By Duy Thai, 1997 Pharmacology Semester 1 page 1 of 4

CHOLINERGIC PHARMACOLOGY III

Metabolism of acetylcholine
• The major mechanism of NA inactivation is reuptake.
• For Ach, inactivation is via metabolism in the synaptic space.
• The enzymes responsible for Ach metabolism are generally called cholinesterases (ChE). There are 2 types:
1. Acetylcholinesterase (TRUE)
• Present in nerve synapses and NMJ.
• Also found in RBC
• The primary substrate is Ach.
• It can also metabolise acteyl beta methyl choline
2. Butyrylcholinesterase (PSEUDO)
• Present in the plasma and in lots of tissues
• Metbolises Ach and other drugs such as suxamethonium.
• Suxamethonium is not metabolised by true ChE. Hence, when it is around nerves
(which is where we want it to act) it is not broken down, but when it enters the plasma,
it is broken down.

Hydrolysis of Ach by ChE

• Step 1:
• The acetyl group of Ach acetylates a serine residue in the binding region of the enzyme. This separates
the acetyl group (which is bound) and the choline (which is still present in the binding site).
• Step 2:
• Hydrolysis results in the removal of the choline group
• Step 3:
• Regeneration of the active enzyme occurs very quickly (in millisecs) and is due to the release of the bound
acetyl group, which forms acetic acid.

Anticholinesterase drugs
• 2 types:
1. Reversible
• Are substrates for cholinesterase
2. Irreversible
• Posphorylate the enzyme
• Commonly organophosphate drugs

Reversible anticholinesterase drugs

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

• Mechanisms of action (taking neostigmine as the prototype)

• Neostigmine acts exactly like Ach when it is taken up by cholinesterase.
• However, the hydrolysis stage is prolonged (taking 15 - 30 min) and the recovery stage is very slow
(compared with Ach which acts in milliseconds).
• During its occupation in the binding site of the enzyme, Ach cannot bind and so it has to hang around in
the synapse waiting for neostigmine to be metabolised.
By Duy Thai, 1997 Pharmacology Semester 1 page 2 of 4

Organophosphorous anti-cholinesterase (considered irreversible)

• Originally developed as nerve gases for warfare.
• The prototype drug is Ecothiopate.
• This drug is very useful for treating glaucoma because it prolongs the action of Ach in the eye by
preventing Ach breakdown. It has very prolonged inhibition of ChE - the eye drops need only be used
once a month.
• Mechanism of action:
1. Hydrolysis in the body results in the cleavage of a side chain.
2. The residue phosphorylates an active serine group in the binding site of the enzyme.
3. Reactivation (hydrolysis of the phosphorylated enzyme) is very, very slow (months as indicated by the
time required to renew the eye drops)
• The process of reactivation of the enzyme can be hastened by giving nucleophilic agents (e.g. Pralidoxime).
Normally, water is used to reactivate the enzyme, but water is a very weak nucleophilic agent.
• Pralidoxime can be used to treat people who are poisoned by organophosphorous drugs (e.g. sarin gas).

Effects of anti-cholinesterases
• They potentiate the action of Ach when it is released
• In the CNS
• Stimulation
• Convulsions
• Respiratory depression/arrest
• All these lethal effects are mediated through Ach acting on M receptors. Hence, atropine is an effective
drug used in anticholinesterase poisoning because it blocks the M receptors, limiting the effects.
• Autonomic system
• Eye Pupillary constriction
• Lung Bronchoconstriction
Increased secretions
• GIT Diarrhea due to spasm of gut smooth muscle
• Bladder Contraction of the bladder
• Cardiovascular system
• Bradycardia
• Not seen in people who have had heart transplants since it is denervated (an hence no resting
tone provided by Ach)
• No effects on blood vessels since there is no cholinergic innervation.
• Neuromuscular junction
• Potentiation of the action of Ach
• Initially there is fasciculations
• Eventually, get myasthenia (muscle weakness)
• Other effects:
• Alteration in receptors
• If receptors are bombarded with high levels of Ach for a long time, they will be down regulated
(so get less N and M receptors)
• Reduction in Ach synthesis
• Direct neurotoxicity
• Only in anticholinesterases which have fluorine atom (Dyflos)

Specificity
• Organophosphorous anticholinesterases are not as specific as the reversible anticholinesterases.
• Reversible anticholinesterases are specific for cholinesterases only (both true and pseudo cholinesterases)
• Organophosphorous anticholinesterases inhibit both A and B group esterases
1. Group A esterases
• Cholinesterases
2. Group B esterases
• Angiotensin Converting enzyme
• Chymotrypsin By inhibiting these enzymes, there is the
• Trypsin possibility of bleeding.
• Thrombin
By Duy Thai, 1997 Pharmacology Semester 1 page 3 of 4

Drugs action at the neuromuscular junction

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

Targets of drug action at the NMJ

• Most useful drugs interact with the nicotinic receptors.
• Toxins (e.g. Tetrodotoxin) Blocks the passage of action potentials down the nerve fibre.
• Hemicholinium Blocks choline uptake into the nerve terminal
• Botulinum toxin Inhibits the release of Ach in the granules Unimportant
• Succinylcholine Depolarises the nerve terminal
• Acteylcholinesterase inhibitors Potentiate the action of Ach.
• Dantrolene Reduces muscle contraction (acts directly on the muscle)

Neuromuscular blockers
• There are 2 types of drugs acting at the N receptors in the neuromuscular junction:
1. Competitive blockers
• Act as competitive antagonists of the nicotinic receptor.
• Prevent Ach from binding to N receptor and causing a muscular contraction (paralysis)
• Prototype drug is Tubocurarine
2. Depolarising blockers
• See next lecture

Main uses of neuromuscular blockers

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

Competetive neuromuscular blockers

• When a motor nerve is stimulated at a certain frequency, there is a corresponding twitch of the muscle occurring at
the same frequency.

• If tubocurarine is added, there is a gradual decline in muscular contraction. There is no initial stimulation before
the blockade (there is no increase in muscle contraction)

• If the stimulation frequency is increased to a frequency causing tetanus (fusing of the individual muscle twitches),
there is an initial spike, but it is depressed and not sustained.
By Duy Thai, 1997 Pharmacology Semester 1 page 4 of 4

• However, when the stimulation frequency returns to normal, there is a post tetanic potentiation.
• This is because, during tetani, there was a massive flood of Ca going into the nerve terminal. Ca leaves
the nerve terminal very slowly. Therefore, the next stimulus that comes along causes heaps of Ach to be
released. Because tubocurarine is a competitive blocker, its effects can be surmounted by high levels of
Ach, and so you see and increase in muscle contraction. As the nerve terminal pumps out Ca, Ach levels
return back to their normal levels which are not high enough to overcome the blockade.

• If tubocurare is added along with another blocker (Gallamine), the effect is to depress muscle contraction much
quicker. (There is summation).