation of the antigenic peptide and/or !he presentation of
the MHC-peptide molecules. This turns off the ~ignal that the
The triggering the apoptotic pathway in the infected cell by activation cells arc infected, enabling the viruses to remain undetected.
R~A Llf it\ Fasreceptor ('death receptor': seep. 79). The laner may also Example., of viruses that can do this are adenovirus, herpes
ilh, be tnggered indirectly through the relea..c of a cytokine such simplex virus, human cytomegalovirus, Epstein-Barr virus
tro- a' tumour necrosis factor (TNF)-a. lf the virus escapes immune and influenza virus.
detection by cytotoxic lymphocytes by modifying the expression fnterference with the apoptolic pathway. Some viruses (e.g.
IU be ot lhe peptide-MHC complex (see below). it may still fall victim adenovirus, human cytomegalovirus, Epstein-Barr virus) can
r !he to natural killer (NK) cells. This reaction to !he absence of subvert this pathway for their own purposes.
by nom1al MHC molecules might be called the 'mother turkey' Adopting the 'baby wrkey' ploy. Some viruses (e.g.
hpox Mrategy (kill everything that does not sound exactly like a baby cytomegalovirus) get round the mother turkey approach of
lfl i ... turkey: see footnote on p. 206). But some viruses also have a NK cells by expressing a homologue of MHC class l (the
Jc11ce for evading NK cells as well (see below). equivalent of a turkey chick's chirping) !hat is close enough
m i'
Within the cell itself, a sophisticated mechanism known as to the real thing to hoodwink K cells.
gene silencing may also provide a further level of protection (see h is evident that evolution has equipped pa!hogenic viruses with
Schutze, 2004). Short double-stranded fragments of RNA, such many efficacious tactics for circumventing host defences, and
b those !hat could arise as a result of the virus's aucmpts to understanding these in more detail is likely to suggest new types
recru1t the ho~t's transcription/translational machinery, actually of antiviral therapy. Fo11unately, the biological arms race is not
cau\e the gene coding for the RNA to be siJenced'- to be one-sided, and evolution has also equipped the host with
'11itched off, probably by DNA phosphorylation. This means !hat sophisticated counrer-measures. In most cases these prevail, with
!Je gene is no longer able to direct further viral protein synthesis, viral infections eventually generally resolving spontaneously,
okcn thu'> mterrupting the replication cycle. This mechanism can be except in an immunocompromised host. The situation does not
'COUS exploited for experimental purposes in many areas of biology, always end happi ly though; some viral infections, such as Lassa
irus .u1d tailored siRNA (small-or short-interfering RNA) is a fever and Ebola virus infection, have a high mortality, and we
mate cheap and useful technique to suppress temporarily expression now discuss a further, grave example of this group: !he HJV
of 3 particular gene under investigation. Attempts to harness !he virus. This is appropriate because I lTV exhibits many of the
xed technique for viricidal purposes have met with some success (sec fearures common to other viral infections, and the sheer scale
ules. 83rik. 2004 ). of the global AIDS problem has pu~hed HIV to the top of the li~t
kill of antiviral targets.
the
VIRAL PLOYS TO CIRCUMVENT HOST
rr by
DEFENCES
HIV AND AIDS
\crrusc~have evolved a variety of strategies to ensure successful
mfecuon, some entailing redirection of the host's re, ponse for HIV is an RNA retrovirus. Two forms are known. HIV-1 is the
the advantage of the virus (discussed by Tortorella et al., 2000). organism responsible for human AlDS. The HfV-2 organism is 681
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
VIruses
Viruses are small infective agents consisting
of nucleic acid (RNA or DNA) enclosed in a protein
coat.
They are not cells and, having no metabolic
machinery of their own, are obligate intracellular
parasites, utilising the metabolic processes of the
host cell they infect to replicate.
DNA viruses usually enter the host cell nucleus and
direct the generation of new viruses.
RNA viruses direct the generation of new viruses,
usually without involving the host cell nucleus (the
influenza virus is an exception in that it does involve
the host cell nucleus).
RNA retroviruses (e.g. HIV, T-cell leukaemia virus)
contain an enzyme, reverse transcriptase, which
makes a DNA copy of the viral RNA. This DNA copy
is integrated into the host cell genome and directs the
generation of new virus particles.
similar to the IIIV- 1 virus in that it also causes immune
suppression, bul il is less virulent. HIV- I is distributed around
the world, whereas the HlV-2 virus is confined to parts of Africa.
We will consider them together in this section.
T In 2004. the World Health Organization estimated that almost
40 million people \\-ere II\ ing with AIDS, and that women and children
constituted upproximately half that total number. During Lhe same year.
some 3 million people died of the disease (including 0.64 million children
under 15 year~). and there were a funher 5 million new cases of AIDS
infection reponed. The epidemic is overwhelmingly centred on sub-
Saharan Africa. which accounL~ for two-thirds of the total global number
of infected persons. nnu where the adult prevalence is 7.4% (compared
with 0.3%- in Europe). For a review of the pathogenesis of AIDS, sec
Mindel & Tenant-Flowers (200 I ).
The interaction of HlV with the host's immune system is complex,
and although it involves mainly cytotoxic T lymphocytes (CTLs,
CD8+ T cells) and CD4+ helper T lymphocytes (CD4 cells),
other immune cell!>, such as macrophages, dendritic cells and K
cells, also play a part. Antibodies are produced by the host to
various HTV components, but it is the action of the CTLs and
CD4 cells that initially prevents the spread of HIV.
Cytotoxic T lym phocytes directly kill virally infected cells
and produce and releru.e antiviral cytokines (Fig. 47.2). The
lethal event is lysis of the target cell, but induction of apoptosis
by interaction of Fas ligand ('death ligand': see Fig. 5.5) on the
CfL with Fas recepto11. on the virally infected cell can also play
a part. CD 4+ cells have an important role as helper cells, and it
is rhe progressive loss of these cells that is the defining
characteristic of HIV infection (Fig. 47.4). Recent work suggests
that CD4 cells may themselves have a direct role (e.g. lysis of
target cells) in the control of HIV replication (Norris et al., 2004).
Once within th e cell, TliV is integrated with the host DNA (the
provirus form), undergoing tran scription and generating new virions
682 when the cell is activated (Fig. 47.3). ln an untreated subject, a
-.taggering 10 111 new virus panicles may be produced each da}.
lnlracellular HIV can remain silent (latent) for a long time.
T The primmg of nat\C T cells to become CfLs during the induction pha
invohe'> interolction of the T-cell receptor complex with antigenic HI\
pepudc tn assoctauon wuh 'v!HC class I molecules on the surfac-e oC
anugen-pre~nung cell'> (APCs: see Figs 13.3 and 13.4). Priming also
require' the prc\Cncc and participation of c~ cells. It is thought thai
both types of cell need to recognise antigen on Lhe surface of the ..unr
APC (Fig. 13.3).
The CTI.'> thu' generated are effective during the initial stages of tk
infection but arc not able to Mop the progression of the di,ease. It 11
believed that thh is because the CfLs have become 'exhausted' ~lhl
dy~functional. 1\vo different mechanisms may be involved. :and thN
are ~ummari.,cd in ~imple terms below.
One possible mechanism has been suggested on the basis of recen
research into a uiff'erent viral infection. The study shows that the
a~~i~tance of CD4+ cells during tile initial priming process moy b.:
essential for the secondary expansion of CTLs on autonomou,
reMimu lotion. The evidence is that, during priming, c04 cells help
uetermine the ucvclopment of the relevant CTL memory and the al>aht)
of CTL!. to mount a ~econdary response. Without thi~. mo~t Cfl eel\
may, on imeracting with antigen again, themselves become exhau,aed
and enter apoptosis (Jan,en et al .. 2004). This throws new light on w
role of CD4 cells in the immune response to HIV.
Another po"ible C)(p)anation for CDS T-cell exhau\tion. al'o ba..ed
on recent \\Ork with another \iral infection. is that these cells 01cr
ex pres~ an apoptotic gene. Admini,tration of an antibod) that bl01:~ed
the interaction bet\\een thi\ factor and its receptor restored the abihty
ofT celb to prohfemte and kill infected cells. thus reducing the ltn:
load. Tim nouon al~o sugge>ts a novel and potentially effe.:tne
immunological ~trategy for treatment of chronic viral infcctiolb ~
as that cau~ed by the HIV 'iruse<, (Barber et al .. 2006).
The HIV virion cannil} attache~ to proteins on the host cell surf..:t 10
gain entry to the cell~. The main targets are CD4 (a glycoprotein lll3rl.l!
of a panicular group of helper T lymphocytes) and CCR5 (a corecept,Y
for cenaan chemol.ines. including monocyte chemoattractant protein-)
and RANTES [regulated on activation normal I-cell ~xpres..ed 4nJ
,llecretcd]). c04 cells normally orche~trate the immune response t"
viruses. but by entering these cells and using them as virion factorie-..
II IV virtual ly cripples this aspect of the itmuune response. Figure 471
show~ an HIV virion infecti ng a CD4+ T cell. Infected activated CD4 T
cells in lymphoiu tissue form the major source of HIV production in HI\
infectcu individuals: infected macrophages are another source.
As for CCRS. evidence from exposed individuals who somehm~ e1Jde
infection indicate~ that this surface protein has a central role in HI\
pathogcne.,i~. Compounds that inhibit the entry of HTV into cell\ b~
blocking CCR5 are in phase tn clinical trials and may soon be av:Uiabl:
commercially (Charo et al.. 2006).
When immune \Uneillance breaks down. other strains of HIV ari-.c
recognasc other ho~t cell ~urface molecules ~uch as CD4 and CXCR4
surface glycnprotem. gpl20. on the HIV en, elope binds to C[).l and
to the T-ccll chemokine coreceptor CXCR4. Another viral gi}CO~
gp41. then cau..es fu~ton of the viral envelope with the plasma membntr
of the cell (Fig.47.3).
Viral replication is error-prone, and there are a large number c
mutations daily at each site in the HIV genome, so HIV soo
escapes recognition by the original cytotoxic lymphoqtt\
Although other cytotoxic lymphocytes arise that recognise the
altered virus protein(s), further mutations. in tum, allow esca~
from surveillance by these cells too. It is suggested that wa1~
after wave of cytotoxic lymphocytes act against new mutanr~ 31
th ey arise. gradually depleting a T-cell repertoire alread)
 ANTIVIRAL DRUGS

of gp120

Reverse

A
... (1 O) New vlrons I

(1) Binding ' I

I

''
?
'

r
\
:nt \
\
\
\
I

(9) A ssembly and

? budding
CXCR4 Ck receptor

PLASMA MEMBRANE

? (8) Protease action 0 __

(3) Uncoating

Inhibito rs
of vir al
Rever se
tra nscriptase
"'~pt;de/
fusion inhibito rs
Translatlo~
\C
ch (7)
(4) Reverse transcrlptase by host
makes a double-stranded ribosomes
l<l
DNA copy of viral RNA - - - - - - - - - - - - -..,..:-._

mANA

l
(6) Transcription of provirus
IV-

i ?
(5) DNA copy (+lntegrue: ) entera nucleua Md CYTOPLASM
lntlgndee with host DNA. forming pnMrul

that
...-\
~~-0
~10. Fig. 47.3 Sc hematic d iagram of infection of a c o 4 T cell by a n HIV virion, w ith the sites of action of the two main c lasses of
li!IDC anti-HIV drugs. The 10 steps of HIV infection, from attachment to the cell to release of new virions, are shown. The virus uses the CD4
coreceptor and the chemokine (Ck) receptor CXCR4 as binding sites to facilitate entry into the cell, where it becomes incorporated into
host DNA (steps 1-5). When transcription occurs (step 6), the T cell itself is activated and the transcription factor nuclear factor KB
of llltliates transcnption of both host cell and provirus DNA. A viral protease cleaves the nascent viral polypeptides (steps 7 and 8) into
pon structural protetns and enzymes ~ntegrase, reverse transcriptase, protease) for the new virion. The new virions are assembled and released
tes. from the cells, initiating a fresh round of infection (steps 9 and 10). The sites of action of the currently used anti-HIV drugs are shown. __.)
thl!
ape
ave
I as
ndy 683
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER

seriously compromised by the loss of CD4+ helper T cells, until
eventually the immune response fails.
There is considerable variability in the progress of the disease,
but the usual clinical course of an untreated HlV infection is
shown in Figure 47.4. An initial acute influenza-like illness is
associated with an increase in the number of virus particles in
the blood, their widespread dissemination through the tissues,
and the seeding of lymphoid tissue with the virion particles.
Within a few weeks, the viraemia is reduced by the action of
cytotoxic lymphocytes as specified above.
The acute initial illness is followed by a symptom-free period
during which there b reduction in the viraemia accompanied by
silent virus replication in the lymph nodes, associated with damage
to lymph node architecture and the loss of CD4+ lymphocytes
and dendritic cells. Clinical latency (median, 10 years) comes to
an end when the immune response finally fails and the signs and
symptoms of AIDS appear--opportunistic infections (e.g. with
Pneumocystis carinii or the tubercle bacillus), neurological disease
(e.g. confusion, paralysis, dementia), bone marrow depression and
cancers. Chronic gastrointe)>tinal infections contribute to the severe
weight loss. Cardiovascular damage and kidney damage can also
occur. In an untreated patient, death usually follows within 2 years.
The advent of complex combination drug regimens has changed
the prognosb at least in countries that are able to deploy them.
There is evidence that genetic factors play an important role
in determining the susceptibility--or resistance-to HIV (see
Flores-Villanueva et al.. 2003).
ANTIVIRAL DRUGS
virus is replicating. Because the initial phases of viral infecu()n
are often asymptomatic. treatment is often delayed until lbe
infection h. well established, and one therefore begins therJpy
at a tactical disadvantage. As is often the case with infecttoos
diseases, an ounce of prevention is worth a pound of cure.
Many antiviral drugs are a1ailable, and we cannot disCU\\ all
the~e in detail for space reasons. However. most fall into onl) a
few groups with similar mechanisms of action and often simtlar
side effects too. Table 47.2 shows the commonest antiviral drug,
their mechanisms of action and some of the diseases the) are
used to treat. Some common side effects are shown in Table 47.3
We wi ll discuss each group brietly.
NUCLEOSIDE REVERSE TRANSCRIPTASE
INHIBITORS
This curre ntl y comprises a large group of nucleoside analogue,
all of which are phosphorylated by host cell enzymes to g11t
the 5' -trisphosphate derivative. This moiety competes with 1M
equivalent host cellular trisphosphate substrates for proviral Dl'iA
synthesis by viral reverse transcriptase (viral RNA-<Iepcndent
DNA polymerase). Eventually. the incorporation of the )'
trisphowhate moiety into the growing viral DNA chain re~uJt, n
chain termination. Mammalian a -DNA polymerase is rclatilttJ
resistant to the effect. However, y-DNA polymerase in the IIOi1
cell mitochondria is fairly sensitive to the compound, and this
may be the ba~is of some unwanted effects. The main utili!} of
these drugs is the treatment of HIV. but a number of them ha1e
useful activity against other viruses also. Some example~ o'
nucleoside reverse transcriptase inhibitors are given belo''

Because viruses hijack many of the metabolic processes of the Zidovudine

host cell itself, it is difficult to find drugs that are selec ti ve for Zidovudine is an tmaloguc of thymidine. It can prolong life 1n
the pathogen. However, there are some enzymes that are virus- HlV-infccted individuals and diminish HIV-associated dementia
specific, and these have proved to be useful drug targets. Most Given to the parturient mother and then to the newborn infant, 11
c urrentl y available antiviral agents are effective only while the can reduce mother-to--baby transmission by more than 20%-. It i1

Pnmary infection
1200

~
Death
Posstble acute HIV syndrome

1000
Wtde d1ssemmation of virus
Seeding of lymphoid organs 1
Opportumsti;lc
1:512
<')

E
~~
800
Cllmcal latency
r------'------. 1
dtseases 1:256
1:128 ~ca
Q)
f
-y II
0 600 Constttubonal
1:64
1-
~~ 1:32
0 400 1:16
0 ~-
1:8 II)
ca
Fig. 47.4 Schematic outline of 200 1:4 a:
the course of HIV infection. The 1:2
co4 T-cell titre is often expressed
O~Lo----r-~~~~~~--~~~~---.----.
, --~ 0
as cells/mm 3 (Adapted from
Pantaleo et al. 1993 N Engl J Med 0 3 6 9 12 2 3 4 5 6 7 8 9 10 11

684
328: 327-335.) Weeks Years j
 ANTIVIRAL DRUGS

n
e Tllble 47.2 Principal classes of antiviral drugs and some common therapeutic uses

~
Common therapeutic indication(s)

Nucleoside reverse transcriptase inhibitors: abacavir, adefovir Mainly HIV, generally in combination with other retrovirals
dtp/vox/1, didanosine, emtricitablne, lamlvudine, stavudine, Lamivudlne and adefovir are also used in the treatment of hepatitis 8
tenofovir, zalcitabine, zidovudine

Non-nucleoside reverse transcriptase Inhibitors: efavirenz, HIV. generally 1n combination with other retrovirals
nevtrapine

Protease inhibitors: amprenawr, atazanavir, indmavir, lopinavir, HIV. generally in combination w1th other retrowals
nelfinavir, ntonavir, saquinavir

Viral DNA polymerase inhibitors: aciclovir 1, cidofovir", Treatment of herpes!, cytomegalovirus, or hepatitis C and
famciclovir 1, foscamet t, ganciciovir', idoxuridine 1, pencic/ovir1, respiratory syncitial virus infections~
nbvarlnt, valacic/ovir't, valganciclovlr'

Inhibitors of HIV fusion with host cells: enfurvitlde HIV, generally in combination with other retrovlrals

lnh1b1tors of viral coat disassembly and neuraminidase Influenza N or A and B

Inhibitors: amantadine', oseltamivir, zanamivir

810log1cs and immunomodulators: interferon-a. pegylated Treatment of hepatitis B and C, herpes' and respiratory syncitial
lllterferon-a. inosine pranobex', palivizumabt v1rusT

Table 47.3 Principal common unwanted effects of some antiviral drugs

Drug type Principal common unwanted effects Comments

Nucleoside reverse transcriptase Gastrointestinal disturbances including nausea, vomiting, abdominal

nhib1tors: zidovudine, abacavir,
dtdanosine, emtricitabine, lamivudine,
stavudine, tenofovir, zalcatabine
pain and diarrhoea
Central nervous system and related effects including headache, insomnia
and dizziness, and neuropathy
Musculoskeletal and dermatological effects including fatigue, myalgia,
arthralgia, rash, urticaria and fever
Blood disorders including anaemia, neutropenia and thrombocytopenia
Metabolic effects including pancreatitis, liver damage and lipodystrophy

Non-nucleoside reverse transcriptase
inhibitors: efavirenz, nevirapine
Dermatological effects including rash and urticaria High (15-25%)
Central nervous system and related effects including fatigue, headache, incidence of rash
sleep disturbances, depression and dizziness
Gastrointestinal disturbances including nausea, vom1ting, abdominal
pain and diarrhoea
Blood disorders Including anaemia, neutropenia and thrombocytopenia
Metabolic effects including pancreatitis, raised cholesterol, liver
dysfunction and lipodystrophy

Protease inhibitors: amprenavir,
stazanavir, lndinavir, lopinavir,
nelfinavir. ritonovir, saquinavir
Gastrointestinal disturbances including nausea, vomiting, abdominal pain
and diarrhoea
Central nervous system and related effects Including fatigue, headache,
sleep disturbances and dizziness, taste disturbances and paraesthesia
Musculoskeletal and dermatological effects including myalgia, arthralgia,
rhabdomyotysis, rash, urticaria and fever
Blood disorders including anaemia, neutropenia and thrombocytopenia
Metabolic effects including pancreatitis, liver dysfunction and
lipodystrophy

'Administration of epoietin (erythropoietin) and molgramostim (recombinant human granulocyte macrophage colony-stimulating factor;
see Ch. 22, p. 354) may alleviate these problems.
685
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
generally administered orally twice daily but can also be given by
intravenous infusion. The bioavailability is 60-80%, and the
peak plasma concentration occurs at 30 minutes. Its half-life is
I hour. and the intracellular half-life of the active trisphosphate
is 3 hour~. The concentration in cerebrospinal fluid (CSF) is 65'*"
of the pla~ma level. Most of the drug is metabolised to the
inactive glucuronide in the liver. only 20o/c of the active form
being excreted in the urine.
Resistance to the antiviral action of zidovudine
Because of rapid mutation, the virus is a constamly moving
target, thus the therapeutic response wanes with long-term use,
particularly in late-stage disease. Furthermore, resistant strains
can be transferred between individuals. Otherfactors that underlie
the loss of efficacy of the drug are decreased activation of
zidovudine to the trisphosphate and increased virus load owing to
reduction in the host immune response.
Didanosine
Didanosine is an analogue of deoxyadenosine. It is given orally.
is rapidly absorbed and is actively secreted by the kidney tubules.
The level in the CSF reaches -20% of the plasma concentration.
The plasma half-life i!> 30 minutes, but the intracellular half-life
is more than 12 hours.
Zalcitabine
Zalcitabine is a homologue of cytosine. It is activated in the
T cell by a different phosphorylation pathway from zidovudine.
It is given orally. Its plal.ma half-life is 20 minutes, and its intra-
cellular half-life is nearly 3 hours: the CSF level is 20% of that
in the pla~ma.
Lamivudine
Lamivudine is an analogue of cytosine. It is given orally, is well
absorbed and most is excreted unchanged in the urine. The CSF
level is 20% of the plasma concentration. Used alone, it could
select for HIV mutants that arc resistant to both the drug itself
as well as other reverse transcriptase inhibitors. Lamivudine is
also used in the therapy of hepatitis B infection.
Stavudine
Stavudine is a thymidine analogue. It is given orally, has a plasma
half-life of I hour, and mo~t is eliminated via the kidney by
active tubular secretion. The CSF level is 55% of that in the plasma.
Abacavir
Abacavir is a guanosine analogue and has so far proved to be
more effective than most other nucleoside reverse transcriptase
inhibitors. lt is well absorbed after oral administration and is
metaboli!>ed in the liver to inactive compounds. The CSF level
is 33% of that in the plasma.
NON-NUCLEOSIDE REVERSE TRANSCRIPTASE
INHIBITORS
Non-nucleoside reverse transcriptasc inhibitors are chemically
686 diverse compounds that bind to the reverse transcriptase enzyme
near the catalytic ~ite and denature it. Most non-nucleo'
reverse transcriptase inhibiton. are inducers, substrates or inhibnt
to varying degreel., of the liver cytochrome P450 enz)
Currently available drug!> nevi rapine are and efavirenz.
Nevirapine
Nevi rapine is given orally, its bioavailability is > 90'k. and
CSF level is 45% of that in the plasma. It is metabolised m
liver, and the metabolite is excreted in the urine. eviraptneC3n
prevent mother-to-baby transmission of HTV if given to the
parturient mother and the neonate.
Efavirenz
Efavircnz is given orally, once daily because of its pJa,t
half-life (-50 hours). It is 99% bound to plasma albumin, an
its CSF concentration is -1% of that in the plasma. It 1
inactivated in the liver.
PROTEASE INHIBITORS
Tn HTV and many other viral infections, the mRNA tran~cn~
from the provirus is translated into two biochemically i~
polyproteins. A virus-specific protease then convert> the
polyproteinl. into various structural and functional proteim 17;
cleavage at the appropriate positions (see Fig. 47.3). Becau-.etlm
protease docs not occur in the host. it is a useful target ~
chemotherapeutic intervention. HIV-spccific protease inhibnoo
bind to the site where cleavage occurs, and their use, in combma!JCI
with reverse transcriptase inhibitors. has transformed the therapj
of ATDS. Examples of current protease inhibitors are shO\\L
Table 47.2 and are exemplified by drugs such as saquinmir
nelfinavir. indinavir, ritonavir and amprenavir.
Pharmacokinetic aspects
The drugs are generally given orally, saquinavir being subject
extensive first-pass metabolism. CSF levels are negligible wnh
saquinavir and highest with indinavir (76% of the pla1ma
concentration). Nelfinavir and ritonavir are best taken with food.
and saquinavir within 2 hours of a meal.
Unwanted effects are also similar (see Table 47.3).
DNA POLYMERASE INHIBITORS
Aciclovir
The era of effective selective antiviral therapy began with aciclo1ir
This agent is a guanosine derivative with a high specificil) f Ga
herpes simplex and varicella zoster viruses. Herpes simplex ,,m
cause cold sores, conjunctivitis. mouth ulcers. genital infectio
and, rarely but very seriously. encephalitis: in immunocom-
promised patients. it is much more aggressive. Varicella ZO\tet afm
2
Vcncreologist~ (now called sexually transmilled disease physician\,
reference~ 10 Vcnu presumably being no longer acceptable) with a tn>te for
cynical humour ask 'What is the difference between tme love and genital
herpes?', their nn,wer being that genital herpes is for ever. h may not be.

11ruses cause shingle~ and chickenpox. Herpes simplex is more
-u-ceptible to aciclovir than varicella zoster. Epstein-Barr virus
ta herpewirus that causes glandular fever) is also slightly
~n,itive. Aciclovir has a small but reproducible effect against
-~tomegalovirus-a herpe~' irus that can affect the fetus with
wt~trophic consequences. can cause a glandular fever- like
s~ndrome in adults and severe disease (e.g. retinitis. which can
re,uJt in blindness) in immunocompromised individuals.
Mechanism of oction
Aciclovir is converted to the monophosphate by thymidine
Lmase, and happily the virus-specific form of this enzyme is
1ery much more effective in carrying out the phosphorylation
than the enzyme of the host cell; it is therefore only activated
adequately in infected cells. The host cell kinases then convert
the monophosphate to the trisphosphate. II is the aciclovir
trisphosphate that inhibits viral DNA polymerase, terminating
the nucleotide chain. It is 30 times more potent against the
herpesvirus enzyme than tJ1e host enzyme. Aciclovir trispho-
sphate is fairly rapidly broken down within the host cells,
pre~umably by cellular phosphatases. Resistance caused by
,hanges in the viral genes coding for thymidine kinase or DNA
pol)merase has been reported, and aciclovir-resistant herpes
,,mplex virus has been the cause of pneumonia. encephalitis and
oucocutaneous infections in immunocomprom.ised patients.
Phormacokinetic aspects
\ciclovir can be given orally. intravenously or topically. When
1~ given orally, only 20% of the dose is absorbed and peak
pJa,ma concentrations are reached in 1-2 hours. The drug is
v.Jdel} distributed, reaching concentrations in the CSF that are
5! of those in the plasma. It i~ excreted by the kidneys, partly
b} glomerular filtration and partly by tubular secretion.
Unwanted effects
These are minimal. Local innammation can occur during
Intravenous injection if there is extravasation of the solution.
Renal dysfunction has been reported when aciclovir is given
mtravenously; slow infusion reduces the risk. Nausea and
lleadache can occur and, rarely, encephalopathy.
There are now many other drugs with a similar action to
aciclovir (see Table 47 .2). This group includes valaciclovir, a
!XOdrug of aciclovir, and famciclovir, which is metabolised to
the active compound penciclovir in vivo. Other viral D A
polymerase inhibitor., include the following.
r Ganciclovir
nus acyclic analogue of guanosine is the drug of choice for
:~romegafo,irus infection. Thi!. is a frequent opportunistic
mfection in immunocompromised or AlDS patiems and has been
r aformidable obstacle to successful transplantation of organs and
hone marrow (which necessitates immunosuppressive therapy).
Like aciclovir, ganciclovir has to be activated to the trispbo-
>phate, and in this form it competes with guanosine trisphosphate
for incorporation into viral DNA. It suppresses viral D A
replication, but unlike aciclovir it does not act as a chain
1erminator and has a longer duration of action, persisting in
infected cells for 18-20 hours.
ANTIVIRAL DRUGS
Clinical uses of drugs for herpes viruses
(e.g. aclclovlr, famclclovir, valaciclovir)
Varicella zoster infections (chickenpox, shingles);
- orally in immunocompetent patients
- intravenously in immunocompromised patients.
Herpes simplex infections (genital herpes,
mucocutaneous herpes and herpes encephalitis).
Prophylactically;
patients who are to be treated with
immunosuppressant drugs or radiotherapy and
who are at risk of herpesvirus infection owing to
reactivation of a latent virus
in individuals who suffer from frequent recurrences
of genital infection with herpes simplex virus.
Phormocokinetic aspects
Ganciclovir is given intravenously. Tt is excreted in the urine and
has a half-life of 4 hours.
Unwonted effects
Ganciclovir has serious unwanted actions. including bone
marrow deprc!.sion and potential carcinogenicity, and is con-
sequently u!.ed only for life- or sight-threatening cytomegalovirus
infections in patients who are immunocompromised. Oral admin-
istration can be used for maintenance therapy in AlDS patients.
Tribavirin (ribavirin)
Tribavirin is a synthetic nucleoside, similar in structure to
guanosine. It is thought to act either by altering virus nucleotide
pools or by interfering with the synthesis of viral mRNA. Tt
inhibits a wide range of DNA and RNA viruses, including many
that affect the lower airways. In aerosol form, it has been used
to treat influenza and infections with respiratory syncytial virus
(an RNA paramyxovirus). It has also been shown to be effective
in hepatitis C as well as Lassa fever, an extremely serious
arenavirus infection. When given promptly to victims of the
latter disease, it has been shown to reduce to 9%, a case fatality
rate previously 76%.
Foscarnet (phosphonoformate)
Foscamet is a synthetic non-nucleoside analogue of pyrophosphate
that inhibitl> viral DNA polymerase by binding directly to the
pyrophosphate-binding site. It can cause serious nephrotoxicity.
Given by intravcnou~ infusion, it is a second-line drug in cyto-
megaloviru<; eye infection in irnmunocompromised patients.
INHIBITORS OF HIV FUSION WITH HOST CELLS
There is only one drug in this group; enfurvirtide. The drug is
generally given by subcutaneous injection in combination with
others to treat HI V when resistance becomes a problem or when
the patient is intolerant of other antiretrovirals. 687
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
Unwanted effects
These include flu-like symptoms, central effects such as
headache, dizziness, alterations in mood, gastrointestinal effects
and sometimes hypersensitivity reactions.
NEURAMINIDASE INHIBITORS AND INHIBITORS
OF VIRAL COAT DISASSEMBLY
Viral neuraminidase is one of three transmembrane proteins
coded by the influenza genome. Infection with these RNA
viruses begins with the attachment of the viral baemaglutinin to
neuraminic (sialic) acid residues on host cells. The viral particle
then enters the cell by an endocytic process. The endosome is
acidified following influx of W through another viral protein, the
M2 ion channel. This facilitates the disassembly of the viral
structure, al lowing the RNA to enter the host nucleus, thus
initiating a round of viral replication. Newly replicated virions
escape from the host cell by budding from the cell membrane.
Viral neuraminidase promotes this by severing the bonds linking
the particle coat and host sialic acid.
The neuraminidase inhibitors zana mivir and oseltamivir are
active against both influenza A and B viruses, and are licensed
for use at early stages in the infection or when use of the vaccine
is impossible. Zanamivir is available as a powder for inhalation,
and oseltamivir as an oral preparation. At the time of writing,
government around the world are stockpiling this latter drug in
the expectation that it may offer some defence against 'bird flu',
should this mutate into an organism capable of infecting humans.
Unwanted effects of both include gastrointestinal symptom
(nausea, vomiting, dyspepsia and diarrhoea). but these are less
frequent and severe in the inhaled preparation.
Am a nta dine, 1 quite an old drug (1966) and seldom
recommended today, effectively blocks the M2 ion channels,
thus inhibiting viral disassembly. It is active against influenza
A virus (an RNA virus) but has no action against influenza B
virus. The closely related rimantadlne is similar in its effects.
Pharmacokinetic aspects. Given orally, amantadine is well
absorbed, reaches hig h levels in secretions (e.g. sal iva) and most
is excreted unchanged via the kidney. Aerosol administration is
feasible.
Unwanted effects are relatively infrequent, occurring in 5-lO%
of patients, and are not serious. Dizziness. insomnia and slurred
speech are the most common adverse effects.
BIOLOGICS AND IMMUNOMODULATORS
A number of other agents have been recruited in the fight against
virus infections, including immunoglobulin preparations, IFNs,
immunomodulators and monoclonal antibodies.
Immunoglobulin
Pooled immunoglobulin contains antibodies against various
viruses present in the population. The antibodies are directed
against the virus envelope and can 'neutralise' some viruses and
688 3
Aiso used for its mildly beneficial effects in Parkinson's disease (see Ch. 35).
prevent their attachment to host cells. If used before the o
of signs and symptoms, it may attenuate or prevent mea>
infectious hepatitis, German measles, rabies or poliom)e
Hyperimmune globulin, specific against panicular viru..cs,
used against hepatitis B. variceiJa zoster and rabies.
Palivisumab
Related in terms of its mechanism of action to immunoglcbl
is palivis uma b, a monoclonal antibody (see Chs 13 and 51
directed against a glycoprotein on the surface of respirah
syncytial virus. It is used (as an intramuscular injection) in infa.
to prevent infection by this organism.
Interferon
Inte rfe rons arc a family of inducible proteins synthesised b<
mammalian cells and now generally produced commerciall.
using recombinant DNA technology. There are at least thre.
types, a, ~. andy, constituting a fami ly of horn10nes involved 1
cell growth and regulation and the modulation of immune reactior'
fFN-y, termed immune inteiferon (seep. 223), is produced mam
by T lymphocytes a~ part of an immunological response to b.
viral and non-viral antigens, the latter including bacteria and thro
products, rickettsiae, protozoa, fungal polysaccharides and a ran:.
of polymeric chemicals and other cytokines. IFN-a and IF:\
are produced by B and T lymphocytes, macrophages and fibrobl
in response to the presence of viruses and cytokines. The genml
actions of the IFNs are described briefly in Chapter 13.
Mechanism of antiviral action
The lFNs bind to specific ganglioside receptors on host ct
membranes. They induce. in host ceU ribosomes, the producu
of enzymes that inhibit the translation of viral mRNA into liT
proteins, thus halting viral replication. They have a bro
spectrum of action and inhibit the replication of most viruse, 1
vitro.
Pharmacokinetic aspects
Given intravenously, JFNs have a half-life of 2-4 hours. \Vit
intramuscular injections, peak blood concentrations are reacllt\1
in 5- 8 hours. They do not cross the blood-brain barrier.
Clinical use
Interferon-a.-2a is used for treatment of hepatitis B infecuoo.
and AIDS-related Kaposi sarcomas; IFN-a-2b is used I
hcpatiti!> C. There are reports that IFNs can prevent reacti1clli
of herpes simplex after trigeminal root section and can pre1em
spread of herpes LOster in cancer patients. Preparations of J.P.\;
conjugated with polyethylene glycol (pegylated IFNs) ha1e a
longer lifetime in the circulation.
Unwanted effects
Unwanted effects are common and include fever, lassitude. head-
ache and myalgia. Repeated injections cause chronic malru,..:
Bone marrow depression, rashes, alopecia and disturbance\ tn
cardiovascular, thyroid and hepatic function can also occur.
Inosine pranobex
lmmunomodulators arc drugs that act by moderating the immunt
response to viruses or use an immune mechanism to target a viru1

or other organism. Inosine pranobex may interfere with viral
nucletc acid synthe1.is but also has immunopotentiating actions
on the ho~t. It is sometimes used to treat herpes infections in
mucosal ti ssues or on the skin.
COMBINATION THERAPY FOR HIV
Two main classes of antivirals arc used to treat HIV: reverse
transcriptase inhibitors and protease inhibitors. A s they have
different mechanisms of action (Fig. 47.3), they can usefully be used
n combinations and this technique has dramatically improved
the prognosis of the disease. The combination treatment is kn own
as highly i\Ctive i\ntiretroviral 1hcrapy (HAART). A typical
H.-\ART combination would involve two nucleoside reverse
tran~criptase inhibitors with either a non-nucleoside reverse
transcriptase inhibitor or one or two protease inhibitors.
Using a HAART protocol, HTV replication i1. inhibited, the
presence in the plasma of HlV RNA is reduced to undetectable
levels. and patient survival is greatly prolonged. But the regimen
is complex and has many unwanted effect~. Compliance is
difficult and treatment is lifelong. The virus is not eradicated but
IJe~ latent in the host genome of memory T cell . ready to
reacuvatc if therapy is stopped.
Unwelcome interactions can occur between the three
component drugs of HAART combinations, and there may be
mterindividual variations in absorption. Some drugs penetrate
poorly into the brain, and this could lead to local proliferation
of the viru s. At present, there is no cross- re~istance between
the three groups of drugs, but it needs to be borne in mind that
the virus has a high mutation rate-so resistance could be a
problem in the f uture. The HTV virus has certainly not yet been
outsmarted.
Antiviral drugs
Most antiviral drugs generally fall into the
following groups:
nucleoside analogues that inhibit the viral reverse
transcriptase enzyme, preventing replication
(e.g. lamivudine, zidovudine)
non-nucleoside analogues that have the same
effect (e.g. efavirenz)
inhibitors of proteases that prevent viral protein
processing (e.g. saquinavir, indinavir)
inhibitors of viral DNA polymerase that prevent
replication (e.g. aciclovir, famciclovir)
inhibitors of viral capsule disassembly (e.g.
amantidine)
inhibitors of neuraminidase that prevent viral
escape from infected cells (e.g. oseltamivir)
immunomodulators that enhance host defences
(e.g. interferons and inosine pranobex)
immunoglobulin and related preparations that
contain neutralising antibodies to various viruses.
ANTIVIRAL DRUGS
Drugs for HIV Infections
Reverse transcriptase inhibitors (RTis):
nucleoside RT!s are phosphorylated by host cell
enzymes to give the 5' -trisphosphate, which
competes with the equivalent host cellular
trisphosphates that are essential substrates for
the formation of proviral DNA by viral reverse
transcriptase (examples are zidovudine and
abacaw); they are used in combination with
protease inhibitors.
non-nucleoside RT!s are chemically diverse
compounds that bind to the reverse transcriptase
near the catalytic site and denature it; an example
is nevirapine.
Protease inhibitors inhibit cleavage of the nascent
viral protetn into functional and structural proteins.
They are often used in combination with reverse
transcriptase inhibitors. An example is saquinavir.
Combination therapy is essential in treating HIV; this
characteristically comprises two nucleoside RTis with
either a non-nucleoside RTI or one or two protease
inhibitors.
Treatment of HIV/ AIDS
A consensus on the use of retroviral therapy in
AIDS has emerged based on the following principles:
monitor plasma viral load and CD4+ cell count
start treatment before immunodeficiency becomes
evident
aim to reduce plasma viral concentration as much
as possible for as long as possible
use combinations of at least three drugs (e.g. two
reverse transcriptase inhibitors and one protease
inhibitor)
change to a new regimen if plasma viral
concentration increases.
The choice of drugs to treat pregnant or breast-feeding women
is difficult. The main aims are to avoid damage to the fetus and
to prevent transmission of the disease to the neonate. Therapy
with zidovudine alone i s often used io these cases. Another area
that requires special consideration is prophy laxis for individuals
who may have been exposed to the virus accidentally. Specific
guidelines have been developed for such cases, but they are
beyond the scope of this chapter.
PROSPECTS FOR NEW ANTIVIRAL DRUGS
A t the beginning of the 1990s, there were only five drugs
available to treat viral infections; 15 years later, this number 689
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER

has increased some sevenfold. New strategies-based on the
growing understanding of the biology of pathogenic viruses and
their action on and in host cells-could well. if vigorously
implemented, have the potential to target the viruses causing
most viral diseases (sec de Clercq. 2002). However, the ultimate
weapon in the fight again~t the virus is vaccination. This has
proved to be ~tunningly effective in the past against diseases
such as polio and smallpox, and more recently against influenza
(both types) and hepatitis B. However, while there have been
many clinical trials. the prospect of a vaccine against HIV !01
indeed many other viruses) still seems rather remote. Part of tht
problem is antigenic drift, a process whereby the virus mutate'
thus presenting different antigenic structures and minimising the
chance of an effective and long-lasting immune response or the
production of a vaccine. The whole problem is the subject of
numerous reviews (see Stratov et al., 2004: Tonini et al.. 2005 .

I
\1<
...
(~

REFERENCES AND FURTHER READING

Viral infections in gcncrul
Hanazal.i K 2004 Antiviral therapy for chronic hepatitis
B: a rc' iew. Curr Drug Targets lnOamm Allergy 3:
63 70 (Hel'in.v th~ 111e of iFN and /amimdirre. al01re
or irr comhmation. in thr trratmrm of tins 'ira/
mftlon)
Lauer G \1. Walker B D 2001 llepaLJLJ~ C VIIUS
infecuon. I' Engl J \1ed 345: 41 - 52 CC'omprrh~mi>t!
,., il"'< ofpathO/Iellt!ftf, rltmral rharoctuistics,
namral hirtol') anJ trratment of hepatitis C inft!ction)
Lee W \1 1997 tlepaum 8 'ru' mfe.:LJOO. ~ Eng! J
Med 337; 1733-17-10 (/Nta./('d CO\'t'rtll(t! oftht:
~pidmtioloto and pathot~mnu of ht:palltu 8 , th<' /if~
cydt! oftht! Hni\ tn th~ human host. ant/tilt! trratnrt:nt
of tht! diS'tJJt!)
Mooma" \t D. Cornea P. Rathbun R C. Wendel K A
2003 Re' ~ of anm ira! therapy for hcrpe$ labialis.
geni1al herpes and herpc; lO>tcr. l:.xpcrt Re Antiinfect
Ther I 283- 295 (Uuful rrrew focusing 011 the role of
acicloir. famcirolovir, pmndmrr tmd mlaciclovir in
trratinf( ''ariou.\ numifemrtions of herpesvinu
inf~ctiOTIS)
Schmid! A C 2004 Antiv.ralthcrnpy for inOuenza: a
clinocnl and economoc cornpnrmive review. Drugs 64:
203 1- 2046 (A IIS~ful miew of i11jlue~~;.a biology,
together with a comprrhetule el'lrluatioll of drug
matment.v. tlrerr mec/uml.lfns of action ami relative
ecmwmic co.tts)
Whi1ley R J, Roi1mnn B 2001 Hcrpc; simplex virus
infeclion\. l..ancel357: 15 13 1518 (A conci>t: rrl'ii'K'
of the ira/ replkatio11 eve/I' and tire potlwl(ettesis and
trratnrmt of l1erp~s srmple.x viTIIS infections)
mv inr~tions
Barber D L, Wherry E J. Mao;opu\1 D e1 al. 2006
Re>lonng fuocuon in exhau,led CDS T cells during
chrome 'lr&llnfccuon 1'a1ure 439: 682-687 (Deals
outh a potential mulranum v.lrert'b) the exhaustion of
T ails mo.\ l>t! "'''"'til
Cs1m' J S. D'Souza M P 1998 Chemoltine> and tiJV-1
o;econd recepl()r<; the lherapculrc conn~-c1roo. Na1 \1ed
-1: 563-568 (f.'tct!llt!nt """" ofthurtpeutic strotegies
that/af'llt!llhl' chl'mol/nt: reU(IUIT$ IISl'd by H/V-J /0
imade hot/ cr//1)
Charo I F, Ran..ohotT R M 2006 The many role.<. of
chcmokmes and chemokme reccpl()r<; in mOammaLJon.
N Engl J Med 354 610-621 ( U.refirl ,...,.,..,. of the roll'
of tht'.>t r~ceptors in facilllallllg H/V entry)
Jansen CA, Piriou E. Bronkc C el al 2()().1 Characterisation
of voru\,pccific Cl)8(+) ciTector T cells in the course
of HI V-I infection: longiludmal analyse> ln slow and
rapid progressors. Clin lmmunol II : 299-309.
Mindel A. Tennnt-Fiowcn. M 2001 Nalural his1ory and
690 managcrncnl or early II IV infection. Br Med J 322:
1290-1293 (A clinical revil'w covt'ring the ('llfiY!III
classification of HiV tliseast'. clinical mtmi/l'lllllimn
ofprimary HIV infect loll anti gmeraltreatment (If //IV
patients)
Norris P J, Moffcll H F, Brander C e1 al. 2004 Fine
specificity and cross-clade reac1ivi1y of HIV l)'pe
Gag-specific c04 T cclb. AIDS Re' llum
Re1t0viruses 20: 315--325
Mechanisms or immune e\asion b) lru;e; und drug
resistance
Hin;cb ~1 S 2002 HIV drug re"-aance: a chml. in the
armor. Engl 1 \led 347: -138439 Cll11orral 011the
drollengl' of dr~~g-rrsistalll HIV: su also Lmle S J l't
al. N Eng/ J Med 3-16: 31!.5 -39-1)
~1urphy p ~~ 2001 Viral expiOII31ion and SUb\Cf'l>IOn Of
the immune system through chcmol.inc mrmocry. Na1
lmmunol 2: 116-122 (1-':xu//em tle<cripllon of
t.irus- immune l)stem intertiCtiOfl)
Tonorella D, Gewurz 8 E e1 al. 2000 Viral subver,ion or
the immune system. Annu Rev lmmunol 18: 861 926
(A comprehensioe and clearly wrillt!n rt:l'il'w of the
arious mechanism< by wltidr viru.-e.o elmle dnecllon
and destruction by tht' host in11mme sy.ttrm)
Immune defences againsl viral ulluck
Guidotti L G. Chisari F v 2001 NoncyLolytic control of
viral infectiOn> by the innate and ndap1ive immune
response. Annu Rev lmmunol 19: 65- 9 1 (Dt'tailed
review emphasising the role of cytokines,for e~crmpll'
iFN-a/fJ aJJd TN F-a. ill tilt' endogt!IIOrt.t control of
viral illf~ction.r)
Levy J A 2001 The importance of Lhe mnale immune
system in conLrolling HIV infec1ion and disea-e.
Trend> lmmunol 22: 312- 316 (Strrll<'l tilt' role of
innate immunity in th' fl'.<pon.ll' 10 IJIV: clt!Dr
expasititm of thl' arious componmt< of th<' rnnmt" and
adaptive immunt! snrems, os l'.'l'/1 as tilt' roll' of mm
cytotoxic CD8' cl'll l'f'Sp<mu 10 HI\')
Scbutze :-.1 2004 siRJ>IA technolog). Mol Cell Endocnnol
213: I IS-I 19 (An ortidt: l'tpltmllnl( tht' uRNA
concept)
l\1~hanisms or aoti~iral drug ac1ion
Balfour H H 1999 Antivirol drug,. N Ent!l J \1ed 140:
1255--1268 (An exc-ellent amJ comp11'hensie m i,..... of
ami'iral agents mhu than tlwu urt'd fi~r 11/V
therapy; describt's their meclrmri.lmo of trttiQir.
adverse t'.ffecf.l and clitricaluse)
de Clercq E 2002 Strmegies in the de,ign of anti\ ral
drugs. Nal Rev Drug Dbcov I: 13 24 (Ouwamling
article describilll( the rtllionale belrinclmr11'111 am/
fillure strategier for antiviral dru~ de~lopment)
Flexner C 1998 HIV-proten~e inhibilors. N ~ngl J Med
338: 1281- 1292 (.reel/em and romprehetuive reitw
coering mulronisms of actio11. clillical a11d
plrarmacokinetic properties, potential drux re1i<tanc;
ami possible trratment failure)
Gubareva L. Kai<er L. Hayden F G 2000 [nfluenza wu'
ncuromrnida.'e inh1bitors. Lance1 355: 827-835
(AJmirahlt' cmerage of this topic; lucid summaT\ onoJ
clear diagrams of the inj/uen~ l'if'Uj a11d iu
r<'plication C)cle: de;cription of till' structuf't! and tltt
actwn of. OJUI rrsistanu to. ~nomil'ir ami O<ellammJ.
and tilt' rrlem/11 phamracokinetu: OSpt!CIS and c/iroicd
t'j]iCOl')')
Pallck A K. Pons K E 1998 Protease inhibilor\ a'
anu' Ira! agems. Clio Microbiol Re II: 614-627 t 4
ust'ful rrvitw that mmmari.re.t .mmr of the gen.rul
f~a/Urt!S of the l'lrtll prai('OSt'S of tht' Hf\1 'inu. tilt
human riiiJLO\'irtiS and the vimses causing ht:rp<<
trmpiP.< and hepatitis C: the amhors discuss tht!
clmicall> uJefulrnhibitors of HJV proteast in ,,_
detar/ a11tl outline tht' possible dewlopm<-nt of
inhibitors of the proteases of the other vinr<e<l
Combination treatm~<nt for mv
Carr A, Cooper D A 2000 Adverse effects of
amiretroviraltherapy. Lancet 356: 1423- 1430 (A
review that focu."-t 011 the pathoge11esis. cli11ica/
features and mcmagemelll of the main unwanted
actio11s of mrrent amirerroviral drugs)
Fle1tner C 2000 Dual pro1case inhibilor therapy in HIV
infected paticniS: pharmacologic rationale and clmo.al
hcncfil~. Annu Rev Phannacol Toxicol 40: 649-674
(Reii'K' emphasising imeractio11s between rndrl'rtl1
protease inhibitors and tht: pott11tiol benejiu am/
di~admmagn of dual therapy)
HammerS l\1 2002 Increasing choices for HJV lhcraP)
N Eng! J Med 346: 2022-2023 (SIICCIIIl't anirk '"
also \\almsley t!l a/. N Eng/ J Med 346: 2039-21}16
R1chman D D 2001 HJV chemotherapy. ~alure -liCk
995-1001 COuwanding anicle: COI'<'TS pathoRen"u
and natural htsiOT)' of HiV inft'ction and the rmpotiiJC
riral Jynumir.f and tmmunl' function of an11rrtM'IIIl1
thl'rapy: Jiscussl's th<' mai11 amirrtroHral dnrt. tfrr:
rrsistanu of HIV and targets for,..., Jr~~~s; ttctllnt
fiKurrs and comprt!hensi,. refuence.<)
Weller I V D. Williams I G 200 I Antireuo..-iral drug\ 8r
~1ed J 322; 141(}...1412 (Pan ofa Brilbh \1edi\:JI
Journal st'rits 011 the ABC of AIDS: clear. wccura
covera}le of amrretroviral regimens, and a list of
pmentialtarget; for new dr~~g dev<'lopment)
New lc11d.s in anlhiral drug therapy
Barik S 2()().1 Control of nOn>egmented negative\lrilJIJ
RNA virus replication by s1 RNA. Virus Res 102:
27-35 (lrrlt'restlng anicle e.xplaitring lww siRNA
techrro/ogy might be used to inhibit viral replitatiJJOI
 Antifungal drugs
Overview 692
Fungi and fungi infections 692
Drugs used to treat fungal infections 693
-Antifungal antibiotics 693
-Synthetic antifungal agents 695
Potential new antifungal therapies 696
OVERVIEW
Fungal infections (mycoses) are widespread in the
population; they are generally associated with the
skin (e.g. ' athlete's foot') or mucous membranes
(e.g. 'thrush' ). In temperate climates such as the
UK, and in otherwise healthy people, they are
mainly benign, being more of a nuisance than a
threat. However, they become a more serious
problem when the immune system is compromised
or when they gain access to the systemic
circulation. When this occurs, fungal infections can
be fatal. In this chapter, w e will briefly review the
main types of fungal infections and discuss the
drugs that can be used to treat them.
FUNGI AND FUNGI INFECTIONS
Fungi are eukaryotic cells and therefore represent a more
complex and evolved organism than we have hitherto considered.
Thousands of fungal species, predominantly parasitic in nature,
have been characterised. Many are of economic importance,
either because they are useful in manufacturing other products
(e.g. yeast in brewing and the production of antibiotics) or
because of the damage they cause to crops or to foodstuffs.
Approximately 50 are pathogenic in humans. These organisms
are present in the environment or may coexist with humans as
commensals without causing any overt risks to health. However,
since the 1970s, there has been a steady increase in the incidence
of serious secondary systemic fungal infections. One of the
692 contributory fac tors has been the widespread use of broad-
spectrum antibiotics, which eliminate or decrease the non-
pathogenic bacterial populations that normally compete with
fungi. Other causes include the spread of AIDS and the usc of
immunosuppressant or cancer chemotherapy agents. The result
has been an increased prevalence of opportunistic infecJiom, i.e
infections that rarely cause disease in healthy individuals. Older
people, diabetics, pregnant women and bum wound victim~ are
particularly at risk of fungal infections such as candidiasu.
Primary fungal infections, rare in many partS of the tempemtt
world, are also now encountered more often because of the
increase in international travel.
Clinically important fungi may be classified into four mam
types on the basis of their morphological and other charJC
teristics. Of particular taxonomic significance is the preS<:na
of hyphae- filamentous projections that may knit together to
form a complex mycelium, a mat-like structure giving the
characteristic appearance of moulds. Drugs vary in their effic:le)
between the groups. and infective agents are remarkably speciti.:
for their preferred location. The main groups are:
yeast~ (e.g. Cryptococcus neoformans)
yeast-like fungi that produce a structure resembling a
mycelium (e.g. Candida albicans)
fi lamentous fu ngi with a true mycelium (e.g. Aspergillus
fumigatus)
'dimorphic' fungi that, depending on nutritional constraints,
may grow as either yeasts or fi lamentous fungi (e.g.
HisToplasma capsularwn).
Another organism. Pneumocystis carinii, shares characteri~tic\
of both protozoa (see Ch. 49) and fungi; however, it is not
susceptible to antifungal drugs and will not be considered here
even though it is an important opportunistic pathogen in patient>
with compromised immune systems (e.g. those suffering from
AIDS).
Table 48.1 gives examples of each type of organism and li'b
some of the diseases caused by these agents and the mo'1
common choice of drug classes. 1
Superficial fungal infections can be classified into th~
dermatomycoses and candidiasis. Dermatomycoses include
infections of the skin, hair and nails (onychomycosis). They rue
most commonly caused by Trichophyton, Microsporum or
Epidermophyton, giving rise to various types of 'ringworm' (not
to be confused with genuine helminth infections; see Ch. 50) or
tinea. 7inea capitis affects the scalp; Tinea cruris, the groin
('Dhobic itch'); 7inea pedis, the feet (athlete's foot); and Tinea
 ANTIFUNGAL DRUGS

Table 48.1 Some common fungal infections and their sensitivity to various classes of antifungals

Organism Principal disease(s) Most common treatment

Polyenes Echlnocandins Azoles Flucytosine

Yeasts
Cryptococcus neoformans Meningitis +++ + +

Yeast -like fungus

Candida albicans Thrush, systemic candidiasis ++ Rarely ++

Filamentous fungi
Trichophyton spp. All these organisms cause skin and nail
non- Mtcrosporum spp. infections and are referred to as tinea or +++
with Epidermophyton floccosum 'ringworm'
ISC of Aspergillus fumigatus Pulmonary aspergillosis ++ + +
esuh
Dimorphic fungi
Histoplasma capsulatum Histoplasmosis ++ ++
Coccidioides immitis Coccidiomycosis ++ ++
Blastomyces dermatides Blastomycosis ++ +

r-:r.tte 'Generally used as an adjunct to amphotericin.

r lhe

main
arac-
ence
er to corporis, the body. ln superficial candidiasis, the yeast-like
the organism may infect the mucous membranes of the mouth or
1agina (thrush), or the skin. Secondary bacterial infections may
CaC)
ific complicate the course and treatment of these conditions.
In !he UK. the commonest systemic (or 'disseminated') fungal
d1~ease is candidiasis. Other more ~crious conditions are crypto-
coccal meningitis. endocarditis, pulmonary aspergillosis, and
rhinocerebral mucormycosis. Jnvasive pulmonary aspergillosis is
now a leading cause of death in recipients of bone marrow
tr3llsplant~ or those with neutropenia. Colonisation of the lungs
of patients with asthma or cystic fibrosis by Aspergillus can lead
ts, to a similar condition termed allergic bronchopulmonary
aspergillosis.
In olher parts of the world. the commonest systemic fungal
mfections include blastomycosis. histopla~mosis, coccidiomycosis
Uics
not and paracoccidiomycosis: these are often primary infections. i.e.
they are not secondary to reduced immunological function or
here
ents ahered commensal micro-organisms.
rom
DRUGS USED TO TREAT FUNGAL
list<;
INFECTIONS
(lOSt
The current therapeutic agents can be broadly classified into two
groups: first, the naturally occurring antifungal antibiotics such
1'> the polyenes and echinocandins, and second. synthetic drugs
including azoles and fluorinated pyrimidines. Because many
infections are superficial, there are many topical preparations.
~1any antifungal agents arc quite toxic, and when systemic
lherapy is required these agent~ must often be used under strict
medical supervision.
rzea Figure 48.1 shows sites of action of common antifungal drugs.
ANTIFUNGAL ANTIBIOTICS
AMPHOTERICIN
Amphotericin (also called amphotericin B) is a mixture of
antifungal substances derived from cultures of Streptomyces.
Structurally, these arc very large ('macrolide') molecules
belonging to the polyene group of antifungal agents.
Mechanism of action
Like other polyene antibiotics (see Ch. 46). the site of
amphotericin action is the funga l cell membranes, where it
interferes with permeability and with transport functions. It
probably has more than one mechanism of action, but its most
important property is probably its ability to fonn large pores in
the membrane. The hydrophilic core of the molecule create!> a
transmembrane ion channel, causing gross disturbances in ion
balance including the loss of intracellular K+. Amphotericin has
a selective action, binding avidly to the membranes of fungi and
some protozoa, less avidly to mammalian cells and not at all
to bacteria. The basis of this relative specificity is the drug's
greater avidity for ergosrerol, a fungal membrane sterol that is
not found in animal cells (where cholesterol is the principal
sterol). Amphotericin is active against most fungi and yeasts,
and is the gold standard for treating disseminated infections
caused by several organisms including Aspergillus and Candida.
Amphotericin also enhances the antifungal effect of Oucytosine
(sec below), providing a useful synergistic combination.
Pharmacokinetic aspects
Amphotericin is very poorly ab!.Orbed when given orally, and this
route is used only for treating fungal infections of the upper
gastrointestinal tract. lt can be used topically with success, but 693
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER

Ur.
Un
un
( Azores }-e~--l~+
Lanosterol

>---~1T
Terbi nafine
Flucyt osine
Naftifine
Amorolfine
Squalene

Nucleus

--Fungal cell wall

Ergosterol-rich fungal
cell membrane
Fig . 48.1 Sit es of action of c ommon antifungal drugs. Fungi are morphologically very diverse organisms, and this diagram of a
'typical' fungus is not intended to be technically correct. The principal sites of action of the main antifungal agents mentioned in this
chapter On yellow boxes) are indicated as shown.

for systemic infections it is generally administered by slow
intravenous injection complexed with liposomes or other lipid-
containing preparations. This improves the pharmacokinetics and
reduces the con!.iderable burden of side effects. Long-circulating
or so-called 'stealth' liposomes containing amphotericin have
been used to good effect.
Amphotericin is very highly protein-bound. It penetrates
tissues and membranes (such as the blood- brain barrier) poorly,
although it is found in fairly high concentrations in inflammatory
exudates and may cross the blood- brain barrier more readily
when the meninge~ are inflamed, and intravenous amphotericin
is used with tlucytosine to treat cryptococcal meningitis. It is
excreted very slowly via the kidney. traces being found in the
urine for 2 months or more after administration has ceased.
Unwanted effects
The commone!.t and most serious unwanted effect of ampho-
tericin is renal toxicity. Some degree of reduction of renal
function occurs in more than 80% of patients receiving the drug;
although thil. generally recovers after treatment is stopped, some
impairment of glomerular filtration may remain. Hypokalaemia
occurs in 25% of patients, requiring potassium chloride
supplementation. llypomagnesaernia also occurs, and anaemia
can be a further problem. Other unwanted effects include impaired
hepatic func tion, thrombocytopenia and anaphylactic reactions.
694 Injection frequently results initially in chills, fever, tinnitus and
headache, and about one in five patients vomits. The drug 11
irritant to the endothelium of the veins, and local thrombophlebiti'
is sometimes seen after intravenous injection. Intrathecal injectiOn\
can cause neurotoxicity, and topical applications cause a 'km
rash. The (considerably more expensive) liposome-encapsulated
and lipid-complexed preparations have no greater efficacy than
the native drug but cause fewer adverse reactions.
NYSTATIN
Nystatin (also called fungicidin) is a polyene macrohd~
antibiotic similar in structure to amphotericin and with the \allle
mechanism of action. There is virtually no absorption from th:
mucous membranes of the body or from skin. and its U\e -
mainly limited to Candida infections of the skin. muco -
membrane and the gastrointel>tinal tract. Unwamed effects rna)
include nau!>ea, vomiting and diarrhoea.
GRISEOFULVIN
Gr iseofulvin is a narrow-spectrum antifungal agent isolated from
cultures of Penicillium griseofulvum. It causes a fungistatic action
by interacting with fungal microtubules and interfering with mit0\1\
Tt can be used to treat dermatophyte infections of skin or nail'
when local treatment is ineffective, but treatment needs to be ve~
prolonged. It has largely been superseded by other drugs.

Pharmacokinetic aspects
Gri-.eofulvin is given orally. It is poorly soluble in water. and
ab,orption varies with the type of preparation, in particular with
?aJ'Iicle size. Peal. plal>ma concentratio ns are reached in about
5hours. It is taken up \electively by newly formed skin and
coocentrated in the keratin. The plasma half-life is 24 hours. but
it IS retained in the skin for much longer. It potently induces
C)tochrome P450 en1ymes and causes several clinically
imponant drug interactions.
Unwanted effects
LnMnted eiTects with griseofulvin use are infrequent. but the
drug can cause gastrointe!>tinal upsets, headache and photosen-
llti\'ity. Allergic reactions (rashe:., fever) may also occur. The
drug ~hou ld not be g iven to pregnant women.
ECHINOCANDINS
Echinocandins comprise a ring of six amino acids linked to a
lipophilic side-chain. All drug:. in this group are based on the
'trucrure of echinocandin B, wh ich is found naturally in A.
mdulans. The cchinocandins inhibit the synthesis of 1.3-~
glucan. a gluco<,e polymer tJmt is necessary for maintaining tlle
structure of fungal cell walb. ln the absence of this polymer,
fungal cell<. lo<,e integrity and ly:.is quickly follows.
Caspofungin i., active in \itro agaimt a wide variety of fungi.
and 11 has proved eiTective in the treatment of candidiasis and
tOr!ns of inva.'>i"e a.-.pergillo~is that are refractory to amphotericin.
Oral absorption is poor. and ca!>pofungin is extensively protein-
bound in the bloodstream. lt b given intravenously. once daily,
and its plasma half-life in human!> il> 9-10 hours.
SYNTHETIC ANTIFUNGAL AGENTS
AZOLES
The azoles arc a g roup of sy nthe ti c fungistatic agents with a
broad spectrum of activity based on the imidazole (clotrimazole,
oconazole. fenticonazole, kctoconazole, miconazole, tioconazole
and sulcoml1'A>Ie) or rria:ole nucleus (itraconazole, voriconazole
and flucon azole).
Mechanism of action of the ozoles
The a7oles inhibit the fungal cytochrome P450 3A enzyme,
lanosine 14a-demcthyla!>c, which is responsible for converting
lmo~h!rol to ergosterol. the main sterol in the fungal cell
membrane. The resulting depletion of ergosterol alters the
fluidity of the membrane. and this interferes with the action of
membrane-a-.sociated en7ymes. The net effect is an inhibition of
replication. Azoic!. al~o inhibit the transformation of candida!
)east cells into hyphae-the inv~ive and pathogenic form of the
parasite. The depletion of membrane ergosterol reduces the
binding sites for amphotericin.
Ketoconazole
Ketoconazolc wa~ the firM at.ole that could be given orally to treat
systemic fungal infecti ons. It is effective against several different
types of organism (sec Table 48.1 ). lt is. however. LOxic (see below),
ANTIFUNGAL DRUGS
and relapse is common after apparently successful treatment. It is
we ll absorbed from the gastrointestinal tract. It is distributed
widely throughout the tissues and tissue fluids but does not reach
therapeutic concentrations in the central nervous system unless
high doses arc given. It is inactivated in the liver and excreted in
bile and in urine. lt-. half-life in the plasma is 8 hours.
Unwonted effects
The main ha7ard of ketoconazole is liver toxicity, which is rare
but can prove fatal and must therefore be taken into account
when deciding on a treatment regimen. Other side effects that
occur arc ga<,trointestinal disturbances and pruritus. inhibition
of adrenocortical Meroid and testosterone synthesis has been
recorded with hi gh d oses, the latter resulting in gynaecomastia
in some male patients. There may be adverse interactions with
other drugs. C iclos p orin. terfen a dine and aste mi zole all
interfere with drug-metabolising e nzymes, causing increa.~ed
plasma co ncentratio ns of ke toconazole or the interacting drug
or both. Ri fam picin, histamine H 2 receptor antagonists and
an tacids decrease the absorption of ke toconazole.
Fluconazole
Fluconazole is well absorbed and can be given o rall y or
intravenou'>ly. It reaches high concentrations in the cerebrospinal
fluid and ocular fluids, and may become the drug of first choice
for most type'> of fungal meningitis. Fungicidal concentrations
are also achieved in 'aginal tio;sue. saliva. skin and nails. It ha!>
a half-life of -25 hours; 90%- is excreted unchanged in the urine
and 10% in the faeces.
Unwanted effects
Unwanted effects, which are generally mild, include nausea.
headache and abdom inal pain. However. exfoliative skin lesions
1
(including. on occa!>ion, Stevens-Jotmson syndrome ) have been
seen in some individuals-primarily in AIDS patients who arc
being treated with multiple drugs. Hepatitis has been reported,
although lhi; is rare, and fluconazole, in the doses usually used,
does not produce the inhibition of hepatic drug metabolism and
of stero idogenesis that occurs witll ketoconazole.
ltraconazole
lt.racon:llole is active against a range of dennatophytes. It may be
given orall y but, after absorption (which is variable), undergoes
extensive hepatic metabolism. It is highly lipid-soluble (and
water-in'>oluble), and a formulation in which the drug is retained
within pocket~ of B-cyclodextrin is available. In this form,
itracona1ole can be administered intravenously, thereby
overcoming the problem of variable absorption from the
gastrointestinal tract. Admi nistered orally, its half-ufe is about
36 houf'>, and it is excreted in the urine. lt does not penetrate the
cerebrospinal nuid.
1
Thi~ is a .,cvcrc and u~ually fatal condition involving blistering of the ski n.
mouth, eyes and ge nital ia. often accompanied by fever. polyanhritis and
695
kidney failure.
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
Unwanted effects
Gastrointestinal disturbances, headache and dizziness can occur.
Rare unwanted effec~ are hepatitis, hypokalaemia and impo-
tence. Allergic skin reactions have been reported (including
Stevens-Johnson '>yndrome; see above). Inhibition of ster-
oidogenesis has not been reported. Drug interactions as a result
of inhibition of cytochrome P450 enzymes occur (similar to
those described above for ketoconazole). It has been associated
with liver damage.
M iconazole
Miconazole is given orally for oral and other infections of the
gastrointestinal tract. It has a short plasma half-life and needs
to be given every 8 hours. It reaches therapeutic concentrations
in bone, joints and lung tissue but not in the central nervous
system, and it is inactivated in the liver.
Unwanted effects
Unwanted effects are relatively infrequent, those most commonly
seen being gastrointestinal disturbances, but pruritus, blood
dyscrasias and hyponatracmia are also reported. There are
isolated reports of liver damage, and it should not be given to
patients with impaired hepatic function.
Other a:zoles
ClotrimaLOie, econuole, tiocon:uole and sulconazole are used
only for topical application. Clotrimazole interferes with amino
acid transport into the fungu:. by an action on Lhe cell membrane.
It is active against a wide range of fungi, including candida!
organisms.
FLUCYTOSINE
Flucytosinc is a synthetic orally active antifungal agent that is
effective against a limited range (mainly yeasts) of systemic
fungal infections. If given alone, drug resistance commonly
arises during treatment, so it is usually combined with
amphotericin for severe systemic infections such as candidiasis
and cryptococcal meningitis.
Mechanism of action
Flucytosine is converted to the antimetabolite 5-fluorouracil in
fungal but not human cells. 5-Fiuorouracil inhibits thymidylate
synthetase and thus DNA synthesis (see Chs 5 and 51). Resistant
mutants may emerge rapidly, so this drug should not be used
alone.
Pharmacokinefic aspects
Aucytosine is usually given by intravenous infusion but can also
be given orally. It is widely distributed Lhroughout the body
fluid~. including the cerebrospinal fluid. About 90% is excreted
unchanged via the kidney~, and the plasma half-life is 3-5 hours.
The dosage should be reduced if renal function is impaired.
Unwanted effects
Unwanted effects arc infrequent. Gastrointestinal disturbances,
anaemia, neutropenia, thrombocytopenia and alopecia have
occurred, but these arc usually mild (but may be more significant
696 in AIDS patients) and are easily reversed when therapy ceases.
Uracil is reported to decrease the toxic effects on the bone
marrow without impairing the antimycotic action. Hepatitis ha sf
been reported but is rare. h
OJ
TERBINAFINE
Terbinafin e ill a highly lipophilic, keratinophilic fungicidal com-
pound active against a wide range of skin pathogens. It ts
particularly useful against nail infections. It acts by selectivel}
inhibiting the enzyme squalene epoxidase, which is involved 1n
the synthesis of ergosterol from squalene in Lhe fungal cell walL
The accumulation of squalene within the cell is toxic to the
organism.
When used to treat ringworm or fungal infections of the naih,
it is given orally. The drug is rapidly absorbed and is taken up Bla
by skin, nails and adipose tissue. Given topically, it penetrates
skin and mucous membranes. It is metabolised in the liver by
the cytochrome P450 system, and the metabolites arc excreted in
the urine.
Unwanted effects
Unwanted effectS occur in about 10% of individuals and are
usually mild and self-limiting. They include ga~trointestina:
di!>turbances, rashes, pruritus, headache and dizziness. Joint and
muscle pains have been reported and, more rarely, hepatitis.
Naftifine is similar in action to terbinafine. Among other
developments. a morpholine derivative. amoroffine, which IX.
interferes with fungal sterol synthesis, is available as a nail l
lacquer, being effective against onchomycoses.
POTENTIAL NEW ANTIFUNGAL
THERAPIES
lncrea~ing numbers of fungal strains are becoming resistant to
the current antifungal drugs (fortunately, drug resistance is not
transferable in fungi), and toxicity and low efficacy also con
tribute to the need for beucr antifungal drugs. An additional problem
is that new strains of commensal-turned-pathogenic fungi have
emerged. Fungal infections are on the rise, partly because of the
prevalence of cancer chemotherapy and transplant-associated
immunosuppression. Encouragingly, new compounds are in
development, some with novel mechanisms of action (for review.
see Neely & Ghannoun, 2000), and the prospect of u~ing
combination therapies has been explored in more depth.
While not yet available in the UK, new echinocandins such
as micafungin and anidulafu ngin have shown promise in treat-
ing infections caused by Aspergillus and Candida spp., even m
patiems who are immunocompromised with AIDS. Unwanted
effects are mild, and their incidence less than that seen \lith
amphotericin. Several 'new generation' triazoles are also in pro,.
pect. Posaconazolc and r avuconazole both have good efficaq
against a wide range of fungal pathogens. Other developrnenl.l
are beyond the scope of this chapter, and the interested readt.'f
is advised to consult the burgeoning literature on the subject (see.
for example, Boucher et al., 2004).
Because funga l infections are often secondary to compromised
host defence, attempts have been made to boost this b}
 ANTIFUNGAL DRUGS

admmi~tration of t:be cytokine granulocyte macrophage colony with only very limited success in animals, and few fungal
'timulating factor (see Ch. 13) and other factors t:bat increase antigens have been characterised. It is hoped that advances in
ho't leucocyte numbers or function. The possibility of devel- antibody technology will soon transform this dismal outlook.
oping an antifungal vaccine, first mooted in the 1960s. has met

m-
s REFERENCES AND FURTHER READING
ety
in 'lwnura M. Ca\:lle D. Pepe M, Tafaro A 2001 Immune
~11. lt'j)OII..es to fungal infection~ and thcrapeuuc
unphcaiiOD>. Curr Drug TargeiS Immune Endocr
lht: 'lc!Jho( Dl~rd (; 189-197 (This pa~rdUl'U.HI!S lh~
nfr vj 1hr ho.lt tmmune response m fungal infec/1011
unJ w11nmes 11orel <lrategies for amt{tm~al therapy
its. Jrn ln,q on tluse da1a)
up 81Ju I W, Fnu-.er A A 2000 Review of comparative
cs \lUdic; between conventional and liposomal
amphotericin B (Arubisome) in neutropenic p:uicnl<
b)
~1th fever of unknown origin and patients with
in ')'temic mycosis. Mycoses 43: 325 -332 (This rr>iew
als "i1h a comparison ~l,.een nomwl
Dmfht>lmcm and lipasotnlll prrparrJiioru)
IW."'Icr H W, Groll A H. Cbiou C C. Wahh T J 2()().1
\<\\cr ')'temlc antifungal agents: pharmaco~ineties,
S>tety and efficacy. Drugs 64: 1997 2020 (II ll<tfitl
"' tt of I he nt'wer echinocandins and ma~okJ
C<mo J \, D1smukes W E 1994 Oral a1ole drug a'
'}'tcmtc antifungal therapy. N Engl J Mcd 330:
163 272 (A bit dated now bUI sli/1 worlh reodi1111 fi>r
tht miew <if~IOCOIIOZOfe, f/IICOIIOZ()/e and itrtr('OIUIZ()/e)
Denntng D W 2003 Echinocandin antifunga l dntgs,
L.1ncet362: 1142-115 1 (Gmeral reviewmtlhr
"htnt><tmtlills,focusing on their cliniettluse)
Dodds E S. Drew R H. Perfect J R 2000 Anufungal
pharmacodynamtc.: teY~cw of the literature and
clinical applicauons. Phannacothcrapy 20: 1335-1355
(Good Tl!>iew of amtfimRa/j tiJtd to lt7al S)'Siemic
uifeclio~~:;; some>~hat clrnicol m tOni')
Gruszecki W I. Gagos M, Hercc M, Kernen P 2003
Organization of antibiottc amphotericin B in model
lipid membranes. A mini review. Ce ll Mol 13iol Leu 8:
161- 170 (I/ you are ifltCI'fSted i11undersumding how
amphotericifl works, lhert lhi.t will he of interest)
Gupta A K, Tomas E 2003 New anti fungal agents.
Demtatol Clin 2 1: 565 576 (Quite a comprehensive
rrview thai deal! mtwtly with thl' newer anrifungals.
their mechanisms of11Wan anti resiswnce)
Hoepricb P D 1995 Aoufungal chcn101hernpy. Prog Drug
Re.. 44: 88-127 (A b11 dmed non bt11 contntns 1'<'1')
dt'toill'd coruagl' of lhl' mom clones of drug:
chemical formulae, mO<lt' of IIC/1011, phamwcokinetics.
adterse ejJec1s) Useful .. eb resources
Kauffman C A 200 I Fungal infectiOn> m older adults.
Clio Infect Oil. 33: 550-555 (lmeresting tl(t'num of
fimt~"l infecliOIIS tmd tlttir 11711/mem)
Neely M N, Ghannoun M A 2000 The exciting future of
antifungal therapy. Eur J Clin Micmbio1 Infect Dis 19:
897-91 4
Van Spnel A B 2003 Novel unmunothcrapeuhc
\lt:llegtc, for Invasive fungal disease. Curr Drug
Targe~ CardtO\:lSC HacmalOI Di~ 3: 209-217
(AIIOIIt~r pa~r 11101 discusses the roll' of tht! hmt
imuumt rripanst in fimgal infection and examrnl"t
tW>,IIIro/1'/liesfor anrifungallheropy dru,.mg on
lltt"udmo)
Vermes A. Guchelanr H J, Dankert J 2000 FlucytoMnc: a
review of iL~ phnnnncology. clinical indications.
phannncokinetics, toxicity and drug intcmct ions.
J Antimicrob Chcmolher46: 171-179 (Thetil/e is ltl/
t!XfJimullory')
Wiederhold N P, Lewis R E 2003 The echinocandm
anti!ungals an ovemew of the pharmacology.
'~-ctrum and clinical efficacy. Expert Optn ln\e,hg
Drug~ 12: 13H-1333 (AIIOthu mi<'l<' oflh~
ttch11ux:and11u 1'1!1') comprehe~~:;iw)
bllp://www.doctorfungus.org (This is anexctllent me
spon:wnd h)' 11 Nm.wniwn of phomwreutical
rOmfJ{IIIit.f. II coters all aspects offimgaf infection\
and drug tl!lrttpy, mul lws ma11y compel/i11g image.<
a/Ill video clip.<. lli!lhl) recommended-<JIUI fim!)

lO
lOt
n-
~111

~e

e
ed
10
M.,
g

ch
l-
m
ed
th

ed
 Antiprotozoal drugs
Overview 698
Host-parasite interactions 698
Amoebiasis and amoebicidal drugs 699
Flagellates 700
-Trypanosomiasis and tryponicidol drugs 700
-Leishmaniosis and leishmonicidol drugs 701
-Trichomoniasis and trichomonicidol drugs 702
-Giardiasis 702
Sporozoa 702
-Malo rio 702
-The life cycle of the molorio parasite 702
-Antimalarial drugs 704
-Potential new antimalarial drugs 709
Toxoplasmosis and taxoplasmocidal drugs 709
Ciliates and others 710
New approaches to antiprotoz:oal therapy 710
OVERVIEW
Protoz:oa (plural form of protozoon) are motile,
unicellular eukaryotic organisms that have
colonised virtually every habitat and ecological
niche. They may be conveniently classified, on the
basis of their method of locomotion, into four main
groups: amoebas, flagellates, sporozoa and a
further group comprising ciliates and other organisms
of uncertain affiliation, such as the Pne umocystis
carinii mentioned in the last chapter. The protozoa
have diverse feeding behaviour, with some being
parasitic. Many have extremely complex life cycles,
sometimes involving several hosts, reminiscent of
the helminths discussed in Chapter SO.
As a group, the protozoa are responsible for an
enormous burden of disease among humans as
well as domestic and wild animal populations.
Table 49.1 lists some of these clinically important
organisms, together w ith the diseases that they
cause, as well an overview of the drugs used to
698 combat infection. In this chapter, we will first
discuss some general features of protozoa-host
interactions and then discuss the therapy of each
group of diseases in turn. In view of its global
importance, a discussion of malaria will occupy
much of the chapter.
HOST-PARASITE INTERACTIONS
Mammal!> have developed very efficient mechanisms for deahng
with invading para~ites. and many of these parasites have. in tum,
evolved clever tactics to evade the defensive responses of the
host. Some of these gambits will be dealt with a~ we discu"
each para'>ite in turn, but we also have some general comment'.
One common parasite ploy is to take refuge within the celh
of the host, where antibodies cannot reach them. Most protoztX.
do this, some (e.g. pla~modia species) taking up residence in m.
cells, some (Leishmania species) infecting macrophage'
exclusively. and some (various trypanosome species) invadin0
many other cell types. The host has also evolved counter-
measures to deal with these intracellular parasites, namely cell-
mediated immune responses involving primarily the T-help<r it i
(Th) I pathway cytokines, such as interleukin (IL)-2, LUmour tin
necrosis factor-o. and interferon-y, that activate macrophages and th
cytotoxic CDS+ T cells (Ch. 14). Activated macrophages kill
intracellular parasites, and cytotox ic T cells collaborate w1th
macrophages by producing macrophage-activating cytokines. orl
The Th I pathway res ponses can be down-regulated by Th~ lit
pathway cytokines such as transforming growth factor-p, IL-l tr
and IL- l 0. Some imracellular parasites have evolved mech- (I{
anisms for manipulating the Th 1- Th2 balance to their 011
advantage by stimulating production of the Th2 cytokines thO!
down-regulate cell-mediated immune reactions. For example. the.
invasion of macrophages by Leishmania species is associated
with induction of transfonning growth factor-P. and the im:biO' 111
ofT cells, 8 cells and macrophages by trypanosomes is associ hi
ated with induction of TL-10 (see Handman & Bullen, 2002. 3111 as
Sacks & Toben-Trauth, 2002, for further detai ls). Sim1lar
mechani!.m!> occur during worm infestations (see Ch. 50).
Toxoplasma gondii has evolved a different ploy: up-regulation
of some host responses. The definitive (i.e. where sexual
recombination occurs) host of this protozoon is the cat, bu1
humans can inadvertently become intermediate hosts, harbouring
the asexual form of the parasite. In humans, T. gondii infect1
numerous cell types and has a highly virulent replicative stage;
 ANTIPROTOZOAL DRUGS

Table 49.1 Principal protozoal infecti ons and common d rug treatments

Organism Disease Common drug treatment

Amoebas
Entamoeba h1stolytica Amoebic dysentery Metronidazole, t1nidazole, diloxanide

Flagellates
Trypanosoma rhodesiense Sleeping sickness Suramin, pentamidine, melarpasol,
Trypanosoma gambiense eflorn1th1ne, nifurtimox

Trypanosoma cruzi Chagas' disease Nifurtimox. benzindazole

}
Leishmania trop1ca Oriental sore
Leishmania donovan! Kala-azar Sodium stibogluconate, amphotericin,
Leishmania brazlliensis Espundia pentamidine isethionate
Leishmania mexicana Chiclero's ulcer

Trichomonas vagina/is Vaginitis Metronidazole, tinidazole

Giardia Iambiia Diarrhoea, steatorrhoea Metronidazole, tinidazole.

Sporozoa
Plasmodium falciparum Malignant tertian malaria Amodiaquine, artemisinin and derivatives,
Plasmodium vivax Benign tertian malaria atovaquone, chloroquine, dapsone,
Plasmodium ovale Benign tertian malaria doxycycline, halofantrine, lumetantrine,
Plasmodium malarariae Quartan malaria mefloquine, pnmaquine, proguanil,
pynmethamine, quinine, tafenoquine and
tetracycline
Toxoplasma gondii Encephalitis, congenital malformations, Pyrimethamine, sulfadiazine pentamidine
eye disease isethionate

Ciliates and others

Pneumocyst1s carinii Pneumonia Co-tnmoxazole, atovaquone, pentamidine
isethionate

es (After Greenwood, 1989.)

g
r-
II-
r 11 i~ therefore important to the parasite that its host survives. To The infectious cy'oh pa'~ into the colon. where they develop into
ur do thi ~. it stimulates production of interferony, thus modulating tmphowites. Thc;c motile organ i ~ms adhere to colonic epithelial cell~.
utilising a galact(l\econtaining lectin on the host cell membrane, where
d the host's cell-med iated responses. which then promote 1he trophot.oi tcs feed, multiply. cncyM and eventually pass ou t in the
Ill cncystmenl of the parasite in the ti1.sues. faecc:,, thu:, completing the life cycle. Some individuals are 'ymptomless
th Improved understanding of host-protozoon relationships has 'ct~rriers'-they harbour the parasite without developing overt disease,

Opc!ned up new vistas for the development of anti protozoal agents. but the cysl~ ;~rc prci>Cnl in their faece and they can infect other
The possibility of using cytokine analogues and/or antagonists to individual<.. The cyst\ can survive outside the body for at least a week in
a moi~t and cool envmlllmcnt.
treat disease caused by prototoa is already being i1wcstigated
1for review. sec Odch, 200 I). The 1ropho7oitc lyo,eo, the colon1c muco<.al cells (hence hisrolytica) u~ing
~~o n tmwebatmre.> Cpepude., thai form pore~ in cell membranes) or by inducing
hoSI cell apoploo,is. The organi<.m then in,ades the submucosa. where it
l 3l
may -.ccrete facto!'\ that modify the ho~t re~pon~. which would othern i<;e
he AMOEBIASIS AND AMOEBICIDAL DRUGS pro\e lethal to the par.!!>itc. It is this proce~~ that produces the
ed charactcrio,tic blood) d1arrhoea and abdominal pain. although in man)
on The main organi-.m in thi'> group to concern us here is Enuunoeha subJCCt\ a chrome inte,unal mfection ma} be present in the ab-.cncc of
ti hutolytica, the cau\ative agent of amoebiasis. which may manifest dy-;entcl). In o,ome o,UbJeCL\. an an1ocbic granuloma (amoeboma) in 1he
lntC\linal "all ma) be prco,cnt. The trophozoite~ rna) also migrate
nd a~ a severe colili'> (dywntery) and sometimes U\'er abscesses.
lhrough the damaged 1ntc~unal tb~ue 1nto the portal blood and hence the
lar ~ The infecuon t\ encountered around the \\Orld. although it is more li\cr. gh ing ri'c to the moM common extraintestinal symptom of the
often encountered in warmer cltmate\. Approximately 500 million di,casc <~mOCblc liver ab!>Ce~se,.
on people are thought to harbour the &,case. with 40000-100000 deaths
!a\ tlCcurring each year"' a re\ult (St;mley. 2003). It i\ considered to be the The u\e of drugs to treat this condition (see Drugs used in
put second leading cnu'c of death from pant\itic di!>ease~ \\Orldwide. amoebiasis lm.1) dcpcnd11 largely on 1he site and type of infection,
The organi'om ht1s a ~imple life cycle. and humans are the chief hosts.
as different drugs are differentially effective in acute amoebic
ng
cts Infection. generally spread by poor hygiene. follow the ingestion of the dysentery, in chronic intestinal amoebiasis. in extrainteslinal
m;uure cyst' i n wmcr or food that is contaminated with human faeces. infection and in the currier state. The main drugs currently used 699
ge;
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
Drugs used In amoebiasis
Amoebiasis is caused by infection with
Entamoeba histolytica, which causes dysentery and
liver abcesses. The organism may be present in motile
invasive form or as a cyst. The main drugs are as follow.
Metronidazole given orally (half-life 7 hours). Active
agatnst the invasive form in gut and liver but not
the cysts. Unwanted effects (rare); gastrointestinal
disturbances and central nervous system symptoms.
Diloxanide is given orally with no serious unwanted
effects. It is active, while unabsorbed, against the
non-invasive form in the gastrointestinal tract.
are metronidazole, tinidazole and diloxanide. These agents
may be used in combination.
The drugs of choice for the various forms of aDlocbiasis arc as
follow:
metronida7ole (or tinidazole) followed by diloxanidc for
acute invasive intestinal amoebiasis resulting in acute severe
amoebic dy~entery
diloxanide for chronic inte~tinal amoebiasis
metroniduole followed by diloxanide for hepatic amoebiasis
diloxanide for the carrier state.
Metronidazole
Metronidazole kills the trophozoites of E. histolytica but has no
ctTcct on the cysts. It is the drug of choice for invasive amoebiasis
of the intestine or the liver, but it is less effective against organ-
isms in the lumen of the gut. Metronidazole is activated by anaer-
obic organisms to a compound that damages parasite DNA, leading
to parasite apoptosi~>.
Phormocokinetic aspects
Metronidazole is usually given orally and is rapidly and com-
pletely absorbed, achieving peak plasma concentration in
1-3 hours, with a half-life of about 7 hours. Rectal and intra-
venous preparation<, are also avai lable. It is distributed rapidly
throughout the tis~ue<,, reaching high concentrations in the body
fluids, including the cerebrospinal fluid. Some is metabolised,
but most is excreted in urine.
Unwonted effects
The drug has a metallic, bitter taste in the mouth but causes few
unwanted effects in therapeutic doses. Minor gastrointestinal
disturbance!> have been reported, as have central nervous system
(CNS) 11ymptoms (diu.iness, headache, sensory neuropathies).
The drug in terfere~ with alcohol metabolism. and concurrent
use of the substance should be strictly avoided. Metronidazole
should not be used in pregnancy.
Tinidazole is similar to metronidazole in its mechanism of
action and unwanted effects, but is eliminated more slowly, having
700 a half-life of 12- 14 hours.
Dilox anide co
Both diloxanide itself and, more particularly. an insoluble e~ter. li
diloxanide fu roate. are the drugs of choice for the asymptomau, 1111.
infected patient, and are often given as a follow-up after the de
di.,ca~e ha~ been reversed using metronidazole. Both drug\ hal't
a direct amoebic ida I action, affecting the parasites before eoc),t
ment. Diloxanide furoate is given orally. the unabsorbed mOiety
being the amoebic ida! agent. It has an excellent safety profile.
Other drug~ that are ~ometimes used outside the uK 1 rer-.
treat this disease include iodoquinol, dehydroemetine all( rno
paromomycin. the
FLAGELLATES
The principal disease-causing organisms in this group are specie,
of Trypwwsoma, Leishmania, Trichomona and Giardia. We 11-ill
discuss each in turn.
TRYPANOSOMIASIS AND TRYPANICIDAL
DRUGS
1l1e three main species of trypanosome that cause disease in hum;ms
arc Trypanosoma gambiense and Trypanosoma rhodenmst,
which cau~c sleeping sickness in Africa. and Trypanosoma cru:~,
which causes Chagas' disease in South America. About IOOOOJ
new ca'>es of sleeping sickness are reported each year. and
60 million people in 36 countries are classed as at risk of con
tracting the di!.ea~e. T. rhodesiense causes the more aggre,,il-e
form of ~leeping sid.ness. All forms of the disease have sho11n
signs of resurgence. becau\e civil unrest, famine and AIDS halt
reduced the chances of receiving adequate medication or becau,,
patients are immunocompromised. Related trypanosome
infections also pose a major risk to livestock and thus have a
secondary impact on human health and well-being.
'Y The vector i I he tset~e ny. In both types of disease, there is an imt1a
local lesion at the ~ ite of entry. wh ich may (in the case of T. rltodesiemr1
develop in to a painful cha ncre. This is followed by bouts of parasilacmiJ
and fever a~ the para~ite enters the haemolymphatic ~ystem. Damage'"
organs is caused by tl1c para;itcs and the toxins they release during 1ht
~econd pha~e of the dbease. This manifests as somnolence ijnd
progrc~sh c neurological breakdown when the parasites reach the C"iS
(;.lceping sicknC\\), or damage to the heart, muscles and sometime' h1e1,
spleen. bone and inte\tine (Chaga!>' disease). Left untreated. \Ucb
infection' arc fatal.
The main drugs used for African sleeping sickness are suramin
with pentamjdine as an alternative, in the haemolymphatic 'tage
of the disease, and the arsenical melarsoprol for the late 'tagc
with CNS involvement (see Burchrnore et al.. 2002; Bum &
Brun, 2003). Other agents include nifurtimox and eflornithine
Nifunimox i), al~o used in Chagas disease as is benznidazole
(but in the acute disease only and not in the UK); however. thell
is, in essence, no really effective treatment for thi~ fom1 or
trypanosomiasis. LS
Dl
Suramin Th
Suramin was introduced into lhe therapy of trypanosomia~is in
1920. The drug binds firmly to host plasma protei ns, and the

complex enters the trypanosome by endocytosis from where it is
liberated by lysosomal proteases. It does not kill the parasites
immediately but inhibits parasite en7ymes, inducing gradual
de~truction of organe lle~. such that the organisms are cleared
from the circulation after a short interval.
The drug is given by slow intravenous injection. The blood
concentration drops rapidly during the first few hours and then
more slowly over the succeeding days. A residual concentration
remains for 3-4 months. Suramin tends to accumulate in the
mononuclear phagocyte system of the host and is also found in
the cells of the proximal tubule in the kidney.
Unwonted effects
Suramin is relatively toxic, particularly in a malnourished patient,
the main toxic effect being in the kidney. Other slowly devel-
oping adverse effects repo rted include optic atrophy, adrenal
insufficiency, skin rashes, haemolytic anaemia and agranulocytosis.
A small proportion of individuals have an immediate idiosyn-
cratic reactio n to suramin injection that may include nausea,
1omiting, shock, seizures and loss of consciousness.
Pentamidine isethionate
Pentamidine has a direct trypanocidal action in vitro. It is rapidly
raken up in the parasites by a high-affinity energy-dependent
carrier and is thought to interact with the D A. The drug is
odministered intravenously or by deep intramuscular injection,
u,uaJiy daily for 10-15 days. After ab!.orption from the injection
'lie, it binds strongly to tissues (especially the kidney) and is
eliminated slowly. only 50'* of a dose being excreted over
5 days. Fairly high concentrations of the drug persist in the
l!dney, the liver and the spleen for several months, but it does
not penetrate the blood- brain barrier. Its usefulness is limited by
lb unwanted effeCt'>-an immediate decrease in blood pressure,
11ith tachycardia, breathlessness and vomiting, and later serious
toxicity, such as kidney damage, hepatic impairment. blood
dyscrasias and hypoglycaemia.
A relatively new drug, e tlorn ithine (the only new drug to be
registered over the past 50 years) has shown good activity against
T. gambiense and is used as a back-up for melarsoprol. although
unfortunately it has limited activity against T. rhodesiense. The drug
targets parasite ornithine metabolism. Side effects are common
.md may be severe, but are readi ly reversed when treatment is
discontinued. A new drug candidate, DB 289. bas shown promise
()~gros et al., 2002), but mcgazol, another useful trypanocidal that
11as under development, has been dropped because of genotoxiciry
tNesslany et al., 2004 ). Unfortunately, there are few (if any) o ther
new drugs in the pipeline. and as resistance develops to the
'tandard agent , the number of deaths from this condjtion is set
to rise. Despite work into likely parasjte antigens, the current
e prospects for a vaccine look bleak (Naula & Burcbmore, 2003).
c concomitantly with the above agents. They may have some action
r on the parasite in their own rigbt. but t.beir main utility is to
LEISHMANIASIS AND LEISHMANICIDAL
DRUGS
There are a variety of Leishmania organisms that cause disease
(sometimes fatal) afflicting about 12 million people in 90 countries;
there are about 2 million new cases each year, mainly in tropical
ANTIPROTOZOAL DRUGS
and subtropical regions. With increasing international travel,
leishmaniasi<. is being imported into areas where it was not
previously seen, and opportunjstic infections are now being
reported (particularly in AIDS patient<;).
~ The insect vector in this case is the sandfly. and the parasite exist'> in
mo forms, a flagellated form (promastigote) found in the gut of the
infected \andfl). and a non-flagellated intrnceUular form (amasrigote)
that occur. m the infected mammalian host. where it is harboured b)
mononuclear phagocytcs. Within this cell. the parasites thrive in modified
phagolyso~omes and protect themselves from the usual intracellular
killing mcchamsms by modif)ing the macrophage\ microbiocidal systems.
apparently by deploying a lipophosphoglycan on their surface (Hand man
& Bullen. 2002). The amastigotes multiply, and eventually the infected
cell releases a new crop of parasites into the haemolymphatic system,
where they can infect further macrophages and possibly other cells.
TI1e diiTercnt species of Leishmania occur in different geographical zones
~nd c~usc different clinical manifestations (see Table 49. 1). Typical
presentations include:
a simple ~kin infection givi ng rise to an unpleasant chancre ('oriental
sore', 'Chiclero's ulcer' and other names) that may heal spontaneously
a mucocutaneou\ form ('espundia' and other names). in which there
may be large ulcers of the mucous membranes
a '>eriou\ visceral form ('kala-azar' and other names), where the
parasite ~pread' through the bloodstream and causes hepatomegaly,
splenomegaly, anaemm and intermittent fever.
The main drugs used in visceral leishmaniasis are pentavalent
antimony compounds !.uch as sodium s tibogluconate and
meglumine a ntimoniate (not in the UK), but resistance to these
agents is increasing and their toxicity is high. Amphotericin (see
Ch. 48) is a useful back-up. and pentamidine isethionate (see
above) is also u\ed in antimony-resistant leishmaniasis. In some
countries, miltefosinc, originally developed as an antitumour drug,
has been used with success to treat the disease.
Sodium stibogluconate
Sodium stibogluconale is given intramuscularly or by slow intra-
venous injection in a I0-day course. It is rapidly eliminated in the
urine, 70% being excreted within 6 hours. More than one course
of treatme nt may be required. Unwanted effects include
anorexia, vomiting, bradycardia and hypotension. Treatment may
also be associated with increased incidence of herpes lOSter.
Coughing and substernal pain may occur during intravenous
infusion. The mechanism of action of sodium stibogluconate is
not clear, but the drug may increase production of oxygen free
radical!>, which are toxic to the parasite.
Miltefosine (hexadecylphosphocholine) is also effective in the
treatment of both cutaneous and visceral leishmaniasis. The drug
may be given orally and is well tolerated. Side effects are mjld
and include nausea and vomiting. In vitro, the drug induces DNA
fragmentation and apoptosis in the parasites (Verma & Dey, 2004).
Other drugs such as antibiotics and antifungals may be given
control the spread of secondary infections. Current drug usage
and possible future a pproaches to the trt'1 tment of leishmaniasis
are discussed by Murrey (2000). At pr<~ nt, there is no vaccine
for leishmaniasis; an approach to this prCblem using recombinant
Leishmania proteins is discussed by Kubar & Fragaki (2005). 701
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
TRICHOMONIASIS AND TRICHOMANICIDAL
DRUGS
The principal Trichomonas organism that produces disease in
humans is Trichomonas mginalis. Virulent strains cause inflam-
mation of the vagina in female' and sometimes of the urethra in
male~. The main drug used in therapy is metronidazole (p. 699),
although resistance to this drug b on the increase. High doses of
tinida;olc are abo effective, \\-ith few side effects.
GIARDIASIS
The fina l flagellate we will discuss is Giardia Iamblia. The tro-
phot.oite form of this parasite colonises the upper gastrointestinal
tract, and the cysts pass out in the faeces. fnfection is then spread
by ingestion of food or water contaminated with faecal matter
containing the cysts. It is encountered worldwide, and epidemics
caused by bad sanitation are not uncommon. Metronida7ole is
the drug of choice, and treatment is usually very effective.
SPOROZOA
MALARIA
Malaria wa-, once considered to arise from marshy land (hence
the name mal aria bad or poisonous air), bur we now recog-
ni'>e that the disea\e i'> cau'>ed by parasites belonging to the genus
Plasmodium. Four '>pecies of plasmodia infect humans:
Plasmodium l'iva.\, Pla:.modium falciparum, Plasmodium o1a/e
and Plasmodium ma/ariae. The insect vector is the female
Anopheles mosquito. which breeds in stagnant water, and the
disease it spreads is one of the major killers on our planet.
The statistics are staggering. According to the World Health
Organization (WHO). malaria is a significant public health prob-
lem in more than 90 countrie:, inhabited by some 2400 million
people (about 40% of the world's population). The disease
causes an e~timated 300 million acute illnesses each year and at
least I million deaths. More than 90% of these occur in sub-
Saharan Africa, and it is estimated that the disease kills an
African child every 30 secondl.. Even those who survive may suffer
from lasting mental impairment. Other high-risk groups include
pregnant women, refugees and labourers entering endemic
region~. Malaria also impo<.e~ a huge economic burden on countries
where the di.,ea\e is rife. 1
The ~ymptom., of malaria include fever, :.hivering, pain in the
joint~. headache, repeated \'Omiting. generalised convulsions and
coma. Symptom\ become apparent only 7-9 days after being
birten by an infected mosquito. By far the most dangerous
parasite is P. falciparwn.
Malaria wa-, eradicated from most temperate countries in
the 20th century. and the WHO artempted to eradicate malaria
1
Taking into accoun1 lac1or, 1uch a~ ini1ial poverty and economic policy, it
has been ca lculmcd that co~f1ries wilh inten~ive malaria grow 1.3% less per
per~on per yenr than malariafree wne~. and that a 1. 1% reduction in
702 maluria i, m.~ociatcd with a (1.3% higher rate of economic growth.
el~ewhere U\ing the powerful 'residual' insecticides and the
highly effective antimalarial drugs that had become available. a,
the end of the 1950'>, the incidence of malaria had dropptd
dramatically. Howe,er, during the 1970~ it became clear that
the anempt at eradication had failed-largely owing to tilt
increasing rcsi!>tancc of the mosquito to the insecticide~ and
of the parasite to the drugs. Sadly. it is now the case that malana
hac; re-emerged in several countries where it was pn:,iou'l)
under control or indeed eradicated. Sporadic ca!>es-the n:'ul
of air travel-arc already quite common in Western Europe an
the USA, where the actual risk of transmission is negligible.'
THE LIFE CYCLE OF THE MALARIA PARASITE
The mosquito. not the human. it> the definitive host for pia,.
modia, and it has been said that the on ly function of humans 1s to
enable the parasite to infect more mosquitoes so that funhcr
sexual recombination can occur. The life cycle of the pami t~'
consists of a se.wal cycle, which takes place in the female
anopheline mosquito, and an asexual cycle, which occurs m
humans (Fig. 49. I and the Malaria box).
Malana is caused by various species of
plasmodia, which are carried by the female
anopheline mosquito. Sporozoites (the asexual form
of the parasite) are introduced into the host by bite of
the insect, and these develop in the liver into:
schizonts (the pre-erythrocytic stage), which
liberate merozoites-these infect red blood cells,
forming motile trophozoites, which, after
development, release another batch of
erythrocyte-infecting merozoites, causing fever;
this constitutes the erythrocytic cycle
dormant hypnozoites, which may liberate
merozoites later (the exoerythrocytic stage).
The main malarial parasites causing tertian ('every
third day') malaria are:
P. vivax, which causes benign tertian malaria
P. falc1parum, which causes malignant tertian
malaria; unlike P. vivax, this plasmodium has no
exoerythrocytic stage.
Some merozoites develop into gametocytes, the
sexual forms of the parasite. When ingested by the
mosquito, these give rise to further stages of the
parasite's life cycle within the insect.
'As an cxnmplc of \Uch 'airport malaria'. the UK registered 236-1 case' of
malaria in 1997, all of them imported by tmveller~. 'Weekend muluria',
which occur~ when city dweller~ in Africa spend weekend~ in the
countryside. i' also becomi ng more of a problem.
 ANTIPROTOZOAL DRUGS

HUMAN

)
It
.'


drugs used for
chemoprophylaxis

4
d
B. Site of action of drugs
used for radical cure
(P. vivax and P. ovale only)
BLOOD

2b t

le
In
1b

I 0
/
- - Liver cell D. Site of action
of drugs which
prevent
.
,.... -.;" 10
9 ~
sA

drugs used to treat

n~o-f'
- -A-. -S-it_e_o_f_a_c-ti_o...

"' ( Spo,.,,.,., transmission the acute attack

" \ injected

MOSQUITO
~~,-----
Fig. 49. 1 The life cyc le of the malarial parasit e and the s ite of action of antimalarial drugs. The pre- or exoerythrocytic cycle in
the liver and the erythrocytic cycle in the blood are shown: 1a Entry of sporozoite into liver cell (the parasite is shown as a small circle
containing dots, and the liver cell nucleus as a blue ova~. 2a and 3a Development of the schizont in liver cell. 4 Rupture of liver cell with
release of merozoites (some may enter liver cells to give resting forms of the parasite, hypnozoites). 5 Entry of merozoites into a red cell.
6 Trophozoite in red cell. 7 and 8 Development of schizont in red cell. 9 Rupture of red cell with release of merozoites, most of which
parasitise other red cells. 10-12 Entry of merozoites into red cells and development of male and female gametocytes. 1b Resting form of
parasite in liver (hypnozoite). 2b and 3b Growth and multiplication of hypnozoites. Sites of drug action are as follow. A Drugs used to
treat the acute attack (also called 'blood schizonticidal agents' or 'drugs for suppressive or clinical cure'). B Drugs that affect the J
exoerythrocytic hypnozoites and result in a 'radical' cure of P. vivax and P. ova/e. C Drugs that block the link between the exoerythrocytic
stage and the erythrocytic stage; they are used for chemoprophylaxis (also termed causa/ prophylactics) and prevent the development of
malarial attacks. D Drugs that prevent transmission and thus prevent increase of the human reservoir of the disease.

~ With the bile of an infected female mo,quito. sporo:oitei-usually
fc~ in number-are inoculated into the bloxhtream. Within 30 minutes.
the) di\app.:ar from the blood and enter the parenchymal cells of the liver.
"'here. during the nc~t 10 14 da)~.they undergo apre-erytlrmcytic stage
of development and multphcatJOn. At the end of this stage. the
par.t\111\ed h' .:r cell\ rupture. and a ho;t of fresh mero:oites are relea~ed.
The\e hind to and enter the red cell\ of the blood and form motile
intracellular p<lra\IIC\ t.:m1ed tmplw:oites. The development and multi-
plication of the pla,modia ~ithin the'>c cell~ constitute> the er)7hrocwic
\lll,~e. During maturation within the red cell. the parasite remodel~ the
host cell. 111\erting pam'>ite protein' and phospholipids into the red
cell mcmbr<1nc. TI1c ho,t\ haemoglobin is digested and tran-,ported to
the parasite~ foocl '<lCuole. ~here it provides a source of amino acid,.
Free haem. which would be toxic to the pla:,mooium. is rendered
harmlcs<; by polymcrisation to haemo:oi11. Some untimalarial drugs
act by inhibiting the haem polymerase en;yme re:,ponsible for this step
(sec below).
following mllollc replication of iL~ nucleus. the parasite in the red cell i!>
tem1ed a fc1Ji:om. and it\ rapid gro~th and division. scfli:ogony. Another
ph<I\C of multiplication re~ul~ m the production of further mero;oites.
which are rclea\Cd ~hen the red cell ruptures. Theoe merozoites then bind
to and enter fre'h red cclh. and the crythroc) Lie cycle stans all o~er again.
In cert:un form' of malaria. some ~poroLOite~ entering the liver
cell., form lnpno:.oites. or 'sleeping forms of the para'>ite. which can be
n:acll\ated month' or year; later to continue an exoerythrocytic cycle of
multiplication.
Malaria para~ite1-. can multiply in the body at a phenomenal
nue-a single parasite of P. l'im.x can give rise to 250 million
mero7oites in 14 days. To appreciate the action required of an
antimalarial drug, note that destruction of 94% of the parasites
every 48 hours will ~>crve only to maintain equilibrium and will not
further reduce their number or their propensity for proliferation. 703
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
Some mero.wites, on entering red cells, differentiate into male
and female forms of the para!>ite. called gamerocytes. These can
complete their cycle only when taken up by the mosquito, whe n
it suck!> the blood of the infected host.
T The cycle m lhe mosquito tn\'Oives fertilisation of lhe female
gametoc)'te by the male gametocyte. with lhe formation of a ::;ygore,
v.hich develop' 1nto an oocnr (sporocyst). A further s!llge of di\ is ion and
multiplication tal.e., place. leading to rupture of the sporocyst with release
of \porotoite), which then mtgrate to lhe mosquitos salivary glands and
enter llnother human host with lhe mosquito's bite.
The periodic episodes of fever that characterise malaria result
from the synchronised rupture of red cells with release of
merozoites and cell debris. The rise in temperature is associated
with a ril>e in the concentration of tumour necrosis factor-a in the
plasma. Relapses of malaria are likely to occur with those fonm
of malaria that have an exoerythrocytic cycle, because the dOimant
hypnozoite form in the liver can emerge after an interval of
weeks or months to start the infection again.
The characteristic presentations of the different forms of
human malaria arc as follow (see Fig. 49.1 for details).
P. falciparum, which has an erythrocytic cycle of 48 hours
in humans, produce!> malignam tertian malaria-' tertian'
because the fever wa!> believed to recur every third day
(actually. it varies), 'malignant' because it is the most severe
form of malaria and can be fatal. The plasmodium induces,
on the infected red cell membrane, receptors for the adhesion
molecules on vascular endothelial cells (seep. 000). These
parasitised red cells then stick to uninfected red cells,
forming clusters (rosettes), and also adhere to and pack the
vessels of the microcirculation, interfering with tissue blood
now and causing organ dysfunction including renal failure
and e ncephalopathy (cerebral malaria). P. falciparum does
not have an exoerythrocytic stage, so if the erythrocytic stage
is eradicated, relapses do not occur.
P. viva.x produces benign tertianmalaria-' benign' because
it is less severe than fa lciparum malaria and is rarely fatal.
Exoerythrocytic forms may persist for years and cause relapses.
P. ovate, which has a 48-hour cycle and an exoerythrocytic
stage, is the cause of a rare form of malaria.
P. malariae has a 72-hour cycle, causes quartan malaria a nd
has no exoerythrocytic cycle.
Individuals living in areas where malaria is endemic may acquire
a natural immunity. butthi!> may be lost if the individual is absent
from the area for more than 6 months.
ANTIMALARIAL DRUGS
The be t way to deal with malaria is to avoid the disease in the
first place by preventing mosquito bites.
T Travcllcn. to mfected area~ ~hould alway~ take ~imple precaution~
!>uch a~ \\Canng clothes that cover much of the skin and using insect
repellent'> in living. and c~pcc tally in sleeping, areas. because mo,quitoes
tend to bi te between du\~ and da\\ n. Bed nets sprayed with insecticide\
such as per meth rin can be very effective.
Some drugs can be used prophylactically to prevent malaria, while
704 others are directed towards treating acute attacks. In general,
Antimalarial therapy and the parasite
IHe cycle
Drugs used in the treatment of malaria may have
several sites of action:
drugs used to treat the acute attack of malaria act
on the parasites in the blood; they can cure
infections with parasites (e.g. Plasmodium
falciparum) that have no exoerythrocytic stage
drugs used for chemoprophylaxis (causal
prophylactics) act on merozoites emerging from
liver cells
drugs used for radical cure are active against
parasites in the liver
some drugs act on gametocytes and prevent
transmission by the mosquito.
an timalarial drugs are classified in terms of the action against the
different stages of the life cycle of the parasite (Fig. 49.1 ).
Drugs used to treat the acute attack
Blood schi:omicidal agent:. (Fig. 49.1. site A) are used to treat
the acute attad. they are also known as drugs that produce 2
suppre!>'>ive' or 'clinical' cure. They act on the erythrocytic forms
of the plasmodium. In infections with P. falciparwn or P. malarltl
which have no exoerythrocytic stage. these drugs effect a cure.
with P. 1'i1a.x or P. om/e. the drugs suppress the actual anacl.
but exoerythrocytic forms can re-emerge later to cause relap~e~.
This group of drugs includes quinolille-metlwnols (e.g. quiniDt
and mefloquine ). various 4-aminoquinolines (e.g. chloroquine!.
the phenanthrene haJofa ntr ine, and agents that interfere either
with the synthesis of folate (e.g. sulfones) or with its action (e.g.
pyri met hamine and progua nil), as well as the hydrOX)
naphthoqu inone compound atovaquo ne. Combinations of these
agents arc frequently used. Some antibiotics, such as tet racycline
~
and doxycycline (sec Ch. 46), have proved useful when combined
t
wi th the above agents. Compounds derived from qinghaosu, f<X
example a rtemether. a rteflene and artesunate, have also pro\ed
effective.
For a brief summary of currently recommended treatme~ Drl.
regimens, see the Antimalarial drugs box and Table 49.~. Son
more detailed coverage of the treatment of malaria is given bj h,l\
ewton & White ( 1999) and Baird (2005). !Fig
thu'
Drugs that eHect a radical cure hut I
7issue schizomicidal agents effect a 'radical' (in the sense c \
striking at the root of the infection) cure by acting on the par.r
sites in the liver (Fig. 49.1, site B). Only the 8-aminoquinolint
(e.g. primaq uine and tafenoq ui ne) have this action. These drug
4-A
also destroy gametocytes and thus reduce the spread of infecti011 Tht:
tFig.
Drugs used for chemoprophylaxis It \-
Drugs used for c he moprophylaxis (also known as causu agra
pmphylactic drugs) block the link between the exocrythrocyti, ol thl
 ANTIPROTOZOAL DRUGS

Table 49.2 Summary of drugs used for treatment and chemoprophylaxis of malaria

Infections Typic al drug choices fo r Typic al drug choices fo r

acute attac ks c he moprophylaxis

All plasmodial infections except Oral chloroquine or sulfadoxin~ Oral chloroquine and/or proguanil
chloroquine-resistant Plasmodium pyrimethamine
falciparum

Infection with chloroquine-resistant Oral quinine plus: Oral chloroquine plus:

P. falciparum (i) tetracycline or (i) proguanil or
(ii) doxycycline, oral halofantrine Oi) doxycycline or
or mefloquine (iii) pyrimethamine, Malarone" or oral mefloquine

(Source: British Nat1onal Formulary.)

'It must be appreciated that this is only a summary, not a definitive guide to prescription, as the recommended drug combinations vary
depending on the patient, the area visited, the overall risk of infection, the presence of resistant forms of the disease and so on.
bMalarone is a proprietary combination of atovaquine and proguanil hydrochloride.

'tage and the erythrocytic stage. and Lhu!> prevent the develop-
c Chloroquine
ment of malarial attacks. True causal prophylaxis-the prevention
Chloroquine is an old drug (1940s) but is sti ll a very potent blood
of infection by the killing of the sporozoites on entry into the
schizonricidal agent (Fig. 49. J, site A), effective against the
host-is not feasible with the drug:, at present in use, although it
erythrocytic form!. of all four plasmodial species (if sensitive to
may be achieved in the future with vaccines. Prevention of the
the drug), but it does not have any effect on sporozoite!>, hyp-
development of clinical attacks can, however. be effected by
nozoites or gametocytes. It has a complex mechanism of action
chemoprophylactic drug!> that kill the para'>ites when tbey emerge
that is not fully understood. It is uncharged at neutral pH and
from the liver after the pre-erythrocytic !>tage (Fig. 49.1, site C).
can therefore diffuse freely into the parasite lysosome. At the
The drugs used for this purpose are mainly those listed above:
... chloroquine. mefloquine. proguanil, pyrimethamine, dapsone and
acid pH of the lysosome, it is converted to a protonated, membrane-
impenneable form and is 'trapped' inside the parasite. At high
doxycycline. They are often used in combinations.
concentrations, chloroquine inhibits protein, RNA and DNA
T Chemoprophylactic agent~ are given to indtvtduals who intend travelling synthesis. but these effects are unlikely to be involved in it!>
to an area"' here malaria is endemic. Admtnt\tr:uion should start 1 week antimalarial activity. Probably. chloroquine acts mainly on haem
before entering the area and should be continued throughoUI the May and
r disposal by preventing digestion of haemoglobin by the parasite
for at least a month afterward~. No chemoproph) lactic regimen b I00%
effective, and the choice of drug is difficult. In addition to the normal and thus reducing the supply of amino acids necessary for parasite
criteria used in ~electing a drug, the unwanted effect' of some antimalarial viability. It also inhibits haem polymerase-the enzyme that
e agents need to be borne in mind and weighed again~Llhe risk of a seriou~. polymerises toxic free haem to haemozoin-rendering it harmless
po~'ibly fatal. para!>itaemia. A further problem b the complexity of the
e to the parasite. Chloroquine is abo used as a disease-modifying
regimens. which require different drugs to be taken at different lime,, and
the fact that different agents may be required for different tro~vcl antirbeumatoid dntg (Ch. 14) and also has some quinid ine-like
r de\tinatioos. For a brief ~umrnary of currently recommended regimens of actions on the heart. The clinical use of chloroquine is summarised
d chemoprophylaxi\. ..ee Table 49.2. in Tables 49.1 and 49.2 and the Antimalarial drugs box.

Drugs used to prevent transmission
Some drugs (e.g. primaquine, proguani l and pyrimethamine)
have the additional action of de!>troying the gametocyte!>
Fig. 49.l. site 0). preventing transmission by the mosquito and
thus preventing the increac;e of the human re~cn oir of the diseru.e-
but they are rarely U!>ed for this action alone.
We will now look at some of these drugs in more detail.
4-AMINOQUINOLINES
The main 4-aminoquinoline used clinically is chloroquine
Irig. 49.2). Amodiaquine has very similar action ro chloroquine.
It was withdrawn several yean, ago because it cau~cd
agranulocytosis. but has now been reintroduced in several areas
of the world where chloroquine resistance is endemic.
Resistance
Plasmodium falciparum is now resistant to chloroquine in most
parts of the world. Resistance appears to result from enhanced
efnux of the drug from parasitic vesicles as a result of mutations
in plasmodja transporter genes (Baird. 2005). Resi!>tance of P.
vii'(U' to chloroquine is also a growing problem in many parts of
the world.
Administration and phormocokinetic aspects
Chloroquine is generally administered orally, but !>evere falci-
parum malaria may be treated by frequent intramuscular or sub-
cutaneous injection of small dolte~. or by slow continuous
intravenous infusion. FoUowing oral dosing, it is completely
absorbed, extensively distributed throughout the tissues and con-
centrated in parasitised red cells. Release from tissues and
infected erythrocytes is slow. The drug is metabolised in the liver 705
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER

Quinoline-methanols 4-Aminoquinoline

CH 3
1 1C2 H5
NH-CH-CH2-CH2-CH2-N
I 'c2Hs

~
\\I

Chloroquine Ra
So
.tni
8-Aminoquinoline llll
CHOH
I

Quinine Mefloquine Primaquine

Fig. 49.2 Structures of some quinoline antimalarial drugs. The quinoline mo1ety is shown in orange.

and excreted in the urine. 70Ck- as unchanged drug and 30'k al>
metabolites. Elimination i~ '>low. the major phase having a half-
life of 50 hou~. and a residue persists for weeks or month~.
Unwanted effects
Chloroquine ha~ fe.,., adverse effects when given for chemo-
prophylaxi~. However. unwanted effects. including nausea and
vomiting, di11incss and blurring of vision. headache and urticarial
symptoms, can occasionally occur when larger doses arc admin-
istered to treat acute attacks of malaria. Large doses have also
sometimes resulted in retinopathies. Bolus intravenous injections
or chloroqui ne may cau1-oe hypotension and, if high doses are
used, fatal dys rhythmias. Chloroqu ine is considered to be safe for
usc by pregnant women.
QUINOLINE-METHANOLS
The two most widely used quinoline-methanols are quinine and
metloquinc (Fig. 49.2).
Quinine
Quinine io, an alkaloid derived from cinchona bark. It has been
used forthe treatment of 'fcvcrs'l>ince the 16th century. when the
bark wao, bought to Europe from Peru by Jesuit missionaries. It is
a blood schizonticidal drug effective against the erythrocytic
form'> of all four specie~ of pla!>modium (Fig. 49.1. site A), but
it ha~ no effect on exoerythrocytic forms or on the gametocytes
of P. fa/ciparum. Its mechanism of uction. like that of chloro-
quine. is as~ocimcd with inhibition of the parasite haem polymerase,
but quinine is not so cxten.,ivcly concentrated in the plasmodium
as ch loroquine, so other mechanisms could also be involved.
With the emergence and spread of chloroquine resistance. quinine
706 is now the main chemotherapeutic agent for P. falcipamm. Other
pharmacological action'> on host tissue include a depre'"""
p.ll
action on the heart. a mild oxytocic effect on the menh L v. j~
pregnancy, a slight blocking action on the neuromuscular juncuoo ell
and a weak untipyretic effect. The clinical use of quinine is gi\en Ta
in Tables 49.1 and 49.2 and in the box.
Ph
Pharmacokinetic aspects ~~
Quinine is well absorbed and is usually administered orally a' a
7-day course. but it can also be given by slow intravenous infu,loo
for severe P. fa/ciparum infections and in patients who ar~
Ur,
vomiting. A loading dose may be required, but bolus inrravenou,
WI
odm inistration is contrai ndicated because of the risk of cardiac
so
dysrhythmias. The half-life of the drug is l0 hours; it is metah
C!-
ol ised in the liver and the metabolites are excreted in the urine
within about 24 hours.
Unwanted effects
Quinine ha!> a bitter taste. and oral compliance is often poor.' II rc~
i~ initant to the gal.tric mucosa and can cause naul>ea and vomiting Ill
If the concentration in the plasma exceeds 30-60 ~moll1. th<.!
'cinchoni~m'--characteri\ed by nausea, dizziness, tinnitu,, hc..J- tc
ache and blurring of vi~ ion-is likely to occur. Excessive pla~ma un
levels of quinine can result in hypotension. cardiac dysrhythmias u~
and severe C S di~turbance!> !>uch as delirium and coma. chi
Other, infrequent, unwanted reactions that have been reponed
are bloo<.l dy~cra'>ia~ (especially thrombocytopenia) and hyper
sensiti\<ity reaction<,. Quinine can stimulate insulin release. Pauent'
PI-
ani
1
Hcncc the invention of palatable dri nks containing the dn1g, including, of
coun,c. the 'Ionic' drunk together wi Lh gin and other be,erages.

1\ith marked falciparum parasitacmia can have low blood -.ugar
for thi~ rca<;on and also because of glucose COihumption by the
parasite. Thb make1> a differential diagnosis- between a coma
caused by cerebr<ll malaria and hypoglycaemic coma-<lifficult.
A rare result of treating malaria with quinine. or of erratic and
inappropriate use of quinine, is 8/ackll'aterje1er, a se\ere and often
fatal condition in which acute haemolytic anaemia is associated
with renal fa ilure.
Resistance
Some degree of resistance is de,cloping. Like chloroquine, re:-.i\t-
ance to quinine is conferred by increased expression of plas-
mo(lial drug efflux 1ransporters.
Mefloquine
\lefloquine (Fig. 49.2) is a blood schizonticidal quinoline-
methanol compound active against P. falciparum and P. l'il'ax
Fig. 49.1. site A); however. it ha., no effect on hepatic form-. of
the parasites, so Lrcatmem of P. l'il'Ox infections should be
followed by a coun.c of primaquine (see below) to eradicate the
hypnoL.oites. Mefloquine is frequently combined with pyrimeth-
amine. The antipara.,ite action is associated with inhibition of the
haem polymerase; however, becau-.e mefloquinc, like quinine, is
no1 as extensively concentrated in the parasite as chloroquine,
other mechanisms might also be involved.
Re.,istance has occurred in P. fa/ciparum in some areas-
oarticularly in South-cast Asia- and is thought to be caused, a<;
with quinine, by increased expression in the parasite of drug
efl1ux transporters. The clinical 11se of metloquine is given in
Tables 49.1 and 49.2 and the Antimalarial drug1 box.
Pharmacokinetic aspects
~lefloquine i~ given orally and i!> rapidly absorbed. It has a ~l ow
onset of action and a very long pla!>ma half-life (up to 30 day.s),
ll'bich may be the result of enterohepatic cycling or tissue storage.
Unwonted effects
When menoquine is used for treatment of the acute attack, about
50o/c of ~ubjccts complain of gaslrOintestinaJ diMurbances. Transient
CNS toxicity-giddiness, confusion, dysphoria and insomnia-
can occur, and there have been a few reports of aberrant
atrioventricular conduction and serious, but rare, skin di!>eases.
Rarely, mefloquine may provoke severe neuropsychiatric
reaction~. Mefloquine is contraindicated in pregnant women or
m those liable to become pregnant within 3 months of stopping
the drug. because of its long half-life and uncertainty about its
teratogenic potential. When used for chemoprophylaxis, the
unwanted actions are usualJy milder. but the drug should not be
u..ed in this way unless there is a h.igh ri<;l.. of acqutring
chloroquine-resistant malaria.
PHENANTHRENE-METHANOL$
Halofantrine
Halofantrine is a blood schizonticidnl drug. It is one of a group
of compounds that were studied during the Second World War
and found to have antimalarial activity but were not de,elopcd
further when chloroquine was brought out of retirement.
However, as chloroquine re!>istance developed, halofantrine
ANTIPROTOZOAL DRUGS
came in from the cold. It is active against ~train~ of P. falciparum
that arc resistant to chloroquine, pyrimethamine and quinine. It is
effective against the erythrocytic form of P. tivax (Fig. 49.1,
site A) but not the hypnozoitcs. However, it is not usually used
for P. l'ilax malaria because this is generally susceptible to
chloroquine. Cro!>\-reSi!>lance bet\\Cen halofanlrine <md menoquine
in falciparum infections has been reported. Its mechanism of
action i.s not known. The clinical use of halofanlrine is given in
Tables 49.1 and 49.2 and the box.
Phormacokinetic aspects
Halofantrine is given orally. It is slowly and rather irregularly
absorbed. with a peak plasma concentration achieved approxi-
mately 4-6 hour1> after inge'>tion. The half-life is I 2 days,
although its main metabolite, which has equal potency, has a
half-life of 3-5 day!.. Absorption is substantially incre<lsed by a
fatty meal, and elimination i!> in the faece!>.
Unwonted effects
Abdominal pain, ga.,trointestinal disturbances, headache, a Lran-
siem rise in hepatic enzymes and cough occur. Pmritus i!. repot1ed
but is less marked than with chloroquine. Halofantrine can produce
change-. in cardiac rhythm (mo\1 notably a lengthening of the QT
interval), panicularly if given with other <;imilar drugs, and it
should be used with caution in patients with a history of
dy~rhythmia. II has caused i>udden cardiac death. Rarer reactions
include haemolytic anaemia and convulsions. Because of such
unwanted actions, halofanlrine is no longer used for 'standby'
treatment of malaria, and il is now reserved for infections caused
by resistant organi~ms. However, even in this case. decreasing
sen\iti' ity and resistance of P. fa/ciparum have been reponed.
DRUGS AFFECTING THE SYNTHESIS OR
UTILISATION OF FOLATE
Anti folate drugs are classified into type I and type 2 compounds.
The type 1 <mtifolates arc the sulfonamides and the sulfones,
which inhibit the synthesis of folate by competing with p-
aminobenL.Oic acid (see Chs 45 and 46). The type 2 antifolates
include drugs !'ouch as pyrimethamine and proguanil, which
prevent the utilisation of folate in the conversion of dihydrofolate
to tctrahydrofolate by inhibiting dihydrofo/ate reductase. Com-
binations of folate antagonists (type 2) with drugs inhibiting
folate S) nthesis (type I) cause sequential blockade. affecting the
same pathway at different points; these combinations thus have
synergistic action.
Pyrimethamine is a 2.4-diaminopyrimidine (see Fig. 49.3) and
is similar in structure to trimelhoprim (sec Ch. 46). The structure
of proguanil is different, but it can assume a configuration similar
to that of pyrimethamine (see fig. 49.3). These compounds inhibit
the formation of tetrahydrofolate and hence DNA synthesis as
outlined in Chapter 51, but both drugs have a greater affinity for
the plasmodial enzyme than for the human enzyme. They have a
slow action against the erythrocytic forms of the parasite
(Fig. 49.1, site A), and proguanil is believed to have an additional
effect on the initial hepatic stage (Ia to 3a in Fig. 49.1) but not
on the hypno.L.oites of P. vim.\ (Fig. 49.1. site B). Pyrimethamine
is used only in combination with either dapsone or a su lfonamide. 707
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER

gc
,---- Pteridine ring -- - -- ~, p-Am1nobenzoic -,,-Glutamic acid--, de)
: : acid (PABA) : 1
I I ! cd
0 COOH
rcq

NH~M--NH--bH
a
im
I gr~.;
I (CH~2COOH :
I
lie: I
'---------------------- Folic acid ------------- ------ ''
1\

6-r;
N
gi
Fig. 49.3 Structures of some
antimalarial drugs that act on the N
HC
HNo-~Cl
folic acid pathway of the
I - AN
plasmodia. Folate antagonists
(pyrimethamine, proguanll) inhibit (CH3h
dlhydrofolate reductase; the Pyrimethamine Proguanil
relationship between these drugs
and the pteridine moiety is shown in
0
orange. Sulfones (e.g. dapsone) and
sulfonamides (e.g. sulfadoxine)
compete with p-aminobenzoic acid
H,N-o-SO,-HN--<.:( HN~~-o-~
2~- I I -
NH

0
2
Q
for dihydropteroate synthetase
(relationship shown In orange box;
Sulfadoxlne
OCH3 OCH3
Dapsone
cc
see also Ch. 46).
Th
qil
n.u
The main sulfonamide used in malaria treatment is sulfadoxine, Ar:
8-AMINOQUINOLINES
and the only sulfone used is dapsone (see Fig. 49.3). Details
of these drugs are given in Chapter 46. The suJfonamides and The only 8-aminoquinoline licensed for current use is primaqume
sulfones are active again\t the erythrocytic fom1s of P. falcipanon (see Fig. 49.2). Etaquine and tafenoquine are more acti\e ard
but are less active against those of P. ~iva.x: they have no activity slowly metabolised analogues of primaquine. The mechanism of
against the sporozoite or hypnozoite forms of the plasmodia. action of these comparatively new compounds is not known.
Pyrimethamine- sulfadoxine has been extensively used for The antimalariaJ action of this class of drugs is exerted again'' rc
chloroquine-resistant malaria, but resistance to this combination the liver hypnotoites. and they can effect a radical cure of rho~e da1
has developed in many areas. forms of malaria in which the parasites have a dormant stage i1 (gll
the liver- P. viva.x and P. male. Primaquine docs not affc.:t or
Pharmacokinetic aspects
sporozoitcs and has little if any action against the erythrocytic on
Both pyrimethamine and proguanil are given orally and are well,
stage of the parasite. However, it has a gametocidal action and'' Ar
although slowly, absorbed. Pyrimethamine has a plasma half-life
the most effective antimalarial drug for preventing transmission
of 4 days, and effective 'suppressive' plasma concentrations mi
of the disease in all four species of plasmodia. It is alm0\1 or
may last for 14 day!.; it is taken once a week. The half-life of
invariably used in combination with another drug, usuall) t~nd
proguani I is 16 hours. 1t is a prodrug and is metabolised in the
chloroquine. Resistance to primaquine is rare, although evidenc, art
liver to its active form. cycloguanil, which is excreted mainly in
of a decreased sensitivity of some P. vimx strains has bee~
the urine. It mu.t be taken daily. Details of the phannacokinetics a11
reponed. The pharmacology of primaquine and like drugs ha'
of dapsone are given in Chapter 46.
been reviewed by Shanks et al. (200 I). Ur.
Unwonted effects 'Jh
Phormocokinetic aspects
These drugs have few untoward effects if used carefully in he a
Primaquine i~ given orally and is well absorbed. Its metaboh' 1
therapeutic doses. Larger doses of the pyrimethamine-dapsone \(~
is rapid, and very little drug is present in the body afttl
combination can cause serious reactions such as haemolytic ca
10-12 hour<;. The half-life is 3-6 hours. Tafenoquine is broke~
anaemia. agranulocytosis and eosinophilic alveolitis. The pyri- th
down much more slowly and therefore has the advantage that It
methamine-sulfado>.ine combination can cause serious s!Jn no
can be given on a weekly basis.
reactions, blood dyscrasias and allergic aJveolitis; it is no longer ha
recommended for chemoprophylaxis. In high doses. pyrimeth- Unwonted effects
amine may inhibit mammalian dihydrofolate reductase and cause Primaquine has few unwanted effects in most patients \\hen
a megaloblastic anaemia (see Ch. 22); folic acid supplements used in normal therapeutic dosage. Dose-related gastrointestinal
tI
shou ld be given if this drug is used during pregnancy. Resistance symptoms can occur, and large doses may cause methaemo- lro
to antifolatc drugs arises from single-point mutations in the globinacmia with cyanosis. This antimalarial drug can, howcwr. tu:r.
708 genes encodi ng parasite dihydrofolate reducta~e. cause haemolysis in individuals with an X chromosome-linked

genetic metabolic condition-glucose 6-phosphate dehydrogenase
deficiency-in red cells. When lhi~ deficiency is present, the red
cell~ are not able to regenerate NADPH. its concentration being
reduced by the oxidant metabolic derivatives of primaquine. As
a consequence, the metabolic functions of the red cells are
impaired and haemoly~is occu~. Primaquine metabolites have
greater haemolytic activity than the parent compound. The
deficiency of the enqme occurs in up to 15% of black males and
b also fairly common in some other ethnic groups. Glucose
6-phosphate dehydrogenase activity should be estimated before
giving primaquine.
ANTIBIOTICS USED IN MALARIA
Some antibiotics, for example doxycycline and tetracycl ine, have
a place in the trea tment of the acute attack of malaria and in
chemoprophylaxis; sec Table 49.2. Detai ls of these antibiotics
are given in Chapter 46.
QINGHAOSU (ARTEMISININ) AND RELATED
COMPOUNDS
The qinghaosu-based compounds arc derived from the herb
qing hao, a traditional Chinese remedy for malaria. The scientific
name, conferred on the herb by Linnaeus, is Artemisia.4
Artemisinin, a poorly soluble chemical extract from Artemisia,
1~ a fa!>l-acting blood schizonticide effective in treating the acute
attack of malaria (including chloroquine-resistant and cerebral
malaria). Artesunate, a water-soluble derivative, and the synthetic
f analogues artemethcr and a r tether have higher activity and are
bener absorbed. The compounds are concentrated in parasitised
r~d cells. The mechanism of action is not known: it may involve
c damage to the parasite membrane by carbon-centred free radicals
tgenerated by the breakdown of ferrous protoporphyrin IX)
or covalent alky lation of proteins. These drugs are without effect
on liver hypnozoitcs and arc not useful for chemoprophylaxis.
Artemisinin can be given orally, intramuscularly or by suppository,
anemether orally or intramuscularly, and artesunate intramuscularly
or intravenously. They arc rapidly absorbed and widely distributed,
and arc converted in the liver to the active metabolite dihydro-
artemisinin. The half-life of a r temisinin is about 4 hours, of
artcsunate 45 minutes and of anemether 4-ll hours.
Unwanted effects
There have been few unwanted effects reported to date. Transient
heart block, decrease in blood neutrophil count, and brief epi-
\Odes of feYer have been reported. In animal studies. artemisinin
r
causes an unusual injury to some brain stem nuclei, particularly
!l
those involved in auditory function; however, there have been
no reported incidences of neurotoxicity in humans. So far, there
have also been no reported cases of resistance.
n The cat is the definitive host of Toxoplasma gondii (i.e. it is the
I only host in which the sexual cycle can occur), and it expels
'The herbs arc no1cd for 1heir exlreme bitterness., and their name derives
from Artemisia. wife and sis1er of the fourth century king of Halicarnassus;
her sorrow on his dcuth led her to mix his nshes wilb wbatever she drank to
make it biller.
ANTIPROTOZOAL DRUGS
In rodent studies, a rtcmis inin potentiated the effects of
mefloquine, primaquine and tetracycline; was additive with
chloroquine: and antagonised the sulfonamides and the folate
antagoni~ts. For thi~ reason, artemis inin derivatives are
frequently used in combination with other antimalarial drugs:
for example, artemether is often given in combination with the
aminoalcohol lum efantrine.
In randomised trials, the qinghaosu compounds have cured
anacks of malaria, including cerebral malaria, more rapidly and
with fewer unwanted effects than other antimalarial agents.
Artemisinin and derivatives arc effective against multidrug-
resistant P. falciparwn in sub-Saharan Africa and. combined with
mefloquine, against multidrug-resistant P. falciparum in South-
east Asia. However, the preclinical and clinical data are at present
insufficient to satisfy the drug reg ulatory requirements in many
countries. For a review of this topic, see Olliaro et al. (200 I).
HYDROXYNAPHTHOQUINONE DRUGS
Atavaq uone is used for the treatment of malaria and can prevent
its development. lt acts primarily to inhibit the parasite's mito-
chondrial electron transport chain, possibly by mimicking the
natural substrate ubiquinone. Atavaquone is usually used in com-
bination with the antifolate drug proguanil, because they act
together to cause a ~ynergistic antimalarial effect. The mechanism
underlying this effect is not known, but synergy is specific for
this particular pair of dntgs, because other antifolate drugs or
electron transport inhibitors have no such effect. When combined
with proguanil, atavaquone is highly effective and well tolerated.
Few side effects of such combination treatment have been reported,
but abdominal pain, nau~ea and vomiting can occur. Pregnant or
breast-feeding women should not take atavaquone. Resistance to
atavaquone is rapid and result!. from a single point mutation in
the gene for cytochrome b. Resistance to combined treatment
with atavaq uone and proguanil is less common.
POTENTIAL N EW ANTIMALARIAL DRUGS
Several new drugs are currently under test for antimalarial
activity, with positive results in animals and in preliminary trials
in humans. One of these, pyrona ridine, has been used in China
for almost 10 year~. It is active against P. falciparum and P.
vimx, and is al<So active in chloroquine-resistant P. falciparwn.
It is effective orally and has low toxicity. The mechanism of
action is unknown. Lumefantrine is structurally related to
quinine and is effective against P. fa/ciparwn. particularly when
combined with either mefloquine or artemisinin derivatives.
TOXOPLASMOSIS AND
TOXOPLASMOCIDAL DRUGS
the infectious cysts in its faeces; humans can inadvertently
become intermediate hosts, harbouring the asexual form of the
parasite. Ingested oocysts develop into sporozoites, then to 709
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
Antimalarial drugs
Chloroquine is a blood schizonticide that is
concentrated in the parasite and inhibits the haem
polymerase. Orally active; half-life 50 hours.
Unwanted effects: gastrointestinal disturbances,
dizziness and urticaria. Bolus intravenous injections
can cause dysrhythmias.
Quinine is a blood schizonticide. It may be given
orally or intravenously; half-life 10 hours. Unwanted
effects: gastrointestinal tract disturbances, tinnitus,
blurred vision and, in large doses, dysrhythmias and
central nervous system disturbances. It is usually
given in combination therapy with:
pyrimethamine, a folate antagonist that acts as a
slow blood schizonticide (orally active; half-life
4 days) and either
dapsone, a sulfone (orally active; half-life
24-48 hours), or
sulfadoxine, a long-acting sulfonamide
(orally active; half-life 7-9 days).
Proguanil, a folate antagonist, is a slow blood
schizonticide with some action on the primary liver
forms of P. vivax. Orally active; half-life 16 hours.
Mefloquine is a blood schizonticidal agent active
against P. falctparum and P. vivax, and acts by
inhibiting the parasite haem polymerase. Orally
active; half-life 30 days. The onset of action is slow.
Unwanted effects: gastrointestinal disturbances,
neurotoxicity and psychiatric problems.
trophoL.Oites, and finally encyst in the tissues. In most
individuals. the disease is asymptomatic or self-limiting, although
intrauterine infections can severely damage the developing fetus
and it may cause fatal generalised infection in immuno-
suppresl>ed patients or those with AIDS, in whom toxoplasmic
encephalitis may occur. In humans, T. gondii infects numerous
cell types and hao; a highly virulent replicative stage.
The treatment of choice is pyrimethamine-sulfadiazine (to be
avoided in pregnant patients); trimethoprim-sulfamethoxazole
or parenteral pentamidine i\ also used and. more recently,
azith romycin ha<, \hown promise.
CILIATES AND OTHERS
First recognbed in 1909. Pneumocystis carinii was presumed to
belong to the protoL.oa, but recent studies have shown that it
shares structural features with both protozoa and fungi, leaving
its precise cla~sification uncertain. Previously considered to be a
widely distributed but largely innocuous micro-organism, it now
causes opportunistic infections in immunocomprornised patients.
It is common in AIDS. where P. carinii pneumonia is often the
710 presenting symptom as well as a leading cause of death.
II
pf.
ar.
Halofantrine is a blood schizonticidal agent ....
active against all species of malarial parasite, including
multiresistant P. falciparum. Orally active; half-life
1-2 days (active metabolite half-life 3-5 days).
Unwanted effects: abdominal pain, gastrointestinal
disturbances, headache. Serious cardiac problems
sometimes occur.
Primaquine is effective against the liver hypnozoites
and is also active against gametocytes. Orally active; II
half- life 36 hours. Unwanted effects: gastrointestinal n
tract disturbances and, with large doses,
methaemoglobinaemia. Erythrocyte haemolysis in
individuals with genetic deficiency of glucose \r
6-phosphate dehydrogenase. II
Artemisinin derivatives are widely used in Asia and
Africa but are not licensed in some other countries.
They are fast-acting blood schizonticidal agents that
are effective against both P. falciparum and P. vivax.
Artesunate is water-soluble and can be given orally or
by intravenous, intramuscular or rectal administration.
Side effects are rare.
Atavaquone (in combination with proguanil) is used for
the treatment of acute, uncomplicated P. falciparum
malaria. The drug combination is effective orally. It 1s
given at regular intervals over 3-4 days. Unwanted
effects: diarrhoea, nausea and vomiting. Resistance to
atavaquone develops rapidly if it is given alone.
High-dOl>C co-trimoxazole (Ch. 46) is the drug of choice. Ill
with parenteral pentamidine (sec above) as an alternative. Other
trealmenl regimens include trimethoprim-dapsone, or atovaquone
or c lindamycin primaquine.
NEW APPROACHES TO ANTIPROTOZOAL
THERAPY
This field is a huge challenge. with each protozoa species pos1r.!
its own distinct problems to the would-be designer of ne\\ ann-
protozoal drug!>. Where appropriate in this chapter, we ha\'e
indicated possible future avenues for research and development.
but the interested reader is referred to the reading liM and "cb
site~ li'ted below for further information. While there illt
undoubtedly many technical issues to be surmounted. ironicall)
these do not represent the major challenge to the eradication of
prototoal diseases. There are a host of socioeconomic problem\
that nlso need to be addressed first.
It is abundnntly clear that the diseases caused by the protozo.
constitute a major global challenge. but the problems of provi~ion
and distribution of new drugs are dau11ting. Managing the cost~
of research and development in this area is complex. Transnational

tmuativcs (e.g. Drugs for Neglected Diseases lnitiarile) and
philanthropic foundations (e.g. lmtitwe for OneWorld Health)
arc proving helpful. but it i\ not \imply a lack of new drugs that
i~ the problem. For economic rellilons. the very countries and
population-; one would 1110\t like to target often lack an efficient
REFERENCES AND FURTHER READING
Host-para;ite in t e ructio n ~
Bremcrl'inch.n MP. l'cllou\ II. DcrOluch-Guergour D
et al 10()1 ChcmolulC' 111 h(l'l para,itc im~ractions.
Trend, Pamsitol 17: 292 29() (GIImlrt'l'irw of mh of
immune n Hem)
\mocbiu~is
Haque R. Hll\ton C 1). llughc' M ct ul. 2003 Amcbia;is.
N Engl J Mcd 348: 1565 1573 (Gomlniew;
C()nt'rllll'tlll"\ 011 rh~ fllllhOHt'ltl'\it tif the i/t\t'USC! lml
ho1 csuwfill whir of drug.\ mul rlltir .1itlt effec/1)
\bnuez-Palomo A. E'pino,n-Cantdlnno M 1998
Amoebia'i': ne" undcr\lundiRg' und new go""
Pata>uol Today 14: 1- 1
Sl.mic) S I. 2(M)I Pathoph)''ology o( amoebous~>. Trends
P.rd\ILOI 17: 280-285 (A ~<><>II a<cmmr of r/oe lumum
dhcdft' 1hat innupt)rcllt"\ \nmr rrut/1\ frmn mumal
,.,Jr/1 ol\11)
~WIIC) S I 200,Amoclln'" l.mcct .161 : 1025 1()34
c,.,prrlommt' 1111d '''"' lnl't'tld II< wullf of rim
d11ea<to, cmrntOII llllolf"'t 1\fmm tlill~llllll\ w
lrturrrocm ~url/nl()
l 11panosomi:o~ls
-\!.50) S. Gibson \1. C. Lehane \I J 21xn lntcra.:uon'
het11.ecn t-.ct'-C amlt') panl>"><>mc' woth mop!Jcauons for
the control oft') pano..oma"' Ad' Paru'itol 53: 1-83
(.~ ,..,, wlwmuw/ ami ct>mpr.-h~ll\1\'1' amd~
cv.rmg rht hwlnJI\ of rltt II<'II<' jh. whido uf.w
dimme.< alrernmil'to mnlwdlfn>m flilltmll111g the
ill<rrl popllltmmo. /.;11 ~""''on <lmg thrrtlf>\, b111 of
\'Oll urf mlt1 rt-Hetl in tiU' hifiiOjH' nj 1/w inwl'l ~:ecwr lJ/
t/ti.\ i \ fi~r .Wm. )
lr\'JWIWSOtni{l,\i.'f tiJt'IJ
8utthmorc R J. Ogbunudc P 0. En<ln&ii B. Ba1Tell M P
2002 Chemotherapy of humnn African
trypano,omit"i'. Curr Jlhurm l)c, 8: 256 -267 (\'el)'
N<>nd cmwise artil'll: nie~ tli.ll 1111imt of/11111/'e
therapeutic J>O.IIIbtlllit,l)
Burri C. Brun R 200.1 IOomithin~ for the trclltmcnt of
human Afric.m trypantl\uma"' P;ua,itol Re
'X~uppl I 1: S49- S52
Oen>e II. Barren M P 2001 Urt.tkc nnd mcxlc 11f act1on
of drug, u,cd agam't ,J,-cpns "~~nc\\. B1ochem
Ph:mnacol61 I 5 ((it>(~/nl\rt'<l)lt'(lfdng rhaapy)
l't-.cr J. Such A. Burro (' 2CMII Ne" drug' for the
lftdlment of human \frican tl)pano-.oma'i' n:-.carc:h
:llld de\elopment Treod, P..u-.t\lic>l 17 42-49 (/::rallmr
tnint. tm (In 1/U-rctuilf!(/\ lh~llft'lllnR dl\l"Oit)
Lcpo-. D. Ollh oer G. Ga,tellu-f'tche~<>rry \1 ct al. 200~
Treaunent ot hum.m Afncan t')pano-.onuo~'"-pre~m
'uuatoon and 11\.'Cth f1>r re-.can:h and dc,elopment.
lanCCI Inf<'Ct 01\ 2: 4 n-4-lO
\JUia f. Burc:hmore R 2003 A plethora of t:tq!eh. a
p.tucrt) of drug' progrc" to" anh the dc,clopmcnt ol
no'el chemothcmpc' for human African
II}J>.~no...omn.'i'. e~pen Rc' Antiinlect Tbcr I: 157- 165
\es>lany F. Brugier S. Mounc' 'VI Act al. 2004 In \Jtro
Jnd in \1\ll chn>mtN>mal oherrauon' induced by
mcga1ol. Mut.u Rc' 560: 147 158
Lrishmu niu~i s
Berman J 2003 Current treatment npproache> to
lehhmania'i'. CUir Opon Infect Di;. 1(): 397-401
infra\tructure for the di!>tribution and safe administration of
the drugs that we already po1>sess. Cultural attitudes. civil war~.
famine, the circulation of counterfeit or defective drugs, drought
and natural disa\ter\ also exacerbate this problem. At the
momem, there '>eem:. no ea:.y way out of this dilemma.
(GIIOd general ret ie\\ rlwr includes 10m~ daw mr nt'\\
clmical rrials)
Handnmn E. Bullen D V R 2002 hucruction ol
IA'i~hmtmia with the ho\t macrophage. Trend'
Para,iiOI 18:332-334 (Vel) ilt>od amclr dtscrihmJI
ho\~o this parasite colonises macroplwgt.'f ami l'Wuli:.,
immcel/11/ar killing; emy ro read)
Jnyanamyan K G, Dey C S 2002. Microwbulcs:
dynamics. drug interact ion and drug rc,i,wucc in
Lei~h11wnia. J Cli n Pharm Tiler 27: 313-320 (Otul
wirh rise tutiou on parasire mic-rorubllle.s of
amileishmanwl drugs-1en specialisrdl
Kubnr J. Fragaki K 2M15 Recombmant D'IA dcnved
Leishmania protein~: from the laboratory to the field.
Lancet Infect Dis 5: 107-114 (Snme mrert'.Hinfl
dsscussio11 mod obsenvuian< t>n pnihlr dntg lll'11tt.\
bur a bir <pecia/i.1ed)
Murre} II W 2000 Treatment of' i.ccrallci,hmo~ni'-'"
tkala-azar): a decade of progre" and future
approacbe>. lnt J Infect 0" 4; 158- 177 (Clrar
<Zccounr ofprt!sent dmiwl rher<lt>.' aJUI porm11al nC'\\
dm.~s)
Sacks D. Toben-Trauth 1\ 2002 The nnmunolog) of
,u,reptibiluy and rc,ist:mce to LetSismmrm maJOr'"
mice. Nat Re\' lmmunol 2: 845 -858 (A le11grltv tmide
rlwt l'.<plores the ho<rre<JHIIII<' wl.e"hmana Jlllrcs!llt
mfection usinr: mmne nuxll'l.~ ofth~ di.\t'tl\~:
ftucinaring and awltnriroti\e-hm on/\' atrtmpr 11 sj
your mununology is up ro scrarch.tl
Venna N K. Dey C S 2004 Po,srhlc mcchan~>m of
millefo,inc-medinted death of Leillmuwia tlml<ll'lllli.
Antimicrob Agents Chemother 48: 30 I0 30 I5
Malaria
Ashley EA. Wllite N J 2005 Artemi,inin ba,cd
combination. Curr Opin Infect o;, IB: 53 1- 536 (Thi;
rt'l'iew details rhe ret11ir< of wct'e.t.iful rliuical rrialt of
artemi.~inin combi-nmion.\ l11 South-eti.H A.tin)
Baird J K 2005 Effccti,eness ol anumnlnrial dru~;s. N
Engl J Med 352. 1565-1577 (All e.tcellmr mmil'l<'
c01ering many aspects of dmR therapy. drug
resisronce mul rlu- soci()('corwmic /ilCI<m a(Jnrm.~ rht:
rreormem ofrlti' diseau thorou!(IJiy rt'<'IJIIUIIImi~J)
Berent A R. Craig A G 1997 Plll.lllll>liismt/illcitlllrum-
'uc~)' J3m> and PECAM p1e. Jl:at Med 3: 1315 t:ll6
(Deals ur/r malaria parosues mod lwnodlwnmr
molecules)
Fole) Ill. Tilley L 1997 Quinoline an11m.1lanah:
mechanism.\ of action and re'"tafl<.'C. 1m J Par:hnol
27: 231- 240 (Good, .<han rein. Ul<'/rtf dsa~ram.;)
Holt R A. Subramanran G M et al. 2002 The genome
:.cquencc of the malaria mosquito Am>p!Je/~1 gambtat'.
Sctence 298: 129-149 (For rloou ~>!Jn wnr tn nplofl'
the genomic aspecrs more rlrorough/\')
Krishna S 1997 Malaria. Br Med J 315: 730-7l2 !Goad.
slton re\'iew in rite uri" Scencc. mcdicme and the
future; useful diat:ranr)
L.ell B. Luckner D et al. 1998 Randomi<ed placcho-
controlled study of movaquonc plus proguani l for
malaria prophylaxis in children. Lnncet 351: 709 713
(State.\ 1har rhis combinmion i1 llighll' t:/JI!cril<' and
welltolermed)
ANTIPROTOZOAL DRUGS
'le" ton P. Wbirc N 1999 Malana: new dcvelopmcnl< in
treatmcm and pre\ention. Annu Rev Med 50: 179-192
(Llallem rel'iew of dmg trcatmell/ and IIUllltlgeml'lll
t>fmalarw)
O'Bncn C 1997 Beating the malaria parasite mit\ own
game. Lancet 350: 192 (Clear. succinct covemlie of
meclumiJuu ofuctimr om! resistanc:e o.f rurrent
lllllinwlarial.v mod J10it'ntial new dr11gs: useful
tfiil!(IW/1)
Odch M 200 I n,e role of tumour necrosis factor-alpha
in the pathogcnc'i' of complicated falciparum malaria.
Cymline 14: l l-18
Olharo PL. llayne R K. Meunier B ct al. 2001 Po<'-ble
mode of action of anenmin-tyJX' compounds. Trend-;
l>ar.Ntol 17: 266-2()8
Shanks G D. K:un K C. Keystone J S 2001 Malana
chemoprophylam'" the age of drug resistanCe. n
l)rug' that tna) be a'ailable 1n the future. Clio Infect
D" 33 381-385 (A us~ful looA ullrad '" """
dm~;)
T:tq!ell G A 1998 Malana - ancl} 1S 1be price of hfe.
'I at \Jed 4. 267-268 (Til<' biological roft'1 nf th~
wrfiru protmrs of malario-mfected red ull I
PncomOC)stis pneumonia
Warren E. GeorgeS ct al. 1997 Adances in the
tre.urucnt and proph) laJU> of Pnemnocys11 5 carinii
pneumoma. Pharmacotherapy I7: 900-916
Future drugs ror prolozoal infections and general
Croft S L 1997 The current swtu~ of anupar:o~ile
chemotherapy. Par.bitology 114: S3-SI5
(Comprrhe11sie coeroge of currelll drugs and outli11e
of ttf>flrt.Ulches to pos:.oble fitturt! ogems)
Ro,cnblau J ll 1999 Antipara<itic agents. Mayo Clin
J>roc 74: 116 1 1175 (11mad rrl'iew article. wide
COI'ffll/1t')
U!>erul " eb resou rce.~
http:/larcbive.bmn.com/;upp/part/swf012.html (An
tnfl'm(rn~ wsimmion .1hfl11ing rloe infecriotl of a
lwman lw.lf with Leishmania by a tsetse fly etror
fml
hnp:l/mo!.quito." ho.inlfcmc. upload/01000/0 15/372/RB
Mlnfo,heel_ l btm (200/- /0 ir rile decade of the
Unttcd Votitmr Roll Bacl Malaria progromm<'. and
r/111 "'" mmum.1 a "'C'alth of srmistics, ph01ograpi1S,
map.1 mrd plonmol) rett cmrring eruJ rupec1 of
r/111 depn11mg di.I<'USC'. Together" u/t the' oth<'r "eb
\lie; sho~tfl beta... it fomJS rh<' tmcleu.r ofa
<omprrlsmsne rrsourre for C'.tpforing r!Je inrplicmimu
of the ~lobo/ mtslano pmblem more closl!l)c 1
hnpJ/w" \\.Oncworldheahh.org (Tile web pnge of tit<'
iionun 'tllm pmfit t>lumnaceutical compan.\'', wirh
tlerm/1 of rltetr <"llrrenr programmes dealin.~ with
.~lol><tlllealth i.r<ue.<)
hup://www.\\bo.mlfen/ (17oe IVHO hom<' page, ~>irlr linh
ro all orher sties relewmr 10 this chupler)
hup:/lwww. who. int/mediacentre/facl~heel~fs094/en/
(Tisis ~>eh rire is o subsire of the IVflO home page am/
comains links ro al/1he major iirformarion on rhe sire
tlralin11 with malllrill. i11duding rhe sire; abo"e-lr
terrific starting polm for.furrlter imestij/ation)
711

Antihelminthic drugs
Overview 712
Helminth infections 712
Antihelminthic drugs 713
Resistance to antihelminthic drugs 716
Vaccines and other novel approaches to
antihelminthic therapy 716
OVERVIEW
Among the most widespread of all chronic infections
are those caused by various species of parasitic
helminths (worms). For example, it is estimated
that over half the world's population may be
infected with gastrointestinal helminths. Inhabitants
of tropical or subtropical low-income countries are
most at risk; children often become infected with
one or more species almost as soon as they are
born and may remain infected throughout their
lives. In some cases (e.g. threadworms), these
infections result mainly in discomfort and do not
cause substantial ill health, but others, such as
schistosomiasis (bilharzia) and hookworm disease,
can produce very serious morbidity. Because of its
prevalence, the problem of the treatment of
helminthiasis is therefore one of very great
practical therapeutic importance. Worm infections
are also a major cause for concern in veterinary
medicine, aHecting both domestic pets and farm
animals. In some parts of the world, fascioliasis is
associated with significant loss of livestock.
HELMINTH INFECTIONS
The helminths comprise two major groups of multicellular worms
that evolved from a common ancestor some 600 million years
ago and diverged into two rather different groups: the
nemathefmintlts (nematodes, roundworms) and the platyhelminths
(tlatwom1s). The latter group is subdivided into the tremarodes
712 (flukes) and the cestodes (tapeworms). Almost 350 species of
(Ill
A
in~
\\h
th~
arc
helminths have been found in humans, and most coloni'e li.
gastrointestinal tract. pr
Helminths have a complex life cycle, often involving se\~ral h:
species. Infection by helminths may occur in many ways, ona hi
poor hygiene is a major contributory factor. Many enter by mouth Ji
in unpurified drinking water or in badly cooked meat from infected
animals or fish. However, other types can enter through the ~km th
following a cut, an insect bite or even after swimming or walking Cl
on infected soil. Humans are generally the primary (or definitile A
host for helminth infections, in the sense that they harbour !he th
sexually mature form that reproduces. Eggs or larvae then pass
out of the body and infect the secondary (intermediate) ho,l.ln
some cases. the eggs or larvae may persist in the human ho't and
become encysted, covered with granulation tissue, giving ri'e 10
cysticercosis. This is characterised by encysted larvae in !he
muscles and the viscera or. more seriously, in the eye or the brai
Approximately 20 helminth species are considered to be chr. h
cally significant, and these fall into two main categories-tho-t b
in which the worm lives in the host's alimentary canal, and thw
in which the worm lives in other tissues of the host's bod}. ll
The main examples of worms that live in the host's alimentm d
canal arc as follow. 0
(
Tapeworms: Taenia saginaw, Taenia solium, Hymenolepis p
nana and Diphy((oborhriwn latum. Some 85 million people <II
in Asia, Africa and parts of America harbour one or other of I
these tapeworm species. Only the first two are likely to be trt
seen in the UK. The usual intermediate hosts of the two mo't
common tapeworms (Taenia saginata and Taenia sofium) are
cattle and pigs, respectively. Humans become infected by
eating raw or undercooked meat containing the larvae. wh1ch
have encysted in the animals' muscle tissue. H. nana rna}
exist as both the adult (the intestinal worm) and the lanai
stage in the same host, which may be human or rodent,
although some insects (fleas, grain beetles) can also sene a'
intermediate hosts. The infection is usually asymptomatic.
Diphylfobothrium latum has two sequential intennediate
hosts: a freshwater crustacean and a freshwater fish. Humans
become infected by eating raw or incompletely cooked fi~h tf
containing the larvae, and vitamin B 12 deficiency sometime~
occurs (see Ch. 22).
Intestinal roundworms: Ascaris lumbricoides (common
roundworm), Enterobius vermicularis (threadworm, called
pinworm in the USA), Trichuris triclziura (whipworm),
Srrongyfoides stercora/is (threadworm in the USA), Necator ani

america1111S and A11J.:ylostoma duode11ale (hookworms).
Again. undercooked meat or contaminated food is an
important cause of infection by roundworm, threadworm and
whipworm, whereas hookworm is generally acquired when
their larvae penetrate the skin.
The main examples of worms that live in the tissues of the host
are a'> follow.
Flukes: Schistosoma haematobium, Schistosoma mansoni,
and Schi.Hosoma japonicum. These cause schistosomiasis
(bilha17ia). The adult worms of both sexel> live and mate in
the veins or venules of the gut wall or the bladder. The
female lays eggs that pass into the bladder or gut and
produce inflammation of these organ!>, resulting in
hacmaturia in the former case and. occa!>ionally, loss of
blood in the faeces in the latter. The eggs hntch in water after
discharge from the body and thus enter the secondary host-
a particular species of snail. After a period of development in
this host, free-swimming cercariae emerge. These are
capable of infecting humans by penetration of the skin.
About 200 million people are infected with one or other of
the c,chi<,tO\Omes.
Tissue ro11ndworms: Trichinella spiralis, Dracunculus
medinensis (guinea worm) and the filariae, which include
Wuchereria bancrofti, Loa loa, Onchocerca volvulus and
Brugia malayi. The adult filariae live in the lymphatics,
connective tissues or mesentery of the host and produce live
embryos or microjilariae, which find their way into the
bloodstream. They may be ingested by mosquitoes or similar
buing insects when they feed. After a period of development
within this secondary host. the lanae pa's to the mouthparts
of the insect and arc reinjected into humans. Major filarial
dic,eases are caused by Wuchereria or Bmgia, which cause
obstruction of lymphatic vessels, producing elephantiasis.
Other related diseases are onchocerciasis (in which the
presence of microfilariae in the eye causes 'river blindness')
and loiasis (in which the microfilariae cause inflammation in
the skin and other tissues). Trichinella spiralis causes
trichinosis; the larvae from the viviparous female worms in
the intestine migrate to skeletal mu1>cle, where they become
encysted. In guinea worm infection, larvae released from
crustaceans in wells and waterholcs arc ingested and migrate
from the intestinal tract to mature and mate in the tissues; the
gravid female then migrates to the ~ubcutaneous tissues of
the leg or the foot, where she may protrude through an ulcer
in the skin. The worm may be up to a metre in length and has
to be removed surgically or by slow mechanical winding of
the worm on to a stick over a period of days.
Hydatid tapeworm. These are cestodcs of the Echinococcus
species for which canines are the primary hosts. and sheep
the intermediate hosts. The primary. intestinal stage does not
occur in humans, but under certain circumstances humans
can function as the intermedjate hoM, in which case the
larvae develop into hydatid cysts within the tissues.
Some nematodes that usually Jive in the gastrointestinal tract of
animals may infect humans and penetrate tissues. A skin infes-
ANTIHELMINTHIC DRUGS
t:ltion. termed creeping emption or cuumeous larva migrans. is
cau~ed by the larvae of dog and cat hookworms. Toxocariasis or
visceral larva migrans is caused by larvae of cat and dog round-
worms of the Toxocara genus.
ANTIHELMINTHIC DRUGS
Mankind has attempted to treat helminth infections since antiquity.
Extracts of herbs or plants such as extracts of male fem formed
the basis of many early 'cures'. but the 20th cenrury saw the
advent of a new group of drugs ba~ed on heavy metals such as
arsenic (atoxyl) or antimony (tartar emetic), which were effective
in trypanosome and schistosome infestations.
Generally speaking, the current antihelminthic therapies act
by incapacitating the parasite by paralysis (e.g. by preventing
muscular contraction), damaging the worm such that the immune
sy~tem can eliminate it, or by altering its metabolic processes
(e.g. by affecting microtubule function). Because the metabolic
requirements of these parasites vary greatly from one species to
another, drugs that are highly effective against one type of worm
may be ineffective against others. Clearly, to be an effective
antihelminthic, a drug must be able to penetrate the tough exterior
cwicle of the worm or gain access to it~ alimentary tract in sufficient
concentrations to be effective. This in itself may present difficulties,
because some worms are exclusively lwemophagous (blood eating),
while others are best described as 'tissue grazers'. A further
complication is that many helminths contain active dmg efflux
pumps that reduce the concentration of the drug in the parasite.
The route and dose of anti helminthic arc therefore important and
mu<;t be chosen carefully. because parasitic worms cannot be relied
on to consume sufficient amounts of the drug to be effectjve.
Some individual antihelminthic drugs are described briefly
below, and indications for their use are given in Table 50.1. For
a more comprehensive coverage of antiparasitic drugs and their
usc in humans and animals, you are directed to the literature cited
in the bibliography. Several of these drugs (i.e. niclosamide,
albendazole, tiabendazole, levamisole and praziquantel) are
available in the UK only on a 'named patient' basis.'
BENZIMIDAZOLE$
One of the principal groups of antihelminthics used clinically are
the substituted benzimidazoles. This group of broad-spectrum
agents includes mebendazole, tiabendazole and aJbendazole.
They are thought to act by inhibiting the polymerisation of helminth
B-tubulin, thus interfering with microtubule-dependent functions
such as glucose uptake. They have a selective inhibitory action,
A relatively rare simatioo in which the ph) \ician ..eeks approval from a
phannaceutical company tO use one of their drugs in a named individual.
The drug i' either a newcomer' thai ha \hown particular promise io
clinical trials but has not yet been liccn,ed or, as in these instances, an
eMabli~hcd dn1g that has not been ticen,cd because the company has not
713
applied for a product licence (possibly for commercial reasons).
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CAN CE R

thr
Table 50.1 Principal drugs used in helminth infections
Th
~
Helminth(s) Drug(s) used
!>id
Threadworm (pinworm) U SL
Enterobius vermicularis Mebendazole, albendazole, piperazine ga~
Strongyloides stercora/is (threadworm in the USA) Albendazole, tiabendazole, ivermectin joi
Common roundworm
mq
Ascaris lumbricoides Levamisole, mebendazole, piperazine by
COl
Other roundworm (filariae) pre
Wuchereria bancroft/, Loa loa Diethylcarbamazine, ivermectin COl
Onchocerca volvulus lvermectin
Guinea worm (Dracunculus medmensis) Praziquantel, mebendazole
Trichiniasis (Trichinella spiralis) Tiabendazole, mebendazole PIA
Cysticercosis (infection with larval Taenia solium) Praziquantel, albendazole
Tapeworm (Taenia saginata, Taenia solium) Praziquantel, niclosamlde PiI
Hydatid disease (Echinococcus granulosus) Albendazole, prazlquantel rou
Hookworm (Ankylostoma duodena/a, Necator americanus) Mebendazole, albendazole
Whipworm (Trichuris trichiura) Mebendazole, albendazole, diethylcarbamazine l'e1
m
Blood flukes (Schistosoma spp.) ne
S. haematobium Praziquantel
S. mansoni Praziquantel
S. japonicum Praziquantel

Cutaneous larva migrans

Ankylostoma caninum Albendazole, ivermectin, tiabendazole
acl
Visceral larva migrans ef
Toxacara canis Albendazole, tiabendazole, diethylcarbamazine
(7
(Sourced mainly from the British National Formulary 2004.)
an
pa
di
the
being 250-400 times more effective in producing this effect in been reported and allergic reactions (fever, rashes) can occur.
helminth than in mammalian tissue. However. the effect tale~ Mebendazole should not be given to pregnant women or children
time to develop and the worms may not be expelled for several less than 2 years old. N
days. Cure rates are generally between 60 and 100% with most Ni
parasites. tio
PRAZIQUANTEL
Only 10% of mebendat.ole is absorbed after oral admin- wJ
i~tration. but a fatty meal increa~es absorption. It is rapidly Praziquantel is a highly efTective broad-spectrum amihelminthl pre
melaboli!ted. the products being excreled in the urine and the bile drug that was imroduced over 20 years ago. It is the drug of we
wi1hin 24-48 hou~. It is generally given as a single dose for choice for aU form~ of ~chisto'>omia~is and is the agent generdll)
threadworm. and twice daily for 3 days for hoolworm and used in large-scale '>Chi'ito~ome eradication programme\. h 11
roundworm infestations. Tiabendatole is rapidly absorbed from abo effective in cysticcrco:.ill, for which there was pre"iou\l) no
the gastrointestinal tract, very rapidly metabolised and excreted effective therapy. The drug affech not only the adult '>Chi,lL~
in the urine in conjugated form. It i!, given twice daily for 3 days somes but also the immature forms and the cercariae-the form po
for g uinea worm and Strongyloide.\ infestations, and for up lo of the parasite that infects humans by penetrating the skin. int
5 days for hookworm and roundworm infestations. AJbendazolc The drug apparently di~>rupts Ca 2+ homeostasis in 1he para,ite isc
is also poorly absorbed but, like mebendazole, this may be by binding to consensus protein kinase C- binding sites in a I' d!l
increased by food, especially fats. It is metabolised extensively subunit of schistosome vohage-gated calcium channels (Grecnllc!!.
by fir::.t-pass metabolism to the ~ulfoxide and sulfone metabolites. 2005). This induce~ an innux of the ion. a rapid and prolongl'd \0
The former is likely to be the pharmacologically active specie'>. contraction of the musculature, and eventual paralysis and death
Unll'allfed effects are fe\' with albendazole or mebcndatole, of the worm. Praziquantcl also disrupts the tegument of the
although gastroimestinal disturbances can occasionally occur. parasite, unmasking novel antigens. and as a result it rna) D
Unwanted effects with tiabendtvole are more frequent but become more susceptible to the host\ normal immune respon'c' Di
usually transient, the commonel>! being gastrointestinal Given oral ly, praziquantel is well absorbed: much of the drub fil
7 14 disturbances, although headache, di;ziness and drowsiness have is rapidly metabolised to inactive metabolites on first pas,age Di

through the liver, and the metabolites are excreted in the urine.
The plasma half-life of the parent compound is 60-90 minutes.
Praziquantel is considered to be a very safe drug with minimal
'ide effects in therapeutic dosage. Such effects as do occur are
u~ually transitory and rarely of clirucal importance. They include
gastrointestinal disturbance. diuiness. aching in muscles and
joint::.. skin eruptions and low-grade fever. Some effects are more
marked in patients with a heavy worm load and may be caused
b) products released from the dead worms. Praziquantel is
considered safe for pregnant and lactating women, an important
property for a drug that is commonly used in national disease
control programmes. Some resistance has developed to the drug.
PIPERAZINE
Piperazine can be used to treat infections with the common
roundwom1 (Ascaris lumbricoides) and the threadworm (Enterobius
l'ermicularis). It reversibly inhibits neuromuscular trans i1Ussion
in the worm, probably by acting like GABA, the inhibitory
neurotransmitter, or GABA-gated chloride channels in nematode
muscle. The paralysed worm~ arc expelled alive by normal
intestinal peristaltic movements.
Piperazine i!> given orally and some, but not all, is absorbed. It
1s partly metabolised, and the remainder is eliminated,
unchanged, via the kidney. The drug has little pharmacological
action in the host. When used to treat roundworm. piperazine is
effective in a single do e. For threadworm, a longer course
17 days) at lower dosage is necessary.
Unwamed effects are uncommon. but gastrointestinal disnrb-
ances. urticaria and bronchospasm occur occasionally, and some
patients experience diuiness. paraesthcsias, vertigo and incoor-
dination. The drug should not be given to pregnant patients or to
those with compromised renal or hepatic function.
NICLOSAMIDE
Niclosamide is widely used for the treatment of tapeworm infec-
tions together with praziquantc l. The scolex (the head of the worm
with the parts that attach to the host intestinal cells) and a
proximal segment arc irreversibly damaged by the drug; the
worm separate!> from the inte!.tinal wall and is expelled. For
Taenia solitun, the drug is given in a single dose after a Jjght
meal, followed by a purgative 2 hours later; this is necessary
p because the damaged tapeworm segments may release ova,
~ 11hich are not affected by the drug. so there is a theoretical
h possibility that cysticerco~i~ may develop. For other tapeworm
infections, it is not neces!.ary to give a purgative after admin-
istration of niclo~amide. There is negligible absorption of the
drug from the gastrointestinal tract.
Unwamed effects are few. infrequent and transient. Nausea and
vomiting can occur.
DIETHYLCARBAMAZINE
Diethylca rbamazine is a piperazine derivative that is active in
g filarial infectio ns caused by W. bancrojii and L. loa.
c Diethylcarbamazine rapidly re moves the microfilariae from the
ANTIHELMINTHIC DRUGS
blood circulation and has a limited effect on the adult worms in
the lymphatics, but it has little action on microfilariae in vitro. It
has been suggested that it modifies the parasite so that it becomes
susceptible to the ho<,t\ normal immune responses. lt may also
interfere with helminth arachidonate metabolism.
The drug i~ ab!.Orbed following oral admirusrration and is
distributed throughout the cells and tissues of the body. excepting
adipose tis~ue. It i!. partly metabolised. and both the parent drug
and its metabolites are excreted in the urine, being cleared from
the body within about 48 hours.
Umvamed effects arc common but transient, subsiding within
a day or so even if the drug is continued. Side effects from the
drug itself include gastrointestinal disturbances, arthralgias,
headache and a general feeling of weakness. Allergic side effects
referable to the products of the dying filariae are common and
vary with the species of worm. In general, these start during the
first day 's treatment and laM 3-7 days: they include s kin reac-
tions, e nlargement of lymph glands, dizziness, tachycardia, and
gastrointe5tinal and respiratory disturbances. When these symp-
toms disappear, larger doses of the drug can be given without
further problem. The drug is not used in patients with
onchocerciasis. in whom it can have serious unwanted effects.
LEVAMISOLE
Levamisole is efTecti\e in infections with the common round-
worm (A.1cari.1 lumbricoides). lt has a nicotine-like action. stimu-
lating and subsequently blocking the neuromuscular junction~.
The paraly~ed worms are then expelled in the faeces. Ova are not
killed. The drug i-. given orally, is rapidly absorbed and is widely
distributed. It cro~ses the blood-brain barrier. It is metabolised in
the liver to inactive metabolites. which are excreted via the
kidney. Its plasma ha lf-life is 4 hours.
When si ng le-do~c therapy is used, unwanted effects are gen-
erally few and ~oon ~ubside. They include gastrointestinal
disturbances, dizziness and skin eruptions. High concentrations
can have nicotin ic actions on autonomic ganglia in the mam-
malian host. There are some rep01ts of encephalopathy associated
with levamisole usage, but this seems to be a rare side effect.
IVERMECTIN
First introduced in 1981 as a veterinary drug, ivermectin has
been used with enormous <,uccess in humans as a safe and highly
effective broad-spectrum antiparasitic. It is lhe first choice of
drug for the treatment of filarial infections and is very effective
in onchocerciasi'l. Over 250 million doses of the drug have been
administered around the world :.ince 1990, and it is frequently
used in global public health campaigns. Chemically. ivermectin
is a semi~ynthetic agent derived from a group of natural
substances, the avermecti n~. obtained from an actinomycete
organism. It has potent antihclminthic activity against filaria in
humans, being the drug of c hoice for o nchocerc iasis. which
causes river blindness; it has also g iven good results against
W. /Jancrofti, which causes e le phantias is. A s ingle dose kills the
immature microfi lariac of 0 . volvulus but not the adult worms.
fvermectin reduces the inc idence of onchocercal b)jndness by up 715
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
to 80%. The drug also has activity against infections with some
roundworms: common roundworms, whipworms, and thread-
worms of both the UK (Enterobius vennicularis) and the US
variety (Strongyloides stercora/is), but not hookworms. It is gi"en
orally and has a half-life of 11 hours.
Jvermectin is thought to kill the worm by opening glutamate-
gated chloride channel!> (found only in invertebrates) and increasing
cr conductance; by binding to a novel allosteric sire on the
acetylcholine nicotinic receptor to cause an increase in trans-
mission, leading to motor paralysis; or by binding to aminobutyric
acid receptors.
Unwamed effects include skin rashes, fever, giddiness, headaches
and pains in muscles, joints and lymph glands. In general, the
drug is very well tolerated.
RESISTANCE TO ANTIHELMINTHIC DRUGS
Resistance to antihelminthic drugs is a widespread and growing
problem affecting not only humans but also the animal health
market. During the 1990s, helminth infections in sheep (and to a
lesser extent cattle) developed varying degrees of resistance to a
number of different antihelminthic drugs. Parasites that develop
such resistance pass this ability on to their offspring. leading in
quick succession to treatment failure and the persistence of the
worm infection. The widespread use of antihelminthic agents in
farming hac; been blamed for the spread of resistant species.
There are probably several factors that contribute to the molecular
mechanisms involved in drug resistance. The presence of the
P-glycoprotein transporter in some species of nematode has
already been mentioned, and it has been demonstrated that the
use of agents such as ve ra pamil that block the transporter can
partially reverse be nzimidazole resistance in trypanosomes.
However, some aspects of benzimidazole resistance may be
attributed to an impairment of high-affinity binding to parasite
P-tubulin. Likewise, resistance to levamisole is associated with
changes in the structure of the target acetylcholine nicotinic receptor.
Whether such changes are the result of random genetic poly-
morphisms or some other facet of parasite biology is not clear.
Of great significance is the way in which helminths evade the
host's immune system. Even though they may thrive in immu-
nologically exposed sites such as the lymphatics or the blood-
stream, many are long-lived and may coexist with their hosts for
many years without seriously affecting tJ1eir health. or in some
cases without even being noticed. It is striking that the two major
families of helminths, while evolving separately, deploy similar
strategic!> to evade destruction by the immune system. Clearly.
this must be of major survival value for the species.
In Chapter 14, we discussed the two main types of inflam-
matory/immune strategies, termed the Thl and the Th2 responses,
the latter being characterised by the development of an antibody-
mediated response rather than the development of a cell-medjated
immune response. It appears that many helminths can actually
exploit this mechanism by steering the immune system away from
a local Th I response, which would be potentially more damaging
to the parasite, and promoting instead a modified systemic Th2
71 6 type of response. This is associated with the production of 'anti-
innammatory' cytokines such as interleuldn-10, and is therefon ol
favourable to, or at least better tolerated by, the parasites. Th ge~
mechanism by which this is achieved is complex and is o~l. E.'to
marginally relevam to the present discussion, so the intere'lt COl
reader is encouraged to pursue the subject separately if ~i\hed \.\i
(Pearce & MacDonald, 2002; Maizels eta!., 2004). gr.
Ironically, the ability of helminths to modify the host immunt
response in thi~ way may confer some survival value on the
hosts themselves. For example. in addition to the local ann
"'
innammatory effect exerted by helminth infections, rapid wour.-'
healing is also seen. Clearly, this is of advantage to parasites th.,
must penetrate tissues without killing the host but may abo lx
beneficial to the host as well. It has been proposed that th,
presence of helminth infections may mitigate some form~ of
malaria and o ther diseases, possibly conferring survival advan
tagcs in popu lations where these diseases are endemic. The
deliberate infestation of Crohn's disease patients with nematode'
has even been suggested as a strategy to induce remission of
the disease, presumably because the Th2 pathways that art
activated during parasite infection down-regulate the Thl
responses that drive this type of intestinal inflammation (~
Hunter & McKay, 2004). Certainly, this can be demonstrated
experimentally in mice. and there is some evidence arising fJ'OI"
human studie~ u~ing the whipworm Trichuris suis that thi' rna)
indeed be a viable therapeutic option. On the basis that Th2
responses can reciprocally inhibit the development of Thl
diseases. it has also been hypothesised that the comparau1e
absence of Crohn 's, a~ well as some other autoimmune disea...:'
in the developing world may be associated with the h1gh
incidence of parasite infection, and that the rise of these disordel\
in the west is associated with the high level of sanitation and
reduced helminth infection! This type of argument is generall)
known as the 'hygiene hypothesis'.
VACCINES AND OTHER NOVEL
APPROACHES TO ANTIHELMINTHIC
THERAPY
~
Despite the enormity of the clinical problem, there have been fell I
recent small-molecule additions to the antihelminthic arsenal. On
a more positive note, the sequencing of the genome of the free
living nematode Caenorhabdiris elegans is now complete, and
the genomes of several other helminths have been paniall)
sequenced. Thb exciting new resource may make it possible m
the future to create a transgenic species that expresses mutations
found in resistant parasitic worms, thus providing a better und(r
standing of the mechanisms underlying resistance. In addiuon.
genome databases can be searched for likely opportunitie~ for
therapeutic intervention. The availability of such informatiOI
also opens the way for other types of antihelmithic agent, such a_,
those based on antisense DNA or small interfering RNA (s..-e
Boyle & Yoshino, 2003).
But it is in the field of antihelminthic vaccines that the mO\t
exciting progress has been made (see Dalton et al., 2003). The
key here has been U1e development of recombinant DNA
technology. Antigens such as the proteins present on the surface
 ANTIHELMINTHIC DRUGS

of the (highly infectious) larval sLage have been identified, the
genes cloned, and the transcripts expressed in high abundance in
Escherichia coli and used as an immunogen. Using this approach,
con iderable success ha~ been achieved in the veterinary field
with vaccines to organisms such as Taenia ovis and Enterobius
granulosus (in sheep) as well as Taenia saginata (in cattle) and
Taenia solium (in pigs), with cure rates of 90-100% often
reported (see Dalton & Mulcahy, 2001; Lightowlers et al., 2003).
Qualified success has also been obtained with vaccines to other
helminth species. Other potential targets for this type of strategy
nught include secreted proteins cmcial to parasite survival (e.g.
the cathepsin protease of Fasciola hepatica and the aspartate
peptidase of schistosomes and hookworms).
While it is true that helminth infections caused by Taenia ovis
and Taenia saginata tie at the margins of economic or medical
importance. this progress is encouraging because, if it can be
replicated in the case of the more serious helminth diseases such
as schistosomi asi~, it would revolutionise the treatment of these
widespread infections, as well as minimising the problem of
developing dmg resistance and reducing the environmental
burden of residual pesticide residues, which sometimes occurs
as a consequence of overenthusiastic antihelminth control cam-
paigns. Looking further into the future, it may be possible to
develop DNA vaccines against these organisms without having to
produce any protein-based immunogen at all.

REFERENCES AND FURTHER READING

f
General papers on helminths and their dise>~SeS
Drake L J, Bundy 0 A 2001 Multiple helminth infections
tn chtldren: impact and control. Para\tlology
e 122 (~uppl):S73-S81 (n,~ mte ,_, utf-~planamory)
HortOn J 2003 Human gaw-oonlc\tinal helminth
onfections: are 1hey now neglected do\C~>? Trends
Para,nol 19: 527-531 CA~aSSLble rrin. 011 helmmth
infa:tmn! atod their trratmmtt)
\ntihelminthic drugs
Bo)le J P, Y<Xhono T P 2003 Gene manopula110n m
pamolic helmonlh; lnt J Par.botol 33: I 259 1268
iDe-als >uth appmacht!.f flldltU antijt!riSt! tht!ropy: for
the mUrrlted rrader t>nl))
Burkhart C "' 2000 hermecun an W><ie~'ment of ttl.
pharmacology. mocmboology and -.:tfety. Vet Hum
To,icol 42: 30-35 (Uuful pttper that /(}(uses on
ntl"'m'crm phamwcolog_v)
CroftS L 1997 The current smtu' of antiparW>ote
chem01hcrnpy. P.drtL>itology 114: S3-S I5
(Comprrhensi e cmeragt of curre111 drugs mrd outlint'
ofapproachl'r 10 po.wblt fiture agents)
Dayan A D 2003 Alhcndntolc. mebendatole and
praziquamel. Review of non-clinical toxicity nnd
pharmacokinetics. Acta Trop86: 14 1- 159
(ComprthNISile revll'w of rhe plwmwcoki11etic.v ami
wxidty of thtst' importalll drugs)
fisher M II , Mro7lk H 1992 TI1c chcmiwy and
phannacology of the avcnnectins. Annu Rev
l'tlannacol Toxicol U: 537-553
Geary T G, Sangster N C, Thompson 0 P 1999
Frontiers in anthelmintic pharmacology. Vet Parasitol
84: 275-295 (Thoughtful account<>/ tht' diffirultil'f
associated with drug tll"otmenJ)
Grecnbe.g R M 2005 Arc Ca~ channels a.ge1s of
praziquamel action?lm J Parasuol 35: I 9
(lmeresring reW.. on provquamal action for thtJU
.. Ito toish to 11<> int<> it i11 depth)
Liu LX. Weller P F 1996 Amipara.-.uc drug5. ~ L.ngl J
Med 334: 1178-1 184 (~UI/t'nt COI't!ragt' of
anuparasiric: drugs and their clmicaiiiSt')
Prichard R. Tait A 2001 The role of molecular btology on
veterinary parasitology. Vet Para~uol 98: 169 194
(Excellent revin. of the application of molentlar
biology to undersumding the problem of dru11
resistanu multo tilt! developmem of nn.
anthelminthic agents)
Robenson A P, Bjorn H E. Manin R J 2000 Pyrnntcl
resistance alters nematode nico1inic acetylcholone
receptor single channel propenies. Eur J Phnrmac<>l
394: 1-8
World Health Organization 1995 WHO model
prescribing infonnation: drugs used in parn;,ilic
diseases. 2nd edn. WHO, Geneva
Antihelminth vaccines
Dalton J P, Brindley P J, Knox D P e1 al. 2003 l lelmimh
vaccines: from mining genomic information for
vaccine targets to systems used for protein exprc'>sion.
lnt J Parasitol33: 621-640 (l~ry comprehensive but
may be oercomJ>IicULed in parts for rloe 11011
specialist)
Dalton J P. Mulcahy G 200 I Parasite vaccines-a
reality? Vet ParW>it 98: I 49-I 67 (tnrerrsting
dtscuwo11 of the promise and pitfalls of \'Occines)
Ltghtowlers M W, Colebrook A L, Gauci C G el at. 2003
Vacconation against cestode parasites: anti-helminth
accme;, that worl< and why. Vet Parasitol 115: 83-123
(Very comprt!hensie revit!>< for tilt! dedicated rrader!)
Immune nasion by helminths and its potenUal
ther11peutic uses
Hunter M \1. McKa) D M 2CJO.I Review article:
helmonth;, a lherapeutoc agent> for inOllllliJI.'Itory
bo"el dosease. Aliment Pharmacol Ther 19: 167-177
(Fasri11atin.~ revit"W on patell/ialtherapt'utic ustS of
helmintlu and why they work)
Mallets R M. Balle A. Gome-z-Escobar Net al. 2()().1
Helmimh parasites-masters of regulation. lmrnunol
Rev 20 I: 89-116 (Excellent and very comprehensit'e
nview tleali11g with mechanisms of imm1me evasion:
complicated i11 txms for the nun-specialist)
Pearce E J, MacDonald A S 2002 The immunobiology
of schistosomiasis. Nat Rev lmmunol 2: 499-512
(Dea/J mainly with the immunology of schisroJome
lllfections in mice)
 il
II

Cancer chemotherapy TH
An
mut
got,.
tlef<=
.tnt!
de"
mul
three people will be diagnosed with cancer during their lifetime ch.tl
Overview 718 and in 200 I (for example) 270 000 new cases were reported m
Background 718 the UK. Cancer is also responsible for approximately one-quarttr
of all deaths in the UK, with lung and bowel cancer comprising
The pathogenesis of cancer 718 the largest category, closely followed by breast and pro\talt
-The genesis of a cancer cell 719 cancer. At first sight, incidence figures for the past 100 yean; 0'
-The special characteristics of cancer cells 719 so give the impression that the disease is increasing in deveiOJll!
General principles of action of cytotoxic countries, but cancer is largely a disea~e of later life, and 1111h
anticancer drugs 721 advance!> in public health and medical science many more pcop.
now live to an age where they are more liable to contract canltr
Drugs used in cancer chemotherapy 722 1l1e tcnns cancer, malignam neopla.1m (neoplasm simply mc:m;
-Aikylating agents and related compounds 723 new growth) and matixnant wmour are synonymous. Both bemg
-Anti metabolites 726 and malignam tumour. manife~t uncontrolled proliferation. but !he c
-Cytotoxic antibiotics 727 laner arc di:.tinguished by their capacity for dedifferemimion. ~
-Plant derivatives 728 their imasi1eness and their ability to metastasise (spread to odler a
-Hormones 729 part'> of the body). In thi~ chapter. we shall be concerned onl} 111th
-Hormone antagonists 729
the therapy of malignant neoplasia or cancer. The appearan~eo(
-Radioactive isotopes 730 these abnormal charactcri~tics reflects altered pauems of gene
-Miscellaneous agents 730 expression in the cancer cells. resulting from genetic mutation\.
Resistance to anticancer drugs 731 There are three main approaches to treating establi\ht~
cancer-surgical excision, irradiation and chemotherapy-and tlk
Treatment schedules 731 relative value of each of these approaches depends on the type o1
Techniques for dealing with emesis and tumour and the stage of its development. Chemotherapy may h: tral
myelosuppression 732 used on its own or as an adjunct to other fomlS of therapy. Olh<r
approaches to cancer treatment, based, for example, on our increa\ TH
Possible future strategies for cancer ing knowledge of the pathobiology of cancer, are being pursuca CE
chemotherapy 732 (sec below) and are beginning to produce results of real value.
Chemotherapy of cancer, as compared with that of bactcna.
UN
disease, presents a diflicult problem. In biochemical terms, micro Sm
organisms are both quantitatively and qualitatively different fror di\i
human cells (see Ch. 45). but cancer cells and normal cells are~ the
OVERVIEW similar in most re!.pects that it is more difficult to find generJI pr<
exploitable. biochernicaJ differences between them. mu
In this chapter, we deal with cancer and anticancer
mu
therapy, emphasising first the pathogenesis of
thc1
cancer before proceeding to describe the drugs that THE PATHOGENESIS OF CANCER tha1
can be used therapeutically. Finally, we consider
C\1
the extent to which our new knowledge of cancer To under~tand the action and drawbacks of current anticanl't
Wit
biology is leading to new treatments. agents and to appreciate the therapeutic hurdles that must bo:
thai
surmounted by putative new drugs. it is important to con~ider
...
in more detail the pathobiology of this disease.
BACKGROUND ati
Cancer cells manifest. to varying degrees. four characterisuc'
or
that distinguish them from normal cells. These are:
Cancer is a disease characterised by uncontrolled multiplication mil
and spread of abnormal forms of the body's own cells. It is one uncontrolled proliferation prot
718 of the major causes of death in the developed nations: one in dedij]'erentiation and loss of function (sc

itrrasi1eness
metastasis.
THE GENESIS OF A CANCER CELL
.\ normal cell turns into a cancer cell because of one or more
mutations in its DNA, which can be acquired or inherited. A
good example is breast cancer: women who inherit a single
defective copy of either of the tumour suppressor genes BRCA I
and BRCA2 (see below) have a significantly increased risl. of
developing breast cancer. However. carcinogenesis is a complex
multistage process. usually involving more than one genetic
change as well as other, epigenetic factors (hom10nal,
cocarcinogen and tumour promoter effects. etc.) that do not
themselves produce cancer but which increase the likelihood that
the genetic mutation(s) will result eventually result in cancer.
There are two main categories of genetic change that arc
imponant.
The activation of J11Vtn-oncogenes to oncogenes. Proto-
oncogencl:> are genes that normally control cell division.
apopto!>is and differentiation, but which can be convened to
oncogene-. that induce malignant change by 'ira I or
carcinogen action.
The inactivation of tumour suppressor genes. Normal cells
contain genes that have the ability to suppress malignant
change-termed 111mour suppressor genes (antioncogene~)
and there is now good evidence that mutations of these genes
are involved in many different cancers. The loss of function
of tumour suppressor genes can be the critical event in
carcinogenesis.
About30 tumour suppre~sor genes and 100 dominant oncogenes
have been identified. The changes that lead to malignancy arc a
result of point mutations. gene amplification or chromosomal
translocation, often caused by viruse!. or chemical carcinogen!..
THE SPECIAL CHARACTERISTICS OF CANCER
CELLS
UNCONTROLLED PROLIFERATION
Some healthy cells (such as neurons) have little or no capacity to
divide and proliferate. whereas other!., in the bone marrow and
the epithelium of the gastrointestinal tract for example, have the
property of continuous rapid division. Some cancer cells
multiply slowly (e.g. those in plasma cell tumours) and some
much more rapidly (e.g. the celb of Burkitt's lymphoma). It is
therefore not generally true that cancer cells proliferate fa:.tcr
than normal cells. The significant is!>ue is that cancer cells have
escaped from the mechanisms that normally regulate cell division
and tissue growth. It is this, rather than their rate of proliferation,
that distinguishes them from normal cells.
What are the changes that lead to the uncontrolled prolifer-
ation of tumour cells? Inactivation of tumour suppressor genes
or transformation of proto-oncogenes into oncogenes can confer
autonomy of growth on a cell and thus result in uncontrolled
proliferation by producing changes in several cellular systems
(see Fig. 51.1 ), including:
CANCER CHEMOTHERAPY
growth factors. their receptors and signalling pathways
the cell cycle transducers, for example cyclins, cyclin-
dcpcndent kinases (cdks) or the cdk inhibitors
the Clpoptotic machinery that normally disposes of abnormal
cells
telomerase e;.pre.\sion
local blood ve!>sels, resulting from tumour-directed
angiogenesis.
Potentially all the genes coding for the above components could be
regarded as oncogenes or tumour suppressor genes (see Fig. 51.2),
although not all arc equally prone to malignant transformation. It
should be understood that malignant transformation of several
components is needed for the development of cancer.
Apoptosis and the genesis of a cancer cell
Apoptosis is programmed cell death (Ch. 5), and genetic
mutations in the antiapoptotic genes are u~ually a prerequisite
for cancer: indeed, resistance to apoptosis is a hallmarl- of the
disease. It can be brought about by inactivation of proapoptotic
factors or by activation of antiapoptotic factors.
Telomerase expression
Telomeres are specialised structures that cap the ends of
chromosomes-like the small metal tubes on the end of
shoelaces-protecting them from degradation, rearrangement
and fusion with other chromosome:.. Put simply. D1 A
polymerase cannot ca~ily duplicate the last few nucleotides at
the ends of DNA, and telomercs prevent loss of the 'end' genes.
With each round of cell division, a portion of the telomere is
eroded, so that eventually it becomes non-functional. At this
point, DNA replication ceases and the cell becomes sene~ccnt.
Rapidly djviding cells, such as stem cells and those of the bone
marrow, the germline. and the epithelium of the gastrointestinal
tract, express telomerase. an enzyme that maintains and ~tabilises
telomeres. While it is absent from most fully differentiated
somatic cells, about 95% of late-stage malignant tumours do
express the enzyme, and it is this that may confer 'immortality'
on cancer cells.
The control of tumour-related blood vessels
The factors described above lead to the uncontrolled proliferation
of individual cancer cells. but we also need to consider factors
that influence the total tumour mass. The actual growth of a solid
tumour depends absolutely on the development of its own blood
supply. Tumour~ 1- 2 mm in diameter can obtain nutrients by
diffu<,ion, but any further expansion require~ angiogenesis, the
development of new blood 'essels (see p. 77). Angiogenesis
occurs in response to growth factors produced by the growing
tumour (see Carmcliet & Jain, 2000: Griffioen & Molema, 2000).
DEDIFFERENTIATION AND LOSS OF FUNCTION
The multiplication of normal cells in a tissue begins with division
of the undifferentiated stem celb giving rise to daughter cell . These
daughter cells eventually differentiate to become the mature cells
of the relevant tissue, ready to perform their programmed
functions. For example, when fibroblasts mature. they secrete 719
 SECTION 5 DRUGS USED IN THE TREATMENT O F INFECTI O N S A N D CAN CER

I I 1
Proto- 1 Proto-oncogene 1 Cancer 1 Ant1cancer
1
oncogene : products : drugs
1 I
Genes for I Growth factors Prostate, breast 1 Research n
growth factors : e.g. IGF colorectal, etc. : progress.
- -e.g.
--- for IGF
- I
.J__ __._ ___________ j_ WTS _
I _______

Growth factors 1
Gene for : Her2. Breast : Inhibited by
EGF receptors I (a receptor : trastuzumab
(e.g. c-erbB) : tyrosine kinase) 1(aka Hercept111l
Growth factor
Gene for
,: PDGF
r-----------r--------
Chronic myeloid
: Inhibited by
receptors
PDGF 1 (a receptor leukaemia 1 imatinib
(c-s/s) : tyrosine kinase) 1 : (aka Gleevec)
.-- CYTOSOL l r-----------r---------
I e-ras 1 Ras proteins 1 30% of 1 Ras inhibitors
I
: : all tumours : in clinical trial
Cytosollc Adapter proteins - ., r ---- ----r--------
transducers Kinase 2 abl 1 Abl tyrosine 1 Chronic myeloid 1 Inhibited by
I
I , Kinase 3 : kinase : leukaemia : imatinib
-- 1 (cytoplasmic) 1 1 (aka Gleevec)
~-- J L - --------1--------
I
I
I
I
I
CS(C
-----------

~!~~~~~r !
J
: Cytoplasmic
tyrosine
kinase
I Breast,
1
pancreas, :
bone
:---~~;emi~~~
1

Research in
..
tl
Nuclear
transducers
I
---------4
''-- ____ _ _[:~!~~c-fos i Tra~~~~~~ion
- -~

L
----
~olo~ctal
-- 1
__)
progress.
WTS
I
I
I
I
- L c-myc 1 (Jun, Fos, Myc) : Lung, neural tissue :

~--
- - Mutation of the delayed response
Positive regulators Negative regulators nuclear proto-oncogenes...
1 of the cell cycle: can alter expression of the regulators
of the cell cycle:
Cell cycle
cyclins p53 protein of the cell cycle, e.g. more than 50%
transducers Rb protein .,.., , , of human tumours have mutations of
cyclindependent
kinases (cdks) cdk inhibitors ', the tumour supressor gene that
-- ' ' codes for p53 protein
Fig. 51.1 Signal transduction pathways initiated by growth factors and their relationship to cancer development A few
examples of proto-oncogenes and the products they code for are given in the table, with examples of the cancers that are associated
with their conversion to oncogenes. Drugs (some available, others in the pipeline) are also shown. Many growth factor receptors are
receptor tyrosine kinases, the cytosolic transducers including adapter proteins that bind to phosphorylated tyrosine residues in the
receptors. Ras proteins are guanine nucleotide-binding proteins and have GTPase action; decreased GTPase action means that Ras
remains activated. EGF, epidermal growth factor; IGF, insulin-like growth factor; PDGF, platelet-derived growth factor; wrs, watch this
space. "Her2 is also termed her2/neu.

s
and organise extracellular matrix; mature muscle cells are capable mucosa, by comparison, invades other tissues forming the rectum in
of contraction. One of the main characteristics of cancer cells is that and may even invade me tissues of other pelvic organs. Cancer fou
they dedifferentiate to varying degrees. In general, poorly different- cells have not only lost, through mutation. the restrainL~ lha1 ca111
iated cancers multiply faster and carry a worse prognosis man well- act on normal cells, but they also secrete enzymes (e.g ~ll

differentiated cancers. metalloproteinases; sec Ch. 5) that break down the extracellular exJl
matrix, enabling hem to move around. fad
INVASIVENESS
METASTASES
Normal cells are not found outside heir 'designated' tissue of
origin; for example, liver cells are not found in the bladder and Metastases are secondary tumours formed by cells mat have been
pancreatic cells are not found in the testis. T!Us is because, during released from the initial or primary tumour and have reach(u
differentiation and tissue or organ growth, normal cells develop other sites through blood vessels or lymphatics. or as a result of In
certain spatial relationships with respect to each odler. These being shed into body cavities. Metastases are me principal cau'l: in
relationships are maintained by various tissue-specific survival of mortality and morbidity in most cancers and constitute a major C)!
factors that prevent apoptosis (see Ch. 5). In this way, any cells problem for cancer therapy.
that escape accidentally lose these survival s ignals and die. As discussed above, dislodgment or aberrant migration of nonnal
Consequently, although the cells of the normal mucosal cells would lead to programmed cell death as a result of withdrawal I fh
epithelium of the rectum proliferate continuously as the lining of the necessary antiapoptotic factors. Cancer cells that metastasise In
720 is shed, they remain as a lining epithelium. A cancer of the rectal have undergone a series of genetic changes that alter their respon~;es div ~
 CANCER CHEMOTHERAPY

Chemicals, viruses, irradiation, etc.

l
Acquired mutations Inherited mutations'

Altered gene express1on

/
------------~--~----~
Proto-oncogenes ___. Oncogenes Decreased express100 of tumour
sis, erbB, ras, myc, gene for cychn D, etc. suppressor genes: p53, Rb1, etc.

~Other factors~
Uncontrolled cell proliferation, Decreased apoptosis,
dedifferentiation alterations in telomerase

~ /
Development of primary tumour

~
Fig. 5 1.2 Simplified o utline of
the g enesis of cancer. The diagram
summarises the information given in Production of metailoproteinases etc.

~
the text. The genesis of cancer is
usually multifactorial, involving more
than one genetic change. 'Other Invasion of nearby tissue by tumour cells

~
factors', as specified above, may
involve the actions of promoters,
cocarcinogens, hormones, etc. AngiogeneSIS
which, while not themselves
carcinogenic, increase the likelihood ~
that genetic mutation(s) will result in Metastasis
cancer. 'It is not cancer that IS
inherited but a gene that has
~
mutated and predisposes to cancer. Development of secondary tumours

to the regulatory factors that control the cellular architecture of
normal tissues, enabling them to establish themselves 'extra-
territorially'. Tumour-induced growth of new blood vessels locally
(see above) makes metastasis easier and more likely.
Secondary tumours occur more frequently in some tissues than
in others. For example, metastases of mammary cancers are often
found in lung, bone and brain. The reason for this is that breast
cancer cells express chemoltine receptors such as CXR4 on their
surfaces, and chemokines that recognise these receptors are
expressed at high level in the e tissues but not in others (e.g. kidney),
facilitating the ~elective accumulation of cells at these sites.
GENERAL PRINCIPLES OF ACTION OF
CYTOTOXIC ANTICANCER DRUGS
In experimenh with rapidly growing transplantable leukaemias
in mice. it has been found that a given therapeutic dose of a
C}10toxic drug' destroys a constant fraction of the malignant
1
The term cytotoxic drug applies to any drug that can damage or kill cells.
In practice. it i~ used more restrictively to refer to drugs that inhibit cell
division and are therefore potenth11ly usefu l in cancer cbemolherapy.
cells. Thus a dose that kills 99.99% of cells, if used to treat a
tumour with 10 11 cells, will still leave I 0 million (10 7) viable
malignanl cells. As the same principle holds for fast-growing
tumours in humans, schedules for chemotherapy are aimed at
producing as ncar a total cell kill as possible because, in contrast
to the situation Jhat occurs in micro-organisms, little reliance can
be placed on the host's immunological defence mechanisms
against the remaining cancer cells.
One of the major difficulties in treating cancer is that tumour
growth is usually far advanced before cancer is diagnosed. Let us
suppose that a tumour arises from a single cell and that the
growth is exponential, as it may well be during the initial stages.
'Doubling' times vary. being. for example. approximately 24
hours with Burkitt'<; lymphoma, 2 weeks in the case of some
leukaemias, and 3 months with mammary cancers. Approxi-
mately 30 doublings would be required to produce a cell mass
with a diameter of 2 em, containing I 09 cells. Such a tumour is
within the limit~ of diagnostic procedures, although it might go
unnoticed if it arose in a tissue such as the liver. A further I 0
doublings would produce 10 12 cells, a tumour mass that is likely
to be lethal, and which would measure about 20 em in diameter
if it were one solid mass.
However, continuous exponential growth of this sort does not
usually occur. In the case of most solid tumours (for example of 721
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
Cancer pathogenesis and cancer
chemotherapy: general principles
The term cancer refers to a malignant neoplasm (new
growth).
Cancer arises as a result of a series of genetic and
epigenetic changes, the main genetic lesions being:
inactivation of tumour suppressor genes (e.g. p53)
- the activation of oncogenes (mutation of the normal
genes controlling cell division and other processes).
Cancer cells have four characteristics that distinguish
them from normal cells:
uncontrolled proliferation
loss of function because of lack of capacity to
differentiate
invasiveness
the ability to metastasise.
Cancer cells have uncontrolled proliferation because
of changes in:
growth factors and/or their receptors
intracellular signalling pathways, particularly those
controlling the cell cycle and apoptosis
telomerase expression
tumour-related angiogenesis.
Most anticancer drugs are antiproliferative-most
damage DNA and thereby initiate apoptosis. They
also affect rapidly dividing normal cells and are thus
likely to depress bone marrow, impair healing and
depress growth. Most cause nausea, vomiting,
sterility, hair loss and teratogenicity.
lung, s10mac h, uterus and so o n), as opposed to leukaemias
(tumours of white blood cells), the growth rate falls as the
neoplasm g rows. This is partly because the tumour partially
necroses as it outgrow!> its abi lity to maintain its blood supply,
and partly because not all the cells proliferate continuously. The
cells of a solid tumour can be considered as belonging to three
compartments:
compartmem A consists of dividing cells, possibly being
continuously in cell cycle (p. 72)
compartment 8 consists of resting cells (0 0 phase) whic h,
although not dividing, arc potentially able to do so
comparrmem C con!>ists of cells that are no longer able to
divide but which contribute to the tumour volume.
Essentially, only cells in compartment A. which may form as
little as 5% of some solid tumours, arc susceptible to the main
current cytotOxic drugs. as is explained below. The cell in com-
partment C do not constitute a problem. but it is the existence of
compartment B that makes cancer chemotherapy difficult,
because these cells arc no t very sensitive to cytotoxic drugs and
are liable to re-enter compartment A following chemotherapy.
Most current anticancer drugs, particularly those that arc
722 'cytotoxic', affect only one charac teristic aspect of cancer cell
biology-cell division-but have no specific inhibitory effect on
invasiveness, the loss of differentiation, or the tendenc} to
meta~tasise. In many cases, the antiproliferalive action result,
from an action during S phase of the cell cycle, and the resultant
damage to DNA initiates apoptosis (see above and p. 7'1
Furthennore, because their main target is cell division, the} 111
affect all rapidly dividing normal tissues. and thus they are likel}
to produce, to a greater or lesser extent. the foUowing general
toxic effect!.:
bone marroll' toxicity (myelosuppression) with decreased
leucocyte production and thus decreased resistance to infection
impaired wound healing
foss of hair (alopecia)
damage to gastroillfestinal epithelium
depression of growth in children
sterility
teratogenicity.
They can also. in certain c irc umstances, be themselves carci
nogenic. Rapid cell destruction also entails extensive purine
catabolism, and uratcs may precipitate in the renal tubules and
cau!.e kidney damage. Finally, virtuall y all cytotoxic drug'
produce severe nausea and vomiting, which has been called the
'inbuilt deterrent' to patient compliance in completing a cour.e
of treatment with these agents (see p. 732). Some compounds h3\c
particular toxic effects that are specific for them. These 1\dl
be dealt with when we come to discuss individual drugs.
DRUGS USED IN CANCER
CHEMOTHERAPY
The main anticancer drugs can be divided into the follo11ing
general categories.
Cytotoxic drugs. The mechanis m of action of these drugs is
discussed more fully be low and summarised in Figure 51.3;
they inc lude:
p
-all.:ylaling agents and related compounds, which act by
Ill
forming covale nt bonds with DNA and thus impeding
replication
as
I:U
-antimetaboliles, which block or subvert one or more of the
metabolic pathways invo lved in DNA synthesis
- cylotO.\ic antibiotics, i.e. substances of microbial origin
that prevent mammalian cell division
-plant deri1atiles (vinca alkaloids, taxanes. campothecins)
-most of these specifically affect microtubule function
AI
and hence the formation of the mitotic spindle.
gn
su
Hormones. of which the most important are steroids. namel>
tm
glucocorticoids, oestrogens and androgens, as well as drug~
\\
that suppress hormone secretion or antagonise honnone action
r~
Miscellaneous agents lhat do not fit into the above categorie,
This group includes a number of recently developed drugs
designed to affect specific tumour-re lated targets.
al
The clinical use o f anticancer drugs is the province of th~
specialist oncologist, who selects treatment regimens appropriate 11
to the patient with the objective of curing, prolonging life or in
 CANCER CHEMOTHERAPY

n
0 PURINE SYNTHESIS PYRIMIDINE SYNTHESIS
h PENTOSTATIN
inhibits adenosine
deaminase
AIBONUCLEOTIDES
/ 5-FLUOAOUAACIL
inhibits DTMP synthesis

BLEOMYCINS
6-MEACAPTOPURINE
6-TIOGUANINE
l
DEOXYAIBONUCLEOTIDES
damage DNA and
prevent repa1r

ALKYLATING AGENTS,
inhibit nucleotide MITOMYCIN, CISPLATIN
n
interconversions

METHOTREXATE
l cross-link DNA

CAMPOTHECINS
DOXORUBICIN
inhibits DTMP synthesis ETOPOSIDE
AMSACRINE
DNA
CYTARABINE
inhibit topoisomerase II
inhibits DNA polymerase
inhibits RNA function 1-' -----... inhibit RNA synthesis

DACTINOMYCIN
CRISANTASPASE
intercalates in DNA
inhibits topoisomerase II
RNA
inhibits RNA synthesis
(transfer, messenger, nbosomal)
1\"C VINCA ALKALOIDS
ill
l
PROTEINS
TAXANES
inhibit function of
microtubules

_/
ENZVMES (etc.) MICROTUBULES

Fig. 5 1.3 Summary of the main sites of action of cytotoxic agents. For some groups of drugs, only one or two examples are
ng
given. DTMP, 2'-d eoxythymidylate. (Adapted from Calabresi P, Parks A E 1980 In: Gilman A G, Goodman L S, Gilman A (eds) The
pharmacological basis of therapeutics, 6th edn. Macmillan, New York.)

providing pal liative therapy. Such matters are not addressed here;
instead, we concentrate o n more phannacological matters suc h
a~ mechanisms o f actio n and the main unwanted effects of
commo nly u ~ed antic ancer agents.
the
ALKYLATING AGENTS AND RELATED
COMPOUNDS
s)
Alkylating agents and related compounds contain c he mical
groups that can fo rm covalent bond<; with particular nucleophilic
'ubstances in the cell. With a ll-.y lating agents themselves, the
~ ly
main l>tep is the formatio n of a carbonium ion-a carbon ato m
with only s ix electron~ in its outer shell. Such ions are highly
reactive and react in~tantancously with an electron donor such as
an amine, hydroxyl o r 1.ultnydry l group. Most of the cytotoxic
anticancer alkylating agents are bifunctional, i.e. they have two
alkylating gro ups (Fig. 5 1.4).
the The nitrogen at position 7 (N7) of guanine, being s trongly
riate nucleophilic, is probably the main molecular target for alkylation
1: or in DNA (Fig. 5 1.5), although N I and N3 of adenine and N3 of
cytosine may also be afrected. A bifunctional agent, being able to
react with two groups, can cause intra- or interchain cross-
linking (Fig. 5 I .4). This interferes not only with transcription but
also with replicatio n. which is probably the critical e ffect o f
anticancer a lky lating agents . Other effects of alkylation at
guanine N7 are excision of the guanine base with main chain
scission, or pairing of the alkylated guanine with thymine instead
of cytosine, and eventual !>ubstitution of the GC pair by an AT
pair. T he ir main impact is seen during re plication (S phase),
when some zones o f the DNA are unpaired and more susceptible
to a lky latio n. Thi~ re~ult~ in a block at G2 (see Fig. 5.3) and
sub!.cquent apoptotic cell death.
All alkylating agenL~ depress bone marrow function and cause
gas tro intestinal diMurbances. With prolonged use , two furthe r
unwanted effects occur: depressio n o f gametogenesis (parti cu-
larly in men), leading to sterility, and an increased risk of acute
non-lymphocytic leukaemia and other malignancies .
All-.ylating agents arc among the most commonly employed
of all anticancer drugs . A large number are ava ilable for usc
in cancer c hemotherapy (some doL.en are approved in the UK at 723
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER

/ CH2CH2CI
A- N _ _...::...;_ __.
\ CH2CH2CI
(1)

0
Bifunctional
alkylatlng agents
can cause ! N: ( :NH
lntrastrand linking
+
and cross-linking ~ N'l' NH2

DNA chain

/
A
I
N '-..
1
O~ICH CH
2 2
CH ;~
2
~ o NH
Fig. 51.4 The effects of bifunctional alkylating agents on
Loss of the second
Cl in a further set of
,~
-l.~A NH2
DNA. Note the cross-linking of two guanines. A, adenine; C, reactions gives a ~

cytosine; G, guanine; T, thymine. cross-link DNA chain

the time of writing). Only a few commonly used ones will be
dealt with here.
Nitrogen mustards
Nitrogen mustards are related to the 'mustard gas' used during
the First World War; their basic fonnu la (R-N-bis-(2-chloroethyl))
is shown in Figure 5 1.5. In the body, each 2-chloroethy l side-
chain undergoes an intramolecular cyclisation with the release
of a Cl . The highly reactive ethylene immonium derivati ve so
formed can interact with DNA (see Figs 5 1.4 and 51.5) and other
molecules.
Cyclophosphamide is probably the most commonly used
alkylating agent. It i!> inactive until metabolised in the liver by the
P450 mixed function oxidases (see Fig. 51.6 and Ch. 8). It has a
pronounced effect on lymphocytes and can also be used as an
immunosuppressant (sec Ch. 14). It is usually given orally or by
intravenous injection but may also be given intramuscularly.
Important toxic eiTccts are nausea and vomiting, bone marrow
depression and haemorrhagic cystitis. This last effect (which also
occurs with the related drug ifosfamide) is caused by the
metabolite acrolein and can be ameliorated by increasing fluid
intake and adminbtering compounds that are sultbydryl donors,
such as N -acetyl cyst eine or m esna (sodium-2-mercaptoethane
sulfonate). These agents interact specifically with acrolein,
forming a non-toxic compound. See also Chapters 8 and 53.
Estramustine is a combination of chlormethi ne (mustine)
with an oestrogen. It has both cytotoxic and hormonal action, and
is generally u!.cd for tJ1e treatment of prostate cancer. Other
724 nitrogen mustards used are m elphal an and chlorambucil.
Fig. 51 .5 A.n example of alkylation and cross-linking of
DNA by a nitrogen mustard. A bis(chloroethyQamine (1)
undergoes Intramolecular cyclisation, forming an unstable
ethylene 1mmonium cation (2) and releasing c1, the tertiary
amine being transformed to a quaternary ammonium
compound. The strained ring of the ethylene immonium
intermediate opens to form a reactive carbonium ion {in yellow
box) (3), which reacts immediately with N7 of guanine {in green
circle) to give 7-alkylguanine (bond shown in blue), the N7
being converted to a quaternary ammonium nitrogen. These
reactions can then be repeated with the other -CH2CH 2CI to
give a cross-link.
Nitrosoureas
Examples of the nitrosoureas are the chloroetbylnitrosourea'
lomustinc and carmustine. As they are lipid-soluble and cro,,
tl1e blood-brain barrier, they may be used against tumoun. of the
brain and meninges. However, most nitrosoureas have a se\en:
cumulative deprel>~ive effect on the bone marrow that start\ J.i
week after initiation of treatment.
Busulfan
Busulfan has a selective effect on the bone marrow. dcpre,,ing
the formation of granulocytes and platelets in low dosage and of
red cells in higher dosage. lt ha~ little or no effect on lymphoid
tissue or the gastrointeMinal tract. I t is used in chronic granulo-
cytic leukaemia.
Other alkylating agents
Other al kylating agents in clinical usc include thiotepa and
trcosulf'an.
 CANCER CHEMOTHERAPY

Fig. 5 1.6 The metabolism of

cyclophosphamide.
Cyclophosphamide is 1nactive
until metabolised in the liver by
P450 mixed function oxidases to Cyclophosphamide
(inactive)
4-hydroxycyclophosphamide, Hepatic cytochrome
which (reversibly) forms oxidase
aldophosphamide.
Aldophosphamide is conveyed to
4-Hydroxycyclophosphamide Aldophosphamide
other tissues, where it is
converted to phosphoramide
mustard, the actual cytotoxic Hepatic aldehyde \ Non-en;
oxidase R .zymatic
molecule, and acrolein, which is
responsible for unwanted effects.
The part of the 4-Ketocyclophosphamide Carboxyphosphamlde Acrolein + Phosphoramide
cyclophosphamide molecule that (inactive) (inactiv~
e(cytotoxic) mustard
gives rise to the active - (cytotoxic)
metabolites is shown in the blue
box. Mesna (sodium 2- CH2 Nl H2 / CH 2CH 2CI
mercaptoethane sulfonate)
Mesna II
CH O= P- N
interacts with acrolein, forming a
non-toxic compound. t HO 6H "'CH2CH2CI

Anticancer drugs: alkylatlng agents and Platinum compounds

related compounds
Alkylating agents have groups that form covalent
bonds w1th cell subst1tuents; a carbonium ion is the
reactive intermediate. Most have two alkylating
groups and can cross-link two nucleophilic sites such
as the N7 of guanine in DNA. Cross-linking can cause
defective replication through pairing of alkylguanine
and thymine, leading to substitution of AT for GC, or
it can cause excision of guanine and chain breakage.
Their principal effect occurs during DNA synthesis
and the resulting damage triggers apoptosis.
Unwanted effects include myelosuppression, sterility
and risk of non-lymphocytic leukaemia.
The main alkylating agents are:
nitrogen mustards, for example
cyclophosphamide, which is activated to give
aldophosphamide, then converted to
phosphoramide mustard (the cytotoxic molecule)
and acrolein (which causes bladder damage that
can be ameliorated by mesna).
Cyclophosphamide myelosuppression affects
I particularly the lymphocytes.
nitrosoureas , for example lomustine, may act on
non-dividmg cells, can cross the blood-brain barrier,
and cause delayed, cumulative myelotoxicity.
f Cisplatin causes intrastrand linking in DNA. It has low
myelotoxicity but causes severe nausea and
vomiting, and can be nephrotoxic. It has
revolutionised the treatment of germ cell tumours.
Cisplatin is a water-soluble planar coordination complex con-
taining a cemral platinum atom surrounded by two chlorine
atoms and two ammonia groups. Its action is analogous to that
of the alkylating agents. When it enters the cell. Cr dissociates.
leaving a reactive complex that reacts with water and then
interacts with DNA. It causes intrastrand cross-Linking, probably
between N7 and 06 of adjacent guanine molecules, which results
in local denaturntion of DNA.
Cisplatin has revolutionised the treatment of solid tumours
of the testes and ovary. Therapeutically, it is given by slow
intravenous injection or infusion. ll is seriously nephrotoxic, and
strict regimens of hydration and diuresis must be instituted. It
has low myelotoxicity but causes very severe nausea and
vomiting. The 5-11T 3 receptor antagonists (e.g. ondansctron;
see Chs 12 and 25) are very effective in preventing this and
have transformed ci!.platin-based chemotherapy. Tinnitus and
hearing loi>s in the high-frequency range may occur. as may
peripheral neuropathies. hyperuricaemia and anaphylactic
reactions.
Carboplatin i~ a derivative of cisplatin. Because it causes less
nephrotoxicity. neurotoxicity, ototoxicity, nausea and vomiting
than ci~platin (although it is more myelotoxic). it is sometimes
given on an outpatiem basis. Oxaliplatin is another platinum-
containing compound with a restricted application.
Dacarbaz:ine
Oacarbazine, a prodrug, is activated in the liver, and the resulting
compound is subsequently cleaved in the target cell to release an
all-ylating derivative. Unwanted effects include myelotoxicity
and severe nausea and vomiting. Temozolimide is a related com-
pound with a rc~tri cted usage (malignant glioma). 72 5
 DRUGS USED IN THE TREATMENT OF IN FECTIONS AND CANCER
ANTIMETABOLITES
Folate antagonists
The main folate antagonist is methotrexate, o ne of the most
widely u!>Cd antimetabolites in cancer chemotherapy. Folates are
essential for the l>ynthelli'> of purine nucleotides and thymidylate,
which in tum are essential for DNA synthesis and cell division.
(This topic is al. o dealt with in Chs 22, 45 and 49.) The main
action of the folate antagonists is to interfere with thymidylate
synthcsi~.
In structure. folatel> con!>ist of three e lements: a pteridine ring,
p-aminoben:.oic acid and glufllmic acid (Fig. 51.7). Folates are
actively taken up into cells, where they are converted to
polyglutamatcs. In order to act as coenzymes, folates must be
reduced to tetrahydrofolate (FH4 ). This two-step reaction is
catalysed by dihydrofolale reductase, which converts the
substrate first to dihydrofolatc (FH 2 ). then to FH4 (Fig. 5 I .8). FH 4
functions as an essential cofactor carrying the methyl groups
necessary for the transformation of 2'-deoxyuridylate (DUMP) to
the 2'-deoxythymidylate (DTMP) required for the synthesis of
DNA and purines. During the formation of DTMP from DUMP,
FH4 is converted back to FJJ 2 enabling the cycle to repeat.
Methotrexate has a higher affinity than FH 2 for dihydrofolate
reductase and thu!> inhibits the e nzyme (Fig. 5 1.8). depleting
intracellular FH.s. The binding of methotrexate to dihydrofolate
reductase ill\Oive-. an additional bond not present when FH 2
binds. The reaction most sensitive to FH4 depletion is DTMP
formation.
Methotrexate is usuaJiy given o rally but can also be given
intramuscularly. intravenously or intrathecaiJy. The drug has low
lipid solubility and thus docs not readily cross the blood-brain
barrier. It is. however. actively taken up into cells by the folate
transport system and is metabolised to polyglutamate derivatives,
which arc retained in the cell for weeks (or even months in
some cases) in the absence of extracellular dmg. Resistance to
methotrexate may develop in tumour cells by a variety of
mechanis ms (sec below, p. 731).
Unwanted effects inc lude depression of the bone marrow
and damage to the epithe lium of the gastrointestinal tract.
r
, --- Pteridine ring -- -, , -- p-Aminobenzoic --, ---- Glutamyl residues-----
:
I
Fig. 51.7 Structure of folic
acid and methotrexate. Both
compounds are shown as Folic acid
polyglutamates. In tetrahydrofolate,
one-carbon groups (A, in orange
box) are transported on N5 or N1 0
or both (shown dotted; See
Figs 22.2 and 22.3.) The points at
726 l which methotrexate differs from
endogenous folic acid are shown
in the blue boxes.
------------------------
Pneumonitis can occur. In addition, when high-dose regimen~
arc used, there may be nephrotoxicity caused by precipitation
of the dmg or a metabolite in the renal tubules. High-do~
regimens (doses I 0 times greater than the standard dose~
sometimes used in patients with methotrexate resistance, mu~t be
followed by rescue' with folinic acid (a form of FH~)-
Pyrimidine analogues
Fluorouracil, an analogue of uracil, also interferes with DT\fP
synthesis (Fig. 5 1.8). ft is converted into a 'fraudulent' nucleotide.
jluorodeoxyuridine monophosphate (FDUMP). This interact'
with thymidylate synthetase but cannot be converted into
DTMP. The result is tnhibition of DNA but not RNA or protein
synthesis. Raltitrexed also inhibits thymidylate synthetase and
pcmctrexcd , thymidylate transferase.
Fluorourac il is usually given parenterally. The main tmwamed
e.fj"ects arc gastrointestinal epithelial damage and myelotoxicity.
Cerebellar dislllrbances can also occur. Another drug,
capecitabine. is metabo lised to fluorouracil.
Cytarabine (cytosine arabinoside) is an analogue of the
naturally OCCUlTing nucleoside 2'-deoxycytidine. The drug enters
the target cell and undergoe& the same phosphorylation reaction'
as the endogenous nucleoside to give cytosine arabino.1idt
trisplwsplwte, which inhibits DNA polymerase (see Fig. 51.91.
The main unwanted effects arc on the bone marrow and the
gastrointestinal tract. It a l ~o causes nausea and vomiting.
Gemcitabinc, a relatively new analogue of cytarabine, ha,
fe\I.Cr unwanted action~. mai nly an influenza-like syndrome and
mild myelotoxicity. It is often given in combination with Olher
dmgs suc h as cisplatin.
Purine analogues
The main anticancer purine analogues include flodarabi ne.
pentos tatin, cladribine, mercaptopurine and tioguanine.
Fludarabine is me tabolised to the trisphosphate and inhibit>
DNA synthesis by actions similar to those of cytarabine. It i>
myclosuppressive. Penloslatin has a different mechanism of
action. It inhibits adenosine deaminase, the enzyme that
trans fo rms adenosine to inosine. This action interferes with
!
I
acid (PABA) f
I
:
I
 CANCER CHEMOTHERAPY

critical pathways in purine metabolism and can have significant

effects on cell proliferation. Cladribine, mercaptopurine and
tioguanine are used mainly in the treatment of leukaemia.

F(glu)11
FH 4 (glu)11 +
one-carbon unit
DTMP
Fig. 51.8 Simplified diagram of action of methotrexate
and fluorouracil on thymidylate synthesis. Tetrahydrofolate
polyglutamate FH 4 (glu)n functions as a carrier of a one-carbon
unit, providing the methyl group necessary for the conversion
of 2'-deoxyuridylate (DUMP) to 2'-deoxythymidylate (DTMP) by
thymidylate synthetase. This one-carbon transfer results in the
oxidation of FH4 (glu)n to FH 2 (glu)n Fluorouracil is converted to
FDUMP, which inhibits thymidylate synthetase. DHFR,
dihydrofolate reductase.
_ _ _ _ _ _ _)
CYTOTOXIC ANTIBIOTICS
This is a widely used group of drugs that mainly produce their
elfeclS through direct action on DNA ru a rule. they should not
be given together with radiotherapy. as the cumulative burden of
toxicity is very high.
The anthracyclines
The main anticancer anthracycline antibiotic is doxorubicin.
Other related compounds include idarubi cin, daunorubi cin,
cpirubicin, aclarubicin, and mitoxantrone (miLOzantrone).
DUMP Doxorubicin has several cy totox ic actions. It binds to DNA
and inhibits both DNA and RNA syntl1esis, but its main cytotoxic
action appears to be mediated through an effect on topoisomerase
n (a DNA gyrase; see Ch. 45), the activity of which is markedly
increased in proliferating cells. The significance of the enzyme
lies in the fact that, during replication of tlle DNA helix.
reversible !>wivelling needs to take place around tlle repljcation
fork in order to prevent tllc daughter D A molecule becoming
inextricably entangled during mitotic segregation. The swivel'
is produced by topoisomerase U. whjch nic~ botll DNA strands
and subsequently reseals the breaks. Doxorubicin intercalmes in
the D A, and its effect is. in essence. to stabilise the
DNA-topoisomcrasc JJ complex after the strands have been nicked.
tllus halting the process at this point.

Incoming
deoxyribonucleoside ..... _!Sr-
trisphosphate ~~\ Anticancer drugs: antlmetabolltes
....'i' _.- c
/
/'

S - P- S - /'
/'
Antimetabolites block or subvert pathways of
I I DNA synthesis.
G A Folate antagonists. Methotrexate inhibits
Ill II dihydrofolate reductase, preventing generation of
C T G A T
I I I I I Template tetrahydrofolate interfering with thymidylate synthesis.
- S - P - S - P - S ~ P - S - P - S - I Methotrexate is taken up into cells by the folate
__ ,
I
carrier and, like folate, is converted to the
polyglutamate form. Normal cells affected by high
doses can be 'rescued' by folinic acid. Unwanted
effects are myelosuppression and possible
nephrotoxicity.
Pyrimidine analogues. Fluorouracil is converted to a
S - P- S ' fraudulent' nucleotide and inhibits thymidylate
I I synthesis. Cytarabine in its trisphosphate form
G A C inhibits DNA polymerase. They are potent
Ill II Ill myelosuppressives.
C T G A
I I I I Purine analogues. Mercaptopurine is converted into
- S - P- S - P- S - P- S --- fraudulent nucleotide. Fludarabine in its trisphosphate
form inhibits DNA polymerase and is
Fig. 51.9 The mechanism of action of cytarabine
myelosuppressive. Pentostatin inhibits adenosine
(cytosine arabinoside). For details of DNA polymerase action,
see Figure 45.8. Cytarabine is an analogue of cytosine. deaminase-a critical pathway in purine metabolism.
\_
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
Doxorubicin is given by intravenous infusion. Extravasation
at the injection site can cause local necrosis. In addition to
the general unwanted effects (p. 722), the drug can cause
cumulative, dose-related cardiac damage. leading to dysrhythmias
and heart failure. Thi'> action may be the result of generation of
free radicals. M arked hair loss frequently occurs.
Dactinomycin
Dactinomycin intercalates in the minor groove of DNA between
adjacent guanosine-cytosine pairs, interfering with the movement
of RNA polymerase along the gene and thus preventing
rranscription. There is also evidence that it has a similar action
to that of the anthracyclines on topoisomerase II. It produces
most of the toxic effects outlined above, except cardiotoxicity. It
is mainly used for treating paediatric cancers.
Bleomycins
The bleomycins are a group of metaJ-cbclating glycopeptide
antibiotics that degrade preformed D NA, causing chain
fragmentation and relea~e of free bases. This action is thought to
involve chelation of ferrous iron and interaction with oxygen,
re!.ulting in the oxidation of the iron and generation of
superoxide and/or hydroxyl radicals. Bleomycin is most
effective in the G 2 phase of the cell cycle and mitosis, but it is
also active against non-dividing cells (i.e. cells in the G0 phase;
Fig. 5.4). It is often used to treat germline cancer. Tn contrast to
most anticancer drugs. bleomycin causes little myelosuppression:
its most serious toxic effect is pulmonary fibrosis, which occurs
in I O'fl: of patients treated and is reported to be fatal in I lk.
Allergic reaction~ can also occur. About half the patients
manife!>l mucocutaneou~ reactions (the palms are frequently
affected), and many develop hyperpyrexia.
Mitomycin
Following enzymic activation. mitomycin functions as a
bifunctional alkylating agent, binding preferentially at 06 of the
guanine nucleus. It cross-links DNA and may also degrade DNA
through the generation of free radicals. lt causes marked delayed
myelosuppression and can also cause kidney damage and fibrosis
of lung tissue.
Procarbazine
Procarbazine inhibits DNA and RNA synthesis and interferes
wi th mitosis at interphase. Its effects may be mediated by the
production of acti"e metabolites. lt is given orally, and its main
use is in Hodgkin's disease. It causes disulfiram-like actions with
alcohol (sec Ch. 52), exacerbates the effects of central nervous
system depressants and, because it is a weak monoamine oxidase
inhibitor, can produce hypertension if given with certain
sympathomimetic agents (sec Ch. 39). It causes the usual
unwanted effects (p. 722), thus it can be leukaemogenic,
carcinogenic and teratogenic. Allergic skin reactions may
necessitate cessation of treatment.
Hydroxycarbamide
H ydroxycarbamide (hydroxyurea) i s a urea analogue that
728 inhibits ribonucleotide reductase, thus interfering with the
conversion of ribonuclcotides to deoxyribonucleotide~. It 11
mainly used to treat leukaemia but has the familiar spectrum of
unwanted effects (p. 722), bone marrow depression being
significant. c.~
of1
PLANT DERIVATIVES
Several naturally occurring substance exert potent C}10to\i,
effects and have earned a place in the arsenal of anticancer drug'
on that basis.
VINCA ALKALOIDS
The vinca alkaloids are derived from the Madagascar periwinkle.
The principal member!> of the group are vincr istine, vinblastine
and vindesine. Vinorel bine is a semisynthetic vinca alkaloid
with similar properties that is mainly used in breast cancer. The
drugs bind to tubulin and inhibit its polymeri sation into
microrubules, preventing ~pindle fonnalioo in dividing celts and
causing arrest at metaphase. Their effects become manife~t onl)
during mitosic;. They also inhibit other cellular acti vities that '11
involve the microtubules, such as leucocyte phagocytosis and
chemotaxis, as well as axonal transport in neurons.
The vinca alkaloids are relatively non-toxic. Vincristine ha' c
very mild myelo!.uppres!.ive activity but causes paracsthe,tal bu
(senc;ory changes). abdominal pain and muscle weakness fairl) 01
frequently. Vinblastine is less neurotoxic but causes leucopenia.
while vindesine has both moderate myelotoxiciry and neuro-
H
toxicity. All membe~ of the group can cause reversible alopecta.
r
Taxanes
Paclitaxel and docetaxel are derived from a naturally occurring
"re
compound found in the bark of the yew tree. They act on h
microtubulcs, stabilising them (in effect 'freezing' them) in the a
01
ca
p
Anticancer drugs: cytotoxic antibiotics
Doxorubicin inhibits DNA and RNA synthesis;
the DNA effect is mainly through interference with
topoisomerase II action. Unwanted effects include
nausea, vomiting, myelosuppression and hair loss. It
is cardiotoxic in high doses.
Bleomycin causes fragmentation of DNA chains. It
acts on non-dividing cells. Unwanted effects include
fever, allergies, mucocutaneous reactions and
pulmonary fibrosis. There is virtually no
myelosuppression.
Dactinomycin intercalates in DNA, interfering with
RNA polymerase and inhibiting transcription. It also
interferes with the action of t opoisomerase II.
Unwanted effects include nausea, vomiting and
myelosuppression.
Mitomycin is activated to give an alkylating
metabolite.

polymerise<! ~tate, achieving a ~imi l ar effect to that of the vinca
alkaloids. Pacl itaxel is given by intravenous infusion and
docetaxel by mouth. Both have a place in the treatment of br~t
cancer, and paclitaxel, given with carboplatin. is the treatment
of choice for ovarian cancer.
Unll'allled effect\. which can lx: serious, include bone marrow
'uppression and cumulative neurotoxicity. Resistant fluid retention
(particularly oedema of the legs) can occur with docetaxel.
H) persensitivity to both compound!> is liable to occur and requires
pretreatment with corticoMeroids and antihistamines.
Etoposide
Etoposide is derived from mandrake root. Its mode of action is
not clearly known, but it may act by inhibiting mitochondrial
fu nction and nucleoside transport, as well as having an effect
on topoisome rase II similar to that seen with doxorub icin
(see above). Unwanted effects include nausea and vomiting,
myclo!>uppres!>ion and hair loss.
Campothecins
The campothecins ir inotecan and to potecan. isolated from the
stem of the tree Campwtheca acuminata, bind to and inhibit
toJX>isomerasc 1, high levels of which occur throughout the cell
C)cle. Diarrhoea and reversible bone marrow depression occur
but. in general, these alkaloids have fewer unwanted effects than
most other anticancer agents.
HORMONES
Tumours derived from hormone-sensitive tissues may be
honnone-dependent, an effect related to the presence of teroid
receptors in the malignant cells. Their growth can be inhibited by
hormones with opposing actions. by hormone antagonists or by
agents that inhibit the endogenous hormone synthesis. Hormones
or their analogues that have inhibitory actions on target tissues
can be used in treatme nt of tumours of those tissues. Such
procedures alo ne ra rely effect a c ure but do mitigate the
symptoms of the cancer and thus play an important part in the
clinical manageme nt of sex ho rmo ne-depe ndent tumours.
Anticancer drugs: plant derivatives
Vincristine inhibits mitosis at metaphase by
binding to tubulin. It is relatively non-toxic but can
cause unwanted neuromuscular effects.
Etoposide inh1b1ts DNA synthesis by an action on
topoisomerase II and also inhibits mitochondrial
function . Common unwanted effects include vomiting,
myelosuppression and alopecia.
Paclitaxe/ stabilises microtubules, inhibiting mitosis;
it is relatively toxic, and hypersensitivity reactions
occur.
lrinotecan inhibits topoisomerase I; it has relatively
few toxic effects.
CANCER CHEMOTHERAPY
Glucocorticoids
Glucocorticoids such ns prednisolone and dexamethasone
have marked inhibitory effects on lymphocyte proliferation
(see Chs 14 and 28) and are used in the treatmem of leukaemias
and lymphomas. Their ability to lower raised intracranial pressure.
and to mitigate c,ome of the side effects of anticancer drugs. make~
them useful as ~upponive therapy when treating other cancers. a!.
well a~ in palliative care.
Oestrogens
Diethyls tilbestrol and ethinylocstradiol are two oestrogcns
used clinically in the palliative treatment of androgen-dependent
pro~latic tumours. The latter compound has fewer side effecl~.
These LUmours are also treated with gonadotrophin-releasing
hormone analogues (see below).
Oestrogens can be used to recruit resting mammary cancer
ceiL (i.e. cells in comprutmcnt B: see above) into the proliferating
pool of cells (i.e. into compartment A). thus faci litating killing
by other, cytotoxic drugs.
Progestogens
Progestogens such as megestrol. no rehisterone and m edroxy-
progeste rone have been useful in endometrial neoplasms and
in renal tumour'>.
Gonadotrophin-releasing hormone analogues
As explained in Chapter 30, analogues of the gonadotrophin-
rclea!>ing hormones, such a!> goserelin, buserelin . leuprorelin
and tripto rclin, can. under certain circumstances. inhibit
gonadotrophin release. The!>C agents are therefore used to treat
advanced breast cancer in premenopausal women ru1d prostate
cancer. The transient surge of testosterone secretion that can
occur in patienl~ treated in this way for prostate cancer can be
prevented by an an tiandrogen s uch as cyp rote rone.
Analogues of somatostatin such as octreotide and lanreotide
(see p. 422) are used to relieve the symptoms of neuroendocrine
tumours, including hormone-secreting tumours of the gastroin-
testinal tract suc h as YlPomas. glucagonomas. carcinoid syndrome
and gastrinomas. These tumo urs express somatostatin receptors,
activation of which inhibits cell proliferation as well as hormone
secretion.
HORMONE ANTAGONISTS
In addition to the hormonel> themselves, hormone antagonist:.
can abo lx: effective in the treauuent of several types of
hormone-sensitive tumours.
Antioestrogens
An antioc trogen. ta moxifcn, is remarkably effective in some
cases of hormone-dependent breast cancer and may have a role
in preventing these cancers. In breast tissue. tamoxifen competes
with endogenous oestrogens for the oestrogen receptors and
therefore inhibit~ the tnmscription of oestrogen-responsive genes.
Tamoxifcn is ai<;O reported to have cardioprotective effect~. partly
by virtue of its ability to protect low-density lipoproteins against
oxidative damage. 729
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
Unwanted effect)> are ~imilar to thol>e experienced by women
following the menopause. Potentially more serious are hyper-
plac,tic event\ in the endometrium, which may progress to
malignant changel>. and the ril>k of thromboembolism.
Other oestrogen receptor antagonists include toremifene and
fulvestrant. Aromata'e inhibitofl> ~uch as anastrozole. letrozole
and exemcstanc, which l>Uppress the synthesis of oestrogen from
androgens. are al<.o effective in the treatment of breast cancer.
Aminoglutcthim idc. which blocks the generation of all steroids,
has been largely replaced by the aromatase inhibitors.
Antiandrogens
The androgen antagonists, fl utamide, cyproterone and bicalu-
tmnidc, may be used either alone or in combination with other
agents to treat tumours of the prostate. They are also used to
control the 'flare' that i~ seen when treati ng patients with
gonadorelin analogues (sec above).
Adre nal hormone synthesis inhibitors
Several agents that inhibit synthesis of adrenal hormones have
effect~ in postmenopausal breast cancer. Tbe drugs used are
trilostanc and (rarely today) aminoglutethimide (see Fig. 28.5),
which inhibit the early \tages of sex hormone synthesis. Replace-
ment of corticosteroids is necessary with these latter two agents.
RADIOACTIVE ISOTOPES
Radioacti\e i\otopcs have an important place in the therapy of
certain tumours; for example, r.ulioaetive iodine ( 131 1) is used in
treating thyroid tumours (discussed in Ch. 29).
MISCELLANEOUS AGENTS
Crisantaspase
Crisantaspase is a preparation of the en~yme asparaginase,
given intramuscularly or intravenously. It breaks down
asparagine to aspa11ic acid and ammonia, and i.s active against
tumour cells, such as those of acute lymphoblastic leukaemia,
that have lost the capacity to 1.ynthesise asparagine and therefore
require an exogenous source. As most normal body cells are able
Anticancer agents: hormones and
radioactive Isotopes
Hormones or their antagonists are used in hormone-
sensitive tumours:
glucocortlcoids for leukaemias and lymphomas
tamoxifen for breast tumours
gonadotrophin-releasing hormone analogues for
prostate and breast tumours
antiandrogens for prostate cancer
inhibitors of sex hormone synthesis for
postmenopausal breast cancer.
Radioactive iostopes can be targeted at specific
tissues, for example 131 1 for thyroid tumours.
730
to synthe),i.,e ac,paragine. the drug has a fairly selective action and re
has very little suppressive effect on the bone marrow. the muC\N
of the gastrointestinal tract or hair follicles. It may cause nau-.ca 0\j
and vomiting, central nervous system depression, anaph}latuc E:
reaction\ and liver damage. eli
tr
Amsacrine
Amsacrine has a mechanism of action similar to that ol
doxorubicin (p. 727). Bone marrow depression and card1ac
toxicity have been reported. lr.
H
Monoclonal antibodies in
Monoclonal antibodies are immunoglobulins, of one molecular p~
typc, 2 produced by hybridoma cells in culture, that react wnh r.~
defined target proteins expressed on cancer cells. Some are pi
luonanised, meaning that they are hybrids or chimerae of human Ul
antibodies with a murine or primate backbone (and hence are le" It
likely to he immunogenic in their own right: sec Ch. 55 for more
details). ln some ca\eS, binding of the antibody to its target activate'
the host's immune mechanisms and the cancer cell il> killed b)
complement-mediated ly~is (see p. 204) or by killer cells ('ee
p. 21 0). Other monoclonal antibodies attach to and inactivate
growth factor receptors on cancer cells, thus inhibiting the
survival pathway and promoting apoptosis (Fig. 5.5). :II
Two monoclonal antibodies are currently in clinical u'o(: I
rituximab and trast uzum ab . d
Rituximob
d
Rituximah i~ a monoclonal antibody that is licensed (In
combination with other chcmothempeulic agents) for treatm~nt
of certain types of lymphoma. lt lyses B lymphocytes by binding
a
to the calcium channel-forming CD20 protein and acti\atmg
complement. It abo sensiti&es resistant cells (sec below) to other
(a
chemotherapeutic drugs. lt is effective in 40--50% of cases when
t~
combined with standard chemotherapy.
II
The drug is given by infusion, and its plasma half- life i'
(;
npproximatcly 3 days when first given, increasing with each
administration to about 8 days by the fourth administration.
it
Umvall/ed e.U'ecls include hypotension. chiJJs and fever during
the initial infusions and subsequent hypersensitivity reaction'
A cywkine relea~e reaction can occur and has been fatal. The
drug may cxacerhate cardiovascular disorders.
Alem tuzumab is another monoclonal antibody that lyses B 1
lymphocytes, and is used in the treatment of resi~tant chrome il
lymphocytic leukaemia. It may also cause a similar C}tokine
rcleal.c reaction to that with rituximab. A
I
Trostuzumob
1
Trastuzumab (Herceplin) is a humanised murine monoclon31
~
antibody that bind'> to a protein termed HER2 (the human
epidermal growth factor receptor 2). a member of the \\ider
family of rcceptOfl> with integral tyrosine kinase activity (Fig. 51.1)
There b 1.omc evidence that. in addition to inducing host immune
1
As oppo:.cd 10 the 'pol yclon~ t nntibodies generally produced by the body
in rc>ponsc to a foreign antigen, which comprise a complex (and variable)
mixture of molecular -.pecics.

responses. trastuzumab induces cell cycle inhibitors p21 and p27
CFig. 5.2). Tumour cell~. in about 25% of breast cancer patients.
o'erexpress this receptor and the cancer proliferates rapidly.
Early results show that tra-;tuzumab given with standard
chemotherapy has re. ulted in a 79% !-year survival rate in
treatment-naive patients '' ith thi~ aggressive fom1 of breast
cancer. The drug is often given with a taxane such as docetaxel.
Unwamed effects are !>imilar to thol>e with rituximab.
lmatinib mesylate
Hailed as a conceptual breakthrough in targeted chemotherapy,
imatinib mesylate is a '>mall-molecule inhibitor of signalling
pathway kina~es. It not only inhibits platelet-derived growth
factor (a receptor tyro~ine kinase; Fig. 51.1 ), but also a cyto-
plasmic kinase (Bcr/Abl kinase, see Fig. 51. 1) considered to be a
unique factor in the pathogl!nesis of cl1ronic myeloid leukaemia.
ll is licensed for the treatment of this tumour when this has
proved to be resistant to o ther therapeutic strategies, as well
as for the treatment of some gastrointestinal tumours not
~usceptible to surgery.
The drug is given orally. Absorption is almost complete, but
plasma protein binding is high (95%). The half-life is long, about
18 hours, and the main '>itc of metabolism is in the liver. where
approximately 75o/c of the drug is converted to a metabolite that
., also biologically active. The bulk (81 %) of the metabolised
drug is excreted i'> the faccel>.
Unll'amed effects include gastrointel>tinal symptoms (pain,
diarrhoea. nau!>ea), fatigue. hcadachel> and l.ometimes rashes.
Biological response modifiers
Agents that enhance the host's response are referred to as
biological response modifiers. Some, for example inte rferon-a:
(and its pcgylatcd derivative). are used in treating some solid
!Umours and lymphoma!., and a ldesleukin (recombinant
interleukin-2) is used in some cases of renal tumours. Tretinoin
(a form of vitamin A) is a powerful inducer of differentiation in
leukaemic cells and is used as an adjunct to chemotherapy to
induce remission.
RESISTANCE TO ANTICANCER DRUGS
The resistance that neopla~tic cells manifest to cytotoxic drugs
1s said to be primary (present when the drug is first given)
or acquired (developing during treatment with the drug).
Acquired rc~istancc may result from either adaptation of the
tumour cells or mutation, with the emergence of cells that are
lm susceptible or resistant to the dmg and consequently have
a selective advantage over the sensitive cells. The following
are examples of variou mechanisms of resistance.
Decreased accumulation of cvrotoxic drugs in cells as a
result of the increased expression of cel l surface, energy-
dependent drug transport proteins. These are responsible for
multidrug re~i~tance to many structurally dissimilar
anticancer drugs (e.g. doxorubicin, vinblastine and
dactinomycin; see Gottesman e t al., 2002). An important
member of this group is P-~-:lycop!Vtein (PGP/MDR I). The
CANCER CHEMOTHERAPY
Anticancer drugs: miscellaneous agents
Procarbazine inhibits DNA and RNA synthesis
and interferes with mitos1s.
Crisantaspase is active against acute lymphoblastic
leukaemia cells, which cannot synthesise asparagine.
Hydroxycarbamide (hydroxyurea) inhibits
ribonucleotide reductase.
Amsacrine acts on topoisomerase II.
Mitoxantrone (mitozantrone) causes DNA chain
breakage.
Trilostane inhibits adrenocortical steroid synthesis.
Monoclonal antibodies: rituximab and alemtuzumab
lyse B lymphocytes and are used for B-cell
lymphomas. Trastuzumab targets epidermal growth
factor receptor and is used for breast cancer.
lmatinib inhibits tyrosine kinase signalling pathways
and is used for chronic myeloid leukaemia.
physiological role of ?-glycoprotein is thought to be the
protection of cells against environmental toxins. Jl functions
as a hydrophobic 'vacuum cleaner', picking up foreign
chemicals, such as drugs. as they enter the cell membrane
and expelling them. Non-cytotoxic agents that reverse
multidrug rec;istance arc being investigated as potential
adjuvants to treatment.
A decrease in the amount of drug taken up by the cell (e.g. in
the case of methotrexate).
lnsufficiem activation of the drug (e.g. mercaptopurine,
fluorouracil and cytarabine). Some drugs require metabolic
activation to manifest their antitumour activity. Tf this fails,
they may be unable to block the metabolic pathways required
to exert their effects. For example, lluorouracil may not be
converted to FDUMP, cytarabine may not undergo
phosphorylation, and me rcaptopurine may not be converted
into a fraudulent nucleotide.
Increase in inactivation (e.g. cytarabine and mercaptopurine).
Increased concentration of target enzyme (methotrexate).
Decreased requirement for substrate (crisantaspase).
Increased utilisation of alternative metabolic pathways
(antimetabol ites).
Rapid repair of drug-induced lesions (alkylating agents).
Altered activity <if target. for example modified
topoisomerase II (doxorubicin).
Mutations in various gcnel>, giving rise to resistant target
molecules. For example. the p53 gene and overexpression of
the Bc/-2 gene family (several cytotoxic drugs).
TREATMENT SCHEDULES
Treatment with combinations of several anticancer agents
increases the cytotoxicity against cancer cells without
necessarily increasing the general toxicity. For example,
methotrexate, with mainly myelosuppressive toxicity, may be 731
 SECTION 5 DRUGS USED IN THE TREATMENT OF INFECTIONS AND CANCER
u~ed in a regimen wi th vincmtme, which has mainly
neurotoxicity. The few drugs we possess with low myclotoxicity,
suc h as cisplatin and bleomycin, are good candidates for
combination regime ns. Treatment with combinations of drugs
also decreases the possibility of the development of resistance
to individual agents. Drugs are often given in large doses
intermittently in several courses, with intervals of 2 3 weeks
between courses, rather than in small doses continuously,
because this pennits the bone marrow to regenerate during
the intervals. Furthermore, it has been shown that the same
total dose of an agent is more effective when given in o ne or
two large doses than in multiple s mall doses.
The possible clinical applications of drug
action during the cell cycle
Cells that arc constantly replicating constitute the 'growth
fraction' of the tumour. Anticancer drugs may be classified in
terms of their actions at particular phases on the cell cycle,
as shown below, and it has been proposed that this information
could be of value in selecting individual agents or combinations
for clinical use. However. not all authorities agree that treatment
schedules based on the~e principles are better than purely
empirical schedules.
Phase-specific agents. Ma ny cytotoxic drugs act at different
points in the cycle. For example, the vinca alkaloids act in
mitosis, whereas cytarabine. hydroxycarbarnide, fluorouracil,
methotrexate and mercaptopurine act inS phase. Some of
these compounds also have some action during G 1 phase and
thus may slow the entry of a cell into S phase. where it
would be more susceptible to the drug.
Cycle-specific agents. These act at all stages of the cell cycle
but do not have much effect on cells o ut of cycle (e.g.
alkylating agents. dactinomycin. doxorubicin and cisplatin).
Cycle non-specific agems. These act on cells whether in
cycle or not (e.g. bleomycin a nd nitrosoureas).
MYELOSUPPRESSION
Myelosuppression limits the use of many anticancer agen11
Regime ns contrived to surmount the problem have included
removal of some of the patient's own bone marrow prior tc
Al
treatment, purging it of cancer cells (using specific monocloo
antibodies; see below) and replacing it after cytotoxic !hemp) "
finished. A protocol in which aliquoLS of stem cells, harve,tt\1
from the blood following administration of the growth factor
molgramostim. are expanded in vitro using further haemopo1e11C
growth factors (Ch. 22) is now frequently used. The use of \U~n
growth facto rs after re placeme nt of the marrow has been
successful in some cases. A further possibility is the introduction.
into the extracted bone marrow. of the mutated gene that confer
multidrug resistance, so that when replaced. the marro\\ ceiJ,
(but not the cancer cells) will be resistant to the cytotoxic acuon
c~
of the anticancer drugs.
POSSIBLE FUTURE STRATEGIES FOR an
CANCER CHEMOTHERAPY Ill
As the reader will have judged by now, our current approach to
cancer chemotherapy embraces an eclectic mixture of drugs and
techniques, all designed to target selectively cancer cells. Real
therapeutic progress has been achieved, although 'cancer' a' d
disease (actually many different diseases with a imilar outcome)
has not been defeated and remains a massive challenge for futun:
generations of researchers. In this therapeutic area. probably
more than in any other, the debate about the risk-benefit of
treatment and the patient quality of life issues has taken cen~rr
p
stage and remains a major area of concern. Many advanced
M
cancers (such as me tastasised lung cancer) re main essentiall)
Ill
incurable, and there is a common perception that chemotherapy.
h.,
with its distressing unwanted effect'> and minor increases u
in
longevity, is largely superfluous in such cases. This is n01
Ill