AUTONOMIC NERVOUS SYSTEM

Col Prafull Mohan, DM (Clinical Pharmacology)

Prof and HoD, Pharmacology
 Cholinergic drugs: Classification
Cholinergic agonists
Choline esters: ACh, Methacholine, Carbechol, Bethanechol
Alkaloids: Muscarine, Pilocarpine, Arecholine
Anticholinesterases (Indirectly acting)
Reversible
Carbamates Physostigmine, Neostigmine, Pyridostigmine,
Rivastigmine
Non-Carbamates Edrophonium, Tacrine, Donepezil,
Galantamine
Irreversible
Carbamates Carbaryl (Sevin), Propoxur* (Baygon)
Organophosphates Dyphlos , Echothiophate, Malathion*,
Diazinon*,
Tabun”, Sarin”, Soman”
Cholinergic Nerve Ending
 Cholinergic Nerve Ending
Botulinum Toxin
Atropine
Black Widow Spider
NaChT: Na Choline
Co-Transporter
ChAT: Choline Acetyl
transferase
VAChT: Vesicle
Acetylcholine
Transporter

Hemicholinium

Hemicholinium Neostigmine,
Physostigmine etc
 Cholinesterase (AChE)
Hydrolyzes ACh after release and choline is recycled

Acetylcholinesterase / True cholinesterase:

• Specific for ACh: Immediate hydrolyses
• All cholinergic sites, RBC, grey matter

Butyrylcholinesterase (BuChE)/ Pseudocholinesterase:

• Nonspecific: Hydrolyses it slowly
• Metabolizes ingested esters
• Plasma, liver, intestine, white matter
 Cholinergic Receptors
• Nicotinic: Ligand gated ion channel
• Muscarinic: GPCR
 Muscarinic Receptors
• Selective Agonist: Muscarine
• Antagonist: Atropine
• Site: On effector cells
Bld vessels (Endothelial cells) - though most lack
cholinergic innervation - activation releases EDRF (NO)-
relaxation

• Effect
– Can be either inhibitory or excitatory
– Depends on the receptor type of the target organ
 Muscarinic Receptors
Sites:
• Primarily - Heart, blood vessels, eye
Smooth muscles & glands of GI, Resp & Urinary Tract
Sweat glands & in CNS
• Autonomic ganglia: Mainly Nicotinic (NN)
Muscarinic receptors also (modulatory role)
• Muscarinic Auto-receptors - Prejunctional on
postganglionic cholinergic nerve endings - activation -
Inhibits ACh release
• Adrenergic terminals - Activation inhibits NA release
(may contribute to vasodilator action of injected ACh)
 Muscarinic receptor Subtypes
• 5 subtypes M1, M2, M3, M4 and M5
Major subtypes M1, M2, M3 –
Effector cells and on prejunctional nerve endings
Peripheral organs and CNS
• M4 & M5: On nerve endings in certain areas of the
brain - regulate the release of other neurotransmitters

• M1,M3,M5 – Gq – IP3/DAG (Excitation)

• M2, M4 – Gi - ↓ cAMP ( Inhibitory)
 Muscarinic receptors
M1 M2 M3
Location & Autonomic Ganglia: SA node: Hyperpolarization, ↓ Visceral & Bronchial
Function Depolarization rate sm muscles:
Gastric Gl: AV node: ↓conduction vel Contraction
Histamine & acid Atrium: ↓APD, ↓contractility Iris: Constriction of
release, Relaxes LES Ventricles: ↓ contractility Pupil
Enteric neurons: Cholinergic n endings: ↓ ACh Ciliary muscles:
Intestinal secretions release Contraction
CNS: Learning, CNS: Tremor, analgesia Exocrine gl:
memory, motor Visceral sm muscles: Secretion
activity Contraction Vasc endoth: NO
release- relaxation

Nature GPCR- GPCR- GPCR-

IP3/DAG - ↑Ca++ K+ Ch opening IP3/DAG - ↑Ca++
PLA2 ↑ - ↑PG ↓ cAMP PLA2 ↑ - ↑PG

Agonist Oxetremorine Methacholine Bethanechol

Antagonist Pirenzepine, Methoctramine, Tripitramine Solefenacin,
Telenzepine Darifenacin
 Nicotinic Receptors
Characteristics NM NN
Location & NM junction - Autonomic ganglia (sym &
Function Skeletal Muscle parasymp) – postganglionic
contraction impulse
Adr medulla: Adr release
CNS: Site specific action

Nature Ion channel (opening of cation Na+, K+ channels)

Agonist PTMA (Phenyl DMPP (Dimethyl phenyl

trimethyl ammonium) piperazinium), Nicotine
Nicotine
Antagonist Tubocurarine, α Hexamethonium,
bungarotoxin Trimethaphan
 Cholinergic Agonists
Actions (ACh as Prototype)
Muscarinic actions:
Heart SA Node: hyperpolarizes node , rate of -ve chronotropy -
(M2) depolarization decreases Bradycardia, even heart block
AV Node & Purkinje fibres: RP increased & -ve dromotropy - PR interval
conduction slowed increases
Partial to complete AV block
Atria: Force of contraction reduced, RP -ve inotropy
reduced Predisposition to AF/flutter
Ventricle: Contractility reduced to a lesser
degree
Blood All Bld vessels dilated (only skin of face, Fall in BP & flushing (Blush
Vessels: neck & salivary gland receive cholinergic area)
M3 enervation)
Release of Endothelium-Derived Relaxing
Factor (EDRF) i.e. Nitric Oxide (NO)
Dilates cavernosal vessels (Penis) Erection (less with injected
cholinomimetic drugs).
Muscarinic actions:
Smooth GIT: Tone & peristalsis increased; Abdominal cramps & evacuation
muscle M3 sphincters relax. of bowel
Most organs - Ureter: Peristalsis increased. Voiding of bladder.
contraction Bladder: Detrusor muscle
contracts while trigone &
sphincter relaxes
Bronchial muscles: constrict Asthmatics highly sensitive →
bronchospasm, dyspnoea, pptn
of an attack
Glands M3 Secretion increased Sweating, salivation, lacrimation,
(some M2) increased tracheobronchial and
gastric secretion.
Eye (M3) Contraction of circular muscle of Miosis
iris
Contraction of ciliary muscle: Spasm of accommodation,
increased aqueous outflow
facility, reduction in intraocular
tension (esp in Glaucoma)
Nicotinic Action
Autonomic Both symp & parasym High dose ACh given after atropine -
ganglia NN: stimulated. (at higher doses) tachycardia and rise in BP due to
stimulation of sympathetic ganglia
and release of catecholamines.
Skeletal Iontophoretic application of Contraction
muscles NM ACh to muscle endplate
Intraarterial injection of Twitching and fasciculations
high dose
i.v. injection No effect (rapid hydrolysis of ACh)
CNS i.v. ACh injected No effect: does not penetrate blood-
brain barrier
Direct injection into the - Arousal response followed by
brain depression
- Cholinergic drugs which enter brain
produce complex behavioral and
neurological effects
 Interactions
Anticholinesterases
• Potentiate ACh & Methacholine (less extent)
• Additive action with carbachol & bethanechol

Atropine (and its congeners): Competitively antagonize

muscarinic actions

Adrenaline: Physiological antagonist

 Choline esters
• ACh is not used: Evanescent & nonselective action
Bethanechol: Rarely used
• Post –op/postpartum nonobstructive urinary retention
• Neurogenic bladder- to promote urination
• Symptomatic relief in congenital megacolon and
gastroesophageal reflux
• Post-op paralytic ilius
• Xerostomia (Alternate to Pilocarpine)

Side effects (prominent): Belching, colic, involuntary

urination/defecation, flushing, sweating, fall in BP,
bronchospasm
 Cholinomimetic alkaloids
Pilocarpine: Natural (leaves of Pilocarpus microphyllus)
Prominent muscarinic actions & also stimulates ganglia

Actions:
• Marked sweating, salivation & ↑ other secretions
• CVS - Small doses ↓BP (muscarinic), but higher doses
↑ BP & tachycardia (ganglionic muscarinic receptors)
• Eye: Penetrates cornea, prompt miosis, spasm of
accommodation, ciliary muscle contraction & ↓IOT
lasting 4–8 hours
Use: 1%, 2%, 4% eye drops, Ocusert (7 days), 5mg tab
• 3rd line drug in open angle glaucoma
• To counteract mydriatics (used for testing refraction)
• To prevent/break adhesions of iris with lens/cornea
(alternating with mydriatics)
• Xerostomia (Sjogrens synd, head & neck radiation)

S/E: Initial stinging sensation in eye

↓ vision, esp in dim light (constricted pupil)
Spasm of accommodation and brow pain
Syst Eff - nausea, diarrhea, sweating & bronchospasm
Muscarine: (poisonous mushrooms - Amanita muscaria
and Inocybe species)
• Only muscarinic actions
• Not used therapeutically
• Mushroom poisoning: Treatment: Atropine

Arecoline: (Betel nut - Areca catechu)

• Muscarinic & Nicotinic actions
• Prominent CNS effect
• No therapeutic use.
 Cholinergic drugs: Classification
Cholinergic agonists
Choline esters: ACh, Methacholine, Carbechol, Bethanechol
Alkaloids: Muscarine, Pilocarpine, Arecholine
Anticholinesterases (Indirectly acting)
Reversible
Carbamates Physostigmine, Neostigmine, Pyridostigmine,
Rivastigmine
Non-Carbamates Edrophonium, Tacrine, Donepezil,
Galantamine
Irreversible
Carbamates Carbaryl (Sevin), Propoxur* (Baygon)
Organophosphates Dyphlos, Echothiophate, Malathion*,
Diazinon*,
Tabun”, Sarin”, Soman”
 Anticholinesterases (anti-ChEs)
• Structural analogs of Acetylcholine
• Enzyme inhibition
• ACh not hydrolysed – accumulates
• Indirectly acting cholinergic drugs

ACh binds to both sites (weak)

Acetylcholine
Acetylated enzyme reacts with
water extremely rapidly &
esteratic site is freed in a
fraction of a millisecond
 Anticholinesterases (anti-ChEs)
• Reversible AntiChE – bind
to both sites, carbamated
enzyme reacts slowly
(hours)

• Edrophonium & Tacrine –

only to Anionic site, weak H-
bonds, reacts fast (Min)
 Anticholinesterases (anti-ChEs)
• OP Comps (irreversible
inhibitors) - only esteratic
site (covalent bonds)
• Phosphorylated enzyme
reacts extremely slowly/not
at all
• The phosphorylated enzyme
undergoes ‘aging’ - loss of
one of the alkyl grp and
becomes totally resistant to
hydrolysis
 Anticholinesterases
Reversible Irreversible
• Tert Amm Compds: Carbamates: Carbaryl, Propoxur
Physostigmine
• Quart Amm Compd: OP Compds:
Neostigmine
• Glaucoma -
• Ultra-short acting – Disofluorophosphate , long
Edrophonium acting
• Long acting - Ambenonium • Pediculosis – Malathion,
• Cerebroselective – Parathion
Rivastigmine , Donepezil, • War gas- Tabun, sarin
Galantamine, Tacrine
• Insecticides- Parathion,
• Others- Pyridostigmine,
Diazinon
Demicarium
 Pharmacokinetics
Physostigmine:
• Rapid absorption
• Eyes - penetrates cornea
• Crosses BBB
• Disposed after hydrolysis by ChE
Neostigmine and congeners:
• Poorly absorbed orally (oral dose 20–30 times parenteral)
• Do not penetrate cornea or BBB
• Partially hydrolysed & partially excreted unchanged (urine)
Organophosphates
• Absorbed from all sites including intact skin and lungs.
• Hydrolysed as well as oxidized
• Little is excreted unchanged.
 Anticholinesterases (anti-ChEs)
Actions: Amplification of endogenous ACh

• Lipid-soluble agents (physostigmine & OP compounds)

- Marked muscarinic & CNS effects
- Stimulate ganglia
- Action on skeletal muscles - less prominent

• Lipid-insoluble agents (neostigmine & other quaternary

ammonium compounds)
- Marked effect on skeletal muscles (also have direct action on
muscle endplate NM receptors)
- Stimulate ganglia
- Muscarinic effects - less prominent
- Do not penetrate CNS
 Lets recall
Effect of Cholinergic agents
• On heart
• On Blood vessels
• On GIT
• On Bladder
• One eyes
• On Glands
• On Lungs
• On CNS
 Lets recall
Which is the shortest acting anticholinesterase?
• Ambenonium
• Edrophonium
• Neostigmine
• Physostigmine
• Rivastigmine
 Anticholinesterases
Reversible Irreversible
• Tert Amm Compds: Carbamates: Carbaryl, Propoxur
Physostigmine
• Quart Amm Compd: OP Compds:
Neostigmine
• Glaucoma -
• Ultra-short acting – Disofluorophosphate, long
Edrophonium acting
• Long acting - Ambenonium • Pediculosis – Malathion,
• Cerebroselective – Parathion
Rivastigmine , Donepezil, • War gas- Tabun, sarin
Galantamine, Tacrine
• Insecticides- Parathion,
• Others- Pyridostigmine,
Diazinon
Demicarium
 Uses
As miotic
(a) In glaucoma (Open angle)
Miosis, ↑tone of ciliary muscle & sphincter pupillae (pull
and improve alignment of trabeculae - outflow facility ↑
- ↓IOT falls

• Pilocarpine (preferred)
• Physostigmine (0.1%) - only to supplement pilocarpine
• 3rd choice drugs - As add on in advanced cases
 Uses
(b) To reverse the effect of mydriatics after refraction
testing

(c) To prevent (and break) formation of adhesions

between iris and lens or iris and cornea (iritis, corneal
ulcer, etc.)
—Miotic is alternated with a mydriatic
 What do these celebrities have in
common?

• Amitabh Bachchan
• Roger Smith
• Laurence Olivier

Myasthenia Gravis
 Uses
Myasthenia Gravis:
• Autoimmune disorder
• Antibodies against NM
receptors – decrease in
number of receptors

• Progressive weakness,
quick and easy
fatiguability of skeletal
muscles
 Myasthenia gravis Treatment
Anticholinesterases:
Neostigmine: Started 15 mg orally 6 hourly
Dose & frequency adjusted
Pyridostigmine: Less frequent dosing
Atropine: Added if intolerable muscarinic S/E present
No effect on disease progression

Thymectomy: Patients with generalized weakness (esp

with thymoma and in younger patients)
 Myasthenia gravis Treatment
Corticosteroids:
• Immunosuppressant action (Inhibit production of
antibodies to NR & increase synthesis of new NRs)
• Patients not responding adequately to antiChEs,
thymectomy failed/unsuitable for it

Prednisolone 30–60 mg/day, then taper

10 mg daily/or alternate days (maintenance)
 Problem of long term use
 Myasthenia gravis Treatment

Immunosuppressants: Azathioprine & Cyclosporine

• Inhibit NR-antibody synth (affect T-cells)

Monoclonal antibody: Eculizumab

Patients who are positive for anti-ACh-R antibody

Plasmapheresis (plasma exchange) – Removal of

antibodies - dramatic but short-lived improvement
 Weakness in Myasthenia gravis
Myasthenic Crisis Cholinergic Crisis
• Tracheal intubation & • Overtreatment with anti-
mechanical ventilation ChEs
• i.v. methylprednisolone • Also produces weakness -
• Anti-ChEs withheld for 2–3 persistent depolarization
days, then gradually of muscle endplate
reintroduced
• Plasmapheresis hastens
recovery

Edrophonium test (Tensilon Test)

• 2mg iv – Improvement – Myasthenic crisis
Worsening – Cholinergic crisis
Diagnostic tests for myasthenia gravis
(a) Ameliorative test:
Edrophonium 2 mg i.v. No effect 8mg after 30–60 sec
• Improvement in MG (not other muscular dystrophies)
Neostigmine 1.5 mg i.v.
Atropine pretreatment - to block the muscarinic effects

(b) Provocative test: (Hazardous- rarely used)

d-tubocurarine 0.5 mg i.v.
• Marked weakness in MG (not other musc dystrophies)

(c) Demonstration of anti-NR antibodies in plasma or

muscle biopsy specimen More reliable test
 Uses (Cont..)
Postoperative paralytic ileus/urinary retention
• 0.5–1 mg s.c. Neostigmine
Postoperative decurarization
• Neostigmine 0.5–2.0 mg (30–50 µg/kg) i.v.
Pre-treated with atropine/glycopyrrolate 10 µg/kg
(to block muscarinic effects)
• Rapidly reverses muscle paralysis induced by
competitive neuromuscular blockers
Cobra bite: (curare like neurotoxin)
• Specific antivenom serum - primary treatment
• Neostigmine + atropine prevent respiratory paralysis.
 Uses
Belladonna poisoning (other anticholinergics)
Physostigmine (specific antidote)
• 0.5–2 mg i.v. - repeated as reqd - Crosses BBB-
antagonizes both central & peripheral actions.
• Itself induces hypotension, arrhythmias and
undesirable central effects
Neostigmine does not block the central effect, but is
less risky.
Other drug overdosages
• Tricyclic antidepressants, phenothiazines & anti-
histaminics (with anticholinergic property)
• Rx Physostigmine
 Anticholinesterase poisoning
Agricultural & household insecticides
Accidental/suicidal/homicidal poisoning common

Symptoms: Irritation of eye, lacrimation, salivation, sweating,

copious tracheo-bronchial secretions, miosis, blurring of vision,
bronchospasm, breathlessness, colic, involuntary defecation and
urination
• Fall in BP, bradycardia, cardiac arrhythmias, vascular collapse
• Muscular fasciculations, weakness, respiratory paralysis
• Irritability, disorientation, unsteadiness, tremor, ataxia,
convulsions, coma and death
• Death- generally due to respiratory failure
 Anticholinesterase poisoning
Symptoms: SLUDGE BBB
• Salivation, Sweating
• Lacrimation
• Urination (involuntary)
• Defecation (involuntary)
• GI symptoms (Emesis)
• Eye (Blurring of vision & miosis)
• Bronchorrhea (copious tracheo-bronchial
secretions)
• Bronchospasm
• Bradycardia
 Anticholinesterase poisoning

Symptoms: DUMBELS
• Diarrhoea
• Urination
• Miosis
• Bronchospasm, Bronchorrhea, Bradycardia
• Emesis
• Lacrimation
• Salivation, Sweating
 Anticholinesterase poisoning
Treatment
1. Termination of further exposure - fresh air, wash
skin and mucous membranes with soap and water,
gastric lavage according to need

2. Maintain patent airway - positive pressure

respiration if reqd

3. Supportive measures—Maintain BP, hydration,

control convulsions (Diazepam).
 Anticholinesterase poisoning
4. Specific antidotes

(a) Atropine:
Dose: 2 mg i.v. repeated every 10 min till dryness of
mouth or other signs of atropinization appear (upto
200 mg /day).
• Maintenance doses may be required for 1–2 weeks.
 Anticholinesterase poisoning
(b) Cholinesterase reactivators: Oximes (Adjunct to
atropine)
• OP compds attach to esteratic site by their PO4 gp
• The phosphorylated ChE reacts very slowly/not at all
with water.

If more reactive OH
groups (oximes) are
provided, reactivation
occurs million times faster
 Anticholinesterase poisoning
Pralidoxime (2-PAM):
• OP compds attach to only
esteratic site of AChE
• Oximes attach to the anionic
site of the enzyme (AChE)
• Their oxime end reacts with
the P-atom attached to the
esteratic site
 The oxime-phosphonate so
formed diffuses away leaving
the reactivated ChE
 Anticholinesterase poisoning
Pralidoxime:
 Slow i.v. 1–2 g (children 20–40 mg/kg) OR
 30 mg/kg i.v. loading dose
8–10 mg/kg/hour continuous infusion till recovery

• Repeat if reqd (max. 12 g in first 24 hrs)

• Cont Lower doses (according to symp) for 1–2 weeks)
• Causes marked reactivation of skeletal muscle ChE
Less at other sites
None in CNS (does not cross BBB)
 Anticholinesterase poisoning
Oxime - Started as early as possible (within few hours)
Before the phosphorylated enzyme has undergone ‘aging’
(loss of one alkyl gp) and become resistant to hydrolysis.
Other oximes
Obidoxime (more potent than pralidoxime)
Diacetyl-monoxime (DAM)
 Anticholinesterase poisoning
Oximes: Ineffective in carbamate anti-ChE poisoning
(physostigmine, neostigmine, carbaryl, propoxur) –
where anionic site of the enzyme is not free to provide
attachment to it.
Contraindicated in carbamate poisoning – Has weak
anti-ChE act