Norepinephrine Anatomy and Functions The widespread norepinephrine (“noradrenergic”)

innervation in brain mainly derives from a very small cluster of neurons located in the locus
coeruleus (LC, part of the pons) in addition to a more diffuse grouping in the lateral tegmental
area (part of the midbrain). These two groups provide input to virtually all brain regions, with
LC neurons primarily targeting the forebrain, thalamus, cerebellum, and spinal cord and the
lateral tegmental neurons principally sending fibers to the hypothalamus and basal forebrain.
A single norepinephrine neuron typically innervates several brain regions. LC norepinephrine
neurons exhibit different activity modes: tonic firing with short periods of burst firing.
Alterations in the tonic mode are associated with the sleep–waking cycle, whereas the phasic
mode occurs in response to arousing stimuli. There is good evidence for an important role of
LC norepinephrine neurons in vigilance, attention, and working memory. Epinephrine Anatomy
and Functions In the sympathetic nervous system (ANS) and the adrenal medulla, epinephrine
shares with norepinephrine the role of final neurotransmitter, and the proportion of this
sharing is species-dependent and hormonally modified. Relatively few epinephrine cells exist
in brain and are found in the medulla, providing innervation to subregions of hypothalamus.
Life Cycle of Dopamine, Norepinephrine and Epinephrine Synthesis. These three
catecholamine neurotransmitters share a common synthetic pathway (Fig. 1.4–1). Blood-borne
tyrosine, derived from dietary proteins and from phenylalanine metabolism, enters the brain
by the large neutral amino acid (LNAA) transport system. Tyrosine in brain extracellular fluid is
taken up into catecholamine neurons by a high affinity amino acid transporter. In the first
reaction tyrosine is converted to L-dopa by the enzyme tyrosine hydroxylase in the cytosol.
Because this step is rate limiting, it sets the pace for the conversion of tyrosine to dopamine,
which makes this step the most susceptible to physiologic regulation and pharmacologic
manipulation. Tyrosine hydroxylase requires tetrahydrobiopterin as a cofactor, and the
synthesis of tetrahydrobiopterin is itself dependent on the activity of another enzyme, GTP-
cyclohydrolase1. The next reaction is the decarboxylation of L-dopa by aromatic amino acid
decarboxylase (AADC) in the cytosol to form dopamine. AADC decarboxylates L-dopa so avidly
that the level of this amino acid in brain is very low under normal conditions. L-dopa is the
principal drug used to treat Parkinson disease as it restores the deficient striatal dopamine
level that occurs in the disorder. Supplying exogenous L-dopa to the neuron ensures efficient
conversion to dopamine because it bypasses tyrosine hydroxylase, the rate-limiting step in
dopamine biosynthesis. An inhibitor of AADC that does not cross the BBB (e.g., carbidopa or
benserazide) is routinely administered with levodopa to patients with Parkinson disease to
inhibit the peripheral decarboxylation of L-dopa to dopamine, which reduces peripheral side
effects resulting from abnormally high circulating levels of dopamine. One prominent side-
effect of excessive circulating dopamine is emesis due to the activation of dopamine receptors
in the area postrema, an area outside the BBB. In fact, D2 antagonists (e.g., promethazine
[Phenergan]) are a widely used class of antiemetic agents. However, because they are prone to
induce parkinsonian-like side effects, alternatives such as 5HT3 antagonists (e.g., ondansetron
[Zofran]) and neurokinin-1 receptor antagonists (e.g., aprepitant [Emend]) are increasingly
used to avoid these problems associated with D2 antagonism. In norepinephrine neurons, as
well as in chromaffin cells of the adrenal medulla, an additional enzyme, dopamine-beta-
hydroxylase (DBH) is present that enables the conversion of dopamine to norepinephrine. This
enzyme is concentrated inside the storage vesicles, so this step of norepinephrine synthesis
does not occur in the cytoplasm. Disulfiram (Antabuse), a drug used to treat alcohol addiction,
is an inhibitor of DBH. However, the principal relevant property of disulfiram in treating
alcoholism is to block acetaldehyde dehydrogenase, the enzyme that metabolizes
acetaldehyde formed from ethanol, and this results in elevated acetaldehyde levels that
causes moderate to severe adverse effects after consumption of ethanol. In central
epinephrine neurons and in adrenal medulla and heart, norepinephrine is N-methylated by the
enzyme phenylethanolamine-Nmethyltransferase (PNMT) to form epinephrine. As PNMT is
located in the cytoplasm, norepinephrine has to exit its storage site in vesicles to be converted
to epinephrine before being transported back into vesicles. This reaction presumably takes
place during spontaneous leakage of norepinephrine from vesicles in cytoplasm, or after
norepinephrine has been released into the synapse and taken back up into the cytoplasm and
exposed to PNMT. Phenylketonuria (PKU) is a rare genetic disease caused by a mutation in the
enzyme phenylalanine hydroxylase, which hampers synthesis of tyrosine as well as disturbing
other metabolic pathways of phenylalanine. The elevated concentrations of phenylalanine
seen in PKU has devastating effects on the developing brain typically leading to severe mental
retardation unless steps are taken to limit dietary intake of phenylalanine. Newborns identified
with such mutation can avoid symptoms of PKU by eliminating phenylalanine from their diet.
Vesicular Transporter. Vesicles present in the presynaptic terminals are specialized for the
uptake and storage of catecholamines, thus protecting the transmitter from degradation by
the enzyme monoamine oxidase (MAO) found in mitochondria. The accumulation and
concentration of transmitter inside the vesicles is accomplished by vesicular monoamine
transporter (VMAT). There are two forms of VMAT and it is VMAT-2 that is expressed in central
neurons. Dopamine Plasma Membrane Transporter. A high-affinity DAT serves to recapture
released dopamine and limits the concentration and actions of dopamine in the synapse (Fig.
1.4–2). Importantly, dopamine neurons in striatum and nucleus accumbens are equipped with
a high density of DATs and so are especially susceptible to drugs that target this site. For
example, blockade of dopamine re-uptake by cocaine in the nucleus accumbens, prolongs and
intensifies dopamine’s actions in this region and is key to the euphoric effects of the drug.
Similarly, amphetamine and methamphetamine amplify dopamine signaling in the nucleus
accumbens by blocking dopamine reuptake and increasing release of dopamine. The VTA-
nucleus accumbens pathway is part of the brain’s reward pathway stimulated by all types of
reinforcing stimuli such as food, sex, and many drugs of abuse. While stimulants can be
addictive, some (e.g., methylphenidate, amphetamine) are used at lower doses to treat ADHD,
and probably achieve their beneficial effects by actions on the dopamine and norepinephrine
transporters (NETs). Lisdexamfetamine (Vyvanse) is a long-acting oral prodrug that is
hydrolyzed in the blood to active Damphetamine, and it has been approved for treating ADHD.
The DAT is also the pharmacological target for the parkinsonian neurotoxins, 6-
hydroxydopamine and 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP). In fact the
toxicity of MPTP is dependent on the combined function of MAO-B, DAT, and VMAT-2. Once
inside the brain, MPTP is metabolized by MAO-B to the actual toxic species, MPP+, which is a
substrate for DAT. When inside the cytoplasm MPP+ acts as a mitochondrial poison, although
its potency is restrained by VMAT2 which can sequester MPP+ inside vesicles away from
mitochondria. The tuberoinfundibular, tuberohypophysial, olfactory bulb, mesoprefrontal, and
mesoamygdala dopamine neurons appear to differ from the other dopamine systems
described by the absence, or diminished expression, of DAT. Norepinephrine Plasma
Membrane Transporter. The NET is located on all norepinephrine neurons and efficiently
recaptures most of the transmitter that is released into the synapse (Fig. 1.4–3). In addition to
the impact of the psychostimulants, such as cocaine and the amphetamines, on DAT, these
drugs also interact with NET and intensify the synaptic actions of NE. The mechanism of certain
antidepressant drugs includes blockade of NET, and these include the tricyclic antidepressants
(TCAs) and the more specific serotonin–norepinephrine reuptake inhibitors (SNRIs) such as
duloxetine (Cymbalta) and venlafaxine (Effexor), norepinephrine– dopamine reuptake
inhibitors (NDRIs) such as bupropion (Wellbutrin), and the selective norepinephrine reuptake
inhibitors (NRIs), such as maprotiline and atomoxetine (Strattera), which is also used in the
treatment of ADHD.

Since the original studies on dopamine uptake, it has been known that dopamine is a good
substrate for the NET. However, not until relatively recently has the importance of this been
appreciated. In regions, such as striatum and nucleus accumbens, where dopamine neurons
express a high density of DAT, there is a relatively sparse norepinephrine innervation, and
dopamine uptake depends primarily on DAT. However, in regions such as the prefrontal
cortex, in which dopamine neurons express low levels of DAT and there is a rich
norepinephrine innervation, dopamine uptake depends strongly on NET. In fact, it has been
suggested that dopamine can be co-released with norepinephrine by norepinephrine neurons,
as a result of nonspecific uptake of dopamine by the NET and/or because dopamine is a
precursor in the biosynthesis of norepinephrine. Epinephrine Plasma Membrane Transporter.
There is no evidence for a specific transporter for epinephrine and no drug that selectively
blocks epinephrine reuptake has been described. All of the pharmacological agents that block
the NET selectively are also effective inhibitors of epinephrine uptake. Thus, it appears unlikely
that a selective transporter for epinephrine exists. Metabolism. The major mammalian
enzymes of importance in the metabolic degradation of catecholamines are MAO and catechol
Omethyltransferase (COMT), and either of these enzymes can catalyze the first step in
catecholamine metabolism. MAO converts its substrates to their corresponding aldehydes, and
these aldehyde intermediates are rapidly metabolized either by the aldehyde dehydrogenase
or aldehyde reductase. Thus, multiple metabolites of catecholamines are formed. In primate
brain the major end metabolites for dopamine is homovanillic acid (HVA), whereas in rodent
brain 3,4-dihydroxyphenylacetic acid (DOPAC) and DOPAC sulfate predominate. For
norepinephrine, 3-methoxy-4- hydroxyphenylglycol (MHPG) is the main end metabolite in
primate brain, but in rodent brain both 3,4-dihydroxyphenylglycol (DHPG) and MHPG exist in
high concentrations and both metabolites are mainly sulfate conjugated. In the periphery, the
major metabolite of dopamine is HVA and for norepinephrine it is vanillylmandelic acid (VMA)
with a significant proportion of both compounds being conjugated to either sulfate or to
glucuronide. It is well documented that, in the animals, short-term fluctuations in the levels of
dopamine metabolites, DOPAC and HVA, in the striatum, nucleus accumbens, and prefrontal
cortex provide a useful index, respectively, of alterations in impulse flow in the nigrostriatal,
mesolimbic, and mesocortical dopamine pathways. Changes in dopamine metabolite
concentration in CSF have also been associated with alterations in central dopaminergic
activity, or integrity of the central dopamine systems. Similarly alterations in the concentration
of MPHG have been associated with changes in norepinephrine function. MAO. This enzyme is
located on the outer membranes of mitochondria. Separate genes encode two isoforms of
MAO (types A and B), which can be distinguished by substrate specificity and sensitivity to the
selective inhibitors. In brain, MAO-A is preferentially located in dopaminergic and
noradrenergic neurons, while MAO-B is the major form present in serotonergic neurons and
glia. Dopamine and norepinephrine are effective substrates for both forms, whereas serotonin
is a preferential substrate for MAO-A. The prototypical inhibitors of the two forms are
clorgyline for MAO-A and selegiline (formerly known as deprenyl) for MAO-B. Selegiline
(Eldepryl) or rasagiline (Azilect) are irreversible MAO-B inhibitors that are used in the
treatment of Parkinson disease, usually in combination with Ldopa to prolong or enhance the
effect of dopamine formed from L-dopa. COMT. There are two isoforms of COMT, a
membrane-bound form and a soluble form. Membrane-bound COMT is the major form found
in the CNS, has a higher affinity for catecholamines, and it is located principally in neurons. The
soluble form has a lower affinity for catecholamines and is the major form expressed in the
periphery, but is present also in CNS glia. Two COMT inhibitors, tolcapone and entacapone, are
used as adjuncts to L-dopa and treatment in Parkinson disease to slow L-dopa metabolism and
thereby prolong its effects and reduce L-dopa requirements. Accumulating evidence from
clinical and preclinical studies shows that COMT plays a more significant role in dopamine
metabolism in the prefrontal cortex than in other regions such as striatum. Another interesting
facet to the role of COMT in frontal cortex is the finding that the COMT gene contains a
polymorphism (Val158Met) that affects the in vivo activity of the enzyme. Met158
homozygotes have approximately one-third less COMT enzyme activity in prefrontal cortex
than Val158 homozygotes. Consistent with its role in modulating prefrontal cortex dopamine
levels, the Val158Met polymorphism is associated with performance on tests of working
memory and executive function, which depend on prefrontal cortex function. Thus, in healthy
volunteers the high-activity Val158 allele is linked with relatively poorer performance on such
tasks, relative to the Met158 allele, presumably as a result of increased dopamine metabolism
and lower synaptic dopamine levels. However, this relationship is not constant across patient
populations and drug-treated individuals as an inverted “U”-shaped curve describes the
relationship between dopaminergic transmission in prefrontal cortex and cognitive
performance, with both suboptimal and supraoptimal dopamine activity impairing cognitive
performance. The COMT polymorphism has been implicated in a number of neuropsychiatric
phenotypes including evidence to support an association between COMT allele frequency and
the genetic risk of schizophrenia. Dopamine Receptors The physiological actions of dopamine
are mediated by five distinct but closely related GPCRs. On the basis of their structure,
pharmacology, and primary effector mechanisms, they are grouped as D1-like (D1 and D5 ) and
D2 -like (D2 , D3 , D4 ) dopamine receptors (Fig. 1.4–2). The D1-like dopamine receptors
activate the Gs family of G proteins, increase adenylate cyclase activity and are found
postsynaptically on dopamine-receptive cell. The D2 - like dopamine receptors (D2 , D3 , and
D4 ) couple to the Gi family, inhibit adenylate cyclase activity, and are expressed both
postsynaptically on dopamine-receptive cells and presynaptically on dopaminergic neurons. In
brain D1 dopamine receptors are expressed in particularly high density in the nigrostriatal,
mesolimbic, and mesocortical dopamine systems, such as the striatum, nucleus accumbens,
and frontal cortex. In contrast, D2 receptors are more evenly distributed in brain, with the
highest levels in striatum and nucleus accumbens. Dopamine transmission through D1 and D2
receptors in striatum and prefrontal cortex plays an essential role in many aspects of motor c
cognition. The alternative splicing of the D2 gene results in generation of two major variants,
termed D2S (D2 -short) and D2L (D2 -long). There is some evidence that D2S is mostly
expressed presynaptically and is involved in autoreceptor functions, with D2L being
predominantly a postsynaptic isoform. The D3 dopamine receptor has a more limited pattern
of distribution, with the highest level of expression being observed in the limbic areas, such as
in the shell subdivision of the nucleus accumbens. Some data suggest that D3 receptors can
operate as autoreceptors, to complement the D2 autoreceptor role in regulating the neuronal
firing rate, synthesis, and release of dopamine. Among the dopamine receptors, the D4
subtype has the lowest level of expression in the brain, with documented expression in frontal
cortex, amygdala, hippocampus, and hypothalamus. D5 dopamine receptors are expressed at
low levels in multiple brain regions, including frontal cortex, hypothalamus, and hippocampus.
D1 , D2 , and D4 dopamine receptors have also been observed in the retina. High expression of
D2 dopamine receptors also occurs in the pituitary gland. In the periphery, all subtypes of
dopamine receptors have been observed in varying proportions in the kidney, adrenal glands,
sympathetic ganglia, gastrointestinal tract, blood vessels, and heart. Some of the older, so-
called “typical,” antipsychotic drugs, such as chlorpromazine, block both D1 and D2 receptors,
while others like haloperidol, are selective for D2 receptors. All “atypical” antipsychotics
effectively block D2 dopamine receptors with little or no impact on D1 receptors. As the full
beneficial effects of antipsychotic drugs can take weeks to develop, it is apparent that the
mechanism involved is more than just blockade of the D2 receptor site. In addition, all
antipsychotic drugs have appreciable affinities for non-DA receptors, and atypical antipsychotic
drugs tend to have substantial potency at serotonin receptors, although it is not clear to what
extent the interaction with serotonin receptors improves the antipsychotic effect or reduces
some of the unwanted effects of dopamine receptor blockade. Typical antipsychotic drugs are
prone to induce extrapyramidal side effects, which include parkinsonism, dystonia, and
choreiform movements (tardive dyskinesia). An additional side effect is elevated serum
prolactin, resulting from a disturbance of dopaminemediated regulation of prolactin secretion.
The consequences of hyperprolactinemia include menstrual disturbances, galactorrhea, sexual
dysfunction, gynecomastia, infertility, decreased bone mineral density, and possibly breast
cancer. Atypical antipsychotics with especially high affinity for D2 receptors, such as
risperidone (Risperdal), are more prone to induce hyperprolactinemia, whereas this side effect
is rare with those drugs that bind to D2 less avidly, such as aripiprazole (Abilify), clozapine
(Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). Although
clozapine was discovered in the 1960s, it still has an important role in combatting treatment-
resistant schizophrenia with low likelihood of extrapyramidal side effects. However,
approximately 1 percent of patients treated with clozapine develop serious agranulocytosis,
while it also shares the frequent side effects of other antipsychotic drugs such as weight gain.
The success of clozapine was initially linked to its antagonism of D4 receptors, which
distinguishes it from other antipsychotic drugs. However, current thinking is that clozapine’s
combined actions at several receptors may be responsible for its therapeutic properties. Of the
newer antipsychotic drugs, olanzapine has the closest receptor profile to clozapine. Atypical
antipsychotic drugs, including clozapine, are generally superior to typical neuroleptics with
regard to treating negative symptoms and cognitive dysfunction associated with
schizophrenia. D2 -like agonists have an important use in the symptomatic treatment of
Parkinson disease. Such drugs include apomorphine, a D2 agonist, and also pramipexole
(Mirapex) and ropinirole (Requip), which are D2 -like agonists with greatest affinity for the D3
receptor. Nonselective dopamine agonists (e.g., rotigotine) have also been used in Parkinson
disease, in addition to restless legs syndrome. D2 autoreceptors are generally activated by a
lower concentration of dopamine agonists than necessary to activate postsynaptic D2
receptors, so it possible in experimental models to demonstrate that the same dopamine
agonist induces a biphasic effect depending on its dose. However, no drugs are used clinically
to preferentially target D2 autoreceptors. Historically, GPCRs are believed to function as
monomeric units; however, it now apparent in some instances dopamine receptors may
directly interact with members of the same receptor family and with structurally divergent
families of receptors to form heteromers with unique functional and pharmacological
properties, although this knowledge has yet to lead to novel pharmacological agents.
Adrenergic Receptors For many years, receptors for norepinephrine and epinephrine
(adrenergic receptors) were divided into just three distinct classes, α1 , α2 , and β. A
postsynaptic location is typical for α1- and β-receptors, whereas α2 - receptors exist both pre-
and postsynaptically. Currently, three α1 subtypes (α1a , α1b , α1d), four α2 -receptor
subtypes (α2A–D), and three β-receptor subtypes (β1–3 ) are recognized (Fig. 1.4–3). All β-
receptor are Gs-coupled, whereas most α1-receptors are Gq-coupled and α2 -receptors are
typically Gi-coupled. As norepinephrine is the transmitter used by most postganglionic neurons
of the ANS, agonists and antagonists at various adrenergic receptors exert profound effects on
the functioning of many peripheral organs by mimicking or blocking respectively the
sympathetic innervation. Agonists are referred to as “sympathomimetics” and antagonist as
“sympatholytics.” In brain, the locus coeruleus noradrenergic system exerts a widespread
influence on neuronal circuits that are essential substrates of arousal and cognition and
several cognitive and affective disorders have been posited to involve a dysregulation of
noradrenergic neurotransmission. In addition, by sending direct projections to the sympathetic
preganglionic neurons in the spinal cord and parasympathetic preganglionic neurons in the
brainstem and spinal cord, the noradrenergic locus coeruleus plays central role regulating
autonomic activity. The predominant peripheral effect of α1-adrenergic agonists is the
constriction of arterial smooth muscle, which in turn causes an increase in blood pressure, and
drugs such as phenylephrine and methoxamine are used occasionally in the clinic to increase
blood pressure during a hypotensive crisis. α1-Adrenergic agonists are also widely used as
nasal decongestants, and their decongestant activity is mediated by constriction of blood flow
to nasal mucosa and by a reduction in airway secretions. Antagonists of α1-adrenergic
receptors inhibit smooth muscle contraction and reduce arteriolar resistance by dilating
arteries. Their major uses are as an adjuvant treatment for hypertension and for treating
symptomatic benign prostatic hypertrophy. α1-Antagonists such as prazosin (Minipress) have
also been shown to be useful in treating some of the symptoms of PTSD. α2 -Adrenergic
agonists, like clonidine (Catapres) and guanfacine (Intuniv) have been used to treat
hypertension and the mechanism appears to be a reduction in sympathetic tone elicited by
activation of α2 -receptors in the anterior hypothalamus. α2 -Adrenergic agonists also have a
role in the treatment of certain CNS disorders, especially those involving prefrontal cortex
dysfunction. Damage to the catecholaminergic innervation of the prefrontal cortex impairs
performance in tests of executive function, and although dopamine has a prominent role in
mediating the effects of these lesions, substantial evidence indicates that norepinephrine also
exerts a potent modulatory influence on prefrontal cortex functions. Early pharmacological
studies on the role of α2 -receptors in prefrontal cortex function focused on clonidine,
although clonidine produces mixed effects, presumably due to competing pre- versus
postsynaptic effects and limitations from sedative and hypotensive side effects. A superior
profile has been observed with the more selective α2Aagonist, guanfacine, which has been
shown to improve working memory in animals and in some human populations, possibly by
binding to postsynaptic α2A-receptors and increasing noradrenergic tone. Guanfacine is now
being used to treat a variety of disorders with prominent prefrontal cortex dysfunction,
including Tourette syndrome and ADHD. Clonidine is also used to manage the acute phase of
opioid withdrawal, an effect achieved by normalizing the hyperactivity of noradrenergic locus
coeruleus neurons. The α2 -antagonist, yohimbine, which increases activity of locus coeruleus
noradrenergic activity by blocking autoreceptors, can induce symptoms of fear and anxiety in
animals and humans. These adrenergic agonists are used in the treatment of certain cases of
hypertension. β-Adrenergic agonists have profound effects on the cardiac and pulmonary
systems and are one of the primary agents used to treat asthma and other chronic obstructive
pulmonary diseases. Antagonists of β- adrenergic receptors are mainstays in the treatment of
ischemic heart disease and hypertension. β-Adrenergic antagonists, such as propranolol, are
also used to reduce signs of increased sympathetic activity in individuals with social anxiety
(stage fright), such as hand tremor, sweating, and rapid heartbeat.