Chapter 7b Cholinergic System and Drugs

CHOLINERGIC TRANSMISSION to a nerve AP synchronous release of multiple

quanta triggers postjunctional events.
Acetylcholine (ACh) is a major neurohumoral
Two toxins interfere with cholinergic trans-
transmitter at autonomic, somatic as well as central
mission by affecting release: botulinum toxin inhi-
sites. These sites are listed in Table 7.1
bits release, while black widow spider toxin
Synthesis, storage and destruction of ACh induces massive release and depletion.
The cholinergic neuronal mechanisms are sum- Botulinum toxin
marized in Fig. 7.1.
Botulinum toxin A and B are highly potent exotoxins produced
Acetylcholine is synthesized locally in the cho- by Clostridium botulinum that are responsible for ‘botulism’
linergic nerve endings by the following pathway— (a type of food poisoning). These neurotoxic proteins cause
long-lasting loss of cholinergic transmission by interacting
ATP + Acetate + CoEn-A with axonal proteins involved in exocytotic release of ACh.
Acetate activating reaction Localized injection of minute quantity of botulinum toxin
A (BOTOX) or its haemagglutinin complex (DYSPORT) can
Acetyl CoEn-A be used in the treatment of a number of spastic and other
neurological conditions due to overactivity of cholinergic
CHOLINE
nerves, like blepharospasm, spastic cerebral palsy, strabismus,
Choline acetyl transferase
spasmodic torticollis, nystagmus, hemifacial spasm, post
ACETYLCHOLINE + CoEn-A stroke spasticity, spasmodic dysphonia, axillary hyperhydrosis,
etc. It is increasing being employed as beauty treatment by
CH3 O removal of age-related facial wrinkles. However, its incorrect
| || Cl¯
injection or overdose can be dangerous; ptosis, diplopia, facial
CH 3—N+—CH2—CH2—O—C—CH3
swelling, dry mouth, dysphagia, dysarthria, muscular weakness
|
and even respiratory paralysis has occurred.
CH3
ACETYLCHOLINE CHLORIDE Cholinesterase Immediately after release, ACh
is hydrolyzed by the enzyme cholinesterase and
Choline is actively taken up by the axonal choline is recycled. A specific (Acetylcholines-
membrane by a Na+: choline cotransporter and terase—AChE or true cholinesterase) and a
acetylated with the help of ATP and coenzyme- nonspecific (Butyrylcholinesterase—BuChE or
A by the enzyme choline acetyl transferase present pseudocholinesterase) type of enzyme occurs in
in the axoplasm. Hemicholinium (HC3) blocks the body; important differences between these two
choline uptake (the rate limiting step in ACh types of the enzyme are given in Table 7.2. While
synthesis) and depletes ACh. Most of the ACh AChE is strategically located at all cholinergic
is stored in ionic solution within small synaptic sites and serves to inactivate ACh instantaneously,
vesicles, but some free ACh is also present in BuChE present in plasma and elsewhere probably
the cytoplasm of cholinergic terminals. Active serves to metabolize ingested esters.
transport of ACh into synaptic vesicles is effected
by another carrier which is blocked by vesamicol.
Acetylcholine
Release of ACh from nerve terminals occurs
Cholinesterase
in small quanta—amount contained in individual
vesicles is extruded by exocytosis. In response Choline + Acetate
100 DRUGS ACTING ON ANS

TABLE 7.1 Sites of cholinergic transmission and type of receptor involved

Site Type of receptor Selective agonist Selective antagonist

1. a. All postganglionic parasymp. 
b. Few postganglionic symp. (sweat  Muscarinic Muscarine Atropine
glands, some blood vessels) 

2. a. Ganglia (both symp. and 

parasymp).  Nicotinic (NN) DMPP* Hexamethonium
b. Adrenal medulla 
3. Skeletal muscles Nicotinic (NM) PTMA** d-tubocurarine
SECTION 2

4. CNS (cortex, basal ganglia, spinal Muscarinic Muscarine/ Atropine

cord and other sites) Oxotremorine
Nicotinic Carbachol d-tubocurarine
* DMPP—Dimethyl phenyl piperazinium
** PTMA—Phenyl trimethyl ammonium

G protein coupled receptor, while the latter is

a ligand gated cation channel.
Muscarinic These receptors are selectively
stimulated by muscarine and blocked by atropine.
They are located primarily on autonomic effector
cells in heart, blood vessels, eye, smooth muscles
and glands of gastrointestinal, respiratory and
urinary tracts, sweat glands, etc. and in the CNS.
Subsidiary muscarinic receptors are also present
in autonomic ganglia where they appear to play
a modulatory role by inducing a long-lasting late
EPSP.
Muscarinic autoreceptors are present prejunctionally on post-
ganglionic cholinergic nerve endings: their activation inhibits
further ACh release. Similar ones have been demonstrated on
adrenergic terminals: their activation inhibits NA release (may
contribute to vasodilator action of injected ACh). All blood
vessels have muscarinic receptors (though most of them lack
cholinergic innervation) located on endothelial cells whose
activation releases EDRF (nitric oxide) which diffuses to the
Fig. 7.1: Cholinergic neuronal mechanisms smooth muscle to cause relaxation.
Minus sign indicates inhibition while bold blue arrow Subtypes of muscarinic receptor By pharma-
indicates active transport
Ch—Choline, ACh—Acetylcholine, ChAT—Choline
cological as well as molecular cloning techniques,
acetyl transferase, AChE—Acetylcholinesterase, Anti- muscarinic receptors have been divided into 5
ChE—Anticholinesterase, M—Muscarinic receptor, N— subtypes M1, M2, M3, M4 and M5. The first 3 are
Nicotinic receptor, HC3—Hemicholinium, BoT— the major subtypes (Table 7.3) that are present on
Botulinum toxin, Vsa—Vesamicol, Na+ChT—Na+–Choline effector cells as well as on prejunctional nerve
Cotransporter.
endings, and are expressed both in peripheral
organs as well as in the CNS. The M4 and M5
Cholinoceptors receptors are present mainly on nerve endings in
Two classes of receptors for ACh are recognised certain areas of the brain and regulate the release
—muscarinic and nicotinic; the former is a of other neurotransmitters. Functionally, M1, M3
 CHOLINERGIC SYSTEM AND DRUGS 101

TABLE 7.2 Differences between the two types of cholinesterases

Acetylcholinesterase (True) Butyrylcholinesterase (Pseudo)

1. Distribution All cholinergic sites, RBC, Plasma, liver, intestine, white matter
gray matter
2. Hydrolysis
ACh Very fast (in µs) Slow
Methacholine Slower than ACh Not hydrolysed
Benzoylcholine Not hydrolysed Hydrolysed
Butyrylcholine Not hydrolysed Hydrolysed

CHAPTER 7
3. Inhibition More sensitive to physostigmine More sensitive to organophosphates
4. Function Termination of ACh action Hydrolysis of ingested esters

and M5 fall in one class while M2 and M4 fall in in cortex, hippocampus and corpus striatum. It plays
another class. Muscarinic agonists have shown little a major role in mediating gastric secretion,
subtype selectivity, but some relatively selective relaxation of lower esophageal sphincter (LES)
antagonists have been produced (pirenzepine for caused by vagal stimulation, and in learning,
M1, tripitramine for M2 and darifenacin for M3). memory, motor functions, etc.
Most organs have more than one subtype, but M2: Cardiac muscarinic receptors are predomi-
usually one subtype predominates in a given tissue. nantly M2 and mediate vagal bradycardia.
M1: The M1 is primarily a neuronal receptor located Autoreceptors on cholinergic nerve endings are also
on ganglion cells and central neurones, especially of M2 subtype. Smooth muscles express some M2

TABLE 7.3 Characteristics of important subtypes of muscarinic receptor

M1 M2 M3
1. Location Autonomic Depolarization SA node: Hyperpolarization, Visceral smooth muscle:
and ganglia: (late EPSP)  rate of impulse generation contraction
function Gastric Hist. release, AV node:  velocity of conduction Iris: constriction of pupil
subserved glands: acid secretion Atrium: shortening of APD, Ciliary muscle: contraction
CNS: Learning,  contractility Exocrine glands: secretion
memory, Ventricle:  contractility (slight) Vascular endothelium:
motor functions (receptors sparse) release of NO
Cholinergic nerve endings: vasodilatation
 ACh release
CNS: tremor, analgesia
Visceral smooth muscle:
contraction
2. Nature Gq-protein coupled Gi/Go-protein coupled Gq-protein coupled
3. Transducer IP 3/DAG— cytosolic Ca , 2+
K channel opening,
+
IP 3/DAG— cytosolic Ca2+
mechanism PLA2—PG synthesis  cAMP PLA 2—PG synthesis
4. Agonists* MCN-343A, Oxotremorine Methacholine Bethanechol
5. Antagonists* Pirenzepine, Telenzepine Methoctramine, Solifenacin,
Tripitramine Darifenacin

*Relatively selective
— ACh activates and atropine blocks all 3 subtypes of muscarinic receptors.
— The CNS contains all subtypes of muscarinic receptors, but M1 appear to predominate.
— Most smooth muscles and glands have both M 2 and M3 subtypes; M3 predominates.
102 DRUGS ACTING ON ANS

TABLE 7.4 Characteristics of subtypes of nicotinic receptor

NM NN
1. Location and function Neuromuscular junction: Autonomic ganglia: depolarization
subserved depolarization of muscle end plate —postganglionic impulse
—contraction of skeletal muscle Adrenal medulla: catecholamine release
CNS: site specific excitation or inhibition
2. Nature Has intrinsic ion channel, pentamer Has intrinsic ion channel, pentamer
of 2   or  and  subunits, each of only  or , subunits, each subunit
subunit has 4 TM segments has 4 TM segments
SECTION 2

3. Transducer mechanism Opening of cation (Na+, K+) channels Opening of cation (Na+, K+, Ca 2+) channels
4. Agonists PTMA, Nicotine DMPP, Nicotine
5. Antagonists Tubocurarine, -Bungarotoxin Hexamethonium, Trimethaphan

receptors as well which, like M3, mediate and antagonists two subtypes N M and N N
contraction. (previously labelled N1 and N2) are recognized
M3: Visceral smooth muscle contraction and (Table 7.4).
glandular secretions are elicited through M3 NM: These are present at skeletal muscle endplate:
receptors, which also mediate vasodilatation are selectively stimulated by phenyl trimethyl
through EDRF release. Together the M2 and M3 ammonium (PTMA) and blocked by tubocurarine.
receptors mediate most of the well-recognized They mediate skeletal muscle contraction.
muscarinic actions including contraction of LES. NN: These are present on ganglionic cells (sym-
The muscarinic receptors are G-protein coupled receptors pathetic as well as parasympathetic), adrenal
having the characteristic 7 membrane traversing amino acid
sequences. The M1 and M3 (also M5) subtypes function through medullary cells (embryologically derived from the
Gq protein and activate membrane bound phospholipase C same site as ganglionic cells) and in spinal cord and
(PLc)—generating inositol trisphosphate (IP3) and diacyl- certain areas of brain. They are selectively stimu-
glycerol (DAG) which in turn release Ca2+ intracellularly— lated by dimethyl phenyl piperazinium (DMPP),
cause depolarization, glandular secretion, raise smooth muscle
tone and release NO (from endothelium). They also activate blocked by hexamethonium, and constitute the
phospholipase A2 resulting in enhanced synthesis and release primary pathway of transmission in ganglia.
of prostaglandins and leucotrienes in certain tissues. The M2
(and M4) receptor opens K+ channels (through  subunits of CHOLINERGIC DRUGS
regulatory protein Gi) and inhibits adenylyl cyclase (through
 subunit of Gi) resulting in hyperpolarization, reduced (Cholinomimetic, Parasympathomimetic)
pacemaker activity, slowing of conduction and decreased force
of contraction in the heart. The M4 receptor has been implicated
These are drugs which produce actions similar
in facilitation/inhibition of transmitter release in certain areas to that of ACh, either by directly interacting with
of the brain, while M5 has been found to facilitate dopamine cholinergic receptors (cholinergic agonists) or by
release and mediate reward behaviour. increasing availability of ACh at these sites
Nicotinic These receptors are selectively acti- (anticholinesterases).
vated by nicotine and blocked by tubocurarine
or hexamethonium. They are rosette-like penta- CHOLINERGIC AGONISTS
meric structures (see Fig. 4.4) which enclose a Choline esters Alkaloids
ligand gated cation channel: their activation causes Acetylcholine Muscarine
opening of the channel and rapid flow of cations Methacholine Pilocarpine
resulting in depolarization and an action potential. Carbachol Arecoline
On the basis of location and selective agonists Bethanechol
 CHOLINERGIC SYSTEM AND DRUGS 103

ACTIONS (of ACh as prototype) 3. Smooth muscle Smooth muscle in most

Depending on the type of receptor through organs is contracted (mainly through M3 recep-
which it is mediated, the peripheral actions of tors). Tone and peristalsis in the gastrointestinal
ACh are classified as muscarinic or nicotinic. The tract is increased and sphincters relax  abdominal
central actions are not so classifiable and are cramps and evacuation of bowel.
described separately. Peristalsis in ureter is increased. The detrusor
muscle contracts while the bladder trigone and
A. Muscarinic actions sphincter relaxes  voiding of bladder.
Bronchial muscles constrict, asthmatics are
1. Heart ACh hyperpolarizes the SA nodal
highly sensitive  bronchospasm, dyspnoea,

CHAPTER 7
cells and decreases their rate of diastolic depolari-
zation. As a result, rate of impulse generation precipitation of an attack of bronchial asthma.
is reduced—bradycardia or even cardiac arrest 4. Glands Secretion from all parasympathe-
may occur. tically innervated glands is increased via M3 and
At the A-V node and His-Purkinje fibres some M2 receptors: sweating, salivation, lacri-
refractory period (RP) is increased and conduction mation, increased tracheobronchial and gastric
is slowed: P-R interval increases and partial to secretion. The effect on pancreatic and intestinal
complete A-V block may be produced. The force glands is not marked. Secretion of milk and bile
of atrial contraction is markedly reduced and RP is not affected.
of atrial fibres is abbreviated. Due to nonuniform
vagal innervation, the intensity of effect on RP 5. Eye Contraction of circular muscle of iris
and conduction of different atrial fibres varies—  miosis.
inducing inhomogeneity and predisposing to atrial Contraction of ciliary muscle  spasm of accom-
fibrillation or flutter. modation, increased outflow facility, reduction in
Ventricular contractility is also decreased but intraocular tension (especially in glaucomatous
the effect is not marked. The cardiac muscarinic patients).
receptors are of the M2 subtype.
B. Nicotinic actions
2. Blood vessels All blood vessels are dila-
ted, though only few (skin of face, neck, salivary 1. Autonomic ganglia Both sympathetic and
glands) receive cholinergic innervation. Fall in parasympathetic ganglia are stimulated. This effect
BP and flushing, especially in the blush area is manifested at higher doses. High dose of ACh
occurs. Muscarinic (M3) receptors are present on given after atropine causes tachycardia and rise
vascular endothelial cells: vasodilatation is in BP due to stimulation of sympathetic ganglia
primarily mediated through the release of an and release of catecholamines.
endothelium dependent relaxing factor (EDRF)
2. Skeletal muscles Iontophoretic applica-
which is nitric oxide (NO). The PLc-IP3/DAG
tion of ACh to muscle endplate causes contraction
pathway activates endothelial NO synthase through
of the fibre. Intraarterial injection of high dose
the Ca +-Calmodulin mechanism. When the
can cause twitching and fasciculations, but i.v.
endothelium is damaged by disease, ACh can
injection is generally without any effect (due to
diffuse to the vascular smooth muscle and cause
vasoconstriction via M3 receptors located on their rapid hydrolysis of ACh).
plasma membrane.
Stimulation of cholinergic nerves to the penis C. CNS actions
causes erection by releasing NO and dilating ACh injected i.v. does not penetrate blood-brain
cavernosal vessels through M3 receptors. However, barrier and no central effects are seen. However,
this response is minimal with injected cholino- direct injection into the brain produces arousal
mimetic drugs. response followed by depression. Cholinergic
104 DRUGS ACTING ON ANS

TABLE 7.5 Properties of choline esters

Choline ester Hydrolysis by Actions Selective

ACh E BuChE Musc. Nico. action on
Acetylcholine ++ + + + Non selective
Methacholine + – + ± CVS
Carbachol – – + ++ g.i.t., bladder
Bethanechol – – + – g.i.t., bladder

drugs which enter brain produce complex vascular effects are complex. Small doses generally
SECTION 2

behavioral and neurological effects. cause fall in BP (muscarinic), but higher doses
The important features of other choline esters elicit rise in BP and tachycardia which is probably
are summarized in Table 7.5. due to ganglionic stimulation (through ganglionic
muscarinic receptors). Applied to the eye, it
Interactions Anticholinesterases potentiate ACh
penetrates cornea and promptly causes miosis,
markedly, methacholine to less extent and have ciliary muscle contraction and fall in intraocular
only additive action with carbachol or bethane- tension lasting 4–8 hours.
chol, depending upon the role of ChE in the ter- Pilocarpine is used only in the eye as 0.5–
mination of action of the particular choline ester. 4% drops. It is a third-line drug in open angle
Atropine and its congeners competitively anta- glaucoma. An initial stinging sensation in the eye
gonize muscarinic actions. and painful spasm of accommodation are frequent
Adrenaline is a physiological antagonist. side effects. Other uses as a miotic are—to
Uses Choline esters are rarely, if ever, clinically counteract mydriatics after they have been used
used. ACh is not used because of evanescent and for testing refraction and to prevent/break
nonselective action. Methacholine was occasio- adhesions of iris with lens or cornea by alternating
nally used to terminate paroxysmal supraventricular it with mydriatics.
tachycardia but is obsolete now. Though it can be used as a sialogogue, no
Bethanechol has been used in postoperative/ oral preparation is available.
postpartum nonobstructive urinary retention, PILOCAR 1%, 2%, 4% eye drops, CARPINE 0.5% eyedrops,
PILODROPS 2% eyedrops.
neurogenic bladder to promote urination. It can
Muscarine It occurs in poisonous mushrooms Amanita
afford symptomatic relief in congenital megacolon
muscaria and Inocybe species and has only muscarinic actions.
and gastroesophageal reflux, but is rarely used It is not used therapeutically but is of toxicological importance.
for these. Side effects are prominent: belching, Mushroom poisoning Depending on the toxic principle
colic, involuntary urination/defecation, flushing, present in the particular species, at least 3 types of mushroom
sweating, fall in BP, bronchospasm. poisoning is known.
Dose: 10–40 mg oral, 2.5–5 mg s.c.; Muscarine type (Early mushroom poisoning) due to
UROTONIN, BETHACOL 25 mg tab. Inocybe and related species. Symptoms characteristic of
muscarinic actions appear within an hour of eating the
CHOLINOMIMETIC ALKALOIDS mushroom, and are promptly reversed by atropine.
Hallucinogenic type It is due to muscimol and other isoxazole
Pilocarpine It is obtained from the leaves of compounds which are present in A. muscaria and related
Pilocarpus microphyllus and other species. It has mushrooms in much larger quantities than is muscarine. These
prominent muscarinic actions and also stimulates compounds activate amino acid receptors, and block muscarinic
receptors in the brain; have hallucinogenic property. Manifesta-
ganglia—mainly through ganglionic muscarinic
tions of poisoning are primarily central. There is no specific
receptors. treatment and atropine is contraindicated. Another hallucino-
Pilocarpine causes marked sweating, saliva- genic mushroom is Psilocybe mexicana whose active principle
tion and increase in other secretions. The cardio- psilocybine is a tryptaminergic (5-HT related) compound.
 CHOLINERGIC SYSTEM AND DRUGS 105

Phalloidin type (Late mushroom poisoning) It is due to In carbamates R1 may have a nonpolar tertiary
peptide toxins found in A. phalloides, Galerina and related amino N, e.g. in physostigmine, rendering the
species. These inhibit RNA and protein synthesis. The
symptoms start after many hours and are due to damage to the compound lipid soluble. In others, e.g. neostig-
gastrointestinal mucosa, liver and kidney. Treatment consists mine, R1 has a quaternary N+—rendering it lipid
of supportive measures. Thioctic acid may have some antidotal insoluble. All organophosphates are highly lipid
effect. soluble except echothiophate which is water
Arecoline It is found in betel nut Areca catechu and has
soluble.
muscarinic as well as nicotinic actions, including those on
skeletal muscle endplate. It also has prominent CNS effect:
has been tried in dementia as an enhancer of cognitive MECHANISM OF ACTION
functions, but not found useful—has no therapeutic use.

CHAPTER 7
The anti-ChEs react with the enzyme essentially
ANTICHOLINESTERASES in the same way as ACh. The carbamates and
phosphates respectively carbamylate and phos-
Anticholinesterases (anti-ChEs) are agents which phorylate the esteratic site of the enzyme.
inhibit ChE, protect ACh from hydrolysis—pro-
The mammalian AChE has been cloned and details of its
duce cholinergic effects in vivo and potentiate structure as well as mode of interaction with ACh and various
ACh both in vivo and in vitro. Some anti ChEs anti-ChEs has been worked out.
have additional direct action on nicotinic cholino- The active region of AChE forms a gorge which contains
ceptors. an anionic site (near glutamate 334) and an esteratic site
formed by serine 203, and histidine 447 (Fig. 7.2A). Hydrolysis
of ACh involves electrostatic attraction of positively charged
Reversible
N+ of ACh to the anionic site (Fig. 7.2B) and nucleophilic
Carbamates Acridine attack by serine-OH which is activated by the adjacent histidine
Physostigmine (Eserine) Tacrine leading to acetylation of serine (Fig. 7.2C). The acetylated
enzyme reacts with water to produce acetic acid and choline
Neostigmine (Fig. 7.2D).
Pyridostigmine
Edrophonium Whereas the acetylated enzyme reacts with
Rivastigmine, Donepezil water extremely rapidly and the esteratic site is
Galantamine freed in a fraction of a millisecond, the carbamy-
lated enzyme (reversible inhibitors) reacts slowly
Irreversible (Fig. 7.2E, F) and the phosphorylated enzyme
Organophosphates Carbamates (irreversible inhibitors) reacts extremely slowly
Dyflos (DFP) Carbaryl* (SEVIN) or not at all (Fig. 7.2G). It is noteworthy that
Echothiophate Propoxur* (BAYGON) edrophonium and tacrine attach only to the anionic
Malathion* site and do not form covalent bonds with the
Diazinon* (TIK-20) *Insecticides enzyme, while organophosphates attach only to
Tabun£, Sarin£, Soman£
£
Nerve gases for the esteratic site forming covalent bonds. Reactiva-
chemical warfare tion of edrophonium-inhibited enzyme occurs in
CHEMISTRY < 10 min, and does not involve hydrolysis of
Anti-ChEs are either esters of carbamic acid or the inhibitor, but only its diffusion—action is brief.
derivatives of phosphoric acid. The half-life of reactivation of carbamylated
The generic formula of carbamates and organo- enzyme (about 30 min) is less than that of synthesis
phosphates is shown below: of fresh enzyme protein, while that of phosphory-
lated enzyme (in days) is more than the regene-
ration time. The phosphorylated enzyme may also
undergo ‘aging’ by the loss of one of the alkyl
groups and become totally resistant to hydrolysis.
Thus, apparently reversible and irreversible
106 DRUGS ACTING ON ANS
SECTION 2

Fig. 7.2: Schematic representation of reaction of acetylcholine (A–D), or carbamate anticholinesterase (E, F), or
organophosphate anticholinesterase (G) with cholinesterase enzyme; and reactivation of phosphorylated enzyme by
oxime (G, H). Ser—Serine; His—Histidine; Glu—Glutamic acid.
 CHOLINERGIC SYSTEM AND DRUGS 107

enzyme inhibition is obtained, though the basic contraction in partially curarized and myasthenic
pattern of inhibitor-enzyme interaction remains muscles is increased. Higher doses cause persistent
the same. depolarization of endplates resulting in blockade
of neuromuscular transmission  weakness and
PHARMACOLOGICAL ACTIONS paralysis. Direct action of neostigmine and its
The actions of anti-ChEs are due to amplification congeners at the muscle endplates results in
of endogenous ACh. As such they are qualitatively augmentation of these features.
similar to those of directly acting cholinoceptor CNS Lipophilic anti-ChEs which penetrate into
stimulants. However, relative intensity of action brain produce a generalized alerting response.

CHAPTER 7
on muscarinic, ganglionic, skeletal muscle and Cognitive function may be improved in Alzheimer’s
CNS sites varies among the different agents. disease. However, higher doses produce excite-
Lipid-soluble agents (physostigmine and orga- ment, mental confusion, disorientation, tremors
nophosphates) have more marked muscarinic and and convulsions followed by coma.
CNS effects; stimulate ganglia but action on
skeletal muscles is less prominent. Other effects These result from stimulation
Lipid-insoluble agents (neostigmine and other of smooth muscles and glands of the gastrointes-
quaternary ammonium compounds) produce more tinal, respiratory, urinary tracts and in the eye
marked effect on the skeletal muscles (direct action as described for ACh.
on muscle endplate cholinoceptors as well),
stimulate ganglia, but muscarinic effects are less PHARMACOKINETICS
prominent. They do not penetrate CNS and have
Physostigmine It is rapidly absorbed from g.i.t.
no central effects.
and parenteral sites. Applied to the eye, it
Ganglia Local hydrolysis of ACh is less penetrates cornea freely. It crosses blood-brain
important in ganglia: inactivation occurs partly barrier and is disposed after hydrolysis by ChE.
by diffusion and hydrolysis in plasma. Anti-ChEs Neostigmine and congeners These are poorly
stimulate ganglia primarily through muscarinic
absorbed orally; oral dose is 20–30 times higher
receptors present there. High doses cause persis-
than parenteral dose. They do not effectively
tent depolarization of the ganglionic nicotinic
penetrate cornea or cross blood-brain barrier. They
receptors and blockade of transmission.
are partially hydrolysed and partially excreted
CVS Cardiovascular effects are complex. Where- unchanged in urine.
as muscarinic action would produce bradycardia Organophosphates These are absorbed from
and hypotension, ganglionic stimulation would tend all sites including intact skin and lungs. They
to increase heart rate and BP. Action on medullary are hydrolyzed as well as oxidized in the body
centres (stimulation followed by depression) further and little is excreted unchanged.
complicates the picture, so does ganglionic blockade
with high doses. Thus, the overall effects are often
unpredictable and depend on the agent and its INDIVIDUAL COMPOUNDS
dose. The important features of physostigmine and
Skeletal muscles After treatment with anti- neostigmine are presented in Table 7.6.
ChEs, the ACh released by a single nerve impulse Physostigmine eye drops are usually prepared
is not immediately destroyed—rebinds to the same freshly by ophthalmology departments.
receptor, diffuses to act on neighbouring receptors BI-MIOTIC 0.25% eye drops with 2% pilocarpine nitrate.
and activates prejunctional fibres  repetitive Neostigmine PROSTIGMIN, MYOSTIGMIN,
firing  twitching and fasciculations. Force of TILSTIGMIN 15 mg tab, 0.5 mg/ml in 1 ml and 5 ml inj.
108 DRUGS ACTING ON ANS

TABLE 7.6 Comparative features of physostigmine and neostigmine

Physostigmine Neostigmine
1. Source Natural alkaloid from Synthetic
Physostigma venenosum
(Calabar bean)
2. Chemistry Tertiary amine derivative Quaternary ammonium compound
3. Oral absorption Good Poor
4. CNS actions Present Absent
5. Applied to eye Penetrates cornea Poor penetration
6. Direct action on NM cholinoceptors Absent Present
SECTION 2

7. Prominent effect on Autonomic effectors Skeletal muscles

8. Important use Miotic (glaucoma) Myasthenia gravis
9. Dose 0.5–1 mg oral/parenteral 0.5–2.5 mg i.m./s.c.
0.1–1.0% eye drops 15–30 mg orally
10. Duration of action Systemic 4–6 hrs 3–4 hrs.
In eye 6 to 24 hrs

Pyridostigmine Resembles neostigmine in all Precautions Anti-ChEs are contraindicated in

respects but is dose to dose less potent and longer sick sinus, A-V conduction defects and hypo-
acting, less frequent dosing is required in tensive states. They are to be used cautiously in
myasthenia gravis. peptic ulcer, asthma, COPD and seizure patients.
DISTINON, MYESTIN 60 mg tab; 1–3 tab TDS.
Ambenonium is another longacting congener used in USES
myasthenia.
Edrophonium Resembles neostigmine in action, has a brief 1. As miotic
duration (10–30 min), suitable only as a diagnostic agent for
myasthenia gravis.
(a) In glaucoma: Miotics increase the tone of
Dose: 2–10 mg i.v. ciliary muscle (attached to scleral spur) and
Tacrine It is a lipophilic acridine compound which interacts sphincter pupillae which pull on and somehow
with ChE in a manner analogous to edrophonium. It crosses improve alignment of the trabeculae so that
blood-brain barrier and has a longer duration of action. By outflow facility is increased  i.o.t. falls in open
increasing brain ACh levels it was found to produce some angle glaucoma.
symptomatic improvement in Alzheimer’s disease, but has gone
into disuse due to hepatotoxicity (see Ch. 35). Pilocarpine is the preferred miotic. The action
is rapid and short lasting (4–6 hr); 6–8 hourly
Rivastigmine This lipophilic relatively cere-
instillation is required and even then i.o.t. may
broselective ChE inhibitor has been introduced for
fluctuate inbetween. Diminution of vision,
Alzheimer’s disease (AD), see Ch. 35.
especially in dim light (due to constricted pupil),
Donepezil Another centrally acting anti-AChE spasm of accommodation and brow pain are
that has produced cognitive and behavioral frequent side effects. Systemic effects—nausea,
improvement in AD. It is long-acting and suitable diarrhoea, sweating and bronchospasm may occur
for once daily administration (see Ch. 35). with higher concentration eye drops.
Galantamine This natural alkaloid inhibitor of Physostigmine (0.1%) is used only to sup-
cerebral AChE has in addition weak agonistic plement pilocarpine. Miotics are now 3rd choice
action on nicotinic receptors. It is being used to drugs, used only as add on therapy in advanced
afford symptomatic relief in AD (see Ch. 35). cases. However, they are effective in aphakic
Dyflos It is Diisopropyl-fluoro-phosphate (DFP), a very glaucoma. Pilocarpine (along with other drugs)
potent and long-acting anti-ChE. It is now obsolete as a miotic. is used in angle closure glaucoma as well.
Echothiophate It is an organophosphate with quaternary (b) To reverse the effect of mydriatics after
structure. It is water soluble; and was used as a long acting miotic. refraction testing.
 CHOLINERGIC SYSTEM AND DRUGS 109

(c) To prevent formation of adhesions between Treatment is usually started with neostigmine
iris and lens or iris and cornea, and even to break 15 mg orally 6 hourly; dose and frequency is
those which have formed due to iritis, corneal then adjusted to obtain optimum relief from
ulcer, etc.—a miotic is alternated with a mydriatic. weakness. However, the dosage requirement may
fluctuate from time to time and there are often
2. Myasthenia gravis unpredictable periods of remission and exacer-
Myasthenia gravis is an autoimmune disorder bation. Pyridostigmine is an alternative which
affecting about 1 in 10,000 population, due to needs less frequent dosing. If intolerable
development of antibodies directed to the nicotinic muscarinic side effects are produced, atropine can
receptors (NR) at the muscle endplate  reduction be added to block them. These drugs have no

CHAPTER 7
in number of free NM cholinoceptors to 1/3 of effect on the basic disorder which often progresses;
normal or less (Fig. 7.3) and structural damage ultimately it may not be possible to restore muscle
to the neuromuscular junction. This results in strength adequately with anti-ChEs alone.
weakness and easy fatigability on repeated activity, Corticosteroids afford considerable improve-
with recovery after rest. The eyelid, external ment in such cases by their immunosuppressant
ocular, facial and pharyngeal muscles are generally action. They inhibit production of NR-antibodies
involved first. Later, limb and respiratory muscles and may increase synthesis of NRs. However,
get affected. Neostigmine and its congeners their long term use has problems of its own (see
improve muscle contraction by allowing ACh Ch. 20). Prednisolone 30–60 mg/day induces
released from prejunctional endings to accumulate remission in about 80% of the advanced cases;
and act on the receptors over a larger area, as 10 mg daily or on alternate days can be used
well as by directly depolarizing the endplate. for maintenance therapy. Other immunosuppres-
sants have also been used with benefit in advan-
ced cases. Both azathioprine and cyclosporine
also inhibit NR-antibody synthesis by affecting
T-cells, but response to the former is slow in
onset (takes upto 1 year), while that to the latter
is relatively quick (in 1–2 months).
Removal of antibodies by plasmapheresis
(plasma exchange) is another therapeutic
approach. Dramatic but short lived improvement
can often be achieved by it in myasthenic crisis.
Thymectomy is effective in a majority of the
cases. It produces gradual improvement and even
complete remission has been obtained. Thymus
may contain modified muscle cells with NRs on
their surface, which may be the source of the
Fig. 7.3: Neuromuscular junction of myasthenic muscle antigen for production of anti-NR antibodies in
In myasthenia gravis the population of nicotinic receptors myasthenic patients.
(NR) available at muscle endplate for binding acetyl-
choline (ACh) is markedly reduced due to their obliteration
Myasthenic crisis is characterized by acute
by nicotinic receptor antibodies (NR-Ab). Acetylcholines- weakness of respiratory muscles. It is managed
terase (AChE) molecules located strategically at the by tracheal intubation and mechanical ventilation.
muscle endplate rapidly hydrolyse ACh. Anticholines- Generally, i.v. methylprednisolone pulse therapy
terases inhibit AChE, allowing the same ACh molecules
to repeatedly interact with the available NRs; frequency is given while anti-ChEs are withheld for 2–3
of ACh-NR interaction is increased days followed by their gradual reintroduction.
110 DRUGS ACTING ON ANS

Most patients can be weaned off the ventilator by atropine or glycopyrrolate 10 g/kg to block
in 1–3 weeks. Plasmapheresis hastens recovery. muscarinic effects, rapidly reverses muscle paralysis
induced by competitive neuromuscular blockers.
Overtreatment with anti-ChEs If the dose of
the antiChE is not adjusted according to the fluc- 5. Cobra bite Cobra venom has a curare like
tuating requirement, relative overdose may occur neurotoxin. Though specific antivenom serum is
from time-to-time. Overdose also produces the primary treatment, neostigmine + atropine
weakness by causing persistent depolarization of prevent respiratory paralysis.
muscle endplate, and is called cholinergic 6. Belladonna poisoning Physostigmine 0.5–2 mg i.v.
weakness. Late cases with high anti-ChE dose repeated as required is the specific antidote for poisoning
with belladonna or other anticholinergics. It penetrates blood-
SECTION 2

requirements often alternately experience myast-

brain barrier and antagonizes both central and peripheral
henic and cholinergic weakness and these may actions. However, physostigmine often itself induces
assume crisis proportions. hypotension, arrhythmias and undesirable central effects. It
The two types of weakness require opposite is therefore employed only as a last resort. Neostigmine does
not block the central effect, but is less risky.
treatments. They can be differentiated by edropho-
nium test— 7. Other drug overdosages Tricyclic antidepressants,
phenothiazines and many antihistaminics have additional
improvementmyasthenic crisis anticholinergic property. Overdose symptoms and coma
Inject produced by these drugs are partly antagonized by
edrophonium physostigmine. However, it may worsen the fall in BP and
(2 mg. i.v.) no improvement or arrhythmias; use therefore is risky. Physostigmine also appears
to have a modest nonspecific arousal effect in CNS depression
worseningcholinergic crisis produced by diazepam or general anaesthetics, but use for
this purpose is rarely warranted.
Diagnostic tests for myasthenia gravis
(a) Ameliorative test: Initially edrophonium 8. Alzheimer’s disease Characterized by
2 mg is injected i.v. as a test dose. If nothing progressive dementia, AD is a neurodegenerative
untoward happens, the remaining 8 mg is injected disorder, primarily affecting cholinergic neurones
after 30–60 sec. Reversal of weakness and short- in the brain. Various measures to augment choli-
lasting improvement in the strength of affected nergic transmission in the brain have been
muscles occurs only in myasthenia gravis and not tried. The relatively cerebroselective anti-ChEs,
in other muscular dystrophies. rivastigmine, donepezil and galantamine are now
In case edrophonium is not available, the test commonly used. For details see Ch. 35.
can be performed with 1.5 mg i.v. neostigmine. ANTICHOLINESTERASE POISONING
Atropine pretreatment may be given to block the
muscarinic effects of neostigmine. Anticholinesterases are easily available and
(b) Provocative test: myasthenics are highly sensitive to extensively used as agricultural and household
d-tubocurarine; 0.5 mg i.v. causes marked weakness in them insecticides; accidental as well as suicidal and
but is ineffective in non-myasthenics. This test is hazardous: homicidal poisoning is common.
facilities for positive pressure respiration must be at hand Local muscarinic manifestations at the site
before performing it. This test is better not performed.
of exposure (skin, eye, g.i.t.) occur immediately
(c) Demonstration of anti-NR antibodies in plasma or muscle
biopsy specimen is a more reliable test. and are followed by complex systemic effects
due to muscarinic, nicotinic and central actions.
3. Postoperative paralytic ileus/urinary
They are—
retention This may be relieved by 0.5–1 mg
• Irritation of eye, lacrimation, salivation, swea-
s.c. neostigmine, provided no organic obstruction
ting, copious tracheo-bronchial secretions,
is present.
miosis, blurring of vision, bronchospasm,
4. Postoperative decurarization Neostig- breathlessness, colic, involuntary defecation
mine 0.5–2.0 mg (30–50 g/kg) i.v., preceded and urination.
 CHOLINERGIC SYSTEM AND DRUGS 111

• Fall in BP, bradycardia or tachycardia, cardiac the esteratic site: the oxime-phosphonate so
arrhythmias, vascular collapse. formed diffuses away leaving the reactivated ChE.
• Muscular fasciculations, weakness, respiratory Pralidoxime is ineffective as an antidote to
paralysis (central as well as peripheral). carbamate anti-ChEs (physostigmine, neostigmine,
• Irritability, disorientation, unsteadiness, tremor, carbaryl, propoxur) in which case the anionic site
ataxia, convulsions, coma and death. of the enzyme is not free to provide attachment
• Death is generally due to respiratory failure. to it. It is rather contraindicated in carbamate
poisoning, because not only it does not reactivate
Treatment carbamylated enzyme, it has weak anti-ChE
activity of its own.

CHAPTER 7
1. Termination of further exposure to the poison—
fresh air, wash the skin and mucous membranes Pralidoxime (NEOPAM, PAM-A INJ. 500 mg/20 ml
with soap and water, gastric lavage according infusion, LYPHE 1 g/vial for inj.) is injected i.v. slowly
to need. in a dose of 1–2 g (children 20–40 mg/kg).
2. Maintain patent airway, positive pressure Another regimen is 30 mg/kg i.v. loading dose,
respiration if it is failing. followed by 8–10 mg/kg/hour continuous infusion
3. Supportive measures—maintain BP, hydration, till recovery. Pralidoxime causes more marked
control of convulsions with judicious use of reactivation of skeletal muscle ChE than at
diazepam. autonomic sites and not at all in the CNS (does
4. Specific antidotes— not penetrate into brain). Treatment should be
(a) Atropine It is highly effective in counter- started as early as possible (within few hours),
acting the muscarinic symptoms, but higher doses before the phosphorylated enzyme has undergone
are required to antagonize the central effects. It ‘aging’ and become resistant to hydrolysis. Doses
does not reverse peripheral muscular paralysis may be repeated according to need (max. 12 g
which is a nicotinic action. All cases of anti-ChE in first 24 hrs. Lower doses according to symptoms
(carbamate or organophosphate) poisoning must are continued 1–2 weeks). The use of oximes
be promptly given atropine 2 mg i.v. repeated in organophosphate poisoning is secondary to that
every 10 min till dryness of mouth or other signs of atropine. Moreover, the clinical benefit of oxime
of atropinization appear (upto 200 mg has been therapy is highly variable depending upon the
administered in a day). Continued treatment with compound involved (different organophosphates
maintenance doses may be required for 1–2 weeks. ‘age’ at different rates), the amount of poison
(b) Cholinesterase reactivators Oximes are that has entered the body, time lapse before therapy
used to restore neuromuscular transmission only is started and dose of the oxime.
in case of organophosphate anti-ChE poisoning. Other oximes are obidoxime (more potent than pralidoxime)
The phosphorylated ChE reacts very slowly or and diacetyl-monoxime (DAM), which is lipophilic.
not at all with water. However, if more reactive
Chronic organophosphate poisoning Repeated
OH groups in the form of oximes (generic formula exposure to certain fluorine containing and triaryl
R–CH = N–OH) are provided, reactivation occurs organophosphates results in polyneuritis and demyelination
more than a million times faster (see Fig. 7.2G after a latent period of days to weeks. Sensory disturbances
and H). occur first followed by muscle weakness, tenderness
and depressed tendon reflexes—lower motor neurone
Pralidoxime (2-PAM) has a positively charged
paralysis. In the second phase, spasticity and upper
quaternary nitrogen: attaches to the anionic site motor neurone paralysis gradually supervenes. Recovery may
of the enzyme which remains unoccupied in the take years. The mechanism of this toxicity is not known,
presence of organophosphate inhibitors. Its oxime but it is not due to inhibition of ChE; there is no specific
end reacts with the phosphorus atom attached to treatment.