CHOLINERGIC AGONISTS

 Drug affecting the ANS are divided into two groups based on
the type of neuron involved in their mechanism of action.
 Cholinergic drugs, act on receptors that are activated by
acetylcholine and adrenergic drugs, act on receptors that are
activated by epinephrine or Norepinephrine.
 Cholinergic and Adrenergic drugs both act by either stimulating
or blocking receptor of the ANS.
Cholinergic Neuron
 Cholinergic neurons are primarily involved in parasympathetic
system and also involved in sympathetic division o sweat glands
and skeletal muscle.
 Examples: A preganglionic fiber terminates in the adrenal
medulla both the sympathetic and parasympathetic fibers and
the postganglionic fibers of parasympathetic division use
acetylcholine as a neurotransmitter.
 Note: Patients with Alzheimer disease have a significant loss of
cholinergic neurons in the temporal lobe and entrorhinal cortex.
Most of the rugs available to treat the disease are
acetylcholinesterase inhibitors.
 Neurotransmission at Cholinergic Neurons: It involves six
sequential steps- 1. Synthesis 2. Storage 3. Release 4. Binding of
Ach to a receptor 5. Degradation of neurotransmitter in the
synaptic cleft 6. Recycling of choline and acetate.
 Synthesis of acetylcholine: Choline is transported from
extracellular fluid into cytoplasm of the cholingeric neuron by
energy –dependent carrier system that cotransports Na+ and it is
inhibited by drug hemicholinium.
 It can’t penetrate through plasma membrane because choline has
quaternary nitrogen and carriers a permanent positive charge.
 The uptake of choline is the rate limiting step in Ach synthesis.
 Choline acetyl-transferase catalyzes the reaction between
choline and acetyl CoA. Acetyl CoA is derived from the
mitochondria and is produced by the pyruvate oxidation and
fatty acid oxidation.
 Storage of acetylcholine in vesicles: By an active transport
process Ach is packed and stored in the vesicle in this process
efflux of protons occurs.
 The mature vesicle not only contains Ach but also ATP where it
will work as co-transmitter that will determine the increase or
decrease the effect of the primary neurotransmitter and
proteoglycan.
 The neurotransmitters in vesicles appear as beadlike structures,
known as varicosities along the nerve terminal of the
presynaptic neuron.
 Release of acetylcholine: when an action potential propagated
by voltage-sensitive sodium channels arrives at nerve ending,
the voltage sensitive calcium channels on the presynaptic
membrane open causing an increase in the concentration of
intracellular calcium causing the fusion of vesicles to cell
membrane and release of Ach.
 This process can be inhibited by botulinum toxic and in opposite
the black widow spider venom cause the release of all Ach into
synaptic cleft.
 Binding to the Receptor: Ach released from the synaptic
vesicles diffuses across the synaptic space a binds to either
postsynaptic receptors on the target cell, to presynaptic receptors
in the membrane of the neuron that released the Ach or to other
targeted presynaptic receptors.
 Postganglionic cholinergic receptors on the surface of effector
organs are divided into two: Muscarinic and Nicotinic.
 Binding to a receptor promotes the biologic response within the
cell such as initiation of a nerve impulse or activation of specific
enzymes in cells as mediated by second-messenger molecules.
  Degradation of acetylcholine: Signal at the post junctional
effector site is rapidly terminated because acetylcholinesterase
cleaves Ach into choline and acetate in the synaptic cleft.
 Note: Butyrylcholinesterase or pseudocholinesterase can also
cleaves the Ach found in the plasma but does not play
significant role in termination.
 Recycling of choline: Choline may be recaptured by sodium
coupled, high affinity uptake system that transports the molecule
back into neuron and Ach will reborn.

Cholinergic Receptors
 It is also called Cholinoceptors and there are two types i.e..,
Muscarinic and Nicotinic and it can be distinguished from
each other on the basis of their different affinities for agents
that mimic the action of Ach.
Muscarinic Receptors
 Muscarinic: These receptors are selectively stimulated by
muscarine and blocked by atropine. They are located on
autonomic effector cells such as heart, blood vessels, eye,
 smooth muscles and glands of gastrointestinal, respiratory and
urinary tract, sweat glands etc., and in the CNS.
 Subordinate muscarinic receptors are also present in autonomic
ganglia where they appear to play a modulatory role by inducing
a long-lasting late EPSP(excitatory postsynaptic potential)
 Muscarinic receptors are present on postganglionic cholinergic
nerve endings; their activation inhibits the release of Ach,
Similar to adrengic receptor; their activation inhibits the release
of NA.
 All blood vessels have muscarinic receptors which are found in
endothelial cells whose activation release EDRF (endothelium-
derived relaxing factor) nitric oxide which diffuses to the
smooth muscle to cause relaxation but some of the blood vessels
they lack of cholinergic innervations.
 Muscarinic receptors are subdivided into 5 types M 1, M2, M3,
M4, M5. The first three types are present on effector organs as
well as o prejunctional nerve endings and are expressed on both
peripheral and CNS organs.
 M4 and M5 receptors are present mainly on nerve endings in
certain area of brain and regulate the release of
neurotransmitters.
 M1: It is primarily a neuronal receptor located on ganglion cells
and central neurons, especially in cortex, hippocampus and
corpus striatum.
 It plays a important role in mediating gastric secretion,
relaxation of lower esophageal sphincter (LES) caused by vagal
stimulation and in learning, motor functions and memory.
 M2: This receptor particularly located on heart (SA node, AV
node, atrium and ventricles). It is also called cardiac muscarinic
receptors and they mediate vagal bradycardia.
 Smooth muscle expresses some M2 and some M3 receptors to
mediate contraction.
 M3: Visceral smooth muscle contraction and glandular secretion
are obtained through M3 receptors, which also mediate
vasodilatation through release of EDRF (nitric oxide).
 Both M2&M3, together mediate most of recognized muscarinic
actions including contraction of LES.
 Muscarinic agonist &antagonists: Attempts are currently
underway to develop muscarinic agonists and antagonists that
are directed against specific receptors subtypes.
 Examples: Pirenzepine, a tricyclic anticholinergic drug,has a
greater affinity for inhibiting M1receptors, such as in gastric
mucosa.
 At therapeutic dosage, pirenzepine does not show many side
effects but it has reflex tachycardia on rapid infusion due to
blockade of M2 receptors in heart.
 Therefore, Pirenzepine is an alternative drug to proton pump
inhibitors in the treatment of gastric and duodenal ulcers.

 Darifenacin is a competitive muscarinic receptor

antagonist with a greater affinity for the M3 receptor than
other muscarinic receptors.
 The drug is used in the treatment of overactive bladder.
Nicotinic Receptors
 These receptors are selectively activated by nicotine and
blocked by tubocurarine or hexamethonium. These receptors are
ligand –gated receptors; there activation causes to opening of
channel and rapid flow of cations resulting in depolarization and
an action potential.
 Nicotinic Receptors are subdivided into two types: NM and NN.
 NM: These are present at skeletal muscle end plate (means
neuromuscular junction) and are selectively stimulated by
phenyl trimethyl ammonium (PTMA) or Nicotine and blocked
by tubocurarine(or)α-Bungarotoxin.
 They mediate the contraction of skeletal muscle.
 NN: These are located on ganglionic cells, adrenal medullary
cells and in spinal cord and certain areas of brain.
  These are selectively stimulated by Dimethyl phenyl
piperzinium (DMPP) or Nicotine and blocked by
Hexamethonium, Trimethaphan.
 It constitutes the primary pathway of transmission in ganglia.
Some of the drugs act on Cholinergic Receptors:
 Direct-acting drugs: Acetylcholine, Bethanechol, Carbachol,
Pilocarpine
 Indirect-acting drugs(Reversible): Ambenonium,Donepezil,
Galantamine,Neostigmine,Physostigmine,Pyridostigmine,
Rivastigmine,Tacrine
 Indirect-acting drugs(Irreversible): Echothiophate
 Reactivation of acetyl cholinesterase: Pralidoxime
 Cholinergic agonists are also called parasympathomimetics,
which it mimic the effects of Ach by binding to the receptors.
 Carbachol and bethanechol are choline ester group which means
it include Ach and synthetic ester of choline.
 Pilocarpine is naturally occurring alkaloids.
 All of these drugs have longer duration of activation than Ach.
 Acetylcholine: It is a quaternary ammonium compound that
cannot penetrate through membranes. It is also a
neurotransmitter to parasympathetic and somatic nerves as well
as autonomic ganglia.
 But it lacks therapeutic uses because of multiplicity of actions
and fast inactivation of cholinesterases.
 Ach has both muscarinic and nicotinic activity. Its actions are:
1. Decrease in heart rate and cardiac output: Actions of
Ach on the heart mimic the effects of vagal stimulation.
Example: If Ach is injected intravenously, it produces a
brief decrease in heart rate means Negative chronotropy
and decrease in stroke volume as a result of reduction of
rate of firing SA node.
2. Decrease in blood pressure: Injection of Ach causes
vasodilation and lowering the blood pressure by an
 indirect action. Ach activates the M3 receptors found on
endothelial cells of smooth muscles of blood vessels where
it releases nitric oxide (NO) from arginine. NO is also
called endothelial derived relaxing factor (EDRF) . In the
absence of administered cholinergic agents, vascular
receptors have no function because Ach is never release
into blood in any significant quantities. Atropine blocks
these muscarinic receptors and prevents Ach from
producing vasodilation.
3. Other actions: In the GI tract, Ach increases salivary
secretion and stimulates intestinal secretions and motility,
and also enhance bronchiolar secretion. In genitourinary
tract, increases the tone of detrusor urinae muscle causing
urination. In eye, it involved in stimulating ciliary muscle
contraction for near vision and in the constriction of
papillae sphincter muscle causing miosis (means excessive
constriction of pupil). Ach 1% solution is used to produce
miosis during ophthalmic surgery.

 Bethanechol: It is an unsubstituted carbamoyl ester, structurally

resemble to Ach in which acetate group is replaced by
carbamylate and the choline is methylated.
 Hence, it is not hydrolyzed by acetylcholinesterase but it
become inactive when it is hydrolyzed with other esterases.
 It lacks nicotinic action due to presence of methyl group, but it
has strong muscarinic activity. Its major actions are on the sooth
musculature of the blabber and GI tract and time of action is
about 1 hr duration.
1. Actions: Bethanechol directly stimulates the muscarinic
receptor (M3) cause increase in intestinal motility and tone. It
also stimulates the detrusor muscle of the bladder where as
trigone and sphincters are relaxed. These increase the voiding
pressure and decreased the bladder capacity to cause
expulsion of urine.
 2. Therapeutic applications: It is used in urologic treatment
because it used to stimulate the atonic (lack of muscular tone)
bladder, particularly in postpartum and postoperative, non
obstructive urinary retention. It is also used to treat
neurogenic atony as well as megacolon( means paralysis of
peristaltic movements)
3. Adverse effects: It causes the effects of generalized
cholinergic stimulation like diarrhea, sweating, salivation,
decreased blood pressure, nausea, abdominal pain, flushing,
and bronchospasm. Atropine sulphate may be administered to
overcome severe cardiovascular or bronchoconstrictor
responses to this agent.
 Carbachol: (Quaternary Amine) It has both muscarinic and
nicotinic activity and lacks the methyl group and it is an ester of
carbamic acid and it is less reactive to AChE (acetyl
cholinesterase), but it is biotransformed by other esterases but at
slower rate.
1. Actions: It has profound effects on cardiovascular and GI
tract/systems because of its ganglion-stimulating activity
and it first stimulate and depresses the system. It can also
cause the release of epinephrine from the adrenal medulla
because of its nicotinic actions. Locally it is used to put
into eye because it mimics the effect of Ach causing
miosis and it also cause the involuntary muscle contraction
of ciliary muscle of the eye.
2. Therapeutic Uses: It is used very rarely because of its high
potency and non selective receptor activation and longer
duration of time except in the eye as a miotic agent to treat
glaucoma by causing papillary contraction and a decrease
in intraocular pressure. Onset of action of miosis is 10 to
20 minutes and intraocular pressure is reduced for 4 to 8
hrs.
3. Adverse effects: At any doses if it is used as
ophthalmologically, little or no side effects occur due to
lack of systemic penetration.
 Pilocarpine: It is a tertiary amine and is stable to hydrolysis by
AChE and compared with Ach and its derivatives it is less
potent but is uncharged and will penetrate into CNS at
therapeutic doses and it will exhibits muscarinic activity and is
used to ophthalmology.
1. Actions: It is applied topically on cornea producing miosis
and contraction of ciliary muscle. The vision becomes
fixed at particular distance making impossible to focus.
Pilocarpine is one of the most potent stimulators of
secretions such as sweat, tears and saliva but this secretion
effect is limited due to lack of selectivity. This drug is
beneficial in promoting salivation in patients with
xerostomia (It is also known as dry mouth and dryness I
the mouth which may be associated with the change in the
composition of saliva) resulting from exposure of radiation
of the head and neck. Sjögren syndrome which is
characterized by the dry mouth and lack of tears is treated
with oral Pilocarpine and cevimeline, a cholinergic drug.
Note: Atropine gives the opposite effect to Pilocarpine.
2. Therapeutic use in glaucoma: Pilocarpine is used to treat
glaucoma and it’s the drug of choice in the emergency
lowering of intraocular pressure of both narrow angle and

wide angle glaucoma. Pilocarpine is extremely effective in

opening the trabecular mesh work and causing an
immediate drop of intraocular pressure as a result of the
increased drainage of aqueous humor. Action of time is few

minutes to 4-8hrs and can be repeated. Organophosphate

Echothiophate inhibits the AChE and exerts same effect for

a longer duration. To reversing the mydriasis effect caused

by atropine, Pilocarpine is used.
  Acetazolamide(carbonic anhydrase inhibitor) as well as β-
adrenergic blocker timolol are effective treatment for chronic
glaucoma but is it not used in emergency.
3. Adverse Effect: Pilocarpine can enter into CNS and
cause CNS disturbance and poisoning with this agent can
cause exaggeration of various parasympathetic effects like
diaphoresis (means sweating at unusual temperature) and
salivation. These effects are similarly produced by the
consumption of mushroom of the genus Inocybe.
Parenteral administration like IV, SC, IM of atropine can
cross blood brain barrier to counter the toxicity of
Pilocarpine.
Note: why we use atropine in Pilocarpine poisoning because atropine
is cholinergic antagonists which means it blocks the Ach receptors.
Indirect acting drugs (Reversible)
 Acetylcholinesterase (AChE) is an enzyme that cleaves Ach into
acetate and choline. These AChE inhibitors indirectly provide
cholinergic action by prolonging the life time of Ach produced
endogenously by the cholinergic nerve endings.
 This results in accumulation of Ach in the synaptic space; hence
these drugs can provoke a response at all cholinoceptors in the
body including both muscarinic and nicotinic receptors of the
ANS and NMJ’s and in the brain.
 The reversible AChE inhibitors can be divided into two groups’
short acting or intermediate acting agents.
 Edrophonium: It is short acting AChE inhibitor. It binds to
active center of AChE preventing hydrolysis of Ach.
 It is rapidly absorbed and has short duration of action like 10 to
20 mins due to renal elimination and its actions are limited.
 It is used to diagnosis of myasthenia gravis, which is an
autoimmne disease caused by antibodies to nicotinic receptor at
NMJs. This causes degeneration of receptors and making few
receptors is available for interaction of neurotransmitter.
 The intravenous injection of Edrophonium leads to a rapid
increase in muscle strength. Atropine is a drug used to treat
edrophonium poisoning.
 Reversing the effects of non-depolarizing neuromuscular
blockers after surgery.
 Edrophonium is used to assess cholinesterase inhibitor therapy
to differentiate the cholinergic and myasthenic crises.
 Physostigmine: It is a nitrogenous carbamic acid ester found in
plants and it’s a substrate for AChE and it forms stable
intermediate with enzyme which then it becomes inactivated.
This results the potential of cholinergic activity throughout the
body.
 Action: It has wide range of effects because it can stimulate
both muscarinic and nicotinic sites of ANS and also stimulate
the nicotinic site in NMJs and cholinergic sites in CNS.
Duration of action is 2 to 4 hrs and it is intermediate acting
agent.
 Therapeutic uses: This drug increases the intestinal and bladder
motility which can use as therapeutic in atony of both organs. It
can also use on eye topically which can produce miosis and
spasm of accommodation and can be useful for glaucoma
treatment but Pilocarpine will be more effective. Physostigmine
is also used in treatment of overdoses of anticholinergic
drugs/Cholinergic antagonist drugs like Atropine,
Phenothiazines and other tricyclic antidepressants.
 Adverse Effects: Physostigmine can cause convulsions when it
taken in higher doses. It can also cause Brachycardia and reduce
the blood pressure (hypotension) and cardiac output. Inhibition
of AChE can cause the accumulation of Ach and results in
paralysis of skeletal muscles but it is rarely seen.
 Neostigmine: It is a synthetic compound and it reversibly
inhibits AChE as similar as Physostigmine.
 Actions: It is quaternary nitrogen so, it is more polar and it
cannot absorbed or poorly absorbed into GI tract and it cannot
 pass through BBB (Blood-brain-barrier)/CNS. It effects on
skeletal muscle is greater than Physostigmine and it can
stimulate contractility before it paralyzes. It is an intermediate
acting drug and duration of action usually 30mins to 2hrs.
 Therapeutic Drugs: It is used to stimulate GI tract and bladder
and it an antidote for Tubocurarine and other competitive
neuromuscular blocking agents and it is used to treat
Myasthenia Gravis. These AChE inhibitors preserve Ach
endogenously which can stimulate a greater number of Ach
receptors at the muscle endplate.
 Adverse effects: The effects include those of generalized
cholinergic stimulation such as salvation, flushing, nausea,
abdominal pain, diarrhea and bronchospasm. Neostigmine does
not cause CNS side effects and it is not used to overcome
toxicity of central acting antimuscarinic agents such as atropine.
 Neostigmine is contraindicated when intestinal or urinary
bladder obstruction is present and it should not be used for
patients who have peritonitis or inflammatory bowel disease.
 Pyridostigmine & Ambenonium: These drugs are other
cholinesterase inhibitors that are used in the chronic
management of myasthenia gravis. Duration of action is 3 to 6
hrs and 4 to 8 hrs respectively but longer than Neostigmine and
adverse effects are similar to those Neostigmine.
 Tacrine,Donepezil,rivastigmine&galantamine: Patients with
Alzheimer disease have a deficiency of cholinergic neurons in
the CNS. This led to the development of anticholinesterases as
possible treatment for the loss of cognitive function. Tacrine
was first available but it replaced by others because of its
hepatotoxicity.
 Donepezil, rivastigmine & galatamine has a ability to delay the
progression of Alzheimer disease but none can stop it
progression. Gl tract distress is primary adverse effect.
Indirect Acting drugs (Irreversible):
 A number of synthetic organophosphate compounds have the
capacity of bind covalently to AChE. The result is long-lasting
increase in Ach at all sites where it is released.
 Many of these drugs are toxic and developed by military as
nerve agents.
 Echothiophate
 Mechanism of action: It is an organophosphate that covalently
binds via it phosphate group to serine –OH group at the active
site of AChE.
 Once it is binds it will permanently inactivated and restoration
of AChE requires chemicals like Pralidoxime (PAM).
 The phosphorylated enzyme slowly release the one of its ethyl
groups and loss of ethyl group which is called aging it makes
impossible to activate the AChE through chemical reactivators
like PAM.
 Actions: Actions include paralysis of motor function ( breathing
difficulty) and convulsions and it also produce miosis and it is
the therapeutic use. It decreases the intraocular pressure to
facilitate the outflow o aqueous humor; it is used to treat
topically to the eye for chronic treatment of open-angle
glaucoma.
 In addition of its side effect, the potential risk for causing
cataracts limits its use.
Toxicology of AChE inhibitors
 Reactivation of AChE: Pralidoxime can reactivate inhibited
AChE, but it is unable to penetrate into CNS. The presence of
charged group allows it to approach an anionic site to phosphate
site to reactivate the enzyme before the aging. It can be reverse
the effects except in CNS.
 With the new nerve agents which can produce aging complex
within seconds PAM is less effective and with higher dose of
PAM it can cause side effects similar to AChE inhibitors.
 It cannot overcome toxicity of reversible AChE inhibitors.

Summary: