1. Pharmacodynamics

3. BoundFree Bound LOCUS OF ACTION “RECEPTORS ” TISSUE RESERVOIRS SYSTEMIC CIRCULATION Free Drug Bound Drug ABSORPTION EXCRETION BIOTRANSFORMATION

4. FDA Approved and Unapproved Uses Interactions with Other Drugs Adverse Effects and Contraindications AIDS MEMORIZATION OF:

5. WHY BE CONCERNED ABOUT HOW DRUGS WORK? Better assessment of new modalities for using drugs Better assessment of new indications for drugs Better assessment of new concerns regarding risk-benefit AIDS EVALUATION OF MEDICAL LITERATURE:

6. WHY BE CONCERNED ABOUT HOW DRUGS WORK? The patient has more respect for and trust in a therapist who can convey to the patient how the drug is affecting the patient’s body. AIDS PATIENT-DOCTOR RELATIONSHIP: A patient who understands his/her therapy is more inclined to become an active participant in the management of the patient’s disease.

7. WHY BE CONCERNED ABOUT HOW DRUGS WORK? Knowledge of how a drug works increases the therapist’s confidence that the drug is being used appropriately. PEACE OF MIND!

8. HOW DO DRUGS WORK? Some antagonize, block or inhibit endogenous proteins Some activate endogenous proteins A few have unconventional mechanisms of action

9. HOW DO DRUGS ANTAGONIZE, BLOCK OR INHIBIT ENDOGENOUS PROTEINS? Antagonists of Cell Surface Receptors Antagonists of Nuclear Receptors Enzyme Inhibitors Ion Channel Blockers Transport Inhibitors Inhibitors of Signal Transduction Proteins

10. A macromolecular component of the organism that binds the drug and initiates its effect. Definition of RECEPTOR: Most receptors are proteins that have undergone various post-translational modifications such as covalent attachments of carbohydrate, lipid and phosphate.

11. A receptor that is embedded in the cell membrane and functions to receive chemical information from the extracellular compartment and to transmit that information to the intracellular compartment. Definition of CELL SURFACE RECEPTOR:

12. HOW DO DRUGS WORK BY ANTAGONIZING CELL SURFACE RECEPTORS? KEY CONCEPTS: Cell surface receptors exist to transmit chemical signals from the outside to the inside of the cell. Some compounds bind to cell surface receptors, yet do not activate the receptors to trigger a response. When cell surface receptors bind the molecule, the endogenous chemical cannot bind to the receptor and cannot trigger a response. The compound is said to “antagonize” or “block” the receptor and is referred to as a receptor antagonist.

13. HOW DO DRUGS WORK BY ANTAGONIZING CELL SURFACE RECEPTORS? Cell Membrane Unbound Endogenous Activator (Agonist) of Receptor Inactive Cell Surface Receptor Extracellular Compartment Intracellular Compartment

14. HOW DO DRUGS WORK BY ANTAGONIZING CELL SURFACE RECEPTORS? Cell Membrane Bound Endogenous Activator (Agonist) of Receptor Active Cell Surface Receptor Extracellular Compartment Intracellular Compartment Cellular Response

15. HOW DO DRUGS WORK BY ANTAGONIZING CELL SURFACE RECEPTORS? Cell Membrane Displaced Endogenous Activator (Agonist) of Receptor Inactive Cell Surface Receptor Upon being Bound Extracellular Compartment Intracellular Compartment Bound Antagonist of Receptor (Drug)

16. Footnote: Most antagonists attach to binding site on receptor for endogenous agonist and sterically prevent endogenous agonist from binding. If binding is reversible - Competitive antagonists If binding is irreversible - Noncompetitive antagonists However, antagonists may bind to remote site on receptor and cause allosteric effects that displace endogenous agonist or prevent endogenous agonist from activating receptor. (Noncompetitive antagonists) HOW DO DRUGS WORK BY ANTAGONIZING CELL SURFACE RECEPTORS?

17. HOW DO DRUGS WORK BY ANTAGONIZING CELL SURFACE RECEPTORS? Cell Membrane Displaced Endogenous Activator (Agonist) of Receptor Inactive Receptor Extracellular Compartment Intracellular Compartment Bound Antagonist of Receptor Allosteric Inhibitor Active Receptor

18. ARE DRUGS THAT ANTAGONIZE CELL SURFACE RECEPTORS CLINICALLY USEFUL? Angiotensin Receptor Blockers (ARBs) for high blood pressure, heart failure, chronic renal insufficiency (losartan [Cozaar ® ]; valsartan [Diovan ® ]) Some important examples: Beta-Adrenoceptor Blockers for angina, myocardial infarction, heart failure, high blood pressure, performance anxiety (propranolol [Inderal ® ]; atenolol [Tenormin ® ])

19. HOW DO DRUGS WORK BY ANTAGONIZING NUCLEAR RECEPTORS? Unbound Endogenous Activator (Agonist) of Nuclear Receptor Inactive Nuclear Receptor in cytosolic compartment Intracellular Compartment Nucleus DNA Inactive Nuclear Receptor in nuclear compartment

20. HOW DO DRUGS WORK BY ANTAGONIZING NUCLEAR RECEPTORS? Intracellular Compartment Nucleus DNA Modulation of Transcription Active Nuclear Receptor Bound Endogenous Activator (Agonist) of Nuclear Receptor

21. HOW DO DRUGS WORK BY ANTAGONIZING NUCLEAR RECEPTORS? Displaced Endogenous Activator (Agonist) of Nuclear Receptor Intracellular Compartment Nucleus DNA Bound Antagonist of Receptor (Drug) Inactive Nuclear Receptor In Cytosolic Compartment Inactive Nuclear Receptor In Nuclear Compartment

22. ARE DRUGS THAT ANTAGONIZE NUCLEAR RECEPTORS CLINICALLY USEFUL? Mineralocorticoid Receptor Antagonists for edema due to liver cirrhosis and for heart failure (spironolactone [Aldactone ® ]) Some important examples: Estrogen Receptor Antagonists for the prevention and treatment of breast cancer (tamoxifen [Nolvadex ® ])

23. HOW DO DRUGS ANTAGONIZE, BLOCK OR INHIBIT ENDOGENOUS PROTEINS? Antagonists of Cell Surface Receptors Antagonists of Nuclear Receptors Enzyme Inhibitors Ion Channel Blockers Transport Inhibitors Inhibitors of Signal Transduction Proteins

24. HOW DO DRUGS WORK BY INHIBITING ENZYMES? Active Enzyme SubstrateProduct Cellular Function Inactive Enzyme Substrate Bound Enzyme Inhibitor (Drug)

25. HOW DO DRUGS WORK BY INHIBITING ENZYMES? KEY CONCEPTS: Enzymes catalyze the biosynthesis of products from substrates. Some drugs bind to enzymes and inhibit enzymatic activity. Loss of product due to enzyme inhibition mediates the effects of enzyme inhibitors.

26. ARE DRUGS THAT INHIBIT ENZYMES CLINICALLY USEFUL? Cyclooxygenase Inhibitors for pain relief, particularly due to arthritis (aspirin; ibuprofen [Motrin ® ]) Some important examples: Angiotensin Converting Enzyme (ACE) Inhibitors for high blood pressure, heart failure, and chronic renal insufficiency (captopril [Capoten ® ]; ramipril [Altace ® ]) HMG-CoA Reductase Inhibitors for hypercholesterolemia (atorvastatin [Lipitor ® ]; pravastatin [Pravachol ® ])

27. HOW DO DRUGS ANTAGONIZE, BLOCK OR INHIBIT ENDOGENOUS PROTEINS? Antagonists of Cell Surface Receptors Antagonists of Nuclear Receptors Enzyme Inhibitors Ion Channel Blockers Transport Inhibitors Inhibitors of Signal Transduction Proteins

28. ARE DRUGS THAT BLOCK ION CHANNELS CLINICALLY USEFUL? Calcium Channel Blockers (CCBs) for angina and high blood pressure (amlodipine [Norvasc ® ]; diltiazem [Cardizem ® ]) Some important examples: Sodium Channel Blockers to suppress cardiac arrhythmias (lidocaine [Xylocaine ® ]; amiodarone [Cordarone ® ])

29. ARE DRUGS THAT INHIBIT TRANSPORTERS CLINICALLY USEFUL? Selective Serotonin Reuptake Inhibitors (SSRIs) for the treatment of depression (fluoxetine [Prozac ® ]; fluvoxamine [Luvox ® ]) Some important examples: Inhibitors of Na-2Cl-K Symporter (Loop Diuretics) in renal epithelial cells to increase urine and sodium output for the treatment of edema (furosemide [Lasix ® ]; bumetanide [Bumex ® ])

30. Tyrosine Kinase Inhibitors for chronic myelocytic leukemia (imatinib [Gleevec ® ]) Some important examples: Type 5 Phosphodiesterase Inhibitors for erectile dysfunction (sildenafil [Viagra ® ]) This is a major focus of drug development ARE DRUGS THAT INHIBIT SIGNAL TRANSDUCTION PROTEINS CLINICALLY USEFUL?

31. HOW DO DRUGS WORK BY ACTIVATING ENDOGENOUS PROTEINS? Agonists of Cell Surface Receptors (e.g. alpha-agonists, morphine agonists) Agonists of Nuclear Receptors (e.g. HRT for menopause, steroids for inflammation) Enzyme Activators (e.g. nitroglycerine (guanylyl cyclase), pralidoxime ) Ion Channel Openers (e.g. minoxidil (K) and alprazolam (Cl))

32. HOW DO CHEMICALS WORK BY ACTIVATING CELL SURFACE RECEPTORS? KEY CONCEPTS: Cell surface receptors exist to transmit chemical signals from the outside to the inside of the cell. Some chemicals bind to cell surface receptors and trigger a response. Chemicals in this group are called receptor agonists. Some agonists are actually the endogenous chemical signal, whereas other agonists mimic endogenous chemical signals.

33. HOW DO CHEMICALS WORK BY UNCONVENTIONAL MECHANISMS OF ACTION? Disrupting of Structural Proteins e.g. vinca alkaloids for cancer, colchicine for gout Being Enzymes e.g. streptokinase for thrombolysis Covalently Linking to Macromolecules e.g. cyclophosphamide for cancer Reacting Chemically with Small Molecules e.g. antacids for increased acidity Binding Free Molecules or Atoms e.g. drugs for heavy metal poisoning, infliximab (anti-TNF)

34. HOW DO DRUGS WORK BY UNCONVENTIONAL MECHANISMS OF ACTION (Continued)? Being Nutrients e.g. vitamins, minerals Exerting Actions Due to Physical Properties e.g. mannitol (osmotic diuretic), laxatives Working Via an Antisense Action e.g. fomivirsen for CMV retininitis in AIDS Being Antigens e.g. vaccines Having Unknown Mechanisms of Action e.g. general anesthetics

35. Characteristics of Drug-Receptor Interactions Chemical Bond: ionic, hydrogen, hydrophobic, Van der Waals, and covalent. Saturable Competitive Specific and Selective Structure-activity relationships Transduction mechanisms

37. NH 4 + -CH 2 (n)-NH 4 +

38. Receptor Transduction Mechanisms Ion channel linked receptors e.g. Ach nicotinic (Na + ) and GABA (Cl - ) Second messenger generation, adenylate cyclase stimulation or inhibition - cAMP, guanylate cyclase - cGMP, phospholipase C - IP3, DAG Some receptors are themselves protein kinases Intracellular receptors (e.g. corticosteroids, thyroid hormone)

39. k1 D + R DR k2 By Law of Mass Action: [D] [R] K 1 = [DR] K 2 Therefore K 2 /K 1 = [D] [R]/[DR] = K d If R T = total # of receptors, then R T = [R] + [DR] Replace [R] by (R T -[DR]) and rearrange: [DR] [D] RT Kd + [D] = OCCUPATION THEORY OF DRUG-RECEPTOR INTERACTIONS EFFECT effect Max. effect =

40. KdKd effect[DR] [D] Max. effectRT Kd + [D] == When [D] = K d [DR] R T = 0.5 [D] [DR]/R T 0 51015 20 0.00 0.25 0.50 0.75 1.00

42. Receptor Binding The dose-response relationship (from C.D. Klaassen, Casarett and Doull’s Toxicology, 5th ed., New York: McGraw-Hill, 1996). % Bound Concentration of Ligand KdKd

43. [D] [DR]/R T 0.010.101.0010.00100.00 0.00 0.25 0.50 0.75 1.00 Kd=1 kd=5 Kd=0.5 Compounds Have Different Affinities for the Same Receptor

44. CompetitiveNoncompetitive Types of Receptor Antagonists

46. [D] (concentration units) % Maximal Effect 0.01 0.101.0010.00100.001000.00 0.0 0.2 0.4 0.6 0.8 1.0 Partial agonist Full Agonist Partial agonist PARTIAL AGONISTS - EFFICACY Even though drugs may occupy the same # of receptors, the magnitude of their effects may differ.

48. Drug (D) Ri DRiDRa Ra CONFORMATIONAL SELECTION HOW TO EXPLAIN EFFICACY? The relative affinity of the drug to either conformation will determine the effect of the drug

49. R R1*R1* R2*R2* R3*R3* R R R1*R1* R1*R1* R2*R2* R2*R2* R3*R3* R3*R3* From Kenakin, T. Receptor conformational induction versus selection: all part of the same energy landscape. TiPS 1996;17:190-191.

50. Spare Receptors

51. Receptor Regulation Sensitization or Up-regulation 1. Prolonged/continuous use of receptor blocker 2. Inhibition of synthesis or release of hormone/neurotransmitter - Denervation Desensitization or Down-regulation 1. Prolonged/continuous use of agonist 2. Inhibition of degradation or uptake of agonist Homologous vs. Heterologous Uncoupling vs. Decreased Numbers

54. From Nies A and Speilberg SP. Principles of Therapeutics. in Goodman and Gilman’s The Pharmacological Basis of Therapeutics. 9 th edition, 1996. Pages 43-62.McGraw Hill,

55. GRADED DOSE- RESPONSE CURVE ED50

56. QUANTAL DOSE- RESPONSE CURVE Frequency Distribution Cumulative Frequency Distribution

58. Morphine Aspirin

59. THERAPEUTIC INDEX – AN INDEX OF SAFETY Hypnosis Death

60. Margin of Safety = LD 1 ED 99 ED 50 A ED 99 A LD 1 A

61. Causes of Variability in Drug Response Those related to the biological system 1. Body weight and size 2. Age and Sex 3. Genetics - pharmacogenetics 4. Condition of health 5. Placebo effect

62. Causes of Variability in Drug Response Those related to the conditions of administration 1. Dose, formulation, route of administration. 2. Resulting from repeated administration of drug: drug resistance; drug tolerance-tachyphylaxis; drug allergy 3. Drug interactions: chemical or physical; GI absorption; protein binding/distribution; metabolism (stimulation/inhibition); excretion (pH/transport processes); receptor (potentiation/antagonism); changes in pH or electrolytes.