Basic & Clinical Pharmacology, 10th Edition

7. Cholinoceptor-Activating & Cholinesterase-Inhibiting Drugs - Achilles J. Pappano, PhD

INTRODUCTION

Acetylcholine receptor stimulants and cholinesterase inhibitors together comprise a large group of drugs that mimic acetylcholine (cholinomimetic agents) (Figure 7-1). Cholinoceptor stimulants are classified pharmacologically by their spectrum of action depending on the type of receptor¾muscarinic or nicotinic¾that is activated. They are also classified by their mechanism of action because some cholinomimetic drugs bind directly to (and activate) cholinoceptors while others act indirectly by inhibiting the hydrolysis of endogenous acetylcholine.

SPECTRUM OF ACTION OF CHOLINOMIMETIC DRUGS

Early studies of the parasympathetic nervous system showed that the alkaloid muscarine mimicked the effects of parasympathetic nerve discharge, ie, the effects were parasympathomimetic. Application of muscarine to ganglia and to autonomic effector tissues (smooth muscle, heart, exocrine glands) showed that the parasympathomimetic action of the alkaloid occurred through an action on receptors at effector cells, not those in ganglia. The effects of acetylcholine itself and of other cholinomimetic drugs at autonomic neuroeffector junctions are called parasympathomimetic effects, and are mediated by muscarinic receptors. In contrast, low concentrations of the alkaloid nicotine stimulated autonomic ganglia and skeletal muscle neuromuscular junctions but not autonomic effector cells. The ganglion and skeletal muscle receptors were therefore labeled nicotinic. When acetylcholine was later identified as the physiologic transmitter at both muscarinic and nicotinic receptors, both receptors were recognized as cholinoceptor subtypes.

Cholinoceptors are members of either G protein-linked (muscarinic) or ion channel (nicotinic) families on the basis of their transmembrane signaling mechanisms. Muscarinic receptors contain seven transmembrane domains whose third cytoplasmic loop is coupled to G proteins that function as transducers (see Figure 2-11). These receptors regulate the production of intracellular second messengers and modulate certain ion channels via their G proteins. Agonist selectivity is determined by the subtypes of muscarinic receptors and G proteins that are present in a given cell (Table 7-1). Muscarinic receptors are located on plasma membranes of cells in the central nervous system, in organs innervated by parasympathetic nerves as well as on some tissues that are not innervated by these nerves, eg, endothelial cells (Table 7-1), and on those tissues innervated by postganglionic sympathetic cholinergic nerves.

Nicotinic receptors are part of a transmembrane polypeptide whose subunits form cation-selective ion channels (see Figure 2-9). These receptors are located on plasma membranes of postganglionic cells in all autonomic ganglia, of muscles innervated by somatic motor fibers, and of some central nervous system neurons (see Figure 6-1).

Unselective cholinoceptor stimulants in sufficient dosage can produce very diffuse and marked alterations in organ system function because acetylcholine has multiple sites of action where it initiates both excitatory and inhibitory effects. Fortunately, drugs are available that have a degree of selectivity, so that desired effects can often be achieved while avoiding or minimizing adverse effects. Selectivity of action is based on several factors. Some drugs stimulate either muscarinic receptors or nicotinic receptors selectively. Some agents stimulate nicotinic receptors at neuromuscular junctions preferentially and have less effect on nicotinic receptors in ganglia. Organ selectivity can also be achieved by using appropriate routes of administration ("pharmacokinetic selectivity"). For example, muscarinic stimulants can be administered topically to the surface of the eye to modify ocular function while minimizing systemic effects.

MODE OF ACTION OF CHOLINOMIMETIC DRUGS

Direct-acting cholinomimetic agents bind to and activate muscarinic or nicotinic receptors (Figure 7-1). Indirect-acting agents produce their primary effects by inhibiting acetylcholinesterase, which hydrolyzes acetylcholine to choline and acetic acid (see Figure 6-3). By inhibiting acetylcholinesterase, the indirect-acting drugs increase the endogenous acetylcholine concentration in synaptic clefts and neuroeffector junctions. The excess acetylcholine, in turn, stimulates cholinoceptors to evoke increased responses. These drugs act primarily where acetylcholine is physiologically released and are thus amplifiers of endogenous acetylcholine.

Some cholinesterase inhibitors also inhibit butyrylcholinesterase (pseudocholinesterase). However, inhibition of butyrylcholinesterase plays little role in the action of indirect-acting cholinomimetic drugs because this enzyme is not important in the physiologic termination of synaptic acetylcholine action. Some quaternary cholinesterase inhibitors also have a modest direct action as well, eg, neostigmine, which activates neuromuscular nicotinic cholinoceptors directly in addition to blocking cholinesterase.

I. BASIC PHARMACOLOGY OF THE DIRECT-ACTING CHOLINOCEPTOR STIMULANTS

Introduction

The direct-acting cholinomimetic drugs can be divided on the basis of chemical structure into esters of choline (including acetylcholine) and alkaloids (such as muscarine and nicotine). A few of these drugs are highly selective for the muscarinic or for the nicotinic receptor. Many have effects on both receptors; acetylcholine is typical.

Chemistry & Pharmacokinetics

A. STRUCTURE
Four important choline esters that have been studied extensively are shown in Figure 7-2. Their permanently charged quaternary ammonium group renders them relatively insoluble in lipids. Many naturally occurring and synthetic cholinomimetic drugs that are not choline esters have been identified; a few of these are shown in Figure 7-3. The muscarinic receptor is strongly stereoselective: (S)-bethanechol is almost 1000 times more potent than (R)-bethanechol.

B. ABSORPTION, DISTRIBUTION, AND METABOLISM
Choline esters are poorly absorbed and poorly distributed into the central nervous system because they are hydrophilic. Although all are hydrolyzed in the gastrointestinal tract (and less active by the oral route), they differ markedly in their susceptibility to hydrolysis by cholinesterase. Acetylcholine is very rapidly hydrolyzed (see Chapter 6); large amounts must be infused intravenously to achieve concentrations sufficient to produce detectable effects. A large intravenous bolus injection has a brief effect, typically 5-20 seconds, whereas intramuscular and subcutaneous injections produce only local effects. Methacholine is more resistant to hydrolysis, and the carbamic acid esters carbachol and bethanechol are still more resistant to hydrolysis by cholinesterase and have correspondingly longer durations of action. The b-methyl group (methacholine, bethanechol) reduces the potency of these drugs at nicotinic receptors (Table 7-2).

The tertiary natural cholinomimetic alkaloids (pilocarpine, nicotine, lobeline; Figure 7-3) are well absorbed from most sites of administration. Nicotine, a liquid, is sufficiently lipid-soluble to be absorbed across the skin. Muscarine, a quaternary amine, is less completely absorbed from the gastrointestinal tract than the tertiary amines but is nevertheless toxic when ingested, eg, in certain mushrooms, and even enters the brain. Lobeline is a plant derivative similar to nicotine. These amines are excreted chiefly by the kidneys. Acidification of the urine accelerates clearance of the tertiary amines.

Pharmacodynamics

A. MECHANISM OF ACTION
Activation of the parasympathetic nervous system modifies organ function by two major mechanisms. First, acetylcholine released from parasympathetic nerves activates muscarinic receptors on effector cells to alter organ function directly. Second, acetylcholine released from parasympathetic nerves interacts with muscarinic receptors on nerve terminals to inhibit the release of their neurotransmitter. By this mechanism, acetylcholine release and circulating muscarinic agonists indirectly alter organ function by modulating the effects of the parasympathetic and sympathetic nervous systems and perhaps nonadrenergic, noncholinergic (NANC) systems.

As indicated in Chapter 6, muscarinic receptor subtypes have been characterized by binding studies and cloned. Several cellular events occur when muscarinic receptors are activated, one or more of which might serve as second messengers for muscarinic activation. All muscarinic receptors appear to be of the G-protein coupled type (see Chapter 2 and Table 7-1). Muscarinic agonist binding activates the inositol trisphosphate (IP₃), diacylglycerol (DAG) cascade. Some evidence implicates DAG in the opening of smooth muscle calcium channels; IP₃ releases calcium from endoplasmic and sarcoplasmic reticulum. Muscarinic agonists also increase cellular cGMP concentrations. Activation of muscarinic receptors also increases potassium flux across cardiac cell membranes and decreases it in ganglion and smooth muscle cells. This effect is mediated by the binding of an activated G protein directly to the channel. Finally, muscarinic receptor activation in some tissues (eg, heart, intestine) inhibits adenylyl cyclase activity. Moreover, muscarinic agonists attenuate the activation of adenylyl cyclase and modulate the increase in cAMP levels induced by hormones such as catecholamines. These muscarinic effects on cAMP generation reduce the physiologic response of the organ to stimulatory hormones.

The mechanism of nicotinic receptor activation has been studied in great detail, taking advantage of three factors: (1) the receptor is present in extremely high concentration in the membranes of the electric organs of electric fish; (2) a-bungarotoxin, a component of certain snake venoms, binds tightly to the receptors and is readily labeled as a marker for isolation procedures; and (3) receptor activation results in easily measured electrical and ionic changes in the cells involved. The nicotinic receptor in muscle tissues is a pentamer of four types of glycoprotein subunits (one monomer occurs twice) with a total molecular weight of about 250,000 (see Figure 2-9). The neuronal nicotinic receptor consists of a and b subunits only (Table 7-1). Each subunit has four transmembrane segments. Each a subunit has a receptor site that, when occupied by a nicotinic agonist, causes a conformational change in the protein (channel opening) that allows sodium and potassium ions to diffuse rapidly down their concentration gradients. Binding of an agonist molecule by one of the two a subunit receptor sites only modestly increases the probability of channel opening; simultaneous binding of agonist by both of the receptor sites greatly enhances opening probability. Nicotinic receptor activation causes depolarization of the nerve cell or neuromuscular end plate membrane.

Prolonged agonist occupancy of the nicotinic receptor abolishes the effector response; that is, the postganglionic neuron stops firing (ganglionic effect), and the skeletal muscle cell relaxes (neuromuscular end plate effect). Furthermore, the continued presence of the nicotinic agonist prevents electrical recovery of the postjunctional membrane. Thus, a state of "depolarizing blockade" is induced that is refractory to reversal by other agonists. As noted below, this effect can be exploited for producing muscle paralysis.

B. ORGAN SYSTEM EFFECTS
Most of the direct organ system effects of muscarinic cholinoceptor stimulants are readily predicted from a knowledge of the effects of parasympathetic nerve stimulation (see Table 6-3) and the distribution of muscarinic receptors. Effects of a typical agent such as acetylcholine are listed in Table 7-3. The effects of nicotinic agonists are similarly predictable from a knowledge of the physiology of the autonomic ganglia and skeletal muscle motor end plate.

1. Eye¾ Muscarinic agonists instilled into the conjunctival sac cause contraction of the smooth muscle of the iris sphincter (resulting in miosis) and of the ciliary muscle (resulting in accommodation). As a result, the iris is pulled away from the angle of the anterior chamber, and the trabecular meshwork at the base of the ciliary muscle is opened. Both effects facilitate aqueous humor outflow into the canal of Schlemm, which drains the anterior chamber.

2. Cardiovascular system¾ The primary cardiovascular effects of muscarinic agonists are reduction in peripheral vascular resistance and changes in heart rate. The direct effects listed in Table 7-3 are modified by important homeostatic reflexes, as described in Chapter 6 and depicted in Figure 6-7. Intravenous infusions of minimally effective doses of acetylcholine in humans (eg, 20-50 mcg/min) cause vasodilation, resulting in a reduction in blood pressure, often accompanied by a reflex increase in heart rate. Larger doses of acetylcholine produce bradycardia and decrease atrioventricular node conduction velocity in addition to hypotension. The direct cardiac actions of muscarinic stimulants include the following: (1) an increase in a potassium current (I_K(ACh)) in atrial muscle cells and in the cells of the sinoatrial and atrioventricular nodes as well; (2) a decrease in the slow inward calcium current (I_Ca) in heart cells; and (3) a reduction in the hyperpolarization-activated current (I_f) that underlies diastolic depolarization. All of these actions are mediated by M₂ receptors and contribute to slowing the pacemaker rate. Effects (1) and (2) cause hyperpolarization and decrease the contractility of atrial cells. Predictably, carbachol does not inhibit sinoatrial rate in animals with mutated M₂ receptors.

The direct slowing of sinoatrial rate and atrioventricular conduction that is produced by muscarinic agonists is often opposed by reflex sympathetic discharge, elicited by the decrease in blood pressure. The resultant sympathetic-parasympathetic interaction is complex because of the muscarinic modulation of sympathetic influences that occurs by inhibition of norepinephrine release and by postjunctional cellular effects. Muscarinic receptors that are present on postganglionic parasympathetic nerve terminals allow neurally released acetylcholine to inhibit its own secretion. The neuronal muscarinic receptors need not be the same subtype as found on effector cells. Therefore, the net effect on heart rate depends on local concentrations of the agonist in the heart and in the vessels and on the level of reflex responsiveness.

Parasympathetic innervation of the ventricles is much less extensive than that of the atria; activation of ventricular muscarinic receptors causes much less physiologic effect than that seen in atria. However, during sympathetic nerve stimulation, the effects of muscarinic agonists on ventricular function are clearly evident because of muscarinic modulation of sympathetic effects ("accentuated antagonism").

In the intact organism, muscarinic agonists produce marked vasodilation. However, earlier studies of isolated blood vessels often showed a contractile response to these agents. It is now known that acetylcholine-induced vasodilation requires the presence of intact endothelium (Figure 7-4). Muscarinic agonists release endothelium-derived relaxing factor (EDRF) from the endothelial cells that relaxes smooth muscle. Isolated vessels prepared with the endothelium preserved consistently reproduce the vasodilation seen in the intact organism. EDRF appears to be largely nitric oxide (NO). This substance activates guanylyl cyclase and increases cGMP in smooth muscle, resulting in relaxation (see Figure 12-2).

The cardiovascular effects of all of the choline esters are similar to those of acetylcholine, the main difference being in their potency and duration of action. Because of the resistance of methacholine, carbachol, and bethanechol to acetylcholinesterase, lower doses given intravenously are sufficient to produce effects similar to those of acetylcholine, and the duration of action of these synthetic choline esters is longer. The cardiovascular effects of most of the cholinomimetic natural alkaloids and the synthetic analogs are also generally similar to those of acetylcholine.

Pilocarpine is an interesting exception to the above statement. If given intravenously (an experimental exercise), it may produce hypertension after a brief initial hypotensive response. The longer-lasting hypertensive effect can be traced to sympathetic ganglionic discharge caused by activation of postganglionic cell membrane M₁ receptors, which close K⁺ channels and elicit slow excitatory (depolarizing) postsynaptic potentials. This effect, like the hypotensive effect, can be blocked by atropine, an antimuscarinic drug.

3. Respiratory system¾ Muscarinic stimulants contract the smooth muscle of the bronchial tree. In addition, the glands of the tracheobronchial mucosa are stimulated to secrete. This combination of effects can occasionally cause symptoms, especially in individuals with asthma.

4. Gastrointestinal tract¾ Administration of muscarinic agonists, like parasympathetic nervous system stimulation, increases the secretory and motor activity of the gut. The salivary and gastric glands are strongly stimulated; the pancreas and small intestinal glands less so. Peristaltic activity is increased throughout the gut, and most sphincters are relaxed. Stimulation of contraction in this organ system involves depolarization of the smooth muscle cell membrane and increased calcium influx. Muscarinic agonists do not cause contraction of the ileum in mutant mice lacking M₂ and M₃ receptors. The M₃ receptor is required for direct activation of smooth muscle contraction while the M₂ receptor reduces cAMP formation and relaxation caused by sympathomimetic drugs.

5. Genitourinary tract¾ Muscarinic agonists stimulate the detrusor muscle and relax the trigone and sphincter muscles of the bladder, thus promoting voiding. The function of M₂ and M₃ receptors in the urinary bladder appears to be the same as in intestinal smooth muscle. The human uterus is not notably sensitive to muscarinic agonists.

6. Miscellaneous secretory glands¾ Muscarinic agonists stimulate secretion by thermoregulatory sweat, lacrimal, and nasopharyngeal glands.

7. Central nervous system¾ The central nervous system contains both muscarinic and nicotinic receptors, the brain being relatively richer in muscarinic sites and the spinal cord containing a preponderance of nicotinic sites. The physiologic roles of these receptors are discussed in Chapter 21.

The role of muscarinic receptors in the central nervous system has been confirmed by experiments in knockout mice. The central nervous system effects of the synthetic muscarinic agonist oxotremorine (tremor, hypothermia, and antinociception) were also lacking in mice with homozygously mutated M₂ receptors. Animals lacking M₃ receptors, especially those in the hypothalamus, had reduced appetite and diminished body fat mass. Knockout of M₁ receptors was associated with different changes in the peripheral and central nervous systems. Oxotremorine did not suppress M current in sympathetic ganglia, and pilocarpine did not induce epileptic seizures in M₁ mutant mice.

In spite of the smaller ratio of nicotinic to muscarinic receptors in the brain, nicotine and lobeline (Figure 7-3) have important effects on the brainstem and cortex. The mild alerting action of nicotine absorbed from inhaled tobacco smoke is the best-known of these effects. In high concentrations, nicotine induces tremor, emesis, and stimulation of the respiratory center. At still higher levels, nicotine causes convulsions, which may terminate in fatal coma. The lethal effects on the central nervous system and the fact that nicotine is readily absorbed form the basis for the use of nicotine as an insecticide.

8. Peripheral nervous system¾ Autonomic ganglia are important sites of nicotinic synaptic action. The nicotinic agents shown in Figure 7-3 cause marked activation of these nicotinic receptors and initiate action potentials in postganglionic neurons (see Figure 6-8). Nicotine itself has a somewhat greater affinity for neuronal than for skeletal muscle nicotinic receptors. The action is the same on both parasympathetic and sympathetic ganglia. The initial response therefore often resembles simultaneous discharge of both the parasympathetic and the sympathetic nervous systems. In the case of the cardiovascular system, the effects of nicotine are chiefly sympathomimetic. Dramatic hypertension is produced by parenteral injection of nicotine; sympathetic tachycardia may alternate with a bradycardia mediated by vagal discharge. In the gastrointestinal and urinary tracts, the effects are largely parasympathomimetic: nausea, vomiting, diarrhea, and voiding of urine are commonly observed. Prolonged exposure may result in depolarizing blockade of the ganglia.

Neuronal nicotinic receptors are present on sensory nerve endings¾especially afferent nerves in coronary arteries and the carotid and aortic bodies as well as on the glomus cells of the latter. Activation of these receptors by nicotinic stimulants and of muscarinic receptors on glomus cells by muscarinic stimulants elicits complex medullary responses, including respiratory alterations and vagal discharge.

9. Neuromuscular junction¾ The nicotinic receptors on the neuromuscular end plate apparatus are similar but not identical to the receptors in the autonomic ganglia (Table 7-1). Both types respond to acetylcholine and nicotine. (However, as discussed in Chapter 8, the receptors differ in their structural requirements for nicotinic blocking drugs.) When a nicotinic agonist is applied directly (by iontophoresis or by intra-arterial injection), an immediate depolarization of the end plate results, caused by an increase in permeability to sodium and potassium ions. The contractile response varies from disorganized fasciculations of independent motor units to a strong contraction of the entire muscle depending on the synchronization of depolarization of end plates throughout the muscle. Depolarizing nicotinic agents that are not rapidly hydrolyzed (like nicotine itself) cause rapid development of depolarization blockade; transmission blockade persists even when the membrane has repolarized (discussed further in Chapters 8 and 27). This block is manifested as flaccid paralysis in the case of skeletal muscle.

II. BASIC PHARMACOLOGY OF THE INDIRECT-ACTING CHOLINOMIMETICS

Introduction

The actions of acetylcholine released from autonomic and somatic motor nerves are terminated by enzymatic hydrolysis of the molecule. Hydrolysis is accomplished by the action of acetylcholinesterase, which is present in high concentrations in cholinergic synapses. The indirect-acting cholinomimetics have their primary effect at the active site of this enzyme, although some also have direct actions at nicotinic receptors. The chief differences between members of the group are chemical and pharmacokinetic¾their pharmacodynamic properties are almost identical.

Chemistry & Pharmacokinetics

A. STRUCTURE
There are three chemical groups of cholinesterase inhibitors: (1) simple alcohols bearing a quaternary ammonium group, eg, edrophonium; (2) carbamic acid esters of alcohols bearing quaternary or tertiary ammonium groups (carbamates, eg, neostigmine); and (3) organic derivatives of phosphoric acid (organophosphates, eg, echothiophate). Examples of the first two groups are shown in Figure 7-5. Edrophonium, neostigmine, and pyridostigmine are synthetic quaternary ammonium agents used in medicine. Physostigmine (eserine) is a naturally occurring tertiary amine of greater lipid solubility that is also used in therapeutics. Carbaryl (carbaril) is typical of a large group of carbamate insecticides designed for very high lipid solubility, so that absorption into the insect and distribution to its central nervous system are very rapid.

A few of the estimated 50,000 organophosphates are shown in Figure 7-6. Many of the organophosphates (echothiophate is an exception) are highly lipid-soluble liquids. Echothiophate, a thiocholine derivative, is of clinical value because it retains the very long duration of action of other organophosphates but is more stable in aqueous solution. Soman is an extremely potent "nerve gas." Parathion and malathion are thiophosphate prodrugs that are inactive as such; they are converted to the phosphate derivatives in animals and plants and are used as insecticides.

B. ABSORPTION, DISTRIBUTION, AND METABOLISM
Absorption of the quaternary carbamates from the conjunctiva, skin, and lungs is predictably poor, since their permanent charge renders them relatively insoluble in lipids. Thus, much larger doses are required for oral administration than for parenteral injection. Distribution into the central nervous system is negligible. Physostigmine, in contrast, is well absorbed from all sites and can be used topically in the eye (see Table 7-4). It is distributed into the central nervous system and is more toxic than the more polar quaternary carbamates. The carbamates are relatively stable in aqueous solution but can be metabolized by nonspecific esterases in the body as well as by cholinesterase. However, the duration of their effect is determined chiefly by the stability of the inhibitor-enzyme complex (see Mechanism of Action, below), not by metabolism or excretion.

The organophosphate cholinesterase inhibitors (except for echothiophate) are well absorbed from the skin, lung, gut, and conjunctiva¾thereby making them dangerous to humans and highly effective as insecticides. They are relatively less stable than the carbamates when dissolved in water and thus have a limited half-life in the environment (compared with the other major class of insecticides, the halogenated hydrocarbons, eg, DDT). Echothiophate is highly polar and more stable than most other organophosphates. When prepared in aqueous solution for ophthalmic use, it retains activity for weeks.

The thiophosphate insecticides (parathion, malathion, and related compounds) are quite lipid-soluble and are rapidly absorbed by all routes. They must be activated in the body by conversion to the oxygen analogs (Figure 7-6), a process that occurs rapidly in both insects and vertebrates. Malathion and a few other organophosphate insecticides are also rapidly metabolized by other pathways to inactive products in birds and mammals but not in insects; these agents are therefore considered safe enough for sale to the general public. Unfortunately, fish cannot detoxify malathion, and significant numbers of fish have died from the heavy use of this agent on and near waterways. Parathion is not detoxified effectively in vertebrates; thus, it is considerably more dangerous than malathion to humans and livestock and is not available for general public use.

All of the organophosphates except echothiophate are distributed to all parts of the body, including the central nervous system. Poisoning with these agents therefore includes an important component of central nervous system toxicity.

Pharmacodynamics

A. MECHANISM OF ACTION
Acetylcholinesterase is the primary target of these drugs, but butyrylcholinesterase is also inhibited. Acetylcholinesterase is an extremely active enzyme. In the initial catalytic step, acetylcholine binds to the enzyme's active site and is hydrolyzed, yielding free choline and the acetylated enzyme. In the second step, the covalent acetylenzyme bond is split, with the addition of water (hydration). The entire process takes place in approximately 150 microseconds.

All of the cholinesterase inhibitors increase the concentration of endogenous acetylcholine at cholinoceptors by inhibiting acetylcholinesterase. However, the molecular details of their interaction with the enzyme vary according to the three chemical subgroups mentioned above.

The first group, of which edrophonium is the major example, consists of quaternary alcohols. These agents reversibly bind electrostatically and by hydrogen bonds to the active site, thus preventing access of acetylcholine. The enzyme-inhibitor complex does not involve a covalent bond and is correspondingly short-lived (on the order of 2-10 minutes). The second group consists of carbamate esters, eg, neostigmine and physostigmine. These agents undergo a two-step hydrolysis sequence analogous to that described for acetylcholine. However, the covalent bond of the carbamoylated enzyme is considerably more resistant to the second (hydration) process, and this step is correspondingly prolonged (on the order of 30 minutes to 6 hours). The third group consists of the organophosphates. These agents also undergo initial binding and hydrolysis by the enzyme, resulting in a phosphorylated active site. The covalent phosphorus-enzyme bond is extremely stable and hydrolyzes in water at a very slow rate (hundreds of hours). After the initial binding-hydrolysis step, the phosphorylated enzyme complex may undergo a process called aging. This process apparently involves the breaking of one of the oxygen-phosphorus bonds of the inhibitor and further strengthens the phosphorus-enzyme bond. The rate of aging varies with the particular organophosphate compound. If given before aging has occurred, strong nucleophiles like pralidoxime are able to break the phosphorus-enzyme bond and can be used as "cholinesterase regenerator" drugs for organophosphate insecticide poisoning (see Chapter 8). Once aging has occurred, the enzyme-inhibitor complex is even more stable and is more difficult to break, even with oxime regenerator compounds.

The organophosphate inhibitors are sometimes referred to as "irreversible" cholinesterase inhibitors, and edrophonium and the carbamates are considered "reversible" inhibitors because of the marked differences in duration of action. However, the molecular mechanisms of action of the three groups do not support this simplistic description.

B. ORGAN SYSTEM EFFECTS
The most prominent pharmacologic effects of cholinesterase inhibitors are on the cardiovascular and gastrointestinal systems, the eye, and the skeletal muscle neuromuscular junction. Because the primary action is to amplify the actions of endogenous acetylcholine, the effects are similar (but not always identical) to the effects of the direct-acting cholinomimetic agonists.

1. Central nervous system¾ In low concentrations, the lipid-soluble cholinesterase inhibitors cause diffuse activation on the electroencephalogram and a subjective alerting response. In higher concentrations, they cause generalized convulsions, which may be followed by coma and respiratory arrest.

2. Eye, respiratory tract, gastrointestinal tract, urinary tract¾ The effects of the cholinesterase inhibitors on these organ systems, all of which are well innervated by the parasympathetic nervous system, are qualitatively quite similar to the effects of the direct-acting cholinomimetics (Table 7-3).

3. Cardiovascular system¾ The cholinesterase inhibitors can increase activity in both sympathetic and parasympathetic ganglia supplying the heart and at the acetylcholine receptors on neuroeffector cells (cardiac and vascular smooth muscles) that receive cholinergic innervation.

In the heart, the effects on the parasympathetic limb predominate. Thus, cholinesterase inhibitors such as edrophonium, physostigmine, or neostigmine mimic the effects of vagal nerve activation on the heart. Negative chronotropic, dromotropic, and inotropic effects are produced, and cardiac output falls. The fall in cardiac output is attributable to bradycardia, decreased atrial contractility, and some reduction in ventricular contractility. The latter effect occurs as a result of prejunctional inhibition of norepinephrine release as well as inhibition of postjunctional cellular sympathetic effects.

Cholinesterase inhibitors have less marked effects on vascular smooth muscle and on blood pressure than direct-acting muscarinic agonists. This is because indirect-acting drugs can modify the tone of only those vessels that are innervated by cholinergic nerves and because the net effects on vascular tone may reflect activation of both the parasympathetic and sympathetic nervous systems. The cholinomimetic effect at the smooth muscle effector tissue is minimal since few vascular beds receive cholinergic innervation. Activation of sympathetic ganglia may increase vascular resistance.

The net cardiovascular effects of moderate doses of cholinesterase inhibitors therefore consist of modest bradycardia, a fall in cardiac output, and no change or a modest fall in blood pressure. Large (toxic) doses of these drugs cause more marked bradycardia (occasionally tachycardia) and hypotension.

4. Neuromuscular junction¾ The cholinesterase inhibitors have important therapeutic and toxic effects at the skeletal muscle neuromuscular junction. Low (therapeutic) concentrations moderately prolong and intensify the actions of physiologically released acetylcholine. This increases strength of contraction, especially in muscles weakened by curare-like neuromuscular blocking agents or by myasthenia gravis. At higher concentrations, the accumulation of acetylcholine may result in fibrillation of muscle fibers. Antidromic firing of the motor neuron may also occur, resulting in fasciculations that involve an entire motor unit. With marked inhibition of acetylcholinesterase, depolarizing neuromuscular blockade occurs and that may be followed by a phase of nondepolarizing blockade as seen with succinylcholine (see Table 27-2 and Figure 27-7).

Some quaternary carbamate cholinesterase inhibitors, eg, neostigmine, have an additional direct nicotinic agonist effect at the neuromuscular junction. This may contribute to the effectiveness of these agents as therapy for myasthenia.

III. CLINICAL PHARMACOLOGY OF THE CHOLINOMIMETICS

Introduction

The major therapeutic uses of the cholinomimetics are for diseases of the eye (glaucoma, accommodative esotropia), the gastrointestinal and urinary tracts (postoperative atony, neurogenic bladder), the neuromuscular junction (myasthenia gravis, curare-induced neuromuscular paralysis), and very rarely, the heart (certain atrial arrhythmias). Cholinesterase inhibitors are occasionally used in the treatment of atropine overdosage. Several newer cholinesterase inhibitors are being used to treat patients with Alzheimer's disease.

Clinical Uses

A. THE EYE
Glaucoma is a disease characterized by increased intraocular pressure. Muscarinic stimulants and cholinesterase inhibitors reduce intraocular pressure by causing contraction of the ciliary body so as to facilitate outflow of aqueous humor and perhaps also by diminishing the rate of its secretion (see Figure 6-9). In the past, glaucoma was treated with either direct agonists (pilocarpine, methacholine, carbachol) or cholinesterase inhibitors (physostigmine, demecarium, echothiophate, isoflurophate). For chronic glaucoma, these drugs have been largely replaced by topical b-blockers and prostaglandin derivatives.

Acute angle-closure glaucoma is a medical emergency that is frequently treated initially with drugs but usually requires surgery for permanent correction. Initial therapy often consists of a combination of a direct muscarinic agonist and a cholinesterase inhibitor (eg, pilocarpine plus physostigmine) as well as other drugs. Once the intraocular pressure is controlled and the danger of vision loss is diminished, the patient can be prepared for corrective surgery (iridectomy). Open-angle glaucoma and some cases of secondary glaucoma are chronic diseases that are not amenable to traditional surgical correction although newer laser techniques appear to be useful. Other treatments for glaucoma are described in the Box, Treatment of Glaucoma in Chapter 10.

Accommodative esotropia (strabismus caused by hypermetropic accommodative error) in young children is sometimes diagnosed and treated with cholinomimetic agonists. Dosage is similar to or higher than that used for glaucoma.

B. GASTROINTESTINAL AND URINARY TRACTS
In clinical disorders that involve depression of smooth muscle activity without obstruction, cholinomimetic drugs with direct or indirect muscarinic effects may be helpful. These disorders include postoperative ileus (atony or paralysis of the stomach or bowel following surgical manipulation) and congenital megacolon. Urinary retention may occur postoperatively or postpartum or may be secondary to spinal cord injury or disease (neurogenic bladder). Cholinomimetics are also sometimes used to increase the tone of the lower esophageal sphincter in patients with reflux esophagitis. Of the choline esters, bethanechol is the most widely used for these disorders. For gastrointestinal problems, it is usually administered orally in a dose of 10-25 mg three or four times daily. In patients with urinary retention, bethanechol can be given subcutaneously in a dose of 5 mg and repeated in 30 minutes if necessary. Of the cholinesterase inhibitors, neostigmine is the most widely used for these applications. For paralytic ileus or atony of the urinary bladder, neostigmine can be given subcutaneously in a dose of 0.5-1 mg. If patients are able to take the drug by mouth, neostigmine can be given orally in a dose of 15 mg. In all of these situations, the clinician must be certain that there is no mechanical obstruction to outflow prior to using the cholinomimetic. Otherwise, the drug may exacerbate the problem and may even cause perforation as a result of increased pressure.

Pilocarpine has long been used to increase salivary secretion. Cevimeline, a quinuclidine derivative of acetylcholine, is a new direct-acting muscarinic agonist used for the treatment of dry mouth associated with Sjogren's syndrome.

C. NEUROMUSCULAR JUNCTION
Myasthenia gravis is a disease affecting skeletal muscle neuromuscular junctions. An autoimmune process causes production of antibodies that bind to the a subunits of the nicotinic receptor. This effect causes accelerated degradation of the receptor and blockade of acetylcholine binding to receptors on muscle end plates. Frequent findings are ptosis, diplopia, difficulty in speaking and swallowing, and extremity weakness. Severe disease may affect all the muscles, including those necessary for respiration. The disease resembles the neuromuscular paralysis produced by d-tubocurarine and similar nondepolarizing neuromuscular blocking drugs (see Chapter 27). Patients with myasthenia are exquisitely sensitive to the action of curariform drugs and other drugs that interfere with neuromuscular transmission, eg, aminoglycoside antibiotics.

Cholinesterase inhibitors¾but not direct-acting acetylcholine receptor agonists¾are extremely valuable as therapy for myasthenia. Almost all patients are also treated with immunosuppressant drugs and some with thymectomy.

Edrophonium is sometimes used as a diagnostic test for myasthenia. A 2 mg dose is injected intravenously after baseline measurements of muscle strength have been obtained. If no reaction occurs after 45 seconds, an additional 8 mg may be injected. If the patient has myasthenia gravis, an improvement in muscle strength that lasts about 5 minutes will usually be observed.

Edrophonium is also used to assess the adequacy of treatment with the longer-acting cholinesterase inhibitors in patients with myasthenia gravis. If excessive amounts of cholinesterase inhibitor have been used, patients may become paradoxically weak because of nicotinic depolarizing blockade of the motor end plate. These patients may also exhibit symptoms of excessive stimulation of muscarinic receptors (abdominal cramps, diarrhea, increased salivation, excessive bronchial secretions, miosis, bradycardia). Small doses of edrophonium (1-2 mg intravenously) will produce no relief or even worsen weakness if the patient is receiving excessive cholinesterase inhibitor therapy. On the other hand, if the patient improves with edrophonium, an increase in cholinesterase inhibitor dosage may be indicated. Clinical situations in which severe myasthenia (myasthenic crisis) must be distinguished from excessive drug therapy (cholinergic crisis) usually occur in very ill myasthenic patients and must be managed in hospital with adequate emergency support systems (eg, mechanical ventilators) available.

Long-term therapy for myasthenia gravis is usually accomplished with pyridostigmine; neostigmine or ambenonium are alternatives. The doses are titrated to optimum levels based on changes in muscle strength. These agents are relatively short-acting and therefore require frequent dosing (every 6 hours for pyridostigmine and ambenonium and every 4 hours for neostigmine; Table 7-4). Sustained-release preparations are available but should be used only at night and if needed. Longer-acting cholinesterase inhibitors such as the organophosphate agents are not used, because the dose requirement in this disease changes too rapidly to permit smooth control with long-acting drugs.

If muscarinic effects of such therapy are prominent, they can be controlled by the administration of antimuscarinic drugs such as atropine. Frequently, tolerance to the muscarinic effects of the cholinesterase inhibitors develops, so atropine treatment is not required.

Neuromuscular blockade is frequently produced as an adjunct to surgical anesthesia, using nondepolarizing neuromuscular relaxants such as pancuronium and newer agents (see Chapter 27). Following surgery, it is usually desirable to reverse this pharmacologic paralysis promptly. This can be easily accomplished with cholinesterase inhibitors; neostigmine and edrophonium are the drugs of choice. They are given intravenously or intramuscularly for prompt effect.

D. HEART
The short-acting cholinesterase inhibitor edrophonium was used to treat supraventricular tachyarrhythmias, particularly paroxysmal supraventricular tachycardia. In this application, edrophonium has been replaced by newer drugs (adenosine and the calcium channel blockers verapamil and diltiazem).

E. ANTIMUSCARINIC DRUG INTOXICATION
Atropine intoxication is potentially lethal in children (see Chapter 8) and may cause prolonged severe behavioral disturbances and arrhythmias in adults. The tricyclic antidepressants, when taken in overdosage (often with suicidal intent), also cause severe muscarinic blockade (see Chapter 30). The muscarinic receptor blockade produced by all these agents is competitive in nature and can be overcome by increasing the amount of endogenous acetylcholine present at the neuroeffector junctions. Theoretically, a cholinesterase inhibitor could be used to reverse these effects. Physostigmine has been used for this application, because it enters the central nervous system and reverses the central as well as the peripheral signs of muscarinic blockade. However, as noted previously, physostigmine itself can produce dangerous central nervous system effects, and such therapy is therefore used only in patients with dangerous elevation of body temperature or very rapid supraventricular tachycardia.

F. CENTRAL NERVOUS SYSTEM
Tacrine is a drug with anticholinesterase and other cholinomimetic actions that has been used for the treatment of mild to moderate Alzheimer's disease. Tacrine's efficacy is modest and hepatic toxicity is significant. Donepezil, galantamine, and rivastigmine are newer, more selective acetylcholinesterase inhibitors that appear to have the same modest clinical benefit as tacrine in treatment of cognitive dysfunction in Alzheimer's patients. Donepezil may be given once daily because of its long half-life, and it lacks the hepatotoxic effect of tacrine. However, no comparative trials of these newer drugs and tacrine have been reported. These drugs are discussed in Chapter 61.

Varenicline is a new direct-acting nicotinic agonist that is approved for use in smoking cessation treatment. It appears to have some selectivity for the a₄b₂ isoform of the N_N receptor. It is orally active and has a half-life of 14-20 hours. Toxicity includes nausea, headache, and sleep disturbances.

Toxicity

The toxic potential of the cholinoceptor stimulants varies markedly depending on their absorption, access to the central nervous system, and metabolism.

A. DIRECT-ACTING MUSCARINIC STIMULANTS
Drugs such as pilocarpine and the choline esters cause predictable signs of muscarinic excess when given in overdosage. These effects include nausea, vomiting, diarrhea, urinary urgency, salivation, sweating, cutaneous vasodilation, and bronchial constriction. The effects are all blocked competitively by atropine and its congeners.

Certain mushrooms, especially those of the genus Inocybe, contain muscarinic alkaloids. Ingestion of these mushrooms causes typical signs of muscarinic excess within 15-30 minutes. Treatment is with atropine, 1-2 mg parenterally. (Amanita muscaria, the first source of muscarine, contains very low concentrations of the alkaloid.)

B. DIRECT-ACTING NICOTINIC STIMULANTS
Nicotine itself is the only common cause of this type of poisoning. The acute toxicity of the alkaloid is well-defined but much less important than the chronic effects associated with smoking. In addition to tobacco products, nicotine is also used in insecticides.

1. Acute toxicity¾ The fatal dose of nicotine is approximately 40 mg, or 1 drop of the pure liquid. This is the amount of nicotine in two regular cigarettes. Fortunately, most of the nicotine in cigarettes is destroyed by burning or escapes via the "sidestream" smoke. Ingestion of nicotine insecticides or of tobacco by infants and children is usually followed by vomiting, limiting the amount of the alkaloid absorbed.

The toxic effects of a large dose of nicotine are simple extensions of the effects described previously. The most dangerous are (1) central stimulant actions, which cause convulsions and may progress to coma and respiratory arrest; (2) skeletal muscle end plate depolarization, which may lead to depolarization blockade and respiratory paralysis; and (3) hypertension and cardiac arrhythmias.

Treatment of acute nicotine poisoning is largely symptom-directed. Muscarinic excess resulting from parasympathetic ganglion stimulation can be controlled with atropine. Central stimulation is usually treated with parenteral anticonvulsants such as diazepam. Neuromuscular blockade is not responsive to pharmacologic treatment and may require mechanical respiration.

Fortunately, nicotine is metabolized and excreted relatively rapidly. Patients who survive the first 4 hours usually recover completely if hypoxia and brain damage have not occurred.

2. Chronic nicotine toxicity¾ The health costs of tobacco smoking to the smoker and its socioeconomic costs to the general public are still incompletely understood. However, the 1979 Surgeon General's Report on Health Promotion and Disease Prevention stated that "cigarette smoking is clearly the largest single preventable cause of illness and premature death in the United States." This statement has been supported by numerous subsequent studies. Unfortunately, the fact that the most important of the tobacco-associated diseases are delayed in onset reduces the health incentive to stop smoking.

Clearly, the addictive power of cigarettes is directly related to their nicotine content. It is not known to what extent nicotine per se contributes to the other well-documented adverse effects of chronic tobacco use. It appears highly probable that nicotine contributes to the increased risk of vascular disease and sudden coronary death associated with smoking. Also, nicotine probably contributes to the high incidence of ulcer recurrences in smokers with peptic ulcer.

C. CHOLINESTERASE INHIBITORS
The acute toxic effects of the cholinesterase inhibitors, like those of the direct-acting agents, are direct extensions of their pharmacologic actions. The major source of such intoxications is pesticide use in agriculture and in the home. Approximately 100 organophosphate and 20 carbamate cholinesterase inhibitors are available in pesticides and veterinary vermifuges used in the USA.

Acute intoxication must be recognized and treated promptly in patients with heavy exposure. The dominant initial signs are those of muscarinic excess: miosis, salivation, sweating, bronchial constriction, vomiting, and diarrhea. Central nervous system involvement usually follows rapidly, accompanied by peripheral nicotinic effects, especially depolarizing neuromuscular blockade. Therapy always includes (1) maintenance of vital signs¾respiration in particular may be impaired; (2) decontamination to prevent further absorption¾this may require removal of all clothing and washing of the skin in cases of exposure to dusts and sprays; and (3) atropine parenterally in large doses, given as often as required to control signs of muscarinic excess. Therapy often also includes treatment with pralidoxime as described in Chapter 8.

Chronic exposure to certain organophosphate compounds, including some organophosphate cholinesterase inhibitors, causes neuropathy associated with demyelination of axons. Triorthocresylphosphate, an additive in lubricating oils, is the prototype agent of this class. The effects are not caused by cholinesterase inhibition.



PREPARATIONS AVAILABLE

DIRECT-ACTING CHOLINOMIMETICS

Acetylcholine (Miochol-E)
Ophthalmic: 1% intraocular solution
Bethanechol (generic, Urecholine)
Oral: 5, 10, 25, 50 mg tablets
Parenteral: 5 mg/mL for SC injection
Carbachol
Ophthalmic (topical, Isopto Carbachol, Carboptic): 0.75, 1.5, 2.25, 3% solution
Ophthalmic (intraocular, Miostat, Carbastat): 0.01% solution
Cevimeline (Evoxac)
Oral: 30 mg capsules
Pilocarpine (generic, Isopto Carpine)
Ophthalmic (topical): 0.5, 1, 2, 3, 4, 6, 8, 10% solutions, 4% gel
Ophthalmic sustained-release inserts (Ocusert Pilo-20, Ocusert Pilo-40): release 20 and 40 mcg pilocarpine per hour for 1 week, respectively
Oral (Salagen): 5 mg tablets
Varenicline (Chantix)
Oral: 0.5, 1 mg tablets

CHOLINESTERASE INHIBITORS

Ambenonium (Mytelase)
Oral: 10 mg tablets
Demecarium (Humorsol)
Ophthalmic: 0.125, 0.25% drops
Donepezil (Aricept)
Oral: 5, 10 mg tablets
Echothiophate (Phospholine)
Ophthalmic: 1.5 mg (0.03%) powder to reconstitute for solution; 0.06, 0.125, 0.25% drops
Edrophonium (generic, Tensilon)
Parenteral: 10 mg/mL for IM or IV injection
Galantamine (Reminyl)
Oral: 4, 8, 12 mg tablets; 4 mg/mL solution
Neostigmine (generic, Prostigmin)
Oral: 15 mg tablets
Parenteral: 0.2, 0.5, 1, 2.5 mg/mL solution
Physostigmine, eserine (generic)
Ophthalmic: 0.25% ointment; 0.25, 0.5% solution
Parenteral: 1 mg/mL for IM or slow IV injection
Pyridostigmine (Mestinon, Regonol)
Oral: 30, 60 mg tablets; 180 mg sustained-release tablets; 12 mg/mL syrup
Parenteral: 5 mg/mL for IM or slow IV injection
Rivastigmine (Exelon)
Oral: 1.5, 3, 4.5, 6 mg tablets; 2 mg/mL solution
Tacrine (Cognex)
Oral: 10, 20, 30, 40 mg tablets



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