2. DIRECT CHOLINERGIC DRUGS Prof. Hanan Hagar Pharmacology Department

3. By the end of this lecture the student should know Classification of nervous system. Describe the various steps in cholinergic transmission. Mention the different types, locations and actions of cholinergic receptors. Describe the effects of acetylcholine on major organs Classify cholinomimetic drugs. Describe the kinetics, actions and uses of direct and indirect- acting cholinomimetic drugs.

4. Nervous system Peripheral nervous system Central nervous system Efferent Division (Motor) Afferent Division (Sensory) Autonomic nervous system Somatic system (skeletal muscles) Enteric nervous system Parasympathetic nervous system Sympathetic nervous system

5. What are the differences between the somatic and the autonomic nervous system? Somatic N.SAutonomic N.S Control skeletal muscles Control internal viscera VoluntaryInvoluntary Somatic nerve is one fiber autonomic nerve is two fibers (Preganglionic & Postganglionic )

6. Pre-ganglionic fiber Post-ganglionic fiber ganglia One fiber

7. Divisions of Autonomic Nervous System Sympathetic nervous system. Parasympathetic nervous system. Enteric nervous system.

8. Parasympathetic Nervous System Parasympathetic Nervous System (craniosacral outflow)

9. Neurotransmitter in parasympathetic or cholinergic system is acetylcholine and nerves are called cholinergic nerves

11. Cholinergic transmission

12. Synthesis Storage Release Binding to receptors Metabolism by acetylcholinesterase to give choline and acetate Recycling of choline

13. Cholinergic transmission

14. Cholinergic or parasympathetic receptors Nicotinic (N, central) receptors. Muscarinic (M, peripheral) receptors. Central nicotinic receptor Peripheral muscarinic receptor

15. Type I receptors : ion channel linked receptors Located in: Autonomic ganglia (Nn). Adrenal medulla (Nn) CNS (Nn) Neuromuscular junction (Nm) Nicotinic receptors

16. Type II receptors : G-protein linked receptors Located at all target organs that are innervated by parasympathetic fibers (e.g, heart, CVS, eye, bladder, etc). Five subclasses exist (M1 - M5) M1, M3, M5 are excitatory in function (stimulation). M2, M4 are inhibitory in function (inhibition). Muscarinic receptors

17. Pharmacological actionsLocationsReceptor CNS excitation Gastric acid secretion CNS gastric parietal cells M1 Excitatory Cardiac inhibition (Bradycardia) HeartM2 Inhibitory Secretion of glands Smooth muscle contraction Vasodilatation (via nitric oxide) Exocrine glands Smooth muscles Vascular endothelium M3 Excitatory memory, arousal, attention andCNSM4 & M5 Muscarinic receptors

18. Cholinergic or parasympathetic receptors

19. Muscarinic receptors Peripheral cholinoceptor Nicotinic receptors Central cholinoceptor G protein linked receptorsIon channel linked receptors On all peripheral organs that receive postganglionic parasympathetic fibers Autonomic ganglia (sympathetic & parasympathetic) stimulation ( Nn ) Heart (M2) inhibition exocrine glands (M3) contraction Adrenal medulla (Nn) release of catecholamines (Adrenaline & Noradrenaline) Smooth muscles (GIT, urinary tract, bronchial muscles) (M3) contraction Skeletal muscle (Neuromuscular junction) (Nm) Contraction Excitatory or inhibitory Almost excitatory

20. What are the actions of parasympathetic nervous system? 1.Nicotinic actions 2.Muscarinic actions

21. Skeletal muscles: Low conc. of nicotine  muscle contraction High conc. of nicotine  persistent depolarization & relaxation. Ganglia: stimulation of sympathetic& parasympathetic ganglia. Adrenal medulla release of catecholamines (A & NA). Nicotinic actions

22. Muscarinic actions Cholinergic actionsOrgans Contraction of circular muscle of iris (miosis)(M3) Contraction of ciliary muscles for near vision (M3) Decrease in intraocular pressure Eye bradycardia ( heart rate ) (M2) Release of NO (EDRF) Heart endothelium Constriction of bronchial smooth muscles Increase bronchial secretion M3 Lung Increase motility (peristalsis) Increase secretion Relaxation of sphincter M3 GIT Contraction of muscles Relaxation of sphincter M3 - Urination Urinary bladder Increase of all secretions sweat, saliva, lacrimal, bronchial, intestinal secretions M3 Exocrine glands

25. Drugs that produce actions similar to stimulation of parasympathetic system (or similar to natural neurotransmitter, Ach). CholinomimeticsParasympathomimetics

26. Types of cholinomimetics Direct cholinomimetics cause direct stimulation of cholinergic receptors. Indirect cholinomimetics (anticholinesterases) increase action of Ach indirectly by inhibiting acetylcholinesterase thus prevent the degradation of Ach.

27. Direct cholinomimetics Acetylcholine (M,N) Carbachol (M,N) Bethanechol (M) Pilocarpine (M) Direct Cholinomimetics

28. Acetylcholine (Ach) Muscarinic and nicotinic agonist Not used clinically because Ach – Is not selective (N, M) – Has short duration of action. Why? – Due to rapid metabolism by acetycholinesterase

29. Synthetic choline esters  include drugs as bethanechol, carbachol  Quaternary ammonium compounds (polar)  Poor distribution  can not cross BBB (No CNS effects)  Not metabolized by cholinesterase.  Have longer duration of action than Ach.  Never given I.V. or I.M BUT S.C.

31. Carbachol 1.Orally-S.C. 2.Not metabolized by cholinesterases. 3.Longer duration of action than Ach 4.Muscarinic actions on Eye, GIT, UT. (Table 5.Has nicotinic actions (what are these actions?). 6.Used for Mainly in glaucoma Urinary retention & paralytic ileus (rarely used due to its nicotinic actions)

32. Bethanechol  Orally-SC  Prominent muscarinic actions on GIT, UT.  No nicotinic action  Not metabolized by cholinesterases.  Longer duration of action than Ach  Used for In paralytic ileus In urinary retention (in cases of post-operative atony, neurogenic bladder)

33. Pilocarpine Natural alkaloids Tertiary amine lipophilic Pharmacokinetics It is well absorbed Good distribution Cross BBB (has central effects). Long duration of action Direct muscarinic agonist (mainly on eye & secretion).

34. Pilocarpine Uses: Xerostomia (dry mouth). Drug of choice in emergency glaucoma applied as eye drops. Adverse effects: Profuse sweating Salivation Bronchoconstriction Diarrhea CNS effects

35. PilocarpineBethanechol CarbacholACh Tertiary non polar Quaternary Polar Chemistry Completebetter absorbed than Ach better absorbed than Ach NOTAbsorption NOT metabolized by cholinesterase Metabolism by cholinesterase Longer (++) Very shortDuration oral, eye drops Oral S.C. Oral, eye drops S.C. I.V. eye drops Administ.

36. Pilocarpine Bethanechol CarbacholACh Muscarinic Nicotinic Muscarinic Nicotinic Receptors +++ Muscarinic More on eye, secretion GIT, Urinary bladder Eye, GIT Urinary bladder NOT Selectivity NO +++ Nicotinic Glaucoma Xerostomia Paralytic ileus Urinary retention Glaucoma Paralytic ileus Urinary retention NO Uses

37. Cevimeline – Direct acting muscarinic agonist – Used for treatment of dry mouth symptom associated with Sjogren's syndrome.

38. Contraindications of cholinomimetics 1.Bronchial asthma. 2.Peptic ulcer. 3.Angina pectoris 4.Incontinence 5.Intestinal obstruction

39. Thank you