CHOLINERGIC SYSTEM AND DRUGS

By

Peter O. Ughachukwu (MB, BS; MSc; PhD)

Associate Professor of Immunopharmacology
 Synthesis and Metabolism of Acetylcholine
Choline taken into the cytosol by choline transporter, CT (rate limiting step)
 Ach is synthesized in the cytosol from AcetylCoA (from mitochondria) and
Choline (from ECF) by Choline acetyltransferase (CAT).

 It is stored in terminal vesicles of the nerve by Ach carrier

 Ach is released from vesicles in response to Ca2+ as a result of action

potential generated by nerve stimulation. Other neurotransmitters (co-
transmitters) are released together with Ach.

 The released Ach interacts with post synaptic receptors on the effector organ to
produce physiological effect.

 Within seconds, the Ach is degraded into choline + acetate by an enzyme

acetylcholinesterase within the cholinergic nerve synapses (found in
cholinergic nerve synapses and RBC but not in plasma).
 Another type of cholinesterse (pseeudocholinesterase, butyryl cholinesterase) found in
plasma, liver, has very low or no affinity for Ach. People with abnormal
pseudocholinesterase (genetically determined) can develop serious toxicity when given
succinylcholine, muscle relaxant that is normally metabolized by pseudocholinesterase.

(From mitochondria) AcetylCoA + Choline ( From ECF)

Choline acetyl transferase CoA
Acetylcholine

Acetylcholinesterase (AChE) Synaptic cleft

Acetate + Choline
 SYNTHESIS OF ACETYLCHOLINE, STORAGE, AND RELEASE IN THE NERVE
TERMINAL

CHT
Mitoch
C AcetylCoA
Choline
+ Chol
. ,in
ChAT
etyl
AP Ach, ATP + CoA

V
2+
Ca PR
pp

AchE Acetate + Choline

AR

Effect. organ e.g. muscle

 Inhibitors of acetylcholine synthesis, storage, release, and
metabolism

1. Hemicolinium: inhibits choline uptake by inhibiting choline transporter

(CT) thereby inhibiting Ach synthesis.

2. Vesamicol: inhibits storage Ach in the vesicle by inhibiting Ach carrier.

3. Botulinum toxin: inhibits the release of Ach into the synaptic cleft.
Useful in the treatment of spastic disorders and dystonias.

4. Anticholinesterases: inhibit breakdown of Ach to choline and acetate

thereby prolonging the action of Ach.
Inhibitors of acetylcholine synthesis, storage, and release
CHOLINERGIC RECEPTORS
 CHOLINERGIC RECEPTORS

The cholinergic receptors are divided into 2: Muscarinic and Nicotinic.

1. Muscarinic Receptors
• Found on nerves, heart, smooth muscles, exocrine glands, CNS.

• Named after the natural alkaloid muscarine which was first found to activate
them (muscarine is the active substance in the poisonous mushroom
Amanita muscaria)

• Further divided into M1 (stomach, nerves), M2 (heart), M3 (smooth muscles

of eye, GIT, bladder, bronchus, glands, endothelium), M4 (CNS), M5 (CNS):
 
M1 → mediate excitatory effects in memory, attention, and arousal.
→ stimulate gastric secretion following vagal stimulation
 
M2 → ↓conduction at SA node (↓HR), Presynaptic inhibition in CNS
 
M3 → contracts bronchial, intestinal, bladder smooth muscles;
→ contracts circular muscles of the iris, ciliary muscles.
→ stimulates salivary, bronchial, sweat and gastric glands.
→ relaxes vascular smooth muscle via release of nitric oxide.
 
M4 , M 5 → poorly defined functions in the CNS.
 Molecular mechanism of muscarinic agonists
protein- coupled.
All muscarinic receptors are G

M 1 , M 3 , M 4 , M 5: c oupled to Gs protein and their activation leads to formation

of intracellular 2 messengers like IP 3 and DAG :

·
Muscarinic agonists.
· ADH.

+
PLC
2+
IP3 release of intracellular Ca

PIP 2
+

2+
DAG Opens of Ca channels
2. NICOTINIC RECEPTORS

These are the sub-types of cholinergic receptors that are found on skeletal
muscles, ganglia, and adrenal medulla.

They are called nicotinic because they were first found to be stimulated by the
natural alkaloid nicotine , the active substance in the plant Nicotiana tobacum.
Further divided into:
 NM (muscle type) → found in skeletal muscle NMJ
 NN (neuronal type) → found in autonomic ganglia, adrenal medulla 

Molecular mechanism of nicotinic receptors

Nicotinic receptors are typical examples of ionotropic receptors (ligand-gated
ion channels). Agonist activation opens the channel leading to Na2+ influx, and
antagonists close or inactivate the channel.
MOLECULAR MECHANISM OF NICOTINIC RECEPTORS
 Organ locations of cholinergic receptors and results of their activation

Cholinoceptor Organ location Physiological action on activation

M1 CNS CNS activation, memory, arousal

Gastric glands Gastric secretion
M2 Myocardium, CNS Cardiac inhibition, neuronal inhibition

M3 Exocrine glands, GI, Urinary, Glandular secretions, contraction of GI, urinary,

Respiratory, ocular, and bronchial, and ocular sm muscles. Relaxation of vascular
vascular smooth muscles smooth muscles via release of NO.

M4 CNS ?

M5 CNS ?

     

NM Skeletal NMJ ↑ skeletal muscle contraction

NN CNS, postganglionic neurones ↑neurotransmitter release in CNS and ganglia.

Adrenal medulla ↑ secretion of adrenaline (80%), noradrenaline (20%)
 PRESYNAPTIC RECEPTORS

A system of negative feed back in the release of neurotransmitters in

autonomic nerves. Presynaptic receptor functions are more defined in the
adrenergic system.

Two main types of presynaptic receptors:

1. Autoreceptors: Presynaptic receptors that respond to the primary

neurotransmitter released by the nerve ending. They are usually
inhibitory to further release of the primary neurotransmitter.

2. Heteroreceptors: Presynaptic receptors that respond to

neurotransmitters released by other nerve endings that did not release
them
 CHOLINERGIC AGONISTS

(A) Direct acting cholinergic agonists. They bind to and activate cholinergic receptors
(B) Indirect acting cholinergic agonists. They inhibit acetyl cholinesterase (hence called
anticholinesterases) thereby increasing the concentration of Ach at the synapses
and prolonging the action of Ach

A. DIRECT ACTING CHOLINERGIC AGONIST

1. Choline esters
 Acetylcholine
 Methacholine.
 Carbachol.
 Bethanechol.
Acetylcholine and choline esters are QAC ( contains permanently charged
group). Therefore poorly absorbed and poorly distributed into the CNS.
CH3
R----N+ CH3

CH3
They are hydrolysed at various sites by choline esterases in the GIT.
Therefore, they are not given orally. Even after IV dose, Ach has very brief
duration of action (15-20 seconds). Therefore, the need for longer acting
choline esters.

Resistance to hydrolysis, and therefore duration of action is in the following

order: Carbachol > Methacholine > Ach
2. Natural alkaloids

a. Pilocarpine
b. Muscarine
c. Arecoline
B. INDIRECT ACTING CHOLINERGIC AGONISTS
They inhibit acetyl cholinesterase thereby increasing the concentration of Ach at the
synapses ( therefore, called anticholinesterases)

Ach AchE acetate + choline

Classified into 3 based on duration of action and chemical composition:

1. Short acting (simple alcohols) : Edrophonium

2. Intermediate acting (carbamic acid esters): Neostigmine, Physostigmine,

pyridostigmine

3. Long acting (organophosphates): Echothiophate, Parathion, Malathion, Soman, Dyflos.

Pharmacological actions of cholinergic agonists
Divided into muscarinic agonists and nicotinic agonists .

Pharmacological actions of muscarinic agonists

On the eye:
↑ secretion and lubrication
 Contraction of circular muscles of iris pupillary constriction (miosis)
 Contraction of ciliary muscles accommodation
opening of anterior angle resulting in ↑
outflow of aqueous humour into the canal of Schlemm

On the CVS:
 Inhibits the SA node ↓ H. R.
 ↓ conduction velocity in AV node ↓ H. R.
 Relaxation of vascular smooth muscle (via release of NO)
↓ B.P.
On the bronchial tree:
Contraction of bronchial smooth muscles Bronchoconstriction
Stimulation of bronchial glands ↑ mucus secretion
On the GIT:
 Contraction of GI smooth muscles ↑ motility
 Relaxation of sphincters ↑ motility
 Stimulation of intestinal glands ↑ secretions
On the urinary bladder:
 Contraction of detrussor muscles Voiding of urine
 Relaxation of sphincter and trigone Voiding of urine
On the glands:
 ↑ secretions of by sweat, salivary, lacrimal, and nasopharyngeal glands
On the CNS:
 Muscarinic agonists improve mental function (cognition)
 In high doses, they induce tremor, hypothermia, and emesis.

CLINICAL USES OF MUSCARINIC AGONISTS

1. Eye: Treatment of chronic (open angle) glaucoma. Pilocarpine, mathacholine,
carbachol.

2. GIT: Disorders of ↓ motility without obstruction such as post op ileus. Bethanechol

is drug of choice.

Urinary bladder: bethanechol is also used for neurogenic bladder and post op urinary
retention.
 Acetylcholine is not used clinically because it is metabolized very quickly by
cholinesterases in the plasma (not effective even by i.v. route).

a. Methacholine has maximum action on myocardium and bronchial

tree. It can be given inhalationally for the diagnosis of bronchial
hyperreactivity in patients who do not have clinically apparent asthma
(methacholine challenge test).

b.Pilocarpine is used in glaucoma (0.5-4.0% solution) due to its ability to

contract the ciliary muscle and ↑ outflow of aqueous humour (short
duration of action is disadvantage).

c.Pilocarpine is also used to treat xerostomia resulting from radiation

therapy in head and neck malignancy or xerostomia of Sjogren’s
syndrome (autoimmune disease where Ab destroy the moisture
producing glands of the body, mainly salivary and lacrimal glands)
ADVERSE EFFECTS OF MUSCARINIC AGONISTS
 Diarrhea
 Excessive salivation
 Urinary urgency
 Bronchoconstriction
 Lacrimation
 ↓ Heart rate
B. INDIRECT ACTING CHOLINERGIC AGONISTS
They inhibit acetyl cholinesterase thereby increasing the concentration of Ach at the synapses ( therefore,
called anticholinesterases)

anticholinesterase

Ach - AchE acetate + choline

Classified into 3 based on duration of action and chemical composition:

1.Short acting (simple alcohols) : Edrophonium

2.Intermediate acting (carbamic acid esters): Neostigmine, Physostigmine, pyridostigmine
3.Long acting (organophosphates): Echothiophate, Parathion, Malathion, Soman, Dyflos.

Physostigmine and the organophosphates (except echothiophate) are TAC and therefore readily absorbed
from all sites and well distributed into the CNS and therefore more toxic.
 Other carbamates and echothiophate are highly polar and poorly
absorbed (b/c they are QAC).
 They are stable in aqueous solutions. Thus they can last for several weeks
in the environment, making them important environmental pollutants.

 Carbamates are metabolized by non-specific esterases and cholinesterases

in the body.

 Parathion and malathion are prodrugs that are converted to paraoxon and
malaoxon respectively. They are used as insecticides.

 Malathion and parathion detoxified to harmless products in birds and

mammals , but not in insects (therefore used as insecticides).
Mechanism of action
All three groups of indirect acting cholinergic agonists ↑endogenous Ach by inhibiting AchE.
They are therefore called Anticholinesterases.

 Molecular mechanisms of enzyme inhibition differ: some are easily reversible,

others irreversible:
1. Edrophonium binds to active site of AchE by H-bond (weak bond) thereby
preventing access by Ach. Inhibition lasts for 2-10 minutes

2. Carbamates bind AchE by a covalent bond forming carbamoylated- AchE

complex. The complex lasts for 1-6 hours before hydrolysis.

3. Organophosphates bind AchE by a covalent bond forming a phosphorylated-

AchE complex that is extremely stable (lasts for weeks). This complex
undergoes a process called aging which strengthens the bond more.
Oximes (e.g. pralidoxime) can break this bond and liberate AchE if aging has
not occurred. These oximes are called cholinesterase regenerators.
Pharmacological effects of anticholinesterases

The organ system effects can be predicted from the effects of Ach on the systems.

At the NMJ, in low doses they prolong and ↑ the actions of physiologically
released Ach resulting in ↑ force of contraction. In higher doses, there is ↑
concentration of Ach resulting in fibrillations and depolarising neuromuscular
block.

Clinical uses of anticholinesterases

1. EYES: Physostigmine, demecarium, and echothiophate were used in the
treatment of glaucoma.

2. GIT &GUT: post op ileus, urinary retention, neurogenic bladder. Neostigmine is

anticholinesterase of choice in these conditions.
3. NMJ (MYASTHENIA GRAVIS)

Autoimmune disease in which antibodies are produced against Ach receptors

at the neuromuscular junction. It is characterized by muscle weakness.

 Edrophonium is used for diagnosis of myasthenia gravis; 2 mg given IV

improves muscle strength.

 Neostigmine, pyridostigmine, ambenonium used for treatment of

myasthenia gravis.

 Organophosphates are not used for myasthenia gravis because drug dose
requirements in myasthenia gravis change rapidly and cannot be
monitored with long acting anticholinesterases (organophosphates).
CHOLINERGIC CRISIS & MYASTHENIC CRISIS
Over dosage with anticholinesterases can result in cholinergic crisis (muscle weakness
due to neuromuscular block, , salivation, etc).

 This must be distinguished from myasthenic crisis (muscle weakness as a result of

lack of cholinergic receptors at the NMJ.

 Edrophonium is used to distinguish b/w these two conditions because it improves

myasthenic crisis but worsens cholinergic crisis.
.
4. Alzheimers disease (CNS)
 This is neurodegenerative disorder characterized by dementia and loss of
cognitive function. Often associated with loss of cholinergic neurons in the brain.
 Tacrine was first used for Alzheimers disease but was abandoned because of
excessive cholinergic adverse effects.
 Currently, Donepezil, rivastigmine, and galanthamine show clinical benefits in
memory disorders of Alzheimers disease.
5. Supraventricular tachycardia
Edrophonium was used in the past to treat supraventricular tachycardia.

6. Anticholinergic (antimuscarinic) drug intoxication

 The antimuscarinic effect produced by atropine is competitive and can be
reversed by ↑ing the concentration of endogenous Ach by the
administration of AchE inhibitors such as neostigmine.
 Physostigmine is prefered because it also reverses the CNS effects since it
enters the CNS.
Toxicity of anticholinesterases (anticholinesterase poisoning).
Carbamates and organophosphates are used as pesticides in the home and in
agriculture. Therefore, accidental anticholinesterase poisoning can occur.
There are three components to manifestations of heavy exposure to
organophosphates:

1. Signs of muscarinic excess such as miosis, salivation, sweating, bronchial

constriction, vomiting, and diarrhoea.

2. Signs of CNS toxicity such as mental confusion and dizziness. Chronic

organophosphate poisoning leads to demyelination of peripheral nerves.

3. Neuromuscular blockade causing muscle weakness and paralysis.

Treatment of anticholinesterase toxicity (poisoning)
1. Maintain vital signs: airways, breathing

2. Decontamination: removal from source of poisoning, clothes, and profuse washing of the body.

3. Drugs:
 Antimuscarinic drugs (atropine in very large doses given frequently).
 Cholinesterase regenerator compounds (oximes) to reverse the effect of organophosphates. The
oximes include:
- Pralidoxime
- Diacetylmorphine
 Pralidoxime does not reverse the CNS effects of organophosphate poisoning b/c it does not
enter the CNS
.
 Diacetylmorphine, on the other hand, enters the CNS and can regenerate CNS cholinesterase.
 ANTICHOLINERGIC DRUGS

They block the action of Ach on:

1. Muscarinic receptors (anti-muscarinic agents)
2. Nicotinic receptors (ganglion blockers, NMJ blockers)

Anti-muscarinic agents
3. Naturally occurring alkaloids (TAC) include
Atropine: From the plants Atropa belladonna and Dantura stramonium.
Scopolamine (Hyoscine): From the plant Hyoscyamus niger.

2. Synthetic agents include

Pirenzepine, benztropine, cyclopentolate, tropicamide, and dicyclomine (TAC ).
Others TACs are oxybutynin, triospium,arifenacin, solifenacin

Ipratropium, tiotropium, propantheline, and glycopyrrolate (QAC)

Pharmacokinetics: Naturally occurring agents (atropine, scopolamine) are TAC and
together with TAC members of synthetic agents are well absorbed from the oral route,
well distributed into all tissues including the CNS.
 QAC members of synthetic group poorly absorbed and distributed.

Pharmacological effects of anti-muscarinic agents

a. On the eye
 Atropine and other anti-muscarinic agents block the action of Ach on the pupillary
constrictor muscles of the iris, thereby causing pupillary dilation (mydriasis).
 Also causes relaxation of ciliary muscles (cycloplegia) which causes loss of
accommodation and
 Cycloplegia may also ↑ IOP due to blockage of canal of Schlemm, especially in pts
with narrow angle glaucoma

 Also↓ secretion of lacrimal glands (dryness of the eyes).

b. On the CVS
 Ach blocks the electrical activity at the SA node thereby ↓ heart rate. Atropine
relieves this block thereby ↑ heart rate.
 Atropine also blocks the vasodilatation produced by Ach thereby causing
vasoconstriction.
c. On the respiratory system
The anti-muscarinic agents relax bronchial smooth muscles (bronchodilation) and ↓
secretion of bronchial glands.

d. On the GIT
The anti-muscarinic agents ↓ intestinal motility and ↓ secretion of salivary and
intestinal glands.
e. On the GUT
The anti-muscarinic agents ↓ contraction of urinary bladder thereby ↓ voiding of urine
(retention of urine)
f. On the sweat glands
Atropine ↓ secretion of sweat glands thereby impairing thermoregulation.
Can cause atropine fever especially in children.

g. On the CNS
 Atropine and scopolamine produce sedation, drowsiness, and amnesia.

 The anticholinergic action is beneficial in Parkinson's disease (Parkinson's

disease results from relative excess of cholinergic activity because of
deficiency of dopaminergic activity in the basal ganglia of the brain).

 Scopolamine is useful in treatment of motion sickness ( Vestibular

function in the ear is mediated via muscarinic receptors)
 Clinical uses of anti-muscarinic agents
  Disease /indication Drug Effect of administration
CNS disorders Parkinson’s disease Benztropine Inhibits relative cholinergic excess
  Motion sickness Scopolamine (hyoscine) Inhibits muscarinic receptors in
organ of Corti
Eye disorders Ophthalmic Atropine, Homatropine, Pupillary dilatation
examination Tropicamide, Relaxation of ciliary muscles
cyclopentholate
 
Respiratory Bronchial asthma Ipratropium, tiotropium Bronchodilation, ↓ secretion
disorders Anaesthetic Atropine ↓ secretions in respiratory tract
premedication

CVS disorders Bradycardia of M.I. Atropine ↑ Heart rate

 
GIT disorders Peptic ulcer disease Propantheline, ↓ gastric acid secretion
  pirenzepine,  
  glycopyrrolate  
     
Diarrhoea Atropine ↓ intestinal motility
 
GUT disorders Post op bladder Oxybutynin, triospium, Relaxes the urinary bladder
spasms Darifenacin, solifenacin
 Others Cholinergic drug Atropine Reverses symptoms/signs of
poisoning cholinergic excess.
 Adverse effects of anti-muscarinic agents
System Adverse effects
GIT Dryness of the mouth, constipation
 

Eyes Blurring of vision

Poor accommodation due to weakness of ciliary muscles
↑ IOP in pts with narrow angle glaucoma

GUT Urinary retention, especially in old men

CVS ↑ Heart rate

 

CNS Sedation
mental confusion
 
Sweat glands ↓ sweating
Atropine fever (in children)
Contraindications to use of anti-muscarinic drugs
Glaucoma
Elderly men
Children (use with caution)