General Pharmacology

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By Duy Thai, 1997 Pharmacology Semester 1 page 1 of 3
ADRENERGIC PHARMACOLOGY I
• When adrenaline is injected into a person we see 2 things happening:

• A rise in blood pressure (and maybe a small drop in blood pressure)
• A rise in heart rate
• Adrenaline causes these effects by acting on 2 different receptors - one on the peripheral blood vessels and one on
the heart.
• The peripheral receptor is the α receptor and causes vessel constriction
• There is also a β receptor which adrenaline can act on to cause a small degree of vessel dilation,
but the α effect predominates.
• The heart receptor is β1 and causes increased force and rate of contraction.
• When ergot alkaloids (α antagonists) are given in conjunction with adrenaline, we see a fall in blood pressure but
the heart rate remains increased.
• The ergot alkaloids inhibit the α receptor
• Hence, adrenaline cannot act on the α receptors in the vessels and so acts on the β receptors, which causes
vasodilation and a drop in blood pressure.
• Noradrenaline causes:
• A rise in blood pressure with no drop afterwards
• A rise in heart rate
• Noradrenaline presumably works on the same receptors as adrenaline described above, but noradrenaline does not
act on the β receptor in the vessels (and so does not cause vasodilation)
• When ergot alkaloids are added, we still see a rise in heart rate, but the blood pressure does not rise or fall
(noradrenaline has no effect on the vessels since the α receptors are blocked and noradrenaline cannot work on the
β receptors.
Noradrenergic neurons
• Tissues that receive sympathetic nerves have lots of noradrenalin associated with them.
• A typical noradrenergic neuron has its cell body in the sympathetic trunk and a long axon, ending with branching
networks containing swellings (varicosities) where the noradrenalin is concentrated.
• The criteria for chemical transmission are:
1. The chemical neurotransmitter must be synthesised by the nerve
2. The neurotransmitter must be stored in the nerve
3. Upon excitation, the neurotransmitter must be released from the nerve.
4. The neurotransmitter must act on specific receptors on the target tissue which leads to a response.
5. The neurotransmitter must have some way of being inactivated (either by reuptake or metabolism).
Synthesis of noradrenaline
• L tyrosine, an essential amino acid is the initial precursor.
L tyrosine
Tyrosine hydroxylase
L dihydroxyphenylalanine (L DOPA)
DOPA decarboxylase
Dopamine
Dopamine β hydroxylase
Noradrenaline
• Dopaminergic nerves use the same synthetic pathway, but they lack the enzymes that further degrade dopamine
(e.g. dopamine B hydroxylase). Hence dopamine is the final synthetic product.
• In the adrenal medulla, the chromaffin cells have an enzyme which can convert noradrenaline into adrenaline.
• This enzyme is phenylethanolamine N methyltransferase (PNMT)
Drugs affecting synthesis

• The targets of drugs affecting the synthesis of noradrenaline are the enzymes.
• Tyrosine hydroxylase
• No therapeutic drugs work here although it may be possible to develop drugs which are structural
analogues of L tyrosine.
• This enzyme is the rate limiting step in the synthesis of catecholamines (therefore it would be nice to have
a drug which inhibits it)
• It is a cytoplasmic enzyme
• DOPA decarboxylase
• The proper name for this is L aromatic aminoacid decarboxylase
• Is also involved in the synthesis of serotonin
• The drugs affecting this enzyme are:
• L DOPA
• Used in the treatment of Parkinsons
• It is not metabolised in the gut
• It can pass through the blood brain barrier
• It is the natural substrate for this enzyme
• carbidopa
• Often given in conjunction with L DOPA
• Does not cross the blood brain barrier so it inhibits DOPA decarboxylase in the
peripheral nerves. By doing this, it prevents peripheral side effects of L DOPA.
• We want L DOPA to act in the CNS, and so we inhibit its effects in the periphery by
giving it in conjunction with carbidopa.
• α methyl DOPA
• Is a synthetic substrate for DOPA decarboxylase.
• Its product is α methyl noradrenaline
• a methyl noradrenaline is a weak agonist of the alpha receptors and so acts as a partial
antagonist of noradrenaline (it prevents noradrenaline from acting on the α receptors
and giving a full response)
• It is often used as an anti hypertensive
• (α2 selective, therefore inhibits NA release)
• Dopamine B hydroxylase
• Present in the vesicle
• Released in conjunction with NA
Storage
• Vesicles contain:
• Noradrenaline
• Dopamine B hydroxylase
• Chromogranins
• Proteins that give the black staining appearance of the granules
• May act as binding proteins for the NA to prevent NA leaking out of the vesicle.
• ATP
• Provides the energy to maintain the high concentrations of NA in the vesicle
• The ration of NA:ATP is 1:4. This may indicate that ATP is involved in the binding of NA and
preventing its loss.
• There are other, larger more dense vesicles which contain cotransmitters (neurotransmitters released in conjunction
with noradrenaline).
• ATP and neuropeptide Y
• Released in conjunction with noradrenaline but acts on different receptors.
• Drugs affecting storage:
• Reserpine
• Depletes NA stores by interfering with the uptake of NA into the vesicles and may also disrupt
the integrity of the membrane so that NA can leak out.
• Leads to decreased blood pressure, depression and impotence.
• The decrease in blood pressure is due to the reduction in NA released.
• Depression is due to the effects reserpine has on the reduced uptake of serotonin in
vesicles.
• Impotence is also due to reduced NA release.
• Ejaculation is caused by and α constriction in the genitalia.
Release
• Noradrenaline can be released via 2 mechanisms
• Exocytotic
• An action potential arrives at the axon terminal and causes an influx of Ca ions. Ca2+ causes the
exocytosis of the vesicle.
• Non exocytotic
• Ca2+ independent
• Via Indirectly Acting Sympathomimetic Amines (IASA)
• Tyramine
• Ephedrine
• Phenylpropanolamine
• Amphetamine
• IASAs displace the NA from the vesicle quickly, so that NA is not deactivated and can be
released from the nerve directly. Hence, IASAs deplete stores but can cause an effect, unlike
reserpine which depletes stores but noradrenaline is inactivated when it leaks out of the vesicle.
ADRENERGIC PHARMACOLOGY II
Release processes
1. Exocytotic
• Triggered by an action potential
• The action potential opens up a Ca2+ channel, causing an influx of Ca2+ into the nerve terminal which is
required for release of the vesicle containing the neurotransmitter.
• Recall that the vesicle contains other chemicals apart from NA. These are:
• Dopamine β hydroxylase
• ATP and NPY
• Chromogranins
• Drugs which can act to inhibit this process are:
• Local anaesthetics which block the Na+ channels, preventing the propagation of an action
potential
• Ca2+ channel antagonists, which block the opening of the Ca2+ channel
• The problem with these drugs is that they are not selective, they block neurotransmission is all
nerves, not just adrenergic nerves.
• An example of a drug which is specific for adrenergic nerves (adrenergic neuron blocking drugs) is
guanethidine.
• Guanethidine is used as an anti-hypertensive drug since it prevents the release of NA
• It works by the following mechanisms
• They selectively accumulate into sympathetic nerves
• They are inhibited by ISA’s
• As well as inhibiting the release of NA, they also prevent the release of ATP and NPY,
which means they must act on the vesicle as a whole.
• They may limit Ca2+ entry into the nerve following depolarisation.
• As with reserpine, can have side effects such as depression and impotence.
2. Non exocytotic
• Drug induced release of stored noradrenaline
• The drugs belong to a class known as Indirectly acting sympathomimetic amines (ISA)
A. Tyramine
• Tyramine is a natural product, present in wines, cheeses, banana skins
• Tyramine can also be a substrate of dopamine β hydroxylase.
• The product of the reaction is octamine, which acts as a false transmitter
having no action
B. Ephedrine
• Found in decongestants
C. Amphetamine
• Commonly a drug of abuse
• ISA’s are able to release NA from the vesicle, but unlike reserpine, the NA is not broken down when it is
released. The drugs displace NA from the vesicles in high enough concentration so as to be able to elicit a
response.
• Reserpine acts by disrupting membrane integrity, causing NA to leak out, but when it does so, it
is inactivated.
Indirectly acting sympathmimetic amines

• Act by displacing noradrenaline from the vesicle
• The release of NA is no Ca2+ dependent
• The drugs enter the nerve terminal by an uptake mechanism
• Inside the nerve terminal, they may possible be substrates for enzymes which break down noradrenaline, which
explains the reason why when NA is displaced from the vesicle, it is not degraded.
Prejunctional modulation
• When noradrenaline is released into the synaptic space, it acts on α or β receptors located on the tissues.
• However, it may also act on a receptor which is located on the nerve terminal itself - an α2 receptor, which inhibits
the release of further NA (a classic negative feedback mechanism, very similar to the prejunctional modulation of
5HT) - Autoinhibition
• ATP and NPY can also act on this receptor to inhibit the release of NA
• Since lots of energy is required to synthesise and release NA, the nerve must have a mechanism to stop excessive
release of NA, and so it uses autoinhibition.
• Drugs which can exploit this are the α2 agonists, which depress the release of NA
• e.g. Clonidine
• There are other chemicals which can augment a NA response

• e.g. Constriction of a blood vessel
• Sympathetic activation releases NA from nerve terminals which act on α receptors on the blood
vessels to cause constriction
• Sympathetic activation of β receptors in the kidney also stimulates the release of renin, which
cleaves angiotensinogen to angiotensin which is converted to angiotensin II.
• Angiotensin II can also increase blood pressure by causing constriction of blood vessels
• In addition, prostaglandins may increase the release of NA from nerves, augmenting the direct
action of AII.
Inactivation of noradrenaline
• Inactivation can occur via 2 mechanisms:
• Uptake into the nerve terminal or tissues
• Metabolism
Neuronal (uptake 1)
NA
Extraneuronal (uptake 2)
• Uptake
• 95% of release NA is recycled
• The nerves have evolved a way of conserving energy by:
1. Modulating the release of NA during heavy use by autoinhibtion
2. Recycling NA
• The reuptake of NA is via a Na+ dependent facilitated diffusion
• Other substrates for the reuptake mechanism are;
• Adrenaline
• Adrenaline is the preferred substrate for extraneuronal uptake
• ISA’s
• Adrenergic neuron blocking drugs (AND)
• Apart from saving energy, reuptake maintains stores of NA so that there will always be sufficient levels to
cause a response under any circumstances. If there were no uptake mechanism, when all the NA was
depleted, we would have to wait a long time for it to be synthesised, stored and released again.
• Uptake blockers have been developed which prevent reuptake of NA.
• This causes NA to accumulate in the synaptic space and so the response you get is bigger and
lasts longer.
• Example of uptake blockers are;
• Desipramine
• Used to treat depression
• Depression is the result of low levels of amines (hence reserpine, and
guanethidine cause depression by lowering the amount of NA
released in the brain)
• Serotonin is also an amine and so it too can cause depression in low
levels (reserpine can act on serotonergic nerves as well)
• Amphetamines increase levels of serotonin, and can elevate mood.

• Prozac (fluoxetine) is a serotonin uptake inhibitor (much like
desipramine) and so prolongs the action of serotonin.
• Cocaine
• Local anaesthetic
• Extraneuronal uptake blockers are corticosteroids
• e.g. In asthma, which is an inflammatory disorder of the bronchi, it is better to treat the
inflammation causing the constriction of the airways, rather than just treating the
constriction.
• Corticosteroids are useful in asthma because they do 2 things:
1. They treat the inflammation
2. They block extraneuronal uptake, which is selective for adrenaline.
• Recall that adrenaline acts on β receptors on the bronchi (there is no
sympathetic innervation) to cause dilation
• Metabolism
MAO
NA
Catechol O methyl transferase
• The primary inactivation process is reuptake

• Metabolism is secondary to reuptake
• If breakdown of NA is inhibited, then NA can accumulate in the nerve terminal and some of it may leak
out into the synaptic space if the concentrations in the nerve terminal are too great.
• MAO inhibitors are used as antidepressants
• There are 2 forms of MAO - MAO A and MAO B
Substrates Inhibitor drug

MAO A/B Dopamine, tyramine Paragyline (irreversible)
MAO A NA, 5HT Moclobemide (reversible)
MAO B Selegiline
• Catechol O methyl transferase inhibitor drugs are not clinically important (pyrogallol)
• Paragyline:
• Is an irreversible inhibitor of MAO. Since it is irreversible, it takes time to replenish stores of
MAO.
• It is used to treat patients with depression
• It takes 4 - 6 weeks for NA levels to accumulate to sufficient concentrations in the nerve terminal
to be able to leak out and cause a response.
• MAO is also present in the GI flora.
• The GI MAO is important in breaking down natural products e.g. tyramine (remember
that tyramine is an ISA)
• If you inhibit the GI MAO by taking paragyline (irreversible inhibitor), and you go to a
party where there is lots of wine and cheese (foods rich in tyramine) then tyramine will
not be broken down and so will be absorbed.
• If tyramine gets to a sympathetic nerve terminal, it will cause displacement of NA and
result in a hypertensive crisis!
• Irreversible MAO inhibitors (moclobemide) is good because it allows competition with tyramine,
so that tyramine is able to be broken down in the gut if the concentrations are high enough to
displace moclobemide.
• The reason why NA and tyramine are not given as oral drugs is because they will be rapidly broken down in the gut
by GI MAO.
ADRENERGIC PHARMACOLOGY III
More on the metabolism of NA

• The enzymes MAO and COMT, although present at different locations (MAO is present in the nerve terminal on
the mitochondrial membrane, COMT is present in the target tissue), tend to work together.
COMT
Normetanephrine Noradrenaline
MAO MAO
Aldehyde Aldehyde
DOMA DOPEG
Diffuse out of nerve
terminal and act on
COMPT in external
VMA tissues MOPEG
(in periphery) (in CNS)
Urine
• NA is taken up by the nerve terminal and degraded by MAO into intermediates. The intermediates diffuse out of
the nerve terminal where they are taken up by the target tissue and further degraded by COMT.
• The products of COMT are VMA and MOPEG which are excreted in the urine.
• Alternatively, NA can be taken up by uptake 2 and metabolised by COMT directly. The product of this is
normetanephrine, which is broken down by MAO into aldehyde which gets converted to VMA and MOPEG.
• Note that uptake 2 mechanisms (tissue uptake) are more sensitive to adrenaline rather than adrenaline. That is why
uptake 2 blockers (corticosteroids) are useful in treating asthma. They block uptake 2 in the bronchi, allowing
adrenaline to have prolonged action, and so you get more bronchodilation.
• Uptake 1 blockers are desipramine and work mainly in the CNS.
Summary of drugs used to affect synthesis and degradation
Process Drug Drug action Clinical relevance

Synthesis L DOPA • Natural substrate of DOPA • Treat Parkinsons
decarboxylase, therefore
increasing the amount of NA
produced in the brain
Storage Reserpine • Disrupts vesicle membrane so NA • Treat hypertension. Has

leaks out and degraded, reducing side effects: depression,
NA stores impotence
Release:
Exocytosis Guanethidine • Specific for adrenergic neurons. • Hypertension. Side
Blocks Ca2+ mediated release of effects: depression,
NA impotence
• Displaces NA from the vesicle in • Increases blood pressure.
ISA Tyramine sufficient amounts to cause it to Present in foods and can
leak out of the nerve cause hypertensive crisis
if irreversible MAO
inhibitor used
Amphetamine • Same as above • CNS stimulant, keeping
people awake
(narcolepsy)
Inactivation:
Uptake Desipramine • Blocks uptake 1 mechanisms into • Antidepressant
the nerve, prolonging NA action
Corticosteroids • Blocks uptake 2 mechanisms into • Cause bronchodilation in
the tissues, prolonging adrenaline asthmatics
action
Metabolism Moclobemide • Reversible MAO inhibitor, which • Antidepressant
allows competition with tyramine
for MAO
Adrenoreceptors
• α effects tend to cause constriction, β effects tend to cause dilation or have specialised effects on special organs.
• α adrenoreceptors:
• Blood vessels Constricts
• GIT Constricts sphincters
• Pupil Constricts radial muscle (pupil dilation)
• β adrenoreceptors:
• Heart Increase heart rate and force
• Skeletal blood vessels Dilation
• Kidney Renin release
• Liver Glycogenolysis
• Bronchi Dilation (via adrenaline)
• Recall that NA and adrenaline have slightly different effects when injected:
• Noradrenaline
• Increases blood pressure (vasoconstricts)
• Increases heart rate
• Adrenaline
• Increases blood pressure (vasoconstricts) but also causes a slight fall in blood pressure
afterwards (vasodilate)
• Increases heart rate.
• This suggests that adrenaline and noradrenaline act on the same receptors in the heart but may act on different
receptors on the blood vessels.
• Adrenaline and noradrenaline have the same effect on β1 receptors of the heart
• Adrenaline and noradrenaline have the same effect on α1 receptors on blood vessels (constriction), but
adrenaline can also act on β2 receptors, causing vasodilation.
• The distribution of α and β receptors on different tissues can be illustrated using sympathomimetic agonists.
Blood pressure (α effect) Heart rate (β effect)
NA
Phenylephrine
Isoprenaline
Phenylephrine is an α agonist
Isoprenaline is a β agonist
Adrenoreceptor classification
• α receptors
• Present in smooth muscle which can be contracted
• Phenylephrine > NA ≥ Adrenaline >>> Isoprenaline
• β receptors
• Present in the heart
• Isoprenaline > Adrenaline ≥ NA >>> Phenylephrine
• Also present on smooth muscle which can be relaxed (e.g. bronchi, blood vessels to skin and muscle)
• Isoprenaline > Adrenaline >>> NA > Phenylephrine
• See how adrenaline has a much higher affinity for the β receptors in the smooth muscles which relax than
noradrenaline, while in the heart, adrenaline and noradrenaline have the same affinity for the β receptor. This has
led to the discovery of receptor subtypes:
• The β receptors on the heart are β1
• The βreceptors on the smooth muscles are β2
• Generally, it is better to classify receptors according to antagonists. Why?

• It is easier to measure the affinity of an antagonist (KB) than it is to measure the affinity of an agonist
(KA). All you need to do is construct a Schild plot.
• The different affinity of an antagonist to different tissues means that there may be different receptor
subtypes on the tissues.
Adrenoreceptor antagonists
Blood pressure (α effect) Heart rate (β effect)
Noradrenaline alone:
Noradrenaline + phentolamine:
Noradrenaline + Propranalol:
Phentolamine is an alpha antagonist

Propranalol is a beta antagonist
Subtypes of α and β receptors
β1 Heart Increase HR
Kidney Cause renin release
β2 Bronchial smooth muscle Relaxation
Vascular smooth muscle Relaxation
Uterine smooth muscle Relaxation
α1 Vascular smooth muscle Constriction
Radial muscle of pupil Constriction (pupil dilation)
Genitourinary muscles Impotence
α2 Nerves on vascular smooth muscle Inhibition of NA release
Vascular smooth muscle
• Recall that adrenaline is a better β2 agonist than noradrenaline!

• On β1, the two are the same.
• Most tissues have a mixture of the receptor subtypes.
α1 agonists
• Found on blood vessels, eye, genitourinary
• Phenylephrine Was the drug responsible for finding α1 receptor
Mydriatic (dilates the pupil for ophthalmic procedures).
Generally, cholinergic antagonists are better!
• Oxymetazoline Ocular decongestant
Increased blood flow to the eye leads to dilation of the vessel and buildup of fluid.
The alpha1 agonist causes constriction of the vessels.
• Methoxamine Nasal decongestant
Runny nose and excess mucous is due to excess blood flow.
• Direct decongestants vs indirect (ISAs)

• Direct decongestants have an advantage because they work quickly, are more specific, have no CNS
effect. However, they tend to overdo the vasoconstriction, and so when the effects wear off, there tends to
be a reactive hyperemia (rebound effect).
• ISAs (e.g. pseudoephedrine) may be better as decongestants because they have a slower onset, release a
natural product (NA) which can be removed naturally, at a slower rate, thus preventing the reactive
hyperemia.
• Why are there so many different drugs for different conditions, if they all have the same effect?
• Because, each drug has a different pharmacokinetic profile which makes it more suitable for some
conditions than others. e.g. Methoxamine would not be suitable as an ocular decongestant because it does
not cross the corneal membrane very well.
α2 agonists
• Found on nerves, blood vessels
• Clonidine
• Was the drug used to identify the α2 receptor
• Is used to treat hypertension by reducing the sympathetic outflow in the CNS (centers
controlling blood pressure).
• It is a partial agonist at α2 receptors, and so is weaker than NA at causing
vasoconstriction. Hence, it is acting as a partial antagonist as well, preventing NA
from exerting its full effects. Also, clonidine is a very effective α2 agonist on nerves
and so it acts to reduce NA release.
• α methyl DOPA
• Is a substrate for DOPA decarboxylase.
• Its product is α methyl NA, which acts as a false transmitter.
• It is a partial agonist at α1, β1 and β2 receptors. However, it is a very effective α2
agonist, and so prevents the release of NA.
• It is used as an antihypertensive.
α antagonists
• α1 and α2 adrenoreceptor antagonists
• Phentolamine
• Competetive
• Used to reverse hypertensive crisis due to tyramine
• Also used in peripheral vascular diseases (Reynaud phenomenon)
• Phenoxybenzamine
• Non competitive
• Used in phaeochromocytoma (in conjunction with β antatagonists)
• Selective α1 antagonist
• Prazosin
• Treat hypertension (its major use – very good at it!)
• Side effects:
• 1st dose effect (if an initial dose is too high, it is possible to get too much vasodilation
resulting in a hypotensive crisis)
• Postural hypotension (failure of the reflex vasoconstriction upon standing up)
• Nasal stuffiness
• Failure of ejaculation due to inhibition of α1 receptors in the vas (which constricts to
propel semen)
• Involuntary micturition
• Selective α2 antagonist
• Yohimbine
• No clinical uses
• Possible aphrodesiac?
Competitive
Non - Competitive
Response Response
• What are the benefits of an irreversible inhibitor like phenoxybenzamine?

• Sometimes irreversible inhibitors are beneficial. They cause a long term blockage which cannot be
overcome by increasing agonist concentration.
• e.g. Phenoxybenzamine can be used to treat phaeochromocytoma, which is a benign tumor of
the adrenal glands causing increased release of adrenaline. If a competitive antagonist were
used, the excess levels of adrenaline would overcome the inhibition. That is why an irreversible
antagonist is used. Furthermore, treatment of the condition is usually surgical removal. Removal
of the adrenal gland causes marked rises in adrenaline levels in the blood, which will not be able
to overcome the irreversible inhibition.
• Sometimes, irreversible antagonists are not beneficial, for example irreversible MAO inhibitors are not
good because ingested tyramine will not be able to compete with the antagonist for MAO and so it is
absorbed in the blood, and cause release of NA (it is an ISA), possibly resulting in hypertensive crisis.
ADRENERGIC PHARMACOLOGY IV
β agonists
• Both β1 and β2
• Isoprenaline
• Was the initial drug which helped identify the β receptor from the α receptor
• Not used clinically since it is not selective for β1 or β2
• Since it is a catechol, it is readily metabolised by COMT in the tissues and gut and
therefore cannot be taken orally (it is taken sublingually)
• Is was once used as an antiasthmatic but is now superseded by salbutamol since it can also
affect the heart (increasing HR)
• Selective β1 agonist (β1 found in heart and kidney)
• Dobutamide
• Is a very weak agonist
• Because of its weak action, it is good for use in people with heart failure (since we want a
mild stimulation of the heart)
• Selective β2 agonist (β2 found in bronchi, uterus, skeletal blood vessels, liver)
• Salbutamol
• Main use is in the treatment of asthma as a bronchodilator.
• It is given as an aerosol so as to have local effects. However, some of it may be absorbed in
the pulmonary capillaries, and so enter the systemic circulation.
• Some side effects are:
• Skeletal muscle tremor
• This is because the β2 receptors increase cAMP levels in skeletal muscle
cells, increasing Ca2+ which causes tremor
• Reduction in K+
• Cardiac effects (mild palpitations)
• Recall that the heart has predominantly β1 receptors. However, they may
constitute only 60 to 80%. 20 to 40% of the remaining receptors are
others (like β2).
• Also, salbutamol is selective for β2 receptors only at a certain
concentration range. At higher concentrations, salbutamol no longer
becomes selective for β2 receptors.
• Another use of salbutamol, when given intravenously, is to prevent premature labour by
relaxing the pregnant uterus.
β Antagonists
• Both β1 and β2 antagonists (non selective)
• Propranalol
• Membrane stabilising (anaesthetic effect)
• The membrane stabilising effect only occurs at concentrations above therapeutic
levels
• Mainly used to treat arrythmias, angina (reduce the O2 demand by decreasing the work of
the heart), hypertension, anxiety (which is due to increased heart rate and palpitations),
glaucoma, phaeochromocytoma (used in conjunction with PBZ to block all adrenoreceptors,
α and β)
• Heaps of side effects limits its therapeutic use:
• Bronchoconstrictor (inhibiting β2 effect)
• Cardiac failure (too much cardiac depression)
• Cold extremities (preventing vasodilation)
• Hypoglycaemia (inhibiting glycogenolysis and gluconeogenesis)
• Fatigue (due to the hypoglycaemia)
• Vivid dreams (due to the lipid solubility of the drug - able to cross blood brain
barrier)
• Oxprenalol
• ISA, membrane stabilising
• Pindolol Both are partial agonists
• ISA
• Timolol
• Given locally as drops. Used as the β antagonist of choice for glaucoma since it is a pure
antagonist (small dose is required for its effect in the eye compared to systemic side effect)
• The eye is a small space and so it is good because only small doses are required.
• It does not have membrane stabilising effects like the other β antagonists
• Glaucoma is due to an increased intraocular pressure as a result of increased aqueous
humor production. This production is cAMP mediated, and so β antagonists work to reduce
cAMP levels.
• Selective β1 antagonist
• Atenolol
• Cardioselective (depends on the concentration)
• Theoretically better
• Care is needed when used in asthmatics (we don’t want to block β2 bonchodilation) and
diabetics (β2 is important in controlling glucose metabolism)
• Selective β2 antagonist
• Butoxamine
• No clinical uses
• Mixed α and β adrenoreceptor antagonist
• Labetalol
• Reduces heart rate (β1 effect)
• Reduces TPR by preventing vasoconstriction (α1 effect) Ideal for hypertension
• Side effects:
• Postural hypotension (because the reflex vasoconstriction is prevented as blood
pools in the legs)
Adrenoreceptor classification
• Receptors were once classified by the development of selective therapeutic agents
• Via agonist structure-activity relationships
• Via antagonist selective inhibition and affinity
• Newer techniques to identify receptors and function are:
• Radioligand binding/autoradiography
• Cellular mechanisms
• Molecule biology and cloning of receptor genes
The new adrenoreceptor classification

• It is now considered that there are 3 main adrenoreceptor subtypes based on sequence, signalling pathway
and pharmacology.
α1 α2 β
Agonist Phenylephrine Clonidine Isoprenaline
Antagonist Prazosin Yohimbine Propranalol
• These subtypes are further divided into:

• α1A, α1B, α1D
• α2A, α2B, α2C
• β 1, β 2, β 3
• β3 receptors are found on adipocytes and are responsible for the lipolytic effects of NA
• Propranalol has a low affinity for this receptor
• There have been specific agonists and antagonists developed experimentally for this receptor (the
names are unimportant to remember)
• Drugs acting at this receptor may have a potential use at treating obesity
Molecular features of adrenoreceptors

• They are all 7 transmembrane, G protein coupled receptors
• The intracellular domain carboxyl tail determines whether the receptor is α or β
Coupling mechanisms
• All β receptors cause an increase in cAMP
• α1 receptors activate PI pathway to produce IP3 and DAG, thus causing the increased release of intracellular
Ca2+ stores (causing smooth muscle contraction)
• α2 receptors decrease cAMP levels (which thus prevents release of NA)
Therapeutic uses of endogenous catecholamines

• Noradrenaline
• Not used clinically
• Cannot be given orally since it will be metabolised by MAO in the gut
• Receptor selectivity:
α1 > α2 ≈ β1 >>> β2
• Adrenaline
• Receptor selectivity:
β1 ≈ β2 ≈ α1 > α2
• Is used as an emergency hormone, especially in anaphylactic shock

• Anaphylactic shock is characterised by:
• Difficulty in breathing (due to bronchoconstriction)
• Fall in blood pressure
• Adrenaline helps by:
• Promoting blood flow and heart rate (α1 vasoconstriction, β2 actions on the heart)
• Opening airways (β2 bronchodilation)
• Stimulate metabolism (β2 actions on the liver to stimulate gluconeogenesis and
glycogenolysis.
• Adrenaline is also added to local anaesthetic solutions to cause local vasoconstriction. This isolates
the local anaesthetic and prevents spread.
• Side effects:
• Arrythmias
ANTI-INFLAMMATORY DRUGS
Inhibition of eicosanoid synthesis

• Corticosteroids
• Also known as steroidal anti inflammatory drugs
• Inhibits arachidonic acid release and metabolism.
• Inhibits both the production of prostinoids and leukotrienes by inhibiting phospholipase A2
• More in the next lecture
• Non Steroidal Anti-inflammatory Drugs (NSAID)
• Inhibits cyclo-oxygenase (mainly COX1)
• Recall that COX1 is the constitutive enzyme which produces physiologically relevant prostaglandins. It
appears that we have inhibited the wrong COX - it would have been preferable to have inhibited COX2
which is activated under pathological conditions.
• Since only COX is inhibited, synthesis of leukotrienes by lipoxygenase is unaffected. In fact, there may be
a slight increase in leukotriene synthesis because we have more arachidonic acid present (since it is not
being used up by COX).
Uses of NSAIDS
• Anti pyretic
• Reduce fever
• Anti inflammatory
• Analgesic
• Reduce pain
• Anti aggregatory
• Reduce platelet plug and clot formation
Examples of NSAIDs
COX inhibition Anti inflammatory activity

Aspirin 1 1
Indomethacin 100 20
Meclofenamate 200 20
(Paracetamol) 0 0
• Note that paracetamol does not have any direct anti inflammatory effect (since it does not inhibit COX). It is often
used in conjunction with aspirin and acts to reduce pain.
• Note that there is a direct correlation between the ability to inhibit COX and the anti inflammatory activity.
• Aspirin is relatively weak compared to the other two examples.
• However, the more potent a drug is, the better it is able to inhibit COX but the more adverse side effects
there are.
Mediators of inflammation
Dilation Vascular permeability Chemotaxis Pain

Histamine ++ ↑↑↑ - -
Serotonin +/- ↑ - -
Bradykinin +++ ↑ - +++
Prostinoids +++ ↑ +++ +
Leukotrienes - ↑↑↑ +++ -
• As you can see, inflammation is mediated by many chemicals, not just prostanoids. However, prostanoids are the
only chemicals involved in all the processes of inflammation. That is why NSAID use which targets prostanoids are
effective at reducing inflammation
• It is possible to achieve greater levels of anti-inflammation by affecting other mediators, not just postanoids.
Uses of NSAIDs
• Mild analgesic
• PGI2 and PGE2 are hyperalgesic, which means that they increase the sensitivity of pain receptors to painful
stimuli (mainly bradykinin)
• NSAIDs are mainly useful to mild or moderate pain which is associated with inflammation.
• Fever Neutrophil Cytokines
Inflammation activation stimulate
synthesis of
PGE2
cAMP
↑ temperature
• cAMP changes the body’s thermostat to a higher temperature (it changes the body’s thermoregulatory set
point.
• NSAIDs prevent the change in set point by reducing the amount of PGE2. An increase in body temperature
as a result of increased PGE2 only occurs in inflammatory states. If body temperature is elevated due to
exertion or the environment, then NSAIDs will be of no use.
• Anti inflammation
• Used mainly to reduce the inflammation associated with arthritis in joints.
Adverse effects
• Gastrointestinal
• Local irritation because NSAIDs are acidic in nature
• They also inhibit the mucosal synthesis of PGI2 and PGE2.
• These prostanoids promote blood flow to the gastrointestinal tract which aids in the production of
mucous to protect the mucosal lining.
• Thus NSAIDs decrease the defense mechanisms of the GIT
• If a normal dose of NSAIDs are taken, it is possible to detect a small amount of blood in the faces
• If a chronic user, there is prolonged damage to the GIT with more severe bleeding and ulceration
• Bleeding time
• A decrease in TxA2 synthesis will prevent platelet aggregation. NSAIDs also inhibit the production of
PGI2 which is produced by the endothelial cells to prevent platelet sticking. However, endothelial cells can
regenerate COX (which platelets cannot) so the inhibition of platelets is more prolonged.
• In coronary artery disease, this is useful as a prophylactic treatment but it can complicate GIT bleeding,
leading to severe hemorrhage and death.
• Renal
• NSAIDs may cause renal failure only if there is an underlying condition that results in underperfusion of
the kidney.
• These conditions may be
• Hypovolemia
• Heart failure leading to decreased cardiac output
• Renal disease (renal stenosis due to atherosclerosis
• Recall that prostaglandins increase the blood flow to the kidney (via vasodilation of the afferent arteriole)
when there is a decrease in renal blood flow. This ensures that there is adequate perfusion of the kidney’s
even under marked reduction in blood pressure.
• A reduction in prostaglandins will result in a reduced perfusion to the kidney’s under conditions
of underperfusion.
• Analgesic nephropathy
• Results from taking a combination of analgesics (e.g. aspirin with other NSAIDs) over a number
of years.
• Long term use can lead to irreversible cell death in the kidney (maybe due to ischaemia
• Pulmonary
• Bronchoconstrictor effect perhaps due to the increased production of leukotrienes
• Leukotriene C4, D4 and E4 are all potent bronchoconstrictors
• Different NSAIDs will result in a different affect on bronchoconstriction. E.g. If aspirin causes
bronchoconstriction, then you can switch to another NSAID which may not cause it.
Individual groups of NSAIDs

Salicylates
• Examples of drugs in this group:
• Aspirin
• Diflunisal (no advantages over aspirin, more expensive)
• Uses:
• Analgesic
• Antipyretic
• Antithrombotic (aspirin is the drug of choice for being an antithrombotic)
• Because aspirin has a lower potency than the other NSAIDs it is less likely to be used as an anti-inflammatant.
However, because it has a lower potency, there are less adverse effects.
• Adverse effects:
• The same as for all NSAIDs, but in addition you can have:
• Reyes syndrome
• An encephaly leading to coma in children using aspirin to treat fever in certain types of
infection.
• Some of these infections are chicken pox, measles and mumps
• Therefore, aspirin must not be given to children less than 14 years with these types of
infections and fever.
• Tinnitus
• Not severe but it is the first indication of an aspirin overdose
• Uric acid retention
• Aspirin competes for uric acid excretion in the kidney tubules. Hence, aspirin will result
in the retention of uric acid and only exacerbate the effects of gout.
• Therefore, aspirin must not be used to treat gout (other NSAIDs are fine).
• How aspirin can kill:
Noirmal therapeutic dose • Uncouple oxidative phosporylation

• Raises cellular respiration. Hence, increases CO2 production which causes
respiratory stimulation. The excess energy produced is dissipated as heat,
hence there is a slight increase in body temperature.
• Central respiratory stimulation
• Causes hyperventilation and respiratory alkalosis
• Respiratory alkalosis is compensated by an increase in HCO3 excretion
• Central respiratory depression

• Results in respiratory acidosis
• The acidosis is made worse by a metabolic acidosis due to:
• High doses of an acidic drug
• Uncoupling of oxidative phosphorylation leading to lactic acid
buildup
• Decreased renal perfusion (no PG’s) leading to failure to excrete
acid so acid accumulates in the blood.
Toxic dose
• Acid accumulates to levels which cause coma and death
• Pharmacokinetics of salicylates
• Since aspirin (and all other NSAIDs) are acidic drugs, they are well absorbed in the stomach (since at an
acidic pH, the drug will be unionised)
• The distribution of aspirin is predominantly in the plasma (Vd = 0.1ml/Kg), with 80-90% being bound to
plasma proteins.
• Aspirin undergoes saturation kinetics at high doseas, having a half life greater thsn 15 hours. At low
doses, the elimination of aspirin follows first order kinetics, with a half life of 4 hours.
• Slow to enter CNS
• To reduce the irritation aspirin has on the stomach, buffered preparations can be used (e.g. Asproclear)
• Aspirin is mixed with a buffer to make it soluble in a glass of water.
• This buffered solution of aspirin enters the stomach, lowers the acidity and reduces damage to the
stomach lining.
• When the aspirin is soluble, it is in an ionised form, and hence, less absorption will occur.
However, because it is already in solution, it can more easily contact the stomach lining and be
absorbed there so absorption is not really affected.
• An alternative to a buffered solution is o have an enteric coating. This coating can only dissolve in a basic
environment, and so will reduce the irritation in the stomach.
Propionic acids
• More potent than aspirin and hence better at inhibiting COX, but comes with more side effects.
• Examples include:
• Naproxen (naprogesic)
• Used to treat menstrual pain.
• In menstruation, there is a large release of prostaglandins which may be associated with the pain.
• Ibuprofen
• These drugs are now available over the counter.
• Uses:
• Antipyretic
• Analgesic
• Antiinflammatory
Acetic acids
• Indomethacin
• Sulindac
• These drugs are very effective
• They have a high potency
• Increase in adverse effects
• 40% of people experience GI problems
• These drugs are predominantly used as anti-inflammatants and not used as anti-pyretics or analgesics because the
risks of using the drugs for those minor conditions are too great.
• Can be given rectally to reduce gastric irritation.
• Other NSAIDs
• Metenamic acid
• Piroxicam
• Diclofenac
• Phenylbutazone
• Only used in severe situations for a short term only. Never used long term
Selective COX 2 inhibitors

• Meloxicam
• Inhibits COX2 100 times more effectively than COX1
• Less adverse effects?
• Reduces the prostaglandins produced in pathological situations
ARACHIDONIC ACID METABOLITES
• The 3 main groups of arachidonic acid metabolites are:

• Prostaglandins (PG)
• Leukotrienes (LT)
• Platelet activating factor (PAF)
• Arachidonic acid is one of 3 essential fatty acids
• An essential fatty acid is one that cannot be formed de novo. It must be obtained from the diet
• The essential fatty acids required by us are:
• Eicosatrienoic acid - 3
• Eicosatetranoic acid - 4
• Eicosapentanoic acid - 5
• Arachidonic acid is not a circulating compound, nor does it have any intrinsic biological activity.
• Arachidonic acid is incorporated into phospholipids which make up the membranes of all cells.
• Hence, arachidonic acid is present in all cells of the body
• The first step in the metabolism of arachidonic acid is the removal of it from the phospholipid.
• This step is done by phospholipase A2 or C.
• The following is the outcome of this first step:
Phospholipids
Phospholipase (A2 or C)
Arachidonic acid
Cyclo-oxygenase Lipoxygenase
Prostinoids Leukotrienes
Thromboxane Prostaglandins
The prostinoids
• The prostinoids are derived from arachidonic acid after the action of cyclo-oxygenase
• Intermediary prostaglandins, PGG2 and PGH2 are very short lasting and not biologically active.
• The intermediary PG’s give rise to the following:
• PGI2 (Prostacyclin)
• PPGF2α All these forms are biologically active, and
• PGD2 have wide ranging effects on different
• PGE2 tissues
• TxA2
• There is more than one form of cyclo-oxygenase (COX).
• COX 1
• This is a constitutive enzyme, meaning that it is always present and active
• It is found in most cells
• It is continuously forming prostaglandins in small amounts
• The prostaglandins it produces are physiologically important (important under normal
conditions)
• COX 2
• This enzyme is not normally active
• Its formation is induced by signals (mainly inflammatory)
• It produces very high levels of prostaglandins in a short amount of time (compared to COX 1
which produces small amounts over a prolonged time)
• The prostaglandins produced are only released during pathological conditions
Prostaglandin Stability (in vitro) Biological activity

PGG2, PGH2 Unstable None
PGE2, PGD2, PGF2α Stable ü
PGI2, TxA2 Unstable ü
• If the prostaglandin is considered stable, it means that it is enzymatically degraded.

• Because they are stable in vitro, it does not mean that they are long lasting in vivo.
• In a single passage through the lungs, 90% of these prostaglandins are degraded by enzymes in the lung.
• These prostaglandins thus will not be able to circulate through the body, they will tend to act locally.
• If the prostaglandin is considered unstable, then it spontaneously degrades
• These prostaglandins (PGI2 and TxA2) are not metabolised by enzymes in the lungs and so they have the
capability to circulated through the body. However, their half lives limit this.
• TxA2 has a half life of 30 sec.
• This means that when it is produced, it can only have time to act locally. It will not get the
chance to circulate.
• PGI2 has a half life of 3 min.
• It is relatively longer lasting, although its main effects would be local.
• It is possible to circulate for a while. Hence, an IV infusion of PGI2 can have wide ranging
systemic effects.
Pharmacological action of prostaglandins

• See table in notes for a quick glance summary
• Thromboxane A2 (TxA2)
• Released locally from activated platelets.
• Due to the short half life, it acts immediately at the site of release
• It is a potent vasoconstrictor (contracts vascular smooth muscle)
• It is also pro-aggregatory (it is released form platelets and promotes further aggregation of platelets)
• TxA2 spontaneously degrades into TxB2 which is an inactive metabolite.
• The action of TxA2 suggests that it attempts to reduce blood flow to a site of damage by vasoconstriction
and formation of a platelet plug.
• Prostacyclin (PGI2)
• Produced by the endothelium
• It is a potent vasodilator (relaxes vascular smooth muscle).
• It spontaneously degrades into 6 keto-PGF1α which is its inactive metabolite.
• It has anti-aggregatory effects on platelets.
Under normal conditions, the actions of TxA2 and PGI2

balance each other out.
When these are out of balance, then we see either a
vasodilation or vasoconstriction.
• The other prostaglandins have very little effect on the vascular smooth muscle. Only TxA2 and PGI2 are the major
vasoactive prostaglandins. The actions of the other prostaglandins affect smooth muscle in more local sites.
• Bronchial smooth muscle

• All prostaglandins cause bronchial relaxation.
• The exception is PGD2 which causes contraction of bronchial smooth muscle
• Leukotrienes have been implicated in the involvement of asthma by being broncho constrictors (more on
leukotrienes later)
• Uterine smooth muscle
• PGE2 and PGF2α cause contraction of the pregnant uterus. (In the non pregnant uterus, PGE2 may cause
relaxation).
• Gastrointestinal smooth muscle
• PGE2 and PGF2α cause the GIT to contract strongly. This can lead to side effects such as abdominal pains,
constipation when giving these prostaglandins therapeutically.
• PGE2 and PGI2 can inhibit gastric acid secretion
• More importantly, they can increase the flow of blood to the gastric lining (due to vasodilator
effect). Increased flow to the stomach enhances mucous secretion, which enhances the
cytoprotection of the gastric cells against the acid environment.
• Kidney arterioles
• Under normal physiological conditions, prostaglandins are of minimal importance.
• However, under conditions where blood flow to the kidney’s is compromised (e.g. When there is a reduced
cardiac output in heart failure, or renal stenosis), prostaglandins become important in causing vasodilation
of the arterioles, maintaining GFR and preventing ischaemia of renal tissue.
• Central nervous system
• PGE2 plays a part in the induction of fever, since when it acts on the hypothalamus, the body’s temperature
set point is altered.
• PGE2 and PGI2 are involved in the generation of pain. They are not algesic (they do not cause pain
directly) but are known as hyperalgesic. They increase the sensitivity of pain receptors to other chemicals
(e.g. bradykinin), thus producing the sensation of pain.
• Inflammation
• Prostaglandins (and leukotrienes) play an important part in all stages of the inflammatory reaction, from
the initial vasodilation, oedema and pain to the recruitment of other cells of the immune response.
Leukotrienes
• Formed by the action of lipoxygenase
Arachidonic acid
Lipoxygenase
LTC4 LTB4
LTD4
LTE4
• Leukotriene C4 is the more powerful form of leukotrienes. Leukotriene D4 and E4 have the same effects, only to a
smaller degree
• Role of leukotrienes:
• LTC4
• A vasoconstrictor
• It acts very well in the coronary circulation
• It can stimulate the release of prostaglandins which would cause vasodilation (negative feedback
effects)
• when it causes vasoconstriction, the spaces between the endothelial cells become wider, allowing
for an exudate to form, resulting in oedema.
• LTB4
• Does not affect smooth muscle in any way
• Is chemotactic for leukocytes and PMN’s, attracting them to the site of its release (usually at the
site of inflammation)
• It can also affect the activation of PMN’s
Why do eicosanoids have so many diverse actions?

• Eicosanoids is the general term for all arachidonic acid metabolites (prostinoids and leukotrienes).
• The reason why we see so many effects is because there are a large number of different receptor subtypes on
different tissues. The subtypes work by different 2nd messenger systems.
• If we know the 2nd messenger used, we can guess as to what function the eicosanoid has on the cell.
• e.g. PGI2 receptor (IP subtype) on vascular smooth muscle works via cAMP. cAMP reduces the availability
of Ca2+, thus causing relaxation.
• e.g. TxA2 receptor (TP subtype) works via an IP3/DAG 2nd messenger system, which causes the release of
stored Ca2+ from intracellular sources (e.g. SR), thus allowing contraction to occur.
• As yet, there are no drugs which have been developed to selectively target and inhibit these receptor subtypes. The
only drugs available are those that alter the function of the enzymes involved in the synthetic pathway of
prostaglandins.
Therapeutic uses of prostaglandins

• Since prostaglandin effects are wide ranging, we have to be able to limit the side effects by trying to give the PG as
close to the target site as possible. Remember that prostaglandins are also relatively short lasting.
• Prostaglandins can keep the ductus arteriosus open in newborn children who have a congenital abnormality of the
aorta (coarctaion). If the ductus arteriosus were to close in these babies, death would occur very quickly.
• PGE2 and PGF2α can be used to stimulate abortion.
• There are many side effects, e.g. cramps, diarrhea, incomplete abortion so surgery must still be performed
to remove residual tissue.
• If the foetus is near term, these prostaglandins are used to induce labour
• In cardiac surgery
• Blood going into the heart lung bypass tends to clot, because platelets become activated as a result of the
abnormal surface.
• If PGI2 is infused in the patient, the platelets will not aggregate because PGI2 is anti-aggregatory.
• After surgery, risk of bleeding is minimal because remember the relatively short half life of PGI2.
• However, the vasodilator effects of PGI2 may cause an unwanted drop in blood pressure which would
cause a reflex tachycardia, which is undesirable especially after cardiac surgery.
• Gastric ulceration
• Long term use of NSAIDs (e.g. aspirin) will cause reduced prostaglandin levels (since COX has been
inhibited).
• Recall that PG’s are required to maintain the viability of the gastric mucosal barrier.
• Impotence
• PGE1 analogue can be injected into the penis (a local injection) to cause vasodilation and increased flow to
the penis (thus causing an erection!).
• There is no systemic side effects due to the local administration
CHOLINERGIC PHARMACOLOGY I
• The major areas where Ach acts as a neurotransmitter are:

• In the presynaptic nerve fibres (both parasympathetic and sympathetic)
• In the postganlionic parasympathetic fibres
• In the postganlionic sympathetic fibres going to the sweat glands of the skin
• In the somatic fibres innervating skeletal muscle
Acetylcholine synthesis
• Very few drugs of therapeutic significance act to interfere with Ach synthesis
• Unlike NA, Ach synthesis is relatively easy
Choline acetyltransferase
Acetyl CoA + choline Coenzyme A + Ach
Obtained from the

Choline breakdown of Ach and also
from the diet (lecithin)
Choline acetytransferase CoA
Acetyl CoA Acetyl choline

ATP citrate ligase
Citrate
Acetyl CoA does not pass

Acetyl CoA through the mitochondrial
membrane, therefore, it is Vesicle storage
converted to citrate first
Ways to interfere with the synthesis

• Provide cofactor deficiencies
• Deficiencies in Fe, O2 and glucose (not a therapeutic possibility)
• Choline acetyltransferase inhibition
• 4 Napthylvinylpyridine (4 NVP)
• Not very effective at inhibiting synthesis because there are also stores of Ach.
• You need to inhibit the synthesis of Ach for a very long time and completely
reduce the stores of Ach. There is a very large safety factor - not much Ach is
required to get a response
• Choline uptake inhibition (active, carrier mediated transport process)
• Hemoccholinium 3 (HC3)
• Can get a slowly, progressive failure of transmission
• A cholinergic nerve which is simulated faster, will increase the loss from stores,
without replenishement
Storage of Ach
• Ach is stored in vesicles in the nerve terminal.
• The vescicle is 40 to 50nm in diameter.
• Unlike the storage vesicles of NA (which are dark due to the presence of chromogranins), the storage vesicles
of Ach are clear.
• The vesicles also contain ATP, and vesiculin (a specific protein - unkown function)
• The drug which blocks the storage of Ach is vesamicol
Exocytotic release
• Ca2+ dependent
• Drugs affecting the release:

• Drugs which increase Ach release (mainly venom toxins)
• β bungarotoxin
• Banded krait venom
• Redback spider venom
• These toxins cause a massive release of Ach which results in fasciculations of muscle
followed by paralysis as all of the Ach is drained from the nerve terminal
• Drugs which decrease Ach release
• Botulinum toxin
• Produced by the Clostridium botulinum
• This bacterium lives in unsterilised canned foods.
• It is very potent, only a few bacteria are needed to have heaps of poison present
• It acts solely on the release process.
• The toxin interacts irreversibly with the lipids inside the nerve terminal. This
explains why, once poisoned by the toxin, it takes months to receover (since lipids
have a slow turnover rate). The effects of the toxin can be attenuated by using
substances containing sialic acid residues (e.g. gangliosides)
• Surprisingly, there is a therapeutic use of this toxin (in small doses)
• When injected into muscles of the eye, it causes prolonged paralysis,
which can be used to treat squint. By the time the effects wear off (in
months) the condition would have corrected itself, preventing the need for
surgery.
Ach receptors
• Early evidence suggested the presence of 2 types of recepotors
• If Ach was given intravenously, you would get a fall in blood pressure
• If atropine was then given, you would get a rise in blood pressure.
• What atropine did was to block the M receptors (which was responsible for the
parasympathetic effects). By blocking the M receptors, it allowed unrestricted action of Ach
on the N receptors, which are present on the sympathetic ganglia.
• Nicotinic receptors are present in:
• All ganglia
• On skeletal muscle
• On the adrenal gland (a specialied ganglia)
• The nicotinic receptor is a ligand gated ion channel designed for very rapid (within millisec)
response times.
• Muscarinic receptors are found in:
• Parasympathetic postganglionic target tissues
• Sympathetic cholinergic target tissues
• The muscarinic receptor is a G protein coupled, 7 transmembrane
Muscarinic receptors
• 7 transmembrane spanning receptor
• Has an intracellular domain which is responsible for coupling with the G protein complex
• Has an extracellular ligand binding unit where Ach binds to
• The intracellular terminal carboxyl tail is responsible for controlling the sensitivity of the receptor. If it is
phosphorylated, then the receptor becomes desensitised.
• Evidence for subtypes:
• There are regional differences in the affinity of antagonists
• The affinity of antagonists can be measured by a Schild plot to find the value of KA.
• If we have exactly the same receptor, no matter where it is found, it will have the same
affinity for an antagonist. (Remember that affinity for a receptor is different to response.
You can have exactly the same receptor, with the same affinity but have a different
response due to different transduction mechanisms.
• The development of selective drugs
• Pirenepine is selective for M1 receptors which control gastric acid secretion
• Molecular biologists have isolated and cloned 5 different subtypes of M receptors
Molecular biology of M receptors

• 5 subtypes (of which the first 3 are important)
• All are 7 transmembrane, G protein coupled receptors (hence have an intermediate response time - seconds)
• There is clear homology (the are clearly related)
• There are specific areas of the receptor which are related to specific functions (structure function
relationship)
• Areas related to G protein coupling
• Areas regulating sensitivity
• Here goes! The receptor subtypes are:
• M1, M3, M5 (the odd receptors)
• Use Gq/G11 G proteins
• The G protein activates the phophoinositol pathway
• The active intermediate is IP3 which stimulates the release of Ca2+
• Closes K+ channel
• M2, M4 (the even receptors)
• Use Gi/Go
• This G protein inhibits adenylate cyclase, hence reducing the levels of cAMP
• The M1 receptor is found in the stomach, controlling gastric acid secretion

• The M3 receptor is found on the endothelium of blood vessels and in the gut (causing increased gut motility)
and exocrine glands.
• The M2 receptor is found predominantly in the heart
• slows the HR
• opens K+ channels
• reduces Ca2+ conductance
The only important, therapeutical muscarinic antagonist is pirenzepine (M1 blocker)
• From all these effects, I make the conclusion that M1 and M3 receptors are the “activator” receptors -
causing acid release and intestinal motility. M2 receptors are the “slowing down” receptors, causing reduced
heart activity.
Structure activity relationships at muscarinic receptors

• Acetylcholine requires the following to be active:
• A quaternary N to form a cationic head
• If the N+ is replaced by a non charged C, then it is inactive
• The size of the cationic head is important:
• If the methyl (-CH3) groups are replaced by ethyl (-CH2CH3) groups, then the following
happens:
• One ethyl substitution (monoethyl substitution) has no effect, the compound
behaves similar to Ach
• Diethyl substitution markedly reduces the activity of the compound at the M
receptor
• Triethyl substitution results in no activity at the M receptor
• The ester link (-CH2 - O - C) has a role in regulating the activity and selective
• If the -O- is replaced with a -CH2- then the selectivity of the compound to M receptors is
reduced (the compound becomes more nicotinic selective)
• If the position of the -O- is changed, then there is not much difference in activity. The
distance is thus more important
• The alkylamine chain regulates the selectivity
• If a methyl group is placed on the β carbon, the compound becomes β methyl choline and is
M selective
• If a methyl group is placed on the α carbon, the compound is α methyl choline and is N
selective.
• The acetyl group is important in the activity of the compound.
• If you lack the acetyl group and only have the choline present, then you will have the same
pharmacological action as Ach, only with 1/1000 of the activity. (That means for every one
molecule of Ach, you need 1000 molecules of choline to get the same effect)
• The -CH3 tail of the acetyl group is important to determine whether the compound can be degraded
by acetylcholinesterase (ACE). If the -CH3 is replaced by a NH2, then the compound will no longer
be a substrate for ACE.
• The design of specific agonists makes use of the previous key structural requirements.
• Bethanechol has the following structual modifications:
• It has a β methyl substitution
• The -CH3 tail of the acetyl group is replaced by a -NH2
• Therefore, bethanechol is a muscarinic selective agonist which has a long lasting activity
(since it is not degraded by ACE)
CHOLINERGIC PHARMACOLOGY II
• Location of muscarinic receptors:
• On tissues innervated by postganglionic parasympathetic nerve fibres:
• Heart
• GIT smooth muscle
• Bronchi
• Eye
• Glands
• On tissues innervated by postganglionic cholinergic sympathetic nerve fibres:
• Sweat glands on the skin
Muscarinic effects on tissues
Organ Effect M receptor

Heart Bradycardia M2 (decrease in cAMP)
Blood vessels Vasodilation M3 (increase IP3 à Ca2+)
Lung Constriction M3
GIT Constriction M3
Glands Secretion M3
Stomach Acid secretion M1
Eye Pupil constriction M3
(constrict circular muscle)
• All the effects on smooth muscle are mediated by M3 receptors which act to increase the levels of intracellular Ca
via IP3. This generally causes constriction.
• The exception is in the blood vessels. Why?
• The blood vessels are lined by a layer of endothelium, with the smooth muscle located
underneath. When an agonist binds to the M3 receptor on the endothelial cells, it stimulates the
release of NO by these cells. NO diffuses down to the smooth muscle cells where it causes
relaxation of the smooth muscle, and hence vasodilation. If the endothelium were removed,
agonists acting directly on the smooth muscle M3 receptor would cause vasoconstriction.
• Hence, the vasodilation is a result of the indirect action of an M3 agonist.
• Note that blood vessels do not receive parasympathetic innervation and so vasodilation caused
by muscarnic receptors only occurs as a result of circulating muscarinic agonists. (Not due to
Ach released from nerve terminals)
Examples of muscarinic agonists

• Naturally occurring
• Anecholine (found in beetle nut)
• Pilocarpine (M agonist used in eye drops)
• Muscarine (found in mushroom, used experimentally)
• McNA343 (experimental, only selective M1 drug)
• Oxotremorine (centrally acting)
• Synthetic:
• Methacholine
• Similar in structure to Ach but with a methyl substitution, thus making it M selective.
• Acts on the heart, blood vessels
• Bethanechol
• Resistance to cholinesterase action, therefore has a longer life.
• Acts in the GIT
• Furthrethonium
• Acts in the bladder
Therapeutic uses of M agonists

• Not many uses, M antagonists are better.
1. Atrial tachycardia
• M agonists slow the heart, but have other effects since they are not M2 selective. It would be nice to have
a M2 selective agonist.
2. Reynauds disease (peripheral vasoconstriction)
• M agonists will cause vasodilation (M3 à NO à smooth muscle).
• Other effects as well sue to non specificity.
3. Paralytic ileus
• One of the good, effective uses of M agonists
• After an abdominal operation, the natural rhythms of the gut do not restart.
• Bethanechol is given to activate M3 receptors to cause gut motility.
4. Glaucoma
• Increase in intraocular pressure
• Give pilocarpine as eye drops which improves drainage of ocular fluid in the canal of Schlemm. It is
given because it gets across the membrane barrier of the eye more easily.
• Pilocarpine causes pupil constriction, which opens the canal of Schlemm. (pupil dilation blocks the canal
of Schelmm)
• Ach cannot be given because:
• It is too highly charged to pass through the membrane easily
• It is rapidly degraded
5. Alzheimers disease
• Found to have a development of cholinergic deficits.
• Oxotremorine has been developed as a M agonist which is able to pass through the blood brain barrier
and act centrally. It is not available for clinical use yet.
Muscarinic antagonists
• The prototype compound is atropine
• Others:
• Scopolamine
• Able to pass through BBB
• Homatropine
• Much shorter action than atropine
• It is the drug of choice when doing investigations of the eye, since it dilates the pupil for a short
time only.
*** IMPORTANT CONCEPT!

• A quaternary derivative of atropine can be produced by placing an extra methyl group on the N atom. A
quaternary N is produced which is now positively charged. This derivative is atropine metanitrate.
• It has the same effect as atropine, but acts locally because it cannot be absorbed.
• If given locally, it is not absorbed by the gut and so its activity is confined to the gut.
• It is often used as an antispasmodic to treat babies with colic.
• If injected, the effects will be purely confined to the periphery (No CNS effects)
• The concept is: if a quaternary derivative is produced, it will be poorly absorbed.
Subtype selective M antagonists

Pirenzepine M1
Methoctramine M2 Not important
HHSiD M3
Effects of blocking M receptors
Organ Effect M receptor

Heart Tachycardia M2
Blood vessels Vasodilation M3
Lung Dilation M3
GIT Relaxation M3
Glands Decrease secretions M3
Stomach Decrease acid M1
Eye Dilate pupil M3
• An antagonist binds to the same site as an agonist but has no effect of its own. Therefore, to see the effects of an
agonist, you need to have the effects of the agonist present first.
• e.g. The hear has resting vagal tone. This means that at rest, the vagus nerve is controlling the heart via
Ach. If, while at rest, atropine is given, it will block the M2 receptor so that Ach cannot work and so you
get a faster heart rate than it was initially. (The atropine did not cause the tachycardia directly).
• Say that the resting heart has go no nervous input. If atropine is given, it will block the M2 receptor but
we would not see any effect because three was no agonist activity to start off with.
• Analogy:
• Say you are riding a bike and you put on the brakes (antagonist). The brakes will cause the bike
to stop, so you say that the antagonist stops the bike. However, you can only see this effect if the
bike is in motion. If the bike is not moving and you put on the brakes, what will hhappen? How
do you know what effect the brakes had on the bike?
• Blood vessels have no parasympathetic innervation from the adventitia, it is only sympathetic. Hence, the resting
tone of blood vessels is not mediated by Ach. If atropine is given, it will block the M3 receptor but will not remove
endogenous tone. A side effect of atropine is that it will stimulate the release of histamine, which causes
vasodilation.
Therapeutic uses of muscarinic antagonists

• There is a much wider range than for angonists
1. Premedication
• Atropine
• Given before operations to prevent unwanted M stimulation.
• Want to eliminate bronchial secretions (don't want the patient to choke on their own secretions)
• Want to block vagal stimulation to the heart and lungs (want to keep airways open)
• During induction of anesthesia, there may be excessive vagal stimulation, which we want to
eliminate.
2. Antispasmodic
• Hyoscine N butyl Bromide
• A quaternary derivative
• Treats colic
3. Bronchodilator (asthma)
• Ipratropium
• A quaternary derivative
• Given by inhalation, get a local effect
4. Treatment of peptic ulcers
• Pirenzepine
• Selective M1 antagonist
• Not as good as H2 antagonists (e.g. cimetidine) or proton pump inhibitors (e.g. omeprazole)
5. Anticholinesterase toxicity
• Anticholinesterases inhibit the activity of ACE, which breaks down acetylcholine. Hence, Ach activity is
prolonged (the action of Ach is potentiated every time it is released) which causes excessive stimulation of
both N and M receptors. It is the M receptors in the brain which cause the lethal effects. Excessive
stimulation of the brain M receptors results in respiratory depression.
• Atropine is used to treat this condition by blocking all M receptors.
6. Parkinson's disease
• Benztropine
7. Motion sickness
• Hyoscine
8. Eye examination
• Homatropine
• Favoured because it passes through the conjunctiva easily and has a brief duration of action.
Nicotinic receptors
• Found in 2 major areas:
1. In autonomic ganglia
2. At skeletal NMJ
• Both types of receptors are clearly related, but they are different enough to be recognised by different drugs.
• The receptors are part of an ion channel.
• The ion channel is made up of α, β, γ, δ subunits, which form a pore.
• The 2 α subunits are the nicotinic receptor portion of the channel which bind Ach.
• A whole variety of α, β, γ and δ subunits have been discovered. Therefore, there may be a whole variety of N
receptors based on different combinations of these subunits.
Nicotinic agonists
• None of therapeutic use
• Nicotine
• Stimulate particularly ganglionic N receptors (also NMJ to some extent)
• Lobeline
• Similar to nicotine.
• Given to smokers in an attempt to stop smoking (by replacing nicotine addiction with lobeline addiction)
• Dimethyl phenylpipenzinium (DMPP)
• Selective for ganglionic N receptors
Nicotinic antagonists at the ganglion

• Hexamethonium
• First effective antihypertensive (not used any more)
• By altering the central carbon chain from 6 carbons to 10 (decamethonium), it changes the drug from
being ganglionic selective to NMJ selective.
• Poorly absorbed due to the presence of 2 highly charged N atoms, hence it is administered intravenously.
• Lots of side effects since it blocks all ganglia. You effectively shut off the whole autonomic nervous
system.
• Can develop tolerance. After a few weeks, the drug becomes less effective.
• Trimethaphan Only marginal improvement - better absorbed than hexamethonium but has the same
• Mecamylamine side effects -
The hexamethonium man - what happens if no ANS?

• Pink Vasodilation
No α1 constriction
• Postural hypotension Loss of sympathetic tone (α1 constriction)
• Handshake warm and dry Vasodilation (warm)
No M3 secretion of sweat glands
• Relaxed No flight or fight response (lack of β1 effects- increase heart rate and α1 effects)
• Cant cry No M3 secretion of lacrimal glands
• Can't blush Loss of vasomotor control
• Dry mouth and throat Loss of M3 secretions of salivary glands
• Long sighted Can't adjust pupil (M3-constriction and α1-dilation effect)
• Blinded by bright light Cant constrict the pupil (M3 effect)
• Cold Loss of heat through continual vasodilation, can’t vasocontrict to
• Thin No β2 effects in liver (gluconeogenesis, glycogenolysis)
• No appetite pains No M3 GIT contractions
• Constipated
• Retention of urine No α1 contraction of ureter and bladder
• Impotent No α1 contraction of vas
CHOLINERGIC PHARMACOLOGY III
Metabolism of acetylcholine
• The major mechanism of NA inactivation is reuptake.
• For Ach, inactivation is via metabolism in the synaptic space.
• The enzymes responsible for Ach metabolism are generally called cholinesterases (ChE). There are 2 types:
1. Acetylcholinesterase (TRUE)
• Present in nerve synapses and NMJ.
• Also found in RBC
• The primary substrate is Ach.
• It can also metabolise acteyl beta methyl choline
2. Butyrylcholinesterase (PSEUDO)
• Present in the plasma and in lots of tissues
• Metbolises Ach and other drugs such as suxamethonium.
• Suxamethonium is not metabolised by true ChE. Hence, when it is around nerves
(which is where we want it to act) it is not broken down, but when it enters the plasma,
it is broken down.
Hydrolysis of Ach by ChE

• Step 1:
• The acetyl group of Ach acetylates a serine residue in the binding region of the enzyme. This separates
the acetyl group (which is bound) and the choline (which is still present in the binding site).
• Step 2:
• Hydrolysis results in the removal of the choline group
• Step 3:
• Regeneration of the active enzyme occurs very quickly (in millisecs) and is due to the release of the bound
acetyl group, which forms acetic acid.
Anticholinesterase drugs
• 2 types:
1. Reversible
• Are substrates for cholinesterase
2. Irreversible
• Posphorylate the enzyme
• Commonly organophosphate drugs
Reversible anticholinesterase drugs

• Physostigmine
• Naturally occurring
• Treat glaucoma (it is one of the few anticholinergic drugs which can get through eye membrane)
• Neostigmine (need to know!)
• Synthetic
• It has a quaternary N, therefore it is not well absorbed and has no CNS effects.
• Used for the reversal of neuromuscular blockade (given intravenously). Often used in myasthenia gravis.
• Edrophonium
• Short acting, given by injection
• Used to diagnose myasthenia gravis - causes temporary improvement of the condition.
• Pyridostigmine
• Drug of choice for myasthenia gravis
• Reasonably well absorbed
• Mechanisms of action (taking neostigmine as the prototype)

• Neostigmine acts exactly like Ach when it is taken up by cholinesterase.
• However, the hydrolysis stage is prolonged (taking 15 - 30 min) and the recovery stage is very slow
(compared with Ach which acts in milliseconds).
• During its occupation in the binding site of the enzyme, Ach cannot bind and so it has to hang around in
the synapse waiting for neostigmine to be metabolised.
Organophosphorous anti-cholinesterase (considered irreversible)

• Originally developed as nerve gases for warfare.
• The prototype drug is Ecothiopate.
• This drug is very useful for treating glaucoma because it prolongs the action of Ach in the eye by
preventing Ach breakdown. It has very prolonged inhibition of ChE - the eye drops need only be used
once a month.
• Mechanism of action:
1. Hydrolysis in the body results in the cleavage of a side chain.
2. The residue phosphorylates an active serine group in the binding site of the enzyme.
3. Reactivation (hydrolysis of the phosphorylated enzyme) is very, very slow (months as indicated by the
time required to renew the eye drops)
• The process of reactivation of the enzyme can be hastened by giving nucleophilic agents (e.g. Pralidoxime).
Normally, water is used to reactivate the enzyme, but water is a very weak nucleophilic agent.
• Pralidoxime can be used to treat people who are poisoned by organophosphorous drugs (e.g. sarin gas).
Effects of anti-cholinesterases
• They potentiate the action of Ach when it is released
• In the CNS
• Stimulation
• Convulsions
• Respiratory depression/arrest
• All these lethal effects are mediated through Ach acting on M receptors. Hence, atropine is an effective
drug used in anticholinesterase poisoning because it blocks the M receptors, limiting the effects.
• Autonomic system
• Eye Pupillary constriction
• Lung Bronchoconstriction
Increased secretions
• GIT Diarrhea due to spasm of gut smooth muscle
• Bladder Contraction of the bladder
• Cardiovascular system
• Bradycardia
• Not seen in people who have had heart transplants since it is denervated (an hence no resting
tone provided by Ach)
• No effects on blood vessels since there is no cholinergic innervation.
• Neuromuscular junction
• Potentiation of the action of Ach
• Initially there is fasciculations
• Eventually, get myasthenia (muscle weakness)
• Other effects:
• Alteration in receptors
• If receptors are bombarded with high levels of Ach for a long time, they will be down regulated
(so get less N and M receptors)
• Reduction in Ach synthesis
• Direct neurotoxicity
• Only in anticholinesterases which have fluorine atom (Dyflos)
Specificity
• Organophosphorous anticholinesterases are not as specific as the reversible anticholinesterases.
• Reversible anticholinesterases are specific for cholinesterases only (both true and pseudo cholinesterases)
• Organophosphorous anticholinesterases inhibit both A and B group esterases
1. Group A esterases
• Cholinesterases
2. Group B esterases
• Angiotensin Converting enzyme
• Chymotrypsin By inhibiting these enzymes, there is the
• Trypsin possibility of bleeding.
• Thrombin
Drugs action at the neuromuscular junction

• The action of a drug depends on various factors:
1. Type of muscle
• Fast twitch (gastrocnemeous)
• Slow twitch (soleus)
2. Type of innervation
• Focally innervated (one end plate per muscle fibre)
• Multiple innervation (multiple end plate per muscle fibre)
• Amphibians and reptiles have mainly multiple innervation. Most muscles in mammals are
focally innervated. Exceptions are:
• Extraocular eye muscles
• Upper oesophagus
Targets of drug action at the NMJ

• Most useful drugs interact with the nicotinic receptors.
• Toxins (e.g. Tetrodotoxin) Blocks the passage of action potentials down the nerve fibre.
• Hemicholinium Blocks choline uptake into the nerve terminal
• Botulinum toxin Inhibits the release of Ach in the granules Unimportant
• Succinylcholine Depolarises the nerve terminal
• Acteylcholinesterase inhibitors Potentiate the action of Ach.
• Dantrolene Reduces muscle contraction (acts directly on the muscle)
Neuromuscular blockers
• There are 2 types of drugs acting at the N receptors in the neuromuscular junction:
1. Competitive blockers
• Act as competitive antagonists of the nicotinic receptor.
• Prevent Ach from binding to N receptor and causing a muscular contraction (paralysis)
• Prototype drug is Tubocurarine
2. Depolarising blockers
• See next lecture
Main uses of neuromuscular blockers

• Premedication during surgery as a muscle relaxant
• Note that the drugs do not cause anesthesia (loss of sensation and consciousness) or analgesia (loss of
pain). They act purely to paralyse muscle - the patient is fully conscious and can feel everything. Just
because they don't respond to a painful stimulus does not mean they are anesthetised; it simply means that
they physically cannot respond nor say something.
• Control convulsions during ECT
• Orthopedic manipulation
• Normally, when bones are broken, there is lots of muscle spasm preventing manipulation of bones. Hence
use a short neuromuscular blocker.
Competetive neuromuscular blockers

• When a motor nerve is stimulated at a certain frequency, there is a corresponding twitch of the muscle occurring at
the same frequency.
• If tubocurarine is added, there is a gradual decline in muscular contraction. There is no initial stimulation before
the blockade (there is no increase in muscle contraction)
• If the stimulation frequency is increased to a frequency causing tetanus (fusing of the individual muscle twitches),
there is an initial spike, but it is depressed and not sustained.
• However, when the stimulation frequency returns to normal, there is a post tetanic potentiation.
• This is because, during tetani, there was a massive flood of Ca going into the nerve terminal. Ca leaves
the nerve terminal very slowly. Therefore, the next stimulus that comes along causes heaps of Ach to be
released. Because tubocurarine is a competitive blocker, its effects can be surmounted by high levels of
Ach, and so you see and increase in muscle contraction. As the nerve terminal pumps out Ca, Ach levels
return back to their normal levels which are not high enough to overcome the blockade.
• If tubocurare is added along with another blocker (Gallamine), the effect is to depress muscle contraction much
quicker. (There is summation).
CHOLINERGIC PHARMACOLOGY IV
• A big advantage of competitive neuromuscular blockers is that you can reverse their effects by giving an
anticholinesterase (e.g. neostigmine). Neostigmine prevents Ach breakdown, allowing Ach to persist at high
concentrations to overcome the competitive blockade.
• Examples of neuromuscular blockers (non depolarising) are:
• Tubocurarine
• Pancuronium
• Gallium
• Atrucurium
• All these drugs competitively block the nicotinic receptors, preventing Ach from binding, but they differ in
some properties.
1. Histamine release
• Tubocurarine is good at stimulating histamine release. Hence it can cause vasodilation.
However, histamine is also a powerful bronchoconstrictor, and in asthmatic patients or
those with type I hypersensitivity, tubocurarine may be a problem. It is working as an
anaphylactoid (not anaphylatoxin which stimulates release of histamine via antibody
mediated mechanisms).
2. Ganglion block
• Although most of these drugs are effective at blocking the nicotinic receptor at the
neuromuscular junction, some can also block the nicotinic receptor in the ganglia.
Tubocurarine is one of these, being able to block ganglia even at therapeutic
concentrations. Hence, tubocurarine, as well as being a muscle relaxant, can also act to
lower blood pressure (by inhibiting sympathetic effects and also releasing histamine)
3. Muscarinic block
• Gallamine and pancuronium can also produce some muscarinic blocking activity. Hence,
they will produce a tachycardia due to loss of the Ach mediated resting tone.
4. NA upatke and release
• Uptake of noradrenaline is inhibited and its release is increased (mainly due to
pancuronium and gallamine. Hence, there is an initial Increase in heart rate and blood
pressure.
5. Anticholinesterase activity
• A feature of pancuronium when used in high and prolonged numbers.
6. Anesthesia
• All of the drugs interact with many inhalation anesthetics (neostigmine), producing
additive effects. Therefore, less concentrations of both the anesthetic and muscle relaxant
needs to be used, resulting in a quicker recover.
Depolarising blockers
• If Ach is injected into a muscle, we see a brief twitch and then Ach is rapidly broken down by
acetylcholinesterase. When poisoned by anticholinesterases, Ach can hang around for a long time, resulting
in continuous depolarisation of a muscle which leads to paralysis. Hence, Ach can act as a depolarising
blocker, although it is not practical to use it since it is rapidly broken down.
• The prototype depolarising blocker is suxamethonium (succinylcholine)
• It is not a substrate for acetylcholinesterase
• It is a substrate for butyrlchlolinesterase
• This means that when it is located at the neuromuscular junction (which is where we want it to act),
it is very stable, but when it gets into plasma, it is rapidly degraded.
• Other features:
• When given, there is an initial stimulation (twitch) before the blockade. Since mammalian
muscle fibres are innervated by a single end plate, a brief depolarisation of one end plate is
not enough to cause a full muscular contraction since it is too small an area. What happens
is that all the end plates of all the different muscle fibres cause a depolarisation, resulting in
fasciculations (but not a contraction).
• With muscles that are multiply innervated, depolarisation of multiple end plates of
a single muscle fibre is enough to cause contraction of the whole muscle fibre,
since the endplates are spread out along the whole length of the fibre.
• Persistent depolarisation means that the muscle cannot respond to a subsequent release of
Ach. Ach causes depolarisation of the muscle fibre, but how can it depolarise something
which is already depolarised!
• Tetanus is depressed but sustained
• There is no post tetanic potentiation
• You can have additive effects when given with another depolarizing blocker
(decamethonium).
• Anticholinesterases do not reverse the block, they tend to potentiate the block.
• If neostigmine is given, it means more Ach floating around (which itself can act as
a depolarising blocker)
• This is a major disadvantage of depolarising blockers - their actions cannot be
reversed pharmacologically. You need to wait for the effects of the drug to wear off
(which is not a problem for suxamethonium since it is not very long acting).
Other features of depolarising neuromuscular blockers

• Reversed by competitive blockers
• Theoretically, by giving a competitive blocker such as tubocurarine, it binds to receptors and
effectively reduces the numbers of receptors available for suxamethonium. This means that
suxamethonium cannot cause as effective a depolarisation of the muscle due to reduced numbers of
receptors. However, the effects are too unpredictable for competitive blockers to be used in
conjunction with deoplarising blockers.
• Dual block
• At high doses and prolonged exposure, the block becomes a competitive block (it has the properties
of a competitive blocker)
• Receptor desensitisation
• Receptors become desensitised to all nicotinic agonists
• Different effects in multiply innervated muscles
• Some muscles in the body are multiply innervated:
• Extraocular eye muscles
• Muscles of the upper oesophagus
• There are heaps of endplates and so heaps of depolarisation along the entire length of a muscle fibre,
which results in a contracture rather than a twitch. The muscle goes into a contractive spasm. This
results in a spastic paralysis rather than a flaccid paralysis (which occurs with competitive blockers).
Depolarising blockers must therefore not be used for eye operations.
Inactivation of suxamethonium
• When suxamethonium diffuses out into the plasma, it is rapidly inactivated by butyrlcholinesterase. Some
people have a genetic deficiency of butyrlcholinesterase.
• There may be a problem with drug interaction (especially drugs which are also substrates for
butyrlcolinesterase, e.g. procaine). Procaine will compete with suxamethonium for the enzyme, resulting in
the prolongation of action of both these drugs.
Side effects
• A rare condition known as malignant hypertermia.
• Intense muscle spasm leads to heaps of heat release due to muscle metabolism. This leads to a
marked increase in body temperature. The condition is genetically based (people mainly have red
hair)
• Depolarisation is due to an influx of Na+ and an outflow of K+. Hence, continual depolarisation would lead to
lots of K+ in the circulation (hyeprkalemia), which can cause cardiac arryhtmias, cardiac arrest and
hypertension.
• Initially, there can be bradycardia and hypotension, followed by tachycardia and hypertension
• This is due to muscarinic stimulation of the heart followed by nicotinic stimulation of the ganglia.
• Myotonia
• Intense muscle spasm which is not relieved by other muscle relaxants
• On recovery, there is muscle soreness in those muscles which have undergone contracture. During induction
of the blockade, there were lots of fasciculations, resulting in muscles rubbing against each other and causing
tearing.
Other drugs acting at the neuromuscular junction

• Dentroline
• Does not act on the nicotinic receptors. It acts directly on the muscle fibre
• It reduces the release of Ca2+ from the sarcoplasmic reticulum
• It has very little effect on cardiac and smooth muscle which are dependent on Ca2+ fluxes across the
membrane rather than stored intraceullular Ca2+.
• Useful in spasticity, stroke, multiple sclerosis, malignant hyperthermia
Myasthenia gravis
• A condition where there is rapidly developing weakness of a muscle
• There is no impairment of:
• Conduction in a nerve
• Contractility of a muscle
• Release of Ach is normal
• What happens is that these people have autoantibodies against the nicotinic receptor in the neuromuscular
junction. This results in a reduction in the numbers of receptors available for Ach to act on.
• These people are insensitive to depolarising blockers since there are too few receptors for the drugs to act on,
to cause a sustained depolarisation.
• These people are very sensitive to competitive blockers
• If a tiny amount of tubocurarine is injected (below therapeutic levels), the people get extreme muscle
weakness.
• This is because there are already a small amount of nicotinic receptors. If a competitive blocker is
added, it will just reduce the numbers of available receptors even further.
• Treatment involved:
• Enhanced release of neurotransmitter
• Anticholinesterases (pyridostigmine is the drug of choice) which prolong the action of Ach
• Immunosuppressants to reduce the levels of nicotinic receptor antibodies
• Glucocorticoids
• Azathioprine which inhibits clonal proliferation of T and B cells
By Duy Thai: www.geocities.com/d.thai 1997 Pharmacology Semester 1 page 1 of 3
DRUG ABSORBPTION
Drug absorption
• In order for a drug to be absorbed, it must be able to pass through cell membranes (which is a lipid barrier).
Lipid soluble drugs would be ideal to pass through the membrane easily, but not all drugs can be lipid soluble
to a great extent. There are 4 main ways drugs can be absorbed:
1. Lipid diffusion
2. Aqueous diffusion
3. Coabsorption with lipids
4. Facilitated diffusion/active transport
Lipid diffusion
• Highly lipid soluble drugs are able to pass across cell membranes quite easily. The movement is driven by
passive diffusion down a concentration gradient.
• The lipid partitioning coefficient is a numerical value of how lipid soluble a drug is.
P=
[lipid ]
[H 2 O]
• If the concentration of the drug is higher in a lipid medium than in an aqueous medium, it will have a high P
and hence have a high lipid solubility.
Aqueous diffusion
• There are such things as aquaporins – special protein channels designed for the movement of water into and
out of cells. Drugs which are small and easily dissolved in solution will be able to pass through the cell
membrane via this route, in conjunction with water which naturally diffuses.
Coabsorption with lipids

• Some drugs can be absorbed in conjunction with lipids via micelles. E.g. Vitamin A, digitoxin.
• A micelle is formed with the drug incorporated into its structure. Therefore, when the micelle is absorbed, so
is the drug.
Facilitated diffusion/active transport

• All cells have specialised transport systems and channels which allow the active (requiring energy) uptake of
materials from the ECF into the cell. These materials are often nutrients required by the cell. If a drug is
structurally similar to the compound a transport system normally takes up, the drug will be able to enter the
cell by making the cell think it is someone else. E.g. Levadopa (used to treat Parkinsons) is taken up via the
aromatic amino acid transport system.
Features of drugs which affect their absorption

• Molecular weight
• Drugs with a small size are absorbed well
• Drugs which are large (often proteins) are absorbed poorly. These drugs are often administered
intravenously to avoid any absorption barriers.
• Chemical and enzymatic stability
• The drug must be able to withstand the acid conditions in the stomach and also the gut enzymes. E.g.
Penicillin G (a β lactam antibiotic) is highly acid labile, which means that it is not stable to acid.
• Aqueous and lipid solubility
• A drug cannot be totally lipid soluble, otherwise it would not be able to dissociate in the circulation
to remain in solution. On the other hand, we don’t want a drug to be totally soluble because it may
have problems in absorption. What is needed is a balance between these 2 properties.
pH and lipid solubility

• Most drugs are either weak acids or weak bases and can exist in either the ionised (less lipid soluble) or unionised
(more lipid soluble) form, depending on the pH of the surrounding environment.
• Acidic drugs have a carboxylic functional group (- COOH)
• Basic drugs have an amine group (-NH2)
Ionisation constants are given by :

• For acids: FOR ACIDS FOR BASES
• A-H ⇔ A- + H+
Ka =
[A ][H ]
− +
Ka =
[B][H + ]
• For bases:
• BH+ ⇔ B + H+
[AH ] [BH ]+
log
[Unionised ] = pKa − pH log
[Unionised ] = pH − pKa
[Ionised ] [Ionised ]
• The ionisation constants give an indication of how strong the acid is. If Ka is large (and hence pKa is small), then
at equilibrium, more of the acid will exist in the ionised form.
• The opposite can be said for bases. If pKa is small for a base, then at equilibrium, more of the base will be in the
unionised form. Hence a stronger base will have a large pKa rather than a small one.
• If an acid drug lives in an acid environment, then the proton which it has (the H+) will be retained and it will exist
preferably in its unionised form.
• If pH = pKa: Equal amounts of the ionised and unionised forms
• If pH < pKa: More of the drug is in the unionised form
• If pH > pKa: More of the drug is in the ionised form
• If a basic drug lives in a basic environment, then it will not want to accept a H+ and so it will exist preferably in its
unionised form.
• If pH = pKa: Equal amounts of the ionised and unionised forms
• If pH < pKa: More of the drug is in the ionised form
Note how it is opposite to acid drugs
• If pH > pKa: More of the drug is in the unionised form
• REMEMBER THAT A DRUG IS ABSORBED BETTER IN THE UNIONISED FORM
• e.g. Aspirin is an acidic drug. In the stomach, the pH is from 1 - 3, which means that it is an acidic environment.
Hence most of the drug will exist in the uinionised form and be better at passing through the lipid membranes (i.e.
better absorbed - around 30% of the oral dose, the rest is absorbed in the small intestine). Do not confuse this with
the solubility of aspirin. A drug in the ionised form is better soluble but not necessarily better absorbed.
• Remember that the majority of a drug is absorbed in the small intestine, but acidic drugs also have a
relatively large proportion of their concentration absorbed in the stomach
• On the other hand, basic drugs such as MIPRAMINE (an antidepressant), has 100% absorption in the
small intestine.
pH changes in the gut

• There is a 106 fold change in the pH as we move from the stomach to the small intestine:
• Stomach pH: 1-3
• Duodenum pH: 5
• Small intestine pH 5-7
Factors affecting gastrointestinal absorption

• Gastrointestinal contents
• Have you eaten yet? Generally, an empty stomach = better absorption since some drugs may interact
with food.
• Gastric retention time
• Drugs which are well absorbed from the small intestine (e.g. ethanol) will benefit from an increased
gastric emptying rate since more of the drug will be ejected from the stomach into the small intestine.
• Intestinal transit, GIT motility????????????????
• First pass effect
• Blood supply from the gut goes directly to the liver via the portal vein. Therefore, orally absorbed drugs
will reach the liver before entering the systemic circulation. This will be bad if the drug is heavily
metabolised by the liver, which in most cases inactivates the drug.
Bioavailabilty
• The amount of drug reaching its site of action
• If a drug is administered intravenously, then the bioavailability will be 100% (provided we want the drug to be
present in the plasma)
• The bioavailability can be much less for other routes of administration.

• e.g. 500µg of a drug is administered but only 100µg enters the circulation. That means 400µg is lost
(wasted) in bodily excretions.
• Factors affecting bioavailability:
• Incomplete absorption
• See the factors which affect absorption above
• First pass effect
• You should know what this is by now
• Enterohepatic shunt
• Lipid soluble drugs can make their way into bile and be excreted along with it. The drug can be
excreted with the bile or reabsorbed with some bile which is reabsorbed via the enterohepatic
circulation.
DRUG ADMINISTRATION
• Pharmacokinetics is the study of the behaviour and time course of the following features of a drug:
• Administration
• When the drug is given
• Absorption
• When the drug is taken up by the body
• Distribution
• When the drug spreads through the body
• Elimination
• When the drug is removed from the body
DRUG ADMINISTRATION
• When drugs are administered, they can have either local or systemic effects.
• A local effect is one which acts near the site of administration
• A systemic effect occurs when the drug gets into the systemic circulation and is distributed throughout the
whole body.
Local administration
• The main advantage of a local administration is that it minimises the systemic side effects. Because the drug does
not enter the systemic circulation, the drug only acts where we want it to act, and not at any other, less desirable
places.
• Examples of some common sites of local administration are:
• Skin: Rubbing ointments, corticosteroids to decrease inflammation, antihistamines to prevent an allergic
reaction
• Nose: Decongestants
• Vagina: Antifungals
• Rectum: Vasoconstrictors to treat hemorrhoids
• Lung: Bronchodilators (salbutamol, a beta agonist). If this drug enters the systemic circulation (which
sometimes happens), then it can have side effects on the heart.
• Eye: Atropine/homatropine which causes dilation of the pupil during eye inspections and surgery.
Systemic administration
• Systemic administration is used if we want a drug to act on hard to reach places such as the heart or brain. We
cannot administer a drug locally (which would be good) because it would be too traumatic (e.g. sticking a needle
into your heart or chest).
• Sites of systemic administration are:
• Skin
• e.g. Glycerol trinitrate which is applied via a patch on the skin, allows the drug to diffuse through the
skin.
• An advantage of this sort of administration is that it avoids the first pass effect by not having to pass
through the gut (explained later).
• Nose
• Also bypasses the gut because the veins in the nasal mucosa drain into the vena cava. e.g. cocaine
• Vagina/rectum
• The blood vessels in the mucosal lining drain into the systemic circulation, thus bypassing the gut.
• Lung
• Ideal for gaseous. The large surface area and high vascularity of the drugs makes it ideal for
absorption of drugs. e.g. general anaesthetics - halothane
• Orally
• See below
• Parenterally
• See below
• Note that these sites are identical to the ones used in local administration (except the last two). It is the
physicochemical properties of the drug which determine whether it will stay at that site and act locally or be
absorbed and act systemically.
Oral administration
• The most common route of systemic administration
• Most of the absorption of drugs occurs in the small intestine because it is specialised for absorption (large surface
area due to villi and microvilli)
• If a drug is to be absorbed effectively, it has to be in solution (hence water soluble), but must also be able
to pass through cell membranes (lipid soluble as well).
• Drugs which are given in solid form (e.g. tablets) have their rate limiting step as the disintegration
and dissolution of the drug.
• e.g. Digitoxin is poorly soluble. The particle size used in the manufacture of the tablet needs to be
very tightly controlled because it has a very small therapeutic window.
• A therapeutic window is when the dose required to have a therapeutic effect is very
close to the dose required to have a toxic effect. You thus have a very small margin for
error.
• If the tablet is made up of small particle sizes it will dissolve easily and therefore get a
high dose. If the particle size is large, dissolution will be less and so result in a smaller
dose.
• A disadvantage of oral administration is that all blood from the gut must pass via the portal vein through the liver
first. The liver metabolises many drugs and so they are inactivated before entering the systemic circulation. This is
the first pass effect.
• There are some drugs/chemicals which are not toxic to the body, but when metabolised by the liver,
become toxic - e.g. carbon tetrachloride.
• Orally administered drugs cannot be proteins because the digestive enzymes of the gut break the protein into
useless amino acids. e.g. insulin cannot be given orally. The drug must also be able to withstand the acidic
conditions of the stomach.
• A special type of oral administration is sublingually. This is where the drug is placed under the tongue where the
veins enter the systemic circulation.
Parenteral administration (via injection)

• The other common alternative to systemic administration
• There are 3 types of parenteral administration:
• Subcutaneous
• Good for non irritant drugs. Advantage being that injection is not too deep and painful.
Disadvantage is that only a small volume can be injected (max 2mL).
• Intramuscular
• Antibiotics are usually given this way (e.g. penicillin), often into the bum (gluteus maximus).
Larger volumes can be administered and the drug can be released slowly into the circulation,
while some of it being stored in the muscle (acting as a reservoir).
• Intravenous
• Though invasive and uncomfortable, this method provides accurate, reliable dosage of a drug
directly into the circulation. It means that the bioavailablity of the drug is 100%. More on
bioavailability later.
• There is a very rapid response because no absorption is required. The drug must be soluble.
• Injection into a vein can be a bolus (all at one go) dose or infused (slowly administered over a
period of time).
Other, more exotic forms of administration

• For example, how do we get protein drugs into the CNS.
• Because of the blood brain barrier, only lipid soluble drugs are able to pass through the barrier and exert their
effects on the brain. Various solutions have been proposed:
• Pumps
• Implanted cells which produce the protein and release it into the surroundings
• Viruses, which work on the same principle, i.e. making a protein and releasing it
• Polymer Encapsulated Genetically Modified Cells
Polymer Encapsulated Genetically Modified Cells

• This (new and experimental) method has been tried to administer neurotrophic factors into the CSF which
prevents cell death.
• A polymer capsule is filled with genetically modified cells. This capsule allows nutrients from the CSF to
pass into the cell, thus sustaining the cells inside, and also allows the neurotrophic factors produced by the
cells out into the surroundings.
• The capsule is implanted into the intrathecal space (in the spinal canal) and has the advantage of being able
to provide continuous administration of the drug. Another benefit is that the polymer capsule prevents an
immune response against the foreign cells, thus reducing the side effects (no allergic reaction for instance).
DRUG DISTRIBUTION
• When a drug gets into the systemic circulation, it needs to be distributed throughout the whole body. This depends
on the blood circulation. If, for example the person is in shock where there is reduced blood flow, it will take longer
for the drug to distribute itself throughout the body.
• Distribution of drugs is rarely uniform.
• Drugs are simultaneously being eliminated and distributed, but distribution is usually faster.
Steps of drug distribution

1. Dilution in blood
• The drug has to reach equilibrium with itself in the blood. You can’t have an area of high concentration
and low concentration. The concentration needs to be uniform.
2. Movement into extracellular fluid surrounding cells
• Drugs need to be able to get out of the vascular system, either between endothelial cells or through them
3. Uptake into cells
• The drug must be able to cross the cell membrane
Factors affecting drug distribution

• Is the drug bound to proteins or not? (Ability of the drug to cross vascular endothelium)
• Most of the vascular endothelium is porous to drugs, however some drugs are bound to plasma proteins.
These drugs will be unable to get out since the proteins are so large.
• Ability of the drug to cross cell membranes
• Is the drug lipid soluble?
• Extent of blood perfusion
• If a tissue is well perfused, the drug is able to get there faster. E.g. Adipose tissue has a low blood perfusion
and so drugs will not be able to reach these places very quickly.
• Sequestration in lipid
• Determine if the drug is lipid soluble
• pH differences across membrane barriers
• A drug will pass through the membrane better if it is unionised. The pH is important regarding whether
the drug is an acid or a base. An acid drug will be unionised in an acid environment, a basic drug will be
unionised in a basic environment.
• Binding of drugs to other tissue components
The blood brain barrier

• Most endothelial cells of the body are leaky except for the brain capillaries.
• These capillaries are special in that they have tight junctions between the endothelial cells, so it is not easy for
substances to pass between the cells.
• The only way a drug can pass from a brain capillary into the brain is if it is sufficiently lipid soluble to pass through
the endothelium, rather than between them.
• Thus, water soluble drugs are immediately excluded as being used as a CNS acting drug. Also are highly polar
compounds and proteins.
• All this is a protective mechanism which effectively shields the brain from all the ups and downs of the peripheral
circulation. The brain wants to live in a constant environment, not a hectic one. The blood brain barrier also
protects to a certain extent against some toxins.
Drug reservoirs
• Drugs do not distribute themselves in an even manner, which leads to pooling of drugs in some places..
• A drug reservoir is a site in the body where drugs accumulate.
• The reservoir is will be like a storage depot – as drug is cleared from the system, the reservoir keeps on releasing
drugs back into the plasma. This is able to prolong the action of the drug because not all of the drug is cleared from
the plasma at once.
• Examples of drug reservoirs are:
• Plasma proteins
• Acidic drugs are preferentially bound
• Only the unbound drug is able to get out of the circulation and into the tissues.
• The binding is non selective
• The bound drug may become displaced by a similar drug with similar properties
• Cells
• Accumulation of drugs in cells occurs due to the active transport of drugs into cells or due to the
binding of the drug to cell membrane receptors.
• E.g. long term treatment of quinacrine (an antimalarial drug) leads to it being concentrated in
the liver. Hence, when the concentration of the drug in the circulation decreases, the liver is able
to release the drug to keep the circulating levels high.
• Fat
• Highly lipid soluble drugs are able to make their way to adipocytes and become stored there.
However, they are slow to get there because fat has low blood perfusion. When the drug is stored
there, it is generally stable because of the low perfusion – the drug is slow to get out into the
circulation.
• Sometime lead can be stored in fat. If people go on crash diets, all the fat goes, releasing a whole
heap of Pb – you get lead poisoning.
• Bone
• Some drugs bind to the bone crystal surface and become incorporated into the crystal lattice.
Example of the principles of drug distribution

• E.g. Thiopental
• This drug is a highly lipid soluble general anaesthetic.
• Because it is lipid soluble, it is able to get through the blood brain barrier and gets there quickly due to
the high brain perfusion.
• It is administered intravenously because we want it to act quickly to put a person to sleep.
• It has a short duration of action because it redistributes quickly to muscle. Muscle is acting as the reservoir, hence
decreasing the concentration of the drug in the body.
• If repeated doses are given, we can greatly lengthen the action by saturating the “sponge” (the muscle). Because the
muscle can no longer absorb any more circulating drug,, the drug is able to circulate. Only when the muscle starts
to break the drug down, will it be able to soak up more drug from the circulation.
Volume of distribution
• “Volume of body water in which a drug appears to be dissolved in after it has distributed throughout the
body”
amount of drug in whole body

Vd =
concentration in plasma
X
=
C
• We then divide the result (which is in litres) by the mass of the person (in kg) to give a value in L/kg
• Often, it is very difficult to measure X, unless you are given an IV infusion. In that case, X can be
approximated as being the amount of drug given (the dose) at time = 0.
X
Vd = 0
C0
Only applies to an IV infusion!
• The factors determining the volume of distribution are:

• Binding to plasma proteins
• If a drug binds to plasma proteins, Vd will be small and approach plasma volume. This is
because most of the drug is found in the plasma (hence a high C, low X). Vd will
approach plasma volume (0.06 L/kg)
• The amount of drug in the whole body is considered to be the amount of free,
unbound drug!
• Binding to tissues
• If a drug passes through the capillaries, but does not enter cell membranes, the drug will
end up in the ECF. Hence the Vd will be close to ECF volume (0.2L/kg)
• A drug will can pass through the cell membrane but is not bound to tissue will have a Vd close to
total body water (0.6 L/kg)
• E.g. Morphine has a Vd = 2.8L/kg because it is bound to sites outside the circulation (X is large, C is small)
What does a pharmacokineticist sees:
Amount of drug
administered
Kabs
Amount of drug in the

body Rate constants
Kelim
Amount of drug
eliminated
• A pharmacokineticist only sees the amount of drugs. (i.e. what they can measure)
• The rate constants determine the speed of movement of the drug between the different amounts (e.g. from
amount administered to the amount in your body).
• Many drugs behave as though they were present in the body in a single compartment once they have reached
equilibrium. This is true for drugs which distribute rapidly throughout the body.
• This leads to the development of the one compartment model
• Absorption and elimination of many drugs is proportional to the amount of drug present.
• This allows 1st order kinetics to be used to monitor the elimination of a drug.
• See the lecture “Drug elimination for more detail”.
Rapid venous administration of a drug

• A drug given intravenously does not have to worry about the process of absorption into the blood. Hence, the
dose given is identical to the dose in the blood (100% bioavailability).
• We only have to worry about the rate of elimination, since there is no absorption component
Amount of drug in the

body
Kelim
Amount of drug
eliminated
What happens if a drug is given orally (Not via IV)

• You take an oral dose of say 500mg
• This 500mg will not appear in the plasma straight away (unlike in an IV infusion)
• In fact, all of this 500mg will probably not appear in the plasma at all (due to 1st pass effect, metabolism
etc).
• Hence, the maximum plasma concentration of the drug will not be 500mg, but may be 100mg.
• The initial slope of the graph is steep because the only thing that is happening is absorption of the drug.
Therefore the plasma concentration of the drug rises quickly.
• However, as time goes by, elimination of the drug is also occurring. Therefore, the rise in plasma
concentration will not be as rapid because some of the drug present in the blood will be undergoing
elimination.
By Duy Thai: www.geocities.com/d.thai Pharmacology Semester 1 page 4 of 7
• At the peak, the rate of drug being absorbed into the plasma is the same as the rate of drug being eliminated
from the plasma.
• Eventually, the amount of drug being absorbed is very slight, and the elimination becomes greater, resulting
in a gradual decline of plasma concentration.
• Once there is no drug left to be absorbed into the plasma, only the elimination of the drug is present, and so
we see a rapid, exponential decline in the plasma concentration.
• What I have said is what you should know, the formula in the notes is a load of crap!!!
Plasma concentration Steady state

Elimination = absorption
Slow decline
absorption > elimination Elimination > absorption
Rapid decline since no drug

absorption occurring
Time
IV infusion curve
Bioavailability
• Bioavailability is the amount of drug which enters the plasma
• For an IV infusion, all the drug administered appears in the plasma, and so bioavailability = 100%
• Bioavailability is often expressed as fractional bioavailability, F, where
AUC oral
F=
AUC iv
amount of drug in the plasma of an oral dose
=
amount of drug in the plasma after IV dose
amount of drug in the plasma of an oral dose
=
actual dose given
• AUC = area under the curve of a plasma concentration vs time graph
Short term IV infusion

• The principles are the same as an oral dose, however the dose given will be the dose that will appear in the
plasma.
• The initial portion of the graph will show an initial steep rise, whereas the graph of the oral dose showed a
slow increase first, gradually getting steeper.
• When IV infusion stops, elimination follows an exponential decay immediately
• There are various formulae to describe this curve, which are not important to remember.
Long term IV infusion – Steady state plasma concentration

• You infuse a drug at a constant rate but the initial part of the curve is not a straight line because you need to
consider the elimination of the drug which is occurring simultaneously.
• You eventually reach a steady state where the rate of infusion = the rate of elimination
• The infusion is maintained for a long duration of time.
• The concentration of drug in the plasma at the steady state is given the symbol, Css
Css
Clearance (Cl)
• The volume (of plasma presumably) from which all the drug is completely removed per unit time.
• Renal clearance is considered in the next lecture (Drug elimination)
• Organ clearance (e.g. by the liver)
CA CV
Q = flow of blood
Organ Q = flow of blood
Some drug eliminated
• Organ clearance is essentially measuring the amount/concentration of drug entering an organ and
then measuring the amount/concentration leaving the organ. Usually, the amount/concentration
leaving the organ is less because a certain fraction has been cleared by the organ.
• Note that amount is equal to the concentration × volume (or flow, if we want a rate)
• We calculate the extraction ratio as being:
Drug concentration in arterial blood - Drug concentration in venous blood

ER =
Drug concentration in arterial blood
(C − C V )
= A
CA
• The extraction ratio tells us how efficient an organ eliminates a drug.

• The rate of elimination is the amount (i.e. mass) of drug cleared from the plasma per minute.
• It is: Rate of elimination = Q.CA – Q.CV
NB:
C = concentration = grams/ml
• The clearance of an organ is: Q = flow = ml/min
Therefore if C × Q, then:
Q(C A − CV ) C(Grams/ml) × Q(ml/min) = grams/min
• Cl =
CA = amount of drug per minute
• The total body clearance (systemic clearance) is the sum of the renal clearance and the organ clearance.
• You can work out the organ clearance and then the renal clearance and add the 2 together to give
you the total clearance of the drug.
• An alternative way is to use this simple formula:
Cls = Volume of distribution × elimination rate constant
= Vd × kelim
• This only works for a one compartment model (1st order kinetics)
• There are some drugs which are eliminated via zero order kinetics
• The elimination of the drug does not depend on the concentration of the drug in the plasma
• E.g. of these drugs are ethanol and aspirin
• The elimination of the drug is practically constant
• These drugs are eliminated by the action of enzymes which are working at their maximum
capability to clear the drug.
• Zero order kinetics is described by Michaelis-Menten kinetics
2 compartment model
• This model is complex but important.
• It is used for drugs which distribute slowly into a second compartment.
• E.g. Thiopental distributes itself into muscle as well as in the plasma.
Amount of drug
administered
Amount of drug in Amount of drug in

central compartment peripheral
(plasma) compartment (e.g.
muscle, fat)
Amount of drug
eliminated
• The equation of the slope is unimportant. What is important is how we got the graph.
• Remember that what we are measuring is the plasma concentration of the drug.
• What we see is that the concentration of the drug in plasma falls very sharply at the start.
• This is because the drug is being removed from the plasma by 2 different processes:
• It is being removed by the kidney/organs
• It is also being sequestered by another, peripheral component.
• When the peripheral component becomes saturated, no more drug can go into the peripheral component and
so the drug is now being cleared from the plasma by only one mechanism.
• That is why the slope of the graph becomes less steep.
• The elimination rate constant is defined as β and can be calculated as being:
β = -2.303 × slope of the straight portion of the graph
• The half life of the drug can be measured by:

0.693
T1/2β =
β
• By extrapolating the straight portion of the graph to the y axis, and then subtracting the x values (the x
values of the first part of the graph – the x values of the extrapolated line), we can get a residual curve which
describes the distribution of the drug into the peripheral component.
• The gradient of this graph (multiplied by –2.303) gives you α, the rate at which the drug is
sequestered by the peripheral component.
Log C
Distribution curve
What is the point of all this?

• The best way to illustrate a concept is to use an example
• 700 mg of a drug was infused into a 70kg man. His plasma drug concentration was measured over time and
plotted.
• It turned out that the drug was eliminated according to 1st order kinetics (a one compartment drug).
• From the log(Concentration) vs time graph, a value of kelim was calculated using the formula:
kelim = -2.303 × gradient of the line
• Kelim turned out to be 0.014

• From there, the half life of the drug was able to be calculated using:
0.693
t1/2 =
k
= 48.6 min
• The volume of distribution was worked out by considering the total amount of drug in the body as being the
same as the dose given intravenously, and the concentration in the plasma is taken as C0 (by extrapolating
the graph)
X
Vd = 0
C0
• Vd turned out to be 7L. Dividing this by the mass of the subject (70kg), we get Vd = 0.1L/kg.
• We know that this is close to the volume of plasma (0.6L/kg) and so we can assume that most of the drug
remains in the plasma (probably bound to plasma proteins – this will be important later).
• The systemic clearance of the drug is worked out using:
Cls = Vd × kelim
= 7 × 0.014
= 0.1L/min
= 100ml/min
• Remember that the systemic clearance is the sum of the renal clearance of the drug and the clearance by
other organs (mostly by the liver).
• A clearance less than normal GFR (125ml/min) indicates that the drug is not being filtered very much by
the kidney or that some of the drug is being reabsorbed. By knowing the Vd of the drug, we could presume
that the drug was mainly in the plasma and hence bound to plasma proteins. This means that the drug will
not likely be filtered much at the glomerulus, hence the low clearance.
DRUG ELIMINATION
Rate of drug elimination

• Most drugs are eliminated at a rate which is proportional to their plasma concentration (at a higher plasma
concentration, the drug is eliminated quicker than at a low plasma concentration).
• This is known as 1st order elimination and is modeled by an exponential decay curve, where
• C = C0.e-kelim.t, or Where C = concentration of drug in plasma at any time

C0 = initial concentration of drug in plasma
kelim = rate of drug elimination from the plasma
• lnC = -kelim.t + lnC0
t = time
• Since it is more preferable to work with logarithms rather than natural logs, we can convert the above
formula into:
kelim × t
log C = log C 0 −
2.303
C0 lnC0
C lnC
Slope = -kelim/2.303
t1/2 Time, t Time, t

• The time taken for the plasma concentration, C, to fall to half its initial value is called the half life of the drug (t½)
• If C/C0 = ½ = e-kelim.t1/2, then
ln 2
t1 / 2 =
kelim
0.693
=
kelim
• Hence, if we know the elimination rate constant of a graph (via graphical interpretation), then we can easily work
out the half life of the drug.
• The half life of a drug can give us an indication of how long a drug will stay in the body.
• There are some drugs which are eliminated out of the body at a constant rate (i.e. independent of plasma
concentration). An example of such a drug is ethanol.
• These drugs are said to undergo zero order kinetics.
Routes of drug excretion

• Kidney
• Biliary system
• Lungs
• External secretions
• Sweat
• Milk
• By far the most important route of drug elimination from the body is via the kidney
Elimination by the kidney

• Drugs which are not metabolised by the liver rely on the kidney as the major way of removal of the drug from the
blood.
• For drugs which are metabolised, the liver modifies the drug so that it is more water soluble (more polar and less
toxic). The water soluble drug will be able to be filtered by the glomerulus and remain in the tubules rather than be
reabsorbed (because they are more polar – remember that unionised substances are more readily absorbed).
• The important processes of the kidney which are responsible for the excretion of a drug are:
• The GFR
• Tubular reabsorption
• A passive process occurring at the distal convoluted tubule
• Substances in the tubule are able to be reabsorbed into the blood (peritubular capillaries)
• The environment inside the tubule is very important in determining which drugs/substances will
be reabsorbed. Remember that unionised substances are absorbed better than ionised ones.
• The pH of the tubular fluid will determine whether or not acid or basic drugs filtered
through the glomerulus will be reabsorbed back into the blood. The normal urine pH is
in the range of 5 – 8. More on this later.
• Tubular secretion
• An active process occurring at the proximal convoluted tubule.
• Substances in the blood (peritubular capillaries) can be secreted into the tubules.
• If we rely solely on renal excretion to remove a drug, then the drug will have a very long half life in the
body (e.g. gentomycin).
Glomerular filtration rate

• Blood enters the kidney via the renal arteries. After many divisions, the afferent arteriole is formed.
• The afferent arteriole brings blood into the glomerulus, which filters the blood; what is not filtered leaves
the glomerulus via the efferent arteriole.
• The criteria which allow a drug to be filtered from the blood are:
1. Only the free drug can be filtered. By free I mean not bound to any plasma proteins.
2. Drugs with a molecular weight less than 20,000 will be filtered (albumin has a MW = 68,000)
• Some drugs are physically too large to be filtered, e.g. warfarin
3. The concentration of the drug in the plasma (a small concentration will be less readily filtered than
a larger concentration)
Tubular reabsorption
• Occurs in the distal convoluted tubule
• What determines whether a drug will be reabsorbed after it has been filtered?
1. Lipid solubility of the drug
• The more lipid soluble, the easier the drug will be able to pass through the tubular cells
and back into the peritubular capillaries.
2. pKa of the drug
• The pKa of a drug gives a measure of how strong an acid or base is.
• A very strong acid has a very low pKa
• A strong acid readily gives away its H+ so that it will be mainly in its ionised
form.
• AH A- + H+
• A very strong base has a very high pKa
• A strong base readily accepts a H+ and so will exist mainly in its ionised form.
• B + H+ BH+
• Strong acids or bases will be largely unaffected by fluctuations in urine pH, and so they
will tend to exist predominantly in an ionised form. This is good for us if these drugs are
in the tubular fluid, because they will be prevented from being reabsorbed.
• log [unionised/ionised] = pKa – pH (for acids)
• log [unionised/ionised] = pH – pKa (for bases)
• Say we have a strong acid with a pKa of 1 and a strong base with a pKa
of 15. The normal urine pH is between 5 and 8.
• At an acidic urine pH of 4,
• log [unionised/ionised] = 1 – 4 = -3 (for acids)
• log [unionised/ionised] = 4 – 15 = -11 (for bases
• As you can see, the acidic drug will have [unionised/ionised] =

10-3 and the basic drug will be 10-11. This means that more of
the drug would be present in its ionised form.
• The same calculation can be done with a basic urine pH.
• Weak acids or bases are generally more fun (by weak, I mean a pKa ≈ 5 à8) because their
ionisation state relies largely on the urine pH.
• An acidic drug in an acidic environment will tend to remain in its unionised
form, being reluctant to give away its H+. This means that if we are trying to get
rid of an acidic drug and we happen to have acidic urine, we may have some
problems.
• To get rid of an acidic drug, the urine pH should be basic.
• Likewise can be said for weakly basic drugs. A basic drug in a basic environment
will be reluctant to accept a H+ and so will tend to exist in an unionised form.
• To get rid of a basic drug, the urine pH should be acidic.
Remember the following lines

(for a base, it is just the reverse)
Acid drugs are absorbed well in acid environment
BUT…..
Acid drugs are excreted well in an alkaline urine
• The urine pH can be made acidic (to increase excretion of basic drug) by diet (eating lots
of proteins).
• The urine pH can be made basic (to increase excretion of acidic drug) by administering
NaHCO3
Tubular secretion
• Occurs at the proximal convoluted tubule
• Uses a Tm system where drugs or endogenous substances can be secreted into the tubular fluid, often against
their concentration gradient.
• The drugs and endogenous substances can share the same transporter. So too can other drugs.
• Hence, to prolong a drugs life, we can prevent it from being secreted into the tubular fluid by giving
another drug which competes for its same transporter. E.g. Probenecid competes with penicillin,
thus prolonging the life of penicillin.
• Drugs bound to plasma proteins cannot be filtered at the glomerulus, but they can be secreted.
• This occurs because as the free drugs are filtered from the blood, more of the bound drug will
dissociate and hence the “new” free drugs which missed being filtered the first time round, will be
able to be secreted.
• The extent of renal excretion varies markedly from drug to drug

• Transport processes depends on the structure of a drug and whether or not it is bound.
• The extent of renal excretion also varies form person to person, since it depends on the renal function of an
individual. Age is an important factor here since as we age, the number of functional nephrons declines.
• To calculate the renal clearance of a drug:
C u .Vu
Renal clearance =
Cp
Cu = Concentration of the drug in the urine
Vu = Urine flow rate
Cp = Concentration of the drug in plasma
• If the clearance of the drug is > GFR, then the drug has been actively secreted into the tubules
• If the clearance of the drug is < GFR, then the some of the drug has been reabsorbed
• If a drug relies heavily on the kidney for its clearance (e.g. gentomycin, digoxin), then renal function is
important and renal impairment is of utmost concern.
• Renal impairment can mean:
• Immature renal handling at birth
• Decline of renal function with age
• Renal disease
• If the drug is in very high concentrations in the kidneys, then crystallisation can occur in the tubules,
resulting in crystalluria.
• As urine flow rate increases, the extent of clearance is increased (fairly obvious)!
Biliary excretion
Excreted in faeces
Drug in bile Intestine
Reabsorbed in enterohepatic
circulation (recycled)
• How does a drug enter the bile?
• Transport systems transport the drug from the plasma into the bile against a concentration gradient
(the concentration of drug in bile > concentration in plasma).
• There are separate processes for acids, bases and uncharged conjugated forms of drugs
• It is a saturable process
• Large molecular weight drugs may be subject to this type of transport.
Lungs
• Can be used to eliminate gases and volatile anesthetics
Sweat and milk

• Drugs which are present in sweat may cause skin sensitivity
• Lactating mothers need to be aware that breast milk may contain drugs which are being taken by the
mother. These drugs may not be able to be handled by the baby
• Summary
• The elimination of a drug in the body depends if it is handled by the liver or kidney
• Need to know whether the function of either liver or kidney is compromised
• Effects of other drugs
• Their effect on the metabolism of drugs in the liver by:
• Induction of enzymes
• Inhibition of enzymes
Relative importance of metabolism and renal excretion – Systemic clearance of a drug

Clearance is: “The volume (of plasma presumably) from which all the drug is completely
removed per unit time.”
• Total clearance = sum of the individual clearances
= renal clearance + organ clearance
• Renal clearance has already been considered
• Organ clearance (e.g. by the liver)
CA CV
Organ
Q = flow of blood Q = flow of blood
Some drug eliminated
• Organ clearance is essentially measuring the amount/concentration of drug entering an organ and
then measuring the amount/concentration leaving the organ. Usually, the amount/concentration
leaving the organ is less because a certain fraction has been cleared by the organ.
• Note that amount is equal to the concentration × volume (or flow, if we want a rate)
• We calculate the extraction ratio as being:
Drug concentration in arterial blood - Drug concentration in venous blood

ER =
Drug concentration in arterial blood
(C A − C V )
=
CA
• The extraction ratio tells us how efficient an organ eliminates a drug.

• The rate of elimination is the amount (i.e. mass) of drug cleared from the plasma per minute.
• It is: Rate of elimination = Q.CA – Q.CV
NB:
C = concentration = grams/ml
• The clearance of an organ is: Q = flow = ml/min
Therefore if C × Q, then:
Q(C A − CV ) C(Grams/ml) × Q(ml/min) = grams/min
• Cl =
CA = amount of drug per minute
• The total body clearance (systemic clearance) is the sum of the renal clearance and the organ clearance.
• You can work out the organ clearance and then the renal clearance and add the 2 together to give
you the total clearance of the drug.
• An alternative way is to use this simple formula:
Cls = Volume of distribution × elimination rate constant
= Vd × kelim
• This only works for a one compartment model (1st order kinetics)
renal clearance
• Fraction excreted unchanged =
Total clearance
hepatic clearance
• Fraction metabolised =
Total clearance
• e.g. The following data was obtained for a particular drug:
Total clearance (L/hr) 3

Vd (L) 25
Fraction excreted unchanged 0.1
Liver blood flow (L/hr) 90
• To calculate renal clearance:

renal clearance
• 0.1 = ∴renal clearance = 0.1 × 3 = 0.3
3
• To calculate hepatic clearance
• Hepatic clearance = total clearance – renal clearance
= 3 – 0.3
= 2.7
Repeated drug doses
Toxic level of drug
Minimum effective level of

drug
• If a drug is administered by slow infusion directly into the circulation, the concentration of the drug in the
plasma will rise in a slow curve until it reaches a plateau, after which the drug concentration will decline in
an exponential decay curve.
• If the drug is not administered continuously in a slow infusion, but given repeated doses, the concentrations
of the drug in the body will fluctuate much more, although the mean will still be essentially the same as the
continuous infusion.
• If the drug was given twice daily, then the maximum dosage will be much smaller than if the drug
was given once daily. Why? Because if the drug was given once daily, more of it will have been
eliminated between injections.
• However, you can see that sometimes the drug concentrations will drop below the minimum
effective level, and so the drugs will have no effect. More importantly, we need to consider that no
all of the drug will have been eliminated from the previous injection, and so any subsequent
injection will add to the concentration of drug still present. This will result in concentrations of
drug which will be higher than the toxic level, causing much harm.
• Drugs such as digitoxin, which has a toxic level very near to its therapeutic level, need to have the
concentration monitored very closely, because there is little margin for error.
• Sometimes a loading dose is given where a large bolus of drug is given to the desired concentration very
quickly and maintained at that level.
DRUG METABOLISM 1
Drug metabolism
• Biotransformation is the same as metabolism.
• Metabolism of a drug involves the modification of a drug via its interaction with endogenous metabolic enzymes.
• These enzymes were not designed to handle the drugs specifically. They were designed to metabolise endogenous
chemicals, not artificial drugs. It just so happens that the enzymes choose to accept a drug as being a substrate. The
enzymes are not very selective.
• Hence, there is competition for enzymes.
• Say we have enzyme A.
• Substance A is the normal endogenous substrate for enzyme A.
• We now have a drug (drug 1) which can act as a substrate for enzyme A.
• Drug 1 and substance A will compete for the enzyme. Hence, the physiological condition of a patient may
affect the metabolism of drug 1 because of varying levels of substance A in the body.
• If there is lots of substance A, then metabolism of drug 1 will be reduced and vice versa.
• If another drug is added (drug 2) which is also a substrate for this same enzyme, we get a 3 way
competition for the enzyme. Hence, when giving drug combinations, it is important to know
how one drug will affect the metabolism of the other.
• Usually, enzymatic modification abolishes a drugs activity. There are exceptions.
• Drug metabolism:
• Reduces the drugs effect
• Often inactivates the drug
• Makes the drug more polar so that it can be readily excreted
• Occurs mainly in the SER of the liver hepatocytes.
• Can also occur in other sites:
• Kidney
• Lungs
• GIT
• Skin
• Occurs in 2 phases:
• Phase I reaction
• Phase II reaction
Phase I reactions
• Phase I reaction usually, but not always occur before phase II reactions.
• It involves the addition of some reactive functional group to the drug.
• This reactive site on the drug serves as a point of attack by a conjugating system which occurs in phase II.
• 3 main types of phase I reactions:
• Oxidation
• Reduction
• Hydrolysis
• Sometimes, reactions in phase I can inactivate a drug before phase II. e.g. Phase I hydrolysis of procaine (a local
anaesthetic) inactivates the drug.
• Sometimes, reactions in phase I can turn an inactive pro-drug into an active one.
• Sometimes, the reaction can turn a harmless chemical into a toxic one.
Phase II reactions
• Combines some endogenous substrate which is added to the phase I product (conjugation).
• Phase II reactions are usually the detoxification step.
• Sometimes, phase II reactions occur before phase I.
• e.g. Isoniazid undergoes acetylation first (conjugation of the drug with Acetyl CoA) and then Hydrolysis.
• There are some drugs which bypass phase I reactions and go straight to phase II.
• There are also drugs which are not metabolised at all (do not undergo phase I or II reactions) and are excreted
unchanged.
Factors affecting bioavailability - First pass effect

• When a drug is administered orally, it enters the gut lumen.
• Some of the drug will pass through the gut without being absorbed and excreted.
• Some of the drug will be metabolised when passing through the gut wall. Penicillin is an example of a
drug which is metabolised by the gut (also, peptide hormone drugs).
• The amount of drug absorbed intact (often considerably less than the original dose) will enter the portal
vein and go to the liver.
• As the drug passes through the liver for the first time, some of the drug will be metabolised (first pass
effect). Thus, the amount of drug which finally enters the systemic circulation is very small compared to
the amount of drug administered.
• Some important terms:
• Bioavailability
• The bioavailability is the amount of drug which actually enters the plasma. It is usually
expressed as a percentage of the original dose.
• e.g. An oral dose of 50mg results in only 10mg entering the plasma (40mg has been
metabolised or lost). Thus, the bioavailability if 10/50 = 20%
• Extraction ration
• The extraction ratio is a measure of how effectively an organ can eliminate a drug. It is usually
expressed as a percentage of the amount of drug eliminated over the amount of drug that entered
the organ.
• e.g. 60mg of a drug enters the liver from the portal circulation. After first pass metabolism, only
10mg of the drug enters the systemic circulation. 50mg of the drug has been eliminated by the
liver. The extraction ration is 50/60 = 83%
• If there is a very small change in bioavailability, the oral dose of the drug approximates the IV dose (an IV dose of
drug has a 100% bioavailability).
• If the bioavailability is very small, virtually all of the drug is eliminated in the first pass effect, so that the oral dose
must be much higher. Often, it is better to find alternative ways of administration to bypass the gut and liver.
• E.g. Glycerol trinitrate is eliminated very rapidly by the liver, hence it is given sublingually.
• The veins under the tongue drain directly to the vena cava.
• Sometimes the first pass effect is useful
• E.g. Salbutamol.
• Salbutamol is a β2 agonist. We want it to work locally at the lungs, but sometimes salbutamol is
swallowed (salbutamol is administered by a puffer).
• Salbutamol can thus enter the gut and passes through the liver.
• If salbutamol were allowed to enter the systemic circulation, it would have adverse
effects on the heart.
• Luckily, salbutamol undergoes a large degree of first pass metabolism in the liver, so
that the amount entering the systemic circulation is minimal.
• The following drugs have a high first pass clearance:
• Aspirin
• Morphine
• Salbutamol
• Verapamil
Phase I reaction – Processes

• The main phase I reactions involve:
• Oxidation
• Reduction
• Hydrolysis
• The most important phase I reaction is oxidation involving the mixed function oxidase system.
• This is an enzyme complex requiring:
• A reducing agent (NADPH)
• Molecular oxygen
• NADPH cytochrome p450 oxidase
• Cytochrome p450
• Many drugs can act to induce or inhibit the cytochrome p450 enzyme.
• Drugs which inhibit cytochrome p450 will prevent the metabolism of other drugs which rely on this
enzyme.
• E.g. Cimitidine blocks p450. If it is administered with digitoxin, digitoxin concentrations will
remain high for longer periods. Digitoxin is dangerous because it has a narrow therapeutic
window, so any factors which could lead to an elevation of digitoxin levels is a potential hazard.
• Drugs which induce the production of cytochrome p450 will accelerate the metabolism of drugs which
rely on this enzyme.
• Examples of drugs which induce p450:
• Polycyclic aromatic hydrocarbons
• Glucocorticoids, macrolide antibiotics, anticonvulsants
• Ethanol
• Benzopyrene (found in cigarette smoke, a possible carcinogen when activated by the
liver)
• PCB
• Barbituates (Phenobarbitone)
• Hence, this is an important factor which needs to be kept in mind when using drug combinations
• Mechanisms of induction (of cytochrome p450)
• Induction involves a drug binding to a cytosolic receptor.
• This drug-receptor complex is translocated to the nucleus where it stimulates the gene transcription and
the increased production of protein.
• Mechanisms of inhibition (of cytochrome p450):
• Poorly understood
• Probably via substrate competition
• A smoker can induce enzymes in the liver and also in other organs, thus increasing the metabolism and breakdown
of drugs. Hence, it important to know whether a person is a smoker or not when prescribing drugs.
Phase II reactions – Processes

• The enzymes involved in phase II reactions are all known as tranferases.
• E.g. UDP glucoronide transferase catalyses the conjugation of a drug with glucoronide.
• If a toxic phase I product is produced, the body must rely on the phase II reaction to detoxify it.
• Therefore, if a drug which has a toxic phase I product is taken at high doses, the liver will be unable to
handle the increased levels of toxic products and hence will not be able to detoxify them in phase II
reactions. The liver is dependent on the availability of endogenous molecules taking part in the
detoxification reactions.
• Conjugation usually allows for easier excretion since the drug is converted into a more hydrophilic form.
Why is first pass clearance important?

• Lets take an example of a drug which has a low extraction ratio by the liver:
• E.g. Theophyline ER = 2% Bioavailability = 98%
If liver enzymes are induced 2 fold ER = 4% Bioavailability = 96%
• Now, lets take an example of a drug which has a high extraction ratio
• E.g. Verapamil ER = 90% Bioavailability = 10%
• If liver enzymes are induced 2 fold ER = 95% Bioavailability = 5%
• What this shows is that for drugs with a low extraction ratio, a change in enzyme activity will lead to a small
change in bioavailability. On the other hand, a drug which has a high extraction ratio will have a large change in
bioavailability when enzyme activity is altered.
• This means that, for high extraction drugs, liver enzyme activity is the major determinant of bioavailability.
Summary
• Drug – drug interactions
• Some drugs may inhibit/induce the enzymes required for the metabolism of the other drug. Hence the
clearance of the other drug may be reduced or increased respectively.
• The oral does and IV dose is altered depending on bioavailability
• For high bioavailability, oral dose ≈ IV dose
• For low bioavailability, oral dose > IV dose
• Patients with liver disease will not metabolise drugs as effectively as someone with a healthy liver.
• Other factors:
• Age
• Children may not yet have the full repertoire of enzymes required for metabolism
• Elderly people have a natural degradation of liver and renal function, hence leading to
impaired clearance of drugs.
• Some drugs may be stored in the liver, e.g. diazepam. Liver degradation can
lead to reduced diazepam storage.
DRUG METABOLISM II
• What happens when there is a parcetamol overdose?
Paracetamol
Glucuronide Sulphate
Overdose
Phase I reactions
Toxic intermediates
Low overdose High overdose

Glutathine
Mercapturic acid Nucleophilic cell

macromolecules
Cell death
• Note that in a low overdose, the enzyme glutathine may be limiting (there may not be enough glutathine)
and so a low overdose may follow the path of a high overdose and cause cell death.
Factors affecting drug metabolism

• Internal factors
• Species differences
• Studies of how drugs behave in lab animals may not give a good indication of how the
drugs will behave in humans, due to species differences in the enzymes used in drug
metabolism.
• Genetic differences
• Differences in the enzymes of metabolism within species (between individuals)
• The differences mainly lie in a defect in the amount of enzyme or the activity of an
enzyme.
• E.g. Some people have a defect in pseudocholinesterase which breaks down
succinylchloride (a neuromuscular blocker). Therefore, people with this defect who are
given this drug will have prolonged neuromuscular blockade, and potentially respiratory
failure.
• E.g. The enzyme acetyl transferase is used to conjugate (via acetylation) isoniazid (an anti
microbial drug). Some people are said to be “slow acetylators” because they have an
autosomal recessive defect in this enzyme, resulting in mutations (genetic polymorphism).
• Other examples of genetic polymorphism:
• Alcohol undergoes a dehydrogenase reaction. Some people have a defect in the
dehydrogenase enzyme, and so are more sensitive to the effects of alcohol, having
intense facial blushing.
• Tolbutamide is used to decrease blood sugar. It undergoes an oxidation reaction.
A defect in the enzyme may lead to increased concentrations, and can be
cardiotoxic.
• Hydrallazine, a vasodilator, is acetylated in phase II reactions.
• Age
• Metabolism of drugs is different in the very young and very old.

• Phase I reactions develop very early in the foetus, however phase II conjugation reactions
develop perinatally. Thus, in a neonate, drugs such as chloramphenicol and morphine can
accumulate to toxic levels (lack glucuronyl transferase).
• The metabolism of some drugs may be enhanced in children. E.g. Theophaline
metabolism may be enhanced in children ages 6 – 12.
• In the elderly, the liver enzymatic ability is reduced (degradation of liver function). In addition,
there may be reduced blood flow to the liver and kidneys (the two important organs of drug
removal) as a result of cardiac impairment. A defective liver may cause hypoalbuminaemia.
• If a drug binds heavily to plasma proteins, its free (and active) concentration will rise.
• A reduced cardiac output will reduce GFR in the kidney.
• Also, in a 70 year old, there is only 50% of functional nephrons left.
• This is important in drugs which rely on kidney’s as their main route of excretion, e.g.
erythromycin or digoxin (both cardiac glycosides – very toxic).
• Diazepam is often given to elderly patients as an anti anxiolytic. The dosage for elderly patients
needs to be reduced as it is not metabolised by the liver as rapidly.
• Gender differences
• There are some differences in alcohol and estrogen metabolism in females as compared to males
• Hormonal effects
• A hypothyroid person has a reduced metabolic activity. This may increase the half life of drugs
such as digoxin. If normal doses of digoxin were given, the concentrations may rise to toxic
levels. Digoxin levels must be monitored closely as it has a small therapeutic window.
Hypothyroid people require lower doses of digoxin to reach therapeutic levels.
• Co-existing disease
• Diseases affecting the liver will generally reduce its metabolic capabilities.
• E.g. cirrhosis, hepatitis, hepatocellular carcinoma.
• Cardiac disease will reduce the amount of blood flow to the liver and kidneys
• External factors
• Drug – drug interactions
• Often, more than one drug is simultaneously administered. Drug – drug interactions may cause:
• Competition for the same enzyme involved in metabolism
• Induction of an enzyme involved in metabolism
• Inhibition of an enzyme involved in metabolism
• E.g. Ethanol may affect the metabolism of diazepam
• In an acutely intoxicated state, ethanol will inhibit the enzymes required for the
metabolism of diazepam. The half life of diazepam will increase.
• In a sober state, but chronically alcoholic, there is induction of phase I and II enzymes
and so the metabolism of diazepam will increase. Thus higher concentrations of the
drug are required.
• In a chronic alcoholic with cirrhosis, there is liver damage and so enzyme activity
would be reduced.
• E.g. Disulfram (antabuse) is used to inhibit the enzyme aldehyde dehydrogenase (ALDH), an
enzyme involved in the breakdown of ethanol.
Ethanol ADH Acid aldehyde ALDH acetic acid
• A buildup of acid aldehyde causes unpleasant reactions, often used to deter heavy
drinking.
• E.g. Digitoxin is used to increase the cardiac contractility. Its toxic levels are close to its
therapeutic levels. If phenobarbital is given in conjunction with digitoxin, it will increase the
metabolism, resulting in a reduction in digitoxin concentrations. More digitoxin is thus required
to obtain a therapeutic level. However, if phenobarbital is removed whilst taking this increased
dosage, the digitoxin concentration will exceed toxic levels.
• Remember that the enzymes involved in drug metabolism are normally required for the
metabolism of endogenous substrates (they did not evolve just for drug metabolism). Thus, you
can have competition for an enzyme between a drug and the enzyme’s natural substrate.
• Dietary factors
• Smokers can induce the enzymes required in the breakdown of theophaline
• A protein deficiency may affect enzyme production. Also may affect the production of plasma
proteins.
• Charcoal meat may induce enzymes.
• Environment
DRUG RECEPTORS
Receptor concept
• Agents do not act unless they are bound
• A drug has to find a site (a discreet surface molecule) and bind to it in order for it to do something.
• Either an endogenously produced chemical or an artificial chemical can bind to a receptor.
• There are things such as drug families
• Drugs in the same family have a chemical link
• Ligand - locus interaction:
• The ligand (drug) must bind to a specific locus (receptive molecule)
• However, the ligand may or may not evoke a response. The binding of ligand to locus is not sufficient to
say that it will evoke a response. The binding is only the first in a whole series of interactions, finally
leading to a response. i.e. Just because a drug binds to a molecule, it does not mean that the drug will have
an action!
• A receptor is a binding site for a drug which leads to a response. Otherwise, it cannot be called a
receptor. A receptor is only called a receptor if it has functional consequences.
• When binding leads to a response, the binding molecule is called a receptor.
• e.g. You can block the effects of Ach on a frogs heart by washing it in methylene blue. When the heart is washed, it
still has a blue appearance since the dye has penetrated into the cells, however, the dye has been washed from the
receptors and so Ach can work again.
• A chemical can bind with great affinity to a receptor.
• A high affinity means that even with low concentrations of the chemical, it is able to bind to many of the
receptors.
• Chemical specificity means that the chemical structure of the drug is specific for a particular receptor and
it also governs the drugs affinity. If the chemical structure is altered slightly, we may be able to change its
affinity.
Types of receptors
• Intracellular receptor
• The drug needs to pass through the cell membrane first to bind to an intracellular receptor. This receptor
could be cytosolic or nuclear.
• Nuclear receptors tend to alter gene transcription.
• e.g. Oestrogen receptor
• The action of drugs acting on these receptors is slow, taking hours or days to show effects.
• Surface receptor
• The binding of a ligand to the receptor changes the tertiary structure of the receptor which leads to
intracellular events.
• e.g. Insulin receptor (tyrosine kinase receptor family)
• Time scale in minutes
• Ion selective pore (channel)
• The drug alters the selectivity and opening of the pore.
• e.g. Nicotinic Ach receptor at the neuromuscular junction.
• Acetylcholine causes perturbation of a Na+ channel, allowing a change in Na+ permeability and
hence membrane potential. This causes contraction of skeletal muscle.
• This is a rapid response.
• A special subset is a voltage gated ion channel.
• This ion channel does not require a ligand for its activation. It relies on a change in membrane
potential.
• Time course in milliseconds
• Indirect coupling
• Binding of a drug to the receptor causes the activation of second messenger system.
• These receptors are classically describes as being 7 transmembrane spanning receptors.
• Time course in seconds
Receptor binding forces

• The least common forces seen in drug interactions is covalent bonding. It is unusual in therapeutic drugs, since the
bond between drug and receptor is difficult to break.
• An example of drugs using covalent bonding are nerve gases, which cause irreversible binding to
receptors.
• A clinical example:
• Blood vessels have α adrenoreceptors. The hear has β adrenoreceptors. Both these receptors
respond to adrenaline/noradrenaline released from the adrenal medulla to increase blood
pressure.
• Adrenaline acts on the α receptor to cause vasoconstriction. Adrenaline acts on β receptors to
cause increased force and contraction of the heart.
• Propanalol can block the β receptor
• Pbz (phenoxybenzamine) forms covalent bonds with the α receptor, thus vasoconstriction will
not occur no matter how much adrenaline is released, since adrenaline cannot displace the
competitive drug.
• Receptors will recycle, so the effects will go away after a while. New receptors will be made
without any drug bound to it.
• The rest of pharmacology is concerned with weak, reversible, electrostatic attractions.
• Ionic bonds:
• Weak, electrostatic attractions between +ve and -ve forces. Easily made and destroyed.
• Dipole - dipole interactions:
• A stronger form of dispersion forces formed by the instantaneous dipole formed as a result of electrons
being biased towards a particular atom in a molecule (an electronegative atom). E.g. Hydrogen bonds.
• Dispersion (Van der Waal) forces
• Fluctuating dipoles, transiently come and go.
• Hydrophobic interactions
• A polar molecule is repulsed in a polar solvent (e.g. H2O)
Receptor ligands
• Agonists
• An agonist binds to a binding site (a “socket”) on a receptor and leads to a response via other molecules.
Simply the act of binding to a receptor does not mean that there will be a response.
• Partial agonists
• Like an agonist but does not have the same efficacy.
• Antagonist
• Binds to the same binding site on a receptor but does not lead to a response. This is a silent antagonist. By
being able to bind to the same site, the antagonist must be of very similar chemical structure to the agonist,
but slightly different.
• By binding to the same site as the agonist, it prevents the agonist from occupying and so no action can
occur.
• There can be competitive and non-competitive (irreversible) antagonists.
• Allosteric antagonists
• Instead of binding to the same binding site as the agonist, an allosteric antagonist binds to a nearby site on
the receptor causing a conformational change. By altering the shape of the receptor, the shape of the
binding site is altered, so it cannot bind the agonist.
Dose - responses
• All or nothing
• Some drugs have an all or nothing response. That means that there is no such thing as half a response.
• e.g. The mouse experiment. A mouse given a drug will respond by sticking up its tail. The tail is either up
or down, not half. So a small amount of drug will not produce a response until it gets to some critical
concentration.
• A clinical example are drugs acting on blood vessels.
• Graded responses
• The effect of the drug on the body is dependent on the concentration of drug administered.
• The effect of the drug can be monitored by analysing the effect vs. Concentration curve.
Special sites on cells act as receptors

• The area of receptors required to elicit a response is very small. Drugs only have to occupy a few sites in order to
give a response.
• e.g. Ach can cause dilation (relaxation) of a vessel. However, if the endothelium is removed, Ach can cause no
response, or contraction.
• What happens is that Ach can bind to receptors on the endothelium. Ach causes an increase in
intracellular Ca2+ which increases the production of NO. NO diffuses the underlying smooth muscle to
cause relaxation (by sequestering intracellular Ca2+).
• If the endothelium is removed, there are other receptors on the smooth muscle which, when Ach binds to
directly, may cause smooth muscle contraction.
Occupation theory
Agonist
Binding site. If there is a

response, it is called a
Transducer receptor
RESPONSE
k+1 k+2
[A] + R [AR] + T [ART] RESPONSE
k-1 k-2
Binding of A to R is
weak, so a reversible Whether or not there is a response is
reaction is possible determined by whether the agonist-
receptor complex does something to a
transducer. If no transducer is
activated, there will be no response
ENDOTHELIUM DERIVED VASOACTIVE FACTORS
Functions of the endothelium

1. A barrier separating the vascular smooth muscle from the luminal contents.
• By acting as a barrier, it also prevents adhesion of blood cells to the lining of the blood vessel (via release
of various factors)
2. Metabolic role
• The endothelium has a number of enzymes. e.g. Serotonin released from the platelets is metabolised by
the endothelium.
3. Source of vasoactive chemicals
A. PGI2
• Predominantly synthesised in the endothelium
• A vasodilator
• Antiaggregatory to platelets
B. Endothelium derived relaxing factor (NO)
C. Endothelin
Endothelium derived relaxing factor

• When Ach is given intravenously in vivo, it causes vasodilation
• When Ach is present in an organ bath in vitro, it causes vasoconstriction
• To explain this is as follows:

• If the endothelium of the blood vessel is intact, Ach acts on receptors on the endothelial cells to produce
NO. It is the NO which diffuses to the underlying smooth muscle to cause vasodilation
• If the endothelium is absent, Ach acts directly on the smooth muscle to cause vasoconstriciton.
• At very high concentrations of Ach, it starts to contract.

• Normally, Ach can cause vasodilation (via NO) and vasoconstriction (direct action) simultaneously. At
low concentrations, the balance favours vasodilation over vasoconstriction. However, at high
concentrations, the balance is reversed, so that there is more vasoconstriction than dilation.
Other vasodilator substances
Endothelium dependent Endothelium independent

Bradykinin Nitrovasodilators (GTN)
Substance P Isoprenaline (beta agonist)
Histamine PGI2
Serotonin
• In addition to mediating vasodilatin on its own, NO can also act as a modulator to vasoconstriciton.
• e.g. If NA is present, it will cause a vasoconstriction. However, if NO is present, the vasoconstriction will be less
strong. If the endothelium were damaged, there will be no NO to modulate the vasoconstriction of NA, and so you
get a higher level of contraction (hypertension)
Functions of NO/EDRF
• Relaxes blood vessels
• Inhibits platelet aggregation and adhesion
• Inhibited by hemoglobin
• NO is rapidly mopped up by RBC, thus preventing it from circulating and also causing it to be very shory
acting
• Reacts with oxygen, making it less able to circulate
• Oxygen radical scavengers can potentiate its action
• Stimulates guanylate cyclase
• Has a very short half life (4 sec)
Synthesis of NO
• L arginine + O2 ----NOS-----> NO + L citrulline + H+
• Since L arginine is available everywhere, the rate limiting step is the activity of NOS (NOS determines whether
NO is produced or not)
• There are 2 forms of NOS:

1. A constitutive form
2. An inducible form
• Comparison of the 2 forms:
Constitutive form Inducible form

Constant activity Only active when stimulated
Found in: Found in:
Endothelium Macrophages
Nerves Vascular smooth muscle
Produces low [NO] Produces high [NO]
Short lasting Sustained
• NO can also be cytotoxic, and hence contribute to inflammatory conditions.
How to inhibit endothelium dependent dilation

1. Remove the endothelium
2. Bind NO (by hemoglobin)
3. Inhibit guanylate cyclase
• Not practical becaue guanylate cyclase is involved in many other functions
4. Inhibit NOS
• Via analogues of L arginine
Effects of NOS inhibition

• Vasoconstriction
• Hypertension
• The basal activity of NO is to modulate the vascular tone (preventing excessive systemic vasoconstriction). Thus,
NO is always being released.
• If NO is stopped being released (by some pathological reason), then hypertension may result.
Physiological role of NO
1. Flow dependent vasodilation
• If there is increased blood flow over the surface of an artery, its diameter will increase due to a more rapid
flow.
• The increase in shear forces will stimulate the release of NO. Thus, you have autoregulation of flow.
2. Inhibits platelet adhesion and aggregation

• By having more rapid flow and turbulence, you increase the likelihood of platelets sticking to the surface.
The NO released will prevent this from happening, thus preventing thrombus formation
3. Neurotranmitter
• In CNS and periphery
Endothelial dysfunction (pathological inactivation)

• Atherosclerosis, hypertension and diabetes can all lead to impairment of endothelial dependent vasodilation.
• However, the question is: is endothelial dysfunction because of these diseases, or does it lead to the diseases. We
don’t know yet!
Impaired response to Ach

• A study was done to look at the effects of Ach in coronary arteries. These arteries had no evidence of
atherosclerosis. These people all had the risk factors accociated with atherosclerosis:
• Old age, elevated cholesterol, smoking and hypertension
• What they found was a negative correlation between the amount of risk factors vs. the effects of Ach on the
coronary blood vessel. Recall that these blood vessels seemed normal in that they did not show atheroma.
Effects of Ach on the coronary vessels

Dilation (intact
endo)
Constrict
(dysfunctional endo)
No. Of risk factors
• What this shows is that exposure to multiple risk factors will lead to progressive endothelial dysfunction,
possibly resulting in coronary artery disease. Ach lost the ability to dilate arteries to increased flow,
therefore you get inappropriate vasoconstriction. Also, an absence of NO will increase the likelihood of
thrombus formation.
Endotoxic shock
• Resistance to vasoconstriction
• Due to stimulation of iNOS (inducible form of NOS) via inflammatory cells
• Vasodilation, reduced sensitivity to vasoconstrictor agents (vasoconstrictors don’t work)
• However, the hypotension is reversed by NOS inhibitors
• This results in restoration of blood pressure.
• However, the NOS inhibitors are not selective for iNOS or cNOS, and so you also get inhibition of
the constitutive form. This can result in constriction of renal arteries, leading to renal failure
Therapeutic uses
• Pulmonary hypertension
• Inhale NO gas to cause vasodilation of the pulmonary vessels
• Won’t have a systemic action because of the shory half life (hence you won’t get systemic
hypertension)
• Angina
• Use drugs which donate NO (glycerol trinitrate)
• NO is released directly from the drug, hence you do not need the endothelium to be intact to get
vasodilation
ENDOTHELIN
• Endothelin is the most potent vasoconstrictor agent

• Comes in a variety of isoforms
• ET1, ET2, ET3
• ET1 is mainly synthesised by endothelial cells
Synthesis
• Big ET1 ET1
• The enzyme is endothelin converting enzyme
• This enzyme is the target of drugs
Endothelin receptors
• ETA ET1=ET2 > ET3
• ETB ET1=ET2=ET3
• ETA and ETB mediate vasoconstriction

• ETB mediates NO and PGI2 (hence vasodilation)
• Endothelin cuases a profound vasoconstriction but is modulated by NO and PGI2 via ETB receptor
• Endothelin is also a potent bronchoconstrictor
Physiological role of endothelin

• May be involved in:
• Ischaemia
• Congestive heart failure
• Pulmonary hypertension
• In all these conditions, you can see a rise in circulating endothelin (since it is not broken down quickly, it
can circulate - it is a stable peptide). NO on the other hand cannot circulate because it only has a half life of
4 sec
• Antagonists of endothelin receptors:
• May be useful as an antihypertensive and also decrease the vasoconstriction in ischaemia.
• Also a treatment of asthma?
ENZYMES AS SITES OF DRUG ACTION I
Targets of drug action

• Drugs which are developed can act on 4 types of proteins:
• Surface receptors
• Ion channels
• Transporters/carriers
• Enzymes
• The reasons why proteins (and I will refer specifically to enzymes here) make good targets is because:
• They have high structural specificity
• Tissue specific expression
• Species differences in enzyme properties.
• Although the enzyme may have the same name and same function, there are slight chemical
differences between species which is exploited by species specific drugs.
• Enzymes act as catalysts for reactions
• Some enzymes work in cascade reactions.
• We must target the rate limiting enzyme because this enzyme limits the rate of all the other
enzymes in the reaction cascade.
• Isoforms
• Most enzymes have more than one isoform.
• The development of drugs which target specific isoforms can help in:
• Improving tissue selectivity
• Reducing side effects.
Mechanisms by which drugs interact with an enzyme

• Competitive inhibitors
• Bind to the same binding site as the substrate.
• Binding is surmountable
• Non-competitive inhibitors
• Does not bind to the same binding site as the substrate.
• Pseudo-irreversible inhibitors
• Have high affinity to an enzyme and a slow off rate. The binding is non-covalent but because the affinity is
so strong, they can be considered irreversible.
• Irreversible inhibitors
• Bind to the enzyme with strong covalent bonds
• Allosteric activation
• Does not participate in a reaction.
• Binds to the enzyme and increases its catalytic ability.
• Binds to a site different from the substrate binding site.
• Substrates and false substrates
• Drugs can act as substrates, substituting for endogenous substrates with biological activity.
Types of enzymes targeted by drugs

• Enzymes regulating cellular metabolism
• Enzymes that pump ions (ion channel ATPases)
• Enzymes involved in homeostatic regulation
• Neurotransmitter/hormone synthesis
• Degradation or action of regulatory factors
• Blood clotting enzymes
Cholesterol synthesis and hypercholesterolaemia

• Cholesterol synthesis occurs in all cells in the body, although the liver has a greater capacity to do this than other
cells.
Acetyl CoA
HMG CoA
HMG CoA Reductase
Mevalonate
Farnesyl-P-P
Squalene
Cholesterol
• The cholesterol which is formed is used for a variety of things:
• Steroid hormones
• Bile acids
• Constituent of cell membranes, making them fluid
• HMG CoA reductase is the rate limiting enzyme of cholesterol synthesis.
• In people with hypercholesterolaemia, we inhibit this enzyme so that production of cholesterol ceases.
• Inhibitors of HMG CoA reductase are:
• Mevastatin
• Lovastatin
• These 2 drugs act globally (there is no need to be tissue specific) because we want to reduce cholesterol
synthesis is all cells of the body.
• The drugs have close structural resemblance to the substrate of this enzyme, namely HMG CoA.
• By binding to the same binding site on the enzyme, HMG CoA cannot move to the next step of
the synthesis pathway.
• Treatment of a cholesterol synthesis inhibitor drug is not enough to reduce the hypercholesterolaemia. The drugs are
usually used in conjunction with drugs which chelate bile salts.
• The bile salts are prevented from being absorbed and going back to the liver (enterohepatic circulation).
They thus remain in the gut to be excreted.
• Remember that bile salts are a major source of cholesterol in the body.
Antiviral drugs
• The 2 antiviral drugs mentioned today are:
• Acyclovir
• Used against herpes virus
• Zidovudine (AZT)
• Used against HIV
• Both drugs show species selectivity. You cannot use one Acyclovir against HIV
• Both drugs are prodrugs.
• They are administered in an inactive form and are activated in the body, either by human enzymes or viral
enzymes.
• Thus, the drugs act as substrates for one set of enzymes and when activated, act as inhibitors to another set
of enzymes.
• Acyclovir is an analogue of a guanine base

• Zidovudine is an analogue of a thymidine base
• Thus, you can predict that the drugs are involved in inhibiting nucleic acid synthesis by competing with the guanine
base or thymidine base.
Acyclovir
• Targets the herpes virus
• Administered as a pro drug
• The active form is acyclovir triposphate (-P-P-P).
Acyclovir
Herpes virus kinases
Acyclovir - P
Human kinases
Acyclovir -P-P-P
DNA polymerase
Viral DNA Copy

• The inactive Acyclovir is selectively activated by the viral kinase.
• Thus, if there were no herpes viral infection, acyclovir would not be activated because it needs specifically
the herpes virus kinase.
• Acyclovir -P-P-P inhibits the viral DNA polymerase by being a competitive inhibitor to the other DNA bases,
namely guanine.
• Here, we have species selectivity between the human and the virus.
• Both humans and virus have DNA polymerase.
• If acyclovir were to act on human DNA polymerase, this would be bad.
• Luckily, acyclovir is designed to be specific for the virus DNA polymerase, and so the human
DNA polymerase is safe
Zidovudine (AZT)
• Targets HIV and other retroviruses.
• A retrovirus is a virus which contains a strand of RNA
• The virus has a special enzyme, reverse transcriptase (humans do not have this enzyme) which allows the
RNA to be “reverse transcribed” into DNA.
• The DNA is incorporated into host cell DNA.
• Whenever the host cell transcribes a section of DNA, the viral DNA is also transcribed along with it.
Transcription of the viral DNA produces viral RNA. Translation of the RNA produces viral proteins
which are necessary for the virus’s viability.
• Mechanism of action
AZT
AZT -P-P-P
Viral reverse transciptase
Viral RNA Viral DNA
Incorporated in to
host DNA
Replication of viral
RNA and protein
• AZT is activated by human kinases. Hence it is activated everywhere in the body, even when there is no viral
infection.
• However, if there is no viral infection, the active form of AZT has got nothing to do because it is species selective for
the enzyme reverse transcriptase.
• Humans do not have this enzyme, so AZT has nothing to bind to unless there is a viral infection by a
retrovirus. Only retroviruses have reverse transcriptase.
• Notice how the drug is species selective between humans and other viruses.
• AZT inhibits reverse transcriptase by preventing the addition of nucleotide bases, particularly thymidine.
• What we have just seen in the 2 examples given are:

• Competition for a natural substrates (the nucleotide bases)
• Species selectivity between humans and virus, and between virus and virus
• Cellular selectivity
• e.g. Acyclovir does not work in all cells of the body. It only works in virally infected cells because
it required the viral kinase to activate it.
A recent breakthrough in the fight against HIV - Protease inhibitors

• After the HIV has reverse transcribed its RNA into DNA, the DNA strand is incorporated into the host cell DNA.
• The viral DNA codes for polyproteins.
• 1 gene codes for several proteins strung together.
• Proteases are used to chop up this string of proteins so that individual proteins are produced.
• Human proteases chop up the polyproteins to produce coat proteins.
• Coat proteins are the proteins found on the surface of the virus
• Viral proteases chop up the polyproteins to produce core proteins.
• Core proteins are found inside the virus particle.

• Protease inhibitors are drugs which inhibit the protease enzyme.
• If we inhibit the human protease, the virus will lack surface proteins. However, the proteases in other,
healthy cells are also inhibited, which is not a good thing.
• Drugs have been developed which specifically target the viral proteases. This prevents formation of the
core proteins.
• The virus particle which is formed, thus has an intact surface coating but lacks core proteins,
rendering it inactive.
• An example of a protease inhibitor is Saquinavir
• Saquinavir competitively inhibits the active site of the protease.
• It mimics the cleavage site of the viral polyprotein.
• Protease inhibitors are often used in conjunction with AZT because resistance can develop against the protease
inhibitor (via mutations in the polyprotein).
Antibacterial drugs - Folic acid metabolism inhibitors

• Folic acid is used in the synthesis of bases (e.g. guanine, thymidine, uracil, cytosine, adenine) of nucleotides which
are used in DNA and RNA synthesis.
• The structure of folic acid is like so:
Pteridine ring pABA Glutamic acid
• Mammalian cells cannot make folic acid. They obtain it from their diet.
• Hence, mammalian cells do have a folic acid transporter molecule.
• Bacteria do not have a folic acid transporter because they don’t need it.
• Bacteria have enzymes which are capable of making folic acid de novo.
• These enzymes are good targets for antibacterial drugs because the enzymes are only found in bacteria.
• An example of this type of drug is Sulphanilamide
• It is an analogue of the pABA portion of folic acid.
• It competitively inhibits the enzyme by binding to the substrate binding site, thus preventing the actual
pABA molecule to bind and form folic acid.
• Other antibacterial drugs;
• Trimethoprim
• Methotrexate
• Both these drugs do not prevent the synthesis of folic acid. Instead, they prevent the recycling of it.
Methotrexate
Trimethoprim
O DHFR = Dihydrofolate reductase
DHFR DHFR
Folic acid FH2 FH4
FH4-C
dTMP dUMP
• Both bacteria and humans have DFHR but the enzymes are slightly different structurally, therefore selective drugs
can be developed to target either the human form or the bacterial form.
• Methotrexate and Trimethoprim are slightly different.
• They do not differ in mechanism of action. Instead, they differ in context of use.
• Trimethoprim is selective for the bacterial form of DHFR.

• Hence, it is used as an antibacterial drug
• Methotrexate is mainly selective for the human form of DHFR
• Methotrexate is used in chemotherapy to prevent the synthesis of nucleotides required for DNA
synthesis in rapidly dividing mammalian cells (cells which are out of control).
Enzymes that pump ions

• e.g. Digitoxin
• Digitoxin belongs to a family known as cardiac glycosides.
• It is used in cardiac failure to improve the cardiac output of the heart by increasing the force of contraction.
• It acts by inhibiting the Na+K+ATPase, particularly in cardiac muscle cells.
• In a cardiac myocyte, a low intracellular Na+ concentration allows Na+ to flow down its concentration
gradient into the cell. This helps to remove a Ca2+ load in the cell.
• The Na+ enters the cell via a Na+ Ca2+ counter exchange.
• Na+ flows in, Ca2+ flows out
• When the Na+ flows into the cell, its concentration is prevented from rising by its removal via a Na+ K+
ATPase which pumps Na+ out of the cell (against its concentration gradient) and K+ into the cell (also
against its concentration gradient).
• Digitoxin binds to the Na+ K+ ATPase pump and shuts it.
• Digitoxin is acting as an allosteric enzyme inhibitor. It does not occupy the ATP binding site.
• If the pump is inactivated, the Na+ concentration in the cell will rise. An increase in intracellular
Na+ concentration reduces the concentration gradient, and so less Na+ ions flow in.
• Less Na+ flowing in means less Ca2+ flowing out and so Ca2+ levels rise.
• The Ca2+ is sequestered by the sarcoplasmic reticulum
• The next time there is a depolarisation, more Ca2+ can be released, resulting in a stronger force of
contraction.
Cardiac glycosides and heart failure

• In heart failure, the heart is unable to deliver enough blood to match the body’s requirement.
• Heart failure can be caused by:
• Heart valve disease
• Damage, ischaemia
• Increased peripheral resistance due to peripheral vascular disease
• Cardiac glycosides help by:
• Increasing the force of contraction
• This increases the cardiac output, resulting in improved perfusion of peripheral tissues
• It reduces the venous pressure (which is high in heart failure) by allowing more venous blood to go to the
heart. This relieves the oedema.
ENZYMES AS SITES OF DRUG ACTION II
Aspirin
• Aspirin is an example of a drug which acts as an irreversible enzyme inhibitor.
• It inhibits the cyclo-oxygenase enzyme in the production of prostinoids.
• Production of arachidonic acid metabolites:
Aspirin Phospholipid
irreversibly
inhibits cyclo-
oxygenase Phospholipase A2
Arachidonic acid
Cyclo-oxygenase Lipoxygenases
PGG2 Leukotrienes
Lipoxins
PGH2
Prostacyclins Prostaglandins Thromboxane
• Phospholipase A2 is not a good target because arachidonic acid is widely used for many important processes in all
cells of the body.
• Arachidonic acid can act as a second messenger to regulate the function of protein kinases.
• The prostinoids (prostacyclin, prostaglandin, thromboxane) have many actions:
• Control vascular homeostasis
• Cellular proliferation
• Immune and inflammatory mediators
• Reproduction
• Aspirin (acetyl salicylic acid) irreversibly inhibits cyclo-oxygenase by the following mechanism:
Acetyl salicylic acid Salicylic acid
Cyclo-oxygenase Acetylated cyclo-oxygenase
• The acetylated cyclo-oxygenase is non-functional, and remains that way.

• A byproduct, salicylic acid, is a reversible inhibitor of cyclo-oxygenase, although much weaker than aspirin.
Clinical uses of aspirin

• Mild analgesic
• Anti pyretic
• Anti inflammatory agent
• Used in the prevention of acute myocardial infarctions
Acute myocardial infarctions

• AMI’s are often caused by a thrombus occluding one of the coronary vessels.
• Blood flow to the myocardium is thus reduced and may be insufficient for the needs of the muscle. An infarct
follows.
• Arterial thrombi are composed largely of aggregated platelets and fibrin.
• Low doses (1 per day) of aspirin can effectively block platelet cyclo-oxygenase.
• This blocks the production of TxA2, a major platelet aggregation factor.
• Therefore, aspirin can prevent the formation of arterial thrombi.
• An advantage of a low aspirin dose is that it will not inhibit the vascular endothelial cyclo-oxygenase to a great
extent. Hence, the endothelial cells can still produce prostacyclin, which is one of the anti-coagulant mechanisms
of healthy endothelium.
• Prostacyclin inhibits platelet aggregation.
• How does low doses of aspirin achieve this?
• Irreversible enzyme inhibitors work better the longer they are in contact with the enzyme. This means
that eventually, you do get irreversible inhibition of cyclo-oxygenase in the endothelial cells. The reason
why this is not a problem can be attributed to pharmacokinetics.
• Aspirin is rapidly metabolised by the liver by the first pass effect.
• Aspirin is taken orally and absorbed in the gut.
• When absorbed in the gut, the aspirin travels in the portal vein.
• While in the portal vein, relatively high concentrations of aspirin are exposed to the circulating platelets
in the portal blood.
• The cyclo-oxygenase in the platelets is irreversibly inhibited.
• Because platelets are anucleate, they are unable to resynthesise cyclo-oxygenase. The only way to get
competent platelets is to wait for new ones to be produced in the bone marrow, which takes 5 - 7 days.
Hence, the inhibition of platelets lasts for a few days.
• After the liver has cleared a significant proportion of aspirin from the portal blood, a lower concentration
of aspirin appears in the systemic circulation.
• Low aspirin concentrations will inhibit endothelial cell cyclo-oxygenase very slightly. But since
endothelial cells are able to resynthesise cyclo-oxygenase, this inhibition is of no concern.
Resynthesis is much faster than having to wait for new platelets to be made.
• Hence, endothelial cells recover from inhibition quicker while inhibition of platelets is prolonged.
• There are other irreversible enzyme inhibitors but they are mainly for toxic use (e.g. inhibitors of cholinesterases
are found in insecticides). Very few are used therapeutically.
Drugs affecting blood clotting enzymes

• e.g. Warfarin
• It has a long lasting effect, mainly due to a long half life.
• Warfarin is an analogue of Vitamin K.
• It acts to inhibit the function of vitamin K as a co-factor in the modification of clotting factors.
• Clotting factors made by the liver need to undergo a post-translational modification. This involves the gamma
carboxylation of a glutamate functional group on the clotting factor to become gamma carboxylated glutamic acid.
Clotting factor Glu Clotting factorGla
Vitamin K Vitamin K
(oxidised) (reduced)
(epoxide) (hydroquinone)
Warfarin Warfarin
Vitamin K
(partially reduced)
(quinone)
• Warfarin prevents the recycling of vitamin K by competing with it for an intracellular enzyme in the liver.
• The clotting factors therefore do not undergo gamma carboxylation.
• Gamma carboxylation gives the clotting factors negatively charges functional groups which can interact
with Ca2+. This enables the clotting factors to work together.
Example of a drug working on an extracellular enzyme

• The renin angiostensin system:
↓ GFR
↓ [Na] in distal tubule
Renin
Angiotensinogen Angiotensin I
Angiotensin converting
enzyme
Angiotensin II
Peripheral Aldosterone
vasoconstriction secretion
↑ Na resorption
↑ BP
• In hypertensive therapy, drugs are used to prevent the formation of angiotensin II by competing for angiotensin
converting enzyme (ACE), which is located on the vascular surface of endothelial cells.
• An example of this type of drug is Captopril
Structurally
Angiotensin I Phe – His – Leu similar to
captopril
ACE cleaves this bond here
Angiotensin II Phe
• Captopril is structurally similar to the peptide fragment produced when angiostensin I is cleaved to angiotensin II.
• It can thus bind competitively to ACE and prevent angiotensin I from binding.
• ACE can also cleave bradykinin, which inactivates it.
• Thus, if you inhibit the formation of angiotensin II by inhibiting ACE, you will also increase bradykinin levels.
Drugs targeting signal transduction enzymes
β adrenorecptor
G protein
Phosphodiesterase
Adenylate cyclase
ATP cAMP AMP
Protein kinase A
(cAMP dependent
protein kinase
Phosphorylates intracellular
proteins
Cellular effects
• Protein kinase A has many different effects depending on the tissue:

• In the heart PKA activates L type Ca2+ channels to increase Ca2+
• In adipose tissue, PKA activates lipolysis
• In liver, PKA can activate glycolysis.
• Phosphodiesterase breaks down, cAMP into AMP, thus terminating its action.
• Inhibitors of PDE will thus cause prolongation of the effects mediated by cAMP. PDE also breaks down cGMP to
GMP.
Isoforms of phosphodiesterase
• There are 5 main families differing in their:
1. Affinity for cyclic nucleotides
2. Selectivity for cAMP or cGMP
3. Tissue and cellular distribution
• Different roles in different tissues
• Therefore, we develop drugs which can target a specific isoform, thus limiting the effect to one
tissue.
4. Selectivity for Ca2+/calmodulin
5. Inhibition by selective inhibitors
• Note the similarity to receptor molecules. You can get the same function but different subtypes of the receptor,
differing in amino acid sequence.
Inhibitors of phosphodiesterase
• Methylxanthines
• e.g. Theophylline, caffeine
• These drugs are unselective for PDE isoforms, hence they can have wide ranging effects.
• They enhance the effects of both cAMP and cGMP.
• Theophylline is clinically used for bronchodilation in asthmatics
• This is a local effect, but if some of it is swallowed while being inhaled, it can have systemic
effects which lead to a large number of unwanted side effects.
• Some methylxanthines are also adenosine receptor antagonists.
• New generation inhibitors
• e.g. Milrinone, amrinone
• Inhibit the type II isoform of PDE.
• This isoform selectively hydrolyses cAMP and is well expressed in cardiac muscle (although it
can be expressed in other tissues as well).
• They are clinically useful as having a positive inotrophic effect in acute heart failure. (Cardiac
glycosides also have this effect but they are very toxic because they can inhibit the Na+K+
ATPase in other tissues.)
Example of a drug which acts as a functional substrate of an enzyme

• Glycerol trinitrate
• A drug used in angina
• It is a pro drug which is activated in vivo. Administered sublingually. Its activated form is NO (nitric
oxide)
• NO is a substrate activator for the enzyme guanylate cyclase.
Endothelial cell derived

Glycerol trinitrate relaxing factor
NO2- Nitric oxide (NO)
Guanylate cyclase
GTP cGMP
Vascular relaxation
• NO has many other effects:

• It acts as a neurotransmitter
• It is used as a cytotoxic chemical by macrophages
• It can be inhaled directly to cause vasorelaxation of pulmonary capillaries.
• In angina:
• Pain occurs when oxygen supplying the myocardium is insufficient for its needs. (Due to atheroma,
vasoconstriction)
• Organic nitrates cause vasodilation of large veins, hence reducing venous pressure and also reducing
cardiac output (so the heart does not have to pump as hard)
• They can also cause vasodilation of large coronary collateral vessels, hence improving perfusion to
ischaemic myocardium.
GENERAL ANAESTHETICS I
Requirements for general anesthetics

• The patient must be unconscious the whole time
• The rate of induction and rate of recovery must be rapid
• Recovery must be prompt and not unpleasant
• The level of anesthesia should be able to be adjusted as required (it must be controllable)
• The patient must not move unexpectedly - reflex responses are abolished or diminished
• Gross physiological disturbances must be avoided
General anaesthesia
• General anesthesia often involves more than one drug to get different, favourable effects.
• Premedication is often used to:
1. Treat anxiety
• Benzodiazapenes
2. Reduce pain
• Opiod anaglesics such as morphine
3. Produce muscle paralysis
• E.g. Tubocurare
4. Reduce secretions
• Induction of anesthesia is often done via intravenous anesthetics, which are quick and easy to administer.
• Maintenance of anesthesia involves inhalation agents.
Some examples of inhalation anesthetics

• Used clinically today:
• Nitrous oxide (N2O)
• N2O is not potent enough to be used as a anesthetic on its own. It is often used as a carrier
gas. It has analgesic effects.
• Halothane (metabolised)
• Isoflurane
These are not broken down in the body, and are highly stable. Hence, if they
• Sevoflurane
get into the atmosphere, they represent a pollution hazard.
• Enflurane
• Older ones (obsolete)
• Cyclopropane
• Methoxyflurane The reason these drugs are no longer used is because of their
• Chloroform potential toxicity to tissues and also they are highly flammable gases.
• Diethylether
• All drugs have the ability to cause unconsciousness, but at very high levels. Agents which are used as general
anesthetics have a primary action to make people drowsy and unconscious at low levels.
• At high levels, most of the general anesthetics have the potential to depress respiration and cause death.
Stages of anesthesia
• Stage I
• Analgesia
• Still conscious but drowsy
• Stage II
• Excitement stage
• Loss of consciousness, however, irregular ventilation may be present which affects absorption of
inhalation agents.
• Reflexes may be exaggerated.
• This is a very dangerous stage
• Stage III
• Surgical anesthesia
• Loss of spontaneous movement
• Regular, shallow respiration
• Relaxation of muscles
• Stage IV
• Medullary paralysis
• Death
• These 4 stages are no longer evident with the newer anesthetics. They were particularly evident with agents
such as ether.
How general anesthetics work?

• We do not know how general anesthetics work because we do not know what consciousness is, so we don’t
know what causes the loss of it.
• We do know that there is a strong relationship between the lipid solubility of the drug (the oil:gas partition
coefficient) and its potency.
• The MAC (minimum alveolar concentration) is a measure of the potency of a drug, and it is
inversely related to the lipid solubility of a drug.
• This means that the more lipid soluble a drug is, the lower the MAC value and the more potent it is.
MAC
Oil:gas partition coefficient
• A theory on how the drugs act is as follows:

• The drugs do not act on a receptor because there is no structural requirement. Only need to be lipid
soluble.
• Since lipid solubility is a prerequisite for potency, it means that the drug must be interacting with
lipid components in the body.
• Cell membranes are rich lipid components
• The drug gets into the lipid bilayer and physically prevents the expansion of certain ion channels
Drug molecule in
lipid bilayer prevents
channel opening
Where does this occur?

• The reticular activating system of the brain stem seems to be the most important area regulating
consciousness.
• At the cellular level, anesthetics may inhibit the conduction of the action potential and inhibit the
transmission at synapses. Higher concentrations are needed to inhibit action potential conduction, and so the
transmission at synapses seems to be more important.
• Theories as to the site of action:
1. Act at the synapse
• Interfere with Ca2+ conductances
• Reduction in transmitter
• Reduction in the sensitivity of the post synaptic cell
2. Afferent blockage
• Reduction in the response to noxious stimuli
• Thalamic depression (so signals cannot go to the cortex)
3. Depression of RAS
• The RAS modulates cortical activity
4. Intercellular communications
• All neurons are connected by gap junctions
• The drug may interfere with the gap junctions, thus interfering with the occilating fields
which maintain our consciousness.
Pharmacokinetics
• Ideally, inhalation anesthetics have a very rapid rate of induction.
• The rate of induction is dependent on various factors:
1. Concentration of the gas in inspired air
2. The solubility of the gas in blood (blood:gas coefficient)
• The higher the coefficient (the more soluble the gas is in the blood), the longer it takes for
the gas to reach equilibrium with the concentration in the lung.
• What we want is for the tension (concentration) of the gas in the blood to reach
equilibrium (become equal to) the concentration of the gas in the lungs (we want Fa/Fi =
1).
• If the gas is very soluble in the blood (essentially, the gas is being removed), then it will
take longer for the gas to reach equilibrium.
3. The solubility of the gas in tissues
• Initially, there is a steep rise in gas tension but as the blood containing the gas starts to
circulate, the gas gets redistributed to tissues.
• Tissues which are normally highly perfused, will get the drug first. These tissues are the
brain, heart, liver, kidney and gut.
• The lipid:gas coefficient (lipid solubility) is a measure of the solubility of the gas in tissues
and gives an indication of the potency. The higher the value, the more readily the gas will
dissolve into the brain (our target organ).
• However, there is a tradeoff. The more the gas is removed from the blood and into the
tissues, the longer it will take for the drug to reach equilibrium. The leveling off of the
graph is due to the redistribution of the drug into the tissues. If the drug did not
redistribute, equilibrium will be reached much quicker.
4. Rate of delivery of the gas into the lungs (respiratory rate)
• The faster you breathe, the quicker the gas reaches the lung and the quicker it takes for the
gas to enter the blood (hence a faster rise in tension)
5. Rate of removal of the gas from the lungs (heart rate)
• The faster the heart rate, the quicker the drug is removed from the blood as a result of the
increased delivery to tissues.
• Therefore, an increased heart rate leads to a prolonged time to equilibrium.
Effect of respiratory rate on arterial tension

Fa/Fi
1.0 8 L/min
4 L/min
2 L/min
Time
Effect of cardiac output on arterial tension

Fa/Fi
1.0 2 L/min
18 L/min
Time
• If a patient is struggling or anxious, their heart rate (and hence CO) will be increased and so they need a
higher concentration of inhalation anesthetic for a longer time to induce anesthesia.
• On the other hand, a person suffering from shock will have a reduced heart rate and increased ventilation.
This means they will get a faster equilibration and induction of drug. If this is not taken into account, and
the person is given normal concentrations, cardiac depression may occur, resulting in heart failure.
• People who have some underlying lung condition, (V/Q mismatch and pulmonary shunt), will take longer to
reach equilibrium because some blood going to the lungs will be bypassing alveoli containing the drug.
Properties of inhalation anesthetics
Drug Blood:gas coefficient Time constant

(time to reach equilibrium)
N2O 0.47 1.2 min
Isoflurane 1.4 1.8
Enflurane 1.80 2.0
Halothane 2.30 3.1
Methoxyflurane 10.0 8.6
Diethyl ether 12 7.2
• The lower the solubility, the faster the onset and the faster the recoverability.
How doses are worked out

• The tension of the gas in the blood comes to equilibrium all at the same time, irrespective of the size of the
person.
• The concentration effect relationship is used to determine the MAC (minimum alveolar concentration) for
anesthesia.
• It is defined as the concentration of inhalation agent needed to cause 50% of the people to go to sleep.
Response
(No. of people
going to
sleep)
Concentration
MAC
• Practically, we do not give the exact MAC value, because we preferably want a better guarantee than 50%
that the patients will be anesthetised. In practice, we use a concentration that will cause around 85% of
people to go to sleep (20 – 30% of the MAC)
• The MAC value is an indication of the potency of an agent.
• It is inversely related to the lipid solubility.
• The higher the lipid solubility, the lower the MAC
• Typical MAC values are:
• Halothane 0.7% of 760mmHg
• Enflurane 1.7
• Isoflurane 1.2
• Sevoflurane 1.7
• Desflurane 6.0
• If the concentration given is too low:

1. Movement may occur Premedication of analgesic drugs and muscle
2. Reflex activity present (laryngeal spasm) relaxants are designed to minimise these effects
3. Hypertension
4. Awareness
• If the concentration given is too high:

1. Myocardial depression
2. Respiratory depression
3. Delayed recovery
Cardiovascular effects of inhalation anesthetics
Agent Effect on BP Effect on contractillity

In isolated heart tissue In vivo
N2O 0 ↓↓ 0
Halothane ↓ ↓↓↓ ↓
Methoxyflurane ↓ ↓↓↓ ↓
Enflurane ↓ ↓↓↓ ↓
• If the heart is depressed, the vasomotor center of the brain will respond to maintain blood pressure.
• However, if a person has some sort of heart disease, the vasomotor center will already be active
(there will already be some amount of vasoconstriction). If anesthetics are given to a person with
heart conditions, compensation will not be available, and so there is a marked drop in blood
pressure.
• The same is true for a patient in shock, whose vasomotor center will be active as well.
Respiratory effects
• All anesthetics cause depression of respiration, leading to an increased PACO2 EXCEPT nitrous oxide!
• In a normal person, when PACO2 is increased, there is a corresponding increase in minute ventilation.
• Howeveer, a person breathing halothane will have an alveolar CO2 level of 60 – 65 (normal 40 –
45) and very little increase in minute ventilation.
• After a while, the brain no longer responds to CO2 levels as a stimulus for breathing (which it
normally does). It is now dependent on oxygen. If something happens and there is no O2 in the gas
mixture, the person will die because they cannot respond.
Side effects of some specific inhalation agents

• Halothane
• Causes dose dependent hypotension, myocardial depression
• May cause arrhythmias
• Liver toxicity in some people
• Raised intracranial pressure
• Pollution
• Enflurane
• Less chance of arrhythmias
• Also causes dose dependent hypotension
• May cause convulsions
• May cause renal dysfunction
HISTAMINE AND ANTIHISTAMINES
Synthesis and metabolism of histamine
Histidine
(From diet)
L histidine decarboxylase
Histamine N Histamine
methyl transferase Diamine oxidase
(DAO)
N methyl histamine Imidazole acetic

acid (IAA)
Monoamine oxidase
(MAO)
N methylimidazole acetic
IAA Riboside
acid (NMAA)
If histamine is
overproduced, NMAA
will be the diagnostic
Excreted in urine
marker in the urine
Distribution, turnover and storage of histmine

• In the tissues, the histamine concentration can range from less than 1 to over 100µg/g
• The tissue distribution of histamine is identical to the mast cell distribution (wherever mast cells are, there
will most likeley be histamine present).
• Mast cells are distributed in:
• Skin
• Bronchial mucosa
• Gut mucosa
• Other mucosal surfaces
• Mast cells synthesis histamine very slowly and store it in specific granules for a very long time (until
needed).
• Histamine levels in the plasma are normally very low.
• Histamine levels in the CSF are high.
• In the brain, stomach, healing tissues and some cells in the skin, histamine is not stored in granules.
• It is produced de novo
• It has a high turnover (made quickly, destroyed quickly)
• Low steady state levels
Basic mast cell biology

• An allergic response will occur when an allergen causes cross linking of IgE molecules.
• The cross linking of IgE antibodies will cause the IgE receptors (Fcε R1) on the surface of the mast cell to be
brought into close proximity to each other.
• The Fcε R1 receptor has an intracellular domain which belongs to the src family of kinases. The kinases are tyrosine
kinases, of which there are 2 (lyn and syk). When IgE binds, it casues a conformational change which allows
phosphorylation of one of these tyrosine residues (lets say lyn – it may be syk).
• Phosphorylation of the tyrosine activates the tyrosine kinase (lyn). This activated tyrosine kinase cross
phosphorylates the other tyrosine kinase (syk) on the other Fcε R1 receptor.
• The phosphorylation of the syk tyrosine kinases allows phosphorylates the enzymes phospholipase C.
• Note that for those who do not get allergic reactions, there is no cross linking of IgE molecules and so only
one Fcε R1 receptor is activated. The binding of IgE to the receptor will cause phosphorylation of the lyn
tyrosine kinase but since there is no other Fcε R1 nearby, cross phosphorylation of syk cannot occur. It is
the syk tyrosine kinase which is able to activate phospholipase C.
• PLC breaks down membrane phospholipids and releases IP3 as a product.
• IP3 causes the release of Ca2+ from intracellular stores.
• Ca2+ results in the release of granules (Ca2+ dependent exocytosis)
• The stored granules have a pH of 5.5. At this pH histamine is positively charged. It is held inside the
granule by ionic interaction with negatively charged molecules also in the granule.
• These molecules are:
• Heparin
• Chondroitin sulphate
• Proteases
• The histamine released can act on the mast cell it came from and inhibit the further release of histamine
(autoinhibition). Histamine does this by acting on a H2 receptor on the mast cell.
• The H2 receptor causes the activation of adenylate cyclase which increases the amount of cAMP.
• cAMP inhibits the release of histamine
• The mast cell also has a β2 receptor which also does the same thing. Therefore, β2 antagonists can inhibit the
release of histamine from mast cells.
What triggeres the release of histamine?

• Anaphylactic triggers
• Antigen specific, IgE mediated
• Anaphylactoid triggers
• Organic bases Many drugs used in therapy
• Morphine can trigger mast cells to
• Tubocuravine release histamine
Neuromuscular blockers
• Succinylchloride
• Contrast media used in radiography
• Dextran
• Vancomycin (an antibiotic)
• Complement (C5a, C3a)
• Some neuropeptides
• Venom from insects (e.g. mastoparan from wasps)
Diseases associated with increased histamine

• Urticaria pigmentosa (mastocytosis)
• Increased mast cells in skin
• Itchy, coloured lesions

• Systemic mastocytosis
• Mast cells increase in organs
• Myelogenous leukemia
• Increased numbers of basophils
• Basophils are of different origin to mast cells but have similar effects
• Gastrinoma
• Zollinger-Ellison syndrome
• Increase in gastrin release resulting in excessive release of histamine from ECL cells in the gut.
• Get ulcers and diarrhea.
• Urticaria
• Dermographism
• Puritis
• Headaches
• Weakness All these can be caused by histamine
• Hypotension
• Flushing of the skin
• GIT disturbances
• Ulcers
Effects of histamine in humans

• Burning Due to sensory nerve stimulation
• Itching Due to senosry nerve stimulation
• Warmth Due to sensory nerve stimulation/vasodilation
• Skin flush Vasodilation
• Hypotension Vasodilaton which leads to reduced peripheral resistance
• Increased HR Reflex tachycardia to compensate for the reduction in blood pressure.
• Headache Vasodilation/stimulation of afferent nerve fibres
• Skin oedema/hives Microvascular leakage
• Colic/nausea GI irritation
• Acid hypersecretion Action of histamine on H2 receptors on partietal cells
• Bronchospasm Effects of histamine on smooth muscle contraction in bronchi
• Triple response
• Red spot Vasodilation
• Wheal Leakage of vessels
• Flare Axon reflex. Stimulation of sensory afferents signals itchy pain. Antidromic impulses from
branches of the axon cause release of chemicals causing nearby flare.
Histamine receptors
• 3 types (H1, H2 and H3)
• All are 7 transmembrane spanning G coupled receptors
• When histamine binds, it causes a conformational change which exposes a region on the intracellular tail of the
receptor which allows G proteins to bind.
Receptor subtype Location Prototype blocker Signalling molecule

H1 Smooth muscle Diphenhydramine PLC, IP3, DAG
Microvessels
Endothelium
Sensory nerves
H2 Stomach Cimetidine Increase in cAMP
Heart
Mast cells (autoinhibition)
Endothelium
(smooth muscle)
(lymphocytes)
H3 Nerves Impromidine G coupled
Brain Ca2+ entry
(gut)
(heart)
You must know the drugs listed on the handout

Signal transduction
• H1 receptor
• G protein
• Activates phospholipase C which causes release of IP3 and DAG
• IP3 stimulates release of intracellular Ca2+ stores
• DAG (in conjunction with Ca2+) activates protein kinase C
• Free intracellular Ca2+ may also activate Ca2+ dependent protein kinases
• e.g. myosin light chain kinase in smooth muscle (causing contraction)
• May also activate phospholipase A2 which causes production of eicosanoids
• H2 receptor
• G protein
• Activates adenylate cyclase
• Incrrease in cAMP
• H3 receptor
• G protein mediated Ca2+ entry from the extracellular compartment into the cell (note the difference to H1
receptors where the increase in cytosolic Ca2+ is from intracellular stores.)
Histamine in the brain

• Histamine is synthesised and degraded by enzymes in synaptosomes.
• H1 receptors in brain
• Found in hypothalamus
• Affect wakefulness (many antihistamines cause drowsiness)
• Appetite suppression
• H1/H2 receptors involved in:
• Drinking
• Thermoregulation
• Secretion of ADH
• Blood pressure regulation
• H3 receptors
• Poorly understood. Modulate H1 effects?
Histamine in the heart

• Increase in atrial and ventricular force via H2 receptors (increase in Ca2+)
• Increase in heart rate by reducing the diastolic depolarisation time is the SA node (H2 receptors)
• Decrease in the AV conduction time (H1 receptors)
• Arrhythmias (only in high doses)
• The above effects of histamine on the heart are only in experimental conditions. In the body, these effects do not
show any significance since they are overshadowed by the baroreflex, which is a more powerful controller of heart
rate and contractility.
Histamine in smooth muscles

• Bronchial smooth muscle H1: contraction is the dominant pathway
• Gut smooth muscle H2: relaxation (via increase in cAMP) is a weak minor compensation
(modulates H1 effects of constriction)
Histamine in the vessels
• H1 activates endothelial relaxation via NO (+PGI2)
• H2 activates a slower onset of direct relaxation. (some micorcirculations are very sensitive to histamine, so that a
H1 spasm may dominate)
Histmaine on the microvasculature

• Contrary to popular belief, histamine does NOT increase capillary permeability.
• Histamine works on the post capillary venule to increase the gap formation between endothelial cells, causing
plasma leakage. (Especially in acute inflammation)
• Histamine may increase the gap formation in 2 possible ways:
• Active contraction of the actin filaments in the endothelial cells.
• Transient de-adhesion
• The endothelial cells are attached to each other via tight junctions. There are also tiny elastic
filaments which are tonically active and will tend to pull the cells apart if there is no physical
connection between the cells. Histamine may cause a loss of adhesion of the tight junctions,
allowing the elastic filaments to cause tiny openings between the endothelial cells.
Agonists and antagonists

• Agonists
• No therapeutic use
• Only used in specialties such as in bronchial hypereactivity testing for asthmatics
• Used by dermatologists as a positive control to test for allergen reactivity.
• Antagonists
• H1 antagonists are used to treat mild allergies
• Hay fever
• Allergic conjunctavitis
• Rhinitis
• Some skin disorders
• Other “potential” uses of H1 antagonists
• Colds (useless, may even be harmful due to their sedative effect)]
• Asthma (never used any more, even though the airways of the asthmatic are filled with mast
cells)
• Useful in histamine overproduction diseases
• Motion sickness (not as effective as ascopolamine)
• Vomiting (not as good as ondansetron)
• H2 antagonists are often used to treat:
• Peptic ulcers
• Dyspepsia/heart burn
• Gastric reflux
Classic H1 antagonists
• Are seadtive
• Often short acting (3 – 6 hours)
• May have significant anti-cholinergic action
• See the handout for the names of the drugs (need to know!)
Non sedating (new generation) H1 antagonists

• Low or zero CNS penetration
• Long acting
• Little anticholinergic effects
• See the handout for the names of the drugs (need to know!)
• An important points about some of the new generation drugs:
• Polymorphic Ventricular Tachycardia (PVT) may occur with astemizole and terfenadine if
these drugs are taken in high doses or in conjunction with certain macrolide antibiotics
(erythromycin and clarithromycin) and/or certain anti-fungal drugs (ketaconazole and
itraconazole). These other drugs inhibit a hepatic cytochrome p450 enzyme which is required
for the metabolism of these 2 H1 antagonists.
H2 antagonists
• Also on the handout, but I will put them here anyway since there are not many
• Cimetidine
• Ranitidine
• Famotidine
• Nizatidine
How H2 receptors mediate acid secretion
Gastrin
G Parietal cell
Cl-
K+
ECL cell Histamine H2

↑ cAMP
H+
K+
M
Ach from Vagus

Proton pump
What we are expected to know

• H1 involved in allergy
• H2 involved in acid
• H3 involved in alertness
• Know:
• Synthesis and degradation pathway of histamine
• The distribution of histamine and mast cells
• Effects of histmine in humans
• Biology of mast cell degranulation
• Histamine receptor subtypes
• G proteins
• Transduction mechanisms
• Biology of acid secretion
• Uses of H1 blockers in allergy
• Differences between classical antagonists and the new generation
• Why H2 blockers are used to treat ulcers
• Be able to give the names of the drugs in the handout
• The basis of PVT
ION CHANNELS 1
• The main ion selective channels present on cell membranes are:

• Na+
• K+
• Ca2+
• Cl-
• Normal concentrations of the ions in the extracellular vs intracellular compartments:
K+ = 5mM
Na+ = 140mM
K+ = 140mM
Na+ = 30 mM
• The equilibrium potential can be calculated using the Nernst equation.

• The equilibrium potential is the membrane potential at which there is no ion flux across the membrane.
• The Nernst equation is:
615
. [ion] outside
E= × log
valency [ion] inside
• Using the Nernst equation the following equilibrium potentials are obtained:
615
. 5
• EK = × log
1 140
= − 89mV
• ENa = + 41 mV
• What this means is that a membrane potential of -89mV is required to prevent K+ from leaving the cell
• A membrane potential of +41mV is required to prevent Na+ from entering the cell.
• The actual membrane potential of a cell is around -60mV. At this membrane potential, the net driving
force of the ions is:
• For K+: K = EM - EK
= -60 - - 89 Note: A +ve value means a net flow out of the cell
= + 29 A -ve value means a net flow into the cell
• For Na : +
K = -60 -+ 41
= -101
• So, at the normal membrane potential, K+ ions would love the get out of the cell and Na+ ions would love
to get into the cell. However, this is not the case. There is some loss of K+ out of the cell (leakage) and
some influx of Na+, however they are not great and the concentrations are maintained at normal values via
the action of a Na-K ATPase which “throws” out any Na+ (against its concentration gradient) which is not
supposed to be inside the cell and “pulls back” any K+ which has leaked out (also against its concentration
gradient).
• The reason why Na+ and K+ cannot move freely across the membrane as they would like to do is
because the cell membrane is not very permeable to charged ions. In order for these ions to cross
the membrane, they must pass through ion specific channels which, under normal membrane
potential, are closed (hence the inability for Na+ to enter cells and K+ to leave).
Voltage gated ion channels

• If the Na+ channel (pore) is open, there is a massive influx of Na+ into the cell (as predicted by the net driving force
of - 101). This influx of Na+ is dependent on:
• The concentration gradient
• Na+ flows down its concentration gradient (from high concentration to low concentration).
• The larger the difference between the outside concentration and the inside concentration, the
greater the driving force (this can be calculated using Nernst)
• Thus, as Na+ enters the cell, the concentration inside the cell will rise, thus reducing the
concentration difference and hence the driving force. There will be a point at which no more Na+
will enter due to equilibration of the Na+ concentration (this does not occur though!)
• Electrochemical gradient.
• Na+, being a positive ion, will obviously be attracted towards the negative intracellular membrane
potential.
• However, as more Na+ enters the cell, the membrane potential will rise towards a more positive
value. If the membrane potential becomes positive, Na+ ions would be repelled rather than
attracted towards the inside of the cell, despite its concentration gradient.
• Back to the ion channel.
• At normal membrane potentials, the Na+ channel is closed. This channel is voltage gated, meaning that whether or
not it is open or closed depends on the membrane voltage (it is closed at normal membrane potential of -60mV).
Na=140 mM 0 mV
Na=30 mM -60 mV
Channel closed at -60mV

Na+ voltage gated
channel
• Lets consider a nerve fibre:

• As an action potential comes along, a voltage sensor becomes activated and opens the Na+ channel. This
allows Na+ to enter the cell causing the inside of the cell to become more positive (depolarisation). The
rapid influx of Na+ corresponds to a marked increase in the Na+ conductance (due to an increased Na+
permeability as a result of the channels opening).
Conductance
Membrane
potential
Time
• As the Na+ is coming in, there is also a voltage gated K+ channel. When this channel opens, K+ will rush out of the
cell. As K+ leaves the cell, the membrane potential will quickly plummet towards resting membrane potential
(replolarisation). The increase in K+ conductance corresponds roughly to when the Na+ conductance starts to
decline.
Drugs which affect the Na+ channel

• Local anaesthetics bind to the Na+ channel and stop it from opening, hence propagation of an action potential
cannot occur.
• The most common local anaesthetics are:
• Lignocaine
• Procaine
• Cocaine
• Benzocaine
• Common neurotoxins are:
• Tetrodotoxin found in puffer fish

• Saxitoxin
• The mechanism whereby the drug can stop channel opening is as follows:
• There are 3 forms of the Na+ channel:
• Resting (closed)
• At resting membrane potential, the Na+ channel is closed by the M gate. The H gate is
open.
• Open
• When there is a depolarisation, the M gate opens, allowing the Na+ channel to let Na+
into the cell. Both the M gate and the H gates are open.
• Inactivated.
• At intense depolarisation, the H gates become closed. This stops any Na+ flowing in and
allows for repolarisation to occur to bring the membrane back to resting potential.
• Closure of the H gates signify an inactivated channel. The channel cannot be stimulated
to open. Closure of this channel and the prevention of any Na+ influx is the basis for the
relative refractory period.
• When the membrane potential returns to resting, the H gates open and the M gates
close, signifying a resting channel waiting to be stimulated.
• The drug binds to the inactivated form of the Na+ channel. It binds specifically to the closed H gates and
prevents them from reopening. Hence, when the membrane potential returns to resting values, instead of
the H gates opening and the M gates closing, the H gates remain closed and no depolarisation can occur,
even if an action potential arrives. The channel is permanently inactivated.
• Most local anaesthetics are weak bases. The drug passes through the membrane in its unionised
form. Once in the cell, where the pH is low, the drug will become protonated and charged.
• It is the charged form of the drug which is active.
• These drugs are said to be use dependent.
• The nerve needs to be stimulated first. The more the nerve is stimulated, the better the drugs
work to keep the channels inactivated.
• As the nerve is stimulated, the M gates open and allows for the entry of Na+. The open gate may
also allow the entry of charged drug molecules to enter dirctly into the cell. Following
depolarisation, the H gates are closed and remain closed when the drrug binds to them.
• If there were no stimulation:
• The channels would not open to allow more charged drug molecules to enter
• The H gates would never be closed, since the channel is in its resting state. Only the M
gates are closed. The drug can only bind to the closed H gate.
Resting Open Inactivated
H gate
M gate
Drugs bind to the inactivated channel

when the H gates are closed and prevent
opening of the H gates.
Drugs which activate the voltage gated Na+ channel - Increase the ability of the Na+ channel to open.
• Normally, the Na+ channel remains closed at resting membrane potential. When the membrane depolarises to a
threshold value, the Na+ channels open.
• Some drugs are able to make the Na+ channels open easier, thus lowering the threshold and causing increased
excitability, and prolonged depolarisation by preventing channel closing.
• Examples of these drugs are:
• Scorpion toxin
• Sea anaemonie toxin
• DDT, pyrethrins
• Veratridine
Ligand gated Na+ channel

• Instead of being activated by a ligand, this channel is activated by the binding of a ligand.
• This type of Na+ channel is typically found at the neuromuscular junction.
• The channel consists of various subunits, and Ach released from the nerve terminal binds to the α subunit. Binding
causes a conformational twist which opens the channel, allowing Na+ to enter the muscle.
• Events at the neuromuscular junction:
1. An action potential is propagated down a nerve fibre via voltage gated Na+ channels.
2. At the nerve terminal, a voltage gated Ca2+ channel is activated, allowing an influx of Ca2+.
3. An increase in intracellular Ca2+ causes the release of Acetylcholine from the nerve terminal
4. Ach binds to the α sububit of a ligand gated Na+ channel of the muscle
• Ach is also broken down in the synaptic cleft by Acetylcholinesterase (ACE).
5. Opening of the ligand gated channel causes an influx of Na+ into the muscle
6. An influx of Na+ causes a depolarisation.
7. This membrane depolarisation triggers the activation of voltage operated Na+ channels on the sarcolemma
which allows the propagation of an action potential down the muscle fibre.
8. This muscle action potential causes the release of intracellular Ca2+ from the sarcoplasmic reticulum.
9. An increase in Ca2+ allows the contractile mechanisms to operate, causing muscle contraction.
The K+ channel
• K+ channels allow K+ to leave the cell, making the membrane potential more negative and hence making the cell
less excitable.
• There are 3 main types of K+ channels:
• Voltage operated K+ channel
• The more depolarised the membrane potential, the more activated these K+ channels. Hence,
when the membrane is depolarised, opening of these channels, allow K+ to leave the cell, thus
repolarising the cell, returning it back to resting states.
• Calcium linked K+ channel
• When the intracellular Ca2+ levels increase, this channel is opened, allowing K+ to leak out and
cause a repolarisation. This repolarisation blocks Ca2+ entry, thus bringing the cell back to a
steady state.
• Blockers of this channel allow Ca2+ levels to rise to dangerous levels in the cell. High levels of
Ca2+ are cytotoxic. Examples are:
• Apamin (found in bee venom)
• Charybdotoxin (found in scorpion venom)
• ATP sensitive K+ channel
• When the ATP levels in the cell is low (as in hypoxia), K+ is allowed to leak out to shut the cell
down (making it go to sleep)
• High levels of ATP inhibit the channel (close the channel)
• Low levels of ATP activate the channel (open the channel)
• This channel is the target of most therapeutic drugs
• Drugs which bind to this channel and facilitate its opening are useful in hypertensive patients. K+
is allowed to leave the vascular smooth muscle cell, hyperpolarising it and making it less
excitable (relaxing it). This relaxation allows for vasodilation to occur.
• Some opener drugs:
• Cromakalim
• Diazoxide
• Pinacidil
• An example of a drug which blocks the opening of this channel is glibenclamide.
• This drug is used as an oral hypoglycemic (lowers blood glucose)
• The β cells of the pancreas have a resting membrane potential which is maintained by
the ATP sensitive K+ channel. Normally, ATP is low and the channel is open, keeping
the membrane potential negative. When there is lots of glucose metabolism, ATP rises,
closing the channel and allowing the β cell to depolarise (since K+ can no longer leak
out).
• Depolarisation of the β cell allows the influx of Ca2+ via a voltage gated Ca2+ channel.
Ca2+ is required for the secretion of insulin.
• By binding to the ATP sensitive K+ channels on β cells of the pancreas, the drug mimic
the effect of high ATP (it keeps the K+ channel open). The β cell is depolarised and
stays that way, allowing for Ca2+ influx and insulin secretion.
• The concentration required to cause this effect in β cells is very low. Glibenclamide can
also be a vasoconstrictor, but the concentrations to achieve this are very high.
Therefore, we don’t have to worry about the effects of vasoconstriction is we want to use
the drug as a hypoglycemic.
ION CHANNELS II
The role of Ca2+ in muscular contraction

• In skeletal muscle
• Depolarisation of the muscle fibre (by the action of Ach and Na+ flow) causes the release of Ca2+ stored in
the sarcoplasmic reticulum. Ca2+ is then able to cause contraction.
• Note that no Ca2+ has been required from the extracellular fluid.
• Contraction stops when the membrane repolarises (the Na+ channels close and K+ channels open).
• C2+ channel blockers do not affect skeletal muscle due to the fact that skeletal muscle does not have any
Ca2+ channels for the drugs to work on!
Excitation
SR
No calcium channels so
drugs do not affect
skeletal muscle
Ca2+ released from SR
Contraction
• In cardiac muscle
• Cardiac muscle contraction differs in many ways to skeletal muscle contraction.
• As you know, the heart has an intrinsic ability to contract, thus no stimulation is required.
• Depolarisation of the cardiac muscle by the SA nodal conduction causes the opening of Na+ channels. As
the membrane depolarises further, Ca2+ channels open. This allows the influx of Ca2+ from the
extracellular fluid. Ca2+ channels stay open longer than Na+ channels, hence the action potential of cardiac
muscle has a prolonged depolarisation which is maintained by the influx of Ca2+.
• The influx of Ca2+ stimulates the sarcoplasmic reticulum to release stored Ca2+. The release of Ca2+ from
the SR in cardiac muscle is thus voltage independent (unlike in skeletal muscle) and relies on Ca2+ (“Ca2+
stimulates Ca2+”).
• After contraction, the intracellular Ca2+ concentration is reduced by being sequestered by the SR or being
removed out of the cell by a Na+ Ca2+ countertransport.
Ca2+ channel
Na+ Ca2+ counter

exchange
Ca2+ SR
Na+
Ca2+
Contraction
• In smooth muscle (e.g. blood vessels)

• Ca2+ may enter the cells via a receptor operated Ca2+ channel (ROC). E.g. Noradrenaline released from
nerve terminals act on α receptors on the vessel to cause the opening of ROC channels.
• Ca2+ may also enter via voltage gates Ca2+ channels VOC, which open when the membrane becomes
depolarised.
• Hormones may also act on receptors on the vessel to cause Ca2+ release from the SR via second messenger
cascades (e.g. IP3 can stimulate the release of Ca2+ from the SR)
Ca2+
conotoxin
N channel
NA
Hormone
Ca2+ Ca2+
Felodipine
α receptor
ROC VOC L channel
Types of Ca2+ channels

• Voltage operated channels (VOC)
• There are multiple subtypes of VOC’s
• L channel
• Found in the heart and blood vessels
• N channel
• Found on neurons
• P channel
• Found on purkinje cells, NMJ
• T channel
• Found in the heart (particularly SA node, AV node), neurons and blood vessels
• Receptor operated channels (ROC)
• Found in smooth muscle (e.g. blood vessels, but also anywhere else which may have smooth muscle)
• The ligands of the receptor can be adrenaline/noradrenaline acting on the α receptor or serotonin acting on
its own receptor.
• Stretch operated channels (SOC)
• Found on the sarcoplasmic reticulum
• Is involved in the myogenic response
• Second messenger operated channels (SMOC)
• Found on vascular smooth muscle
• Open by an intracellular second messenger (e.g. IP3, cAMP)
• The Ca2+ channel blockers only work on the voltage operated channels, and hence these are the channels which I
will go into more detail with.
Voltage operated calcium channels

• The different subtypes of VOC’s are characterised by their electrophysiological characteristics.
• In cardiac muscle or nerves, initial membrane depolarisation is the result of Na+ channels opening, causing a
massive influx of positive Na+ ions going into the cell, making the cell depolarise.
• In the nerve cell, as the membrane depolarises to a certain point, the Na+ channels close and K+ channels open,
allowing for K+ ions to move out of the cell, bringing the membrane potential back towards negative
(repolarisation).
• In cardiac muscle, the muscle potential is very different. As the membrane is depolarising, Ca2+ channels are
opening as well as Na+ channels. However, when the Na+ channels close, the Ca2+ channels are still open,
maintaining a depolarisation for longer (plateau stage), before the K+ channels open and repolarise the cell.
Na+ channels close

Na+ channels open
Ca2+ L channel
maintains the
Na+ channels close depolarisation during
K+ channels open plateau
K+ channels open
Nerve action potential Na+ and Ca2+ L Cardiac action potential

channel open
• In the nerve, the Ca2+ channel is known as the N channel.

• It opens when the membrane depolarises at around –20 mV
• Is stays open for 50 – 80 ms
• Its conductance is 13pS (pico Siemens)
• The conductance tells us about the bulk of Ca2+ flowing
• Entry of Ca2+ into the nerve terminal allows the release of neurotransmitter.
• The L channel (Long opening)
• Found in the heart and blood vessels
• Opens when the membrane depolarises at –10mV
• It stays open for > 500ms
• Its conductance is 25pS
• This channel is the channel predominantly responsible for the prolonged depolarisation during the
plateau phase in cardiac muscle.
• The T channel (Transient)
• Opens very early on during the depolarisation, at –70 mV
• However, it is open for a very short time, 20 – 50ms
• It has a low conductance of 8pS
• Only one newly discovered drug has been shown to affect it – Mibefradil
The Ca2+ channel blockers

• To date, most of the drugs developed act on the L channel. The first T channel blocker is newly discovered and is
called mibefradil.
• There are 3 classes of L channel blocker drugs
• Dihydropyridines
• Nifedipine
• Nicardipine
• Amiodipine
• Felodipine
• Laudipine
• Nisoldipine
• Phenylalkylamines
• Verapamil
• Mibefradil was developed as an analogue of verapamil and is able to be a good
peripheral and coronary vasodilator while having little potency in depressing the heart.
• Verapamil is a good vasodilator but has quite a strong action on the heart.
• Benzothiazapenes
• Diltiazem
• Nifedipine was the first discovered L channel blocker.

• It was found to reduce the force of contraction of the heart by reducing the plateau phase of the cardiac
action potential.
Plateau phase Plateau phase

shortened abolished
Increasing concentration of nifedipine
Decreasing force of contraction
• A L channel blocker can be good as a vasodilator because it will relax the smooth muscle in the blood
vessels (coronary arteries included) because Ca2+ entry into the cell is also required for smooth muscle
contraction. However, the drug may also cause an unwanted negative inotrophic effect on the heart.
Usefulness of N channel blocker

• Conotoxin GVIA is found in a deadly marine creature
• It kills by paralysing its prey by blocking the N channel on nerves
• It prevents the release of neurotransmitter from nerve terminals by preventing the entry of Ca2+ upon
depolarisation.
• It is similar to tetrodotoxin of the puffer fish, which prevents neurotransmitter release by blocking Na+
channels, thus no depolarisation of the nerve can take place (hence Ca2+ channels can’t open).
• N channels are also on the sensory nerves in the spinal cord.
• An analogue of CTX, ω-conotoxin, can be infused directly into the spinal canal to paralyse these sensory
nerves, thus shutting off pain.
Effects of Ca2+ channel blockers at different sites
Site Response When Ca2+ antagonist present

SA node Rate Slowed rate
AV node Conduction Slowed conduction
Coronary arteriole Flow Increased flow
Cardiac muscle Force Reduced force
Structure of the Ca2+ channel

• The L channel is made up of α, β, γ and δ subunits.
• The α and β subunits together make up an important part of the channel which controls the selectivity of the
channel for Ca2+ ions and not Na+ ions.
• Variations in the α subunit proteins determines whether the channel will be an L, T or N channel.
• The 3 chemical classes of Ca2+ channel blockers bind to L channels, but bind to different binding sites on the
channel. This is an example of allosteric binding. If the drugs were to bind to the same binding site, we would have
competition between them.
Effects on blood vessels

• The blood vessel has both voltage operated and receptor operated Ca2+ channels.
• How do we know whether a drug acts on the VOC or ROC?
• We have a vessel and contract it with serotonin and NA.
• Serotonin acts on the ROC.
• When nicardipine was added, there was no effect.
• We now add K+ to the outside, thus abolishing the K+ concentration gradient. K+ can no longer leave the cell and
so the membrane becomes depolarised. The depolarisation opens the L channels.
• Now, when nicardipine is added, the contraction stops.
• We know that nicardipine only works on the L VOC channel, and leaves the ROC alone.
Cardiac selectivity
• Not all of the drugs act with equal selectivity for cardiac muscle and smooth muscle.
• Verapamil and diltiazem are fairly cardiac selective (verapamil moreso than diltiazem).
• These 2 drugs are useful in slowing down the heart (by acting on the nodal/conducting tissue)
• They also reduce the force of contraction
• They are less effective are affecting blood vessels.
• Nifedipine is more effective at increasing the coronary flow.
• However, if you have enough concentrations of any of the drugs, they will all affect both the heart and blood
vessels.
Vascular to cardiac selectivity

• Felodipine 100:1
• Nifedipine 14:1
• Diltiazem 7:1
• Verapamil 1:1
• If you have a drug which acts quickly to cause peripheral vasodilation, then there will be a reflex tachycardia due to
the quick fall in blood pressure as a result of the drugs causing vasodilation.
• This is not good, especially if we have a patient with heart failure. If we cause the heart to pump harder, then we
will cause death. That is why the only drugs which are available now are the slow release versions. E.g. Nifedipine
SR. By having a slow onset, there will be better control of blood pressure and a reduction in the baroreflex causing
cardiac arrhythmia’s.
Clinical uses of the drugs

• By knowing whether a drug is more selective towards the heart or blood vessels, we can deduce the possible use of
the drug in a variety of cardiovascular disorders.
• In supraventricular tachycardia
• We want to slow the heart down, and so we use a cardiaselective drug, e.g. verapamil
• In angina
• We want to reduce the workload of the heart, improve blood flow to the heart (coronary vasodilation) as
well as reducing the oxygen consumption of the heart by making it pump less.
• We thus are able to give a vascular selective drug (e.g. nifedipine) along with a cardioselective drug (e.g.
diltiazem or verapamil).
• We would not give verapamil to a person with angina who has heart disease because the heart is
working hard to just keep the body alive. If we give verapamil to reduce the contraction of the
heart, the amount of blood pumped will be insufficient to keep the body alive.
• In hypertension
• The main problem is to reduce the peripheral resistance, which will reduce the workload on the heart.
• Drugs which are vascular selective would be a good choice here.
• E.g. felodipine SR, or nifedipine SR
Side effects:
• Verapamil:
• Constipation as a result of smooth muscle of the bowel being inhibited. The smooth muscle cannot
contract to push faeces along, so you get buildup of faeces and constipation.
• AV block
• Nifedipine
• Headache due to vasodilation of cerebral arteries, causing increased blood flow to the brain
• Flushing due to vasodilation of facial vessels
• Ankle oedema
• By slowing down the heart, there is a real risk of developing congestive heart failure (buildup of blood in the
pulmonary circulation).
PEPTIDE NEUROTRANSMITTERS
Developments beyond cholinergic and NA transmission

• Quick revision:
• Noradrenaline is stored in vesicles, together with:
• ATP
• Neuropeptide Y
• Chromogranins
• ATP is though to be involved in keeping NA in the vesicle, and may have some transmitter effect.
• Neuropeptide Y, on its own, is not a good vasoconstrictor, but it markedly enhances vasoconstriction by
noradrenaline
• In the parasympathetic system, Ach is also stored in vesicles in conjunction with other chemicals:
• Vasoactive intestinal peptide (VIP)
• This chemical is especially present in parasympathetic nerves innervating the salivary
glands.
• It does little on its own, but when used in conjunction with Ach, markedly increases
salivary secretion.
• Hence, these other peptide neurotransmitters may be acting as modulators.
Substance P
• This was the first peptide neurotransmitter discovered
• Peptide neurotransmitters seem to exist in a wider family of peptides.
• Substance P belongs to a peptide family known as tachykinins
• Other members of the tachykinin family are neurokinin A and B
Tachykinins
• Synthesis:
• Because these chemicals are peptides, they are synthesised by genetic transcription and translation.
Hence, their synthesis may take hours.
• There are 2 genes involved in the synthesis of tachykinins:
• Gene 1
• Transcription and translation produces 3 precursor proteins. These precursor proteins
undergo postranslational modification to form either substance P or NKA
• α preprotachykinin A
• Substance P
• β preprotachykinin A
• Substance P
• NKA
• γ preprotachykinin A
• Substance P
• NKA
• Gene 2
• Same thing occurs as for gene 1:
• preprotachykinin B
• Neurokinin B
• The nerves which have these genes are found in:

• The CNS (mainly in areas involved in motor function)
• In peripheral nerve fibres
• Mainly in nociceptive fibres and enteric nerves
Actions of substance P
• Contracts the gut and bronchi
• Substance P containing nerves control peristalsis and asthma
• Stimulates cutaneous pain receptors
• It is the transmitter used in primary afferent sensory fibres
• Relaxes vascular smooth muscle (probably via NO released from endothelial cells)
• Lowers blood pressure if injected intravenously
• Axon reflex in the triple response
• Increases vascular permeability Seems to be involved in the inflammatory process
• Dilation of cerebral vessels (migraine?)
• Histamine release, exocrine secretions:
• Diuresis
• Lacrimation
• Salivation
Substance P receptors
Receptor Agonist
NK1 Substance P
NK2 NKA
NK3 NKB
• Antagonist:
• The only important one is spantide which inhibits NK1 receptor
• Can be injected intrathecally to people with chronic back pain. Since substance P seems to be
the transmitter in the primary sensory afferent fibres involved in pain, blocking its effects can be
used to relieve pain.
• Other possible uses:
• Analgesics, asthma, headaches
• Since all these chemicals are peptides, they cannot be given orally, since they will be digested by the enzymes in
the gut.
Drug acting on the storage of substance P

• Capraicin
• Found in capraicin spray, chilli peppers
• Causes release of SP from sensory fibres, resulting in painful sensations, flushing, stinging, watery eyes
and salivation (all the effects of substance P) - To remember the actions of substance P, recall what it is
like to eat a chilli pepper!
• Continual stimulation can deplete stores (since it takes a long time to make new substance P)
• Used clinically for people with herpes lesions on the skin, which are extremely painful. When given, it
will cause an initial increase in SP release, but since the people are experiencing pain already, they won't
notice. When SP has been depleted, the people will get relief.
Inactivation of substance P
• Peptidyl dipeptidase
• Maybe angiotensin converting enzyme
Endogenous opiods
• Endogenous opioids are endogenous pain modulators
• Morphine is an opiate analgesic, obtained from the opium poppy
• The effects of morphine can be antagonised by naloxone.
• Certain pentapeptides (met-enchephalin, leu-encephalin) found in the brain are found to be agonists of the binding
site of morphine. These peptides may be the body's natural opiods.
Endorphins
• A generic term comprising of a family of peptides derived from 3 distinct precursors
• Terminology:
• Opiates: Synthetic morphine analogues
• Opiods: Morphine analogues which includes the peptides
• Endorphins: A general family derived from 3 distinct precursors.
Synthesis of endogenous opiods

• 1st precursor
• Preproopiomelanocortin
• Located mainly in the pituitary gland (and hypothalamus)
• Can produce:
• Melanocyte stimulating hormone
• ACTH
• β endorphin
• β lipotropin
• met and leu encephalin are present in the precursor protein but there is no evidence
that they are released. The main one is beta endorphin
• 2nd precursor
• Preproencephalin
• Found in the CNS, spinal cord, GIT and adrenals
• Can produce:
• Met and leu enchephalin
• 3rd precursor
• Preprodynorphin
• Found in CNS, GIT and pituitary
• Produces dynorphin A
Actions of opiods
1. Analgesia
• Supraspinal analgesia
• Can feel pain but not disturbed by the pain
• Spinal analgesia
• Can prevent transmission of the pain (may inhibit the transmission of substance P)
2. Psychotropic
• Euphoria
• Sedation Whether euphoric or not depends on the concentration
• Dependence
3. GIT
• Constipation (may inhibit substance P which causes GIT motility)
4. Respiration
• Respiratory depression
5. Decreases the excitability of other neurons by opening K+ channels, hyperpolarising the membrane. This limits
Ca2+ entry, hence the nerve can't release transmitter.
Endogenous opiod receptors

• µ beta endorphin, met-encephalin
• δ leu-encephalin
• κ dynorphin
• σ No longer considered an opiod receptor since it can be activated by other, non opiod substances,
e.g. phencyclidine (angel dust), haloperidol (dopamine agonist)
• Morphine tends to show µreceptor selectivity
• Antagonists: Naloxone
Roles of opiods
• Pain modulation
• Affects how the body senses and reacts to pain
• Released during acupuncture
• Released during marathons so runners can cope with the pain
• Side effects
• Decrease in gut motility, causing constipation
• All these effects may be due to inhibiting the release of substance P

PERIPHERAL PEPTIDE HORMONES
• Low molecular weight transmitters

• Noradrenaline
• Adrenaline
• Neuropeptides
• Substance P (pain transmission)
• Opiods (pain modulation)
• Vasoactive peptides (hormones)
• Angiotensin (BP control)
• Bradykinin
ANGIOTENSIN II
The renin angiotensin system

• The R-A system is involved in homeostatic control of blood pressure and fluid and electrolyte balance.
• If there is a decrease in blood pressure and/or Na in the blood, various autonomic reflexes are enabled to bring
things back to normal.
• A fall in blood pressure causes the baroreceptors to activate sympathetics
• Sympathetic activation causes increased cardiac output and peripheral vasoconstriction.
• Sympathetic nerves innervating the kidney stimulates the release of renin from the juxtaglomerular cells
(beta 1 receptor).
• The release of renin is also mediated by:
• The afferent arteriole sensing a decrease in stretch (less blood flow)
• The macula densa sensing a decreased Na load.
• Renin cleaves angiotensinogen to angiotensin I.

• Angiotensin I is converted to angiotensin II via Angiotensin converting enzyme (ACE) found in the lungs.
• Angiotensin II has many diverse effects, all leading to an increase in blood pressure and sodium retention.
Actions of angiotensin II
1. Immediate effects:
• Increasing peripheral resistance via:
A. Vasoconstriction (arteries > veins)
B. Enhancing NA release from sympathetic neurons
2. Intermediate effects:
• Effects on renal function (fluid balance control):
A. Stimulating aldosterone release
• Increase in sodium reabsorption
B. Renal hemodynamics
• Angiotensin II can act directly to cause Na reabsorption
• AII also causes vasoconstriction of the efferent arteriole > afferent arteriole to increase
GFR
3. Long term effects
• Effects on cardiovascular structure:
A. By increasing peripheral resistance, there is an increase in afterload. The heart thus has to pump
harder, resulting in hypertrophy
B. AII is also mitogenic, stimulating cardiac muscle growth
• Long term effects may be related to a more chronic rise in blood pressure (possibly leading to
hypertension)
Receptors
• AT1
• AT2
• Most of the effects of Angiotensin II are via the AT1 receptor. Currently, there is no functional role for the AT2
receptor.
Therapeutic use of renin angiotensin system inhibitors

• All these drugs are effective antihypertensive agents
1. Drugs acting on the receptor

• Saralasin
• A peptide, hence can't be taken orally
• A partial agonist
• When AII concentrations are low, we see an increase in blood pressure as saralasin is
acting to mimic the effects of angiotensin II
• However, when AII concentrations are high, it acts as a antagonist because it prevents
AII from exerting its full effects.
• Lorsatin
• A non peptide drug, therfore better absorbed
• Selective AT1 antagonist
• Why do we need another antihypertensive drug? Aren't beta blockers good enough?
• The problem with beta blockers is that they may be a problem for some people, e.g.
asthmatics. A beta1 blocker (e.g. atenolol) can be used to inhibit the release of renin
but atenolol is only selective for beta1 at a certain concentration. Above this, it can act
on beta2 receptors. If beta2 receptors in the bronchi are blocked, you can get a
bronchoconstricton.
2. Drugs acting on renin release

• Substrate analogues of angiotensinogen to bind to renin and prevent angiotensinogen from binding. Not
useful
• Beta1 adrenoreceptor antagonists (Atenolol)
3. Drugs acting on ACE (very effective)

• Captopril
• An analogue of angiotensin I
• Binds to ACE and prevents angiotensin I from being converted to angiotensin II.
• Can be taken orally
• Very goo antihypertensive
• The only problem is that it has a short half life (4 - 8 hrs)
• Enalapril
• The inactive prodrug which is given orally
• In the body, it is converted to Enalaprilate
• Enalaprilate is a modified tripeptide which acts in a similar way to captopril. It has the
advantage however, of having a longer half life (needs to be taken once daily)
• These drugs are also effective in congestive heart failure where there is cardiac hypertrophy.
• Side effects:
• Dry cough, loss of taste
• Angioedema (excess fluid in the vascular wall)
• ACE is not a selective enzyme. It can also involved in the synthesis of substance P and
the breakdown of bradykinin. Inhibition of ACE can thus cause decreased substance P
and increased bradykinin.
• A decrease in substance P can cause the dry mouth and cough (because substance P is
involved in salivary and mucous secretion.)
• An increase in bradykinin results in the angioedema
• If lorsartin works, it will prevent these problems beacuse it is acting on a specific receptor which
is only used by angiotensin II, hence no overlap of functions.
THE KININS
• Kinins are local mediators of pain and inflammation

• The kinins are a family of small peptide molecules which include:
• Bradykinin
• Kallidin
• des Arg9 Bradykinin
Synthesis of kinins
1. Kinins are produced in response to tissue damage
2. Tissue damage causes the activation of Hageman factor which is involved in the clotting mechanism.
3. Hageman factor converts plasma prekallikrien to plasma kallikrein.
• Kallikreins are enzymes which break down kininogens (the precursors of kinins)
• There are 2 forms of kallikreins:
• Plasma kallikrein
• Tissue kallikrein (found in the pancreas)
4. Plasma kallikrein converts high molcular weight kininogen to bradykinin.
5. Tissue kallikrein converts low molecular weight kininogen to kallidin.
• The kininogens are liver derived alpha2 globulins
Metabolism of kinins
• 2 types of enzymes metabolise kinins:
1. Aminopeptidases
2. Carboxypeptidases
• Aminopeptidases:
• Converts kallidin to bradykinin
• Carboxypeptidase:
• 2 forms:
1. Kininase I
• Inactivates des Arg9 Bradykinin
2. Kininase II (ACE)
• Inactivates bradykinin
Actions of bradykinin
1. Cardiovascular
A. Dilates arterioles and venules
• Not a direct effect. Probably mediated by PGI2 or NO
B. Constricts large arteries and venules
• A direct effect.
• Mediated by des Arg9 Bradykinin which acts on the B1 receptor
2. Neural
• Stimulates sensory nerve endings, eliciting pain (similar to substance P)
3. Others
A. Constriction of smooth muscle
B. In uterus, airways, gut
C. Secretions in airways and gut.
Inflammation is a process which does not involve a single chemical mediator. It involves heaps (e.g. prostaglandins,
leukotrienes, histamine, serotonin, bradykinins) all of which reinforce the actions of each other!
Receptors of bradykinin
• 2 receptors:
Receptor B1 B2
Agonist: Bradykinin des Arg9 Bradykinin
Effects: All effects except vasoconstriction Vasoconstriction
Antagonists: Icatibant Analogues of bradykins
Therapeutic drugs
1. Drugs acting on the receptor:
• Icatibant
• Used as a spray
• Rhinitis
2. Drugs acting to inhibit kallikrein

• Aprotinin
• Used to treat angioedema
• Carcinoid syndrome
3. Drugs which increae the action of kinins

• Captopril
• Inhibits ACE (Kininase II) which breaks down bradykinin
• Used to treat hypertension
• Reduces vasoconstriction by:
A. Reducing the amount of angiotensin II (a constrictor)
B. Increasing the amount of bradykinin (a dilator)
• Side effects (as a result of increased kinin levels)
• Cough due to increased bronchial secretion
PHARMACODYNAMICS 1
Receptor occupancy - mass action

• The interaction of a drug with a receptor is reversible due to interactions via weak bonds (not covalent).
k1
• [A] + [R] [AR]
k-1
• [A] = Agonist concentration

• [R] = Receptor concentration
• [AR] = Agonst - receptor complex
• There is a limited number of receptors on a cell surface.
• [RT] = [R] + [AR]
• [RT] = Total concentration of receptors
• [R] = Concentration of unbound receptors
• [AR] = Concentration of bound receptors with agonist
• At equilibrium, the forward rate = backward rate, so that:
• k1.[A][R] = k-1.[AR]
• Combining this with the number of receptors equation, we get an equation relating the concentration of
drug to its occupancy (how much of the drug is bound to receptor).
[ AR] = [ A]
[ R T ]  k −1 + [ A]
 k1 
• [AR]/[RT] is the drug occupancy.
• It is the fraction of bound receptors over the total number of receptors
• k-1/k1 is known as the equilibrium dissociation constant.
• It is given the symbol KA
• It corresponds to the concentration of drug at which half the receptors are occupied.
• A low value of KA means that the forward rate (formation of [AR] complexes) is greater than the
backward rate (dissociation of drug from the receptor). i.e. k1 > k-1
• Hence, KA can also be considered as a measure of a drug’s affinity for its receptor.
• Low KA means there is high affinity because the drug “likes” to be bound to a receptor.
A low KA signifies that a lower concentration of drug is required to occupy half the
receptors than another drug with a higher KA.
• A graph of the occupancy vs drug concentration looks like this:
Occupancy
[AR]/[RT] KA = concentration of
drug at which half the
receptors are bound
Concentration of drug [A]
• With an increasing concentration of drug, there is an increase in the fraction of receptor binding (occupancy), until
we get to a point of maximum occupancy at which all the receptors are occupied.
• At this point, it is important to note that no response has been mentioned yet, only occupancy. Whether or not
there is a response is determined by other factors. Binding of drug to receptor alone is not sufficient to say that it
will cause a response!
• To make analysis of this curve easier, we do a mathematical trick of making the x scale a logarithmic scale. By
doing this, the curve is converted to a sigmoid curve. Advantages of this curve:
• It is linear over 20-80% of the occupancy range
• It is more easier to quantitative values looking off the curve
• It can show a much larger range of concentrations. At low concentrations, we are able to see the rapid
changes that occur, while at the higher concentrations, where things are much more boring, we don’t see
much.
• Figure 1: sigmoid curve of occupancy vs concentration
Occupancy
[AR]/[RT]
logKA
log[A]
• As you can see from the graphs, when the concentration of drug is at KA, half the receptors are occupied.
• The KA remains constant for a given drug receptor combination.
• If you change the drug, the new drug will have a new KA value. Depending on the chemical
structure of the new drug, the KA may be less (the drug has a higher affinity to the receptor) or
greater (the drug has a lower affinity) than the original drug. Similarly, a change in receptor,
with the drug remaining constant will alter the KA.
• Potency of a drug is related to the affinity.
• If we compare 2 different drugs acting on the same receptor, we can see that one drug has a higher affinity
(lower KA) to the receptor than the other drug.
Drug 1 Drug 2
Drug 1 has higher
affinity to the receptor
than drug 2
KA1 KA2
• The drug with the higher affinity also has a higher potency.
• Potency is actually concerned with the response of a drug, rather than its occupancy. When we
say that a drug has high affinity, it means that more of the drug can bind to receptors at low drug
concentrations. When we say that a drug has high potency, we mean that at low concentrations,
the drug with higher potency will have a larger response/effect than a drug with low potency.
• Potency is related to EC50 rather than KA (see later).
• A high potency does not necessarily mean it is better therapeutically. Why?
• It is harder to control the dosage. Sometimes we want to regulate the dosage of a drug by
deliberately trying to make it act more slowly. This is important for drugs with a small
therapeutic window.
• What we have considered so far is the binding of drug to receptor. This is only the very first part of the stimulus -
response interaction.
The response
• [A] + [R] [AR] + Transducer [AR]-Transducer Response
• In order for the drug receptor interaction to produce a response, it must interact with a transducer.
• The response is all dependent on the transducer.
• A weak transducer will result in a weaker response
• A strong transducer results in a stronger response
• What does the drug - response curve look like?
• The drug - response curve looks sigmoidal (if graphed against the log[A]), and it can mirror the drug -
occupancy curve. However, this may not always be the case.
Scenario one NB: The response curve is superimposed on the

occupancy curve
Occupancy Response curve

Response
100% Occupancy Maximum
curve possible response
Log[A]
• In this case, the response curve is identical to the occupancy curve.

• If we have half of the receptors occupied, we would get half a response.
• The concentration of drug at which we see half a response is called the EC50 (the effective concentration that gives
50% response)
• In this case, EC50 = KA
• What this means is that when 100% of the receptors are occupied, we get 100% response (maximum response)
• In real life, we find that this is not often the case.
• Normally, we do not need to occupy all the receptors in order to get a maximal response.
Scenario two
Occupancy Response
Response curve
100% Maximum
possible response
Occupancy
curve
½ max response
EC50
Log[A]
• In this situation, we can get a maximum response when only ½ the receptors are occupied.
• EC50 < KA
• This occurs because the transducer is very effective at converting the drug-receptor signal into a response.
• Since we can have a maximum response when not all of the receptors are occupied, we have the concept of receptor
reserve. Therefore, we can lose some receptors (in this case up to 50%) and still get a maximum response.
Scenario three:
Occupancy Occupancy curve
Response
100% Maximum
possible response
Response curve
Submaximal response
Log [A]
• If the transducer is weak, we will find that even when all the receptors are occupied, we still cannot get a maximum
response.
• It is not really the transducers fault.
• All the transducer is doing is responding to the interaction between drug and receptor. If the binding of the
drug to the receptor is not very good, the effectiveness of the transducer is thus diminished.
• We see this effect with the use of partial agonists.
• EC50 > KA
• The response ≠ receptor occupancy unless under special circumstances. i.e. EC50 does not always = KA
Different types of agonist
Drug A
Drug B
Response
Drug C
Log[A]
• Drug A is a full agonist because it can produce a maximum response

• Drugs B is a partial agonist because it has a range of response which is sub-maximal. They can never get a
maximum response, no matter how many receptors are present.
• Drug C has got no response, so it termed a silent agonist.
• However, it may still have full occupancy of the receptors.
• Efficacy is a term used to describe the maximum response of a drug.
• Drug A has a better efficacy than drugs B and C
• Intrinsic activity is a mathematical value which determines the efficacy of a drug. It acknowledges the fact that not
all agonists to a receptor produce a maximum response.
α × E max × [A]
E=
EC50 + [A]
• E stands for response
• α stands for intrinsic activity
• When α = 1 Full agonist
0 < α < 1 Partial agonist
α = 0 Silent agonist (an antagonist)
• The way the agonist pertubates (changes the receptor shape) the receptor affects the activity of the transducer.
This can lead to a good or bad response.
The transducer and its role in the response to agonist

• What happens if you want to stimulate a receptor in the heart to cause increased contractility but there is exactly the
same receptor in the blood vessel which causes vasodilation (hence a decrease in BP). We can’t stimulate both
because the vasodilation would cause a reduced perfusion to a heart which is pumping harder than ever. This would
cause an infarct of heart muscle due to insufficient blood supply.
• We can find a drug which is only specific to the heart, but this is hard because the receptors are exactly the same.
• In times like these, mother nature has given us a helping hand.
• It turns out that with the same drug, acting on the same receptor, but in different tissues, we find that the efficacy of
the drug differs.
Response of drug Remember:
acting on the heart
Same drug +
Same receptor +
Response of drug
Different tissue =
Response Different response
acting on blood
vessel compared with:
Different drug +
Same receptor +
Same tissue =
Different response
• In this example, the drug acting on the heart acts as a full agonist whereas the drug acting on the blood vessel is
acting as a partial agonist. Because the drug and receptor are the same, only the transducer is left to blame.
• This is an important concept: in different tissues, there may be different transducers, and so the efficacy of the drug
will be altered at different tissues.
• Efficiency (not efficacy) explains the drug-receptor interaction with the transducer.
• A good example of a drug with this property is glibenclamide (a hypoglycemic). See lecture “Ion channels 1”.
• Glibenclamine is designed to work on the β cells of the pancreas to cause insulin secretion. It also acts on
vessels to cause vasoconstriction.
• The potency of glibenclamide on β cells is greater than it is on vessels. Hence, at low drug concentrations,
glibenclamide is able to cause a response on the β cells but cannot cause a response in vessels. The vessels
require a higher concentration of glibenclamide to have a response.
• The response to agonist depends on:

• The chemical property of the drug and its interaction with receptor.
• The affinity of the drug to the receptor may change
• The efficacy of the drug will change
• Efficacy is a measure of the maximum possible response
• In tissues:
• Variations in receptor density
• Does not pose as much a problem if there is receptor reserve
• Efficiency of the coupling

• Efficiency is the drug - receptor interaction with the transducer
PHARMACODYNAMICS II
Antagonists
• Are structurally similar to the binding site of a receptor and thus show affinity towards the receptor. However, they
have zero intrinsic efficacy (you don’t see any effect – it is silent).
• They compete with the agents for the receptor binding site.
• They can bind reversibly, and thus display competitive inhibition
• They can bind irreversibly (non-surmountable) via covalent bonds. The agonist cannot displace the antagonist from
the binding site.
• Antagonists are important for receptor classification. This is because, theoretically, an antagonist is designed to
work at a specific type of receptor, whereas an agonist may have multiple effects on a wide range of receptors in
different tissues.
Competitive antagonism
• We have 2 drugs acting at the one receptor, both drugs wanting to occupy the same binding site.
Agonist: [A] + [R] [AR]
Antagonist: [B] + [R] [BR]
The total number of receptors, [RT] = [R] + [AR] + [BR]
(A = agonist, B = antagonist, R = receptors)
• The Gladdum equation can be used to describe the occupancy curve of an agonist in the presence of an antagonist.
[AR] [A' ]
=
[R T ]  [B] 
[A' ] + K A 1 + 
 KB 
• Where [A'] = new KA of the agonist (the concentration at which 50% of receptors are occupied by an agonist in the
presence of an antagonist.
• KB = concentration of antagonist at which 50% of the receptors are occupied by antagonist.
No antagonist present, B=0 • All the antagonist (B) has
done is change the location
Antagonist present
of the curve to the right
(there has been no change in
shape and no change in
efficacy.
• Essentially, what B has done
is dilute the concentration of
A, so that you need more
agonist to get the same
KA A' Concentration of agonist response.
• A very important thing to note: The occupancy curve is not the same as the response curve IN THEORY.
However, since their shapes are the same, we tend to work more with response curves because measuring the
response is much easier than measuring the occupancy of a drug. Hence, instead of working with KA (which is the
concentration of agonist required to occupy 50% of the receptors), we tend to work more with EC50 (the
concentration of agonist required to get 50% of a response). Remember that KA and EC50 are not always the same.
• Also, KA is very hard to measure (because occupancy is hard to measure). We tend to measure EC50 more
easily by just reading off the response curve.
• Why do we want to measure KB?
• KB is specific for a type of receptor, and hence it is a good way to characterise a particular receptor.
• We can find the KB very easily by plotting a Schild plot.
The schild plot

• The Schild plot can only be used when we are working with competitive antagonist.
• The following are the criteria for a competitive antagonist:
• In the presence of an antagonist, the response curve must be shifted to the right
• The efficacy of the antagonist must not be changed (the maximum response is still possible)
• The shape of the curve must be identical
• If all these are correct, the slope of the Schild plot should be equal to 1
• To plot a Schild plot, we take the following steps (an example is given):
Step 1:
• Plot the response curves of an agonist in the presence of varying concentrations of antagonist.
• Curve A is the control and has no antagonist
• Curve B has a concentration of antagonist of 0.3 nM
• Curve C has a concentration of antagonist of 1.0 nM
• Curve D has a concentration of antagonist of 3.0 nM
Response
A B C D
Concentration of agonist
Step 2:
• The next step is to find the EC50 of each of the curves by reading off the graph:
• EC50 of curve A = 0.3 µM
• EC50 of curve B = 1.0 µM
• EC50 of curve C = 3.0 µM
• EC50 of curve D = 10.0 µM
Step 3:
• Find the concentration ratio of each of the curves (except curve A)
• The concentration ratio is a measure of how much the curve has shifted to the right.
• A concentration ratio of 2 means that there is a two fold shift of the normal curve (curve with no
antagonist present) to the right.
• A CR of 5 means a five fold shift of the curve to the right.
• The concentration ration can be calculated by:
EC50 of the shifted curve
CR =
EC50 of the normal curve
• In our example, EC50 of the normal curve (curve A) is 0.3
• CR of curve B = 1.0/0.3
= 3.3
• CR of curve C = 10
• CR of curve D = 33
Step 4:
• The equation of the Schild plot is:
log(CR – 1) = log[Antagonist] - logKB
• We plot log(CR – 1) vs log[Antagonist]

• In our example:
Curve [Antagonist] log[Antagonist] CR CR – 1 Log(CR – 1)

nM
A 0
B 0.3 -9.5 3.3 2.3 0.36
C 1 -9.0 10 9 0.95
D 3 -8.5 33 32 1.5
logKB
Log(CR – 1)
Log[Antagonist]
• When log(CR – 1) = 0, i.e. when CR = 2, then log[Antagonist] = logKB.

• This means that the intersection of the line with the x axis is equal to logKB
• KB can thus be defines as the concentration of antagonist required to shift the dose-response curve 2 fold to the
right (i.e. we want to increase the EC50 of the antagonist by 2 times).
• In this example, KB turns out to be 0.31nM
A clinical example
• Propranalol if a β adrenoreceptor antagonist. It has a KB of 1 × 10-8 M
• This means that we need a concentration of 1 × 10-8 M of propranalol to occupy ½ of the β receptors. This will lead
to a 2 fold shift in the normal curve of agonist (lets say isoprenalol) acting on the β receptor.
• We measure the response as being the heart rate.
• Under normal conditions (with no propranalol) isoprenalol can give a heart rate of 50 beats per minute at
a given concentration of 5mM (the EC50).
• In the presence of 1 × 10-8 M propranalol, the EC50 of the curve has been shifted 2 fold to the right, i.e.
the new EC50 is 10mM.
Heart rate
1 × 10-8 M of propranalol
50
25
5 10 Concentration of isoprenalol
• We can interpret the outcome of using the antagonist in 2 ways:

• At the same concentration of isoprenalol (5mM) we can get 50 heart beats without an antagonist or 25
heart beats in the presence of antagonist.
• To maintain the heart rate at 50 beats, we need to increase the concentration of isoprenalol (or if this were
a natural β agonist, work much harder)
Irreversible antagonists
• Irreversible antagonists bind irreversibly to the receptor.
• If the tissue has spare receptors, a small concentration of irreversible antagonist will bind to some receptors, but the
remaining number of receptors is sufficient to maintain a maximal response.
• As we gradually increase the concentration of antagonist, we find that more and more of the receptors are being
irreversibly bound, resulting in fewer free receptors for the agonist.
• As a result, the maximal response starts to diminish, until we add enough antagonists to fill up all the receptors,
leaving none left for the agonist to bid to. This would result in total inhibition of the agonist, with 0 response.
Response
• As you can see, the curves are quite different to a competitive (reversible) antagonist
• The curves are not the same shape
• The maximal response is not maintained
• We cannot construct a schild plot for this antagonist!
Partial agonists
• A partial agonist has a lower maximal response than a full agonist (it has a lower intrinsic efficacy).
• Let me give an analogy:
Normal curve, no
partial agonist present
Increase in initial
response due to partial
agonist helping low Competitive inhibition of the full agonist
concentrations of full by the partial agonist because the partial
agonist. agonist is occupying sites that the full
agonist wants to have
Increasing concentration of full agonist

• Say we have 10 punching bags.

• If we have one strong adult (full agonist) present, he punches one bag and gets a response of say 5
• If we have 1 adult and 1 kid (partial agonist), the adult can give a response of 5 but the kid hits the bag
and gets a response of 2. The total repines is 7.
• If we have 1 adult and 3 kids, the total initial response is 11.
• If we have 1 adult and 9 kids, the total initial response is 23.
• See how the presence of a partial agonist at low concentrations of full agonist will raise the
initial response.
• However, say we have 10 kids and 1 adult. The 10 kids will probably all be using the bags and so the
maximum response is 20. The 1 adult does not get a go. If we increase the number of adults, they will be
able to kick the kids off and use the bags themselves, but the kids will be trying to push in and play. The
effectiveness of the adults is reduced because they have to waste time telling the kids to get lost.
• With heaps of adults, say 50 and 10 kids, the kids will be too scared to push in and the adults can go
about their business punching bags to their maximum capabilities.
• When we have a partial agonist in conjunction with a full agonist, initially, we get an increased response due to the
additive effects of partial agonist with small concentrations of full agonist.
• However, the partial agonist is also acting as a competitive antagonist because it occupies the same binding site as
the full agonist but has lower efficacy. Every receptor that it occupies prevents the full agonist from binding and
producing a better response.
• That is why we see a shift in the curve to the right. The partial agonist is preventing the full agonist from working
to its full potential by binding to sites. With enough concentration of agonist, the partial agonist will be
overwhelmed and the full agonist can operate to give a maximum response.
• Efficacy is the property of a tissue. A drug can have a better efficacy on one tissue than another due to:
• Differences in receptor number
• Differences in transducer coupling
PRINCIPLES OF NEUROTRANSMISSION
• In pharmacology, we are interested in the target organ (e.g. skeletal muscle). If we know which organ is targeted by
nerves, we can find drugs that can alter the function of the organ.
CNS
Brain &
Spinal cord
Autonomic Somatic
(involuntary) (voluntary)
Skeletal muscle
Sympathetic Parasympathetic
Enteric
The autonomic nervous system

• The ANS is essentially a 2 fibre system, with preganglionic fibres leaving the CNS to synapse with postganglionic
fibres in the autonomic ganglia.
Ganglion
Preganglionic fibre Postganglionic fibre
• There are 2 divisions of the autonomic nervous system (3 if you include the enteric)
1. Parasympathetic
• Anatomically, the parasympathetic fibres are located craniosacrally in the spinal cord
• The have long preganglionic fibres
• Short postganglionic fibres, with the ganglion close to or in the target tissue
2. Sympathetic
• Anatomically, are located in the thoracolumbar portion of the spinal cord
• Have short preganglionic fibres which synapse in ganglia which form a chain - the sympathetic
trunk.
• The postganglionic fibres leave this chain and head off to the tissues. Hence, they tend to be
relatively long.
• Most tissues are innervated by both parasympathetics and sympathetics nerves, however there are some exceptions
to this:
• Tissues predominantly sympathetic nerves:
• Blood vessels
• Skin
• Kidney, liver
• Adipose tissue
• Tissues predominantly parasympathetic nerves:
• Bronchi (note that you can have sympathetic stimulation of bronchi via adrenaline - not by direct
nervous stimulation)
• There are also some exceptions to the general layout of the autonomic fibres:
• Some sympathetic preganglionic fibres may pass right through the sympathetic trunk without synapsing
and go directly to the gut where there is a sympathetic ganglion in the viscera.
• There is a single sympathetic fibre which goes directly to a tissue without synapsing - the tissue is the
adrenal glands, which when stimulated release noradrenaline and adrenaline.
Chemical transmission
• How does information travel from the brain to the target?
• Electrical transmission via action potentials transmit messages down a nerve fibre
• Chemical transmission is used to transmit signals from neuron to neuron via the synapse.
• Evidence for chemical transmission was based on the fact that the presynaptic terminal had a
morphology similar to a hormone secretory cell. It contained vesicles which presumably
contained chemicals which could be exocytosed into the synaptic cleft to act on the post synaptic
terminal
• For chemical transmission to be accepted, it was not good enough to say that the chemical was there . There needed
to be more evidence to show that:
1. The nerve can synthesise the chemical de novo
2. The nerve can store the chemical
3. There must be some way of being able to release the chemical
4. The chemical needs to have a receptive site on the target
5. The chemical needs to be able to be inactivated via:
• Metabolism
• Reuptake
The blending of anatomy with pharmacology

• All parasympathetic post ganglionic fibres contain acetylcholine (Ach)
• Most sympathetic postganglionic fibres contain noradrenaline (NA)
• The exception is postganglionic fibres innervating the skin, which use Ach
• All preganglionic fibres (both sympathetic and parasympathetic) contain Ach
• In the somatic nervous system, only a single fibre goes straight to the skeletal muscle and releases Ach.
• We can therefore make a generalisation that all peripheral fibres leaving the spinal cord release acetylcholine
Physiology of the autonomic nervous system

• The autonomic nervous system regulates involuntary functions which have a role in homeostasis.
• Generally, it can be said that:
• Parasympathetics are involved with anabolic processes, rest and repose
• Sympathetics are involved with catabolic processes, flight and fright
• Parasympathetics
1. Decrease heart rate
2. Noisy breathing (bronchial constriction)
3. Small pupils (contraction of the circular muscle)
4. Increased salivation
5. Increased gut motility
• Sympathetics
1. Increased heart rate and force of contraction
2. Blood vessels constrict (especially in the skin and viscera)
• When you are nervous your skin feels cold and you stomach feels tight (due to reduced blood
volume going to the gut and making it anoxic - not because the gut is constricting, which is
parasympathetics)
3. Skeletal muscle blood vessels dilate so muscles can get more blood
4. Pupils dilate (contraction of radial muscles)
5. Bronchioles dilate
• This is not due to a direct innervation by sympathetic nerves. Instead, adrenaline released from
the adrenal glands cause the dilation
6. Blood sugar rises
7. Hair becomes erected on skin
The blending of physiology with pharmacology

• The effects are due to the neurotransmitter released from the postganglionic fibres activating specific receptors on
the target tissues.
• Postganglionic parasympathetic fibres
• All fibres release Ach

• The receptors for Ach in the tissues are muscarinic receptors
• Postganglionic sympathetic fibres
• Release mainly noradrenaline
• The receptors for noradrenaline (and adrenaline) in the tissues are α and β receptors
• Generally, α effects cause constriction, β effects cause dilation
• Preganglionic fibres
• All release Ach
• The Ach acts on nicotinic receptors which are located on postganglionic nerve cell bodies and also in
skeletal muscle.
N Heart
Ach Ach
Parasympathetic M GIT
Bronchi
N
Ach Ach
M Sweat glands
Sympathetic N Heart
Ach Noradrenaline
α, β GIT
Blood vessels
Ach N
Adrenal release of NA
and adrenaline
Somatic Ach N Skeletal muscle
Nicotinic receptors
• Can mimic the sympathetic or parasympathetic system, depending on where the agonist is placed.
• If the agonist is placed in the sympathetic trunk, then most likely you would get a sympathetic response
• If the agonist was placed in the tissues, which is where the parasympathetic ganglia are located, you would
get a parasympathetic response
• If an agonist is placed on skeletal muscle, contraction of skeletal muscle can occur
• Heart Decrease rate and force
• Bronchi Constriction The ones in bold are supplied
predominantly by parasympathetics
• GIT Increased motility, dilation of sphincters
• Pupil Constriction
• Glands Secretion
Adrenoreceptor activation
• α adrenoreceptors
• Blood vessels Constriction (control of BP)
• GIT Constrict sphincters
• Pupil Dilates
• β adrenoreceptors
• Heart Increased rate and force
• Skeletal blood vessels Dilation
• Kidney Renin secretion
• Liver Glycogenolysis
• Bronchi Dilation (via circulating adrenaline)
Receptor transduction (a brief introduction)

• The response of an organ/tissue is dependent on the activation of one of 3 receptor types:
• Muscarinic receptors
• α, β receptors
• Nicotinic receptors
• Muscarinic and αβ receptors work via ion channels or second messenger systems, and so they mediate slower
transmission
• Nicotinic receptors are the odd one out.
• They are generally at the site of fast transmission (such as between nerve to nerve, or nerve to skeletal
muscle)
General summary of the effects of the autonomic nervous system
Organ Sympathetic Receptor Parasympathetic Recepotor

Heart Increase rate and force β Decrease rate and force M
Blood vessels
Arteries/veins Constriction α
Skeletal muscle Dilation β
Bronchi
Smooth muscle Dilation (adrenaline) β Constriction M
Glands Secretion M
GIT
Smooth muscle Decrease motility α, β Increase motility M
Sphincters Constriction α Dilation M
Glands Secretion M
Eye
Pupil Dilation α Constriction M
Ciliary muscle Relaxation β Constriction M
Kidney Renin secretion β
Liver Glycogenolysis β
Gluconeogenesis β
Skin
Pilomotor Piloerection α
Sweat glands Secretion (via Ach) M
Adipose tissue Lipolysis β
SEROTONIN
• Serotonin – a.k.a. 5 hydroxytryptamine (5HT)

• Complex, astonishingly diverse biology
• Very medically important
• Is the subject of intense research
• There have been heaps of serotonin receptors discovered (7 families to date) with new ones popping up
and the mechanisms of the current ones being elucidated.
Synthesis and metabolism

Tryptophan (from diet)
Tryptophan hydroxylase
5 Hydroxytryptophan
Aromatic amino acid decarboxylase
5 Hydroxytryptamine
Monoamine oxidase +
N acetyl serotonin aldehyde dehydrogenase
Melatonin (in pineal) 5 hydroxy indole acetic acid

Involved in setting our (5 HIAA)
circadian rhythms Elevated levels of this
indicate hypersecretion of
serotonin
Location of serotonin: uptake vs synthesis

• Gastrointestinal tract
• 90% of the body's total 5HT is found in the GIT
• It is synthesised and stored (in secretory granules) in the enterochromaffin cells
• It is also made in some nerves (serotonergic nerves) which make up a minor component of the myenteric
plexus.
• Blood
• Platelets take up serotonin very efficiently so that there are only trace amounts of 5HT in the blood.
• Serotonin is taken up via a Na+ dependent carrier mediated uptake. This upstake can create
concentration gradients of 1000:1 (serotonin in platelets:blood)
• It is bound tightly to granules found in the platelets.
• It is not synthesised by the platelets.
• It has a very slow turnover
• CNS
• Serotonin is synthesised de novo by tryptaminergic neurons. This is because serotonin cannot pass
through the blood brain barrier and so neurons must be able to produce it.
• Serotonin is stored in vesicles.
• Serotonin is also taken up in the axons of serotonergic neurons as a means of terminating its action in the
synaptic cleft.
Serotonin receptor subtypes

• All 5HT receptors are 7 transmembrane spanning receptors EXCEPT 5HT3
• 5HT1
• Has 5 members (5HT1A, B, D, E, F)
• The receptor is G coupled
• Decreases the amount of cAMP (by inhibiting adenylate cyclase)
• 5HT1A
• Activates receptor operated K+ channels Both these factors affect ion conductions
• Inhibits voltage gated Ca2+ channels in the brain
• 5HT1D
• Expressed in substantia nigra
• Expressed in basal ganglia
• May regulate dopamine nerves by presynaptic modulation
• 5HT1D receptors are also found on pial and coronary vessels (causing
vasoconstriction) - important because sometimes use of 5HT1D agonist (sumatriptan)
for migranes may also cause coronary vasoconstriction, and in people with coronary
atherosclerosis, a reduction in luminal radius will result in coronary ischaemia.
• 5HT1A and 5HT1D
• Are also inhibitory autoreceptors
• 5HT1A is a somatodendritic inhibitory autoreceptor on serotonergic nerves in the
raphe nucleus of the brainstem
• 5HT1D is a presynaptic inhibitory autoreceptor
• Autoreceptos are found on the raphe nuclei in the brainstem.
• The presence of these inhibitory autoreceptors acts as safeguards to prevent
overactivity of these nerves.
⊗
⊗
5HT1A
5HT1D
5HT Target
Presynaptic
Diffusion to affect other neurons
Somatodendritic
• In the brain, serotonin acts at a distance from its target (most neurotransmitters are released close to the
target receptor and act locally). By acting at a distance, serotonin is able to diffuse out of the synaptic cleft
and affect other nearby nerves. Hence, serotonin can act as both a neurotransmitter and neuromodulator.
• 5HT2
• Has 3 members (5HT2A, B, C)
• G coupled
• Activates phospholipase C
• 5HT2A
• Found everywhere in the brain
• Found on platelets (plays a role in platelet aggregation)
• Found on smooth muscle cells (contraction)
• 5HT2B
• Found in the stomach fundus (contraction of the smooth muscle found there)
• 5HT2C
• Found in the choroid plexus (unknown function)
• 5HT3 (Special one!!!)

• Contains one member
• It is a 4 transmembrane spanning ligand gated ion channel
• It gates the ions Na+ and K+
• Found on peripheral sensory (afferent) nerves
• Located on vagal and splanchnic afferents
These regions play an important role in
• Also in the nucleus tractus solitarius
emesis
• Also found in the area postrema
• Are neuroexcitatory
• 5HT4
• One member
• G coupled
• Increases cAMP
• Neuroexciatory
• Locations:
• Found in the hippocampus
• Found in the gut:
• Myenteric plexus
• Smooth muscle cells Facilitate the peristaltic reflex
• Secretory cells (promote secretion)
• 5HT5
• 2 members (A, B)
• Unknown transduction
• 5HT6
• 1 member
Unknown functions, mostly in CNS (5HT7 in also present in
• G coupled
the GIT as well)
• Increases cAMP
• 5HT7
• 1 member
• G coupled
• Increases cAMP
• New drugs may be developed to target these receptors to affect mood, anxiety, schizophrenia and a whole range of
neurological disorders.
5HT and human disease

• Carcinoid syndrome
• Overproduction of serotonin as a result of a tumor of enterochromaffin cells
• Results in hypotension/cardiovascular system disorders
• Flushing (due to vasodilation)
• Bronchospasm
• Diarrhoea
• Treatment of carcinoid tumors involves the following drugs:
• Fenclanine
• A serotonin synthesis inhibitor
• Tends to be the preferred treatment.
• Cyproheptadine
• Block 5HT receptors (as well as H1 receptors)
• Serotonin is also involved in the following:
• Migrane
• Emesis (vomiting)
• Anxiety
• Phycosis/Schizophrenia
• Appetite Diversity of effects due to lots of receptor subtypes
• Depression
• Obsessive compulsive disorders
• Gastrointestinal disorders
Biology of serotonin: its physiological effects

• Platelet aggregation (role of serotonin in hemostasis)
• Serotonin is not synthesised by platelets
• It is taken up by platelets and stored in high concentration is dense core granules.
• Normally, platelets are continuously making contact with the endothelium but do not stick or become
activates since the intact endothelium produced anti-aggregatory factors such as EDRF. When the
endothelium is damaged, platelets become activated.
• The injured endothelium triggers the release of serotonin from platelets (along with ADP,
thrombin, thromboxaneA2)
• These factors all promote platelet aggregation.
• Serotonin acting on 5HT2A receptors:
• On other platelets enhances platelet aggregation.
• On vascular smooth muscle causes direct vasoconstriction
• Serotonin acting on 5HT1 receptors causes vasodilation via EDRF (endothelial derived relaxing
factor or NO)
• If the vessel wall is intact, serotonin can only get access to the endothelial cells and so
will promote the release of the anti-aggregatory EDRF by acting on 5HT1 receptors.
• However, if the endothelial layer is damaged, two things happen:
1. The endothelium stops making EDRF
2. Exposure of the underlying smooth muscle means serotonin can now act on
5HT2A receptors and cause vasoconstriction.
• Serotonin may have a role in the pathogenesis of:
• Atherosclerosis
• Coronary vasospasm (if platelets release serotonin abnormally)
• Raynauds syndrome
• Constriction of vessels in hands and periphery, leading to cold extremities.
• Serotonin in the cardiovascular system
• Causes direct contraction of arteries (EDRF modulates this effect) by acting on 5HT2A receptors on
smooth muscle.
• May also cause constriction of other blood vessels:
• Splanchnic
• Renal
• Pulmonary
• Cerebral
• Will also contract bronchial smooth muscle, leading to bronchial constriction.
• Direct stimulation of vagal nerve endings to the heart.
• Results in Bezold-Jarisch reflex (5HT3 mediated)
• Bradycardia and hypotension
• Amplifies the effects of:
• Histamine
• Noradrenaline
• Angiotensin II
• Increases the rate of SA node, thus increasing the heart rate (5HT4 mediated)
• Serotonin in the gut
• There are 5HT receptor types in the gut, and so serotonin may have many different actions, enhancing or
inhibiting motility.
• 5HT4 increases motility (peristalsis) hence increasing transit time (5HT4 is found on myenteric plexus
nerves)
• Enteric serotonin released from nerves in the myenteric plexus may regulate tone.
• Serotonin acting on 5HT3 receptors on afferent nerves (sensory nerves from the gut) may stimulate
emesis.
• The major source of serotonin in the gut is from enterochromaffin cells.
• The release of serotonin from the enterochromaffin cells is probably due to stretching of the gut
wall.
• Serotonin can then act on 5HT3 receptors on the sensory nerves or on 5HT4 receptors in the
myenteric plexus to regulate peristalsis.
• Serotonin in the central nervous system

• Serotonin has 2 roles in the CNS
• As a neurotransmitter
• Serotonin is produced de novo by neurons because it cannot pass through the blood
brain barrier.
• As a neuromodulator
• Serotonin diffuses out of the synaptic cleft to affect nearby nerves.
• The principle cell bodies where serotonin is synthesised are in the raphe nucleus of the brainstem, which
project up to the brain and also down to the spine.
• Serotonin may be involved in:
• The sleep/wake cycle (depletion of serotonin with p-chlorophenylalanine can cause insomnia)
• Aggression
• Serotonin acting on 5HT1B receptors (???) may cause aggression in some people. This
is evidenced by drugs which prolong serotonin action (fluoxitine - Prozac). Prozac is
found to cause some people to have aggression.
• Anxiety/depression
• Mediated by 5HT1A, 2A, 2C, 3
What happens at a serotonergic synapse
Tryptophan
5HT
p-chlorophenylalanine Iproniazid
(fenclonine)
Reserpine
Granule 5HIAA
MAO
5HT1D 5HT
8 OH DPAT reuptake
5HT
Neuromodulation
Fluoxetine
• p-chlorophenylalanine (fenclonine)
• Inhibits the synthesis of serotonin
• reserpine
• Inhibits the uptake of serotonin into storage vesicles
• Promotes direct release of serotonin from the nerve
• iproniazid
• Inhibits the enzyme MAO, which is used to degrade serotonin
• 8-OH-DPAT
• Presynaptic modulation via 5HT1D receptor (the drug is an agonist)
• Inhibits the exocytosis of vesicles storing serotonin
• Fluoxetine
• Prevents the reuptake of serotonin, thus prolonging the action of serotonin
Theories of migrane
• A primary neuronal disturbance causes hyperactivity of NA and serotonin releasing neurons.
• NA and serotonin may cause cerebral vasoconstriction, explaining the initial visual disturbances.
• Serotonin may also cause perivascular inflammation, the inflamed vessels release prostaglandins and bradykinin
which sensitise nociceptive nerve terminals.
• Inflammation may cause vasodilation and the distention may stimulate afferent nerves which are sensitised to pain,
thus we get a headache.
• Drugs used to treat migranes:
• Sumatriptan
• Acts on the 5HT1D inhibitory autoreceptor to prevent the release of serotonin from serotonergic
nerved.
• Aspirin
• Inhibits the formation of prostaglandins which have a role in mediating pain
• Ergotamine
• Causes vasoconstriction of the cerebral vasculature.
Theories of emesis
• All pathways of emesis finally reach the medullary emetic center.
Higher centers
(psycogenic induced
vomiting)
Solitary tract
nucleus
Medulla emetic 5HT3, D2, M, H1
center
Cerebellum 5HT3, D2, M
H1, M
CNX CNV, CNIX
Area postrema
chemoreceptor
trigger zone
5HT3, D2, M
Inner ear
Pharynx
Cytotoxics,
emetics Gut
5HT3
Radiation
• 3 receptors may be involved in the pathway towards vomiting:

• H1 (histamine) receptor
• 5HT3 (serotonin) receptor
• D2 (dopamine) receptor
• M (muscarinic) receptor
• Drugs which are antagonists of these receptors have proved useful in the treatment of emesis.
• H1 Difenhydramine
• 5HT3 Ondansetron
• D2 Metaclopromide
• M Scopolamine
Clinically important drugs
• Know the drugs on the handout!!!

STEROIDAL ANTI-INFLAMMATORY DRUGS

& DRUGS USED TO TREAT RHEUMATOID ARTHRITIS AND GOUT
• Steroidal anti-inflammatory drugs are also known as corticosteroids
Functions
• Anti-inflammatory
• Immunosuppressant
Mechanisms of action
• Corticosteroids, being steroids, are highly lipophilic and can thus penetrate cell membranes fairly easily.
• They bind to intracellular receptors which modify gene transcription.
• Corticosteroids have wider ranging effects than NSAIDs because they inhibit a wider variety of enzymes by
reducing their synthesis:
• Inhibit phospholipase A2
• Inhibit COX 2 (not COX 1)
• Inhibit cytokine system
Glucocorticoid
Glucocorticoid Reduction in the synthesis of:

receptor Cytokines
COX 2
Phospholipase A2
nGRE
Negative
glucocorticoid
response element
• Glucocorticoids bind to a glucocorticoid receptor in the cytosol.

• Once bound, the drug-receptor complex (in this case the negative glucocorticoid response element) goes into the
cell nucleus and acts on the promoter region of a gene to block the transcription of cytokines, COX 2 and
phospholipase A2.
• By inhibiting phospholipase A2 we are able to achieve a higher level of anti-inflammation by reducing the
synthesis of all eicosanoids (both prostinoids and leukotrienes).
• The nGRE inhibits the transcription of certain genes. There is also the formation of a +GRE which increases the
transcription and synthesis of lipocortin 1.
Glucocorticoid
Increased synthesis of
Glucocorticoid lipocortin 1
receptor
mRNA
+GRE
Positive
glucocorticoid
response element
• Lipocortin 1 is an endogenous anti-inflammatory agent.

• Normally, phospholipase A2 is inactive and must be activated for it to breakdown phospholipids into arachidonic
acid. If it were always active, cell membranes would be constantly breaking down.
• Lipocortin 1 binds to the inactive phospholipase A2 and keeps it inactive.
• Normally, inflammation will activate protein kinase C which converts lipocortin 1 into an inactive form
• It then releases phospholipase A2 which can now become active.
• Corticosteroids act to increase the synthesis of lipocortin.
• Note that the inflammatory system is still active (we have done nothing to inhibit it) and so it is still acting to
inactivate lipocortin. However, since at the same time, we are stimulating the synthesis of active lipocortin at a
faster rate, there will be a net increase in lipocortin levels. Lipocortin is thus more likely to hold phospholipase A2
in an inactive form. Also, there is reduced synthesis of phospholipase A2 which makes it even better, because lots
of lipocortin can find and bind easily with small levels of PLA2.
Uses
• Usage of these drugs are associated with a higher level and more severe adverse effects.
• Anti-inflammatory
• E.g. Asthma. Local inhalation of beclomethasone.
• Topical (local)administration to a specific site
• E.g. On the skin, or eyes
• A topical administration is useful to try and diminish the systemic side effects
• Rheumatoid arthritis
• Treated with prednisolone
• This is a systemic treatment and is often used only as a last resort. We tend to use NSAIDs as the first
resort.
Adverse effects
• Suppression of endogenous glucocorticoid synthesis.
• High levels of steroids negatively feed back on the pituitary to decrease the release of ACTH from the
anterior pituitary. ACTH, apart from stimulating the release of adrenal hormone, is also trophic to the
adrenal cortex. Hence, reduced ACTH will eventually lead to atrophy of the adrenal glands.
• If we try to remove steroid treatment, we often get symptoms similar to a withdrawal effect, e.g. fever, muscle pain
• If steroid treatment is initiated, it is often for life. In order to stop treatment, we need to slowly reduce the
dosage over a long period of time to minimise withdrawal effects.
• Suppression of the response to infection or injury
• These drugs are immunosuppressants and also suppress wound repair due to the reduction in protein
synthesis.
• E.g. For an eye infection, we may treat the inflammation but the micro-organisms which caused the
inflammation is still around (because the body’s immune system has not responded to eliminate the
organism) and so things can get worse.
• E.g. Sometimes a combination of steroid treatment with NSAIDs are given. NSAIDs may cause gastric
ulceration and GIT disorders, but the steroids only exacerbate the adverse effects of NSAIDs because they
suppress the repair of the ulcers.
• The point is that we must treat the cause, not the symptoms. We may be able to treat the inflammation
associated with a wound but will not get any wound repair.
• Behavioural disturbances
• Cataract, glaucoma
• An increase in intraocular pressure is the normal response to steroidal treatment.
• Fluid and electrolyte disturbances.
• Similarity to aldosterone or cortisol – increased reabsorption of Na, increased secretion of K.
Metabolic effects
• Osteoporosis
• Muscle wasting
Due to mimicking the actions of cortisol.
• Hyperglycemia
• Inhibition of bone growth in children
• Steroids cause fusion of the epiphyseal plates.
• A lot of children are given steroids to treat asthma – not good!
• The use of topical steroids is more desirable to reduce the systemic effects.
• Both NSAIDs and steroid treatment aim to treat the symptoms (reduce pain, inflammation and discomfort),
but may not do a good job in treating the cause of the disease. Unless the cause is treated, the disease will
keep on getting worse.
Anti rheumatoid drugs

• NSAIDs are the first line of defense
• Alternatively, specific drugs used to treat the rheumatoid arthritis can be used. These drugs do not have
general anti-inflammatory effects.
• The drugs are often known as Slow acting anti rheumatoid drugs (SAARDs) or Disease modifying anti
rheumatoid drugs (DMARDs).
• The following drugs used for rheumatoid arthritis are effective but we do not know their mechanism of
action.
• Gold compounds
• Aurothiomalate
• Intramuscular injection
• Auranofin
• Oral, less common
• ↓ lymphocyte proliferation
• ↓ lysosomal enzyme release
• ↓ superoxide production
• ↓ neutrophil chemotaxis
• ↓ IL-1 synthesis
• May take months to see a beneficial effect.
• Adverse effects:
• Commonly allergic type reactions at the skin and mucous membranes
• Renal injury
• Blood dyscrasias (any adverse change in blood function)
• Chloroquine
• Is used in the treatment of malaria
• An anti-inflammatory only in rheumatic disease
• Less adverse systemic effects but tends to seriously affect the eyes
• The cornea of the patient undergoing this treatment needs to be monitored
carefully. Retinopathy which occurs may be irreversible, causing blindness.
• Very slow onset (months)
• Sulphasalazine
• A combination of sulphonamide and salicylate
• A free radical scavenger?
• Free radicals cause cell injury and inflammation
• Has marked GI irritation and so is only available with an enteric coating.
• Methotrexate
• Immunosuppresant
• Folate antagonist
• Also used to treat cancer (see lecture “enzymes 1”)
• Penicillamine
• Adverse effects similar to gold compounds.
• Not as effective, most probably be obsolete soon.
• All these drugs are slow releases, with the effects being seen in weeks to months. Once the effects are
observed, they will slow the disease progress, not just treating the inflammation.
Drugs used in the treatment of gout

• Gout is due to an accumulation of uric acid (a breakdown product of adenosine). High concentrations of uric
acid leads to crystallisation and deposition in the synovium of joints, resulting in arthritic pain.
• Acute treatment of gout involves:
• NSAIDs (but NOT aspirin because aspirin inhibits the excretion of uric acid)
• Colchicine
• Glucocorticoids
• Chronic treatment involves:
• Allopurinol
• Colchicine
• Probenecid
Adenosine
Hypoxanthine
Xanthine oxidase
Xanthine
Xanthine oxidase
Uric acid
Synovial deposition
(inflammation, classically
in the big toes)
• Colchicine
• An antimitotic agent. It interferes with tubulin, which prevents leukocyte migration
• Reduced leukocytes in the synovial joints affected by gout would reduce the pain and
discomfort as a result of the cytokines released by neutrophils.
• Can be used as an acute treatment
• Also can be used as a chronic treatment as prevention (prohpylacticaly) in conjunction with
allopurinol.
• Allopurinol
• An analogue of hypxanthine
• It thus competitively inhibits the enzyme xanthine oxidase, preventing hypoxanthine from binding.
• The product of allopurinol with xanthine oxidase is alloxanthine.
• Alloxanthine is an irreversible inhibitor of xanthine oxidase.
• Thus, there is decreased synthesis of uric acid and the concentrations fall.
• Probenecid
• A uricosuric agent (increases the excretion of uric acid)
• It inhibits the tubular reabsorption of uric acid in the kidneys
• It has a limited use, not as effective as allopurinol
• It is used when a person has an inability to excrete uric acid (in most patients, an increased uric
acid is mainly due to an increase in production and so allopurinol is better suited).

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• When adrenaline is injected into a person we see 2 things happening:

Drugs affecting synthesis

Indirectly acting sympathmimetic amines

• There are other chemicals which can augment a NA response

• Amphetamines increase levels of serotonin, and can elevate mood.

Catechol O methyl transferase

• The primary inactivation process is reuptake

Substrates Inhibitor drug

ADRENERGIC PHARMACOLOGY III

More on the metabolism of NA

Summary of drugs used to affect synthesis and degradation

Process Drug Drug action Clinical relevance

Storage Reserpine • Disrupts vesicle membrane so NA • Treat hypertension. Has

Blood pressure (α effect) Heart rate (β effect)

• Generally, it is better to classify receptors according to antagonists. Why?

Phentolamine is an alpha antagonist

Subtypes of α and β receptors

• Recall that adrenaline is a better β2 agonist than noradrenaline!

• Most tissues have a mixture of the receptor subtypes.

• Direct decongestants vs indirect (ISAs)

• What are the benefits of an irreversible inhibitor like phenoxybenzamine?

The new adrenoreceptor classification

• These subtypes are further divided into:

Molecular features of adrenoreceptors

• α2 receptors decrease cAMP levels (which thus prevents release of NA)

Therapeutic uses of endogenous catecholamines

• Is used as an emergency hormone, especially in anaphylactic shock

Inhibition of eicosanoid synthesis

COX inhibition Anti inflammatory activity

Dilation Vascular permeability Chemotaxis Pain

Individual groups of NSAIDs

Noirmal therapeutic dose • Uncouple oxidative phosporylation

• Central respiratory depression

Selective COX 2 inhibitors

ARACHIDONIC ACID METABOLITES

• The 3 main groups of arachidonic acid metabolites are:

Prostaglandin Stability (in vitro) Biological activity

• If the prostaglandin is considered stable, it means that it is enzymatically degraded.

Pharmacological action of prostaglandins

Under normal conditions, the actions of TxA2 and PGI2

• Bronchial smooth muscle

Why do eicosanoids have so many diverse actions?

Therapeutic uses of prostaglandins

• The major areas where Ach acts as a neurotransmitter are:

Obtained from the

Choline acetytransferase CoA

Acetyl CoA Acetyl choline

Acetyl CoA does not pass

Ways to interfere with the synthesis

• Drugs affecting the release:

Molecular biology of M receptors

• The M1 receptor is found in the stomach, controlling gastric acid secretion

The only important, therapeutical muscarinic antagonist is pirenzepine (M1 blocker)

Structure activity relationships at muscarinic receptors

Muscarinic effects on tissues

Organ Effect M receptor

Examples of muscarinic agonists

Therapeutic uses of M agonists

*** IMPORTANT CONCEPT!

Subtype selective M antagonists

Effects of blocking M receptors