Cholinergic agents such as nicotine, muscarine, and pilocarpine act by mimicking acetylcholine at nicotinic and muscarinic sites. Acetylcholinesterase inhibitors such as neostigmine, pyridostigmine, and organophosphates promote the accumulation of acetylcholine by irreversibly or reversibly inhibiting the enzyme. These agents are used therapeutically for conditions like glaucoma but produce toxic effects in high doses by overstimulating cholinergic receptors. Pralidoxime can reactivate phosphorylated acetylcholinesterase and reverse some effects of organophosphate poisoning.

1. Cholinergic Agents

2. Cholinergic Agents Alkaloids Nicotine Lobeline Arecoline Muscarine Pilocarpine Synthetic Agents Dimethylphenylpiperazinium-(DMPP) Oxotremorine Methacholine Bethanechol Carbachol Cevimeline

3. Nicotine Nicotine mimics the actions of acetylcholine at nicotinic sites Cell body of the postsynaptic neurons sympathetic and parasympathetic divisions Chromaffin cells of the adrenal medulla End plate of skeletal muscle fiber Affinity for N N sites versus N M sites Used as an insecticide

4. Muscarine Muscarine mimics the actions of acetylcholine at smooth muscles, cardiac muscles, and glands Poisoning by muscarine produces intense effects qualitative to those produced by cholinergic stimulation of smooth muscles, cardiac muscle, and glands Muscarine is found in various mushrooms Amanita muscaria : content of muscarine is very low Inocybe sp : content of muscarine is high Clitocybe sp : content of muscarine is high

5. Pilocarpine Has muscarinic actions Used for xerostomia Used for glaucoma

6. Structure of Acetylcholine and its Derivatives Acetylcholine Methacholine Bethanechol Carbachol

7. Therapeutic Uses of Cholinergic Agonists Dentistry Pilocarpine Cevimeline Ophthalmology Pilocarpine Carbachol Gastrointestinal tract Bethanechol Urinary bladder Bethanechol

8. Contraindications to the Use of Choline Esters Hyperthyroidism Asthma Coronary insufficiency Peptic ulcer Organic obstruction in bladder or gastrointestinal tract

9. Toxicity of Choline Esters Flushing SWEATING (diaphoresis) Abdominal cramps Spasm of the urinary bladder Spasm of accomodation Miosis Headache Salivation Bronchospasm Lacrimation Hypotension Bradycardia

10. Agents That Inhibit Acetylcholinesterase

11. Acetylcholinesterase (True Cholinesterase)

12. Acetylcholinesterase (1) Sites of location Cholinergic neurons Cholinergic synapses Neuromuscular junction Red blood cells Substrates Acetylcholine is the best substrate Methacholine is a substrate Hydrolyzes ACh at greater velocity than choline esters with acyl groups larger than acetate or proprionate

13. Acetylcholinesterase (2) Esters that are not substrates Bethanechol Carbachol Succinylcholine Its inhibition produces synergistic interaction with methacholine and additive actions with bethanechol and carbachol Drugs that block its hydrolysis of esters are called cholinesterase inhibitors

14. Drug Interactions of Choline Esters and Inhibitors of Acetylcholinesterase - Synergism versus Additivity Methacholine Carbachol Bethanechol

15. Butyrylcholinesterase (Plasma esterase, pseudocholinesterase, serum esterase, BuChE, PseudoChE)

16. Butyrylcholinesterase (1) Sites of location Plasma, liver, glial cells, other tissues Substrates Butyrylcholine is the best Acetylcholine Succinylcholine Procaine

17. Butyrylcholinesterase (2) Esters that are not substrates Methacholine, bethanechol, and carbachol Is inhibited by carbamyl and organophosphate inhibitors of acetylcholinesterase

18. Active Site of Acetylcholinesterase

19. Interaction of AChE and Acetylcholine

21. Acetylation of AChE and Release of Choline

22. Hydroxyl Group of Water Attacks the Carbonyl Group of Acetylated-AChE to Liberate AChE

23. Carbamyl Inhibitors of AChE

24. Their action promoting accumulation of ACh at muscarinic or nicotinic receptors is the basis of their pharmacological, therapeutic, and toxic actions Are derivatives of carbamic acid Bind covalently to the esteratic site of AChE, resulting in carbamylation of the enzyme Carbamyl Inhibitors of AChE (1) Carbamic acid Carbamic acid ester

25. Quaternary compounds bind to the ionic binding site of AChE Their induce accumulation of AChE at nicotinic and muscarinic sites, producing pharmacological responses qualitative to cholinergic stimulation Inhibition of AChE is reversible, in the order of hours Are metabolized in the plasma by plasma esterases Carbamyl Inhibitors of AChE (2)

26. High doses produce skeletal muscle weakness due to depolarizing blockade at the end plate of the neuromuscular junction High doses produce a profound fall in cardiac output and blood pressure Their inhibition of AChE is not reversed by pralidoxime Carbamyl Inhibitors of AChE (3)

27. Quaternary ammonium compounds do not cross the blood-brain barrier For oral administration, high doses must be given Carbamyl Inhibitors of AChE (4)

28. Neostigmine Carbamylates Acetylcholinesterase

29. Slow Hydrolysis of Carbamylated-AChE and Enzyme Liberation

30. Organophosphate Inhibitors of Acetylcholinesterase

31. Chemical characteristics Promote accumulation of ACh at N M nicotinic receptor N N nicotinic receptor Muscarinic receptor Organophosphate Inhibitors of Acetylcholinesterase (1)

32. Their action promoting accumulation of ACh at the muscarinic receptor of the ciliary muscle is the basis of their therapeutic effectiveness in open angle glaucoma Only two of these agents are used for therapeutics Echothiophate for glaucoma Diisopropylflurophosphate (DFP) for glaucoma (?) Organophosphate Inhibitors of AChE (2)

33. Inhibition of AChE by these agents is irreversible New enzyme synthesis is required for recovery of enzyme function They also inhibit pseudocholinesterase Metabolized by A-esterases (paroxonases) present in plasma and microsomes. They are metabolized by CYP450. Organophosphate Inhibitors of AChE (3)

34. Enzyme inhibition by these agents can be reversed by cholinesterase reactivators such as pralidoxime if administered before “aging” of AChE has occurred. Inhibition by agents that undergo rapid “aging” is not reversed. Except for echothiophate, these agents are extremely lipid soluble, and some are very volatile. Organophosphate Inhibitors of AChE (4)

35. Diisopropylflurophosphate (DFP) is a Substrate for AChE

36. The Extremely Slow Hydrolysis of Phosphorylated-AChE New enzyme synthesis is required for recovery of enzyme function

37. Various “States” of Acetylcholinesterase Clockwise: free AChE, acetylated AChE, carbamylated AChE, phosphorylated AChE

38. Acetylated-AChE Is Very Rapdily Hydrolyzed AChE + Acetylcholine  AChE-acetylated + choline AChE-acetylated + H 2 O  AChE + acetate Hydrolysis of AChE-acetylated is rapid, in the order of microseconds P

39. Carbamylated-AChE Is Hydrolyzed Slowly AChE + Carbamyl inhibitor  AChE-carbamylated + noncarbamylated metabolite AChE-carbamylated + H 2 O  AChE + carbamic acid derivative Hydrolysis of the AChE-carbamylated is slow, in the order of hours. The carbamylated enzyme is reversibly inhibited, and recovery of function is in the order of hours Enzyme after phosphorylation by neostigmine

40. Phosphorlylated-AChE Is Hydrolyzed Extremely Slowly AChE + organophosphate inhibitor  AChE-phosphorylated + nonphosphorylated metabolite AChE-phosphorylated + H 2 O  AChE + phosphorylated derivative Hydrolysis of the AChE-phosphorylated is extremely slow, in the order of days. The phosphorylated enzyme is considered to be irreversibly inhibited, and recovery of function is in the order of days. Pralidoxime, a reactivating agent, may be adminstered to a subject before the enzyme has “aged.” Enzyme after phosphorylation by DFP

41. AGING OF ACETYLCHOLINESTERASE

42. Loss of An Alkyl Group From Phosphorylated AChE “Ages” the Enzyme AChE, phosphorylated and inhibited by DFP “ Aged” AChE

43. “ Aging” of Phosphorylated- AChE

44. Cholinesterase Reactivation

45. Reactivation of Phosphorylated Acetylcholinesterase Oximes are used to reactivate phosphorylated AChE The group (=NOH) has a high affinity for the phosphorus atom Pralidoxime has a nucleophilic site that interacts with the phosphorylated site on phosphorylated-AChE

46. Pralidoxime Reacts Chemically with Phosphorylated-AChE The oxime group makes a nucleophilic attack upon the phosphorus atom

47. Oxime Phosphonate and Regenerated AChE

48. Limitations of Pralidoxime Pralidoxime does not interact with carbamylated-AChE Pralidoxime in high doses can inhibit AChE Its quaternary ammonium group does not allow it to cross the blood brain barrier “ Aging” of phosphorylated-AChE reduces the effectiveness of pralidoxime and other oxime reactivators

49. Other Cholinesterase Reactivators Diacetylmonoxime Crosses the blood brain barrier and in experimental animals, regenerates some of the CNS cholinesterase HI-6 is used in Europe Has two oxime centers in its structure More potent than pralidoxime

50. Edrophonium

51. Edrophonium is a Short Acting Inhibitor that Binds to the Ionic Site but Not to the Esteratic Site of AChE

52. Pharmacology of Acetylcholinesterase Inhibition

53. Inhibition of Acetylcholinesterase Produces Stimulation of All Cholinergic Sites

54. Carbamyl Inhibitors of AChE Physostigmine Neostigmine (N + ) Pyridostigmine (N + ) Ambenonium (N + ) Demecarium (N + ) Carbaryl

55. Pharmacology of Carbamyl Inhibitors of Acetylcholinesterase Eye Exocrine glands Cardiac muscle Smooth muscles Skeletal muscle Toxicity

56. Therapeutic Uses of Inhibitors of Acetylcholinesterase Glaucoma (wide angle) Atony of the bladder Atony of the gastrointestinal tract Intoxication by antimuscarinic agents (use physostigmine) Intoxication by tricyclic antidepressants (TCA’s) or phenothiazines (use physostigmine) Recovery of neuromuscular function after competitive blockade of N N receptor of skeletal muscle fibers Myasthenia gravis

57. Therapeutic Uses of Edrophonium Diagnosis of myasthenia gravis In conjunction with chosen therapeutic agent to determine proper dose of agent

58. Determining Proper Dose of AChE Inhibitor

59. Inhibitors of AChE Are Used for Therapy of Alzheimer’s Disease Tacrine Donepezil Rivastigmine Galantamine

60. Organophosphate Inhibitors of AChE

61. Some Organophosphate Inhibitors of Acetylcholinesterase Tetraethylpyrophosphate Echothiophate (N + ) Diisopropylflurophosphate (DFP) Sarin Soman Tabun Malathion Parathion Diazinon Chlorpyrifos Many others

62. Organophosphate Inhibitors - 2 Diisopropylfluorophosphate (DFP) Soman Sarin Tabun

63. Echothiophate Therapeutic use - local application to the eye for wide angle glaucoma

64. Conversion of Parathion to Paraoxon

65. Conversion of Malathion to Malaoxon

66. Malathion Is Hydrolyzed by Plasma Carboxylases in Birds and Mammals but Not Insects

67. Carboxyl Esterases Preferentially hydrolyzes aliphatic esters Malathion is a substrate Are inhibited by organophosphates May also be called aliesterases

68. Uses of Malathion Insecticide Therapeutics Used as a lotion for Pediculus humanus capitis associated with pediculosis 0.5% solution in 78% isopropranolol is pediculicidal and ovicidal Ovide is the brand name Primoderm was the former brand name

69. Malathion Metabolism Rapidly metabolized by birds and mammals Plasma carboxylases are involved Insects do not possess the enzyme Organophosphates inhibit malathion metabolism Malathion is toxic to fish

70. Aryl Esterases Are found in the plasma and liver Hydrolyzes organophosphates at the P-F bond P-CN bond Phosphoester bond Anhydride bond

71. EPA And Organophosphates Diazinon No longer allowed to be manufactured for indoor use in as of March 1, 2001 or for garden use as of June 3, 2001 Found in Real Kill ® , Ortho ® , Spectracide ® Limited agricultural use is allowed Chlorpyrifos (Dursban) has been phased out Parathion has been phased out for agricultural use in the United States

72. NERVE AGENT VX Chemical name: O-ETHYL-S-(2-DIISOPROPYLAMINOMETHYL)METHYL-PHOSHONOTHIOLATE Trade name: PHOSPHONOTHIOIC ACID NERVE AGENT VX

73. NERVE AGENT VX Chemical name: O-ETHYL-S-(2-DIISOPROPYLAMINOMETHYL)METHYL-PHOSHONOTHIOLATE Trade name: PHOSPHONOTHIOIC ACID

74. Organophosphates as Nerve Gas Agents in Chemical Warfare (1) Extremely volatile agents such as sarin, tabun, soman, and agent VX may be used as nerve agents in chemical warfare. Accumulation of ACh at cholinergic receptors produces effects reflecting stimulation of cardiac muscle, smooth muscles and glands. Such effects would be identical to those caused by muscarine poisoning. Bradycardia and hypotension occur. However, in some cases, tachycardia may be observed, due to intense sympathetic discharge in response severe hypoxemia.

75. Organophosphates as Nerve Gas Agents in Chemical Warfare (2) Irreversible inhibition of acetylcholinesterase by these agents produces accumulation of ACh at the end plate of skeletal muscle fibers. This in turn leads to depolarizing blockade of the N M nicotinic receptor. Skeletal muscle paralysis occurs. Movement is impossible. The diaphragm is also paralyzed. The individual eventually dies due to respiratory paralysis. Pralidoxime, atropine, and removal of the person from the source of exposure are all to be employed in cases of posioning.

76. Use of Pyridostigmine During the Gulf War