PRINCIPLES of PHARMACOLOGY

T H E PAT H O P H Y S I O L O G I C B A S I S O F D R U G T H E R A P Y

Third Edition
PRINCIPLES of PHARMACOLOGY
T H E PAT H O P H Y S I O L O G I C B A S I S O F D R U G T H E R A P Y

Third Edition

David E. Golan, MD, PhD

Editor in Chief

Armen H. Tashjian, Jr., MD

Deputy Editor

Ehrin J. Armstrong, MD, MSc

April W. Armstrong, MD, MPH
Associate Editors
Acquisitions Editor: Susan Rhyner
Product Manager: Stacey Sebring
Vendor Manager: Bridgett Dougherty
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Library of Congress Cataloging-in-Publication Data

Principles of pharmacology : the pathophysiologic basis of drug therapy / David E. Golan, editor in chief ; Armen H. Tashjian Jr.,
deputy editor. 3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-60831-270-2 (alk. paper)
1. Pharmacology. 2. Physiology, Pathological. I. Golan, David E. II. Tashjian, Armen H.
[DNLM: 1. Pharmacological Phenomena. 2. Drug Therapy. QV 38]
RM301.P65 2011
615'.1dc22
2011008453

Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the
authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information
in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the
publication. Application of the information in a particular situation remains the professional responsibility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in
accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in
government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check
the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly
important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in
restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned
for use in their clinical practice.

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10 9 8 7 6 5 4 3 2 1
To Armen H. Tashjian, Jr. (19322009)
Friend, mentor, colleague
The pharmacologists pharmacologist
Your spirit lives on within us
and within this textbook
The Editors
 Contents
Foreword ................................................................................... ix Section IIB
Preface ..................................................................................... xi Principles of Autonomic and Peripheral
Nervous System Pharmacology 109
Preface to the First Edition .........................................................xiii
Acknowledgments..................................................................... xv 9 Cholinergic Pharmacology ..............................................110
Alireza Atri, Michael S. Chang, and Gary R. Strichartz
Contributors.............................................................................xvii
10 Adrenergic Pharmacology ..............................................132
Brian B. Hoffman and Freddie M. Williams
Section I
Fundamental Principles of Pharmacology 1 11 Local Anesthetic Pharmacology ......................................147
Joshua M. Schulman and Gary R. Strichartz
1 Drug-Receptor Interactions ................................................2
Zachary S. Morris and David E. Golan Section IIC
2 Pharmacodynamics..........................................................17 Principles of Central Nervous System Pharmacology 163
Quentin J. Baca and David E. Golan
12 Pharmacology of GABAergic and Glutamatergic
3 Pharmacokinetics ............................................................27 Neurotransmission .........................................................164
Quentin J. Baca and David E. Golan Stuart A. Forman, Janet Chou, Gary R. Strichartz,
4 Drug Metabolism..............................................................43 and Eng H. Lo
Cullen Taniguchi and F. Peter Guengerich 13 Pharmacology of Dopaminergic Neurotransmission ........186
5 Drug Toxicity ....................................................................56 David G. Standaert and Ryan R. Walsh
Michael W. Conner, Catherine Dorian-Conner, 14 Pharmacology of Serotonergic and Central Adrenergic
Laura C. Green, Sarah R. Armstrong, Cullen Taniguchi, Neurotransmission .........................................................207
Armen H. Tashjian, Jr., and David E. Golan Miles Berger and Bryan Roth
6 Pharmacogenomics .........................................................71 15 Pharmacology of Abnormal Electrical
Liewei Wang and Richard M. Weinshilboum Neurotransmission in the Central Nervous System .........225
Susannah B. Cornes, Edmund A. Griffin, Jr.,
Section II and Daniel H. Lowenstein
Principles of Neuropharmacology 80
16 General Anesthetic Pharmacology ..................................240
Jacob Wouden and Keith W. Miller
Section IIA 17 Pharmacology of Analgesia ............................................264
Fundamental Principles of Neuropharmacology 81 Robert S. Griffin and Clifford J. Woolf
7 Principles of Cellular Excitability and Electrochemical 18 Pharmacology of Drugs of Abuse ....................................284
Transmission....................................................................82 Peter R. Martin, Sachin Patel, and Robert M. Swift
Lauren K. Buhl, John Dekker, and Gary R. Strichartz
8 Principles of Nervous System Physiology Section III
and Pharmacology ...........................................................93 Principles of Cardiovascular Pharmacology 310
Joshua M. Galanter, Susannah B. Cornes, 19 Pharmacology of Cholesterol and
and Daniel H. Lowenstein Lipoprotein Metabolism ..................................................311
David E. Cohen and Ehrin J. Armstrong
20 Pharmacology of Volume Regulation...............................332
Mallar Bhattacharya and Seth L. Alper

vii
viii Contents
21 Pharmacology of Vascular Tone ......................................353
Deborah Yeh Chong and Thomas Michel
22 Pharmacology of Hemostasis and Thrombosis ................372
April W. Armstrong and David E. Golan
23 Pharmacology of Cardiac Rhythm...................................401
Ehrin J. Armstrong, April W. Armstrong, and David E. Clapham
24 Pharmacology of Cardiac Contractility ............................422
Ehrin J. Armstrong and Thomas P. Rocco
25 Integrative Cardiovascular Pharmacology:
Hypertension, Ischemic Heart Disease,
and Heart Failure............................................................437
Ehrin J. Armstrong, April W. Armstrong,
and Thomas P. Rocco
Section IV
Principles of Endocrine Pharmacology 464
26 Pharmacology of the Hypothalamus
and Pituitary Gland .........................................................465
Anand Vaidya and Ursula B. Kaiser
27 Pharmacology of the Thyroid Gland ................................480
Ehrin J. Armstrong, Armen H. Tashjian, Jr.,
and William W. Chin
28 Pharmacology of the Adrenal Cortex ...............................489
Rajesh Garg and Gail K. Adler
29 Pharmacology of Reproduction .......................................505
Ehrin J. Armstrong and Robert L. Barbieri
30 Pharmacology of the Endocrine Pancreas and
Glucose Homeostasis .....................................................524
Aimee D. Shu and Steven E. Shoelson
31 Pharmacology of Bone Mineral Homeostasis ..................541
Robert M. Neer, Ehrin J. Armstrong,
and Armen H. Tashjian, Jr.
Section V
Principles of Chemotherapy 562
32 Principles of Antimicrobial and Antineoplastic
Pharmacology ................................................................563
Quentin J. Baca, Donald M. Coen, and David E. Golan
33 Pharmacology of Bacterial Infections: DNA Replication,
Transcription, and Translation .........................................581
Marvin Ryou and Donald M. Coen
34 Pharmacology of Bacterial and Mycobacterial
Infections: Cell Wall Synthesis ........................................599
Tania Lupoli, David C. Hooper, Ramy A. Arnaout,
Daniel Kahne, and Suzanne Walker
35 Pharmacology of Fungal Infections .................................618
Ali Alikhan, Charles R. Taylor, and April W. Armstrong
36 Pharmacology of Parasitic Infections ..............................629
Louise C. Ivers and Edward T. Ryan
37 Pharmacology of Viral Infections.....................................649
Robert W. Yeh and Donald M. Coen
38 Pharmacology of Cancer: Genome Synthesis,
Stability, and Maintenance .............................................674
David A. Barbie and David A. Frank
39 Pharmacology of Cancer: Signal Transduction ................699
David A. Barbie and David A. Frank
40 Principles of Combination Chemotherapy .......................716
Quentin J. Baca, Donald M. Coen, and David E. Golan
Section VI
Principles of Inflammation and Immune Pharmacology 728
41 Principles of Inflammation and the Immune System .......729
Ehrin J. Armstrong and Lloyd B. Klickstein
42 Pharmacology of Eicosanoids .........................................740
David M. Dudzinski and Charles N. Serhan
43 Histamine Pharmacology................................................765
Cindy Chambers, Joseph C. Kvedar,
and April W. Armstrong
44 Pharmacology of Hematopoiesis
and Immunomodulation .................................................776
Andrew J. Wagner, Ramy A. Arnaout,
and George D. Demetri
45 Pharmacology of Immunosuppression ............................790
April W. Armstrong, Ehrin J. Armstrong, and Lloyd B. Klickstein
46 Integrative Inflammation Pharmacology:
Peptic Ulcer Disease..........................................................807
Dalia S. Nagel and Helen M. Shields
47 Integrative Inflammation Pharmacology: Asthma ............820
Joshua M. Galanter and Stephen Lazarus
48 Integrative Inflammation Pharmacology: Gout.................837
Ehrin J. Armstrong and Lloyd B. Klickstein
Section VII
Fundamentals of Drug Development and Regulation 846
49 Drug Discovery and Preclinical Development ..................847
John L. Vahle, David L. Hutto, Daniel M. Scott,
and Armen H. Tashjian, Jr.
50 Clinical Drug Evaluation and Regulatory Approval ...........860
Mark A. Goldberg, Alexander E. Kuta, and John L. Vahle
51 Systematic Detection of Adverse Drug Events.................872
Jerry Avorn
Section VIII
Environmental Toxicology 880
52 Environmental Toxicology ...............................................881
Laura C. Green, Sarah R. Armstrong, Joshua M. Galanter,
and Armen H. Tashjian, Jr.
Section IX
Frontiers in Pharmacology 894
53 Protein Therapeutics ......................................................895
Quentin J. Baca, Benjamin Leader, and David E. Golan
54 Drug Delivery Modalities ................................................917
Joshua D. Moss and Robert S. Langer
Credit List...............................................................................924
Index ......................................................................................928

In such a night,
Medea gatherd the enchanted herbs
That did renew old Aeson.
William Shakespeare
The Merchant of Venice (Act 5; Scene 1)
The human need for medicines to alleviate suffering, cure
disease, and even delay aging is both timeless and personal.
Indeed, the critical goal of personalized medicine is to address
this need for each individual. Identifying the right drug for the
right patient at the right dose and time promises to revolution-
ize the treatment of disease while also improving drug safety.
Pharmacologythe scientific discipline that seeks to describe
the actions of drugs on living systemshas begun to provide
us with answers to these age-old questions.
My own career as a medical researcher and teacher at
Harvard Medical School and as a leader of a drug discovery
group in a pharmaceutical company has focused on the fun-
damental role that pharmacology plays in all fields of medi-
cine. The study of pharmacology is essential to understand
not only the mechanisms of action of drugs that treat dis-
eases, but also important properties of drugs that may vary
from individual to individual. Such properties include varia-
tions in drug absorption, tissue distribution, metabolism and
excretion, as well as the synergistic, antagonistic, and other
interactions that may occur when drugs are administered in
combinations (as is increasingly the case).
This third edition of Principles of Pharmacology: The
Pathophysiologic Basis of Drug Therapy refreshes substan-
tively the previous editions, which have already drawn justi-
fiable acclaim. Born from the needs of students of medicine
and other health care professions, and created by the inspi-
ration and collaborative efforts of students and faculty at
Harvard Medical School, this textbook serves the purpose
Foreword
well. The chapters are all clearly organized and written, with
many major updates and revisions. Of note, there are new
sections in the third edition on pharmacogenomics and pro-
tein therapeutics. In total, the textbook embodies a seam-
less and clear exposition of the principles of pharmacology.
The books emphasis on pharmacologic, physiologic, and
pathophysiologic mechanisms makes this text indispens-
able for students, practicing scientists, and health care pro-
fessionals. The chapters add practical texture to the didactic
material by providing clinical case studies relevant to the
physiologic and pathophysiologic system under discussion,
and the illustrations and tables are clear and displayed in
multiple brilliant hues.
It is with considerable sadness that I note the recent pass-
ing of Armen H. Tashjian, Jr., MD, one of the original authors
and editors of Principles of Pharmacology: The Pathophysi-
ologic Basis of Drug Therapy. Armens legacy of care, en-
thusiasm, and critical thought, all brought to serve the needs
of students and teachers, is established in these volumes. He
will be missed.
This contribution by Dr. Golan and colleagues will un-
doubtedly provide future generations of teachers and students
a strong foundation for the therapeutic practice of medicine
and allied fields. In this sense, Principles of Pharmacology:
The Pathophysiologic Basis of Drug Therapy will contribute
to the care of countless patients both now and in the future.
William W. Chin, MD
Bertarelli Professor in Translational
Medical Science
Executive Dean for Research
Harvard Medical School
Professor of Medicine
Brigham and Womens Hospital
Boston, Massachusetts
ix

The editors are grateful for many helpful suggestions from
readers of the first and second editions of Principles of Phar-
macology: The Pathophysiologic Basis of Drug Therapy.
The third edition features many changes to reflect the rapidly
evolving nature of pharmacology and drug development. We
believe that these updates will continue to contribute to the
learning and teaching of pharmacology both nationally and
internationally:
Creation of full-color figures throughout the textbook
about 450 in all. Every figure has been updated and color-
ized and over 50 figures are new or substantially modified
to highlight advances in our understanding of physiologic,
pathophysiologic, and pharmacologic mechanisms. As in
the first two editions, our collaboration with a single illus-
trator creates a uniform look and feel among the figures
that facilitates understanding and helps the reader make
connections across broad areas of pharmacology.
Addition of new pedagogical elements to enhance learn-
ing, including icons placed within the text to indicate an-
swers to the introductory case questions in each chapter.
Reorganization of chapters in the fundamentals of phar-
macology. Along with drug-receptor interactions, phar-
macodynamics, pharmacokinetics, drug metabolism, and
drug toxicity, pharmacogenomics is now discussed in
the first section of the textbook to complete a conceptual
framework for the fundamental principles of pharmacol-
ogy that serve as the foundation for material in all subse-
quent chapters.
Comprehensive update of all 37 drug summary tables.
These tables, which have been particularly popular with
readers, group drugs and drug classes according to mech-
anism of action and list clinical applications, serious and
common adverse effects, contraindications, and therapeu-
tic considerations for each drug discussed in the chapter.
Comprehensive update of all chapters, including new
drugs approved through 2010. We have focused espe-
cially on newly discovered and revised mechanisms that
sharpen our understanding of the physiology, pathophysi-
ology, and pharmacology of the relevant system. Sections
Preface
throughout the book contain substantial amounts of new
and updated material, especially the chapters on drug
toxicity, pharmacogenomics, adrenergic pharmacology,
the pharmacology of analgesia, the pharmacology of ad-
diction, the pharmacology of the endocrine pancreas, the
pharmacology of bone mineral metabolism, the pharma-
cology of bacterial and mycobacterial cell wall synthesis,
the pharmacology of eicosanoids, the pharmacology of
immunosuppression, the fundamentals of drug develop-
ment and regulation, and protein therapeutics.
As with the second edition, we have recruited a panel of
new, expert chapter authors who have added tremendous
strength and depth to the existing panel of authors, and the
editorial team has reviewed each chapter in detail to achieve
uniformity of style, presentation, and currency across the
entire text.
We note with great sadness the passing of Armen H.
Tashjian, Jr., MD, the most senior author and editor of the
first and second editions of this text. Armens career was
long and distinguished, with research and teaching accom-
plishments and recognition across the spectrum of pharma-
cology, toxicology, endocrinology, and cell biology. His
laboratory made a great many contributions to our funda-
mental understanding of pituitary hormone regulation and
calcium homeostasis. Of equal importance was his guid-
ance and mentorship of two generations of scientists and
physicians. Armen brought to our shared enterprise a love
of science and medicine, an encyclopedic knowledge base,
a voracious appetite for the literature, an infectious enthu-
siasm for drug discovery, a keen appreciation for analytic
rigor, a prodigious work ethic, and a genuine warmth and
excitement for people. His spirit lives on in the hearts and
memories of his family, friends, students, and colleagues
and in this and future editions of this textbook.
David E. Golan, MD, PhD
Ehrin J. Armstrong, MD, MSc
April W. Armstrong, MD, MPH
xi

This book represents a new approach to the teaching
of a first or second year medical school pharmacology
course. The book, titled Principles of Pharmacology: The
Pathophysiologic Basis of Drug Therapy, departs from stan-
dard pharmacology textbooks in several ways. Principles
of Pharmacology provides an understanding of drug ac-
tion in the framework of human physiology, biochemistry,
and pathophysiology. Each section of the book presents the
pharmacology of a particular physiologic or biochemical
system, such as the cardiovascular system or the inflam-
mation cascade. Chapters within each section present the
pharmacology of a particular aspect of that system, such as
vascular tone or eicosanoids. Each chapter presents a clini-
cal vignette, illustrating the relevance of the system under
consideration; then discusses the biochemistry, physiology,
and pathophysiology of the system; and, finally, presents the
drugs and drug classes that activate or inhibit the system by
interacting with specific molecular and cellular targets. In
this scheme, the therapeutic and adverse actions of drugs are
understood in the framework of the drugs mechanism of ac-
tion. The physiology, biochemistry, and pathophysiology are
illustrated using clear and concise figures, and the pharma-
cology is depicted by displaying the targets in the system
on which various drugs and drug classes act. Material from
the clinical vignette is referenced at appropriate points in the
discussion of the system. Contemporary directions in mo-
lecular and human pharmacology are introduced in chapters
on modern methods of drug discovery and drug delivery and
in a chapter on pharmacogenomics.
This approach has several advantages. We anticipate that
students will use the text not only to learn pharmacology, but
Preface
to the First Edition
also to review essential aspects of physiology, biochemistry,
and pathophysiology. Students will learn pharmacology in a
conceptual framework that fosters mechanism-based learn-
ing rather than rote memorization, and that allows for ready
incorporation of new drugs and drug classes into the stu-
dents fund of knowledge. Finally, students will learn phar-
macology in a format that integrates the actions of drugs
from the level of an individual molecular target to the level
of the human patient.
The writing and editing of this textbook have employed
a close collaboration among Harvard Medical School stu-
dents and faculty in all aspects of book production, from
studentfaculty co-authorship of individual chapters to
studentfaculty editing of the final manuscript. In all,
43 HMS students and 39 HMS faculty have collaborated
on the writing of the books 52 chapters. This development
plan has blended the enthusiasm and perspective of student
authors with the experience and expertise of faculty authors
to provide a comprehensive and consistent presentation of
modern, mechanism-based pharmacology.
David E. Golan, MD, PhD
Armen H. Tashjian, Jr., MD
Ehrin J. Armstrong, MD, MSc
Joshua M. Galanter, MD
April W. Armstrong, MD, MPH
Ramy A. Arnaout, MD, DPhil
Harris S. Rose, MD
FOUNDING EDITORS
xiii
 Acknowledgments
The editors are grateful for the support of students and fac-
ulty from around the world who have provided encourage-
ment and helpful suggestions.
Stuart Ferguson continued his exemplary work as an
executive assistant by managing all aspects of project co-
ordination, including submission of chapter manuscripts,
multiple layers of editorial revisions, coordination of figure
generation and revision, and delivery of the final manuscript.
We are extraordinarily grateful for his unwavering dedica-
tion to this project.
Rob Duckwall did a superb job to create the full-color fig-
ures. Robs standardization and coloration of the figures in
this textbook reflect his creativity and expertise as a leading
medical illustrator. His artwork is a major asset and highlight
of this textbook.
Liz Allison provided constant support and guidance with
all aspects of this project. Her timely and insightful advice
was vital to the successful completion of this edition.
Quentin Baca and Sylvan Baca electronically rendered
the striking images on the cover and inside front cover of
this textbook. We are most grateful for their creativity and
expertise.
The editors would like to thank profusely the publication,
editorial, and production staff at LWW. Susan Rhyner pro-
vided leadership in the development and execution of this
new edition. Keith Donnellan was a highly effective project
manager; with good humor, attention to detail, and tremen-
dous organization, he kept a complicated text and art pro-
gram running smoothly. Stacey Sebring and Kelley Squazzo
expertly managed the production of this handsome volume.
David Golan would like to thank the many faculty, stu-
dent, and administrative colleagues whose support and un-
derstanding were critical for the successful completion of
this project. Members of the Golan laboratory and faculty
and staff in the Department of Biological Chemistry and
Molecular Pharmacology at Harvard Medical School and
in the Hematology Division at Brigham and Womens Hos-
pital and the Dana-Farber Cancer Institute were gracious
and supportive throughout. Deans Jeffrey Flier and Richard
Mills were especially supportive and encouraging. Laura,
Liza, and Sarah provided valuable insights at many critical
stages of this project and were constant sources of support
and love.
Ehrin Armstrong would like to thank April for making
life meaningful and fun. He is also grateful to the cardiol-
ogy divisions at the University of California, San Francisco
and Davis for providing research time during fellowship to
complete this edition.
April Armstrong would like to thank Ehrin for being her
best friend and bringing her joy every day. April is grateful
for unwavering support and mentorship from Dr. Fu-Tong
Liu, whose dedication to research and exemplary work ethic
are a source of inspiration. She also thanks her sister Amy,
mom Susan, and grandma Chen Xiao Chun for their affec-
tion and support.
Credit lines identifying the original source of a figure
or table borrowed or adopted from copyrighted material,
and acknowledging the use of noncopyrighted material, are
gathered together in a list at the end of the book. We thank
all of these sources for permission to use this material.
xv

Gail K. Adler, MD, PhD
Associate Professor of Medicine
Harvard Medical School
Associate Physician
Division of Endocrinology, Diabetes
and Hypertension
Department of Medicine
Brigham and Womens Hospital
Boston, Massachusetts
Ali Alikhan, MD
Resident, Department of
Dermatology
Mayo Clinic
Rochester, Minnesota
Seth L. Alper, MD, PhD
Professor of Medicine
Harvard Medical School
Renal Division and Molecular and
Vascular Medicine Division
Department of Medicine
Beth Israel Deaconess Medical Center
Boston, Massachusetts
April W. Armstrong, MD, MPH
Assistant Professor of Dermatology
Director, Dermatology Clinical
Research Unit
Director, Teledermatology Program
University of California Davis Health
System
Davis, California
Ehrin J. Armstrong, MD, MSc
Clinical Fellow in Cardiology
University of California,
San Francisco
San Francisco, California
Sarah R. Armstrong, MS, DABT
Senior Scientist
Cambridge Environmental, Inc.
Cambridge, Massachusetts
Contributors
Ramy A. Arnaout, MD, DPhil
Instructor in Pathology
Harvard Medical School
Associate Director, Clinical
Microbiology
Department of Pathology
Beth Israel Deaconess Medical
Center
Boston, Massachusetts
Alireza Atri, MD, PhD
Clinical Instructor in Neurology
Harvard Medical School
Assistant in Neurology
Massachusetts General Hospital
Boston, Massachusetts
Deputy Director
Geriatric Research, Education and
Clinical Center
Bedford, Massachusetts
Jerry Avorn, MD
Professor of Medicine
Harvard Medical School
Chief, Division of
Pharmacoepidemiology
Brigham and Womens Hospital
Boston, Massachusetts
Quentin J. Baca, PhD
MD Candidate, Harvard-MIT
MD-PhD Program
Department of Biological Chemistry
and Molecular Pharmacology
Harvard Medical School
Boston, Massachusetts
David A. Barbie, MD
Assistant Professor of Medicine
Harvard Medical School
Associate Physician
Department of Medical Oncology
Dana-Farber Cancer Institute
Boston, Massachusetts
Robert L. Barbieri, MD
Kate Macy Ladd Professor of
Obstetrics, Gynecology and
Reproductive Biology
Department of Obstetrics, Gynecology
and Reproductive Biology
Harvard Medical School
Chairman, Department of Obstetrics
and Gynecology
Brigham and Womens Hospital
Boston, Massachusetts
Miles Berger, MD, PhD
Resident, Department of Anesthesiology
Duke University Medical Center
Durham, North Carolina
Mallar Bhattacharya, MD, MSc
Clinical Instructor of Medicine
University of California, San Francisco
San Francisco, California
Lauren K. Buhl, MB
PhD Candidate
Department of Brain and Cognitive
Sciences
Massachusetts Institute of Technology
Cambridge, Massachusetts
MD Candidate
Division of Health Sciences and
Technology
Harvard Medical School
Boston, Massachusetts
Cindy Chambers, MAS, MPH
MD Candidate
University of California, Davis
Sacramento, California
Michael S. Chang, MD
Fellowship Director
Adult and Pediatric Spine Surgery
Sonoran Spine Center
Phoenix, Arizona
xvii
xviii Contributors
Lily Cheng, BS
Co-author for Drug Summary Tables
MD Candidate
University of California, Davis
Sacramento, California
William W. Chin, MD
Bertarelli Professor in Translational
Medical Science
Executive Dean for Research
Harvard Medical School
Professor of Medicine
Brigham and Womens Hospital
Boston, Massachusetts
Deborah Yeh Chong, MD
Assistant Professor
Department of Ophthalmology
University of Texas Southwestern
Medical School
Dallas, Texas
Janet Chou, MD
Instructor, Department of Pediatrics
Harvard Medical School
Assistant in Medicine
Department of Immunology
Childrens Hospital Boston
Boston, Massachusetts
David E. Clapham, MD, PhD
Aldo R. Castaeda Professor of
Cardiovascular Research
Professor of Neurobiology
Harvard Medical School
Chief, Basic Cardiovascular
Research
Department of Cardiology
Childrens Hospital Boston
Boston, Massachusetts
Donald M. Coen, PhD
Professor of Biological Chemistry and
Molecular Pharmacology
Harvard Medical School
Boston, Massachusetts
David E. Cohen, MD, PhD
Robert H. Ebert Associate Professor of
Medicine and Health Sciences and
Technology
Director, Harvard-Massachusetts
Institute of Technology
Division of Health Sciences and
Technology
Harvard Medical School
Director of Hepatology
Division of Gastroenterology,
Hepatology and Endoscopy
Department of Medicine
Brigham and Womens Hospital
Boston, Massachusetts
Michael W. Conner, DVM
Vice President
Safety Assessment
Theravance, Inc.
South San Francisco, California
Susannah B. Cornes, MD
Assistant Professor, Department of
Neurology
University of California,
San Francisco
Department of Neurology
UCSF Medical Center
San Francisco, California
John P. Dekker, MD, PhD
Resident, Department of Pathology
Massachusetts General Hospital
Boston, Massachusetts
George D. Demetri, MD
Associate Professor of Medicine
Department of Medical Oncology
Harvard Medical School
Director, Ludwig Center at
Dana-Farber/Harvard Cancer
Center
Department of Experimental
Therapeutics and Medical
Oncology
Dana-Farber Cancer Institute
Boston, Massachusetts
Catherine Dorian-Conner,
PharmD, PhD
Consultant in Toxicology
Half Moon Bay, California
David M. Dudzinski, MD, JD
Clinical Fellow in Medicine
Harvard Medical School
Fellow, Department of Cardiology
Massachusetts General Hospital
Boston, Massachusetts
Stuart A. Forman, MD, PhD
Associate Professor of
Anaesthesia
Harvard Medical School
Boston, Massachusetts
David A. Frank, MD, PhD
Associate Professor of Medicine
Harvard Medical School
Associate Professor
Departments of Medicine and
Medical Oncology
Dana-Farber Cancer Institute
Boston, Massachusetts
Joshua M. Galanter, MD
Fellow, Department of Medicine
University of California,
San Francisco
San Francisco, California
Rajesh Garg, MD
Assistant Professor of Medicine
Harvard Medical School
Associate Physician
Division of Endocrinology, Diabetes
and Hypertension
Department of Medicine
Brigham and Womens Hospital
Boston, Massachusetts
David E. Golan, MD, PhD
Professor of Biological Chemistry and
Molecular Pharmacology
Professor of Medicine
Dean for Graduate Education
Special Advisor for Global
Programs
Harvard Medical School
Scholar and Founding Member, The
Academy at Harvard Medical School
Physician, Hematology Division,
Brigham and Womens Hospital
and Dana-Farber Cancer Institute
Department of Biological Chemistry
and Molecular Pharmacology,
Department of Medicine
Harvard Medical School
Boston, Massachusetts
Mark A. Goldberg, MD
Associate Professor of Medicine
Harvard Medical School
Boston, Massachusetts
Senior Vice President
Clinical Development
Genzyme Corporation
Cambridge, Massachusetts
Laura C. Green, PhD, DABT
Senior Scientist and President
Cambridge Environmental, Inc.
Cambridge, Massachusetts
Edmund A. Griffin, Jr
Resident Physician
Department of Psychiatry
Columbia University
New York State Psychiatric Institute
New York, New York
Robert S. Griffin, MD
Resident, Department of Anesthesia,
Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts

F. Peter Guengerich, PhD
Professor, Department of
Biochemistry
Vanderbilt University School of
Medicine
Nashville, Tennessee
Brian B. Hoffman, MD
Professor of Medicine
Harvard Medical School
Physician, Department of Medicine
VA Boston Healthcare System
Boston, Massachusetts
David C. Hooper, MD
Professor of Medicine
Harvard Medical School
Chief, Infection Control Unit
Massachusetts General Hospital
Boston, Massachusetts
David L. Hutto, DVM, PhD, DACVP
Senior Director, Drug Safety
Eisai, Inc.
Andover, Massachusetts
Louise C. Ivers, MD, MPH, DTM&H
Assistant Professor of Medicine
Harvard Medical School
Associate Physician
Department of Medicine
Brigham and Womens Hospital
Boston, Massachusetts
Daniel Kahne, PhD
Professor of Chemistry and Chemical
Biology
Harvard University
Cambridge, Massachusetts
Ursula B. Kaiser, MD
Associate Professor of Medicine
Harvard Medical School
Chief, Division of Endocrinology,
Diabetes and Hypertension
Brigham and Womens Hospital
Boston, Massachusetts
Lloyd B. Klickstein, MD, PhD
Head of Translational Medicine
New Indication Discovery Unit
Novartis Institutes for Biomedical
Research
Cambridge, Massachusetts
Alexander E. Kuta, PhD
Vice President, Regulatory Affairs
AMAG Pharmaceuticals
Lexington, Massachusetts
Joseph C. Kvedar, MD
Associate Professor
Department of Dermatology
Harvard Medical School
Dermatologist
Department of Dermatology
Massachusetts General Hospital
Boston, Massachusetts
Robert S. Langer, ScD
David H. Koch Institute Professor
Departments of Chemical Engineering
and Bioengineering
Massachusetts Institute of Technology
Cambridge, Massachusetts
Senior Research Associate
Childrens Hospital Boston
Boston, Massachusetts
Stephen C. Lazarus, MD
Professor of Medicine
Division of Pulmonary and Critical
Care Medicine
Director, Training Program in
Pulmonary and Critical Care
Medicine
University of California,
San Francisco
San Francisco, California
Benjamin Leader, MD, PhD
Chief Executive Officer
ReproSource
Woburn, Massachusetts
Eng H. Lo, PhD
Professor of Neuroscience
Harvard Medical School
Director, Neuroprotection Research
Laboratory
Departments of Radiology and
Neurology
Massachusetts General Hospital
Boston, Massachusetts
Daniel H. Lowenstein, MD
Professor, Department of Neurology
University of California,
San Francisco
Director, UCSF Epilepsy Center
UCSF Medical Center
San Francisco, California
Tania Lupoli, AM
PhD Candidate
Department of Chemistry and
Chemical Biology
Harvard University
Cambridge, Massachusetts
Contributors xix
Peter R. Martin, MD
Professor, Departments of Psychiatry
and Pharmacology
Vanderbilt University
Director, Division of Addiction
Psychiatry and Vanderbilt
Addiction Center
Vanderbilt University Medical Center
Nashville, Tennessee
Thomas Michel, MD, PhD
Professor of Medicine
(Biochemistry)
Harvard Medical School
Senior Physician in Cardiovascular
Medicine
Department of Medicine
Brigham and Womens Hospital
Boston, Massachusetts
Keith W. Miller, MA, DPhil
Edward Mallinckrodt Professor of
Pharmacology
Department of Anaesthesia
Harvard Medical School
Pharmacologist, Department of
Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, Massachusetts
Zachary S. Morris, PhD
MD Candidate, Harvard-MIT
MD-PhD Program
Department of Pathology
Harvard Medical School
Boston, Massachusetts
Joshua D. Moss, MD
Assistant Professor of Medicine
Heart Rhythm Center
University of Chicago Medical Center
Chicago, Illinois
Dalia S. Nagel, MD
Clinical Instructor, Department of
Ophthalmology
Mount Sinai School of Medicine
Attending Physician
Department of Ophthalmology
Mount Sinai Hospital
New York, New York
Robert M. Neer, MD
Associate Professor of Medicine
Harvard Medical School
Endocrine Unit, Department of
Medicine
Massachusetts General Hospital
Boston, Massachusetts
xx Contributors
Sachin Patel, MD, PhD
Assistant Professor, Departments
of Psychiatry and Molecular
Physiology and Biophysics
Vanderbilt University Medical Center
Nashville, Tennessee
Thomas P. Rocco, MD
Associate Professor of Medicine
Harvard Medical School
Cardiovascular Division, Brigham and
Womens Hospital
Boston, Massachusetts
Cardiology Section, VA Boston
Healthcare System
West Roxbury, Massachusetts
Bryan L. Roth, MD, PhD
Michael Hooker Distinguished
Professor
Department of Pharmacology
University of North Carolina Chapel
Hill Medical School
Chapel Hill, North Carolina
Edward T. Ryan, MD
Associate Professor of Medicine
Harvard Medical School
Associate Professor of Immunology
and Infectious Diseases
Harvard School of Public Health
Director, Tropical Medicine
Massachusetts General Hospital
Boston, Massachusetts
Marvin Ryou, MD
Instructor in Medicine
Harvard Medical School
Advanced Endoscopy /
Gastrointestinal Interventional
Fellow
Division of Gastroenterology
Brigham and Womens Hospital
Gastrointestinal Unit
Massachusetts General Hospital
Boston, Massachusetts
Joshua M. Schulman, MD
Resident, Department of Dermatology
University of California, San Francisco
San Francisco, California
Daniel M. Scott, PhD
Director of Chemistry
Pharmaceutical CMC Management
Biogen Idec, Inc.
Cambridge, Massachusetts
Charles N. Serhan, PhD
Simon Gelman Professor of
Anaesthesia (Biochemistry and
Molecular Pharmacology)
Department of Anesthesiology,
Perioperative and Pain Medicine
Harvard Medical School
Director, Center for Experimental
Therapeutics and Reperfusion
Injury
Brigham and Womens Hospital
Boston, Massachusetts
Helen Marie Shields, MD
Professor of Medicine
Harvard Medical School
Physician, Department of Medicine
Beth Israel Deaconess Medical Center
Boston, Massachusetts
Steven E. Shoelson, MD, PhD
Professor of Medicine
Harvard Medical School
Associate Director of Research,
Section Head, Cellular and
Molecular Physiology
Joslin Diabetes Center
Boston, Massachusetts
Aimee Der-Huey Shu, MD
Assistant Professor, Departments
of Medicine and Obstetrics and
Gynecology
Division of Endocrinology
Columbia University Medical Center
New York, New York
David G. Standaert, MD, PhD
Professor, Department of Neurology
University of Alabama at Birmingham
Director, Division of Movement
Disorders
University Hospital
Birmingham, Alabama
Gary R. Strichartz, PhD
Professor of Biological Chemistry and
Molecular Pharmacology
Harvard Medical School
Vice-Chairman for Research,
Department of Anesthesiology
Brigham and Womens Hospital
Boston, Massachusetts
Robert M. Swift, MD, PhD
Professor of Psychiatry and Human
Behavior
Center for Alcohol and Addiction Studies
Brown University
Associate Chief of Staff for Research
Providence Veterans Administration
Medical Center
Providence, Rhode Island
Cullen Taniguchi, MD, PhD
Resident, Department of Radiation
Oncology
Stanford University
Stanford, California
*Armen H. Tashjian, Jr., MD
Professor of Biological Chemistry and
Molecular Pharmacology, emeritus
Harvard Medical School
Professor of Toxicology, emeritus
Harvard School of Public Health
Department of Genetics and Complex
Diseases
Harvard School of Public Health
Boston, Massachusetts
*deceased
Charles Russell Taylor, MD
Associate Professor of Dermatology
Harvard Medical School
Director of Phototherapy and Staff
Dermatologist
Department of Dermatology
Massachusetts General Hospital
Boston, Massachusetts
John L. Vahle, DVM, PhD, DACVP
Research Fellow, Department of
Toxicology and Pathology
Lilly Research Laboratories
Indianapolis, Indiana
Anand Vaidya, MD
Research Fellow in Medicine
(Endocrinology)
Harvard Medical School
Division of Endocrinology, Diabetes,
and Hypertension
Brigham and Womens Hospital
Boston, Massachusetts
Andrew J. Wagner, MD, PhD
Instructor, Department of Medicine
Harvard Medical School
Medical Oncologist
Center for Sarcoma and Bone Oncology
Dana-Farber Cancer Institute
Boston, Massachusetts
Suzanne Walker, PhD
Professor of Microbiology and
Molecular Genetics
Harvard Medical School
Boston, Massachusetts
Ryan R. Walsh, MD, PhD
Instructor, Department of Neurology
University of Alabama at Birmingham
University of Alabama at Birmingham
Hospital
Birmingham, Alabama

Liewei Wang, MD, PhD
Associate Professor, Department
of Molecular Pharmacology and
Experimental Therapeutics
Mayo Clinic College of Medicine
Rochester, Minnesota
Richard M. Weinshilboum, MD
Professor, Department of Molecular
Pharmacology and Experimental
Therapeutics
Mayo Clinic College of Medicine
Rochester, Minnesota
Freddie M. Williams, MD
Senior Cardiologist
Wellmont CVA Heart Institute
Kingsport, Tennessee
Clifford J. Woolf, MD, BCh, PhD
Professor of Neurology and
Neurobiology
Harvard Medical School
Director, F.M. Kirby Neurobiology
Center
Childrens Hospital Boston
Boston, Massachusetts
Contributors xxi
Jacob Wouden, MD
Radiologist, Washington Hospital
Medical Staff
Washington Hospital Healthcare Group
Fremont, California
Robert W. Yeh, MD, MSc
Instructor in Medicine
Harvard Medical School
Interventional Cardiologist
Department of Medicine
Massachusetts General Hospital
Boston, Massachusetts
LWBK942-FM.qxd 6/25/11 8:45 AM Page x
 I

Fundamental Principles
of Pharmacology
1
DrugReceptor Interactions
Zachary S. Morris and David E. Golan
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-3
CONFORMATION AND CHEMISTRY OF DRUGS
AND RECEPTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Impact of Drug Binding on the Receptor . . . . . . . . . . . . . . . . 4
Membrane Effects on DrugReceptor Interactions . . . . . . . . 5
MOLECULAR AND CELLULAR DETERMINANTS
OF DRUG SELECTIVITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
MAJOR TYPES OF DRUG RECEPTORS . . . . . . . . . . . . . . . . . . . 6
Transmembrane Ion Channels . . . . . . . . . . . . . . . . . . . . . . . 7
Transmembrane G Protein-Coupled Receptors . . . . . . . . . . . 9
Transmembrane Receptors with Enzymatic
Cytosolic Domains . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Receptor Tyrosine Kinases . . . . . . . . . . . . . . . . . . . . . . 11
Receptor Tyrosine Phosphatases . . . . . . . . . . . . . . . . . . 12
 INTRODUCTION
Why is it that one drug affects cardiac function and an-
other alters the transport of specific ions in the kidney?
Why does ciprofloxacin effectively kill bacteria, but rarely
harms a patient? These questions can be answered by first
examining the interaction between a drug and its specific
molecular target and then considering the role of that ac-
tion in a broader physiologic context. This chapter focuses
on the molecular details of drugreceptor interactions,
emphasizing the variety of receptors and their molecular
mechanisms. This discussion provides a conceptual basis
for the action of the many drugs and drug classes dis-
cussed in this book. It also serves as a background for
Chapter 2, Pharmacodynamics, which discusses the quan-
titative relationships between drugreceptor interactions
and pharmacologic effect.
Although drugs can theoretically bind to almost any
three-dimensional target, most drugs achieve their desired
(therapeutic) effects by interacting selectively with tar-
get molecules that play important roles in physiologic or
pathophysiologic functioning. In many cases, selectivity
of drug binding to receptors also determines the undesired
(adverse) effects of a drug. In general, drugs are molecules
that interact with specific molecular components of an
organism to cause biochemical and physiologic changes
within that organism. Drug receptors are macromolecules
2
Tyrosine Kinase-Associated Receptors . . . . . . . . . . . . . 12
Receptor Serine/ Threonine Kinases . . . . . . . . . . . . . . . 12
Receptor Guanylyl Cyclases . . . . . . . . . . . . . . . . . . . . . 12
Intracellular Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Extracellular Enzymes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Cell Surface Adhesion Receptors . . . . . . . . . . . . . . . . . . . . 13
PROCESSING OF SIGNALS RESULTING FROM
DRUGRECEPTOR INTERACTIONS. . . . . . . . . . . . . . . . . . . . . 13
CELLULAR REGULATION OF DRUGRECEPTOR
INTERACTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
DRUGS THAT DO NOT FIT THE DRUGRECEPTOR
MODEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . . 15
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
that, upon binding to a drug, mediate those biochemical
and physiologic changes.
 CONFORMATION AND CHEMISTRY
OF DRUGS AND RECEPTORS
Why does imatinib act specifically on the BCR-Abl receptor
tyrosine kinase and not on other molecules? The answer to
this question, and an understanding of why any drug binds to
a particular receptor, can be found in the structure and chemi-
cal properties of the two molecules. This section discusses the
basic determinants of receptor structure and the chemistry of
drugreceptor binding. The discussion here focuses primar-
ily on the interactions of drugs that are small organic mol-
ecules with target receptors that are mainly macromolecules
(especially proteins), but many of these principles also apply
to the interactions of protein-based therapeutics with their mo-
lecular targets (see Chapter 53, Protein Therapeutics).
Because many human and microbial drug receptors are pro-
teins, it is useful to review the four major levels of protein struc-
ture (Fig. 1-1). At the most basic level, proteins consist of long
chains of amino acids, the sequences of which are determined by
the sequences of the DNA that code for the proteins. A proteins
amino acid sequence is referred to as its primary structure.
Once a long chain of amino acids has been synthesized on a ri-
bosome, many of the amino acids begin to interact with nearby
Primary

Amino acids

Secondary

Beta pleated Alpha helix

sheet

Tertiary

Beta sheet

Alpha helix

Quaternary
A B Glu 286
C
Met 290 Imatinib

Ile 313

Imatinib Phe 382

Ala 269
Gly 383
Asp 381
Asn 368 Activation loop
of kinase
Thr 315

Phe 382 Lys 271

Asp 363

Leu 248 Phe 317

Asp 381 Arg 367 Tyr 393
Tyr 253 Val 256

Met 318
Gly 321

Leu 370
A B C D

GDP
A

Ligand binding sites

O
Receptor gate closed
N+
O
Acetylcholine

Na+

Na+
Receptor gate open
 CHAPTER 1 / DrugReceptor Interactions 9

increase the conductance of chloride ions across neuronal
membranes, thereby driving the membrane potential farther
away from its threshold for activation.
Transmembrane G Protein-Coupled Receptors
G protein-coupled receptors are the most abundant class of
receptors in the human body. These receptors are exposed at
the extracellular surface of the plasma membrane, traverse
the membrane, and possess intracellular regions that activate
a unique class of signaling molecules called G proteins. (G
proteins are so named because they bind the guanine nucle-
otides GTP and GDP.) G protein-coupled signaling mecha-
nisms are involved in many important processes, including
vision, olfaction, and neurotransmission.
G protein-coupled receptors have seven transmembrane
regions within a single polypeptide chain. Each transmem-
brane region consists of a single helix, and the heli-
ces are arranged in a characteristic structural motif that is
similar in all members of this receptor class. The extracel-
lular domain of this class of proteins usually contains the
ligand-binding region, although some G protein-coupled
receptors bind ligands within the transmembrane domain
of the receptor. G proteins have and subunits that are
noncovalently linked in the resting state. Stimulation of a
G protein-coupled receptor causes its cytoplasmic domain
to bind and activate a nearby G protein, whereupon the
subunit of the G protein exchanges GDP for GTP. The -
GTP subunit then dissociates from the subunit, and the
or subunit diffuses along the inner leaflet of the plasma
membrane to interact with a number of different effectors.
These effectors include adenylyl cyclase, phospholipase C,
various ion channels, and other classes of proteins. Signals
mediated by G proteins are usually terminated by the hy-
drolysis of GTP to GDP, which is catalyzed by the inherent
GTPase activity of the subunit (Fig. 1-5).
One major role of the G proteins is to activate the produc-
tion of second messengers; that is, signaling molecules that
convey the input provided by the first messengerusually
an endogenous ligand or an exogenous drugto cytoplas-
mic effectors (Fig. 1-6). The activation of cyclases such
as adenylyl cyclase, which catalyzes the production of the
second messenger cyclic adenosine-3,5-monophosphate
(cAMP), and guanylyl cyclase, which catalyzes the pro-
duction of cyclic guanosine-3,5-monophosphate (cGMP),
constitutes the most common pathway linked to G proteins.
In addition, G proteins can activate the enzyme phospholi-
pase C (PLC), which, among other functions, plays a key
role in regulating the concentration of intracellular calcium.
Upon activation by a G protein, PLC cleaves the mem-
brane phospholipid phosphatidylinositol-4,5-bisphosphate
(PIP2) to the second messengers diacylglycerol (DAG) and
inositol-1,4,5-trisphosphate (IP3). IP3 triggers the release of
Ca2 from intracellular stores, thereby dramatically increas-
ing the cytosolic Ca2 concentration and activating down-
stream molecular and cellular events. DAG activates protein
kinase C, which then mediates other molecular and cellular
events including smooth muscle contraction and transmem-
brane ion transport. All of these events are dynamically regu-
lated, so that the different steps in the pathways are activated
and inactivated with characteristic kinetics.
A large number of G protein isoforms have now been
identified, each of which has unique effects on its targets.
A few of these G proteins include G-stimulatory (Gs), G-
inhibitory (Gi), Gq, Go, and G12/13. Examples of the effects
of these isoforms are shown in Table 1-4. The differential

Receptor
Effector
A

1 Agonist unbinding 1 Agonist binding

2 GTP hydrolysis 2 GTP-GDP exchange

3 Heterotrimeric 3 G protein activation
G protein reconstituted GDP

Agonist
Effector activated GTP

C B

1 -GTP diffusion to effector

2 Effector activation

GTP GTP

GDP

FIGURE 1-5. Receptor-mediated activation of a G protein and the resultant effector interaction. A. In the resting state, the and subunits of a G protein
are associated with one another, and GDP is bound to the subunit. B. Binding of an extracellular ligand (agonist) to a G protein-coupled receptor causes the exchange
of GTP for GDP on the subunit. C. The subunit dissociates from the subunit, which diffuses to interact with effector proteins. Interaction of the GTP-associated
subunit with an effector activates the effector. In some cases (not shown), the subunit can also activate effector proteins. Depending on the receptor subtype and
the specific G isoform, G can also inhibit the activity of an effector molecule. The subunit possesses intrinsic GTPase activity, which leads to hydrolysis of GTP to
GDP. This leads to reassociation of the subunit with the subunit, and the cycle can begin again.
A Agonist
Receptor Adenylyl cyclase

s

GTP
ATP cAMP

PKA

Protein phosphorylation

B
PLC

PIP2 DAG

PKC
(active)
q

GTP PKC
IP3

Ca2+

Ca2+
Protein phosphorylation
 CHAPTER 1 / DrugReceptor Interactions 11

FIGURE 1-7. Major types of transmembrane receptors with enzymatic

cytosolic domains. There are five major categories of transmembrane receptors
A with enzymatic cytosolic domains. A. The largest group is comprised of receptor
tyrosine kinases. After ligand-induced activation, these receptors dimerize and
transphosphorylate tyrosine residues in the receptor and, often, on target cytosolic
proteins. Examples of receptor tyrosine kinases include the insulin receptor and
the BCR-Abl protein. B. Some receptors can act as tyrosine phosphatases. These
Tyr Tyr P Tyr Tyr P receptors dephosphorylate tyrosine residues either on other transmembrane re-
ceptors or on cytosolic proteins. Many cells of the immune system have receptor
tyrosine phosphatases. C. Some tyrosine kinase-associated receptors lack a de-
Tyrosine kinase Cytoplasmic finitive enzymatic domain, but binding of ligand to the receptor triggers activation
activity protein
Tyr
of receptor-associated protein kinases (termed nonreceptor tyrosine kinases)
P Tyr
that then phosphorylate tyrosine residues on certain cytosolic proteins. D. Receptor
serine/threonine kinases phosphorylate serine and threonine residues on certain
target cytosolic proteins. Members of the TGF- superfamily of receptors are in
B
this category. E. Receptor guanylyl cyclases contain a cytosolic domain that cata-
lyzes the formation of cGMP from GTP. The receptor for B-type natriuretic peptide is
one of the receptor guanylyl cyclases that has been well characterized.

play roles in a diverse set of physiologic processes, includ-

ing cell metabolism, growth, and differentiation. Recep-
Tyrosine phosphatase
activity
tors that have an intracellular enzymatic domain can be
P Tyr Tyr grouped into five major classes based on their cytoplasmic
mechanism of action (Fig. 1-7). All of these receptors are
C
singlemembrane-spanning proteins, in contrast to the seven
membrane-spanning motif present in G protein-coupled re-
ceptors. Many receptors with enzymatic cytosolic domains
form dimers or multisubunit complexes to transduce their
signals.
Activated kinase
Many of the receptors with enzymatic cytosolic domains
Inactive modify proteins by adding or removing phosphate groups to
kinase Tyrosine kinase
activity or from specific amino acid residues. Phosphorylation is a
Tyr P Tyr
ubiquitous mechanism of protein signaling. The large nega-
tive charge of phosphate groups can dramatically alter the
three-dimensional structure of a protein and thereby change
that proteins activity. In addition, phosphorylation is eas-
D ily reversible, thus allowing this signaling mechanism to act
specifically in time and space.

Receptor Tyrosine Kinases

The largest group of transmembrane receptors with enzy-
Ser/Thr P Ser/Thr matic cytosolic domains is the receptor tyrosine kinase fam-
ily. These receptors transduce signals from many hormones
Serine/threonine and growth factors by phosphorylating tyrosine residues on
kinase activity the cytoplasmic tail of the receptor. This leads to recruitment
Ser/Thr P Ser/Thr and subsequent tyrosine phosphorylation of a number of cy-
tosolic signaling molecules.
E The insulin receptor is a well-characterized receptor ty-
rosine kinase. This receptor consists of two extracellular
subunits that are covalently linked to two membrane-spanning
subunits. Binding of insulin to the subunits results in a
change in conformation of the adjacent subunits, causing
the subunits to move closer to one another on the intracel-
lular side of the membrane. The proximity of the two sub-
Guanylyl cyclase units promotes a transphosphorylation reaction, in which one
activity
GTP cGMP subunit phosphorylates the other (autophosphorylation).
The phosphorylated tyrosine residues then act to recruit other
cytosolic proteins, known as insulin receptor substrate (IRS)
proteins. Type 2 diabetes mellitus may, in some cases, be as-
sociated with defects in post-insulin receptor signaling; thus,
understanding the insulin receptor signaling pathways is rel-
evant for the potential design of rational therapeutics. The
mechanism of insulin receptor signaling is discussed in more

Steroid hormone
Hormone
receptor
A Chaperone
Nucleus
B processes such as vasoconstriction and neurotransmission.
DNA
C Chapter 20). Another example is acetylcholinesterase,
FIGURE 1-8. Lipophilic molecule binding to an intracellular transcription
factor. A. Small lipophilic molecules can diffuse through the plasma membrane and
bind to intracellular transcription factors. In this example, steroid hormone binding to
a cytosolic hormone receptor is shown, although some receptors of this class may be
located in the nucleus before ligand binding. B. Ligand binding triggers a conforma-
tional change in the receptor (and often, as shown here, dissociation of a chaperone
repressor protein) that leads to transport of the ligandreceptor complex into the
nucleus. In the nucleus, the ligandreceptor complex typically dimerizes. In the ex-
ample shown, the active form of the receptor is a homodimer (two identical receptors
binding to one another), but heterodimers (such as the thyroid hormone receptor and
the retinoid X receptor) may also form. C. The dimerized ligandreceptor complex
binds to DNA and may then recruit coactivators or corepressors (not shown). These
complexes alter the rate of gene transcription, leading to a change (either up or down)
in cellular protein expression.
the intracellular or extracellular concentrations of specific
gene products, drugs that target transcription factors can
have a profound effect on cellular function. The cellular
responses to such drugs, and the effects that result from
this cellular response in tissues and organ systems, provide
links between the molecular drugreceptor interaction and
the effects of the drug on the organism as a whole. Because
gene transcription is a relatively slow (minutes to hours)
and long-lasting process, drugs that target transcription
factors often require a longer period of time for the onset
of action to take place, and have longer-lasting effects,
than do drugs that alter more transient processes such as
ion conduction (seconds to minutes).
Structural proteins are another important class of
cytosolic drug targets. For example, the antimitotic vinca
alkaloids bind to tubulin monomers and prevent the po-
lymerization of this molecule into microtubules. This
inhibition of microtubule formation arrests the affected
cells in metaphase, making the vinca alkaloids useful an-
tineoplastic drugs. Other drugs bind directly to RNA or
ribosomes; such drugs are important agents in antimicro-
bial and antineoplastic chemotherapy. With the continued
development of RNA interference (RNAi) therapeutics,
such targets may become increasingly prominent. RNAi
technology could someday enable physicians to routinely
CHAPTER 1 / DrugReceptor Interactions 13
modify the expression levels of specific gene transcripts,
although technical challenges in delivering such therapeu-
tics to their targets currently limit their utility to special-
ized applications.
Extracellular Enzymes
Many important drug receptors are enzymes with active
sites located outside the plasma membrane. The extra-
cellular environment consists of a milieu of proteins and
signaling molecules. Many of these proteins serve a struc-
tural role, and others are used to communicate information
between cells. Enzymes that modify the molecules me-
diating these important signals can influence physiologic
One example of this class of receptor is the angiotensin
converting enzyme (ACE), which converts angiotensin I
to the potent vasoconstrictor angiotensin II. ACE inhibi-
tors are drugs that inhibit this enzymatic conversion and
thereby lower blood pressure (among other effects; see
which degrades acetylcholine after this neurotransmitter is
released from cholinergic neurons. Acetylcholinesterase
inhibitors enhance neurotransmission at cholinergic syn-
apses by preventing neurotransmitter degradation at these
sites (see Chapter 9, Cholinergic Pharmacology).
Cell Surface Adhesion Receptors
Cells often interact directly with other cells to perform spe-
cific functions or to communicate information. The forma-
tion of tissues and the migration of immune cells to a site
of inflammation are examples of physiologic processes that
require cellcell adhesive interactions. A region of contact
between two cells is termed an adhesion, and cellcell ad-
hesive interactions are mediated by pairs of adhesion recep-
tors on the surfaces of the individual cells. In many cases,
several such receptorcounter-receptor pairs combine to
secure a firm adhesion, and intracellular regulators control
the activity of the adhesion receptors by changing their af-
finity or by controlling their expression and localization on
the cell surface. Several adhesion receptors involved in the
inflammatory response are attractive targets for selective in-
hibitors. Inhibitors of a specific class of adhesion receptors,
known as integrins, have entered the clinic in recent years,
and these drugs are being studied in the treatment of a range
of conditions including coagulation, inflammation, multiple
sclerosis, and cancer (see Chapter 45).
 PROCESSING OF SIGNALS RESULTING
FROM DRUGRECEPTOR INTERACTIONS
Many cells in the body are continuously bombarded with
multiple inputs, some stimulatory and some inhibitory.
How do cells integrate these signals to produce a coherent
response? G proteins and other second messengers appear
to provide important points of integration. As noted above,
relatively few second messengers have been identified, and
it is unlikely that many more remain to be discovered. Thus,
second messengers are an attractive candidate mechanism
for providing cells with a set of common points upon which
numerous outside stimuli could converge to generate a coor-
dinated cellular effect (Fig. 1-9).
14 Fundamental Principles of Pharmacology

Ligand 1 Adenylyl cyclase Ligand 2

Receptor Receptor

s s s i i i

GDP GTP GTP GTP GTP GDP
ATP cAMP cAMP ATP

Net result = integrated effect

FIGURE 1-9. Signaling convergence of two receptors. A limited number of mechanisms are used to transduce intracellular signal cascades. In some cases, this
allows for convergence, where two different receptors have opposite effects that tend to negate one another in the cell. In a simple example, two different G protein-cou-
pled receptors could be stimulated by different ligands. The receptor shown on the left is coupled to Gs, a G protein that stimulates adenylyl cyclase to catalyze the for-
mation of cAMP. The receptor shown on the right is coupled to Gi, a G protein that inhibits adenylyl cyclase. When both of these receptors are activated simultaneously,
they can attenuate or even neutralize each other, as shown. Sometimes, signaling through a pathway may alternate as the two receptors are sequentially activated.

Ion concentrations provide another point of integration for
cellular effects because the cellular concentration of a partic-
ular ion is the result of the integrated activity of multiple ionic
currents that both increase and decrease the concentration of
the ion within the cell. For example, the contractile state of a
smooth muscle cell is a function of the intracellular calcium
ion concentration, which is determined by several different
Ca2 conductances. These conductances include calcium ion
leaks into the cell and calcium currents into and out of the
cytoplasm through specialized channels in the plasma mem-
brane and smooth endoplasmic reticulum.
Because the magnitude of cellular response is often con-
siderably greater than the magnitude of the stimulus that
caused the response, cells appear to have the ability to am-
plify the effects of receptor binding. G proteins provide an
excellent example of signal amplification. Ligand binding to
a G protein-coupled receptor activates a single G protein mol-
ecule. This G protein molecule can then bind to and activate
many effector molecules, such as adenylyl cyclase, which
can then generate an even greater number of second messen-
ger molecules (in this example, cAMP). Another example
of signal amplification is trigger Ca2, in which a small
influx of Ca2 through voltage-gated Ca2 channels in the
plasma membrane triggers the release of larger amounts of
Ca2 into the cytoplasm from intracellular stores.
 CELLULAR REGULATION OF
DRUGRECEPTOR INTERACTIONS
Drug-induced activation or inhibition of a receptor often has
a lasting impact on the receptors subsequent responsiveness
to drug binding. Mechanisms that mediate such effects are
important because they prevent overstimulation that could
lead to cellular damage or adversely affect the organism as
a whole. Many drugs show diminishing effects over time;
this phenomenon is called tachyphylaxis. In pharmacologic
terms, the receptor and the cell become desensitized to the
action of the drug. Mechanisms of desensitization can be di-
vided into two types: homologous, in which the effects of
agonists at only one type of receptor are diminished; and
heterologous, in which the effects of agonists at two or
more types of receptors are coordinately diminished. Het-
erologous desensitization is thought to be caused by drug-
induced alteration in a common point of convergence in the
mechanisms of action of the involved receptors, such as a
shared effector molecule.
Many receptors exhibit desensitization. For example, the
cellular response to repeated stimulation of -adrenergic
receptors by epinephrine diminishes steadily over time
(Fig. 1-10). -Adrenergic receptor desensitization is medi-
ated by epinephrine-induced phosphorylation of the cyto-
plasmic tail of the receptor. This phosphorylation promotes
the binding of -arrestin to the receptor; in turn, -arrestin
inhibits the receptors ability to stimulate the G protein Gs.
With lower levels of activated Gs present, adenylyl cyclase
produces less cAMP. In this manner, repeated cycles of
ligandreceptor binding result in smaller and smaller cel-
lular effects. Other molecular mechanisms have even more
profound effects, completely turning off the receptor to
stimulation by ligand. The latter phenomenon, referred to
as inactivation, may also result from phosphorylation of
the receptor; in this case, the phosphorylation completely
blocks the signaling activity of the receptor or causes
removal of the receptor from the cell surface.
Another mechanism that can affect the cellular response
caused by drugreceptor binding is called refractoriness.
Receptors that assume a refractory state following acti-
vation require a period of time to pass before they can be
stimulated again. As noted above, voltage-gated sodium
channels, which mediate the firing of neuronal action po-
tentials, are subject to refractory periods. After channel
opening induced by membrane depolarization, the voltage-
gated sodium channel spontaneously closes and cannot be
reopened for some period of time (called the refractory
period). This inherent property of the channel determines
the maximum rate at which neurons can be stimulated and
transmit information.
The effect of drugreceptor binding can also be influ-
enced by drug-induced changes in the number of receptors
on or in a cell. One example of a molecular mechanism
by which receptor number can be altered is called down-
 P
A Phosphorylation by P
-arrestin
P P

PKA and/or ARK

P
P P
P binding
-arrestin

Agonist
G protein binding
prevented

B Sequestration

C Degradation

Endosome

Lysosome
16 Fundamental Principles of Pharmacology
mechanisms of action described in this chapter serve as
paradigms for the principles of pharmacodynamics. The
ability to classify drugs based on their mechanisms of ac-
tion makes it possible to simplify the study of pharma-
cology, because the molecular mechanism of action of a
drug can usually be linked to its cellular, tissue, organ,
and system levels of action. In turn, it becomes easier
to understand how a given drug mediates its therapeutic
effects and its unwanted or adverse effects in a particu-
lar patient. The major aim of modern drug development
is to identify drugs that are highly selective by tailoring
drug molecules to unique targets responsible for disease.
As knowledge of drug development and the genetic and
pathophysiologic basis of disease progresses, physicians
and scientists will learn to combine the molecular spec-
ificity of a drug with the genetic and pathophysiologic
specificity of the drug target to provide more and more
selective therapies.
Acknowledgment
We thank Christopher W. Cairo and Josef B. Simon for their
valuable contributions to this chapter in the First and Second
Editions of Principles of Pharmacology: The Pathophysi-
ologic Basis of Drug Therapy.
Suggested Reading
Alexander SP, Mathie A, Peters JA. Guide to receptors and channels. 3rd ed.
Br J Pharmacol 2008;153(Suppl 2):S1S209. (Brief overview of molecular
targets for drugs, organized by types of receptors.)
Berg JM, Tymoczko JL, Stryer L. Biochemistry. 6th ed. New York: WH
Freeman and Company; 2006. (Contains structural information on recep-
tors, especially G proteins.)
Lagerstom MC, Schloth HB. Structural diversity of G protein-coupled recep-
tors and significance for drug discovery. Nat Rev Drug Discov 2008;7:339
357. (Discusses the five families of G protein-coupled receptors, with an eye
toward future drug development.)
Pratt WB, Taylor P, eds. Principles of drug action: the basis of pharmacol-
ogy. 3rd ed. New York: Churchill Livingstone; 1990. (Contains a detailed
discussion of drugreceptor interactions.)
Whitehead KA, Langer R, Anderson DG. Knocking down barriers: ad-
vances in siRNA delivery. Nat Rev Drug Discov 2009;8:129138. (High-
lights early successes and remaining challenges in the development of RNAi
therapeutics.)
Zhang J, Yang PL, Gray NS. Targeting cancer with small molecule ki-
nase inhibitors. Nat Rev Cancer 2009;9:2839. (Discusses the dysregu-
lation of protein kinases in cancer and the targeting of these molecules
by drugs such as imatinib.)

Pharmacodynamics
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . . . 17-18
DRUGRECEPTOR BINDING . . . . . . . . . . . . . . . . . . . . . . . . . . 17
DOSERESPONSE RELATIONSHIPS . . . . . . . . . . . . . . . . . . . . 18
Graded DoseResponse Relationships . . . . . . . . . . . . . . . . 19
Quantal DoseResponse Relationships . . . . . . . . . . . . . . . 19
DRUGRECEPTOR INTERACTIONS. . . . . . . . . . . . . . . . . . . . . 20
Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Competitive Receptor Antagonists . . . . . . . . . . . . . . . . . 21
 INTRODUCTION
Pharmacodynamics is the term used to describe the effects
of a drug on the body. These effects are typically described
in quantitative terms. The previous chapter considered the
molecular interactions by which pharmacologic agents exert
their effects. The integration of these molecular actions into
an effect on the organism as a whole is the subject addressed
in this chapter. It is important to describe the effects of a drug
quantitatively in order to determine appropriate dose ranges
for patients, as well as to compare the potency, efficacy, and
safety of one drug to that of another.
 DRUGRECEPTOR BINDING
The study of pharmacodynamics is based on the concept of
drugreceptor binding. When either a drug or an endogenous
ligand (such as a hormone or neurotransmitter) binds to its
receptor, a response may result from that binding interaction.
When a sufficient number of receptors are bound (or occu-
pied) on or in a cell, the cumulative effect of receptor oc-
cupancy may become apparent in that cell. At some point,
all of the receptors may be occupied, and a maximal response
may be observed (an exception is the case of spare receptors;
see below). When the response occurs in many cells, the ef-
fect can be seen at the level of the organ or even the patient.
But this all starts with the binding of drug or ligand to a re-
ceptor (for the purpose of discussion, drug and ligand equation. First, as ligand concentration is increased, the con-
will be used interchangeably for the remainder of this chap-
ter). A model that accurately describes the binding of drug to
receptor would therefore be useful in predicting the effect of
the drug at the molecular, cellular, tissue (organ), and organ-
ism (patient) levels. This section describes one such model.
2
Quentin J. Baca and David E. Golan
Noncompetitive Receptor Antagonists . . . . . . . . . . . . . . 22
Nonreceptor Antagonists . . . . . . . . . . . . . . . . . . . . . . . . 23
Partial Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Inverse Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Spare Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
CONCEPTS IN THERAPEUTICS . . . . . . . . . . . . . . . . . . . . . . . . 25
Therapeutic Index and Therapeutic Window . . . . . . . . . . . . 25
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . . 26
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Consider the simplest case, in which the receptor is either
free (unoccupied) or reversibly bound to drug (occupied).
We can describe this case as follows:
kon
L  R
LR Equation 2-1
koff
where L is ligand (drug), R is free receptor, and LR is bound
drugreceptor complex. At equilibrium, the fraction of re-
ceptors in each state is dependent on the dissociation con-
stant, Kd, where Kd koff /kon. Kd is an intrinsic property of
any given drugreceptor pair. Although Kd varies with tem-
perature, the temperature of the human body is relatively
constant, and it can therefore be assumed that Kd is a con-
stant for each drugreceptor combination.
According to the law of mass action, the relationship
between free and bound receptor can be described as
follows:
[L][R] [L][R]
Kd  , rearranged to [LR]  Equation 2-2
[LR] Kd
where [L] is free ligand concentration, [R] is free receptor
concentration, and [LR] is ligandreceptor complex concen-
tration. Because Kd is a constant, some important properties
of the drugreceptor interaction can be deduced from this
centration of bound receptors increases. Second, and not so
obvious, is that as free receptor concentration is increased
(as may happen, for example, in disease states or upon re-
peated exposure to a drug), bound receptor concentration
also increases. Therefore, an increase in the effect of a drug
17
 [L][R]
[Ro]  [R]  [LR]  [R] 
Kd

 [R] 1 
[L]
Equation 2-3
Kd

[Ro] [L]
[LR]  , rearranged to
[L]  Kd
[LR] [L] response [DR] [D]
 Equation 2-4   Equation 2-5
[Ro] [L]  Kd max response [Ro] [D]  Kd
A Linear

1.0
Drug A

Drug B
[LR]
0.5
[Ro]

0
KdA KdB
[L]

B Semilogarithmic

1.0

Drug A
A Linear
Drug B
[LR] 1.0
0.5
[Ro] Drug A

Drug B
E
0.5
0 EMAX
KdA KdB
[L]

0
EC50(A) EC50(B)
[L]

B Semilogarithmic

1.0

Drug A

Drug B
E
0.5
EMAX

0
EC50(A) EC50(B)
[L]
Cumulative % exhibiting
Therapeutic effect Toxic effect Lethal effect

100
% Individuals responding

% Requiring dose to achieve

Therapeutic Toxic effect Lethal effect
effect
50

ED50 TD50 LD50

Dose

DR
D  R*
Equation 2-6
DR DR*

DR
DR** Equation 2-7

kon k
DR DR DR* Equation 2-8

koff k
Potency Efficacy
 CHAPTER 2 / Pharmacodynamics 21

Antagonists

Receptor Nonreceptor
antagonists antagonists

Active site Allosteric

binding binding

Reversible Irreversible Reversible Irreversible

Competitive Noncompetitive Noncompetitive Chemical Physiologic

antagonist active site allosteric antagonist antagonist
antagonist antagonist

FIGURE 2-4. Antagonist classification. Antagonists can be categorized based on whether they bind to a site on the receptor for agonist (receptor antagonists) or
interrupt agonistreceptor signaling by other means (nonreceptor antagonists). Receptor antagonists can bind either to the agonist (active) site or to an allosteric site on
the receptor; in either case, they do not affect basal receptor activity (i.e., the activity of the receptor in the absence of agonist). Agonist (active) site receptor antagonists
prevent the agonist from binding to the receptor. If the antagonist competes with the ligand for agonist site binding, it is termed a competitive antagonist; high concentra-
tions of agonist are able to overcome competitive antagonism. Noncompetitive agonist site antagonists bind covalently or with very high affinity to the agonist site, so that
even high concentrations of agonist are unable to activate the receptor. Allosteric receptor antagonists bind to the receptor at a site other than the agonist site. They do not
compete directly with agonist for receptor binding, but rather alter the Kd for agonist binding or inhibit the receptor from responding to agonist binding. High concentrations
of agonist are generally unable to reverse the effect of an allosteric antagonist. Nonreceptor antagonists fall into two categories. Chemical antagonists sequester agonist
and thus prevent the agonist from interacting with the receptor. Physiologic antagonists induce a physiologic response opposite to that of an agonist, but by a molecular
mechanism that does not involve the receptor for agonist.

Antagonists an agonist to initiate a response. At the molecular level, this

inhibition can occur by inhibiting the agonist directly (e.g.,
An antagonist is a molecule that inhibits the action of an agonist
using antibodies), by inhibiting a downstream molecule in
but has no effect in the absence of the agonist. Figure 2-4 shows
the activation pathway, or by activating a pathway that op-
one approach to classifying the various types of antagonists.
poses the action of the agonist. Nonreceptor antagonists can
Antagonists can be divided into receptor and nonreceptor an-
be divided into chemical antagonists and physiologic antag-
tagonists. A receptor antagonist binds to either the active site
onists. Chemical antagonists inactivate an agonist before it
(agonist binding site) or an allosteric site on a receptor. Binding
has the opportunity to act (e.g., by chemical neutralization);
of an antagonist to the active site prevents the binding of the
physiologic antagonists cause a physiologic effect opposite
agonist to the receptor, whereas binding of an antagonist to an
to that induced by the agonist.
allosteric site either alters the Kd for agonist binding or prevents
The following section discusses competitive receptor an-
the conformational change required for receptor activation.
tagonists and noncompetitive receptor antagonists. Nonre-
Receptor antagonists can also be divided into reversible and
ceptor antagonists are also examined briefly.
irreversible antagonists; that is, antagonists that bind to their
receptors reversibly and those that bind irreversibly. Figure 2-5 Competitive Receptor Antagonists
illustrates the general effects of these antagonist types on ago- A competitive antagonist binds reversibly to the active site
nist binding; more detail is provided in the following sections. of a receptor. Unlike an agonist, which also binds to the ac-
A nonreceptor antagonist does not bind to the same re- tive site of the receptor, a competitive antagonist does not
ceptor as an agonist, but it nonetheless inhibits the ability of stabilize the conformation required for receptor activation.

Agonist
Agonist Agonist
Agonist Allosteric Competitive
binding site antagonist antagonist
binding site Noncompetitive
A B C D antagonist

Unbound receptor Agonist binding Competitive antagonist Noncompetitive antagonist

binding binding

FIGURE 2-5. Types of receptor antagonists. A schematic illustrating the differences between agonist (active) site and allosteric antagonists. A. The unbound
inactive receptor. B. The receptor activated by agonist. Note the conformational change induced in the receptor by agonist binding, for example, the opening of a
transmembrane ion channel. C. Agonist site antagonists bind to the receptors agonist site but do not activate the receptor; these agents block agonist binding to
the receptor. D. Allosteric antagonists bind to an allosteric site (different from the agonist site) and thereby prevent receptor activation, even when the agonist is
bound to the receptor.
AR
A  D  R DR* Equation 2-9

[DR] [D]
 Equation 2-10
[D]  Kd 1 
[Ro] [A]
KA

A Competitive antagonist

100
Agonist alone
% Response

Agonist + Antagonist
50

Antagonist alone
0

B Noncompetitive antagonist

100
Agonist alone
% Response

Agonist + Antagonist
50

Antagonist alone
0

Agonist or antagonist concentration

 CHAPTER 2 / Pharmacodynamics 23

for receptor binding, effectively reducing the receptors affinity

for an agonist without limiting the number of available recep- A
tors. In contrast, a noncompetitive antagonist removes func-
100
tional receptors from the system, thereby limiting the number
of available receptors. Figures 2-6A and 2-6B compare the ef-
fects of competitive and noncompetitive antagonists on the Butyl
agonist doseresponse relationship. Hexyl
Heptyl
Aspirin is one example of a noncompetitive antagonist.

% Contraction
This agent irreversibly acetylates cyclo-oxygenase, the en-
zyme responsible for generating thromboxane A2 in plate-
50
lets. In the absence of thromboxane A2 generation, platelet
Octyl
aggregation is inhibited. Because the inhibition is irrevers-
ible and platelets are not capable of synthesizing new cyclo-
oxygenase molecules, the effects of a single dose of aspirin
last for 7 to 10 days (the time required for the bone mar-
row to generate new platelets), even though the free drug is
cleared from the body much more rapidly.
0
10-7 10-6 10-5 10-4 10-3
Nonreceptor Antagonists
Nonreceptor antagonists can be divided into chemical antag- [D] (Molar)
B
onists and physiologic antagonists. A chemical antagonist
inactivates the agonist of interest by modifying or seques-
100
tering it, so that the agonist is no longer capable of bind-
ing to and activating the receptor. Protamine is an example Morphine
of a chemical antagonist; this basic protein binds stoichio-
% Analgesia
metrically to the acidic heparin class of anticoagulants and
thereby inactivates these agents (see Chapter 22, Pharma-
50
cology of Hemostasis and Thrombosis). Because of this Buprenorphine
chemical antagonism, protamine can be used to terminate
the effects of heparin rapidly.
A physiologic antagonist most commonly activates or
blocks a receptor that mediates a response physiologically 0
opposite to that of the receptor for the agonist. For example, 0.01 0.1 ED50(B) ED50(M) 10
in the treatment of hyperthyroidism, -adrenergic antago-
nists are used as physiologic antagonists to counteract the [D] (mg/kg)
tachycardic effect of endogenous thyroid hormone. Although
thyroid hormone does not produce its tachycardic effect via
-adrenergic stimulation, blocking -adrenergic stimulation FIGURE 2-7. Full and partial agonist doseresponse curves. There are
can nonetheless relieve the tachycardia caused by hyper- many instances in which drugs that all act at the agonist site on the same recep-
thyroidism (see Chapter 10, Adrenergic Pharmacology, and tor produce different maximal effects. A. Various alkyl derivatives of trimethylam-
monium all stimulate muscarinic acetylcholine (ACh) receptors to cause muscle
Chapter 27, Pharmacology of the Thyroid Gland).
contraction in the gut, but they produce different maximal responses, even when
all receptors are occupied. In this example, the butyl and hexyl trimethylammo-
Partial Agonists nium derivatives are full agonistsalthough they have different potencies, they
are both capable of eliciting a maximal response. Agonists that produce only a
A partial agonist is a molecule that binds to a receptor at its partial response, such as the heptyl and octyl derivatives, are called partial ago-
active site but produces only a partial response, even when nists. Note that the doseresponse curves of these partial agonists plateau at
all of the receptors are occupied (bound) by the agonist. Fig- values less than those of full agonists. ACh acts as a full agonist in this system
ure 2-7A shows a family of doseresponse curves for several (not shown). B. Partial agonists may be more or less potent than full agonists.
full and partial agonists. Each agonist acts by binding to the In this case, buprenorphine (ED50 0.3 mg/kg) is more potent than morphine
same site on the muscarinic acetylcholine (ACh) receptor. (ED50 1.0 mg/kg), although it cannot achieve the same maximal response as
Note that butyl trimethylammonium (TMA) is not only more the full agonist. Buprenorphine is used clinically in the treatment of opioid addic-
potent than longer-chain derivatives at stimulating muscle tion, where it is desirable to use a partial agonist that is less efficacious than an
addicting opioid such as heroin or morphine. Low concentrations of the partial
contraction, but also more efficacious than some of the de-
agonist buprenorphine bind tightly to the opioid receptor and competitively inhibit
rivatives (e.g., the heptyl and octyl forms) at producing a the binding of the more efficacious opioids. Very high doses of buprenorphine
greater maximal response. For this reason, butyl TMA is show a paradoxically diminished analgesic effect that may be due to lower-affinity
a full agonist at the muscarinic ACh receptor, whereas the interactions of the drug with nonmu-opioid receptors (not shown).
octyl derivative is a partial agonist at this receptor.
Because partial agonists and full agonists bind to the same
site on a receptor, a partial agonist can reduce the response
produced by a full agonist. In this way, the partial agonist
can act as a competitive antagonist. For this reason, partial
agonists are sometimes called partial antagonists or even
mixed agonist-antagonists.
24 Fundamental Principles of Pharmacology
It is interesting to consider how an agonist could produce a
less-than-maximal response if a receptor can exist in only the
active or the inactive state. This is an area of current inves-
tigation, for which several hypotheses have been proposed.
Recall that Equation 2-6 was simplified to Equation 2-7 based
on the assumption that R and DR* are much more stable than
R* and DR. But what would happen if a drug (call it a partial
agonist) could stabilize DR as well as DR*? In that case, addi-
tion of the partial agonist would result in stabilization of some
receptors in the DR form and some receptors in the DR* form.
At full receptor occupancy, some receptors would be in the
active state and some in the inactive state, and the efficacy of
the drug would be reduced compared to that of a full agonist
(which stabilizes only DR*). In this formulation, a full agonist
binds preferentially to the active state of the receptor, a partial
agonist binds with comparable affinity to both the active and
inactive states of the receptor, and an inverse agonist binds
preferentially to the inactive state of the receptor (see below).
A second hypothesis for the action of partial agonists is
that a receptor may have multiple DR* conformations, each
with a different intrinsic activity. Depending on the particular
conformations of the receptor that are bound by the agonist,
a fraction of the maximum possible effect may be observed
even when a partial agonist is bound to 100% of the receptors.
This may be the case with the so-called selective estrogen
receptor modulators (SERMs) such as raloxifene and ta-
moxifen (see Chapter 29, Pharmacology of Reproduction).
Raloxifene acts as a partial agonist at estrogen receptors in
bone and an antagonist at estrogen receptors in breast. The
crystal structure of raloxifene bound to the estrogen recep-
tor, when compared to that of estrogen bound to the estrogen
receptor, reveals that the side chain of raloxifene inhibits an
helix of the estrogen receptor from aligning in the active
site (see Figure 29-8). This may result in inhibition of some
downstream effects of the estrogen receptor, while maintain-
ing other effects. At a physiologic level, this would be ob-
served as partial agonist activity in bone (see Figure 29-7).
A recent study of partial agonists acting on ligand-gated ion
channels has suggested a third model, in which the receptor
requires a priming conformational change that must occur
before activation of the receptor is possible. In this model, al-
though a partial agonist may bind to the receptor with high
affinity, it is less efficient than a full agonist at inducing the
primed conformation of the receptor. Because this primed Recall that the initial discussion of drugreceptor binding as-
conformation is a prerequisite for activation of the receptor,
the receptor will spend less time in the open conformation, and
a partial agonist will have lower efficacy than a full agonist.
The relative potency of full agonists and partial agonists may
be clinically relevant (Figure 2-7B). A partial agonist with high
affinity for its receptor (such as buprenorphine) may be more
potent but less efficacious than a full agonist with lower affinity
for the same receptor (such as morphine). This characteristic
is leveraged clinically when the partial agonist buprenorphine
is used to treat opioid addiction. Buprenorphine, with its high
affinity for the mu-opioid receptor, can be administered to out-
compete other opioids taken by a patient and can therefore help
to prevent relapse of opioid addiction. Buprenorphine must be
carefully administered to a patient who is currently addicted to
full-agonist opioids such as heroin or morphine, because it can
out-compete these opioids and cause withdrawal symptoms.
Another example of a partial agonist is pindolol, a drug
often classified as a -adrenergic antagonist (see Chapter 10).
In actuality, however, pindolol demonstrates partial agonist
properties, and this drug may be of clinical value because of the
intermediate response that it produces. Although resting heart
rate and blood pressure are not reduced as much by pindolol as
by other pure -adrenergic antagonists, pindolol does inhibit the
potentially dangerous heart rate and blood pressure increases
that would otherwise occur with sympathetic stimulation (e.g.,
with exercise) in patients with cardiovascular disease.
Inverse Agonists
The action of inverse agonists can be understood by consid-
ering Equation 2-6 again. As noted above, in some cases,
receptors can have inherent stability in the R* state. In
these cases, there is intrinsic activity (tone) of the recep-
tor system, even in the absence of an endogenous ligand or
an exogenously administered agonist. An inverse agonist
acts by abrogating this intrinsic (constitutive) activity of
the free (unoccupied) receptor. Inverse agonists may func-
tion by binding to and stabilizing the receptor in the DR
(inactive) form. This has the effect of deactivating recep-
tors that had existed in the R* form in the absence of drug.
The physiologic importance of receptors that have inherent
stability in the R* state is currently under investigation;
receptors with mutations that render them constitutively
active may become attractive targets for inverse agonist
approaches.
Consider the similarities and differences between the ac-
tions of inverse agonists and competitive antagonists. Both
types of drug act to reduce the activity of a receptor. In the
presence of a full agonist, both competitive antagonists and
inverse agonists act to reduce agonist potency. Recall, how-
ever, that a competitive antagonist has no effect in the ab-
sence of an agonist, whereas an inverse agonist deactivates
receptors that are constitutively active in the absence of an
agonist. Using Equations 2-6 through 2-9 as models, these
concepts can be summarized by stating that full agonists sta-
bilize DR*, partial agonists stabilize both DR and DR* (or
alternate forms of DR* or primed forms of DR), inverse
agonists stabilize DR, and competitive antagonists stabi-
lize R (or AR) by preventing full, partial, and inverse ago-
nists from binding to the receptor.
Spare Receptors
sumed that 100% receptor occupancy is required for an agonist
to exert its maximal effect. Now, consider the possibility that a
maximal response could be achieved with less than 100% recep-
tor occupancy. Figure 2-8 shows an example of a drugreceptor
binding curve and a doseresponse curve that illustrate this
situation. In this example, a maximal effect is achieved at a
lower dose of agonist than that required for receptor satura-
tion, that is, the EC50 is less than the Kd for this system. This
type of discrepancy between the drugreceptor binding curve
and the doseresponse curve signifies the presence of spare
receptors. At least two molecular mechanisms are thought to
be responsible for the spare receptor phenomenon. First, the
receptor could remain activated after the agonist departs, al-
lowing one agonist molecule to activate several receptors. Sec-
ond, the cell signaling pathways described in Chapter 1 could
allow for significant amplification of a relatively small signal,
and activation of only a few receptors could be sufficient to
produce a maximal response. The latter is true, for example,
with many G protein-coupled receptors; activation of a single
A Drug-receptor binding curve
1.0

[DR]
[Ro] 0.5

0
Kd

B Dose-response curve
1.0

TD50
E
Therapeutic Index (TI)  Equation 2-11
0.5 ED50
EMAX

0
EC50 Kd

[D]

1.0
Agonist only

E
0.5
EMAX

Agonist + increasing
noncompetitive antagonist

0
[D]

Pharmacokinetics
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . . . 27-28
PHYSIOLOGIC BARRIERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Biological Membranes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Traversing the Membrane . . . . . . . . . . . . . . . . . . . . . . . 28
Membrane Diffusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Central Nervous System. . . . . . . . . . . . . . . . . . . . . . . . . . . 29
ABSORPTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Administration Routes and Rationale . . . . . . . . . . . . . . . . . 30
Enteral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Parenteral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Mucous Membrane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Transdermal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Local, Regional, and Systemic Factors
Affecting Absorption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
DISTRIBUTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Volume of Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Plasma Protein Binding . . . . . . . . . . . . . . . . . . . . . . . . . 33
 INTRODUCTION
Even the most promising of pharmacologic therapies will
fail in clinical trials if the drug is unable to reach its target
organ at a concentration sufficient to have a therapeutic ef-
fect. Many of the characteristics that render the human body
resistant to harm by foreign invaders and toxic substances
also limit the ability of modern drugs to combat pathologic
processes within a patient. An appreciation of the many fac-
tors that affect a drugs ability to act within a patient and the
dynamic nature of these factors over time is vitally impor-
tant to the clinical practice of medicine.
All drugs must meet certain minimal requirements to
achieve clinical effectiveness. A successful drug must be
able to cross the physiologic barriers that limit the access of
foreign substances to the body. Drug absorption may occur
by a number of mechanisms that are designed either to ex-
ploit or to breach these barriers. After absorption, the drug
uses distribution systems within the body, such as the blood
and lymphatic vessels, to reach its target organ in an appro-
priate concentration. The drugs ability to access its target is
also limited by several processes within the patient. These
processes fall broadly into two categories: metabolism, in
which the body inactivates the drug through enzymatic deg-
radation (primarily in the liver), and excretion, in which the
3
Quentin J. Baca and David E. Golan
Modeling the Kinetics and Thermodynamics of
Drug Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
METABOLISM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Oxidation/Reduction Reactions. . . . . . . . . . . . . . . . . . . . . . 34
Conjugation/Hydrolysis Reactions . . . . . . . . . . . . . . . . . . . 34
EXCRETION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Renal Excretion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Biliary Excretion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
CLINICAL APPLICATIONS OF PHARMACOKINETICS . . . . . . . 37
Clearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Metabolism and Excretion Kinetics . . . . . . . . . . . . . . . . 37
Half-Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Factors Altering Half-Life. . . . . . . . . . . . . . . . . . . . . . . . 38
Therapeutic Dosing and Frequency . . . . . . . . . . . . . . . . . . 39
Loading Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Maintenance Dose . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . . 42
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
drug is eliminated from the body (primarily by the kidneys
and liver, and in the feces). This chapter presents a broad
overview of the pharmacokinetic processes of absorption,
distribution, metabolism, and excretion (often abbreviated
as ADME; Fig. 3-1), with a conceptual emphasis on basic
principles that, when applied to an unfamiliar situation,
should enable the student or physician to understand the
pharmacokinetic basis of drug therapy.
 PHYSIOLOGIC BARRIERS
A drug must overcome physical, chemical, and biological
barriers to reach its molecular and cellular sites of action.
The epithelial lining of the gastrointestinal tract and other
mucous membranes is one sort of barrier; additional barriers
are encountered after the drug enters the blood and lymphat-
ics. Most drugs must distribute from the blood into local tis-
sues, a process that may be impeded by structures such as
the bloodbrain barrier. Typically, drugs leave the intravas-
cular compartment at the level of the postcapillary venules,
where there are gaps between the endothelial cells through
which the drug can pass. Drug distribution occurs mainly
through passive diffusion, the rate of which is affected by
local ionic and cellular conditions. This section describes
the major physical, chemical, and biological barriers to drug
27
 Receptors Tissue
Free Bound reservoirs
Free Bound

Systemic
circulation

Absorption Free drug Excretion

Metabolites
(active and
Protein-bound
inactive)
drug

Metabolism

(C2  C1)  (Area  Permeability)

Flux  Equation 3-1
Thicknessmembrane

factors such as ionic, pH, and charge gradients across the
membrane. In vivo, however, these additional factors affect
the ability of a drug to enter cells. For example, a higher
concentration of drug outside the cell would ordinarily favor
net drug entry into the cell, but if both the cell interior and
the drug are negatively charged, then net drug entry into the
cell may be impeded. In contrast, a negatively charged cell
interior could favor entry of a positively charged drug.
Net diffusion of acidic and basic drugs across lipid bilayer
membranes may also be affected by a charge-based phenom-
enon known as pH trapping, which depends on the drugs
acid dissociation constant (pKa) and the pH gradient across
the membrane. For weakly acidic drugs, such as phenobarbi-
tal and aspirin, the protonated, electrically neutral, form of the
drug is predominant in the highly acidic environment of the
stomach. The uncharged form of the drug can pass through
the lipid bilayers of the gastric mucosa, speeding the drugs
absorption (Fig. 3-2). The weakly acidic drug is then effec-
tively trapped as it is deprotonated to its electrically charged
form in the more basic environment of the plasma.
In quantitative terms, the pKa of a drug represents the pH
value at which one-half of the drug is present in its ionic
form. The HendersonHasselbalch Equation describes the
relationship between the pKa of an acidic or basic drug A
and the pH of the biological medium containing the drug:
[HA]
pKa  pH  logg Equation 3-2
[A]
where HA is the protonated form of drug A. For example,
consider the hypothetical case of a weakly acidic drug with
[1,000] [1]
HA A- + H+
Stomach pH~1
Gastric Mucosal Barrier
Plasma pH~7
HA A- + H+
[1,000] [1,000,000]
FIGURE 3-2. pH trapping across lipid bilayers. In the example shown, con-
sider a hypothetical drug with pKa 4. Although this drug is a weak acid, in the
highly acidic environment of the stomach, it is largely protonated. If the stomach
pH is approximately 1, then for every 1,001 molecules of drug, 1,000 molecules
are protonated (and neutral) and only 1 is deprotonated (and negatively charged).
The protonated, neutral form of the drug is able to diffuse across the gastric mu-
cosal barrier into the blood. Because the blood plasma has a pH of approximately
7 (it is actually 7.4), and the drug has a pKa of 4, the vast majority of drug now
exists in the deprotonated (negatively charged) form: for every 1,001 molecules
of drug, only 1 molecule is protonated (and neutral), while 1,000 molecules are
deprotonated (and negatively charged). The negatively charged form of the drug
is no longer able to diffuse across the lipid bilayers of the gastric mucosa, and the
drug is effectively trapped in the plasma.
CHAPTER 3 / Pharmacokinetics 29
a pKa of 4. In the stomach, which has a pH of approximately
1, Equation 3-2 becomes:
[HA]
pKadrug  pHstomach  log ,
[A]
which simplifies to:
[HA]
3  log ,
[A]
and finally:
[HA]
1,000  .
[A]
The protonated form of the drug is present at 1,000 times
the concentration of the deprotonated form, and 99.9% of
the drug is in the neutral form. Conversely, in the plasma,
where the pH is approximately 7.4, more than 99.9% of the
drug is in the deprotonated form (see Fig. 3-2).
Central Nervous System
The central nervous system (CNS) presents special chal-
lenges to pharmacologic therapy. Unlike most other anatomic
regions, the CNS is particularly well insulated from foreign
substances. The bloodbrain barrier uses specialized tight
junctions to prevent the passive diffusion of most drugs from
the systemic to the cerebral circulation. Therefore, drugs de-
signed to act in the CNS must either be sufficiently small and
hydrophobic to traverse biological membranes easily or use
existing transport proteins in the bloodbrain barrier to pen-
etrate central structures. Hydrophilic drugs that fail to target
facilitated or active transport proteins in the bloodbrain bar-
rier cannot penetrate the CNS. The bloodbrain barrier can
be bypassed using intrathecal drug infusion, in which drugs
are delivered directly into the cerebrospinal fluid (CSF). Al-
though this approach can be used to treat infectious or carci-
nomatous meningitis, the intrathecal route is impractical for
drugs that must be taken regularly by a patient.
 ABSORPTION
The human body presents formidable obstacles to inva-
sion by micro-organisms. The integument has a keratinized
outer layer and defensins in the epithelium. Mucous mem-
branes are protected by mucociliary clearance in the trachea,
lysozyme secretion from lacrimal ducts, acid in the stomach,
and base in the duodenum. These nonspecific defense mech-
anisms present barriers to drug absorption and may limit the
drugs bioavailability at target organs. Bioavailability, or the
fraction of administered drug that reaches the systemic cir-
culation, may depend on the route by which the drug is ad-
ministered, the chemical form of the drug, and a number of
patient-specific factors, such as gastrointestinal and hepatic
transporters and enzymes.
Bioavailability is defined quantitatively as:
Quantity of drug
reaching systemic
circulation
Bioavailability  Equation 3-3
Quantity of drug
administered
 Oral, subcutaneous,
Plasma drug concentration

Intravenous or intramuscular:
100% bioavailability

Oral, subcutaneous,
or intramuscular:
50% bioavailability

Time
 Plasma drug concentration

Time
 CHAPTER 3 / Pharmacokinetics 33

accounted for in designing dosing regimens that achieve

therapeutic drug levels. A Site of
pharmacologic
action
Volume of Distribution Vascular space
The volume of distribution (Vd) describes the extent to which
a drug partitions between the plasma and tissue compart-
ments. In quantitative terms, Vd represents the fluid volume
that would be required to contain the total amount of absorbed
drug in the body at a concentration equivalent to that in the
plasma at steady state:
Clearing
Dose organ
Vd  Equation 3-4
[Drug]plasma

The volume of distribution is an extrapolated volume

based on the concentration of drug in the plasma, not a
physical volume. Thus, Vd is low for drugs that are retained
primarily within the vascular compartment and high for
drugs that are highly distributed into muscle, adipose, and
other nonvascular compartments. For very highly distributed
drugs, the volume of distribution is often much greater than
the volume of total body water, reflecting the low concen-
tration of drug in the vascular compartment at steady state.
A number of drugs have very large volumes of distribution;
examples include amiodarone (4,620 liters [L] for a 70-kg
person), azithromycin (2,170 L), chloroquine (9,240 L), and
digoxin (645 L), among others.
The capacity of the blood and the various organs and
tissues to take up and retain a drug depends on both the
volume (mass) of the tissue and the density of specific and
nonspecific binding sites for the drug within that tissue.
A drug that is taken up in large quantities by tissues such as
adipose and muscle will be largely removed from the circu-
lation at steady state. In many cases, these tissues must be
saturated before plasma levels of such drugs can increase
sufficiently to affect the drugs target organ. Thus, for drugs
of equal potency, a drug that is more highly distributed
among body tissues generally requires a higher initial dose
to establish a therapeutic plasma concentration than does a
drug that is less highly distributed.
Plasma Protein Binding
The capacity of muscle and adipose tissue to bind a drug
increases the tendency of the drug to diffuse from the blood
into nonvascular compartments, but this tendency can be
counteracted to some extent by plasma protein binding of the
drug. Albumin is the most abundant plasma protein (4 g/dL)
and is the protein responsible for most drug binding. Many
drugs bind with low affinity to albumin through both hydro-
phobic and electrostatic forces. Plasma protein binding tends
to reduce the availability of a drug for diffusion or transport
into the drugs target organ because, in general, only the free
or unbound form of the drug is capable of diffusion across
membranes (Fig. 3-5). Plasma protein binding may also re-
duce the transport of drugs into nonvascular compartments
such as adipose tissue and muscle. Because a highly protein-
bound drug tends to remain within the vasculature, such a
drug often has a relatively low volume of distribution (typi-
cally, 7 to 8 L for a 70-kg person).
Theoretically, plasma protein binding could be important
as a mechanism for some drugdrug interactions. Coadminis-
tration of two or more drugs that bind to plasma protein could
B
Site of
pharmacologic
action
Vascular space
Clearing
organ
Drug A bound
Drug A to albumin
Albumin
Drug B bound
Drug B to albumin
FIGURE 3-5. Protein binding and drug trapping. A drug that is bound to albu-
min or other plasma proteins cannot diffuse from the vascular space into surround-
ing tissues. A. Drugs that do not bind plasma proteins appreciably (shown here as
Drug A) diffuse readily into tissues. This results in both a high level of binding to
the site of pharmacologic action (usually receptors) and a high rate of elimination
(represented by flux through a clearing organ). Examples of such drugs include ac-
etaminophen, acyclovir, nicotine, and ranitidine. B. In contrast, for drugs that exhibit
high levels of binding to plasma proteins (shown here as Drug B), a higher total
plasma drug concentration is required to ensure an adequate concentration of free
(unbound) drug in the circulation. Otherwise, only a small fraction of the drug can
diffuse into the extravascular space and only a small percentage of the receptors
are occupied. Examples of such drugs include amiodarone, fluoxetine, naproxen,
and warfarin. It should be emphasized that plasma protein binding is only one of
many variables that determine drug distribution. Drug molecule size, lipophilicity,
and rate of metabolism are other important parameters that must be taken into
account when considering the pharmacokinetics of a particular drug.
result in a higher-than-expected plasma concentration of the
free form of either or both drugs as the coadministered drugs
compete for the same binding sites. The increased free drug
concentration could potentially cause increased therapeutic
and/or toxic effects of the drug. In such cases, the dosing reg-
imen of one or both of the drugs would need to be adjusted to
34 Fundamental Principles of Pharmacology
keep the free drug concentration in the therapeutic range. In
practice, however, it has been difficult to demonstrate clini-
cally significant drugdrug interactions caused by competi-
tive binding of drugs to plasma proteins, possibly due to the
increased clearance of the free drugs as they are displaced
from their plasma protein binding sites (see below).
Modeling the Kinetics and Thermodynamics
of Drug Distribution
Most drugs are distributed rapidly from the systemic circu-
lation (intravascular compartment) to other compartments
in the body. This distribution phase results in a sharp de-
crease in the plasma drug concentration shortly after intra-
venous administration of a drug bolus. Even after the drug
equilibrates among its tissue reservoirs, the plasma drug
concentration continues to decline because of drug elimina-
tion from the body. However, the plasma drug concentration
decreases more slowly during the elimination phase, in part
due to a reservoir of drug in the tissues that can diffuse
back into the blood to replace the drug that has been elimi-
nated (Figs. 3-6 and 3-7).
The tendency for a drug to be taken up by adipose and
muscle tissue during the distribution phase determines a
set of dynamic equilibria among drug concentrations in the
various body compartments. As shown in Figure 3-8, the
rapid decline of plasma drug concentration after administra-
tion of an intravenous bolus of drug can be approximated
by using a four-compartment model consisting of the blood
and vessel-rich, muscle-rich, and adipose-rich tissues. The
vessel-rich group is the first extravascular compartment
in which the concentration of drug increases, because the
high blood flow received by this group kinetically favors
drug entry into this compartment. However, the muscle-rich
group and adipose-rich group often have a higher capac-
ity for taking up drug than the vessel-rich group, with the
Plasma drug concentration
Distribution phase
Elimination phase
Time
FIGURE 3-6. Drug distribution and elimination after intravenous
administration. Immediately after intravenous administration of a drug, the
plasma drug concentration declines rapidly as the drug distributes from the vas-
cular compartment to other body compartments. This rapid decline is followed
by a slower decline as the drug is metabolized and excreted from the body. Both
drug distribution and elimination display first-order kinetics, as demonstrated by
linear kinetics on a semilogarithmic plot.
adipose-rich group accumulating the greatest amount of
drug at the slowest rate.
The capacity of a compartment for a drug and the rate of
blood flow to the compartment also affect the rate at which
the drug exits from the compartment. Drugs tend to exit first
from the vessel-rich group, followed by the muscle group
and then the adipose group. A complex and dynamic pattern
of changing blood concentrations may develop, and the
pattern is specific for each drug. The pattern may also be
patient-specific, depending on factors such as the size, age,
and fitness level of the patient. For example, an older patient
typically has less skeletal muscle mass than a younger patient,
decreasing the contribution of muscle uptake to changes in
the plasma concentration of drug. An opposite effect may be
seen in an elite athlete, who would be expected to have both
greater muscle mass and greater proportional muscle blood
flow. As a third example, an obese person typically exhibits
greater capacity for drug uptake into adipose tissue.
 METABOLISM
A number of organs are capable of metabolizing drugs to
some extent, using enzymatic reactions that are discussed in
Chapter 4, Drug Metabolism. The kidneys, gastrointestinal
tract, lungs, skin, and other organs all contribute to systemic
drug metabolism. However, the liver contains the greatest di-
versity and quantity of metabolic enzymes, and the majority
of drug metabolism occurs there. The ability of the liver to
modify drugs depends on the amount of drug that enters the
hepatocytes. Highly hydrophobic drugs can generally enter
cells readily (including liver cells), and the liver preferentially
metabolizes hydrophobic drugs. However, the liver contains
a multitude of transporters in the human solute-linked car-
rier (SLC) superfamily that allow entry of some hydrophilic
drugs into hepatocytes as well. Hepatic enzymes chemically
modify a variety of substituents on drug molecules, thereby
either rendering the drugs inactive or facilitating their elimi-
nation. These modifications are collectively referred to as bi-
otransformation. Biotransformation reactions are classified
into two types, termed oxidation/reduction reactions and
conjugation/hydrolysis reactions. (Although biotransforma-
tion reactions are often called phase I and phase II reactions,
in this book, we typically use the more precise terms oxida-
tion/reduction and conjugation/hydrolysis; see Chapter 4.)
Oxidation/Reduction Reactions
Oxidation/reduction reactions modify the chemical structure
of a drug; typically, a polar group is added or uncovered.
The most common pathway, the microsomal cytochrome
P450 enzyme system in the liver, mediates a large number
of oxidative reactions. Some drugs may be administered in
inactive (prodrug) form and are altered metabolically by
oxidation/reduction reactions to the active (drug) form in the
liver. This prodrug strategy can facilitate oral bioavailability,
decrease gastrointestinal toxicity, and/or prolong the elimi-
nation half-life of a drug.
Conjugation/Hydrolysis Reactions
Conjugation/hydrolysis reactions hydrolyze a drug or con-
jugate a drug to a large, polar molecule in order to inacti-
vate the drug or, more commonly, to enhance the drugs
solubility and excretion in the urine or bile. Occasionally,
 CHAPTER 3 / Pharmacokinetics 35

concentration
Plasma drug
A

Extravascular Blood Time

volume

concentration
Plasma drug
B

Blood Time
concentration
Plasma drug

Extravascular Blood Time

volume

FIGURE 3-7. Schematic model of drug distribution and elimination. A two-compartment pharmacokinetic model can be used to describe drug distribution and
elimination after administration of a single intravenous dose. The drug concentration rises rapidly as the drug is added to the first compartment. A. In the absence of
elimination, the initial rise in drug concentration is followed by a rapid decline to a new plateau as the drug equilibrates (distributes) between the two compartments.
B. If the distribution of the drug is confined to the blood volume, then the plasma drug concentration declines more slowly as the drug is eliminated from the body. In
both cases, as the concentration of drug in the plasma decreases, the forces driving (A) drug distribution and (B) elimination decrease, and the absolute amount of drug
distributed or eliminated per unit time decreases. Therefore, the kinetics of both distribution and elimination appear as straight lines on a semilogarithmic plot; this is
the definition of first-order kinetics. Note that the half-time for drug elimination is generally longer than the half-time for drug distribution. C. When drug distribution and
elimination are occurring simultaneously, the decline of plasma drug concentration with time is represented by the sum of the two processes. Note that the curve in (C) is
the sum of the two first-order processes shown in (A) and (B). In the schematics on the left of the figure, the volume in the Blood compartment represents plasma drug
concentration, the volume in the Extravascular volume compartment represents tissue drug concentration, the dropper above the Blood compartment represents
absorption of drug into the systemic circulation, and the drops below the Blood compartment represent elimination of drug by metabolism and excretion.

hydrolysis or conjugation can result in the metabolic activa-
tion of prodrugs. The most commonly added groups include
glucuronate, sulfate, glutathione, and acetate.
As described in more detail in the next chapter, the effects
of oxidation/reduction and conjugation/hydrolysis reactions
on a particular drug also depend on the presence of other
drugs that are being taken concomitantly by the patient.
Certain classes of drugs, such as barbiturates, are powerful
inducers of enzymes that mediate oxidation/reduction reac-
tions; other drugs are capable of inhibiting these enzymes. An
understanding of these drugdrug interactions is an essential
prerequisite to the appropriate dosing of drug combinations.
Physicians and researchers have begun to elucidate the im-
portant role of genetic differences among individuals in the var-
ious transporters and enzymes responsible for drug absorption,
distribution, excretion, and especially metabolism. For exam-
ple, an individuals complement of cytochrome P450 enzymes
in the liver determines the rate and extent to which that indi-
vidual can metabolize numerous therapeutic agents. This topic
is discussed in detail in Chapter 6, Pharmacogenomics.
36 Fundamental Principles of Pharmacology
1.0
Fraction of dose in compartment
Blood Muscle
0.8
VRG
0.6
Adipose
0.4
0.2
0.1
0.1 1.0 10 100 1000
Time (minutes)
FIGURE 3-8. Four-compartment model of drug distribution. After
administration of an intravenous bolus, the drug is delivered to various tissues via
the systemic circulation. The fraction of the administered dose is initially highest in
the vascular compartment (blood), but the blood fraction subsequently falls rapidly
as the drug is distributed to the different tissue compartments. The most vessel-rich
tissues (i.e., the tissues that are supplied by the highest fraction of the cardiac out-
put) are generally the first to accumulate drug. However, the tissue compartments
also vary in their capacity for taking up drug. Because the mass of the muscle group
is larger than that of the vessel-rich group (VRG), the muscle group has a larger
uptake capacity. But because the muscles are less well perfused than the vessel-
rich group, this effect is manifested only after the drug has begun to distribute to the
VRG. The most poorly perfused group is the adipose-rich group, but this group has
the highest capacity to accumulate drug. The peak level of drug in the adipose group
is not as high as that in the muscle-rich group, because a significant amount of drug
has been eliminated by metabolism or excretion before the adipose group begins to
accumulate drug. After the administration of drug has been completed, the reverse
pattern is seenthe drug leaves first from the vessel-rich group and then from the
muscle and adipose groups, respectively. The drug in this example is thiopental, a
barbiturate used to induce general anesthesia.
 EXCRETION
Oxidation/reduction and conjugation/hydrolysis reactions
enhance the hydrophilicity of a hydrophobic drug and its
metabolites, enabling such drugs to be excreted along a final
common pathway with drugs that are intrinsically hydro-
philic. Most drugs and drug metabolites are eliminated from
the body through renal and biliary excretion. Renal excre-
tion is the most common mechanism of drug excretion, and
it relies on the hydrophilic character of a drug or metabolite.
Only a relatively small number of drugs are excreted pri-
marily in the bile or through respiratory and dermal routes.
Many orally administered drugs are incompletely absorbed
from the upper gastrointestinal tract, and residual drug is
eliminated by fecal excretion.
Renal Excretion
Renal blood flow comprises about 25% of total systemic
blood flow, ensuring that the kidneys are continuously
exposed to any drug found in the blood. The rate of drug
elimination through the kidneys depends on the balance of
drug filtration, secretion, and reabsorption rates (Fig. 3-9).
The afferent arteriole introduces both free (unbound) drug
and plasma protein-bound drug into the glomerulus. Typi-
cally, however, only the free drug form is filtered into
the renal tubule. Therefore, renal blood flow, glomerular
filtration rate, and drug binding to plasma protein all affect
the amount of drug that enters the tubule at the glomerulus.
Enhancing blood flow, increasing glomerular filtration rate,
and decreasing plasma protein binding cause a drug to be
excreted more rapidly. Renal excretion plays the primary
role in the clearance of many drugs; examples include
vancomycin, atenolol, and ampicillin. Drugs such as these
can accumulate to toxic levels in patients with compromised
renal function and in elderly patients (who often manifest
some degree of renal compromise).
Urinary drug concentration rises in the proximal tubule
because of passive diffusion of uncharged drug molecules,
facilitated diffusion of charged or uncharged molecules, and
active secretion of anionic and cationic molecules from the
blood into the urinary space. The secretory mechanisms are
generally not specific for the drugs; rather, drug secretion
takes advantage of molecular similarities between the drug
and naturally occurring substances such as organic anions
(transported by OAT family proteins) and cations (transported
by OCT family proteins). Penicillin is an example of a drug
that is eliminated largely by active transport in the proximal
tubule. The extent of plasma protein binding appears to have
a relatively small effect on drug secretion into the proximal
tubule, because the highly efficient transporters that mediate
active tubular secretion rapidly remove free (unbound) drug
from the peritubular capillaries and thereby alter the equilib-
rium between free and protein-bound drug at these sites.
Peritubular Proximal
capillary tubule
Tubular Glomerular
Secretion Afferent
Filtration
1 arteriole
2
Drug
in blood
3
Tubular
Reabsorption
Efferent
4 arteriole
Urine
FIGURE 3-9. Drug filtration, secretion, and reabsorption in the kidney. Drugs
may be (1) filtered at the renal glomerulus, (2) secreted into the proximal tubule,
(3) reabsorbed from the tubular lumen and transported back into the blood, and (4)
excreted in the urine. The relative balance of filtration, secretion, and reabsorption
rates determines the kinetics of drug elimination by the kidney. Enhancing blood flow,
increasing glomerular filtration rate, and decreasing plasma protein binding all cause
a drug to be excreted more rapidly, because all these changes result in increased fil-
tration of drug at the glomerulus. Some drugs, such as penicillin, are actively secreted
into the proximal tubule. Although reabsorption can decrease the elimination rate of a
drug, many drugs exhibit pH trapping in the distal tubule and are therefore efficiently
excreted in the urine. For drugs that are dependent on the kidney for elimination,
compromised renal function can result in higher plasma drug concentrations, and the
dose and frequency of drug administration must be altered accordingly.

The urinary concentration of a drug may fall as the drug is
reabsorbed in the proximal and distal tubules. Reabsorption
is limited primarily by pH trapping, as described above. The
renal tubular fluid is typically acidic in and beyond the proxi-
mal tubule, which tends to favor trapping of the ionic form of
weak bases. Because this region of the tubule contains trans-
porter proteins that are different from those in preceding seg-
ments of the nephron, ionic drug forms resist facilitated diffu-
sional reabsorption, and their excretion is thereby enhanced.
Drug reabsorption in the tubule can be enhanced or inhibited
by chemical adjustment of the urinary pH. Changing the rate
of urine flow through the tubules can also modify the rate of
drug reabsorption. An increased rate of urine output tends to
dilute the drug concentration in the tubule and to decrease the
amount of time during which facilitated diffusion can occur;
both of these effects tend to decrease drug reabsorption. For
example, aspirin is a weak acid that is excreted by the kidney.
Aspirin overdose is treated by administering sodium bicar-
bonate to alkalinize the urine (and thus trap aspirin in the
tubule) and by increasing the urine flow rate (and thus dilute
the tubular concentration of the drug). Both of these clinical
maneuvers result in faster elimination of the drug.
Biliary Excretion
Drug reabsorption also plays an important role in biliary
excretion. Some drugs are secreted from the liver into the bile
by members of the ATP binding cassette (ABC) superfamily
of transporters, which includes seven families of proteins
such as the multidrug resistance (MDR) family. Because
the bile duct enters the gastrointestinal tract in the duodenum,
such drugs must pass through the length of the small and
large intestine before being eliminated. In many cases, these
drugs undergo enterohepatic circulation, in which they are
reabsorbed in the small intestine and subsequently retained
in the portal and then the systemic circulation. Drugs such as
steroid hormones, digoxin, and some cancer chemotherapeu-
tic agents are largely excreted in the bile.
 CLINICAL APPLICATIONS OF
PHARMACOKINETICS
The dynamic interactions among drug absorption, distribu-
tion, metabolism, and excretion determine the plasma con-
centration of a drug and dictate the ability of the drug to
reach its target organ in an effective concentration. Often,
the desired duration of drug therapy exceeds that achievable
by a single dose, and multiple doses are needed to provide a
relatively constant plasma concentration of drug within the
limits of efficacy and toxicity. The results of clinical trials of
drugs under development, as well as clinical experience using
U.S. Food and Drug Administration (FDA)-approved drugs,
suggest target plasma levels for a drug in the average patient.
However, pharmacokinetic and other differences among pa-
tients (such as disease status and pharmacogenomic profile)
must also be considered in designing a dosing regimen for a
drug or drug combination in the individual patient.
Clearance
The clearance of a drug is the pharmacokinetic parameter
that most significantly limits the time course of action of the
drug at its molecular, cellular, and organ targets. Clearance
CHAPTER 3 / Pharmacokinetics 37
can be conceptualized in two complementary ways. First,
it is defined as the rate of elimination of the drug from the
body relative to the concentration of the drug in plasma. Al-
ternatively, clearance is the rate at which plasma would have
to be cleared of the drug to account for the observed kinetics
of change of the total amount of drug in the body, assuming
that all the drug in the body is present at the same concentra-
tion as that in the plasma. Therefore, clearance is expressed
in units of volume/time, as follows:
Metabolism  Excretion
Clearance  Equation 3-5
[Drug]plasma
where metabolism and excretion are expressed as rates
(amount/time).
Although metabolism and excretion are distinct physio-
logic processes, the pharmacologic endpoint is equivalenta
reduction in circulating levels of active drug. As such, me-
tabolism and excretion are often referred to collectively as
clearance mechanisms, and the principles of clearance can
be applied to both:
Clearancetotal  Clearancerenal  Clearancehepatic
 ClearanceOther Equation 3-6
Metabolism and Excretion Kinetics
The rate of drug metabolism and excretion by an organ is
limited by the rate of blood flow to that organ. The majority
of drugs demonstrate first-order kinetics when used in
standard therapeutic doses; that is, the amount of drug that
is metabolized or excreted in a given unit of time is directly
proportional to the concentration of drug in the systemic
circulation at that time. Because the clearance mechanisms
for most drugs are not saturated under ordinary circum-
stances, increases in plasma drug concentration are matched
by increases in the rate of drug metabolism and excretion
(see Equation 3-5). The first-order elimination rate (where
elimination includes both metabolism and excretion) follows
MichaelisMenten kinetics:
Vmax  C
E Equation 3-7
Km  C
where Vmax is the maximum rate of drug elimination, Km is
the drug concentration at which the rate of elimination is
1/2 Vmax, C is the concentration of drug in the plasma, and
E is the elimination rate (Fig. 3-10). Because elimination
is usually a first-order process, a semilogarithmic plot of
plasma drug concentration versus time typically shows a
straight line during the elimination phase (see Fig. 3-6).
A small number of drugs (e.g., phenytoin) and recreational
substances (e.g., ethanol) demonstrate saturation kinetics,
in which the clearance mechanisms become saturated at or
near the therapeutic concentration of the drug. Once satura-
tion occurs, the clearance rate fails to increase with increas-
ing plasma drug concentrations (zero-order kinetics). This
can result in dangerously elevated plasma concentrations of
the drug that can cause toxic (or even lethal) effects.
 Vmax
Drug elimination rate

Vmax
2

Km
Plasma drug concentration

Cin  Cout
Extraction  Equation 3-8
Cin

0.693  Vd
t1/2  Equation 3-9
Clearance
40 Fundamental Principles of Pharmacology

see Chapter 2.) In contrast, a highly distributed drugas evi-
denced by a high volume of distributionnecessitates higher
drug dosing. The elimination rate of a drug influences its half-
life and thereby determines the frequency of dosing required
to maintain therapeutic plasma drug levels.
In general, therapeutic dosing of a drug seeks to maintain
the peak (highest) plasma drug concentration below the
toxic concentration, and the trough (lowest) drug concen-
tration above the minimally effective level (Fig. 3-11). This
can be accomplished most efficiently using continuous drug
delivery by intravenous (continuous infusion), subcutane-
ous (continuous pump or implant), oral (sustained-release
tablet), and other routes of administration, as described in
more detail in Chapter 54, Drug Delivery Modalities. In
many cases, however, the dosing regimen must also consider
patient convenience. Frequent small doses (usually oral) can
be administered to achieve minimal variation in steady-state
plasma drug concentration, but this strategy subjects the
patient to the inconvenience of frequent drug administration.
Less frequent dosing requires the use of higher doses and
leads to greater fluctuations in peak and trough drug levels;
this type of regimen is more convenient for the patient but
also more likely to cause problems due to excessive (toxic)
or insufficient (subtherapeutic) drug levels (Fig. 3-12).
Optimal dosing regimens typically maintain the steady-
state plasma drug concentration within the therapeutic window
for that drug. Because steady state is reached when the rate of
drug input is equal to its output, the steady-state drug concen-
tration is affected by drug bioavailability, clearance, dose, and
dosing interval (the frequency of administration):
Bioavailability  Dose
Csteady state  Equation 3-10
Intervaldosing  Clearance
where C is the plasma concentration of the drug.
Immediately following the initiation of drug therapy, the
rate of drug entry into the body (kin) is much greater than
the elimination rate (kout); therefore, the drug concentration
in the blood increases. Assuming that elimination follows

A Therapeutic Dosing B Therapeutic Dosing with Loading Dose

Plasma drug concentration

Plasma drug concentration

Toxic range Toxic range

2.0 2.0

1.5 1.5

1.0 1.0
Therapeutic range Therapeutic range

0.5 0.5

Subtherapeutic range Subtherapeutic range

0 0
0 3 6 9 12 0 3 6 9 12

1st dose Days 1st dose Days

C Toxic Dosing D Subtherapeutic Dosing

Plasma drug concentration

Plasma drug concentration

Toxic range
Toxic range
2.8 2.0

2.1 1.5

1.4 1.0 Therapeutic range

Therapeutic range
0.7 0.5

Subtherapeutic range Subtherapeutic range

0
0 3 6 9 12 0
0 3 6 9 12
1st dose Days 1st dose Days

FIGURE 3-11. Therapeutic, subtherapeutic, and toxic drug dosing. From a clinical perspective, drug concentrations in plasma can be divided into subtherapeutic,
therapeutic, and toxic ranges. The goal of most drug-dosing regimens is to maintain the drug at concentrations within the therapeutic range (referred to as the thera-
peutic window). A. The first several doses of a drug are typically subtherapeutic as the drug equilibrates to its steady-state concentration (approximately four elimina-
tion half-lives are required to achieve steady state). Appropriate drug dosing and dosing frequency result in steady-state drug levels that are therapeutic, and the maxi-
mal and minimal concentrations of the drug remain within the therapeutic window. B. If the initial (loading) dose is larger than the maintenance dose, the drug reaches
therapeutic concentrations more rapidly. The magnitude of the loading dose is determined by the volume of distribution of the drug. C. Excessive maintenance doses or
dosing frequency result in drug accumulation and toxicity. D. Insufficient maintenance doses or dosing frequency result in subtherapeutic steady-state drug concentra-
tions. In all four panels, the drug is administered once daily, distributed very rapidly to the various body compartments, and eliminated with first-order kinetics.
 Continuous infusion
Infrequent large doses
Frequent small doses
0.93  5 mg
Therapeutic range Csteady state   1.01 mg/L
Plasma drug concentration (mg/L)

24 h  0.192 L/h
8

0
0
Time

Doseloading  Vd  Csteady state Equation 3-11

Doseloading  77 L  3.5 mg/L  269.5 mg

Dosemaintenance  Clearance  Csteady state Equation 3-12

 Toxic range
Plasma drug concentration

Loading dose
Initial concentration =
Therapeutic range
Volume of
distribution

Fraction absorbed
Maintenance dose
Steady-state concentration =
Dosing interval
Clearance
Subtherapeutic range

0.693 Volume
Time of distribution
Elimination half -life =
Clearance

Dosemaintenance  0.192 L/h  1.01 mg/La

 0.194 mg/h  4.65 mg/day

Drug Metabolism
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . . . 43-44
SITES OF DRUG METABOLISM. . . . . . . . . . . . . . . . . . . . . . . . 43
PATHWAYS OF DRUG METABOLISM . . . . . . . . . . . . . . . . . . . 44
Oxidation/Reduction Reactions. . . . . . . . . . . . . . . . . . . . . . 47
Conjugation/Hydrolysis Reactions . . . . . . . . . . . . . . . . . . . 47
Drug Transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Induction and Inhibition . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Active and Toxic Metabolites . . . . . . . . . . . . . . . . . . . . . . . 50
 INTRODUCTION
Our tissues are exposed on a daily basis to xenobiotics
foreign substances that are not naturally found in the body.
Most drugs are xenobiotics that are used to modulate bodily
functions for therapeutic ends. Drugs and other environmental
chemicals that enter the body are modified by a vast array
of enzymes. The biochemical transformations performed by
these enzymes can alter the compound to render it benefi-
cial, harmful, or simply ineffective. The processes by which
biochemical reactions alter drugs within the body are collec-
tively called drug metabolism or drug biotransformation.
The previous chapter introduced the importance of renal
clearance in the pharmacokinetics of drugs. Although the
biochemical reactions that alter drugs to renally excre-
table forms are an essential part of drug metabolism, drug
metabolism encompasses more than this one function. Drug
biotransformation can alter drugs in four important ways:
An active drug may be converted to an inactive drug.
An active drug may be converted to an active or toxic
metabolite.
An inactive prodrug may be converted to an active drug.
An unexcretable drug may be converted to an excretable
metabolite (e.g., to enhance renal or biliary clearance).
This chapter presents the major processes of drug me-
tabolism. Following the case is an overview of the sites
of drug metabolism, focusing principally on the liver. The
two major types of biotransformation are then discussed;
these are often termed phase I and phase II reactions,
although the terminology is imprecise and it incorrectly
implies a temporal order of the reactions. (In addition,
phase III is sometimes used to describe the process
of drug transport, which is even more confusing.) In this
4
Cullen Taniguchi and F. Peter Guengerich
INDIVIDUAL FACTORS AFFECTING DRUG METABOLISM . . . . 50
Pharmacogenomics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Race and Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Age and Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Diet and Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Metabolic Drug Interactions . . . . . . . . . . . . . . . . . . . . . . . . 54
Diseases Affecting Drug Metabolism . . . . . . . . . . . . . . . . . 54
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . . 54
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
chapter we use oxidation/reduction and conjugation/
hydrolysis to describe these processes more accurately.
The chapter concludes with a discussion of the factors
that can lead to differences in drug metabolism among
individuals.
 SITES OF DRUG METABOLISM
The liver is the main organ of drug metabolism. This fact
figures prominently in the phenomenon known as the first-
pass effect. Orally administered drugs are often absorbed
in the gastrointestinal (GI) tract and transported directly to
the liver via the portal circulation (Fig. 4-1). In this manner,
the liver has the opportunity to metabolize drugs before they
reach the systemic circulation and, therefore, before they
reach their target organs. The first-pass effect must be taken
into account when designing dosing regimens because, if
hepatic metabolism is extensive, the amount of drug that
reaches the target tissue is much less than the amount (dose)
that is administered orally (see Chapter 3, Pharmacokinet-
ics). Certain drugs are inactivated so efficiently upon their
first pass through the liver that they cannot be administered
orally and must be given parenterally. One such drug is the
antiarrhythmic lidocaine, which has a bioavailability of only
3% when taken orally.
Although the liver is quantitatively the most important
organ in metabolizing drugs, every tissue in the body is
capable of drug metabolism to some degree. Particularly
active sites include the skin, the lungs, the gastrointesti-
nal tract, and the kidneys. The gastrointestinal tract de-
serves special mention because this organ, like the liver,
can contribute to the first-pass effect by metabolizing
orally administered drugs before they reach the systemic
circulation.
43
 PO
Subcutaneous

Transdermal

GI IV

Portal vein Contains

first-pass
Liver metabolites
Systemic circulation

Other
organs
 OH

R
R
OH
R
O

HO
R R

O
R1 +
N R2 R1
H NH2 H R2

O R2 OH +
R R H R2

O
S S
R1 R2 R1 R2

H
NH2 N
R R OH

S O

R1 R2 R1 R2

O
R1
R2 R1 R2

O O

R OH
R H R OH

O
+ NH3
R NH2
R H

OH
R R OH
+ CO2
O

O2N H2N
R R

R X R H

O OH

R1 R2 R1 R2
 O O
R2
R2 + HO
R1 O R1 OH

O O
+ R2
R2 H2N
R1 N R1 OH
H

OH
O
R1
R2
R1 R2
OH

COOH
COOH
O
O OH R
OH + OH UDP O
R O OH
OH OH
OH

O O
OH + CoA R
R
S O

O O O
H
+ H2N R N
R OH OH OH
O

H
NH2 O N
R + HO3S ADP R SO3H

OH O O
R
+ HO3S ADP R SO3H

O NH2
H
N
X + HOOC N COOH
R H
O
HS

O NH2
H
N
HOOC N COOH
H
O
S
R
H
HOOC N

R O
S

H
N N
R1 R2 R1 R2

HO R O R

HO HO

SH S
R R

Oxidation/Reduction Reactions
Oxidation reactions involve membrane-associated enzymes
expressed within the endoplasmic reticulum (ER) of hepa-
tocytes and, to a lesser extent, of cells in other tissues. The
enzymes that catalyze these phase I reactions are typically
oxidases; the majority of these enzymes are heme protein
mono-oxygenases of the cytochrome P450 class. Cyto-
chrome P450 enzymes (sometimes abbreviated CYP) are
also known as microsomal mixed-function oxidases and
are involved in the metabolism of approximately 75% of
all drugs used today. (The term P450 refers to the 450-nm
absorption peak characteristic of these heme proteins when
they bind carbon monoxide.)
The net result of a cytochrome P450-dependent oxidation
reaction is:
Drug  O2  NADPH  H
Drug-OH  H2O  NADP Equation 4-1
The reaction proceeds when the drug binds to the oxidized
(Fe3) cytochrome P450 to form a complex, which is then
reduced in two sequential oxidation/reduction steps as out-
lined in Figure 4-2A. Nicotinamide adenine dinucleotide
phosphate (NADPH) donates the electrons in both of these
steps via a flavoprotein reductase. In the first step, the do-
nated electron reduces the cytochrome P450drug complex.
In the second step, the electron reduces molecular oxygen
to form an activated oxygencytochrome P450drug com-
plex. Finally, as the complex becomes more active through
rearrangement, the reactive oxygen atom is transferred to
the drug, resulting in the formation of the oxidized drug
product and recycling oxidized cytochrome P450 in the
process. The mechanism of these reactions is illustrated in
Figure 4-2B.
Most liver cytochrome P450 oxidases exhibit broad sub-
strate specificity (Table 4-1). This is due in part to the acti-
vated oxygen of the complex, which is a powerful oxidizing
agent that can react with a variety of substrates. The names of
the cytochrome P450 enzymes are sometimes designated by
P450 followed by the number of the P450 enzyme family,
capital letter of the subfamily, and an additional number to
identify the specific enzyme (e.g., P450 3A4). Many of the
P450 enzymes have partially overlapping specificities that
together allow the liver to recognize and metabolize a wide
array of xenobiotics.
Together, P450-mediated reactions account for more than
95% of oxidative biotransformations. Other pathways may
also oxidize lipophilic molecules. A pertinent example of a
non-P450 oxidative pathway is the alcohol dehydrogenase
pathway that oxidizes alcohols to their aldehyde derivatives
as part of the overall process of excretion. These enzymes
are the basis for the toxicity of methanol. Methanol is oxi-
dized by alcohol dehydrogenase to formaldehyde, which
does considerable damage to some tissues. The optic nerve
is particularly sensitive to formaldehyde, and methanol tox-
icity can cause blindness.
Another important non-P450 enzyme is monoamine
oxidase (MAO). This enzyme is responsible for the oxida-
tion of amine-containing endogenous compounds such as
catecholamines and tyramine (see Chapter 10, Adrenergic
Pharmacology) and some xenobiotics, including drugs.
CHAPTER 4 / Drug Metabolism 47
Conjugation/Hydrolysis Reactions
Conjugation and hydrolysis reactions provide a second
set of mechanisms for modifying compounds for excre-
tion (Fig. 4-3). Although hydrolysis of ester- and amide-
containing drugs is sometimes included among the phase
I reactions (in the older terminology), the biochemistry of
hydrolysis is more closely related to conjugation than to
oxidation/reduction. Substrates for these reactions include
both metabolites of oxidation reactions (e.g., epoxides) and
compounds that already contain chemical groups appropri-
ate for conjugation, such as hydroxyl (-OH), amine (-NH2),
or carboxyl (-COOH) moieties. These substrates are cou-
pled by transfer enzymes to endogenous metabolites (e.g.,
glucuronic acid and its derivatives, sulfuric acid, acetic acid,
amino acids, and the tripeptide glutathione) in reactions that
often involve high-energy intermediates (Table 4-2). The
conjugation and hydrolysis enzymes are located in both the
cytosol and the endoplasmic reticulum of hepatocytes (and
other tissues). In most cases, the conjugation process makes
the drug more polar. Virtually all of the conjugated products
are pharmacologically inactive, with some important excep-
tions (e.g., morphine glucuronide).
Some conjugation reactions are important clinically in
the case of neonates, who have not yet fully developed the
capacity to carry out this set of reactions. UDP-glucuronyl
transferase (UDPGT) is responsible for conjugating bilirubin
in the liver and facilitating its excretion. The developmen-
tal deficiency of this enzyme at birth puts infants at risk for
neonatal jaundice, which results from increased serum levels
of unconjugated bilirubin. Neonatal jaundice is a problem
because neonates have not only underdeveloped activity of
this enzyme but also an undeveloped bloodbrain barrier. Un-
conjugated bilirubin is water-insoluble and very lipophilic; it
binds readily to the unprotected neonatal brain and is capable
of causing significant damage to the central nervous system.
This pathologic condition is known as bilirubin encephal-
opathy or kernicterus. Neonatal hyperbilirubinemia (un-
conjugated) can be treated with phototherapy with 450-nm
light, which converts circulating bilirubin to an isomer that is
more rapidly excreted. Another effective treatment is the ad-
ministration of small doses of the barbiturate phenobarbital,
which powerfully up-regulates the expression of the enzyme
UDPGT and thereby reduces serum levels of unconjugated
bilirubin. This illustrates a recurring theme: understanding
drug metabolism can help predict both adverse and poten-
tially advantageous drugdrug interactions.
It is important to note that conjugation and hydrolysis
reactions do not necessarily constitute the last step of biotrans-
formation. Since the conjugation of these highly polar moi-
eties occurs intracellularly, they often require active transport
across cellular membranes to be excreted (active transport of
the parent drug can also occur). Moreover, some conjugation
products may be subjected to further metabolism.
Drug Transport
Although many drugs are sufficiently lipophilic to cross cell
membranes passively, it is now appreciated that many drugs
need to be transported actively into cells. This fact has sig-
nificant consequences for oral bioavailability (transport into
enterocytes or active excretion into the intestinal lumen), he-
patic metabolism (transport into hepatocytes for enzymatic
metabolism and for excretion into bile), and renal clearance
48 Fundamental Principles of Pharmacology

A NADP+ NADPH

Flavoprotein Flavoprotein
(reduced) (oxidized)

2
+e-

RH P450-Fe2+

+e-
RH P450-Fe3+ 3
O2

RH P450-Fe2+
H2O
O 2-
1
4
P450-Fe3+

R-H R-OH
(parent drug) (oxidized drug)

R-OH H H
B
(oxidized drug) 0 R-H (parent drug)
H 2O

H2O
Fe3+ H2O

0 6
Heme 1
R-H R-H

Fe3+ Fe3+
Flavoprotein NADP+
(reduced)
H2O e-

5
2 Flavoprotein NADPH
2H+ (oxidized)
2-
0 0
R-H R-H

Fe3+ Fe2+

0 0-
4 0 0
R-H R-H O2
3
e- Fe2+ Fe3+
(from NADPH)

FIGURE 4-2. Cytochrome P450-mediated drug oxidation. Many drug metabolism reactions involve a system of hepatic P450 microsomal enzymes that catalyze
the oxidation of drugs. A. An overview of the reaction involves a set of oxidation/reduction steps in which an iron moiety in the P450 enzyme acts as an electron carrier
to transfer electrons from NADPH to molecular oxygen. The reduced oxygen is then transferred to the drug, resulting in an additional -OH group on the now-oxidized drug
(for this reason, P450 enzymes are sometimes referred to colloquially as oxygen guns or even natures blowtorch). The addition of the -OH group results in increased
drug hydrophilicity and an increased rate of drug excretion. B. The detailed mechanism of the P450 reaction can be divided into six steps: (1) drug complexes with
oxidized cytochrome P450; (2) NADPH donates an electron to the flavoprotein reductase, which reduces the P450-drug complex; (3 and 4) oxygen joins the complex, and
NADPH donates another electron, creating the activated oxygenP450 substrate complex; (5) iron is oxidized, with the loss of water; and (6) the oxidized drug product
is formed. There are multiple P450 enzymes; each has a somewhat different specificity for substrates (such as drugs). Five of the human P450s (1A2, 2C9, 2C19, 2D6,
and 3A4) account for approximately 95% of the oxidative metabolism of drugs.

D-glucuronate
D on the transporter OATP1B1, which transports the drug into
D-acetate
Drug or
phase I D-glycine
Excretion
drug metabolite D-sulfate
OH NH2
D-glutathione
D D
D-methyl
FIGURE 4-3. Conjugation reactions. In these reactions, a drug (represented by
D) or drug metabolite (represented by D-OH and D-NH2) is conjugated to an endog-
enous moiety. Glucuronic acid, a sugar, is the most common group that is conjugated
to drugs, but conjugations of acetate, glycine, sulfate, glutathione, and methyl groups
are also common. The addition of one of these moieties makes the resulting drug
metabolite more hydrophilic and often enhances drug excretion. (Methylation, an
important exception, does not increase drug hydrophilicity.) Transport mechanisms
also play a major role in the elimination of drugs and their metabolites.
(transport into proximal tubular cells and excretion into the
tubular lumen). Several important molecules mediate these
processes. The multidrug resistance protein 1 (MDR1), or
P-glycoprotein, which is a member of the ABC family of
efflux transporters, actively transports compounds back into
the intestinal lumen. This process limits the oral bioavail-
ability of several important drugs, including digoxin and
HIV-1 protease inhibitors. The metabolism of drugs from
the portal circulation (i.e., the first-pass effect) often requires
the transport of compounds into hepatocytes via the organic
anion transporting polypeptide (OATP) and the organic
cation transporter (OCT) family of proteins. These trans-
porters are particularly relevant for the metabolism of sev-
eral 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA)
reductase inhibitors (statins), which are used in the treat-
ment of hypercholesterolemia. For example, metabolism of
A D
Extracellular
Cytoplasm
A C
P450 enzyme
Nucleus
Coactivator
A receptor (CAR) or the aryl hydrocarbon receptor (AhR) (not shown). Drug D enters
RxR
PXR P450 transcription
CHAPTER 4 / Drug Metabolism 49
the HMG-CoA reductase inhibitor pravastatin is dependent
hepatocytes. Drug uptake into hepatocytes via OATP1B1 is
thought to be the rate-limiting step in the clearance of pravas-
tatin. The uptake of pravastatin on its first pass through the
liver also provides a potential advantage by keeping the drug
out of the systemic circulation, from which it could be taken
up by muscle cells and thereby cause toxic effects such as
rhabdomyolysis. The organic anion transporter (OAT)
family of transporters is responsible for renal secretion of
many clinically important anionic drugs, such as -lactam
antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs),
and antiviral nucleoside analogs.
Induction and Inhibition
The use of phenobarbital to prevent neonatal jaundice dem-
onstrates that drug metabolism can be influenced by the
expression levels of drug-metabolizing enzymes. Although
some P450 enzymes are constitutively active, others can be
induced or inhibited by different compounds. Induction or
inhibition can be incidental (a side effect of a drug) or delib-
erate (the desired effect of therapy).
The primary mechanism of P450 enzyme induction is an
increase in the expression of the enzyme chiefly through in-
creased transcription, although augmented translation and
decreased degradation can also have minor roles. The induc-
tion of P450 enzymes by a wide array of drugs reflects the
biology of xenobiotic receptors that act as the bodys sur-
veillance system to metabolize potentially toxic compounds.
Drugs, environmental pollutants, industrial chemicals, and
even foodstuffs can enter hepatocytes and bind to several dif-
ferent xenobiotic receptors, such as the pregnane X receptor
(PXR), constitutively active/androstane receptor (CAR), and
aryl hydrocarbon receptor (AhR) (Fig. 4-4). These molecules
D D
OH
D D D D D D
I
P450 P450 P450
FIGURE 4-4. Conceptualization of P450 induction and inhibition. Drugs
can both induce the expression and inhibit the activity of P450 enzymes. Some
drugs can induce the synthesis of P450 enzymes (left panel). In this example, drug
A activates the pregnane X receptor (PXR), which heterodimerizes with the retinoid
X receptor (RXR) to form a complex with co-activators and initiate transcription of
the P450 enzyme. Induction can also occur via the constitutively active/androstane
the cell and is hydroxylated by a P450 enzyme (right panel). The P450 enzyme can
be inhibited by a second drug acting as a competitive inhibitor (drug C) or an irre-
versible inhibitor (drug I). The mechanism by which a drug inhibits P450 enzymes
is not necessarily predictable from the drugs chemical structure; the mechanism
can only be determined experimentally. In addition, metabolites of drugs A, C, and
I can play a role in enzyme induction and inhibition (not shown).

Ho RH, Kim RB. Transporters and drug therapy: implications for drug dis-
position and disease. Clin Pharmacol Ther 2005;78:260277. (Review of
the crucial role played by drug transporters in drug metabolism.)
Kliewer SA, Goodwin B, Willson TM. The nuclear pregnane X receptor:
a key regulator of xenobiotic metabolism. Endocr Rev 2002;23:687702.
(Review of PXR induction.)
Mega JL, Close SL, Wiviott SD, Shen L, Hockett RD, Brandt JT, Walker
JR, Antman EM, Macias W, Braunwald E, Sabatine MS. Cytochrome P450
polymorphisms and response to clopidogrel. N Engl J Med 2009;360:354
362. (Example of P450 genetic polymorphisms and clinical efficacy of
clopidogrel.)
Wienkers L, Pearson P, eds. Handbook of drug metabolism. 2nd ed. New York:
Marcel Dekker; 2009. (Collection of articles on aspects of drug metabolism.)
CHAPTER 4 / Drug Metabolism 55
Wilke RA, Lin DW, Roden DW, Watkins PB, Folckhart D, Zineh I, Giacomini
KM, Krauss RM. Identifying genetic risk factors for serious adverse reac-
tions: current progress and challenges. Nat Rev Drug Discov 2007;6:904-916.
(Review of current status of use of genetics for predicting adverse reactions.)
Wilkinson GR. Drug metabolism and variability among patients in drug
response. N Engl J Med 2005;352:22112221. (An excellent basic review of
the P450 system and drugdrug interactions.)
Zhang D, Zhu M, Humphreys WG, eds. Drug metabolism in drug design and
development: basic concepts and practice. Hoboken, NJ: John Wiley & Sons;
2007. (Drug metabolism as it pertains to development of new pharmaceuticals.)
Zhou S, Gao Y, Jiang W, Huang M, Xu A, Paxton JW. Interactions of herbs
with cytochrome P450. Drug Metab Rev 2003;35:3598. (Review of P450
interactions with herbal medicines.)
5
Drug Toxicity
Michael W. Conner, Catherine Dorian-Conner, Laura C. Green,
Sarah R. Armstrong, Cullen Taniguchi, Armen H. Tashjian, Jr., and David E. Golan
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . . 56-57
MECHANISMS OF DRUG TOXICITY . . . . . . . . . . . . . . . . . . . . 57
On-Target Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Off-Target Effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Idiosyncratic Toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
CONTEXTS OF DRUG TOXICITY . . . . . . . . . . . . . . . . . . . . . . . 61
Drug Overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
DrugDrug Interactions . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Pharmacokinetic DrugDrug Interactions . . . . . . . . . . . 61
Pharmacodynamic DrugDrug Interactions . . . . . . . . . . 61
DrugHerb Interactions . . . . . . . . . . . . . . . . . . . . . . . . . 61
Cellular Mechanisms of Toxicity: Apoptosis
and Necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
 INTRODUCTION
Like many medical interventions, the use of drugs for ther-
apeutic benefit is subject to the law of unintended conse-
quences. These consequencestermed side effects, adverse
effects, or toxic effectsare a function of the mechanisms
of drug action, the size of the drug dose, and the character-
istics and health status of the patient. As such, the principles
of pharmacology, presented in the preceding chapters, apply
to drug toxicology as well. Many subsequent chapters con-
tain Drug Summary Tables that list, among other properties,
the specific adverse effects that can be caused by each drug.
This chapter focuses on the mechanisms underlying these
adverse effects.
As a general matter, adverse effects range from those that
are common and relatively benign to those that pose seri-
ous risk of organ damage or death. Even the former group
of side effects, however, can cause considerable discomfort
and lead patients to avoid or reduce their use of medication.
Also, in general, the type and risk of adverse effects depend
on the margin of safety between the dose required for effi-
cacy and the dose that causes side effects. When the margin
of safety is large, toxicity results primarily from overdoses;
when this margin is small or nonexistent, side effects may
be manifest at therapeutic doses. These principles apply to
over-the-counter drugs as well, such as acetaminophen and
aspirin. Note that safety margins are a function not only
of the drug but also of the patient, in that genetic or other
56
Organ and Tissue Toxicity. . . . . . . . . . . . . . . . . . . . . . . . . . 62
Harmful Immune Responses and Immunotoxicity . . . . . . . 62
Drug-Induced Hepatotoxicity . . . . . . . . . . . . . . . . . . . . . 65
Drug-Induced Renal Toxicity . . . . . . . . . . . . . . . . . . . . . 66
Drug-Induced Neurotoxicity . . . . . . . . . . . . . . . . . . . . . 66
Drug-Induced Skeletal Muscle Toxicity . . . . . . . . . . . . . 66
Drug-Induced Cardiovascular Toxicity . . . . . . . . . . . . . . 67
Drug-Induced Pulmonary Toxicity . . . . . . . . . . . . . . . . . 67
Carcinogenesis Due to Drug Therapy . . . . . . . . . . . . . . 67
Teratogenesis Due to Drug Therapy . . . . . . . . . . . . . . . 67
PRINCIPLES FOR TREATING PATIENTS WITH
DRUG-INDUCED TOXICITY . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . . 69
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
characteristicssuch as polymorphisms of enzymes that
detoxify harmful metabolites, comorbidities, or reduced
functional reserves in key organsrender patients more or
less capable of defending against toxicity. This is one reason
why, all other things being equal, new medications should be
initiated at the lowest doses likely to be therapeutic.
Drug toxicity is critically important in drug development
(see Chapter 49, Drug Discovery and Preclinical Develop-
ment, and Chapter 50, Clinical Drug Evaluation and Regula-
tory Approval). Early in drug development, preclinical and
clinical studies are used to evaluate compound potency, se-
lectivity, pharmacokinetic and metabolic profiles, and toxic-
ity. Prior to marketing, the regulatory agencies responsible
for drug approval review the test data and decide whether the
benefits of the drug outweigh its risks. Once a drug is mar-
keted and many more patients are exposed, the appearance of
unexpected types or frequencies of adverse effects may cause
a re-evaluation of the drug, such that its use may be restricted
to specific patient populations or withdrawn entirely (as in
the cases, for example, of the nonsteroidal anti-inflammatory
drug rofecoxib and the antidiabetic drug troglitazone).
In this chapter, categories of drug toxicities that derive
from inappropriate activation or inhibition of the intended
drug target (on-target adverse effects) or unintended tar-
gets (off-target adverse effects) are discussed first. The phe-
notypic effects of these drug toxicities are then discussed
at the physiologic, cellular, and molecular levels. General
principles and specific examples are also illustrated in this
58 Fundamental Principles of Pharmacology

Intended Unintended
tissue tissue

D D

Drug Drug
metabolism metabolism

D-X D-X

Unintended Intended
Intended receptor receptor Unintended
receptor receptor

"On-target" "Off-target" "On-target" "Off-target"

adverse effects adverse effects adverse effects adverse effects
Dose too high Incorrect receptor Correct receptor, Incorrect receptor
Chronic activation is activated or but incorrect tissue is activated or
or inhibition inhibited Dose too high inhibited
effects Chronic activation
or inhibition
effects

Toxic cellular effects

FIGURE 5-1. On-target and off-target adverse drug effects. Drug D is intended to modulate the function of a specific receptor (Intended receptor) in a particular
tissue (Intended tissue). On-target adverse effects in the intended tissue could be caused by a supratherapeutic dose of the drug or by chronic activation or inhibition of
the intended receptor by Drug D or its metabolite DX. The same on-target effects could occur in a second tissue (Unintended tissue); in addition, the intended recep-
tor could mediate an adverse effect because the drug is acting in a tissue for which it was not designed. Off-target effects occur when the drug and/or its metabolites
modulate the function of a target (Unintended receptor) for which it was not intended.

or kidney disease or to interactions with other drugs), or by
changes in the pharmacodynamics of the drugreceptor inter-
action that alter the pharmacologic response (e.g., changes in
receptor number). All such changes can lead to an increase in
the effective concentration of the drug and thus to an increased
biological response. Because on-target effects are mediated
via the desired mechanism of action of the drug, these effects
are often shared by every member of the therapeutic class and
are thus also known as class effects.
An important set of on-target adverse effects may occur
because the drug, or one of its metabolites, interacts with
the appropriate receptor but in tissues other than those af-
fected by the disease condition being treated. Many drug
targets are expressed in more than one cell type or tissue.
For example, the antihistamine diphenhydramine is an H1
receptor antagonist used to ameliorate the effects of hista-
mine release in allergic conditions. Diphenhydramine also
crosses the bloodbrain barrier to antagonize H1 receptors
in the central nervous system, leading to somnolence. This
adverse effect led to the design of second-generation H1 re-
ceptor antagonists that do not cross the bloodbrain barrier
and thus do not induce drowsiness. Notably, the first of these
second-generation H1 antagonists, terfenadine, produced
an off-target effect (interaction with cardiac potassium
channels) that led to a different and serious side effectan
increased risk of cardiac death. This example is discussed
later in this chapter.
Local anesthetics such as lidocaine and bupivacaine pro-
vide a second example of an on-target adverse effect. These
drugs are intended to prevent axonal impulse transmission by
blocking sodium channels in neuronal membranes near the
site of injection. Blockade of sodium channels in the central
nervous system (CNS) following overdose or inappropriate
administration (e.g., intravascular administration) can lead
to tremors, seizures, and death. These on-target effects are
discussed in greater detail in Chapter 11, Local Anesthetic
Pharmacology.
The antipsychotic agent haloperidol produces its benefi-
cial effect through blockade of mesolimbic and mesocorti-
cal D2 receptors. One consequence of blocking D2 receptors
in the pituitary gland is an increase in prolactin secretion,
leading in some cases to amenorrhea, galactorrhea, sexual
dysfunction, and osteoporosis. These on-target effects are
discussed in Chapter 13, Pharmacology of Dopaminergic
Neurotransmission.
Sometimes on-target adverse effects unmask important
functions of the biological target. A prominent example of
this phenomenon occurs with administration of hydroxy-
methylglutaryl-coenzyme A (HMG-CoA) reductase inhibi-
tors (so-called statins), which are used clinically to decrease
cholesterol levels. The intended target tissue of these drugs
is the liver, where they inhibit HMG-CoA reductase, the
rate-limiting enzyme of isoprenoid synthesis. A rare ad-
verse effect of statin therapy is muscle toxicity, including
 CHAPTER 5 / Drug Toxicity 59

A
Hapten Mast cell
1 2

Hapten-bound
Protein protein

B Complement-mediated
RBC lysis
Cytotoxic
Antigen T cell
1 2 3

Antigen-bound RBC lysis

RBC RBC Antibodies bind
RBC
RBC removal by
reticuloendothelial system

C Macrophage

Antigen
1 2 3

Antibodies
Antigenantibody Immune complex
complexes deposition in tissues

D
Hapten
1 2 3

Hapten-bound
Protein protein
Antigen Antigen presented
phagocytosis Activated
T cell

FIGURE 5-2. Mechanisms of hypersensitivity reactions. A. Type I hypersensitivity reactions occur when a hapten binds to a protein (1). The antigen crosslinks IgE
antibodies on the surface of a mast cell, leading to mast cell degranulation (2). Mast cells release histamine and other inflammatory mediators. B. Type II hypersensitivity
reactions occur when an antigen binds to the surface of a circulating blood cell, usually a red blood cell (RBC) (1). Antibodies to the antigen then bind the surface of the
RBC (2), attracting cytotoxic T cells (3), which release mediators that lyse the RBC. Binding of antibody to RBCs can also directly stimulate complement-mediated RBC
lysis and RBC removal by the reticuloendothelial system. C. Type III hypersensitivity reactions occur when antibodies bind to a soluble toxin, acting as an antigen (1).
The antigenantibody complexes are then deposited in the tissues (2), attracting macrophages (3) and starting a complement-mediated reaction sequence (not shown).
D. Type IV hypersensitivity reactions occur when a hapten binds to a protein (1) and the hapten-bound protein is phagocytosed by a Langerhans cell (2). The Langerhans
cell migrates to a regional lymph node, where it presents the antigen to a T cell, thereby activating the T cell (3).

rhabdomyolysis and myositis; the fact that this effect oc-
curs highlights the physiologic role of HMG-CoA reductase
in regulating the post-translational modification of several
muscle proteins through a lipidation process called geranyl-
geranylation. Statins, as examples of drugs causing skeletal
muscle injury, are also referenced later in this chapter.
Off-Target Effects
Off-target adverse effects occur when a drug interacts with
unintended targets. Indeed, few drugs are so selective that
they interact with only one molecular target. A prominent
example of an off-target effect is the interaction of numer-
ous compounds with cardiac IKr potassium channels. (Be-
cause the human ether--go-go-related gene [hERG] codes
for one subunit of the human IKr channel, these channels
are also called hERG channels.) Inhibition of potassium
currents carried by IKr channels can lead to delayed repolar-
ization of cardiac myocytes (see Chapter 23, Pharmacology
of Cardiac Rhythm). In turn, delayed repolarization can lead
to increases in the heart-rate corrected QT interval (QTc),
cardiac arrhythmias including torsades de pointes, and sud-
den death. The antihistamine terfenadine was one of the
earliest examples of compounds found to interfere with car-
diac potassium channel currents, leading to potentially fatal
arrhythmias. This drug was designed to avoid drowsiness,
an adverse effect of the first-generation H1 antagonists (see
earlier discussion). The observation of increased deaths due
to cardiac arrhythmia in patients receiving terfenadine led
to withdrawal of this compound from the market and vigor-
ous efforts to understand how to prevent such events. Sur-
veys have shown that, although many compounds inhibit
the hERG channel, compounds with a half-maximal inhibi-
tory concentration (IC50) more than 30-fold greater than the
62 Fundamental Principles of Pharmacology
products contain alkaloids that may deplete hepatic glutathi-
one stores, increasing the risk of acetaminophen toxicity. In
combination with selective serotonin reuptake inhibitors, St.
Johns wort may cause a mild serotonergic syndrome.
Cellular Mechanisms of Toxicity:
Apoptosis and Necrosis
Cells are equipped with various mechanisms to avoid or re-
pair damage: toxicity occurs if and when these defenses are
overwhelmed. In some cases, toxicity can be minimized in
the short term, but repeated insults (for example, those lead-
ing to fibrosis) can eventually compromise organ function.
The primary cellular responses to a potentially toxic drug
are illustrated in Fig. 5-3A and 5-3B, using the hepatocyte
as an example. Depending on the severity of the toxic insult,
a cell may undergo apoptosis (programmed cell death) or
necrosis (uncontrolled cell death). Apoptosis allows the cell
to undergo ordered self-destruction by the coordinated acti-
vation of a number of dedicated proteins. Apoptosis can be
beneficial when it eliminates damaged cells without damage
to surrounding tissue. Inhibition of apoptosis is common in
many cancer cells.
If the toxic insult is so severe that ordered cell death cannot
be accomplished, the cell undergoes necrosis. Necrosis is char-
acterized by enzymatic digestion of cellular contents, denatur-
ation of cellular proteins, and disruption of cellular membranes.
While apoptotic cells undergo cell death with minimal inflam-
mation and disruption of adjacent tissue, necrotic cells attract
inflammatory cells and can damage nearby healthy cells.
Organ and Tissue Toxicity
Most chapters in this book contain tables that list the seri-
ous and common adverse effects of the drugs discussed in
that chapter. Here, we consider common mechanisms of in-
jury and repair pertaining to the toxic effects of drugs on the
major organ systems. This chapter is not intended to cata-
logue every possible injury to each organ or organ system,
since the range of drug-associated organ and tissue toxicity
is so great that is not possible to discuss all the specific toxic-
ities of all the individual drugs in a single chapter. Instead, a
few specific examples of injury are provided to demonstrate
the general features of drug toxicity.
Harmful Immune Responses and Immunotoxicity
Stimulation of the immune system plays a role in the toxicity
of several drugs and drug classes. Drugs can be responsible
for immune reactions (the classic type I through type IV
reactions), syndromes that mimic some features of immune
responses (red man syndrome), and skin rashes (eruptions)
including severe and life-threatening conditions such as
Stevens-Johnson syndrome and toxic epidermal necrolysis.
Drugs can also compromise the normal function of the im-
mune system (immunotoxicity), leading to secondary effects
such as increased risk of infection.
Some drugs may be recognized by the immune system
as foreign substances. Small-molecule drugs with a mass of
less than 600 daltons are not direct immunogens, but can act
as haptens, where the drug binds (often covalently) to a pro-
tein in the body and is then capable of triggering an immune
response. If a drug is sufficiently large (e.g., a therapeutic
peptide or protein), it may directly activate the immune sys-
tem. The two principal immune mechanisms by which drugs
can produce damage are hypersensitivity responses (aller-
gic responses) and autoimmune reactions.
The hypersensitivity responses are classically divided
into four types (Fig. 5-2). Table 5-1 provides information
about the mediators and clinical manifestations of the four
types of hypersensitivity reactions. Prior exposure to a sub-
stance is required for each of the four types of reactions.
A type I hypersensitivity response (immediate hyper-
sensitivity or anaphylaxis) results from the production of
IgE after exposure to an antigen. The antigen may be a for-
eign protein, such as the bacterially derived thrombolytic
drug streptokinase, or it may be an endogenous protein
modified by a hapten to become immunogenic. Penicillin
fragmentseither in the administered drug formulation or
formed in vivocan act as haptens and activate the immune
system. Subsequent exposure to the antigen causes mast
cells to degranulate, releasing inflammatory mediators such
as histamine and leukotrienes that promote bronchoconstric-
tion, vasodilatation, and inflammation. Type I hypersensitiv-
ity responses manifest as a wheal-and-flare reaction in the
skin. Symptoms of hay fever such as conjunctivitis and
rhinitis may develop in the upper respiratory tract, while
asthmatic bronchoconstriction may occur in the lower respi-
ratory tract (see Chapter 47, Integrative Inflammation Phar-
macology: Asthma).
A type II hypersensitivity response (antibody-dependent
cytotoxic hypersensitivity) occurs when a drug binds to cells,
usually red blood cells, and is recognized by an antibody,
usually IgG. The antibody triggers cell lysis by complement
fixation, phagocytosis by macrophages, or cytolysis by cyto-
toxic T cells. Type II responses are rare adverse responses to
several drugs, including penicillin and quinidine.
Type III hypersensitivity responses (immune complex-
mediated hypersensitivity) occur when antibodies, usually
IgG or IgM, are formed against soluble antigens. The anti-
genantibody complexes are deposited in tissues such as kid-
neys, joints, and lung vascular endothelium. These complexes
cause damage by initiating serum sickness, an inflammatory
response in which leukocytes and complement are activated
within the tissues. For example, type III hypersensitivity can
be caused by the administration of antivenins, horse serum
proteins obtained by inoculating a horse with the venom to be
neutralized. Examples of other drugs that may pose a risk of
serum sickness are bupropion and cefaclor.
A type IV hypersensitivity response (delayed-type
hypersensitivity) results from the activation of TH1 and
cytotoxic T cells. It most commonly presents as contact
dermatitis when a substance acts as a hapten and binds to
host proteins. The first exposure does not normally pro-
duce a response, but subsequent dermal exposures can
activate Langerhans cells, which migrate to local lymph
nodes and activate T cells. The T cells then return to the
skin and initiate an immune response. Well-known type
IV hypersensitivity responses include reactions to poison
ivy and the development of latex allergies. Repeated ex-
posure to a drug recognized as foreign by the immune
system can trigger a massive immune response. This cy-
tokine storm can lead to fever, hypotension, and even
organ failure. Thus, physicians should consider possible
immune reactions to all administered drugs, even those
that have appeared to be safe in broader populations. In
the case presented at the beginning of the chapter, Ms. Gs
fever and rash were likely caused by a T-cell mediated
 CHAPTER 5 / Drug Toxicity 63

A Drug

Quiescent
Kupffer cell
Hepatocyte

Cytotoxins
(IL-1, -TNF)
Mitochondrial uncoupling
ROS Activated
Consumption of ATP
Stressed Kupffer cell
Consumption of antioxidants
hepatocyte
Lipid and protein oxidation
IL-1
Disturbance of Ca2+ homeostasis ROS
EC-GF
ROS TGF-
RNI

ROS
TGF-

Apoptotic Endothelial cells Ito cell

hepatocyte (activation and proliferation)

Fibrosis

B
Drug
Circulating
monocytes

Quiescent
Kupffer cell
Hepatocyte Chemotactic
activating
factors
(LTB4, LPO)

Plasma membrane blebs

Injured Increased cellular volume Cytotoxins
hepatocyte Mitochondrial swelling (RNI, ROS) Activated
Dilated endoplasmic reticulum
Kupffer cell

ROS
RNI IL-1 ROS

Endothelial cells
Necrotic (activation)
hepatocyte

FIGURE 5-3. Subtoxic and toxic damage to hepatocytes in response to moderate and high doses of drug. A. Subtoxic damage. Moderate doses of a poten-
tially toxic drug activate Kupffer cells and are metabolized by hepatocytes. The resulting hepatocyte stress may be exacerbated by the effects of reactive oxygen species
(ROS) and reactive nitrogen intermediates (RNI) elaborated by activated endothelial cells. Hepatocyte apoptosis and Ito cell activation may result, leading to fibrosis.
B. Toxic damage. High doses of a toxic drug are metabolized by hepatocytes to reactive metabolites that can induce cell injury. Chemotactic activating factors released
by the injured hepatocytes activate Kupffer cells and endothelial cells, which elaborate toxic ROS and RNI. The end result of this toxic cascade is hepatocyte necrosis.
EC-GF, endothelial cell growth factor; IL-1, interleukin-1; IL-1, interleukin-1; LPO, lipid peroxidation; LTB4, leukotriene B4; TGF-, transforming growth factor ; -
TNF, tumor necrosis factor .
 CHAPTER 5 / Drug Toxicity 65

at concentrations of drug that are required for efficacy. For O

these agents, there is generally little safety margin for dam- NH

O

age to normal tissues, and successful therapy depends on a O NH

greater sensitivity of the cancer cells compared to normal
tissues. An increased risk of infection often accompanies NH
therapy with agents that are cytotoxic to white blood cells. -
O O Glucuronyl
transferase Sulfotransferase
The margin between adverse effects and therapeutic effects O
O

may be increased by the use of agents that stimulate leuko- OH -

O O
S
cyte production (filgrastim). OH
OH OH O O
Targeting of the immune system may be appropriate when
the disease is exacerbated by a deleterious immune response Acetaminophen Acetaminophen Acetaminophen
glucuronide sulfate
(see Chapter 45). For example, inhaled corticosteroids may
be used to control symptoms in patients with frequent, severe
exacerbations of chronic obstructive pulmonary disease (see P450 enzyme

Chapter 47). By inhibiting immune responses to pathogenic or

micro-organisms, however, such treatment is also associated PHS
with an increased risk of pneumonia. O
Some immunotherapies target specific cell types in the O

immune system and are associated with an increased risk NH

N
of serious infection. Rituximab is a monoclonal antibody
Gly
(mAb) that targets CD20-positive B cells, which are in-
volved in the pathogenesis of non-Hodgkins lymphoma S O
(malignant CD20-positive B cells) and rheumatoid arthritis Glutathione OH NH
(antibody-producing CD20-positive B cells). Two potentially O Glu
serious adverse effects that have been observed with the use N-acetyl-p-benzoquinoneimine Glutathione conjugate
of rituximab are progressive multifocal leukoencephalopa- (NAPQI)
thy (PML), an infection caused by a polyomavirus, the JC
virus (JCV), and hepatitis B reactivation with the potential
for fulminant hepatitis. These infectious agents are gener-
ally present in latent form in patients prior to treatment with Hepatotoxicity Excretion
O
rituximab, but the loss of immunocompetence as a result H
N
of treatment allows expression of these serious infections. OH
Similarly, efalizumab is a monoclonal antibody that tar- O
gets CD11a, the subunit of leukocyte function-associated HS

antigen-1 (LFA-1), which is expressed on all leukocytes. N-acetylcysteine

By decreasing the cell surface expression of CD11a and in-
hibiting the binding of LFA-1 to the intercellular adhesion
molecule-1 (ICAM-1), efalizumab inhibits leukocyte adhe-
sion and acts as an effective immunotherapy for psoriasis.
However, because CD11a is also expressed on the surface
of B cells, monocytes, neutrophils, natural killer cells, and
other leukocytes, efalizumab can affect the activation, adhe-
sion, migration, and destruction of these cells as well. Like
rituximab, efalizumab has been associated with PML; this
serious adverse effect led to its withdrawal from the mar-
ket in 2009. A similar increase in the frequency of PML has
been found in patients receiving natalizumab for multiple
sclerosis. Natalizumab binds to the 4 subunit of 41 and
47 integrins expressed on the surface of all leukocytes ex-
cept neutrophils; by inhibiting the 4-mediated adhesion of
leukocytes to their target cells, further leukocyte recruitment
and activation are prevented.
(NAC)
FIGURE 5-4. Mechanism of acetaminophen poisoning and treatment.
Therapeutic doses of acetaminophen are nontoxic, but one metabolite formed at
supratherapeutic doses can cause potentially lethal hepatotoxicity. Under ordi-
nary circumstances, acetaminophen is metabolized primarily by glucuronidation
(5560%) and sulfation (3035%); another 5% or less is excreted unchanged.
The remaining 510% is oxidized to a reactive intermediate, N-acetyl-p-benzo-
quinoneimine (NAPQI). This oxidation is catalyzed by cytochrome P450 enzymes
(CYP), primarily CYP2E1, as well as CYP3A4 and CYP1A2, and by prostaglandin
H synthase (PHS). At therapeutic doses, NAPQI reacts rapidly with glutathione
to form a nontoxic metabolite that is readily excreted. Under conditions of over-
dosing, however, NAPQI formation exceeds glutathione production, allowing free
NAPQI to attack mitochondrial and cellular proteins. If this process is unchecked,
hepatocyte necrosis and acute liver failure can result. Timely administration of
the antidote N-acetylcysteine (NAC) can be lifesaving (within 10 hours of acet-
aminophen overdosing), in that NAC both reacts directly with NAPQI and serves as
a precursor to glutathione.

Drug-Induced Hepatotoxicity
As described in Chapter 4, many drugs are metabolized in
the liver, and some of these metabolites can cause liver dam-
age. A clinically significant example is acetaminophen,
a widely used analgesic and antipyretic. In its therapeutic
dose range, acetaminophen is metabolized predominantly by
glucuronidation and sulfation, resulting in readily excreted
metabolites; a small fraction of the dose is also excreted un-
changed. As shown in Figure 5-4, however, acetaminophen
can also be oxidized to a reactive and potentially toxic species,
N-acetyl-p-benzoquinoneimine (NAPQI). Glutathione can
conjugate with and thus detoxify NAPQI, but overdosing
with acetaminophen depletes glutathione reserves (as can
other conditions), leaving NAPQI free to attack cellular and
mitochondrial proteins, resulting ultimately in the necrosis of
hepatocytes. Timely (within about 10 hours of acetaminophen
overdosing) administration of the antidote N-acetylcysteine
(NAC) replenishes glutathione stores and can avert liver fail-
ure and death. This example underscores the importance of
66 Fundamental Principles of Pharmacology
dose: although acetaminophen is used safely by millions of
individuals every day, the same drug, when taken in excess,
is responsible for some 50% of the cases of acute liver failure
in the United States.
Unexpected hepatotoxicity is the most frequent reason for
drug withdrawals in the United States. Many cases of fulmi-
nant hepatitis following drug therapy are idiosyncraticthat
is, the mechanism by which the patient develops hepatic injury
is not knownmaking it difficult to identify at-risk patients.
In some cases, failure to determine the mechanism(s) respon-
sible for hepatic injury is due to the inability to reproduce the
injury in laboratory animals. A further challenge is that hepa-
totoxicity may not be anticipated based on preclinical studies,
because compounds exhibiting significant hepatotoxicity in
animal studies at doses near the anticipated therapeutic expo-
sures in humans are generally eliminated from development.
Further confounding the prevention of hepatotoxicity is that
clinical trials of a drug typically include a few thousand pa-
tients, even though a risk of drug-induced hepatotoxicity in
the range of 1 in 10,000 to 1 in 100,000 patients would be
of sufficient concern to result in withdrawal. In other words,
many clinical trials are too small, or have been designed with
exclusion criteria not maintained once the drug is marketed,
to detect unacceptable risks of hepatotoxicity. Withdrawal of
the insulin-sensitizing agent troglitazone, for example, oc-
curred only after it was noted that approximately 1 in 10,000
patients taking the drug died from acute liver failure.
The serum activities of certain enzymes (alanine amino-
transferase [ALT], aspartate aminotransferase [AST], and
alkaline phosphatase [ALP]) and bilirubin are often used to
monitor for potential hepatotoxicity in patients. The com-
bination of hepatocellular injury (indicated by increased
serum activity of ALT, AST, and ALP) and decreased hepatic
function (indicated by elevated bilirubin) is the best predic-
tor of outcome for drug-induced hepatotoxicity. Elevation of
serum ALT to 3 times the upper limit of normal, combined
with elevation of serum bilirubin to 2 times the upper limit
of normal, is associated with a mortality rate of at least 10%.
This predictor has become known as Hys Rule, named for
the hepatologist Hyman Zimmerman.
Drug-Induced Renal Toxicity
The kidney is the major route of elimination of many drugs
and their metabolites. Nephrotoxicity may manifest as al-
terations in renal hemodynamics, tubular damage and ob-
struction, glomerular nephropathy, and interstitial nephritis.
Progressive renal failure, characterized by progressive in-
creases in serum creatinine, may result from loss of func-
tion of a sufficient number of nephrons. Examples of drug
classes that can cause renal failure include certain antibiot-
ics, NSAIDs, antineoplastic agents, immunomodulators, and
angiotensin converting enzyme (ACE) inhibitors. Here, we
describe the mechanisms of nephrotoxicity caused by the
aminoglycoside antibiotic gentamicin and the antifungal
agent amphotericin B. Renal injury is a common adverse
effect of treatment with both of these agents.
Gentamicin causes renal injury in part through its inhibi-
tion of lysosomal hydrolases (sphingomyelinase, phospho-
lipases) in proximal tubules of the kidney, leading to the
lysosomal accumulation of electron-dense lamellar structures
containing undegraded phospholipids. This process is called
renal phospholipidosis. Lysosomal rupture leads to cell death
in the form of acute tubular necrosis. Renal tubular injury by
gentamicin and other aminoglycoside antibiotics is reversible
upon cessation of treatment, provided that the initial injury is
not too severe.
The polyene amphotericin B damages fungal cell mem-
branes by interacting with ergosterol and forming membrane
pores through which potassium leaks, leading to cell death.
Amphotericin-induced renal injury appears to occur via a
similar mechanism, with initial binding of drug to sterols in
the membranes of renal tubular epithelial cells. Because the
mechanism responsible for efficacy is shared by the mecha-
nism responsible for toxicity, the margin between the expo-
sures required for antifungal activity and those required for
renal injury is small, leading to a high frequency of renal in-
jury in patients receiving amphotericin B. Liposomal formu-
lations of amphotericin B have been developed in an attempt
to reduce this toxicity and to increase the plasma half-life
of the drug. If the initial injury is not too severe, cessation
of treatment with amphotericin often results in recovery of
renal function.
Contrast media is administered intra-arterially or intra-
venously to provide radiographic delineation of the vascula-
ture in organs such as the heart and the brain. These agents
appear to cause renal injury both by direct toxicity to renal
tubular epithelial cells and by constriction of the vasa recta
leading to reduced renal medullary blood flow. The nephro-
toxicity of contrast media is dose-related, and patients with
preexisting reductions in medullary blood flowdue, for
example, to renal insufficiency, intravascular volume deple-
tion, heart failure, diabetes, or diuretic or NSAID useare
at higher risk.
Drug-Induced Neurotoxicity
Drug-induced neurotoxicity is most often associated with
the use of cancer chemotherapeutic agents. In most cases,
neurotoxicity manifests in the peripheral nerves, but the
central nervous system may be affected as well. Periph-
eral neuropathy has been associated with vinca alkaloids
(e.g., vincristine, vinblastine), taxanes (e.g., paclitaxel),
and platinum compounds (e.g., cisplatin). The neuropathy
caused by vinca alkaloids and taxanes is directly related to
their primary mechanism of action, microtubule disruption
(see Chapter 38). In peripheral nerves, microtubule disrup-
tion is thought to result in altered axonal trafficking and both
sensory and motor neuropathy. Platinum-containing com-
pounds may have direct toxic effects on peripheral nerves.
Drug-Induced Skeletal Muscle Toxicity
Drug classes associated with skeletal muscle injury include
HMG-CoA reductase inhibitors (statins), corticosteroids
(dexamethasone, betamethasone, prednisolone, hydro-
cortisone), and zidovudine (AZT or ZDV). Statin-induced
myopathy appears to relate to the inhibition of geranyl-
geranylation of several muscle proteins. Corticosteroid-induced
muscle injury is complex, involving altered carbohydrate me-
tabolism, decreased protein synthesis, and alterations in mi-
tochondrial function that reduce oxidative capacity. Patients
treated with corticosteroids can manifest weakness, atrophy,
myalgia, and microscopic decreases in muscle fiber size. Cor-
ticosteroid-associated muscle injury is reversible, albeit slowly.
Understanding the pathogenesis of zidovudine-induced myo-
pathy is complicated by the ability of HIV, the viral infection
for which zidovudine is administered, to induce myopathy in
the absence of drug therapy. Nonetheless, the improvement in

muscle function upon withdrawal of zidovudine and the inde-
pendent demonstration of zidovudine-induced myopathy in ro-
dents suggest that the drug itself causes myopathy, at least in
some patients. The mechanism of zidovudine-associated myo-
pathy is not well understood, but accumulation of the drug in
skeletal muscle, disruption of mitochondrial cristae, and dimin-
ished oxidative phosphorylation are thought to play a role.
Drug-Induced Cardiovascular Toxicity
Three major mechanisms of drug-induced cardiovascular
toxicity have been recognized. First, as discussed earlier,
many drugs interact with cardiac potassium channels to
cause QTc prolongation, delayed repolarization, and car-
diac arrhythmia. Second, some drugs are directly toxic to
cardiac myocytes. The anthracycline antineoplastic agent
doxorubicin avidly binds to iron; in the presence of oxygen,
the iron can cycle between the iron(II) and iron(III) states,
leading to the production of reactive oxygen species (ROS).
These ROS promote cytotoxicity and death of cardiac myo-
cytes, which possess low activity of antioxidant enzyme sys-
tems. Cardiotoxicity, leading to heart failure and arrhythmia,
is often the dose-limiting toxicity in patients receiving this
drug. Third, as noted earlier, some drugs are toxic to heart
valves. The amphetamine analog fenfluramine exerts its de-
sired anorectic effect by both increasing the release of sero-
tonin and decreasing the uptake of serotonin. Fenfluramine
and its metabolite norfenfluramine also bind with high af-
finity to 5-HT2B receptors. Drug binding to 5-HT2B recep-
tors in heart valves activates mitogenic pathways, resulting
in proliferation of valvular myofibroblasts that form myxoid
plaques on the atrioventricular valves, leading to valvular
insufficiency and death in some patients. The 5-HT activ-
ity of fenfluramine can also increase vascular resistance and
remodel the pulmonary arterial system, leading to the de-
velopment of pulmonary hypertension. Because of the po-
tential severity of these cardiovascular toxicities, there is a
concerted effort to avoid selection of compounds for drug
development that exhibit significant prolongation of the QTc
interval or binding affinity for 5-HT2B receptors.
Drug-Induced Pulmonary Toxicity
Adverse effects in the lungs range from acute, reversible ex-
acerbations of asthmatic symptoms to chronic injury char-
acterized by remodeling and/or fibrosis. Reversible airway
obstruction can be associated with beta-agonist therapy,
whereas chronic injury is observed in some patients receiving
the chemotherapeutic agent bleomycin or the antiarrhythmic
drug amiodarone. The response to injury after cellular dam-
age is largely determined by the regenerative capacity of the
target organ. Repeated insults to the lung, particularly to the
epithelial cells lining conducting airways and alveoli, may
be followed by regeneration. Repeated cycles of epithelial
injury can lead to excessive deposition of collagen and ex-
tracellular matrix proteins in alveolar septa and the alveolar
spaces, causing fibrosis. Pulmonary fibrosis is manifested as
loss of function. Bleomycin and amiodarone are contraindi-
cated in patients with existing disease of the lung parenchyma
because both of these agents can cause pulmonary fibrosis.
Carcinogenesis Due to Drug Therapy
Drugs (and other agents) that can cause cancer are termed
carcinogens. More broadly, a carcinogen is a chemical,
physical, or biological insult that acts by causing specific
CHAPTER 5 / Drug Toxicity 67
types of DNA damage (these agents are termed initiators)
or by facilitating proliferation of cells carrying precancer-
ous mutations (these agents are promoters). Initiators act
by damaging DNA, interfering with DNA replication, or
interfering with DNA repair mechanisms. Most initiators
are reactive species that covalently modify the structure of
DNA, preventing accurate replication and, if unrepaired or
misrepaired, leading to a mutation(s). If the mutation(s) af-
fects a gene(s) that controls cell cycle regulation, neoplastic
transformation may be initiated. Carcinogenesis is a complex
process, involving multiple genetic and epigenetic changes,
that usually takes place over years or decades.
For most therapeutic areas, compounds that cause direct
DNA damage are avoided. Yet DNA damage and/or inter-
ference with DNA repair is the desired therapeutic effect
of many agents used to treat neoplasia. Damage to normal
blood cell progenitors is an important on-target adverse effect
of cytotoxic alkylating agents used in cancer chemotherapy
(chlorambucil, cyclophosphamide, melphalan, nitrogen
mustards, and nitrosoureas). These agents can cause myelo-
dysplasia and/or acute myeloid leukemia (AML). Indeed, 10%
to 20% of cases of AML in the United States arise secondary
to treatment of other cancers with such anticancer drugs.
Tamoxifen, a nongenotoxic estrogen receptor modulator,
is an effective treatment in patients with estrogen-sensitive
breast cancer. However, this agent also increases the risk of
some tumors. Although tamoxifen is an antagonist of estro-
gen receptors in the breast, it acts as a partial agonist in other
tissues that express the estrogen receptor, most notably the
uterus. Therefore, an adverse effect of breast cancer treatment
with tamoxifen can be the development of endometrial cancer.
Newer estrogen receptor modulators, such as raloxifene, do
not stimulate uterine estrogen receptors and may be used to
treat or prevent breast cancer with a lower risk of endometrial
cancer (see Chapter 29, Pharmacology of Reproduction).
Product labels describe the preclinical assessment of each
drug in the section entitled Carcinogenesis, Mutagenesis, Im-
pairment of Fertility. In this section, it is not unusual to find
descriptions of rodent studies that suggest carcinogenic po-
tential for drugs. Since mutagens are not typically developed
as drugs (with the exceptions noted above), the treatment-
related tumors observed in these lifetime studies in rodents
administered high doses of drug are generally attributed to
nongenotoxic (epigenetic) mechanisms. To assess whether the
rodent findings represent a risk to the intended patient popu-
lation, it is important to understand the mechanism by which
these tumors occur. The proton pump inhibitor omeprazole,
for example, causes tumors of the gastric enterochromaffin-
like (ECL) cells in rodents. The development of these tumors
results from a dose-related and sustained increase in gastrin,
which is secondary to the desired effect of the compound (de-
creased acid secretion). However, the exposures required for
sustained gastrin elevation and tumor formation in rodents
far exceed the exposures required for efficacy in patients.
Further, the gastrin elevations noted in patients are of low
magnitude and are not sustained. Thus, the carcinogenic find-
ing in the rodent studies is not considered to signal a risk for
tumor development in patients.
Teratogenesis Due to Drug Therapy
Drugs given to pregnant patients may adversely affect the
fetus. Teratogenesis is the induction of structural defects
in the fetus, and a teratogen is a substance that can induce

Another example of an on-target teratogenic effect is in
utero exposure of the fetus to ACE inhibitors. Although ACE
inhibitors were previously not contraindicated in the first tri-
mester of pregnancy, recent data indicate that fetal exposure
during this period significantly increases the risks of cardio-
vascular and central nervous system malformations. ACE
inhibitors can cause a group of conditions including oligo-
hydramnios, intrauterine growth retardation, renal dysplasia,
anuria, and renal failure, reflecting the importance of the an-
giotensin pathway on renal development and function.
 PRINCIPLES FOR TREATING PATIENTS
WITH DRUG-INDUCED TOXICITY
Treatment of drug-induced toxicity may include: (1) reduc-
ing or eliminating exposure to the drug; (2) administering
specific treatments based on antagonizing the mechanism of
action of the drug or altering its metabolism; and/or (3) pro-
viding supportive measures.
Reduction of exposure to a therapeutic agent in a patient
who experiences adverse effects may seem intuitive, but it
is not always the correct choice. The appearance of an ad-
verse effect during therapy does not necessarily indicate that
the effect is due to the drug, despite the temporal relation-
ship between the initiation of therapy and the appearance
of the adverse effect. Even if the adverse effect most likely
occurred because of the drug, the risks of cessation must be
weighed against the benefits of continuing that drug. Ces-
sation of therapy is more obviously a correct choice when
the adverse effects have been previously associated with the
drug and are life-threatening, such as anaphylaxis due to a
beta-lactam antibiotic. Needless to say, for such patients,
future therapy with this class of antibiotics would also be
contraindicated. Adverse effects that are irreversible and/or
likely to increase in severity with continued treatment may
also lead to the appropriate decision to terminate therapy.
Many adverse effects, however, are considered tolerable and
reversible. Depending on the severity of the disease condi-
tion being treated, it may be that the overall benefit to the pa-
tient is greater with drug treatment than without. An example
of such circumstances is the leukopenia that often occurs in
patients receiving chemotherapy with cytotoxic drugs. Thus,
the decision to withdraw or reduce therapy can be complex
and often requires evaluation of many factors affecting the
patients immediate and long-term health.
Therapies designed to counteract the adverse effects pro-
duced by a given drug are often based on antagonizing the
pharmacologic (on-target) activity of the drug or interfering
with effects related to metabolism of the drug. Antagonizing the
pharmacologic activity of a drug is a useful approach in over-
doses of opioids, benzodiazepines, and acetylcholinesterase
(AChE) inhibitors. Interference with the toxic effects of drug
metabolites is a useful approach in the treatment of acetamino-
phen toxicity. These examples are briefly discussed below.
Conceptually, the simplest treatment for drug overdose
is the administration of an antagonist that blocks the ac-
tion of a drug that, directly or indirectly, results in supra-
physiologic activation of a receptor. For example, an opioid
overdose can be treated with naloxone, a pharmacologic
antagonist of the opioid receptor. By competitively bind-
ing to opioid receptors, naloxone prevents or reverses the
toxic effects of natural or synthetic opioids, including
CHAPTER 5 / Drug Toxicity 69
respiratory depression, sedation, and hypotension. Nalox-
one has a rapid onset of action and is highly potent; indeed,
if no clinical improvement is observed within 10 minutes
after naloxone doses of up to 10 mg, a different diagnosis or
multiple toxic entities should be considered. Naloxone has
a relatively short half-life, so it must be given every 1 to 4
hours to provide adequate receptor antagonism while the
opioid is being cleared.
Flumazenil, a pharmacologic antagonist at the GABAA
(benzodiazepine) receptor, is used to treat benzodiazepine
overdose. Flumazenil acts by competitive inhibition at
benzodiazepine receptors in the central nervous system to
completely or partially reverse the sedative effects of ben-
zodiazepines. Like naloxone, it has a rapid onset of action
and is highly potent; its effects should be seen within 5 min-
utes at a dose of not more than 3 mg. Flumazenil also has
a short half-life (approximately 1 hour) and must be given
frequently to provide adequate receptor antagonism while
the benzodiazepine is being cleared.
Pharmacologic antagonism can also be used when the
toxic agent is not a direct agonist but rather indirectly in-
creases the concentration of the natural ligand for a receptor.
AChE inhibitors produce a supraphysiologic concentration
of acetylcholine in the synaptic cleft and a characteristic
toxidrome of cholinergic excessbradycardia, miosis, hy-
persalivation, sweating, diarrhea, vomiting, bronchocon-
striction, weakness, respiratory paralysis, and convulsions.
Although it is sometimes possible to restore AChE activity,
the treatment of AChE inhibition generally depends on ad-
ministering an anticholinergic agent such as atropine. By
antagonizing the muscarinic acetylcholine receptor, atropine
restores cholinergic balance and prevents bronchoconstric-
tion, the most common cause of death in patients exposed to
AChE inhibitors.
As noted earlier, a consequence of acetaminophen over-
dose is depletion of intracellular glutathione by the drugs
metabolite N-acetyl-p-benzoquinoneimine (NAPQI). Glu-
tathione stores can be replenished by administering N-
acetylcysteine (NAC), a metabolic precursor of glutathione
(see Fig. 5-4 for details). In addition to supportive therapy
(gastric lavage and/or charcoal), NAC is given orally or in-
travenously within 8 to 10 hours following ingestion of a
potentially hepatotoxic dose of acetaminophen to prevent or
lessen hepatic injury.
Finally, supportive therapy can be provided in the face
of drug-induced toxicity. One example is the administration
of intravenous fluids to patients with renal injury in order
to maintain adequate renal blood flow. In cases of severe
renal injury, dialysis may be required until renal function is
regained. Another example is the treatment of bone marrow
suppression resulting from the administration of cytotoxic
agents in cancer chemotherapy. Filgrastim, a recombinant
human granulocyte colony-stimulating factor (G-CSF), can
be used to stimulate leukocyte production and provide sup-
portive therapy until endogenous production of leukocytes re-
sumes in the bone marrow upon completion of the cytotoxic
therapy.
 CONCLUSION AND FUTURE DIRECTIONS
This chapter has presented a mechanism-based approach
to understanding drug toxicity and provided examples to

Pharmacogenomics
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . . . 71-72
PHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Genomic Variation and Pharmacogenomics . . . . . . . . . . . . 71
PHARMACOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Variation in Enzymes of Drug Metabolism:
Pharmacokinetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Variation in Drug Targets: Pharmacodynamics . . . . . . . . . . 75
 INTRODUCTION
Although modern pharmacologic agents can be used to treat
or control diseases that range from hypertension to human im-
munodeficiency virus (HIV) infection, there are large individual
variations in response to drug therapy. These variations can range
from potentially life-threatening adverse drug reactions to equally
serious lack of therapeutic efficacy. Many factors can influence
the drug response phenotype, including age, gender, and under-
lying disease, but genetic variation also plays an important role.
Interindividual differences in the genes that encode drug targets,
drug transporters, or enzymes that catalyze drug metabolism can
profoundly affect the success or failure of pharmacotherapy.
Pharmacogenetics is the study of the role of inheritance
in variation in drug response. The convergence of recent
advances in genomic science and equally striking advances
in molecular pharmacology has resulted in the evolution of
pharmacogenetics into pharmacogenomics. The promise of
pharmacogenetics-pharmacogenomics is the possibility that
knowledge of a patients DNA sequence could be used to en-
hance pharmacotherapy, maximize drug efficacy, and reduce
the incidence of adverse drug reactions. Therefore, pharma-
cogenetics and pharmacogenomics represent an important
aspect of the aspiration to personalize or individualize
medicinein this case, drug therapy. This chapter describes
the principles of pharmacogenetics and pharmacogenomics
as well as recent developments in this discipline. Several key
examples are cited in which knowledge of pharmacogenetics-
pharmacogenomics may help to individualize drug therapy.
 PHYSIOLOGY
Genomic Variation and Pharmacogenomics
The human genome contains approximately three billion nu-
cleotides. According to current estimates, the genome contains
6
Liewei Wang and Richard M. Weinshilboum
Pathway-Based Pharmacogenetics-
Pharmacogenomics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Idiosyncratic Drug Reactions . . . . . . . . . . . . . . . . . . . . . . . 77
Modern Pharmacogenetics-Pharmacogenomics. . . . . . . . . 77
Pharmacogenomics and Regulatory Science . . . . . . . . . . . 78
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . . 79
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
approximately 25,000 genes that, through alternative splicing
and post-translational modification, may encode 100,000 or
more proteins. Any two people differ on average at about one
nucleotide in every 1,000 in their genome, totaling an average
interindividual difference of 3 million base pairs throughout
the genome. The majority of these differences are so-called
single nucleotide polymorphisms or SNPs (pronounced
snips), in which one nucleotide is exchanged for another
at a given position. SNPs and other differences in DNA se-
quence can occur anywhere in the genome, in both coding
regions and noncoding regions. If a SNP changes the encoded
amino acid, it is called a nonsynonymous coding SNP (cSNP).
The remaining differences in DNA sequence involve inser-
tions, deletions, duplications, and reshufflings, sometimes of
just one or a few nucleotides but occasionally of whole genes
or larger DNA segments that include many genes. Function-
ally significant DNA sequence differences that we currently
understand tend to fall within genes, either within their coding
sequences or in the promoters, enhancers, splice sites, or other
sequences that control gene transcription or mRNA stability.
Taken together, these differences constitute each persons ge-
netic individuality. Some of that individuality affects the way
in which each person will respond to drug treatment.
 PHARMACOLOGY
The concept that inheritance might be an important determi-
nant of individual variation in drug response emerged half a
century ago. It originally grew out of clinical observations of
striking differences among patients in their response to stan-
dard doses of a drug. Those observations, in addition to twin
and family studies that showed inherited variations in plasma
drug concentrations and other pharmacokinetic parameters, led
to the birth of pharmacogenetics. Many of those original exam-
ples of pharmacogenetic variation, and many of the most strik-
ing examples even today, involve pharmacokineticsfactors
71
74 Fundamental Principles of Pharmacology
A CYP2D6 pharmacogenetics
Ultrarapid Extensive Poor
metabolizers metabolizers metabolizers
120
Number of subjects
80
40
0 that are good CYP2D6 substrates, they receive less bene-
0.01 0.10 1 10 100
Debrisoquine: 4-Hydroxydebrisoquine metabolic ratio
B AmpliChip CYP450 array
FIGURE 6-1. CYP2D6 pharmacogenetics. A. Frequency distribution of the
metabolic ratio for the cytochrome P450 2D6 (CYP2D6)-catalyzed metabolism of
debrisoquine to form its 4-hydroxy metabolite. Data for 1,011 Swedish subjects
are plotted as the ratio of metabolites in the urine. Most subjects metabolize de-
brisoquine extensively, while some subjects metabolize the compound ultrarapidly
and others metabolize the compound poorly. B. The AmpliChip CYP450 array can
be used to determine variant genotypes for cytochrome P450 genes that influence
drug metabolism.
the neuroleptic haloperidol, the opioids codeine and dex-
tromethorphan, and the antidepressants fluoxetine, imip-
ramine, and desipramine, among many others (Table 6-1).
Therefore, poor metabolizers for CYP2D6 can potentially
experience an adverse drug effect when treated with standard
doses of agents such as metoprolol that are inactivated by
CYP2D6, whereas codeine is relatively ineffective in poor
metabolizers because it requires CYP2D6-catalyzed metabo-
lism to form the more potent opioid morphine. Conversely,
ultrarapid metabolizers may require unusually high doses
of drugs that are inactivated by CYP2D6, but those same
subjects can be overdosed with codeine, suffering respi-
ratory depression or even respiratory arrest in response to
standard doses. In one tragic case, a nursing infant whose
mother was an ultrarapid CYP2D6 metabolizer died when
the mother was prescribed a standard dose of codeine and the
baby was overdosed on morphine present in the breast milk.
CYP2D6 genetic polymorphisms are also important for
the efficacy of the breast cancer drug tamoxifen. Tamoxifen
is used to block the estrogen receptor (ER) in approximately
60% of breast cancer patients with ER-positive tumors.
However, tamoxifen is a prodrug that requires metabolic
activation to form 4-hydroxytamoxifen and 4-hydroxy-N-
desmethyltamoxifen (endoxifen) (Fig. 6-2A). These metabo-
lites are approximately 100 times more potent as antagonists
of the ER than the parent drug. As a result, patients who
are CYP2D6 poor metabolizers (Fig. 6-1) are relatively un-
able to form the active 4-hydroxy metabolites of tamoxifen.
Poor-metabolizer patients have worse outcomes with respect
to breast cancer recurrence than do CYP2D6 extensive me-
tabolizers (EMs) (Fig. 6-2B). Furthermore, if EM patients
are co-administered other drugs such as antidepressants
fit from tamoxifen therapy than do CYP2D6 EMs who are
not co-administered drugs that compete with tamoxifen for
CYP2D6-catalyzed metabolism.
In the past, an individuals genotype for CYP2D6 and
many other genes encoding drug-metabolizing enzymes was
inferred from phenotype (e.g., the urinary metabolic ratio
that can be measured by assaying the urinary excretion of a
specific metabolite after the administration of a probe drug)
(Fig. 6-1A). As discussed below, genotype assignment is
now increasingly dependent on DNA-based tests performed
with devices such as the chip shown in Figure 6-1B.
TPMT represents another example of an important and
clinically relevant genetic polymorphism for drug metabo-
lism. TPMT catalyzes the S-methylation of thiopurine drugs
such as 6-mercaptopurine and azathioprine (see Chapter
38, Pharmacology of Cancer: Genome Synthesis, Stability,
and Maintenance). Among other indications, these cytotoxic
and immunosuppressive agents are used to treat acute lym-
phoblastic leukemia of childhood and inflammatory bowel
disease. Although thiopurines are useful drugs, they have a
narrow therapeutic index (i.e., the difference between the
toxic and therapeutic dose is small), with occasional patients
suffering from life-threatening thiopurine-induced myelo-
suppression.
In Caucasians, the most common variant allele for
TPMT is TPMT*3A; the frequency of this allele is approxi-
mately 5%, so 1 in 300 subjects carries two copies of the
TPMT*3A allele. TPMT*3A is predominantly responsible
for the trimodal frequency distribution of the level of red
blood cell TPMT activity shown in Figure 6-3. TPMT*3A
has two nonsynonymous cSNPs, one in exon 7 and another
in exon 10 (Fig. 6-3). The presence of TPMT*3A results in a
striking decrease in tissue levels of TPMT protein. Mecha-
nisms responsible for the observed decrease in TPMT*3A
protein level include both accelerated TPMT*3A degrada-
tion and intracellular TPMT*3A aggregation, probably as a
result of protein misfolding. As a result, drugs such as 6-
mercaptopurine are poorly metabolized and may reach toxic
levels. Subjects homozygous for TPMT*3A are at greatly
increased risk for life-threatening myelosuppression when
treated with standard doses of thiopurine drugs. These pa-
tients have to be treated with approximately one-tenth to
one-fifteenth the standard dose. There are striking ethnic dif-
ferences in the frequency of variant alleles for TPMT. For
example, TPMT*3A is rarely observed in East Asian popula-
tions, whereas TPMT*3C, which has only the exon 10 SNP,
is the most common variant allele in those populations.
 CHAPTER 6 / Pharmacogenomics 75

A
N N

% Subjects per 0.5 units of activity

O O

TPMTH/TPMTH
CYP2D6 SULT1A1 10
(CYP2B6, CYP2C9,
CYP2C19, CYP3A)
OH

Tamoxifen (TAM) 4-hydroxyTAM TPMTL/TPMTH

5
CYP3A4/5 TPMTL/TPMTL
(CYP2C9 + other CYP3A4/5
CYP isoforms)

N
N
0
O
H O 0 5 10 15 20
H
TPMT activity (units/ml RBC)
CYP2D6 SULT1A1

OH 1 2 3 4 5 6 7 8 9 10
TPMT*1
N-desmethylTAM Endoxifen (wild type)
VNTR

TPMT*3A

B VNTR
G460A A719G
100 Ala154Thr Tyr240Cys
Relapse-free survival (%)

FIGURE 6-3. TPMT pharmacogenetics. Frequency distribution of red blood

80 cell (RBC) thiopurine S-methyltransferase (TPMT) activity for 298 unrelated Cau-
casian subjects. TPMT L indicates an allele or alleles for the trait of low activity,
EM
60 while TPMT H refers to the wild type (TMPT*1) allele for high activity. The ob-
IM
served trimodal frequency distribution for RBC TPMT activity is due mainly to the
effect of TPMT*3A, the most common variant allele for low activity in a Caucasian
40
population. TMPT*1 and TPMT*3A differ by two nonsynonymous single nucleotide
PM
polymorphisms (SNPs), one in exon 7 and one in exon 10. VNTR, variable number
20 tandem repeat.
P=0.013

0
0 2 4 6 8 10 12
Because of its clinical significance, TPMT was the first
Years after randomization example selected by the FDA for public hearings on the in-
clusion of pharmacogenetic information in drug labeling.
100
For the same reason, clinical testing for TPMT genetic poly-
Disease-free survival (%)

morphisms is widely available. The phenomenon of marked

80
EM
changes in the level of a protein as a result of the alteration
of only one or two amino acids in the protein has been ob-
60 served repeatedly for many other genes of pharmacogenetic
IM
significance and is a common explanation for the functional
40 effects of nonsynonymous cSNPs.
PM The BChE, NAT2, CYP2D6, and TPMT genetic polymor-
20 Second pain phisms all behave as monogenic (single-gene) Mendelian
P=0.009
traits, as do many other early examples from pharmacogenet-
0 ics. However, pharmacogenetics-pharmacogenomics has now
0 2 4 6 8 10 12 moved beyond monogenic pharmacokinetic traits, and the
Years after randomization focus increasingly involves functionally and clinically sig-
nificant variation in drug targets as well as drug-metabolizing
enzymes. Variation can also involve multiple genes that influ-
FIGURE 6-2. Tamoxifen pharmacogenetics. A. Tamoxifen is metabolized by ence both pharmacokinetics and pharmacodynamics.
two cytochrome P450 pathways to form the active metabolites 4-hydroxytamoxifen
(4-hydroxyTAM) and endoxifen, which are further metabolized by sulfotransferase Variation in Drug Targets: Pharmacodynamics
(SULT) 1A1 (not shown). Genetic variations in CYP2D6 can influence the extent of
tamoxifen metabolism. B. Kaplan-Meier curves showing the influence of CYP2D6
Drugs generally exert their effects by interacting with spe-
metabolizer status on the survival of women with estrogen receptor-positive cific target proteins. Therefore, genetic variations in these
[ER()] breast cancer who were treated with tamoxifen. Patients who were exten- target proteins, or in signaling pathways downstream from
sive metabolizers (EM) of tamoxifen had improved relapse-free survival and disease- the target proteins, can influence the outcome of pharmaco-
free survival relative to intermediate metabolizers (IM) and poor metabolizers (PM). therapy (Table 6-2). Furthermore, variation in drug targets
Precursors of Active
clotting factors clotting factors
O2
CO2

Vitamin K-dependent
-glutamyl carboxylase

Vitamin K reduced Vitamin K epoxide

Vitamin K epoxide
reductase

6-Hydroxywarfarin
7-Hydroxywarfarin
CYP2C9

S-Warfarin
78 Fundamental Principles of Pharmacology

rs4363657
8 P=4x10-9
7
EM
6
-Log10 P Value

IM
5
PM
4
P=0.013
3

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 19 21 X
18 20 22
Chromosome

FIGURE 6-5. Genome-wide association study of statin-induced myopathy. In the first genome-wide association study of drug response, patients who developed
myopathy while taking the statin medication simvastatin were compared to controls who did not develop myopathy. The statistical association of myopathy with each
single nucleotide polymorphism (SNP) was plotted against the chromosomal location of the SNP. Genome-wide association revealed a single SNP that was highly as-
sociated (p value 4 109) with the development of myopathy. The arrow points to the SNP in the SLCO1B1 gene, which encodes an organic anion transporter that
mediates hepatic uptake of statins. Patients with this variant may have higher plasma levels of statins at any given dose of drug.

Attaining the goal of truly personalized drug therapy and
translating genomic knowledge into clinical practice rapidly
will require the application of high-throughput genotyping
technologies. An excellent example involves the use of GWAS
to identify a genomic biomarker for statin-induced myopathy.
Cholesterol-lowering HMG-CoA reductase inhibitors, such
as simvastatin and atorvastatin (see Chapter 19, Pharmacol-
ogy of Cholesterol and Lipoprotein Metabolism), are among
the most widely prescribed drugs worldwide. Although these
drugs are generally very safe, statins can rarely cause serious
myopathy with rhabdomyolysis and renal failure. In an at-
tempt to predict and prevent this serious adverse drug reac-
tion, the SEARCH collaborative group performed a GWAS in
which approximately 300,000 SNPs across the genome were
genotyped using DNA from 85 patients who had developed
severe statin-induced myopathy and 90 control subjects who
had not developed this adverse drug reaction. The results, de-
picted in Figure 6-5, showed that rs4363657, a single SNP
located within the SLCO1B1 gene on chromosome 12, had a
strong association with myopathy ( p value of 4 109). The
odds ratio for myopathy risk in subjects homozygous for the
variant nucleotide at the SNP was 16.9, and it was estimated
that more than 60% of the cases of myopathy in this 12,064-
patient trial were associated with this one SNP. The SLCO1B1
gene encodes an organic anion transporter that mediates sta-
tin uptake by the liver; patients homozygous for the variant
SNP may have higher plasma levels of statins and therefore be
more likely to develop rhabdomyolysis at any given dose of
drug. This example is undoubtedly only the first of many ap-
plications of genome-wide techniques to pharmacogenomics.
Pharmacogenomics and Regulatory Science
To achieve individualized drug therapy, we need not only
to understand the science underlying pharmacogenetics and
pharmacogenomics and to develop state-of-the-art technol-
ogies to detect and assay DNA sequence data, but also to
translate that knowledge into the clinic. That translation pro-
cess will require the active involvement of the FDA and the
pharmaceutical industry, which develops virtually all new
drugs. In 2003, the FDA issued a Draft Guidance with regard
to pharmacogenomic data, and that draft was approved in
2005. The FDA also initiated a series of public hearings with
regard to the incorporation of pharmacogenomic data into
drug labeling. Those hearings began with thiopurine drugs
and TPMT and were followed by hearings on a genetic poly-
morphism in UGT1A1, a gene encoding a phase II enzyme
involved in biotransformation of the antineoplastic agent iri-
notecan. Public hearings have also been held on CYP2C9,
VKORC1, and warfarinresulting in relabelingand on
tamoxifen and CYP2D6.
The attention given to pharmacogenetics-pharmaco-
genomics by the FDA is having an impact on the pharmaceu-
tical industry, especially within the context of the unfortunate
series of events that resulted in the withdrawal of the COX-2
inhibitor rofecoxib (Vioxx) from the market for reasons of
safety. It is unclear whether pharmacogenetics played a role
in the Vioxx-induced cardiovascular disease that led to the
withdrawal of that drug. However, pharmacogenetics almost
certainly could contribute to postmarketing surveillance, not
only to help avoid adverse reactions, but also to rescue
drugs that might be of benefit to groups of patients selected
on the basis of genetic variation in drug response. The latter
situation was highlighted by reports that a polymorphism in
the 1-adrenoceptor influences response to the 1-adrenergic
antagonist bucindololboth in vitro and in patients with
heart failure. This -antagonist had initially failed in a clini-
cal trial that did not include genotyping, perhaps because
only patients with the wild-type 1-adrenoceptor genotype
displayed the desired clinical response.

 CONCLUSION AND FUTURE DIRECTIONS
Pharmacogenetics and pharmacogenomics involve the study
of ways in which DNA sequence variation affects the response
of individual patients to medications. The goal of pharmaco-
genetics and pharmacogenomics is to maximize efficacy and
minimize toxicity, based on knowledge of an individuals ge-
netic composition. Although many factors other than inheri-
tance influence differences among patients in their response
to drugs, the past half-century has demonstrated that genetics
is an important factor responsible for variation in the occur-
rence of adverse drug reactions or the failure of individual
patients to achieve the desired therapeutic response. Pharma-
cogenetics has evolved during that half-century from classical
examples, such as CYP2D6 and TPMT, to include more com-
plex situations such as that represented by the pharmacoge-
netics of warfarin, a drug that displays both pharmacokinetic
and pharmacodynamic pharmacogenetic variation. This area
of genomic medical science also presents unique challenges
in its translation into the clinic. However, there can no longer
be any doubt that pharmacogenetics and pharmacogenomics
will be applied to clinical medicine with increasing breadth
and depth and that, ultimately, they will enhance our ability to
individualize drug therapy.
Suggested Reading
Broder S, Venter JC. Sequencing the entire genomes of free-living
organisms: the foundation of pharmacology in the new millennium.
CHAPTER 6 / Pharmacogenomics 79
Ann Rev Pharmacol Toxicol 2000;40:97132. (Overview of genome se-
quencing and a primer on the possible implications of genetic diversity
for pharmacology.)
Drazen JM, Yandava CN, Dube L, et al. Pharmacogenetic association be-
tween ALOX5 promoter genotype and the response to anti-asthma treat-
ment. Nat Med 1999;22:168171. (Original study that showed different
pharmacologic responses in people with different polymorphisms of the
ALOX5 gene.)
Evans WE, McLeod HL. Pharmacogenomicsdrug disposition, drug tar-
gets, and side effects. N Engl J Med 2003;348:538549. (Review describing
the integration of genomics with pharmacogenetics.)
Mallal S, Phillips E, Carosi G, et al. HLA-B*5701 screening for hyper-
sensitivity to abacavir. N Engl J Med 2008;358:568579. (A double-blind
randomized study of a genetic biomarker for an idiosyncratic adverse drug
response.)
Rieder MJ, Reiner AP, Gage BF, et al. Effect of VKORC1 haplotypes on
transcriptional regulation and warfarin dose. N Engl J Med 2005;352:
22852293. (Description of VKORC1 haplotypes, CYP2C9 genotypes, and
their relationship to warfarin dose.)
The SEARCH Collaborative Group. SLCO1B1 variants and statin-induced
myopathya genomewide study. N Engl J Med 2008;359:789799. (The
first genome-wide association study of a drug response.)
Wang L, Weinshilboum RM. Pharmacogenomics: candidate gene
identification, functional validation and mechanisms. Hum Mol Genet
2008;17:R174R179. (Overview of the evolution of pharmacogene-
tics into pharmacogenomics with the incorporation of genome-wide
techniques.)
Weinshilboum RM, Wang L. Pharmacogenetics and pharmacogenomics:
development, science and translation. Annu Rev Genomics Hum Genet
2006;7:223245. (Review of pharmacokinetic and pharmacodynamic
pharmacogenomic variation, as well as challenges to the translation of
this science into the clinic.)
II

Principles of
Neuropharmacology
 IIA

Fundamental Principles
of Neuropharmacology
7
Principles of Cellular Excitability
and Electrochemical
Transmission
Lauren K. Buhl, John Dekker, and Gary R. Strichartz
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . . . 82-83
CELLULAR EXCITABILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Ohms Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Ion Channels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Channel Selectivity, the Nernst Equation,
and the Resting Potential . . . . . . . . . . . . . . . . . . . . . . . . . . 84
The Goldman Equation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
The Action Potential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
 INTRODUCTION
Cellular communication is essential for the effective func-
tioning of any complex multicellular organism. The major
mode of intercellular communication is the transmission
of chemical signals, such as neurotransmitters and hor-
mones. In excitable tissues, such as nerves and muscles,
rapid intracellular communication relies on the propagation
of electrical signalsaction potentialsalong the plasma
membrane of the cell. Both chemical and electrical trans-
mission commonly involve the movement of ions across the
plasma membrane that separates the cell from its environ-
ment or across the membranes of internal organelles such
as the endoplasmic reticulum or mitochondria. Ionic move-
ments can directly change the cytoplasmic concentration of
ions, such as Ca2, that are key regulators of biochemical
and physiologic processes such as phosphorylation, secre-
tion, and contraction. Ionic movements also change the elec-
trical potential across the membrane through which the ions
flow, thus regulating various voltage-dependent functions
such as the opening of other ion channels. Some of these
events are brief, with durations and actions of several mil-
liseconds (0.001 sec). Others can take many seconds, with
biochemical consequencessuch as phosphorylation of
proteinsthat can persist for minutes or hours. Even gene
expression can be regulated by changes in ion concentra-
tions, resulting in long-term changes in cellular physiology,
growth, differentiation, and death.
82
PHARMACOLOGY OF ION CHANNELS . . . . . . . . . . . . . . . . . . 89
ELECTROCHEMICAL TRANSMISSION . . . . . . . . . . . . . . . . . . 89
Synaptic Vesicle Regulation . . . . . . . . . . . . . . . . . . . . . . . . 91
Postsynaptic Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Transmitter Metabolism and Reuptake . . . . . . . . . . . . . . . . 92
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . . 92
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Many drugs modify chemical or electrical signaling to in-
crease or decrease cellular excitability and electrochemical
transmission. To appreciate how such drugs act, the present
chapter explains the electrochemical foundations that under-
lie these phenomena. These general principles are applicable
to many areas of pharmacology, including those discussed
in Chapters 9 to 11 (Section IIB, Principles of Autonomic
and Peripheral Nervous System Pharmacology), Chapters
12 to 18 (Section IIC, Principles of Central Nervous System
Pharmacology), and Chapter 23, Pharmacology of Cardiac
Rhythm.
 CELLULAR EXCITABILITY
Excitability refers to the ability of a cell to generate and
propagate electrical action potentials. Neuronal, cardiac,
smooth muscle, skeletal muscle, and many endocrine cells
have an excitable character. Action potentials may propagate
over large distances, as in peripheral nerve axons that con-
duct over several meters, or they may stimulate activity in
cells of much smaller size such as the 30- to 50-m-diameter
interneurons that are contained within a single autonomic
ganglion. The function of action potentials differs depending
on the cell in which they occur. Propagating waves of action
potentials rapidly conduct encoded information with fidelity
over long distances along axons. Within a small cell, action
potentials excite the whole cell at once, causing an increase
in intracellular ions (e.g., Ca2) followed by a rapid release
I  V/R Equation 7-1a

Outward current

I
I=gV

Negative Positive
potential potential
V

I  gV Equation 7-1b

Inward current
84 Fundamental Principles of Neuropharmacology
Ion Channels
How does current actually flow across a cell membrane?
Biological membranes are composed of a lipid bilayer
within which some proteins are embedded and to which
other proteins are attached (Fig. 7-2). Pure lipid membranes
are virtually impermeable to most polar or charged sub-
stances, thus having a very high intrinsic resistance. From
an electrical perspective, the lipid bilayer also acts as a
capacitor by separating the extracellular and intracellular
ions. To allow the passage of ions that carry electrical cur-
rent, ion channels span the membrane. Most ion channels
discriminate among the various types of ions and remain
closed until specific signals dictate their opening, showing
the respective properties of ion selectivity and of gating.
From an electrical perspective, a set of ion channels is a
variable conductor: it provides many individual conduc-
tances for ion flow between the extracellular and intracellu-
lar environments. The magnitude of the overall conductance
depends on the fraction of channels in the open state and the
conductance of the individual open channels.
Channel Selectivity, the Nernst Equation,
and the Resting Potential
By itself, the hypothetical I-V relation in Figure 7-1 does not
explain the electrical behavior of most real cells. If a cell be-
haved according to Equation 7-1, then the potential difference
across the membrane would be zero in the absence of an exter-
nally applied current. Instead, most cells maintain a negative
potential difference across their plasma membrane. This volt-
age difference is most pronounced in neuronal and cardiac ven-
tricular cells, where a resting potential (the voltage difference
Capacitor
Resistor (plasma membrane)
(ion channel)
Ii Ic
IT = Ii + Ic
FIGURE 7-2.
Electric circuit model of the cell membrane. The cell mem-
brane can be modeled as a simple electric circuit containing a resistor and a
capacitor. Ion-selective channels function as resistors (identical to conductors),
through which ions can flow down their electrochemical gradient. The lipid bilayer
acts as a capacitor by maintaining a separation of charges between the extracellu-
lar and intracellular spaces. This circuit (referred to as an RC, or resistor-capacitor,
circuit) changes the timing between the flow of charges across the membrane
(current) and changes in transmembrane potential (voltage), because the lipid
bilayer, acting as a capacitor, stores some of the charge that passes across the
membrane. Time is required to store this charge; therefore, the initial change in
voltage associated with a step of current is slow. As the capacitor (lipid bilayer) fills
with charges and the voltage change grows, more of the charge passes through
the resistor, until a new steady state is reached and the currentvoltage relation-
ship becomes more linear. (Ic, capacitor current; Ii, ionic current; IT, total current.)
across the membrane in the absence of external stimuli) of
60 to 80 mV can be recorded. The resting potential results
from three factors: (1) an unequal distribution of positive and
negative charges on each side of the plasma membrane; (2) a
difference in selective permeabilities of the membrane to the
various cations and anions; and (3) the current-generating ac-
tion of active (energy-requiring) and passive pumps that help
to maintain the ion gradients. The effects of these interrelated
factors can be explained best with an example.
Consider the case when there are only potassium ions
(K) and protein-bound anions (A) inside the cell and no
other ions outside the cell (Fig. 7-3). If this cells membrane
is permeable to potassium alone, then K will flow outward,
while A will remain inside. The K ions flow outward be-
cause of a chemical gradient; that is, K efflux is favored
because the K concentration inside the cell is greater than
that outside the cell. A potential efflux of the anion, A, is
also favored by its chemical gradient, but the absence of
transmembrane channels permeable to A prevents this
anion from flowing across the membrane. Because of this
selective permeability for K, every K ion that exits the
cell leaves one net negative charge (an A ion) on the inside
of the cell and adds one net positive charge (a K ion) on
the outside of the cell. This separation of charges across the
membrane creates a negative membrane potential.
If a negative membrane potential were not established
as K leaves the cell, then K ions would continue to exit
until the extracellular concentration of K was equal to the
intracellular concentration of K. However, the establish-
ment of a voltage difference creates an electrostatic force
that eventually prevents net K efflux (Fig. 7-3B). Thus, the
electrical gradient (Vm) and the chemical gradient pull the
K ions in opposite directions: the electrical gradient favors
an inward flow of K ions, while the chemical gradient fa-
vors an outward flow of K ions. These forces combine to
create an electrochemical gradient, which is equal to the
sum of the electrical gradient and the chemical gradient. The
transmembrane electrochemical gradient is the net driving
force for ion movement across biological membranes.
As a result of the electrochemical gradient, the extracel-
lular concentration of K does not equilibrate with the intra-
cellular concentration. Instead, an equilibrium is established
in which the electrostatic force pulling K back into the
cell is balanced exactly by the chemical gradient favoring
K efflux. The electrical potential at which this equilibrium
occurs, for any permeant ion X, is a function of the charge
of the ion (z), the temperature (T), and the intracellular and
extracellular concentrations of the ion. This relationship is
expressed as the Nernst equation:
RT [X]out
Vx  Vin  Vout  ln Equation 7-2
zF [X]in
where Vx is the transmembrane potential that a membrane se-
lectively permeable to ion X would reach at equilibrium (i.e.,
the Nernst potential for that ion), Vin Vout is the trans-
membrane voltage difference, RT/zF is a constant for a given
temperature and charge (this number simplifies to 26.7 mV
for a charge of 1 at a temperature of 37C), and [X]out and
[X]in are the extracellular and intracellular concentrations,
respectively, of ion X. The electrochemical driving force on
ion X is equal to the difference between the actual membrane
potential and the Nernst potential for that ion, Vm Vx.
 A K+ selective channel B + C + K
+
K + K
K
+
K
+ + +
K K K
+
K - -
+ - - - A - - A -
K A - A A A A A
A + +
+ K + + K +
- + K K K K
A K - - -
- A - - A - - A
A A A A A
+
K A
- + A
- + -
A +
K K K

Chemical force

Electrical force ZERO

Electrochemical gradient =
chemical force + electrical force ZERO
86 Fundamental Principles of Neuropharmacology
I(nA)
IK
INet = IK + INa
VK VNa
VR
V(mV)
INa gK : gNa = 5:1
-92 -70 +40
IK K+ current
VK K+ Nernst potential
gK K+ conductance
INa Na+ current
VNa Na+ Nernst potential
gNa Na+ conductance
VR Resting membrane potential
INet Net current
FIGURE 7-4. Relative contribution of K and Na to the resting
membrane potential. The relative membrane permeabilities of K, Na, and
other ions, and the Nernst (electrochemical equilibrium) potentials of these
ions, together determine the resting membrane potential. In the example
shown, the conductance of K is five times the conductance of Na (shown
by the slopes of the I versus V lines for IK and INa, respectively). That is, the
membrane is five times_more permeable to K than to Na. The K current
is described by IK [IK gK(V VK)], while Na current is described by INa
_ _ the _
[INa gNa(V VNa)]. (In this example, gK and gNa are constant conductances
over all voltages.) INet, the net membrane current, is the sum of these two
currents (INet IK INa). The resting membrane potential (VR) is the value
of V at which INet equals zero. In this example, note that VR is close to, but
greater than, VK. This is because, although K is the primary determinant of
the resting potential, the minor Na current depolarizes VR to a value more
positive than VK.
potential for K (about 90 mV). In reality, the additional,
weak permeabilities of other ionic species raise the resting
membrane potential above that for K. Thus, although K is
the most permeant ion, the permeability of the other ions and
the action of the electrogenic pumps also contribute to the
overall resting potential. At the steady state that describes
the true resting membrane potential (Fig. 7-4), Vm does not
equal the Nernst potential for any of the individual ions, and
each ionic species experiences a net electrochemical force.
In other words, (Vm Vion) is nonzero, and small ion fluxes
occur. The algebraic sum of these inward and outward cur-
rents is small and is balanced by currents from active, elec-
trogenic pumps, so there is no net current across the resting
membrane. It has been estimated that up to 25% of all cel-
lular energy in excitable tissues is expended in maintaining
ion gradients across cellular membranes.
The Goldman Equation
The example shown in Figure 7-3 addresses a situation
where only one ionic species flows across the plasma
membrane. In reality, many cells possess a number of
different channels that are selective for different ions, all
of which contribute to the overall resting membrane po-
tential. When the resting potential is determined by two
or more species of ions, the influence of each species is
governed by its concentrations inside and outside the cell
and by the relative permeability of the membrane to that
ion. Quantitatively, this relationship is expressed as the
Goldman-HodgkinKatz Equation:
RT P [K ]  PNa[Na ]o  PCl[Cl ]i
Vm  ln K  o Equation 7-3
F PK [K ]i  PNa[Na ]i  PCl [Cl ]o
where Px is the membrane permeability of ion x. (Px is
expressed as a fraction, with a value of 1 indicating maxi-
mum permeability.) Essentially, this expression states that
the higher the concentration gradient of a particular ion and
the greater its membrane permeability, the greater its role
is in determining the membrane potential. In the extreme
case, when the permeability of one ion is exclusively domi-
nant, the Goldman equation reverts to the Nernst equation
for that ion. For example, if PK PCl, PNa, the equation
becomes
RT [K ]
Vm  ln  o
F [K ]i
Alternatively, if PNa greatly exceeds PK, PCl, then Vm VNa,
and the membrane is strongly depolarized. This important
concept links changes in ion channel permeability to changes
in membrane potential. Whenever an ion-selective channel
opens, the membrane potential shifts toward the Nernst po-
tential for that ion. The relative contribution of a given chan-
nel to the overall membrane potential depends on the extent
of ion flow through that channel. Time-dependent changes in
the membrane permeabilities of Na and K (and, in cardiac
cells, Ca2) account for the major distinguishing feature of
electrically excitable tissuesthe action potential.
The Action Potential
According to Ohms law, passage of a small amount of current
across a cell membrane causes the voltage across the membrane
to change, reaching a new steady-state value that is determined
by the membranes resistance (see above). The time course of
this voltage change is determined by the product of the resis-
tance rm and the capacitance cm of the membrane, with a rate
constant equal to [rm cm]1. (The membranes capacitance
results from having an insulator, the hydrocarbon core of the
phospholipids in the membrane, between two conductors, the
ionic solutions on either side of the membrane [see Fig. 7-2].
Capacitors store charge at both surfaces and require time to
change the magnitude of this charge.) If the stimulated poten-
tial change is less than the threshold value, then the membrane
voltage changes smoothly and returns to its resting value when
the stimulating current is turned off (Fig. 7-5A). On the other
hand, if the membrane voltage changes positively by more than
the threshold value, then a dramatic event occurs: the membrane
voltage rises much more rapidly, to a value of approximately
50 mV, and then drops to its resting value of approximately
80 mV (Fig. 7-5B). This suprathreshold event is known as
the action potential (AP). Importantly, hyperpolarizing stimuli
cannot trigger an AP (Fig. 7-5C).
 CHAPTER 7 / Principles of Cellular Excitability and Electrochemical Transmission 87
A depolarizations to 50 mV or above cause Na channels to
Voltage (mV) 0 open, with a probability that increases to a maximum value
-50
Threshold voltage
-90
Small depolarizing stimulus
B membrane (in a process called voltage-clamping); when
Voltage (mV)
0 a large reserve of unopened channels provides a margin of
Threshold voltage
-50
-90
Large depolarizing stimulus
C INa  gNa (Vm  VNa )
0 Large hyperpolarizing stimulus
Voltage (mV)
-50
Threshold voltage
-90
Time
FIGURE 7-5. The action potential. A. In the example shown, a resting cell has a
membrane potential of approximately 80 mV. If a small depolarizing stimulus is ap-
plied to the cell (for example, a stimulus that opens a few voltage-gated Ca2 chan-
nels), the membrane slowly depolarizes in response to the influx of Ca2 ions. Once
the stimulus ends and the Ca2 channels close, the membrane returns to its resting
potential. The time course of the voltage change is determined by the membrane ca-
pacitance (see Fig. 7-2). B. If a larger depolarizing stimulus is applied to the cell, such
that the membrane potential exceeds its threshold voltage, the membrane rapidly
depolarizes to about 50 mV and then returns to its resting potential. This event is
known as an action potential; its magnitude, time course, and shape are determined
by voltage-gated Na and K channels that open in response to membrane depolar-
ization. C. In comparison, application of a hyperpolarizing stimulus to a cell does not
generate an action potential, regardless of the magnitude of hyperpolarization.
In most neurons, the balance between voltage-gated Na
and K channels regulates the AP. (In cardiac cells, voltage-
gated Ca2 channels are also involved in AP regulation; see
Chapter 23.) Voltage-gated Na channels conduct an inward
current that depolarizes the cell at the beginning of the AP.
Voltage-gated K channels conduct an outward current that
repolarizes the cell at the end of the AP, in preparation for the
next excitatory event. Figure 7-6 shows the currentvoltage
(I-V) relationships for the voltage-gated Na channel and
the resting K channel. The total Na conductance of
the membrane is the product of the conductance of a single
open Na channel, the total number of Na channels, and
the probability that an individual Na channel is open, Po.
Key to the excitability of the membrane is the voltage
dependence of Po, shown in Figure 7-6A. Rapid membrane
of 1.0 at about 0 mV. The open channel probability repre-
sents the fraction of all Na channels that open in response
to a single voltage step. For example, at very negative poten-
tials (e.g., 85 mV), essentially no Na channels are open;
as the membrane is depolarized through 0 mV, most or all
Na channels open; and fast depolarizations to 25 mV
open about half of the Na channels. These are the relations
that occur when a constant depolarization is imposed on the
the brief depolarization of an AP stimulates the membrane,
fewer Na channels have time to reach the open state, and
safety for impulse transmission.
Recall that ionic current is the product of the ionic con-
ductance (g) and a potential difference. For ions, the potential
difference is the same as the electrochemical driving force,
Vm Vx, where Vx is the Nernst potential for the specified
ion. For example, for Na current:
or
INa  gNa Po (Vm  VNa ) Equation 7-4
_
Here, gNa is the Na conductance of the membrane when
all Na channels are open, and Po is, as above, the prob-
ability that any individual Na channel is open. The graphic
illustration of this equation is shown in Figure 7-6B, where
the Na current for a fully activated membrane is described
by the straight line that passes with positive slope through
VNa. If there were no voltage dependence_ to the Na conduc-
tance (i.e., if gNa were always equal to gNa), this line would
extend throughout the negative voltage range, as shown by
its dashed-line extrapolation. However, the voltage depen-
dence of Po (Fig. 7-6A) causes the actual Na conductance
gNa to be voltage-dependent, resulting in deviation of the real
INa from this theoretical fully activated condition. Thus,
increasing depolarizations from rest (caused, for example,
by an applied stimulus) result in inward Na currents that
first become larger as more channels open and then become
smaller as Vm approaches VNa (Fig. 7-6B).
Potassium channels conduct outward currents that oppose
the depolarizing actions of inward Na currents. Although
there are many types of K channels with diverse gating
properties, only two types need to be considered in order to
appreciate the role of K channels in excitability. These two
K channel types include the voltage-independent leak
channels and the voltage-gated delayed rectifier channels.
Leak channels are the K channels that contribute to the
resting membrane potential by remaining open throughout
the negative range of membrane potentials. The K current
that flows through these channels is shown by the dashed
line in Figure 7-6B; for these channels, K current is out-
ward for all Vm VK.
The summation of INa and IK(leak) is represented by the
dashed blue line in Figure 7-6C. Three important points on
this line define three critical aspects of the AP. The net ionic
current (INet) is zero at all three of these points. First, at rest,
Vm VK. Under this condition, small, transient membrane
depolarizations caused by external stimuli result in net
88 Fundamental Principles of Neuropharmacology
A
1
P0
0 able to a population of voltage-gated Na channels, so that virtually 100% of
-50 0 50
B
INa, IK
Outward
Current Na+ channels begin to open
IK
-90 -50 50
Inward VNa
Current
All Na+ channels open
C the I-V graph (denoted by blue circles) at which the net current is zero. The first
INa, IK, INet
Outward IK INa
Current VK VT VP
-90 -50 50
Inward
Current
INet
outward currents from ion conductances that repolarize the
membrane back to rest when the external stimulus ends. Sec-
ond, at Vm VT, the outward potassium currents are matched
by inward sodium currents, and the net current is also zero.
Under this condition, however, even a small further depolar-
ization results in a net inward current that further depolarizes
the membrane, which leads to a larger inward current and
further membrane depolarization. This positive feedback loop
constitutes the rising phase of the AP. Thus, the AP occurs in
response to any rapid depolarization beyond VT, which is de-
fined as the threshold potential. Third, Vp is the potential at
the peak of the AP. Once Vm reaches this maximum depolar-
ization, the net current switches sign from inward to outward,
and consequently, the membrane begins to be repolarized.
Voltage-gated (delayed rectifier) K channels contribute to
the rapid repolarization phase of the AP. Although membrane
depolarization opens these channels, they open and close more
slowly than do Na channels in response to depolarization.
Therefore, inward Na current dominates the early (depolar-
ization) phase of the AP, and outward K current dominates
the later (repolarization) phase (Fig. 7-7). This is why the AP is
characterized by an initial rapid depolarization (caused by fast
inward Na current) followed by a prolonged repolarization
(caused by slower and more sustained outward K current).
The final feature determining membrane excitability is
the limited duration of Na channel opening in response to
membrane depolarization. After opening in response to rapid
FIGURE 7-6. Voltage dependence of channel activity. A. Po, the probabil-
ity that an individual voltage-gated Na channel will open, is a function of the
membrane voltage (V ). At voltages more negative than 50 mV, there is a very
low probability that a voltage-gated sodium channel will open. At voltages more
positive than 50 mV, this probability begins to increase and approaches 1.0
(i.e., a 100% chance of opening) at 0 mV. These probabilities are also generaliz-
V (mV) voltage-gated Na channels in the membrane will open at 0 mV. B. The Na
current across a membrane (INa) is a function of the voltage dependence of the
Na channels that carry the current. At voltages more negative than 50 mV,
the Na current is zero. As the voltage increases above 50 mV, Na chan-
nels begin to open, and there is an increasingly inward (negative) Na current.
INa The maximum inward Na flux is reached at 0 mV, when all the channels are
open. As the voltage continues to increase above 0 mV, the Na current is still
inward, but decreasing, because inward flow of the positively charged Na
ions is opposed by the increasingly positive intracellular potential. The Na
V (mV) current is zero at VNa (the Nernst potential for Na) because, at this voltage, the
electrical and chemical gradients for Na ion flow are balanced. At voltages
more positive than VNa, the Na current is outward (positive). The dashed line
indicates the relationship that would exist between Na current and voltage
if the open probability of the Na channels were not voltage-dependent. The
potassium current that flows through voltage-independent K leak channels
is shown by the dashed line (IK). C. The summation of plasma membrane Na
currents (INa ) and K currents (IK ) demonstrates three key transition points in
of these points occurs at a membrane potential of 90 mV, where V VK. At
this voltage, a small increase in potential (i.e., a small depolarization) results
in an outward (positive) K current that brings the membrane potential back
toward VK. The second point occurs at VThreshold, the threshold voltage (VT ). At
this voltage, INa IK; further depolarization results in the opening of more
V (mV) voltage-dependent Na channels and a net negative (inward) current, which
initiates the action potential. The third point occurs at VPeak, the peak voltage
(VP). At this voltage, the transition occurs from a net negative current to a net
positive (outward) current. As the Na channels inactivate, the net positive cur-
rent is dominated by IK, and the membrane potential returns toward VK (i.e., the
membrane is repolarized).
membrane depolarization, most Na channels enter a closed
state in which they are inactivated (i.e., prevented from sub-
sequent opening). Recovery from inactivation occurs only
when the membrane is repolarized, whereupon the Na chan-
nels return to the closed, resting state from which they can
open in response to a stimulus. This inactivation of Na con-
ductance, combined with the slowly decaying voltage-gated
K conductance, produces dynamic changes in membrane
excitability. Following _just one AP, fewer Na channels are
available to open (i.e., gNa is temporarily smaller), more K
channels are open (i.e., gK is larger), the corresponding ionic
currents are changed, and VT is more positive than it was
before the AP. An excitable membrane is in its so-called re-
fractory state during this period, which lasts from just after
the AP until the conditions of fast gNa inactivation and slow
gK activation have returned to their resting values. Very slow
depolarizing stimuli will fail to induce an AP, even when the
membrane reaches the threshold potential defined by a rapid
depolarizing stimulus, because of the accumulation of inacti-
vated Na channels during the slow depolarizing stimulus.
The inactivation property of Na channels is important in the
concept of use-dependent block, as discussed in Chapter 11,
Local Anesthetic Pharmacology, and Chapter 23, Pharmacol-
ogy of Cardiac Rhythm. Also, under pathologic conditions,
cells may express Na channels that inactivate incompletely
and therefore continue to carry an inward current after termi-
nation of the AP. Such currents may be adequate to raise the
 VNa

Vm
Voltage

VT
Vr

VK

0 1 2 3 4

gNa
Conductance

gK

0 1 2 3 4
Time (ms)
Depolarizating
stimulus
90 Fundamental Principles of Neuropharmacology

3. Depolarization of the nerve terminal membrane causes

opening of voltage-dependent Ca2 channels and influx
of Ca2 through these open channels into the presynap-
tic nerve terminal. In many neurons, this Ca2 influx
is regulated by P/Q-type (Cav 2.1) or N-type (Cav 2.2)
Presynaptic Ca2 channels.
neuron 4. In the presynaptic terminal, the rapid rise in cytosolic free
Action potential
Ca2 concentration is sensed by specialized protein ma-
chinery, causing neurotransmitter-filled vesicles to fuse
2 Neurotransmitter with the presynaptic plasma membrane (see the next sec-
transporter tion, Synaptic Vesicle Regulation). After vesicle fusion,
1
6b
neurotransmitter is released into the synaptic cleft.
Precursor 5. Released neurotransmitter diffuses across the synaptic
+
Na cleft, where it can bind to two classes of receptors in
Na+
Neurotransmitter the postsynaptic membrane:
a. Binding of neurotransmitter to ligand-gated ionotro-
Ca2+ pic receptors opens channels that mediate ion flux
across the postsynaptic membrane. Within millisec-
onds, this ion flux leads to excitatory or inhibitory
3 postsynaptic potentials.
4 b. Binding of neurotransmitter to metabotropic recep-
tors (e.g., G protein-coupled receptors) causes acti-
vation of intracellular second messenger signaling
Synaptic cleft
cascades. These signaling events can then modulate
ion channel function, leading to changes in the post-
5a K+ 5b Adenylyl cyclase 6a synaptic potential, although the time course of these
Ca2+ changes is slower (generally seconds to minutes).
Na+
E
Some neurotransmitters may also bind to a third class
of receptors on the presynaptic membrane. These re-

GDP GTP ceptors are called autoreceptors because they regulate
neurotransmitter release.
ATP cAMP
6. Excitatory postsynaptic potentials (EPSPs) and inhibi-
7 tory postsynaptic potentials (IPSPs) propagate passively
Postsynaptic cell Phosphodiesterase (i.e., without generating an AP) along the membrane
of the postsynaptic cell. A large number of EPSPs can
AMP
summate to cause the postsynaptic membrane potential
to exceed threshold voltage (VT). If this occurs, an AP
can be generated in the postsynaptic cell. (This process
is not shown in Fig. 7-8.)
7. Stimulation of the postsynaptic cell is terminated by
removal of the neurotransmitter, desensitization of the
FIGURE 7-8. Steps in synaptic transmission. Synaptic transmission can be postsynaptic receptor, or a combination of both. Neu-
divided into a series of steps that couple electrical depolarization of the presynap-
rotransmitter removal occurs by two mechanisms:
tic neuron to chemical signaling between the presynaptic and postsynaptic cells.
1. Neuron synthesizes neurotransmitter from precursors and stores the transmitter
a. Degradation of the neurotransmitter by enzymes in
in vesicles. 2. An action potential traveling down the neuron depolarizes the pre- the synaptic cleft.
synaptic nerve terminal. 3. Membrane depolarization activates voltage-dependent b. Uptake of the neurotransmitter by specific transport-
Ca2 channels, allowing Ca2 entry into the presynaptic nerve terminal. 4. The ers into the presynaptic terminal (or the surround-
increased cytosolic Ca2 enables vesicle fusion with the plasma membrane of the ing glial cells), which terminates synaptic action
presynaptic neuron, with subsequent release of neurotransmitter into the synaptic and allows the neurotransmitter to be recycled into
cleft. 5. Neurotransmitter diffuses across the synaptic cleft and binds to one of two synaptic vesicles in preparation for a new release
types of postsynaptic receptors. 5a. Neurotransmitter binding to ionotropic recep- event.
tors causes channel opening and changes the permeability of the postsynaptic 8. For G protein-coupled metabotropic receptors in the
membrane to ions. This may also result in a change in the postsynaptic mem-
postsynaptic cell, termination of the response to a
brane potential. 5b. Neurotransmitter binding to metabotropic receptors on the
postsynaptic cell activates intracellular signaling cascades; the example shows
transmitter stimulus is also dependent on intracellular
G protein activation leading to the formation of cAMP by adenylyl cyclase. In turn, enzymes that inactivate second messengers (e.g., phos-
such a signaling cascade can activate other ion-selective channels (not shown). phodiesterases that convert cAMP to its inactive me-
6. Signal termination is accomplished by removal of transmitter from the synap- tabolite AMP).
tic cleft. 6a. Transmitter can be degraded by enzymes (E ) in the synaptic cleft.
The prototypic chemical synapse is that of the neuromus-
6b. Alternatively, transmitter can be recycled into the presynaptic cell by reuptake
transporters. 7. Signal termination can also be accomplished by enzymes (such
cular junction (see Fig. 9-4 for more detail). At this junc-
as phosphodiesterase) that degrade postsynaptic intracellular signaling molecules tion, terminal branches of the motor axon lie in a synaptic
(such as cAMP). trough on the surface of the muscle cells. When the neuron
fires, acetylcholine (ACh) is released from the motor neuron
 CHAPTER 7 / Principles of Cellular Excitability and Electrochemical Transmission 91

terminals. The released ACh diffuses across the synaptic in neurotransmitter release by controlling the availability of
cleft to bind to ligand-gated ionotropic receptors located on synaptic vesicles for Ca2-dependent exocytosis. SNAREs
the postsynaptic muscle membrane. This binding of ACh to (soluble N-ethylmaleimide-sensitive factor attachment pro-
its receptors causes a transient increase in the probability of tein receptors) present in both the vesicle membrane (synap-
opening of receptor-associated ion channels. The channel tobrevin) and presynaptic plasma membrane (syntaxin and
pore is equally permeable to Na and K, and these channels SNAP-25) provide the driving force for both Ca2-regulated
have a reversal potential (i.e., a potential at which there is and Ca2-independent vesicle exocytosis (Fig. 7-9). Certain
no net current flowing through the channel) of approximately neurotoxins, such as tetanus toxin and botulinum toxin (see
0 mV (the average of the individual Na and K Nernst po- Chapter 9), appear to act by selectively cleaving SNAREs
tentials). The net inward current passing through these open
channels depolarizes the muscle cell membrane. Although
Neurotransmitter
this particular end-plate potential is sufficiently large to
A
stimulate an AP in the muscle, its magnitude is unusual, be-
cause most neuronal excitatory postsynaptic potentials are of Synaptic vesicle
insufficient magnitude to stimulate an AP. More commonly, membrane
several neuronal excitatory postsynaptic potentials must
Cytoplasm
occur together, within a short time (10 ms) and at closely
spaced synapses, in order for the postsynaptic depolarization SNARE complex
to reach the threshold value for firing of an AP.
The following discussion highlights steps in the basic
Presynaptic plasma
processes of neurotransmission that can be modified by membrane
pharmacologic agents.
Voltage-gated
calcium channel Action potential
Synaptic Vesicle Regulation (closed)
Nerve terminals contain two types of secretory vesicles: small,
B
clear-core synaptic vesicles and large, dense-core synaptic
vesicles. The clear-core vesicles store and secrete small
organic neurotransmitters such as acetylcholine, GABA,
glycine, and glutamate. Dense-core vesicles are more likely Synaptotagmin-1
(Ca2+ sensor)
to contain peptide or amine neurotransmitters. The larger
dense-core vesicles are similar to the secretory granules of
endocrine cells because their release is not limited to active
Ca2+
zones on the presynaptic cell. Dense-core vesicle release is
also more likely to follow a train of impulses (continuous or
rhythmic stimulation) than a single AP. Hence, the smaller
Ca2+
clear-core vesicles are involved in rapid chemical transmis-
sion, while the larger dense-core vesicles are implicated in
slow, modulatory, or distant signaling.
Over the past several years, many of the proteins that con- C
trol synaptic vesicle trafficking have been identified. Syn-
apsin is a protein with dynamic affinity for synaptic vesicles
that also binds to actin. This binding allows it to link vesicles
to the cytoplasmic actin cytoskeleton at nerve terminals.
Because synapsin is a major substrate for a variety of pro-
tein kinases, including those regulated by cAMP and Ca2/
calmodulin, it is thought that these second messengers act

FIGURE 7-9. Current model of neurotransmitter release. A. Synaptic

vesicles are tethered close to the plasma membrane of the presynaptic neuron
by several proteinprotein interactions. The most important of these interactions
involve SNARE (soluble N-ethylmaleimide-sensitive factor attachment protein re- D
ceptor) proteins present in both the vesicle membrane and the plasma membrane.
The SNARE proteins include synaptobrevin (red), syntaxin-1 (yellow), and SNAP-25
(green). Voltage-gated Ca2 channels are located in the plasma membrane in close
proximity to these SNARE complexes; this facilitates the sensing of Ca2 entry
by Ca2-binding proteins (synaptotagmin-1, in blue) localized to the presynaptic
plasma membrane and/or the synaptic vesicle membrane. BD. Voltage-gated
calcium channels open in response to an action potential, allowing entry of ex-
tracellular Ca2 into the cell. The increase in intracellular Ca2 triggers binding of
synaptotagmin-1 to the SNARE complex and fusion of the vesicle membrane with
the plasma membrane, releasing neurotransmitter molecules into the synaptic
cleft. Several additional proteins (Munc18-1, Munc13-1, complexin-1, and others)
may also be involved in the regulation of synaptic vesicle fusion (not shown).
92 Fundamental Principles of Neuropharmacology
and thereby inhibiting synaptic vesicle exocytosis. SNARE-
associated proteins such as synaptotagmin and complexin are
critical for the Ca2 sensitivity of vesicle release; together
with synapsin, the SNAREs, and other recently discovered
proteins involved in neurotransmitter release, these SNARE-
associated proteins may provide future targets for pharmaco-
logic control of synaptic transmission.
Postsynaptic Receptors
A large number of neuropharmacologic drugs act on post-
synaptic receptors. These integral membrane proteins fall
into two classes: ionotropic and metabotropic.
Ionotropic receptors, such as nicotinic acetylcholine re-
ceptors and A type GABA receptors, are almost always
composed of four to five subunits that oligomerize in the
membrane to form a ligand-gated channel. Binding of one
(or sometimes two) ligand molecule to the receptor leads to
an allosteric conformational change that opens the channel
pore. The subunits composing the same functional receptor
often differ among different tissues and, as a consequence,
the detailed molecular pharmacology of the receptors is
tissue-dependent. For example, although acetylcholine is
the endogenous transmitter for all nicotinic cholinergic
receptors, a number of synthetic agonists (or antagonists)
selectively activate (or inhibit) these receptors in skeletal
muscle, autonomic ganglia, or the central nervous system
(see Chapter 9).
Metabotropic receptors are similarly diverse. Although
most are G protein-coupled receptors, the extracellular and
cytoplasmic domains of these receptors differ significantly.
These differences enable the development of agonists (or
antagonists) that activate (or inhibit) specific subtypes of
metabotropic receptors.
Transmitter Metabolism and Reuptake
Altering the metabolism of the neurotransmitter provides an
important mechanism for pharmacologic intervention at the
synapse. The two major types of intervention involve inhibition
of neurotransmitter degradation and antagonism of neurotrans-
mitter reuptake. Acetylcholinesterase, the enzyme responsible
for degrading acetylcholine, is an example of the first type of
drug target. Acetylcholinesterase inhibitors are the mainstays
of treatment for myasthenia gravis (see Chapter 9).
The transporters that facilitate neurotransmitter reuptake
from the synaptic cleft into the presynaptic cell are of even
greater importance. Because these reuptake transporters are
crucial for the termination of synaptic transmission, their in-
hibition has profound effects. For example, the psychotropic
effects of cocaine derive from this drugs ability to inhibit
dopamine and norepinephrine reuptake in the brain, and the
therapeutic benefit of antidepressants such as fluoxetine
likely results from inhibition of serotonin-selective reuptake
(see Chapter 14, Pharmacology of Serotonergic and Central
Adrenergic Neurotransmission). Because reuptake trans-
porters tend to be substrate-specific, it is anticipated that
new drugs can be designed to selectively target other specific
transporter subtypes as well.
 CONCLUSION AND FUTURE DIRECTIONS
Cellular excitability is a crucial component of intercellular
communication. The fundamental basis for cellular excitabil-
ity lies in the electrochemical gradients that are established
by ion pumps across the lipid bilayer of the plasma mem-
brane. Ion-selective channels enable cellular membranes to
regulate the permeability of the membrane selectively for
different ionic species, allowing a change in membrane volt-
age to be coupled to a chemical stimulus or response. The
action potential, a special type of stereotyped response found
in excitable cells, is made possible by the voltage-dependent
properties of Na and K channels.
The basic processes of electrochemical transmission pro-
vide the substrate for pharmacologic modulation of cellular
excitation and communication, topics that are addressed in
more detail throughout this book.
Acknowledgment
We thank Michael Ty for his valuable contributions to this
chapter in the First and Second Editions of Principles of Phar-
macology: The Pathophysiologic Basis of Drug Therapy.
Suggested Reading
Nestler EJ, Hyman SE, Malenka RC. Molecular neuropharmacology: a foun-
dation for clinical neuroscience. 2nd ed. New York: McGraw-Hill Profes-
sional; 2008. (An overview of neuropharmacology.)
Rizo J, Rosenmund C. Synaptic vesicle fusion. Nat Struct Mol Biol
2008;15:665674. (Review of mechanisms that regulate synaptic vesicle
fusion.)
Rizzoli SO, Betz WJ. Synaptic vesicle pools. Nat Rev Neurosci 2005;6:5769.
(Advances in synaptic vesicle biology.)
Sutton MA, Schuman EM. Partitioning the synaptic landscape: distinct mi-
crodomains for spontaneous and spike-triggered neurotransmission. Sci Signal
2009;2:pe19. (Recent research on regulation of synaptic transmission.)

Principles of Nervous System
Physiology and Pharmacology
Joshua M. Galanter, Susannah B. Cornes, and Daniel H. Lowenstein
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . . 93-94
NEUROANATOMY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Anatomy of the Peripheral Nervous System . . . . . . . . . . . . 93
Autonomic Nervous System . . . . . . . . . . . . . . . . . . . . . 94
Peripheral Motor and Sensory Systems . . . . . . . . . . . . . 96
Anatomy of the Central Nervous System . . . . . . . . . . . . . . 96
Cerebrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Diencephalon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Cerebellum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Brainstem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Spinal Cord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Cellular Organization of the Nervous System . . . . . . . . . . . 99
Long Tract Neuronal Organization . . . . . . . . . . . . . . . . . 99
 INTRODUCTION
The nervous system contains more than 10 billion neurons.
Most neurons form thousands of synaptic connections, giv-
ing the nervous system complexity unlike that seen in any
other organ system. Interactions among neuronal circuits
mediate functions ranging from primitive reflexes to lan-
guage, mood, and memory. To perform these functions, the
individual neurons that comprise the nervous system must
be organized into functional networks, which, in turn, are
organized into larger anatomical units.
The previous chapter reviewed the physiology of indi-
vidual neurons by describing electrical transmission within
a neuron and chemical transmission from one neuron to
another. This chapter discusses neuronal systems by exam-
ining two levels of organization. First, the gross anatomical
organization of the nervous system is presented, to place in
context the sites of action of pharmacologic agents that act
on this system. Second, the major patterns of neuronal con-
nectivity (so-called neuronal tracts) are presented, because
knowledge of the ways in which neuronal cells are orga-
nized to transmit, process, and modulate signals facilitates
a deeper understanding of the actions of drugs on these
tracts. This chapter also discusses the major types of neu-
rotransmitters and the bloodbrain barrier; these functional
and metabolic concepts have important pharmacologic
consequences for drugs that act on the nervous system.
8
Local Circuit Neuronal Organization . . . . . . . . . . . . . . 100
Single-Source Divergent Neuronal Organization . . . . . 100
NEUROPHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Neurotransmitters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Amino Acid Neurotransmitters. . . . . . . . . . . . . . . . . . . 102
Biogenic Amines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Other Small Molecule Neurotransmitters . . . . . . . . . . . 106
Neuropeptides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
The BloodBrain Barrier . . . . . . . . . . . . . . . . . . . . . . . . . . 106
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 107
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
 NEUROANATOMY
The nervous system can be divided structurally and func-
tionally into peripheral and central components. The periph-
eral nervous system includes all nerves traveling between
the central nervous system and somatic and visceral sites.
It is divided functionally into the autonomic (involuntary)
nervous system and the sensory and somatic (voluntary)
nervous system.
The central nervous system (CNS) includes the ce-
rebrum, diencephalon, cerebellum, brainstem, and spi-
nal cord. The CNS relays and processes signals received
from the peripheral nervous system; the processing results
in responses that are formulated and relayed back to the
periphery. The CNS is responsible for important functions
such as perceptionincluding sensory, auditory, and visual
processingwakefulness, language, and consciousness.
Anatomy of the Peripheral Nervous System
The autonomic nervous system regulates involuntary re-
sponses of smooth muscle and glandular tissue. For example,
it controls vascular tone, heart rate and contractility, pupil-
lary constriction, sweating, salivation, piloerection (goose
bumps), uterine contraction, gastrointestinal (GI) motility,
and bladder function. The autonomic nervous system is di-
vided into the sympathetic nervous system, responsible for
93
 Dorsal root ganglion

Dorsal root
Gray matter
White matter

Sympathetic nerve trunk

Spinal cord

Skin

Ventral root
Prevertebral ganglion
Smooth muscle
Sensory neuron Skeletal muscle
Paravertebral
Somatic motor neuron chain ganglion
Preganglionic neuron
Postganglionic neuron Adrenal medulla
 CHAPTER 8 / Principles of Nervous System Physiology and Pharmacology 95

Sympathetic Parasympathetic
nervous system nervous system

Eyes
Oculomotor nerve (CN III)

Salivary glands

Facial nerve (CN VII)

Respiratory tract
Glossopharyngeal nerve (CN IX)
Cranial

Vagus
nerve
C1 (CN X)
C2
C3 Heart
C4 Cervical
C5 Skin
C6 Liver
C7
T1
T2
Stomach
T3
T4
T5
T6 Thoracic
T7
T8 Celiac
ganglion
T9
T10
Adrenal
T11 gland Pancreas
T12
L1 Intestines
Kidney
L2
L3 Lumbar
L4 Bladder
Superior
L5 mesenteric
S1 ganglion
S2 Peripheral
S3 blood vessel Sacral
S4
S5 Sympathetic
trunk

Inferior
mesenteric External genitalia
ganglion

Sympathetic preganglionic fibers

Paravertebral Prevertebral
ganglia ganglia Sympathetic postganglionic fibers
Parasympathetic preganglionic fibers
Parasympathetic postganglionic fibers

FIGURE 8-2. Patterns of sympathetic and parasympathetic innervation. Sympathetic preganglionic neurons arise in the thoracic and lumbar segments of the spinal
cord. Sympathetic preganglionic neurons project onto postganglionic neurons in ganglia that lie close to the spinal cord, most notably the paravertebral ganglia, and in the
prevertebral ganglia located near the aorta. Parasympathetic ganglia generally lie close to the organs they innervate. Thus, parasympathetic preganglionic neurons, which arise
in nuclei in the brainstem and the sacral segments of the spinal cord, are generally long and project onto short postganglionic neurons.

organ. As discussed below, the anatomical location of these
connections differs for neurons of the sympathetic and para-
sympathetic divisions of the autonomic nervous system.
Anatomy of the Sympathetic Nervous System
The sympathetic nervous system is also known as the tho-
racolumbar system, because its preganglionic fibers arise
from the first thoracic segment to the second or third lum-
bar segment of the spinal cord (Fig. 8-2). Specifically, the
preganglionic nerve cell bodies arise from the intermedio-
lateral columns in the spinal cord. Preganglionic nerves exit
the spinal cord at the ventral roots of each vertebral level and
make synaptic connections with postganglionic neurons in
sympathetic ganglia. Most sympathetic ganglia are located in
96 Fundamental Principles of Neuropharmacology
the sympathetic chain, which consists of 25 pairs of intercon-
nected ganglia that lie on either side of the vertebral column.
The first three ganglia, termed the superior cervical ganglion,
middle cervical ganglion, and inferior cervical ganglion,
send their postganglionic fibers via the cranial and cervical
spinal nerves. The superior cervical ganglion innervates the
pupil, salivary glands, and lacrimal glands, as well as blood
vessels and sweat glands in the head and face (Fig. 8-2). Post-
ganglionic neurons arising in the middle and inferior cervical
ganglia, as well as the thoracic ganglia, innervate the heart and
lungs. Fibers arising from the remaining paravertebral ganglia
innervate sweat glands, pilomotor muscles, and blood vessels
of skeletal muscle and skin throughout the body.
Postganglionic neurons that innervate the GI tract down
to the sigmoid colon, including the liver and pancreas,
arise from ganglia that are located anterior to the aorta, at
the origins of the celiac, superior mesenteric, and inferior
mesenteric blood vessels (Fig. 8-2). Hence, these ganglia,
collectively known as prevertebral ganglia, are named the
celiac ganglion, superior mesenteric ganglion, and infe-
rior mesenteric ganglion, respectively. In contrast to the
paravertebral ganglia, the prevertebral ganglia have long
preganglionic fibers and short postganglionic fibers.
The adrenal medulla is contained within the adrenal
glands that lie on the superior surface of the kidneys. The
adrenal medulla contains postsynaptic neuroendocrine cells
(Fig. 8-2). Unlike sympathetic postganglionic neurons,
which synthesize and release norepinephrine, neuroendo-
crine cells of the adrenal medulla synthesize primarily epi-
nephrine (85%) and release this neurotransmitter into the
bloodstream rather than at synapses on a specific target organ
(see Chapter 10, Adrenergic Pharmacology).
Many pharmacologic agents modulate sympathetic ner-
vous system activity. As discussed in Chapter 10, the sym-
pathetic nervous system has an organ-specific distribution
of adrenergic receptor types. This organ-specific receptor
expression allows drugs to modulate sympathetic activity
selectively. For example, certain sympathetic agonists, such
as albuterol, can dilate bronchioles selectively, while certain
sympathetic antagonists, such as metoprolol, can selectively
decrease heart rate and contractility.
Anatomy of the Parasympathetic Nervous System
Nearly all of the parasympathetic ganglia lie in or near the
organs they innervate. The preganglionic fibers of the para-
sympathetic nervous system arise in the brainstem or in
sacral segments of the spinal cord; thus, the parasympathetic
system is also called the craniosacral system (Fig. 8-2).
In some cases, parasympathetic preganglionic neurons can
travel almost one meter before synapsing with their postgan-
glionic targets. Preganglionic nerve fibers of cranial nerve
(CN) III, the oculomotor nerve, arise from a region of the
midbrain termed the Edinger-Westphal nucleus and in-
nervate the pupil, stimulating it to constrict. The medulla of
the brain contains nuclei for parasympathetic nerve fibers
in CNs VII, IX, and X. Parasympathetic fibers in the facial
nerve (CN VII) stimulate salivary secretion by the submaxil-
lary and sublingual glands as well as tear production by the
lacrimal gland. Parasympathetic fibers in the ninth cranial
nerve, the glossopharyngeal nerve, stimulate the parotid
gland. The 10th cranial nerve, termed the vagus nerve, pro-
vides parasympathetic innervation to the major organs in the
chest and abdomen, including the heart, tracheobronchial
tree, kidneys, and GI system down to the proximal colon.
Parasympathetic nerves originating in the sacral region of
the spinal cord innervate the remainder of the colon, urinary
bladder, and genitalia.
Many pharmacologic agents modulate parasympathetic
nervous system activity. For example, bethanechol is a para-
sympathomimetic that promotes GI and urinary tract motility.
Antagonists of parasympathetic activity include atropine,
a drug used locally to dilate the pupils or systematically to in-
crease heart rate, and ipratropium, a drug used to dilate bron-
chioles. These agents and others are discussed in Chapter 9,
Cholinergic Pharmacology.
Peripheral Motor and Sensory Systems
Fibers of the somatic nervous system innervate their target
striated muscles directly (Fig. 8-1). The first-order neurons
from the motor cortex send projections that cross in the lower
medulla and descend through the spinal cord in the lateral
corticospinal tract before synapsing on the second-order neu-
rons in the ventral horns of the spinal cord. Projections from
the second-order neurons exit through the ventral roots and
join the dorsal roots, carrying sensory nerve fibers, to form
the spinal nerves. Spinal nerves exit the vertebral column
through the intervertebral foramina, after which they separate
into peripheral nerves. Somatic components of the peripheral
nerves innervate muscles directly. Muscles are innervated in
a myotomal distribution. That is, neurons originating from a
particular ventral root level of the spinal cord (e.g., C6) inner-
vate specific muscles (e.g., flexor muscles of the forearm).
Sensory neurons have cell bodies in the dorsal root
ganglia. The endings of sensory nerves lie in the skin and
joints and enter the spinal cord through the dorsal roots. Neu-
rons for vibration and position sense (proprioception) ascend
through the ipsilateral dorsal columns in the spinal cord and
synapse with secondary neurons in the contralateral lower
medulla. Sensory neurons that carry sensations of pain and
temperature synapse with secondary neurons in the posterior
horn of the spinal cord and then cross within the spinal cord
to ascend in the contralateral spinothalamic tract. Both the
spinothalamic tract and the dorsal column tracts connect with
third-order neurons in the thalamus, part of the diencephalon
(see below), before ultimately reaching the somatosensory
cortex. Sensory information is encoded in a dermatomal
distribution. That is, neurons originating from a particular
dorsal root level of the spinal cord (e.g., C6) carry sensory in-
formation corresponding to a particular area of the skin (e.g.,
the lateral aspects of the forearm and hand).
A number of pharmacologic agents modulate the activity
of the somatic nervous system. For example, antagonists of
neuromuscular junction activity, such as pancuronium, are
used to induce paralysis during surgery. In contrast, drugs
that increase neuromuscular junction activity, such as edro-
phonium and neostigmine, are used in the diagnosis and
treatment of myasthenia gravis, an autoimmune disease
characterized by decreased skeletal muscle stimulation at
the neuromuscular junction. These agents and others are dis-
cussed in Chapter 9.
Anatomy of the Central Nervous System
The CNS is divided anatomically into seven major divisions,
namely, the cerebral hemispheres, diencephalon, cerebel-
lum, midbrain, pons, medulla, and spinal cord (Fig. 8-3).
 CHAPTER 8 / Principles of Nervous System Physiology and Pharmacology 97

Cerebral hemisphere: perception, planning and ordering motor functions, cogni-

Cerebral cortex Diencephalon tive functions, such as abstract reasoning, and language.
Basal ganglia The cortex is divided anatomically and functionally into
the frontal, temporal, parietal, and occipital lobes (Fig.
8-4A). Subregions of the cortex have specific functions.
For example, stimulation of part of the precentral gyrus,
which lies in the frontal cortex, induces peripheral motor
Midbrain function (movement), and ablation of this structure inhibits
Brainstem Pons Cerebellum movement. From a pharmacologic perspective, the cere-
Medulla bral cortex is a site of action of many drugs, sometimes as

Cervical
A

Frontal lobe Parietal lobe

Temporal lobe

Spinal cord
Thoracic

Occipital lobe

Cingulate gyrus Corpus callosum

Lumbar

Sacral

FIGURE 8-3. Anatomic organization of the central nervous system. The C r nal capsule
central nervous system is divided into seven major regions: the cerebral hemi- Inte
spheres, diencephalon (thalamus), cerebellum, midbrain, pons, medulla, and spi- Caudate
nal cord. The cerebral hemispheres include the cerebral cortex, underlying white Thalamus
matter (not shown), and basal ganglia. The midbrain, pons, and medulla together
make up the brainstem. The spinal cord is further divided into cervical, thoracic,
Putamen
lumbar, and sacral segments.

The midbrain, pons, and medulla are collectively known as

the brainstem and together connect the spinal cord with the
cerebrum, diencephalon, and cerebellum.
Cerebrum
The cerebral hemispheres constitute the largest division of
the human brain. These structures contain several subdivi-
sions, including the cerebral cortex, its underlying white
matter, and the basal ganglia (Fig. 8-4). The cerebral
hemispheres are divided into left and right sides that are
connected by the corpus callosum. The cerebral cortex
is responsible for high-level functions, including sensory
FIGURE 8-4. Anatomy of the cerebral hemispheres. A. In this lateral view,
the cerebral hemispheres are divided into four lobesfrontal, parietal, occipital,
and temporalwhich are structurally and functionally distinct from each other.
B. A sagittal view of the cerebral hemispheres shows the corpus callosum and
cingulate gyrus. The corpus callosum connects the left and right hemispheres
and coordinates their actions. The cingulate gyrus is part of the limbic system;
it lies immediately superior to the corpus callosum. C. The basal ganglia include
the caudate and putamen, which are together known as the striatum, and the
globus pallidus (medial to the putamen, not shown). The thalamus lies medial
to the basal ganglia. Arrows indicate the trajectory of neurons in the internal
capsule, a bundle of white matter that carries motor commands from the cortex
to the spinal cord.
 Flocculonodular lobe

Cerebellar vermis

Cerebellar hemispheres
 CHAPTER 8 / Principles of Nervous System Physiology and Pharmacology 99
Brainstem
The midbrain, pons, and medulla are collectively known as
the brainstem. The brainstem connects the spinal cord to the
thalamus and cerebral cortex. It is arranged with the midbrain
superior, the medulla inferior, and the pons bridging the mid-
brain and medulla (Fig. 8-3). White matter pathways intercon-
necting the spinal cord, cerebellum, thalamus, basal ganglia,
and cerebral cortex course through this small region of the
brain. In addition, the brainstem gives rise to most of the cra-
nial nerves. Some of these nerves are conduits for sensation
from the head and face, including hearing, balance, and taste.
The cranial nerves also control the motor output to the skeletal
muscles of mastication, facial expression, swallowing, and
eye movement. The brainstem also regulates parasympathetic
output to the salivary glands and the iris.
The medulla contains several control centers that are essen-
tial for life, including centers that direct the output of the auto-
nomic nuclei, pacemakers that regulate heart rate and breathing,
and centers that control reflex actions such as coughing and
vomiting. Several relay structures in the pons also play a role (in
conjunction with the midbrain) in regulating vital functions such
as respiration. The base of the pons contains white matter tracts
connecting the cerebral cortex and the cerebellum. Neurons in
the periaqueductal gray, especially in the midbrain, send de-
scending projections to the spinal cord that modulate pain per-
ception (see Chapter 17, Pharmacology of Analgesia).
Clusters of diffusely projecting neurons lie throughout the
brainstem, hypothalamus, and the surrounding base of the
brain. These nuclei, which include the locus ceruleus, raphe
nucleus, and several others, comprise the reticular activat-
ing system, which is responsible for consciousness and sleep
regulation. The nuclei each use a different neurotransmitter
system (see below), and thus a variety of classes of medica-
tions can have effects on this system. For example, it is via
these nuclei that antihistamines cause sedation and stimu-
lants such as cocaine cause heightened alertness.
Spinal Cord
The spinal cord is the most caudal division of the central
nervous system. It runs from the base of the brainstem (me-
dulla) at the level of the first cervical vertebra down to the
first lumbar vertebra. Like the cerebrum, the spinal cord is
organized into white matter tracts and regions of gray mat-
ter. The white matter tracts connect the periphery and spinal
cord to more rostral divisions of the CNS, while the gray
matter forms the nuclear columns that lie in an H-shaped
pattern in the center of the spinal cord (Fig. 8-6).
Neurons in the spinal cord can be defined by their spatial
location relative to the gray matter H. These neurons in-
clude sensory neurons located in the dorsal horns of the H,
motor neurons located in the ventral horns of the H, and
spinal interneurons. The sensory neurons relay information
from the periphery to more rostral divisions of the CNS via
the dorsal columns or spinothalamic tracts (see above). The
motor neurons relay commands arising in the central motor
areas and descend in the corticospinal tract to peripheral
muscles. Interneurons connect sensory and motor neurons
and are responsible for mediating reflexes, such as the deep
tendon reflexes, by coordinating the action of opposing mus-
cle groups. Because the spinal cord carries sensory signals
including sensations of painto the central nervous system,
it is an important target for analgesic drugs such as opioids
(see Chapter 17).
Gray matter Ventral horn
White matter
Dorsal horn
Dorsal root
Dorsal root
ganglion
Dura
FIGURE 8-6. Anatomy of the spinal cord. The spinal cord has an H-shaped
wedge of gray matter that includes the dorsal and ventral horns. The dorsal horn
is responsible for sensory relays to the brain, and the ventral horn is responsible
for motor relays to skeletal muscle. The white matter carries signals to and from
more rostral divisions of the CNS.
Cellular Organization of the Nervous System
Cellular organization in the autonomic and peripheral ner-
vous system involves a limited number of neurons that make
few connections. For example, somatic and sensory infor-
mation is carried directly between the spinal cord and the
periphery. Autonomic nerves are slightly more complex, in
that the signal must undergo synaptic transmission between
a preganglionic and a postganglionic neuron. In both cases,
however, few ancillary neuronal connections are made, and
little or no modification of information occurs.
In contrast, cellular organization in the central nervous sys-
tem is far more complex. Information is not simply relayed
from one area to another; instead, central neurons receive sig-
nals from numerous sources and distribute their own axons
widely. Some neurons synapse with hundreds of thousands of
other neurons. Moreover, not every synaptic connection is ex-
citatory (i.e., designed to depolarize the postsynaptic neuron).
Some connections are inhibitory (i.e., designed to hyperpolar-
ize the postsynaptic neuron). Other neurons projecting onto a
target neuron can modulate the relative excitability of the cell,
affecting the response of the postsynaptic neuron to other sig-
nals. The complexity generated by this variability is needed to
carry out the many intricate processes performed by the brain.
Although the CNS possesses immense complexity at the
level of neuronal connectivity, three major motifs are used to
organize neurons into functional units in the nervous system:
the long tract neuronal systems, local circuits, and single-
source divergent systems (Fig. 8-7). The peripheral nervous
system is organized exclusively as a long tract system, while
the central nervous system uses all three motifs.
Long Tract Neuronal Organization
Long tract neuronal organization involves neural pathways
that connect distant areas of the nervous system to one an-
other (Fig. 8-7A). It is the organization used by the peripheral
100 Fundamental Principles of Neuropharmacology
A Long-tract B Local circuit
Convergent
signaling
Divergent
signaling
FIGURE 8-7. Cellular organization of the central nervous system. The CNS has three main organizational motifs. A. Long-tract neurons act as relays between
the periphery and higher sites in the CNS. Long-tract neurons receive signals from many different neurons (convergent signaling) and synapse with many downstream
neurons (divergent signaling). B. Local circuit neurons show a complicated structural motif, arranged in layers, which includes both excitatory and inhibitory neurons.
These circuits are used to process information. C. Single-source divergent neurons typically originate in a nucleus in the brainstem and have axonal terminals that in-
nervate thousands of neurons, usually in the cerebral cortex.
nervous system, and it is important for the transmission of
signals from one region to another within the central nervous
system.
In the peripheral nervous system, signals are transmitted
with little modification. Sensory neurons respond to stimuli
such as touch, temperature, pressure, vibration, and nox-
ious chemicals and, if the initial membrane depolarization
is strong enough, transmit an action potential directly to the
spinal cord. There, sensory neurons synapse directly with so-
matic motor neurons, forming reflex arcs, and with ascend-
ing spinal neurons that transmit the information to higher
levels. Motor neurons carry information directly from the
spinal cord out through the ventral roots and project directly
on the motor end plates of the muscles they innervate. The
long axon tracts of the peripheral sensory and motor neurons
are bundled together and travel as peripheral nerves.
As described above, preganglionic neurons of the auto-
nomic nervous system form synaptic connections with post-
ganglionic neurons at ganglia that are located prevertebrally,
paravertebrally, or near the innervated visceral organs. One
preganglionic neuron typically makes synaptic connections
with up to several thousand postganglionic neurons, an organi-
zation that is termed divergent signaling. Although divergent
signaling does result in some processing and modification of
information, the autonomic nervous system does not generally
modify neural signals appreciably.
In contrast to neurons in the peripheral pathways, neurons
in long tract systems of the central nervous system not only
relay but also integrate and modify signals. CNS long tract
neurons display divergent signaling like autonomic neurons,
but also receive synaptic connections from many upstream
neurons (convergent signaling). The CNS uses both excit-
atory and inhibitory neurotransmitters to localize a signal, a
strategy that is known as center-surround signaling. For ex-
ample, sensory perception in the CNS can precisely localize
a signal by activating cortical neurons that map to one area
of the body and inhibiting neurons that map to surrounding
areas of the body.
C Single-source divergent
Local Circuit Neuronal Organization
Local circuit neurons maintain connectivity primarily
within the immediate area. These neurons are generally re-
sponsible for modulating signal transmission (Fig. 8-7B).
For example, neurons in the cerebral cortex are organized
in layers, usually six in number. While information flows
into one layer and out of a different layer through long tract
connections, links between the layers process the signals and
interpret the inputs. Local synaptic connections can be both
excitatory and inhibitory, ensuring that only certain patterns
of inputs are passed along. For example, information origi-
nating in the lateral geniculate neurons enters the primary
visual cortex through a long tract connection called the optic
tract. In an area of the cortex designed to perceive lines, the
outgoing neurons will be excited only if the incoming neu-
rons fire in a particular pattern, in this case designating a line
in a particular orientation. The outgoing signal might then
serve as the input to another area of the brain that recognizes
shapes. If this area receives an appropriate pattern of lines
from the appropriate sources, it might recognize a particular
object, such as the grid on a tic-tac-toe board.
Single-Source Divergent Neuronal Organization
Nuclei in the brainstem, hypothalamus, and basal forebrain fol-
low single-source divergent circuit organization (Fig. 8-7C),
in which neurons originating in one nucleus innervate many
target cells. Because single-source divergent neuronal organi-
zation involves the action of signals on a wide variety of neu-
rons, it is also commonly referred to as a diffuse system of
organization. Instead of stimulating their targets directly, di-
vergent neurons typically exert a modulatory influence by using
neurotransmittersgenerally, biogenic amines (see below)
that act on G protein-coupled receptors. These receptors alter
the resting potential and ion channel conductance of the neu-
ronal membranes in which they are embedded, thereby altering
the ease of depolarization of these neurons. Neurons constitut-
ing single-source divergent circuits do not generally have my-
elin sheaths, because their modulatory influences vary over the
A Dopaminergic and cholinergic pathways

Medial septal Striatum

nuclei

Nucleus basalis

Ventral tegmental area

Pedunculopontine
Substantia nigra nucleus

Dopaminergic neurons Cholinergic neurons

B Noradrenergic and serotonergic pathways

Locus ceruleus
Raphe nuclei
Spinal cord

Noradrenergic neurons Serotonergic neurons

102 Fundamental Principles of Neuropharmacology

projects to the cortex and regulates alertness, while the latter
nucleus controls sleepwake cycles and arousal. Cells in the
basal forebrain that receive inputs from the pedunculopontine
nucleus degenerate in several diseases, including Alzheimers
disease. The tuberomamillary nucleus uses the neurotrans-
mitter histamine (see below) and may help maintain arousal
through its actions on the forebrain. The somnolence induced
by first-generation antihistamineshistamine H1 receptor
antagonists used to treat allergies (see Chapter 43, Histamine
Pharmacology)may be caused by inhibition of transmis-
sion involving tuberomamillary nucleus neurons.
 NEUROPHYSIOLOGY
Neurotransmitters
The peripheral nervous system uses only two neurotransmit-
ters, acetylcholine and norepinephrine (Fig. 8-9). In contrast,
the CNS uses not only a wide variety of small molecule neu-
rotransmitters, including acetylcholine and norepinephrine
(Table 8-2), but also many neuroactive peptides. These
peptides may be transmitted concurrently with the small
molecule neurotransmitters, and they generally have a neu-
romodulatory role.
The small molecule neurotransmitters can be organized
into several broad categories, based on both their structure
and function (Fig. 8-10). The first category, the amino acid
neurotransmitters, includes glutamate, aspartate, GABA,
and glycine. The biogenic amine neurotransmitters, which
are derived from decarboxylated amino acids, include
dopamine, norepinephrine, epinephrine, serotonin, and
histamine. Acetylcholine, which is neither an amino acid
nor a biogenic amine, is used as a neurotransmitter in both
the CNS and the peripheral nervous system. The purines ad-
enosine and adenosine triphosphate (ATP) are also used
in central neurotransmission, although their roles have not
been studied in as much detail as those of other neurotrans-
mitters. The lipid-soluble gas nitric oxide (NO), which has
many effects in peripheral tissues, has recently been shown
to act as a diffusible neurotransmitter in the CNS.
Amino Acid Neurotransmitters
The amino acid neurotransmitters are the primary excitatory
and inhibitory neurotransmitters in the CNS. Two types of

A Sympathetic B Parasympathetic C Somatic

Preganglionic Acetylcholine
neuron

Nicotinic
receptors

Acetylcholine

Nicotinic
receptors
Postganglionic
neuron

Norepinephrine Acetylcholine Acetylcholine

or Acetylcholine

Adrenergic Muscarinic Nicotinic

Tissue receptor
Muscarinic (sweat glands)

FIGURE 8-9. Neurotransmitters in the peripheral nervous system (A-C). Only two neurotransmitters are required to mediate neurotransmission in the peripheral
nervous system. Acetylcholine is released by sympathetic and parasympathetic preganglionic neurons, parasympathetic postganglionic neurons, somatic motor neurons,
and sympathetic postganglionic neurons that innervate sweat glands. All other sympathetic postganglionic neurons release norepinephrine. Acetylcholine stimulates
nicotinic acetylcholine receptors on sympathetic and parasympathetic postganglionic neurons and at the neuromuscular junction. Acetylcholine stimulates muscarinic
acetylcholine receptors on sweat glands and on tissues innervated by parasympathetic postganglionic neurons. Norepinephrine stimulates - and -adrenergic recep-
tors on tissues (except for sweat glands) innervated by sympathetic postganglionic neurons.
 Amino Acid Neurotransmitters
O
O
H2N
H2N OH
OH
HO

O HO O
Aspartic acid Glutamic acid

O O
H2N H2N
OH OH
Glycine -Aminobutyric acid (GABA)

Biogenic Amine Neurotransmitters

OH
HO NH2 H
HO N

HO HO
Dopamine Epinephrine
OH
HO NH2

HO
Norepinephrine

NH2
HN

N NH2

HN OH
Histamine Serotonin

Other Neurotransmitters
O
N
N+
H2N N O
Acetylcholine
O
N N
OH

HO OH NO
Adenosine Nitric oxide
 CHAPTER 8 / Principles of Nervous System Physiology and Pharmacology 105

O Clonidine is a partial agonist that acts on presynaptic 2-

receptors. Some antidepressants increase the synaptic
OH concentration of norepinephrine by blocking its reuptake
(tricyclic antidepressants [TCAs]), while others increase
NH2 the intracellular pool of norepinephrine available for synap-
HO
tic release by inhibiting its chemical degradation (monoam-
Tyrosine ine oxidase inhibitors [MAOIs]).
5-Hydroxytryptamine (5-HT, also known as serotonin)
Tetrahydrobiopterin is formed from the amino acid tryptophan by enzymatic oxi-
Tyrosine hydroxylase (TH)
O2, Fe2+
dation at the 5 position followed by enzymatic decarboxy-
lation. This sequence of reactions is similar to that used in
O the synthesis of dopamine, although the enzymes that carry
HO out the reactions are different (Fig. 8-12). Several classes
OH of drugs target serotonergic neurotransmission. Tricyclic
antidepressants, which block norepinephrine reuptake, also
NH2
HO block serotonin reuptake. Selective serotonin reuptake
inhibitors (SSRIs), which act more selectively on serotonin
L-DOPA
reuptake transporters, are also used to treat depression. The
role of serotonergic neurons in depression and the various
Aromatic L-amino acid
Pyridoxal phosphate decarboxylase
therapies for depression that target serotonergic neurotrans-
mission are discussed in more detail in Chapter 14.

HO NH2
O

HO HN OH
Dopamine NH2

Ascorbic acid
Dopamine -hydroxylase
O2, Cu2+
Tryptophan

OH
Tryptophan hydroxylase (TPH)
HO NH2

O
HO
Norepinephrine
HN OH
NH2
Phenylethanolamine
S-adenosylmethionine
N-methyltransferase

OH
OH
H 5-Hydroxytryptophan
HO N

Aromatic L-amino acid decarboxylase

HO
Epinephrine
NH2
FIGURE 8-11. Synthesis of catecholamines. Catecholamines are all syn- HN
thesized from tyrosine. Sequential enzymatic reactions result in hydroxylation of
tyrosine to form L-DOPA, decarboxylation of L-DOPA to form dopamine, hydroxyla-
tion of dopamine to form norepinephrine, and methylation of norepinephrine to
form epinephrine. Depending on the enzymes (shown in blue lettering) expressed
in a particular type of presynaptic neuron, the reaction sequence may stop at any
of the last three steps, so that dopamine, norepinephrine, or epinephrine can be OH
the final product that is synthesized and used as a neurotransmitter. 5-Hydroxytryptamine
(Serotonin)

FIGURE 8-12. Synthesis of 5-hydroxytryptamine (serotonin). Tryptophan

is first oxidized by tryptophan hydroxylase (TPH) and then decarboxylated by aro-
matic L-amino acid decarboxylase to yield serotonin.
106 Fundamental Principles of Neuropharmacology
Histamine is formed by decarboxylation of the amino acid
histidine. Histamine functions as a diffuse neurotransmitter
in the CNS; it also has a particular role in the maintenance
of arousal via the tuberomamillary nucleus of the hypothala-
mus and in the sensation of nausea via the area postrema in
the floor of the fourth ventricle. Few therapeutics intention-
ally target central histaminergic neurotransmission. Instead,
most drugs in this class act on peripheral histamine H1 recep-
tors, at which histamine mediates the inflammatory response
to allergic stimuli, or on H2 receptors in the treatment of
peptic ulcer disease (see Chapters 43 and 46). Peripherally
acting antihistamines are sometimes used to effect sedation
or as antiemetics, acting via the central neuroanatomic sub-
strates noted above.
Other Small Molecule Neurotransmitters
Acetylcholine plays a major role in peripheral neurotrans-
mission. At the neuromuscular junction, this molecule is
used by somatic motor neurons to depolarize striated mus-
cle. In the autonomic nervous system, acetylcholine is the
neurotransmitter used by all preganglionic neurons and by
parasympathetic postganglionic neurons. The multiple func-
tions of acetylcholine in the peripheral nervous system have
spurred the development of a wide range of drugs that tar-
get peripheral cholinergic neurotransmission. These include
muscle paralytics, which interfere with neurotransmission at
the motor end plate, acetylcholinesterase inhibitors, which
increase local acetylcholine concentration by interfering
with the metabolic breakdown of the neurotransmitter, and
receptor-specific agonists and antagonists.
In the CNS, acetylcholine acts as a diffuse system
neurotransmitter. Like the biogenic amines, it is thought
to regulate sleep and wakefulness. Donepezil, a reversible
acetylcholinesterase inhibitor that acts at central cholinergic
synapses, helps to brighten patients with dementia (see
Chapter 9). Peripheral anticholinergic agents may cause cen-
tral cholinergic blockade and thereby result in major adverse
effects. For example, the antimuscarinic drug scopolamine
can cause drowsiness, amnesia, fatigue, and dreamless sleep.
In contrast, cholinergic agonists such as pilocarpine can in-
duce adverse effects of cortical arousal and alertness.
The purinergic neurotransmitters adenosine and adenosine
triphosphate have a role in central neurotransmission. This role
is most evident in the effects of caffeine, which is a competitive
antagonist at adenosine receptors and causes a mild stimulant
effect. In this case, the adenosine receptors, which are located
on presynaptic noradrenergic neurons, act to inhibit the release
of norepinephrine. Antagonism of these adenosine receptors by
caffeine causes the release of norepinephrine to be disinhibited,
which causes the characteristic stimulatory effects of the drug.
Nitric oxide (NO), which has generated significant interest
as a peripheral vasodilator, acts in the brain as a neurotrans-
mitter. Unlike the other small molecule neurotransmitters,
NO diffuses through the neuronal membrane and binds to its
receptors within the target cell. Receptors for NO are thought
to reside in presynaptic neurons, allowing NO to act as a ret-
rograde messenger. While many therapeutics target the pe-
ripheral vasodilatory effects of NO, none as of yet target its
actions as a central neurotransmitter.
Neuropeptides
The neuroactive peptides are the last major class of
neurotransmitters. Many neuropeptides also have endocrine,
autocrine, and paracrine actions. Major examples of neuro-
active peptide families are the opioids, tachykinins, secre-
tins, insulins, and gastrins. Neuropeptides also include the
pituitary hormone release and inhibiting factors, including
corticotropin-releasing hormone (CRH), gonadotropin-
releasing hormone (GnRH), thyrotropin-releasing hor-
mone (TRH), growth hormone-releasing hormone (GRH),
and somatostatin. The opioid peptide family includes the en-
kephalins, dynorphins, and endorphins. Opioid receptors,
which are distributed widely in areas of the spinal cord and
brain that are involved in pain sensation, are the principal
pharmacologic targets of opioid analgesics such as morphine
(see Chapter 17) and of some drugs of abuse such as heroin
(see Chapter 18).
The BloodBrain Barrier
In the case of Ms. P, L-DOPA, the immediate precursor of
dopamine, is administered rather than the neurotransmit-
ter itself. Unlike L-DOPA, which is able to cross from the
blood to the brain tissue where it acts to treat Ms. Ps Par-
kinsons disease, dopamine is unable to cross that boundary.
The reason for this exclusion is the existence of a selective
filter, termed the bloodbrain barrier, which regulates the
transport of many molecules from the blood into the brain
(Fig. 8-13). The bloodbrain barrier protects the brain tissue
both from toxic substances that circulate in the blood and
from neurotransmitters such as epinephrine, norepinephrine,
glutamate, and dopamine that have systemic effects in body
tissues but that would bind receptors in the CNS and cause
undesirable effects if access were permitted.
The structural basis for the bloodbrain barrier resides in
the unique design of the cerebral microcirculation. In most
tissues, there are small gaps, called fenestrae, between the
endothelial cells that line the microvasculature. These gaps
allow water and small molecules to diffuse across the lin-
ing without resistance but filter out large proteins and cells.
In the CNS, the endothelial cells form tight junctions that
prevent diffusion of small molecules across the vessel wall.
Also, unlike peripheral endothelial cells, CNS endothelial
cells do not generally have pinocytotic vesicles that trans-
port fluid from the blood vessel lumen to the extracellular
space. In addition, blood vessels in the CNS are covered by
cellular processes derived from astroglia. These processes
play an important role in selectively transporting certain nu-
trients from the blood to central neurons.
In the absence of a selective transport mechanism, the
bloodbrain barrier generally excludes water-soluble sub-
stances. In contrast, lipophilic substances, including impor-
tant lipid-soluble gases such as oxygen and carbon dioxide,
can usually diffuse across the endothelial membranes. The
oil/water partition coefficient is a good indicator of the ease
with which a small molecule can enter the CNS. Lipophilic
substances with high oil/water partition coefficients can gen-
erally diffuse across the bloodbrain barrier, whereas hydro-
philic substances with low oil-water partition coefficients
are typically excluded (Fig. 8-14).
Many important hydrophilic nutrients, such as glucose
and a number of amino acids, would not be able to cross the
bloodbrain barrier without the existence of specific trans-
porters. Glucose, for example, is transported across the bar-
rier by a hexose transporter that allows this nutrient to
move down its concentration gradient in a process called
 1.00
Nicotine Diazepam

Relative penetration into brain

Peripheral capillary Ethanol
Heroin

Glucose Chloramphenicol

L-DOPA
0.10
Phenobarbital Phenytoin

Fenestra
Dopamine
Methotrexate
Mannitol Morphine

Penicillin
0.01 Sodium
Pinocytotic vesicles Endothelial cell
0.001 0.01 0.1 1.0 10 100
Oil/Water partition coefficient

Brain capillary

Pericyte

Astroglial process

Basement membrane
Mitochondria
Tight junction
108 Fundamental Principles of Neuropharmacology
drugs as examples, the focus is on the general principles
of anatomy and neurotransmission that are important for
understanding the action of all pharmacologic agents af-
fecting the nervous system. The remaining chapters in this
section discuss specific neurotransmitter systems and spe-
cific agents that act on the peripheral and central nervous
systems. Thus, Chapters 9 and 10 describe peripheral cho-
linergic and adrenergic systems, and Chapter 11 discusses
the production of local anesthesia by inhibition of electri-
cal transmission through peripheral and spinal neurons.
Chapter 12 describes central excitatory and inhibitory neu-
rotransmission. Although few therapeutics currently take
advantage of glutamatergic neurotransmission, two major
classes of drugs, the benzodiazepines and the barbiturates,
affect GABAergic neurotransmission by potentiating the
effect of GABA at the GABAA receptor. Chapter 13 dis-
cusses dopaminergic systems, describing in more detail
the concept, introduced in the present chapter, that some
of the symptoms of Parkinsons disease can be alleviated
by drugs that increase dopaminergic transmission. Chapter
13 also explains how inhibiting dopaminergic transmis-
sion can alleviate some of the symptoms of schizophrenia,
implying that dopamine may play a role in this disease.
Chapter 14 discusses drugs that modify affect, the outward
manifestations of mood. These agents include antidepres-
sants, which block reuptake or inhibit metabolism of the
biogenic amines norepinephrine and serotonin, as well as
the mood stabilizer lithium, which is thought to affect
a signal transduction pathway. Chapter 15 explores the
pharmacology of abnormal electrical neurotransmission,
including the action of channel blockers, such as phe-
nytoin, which block the propagation of action potentials
and thereby inhibit many types of seizures. Chapter 16
describes the pharmacology of general anesthetics, agents
whose mechanism of action remains an area of active in-
vestigation. Chapter 17 discusses the pharmacology of an-
algesia, including opioid receptor agonists and nonopioid
analgesics. To conclude, Chapter 18 focuses on the phar-
macology of drugs of abuse.
Suggested Reading
Blumenfeld H. Neuroanatomy through clinical cases. 2nd ed. Sunderland,
MA: Sinauer Associates, Inc.; 2010. (Thorough review of human neuro-
anatomy with an emphasis on clinical correlation; includes many exem-
plary clinical cases.)
Squire LR, Berg D, Bloom F, du Lac S, Ghosh A. Fundamental neurosci-
ence. 3rd ed. Academic Press; 2008. (Comprehensive textbook containing
detailed information on human neuroanatomy and neurophysiology.)
 IIB

Principles of Autonomic and

Peripheral Nervous System
Pharmacology
9
Cholinergic Pharmacology
Alireza Atri, Michael S. Chang, and Gary R. Strichartz
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 110-111
BIOCHEMISTRY AND PHYSIOLOGY OF
CHOLINERGIC NEUROTRANSMISSION . . . . . . . . . . . . . . . . . 110
Synthesis of Acetylcholine . . . . . . . . . . . . . . . . . . . . . . . . 110
Storage and Release of Acetylcholine . . . . . . . . . . . . . . . . 111
Cholinergic Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Muscarinic Receptors . . . . . . . . . . . . . . . . . . . . . . . . . 113
Nicotinic Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Degradation of Acetylcholine . . . . . . . . . . . . . . . . . . . . . . 114
Physiologic Effects of Cholinergic
Transmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Neuromuscular Junction . . . . . . . . . . . . . . . . . . . . . . . 115
Autonomic Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
CNS Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
 INTRODUCTION
Cholinergic pharmacology is centered on the properties of
the neurotransmitter acetylcholine (ACh). The functions of
cholinergic pathways are complex, but generally involve the
neuromuscular junction (NMJ), the autonomic nervous sys-
tem, and the central nervous system. Despite the many im-
portant physiologic actions of ACh, the current therapeutic
uses for cholinergic and anticholinergic drugs are limited by
the ubiquitous and complicated nature of cholinergic path-
ways, and thus, by the inherent difficulty in effecting a spe-
cific pharmacologic intervention without inducing adverse
effects. Nonetheless, medications with somewhat targeted
cholinomimetic and anticholinergic actions are in wide-
spread clinical use for their effects on the brain (especially
cognition and behavior), neuromuscular junction, heart,
eyes, lungs, and genitourinary and gastrointestinal tracts.
Other relevant chapters discussing applications of cholin-
ergic pharmacology are Chapter 17, Pharmacology of Anal-
gesia; Chapter 46, Integrative Inflammation Pharmacology:
Peptic Ulcer Disease; and Chapter 47, Integrative Inflamma-
tion Pharmacology: Asthma.
 BIOCHEMISTRY AND PHYSIOLOGY OF
CHOLINERGIC NEUROTRANSMISSION
Acetylcholine synthesis, storage, and release follow a simi-
lar set of steps in all cholinergic neurons. The specific effects
110
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 119
Inhibitors of Acetylcholine Synthesis,
Storage, and Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Acetylcholinesterase Inhibitors . . . . . . . . . . . . . . . . . . . . . 120
Structural Classes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Clinical Applications . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Receptor Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Muscarinic Receptor Agonists . . . . . . . . . . . . . . . . . . . 122
Nicotinic Receptor Agonists. . . . . . . . . . . . . . . . . . . . . 123
Receptor Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Muscarinic Receptor Antagonists . . . . . . . . . . . . . . . . 124
Nicotinic Receptor Antagonists . . . . . . . . . . . . . . . . . . 126
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 126
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
of ACh at a particular cholinergic synapse are largely deter-
mined by the ACh receptor type at that synapse. Cholinergic
receptors are divided into two broad classes. Muscarinic
cholinergic receptors (mAChR) are G protein-linked and ex-
pressed at the terminal synapses of all parasympathetic post-
ganglionic fibers and a few sympathetic postganglionic fibers,
at autonomic ganglia, and in the CNS. Nicotinic cholinergic
receptors (nAChR) are ligand-gated ion channels that are
concentrated postsynaptically at many excitatory autonomic
synapses and presynaptically in the CNS. Acetylcholinest-
erase (AChE), the enzyme responsible for acetylcholine deg-
radation, is also an important pharmacologic target. In this
section, a description of the biochemistry of each of these
pharmacologic targets is followed by a discussion of the phys-
iologic effects of acetylcholine at the neuromuscular junction,
in the autonomic nervous system, and in the CNS.
Synthesis of Acetylcholine
Acetylcholine is synthesized in a single step from choline
and acetyl coenzyme A (acetyl CoA) by the enzyme choline
acetyltransferase (ChAT):
Acetyl Coenzyme A Choline ChAT
Acetylcholine Coenzyme A H2O Equation 9-1
In the CNS, choline used for the synthesis of acetylcho-
line arises from one of three sources. Approximately 35%
112 Principles of Autonomic and Peripheral Nervous System Pharmacology

Na+

Choline
Cholinergic neuron

AcCoA + Choline Hemicholinium

Choline
Vesamicol acetyltransferase

ACh

Calcium Calcium
channel channel

Ca2+ Ca2+

ACh H +
LEMS
(autoantibody)
Botulinum
toxin
ACh

Muscarinic ACh receptor Nicotinic ACh receptor

(M2, M4) ACh
Choline +
acetate
Synaptic cleft
AChE AChE
Inhibitors
Acetylcholinesterase

Nicotinic
Postsynaptic Muscarinic ACh receptor
cell ACh receptor
M1, M3, M5 M2, M4
Opens Na+/K+ channel
Gq Gi
Excitatory
PLC AC,
K+ channel

Excitatory Inhibitory

FIGURE 9-1. Acetylcholine synthesis, storage, release, and degradation pathways, and pharmacologic agents that act on these pathways. Choline is trans-
ported into the presynaptic cholinergic nerve terminal by a high-affinity Na-choline co-transporter. This transporter is inhibited by hemicholinium. The cytosolic enzyme
choline acetyltransferase catalyzes the formation of acetylcholine (ACh) from acetyl coenzyme A (AcCoA) and choline. Newly synthesized ACh is packaged (together with ATP
and proteoglycans) into vesicles for storage. Transport of ACh into the vesicle is mediated by a H-ACh antiporter, which is inhibited by vesamicol. The ACh-containing vesicles
fuse with the plasma membrane when intracellular calcium levels rise in response to a presynaptic action potential, releasing the neurotransmitter into the synaptic cleft.
LambertEaton myasthenic syndrome (LEMS) results from an autoantibody that blocks the presynaptic Ca2 channel. Botulinum toxin prevents the exocytosis of presynaptic
vesicles, thereby blocking ACh release. Acetylcholine diffuses in the synaptic cleft and binds to postsynaptic and presynaptic receptors. Acetylcholine receptors are divided
into nicotinic and muscarinic receptors. Nicotinic receptors are ligand-gated ion channels that are permeable to cations, while muscarinic receptors are G protein-coupled
receptors that alter cell signaling pathways, including activation of phospholipase C (PLC), inhibition of adenylyl cyclase (AC), and opening of K channels. Postsynaptic
nicotinic receptors and M1, M3, and M5 muscarinic receptors are excitatory; postsynaptic M2 and M4 muscarinic receptors are inhibitory. Presynaptic nicotinic receptors
enhance Ca2 entry into the presynaptic neuron, thereby increasing vesicle fusion and release of ACh; presynaptic M2 and M4 muscarinic receptors inhibit Ca2 entry into the
presynaptic neuron, thereby decreasing vesicle fusion and release of ACh. Acetylcholine in the synaptic cleft is degraded by membrane-bound acetylcholinesterase (AChE)
into choline and acetate. Numerous inhibitors of AChE exist; most clinically relevant anticholinesterases are competitive inhibitors of the enzyme.

Transmission, for additional details on electrochemical
transmission.)
Two stores of ACh play distinct roles during the pro-
cess of ACh release. One store, known as the depot
pool, consists of vesicles positioned near the plasma
membrane of the axon terminal. Axonal depolariza-
tion causes these vesicles to release ACh rapidly. The
reserve pool serves to refill the depot pool as it is being
used. An adequate rate of reserve pool mobilization is
required to sustain ACh release for an extended period
of time. Of the two stores, the depot pool is replenished
first by vesicles loaded with newly synthesized ACh; this
process displaces some of the older depot pool vesicles
into the reserve pool.

Cholinergic Receptors
After ACh has been released into the synaptic cleft, it
binds to one of two classes of receptors, usually on the
membrane surface of the postsynaptic cell. Muscarinic
receptors (mAChR) are seven-transmembrane-domain G
protein-coupled receptors (GPCRs), and nicotinic receptors
(nAChR) are ligand-gated ion channels. Although muscar-
inic receptors are sensitive to the same neurotransmitter as
nicotinic receptors, these two classes of cholinergic recep-
tors share little structural similarity.
Muscarinic Receptors
Muscarinic cholinergic transmission occurs mainly at auto-
nomic ganglia, at end organs innervated by the parasympa-
thetic division of the autonomic nervous system, and in the
CNS. Muscarinic receptors belong to the same family as a
number of other cell surface receptors (such as the adren-
ergic receptors) that transduce signals across the cell mem-
brane and interact with GTP-binding proteins. Because all
the effects of muscarinic receptor activation occur through
the actions of these G proteins, there is a latency of at least
100250 ms associated with muscarinic responses to recep-
tor activation. (In contrast, nicotinic channels have latencies
on the order of 5 ms.)
G protein activation by agonist binding to muscarinic
receptors may have several different effects on cells. These
include inhibition of adenylyl cyclase (via Gi) and stimula-
tion of phospholipase C, both mediated by an subunit of
the G protein. (See Chapter 1, DrugReceptor Interactions,
for a discussion of these signaling mechanisms.) Muscarinic
activation also influences ion channels via second messenger
molecules. The predominant effect of such mAChR stimula-
tion is to increase the opening of specific potassium chan-
nels (G protein-modified inwardly rectifying K channels, or
GIRKs), thereby hyperpolarizing the cell. This effect is medi-
ated through the subunit of a G protein (Go), which binds
to the channel and enhances its probability of being open.
Five distinct cDNAs for human muscarinic receptors,
denoted M1M5, have been isolated and detected in cells.
These receptor types form two functionally distinct groups.
M1, M3, and M5 are coupled to G proteins responsible for
the stimulation of phospholipase C. M2 and M4, on the other
hand, are coupled to G proteins responsible for adenylyl cy-
clase inhibition and K channel activation. The receptors of
each functional group can be distinguished based on their
responses to pharmacologic antagonists (Table 9-1). Gen-
erally, M1 is expressed in cortical neurons and autonomic
ganglia, M2 in cardiac muscle, and M3 in smooth muscle and
glandular tissue. Because stimulation of M1, M3, and M5 re-
ceptors facilitates excitation of the cell, while stimulation of
M2 and M4 receptors suppresses cellular excitability, there is
a predictable correlation between the receptor subtype and
the effect of ACh on the cell. The various muscarinic recep-
tor subtypes account for much of the diversity in cellular
responses to mAChR agonists.
Nicotinic Receptors
Nicotinic cholinergic transmission results from the binding
of ACh to the nAChR (Fig. 9-2). This phenomenon is known
as direct ligand-gated conductance. The binding of two ACh
molecules to one nAChR elicits a conformational change in
the receptor that creates a monovalent cation-selective pore
CHAPTER 9 / Cholinergic Pharmacology 113
through the cell membrane. Open channels of the activated
nAChR are equally permeable to K and Na ions. (Since
the resting membrane potential is close to the Nernst poten-
tial for K and far below the Nernst potential for Na, the
predominant ion passing through the open nACR is Na.) A
relatively small permeability to Ca2 ions nevertheless re-
sults in important elevations of intracellular [Ca2]. There-
fore, when open, these channels produce a net inward Na
current that depolarizes the cell. Stimulation of multiple
nAChRs may depolarize the cell sufficiently to generate ac-
tion potentials and to open voltage-dependent calcium chan-
nels. This latter action, and the direct entry of Ca2 through
the nAChR pore, can lead to activation of several intracel-
lular signaling pathways.
Because ACh dissociates rapidly from active-state re-
ceptor molecules and acetylcholinesterase rapidly degrades
free (unbound) ACh in the synaptic cleft (see below), the
depolarization mediated by nAChRs is brief (10 ms). Al-
though the simultaneous binding of two ACh molecules is
required for channel opening, it is not necessary for both
molecules to dissociate for the channel to open again; bind-
ing of a second ACh molecule to a receptor that still has
one ACh bound may, once again, result in channel opening.
The kinetics of nAChR binding and channel opening are
detailed in Figure 9-3.
Structurally, the nicotinic acetylcholine receptor com-
prises five subunits, each of which has a mass of approxi-
mately 40 kilodaltons (Fig. 9-2A). Several types of subunits
have been identified in the nAChR, designated , , , ,
and . All of these subunits share 3550% homology with
one another. Each receptor at the NMJ is composed of two
subunits, one and one subunit, and either one or
one subunit. (The 2 form dominates at the neuromus-
cular junction in mature skeletal muscle, while the 2
form is expressed in embryonic muscle.) Agonist molecules
bind at a hydrophobic pocket that is formed between each
subunit and the adjacent, complementary subunitthis is
the structural basis for the binding of two ACh molecules to
each receptor. The conformational change in the subunits
induced by the binding of ACh initiates the overall changes
in the pore that permit ion flow through the receptor (i.e.,
that open the channel).
Besides simply opening and closing in response to ACh
binding, nicotinic receptors also modulate their responses to
various concentration profiles of ACh. The receptors react
differently to discrete, brief pulses of ACh than to neu-
rotransmitter that is present continuously. As noted above,
under normal conditions, a closed, resting-state channel re-
sponds to dual ACh binding by opening transiently, and the
low affinity of the receptor for ACh causes rapid dissocia-
tion of ACh from the receptor and return of the receptor to
its resting conformation. In comparison, continuous expo-
sure of the receptor to ACh causes it to undergo a change
to a desensitized conformation in which the channel is
locked closed. The desensitized state is also characterized
by a greatly increased affinity of the receptor for ACh, so
that ACh remains bound to the receptor for a relatively long
period of time. This prolonged binding of ACh to the desen-
sitized conformation of the receptor delays the conversion of
the receptor to its unstimulated, resting state.
Nicotinic cholinergic receptors at autonomic ganglia and
in the central nervous system (termed N2 or NN) are similar
to receptors at the NMJ (N1 or NM), with the exception that
 CHAPTER 9 / Cholinergic Pharmacology 115

A Overall Structure a minor role in early neural development as a co-regulator of

ACh (it can hydrolyze ACh, but at rates much slower than

N AChE) and may be involved in the pathogenesis of Alzheim-
M4 C
ers disease. Because of its central importance to cholinergic
M1 transmission, an entire class of drugs known as acetylcholin-
esterase inhibitors has been designed to target AChE.
M3
M2 Physiologic Effects of Cholinergic
Transmission
Neuromuscular Junction
Acetylcholine is the principal neurotransmitter at the neuro-
muscular junction (Fig. 9-4). The binding of ACh released
by motor neurons to nicotinic receptors in the muscle cell
B Acetylcholine Binding Site membrane results in motor end-plate depolarization. The
extent of depolarization depends on the quantity of ACh
Amino acids released into the synaptic cleft. Release of ACh is quantal
in nature; that is, ACh is released in discrete quantities by
the presynaptic motor neuron. Each quantum of ACh cor-
responds to the contents of a single synaptic vesicle and
Y W elicits a small depolarization in the motor end-plate termed
W a miniature end-plate potential (MEPP). Under resting
ACh
conditions, sporadic MEPPs are detected at the motor end-
binding sites Y
N plate, corresponding to a low baseline level of unstimulated
Y
C C Y ACh release that arises from spontaneous vesicle fusion with
the motor axons presynaptic membrane. In contrast, the ar-
Acetylcholine rival of an action potential at the motor axon terminal causes
binding site many more vesicles (up to thousands) to fuse with the neu-
ronal membrane and release their ACh. At the motor end-
C Ion Channel plate, the result is a relatively large depolarization termed
M2 M2
the end-plate potential (EPP) (Fig. 9-5). The magnitude
M2 M2 of the EPP is more than sufficient to trigger a propagating
action potential throughout the muscle fiber and, hence, to
produce a single contraction or twitch.
M2 M2 Acetylcholine not only triggers muscle contraction as its
M2 primary effect at the NMJ, but also modulates its own ac-
Amino Leucine
acids ring tion at this site. Presynaptic cholinergic receptors, located
on the axon terminal of the motor neuron, respond to ACh
binding by facilitating the mobilization of synaptic vesicles
from the reserve pool to the depot pool. This positive feed-
back loop, in which the release of ACh stimulates additional
release, is necessary to ensure sufficient ACh release under
high-frequency stimulation of the nerve (100 Hz). Despite
this mechanism, the ACh output per nerve impulse wanes
rapidly during persistent high-frequency stimulation. Fortu-
FIGURE 9-2. Structural biology of the nicotinic acetylcholine receptor.
A. Overall structure of the nicotinic acetylcholine receptor (NM type) and its five
nately, because an excess of ACh is released and an excess of
subunits (2). Each subunit is composed of a transmembrane protein that ACh receptors is present, there is a large safety margin. Only
has four membrane-spanning (hydrophobic) alpha-helical regions (M1, M2, M3, when 50% or more of the postsynaptic receptors are desen-
M4). The large hydrophilic N-terminal domains of the two subunits contain sitized is a decline in muscle tension observed during tetanic
the binding sites for acetylcholine. B. Acetylcholine binding site viewed from stimulation (a phenomenon known as tetanic fade). Impor-
above (inset: lower magnification). The labeled amino acids of the subunit tantly, selective blockade of the modulatory presynaptic cho-
hydrophilic domain are particularly important in binding acetylcholine. The con- linergic receptors by antagonists such as hexamethonium
formational change that results from the binding of two acetylcholine molecules prevents facilitation and causes rapid tetanic fade to occur
opens the channel. C. The M2 domains of the five subunits all face the inte- under otherwise normal conditions (Fig. 9-6).
rior of the protein and together form the transmembrane channel (inset). Three
negatively charged rings of five amino acids (one from each M2 subunit) draw Autonomic Effects
positively charged ions through the channel. At the center, an uncharged leucine
Neurotransmission through autonomic ganglia is compli-
ring (purple ) participates in closing the ion channel when the receptor becomes
desensitized to acetylcholine.
cated because several distinct receptor types contribute to
the complex changes observed in postganglionic neurons.
The generalized postsynaptic response to presynaptic im-
pulses can be separated into four distinct components (Fig.
9-7). The primary event in the postsynaptic ganglionic re-
sponse is a rapid depolarization mediated by nicotinic ACh
116 Principles of Autonomic and Peripheral Nervous System Pharmacology

ACh

ACh ACh ACh

binding
sites
ACh ACh ACh ACh ACh

Receptor gate
Receptor gate
(closed)
kon k'on (open)
2A + R A + AR A 2R A2R *
koff k'off
FIGURE 9-3. Kinetics of nicotinic acetylcholine receptor binding and channel opening. Each transition between states of receptor binding and channel opening is
completely reversible, and it is not necessary to go through all of the possible conformations before returning to a given state. For example, a receptor with two associated
ligands may lose one and then gain another to return to its initial state, without the need for both ligands to dissociate. A, ligand (ACh); R, nicotinic ACh receptor (closed);
R*, nicotinic ACh receptor (open); kon, rate constant for association (binding) of the first ACh molecule to the receptor; kon, rate constant for association of the second ACh
molecule to the receptor; koff, rate constant for dissociation of the first ACh molecule from the receptor; koff, rate constant for dissociation of the second ACh molecule from
the receptor; , rate constant of channel opening after both ACh molecules have bound; , rate constant of channel closure. Note that channel opening and closing are
much slower events than binding of ACh to the receptor.

receptors on the postganglionic neuron. The mechanism is
similar to that in the NMJ, in that an inward current elicits a
near-immediate excitatory postsynaptic potential (EPSP) of
1050 ms in duration. Typically, the amplitude of such an
EPSP is only a few millivolts, and many such events must
sum for the postsynaptic cell membrane to reach the threshold
for firing an action potential (Fig. 9-7A). The three remain-
ing events of ganglionic transmission modulate this primary
signal and are known as the slow EPSP, the IPSP (inhibitory
postsynaptic potential), and the late, slow EPSP. The slow
EPSP occurs after a latency of 1 second and is mediated by
M1 muscarinic ACh receptors. The duration of this effect is
1030 seconds (Fig. 9-7C). The IPSP is largely a product of
catecholamine (i.e., dopamine and norepinephrine) stimula-
tion of dopaminergic and -adrenergic receptors (see Chap-
ter 10, Adrenergic Pharmacology), although some IPSPs in
a few ganglia are mediated by M2 muscarinic receptors. The
latency and duration of the IPSPs generally vary between
those of the fast and slow EPSPs. The late, slow EPSP is
mediated by a decrease in potassium conductance induced
by stimulation of receptors for peptide transmitters (i.e., an-
giotensin, substance P, and luteinizing hormone-releasing
hormone). Lasting for several minutes, the late, slow EPSP
is thought to play a role in the long-term regulation of post-
synaptic neuron sensitivity to repetitive depolarization.
One pharmacologic consequence of such a complex pat-
tern of depolarization in autonomic ganglia is that drugs
selective for the IPSP, slow EPSP, and late, slow EPSP are
generally not capable of eliminating ganglionic transmission.
Instead, such agents alter only the efficiency of transmission.
For example, methacholine, a muscarinic receptor agonist,
has modulatory effects on autonomic ganglia that resemble
the stimulation of slow EPSPs (see below). Blockade of ex-
citatory transmission through autonomic ganglia relies on
inhibition of the nAChRs that mediate fast EPSPs.
The overall effect of ganglionic blockade is complex and
depends on the relative predominance of sympathetic and
parasympathetic tone at the various end organs (Table 9-2).
For example, the heart is influenced at rest primarily by the
parasympathetic system, whose tonic effect is a slowing of
the heart rate. Thus, blockade of autonomic ganglia that in-
nervate the heart by moderate to high doses of the antimus-
carinic agent atropine results in blockade of vagal slowing
of the sinoatrial node, and hence in relative tachycardia. It
should be noted that in low doses, the central parasympathetic
stimulating effects of atropine predominate, initially resulting
in bradycardia prior to its peripheral vagolytic action. Blood
vessels, in contrast, are innervated only by the sympathetic
system. Because the normal effect of sympathetic stimula-
tion is to cause vasoconstriction, ganglionic blockade results
in vasodilation. It is important to realize, however, that the
responses described above ignore the presence of muscarinic
ACh receptors at many of the end organs. When stimulated
directly by cholinergic agents, such receptors often mediate
a response that overrides the response produced by gangli-
onic blockade. In general, the expected net cardiovascular
effects of muscarinic blockade produced by clinical doses of
atropine in a healthy adult with a normal hemodynamic state
are mild tachycardia, with or without flushing of the skin,
and no profound effect on blood pressure.
The muscarinic receptor subtypes expressed in visceral
smooth muscle, cardiac muscle, secretory glands, and en-
dothelial cells mediate highly diverse responses to cholin-
ergic stimulation. These effects are detailed in Table 9-3. In
general, these end-organ effects tend to predominate over
ganglionic influences. That is, for systemically administered
cholinergic agents, the overall response is generally similar
to that caused by direct stimulation of these postganglionic
effector sites and often different from that caused by gangli-
onic stimulation alone.
CNS Effects
CNS functions of ACh include modulation of sleep, wakeful-
ness, learning, and memory; suppression of pain at the spinal
cord level; and essential roles in neural plasticity, early neural
development, immunosuppression, and epilepsy. While the
 CHAPTER 9 / Cholinergic Pharmacology 117

past two decades have improved understanding of the diver-

sity of subunits and molecular properties of neuronal nicotinic
receptors, important questions remain about the anatomical
distributions and functional roles of different neuronal recep-
Neuron
tor subtypes in the CNS, and of their changes in disease states
and during nicotine abuse, as occurs with smoking.
As part of the ascending reticular activating system,
cholinergic neurons play an important role in arousal and
Neuromuscular attention (see Fig. 8-8). Levels of ACh throughout the brain
junction increase during wakefulness and REM sleep and decrease
during inattentive states and non-REM/slow-wave sleep
Muscle fiber (SWS). During an awake or aroused state, cholinergic pro-
jections from the pedunculopontine nucleus, the lateral teg-
mental nucleus, and the nucleus basalis of Meynert (NBM)
are all active. Because the NBM projects diffusely through-
out the cortex and hippocampus (see Fig. 8-8), activation of
the NBM causes a global increase in ACh levels. Acetylcho-
line markedly potentiates the excitatory effects of other in-
Myelin puts to its cortical target cells without affecting the baseline
Axon End-plate
activity of these neurons, an effect that likely derives from
Schwann cell region its modulation of excitatory neurotransmitter release. This
sheath primed state is thought to improve the ability of such neu-
rons to process incoming inputs. For the brain as a whole,
the result is a heightened state of responsiveness.
The cholinergic link to memory processes is supported
by evidence from diverse experimental models. Whereas
elevated ACh levels during wakefulness appear to benefit
Presynaptic memory encoding processes, consolidation of hippocampus-
boutons Synaptic
clefts mediated, episodic, explicit memories benefit from SWS,
when ACh levels are at their minimum. By artificially keep-
ing ACh levels elevated during SWS (e.g., by administra-
Mitochondria tion of an AChE inhibitor), consolidation of newly acquired
explicit learning and episodic memories can be disrupted.
Synaptic vesicle (ACh) Current understanding of the interplay among ACh, sleep,
and memory is as follows. During awake states, ACh pre-
Dense bar (active zone)
vents interference in the hippocampus during initial learning
Presynaptic by suppressing retrieval of previously stored memories (to
membrane
prevent them from interfering with new encoding), but re-
lease of this suppression is necessary to allow consolidation
Synaptic cleft
of new memories. During sleep (in particular, during SWS),
lower ACh levels are required for proper consolidation of
Postsynaptic newly acquired memories because stronger excitatory feed-
membrane
back transmission is needed to reactivate memories for con-
solidation within neocortical brain areas. Therefore, it may
Junctional fold be useful to remember to sleep, as sleep is needed to remem-
ber, or at least to remember better.
The clinical importance of ACh for cognitive function is
illustrated by the pathophysiology and treatment of Alzheim-
ACh Acetylcholinesterases ers disease (AD) and other neurodegenerative dementias, in-
receptors cluding diffuse Lewy body dementia (DLB) and Parkinsons
disease with dementia (PDD). Neurodegenerative dementias
FIGURE 9-4. The neuromuscular junction (NMJ). At the neuromuscular and brain injury produce central cholinergic dysfunction. Pa-
junction, motor neurons innervate a group of muscle fibers. The area of muscle tients with these conditions manifest cognitive, functional,
fibers innervated by an individual motor neuron is referred to as the end-plate and behavioral deficits that are at least partially related to cho-
region. Multiple presynaptic terminals extend from the axon of the motor neuron.
linergic deficits and amenable to symptomatic treatment with
When the motor neuron is depolarized, its synaptic vesicles fuse with the pre-
synaptic membrane, releasing ACh into the synaptic cleft. ACh receptors of the
procholinergic medications. An example is the symptomatic
neuromuscular junction are exclusively nicotinic, and stimulation of these recep- treatment of AD with acetylcholinesterase inhibitors.
tors results in depolarization of the muscle cell membrane and generation of an Acetylcholine also plays a role in pain modulation through
end-plate potential. inhibition of spinal nociceptive transmission. Cholinergic
neurons located in the rostral ventromedial medulla extend
processes to the superficial lamina of the dorsal horn at all
levels of the spinal cord, where secondary neurons in afferent
sensory pathways are located. ACh released by the cholinergic
 Membrane potential (mV)
Threshold potential Action potential Action potential
of postsynaptic cell
0
Resting
potential

-55
-70

Q Q Q Q 2Q

A Subthreshold, B Temporal summation C Spatial summation

no summation

FIGURE 9-5. Quantal release of acetylcholine and muscle contraction. Muscle contraction relies on the accumulation of a sufficient concentration of acetylcholine at the
motor end-plate to depolarize the muscle beyond the threshold potential (typically, about 55 mV). After local depolarization occurs, a self-propagating action potential is generated
that can spread along the muscle fiber and result in muscle contraction. A. As a single cholinergic vesicle releases its contents into the NMJ, a small depolarization (Q), otherwise
known as a miniature end-plate potential (MEPP), occurs in the local region of the muscle. This MEPP is insufficient to generate an action potential. When a sufficient number of
individual cholinergic vesicles empty their contents into the NMJ, either in quick succession (B) or simultaneously (C), sufficient depolarization occurs (termed the end-plate poten-
tial, or EPP) that the motor end-plate threshold for action potential generation is exceeded, and muscle contraction occurs. An isolated action potential produces a twitch, while a
train of action potentials may produce sustained contraction of the muscle. Note that although this example uses two MEPPs for simplicity, many more than two MEPPs are actually
required to achieve threshold-level depolarization. In this figure, the x-axis is time.

A Fast EPSP

B Slow IPSP
Voltage (mV)

0.1 Hz 2 Hz 50 Hz 0.1 Hz
C Slow EPSP

D Late, slow EPSP

Stimulus 15 sec 30 sec 5 min

applied
0.1 Hz 2 Hz 50 Hz 0.1 Hz Time

FIGURE 9-7. Four types of synaptic signals in an autonomic ganglion. The

FIGURE 9-6. Tetanic fade and the effects of hexamethonium. A. Control
stimulation. Rapid stimulation of muscle contraction relies on presynaptic ace-
tylcholine autoreceptors that provide positive feedback and thereby increase the
amount of acetylcholine released with each depolarization. The diagram shows
control muscle responses to single-shock stimulation (0.1 Hz), a train of four
stimulations (2 Hz), or tetanic stimulation (50 Hz). Positive feedback increases the
amount of ACh released with each depolarization during tetanic stimulation, pro-
viding enhanced muscle contraction that gradually fades back to baseline during
subsequent single-shock stimulation. B. Stimulation after the administration of
hexamethonium. Note that although the response to isolated (0.1 Hz) stimuli is un-
changed in the presence of hexamethonium, the drug prevents the increased effect
that normally occurs with higher-frequency (50 Hz) stimulation. This is a result of
hexamethoniums antagonism of the acetylcholine autoreceptor on the presynaptic
terminal that is normally responsible for positive feedback of ACh release.
response of autonomic ganglia to neurotransmission is a complex event mediated
by a number of different neurotransmitters and receptor types and occurring on
several distinct time scales. A. The primary mode of neurotransmission is the
action potential, which is produced by a sufficiently strong (suprathreshold) ex-
citatory postsynaptic potential (EPSP). The fast EPSP is mediated by acetylcholine
acting on postsynaptic nicotinic ACh receptors. B. The slow inhibitory postsyn-
aptic potential (IPSP) is a membrane hyperpolarization response. This response
is thought to be mediated by several different postsynaptic receptor types, in-
cluding modulatory dopamine receptors and -adrenergic receptors as well as
M2 muscarinic ACh receptors. C. The slow EPSP is mediated by M1 muscarinic
receptors, has a latency of about 1 second after an initial depolarization, and lasts
for 1030 seconds. D. The late, slow EPSP occurs on the order of minutes after a
depolarization event. This excitatory response may be mediated by peptides that
are co-released with acetylcholine.

118
120 Principles of Autonomic and Peripheral Nervous System Pharmacology
(12) bladder spasms and urinary incontinence, (13) cosmetic
effects on skin lines and wrinkles, and (14) treatment of Al-
zheimers disease, cognitive dysfunction, and dementias.
Slight variations in the pharmacologic properties of indi-
vidual cholinergic and anticholinergic agents are responsible
for their large differences in therapeutic utility. The relative
selectivity of action of the most useful agents depends on
both pharmacodynamic and pharmacokinetic factors, in-
cluding inherent differences in receptor binding affinity, bio-
availability, tissue localization, and resistance to degradation.
These variations, in turn, derive from the molecular structure
and charge of the drug. The structure of pirenzepine, for ex-
ample, allows the drug to bind M1 muscarinic receptors (lo-
cated in autonomic ganglia) with higher affinity than M2 and
M3 receptors (located at parasympathetic end organs). As a
result, the drugs predominant effect at clinically used doses
is ganglionic blockade (see Table 9-1). Similarly, the addi-
tion of a methyl group to acetylcholine yields methacholine,
which is more resistant to degradation by AChE and, hence,
possesses a longer duration of action. Charged agents such
as muscarine generally do not cross membrane barriers. The
absorption of such drugs through both the gastrointestinal
(GI) mucosa and the bloodbrain barrier is significantly im-
paired, unless specific carriers are available to transport the
drug; therefore, such drugs typically have little or no effect
on the CNS. In contrast, lipophilic agents have excellent
CNS penetration. As one example, the high CNS penetration
of physostigmine makes this drug the agent of choice for
treating the CNS effects of anticholinergic overdose.
The following discussion is ordered mechanistically.
For each class of drugs, the selectivity of individual agents
within the class is used as a basis to explain the therapeutic
uses of each agent.
Inhibitors of Acetylcholine Synthesis, Storage,
and Release
Drugs that inhibit the synthesis, storage, or release of ACh
have only recently begun to have clinical use (Fig. 9-1).
Hemicholinium-3 blocks the high-affinity transporter for
choline and thus prevents the uptake of choline required for
ACh synthesis. Vesamicol blocks the ACh-H antiporter
that is used to transport ACh into vesicles, thereby prevent-
ing the storage of ACh. Both of these compounds are utilized
only in research settings, however. Botulinum toxin A, pro-
duced by Clostridium botulinum, degrades SNAP-25 and
thus prevents synaptic vesicle fusion with the axon terminal
(presynaptic) membrane. This paralysis-inducing property is
currently used in the treatment of several diseases associ-
ated with increased muscle tone, such as torticollis, achala-
sia, strabismus, blepharospasm, and other focal dystonias.
Botulinum toxin is also approved for cosmetic treatment of
facial lines or wrinkles and is used to treat various headache
and pain syndromes (e.g., by intrathecal delivery into the
spinal fluid). Because it degrades a protein common to the
synaptic-vesicle fusion machinery in multiple types of nerve
terminals, botulinum toxin has a general effect on the release
of many different neurotransmitters, not just ACh.
Acetylcholinesterase Inhibitors
Agents in this class bind to and inhibit AChE, thereby el-
evating the concentration of endogenously released ACh in
the synaptic cleft. The accumulated ACh subsequently acti-
vates nearby cholinergic receptors. Agents in this class are
also referred to as indirectly acting ACh receptor agonists
because they generally do not activate receptors directly. It
is important to note that a few AChE inhibitors have a di-
rect action as well. For example, neostigmine, a quaternary
carbamate, not only blocks AChE but also binds to and acti-
vates nAChRs at the neuromuscular junction.
Structural Classes
All indirectly acting cholinergic agonists interfere with the
function of AChE by binding to the active site of the enzyme.
There are three chemical classes of such agents, including
(1) simple alcohols with a quaternary ammonium group,
(2) carbamic acid esters of alcohols bearing either quaternary
or tertiary ammonium groups, and (3) organic derivatives of
phosphoric acid (Fig. 9-8). The most important functional
difference among these classes is pharmacokinetic.
Edrophonium is a simple alcohol that inhibits AChE by
reversibly associating with the active site of the enzyme. Be-
cause of the noncovalent nature of the interaction between
the alcohol and AChE, the enzymeinhibitor complex lasts
for only 210 minutes, resulting in a relatively rapid but
completely reversible block.
The carbamic acid esters neostigmine and physostigmine
are hydrolyzed by AChE, so a labile covalent bond is formed
between the drug and the enzyme. However, the rate at which
this reaction occurs is many orders of magnitude slower than
for ACh. The resulting enzymeinhibitor complex has a half-
life of approximately 1530 minutes, corresponding to an ef-
fective inhibition lasting 38 hours.
Organophosphates such as diisopropyl fluorophosphate
have a molecular structure that resembles the transition state
formed in carboxyl ester hydrolysis. These compounds are
hydrolyzed by AChE, but the resulting phosphorylated en-
zyme complex is extremely stable and dissociates with a
half-life of hundreds of hours. Furthermore, the enzyme
organophosphate complex is subject to a process known as
aging, in which oxygenphosphorus bonds within the in-
hibitor are broken spontaneously in favor of stronger bonds
between the enzyme and the inhibitor. Once aging occurs,
the duration of AChE inhibition is increased even further.
Thus, organophosphate inhibition is essentially irreversible,
and the body must synthesize new AChE molecules to re-
store AChE activity. However, if strong nucleophiles (such
as pralidoxime) are administered before aging has occurred,
it is possible to recover enzymatic function from the inhib-
ited AChE.
Clinical Applications
Acetylcholinesterase inhibitors have a number of clinical
applications, including (1) increasing transmission at the
neuromuscular junction, (2) increasing parasympathetic
tone, and (3) increasing central cholinergic activity (e.g.,
to treat symptoms of AD).
Because of their ability to increase the activity of endog-
enous ACh, AChEs are especially useful in diseases of the
neuromuscular junction, where the primary defect is an in-
sufficient quantity of either ACh or AChR. In myasthenia
gravis, autoantibodies are generated against NM receptors.
These antibodies both induce NM receptor internalization and
block the ability of ACh to activate the receptors. As a result,
patients with myasthenia gravis present with significant
A Simple Alcohols B Carbamic Acid Esters C Organophosphates

N+ O
HO N O N+
P
O O
O F
Edrophonium Neostigmine Isoflurophate

H
N O
N
O
N

Physostigmine
A Choline Esters B Alkaloids

HO
O
N+
O N+
O
Acetylcholine
Muscarine
O
N+
O
N
Methacholine O

O N
O
Pilocarpine
N+
H2N O
Carbachol

O
N+
H2N O

Bethanechol

responses that are opposite to those produced by normal au-
tonomic tone.
Muscarinic receptors are G protein-coupled receptors
that bind acetylcholine and initiate signaling through sev-
eral intracellular pathways. These receptors are expressed
in the autonomic ganglia and effector organs, where they
mediate a parasympathetic response. The primary uses
of muscarinic receptor agonists and antagonists are to
modulate autonomic responses of effector organs. Both
nicotinic and muscarinic receptors are ubiquitous in the
CNS, where the effects of acetylcholine include analge-
sia, arousal, and attention. The relative roles of mAChRs
and nAChRs in the brain and spinal cord are not fully un-
derstood, and the most effective currently available CNS
drugs increase endogenous cholinergic transmission by
inhibiting the action of acetylcholinesterase, the enzyme
that hydrolyzes ACh.
Although cholinergic pharmacology is a relatively ma-
ture field with a number of receptor-selective agents, the
specificity of action of the various agents continues to be
refined. The discovery of muscarinic-receptor subtype
diversity may lead to the development of agents specific
for subtypes that are expressed in a tissue-specific pat-
tern. Similarly, elucidation of the role of nicotinic-receptor
subunit diversity in the CNS may spur the development of
more selective agents that modulate the activity of these
receptor subtypes. Acetylcholinesterase inhibitors are now
widely used in clinical practice and are standard-of-care in
the treatment of AD and other dementias. Currently avail-
able AChE inhibitors provide modest symptomatic ben-
efits, and several nicotinic and muscarinic agonists are in
clinical development for treatment of cognitive impairment
CHAPTER 9 / Cholinergic Pharmacology 127
and AD. Nicotinic receptors may also provide targets for
future treatment approaches in epilepsy.
Suggested Reading
Andersson KE. Antimuscarinics for treatment of overactive bladder. Lancet
Neurol 2004;3:4653. (Review of overactive bladder pathophysiology and
pharmacology.)
Atri A, Shaughnessy LW, Locascio JJ, Growdon JH. Long-term course and
effectiveness of combination therapy in Alzheimer disease. Alzheimer Dis
Assoc Disord 2008;22:209221. (Reviews clinical efficacy data for anti-AD
medications, including AChE inhibitors, and assesses their long-term im-
pact on the course of AD.)
Atri A, Sherman S, Norman KA, et al. Blockade of central cholinergic re-
ceptors impairs new learning and increases proactive interference in a word
paired-associate memory task. Behav Neurosci 2004;118:223236. (Reviews
the theoretical and experimental basis of cholinergic influences on learning
and memory and the effects of central blockade on cognitive processes.)
Bertrand D, Elmslie F, Hughes E, et al. The CHRNB2 mutation I312M
is associated with epilepsy and distinct memory deficits. Neurobiol Dis
2005;20:799804. (Reviews the role of alterations in nicotinic ACh recep-
tors in genetic epilepsy.)
Caccamo A, Fisher A, LaFerla FM. M1 agonists as a potential disease-mod-
ifying therapy for Alzheimers disease. Curr Alzheimer Res 2009;6:112
117. (Discusses the role and future research directions for M1 agonists in
the treatment of AD.)
Dani JA, Bertrand D. Nicotinic acetylcholine receptors and nicotinic cholin-
ergic mechanisms of the central nervous system. Ann Rev Pharmacol Toxicol
2007;47:699729. (A thorough yet readable review with many citations.)
Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating
the Beers criteria for potentially inappropriate medication use in older adults:
results of a US consensus panel of experts. Arch Intern Med 2003;163:2716
2724. (Recommendations regarding medications to avoid in older adults.)
Jann MW, Shirly KL, Small GW. Clinical pharmacokinetics and pharmaco-
dynamics of cholinesterase inhibitors. Clin Pharmacokinet 2002;41:719
739. (Review of clinical pharmacology of oral cholinesterase inhibitors.)
10
Adrenergic Pharmacology
Brian B. Hoffman and Freddie M. Williams
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 132-133
BIOCHEMISTRY AND PHYSIOLOGY OF
ADRENERGIC FUNCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Catecholamine Synthesis, Storage, and Release . . . . . . . 132
Reuptake and Metabolism of Catecholamines . . . . . . . . . 133
Catecholamine Receptors . . . . . . . . . . . . . . . . . . . . . . . . 135
1- and 2-Adrenoceptors . . . . . . . . . . . . . . . . . . . . . 135
-Adrenoceptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Regulation of Receptor Response. . . . . . . . . . . . . . . . . . . 137
Physiologic and Pharmacologic Effects
of Endogenous Catecholamines . . . . . . . . . . . . . . . . . . . . 137
Epinephrine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Norepinephrine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Dopamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
 INTRODUCTION
Adrenergic pharmacology involves the study of agents that
act on pathways mediated by the endogenous catecholamines
norepinephrine, epinephrine, and dopamine. The sympa-
thetic nervous system is the major source of endogenous
catecholamine production and release. Signaling through cat-
echolamine receptors mediates diverse physiologic effects,
including: increasing the rate and force of cardiac contraction,
modifying the peripheral resistance of the arterial system, in-
hibiting the release of insulin, stimulating hepatic release of
glucose, and increasing adipocyte release of free fatty acids.
Drugs that target the synthesis, storage, release, and reuptake
of norepinephrine and epinephrine or that directly target the
postsynaptic receptors for these transmitters are frequent ther-
apies for many major diseases, including hypertension, shock,
asthma, and angina. This chapter examines the biochemical
and physiologic basis for adrenergic action and then discusses
the action of the different classes of adrenergic drugs.
 BIOCHEMISTRY AND PHYSIOLOGY
OF ADRENERGIC FUNCTION
The autonomic nervous system contributes to homeostasis
through the concerted action of its sympathetic and parasym-
pathetic branches. Catecholamines are the major effectors
of sympathetic signaling. The following discussion presents
the biochemistry of catecholamine action, from synthesis to
132
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 137
Inhibitors of Catecholamine Synthesis . . . . . . . . . . . . . . . 137
Inhibitors of Catecholamine Storage. . . . . . . . . . . . . . . . . 138
Inhibitors of Catecholamine Reuptake . . . . . . . . . . . . . . . 139
Inhibitors of Catecholamine Metabolism. . . . . . . . . . . . . . 139
Receptor Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
-Adrenergic Agonists . . . . . . . . . . . . . . . . . . . . . . . . 139
-Adrenergic Agonists . . . . . . . . . . . . . . . . . . . . . . . . 140
Receptor Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
-Adrenergic Antagonists . . . . . . . . . . . . . . . . . . . . . . 140
-Adrenergic Antagonists . . . . . . . . . . . . . . . . . . . . . . 141
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 142
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
metabolism to receptor activation. Then the physiologic roles
of the endogenous catecholamines epinephrine, norepineph-
rine, and dopamine are discussed, with emphasis on the spec-
ificity of receptor expression in different organ systems.
Catecholamine Synthesis, Storage,
and Release
Catecholamines are synthesized by sequential chemical mod-
ifications of the amino acid tyrosine. This synthesis occurs
primarily at sympathetic nerve endings and in chromaffin
cells. Epinephrine is predominately synthesized in chromaf-
fin cells of the adrenal medulla; sympathetic neurons produce
norepinephrine as their primary neurotransmitter (Fig. 10-1).
Tyrosine, the precursor for catecholamine synthesis, is trans-
ported into neurons via an aromatic amino acid transporter
that uses the Na gradient across the neuronal membrane to
concentrate tyrosine (as well as phenylalanine, tryptophan,
and histidine). The first step in catecholamine synthesis, the
oxidation of tyrosine to dihydroxyphenylalanine (DOPA),
is mediated by the enzyme tyrosine hydroxylase (TH). TH is
the rate-limiting enzyme in catecholamine synthesis. DOPA
is converted to dopamine by a relatively nonspecific aro-
matic amino acid decarboxylase. Dopamine is then hydroxy-
lated by dopamine--hydroxylase to yield norepinephrine.
In tissues that produce epinephrine, norepinephrine is then
methylated on its amino group by phenylethanolamine N-
methyltransferase (PNMT). Expression of PNMT in the ad-
renal medulla is largely dependent on the high concentrations
134 Principles of Autonomic and Peripheral Nervous System Pharmacology

Aromatic L-amino acid A Normal uptake of norepinephrine from synaptic cleft and
transporter concentration of NE in synaptic vesicle

Tyrosine Cytoplasm Synaptic cleft

Na+
Tyrosine
ATP H+ ADP
Tyrosine hydroxylase

Dihydroxyphenylalanine
Adrenergic (L-DOPA) VMAT
NE transporter
neuron Aromatic H+
L-amino acid NE (NET)
decarboxylase Na+
Action potential NE NE
NE
Dopamine NE
NE
VMAT NE transporter
NE NE

Na+
Ca2+ H+ Dopamine NE
Dopamine
hydroxylase
NE
B Cocaine inhibits NE transporter

NE

ATP H+ ADP
2 (autoreceptor) MAO
adrenergic receptor NE
DOPGAL Cocaine
VMAT NET

NE
H+

NE NE NE
Synaptic NE NE
NE
cleft NE

1 1 2
C Reserpine inhibits VMAT
Postsynaptic adrenergic
receptors
Postsynaptic cell
ATP H+ ADP

VMAT NET
Na+

FIGURE 10-1. Catecholamine synthesis, storage, release, and reuptake
pathways. The endogenous catecholamines dopamine, norepinephrine, and epi-
nephrine are all synthesized from tyrosine. The rate-limiting step in catecholamine
synthesis, the oxidation of cytoplasmic tyrosine to dihydroxyphenylalanine
(L-DOPA), is catalyzed by the enzyme tyrosine hydroxylase. Aromatic L-amino
acid decarboxylase then converts L-DOPA to dopamine. Vesicular monoamine
transporter (VMAT) translocates dopamine (and other monoamines) into synaptic
vesicles. In adrenergic neurons, intravesicular dopamine--hydroxylase converts
dopamine to norepinephrine (NE). Norepinephrine is then stored in the vesicle until
release. In adrenal medullary cells, norepinephrine returns to the cytosol, where
phenylethanolamine N-methyltransferase (PNMT) converts norepinephrine to epi-
nephrine. The epinephrine is then transported back into the vesicle for storage (not
shown). -Methyltyrosine inhibits tyrosine hydroxylase, the rate-limiting enzyme
in catecholamine synthesis (not shown). Released norepinephrine can stimulate
postsynaptic 1-, 1-, or 2-adrenergic receptors or presynaptic 2-adrenergic brane H gradient. This H gradient is used by VMAT to drive monoamine trans-
autoreceptors. Released norepinephrine can also be taken up into presynaptic
terminals by the selective NE transporter. NE in the cytoplasm of the presynap-
tic neuron can be further taken up into synaptic vesicles by VMAT (not shown)
or degraded to 3, 4-dihydroxyphenylglycoaldehyde (DOPGAL; see Fig. 10-3) by
mitochondrion-associated monoamine oxidase (MAO).
NE
NE
NE
NE
Reserpine
FIGURE 10-2. Mechanisms of action of cocaine and reserpine.
A. Norepinephrine (NE) that has been released into the synaptic cleft can be
taken up into the cytoplasm of the presynaptic neuron by the selective NE trans-
porter (NET), a Na-NE co-transporter. Cytoplasmic NE is concentrated in syn-
aptic vesicles by the nonselective vesicular monoamine transporter (VMAT), an
H-monoamine antiporter. An H-ATPase uses the energy of ATP hydrolysis to
concentrate protons in synaptic vesicles, and thereby generates a transmem-
port into the synaptic vesicle. B. Cocaine inhibits the NE transporter, allowing
released NE to remain in the synaptic cleft for a longer period of time. By this
mechanism, cocaine potentiates neurotransmission at adrenergic synapses. C.
Reserpine inhibits the vesicular monoamine transporter, preventing the refilling
of synaptic vesicles with NE and eventually depleting the adrenergic terminal
of neurotransmitter. By this mechanism, reserpine inhibits neurotransmission at
adrenergic synapses.
 Neurotransmitter

OH
HO NH2
Catechol-O-methyl Monoamine oxidase
transferase HO (MAO)
(COMT) Norepinephrine OH
HO H
OH
O
O NH2 HO
Aldehyde
reductase DOPGAL
HO
Aldehyde
Normetanephrine OH dehydrogenase
HO OH
OH
MAO
HO HO OH
OH DOPEG
O
O H HO
DOMA
HO
O COMT
MOPGAL Aldehyde
COMT
reductase OH
O OH
OH
O OH
HO
MOPEG
O
HO
Aldehyde Vanillylmandelic
dehydrogenase acid (VMA)

Major metabolite
(excreted in urine)

action has led to speculation that 3-agonists may be useful in
the treatment of obesity, noninsulin-dependent diabetes mel-
litus, and other potential indications, but such selective phar-
macologic agents remain to be developed for clinical use.
Regulation of Receptor Response
The ability of receptor agonists to initiate downstream sig-
naling is proportional to the number of receptors activated.
Accordingly, changes in the density of receptors on the cell
surface will alter the apparent efficacy of an agonist. Thus, both
short-term (desensitization) and long-term (down-regulation)
changes in the number of functional adrenoceptors are impor-
tant in regulating tissue response (see Fig. 1-10).
When an agonist activates an adrenoceptor, the disso-
ciation of heterotrimeric G proteins leads to downstream
signaling as well as a negative feedback mechanism that
limits tissue responses. The accumulation of subunits
in the membrane recruits a G protein receptor kinase
(GRK), which phosphorylates the receptor at residues in
the C-terminus that are important targets for inactivator pro-
teins. Alternatively, protein kinase A and protein kinase C
can phosphorylate G proteins. The phosphorylated state of
a G protein can bind to another protein called -arrestin
that sterically inhibits the receptorG protein interaction,
effectively silencing receptor signaling. On a longer time
scale, the receptor-arrestin complex is sequestered, in a
clathrin-dependent manner, into an endocytic compartment
for internalization, a process called down-regulation. Each
of these processes is important in regulating tissue respon-
siveness on a short- or long-term basis. Somewhat paradoxi-
cally, recent evidence suggests that -arrestins can turn on
(rather than off) novel signaling pathways involving activa-
tion of tyrosine kinases and small GTP-binding proteins.
Physiologic and Pharmacologic Effects
of Endogenous Catecholamines
The endogenous catecholamines epinephrine and norepi-
nephrine act as agonists at both - and -adrenoceptors. At
supraphysiologic concentrations, dopamine can also act as
an agonist at - and -receptors. The overall effect of each
catecholamine is complex and depends on the concentration
of the agent and on tissue-specific receptor expression.
Epinephrine
Epinephrine is an agonist at both - and -adrenoceptors.
At low concentrations, epinephrine has predominantly 1
and 2 effects, while at higher concentrations, its 1 effects
become more pronounced. Acting at 1-receptors, epineph-
rine increases cardiac contractile force and cardiac output,
with consequent increases in cardiac oxygen consump-
tion and systolic blood pressure. Vasodilation mediated by
2-receptors causes a decrease in peripheral resistance and
a decrease in diastolic blood pressure. Stimulation of 2-
receptors also increases blood flow to skeletal muscle, relaxes
bronchial smooth muscle, and increases the concentrations
of glucose and free fatty acids in the blood. These 1 and 2
effects are all components of the fight-or-flight response.
Epinephrine was used to treat acute asthmatic attacks shortly
after its discovery more than 100 years ago; other drugs with
greater selectivity for 2-receptors are now more often used in
the treatment of asthma. Epinephrine remains a drug of choice
for the treatment of anaphylaxis. Locally injected epinephrine
CHAPTER 10 / Adrenergic Pharmacology 137
causes vasoconstriction and prolongs the action of local an-
esthetics; for example, it is often used in combination with a
local anesthetic in dentistry. It is ineffective orally due to ex-
tensive first-pass metabolism. Epinephrine has a rapid onset
and a brief duration of action when injected intravenously.
Adverse consequences of rapid intravenous infusions include
increased cardiac excitability that may lead to cardiac arrhyth-
mias and excessive increases in blood pressure.
Norepinephrine
Norepinephrine is an agonist at 1- and 1-receptors, but
has relatively little effect at 2-receptors. Because of the lack
of action at 2-receptors, systemic administration of norepi-
nephrine increases not only systolic blood pressure (1 ef-
fect) but also diastolic blood pressure and total peripheral
resistance. Norepinephrine is used in the pharmacologic
treatment of hypotension in patients with distributive shock,
most frequently due to sepsis.
Dopamine
Although dopamine is a prominent CNS neurotransmitter,
systemic administration has few CNS effects because it does
not readily cross the bloodbrain barrier. Dopamine activates
one or more subtypes of catecholamine receptor in peripheral
tissues, and the predominant effect is dependent on the local
concentration of the compound. At low doses (2 g/kg per
min), a continuous intravenous infusion of dopamine acts pre-
dominately on D1 dopaminergic receptors in renal, mesenteric,
and coronary vascular beds. D1 dopaminergic receptors acti-
vate adenylyl cyclase in vascular smooth muscle cells, leading
to increased cAMP levels and vasodilation. At higher rates of
infusion (210 g/kg per min), dopamine is a positive inotrope
via its activation of 1-adrenergic receptors. At still higher rates
of infusion (10 g/kg per min), dopamine acts on vascular
1-adrenergic receptors to cause vasoconstriction. Dopamine
is used in the treatment of shock, particularly in states of shock
caused by low cardiac output and accompanied by compro-
mised renal function leading to oliguria. However, efficacy in
protecting the kidneys has not been clearly demonstrated.
 PHARMACOLOGIC CLASSES
AND AGENTS
Pharmacologic intervention is possible at each of the major
steps in catecholamine synthesis, storage, reuptake, metabo-
lism, and receptor activation. The following discussion pres-
ents the various classes of agents in the order of their action
on adrenergic pathways, from neurotransmitter synthesis to
receptor activation.
Inhibitors of Catecholamine Synthesis
Inhibitors of catecholamine synthesis have limited clinical util-
ity because such agents nonspecifically inhibit the formation
of all catecholamines (see Fig. 10-1). -Methyltyrosine is a
structural analogue of tyrosine that is transported into nerve ter-
minals, where it inhibits tyrosine hydroxylase, the first enzyme
in the catecholamine biosynthesis pathway. This agent is used
occasionally in the treatment of hypertension associated with
pheochromocytoma (a tumor of the enterochromaffin cells of
the adrenal medulla that produces norepinephrine and epineph-
rine). Its clinical use is limited, however, because it causes sig-
nificant orthostatic hypotension and sedation, and many other
antihypertensive drugs are available for this indication.
A Acute effect of indirect sympathomimetic

NE
NE

G VMAT NET
G NE NE
G NE NE
G NE
NE G NE NE
NE
MAO NE

Mitochondrion DOPGAL

B Chronic effect of indirect sympathomimetic

VMAT NET
G

G
G G NE

NE G NE

MAO

Mitochondrion DOPGAL
140 Principles of Autonomic and Peripheral Nervous System Pharmacology
supporting its capacity to decrease adverse cardiovascular
outcomes in patients with hypertension is quite limited.
Clonidine has limited utility in ameliorating symptoms of
withdrawal from ethanol and opioid drugs. Adverse effects
include bradycardia caused by decreased sympathetic ac-
tivity and increased vagal activity, as well as dry mouth and
sedation. Because sympathetic nervous system activation
is an important mechanism in maintaining blood pressure
on standing, postural hypotension may also complicate
therapy with this drug.
Other centrally acting 2-agonists include the seldom-used
agents guanabenz and guanfacine. These agents have adverse
effect profiles similar to that of clonidine. Dexmedetomidine
is an 2-receptor agonist whose capacity to cause sedation has
been exploited as a beneficial effect in surgical patients, be-
cause sedation is induced by this drug without additional respi-
ratory depression. Suppression of sympathetic nervous system
activity by this drug helps to avoid swings in blood pressure in
surgical patients, who are carefully monitored by anesthetists
during surgical procedures. Dexmedetomidine may also pos-
sess analgesic properties. Note that the 2-mediated effects
of sedation and decreased sympathetic activity are adverse
effects of clonidine in the setting of outpatient treatment for
hypertension but beneficial effects of dexmedetomidine in the
controlled setting of the surgical patient.
-Methyldopa is a precursor (prodrug) to the 2-agonist
-methylnorepinephrine. Endogenous enzymes catalyze the
metabolism of methyldopa to methylnorepinephrine, and the
-methylnorepinephrine is then released by the adrenergic
nerve terminal, where it can act presynaptically as an 2-
agonist. This action results in decreased sympathetic outflow
from the CNS and consequent lowering of blood pressure
in hypertensive patients. Because -methyldopa use can be
associated with rare hepatotoxicity, autoimmune hemolytic
anemia, and adverse CNS effects, this drug is very rarely
used in the treatment of hypertension in the United States,
with one exceptionthere is considerable experience with
methyldopa as an antihypertensive drug in pregnancy, and it
is still used as a preferred drug in that context.
-Adrenergic Agonists
Stimulation of 1-adrenergic receptors causes an increase
in heart rate and the force of cardiac muscle contraction,
resulting in increased cardiac output, while stimulation of
2-adrenergic receptors causes relaxation of vascular, bron-
chial, and gastrointestinal smooth muscle. Isoproterenol is a
nonselective -agonist. This drug lowers peripheral vascular
resistance and diastolic blood pressure (a 2 effect), while sys-
tolic blood pressure remains unchanged or slightly increased
(a 1 effect). Because isoproterenol is a positive inotrope (in-
creases cardiac contractility) and chronotrope (increases heart
rate), cardiac output is increased. Isoproterenol can be used to
relieve bronchoconstriction in asthma (2 effect). However,
because isoproterenol is a nonselective activator of 1- and 2-
adrenoceptors, its use for relief of bronchoconstriction is often
accompanied by adverse cardiac effects. Use of this drug in
asthma has therefore been supplanted by newer 2-selective
agonists (see below). Isoproterenol may occasionally be used
to stimulate heart rate in emergency situations of profound
bradycardia, typically in anticipation of the placement of an
electrical cardiac pacemaker.
The overall effect of dobutamine depends on the differen-
tial effects of the two stereoisomers contained in the racemic
mixture (see Chapter 1 for a discussion of stereoisomers). The
() isomer acts as both an 1-agonist and a weak 1-agonist,
whereas the () isomer acts as both an 1-antagonist and a
potent 1-agonist. The 1-agonist and antagonist properties
effectively cancel each other out when the racemic mixture
is administered, and the observed clinical result is that of a
selective 1-agonist. This agent has more prominent inotropic
than chronotropic effects, resulting in increased contractility
and cardiac output. Dobutamine can be used intravenously in
the urgent treatment of severe heart failure. It is also used as a
diagnostic agent, in conjunction with imaging of the heart, in
the investigation of ischemic heart disease.
2-selective agonists are valuable in the treatment of
asthma. These drugs represent pharmacologic improvements
over epinephrine (an agonist at all adrenergic receptors) and
isoproterenol (an agonist at 1- as well as 2-receptors) in
that their effects are more limited at nontarget tissues. It is
particularly important that these selective drugs have lim-
ited capacity to stimulate 1-adrenoceptors in the heart and,
therefore, limited capacity to produce adverse cardiac ef-
fects. Specificity for the lung rather than the heart or other
peripheral tissues has been further enhanced by generally
delivering these drugs via aerosols inhaled into the lungs.
Administration of these drugs directly into the lungs low-
ers the amount of drug that reaches the systemic circulation,
again limiting the activation of cardiac 1-receptors and
skeletal muscle 2-receptors. The most important effects of
these agents are relaxation of bronchial smooth muscle and
decrease in airway resistance. 2-selective agonists are not
completely specific for airway 2-receptors, however, and
adverse effects can include skeletal muscle tremor (through
2-stimulation) and tachycardia (through 1-stimulation).
Metaproterenol is the prototype 2-selective agonist.
This drug is used to treat obstructive airway disease and acute
bronchospasm. Terbutaline and albuterol are two other
agents in this class that have similar efficacy and duration
of action. Salmeterol is a long-acting 2-agonist; its effects
last for about 12 hours. The clinical utility of 2-selective
agonists is discussed more fully in Chapter 47, Integrative
Inflammation Pharmacology: Asthma.
Receptor Antagonists
There is a wide spectrum of disease states that respond to
modulation of adrenoceptor activity, and antagonists at -
and -adrenoceptors are among the most widely used drugs
in clinical practice.
-Adrenergic Antagonists
-Adrenergic antagonists block endogenous catecholamines
from binding to 1- and 2-adrenoceptors. These agents
cause vasodilation, decreased blood pressure, and decreased
peripheral resistance. The baroreceptor reflex usually at-
tempts to compensate for the fall in blood pressure, resulting
in reflex increases in heart rate and cardiac output.
An important laboratory tool since the 1950s, phenoxy-
benzamine is an alkylating agent that blocks both 1- and
2-receptors irreversibly. In addition, phenoxybenzamine in-
hibits catecholamine uptake into both adrenergic nerve ter-
minals and extraneuronal tissues. Because of its many direct
and indirect effects on the sympathetic nervous system and
target tissues, phenoxybenzamine, once used in the treatment
of hypertension and benign prostatic hyperplasia (BPH), is
142 Principles of Autonomic and Peripheral Nervous System Pharmacology
have not been developed clinically as there is no obvious
indication for selective 2-receptor antagonism.
Propranolol, nadolol, and timolol do not distinguish be-
tween 1- and 2-receptors in their binding affinities. This is
the origin of the term nonselective -blockers. At clinical
doses, these drugs do not block -receptors. Nonselective
-blockers have been used for many years in the treatment of
hypertension and angina. Although nonselective -blockers
are relatively contraindicated in patients with asthma, these
drugs are often well tolerated in patients with chronic ob-
structive pulmonary disease (COPD) and may be initiated
cautiously in many such patients if they have a compelling
indication (e.g., coronary artery disease). Nadolol is also
efficacious in the prevention of bleeding from esophageal va-
rices in patients with cirrhosis. It is pharmacologically attrac-
tive for this indication because it has a long half-life, allowing
once-daily administration, and, because the drug is excreted
primarily by renal elimination without hepatic metabolism,
no dosing adjustments are needed on account of hepatic in-
sufficiency. Penbutolol is an additional drug in this class. An
ocular formulation of timolol is used in the treatment of glau-
coma; even when administered to the eye, systemic absorption
of the drug may be sufficiently high to cause adverse effects in
susceptible patients. Levobunolol and carteolol are additional
nonselective -blockers that are indicated for administration
via eye drops in the treatment of glaucoma.
Labetalol and carvedilol block 1-, 1-, and 2-receptors.
Labetalol has two chiral centers; the clinically used drug is a
combination of four stereoisomers that have differing phar-
macologic properties. Because the effect and metabolism
of these isomers may vary among individual patients, the
relative proportion of 1- versus -blockade is variable. The
1-receptor blockade tends to lower peripheral resistance;
-blockade also contributes to a decrease in blood pressure,
as indicated above. An intravenous formulation of labetalol is
available for the lowering of blood pressure in patients with
hypertensive emergencies. An unpredictable and idiosyncratic
adverse effect of labetalol is drug-induced hepatitis. While
carvedilol is also efficacious in the outpatient management of
hypertension, much interest in this drug has been due to its
efficacy in the management of heart failure with decreased
systolic function.
Pindolol is a partial agonist at 1- and 2-receptors.
The drug blocks the action of endogenous norepineph-
rine at 1-receptors and is useful in treating hypertension.
As a partial agonist, pindolol also causes partial stimula-
tion of 1-receptors, leading to overall smaller decreases
in resting heart rate and blood pressure than those caused
by pure -antagonists. Acebutolol is a partial agonist at
1-adrenoceptors but has no effect at 2-receptors. This
agent is also used to treat hypertension. While it has been
suggested that partial agonists may be less likely to cause
adverse effects in patients with bradycardia, the clinical ad-
vantages of drugs in this category remain unclear.
Esmolol, metoprolol, atenolol, and betaxolol are 1-
selective adrenergic antagonists. The elimination half-life
is the main feature that distinguishes among these agents.
Esmolol has an extremely short half-life (34 minutes);
metoprolol and atenolol have intermediate half-lives
(49 hours). Because of its short half-life, esmolol may be
safer in unstable patients requiring -blockade. Esmolol is
rapidly metabolized by esterases. Clinical trials have shown
that some -blockers, including metoprolol, prolong life ex-
pectancy in patients with mild to moderate heart failure and
in patients who have survived a first myocardial infarction
(see Chapter 25, Integrative Cardiovascular Pharmacology:
Hypertension, Ischemic Heart Disease, and Heart Failure).
Nebivolol is a novel 1-selective adrenergic antagonist that
has the ancillary property of promoting vasodilation via ni-
tric oxide release from endothelial cells.
Many of the major adverse effects of -adrenergic an-
tagonists are a predictable extension of their pharmacologic
effects. Such effects include worsening of bronchoconstric-
tion in patients with asthma, decreased cardiac output in
patients with decompensated heart failure, or potentially
impaired recovery from hypoglycemia in diabetic patients
receiving insulin. While 1-selective adrenergic antagonists
may have less propensity to block 2-receptors in bronchial
smooth muscle, the selectivity of these drugs is modest and
may not be a clinically reliable safeguard against adverse ef-
fects. With chronic administration of -receptor antagonists,
pharmacologic adaptations may occur that leave cells hyper-
sensitive to catecholamines if the drug is stopped suddenly.
 CONCLUSION AND FUTURE DIRECTIONS
Adrenergic pharmacology encompasses drugs that act at
essentially every step of adrenergic neurotransmission,
from synthesis of catecholamines to stimulation of - and
-receptors. Additional drugs, such as L-channel Ca2
blockers, interfere with effector responses activated by
these receptors. Novel drugs are being developed that se-
lectively inhibit the downstream effector pathways activated
by adrenergic receptors. The drugs discussed in this chap-
ter are mainstays of therapy for hypertension, angina, heart
failure, shock, asthma, pheochromocytoma, and other condi-
tions. The beneficial pharmacologic actions of these drugs,
as well as many of their important adverse effects, can be
anticipated from knowledge of their molecular and cellu-
lar mechanisms of action and how these actions affect the
processes of adrenergic neurotransmission. While nine sub-
types of adrenergic receptor have been identifiedthree in
each of the major classesthe pharmacologic implications
of these discoveries, in terms of the development of novel
subtype-selective drugs, may not have been fully exploited.
Therefore, the clinical relevance of these subtypes has not
yet been fully determined; the development of more selec-
tive agonists and antagonists may lead to more effective (and
less toxic) therapies.
Acknowledgment
We thank Timothy J. Turner for his valuable contributions to
this chapter in the First and Second Editions of Principles of
Pharmacology: The Pathophysiologic Basis of Drug Therapy.
Suggested Reading
DeWire SM, Ahn S, Lefkowitz RJ, Shenoy SK. Beta-arrestins and cell sig-
naling. Annu Rev Physiol 2007;69:483510. (Review of novel mechanisms
of signaling via seven transmembrane receptors.)
Rosenbaum DM, Rasmussen SG, Kobilka BK. The structure and function of
G protein-coupled receptors. Nature 2009;459:356363. (Detailed review of
the structure of adrenergic receptors.)

Local Anesthetic Pharmacology
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 147-148
PHYSIOLOGY OF NOCICEPTION . . . . . . . . . . . . . . . . . . . . . . 147
Transmission of Pain Sensation . . . . . . . . . . . . . . . . . . . . 149
First Pain and Second Pain . . . . . . . . . . . . . . . . . . . . . 149
Pain Perception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Analgesia and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . 150
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 151
Chemistry of Local Anesthetics . . . . . . . . . . . . . . . . . . . . 151
Aromatic Group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Amine Group. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Mechanism of Action of Local Anesthetics . . . . . . . . . . . . 152
Anatomic Considerations . . . . . . . . . . . . . . . . . . . . . . 152
Voltage-Gated Sodium Channel. . . . . . . . . . . . . . . . . . 153
Other Receptors for Local Anesthetics . . . . . . . . . . . . . 155
Pharmacokinetics of Local Anesthetics . . . . . . . . . . . . . . 155
Systemic Absorption . . . . . . . . . . . . . . . . . . . . . . . . . . 155
 INTRODUCTION
The word anesthesia comes directly from the Greek: an
meaning without, and aisthesis meaning feeling or sensa-
tion. Local anesthetics (LAs) are a set of locally applied
chemicals, with similar molecular structures, that can both
inhibit the perception of sensations (importantly pain) and
prevent movement. They are used in a variety of situations,
ranging from topical application for burns and small cuts,
to injections during dental care, to epidural and intrathe-
cal (spinal) blocks during obstetric procedures and major
surgery.
Cocaine, the first local anesthetic, comes from the leaves
of the coca shrub (Erythroxylon coca). It was first isolated
in 1860 by Albert Niemann, who noted its numbing pow-
ers. In 1886, Carl Koller introduced cocaine into clinical
practice as a topical ophthalmic anesthetic. However, its
addictive properties and toxicity prompted the search for
substitutes. Procaine, the first of these substitutes, was
synthesized in 1905. Known as Novocain, it is still used
today, although less frequently than some more recently
developed LAs.
Local anesthetics exert their effect by blocking voltage-
gated sodium channels, thus inhibiting the propagation of
action potentials along neurons (see Chapter 7, Principles
of Cellular Excitability and Electrochemical Transmission).
By inhibiting action potential propagation, LAs prevent
11
Joshua M. Schulman and Gary R. Strichartz
Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Metabolism and Excretion . . . . . . . . . . . . . . . . . . . . . . 156
Administration of Local Anesthetics . . . . . . . . . . . . . . . . . 156
Topical Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Infiltration Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . 156
Peripheral Nerve Blockade . . . . . . . . . . . . . . . . . . . . . 156
Central Nerve Blockade . . . . . . . . . . . . . . . . . . . . . . . 157
Intravenous Regional Anesthesia . . . . . . . . . . . . . . . . . 157
Major Toxicities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Individual Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Ester-Linked Local Anesthetics . . . . . . . . . . . . . . . . . . 158
Amide-Linked Local Anesthetics . . . . . . . . . . . . . . . . . 158
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 159
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
transmission of information to and from the central nervous
system (CNS). LA actions are not selective for pain fibers;
they can also block other sensory fibers as well as motor
and autonomic fibers and action potentials in skeletal and
cardiac muscle. This nonselective blockade can serve other
useful functions (see Chapter 23, Pharmacology of Cardiac
Rhythm) or can be a source of toxicity.
 PHYSIOLOGY OF NOCICEPTION
Nociception is the activation of primary sensory nerve fi-
bers (nociceptors) by noxious stimuli, that is, stimuli that
are potentially tissue damaging. These include high tem-
peratures, intense mechanical perturbations, and harsh
chemicals. Nociceptors have free nerve endings located
in the skin, deep soma, and viscera. Nociceptor cell bod-
ies are located in the dorsal root ganglia close to the spi-
nal cord, or in the trigeminal ganglion for innervation of
the face (Fig. 11-1). Nociceptors transmit impulses from
the periphery to the dorsal horn of the spinal cord, where
the information is subsequently processed through synaptic
circuitry and transmitted to various parts of the brain. Thus,
nociceptors are the first in a chain of neurons responsible
for pain perception. Because nociceptors, among other sen-
sory fibers, transmit information toward the brain, they are
termed afferent neurons.
147
 Dorsal root ganglion

To brain
1a
Thermal 2 Free nerve endings
Mechanical
Chemical Nociceptor
1b activation
Nearby cell Spinal cord
damage

Bradykinin
Serotonin
Axon
Prostaglandins
3
Serotonin
CGRP and substance P
released by activated nociceptors
4b
Mast cell
degranulation
4a
Blood vessel
dilation
150 Principles of Autonomic and Peripheral Nervous System Pharmacology

peripheral sensory (including pain), motor, and autonomic

A First and second pain (no block) pathways. Analgesics have actions at specific receptors on
primary nociceptors and in the CNS (see Chapter 17). For
First pain Second pain
example, opioid analgesics activate opiate receptors, which
signal cells to increase potassium conductance in postsyn-
Pain intensity

aptic neurons and to decrease calcium entry into presynap-

tic neurons. By these mechanisms, postsynaptic excitability
and presynaptic transmitter release are reduced, and pain
sensations are not transmitted as effectively to the brain (or
Painful Time (sec) within it). Importantly, the transmission of other sensations
stimulus and motor information is not affected.
Local anesthetics act by a different mechanism. These
B Effect of A fiber block agents inhibit conduction of action potentials in all affer-
ent and efferent nerve fibers, usually in the peripheral ner-
vous system. Thus, pain and other sensory modalities are
Pain intensity

3 neuron projects to
various regions of the brain
2 neuron synapses
Primary somatic with 3 neuron
Painful Time (sec) sensory cortex in thalamus
stimulus

C Effect of C fiber block

Pain intensity

Time (sec) Cerebrum

Painful
stimulus
Ventral posterior
lateral nucleus
FIGURE 11-2. First and second pain. First pain, which is transmitted by of thalamus
A-fibers, is sharp and highly localizable. Second pain, which is transmitted by
C-fibers, is slower in arriving, duller, and longer lasting (A). First pain can be pre- Midbrain
vented by selective blockade of A-fibers (B), and second pain can be prevented
by selective blockade of C-fibers (C). Because A-fibers are more susceptible than
C-fibers to blockade by local anesthetics, first pain often disappears at concentra-
tions of anesthetic lower than those required to eliminate second pain.
Pons
lateral areas of the spinal cord and project mainly to the thala-
mus, a gray-matter structure just superior to the brainstem. The
thalamus has cells that project to the somatosensory cortex of
the parietal lobe and to other areas of the cortex (Fig. 11-3). Dorsal root ganglion
Pain perception is a complex process that normally results Medulla
from the activation of non-nociceptive as well as nociceptive 1 neuron
2 neurons (nociceptor)
afferents, and can be altered depending on the situation, the
persons state of mind, and other factors. The CNS uses ef- Cervical
ferent projections within the brain and spinal cord to modu- spinal cord
late the incoming nociceptive signals and thus to modify pain 1 and 2 neurons
perception (see Chapter 17, Pharmacology of Analgesia). For synapse in dorsal
example, an athlete focused on an important game might not horn of spinal cord
feel the pain of an injury intensely until after the game is over.
Her brain modulates the effect of the input so that the same FIGURE 11-3. Pain pathways. Primary (1) nociceptors have cell bodies in
stimulus is less painful at certain times than at others. the dorsal root ganglion and synapse with secondary (2) afferent neurons in the
dorsal horn of the spinal cord. Primary afferents use the neurotransmitter gluta-
Analgesia and Anesthesia mate. The 2 afferents travel in the lateral areas of the spinal cord and eventually
reach the thalamus, where they synapse with tertiary (3) afferent neurons. The
The terms analgesic and anesthetic have different mean- processing of pain is complex, and 3 afferents have many destinations including
ings. Analgesics are specific inhibitors of pain pathways, the somatosensory cortex (localization of pain) and the limbic system (emotional
whereas local anesthetics are nonspecific inhibitors of aspects of pain).
 CHAPTER 11 / Local Anesthetic Pharmacology 151

not transmitted effectively to the brain, and motor and au-
tonomic impulses are not transmitted effectively to muscles
and end-organs in the periphery.
 PHARMACOLOGIC CLASSES
AND AGENTS
Local anesthetics can be structurally classified as ester-linked
LAs or amide-linked LAs. Because all LAs share similar
properties, the next section highlights the general principles
of LA pharmacology. Specific LA agents are discussed at the
end of the chapter.
Amine Group
The amine group of a local anesthetic molecule can exist in
either the protonated (positively charged) form or the depro-
tonated (neutral) or base form.
The pKa is the pH at which the concentrations of a base and
its conjugate acid are equal. LAs are weak bases; their pKa
values range from about 8 to 10. Thus, at the physiologic pH
of 7.4, substantial amounts of both the protonated form and the
neutral form coexist in solution. As the pKa of a drug increases,
a greater fraction of molecules exists in solution in the proto-
nated form at physiologic pH (see Chapter 1, DrugReceptor
Interactions). Protonation and deprotonation reactions are very

Chemistry of Local Anesthetics A Ester-linked local anesthetic (procaine)

All local anesthetics have three structural domains: an aro- Aromatic Ester Tertiary
matic group, an amine group, and an ester or amide linkage group (R) linkage amine (R')
connecting these two groups (Fig. 11-4). As discussed below,
the structure of the aromatic group influences the hydropho- O
bicity of the drug, and the nature of the amine group influ-
ences the charge on the drug. Both features define the rate of N
O
onset, potency, duration of action, and adverse effects of an
individual local anesthetic. H+
H2N
Aromatic Group H+
Basic form
All local anesthetics contain an aromatic group that gives the
molecule much of its hydrophobic character. Adding alkyl O
substituents on the aromatic ring, or on the amino nitrogen, NH +
increases the hydrophobicity of these drugs. O
Biological membranes have a hydrophobic interior be-
cause of their lipid bilayer structure. The hydrophobicity H2N
of an LA drug affects the ease with which the drug passes
through nerve cell membranes to reach its target site, which Protonated (acidic) form
is the cytoplasmic side of the voltage-gated sodium channel
(Fig. 11-5). Molecules with low hydrophobicity partition B Amide-linked local anesthetic (lidocaine)
very poorly into the membrane because their solubility in the Aromatic Amide Tertiary
lipid bilayer is so low; such molecules are largely restricted group linkage amine
to the polar aqueous environment. As the hydrophobicity of a (R) (R')

series of drugs increases, the concentration in the membrane

and the correlated permeability of the drugs through the cell
membrane also increase. However, at a certain hydropho-
bicity, this relationship reverses, and a further increase in
hydrophobicity results in a decrease in permeability. This
somewhat paradoxical behavior occurs because molecules
that are very hydrophobic partition so strongly into the cell
membrane that they remain there. The same strong hydro-
phobic forces that concentrate such molecules in the cell
membrane cause them to dissociate very slowly from that
compartment. To be effective, a local anesthetic must parti-
tion into, diffuse across, and finally dissociate from the mem-
brane into the cytoplasm; the compounds most likely to do so
have moderate hydrophobicity.
The LA binding site on the sodium channel also contains
hydrophobic residues. Therefore, more hydrophobic drugs
bind more tightly to the target site, increasing the potency of
the drug. However, as noted above, because of the practical
need for the drug to diffuse across several membranes in order
to reach the target site, LAs with moderate hydrophobicity are
the clinically most effective forms. In addition, excessively hy-
drophobic drugs have limited solubility in the aqueous environ-
ment around a nerve, and even the molecules that do dissolve
remain in the first membrane that is encountered, never reach-
ing the target site (despite their high affinity for that site).
H
N
N
O H+
H+
Basic form
H
N H+
N
O
Protonated (acidic) form
FIGURE 11-4. Prototypical local anesthetics. Procaine (A) and lidocaine (B)
are prototypical ester-linked and amide-linked local anesthetics, respectively. Local
anesthetics have an aromatic group on one end and an amine on the other end
of the molecule; these two groups are connected by an ester (-RCOOR) or amide
(-RHNCOR) linkage. In solution at high pH, the equilibrium between the basic (neu-
tral) and acidic (charged) forms of a local anesthetic favors the basic form. At low
pH, the equilibrium favors the acidic form. At intermediate (physiologic) pH, nearly
equal concentrations of the basic and acidic forms are present. Generally, ester-
linked local anesthetics are easily hydrolyzed to a carboxylic acid (RCOOH) and an
alcohol (HOR) in the presence of water and esterases. In comparison, amides are
far more stable in solution. Consequently, amide-linked local anesthetics generally
have a longer duration of action than do ester-linked anesthetics.
152 Principles of Autonomic and Peripheral Nervous System Pharmacology
A Poorly hydrophobic local anesthetic
LA
1 is why moderately hydrophobic weak bases are so effective
Linker region
B Moderately hydrophobic local anesthetic
Voltage-gated
LA
Na+ channel
1 4 H+ Extracellular
LA
2 Local anesthetic
binding site
LA
LA
Intracellular
3 Mechanism of Action of Local Anesthetics
C Extremely hydrophobic local anesthetic
LA
1
LA
2
FIGURE 11-5. Local anesthetic hydrophobicity, diffusion, and binding.
Local anesthetics (LAs) act by binding to the cytoplasmic (intracellular) side of the
voltage-gated Na channel. The hydrophobicity of a local anesthetic determines
how efficiently it diffuses across lipid membranes and how tightly it binds to the
Na channel, and therefore governs its potency. A. Poorly hydrophobic LAs are
unable to cross the lipid bilayer efficiently: (1) Neutral LA cannot adsorb to or enter
the neuronal cell membrane because the LA is very stable in the extracellular so-
lution and has a very high activation energy for entering the hydrophobic mem-
brane. B. Moderately hydrophobic LAs are the most effective agents: (1) Neutral
LA adsorbs to the extracellular side of the neuronal cell membrane; (2) LA diffuses
through the cell membrane to the cytoplasmic side; (3) LA diffuses and binds to
its binding site on the voltage-gated sodium channel; and (4) once bound, LA can
switch between its neutral and protonated forms by binding and releasing protons.
C. Extremely hydrophobic LAs become trapped in the lipid bilayer: (1) Neutral LA
adsorbs to the neuronal cell membrane (2) where it is so stabilized that it cannot
dissociate from or translocate across the membrane.
rapid in solution (103 sec1), but drugs in membranes or bound
to proteins are protonated and deprotonated more slowly.
The neutral forms of LAs cross membranes much more
easily than do the positively charged forms. However, the
positively charged forms bind with much higher affinity to
the drugs target binding site. This site is located in the pore
of the voltage-gated sodium channel and is accessible from
the intracellular, cytoplasmic entrance of the channel. This
as local anesthetics. At physiologic pH, a significant frac-
tion of the weak base molecules are in the neutral form that,
because of its moderate hydrophobicity, can rapidly cross
membranes to enter nerve cells. Once the drug is inside
the cell, it can then readily gain a proton, become positively
charged, and bind to the sodium channel.
Surprisingly, the major path by which protons reach local
anesthetics is through the Na channels pore. As the extra-
cellular pH becomes more acidic, there is a higher chance
that the drug will become protonated at its binding site in
the channel. Once protonated, the drug dissociates much
more slowly from the channel. The pH inside the cell does
not have an important effect on the protonation state of drug
molecules that are already bound to the channel; this lack
of effect is thought to be attributable to the orientation of
the drug, which effectively blocks H access from within
the cell. Some nonionizable drugs, such as benzocaine, are
permanently neutral but are still able to block sodium chan-
nels. For these drugs, however, the block is weak and rapidly
reversible and does not depend on extracellular pH.
Anatomic Considerations
The peripheral nerve is composed of a collection of dif-
ferent types of nerve fibers (A-, B-, and C-fibers) sur-
rounded by three protective membranes, or sheaths: the
epineurium, perineurium, and endoneurium. Local anes-
thetic molecules must pass through these sheaths, which
present the same permeation-limiting barriers as the nerve
cell membranes, considered above, before they can reach
the neuronal membranes to block conduction (Fig. 11-6).
The sheaths are made up of connective tissue and cellu-
lar membranes. LAs are injected outside the most external
sheath, the epineurium, to avoid mechanical needle dam-
age to the nerve, but the major barrier to LA penetration
into the nerve is the perineurium, an epithelium-like tissue
that bundles axons into separate fascicles. Recall that LAs
affect not only nociceptors but also other afferent and effer-
ent, somatic and autonomic nerve fibers. All of these fibers
may be contained within a peripheral nerve, and conduction
in all fibers can be blocked by local anesthetics. If the pe-
ripheral nerve is considered to represent a multilane road,
then each fiber type can be considered a lane in this road.
A blockade across the whole road (the blockade by a local
anesthetic) will stop traffic in all lanes in both directions.
This is why, in the introductory case, EM experienced not
only loss of pain sensation, but also a more complete block
of all sensation in his digits.
In general, more proximal regions of the body (shoulder,
thigh) are innervated by axons traveling relatively superfi-
cially in a peripheral nerve, while more distal regions (hands,
feet) are innervated by axons traveling closer to the core of
the nerve. Because local anesthetics are applied to the out-
side of a peripheral nerve, external to the epineurium, the
axons innervating more proximal areas are usually reached
first by the local anesthetic diffusing radially into the nerve.
Consequently, in the anatomic progression of functional
block, proximal areas are numbed before distal areas. For
example, if a nerve block is applied in the brachial plexus,
 Epineurium
Perineurium
Endoneurium

Schwann cell

1 2 3

Needle injecting LA

Unmyelinated fiber bundle (C fibers)

Myelinated fiber (A fibers)

154 Principles of Autonomic and Peripheral Nervous System Pharmacology

A Resting conformation Intermediate closed Open conformation Inactivated conformation

conformation

Extracellular S4 regions Na+

+ + + Voltage + + + + + +
+ + + + + + + +
+ + + + + + After + +
Voltage
1 ms

Intracellular
Linker
region

Voltage ("refractory period")

Intermediate closed
Resting conformation Open conformation Inactivated conformation
B conformation
(low affinity for LA) (high affinity for LA) (high affinity for LA)
(high affinity for LA)

+ + + Voltage + + + + + +
+ + + + + + + +
+ + + + + + + +
Voltage LA LA LA

Stabilized conformation

Voltage (longer "refractory period")

FIGURE 11-7. Local anesthetic binding to different conformations (states) of the sodium channel. A. The sodium channel is composed of one polypeptide
chain that has four repeating units. One region, known as the S4 region, has many positively charged amino acids (lysine and arginine). These residues give the channel
its voltage dependence. At rest, the pore is closed. When the membrane is depolarized, the charged residues move in response to the change in the electric field. This
results in several conformational changes (intermediate closed states) that culminate in channel opening. After about 1 ms (the channel open time), the 34 amino
acid linker region plugs the open channel, yielding the inactivated conformation. The inactivated conformation returns to the resting state only when the membrane
is repolarized; this conformational change involves the return of the S4 region to its original position and the expulsion of the linker region. The time required for the
channel to return from the inactivated state to the resting state is known as the refractory period ; during this period, the sodium channel is incapable of being activated.
B. The binding of local anesthetic (LA) alters the properties of the intermediate forms assumed by the sodium channel. Sodium channels in any of the conformations
(resting, closed, open, or inactivated) can bind local anesthetic molecules, although the resting state has a low affinity for LA, while the other three states have a high
affinity for LA. LA can dissociate from the channelLA complex in any conformational state, or the channel can undergo conformational changes while associated with
the LA molecule. Ultimately, the channelLA complex must dissociate, and the sodium channel must return to the resting state to become activated. LA binding extends
the refractory period, including both the time required for dissociation of the LA molecule from the sodium channel and the time required for the channel to return to
the resting state.

bound channels increases with each successive impulse; the
inhibition is said to be phasic, or use-dependent (Fig. 11-8).
Tonic inhibition occurs when the time between action
potentials is long compared to the time for dissociation of
the LA from the sodium channel. Assume, for example, that
before an action potential arrives, an equilibrium has been
established where 5% of the sodium channels are bound by
local anesthetic molecules. When an action potential arrives,
the other 95% of the channels are available to open and sub-
sequently to inactivate. During the brief impulse, some of
these channels become bound by local anesthetic molecules.
However, in the relatively long time before the next impulse
arrives at the LA-exposed region, the bound LA can disso-
ciate from the sodium channel, allowing those channels to
return to the resting state. Thus, before the next action poten-
tial arrives, the 5% binding equilibrium is reestablished. The
next action potential will, therefore, be blocked to the same
extent as the previous one.
Phasic inhibition occurs when there is not enough time
between action potentials for this equilibrium to be rees-
tablished. Rapidly arriving action potentials cause resting
sodium channels to open and then inactivate, and some of
these channels will be bound by LAs. However, because
there is not enough time between impulses for all the newly
formed LAsodium channel complexes to dissociate, only
some of the channels are able to return to the resting state.
With each arriving action potential, more and more channels
are blocked, until a new steady state of LAsodium channel
binding is reached. This is the phenomenon of phasic, or use-
dependent, inhibition. As more of the channels are bound by
LA, fewer and fewer channels are available to open when
the next action potential arrives. Consequently, action poten-
tial conduction is increasingly inhibited at higher frequen-
cies of impulses.
The clinical importance of this phenomenon is that tis-
sue injury or trauma causes nociceptors in the area of injury
 A Tonic block (low frequency stimulation)

Depolarized
Voltage
Resting

Fraction of 0.5
bound channels
0

LA in equilibrium Equilibrium
with sodium channels reestablished

Time

B Phasic block (high frequency stimulation)

Depolarized
Voltage
Resting

Fraction of 0.5
bound channels
0

LA in equilibrium New baseline

with sodium channels established

Time
158 Principles of Autonomic and Peripheral Nervous System Pharmacology
Local anesthetics have complex effects on the peripheral
vasculature. Lidocaine, for example, initially causes vasocon-
striction, but at later times, it produces vasodilation. Such
biphasic actions may be attributable to separate effects on
the vascular smooth muscle and on sympathetic nerves that
innervate resistance arterioles. Bronchial smooth muscle is
also affected in a biphasic manner. Initially, local anesthet-
ics cause bronchoconstriction, but at later times, they cause
bronchorelaxation. The early event may reflect LA-induced
release of calcium ions into the cytoplasm from intracellular
stores, while the later effect may be caused by LA inhibition of
plasma membrane sodium and calcium channels (see below).
The cardiac effects of LAs are complex due to their ac-
tions on different molecular targets, including Na, K, and
Ca2 channels. An early effect is to reduce the conduction
velocity of the cardiac action potential through both con-
ducting and nodal tissues. At very low concentrations, LAs
can act as antiarrhythmic drugs because of their ability to
prevent ventricular tachycardia and ventricular fibrillation
(this is an example of use-dependent block; see above).
Lidocaine, for example, acts as both a local anesthetic and
a class I antiarrhythmic (see Chapter 23). Local anesthetics
also cause a dose-dependent decrease in cardiac contractility
(a negative inotropic effect). The mechanism of this effect is
not entirely understood but may be caused by LA-mediated
slow release of calcium from the sarcoplasmic reticulum,
with a consequent reduction in the stores of calcium avail-
able to drive subsequent contractions. LAs can also directly
inhibit calcium channels in the plasma membrane. The
combination of reduced intracellular calcium storage and
decreased calcium entry may lead to decreased myocardial
contractility.
It has recently been shown that lipid emulsions injected
into the circulation can rapidly reverse the cardiac toxic-
ity from systemic LAs such as bupivacaine. This finding
has been demonstrated in animal models of local anesthetic
toxicity and in several clinical case reports of successful
resuscitation after cardiac arrest related to local anesthetic
overdose.
Hypersensitivity to local anesthetics is rare. This adverse
effect is usually manifested as allergic dermatitis or asthma.
LA-induced hypersensitivity occurs almost exclusively with
ester-linked LAs. For example, a metabolite of procaine, para-
aminobenzoic acid (PABA), is a known allergen (as well as
the active agent in many sunscreens).
Individual Agents
Having discussed the general properties of local anesthetics,
this section presents the individual anesthetics in current
clinical use, with an emphasis on the agents differences in
potency and half-life.
Ester-Linked Local Anesthetics
Procaine
Procaine (Novocain) is a short-acting, ester-linked LA. Its
low hydrophobicity allows for rapid removal of drug from
the site of administration via the circulation and results in
little sequestration of drug in the local tissue surrounding
the nerve. In the bloodstream, procaine is degraded rapidly
by plasma pseudocholinesterases, and the metabolites are
subsequently excreted in the urine. Procaines low hydro-
phobicity also causes it to dissociate rapidly from its binding
site on the sodium channel, accounting for the low potency
of this agent.
Procaines primary uses are in infiltration anesthesia and
in dental procedures. Occasionally it is used in diagnostic
nerve blocks. Procaine is rarely used for peripheral nerve
block because of its low potency, slow onset, and short dura-
tion of action. However, the rapidly hydrolyzed, short-acting
homologue of procaine, 2-chloroprocaine (Nesacaine), is
popular as an obstetric anesthetic that is sometimes given
epidurally just before delivery to control pain.
One of the metabolites of procaine is PABA, a compound
required by some bacteria for purine and nucleic acid synthe-
sis. The antibacterial sulfonamides are structural analogues
of PABA that competitively inhibit the synthesis of an essen-
tial metabolite in folate biosynthesis (see Chapter 32, Prin-
ciples of Antimicrobial and Antineoplastic Pharmacology).
Excess PABA can reduce the effectiveness of sulfonamides
and therefore exacerbate bacterial infections. As mentioned
above, PABA is also an allergen.
Tetracaine
Tetracaine is a long-acting, highly potent, ester-linked LA. Its
long duration of action is caused by its high hydrophobicityit
has a butyl group attached to its aromatic groupwhich al-
lows tetracaine to remain in the tissue surrounding a nerve for
an extended period of time. Tetracaines hydrophobicity also
promotes prolonged interaction with its binding site on the so-
dium channel, accounting for its greater potency than lidocaine
and procaine. It is mainly used in spinal and topical anesthesia.
Its effective metabolism is slow, despite the potential for rapid
hydrolysis by esterases, because it is released only gradually
from tissues into the bloodstream.
Cocaine
Cocaine, the prototypical and only naturally occurring LA,
is ester-linked. It has a medium potency (one-half that of
lidocaine) and a medium duration of action. Cocaines struc-
ture is slightly unusual for local anesthetics; its tertiary amine
is part of a complex cyclic structure to which a secondary
ester group is attached.
Cocaines primary therapeutic uses are in ophthalmic an-
esthesia and as part of the topical anesthetic TAC (tetracaine,
adrenaline, cocaine; see above). Like prilocaine (see below),
cocaine has a marked vasoconstrictive action that results
from its inhibition of catecholamine uptake in synaptic ter-
minals of both the peripheral and central nervous systems
(see Chapter 10, Adrenergic Pharmacology). Inhibition of
this uptake system is also the mechanism for cocaines pro-
found cardiotoxic potential, and for the high associated
with cocaine use. Cardiotoxicity and euphoria limit the value
of cocaine as a local anesthetic.
Amide-Linked Local Anesthetics
Lidocaine and Prilocaine
Lidocaine, the most commonly used LA and the one used
in EMs case, is an amide-linked drug of moderate hydro-
phobicity. It has a rapid onset of action and a medium dura-
tion of action (about 12 hours) and is moderately potent.
Lidocaine has two methyl groups on its aromatic ring, which
enhance its hydrophobicity relative to procaine and slow its
rate of hydrolysis.
Lidocaine has a relatively low pKa, and a large fraction of
the drug is present in neutral form at physiologic pH. This
160 Principles of Autonomic and Peripheral Nervous System Pharmacology
that seen in patients with diabetic neuropathy, postherpetic
neuralgia, burns, cancer, and strokes. The development of
ultralong-acting LAs (whose effects could last for days) is
continuing to be investigated; these studies involve altering
LA structure at the molecular level, using a variety of drug
delivery systems, and discovering new classes of neuronal
impulse blockers.
Lastly, a promising area of current discovery involves
nociceptor-specific LAs. Some of these experimental agents
bind to particular sodium channel subtypes that are ex-
pressed preferentially on A- or C-fibers. Others are charged
anesthetics that typically cannot diffuse through neuronal
cell membranes; co-administration of these anesthetics with
agents that activate ion channels found preferentially on no-
ciceptors (such as TRPV1) allows the anesthetic molecules
to cross the nociceptor membrane through these open chan-
nels in a modality-specific fashion. Nociceptor-specific LAs
have the potential to block pain perception without affect-
ing motor, autonomic, or other neuronal signaling and may
therefore be useful in a variety of clinical settings.
Suggested Reading
Berde CB, Strichartz GR. Local anesthetics. In: Miller RD, et al, eds. Mill-
ers anesthesia. 7th ed. Philadelphia: Elsevier Churchill Livingstone; 2009.
(A more complete mechanistic and, primarily, clinical summary.)
Crystal CS, McArthur TJ, Harrison B. Anesthetic and procedural sedation tech-
niques for wound management. Emerg Med Clin North Am 2007;25:4171.
(A clinically oriented review that discusses how to administer LAs at various
anatomic sites.)
McLure HA, Rubin AP. Review of local anaesthetic agents. Minerva Anestesiol
2005;71:5974. (A clear discussion of both general concepts and individual
agents.)
Suzuki S, Gerner P, Colvin AC, Binshtok AM. C-fiber-selective peripheral
nerve blockade. Open Pain J 2009;2:2429. (Recent research on agents that
may have selectivity for C-fibers.)
 IIC

Principles of Central
Nervous System
Pharmacology
12
Pharmacology of GABAergic
and Glutamatergic
Neurotransmission
Stuart A. Forman, Janet Chou, Gary R. Strichartz, and Eng H. Lo
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 164-165
OVERVIEW OF GABAERGIC AND GLUTAMATERGIC
NEUROTRANSMISSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
PHYSIOLOGY OF GABAERGIC NEUROTRANSMISSION. . . . . 165
GABA Metabolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
GABA Receptors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Ionotropic GABA Receptors: GABAA and GABAC . . . . . . 166
Metabotropic GABA Receptors: GABAB. . . . . . . . . . . . . 168
PHARMACOLOGIC CLASSES AND AGENTS AFFECTING
GABAERGIC NEUROTRANSMISSION . . . . . . . . . . . . . . . . . . 168
Inhibitors of GABA Metabolism . . . . . . . . . . . . . . . . . . . . . 169
GABAA Receptor Agonists and Antagonists . . . . . . . . . . . . 170
GABAA Receptor Modulators. . . . . . . . . . . . . . . . . . . . . . . 170
Benzodiazepines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Barbiturates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Etomidate, Propofol, and Alphaxalone . . . . . . . . . . . . . 175
GABAB Receptor Agonists and Antagonists . . . . . . . . . . . . 175
 INTRODUCTION
Inhibitory and excitatory neurotransmitters regulate al-
most every behavioral process, including consciousness,
sleep, learning, memory, and all sensations. Inhibitory
and excitatory neurotransmitters are also implicated in
pathologic processes such as epilepsy and the neurotox-
icity associated with stroke. The interactions among ion
channels, the receptors that regulate these channels, and
amino acid neurotransmitters in the central nervous system
(CNS) constitute the molecular basis for these processes.
This chapter discusses the physiology, pathophysiology,
and pharmacology of -aminobutyric acid (GABA) and
glutamate neurotransmission. Together, these molecules
are the two most important amino acid neurotransmitters
in the CNS.
164
Nonprescription Uses of Drugs That Alter GABA
Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Ethanol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Chloral Hydrate, -Hydroxybutyric Acid,
and Flunitrazepam . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
PHYSIOLOGY OF GLUTAMATERGIC
NEUROTRANSMISSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Glutamate Metabolism . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Glutamate Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Ionotropic Glutamate Receptors . . . . . . . . . . . . . . . . . 176
Metabotropic Glutamate Receptors . . . . . . . . . . . . . . . 177
PATHOPHYSIOLOGY AND PHARMACOLOGY
OF GLUTAMATERGIC NEUROTRANSMISSION . . . . . . . . . . . 178
Neurodegenerative Diseases . . . . . . . . . . . . . . . . . . . . . . 178
Stroke and Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Hyperalgesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 180
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
 OVERVIEW OF GABAERGIC AND
GLUTAMATERGIC NEUROTRANSMISSION
The CNS has high concentrations of certain amino acids that
bind to postsynaptic receptors and thereby act as inhibitory
or excitatory neurotransmitters. Of the two main classes of
neuroactive amino acids, -aminobutyric acid (GABA) is
the major inhibitory amino acid, and glutamate is the pri-
mary excitatory amino acid.
Amino acid neurotransmitters elicit inhibitory or excit-
atory responses by altering the conductance of one or more
ion-selective channels. Inhibitory neurotransmitters induce
a net outward current, generally hyperpolarizing the mem-
brane. For example, inhibitory neurotransmitters may open
K channels or Cl channels to induce K efflux or Cl
influx, respectively. Either type of ion movementthe loss
 A Effects of inhibitory neurotransmitters

Extracellular
Direct effects Indirect effects
Intracellular Cl- Ca2+

+
K
Cl- channel +
K channel Ca2+ channel
(closed)

B Effects of excitatory neurotransmitters

Extracellular

Direct effects Indirect effects

Na+
Ca2+ Ca2+

+
K
Intracellular

Na+ channel Ca2+ channel K+ channel Ca2+ channel

(closed)
166 Principles of Central Nervous System Pharmacology

GABA Metabolism
The synthesis of GABA is mediated by glutamic acid decar-
boxylase (GAD), which catalyzes the decarboxylation of glu-
tamate to GABA in GABAergic nerve terminals (Fig. 12-2A).
Thus, the amount of GABA in brain tissue correlates with the
amount of functional GAD. GAD requires pyridoxal phos-
phate (vitamin B6) as a cofactor. GABA is packaged into pre-
synaptic vesicles by a transporter (VGAT), which is the same
transporter expressed in nerve terminals that release glycine,
another inhibitory neurotransmitter. In response to an action
potential and the presynaptic elevation of intracellular Ca2,
GABA is released into the synaptic cleft by fusion of GABA-
containing vesicles with the presynaptic membrane.
Termination of GABA action at the synapse depends on
the removal of GABA from the extracellular space. Neurons
and glia take up GABA via specific GABA transporters
(GATs). Four GATs have been identified, GAT-1 through
GAT-4, each with a characteristic distribution in the CNS.
Within cells, the widely distributed mitochondrial enzyme
GABA-transaminase (GABA-T) catalyzes the conversion
of GABA to succinic semialdehyde (SSA), which is sub-
sequently oxidized to succinic acid by SSA dehydrogenase
and then enters the Krebs cycle to become -ketoglutarate.
GABA-T then regenerates glutamate from -ketoglutarate
(Fig. 12-2A).
GABA Receptors
GABA mediates its neurophysiologic effects by binding to
GABA receptors. There are two types of GABA receptors.
Ionotropic GABA receptors (GABAA and GABAC) are
multisubunit membrane proteins that bind GABA and open
an intrinsic chloride ion channel. Metabotropic GABA
receptors (GABAB) are heterodimeric G protein-coupled
receptors that affect neuronal ion currents through second
messengers.
Ionotropic GABA Receptors: GABAA and GABAC
The most abundant GABA receptors in the CNS are ionotro-
pic GABAA receptors, which are members of the superfamily
of fast neurotransmitter-gated ion channels. This superfam-
ily includes peripheral and neuronal nicotinic acetylcholine
receptors (nAChRs), serotonin type 3A/B (5-HT3A/B) recep-
tors, and glycine receptors. Like other members of this su-
perfamily, GABAA receptors are pentameric transmembrane

O O O O
A

HO OH HO OH

O NH2
Via the
Krebs cycle -ketoglutarate Glutamate

GABA-T O
GAD C

O O O

OH SSADH H O
HO HO
NH2
O O HO
Succinic acid Succinic semialdehyde GABA
Vigabatrin

Presynaptic Glial cell Glutamine

B neuron synthetase
Gln
Gln FIGURE 12-2. Glutamate and GABA synthesis and metabolism.
Glu A. Glutamate synthesis and metabolism are intertwined with GABA synthesis
Glutaminase
and metabolism. In one pathway for glutamate synthesis, -ketoglutarate
Glu produced by the Krebs cycle serves as a substrate for the enzyme GABA
transaminase (GABA-T), which reductively transaminates intraneuronal
Gt(n) Gt(g)
-ketoglutarate to glutamate. The same enzyme also converts GABA to
succinic semialdehyde. Alternatively, glutamate is converted to GABA by the
Glu enzyme glutamic acid decarboxylase (GAD), changing the major excitatory
Glu neurotransmitter to the major inhibitory transmitter. GABA-T is irreversibly
Glu
inhibited by vigabatrin; by blocking the conversion of GABA to succinic
semialdehyde, this drug increases the amount of GABA available for release
at inhibitory synapses. GABA-T, GABA transaminase; SSADH, succinic semi-
aldehyde dehydrogenase; GAD, glutamic acid decarboxylase. B. Glutamate
transporters present in neurons [Gt(n)] and glial cells [Gt(g)] sequester glu-
Glutamate receptors tamate (Glu) from the synaptic cleft into their respective cells. In the glial
cell, the enzyme glutamine synthetase transforms glutamate into glutamine
Postsynaptic cell (Gln). Glutamine is then transferred to the neuron, which converts it back to
glutamate via mitochondria-associated glutaminase.
 CHAPTER 12 / Pharmacology of GABAergic and Glutamatergic Neurotransmission 167
A 1 subunit
N C
GABAA receptor
B
GABA (+) and
Benzodiazepines (+)
competitive antagonists (-)
Flumazenil (-)
Penicillin (-)
Furosemide (-) Barbiturates (+)
Neurosteroids (+)
Picrotoxin (-)
FIGURE 12-3. Schematic representation of the GABAA receptor. A. The
pentameric structure of the GABAA receptor. Each of the five subunits is one of
three predominant subtypes: , , or . Activation requires the simultaneous bind-
ing of two GABA molecules to the receptor, one to each of the two binding sites at
the interface of the and subunits. Each subunit of the GABAA receptor has four
membrane-spanning regions and a cysteine loop in the extracellular N-terminal
domain (depicted as a blue segment and a dashed line). B. Drug binding sites on
the GABAA receptor. For most of the exact locations schematically indicated in this
diagram, the current evidence is largely indirect. () indicates agonist or allosteric
modulator action at the GABAA receptor; () indicates competitive or noncompeti-
tive antagonist action.
glycoproteins assembled to form a central ion pore surrounded
by five subunits, each of which has four membrane-spanning
domains (Fig. 12-3A). Sixteen different GABAA receptor sub-
units (16, 13, 13, , , , ) are currently known. The
number of pentameric ion channels that could be formed by
potential combinations of 16 subunits is very large, but only
about 20 different subunit combinations have been identified
in native GABAA receptors. Importantly, receptors containing
different subunit combinations display distinct distributions
at the cellular and tissue levels, and evidence is accumulat-
ing that different GABAA receptor subtypes play distinct roles
in specific neural circuits. Most synaptic GABAA receptors
consist of two , two , and one subunit. Extrasynaptic
GABAA receptors have also been identified on dendrites,
axons, and neuronal cell bodies. These often contain a or
subunit instead of a subunit.
The five subunits of GABAA receptors surround a cen-
tral chloride-selective ion pore that opens in the presence of
GABA. GABA and other agonists bind to two sites, which
are located in extracellular portions of the receptor-channel
complex at the interface between the and subunits.
GABAA receptors also contain a number of modulatory
sites where other endogenous ligands and/or drugs bind
(Fig. 12-3B). In many cases, the presence of these sites and
the impact of ligand binding depend on the receptor sub-
unit composition.
GABAA receptor-channel activation follows the binding
of two molecules of GABA, one to each of the receptors
agonist sites (Fig. 12-3). Fast inhibitory postsynaptic cur-
rents (IPSCs) are responses activated by very brief (high-
frequency) bursts of GABA release at synapses. Uptake by
GAT removes GABA from the synapse in less than 1 ms;
IPSCs deactivate over about 1220 ms, a rate that is deter-
mined by both closure of the GABAA receptor ion channel
and dissociation of GABA from the receptor. Prolonged oc-
cupation of the agonist sites by GABA also leads to GABAA
receptor desensitization, a transition to an inactive agonist-
bound state (Fig. 12-4). During burst (or phasic) firing, the
presynaptic nerve membrane releases quanta (1 mM) of
GABA by exocytosis of synaptic vesicles, resulting in tran-
sient, large-amplitude inhibitory postsynaptic potentials
(IPSPs). Low levels of GABA can also cause a baseline
inhibitory current in many neurons. Recent studies suggest
that basal inhibitory currents are caused by activation of ex-
trasynaptic GABAA receptors, which are activated by low
micromolar concentrations of GABA that diffuse into cere-
brospinal fluid and interstitial spaces.
Because the internal chloride concentration [Cl]in of ma-
ture neurons is lower than the extracellular Cl concentration
[Cl]out, activation of chloride-selective channels (increasing
conductance) shifts the neuronal transmembrane voltage to-
ward the Cl equilibrium potential (ECl 70 mV). This Cl
flux hyperpolarizes or stabilizes the postsynaptic cell near its
normal resting membrane potential (Vm 65 mV), reduc-
ing the likelihood that excitatory stimuli will initiate action
potentials. Open Cl channels attenuate the change in mem-
brane potential caused by excitatory synaptic currents, an ef-
fect called shunting. This is the molecular explanation for the
inhibitory effects of GABA signaling via GABAA receptors.
(In immature neurons, as found in neonates, the Cl ion gradi-
ent is reversed, due to a difference in the Cl ion transporting
pumps, such that Cl ions flow out of the cell constituting an
Cl- current
0
3 M GABA 30 M GABA 300 M GABA
Time (shaded bar = 1 sec)
FIGURE 12-4. Effects of GABA on GABAA-mediated chloride conduc-
tance. Increasing concentrations of GABA induce both greater Cl currents and
more rapid receptor desensitization. The latter phenomenon can be observed as
the rapid decline from the peak current during continuous exposure to 300 M
GABA (right panel). In each panel, the shaded bar indicates the 1-second period
during which GABA was applied. Although individual presynaptic endings will re-
lease GABA for much shorter times, the cumulative GABA released from many
presynaptic elements, stimulated by trains of invading action potentials, can per-
sist for seconds.
168 Principles of Central Nervous System Pharmacology
GABAB receptor
Ca2+
K
+ GTP
Closes Opens
GTP-GDP exchange
Ca2+ channel K+ channel
FIGURE 12-5. Downstream signaling of the GABAB receptor. GABAB receptor activation alters cytoplasmic G proteins that then dissociate into and subunits,
the latter of which bind directly to K or Ca2 channels (leftward arrow). The released subunits are linked to second messenger systems such as adenylyl cyclase (AC)
or phospholipase C (PLC) (rightward arrow). The increased K efflux leads to slow, long-lasting inhibitory postsynaptic potentials. The reduced Ca2 influx may account
for the ability of GABAB autoreceptors to inhibit presynaptic neurotransmitter release. The GABAB receptor functions as an obligate heterodimer of GABAB1 and GABAB2
subunits, each of which is a seven-transmembrane-spanning G protein-coupled receptor (not shown).
inward current and thus depolarizing rather than hyperpolar-
izing the membrane. Importantly, as a consequence of this,
drugs that activate or potentiate GABAA receptors will have
an excitatory action in the very young instead of the inhibitory
effect that they have later in development.)
The molecular role of GABAA receptors in neurons is
consistent with their known physiologic roles in CNS dis-
ease and their pharmacology. Drugs that inhibit GABAA
receptors produce seizures in animals, and mutations in
GABAA receptor subunits that impair activation at the mo-
lecular level are associated with inherited human epilepsies.
Conversely, endogenous or exogenous substances that en-
hance the activation of GABAA receptors reduce neuronal
excitability and may impair numerous CNS functions. Re-
cent evidence indicates that GABAA receptors are also ex-
pressed in airway epithelium. Activation of these receptors
may enhance smooth muscle relaxation (bronchodilation)
and could represent a future therapy for asthma.
Certain endogenous steroids, known as neurosteroids, al-
losterically modulate GABAA receptor activity. The steroid
hormones deoxycorticosterone and progesterone are me-
tabolized in the brain to produce pregnenolone, dehydroe-
piandrosterone (DHEA), 5-dihydrodeoxycorticosterone
(DHDOC), 5-tetrahydrodeoxycorticosterone (THDOC),
and allopregnanolone. Rather than acting through nuclear
receptors like most steroid hormones, neurosteroids alter
GABAA receptor function by binding to allosteric sites on
the receptor protein, causing increased GABAA receptor ac-
tivation. DHDOC and THDOC are thought to modulate brain
activity during stress. Menstrual variations in allopregnano-
lone, a metabolite of progesterone, contribute to perimen-
strual (catamenial) epilepsy. Sulfation of pregnenolone and
DHEA results in neurosteroids that inhibit GABAA recep-
tors. Another endogenous substance that enhances GABAA
receptor activity is oleamide, a fatty acid amide found in the
cerebrospinal fluid of sleep-deprived animals. Injection of
oleamide into normal animals induces sleep, in part through
potentiation of GABAA receptors.
Another group of ionotropic GABA receptors, GABAC,
are formed by three subunits that are not found in GABAA
receptors (13). GABAC receptors are also pentameric
ligand-gated chloride channels, but their distribution in the
CNS is restricted primarily to the retina. GABAC receptors
display distinct pharmacologic properties that differ from
GABA Effector protein
(PLC or AC)
GDP GTP
GTP-GDP exchange
those of most GABAA receptors. No drugs currently in use
target GABAC receptors.
Metabotropic GABA Receptors: GABAB
GABAB receptors are G protein-coupled receptors that are
expressed at lower levels than GABAA receptors and are
found principally in the spinal cord (Fig. 12-5). They func-
tion as heterodimers of GABAB1 and GABAB2 subunits.
The GABAB receptor interacts with heterotrimeric G pro-
teins, leading to the dissociation of their subunit, which
directly activates K channels and inhibits the opening of
voltage-gated Ca2 channels (Fig. 12-5). (GABAB receptor
activation also leads to suppression of adenylyl cyclase and
concomitant reduction in cAMP, but this seems to have only
minor effects on cellular excitability.) At GABAergic syn-
apses, GABAB receptors are expressed both presynaptically
and postsynaptically. Presynaptic autoreceptors modulate
neurotransmitter release by reducing Ca2 influx, while post-
synaptic GABAB receptors produce slow IPSPs through acti-
vation of G protein-activated inward rectifier K channels
(GIRKS). The slower rates of activation and deactivation for
GABAB currents in comparison with GABAA currents are
due to the relatively slow second messenger signal transduc-
tion mechanisms.
Activation of K channels by GABAB-coupled G proteins
inhibits neuronal firing, because K has an equilibrium poten-
tial near 70 mV. Thus, increased K conductance, like in-
creased Cl conductance, drives the neuronal transmembrane
voltage toward resting potentials, reduces the frequency of
action potential initiation, and shunts excitatory currents.
 PHARMACOLOGIC CLASSES AND
AGENTS AFFECTING GABAERGIC
NEUROTRANSMISSION
Pharmacologic agents acting on GABAergic neurotrans-
mission affect GABA metabolism or receptor activity. The
majority of pharmacologic agents affecting GABAergic
neurotransmission act on the ionotropic GABAA receptor.
Several drug classes can regulate GABAA receptors by inter-
acting with the GABA binding sites or with allosteric sites
(Fig. 12-3). Therapeutic agents that activate GABAA recep-
tors are used for sedation, anxiolysis, hypnosis (general
170 Principles of Central Nervous System Pharmacology

Vigabatrin is used in the treatment of epilepsy, and it is
being investigated for treatment of drug addiction, panic dis-
order, and obsessive-compulsive disorder. Adverse effects
of -vinyl GABA include drowsiness, confusion, and head-
ache. The drug has been reported to cause bilateral visual
field defects associated with irreversible diffuse atrophy of
the peripheral retinal nerve fiber layer. This appears to result
from accumulation of the drug in retinal nerves.
studies. Furthermore, in clinical states associated with low
albumin, such as acute hemodilution or liver dysfunction,
the clinical potency of benzodiazepines may be dramatically
increased.
Benzodiazepines act as positive allosteric modulators by
enhancing GABAA receptor channel gating in the presence of
GABA (Fig. 12-6). Benzodiazepines increase the frequency

GABAA Receptor Agonists and Antagonists

A
Agonists such as muscimol and gaboxadol activate the
GABAA receptor by binding directly to the GABA binding 100
site. Muscimol, first derived from hallucinogenic Amanita

Cl- current (% maximum)

muscaria mushrooms, is a full agonist at many GABAA re- Low GABA +
pentobarbital
ceptor subtypes and is used primarily as a research tool. Pu- 80
rified muscimol (as well as other GABAA receptor agonists)
does not induce hallucinations, which are probably caused 60
by other factors from Amanita muscaria. Gaboxadol at high
concentrations is a partial agonist at synaptic GABAA recep-
tors; at low concentrations, gaboxadol selectively activates 40 Low GABA +
midazolam
extrasynaptic receptors containing 4, 3, and subunits. Low GABA
Gaboxadol was initially approved for treatment of epilepsy 20 alone
and anxiety, but therapeutic doses were associated with
ataxia and sedation. Lower gaboxadol doses, which activate
0
extrasynaptic receptors, induce slow-wave sleep in labora- 10-9 10-8 10-7 10-6 10-5 10-4 10-3
tory animals. Human trials of gaboxadol for treatment of in-
somnia were halted in 2007 due to concerns about adverse Midazolam or pentobarbital (Molar)
effects such as hallucinations, disorientation, sleepwalking, B
and sleep-driving.
Bicuculline and gabazine are competitive antagonists 100 GABA + high-dose
pentobarbital
Cl- current (% maximum)

that bind at the GABA sites on GABAA receptors. Picro-

toxin is a noncompetitive inhibitor of GABAA receptors that
blocks the ion pore. All of these GABAA antagonists produce
epileptic convulsions and are used exclusively for research;
they also illustrate the importance of the tonic activity of
GABAA receptors in maintaining a state of relatively normal
excitability in the CNS.
GABAA Receptor Modulators
Benzodiazepines and barbiturates are modulators of GABAA
receptors that act at allosteric binding sites to enhance GABAer-
gic neurotransmission (Fig. 12-3B). Benzodiazepines have
sedative, hypnotic, muscle relaxant, amnestic, and anxiolytic
effects. At high doses, benzodiazepines can cause hypnosis
and stupor. However, when used alone, these drugs rarely
cause fatal CNS depression. Barbiturates constitute a large
group of drugs that were first introduced in the mid-twentieth
century and continue to be used, albeit with diminishing fre-
quency, for control of epilepsy, as general anesthetic induction
agents, and for control of intracranial hypertension.
Benzodiazepines
Benzodiazepines are high-affinity, highly selective drugs
that bind at a single site on GABAA receptors containing 1,
2, 3, or 5 subunits and a subunit. In molecular stud-
ies, benzodiazepine potency correlates with hydrophobicity.
However, benzodiazepines are highly bound to plasma pro-
teins such as albumin, and hydrophobicity enhances protein
binding and thereby reduces the drugs free concentration and
transport across the bloodbrain barrier. Therefore, highly
protein-bound benzodiazepines may appear less potent in
vivo even though they display higher potency in molecular
80
GABA +
60 maximal
midazolam
40
GABA alone
20
0
10-7 10-6 10-5 10-4 10-3
GABA (Molar)
FIGURE 12-6. Effects of benzodiazepines and barbiturates on GABAA
receptor activity. A. Both benzodiazepines and barbiturates enhance GABAA receptor
activation (measured experimentally by Cl current), but with different potencies and
efficacies. Midazolam (a benzodiazepine) maximally enhances by about three-fold the
current evoked by 10 M GABA. In contrast, the anesthetic barbiturate pentobarbital
increases the current evoked by 10 M GABA to a much greater extent (near that
of a maximal GABA response), but its maximal effect requires concentrations over
100 M. Thus, benzodiazepines such as midazolam are high-potency, low-efficacy
modulators of GABAA receptor activity, while barbiturates such as pentobarbital are
low-potency, high-efficacy modulators. B. Another way to compare the efficacy of
benzodiazepines and barbiturates is to measure the degree to which they enhance
the sensitivity of GABAA receptors to GABA. Maximally effective concentrations of mi-
dazolam shift the GABA concentrationresponse curve modestly to the left, reducing
the EC50 (increasing the potency) of GABA by about two-fold. In contrast, high-dose
pentobarbital causes a much greater shift to the left, reducing the EC50 of GABA by ap-
proximately 20-fold. Pentobarbital at high concentrations also directly activates GABAA
receptors, even in the absence of GABA (note the nonzero Cl current at 107 M
GABA). In contrast, the benzodiazepines do not show direct agonist activity.
 CHAPTER 12 / Pharmacology of GABAergic and Glutamatergic Neurotransmission 171

of channel openings in the presence of low GABA concentra-
tions, and, at GABA concentrations similar to those in syn-
apses, receptor deactivation is slowed. Both actions result in
a net increase of Cl influx. In addition, GABAA receptors
in the open state have a higher affinity for GABA than in the
closed state, so the ability of benzodiazepines to favor chan-
nel openness results, secondarily, in an apparently higher
agonist affinity.
Benzodiazepines do not activate native GABAA recep-
tors in the absence of GABA, but they do activate certain
mutant receptors and enhance maximal activation by partial
agonists, indicating that they are weak positive allosteric
agonists (Fig. 12-7). This mechanism is consistent with the
known location of the benzodiazepine-binding site at the in-
terface between the external domains of the and subunits.
This site is a structural homolog of the two GABA agonist
sites at the interfaces between the and subunits.
In GABA doseresponse studies, benzodiazepines shift
the response curve to the left, increasing the apparent potency
of GABA up to three-fold (Fig. 12-6B). This is a smaller
allosteric effect than that caused by other modulators, such
as barbiturates or other general anesthetics (see etomidate,
below). The limited efficacy of benzodiazepines is accom-
panied by a reduced potential for fatal overdose. However,
the margin of safety decreases when benzodiazepines are co-
administered with alcohol or other sedative/hypnotics.
Clinical Applications
Benzodiazepines are used as sleep enhancers, anxiolytics,
sedatives, antiepileptics, and muscle relaxants, and for treat-
ment of ethanol withdrawal symptoms (Table 12-2). Benzo-
diazepines achieve an anxiolytic effect by inhibiting synapses
in the limbic system, a CNS region that controls emotional
behavior and is characterized by a high density of GABAA re-
ceptors. Benzodiazepines such as diazepam and alprazolam
are used to mitigate chronic, severe anxiety and the anxiety
associated with some forms of depression and schizophre-
nia. Because of the potential for the development of toler-
ance, dependence, and addiction, benzodiazepine use should
be intermittent. In acute-care settings, such as in preparation
for invasive procedures, midazolam is frequently used as a
rapid-onset and short-acting anxiolytic/sedative/amnestic.
Benzodiazepines are often adequate as sedatives for brief,
uncomfortable procedures associated with minimal sharp
pain, such as endoscopy. When combined with opioids, how-
ever, a synergistic potentiation of both sedation and respira-
tory depression can occur. Given prior to general anesthesia,
benzodiazepines reduce the requirement for hypnotic agents.
Many benzodiazepines, including estazolam, flurazepam,
quazepam, temazepam, triazolam, and zolpidem, are pre-
scribed for treatment of insomnia. Benzodiazepines both facili-
tate sleep onset and increase the overall duration of sleep. They
also alter the proportion of the various sleep stages: they in-
crease the length of stage 2 non-rapid eye movement (NREM)
sleep (the light sleep that normally comprises approximately
half of sleeping time) and decrease the length of REM sleep
(the period characterized by frequent dreams) and slow-wave
sleep (the deepest level of sleep). After extended use, these
effects may diminish because of tolerance. In a healthy indi-
vidual, hypnotic doses of benzodiazepines induce respiratory
changes comparable to those present during natural sleep and
do not cause significant cardiovascular changes. Patients with
either pulmonary or cardiovascular disease may experience
significant respiratory or cardiovascular depression because of
medullary depression from otherwise therapeutic doses of these
drugs. Patients who have suffered brain damage from stroke
or head trauma may also become profoundly sedated with
these drugs.
The sedative benzodiazepines differ in their rates of
onset, durations of effect, and tendencies to cause rebound
insomnia when withdrawn. For example, flurazepam is a
long-acting benzodiazepine that facilitates sleep onset and
maintenance and increases sleep duration. Although it does
not cause significant rebound insomnia, its long elimination
half-life (about 74 hours) and the accumulation of active me-
tabolites may cause daytime sedation. Triazolam is a fast-
onset benzodiazepine that also decreases the time needed to
fall asleep. Intermittent rather than chronic administration
of this drug is recommended to lessen the rebound insom-
nia associated with its discontinuation. Zolpidem is unique

A B
Cl- current (% maximum)

100
Maximal
80 GABA P4S +
response midazolam
Midazolam alone
60
Current from activates current
P4S alone spontaneously
40 active mutant
GABAA channels
20

0 Picrotoxin
blocks current

Time (sec)

FIGURE 12-7. Evidence that benzodiazepines enhance the GABAA receptor channel opening probability. A. When GABAA receptors are activated using saturat-
ing concentrations of the partial agonist P4S, midazolam increases the peak current. This indicates that the P4S efficacy (the maximal channel opening probability) is in-
creased by the addition of midazolam. B. GABAA receptors containing a single point mutation are spontaneously active, which can be demonstrated by the loss of current
caused by picrotoxin (a noncompetitive GABAA receptor antagonist). When these mutant receptors are exposed to midazolam, the amount of current increases, indicating
that midazolam directly influences the opening of GABAA receptors. This effect is not observed in wild-type channels, which exhibit only rare spontaneous openings.
 N 1 subunit
A

Tetrameric structure

C
B
Glutamate/AMPA/Kainate Glutamate/NMDA

Alcohols, volatile Glycine

anesthetics? Phencyclidine
Na+ Barbiturate Ca2+
Zn2+ Mg2+

+
K +
K
AMPA/Kainate receptor NMDA receptor
 CHAPTER 12 / Pharmacology of GABAergic and Glutamatergic Neurotransmission 175
Tolerance and Dependence
Repeated and extended misuse of barbiturates induces toler-
ance and physiologic dependence. Prolonged barbiturate use
increases the activity of cytochrome P450 enzymes and accel-
erates barbiturate metabolism, thereby contributing to the de-
velopment of tolerance to barbiturates and cross-tolerance to
benzodiazepines, other sedative/hypnotics, and ethanol. De-
velopment of physiologic dependence results in a drug with-
drawal syndrome characterized by tremors, anxiety, insomnia,
and CNS excitability. If left untreated, these withdrawal signs
may progress to seizures and cardiac arrest.
Etomidate, Propofol, and Alphaxalone
Etomidate, propofol, and alphaxalone are drugs used for
induction of general anesthesia. Etomidate and propofol
are also discussed in Chapter 16. Like barbiturates, these
intravenous anesthetics act primarily on GABAA recep-
tors. Etomidate is particularly useful during induction of
anesthesia in hemodynamically unstable patients. Propofol
is the most widely used anesthetic induction agent in the
United States. It is used both for single-bolus induction of
anesthesia and for maintenance via continuous intravenous
infusion. Alphaxalone is a neuroactive steroid that is rarely
used clinically.
Mechanisms of Action
Like barbiturates, etomidate, propofol, and alphaxalone en-
hance activation of GABAA receptors by GABA and, at high
concentrations, can act as agonists. For etomidate, both of
these actions display similar stereoselectivity. Quantitative
analysis indicates that both actions are caused by etomidate
binding at a single set of two identical allosteric sites per re-
ceptor. It is unknown whether a similar mechanism accounts
for the actions of propofol and alphaxalone.
Etomidate and propofol act selectively at GABAA receptors
that contain 2 and 3 subunits. Based on knock-in animal
experiments, where 3 subunits are expressed as transgenes,
3-containing receptors are the most important for the hypno-
sis and muscle relaxation associated with general anesthesia.
Alphaxalone shows little selectivity among synaptic GABAA
receptors but is more potent at extrasynaptic receptors that
contain subunits.
Pharmacokinetics and Metabolism
Etomidate and propofol both induce anesthesia rapidly fol-
lowing bolus intravenous injection. Like barbiturates, these
hydrophobic drugs cross the bloodbrain barrier rapidly.
The CNS effect of a bolus dose lasts for only several min-
utes, because redistribution to muscle and other tissues rap-
idly reduces the CNS drug concentrations. Propofol has an
extremely large volume of distribution, and prolonged con-
tinuous infusions may be used without significant changes in
the apparent clearance of the drug. Metabolism of etomidate
and propofol is primarily hepatic.
Adverse Effects
Etomidate inhibits the synthesis of cortisol and aldosterone.
Suppression of cortisol production is thought to contribute to
mortality among critically ill patients who receive prolonged
etomidate infusions, and administration of exogenous glucocor-
ticoids is effective in preventing this complication. Etomidate is
generally used only for single-dose induction of anesthesia, not
for anesthesia maintenance. It is also used rarely at subhypnotic
doses for treatment of metastatic cortisol-producing tumors.
The major toxicity of propofol as a general anesthetic is
depression of cardiac output and vascular tone. Hypotension
is observed in patients who are hypovolemic or, as with many
elderly patients, dependent on vascular tone to maintain blood
pressure. Propofol is formulated in a lipid emulsion, and hy-
perlipidemia has been reported in patients receiving prolonged
infusions for sedation.
There is growing evidence in cellular and animal models
that positive GABAA receptor modulators lead to neurotoxic-
ity and increased neuroapoptosis. The mechanism suggested
for this toxicity, which is not seen in adult animals, is that
GABAA receptors are excitatory in some fetal and neonatal
neurons (see above), resulting in excitotoxicity in the pres-
ence of certain drugs. These data have raised concerns about
potential damage to the brains of human fetuses and neonates
that are exposed to general anesthetics. Clinical studies are
underway to assess the clinical relevance of this toxicity.
GABAB Receptor Agonists and Antagonists
Baclofen is the only compound currently in clinical use that
targets GABAB receptors. It was first synthesized as a GABA
analogue and screened for antispastic action before GABAB
receptors were discovered. Subsequently, it was found that
baclofen is a selective GABAB receptor agonist. It is used pri-
marily for treatment of spasticity associated with motor neu-
ron diseases (e.g., multiple sclerosis) or spinal cord injury.
Oral baclofen is effective for mild spasticity. Severe spastic-
ity may be treated with intrathecal baclofen therapy using
doses that are far lower than those required systemically. By
activating metabotropic GABA receptors in the spinal cord,
baclofen stimulates downstream second messengers to act
on Ca2 and K channels. Although baclofen is prescribed
primarily for treatment of spasticity, clinical observations
suggest that it also modulates pain and cognition, and it is
being investigated as a therapy for drug addiction.
Baclofen is absorbed slowly after oral administration;
peak plasma concentrations are reached after 90 minutes. It
has a modest volume of distribution and does not readily
cross the bloodbrain barrier. Baclofen is primarily cleared
from the circulation in an unmodified form in the urine;
about 15% of the drug is metabolized by the liver before ex-
cretion in bile. The elimination half-time is about 5 hours in
patients with normal renal function, and dosing is typically
three times daily. Following intrathecal injection and infu-
sion, spasmolytic effects are observed after 1 hour and peak
effects are observed at 4 hours.
Adverse effects of baclofen include sedation, somnolence,
and ataxia. These are worsened when baclofen is taken with
other sedative drugs. Reductions in renal function may pre-
cipitate toxicity as drug levels rise. Baclofen overdose can
produce blurry vision, hypotension, cardiac and respiratory
depression, and coma.
Tolerance apparently does not develop to oral baclofen.
In contrast, dosing requirements after initiation of intrathe-
cal baclofen often increase over the first 1 to 2 years. With-
drawal from baclofen therapy, especially from intrathecal
infusion, can precipitate acute hyperspasticity, rhabdomy-
olysis, pruritus, delirium, and fever. Withdrawal has also led
to multiorgan failure, coagulation abnormalities, shock, and
death. If withdrawal symptoms persist, effective treatments
reportedly include benzodiazepine, propofol, intrathecal
opioid administration, and restarting baclofen.
176 Principles of Central Nervous System Pharmacology
Nonprescription Uses of Drugs That Alter
GABA Physiology
Ethanol
Ethanol acts as an anxiolytic and sedative by causing CNS
depression, but not without significant potential toxicity. Etha-
nol appears to exert its effects by acting on multiple targets,
including GABAA and glutamate receptors. Ethanol increases
GABAA-mediated Cl influx and inhibits the excitatory ef-
fects of glutamate at NMDA receptors. Ethanol interacts syn-
ergistically with other sedatives, hypnotics, antidepressants,
anxiolytics, anticonvulsants, and opioids.
Ethanol tolerance and dependence are associated with
changes in GABAA receptor function. In animal models,
chronic ethanol administration blunts the ethanol-mediated
potentiation of GABA-induced Cl influx in the cerebral cor-
tex and cerebellum. Acute tolerance to ethanol occurs without
a change in the number of GABAA receptors, but chronic eth-
anol exposure alters GABAA receptor subunit expression in
the cortex and cerebellum. Changes in the subunit composi-
tion of GABAA receptors may be responsible for the changes
in receptor function associated with chronic ethanol use.
Other mechanisms proposed for the development of toler-
ance to ethanol include post-translational modifications of
GABAA receptors and changes in second messenger systems,
for example, alterations in the expression patterns of differ-
ent isoforms of protein kinase C (PKC). The up-regulation
of NMDA receptor expression that occurs with prolonged
ethanol use may account for the hyperexcitability associated
with ethanol withdrawal.
Benzodiazepines, such as diazepam and chlordiazepox-
ide, reduce the tremors, agitation, and other effects of acute
alcohol withdrawal. Use of these medications in a patient ex-
periencing withdrawal from chronic alcohol abuse can also
prevent the development of withdrawal seizures (delirium
tremens).
Chloral Hydrate, -Hydroxybutyric Acid, and Flunitrazepam
Chloral hydrate is an older sedativehypnotic rarely used today
to alleviate insomnia. It has occasionally been employed to in-
capacitate individuals against their will; for example, to facili-
tate the commission of a crime. Gamma ()-hydroxybutyric
acid (GHB) is a GABA isomer that has clinical utility as a
sedative and treatment for narcolepsy, but finds much wider
illicit use as a recreational drug and date rape drug. There is
recent evidence that GHB acts in part by activating GABAB re-
ceptors, but it is also an endogenous molecule that may act as a
neurotransmitter at other receptors that have not yet been iden-
tified. Like barbiturates, high doses of GHB can produce deep
sedation and coma, and its effects are exacerbated by ethanol.
Flunitrazepam (Rohypnol) is a fast-acting benzodiazepine
that can cause amnesia and thereby prevent an individuals re-
call of events that occurred under the drugs influence. This
drug has also been reported to facilitate date rape.
 PHYSIOLOGY OF GLUTAMATERGIC
NEUROTRANSMISSION
Glutamatergic synapses exist throughout the CNS. The bind-
ing of glutamate to its receptors initiates excitatory neuronal
responses associated with motor neuron activation; acute
sensory responses, including the development of elevated
pain sensation (hyperalgesia); synaptic changes involved in
certain types of memory formation; and cerebral neurotoxic-
ity from brain ischemia as well as functional deficits from
spinal cord injury. Although the clinical applications of glu-
tamate pharmacology are currently limited, it is anticipated
that glutamate pharmacology will become an increasingly
important area of neuropharmacology.
Glutamate Metabolism
Glutamate synthesis occurs via two distinct pathways. In
one pathway, -ketoglutarate formed in the Krebs cycle is
transaminated to glutamate in CNS nerve terminals, a step
that is directly linked to GABA conversion (Fig. 12-2A). Al-
ternatively, glutamine produced and secreted by glial cells is
transported into nerve terminals and converted to glutamate
by glutaminase (Fig. 12-2B).
Glutamate is released via calcium-dependent exocytosis of
transmitter-containing vesicles. Glutamate is removed from
the synaptic cleft by glutamate reuptake transporters located
on presynaptic nerve terminals and on the plasma membrane
of glial cells. These transporters are Na-dependent and have
a high affinity for glutamate. In glial cells, the enzyme glu-
tamine synthetase converts glutamate to glutamine, which
is recycled into adjacent nerve terminals for conversion back
to glutamate. Glutamine generated in glial cells can also
enter the Krebs cycle and undergo oxidation; the resulting -
ketoglutarate enters neurons to replenish the -ketoglutarate
consumed during glutamate synthesis (Fig. 12-2B).
Glutamate Receptors
As with GABA receptors, glutamate receptors are divided
into ionotropic and metabotropic subgroups.
Ionotropic Glutamate Receptors
Ionotropic glutamate receptors mediate fast excitatory synap-
tic responses. These receptors are multisubunit, cation-selec-
tive channels that, on activation, permit the flow of Na, K,
and, in some channels, Ca2 ions across plasma membranes.
Ionotropic glutamate receptors are thought to be tetramers
composed of different subunits, with each subunit contain-
ing helical domains that span the membrane three times, in
addition to a short sequence that forms the channels pore
when the entire tetramer is assembled (Fig. 12-8A).
There are three main subtypes of glutamate-gated ion
channels, classified according to their activation by the se-
lective agonists AMPA, kainate, and NMDA. The diversity
of ionotropic receptors arises from differences in amino acid
sequence because of alternative mRNA splicing and post-
transcriptional mRNA editing, and from the use of different
combinations of subunits to form the receptors (Table 12-5).
AMPA (-amino-3-hydroxy-5-methyl-4-isoxazole pro-
pionic acid) receptors are located throughout the CNS, par-
ticularly in the hippocampus and cerebral cortex. Four AMPA
receptor subunits (GluR1GluR4) have been identified (Table
12-5). AMPA receptor activation results primarily in Na in-
flux (as well as some K efflux), allowing these receptors to
regulate fast, excitatory postsynaptic depolarization at gluta-
matergic synapses (Fig. 12-8B). Although most AMPA recep-
tors in the CNS have low Ca2 permeability, the absence of
certain subunits (such as GluR2) in the receptor complex in-
creases the Ca2 permeability of the channel. Calcium entry
through AMPA receptors may play a role in long-term changes
in neuronal phenotype and in neuronal damage during stroke.
 Metabotropic
Neurotransmitter glutamate
N binding regions receptor Glutamate

Effector protein Ion channel

(PLC or AC) 1 Ca2+
Glu

4
3
+
GTP K
C GTP 2 GDP 2
Closes Opens
GTP-GDP exchange GTP-GDP exchange
G protein K+ channel Ca2+ channel
binding regions
 CHAPTER 12 / Pharmacology of GABAergic and Glutamatergic Neurotransmission 179

Stroke and Trauma effects, memory impairment, and neurotoxic reactions. Fu-
ture pharmacologic research will be directed at the develop-
In ischemic stroke, interruption of blood flow to the brain pro-
ment and use of drugs with fewer adverse effects, such as the
vides the initial deficits in oxygen supply and glucose metabo-
noncompetitive NMDA receptor antagonist memantine or
lism that trigger excitotoxicity (Fig. 12-10). In hemorrhagic
drugs targeted to specific subunits of the NMDA or AMPA
strokes, high concentrations of glutamate are found in blood
receptor complex.
leaking into the brain. In traumatic brain injury, the direct rup-
Glutamate released during ischemic or traumatic brain
ture of brain cells can release high intracellular stores of gluta-
damage can also activate metabotropic receptors. In animal
mate and K into the restricted extracellular space.
models of stroke, pharmacologic antagonism of the mGluR1
Once excitatory transmitters such as glutamate become
receptor subtype facilitates recovery and survival of hip-
unbalanced, widespread membrane depolarization and el-
pocampal neurons and prevents memory and motor loss
evation of intracellular Na and Ca2 concentrations propa-
caused by trauma. These findings suggest that the mGluR1
gate, and more glutamate is released from adjacent neurons.
subunit may represent another target for future pharmaco-
Increasing glutamate levels activate Ca2-permeable NMDA
logic intervention (Figs. 12-10 and 12-11).
and AMPA receptor-coupled channels. Ultimately, the re-
sultant accumulation of intracellular Ca2 activates many
Ca2-dependent degradation enzymes (e.g., DNAses, pro- Hyperalgesia
teases, phosphatases, phospholipases) that lead to neuronal Hyperalgesia is the elevated perception of pain, often due to
cell death. stimuli that, under normal conditions, cause little or no pain.
Although the highly Ca2-permeable NMDA receptor was It occurs in the presence of peripheral nerve injury, inflam-
originally viewed as the major contributor to neuronal cell mation, surgery, and diseases such as diabetes. Although
death caused by Ca2 overload, AMPA receptors have also hyperalgesia is reversed in most cases when the underlying
been implicated. Clinical trials of NMDA and AMPA recep- pathophysiology has resolved, it may persist even in the ab-
tor antagonists in patients with stroke have not been success- sence of an identified organic source, leading to chronic pain
ful to date and, in some cases, have led to schizophrenia-like that is physically crippling and psychologically debilitating.
There is accumulating evidence that glutamatergic trans-
mission contributes to the development and/or maintenance
of hyperalgesia. NMDA receptors enhance synaptic trans-
Ischemia mission between nociceptive afferent fibers and neurons in
the dorsal horn of the spinal cord. As discussed in Chapter
17, Pharmacology of Analgesia, experimental hyperalgesia
O2
often involves a phenomenon called central sensitization,
in which repeated nociceptive stimuli in the periphery lead to
ATP
progressively increasing excitatory postsynaptic responses in
postsynaptic pain neurons in the superficial dorsal horn. One
mechanism by which this synaptic potentiation occurs in-
Disrupted ion gradients volves postsynaptic NMDA receptors that, when stimulated
chronically, increase the strength of excitatory connections
between pre- and postsynaptic neurons in spinal pain circuits.
Membrane depolarization Impaired Na+-coupled In turn, the Ca2 influx through activated NMDA receptors
glutamate transporters acts on special localized kinases to effect a phosphorylation-
induced switch of the subunits of the AMPA receptor, allow-
Increased synaptic glutamate ing more Ca2 to enter through AMPA receptors. Increased
intracellular Ca2 also activates Ca2-sensitive transcription
factors, such as CREB, and induces changes in protein syn-
thesis via ribosomes located right at the synaptic terminals.
NMDA-R AMPA-R mGluR Experimental NMDA receptor antagonists can both pre-
activation activation activation vent and reverse central sensitization in patients. Many of
these antagonists, however, also inhibit a wide range of fast
intracellular Ca2+ excitatory synaptic pathways in the CNS. For this reason,
current NMDA receptor drug development focuses on in-
traspinal or extradural administration of NMDA receptor
Activation of DNases, proteases, Mitochondrial antagonists to limit the effects of the drug to the dorsal horn
phosphatases, phospholipases damage of the spinal cord. The high density of kainate receptors in
sensory neurons may also modulate transmitter release, pro-
viding another future pharmacologic target for the relief of
Intracellular and Damage by Release of chronic pain.
membrane damage free radicals pro-apoptotic factors
Epilepsy
FIGURE 12-10. Role of glutamate receptors in excitotoxicity. Although a
multiplicity of damaging cellular processes occur as a consequence of the de- Seizures can result from overstimulation of glutamatergic
creased ATP levels that result from impaired oxidative metabolism or from the pathways, beginning with overactivation of AMPA recep-
superoxidative damage from activated neutrophils that invade an ischemic region, tors and progressing to overactivation of NMDA receptors.
only glutamate-mediated processes are depicted here. In animal models, inhibition of AMPA receptor activation
180 Principles of Central Nervous System Pharmacology

prevents seizure onset, whereas NMDA receptor antagonists

decrease seizure intensity and duration. Lamotrigine, a drug
used in the treatment of refractory focal seizures (see Chap-
Action ter 15), stabilizes the inactivated state of the voltage-gated
potential Na channel, and thereby reduces membrane excitability,
the number of action potentials in a burst, glutamate release,
Presynaptic and glutamate receptor activation. Felbamate is another an-
neuron tiepileptic that has a variety of actions, including the inhibi-
tion of NMDA receptors. Because of associated aplastic ane-
Na+ mia and hepatotoxicity, its use is restricted to patients with
refractory seizures.

Ca2+ Glu
u

Glu
G
Glu  CONCLUSION AND FUTURE DIRECTIONS
GABA and glutamate represent the major inhibitory and
excitatory neurotransmitters in the CNS, respectively. Most
drugs that act on GABAergic neurotransmission enhance
Glu GABAergic activity and thereby depress CNS functions.
Modulation of GABAergic transmission can occur either
presynaptically or postsynaptically. Drugs acting at presyn-
Glu aptic sites primarily target GABA synthesis, degradation,
Glu
and reuptake. Drugs acting postsynaptically affect GABA
Glu
Synaptic Glu receptors directly, either by occupying the GABA binding
cleft site or by an allosteric mechanism. Each of the three main
NMDA-R
NMDA-R GABA receptor types has a distinct pharmacology. The
Ca2+ AMPA-R
PLC Glu Mg2+
GABAA receptor is targeted by the largest number of drugs,
mGluR DAG Na+
including GABA binding-site agonists, benzodiazepines,
PKC 3
PIP2 (active) barbiturates, general anesthetics, and neuroactive steroids.
2
GABAB receptors are currently targeted by only a few thera-
GTP PKC Ca2+
1 peutic agents, which are used to treat spasticity. Recently,

GDP
IP3 Removal of Mg2+ GABAB receptors have been found to influence pain, cogni-
Na+
blockade of tion, and addictive behavior, and interest is growing in drugs
NMDA-R that modulate these receptors. GABAC receptors have not
Ca2+ Kinases Depolarization yet been developed as a target of pharmacologic agents.
To improve safety and reduce adverse effects, including
ataxia, tolerance, and physical dependence, development of
Postsynaptic new anxiolytics and sedatives has aimed for low-efficacy
neuron
compounds (e.g., benzodiazepines) as well as compounds
Release of retrograde messengers leading with selective activity at GABAA receptor subtypes. Ani-
to increased presynaptic transmitter release
mal models with selectively mutated GABAA receptor sub-
units have revealed that sedation/hypnosis is produced by
FIGURE 12-11. Interactions among metabotropic, AMPA, and NMDA
classes of glutamate receptors. Action potentials depolarize the plasma mem-
enhancing the activity of receptors containing 1 subunits.
brane of presynaptic neurons, leading to opening of voltage-gated Ca2 chan- In contrast, anxiolysis is produced by modulation of 2- or
nels and ultimately to glutamate release into the synaptic cleft. Studies have 3-containing receptors, and amnesia is associated with
proposed a tonic physiologic role for activation of the metabotropic glutamate 5-containing receptors. There is also evidence for distinct
receptor (mGluR) during low-frequency stimulation of postsynaptic neurons by pharmacology and physiology of synaptic GABAA receptors
glutamate. In contrast, high-frequency presynaptic stimulation phasically ac- containing different subunits.
tivates AMPA receptors (1 ) and thereby induces the prolonged membrane de- Because of the potential role of excitatory neurotransmis-
polarization required to relieve the Mg2 blockade of NMDA receptors (2 ). The sion in a number of pathologic processes, such as neurodegen-
activated, Mg2-free NMDA receptor (3 ) is then able to activate downstream erative diseases, stroke, trauma, hyperalgesia, and epilepsy,
kinases independently of the mGluR. Kinases associated with the postsynap-
glutamate receptors have become important targets for drug
tic densities, which act to scaffold the ionotropic receptors to the membrane,
phosphorylate AMPA receptor subunits and thereby cause a change in that
development. The diversity of glutamate receptors and recep-
receptors composition (not shown). AMPA-R, AMPA receptor; DAG, diacylglyc- tor subunits constitutes a potential advantage for the develop-
erol; IP3, inositol-1,4,5-trisphosphate; mGluR, metabotropic glutamate receptor; ment of glutamate receptor antagonists that are selective for
NMDA-R, NMDA receptor; PIP2, phosphatidylinositol-4,5-bisphosphate; PKC, a particular receptor subtype. In the future, highly specific
protein kinase C; PLC, phospholipase C. antagonists for glutamate receptor subtypes could potentially
protect the CNS in stroke, prevent hyperalgesia after tissue
trauma, and treat epileptic seizures.
Although neurotransmitter receptors comprise the tradi-
tional targets for drug development, recent experimental stud-
ies suggest that targeting scaffolding proteins may also be
a promising area for treatment of stroke and other diseases.
 CHAPTER 12 / Pharmacology of GABAergic and Glutamatergic Neurotransmission 181
Postsynaptic cytoskeletal proteins such as postsynaptic den-
sity protein-95 (PSD-95) comprise an important part of the
dendrite scaffolding structure, and PSD-95 mediates the intra-
cellular signaling that occurs after glutamate receptor activa-
tion. In the context of excitotoxicity, PSD-95 can amplify the
initial NMDA signal into deleterious cascades of nitric oxide
generation. Blockade of PSD-95 reduces ischemic brain injury
after experimental stroke in rats. A clinical trial testing this ap-
proach as a therapy for ischemic stroke is now ongoing.
Suggested Reading
Aarts M, Liu Y, Liu L, Besshoh S, Arundine M, Gurd JW, Wang YT, Salter
MW, Tymianski M. Treatment of ischemic brain damage by perturbing
NMDA receptor-PSD-95 protein interactions. Science 2002;298:846850.
(Scaffolding proteins as therapeutic targets for glutamate excitotoxicity and
neuropathic pain.)
Besancon E, Guo S, Lok J, Tymianski M, Lo EH. Beyond NMDA and
AMPA glutamate receptors: emerging mechanisms for ionic imbalance and
cell death in stroke. Trends Pharmacol Sci 2008;29:268275. (This review
expands on traditional concepts of excitotoxicity to include newly discov-
ered mechanisms of cell death.)
Foster AC, Kemp JA. Glutamate- and GABA-based CNS therapeutics. Curr
Opin Pharmacol 2006;6:717. (General overview of pharmacologic strate-
gies in GABAergic and glutamatergic neurotransmission.)
Herd MD, Belelli D, Lambert JJ. Neurosteroid modulation of synaptic
and extrasynaptic GABAA receptors. Pharmacol Ther 2007;116:2034.
(Reviews physiology of neurosteroids and their interactions with GABAA
receptors.)
Lo EH, Dalkara T, Moskowitz MA. Mechanisms, challenges and opportuni-
ties in stroke. Nat Rev Neurosci 2003;4:399415. (Advances in pathophysi-
ology of excitotoxicity in stroke.)
Mizuta K, Xu D, Pan Y, Comas G, Sonett JR, Zhang Y, Paettieri RA
Jr, Yang J, Emala CW Sr. GABAA receptors are expressed and facili-
tate relaxation in airway smooth muscle. Am J Physiol Lung Cell Mol
Physiol 2008;294:L1206L1216. (Points to a role for GABAA receptors
in airway tone.)
Olsen RW, Sieghart W. GABAA receptors: subtypes provide diversity
of function and pharmacology. Neuropharmacology 2008;56:141148.
(Reviews different GABAA receptor subtypes and their physiologic and
pharmacologic roles.)
13
Pharmacology of Dopaminergic
Neurotransmission
David G. Standaert and Ryan R. Walsh
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 186187
BIOCHEMISTRY AND CELL BIOLOGY OF
DOPAMINERGIC NEUROTRANSMISSION . . . . . . . . . . . . . . . 186
Dopamine Storage, Release, Reuptake, and
Inactivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Dopamine Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Central Dopamine Pathways . . . . . . . . . . . . . . . . . . . . . . 189
DOPAMINE AND CONTROL OF MOVEMENT:
PARKINSONS DISEASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Physiology of Nigrostriatal Pathways . . . . . . . . . . . . . . . . 191
Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Pharmacologic Classes and Agents . . . . . . . . . . . . . . . . . 193
Dopamine Precursors . . . . . . . . . . . . . . . . . . . . . . . . . 193
Dopamine Receptor Agonists . . . . . . . . . . . . . . . . . . . 194
 INTRODUCTION
Dopamine (DA) is a catecholamine neurotransmitter that
is the therapeutic target for a number of important central
nervous system (CNS) disorders, including Parkinsons
disease and schizophrenia. DA is also a precursor for the
other catecholamine neurotransmitters norepinephrine and
epinephrine. The machinery of catecholamine neurotrans-
mission has a number of components that are shared
among members of the class, including biosynthetic and
metabolic enzymes. There are also components that are
specialized for the individual members of the class, in-
cluding reuptake pumps and presynaptic and postsynaptic
receptors. This chapter presents the principles that under-
lie current therapies for diseases that directly or indirectly
involve changes in dopaminergic neurotransmission. The
chapter begins with a discussion of the biochemistry and
cell biology of dopaminergic neurotransmission and the
localization of the major DA systems in the brain. Follow-
ing this background, the chapter explores the physiology,
pathophysiology, and pharmacology of Parkinsons dis-
ease, which results from the specific loss of neurons in
one of these DA systems, and schizophrenia, which is cur-
rently treated, in part, with drugs that inhibit dopaminergic
neurotransmission.
186
Inhibitors of Dopamine Metabolism . . . . . . . . . . . . . . . 195
Nondopaminergic Pharmacology in
Parkinsons Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Treatment of Patients with Parkinsons
Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
DOPAMINE AND DISORDERS OF THOUGHT:
SCHIZOPHRENIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Pharmacologic Classes and Agents . . . . . . . . . . . . . . . . . 197
Typical Antipsychotic Agents . . . . . . . . . . . . . . . . . . . . 197
Atypical Antipsychotic Agents . . . . . . . . . . . . . . . . . . . 199
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 200
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
 BIOCHEMISTRY AND CELL BIOLOGY OF
DOPAMINERGIC NEUROTRANSMISSION
Dopamine belongs to the catecholamine family of neu-
rotransmitters. In addition to dopamine, this family includes
norepinephrine (NE) and epinephrine (EPI). As the name
suggests, the basic structure of the catecholamines consists
of a catechol (3,4-dihydroxybenzene) moiety connected to
an amine group by an ethyl bridge (Fig. 13-1A). Recall from
Chapter 8, Principles of Nervous System Physiology and
Pharmacology, that catecholaminergic pathways in the brain
have single source-divergent organization, in that they
arise from small clusters of catecholamine neurons that give
rise to widely divergent projections. CNS catecholamines
modulate the function of point-to-point neurotransmission
and affect complex processes such as mood, attentiveness,
and emotion.
The neutral amino acid tyrosine is the precursor for all
catecholamines (Fig. 13-1B). The majority of tyrosine is ob-
tained from the diet; a small proportion may also be synthe-
sized in the liver from phenylalanine. The first step in the
synthesis of DA is the conversion of tyrosine to L-DOPA
(L-3,4-dihydroxyphenylalanine, or levodopa) by oxidation
of the 3 position on the benzene ring. This reaction is cat-
alyzed by the enzyme tyrosine hydroxylase (TH), a ferro
188 Principles of Central Nervous System Pharmacology

A Inhibition of MAO-A, on the other hand, retards the break-

HO R down of all central and peripheral catecholamines; as noted in
Chapter 10, MAO-A inhibition may lead to life-threatening
toxicity when combined with catecholamine releasers such
HO as the indirect-acting sympathomimetic tyramine found in
Catechol nucleus
certain wines and cheeses.
Synaptic DA that is not taken up into the presynaptic cell
can either diffuse out of the synaptic cleft or be degraded by
the action of COMT. COMT is expressed in the brain, liver,
O kidney, and heart; it inactivates catecholamines by adding a
B
methyl group to the hydroxyl group at the 3 position of the
OH benzene ring. In the CNS, COMT is expressed primarily by
NH2
HO
Tyrosine Aromatic L-amino acid
transporter
Tetrahydrobiopterin Tyrosine hydroxylase
O2, Fe2+ Tyrosine
Na+
O
Tyrosine
HO
OH L-DOPA
Action potential
NH2 Dopamine
HO
L-DOPA DA
Dopaminergic
Aromatic L-amino acid neuron
Pyridoxal phosphate H+ ADP Dopamine transporter
decarboxylase ATP

HO NH2 Na+

DA
DA
Ca2+ DA
HO
H+
Dopamine VMAT DA

Ascorbic acid
Dopamine -hydroxylase Dopamine MAO
O2, Cu2+ DA
autoreceptor
DOPAC
OH

HO NH2

Synaptic
HO cleft

Norepinephrine

Phenylethanolamine
S-adenosylmethionine
N-methyltransferase Postsynaptic
dopamine receptors
OH
H Postsynaptic cell
HO N

HO
Epinephrine
FIGURE 13-1. Catecholamine synthesis. A. Catecholamines consist of a
catechol nucleus with an ethylamine side chain (R group). The R group is ethylam-
ine in dopamine, hydroxyethylamine in norepinephrine, and N-methyl hydroxyeth-
ylamine in epinephrine. B. Dopamine is synthesized from the amino acid tyrosine
in a series of step-wise reactions. In cells that contain dopamine -hydroxylase,
dopamine can be further converted to norepinephrine; in cells that also contain
phenylethanolamine N-methyltransferase, norepinephrine can be converted to
epinephrine.
FIGURE 13-2. Dopaminergic neurotransmission. Dopamine (DA) is syn-
thesized in the cytoplasm and transported into secretory vesicles by the action
of a nonselective monoamine-proton antiporter (VMAT) that is powered by the
electrochemical gradient created by a proton ATPase. Upon nerve cell stimulation,
DA is released into the synaptic cleft, where the neurotransmitter can stimulate
postsynaptic dopamine receptors and presynaptic dopamine autoreceptors. DA
is transported out of the synaptic cleft by the selective, Na-coupled dopamine
transporter (DAT). Cytoplasmic DA is re-transported into secretory vesicles by
VMAT or degraded by the enzyme monoamine oxidase (MAO).
 CHAPTER 13 / Pharmacology of Dopaminergic Neurotransmission 189

Neurotransmitter ganglia, as well as in the nucleus accumbens (see Chapter 18,

Pharmacology of Drugs of Abuse) and olfactory tubercle.
D2 receptors are also expressed at high levels on anterior pi-
HO NH2
Monoamine
tuitary gland lactotrophs, where they regulate prolactin secre-
oxidase / tion (see Chapter 26, Pharmacology of the Hypothalamus and
Aldehyde
HO
Pituitary Gland). D2 receptors are thought to play a role in
dehydrogenase Catechol-O-
(MAO / AD) methyltransferase
schizophrenia because many antipsychotic medications have
Dopamine high affinity for these receptors (see below), although the local-
(COMT)
ization of the D2 receptors involved remains to be elucidated.
D3 and D4 receptors are structurally and functionally related
HO OH O NH2 to D2 receptors and may also be involved in the pathogenesis
of schizophrenia. High levels of D3 receptors are expressed in
O the limbic system, including the nucleus accumbens and ol-
HO HO factory tubercle, while D4 receptors have been localized to the
Dihydroxyphenylacetic acid 3-Methoxytyramine frontal cortex, diencephalon, and brainstem. D5 receptors
(DOPAC) are distributed sparsely and expressed at low levels, mainly in
the hippocampus, olfactory tubercle, and hypothalamus.
COMT MAO / AD Regulation of cAMP formation is the defining characteris-
tic of the dopamine receptor classes, but dopamine receptors
O OH can also affect other aspects of cellular function depending on
their localization and linkage to second messenger systems.
O Most dopamine receptors are expressed on the surface of post-
HO synaptic neurons at dopaminergic synapses. The density of
Homovanillic acid these receptors is tightly controlled through regulated insertion
(HVA) and removal of dopamine receptor proteins from the postsyn-
aptic membrane. DA receptors are also expressed presynapti-
Major metabolite cally on the terminals of dopaminergic neurons. Presynaptic
(excreted in urine) dopamine receptors, most of which are of the D2 class, serve
as autoreceptors. These autoreceptors sense dopamine over-
FIGURE 13-3. Catecholamine metabolism. Dopamine is metabolized to flow from the synapse and reduce dopaminergic tone, both
homovanillic acid (HVA) in a series of reactions. Dopamine is oxidized to dihy- by decreasing DA synthesis in the presynaptic neuron and
droxyphenylacetic acid (DOPAC) by sequential action of the enzymes monoamine
by reducing the rate of neuronal firing and dopamine release.
oxidase (MAO) and aldehyde dehydrogenase (AD). Catechol-O-methyltransferase
(COMT) then oxidizes DOPAC to HVA. Alternatively, dopamine is methylated to
Inhibition of DA synthesis occurs through cAMP-dependent
3-methoxytyramine by COMT, and then oxidized to HVA by MAO and AD. HVA, the down-regulation of TH activity, while the inhibitory effect on
most stable dopamine metabolite, is excreted in the urine. DA release and neuronal firing is due, in part, to a separate
mechanism involving the modulation of K and Ca2 chan-
nels. Increased K channel opening results in a larger current
that hyperpolarizes the neuron, so that a larger depolarization
neurons. The sequential action of COMT and MAO degrades
is needed to reach the firing threshold. Decreased Ca2 chan-
DA to the stable metabolite homovanillic acid (HVA), which
nel opening results in decreased levels of intracellular Ca2.
is excreted in the urine (Fig. 13-3).
Because Ca2 is required for synaptic vesicle trafficking to
and fusion with the presynaptic membrane, decreases in intra-
Dopamine Receptors cellular Ca2 levels result in decreased dopamine release.
Dopamine receptors are members of the G protein-coupled
family of receptor proteins. The properties of dopamine recep-
tors were originally classified by their effect on the formation Central Dopamine Pathways
of cyclic AMP (cAMP): activation of D1 class receptors leads Most central dopaminergic neurons originate in discrete areas
to increased cAMP, while activation of D2 class receptors in- of the brain, as shown in Figure 13-6 (see also Fig. 8-8), and
hibits cAMP generation (Fig. 13-4). Subsequent studies led to have divergent projections. Three major pathways can be dis-
cloning of the receptor proteins, revealing five distinct recep- tinguished. The largest DA tract in the brain is the nigrostriatal
tors, each encoded by a separate gene. All known DA recep- system, which contains about 80% of the brains DA. This
tors have the typical structure of G protein-coupled receptors, tract projects rostrally from cell bodies in the pars compacta
with seven transmembrane domains. The D1 class contains of the substantia nigra to terminals that richly innervate the
two dopamine receptors (D1 and D5), while the D2 class con- caudate and putamen, two nuclei that are collectively called
tains three receptors (D2, D3, and D4). There are two alterna- the striatum. The striatum is named for the striped appearance
tive forms of the D2 protein, D2S (i.e., short) and D2L (i.e., of the white fiber tracts that run through it; the substantia nigra
long), which represent alternate splice variants of the same is named for the dark pigmentation that results from the de-
gene; their difference lies in the third cytoplasmic loop, which composition of DA to melanin. Dopaminergic neurons of the
affects G protein interaction but not dopamine binding. nigrostriatal system are involved in the stimulation of purpose-
The five different dopamine receptor proteins have distinct ful movement. Their degeneration results in the abnormalities
distributions in the brain (Fig. 13-5). Both D1 and D2 recep- of movement that are characteristic of Parkinsons disease.
tors are expressed at high levels in the striatum (caudate and Medial to the substantia nigra is an area of dopaminergic cell
putamen), where they play a role in motor control by the basal bodies in the midbrain called the ventral tegmental area (VTA).
190 Principles of Central Nervous System Pharmacology

D1 Receptor Family D2 Receptor Family

N N

Schematic
structure

C
C

Second cAMP (via Gs) cAMP (via Gi)

messenger PIP2 hydrolysis K+ currents
systems Ca2+ mobilization (via IP3) Voltage-gated Ca2+ currents
PKC activation

D1 D5 D2 D3 D4
Striatum Hippocampus Striatum Olfactory tubercle Frontal cortex
Distribution Neocortex Hypothalamus Substantia nigra Nucleus accumbens Medulla
in CNS Pituitary gland Hypothalamus Midbrain

FIGURE 13-4. Dopamine receptor families. The five dopamine receptor subtypes (D1D5) can be classified into two major families of receptors. The D1 receptor
family has a long C-terminal tail and a short cytoplasmic loop between transmembrane helices 5 and 6, whereas the D2 receptor family has a short C-terminal tail and
a long cytoplasmic loop between helices 5 and 6. Stimulation of the D1 family is excitatory, increasing cAMP and intracellular Ca2 levels and activating protein kinase
C (PKC). Stimulation of the D2 family is inhibitory, decreasing cAMP and intracellular Ca2 levels and hyperpolarizing the cell. The five receptor subtypes exhibit distinc-
tive patterns of distribution in the central nervous system. Within the D2 receptor subtype, there are D2S and D2L isoforms (not shown). IP3, inositol trisphosphate; PIP2,
phosphatidylinositol-4,5-bisphosphate.

The VTA has widely divergent projections that innervate many
forebrain areas, most notably the cerebral cortex, the nucleus
accumbens, and other limbic structures. These systems play an
important and complex (as yet poorly understood) role in moti-
vation, goal-directed thinking, regulation of affect, and positive
reinforcement (reward). Derangement of these pathways may
be involved in the development of schizophrenia; as discussed
below, the blocking of dopaminergic neurotransmission can
lead to a remission in psychotic symptoms. (See Chapter 18 for
a more complete discussion of the reward pathway.)
DA-containing cell bodies in the arcuate and paraventric-
ular nuclei of the hypothalamus project axons to the median

D1 D5 D2 D3 D4
Cx Cx

C C
nAc P nAc P nAc
AM AM AM
OT OT
OT OT
H H H
VTA

HIPP HIPP SN HIPP SN HIPP

FIGURE 13-5. Location of dopamine receptors in the brain. The location of the five dopamine receptor subtypes in the human brain, as determined by localization
of receptor mRNAs in corresponding regions of the rat brain, is shown in orange in coronal section. Both D1 and D2 receptors are localized in the caudate and putamen (the
striatum), nucleus accumbens, amygdala, olfactory tubercle, and hippocampus. In addition, D1 receptors are present in the cerebral cortex, whereas D2 receptors are pres-
ent in the substantia nigra, ventral tegmental area, and hypothalamus. Abbreviations: AM, amygdala; C, caudate; Cx, cerebral cortex; H, hypothalamus; HIPP, hippocampus;
nAc, nucleus accumbens; OT, olfactory tubercle; P, putamen; SN, substantia nigra; VTA, ventral tegmental area.
Hypothalamus
Area postrema
Ventral tegmental area Substantia nigra
192 Principles of Central Nervous System Pharmacology

Normal
Balanced activity of direct and indirect pathways

Motor
Glutamatergic input
cortex Putamen from cortex

D1

Direct pathway ACh

(enables movement)

D2

Caudate Indirect pathway

(inhibits movement) Dopaminergic input
from SNc

Direct Parkinson's disease

pathway Direct pathway inhibited and indirect pathway activated,
Thalamus
Putamen
both leading to reduced movement
Glutamatergic input
Indirect from cortex
pathway Putamen
STN
GPi GPe D1
Direct pathway
SNc
SNr Activity reduced, ACh
because of loss of
D1 stimulation
D2
Movement inhibited

Indirect pathway
Dopaminergic input
Activity increased,
To spinal from SNc
because of release of
motor neurons D2 inhibition
Movement inhibited

FIGURE 13-7. Effect of Parkinsons disease on dopaminergic pathways that regulate movement. Two principal pathways in the basal ganglia regulate move-
ment: the indirect pathway, which inhibits movement, and the direct pathway, which enables movement. Dopamine inhibits the indirect pathway and stimulates the
direct pathway, yielding a net bias that allows purposeful movement. Excitatory pathways are shown in blue, and inhibitory pathways are shown in black. The direct
pathway signals from putamen to GPi to thalamus to cortex, while the indirect pathway signals from putamen to GPe to STN to GPi to thalamus to cortex. GPi, internal
segment of the globus pallidus; GPe, external segment of the globus pallidus; SNc, substantia nigra pars compacta; SNr, substantia nigra pars reticulate; STN, subtha-
lamic nucleus. Inset: Both direct and indirect pathway neurons in the putamen receive inputs from the nigrostriatal dopaminergic system (dotted blue arrow) and from
cortical glutamatergic systems (solid blue arrow), process these inputs in the context of local cholinergic influences (ACh), and transmit a GABAergic output (not shown).
Degeneration of dopaminergic neurons in the substantia nigra results in understimulation of the direct (movement-enabling) pathway and underinhibition of the indirect
(movement-inhibiting) pathway. The net result is a paucity of movement. Dotted gray arrow indicates decreased activity caused by understimulation, and thick black
arrow indicates increased activity caused by underinhibition.

This model of basal ganglia function is greatly simplified,
of course, but it has been useful in developing a deeper under-
standing of how the basal ganglia work. An important predic-
tion of the model is that, in Parkinsons disease, the indirect
pathway (and, in particular, the subthalamic nucleus) should
be overactive. This prediction has been proven directly by in
vivo electrical recordings in patients with Parkinsons disease.
Furthermore, surgical therapies that target the subthalamic nu-
cleus, such as deep brain stimulation in this location, are now
often used to treat Parkinsons disease when pharmacologic
treatments are inadequate.
Pathophysiology
In Parkinsons disease, there is a selective loss of dopaminergic
neurons in the substantia nigra pars compacta (Fig. 13-7).
The extent of loss is profound, with at least 70% of the neu-
rons destroyed at the time symptoms first appear; often, 95%
of the neurons are missing at autopsy. The destruction of
these neurons results in the core motor features of the disease:
bradykinesia, or slowness of movement; rigidity, a resistance
to passive movement of the limbs; impaired postural balance,
which predisposes to falling; and a characteristic tremor when
the limbs are at rest.
The mechanisms underlying the destruction of DA neurons
in the substantia nigra in Parkinsons disease are not fully un-
derstood. Both environmental factors and genetic influences
have been implicated. In 1983, the unexpected development
of Parkinsons disease in abusers of the synthetic opioid me-
peridine (see Chapter 17, Pharmacology of Analgesia) yielded
the first agent known to produce Parkinsons disease directly
and the strongest evidence that environmental factors can
cause Parkinsons disease. These individuals, who tended to
be young and otherwise healthy, suddenly developed severe,
levodopa-responsive parkinsonian symptoms. The cases were
all linked to a single contaminated batch of meperidine that
 Periphery Brain

3-O-MD 3MT

Entacapone Tolcapone
COMT COMT
Tolcapone

LNAA AADC
L-DOPA L-DOPA DA

Selegiline
Carbidopa AADC MAOB
Rasagiline

DA DOPAC

Blood-brain barrier
 CHAPTER 13 / Pharmacology of Dopaminergic Neurotransmission 195
Dopamine receptor agonists may also trigger symptoms of
the dopamine dysregulation syndrome, in which patients
exhibit impaired impulse control. Common manifestations
include pathological gambling, overspending, compulsive
eating, and hypersexuality. These behaviors may be socially
destructive and require discontinuation of the medications.
Recent studies have examined the use of pramipexole and
ropinirole as initial monotherapy for Parkinsons disease. It
was thought that, because the dopamine agonists have longer
half-lives than levodopa, they might be less likely to induce
off periods. These studies show that use of the dopamine
receptor agonists as initial treatment for Parkinsons disease
does delay the onset of off periods and dyskinesias, but
there is also an increased rate of adverse effects compared
to initial treatment with levodopa. At present, many prac-
titioners use dopamine agonists as the initial treatment for
Parkinsons disease, especially in younger individuals.
Inhibitors of Dopamine Metabolism
A third strategy that has been employed to treat Parkinsons
disease involves the inhibition of DA breakdown. Inhibitors of
both MAO-B (the isoform of MAO that predominates in the
striatum) and COMT have been used as adjuvants to levodopa
in clinical practice (Fig. 13-8). Selegiline is an MAO inhibitor
that, in low concentrations, is selective for MAO-B. It does
not interfere with the peripheral metabolism of monoamines
by MAO-A, and it avoids the toxic effects of dietary tyramine
and other sympathomimetic amines that are associated with
nonselective MAO blockade (see Chapter 14, Pharmacology
of Serotonergic and Central Adrenergic Neurotransmission).
A drawback of selegiline is that this drug forms a potentially
toxic metabolite, amphetamine, which can cause sleeplessness
and confusion, especially in the elderly. Rasagiline, a newer
MAO-B inhibitor that does not form toxic metabolites, has
recently been approved in the United States. Both rasagiline
and selegiline improve motor function in Parkinsons disease
when used alone, and both can augment the effectiveness of
levodopa therapy. There has also been interest in the question
of whether MAO inhibitors can limit the formation of reac-
tive free radicals associated with dopamine catabolism and
thereby alter the rate of disease progression. Early studies of
the potential protective properties of selegiline were incon-
clusive. More recent studies with rasagiline have been prom-
ising but have not yet proven a disease-modifying effect.
Tolcapone and entacapone inhibit COMT and thereby
inhibit the degradation of levodopa as well as DA. Tolcapone
is a highly lipid-soluble agent that can cross the BBB, while
entacapone distributes only to the periphery. Both drugs de-
crease the peripheral metabolism of levodopa and thereby
make more levodopa available to the CNS. Tolcapone has
the additional property of crossing the blood-brain barrier ef-
fectively and inhibiting central as well as peripheral COMT.
In clinical trials, both tolcapone and entacapone have been
shown to reduce the off periods that are associated with
decreasing plasma levodopa levels. Although the central ef-
fect of tolcapone is an advantage (Fig. 13-8), there have been
several reports of fatal hepatic toxicity associated with tolca-
pone, and it must be used with great care. In practice, there-
fore, entacapone is the most widely used COMT inhibitor.
Nondopaminergic Pharmacology in Parkinsons Disease
Amantadine, trihexyphenidyl, and benztropine are all drugs
that do not clearly affect dopaminergic pathways but are
nonetheless effective in the treatment of Parkinsons disease.
Amantadine was developed and is marketed primarily as an
antiviral that reduces the length and severity of influenza A
infections (see Chapter 37, Pharmacology of Viral Infections).
In patients with Parkinsons disease, however, amantadine is
used to treat levodopa-induced dyskinesias that develop late
in the course of the disease. The mechanism by which aman-
tadine reduces dyskinesia is thought to involve blockade of
excitatory NMDA receptors. Trihexyphenidyl and benztro-
pine are muscarinic receptor antagonists that reduce cholin-
ergic tone in the CNS. They reduce tremor more than bradyki-
nesia and are therefore more effective in treating patients for
whom tremor is the major clinical manifestation of Parkin-
sons disease. These anticholinergic drugs are thought to act
by modifying the actions of striatal cholinergic interneurons,
which regulate the interactions of direct and indirect pathway
neurons. They also cause a range of anticholinergic adverse
effects, which may include dry mouth, urinary retention, and
most importantly, impairment of memory and cognition.
Treatment of Patients with Parkinsons Disease
The treatment of patients with Parkinsons disease is an in-
dividualized process that must take into account not only the
extent of symptoms but also the patients age, occupation, ac-
tivities, and perceived disabilities. There is at present no labo-
ratory test that can specifically confirm the diagnosis; instead,
diagnosis is based on history and physical examination, along
with laboratory studies to exclude other possible diagnoses.
In patients with early disease, it may be appropriate to recom-
mend a nonpharmacologic approach to treatment that empha-
sizes exercise and lifestyle modification. Almost all patients
eventually require treatment with medication. In patients with
mild symptoms, MAO-B inhibitors, amantadine, or anticho-
linergic medications may be considered. When symptoms
are more advanced, a dopaminergic therapy is indicated.
Levodopa is the most effective therapy, but many younger
patients are treated first with a dopamine agonist in the hope
of delaying the onset of motor fluctuations. Advanced dis-
ease with fluctuations requires polypharmacy, often including
levodopa, dopamine agonists, entacapone, MAO-B inhibitors,
and amantadine. It is important to be vigilant for the develop-
ment of cognitive symptoms and adverse effects, which may
require modification of the therapeutic approach.
 DOPAMINE AND DISORDERS
OF THOUGHT: SCHIZOPHRENIA
Pathophysiology
Schizophrenia is a thought disorder characterized by one or
more episodes of psychosis (impairment in reality testing).
Patients may manifest disorders of perception, thinking,
speech, emotion, and/or physical activity. Schizophrenic
symptoms are divided into two broad categories. Positive
symptoms involve the development of abnormal functions;
these symptoms include delusions (distorted or false be-
liefs and misinterpretation of perceptions), hallucinations
(abnormal perceptions, especially auditory), disorganized
speech, and catatonic behavior. Negative symptoms in-
volve the reduction or loss of normal functions; these symp-
toms include affective flattening (decrease in the range or
intensity of emotional expression), alogia (decrease in the
 CHAPTER 13 / Pharmacology of Dopaminergic Neurotransmission 197
hyperactivity is responsible for the positive symptoms of
schizophrenia. This hypothesis is supported by positron emis-
sion tomography (PET) scans of the brains of patients display-
ing the earliest signs of schizophrenia; these PET images show
changes in blood flow to the mesolimbic system that represent
changes in the level of functioning of this system. Dopaminer-
gic neurons of the mesocortical system originate in the ventral
tegmental area and project to regions of the cerebral cortex,
particularly the prefrontal cortex. Because the prefrontal cortex
is responsible for attention, planning, and motivated behavior,
the hypothesis has been advanced that the mesocortical system
plays a role in the negative symptoms of schizophrenia.
All of the evidence implicating DA in the pathogenesis
of schizophrenia is circumstantial, however, and much of it
is conflicting. Changes in DA levels, particularly in the me-
solimbic and mesocortical systems, could simply reflect
downstream consequences of a pathologic process in a hereto-
fore undiscovered pathway. One hypothesis involving such an
upstream process suggests that an imbalance in glutamatergic
neurotransmission plays an important role in schizophrenia.
This model is supported by the observation that phencyclidine
(PCP) (see Chapter 18), an antagonist at NMDA receptors,
causes symptoms similar to those of schizophrenia. In fact, the
syndrome seen in patients taking PCP chronicallyconsisting
of psychotic symptoms, visual and auditory hallucinations,
disorganized thought, blunted affect, withdrawal, psychomo-
tor retardation, and an amotivational statehas components
of both the positive and negative symptoms of schizophrenia.
Dopaminergic neurons and excitatory glutamatergic neurons
often form reciprocal synaptic connections, which could ac-
count for the efficacy of DA receptor antagonists in schizo-
phrenia. Even if this hypothesis is correct, at present, there
are no useful therapies for schizophrenia that act at glutamate
receptors. Glutamate is the primary excitatory transmitter in
the brain, and further research will be required to identify
drugs that are selective enough for use in schizophrenia and
that have an acceptable adverse effect profile.
Pharmacologic Classes and Agents
Although the biological basis of schizophrenia remains contro-
versial, a number of drugs are effective in treating the illness.
When successful, these medications can lead to a remission of
psychosis and allow the patient to integrate into society. Patients
only rarely return completely to their premorbid state, however.
D rugs used in the management of psychosis are often called
neuroleptics or antipsychotics. Although these terms are fre-
quently used interchangeably, they have slight yet important
differences in connotation. The term neuroleptic emphasizes the
drugs neurological actions that are commonly manifested as
adverse effects of treatment. These adverse effects, often called
extrapyramidal effects, result from DA receptor blockade in
the basal ganglia and include the parkinsonian symptoms of
slowness, stiffness, and tremor. The term antipsychotic denotes
the ability of these drugs to abrogate psychosis and alleviate dis-
ordered thinking in schizophrenic patients. The antipsychotics
may be further divided into typical antipsychotics, older drugs
with prominent actions at the D2 receptor, and atypical anti-
psychotics, a newer generation of drugs with less prominent D2
antagonism and consequently fewer extrapyramidal effects.
Typical Antipsychotic Agents
The history of the typical antipsychotic drugs dates back
to the approval of chlorpromazine in 1954. Approval was
based on observations of the drugs effectiveness in schizo-
phrenia, but there was little understanding of its mechanism
of action. In the 1960s, as the role of DA in the brain became
better understood, the ability of the typical antipsychotic
drugs to block dopaminergic neurotransmission in the CNS
was first elucidated. Affinity binding studies performed in
the 1980s demonstrated that both therapeutic efficacy and
extrapyramidal adverse effects of the typical antipsychotics
correlate directly with the affinity of these drugs for D2 re-
ceptors. As shown in Figure 13-9, drugs with higher affin-
ity for D2 receptors, as represented by lower dissociation
constants, tend to require smaller doses to control psychotic
symptoms and alleviate schizophrenia.
Mechanism of Action
Although the typical antipsychotics block D2 receptors in
all of the CNS dopaminergic pathways, their mechanism
of action as antipsychotics appears to involve antagonism
of mesolimbic, and possibly mesocortical, D2 receptors.
As described above, one hypothesis holds that the positive
symptoms of schizophrenia correlate with hyperactivity of
the mesolimbic system, and antagonism of mesolimbic dop-
amine receptors could alleviate these symptoms. The typical
antipsychotics are relatively less effective at controlling the
negative symptoms of schizophrenia. This relative lack of
efficacy at treating the negative symptoms could relate to
the hypothesis that the negative symptoms correlate with hy-
poactivity of mesocortical neurons, because the antagonist
action of the antipsychotics would not be expected to correct
dopaminergic hypoactivity. Many of the adverse effects of
the typical antipsychotics are likely mediated by binding of
these drugs to D2 receptors in the basal ganglia (nigrostriatal
pathway) and pituitary gland (see below).
The typical antipsychotics fall into several structural
classes, of which the most prominent are the phenothiazines
and the butyrophenones (Fig. 13-10). Chlorpromazine is
the prototypical phenothiazine, and haloperidol is the most
widely used butyrophenone. Despite differences in struc-
ture and D2 receptor affinity, all typical antipsychotics have
similar clinical efficacy at their standard doses. In general,
aliphatic phenothiazines (such as chlorpromazine) are less
potent antagonists at D2 receptors than are butyrophenones,
thioxanthenes (phenothiazines in which a nitrogen in the
phenothiazine nucleus is substituted by a carbon), or phe-
nothiazines functionalized with a piperazine derivative
(such as fluphenazine). For all of these drugs, the clinical
dose can be adjusted to account for the in vitro D2 receptor
binding affinity, so that efficacy is unaffected by potency at
clinically useful doses. However, the potency of the typical
antipsychotics is critical in determining the drugs adverse
effects profiles.
Adverse Effects
The adverse effects of typical antipsychotic drugs can be di-
vided into two broad categories: those caused by antagonist
action at dopamine D2 receptors outside the mesolimbic and
mesocortical systems (on-target effects) and those caused by
nonspecific antagonist action at other receptor types (off-target
effects). Given the broad distribution of dopamine receptors,
it is not surprising that dopamine receptor antagonists have
a wide range of on-target adverse effects. As noted above,
the most prominent of these effects are often referred to as
extrapyramidal effects. Because endogenous stimulation of
198 Principles of Central Nervous System Pharmacology
1000
Dissociation constant at D2 receptor (nM) 100
10
1.0
0.10
0.01
0.1
FIGURE 13-9. Antipsychotic potency of dopamine receptor antagonists. Over at least three orders of magnitude, the clinically effective dose of the typical anti-
psychotics is proportional to the dissociation constant of the drugs at D2 receptors. (Note that a higher dissociation constant represents a lower binding affinity.) Atypical
antipsychotics such as clozapine and remoxipride (blue diamonds) are exceptions to this rule; these agents have clinical effects at a dose lower than that predicted by
their dissociation constants. Data points represent the mean dissociation constant (averaged over multiple studies) at the most common clinically effective dose. The
dotted line represents the best fit to the data for all of the typical antipsychotics (blue circles).
dopamine D2 receptors inhibits the indirect pathway within
the basal ganglia, antagonism of D2 receptors by typical an-
tipsychotic drugs can disinhibit the indirect pathway and
thereby induce parkinsonian symptoms. Such symptoms can
sometimes be treated with the nondopaminergic therapies for
Parkinsons disease, such as amantadine and anticholinergic
drugs. Dopaminergic drugs are often ineffective because of
the high affinity of the antagonists for the D2 receptor and
because, when used in this setting, dopaminergic drugs could
cause a relapse of schizophrenic symptoms.
The most severe adverse effect of the typical antipsychotics is
the so-called neuroleptic malignant syndrome (NMS), a rare
but life-threatening syndrome characterized by catatonia, stu-
por, fever, and autonomic instability; myoglobinemia and death
occur in about 10% of these cases. NMS is most commonly
associated with the typical antipsychotic drugs that have a high
affinity for D2 receptors, such as haloperidol. It can also be seen
in patients with Parkinsons disease who abruptly discontinue
dopaminergic medications, emphasizing the importance of do-
pamine in the causation of NMS. The symptoms are thought to
arise at least in part from the actions of the antipsychotics on the
dopaminergic systems in the hypothalamus, which are essential
for the bodys ability to control temperature.
Treatment with antipsychotics and other dopamine antago-
nists can also cause abnormal movements, a condition known
as tardive dyskinesia. This condition is observed most fre-
quently after prolonged treatment with drugs that have a
high affinity for the D2 receptor, such as haloperidol. It is
Remoxipride
Clozapine
Sulpiride
Thioridazine
Prochlorperazine
Chlorpromazine
Trifluoperazine
Olanzapine Moperone
Haloperidol
Raclopride
Fluphenazine Butaclamol
Flupentixol Thiothixene
Trifluperidol Droperidol
Pimozide
Benperidol
Spiroperidol
1 10 100 1000 10000
Antipsychotic drug dose (mg/day)
occasionally seen in patients after only short-term treatment
and has been reported to occur after a single dose of a D2
receptor antagonist. The syndrome is characterized by repeti-
tive, involuntary, stereotyped movements of the facial mus-
culature, arms, and trunk. The exact mechanism is unknown,
but it is believed to involve adaptive hypersensitivity of D2
receptors in the striatum, which, in turn, results in excessive
dopaminergic activity. Antiparkinsonian drugs can exacerbate
tardive dyskinesia, and discontinuation of antiparkinsonian
drugs can ameliorate the symptoms. Administration of high
doses of high-potency typical antipsychotics can temporarily
suppress the disorder, presumably by overcoming the adap-
tive response in striatal neurons, but may in the long run lead
to worsening of symptoms. In many cases, cessation of all
typical antipsychotic medications will lead to slow reversal
of the striatal adaptations, with eventual improvement in the
symptoms of tardive dyskinesia. Some patients, however, are
left with a permanent and irreversible movement disorder.
Some adverse effects of typical antipsychotics are thought
to be caused by antagonist action at dopamine receptors
in the pituitary gland, where dopamine tonically inhibits
prolactin secretion. Antagonism of D2 receptors increases
prolactin secretion, leading to amenorrhea, galactorrhea, and
false-positive pregnancy tests in women, and to gynecomas-
tia and decreased libido in men.
Other adverse effects of the typical antipsychotics result
from nonspecific antagonism of muscarinic and -adrenergic
receptors. Antagonism of peripheral muscarinic pathways
 CHAPTER 13 / Pharmacology of Dopaminergic Neurotransmission 199

S during chronic antipsychotic use, it is considered an adverse

effect. In the acutely psychotic patient, however, sedation
may be part of the drugs intended spectrum of action.
N R2 The adverse effect profiles of the typical antipsychotics
R1 depend on their potency. High-potency drugs (whose clinical
doses are only a few milligrams) tend to have fewer sedative
Phenothiazine skeleton
effects and cause less postural hypotension than drugs with
lower potency (i.e., drugs that require high doses to achieve a
S therapeutic effect). On the other hand, lower potency typical
antipsychotics tend to cause fewer extrapyramidal adverse
effects. These observations can be rationalized by the fact
N Cl that high-potency drugs have high affinity for D2 receptors
and are therefore more selective in their action. Thus, these
N drugs are more likely to cause adverse effects mediated by
D2 receptors (i.e., extrapyramidal effects) and fewer adverse
effects mediated by muscarinic and -adrenergic receptors
Chlorpromazine
(i.e., anticholinergic effects, sedation, and postural hypoten-
S
sion). Conversely, low-potency typical antipsychotics do not
bind D2 receptors as tightly and cause fewer extrapyramidal
effects, while their lower selectivity results in more promi-
N CF3 nent anticholinergic and antiadrenergic effects.

Pharmacokinetics, Metabolism, and Drug Interactions

N
N chotics are highly lipophilic. In part because of this lipophi-
OH
Fluphenazine
S lated as oral or intramuscular dosage forms. The latter are
C R2
H R1
Thioxanthene skeleton
OH
O
N injected intramuscularly, where they are slowly hydrolyzed
F 4 weeks. These formulations are particularly useful for treat-
Haloperidol (a butyrophenone)
FIGURE 13-10. Chemical structures of the typical antipsychotics. The
structure of the phenothiazines is based on a common skeleton, with two variable
functional groups. Chlorpromazine, the first approved antipsychotic, has substi-
tuted aminopropyl (R1) and chloride (R2) side groups. Piperazine (in blue box)-
substituted phenothiazines, such as fluphenazine, are significantly more potent
than aliphatic-substituted phenothiazines, such as chlorpromazine. The fourth
structure represents the skeleton of a thioxanthene, which substitutes a carbon
(in blue box) for the phenothiazine nitrogen. As illustrated by the structure of halo-
peridol, butyrophenones (in blue box) are structurally distinct from phenothiazines
and thioxanthenes.
causes anticholinergic effects, including dry mouth, consti-
pation, difficulty urinating, and loss of accommodation (see
Chapter 9, Cholinergic Pharmacology). -Adrenergic antag-
onism can cause orthostatic hypotension and, in men, failure
to ejaculate. Sedation can also occur because of inhibition
of central -adrenergic pathways in the reticular activating
system. When sedation interferes with normal functioning
As with many drugs active in the CNS, the typical antipsy-
licity, typical antipsychotics tend to be metabolized in the
liver and to exhibit both high binding to plasma proteins and
high first-pass metabolism. The drugs are generally formu-
useful in treating acutely psychotic patients who may be a
danger to themselves or others, while the oral formulations
are generally used for chronic therapy. Elimination half-lives
of the typical antipsychotics are erratic because their kinetics
of elimination typically follow a multiphasic pattern and are
not strictly first-order. In general, however, the half-lives of
most typical antipsychotics are on the order of 1 day, and it is
common practice to follow a once-daily dosing regimen.
Two drugs, haloperidol and fluphenazine, are available
as the decanoate esters. These highly lipophilic drugs are
and released. The decanoate ester dosage forms provide a
long-acting formulation that can be administered every 3 to
ing poorly compliant patients.
Because typical antipsychotics are antagonists at dopamine
receptors, it is logical that these drugs should interact promi-
nently with antiparkinsonian drugs that act either by increasing
synaptic dopamine concentrations (levodopa) or through direct
stimulation of dopamine receptors (dopamine agonists). Anti-
psychotics inhibit the action of both of these drug classes, and
the administration of typical antipsychotics to patients with Par-
kinsons disease often leads to a marked worsening of parkin-
sonian symptoms. In addition, typical antipsychotics potentiate
the sedative effects of benzodiazepines and centrally active anti-
histamines. Because the latter are pharmacodynamic effects that
result from the nonspecific binding of typical antipsychotics to
cholinergic and adrenergic receptors, the low-potency typical
antipsychotics tend to manifest more pronounced sedative ef-
fects than their high-potency counterparts.
Atypical Antipsychotic Agents
The so-called atypical antipsychotics have efficacy and ad-
verse effect profiles that differ from those of the typical
200 Principles of Central Nervous System Pharmacology
antipsychotics. The six principal atypical antipsychotics
are risperidone, clozapine, olanzapine, quetiapine, zi-
prasidone, and aripiprazole. All of these drugs are more
effective than the typical antipsychotics at treating the
negative symptoms of schizophrenia. In addition, direct
comparisons of risperidone and haloperidol have shown
that risperidone is more effective at combating the positive
symptoms of schizophrenia and preventing a relapse of the
active phase of the disease. Atypical antipsychotics cause
significantly milder extrapyramidal symptoms than typical
antipsychotics.
The atypical antipsychotics have a relatively low affin-
ity for D2 receptors; unlike the typical antipsychotics, their
affinity for D2 receptors does not correlate with their clini-
cally effective dose (Fig. 13-9). Three main hypotheses have
emerged to explain this discrepancy. The 5-HT2 hypothesis
states that antagonist action at the serotonin 5-HT2 recep-
tor (see Chapter 14), or antagonist action at both 5-HT2 and
D2 receptors, is critical for the antipsychotic effect of the
atypical antipsychotics. This hypothesis is based on the find-
ing that the Food and Drug Administration (FDA)-approved
atypical antipsychotics are all high-affinity 5-HT2 receptor
antagonists. It is not clear, however, how 5-HT2 antagonism
contributes to the antipsychotic effect. The second model,
the D4 hypothesis, is based on the finding that many of the
atypical antipsychotics are also dopamine D4 receptor an-
tagonists. This model suggests that selective D4 antagonism,
or a combination of D2 and D4 antagonism, is critical to the
mechanism of action of the atypical antipsychotics. Quetia-
pine does not act as a D4 receptor antagonist, however, so the
D4 hypothesis cannot account for the mechanism of action
of all atypical antipsychotics. The final hypothesis states that
the atypical antipsychotics exhibit a milder adverse effect
profile because of their relatively rapid dissociation from the
D2 receptor. As described in Chapter 2, Pharmacodynamics,
the binding affinity (Kd) of a drug is equal to the ratio of its
rate of dissociation from the receptor (koff) to its rate of as-
sociation to the receptor (kon):
kon koff
DR
DR
DR
koff
Kd  Equation 13-1
kon
Because of their rapid off-rates, atypical antipsychotics bind
D2 receptors more transiently than do typical antipsychotics.
This could allow the atypical antipsychotics to inhibit the
low-level, tonic dopamine release that may occur in the me-
solimbic system. However, the drugs would be displaced by
a surge of dopamine, as would occur in the striatum during
the initiation of movement. Thus, extrapyramidal adverse ef-
fects would be minimized.
The atypical antipsychotics comprise a structurally di-
verse set of drugs. Their receptor-binding profiles also differ,
as summarized in the Drug Summary Table. As noted above,
these agents all show combined antagonist properties at do-
pamine D2 and serotonin 5-HT2 receptors, and most of the
drugs are also dopamine D4 receptor antagonists. Clozapine
has a distinct pharmacology; it binds D1D5 receptors and
5-HT2 receptors and it blocks 1-adrenergic, H1, and musca-
rinic receptors as well. Clozapine has been used therapeuti-
cally in patients who have failed other antipsychotic drugs,
whether for lack of efficacy or intolerable adverse effects.
Clozapine has not been used as a first-line agent because of a
small but significant risk of agranulocytosis (approximately
0.8% per year) and seizures. The administration of clozapine
requires frequent monitoring of white blood cell counts and
close follow-up.
Although the atypical antipsychotics are primarily ap-
proved for use in schizophrenia and other primary psychotic
disorders, they have also been used in the management of
psychosis associated with Parkinsons disease and dementia.
In Parkinsons disease, quetiapine has proved particularly
useful because it does not seem to worsen the motor fea-
tures of the disease. The atypical agents can also be used in
managing patients with dementia, although epidemiological
studies have shown that this use is associated with an in-
creased risk of stroke and cerebral vascular disease; there-
fore, the risks and benefits of the therapies in this setting
must be weighed carefully.
 CONCLUSION AND FUTURE DIRECTIONS
Treatments for both Parkinsons disease and schizophrenia
modulate dopaminergic neurotransmission in the CNS. In Par-
kinsons disease, the degeneration of dopaminergic neurons
that project to the striatum is responsible for motor symptoms,
including resting tremor, rigidity, and bradykinesia. In this
disease, the direct pathwaywhich enables movementis
understimulated, whereas the indirect pathwaywhich in-
hibits movementis disinhibited. Pharmacologic treatment
of Parkinsons disease depends on agents that increase dop-
amine release or activate dopamine receptors in the caudate
and putamen, and thereby help restore the balance between
the direct and indirect pathways.
Schizophrenia is treated by inhibiting dopamine recep-
tors at various sites in the limbic system. The pathophysiol-
ogy of schizophrenia is not fully understood, and this lack of
knowledge about etiology limits rational drug development.
The clinical effectiveness of the various antipsychotic agents
has provided useful clues, however. In particular, the phar-
macology of the typical antipsychotic agents has formed the
basis of the dopamine model of schizophrenia, which argues
that dysregulated levels of dopamine in the brain play a role
in the pathophysiology of the disease. The effectiveness of
the atypical antipsychotic agents, which affect the function
of several different receptor types, has highlighted the fact
that the dopamine hypothesis is a simplification. The atypi-
cal agents represent an attractive new modality for treating
schizophrenia because they have fewer extrapyramidal ef-
fects and are more effective for some disease symptoms than
the typical antipsychotics.
Future developments in the treatment of Parkinsons
disease and schizophrenia are focused on creating more se-
lective agents within the current drug classes and on better
elucidating the underlying pathophysiology of the disorders.
New dopamine receptor agonists with higher selectivity, par-
ticularly those that bind D1 receptors, may one day provide
more effective treatment for Parkinsons disease with less se-
vere adverse effects. The development of newer antipsychot-
ics with increased receptor selectivity may similarly expand
the therapeutic options for treating schizophrenia. Because
Parkinsons disease involves the death of dopaminergic neu-
rons, much effort is currently directed at neuroprotective
drugs that may slow the progression of the disease. Further
research into a potential role for a glutamate deficit in the
 CHAPTER 13 / Pharmacology of Dopaminergic Neurotransmission 201
pathophysiology of schizophrenia may yield new therapeu-
tics for this disorder. For example, the development of selec-
tive glutamate receptor agonists may one day complement
or even replace the use of dopamine receptor antagonists.
Another important advance in the treatment of schizophre-
nia will likely result from the elucidation of models for the
mechanism of the atypical antipsychotics, which will allow
rational development of more effective drugs.
Acknowledgment
We thank Joshua M. Galanter for his valuable contributions to
this chapter in the First and Second Editions of Principles of
Pharmacology: The Pathophysiologic Basis of Drug Therapy.
Suggested Reading
Albin RL, Young AB, Penney JB. The functional anatomy of basal ganglia
disorders. Trends Neurosci 1989;12:366375. (A classic article that describes
the concept of direct and indirect pathways.)
Farrer MJ. Genetics of Parkinson disease: paradigm shifts and future pros-
pects. Nat Rev Genet 2006;7:306318. (A review of the rapidly evolving
genetics of Parkinsons disease.)
Kellendonk C, Simpson EH, Polan HJ, et al. Transient and selective over-
expression of dopamine D2 receptors in the striatum causes persistent ab-
normalities in prefrontal cortex functioning. Neuron 2006;49:603615. (A
new mouse model for schizophrenia suggesting a role for D2 receptors in
cognitive impairment.)
Langston JW. The Parkinsons complex: parkinsonism is just the tip of the
iceberg. Ann Neurol 2006;59:591596. (A review that emphasizes the many
aspects of Parkinsons disease beyond the motor abnormalities.)
Spooren W, Riemer C, Meltzer H. NK3 receptor antagonists: the next gen-
eration of antipsychotics? Nat Rev Drug Discov 2005;4:967975. (Discusses
pathophysiologic basis of potential antipsychotic agents.)
Suchowersky O, Reich S, Perlmutter J, et al. Practice parameter: diagnosis
and prognosis of new onset Parkinson disease (an evidence-based review).
Report of the Quality Standards Subcommittee of the American Academy
of Neurology. Neurology 2006;66:968975. (This parameter, as well as
several others published in the same issue, represents the product of a care-
ful review of the evidence for the effectiveness of various treatments for
Parkinsons disease.)

Pharmacology of Serotonergic
and Central Adrenergic
Neurotransmission
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 207-208
BIOCHEMISTRY AND PHYSIOLOGY OF SEROTONERGIC
AND CENTRAL ADRENERGIC NEUROTRANSMISSION . . . . . 208
Serotonin Synthesis and Regulation . . . . . . . . . . . . . . . . . 208
Serotonin Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
PATHOPHYSIOLOGY OF AFFECTIVE DISORDERS . . . . . . . . . 211
Clinical Characteristics of Affective Disorders . . . . . . . . . . 211
The Monoamine Theory of Depression . . . . . . . . . . . . . . . 212
Limitations of the Monoamine Theory . . . . . . . . . . . . . 213
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 213
Inhibitors of Serotonin Storage . . . . . . . . . . . . . . . . . . . . . 213
Inhibitors of Serotonin Degradation . . . . . . . . . . . . . . . . . 214
Reuptake Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Tricyclic Antidepressants (TCAs) . . . . . . . . . . . . . . . . . 215
 INTRODUCTION
This chapter introduces the neurotransmitter serotonin (5-
hydroxytryptamine; 5-HT), which is the target for many of
the drugs used to treat psychiatric disorders such as depres-
sion. Many of these medications also affect norepinephrine
(NE) neurotransmission, and both neurotransmitter pathways
are believed to be central to the modulation of mood. The dif-
ferent mechanisms by which medications can alter serotonin
and norepinephrine signaling are discussed. Although many
of the drugs presented function as antidepressants, medica-
tions in this pharmacologic group are also effective treatments
for migraine headache, irritable bowel syndrome, and other
conditions. Lithium and other drugs used to treat bipolar af-
fective disorder are also briefly discussed.
The major mood disorders are defined by the presence
of depressive and/or manic episodes. Patients who have
experienced at least one manic episode, with or without an
additional history of depressive episodes, are said to have
bipolar affective disorder (BPAD); patients with recurrent
depressive episodes and no history of mania are said to have
major depressive disorder (MDD). The lifetime prevalence
14
Miles Berger and Bryan Roth
Selective Serotonin Reuptake
Inhibitors (SSRIs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Serotonin-Norepinephrine Reuptake
Inhibitors (SNRIs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Norepinephrine-Selective Reuptake
Inhibitors (NRIs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Atypical Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . 217
Serotonin Receptor Agonists . . . . . . . . . . . . . . . . . . . . . . 217
Serotonin Receptor Antagonists . . . . . . . . . . . . . . . . . . . . 217
Mood Stabilizers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Lithium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 219
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
of MDD is approximately 17%, whereas that of BPAD is
12%. There is a particularly strong heritable risk in BPAD,
even though environmental factors are often triggers for the
manic or depressive episodes. Although mania is character-
istic of BPAD, bipolar patients spend significant periods of
their lives depressed, and the mortality of the disorder de-
rives primarily from suicide. MDD can occur as an isolated
illness or can be comorbid with other diseases such as stroke,
dementia, diabetes, cancer, and coronary artery disease. Al-
though there is some genetic predisposition for MDD, stress
is a greater predictor of depressive episodes than any single
genetic variant. Aging and cerebral microvascular athero-
sclerosis are also associated with late-onset depression in
the elderly. In addition to genetic and environmental trig-
gers, many classes of drugs can exacerbate depression (e.g.,
interferon and chemotherapeutic agents).
Both MDD and BPAD are major causes of morbidity
worldwide, resulting in lost productivity and substantial use
of medical resources. Affective illnesses are associated with
a substantially increased risk of suicide. In the majority of
suicides, a physician (not necessarily a psychiatrist) will
have seen the patient less than 1 month before the suicide.
207
 CHAPTER 14 / Pharmacology of Serotonergic and Central Adrenergic Neurotransmission 209

O
For review, the synthesis of norepinephrine is summarized
A O B
in Figure 14-1B, and the metabolic cycle of norepinephrine
is summarized in Figure 14-3.
HN OH OH
For all monoamines, the first synthetic step is rate-limiting.
NH2 NH2 Thus, DA and NE synthesis is rate-limited by tyrosine
HO hydroxylase (TH), and 5-HT synthesis is rate-limited by
Tyrosine tryptophan hydroxylase (TPH). Both enzymes are tightly
Tryptophan
regulated by inhibitory feedback via autoreceptors. 5-HT
presynaptic autoreceptors respond to locally increased 5-HT
Tryptophan Tyrosine concentrations by Gi protein signaling, which decreases TPH
hydroxylase hydroxylase
activity and serotonergic neuron firing. This autoregulatory
O loop could be one explanation for the observed time course
O
of clinical action of the antidepressants, which is discussed
HN OH HO below (The Monoamine Theory of Depression).
OH
NH2 5-HT is transported into vesicles by the vesicular mono-
NH2 amine transporter (VMAT). The transporter is a nonspecific
HO monoamine transporter that is important for the vesicular
L-DOPA packaging of dopamine (DA) and epinephrine (EPI) as well as
OH 5-HT. Reserpine binds irreversibly to VMAT and thereby in-
5-Hydroxytryptophan Aromatic L-amino hibits the packaging of DA, NE, EPI, and 5-HT into vesicles.
acid decarboxylase
Selective serotonin reuptake transporters recycle 5-HT
Aromatic L-amino from the extracellular space back into the presynaptic
acid decarboxylase
HO NH2
NH2
HN
HO Aromatic L-amino acid
transporter
Dopamine
Dopamine- Tryptophan
Na+
-hydroxylase Tryptophan hydroxylase
OH Tryptophan (rate limiting)
5-Hydroxytryptamine OH
5-Hydroxytryptophan
(Serotonin; 5HT)
HO NH2 Aromatic L-amino
Action potential acid decarboxylase
CO2

HO Serotonergic 5HT Serotonin

Norepinephrine neuron H+
5HT transporter
Phenylethanolamine
N-methyltransferase VMAT
Na+
Na+

OH 5HT
5HT
H Ca2+ 5
5H
5HT
HO N 5HT

5HT

HO
Epinephrine
FIGURE 14-1. Synthesis of serotonin and norepinephrine. A. 5-
Hydroxytryptamine (serotonin) is synthesized from the amino acid tryptophan
in two steps: the hydroxylation of tryptophan to form 5-hydroxytryptophan by
tryptophan hydroxylase, and the subsequent decarboxylation of this intermediate
to produce 5-hydroxytryptamine (5-HT) by aromatic L-amino acid decarboxylase.
Tryptophan hydroxylase is the rate-limiting enzyme in this pathway. B. Norepi-
nephrine is synthesized from the amino acid tyrosine in a three-step process
similar to the synthetic pathway for serotonin. Tyrosine is first oxidized to L-DOPA
by the enzyme tyrosine hydroxylase and then decarboxylated to dopamine. After
dopamine is transported into the synaptic vesicle, it is hydroxylated by the en-
zyme dopamine -hydroxylase to form norepinephrine. The same enzyme decar-
boxylates 5-hydroxytryptophan and L-DOPA; it is known generically as aromatic
L-amino acid decarboxylase. Tyrosine hydroxylase is the rate-limiting enzyme in
this pathway.
MAO
5HT1B receptor 5HT
(autoreceptor) 5-hydroxyindole
acetaldehyde
5HT
5HT
FIGURE 14-2. Presynaptic regulation of serotonin neurotransmission.
Serotonin (5-HT) is synthesized from tryptophan in a two-reaction pathway: the
rate-limiting enzyme is tryptophan hydroxylase. Both newly synthesized 5-HT and
recycled 5-HT are transported from the cytoplasm into synaptic vesicles by the
vesicular monoamine transporter (VMAT). Neurotransmission is initiated by an ac-
tion potential in the presynaptic neuron, which eventually causes synaptic vesicles
to fuse with the plasma membrane in a Ca2-dependent manner. 5-HT is removed
from the synaptic cleft by a selective 5-HT transporter as well as by nonselective
reuptake transporters (not shown). 5-HT can stimulate 5-HT1B autoreceptors on the
presynaptic membrane to provide feedback inhibition. Cytoplasmic 5-HT is either
sequestered in synaptic vesicles by VMAT or degraded by mitochondrial monoam-
ine oxidase (MAO).
210 Principles of Central Nervous System Pharmacology

Aromatic L-amino acid space is another important degradation enzyme for monoam-
transporter
ines, although COMT plays a less significant role in the CNS
Tyrosine
than it does peripherally.
Na+

Tyrosine Serotonin Receptors

Fifteen 5-HT receptors have been characterized, and all but
L-DOPA
one are G protein-coupled (Table 14-1). In general, the 5-HT1
Action potential Dopamine class of receptors inhibits cellular activity via the Gi pathway
DA
(thus decreasing adenylyl cyclase activity and opening K
channels), the 5-HT2 class increases signaling through the
Adrenergic Gq pathway to cause phosphatidylinositol turnover, and the
neuron ATP H+ ADP NE transporter 5-HT4, 5-HT6, and 5-HT7 classes signal through the Gs path-
way to stimulate adenylyl cyclase. The only known ligand-
Na+ gated ion channel is the 5-HT3 receptor. 5-HT1A receptors are
NE expressed both on serotonergic cell bodies in the raphe nuclei
DA
Ca2+ DA
(autoreceptors) and on postsynaptic neurons in the hippocam-
NE pus and act to hyperpolarize neurons via the Gi pathway (as
H+
VMAT described above). Presynaptic 5-HT1B receptors are expressed
NE
on serotonergic nerve terminals, where they autoinhibit 5-HT
neurotransmission. 5-HT2A and 5-HT2C signaling is excit-
2 (autoreceptor) MAO
atory and lowers the threshold for neuronal firing.
adrenergic receptor NE
DOPGAL The various serotonin receptors are expressed differen-
tially throughout the brain and are differentially innervated
by raphe projections. For example, a subset of 5-HT projec-
tions to the cortex stimulates postsynaptic 5-HT2A receptors,
while other projections to the limbic system stimulate post-
FIGURE 14-3. Presynaptic regulation of norepinephrine neurotransmission. synaptic 5-HT1A receptors. There is considerable overlap of
Norepinephrine in the synaptic vesicle is derived from two sources. First, dopamine receptor subtype expression, however, and the physiologic
synthesized from tyrosine is transported into the vesicle by the vesicular monoam- significance of this overlap is unclear.
ine transporter (VMAT). Inside the vesicle, dopamine is converted to norepinephrine The signaling mechanisms of norepinephrine (adrener-
by dopamine -hydroxylase. Second, recycled NE is transported from the cytoplasm gic) receptor subtypes are discussed in Chapter 10 and re-
into the vesicle, also by VMAT. Neurotransmission is initiated by an action potential viewed in Table 14-1.
in the presynaptic neuron, which eventually causes synaptic vesicles to fuse with
the plasma membrane in a Ca2-dependent manner. NE is removed from the syn-
aptic cleft by a selective norepinephrine transporter (NET) as well as by nonselective
reuptake transporters (not shown). NE can stimulate 2-adrenergic autoreceptors
to provide feedback inhibition. Cytoplasmic NE that is not sequestered in synaptic TABLE 14-1 Signaling Mechanisms of Norepinephrine
vesicles by VMAT is instead degraded to 3,4-dihydroxyphenylglycoaldehyde (DOP- and Serotonin Receptor Subtypes
GAL) by monoamine oxidase (MAO) on the outer mitochondrial membrane.

NE RECEPTOR SUBTYPE SIGNALING MECHANISMS

neuron. Selective monoamine reuptake transporters are 12- 1 IP3, DAG

transmembranespanning proteins that couple neurotransmit-
ter transport to the transmembrane sodium gradient. Unlike 2* cAMP
VMAT, which is a nonspecific monoamine transporter, the
individual monoamine reuptake transporters show selectivity, 1,2 cAMP
high affinity, and low capacity for each individual monoam-
ine. The selective monoamine transporters, which include the
5-HT RECEPTOR SUBTYPE
serotonin transporter (SERT), norepinephrine transporter
(NET), and dopamine transporter (DAT), are also capable of
transporting the other monoamines, although less efficiently. 5-HT1A,B*,D,E,F cAMP, K channel opening
Once 5-HT is returned to the neuronal cytoplasm, the
neurotransmitter is transported into vesicles via VMAT 5-HT2A,B,C IP3, DAG
or degraded by the monoamine oxidase (MAO) system.
MAOs are mitochondrial enzymes that regulate the levels 5-HT3 Ligand-gated ion channel
of monoamines in neural tissues and inactivate circulating
and dietary monoamines (such as tyramine) in the liver and 5-HT4,6,7 cAMP
gut. The two isoforms, MAO-A and MAO-B, differ accord-
ing to substrate specificity; MAO-A oxidizes 5-HT, NE, and
Abbreviations: cAMP, cyclic AMP; DAG, diacylglycerol; IP3, inositol 1,4,
DA, and MAO-B preferentially oxidizes DA. Monoamine 5-trisphosphate.
oxidases inactivate monoamines by oxidative deamination, *2-Adrenergic and 5-HT1B are presynaptic autoreceptors important for
using a functional flavin moiety as an electron acceptor. feedback inhibition.
Catechol-O-methyltransferase (COMT) in the extracellular
214 Principles of Central Nervous System Pharmacology

Neurotransmitter Neurotransmitter Postsynaptic FIGURE 14-4. Postulated mechanism of the delay in onset of the therapeu-
Synthesis Release Effect tic effect of antidepressant medications. A. Before treatment, neurotransmitters
(NE and/or 5HT) are released at pathologically low levels and exert steady-state levels of autoin-
hibitory feedback. The net effect is an abnormally low baseline level of postsynaptic
A Before treatment
receptor activity (signaling). B. Short-term use of antidepressant medication results
in increased release of neurotransmitter and/or increased duration of neurotrans-
mitter action in the synaptic cleft. Both effects cause increased stimulation of in-
Postsynaptic hibitory autoreceptors, with increased inhibition of neurotransmitter synthesis and
receptor increased inhibition of exocytosis. The net effect is to dampen the initial effect of
the medication, and postsynaptic receptor activity remains at pretreatment levels.
C. Chronic use of antidepressant medication results in desensitization of the presyn-
aptic autoreceptors. Thus, the inhibition of neurotransmitter synthesis and exocyto-
sis is reduced. The net effect is enhanced postsynaptic receptor activity, leading to a
Low level of therapeutic response. NE, norepinephrine; 5-HT, serotonin; TCA, tricyclic antidepres-
signaling sant; SSRI, selective serotonin reuptake inhibitor; SNRI, serotonin-norepinephrine
reuptake inhibitor.

and blood pressure and can induce tremors. These drugs

have substantial potential for substance abuse; because the
Presynaptic
autoreceptor inactive prodrug lisdexamfetamine is converted relatively
NE and/or 5HT transporter
slowly to the active compound dextroamphetamine by rate-
B Acute treatment limiting hepatic metabolism, it may have less abuse potential
than other amphetamine derivatives.
Fenfluramine and dexfenfluramine are halogenated am-
phetamine derivatives that are modestly selective for 5-HT
storage vesicles. These drugs were used briefly in the United
States for appetite suppression, but severe cardiac toxicity
led to their withdrawal. Another amphetamine derivative,
methylenedioxymethamphetamine (MDMA), is both a
selective serotonin storage inhibitor and a 5-HT receptor li-
Low level of gand. It is not approved for use in medical practice but is a
signaling
significant drug clinically due to its illicit use (as Ecstasy).

Inhibitors of Serotonin Degradation

TCA, SSRI, or SNRI
C Long-term treatment
Therapeutic level
of signaling
TCA, SSRI, or SNRI
it may seem counterintuitive that a disorder such as ADHD
could be treated by drugs that increase catecholamine lev-
els, this finding makes sense in light of the differing roles
of central versus peripheral NE. In the prefrontal cortex,
increased NE promotes attention and higher cognitive pro-
cesses, while peripheral increases in NE increase heart rate
The major pathway for serotonin degradation is mediated
by MAO; accordingly, MAOIs have significant effects on
serotonergic neurotransmission. The MAOIs are classified
according to their specificity for the MAO-A and MAO-B
isoenzymes and according to the reversibility or irreversibil-
ity of their binding. The older MAOIs are nonselective, and
most older MAOIs, such as iproniazid, phenelzine, and iso-
carboxazid, are irreversible inhibitors. Newer MAOIs, such
as moclobemide, befloxatone, and brofaromine, are selec-
tive for MAO-A and bind reversibly. Selegiline, a selective
MAO-B inhibitor at low doses (see Chapter 13, Pharma-
cology of Dopaminergic Neurotransmission), also inhibits
MAO-A at higher doses.
MAOIs block the deamination of monoamines by bind-
ing to and inhibiting the functional flavin group of MAO
(Fig. 14-5). By inhibiting the degradation of monoamines,
MAOIs increase the 5-HT and NE available in the cyto-
plasm of presynaptic neurons. The increase in cytoplasmic
levels of these monoamines leads not only to increased up-
take and storage of 5-HT and NE in synaptic vesicles, but
also to some constitutive leakage of the monoamines into
the extracellular space.
As noted in Chapter 10, the most toxic adverse effect
of MAOI use is systemic tyramine toxicity. Because GI
and hepatic MAO metabolizes tyramine, consumption of
foods that contain tyramine, such as processed meats, aged
hard cheeses, and red wine, can lead to excess levels of
circulating tyramine. Tyramine is an indirect sympathomi-
metic that can stimulate the release of large amounts of
 CHAPTER 14 / Pharmacology of Serotonergic and Central Adrenergic Neurotransmission 215

A stored catecholamines by reversing the reuptake transport-

Dopamine Reserpine ers. This uncontrolled catecholamine release can induce a
DA
hypertensive crisis characterized by headache, tachycardia,
Serotonin-norepinephrine
reuptake inhibitors (SNRIs) nausea, cardiac arrhythmia, and stroke. The older MAOIs
are no longer considered first-line therapy for depression
H+ Tricyclic antidepressants
(TCAs) because of the potential for systemic tyramine toxicity;
VMAT
they should be prescribed only to patients able to commit
Na+ to a tyramine-free diet.
DA
NE The newer MAOIs (i.e., the reversible inhibitors of
MAO-A [RIMAs] that bind reversibly to MAO) are displaced
NE by high concentrations of tyramine, resulting in significantly
more tyramine metabolism and hence less tyramine toxicity.
NE
MAOI Selegiline has been approved as a transdermal patch, thus
bypassing the GI system. Transdermal selegiline can maxi-
NE mally inhibit brain MAO-A (and MAO-B) at doses that re-
DOPGAL duce gastrointestinal MAO-A activity by only 3040%, thus
reducing the risk of a tyramine-induced hypertensive crisis
and allowing patients greater dietary freedom. MAOIs, like
other antidepressants, can precipitate manic or hypomanic
episodes in some bipolar patients.
All antidepressant drugs, including MAOIs, are hydro-
phobic and cross the bloodbrain barrier. They are well ab-
Reserpine
sorbed orally and are metabolized to active metabolites by
B the liver. These metabolites are subsequently inactivated by
Serotonin-norepinephrine
Serotonin reuptake inhibitors (SNRIs) acetylation, also in the liver. Excretion is primarily via renal
Tricyclic antidepressants clearance. The older, irreversibly binding MAOIs are cleared
5HT
(TCAs) from the circulation as complexes with MAO and are effec-
H+ Selective serotonin tively inactivated only when a new enzyme is synthesized.
reuptake inhibitors (SSRIs)
VMAT Because of the extensive effects of MAOIs on cytochrome
P450 enzymes in the liver, they can cause numerous drug
Na+
drug interactions. All members of a patients medical team
5HT
5HT must prescribe other drugs with caution when a patient is
5H
5HT taking an MAOI.
5HT

5HT Reuptake Inhibitors

MAOI
5HT1B receptor 5HT
(autoreceptor) 5-hydroxyindole
acetaldehyde
5HT
5HT
FIGURE 14-5. Sites and mechanisms of action of antidepressant
drugs. The sites of action of antidepressant drugs and of reserpine (which
can induce depression) are indicated in noradrenergic neurons (A) and se-
rotonergic neurons (B). Monoamine oxidase inhibitors (MAOIs) inhibit the
mitochondrial enzyme monoamine oxidase (MAO); the resulting increase in
cytosolic monoamines leads to increased vesicular uptake of neurotransmitter
and to increased release of neurotransmitter during exocytosis. Tricyclic anti-
depressants (TCAs) and serotonin-norepinephrine reuptake inhibitors (SNRIs)
inhibit both the norepinephrine transporter (NET) and the serotonin transporter
(SERT), causing increased levels of both NE and 5-HT in the synaptic cleft.
Selective serotonin reuptake inhibitors (SSRIs) specifically inhibit the SERT-
mediated reuptake of 5-HT. TCAs, SNRIs, and SSRIs increase the duration of
neurotransmitter action in the synaptic cleft, leading to increased downstream
signaling. Reserpine, which can induce depression in humans and in animal
models, blocks the VMAT-mediated uptake of monoamines into synaptic vesi-
cles, which ultimately destroys the vesicles.
Serotonergic tone is maintained at steady state by the balance
between transmitter release and reuptake. Thus, inhibitors of
the serotonin reuptake transporter decrease the reuptake rate,
resulting in a net increase in the concentration of 5-HT in the
extracellular space. These drugs alleviate the symptoms of
a variety of common psychiatric conditions, including de-
pression, anxiety, and obsessive-compulsive disorder. Four
classes of reuptake inhibitors are in use: the nonselective tricy-
clic antidepressants (TCAs), selective serotonin reuptake
inhibitors (SSRIs), serotonin-norepinephrine reuptake in-
hibitors (SNRIs), and the newer norepinephrine-selective
reuptake inhibitors (NRIs). Each class is discussed below,
followed by a discussion of atypical antidepressants that do
not fall clearly into one of these four categories.
Tricyclic Antidepressants (TCAs)
The TCAs derive their name from their common chemical
backbone, consisting of three rings that include two aromatic
rings attached to a cycloheptane ring. The prototype TCA is
imipramine, and other members of this class include ami-
triptyline, desipramine, nortriptyline, and clomipramine
(which is a first-line agent for obsessive-compulsive disor-
der). TCAs with secondary amines preferentially affect the
NE system, whereas those with tertiary amines primarily
affect the 5-HT system. Tetracyclic antidepressants, which
include maprotiline, have also been developed, but they are
not widely used. Tetracyclic antidepressants tend to be more
selective for the NE system.
 CHAPTER 14 / Pharmacology of Serotonergic and Central Adrenergic Neurotransmission 217
approved for the treatment of depression as well as neuro-
pathic pain and other pain syndromes. Milnacipran is a selec-
tive NE and 5-HT reuptake inhibitor that has recently been
approved for the treatment of fibromyalgia, based on clinical
trials in which it improved symptoms of pain and dysphoria.
Norepinephrine-Selective Reuptake Inhibitors (NRIs)
Atomoxetine is a NE-selective reuptake inhibitor that is
used in the treatment of ADHD. It is thought to improve
ADHD symptoms by blocking NE reuptake and thereby
increasing NE levels in the prefrontal cortex. (Note that
methylphenidate and amphetamines are thought to improve
ADHD symptoms by increasing NE levels in the prefrontal
cortex via increased NE release.) Atomoxetine has several
advantages over the amphetamines, including a lower abuse/
addiction potential and a longer plasma half-life that allows
for once daily dosing. Atomoxetine increases peripheral as
well as central NE levels, and thus increases heart rate and
blood pressure.
Atypical Antidepressants
Several drugs that interact with multiple targets and are indi-
cated for the treatment of depression are sometimes referred
to as atypical antidepressants. These agents include bu-
propion, mirtazapine, nefazodone, and trazodone. They are
categorized together here only because they do not fit con-
veniently into other categories. These agents are newer than
the TCAs and act by several different mechanisms, although
some have unknown or incompletely characterized mecha-
nisms of action.
Bupropion appears to act mechanistically like the am-
phetamines and is particularly useful for the treatment of
atypical depression because it increases both serotonin and
dopamine levels in the brain. Bupropion is the antidepressant
with the fewest sexual adverse effects. It is also believed to
induce less switching into mania than the other antidepres-
sants. The principal contraindication to the use of bupropion
is a predisposition to seizures, since it lowers the seizure
threshold. Thus, bupropion is contraindicated in patients
with seizure disorders, electrolyte abnormalities, or eating
disorders (since these can cause electrolyte imbalances).
Mirtazapine blocks postsynaptic 5-HT2A and 5-HT2C
receptors and the 2-adrenergic autoreceptor, and presum-
ably decreases neurotransmission at 5-HT2 synapses while
increasing NE neurotransmission. Mirtazapine is an effec-
tive somnorific as well as an appetite stimulant, making it a
particularly useful antidepressant for the elderly population
(who often present with insomnia and weight loss) and for
other patients with weight loss and depression.
Nefazodone and trazodone also block postsynaptic
5-HT2A and 5-HT2C receptors and are discussed below.
Overall, the atypical antidepressants have relatively few
adverse effects and demonstrate similar clinical efficacies
despite their widely heterogeneous mechanisms of action
and molecular targets.
Serotonin Receptor Agonists
Ergots are naturally occurring serotonin receptor ago-
nists. Several dozen structurally similar ergots are elabo-
rated by the rye rust fungus Claviceps purpurea. Many
naturally occurring ergot alkaloids produce intense va-
soconstriction by acting as agonists of serotonin receptors
in vascular smooth muscle. This action was responsible
for ergotismdescribed during the Middle Ages as St.
Anthonys Firein which consumers of fungus-infected
grains experienced severe peripheral vasoconstriction lead-
ing to necrosis and gangrene. In modern times, a number of
ergot alkaloids have been employed clinically. The semi-
synthetic ergot lysergic acid diethylamide (LSD) produces
hallucinations and sensory dysfunction at doses as small as
50 g in humans.
5-HT receptor subtype-selective agonists have become
therapeutics of increasing interest in the past decade. These
agents are used primarily to treat anxiety and migraine
headaches. Buspirone is a nonbenzodiazepine anxiolytic
that does not bind to GABA receptors, but rather acts as a
5-HT1A-selective partial agonist. It is nonsedating with mod-
erate anxiolytic properties. Although it is often not as clini-
cally effective as a benzodiazepine, buspirone is nonetheless
attractive because it is nonaddictive, does not have abuse po-
tential, and is nonsedating.
Migraine headaches are believed to be precipitated by
cerebral vasodilation with subsequent activation of small
pain fibers. A class of selective serotonin agonists (5-HT1
agonists) has been found to be particularly effective in the
treatment of migraine headaches, presumably because of
their potent vasoconstrictive effects. Sumatriptan is the pro-
totype 5-HT1D agonist of this group, known collectively as
the triptans, which also includes rizatriptan, almotriptan,
frovatriptan, eletriptan, and zolmitriptan. The triptans, as
well as the less selective ergot alkaloid ergotamine, act on
5-HT1 receptors in the vasculature to alter intracranial blood
flow. These agents are most useful for acute migraine attacks
when taken at the onset of an episode, rather than as prophy-
laxis. They must be taken early in a migraine (ideally, at the
time of the aura) to effectively block the activation of pain
receptors. The triptans are thought to activate both 5-HT1D
and 5-HT1B receptors. In the CNS, both receptor subtypes
are present on presynaptic endings of a variety of neurons in
the vasculature.
There are relatively few 5-HT2 agonists used clini-
cally. Trazodone is a prodrug that is converted into meta-
chlorophenylpiperazine (mCPP), a selective 5-HT2A/2C
agonist used in the treatment of depression and insomnia.
Trazodone is used principally as a somnorific because the
higher doses required for antidepressant effects are usu-
ally oversedating. The ergot derivative methysergide is
a partial agonist of 5-HT2 that also has adrenergic and
muscarinic effects; this agent is no longer available in the
United States.
Serotonin and serotonin receptors are abundant in the GI
tract. Serotonin is a critical regulator of GI motility, mediated
in large part by 5-HT4 receptors. Cisapride, a 5-HT4 agonist
that also enhances acetylcholine release from the myenteric
plexus, induces gastric motility. However, cisapride has been
withdrawn in the United States due to safety concerns; it can
cause QT prolongation and cardiac arrhythmias as a conse-
quence of hERG K channel blockade.
Serotonin Receptor Antagonists
Serotonin receptor antagonists are increasingly important
therapeutics. Like many receptor ligands, these drugs show
varying degrees of receptor subtype selectivity and often
cross-react with adrenergic, histamine, and muscarinic
 CHAPTER 14 / Pharmacology of Serotonergic and Central Adrenergic Neurotransmission 219
increased lithium reabsorption in the proximal tubule and
elevation of plasma lithium concentration to toxic levels.
Lithiums inhibition of K entry into myocytes leads to
abnormalities in membrane repolarization, resulting in ab-
normal T waves seen by ECG. In addition, the transmem-
brane electrical potential is shifted because inhibition of K
entry into cells leads to extracellular hyperkalemia and intra-
cellular hypokalemia. This shift in transmembrane potential
exposes patients to a greater risk of sudden cardiac arrest
from small changes in potassium balance.
Antidiuretic hormone and thyroid-stimulating hormone both
activate adenylyl cyclase, which is inhibited by lithium. By this
mechanism, lithium treatment can also lead to nephrogenic
diabetes insipidus and to hypothyroidism and/or goiter.
Given the wide range of adverse effects that may ac-
company lithium treatment and the euphoria that may be
associated with manic or hypomanic episodes, many pa-
tients are hesitant to begin treatment. Careful serum moni-
toring and lithium dose titration can help to avoid some, if
not all, of the adverse effects discussed above, although this
requires peripheral blood draws on a regular basis. Despite
its drawbacks, lithium is the most effective agent for treat-
ing bipolar disorder. Lithium and a limited number of other
mood-stabilizing drugs (see Drug Summary Table) help to
prevent depressive episodes as well as mania, and lithium is
the only drug shown in clinical trials to reduce suicide risk
in patients with bipolar disorder.
 CONCLUSION AND FUTURE DIRECTIONS
This chapter discusses central monoamine neurotransmis-
sionprimarily serotonin pathways, but also norepineph-
rine and, to a lesser extent, dopamine pathways. Serotonin is
a critical mediator of mood and anxiety and is also involved
in the pathophysiology of migraine headache and IBS. The
focus of the chapter is on the antidepressant class of medica-
tions. The monoamine theory of depression forms an intel-
lectual framework for conceptualizing the pathophysiology
and treatment of MDD, although this theory is clearly an
oversimplification. Therapy with drugs that increase synaptic
concentrations of 5-HT and NE is effective in many cases of
MDD and forms the basis of treatment for this disorder. The
delay between initiation of treatment and onset of clinical
improvement may occur because of slow changes in presyn-
aptic autoreceptor sensitivity and/or changes in postsynaptic
neural circuitry (such as increased neurogenesis).
TCAs, SSRIs, MAOIs, and other antidepressants have
similar clinical efficacies when tested on groups of patients,
although individual patients may respond to one drug and
not to another. TCAs nonselectively inhibit 5-HT and NE
reuptake transporters (in addition to other receptors); SSRIs
selectively block 5-HT reuptake transporters; SNRIs selec-
tively block 5-HT and NE reuptake transporters; and MAOIs
inhibit the degradation of both 5-HT and NE. The choice of
antidepressant medication for an individual patient depends
on the two goals of finding an effective agent for that pa-
tient and minimizing adverse effects. The type of depressive
symptoms may suggest one treatment modality over another.
SSRIs have become the most commonly prescribed antide-
pressants because of their favorable therapeutic index and are
the first-line choice for treatment of MDD, anxiety, obses-
sive-compulsive disorder, and post-traumatic stress disorder.
BPAD is less well understood than MDD in terms of both
its pathophysiology and the mechanisms underlying effec-
tive therapies. Agents used to treat BPAD include lithium,
antiepileptics, and antipsychotics. Lithium and valproic acid
are referred to as mood stabilizers because they limit the ex-
tremes of both mania and depression; however, their mecha-
nisms of action are not well understood.
Recent advances in drug development for the treatment of
MDD have focused on a deeper understanding of the mecha-
nism of action of current drugs and the physiology of their
molecular targets. Currently approved antidepressants are
administered as racemic mixtures, and the isolation of ac-
tive stereoisomers, such as S-citalopram, may yield drugs
that are better tolerated. Pharmacogenomic approaches have
uncovered genetic variants that affect the likelihood of SSRI
treatment response. Thus, pharmacogenomics may lead to
better matching of drugs to patients by identifying patients
who are particularly likely or particularly unlikely to respond
to or tolerate a specific drug. Other drug targets beyond the
monoamine systems are also promising, including substance
P and corticotropin-releasing hormone.
Acknowledgment
We thank Mireya Nadal-Vicens, Jay H. Chyung, and Timothy
J. Turner for their valuable contributions to this chapter in
the First and Second Editions of Principles of Pharmacology:
The Pathophysiologic Basis of Drug Therapy.
Suggested Reading
Berger M, Gray J, Roth BL. The expanded biology of serotonin. Annu Rev
Med 2009;60:355366. (Broad review of serotonins role in modulating
physiologic processes.)
Krishnan V, Nestler EJ. The molecular neurobiology of depression. Nature
2008;455:894902. (Current understanding of mood disorders and targets
for new antidepressant drugs.)
Phiel CJ, Klein PS. Molecular targets of lithium action. Annu Rev Phar-
macol Toxicol 2001;41:789813. (Review of lithiums likely mechanism(s)
of action.)
Richelson E. Pharmacology of antidepressants. Mayo Clin Proc 2001;
76:511527. (Broad and thorough overview of the molecular mechanisms
and cellular targets of antidepressant medications.)
Tkachev D, Mimmack ML, Ryan MM, et al. Oligodendrocyte dysfunction
in schizophrenia and bipolar disorder. Lancet 2003;362:798805. (Research
article on BPAD.)

Pharmacology of Abnormal
Electrical Neurotransmission in
the Central Nervous System
Susannah B. Cornes, Edmund A. Griffin, Jr., and Daniel H. Lowenstein
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 225-226
PHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
PATHOPHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Pathophysiology of Focal Seizures . . . . . . . . . . . . . . . . . . 227
Pathophysiology of Secondary
Generalized Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Pathophysiology of Primary Generalized Seizures. . . . . . . 229
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 231
Drugs That Enhance Na
Channel-Mediated Inhibition . . . . . . . . . . . . . . . . . . . . . . 231
Phenytoin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Carbamazepine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Lamotrigine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
Lacosamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
 INTRODUCTION
With over 10 billion neurons and an estimated 1014 synap-
tic connections, the human brain boasts unparalleled electri-
cal complexity. Unlike myocardial tissue, where electrical
signals spread synchronously through a syncytium of cells,
proper functioning of the brain requires distinct isolation of
electrical signals and thus demands a far higher level of regu-
lation. Control of this complex function begins at the level of
the ion channel and is further maintained through the effects
of these ion channels on the activity of highly organized neu-
ronal networks. Abnormal function of ion channels and neural
networks can result in rapid, synchronous, and uncontrolled
spread of electrical activity, which is the basis of a seizure.
A seizure can present with a variety of symptoms and
result from a variety of causes. A single seizure should be
distinguished from epilepsy, which refers to the condition in
which an individual has a tendency toward recurrent seizures
(i.e., a patient who has had a single seizure does not necessar-
ily have epilepsy). Seizure symptoms vary according to the
location of seizure activity and may include prominent motor
15
Drugs That Inhibit Calcium Channels . . . . . . . . . . . . . . . . 233
Ethosuximide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Valproic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Gabapentin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Pregabalin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Drugs That Enhance GABA-Mediated Inhibition . . . . . . . . 234
Benzodiazepines (Diazepam, Lorazepam,
Midazolam, Clonazepam) . . . . . . . . . . . . . . . . . . . . . . 234
Barbiturates (Phenobarbital) . . . . . . . . . . . . . . . . . . . . 234
Vigabatrin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Drugs That Inhibit Glutamate Receptors . . . . . . . . . . . . . . 235
Felbamate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Rufinamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 235
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
symptoms and loss of consciousness (as seen in tonicclonic
seizures), paroxysmal alterations in nonmotor functions (e.g.,
sensation, olfaction, vision), or changes in higher-order func-
tions (e.g., emotion, memory, language, insight).
This chapter explores the molecular mechanisms by which
the brain maintains precise control over the spread of electri-
cal activity and how various abnormalities can undermine
these physiologic mechanisms and lead to seizures. The var-
ious classes of antiepileptic drugs are then discussed, with an
emphasis on molecular mechanisms for restoring inhibitory
function in the brain and suppressing seizure activity.
 PHYSIOLOGY
The normal human brain, in the absence of any lesions or ge-
netic abnormalities, is capable of undergoing a seizure. Acute
changes in the availability of excitatory neurotransmitters (e.g.,
caused by ingestion of the toxin domoate, which is a structural
analogue of glutamate) or changes in the effect of inhibitory
neurotransmitters (e.g., caused by injection of penicillin, a
GABAA antagonist) can result in massive seizure activity in the
225
 1 2 3
Resting state Activated state Inactivated state
(closed) (open) (closed)
Na+ Extracellular

+ + + + + +
+ + + + + +
+ + + + + +

S4 regions Intracellular
Na+

Linker
region
Membrane potential (mV)

Vr

Time (ms)
 Activated circuit
Inhibitory surround

D
B
A Focal seizure
Seizure focus

B Secondary generalized seizure

Seizure focus

Thalamus

C Primary generalized seizure

Thalamus
(seizure focus)
Membrane voltage (mV)

Tonic phase Clonic phase Postictal phase

Action potentials
0
-20
-40
-60 1 sec
-80

Sodium (AMPA-R)
Channel activity

Chloride (GABAA-R)

Calcium (NMDA-R)

Calcium (gCa)
230 Principles of Central Nervous System Pharmacology
generalized seizure emanates from central brain regions and
then spreads rapidly to both hemispheres. These seizures do
not necessarily begin with an aura (which is an important
method of clinically distinguishing primary generalized sei-
zures from focal seizures that secondarily generalize).
Currently, the best understood of the primary generalized
seizures is the absence seizure (also known as the petit mal
seizure). Absence seizures are characterized by sudden in-
terruptions in consciousness that are often accompanied by
a blank stare and occasional motor symptoms, such as rapid
blinking and lip smacking. Absence seizures are thought to
result from abnormal synchronization of thalamocortical and
cortical cells. The underlying pathophysiology of absence
seizures is based on the observation that patients experienc-
ing absence seizures have EEG readings somewhat similar
to the patterns generated during slow-wave (stage 3) sleep.
Relay neurons connecting the thalamus to the cortex exist
in two different states depending on the level of wakefulness
(Fig. 15-5A). During the awake state, these neurons function
in transmission mode, whereby incoming sensory signals
A
1. Awake 2. Slow-wave sleep
EEG
Single spikes
Thalamic
50 mV
firing
100 ms
Voltage-gated
Na+ channel activity
T-type Ca2+
channel activity
B Cerebral cortex
2 as small, desynchronized, low-voltage waves. 2. During slow-wave sleep, signals relayed
1 the T-type calcium channel during the awake state, resulting in a similar spike-and-wave
3
Thalamus
are faithfully transmitted to the cortex. During sleep, how-
ever, the transient, bursting activity of a unique, dendritic
T-type calcium channel alters incoming signals so that
output signals to the cortex have an oscillatory firing rate,
which, on an EEG, has a characteristic spike and wave
readout. In this slow-wave sleep state, sensory information
is not transmitted to the cortex.
For reasons not yet understood, absence seizures are as-
sociated with activation of the T-type calcium channel dur-
ing the awake state (Fig. 15-5B). Because this channel is
active only when the cell is hyperpolarized, several factors
can activate the channel during the awake state. These fac-
tors include an increase in intracellular K, an increase in
GABAergic input from the reticular nucleus, or a loss of
excitatory input. A variety of studies have shown that the ac-
tivity of the T-type calcium channel in the relay neurons is es-
sential to the 3-per-second spike-and-wave activity observed
in absence seizures. Because of its important pathophysio-
logic role, the T-type calcium channel is a primary target in
the pharmacologic treatment of absence seizures.
3. Typical absence seizure (EEG)
Bursts
50 mV
100 ms
FIGURE 15-5. Mechanism of absence seizure. A. EEG recordings of patients expe-
riencing absence seizures are similar to sleep spindle patterns generated during slow-
wave sleep. The 3-per-second oscillatory pattern is generated by the burst activity of a
dendritic T-type calcium channel in the thalamus. 1. During the awake state, relay neu-
rons of the thalamus are in transmission mode, in which incoming signals are faithfully
transmitted to the cortex as single spikes. These signals to the cortex register on the EEG
through the thalamus are altered because of the bursting activity of a dendritic T-type
calcium channel (see below). During this stage, called burst mode, sensory information
is not transmitted to the cortex. 3. Absence seizures result from abnormal activation of
EEG pattern. B. The absence seizure is generated by a self-sustaining cycle of activity
between the thalamus and the cortex. Synchronicity is initiated by hyperpolarization of
the thalamic relay neurons (white). This occurs normally during slow-wave sleep and is
caused by GABAergic input from the reticular thalamic nucleus (purple). The factors that
cause hyperpolarization in relay neurons during an absence seizure are poorly under-
stood. 1. Hyperpolarization of relay neurons induces burst activity of the T-type calcium
channel, resulting in synchronous depolarization in the cortex via excitatory connections.
This large depolarization in the cortex registers as a spike-and-wave pattern on the EEG.
2. Excitatory input from the cortex (light yellow) activates the reticular thalamic neurons
(dark yellow). 3. The activated GABAergic reticular neurons hyperpolarize the thalamic
relay neurons and reinitiate the cycle.
 CHAPTER 15 / Abnormal Electrical Neurotransmission in the Central Nervous System 231
 PHARMACOLOGIC CLASSES
AND AGENTS
The current approach to treating a patient with epilepsy de-
pends in part on the type of seizure(s) experienced by the
patient. An appropriate antiepileptic drug regimen will take
into account whether a patient is having focal seizures, with
or without secondary generalization, or primary generalized
seizures. In addition, for patients with focal seizures, there is
also an attempt to determine whether the seizures are caused
by an identifiable focal lesion that can be removed surgically
or ablated by other means.
Mechanistically, the efficacy of antiepileptic drugs (AEDs)
centers on manipulation of ion channel activity. As discussed
above, physiologic protection against repetitive firing oc-
curs via inhibition at two levels: the cellular level (e.g., Na
channel inactivation), and the network level (e.g., GABA-
mediated inhibition). Accordingly, currently available AEDs
fall into four main categories: (1) drugs that enhance Na
channel-mediated inhibition, (2) drugs that inhibit calcium
channels, (3) drugs that enhance GABA-mediated inhibition,
and (4) drugs that inhibit glutamate receptors.
Although AEDs fall into several different mechanistic
classes, it is important to keep in mind that the therapeutic
efficacy of many of the AEDs is only partially explained by
the known mechanisms described below, primarily because
the AEDs act pleiotropically. Valproic acid, for example, sta-
bilizes Na channels, but the drug also has an effect on T-type
calcium channels and may have effects on GABA metabo-
lism as well. Thus, although in vitro studies may suggest that
a drug is best suited for the treatment of one particular type
of seizure, other seizure types may also respond to the drug.
(One benefit of this pleiotropy is that many of the drugs are
interchangeable, to the extent that minimization of adverse ef-
fects is often the main clinical criterion underlying the choice
of AED.) The classification below is shown only for simplic-
ity and is based on the primary target of the drug. A list of the
main drugs discussed here and their multiple mechanisms of
action is provided in Table 15-2.
Drugs That Enhance Na Channel-Mediated
Inhibition
Each neuron in the brain is equipped with the machinery to
prevent rapid, repetitive firing. As discussed above, depolar-
ization of the neuronal membrane results in sodium channel in-
activation. This inactivation of the Na channel provides a key
checkpoint in the prevention of repetitive firing within a po-
tential seizure focus. The AEDs phenytoin, carbamazepine,
lamotrigine, lacosamide, and valproic acid act directly on
the Na channel (Fig. 15-6A) to increase channel inactivation,
thereby enhancing inhibition at the single-cell level.
In general, antiepileptic drugs that act on Na channels
show strong specificity for the treatment of focal and second-
ary generalized seizures. This is consistent with their molecu-
lar profile. The Na channel blockers act in a use-dependent
manner, much like the action of lidocaine on peripheral nerves
(see Chapter 11, Local Anesthetic Pharmacology). Thus, neu-
rons that fire rapidly are particularly susceptible to inhibition
by this class of drug. Conversely, many Na channel blockers
(particularly those that act only at the Na channel, such as phe-
nytoin) have little effect on absence seizures. Presumably, the
thalamocortical cells activated during an absence seizure have
a slow firing rate, such that Na channel blockers do not have a
use-dependent effect on the Na channels in these cells.
Phenytoin
Phenytoin acts directly on the Na channel to slow the rate of
channel recovery from the inactivated state to the closed state.
As described above, the Na channel exists in three confor-
mationsclosed, open, and inactivatedand the probability
of a channel existing in each state depends on the membrane
potential (Fig. 15-1; see also Fig. 11-7). By slowing the rate of
recovery from the inactivated state to the closed state, pheny-
toin increases the threshold for action potentials and prevents
repetitive firing. This has the effect of stabilizing the seizure
focus by preventing the paroxysmal depolarizing shift (PDS)
that initiates the focal seizure. In addition, phenytoin prevents
the rapid spread of seizure activity to other neurons, account-
ing for its efficacy in secondarily generalized seizures.
Importantly, phenytoin targets Na channels in a use-
dependent manner (see Fig. 11-8). Thus, only channels that
are opened and closed at high frequency (i.e., those involved
in the PDS) are likely to be inhibited. This use-dependency
lessens the effects of phenytoin on spontaneous neuronal ac-
tivity and avoids many of the adverse effects observed with
GABAA potentiators (which are not use-dependent).
Because of its use-dependent blockade, as well as its abil-
ity to prevent sudden rapid firing, phenytoin is a major drug
of choice for focal seizures and tonicclonic seizures. It is
not used in absence seizures. The complex pharmacokinetics
and drug interactions of phenytoin play a decisive role in the
choice between phenytoin and similarly acting drugs such as
carbamazepine.
Phenytoin is more than 95% bound to plasma albumin. Phe-
nytoin is inactivated by metabolism in the liver and, at typi-
cal doses, has a plasma half-life of about 24 hours. Phenytoin
metabolism shows properties of saturation kinetics, whereby
small increases in dose can cause large and often unpredictable
increases in plasma drug concentration (see Chapter 3, Pharma-
cokinetics). These increases in plasma phenytoin concentration
increase the risk of adverse effects, including ataxia, nystagmus,
incoordination, confusion, gingival hyperplasia, megaloblastic
anemia, hirsutism, facial coarsening, and a systemic skin rash.
Phenytoin inactivation by the hepatic microsomal P450 en-
zyme system is susceptible to alteration by several drugs. Drugs
that inhibit the P450 system, such as chloramphenicol, cimeti-
dine, disulfiram, and isoniazid, increase phenytoin plasma con-
centration. Carbamazepine, an antiepileptic drug that induces
the hepatic P450 system, increases the metabolism of phenytoin,
thereby lowering phenytoin plasma concentration when these
drugs are used concurrently. Similarly, phenytoin, because of
its ability to induce the hepatic P450 system, increases the me-
tabolism of drugs that are inactivated by this system. Some of
these drugs include oral contraceptives, quinidine, doxycycline,
cyclosporine, methadone, and levodopa.
Carbamazepine
Although structurally unrelated to phenytoin, carbamazepine
appears to exert its antiseizure activity in a manner similar to
phenytoin. That is, carbamazepine is a Na channel blocker
that slows the rate of recovery of Na channels from the in-
activated state to the closed state. This has the effect of sup-
pressing a seizure focus (by preventing the PDS) as well as
preventing rapid spread of activity from the seizure focus.
A metabolite of carbamazepine, 10,11-epoxycarbamazepine,
 CHAPTER 15 / Abnormal Electrical Neurotransmission in the Central Nervous System 233

Seizure focus

Drug
treatment Action potentials
(transmission
1 inhibited)
3

Loss of inhibitory
surround Barbiturate or

+
+
+
Felbamate benzodiazepine
Cl-
NMDA-R

+
+
+
2 (closed) Phenytoin,
GABAA
carbamazepine, Voltage-gated
channel
Gabapentin
(open)
or lamotrigine Na+ channel
HVA Ca2+ channel (inactivated)
(closed)

Cl-
B Benzodiazepine GABAA channel
(clonazepam) (open)

Ethosuximide or
1 valproic acid
T-type Ca2+
Thalamus channel
(seizure focus) (blocked)

2 3

FIGURE 15-6. Mechanisms of pharmacotherapy for seizures. A. The focal seizure (1) results from rapid, uncontrolled neuronal firing and a loss of surround inhibi-
tion (2). Antiepileptic drugs act at four molecular targets to enhance inhibition and prevent spread of synchronous activity (3). Barbiturates and benzodiazepines prevent
seizure spread by acting on the GABAA receptor to potentiate GABA-mediated inhibition. Na channel inhibitors such as phenytoin, carbamazepine, and lamotrigine prevent
rapid neuronal firing by selectively prolonging Na channel inactivation in rapidly firing neurons (see Figs. 11-7 and 11-8). Felbamate suppresses seizure activity by inhibit-
ing the NMDA receptor and thereby decreasing glutamate-mediated excitation. Gabapentin decreases release of excitatory neurotransmitter by inhibiting the high-voltage-
activated (HVA) calcium channel. B. The absence seizure (1) is caused by a self-sustaining cycle of activity generated between thalamic and cortical cells (2). Antiepileptic
drugs prevent this synchronous thalamocortical cycle (3) by acting at two molecular targets. Clonazepam, a benzodiazepine, potentiates GABAA channels in the reticular
thalamic nucleus, thus decreasing the activation of the inhibitory reticular neurons and decreasing the hyperpolarization of the thalamic relay neurons. T-type calcium
channel inhibitors such as ethosuximide and valproic acid prevent the burst activity of thalamic relay neurons that is required for synchronous activation of cortical cells.

lacosamide over other effective sodium-modulating agents,
and early data suggest that the therapeutic window may be
limited by dose-dependent adverse effects. At the least, lacos-
amide provides another medication option for patients with
drug-resistant epilepsy.
Drugs That Inhibit Calcium Channels
Drugs used to treat epilepsy through inhibition of calcium
channels fall into two main classes: those that inhibit the T-
type calcium channel and those that inhibit the high-voltage-
activated (HVA) calcium channel.
The T-type calcium channel is depolarized and inactive
during the awake state (Fig. 15-5B). In absence (petit mal)
seizures, paroxysmal hyperpolarization is thought to activate
the channel during the awake state, initiating the spike and
wave discharges characteristic of this seizure type. Thus,
drugs inhibiting the T-type calcium channel are specifically
used to treat absence seizures.
HVA calcium channels play an important role in control-
ling the entry of calcium into the presynaptic terminal and
therefore help to regulate neurotransmitter release. The HVA
calcium channel is formed by an 1 protein that assembles
into the channel pore, and it has several auxiliary subunits.
Drugs that inhibit HVA calcium channels tend to have pleio-
tropic effects; although they are used primarily for focal sei-
zures with or without secondary generalization, they can also
be used for generalized seizures other than absence seizures.
234 Principles of Central Nervous System Pharmacology
Ethosuximide
In vitro, ethosuximide has a highly specific molecular pro-
file. In experiments on thalamocortical preparations from rats
and hamsters, ethosuximide has been shown to reduce low-
threshold T-type currents in a voltage-dependent manner.
This inhibition occurs without altering the voltage depen-
dence or recovery kinetics of the Na channel. Ethosuximide
does not have any effect on GABA-mediated inhibition.
Ethosuximide is often the first-line therapy for uncomplicated
absence seizures. Consistent with its molecular profile as a spe-
cific T-type Ca2 channel blocker, ethosuximide is not effective
in the treatment of focal or secondary generalized seizures.
Valproic Acid
As is the case for many other AEDs, valproic acid acts pleio-
tropically in vitro. Similar to phenytoin and carbamazepine,
valproic acid slows the rate of Na channel recovery from
the inactivated state. At slightly higher concentrations than
those necessary to limit repetitive firing, valproic acid has
also been shown to limit the activity of the low-threshold
T-type calcium channel.
A third proposed mechanism of valproic acid action oc-
curs at the level of GABA metabolism. In vitro, valproic acid
increases the activity of glutamic acid decarboxylase, the en-
zyme responsible for GABA synthesis, while it inhibits the
activity of enzymes that degrade GABA. Taken together, these
effects are thought to increase the availability of GABA in the
synapse and thereby to increase GABA-mediated inhibition.
Perhaps because of its many potential sites of action, val-
proic acid is one of the most effective antiepileptic drugs
for the treatment of patients with generalized epilepsy syn-
dromes having mixed seizure types. Valproic acid is also
the drug of choice for patients with idiopathic generalized
seizures and is used for the treatment of absence seizures
that do not respond to ethosuximide. Valproic acid is also
commonly used as an alternative to phenytoin and carba-
mazepine for the treatment of focal seizures.
Gabapentin
Gabapentin was one of the first AEDs developed using
the concept of rational drug design. That is, with the rec-
ognition that GABA receptors play an important role in the
control of seizure spread, gabapentin was synthesized as a
structural analogue of GABA and was predicted to enhance
GABA-mediated inhibition. Consistent with this hypothesis,
gabapentin has been shown to increase the content of GABA
in neurons and glial cells in vitro. However, the main antisei-
zure effect of gabapentin appears to be through its inhibition
of HVA calcium channels, which results in decreased neu-
rotransmitter release. A main advantage of gabapentin is that,
because its structure is similar to that of endogenous amino
acids, it has few interactions with other drugs. On the other
hand, gabapentin does not appear to be as effective as the
other AEDs, and it is not generally used as a first-line agent.
Pregabalin
Like gabapentin, pregabalin is structurally related to GABA,
but it exerts its main therapeutic effect through inhibition
of HVA calcium channels, reducing the release of several
neurotransmitters including glutamate and norepinephrine.
It also has effects on substance P and calcitonin, which may
contribute to its varied clinical uses. More potent than gaba-
pentin, pregabalin is a reasonable adjunctive treatment for
focal seizures. It is particularly useful in patients with he-
patic dysfunction, since it is metabolized in the kidney and
has few drugdrug interactions.
Drugs That Enhance GABA-Mediated Inhibition
In contrast to Na channel blockers and calcium channel in-
hibitors, whose mechanistic properties correlate well with their
clinical activity, the enhancers of GABA-mediated inhibition
have more varied effects and tend not to be as interchangeable.
This is largely because of the diversity of GABAA receptors in
the brain. The GABAA receptor channel has five subunits, with
at least two alternative splice variants of several of the subunits
(see Chapter 12). There are at least 10 known subtypes of the
GABAA receptor, with varying distributions of these subtypes
throughout the brain. Barbiturates and benzodiazepines both
increase Cl influx through GABAA channels, but benzodiaz-
epines act on a specific subset of GABAA channels, whereas
barbiturates appear to act on all GABAA channels. The recently
approved medication vigabatrin enhances GABA-mediated
activity indirectly via inhibition of GABA metabolism. These
different mechanisms of action result in distinct clinical profiles.
Drugs that nonspecifically increase GABA content (e.g., through
enhancement of synthetic pathways or reduced metabolism of
GABA) tend to have a profile similar to the barbiturates.
Benzodiazepines (Diazepam, Lorazepam,
Midazolam, Clonazepam)
Benzodiazepines increase the affinity of GABA for the
GABAA receptor and enhance GABAA channel gating in the
presence of GABA, and thereby increase Cl influx through
the channel (see Chapter 12). This action has the dual effect
of suppressing the seizure focus (by raising the threshold of
the action potential) and strengthening surround inhibition.
Thus, benzodiazepines such as diazepam, lorazepam, and
midazolam are well suited for the treatment of focal and
tonicclonic seizures. The benzodiazepines cause prominent
adverse effects, however, including dizziness, ataxia, and
drowsiness. Thus, these drugs are typically used only to ab-
late seizures acutely.
Clonazepam is unique among the benzodiazepines in
its ability to inhibit T-type Ca2 channel currents in in vitro
preparations of thalamocortical circuits. In vivo, clonazepam
acts specifically at GABAA receptors in the reticular nucleus
(Fig. 15-5B), augmenting inhibition in these neurons and essen-
tially turning off the nucleus. By this action, clonazepam pre-
vents GABA-mediated hyperpolarization of the thalamus and
thereby indirectly inactivates the T-type Ca2 channel, which
is the channel thought to be responsible for generating absence
seizures (see above). However, as with diazepam, clonazepam
use is limited because of its extensive adverse effects. Clo-
nazepam is the fourth drug of choice in the treatment of absence
seizures, after ethosuximide, valproic acid, and lamotrigine.
Barbiturates (Phenobarbital)
Phenobarbital binds to an allosteric site on the GABAA
receptor and thereby potentiates the action of endogenous
GABA by increasing the duration of Cl channel opening.
In the presence of phenobarbital, there is a much greater
influx of Cl ions for each activation of the channel (see
Chapter 12). Barbiturates also display weak agonist activity
at the GABAA channel, perhaps furthering the ability of this
drug to increase Cl influx. This enhancement of GABA-
mediated inhibition, similar to that of the benzodiazepines,
 CHAPTER 15 / Abnormal Electrical Neurotransmission in the Central Nervous System 235
may explain the effectiveness of phenobarbital in the treat-
ment of focal seizures and tonicclonic seizures.
In contrast to the benzodiazepines, which are sometimes
useful in treating the spike-and-wave discharges of the ab-
sence seizure, the barbiturates may actually exacerbate this
type of seizure. This exacerbation may be caused by two fac-
tors. First, barbiturates act at all GABAA receptors. Unlike
benzodiazepines, which selectively augment GABA inhibi-
tion in the reticular nucleus, barbiturates potentiate GABAA
receptors in both the reticular nucleus and the thalamic relay
cells. Importantly, the latter effect enhances the T-type cal-
cium currents that are responsible for the absence seizure
(Fig. 15-5B). Second, unlike benzodiazepines, which are
purely allosteric enhancers of endogenous GABA activity,
barbiturates can also act on the GABAA channel in the ab-
sence of the native ligand. The latter property may function
to increase nonspecific activity of the barbiturates.
Phenobarbital is used primarily as an alternative drug in
the treatment of focal seizures and tonicclonic seizures.
Because of the pronounced sedative effects of this drug, its
clinical use has been decreasing as more effective antiepi-
leptic medications have become available.
Vigabatrin
Vigabatrin is a structural analogue of GABA that irreversibly
inhibits the enzyme GABA transaminase, thereby increasing
levels of GABA in the brain (see Fig. 12-2). Serious adverse
effects, most notably peripheral visual field defects, limit
the clinical utility of vigabatrin. The drug is generally used
for infantile spasms and refractory focal epilepsy, and any
patient treated with vigabatrin should undergo baseline and
routine visual field testing.
Drugs That Inhibit Glutamate Receptors
Glutamate is the principal excitatory neurotransmitter of the
CNS (see Chapter 12). Not surprisingly, excessive activa-
tion of excitatory glutamatergic synapses is a key component
of many forms of seizure activity. Numerous studies using
animal models have shown that inhibition of the NMDA
and AMPA subtypes of glutamate receptors can inhibit the
generation of seizure activity and protect neurons from sei-
zure-induced injury. However, none of the specific and po-
tent glutamate receptor antagonists have been routinely used
clinically for the treatment of seizures because of unaccept-
able behavioral adverse effects.
Felbamate
Felbamate has a variety of actions, including the inhibition
of NMDA receptors. It appears to have some selectivity for
NMDA receptors that include the NR2B subunit. Because
this receptor subunit is not expressed ubiquitously through-
out the brain, NMDA receptor antagonism by felbamate is
not as widespread as that with other NMDA antagonists. This
relative selectivity may explain why felbamate lacks the be-
havioral adverse effects observed with the other agents. Ben-
efits of felbamate include its potency as an antiepileptic drug
and its lack of the sedative effects common to many other
antiepileptic drugs. However, felbamate has been associated
with a number of cases of fatal aplastic anemia and liver fail-
ure, and its use is now restricted primarily to patients with
refractory epilepsy.
Rufinamide
Rufinamide is a recently approved drug for the treatment of
focal seizures and drop attacks in Lennox-Gastaut syndrome
(a syndrome characterized by childhood onset of frequent
and sometimes refractory seizures). While rufinamide acts
predominantly by prolonging sodium channel inactivation, it
is structurally unrelated to the other antiepileptic agents with
this mechanism of action. At higher doses, it may have an
inhibitory effect on a subset of glutamate receptors (mGluR5
subtype), and it is included here based on that secondary
mechanism and because its clinical profile is most similar
to felbamate. Unlike felbamate, however, rufinamide has not
been demonstrated to have any serious adverse effects, and
it may provide an alternative option for patients with refrac-
tory epilepsy.
 CONCLUSION AND FUTURE DIRECTIONS
In recent years, improved understanding of the physiology
and pathophysiology of neuronal signaling in the CNS has
led to a more thorough understanding of the current antiepi-
leptic drugs (AEDs), as well as the design and discovery of
novel agents. Under physiologic conditions, Na channel in-
activation and GABA-mediated surround inhibition prevent
uncontrolled, rapid spread of electrical activity. There are,
however, numerous potential alterations in the brain that can
weaken these inhibitory forces, such as damage and degen-
eration of GABAergic neurons, abnormal ion gradients in-
duced by space-occupying lesions, and gene mutations that
alter channel function.
The AEDs described in this chapter restore the inherent
inhibitory capacity of the brain. These include drugs such
as phenytoin, which increases Na channel inactivation,
and clonazepam, which enhances GABA-mediated inhibi-
tion. Newer classes of AEDs extend this repertoire by acting
through modulation of the Ca2 channel required for neu-
rotransmitter release and modulation of excitatory receptors
such as the NMDA receptor.
Despite increased understanding of the mechanisms of
certain seizure types, the efficacy of many of the antiepi-
leptics is only partially explained by their known molecular
profiles. Hence, current decisions about therapy are often
driven by empirical example rather than by known molecu-
lar mechanisms. As a better understanding is gained of the
role of genetics in not only simple inherited epilepsy but in
complicated polygenic cases, the application of a more ratio-
nal, mechanism-based pharmacology will become increas-
ingly possible.
Suggested Reading
Lowenstein DH. Seizures and epilepsy. In: Harrisons principles of internal
medicine. 17th ed. New York: McGraw Hill; 2008. (Discussion of seizure
pathophysiology and extensive discussion of clinical uses of antiepileptic
drugs.)
Shorvon S. Drug treatment of epilepsy in the century of the ILAE: the sec-
ond 50 years, 19592009. Epilepsia 2009;50(Suppl 3):93130. (An historical
perspective cataloging the introduction of each therapeutic agent over time.)
Westbrook GL. Seizures and epilepsy. In: Kandel ER, Schwartz JH, Jes-
sell TM, eds. Principles of neural science. 4th ed. New York: McGraw-
Hill; 2000. (Detailed description of normal electrical signaling and seizure
pathophysiology.)
16
General Anesthetic
Pharmacology
Jacob Wouden and Keith W. Miller
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 240-241
PHARMACODYNAMICS OF INHALED ANESTHETICS . . . . . . 240
The Minimum Alveolar Concentration (MAC). . . . . . . . . . . 241
Therapeutic and Analgesic Indices . . . . . . . . . . . . . . . . . . 241
The MeyerOverton Rule . . . . . . . . . . . . . . . . . . . . . . . . . 242
PHARMACOKINETICS OF INHALED ANESTHETICS . . . . . . . 244
Concepts from Respiratory Physiology . . . . . . . . . . . . . . . 245
Local Equilibration . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Global Equilibration . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
The Uptake Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Equilibration of Alveolar with
Inspired Partial Pressure . . . . . . . . . . . . . . . . . . . . . . . 246
Equilibration of Tissue with
Alveolar Partial Pressure . . . . . . . . . . . . . . . . . . . . . . . 247
The Rate-Limiting Step . . . . . . . . . . . . . . . . . . . . . . . . 249
Applications of the Uptake Model . . . . . . . . . . . . . . . . . . . 250
Effects of Changes in Ventilation . . . . . . . . . . . . . . . . . 251
Effects of Changes in Cardiac Output . . . . . . . . . . . . . 251
Effects of Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
 INTRODUCTION
Before the discovery of general anesthetics, pain and shock
severely limited the possibilities for surgical intervention.
Postoperative mortality dropped dramatically following the
first public demonstration of diethyl ether at Massachusetts
General Hospital in 1846. Since then, the administration of
agents for the induction and maintenance of anesthesia has
become a separate medical specialty. The modern anesthesi-
ologist is responsible for all aspects of patient health during
surgery. As part of this process, the anesthesiologist controls
the depth of anesthesia and maintains homeostatic equilib-
rium with an arsenal of inhaled and intravenous anesthetics
as well as many adjuvant drugs.
General anesthetics induce a generalized, reversible de-
pression of the central nervous system (CNS). Under general
anesthesia, there is a lack of perception of all sensations. The
anesthetic state includes loss of consciousness, amnesia, and
immobility (a lack of response to noxious stimuli), but not
necessarily complete analgesia. Other desirable effects pro-
vided by anesthetics or adjuvants during surgery may include
240
Effects of Abnormal States . . . . . . . . . . . . . . . . . . . . . 252
Control of Induction. . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
PHARMACOLOGY OF GENERAL ANESTHETICS
AND ADJUVANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Inhaled Anesthetic Agents . . . . . . . . . . . . . . . . . . . . . . . . 254
Intravenous Anesthetic Agents . . . . . . . . . . . . . . . . . . . . . 255
Adjuvant Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Balanced Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
MECHANISM OF ACTION OF GENERAL ANESTHETICS . . . . 256
The MeyerOverton Rule and the Lipid
Solubility Hypothesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
Effects on Ion Channels . . . . . . . . . . . . . . . . . . . . . . . . . . 257
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 258
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
APPENDIX A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
APPENDIX B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
muscle relaxation, loss of autonomic reflexes, analgesia, and
anxiolysis. All of these effects facilitate safe and painless
completion of the procedure; some effects are more important
in certain types of surgery than others. For example, abdomi-
nal surgery necessitates near complete relaxation of the ab-
dominal muscles, whereas neurosurgery often requires light
anesthesia that may be lifted rapidly when the neurosurgeon
needs to judge the patients ability to respond to commands.
This chapter provides a framework for understanding the
pharmacodynamics and pharmacokinetics of general anes-
thetics in the context of physiologic and pathophysiologic
variables. After discussing the pharmacology of specific
agents and how a balanced anesthetic approach is achieved,
the chapter considers what is currently known about the
mechanism of action of general anesthetics.
 PHARMACODYNAMICS OF INHALED
ANESTHETICS
General anesthetics distribute well to all parts of the body,
becoming most concentrated in the fatty tissues. The CNS
 Awake Awake

Stage I: Analgesia

Analgesia (depends on agent)

Recovery from anesthesia

Amnesia
Deepening anesthesia

Euphoria

Stage II: Excitement

Excitement
Delirium
Combative behavior

Stage III: Surgical Anesthesia

Unconsciousness
Commence Regular respiration Surgery
surgery Decreasing eye movement completed

Stage IV: Medullary Depression

Respiratory arrest
Cardiac depression and arrest
No eye movement
 MAC LP 50
100
Non-responsive to
trapezius squeeze
Percentage of patients exhibiting

Non-responsive
80 to skin incision
each endpoint

Non-responsive to
60 intubation

40

Cardiac arrest
20 (death)

0
0.01 0.02 0.03 0.04 0.05
Alveolar partial pressure of isoflurane (atm)
MAC 1.3/(oil/gas) Equation 16-1
 CHAPTER 16 / General Anesthetic P harmacology 245

10,000 the lung optimizes the rate of gas diffusion. Accordingly, the
alveolar partial pressure Palv and the systemic arterial partial
Thiomethoxyflurane
pressure Part are nearly the same at all times. (In normal in-
1,000 Methoxyflurane dividuals, small amounts of physiologic shunting keep Part
slightly lower than Palv.) By using the lungs as an uptake sys-
Isoflurane Halothane tem for inhaled anesthetics, anesthesiologists take advantage
Potency (1/atm)

100
Diethylether Enflurane of the bodys system for absorbing oxygen.
Similarly, the capillary beds in tissues have evolved to de-
10 Cyclopropane liver oxygen rapidly to all cells in the body. The distances be-
tween arterioles are small, and diffusion pathways are on the
Xenon order of one cell diameter. Consequently, the arterial partial
1
Nitrous oxide pressure of a general anesthetic can equilibrate completely
with tissues in the time required for blood to traverse the cap-
0.1 illary bed. Likewise, the partial pressure in the postcapillary
venules Pvenule equals the partial pressure in the tissue Ptissue.
Nitrogen
Another way of stating the above conclusion is that the
0.01 transfer of anesthetic in both the lungs and the tissues is lim-
0.01 0.1 1 10 100 1,000 10,000
ited by perfusion rather than diffusion. Because perfusion is
Oil/Gas partition coefficient rate-limiting, increasing the rate of diffusion (e.g., by using
a lower molecular weight anesthetic) will not, by itself, in-
crease the rate of induction of anesthesia.
FIGURE 16-3. The MeyerOverton rule. Molecules with a larger oil/gas par-
tition coefficient [(oil/gas)] are more potent general anesthetics. This loglog plot Global Equilibration
shows the very tight correlation between lipid solubility [(oil/gas)] and anesthetic
If an anesthetic is inspired for a long enough period of time,
potency over five orders of magnitude. Note that even such gases as xenon and
nitrogen can act as general anesthetics when breathed at high enough partial
all compartments in the body will equilibrate to the same
pressures. The equation describing the line is: Potency  (oil/gas) / 1.3. Recall partial pressure (equal to PI). This global equilibration may
that Potency  1/MAC. be divided into a series of partial pressure equilibrations be-
tween each successive compartment and its incoming flow
of anesthetic. In the case of the tissues, the incoming flow is
the arterial blood flow, with partial pressure approximately
As discussed below, the uptake model depends on calcula- equal to Palv. In the case of the alveoli, the incoming flow is
tions of the time required for the equilibration of anesthetic the alveolar ventilation with partial pressure PI.
partial pressures in the tissues with the inspired anesthetic The time constant  describes the rate of approach of a
partial pressure. compartments partial pressure to that of its incoming flow.
Specifically,  is the time required for equilibration to be
Concepts from Respiratory Physiology 63% complete. This time constant is convenient because it
can be calculated by dividing the compartments volume ca-
Local Equilibration
pacity (relative to the delivering medium; see below) by the
During general anesthesia, the patient breathes, either spon-
flow rate. In other words, once a volume of flow equal to
taneously or via a ventilator, an anesthetic or mixture of
the capacity of a compartment has gone through that com-
anesthetics together with oxygen and/or normal air. Once the
partment, the partial pressure of anesthetic in the compart-
anesthetic gas reaches the alveoli, it must diffuse across the
ment (i.e., in the tissues or alveoli) will be 63% of the partial
respiratory epithelium into the alveolar capillary bed. Ac-
pressure in the incoming flow (i.e., in the arterial blood flow
cording to Ficks law, the rate of diffusion of gas through a
or alveolar ventilation, respectively). Equilibration is 95%
sheet of tissue down its partial pressure gradient is propor-
complete after three time constants.
tional to the tissue area and the partial pressure difference
between the two sides, and is inversely proportional to the
thickness of the sheet:   Volume Capacity/Flow Rate Equation 16-3

Pcompartment  Pflow [ 1  e(t/)] Equation 16-4

Diffusion rate  D  (A/ l)  P Equation 16-2

where t  elapsed time.

where D  diffusion constant; A  surface area; l  thickness;
These equations describe what should make intuitive
and P  partial pressure difference.
sense: equilibration of the partial pressure of the compart-
One principle evident from Ficks law is that the equal-
ment with the incoming flow takes place more quickly (i.e.,
ization of the partial pressure of the gas, not its concentra-
the time constant is smaller) when the inflow is larger or the
tion, defines the approach to equilibrium across a boundary
compartment capacity is smaller.
sheet. Thus, at equilibrium (i.e., when the net diffusion rate
is zero), the partial pressure in the two compartments is the
same, even though the concentration in the two compart- The Uptake Model
ments may be different. For simplicity, the model of anesthetic uptake and distribution
With its enormous alveolar surface area (75 m2, or organizes the tissues of the body into groups based on simi-
nearly half a tennis court) and thin epithelium (0.3 m, lar characteristics. Each group can be modeled as a container
which is less than 1/20th the diameter of a red blood cell), with a particular capacity for anesthetic and a particular level
246 Principles of Central Nervous System Pharmacology

PI

Palv

PMVR Part

Vol. cap. Vol. cap.

Tissue % Cardiac % Body for N2O at for halo. at
group output weight Palv = 0.8atm Palv = 0.8atm

VRG: brain, liver, kidneys VRG 75% 9% 2.6 L 0.30 L

PVRG

MG: muscle, skin MG 18% 50% 16 L 3.0 L

PMG

FG: fat FG 5.5% 19% 12 L 17 L

PFG

VPG: bone, cartilage, ligaments VPG 1.5% 22% 7.0 L 1.3 L

PVPG

FIGURE 16-4. Distribution of cardiac output and volume capacity for general anesthetics among the major tissue compartments. The tissues of the body can be
divided into four groups based on their level of perfusion and their capacity to take up anesthetic. These include the vessel-rich group (VRG), muscle group (MG), fat group (FG), and
vessel-poor group (VPG). (The contribution of the VPG is generally ignored in most pharmacokinetic models of anesthesia.) The VRG, which contains the internal organs including
the brain, constitutes a small percentage of the total body weight (9%), has the lowest capacity for anesthetic, and receives most of the cardiac output (75%). The high perfusion
and low capacity allow PVRG to equilibrate rapidly with Part. Also, the VRG makes the largest contribution to the mixed venous return partial pressure PMVR, which is equal to (0.75
PVRG  0.18 PMG  0.055 PFG  0.015 PVPG). N2O, nitrous oxide; Halo., halothane; Vol. cap., volume capacity.

of blood flow delivering anesthetic. An adequate approxima-
tion groups the tissues into three main compartments that are
perfused in parallel (Fig. 16-4). The vessel-rich group (VRG),
which consists of the CNS and visceral organs, has a low capac-
ity and high flow. The muscle group (MG), which consists of
muscle and skin, has a high capacity and moderate flow. The fat
group (FG) has a very high capacity and low flow. (A fourth
group, the vessel-poor group [VPG], which consists of bone,
cartilage, and ligaments, has a negligible flow and capacity, and
its omission does not significantly affect the model.)
The rate of increase of the partial pressure in the VRG
(PVRG) is of the greatest interest because the VRG includes
the CNS. The overall equilibration of PVRG with the inspired
partial pressure occurs in two steps, either of which may be
rate-limiting. First, the alveolar and inspired partial pressures
equilibrate (Palv approaches PI, or Palv PI). Second, PVRG
(and specifically PCNS) equilibrates with the arterial partial
pressure (which is essentially equal to the alveolar partial
pressure) (PVRG Part). The discussion will now consider
the time constant for each of these two steps and define con-
ditions under which one or the other is rate-limiting.
Equilibration of Alveolar with Inspired Partial Pressure
The equilibration of Palv with PI is conceptually the first step
of the equilibration of PVRG with PI. During induction of
anesthesia, PVRG can never be higher than Palv; if Palv rises
slowly, then PVRG must also rise slowly.
To calculate the time constant for the approach of Palv to PI,
{PalvPI}, the flow rate and volume capacity must be defined.
The delivering medium is free gas arriving through the airways,
and the compartment is the lung and alveoli. The volume capac-
ity is simply the volume of gas that remains in the lungs after

normal exhalation, or the functional residual capacity (FRC,
typically 3 L for an average adult). Assume initially that the
only component of the flow rate is the rate of alveolar ventila-
tion, which delivers the anesthetic (Valv  {Tidal Volume this is analogous to increasing the leakiness of the bucket. Thus,
Dead Space}  Respiratory Rate; for an average adult, Valv 
{0.5 L 0.125 L}  16 min 1 6 L/min). Then, because
{P alv PI }  FRC/Valv Equation 16-5
a typical value for {PalvPI} is 3 L / 6 L/min, or 0.5 min
independent of the particular gas being inhaled. In children,
the increased alveolar ventilation rate and decreased FRC
(smaller lungs) both tend to shorten the time constant and
to accelerate equilibration between the alveolar and inspired
partial pressures.
The assumption to this point has been that no uptake of an-
esthetic into the bloodstream occurs, as would be the case if the
solubility of the anesthetic in blood were zero. In practice, at the
same time that alveolar ventilation is delivering anesthetic to
the alveoli, anesthetic is also being removed from the alveoli by
diffusion into the bloodstream. The balance between delivery
and removal is analogous to adding water into a leaky bucket
(Fig. 16-5). The level of water in the bucket (which represents
the alveolar partial pressure) is determined both by the rate at
which the water is added (the minute ventilation) and the size
of the leak (the rate of anesthetic uptake from the alveoli into
the bloodstream). Increasing anesthetic delivery (for example,
by using a higher ventilation rate or a higher inspired partial
pressure) will increase the alveolar partial pressure of the gas,
just as adding water faster will increase the level of water in the
Ventilation brings
anesthetic into alveoli
The balance between
Palv input and output
sets the level of Palv
Uptake into bloodstream
removes anesthetic from alveoli
FIGURE 16-5. Determinants of the alveolar partial pressure of an inhaled
anesthetic. The alveolar partial pressure, represented by the depth of fluid in the
bucket, results from the balance between delivery by ventilation and removal by
uptake into the bloodstream. Increased delivery of anesthetic, resulting from either
increased ventilation or an increased inspired partial pressure of anesthetic, raises Palv.
In contrast, increased uptake into the bloodstream, caused by a large (blood/gas) or
increased cardiac output, lowers Palv.
CHAPTER 16 / General Anesthetic P harmacology 247
bucket. Conversely, increasing anesthetic removal (for example,
by increasing the perfusion rate or using a more blood-soluble
anesthetic) will decrease the alveolar partial pressure of the gas;
uptake of anesthetic from the alveoli into the bloodstream con-
stitutes a negative component to the flow (i.e., a flow out of the
lungs), which makes the time constant longer than the theoreti-
cal case where {PalvPI} equals FRC divided by Valv.
The magnitude of the increase in the time constant com-
pared to the limiting case depends on the rate of uptake of
anesthetic by the blood, with longer {PalvPI} resulting
from greater uptake. If one knows the cardiac output (i.e.,
the volume of blood pumped by the heart in 1 minute) and
the value of the instantaneous difference between the pul-
monary arterial partial pressure (which equals the systemic
partial pressure of the mixed venous return, PMVR) and the
pulmonary venous partial pressure (which equals the sys-
temic arterial partial pressure, Part), then one can calculate
the rate of uptake of a gas from the alveoli:
Rate of uptake {in Lgas /min}
 (blood/gas)  (Part  PMVR)  CO Equation 16-6
where CO  cardiac output in liters of blood per minute.
Equation 16-7 follows from Equation 16-6 because the anes-
thetic concentration [A]blood is equal to (blood/gas)  Pblood
(see Box 16-2):
Rate of uptake  ([ A]art  [ A]MVR )  CO Equation 16-7
If any of the terms in these equations approaches zero, the
rate of uptake becomes small, and the delivery of anesthetic
by ventilation drives the alveolar partial pressure toward the
inspired partial pressure. In other words, equilibration of al-
veolar with inspired partial pressure is faster (i.e., {PalvPI}
is smaller) with lower blood solubility of the anesthetic
[smaller (blood/gas]), lower cardiac output, or smaller ar-
terial (alveolar) to venous partial pressure difference.
Equilibration of Tissue with Alveolar Partial Pressure
In addition to the equilibration between Palv and PI, equili-
bration between Ptissue and Part (which is nearly equal to Palv)
must occur for Ptissue to equilibrate with PI. Changes in Palv
are transmitted rapidly to systemic arterioles, because equili-
bration across the pulmonary epithelium is fast and the cir-
culation time from pulmonary veins to tissue capillaries is
generally less than 10 seconds. Thus, the time constant for
equilibration between Ptissue and Palv can be approximated as
the time constant for equilibration between Ptissue and Part.
To calculate the time constant {PtissuePart}, one must de-
fine the capacity of the compartment and the flow rate of the
delivering medium. The flow rate is simply the rate at which
blood perfuses the tissue. Recall that capacity is a volume
capacity relative to the delivering medium. Specifically, the
capacity is the volume that the tissue would need to contain
all of its gas if the solubility of the gas in the tissue were
the same as that in the blood. (This definition is similar to
that of the volume of distribution of a drug; see Chapter 3,
Pharmacokinetics):
Relative Volume Capacity of Tissue
 ([A]tissue  Voltissue)/[A]blood Equation 16-8
Relative Volume Capacity of Tissue
  (tissue/blood)  Voltissue Equation 16-9

{Ptissue Part } {Ptissue Palv }

 Relative Vol. Cap. of Tissue /Qtissue Equation 16-10

{Ptissue Part}
 (tissue/blood)  Voltissue /Qtissue Equation 16-11
 Nitrous oxide Halothane
(PI = 0.75) (PI = 0.01)
100
Alveolar MG
VRG FG
% of inspired partial pressure

80

63% equilibration
60

40

20

0
1 10 100 1 10 100

Time (min) Time (min)

Alveolar partial pressure as fraction of inspired

1.0
Nitrous oxide, = 0.47

Desflurane, = 0.45
0.8
Isoflurane, = 1.4
partial pressure (Palv/PI)

63% equilibration
0.6

Halothane, = 2.3

0.4

0.2
Ether, = 12.0

0.0
0 10 20 30
Minutes of administration
250 Principles of Central Nervous System Pharmacology
A Initial Palv = 0.1 atm B Initial Palv = 0.1 atm
(blood/gas) = 0.5 (blood/gas) = 11
Final Palv = Part = 0.067 atm Final Palv = Part = 0.0083 atm
Anesthetic
Alveolus
Capillary
FIGURE 16-8. Why do anesthetics with smaller (blood/gas) have
shorter induction times? Consider two equally potent anesthetics inspired
at the same partial pressure, PI. Before any anesthetic molecules have been
taken up from the alveolus into the blood, the alveolar partial pressure, Palv,
of each anesthetic is 0.1 atm. This partial pressure would be represented in
the diagram by 12 anesthetic spheres in each alveolus. For each anesthetic,
equilibration of the partial pressures in the alveolus and the capillary then
takes place. For a relatively blood-insoluble agent with (blood/gas)  0.5
(Anesthetic A, which closely resembles nitrous oxide, desflurane, sevoflurane,
and cyclopropane), the transfer of a small amount of anesthetic from the al-
veolus significantly raises the partial pressure in the capillary. To illustrate,
consider a time, tv, when the volume of blood that has flowed past the alveolar
wall is equal to the volume of the alveolus. At that time, the concentration in the
alveolus will be twice that in the capillary (because  (blood/gas)  0.5; see
Box 16-2) when four of the spheres have been transferred from the alveolus
to the capillary and eight spheres remain in the alveolus. The partial pressure
in the alveolus will now have dropped to (8/12)  0.1  0.067 atm. This is
also the partial pressure in the capillary. In contrast, for a very blood-soluble
agent with (blood/gas)  11 (Anesthetic B, which closely resembles diethyl
ether), much larger amounts of anesthetic must dissolve in the blood to raise
the partial pressure in the capillary. Using the same illustration as above, at
tv, 11 of the 12 spheres will have been transferred from the alveolus to the
capillary, and the remaining Palv will be given by (1/12)  0.1  0.0083 atm.
Thus, although the inspired partial pressure of the two anesthetics is the same,
at time tv, the Palv and Part of Anesthetic A will be eight times higher than that of
Anesthetic B. Within approximately 2 minutes (Table 16-3), Pbrain will also reach
these values. Thus, the brain partial pressure rises toward the inspired partial
pressure much more rapidly for Anesthetic A than for Anesthetic B (i.e., the
induction time for Anesthetic A is much shorter than that for Anesthetic B). If the
reader is confused by the fact that more molecules of Anesthetic B are being
carried to the brain, recall that (brain/blood) is 1 for all of the commonly
used anesthetics [that is, for each agent, (blood/gas) is approximately equal
to (brain/gas); see Table 16-2]. Thus, proportionally many more molecules of
Anesthetic B than Anesthetic A must be delivered to the brain in order to raise
the partial pressure of each anesthetic by an equivalent amount. See Boxes
16-1 and 16-2 and the Appendix for definitions.
has a small (blood/gas), while Anesthetic B has a large
(blood/gas). Because Anesthetics A and B are identical
in (oil/gas), they have the same MAC. They also have
identical (brain/blood), so their {PbrainPalv} is the same
(see Equations 16-12 and 16-13). To cause anesthesia, both
must achieve the same partial pressure in the CNS. At any
particular partial pressure, however, the blood and CNS
contain more moles of Anesthetic B than Anesthetic A be-
cause Anesthetic B is more soluble than Anesthetic A in the
blood and CNS. The transfer of a larger number of moles of
Anesthetic B out of the lungs slows the rate of rise of Palv,
so a longer period is necessary for Anesthetic B than for
Anesthetic A to achieve the anesthetic partial pressure in
the CNS (Fig. 16-8).a
Applications of the Uptake Model
Throughout the following discussion, it is critical to remem-
ber that the primary responsibility of the anesthesiologist is
to keep the patient well oxygenated and the vital signs stable
while manipulating the inspired partial pressure of anes-
thetic to maintain the desired depth of anesthesia.
Armed with the uptake model, the anesthesiologist can
predict the effects of cardiopulmonary changes and patho-
logic states on the depth of anesthesia. Changes in ventilation
and cardiac output may be caused by the general anesthetic
itself, by the trauma of surgery, or by some other physiologic
or pathophysiologic process.
The effects of changes in both ventilation and cardiac
output on PCNS are greatest when the difference between PI
and Palv is greatest; that is, early in the course of anesthesia
(Fig. 16-6). To understand this, consider the partial pressure in
the mixed venous return (MVR), PMVR, which is a weighted
average of the partial pressures in each of the tissue groups,
with PVRG making the largest contribution because the VRG
receives the majority of the cardiac output (Fig. 16-4). When
Palv (and thus PVRG) is much less than PI, PMVR is low, and the
bloodstream is capable of carrying large amounts of anesthetic
away from the alveoli to the tissues. Under these conditions,
the rate of uptake of anesthetic from the alveoli into the blood-
stream can be greatly modified by cardiopulmonary changes,
and PCNS can be greatly affected by changes in ventilation and
cardiac output. As each successive tissue group approaches
saturation with anesthetic, PMVR approaches PI. When PMVR is
nearly equal to PI, the bloodstream cannot remove much anes-
thetic from the lungs under any circumstances, and changes in
ventilation or cardiac output have little effect on PCNS.
Upon commencement of anesthetic administration, the length
of time during which there is a significant difference between PI
and Palv increases with (blood/gas). With ventilation-limited
anesthetics, such as diethyl ether and halothane, the prolonged
time during which Palv lags behind PI allows cardiopulmonary
changes to modulate Palv significantly, potentially leading to
unexpected CNS partial pressures. With perfusion-limited an-
esthetics, such as nitrous oxide, the alveolar partial pressure
rises so rapidly that Palv is significantly less than PI for only a
short time, minimizing the time during which cardiopulmonary
changes could have a significant effect on PCNS (Fig. 16-6).
a
In this hypothetical model, one may correctly note that the concentration of
Anesthetic B in the CNS as a whole will be higher than that of Anesthetic A at
any particular time point. One may, therefore, wonder how Anesthetic B can
have a slower induction, if anesthesia results when a particular concentration
(0.05 M) is reached at the site of action (see Pharmacodynamics, above). At
this point, one must recognize that the brain is primarily aqueous, but that
anesthetics are likely to have a hydrophobic site of action, and that both An-
esthetic A and Anesthetic B must have the same concentration (0.05 M) in
the key hydrophobic portions of the brain at their anesthetic partial pressures.
However, Anesthetic B, with its larger aqueous solubility [(blood/gas)], will
partition relatively more than Anesthetic A into the aqueous portions of the
brain. To provide the higher aqueous concentrations, many more moles of
Anesthetic B than Anesthetic A must be transferred from the lungs.
The overall conclusion still holds if (oil/gas) and thus MAC differ for the
two hypothetical anesthetics. Palv for a less blood-soluble agent will rise pro-
portionally faster toward its PI than a more blood-soluble agent, independent of
what that PI is (note that PI will be larger for the less oil-soluble anesthetic). A
larger (oil/gas) allows the anesthetic to cause anesthesia at a lower partial pres-
sure, but does not affect the proportional rate at which the partial pressure rises.
 CHAPTER 16 / General Anesthetic P harmacology 251

Effects of Changes in Ventilation
Hypoventilation decreases the delivery of anesthetic to
the alveoli. Meanwhile, removal of anesthetic from the
alveoli continues provided that cardiac output is main-
tained. Consequently, the alveolar partial pressure rises
more slowly, and {PalvPI} is prolonged. In other words,
hypoventilation slows induction. This effect is greater
with ventilation-limited than with perfusion-limited anes-
thetics (Fig. 16-9A).
General anesthetics themselves can cause hypoventilation
by depressing the medullary respiratory center. In this man-
ner, anesthetic-induced hypoventilation sets up a beneficial
A Ventilation Effects
1.0
Nitrous oxide
63% equilibration
Palv/PI
negative feedback loop on the depth of anesthesia. Increas-
ing anesthetic depth leads to medullary depression, which,
in turn, depresses respiration. The beneficial effect of this
physiologic response is that the depressed ventilation slows
the rate of rise of the alveolar partial pressure, while per-
fusion continues to remove anesthetic from the lung at the
same rate (Fig. 16-5). Thus, Palv falls, and shortly thereafter,
the partial pressure of anesthetic in the medulla falls as well.
This decrease in PCNS relieves the respiratory depression. In
the extreme example of a full respiratory arrest, there is no
ventilation to deliver anesthetic to the alveoli, but cardiac
output continues to distribute anesthetic from the alveoli and
VRG to the MG and FG. In the case of diethyl ether, the
decrease in PCNS can be of a sufficient magnitude that spon-
taneous ventilation resumes.
Hyperventilation delivers anesthetic more quickly to the
alveoli. This decreases the time constant for equilibration
of the alveolar with the inspired partial pressure (recall that
{PalvPI}  FRC / Valv, in the limiting case). However, the
hyperventilation-induced hypocapnia may concomitantly
decrease cerebral blood flow, increasing {PCNSPart}. Thus,
while the partial pressure in the alveoli rises faster, the rate

0.5 Halothane of equilibration between the CNS and the alveoli could be
slower. The net effect depends on which of these two steps
is rate-limiting. For perfusion-limited anesthetics such as ni-
trous oxide, the decrease in cerebral blood flow results in
Diethyl ether
a slower induction. For the most soluble ventilation-limited
anesthetics such as diethyl ether, the faster delivery of an-
0.0 esthetic to the alveoli hastens induction. For less soluble
0 20 40 ventilation-limited anesthetics such as isoflurane, the effects
Minutes roughly balance, and induction is not significantly affected.
2 L/min ventilation 8 L/min ventilation
Effects of Changes in Cardiac Output
B Cardiac Output Effects At anesthetic partial pressures higher than those required to
depress the respiratory center, cardiac output falls. When car-
1.0 diac output falls, the bloodstream removes anesthetic from
the alveoli at a slower rate. Consequently, the alveolar partial
Nitrous oxide pressure rises faster (Fig. 16-9B). Because the alveolar partial
pressure equilibrates relatively quickly with the VRG (even at
63% equilibration the lower cardiac output), the partial pressure in the CNS also
Palv/PI

0.5
Halothane
Diethyl ether
0.0
0 20 40
Minutes
2 L/min cardiac output 18 L/min cardiac output
FIGURE 16-9. Effects of changes in ventilation and cardiac output on the
rate at which alveolar partial pressure rises toward inspired partial pressure.
The rate of equilibration of the alveolar partial pressure with the inspired partial
pressure can be affected by changes in ventilation (A) and cardiac output (B). In-
creasing ventilation from 2 L/min (dashed lines) to 8 L/min (solid lines) accelerates
equilibration. On the other hand, increasing cardiac output from 2 L/min (dashed
lines) to 18 L/min (solid lines) slows equilibration. Both effects are much larger for
more blood-soluble gases, such as halothane and diethyl ether, which have rather
slow induction times. For nitrous oxide, the rate of equilibration is so fast that
any changes caused by hyperventilation or decreased cardiac output are small.
The dashed horizontal line represents 63% equilibration of Palv with PI ; the time
required for each curve to cross this line represents {PalvPI }.
rises more rapidly. In other words, decreased cardiac output
speeds induction. This effect is more marked with ventilation-
limited than with perfusion-limited anesthetics.
Moreover, cardiac depression by anesthetics sets up a
harmful positive feedback loop on the depth of anesthesia.
Increasing PCNS depresses cardiac function, which further
increases Palv, which further increases PCNS, which further
depresses cardiac function. If cardiac arrest occurs, then pos-
itive measures must be taken to restore the circulation (e.g.,
CPR) while reducing the alveolar partial pressure through
controlled breathing with oxygen.
Increased cardiac output increases perfusion to the lungs
and accelerates equilibration between the alveoli and the tis-
sues. However, because the increased blood flow to the lungs
removes anesthetic from the alveoli at a faster rate, the rate
of rise of the alveolar partial pressure is slowed. Thus, in-
creased cardiac output slows induction. This effect is greater
with ventilation-limited than with perfusion-limited agents.
Effects of Age
Relative to their body weight, young children such as Mat-
thew have higher ventilation than do adults. This effect tends
to speed induction. However, young children also have
 0.9
Children
(15 years)
0.8

0.7
Palv/PI

Adults

0.6

0.5

0.4
0 10 20 30 40 50 60

Minutes of anesthesia
 Clinical Status
of Patient
0.03
Respiratory
depression
Alveolar partial pressure (Atm)

Continuing at PI = 0.04 Atm (toxic range)

0.02
Anesthesia
Varying PI between 0.015 and 0.02 Atm (therapeutic range)

0.01 Desired Pbrain

for anesthesia Awake
PI = 0.04 Atm PI = 0.01 Atm
(subtherapeutic
range)
0.00
0 5 10 15

Time (min)
 Nitrous oxide Halothane Methoxyflurane
(blood/gas) = 0.47 (blood/gas) = 2.3 (blood/gas) = 13.0
1.0
Minutes of Anesthesia

240
120
60
30
PE/PE0

15
0.5

0
0 40 80 120 0 40 80 120 0 40 80 120

Time (min) Time (min) Time (min)


Isoflurane and enflurane are somewhat less potent than
halothane [they have a smaller (oil/gas)], but they equili-
brate faster because they have a smaller (blood/gas). Enflu-
rane is metabolically defluorinated to a greater extent than
isoflurane, and may thus have a greater risk of causing renal
toxicity. It also induces seizure-like activity in the EEG of
some patients. Isoflurane is probably the most widely used
general anesthetic today.
Although less potent than isoflurane and enflurane, di-
ethyl ether is still quite potent with a rather high (oil/gas).
However, because of its flammability and very slow induc-
tion attributable to its extremely high (blood/gas), this
agent is no longer in common use in the United States and
Europe. In developing countries, however, its low price and
simplicity of application favor its continued use.
Nitrous oxide has a very low (blood/gas) and thus
equilibrates extremely rapidly. However, its low (oil/gas)
results in a very high MAC, close to one atmosphere. Thus,
the need to maintain an acceptable partial pressure of oxy-
gen (normally greater than 0.21 atm) prevents the attainment
of full anesthesia using nitrous oxide alone, and this agent is
commonly employed in combination with other agents (see
Balanced Anesthesia below).
Desflurane and sevoflurane are newer anesthetics that,
by design, have low (blood/gas); times of equilibration be-
tween their alveolar and inspired partial pressures are nearly
as short as that of nitrous oxide. Furthermore, they are much
more potent than nitrous oxide because their oil/gas parti-
tion coefficients are higher. Thus, these agents offer great
improvements over earlier agents. However, desflurane is a
poor induction agent because its pungency irritates the air-
way, potentially causing cough or laryngospasm. Sevoflu-
rane is sweet-tasting, but can be chemically unstable when
exposed to some carbon dioxide adsorbents in anesthetic
machinery, degrading to an olefinic compound that is po-
tentially nephrotoxic. These disadvantages have been over-
come with improved machinery, and sevoflurane is gaining
in popularity.
Intravenous Anesthetic Agents
Intravenous anesthetics, such as barbiturates (see also
Chapter 12), allow for rapid induction. Ultrashort-acting
barbiturates, such as thiopental, are capable of inducing
surgical anesthesia within seconds. As nonvolatile com-
pounds, intravenous agents differ from inhaled anesthetics
in that they cannot be removed from the body by venti-
lation. Accordingly, one must take great care during their
administration to avoid severe medullary depression that
is not easily reversible. The primary method of removal of
these agents from the CNS is by redistribution from the
VRG to the MG and finally to the FG. Metabolism and/or
excretion then slowly decrease the overall body levels of
drug (Fig. 16-13).
Propofol is an important intravenous anesthetic prepared
in an intralipid formulation. This agent produces anesthesia
at a rate similar to the ultrashort-acting barbiturates. Propo-
fol is both rapidly redistributed and rapidly metabolized, re-
sulting in a faster recovery than for barbiturates. Propofol
is used both for induction and for maintenance, especially
in short day-surgery procedures where its fast elimination
favors prompt recovery and early discharge. The intralipid
preparation of propofol can rarely be a source of infection,
CHAPTER 16 / General Anesthetic P harmacology 255
100
Blood
MG
80
Percent of dose
60 VRG
40
FG
20
0
0.1 1 10 100
Time (min)
FIGURE 16-13. Distribution of a bolus of intravenous anesthetic. When a
bolus of intravenous anesthetic is administered, it is initially transported through
the vascular system to the heart and then distributed to the tissues. The vessel-
rich group (VRG) receives the highest percentage of the cardiac output; its anes-
thetic concentration rises rapidly, reaching a peak within 1 minute. Redistribution
of anesthetic to the muscle group (MG) then quickly decreases the anesthetic level
in the VRG. Because of very low fat group (FG) perfusion, redistribution from the
MG to the FG does not occur until much later. Note that rapid redistribution from
the VRG to the MG does not occur if the MG has previously approached saturation
through prolonged administration of anesthetic (not shown); this can lead to sig-
nificant toxicity if intravenous barbiturates are administered continuously for long
periods of time. Newer agents, such as propofol, are designed to be eliminated by
rapid metabolism and, therefore, can be used safely for longer periods of time.
and the lipid preparation provides a large caloric source;
these considerations can be important in critically ill patients
who may receive prolonged propofol infusions.
Etomidate is an imidazole that is used for induction of
anesthesia because its kinetics are similar to those of propo-
fol. This agent causes minimal cardiopulmonary depression,
perhaps because of its unique lack of effect on the sympa-
thetic nervous system.
Unlike the above agents, ketamine produces dissocia-
tive anesthesia, in which the patient seems to be awake but
is actually in an analgesic and amnesic state. Ketamine has
the unusual property that it increases cardiac output by in-
creasing sympathetic outflow; for this reason, it is occasion-
ally useful in emergency trauma situations. However, it can
also produce unpleasant hallucinations. This agent is rarely
used today.
Adjuvant Drugs
Adjuvant drugs provide additional effects that are desirable
during surgery but are not necessarily provided by the gen-
eral anesthetics. Benzodiazepines (see Chapter 12), such as
diazepam, lorazepam, and midazolam, are often given for
their anxiolytic and anterograde amnesic properties. These
agents are administered 15 to 60 minutes before the induc-
tion of anesthesia to calm the patient and obliterate memory
of the induction, although they may also be used for intraop-
erative sedation. If necessary, benzodiazepine effects can be
reversed with the antagonist flumazenil.
 CHAPTER 16 / General Anesthetic P harmacology 257

If interfacial solubilities (i.e., the solubility of a compound

A Inhaled anesthetics B Intravenous anesthetics
at an aqueouslipid interface) are considered instead of
O simple lipid solubilities, then the MeyerOverton Rule is
N N O much more successful at explaining the activity of transi-
HN
Nitrous oxide tional and nonanesthetic compounds. This finding is likely
O
* to mean that anesthetics act at a hydrophobichydrophilic
HN interface. Examples of such an interface could include a
F F
O watermembrane interface, a proteinmembrane interface,
F3C O F Pentobarbital or an interface between a hydrophobic protein pocket and
the hydrophilic lumen of an ion-conducting pore.
Desflurane
O
CF3 HN
Effects on Ion Channels
Current research has focused on proteins that may alter
S
F3C O F * neuronal excitability when acted on by anesthetics, either
HN directly or indirectly. Anesthetics affect both axonal conduc-
Sevoflurane
O tion and synaptic transmission, but modulation of synaptic
Thiopental transmission occurs at lower anesthetic concentrations and is,
O therefore, likely to be the pharmacologically relevant action.
Accordingly, anesthetics are thought to act on ligand-gated
Diethyl ether OH
(Ether) ion channels at lower concentrations than on voltage-gated
ion channels. Both presynaptic and postsynaptic modulation
occur, although the postsynaptic actions seem to dominate.
Br
A superfamily of genetically and structurally related
F3C * ligand-gated channels is sensitive to modulation by anes-
Cl Propofol thetics at clinically relevant concentrations. Members of this
Halothane superfamily have five homologous subunits, each with four
O Cl
transmembrane regions. The sensitivity of these ligand-gated
ion channels to anesthetics can vary with their subunit com-
Cl F position. The superfamily includes the excitatory nicotinic
* * acetylcholine and 5-HT3 receptors, as well as the inhibitory
F3C O F NH GABAA and glycine receptors (see Fig. 9-2 and Fig. 12-3).
Isoflurane Although receptors for glutamate, the major excitatory neu-
Ketamine rotransmitter in the brain, do not belong to this superfamily,
NMDA glutamate receptors are also modulated by some an-
F F esthetics (e.g., ketamine and nitrous oxide).
F
F O
Excitatory receptors (nicotinic acetylcholine, 5-HT3, and
* O F NMDA) are inhibited by anesthetics. The binding of anes-
O
Cl thetic to these receptors lowers their maximum activation,
* N without changing the concentration of agonist required to
Enflurane
achieve a half-maximal effect (EC50) (Fig. 16-15). This ac-
N tion is consistent with noncompetitive inhibition and an al-
Etomidate
losteric site of action (see also Chapter 2).
In contrast, inhibitory receptors (GABAA and glycine) are
potentiated by anesthetics. The binding of anesthetic to these
FIGURE 16-14. Structures of general anesthetics. A. Structures of some receptors decreases the concentration of agonist required to
inhaled anesthetics. B. Structures of some intravenous anesthetics. The extreme achieve a maximum response, and thereby prolongs the syn-
variability in the structures of these molecules, all of which are capable of caus- aptic current. The activation curves for these receptors are
ing general anesthesia, suggests that not all general anesthetics interact with a
shifted to the left (lower EC50), and the maximal response
single receptor site. * Indicates carbons where asymmetry results in enantiomeric
structures.
often increases as well because the anesthetics stabilize the
open state of the receptor (Fig. 16-15).
Until recently, GABAA receptors seemed to be the most
and anesthetic steroids) do exhibit substantial stereoselectiv- relevant receptors for general anesthetic action, based on the
ity. That is, one enantiomer is more potent than the other. sensitivity of GABAA receptors to clinical concentrations of
Second, many so-called nonanesthetics or nonimmobiliz- anesthetics and the wide range of agents that act on these
ers are chemically similar to known anesthetics but do not receptors. However, it now seems that glycine receptors and
cause anesthesia. For example, straight-chain alcohols with some neuronal acetylcholine receptors are equally sensitive
more than 12 carbons lack anesthetic activity, even though to many anesthetics, and that nonpolar anesthetics such as
their (oil/gas) is larger than the shorter alcohols. Other com- xenon and cyclopropane (both of which have been used in
pounds, called transitional anesthetics, have a much higher clinical practice), as well as nitrous oxide and ketamine, act
MAC than that predicted by the MeyerOverton Rule. by inhibiting nicotinic acetylcholine and NMDA glutamate
Refinements to the MeyerOverton Rule have been pro- receptors rather than by potentiating GABAA receptors.
posed to account for some of the weaknesses listed above. Thus, it currently appears that an agent must cause either
258 Principles of Central Nervous System Pharmacology
and  subunits of the GABAA receptor; the site is lo-
150
Inhibitory synapse
with general anesthetic
125
Relative response (%)
100
Control
75 EC50
EC50
50 Excitatory
synapse
with general
EC50 anesthetic
25
subunit attenuates the channels response to vola-
0 tile anesthetics but not to etomidate. Thus, although differ-
0.01 0.1 1.0 10 100
Relative agonist concentration
FIGURE 16-15. Actions of anesthetics on ligand-gated ion channels.
Anesthetics potentiate the action of endogenous agonists at inhibitory receptors,
such as GABAA and glycine receptors, and inhibit the action of endogenous ago-
nists at excitatory receptors, such as nicotinic acetylcholine, 5-HT3, and NMDA
glutamate receptors. At GABAA receptors, anesthetics both decrease the EC50 of
GABA (i.e., GABA becomes more potent) and increase the maximum response (i.e.,
GABA becomes more efficacious). The latter effect is thought to be due to the abil-
ity of anesthetics to stabilize the open state of the receptor channel. At excitatory
receptors, anesthetics decrease the maximum response while leaving the EC50
unchanged; these are the pharmacologic hallmarks of noncompetitive inhibition.
sufficient enhancement of inhibition (e.g., etomidate) or in-
hibition of excitation (e.g., ketamine), or a mixture of the
two (e.g., volatile anesthetics), to cause anesthesia. This hy-
pothesis also suggests that surgical anesthesia may represent
more than one neurological state.
Direct anestheticprotein interactions are probably re-
sponsible for the effects of anesthetics on ligand-gated ion
channels. Anesthetics could bind in the pore of excitatory
channels and thereby directly plug the channel. Alterna-
tively, anesthetics could bind elsewhere on the protein and
thereby affect the channels conformation (and, thus, the
equilibrium among its open, closed, and desensitized states).
Site-directed mutagenesis, photolabeling, and kinetic studies
suggest that inhibition of excitatory acetylcholine receptors
probably occurs at a site in the pore of the ion channel that
is on the central axis of symmetry and in contact with all
five subunits. However, the site of anesthetic binding to in-
hibitory GABAA receptors cannot be in the ion pore because
potentiation, not inhibition, is observed at therapeutic con-
centrations. Indeed, GABAA receptors lack a stretch of hy-
drophobic amino acids that is present in the pore of excitatory
receptors. Instead, site-directed mutagenesis studies suggest
that an anesthetic binding site is located on the outside of
one of several alpha helices that line the GABAA ion chan-
nel. This evidence places the volatile anesthetic site within
the four transmembrane helices of a single receptor subunit.
In contrast, recent photolabeling evidence, using an analog
of the highly potent intravenous anesthetic etomidate, places
the binding site for that anesthetic at the interface between
the
cated within the membrane region and about 50 below the
agonist (GABA) site in the same subunit interface.
Although current research is focused on protein sites of
anesthetic action, no single site has been found that accounts
for the MeyerOverton Rule or the pharmacology of all gen-
eral anesthetics. Consequently, adoption of such protein-site
theories may have to be accompanied by an abandonment
of the unitary hypothesis. Some new unifying principles
are emerging, however. For example, a single mutation in
the alpha helix of the GABAA receptor 2 or 3 subunit that
lines the ion channel (see paragraph above) attenuates the
action of etomidate on this receptor, although this mutation
has no effect on the potency of volatile anesthetics. Mice
genetically engineered to contain the mutation are normally
sensitive to volatile anesthetics but much less sensitive to an-
esthesia with etomidate. In contrast, the equivalent mutation
in the
ent classes of anesthetics act on different GABAA receptor
subunits, and by implication different binding sites, all these
sites are within the membrane region where the conforma-
tion of the receptor changes upon gating. It is possible that
each class acts in a similar manner on the subunit to which it
binds and that selectivity is a function of the detailed archi-
tecture of each subunit at that site.
 CONCLUSION AND FUTURE DIRECTIONS
Inhaled and intravenous anesthetics are used to produce
the clinical features of general anesthesia, including un-
consciousness, immobility, and amnesia. The pharmacody-
namics of general anesthetics are unique. Anesthetics have
steep doseresponse curves and small therapeutic indices,
and they lack a pharmacologic antagonist. According to the
MeyerOverton Rule, the potency of a general anesthetic can
be predicted simply from its oil/gas partition coefficient.
The pharmacokinetics of inhaled anesthetics can be mod-
eled assuming three principal tissue compartments that are
perfused in parallel. Equilibration of the partial pressure
of anesthetic in the CNS with the inspired partial pressure
proceeds in two steps: (1) equilibration between the alveo-
lar partial pressure and the inspired partial pressure; and
(2) equilibration between the CNS partial pressure and the
alveolar partial pressure. With ventilation-limited anesthetics,
which have a large blood/gas partition coefficient, the first of
these steps is slow and rate-limiting. With perfusion-limited
anesthetics, which have a small blood/gas partition coeffi-
cient, both steps are rapid and neither is clearly rate-limiting;
changes in either can affect induction time. Recovery from
anesthesia occurs roughly as the reverse of induction, except
that redistribution of anesthetic from the vessel-rich group to
the muscle group and fat group can also occur.
The ideal inhaled anesthetic has not yet been found.
Future researchers may attempt to identify a nonflamma-
ble anesthetic with high (oil/gas), low (blood/gas), high
therapeutic index, good vapor pressure, and few or no sig-
nificant adverse effects. Currently, the combined use of adju-
vants and balanced anesthesia with multiple inhaled and/or
intravenous anesthetics achieves all of the goals of general
anesthesia, including fast induction and a state of analgesia,
amnesia, and muscle relaxation.

The exact mechanism of action of general anesthetics re-
mains a mystery. Although the site of action was formerly
thought to reside in lipid bilayers, direct interactions with sev-
eral ligand-gated ion channelsmembers of the four-transmem-
branehelices, Cys-loop superfamily and the glutamate receptor
familynow seem to be more likely. More research is required
to elucidate the mechanisms of action of general anesthetics.
Once discovered, these mechanisms could shed light on such
far-reaching issues as the generation of consciousness itself.
Suggested Reading
Campagna JA, Miller KW, Forman SA. The mechanisms of volatile anes-
thetic actions. N Engl J Med 2003;348:21102124. (Reviews how general
anesthetics act.)
CHAPTER 16 / General Anesthetic P harmacology 259
Eger EI. Uptake and distribution. In: Miller RD, ed. Anesthesia. Philadel-
phia: Churchill Livingstone; 2000:7495. (Pharmacokinetics and uptake of
inhaled anesthetics.)
Rudolph U, Antkowiak B. Molecular and neuronal substrates for general
anesthetics. Nat Rev Neurosci 2004;5:709720. (A short review with good
diagrams.)
Various authors. Molecular and cellular mechanisms of anaesthesia. In:
Can J Anesth 2011; Feb issue. (This special issue is a compilation of de-
tailed reviews relating to all major current theories on the mechanism of
action of general anesthetics.)
Wiklund RA, Rosenbaum SH. Anesthesiology. N Engl J Med 1997;337:
11321151, 12151219. (Two-part review covers many aspects of the mod-
ern practice of anesthesiology.)
Winter PM, Miller JN. Anesthesiology. Sci Am 1985;252:124131. (A good
account of the clinical approach of the anesthesiologist.)
Appendix A
Abbreviations and Symbols
PI  inspired partial pressure
PE  exhaled partial pressure
Palv  alveolar partial pressure
Part  arterial partial pressure
Ptissue  partial pressure in a tissue
Pvenule  partial pressure in a venule
PMVR  mixed venous partial pressure
Psolvent  partial pressure in a solvent
PCNS  partial pressure in the central nervous system
PVRG  partial pressure in the vessel-rich group
(oil/gas)  partition coefficient defining solubility of a gas
in a lipophilic solvent such as oil
(blood/gas)  partition coefficient defining solubility of a
gas in blood
(tissue/gas)  partition coefficient defining solubility of a
gas in a tissue
(tissue/blood)  partition coefficient describing ratio of
solubility in tissue to solubility in blood
 (tissue/gas) / (blood/gas)
 time constant for 63% equilibration
{PalvPI}  time constant for 63% equilibration of Palv
with PI
{PtissuePalv}  time constant for 63% equilibration of
Ptissue with Palv
262
[A]  concentration of gas A, in terms of either Lgas/Lsolvent
or mol/Lsolvent
CNS  central nervous system
VRG  vessel-rich group (includes CNS, liver, kidney)
MG  muscle group (includes muscle, skin)
FG  fat group (includes adipose tissue)
VPG  vessel-poor group (includes bone, cartilage,
ligaments, tendons)
FRC  functional residual capacity of lung
Valv  alveolar ventilation
CO  cardiac output
Q  perfusion rate
Voltissue  volume of tissue
MAC  minimum (or median) alveolar concentration
P50  alveolar partial pressure sufficient for immobility in
50% of patients MAC
AP50  alveolar partial pressure sufficient to cause analge-
sia in 50% of patients
LP50  alveolar partial pressure sufficient to cause death in
50% of subjects
EC50  concentration of agonist required to activate 50%
of channels
 Appendix B
Equations
 GAS CONCENTRATIONS  EQUILIBRATION TIME CONSTANTS
In an ideal gas mixture: [A]mixture  nA / V  PA / RT (FOR 63% EQUILIBRATION)
{in terms of mol/L}   Volume Capacity / Flow Rate
In solution (Henrys law): {PtissuePalv} {PtissuePart}
[A]solution  Psolvent  (solvent/gas) {in terms of Lgas/Lsolvent}  Volume Capacity of Tissue / Tissue Blood Flow
[A]solution  Psolvent  (solvent/gas) / 24.5 {in terms of mol/  (tissue/blood)  Volume of Tissue / Tissue Blood Flow
Lsolvent}
{PbrainPart}  (brain/blood)  Volume of Brain / Blood
{where nA  moles of gas A, V  total volume, PA  Flow to Brain
partial pressure of A, R  universal gas constant, T 
temperature in degrees Kelvin} Pcontainer  Pflow [1 e (t/)]

 MEYEROVERTON RULE  VOLUME CAPACITY

Volume Capacity  ([A]compartment  Volume of
MAC 1.3 / (oil/gas)
compartment) / [A]medium {at equilibrium}
 (compartment/medium)  Volume of Compartment
 FICKS LAW FOR DIFFUSION ACROSS
A BOUNDARY  MIXED VENOUS PARTIAL PRESSURE
Rate of diffusion  D  (A / l)  P
PMVR  0.75 PVRG  0.18 PMG  0.055 PFG  0.015 PVPG
{where D  Diffusion constant; A  Surface area;
l  Thickness; P  Partial pressure difference}

 ALVEOLAR CAPILLARY RATE OF UPTAKE

Rate of uptake  ([A]art [A]MVR)  CO {in Lgas/min}
Rate of uptake  (blood/gas)  (Part PMVR)  CO
{where CO  cardiac output}

263
17
Pharmacology of Analgesia
Robert S. Griffin and Clifford J. Woolf
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 264-265
PHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Sensory Transduction: Excitation of
Primary Afferent Neurons . . . . . . . . . . . . . . . . . . . . . . . . . 265
Conduction from the Periphery to the Spinal Cord . . . . . . 267
Transmission in the Dorsal Horn of the Spinal Cord . . . . . 267
Descending and Local Inhibitory Regulation in the
Spinal Cord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
PATHOPHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Clinical Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
Peripheral Sensitization . . . . . . . . . . . . . . . . . . . . . . . . . . 270
Central Sensitization . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
Neuropathic Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
Migraine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 273
Opioid Receptor Agonists . . . . . . . . . . . . . . . . . . . . . . . . . 273
Mechanism of Action and Major Adverse Effects . . . . . 273
 INTRODUCTION
Everyone has experienced pain in response to an intense
or noxious stimulus. This physiologic ouch pain helps
us to avoid potential damage by acting as an early warning
or protective signal. Pain can, however, also be incapaci-
tating, as after trauma, during recovery from surgery, or
in association with medical conditions that are character-
ized by inflammation, such as rheumatoid arthritis. Under
circumstances where tissue injury and inflammation are
present, noxious stimuli elicit more severe pain than nor-
mal because of increases in the excitability of the soma-
tosensory system, and stimuli that would not normally
cause pain become painful. In addition, nerve injury pro-
duced by disease or trauma, as in amputation, HIV infec-
tion, varicella zoster (VZV) infection, cytotoxic treatment,
and diabetes mellitus, evokes pain that persists long after
the initiating cause has disappeared. In these conditions,
pathologic and sometimes irreversible alterations in the
structure and function of the nervous system lead to se-
vere and intractable pain. For such patients, the pain is the
pathology rather than a physiologic defense mechanism.
Finally, there are patients with no noxious stimuli and no
inflammation or lesions to the nervous system, but who
experience considerable pain. This dysfunctional pain, as
in tension-type headache, fibromyalgia, or irritable bowel
264
Morphine, Codeine, and Derivatives . . . . . . . . . . . . . . 274
Synthetic Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Partial and Mixed Agonists . . . . . . . . . . . . . . . . . . . . . 275
Opioid Receptor Antagonists . . . . . . . . . . . . . . . . . . . . 275
Nonsteroidal Anti-Inflammatory Drugs and
Nonopioid Analgesics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
General Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Specific Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Antiepileptic Drugs and Antiarrhythmics . . . . . . . . . . . . . . 277
NMDA Receptor Antagonists . . . . . . . . . . . . . . . . . . . . . . 277
Adrenergic Agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Migraine Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 278
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
syndrome, results from an abnormal function of the ner-
vous system.
These categories of painphysiologic, inflammatory,
neuropathic, and dysfunctionalare produced by a num-
ber of different mechanisms. Ideally, treatment should be
targeted at specific mechanisms rather than at suppressing
the symptom of pain. A number of pharmacologic agents
are currently available to relieve pain. These drugs have
mechanisms of action that interfere with the response of pri-
mary sensory neurons to somatic or visceral sensory stim-
uli, with the relaying of information to the brain, and with
the perceptual response to a painful stimulus. The following
discussion of pain and analgesic pharmacology begins by
describing the mechanisms by which noxious stimuli lead
to the perception of pain. The chapter continues by consid-
ering the processes responsible for the heightened pain sen-
sitivity that occurs in response to inflammation and lesions
of the nervous system. The chapter concludes by describing
the mechanisms of action of the major drug classes used for
clinical pain relief.
 PHYSIOLOGY
Pain is the end perceptual consequence of the neural
processing of particular sensory information. The initial
stimulus usually arises in the periphery and is transferred
 Central perception Cortex

Thalamus

Relay and descending

modulation

Brainstem

Transmission
Spinal cord

Conduction
Peripheral stimulus

Signal transduction
 ASIC, P2X, P2Y, B1, B2
Chemical receptors

Generator Reach
Mechanical Na+/Ca2+ potential Action
voltage-gated
influx (membrane potential
Mec
Mechanosensitive sodium channel
ion channels depolarization) threshold

Thermal
TRPV1, TRPV2
T
receptors
268 Principles of Central Nervous System Pharmacology

that descend from the brainstem to the dorsal horn. Be-

cause these systems can limit transfer of incoming sensory
information to the brain, they represent an important site
Primary
sensory neuron for pharmacologic intervention. The major inhibitory neu-
central terminal rotransmitters in the dorsal horn of the spinal cord are opioid
peptides, norepinephrine, serotonin (5-HT), glycine, and
Action potential GABA (Fig. 17-4). The physiology of GABA receptors is
discussed in Chapter 12, Pharmacology of GABAergic and
Glu
Glutamatergic Neurotransmission.
The opioid peptides inhibit synaptic transmission and
Ca2+ are released at several CNS sites in response to noxious

Calcium
influx
Synaptic vesicle
Glu release

Neuropeptides
CGRP Primary
Substance P sensory neuron
central terminal

Na+ 2+
Ca Glu
Glu
Na +
Action potential
2 Norepinephrine

Glu NMDA-R Glu

Ca2+
Voltage-dependent mGluR NK1 GABA
AMPA-R Na+ and Ca2+ CGRP-R
+ influx
Rapid Na Calcium
influx influx GABAB

Slow modulatory
Synaptic vesicle Glu
response release
Endorphins
Enkephalins
Neuropeptides
Postsynaptic depolarization CGRP
Substance P
Secondary
relay neuron
(postsynaptic Reach voltage-gated
membrane) Na+ channel threshold Na+ 2+
Ca Glu
Na +
Glu 2
Glu NMDA-R

Action potential mGluR NK1

CGRP-R GABAB
FIGURE 17-3. Neurotransmission in the spinal cord dorsal horn. An in- AMPA-R Voltage-dependent
+ 2+
coming action potential from the periphery activates presynaptic voltage-sensitive Rapid Na+ Na and Ca
calcium channels, leading to calcium influx and subsequent synaptic vesicle re- influx influx
lease. The released neurotransmitters (i.e., glutamate and neuropeptides, such as Cl- conductance K+
calcitonin gene-related peptide [CGRP] and substance P) then act on postsynaptic GABAA
Cl- K+ conductance
receptors. Stimulation of ionotropic glutamate receptors leads to fast postsynaptic
depolarization, while activation of other modulatory receptors mediates slower K+
Cl-
depolarization. Postsynaptic depolarization, if sufficient, leads to action potential Postsynaptic hyperpolarization
production (signal generation) in the secondary relay neuron.
Secondary
relay neuron Voltage-gated Na+ channels
(postsynaptic reaching threshold
neuropeptide-containing synaptic vesicles requires higher- membrane)
frequency and longer-lasting action potential trains than
release of glutamate-containing vesicles. Action potential generation
FIGURE 17-4. Inhibitory regulation of neurotransmission. Norepinephrine,
Descending and Local Inhibitory Regulation in GABA, and opioids, released by descending and/or local-circuit inhibitory neurons,
act both presynaptically and postsynaptically to inhibit neurotransmission. Presyn-
the Spinal Cord aptic inhibition is mediated through reduced activity of voltage-sensitive calcium
Synaptic transmission in the spinal cord is regulated by the channels, whereas postsynaptic inhibition is mediated primarily by enhanced
actions of both local inhibitory interneurons and projections chloride influx and potassium efflux.

stimuli. All endogenous opioid peptides, which include -
endorphin, the enkephalins, and the dynorphins, share
the N-terminal sequence Tyr-Gly-Gly-Phe-Met/Leu. The
opioids are proteolytically released from the larger pre-
cursor proteins pro-opiomelanocortin, proenkephalin, and
prodynorphin. Opioid receptors traditionally fall into three
classes, designated , , and , all of which are seven-
transmembrane G protein-coupled receptors. The -opioid
receptors mediate morphine-induced analgesia. This conclu-
sion is based on the observation that the -opioid receptor
knockout mouse exhibits neither analgesia nor adverse ef-
fects in response to morphine administration. The endog-
enous opioid peptides are receptor-selective: the dynorphins
act primarily on receptors, while both enkephalins and -
endorphin act on and receptors. The related ORL recep-
tor for the peptide nociceptin has recently been identified.
The physiologic role of these endogenous opioid peptides
remains poorly understood. The effects of opioid receptor
signaling include reduced presynaptic calcium conductance,
enhanced postsynaptic potassium conductance, and reduced
adenylyl cyclase activity. The first function impedes presyn-
aptic neurotransmitter release; the second reduces postsyn-
aptic neuronal responses to excitatory neurotransmitters; the
physiologic role of the last remains unknown.
Opioids produce analgesia because of their action in the
brain, brainstem, spinal cord, and peripheral terminals of
primary afferent neurons. In the brain, opioids alter mood,
produce sedation, and reduce the emotional reaction to pain.
In the brainstem, opioids increase the activity of cells that
provide descending inhibitory innervation to the spinal cord;
here, opioids also produce nausea and respiratory depres-
sion. Spinal opioids inhibit synaptic vesicle release from pri-
mary afferents and hyperpolarize postsynaptic neurons (see
above). There is also evidence that peripheral opioid receptor
stimulation reduces the activation of primary afferents and
modulates immune cell activity. Action of opioids at these
serially located sites is thought to have a synergistic effect to
inhibit information flow from the periphery to the brain.
Norepinephrine is released by projections that descend
from the brainstem to the spinal cord. The 2-adrenergic re-
ceptor, a seven-transmembrane G protein-coupled receptor
(see Chapter 10, Adrenergic Pharmacology), is the primary
receptor for norepinephrine in the spinal cord. As with opioid
receptor activation, 2-adrenergic receptor activation inhib-
its presynaptic voltage-gated calcium channels, opens post-
synaptic potassium channels, and inhibits adenylyl cyclase.
Because 2-adrenergic receptors are expressed both presyn-
aptically and postsynaptically, spinal norepinephrine release
can both reduce presynaptic vesicle release and decrease
postsynaptic excitation. The 2-adrenergic receptor agonist
clonidine is sometimes used to treat pain, although this ap-
plication is limited by adverse effects that include sedation
and postural hypotension. Serotonin is also released in the
spinal cord by projections that descend from the brainstem.
This neurotransmitter acts on several receptor subtypes that
mediate both excitatory and inhibitory effects on nociception.
The 5-HT3 ligand-gated channel may be responsible for the
excitatory actions of serotonin in the spinal cord; several of
the 5-HT G protein-coupled receptors may mediate the inhib-
itory actions of 5-HT. Given this complexity, the mechanism
of the analgesic effect of serotonin is not fully understood.
Selective serotonin reuptake inhibitors have been tested in
the treatment of pain but generally have had little beneficial
CHAPTER 17 / Pharmacology of Analgesia 269
effect. Selective norepinephrine (NE) reuptake inhibitors do
have an analgesic action, as do dual NE/5-HT reuptake inhib-
itors such as duloxetine. Tramadol, a weak centrally acting
opioid, also has monoaminergic actions and is widely used to
treat mild pain. Its relatively weak efficacy as a single agent
is increased when combined with acetaminophen, and its lack
of abuse potential makes the drug attractive to prescribers.
Other compounds also have regulatory roles in the spinal
cord. The cannabinoid receptors and the endogenous canna-
binoids have recently become a focus for research on pain reg-
ulation. There are two cannabinoid receptors, both of which are
G protein-coupled: CB1, expressed in the brain, spinal cord,
and sensory neurons; and CB2, largely expressed in nonneu-
ral tissues, especially immune cells including microglia. Sev-
eral endogenous cannabinoids have been identified, including
members of the anandamide and 2-arachidonylglycerol
(2AG) families. Anandamide and 2-AG are synthesized via
separate pathways for immediate use without storage. Anan-
damide has relatively low efficacy at CB1 and CB2, whereas
2-AG has high efficacy at both receptors. Clearance of anan-
damide is mediated by fatty acid amino hydrolase (FAAH);
2-AG is cleared via monacylglycerol lipase. A combination
of anecdotal evidence and clinical trial data suggests that
marijuana has an analgesic effect in patients with AIDS neu-
ropathy or multiple sclerosis. Selective cannabinoid receptor
agonists and FAAH inhibitors under development may prove
useful for pain management. Preclinical data have specifically
implicated the CB1 receptor as a mediator of analgesia fol-
lowing a stressor, whereas CB2 receptors are up-regulated in
spinal cord microglia after peripheral nerve injury.
Endogenous cannabinoids could modulate pain via can-
nabinoid receptors that are located peripherally or in the
spinal cord and that affect nociceptive transmission or via
receptors in the periaqueductal gray that affect descending
inhibitory projections. Centrally acting CB1 agonists could
have psychotropic effects and may have abuse potential. The
CB1 receptor antagonist rimonabant was approved in 2006
in Europe for use in the treatment of obesity but was later
withdrawn because of concerns about adverse effects includ-
ing severe depression and suicidality. This agent was never
approved for use in the United States.
 PATHOPHYSIOLOGY
The pain processing circuit described above is responsible
for producing acute nociceptive pain, a physiologic, adap-
tive sensation elicited only by noxious stimuli that acts as a
warning or protective signal. There are some clinical situa-
tions, such as acute trauma, labor, or surgery, in which it is
necessary to control nociceptive pain. In these cases, the pain
pathway can be interrupted either by blocking transmission
with local anesthetics (see Chapter 11) or by administering
high-dose opioids. The opioids may be rapidly acting, such
as remifentanil for intraoperative use, or more slowly act-
ing, such as morphine; administered perioperatively, mor-
phine retains activity for postoperative pain control.
Both peripheral inflammation and nervous system dam-
age produce pain that is characterized by hypersensitivity to
noxious and innocuous stimuli and by spontaneous pain that
arises in the absence of any obvious stimulus. Understanding
the mechanisms responsible for these types of clinical pain
will facilitate both the appropriate use of currently available
drugs and the development of novel therapeutic agents.
Mechanical
Chemical P
Na+/Ca2+
Thermal
influx Generator
potential Reach
(membrane voltage-gated Action
depolarization) sodium channel potential
threshold

PKC activation
Sensitizing
agents PKA activation
P

Tyr
Na+
TrkA
 Primary
sensory neuron
central terminal

Action potential

Glu

Ca2+

Calcium
influx

Glu Synaptic vesicle

S
release

BDNF
Substance P

Ca2+
Mg2+
Glu
Na+ Glu

Glu NMDA-R
P
AMPA-R mGluR P Tyr
NK1 Tyr
P Ca2+ P
+
Na
TrkB

Initial Kinase activation

depolarization (PKC, CAMK II, ERK)

Phosphorylation of Phosphorylation of
postsynaptic gene regulatory
proteins proteins

Secondary
relay neuron
(postsynaptic Altered gene
membrane) expression

Short term Long term

sensitization sensitization
 CHAPTER 17 / Pharmacology of Analgesia 273

To brain

Altered gene expression Dorsal horn

Dorsal root ganglion
and sensitivity

Schwann cell reaction, inflammatory

cell infiltration, cytokine and growth
factor secretion
Free nerve endings

Neurotrophic
support

Site of
axonal injury
Loss of
neurotrophic Spinal cord
support
FIGURE 17-7. Schematization of neuropathic pain. Nerve injury results in a combination of negative signals and positive signals that alter the physiology of the
nociceptive system. The loss of neurotrophic support alters gene expression in the injured nerve fiber, whereas the release of inflammatory cytokines alters gene expres-
sion in both the injured and adjacent uninjured nerve fibers. These changes in gene expression can lead to altered sensitivity and activity of nociceptive fibers and, thus,
to the continued perception of injury that is characteristic of neuropathic pain.

Evidence from a rare autosomal dominant disorder, fa-
milial hemiplegic migraine (FHM), may shed light on the
mechanisms of migraine in general. This disorder consists
of migraine attacks with a particular aura characterized by
one-sided motor paralysis. Three genes have been associated
with FHM: CACNA1A, ATP1A2, and SCNA1. CACNA1A
encodes a Cav2.1 voltage-sensitive calcium channel subunit.
In animal models, Cav2.1 gain-of-function mutations cause
increased presynaptic calcium and increased glutamate re-
lease, which may help explain the trigger for cortical spread-
ing depression. ATP1A2 encodes a subunit of the Na/K
ATPase, which is critical for the maintenance of neuronal
membrane potential and which produces the Na gradient
needed for glutamate transport. SCNA1 encodes a voltage-
sensitive sodium channel subunit that is involved in action
potential conduction. Whether the more common forms of
migraine are associated with similar changes in these genes
remains unknown.
 PHARMACOLOGIC CLASSES AND
AGENTS
Several drug classes are widely used for pain relief. These
include opioid receptor agonists, NSAIDs (see Chapter 42),
tricyclic antidepressants (see Chapter 14, Pharmacology of
Serotonergic and Central Adrenergic Neurotransmission), an-
tiepileptic drugs (sodium channel blockers) (see Chapter 15,
Pharmacology of Abnormal Electrical Neurotransmission in
the Central Nervous System), NMDA receptor antagonists
(see Chapter 12, Pharmacology of GABAergic and Gluta-
matergic Neurotransmission), and adrenergic agonists. In
addition, 5-HT1 receptor agonists have specific applications
in the acute treatment of migraine.
Opioid Receptor Agonists
Opioid receptor agonists are the primary drug class used
in the acute management of moderate to severe pain. The
naturally occurring opioid receptor agonist morphine has
the greatest historical importance and remains in wide use,
but synthetic and semisynthetic opioids add pharmacokinetic
versatility. Historically, opioids have been most widely used
to treat acute and cancer-related pain, but in recent years,
they have become one component of the management of
chronic noncancer pain as well.
Mechanism of Action and Major Adverse Effects
Opioid receptor agonists produce both analgesia and other
effects by acting on -opioid receptors (Fig. 17-8). Sites of
analgesic action include the brain, brainstem, spinal cord, and
primary afferent peripheral terminals, as described previously.
Opioids produce a wide array of adverse effects. These
effects are qualitatively similar across opioids, but may
vary in intensity. In the cardiovascular system, opioids
can reduce sympathetic tone and lead to orthostatic hy-
potension; a subgroup of opioids, most notably morphine,
causes histamine release that can also contribute to ortho-
static hypotension via vasodilation. Opioids can also cause
bradycardia. Respiratory effects are often the major, dose-
limiting adverse effect of opioids. By acting on the medul-
lary respiratory control center, opioids blunt the respiratory
response to carbon dioxide and can cause periods of apnea.
Importantly, the respiratory effects of opioids interact with
other stimuli; painful or other arousing stimuli can promote
ventilation, while natural sleep synergizes with opioids to
suppress ventilation. Acting through receptors in the med-
ullary chemoreceptor zone and the gastrointestinal tract,
opioids also produce nausea, vomiting, and constipation.
Acting through receptors in the genitourinary system, opi-
oids can cause urinary urgency and urinary retention. In the
central nervous system, opioids can cause sedation, confu-
sion, dizziness, euphoria, and myoclonus. It has recently
become apparent that excessive use of opioids can lead to a
paradoxical opioid-induced hyperalgesia.
Opioid use is often associated with the development of
tolerance, in which repeated use of a constant dose of a drug
 Primary
sensory neuron
central terminal

Action potential
-agonist

Glu

Ca2+

Calcium
influx

Glu Synaptic vesicle

release

Descending
Neuropeptides
modulation
CGRP
or exogenous
Substance P
drug
-agonist
K+ (opioid, enkephalin,
endorphin)
Na+
K+ channel
Glu -opioid
receptor
AMPA-R
K+

Na+
K+ conductance

Postsynaptic hyperpolarization

Voltage-gated Na+ channels

reaching threshold
Secondary
relay neuron
(postsynaptic
membrane) Action potential
generation
276 Principles of Central Nervous System Pharmacology
Peripheral Central cytokine
inflammation release
COX-2 upregulation COX-2 upregulation in dorsal
in inflammatory cells horn neurons and supporting cells
Acetaminophen
Celecoxib
NSAIDs
Prostaglandin Prostaglandin
production production
Constitutive COX-1
Action on peripheral Action on PGE2 receptors
terminal PGE2 receptors on dorsal horn neurons
Peripheral Enhanced depolarization of
sensitization secondary sensory neurons
FIGURE 17-9. Mechanism of analgesic action of cyclooxygenase
inhibitors. Inflammatory states are often associated with the production of pros-
taglandins, which are important mediators of both peripheral (left) and central
(right) pain sensitization. In the periphery, prostaglandins produced by inflam-
matory cells sensitize peripheral nerve terminal prostaglandin (EP ) receptors,
making them more responsive to a painful stimulus. In central pain pathways,
cytokines released in response to inflammation induce prostaglandin production
in the dorsal horn of the spinal cord. These prostaglandins sensitize secondary
nociceptive neurons and thereby increase the perception of pain. Nonsteroidal
anti-inflammatory drugs (NSAIDs) block peripheral and central sensitization medi-
ated by prostanoids that are released in inflammation; NSAIDs also reduce the
extent of inflammation.
effects are primarily attributable to inhibition of COX-1, a
constitutive enzyme responsible for the production of pros-
tanoids involved in physiologic tissue maintenance and
vascular regulation. However, this view may be an over-
simplification because COX-2 may be induced to support
COX-1 activity in the setting of gastric mucosal injury, and
COX-1 may produce prostaglandins in tandem with COX-2
in inflammatory states. There is also concern that COX-2
inhibition may promote thrombosis and reduce or delay
wound healing.
Specific Agents
There are several major classes of NSAIDs, including the
salicylates (aspirin or acetylsalicylate), indole acetic acid
derivatives (indomethacin), pyrrole acetic acid derivatives
(diclofenac), propionic acid derivatives (ibuprofen), and
benzothiazines (piroxicam). The para-aminophenols (acet-
aminophen) are a related class of compounds with analgesic
and antipyretic activity, but not anti-inflammatory activity.
The COX-2 selective inhibitors celecoxib, rofecoxib, and
valdecoxib were designed to produce analgesia equivalent
to that of the NSAIDs while decreasing the adverse effects
associated with chronic NSAID use. This has turned out to
be a disappointment, and both rofecoxib and valdecoxib have
been withdrawn from the market because of an increased
risk of cardiovascular effects and skin reactions. Representa-
tive agents are discussed here; further information on their
anti-inflammatory uses and adverse effects is discussed in
Chapter 42.
Acetylsalicylic acid (aspirin) acts by covalently acety-
lating the cyclooxygenase active site in both COX-1
and COX-2. Aspirin is rapidly absorbed and distributed
throughout the body. Chronic aspirin use can produce
gastric irritation and erosion, hemorrhage, vomiting, and
renal tubular necrosis. Aspirin is of great value in the treat-
ment of mild or moderate pain.
The coxibs are COX-2 selective enzyme inhibitors. Cur-
rently, only celecoxib remains in clinical use in the United
States. This class of drugs was originally reserved for
patients who required NSAIDs but were at high risk for
developing gastrointestinal (GI), renal, or hematologic
adverse effects, although there is no clinical evidence that
celecoxib reduces the risk of GI adverse effects.
The widely used compound ibuprofen is a derivative of
propionic acid. Used primarily for analgesia and anti-
inflammatory action, it also is an antipyretic, and it has a
lower incidence of adverse effects than aspirin. Another
common propionic acid derivative is naproxen. Compared
to ibuprofen, naproxen is more potent and has a longer
half-life; therefore, it can be administered less frequently
with equivalent analgesic efficacy. Its adverse effect profile
is similar to ibuprofen, and it is generally well tolerated.
As with all NSAIDs, ibuprofen and naproxen can cause GI
complications ranging from dyspepsia to gastric bleeding.
The pyrrole acetic acid derivatives diclofenac and ketoro-
lac are used to treat moderate to severe pain. Ketorolac can
be administered orally or parenterally, while diclofenac is
available in oral formulations. Both agents carry a risk of
severe adverse effects, including anaphylaxis, acute renal
failure, StevensJohnson syndrome (a diffuse life-threaten-
ing rash involving the skin and mucous membranes), and
gastrointestinal bleeding. Ketorolac is valuable for short-
term pain control when avoidance of opioid adverse effects
is desirable, for example, in day-surgery patients. Topical
formulations of these drugs may have some utility.
Acetaminophen (paracetamol) preferentially reduces cen-
tral prostaglandin synthesis by an uncertain mechanism;
as a result, the drug produces analgesia and antipyresis but
has little anti-inflammatory efficacy. Acetaminophen is
frequently combined with weak opioids for the treatment
of moderate pain, and preparations featuring acetamino-
phen combined with codeine, hydrocodone, oxycodone,
pentazocine, or propoxyphene are available. Following
deacetylation to its primary amine, acetaminophen is con-
jugated to arachidonic acid by fatty acid amide hydrolase
in the brain and spinal cord; the product of this reaction,
N-arachidonoylphenolamine, may inhibit COX-1 and
COX-2 in the CNS. N-arachidonoylphenolamine is an en-
dogenous cannabinoid and an agonist at TRPV1 receptors,
suggesting that direct or indirect activation of TRPV1 and/
or cannabinoid CB1 receptors could also be involved in
the mechanism of acetaminophen action. A major concern
for acetaminophen is its low therapeutic index, as the drug
is hepatotoxic and overdose can result in liver failure.
Tramadol is a centrally acting analgesic. Analgesia ap-
parently results from a monoaminergic effect within the
CNS, as well as an opioid effect mediated by a metabolite
that is formed by O-demethylation of the parent drug by
CYP2D6. Tramadol has minimal abuse liability, but it does
278 Principles of Central Nervous System Pharmacology

Clonidine does, however, cause postural hypotension; this producing pain; intervention at several steps may be required
effect limits its usefulness in pain control. to achieve adequate analgesia (Fig. 17-10). Because many
drugs used to treat pain are also active systemically and/or
Migraine Therapy in parts of the nervous system that are not related to somatic
The treatment of pain associated with migraine has fea- sensation, analgesics can produce deleterious adverse ef-
tures distinct from the treatment of other pain conditions. fects. One approach to limiting toxicity is to use localized
In many but not all patients, an effective treatment for (nonsystemic) forms of drug delivery. In particular, epidural
migraine is the triptan class of serotonin receptor ago- and topical delivery limit the drug to a local site of action.
nists; the most well-studied example is sumatriptan. The
triptans are selective for the 5-HT1B and 5-HT1D receptor
subtypes of the 5-HT1 family, one of the seven families of
serotonin receptor. 5-HT1B receptors are located on vascu- Central perception
Cortex
lar endothelial cells, smooth muscle cells, and neurons, in- (opioids)
cluding trigeminal nerves. 5-HT1D receptors are present in
the trigeminal nerves that innervate the meningeal blood
vessels. Triptrans reduce both sensory activation in the
periphery and nociceptive transmission in the brainstem
trigeminal nucleus, where they diminish central sensitiza-
tion. The triptans also cause vasoconstriction, opposing
the vasodilation thought to be involved in the pathophysi-
ology of migraine attacks. It remains unclear whether the
vasoconstriction is helpful in producing the antimigraine Thalamus
actions of these drugs, however. Furthermore, as a result
of this vasoconstrictive effect, the triptans can be danger-
Relay and descending
ous in patients with coronary heart disease. The triptans modulation
can reduce the pain and other symptoms associated with
acute migraine attack and have largely replaced the va-
soconstrictive agent ergotamine in the treatment of mi-
graine. Sumatriptan can be administered subcutaneously,
orally, or by nasal inhalation; the nasal formulation may
have an improved therapeutic index. Several other orally
administered agents in the triptan class are also available, Brainstem
including zolmitriptan, naratriptan, and rizatriptan (see
Drug Summary Table). NSAIDs, opioids, caffeine, and
antiemetics also have activity and some utility for treat-
ment of acute migraine headaches. For example, a com-
bination of indomethacin, prochlorperazine, and caffeine
may have effectiveness similar to triptans in the treatment Transmission
of migraine attacks. During an attack, migraine patients (opioids, antidepressants,
often experience gastric stasis that can reduce the bioavail- Spinal cord NSAIDs, antiepileptics,
ability of oral medications. CGRP receptor antagonists are 2 adrenergic agonists,
celecoxib,
promising candidates for migraine therapy. 2 binding agents)
Although the triptans are relatively effective in ameliorat- Conduction
ing the acute symptoms of migraine, other classes of drugs (sodium channel Peripheral stimulus
are used to reduce the frequency of attacks. Numerous drugs blockers)
are used for migraine prophylaxis, including -adrenergic
blockers, valproic acid, serotonin antagonists, and calcium
channel blockers. These agents are generally chosen based Signal transduction
on the severity and frequency of the migraine attacks, the (NSAIDs)
cost of the drug, and the adverse effects of the drug in the
context of the individual patient. None has been shown to FIGURE 17-10. Summary of the sites of action of the major drug classes
used for pain management. Analgesics target various steps in pain perception,
have a high level of efficacy, and new drugs need to be devel- from the initiation of a pain stimulus to the central perception of that pain. NSAIDs
oped for more effective migraine prophylaxis. modulate the initial membrane depolarization (signal transduction) in response
to a peripheral stimulus. Sodium channel blockers decrease action potential
conduction in nociceptive fibers. Opioids, antidepressants, NSAIDs, antiepileptic
 CONCLUSION AND FUTURE DIRECTIONS drugs (anticonvulsants), and 2-adrenergic agonists all modulate transmission
of pain sensation in the spinal cord by decreasing the signal relayed from pe-
Because of the limited efficacy of any single drug, it is com- ripheral to central pain pathways. Opioids also modulate the central perception
mon in clinical practice to use a polypharmacy approach to of painful stimuli. The multiple sites of action of analgesics allow a combination
manage pain. In combination, several drugs that are only drug approach to be used in pain management. For example, moderate pain is
moderately effective as single agents can have additive or often treated with combinations of opioids and NSAIDs. Because these drugs have
supra-additive effects. This is largely a consequence of the different mechanisms and sites of action, the combination of the drugs is more
multiple processing events and mechanisms responsible for effective than one drug alone.

Many of the opioids are short-acting and must be adminis-
tered frequently to patients in severe pain. Modes of drug
delivery have also been developed to optimize the pharma-
cokinetics of the short-acting opioids; these methods include
transdermal and buccal dosage forms, patient-controlled
analgesia devices, and controlled-release oral preparations.
Patient-controlled devices ensure that patients do not suffer
pain because of waning drug effects, and instrumental con-
trols can effectively prevent overdose. At the present time,
however, patient-controlled technologies are suitable only
for inpatient treatment.
Most of the currently available analgesics have been
identified by empirical observation (opioids, NSAIDs, and
local anesthetics) or serendipity (antiepileptic drugs). Now
that the mechanisms responsible for pain are being explored
at a molecular level, many new targets are being revealed
that are likely to lead to new and different classes of analge-
sics. It is hoped that drugs active at these targets will achieve
greater efficacy and have fewer adverse effects than current
therapies. Effective pain management approaches must not
only rely on pharmacologic intervention; physical therapy
and rehabilitation and, in some very limited situations, sur-
gical approaches may also have a role. The placebo reaction
produces analgesia and may explain the limited success pro-
duced by treatments such as acupuncture and homeopathy.
These effects are usually unpredictable, modest, and of short
duration. The growing complexity of pain management has
spawned specialized pain services for inpatient pain control,
as well as pain clinics and centers for the outpatient manage-
ment of chronic pain.
CHAPTER 17 / Pharmacology of Analgesia 279
Acknowledgments
The authors thank Salahadin Abdi, MD, Rami Burstein,
PhD, Carl Rosow, MD, PhD, and Joachim Scholz, MD, for
their valuable comments.
Suggested Reading
Costigan M, Scholz J, Woolf CJ. Neuropathic pain: a maladaptive response
of the nervous system to damage. Annu Rev Neurosci 2009;32:132. (Over-
view of mechanisms of neuropathic pain.)
Drenth JP, Waxman SG. Mutations in sodium-channel gene SCN9A cause
a spectrum of human genetic pain disorders. J Clin Invest 2007;117:3603
3609. (Reviews channelopathies that produce pain and their treatment.)
Eisenberg E, McNicol ED, Carr DB. Efficacy and safety of opioid ago-
nists in the treatment of neuropathic pain of nonmalignant origin. JAMA
2005;293:30433052. (A systematic review of published randomized con-
trolled trials using opioids for nonmalignant neuropathic pain.)
Finnerup NB, Otto M, McQuay HJ, et al. Algorithm for neuropathic pain
treatment: an evidence-based proposal. Pain 2005;118:289305. (Clinical
approach to management of neuropathic pain.)
Patapoutian A, Tate S, Woolf CJ. Transient receptor potential channels: tar-
geting pain at the source. Nat Rev Drug Discov 2009;8:5568. (Review of
the status of TRP channels as analgesic targets.)
Rosow CE, Dershwitz M. Pharmacology of opioid analgesics. In: Long-
necker D, Brown DL, Newman MF, Zapol WM, eds. Anesthesiology. New
York: McGraw Hill; 2008. (Detailed review of opioid pharmacology.)
Taylor CP. Mechanisms of analgesia by gabapentin and pregabalincalcium
channel alpha2-delta [Cavalpha2-delta] ligands. Pain 2009;142:1316. (Re-
view on the mechanisms of action of alpha 2 delta ligands as analgesics.)
Woolf CJ. Pain: moving from symptom control toward mechanism-specific
pharmacologic management. Ann Intern Med 2004;140:441451. (Advances
in molecular understanding of pain pathways.)
18
Pharmacology of Drugs of Abuse
Peter R. Martin, Sachin Patel, and Robert M. Swift
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 284-285
DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
MECHANISMS OF TOLERANCE, DEPENDENCE,
AND WITHDRAWAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Dependence and Withdrawal . . . . . . . . . . . . . . . . . . . . . . 289
MECHANISMS OF ADDICTION . . . . . . . . . . . . . . . . . . . . . . . 291
Learning and Development of Addiction . . . . . . . . . . . . . . 291
Variables Affecting the Development of Addiction . . . . . . . 293
Role of Personality Characteristics and
Co-Occurring Disorders in Addiction. . . . . . . . . . . . . . . . . 295
DRUGS OF ABUSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
Opioids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
Benzodiazepines and Barbiturates . . . . . . . . . . . . . . . . . . 296
 INTRODUCTION
This chapter considers pharmacologic agents implicated in
drug abuse and dependence and the brain processes relevant
to understanding drug addiction. While the pharmacology
of these agents is important to understanding their effects
on behavior and their abuse liability, personality characteris-
tics, as well as the presence of co-occurring psychiatric and
medical conditions, may also contribute to the risk of devel-
oping drug abuse and addiction. Understanding abuse and
addiction as a biopsychosocial disorder, rather than simply
the pharmacologic consequences of chronic drug use, has
led to recognition of the central role that learning plays in
drug addiction and the potential for an integrated pharma-
copsychosocial approach to treatment.
Most individuals with drug use disorders also have a
second diagnosable psychiatric condition, but it is not easy
to determine whether psychiatric symptoms are a cause or
consequence of drug use. For example, although alcohol
is widely used to self-medicate depression and/or anxiety,
it may be difficult to determine whether such psychiatric
symptoms in alcoholics are the cause of drinking or its ef-
fect, because the actions of alcohol per se, as well as alcohol
withdrawal and dependence, can also result in significant
anxiety or depression.
Genetic determinants of the psychopharmacologic actions
of abused drugs are increasingly recognized. Nonetheless,
environmental variables have a significant influence on the
284
Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Nicotine and Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Cocaine and Amphetamine . . . . . . . . . . . . . . . . . . . . . . . 299
Marijuana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
Other Abused Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
MEDICAL COMPLICATIONS OF DRUG ABUSE
AND DEPENDENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
TREATMENTS FOR ADDICTION . . . . . . . . . . . . . . . . . . . . . . 302
Detoxification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
Self-Help and Mutual Support Programs . . . . . . . . . . . . . 303
Pharmacologic Treatment of Addiction . . . . . . . . . . . . . . . 304
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 306
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
development of addiction. For example, societal attitudes to-
ward drug use often influence the likelihood that a drug will
be taken in the first place. The availability and cost of a drug
are also affected by its legal and tax status. The availability
of other, nondrug alternatives may be a key factor in deter-
mining the likelihood of drug use and addiction.
This chapter describes the mechanisms of action of se-
lected representative drugs of abuse, and the mechanisms of
other important drugs of abuse are summarized in Table 18-1.
Since addiction is a disorder of brain reward pathways, learn-
ing, and motivated behavior, the use of medications in an in-
tegrated pharmacopsychosocial approach to treat addiction
is also discussed.
 DEFINITIONS
The empirically based nomenclature promulgated by the
American Psychiatric Association (APA) in the Diagnostic and
Statistical Manual (DSM, Box 18-1) defines substance depen-
dence (used interchangeably in this chapter with addiction)
as maladaptive use leading to significant impairment or
distress. This definition avoids value judgment and is gener-
alizable across cultures. Psychosocial features of dependence
are similar for diverse psychopharmacologic agents with abuse
liability and are likely more important in the development and
maintenance of pathologic drug use than the unique pharma-
cologic profile of any given drug. Diagnostic features are con-
ceptualized as clinical clusters of symptoms: loss of control,
288 Principles of Central Nervous System Pharmacology

Acute use Withdrawal

A GABAA-R(4)
Cl- Cl- Cl- Ca2+
Cl- Ca2+
GABAA-R

Ca2+ Ca2+
P
Cl- Cl- Cl- Ca2+ P
Ca2+ NMDA-R(NR2B)
Alcohol Ca2+ Ca2+ P

NMDA-R

Decreased
excitability Increased
excitability
B Acute use Withdrawal
Anxiolysis/
sedation Anxiety
GABA
Coma Seizures Morphine

i

Neuroadaptation GDP i

K+ GDP P
Time x Dose Receptor
K+channel AC degradation
Dependence AC
AC K+
-opioid
receptor PKA
PKA K+ channel
(closed)

CREB
Gene
transcription
C

Decreased Increased
excitability excitability
Arousal/pleasure Fatigue/dysphoria
Dopamine Decreased Increased
receptor neurotransmitter neurotransmitter
Dopamine release release

Acute use Withdrawal

Euphoria Withdrawal
symptoms
(dysphoria,
Cocaine lacrimation,
diarrhea)
Amphetamine
Neuroadaptation
Time x Dose
DA transporter Dependence

Dopamine D2
receptor
DA DA

L-DOPA L-DOPA
Tyrosine Tyrosine
hydroxylase hydroxylase
Tyrosine Tyrosine

Neuroadaptation
Time x Dose
Dependence
 CHAPTER 18 / Pharmacology of Drugs of Abuse 289

FIGURE 18-1. Mechanisms of acute drug action for depressants, opioids, and psychostimulants, and development of neuroadaptation and dependence in
response to chronic drug use. (A) Alcohol modulates the major inhibitory and excitatory neurotransmitter systems of the brain via effects on GABAA and NMDA recep-
tors, respectively. Alcohol is a positive allosteric modulator of GABAA receptors. Alcohol increases chloride conductance through GABAA receptors, resulting in cellular
hyperpolarization. Alcohol also decreases calcium conductance through NMDA receptors, further decreasing cellular excitation. These dual actions on GABAA and NMDA
receptors contribute to alcohols anxiolytic, sedative, and CNS-depressant effects. Molecular adaptations to chronic alcohol exposure include: (1) internalization and
decreased surface expression of normal 1 subunit-containing GABAA receptors; (2) increased surface expression of low alcohol sensitivity 4 subunit-containing
GABAA receptors; and (3) increased phosphorylation of NMDA receptors containing high conductance NR2B subunits. Thus, neuroadaptation results in tolerance to
the acute depressant effects of alcohol and occurs concomitantly with dependence. During withdrawal (i.e., in the dependent state but in the absence of alcohol), these
adaptations result in generalized hyperexcitability of neurons. CNS excitation is expressed as anxiety, insomnia, delirium, and potentially seizures. (B) Opioids activate
-opioid receptors located on synaptic nerve terminals. Acute activation of -opioid receptors results in G protein-dependent activation of potassium channels and
inhibition of adenylyl cyclase activity. These effects result in cellular hyperpolarization and decreased GABA release from the nerve terminal; the decreased GABA release
results in disinhibition of ventral tegmental area (VTA) dopamine neurons. Molecular adaptations to chronic -opioid receptor stimulation include: (1) increased -opioid
receptor phosphorylation, resulting in receptor internalization and degradation; (2) decreased efficacy of -opioid signal transduction; and (3) hyperactivation of adenylyl
cyclase signaling, leading to enhanced GABA release and to increased gene transcription via activation of transcription factors including cyclic AMP response element
binding protein (CREB). Thus, neuroadaptation results in tolerance to the euphoric effects of opioids. During withdrawal (i.e., in the dependent state but in the absence
of opioid), the enhanced GABA release from inhibitory interneurons results in inhibition of VTA dopamine neurons, dysphoria, and anhedonia. (C) Acute cocaine exposure
inhibits dopamine reuptake transporters (DAT), resulting in increased synaptic dopamine levels and increased postsynaptic dopamine receptor activation at synapses
in the nucleus accumbens; in turn, these effects cause feelings of euphoria and increased energy. Increased extrasynaptic dopamine also results in D2 autoreceptor
activation, which decreases dopamine synthesis. Amphetamine both releases vesicular transmitter stores into the cytoplasm and inhibits neurotransmitter reuptake into
vesicles; these combined actions cause neurotransmitter concentrations to increase in the synaptic cleft. During chronic psychostimulant exposure, DAT expression
increases, the number of postsynaptic dopamine receptors decreases, and presynaptic dopamine is depleted. Thus, neuroadaptation results in tolerance to the euphoric
effects of psychostimulants. During withdrawal (i.e., in the dependent state but in the absence of psychostimulant), the decreased synaptic levels of dopamine that
result from reduced dopamine synthesis and increased clearance through DAT cause decreased activation of postsynaptic dopamine receptors and feelings of dysphoria,
fatigue, and anhedonia.

Dependence and Withdrawal
Dependence is typically associated with tolerance, and it re-
sults from mechanisms closely related to those that produce
pharmacodynamic and learned tolerance. The dependence
syndrome results from the need for the drug to be present
in the brain to maintain near-normal functioning. If the
drug is eliminated from the body so that it no longer occu-
pies its site of action, the adaptations that produced depen-
dence are unmasked and manifested as an acute withdrawal
syndrome that lasts until the system re-equilibrates to the
absence of drug (days). Subsequently, a protracted with-
drawal syndrome, characterized by craving for the drug
(i.e., an intense preoccupation with obtaining the drug), may
emerge and continue indefinitely (years). Protracted with-
drawal is also associated with subtle dysregulation of learn-
ing, drives/motivations, and reward. This syndrome should
be distinguished from premorbid risk factors for addiction
that do not resolve with abstinence and from brain injury that
is sustained as a result of drug use.
Like tolerance, dependence is associated with changes
in cellular signaling pathways (Fig. 18-1). For example, up-
regulation of the cAMP pathway by a drug contributes to
acute withdrawal upon discontinuation of the drug because
up-regulated adenylyl cyclase effects a supranormal re-
sponse in neurons when physiologic amounts of neurotrans-
mitter stimulate the cAMP-coupled receptor. Conversely, a
drug that produces dependence by decreasing receptor num-
ber or receptor sensitivity renders the down-regulated recep-
tors understimulated after drug discontinuation.
The effects of alcohol illustrate that excitatory and inhibi-
tory mechanisms can act in a synergistic fashion on oppos-
ing neurotransmitter systems. Acute alcohol intake causes
sedation by facilitating the inhibitory activity of GABA at its
receptors and inhibiting the excitatory activity of glutamate
at its receptors. Over time, the GABA receptors are down-
regulated and their subunit structure is modified through
a variety of molecular mechanisms, thus decreasing the
level of inhibition to counter the sedative effects of alco-
hol. Simultaneously, the NMDA receptors are up-regulated,
also decreasing the level of inhibition due to alcohol. If the
alcohol is abruptly removed, the decreased GABAergic in-
hibition and enhanced glutamatergic excitation result in a
state of central nervous system hyperactivity, which causes
the signs and symptoms of alcohol withdrawal. The balance
between these inhibitory (GABAergic) and excitatory (glu-
tamatergic) pathways may explain the alternating sedation
and hyperactivity characteristic of alcohol withdrawal.
Because dependence can occur without tolerance and vice
versa, it is clear that learning-related changes, not necessar-
ily due to the pharmacologic actions of a drug, are also in-
volved. In the 1950s, Olds and Milner implanted electrodes
in various regions of the rat brain to systematically determine
which neuroanatomic areas could reinforce self-stimulation.
(Self-stimulation consisted of a short pulse of nondestruc-
tive electric current that was delivered in the brain at the
site of the electrode upon the animals pressing of a lever.)
The medial forebrain bundle and ventral tegmental area
(VTA) in the midbrain were found to be particularly effective
sites. These sites have been termed pleasure centers, or the
foci of reward in the brain. A subset of dopaminergic neu-
rons projects directly from the VTA to the nucleus accum-
bens (NAc) via the medial forebrain bundle. It is believed
that these neurons are crucial for the brain reward pathway,
which reinforces motivated behavior and facilitates learning
and memory via links to the hippocampus, amygdala, and
prefrontal cortex. Severing this pathway, or blocking dop-
amine receptors in the NAc with a dopamine receptor an-
tagonist (such as haloperidol; see Chapter 13, Pharmacology
of Dopaminergic Neurotransmission), decreases electrical
self-stimulation of the VTA. Moreover, release of dopamine
in the NAc can be detected in vivo using the technique of
microdialysis, whereby a cannula is inserted into a specific
brain region in order to determine the concentrations of neu-
rotransmitters. These measurements show that increases in
290 Principles of Central Nervous System Pharmacology

From cortex
A Sensory cues B Sensory cues C
(action potential) (action potential)

Glutamate

NMDA-R Neuroadaptation
Dopamine Ca2+ Na+ Ca2+ Na+ Time x Dose
Increase in
receptor non-NMDA-R Dependence glutamate
receptors
Natural reward Ca2+ Na+ Drug of abuse Ca2+ Na+

From VTA Increase in

structural
proteins
Dopamine CaMKII CaMKII

NAc NAc NAc

Gene Gene
transcription transcription

Reward learning Out of control drug use Dependence

Period of abstinence

D Relapse mechanisms

Sensory cues
1 2 3

Ca2+ Na+ Ca2+ Na+ Ca2+ Na+

Stress Drug re-exposure

Cellular Cellular Cellular

NAc excitation NAc excitation NAc excitation

Relapse Relapse Relapse

FIGURE 18-2. Synaptic changes linking environmental stimuli, drug effects, and reward learning in drug dependence and mechanisms of relapse after
abstinence. (A) Natural rewards such as food or sex increase dopamine release in the nucleus accumbens (NAc) and give rise to reward learning that links relevant
environmental stimuli (sensory cues) with concurrent rewarding elements by altering neural circuitry in associative areas of the brain. Spiny neurons within the NAc
receive glutamatergic inputs from the cortex that relay sensory cue information and dopaminergic inputs from the ventral tegmental area (VTA). The glutamatergic inputs
act via NMDA receptors (permeable to calcium) and non-NMDA receptors (permeable to sodium). Coincident release of dopamine and glutamate results in potentiation
of NMDA signaling, activation of calcium-calmodulin dependent kinase (CaMKII), and ultimately alterations in transcription of structural protein genes and glutamate
receptor genes. These synaptic changes are thought to underlie reward learning. (B) Drugs of abuse induce amplified dopamine release and activate the same synaptic
adaptations as natural reinforcers. Thus, drugs of abuse are thought to hijack evolutionary brain reward learning systems in a manner that leads to out-of-control
drug use. (C) After chronic drug use, synaptic adaptations result in potentiated synapses. This potentiation is mediated via increased dendritic spine size, increased
structural protein expression, and increased glutamate receptor surface expression; all of these adaptations occur in response to long-term transcriptional changes.
(D) After a period of abstinence from drug use, multiple mechanisms can induce relapse to drug-taking behavior. (1) Stress can trigger relapse by increased dopamine
release. In this potentiated state, dopamine can trigger cellular excitation and trigger relapse behaviors. (2) Exposure to drug-related sensory cues can trigger relapse
via increased glutamate release, and the increased surface expression of glutamate receptors can lead to cellular excitation and relapse. (3) Exposure to small amounts
of drug can reactivate relapse to drug self-administration in this potentiated state, since the amplified dopamine release can trigger cellular excitation.

Prefrontal cortex
Executive function
Cognitive control
Hippocampus
Context / Memory
NAc
Orbitofrontal cortex
Judgment Locus ceruleus
Amygdala
Decision making
Arousal / Novelty
Stress / Anxiety
Ventral tegmental area
concentrations of dopamine are associated with drug self-
administration by laboratory animals and that dopaminergic
synapses in the NAc are active during electrical stimulation
of the brain reward pathway, supporting the hypothesis that
NAc dopamine is necessary for reward. Drugs capable of
causing dependence are readily self-administered by ani-
mals directly into the VTA, NAc, or the cortical or subcorti-
cal areas that innervate these two areas, often at the cost even
of eating food (Fig. 18-3).
Although the dopaminergic pathway mediates reward,
dopamine may also increase the salience of stimuli, alert
the organism to the importance of stimuli, and guide motor
activity to seek rewarding stimuli. As discussed above, the
dopamine pathway is activated by all drugs of abuse. Im-
portantly, behaviors that are necessary for survival of the
species (e.g., feeding, reproduction, and exploration) also
result in dopamine release in the NAc but to a much smaller
degree, suggesting that drugs of abuse may pharmacologi-
cally hijack the normal evolutionary functions of reward
pathways. With repeated experiences via conditioning (i.e.,
the association of an element of the environment with the re-
ward through rewiring of brain circuits), this dopamine path-
way is also activated during anticipation of the reward, as
can be demonstrated in humans using functional neuroimag-
ing techniques such as positron emission tomography (PET)
when addicts are exposed to drug-related sensory cues. Al-
though the dopaminergic neurons that link the VTA and the
NAc serve as the final common pathway of reward, these
neurons receive inputs from a number of brain regions (cor-
tex, hippocampus, thalamus, amygdala, and raphe nuclei)
that modify reward and thereby mediate reward-associated
learning (Fig. 18-4).
Since withdrawal from certain drugs of abuse can be
aversive, avoiding acute withdrawal was for many years
thought to be the primary motivation for continued abuse.
However, this explanation is not consistent with the ob-
servations that: the effects of addiction are felt long after
the physical symptoms of withdrawal have abated; with-
drawal can occur without concomitant drug-seeking, as
is often the case after treatment for acute pain; and drugs
CHAPTER 18 / Pharmacology of Drugs of Abuse 291
FIGURE 18-3. Integration of brain behavioral systems via con-
nections to the mesolimbic dopamine pathway. Noradrenergic neu-
rons originating in the locus ceruleus (black) relay information regarding
novelty and arousal to dopaminergic neurons in the ventral tegmental
area (VTA). The VTA projects to the nucleus accumbens (NAc) and cortex
(red). Multiple inputs from the brain modify VTA output: glutamatergic
input from the prefrontal cortex relays executive function and cognitive
control; excitatory input from the amygdala signals stress and anxiety;
and glutamatergic input from the hippocampus conveys contextual
information and past experiences (blue). Together, these multiple inputs
modify signaling in the mesolimbic dopamine pathway and modulate
the perception of pleasure.
such as stimulants, hallucinogens, and cannabinoids cause
significant dependence without a striking acute withdrawal
syndrome. Years after an addict has discontinued use of a
substance, s/he can experience intense cravings and, thus,
is prone to relapse. The likelihood of relapse is especially
strong in situations in which individuals simultaneously en-
counter both stress and the context in which the drug was
previously used. In part, this is due to the interplay between
reward and memory circuitry in the brain that, under normal
circumstances, assigns emotional value to certain memo-
ries. Hence, the motivational underpinnings of drug-seeking
are tied to both socioenvironmental stimuli and subjective
effects of the drug, each of which can have both rewarding
and aversive linkages with previous experiences via learn-
ing. This is a more complex explanation than the simple
avoidance of acute withdrawal.
 MECHANISMS OF ADDICTION
The drug-seeking activity characteristic of addiction results
from the interplay of learning, reward mechanisms, and indi-
vidual propensity toward the development of addiction.
Learning and Development of Addiction
Recognition that chronic drug self-administration results in
long-lasting changes in the experience of reward has led to
our understanding that the relevant neural circuits can never
return to their predrug state. The term allostasis describes
this enduring, progressively evolving adaptive process in
brain reward pathways upon repeated exposure to abused
drugs. Allostasis means that the baseline to which the brain
returns upon discontinuing drug use can change even after
acute withdrawal has abated. (This is in contrast to homeo-
stasis, which is defined as the process whereby a system
repeatedly equilibrates to the same baseline.) Accordingly,
even when the drug is no longer present in the brain, the
addict cannot experience positive emotions in the way he
did prior to beginning drug use (termed anhedonia); the un-
successful attempt to recapture the previous near-normal
292 Principles of Central Nervous System Pharmacology

Prefrontal DA Nicotine
cortex
ACh
Ventral
tegmental area Nicotinic ACh
NAc receptor

Cannabinoids

Opioids CB1 receptor

C

-opioid
receptor
GABA
Cortex

NMDA-R

-opioid receptor

Opioids
NAc

Alcohol Cocaine
PCP Amphetamine
Cannabinoids
DAT

CB1 receptor DA

FIGURE 18-4. The mesolimbic dopamine pathway: a final common substrate for the rewarding actions of drugs. All drugs of abuse activate the mesolimbic
dopamine pathway, which comprises ventral tegmental area (VTA) dopamine neurons that project to the nucleus accumbens (NAc). Different interneurons interact with
VTA neurons and NAc neurons to modulate mesolimbic neurotransmission. Nicotine interacts with excitatory nicotinic cholinergic receptors located on VTA dopamine
neuron cell bodies to enhance dopamine release in the nucleus accumbens (NAc). Cocaine acts predominantly at the dopamine nerve terminal to inhibit reuptake of
dopamine via the dopamine transporter (DAT), thus increasing synaptic levels of dopamine that can impinge on NAc. Amphetamine also acts at the dopamine nerve
terminal to facilitate release of dopamine-containing vesicles, and possibly to enhance reverse transport of dopamine through DAT (not shown). Both cannabinoids
and opioids decrease GABA release from local inhibitory interneurons in the VTA, resulting in disinhibition of dopamine neuron activity and increased dopaminergic
neurotransmission. Cannabinoids and opioids can also act within the NAc. Alcohol and other CNS depressants act on NMDA receptors (NMDA-R) to reduce glutamater-
gic neurotransmission in the NAc. The effects of alcohol on dopaminergic neurons in the VTA appear to be both excitatory and inhibitory, and are the subject of active
investigation (not shown).

state fuels drug-seeking. Human and animal studies have
found evidence for long-term neuroadaptation in altered
neurotransmitter levels (e.g., dopamine and serotonin de-
pletion after chronic alcohol or stimulant use), changes in
neurotransmitter receptors, altered signal transduction path-
ways, changes in gene expression, and altered synaptic con-
figuration and function. Clinically, abstinent patients report
not only craving but also dysphoria, sleep disturbances, and
increased stress reactivity (e.g., panic attacks), which can
last for weeks, months, or years after detoxification.
A common misconception is that addicts are pleasure
seekers and that their focus on drugs represents withdrawal
from life into irresponsible hedonism. Current thinking
about addiction recognizes the heterogeneity of the addic-
tive process. For some individuals, reward factors (positive
reinforcement) may predominate, and getting high or feel-
ing euphoric motivates drug use. For others, relief factors
(negative reinforcement) predominate, such as drinking to
reduce stress or to reduce the dysphoria of protracted with-
drawal. A large proportion of addicts self-medicate to reduce
distress associated with co-occurring psychiatric and medi-
cal disorders. Furthermore, the motivations to use early in
the course of addiction may differ substantially from moti-
vations as the illness progresses (Fig. 18-5). As a result of
allostasis, positive reinforcement is rare in the later stages
of the illness. For example, drinking in ones teens to relieve

Socio-environmental stimuli Discriminative stimuli
Peer group Subjective effects of drug
Drug paraphernalia Drug taste, smell, appearance
Initiation of Chronic drug
drug use dependence
Reinforcers Reinforcers
Euphoria Continued Social interaction
Behavioral activation drug seeking Prevention of
Novelty withdrawal
Anxiolysis
Analgesia
Aversive effects Aversive effects
Sedation Cessation Organic disease
Acute withdrawal of drug Societal stigma
(hangover) Legal problems
Nausea
Legal problems
FIGURE 18-5. Clinical determinants of drug-seeking change throughout
the life course of addiction. The motivational underpinnings of drug-seeking are
determined by socioenvironmental stimuli paired with subjective effects of the
drug. Reinforcers of drug self-administration result in continued drug use, whereas
aversive drug effects contribute to cessation of drug self-administration: whether
an individual continues to use is a function of whether reinforcing or aversive ef-
fects predominate under the circumstances. Brain reward pathways are modified
during the course of repeated drug self-administration, such that reinforcing and
aversive effects are often different when drug use first begins compared to later in
the course when drug self-administration may have become repetitive and out-of-
control. Ultimately, whether addiction progresses or the addictive disorder can be
successfully arrested is determined by learning-related modification of reinforcing
and aversive effects of drugs using pharmacopsychosocial interventions.
shyness may progress to drinking for euphoria and disinhi-
bition. Ultimately, after years of drinking to intoxication,
the middle-aged person may drink to prevent withdrawal-
associated depression and anxiety, or perhaps to alleviate
chronic pain. Drug use in each of these situations is linked
via learning to elements of the environment associated with
drug use or to memories and emotions, each of which can
trigger craving and drug-seeking.
The essence of addiction is drug-seeking behavior,
whereby an individual cannot control the urge to obtain and
use a psychoactive substance despite recognized negative
consequences and at the exclusion of other needs that typi-
cally constitute a balanced life. Studies in laboratory animals
suggest that drug-seeking behavior is the result of dysfunc-
tional reward learning, i.e., the processes that guide the
organism to fulfill needs or goals have gone awry. Thus, if
the organism initiates an action that results in a goal or re-
ward (e.g., self-administration of a psychoactive agent),
and if the organism learns that its action resulted in the
reward, the likelihood of engaging in that behavior is en-
hanced. For example, if a person uses cocaine for the first
time and finds it pleasurable or that it alleviates depressive
symptoms from which the individual is suffering, obtaining
and using cocaine are reinforced. The intense experience of
cocaine, relative to natural rewards such as food and sex,
results in a preferential expenditure of energy to obtain
CHAPTER 18 / Pharmacology of Drugs of Abuse 293
cocaine over other rewards. Thus, cocaine has effectively
hijacked reward-learning systems, biasing future behavior
in favor of obtaining cocaine over natural rewards. Reexpo-
sure to environmental or affective states that are associated
with cocaine use serve as cues to increase drug-seeking be-
havior. For example, reexposure to drug paraphernalia can
induce intense craving, drug-seeking behavior, and relapse
in cocaine addicts.
Variables Affecting the Development
of Addiction
The development of addiction is dependent on the nature of
the drug; genetic, acquired, psychological, and social traits
of the drug user; and environmental factors.
The ability of a drug to activate reward mechanisms is
strongly correlated with its ability to cause addiction. Phar-
macokinetic properties of the drug can significantly influ-
ence its effects on the brain. In general, the more rapid the
rise in drug concentrations at the target neurons, the greater
the activation of reward pathways. For example, many
drugs of abuse are highly lipophilic and can easily perme-
ate the bloodbrain barrier. In addition, direct injection or
rapid absorption of drug through a large surface area (e.g.,
through the lungs via smoking) is more highly reinforcing
than slower absorption through the intestinal or nasal mu-
cosa. Furthermore, rapidly eliminated drugs are more ad-
dictive than slowly eliminated drugs, since slow clearance
of a drug maintains the drug concentration at the site of ac-
tion for a longer duration, diminishing the severity of acute
withdrawal.
The importance of pharmacokinetic effects is dem-
onstrated by the potential for abuse of various forms of
cocaine (Fig. 18-6), and these principles are readily appli-
cable to other drugs of abuse. The use of coca leaves as a
chew or in teas is widely practiced among people living
in the Andean mountains: this has a relatively low poten-
tial for addiction, because of the slow rate of rise and low
peak concentration of drug attained by absorption through
the buccal or intestinal mucosa. The rapid absorption of
extracted cocaine through the nasal mucosa is substan-
tially more reinforcing. The most reinforcing and addictive
forms of cocaine are intravenous injections and inhalation
of smoked freebase (crack cocaine), both of which result in
a very rapid rise in plasma concentration and a high peak
concentration of drug.
Different people react differently to drugs. Some indi-
viduals use a drug once and never use it again; others use
a drug repeatedly in moderate amounts without developing
addiction; in others, the first use of a drug produces such
an intense effect that the likelihood of addiction is high.
The factors that make individuals more or less vulnerable
to addiction upon exposure to a given drug are of contin-
ued research interest. A variety of predisposing or protective
genetic, acquired, psychosocial, and environmental factors
have been identified, butas expected in a complex, multi-
factorial illnessindividually each can explain only a rela-
tively small component of the risk for addiction. Individual
factors include: (1) resistance or sensitivity to the acute ef-
fects of a given drug; (2) differences in drug metabolism;
(3) the potential for neuroadaptive changes with chronic drug
exposure; (4) personality traits and co-occurring psychiatric
and medical disorders that incline an individual to drug use;
294 Principles of Central Nervous System Pharmacology

500

Plasma concentration of cocaine

(ng/ml) 400

300

200

100

0
0 60 120 180 240 300 360

Time (minutes after dose)

B
50

Route and Dose

Intoxication level (0 100 scale)

40
IV0.6 mg/kg
Smoked 100 mg base
30 Nasal 2 mg/kg
Oral 2 mg/kg
20 Placebo

10

0
0 60 120 180 240 300 360

Time (minutes after dose)

FIGURE 18-6. Plasma cocaine concentrations and levels of intoxication as a function of route of administration of the drug. The pharmacokinetics (A) and
pharmacodynamics (B) of cocaine are highly dependent on the route of administration of the drug. Intravenous (IV) cocaine and smoked free-base cocaine are associ-
ated with very rapid attainment of peak plasma drug concentrations (A) and high levels of intoxication (B). In contrast, the nasal and oral routes of administration are
associated with a slower rise in plasma drug concentrations (A) and lower levels of intoxication (B). Because of the very rapid rise in plasma drug concentration and
very high intoxication levels, intravenous and smoked cocaine carry a higher risk of addiction than cocaine taken nasally or orally.

and (5) susceptibility of the individual to brain injury associ-
ated with drug use that may modify drug effects.
Genetic influences have been best studied in indi-
viduals with alcohol dependence. Heritability estimates
suggest that genetic factors account for 5060% of the
variance associated with alcohol abuse, but the specific
determinant(s) that lead to alcoholism in an individual are
not known. In fact, many individuals whose family his-
tory highly predisposes them to alcohol dependence do
not develop the disorder. Alcohol abuse and dependence
are complex phenotypes determined by multiple genes,
environmental exposures throughout the lifespan, gene
environment interactions, genebehavior interactions, and
genegene interactions.
The best known examples of candidate genes that alter risk
for alcohol dependence are the alcohol metabolism genes, in-
cluding those encoding the alcohol dehydrogenases ADH1B*2,
ADH2, and ADH3 that metabolize alcohol more rapidly and
those encoding certain aldehyde dehydrogenases (particularly
ALDH2*2). Polymorphisms in these genes alter enzymatic
activity and increase the levels of acetaldehyde, which causes
aversive symptoms that act as a deterrent to drinking alcohol
and to the development of alcohol dependence.
Sensitivity to alcohol is also a physiologically based trait
influenced by genetic inheritance. Low sensitivity to alcohol
(high innate tolerance) is associated with an increased risk
for developing alcoholism. Schuckit and colleagues have
found evidence for genetic linkage of the low level of re-
sponse phenotype to the same region on chromosome 1 that
is linked to the alcohol dependence phenotype. However,
subjective response to alcohol is a complex trait affected by
several neurotransmitter systems. For example, individu-
als with the alcohol dependence-associated GABRA2 allele
have a blunted subjective response to alcohol, and individu-
als carrying the ASP40 variant of the -opioid receptor or
those with a certain single nucleotide polymorphism of the
cannabinoid receptor appear to have an enhanced euphoric
response to alcohol.

Role of Personality Characteristics
and Co-Occurring Disorders in Addiction
The clinical characterization of individuals who develop a
drug-use disorder has been most extensively studied for al-
cohol dependence. The Cloninger classification of alcoholic
subtypes relates genetic and neurobiological differences to
the age of alcoholism onset and to personality traits. Type 1
(late onset) alcoholism is characterized by alcohol-related
problems beginning after 25 years of age, less antisocial
behavior, infrequent spontaneous drinking or loss of con-
trol, and guilt and concern about ones alcoholism. Type 1
alcoholics are low in thrill-seeking, are harm-avoidant, and
are dependent on approval from others. In contrast, type
2 alcoholism is characterized by early onset of alcohol-
related problems (before age 25), antisocial behavior, fre-
quent spontaneous alcohol-seeking and loss of control, and
little concern about the consequences of ones drinking or
its effects on others. Genetic predispositions to late-onset
alcohol dependence are significantly influenced by precipi-
tating environmental factors, whereas genetic predisposi-
tions to early-onset alcohol dependence are less influenced
by the environment. The Lesch classification envisions four
alcoholism subtypes: type 1 exhibits withdrawal symptoms,
including alcohol-related delirium and seizures, relatively
early in the drinking history; type 2 exhibits anxiety related
to premorbid conflicts; type 3 is characterized by associated
mood disorders; and type 4 has premorbid cerebral injuries
and associated social problems. Alcohol subtypes are now
being examined as predictors of response to medications
used for the treatment of alcoholism. For example, early-
onset alcoholics may worsen their drinking and impulsive
behavior in response to a selective serotonin reuptake in-
hibitor (SSRI), whereas late-onset alcoholics may improve
with an SSRI.
According to a major epidemiologic survey in the United
States, the odds of having a mental disorder are three times
greater if an individual also has a drug-use disorder than if
the individual has no drug-use disorder. In decreasing order
of association, these psychiatric diagnoses include bipolar
affective disorder, antisocial personality disorder, schizo-
phrenia, major depressive disorder, and anxiety disorders.
Drug-use disorders occur at higher rates in those with alco-
holism, and alcoholism is more prevalent among individuals
with addiction to other drugs. The association between psy-
chiatric disorders and drug-use disorders has led to theories
of common pathogenesis and treatment strategies. For ex-
ample, individuals with major depressive disorder are two to
three times more likely to have a drug-use disorder through-
out their lifetime than those without depression, and exacer-
bations of mood symptoms are prime precipitants of relapse
to drug use (and vice versa). Of note, these associations seem
to be generic with respect to which drugs are abused, sug-
gesting that such abuse is related more to availability than to
a specific pharmacologic mechanism of action.
Physical disability and pain associated with medical ill-
ness or traumatic injury can greatly enhance the risk of a
co-occurring drug-use disorder. Moreover, drug use not
only complicates certain medical conditions, but for many
of these illnesses (e.g., cirrhosis or traumatic brain injury
due to motor vehicle accidents), alcohol and drug use should
also be considered a significant causal factor. Similarly, in-
creased pain perception is now understood to be a frequent
CHAPTER 18 / Pharmacology of Drugs of Abuse 295
complication of chronic opioid administration (opioid
hyperalgesia). Thus, many pain physicians no longer advise
long-term use of opioid analgesics for treatment of chronic
(nonterminal) pain, recognizing that detoxifying a patient
from chronic opioid use can often result in a preferable out-
come to continuing to increase the opioid dose. In conclu-
sion, drug-use disorders are not only illnesses in their own
right, but also common consequences of many psychiatric
and medical conditions that, in turn, are further exacerbated
by continued drug use.
 DRUGS OF ABUSE
Many psychoactive substances have abuse potential through
their activation of inputs in brain reward pathways. It is
vital to understand the unique pharmacology of each agent
to appropriately address overdose complications, metabolic
consequences, and organ toxicity associated with abuse of
these drugs. Several drugs with the potential to cause depen-
dence are readily available and widely used, and they exact
an enormous toll on public health (e.g., alcohol, nicotine).
Other drugs are commonly prescribed for accepted medical
purposes, and their mechanisms of action have been dis-
cussed in detail in previous chapters (e.g., opioids, barbitu-
rates, benzodiazepines, stimulants). These drugs represent a
significant cause of iatrogenic dependence in patients, and
prescription drug abuse represents perhaps the fastest grow-
ing U.S. drug problem. Other commonly abused drugs are
not generally prescribed in medical practice and are typically
available only from illicit sources (e.g., cocaine, heroin).
Finally, some drugs affect receptors that are actively being
pursued as potential targets for therapeutic intervention, and
it is controversial whether or how they should be regulated
(e.g., cannabis, nicotine).
Opioids
Opioid alkaloids have been used medically for centuries for
analgesia, treatment of diarrhea and cough, and sleep induc-
tion. Central effects of opioids are biphasic, with behavioral
activation at low doses and sedation at higher doses. These
drugs depress respiration, and death from opioid overdose is
invariably due to respiratory arrest. The -opioid receptor
appears to be the most important subtype for the reinforc-
ing actions of opioids. Addicts describe an intense euphoric
feeling (rush) that lasts for less than a minute upon the
intravenous injection of heroin and that seems to be the rea-
son for abuse.
There appear to be two pathways by which opioids inter-
act with the brain reward system. One site of action lies in
the ventral tegmental area, where GABAergic interneurons
tonically inhibit the dopaminergic neurons responsible for
activating the brain reward pathway in the nucleus accum-
bens. These GABAergic interneurons can be inhibited by en-
dogenous enkephalins, which bind to -opioid receptors on
the GABAergic terminals. Because exogenous opioids such
as morphine also bind to and activate -opioid receptors (see
Chapter 17), exogenously administered opioids can activate
the brain reward pathway by disinhibiting dopaminergic neu-
rons in the ventral tegmental area (Fig. 18-4, Fig. 18-7). The
second pathway is localized in the nucleus accumbens. Opi-
oids acting in this region may inhibit GABAergic neurons
that project back to the ventral tegmental area, perhaps as
 A Inhibitory neuron

Endogenous
enkephalins Tonic
GABA Dopaminergic neuron dopamine
release

REWARD

Ventral tegmental area Nucleus accumbens

B Inhibitory neuron

Exogenous
opioids
or Increased
GABA Dopaminergic neuron dopamine
Endogenous
enkephalins release

REWARD

Ventral tegmental area Nucleus accumbens

 CHAPTER 18 / Pharmacology of Drugs of Abuse 297

A B

100 100
Full agonist

% Maximal binding
% Maximal signal
transduction Buprenorphine

50 Partial agonist 50 Naloxone

Morphine
Antagonist
0 0

Time after drug Drug concentration

Morphine Buprenorphine
C
-opioid receptor

i i i i i

GTP GDP GDP GTP GDP

ATP ATP ATP

cAMP cAMP cAMP

Nicotine Varenicline
D
nAChR
nAChR (open) (closed)

Acute drug Drug withdrawal Treatment with partial

effects and craving agonist reduced
withdrawal symptoms

FIGURE 18-8. Partial agonists in the treatment of addiction. (A) Full agonists at -opioid receptors, such as morphine, produce maximal signal transduction
(100%). Partial agonists, such as buprenorphine, produce reduced signal transduction (50% of a full agonist). Antagonists, such as naloxone, do not stimulate signal
transduction. (B) Both buprenorphine and naloxone have very high binding affinities for -opioid receptors compared to morphine. Consequently, when -opioid recep-
tors are fully occupied by an agonist like morphine, both naloxone and buprenorphine displace morphine from the receptor and lead to withdrawal. (C) Upon morphine
binding to -opioid receptors, intracellular signaling leads to inhibition of adenylyl cyclase activity and a decrease in cyclic AMP (cAMP) production. Upon removal of
morphine from -opioid receptors, either by discontinuing morphine or by administration of an antagonist or partial agonist (withdrawal), the inhibition of adenylyl
cyclase is released. The resulting large increase in cAMP production causes withdrawal symptoms, such as diarrhea, hyperalgesia, tachypnea, and photophobia. The
use of a partial agonist, buprenorphine, can alleviate these withdrawal symptoms by partial activation of -opioid receptors. In addition, binding of the high-affinity
buprenorphine molecule to -opioid receptors prevents lower affinity full agonists, such as morphine, from binding to and activating the receptor. Thus, the physiologic
antagonist property of buprenorphine prevents the high associated with morphine use, but also alleviates craving and drug-seeking behavior. (D) Nicotine activates
nicotinic acetylcholine receptors (nAChR), causing neuronal excitation. Nicotine withdrawal causes a rapid decrease in nAChR activity and a withdrawal syndrome as-
sociated with intense craving. Treatment with the partial nAChR agonist varenicline results in partial activation of nAChR and alleviation of withdrawal symptoms, but
this activation is insufficient to cause dependence or a high. Importantly, binding of the high-affinity varenicline molecule to nAChRs prevents the lower affinity nicotine
molecule from binding to and activating the receptor. Thus, varenicline can prevent the subjective high associated with nicotine use.
298 Principles of Central Nervous System Pharmacology

FIGURE 18-9. Pharmacokinetic determinants of CNS depressant-induced

withdrawal severity. (A) Due to rapid elimination of alcohol and alprazolam, A
plasma levels fall rapidly after cessation of drug use. Plasma levels of diazepam,
which has a long elimination half-life, decline at a slower rate. Furthermore, the

concentration
Alcohol

Plasma drug
effective biological half-life of diazepam is longer still because the active me- Alprazolam
tabolites desmethyldiazepam (which has an even longer elimination half-life) and
Diazepam
oxazepam are formed via the metabolism of diazepam. (B) The onset, severity,
and duration of the CNS-depressant withdrawal syndrome are directly related to
the rate of elimination of the drug, and thus the rate of removal of the drug from
its target receptor. Alprazolam and alcohol withdrawal are more rapid in onset, of
greater severity, and of relatively limited duration compared to diazepam with- 0 1 2 3 4 5 6
drawal. (C) Treatment of CNS-depressant withdrawal is aimed at maintaining oc-
Days after last dose
cupancy of the target receptor for a sufficiently long period of time that the system B
can re-equilibrate and thereby minimize the risk of severe withdrawal symptoms.
This is accomplished by using a cross-tolerant drug (i.e., another CNS depres-
Alcohol
sant) with a relatively slower rate of removal from the target receptor than the

Withdrawal
abused drug. Administration of diazepam to treat alcohol withdrawal illustrates Alprazolam

severity
this point. Although plasma levels of alcohol drop rapidly, administration of di- Diazepam
azepam results in continued occupancy and activation of receptor sites (such as
the GABAA receptor) for a much longer period of time and throughout the period
of highest risk for withdrawal-related seizures. (D) The more gradual reduction in
receptor occupancy after diazepam administration reduces the severity of alcohol
withdrawal symptoms, prevents seizures, and reduces the morbidity and mortality 0 1 2 3 4 5 6 7
from alcohol withdrawal. (E) In addition to its slower elimination compared to alco-
Days after last dose
hol, diazepam has higher efficacy at GABAA receptors than alcohol, resulting in en-
C
hanced GABAA receptor activation. This property holds even when the receptor is
in a desensitized state due to chronic alcohol consumption. Thus, the combination
of the slower elimination and the higher efficacy of diazepam compared to alcohol Alcohol
concentration
Plasma drug
makes it the medication of choice for the treatment of alcohol withdrawal. Diazepam

window than benzodiazepines and are used less frequently.

For both of these drug classes, euphoric feelings are often 0 1 2 3 4 5 6 7
reported in the early stage of intoxication and typically are
Days after last dose
the expressed reason for drug self-administration. Anxiolytic
D
and tension-reducing properties may also contribute to the
reinforcing actions and abuse potential of these drugs. All Seizure threshold
Withdrawal

sedative-hypnotics can cause dependence, but the risk of

severity

abuse can be limited if they are used judiciously in a time- Alcohol alone
limited fashion. Benzodiazepines and barbiturates increase Alcohol + diazepam
treatment
the efficiency of GABAergic pathways, and chronic use
can induce down-regulation of these pathways by neuro-
adaptation. One possible mechanism of down-regulation
is uncoupling of the benzodiazepine site from the GABA 0 1 2 3 4 5 6 7
site on GABAA receptors (see Chapter 12). Thus, the bind- Days after last dose
ing of benzodiazepines to GABAA receptors would remain E
unchanged, but the drug would have little or no potentiat-
Efficacy at GABAA receptor

ing effect on the binding of GABA to the receptor. Down-

regulation of inhibitory GABAergic pathways would be
(arbitrary units)

expected to leave the brain underinhibited, increasing the

possibility of seizures and delirium upon abrupt withdrawal
of the benzodiazepine or barbiturate (see Chapter 15). As-
sociated central sympathetic hyperactivity can lead to Diazepam
physical symptoms such as anxiety, sleep disturbance, and
Alcohol
dizziness and to emotional concomitants such as fear and
panic. Because the central nervous system depressant ac-
tions of barbiturates are more widespread than those of the
GABAA-specific benzodiazepines (Fig. 18-9), barbiturate Time after drug administration
dependence is associated with a more severe and potentially (arbitrary units)
dangerous withdrawal syndrome than benzodiazepine de-
pendence. Within a given class of sedative-hypnotics, the
onset, amplitude, and duration of the withdrawal syndrome
are determined by the rate of elimination of the drug and its
active metabolites. For example, among the barbiturates and

benzodiazepines, withdrawal usually begins within 12 hours
after drug discontinuation and is most severe for rapidly
eliminated compounds (e.g., amobarbital and triazolam);
withdrawal may be delayed for several days and is less se-
vere for slowly eliminated compounds (e.g., phenobarbital,
diazepam, and clonazepam) (Fig. 18-9).
Co-occurring dependence on benzodiazepines or bar-
biturates and alcohol is particularly prevalent due to the
similarity of these drugs effects on GABAergic neurotrans-
mission (Fig. 18-9). Benzodiazepines (not barbiturates) are
the accepted treatment for alcohol withdrawal; these drugs
are efficacious in alleviating rough spots when alcoholics
cannot drink, and the effects of alcohol are greatly accentu-
ated by benzodiazepines (or barbiturates). Benzodiazepines
are almost never associated with mortality due to overdose
when used alone; combined with alcohol, however, they can
be fatal because of synergistic depression of cardiorespira-
tory centers.
Benzodiazepines and opioids can sometimes be co-
prescribed under conditions when pain is associated with
significant anxiety. This combination can also be fatal due to
synergistic effects on respiration; in fact, even the relatively
safe partial agonist buprenorphine can cause respiratory
arrest when combined with benzodiazepines. Physicians
may try to limit use of these dangerous combinations, but
some drug-seeking patients may resort to obtaining prescrip-
tions from multiple physicians or even forging prescriptions,
especially after suboptimal management of the underlying
condition. Nonetheless, undermedication of pain must be
avoided, and benzodiazepines should be used for treatment
of alcohol withdrawal or significant anxiety.
Another serious concern is the misuse of prescription opi-
oids (or, less commonly, benzodiazepines or barbiturates) by
health professionals. For at least two reasons, health profes-
sionals who misuse prescription medication are at greater
risk for developing addiction. First, they have more ready
access to prescription medication. Second, they may mistak-
enly believe that, because they understand a drugs effects,
they will be able to control its use more easily.
Alcohol
Alcoholic beverages are readily available at affordable cost
with minimal legal restriction. Alcohol abuse stands as the
most prevalent drug problem in the United States. Early
in intoxication, CNS stimulation and euphoria result from
depression of inhibitory control, and aspects of discrimina-
tion, memory, and insight are impaired. As blood levels rise,
judgment, emotional control, and motor coordination suffer.
Traumatic injuries sustained while intoxicated are likely the
most common public health problem associated with alco-
hol abuse. Respiratory depression and death can result from
overdose, and the most serious consequences occur when
alcohol is combined with other psychoactive agents.
Ethanol affects GABAA receptors, NMDA glutamate recep-
tors, and cannabinoid receptors. Although the specific sites of
action are unknown, GABAA channels are believed to mediate
the anxiolytic and sedative effects of alcohol, as well as the ef-
fects of alcohol on motor coordination, tolerance, dependence,
and self-administration. Alcohol increases GABA-mediated
chloride conductance and enhances hyperpolarization of the
neuron. Its mechanisms of dependence are likely similar
to those of other sedative-hypnotic drugs affecting GABA
CHAPTER 18 / Pharmacology of Drugs of Abuse 299
neurotransmission. In severity and time course, the symptoms
of alcohol withdrawal lie between those of short-acting barbi-
turates and intermediate-acting benzodiazepines.
Evidence also points to a role for NMDA receptors in
the development of tolerance and dependence to alcohol, and
NMDA receptors also have a role in the alcohol withdrawal
syndrome. Specifically, alcohol inhibits subtypes of NMDA
receptors that seem to be capable of long-term potentiation.
The rewarding effects of alcohol may also be mediated in part
by indirect activation of cannabinoid receptors. Endogenous
cannabinoids are retrograde neuromodulators that act as a
feedback mechanism to enhance dopaminergic activity in the
mesolimbic reward pathway (Fig. 18-10; see also Fig. 18-4).
Endocannabinoid signaling has been implicated in reward learn-
ing, appetite regulation, mood regulation, pain modulation, and
cognition. Thus, although GABA receptors have a vital role in
mediating the effects of alcohol, the ability of alcohol to interact
with a number of different receptor types suggests that our un-
derstanding of its mechanisms of action remains incomplete.
Nicotine and Tobacco
Smoking, or the combustion of tobacco for the purpose of
nicotine self-administration, represents a major source of pre-
ventable medical morbidity and mortality. Nicotine activates
nicotinic acetylcholine receptors that are located centrally,
peripherally, and at the neuromuscular junction. Cholinergic
neurons arising from the laterodorsal tegmental area (near
the border of the midbrain and pons) activate nicotinic and
muscarinic acetylcholine receptors on dopaminergic neu-
rons in the ventral tegmental area; stimulation of these nico-
tinic receptors by nicotine activates the dopaminergic brain
reward pathway (Fig. 18-4). In addition, activation of pre-
synaptic nicotinic receptors on dopaminergic axon terminals
facilitates the release of dopamine. These strong and direct
effects on the mesolimbic reward pathway, combined with
the inhalational route of administration and short half-life of
nicotine, explain the high addiction potential of nicotine, and
hence of cigarettes and other forms of tobacco. Activation of
central nicotinic receptors also produces anxiolytic effects,
increases arousal, and suppresses appetite, while activation
of peripheral nicotinic receptors increases blood pressure
and stimulates smooth muscle contraction.
A strong and spontaneous withdrawal syndrome is asso-
ciated with the decreases in plasma levels of nicotine that
occur upon cessation of smoking. The major symptoms in-
clude irritability, anxiety, autonomic arousal, and intense
craving and associated drug-seeking behavior. These symp-
toms are readily relieved by smoking, and given the wide-
spread availability of tobacco products, it is easy to see why
smoking is so recalcitrant to treatment. Because smoking
can alleviate a number of symptoms associated with depres-
sion and anxiety, it is commonly associated with the use of
other drugs and with mental disorders.
Cocaine and Amphetamine
Cocaine is isolated from the South American shrub
Erythroxylon coca and has been used as a local anesthetic
since 1884. Amphetamine and congeners are used clini-
cally as nasal decongestants, analeptics, antidepressants,
and diet pills, and for treatment of attention-deficit hyperac-
tivity disorder (ADHD). Cocaine and many amphetamine-
related drugs have substantial abuse liability; hence, other
300 Principles of Central Nervous System Pharmacology

A B
GABA GABA
terminal terminal

Rimonabant
2-AG

CB1
receptor

GABA
DAGL DAGL
Action Action
potential potential
Cl-
GABAA-R
Cl-
Enhanced excitation Increased inhibition
of VTA dopaminergic neuron of VTA dopaminergic neuron

FIGURE 18-10. Endogenous cannabinoid neurotransmission in the mesolimbic dopamine pathway. (A) Endogenous cannabinoids are a class of lipid neu-
rotransmitters that act as retrograde signals to inhibit release of other neurotransmitters. Here, activation of dopaminergic neurons in the ventral tegmental area (VTA)
results in rapid synthesis of the endocannabinoid 2-arachidonoylglycerol (2-AG) via the activity of diacylglycerol lipase (DAGL). 2-AG then activates CB1 cannabinoid
receptors located on presynaptic GABAergic terminals. Activation of CB1 receptors causes a transient decrease in vesicular release of GABA on a time scale of seconds
to minutes. This results in feed-forward enhancement of VTA dopaminergic neuron activity and could contribute to drug-seeking behavior. Thus, endocannabinoids can
modulate VTA dopaminergic neuronal activity by inhibiting GABAergic (inhibitory) inputs to the VTA. Activation of VTA dopaminergic neurons in response to environmental
cues associated with drug use can often trigger relapse (see Fig. 18-2). (B) The CB1 receptor antagonist rimonabant has been shown to inhibit cue-induced relapse in
preclinical studies. A putative mechanism of action of rimonabant involves blockade of CB1 receptors on presynaptic GABAergic terminals in the VTA, which would sustain
high levels of GABA and thus inhibit VTA dopaminergic neuron activity in response to drug-associated cues, and possibly reduce relapse.

medications with lower risk profiles have taken their place
for many of their uses. Nevertheless, these drugs are widely
available by prescription and through illicit sources. They
are highly reinforcing because of the profound sense of
well-being, energy, and optimism associated with stimu-
lant intoxication; however, this state can rapidly progress to
psychomotor agitation, severe paranoia, and even psychosis
due to augmented dopamine neurotransmission. The initial
euphoric effects of cocaine appear to be more pronounced
than those of amphetamine, while amphetamine intoxication
far outlasts that of cocaine. Elevated mood is often followed
by listlessness, drowsiness, and depressed mood upon the
withdrawal of stimulants. Appetite suppression can be fol-
lowed by ravenous hunger. Stimulants are almost always
taken with another drug of abuse, most commonly alcohol,
since the other drug accentuates the high and alleviates the
sleeplessness and sense of being wired (Fig. 18-4).
By blocking or reversing the direction of the neurotrans-
mitter transporters that mediate reuptake of the monoamines
dopamine, norepinephrine, and serotonin into presynaptic
terminals, cocaine and amphetamine potentiate dopaminer-
gic, adrenergic, and serotonergic neurotransmission. Cocaine
is most potent at blocking the dopamine transporter (DAT),
although higher concentrations block the serotonin and
norepinephrine transporters (SERT and NET, respectively).
Recall that the tricyclic antidepressants (TCAs) and selective
serotonin reuptake inhibitors (SSRIs) function in a similar
manner, blocking reuptake of norepinephrine and serotonin
(TCAs) or serotonin alone (SSRIs) into presynaptic neurons.
Amphetamine reverses the direction of all three monoam-
ine transporters, although this drug is more effective at the
norepinephrine transporter. Amphetamine also releases
vesicular transmitter stores into the cytoplasm; these com-
bined actions cause the catecholamine neurotransmitter to be
transported into, rather than out of, the extracellular space.
By these actions, cocaine and amphetamine increase the con-
centration of monoamine neurotransmitters in the extracel-
lular space, potentiating neurotransmission (Fig. 18-1).
Although cocaine and amphetamine act on monoaminergic
neurons throughout the body, it is the action of these drugs on
neurons in two major centers in the brain that likely governs
their potential for abuse. The first set of neurons, in the locus
ceruleus in the pons, sends ascending adrenergic projections
throughout the hypothalamus, thalamus, cerebral cortex, and
cerebellum and descending projections to the medulla and
spinal cord. These projections maintain alertness and respon-
siveness to unexpected stimuli (see Chapter 10, Adrenergic
Pharmacology). Thus, drugs such as cocaine and amphetamine,
which potentiate the actions of norepinephrine by inhibiting
neurotransmitter reuptake, produce enhanced arousal and vigi-
lance and are called psychostimulants. The second major site at
which cocaine and amphetamine act is on midbrain dopamin-
ergic neurons, the axons of which terminate in the nucleus ac-
cumbens, striatum, and cortex (Fig. 18-4). As discussed above,
these dopaminergic terminals in the nucleus accumbens are a
critical component of the brains reward pathway.

It was long believed that the psychostimulants do not
cause significant withdrawal and that behaviors to seek these
drugs rarely attain levels that are out of control. However,
cocaine use can be associated with withdrawal symptoms
such as bradycardia, sleepiness, and fatigue. Withdrawal
from cocaine or amphetamine also produces psychological
symptoms, such as dysphoria and anhedonia (an inability to
experience pleasure), that are opposite to the euphoria expe-
rienced immediately following administration of the drug.
Many of these symptoms are not strictly attributable to with-
drawal because they cannot be alleviated by the administra-
tion of more cocaine or amphetamine. In fact, symptoms of
withdrawal can appear even when psychostimulant levels in
the plasma are high. This phenomenon occurs both because
of allostasis of reward pathways (discussed earlier) and be-
cause these drugs cause tachyphylaxis, an acute process in
which the target tissue becomes less and less responsive to
constant concentrations of a drug. In the case of cocaine and
amphetamine, tachyphylaxis may be caused by depletion
of the neurotransmitter. Because the drugs block presyn-
aptic neurotransmitter reuptake, the elevated levels of neu-
rotransmitter in the extracellular space feed back to inhibit
its synthesis, and neurotransmitter stores in the presynaptic
terminal are progressively depleted. The combination of
tachyphylaxis and allostasis makes discontinuation of stimu-
lants particularly difficult for addicts, both in the short and
long term.
Marijuana
Cannabinoids are compounds derived from Cannabis
sativa (marijuana). The primary psychoactive component of
marijuana is 9-tetrahydrocannabinol (THC), which is a
partial agonist at the G protein-coupled type-1 cannabinoid
receptor (CB1). The endogenous ligand of the CB1 recep-
tor is the arachidonic acid derivative anandamide, which
is representative of a class of endocannabinoid retrograde
neuromodulators that act as a feedback mechanism to reduce
neuronal excitation (Fig. 18-10). Since blockade of CB1 re-
ceptors by the antagonist rimonabant eliminates the effects
of smoked marijuana in humans, the subjective effects of
marijuana are thought to be mediated by the CB1 receptor.
The CB1 receptor is widely distributed within the prefrontal
cortex, hippocampus, amygdala, basal ganglia, and cerebel-
lum. Endogenous cannabinoids appear to modulate a variety
of appetitive (reinforcing and consumptive) behaviors in-
cluding eating, smoking, and alcohol drinking. Cannabinoid
use causes a prompt and generalized high characterized by
euphoria, laughter, giddiness, and depersonalization. After
12 hours, cognitive functions such as memory, reaction
time, coordination, and alertness are compromised, and the
user has difficulty concentrating. This effect corresponds to
a mellowing phase, which results in relaxation and even
sleep. In rats, the administration of natural and synthetic can-
nabinoids causes dopamine release in the nucleus accumbens
of the brain reward pathway. High doses of marijuana can
cause anxiety, overt panic reactions, perceptual distortions,
impairments in reality testing, and, rarely, overt psychosis in
susceptible individuals. Overt panic reactions are the most
common reason cited for stopping marijuana use. Tolerance
to marijuana occurs via down-regulation of CB1 receptor
expression and post-translational modifications that reduce
signal transduction efficiency. Withdrawal from marijuana is
CHAPTER 18 / Pharmacology of Drugs of Abuse 301
generally mild due to its high volume of distribution and long
elimination half-life. Withdrawal symptoms can include in-
somnia, loss of appetite, irritability, and anxiety, perhaps due
to activation of central corticotropin-releasing factor (CRF)
systems, particularly in the amygdala.
Other Abused Drugs
Phencyclidine (PCP) was developed initially as a dissocia-
tive anesthetic but is no longer used because of behavioral
toxicity. PCP blocks NMDA glutamate receptors, which
mediate excitatory synaptic transmission and are involved
in synaptic plasticity and memory. By interfering with these
processes, PCP produces complex effects such as anesthesia,
delirium, hallucinations, intense paranoia, and amnesia.
Methylenedioxymethamphetamine (MDMA), known
colloquially as ecstasy, is one in the class of phenyl-
ethylamine hallucinogenics that unfortunately has been
falsely advertised by some as a safe drug. Although it is
chemically related to methamphetamine and has similar
dopaminergic effects, the primary effect of MDMA is on
serotonergic neurotransmission. MDMA causes serotonin
release into the extracellular space, inhibition of serotonin
synthesis, and block of serotonin reuptake. Together, these
complex actions of MDMA increase serotonin in the extra-
cellular space while depleting presynaptic stores of the neu-
rotransmitter. The drug causes a central stimulant effect like
cocaine and amphetamine but, unlike those drugs, it also has
hallucinogenic properties. Like cocaine and amphetamine,
MDMA affects the brain reward pathway through dopamin-
ergic stimulation. MDMA may be neurotoxic to a subpopu-
lation of serotonergic neurons when the drug is administered
repeatedly or in large amounts.
Caffeine and the related methylxanthines theophyl-
line and theobromine are ubiquitous drugs found in coffee,
tea, cola, energy drinks, chocolate, and many prescribed
and over-the-counter medications. Methylxanthines act by
blocking adenosine receptors that are expressed presynapti-
cally on many neurons, including dopaminergic and adren-
ergic neurons. Because activation of adenosine receptors
inhibits dopamine and norepinephrine release, competitive
antagonism of the receptors by caffeine increases dopamine
and norepinephrine release and, thus, acts as a stimulant.
Caffeine may also block adenosine receptors on cortical
neurons, and thereby disinhibit these neurons. Because CNS
adenosine is a natural promoter of sleep and drowsiness, caf-
feines blocking of adenosine receptors has alerting effects
and improves performance in a variety of circumstances, but
can also produce insomnia. Symptoms of withdrawal from
caffeine can include lethargy, irritability, and a characteristic
headache, but addiction, although documented, is rare. Caf-
feine withdrawal symptoms are commonly observed in even
low to moderate users of caffeine, but these typically resolve
without treatment.
Inhalants are volatile organic compounds that are inhaled
(sometimes called huffing) for their psychoactive effects.
The typical user of inhalants is a male teenager. Inhalants in-
clude organic solvents such as gasoline, toluene, ethyl ether,
fluorocarbons, and volatile nitrates, including nitrous oxide
and butyl nitrate. Inhalants are readily available in many
households and workplaces. At low doses, inhalants produce
mood changes and ataxia; at high doses, they may produce
dissociative states and hallucinations. Dangers of organic
302 Principles of Central Nervous System Pharmacology
solvent use include suffocation and organ damage, espe-
cially hepatotoxicity and neurotoxicity in the central and pe-
ripheral nervous systems. Cardiac arrhythmias and sudden
death can occur. Inhaled nitrates can produce hypotension
and methemoglobinemia. Hydrocarbon inhalants do not ap-
pear to act at a specific receptor, but rather to disrupt cell
functions by binding nonspecifically to hydrophobic sites on
receptors, signal transduction proteins, and other macromol-
ecules. Nitrates, however, act at specific receptors for nitric
oxide, a small-molecule neuromodulator (see Chapter 21,
Pharmacology of Vascular Tone).
 MEDICAL COMPLICATIONS OF
DRUG ABUSE AND DEPENDENCE
Individuals with drug-use disorders typically present to a
physician complaining of the indirect effects of drug self-
administration. These can include family disruptions and
emotional trauma, legal problems and physical injury, self-
neglect (e.g., malnutrition, harm from adulterants mixed with
drugs, infection from needle administration), inappropriate
use of prescribed medication (e.g., analgesics, anxiolytics),
and lack of adherence with medical regimens for coexisting
illnesses. These effects are clearly not specific to the pharma-
cologic actions of any given drug but are the consequence of
out-of-control, often self-destructive behaviors that interfere
with a balanced life because the reward and salience of drug
use supersede that of other elements of the environment. Less
commonly, patients seek medical care for acute and chronic
direct pharmacologic and toxic actions of substance(s) of
abuse. Given the multiplicity of drugs, the means by which
they are obtained, and the variety of routes of administration,
complications may also be secondary to tissue toxicity and
induced metabolic changes. Adequate treatment of the medi-
cal complications related to drug abuse requires knowledge
of a given drugs pharmacologic actions.
Many patients who abuse drugs use more than one sub-
stance. Pharmacodynamic and pharmacokinetic effects of
polysubstance abuse are often difficult to predict from the
actions of each individual agent. For example, research has
revealed a potentially dangerous interaction between cocaine
and alcohol. When taken together, the two drugs are converted
to cocaethylene. Cocaethylene has a longer duration of action
in the brain and is more toxic than either drug alone. The vast
majority of individuals with drug-use disorders also smoke
cigarettes and, despite attaining abstinence from their drug of
choice, the eventual cause of death is often related to compli-
cations of cigarettes (e.g., cancer, cardiovascular disease).
Alcohol abuse is associated with widespread toxicity. Al-
coholic cardiomyopathy can result in a life-threatening de-
crease in left ventricular function. Ethanol is directly toxic
to heart muscle cells, affecting contractility of the myocytes
and inhibiting the repair of injury to these cells. The mecha-
nism of myocyte damage may relate to the overproduction of
oxygen-containing molecules secondary to alcohol metabo-
lism, with damage to the plasma membrane of the myocyte.
Nutritional deficiencies of water-soluble vitamins such as thi-
amine may also be involved. With moderate drinking, there
is typically an increase in systolic blood pressure. Alcohol
withdrawal also plays a role in hypertension because sympa-
thetic activity is increased during withdrawal. Stress appears
to cause a greater rise in blood pressure in drinkers than in
nondrinkers. There appears to be a protective effect of drink-
ing on coronary artery disease, at least in older individuals
and those otherwise at risk for coronary disease. The so-called
J-shaped mortality curve shows that these populations have
decreased mortality with low to moderate drinking (generally
0.52 drinks/day) and increased mortality with heavy drink-
ing. The mechanism of this protection involves beneficial ef-
fects of ethanol on lipoprotein metabolism and thrombosis:
ethanol increases high-density lipoprotein (HDL) levels in a
dose-dependent manner, and ethanol inhibits platelet aggre-
gation and lowers plasma fibrinogen levels.
Chronic alcoholism has other significant medical compli-
cations. Metabolic consequences of alcohol abuse include
gout, hyperlipidemia and fatty liver, and hypoglycemia.
Chronic alcoholics can develop obesity when the high ca-
loric content of alcohol is added to normal food intake;
when food intake is limited and/or malabsorption is pres-
ent, weight loss with mineral and electrolyte imbalances and
vitamin deficiencies can result. Alcohol toxicity can lead to
pancreatic insufficiency and diabetes. The gastrointestinal
system is frequently affected by chronic alcohol consump-
tion, resulting in esophagitis, gastritis or ulcer, pancreati-
tis, and alcoholic hepatitis and cirrhosis. Effects of alcohol
on the cytochrome P450 system alter drug and carcinogen
metabolism, accounting for significant drug interactions
and increased cancer incidence in chronic alcoholics. Al-
cohol increases the release of ACTH, glucocorticoids, and
catecholamines and inhibits testosterone synthesis and the
release of ADH and oxytocin. Neurologic complications of
chronic alcoholism include dementia, amnestic disorder,
cerebellar degeneration, and neuropathy, due to both direct
neurotoxicity and thiamine deficiency. Finally, alcohol con-
sumption during pregnancy has widespread teratogenic con-
sequences, termed fetal alcohol spectrum disorder.
Pharmacologic consequences of psychostimulant abuse
relate to specific effects of these drugs on the nervous and
cardiovascular systems. Potentiation of norepinephrine
neurotransmission increases heart rate and blood pressure.
Cocaine, in particular, can cause vasospasm leading to stroke,
cerebrovasculitis, myocardial infarction, and aortic dissec-
tion. The inhibition of cardiac and CNS sodium channels by
cocaine can cause arrhythmias and seizures. Psychostimu-
lants can reset temperature regulation, causing hyperpyrexia
and associated rhabdomyolysis. Cocaine and amphetamine
can also cause involuntary movements through their action
on the basal ganglia.
 TREATMENTS FOR ADDICTION
Despite the high prevalence of alcohol and drug problems
in medical practice (1015% in ambulatory care, 3050%
in emergency departments, and 3060% in general hospital
settings), the diagnosis is often overlooked. As is the case
with other stigmatized diseases, specialized services are
often inaccessible. Recent health legislation in the United
States promises parity for medical and mental disorders (in-
cluding alcohol and drug problems) and more widespread
availability of addiction treatment.
Treatments for addiction can be divided into two broad
approaches, pharmacologic and psychosocial. Traditionally,
pharmacologic treatments for addiction have focused on
acute detoxification to relieve the withdrawal symptoms that
304 Principles of Central Nervous System Pharmacology
Pharmacologic Treatment of Addiction
The recognition that addiction is caused by fundamental
changes in brain reward pathways indicates that pharmaco-
therapy could have an important role in the management of
addiction. To date, several pharmacologic strategies have
been employed.
The first of these strategies is the chronic administration of
an agent that causes aversive effects when the drug of abuse
is used. For example, disulfiram inhibits aldehyde dehydro-
genase, a critical enzyme in the alcohol metabolism pathway.
In an individual who ingests ethanol while taking disulfiram,
alcohol dehydrogenase oxidizes the ethanol to acetaldehyde,
but disulfiram prevents aldehyde dehydrogenase from me-
tabolizing the acetaldehyde. Therefore, this toxic metabolite
accumulates in the blood. Acetaldehyde causes a number of
aversive symptoms, including facial flushing, headache, nau-
sea, vomiting, weakness, orthostatic hypotension, and respi-
ratory difficulty. These symptoms can last from 30 minutes
to several hours and are followed by exhaustion and fatigue.
The aversive effects of alcohol consumption in the presence
of disulfiram are intended as a deterrent to further drinking.
Unfortunately, the effectiveness of disulfiram is limited by
failures in adherence and by substantial toxicity.
A second strategy used to treat addiction is to block the ef-
fects of the drug of abuse. Naltrexone is an opioid antagonist
that competitively blocks the binding of opioids to the opioid
receptor. Thus, a patient who injects an opioid, such as heroin,
while taking naltrexone will not experience the high that nor-
mally accompanies drug use. Studies have shown that naltrex-
one also acts as an opioid inhibitor in the brain reward pathway.
Thus, the effects of a drug such as ethanol, which releases en-
dogenous opioids resulting in a disinhibition (or stimulation) of
mesolimbic dopamine, share a final common reward pathway
Heroin
Plasma concentration of drug
Methadone
0 6 12 18
FIGURE 18-11. Pharmacokinetics and pharmacodynamics of a fast-acting opioid (heroin) compared to a slow-acting opioid (methadone). The plasma
concentration of a fast-acting opioid such as heroin rises rapidly after intravenous administration, generating a high, but also falls quickly, producing withdrawal
symptoms. In contrast, the plasma concentration of a slow-acting, long half-life drug such as methadone remains in the asymptomatic range for a period of over 24
hours, so that the patient does not experience either the high or the withdrawal symptoms. Moreover, because of its long plasma half-life, methadone needs to be
administered only once daily.
involving the opioid receptor and dopamine and are therefore
also inhibited by naltrexone. For this reason, naltrexone has
been used to treat alcohol addiction. Placebo-controlled clini-
cal trials have generally shown efficacy of naltrexone compared
to placebo, particularly in reducing relapse to heavy drinking.
Naltrexone should not be administered when there are traces
of exogenous opioids in the system, because antagonism of
remaining drug by naltrexone can lead to the development or
exacerbation of opioid withdrawal symptoms. Although nal-
trexone can effectively prevent the high associated with opi-
oid abuse, it does not alleviate cravings or withdrawal effects,
and there is a relatively high likelihood of non-adherence.
Therefore, naltrexone has been effective only in individuals ad-
dicted to opioids or alcohol who have a high motivation to stay
drug-free or who have supervised administration. An injectable
long-acting naltrexone preparation has been approved by the
U.S. Food and Drug Administration (FDA) for the treatment
of alcohol dependence. This sustained-release naltrexone is in-
jected intramuscularly once a month; it has been demonstrated
to reduce heavy alcohol consumption and increase alcohol ab-
stinence, and it may also be beneficial in opioid dependence,
especially in those with low adherence to treatment.
A third pharmacologic approach is the use of a long-
acting agonist for medication maintenance. Methadone, as
discussed above, is a long-acting opioid agonist. Because
it is taken orally, it is less likely to produce the sharp in-
creases in plasma levels required to elicit a high such as
that accompanying the injection of heroin or other opioids.
Methadone also has a long half-life compared to heroin or
morphine. Thus, once-daily administration of methadone
produces plasma opioid levels that remain relatively constant
over time and, therefore, mitigate cravings and prevent the
emergence of withdrawal signs and symptoms (Fig. 18-11).
High
Asymptomatic
Withdrawal symptoms
24 30 36 42 48 54 60
Time (hours)
306 Principles of Central Nervous System Pharmacology
dopamine -hydroxylase and can increase brain dopamine
levels, possibly counteracting the dopamine-depleting ef-
fects of chronic cocaine use. Because cocaine sensitization
involves glutamate, antiepileptics such as topiramate are
also being studied for efficacy in the treatment of cocaine
dependence.
 CONCLUSION AND FUTURE DIRECTIONS
This chapter has discussed the major causes of drug depen-
dence and drug addiction. Dependence is defined as a mal-
adaptive pattern of drug use associated with context-induced
craving and drug-seeking, especially under situations of
stress, that leads to clinically significant impairment or dis-
tress. Drug addiction is caused by an allostatic adaptation to
the presence of the drug in brain reward pathways. Although
each drug has its own molecular and cellular mechanism of
action that may account for drug toxicity, all abused drugs
specifically affect the mesolimbic dopamine brain reward
pathway. This chapter has also discussed the major treat-
ments for addiction, including the pharmacologic preven-
tion and treatment of withdrawal symptoms, the long-term
psychosocial management of addiction, and newer phar-
macologic treatments that, when integrated with psycho-
social approaches, promote long-lasting sobriety. Together,
these addiction treatments achieve outcomes approximating
those of other long-term chronic medical disorders, such as
atherosclerosis, hypertension, and diabetes.
New directions in addiction research are focused on the
pharmacologic modulation of brain reward, stress responses,
and learning-related neural processes. In addition, these ap-
proaches are complemented by basic and clinical studies of
the neurobiology of learning and memory and the modifi-
cation of these processes through psychosocial treatments.
Current approaches to cocaine addiction provide two spe-
cific examples. First, drugs that specifically interact with
different dopamine receptor subtypes have been explored,
investigating the hypotheses that a D1-specific agonist or
D4-specific antagonist could suppress drug cravings, and
that a D2-specific antagonist could prevent the reinforcing
effects of cocaine. Second, researchers have recently com-
pleted clinical trials of a cocaine vaccine, under the theory
that cocaine will be less reinforcing in vaccinated persons
who are exposed to the drug. If successful, this approach
could be extended to other drugs of abuse. (Trials of an anal-
ogous anti-nicotine vaccine are also forthcoming.) However,
vaccinated individuals may switch to other drugs of abuse
for which they have not produced antibodies, and hence, this
is not likely to be a totally satisfactory approach.
Broader and more promising are efforts to develop phar-
macologic treatments for addiction aimed at: (1) modulating
the chemical mediators of synaptic plasticity that underlie
reward learning and memory; and (2) modifying the negative
affective states and stress responses, the previously mentioned
allostatic load, associated with chronic drug abuse. These
approaches address shared brain mechanisms of addiction
to all drugs of abuse. For example, a failure of the prefrontal
cortex to control drug-seeking behaviors has been linked to
glutamatergic dysfunction in reward pathways, which may
be amenable to new glutamate- and neuroplasticity-based
pharmacotherapies. Another approach targets neural systems
mediating behavioral stress responses; for example, an an-
tagonist of the neurokinin-1 receptor, which is expressed in
brain areas involved in stress responses and drug reward, has
been shown in preliminary studies to suppress alcohol crav-
ings, improve well-being, and attenuate the cortisol stress
response in abstinent alcoholics. Preclinical studies have
shown that CRF antagonists may block stress-induced rein-
statement of drug use in animal models of addiction. Endo-
cannabinoid signaling has also been implicated in a variety
of physiologic functions including reward learning, appetite,
mood, pain, and cognition. Elucidation of endocannabinoid
signaling as a pro-hedonic system involving CB1 receptor
activation led to findings that the CB1 cannabinoid recep-
tor antagonist rimonabant was effective in obesity treatment,
and this drug is now being investigated as a treatment for
drug addiction. Rimonabant has not received FDA approval
because it is associated with significant psychiatric adverse
effects, but this approach remains a promising direction for
future research.
Acknowledgment
We thank David C. Lewis, Joshua M. Galanter, and Alan A.
Wartenberg for their valuable contributions to this chapter in
the First and Second Editions of Principles of Pharmacology:
The Pathophysiologic Basis of Drug Therapy.
Suggested Reading
Cam J, Farr M. Mechanisms of disease: drug addiction. N Engl J Med
2003;349:975986. (Current understanding of neural mechanisms leading
to addiction.)
Dani JA, Harris RA. Nicotine addiction and comorbidity with alcohol abuse
and mental illness. Nat Neurosci 2005;8:14651470. (Examines the inter-
face between the neuropharmacologic underpinnings of nicotine addiction
and psychiatric disorders, especially alcoholism.)
Goldstein RZ, Craig AD, Bechara A, Garavan H, Childress AR, Paulus
MP, Volkow ND. The neurocircuitry of impaired insight in drug addiction.
Trends Cog Sci 2009;13:372380. (Discusses current understanding of lack
of insight and awareness in addiction.)
Kalivas PW, OBrien C. Drug addiction as a pathology of staged neuroplas-
ticity. Neuropsychopharmacol 2007;33:166180. (Review that links learn-
ing mechanisms to reward through the glutamatergic system.)
Koob GF, Le Moal M. Neurobiological mechanisms for opponent moti-
vational processes in addiction. Philos Trans R Soc B Biol Sci 2008;363:
31133123. (Reviews relationships between stress and reward pathways.)
McLellan AT, Lewis DC, OBrien CP, Kleber HD. Drug dependence, a
chronic medical illness: implications for treatment, insurance, and out-
comes evaluation. JAMA 2000;284:16891695. (Seminal analysis of the
status of drug use disorders in the health care system.)
Nestler EJ. Transcriptional mechanisms of addiction: role of delta-FosB.
Philos Trans R Soc B Biol Sci 2008;363:32453255. (Reviews the role of
gene regulation as a unitary neurobiological mechanism in reward and
stress responses.)
Alcoholics Anonymous. www.aa.org. (Excellent information on Alcoholics
Anonymous.)
Substance Abuse and Mental Health Services Administration. www.samhsa
.gov. (Contains a wealth of information about prevention and treatment and
co-occurring diagnoses; also access to listings of evidence-based treatment
practices.)
III

Principles of Cardiovascular
Pharmacology

Pharmacology of Cholesterol
and Lipoprotein Metabolism
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 311-312
BIOCHEMISTRY AND PHYSIOLOGY OF CHOLESTEROL
AND LIPOPROTEIN METABOLISM . . . . . . . . . . . . . . . . . . . . 311
Metabolism of ApoB-Containing Lipoproteins . . . . . . . . . . 313
Assembly of ApoB-Containing Lipoproteins . . . . . . . . . 313
Intravascular Metabolism of ApoB-Containing
Lipoproteins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Receptor-Mediated Clearance of ApoB-Containing
Lipoproteins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
Formation and Clearance of LDL Particles . . . . . . . . . . 317
HDL Metabolism and Reverse Cholesterol Transport . . . . . 318
HDL Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
Intravascular Maturation of HDL . . . . . . . . . . . . . . . . . 320
HDL-Mediated Cholesterol Efflux from Cells . . . . . . . . 320
Delivery of HDL Cholesterol to the Liver . . . . . . . . . . . 320
Biliary Lipid Secretion . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
Cholesterol Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
 INTRODUCTION
Lipids are insoluble or sparingly soluble molecules that
are essential for membrane biogenesis and maintenance of
membrane integrity. They also serve as energy sources, hor-
mone precursors, and signaling molecules. In order to fa-
cilitate transport through the relatively aqueous environment
of the blood, nonpolar lipids, such as cholesteryl esters and
triglycerides, are packaged within lipoproteins.
Increased concentrations of certain lipoproteins in the cir-
culation are associated strongly with atherosclerosis. Much
of the prevalence of cardiovascular disease (CVD), the lead-
ing cause of death in the United States and most Western
countries, can be attributed to elevated blood concentrations
of cholesterol-rich low-density lipoprotein (LDL) particles
as well as lipoproteins that are rich in triglycerides. Epidemi-
ologically, decreased concentrations of high-density lipopro-
teins (HDL) also predispose to atherosclerotic disease. The
major contributors to lipoprotein abnormalities appear to be
Western diets combined with sedentary lifestyles, but a lim-
ited number of genetic causes of hyperlipidemia have also
been identified. The role of genetics in the common forms
of hyperlipidemia is the subject of intense study utilizing
19
David E. Cohen and Ehrin J. Armstrong
PATHOPHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Hypercholesterolemia . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
Hypertriglyceridemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
Mixed Hyperlipidemia . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Disorders of HDL Metabolism. . . . . . . . . . . . . . . . . . . . . . 323
Secondary Hyperlipidemia . . . . . . . . . . . . . . . . . . . . . . . . 323
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 324
Inhibitors of Cholesterol Synthesis . . . . . . . . . . . . . . . . . . 324
Inhibitors of Bile Acid Absorption . . . . . . . . . . . . . . . . . . . 326
Inhibitors of Cholesterol Absorption . . . . . . . . . . . . . . . . . 326
Fibrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Niacin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
Omega-3 Fatty Acids . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 329
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
cutting-edge genomic approaches. It is apparent that genes
modify both the sensitivity of individuals to adverse dietary
habits and lifestyles and the response of individuals to lipid-
lowering therapies.
This chapter highlights the biochemistry and physiology
of cholesterol and lipoproteins, with an emphasis on the role
of lipoproteins in atherogenesis, and the pharmacologic in-
terventions that can ameliorate hyperlipidemia. Abundant
clinical outcomes data have proven that morbidity and mor-
tality from cardiovascular disease can be reduced by the use
of lipid-lowering drugs.
 BIOCHEMISTRY AND PHYSIOLOGY
OF CHOLESTEROL AND LIPOPROTEIN
METABOLISM
Lipoproteins are macromolecular aggregates that transport
triglycerides and cholesterol in the blood. Circulating lipo-
proteins can be differentiated on the basis of density, size,
and protein content (Table 19-1). As a general rule, larger,
less dense lipoproteins have a greater percentage composi-
tion of lipids; chylomicrons are the largest and least dense
311
 CHAPTER 19 / Pharmacology of Cholesterol and Lipoprotein Metabolism 313
Core:
Triglyceride and
cholesteryl esters
Free cholesterol
Apolipoprotein B100 Apolipoprotein E
Apolipoprotein C
Phospholipid
monolayer
FIGURE 19-1. Structure of lipoprotein particles. Lipoproteins are spherical
particles (7100 nm in diameter) that transport hydrophobic molecules, principally
cholesterol and triglycerides, as well as fat-soluble vitamins. The surface of the
particle is composed of a monolayer of phospholipid and unesterified cholesterol
molecules. These polar lipids form a coating that shields a hydrophobic core of
nonpolar triglyceride and cholesteryl esters from interacting with the aqueous
environment of plasma. Lipoproteins contain amphipathic apolipoproteins (also
called apoproteins ) that associate with the surface lipids and hydrophobic core.
Apolipoproteins provide structural stability to the lipoprotein particle and act as
ligands for specific cell-surface receptors or as cofactors for enzymatic reactions.
In the example shown, a very-low-density lipoprotein (VLDL) particle contains
apolipoprotein E, apolipoprotein B100, and apolipoproteins CI, CII, and CIII (shown
here as apolipoprotein C ).
lipoprotein subclass, whereas HDLs are the smallest lipo-
proteins, containing the lowest lipid content and the highest
proportion of protein.
Structurally, lipoproteins are microscopic spherical par-
ticles ranging from 7 to 100 nm in diameter. Each lipoprotein
particle consists of a monolayer of polar, amphipathic lipids
that surrounds a hydrophobic core. Each lipoprotein particle
also contains one or more types of apolipoprotein (Fig. 19-1).
The polar lipids that comprise the surface coat are unesteri-
fied cholesterol and phospholipid molecules arranged in a
monolayer. The hydrophobic core of a lipoprotein contains
cholesteryl esters (cholesterol molecules linked by an ester
bond to a fatty acid) and triglycerides (three fatty acids esteri-
fied to a glycerol molecule). Apolipoproteins (also referred to
as apoproteins) are amphipathic proteins that intercalate into
the surface coat of lipoproteins. In addition to stabilizing the
structure of lipoproteins, apolipoproteins engage in biologi-
cal functions. They may act as ligands for lipoprotein recep-
tors or may activate enzymatic activities in the plasma. The
apolipoprotein composition determines the metabolic fate of
the lipoprotein. For example, each LDL particle contains one
apoB100 molecule, which is a ligand for the low-density lipo-
protein receptor (discussed below); in turn, binding of LDL to
the LDL receptor promotes cholesterol uptake into cells.
From a metabolic perspective, lipoprotein particles can
be divided into lipoproteins that participate in the deliv-
ery of triglyceride molecules to muscle and fat tissue (the
apolipoprotein B [apoB]-containing lipoproteins, chylo-
microns, and VLDL) and lipoproteins that are involved
primarily in cholesterol transport (HDL and the remnants
of apoB-containing lipoproteins). HDL also serves as a
reservoir for exchangeable apolipoproteins in the plasma, in-
cluding apoAI, apoCII, and apoE. The following discussion
presents each lipoprotein class in the context of its function.
Metabolism of ApoB-Containing Lipoproteins
The primary function of apoB-containing lipoproteins is to
deliver fatty acids in the form of triglycerides to muscle tissue
for use in ATP biogenesis and to adipose tissue for storage.
Chylomicrons are formed in the intestine and transport di-
etary triglycerides, whereas VLDL particles are formed
in the liver and transport triglycerides that are synthesized
endogenously. The metabolic lifespan of apoB-containing
lipoproteins can be divided into three phases: assembly, in-
travascular metabolism, and receptor-mediated clearance.
This is a convenient categorization because pharmacologic
agents are available that influence each phase.
Assembly of ApoB-Containing Lipoproteins
The cellular mechanisms by which chylomicrons and VLDL
are assembled are quite similar. Regulation of the assembly
process depends on the availability of apolipoprotein B and
triglycerides, as well as the activity of microsomal triglyceride
transfer protein (MTP).
The gene that encodes apoB is transcribed principally in
the intestine and the liver. Apart from this tissue-specific ex-
pression, there is little transcriptional regulation of the apoB
gene. In contrast, a key regulatory event that differentiates
chylomicron metabolism from VLDL metabolism is the
editing of apoB mRNA (Fig. 19-2). Within enterocytes but
not hepatocytes, a protein named apoB editing complex-1
(apobec-1) is expressed. This protein constitutes the cata-
lytic subunit of the apoB editing complex, which deaminates
apoB gene
Transcription Liver and intestine
apoB mRNA
Editing Small No editing Liver
intestine
Stop codon
mRNA
Translation
Protein
apoB48 apoB100
FIGURE 19-2. Editing of apoB mRNA. The apoB gene, with exons repre-
sented by rectangles and introns by lines, is transcribed in both the intestine and
the liver. In the intestine, but not the liver, a protein complex containing apobec-1
modifies a single nucleotide in the apoB mRNA. As a result, the codon containing
this nucleotide is converted to a premature stop codon, as indicated by the X.
The protein that is synthesized in the intestine (apoB48) is only 48% as long as the
full-length protein that is synthesized in the liver (apoB100).
314 Principles of Cardiovascular Pharmacology

a cytosine at position 6666 of the apoB mRNA molecule. Monoglyceride

Deamination converts the cytosine to uridine. As a result, Cholesterol
the codon containing this nucleotide is converted from Phospholipid

glutamine to a premature stop codon. When translated, the Fatty acid

intestinal form apoB48 is 48% as long as the full-length pro- Bile salt
tein that is expressed in the liver and referred to as apoB100.
As a consequence, chylomicrons, the apoB-containing lipo- Apical Basolateral
protein produced by the intestine, contain apoB48, whereas membrane membrane
VLDL particles produced by the liver contain apoB100.
Figure 19-3 illustrates the cellular mechanisms for the as- Ezetimibe
sembly and secretion of apoB-containing lipoproteins. As the Micelle
apoB protein is synthesized by ribosomes, it crosses into the
NPC1L1
endoplasmic reticulum. Within the endoplasmic reticulum, tri- Cholesterol
glyceride molecules are added co-translationally to the elongat-
ing apoB protein (i.e., apoB is lipidated) by the action of a co- ACAT
factor protein, MTP. Once apoB has been fully synthesized, the
nascent lipoprotein is enlarged in the Golgi apparatus; during
Cholesteryl ester
this process, MTP adds additional triglycerides to the core of
the particle. By unclear mechanisms, cholesteryl esters are also ABCG5/G8

added to the core. This entire assembly process produces lipo-

protein particles, each containing a single molecule of apoB. Monoglyceride
Because the diet is the main source of triglycerides in chy-
lomicrons (Fig. 19-4), the assembly, secretion, and metabolism
of these particles are collectively referred to as the exogenous DGAT
pathway of lipoprotein metabolism. By contrast, cholesteryl
esters in chylomicrons are derived mainly (approximately Triglyceride
id
75%) from biliary cholesterol, with the remainder contrib- Fatty acid
uted by dietary sources. During digestion, cholesteryl esters
and triglycerides in food are hydrolyzed to form unesterified
cholesterol, free fatty acids, and monoglycerides. Bile acids,
phospholipids, and cholesterol are secreted by the liver into
bile and stored in the gallbladder during fasting as micelles
and vesicles, which are macromolecular lipid aggregates that
form due to the detergent properties of bile acid molecules. FIGURE 19-4. Absorption of cholesterol and triglycerides. Exogenous cho-
lesterol and triglycerides are simultaneously absorbed from the intestinal lumen
The stimulus of eating a meal promotes emptying of gall- by different mechanisms. Cholesterol is taken up from micelles across a regula-
bladder bile into the small intestine, where the micelles and tory channel named NPC1L1. A fraction of the cholesterol is pumped back into the
vesicles solubilize the digested lipids. lumen by ABCG5/G8, a heterodimeric ATP-dependent plasma membrane protein.
The remainder of the cholesterol is converted to cholesteryl esters by ACAT. Tri-
glycerides are taken up as fatty acids and monoglycerides, which are re-esterified
Enterocyte or hepatocyte to triglycerides by DGAT.

Cytosol Cholesteryl Lipid absorption into enterocytes of the duodenum and

ester
jejunum is facilitated mainly by micelles. Long-chain fatty
acids and monoglycerides are taken up separately into the
Ribosome Chylomicron
(enterocyte) enterocyte by carrier-mediated transport and then re-ester-
Lipidation MTP or ified to form triglycerides by the enzyme diacylglycerol
VLDL
MTP (hepatocyte) acyltransferase (DGAT). By contrast, medium-chain fatty
ApoB acids are absorbed directly into the portal blood and me-
Endoplasmic tabolized by the liver. Dietary and biliary cholesterol from
reticulum micelles enter the enterocyte via a protein channel named
Triglyceride
Niemann-Pick C1-like 1 protein (NPC1L1). Some of this
cholesterol is immediately pumped back into the intestinal
lumen by the ATP-dependent action of a heterodimeric pro-
FIGURE 19-3. Assembly and secretion of apolipoprotein B-containing tein, ABCG5/ABCG8 (ABCG5/G8). The fraction of cho-
lipoproteins. Chylomicrons and VLDL particles are assembled and secreted by lesterol that remains is esterified to a long-chain fatty acid
similar mechanisms in the enterocyte and hepatocyte, respectively. The apoB pro-
by acetyl-CoA:cholesterol acyltransferase (ACAT). Once
tein (i.e., apoB48 or apoB100) is synthesized by ribosomes and enters the lumen
of the endoplasmic reticulum. If triglycerides are available, the apoB protein is
triglycerides and cholesteryl esters are packaged together
lipidated by the action of microsomal triglyceride-transfer protein (MTP) in two with apoB48, apoA1 is added as an additional structural
distinct steps, accumulating triglyceride as well as cholesteryl ester molecules. apolipoprotein and the chylomicron particle is exocytosed
The resulting chylomicron or VLDL particle is secreted by exocytosis into the into the lymphatics for transport to the circulation via the
lymphatics by enterocytes or into the plasma by hepatocytes. In the absence of thoracic duct. The plasma concentration of triglyceride-rich
triglycerides, the apoB protein is degraded (not shown). chylomicrons varies in proportion to dietary fat intake.
 CHAPTER 19 / Pharmacology of Cholesterol and Lipoprotein Metabolism 315

Very-low-density lipoproteins (VLDL) contain triglycer-
ides that are assembled by the liver using plasma fatty acids
derived from adipose tissue or synthesized de novo. For this
reason, the assembly, secretion, and metabolism of VLDL are
often referred to as the endogenous pathway of lipoprotein
metabolism. Hepatocytes synthesize triglycerides in response
to increased free fatty acid flux to the liver. This typically oc-
curs in response to fasting, thereby ensuring a continuous sup-
ply of fatty acids for delivery to muscle in the absence of tri-
glycerides from the diet. Interestingly, dietary saturated fats as
well as carbohydrates also stimulate the synthesis of triglycer-
ides within the liver. By cellular mechanisms that are similar
to those that produce chylomicrons (Fig. 19-3), MTP in he-
patocytes lipidates apoB100 to form nascent VLDL particles.
Under the continued influence of MTP, the nascent VLDL
particles coalesce with larger triglyceride droplets and are se-
creted directly into the circulation. VLDL particles may also
acquire apoE, apoCI, apoCII, and apoCIII within the hepato-
cyte prior to secretion. However, these apolipoproteins may
also be transferred to VLDL from HDL in the circulation.
The synthesis of apoB48 in the intestine and apoB100
in the liver is constitutive. This permits the immediate
production of chylomicrons and VLDL particles when tri-
glyceride molecules are available. In the absence of tri-
glycerides, such as in enterocytes during fasting, apoB is
degraded by a variety of cellular mechanisms.
Intravascular Metabolism of ApoB-Containing Lipoproteins
Within the circulation, chylomicrons and VLDL particles must
be activated in order to target triglyceride delivery to muscle
and adipose tissue (Fig. 19-5). Activation requires the addition
of an optimal complement of apoCII molecules, which occurs
by aqueous transfer of apoCII from HDL particles. Because
there is an inherent delay in the transfer of apoCII to chylomi-
crons and VLDL particles, there is time for widespread circula-
tion of triglyceride-rich particles throughout the body.
Lipoprotein lipase (LPL) is a lipolytic enzyme expressed
on the endothelial surface of capillaries in muscle and fat
tissue. LPL is a glycoprotein that is anchored in place by
electrostatic interactions with a separate glycoprotein on the
endothelial cell membrane. Once chylomicrons and VLDL
particles acquire apoCII, they can bind to LPL, which hydro-
lyzes triglycerides from the core of the lipoprotein (Fig. 19-5).
LPL-mediated lipolysis liberates free fatty acids and glycerol.

HDL

apoA-I

apoE

apoC-II

Liver Intestines
apoC-II apoC-II

apoB100 apoB48

VLDL Chylomicron

Plasma
Muscle or Muscle or
adipose tissue adipose tissue
apoC-II

apoB48
apoC-II
Fatty acids
apoB100
Fatty acids VLDL Chylomicron

Lipoprotein Lipoprotein
lipase
Capillary Capillary lipase
endothelium endothelium

FIGURE 19-5. Intravascular metabolism of apoB-containing lipoproteins. Following secretion, chylomicrons and VLDL particles are activated for lipolysis when
they encounter HDL particles in the plasma and acquire the exchangeable apolipoprotein apoCII. When chylomicrons and VLDL circulate into capillaries of muscle or
adipose tissue, apoCII promotes binding of the particle to lipoprotein lipase, which is bound to the surface of endothelial cells. Lipoprotein lipase mediates hydrolysis of
triglycerides, but not cholesteryl esters, from the core of the lipoprotein particle. The resulting fatty acids are taken up into muscle or adipose tissue.
316 Principles of Cardiovascular Pharmacology

A VLDL remnant Chylomicron B apoB48 Chylomicron or

(IDL) remnant VLDL remnant
Triglyceride
Hepatic
apoB100
sinusoidal
endothelium
apoE

apoC-II
apoC-II
apoB48 Heparan sulfate
Cholesteryl ester proteoglycan
apoB48
HDL
Sequestration

apoE
apoE
apoA-I Hepatic lipase
Space of
Disse
HDL
Fatty acid
apoB48

Lipolysis
apoC-II
apoA-I
apoE

VLDL remnant Chylomicron

(IDL) remnant

apoB100 LRP
LDL-R HSPG
Uptake

Hepatocyte
apoE apoE

apoB48

FIGURE 19-6. Formation and hepatic uptake of remnant particles. A. Upon completion of hydrolysis, chylomicrons and VLDL lose affinity for lipoprotein lipase.
When an HDL particle is encountered, apoCII is transferred back to HDL particles in exchange for apoE. The resulting particles are chylomicron and VLDL remnants.
B. The activity of lipoprotein lipase results in remnant lipoprotein particles that are small enough to enter the space of Disse. Remnant lipoproteins are sequestered in
the space of Disse by binding to high-molecular-weight heparan sulfate proteoglycan (HSPG) molecules. This is followed by the action of hepatic lipase, which promotes
lipolysis of some residual triglycerides in the core of the remnant lipoproteins and the release of fatty acids. Uptake of remnant lipoprotein particles into hepatocytes is
mediated by the LDL receptor (LDL-R), the LDL-receptor-related protein (LRP), a complex formed between LRP and HSPG, or HSPG alone.

The free fatty acids are then taken up by the neighboring pa-
renchymal cells. The expression level and intrinsic activity of
LPL in muscle and adipose tissue are regulated according to
the fed/fasting state, allowing the body to direct the delivery
of fatty acids preferentially to muscle during fasting and to
adipose after a meal. The rate of lipolysis of chylomicron and
VLDL triglycerides is also controlled by apoCIII, which is an
inhibitor of LPL activity. LPL inhibition by apoCIII may be
an additional mechanism promoting widespread distribution
of triglyceride-rich particles in the circulation.
Receptor-Mediated Clearance of ApoB-Containing Lipoproteins
As LPL continues to hydrolyze triglycerides from chylomi-
crons and VLDL, the particles become progressively depleted
of triglycerides and relatively enriched in cholesterol. Once
approximately 50% of the triglycerides have been removed,
the particles lose their affinity for LPL and dissociate from
the enzyme. The exchangeable apolipoproteins apoAI and
apoCII (as well as apoCI and apoCIII) are then transferred
to HDL in exchange for apoE (Fig. 19-6A), which serves
as a high-affinity ligand for receptor-mediated clearance of
the particles. Upon acquiring apoE, the particles are termed
chylomicron or VLDL remnants.
Remnants of chylomicrons and VLDL are taken up by
the liver in a three-step process (Fig. 19-6B). The first step
is sequestration of the particles within the space of Disse
between the fenestrated endothelium of the liver sinusoids
and the sinusoidal (basolateral) plasma membrane of the he-
patocytes. Sequestration requires that the remnant particles
become small enough during lipolysis to fit between the
endothelial cells. Once in the space of Disse, remnants are
bound and sequestered by large heparan sulfate proteogly-
cans. The next step is particle remodeling within the space of
Disse by the action of hepatic lipase, a lipolytic enzyme that
is similar to LPL but is expressed by hepatocytes. Hepatic li-
pase appears to optimize the triglyceride content of remnant
 CHAPTER 19 / Pharmacology of Cholesterol and Lipoprotein Metabolism 317

particles so that they can be cleared efficiently by receptor-
mediated mechanisms. The final phase of remnant clearance
is receptor-mediated particle uptake. This is accomplished
by one of four pathways. At the sinusoidal hepatocyte
plasma membrane, remnant particles may be bound and
taken up by the LDL receptor, the LDL-receptor-related
protein (LRP), or heparan sulfate proteoglycans. A fourth
pathway is mediated by the combined activities of LRP and
heparan sulfate proteoglycans. These redundant mechanisms
allow for efficient particle clearance, so that the half-life of
remnants in the plasma is approximately 30 minutes.
Formation and Clearance of LDL Particles
ApoB48-containing chylomicron remnants are completely
cleared from the plasma. In contrast, the presence of apoB100
alters the metabolism of VLDL remnants so that only
approximately 50% are cleared by the pathways for remnant
particles. The difference is manifested during the metabolism
of the remnant particles by LPL. VLDL remnants are avidly
metabolized by LPL, becoming an increment smaller, rela-
tively more deficient in triglycerides, and relatively enriched
in cholesteryl esters. When converted to remnants following
exchange of apolipoproteins with HDL, these more dense
particles are called intermediate-density lipoproteins (IDL).
Because IDL contains apoE, a fraction of these particles
(approximately 50%) may be cleared into the liver by rem-
nant receptor pathways (Fig. 19-6). However, the remainder
are converted to LDL by hepatic lipase, which further hydro-
lyzes triglycerides in the core of IDL. The further reduction in
size of the particle results in the transfer of apoE to HDL. As a
result, LDL is a distinct, cholesteryl ester-enriched lipoprotein
with apoB100 as its only apolipoprotein (Fig. 19-7A).

A Hepatic
lipase apoC-II

Liver apoB100 apoB100

Fatty
acid

apoE

IDL LDL

apoE
apoC-II

B apoB100
LDL
Cholesteryl apoA-I
linoleate HDL
LDL binding to LDL receptor

LDL-R

Internalization
LDL receptor
recycling

Lysosome

Hydrolysis
Cholesterol FIGURE 19-7. Formation and clearance of LDL particles. A. Formation of
Hydrolysis
LDL occurs when IDL particles interact with hepatic lipase to become denser and
cholesteryl ester-enriched. As a result, both apoE and apoCII lose affinity for the
particle and are transferred to HDL, leaving only apoB100. B. Binding of apolipo-
Amino acids protein B100 to LDL receptors on hepatocytes or other cell types promotes LDL
ER
internalization into endocytic vesicles and fusion of the vesicles with lysosomes.
LDL receptors are recycled to the cell surface, whereas lipoprotein particles are
hydrolyzed to amino acids (from apoB100) and free cholesterol (from cholesteryl
esters). Intracellular cholesterol has three regulatory effects on the cell. First, cho-
1 2 3 lesterol decreases the activity of HMG-CoA reductase, the rate-limiting enzyme
HMG CoA reductase ACAT LDL receptors in cholesterol biosynthesis. Second, cholesterol activates acetyl-CoA:cholesterol
acyltransferase (ACAT), an enzyme that esterifies free cholesterol into cholesteryl
esters for intracellular storage or export. Third, cholesterol inhibits the transcrip-
Cholesteryl oleate
tion of the gene encoding the LDL receptor, and thereby decreases further uptake
of cholesterol by the cell.
Vessel lumen Circulating
monocytes Endothelial
Native LDL dysfunction
Endothelial
injury

D
B

A SR-A

Resident
monocyte-
macrophage C

Cell-mediated
oxidation Foam cell
Foam cell
Oxidized LDL
necrosis
Subendothelial space
 LCAT
A Liver
PLTP
Cholesterol

Phospholipid Pre--HDL
Cholesteryl
ester ABCA1
SR-BI

Fatty apoA-I Plasma

acid -HDL
Tissues

Cholesterol
Hepatic
lipase

CETP

LCAT
PLTP

Chylomicron or Plasma
VLDL remnant
Albumin

Lyso-PC

Cell
LCAT
PLTP

CETP

PC Lyso-PC
LCAT -HDL

Cholesterol Cholesteryl ester

FIGURE 19-9. Reverse cholesterol transport. A. The process of reverse cholesterol transport begins when apoAI is secreted from the liver. ApoAI in plasma interacts
with ATP binding cassette protein AI (ABCA1), which incorporates a small amount of phospholipid and unesterified cholesterol from hepatocyte plasma membranes to form a
discoidal-shaped pre--HDL particle. Due to the activity of lecithin:cholesterol acyltransferase (LCAT) in plasma, pre--HDL particles mature to form spherical -HDL. Spherical
-HDL particles function to accept excess unesterified cholesterol from the plasma membranes of cells in a wide variety of tissues. The unesterified cholesterol is transferred
from the cell to nearby HDL particles by diffusion through the plasma. As explained in Panel B, LCAT and phospholipid transfer protein (PLTP) increase the capacity of HDL to
accept unesterified cholesterol molecules from cells by allowing for expansion of the core and the surface coat of the particle. Cholesteryl ester transfer protein (CETP) removes
cholesteryl ester molecules from HDL and replaces them with triglycerides from remnant particles. HDL particles interact with scavenger receptor, class B type I (SR-BI), which
mediates selective hepatic uptake of cholesteryl esters, but not apoAI. This process is facilitated when hepatic lipase hydrolyzes triglycerides from the core of the particle. The
remaining apoAI molecules may begin the cycle of reverse cholesterol transport again. B. LCAT, PLTP, and CETP promote the removal of excess cholesterol from the plasma
membranes of cells. LCAT removes a fatty acid from a phosphatidylcholine molecule in the surface coat of - (or pre--) HDL and esterifies an unesterified cholesterol molecule
on the surface of the particle. The resulting lysophosphatidylcholine (lyso-PC) becomes bound to albumin in the plasma, whereas the cholesteryl ester migrates spontaneously
into the core of the lipoprotein particle. The unesterified cholesterol molecules that are consumed by LCAT are replaced by unesterified cholesterol from cells. HDL phospholipids
that are consumed by LCAT action are replaced with excess phospholipids from remnant particles by the activity of PLTP. As described in Panel A, CETP increases the efficiency
of cholesterol movement to the liver by transporting cholesteryl ester molecules from -HDL to VLDL remnants in exchange for triglycerides. Unlike phospholipids, triglycerides,
and cholesteryl esters, unesterified cholesterol and lyso-PC move by diffusion through the plasma.

319
320 Principles of Cardiovascular Pharmacology
incorporates a small amount of membrane phospholipid and
unesterified cholesterol into the apoAI molecule. The resulting
small, disk-shaped particle, which consists mainly of phospho-
lipid and apolipoprotein AI, is referred to as nascent or pre--
HDL, due to its characteristic migration on agarose gels.
Intravascular Maturation of HDL
Because disk-shaped pre--HDL particles are relatively
inefficient at removing excess cholesterol from cell mem-
branes, these particles must mature into spherical particles
in the plasma. HDL maturation occurs as a result of the ac-
tivity of two distinct circulating proteins (Fig. 19-9A, B).
Lecithin:cholesterol acyltransferase (LCAT) binds pref-
erentially to disk-shaped HDL and converts cholesterol
molecules within the particle to cholesteryl esters. This is
accomplished by transesterification of a fatty acid from a
phosphatidylcholine molecule on the surface of the HDL
to the hydroxyl group of a cholesterol molecule. The reac-
tion also creates a lysophosphatidylcholine molecule, which
dissociates from the particle and binds to serum albumin.
Because they are highly insoluble, cholesteryl esters mi-
grate into the core of the HDL particle. The development of
a hydrophobic core converts the pre--HDL to a spherical
-HDL particle.
The second important protein that contributes to HDL
maturation in the plasma is phospholipid transfer protein
(PLTP). PLTP transfers phospholipids from the surface coat
of apoB-containing remnant particles to the surface coat of
HDL. During LPL-mediated lipolysis of apoB-containing
lipoproteins, the particles become smaller as triglycerides
are removed from the core. This leaves a relative excess of
phospholipids on the surface of the particle. Because phos-
pholipids are highly insoluble and cannot otherwise dissoci-
ate from a particle, PLTP removes excess phospholipids and
thereby maintains the appropriate surface concentration for
the shrinking core. By transferring phospholipids to the sur-
face of HDL, PLTP also replaces the molecules that are con-
sumed by the LCAT reaction. This allows the core of HDL
to continue to enlarge.
HDL-Mediated Cholesterol Efflux from Cells
Cellular cholesterol efflux is the mechanism by which ex-
cess insoluble cholesterol molecules are removed from cells.
This occurs when unesterified cholesterol is transferred
from the plasma membrane of cells to an HDL particle. The
mechanism of cholesterol efflux varies depending on the cell
type and the type of HDL particle. Lipid-poor pre--HDL
particles can promote cholesterol efflux by interacting with
ABCA1. This process is not only important in HDL forma-
tion by the liver, but is also a mechanism for removing ex-
cess cholesterol from cells within the subendothelial space
and for protecting macrophages from cholesterol-induced
cytotoxicity. Spherical HDL very efficiently stimulates cho-
lesterol efflux by several different mechanisms. First, the
interaction of apoAI on HDL with SR-BI on the plasma mem-
brane promotes cholesterol efflux. Second, macrophages ex-
press not only ABCA1 and SR-BI but also ABCG1, which
also mediates cholesterol efflux to spherical HDL. Finally,
spherical HDL particles may promote cholesterol efflux in
the absence of binding to a specific cell-surface protein. Al-
though cholesterol has very low monomeric solubility, it can
dissociate in appreciable amounts and travel short distances
through the plasma to acceptor particles that are enriched
with phospholipids on their surfaces. Quantitatively, efflux
to spherical HDL particles accounts for most of the removal
of excess cholesterol from cells. This capacity of HDL to
remove cellular cholesterol is enhanced by the activities of
LCAT and PLTP, which prevent the surface coat of the par-
ticle from becoming saturated with cholesterol.
Delivery of HDL Cholesterol to the Liver
When mature HDL particles circulate to the liver, they interact
with SR-BI, the principal HDL receptor (Fig. 19-9A). SR-BI
is highly expressed on the sinusoidal plasma membranes of
hepatocytes. In contrast to its action on most nonhepatic cells,
where SR-BI mediates efflux of excess cholesterol from the
membrane, SR-BI in the liver promotes selective uptake of
lipids. In this process, the cholesterol and cholesteryl esters of
HDL particles are taken up into the hepatocyte in the absence
of uptake of apolipoproteins. During SR-BImediated selec-
tive lipid uptake, apoAI is liberated to participate in pre--
HDL formation. The lifespan of an HDL particle is 25 days,
suggesting that each apoAI molecule can participate in many
cycles of reverse cholesterol transport. Among the nonhepatic
tissues that express high levels of SR-BI are the adrenal glands
and gonads, presumably reflecting the requirement of these or-
gans for cholesterol to support steroidogenesis.
Delivery of cholesterol from extrahepatic tissues to the
liver is optimized by two additional proteins, cholesterol ester
transfer protein (CETP) and hepatic lipase. CETP is a plasma
protein that transfers cholesteryl esters from mature spherical
HDL to the cores of remnant lipoproteins in exchange for a
triglyceride molecule, which is inserted into the core of the
HDL particle (Fig. 19-9B). This process allows the body to
utilize remnant particles that have completed their function of
triglyceride transport for purposes of transporting cholesterol
to the liver. Removal of cholesteryl ester molecules from HDL
appears to serve two functions. First, it further increases the
capacity of HDL to take on additional cholesterol molecules
from cells. Second, it makes the process of selective uptake by
SR-BI more efficient. This is because hydrolysis of triglycer-
ides by hepatic lipase on the hepatocyte surface facilitates the
activity of SR-BI (Fig. 19-9A).
As noted above, reverse cholesterol transport is the over-
all process by which HDL removes cholesterol from mac-
rophages and other extrahepatic tissues and returns it to the
liver. The concept that increased plasma concentrations of HDL
cholesterol may reflect increased rates of reverse cholesterol
transport provides a possible explanation for the inverse rela-
tionship between plasma HDL levels and risk of cardiovascu-
lar disease. HDL particles also exert direct beneficial effects on
vascular tissue, including enhancement of antioxidant enzyme
activities that inhibit oxidation of LDL. HDL also inhibits the
expression of inflammatory mediators (e.g., intercellular ad-
hesion molecule [ICAM] and vascular cell adhesion molecule
[VCAM]) by vascular cells. Increased understanding of HDL
metabolism may lead to the development of novel biochemical
targets for increasing reverse cholesterol transport in order to
slow or even reverse the progression of atherosclerosis.
Biliary Lipid Secretion
Once cholesterol is delivered to the liver by the process of
reverse cholesterol transport, it is eliminated by biliary se-
cretion. An essential step occurs when a fraction of the cho-
lesterol is converted to bile acids (Fig. 19-10A). Cholesterol
7-hydroxylase (CYP7A1), an enzyme expressed only in
 CHAPTER 19 / Pharmacology of Cholesterol and Lipoprotein Metabolism 321
A into the small intestine. As described above, bile facilitates
HO
Cholesterol
7-hydroxylase COO-
(liver)
HO HO OH
Cholesterol Bile acid
(Cholate)
B participating in cholesterol transport and fat digestion; in-
Blood Sinusoidal membrane Bile
ABCG5/G8
Cholesterol
Micelle
Hepatocyte
ABCB11
Bile acid
Bile salt
ABCB4
Phospholipid
Canalicular membrane
FIGURE 19-10. Biliary lipid secretion. A. Within hepatocytes, a portion of
cholesterol is converted to bile acids. This process is rate-limited by cholesterol
7-hydroxylase, which is expressed only in hepatocytes. Cholate is the most
abundant bile acid synthesized by the human liver. B. Within the canalicular (api-
cal) membranes, an ATP-dependent pump ABCB11 drives the secretion of bile
acids out of the cell against a concentration gradient. Bile acids then stimulate
the activities of two other proteins, ABCB4 and a heterodimer of ABCG5 and
ABCG8 (ABCG5/G8), to secrete phospholipids and cholesterol, respectively, into
bile. Within bile, the interactions among bile acids, phospholipids, and cholesterol
result in the formation of micelles.
hepatocytes, catalyzes the rate-limiting step in the catabo-
lism of cholesterol to bile acids. Bile acids, unlike choles-
terol, are highly soluble in water. Moreover, bile acids are
biological detergents that promote the formation of micelles
(Fig. 19-10B). These macromolecular aggregates, which are
rich in phospholipids derived from hepatocyte membranes,
solubilize cholesterol in bile for transport from the liver to
the small intestine. In this way, micelles serve as a functional
counterpart to HDL particles in plasma.
Bile formation begins when bile acids are pumped into
bile by the action of a canalicular membrane transport pump
known as ABCB11 (Fig. 19-10B). In turn, these bile acids
stimulate the biliary secretion of phospholipids and choles-
terol. Phospholipid and cholesterol secretion are mediated
by two additional transporters, ABCB4 for phospholipids
and a heterodimer of ABCG5 and ABCG8 for cholesterol.
Large amounts of bile acids, phospholipids, and cholesterol
are secreted into bile at approximate rates of 24, 11, and
1.2 grams each day, respectively. Biliary lipids are stored in
the gallbladder during fasting. The stimulus of a fatty meal
leads to gallbladder contraction, which propels its contents
the digestion and absorption of fats, in addition to promoting
the elimination of endogenous cholesterol.
Cholesterol Balance
Because cholesterol is converted by the liver to bile acids
and secreted unmodified into bile, overall cholesterol bal-
ance depends on the disposition of both cholesterol and bile
acids. Most bile acid molecules are not lost in the feces after
stead, they are taken up and recycled by high-affinity trans-
port proteins in the distal ileum. Bile acids enter the portal
circulation and are transported back to the liver, where they
are cleared from the blood by hepatocytes with high first-
pass efficiency. Bile acids are then re-secreted into bile. This
process of recycling bile acids between the liver and intes-
tine is referred to as enterohepatic circulation.
The enterohepatic circulation is highly efficient, allowing
5% of secreted bile acids to be lost in the feces. However,
because bile acids are secreted in such large amounts, the
small fractional loss of bile acids amounts to about 0.4 grams
per day. Considering that cholesterol is the substrate for bile
acid synthesis, fecal bile acids represent a source of choles-
terol loss from the body. Sensitive nuclear hormone recep-
tors within the liver are capable of detecting the rate of loss
of bile acids into the feces. These receptors tightly regulate
transcription of bile acid synthetic genes. As a result, the
liver synthesizes precisely the amount of bile acids that is
sufficient to replace what is lost in the feces.
In addition to the 1.2 grams of cholesterol that are secreted
into bile each day, the average American diet contributes ap-
proximately 0.4 grams each day to intestinal cholesterol. There-
fore, dietary cholesterol represents only a minor fraction (25%)
of the total (i.e., biliary and dietary) cholesterol that passes
through the intestine. The extent to which intestinal cholesterol
is absorbed appears to be genetically regulated. Each individ-
ual absorbs a fixed percentage of intestinal cholesterol. In the
population, percentages range from as low as 20% to more than
80%. For example, when an average individual absorbs 50% of
intestinal cholesterol, this will amount to half of the 1.6 grams
(i.e., 1.2 grams of biliary cholesterol plus 0.4 grams of dietary
cholesterol), and the other half (0.8 grams) will be lost in the
feces. Combined with a loss of 0.4 grams per day of choles-
terol in the form of fecal bile acids, this yields a total cholesterol
loss from the body of 1.2 grams each day. Taking into account
intestinal absorption of dietary cholesterol and reabsorption of
biliary cholesterol, total body cholesterol synthesis is approxi-
mately 0.8 grams per day (i.e., cholesterol synthesis fecal
loss of cholesterol plus bile acids dietary cholesterol intake).
Thus, the amount of endogenous cholesterol synthesis is about
twofold greater than the amount consumed in the average diet.
 PATHOPHYSIOLOGY
Numerous studies have demonstrated a definitive link be-
tween elevated plasma lipid concentrations and the risk of
cardiovascular disease. Increased risk of cardiovascular mor-
tality is most closely linked to elevated levels of LDL choles-
terol and decreased levels of HDL cholesterol. In addition,
hypertriglyceridemia represents an independent risk factor.
The risk is further increased when hypertriglyceridemia is
associated with low HDL-cholesterol concentrations, even if
 CHAPTER 19 / Pharmacology of Cholesterol and Lipoprotein Metabolism 325

Increased treatment group have a greater absolute risk of death and

LDL-R expression
and uptake of
therefore display the largest benefit from statins. It is also
plasma LDL important to note that statins have proven to be effective in
reducing cardiovascular disease risk for high-risk patients
(e.g., diabetic patients) with average, or even below average,
Acetyl CoA + Acetoacetyl CoA LDL-cholesterol levels.
Statins The magnitude of LDL-cholesterol lowering depends on
the efficacy and dose of the statin that is administered. In
HMG CoA
general, statins reduce LDL-cholesterol concentrations by
HMG CoA reductase up to about 60%. Statins increase HDL-cholesterol concen-
trations by an average of 10%, and reduce triglyceride con-
Mevalonate centrations by up to about 40%, depending on statin dose
Increased LDL
receptor expression and degree of hypertriglyceridemia. The effect of statins on
5-pyrophosphomevalonate triglyceride levels is mediated by decreased VLDL produc-
tion and increased clearance of remnant lipoproteins by the
Isopentylpyrophosphate liver. The doseresponse relationship of statins is nonlinear:
the largest effect occurs with the starting dose. Each sub-
3,3-dimethylallylpyrophosphate sequent doubling of the dose produces, on average, an ad-
Isoprenoids ditional 6% LDL reduction. This is sometimes referred to as
Geranylpyrophosphate the rule of 6s.
In addition to reducing LDL-cholesterol concentrations,
Farnesylpyrophosphate
statins have a number of other pharmacologic consequences.
These are collectively referred to as pleiotropic effects, which
include: decreased inflammation, reversal of endothelial dys-
Squalene
function, decreased thrombosis, and improved stability of
atherosclerotic plaques. Evidence for diminished inflamma-
Lanosterol
tion during statin therapy includes decreases in acute-phase
reactants, which are plasma proteins that are increased during
Cholesterol inflammatory states and may play a role in the destabilization
of atherosclerotic plaques. The best characterized of the acute-
Cholesterol phase reactants is C-reactive protein (CRP). Importantly, a
recent large randomized clinical trial has shown that, among
Protease activation patients with a moderate risk of developing cardiovascular
SREBP
disease and with elevated baseline CRP levels, use of a statin
(inactive) reduces cardiovascular morbidity and mortality, even when the
patients do not have elevated LDL-cholesterol concentrations.
SREBP Nucleus
(active) Evidence for reversal of endothelial dysfunction during
statin therapy includes an improved vasodilatory response of
LDL-R gene
endothelium to NO. Improved vasodilation could help prevent
ischemia. Evidence for decreased thrombosis during statin
SRE therapy includes a decrease in prothrombin activation and a
decrease in tissue factor production. Because thrombosis is
at the root of most acute coronary syndromes, its reduction
could contribute to the survival benefit of statins. Finally,
plaque stability is enhanced during statin therapy because the
fibrous cap that overlies the lipid-rich plaque becomes thicker.
FIGURE 19-11. Mechanism of LDL lowering by statins. Statins competi- This effect may be attributable to decreased macrophage infil-
tively inhibit HMG-CoA reductase, the enzyme that catalyzes the rate-limiting step
in cholesterol biosynthesis. Decreased cellular cholesterol concentrations lead to
tration and inhibition of vascular smooth muscle proliferation.
protease activation and cleavage of the sterol regulatory element binding protein It is important to emphasize that most of these pleiotropic ef-
(SREBP), which is a transcription factor that normally resides in the cytoplasm. fects of statins have been demonstrated only in vitro or in ani-
The cleaved SREBP diffuses into the nucleus, where it binds to sterol response mal models, and their relevance in humans is unclear. Clinical
elements (SRE), leading to up-regulation of LDL receptor gene transcription. This data indicate that the reductions in cardiovascular morbidity
leads to increased cellular LDL receptor expression. This promotes uptake of LDL and mortality due to statins are primarily attributable to the
particles and results in reduced LDL-cholesterol concentrations in the plasma. lowering of LDL-cholesterol concentrations in the plasma.
Seven statinslovastatin, pravastatin, simvastatin,
fluvastatin, atorvastatin, rosuvastatin, and pitavastatin
are currently approved for use in hypercholesterolemia and
decrease mortality even in the absence of overt cardiovas- mixed dyslipidemia. They are considered first-line therapy for
cular disease, which is called primary prevention. Despite increased LDL levels, and their use is supported by numer-
these convincing percentage risk reductions in both second- ous trials showing that statins decrease both cardiovascular-
ary and primary prevention trials, it should be noted that sta- related and total mortality. Stroke is also reduced. All of the
tin use is associated with a greater absolute risk reduction in statins are believed to act by the same mechanism. The main
secondary prevention; the reason may be that patients in this differences are attributable to potency and pharmacokinetic
 Fibrates

PPAR
activation

apoA-I, apoA-II apoC-III synthesis Fatty acid

synthesis in in hepatocytes oxidation in
hepatocytes and hepatocytes
Lipoprotein lipase
expression in muscle
vascular beds
Plasma HDL

Fatty acid uptake in Triglyceride

muscle cells synthesis
and
Fatty acid oxidation in
muscle cells

Plasma triglycerides
 Adipose tissue Liver Peripheral cells

Decreased Decreased Decreased Cholesterol

plasma plasma VLDL plasma LDL delivery
free fatty Decreased
acids synthesis of
Hormone-sensitive triglycerides
lipase
Cholesterol Increased Cholesterol
delivery plasma HDL removal

Niacin Increased
receptor excretion of Decreased
Niacin cholesterol in bile apoA-I
clearance

Niacin
 CHAPTER 19 / Pharmacology of Cholesterol and Lipoprotein Metabolism 329
patients. Rarely, niacin may cause myopathy. Concurrent
administration of niacin with a statin slightly increases the
risk of myopathy.
Niacin is indicated for patients with elevations of both
triglycerides and cholesterol, usually in combination with a
statin. Because niacin is currently the most effective agent
available for raising HDL, it may also be the drug of choice
for patients with modestly elevated LDL and decreased
HDL. It is not clear whether both the LDL-lowering and
HDL-raising effects of niacin contribute to improved clini-
cal outcomes.
Omega-3 Fatty Acids
The omega-3 fatty acids eicosapentaenoic acid (EPA) and
docosahexaenoic acid (DHA), also referred to as fish oils,
are effective at reducing plasma triglycerides by up to 50%
in patients with hypertriglyceridemia. The likely mechanism
of triglyceride lowering involves regulation of nuclear tran-
scription factors, including SREBP-1c and PPAR, to cause
reduced triglyceride biosynthesis and increased fatty acid
oxidation in the liver. Omega-3 fatty acids are available over
the counter as nutritional supplements in the form of fatty
acid ethyl esters. Lovaza, a prescription-strength form of
omega-3 fatty acids, has also become available. Lovaza is
enriched (84%) in EPA and DHA, whereas most dietary sup-
plements contain 1363% fish oils. The recommended dose
of Lovaza is 4 grams, once a day. Omega-3 fatty acids are
generally added to therapy when plasma triglyceride con-
centrations exceed 500 mg/dL. The influence of omega-3
fatty acid use on clinical outcomes is uncertain.
 CONCLUSION AND FUTURE DIRECTIONS
LDL reduction by the available lipid-lowering drugs
particularly the statinsrepresents an important advance in
reducing cardiovascular disease mortality. Future drug trials
will examine the possible benefits of raising HDL and lower-
ing triglyceride levels on cardiovascular disease. Also under
development are pharmacologic therapies for new biochemi-
cal targets such as CETP and MTP. Inhibition of CETP raises
HDL and lowers LDL by inhibiting the transfer of choles-
terol from HDL to remnant particles, whereas inhibition of
MTP reduces VLDL secretion.
Suggested Reading
Adult Treatment Panel III. Executive summary of the National Cholesterol
Education Program (NCEP) expert panel on detection, evaluation, and
treatment of high blood cholesterol in adults. JAMA 2001;285:24862497.
(Clinical guidelines for cholesterol-lowering therapy.)
Ballantyne CM, ed. Clinical lipidology: a companion to Braunwalds heart
disease. Philadelphia: Saunders/Elsevier; 2009; 584 pp. (Concise chapters
cover all aspects of lipoprotein metabolism and pharmacology.)
Duffy D, Rader DJ. Emerging therapies targeting high-density lipopro-
tein metabolism and reverse cholesterol transport. Circulation 2006;113:
11401150. (Future directions in pharmacology of HDL metabolism.)
Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical tri-
als for the National Cholesterol Education Program Adult Treatment Panel
III Guidelines. J Am Coll Cardiol 2004;44:720732. (Supplemental clini-
cal guidelines for cholesterol-lowering therapy with lower LDL-cholesterol
goals for high-risk patients.)
Tunaru S, Kero J, Schaub A, et al. PUMA-G and HM74 are receptors
for nicotinic acid and mediate its anti-lipolytic effect. Nat Med 2003;9:
352355. (Identification of the G protein-coupled receptor ligand for phar-
macologic effects of niacin.)
20
Pharmacology of
Volume Regulation
Mallar Bhattacharya and Seth L. Alper
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 332-333
PHYSIOLOGY OF VOLUME REGULATION . . . . . . . . . . . . . . . 332
Determinants of Intravascular Volume . . . . . . . . . . . . . . . 332
Volume Sensors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
Volume Regulators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334
Renin-AngiotensinAldosterone System . . . . . . . . . . . 334
Natriuretic Peptides . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Antidiuretic Hormone . . . . . . . . . . . . . . . . . . . . . . . . . 337
Renal Sympathetic Nerves . . . . . . . . . . . . . . . . . . . . . 337
Renal Control of Na Excretion . . . . . . . . . . . . . . . . . . . . 337
Proximal Tubule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
Thick Ascending Limb of the Loop of Henle . . . . . . . . . 338
Distal Convoluted Tubule . . . . . . . . . . . . . . . . . . . . . . . 339
Collecting Duct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
PATHOPHYSIOLOGY OF EDEMA FORMATION . . . . . . . . . . . 340
Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
 INTRODUCTION
Coordinated regulation of volume homeostasis and vascu-
lar tone maintains adequate tissue perfusion in response to
varying environmental stimuli. This chapter discusses the
pharmacologically relevant physiology of volume regula-
tion, with emphasis on the hormonal pathways and renal
mechanisms that modulate systemic volume. (Control of
vascular tone is discussed in Chapter 21, Pharmacology of
Vascular Tone.) Dysregulation of volume homeostasis can
result in edema, the pathologic accumulation of fluid in the
extravascular space. Pharmacologic modulation of volume is
targeted at reducing volume excess; this is an effective treat-
ment for hypertension and heart failure (HF), as well as for
cirrhosis and the nephrotic syndrome. The two broad classes
of pharmacologic agents used to modify volume status are
modulators of neurohormonal regulators (e.g., angiotensin
converting enzyme [ACE] inhibitors) and diuretics, agents
that increase renal Na excretion. Drugs that modify vol-
ume regulation also have many other clinically important
effects on the body, because these volume regulators act as
diverse hormonal modulators in multiple physiologic path-
ways. Many of the clinical applications of these agents are
discussed further in Chapter 25, Integrative Cardiovascular
332
Cirrhosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Nephrotic Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 342
Agents That Modify Volume Regulators . . . . . . . . . . . . . . 342
Inhibitors of the ReninAngiotensin System . . . . . . . . 342
B-Type Natriuretic Peptide . . . . . . . . . . . . . . . . . . . . . 344
Vasopressin Receptor Antagonists and Agonists . . . . . 344
Agents That Decrease Renal Na Reabsorption . . . . . . . . 344
Carbonic Anhydrase Inhibitors . . . . . . . . . . . . . . . . . . . 345
Osmotic Diuresis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Loop Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Thiazides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
Collecting Duct (Potassium-Sparing) Diuretics. . . . . . . 347
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 347
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
Pharmacology: Hypertension, Ischemic Heart Disease, and
Heart Failure.
 PHYSIOLOGY OF VOLUME REGULATION
An intricate set of mechanisms sense, signal, and modu-
late changes in plasma volume. Volume sensors are located
throughout the vascular tree, including in the atria and in the
kidneys. Many of the volume regulators activated by these
sensors include systemic and autocrine hormones, while
others involve neural circuits. The integrated result of these
signaling mechanisms is to alter vascular tone and to regulate
renal Na reabsorption and excretion. Vascular tone maintains
end-organ tissue perfusion; changes in renal Na excretion
alter total volume status.
Determinants of Intravascular Volume
Intravascular volume is a small proportion of total body water,
but the amount of fluid in the vascular compartment critically
determines the extent of tissue perfusion. Approximately 2/3
of total body water is intracellular, while 1/3 is extracellular.
Of the extracellular fluid (ECF), approximately 3/4 resides in
the interstitial space, while 1/4 of ECF is plasma.
334 Principles of Cardiovascular Pharmacology

A Volume Regulators
Pif c Pif Together, the low-pressure and high-pressure feedback systems
c
integrate neurohumoral volume signals to maintain volume ho-
meostasis in the face of volume perturbations. The neurohor-
monal response to a change in volume status is controlled by
Arterial
end
Pc if Pc if Venous
end
four main systems: the renin-angiotensinaldosterone system
(RAAS), natriuretic peptides, ADH, and renal sympathetic
nerves. The RAAS, ADH, and renal sympathetic nerves are
Flow
active in situations of intravascular volume depletion, while
natriuretic peptides are released in response to intravascular
volume overload.
B
Renin-AngiotensinAldosterone System
Out
Renin is an aspartyl protease produced and secreted by the
juxtaglomerular apparatus, a specialized set of smooth
muscle cells that line the afferent and efferent arterioles of
Net fluid movement

the renal glomerulus. The ultimate result of renin secretion

is vasoconstriction and Na retention, actions that main-
0
tain tissue perfusion and increase extracellular fluid volume
(Fig. 20-2).
At least three mechanisms are thought to control juxta-
glomerular cell renin release (Fig. 20-3). First, a direct pres-
In
sure-sensing mechanism of the afferent arteriole increases
juxtaglomerular cell release of renin in response to decreased
Arterial Venous arteriolar wall tension. The detailed molecular mechanism of
end Position along capillary end

FIGURE 20-1. Capillary fluid filtration. The balance of hydrostatic pressure

Angiotensinogen
and oncotic pressure determines fluid filtration along the capillary. The example (secreted by liver)
shown here is for a hypothetical capillary where fluid filtration exceeds fluid reab-
sorption. A. At the arterial end of the capillary, the capillary hydrostatic pressure
(Pc ) is large (long arrow ), and the sum of Pc and interstitial oncotic pressure (if) Renin
(secreted by kidney)
exceeds the sum of interstitial hydrostatic pressure (Pif) and capillary oncotic pres-
sure (c ). Therefore, fluid moves out of the capillary into the interstitial space. As Angiotensin I
fluid continues to filter along the length of the capillary, the increased fluid filtra-
tion results in decreased Pc and increased c, thus decreasing the driving force
for fluid filtration from the capillary to the interstitium. Throughout the length of Angiotensin converting enzyme
(expressed in lung endothelium)
the capillary, Pif and if remain relatively constant. B. A graphic representation of
net fluid movement along the capillary length shows the decreasing driving force
for fluid filtration into the interstitium. In the hypothetical capillary shown here, Angiotensin II
fluid is filtered into the interstitium along the entire capillary length; lymphatic
vessels eventually return the excess interstitial fluid to the systemic circulation
(not shown).
Adrenal Renal Renal Hypothalamus
cortex proximal efferent (thirst; increased
(zona glomerulosa) tubule arterioles ADH secretion)
(increased (vasoconstriction;
NaCl absorption) maintains GFR)
the atria and pulmonary vasculature transmit a signal to nor-
adrenergic neurons in the medulla of the central nervous
system (CNS). This signal is relayed to the hypothalamus, re- Aldosterone (increased NaCl absorption) acting at
sulting in increased secretion by the posterior pituitary gland 1. Medullary thick ascending limb of Henle
of antidiuretic hormone (ADH, also known as vasopressin). 2. Distal tubule
Together with increased peripheral sympathetic tone, ADH 3. Collecting duct
maintains distal tissue perfusion. In response to increased FIGURE 20-2. The renin-angiotensinaldosterone axis. Angiotensinogen
wall stress (e.g., caused by increased intravascular volume), is a prohormone secreted into the circulation by hepatocytes. Renin, an aspartyl
cells of the atria produce and secrete natriuretic peptide, pro- protease secreted by juxtaglomerular cells of the kidney, cleaves angiotensinogen
moting vasodilation and natriuresis (increased renal Na to angiotensin I. Angiotensin converting enzyme (ACE), a protease expressed on
excretion). pulmonary capillary endothelium (and elsewhere), cleaves angiotensin I to angio-
The high-pressure system consists of specialized barore- tensin II. Angiotensin II has four actions that increase intravascular volume and
maintain tissue perfusion. First, angiotensin II stimulates zona glomerulosa cells of
ceptors in the aortic arch, carotid sinus, and juxtaglomerular
the adrenal cortex to secrete aldosterone, a hormone that increases renal NaCl re-
apparatus. These sensors modulate hypothalamic control of absorption at multiple segments along the nephron. Second, angiotensin II directly
ADH secretion and sympathetic outflow from the brainstem. stimulates renal proximal tubule reabsorption of NaCl. Third, angiotensin II causes
In addition, sympathetic input stimulates the juxtaglomeru- efferent arteriolar vasoconstriction, an action that increases intraglomerular pres-
lar apparatus to secrete renin, a proteolytic enzyme that acti- sure and thereby increases GFR. Fourth, angiotensin II stimulates hypothalamic
vates the renin-angiotensinaldosterone system (see below). thirst centers and promotes ADH secretion.

Macula densa
cell
Juxtaglomerular
cell Adenosine (A) Tubular lumen
1-agonist Na+
Cl-
1-AR
K+
A1 receptor
? sensed by shear stress. The former may be directly sensed
Na+
2Cl-
Gs [Na+] NKCC2 K+
Gi [Cl-]
COX-2
cAMP
Prostaglandins (PG)
Renin
Gs
PG receptor
FIGURE 20-3. Modulation of renin release. Renin is released by juxta-
glomerular cells in response to diverse stimuli that signal volume depletion. First,
decreased pressure in the afferent arteriole (not shown) stimulates increased renin
release, possibly by releasing prostaglandins. Second, juxtaglomerular cells express
1-adrenergic receptors (1-AR) coupled to Gs, which stimulates adenylyl cyclase to
increase the intracellular level of cAMP, which is a stimulus for renin release. Third,
cells lining the diluting segments of the nephron modulate renin release based on
the extent of luminal NaCl flux. In cases of decreased NaCl flux, decreased Cl entry
through the Na/2Cl/K transporter (NKCC2) on the apical membrane of macula
densa cells in the distal convoluted tubule stimulates cyclooxygenase-2 (COX-2)
activity, which increases prostaglandin production. The prostaglandins diffuse to
and activate juxtaglomerular-cell prostaglandin (PG) receptors, which stimulate re-
lease of renin by increasing cAMP production. In contrast, increased cortical thick
ascending limb (TAL) NaCl delivery leads, through still-debated mechanisms, to in-
creased generation of adenosine in the juxtaglomerular mesangial interstitium. Ac-
tivation of Gi-coupled A1 adenosine receptors of the juxtaglomerular cell decreases
intracellular cAMP, which leads to decreased renin release.
this sensory transduction is unknown, but may involve auto-
crine prostaglandin and purinergic signaling. Second, sym-
pathetic innervation of juxtaglomerular cells promotes renin
release via 1-adrenoceptor signaling. Third, an autoregu-
latory mechanism known as tubuloglomerular feedback
senses distal nephron chloride (and/or sodium) delivery and
modulates renin release. Nephron anatomy is organized such
that the distal end of the cortical thick ascending limb (TAL)
of each nephron is closely apposed to the juxtaglomeru-
lar mesangium of that same nephron. This spatial proxim-
ity allows rapid integrative regulation of afferent arteriolar
diameter and glomerular mesangial contractility by distal
nephron electrolyte concentration and/or salt load. Macula
densa cells of the cortical thick ascending limb respond to
CHAPTER 20 / Pharmacology of Volume Regulation 335
increased luminal NaCl delivery by increasing extracellular
adenosine in the juxtaglomerular interstitium and thereby ac-
tivating A1 receptors on the juxtaglomerular mesangial cells
to decrease renin release. Conversely, decreased luminal
NaCl delivery activates a mesangial prostaglandin signaling
cascade that culminates in increased renin release. Macula
densa cells sense luminal NaCl delivery by monitoring both
luminal NaCl concentration and luminal fluid flow rate as
by receptors in the apical sensory monocilia of the macula
densa cells; the latter by direct bending of the monocilia.
Molecular components in the extraciliary apical membrane
likely also contribute to these signal transduction processes.
After renin is secreted, it acts as a protease to cleave
the circulating 14-amino-acid hepatic prohormone an-
giotensinogen to generate the decapeptide angiotensin I.
Angiotensin I is then cleaved to the active octapeptide an-
giotensin II (AT II) by the carboxypeptidase angiotensin
converting enzyme (ACE I) located on the endothelial cell
surface. Although ACE is expressed primarily in the pulmo-
nary vascular endothelium and coronary circulation, ACE
activity regulates local production of AT II in all vascular
beds. Indeed, an incompletely understood local renin
angiotensin system is also expressed in the vasculature, pro-
ducing these substances as autocrine factors independently
of the kidney and liver. ACE has a broad proteolytic sub-
strate specificity that includes bradykinin and other kinins
that are venodilatory autacoids released in response to in-
flammation. For this reason, ACE is also known as kininase
II. Kininase activity has important pharmacologic conse-
quences, as discussed below.
AT II binding to the AT II receptor subtype I (the G
protein-coupled AT1 receptor, AT1R) produces at least four
physiologic responses: (1) stimulation of aldosterone secre-
tion by zona glomerulosa cells of the adrenal glands; (2) in-
creased reabsorption of NaCl from the proximal tubule and
other nephron segments; (3) central stimulation of thirst and
ADH secretion; and (4) arteriolar vasoconstriction. All four
of these actions increase intravascular volume and therefore
help to maintain perfusion pressure: aldosterone secretion
increases distal-tubule Na reabsorption; proximal-tubule
NaCl reabsorption increases the fraction of filtered Na that
is reabsorbed; stimulation of thirst increases the free water
absorbed into the vasculature; secretion of ADH increases
collecting-duct free water absorption; and arteriolar vaso-
constriction maintains blood pressure.
The actions of AT II are best understood in vascular
smooth muscle cells, where AT1R activates phospholipase C,
leading to the release of Ca2 from intracellular stores and
activation of protein kinase C. Inhibition of AT1R can de-
crease vascular smooth muscle cell contractility, and thereby
decrease systemic vascular resistance and blood pressure
(see below). A second G protein-coupled AT II receptor,
AT2R, is expressed more prominently in fetal than in adult
tissue. AT2R appears to have a vasodilatory role.
Natriuretic Peptides
Natriuretic peptides are hormones released by atria, ventri-
cles, and vascular endothelium in response to volume over-
load. The classical natriuretic peptides are A-type, B-type,
and C-type natriuretic peptides. A-type natriuretic peptide
(ANP) is released primarily by the atria, while B-type na-
triuretic peptide (BNP) is released mainly by the ventricles.
336 Principles of Cardiovascular Pharmacology

C-type natriuretic peptide (CNP) is released by vascular en-
dothelial cells. The natriuretic peptide uroguanylin (UGN)
is released by enterocytes in response to dietary ingestion
of salt.
Vascular natriuretic peptides are released in response to
increased intravascular volume, an effect that may be sig-
naled by increased stretch of natriuretic peptide-secreting
cells. Circulating natriuretic peptides bind to one of three
receptors, termed NPR-A, NPR-B, and NPR-C. NPR-A
and NPR-B are transmembrane proteins with cytoplasmic
guanylyl cyclase domains (see Chapter 1, DrugReceptor
Interactions); activation of these receptors increases intra-
cellular cGMP levels. NPR-C lacks an intracellular guanylyl
cyclase domain and may serve as a decoy or buffer
receptor to reduce the level of circulating natriuretic pep-
tides available to bind to the two signaling receptors. Both
ANP and BNP bind with high affinity to NPR-A, while only
CNP binds to NPR-B. All three natriuretic peptides bind to
NPR-C (Fig. 20-4A). UGN binds to and activates transmem-
brane guanylyl cyclase C in both renal proximal tubule cells
and enterocytes, and binds to an undefined receptor in the
renal collecting duct.
Natriuretic peptides affect the cardiovascular system, the
kidney, and the central nervous system. Integration of na-
triuretic peptide-derived signals serves to decrease volume
overload and its sequelae. ANP relaxes vascular smooth
muscle by increasing intracellular cGMP, which causes
dephosphorylation of myosin light chain and subsequent va-
sorelaxation (see Chapter 21). ANP also increases capillary
endothelial permeability; this effect reduces blood pressure
by favoring fluid filtration from the plasma into the intersti-
tium (see Equation 20-1).
In the kidney, natriuretic peptides promote both increased
glomerular filtration rate (GFR) and natriuresis. GFR is in-
creased because of constriction of the efferent arteriole and
dilation of the afferent arteriole, resulting in higher intra-
glomerular pressure and therefore increased plasma filtration.
The natriuretic effects on the kidney result from antagonism
of ADH action in the collecting ducts and antagonism of Na
reabsorption in multiple nephron segments.
The central effects of natriuretic peptides are less well
understood, but they include decreased perception of thirst
(and therefore decreased fluid intake), decreased release of
antidiuretic hormone, and decreased sympathetic tone. The
signaling mechanisms mediating these actions are uncertain,
but may be via CNP, as this natriuretic peptide is expressed
at high levels in the brain.
Although many of the effects of natriuretic peptides are
still not understood completely, these hormones appear to
play an important role in regulating the pathophysiology of
volume excess. Much interest has recently focused on the
relationship between natriuretic peptides and heart failure.
The physiology and pharmacology of natriuretic peptides
and their receptors remain subjects for active investigation.

A B Apical Basolateral
membrane membrane

NPR-A Vasopressin/
GTP
ADH
Lumen of Vesicle containing AQP2
Biological effects, collecting
cGMP duct
including increased
natriuresis

ANP/BNP GDP
V2-receptor
AQP2
NPR-C

Degradation Internalization GTP

Water
cAMP
Translocation/insertion
Adenylyl
ATP cyclase
Water

FIGURE 20-4. Natriuretic peptide and antidiuretic hormone signaling pathways. A. A-type and B-type natriuretic peptides (ANP and BNP) are hormones secreted
in response to volume overload. These peptides bind to natriuretic peptide receptor-A (NPR-A) and natriuretic peptide receptor-C (NPR-C). NPR-A is a transmembrane
receptor with intrinsic guanylyl cyclase activity associated with its cytoplasmic domain. Increased intracellular cGMP levels mediate the effects of natriuretic peptides,
including increased natriuresis. NPR-C is believed to be a decoy receptor, because the protein lacks the intracellular catalytic domain. Binding of natriuretic peptide to
NPR-C may result in receptor internalization and in degradation of the internalized receptor together with the bound natriuretic peptide. A third natriuretic peptide, CNP,
is expressed by vascular endothelial cells and binds to NPR-B (not shown). B. Antidiuretic hormone (ADH), also known as vasopressin, is secreted by the hypothalamus
in response to increased osmolality and volume depletion. ADH mediates renal collecting-duct water reabsorption by activating the Gs-coupled V2 vasopressin receptor.
Activation of Gs leads to increased adenylyl cyclase activity and increased cAMP levels. cAMP increases collecting-duct water reabsorption by promoting the transloca-
tion and insertion of aquaporin 2 water channel (AQP2)-containing vesicles into the collecting duct apical membrane. The increased apical membrane AQP2 results in
increased water flux across the collecting duct, and therefore greater reabsorption of filtered water. Hydrolysis of cAMP by phosphodiesterase leads to removal of AQP2
from the luminal membrane by endocytosis of AQP2-containing vesicles (not shown).

Antidiuretic Hormone
Antidiuretic hormone (ADH, or vasopressin) is a nonapep-
tide hormone secreted by the posterior pituitary gland in re-
sponse to increased plasma osmolality or severe hypovolemia.
ADH constricts the peripheral vasculature and promotes
water reabsorption in the renal collecting duct. Its actions are
mediated by two distinct G protein-coupled receptors. The
V1 receptor, present in vascular smooth muscle cells, stimu-
lates vasoconstriction through a Gq-mediated mechanism.
The V2 receptor, expressed in collecting duct principal cells,
stimulates water reabsorption by a Gs-mediated mechanism
(Fig. 20-4B). This Gs signal increases cytosolic cAMP, which
leads to activation of protein kinase A (PKA). PKA phospho-
rylates the water channel aquaporin 2 and activates transport
and fusion of aquaporin 2-containing vesicles into the apical
membrane of the principal cell. Increased aquaporin 2 ex-
pression at the apical membrane promotes increased water
reabsorption. Regulation of renal water reabsorption in the
collecting duct modulates urine and plasma osmolality, and
serves as a reserve mechanism for increasing intravascular
volume in situations of severe dehydration.
Renal Sympathetic Nerves
Renal sympathetic nerves innervate both afferent and efferent
arterioles. In response to a decrease in intravascular volume,
the renal sympathetic nerves decrease GFR by stimulating
constriction of the afferent arteriole to a greater degree than
the efferent arteriole. The decreased GFR resulting from
preferential constriction of the afferent arteriole ultimately
leads to decreased natriuresis. Renal sympathetic nerves also
increase renin production by stimulation of 1-adrenergic
receptors on juxtaglomerular mesangial cells, and increase
proximal-tubule NaCl reabsorption. Since transplanted kid-
neys function normally, and these kidneys lack sympathetic
nerve input, it appears that renal innervation is not required
for clinically normal kidney function.
Renal Control of Na Excretion
Over the course of 24 hours, the kidneys filter approximately
180 L of fluid. To increase or decrease body fluid volume,
the kidneys must increase or decrease renal Na reabsorp-
tion from the large daily volume of glomerular filtrate. For
this reason, the neurohormonal mechanisms controlling ex-
tracellular volume status have important actions on the kid-
ney. An understanding of the renal control of Na excretion
is crucial to understanding the role of the kidney in regula-
tion of body fluid volume.
The renal glomerulus produces an ultrafiltrate of plasma
that flows through and is processed by the nephron, the func-
tional unit of the kidney (Fig. 20-5). The postglomerular
nephron is responsible for solute and water reabsorption from
the filtrate, as well as for excretion of metabolic waste prod-
ucts and xenobiotics, including drugs. The renal tubular epi-
thelial cells of the postglomerular nephron enclose a lengthy
tubular lumen, the urinary space, which leads to the ureters,
urinary bladder, and urethra. The initial glomerular ultrafil-
trate contains solutes of low molecular weight at concentra-
tions similar to those in the plasma. As the ultrafiltrate passes
through the nephron, substrate-specific transporters and
channels in the luminal (apical) membrane of polarized renal
tubular epithelial cells sequentially alter the solute concen-
trations of the tubular fluid. The function of these transport-
ers and channels is, in turn, influenced by changes in solute
CHAPTER 20 / Pharmacology of Volume Regulation 337
Carbonic anhydrase
inhibitors
Glomerulus 1 PCT
JG
Afferent arteriole
Efferent arteriole
CCD
DCT
3
4
Thiazide
diuretics
CTAL Potassium- OMCD
sparing
diuretics
Loop diuretics 2
MTAL
IMCD
ATL TDL
FIGURE 20-5. Nephron anatomy and sites of action of diuretics. Nephron
fluid filtration begins at the glomerulus, where an ultrafiltrate of the plasma enters
the renal epithelial (urinary) space. This ultrafiltrate then flows sequentially through
four axially distinct nephron segments (14). From the glomerulus, ultrafiltrate
travels to the proximal convoluted tubule (PCT) (1), then to the loop of Henle (2),
which includes the thin descending limb (TDL), ascending thin limb (ATL), medullary
thick ascending limb (MTAL), and cortical thick ascending limb (CTAL) of Henle. The
distal convoluted tubule (DCT ) (3) includes the macula densa and juxtaglomeru-
lar (JG) apparatus. The collecting duct (4) consists of the cortical collecting duct
(CCD ), outer medullary collecting duct (OMCD), and inner medullary collecting duct
(IMCD). Pharmacologic agents inhibit specific solute transporters within each seg-
ment of the nephron. Carbonic anhydrase inhibitors act primarily at the proximal
convoluted tubule; loop diuretics act at the medullary and cortical thick ascending
limbs; thiazide diuretics inhibit solute transport in the distal convoluted tubule; and
potassium-sparing diuretics inhibit collecting-duct Na reabsorption.
concentrations in the cells themselves, as regulated in part by
channels and transporters on the contraluminal (basolateral)
side of the cells. Systemic volume regulation by the kidney
is accomplished by tubular solute reabsorption through inte-
grated action of ion channels and ion transporters in the api-
cal and basolateral membranes of tubular epithelial cells and
by the accompanying reabsorption of water.
The nephron beyond the glomerulus exhibits remarkable
heterogeneity along its length. Four segments of the nephron
are especially relevant to the pharmacology of body volume
regulation (Fig. 20-5). These are the proximal tubule, the
thick ascending limb (TAL) of the loop of Henle, the distal
convoluted tubule (DCT), and the cortical collecting duct
(CCD). In each tubular segment, a complex but tightly cho-
reographed group of segment-specific ion transporters and
channels collaborate in the reabsorption of NaCl from the
338 Principles of Cardiovascular Pharmacology
lumen across the cellular monolayer of tubular epithelium
into the interstitial space. NaCl reabsorption is key for sys-
temic water retention. Solute and water transport across each
segment requires coordination of transporter function in the
luminal and basolateral membranes. In addition, paracellu-
lar transport of ions across the tight junctions between cells
requires regulated communication between adjacent cells of
the tubular epithelium. Integration of the transcellular and
paracellular components of transepithelial transport requires
integration of signals transmitted by sensors of extracellular
and intracellular ion concentrations and of intracellular, local
extracellular, and systemic volume. Alteration of ion trans-
port by drugs in any nephron segment can induce compensa-
tory regulation locally and in more distal nephron segments.
Proximal Tubule
The proximal tubule (PT) is the first reabsorptive site in the
nephron. It is responsible for approximately two-thirds of so-
dium reabsorption, 8590% of bicarbonate reabsorption, and
approximately 60% of chloride reabsorption (Fig. 20-6). Spe-
cific sodium-coupled symporters in the proximal tubule api-
cal membrane drive renal reabsorption of all glucose, amino
acids, phosphate, and sulfate from the glomerular filtrate. The
proximal tubule also mediates secretion and reabsorption of
organic weak acids and weak bases coupled to processes of
sodium or proton symport or antiport, or to anion exchange
Apical Basolateral
membrane membrane
Lumen of
proximal
convoluted
tubule
Na+ 3HCO3-
NHE3 NBCe1
H+ Na+
H2CO3
vH+
3Na+
H+ + HCO3- ATPase
H+ Na+/K+
H2CO3 CAII
ATPase
2K+
CAIV
Acetazolamide
Acetazolamide CO2 + H2O
CO2 + H2O
FIGURE 20-6. Proximal convoluted tubule cell. A significant percentage of
proximal convoluted tubule Na is reabsorbed via the NHE3 Na/H antiporter. is hypertonic and has an elevated NaCl concentration. The
The action of this antiporter, together with that of an apical membrane vacuolar
ATPase (vH ATPase), results in significant H extrusion into the proximal con-
voluted tubule urinary space. H extrusion is coupled to HCO3 reabsorption by
the action of an apical membrane carbonic anhydrase IV (CAIV) that catalyzes the
cleavage of HCO3 into OH and CO2. OH combines with H to form water, while thick ascending limb of Henle is devoid of aquaporins, as
CO2 diffuses into the cytoplasm of the epithelial cell. The cytoplasmic enzyme
carbonic anhydrase II (CAII) catalyzes the formation of HCO3 from CO2 and OH;
the HCO3 is then transported into the interstitium together with Na. The net
result of this process is reabsorption of HCO3 and Na by the basolateral co-
transporter NBCe1. Acetazolamide inhibits both isoforms of carbonic anhydrase;
the decreased carbonic anhydrase activity results in decreased Na and HCO3
absorption.
mechanisms. Among these weak acids and bases are many of
the drugs used to regulate systemic volume (see below).
Bicarbonate reabsorption requires the coordinated action
of apical and basolateral ion transporters together with api-
cal and intracellular enzymatic activities (Fig. 20-6). At the
luminal surface of the proximal tubule, filtered bicarbonate
encounters active proton secretion across the proximal tu-
bule brush-border microvilli. Two-thirds of the proton efflux
is in exchange for influx of Na, largely via the NHE3 Na/
H exchanger. The remaining third of proton efflux is medi-
ated by the vacuolar H-ATPase (vH ATPase).
The HCO3 permeability of the luminal membrane of the
proximal tubular cell is low. However, the outer leaflet of the
luminal membrane harbors the glycosylphosphatidylinositol-
linked exoenzyme carbonic anhydrase IV (CAIV). CAIV
converts luminal HCO3 to CO2 and OH. The OH is rapidly
hydrated to water by the abundance of local protons, and the
CO2 freely diffuses into the cytoplasm of the proximal tubular
epithelial cell. The intracellular CO2 is rapidly rehydrated to
HCO3 by cytoplasmic carbonic anhydrase II (CAII); this
reaction consumes the intracellular OH accumulated as a re-
sult of the H-extruding activities of apical NHE3 and vH
ATPase. The HCO3 produced by the CAII reaction is then co-
transported with Na across the basolateral membrane of the
epithelial cell, accounting for the net reabsorption of sodium
and bicarbonate. The Na/HCO3 co-transporter NBCe1
mediates electrogenic basolateral efflux of three HCO3 ions
with each co-transported Na ion. Basolateral K channels
maintain an inside-negative membrane potential to enhance
the driving force for net efflux of two negative charges per
NBCe1 transport cycle. Emerging evidence also suggests the
presence of several types of transmembrane ecto-carbonic an-
hydrases in the basolateral membrane that help dissipate the
local accumulation of bicarbonate within the small interstitial
space between the epithelial cells and peritubular capillaries.
Solute absorption in the proximal tubule is iso-osmotic
water accompanies reabsorbed ions to maintain osmotic
balance. In the past, water flow was assumed to be largely
paracellular. However, data from mice genetically modified
to lack the aquaporin water channel AQP1 (and from rare
cases of humans lacking AQP1) demonstrate that most water
reabsorption across the proximal tubuleand, beyond that,
across the thin descending limb of Henleis transcellular.
Aquaporins are central to transepithelial water permeability
in all water-permeable nephron segments. Thus, the transi-
tion from the water-permeable thin descending limb of Henle
to the water-impermeable ascending thin limb is paralleled
by decreased AQP1 expression.
Thick Ascending Limb of the Loop of Henle
The tubular fluid emerging from the ascending thin limb
three nephron segments into which this fluid flows, the thick
ascending limb (TAL), the distal convoluted tubule (DCT),
and the connecting tubule or segment (CNT), together con-
stitute the diluting segment. The apical membrane of the
is the apical membrane of the rest of the diluting segment;
therefore, these nephron segments reabsorb NaCl and urea
without accompanying water (Fig. 20-7), thus diluting the
solutes of the tubular fluid. Reabsorption of NaCl and urea
across the TAL provides the interstitial solute that generates
and maintains the corticomedullary osmotic gradient of the

Apical Basolateral
membrane membrane
Lumen of
medullary thick
ascending limb
Loop diuretics
3Na+
Na+/K+
Na+ ATPase
2Cl- 2K+
NKCC2
K+
ROMK K+ Cl- CLC-K2
Ca2+
Mg2+
Na+ 10mV
FIGURE 20-7. Medullary thick ascending limb cell. The medullary thick
ascending limb of the loop of Henle absorbs Na through an apical membrane
Na/K/2Cl (NKCC2) transporter. The Na/K-ATPase pumps sodium from the
cytoplasm into the interstitium, and a basolateral Cl channel (CLC-K2) transports
Cl into the interstitium. K is primarily recycled into the urinary space via a lu-
minal K channel (ROMK). The combined activities of apical ROMK and baso-
lateral CLC-K2 result in a lumen-positive transepithelial potential difference
(approximately 10 mV) that drives paracellular absorption of cations, including
Ca2 and Mg2. Loop diuretics inhibit NKCC2, resulting in significantly increased
renal sodium excretion. Disruption of the positive transepithelial potential by loop
diuretics also increases the excretion of Ca2 and Mg2.
kidney, allowing operation of the countercurrent multiplier
that can concentrate the urine of humans to 1,200 mOsM and
that of desert rodents to 4,000 mOsM.
The TAL reabsorbs between 25% and 35% of the filtered
Na load by means of the luminal membrane Na-K-2Cl
co-transporter, NKCC2. The Cl imported by NKCC2 exits
the basolateral side of the cell via CLC-K2 chloride chan-
nels. The Na imported from the lumen via NKCC2 leaves
the basolateral side of the cell via the Na/K-ATPase. Be-
cause Cl carries a negative charge, exit of unaccompanied
Cl through basolateral CLC-K2 depolarizes the cell. The
stoichiometry of the Na/K ATPase, 3Na outward per
2 K inward, partly counters this depolarization; additional
repolarization of the cell is accomplished by the apical K
channel ROMK, which recycles back into the lumen the K
imported into the cell via NKCC2.
The coordinated operation of these apical and basolateral
transporters and channels generates a lumen-positive electri-
cal potential across the TAL. This transepithelial potential dif-
ference drives the paracellular reabsorption of additional Na
from lumen to interstitium. The paracellular component of
Na reabsorption, approximately 50% of the Na reabsorbed
by the TAL, effectively reduces by 50% the energetic cost
to TAL epithelial cells (measured as ATP consumption), be-
cause Na/K transport consumes most of the ATP in the TAL
cell. Even with the energy conserved by the paracellular Na
absorptive pathway, the TAL working at maximal capacity
can consume up to 25% of the bodys total ATP production,
or approximately 65 moles per day at rest. The lumen-positive
transepithelial potential of the TAL also drives paracellular
CHAPTER 20 / Pharmacology of Volume Regulation 339
reabsorption of luminal calcium and magnesium ions across
cation-selective channels, called paracellins or claudins, that
reside among components of the tight junctions between the
apical membranes of adjacent TAL epithelial cells.
Distal Convoluted Tubule
This continuation of the diluting segment actively reabsorbs
between 2% and 10% of the filtered NaCl load, while remain-
ing impermeable to luminal water (Fig. 20-8). Luminal Na
enters the epithelial cells of the distal convoluted tubule via the
electroneutral, K-independent NCC Na-Cl co-transporter.
Basolateral exit of Na is mediated by Na/K-ATPase,
while the imported Cl exits by basolateral anion pathways
that include both electrogenic Cl channels and (at least in the
mouse) electroneutral K-Cl co-transport. The distal con-
voluted tubule (DCT) also mediates transepithelial reabsorp-
tion of luminal calcium and magnesium ions via ion-specific,
regulated TRPV5 calcium channels and TRPM6 magnesium
channels in the apical membrane. The reabsorbed calcium
crosses the DCT cell basolateral membrane via specific NCX
Na/Ca2 exchangers and Ca2-ATPases. The basolateral exit
pathway(s) for magnesium remain undefined, but the recent
molecular cloning of several Mg2 transporters suggests that
these pathways will soon be identified.
Collecting Duct
This terminal portion of the nephron is divided into cortical,
outer medullary, and inner medullary collecting duct
(CD) segments (Fig. 20-9). The cortical and outer medullary
CD segments consist of two cell types, principal cells and
Apical Basolateral
membrane membrane
Lumen of distal
convoluted tubule
Ca2+
NCX1
3Na+
Ca2+
TRPV5
3Na+
Na+/K+
Na+ ATPase
NCC
2K+
Cl-
Cl- gCl-
Thiazides
FIGURE 20-8. Distal convoluted tubule cell. Distal convoluted tubule cells
absorb Na via an apical membrane NaCl co-transporter (NCC). Na is then trans-
ported across the basolateral membrane into the interstitium via the Na/K-
ATPase, and Cl is transported from the cytosol into the interstitium via Cl chan-
nels (gCl) and perhaps by K-Cl co-transporters (not shown). Renal epithelial
cells of the distal convoluted tubule also absorb Ca2 via apical membrane Ca2
channels (TRPV5), and Ca2 is transported across the basolateral membrane into
the interstitium by the Na/Ca2 exchanger NCX1 and by the Ca2-ATPase PMCA
(not shown). Thiazides inhibit NCC, resulting in increased Na excretion. Thiazides
also increase epithelial cell absorption of Ca2 by an unknown mechanism (not
shown).
340 Principles of Cardiovascular Pharmacology

Apical Basolateral IC secrete protons via the apical H-ATPase and reabsorb
membrane membrane
bicarbonate through the basolateral Cl/HCO3 exchanger
(also known as kidney AE1). Type B IC secrete HCO3
through the apical Cl/HCO3 exchanger pendrin and re-
Amiloride, Principal cell absorb protons via the basolateral H-ATPase. Pendrin also
Triamterene
ENaC expression 3Na+ likely mediates Cl reabsorption via a third IC type, the
Na+/K+ ATPase expression Na+/K+
non-A, non-B IC. In addition, intercalated cells mediate
Na+
ATPase
K absorption by electroneutral luminal H/K-ATPases,
flow-sensitive K secretion by Ca2-activated maxi-K
ENaC
2K+

Nucleus channels, and NH4 secretion by proteins related to the

erythroid Rhesus (Rh) antigens.
+
K+
 PATHOPHYSIOLOGY OF EDEMA
K channel
Mineralocorticoid
receptor
FORMATION
Lumen of Edema is defined as the accumulation of fluid in the interstitial
cortical space. Edema can be either exudative (having a high pro-
collecting duct
tein content) or transudative (having a low protein content,
Spironolactone essentially a plasma ultrafiltrate). Exudative edema occurs
Aldosterone
O
O
as part of the acute inflammatory response (see Chapter 41,
O
O
OH Principles of Inflammation and the Immune System). The
HO
H
type of edema considered here is transudative edema,
which can result from pathologic renal retention of Na.
H

H H H H Under physiologic conditions, any increased fluid filtration

O S O across the capillary membrane is quickly counterbalanced by
O homeostatic mechanisms. This return to a physiologic set-
FIGURE 20-9. Cortical collecting duct principal cell. Cortical collecting
duct principal cells absorb Na via an apical membrane Na channel (ENaC).
Cytoplasmic Na is then transported across the basolateral membrane via the
Na/K-ATPase. In addition, collecting duct cells express apical membrane K
channels that allow K to exit into the urinary space. ENaC expression and apical
surface localization is modulated by aldosterone. Aldosterone binds to the min-
eralocorticoid receptor, which then increases transcription of the gene encoding
ENaC as well as genes encoding other proteins involved in Na reabsorption (such
as Na/K-ATPase). The collecting duct principal cell is the site of action of the
two classes of potassium-sparing diuretics. Mineralocorticoid receptor antago-
nists such as spironolactone competitively inhibit the interaction of aldosterone
with the mineralocorticoid receptor, and thereby decrease expression of ENaC.
Direct inhibitors of ENaC, such as amiloride and triamterene, inhibit Na influx
through ENaC channels at the apical plasma membrane.
intercalated cells. Principal cells reabsorb between 1% and
5% of the filtered sodium load, depending on plasma aldos-
terone levels (aldosterone increases sodium reabsorption and
water retention, see below). Luminal Na enters the prin-
cipal cells of the cortical collecting duct via heterotrimeric
epithelial Na channels, ENaC, in the apical membrane.
Intracellular Na exits the basolateral side of the cell via
the Na/K-ATPase. Principal cells also secrete K into the
lumen to maintain tight control of plasma [K], as well as
to minimize the transepithelial potential difference resulting
from Na reabsorption. In addition, cortical and outer med-
ullary principal cells, as well as cells of the inner medullary
collecting duct, express vasopressin (ADH)-responsive water
channels. ADH activates water reabsorption by stimulating a
Gs protein-coupled V2 receptor in the basolateral membrane;
in turn, Gs protein signaling promotes the reversible insertion
into the apical membrane of intracellular vesicles containing
aquaporin 2 (AQP2) water channels (Fig. 20-4B).
At least two subtypes of intercalated cells (IC) contrib-
ute to systemic acidbase balance through cell type-specific
polarized expression of the vacuolar H-ATPase. Type A
point is mediated by three factors: osmotic forces, lymphatic
drainage, and long-term modulation of volume by physi-
ologic sensors and signals. Osmotic forces play an immedi-
ate role in fluid shifts between compartments. For example,
increased fluid shift to the interstitial space will result in in-
creased interstitial hydrostatic pressure and increased plasma
oncotic pressure. Both of these variables favor fluid shift
back into the intravascular space (Fig. 20-1). The lymphatic
system can also increase return of filtered fluid dramatically,
thereby decreasing the amount of filtered fluid that remains in
the interstitial space. Over a period of days to weeks, volume
sensors and signals respond to changes in volume by altering
the extent of natriuresis or sodium reabsorption necessary to
maintain a constant intravascular volume. These combined
systems closely monitor and regulate intravascular volume.
Therefore, the pathophysiology of transudative edema for-
mation almost always requires an element of pathologic
renal Na retention.
The three most common clinical situations resulting in
edema formation are heart failure, cirrhosis, and nephrotic
syndrome. All of these diseases manifest deranged Na reab-
sorption caused by pathologic alterations in volume regula-
tion. Understanding the pathophysiology of edema formation
in these diseases provides a rationale for the therapeutic use
of natriuretic agents.
Heart Failure
Heart failure (HF) is defined by the inability of the heart to
perfuse tissues and organs adequately. Insufficient cardiac out-
put and subsequent decreased blood flow through the arterial
vascular bed leads to congestion in the venous capacitance
vessels. The resulting increase in capillary hydrostatic pressure
favors fluid transudation into tissue interstitial spaces. Right
heart failure leads initially to peripheral edema, whereas
left heart failure can lead first to pulmonary edema. In the
introductory case, Mr. Rs compromised cardiac function
 Compromised cardiac
function

Decreased arterial
blood pressure

Fluid transudation

Systemic and pulmonary

congestion, decreased
lymphatic drainage

Elevated cardiac Renal sensors

Extracellular fluid
atrial pressure perceive decreased
volume expansion
volume

Chronic dilation of
cardiac chambers

Attenuation of
natriuretic response

Renal sodium retention

342 Principles of Cardiovascular Pharmacology
A "Underfill model" B "Overflow model"
Hepatic venous Liver injury leading to
outflow obstruction post-sinusoidal obstruction
Ascites formation Hepato-renal reflex
Decreased intravascular Primary renal Na+
volume retention
Low venous
filling pressure
Increased plasma
volume
Low cardiac output Ascites formation
Activation of
baroreceptors
Renal Na+ retention
FIGURE 20-11. Proposed mechanisms of Na retention in cirrhosis. The
postsinusoidal obstruction in cirrhosis is associated with renal Na retention as
well as the accumulation of ascites fluid. Two models have been proposed to
explain the mechanisms of these effects. A. Hepatic venous outflow obstruction
causes increased hydrostatic pressure, which initiates ascites formation. The ac-
cumulation of ascites fluid decreases intravascular volume, leading to low venous
filling pressure, decreased cardiac output, and subsequent activation of arterial
baroreceptors that initiate renal Na retention. B. Postsinusoidal obstruction
activates the hepato-renal reflex, an autonomic response involving the liver and
kidney that initiates renal Na reabsorption by a poorly understood mechanism.
The renal Na retention leads to an expansion of plasma volume, increased hydro-
static pressure in the portal circuit, and the formation of ascites.
pathologic Na retention leads to intravascular volume ex-
pansion, increased portal hydrostatic pressure, and formation
of ascites. Although not well understood, this mechanism is
consistent with a number of experimental model systems
demonstrating that renal Na retention in cirrhosis occurs
before the development of ascites.
Ascites formation may well involve elements of both the
underfill and overflow models. Both models begin with the
observation that cirrhosis leads to significant hepatic outflow
obstruction, and both must consider compromised portal
hemodynamics, decreased hepatic synthetic and secretory
functions leading to decreased plasma oncotic pressure, and
poorly characterized neural or hormonal interactions be-
tween the liver and the kidney. Elucidation of the mechanism
of the hepato-renal reflex may lead in the future to more ef-
fective pharmacologic interventions to manage the develop-
ment of ascites in cirrhosis.
Nephrotic Syndrome
Nephrotic syndrome is characterized by massive proteinuria
(3.5 g/day), edema, hypoalbuminemia, and often hyper-
cholesterolemia. The primary cause of nephrotic syndrome
is glomerular dysfunction, which may be due to immune
complex disease, diabetes, lupus, amyloidosis, or other con-
ditions affecting glomerular function.
A classical explanation of edema formation in nephrotic
syndrome follows this sequence. First, massive proteinuria
leads to decreased plasma oncotic pressure, reducing the
forces favoring fluid retention in the capillary and leading
to fluid transudation into the interstitium. The increased net
fluid transudation decreases intravascular volume, activating
volume sensors to enhance renal Na retention. The result-
ing expansion in fluid volume, in the absence of adequate
compensatory albumin synthesis, maintains low plasma on-
cotic pressure and continued edema formation. In this view,
renal Na retention is secondary to decreased renal arterial
perfusion. However, the edema of nephrotic syndrome may
also be caused by intrinsic changes in capillary junctional
permeability and/or by primary renal Na retention. The pos-
tulated primary Na retention of nephrotic syndrome may
be localized to the distal nephron, arising from resistance to
natriuretic peptides, increased sympathetic nervous system
activity, or increased ENaC activation by luminal proteases.
Although treatment of nephrotic syndrome can include
diuretics to counter renal Na retention, correction of edema
typically requires correction of the underlying glomerular
disorder, eventually leading to decreased proteinuria and
correction of the edema. The glucocorticoids and immuno-
suppressants used to treat some forms of nephrotic syndrome
can themselves promote further sodium retention. Diuretics
are used in the short term to minimize edema formation.
 PHARMACOLOGIC CLASSES
AND AGENTS
Pharmacologic modulators of extracellular fluid volume can
be divided into agents that modify neurohormonal volume
regulators and agents that act directly on the nephron seg-
ments to alter renal Na handling. The former category in-
cludes agents that interrupt the reninangiotensin axis, alter
circulating levels of natriuretic peptides, or interrupt ADH
signaling. The latter category includes the various classes of
diuretics, which directly target renal ion transporter or chan-
nel function or expression to increase renal Na excretion.
Neurohormonal volume regulators may also act directly on
Na reabsorption through mechanisms less well understood
than those of the diuretics.
Agents That Modify Volume Regulators
Inhibitors of the ReninAngiotensin System
There are four clinically available pharmacologic strategies
for interruption of the renin-angiotensinaldosterone system
(RAAS). First, inhibition of the enzymatic activity of renin
prevents generation of angiotensin I. Second, ACE inhibi-
tors interrupt the conversion of angiotensin I to angiotensin
II. Third, angiotensin receptor antagonists are competitive
antagonists of the AT1 receptor, and thus inhibit the target-
organ effects of angiotensin II. Fourth, antagonists of the
mineralocorticoid receptor block aldosterone action at the
nephron collecting duct. The first three classes of agents are
discussed here; antagonists of aldosterone action are con-
sidered diuretics and are addressed below (see Potassium-
Sparing Diuretics).
Renin Inhibitors
Aliskiren is the first approved inhibitor of the enzymatic ac-
tivity of renin. By blocking the activity of renin, aliskiren
prevents the conversion of angiotensinogen to angiotensin I.
Aliskiren is an effective antihypertensive and can be used in
hypertensive patients with renal insufficiency. Aliskiren may
 Angiotensinogen Kininogen

Renin Renin inhibitor Kallikrein

Angiotensin I Bradykinin

ACE ACE inhibitor Kininase II

Angiotensin II Inactive

AT1 receptor
antagonists

Aldosterone Vasoconstriction Vasodilation

secretion (mediated by AT1
(mediated by AT1 receptors)
receptors)

Increased Na+ Increased peripheral Decreased peripheral

and H2O vascular resistance vascular resistance
reabsorption

Increased blood Decreased blood

pressure pressure
344 Principles of Cardiovascular Pharmacology
hemodynamics. ACE inhibitors may be used in combination
with aliskiren if required. ACE inhibitors are contraindicated
in pregnancy (including for treatment of pregnancy-associated
hypertension), since they have been associated with an in-
creased risk of major fetal malformations.
Angiotensin Receptor Antagonists
AT1 receptor antagonists, such as losartan and valsartan, in-
hibit the action of angiotensin II at its receptor (Fig. 20-12).
Compared to ACE inhibitors, AT1 receptor antagonists may
allow more complete inhibition of angiotensin IIs actions,
because ACE is not the only enzyme that can generate angio-
tensin II. In addition, because AT1 receptor antagonists have
no effect on bradykinin metabolism, their use may minimize
the incidence of drug-induced cough and angioedema. How-
ever, the inability of AT1 receptor antagonists to potentiate the
vasodilatory effects of bradykinin may result in less effective
vasodilation. Unlike ACE inhibitors, AT1 receptor antagonists
may indirectly increase vasorelaxant AT2 receptor activity.
Both ACE inhibitors and AT1 antagonists increase renin re-
lease as a compensatory mechanism; in the case of AT1 block-
ade, the increased angiotensin II that results could lead to in-
creased interaction of angiotensin II with AT2 receptors.
AT1 receptor antagonists are approved for the treatment of
hypertension. Although these agents were initially prescribed
only for patients with intolerable adverse reactions to ACE
inhibitors, they are now considered first-line treatments for
hypertension. AT1 receptor antagonists are also under study
for the treatment of heart failure. Recent trials have suggested
that the combination of an AT1 receptor antagonist and an
ACE inhibitor may have some clinical benefit in severe heart
failure, and studies testing such combinations in the treat-
ment of chronic kidney disease and cardiac disease progres-
sion are currently under way. Combined therapy using AT1
receptor antagonists and aliskiren is also under investigation
for treatment of hypertension, heart failure, and renal failure.
AT1 receptor antagonists may protect against stroke, not only
by controlling hypertension but also through beneficial sec-
ondary effects. These include reduced platelet aggregation,
decreased serum uric acid levels, decreased incidence of
atrial fibrillation, and antidiabetic effects. The mechanisms
of these secondary effects remain to be elucidated.
B-Type Natriuretic Peptide
Nesiritide, a recombinant human-sequence B-type natriuretic
peptide (BNP), can be used for short-term management of
decompensated heart failure. Because nesiritide is a peptide, it
is ineffective when given orally. In clinical trials of nesiritide
in acute heart failure, the drug decreased pulmonary capil-
lary wedge pressure (a measure of hydrostatic pressure in the
pulmonary system), decreased systemic vascular resistance,
and improved cardiac hemodynamic parameters such as
stroke volume. Although nesiritide was not more efficacious
in these trials than the more commonly used dobutamine (see
Chapter 25), nesiritide may be associated with a lower inci-
dence of arrhythmias than dobutamine. At low doses, nesir-
itide appears to promote water excretion to a greater degree
than sodium excretion.
Hypotension is a major adverse effect of nesiritide, reflect-
ing the vasorelaxant properties of the natriuretic peptides.
The risk of hypotension is increased by co-administration of
nesiritide with an ACE inhibitor. Nesiritide treatment is also
associated with an increased risk of renal dysfunction. These
adverse effects have not been reported in preliminary clini-
cal trials of an investigational peptide related to ANP, which
exhibits powerful natriuretic as well as diuretic properties.
Vasopressin Receptor Antagonists and Agonists
The tetracycline analogue demeclocycline has long been
used in the treatment of syndromes of inappropriate ADH
secretion (SIADH), when dietary water restriction is not
feasible or sufficient. Its mechanism of action is uncertain.
Conivaptan is the first specific nonpeptide vasopressin
receptor antagonist approved for treatment of euvolemic
hyponatremias (SIADH). Its disadvantages include a re-
quirement for intravenous administration and some V1 re-
ceptor antagonist activity. However, the V2-selective recep-
tor antagonist tolvaptan is orally bioavailable. In clinical
trials, V2 receptor antagonists have also shown benefit in the
treatment of other conditions associated with inappropriate
ADH-induced water retention, including heart failure and
cirrhotic ascites. V2 receptor antagonists are also showing
promise as agents to retard vasopressin-driven renal cyst
growth in autosomal dominant polycystic kidney disease.
Congenital nephrogenic diabetes insipidus may result
from mutations in either the V2 receptor or the collecting-
duct principal-cell aquaporin AQP2. Some V2 receptor mu-
tations are associated with trapping of newly synthesized
receptor polypeptides inside the principal cell. Vasopressin
receptor antagonists may act as molecular chaperones for
a subset of these mutant receptors; in these cases, antago-
nist binding presumably promotes a receptor conformation
that allows insertion of the mutant protein into the apical
membrane of the cell. Cell-permeant, vasopressin-mimetic
small molecules have also been shown to activate mutant V2
receptors inside cells, generating sufficient cAMP to mobi-
lize aquaporin 2 water channels to the apical surface. This
strategy is thus far the most promising approach to the treat-
ment of V2 receptor-linked nephrogenic diabetes insipidus.
Similar strategies are being adopted for many hereditary dis-
eases of G protein-coupled receptors.
Terlipressin is an investigational vasopressin analog with
moderate V1 receptor agonist activity and specificity. It may
have potential clinical application in reducing portal hyper-
tension and improving renal hemodynamics in liver failure
and ascites.
Agents That Decrease Renal Na Reabsorption
As discussed above, the kidney modifies the ionic compo-
sition of the glomerular filtrate by the concerted action of
ion transporters and channels in both apical and basolateral
membranes of renal tubular epithelial cells. This transepi-
thelial ion transport can be modulated pharmacologically by
the actions of diuretic drugs to regulate urinary volume and
composition. Pharmacologic inhibition of ion reabsorption
leads to reduction of the osmotic driving force that favors
water reabsorption in the water-permeable segments of the
nephron. Diuretics target sodium reabsorption along four
segments of the nephron: the proximal tubule, medullary
thick ascending limb, distal convoluted tubule, and collect-
ing duct. The kidney concentrates and secretes these drugs
into the tubule lumen, allowing diuretics to reach higher
concentrations in the tubule than in the blood. Because of
this concentrating effect, therapeutic diuretic doses are often
accompanied by low blood levels of diuretics and by mild
extrarenal adverse effects.

Carbonic Anhydrase Inhibitors
Carbonic anhydrase inhibitors, exemplified by acetazol-
amide, inhibit sodium reabsorption by noncompetitively and
reversibly inhibiting proximal-tubule cytoplasmic carbonic
anhydrase II and luminal carbonic anhydrase IV (Fig. 20-6).
Inhibition of carbonic anhydrase leads to increased delivery of
sodium bicarbonate to more distal segments of the nephron.
Much of this sodium bicarbonate is initially excreted, result-
ing in an acute decrease in plasma volume (diuresis). However,
over the course of several days of therapy, the diuretic effect
of the drug is diminished by compensatory up-regulation of
NaHCO3 reabsorption and by increased NaCl reabsorption
across more distal nephron segments (by incompletely under-
stood mechanisms).
Use of carbonic anhydrase inhibitors is often associated
with mild-to-moderate metabolic acidosis, arising not only
from inhibition of proximal tubular H secretion, but also
from inhibition of carbonic anhydrase in acid-secreting in-
tercalated cells of the collecting duct. The alkalinized urine
resulting from carbonic anhydrase inhibition increases the
urinary excretion of organic acid anions, including aspirin.
The clinical use of carbonic anhydrase inhibitors is pri-
marily restricted to several carbonic anhydrase-dependent
conditions (see below). In addition, carbonic anhydrase in-
hibitors are occasionally used to restore acidbase balance
in heart failure patients with metabolic alkalosis due to treat-
ment with loop diuretics.
Carbonic anhydrase inhibitors also have ophthalmologic
applications. The ciliary process epithelium of the anterior
chamber of the eye secretes sodium chloride into the aque-
ous humor. This NaCl secretion requires carbonic anhydrase
activity, because a portion of the basolateral Cl uptake by
the ciliary epithelium requires coupled Cl-HCO3 and
Na-H exchange as well as Na-HCO3 symport. The ba-
solateral membrane Na-K-2Cl co-transporter NKCC1
mediates most remaining Cl uptake by ciliary epithelial
cells. Glaucoma is characterized by increased pressure in
the anterior chamber of the eye. This is usually attributed to
partially obstructed outflow of aqueous humor, but in some
cases, overproduction of aqueous humor may also contrib-
ute. Inhibition of carbonic anhydrase in the ciliary process
epithelium reduces secretion of aqueous humor and may
thereby reduce elevated intraocular pressure. Topical lipo-
philic carbonic anhydrase inhibitors are often used in con-
cert with topical -adrenergic antagonists in the treatment of
glaucoma (see Chapter 10, Adrenergic Pharmacology).
Ascent to altitudes greater than 3,000 m above sea level
predisposes several body organs, including the brain, to
edema and ionic disequilibria. Symptoms of acute mountain
sickness can include nausea, headache, dizziness, insom-
nia, pulmonary edema, and confusion. Carbonic anhydrase
is involved in the secretion of chloride and bicarbonate into
the cerebrospinal fluid by the choroid plexus of the cerebral
ventricles, and inhibition of carbonic anhydrase can be used
prophylactically against acute mountain sickness. The still-
controversial mechanism(s) of action include effects on the
choroid plexus and ependyma, on the respiratory control cen-
ters of the brain, and on the bloodbrain barrier. Carbonic an-
hydrase inhibitors are also used in the treatment of epilepsy,
although the antiepileptic mechanism of some of these drugs
may not require inhibition of carbonic anhydrase. One such
antiepileptic drug, topiramate, can produce mild-to-moderate
acidosis due to impaired renal acidification of the urine.
CHAPTER 20 / Pharmacology of Volume Regulation 345
The treatment of hyperuricemia or gout (see Chapter 48,
Integrative Inflammation Pharmacology: Gout) may involve
alkalinization of the urine to increase the urinary solubility
of uric acid. Increased uric acid solubility prevents uric acid
precipitation in the urine, with consequent uric acid neph-
ropathy and nephrolithiasis (kidney stones). Urinary alka-
linization can be achieved by oral bicarbonate, supplemented
as needed by a carbonic anhydrase inhibitor to reduce renal
reabsorption of the filtered bicarbonate.
Osmotic Diuresis
Osmotic diuretics, such as mannitol, are small molecules
that are filtered at the glomerulus but not subsequently re-
absorbed in the nephron. Thus, they constitute an intralu-
minal osmotic force limiting reabsorption of water across
water-permeable nephron segments. The effect of osmotic
agents is greatest in the proximal tubule, where most iso-
osmotic reabsorption of water takes place. By causing water
loss in excess of sodium excretion, osmotic diuresis can
sometimes lead to unintended hypernatremia. Alternatively,
the increased urine volume associated with osmotic diure-
sis can also promote vigorous natriuresis. Therefore, careful
monitoring of clinical volume status and serum electrolytes
is warranted. Mannitol is used primarily for rapid (emergent)
treatment of increased intracranial pressure. In the setting
of head trauma, brain hemorrhage, or a symptomatic cerebral
mass, the increased intracranial pressure can be relieved, at
least transiently, by the acute reduction in cerebral intravas-
cular volume that follows the mannitol-induced reduction in
systemic vascular volume.
Osmotic diuresis can also occur as a result of pathologic
states. Two common examples of this phenomenon are hy-
perglycemia and the use of radiocontrast dyes. In diabetic
hyperglycemia, the filtered glucose load exceeds the reab-
sorptive capacity of the proximal tubule for glucose. As a
result, significant quantities of glucose remain in the lumen
of the nephron and act as an osmotic agent to increase fluid
retention in the tubular lumen, thereby decreasing fluid re-
absorption. Radiocontrast agents used for radiologic imag-
ing studies are filtered at the glomerulus but not reabsorbed
by the tubular epithelium. Thus, these dyes constitute an
osmotic load and can produce osmotic diuresis. In patients
with borderline cardiovascular status, the consequent re-
duction in intravascular volume can lead to hypotension or
to renal and/or cardiac insufficiency secondary to reduced
organ perfusion.
Loop Diuretics
The so-called loop diuretics act at the TAL of the loop of
Henle. These agents reversibly and competitively inhibit the
Na-K-2Cl co-transporter NKCC2 in the apical (luminal)
membrane of TAL epithelial cells (Fig. 20-7). In addition
to the primary effect of inhibiting Na reabsorption across
the TAL, inhibition of transcellular NaCl transport sec-
ondarily reduces or abolishes the lumen-positive transepi-
thelial potential difference across the TAL. Consequently,
paracellular reabsorption of divalent cations, particularly
calcium and magnesium, is also inhibited. The increased
delivery of luminal calcium and magnesium to downstream
reabsorptive sites in the distal convoluted tubule can lead
to increased urinary excretion of calcium and magnesium.
The resultant hypocalcemia and/or hypomagnesemia can be
clinically significant in some patients who require prolonged
348 Principles of Cardiovascular Pharmacology
and ensures that the kidney is able to filter waste products
from the plasma. Regulation of extracellular volume is ac-
complished by integrated neurohormonal mechanisms that
respond to changes in arterial and atrial wall stress. These
hormones modulate numerous steps in renal Na handling,
and thereby maintain a homeostatic balance between dietary
Na intake and Na excretion. Edema can develop when
the capillary hydrostatic pressure gradient favoring fluid fil-
tration exceeds the opposing oncotic forces favoring fluid
entry into the intravascular space. Pharmacologic treatment
of dysregulated extracellular volume involves modification
of neurohormonal signaling and direct inhibition of renal
Na reabsorption. ACE inhibitors prevent the conversion
of angiotensin I to angiotensin II; drugs in this class have
important vasodilatory actions. Angiotensin receptor an-
tagonists and renin inhibitors are also useful in interrupting
the angiotensinaldosterone axis. Both ACE inhibitors and
angiotensin receptor antagonists have beneficial effects in
slowing the progression of hypertrophy and fibrosis in the
heart, the kidney, and the vasculature. B-type natriuretic
peptide (nesiritide) is used in the treatment of decompen-
sated heart failure, and terlipressin is under investigation for
the treatment of portal hypertension.
Diuretics are agents that alter nephron Na reabsorption
and secondarily alter the reabsorption and secretion of other
ions. Essential to understanding diuretic mechanisms is an
appreciation of the functional organization of the nephron.
With the exception of osmotic diuretics, which increase
urinary flow by osmotic retention of water throughout the
nephron, specific classes of diuretic drugs target each of the
four segments of the nephron. Carbonic anhydrase inhibi-
tors such as acetazolamide decrease sodium and bicarbonate
reabsorption in the proximal tubule; loop agents such as fu-
rosemide decrease sodium and chloride reabsorption by the
apical Na-K-2Cl pump in the thick ascending limb of the
loop of Henle; thiazides such as hydrochlorothiazide inhibit
the apical Na-Cl co-transporter in the distal convoluted
tubule; and potassium-sparing diuretics such as spironolac-
tone and amiloride inhibit, respectively, the aldosterone re-
ceptor and the ENaC apical Na channel in the collecting
duct. The most important use of diuretics is in the treatment
of hypertension; the second most important use is to treat
edema of any cause.
Future developments in the pharmacology of extracellu-
lar volume regulation will likely focus on interrupting or en-
hancing the hormonal pathways implicated in the disruption
of volume homeostasis, as well as on the solute and water
transporters themselves. Specific V2 vasopressin receptor
antagonists will be used increasingly in hypervolemic con-
ditions accompanied by elevated ADH levels or action. V2
receptor antagonists have also shown promise in retarding
progression of cyst growth in autosomal dominant poly-
cystic kidney disease. Aquaporin blockers (aquaretics) are
under development for regulation of fluid homeostasis, and
aquaglyceroporin blockers are under investigation as treat-
ments for skin conditions and as modulators of lipid me-
tabolism. Chloride channel blockers and potassium channel
blockers are under development to treat the volume deple-
tion of severe toxigenic and infectious diarrhea as well as
rare congenital diarrheas. Chloride channel activators and
potassium channel activators are being developed to treat
the pulmonary, gastrointestinal, and genitourinary hypo-
secretion disorders of cystic fibrosis, sicca syndromes, and
inflammatory biliary cirrhosis. Carbonic anhydrase II has re-
cently been shown to act as a nitrate reductase and thereby to
generate nitric oxide at the acidic pH of ischemic or hypoxic
tissue. Surprisingly, this nitrite reductase activity is activated
by sulfonamide carbonic anhydrase inhibitors even as they
inhibit carbonic anhydrase activity. This property may ex-
plain the vasodilation associated with use of carbonic anhy-
drase inhibitors and encourages consideration of new uses
for this old drug class.
New drugs to interrupt the renin-angiotensinaldosterone
axis may include neutral endopeptidase inhibitors, (pro)
renin receptor antagonists, AT2 receptor agonists, selective
endothelin receptor antagonists, and natriuretic peptides of
increased potency and selectivity. The latter will likely play
an increasingly important role in the management of de-
compensated heart failure and possibly the ascites of hepatic
failure. Drugs acting on the renin-angiotensinaldosterone
axis will also likely be useful in slowing the rate of renal and
cardiac fibrosis, reinforcing or improving on the actions of
ACE inhibitors, AT1 receptor antagonists, and mineralocor-
ticoid receptor blockers. These drugs also have general and
cell type-specific trophic actions. One example is provided
by the role of the AT1 receptor in promoting proliferation
of epidermal growth factor receptor ERBB2-negative mam-
mary tumor cells in culture and in xenografts. AT1 recep-
tor blockers have slowed mammary cell tumor xenograft
growth. Thus, AT1 blockade is a reasonable candidate ad-
junct therapy for mammary tumors that may not respond to
more conventional therapy.
Suggested Reading
Christova M, Alper SL. Core curriculum in nephrology. Tubular transport:
Core curriculum 2010. Am J Kidney Dis 2010; 56:12021217. (Annotated
review of transport by renal tubular epithelial cells.)
Ernst ME, Moser M. Drug therapy: use of diuretics in patients with hyper-
tension. N Engl J Med 2009;361:21532164. (Clinical pharmacology of
diuretics.)
Greenberg A, Verbalis JG. Vasopressin receptor antagonists. Kidney Int
2006;69:21242130. (Introduction to the physiology and clinical indica-
tions of this drug class.)
Okusa MD, Ellison DH. Physiology and pathophysiology of diuretic action.
In: Alpern RJ, Hebert SC, eds. The kidney: physiology and pathophysiol-
ogy. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2008:10511094;
Chapter 37. (Full discussion of the physiology and pathophysiology of
diuretic action.)
Palmer BF, Sterns RH. Fluid, electrolyte, and acid base disturbances.
NephSAP (American Society of Nephrology) 2009;8:61165. (Updated
nephrology board review summary and questions about fluid and electro-
lyte disorders.)
Potter LR, Yoder AR, Flora DR, Antos LK, Dickey DM. Natriuretic peptides:
their structures, receptors, physiological functions, and therapeutic applica-
tions. Handb Exp Pharmacol 2009;191:341366. (Overview of natriuretic
peptide physiology in volume regulation.)

Pharmacology of Vascular Tone
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 353-354
PHYSIOLOGY OF VASCULAR SMOOTH
MUSCLE CONTRACTION AND RELAXATION. . . . . . . . . . . . . 353
Vascular Resistance and Capacitance . . . . . . . . . . . . . . . 353
Vascular Smooth Muscle Contraction
and Relaxation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
Regulation of Vascular Tone . . . . . . . . . . . . . . . . . . . . . . . 356
Vascular Endothelium . . . . . . . . . . . . . . . . . . . . . . . . . 356
Autonomic Nervous System . . . . . . . . . . . . . . . . . . . . 357
Neurohormonal Mechanisms . . . . . . . . . . . . . . . . . . . 358
Local Mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 358
Organic Nitrates, Inhaled Nitric Oxide, and
Sodium Nitroprusside . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Mechanism of Action . . . . . . . . . . . . . . . . . . . . . . . . . 359
Pharmacokinetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
Pharmacologic Tolerance . . . . . . . . . . . . . . . . . . . . . . 361
 INTRODUCTION
In combination with cardiac output, vascular tone (i.e., the
degree of contraction of vascular smooth muscle) deter-
mines the adequacy of perfusion of the tissues of the body.
The importance of vascular tone is underscored by the wide
spectrum of disease statesranging from angina pectoris to
hypertension to Raynauds phenomenon to migraine head-
achesthat are associated with dysregulated vascular tone.
As the major factors that govern the regulation of blood ves-
sel diameter have become understood at the molecular level,
it has become apparent that a complex array of mechanisms
is required to maintain proper vascular tone in the face of
diverse stimuli. Pharmacologic strategies for intervention in
these regulatory pathways have already yielded many suc-
cessful therapies for disorders of vascular tone, and provide
hope that, in the future, even better therapies will be avail-
able to manage the multiple types of vascular disorders.
 PHYSIOLOGY OF VASCULAR SMOOTH
MUSCLE CONTRACTION AND
RELAXATION
Vascular tone is a key regulator of tissue perfusion, which de-
termines whether tissues receive sufficient O2 and nutrients to
meet their demands. The delicate balance between O2 supply
21
Deborah Yeh Chong and Thomas Michel
Effects of Nitrates in Addition to Vasodilation . . . . . . . . 362
Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
Phosphodiesterase Inhibitors . . . . . . . . . . . . . . . . . . . . . . 362
Ca2 Channel Blockers . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Mechanism of Action . . . . . . . . . . . . . . . . . . . . . . . . . 363
Chemical Classes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
Pharmacokinetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
Toxicities and Contraindications . . . . . . . . . . . . . . . . . 364
K Channel Openers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Endothelin Receptor Antagonists . . . . . . . . . . . . . . . . . . . 365
Other Drugs That Modulate Vascular Tone . . . . . . . . . . . . 365
Hydralazine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
1-Adrenergic Antagonists . . . . . . . . . . . . . . . . . . . . . 365
-Adrenergic Antagonists . . . . . . . . . . . . . . . . . . . . . . 366
ReninAngiotensin System Blockers . . . . . . . . . . . . . . 366
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 366
SUGGESTED READING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
and demand is critical for the function of all tissues, especially
for the myocardium. Vascular tone is an important determinant
of both myocardial O2 supply and demand. Myocardial O2 sup-
ply depends on the tone of the coronary arteries, while myo-
cardial O2 demand depends on the tone of both the systemic
arterioles (resistance vessels) and veins (capacitance vessels).
Vascular Resistance and Capacitance
The tone of the arterial portion of the circulation and the tone
of the venous portion of the circulation play important yet
distinctive roles in modulating the balance of myocardial O2
demand. The major determinants of myocardial O2 demand
are heart rate, contractility, and ventricular wall stress. Wall
stress can be expressed as:
  (P  r)/2h Equation 21-1
where is wall stress, P is ventricular pressure, r is ventricular
chamber radius, and h is ventricular wall thickness. Systolic
and diastolic ventricular wall stresses are influenced by sys-
temic arteriolar and venous tone, respectively. Arteriolar tone
directly controls systemic vascular resistance and, thus, arte-
rial blood pressure:
MAP  SVR  CO Equation 21-2
353
 Myocardial O2 Myocardial O2
SUPPLY DEMAND

Perfusion of the heart Ventricular wall stress

Vascular tone of the

coronary arteries Preload Afterload

Heart
(pump)
Venous tone Arteriolar tone

Veins Arteries

Left circumflex
coronary artery
Capillaries
Right coronary
artery

Left anterior descending

Veins (capacitance vessels) Arterioles (resistance vessels)
coronary artery

Vascular smooth
muscle cell Sarcoplasmic
reticulum
Extracellular space
Ca2+

Cytosol

Ca2+ Actin-myosin Ca2+

crossbridges

Ca2+
Contraction
356 Principles of Cardiovascular Pharmacology

Contraction Relaxation

Ca2+
NO
L-type voltage-gated
Ca2+ channel

Guanylyl Guanylyl
Ca2+ + CaM cyclase cyclase

cGMP GTP
Ca2+-CaM
Myosin-LC phosphatase

MLCK MLCK
Myosin-LC phosphatase

Myosin-LC Myosin-LC P Myosin-LC

Actin-myosin
crossbridges

Contraction Relaxation
Vascular smooth
muscle cell

FIGURE 21-3. Mechanism of vascular smooth muscle cell contraction and relaxation. Vascular smooth muscle cell contraction and relaxation are controlled
by the coordinated action of several intracellular signaling mediators. Ca2 entry through L-type voltage-gated Ca2 channels (left panel) is the initial stimulus for
contraction. Ca2 entry into the cell activates calmodulin (CaM). The Ca2-CaM complex activates myosin light chain kinase (MLCK) to phosphorylate myosin light chain
(myosin-LC). The phosphorylated myosin-LC interacts with actin to form actinmyosin cross-bridges, a process that initiates vascular smooth muscle cell contraction.
Relaxation (right panel) is a coordinated series of steps that act to dephosphorylate (and hence inactivate) myosin-LC. Nitric oxide (NO) diffuses into the cell and acti-
vates guanylyl cyclase. The activated guanylyl cyclase catalyzes the conversion of guanosine triphosphate (GTP) to guanosine 3,5-cyclic monophosphate (cGMP). cGMP
stimulates cGMP-dependent protein kinase (not shown ), which activates myosin-LC phosphatase, which dephosphorylates myosin light chain, preventing actinmyosin
cross-bridge formation. As a result, the vascular smooth muscle cell relaxes. The active form of each enzyme is italicized and blue.

then activates myosin light chain phosphatase. Dephos-
phorylation of the myosin light chain inhibits the interaction
of the myosin head with actin, leading to smooth muscle re-
laxation (Fig. 21-3, right panel).
Regulation of Vascular Tone
Vascular tone is governed by a wide variety of mechanisms.
Recent research has highlighted the importance of interac-
tions between vascular endothelial cells and vascular smooth
muscle cells in the control of vascular tone. The autonomic
nervous system and a number of neurohormonal mediators
also control vascular smooth muscle contraction and relax-
ation. Many of these physiologic mechanisms provide the
basis for current drug discovery research.
Vascular Endothelium
Research in the past two decades has elucidated several sig-
naling modes in the vascular endothelium to control vascular
tone. Endothelial cells elaborate many signaling mediators
and alter the expression of many genes in response to diverse
stimuli. Two of the most pharmacologically relevant targets,
nitric oxide and endothelin, are discussed here.
Nitric Oxide
The obligatory role of endothelial cells in regulating vas-
cular tone was first recognized with the observation that
acetylcholine causes vasoconstriction when applied directly
to de-endothelialized blood vessels, but causes vasodilation
when applied to normally endothelialized vessels (Fig. 21-4).
It was hypothesized that muscarinic cholinergic stimulation
of the endothelium induces the production of a relaxant mol-
ecule in the endothelial cell and that this molecule then dif-
fuses to subjacent vascular smooth muscle cells to activate
guanylyl cyclase. The putative vasodilatory compound was
termed endothelial-derived relaxing factor, or EDRF.
Before the molecular identity of EDRF was determined to
be nitric oxide (NO), nitroglycerinan organic nitrate com-
monly prescribed for angina pectoriswas known to be me-
tabolized in the body to form NO, and NO was known to cause
relaxation of vascular smooth muscle. Based on these find-
ings, it was hypothesized and later confirmed that the EDRF
released from endothelial cells is NO, a gas that reacts with a
wide range of biomolecules to elicit cellular responses.
Although acetylcholine was the first ligand to be identi-
fied that promotes endothelial-cell synthesis of NO, a num-
ber of other mediators have since been described. Shear
stress, acetylcholine, histamine, bradykinin, sphingosine
1-phosphate, serotonin, substance P, and ATP can all elicit
increased NO synthesis by vascular endothelial cells. NO
is synthesized by a family of Ca2-CaMactivated NO syn-
thases. The endothelial isoform of nitric oxide synthase
(eNOS) is responsible for endothelial-cell NO synthesis;
this enzyme plays a critical role in controlling vascular tone
and platelet aggregation. The importance of NO in regulat-
ing vascular tone is underscored by the observation that
eNOS-deficient mice are hypertensive.
Recent evidence suggests that NO may effect vasodilation
not only by activating guanylyl cyclase, but also by activating
Ca2-dependent K channels in vascular smooth muscle cells
(Fig. 21-4). NO appears to activate these K channels directly
via a guanylyl cyclase-independent mechanism, leading to

Agonist
(e.g., acetylcholine, bradykinin)
Ca2+
Endothelial cell
Ca2+ Ca2+
Ca2+-CaM
Sarcoplasmic
eNOS eNOS reticulum
L-Arg NO
Ca2+-dependent
K+ channel NO
Vascular smooth
muscle cell
NO
Guanylyl Guanylyl
cyclase cyclase
K+
Hyperpolarization
Relaxation
FIGURE 21-4. Endothelial regulation of nitric oxide-mediated vascular
smooth muscle relaxation. Endothelial-cell production of nitric oxide (NO) con-
trols the extent of vascular smooth muscle cell relaxation. Production of NO is
stimulated by agonists such as acetylcholine or bradykinin. Stimulation of recep-
tors by these agonists activates Ca2 second messenger systems and promotes
direct entry of Ca2 into the cytosol. The increased cytosolic Ca2 activates a
Ca2-calmodulin complex that stimulates endothelial nitric oxide synthase (eNOS),
an enzyme that catalyzes the formation of NO from L-arginine (L-Arg, an amino
acid). NO diffuses from the endothelial cell into subjacent vascular smooth muscle
cells, where it activates guanylyl cyclase, promoting smooth muscle cell relaxation
(see Fig. 21-3). NO can also directly activate Ca2-dependent K channels. This
parallel signaling pathway contributes to relaxation by hyperpolarizing the smooth
muscle cell. The active form of each enzyme is italicized and blue.
hyperpolarization of the cells and, subsequently, to vasodila-
tion. (See below for a further explanation of how opening K
channels leads to hyperpolarization and vasodilation.)
Endothelin
Endothelin is a 21-amino acid vasoconstrictor peptide. It is
the most potent endogenous vasoconstrictor yet discovered.
Endothelin can be considered a functional mirror-image of
NO: it is a potent endothelium-derived vasoconstrictor, while
NO is a potent endothelium-derived vasodilator. In addition to
its effects on the vasculature, endothelin has positive inotropic
and chronotropic actions on the heart, and it contributes to re-
modeling within the cardiovascular system. Proposed mecha-
nisms of endothelin-induced remodeling include neointimal
proliferation and increased collagen deposition leading to fi-
brosis. Endothelin also plays an important role in the lungs,
kidneys, and brain. Three isoforms of endothelinET-1,
ET-2, and ET-3have been identified. ET-1the isoform
mainly involved in cardiovascular actionsis produced by en-
dothelial cells (and vascular smooth muscle cells under inflam-
matory conditions), and it appears to act locally in a paracrine
or autocrine fashion. The local ET-1 concentration within the
CHAPTER 21 / Pharmacology of Vascular Tone 357
vascular wall is more than 100 times greater than that in the
circulation, because ET-1 is secreted chiefly on the basal side
of endothelial cells (Fig. 21-5).
Endothelin precursors are proteolytically processed in
two steps to generate the mature active peptides. First,
preproendothelin is cleaved into big endothelin. Second, big
endothelin is cleaved by endothelin-converting enzyme into
endothelin. There are two endothelin receptor subtypes, ETA
and ETB. Both ETA and ETB are G protein-coupled receptors
whose effectors likely involve phospholipase C-modulated
pathways. ET-1 binds to ETA receptors on vascular smooth
muscle cells as well as ETB receptors on both endothelial cells
and vascular smooth muscle cells. ETA receptors on vascular
smooth muscle cells mediate vasoconstriction. ETB receptors
are located predominantly on vascular endothelial cells, where
they mediate vasodilation via the release of prostacyclin and
NO. ETB receptors are also found on vascular smooth muscle
cells, where they mediate vasoconstriction.
Autonomic Nervous System
The sympathetic nervous system is an important determinant of
vascular tone. The firing of certain sympathetic postganglionic
neurons releases norepinephrine from nerve terminals that end
Lumen
Endothelial cells
Arachidonic
acid
COX L-Arg Endothelin precursors
Prostacyclin eNOS
NO Endothelin-1
ETB
Endothelin-1
Endothelin-1
Prostacyclin NO
ETB
IP ETA
NO
Relaxation Contraction
Vascular smooth
muscle cells
FIGURE 21-5. Effects of endothelin on the blood vessel wall. Endothelin
mediates both contraction and relaxation of vascular smooth muscle cells. Endothelin
precursors in endothelial cells are processed to endothelin-1. Endothelin-1 is secreted
on the basal side of the endothelial cell, where it interacts with ETA and ETB receptors
on vascular smooth muscle cells. Activation of these receptors stimulates contraction
by incompletely understood mechanisms. ETB receptors are also expressed on en-
dothelial cells. Endothelial cell ETB activation stimulates cyclooxygenase (COX), which
catalyzes the formation of prostacyclin from arachidonic acid. Prostacyclin diffuses
from the endothelial cell to the vascular smooth muscle cell membrane, where it binds
to and activates the isoprostanoid (IP) receptor. ETB activation also stimulates endothe-
lial nitric oxide synthase (eNOS), which catalyzes the formation of NO from arginine
(L-Arg). Both prostacyclin and NO stimulate vascular smooth muscle cell relaxation.
358 Principles of Cardiovascular Pharmacology

on vascular smooth muscle cells. Activation of 1-adrenergic
receptors on vascular smooth muscle cells causes vasoconstric-
tion, whereas activation of 2-adrenergic receptors on vascular
smooth muscle cells induces vasodilation. The effect of nor-
epinephrine at 1-adrenergic receptors is typically greater than
its effect at 2-adrenergic receptors, especially in organs that
receive decreased blood flow during fight or flight responses
(i.e., skin and viscera). Thus, the net effect of norepinephrine on
these vascular beds is typically vasoconstrictive.
Because blood vessels are not innervated by parasympa-
thetic fibers, the parasympathetic nervous system has little
influence on vascular tone.
Neurohormonal Mechanisms
Many neurohormonal mediators act on vascular smooth mus-
cle cells, endothelial cells, and neurons to regulate vascular
tone. For example, circulating catecholamines from the ad-
renal gland (i.e., epinephrine) can influence vascular tone via
1-adrenergic and 2-adrenergic receptors on vascular smooth
muscle cells: as noted above, stimulation of 1-adrenergic
receptors leads to vasoconstriction, while stimulation of 2-
adrenergic receptors leads to vasodilation. Other examples
of neurohormonal mediators include angiotensin II, which
stimulates the angiotensin II receptor subtype 1 (AT1) to
vasoconstrict arterioles and increase intravascular volume;
aldosterone, which acts via the mineralocorticoid receptor
to increase intravascular volume; natriuretic peptides, which
both promote renal natriuresis (sodium excretion) in situations
of volume overload and cause vasodilation by stimulating
guanylyl cyclase receptors on endothelial cells and vascular
smooth muscle cells; and antidiuretic hormone/arginine vaso-
pressin, which stimulates arteriolar V1 receptors to constrict
arterioles and activates renal V2 receptors to increase intra-
vascular volume. These mediators, which also have important
roles in volume regulation, are all discussed in greater detail
in Chapter 20, Pharmacology of Volume Regulation.
Local Mechanisms
A panoply of local control mechanisms also modulate vascular
tone. Autoregulation is a homeostatic mechanism in which vas-
cular smooth muscle cells respond to increases or decreases in
perfusion pressure by vasoconstriction or vasodilation, respec-
tively, to preserve blood flow at a relatively constant level (Flow
Perfusion Pressure/Resistance). Vascular tone, and thus blood
flow, is also governed by metabolitessuch as H, CO2, O2, ad-
enosine, lactate, and Kproduced in surrounding tissue. Local
mechanisms of vascular tone regulation predominate in the vas-
cular beds of essential organs (e.g., heart, brain, lung, kidney), so
that blood flow, and thus O2 supply, can be adjusted quickly to
meet the demands of local metabolism in these organs.
 PHARMACOLOGIC CLASSES AND AGENTS
The pharmacologic agents considered in this chapter are
all vasodilators, that is, drugs that act on vascular smooth
muscle and/or on the adjacent vascular endothelium to de-
crease vascular tone. Most vasodilators act by reducing the
contractility of actinmyosin complexes in vascular smooth
muscle cells. There are a number of categories of vasodila-
tors (Fig. 21-6). Pharmacologic donors of NOsuch as the

ETA, ETB
antagonists
1 antagonists
K+ channel ET-1 ACE inhibitors
openers NE

Ca2+ channel KATP 1 ETA, ETB Inactive Bradykinin

blockers L-type Ca2+
channel KII

ACE inhibitors Ca2+ channel

PDE5 inhibitors
K+ GMP Arginine
AT-I AT-II
ACE Hyperpolarization Bradykinin
AT1 PDE eNOS receptor
Ca2+ cGMP NO Nitrates
CaM
AT1 antagonists
Myosin-LC phosphatase
Ca2+-CaM

MLCK MLCK Myosin-LC phosphatase

Myosin-LC Myosin-LC P Myosin-LC

Contraction Relaxation

Vascular smooth muscle cell

FIGURE 21-6. Sites of action of vasodilators. Vasodilators act at several sites in the vascular smooth muscle cell. Left panel: Ca2 channel blockers and K chan-
nel openers inhibit the entry of Ca2 into vascular smooth muscle cells by decreasing activation of L-type Ca2 channels. ACE inhibitors, AT1 antagonists, 1-antagonists,
and endothelin receptor (ETA, ETB) antagonists all decrease intracellular Ca2 signaling. The decreased cytosolic Ca2 results in decreased vascular smooth muscle cell
contraction, and, hence, in relaxation. Right panel: ACE inhibitors inhibit kininase II (KII), leading to increased levels of bradykinin. Nitrates release NO. Sildenafil and
other PDE5 inhibitors inhibit phosphodiesterase (PDE). These agents all cause an increase in cGMP, an effect that promotes vascular smooth muscle relaxation. The active
form of each enzyme is italicized and blue. 1, 1-adrenergic receptor; ACE, angiotensin converting enzyme; AT-I, angiotensin I; AT-II, angiotensin II; AT1, angiotensin II
receptor; CaM, calmodulin; eNOS, endothelial nitric oxide synthase; ET-1, endothelin-1; MLCK, myosin light chain kinase; myosin-LC, myosin light chain.
 Sodium nitroprusside Organic nitrates
(SNP) (RNO2)
Enzymes and
Spontaneous extracellular
reductants

Nitric oxide S-Nitrosothiol

(NO) (RSNO)

RNO2

Enzymes and
intracellular
reductants
RSNO

Endothelial
cell

SNP RSNO2
RSNO
NO NO

Guanylyl cyclase

Relaxation

Vascular smooth
muscle cell
360 Principles of Cardiovascular Pharmacology

Heart little effect on systemic blood pressure when administered

(pump)
Organic nitrates by inhalation. Therapy with inhaled NO has established ef-
Myocardial O2 supply ficacy in the treatment of primary pulmonary hypertension
Veins Arteries by dilating large of the newborn, but the therapeutic value of inhaled NO in
epicardial arteries
other conditions characterized by elevated pulmonary artery
pressures (including heart failure and various forms of lung
Capacitance Resistance
vessels vessels disease) remains to be established.
Sodium nitroprusside is a nitrate compound that consists
of a nitroso group, five cyanide groups, and an iron atom
(Fig. 21-10A). As with the organic nitrates, sodium nitroprus-
side effects vasodilation by release of NO. Unlike the organic
nitrates, however, sodium nitroprusside appears to liberate
NO primarily through a nonenzymatic process (Fig. 21-7).
Organic nitrates Organic nitrates As a result of this nonenzymatic conversion to NO, sodium
Preload Afterload nitroprussides action does not appear to be targeted to spe-
Myocardial O2 demand Myocardial O2 demand cific types of vessels and, consequently, the drug dilates both
arteries and veins.
FIGURE 21-8. Sites of action of organic nitrates. Organic nitrates exert the Sodium nitroprusside is used intravenously for powerful
majority of their vasodilator action on venous capacitance vessels. This selectiv- hemodynamic control in hypertensive emergencies and severe
ity results in greatly decreased preload, with resulting decreased myocardial O2 heart failure. Because of its rapid onset of action, short duration
demand. Organic nitrates also mildly dilate arteriolar resistance vessels, with re-
sulting decreased afterload and decreased myocardial O2 demand. Myocardial O2
supply is mildly increased by dilation of large epicardial arteries.
ONO2
O2NO ONO2
Clinically, the administration of doses of organic nitrates
sufficient to vasodilate the large epicardial arteries can be Nitroglycerin
(Glyceryl trinitrate)
dangerous because such doses may also induce excessive
peripheral arteriolar vasodilation and refractory hypoten-
sion. The excessive decrease in mean arterial pressure can
be manifested as dizziness, lightheadedness, and occasion- ONO2 OH
ally, overt syncope, and can even lead to myocardial ische-
mia. Because coronary perfusion depends on the pressure O2NO OH O2NO ONO2
gradient between the aorta and the endocardium during
diastole, a marked decrease in diastolic aortic pressure can Glyceryl 1,2-dinitrate Glyceryl 1,3-dinitrate
lead to an insufficient supply of O2 to the heart. Moreover,
systemic hypotension can lead to reflex tachycardia, which
also decreases myocardial O2 supply by shortening diastole O2NO
H
and, thus, myocardial perfusion time. As noted above, re- O
flex tachycardia can also harm the delicate myocardial O2
supply:demand balance by increasing myocardial O2 con-
sumption. Reflex tachycardia is typically observed when O
baroreceptors in the aortic arch and carotid sinuses sense a H
ONO2
decrease in blood pressure. In patients with overt heart fail-
Isosorbide dinitrate
ure, however, reflex tachycardia is rare. Thus, nitrates can
often be used to decrease pulmonary congestion in patients
with heart failure (by effecting venodilation and decreasing
end-diastolic pressure), without eliciting significant reflex HO
H O2NO
tachycardia. Several important adverse effects of nitrates H
are the result of excessive vasodilation; these include flush- O O
ing, caused by vasodilation of cutaneous vascular beds, and
headache, caused by vasodilation of cerebral arteries. O O
Several different preparations of organic nitrates are H H
ONO2 OH
currently available. The most commonly used organic ni-
trates include NTG, isosorbide dinitrate, and isosorbide Isosorbide 2-mononitrate Isosorbide 5-mononitrate
5-mononitrate (Fig. 21-9). Although these organic nitrates
share a common mechanism of action, they differ in their FIGURE 21-9. Chemical structures and metabolism of nitroglycerin and
routes of administration and pharmacokinetics, leading to isosorbide dinitrate. Nitroglycerin and isosorbide dinitrate are biologically active
important differences in their therapeutic utility in a variety nitrates that are metabolized into active molecules with longer half-lives than their
of clinical settings. parent compounds. Nitroglycerin is denitrated into glyceryl 1,2-dinitrate and glyc-
Inhaled nitric oxide gas can be used to selectively dilate eryl 1,3-dinitrate; these active metabolites have a half-life of approximately 40 min-
the pulmonary vasculature. Because NO is rapidly inacti- utes. Isosorbide dinitrate is denitrated into isosorbide 2-mononitrate and isosorbide
vated by binding to hemoglobin in the blood, NO gas has 5-mononitrate; these active metabolites have half-lives of 2 and 4 hours, respectively.
A NO

NC CN
Fe+2
NC CN

CN
Nitroprusside

B
Sodium nitroprusside

Liver
NO Cyanide Thiocyanate Renal
excretion
Sulfhydryl
donor
Vasodilation
SA node AV node
Automaticity Conduction

Cardiac myocytes
Afterload
Myocardial O2 demand

Coronary arteries
Vasodilation
Myocardial O2 supply

Veins Arteries

Heart
Peripheral veins (pump)

Minimal venodilation

Peripheral arterioles
Vasodilation
Afterload
Myocardial O2 demand

have suggested that Ca2 channel blockers increase the
risk of mortality in patients with heart failure, and Ca2
channel blockers are therefore contraindicated in the man-
agement of heart failure. Some reports also suggest that
the short-acting agent nifedipine is associated with an in-
creased risk of myocardial ischemia and infarction, by vir-
tue of this drugs tendency to disturb the myocardial O2
supply:demand balance (see above).
K Channel Openers
K channel openers cause direct arterial vasodilation by
opening ATP-modulated K channels (sometimes called
KATP channels) in the plasma membrane of vascular
smooth muscle cells. Because these agents act by a mecha-
nism that is entirely different from that of other vasodilators,
KATP channel openers represent a powerful family of drugs
that can be used to treat hypertension refractory to other an-
tihypertensive therapeutics.
What is the normal function of ATP-modulated K chan-
nels? Recall that the Nernst equilibrium potential for K is
about 90 mV, while the resting membrane potential is less
negative than this value. Therefore, opening K channels
hyperpolarizes the membrane. If a sufficient number of K
channels are open at the same time, then normal excitatory
stimuli are not able to promote membrane depolarization. In
the absence of depolarization, voltage-gated Ca2 channels
do not open, and Ca2 influx and smooth muscle contraction
are inhibited (Fig. 21-6).
The KATP channel opener drugs include minoxidil, cro-
makalim, pinacidil, and nicorandil. These drugs act primar-
ily on arterial smooth muscle cells, and therefore decrease
arterial blood pressure. Adverse effects of the KATP channel
openers include headache, caused by excessive dilation of
cerebral arteries, and flushing, caused by excessive dilation
of cutaneous arteries. When arterial vasodilators (e.g., Ca2
channel blockers or KATP channel openers) are used as mono-
therapy, the decrease in arterial pressure often elicits reflex
sympathetic discharge, leading to tachycardia and increased
cardiac work. As noted above in the discussion of nifedipine,
reflex sympathetic discharge can upset the balance between
myocardial O2 supply and demand, precipitating myocardial
ischemia; this effect is of particular concern in patients with
preexisting coronary artery disease. However, the use of -
blockers in combination with arterial vasodilators can help to
block the effects of reflex sympathetic activity, and thereby
preserve the therapeutic utility of the arterial vasodilators.
Endothelin Receptor Antagonists
Bosentan is a competitive antagonist at ETA and ETB recep-
tors. It is approved for use in the treatment of pulmonary
hypertension. In clinical trials involving patients with se-
vere dyspnea related to pulmonary hypertension, bosentan
significantly improved 6-minute walk-test distance (i.e., the
distance a patient can walk in 6 minutes) and decreased pul-
monary vascular resistance relative to placebo. The major
adverse effect of bosentan is an elevation in serum transami-
nase levels, with approximately 10% of patients having el-
evations that exceed three times the upper limit of normal. It
is therefore necessary to monitor liver function tests monthly
in patients taking bosentan.
Ambrisentan is an endothelin receptor antagonist with
relative specificity for the ETA receptor. As with bosentan,
CHAPTER 21 / Pharmacology of Vascular Tone 365
patients with pulmonary hypertension have improved 6-minute
walk-test distance and increased functional status when taking
this medication. Ambrisentan may have less hepatotoxicity
than bosentan.
Other Drugs That Modulate Vascular Tone
Hydralazine
Hydralazine is an orally administered arteriolar vasodila-
tor that is sometimes used in the treatment of hypertension
and, in combination with isosorbide dinitrate, in the treat-
ment of heart failure. The mechanism of action of hydrala-
zine remains unclear; studies have suggested that membrane
hyperpolarization, KATP channel opening, and inhibition
of IP3-induced Ca2 release from the sarcoplasmic reticu-
lum in vascular smooth muscle cells may all be involved.
Hydralazine appears to prevent the development of nitrate
tolerance, perhaps by inhibiting vascular superoxide produc-
tion. A combination pill containing isosorbide dinitrate and
hydralazine has recently been found to reduce morbidity and
mortality in black Americans with advanced heart failure; it
remains to be determined whether the benefits of this therapy
extend to other patient populations. However, if the success
of this hydralazineisosorbide dinitrate combination therapy
for heart failure is related to hydralazines prevention of ni-
trate tolerance, then these drugs may be broadly efficacious
in heart failure treatment.
The use of hydralazine has been limited because it
was initially thought that the frequent dosing required for
sustained blood pressure control and the rapid develop-
ment of tachyphylaxis to its antihypertensive effects made
chronic use of this drug impractical. As the benefits of
combination therapy for hypertension and heart failure
are becoming better appreciated, it may be possible for
hydralazine to be used more effectively, especially in pa-
tients for whom other vasodilators (e.g., ACE inhibitors)
are contraindicated.
Hydralazine typically has low bioavailability because of
extensive first-pass hepatic metabolism. The rate of its me-
tabolism depends on whether the patient is a slow or fast
acetylator, however. In slow acetylators (see Chapter 4), hy-
dralazine has a slower rate of hepatic degradation and, thus,
higher bioavailability and higher plasma concentrations. A
rare adverse effect of hydralazine is the development of a
reversible lupus erythematosus-like syndrome; this effect
occurs chiefly in slow acetylators.
1-Adrenergic Antagonists
Epinephrine and norepinephrine stimulate 1-adrenergic
receptors on vascular smooth muscle, and thereby induce
vasoconstriction. The 1-adrenergic receptor is a G protein-
coupled receptor that associates with the heterotrimeric G pro-
tein Gq, which activates phospholipase C to generate inositol
trisphosphate and diacylglycerol. 1-Adrenergic antagonists,
such as prazosin, block 1-adrenergic receptors in arterioles
and venules, leading to vasodilation. The effect of these agents
is greater in arterioles than in venules. The 1-adrenergic an-
tagonists cause a significant reduction in arterial pressure, and
are thus useful in the treatment of hypertension. Initiation of
therapy with 1-adrenergic antagonists can be associated
with orthostatic hypotension. Like other arterial vasodilators,
the 1-adrenergic antagonists can also cause retention of salt
and water. -Adrenergic blockers and diuretics may be used
366 Principles of Cardiovascular Pharmacology
together with 1-adrenergic antagonists to mitigate these com-
pensatory responses. Some 1-adrenergic antagonists, such
as terazosin, are used principally to inhibit the contraction of
nonvascular smooth muscle (e.g., prostatic smooth muscle),
but these agents also have some effect on the vasculature (see
Chapter 10, Adrenergic Pharmacology).
-Adrenergic Antagonists
Activation of 2-adrenergic receptors on vascular smooth
muscle cells leads to vasodilation. The increased intracel-
lular cAMP induced by 2-receptor stimulation may cause
smooth muscle relaxation by accelerating the inactivation of
myosin light chain kinase and by increasing the extrusion of
Ca2 from the cell. Activation of 2-adrenergic receptors on
endothelial cells also leads to vasodilation through activa-
tion of endothelial nitric oxide synthase. Despite the benefi-
cial vasodilatory effects of 2- and 3-agonist action in the
systemic circulation, -adrenergic antagonists are of major
clinical importance in the treatment of hypertension, angina,
cardiac arrhythmias, and other conditions. Acting at cardiac
1-adrenergic receptors, -adrenergic antagonists have neg-
ative inotropic and chronotropic effects on the heart; these
actions reduce cardiac output, which is an important deter-
minant of both myocardial O2 demand and blood pressure
(see Equation 21-2). The cardiac effects of -adrenergic
antagonists are discussed in greater detail in Chapter 10.
These drugs also have important effects on the vasculature:
antagonism of 2-adrenergic receptors on vascular smooth
muscle cells can lead to unopposed vasoconstriction medi-
ated by 1-adrenergic receptors and, consequently, to an in-
crease in systemic vascular resistance. Importantly, although
some -adrenergic antagonists may initially increase sys-
temic vascular resistance, the net effect in most cases is a
decrease in blood pressure. This hypotensive effect reflects
the combined negative inotropic effect (leading to a decrease
in cardiac output), inhibition of renin secretion, and central
nervous system effects of the -blockers.
ReninAngiotensin System Blockers
As discussed in Chapter 20, inhibition of the renin
angiotensin system results in significant vasorelaxation. The
hypotensive effect of ACE inhibitors may be caused in part
by decreased catabolism of bradykinin, a vasorelaxant re-
leased in response to inflammatory stimuli. Antagonists at
the AT1 receptor, which selectively inhibit angiotensin II-
mediated vasoconstriction at the level of the target organ,
have a more direct effect. ACE inhibitors and AT1 receptor
antagonists are considered balanced vasodilators because
they affect both arterial and venous tone. Both classes of
drugs are effective in the treatment of hypertension and heart
failure, as discussed in Chapter 25.
 CONCLUSION AND FUTURE DIRECTIONS
Vascular tone is subject to exquisite control, as would be
expected for a system that must perfuse all the tissues of the
body. Vascular tone represents a balance between vascular
smooth muscle contraction and relaxation. Vasoconstric-
tion occurs when an increase in intracellular Ca2 activates
Ca2-CaMdependent myosin light chain kinase (MLCK).
In turn, MLCK phosphorylates myosin light chains and al-
lows the formation of actinmyosin cross-bridges. Vascular
smooth muscle relaxes when the intracellular Ca2 concen-
tration returns to basal levels and myosin light chains are de-
phosphorylated, terminating the formation of actinmyosin
cross-bridges. Vascular tone is influenced by the state of the
vascular smooth muscle cells and the overlying endothelial
cells, by sympathetic innervation, and by neurohormonal
and local regulators.
Diverse therapeutic agents modulate various compo-
nents of this critical system, with important differences in
molecular mechanisms and effects. Classes of vasodila-
tors include nitrates, Ca2 channel blockers, K channel
openers, 1-adrenergic receptor antagonists, ACE inhibi-
tors, AT1 receptor antagonists, and endothelin receptor an-
tagonists (Fig. 21-6). Nitrates dilate primarily veins, not
arteries. These agents act by releasing NO in vascular
smooth muscle cells; in turn, NO activates guanylyl cy-
clase, which increases intracellular cGMP, which activates
cGMP-dependent protein kinase, which activates myosin
light chain phosphatase, which terminates the formation
of actinmyosin cross-bridges. Ca2 channel blockers act
mainly on arteries and resistance arterioles, and may also
have direct effects on the heart. These drugs cause vasodila-
tion by blocking L-type voltage-gated Ca2 channels in the
plasma membrane of vascular smooth muscle cells, thereby
inhibiting the Ca2 influx through these channels that is
necessary for contraction. KATP channel openers, as with
Ca2 channel blockers, are predominantly arteriodilators,
not venodilators. This class of drugs opens ATP-modulated
K channels, thereby hyperpolarizing vascular smooth
muscle cells and preventing the activation of voltage-gated
Ca2 channels that is necessary for Ca2 influx and muscle
contraction. 1-Adrenergic receptor antagonists, AT1 recep-
tor antagonists, and endothelin receptor antagonists prevent
vasoconstriction by inhibiting the activation of their respec-
tive receptors by endogenous agonists.
The mechanisms that control vascular tone are regulated
by multiple intersecting signaling pathways. The emerging
science of systems biology combines mathematical, compu-
tational, and experimental approaches to understand complex
signaling pathways in a wide array of tissues and organs.
This integrated approach to signaling will provide novel
quantitative information regarding the interplay of intracel-
lular signaling pathways in the vasculature, and may lead to
the identification of new drug targets. For example, insights
into the relationships among cGMP-modulated regulatory
pathways in vascular smooth muscle cells have recently led
to new therapeutic applications for PDE5 inhibitors, such as
sildenafil, in the treatment of pulmonary hypertension and
heart failure.
A new class of drug, exemplified by ranolazine, appears
to have minimal direct effects on cardiac contractility or
vascular tone, yet appears to have efficacy in the treatment
of angina. This drug and other new agents may exert their
principal therapeutic effects on the cardiovascular system
by affecting metabolic pathways in target tissues. A recently
approved -adrenergic blocker, nebivolol, has the interest-
ing property that it is both a 1-adrenergic antagonist and
a 3-adrenergic agonist. This drug, which appears to be as
efficacious as other -blockers in the treatment of hyper-
tension, combines cardiac-selective 1-adrenergic blockade

with stimulation of 3 receptors, which activate nitric oxide
synthase in the vasculature. Continued elucidation of com-
plex signaling pathways will likely lead to the identification
of new points for pharmacologic intervention in the cellular
milieu of the vascular wall, and will help to integrate the
pharmacology of vascular tone across the spectrum of car-
diovascular disease.
Suggested Reading
Abrams J. Chronic stable angina. N Engl J Med 2005;352:25242533. (An
informative case vignette and review of the pathophysiology and pharma-
cotherapy of angina pectoris.)
CHAPTER 21 / Pharmacology of Vascular Tone 367
Bloch KD, Ichinose F, Roberts JD Jr, Zapol WM. Inhaled NO as a therapeu-
tic agent. Cardiovasc Res 2007;75:339348. (A useful review of the thera-
peutic applications of inhaled nitric oxide.)
Cheng JW. Nebivolol: a third-generation beta-blocker for hypertension.
Clin Ther 2009;31:447462. (A review of trials that study a recently
approved -adrenergic blocker that combines 1-antagonist with 3-
agonist properties.)
Mark JD, Griffiths M, Evans TW. Drug therapy: inhaled nitric oxide ther-
apy in adults. N Engl J Med 2005;353:26832695. (Reviews the history of
inhaled NO and current indications for this therapy.)
Tsai EJ, Kass DA. Cyclic GMP signaling in cardiovascular pathophysiol-
ogy and therapeutics. Pharm Ther 2009;122:216238. (This review explores
mechanisms and therapies involving cyclic GMP in the control of vascular
tone and cardiac function.)
22
Pharmacology of Hemostasis
and Thrombosis
April W. Armstrong and David E. Golan
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . 372-373
PHYSIOLOGY OF HEMOSTASIS . . . . . . . . . . . . . . . . . . . . . . 372
Vasoconstriction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
Primary Hemostasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
Platelet Adhesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
Platelet Granule Release Reaction . . . . . . . . . . . . . . . 373
Platelet Aggregation and Consolidation . . . . . . . . . . . . 375
Secondary Hemostasis: The Coagulation Cascade . . . . . . 376
Regulation of Hemostasis . . . . . . . . . . . . . . . . . . . . . . . . 379
PATHOGENESIS OF THROMBOSIS . . . . . . . . . . . . . . . . . . . . 380
Endothelial Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Abnormal Blood Flow . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Hypercoagulability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 381
Antiplatelet Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Cyclooxygenase Inhibitors . . . . . . . . . . . . . . . . . . . . . . 382
Phosphodiesterase Inhibitors . . . . . . . . . . . . . . . . . . . 383
ADP Receptor Pathway Inhibitors . . . . . . . . . . . . . . . . 386
GPIIbIIIa Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . 386
 INTRODUCTION
Blood carries oxygen and nutrients to tissues and takes meta-
bolic waste products away from tissues. Humans have devel-
oped a well-regulated system of hemostasis to keep the blood
fluid and clot-free in normal vessels and to form a localized
plug rapidly in injured vessels. Thrombosis describes a patho-
logic state in which normal hemostatic processes are activated
inappropriately. For example, a blood clot (thrombus) may
form as the result of a relatively minor vessel injury and occlude
a section of the vascular tree. This chapter presents the normal
physiology of hemostasis, the pathophysiology of thrombosis,
and the pharmacology of drugs that can be used to prevent or
reverse a thrombotic state. Drugs introduced in this chapter are
used to treat a variety of cardiovascular diseases, such as deep
vein thrombosis, stroke, and myocardial infarction.
 PHYSIOLOGY OF HEMOSTASIS
An injured blood vessel must induce the formation of a blood
clot to prevent blood loss and to allow healing. Clot formation
372
Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
Warfarin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
Unfractionated and Low-Molecular-
Weight Heparins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 389
Selective Factor Xa Inhibitors . . . . . . . . . . . . . . . . . . . 391
Direct Thrombin Inhibitors . . . . . . . . . . . . . . . . . . . . . 391
Recombinant Activated Protein C (r-APC) . . . . . . . . . . 392
Thrombolytic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
Streptokinase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
Recombinant Tissue Plasminogen
Activator (t-PA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Tenecteplase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Reteplase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Inhibitors of Anticoagulation and Fibrinolysis . . . . . . . . . . 393
Protamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Serine-Protease Inhibitors . . . . . . . . . . . . . . . . . . . . . 393
Lysine Analogues . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 393
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
must also remain localized to prevent widespread clotting
within intact vessels. The formation of a localized clot at the
site of vessel injury is accomplished in four temporally over-
lapping stages (Fig. 22-1). First, localized vasoconstriction
occurs as a response to a reflex neurogenic mechanism and
to the secretion of endothelium-derived vasoconstrictors
such as endothelin. Immediately following vasoconstriction,
primary hemostasis occurs. During this stage, platelets are
activated and adhere to the exposed subendothelial matrix.
Platelet activation involves both a change in shape of the
platelet and the release of secretory granule contents from the
platelet. The secreted granule substances recruit other plate-
lets, causing more platelets to adhere to the subendothelial
matrix and to aggregate with one another at the site of vascu-
lar injury. Primary hemostasis ultimately results in the forma-
tion of a primary hemostatic plug.
The goal of the final two stages of hemostasis is to form a
stable, permanent plug. During secondary hemostasis, also
known as the coagulation cascade, the activated endothelium
and other nearby cells (see below) express a membrane-bound
procoagulant factor called tissue factor, which complexes
374 Principles of Cardiovascular Pharmacology

Endothelin release
by activated endothelium

Reflex
vasoconstriction

A E

Site of vascular injury

(denuded endothelium)
Vascular smooth muscle Resting platelets Activated spread Activated contracted
platelet platelet
Basement membrane

Endothelial cells FIGURE 22-1. Sequence of events in hemostasis. The hemostatic process
can be divided conceptually into four stagesvasoconstriction, primary hemosta-
sis, secondary hemostasis, and resolutionalthough recent evidence suggests
that these stages are temporally overlapping and may be nearly simultaneous.
1. Subendothelial matrix A. Vascular injury causes endothelial denudation. Endothelin, released by acti-
exposure vated endothelium, and neurohumoral factor(s) induce transient vasoconstriction.
2. Platelet adhesion 6. Platelet aggregation
and activation (hemostatic plug) B. Injury-induced exposure of the subendothelial matrix (1 ) provides a substrate
B for platelet adhesion and activation (2 ). In the granule release reaction, activated
platelets secrete thromboxane A2 (TxA2) and ADP (3 ). TxA2 and ADP released by
activated platelets cause nearby platelets to become activated; these newly ac-
tivated platelets undergo shape change (4 ) and are recruited to the site of injury
5. Platelet recruitment (5 ). The aggregation of activated platelets at the site of injury forms a primary
ADP hemostatic plug (6 ). C. Tissue factor expressed on activated endothelial cells (1)
4. Platelet shape change and leukocyte microparticles (not shown), together with acidic phospholipids ex-
TxA2 pressed on activated platelets and activated endothelial cells (2 ), initiate the steps
3. Platelet granule release of the coagulation cascade, culminating in the activation of thrombin (3 ). Thrombin
proteolytically activates fibrinogen to form fibrin, which polymerizes around the
Fibrin site of injury, resulting in the formation of a definitive (secondary) hemostatic plug
(4 ). D. Natural anticoagulant and thrombolytic factors limit the hemostatic process
1. Tissue factor expression
on activated
to the site of vascular injury. These factors include tissue plasminogen activator
endothelium (t-PA), which activates the fibrinolytic system (1 ); thrombomodulin, which acti-
C vates inhibitors of the coagulation cascade (2 ); prostacyclin, which inhibits both
platelet activation and vasoconstriction (3 ); and surface heparin-like molecules,
which catalyze the inactivation of coagulation factors (4 ). E. Scanning electron
4. Fibrin polymerization micrographs of resting platelets (1 ), a platelet undergoing cell spreading shortly
after cell activation (2 ), and a fully activated platelet after actin filament bundling
3. Thrombin activation and cross-linking and myosin contraction (3 ).

2. Phospholipid complex expression

that are coupled to the various agonist receptors. Release

D t-PA
PGI2
1. Release of t-PA
(fibrinolysis)
2. Thrombomodulin
(blocks coagulation cascade)
3. Release of prostacyclin (inhibits
platelet aggregation and vasoconstriction)
4. Surface heparin-like molecules
(blocks coagulation cascade)
important in mediating platelet aggregation, causing
platelets to become sticky and adhere to one another
(see below). Although strong agonists (such as thrombin
and collagen) can trigger granule secretion even when ag-
gregation is prevented, ADP can trigger granule secretion
only in the presence of platelet aggregation. Presumably,
this difference is caused by the set of intracellular effectors
of Ca2 ions is also important for the coagulation cascade,
as discussed below.
Although platelet activation can be initiated via exposure
of subendothelial collagen, a separate and parallel process
of platelet activation occurs without disruption of the en-
dothelium and without the involvement of von Willebrand
factor. This second pathway of platelet activation is initi-
ated by tissue factor, a lipoprotein expressed by activated
leukocytes and by microparticles derived from activated
leukocytes (see below). As in the coagulation cascade, tis-
sue factor forms a complex with factor VIIa, and the tissue
factorfactor VIIa complex activates factor IX. Factor IX
activation leads to a proteolytic cascade that results in the
generation of thrombin (factor IIa), a multifunctional en-
zyme that plays a critical role in the coagulation cascade
(see below). In the tissue-factor initiated pathway of plate-
let activation, thrombin cleaves protease-activated receptor
4 on the platelet surface and thereby causes the platelets
to release ADP, serotonin, and TxA2. By activating other
nearby platelets, these agonists amplify the signal for
thrombus formation.
 CHAPTER 22 / Pharmacology of Hemostasis and Thrombosis 375
Endothelium
Collagen
Platelet
Fibrinogen
GPVI
GPIIb-IIIa
GPIb
von Willebrand
factor
Collagen (subendothelium)
FIGURE 22-2. Platelet adhesion and aggregation. von Willebrand factor
mediates platelet adhesion to the subendothelium by binding both to the plate-
let membrane glycoprotein GPIb and to exposed subendothelial collagen. Platelet
adhesion to the subendothelial matrix also requires a direct binding interaction
between platelet membrane glycoprotein GPVI and subendothelial collagen. Dur-
ing platelet aggregation, fibrinogen cross-links platelets to one another by binding
to GPIIbIIIa receptors on platelet membranes.
Platelet Aggregation and Consolidation
TxA2, ADP, and fibrous collagen are all potent mediators
of platelet aggregation. TxA2 promotes platelet aggrega-
tion through stimulation of G protein-coupled TxA2 recep-
tors in the platelet membrane (Fig. 22-4). Binding of TxA2
to platelet TxA2 receptors leads to activation of phospholi-
pase C (PLC), which hydrolyzes phosphatidylinositol 4,5-
bisphosphate (PI[4,5]P2) to yield inositol 1,4,5-trisphosphate
(IP3) and diacylglycerol (DAG). IP3 raises the cytosolic Ca2
concentration, and DAG activates protein kinase C (PKC),
which in turn promotes the activation of PLA2. Through
an incompletely understood mechanism, PLA2 activation
induces the expression of functional GPIIbIIIa, the mem-
brane integrin that mediates platelet aggregation.
ADP triggers platelet activation by binding to G protein-
coupled ADP receptors on the platelet surface (Fig. 22-5). The
two subtypes of G protein-coupled platelet ADP receptors are
termed P2Y1 receptors and P2Y(ADP) receptors. P2Y1, a
Gq-coupled receptor, releases intracellular calcium stores
through activation of phospholipase C. P2Y(ADP), a Gi-
coupled receptor, inhibits adenylyl cyclase. The P2Y(ADP)
receptor is the target of the antiplatelet agents ticlopidine,
Endothelium
Collagen
Resting platelet
Tissue factor
TXA2
Prothrombin
ADP Thrombin
von Willebrand
factor
Activated endothelium Collagen
FIGURE 22-3. Platelet activation. Platelet activation is initiated at the site of vas-
cular injury when circulating platelets adhere to exposed subendothelial collagen and
are activated by locally generated mediators. Activated platelets undergo shape change
and granule release, and platelet aggregates are formed as additional platelets are re-
cruited and activated. Platelet recruitment is mediated by the release of soluble platelet
factors, including ADP and thromboxane A2 (TxA2). Tissue factor, expressed on activated
endothelium, is a critical initiating component in the coagulation cascade. The mem-
branes of activated platelets provide a surface for a number of critical reactions in the
coagulation cascade, including the conversion of prothrombin to thrombin.
clopidogrel, and prasugrel (see below). Activation of ADP
receptors mediates platelet shape change and expression of
functional GPIIbIIIa.
Fibrous collagen activates platelets by binding directly to
platelet glycoprotein VI (GPVI). Activation of GPVI by colla-
gen initiates signaling cascades that promote the granule release
reaction and that induce conformational changes in cell-surface
integrins (especially GPIIbIIIa and 21) that promote the di-
rect or indirect binding of these integrins to collagen. These
additional binding interactions further strengthen the adhesion
of activated platelets to the subendothelial matrix.
Platelets aggregate with one another through a bridging
molecule, fibrinogen, which has multiple binding sites for
functional GPIIbIIIa (Fig. 22-2). Just as the vWF:GPIb
interaction is important for platelet adhesion to exposed
subendothelial collagen, the fibrinogen:GPIIbIIIa interac-
tion is critical for platelet aggregation. Platelet aggregation
ultimately leads to the formation of a reversible clot, or a
primary hemostatic plug.
Activation of the coagulation cascade proceeds nearly
simultaneously with the formation of the primary hemo-
static plug, as described below. Activation of the coagulation
376 Principles of Cardiovascular Pharmacology

Arachidonic acid
1
Generation of Cyclooxygenase
thromboxane A2
by activated
platelets
3
TXA2 G protein-mediated 4
activation of PLC hydrolyzes PIP2
PLC
phospholipase C to yield IP3 and DAG

PIP2 DAG
TXA2-R q PKC
q GTP
(active)

GDP
6
2 Activation of protein
PKC
Activation of kinase C
IP3
thromboxane A2
receptor
Ca2+

Ca2+ 7
5 Activation of
Increase in cytosolic PLA2 phospholipase A2
calcium concentration

8 GP
Activation of IIb
-III
GPIIb-IIIa a

9
Binding of fibrinogen
to GPIIb-IIIa

Fibrinogen

10
Platelet aggregation

FIGURE 22-4. Platelet activation by thromboxane A2. 1. Thromboxane A2 (TxA2) is generated from arachidonic acid in activated platelets; cyclooxygenase cata-
lyzes the committed step in this process. 2. Secreted TxA2 binds to the cell-surface TxA2 receptor (TxA2-R), a G protein-coupled receptor. 3. The G isoform Gq activates
phospholipase C (PLC). 4. PLC hydrolyzes phosphatidylinositol 4,5-bisphosphate (PIP2) to yield inositol 1,4,5-trisphosphate (IP3) and diacylglycerol (DAG). 5. IP3 raises the
cytosolic Ca2 concentration by promoting vesicular release of Ca2 into the cytosol. 6. DAG activates protein kinase C (PKC). 7. PKC activates phospholipase A2 (PLA2). 8.
Through an incompletely understood mechanism, activation of PLA2 leads to the activation of GPIIbIIIa. 9. Activated GPIIbIIIa binds to fibrinogen. 10. Fibrinogen cross-
links platelets by binding to GPIIbIIIa receptors on other platelets. This cross-linking leads to platelet aggregation and formation of a primary hemostatic plug.

cascade leads to the generation of fibrin, initially at the pe-
riphery of the primary hemostatic plug. Platelet pseudopods
attach to the fibrin strands at the periphery of the plug and
contract. Platelet contraction yields a compact, solid, irre-
versible clot, or a secondary hemostatic plug.
Secondary Hemostasis:
The Coagulation Cascade
Secondary hemostasis is also termed the coagulation cas-
cade. The goal of this cascade is to form a stable fibrin clot at
the site of vascular injury. Details of the coagulation cascade
are presented schematically in Figure 22-6. Several general
principles should be noted.
First, the coagulation cascade is a sequence of enzymatic
events. Most plasma coagulation factors circulate as inactive
proenzymes, which are synthesized by the liver. These proen-
zymes are proteolytically cleaved, and thereby activated, by
the activated factors that precede them in the cascade. The
activation reaction is catalytic and not stoichiometric. For
example, one unit of activated factor X can potentially
generate 40 units of thrombin. This robust amplification
process rapidly generates large amounts of fibrin at a site of
vascular injury.
Second, the major activation reactions in the cascade occur
at sites where a phospholipid-based proteinprotein complex
has formed (Fig. 22-7). This complex is composed of a mem-
brane surface (provided by activated platelets, activated en-
dothelial cells, and possibly activated leukocyte microparticles
[see below]), an enzyme (an activated coagulation factor), a
substrate (the proenzyme form of the downstream coagulation
factor), and a cofactor. The presence of negatively charged
phospholipids, especially phosphatidylserine, is critical for as-
sembly of the complex. Phosphatidylserine, which is normally
sequestered in the inner leaflet of the plasma membrane, trans-
locates to the outer leaflet of the membrane in response to ago-
nist stimulation of platelets, endothelial cells, or leukocytes.
Calcium is required for the enzyme, substrate, and cofactor to
adopt the proper conformation for the proteolytic cleavage of
a coagulation factor proenzyme to its activated form.
 CHAPTER 22 / Pharmacology of Hemostasis and Thrombosis 377

Thrombin

4 ADP
ADP Adenylyl cyclase Thrombin
receptor PLC 5
1

i P2Y1 receptor

q q

P2Y(ADP) receptor i GTP
GDP 6 GTP
GDP ATP q
cAMP
2 GDP
PDE

PKA 7
AMP Increased PLC activity
leads to platelet activation

3
Decreased PKA activity
leads to platelet activation

FIGURE 22-5. Platelet activation by ADP and thrombin. Left panel: 1. Binding of ADP to the P2Y(ADP) receptor activates a Gi protein, which inhibits adenylyl cyclase.
2. Inhibition of adenylyl cyclase decreases the synthesis of cAMP, and hence decreases protein kinase A (PKA) activation (dashed arrow). cAMP is metabolized to AMP by
phosphodiesterase (PDE). 3. PKA inhibits platelet activation through a series of poorly understood steps. Therefore, the decreased PKA activation that results from ADP bind-
ing to the P2Y(ADP) receptor causes platelet activation. Right panel: 4. Thrombin proteolytically cleaves the extracellular domain of its receptor. This cleavage creates a new
N-terminus, which binds to an activation site on the thrombin receptor to activate a Gq protein. 5. ADP also activates Gq by binding to the P2Y1 receptor. 6. Gq activation (by
either thrombin or ADP) activates phospholipase C (PLC). 7. PLC activity leads to platelet activation, as shown in Figure 22-4. Note that ADP can activate platelets by binding
to either the P2Y(ADP) receptor or the P2Y1 receptor, although evidence suggests that full platelet activation requires the participation of both receptors.

Third, the coagulation cascade has been divided traditionally
into the intrinsic and extrinsic pathways (Fig. 22-6). This divi-
sion is a result of in vitro testing and is essentially arbitrary. The
intrinsic pathway is activated in vitro by factor XII (Hageman
factor), while the extrinsic pathway is initiated in vivo by tis-
sue factor, activated endothelial cells, subendothelial smooth
muscle cells, and subendothelial fibroblasts at the site of vascu-
lar injury. Although these two pathways converge at the activa-
tion of factor X, there is also much interconnection between the
two pathways. Because factor VII (activated by the extrinsic
pathway) can proteolytically activate factor IX (a key factor in
the intrinsic pathway), the extrinsic pathway is regarded as the
primary pathway for the initiation of coagulation in vivo.
Fourth, both the intrinsic and extrinsic coagulation
pathways lead to the activation of factor X. In an important
reaction that requires factor V, activated factor X proteolyti-
cally cleaves prothrombin (factor II) to thrombin (factor IIa)
(Fig. 22-8). Thrombin acts in the coagulation cascade in four
important ways: (1) it converts the soluble plasma protein
fibrinogen into fibrin, which then forms long, insoluble
polymer fibers; (2) it activates factor XIII, which cross-links
the fibrin polymers into a highly stable meshwork or clot;
(3) it amplifies the clotting cascade by catalyzing the feedback
activation of factors VIII and V; and (4) it strongly activates
platelets, causing granule release, platelet aggregation, and
platelet-derived microparticle generation. In addition to its
procoagulant properties, thrombin acts to modulate the co-
agulation response. Thrombin binds to thrombin receptors on
the intact vascular endothelial cells adjacent to the area of
vascular injury, and stimulates these cells to release the plate-
let inhibitors prostacyclin (PGI2) and nitric oxide (NO), the
profibrinolytic protein tissue plasminogen activator (t-PA),
and the endogenous t-PA modulator plasminogen activator
inhibitor 1 (PAI-1) (see below).
The thrombin receptor, a protease-activated G protein-
coupled receptor, is expressed in the plasma membrane of
platelets, vascular endothelial cells, smooth muscle cells,
and fibroblasts. Activation of the thrombin receptor involves
proteolytic cleavage of an extracellular domain of the re-
ceptor by thrombin. The new NH2-terminal-tethered ligand
binds intramolecularly to a discrete site within the receptor
and initiates intracellular signaling. Activation of the throm-
bin receptor results in G protein-mediated activation of PLC
(Fig. 22-5) and inhibition of adenylyl cyclase.
Finally, evidence from intravital (in vivo) microscopy ex-
periments suggests that microparticles have an important role
in coupling platelet plug formation (primary hemostasis) to
fibrin clot formation (secondary hemostasis). Microparticles
378 Principles of Cardiovascular Pharmacology

Proteolytic cleavage
Intrinsic pathway Extrinsic pathway (activation) of factor X
XII Tissue injury
Kallikrein
VII Proteolytic cleavage
IXa X (activation) of prothrombin
XIIa Prekallikrein
2+
VIIIa Ca a IXa
Xa IX
HMWK IX Thrombin (IIa) 2+
VIIa
VIIIa Ca
XI XIa
Xa
Ca2+ Prothrombin (II)
Thrombin (IIa) Xa
Va Ca2+ Thrombin (IIa)
Tissue
factor Va Ca2+
VIII VIIIa X VIIa
IXa Ca2+
Ca2+ Ca2+

Common pathway
Xa
FIGURE 22-7. Coagulation factor activation on phospholipid surfaces.
Thrombin (IIa) Surface catalysis is critical for a number of the activation reactions in the coagula-
tion cascade. Each activation reaction consists of an enzyme (e.g., factor IXa), a
substrate (e.g., factor X), and a cofactor or reaction accelerator (e.g., factor VIIIa),
V Va all of which are assembled on the phospholipid surface of activated platelets, en-
Xa
Ca2+ dothelial cells, and leukocytes. Ca2 allows the enzyme and substrate to adopt the
proper conformation in each activation reaction. In the example shown, factor VIIIa
XIII and Ca2 act as cofactors in the factor IXa-mediated cleavage of factor X to factor
Xa. Factor Va and Ca2 then act as cofactors in the factor Xa-mediated cleavage
Prothrombin (II) Thrombin (IIa) Ca2+
of prothrombin to thrombin.
XIIIa
Ca2+

Fibrinogen Fibrin Fibrin Crosslinked

polymer fibrin polymer
Resting
endothelial Activated
cells endothelial
cells
VII VIIa VIII VIIIa
V Va XI XIa
FIGURE 22-6. Coagulation cascade. The coagulation cascade is arbitrarily
divided into the intrinsic pathway, the extrinsic pathway, and the common pathway. Prothrombin (II)
The intrinsic and extrinsic pathways converge at the level of factor X activation. Va
The intrinsic pathway is largely an in vitro pathway, while the extrinsic pathway Xa Ca2+
accounts for the majority of in vivo coagulation. The extrinsic pathway is initiated PL Resting
at sites of vascular injury by the expression of tissue factor on several different cell platelets
types, including activated endothelial cells, activated leukocytes (and leukocyte Thrombin (IIa)
microparticles), subendothelial vascular smooth muscle cells, and subendothelial
fibroblasts. Note that Ca2 is a cofactor in many of the steps, and that a number
of the steps occur on phospholipid surfaces provided by activated platelets, ac- Fibrinogen
g Activated
platelets
tivated endothelial cells, and activated leukocytes (and leukocyte microparticles).
Activated coagulation factors are shown in blue and indicated with a lower case XIII XIIIa
a. HMWK, high-molecular-weight kininogen. Fibrin
n

are vesicular structures derived from leukocytes, monocytes,

platelets, endothelial cells, and smooth muscle cells; they
display proteins of the cells from which they were derived.
For example, a subpopulation of microparticles is released
from monocytes that are activated in the context of tissue
injury and inflammation. These microparticles appear to ex-
press both tissue factor and P-selectin glycoprotein ligand-1
(PSGL-1). In turn, PSGL-1 on the microparticles binds to
the P-selectin adhesion receptor expressed on activated
platelets. By recruiting tissue factor-bearing microparticles
throughout the developing platelet plug (primary hemosta-
sis), thrombin generation and fibrin clot formation (second-
ary hemostasis) could be greatly accelerated within the plug
itself. Indeed, it seems that both vessel-wall tissue factor
(expressed by activated endothelial cells, subendothelial
Crosslinked
fibrin polymer
FIGURE 22-8. Central role of thrombin in the coagulation cascade.
In the coagulation cascade, prothrombin is cleaved to thrombin by factor Xa;
factor Va and Ca2 act as cofactors in this reaction, and the reaction takes
place on an activated (phosphatidylserine-expressing) phospholipid surface
(PL). Thrombin converts the soluble plasma protein fibrinogen to fibrin, which
spontaneously polymerizes. Thrombin also activates factor XIII, a transglu-
taminase that cross-links the fibrin polymers into a highly stable meshwork
or clot. Thrombin also activates cofactors V and VIII, as well as coagulation
factors VII and XI. In addition, thrombin activates both platelets and endothe-
lial cells. Finally, thrombin stimulates the release of several antithrombotic
factorsincluding PGI2, NO, and t-PAfrom resting (intact) endothelial cells
near the site of vascular injury; these factors limit primary and secondary
hemostasis to the injured site (not shown).

fibroblasts, and smooth muscle cells) and microparticle tis-
sue factor are important for the formation of a stable clot.
Regulation of Hemostasis
Hemostasis is exquisitely regulated for two major reasons.
First, hemostasis must be restricted to the local site of vascular
injury. That is, activation of platelets and coagulation factors
in the plasma should occur only at the site of endothelial dam-
age, tissue factor expression, and procoagulant phospholipid
exposure. Second, the size of the primary and secondary he-
mostatic plugs must be restricted so that the vascular lumen
remains patent. After vascular injury, intact endothelium in
the immediate vicinity of the injury becomes activated. This
activated endothelium presents a set of procoagulant factors
that promote hemostasis at the site of injury, and anticoagu-
lant factors that restrict propagation of the clot beyond the site
of injury. The procoagulant factors, such as tissue factor and
phosphatidylserine, tend to be membrane-bound and localized
to the site of injurythese factors provide a surface on which
the coagulation cascade can proceed. In contrast, the anti-
coagulant factors are generally secreted by the endothelium
and are soluble in the blood. Thus, the activated endothelium
maintains a balance of procoagulant and anticoagulant fac-
tors to limit hemostasis to the site of vascular injury.
ATIII
+ Heparin
Endogenous heparin-like
molecules or
exogenous
Antithrombin III unfractionated heparin
B
Active
coagulation factors
Thrombin
Xa
+ ATIII
IXa
Heparin
XIa
XIIa
FIGURE 22-9. Antithrombin III action. Antithrombin III (ATIII) inactivates thrombin and factors IXa, Xa, XIa, and XIIa by forming a stoichiometric complex with these
coagulation factors. These reactions are catalyzed physiologically by heparin-like molecules expressed on healthy endothelial cells; sites of vascular injury do not ex-
press heparin-like molecules because the endothelium is denuded or damaged. Pharmacologically, these reactions are catalyzed by exogenously administered heparin.
In more detail, the binding of heparin to ATIII induces a conformational change in ATIII (A) that allows the ATIII to bind thrombin or coagulation factors IXa, Xa, XIa, or XIIa.
The stoichiometric complex between ATIII and the coagulation factor is highly stable, allowing heparin to dissociate without breaking up the complex (B).
CHAPTER 22 / Pharmacology of Hemostasis and Thrombosis 379
After vascular injury, the endothelium surrounding the
injured area participates in five separate mechanisms that
limit the initiation and propagation of the hemostatic process
to the immediate vicinity of the injury. These mechanisms
involve prostacyclin (PGI2), antithrombin III, proteins C and
S, tissue factor pathway inhibitor (TFPI), and tissue-type
plasminogen activator (t-PA).
Prostacyclin (PGI2) is an eicosanoid (i.e., a metabolite
of arachidonic acid) that is synthesized and secreted by the
endothelium. By acting through Gs protein-coupled platelet-
surface PGI2 receptors, this metabolite increases cAMP levels
within platelets and thereby inhibits platelet aggregation and
platelet granule release. PGI2 also has potent vasodilatory ef-
fects; this mediator induces vascular smooth muscle relax-
ation by increasing cAMP levels within the vascular smooth
muscle cells. (Note that these mechanisms are physiologically
antagonistic to those of TxA2, which induces platelet activa-
tion and vasoconstriction by decreasing intracellular cAMP
levels.) Therefore, PGI2 both prevents platelets from adhering
to the intact endothelium that surrounds the site of vascular in-
jury and maintains vascular patency around the site of injury.
Antithrombin III inactivates thrombin and other coagu-
lation factors (IXa, Xa, XIa, and XIIa, where a denotes
an activated factor) by forming a stoichiometric complex
with the coagulation factor (Fig. 22-9). These interactions are
ATIII
Heparin
Inactive
coagulation factors
Thrombin Thrombin
ATIII ATIII
Heparin
Xa Xa
ATIII ATIII + Heparin
Heparin
IXa IXa
XIa XIa
XIIa ATIII XIIa ATIII
Heparin
380 Principles of Cardiovascular Pharmacology
Tissue-type or Tissue-type or
urokinase-type
plasminogen
urokinase-type
plasminogen
activator activator
(inactive)
Plasminogen Plasminogen
activator activator
inhibitor 1 or 2 inhibitor 1 or 2
Inactivated
Plasminogen plasmin
Plasmin
+ gen, a plasma protein that is synthesized in the liver. The
fibrin polymer
Fibrin degradation
products
FIGURE 22-10. The fibrinolytic system. Plasmin is formed by the proteolytic
cleavage of plasminogen by tissue-type or urokinase-type plasminogen activator.
Plasmin formation can be inhibited by plasminogen activator inhibitor 1 or 2, which
binds to and inactivates plasminogen activators. In the fibrinolytic reaction, plasmin
cleaves cross-linked fibrin polymers into fibrin degradation products. 2-Antiplasmin,
which circulates in the bloodstream, neutralizes free plasmin in the circulation.
enhanced by a heparin-like molecule that is expressed at the
surface of intact endothelial cells, ensuring that this mecha-
nism is operative at all locations in the vascular tree except
where endothelium is denuded at the site of vascular injury.
(These endothelial cell surface proteoglycans are referred to
as heparin-like because they are the physiologic equivalent
of the pharmacologic agent heparin, discussed below.) Hep-
arin-like molecules on the endothelial cells bind to and acti-
vate antithrombin III, which is then primed to complex with
(and thereby inactivate) the activated coagulation factors.
Protein C and protein S are vitamin K-dependent
proteins that slow the coagulation cascade by inactivat-
ing coagulation factors Va and VIIIa. Protein C and pro-
tein S are part of a feedback control mechanism, in which
excess thrombin generation leads to activation of pro-
tein C, which, in turn, helps to prevent the enlarging fi-
brin clot from occluding the vascular lumen. Specifically,
the endothelial cell-surface protein thrombomodulin is
a receptor for both thrombin and protein C in the blood.
Thrombomodulin binds these proteins in such a way that
thrombomodulin-bound thrombin cleaves protein C to ac-
tivated protein C (also known as protein Ca). In a reaction
that requires the cofactor protein S, activated protein C
then inhibits clotting by cleaving (and thereby inactivat-
ing) factors Va and VIIIa.
Tissue factor pathway inhibitor (TFPI), as its name indi-
cates, limits the action of tissue factor (TF). The coagulation
cascade is initiated when factor VIIa complexes with TF at the
site of vascular injury (Fig. 22-6). The resulting VIIa:TF com-
plex catalyzes the activation of factors IX and X. After limited
quantities of factors IXa and Xa are generated, the VIIa:TF
complex is feedback inhibited by TFPI in a two-step reaction.
First, TFPI binds to factor Xa and neutralizes its activity in a
Ca2-independent reaction. Subsequently, the TFPI:Xa com-
plex interacts with the VIIa:TF complex via a second domain
on TFPI, so that a quaternary Xa:TFPI:VIIa:TF complex is
formed. The molecular knots of the TFPI molecule hold the
quaternary complex tightly together and thereby inactivate the
VIIa:TF complex. In this manner, TFPI prevents excessive
TF-mediated activation of factors IX and X.
Plasmin exerts its anticoagulant effect by proteolytically
cleaving fibrin into fibrin degradation products. Because
plasmin has powerful antithrombotic effects, the formation
of plasmin has intrigued researchers for many years, and a
number of pharmacologic agents have been developed to
target the plasmin formation pathway (Fig. 22-10). Plas-
min is generated by the proteolytic cleavage of plasmino-
proteolytic cleavage is catalyzed by tissue plasminogen
activator (t-PA), which is synthesized and secreted by the
endothelium. Plasmin activity is carefully modulated by
three regulatory mechanisms in order to restrict plasmin ac-
tion to the site of clot formation. First, t-PA is most effective
when it is bound to a fibrin meshwork. Second, t-PA activity
can be inhibited by plasminogen activator inhibitor (PAI).
When local concentrations of thrombin and inflammatory
cytokines (such as IL-1 and TNF-) are high, endothelial
cells increase the release of PAI, preventing t-PA from acti-
vating plasmin. This ensures that a stable fibrin clot forms at
the site of vascular injury. Third, 2-antiplasmin is a plasma
protein that neutralizes free plasmin in the circulation and
thereby prevents random degradation of plasma fibrinogen.
Plasma fibrinogen is important for platelet aggregation in
primary hemostasis (see above), and it is also the precursor
for the fibrin polymer that is required to form a stable clot.
 PATHOGENESIS OF THROMBOSIS
Thrombosis is the pathologic extension of hemostasis. In
thrombosis, coagulation reactions are inappropriately reg-
ulated so that a clot uncontrollably enlarges and occludes
the lumen of a blood vessel. The pathologic clot is now
termed a thrombus. Three major factors predispose to
thrombus formationendothelial injury, abnormal blood
flow, and hypercoagulability. These three factors influence
one another and are collectively known as Virchows triad
(Fig. 22-11).
Endothelial
injury
Thrombosis
Abnormal Hypercoagulability
blood flow
FIGURE 22-11. Virchows triad. Endothelial injury, abnormal blood flow, and
hypercoagulability are three factors that predispose to thrombus formation. These
three factors are interrelated; endothelial injury predisposes to abnormal blood
flow and hypercoagulability, while abnormal blood flow can cause both endothelial
injury and hypercoagulability.
384 Principles of Cardiovascular Pharmacology

Membrane phospholipids

Phospholipase A2
NSAIDs
(aspirin, others)

COOH

Cyclooxygenase Arachidonic acid Lipoxygenase

O COOH OOH

O COOH

OOH
Prostaglandin G2 5-HPETE

Peroxidase Dehydrase

O
O COOH COOH
O

OH
Leukotriene A 4
Prostaglandin H2
Glutathione-
COOH S-transferase
PGI2 synthase Prostaglandin synthases OH
O
COOH
H H
Other
S
prostaglandins
H
OH OH N COOH
HN
Prostacyclin (PGI2) PGE2 synthase
H2N O
O
TxA2 synthase COOH
O
Leukotriene C 4
COOH COOH
O
O
HO OH
OH
Thromboxane A 2 Prostaglandin E2

FIGURE 22-12. Overview of prostaglandin synthesis. Membrane phospholipids are cleaved by phospholipase A2 to release free arachidonic acid. Arachi-
donic acid can be metabolized through either of two major pathways, the cyclooxygenase pathway or the lipoxygenase pathway. The cyclooxygenase pathway,
which is inhibited by aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), converts arachidonic acid into prostaglandins and thromboxanes.
Platelets express TxA2 synthase and synthesize the pro-aggregatory mediator thromboxane A2; endothelial cells express PGI2 synthase and synthesize the
anti-aggregatory mediator prostacyclin. The lipoxygenase pathway converts arachidonic acid into leukotrienes, which are potent inflammatory mediators.
(See Chapter 42, Pharmacology of Eicosanoids, for a detailed discussion of the lipoxygenase and cyclooxygenase pathways.) Aspirin inhibits cyclooxygenase by
covalent acetylation of the enzyme near its active site. Because platelets lack the capability to synthesize new proteins, aspirin inhibits thromboxane synthesis
for the life of the platelet.
 CHAPTER 22 / Pharmacology of Hemostasis and Thrombosis 385

A
Arachidonic acid
NSAIDs Cyclooxygenase
(aspirin, others)

TXA2 (released by activated platelets)

PLC

PIP2 DAG
TXA2-R q PKC
q GTP
(active)

GDP
PKC
IP3

Ca2+

Ca2+

PLA2

GP
IIb
-III
a
Abciximab,
eptifibatide,
tirofiban

Fibrinogen

Thrombin
B
ADP Adenylyl cyclase ADP
Thrombin
Clopidogrel, receptor PLC
ticlopidine,
prasugrel
i
P2Y1 receptor
q q

P2Y(ADP) receptor i GTP
GDP
GTP
GDP ATP q
cAMP
Dipyridamole GDP

PDE
PKA
Platelet activation
AMP

Platelet activation

FIGURE 22-13. Mechanism of action of antiplatelet agents. A. NSAIDs and GPIIbIIIa antagonists inhibit steps in thromboxane A2 (TxA2)-mediated platelet
activation. Aspirin inhibits cyclooxygenase by covalent acetylation of the enzyme near its active site, leading to decreased TxA2 production. The effect is profound because
platelets lack the ability to synthesize new enzyme molecules. GPIIbIIIa antagonists, such as the monoclonal antibody abciximab and the small-molecule antagonists
eptifibatide and tirofiban, inhibit platelet aggregation by preventing activation of GpIIbIIIa (dashed line), leading to decreased platelet cross-linking by fibrinogen.
B. Clopidogrel, ticlopidine, prasugrel, and dipyridamole inhibit steps in ADP-mediated platelet activation. Clopidogrel, ticlopidine, and prasugrel are antagonists of the
P2Y(ADP) receptor. Dipyridamole inhibits phosphodiesterase (PDE), thereby preventing the breakdown of cAMP and increasing cytoplasmic cAMP concentration.
 CHAPTER 22 / Pharmacology of Hemostasis and Thrombosis 387
Anticoagulants
As with antiplatelet agents, anticoagulants are used both to
prevent and treat thrombotic disease. There are four classes of
anticoagulants: warfarin, unfractionated and low-molecular-
weight heparins, selective factor Xa inhibitors, and direct
thrombin inhibitors. Anticoagulants target various factors
in the coagulation cascade, thereby interrupting the cascade
and preventing the formation of a stable fibrin meshwork
(secondary hemostatic plug). In this section, the four classes
of anticoagulants are discussed in order of selectivity, from
the least selective agents (warfarin and unfractionated hepa-
rin) to the most selective agents (selective factor Xa inhibi-
tors and direct thrombin inhibitors). Recombinant activated
protein C also has anticoagulant activity, although its clini-
cal indication is severe sepsis. Because of the mechanisms of
action of these drugs, bleeding is an adverse effect common
to all anticoagulants.
Warfarin
In the early 1900s, farmers in Canada and the North Dakota
plains adopted the practice of planting sweet clover instead
of corn for fodder. In the winter months of 1921 to 1922, a
fatal hemorrhagic disease was reported in cattle that had for-
aged on the sweet clover. In almost every case, it was found
that the affected cattle had foraged on sweet clover that
had been spoiled by the curing process. After an intensive
investigation, scientist K. P. Link reported that the spoiled
clover contained the natural anticoagulant 3,3-methylene-
bis-(4-hydroxycoumarin) or dicumarol. Dicumarol and
warfarin (a potent synthetic congener) were introduced
during the 1940s as rodenticides and as oral anticoagulants.
Because the oral anticoagulants act by affecting vitamin K-
dependent reactions, it is important to understand how vita-
min K functions.
Mechanism of Action of Vitamin K
Vitamin K (K is derived from the German word Koagu-
lation) is required for the normal hepatic synthesis of four
coagulation factors (II, VII, IX, and X), protein C, and pro-
tein S. The coagulation factors, protein C, and protein S
are biologically inactive as unmodified polypeptides fol-
lowing protein synthesis on ribosomes. These proteins gain
biological activity by post-translational carboxylation of
their 9 to 12 amino-terminal glutamic acid residues. The
-carboxylated glutamate residues (but not the unmodi-
fied glutamate residues) are capable of binding Ca2 ions.
Ca2 binding induces a conformational change in these
proteins that is required for efficient binding of the pro-
teins to phospholipid surfaces. The binding of Ca2 to the
-carboxylated molecules increases the enzymatic activity
of coagulation factors IIa, VIIa, IXa, Xa, and protein Ca
by approximately 1,000-fold. Thus, vitamin K-dependent
carboxylation is crucial for the enzymatic activity of the
four coagulation factors and protein C, and for the cofactor
function of protein S.
The carboxylation reaction requires (1) a precursor form
of the target protein with its 9 to 12 amino-terminal glutamic
acid residues, (2) carbon dioxide, (3) molecular oxygen, and
(4) reduced vitamin K. The carboxylation reaction is sche-
matically presented in Figure 22-14. During this reaction,
vitamin K is oxidized to the inactive 2,3-epoxide. An en-
zyme, vitamin K epoxide reductase (also called VKORC1),
is then required to convert the inactive 2,3-epoxide into the
active, reduced form of vitamin K. Thus, the regeneration
of reduced vitamin K is essential for the sustained synthe-
sis of biologically functional clotting factors II, VII, IX, and
X, all of which are critical components of the coagulation
cascade.
Mechanism of Action of Warfarin
Warfarin acts on the carboxylation pathway, not by inhibit-
ing the carboxylase directly, but by blocking the epoxide re-
ductase that mediates the regeneration of reduced vitamin K
(Fig. 22-14). Because depletion of reduced vitamin K in the
liver prevents the -carboxylation reaction that is required
for the synthesis of biologically active coagulation factors,
the onset of action of the oral anticoagulants parallels the
half-life of these coagulation factors in the circulation. Of the
four affected clotting factors (II, VII, IX, and X), factor VII
has the shortest half-life (6 hours). Thus, the pharmacologic
effect of a single dose of warfarin is not manifested for ap-
proximately 1824 hours (i.e., for 34 factor VII half-lives).
This delayed action is one pharmacologic property that dis-
tinguishes the warfarin class of anticoagulants from all the
other classes of anticoagulants.
Evidence from studies of long-term rodenticide use and
of anticoagulant use supports the hypothesis that the epoxide
reductase is the molecular target of oral anticoagulant action.
The use of oral anticoagulants as rodenticides has been a wide-
spread practice in farming communities. In some areas of the
United States, heavy rodenticide use has selected for a popula-
tion of wild rodents that is resistant to 4-hydroxycoumarins. In
vitro studies of tissues from these rodents have demonstrated
a mutation in the rodent epoxide reductase that renders the
enzyme resistant to inhibition by the anticoagulant. Similarly,
a small population of patients is genetically resistant to war-
farin because of mutations in their epoxide reductase gene.
These patients require 1020 times the usual dose of warfarin
to achieve the desired anticoagulant effect. More generally,
genetic variation in the VKORC1 gene has recently been asso-
ciated with approximately 2530% of the variance in warfarin
maintenance dose in patients taking this drug (see Chapter 6,
Pharmacogenomics).
Clinical Uses of Warfarin
Warfarin is often administered to complete a course of anti-
coagulation that has been initiated with heparin (see below)
and to prevent thrombosis in predisposed patients. Orally
administered warfarin is nearly 100% bioavailable, and its
levels in the blood peak at 0.54 hours after administration.
In the plasma, 99% of racemic warfarin is bound to plasma
protein (albumin). Warfarin has a relatively long elimination
half-life (approximately 36 hours). The drug is hydroxy-
lated by the cytochrome P450 system in the liver to inac-
tive metabolites that are subsequently eliminated in the urine
(see Fig. 6-4).
Drugdrug interactions must be carefully considered in
patients taking warfarin. Because warfarin is highly albu-
min-bound in the plasma, co-administration of warfarin with
other albumin-bound drugs can increase the free (unbound)
plasma concentrations of both drugs. In addition, because
warfarin is metabolized by P450 enzymes in the liver, co-
administration of warfarin with drugs that induce and/or
compete for P450 metabolism can affect the plasma concen-
trations of both drugs. Tables 22-2 and 22-3 list some of the
major interactions between warfarin and other drugs.
388 Principles of Cardiovascular Pharmacology

O FIGURE 22-14. Mechanism of action of warfarin. Vitamin

H K is a necessary cofactor in the post-translational carboxylation
O N
N of glutamate residues on factors II, VII, IX, and X. During the
H H carboxylation reaction, vitamin K is oxidized to the inactive 2,3-
N
N COOH epoxide. The enzyme vitamin K epoxide reductase (also called
H VKORC1) converts the inactive vitamin K 2,3-epoxide into the
COOH active, reduced form of vitamin K. The regeneration of reduced
COOH
vitamin K is essential for the sustained synthesis of biologically
Glutamate residue in -Carboxyglutamate residue in functional coagulation factors II, VII, IX, and X. Warfarin acts on
coagulation factor coagulation factor the carboxylation pathway by inhibiting the epoxide reductase
CO2 that is required for the regeneration of reduced (active) vitamin
K. Dicumarol is the natural anticoagulant formed in spoiled clo-
Vitamin K-dependent ver. Both warfarin and dicumarol are orally bioavailable and are
carboxylase often termed oral anticoagulants.

O2

OH O
R R
O

OH O
Vitamin K-reduced Vitamin K 2,3-epoxide
(active form) (inactive form)

Epoxide
reductase

NAD+ NADH

Oral anticoagulants
O

OH OH OH

O OO O O O
Dicumarol Warfarin

Among the adverse effects of warfarin, bleeding is the
most serious and predictable toxicity. Withdrawal of the drug
may be recommended for patients who suffer from repeated
bleeding episodes at otherwise therapeutic drug concen-
trations. For severe hemorrhage, patients should promptly
receive fresh frozen plasma, which contains biologically
functional clotting factors II, VII, IX, and X. Warfarin
should never be administered to pregnant women because it
can cross the placenta and cause a hemorrhagic disorder in
the fetus. In addition, newborns exposed to warfarin in utero
may have serious congenital defects characterized by abnor-
mal bone formation (note that certain bone matrix proteins
are -carboxylated). Rarely, warfarin causes skin necrosis
as a result of widespread thrombosis in the microvascula-
ture. The fact that warfarin can cause thrombosis may seem
paradoxical. Recall that, in addition to inhibiting the synthe-
sis of biologically active coagulation factors II, VII, IX, and
X, warfarin also prevents the synthesis of biologically active
proteins C and S, which are natural anticoagulants. In pa-
tients who are genetically deficient in protein C or protein S
(most commonly, patients who are heterozygous for protein
C deficiency), an imbalance between warfarins effects on
coagulation factors and its effects on proteins C and S may
lead to microvascular thrombosis and skin necrosis.
Because warfarin has a narrow therapeutic index and
participates in numerous drugdrug interactions, the phar-
macodynamic (functional) effect of chronic warfarin ther-
apy must be monitored regularly (on the order of every
24 weeks). Monitoring is most easily performed using
the prothrombin time (PT), which is a simple test of the
390 Principles of Cardiovascular Pharmacology

Anticoagulant class Effect on Thrombin Effect on Factor Xa

Unfractionated heparin

(about 45 saccharide units, Thrombin Xa

MW ~ 13,500) ATIII ATIII

Heparin Heparin

Binds to antithrombin III (ATIII) Binds to antithrombin III (ATIII)

and thrombin via pentasaccharide
(inactivates thrombin) (sufficient to inactivate Xa)

Low molecular weight (LMW) heparins

(about 15 saccharide units, Thrombin Xa

MW ~ 4,500) ATIII ATIII

LMWH LMWH

Binds to antithrombin III (ATIII) Binds to antithrombin III (ATIII)

but not to thrombin via pentasaccharide
(poorly inactivates thrombin) (sufficient to inactivate Xa)

Xa
ATIII
Selective factor Xa inhibitors No effect on thrombin

Fondaparinux
Binds to antithrombin III (ATIII)
via pentasaccharide
(sufficient to inactivate Xa)

Substrate recognition
site (Exosite)

Thrombin Catalytic site

(Active site)
Heparin-
binding
Direct thrombin inhibitors site No effect on Xa
Argatroban

Thrombin

Lepirudin

Thrombin

Selectively inactivate thrombin

FIGURE 22-15. Differential effects of unfractionated heparin, low-molecular-weight heparins, selective factor Xa inhibitors, and direct thrombin inhibitors on
coagulation factor inactivation. Effect on thrombin: To catalyze the inactivation of thrombin, heparin must bind both to antithrombin III via a high-affinity pentasaccharide unit and
to thrombin via an additional 13-saccharide unit. Low-molecular-weight heparin (LMWH) does not contain a sufficient number of saccharide units to bind thrombin, and therefore is a
poor catalyst for thrombin inactivation. Selective factor Xa inhibitors do not inactivate thrombin, while direct thrombin inhibitors selectively inactivate thrombin. Argatroban and dabiga-
tran (not shown ) bind only to the active (catalytic) site of thrombin, while lepirudin and bivalirudin (not shown) bind to both the active site and the substrate-recognition site of thrombin.
Effect on factor Xa: Inactivation of factor Xa requires only the binding of antithrombin III to the high-affinity pentasaccharide unit. Since unfractionated heparin, low-molecular-weight
heparin, and fondaparinux all contain this pentasaccharide, these agents are all able to catalyze the inactivation of factor Xa. Direct thrombin inhibitors have no effect on factor Xa.
392 Principles of Cardiovascular Pharmacology
Thus, direct thrombin inhibitors would be expected to have
profound effects on coagulation. The currently approved
direct thrombin inhibitors include lepirudin, desirudin,
bivalirudin, argatroban, and dabigatran. These agents are
specific inhibitors of thrombin, with negligible anti-factor
Xa activity (Fig. 22-15).
Lepirudin, a recombinant 65-amino-acid polypeptide de-
rived from the medicinal leech protein hirudin, is the pro-
totypical direct thrombin inhibitor. For years, surgeons have
used medicinal leeches to prevent thrombosis in the fine ves-
sels of reattached digits. Lepirudin binds with high affinity
to two sites on the thrombin moleculethe enzymatic active
site and the exosite, a region of the thrombin protein that
orients substrate proteins. Lepirudin binding to thrombin
prevents the thrombin-mediated activation of fibrinogen and
factor XIII. Lepirudin is a highly effective anticoagulant be-
cause it can inhibit both free and fibrin-bound thrombin in
developing clots and because lepirudin binding to thrombin
is essentially irreversible. It is approved for use in the treat-
ment of heparin-induced thrombocytopenia. Lepirudin has
a short half-life, is available parenterally, and is renally ex-
creted. It can be administered with relative safety to patients
with hepatic insufficiency. As with all direct thrombin inhib-
itors, bleeding is the major adverse effect of lepirudin, and
clotting times must be monitored closely. A small percent-
age of patients may develop anti-hirudin antibodies, limiting
the long-term effectiveness of this agent as an anticoagulant.
Another recombinant formulation of hirudin, desirudin, has
been approved for prophylaxis against deep vein thrombosis
in patients undergoing hip replacement.
Bivalirudin is a synthetic 20-amino-acid peptide that,
like lepirudin and desirudin, binds to both the active site and
exosite of thrombin and thereby inhibits thrombin activity.
Thrombin slowly cleaves an arginineproline bond in biva-
lirudin, leading to reactivation of the thrombin. Bivalirudin
is approved for anticoagulation in patients undergoing coro-
nary angiography and angioplasty and may reduce rates of
bleeding relative to heparin for this indication. The drug is
excreted renally and has a short half-life (25 minutes).
Argatroban is a small-molecule inhibitor of thrombin that
is approved for the treatment of patients with heparin-induced
thrombocytopenia. Unlike other direct thrombin inhibitors,
argatroban binds only to the active site of thrombin (i.e., it
does not interact with the exosite). Also unlike other direct
thrombin inhibitors, argatroban is excreted by biliary secre-
tion and can therefore be administered with relative safety to
patients with renal insufficiency. Argatroban has a short half-
life and is administered by continuous intravenous infusion.
Dabigatran is an orally available direct thrombin in-
hibitor that has recently been approved for prevention of
thromboembolism in patients with non-valvular atrial fibril-
lation (i.e., atrial fibrillation not related to mitral stenosis
or a prosthetic heart valve). Dabigatran is a prodrug that is
metabolized to an active species that, like argatroban, binds
competitively to the active site of thrombin. Like other an-
ticoagulants, dabigatran may cause significant bleeding.
One advantage relative to warfarin is that plasma levels of
dabigatran do not need to be monitored.
Recombinant Activated Protein C (r-APC)
As described above, endogenously activated protein C (APC)
exerts an anticoagulant effect by proteolytically cleaving fac-
tors Va and VIIIa. APC also reduces the amount of circulating
plasminogen activator inhibitor 1, thereby enhancing fibrin-
olysis. Finally, APC reduces inflammation by inhibiting the
release of tumor necrosis factor (TNF-) by monocytes.
Because enhanced coagulability and inflammation are both
hallmarks of septic shock, APC has been tested both in ani-
mal models of this disorder and in humans. Recombinant
activated protein C (r-APC) has been found to significantly
reduce mortality in patients at high risk of death from septic
shock, and the U.S. Food and Drug Administration (FDA)
has approved r-APC for the treatment of patients with severe
sepsis who demonstrate evidence of acute organ dysfunc-
tion, shock, oliguria, acidosis, and hypoxemia. r-APC is not
indicated for the treatment of patients with severe sepsis and
a lower risk of death, however. As is the case with other anti-
coagulants, r-APC increases the risk of bleeding. This agent
is therefore contraindicated in patients who have recently un-
dergone a surgical procedure and in those with chronic liver
failure, kidney failure, or thrombocytopenia.
Thrombolytic Agents
Although warfarin, unfractionated and low-molecular-weight
heparins, selective factor Xa inhibitors, and direct throm-
bin inhibitors are effective in preventing the formation and
propagation of thrombi, these agents are generally ineffective
against preexisting clots. Thrombolytic agents are used to
lyse already-formed clots, and thereby to restore the patency
of an obstructed vessel before distal tissue necrosis occurs.
Thrombolytic agents act by converting the inactive zymogen
plasminogen to the active protease plasmin (Fig. 22-10). As
noted above, plasmin is a relatively nonspecific protease that
digests fibrin to fibrin degradation products. Unfortunately,
thrombolytic therapy has the potential to dissolve not only
pathologic thrombi, but also physiologically appropriate fi-
brin clots that have formed in response to vascular injury
(systemic fibrinolysis). Thus, the use of thrombolytic agents
can lead to hemorrhage of varying severity.
Streptokinase
Streptokinase is a protein produced by -hemolytic strep-
tococci as a component of that organisms tissue-destroying
machinery. The pharmacologic action of streptokinase in-
volves two stepscomplexation and cleavage. In the com-
plexation reaction, streptokinase forms a stable, noncovalent
1:1 complex with plasminogen. The complexation reaction
produces a conformational change in plasminogen that ex-
poses this proteins proteolytically active site. Streptokinase-
complexed plasminogen, with its active site exposed and
available, can then proteolytically cleave other plasminogen
molecules to plasmin. In fact, the thermodynamically stable
streptokinase:plasminogen complex is the most catalytically
efficient plasminogen activator in vitro.
Although streptokinase exerts its most dramatic and po-
tentially beneficial effects in fresh thrombi, its use has been
limited by two factors. First, streptokinase is a foreign pro-
tein that is capable of eliciting antigenic responses in hu-
mans upon repeated administration. Previous administration
of streptokinase is a contraindication to its use, because of
the risk of anaphylaxis. Second, the thrombolytic actions
of streptokinase are relatively nonspecific and can result in
systemic fibrinolysis. Currently, streptokinase is approved
for treatment of ST elevation myocardial infarction and for
treatment of life-threatening pulmonary embolism.
 CHAPTER 22 / Pharmacology of Hemostasis and Thrombosis 393
Recombinant Tissue Plasminogen Activator (t-PA)
An ideal thrombolytic agent would be nonantigenic and would
cause local fibrinolysis only at the site of a pathologic throm-
bus. Tissue plasminogen activator (t-PA) approximates these
goals. t-PA is a serine protease produced by human endothe-
lial cells; therefore, t-PA is not antigenic. t-PA binds to newly
formed (fresh) thrombi with high affinity, causing fibrinolysis
at the site of a thrombus. Once bound to the fresh thrombus,
t-PA undergoes a conformational change that renders it a po-
tent activator of plasminogen. In contrast, t-PA is a poor acti-
vator of plasminogen in the absence of fibrin-binding.
Recombinant DNA technology has allowed the production
of recombinant t-PA, generically referred to as alteplase. Re-
combinant t-PA is effective at recanalizing occluded coronary
arteries, limiting cardiac dysfunction, and reducing mortality
following an ST elevation myocardial infarction. At pharma-
cologic doses, however, recombinant t-PA can generate a sys-
temic lytic state and (as with other thrombolytic agents) cause
unwanted bleeding, including cerebral hemorrhage. Thus,
its use is contraindicated in patients who have had a recent
hemorrhagic stroke. Like streptokinase, t-PA is approved for
use in the treatment of patients with ST elevation myocardial
infarction or life-threatening pulmonary embolism. It is also
approved for the treatment of acute ischemic stroke.
Tenecteplase
Tenecteplase is a genetically engineered variant of t-PA.
The molecular modifications in tenecteplase increase its
fibrin specificity relative to t-PA and make tenecteplase
more resistant to plasminogen activator inhibitor 1. Large
trials have shown that tenecteplase is identical in efficacy
to t-PA, with similar (and possibly decreased) risk of bleed-
ing. Additionally, tenecteplase has a longer half-life than
t-PA. This pharmacokinetic property allows tenecteplase to
be administered as a single weight-based bolus, thus sim-
plifying administration.
Reteplase
Similar to tenecteplase, reteplase is a genetically engineered
variant of t-PA with longer half-life and increased specific-
ity for fibrin. Its efficacy and adverse-effect profile are simi-
lar to those of streptokinase and t-PA. Because of its longer
half-life, reteplase can be administered as a double bolus
(two boluses, 30 minutes apart).
Inhibitors of Anticoagulation and Fibrinolysis
Protamine
Protamine, a low-molecular-weight polycationic protein,
is a chemical antagonist of heparin. This agent rapidly
forms a stable complex with the negatively charged hepa-
rin molecule through multiple electrostatic interactions.
Protamine is administered intravenously to reverse the ef-
fects of heparin in situations of life-threatening hemorrhage
or great heparin excess (for example, at the conclusion of
coronary artery bypass graft surgery). Protamine is most
active against the large heparin molecules in unfraction-
ated heparin and it can partially reverse the anticoagulant
effects of low-molecular-weight heparins, but it is inactive
against fondaparinux.
Serine-Protease Inhibitors
Aprotinin, a naturally occurring polypeptide, is an inhibi-
tor of the serine proteases plasmin, t-PA, and thrombin.
By inhibiting fibrinolysis, aprotinin promotes clot stabili-
zation. Inhibition of thrombin may also promote platelet
activity by preventing platelet hyperstimulation. At higher
doses, aprotinin may also inhibit kallikrein and thereby
(paradoxically) inhibit the coagulation cascade. Clinical
trials have demonstrated decreased perioperative bleeding
and erythrocyte transfusion requirement in patients treated
with aprotinin during cardiac surgery. However, these
positive findings have been tempered by recent evidence
suggesting that, compared to other antifibrinolytic agents,
aprotinin may increase the risk of postoperative acute renal
failure.
Lysine Analogues
Aminocaproic acid and tranexamic acid are analogues
of lysine that bind to and inhibit plasminogen and plasmin.
Like aprotinin, these agents are used to reduce periopera-
tive bleeding during coronary artery bypass grafting. Unlike
aprotinin, these agents may not increase the risk of post-
operative acute renal failure.
 CONCLUSION AND FUTURE DIRECTIONS
Hemostasis is a highly regulated process that maintains the
fluidity of blood in normal vessels and initiates rapid forma-
tion of a stable fibrin-based clot in response to vascular in-
jury. Pathologic thrombosis results from endothelial injury,
abnormal blood flow, and hypercoagulability. Antiplatelet
agents, anticoagulants, and thrombolytic agents target dif-
ferent stages of thrombosis and thrombolysis. Antiplatelet
agents interfere with platelet adhesion, the platelet release
reaction, and platelet aggregation; these agents can provide
powerful prophylaxis against thrombosis in susceptible in-
dividuals. Anticoagulants primarily target plasma coagula-
tion factors and disrupt the coagulation cascade by inhibiting
crucial intermediates. After a fibrin clot has been established,
thrombolytic agents mediate dissolution of the clot by pro-
moting the conversion of plasminogen to plasmin. These
classes of pharmacologic agents can be administered either
individually or in combination, to prevent or disrupt throm-
bosis and to restore the patency of blood vessels occluded
by thrombus.
Future development of new antiplatelet, anticoagulant,
and thrombolytic agents will be forced to contend with two
major constraints. First, for many clinical indications in this
field, highly effective, orally bioavailable, and inexpensive
therapeutic agents are already available: these include the
antiplatelet drug aspirin and the anticoagulant warfarin.
Second, virtually every antithrombotic and thrombolytic
agent is associated with the mechanism-based toxicity of
bleeding, and this adverse effect is likely to plague new
agents under development. Nonetheless, opportunities re-
main for the development of safer and more effective ther-
apies. It is likely that pharmacogenomic techniques (see
Chapter 6) will be capable of identifying individuals in the
population who carry an elevated genetic risk of thrombo-
sis, and such individuals may benefit from long-term anti-
thrombotic treatment. Combinations of antiplatelet agents,
low-molecular-weight heparins, orally bioavailable direct
thrombin inhibitors, and new agents that target currently
unexploited components of hemostasis (such as inhibitors
of the factor VIIa/tissue factor pathway) could all be useful
in these settings. At the other end of the spectrum, there
394 Principles of Cardiovascular Pharmacology
remains a great need for new agents that can achieve rapid,
noninvasive, convenient, and selective lysis of acute throm-
boses associated with life-threatening emergencies such as
ST elevation myocardial infarction and stroke. Carefully
designed clinical trials will be critical to optimize the indi-
cations, dose, and duration of treatment for such drugs and
drug combinations.
Suggested Reading
Angiolillo DJ, Bhatt DL, Gurbel PA, Jennings LK. Advances in anti-
platelet therapy: agents in clinical development. Am J Cardiol 2009;
103(3 Suppl):40A51A. (Reviews new antiplatelet agents, including prasu-
grel, cangrelor, ticagrelor, and SCH530348.)
Bates SM, Ginsberg JS. Treatment of deep-vein thrombosis. N Engl
J Med 2004;351:268277. (Reviews treatment options for deep vein
thrombosis.)
Brass LF. The molecular basis for platelet activation. In: Hoffman R, Benz
EJ, Shattil SJ, et al, eds. Hematology: basic principles and practice. 5th ed.
Philadelphia: Churchill Livingstone; 2008. (Detailed and mechanistic de-
scription of platelet activation.)
Di Nisio M, Middeldorp S, Buller HR. Direct thrombin inhibitors. N Engl
J Med 2005;353:10281040. (Reviews mechanism of action and clinical
indications for direct thrombin inhibitors.)
Franchini M, Veneri D, Salvagno GL, et al. Inherited thrombophilia. Crit
Rev Clin Lab Sci 2006;43:249290. (Reviews epidemiology, pathophysiol-
ogy, and treatment of hypercoagulable states.)
Furie B, Furie BC. Mechanisms of thrombus formation. N Engl J Med
2008;359:938949. (Reviews mechanisms of hemostasis and thrombosis.)
Grosser T, Fries S, FitzGerald GA. Biological basis for the cardiovascular
consequences of COX-2 inhibition: therapeutic challenges and opportuni-
ties. J Clin Invest 2006;116:415. (Reviews effects of COX-2 inhibition in
cellular, animal, and human studies.)
Levy JH. Hemostatic agents. Transfusion 2004;44:58S62S. (Reviews
aprotinin, aminocaproic acid, and tranexamic acid.)

Pharmacology of
Cardiac Rhythm
Ehrin J. Armstrong, April W. Armstrong, and David E. Clapham
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 401-402
ELECTRICAL PHYSIOLOGY OF THE HEART . . . . . . . . . . . . . 401
Pacemaker and Nonpacemaker Cells . . . . . . . . . . . . . . . . 401
Cardiac Action Potentials . . . . . . . . . . . . . . . . . . . . . . . . . 402
Determination of Firing Rate . . . . . . . . . . . . . . . . . . . . . . 406
PATHOPHYSIOLOGY OF ELECTRICAL DYSFUNCTION . . . . . . 406
Defects in Impulse Formation (SA Node) . . . . . . . . . . . . . 406
Altered Automaticity . . . . . . . . . . . . . . . . . . . . . . . . . . 406
Triggered Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
Defects in Impulse Conduction . . . . . . . . . . . . . . . . . . . . . 407
Re-entry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
Conduction Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408
Accessory Tract Pathways. . . . . . . . . . . . . . . . . . . . . . 408
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 408
General Mechanisms of Action
of Antiarrhythmic Agents . . . . . . . . . . . . . . . . . . . . . . . . . 408
 INTRODUCTION
The human heart is both a mechanical and an electrical organ.
To perfuse the body adequately with blood, the mechanical and
electrical components of the heart must work in precise concert
with each other. The mechanical component pumps the blood;
the electrical component controls the rhythm of the pump. When
the mechanical component fails despite a normal rhythm, heart
failure can result (see Chapter 25, Integrative Cardiovascular
Pharmacology: Hypertension, Ischemic Heart Disease, and
Heart Failure). When the electrical component goes awry (called
an arrhythmia), cardiac myocytes fail to contract in synchrony,
and effective pumping is compromised. Changes in the mem-
brane potential of cardiac cells directly affect cardiac rhythm,
and most antiarrhythmic drugs act by modulating the activity of
ion channels in the plasma membrane. This chapter discusses
the ionic basis of electric rhythm formation and conduction in
the heart, the pathophysiology of electrical dysfunction, and the
pharmacologic agents used to restore a normal cardiac rhythm.
 ELECTRICAL PHYSIOLOGY OF THE HEART
Electrical activity in the heart, leading to rhythmic cardiac
contraction, is a manifestation of the hearts exquisite control
23
Classes of Antiarrhythmic Agents . . . . . . . . . . . . . . . . . . . 409
Class I Antiarrhythmic Agents:
Fast Na Channel Blockers . . . . . . . . . . . . . . . . . . . . . 409
Class II Antiarrhythmic Agents:
-Adrenergic Antagonists . . . . . . . . . . . . . . . . . . . . . . 413
Class III Antiarrhythmic Agents:
Inhibitors of Repolarization . . . . . . . . . . . . . . . . . . . . . 413
Class IV Antiarrhythmic Agents:
Ca 2 Channel Blockers . . . . . . . . . . . . . . . . . . . . . . . . 415
Other Antiarrhythmic Agents . . . . . . . . . . . . . . . . . . . . 416
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 416
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
of cell depolarization and impulse conduction. Once initi-
ated, a cardiac action potential is a spontaneous event that
proceeds based on the characteristic responses of ion chan-
nels to changes in membrane voltage. At the completion of
a cycle, the spontaneous depolarization of pacemaker cells
ensures that the process repeats without interruption.
Pacemaker and Nonpacemaker Cells
The heart contains two types of cardiac myocytesthose
that can spontaneously initiate action potentials and those
that cannot. Cells possessing the ability to initiate spontane-
ous action potentials are termed pacemaker cells. All pace-
maker cells possess automaticity, the ability to depolarize
above a threshold voltage in a rhythmic fashion. Automa-
ticity results in the generation of spontaneous action poten-
tials. Pacemaker cells are found in the sinoatrial node (SA
node), the atrioventricular node (AV node), and the ventricu-
lar conducting system (bundle of His, bundle branches, and
Purkinje fibers). Together, the pacemaker cells constitute
the specialized conducting system that governs the electri-
cal activity of the heart. The second type of cardiac cells,
the nonpacemaker cells, includes the atrial and ventricular
myocytes. The nonpacemaker cells contract in response to
depolarization and are responsible for the majority of cardiac
401
 CHAPTER 23 / Pharmacology of Cardiac Rhythm 403

myocyte remains near EK until the cell is stimulated by a

A SA node cell wave of depolarization that is initiated by nearby pacemaker
Depolarize
160 cells. The five phases of the ventricular myocyte action po-
ECa tential result from an intricately woven cascade of channel
120 +150 mV openings and closings; the phases are numbered from 0 to 4
(Fig. 23-3 and Table 23-1).
80
ENa
Em (mV)

40 +70 mV
+10
0 Phases of SA Node
Major Currents
Action Potential
Repolarize

-40
-55
Phase 4 If = Pacemaker current, relatively
-80 nonselective. IK1 = Inward
EK
-120 rectifier, outward K+ current
-94 mV
0 100 200 300 400 500 Phase 0 ICa = Inward Ca2+ current
Time (ms)
Phase 3 IK = Delayed rectifier,
outward K+ current
B Ventricular muscle cell
160
Depolarize

ECa Ca2+
K+
120 +150 mV
K+
80 Na+
ENa
+45
Em (mV)

40 +70 mV
A SA node action potential
0 40
Membrane potential (mV)
Repolarize

-40 20
-80 -85
0
EK
-120 ICa
-94 mV IK
0 100 200 300 400 500 -20
Phase 0 Phase 3
Time (ms) -40 IK IK1
1
If Phase 4 If
-60
FIGURE 23-1. SA node and ventricular muscle cell action potentials. 0 150
The resting membrane potential of a sinoatrial (SA) node cell is approximately Time (ms)
55 mV, while that of a ventricular muscle cell is 85 mV. The shaded areas
represent the approximate depolarization required to trigger an action potential in B Ion currents of SA node action potential
each cell type. Together, the cardiac action potentials last for approximately half a 4
second. SA node cells (A) depolarize to a peak of 10 mV, and ventricular muscle IK
cells (B) depolarize to a peak of 45 mV. Note that the ventricular action potential 2
membrane (A/F)

IK1 IK1
Currents across

has a much longer plateau phase. This long plateau ensures that ventricular myo-
cytes have adequate time to contract before the onset of the next action potential. 0
The Nernst equilibrium potentials of the major ions (ECa, ENa, EK) are shown as If
If
dashed horizontal lines. Em, membrane potential. -2

SA node action potential, the kinetics of this depolarization
are modulated by voltage-gated Na channels that are also
expressed in the node. There are gradients of expression of
If channels and of the more selective voltage-gated Na and
Ca2 channels within the SA node, such that cells at the bor-
der of the node express relatively more voltage-gated Na
channels and cells in the center of the node express relatively
more If and voltage-gated Ca2 channels. The expression of
voltage-gated Na channels in the SA node is partly respon-
sible for the effect of certain antiarrhythmics on the automa-
ticity of SA nodal cells (see below).
Unlike SA nodal cells, ventricular myocytes do not de-
polarize spontaneously under physiologic conditions. As
a result, the membrane potential of the resting ventricular
-4 ICa
-6
(Outward currents are +; inward currents are -)
0 150
Time (ms)
FIGURE 23-2. SA node action potential and ion currents. A. SA nodal cells
are depolarized slowly by the pacemaker current (If ) (phase 4), which consists of
an inward flow of sodium (mostly) and calcium ions. Depolarization to the thresh-
old potential opens highly selective voltage-gated calcium channels, which drive
the membrane potential toward ECa (phase 0). As the calcium channels close and
potassium channels open (phase 3 ), the membrane potential repolarizes. B. The
flux of each ion species correlates roughly with each phase of the action potential.
Positive currents indicate an outward flow of ions (blue and purple ), while nega-
tive currents are inward (gray and black ).
PR QT
R
5 mm =
0.5 mV

P T

Q
S
ST
QRS

5 mm = 0.2 second
406 Principles of Cardiovascular Pharmacology
Determination of Firing Rate
The specialized conduction system of the heart consists of
the SA node, AV node, bundle of His, and Purkinje system.
These different populations of cells have different intrin-
sic rates of firing. Three factors determine the firing rate.
First, as the rate of spontaneous depolarization in phase 4
increases, the rate of firing increases because the threshold
potential (the minimum potential necessary to trigger an ac-
tion potential) is reached more quickly at the end of phase 4.
Second, if the threshold potential becomes more negative,
the rate of firing increases because the threshold potential
is reached more quickly at the end of phase 4. Third, if the
maximum diastolic potential (the resting membrane poten-
tial) becomes more positive, the rate of firing increases be-
cause less time is needed to repolarize the membrane fully at
the end of phase 3.
Because the various populations of pacemaker cells pos-
sess different intrinsic rates of firing, the pacemaker popula-
tion with the fastest firing rate sets the heart rate. The SA
node possesses the fastest intrinsic firing rate60100 times
per minuteand is the native pacemaker of the heart. The
cells of the atrioventricular (AV) node and bundle of His fire
intrinsically between 50 and 60 times per minute, and the
cells of the Purkinje system have the slowest intrinsic firing
rate3040 times per minute. The cells of the AV node, bun-
dle of His, and Purkinje system are termed latent pacemak-
ers, because their intrinsic rhythm is overridden by the faster
SA-node automaticity. In a mechanism termed overdrive
suppression, the SA node suppresses the intrinsic rhythm of
the other pacemaker populations and entrains them to fire at
the SA nodal firing rate.
 PATHOPHYSIOLOGY OF ELECTRICAL
DYSFUNCTION
Causes of electrical dysfunction in the heart can be divided
into defects in impulse formation and defects in impulse
conduction. In the former case, SA-node automaticity is in-
terrupted or altered, leading to missed beats or ectopic beats,
respectively. In the latter case, impulse conduction is altered
(for example, in the case of re-entrant rhythms), and sus-
tained arrhythmias can result.
Defects in Impulse Formation (SA Node)
As the native pacemaker of the heart, the SA node has a
pivotal role in normal impulse formation. Electrical events
that alter SA nodal function or disturb overdrive suppression
can lead to impaired impulse formation. Two mechanisms
commonly associated with defective impulse formation are
altered automaticity and triggered activity.
Altered Automaticity
Some mechanisms that alter automaticity of the SA node are
physiologic. In particular, the autonomic nervous system often
modulates automaticity of the SA node as part of a physi-
ologic response. In sympathetic stimulation during exercise,
an increased concentration of catecholamines leads to greater
1-adrenergic receptor activation. Activation of 1 receptors
causes the opening of a greater number of pacemaker chan-
nels (If channels); a larger pacemaker current is then conducted
through these channels; and faster phase 4 depolarization results.
Sympathetic stimulation also causes the opening of a greater
number of Ca2 channels, and thereby shifts the threshold to
more negative potentials. Both of these mechanisms increase
heart rate. The parasympathetic vagus nerve affects the SA
node by a number of mechanisms that oppose the sympathetic
regulation of heart rate. Vagus nerve release of acetylcholine
initiates an intracellular signaling cascade that: (1) reduces the
pacemaker current by decreasing pacemaker channel opening;
(2) shifts the threshold to more positive potentials by reducing
Ca2 channel opening; and (3) makes the maximum diastolic
potential (analogous to the resting membrane potential in these
spontaneously firing cells) more negative by increasing K
channel opening. The SA node, atria, and AV node are highly
innervated and are thus more sensitive than the ventricular con-
ducting system to the effects of vagal stimulation.
In pathologic conditions, automaticity can be altered when
latent pacemaker cells take over the SA nodes role as the
pacemaker of the heart. When the SA nodal firing rate becomes
pathologically slow or when conduction of the SA impulse is
impaired, an escape beat may occur as a latent pacemaker
initiates an impulse. A series of escape beats, known as an
escape rhythm, may result from prolonged SA nodal dys-
function. On the other hand, an ectopic beat occurs when la-
tent pacemaker cells develop an intrinsic rate of firing that is
faster than the SA nodal rate, in some cases despite the pres-
ence of a normally functioning SA node. A series of ectopic
beats, termed an ectopic rhythm, can result from ischemia,
electrolyte abnormalities, or heightened sympathetic tone.
Direct tissue damage (such as can occur after a myocar-
dial infarction) also results in altered automaticity. Tissue
injury can cause structural disruption of the cell membrane.
Disrupted membranes are unable to maintain ion gradients,
which are critical for maintaining appropriate membrane
potentials. If the resting membrane potential becomes suf-
ficiently positive (more positive than 60 mV), nonpace-
maker cells may begin to depolarize spontaneously. Another
mechanism by which tissue damage leads to altered automa-
ticity is through the loss of gap junction connectivity. Direct
electrical connectivity is important for the effective delivery
of overdrive suppression from the SA node to the rest of the
cardiac myocytes. When connectivity is disrupted due to tis-
sue injury, overdrive suppression is not efficiently relayed,
and the unsuppressed cells can initiate their own rhythm.
This abnormal rhythm can lead to cardiac arrhythmia.
Triggered Activity
Afterdepolarizations occur when a normal action potential
triggers extra abnormal depolarizations. That is, the first
(normal) action potential triggers additional oscillations of
membrane potential, which may lead to arrhythmia. There
are two types of afterdepolarizationsearly afterdepolariza-
tions and delayed afterdepolarizations.
If the afterdepolarization occurs during the inciting ac-
tion potential, it is termed an early afterdepolarization
(Fig. 23-5). Conditions that prolong the action potential
(e.g., drugs that prolong the QT interval, such as procain-
amide and ibutilide) tend to trigger early afterdepolariza-
tions. Specifically, an early afterdepolarization can occur
during the plateau phase (phase 2) or the rapid repolariza-
tion phase (phase 3). During the plateau phase, because most
of the Na channels are inactivated, an inward Ca2 cur-
rent is responsible for the early afterdepolarization. On the
other hand, during the rapid repolarization phase, partially
recovered Na channels can conduct an inward Na current
 CHAPTER 23 / Pharmacology of Cardiac Rhythm 407

50
Defects in Impulse Conduction
Early Repetitive
afterdepolarization afterdepolarization
The second type of electrical disturbance of the heart involves
defects in impulse conduction. Normal cardiac function re-
Membrane potential (mV)

quires unobstructed and timely propagation of an electrical

0 impulse through the cardiac myocytes. In pathologic condi-
tions, altered impulse conduction can result from one or a
Na+ channels
combination of three mechanisms: re-entry, conduction block,
Triggered and accessory tract pathways.
recover from
inactivation arrhythmia
-50
Re-entry
Normal cardiac conduction is initiated at the SA node and
propagated to the AV node, bundle of His, Purkinje system,
and myocardium in an orderly fashion. The cellular refrac-
-100 tory period ensures that stimulated regions of the myocar-
0 0.2 0.4 0.6 0.8 dium depolarize only once during propagation of an impulse.
Time (sec) Figure 23-7A depicts normal impulse conduction, in which
an impulse arriving at point a travels synchronously down
two parallel pathways, 1 and 2.
FIGURE 23-5. Early afterdepolarization. Early afterdepolarizations gener- Re-entry of an electrical impulse occurs when a self-
ally occur during the repolarizing phase of the action potential, although they can sustaining electrical circuit stimulates an area of the myocar-
also occur during the plateau phase. Repetitive afterdepolarizations can trigger dium repeatedly and rapidly. Two conditions must be present
an arrhythmia.

Cardiac
action
that contributes to the early afterdepolarization. If an early potential
afterdepolarization is sustained, it can lead to a type of ven- A Normal conduction
tricular arrhythmia termed torsades de pointes. Torsades de
pointes, French for twisting of the points, is characterized
by QRS complexes of varying amplitudes as they twist a Non-excitable area
along the baseline; this rhythm is a medical emergency that
can lead to death if not treated emergently with antiarrhyth- 1 2
mics and/or defibrillation.
In contrast to early afterdepolarizations, delayed afterdepo-
larizations occur shortly after the completion of repolarization
(Fig. 23-6). The mechanism of delayed afterdepolarizations is
not well understood; it has been proposed that high intracellu-
lar Ca2 concentrations lead to an inward Na current, which,
in turn, triggers the delayed afterdepolarization. Cardiac
action
potential Unidirectional
B Re-entrant circuit conduction block
50 Abnormally slow
A delayed afterdepolarization Re-entrant retrograde
a
that reached threshold voltage conduction conduction
Membrane potential (mV)

1 2 (damaged or partially
depolarized cells)
0
Slow upstroke
velocity
b

-50 Delayed
afterdepolarization FIGURE 23-7. Normal and re-entrant electrical pathways. A. In normal im-
pulse conduction, an impulse traveling down a pathway arrives at point a, where it is
able to travel down two alternate pathways, 1 and 2. In the absence of re-entry, the
impulses continue on and depolarize different areas of the ventricle. B. A re-entrant
-100 circuit can develop if one of the branch pathways is pathologically disrupted. When
0 0.2 0.4 0.6 0.8 the impulse arrives at point a, it can travel only down pathway 1 because pathway 2
Time (sec) is blocked unidirectionally (i.e., the effective refractory period of the cells in pathway 2
is prolonged to such an extent that anterograde conduction is prohibited). The impulse
conducts through pathway 1 and proceeds to point b. At this point, the cells in path-
FIGURE 23-6. Delayed afterdepolarization. Delayed afterdepolarizations occur way 2 are no longer refractory, and the impulse conducts in a retrograde fashion up
shortly after repolarization. Although the mechanism has not been firmly elucidated, it pathway 2 toward point a. When the retrograde impulse arrives at point a, it can initiate
appears that intracellular Ca2 accumulation activates the Na/Ca2 exchanger, and re-entry. Re-entry can result in a sustained pattern of rapid depolarizations that trigger
the resulting electrogenic influx of 3 Na for each extruded Ca2 depolarizes the cell. tachyarrhythmias. This mechanism can occur over small or large regions of the heart.
408 Principles of Cardiovascular Pharmacology
for a re-entrant electrical circuit to occur: (1) unidirectional
block (anterograde conduction is prohibited, but retrograde
conduction is permitted); and (2) slowed retrograde con-
duction velocity. Figure 23-7B shows a re-entrant electrical
circuit. As the impulse arrives at point a, it can travel only
down pathway 1 (the left branch), because pathway 2 (the
right branch) is blocked unidirectionally in the anterograde
direction. The impulse conducts through pathway 1 and
travels to point b. At this junction, the impulse travels in a
retrograde fashion up pathway 2 toward point a. The con-
duction time from point b to point a is slowed because of cell
damage or the presence of cells that are still in the refractory
state. By the time the impulse reaches point a, the cells in
pathway 1 have had adequate time to repolarize, and these
cells are stimulated to continue conducting the action poten-
tial toward point b. In this manner, tachyarrhythmias result
from the combination of unidirectional block and decreased
conduction velocity in the abnormal pathway.
Conduction Block
Conduction block occurs when an impulse fails to propagate
because of the presence of an area of inexcitable cardiac tis-
sue. This area of inexcitable tissue could consist of normal
tissue that is still refractory, or it could represent tissue that
has been damaged by trauma, ischemia, or scarring. In either
case, the myocardium is unable to conduct an impulse. Be-
cause conduction block removes overdrive suppression by
the SA node, the cardiac myocytes are free to beat at their
intrinsically slower frequency. For this reason, conduction
block can be manifested clinically as bradycardia.
Accessory Tract Pathways
During the normal cardiac cycle, the SA node initiates an
impulse that travels quickly through the atrial myocardium
and arrives at the AV node. Impulse conduction then slows
through the AV node, allowing sufficient time for filling of
the ventricles with blood before ventricular contraction is
Bundle of His
AV node
SA node Purkinje
fibers
Bypass tract
(Bundle of Kent)
FIGURE 23-8. Bundle of Kent. The bundle of Kent is an accessory electrical
pathway that conducts impulses directly from the atria to the ventricles, bypassing the
AV node. Impulse conduction through this accessory tract is more rapid than conduc-
tion through the AV node, setting up the conditions for re-entrant tachyarrhythmias.
initiated. After the impulse travels through the AV node, it
again propagates quickly throughout the ventricles to trigger
ventricular contraction.
Some individuals possess accessory electrical pathways
that bypass the AV node. One common accessory pathway is
the bundle of Kent, a band of myocardium that conducts im-
pulses directly from the atria to the ventricles, bypassing the
AV node (Fig. 23-8). In these individuals, an impulse originat-
ing in the SA node is conducted through the bundle of Kent
to the ventricles more rapidly than the same impulse would
be conducted through the AV node. Because the bundle of
Kent is an accessory pathway, the ventricular tissue receives
impulses from both the normal conduction pathway and the
accessory pathway. As a result, electrocardiograms from these
individuals typically exhibit a wider-than-normal QRS com-
plex and an earlier-than-normal ventricular upstroke. More
importantly, because the two conduction tracts have different
conduction velocities, the presence of an accessory tract can
set up the conditions for a re-entrant loop, and thereby predis-
pose the individual to tachyarrhythmias.
 PHARMACOLOGIC CLASSES
AND AGENTS
Ion currents across the plasma membrane induce changes in the
membrane potential of cells. Changes in the membrane poten-
tial of cardiac pacemaker cells underlie the timely contraction
of cardiac myocytes. Defects in impulse formation and altered
impulse conduction can lead to disturbances in cardiac rhythm.
Antiarrhythmic agents are used to restore normal cardiac
rhythm by targeting proarrhythmic regions of the heart.
General Mechanisms of Action
of Antiarrhythmic Agents
Although there are many different antiarrhythmic agents, there
are surprisingly few mechanisms of antiarrhythmic action.
In general, drugs that affect cardiac rhythm act by altering:
(1) the maximum diastolic potential in pacemaker cells (and/
or the resting membrane potential in ventricular cells); (2) the
rate of phase 4 depolarization; (3) the threshold potential; or
(4) the action potential duration. The specific effect of a par-
ticular channel blocker follows directly from the role of the
current carried by that channel in the cardiac action potential.
For example, Na and Ca2 channel blockers typically alter
the threshold potential, while K channel blockers tend to pro-
long action potential duration. These drugs generally block the
pore from inside the cell; they can access their sites of action
by either traversing the pore of the channel or diffusing across
the lipid bilayer within which the channel is embedded.
State-dependent ion channel block is an important con-
cept in antiarrhythmic drug action. Ion channels are capable of
switching among various conformational states, and changes
in the permeability of the membrane to a particular ion are
mediated by conformational changes in the channels that pass
that ion. Antiarrhythmic drugs often have different affinities
for different conformational states of the ion channel; that
is, these drugs bind to one conformation of the channel with
higher affinity than they do to other conformations of the chan-
nel. This type of binding is referred to as state-dependent.
Na channel blockers serve as an excellent example to
illustrate the concept of state-dependent ion channel block.
The Na channel undergoes three major state changes
410 Principles of Cardiovascular Pharmacology

(Fig. 23-9). The block of Na channels leaves fewer chan-
nels available to open in response to membrane depolariza-
tion, thereby raising the threshold for action potential firing
and slowing the rate of depolarization. Both of these effects
extend the duration of phase 4, and thereby decrease heart
rate. Furthermore, the shift in threshold potential means that,
in patients with implanted defibrillators who are treated with
Na channel blockers, a higher voltage is needed to defibril-
late the heart. Therefore, it is important to take into account
the effect of Na channel blockers when choosing appropri-
ate settings for implanted defibrillators.
In addition to decreasing SA-node automaticity, Na
channel blockers act on ventricular myocytes to decrease re-
entry. This is achieved mainly by decreasing the upstroke
velocity of phase 0 and, for some Na channel blockers,
by prolonging repolarization (Fig. 23-10). By decreasing
A tential in the SA node, there are important differences in
60
Membrane potential (mV)
phase 0 upstroke velocity, Na channel blockers decrease the
conduction velocity through cardiac tissue. Ideally, conduc-
tion velocity is reduced to such an extent that the propagat-
ing wavefront is extinguished before it is able to restimulate
myocytes in a re-entrant pathway. However, if conduction
velocity is not sufficiently decreased, and the impulse is
not extinguished, then the slowed impulse can support re-
entry as it reaches cells that are no longer refractory (see
above), and thereby precipitate an arrhythmia. In addition to
decreasing phase 0 upstroke velocity, class IA Na channel
blockers prolong repolarization. Prolonged repolarization
increases the effective refractory period, so that cells in a re-
entrant circuit cannot be depolarized by the re-entrant action
potential. In summary, Na channel blockers decrease the
likelihood of re-entry, and thereby prevent arrhythmia, by:
(1) decreasing conduction velocity, and (2) increasing the
refractory period of ventricular myocytes.
Although the three subclasses of class I antiarrhythmics
(class IA, IB, and IC) have similar effects on the action po-
their effects on the ventricular action potential.
Class IA Antiarrhythmics
Class IA antiarrhythmics exert a moderate block on Na

30
channels and prolong the repolarization of both SA nodal
cells and ventricular myocytes. By blocking Na chan-
0 nels, these agents decrease the phase 0 upstroke velocity,
which decreases conduction velocity through the myocar-
-30 Increased dium. Class IA antiarrhythmics also block K channels, and
threshold
thereby reduce the outward K current responsible for re-
Normal threshold polarization of the membrane. This prolongation of repolar-
-60 ization increases the effective refractory period of the cells.
Decreased slope of
phase 4 depolarization Together, the decreased conduction velocity and increased
-90
effective refractory period decrease re-entry.
0 100 200 300 400 500 600 700 Quinidine is often considered the prototypical drug
Time (ms) among the class IA antiarrhythmics, but it is becoming less
B frequently used due to its adverse effects. In addition to the
60 pharmacologic actions described above for all class IA antiar-
rhythmics, quinidine exerts an anticholinergic (vagolytic) ef-
fect, most likely by blocking the K channels that are opened
Membrane potential (mV)

30
upon vagal stimulation of M2 muscarinic receptors in the AV
node (see Fig. 23-9B, Fig. 9-1). The anticholinergic effect
0 is significant clinically because it can increase conduction
velocity through the AV node. Increased AV nodal conduc-
tion can have potentially detrimental effects in patients with
-30
Normal threshold
atrial flutter. Such patients manifest an average atrial firing
rate of 280300 beats per minute. Because some of these im-
-60 pulses reach the AV node while it is still refractory, not all of
Addition of the impulses are transmitted to the ventricles. Therefore, the
ACh or adenosine atria fire much faster than the ventriclesthere is typically
Decreased slope
-90
Hyperpolarization
of phase 4 a 2:1 or 4:1 ratio of atrial to ventricular firing rates. When
depolarization
quinidine is administered to patients with atrial flutter, the
0 100 200 300 400 500 600 700 atrial firing rate decreases because of quinidines pharma-
Time (ms) cologic action in slowing conduction velocity through the
myocardium. At the same time, however, AV nodal conduc-
tion velocity increases because of the vagolytic effects of the
FIGURE 23-9. Effects of class I antiarrhythmics and natural agonists on drug. The increase in AV nodal conduction velocity abolishes
the SA-node action potential. A. The normal SA-node action potential is shown
the 2:1 or 4:1 ratio of atrial to ventricular firing rates, and a
as a solid curve. Class I antiarrhythmics (Na channel blockers) alter SA-node
automaticity by affecting two aspects of the SA nodal action potential: (1) the
1:1 ratio of atrial to ventricular firing rates is often estab-
threshold is shifted to more positive potentials; and (2) the slope of phase 4 lished. For example, with an atrial flutter rate of 300 and 2:1
depolarization is decreased. B. Acetylcholine and adenosine slow the SA nodal AV block, the ventricles are driven at a rate of 150, which
firing rate by opening K channels that hyperpolarize the cell and decrease the most individuals can tolerate. If the flutter rate is slowed to
slope of phase 4 depolarization. 200 and AV conduction is enhanced to 1:1, however, the

Prolonged
repolarization
Moderate Mild Na+
Na+ channel channel block
Membrane potential (mV)
block
Class IA
Time
FIGURE 23-10. Effects of class IA, IB, and IC antiarrhythmics on the ventricular action potential. Class I antiarrhythmics (Na channel blockers) act on ven-
tricular myocytes to decrease re-entry. All subclasses of the class I antiarrhythmics block the Na channel to some degree: class IA agents exhibit moderate Na channel
block, class IB agents rapidly bind to (block) and dissociate from (unblock) Na channels, and class IC agents produce marked Na channel block. Class IA, IB, and IC
agents also differ in the degree to which they affect the duration of the ventricular action potential.
ventricles are driven at a rate of 200, which is usually too fast
for effective ventricular pumping. For this reason, an agent
that slows AV nodal conductionsuch as a -adrenergic an-
tagonist or verapamil (a Ca channel blocker)should be
used in conjunction with quinidine to prevent an excessively
rapid ventricular response in patients with atrial flutter.
The most common adverse effects of quinidine are diar-
rhea, nausea, headache, and dizziness. These effects make it
difficult for patients to tolerate chronic therapy with quini-
dine. Quinidine is contraindicated in patients with QT pro-
longation and in patients who are taking medications that
predispose to QT prolongation, because of the increased risk
of torsades de pointes. Relative contraindications to quini-
dine use include sick sinus syndrome, bundle branch block,
myasthenia gravis (because of quinidines anticholinergic
action), and liver failure.
Quinidine is administered orally and metabolized by cy-
tochrome P450 enzymes in the liver. Quinidine increases
plasma levels of digoxin (an inotropic agent), most likely
by competing for the P450 enzymes that are responsible for
digoxin metabolism. Because digoxin has a narrow thera-
peutic index (see Chapter 24, Pharmacology of Cardiac
Contractility), quinidine-induced digoxin toxicity occurs
in a significant fraction of patients. The plasma potassium
level must be carefully monitored in patients treated with
quinidine, because hypokalemia decreases quinidine effi-
cacy, exacerbates QT prolongation, and, most importantly,
predisposes to torsades de pointes. It is hypothesized that
torsades de pointes is the mechanism most likely responsible
for quinidine-induced syncope. Because of quinidines nu-
merous adverse effects and contraindications, this drug has
largely been replaced by class III agentssuch as ibutilide
and amiodaronefor the pharmacologic conversion of atrial
flutter or atrial fibrillation to normal sinus rhythm.
Procainamide is a class IA antiarrhythmic agent that is
effective in the treatment of many types of supraventricular
and ventricular arrhythmias. Procainamide is often used in the
pharmacologic conversion of new-onset atrial fibrillation to
normal sinus rhythm, although with less efficacy than intra-
venous ibutilide. Procainamide can be used safely to decrease
the likelihood of re-entrant arrhythmias in the setting of acute
CHAPTER 23 / Pharmacology of Cardiac Rhythm 411
Shortened No change in
repolarization repolarization
Marked Na+
channel block
Class IB Class IC
myocardial infarction, even in the presence of decreased car-
diac output. Procainamide can also be administered by slow
intravenous infusion to treat acute ventricular tachycardia.
Unlike quinidine, procainamide has few anticholinergic
effects and does not alter plasma levels of digoxin. Pro-
cainamide can cause peripheral vasodilation via inhibition
of neurotransmission at sympathetic ganglia. With chronic
therapy, almost all patients develop a lupus-like syndrome
and positive antinuclear antibodies; the precise mecha-
nism of this reaction is not known, but it remits if the drug
is discontinued. Procainamide is acetylated in the liver to
N-acetyl-procainamide (NAPA); this active metabolite pro-
duces the pure class III antiarrhythmic effects of prolonging
the refractory period and lengthening the QT interval. NAPA
does not appear to cause the lupus-like adverse effects of
procainamide.
Disopyramide is similar to quinidine in its electrophysi-
ologic and antiarrhythmic effects; the difference between
the two drugs lies in their adverse effects. Disopyramide
causes fewer gastrointestinal problems but has even more
profound anticholinergic effects than quinidine, producing
such adverse effects as urinary retention and dry mouth. The
profound anticholinergic effects of disopyramide appear to
be related to the drugs action as an antagonist at muscarinic
acetylcholine receptors. Disopyramide is contraindicated
in patients with obstructive uropathy or glaucoma. Disopy-
ramide is also contraindicated in patients with conduction
block between the atria and ventricles and in patients with
sinus-node dysfunction. Disopyramide has the prominent
but unexplained effect that it depresses cardiac contractil-
ity, which has led to its use in the treatment of hypertrophic
obstructive cardiomyopathy and neurocardiogenic syncope.
Because of its negative inotropic effects, disopyramide is
absolutely contraindicated in patients with decompensated
heart failure. Oral disopyramide is approved only for the
treatment of life-threatening ventricular arrhythmias; oral or
intravenous disopyramide is sometimes used to convert su-
praventricular tachycardia to normal sinus rhythm. The cur-
rent trend in the treatment of life-threatening arrhythmias,
however, is away from class I antiarrhythmic agents and to-
ward class III agents and electrical devices.
412 Principles of Cardiovascular Pharmacology
Class IB Antiarrhythmics
Class IB antiarrhythmics include lidocaine, mexiletine, and
phenytoin. Lidocaine is the prototypical class IB agent.
These drugs alter the ventricular action potential by block-
ing Na channels and sometimes by shortening repolariza-
tion; the latter effect may be mediated by the drugs ability to
block the few Na channels that inactivate late during phase
2 of the cardiac action potential (Fig. 23-10). In compari-
son to class IA antiarrhythmics, which preferentially bind
to open Na channels, class IB drugs bind to both open and
inactivated Na channels. Therefore, the more time Na
channels spend in the open or inactivated state, the more
blockade the class IB antiarrhythmics can exert. The major
distinguishing characteristic of the class IB antiarrhythmics
is their fast dissociation from Na channels. Because Na
channels recover quickly from class IB blockade, these
drugs are most effective in blocking depolarized or rapidly
driven tissues, where there is a higher likelihood of the Na
channels being in the open or inactivated state. Thus, class
IB antiarrhythmics exhibit use-dependent block in diseased
myocardium, where the cells have a tendency to fire more
frequently; these antiarrhythmics have relatively little effect
on normal cardiac tissue.
Myocardial ischemia provides an example of the therapeu-
tic utility of the use-dependent block exerted by class IB an-
tiarrhythmics. The increase in extracellular H concentration
in ischemic tissue activates membrane pumps that cause an
increase in the extracellular K concentration. This increase
in extracellular K shifts EK to a more depolarized (more
positive) value; for example, EK may shift from 94 mV to
85 mV. The altered electrochemical K gradient provides
a smaller driving force for K ions to flow out of cells, and
depolarization of the membrane leads to a higher likelihood
of action potential firing. Because ischemic cardiac myocytes
tend to fire more frequently, the Na channels spend more
time in the open or inactivated state, serving as a better target
for blockade by class IB antiarrhythmics.
Lidocaine is commonly used to treat ventricular arrhyth-
mias in emergency situations. This drug is not effective in treat-
ing supraventricular arrhythmias. In hemodynamically stable
patients, lidocaine is reserved for treatment of ventricular tach-
yarrhythmias or frequent premature ventricular contractions
(PVCs) that are bothersome or hemodynamically significant.
Lidocaine has a short plasma half-life (approximately
20 minutes), and it is metabolically de-ethylated in the liver.
Its metabolism is governed by two factors, liver blood flow
and liver cytochrome P450 activity. For patients whose liver
blood flow is decreased by old age or heart failure, or whose
P450 enzymes are acutely inhibited, for example, by cimet-
idine (see Chapter 4, Drug Metabolism), a lower dose of lido-
caine should be considered. For patients whose P450 enzymes
are induced by drugs such as barbiturates, phenytoin, or ri-
fampin, the dose of lidocaine should be increased.
Because lidocaine shortens repolarization, possibly by
blocking the few Na channels that inactivate late during
phase 2 of the cardiac action potential, it does not prolong
the QT interval. Therefore, the drug is safe for use in patients
with long QT syndrome. However, because lidocaine also
blocks Na channels in the central nervous system (CNS),
it can produce CNS adverse effects such as confusion,
dizziness, and seizures. In addition to its use as an acute in-
travenous therapy for ventricular arrhythmias, lidocaine is
used as a local anesthetic (see Chapter 11).
Mexiletine, an analogue of lidocaine, is available in oral
formulation. While the efficacy of mexiletine is similar to
that of quinidine, mexiletine does not prolong the QT interval
and it lacks vagolytic effects. In addition, little hemodynamic
depression has been reported with the use of mexiletine. The
primary indication for mexiletine is life-threatening ventricu-
lar arrhythmia. In practice, however, mexiletine is often used
as an adjunct to other antiarrhythmic agents. For example,
mexiletine is used in combination with amiodarone in pa-
tients with implantable cardioverter-defibrillators (ICDs) and
in patients with recurrent ventricular tachycardia. Mexiletine
is also used in combination with quinidine or sotalol to in-
crease antiarrhythmic efficacy while reducing adverse effects.
There are no data supporting reduced mortality with the use of
mexiletine or any of the other class IB antiarrhythmic agents.
Major adverse effects of mexiletine include dose-related
nausea and tremor, which can be ameliorated when the medi-
cation is taken with food. Mexiletine undergoes hepatic me-
tabolism, and its plasma levels may be altered by inducers of
hepatic P450 enzymes such as phenytoin and rifampin.
While phenytoin is usually considered an antiepileptic
medication, its effects on the myocardium also allow it to
be classified as a class IB antiarrhythmic agent. The phar-
macologic properties of phenytoin are discussed in detail
in Chapter 15, Pharmacology of Abnormal Electrical Neu-
rotransmission in the Central Nervous System. Although
the use of phenytoin as an antiarrhythmic agent is limited,
it has been found to be effective in ventricular tachycardia
of young children. Specifically, phenytoin has been used in
the treatment of congenital prolonged QT syndrome when
therapy with -adrenergic antagonists alone has failed; it
is also used to treat ventricular tachycardia after congenital
heart surgery. Phenytoin maintains AV conduction in digox-
in-toxic arrhythmias, and it is especially useful in the rare
patient who has concurrent epilepsy and cardiac arrhythmia.
Phenytoin is an inducer of hepatic enzymes including P450
3A4, and thus affects plasma levels of other antiarrhythmic
agents such as mexiletine, lidocaine, and quinidine.
Class IC Antiarrhythmics
Class IC antiarrhythmics are the most potent Na channel
blockers, and they have little or no effect on action potential
duration (Fig. 23-10). By markedly decreasing the rate of
phase 0 upstroke of ventricular cells, these drugs suppress
premature ventricular contractions. Class IC antiarrhythmics
also prevent paroxysmal supraventricular tachycardia and
atrial fibrillation. However, these drugs have marked depres-
sive effects on cardiac function and, thus, must be used with
discretion. In addition, the CAST (Cardiac Arrhythmia Sup-
pression Trial) and other studies have brought attention to
the proarrhythmic effects of these agents.
Flecainide is the prototypical class IC drug; other
members of this class include encainide, moricizine, and
propafenone. Flecainide illustrates the principle that antiar-
rhythmic agents can also cause arrhythmia. When flecain-
ide is administered to patients with preexisting ventricular
tachyarrhythmias and to those with a history of myocardial
infarction, it can worsen the arrhythmia even at normal
doses. Currently, flecainide is approved for use only in life-
threatening situations; for example, when paroxysmal su-
praventricular or ventricular arrhythmia is unresponsive to
other measures. Flecainide is eliminated very slowly from
the body; it has a plasma half-life of 1230 hours. Because

of its marked blockade of Na channels and its suppressive
effects on cardiac function, flecainide use is associated with
adverse effects that include sinus-node dysfunction, a marked
decrease in conduction velocity, and conduction block.
Class II Antiarrhythmic Agents: -Adrenergic Antagonists
Class II antiarrhythmic agents are -adrenergic antago-
nists (also called -blockers). These agents act by inhib-
iting sympathetic input to the pacing regions of the heart.
(-Adrenergic antagonists are more extensively discussed in
Chapter 10, Adrenergic Pharmacology.) Although the heart
is capable of beating on its own without innervation from the
autonomic nervous system, both sympathetic and parasym-
pathetic fibers innervate the SA node and the AV node, and
thereby alter the rate of automaticity. Sympathetic stimula-
tion releases norepinephrine, which binds to 1-adrenergic
receptors in the nodal tissues. (1-Adrenergic receptors are
the adrenergic subtype preferentially expressed in cardiac
tissue.) Activation of 1-adrenergic receptors in the SA node
triggers an increase in the pacemaker current (If), which in-
creases the rate of phase 4 depolarization and, consequently,
leads to more frequent firing of the node. Stimulation of
1-adrenergic receptors in the AV node increases Ca2 and
K currents, thereby increasing the conduction velocity and
decreasing the refractory period of the node.
1-Antagonists block the sympathetic stimulation of 1-
adrenergic receptors in the SA and AV nodes (Fig. 23-11).
The AV node is more sensitive than the SA node to the
effects of 1-antagonists. 1-Antagonists affect the action
potentials of SA and AV nodal cells by: (1) decreasing the
rate of phase 4 depolarization; and (2) prolonging repolariza-
tion. Decreasing the rate of phase 4 depolarization results in
decreased automaticity, and this, in turn, reduces myocardial
oxygen demand. Prolonged repolarization at the AV node in-
creases the effective refractory period, which decreases the
incidence of re-entry.
60
Tonic
Prolonged
repolarization
Membrane potential (mV)
-adrenergic
30 at AV node
levels
0 action potential, the hyperpolarizing K currents eventu-
-30
Threshold
-60
Decreased slope of phase 4 depolarization
(Block of adrenergic tone)
-90
0 100 200 300 400 500 600
Time (ms)
FIGURE 23-11. Effects of class II antiarrhythmics on pacemaker cell
action potentials. Class II antiarrhythmics (-antagonists) reverse the tonic
sympathetic stimulation of cardiac 1-adrenergic receptors. By blocking the
adrenergic effects on the SA and AV nodal action potentials, these agents de-
crease the slope of phase 4 depolarization (especially important at the SA node)
and prolong repolarization (especially important at the AV node). These agents are
useful in the treatment of supraventricular and ventricular arrhythmias that are
precipitated by sympathetic stimulation.
CHAPTER 23 / Pharmacology of Cardiac Rhythm 413
1-Antagonists are the most frequently used agents in the
treatment of supraventricular and ventricular arrhythmias pre-
cipitated by sympathetic stimulation. 1-Adrenergic antago-
nists have been shown to reduce mortality after myocardial
infarction, even in patients with relative contraindications
to this therapy such as severe diabetes mellitus or asthma.
Because of their wide spectrum of clinical application and es-
tablished safety record, -adrenergic antagonists are the most
useful antiarrhythmic agents currently available.
There are several generations of -antagonists, each
characterized by slightly different pharmacologic properties.
First-generation -antagonists, such as propranolol, are
nonselective -adrenergic antagonists that antagonize both
1-adrenergic and 2-adrenergic receptors. They are widely
used to treat tachyarrhythmias caused by catecholamine
stimulation during exercise or emotional stress. Because
propranolol does not prolong repolarization in ventricular
tissue, it can be used in patients with long QT syndrome.
Second-generation agents, including atenolol, metoprolol,
acebutolol, and bisoprolol, are relatively selective for
1-adrenergic receptors when administered in low doses.
Third-generation -antagonists cause vasodilation in addi-
tion to 1-receptor antagonism. Labetalol and carvedilol
induce vasodilation by antagonizing -adrenergic receptor-
mediated vasoconstriction; pindolol is a partial agonist at the
2-adrenergic receptor; and nebivolol stimulates endothelial
production of nitric oxide.
The different generations of -antagonists produce vary-
ing degrees of adverse effects. Three general mechanisms
are responsible for the adverse effects of -blockers. First,
antagonism at 2-adrenergic receptors causes smooth mus-
cle spasm, leading to bronchospasm, cold extremities, and
impotence. These effects are more commonly caused by the
nonselective first-generation -antagonists. Second, exag-
geration of the therapeutic effects of 1-receptor antagonism
can lead to excessive negative inotropic effects, heart block,
and bradycardia. Third, drug penetration into the CNS can
produce insomnia and depression.
Class III Antiarrhythmic Agents: Inhibitors of Repolarization
Class III antiarrhythmic agents block K channels. Two types
of currents determine the duration of the plateau phase of the
cardiac action potential: inward, depolarizing Ca2 currents
and outward, hyperpolarizing K currents. During a normal
ally dominate, returning the membrane potential to more
hyperpolarized values. Larger hyperpolarizing K currents
shorten plateau duration, returning the membrane potential
to its resting value more rapidly, while smaller hyperpolar-
izing K currents lengthen plateau duration and delay return
of the membrane potential to its resting value.
When K channels are blocked, a smaller hyperpolarizing
700 K current is generated. Therefore, K channel blockers cause

a longer plateau and prolong repolarization (Fig. 23-12). The
ability of K channel blockers to lengthen plateau duration is
responsible for both their pharmacologic uses and their adverse
effects. On the beneficial side, prolongation of the plateau du-
ration increases the effective refractory period, which, in turn,
decreases the incidence of re-entry. On the toxic side, prolon-
gation of the plateau duration increases the likelihood of devel-
oping early afterdepolarizations and torsades de pointes. With
the exception of amiodarone, K channel blockers also exhibit
the undesirable property of reverse use-dependency: action
 50
Block of repolarizing
K+ channels
Membrane potential (mV)

0 Balance of Ca2+
(depolarizing)
and K+
(hyperpolarizing)
currents
-50 Prolonged
repolarization

-100
0 0.2 0.4 0.6 0.8
Time (sec)
 60
Membrane potential (mV)

Slow rise of
30 action potential

-30
Threshold

-60

-90
0 100 200 300 400 500 600 700
Time (ms)

models are used for the majority of ion channel research;
comparatively little is known about the clinical pharmacol-
ogy of ion channels expressed in humans. With the mouse
and human genomes now completely sequenced, research-
ers will be able to investigate the possibility that newly
identified gene products can serve as selective targets for
new therapeutic agents. The identification of ion channel
gene expression in the various tissues of the human heart
(SA node, AV node, atrial conduction pathways, endocar-
dium, ventricular conduction pathways, etc.), both dur-
ing development and in response to injury, may provide
new targets that are not now known. Many of the genes
are likely to encode channels that form heteromultimers,
and there are likely to be many genetic variants within the
population. This enormous complexity will likely represent
a boon to drug development because it will allow more tai-
lored strategies to be employed. For example, current re-
search in atrial fibrillation has focused on the development
of antiarrhythmics selective for ion channels that are ex-
pressed selectively in the atria. In parallel, the development
of implantable computers, stimulators, and defibrillators
CHAPTER 23 / Pharmacology of Cardiac Rhythm 417
will constitute an alternative strategy to prevent or termi-
nate arrhythmias.
Suggested Reading
Ackerman MJ, Clapham DE. Ion channelsbasic science and clinical dis-
ease. N Engl J Med 1997;336:15751586. (Broad review of ion channels.)
Delacretaz E. Clinical practice. Supraventricular tachycardia. N Engl J Med
2006;354:10391051. (Discussion of the clinical uses of antiarrhythmic
agents in treating supraventricular tachycardia.)
Hohnloser SH, Crijns HJ, van Eickels M, et al. Effect of dronedarone on
cardiovascular events in patients with atrial fibrillation. N Engl J Med
2009;360:668678. (Trial of dronedarone suggesting safety in patients with
atrial fibrillation.)
McBride BF. The emerging role of antiarrhythmic compounds with atrial
selectivity in the management of atrial fibrillation. J Clin Pharmacol
2009;49:258267. (Future directions in drug development for treatment of
atrial fibrillation.)
Nash DT, Nash SBD. Ranolazine for chronic stable angina. Lancet 2008;
372:13351341. (Recent review of ranolazine.)
Rudy Y, Silva JR. Computational biology in the study of cardiac ion channels
and cell electrophysiology. Quarterly Rev Biophys 2006;39:57116. (Summa-
rizes the known cardiac ion channels in models of cardiac action potentials.)
24
Pharmacology of Cardiac
Contractility
Ehrin J. Armstrong and Thomas P. Rocco
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 422-423
PHYSIOLOGY OF CARDIAC CONTRACTION . . . . . . . . . . . . . 422
Myocyte Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
Myocyte Contraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
Regulation of Contractility . . . . . . . . . . . . . . . . . . . . . . . . 424
The Sodium Pump and
SodiumCalcium Exchange . . . . . . . . . . . . . . . . . . . . 424
Calcium Storage and Release . . . . . . . . . . . . . . . . . . . 425
Adrenergic Receptor Signaling
and Calcium Cycling . . . . . . . . . . . . . . . . . . . . . . . . . . 426
Sensitivity of Contractile Proteins
to Calcium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
PATHOPHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Cellular Pathophysiology of Contractile Dysfunction . . . . . 427
 INTRODUCTION
In 1785, Dr. William Withering described the cardiovascu-
lar benefits of a preparation from the foxglove plant called
digitalis. He used this preparation to treat patients suffering
from dropsy, a condition in which accumulation of ex-
travascular fluid leads to dyspnea (difficulty breathing) and
peripheral edema. These symptoms are now recognized as
characteristic manifestations of heart failure (HF), a clini-
cal syndrome most commonly caused by systolic dysfunc-
tion of the left ventricle (LV). In this condition, the LV is
unable to maintain adequate stroke volume despite normal
filling volumes, and the LV end-diastolic volume increases
in an effort to preserve stroke output. However, beyond a
certain end-diastolic volume, LV diastolic pressures begin
to increase, often precipitously. This increase in LV dia-
stolic pressure results in increased left atrial and pulmonary
capillary pressures, which, in turn, lead to interstitial and
alveolar pulmonary edema and to increased right heart and
pulmonary artery pressures. The elevated right heart pres-
sures result in systemic venous hypertension and peripheral
edema.
Dr. Witherings use of digitalis presaged the current use of
digoxin, a member of the cardiac glycoside family of drugs,
to treat conditions in which myocardial contractility is im-
paired. Cardiac glycosides are positive inotropes, defined
422
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 429
Cardiac Glycosides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Digoxin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Digitoxin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
-Adrenergic Receptor Agonists . . . . . . . . . . . . . . . . . . . 431
Dopamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
Dobutamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432
Epinephrine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432
Norepinephrine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432
Isoproterenol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432
Phosphodiesterase (PDE) Inhibitors . . . . . . . . . . . . . . . . . 432
Calcium-Sensitizing Agents . . . . . . . . . . . . . . . . . . . . . . . 433
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 433
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
as agents that increase the contractile force of cardiac myo-
cytes. Since the advent of digitalis, elucidation of the cel-
lular mechanism of cardiac contraction has facilitated the
development of other inotropic agents. After reviewing the
physiology of cardiac contraction and the cellular pathophys-
iology of contractile dysfunction, this chapter describes four
classes of positive inotropic drugs that are either approved
for use or under investigation in clinical trials. An integrated
discussion of therapeutic strategies for HF can be found
in Chapter 25, Integrative Cardiovascular Pharmacology:
Hypertension, Ischemic Heart Disease, and Heart Failure.
 PHYSIOLOGY OF CARDIAC CONTRACTION
The heart is responsible for receiving deoxygenated blood
from the periphery, propelling this blood through the pulmo-
nary circulation (where the hemoglobin is reoxygenated), and
ultimately distributing the oxygenated blood to peripheral tis-
sues. To accomplish the latter task, the left ventricle (LV) must
develop sufficient tension to overcome the impedance to ejec-
tion that resides in the peripheral circulation. The relationship
between the tension generated during the systolic phase of the
cardiac cycle and the extent of LV filling during diastole is re-
ferred to as the contractile state of the myocardium. Together
with preload (intraventricular blood volume), afterload
(the resistance against which the left ventricle ejects), and
424 Principles of Cardiovascular Pharmacology

T-tubule

Sarcotubular network
Terminal cisterna Ca2+

T-tubule Ca2+
Sarcolemma
Mitochondrion
Myofibrils

Ca2+

Sarcoplasmic reticulum

Sarcomere

I band A band Z line Z line A band Z line

Actin Myosin

FIGURE 24-1. Cardiac myocyte structure. Each cardiac myocyte contains myofibrils and mitochondria surrounded by a specialized plasma membrane termed the
sarcolemma. Invaginations of the sarcolemma, called T-tubules, provide conduits for Ca2 influx. Within the cell, an extensive sarcoplasmic reticulum stores Ca2 for
use in contraction. Extracellular Ca2 enters through the sarcolemma and its T-tubules during phase 2 of the action potential. This trigger Ca2 binds to channels on the
sarcoplasmic reticulum membrane, causing release into the cytosol of a large pool of so-called activation Ca2. Increased cytosolic Ca2 initiates myofibril contraction.
The sarcomere is the functional unit of the myofibril. Each sarcomere consists of interdigitating bands of actin and myosin. These bands form distinctive structures under
the electron microscope. The A bands correspond to regions of overlapping actin and myosin. The Z lines demarcate the borders of each sarcomere. The I bands span
neighboring sarcomeres and correspond to regions of actin without overlapping myosin. During cardiac myocyte contraction, the I bands become shorter (i.e., the Z lines
approach one another), but the A bands maintain a constant length.

stretch (length) of the muscle exposes additional sites for
calcium binding and for actinmyosin interaction; increased
stretch also effects greater release of calcium from the SR.
These cellular events provide the mechanistic explanation
for the FrankStarling law: an increase in the end-diastolic
volume of the left ventricle leads to an increase in ventricular
stroke volume during systole. Chapter 25 describes the organ-
level implications of the FrankStarling law in more detail.
Regulation of Contractility
Three major control mechanisms regulate calcium cycling
and myocardial contractility in cardiac myocytes. At the sar-
colemma, calcium flux is mediated by interactions between
the sodium pump and sodiumcalcium exchanger. At the sar-
coplasmic reticulum, calcium channels and pumps regulate
the extent of calcium release and reuptake. Neurohumoral
influences, especially the -adrenergic signaling pathway,
further modulate calcium cycling through these channels
and transporters.
The Sodium Pump and SodiumCalcium Exchange
In the sarcolemma, the three key proteins involved in cal-
cium regulation are the Na/K-ATPase, hereafter referred
to as the sodium pump, the sodiumcalcium exchanger,
and the calciumATPase or calcium pump (Fig. 24-3). The
activity of the sodium pump is crucial to maintain both the
resting membrane potential and the concentration gradients
of sodium and potassium across the sarcolemma ([Na]out
145 mM, [Na]in 15 mM, [K]out 5 mM, [K]in
150 mM). Sodium-pump activity is closely linked to the in-
tracellular calcium concentration via the sodiumcalcium
exchanger; this antiporter exchanges sodium and calcium
in both directions across the sarcolemma. Changes in the
concentration of either sodium or calcium ions inside or
outside the cell affect the direction and magnitude of sodi-
umcalcium exchange. Under normal conditions, the low
intracellular sodium concentration favors sodium influx
and calcium efflux. Some drugs take advantage of the func-
tional coupling between the sodium pump and the sodium
calcium exchanger to exert their effect as positive inotropes.
Digoxin, discussed in the introductory case and described
in detail below, is the prototype of an inotropic agent that
acts by inhibiting the sodium pump. A sarcolemmal calcium
pump also helps to maintain calcium homeostasis by ac-
tively extruding calcium from the cytoplasm after cardiac
contraction. A high concentration of ATP favors calcium re-
moval (relaxation), both directly via the calcium pump and
indirectly via the sodium pump.
 Tropomyosin

Actin
filament
TN-I TN-T
Troponin complex TN-C

1
ATP hydrolysis

ATP ADP
P
Myosin

Ca2+ Relaxed Relaxed, energized

4 2
Dissociation of Formation of
actin and myosin active complex
ATP Ca2+

Ca2+ Ca2+ ADP

3 P
Product
dissociation
Rigor complex Active complex
ADP + P
426 Principles of Cardiovascular Pharmacology

A by regulating calcium reuptake into the SR: unphosphorylated

Sarcolemma phospholamban slows relaxation, while phosphorylated phos-
Ca2+ pholamban accelerates relaxation.
1 2 Ca2+ - induced Ca2+ release
T-tubule
Adrenergic Receptor Signaling and Calcium Cycling
1-Adrenoceptor stimulation supports cardiac performance in
several ways. First, -receptor agonists increase -adrenoceptor-
Ca2+ Ca2+ mediated increases in Ca2 entry during systole; increased Ca2
Ca
Ca2+2+ entry increases fractional shortening of cardiac muscle during
Ca2+ contraction. This positive inotropic effect results in a greater
stroke volume for any given end-diastolic volume. -Agonists
also have a positive chronotropic effect, increasing heart rate in
3 Myofibril contraction
a relatively linear dose-dependent manner. The net effect of these
inotropic and chronotropic effects is to increase cardiac output:
free Ca2+

CO HR SV Equation 241

where CO is cardiac output, HR is heart rate, and SV is stroke

volume. A third, but less widely appreciated, mechanism by

B
4 Na+/Ca2+ 5 Na+/K+
exchange ATPase

Ca2+ 3Na+ 3Na+ 2K+ Cardiac

myocyte

Na+/K+ 1-agonist 1-receptor

NCX ATPase
Adenylyl cyclase Ca2+
ATP ADP

Ca2+ 3Na+ 3Na+ 2K+

6
Cytoplasm
Phospholamban ADP s P
Ca2+ P
Ca2+
GTP Ca2+
PKA ATP
SERCA ATP cAMP
Amrinone

Sarcoplasmic Ca2+ Phosphodiesterase

reticulum PKA PKA
inactive active
AMP
Phospholamban
FIGURE 24-3. Regulation of cardiac myocyte Ca2 flux. A. During contrac- ADP
P
tion: 1. Extracellular Ca2 enters the cardiac myocyte through Ca2 channels in the Ca2+
sarcolemma. 2. This trigger Ca2 induces release of Ca2 from the sarcoplasmic
reticulum into the cytosol (so-called Ca2-induced Ca2 release). 3. The increased ATP
cytosolic Ca2 facilitates myofibril contraction. B. During relaxation: 4. The Na/
Ca2 exchanger (NCX) extrudes Ca2 from the cytosol, using the Na gradient as Ca2+
a driving force. 5. The Na/K ATPase (sodium pump) maintains the Na gradient, Sarcoplasmic
thus keeping the cardiac myocyte hyperpolarized. The sodium pump is tonically in- reticulum
hibited by phospholemman; phosphorylation of phospholemman by protein kinase
A (PKA) disinhibits the pump, thereby increasing sodium extrusion and indirectly FIGURE 24-4. Regulation of cardiac contractility by -adrenergic receptors.
enhancing Na/Ca2 exchange (not shown). 6. The sarcoendoplasmic reticulum -Adrenergic receptors increase cardiac myocyte contractility but also enhance relax-
Ca2 ATPase (SERCA) in the sarcoplasmic reticulum membrane is tonically inhib- ation. Binding of an endogenous or exogenous agonist to 1-adrenergic receptors on the
ited by phospholamban. Phosphorylation of phospholamban by PKA disinhibits the surface of cardiac myocytes causes G proteins to activate adenylyl cyclase, which in
Ca2 ATPase, allowing sequestration of cytosolic Ca2 in the sarcoplasmic reticu- turn catalyzes the conversion of ATP to cAMP. cAMP activates multiple protein kinases,
lum. A sarcolemmal Ca2 ATPase (calcium pump) also helps to maintain calcium including protein kinase A (PKA). PKA phosphorylates and activates sarcolemmal Ca2
homeostasis by actively extruding calcium from the cytoplasm (not shown). channels and thereby increases cardiac myocyte contractility. PKA also phosphorylates
phospholamban. The SERCA pump becomes disinhibited and pumps Ca2 into the
sarcoplasmic reticulum; the increased rate of Ca2 sequestration enhances cardiac
A third mediator of SERCA activity is phospholamban, myocyte relaxation. Finally, PKA phosphorylates phospholemman, thereby disinhibiting
an SR membrane protein that inhibits SERCA. High levels of the sarcolemmal sodium pump and enhancing sarcolemmal Na/Ca2 exchange (not
intracellular cAMP stimulate protein kinase A to phosphory- shown ). cAMP is converted to AMP by phosphodiesterase, resulting in termination of 1-
late phospholamban, which reverses its inhibition of SERCA adrenergic receptor-mediated actions. The phosphodiesterase is inhibited by amrinone
(Fig. 24-3). Phospholamban thus controls the rate of relaxation (also known as inamrinone), a drug that can be used in the treatment of heart failure.
428 Principles of Cardiovascular Pharmacology

Normal myocardium Failing myocardium

A Calcium homeostasis

Ca2+ Ca2+ 3Na+ Ca2+ Ca2+ 3Na+

NCX NCX

Ca2+ Ca2+ 3Na+ Ca2+ Ca2+ 3Na+

Phospholamban Phospholamban
ADP
P
Ca2+

ATP

SERCA SERCA
Ca2+
Sarcoplasmic Sarcoplasmic
reticulum reticulum

B Contractile filaments

ATP ADP ATP ADP

Myosin Actin Myosin Actin

P
TN-I TN-T TN-I TN-T
TN-C TN-C

C Adenylyl cyclase signaling pathway

-AR 1-agonist -AR

Adenylyl cyclase Adenylyl cyclase

s s
P P
GTP GTP
P P
ATP cAMP ATP cAMP

-arrestin
PKA PKA PKA PKA
inactive active inactive active

FIGURE 24-5. Cellular mechanisms of contractile pathophysiology. In the failing myocardium, there are derangements in Ca2 homeostasis, the contractile ele-
ments, and the adenylyl cyclase signaling pathway. In each panel (A, B, and C), normal myocardium is shown on the left and failing myocardium on the right. A. In the
normal myocardium, Ca2 homeostasis is tightly controlled by Ca2 channels, including the Na/Ca2 exchanger (NCX) and the Ca2 ATPase (SERCA). Operation of these
pathways allows the myocardium to relax during diastole. In the failing myocardium, diastolic Ca2 remains elevated because phospholamban is not phosphorylated
and therefore tonically inhibits SERCA. Also, the expression of NCX increases (large arrows), so that cytosolic Ca2 is extruded from the cardiac myocyte rather than
stored in the sarcoplasmic reticulum. B. In the normal myocardium, phosphorylation of troponin-I (TN-I) exposes the actinmyosin interaction site, and myosin effectively
hydrolyzes ATP during each contraction cycle. In the failing myocardium, there is decreased phosphorylation of TN-I, resulting in less efficient actinmyosin cross-linking.
Myosin does not hydrolyze ATP as efficiently (dashed arrow), further reducing the effectiveness of each contraction cycle. There is also increased expression of the fetal
isoform of TN-T in the failing myocardium; the significance of this alteration is uncertain. C. In the normal myocardium, -agonists stimulate cAMP formation and subse-
quent activation of protein kinase A (PKA). In the failing myocardium, -arrestin binds to and inhibits the activity of -adrenergic receptors (-AR), leading to decreased
stimulation of adenylyl cyclase (dashed arrows). Expression of the inhibitory G isoform Gi is also induced in the failing myocardium (not shown ).
 2 Ca2+ extrusion 1 Na+ extrusion

Ca2+ 3Na+ 3Na+ 2K+

Sarcolemma Digoxin

Na+/Ca2+ exchanger Na+/K+ -ATPase

Ca2+ 3Na+ 3Na+ 2K+

3 Ca2+ stores 4 Myofibril contraction

ADP
Ca2+ P
stored Ca2+
ATP

Ca2+
released Ca2+

milrinone increase contractility and enhance the rate and
extent of diastolic relaxation. PDE3 inhibitors also have
important vasoactive effects in the peripheral circulation.
These peripheral actions occur through cAMP-mediated ef-
fects on intracellular calcium handling in vascular smooth
muscle and result in decreased arterial and venous tone. In
the systemic arterial circulation, vasodilation leads to a de-
crease in systemic vascular resistance (decreased afterload);
in the systemic venous circulation, an increase in venous ca-
pacitance results in a decrease in venous return to the heart
(decreased preload). The combination of positive inotropy
and mixed arterial and venous dilation has led to the desig-
nation of PDE inhibitors as ino-dilators.
Similar to -agonists, PDE inhibitors have found clinical
utility in short-term support of the severely failing circula-
tion. Widespread application of inamrinone has been limited
by the adverse effect of clinically significant thrombocy-
topenia in about 10% of patients. Oral formulations of PDE3
inhibitors have been developed. Unfortunately, long-term
use of these agents has been limited by data demonstrating
increased mortality.
Calcium-Sensitizing Agents
Calcium-sensitizing drugs, such as levosimendan, are a novel
class of positive inotropes that are under investigation as pos-
sible therapeutic agents. Calcium sensitizers, which have the
same ino-dilator actions as PDE inhibitors, augment myo-
cardial contractility by enhancing the sensitivity of troponin
C to calcium. This potentiating effect increases the extent
of actinmyosin interactions at any given concentration of
intracellular calcium, without a substantial increase in myo-
cardial oxygen consumption. In the peripheral circulation,
levosimendan activates ATP-sensitive K channels, lead-
ing to peripheral vasodilation. Preliminary clinical trial data
suggest that levosimendan improves cardiac hemodynamics
in severe systolic HF and may reduce short-term mortality.
Levosimendan is available in some European countries but is
not currently approved for use in the United States.
 CONCLUSION AND FUTURE DIRECTIONS
Knowledge of the cellular and molecular bases for myocar-
dial contraction has provided several pharmacologic strate-
gies designed to increase myocardial contractility in patients
with heart failure attributable to left ventricular systolic
dysfunction. By inhibiting the sodium pump, digoxin raises
intracellular calcium levels and thereby increases contractile
force. This drug is the only oral inotropic agent in wide clini-
cal use today. Although digoxin has no demonstrable impact
on the mortality of patients with heart failure, it helps alle-
viate symptoms and improves functional capacity. Digoxin
also slows AV nodal conduction, an effect that is useful in
treating patients with atrial fibrillation and rapid ventricu-
lar response rates. The -adrenergic receptor agonists
including the endogenous amines dopamine, norepinephrine,
CHAPTER 24 / Pharmacology of Cardiac C ontractility 433
and epinephrine and the synthetic agents dobutamine and
isoproterenolact through G protein-mediated elevation of
intracellular cAMP to enhance both myocardial contractility
and diastolic relaxation. The latter effect allows the left ven-
tricle to fill adequately during diastole, despite the increase
in heart rate that is stimulated by these agents. -Agonists
are administered intravenously, and they provide short-term
hemodynamic support to patients with cardiogenic circula-
tory failure. The longer-term utility of these agents has been
limited both by the lack of an oral formulation with accept-
able bioavailability and by the adverse-effect profile of these
drugs. PDE inhibitors, including inamrinone and milrinone,
act as positive inotropes and as mixed arterial and venous di-
lators by increasing the levels of cyclic AMP in the heart and
vascular smooth muscle. The increased mortality associated
with longer-term use of these agents has similarly restricted
their role to the short-term management of severe HF.
New classes of pharmacologic agents are under investiga-
tion for their ability to augment myocardial contractility. These
agents are directed at a variety of biochemical targets, includ-
ing the efficiency of actinmyosin interactions (e.g., cardiac
myosin activators) and the synthesis of contractile proteins
(e.g., cardiac neuregulins). These approaches may improve
cardiac contractility without increasing myocardial oxygen
demand or significantly altering calcium signaling. Alterna-
tive strategies attempt to preserve myocardial contractility by
inhibiting the effects of proinflammatory cytokines associated
with HF, but recent trials of these agents, such as endothelin
receptor antagonists, have met with limited success. Finally,
gene therapy methods are being investigated to increase con-
tractility, including the delivery of genes with cardiac-specific
promoters that alter the production of contractile proteins,
channels, and regulators in the heart. At the present time, the
most promising candidates for gene therapy include the SR
calcium pump, phospholamban, and cardiac troponin I.
Suggested Reading
Endoh M. Cardiac calcium signaling and calcium sensitizers. Circ J
2008;72:19151925. (Physiology of excitationcontraction coupling and
pharmacology of investigational agents for treatment of heart failure.)
Gheorghiade M, Adams KF, Colucci WS. Digoxin in the management of
cardiovascular disorders. Circulation 2004;109:29592964. (Reviews the
clinical pharmacology of digoxin.)
Libby P, ed. Braunwalds heart disease: a textbook of cardiovascular medicine.
8th ed. Philadelphia: WB Saunders; 2008. (Encyclopedic reference that in-
cludes a good survey of pharmacologic agents, trials, and new approaches.)
Lilly LS, ed. Pathophysiology of heart disease. 4th ed. Baltimore: Lippincott
Williams & Wilkins; 2008. [Excellent introduction to cardiovascular medi-
cine: Chapters 1 (Basic Cardiac Structure and Function), 9 (Heart Failure),
and 17 (Cardiovascular Drugs) relate to the physiology, pathophysiology,
and pharmacology of contractile function.]
Peterson JW, Felker GM. Inotropes in the treatment of acute heart failure.
Crit Care Med 2008;36:S106S111. (Evidence underlying the use of ino-
tropes, with emphasis on future directions.)
Teerlink JR. A novel approach to improve cardiac performance: cardiac
myosin activators. Heart Fail Rev 2009;14:289298. (One of the possible
future approaches to treatment of acute heart failure.)

Integrative Cardiovascular
Pharmacology: Hypertension,
Ischemic Heart Disease,
and Heart Failure
Ehrin J. Armstrong, April W. Armstrong, and Thomas P. Rocco
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
CASE, PART I: HYPERTENSION . . . . . . . . . . . . . . . . . . . . . . 438
PATHOPHYSIOLOGY OF HYPERTENSION . . . . . . . . . . . . . . . 438
Cardiac Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439
Vascular Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439
Renal Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 440
Neuroendocrine Function . . . . . . . . . . . . . . . . . . . . . . . . . 440
CLINICAL MANAGEMENT OF HYPERTENSION . . . . . . . . . . . 440
Reduction of Intravascular Volume . . . . . . . . . . . . . . . . . . 441
Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
Down-Regulation of Sympathetic Tone . . . . . . . . . . . . . . . 442
-Adrenoceptor Antagonists . . . . . . . . . . . . . . . . . . . . 442
-Adrenoceptor Antagonists . . . . . . . . . . . . . . . . . . . . 443
Central Sympatholytics . . . . . . . . . . . . . . . . . . . . . . . . 443
Modulation of Vascular Smooth Muscle Tone . . . . . . . . . . 443
Ca 2 Channel Blockers . . . . . . . . . . . . . . . . . . . . . . . . 443
K Channel Openers . . . . . . . . . . . . . . . . . . . . . . . . . 443
Modulation of the Renin-AngiotensinAldosterone System . . 444
Renin Inhibitors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444
Angiotensin Converting Enzyme Inhibitors . . . . . . . . . . 444
AT1 Antagonists (Angiotensin Receptor Blockers). . . . . 444
Monotherapy and Stepped Care . . . . . . . . . . . . . . . . . . . . 444
Possible Demographic Factors . . . . . . . . . . . . . . . . . . . . . 445
Hypertensive Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
CASE, PART II: ISCHEMIC HEART DISEASE . . . . . . . . . . . . . 446
PATHOPHYSIOLOGY OF ISCHEMIC HEART DISEASE . . . . . . 446
Chronic Coronary Artery Disease . . . . . . . . . . . . . . . . . . . 446
Coronary Flow Reduction . . . . . . . . . . . . . . . . . . . . . . 447
Endothelial Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . 448
Acute Coronary Syndromes . . . . . . . . . . . . . . . . . . . . . . . 448
CLINICAL MANAGEMENT OF ISCHEMIC HEART DISEASE . . 449
Chronic Coronary Artery Disease . . . . . . . . . . . . . . . . . . . 450
-Adrenoceptor Antagonists . . . . . . . . . . . . . . . . . . . . 450
Ca 2 Channel Blockers . . . . . . . . . . . . . . . . . . . . . . . . 450
Nitrates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
Aspirin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
25
Lipid-Lowering Agents . . . . . . . . . . . . . . . . . . . . . . . . 451
Metabolic Modulators . . . . . . . . . . . . . . . . . . . . . . . . . 452
Unstable Angina and Non-ST Elevation Myocardial Infarction . 452
Antianginal Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
Heparin and Aspirin. . . . . . . . . . . . . . . . . . . . . . . . . . . 453
Glycoprotein IIbIIIa Antagonists . . . . . . . . . . . . . . . . . 453
ADP Receptor Antagonists. . . . . . . . . . . . . . . . . . . . . . 453
Direct Thrombin Inhibitors . . . . . . . . . . . . . . . . . . . . . . 453
ST Elevation Myocardial Infarction . . . . . . . . . . . . . . . . . . 453
Thrombolytics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
Primary Percutaneous Intervention . . . . . . . . . . . . . . . 454
Postmyocardial Infarction Management . . . . . . . . . . . . . . 454
CASE, PART III: HEART FAILURE . . . . . . . . . . . . . . . . . . . . . 455
PATHOPHYSIOLOGY OF HEART FAILURE . . . . . . . . . . . . . . . 455
Etiologies of Contractile Dysfunction . . . . . . . . . . . . . . . . 455
Cardiac Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . 457
FrankStarling Mechanism . . . . . . . . . . . . . . . . . . . . . 457
Cardiac Remodeling and Hypertrophy . . . . . . . . . . . . . 457
Neurohumoral Activation . . . . . . . . . . . . . . . . . . . . . . . 458
CLINICAL MANAGEMENT OF HEART FAILURE . . . . . . . . . . . 458
Preload Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
Aquaretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 460
Aldosterone Receptor Antagonists . . . . . . . . . . . . . . . . 460
Venodilators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
Afterload Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
ACE Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
-Adrenoceptor Antagonists . . . . . . . . . . . . . . . . . . . . 461
Vasodilators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
Inotropic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
Cardiac Glycosides . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
Sympathomimetic Amines . . . . . . . . . . . . . . . . . . . . . 462
Phosphodiesterase Inhibitors . . . . . . . . . . . . . . . . . . . 462
Combination Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 462
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
437
 BP

CO SVR

Direct Circulating Local

HR SV innervation regulators regulators
PSNS Catecholamines NO
SNS ATII Prostacyclin
Catecholamines Endothelin
ATII
O2
H+
Contractility Preload Adenosine
SNS
Catecholamines

Venous tone Intravascular volume

SNS
Catecholamines

Thirst Na+/H2O retention

SNS
Aldosterone
ADH
Natriuretic peptides
 CHAPTER 25 / Integrative Cardiovascular Pharmacology: Hypertension, Ischemic Heart Disease, and Heart Failure 441

CCB Hypertension
BP Direct arterial vasodilators
Pharmacologic
interventions
CO SVR
BP

Direct Circulating Local

HR SV innervation regulators regulators
Baroreceptor Renal
Endothelin
antagonists reflex perfusion
Sodium
Renin inhibitors nitroprusside
Sympathetic Renin
Renin inhibitors
ouflow release
ACE inhibitors Diuretics
AT1 antagonists Renin inhibitors
Contractility Preload ACE inhibitors
AT1 antagonists
Tachycardia, Na+/H2O
contractility retention

Venous tone Intravascular volume

Vasoconstriction BP

Renin inhibitors Na+/H2O retention
Diuretics
Renin inhibitors
ACE inhibitors
AT1 antagonists
FIGURE 25-2. Pharmacologic effects of commonly used antihyperten-
sive agents. Antihypertensive agents modulate blood pressure by interfering with
the determinants of blood pressure. Many of these antihypertensive drugs have
multiple actions. For example, reninangiotensin system blockers, such as ACE
inhibitors and AT1 antagonists, alter the levels of local regulators and circulating
regulators, and affect renal Na retention and venous tone. BP, blood pressure;
CO, cardiac output; SVR, systemic vascular resistance; HR, heart rate; SV, stroke
volume; CCB, Ca2 channel blockers; ACE, angiotensin converting enzyme.
dose adjustments and/or the use of more than one agent to
achieve long-term blood pressure control (Fig. 25-3).
FIGURE 25-3. Compensatory homeostatic responses to antihypertensive
treatment. When blood pressure is lowered by pharmacologic interventions, ho-
meostatic responses are activated to increase blood pressure. These homeostatic re-
sponses can be divided broadly into baroreceptor reflexes and renal perfusion reflexes.
Baroreceptor reflexes originating in the aortic arch and carotid sinus increase sym-
pathetic outflow, leading to tachycardia, increased contractility, and vasoconstriction;
these effects all increase blood pressure. Sympatholytics, such as -antagonists, blunt
the tachycardia and contractility responses by interrupting the sympathetic nervous
system. 1-Antagonists inhibit vasoconstriction but have minimal effects on tachycar-
dia or contractility. Decreased renal perfusion causes increased release of renin from
juxtaglomerular cells of the kidney. Renin then cleaves angiotensinogen to angiotensin
I, which, in turn, is activated to the potent vasoconstrictor angiotensin II (not shown).
Angiotensin II increases adrenal secretion of aldosterone, which acts on principal
cells of the collecting duct to increase Na (and, therefore, water) reabsorption. The
increased Na reabsorption increases intravascular volume, and thereby results in
increased blood pressure. Diuretics interrupt this homeostatic response by decreasing
Na reabsorption from the nephron; renin inhibitors prevent the generation of angio-
tensin I; angiotensin converting enzyme (ACE) inhibitors interrupt the formation of an-
giotensin II; and AT1 antagonists prevent the target-organ signaling of angiotensin II.

Reduction of Intravascular Volume

Diuretics
Although diuretics have long been a cornerstone of antihy-
pertensive therapy, the mechanism of action of diuretics in
hypertension is incompletely understood. As discussed in
Chapter 20, Pharmacology of Volume Regulation, diuretics
decrease intravascular volume by increasing renal excretion
of Na and H2O. However, volume depletion alone is unlikely
to fully explain the antihypertensive effect of diuretics.
Thiazide diuretics (e.g., hydrochlorothiazide) are the
natriuretic drugs most commonly prescribed for the treat-
ment of hypertension (Table 25-3). The pharmacokinetic
and pharmacodynamic characteristics of the thiazides make
them especially useful agents in the treatment of chronic hy-
pertension. Thiazides have high oral availability and long
duration of action. The initial antihypertensive effect seems
to be mediated by decreasing intravascular volume. There-
fore, thiazides are particularly effective in patients with vol-
ume-based hypertension, such as patients with primary renal
disease and African-American patients. Thiazides induce an
initial decrease in intravascular volume that decreases blood
pressure by lowering cardiac output. However, the decrease
in cardiac output stimulates the reninangiotensin system,
which leads to volume retention and attenuation of the effect
of the thiazide on volume status. It is hypothesized that a
vasodilatory effect of the thiazides complements the com-
pensated volume depletion, leading to a sustained decrease
in blood pressure. This hypothesis is supported by the obser-
vation that the maximal antihypertensive effect of the thia-
zides is frequently achieved at doses lower than those needed
to achieve a maximal diuretic effect. Therefore, thiazides
achieve their blood pressure effect by influencing both car-
diac output and systemic vascular resistance.
The Joint National Commission (JNC) Stepped-Care
algorithm suggests thiazide diuretics as the first-line agents
of choice for the majority of patients, unless there is a spe-
cific indication for another antihypertensive drug (such as an
ACE inhibitor in a patient with diabetes). This recommenda-
tion arises from the results of a large-scale trial, which found
favorable outcomes and decreased cost associated with thi-
azide therapy. The practice at present is to initiate thiazide
therapy at low doses (e.g., 12.525 mg/day); this recommen-
dation represents a significant reduction in dose when com-
pared with earlier iterations of the JNC guidelines.
Loop diuretics (e.g., furosemide) are infrequently pre-
scribed for the treatment of mild or moderate hypertension.
These agents typically have a relatively short duration of
 CHAPTER 25 / Integrative Cardiovascular Pharmacology: Hypertension, Ischemic Heart Disease, and Heart Failure 443
the long-term treatment of hypertension. One potential ad-
vantage of this drug is that the decrease in blood pressure
achieved by reduction of systemic vascular resistance (via
antagonism of 1-receptors) is not associated with the re-
flex increase in heart rate or cardiac output (because cardiac
1-receptors are also antagonized) that can occur when pure
vasodilator drugs are used as monotherapy.
In recent years, -adrenoceptor antagonists have been used
less frequently in the initial treatment of hypertension, due to
clinical data suggesting that they may not be as efficacious
as diuretics or inhibitors of the renin-angiotensinaldosterone
system. However, these agents are still important in the treat-
ment of hypertension when there are other clinical indications
for a -adrenoceptor antagonist, such as coronary artery dis-
ease or heart failure. -receptor antagonists are generally effi-
cacious in the treatment of hypertension in younger patients.
-Adrenoceptor Antagonists
1-Adrenergic antagonists (e.g., prazosin, terazosin, dox-
azosin) are also used in the treatment of high blood pressure.
1-Adrenergic antagonists inhibit peripheral vasomotor tone,
reducing vasoconstriction and decreasing systemic vascular re-
sistance. The absence of adverse effects on the serum lipid pro-
file during long-term treatment with 1-adrenergic antagonists
is often cited as a distinctive advantage of these agents relative
to other antihypertensive medications. However, the long-term
benefit of this advantage, if any, remains to be determined in
randomized clinical trials. Furthermore, in a large trial com-
paring different antihypertensives, there was an increased inci-
dence of heart failure in the group randomized to doxazosin.
Nonselective -adrenergic antagonists (e.g., phenoxy-
benzamine, phentolamine) are not employed in the long-
term treatment of hypertension, because excessive com-
pensatory responses can result from their long-term use.
For example, antagonism of central 2-adrenergic receptors
disinhibits sympathetic outflow, resulting in unopposed re-
flex tachycardia. However, these agents are indicated for the
medical treatment of pheochromocytoma.
Central Sympatholytics
The 2-adrenergic agonists methyldopa, clonidine, and
guanabenz reduce sympathetic outflow from the medulla,
leading to decreases in heart rate, contractility, and vaso-
motor tone. These drugs are available in oral formulations
(clonidine is also available as a transdermal patch), and were
widely used in the past despite their unfavorable adverse-
effect profile. The availability of multiple alternative agents,
as well as the current trend toward the use of multidrug regi-
mens at submaximal doses, have substantially diminished the
clinical role of 2-agonists in the treatment of hypertension.
Ganglionic blockers (e.g., trimethaphan, hexamethonium)
inhibit nicotinic cholinergic activity at sympathetic ganglia.
These agents are extremely effective at lowering blood pres-
sure. However, the severe adverse effects of combined para-
sympathetic and sympathetic blockade (e.g., constipation,
blurred vision, sexual dysfunction, and orthostatic hypoten-
sion) have made ganglionic blockers of historic interest only.
Some sympatholytic agents (e.g., reserpine, guanethidine)
are taken up into the terminals of postganglionic adrenergic
neurons, where they induce long-term depletion of neurotrans-
mitter from norepinephrine-containing synaptic vesicles (see
Chapter 10). These agents lower blood pressure by decreas-
ing the activity of the sympathetic nervous system. However,
reserpine and guanethidine have little role in the contemporary
treatment of hypertension because of their significant adverse-
effect profiles, which include severe depression (reserpine) and
orthostatic hypotension and sexual dysfunction (guanethidine).
Modulation of Vascular Smooth Muscle Tone
As discussed in Chapter 21, vascular tone is dependent on the
degree of vascular smooth muscle contraction. Vasodilators re-
duce systemic vascular resistance by acting on arteriolar smooth
muscle and/or the vascular endothelium. The major mecha-
nisms of action of the arterial vasodilators include blockade of
Ca2 channels and opening of metabotropic K channels.
Ca 2 Channel Blockers
Ca2 channel blockers (e.g., verapamil, diltiazem, nifedipine,
amlodipine) are oral agents that are widely used in the long-term
treatment of hypertension. Calcium channel blockers (CCBs)
have a variety of hemodynamic effects, reflecting the multiple
sites at which calcium is involved in the electrical and mechani-
cal events of the cardiac cycle and in vascular regulation. These
agents can act as arterial vasodilators, negative inotropes, and/or
negative chronotropes. The dihydropyridine agents nifedipine
and amlodipine act primarily as vasodilators. In contrast, the
nondihydropyridine drugs verapamil and diltiazem act princi-
pally as negative inotropes and chronotropes, thereby decreas-
ing myocardial contractility, heart rate, and impulse conduc-
tion. Thus, CCBs can lower blood pressure through reduction
of both systemic vascular resistance and cardiac output. CCBs
are often used in combination with other cardioactive drugs,
either as components of a multidrug antihypertensive regimen
or for combined antihypertensive and antianginal treatment in
patients with ischemic heart disease (IHD).
Given the distinctive pharmacodynamic effects of the dif-
ferent CCBs, the potential adverse effects of CCB therapy
(including adverse interactions with other cardiovascular
therapies) are agent-specific. The nondihydropyridine agents
should be used with caution in patients who have impaired
left ventricular (LV) systolic function, as these agents can
exacerbate systolic heart failure (see below). These agents
should also be used with caution in patients with conduction
system disease, as these drugs can potentiate functional ab-
normalities of the sinoatrial (SA) and atrioventricular (AV)
nodes. Both of these cautions are particularly relevant in pa-
tients receiving concomitant -antagonist therapy.
K  Channel Openers
Minoxidil and hydralazine are orally available arterial vaso-
dilators that are occasionally used in the long-term treatment
of hypertension. Minoxidil is a metabotropic K channel
opener that hyperpolarizes vascular smooth muscle cells
and thereby attenuates the cellular response to depolarizing
stimuli. Hydralazine is a less powerful vasodilator with an
uncertain mechanism of action. Both minoxidil and hydrala-
zine can cause compensatory retention of Na and H2O as
well as reflex tachycardia; these adverse effects are more fre-
quent and more severe with minoxidil than with hydralazine.
Concomitant use of a -antagonist and a diuretic can mitigate
these adverse effects. The use of hydralazine is limited by
the frequent occurrence of tolerance and tachyphylaxis to the
drug. In addition, increases in the total daily dose of hydrala-
zine can be associated with a drug-induced lupus syndrome.
Given the more favorable safety profile of the Ca2 chan-
nel blockers, the use of minoxidil is now largely restricted to
 CHAPTER 25 / Integrative Cardiovascular Pharmacology: Hypertension, Ischemic Heart Disease, and Heart Failure 447

Ischemic heart disease This ability to modulate blood flow is referred to as the
coronary flow reserve:

CFR  maximal CBF/resting CBF

where CFR is coronary flow reserve and CBF is coronary

Chronic coronary blood flow. In healthy individuals, the maximal CBF is ap-
Acute coronary
artery disease
(stable angina)
syndromes proximately five-fold greater than the resting CBF. Because
of this wide safety margin, the resting CBF does not de-
crease until an epicardial stenosis exceeds 8090% of the
original arterial diameter. Changes in maximal CBF can be
observed more readily with exercise, as maximal CBF be-
na

fa tion
rc n

n
n
fa tio

tio
gi

tio
gins to decrease during exercise when an epicardial stenosis

l in a
l in va
an

rc
ia lev
ia l e
le

exceeds 5070% of the original arterial diameter. In patients

rd e
rd e
ab

ca T
ca ST

S
st

with chronic CAD, the decrease in CFR is directly related

yo n-
Un

m oN

to the severity of epicardial artery stenosis; the coronary

yo
m
FIGURE 25-4. Classification of ischemic heart disease. Ischemic heart dis-
ease is divided into two broad categories: chronic coronary artery disease and acute
A Normal
coronary syndromes. Stable angina is the prototypical manifestation of chronic cor- Endothelial cell
onary artery disease. Acute coronary syndromes constitute a series (not necessar-
ily a linear progression) of clinical presentations, including unstable angina, non-ST
elevation myocardial infarction, and ST elevation myocardial infarction.
Patent lumen
Lumen Normal endothelial function
Platelet aggregation inhibited
demand, leading to functional cardiac abnormalities (poor
contraction of the ischemic portion of the myocardium) as
well as clinical symptoms of CAD. The basic physiology
of myocardial oxygen supply and demand is discussed in B Stable angina
Chapter 21. Imbalances in myocardial oxygen supply and Plaque
demand occur mainly as a result of coronary flow reduction
and endothelial dysfunction.
Lumen narrowed by plaque
Coronary Flow Reduction Inappropriate vasoconstriction
The coronary vasculature is composed of two types of ves-
sels: large, proximal epicardial vessels, and small, distal en-
docardial vessels. The epicardial vessels are the more frequent
sites of atheroma formation; in disease states, total coronary
artery blood flow is limited by the extent of epicardial vessel C Unstable angina
stenosis. In comparison, endocardial vessels regulate intrinsic Platelet
coronary vascular resistance in response to local metabolic Ruptured
changes. When myocardial oxygen demand is increased, en- plaque Plaque ruptured
docardial vessels dilate in response to local metabolic factors, Platelet aggregation
resulting in a regional increase in myocardial blood flow and Thrombus formation
thereby providing increased oxygen to these metabolically Unopposed vasoconstriction
active tissues. Thrombus
Angina pectoris (Fig. 25-5) is the principal clinical man-
ifestation of chronic CAD. This symptom is characterized by D Variant angina
precordial pressure-like discomfort resulting from myocar-
dial ischemia. Most patients with chronic CAD experience
stable angina, a clinical syndrome in which ischemic chest
No overt plaques
pain occurs at characteristic and reproducible workloads
Intense vasospasm
(e.g., walking up a flight of stairs). Pathologically, chronic
CAD is associated with subintimal deposition of atheroma in
the epicardial coronary arteries. In general, atherosclerotic
plaques in patients with chronic stable angina are character- FIGURE 25-5. Pathophysiology of anginal syndromes. A. Normal coronary
ized by an overlying fibrous cap that is thick and resistant to arteries are widely patent, the endothelium functions normally, and platelet aggrega-
tion is inhibited. B. In stable angina, atherosclerotic plaque and inappropriate vaso-
disruption.
constriction (caused by endothelial damage) reduce the vessel-lumen diameter, and
The immediate cause of angina pectoris is an imbalance hence decrease coronary blood flow. C. In unstable angina, rupture of the plaque trig-
between myocardial oxygen supply and demand. Under gers platelet aggregation, thrombus formation, and vasoconstriction. Depending on
normal physiologic conditions, coronary blood flow is the anatomic site of plaque rupture, this process can progress to non-Q wave (non-ST
modulated carefully to ensure adequate tissue perfusion in elevation) or Q wave (ST elevation) myocardial infarction. D. In variant angina, athero-
response to varying levels of myocardial oxygen demand. sclerotic plaques are absent, and ischemia is caused by intense vasospasm.
448 Principles of Cardiovascular Pharmacology
5 dothelial control of smooth muscle contraction: arterial beds
4 ical exertion triggers activation of the sympathetic nervous
Relative coronary blood flow
Maximal coronary flow
3
2 NO predominate over the vasoconstrictor effects of SNS
Resting coronary flow
1 production of endothelial vasodilators is decreased and cate-
0
0 20 40 60 80 100
Percent occlusion of coronary artery
FIGURE 25-6. Effect of coronary artery occlusion on resting and maximal
coronary blood flow. The dotted line depicts resting coronary blood flow, and
the solid line represents maximal blood flow when there is full dilation of distal
coronary arteries. Comparison of these two lines shows that maximal coronary
blood flow is compromised when the lesion occludes more than about 50% of
the arterial lumen, whereas resting coronary blood flow is relatively unaffected
until the lesion exceeds about 80% of the arterial diameter. The y-axis represents
coronary artery blood flow relative to the flow in a resting coronary artery with
0% occlusion.
flow reserve may be further impaired as a consequence of
endothelial dysfunction (discussed below), resulting in a
further reduction in CBF. During periods in which myocar-
dial oxygen demand exceeds myocardial oxygen delivery,
demand-related ischemia occurs, and the patient experiences
angina pectoris.
The degree of epicardial artery stenosis and the degree
of compensatory endocardial artery dilation determine the
hemodynamic consequence of an atherosclerotic plaque
(Fig. 25-6). If the endocardial arteries are normal, an epicar-
dial stenosis that narrows the diameter of the arterial lumen
by less than 50% does not significantly reduce maximal
coronary blood flow. However, if the stenosis narrows the
arterial lumen diameter by more than 80%, then the endocar-
dial vessels must dilate to provide adequate perfusion to the
myocardium, even at rest. The need for endocardial vessels
to dilate at rest attenuates coronary flow reserve, because
the endocardial vessels cannot then dilate further during
exercise. This reduction in coronary flow reserve leads to
inadequate myocardial blood flow during hyperemic stress.
Myocardial ischemia can occur at rest when the epicardial
artery stenosis exceeds 90% of the lumen diameter: under
these conditions, endocardial vessels cannot maintain ad-
equate myocardial perfusion even at maximal dilation.
Endothelial Dysfunction
Endothelial dysfunction is a general term for pathologic en-
dothelial cell regulation. Clinically, endothelial dysfunction
is manifested by abnormal vascular tone and prothrombotic
properties.
Abnormal vascular tone is a result of dysregulated en-
with endothelial dysfunction cannot dilate in response to
hyperemic stimuli. For example, when mental stress or phys-
system (SNS), two opposing forces act on the coronary vas-
cular endothelium: catecholamine-mediated vasoconstric-
tion and nitric oxide (NO)-mediated vasodilation. Normally,
endothelial release of NO is stimulated by the shear stress
on the coronary vascular endothelium that results from in-
creased blood flow. Eventually, the vasodilator effects of
activation, and the overall effect is coronary vasodilation.
However, when the vascular endothelium is damaged, the
cholamine-mediated vasoconstriction predominates.
Because the endothelium also plays a crucial role in regulat-
ing platelet activation and the coagulation cascade, endothelial
dysfunction can promote blood coagulation (thrombosis) at the
site of endothelial injury. Endothelial-derived NO and pros-
tacyclin exert significant antiplatelet effects, and molecules
on the surface of healthy endothelial cells have significant
anticoagulant properties (see Chapter 22, Pharmacology of
Hemostasis and Thrombosis). Endothelial damage decreases
the ability of the endothelium to utilize these endogenous an-
tiplatelet and anticoagulant mechanisms, leading to a local
predominance of procoagulant factors and increasing the like-
lihood of platelet and coagulation factor activation.
Acute Coronary Syndromes
Acute coronary syndromes (ACS) are most often caused by
the fissuring or rupture of atherosclerotic plaques. These so-
called unstable or vulnerable plaques are characterized by
thin fibrous caps that are prone to rupture. Plaque rupture
results in the exposure of procoagulant factors, such as sub-
endothelial collagen (Fig. 25-7), that activate platelets and
the coagulation cascade. Under physiologic circumstances,
hemostasis at a site of vascular injury is self-limited by
endogenous anticoagulant mechanisms (see Chapter 22).
However, the dysfunctional endothelium overlying the ath-
erosclerotic plaque cannot elaborate sufficient anticoagulant
factors to control the extent of clot formation. Dysregulated
coagulation can then result in intraluminal thrombus forma-
tion, which leads to myocardial ischemia and potentially to
irreversible myocardial injury.
The three subtypes of acute coronary syndromes are un-
stable angina, non-ST elevation MI, and ST elevation MI. In
unstable angina, patients experience either acceleration in
the frequency or severity of chest pain, new-onset anginal
pain, or characteristic anginal chest pain that abruptly oc-
curs at rest. Enzymatic evidence of tissue infarction (e.g.,
elevated troponin levels) is absent in unstable angina, but
patients are at high risk for MI because of the presence of an
active prothrombotic surface at the site of plaque rupture.
Non-ST elevation myocardial infarction occurs when
an unstable plaque abruptly ruptures and significantly com-
promises (but does not completely occlude) the lumen of an
epicardial coronary artery. Because the artery is partially oc-
cluded and there is a persistent prothrombotic surface at the
site of plaque rupture, patients with non-ST elevation MI are
at high risk for recurrence of ischemia. The pathophysiol-
ogy and clinical management of unstable angina and non-ST
 CHAPTER 25 / Integrative Cardiovascular Pharmacology: Hypertension, Ischemic Heart Disease, and Heart Failure 449

A B C D E

FIGURE 25-7. Pathogenesis of acute coronary syndromes. A. A normal coronary artery has an intact endothelium surrounded by smooth muscle cells.
B. Endothelial cell activation or injury recruits monocytes and T lymphocytes to the site of injury, leading to development of a fatty streak. C. Continued oxidative
stress within a fatty streak leads to development of an atherosclerotic plaque. D. Macrophage apoptosis and continued cholesterol deposition cause further plaque
organization, and may induce the expression of additional inflammatory proteins and matrix metalloproteinases. At this stage, the cap of the fibroatheroma remains
intact. E. Continued inflammation within an atherosclerotic plaque leads to thinning of the fibrous cap and, eventually, to plaque erosion or rupture. Exposure of plaque
constituents to the bloodstream activates platelets and the coagulation cascade, with resulting coronary artery occlusion.

elevation MI are very similar, and these two syndromes are
often referred to by the combined acronym unstable angina/
non-ST elevation MI (UA/NSTEMI).
If the intraluminal thrombus completely occludes the
epicardial coronary artery at the site of plaque rupture, then
blood flow ceases downstream from the locus of obstruction.
Persistent, total epicardial artery occlusion provides the sub-
strate for acute myocardial injury (ST elevation myocardial
infarction; STEMI) that will progress inexorably to trans-
mural infarction unless perfusion is reestablished. This clini-
cal syndrome can also present as out-of-hospital sudden
cardiac death (30% of patients); in these cases, death is
usually caused by ischemia-induced electrical instability of
the myocardium. In the absence of fatal electrical instability,
ST elevation MI typically presents with unremitting chest
pain that is often accompanied by dyspnea and ischemic left
heart failure. Mortality in STEMI is significantly reduced by
prompt relief of the complete epicardial obstruction. There-
fore, the principal management goal in STEMI is expeditious
reperfusion of the occluded artery.
The extent of myocardial necrosis following ischemic
injury depends on the mass of myocardium supplied by the
occluded artery, the amount of time over which the artery
is totally occluded, and the degree of collateral circulation.
Regions of the myocardium that are supplied directly and
exclusively by the occluded artery sustain extensive ischemic
injury. Cell death occurs in a wavefront that progresses both
spatially and temporally from the subendocardial region to the
epicardial surface of the myocardium. As a result, the extent
of transmurality of an MI bears a direct relationship to the
duration of coronary artery occlusion. Adjacent to the region
of transmural necrosis, a border zone of myocardium receives
nutrients and oxygen from collateral vessels; this collateral
perfusion can maintain the viability of border-zone cells for
some period of time. However, in the absence of reperfusion
of the occluded (infarct-causing) artery, lethal cardiomyocyte
injury eventually occurs in these border zones as well.
 CLINICAL MANAGEMENT OF ISCHEMIC
HEART DISEASE
As noted above, both the pathophysiology and the clinical
management of ischemic heart disease are different in pa-
tients with chronic coronary artery disease compared to pa-
tients with acute coronary syndromes. Chronic CAD results
from an imbalance between myocardial oxygen supply and
demand, and the treatment of chronic CAD focuses on mod-
ulating this balance, usually by reduction of oxygen demand.
In comparison, treatment of ACS relies on reestablishing and
450 Principles of Cardiovascular Pharmacology
maintaining the patency of the occluded epicardial coronary
artery as rapidly as possible. All patients with CAD, irre-
spective of clinical presentation, also require modification of
underlying risk factors, including aggressive lipid-lowering
therapy and blood pressure control.
Chronic Coronary Artery Disease
The treatment goal in chronic CAD is to restore the balance
between myocardial oxygen supply (coronary artery blood
flow) and myocardial oxygen demand (myocardial oxygen
consumption). Pharmacologic therapies concentrate on the
reduction of myocardial oxygen demand, which is governed
by heart rate, contractility, and ventricular wall stress (see
Chapter 21). Antianginal drugs can be categorized on the
basis of their impact on these parameters.
-Adrenoceptor Antagonists
Activation of 1-adrenergic receptors by the sympathoadre-
nal system leads to an increase in heart rate, contractility,
and conduction through the AV node. It follows that antago-
nists acting at 1-adrenergic receptors decrease sinus rate,
reduce inotropic state, and slow AV nodal conduction.
1-Adrenoceptor antagonists (also referred to as - nism of the 2-adrenergic receptors that mediate dilation of
blockers) are the cornerstone of medical treatment regi-
mens in patients with chronic stable angina. -Antagonists
reduce myocardial oxygen demand by decreasing heart rate
and contractility, and the drug-induced decrease in heart
rate may also increase myocardial perfusion via prolonga-
tion of the diastolic filling time. When used in chronic an-
gina, -antagonists decrease both the resting heart rate and
the peak heart rate achieved during exercise and delay the
time to onset of angina. Dosing regimens for -antagonists
are drug-specific, reflecting the characteristic pharmacoki-
netics of each individual agent. As a general rule, the dose
of drug is calibrated to maintain the resting heart rate at ap-
proximately 50 beats/min and to maintain the peak heart rate
during exertion at approximately 110 to 120 beats/min.
-Antagonists are frequently co-administered with or-
ganic nitrates in patients with stable angina. This combina-
tion is often more effective than either agent used alone.
-Antagonists are also frequently combined with CCBs
typically, with agents of the dihydropyridine class (see
below). (In early clinical trials, short-acting formulations
of the dihydropyridine CCB nifedipine were associated
with reflex tachycardia when administered as monotherapy;
this tachycardia was attenuated when nifedipine was co-
administered with a -antagonist. In current practice, the
availability of long-acting dihydropyridine agents has ef-
fectively diminished this adverse effect.)
Although -antagonists are generally well tolerated in
patients with stable angina, certain clinical scenarios re-
quire caution. Combining -antagonists with CCBs of the
nondihydropyridine classes (e.g., diltiazem or verapamil)
can result in synergistic suppression of SA-node automatic-
ity (leading to extreme sinus bradycardia) and/or AV-node
conduction (leading to high-grade AV conduction block).
Likewise, because of their depressant effects on nodal tis-
sues, -antagonists may exacerbate preexisting bradycardia
and/or high-grade AV block. However, given the clear and
consistent mortality benefit associated with -antagonists in
secondary prevention trials, it is currently standard clinical
practice to implant a permanent transvenous pacing device
if such rhythm abnormalities are the major contraindication
to the use of -antagonists, and then to administer the -
antagonist. (Secondary prevention trials test the efficacy of
pharmacologic interventions to reduce adverse cardiovascu-
lar events in patients with known CAD.)
-Antagonists are now also used in patients with clini-
cally stable heart failure (see below). It must be emphasized
that the survival benefit demonstrated in HF treatment trials
occurred when these agents were initiated during periods of
clinical stability. -Antagonists must not be administered to
patients with decompensated HF.
When used in an attempt to treat the rare patient with pure
vasospastic or variant angina (i.e., angina in the absence of
epicardial artery obstruction; see Fig. 25-5), -antagonists
can induce coronary vasospasm as a consequence of unop-
posed -receptormediated vasoconstriction. -Antagonists
can also exacerbate bronchospasm in patients with asthma
and chronic airway obstruction. However, in such patients,
the decision to exclude -antagonists should be based on
objective documentation of exacerbation of airflow obstruc-
tion during -antagonist therapy. Peripheral vascular disease
is another relative contraindication to -antagonist therapy;
the concern in this circumstance is the potential for antago-
peripheral vessels. In clinical practice, however, this con-
cern is rarely justified. Furthermore, patients with peripheral
arterial disease have an extremely high risk of concomitant
CAD and are therefore likely to benefit significantly from
-antagonist therapy.
Common adverse effects of -antagonists include fatigue,
lethargy, insomnia, and impotence. Although the precise
mechanism of fatigue is unclear, decreased exercise capac-
ity is directly related to drug-induced blunting of the physi-
ologic tachycardia of exercise. The impotence reported by
1% of patients treated with -antagonists is due to inhibition
of 2-adrenoceptormediated peripheral vasodilation.
Ca2 Channel Blockers
Calcium channel blockers (CCBs) decrease the influx of cal-
cium through voltage-gated L-type calcium channels in the
plasma membrane. The resulting decrease in intracellular cal-
cium concentration leads to reduced contraction of both cardiac
myocytes and vascular smooth muscle cells (see Chapter 21).
Calcium channel blockers decrease myocardial oxygen
demand and may also increase myocardial oxygen supply.
Calcium channel blockers decrease myocardial oxygen de-
mand by decreasing systemic vascular resistance and by
decreasing cardiac contractility. In the periphery, calcium
entry into vascular smooth muscle cells is required for con-
traction of the cells and is therefore a central determinant of
resting vasomotor tone. By blocking calcium entry, CCBs
cause relaxation of vascular smooth muscle and thereby
reduce systemic vascular resistance. Calcium channel block-
ers can theoretically increase myocardial oxygen supply by
blocking calcium-mediated increases in coronary vasomotor
tone; the resulting dilation of epicardial vessels and arteriolar
resistance vessels would, in theory, increase coronary blood
flow. However, the contribution of this coronary vasodila-
tor mechanism to the clinical effects of the CCBs is contro-
versial, because regional metabolic abnormalities that result
from myocardial ischemia should effect a maximal vasodila-
tor response in the absence of pharmacologic modulation.
The different classes of calcium channel blockers have dis-
tinctive inotropic effects on cardiac myocytes. Compared to
452 Principles of Cardiovascular Pharmacology

Metabolic Modulators latter circumstance, management strategies appropriate for

Some patients with stable angina continue to experience
frequent angina despite maximal attempts at medical man-
agement and revascularization. In these cases, metabolic
modulators that increase the efficiency of ATP utilization
may be clinically useful. In this class of drugs, ranolazine
is approved for the second-line treatment of refractory an-
gina despite otherwise maximal therapy. Clinical trials of
ranolazine in stable angina have demonstrated improved ef-
fort tolerance and decreased frequency of anginal symptoms
relative to placebo. Other metabolic modulators remain an
active area of investigation and drug development.
Unstable Angina and Non-ST Elevation
Myocardial Infarction
Unstable angina (UA) and non-ST elevation myocardial
infarction (NSTEMI) may occur as the first presentation of
CAD or in patients with a history of stable CAD. (In the
unstable angina take precedence over those for stable CAD.)
It is estimated that, in the absence of treatment, patients with
UA have a 1520% risk of progression to acute MI over a pe-
riod of 46 weeks. Aggressive treatment can reduce this risk
by more than 50%. Patients with UA have no overt evidence
of myocardial damage, whereas patients with NSTEMI have
elevated biomarkers that reflect cardiomyocte necrosis. Un-
treated UA may progress to NSTEMI, or NSTEMI may be
the initial result of plaque rupture with extensive inflamma-
tion and coagulation at the rupture site.
Goals of treatment in UA/NSTEMI are to relieve ischemic
symptoms and to prevent additional thrombus formation at
the site of plaque rupture. UA/NSTEMI is typically treated
with aspirin, heparin, and -antagonists. Other antiplatelet
agents (GPIIbIIIa antagonists and ADP receptor antago-
nists) and/or direct thrombin inhibitors (bivalirudin) are in-
dicated in high-risk patients to prevent additional thrombus
formation (Fig. 25-8). Although conventional antianginal

Ischemic heart disease

Chronic coronary artery disease

Acute coronary syndromes
(stable angina)

Aspirin Aspirin
-Antagonists -Antagonists
Nitrates Nitrates
Ca2+ channel blockers
ACE inhibitors
Ranolazine

No ST elevation on ECG: ST elevation on ECG:

Unstable angina or non-ST elevation ST elevation myocardial infarction
myocardial infarction

Thrombolysis Angioplasty

Add: Heparin Add: Thrombolytic agent Add: Heparin

GPIIb-IIIa antagonist
ADP receptor antagonist
or
Bivalirudin
ADP receptor antagonist
Heparin GPIIb-IIIa antagonist
ADP receptor antagonist ADP receptor antagonist
or
Bivalirudin
ADP receptor antagonist

Post-myocardial infarction management

Possible addition of: Statin

ACE inhibitor
Aldosterone receptor antagonist
Continue : Aspirin
ADP receptor antagonist

FIGURE 25-8. Pharmacologic management of acute coronary syndromes. All patients with chronic coronary artery disease are given aspirin unless a life-threatening
contraindication is present. -Antagonists, nitrates, calcium channel blockers, ACE inhibitors, and ranolazine are primarily used to reduce myocardial oxygen demand. All patients
with symptoms that raise concerns about a possible acute coronary syndrome are given aspirin and, if tolerated, a -antagonist. Sublingual or intravenous nitrates can also be
given to relieve chest discomfort and minimize ischemia. Electrocardiographic (ECG) findings of ST elevation should prompt emergency measures to open the occluded artery,
either with a thrombolytic agent (thrombolysis) or mechanical revascularization (angioplasty). Additional adjunctive pharmacologic therapies for ST elevation myocardial infarc-
tion may include aspirin, -antagonists, nitrates, heparin, ADP receptor antagonists, and GPIIbIIIa antagonists or bivalirudin. For patients with acute coronary syndrome but no
ST elevation on the electrocardiogram, laboratory assays of myocyte damage (e.g., troponin I or troponin T) determine whether the patient is classified as experiencing unstable
angina or non-ST elevation myocardial infarction. In either case, management generally includes administration of aspirin, -antagonists, nitrates, ADP receptor antagonists,
and bivalirudin or heparin with GPIIbIIIa antagonists. For all patients with acute coronary syndrome, postmyocardial infarction management should include modification of risk
factors; possible addition of lipid-lowering agents (statins), ACE inhibitors, and aldosterone receptor antagonists; and continuation of aspirin and ADP receptor antagonists.
456 Principles of Cardiovascular Pharmacology
Additional causes of systolic HF include chronic abnormali-
ties of the loading conditions imposed on the heart, such as
systemic arterial hypertension (pressure loading) and valvu-
lar heart disease (volume loading from mitral regurgitation or
aortic insufficiency; pressure loading from aortic stenosis).
The contractile performance of the myocardium is initially
preserved in disease states associated with abnormal load-
ing conditions, but cardiomyocyte injury and whole-organ
contractile dysfunction supervene if the abnormal loading
conditions are not corrected. The latter phase of cardiac
pump dysfunction has been referred to as cardiomyopathy of
chronic overload. Systolic dysfunction can also result from
diverse conditions in which the proximate pathologic abnor-
mality is cardiomyocyte injury or dysfunction. These condi-
tions are referred to as dilated cardiomyopathies, because
the heart characteristically remodels to produce LV chamber
dilation (with or without wall thinning) in states of primary
myocyte dysfunction.
Symptomatic HF can also occur in patients with normal or
near-normal LV systolic function (i.e., preserved LV ejection
fraction). In such cases, the symptoms of left HF are caused
by abnormalities of LV relaxation and/or filling (diastolic
heart failure). Impaired relaxation results in an elevation of
LV diastolic pressure at any given filling volume. This eleva-
tion of LV diastolic pressure causes elevation of left atrial
and pulmonary capillary pressures, leading to transudation of
fluid into the pulmonary interstitium (as well as secondary, or
passive, elevation of pulmonary artery and right heart pres-
sures). The most common acute cause of isolated diastolic
HF is acute myocardial ischemia. In the setting of acute re-
versible ischemia (i.e., ischemia not associated with MI), LV
diastolic pressures increase as a consequence of incomplete
LV relaxation. (Recall from the discussion in Chapter 24,
Pharmacology of Cardiac Contractility, that both contraction
and relaxation of cardiomyocytes depend on adequate levels
of intracellular ATP.)
Both systolic and diastolic HF can be understood by con-
sidering the determinants of cardiac performance and the
pathophysiologic conditions that affect these parameters.
Although diastolic dysfunction is now appreciated as a com-
mon cause of clinical heart failure, the balance of this section
will deal principally with heart failure due to systolic dys-
function. Each of the major factors affecting stroke volume
preload, afterload, and contractilitycan be described by
its effect on cardiac function curves. Figure 25-9 illustrates
a normal LV pressure-volume loop. In the normal cycle, LV
volume increases when the mitral valve opens during diastole.
Isovolumetric contraction begins when LV pressure exceeds
left atrial pressure and the mitral valve closes; during this seg-
ment of the cardiac cycle, intraventricular pressure increases
while intracavitary volume remains constant. Ejection begins
when the impedance to LV ejection is exceeded and the aortic
valve opens; ejected blood is then transmitted to the systemic
circulation by the elastic properties of the aorta. The aortic
valve closes when LV pressure falls below aortic pressure; at
this point, intraventricular pressure decreases rapidly (isovol-
umetric relaxation), up to (and perhaps beyond) the point at
which the mitral valve opens, and the cycle is repeated.
As illustrated in Figure 25-10A, the forward stroke vol-
ume ejected by the LV depends on the degree of LV filling
during diastole, or preload. This fundamental relationship
between preload and stroke volume is the FrankStarling
law; it derives from the relationship between muscle length
Ventricular emptying
AV closes
ESP AV opens
LV Pressure (mm Hg)
Relaxation Stroke volume Contraction
EDP MV closes
MV opens
Ventricular filling
ESV EDV
LV Volume (ml)
FIGURE 25-9. Normal left ventricular pressure-volume loop. Mitral valve
(MV ) opening allows the left ventricular (LV ) volume to increase as the chamber
fills with blood during diastole. When ventricular pressure exceeds left atrial pres-
sure, the mitral valve closes. During the isovolumetric phase of systolic contrac-
tion, the left ventricle generates a high pressure, which eventually forces open
the aortic valve (AV ). Ejection of the stroke volume ensues, and the aortic valve
closes when aortic pressure exceeds LV pressure. Isovolumetric relaxation returns
the ventricle to its lowest pressure state, and the cycle is repeated. Stroke volume
(i.e., the volume of blood ejected with each contraction cycle) is the difference
between end-diastolic volume (EDV ) and end-systolic volume (ESV ). EDP, end-
diastolic pressure; ESP, end-systolic pressure.
and degree of muscle shortening, as described in Chapter 24.
In brief, increased diastolic volume increases myocardial
fiber length. As a result, a higher fraction of the actin fila-
ment length is exposed in each sarcomere and is thereby
available for myosin cross-bridge formation when the car-
diomyocyte is depolarized.
Impedance to LV ejection, or afterload, is the second de-
terminant of stroke volume (Fig. 25-10B). As impedance to
ejection (afterload) increases, the stroke output of the ven-
tricle falls. This characteristic of the intact heart derives from
the fact that increasing the resistance against which cardiac
muscle must contract leads to a decrease in the extent of
shortening (i.e., to reduced stroke volume). Because the sen-
sitivity of stroke volume to outflow resistance is accentuated
in the failing ventricle, agents that decrease afterload are
able to increase LV stroke volume in patients with systolic
HF (see below).
A third determinant of cardiac performance is contractility,
also described in Chapter 24. The contractile state of the LV is
described by the end-systolic pressure-volume relationship
(ESPVR, Fig. 25-10C). The ESPVR is, in effect, a variant of
the FrankStarling law. While the FrankStarling law defines
the relationship between LV diastolic volume (or preload) and
LV stroke volume (or cardiac output), the ESPVR describes
the relationship between diastolic filling volume and LV ten-
sion development during isovolumetric contraction. As shown
in Figure 25-10C, an increase in the contractile state of the LV,
reflected by an upward shift of the ESPVR, results in a greater
degree of tension development for any given end-diastolic
volume. In the presence of a fixed afterload, increased con-
tractility results in a greater degree of muscle shortening and
an increase in LV stroke volume.
 CHAPTER 25 / Integrative Cardiovascular Pharmacology: Hypertension, Ischemic Heart Disease, and Heart Failure 457

A B C

ESPVR ESPVR-2
ESPVR-1
LV Pressure (mm Hg)

ESV 3

1 2 3 2 1

EDV

LV Volume (ml)

FIGURE 25-10. Determinants of cardiac output. Changes in preload, afterload, and myocardial contractility alter the pressure-volume relationship of the cardiac
cycle. A. Increases in preload (lines 1, 2, 3) result in greater stretch of ventricular myocytes, development of greater ventricular end-diastolic pressure, and ejection of
greater stroke volume (the FrankStarling mechanism). Note that the end-systolic volume (ESV ) is the same in each case, because the contractility of the heart has
not changed. B. Increases in afterload (points 1, 2, 3) create greater impedance to left ventricular output and result in proportionately decreased stroke volume (the
difference between end-diastolic volume [EDV ] and ESV ). The end-systolic pressure is linearly related to ESV; this linear relationship is called the end-systolic pressure-
volume relationship (ESPVR ). C. Increases in myocardial contractility (lines 1, 2), as occurs after administration of a positive inotrope, shift the ESPVR up and to the left,
resulting in increased stroke volume.

A final determinant of cardiac pump performance is heart
rate. However, if LV contractile performance is preserved,
then impairment of cardiac output occurs as a consequence
of abnormal heart rate only at extreme rates outside the
physiologic range. Heart rate can be an important determi-
nant of cardiac output in patients with systolic contractile
dysfunction.
Cardiac Compensation
As the ability of the myocardium to maintain normal for-
ward output fails, compensatory mechanisms are activated
to preserve circulatory function. The FrankStarling mecha-
nism increases stroke volume in direct response to increased
preload. This recruitment of preload reserve is the first re-
sponse of the system to hemodynamic stress. Hemodynamic
stress that cannot be fully compensated by the FrankStarling
mechanism stimulates signaling systems that initiate struc-
tural changes at the cellular level, a process referred to as
remodeling of the myocardium. Although the underlying
stimuli for remodeling remain an active area of investigation,
it has been noted that the specific pattern of remodeling is
determined by the nature of the applied stress. If the Frank
Starling mechanism and remodeling mechanisms are unable
to reestablish adequate forward cardiac output, neurohumoral
systems are then activated. These systems modulate intravas-
cular volume and vasomotor tone to maintain oxygen deliv-
ery to critical organs. Although each of these compensatory
mechanisms contributes to the maintenance of circulatory
function, each may also contribute to the development and
progression of pump dysfunction and circulatory failure, as
described below.
FrankStarling Mechanism
In the intact heart, increased preload leads to increased stroke
volume via the FrankStarling mechanism. This mechanism
remains operative in the failing heart; importantly, though,
the relationship between end-diastolic volume and stroke
volume is altered. In patients with systolic dysfunction, the
relationship between end-diastolic volume and stroke volume
is characterized by a flatter plateau (Fig. 25-11). Therefore,
unlike normal individuals who are operating on the ascending
limb of the Starling curve, where volume expansion can be a
useful strategy for increasing stroke volume, the majority of
patients with heart failure operate with elevated intravascu-
lar volume. This increased intravascular volume reflects the
end result of neurohumoral activation (i.e., the sympatho-
adrenal axis and the renin-angiotensinaldosterone system;
see below). Thus, the treatment of cardiogenic circulatory
failure rarely involves volume expansion. It also merits em-
phasis that preload expansion can result in significant LV
dilation, thereby increasing LV systolic and diastolic wall
stress and exacerbating pulmonary congestion.
Cardiac Remodeling and Hypertrophy
In the setting of increased myocardial wall stress, cardiac
hypertrophy develops in order to maintain ventricular sys-
tolic performance. Because LV ejection fraction is inversely
proportional to wall stress, adaptations that decrease systolic
wall stress increase LV ejection fraction. Laplaces law states
that wall stress () is directly proportional to the pressure (P)
and radius (R) of a chamber, and inversely proportional to
wall thickness (h):
  P  R/2h Equation 25-1
In cases of chronic pressure overload, such as aortic
stenosis or systemic hypertension, the LV develops a con-
centric pattern of hypertrophy as contractile proteins and
new sarcomeres are added in parallel to the existing myofil-
aments. Concentric hypertrophy simultaneously increases
wall thickness (h) and decreases cavity size (R), resulting in
a net reduction in systolic wall stress and thereby preserv-
ing systolic performance. The disadvantage of concentric
remodeling derives from the decrease in LV compliance that
occurs as a consequence of this pattern of hypertrophy. In a
ventricle with reduced compliance, diastolic pressure in the
458 Principles of Cardiovascular Pharmacology

Symptoms of high Symptoms of high

end-diastolic pressure end-diastolic pressure

Normal Normal
Cardiac output

Cardiac output
HF with HF with
positive inotrope ACE inhibitor
D
F
Afterload reduction
A E Untreated HF Untreated HF
C C
G Preload
reduction
B

Ventricular end-diastolic pressure Symptoms of low Ventricular end-diastolic pressure Symptoms of low
cardiac output cardiac output

FIGURE 25-11. The FrankStarling relationship in heart failure (HF). Left panel: The normal FrankStarling relationship shows a steep increase in cardiac
output with increasing ventricular end-diastolic pressure (preload). Point A describes the end-diastolic pressure and cardiac output of a normal heart under resting
conditions. With contractile dysfunction (untreated HF), cardiac output falls ( B ) and the FrankStarling curve flattens, so that increasing preload translates to only a
modest increase in cardiac output ( C ). This increase in cardiac output is accompanied by symptoms of high end-diastolic pressure, such as dyspnea. Treatment with
a positive inotrope, such as digitalis, shifts the FrankStarling curve upward, and cardiac output increases ( D ). The improvement in myocardial contractility supports a
sufficient reduction in preload that the venous congestion is relieved ( E ). Right panel: Two of the principal pharmacologic treatments of HF are afterload reduction (e.g.,
ACE inhibitors) and preload reduction (e.g., diuretics). Afterload reduction ( F ) increases cardiac output at any given preload, and thereby elevates the FrankStarling
relationship. Preload reduction ( G ) alleviates congestive symptoms by decreasing ventricular end-diastolic pressure along the same FrankStarling curve.

chamber is increased at any given filling volume. This in
turn leads to elevation of LA and pulmonary capillary pres-
sures, thereby predisposing to congestive symptoms.
In conditions of chronic volume overload, such as mitral
or aortic regurgitation, the LV develops an eccentric pattern
of hypertrophy as contractile proteins and new sarcomeres
are added in series to the existing myofilaments. Eccentric
hypertrophy helps to maintain cardiac performance via
modulation of diastolic wall stress. In contrast to the situ-
ation that occurs after concentric remodeling, eccentric hy-
pertrophy is associated with increased LV compliance. The
increase in compliance allows LV end-diastolic volume to
increase without a significant elevation in left ventricular
and left atrial diastolic pressures. This attenuation of the rise
in chamber pressure allows the system to maintain forward
cardiac output by a volume-driven increase in total stroke
volume. During the compensated phase of eccentric hyper-
trophy, LV wall thickness increases in approximate propor-
tion to the increase in chamber radius.
Neurohumoral Activation
Failure of the heart to provide adequate forward output ac-
tivates several neurohumoral systems, often with deleteri-
ous consequences (Fig. 25-12). Decreased arterial pressure
activates the baroreceptor reflex, stimulating release of cat-
echolamines; in turn, the catecholamines produce tachycar-
dia (via 1-receptors) and vasoconstriction (via peripheral
1-receptors). Stimulation of 1-receptors on renal juxta-
glomerular (JG) cells promotes the release of renin. JG cells
also release renin in response to the decreased renal perfusion
that accompanies decreased cardiac output. Renin cleaves
circulating angiotensinogen to angiotensin I, which is subse-
quently converted by angiotensin converting enzyme (ACE)
to angiotensin II (AT II). AT II acts through AT1 receptors to
increase arterial vasomotor tone. AT II also activates several
physiologic mechanisms that increase intravascular volume,
including aldosterone release from the adrenal glands (thus
promoting salt and water retention), vasopressin (ADH) re-
lease from the posterior pituitary gland, and thirst center acti-
vation in the hypothalamus. In addition, AT II appears to be an
important mediator of vascular and myocardial hypertrophy.
The tachycardia and increased intravascular volume that
accompany activation of these neurohumoral mechanisms
help to maintain forward cardiac output, and the systemic
vasoconstriction provides a mechanism by which central
regulatory centers can override local autoregulation of blood
flow. Together, these mechanisms allow the cardiovascular
system to maintain perfusion of critical organs in the setting
of reduced cardiac output. However, sympathetic stimula-
tion of the heart also increases myocardial oxygen demand
by increasing both afterload (arteriolar constriction) and
preload (retention of sodium and water). Continued sympa-
thetic stimulation eventually results in down-regulation of
-adrenergic receptors, further impairing the ability of the
system to maintain forward output. The central aim of the
current pharmacologic management of HF is to modulate
the action of these neurohumoral effectors (Fig. 25-13).
 CLINICAL MANAGEMENT OF HEART
FAILURE
The pharmacologic treatment of HF has expanded dramati-
cally over the past three decades. Numerous large-scale clin-
ical trials have demonstrated that the new, load-active ther-
apies are associated with statistically significant reductions
in morbidity and mortality in patients with HF. In addition,
improvements in the detection and treatment of hypertension
 CHAPTER 25 / Integrative Cardiovascular Pharmacology: Hypertension, Ischemic Heart Disease, and Heart Failure 459

Compromised cardiac Compromised cardiac

function function

Decreased arterial Decreased arterial

blood pressure blood pressure

Baroreceptor Baroreceptor
reflex reflex

Increased Increased sympathetic Increased Increased sympathetic

renin outflow renin outflow

ACE inhibitors

Increased Increased Vasoconstriction Increased Increased Vasoconstriction

aldosterone ATII aldosterone ATII
Vasodilators
Spironolactone
Increased afterload Diuretics Increased afterload
Na+ retention Na+ retention

Intravascular Increased Increased myocardial Intravascular Increased Increased myocardial

volume preload O2 demand volume preload O2 demand
expansion expansion

Worsening Venodilators Worsening

heart failure heart failure

FIGURE 25-12. Neurohumoral effects of heart failure. Compromised car-
diac function leads to decreased arterial blood pressure, which activates barore-
ceptors that increase sympathetic outflow. -Adrenergic sympathetic outflow
() causes vasoconstriction, an effect that increases afterload. The increased
afterload creates a greater pressure against which the heart must contract, and
thereby increases myocardial O2 demand. -Adrenergic sympathetic outflow
() increases juxtaglomerular cell release of renin. Renin cleaves angiotensino-
gen to angiotensin I, and angiotensin I is then converted to the active hormone
angiotensin II (AT II). AT II has a direct vasoconstrictor action; it also increases
aldosterone synthesis and secretion. Aldosterone increases collecting duct Na
reabsorption, leading to intravascular volume expansion and increased preload.
Together, the increased afterload and preload increase myocardial O2 demand. In
the already compromised heart, these increased stresses can lead to worsening
heart failure.
and the management of complex multivessel CAD have
dramatically altered the clinical course of patients with con-
tractile dysfunction. It is helpful to organize the treatment
strategies for contractile dysfunction in patients who exhibit
or are at risk to develop symptomatic heart failure accord-
ing to the following physiologic goals: preload reduction,
afterload reduction, and contractility enhancement (in-
creased inotropy). Table 25-6 provides a summary of the
hemodynamic effects and mechanisms of action of the drug
classes that are commonly used to treat heart failure.
Preload Reduction
Diuretics
Diuretics have long been cornerstones of the pharmacologic
management of patients with left ventricular failure and re-
main integral components of the treatment of patients with
congestive symptoms and/or intravascular volume overload.
However, despite the efficacy of these agents at reducing con-
gestive symptoms, there is no evidence of a mortality benefit
from treatment with either loop diuretics or thiazide diuretics.
FIGURE 25-13. Pharmacologic modulation of the neurohumoral effects
of heart failure. Many therapeutic agents used in the management of heart failure
modulate the neurohumoral systems that are activated by compromised cardiac
function. The renin-angiotensinaldosterone system can be inhibited by (1) -
adrenergic antagonists, which inhibit renin release by the juxtaglomerular cells
of the kidney; (2) ACE inhibitors, which prevent the conversion of angiotensin I to
the active hormone angiotensin II; and (3) spironolactone, which competitively an-
tagonizes aldosterone binding to the mineralocorticoid receptor. Diuretics promote
Na excretion, and thereby counteract the Na retention stimulated by activation
of the renin-angiotensinaldosterone system. Venodilators counteract the effect of
intravascular volume expansion by increasing peripheral venous capacitance and
thereby decreasing preload. Direct arterial vasodilators alleviate the -adrenergic
receptor-mediated and angiotensin II receptor-mediated vasoconstriction induced
by increased sympathetic outflow. Cardiac glycosides, -adrenergic agonists, and
cardiac phosphodiesterase inhibitors are also used in HF to increase myocardial
contractility (not shown).
The natriuretic agents most commonly used in HF are the
loop diuretics furosemide and bumetanide. These drugs in-
hibit the Na-K-2Cl co-transporter (NKCC2) in the thick
ascending limb of Henle, resulting in increased excretion
of sodium, potassium, and water. Thiazide diuretics such as
hydrochlorothiazide are also used to treat congestive symp-
toms, particularly in patients with hypertensive heart disease
and LV systolic dysfunction. Thiazides inhibit sodium and
chloride reabsorption via the Na-Cl co-transporter (NCC)
in the distal convoluted tubule. Thiazides are less efficacious
natriuretic agents than loop diuretics and are often ineffective
as monotherapy for congestive symptoms in patients with
chronic kidney disease. Thiazides are sometimes co-admin-
istered with loop diuretics in patients with reduced GFR and
refractory volume overload, and in selected patients with HF
in whom treatment with loop diuretics alone does not achieve
adequate diuresis. (Refer to Chapter 20 for an extended dis-
cussion of diuretics.) In the introductory case, the decrease in
 CHAPTER 25 / Integrative Cardiovascular Pharmacology: Hypertension, Ischemic Heart Disease, and Heart Failure 463
Ischemic Heart Disease
Abrams J. Chronic stable angina. N Engl J Med 2005;352:25242533.
(Clinical pharmacology of chronic coronary artery disease treatments.)
American Heart Association 2005 guidelines for cardiopulmonary resusci-
tation and emergency cardiac care. Part 8: stabilization of the patient with
acute coronary syndromes. Circulation 2005;IV(Suppl):89110. (Emergency
management of acute coronary syndromes.)
Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for
the management of patients with unstable angina and non-ST elevation myo-
cardial infarction. Summary article: a report of the American College of Car-
diology/American Heart Association Task Force on practice guidelines. J Am
Coll Cardiol 2007;50:652726. (Current guidelines for evaluating and treating
patients with unstable angina and non-ST elevation myocardial infarction.)
Armstrong EJ, Morrow DA, Sabatine MS. Inflammatory biomarkers
in acute coronary syndromes. Part I: introduction and cytokines. Part II:
acute-phase reactants and biomarkers of endothelial cell activation. Part III:
biomarkers of oxidative stress and angiogenic growth factors. Part IV: ma-
trix metalloproteinases and biomarkers of platelet activation. Circulation
2006;113:7275, 152155, 289292, 382385. (Four-part series reviewing 492497. (Two-part series examining use of inotropic agents in heart
pathophysiology and clinical evidence concerning the role of inflammatory
mediators in acute coronary syndromes.)
Cannon CP, Braunwald E, McCabe CH, et al. Intensive versus moderate
lipid lowering with statins after acute coronary syndromes. N Engl J Med
2004;350:14951504. (Trial demonstrating clinical benefit for aggressive
statin therapy after acute coronary syndrome.)
Libby P. The molecular mechanisms of the thrombotic complications of
atherosclerosis. J Int Med 2008;263:517527. (Molecular basis of coronary
artery atherosclerosis.)
Heart Failure
ACCF/AHA 2009 focused update: guidelines for the diagnosis and man-
agement of heart failure in adults. J Am Coll Cardiol 2009;53:e1e90.
(Consensus guidelines for management of heart failure.)
Jessup M, Brozena S. Heart failure. N Engl J Med 2003;348:20072018.
(Clinical approach to heart failure.)
Opie LH. Cellular basis for therapeutic choices in heart failure. Circulation
2004;110:25592561. (Molecular basis of heart failure therapeutics.)
Stevenson LW. Clinical use of inotropic agents for heart failure: look-
ing backward or forward. Part I: inotropic infusions during hospitaliza-
tion. Part II: chronic inotropic therapy. Circulation 2003;108:367372,
failure.)
Taylor AL, Ziesche S, Yancy C, et al. Combination of isosorbide dinitrate and
hydralazine in blacks with heart failure. N Engl J Med 2004;351:20492057.
(Trial showing mortality benefit in self-identified black patients.)
IV

Principles of Endocrine
Pharmacology

Pharmacology of
the Hypothalamus
and Pituitary Gland
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 465-466
HYPOTHALAMIC AND PITUITARY PHYSIOLOGY . . . . . . . . . 465
Relationship Between the Hypothalamus
and Pituitary Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
Feedback Inhibition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 468
PHYSIOLOGY, PATHOPHYSIOLOGY, AND
PHARMACOLOGY OF INDIVIDUAL AXES . . . . . . . . . . . . . . . 468
Anterior Pituitary Gland . . . . . . . . . . . . . . . . . . . . . . . . . . 468
Hypothalamic-PituitaryGrowth Hormone Axis . . . . . . 468
 INTRODUCTION
The hypothalamus and pituitary gland function cooperatively
as master regulators of the endocrine system. Together, hor-
mones secreted by the hypothalamus and pituitary gland
control important homeostatic and metabolic functions, includ-
ing reproduction, growth, lactation, thyroid and adrenal gland
physiology, and water homeostasis. This chapter introduces
the physiology and regulation of hypothalamic and pituitary
hormones through a discussion of feedback regulation and the
various axes of hormonal regulation. The pharmacologic util-
ity of hypothalamic and pituitary factors is then discussed, with
emphasis on the regulation of specific endocrine pathways.
Three concepts are of special importance in this chapter: (1)
hypothalamic control of pituitary hormone release; (2) nega-
tive feedback inhibition; and (3) endocrine axes. A thorough
understanding of these pathways and their mechanisms pro-
vides the foundation for understanding the use of pharmaco-
therapy to modulate the hypothalamicpituitary axes.
 HYPOTHALAMIC AND PITUITARY
PHYSIOLOGY
Relationship Between the Hypothalamus
and Pituitary Gland
From a developmental perspective, the pituitary gland con-
sists of two closely associated organs. The anterior pituitary
26
Anand Vaidya and Ursula B. Kaiser
Hypothalamic-PituitaryProlactin Axis . . . . . . . . . . . . . 471
Hypothalamic-PituitaryThyroid Axis . . . . . . . . . . . . . . 472
Hypothalamic-PituitaryAdrenal Axis. . . . . . . . . . . . . . 472
Hypothalamic-PituitaryGonadal Axis . . . . . . . . . . . . . 473
Posterior Pituitary Gland. . . . . . . . . . . . . . . . . . . . . . . . . . 474
Antidiuretic Hormone (ADH) . . . . . . . . . . . . . . . . . . . . 474
Oxytocin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 476
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476
(adenohypophysis) is derived from ectodermal tissue. The
posterior pituitary (neurohypophysis) is a neural structure
derived from the ventral surface of the diencephalon. The
prefixes adeno- and neuro- denote the oral ectodermal and
neural ectodermal origin of the anterior and posterior pitu-
itary gland components, respectively. An intermediate lobe
also exists in most mammals but is vestigial in humans.
Although the anterior and posterior pituitary glands de-
rive from different embryologic origins, the hypothalamus
controls the activity of both lobes. The connection between
hypothalamus and pituitary gland is one of the most impor-
tant points of interaction between the nervous and endo-
crine systems. The hypothalamus acts as a neuroendocrine
transducer by integrating neural signals from the brain and
converting those signals into chemical messages (largely
peptides) that regulate the secretion of pituitary hormones.
In turn, the pituitary hormones alter the activities of periph-
eral endocrine organs.
Hypothalamic control of the anterior pituitary gland
occurs via hypothalamic secretion of hormones into the
hypothalamicpituitary portal vascular system (Fig. 26-1).
The initial capillary bed of this portal system is formed from
branches of the superior hypophyseal artery that fan around
the axon terminals of hypothalamic neurons. Endothelial
fenestrations in this capillary bed allow hypothalamic fac-
tors to be released into the bloodstream. These capillaries
then coalesce into short veins that extend to the anterior pitu-
itary gland. Upon arriving at the anterior pituitary, the veins
465
 Hypothalamic area

Optic chiasm
Paraventricular and
supraoptic nuclei
Superior
hypophyseal
artery

Hypothalamic-
pituitary portal Inferior
system hypophyseal
artery
To systemic
circulation

To systemic
Pituitary gland: circulation
Anterior lobe
Posterior lobe
Hypothalamus
CRH

ACTH
Pituitary
gland

Cortisol

Adrenal
gland
 CHAPTER 26 / Pharmacology of the Hypothalamus and Pituitary Gland 469

gastric fundal cells during the fasting state, linking growth
with nutritional status and energy balance. Nonpeptide,
orally active ghrelin mimetics are currently under clini-
cal investigation as GH secretagogues, and antagonists are
being studied for appetite control. Several environmental
factors inhibit GH release, including hyperglycemia, sleep
deprivation, and poor nutritional status. The most significant
endogenous biological factors that inhibit GH secretion are
somatostatin, IGF-1, and GH.
Pathophysiology and Pharmacology of Growth
Hormone Deficiency
Failure to secrete growth hormone or to enhance IGF-1
secretion during puberty results in growth retardation
(Fig. 26-3AD). GH deficiency most commonly results
from defective hypothalamic release of GHRH (tertiary
deficiency, Fig. 26-3D) or from pituitary insufficiency
(secondary deficiency, Fig. 26-3C). Importantly, how-
ever, failure of IGF-1 secretion in response to GH (Laron

A Normal axis B Growth hormone insensitivity

Ghrelin GHRH Ghrelin GHRH
Somatostatin Somatostatin

GH GH

IGF-1 IGF-1

C Secondary deficiency D Tertiary deficiency E Growth hormone excess

Ghrelin GHRH Ghrelin GHRH Ghrelin GHRH
Somatostatin Somatostatin Somatostatin

GH GH GH

IGF-1 IGF-1 IGF-1

FIGURE 26-3. Hypothalamic-pituitarygrowth hormone axis in health and disease. A. In the normal hypothalamic-pituitarygrowth hormone axis, hypotha-
lamic secretion of growth hormone-releasing hormone (GHRH) or ghrelin stimulates release of growth hormone (GH), while somatostatin inhibits release of GH. Secreted
GH then stimulates the liver to synthesize and secrete insulin-like growth factor 1 (IGF-1), which promotes systemic growth. IGF-1 also inhibits GH release from the
anterior pituitary gland. B. In GH insensitivity, the anterior pituitary gland secretes GH, but the liver is unresponsive to stimulation by GH. As a result, IGF-1 secretion is
reduced (indicated by dashed lines). The decreased feedback inhibition of GH release results in higher plasma levels of GH (thick line). C. In secondary deficiency, the
pathology lies in an unresponsive anterior pituitary gland, which secretes reduced amounts of GH. Because GH levels are low, the liver is not stimulated to produce
IGF-1. D. In tertiary deficiency, the hypothalamus fails to secrete GHRH appropriately (dashed line); the role of ghrelin in this condition is unknown. Lack of sufficient
GHRH results in lack of adequate stimulation of GH secretion by the anterior pituitary gland and, therefore, diminished production of IGF-1. E. In GH excess, GH is most
commonly hypersecreted from an anterior pituitary adenoma. Elevated, and unregulated, GH levels result in increased hepatic production of IGF-1, and thus in systemic
trophic effects. Because GH secretion occurs via an autonomous adenoma in the pituitary, negative feedback by IGF-1 is usually less effective.
 TRH
Dopamine

PRL

Breasts/
Mammary tissue

Estrogen Lactation
472 Principles of Endocrine Pharmacology

frequently used to treat prolactinomas have not shown a sig- A Normal axis B Primary adrenal tumor/
nificant link to valvular heart disease to date. Cushing's syndrome
CRH

Hypothalamic-PituitaryThyroid Axis
The hypothalamus secretes TRH, which stimulates thyrotro-
phs in the anterior pituitary gland to produce and secrete
TSH. In turn, TSH promotes biosynthesis and secretion of
thyroid hormone by the thyroid gland. Thyroid hormone reg-
ulates overall body energy homeostasis. Thyroid hormone
ACTH ACTH
negatively controls hypothalamic and pituitary release of
TRH and TSH, respectively (see Fig. 27-4).
Because thyroid hormone replacement is an effective ther-
Cortisol Cortisol
apy for hypothyroidism, TRH and TSH are used mainly for
diagnosis of disease etiology. If hypothyroidism is caused by
an unresponsive thyroid gland (primary deficiency), serum
TSH levels will be high because of decreased negative feed-
back from thyroid hormone. For this reason, serum TSH is
the main test used in screening for primary thyroid disease.
TRH administration would produce an exaggerated increase
in TSH, although this test is no longer used regularly in clini- C Pituitary adenoma/ D Ectopic ACTH-secreting tumor
cal practice. Conversely, if hypothyroidism is caused by a Cushing's disease
defect in pituitary TSH production (secondary deficiency),
the TSH level will not be high despite the presence of low
thyroid hormone levels. In this scenario, if TRH were to be
administered, the normally expected rise in TSH would be
absent or significantly reduced.
Recombinant TSH (thyrotropin) is commonly used
during radioactive iodine treatment of thyroid cancer. Thy- ACTH ACTH
rotropin is administered before radioactive iodine therapy
to maximize uptake of radiolabeled 131I isotope into thyroid
tissue in patients with thyroid cancer. This approach enables
Cortisol Cortisol Tumor
the administration of smaller quantities of radioisotope,
maintaining maximum radiation exposure specifically to
thyroid tissue with less radiation exposure to other tissues.
Other aspects of thyroid gland pharmacology are discussed
in Chapter 27, Pharmacology of the Thyroid Gland. ACTH

Hypothalamic-PituitaryAdrenal Axis
Neurons from the paraventricular nucleus of the hypo-
thalamus synthesize and secrete corticotropin-releasing
hormone (CRH). CRH binds to cell-surface receptors on
corticotrophs of the anterior pituitary gland and stimulates
corticotrophs to synthesize and release adrenocorticotropin-
releasing hormone (ACTH). ACTH is synthesized as part of
proopiomelanocortin (POMC), a precursor polypeptide that
is cleaved into multiple effector molecules. In addition to
ACTH, cleavage of POMC yields melanocyte-stimulating
hormone (MSH), lipotropin, and -endorphin. MSH has
effects on skin pigmentation. Because of the structural
similarities between ACTH and MSH, high concentrations
of ACTH can bind to and activate MSH receptors. This
becomes important in primary hypoadrenalism, where in-
creased ACTH levels result in enhanced skin pigmentation.
ACTH stimulates the synthesis and secretion of adre-
nocortical steroid hormones, including glucocorticoids,
androgens, and mineralocorticoids (Fig. 26-5A). ACTH is
required for secretion of glucocorticoids and adrenal an-
drogens. Mineralocorticoid production is also regulated by
potassium balance and volume status, and ACTH has a rela-
tively minor role in regulating mineralocorticoids. ACTH
also has a trophic effect on the zona fasciculata and zona
reticularis of the adrenal cortex (see Fig. 28-1); excessive
ACTH secretion causes adrenal hyperplasia, while ACTH
FIGURE 26-5. Hypothalamic-pituitaryadrenal axis in health and disease.
A. In the normal hypothalamic-pituitaryadrenal axis, hypothalamic secretion of
corticotropin-releasing hormone (CRH) stimulates release of adrenocorticotropic
hormone (ACTH). ACTH, in turn, stimulates synthesis and secretion of cortisol by
the adrenal cortex. Cortisol inhibits further release of CRH and ACTH. B. A primary
adrenal tumor causes Cushings syndrome by autonomously producing cortisol
(thick line), independent of regulation by ACTH. The excessive cortisol production
suppresses ACTH production (dashed line). C. An ACTH-producing pituitary ad-
enoma causes Cushings disease by autonomously secreting excessive levels of
ACTH (thick line), which stimulate the adrenal gland to produce increased levels
of cortisol (thick line). ACTH secretion by the tumor has a blunted sensitivity to
feedback inhibition by cortisol. D. An ectopic ACTH-secreting tumor (such as a small
cell carcinoma of the lung) also stimulates the adrenal gland to produce increased
levels of cortisol, which suppress pituitary ACTH production. However, circulating
ACTH levels remain elevated due to the ectopic-source production of the hormone.
deficiency ultimately causes adrenal atrophy. Among the
several steroid products of adrenal biosynthesis, cortisol is
arguably the most crucial. In addition to serving as the main
feedback inhibitor of pituitary ACTH release, cortisol func-
tions as a stress hormone and is involved in vascular tone,
electrolyte balance, and glucose homeostasis. Deficiency of
cortisol can rapidly lead to critical illness or death, while
cortisol excess results in Cushings syndrome (Fig. 26-5B).
 CHAPTER 26 / Pharmacology of the Hypothalamus and Pituitary Gland 473
A synthetic form of ACTH, known as cosyntropin,
can be used to diagnose suspected cases of adrenal insuf-
ficiency, and specifically to assist in ascertaining whether
the insufficiency is primary or secondary. Administration
of cosyntropin to a patient with primary adrenal insuffi-
ciency will fail to increase plasma cortisol concentration
due to the inherent dysfunction of adrenal biosynthesis.
Conversely, administration of cosyntropin to a patient with
new-onset secondary adrenal insufficiency will result in a
robust increase in plasma cortisol. However, patients with
long-standing secondary adrenal insufficiency may have a
blunted cortisol response to cosyntropin, owing mainly to
progressive adrenal cortical atrophy in the absence of the
trophic effects of ACTH. Conditions requiring physiologic
replacement of glucocorticoids are usually treated with
synthetic analogues of cortisol, rather than ACTH, because
use of the target hormone generally allows for more precise
physiologic control. Cortisol physiology and pharmacology
are discussed in greater detail in Chapter 28, Pharmacology
of the Adrenal Cortex.
CRH is used as a diagnostic tool in petrosal sinus sampling
for ACTH. It can be used to distinguish whether excessive cor-
tisol secretion results from an ACTH-secreting pituitary ade-
noma or from an ectopic ACTH-secreting tumor (Fig. 26-5). If
the hypercortisolism derives from a pituitary corticotroph ade-
noma (Cushings disease), administration of CRH will usually
increase blood ACTH levels (Fig. 26-5C). This response is not
seen in the case of an ACTH-secreting ectopic tumor, which
secretes ACTH at a constant autonomous rate (Fig. 26-5D).
Cushings syndrome resulting from primary adrenal
tumors is often treated with surgical resection; however,
several medical therapies also exist. Metyrapone, ketocon-
azole, and mitotane all have potent inhibitory effects on
adrenal steroidogenesis and can be used to reduce cortisol
production, while mifepristone antagonizes peripheral cor-
tisol receptor binding (see Chapter 28).
Hypothalamic-PituitaryGonadal Axis
Gonadotrophs are unique among anterior pituitary gland
cells because they secrete two glycoprotein hormonesLH
and FSH. Together, these hormones are referred to as go-
nadotropins. LH and FSH are both heterodimers composed
of and subunits. LH and FSH share the same subunit
with TSH and hCG, but possess unique subunits. Gonado-
trophs regulate the secretion of FSH and LH independently.
This axis is diagrammed in Figure 26-6.
Gonadotropins control hormone production by the go-
nads, promoting the synthesis of androgens and estrogens.
The effects of estrogen and other reproductive hormones on
the anterior pituitary gland are complex. In males, gonado-
tropins are inhibited via negative feedback by testosterone.
In contrast, in females, depending on the rate of change and
absolute concentration of estrogen, as well as the stage of
the menstrual cycle, estrogen can exert both inhibitory and
excitatory effects on gonadotropins. Inhibin is a hormone
produced in the gonads that has inhibitory effects primar-
ily on FSH secretion, with little effect on LH secretion.
Activin is a paracrine factor that is produced and acts lo-
cally both in the pituitary and in the gonads, and functions
in the pituitary gland to stimulate primarily FSH secretion
(Fig. 26-6). Endocrine control of the reproductive process
is discussed in greater detail in Chapter 29, Pharmacology
of Reproduction.
GnRH
(pulsatile)
GnRH Activin
(continuous)
LH
and
FSH
Estrogen (+/-) Testosterone (-)
Inhibin (-) Inhibin (-)
Ovaries or testes
FIGURE 26-6. The hypothalamic-pituitarygonadal axis. Gonadotropin-
releasing hormone (GnRH) is secreted by the hypothalamus in a pulsatile fashion,
stimulating gonadotroph cells of the anterior pituitary gland to secrete luteinizing
hormone (LH) and follicle-stimulating hormone (FSH). LH and FSH stimulate the
ovaries or testes to produce the sex hormones estrogen or testosterone, respec-
tively, which inhibit further release of LH and FSH. Paradoxically, however, the
increasing estrogen levels that are secreted from developing follicles during the
follicular phase of the menstrual cycle induce a positive-feedback, mid-cycle ovu-
latory surge of LH and FSH secretion. Inhibin is also produced by the gonads in
response to FSH and exerts negative feedback on gonadotrophs to inhibit further
release of FSH. Locally produced pituitary activin acts in a paracrine fashion to
stimulate FSH secretion. Exogenous pulsatile GnRH can be used to induce ovula-
tion in women with infertility of hypothalamic origin. However, continuous admin-
istration of GnRH suppresses the gonadotroph response to endogenous GnRH, and
thereby causes decreased production of sex hormones. Analogues of GnRH with
increased metabolic stability and prolonged half-lives take advantage of this effect
and are used to suppress sex hormone production in clinical conditions such as
precocious puberty and prostate cancer.
Native GnRH, which has a short half-life, can be admin-
istered in a pulsatile fashion to stimulate patterned gonado-
tropin release, while GnRH analogues with longer half-lives
are used to suppress production of sex hormones by desen-
sitizing the pituitary gland to the stimulating activity of the
releasing factor (Fig. 26-6). The main pharmacologic dif-
ference among the currently approved GnRH agonists is the
method of administration. Leuprolide is the most commonly
used GnRH agonist and can be administered as a daily sub-
cutaneous injection or as a monthly depot injection. Osmotic
pump implants (see Chapter 54, Drug Delivery Modalities)
are also available that deliver leuprolide acetate at a con-
trolled rate for up to 12 months. Long-acting agonists are
utilized therapeutically to suppress gonadotropins in sev-
eral conditions, including endometriosis, uterine fibroids,
474 Principles of Endocrine Pharmacology
precocious puberty, and androgen-dependent prostate cancer.
Their main drawback is that gonadotroph suppression does
not occur immediately; instead, there is a transient (several
days) increase (flare) in sex hormone levels, followed by a
lasting suppression of hormone synthesis and secretion.
FSH is used clinically to stimulate ovulation for in vitro
fertilization. Two Food and Drug Administration (FDA)-
approved formulations are available. Urofollitropin is
purified FSH isolated from the urine of postmenopausal
women, and follitropin is a recombinant form of FSH. Both
agents effectively stimulate ovulation but may cause ovar-
ian hyperstimulation syndrome. Interestingly, a rare form
of ovarian hyperstimulation syndrome that occurs during
pregnancy (familial gestational ovarian hyperstimulation
syndrome) is caused by an inherited mutation in the FSH re-
ceptor. This mutation allows human chorionic gonadotropin
(hCG), a hormone present in high concentrations during the
early stages of pregnancy, to activate the FSH receptor. The
resulting overstimulation of the FSH receptor is thought to
cause the follicular enlargement and other sequelae char-
acteristic of this syndrome. Whether similar mutations in
the FSH receptor could be associated with cases of drug-
induced ovarian hyperstimulation syndrome is an area of
active investigation.
The GnRH antagonists cetrorelix and ganirelix are some-
times used in assisted reproduction; they suppress premature
surges in LH in the early to mid-follicular phase of the men-
strual cycle, resulting in improved rates of implantation and
pregnancy (see Chapter 29, Pharmacology of Reproduction).
GnRH antagonists also have applications for palliation of
metastatic prostate cancer. In this situation, a direct GnRH
antagonist has the advantage of avoiding the initial surge in
testosterone caused by treatment with GnRH agonists.
Posterior Pituitary Gland
In comparison to the numerous hormones of the anterior
pituitary gland, the posterior lobe of the pituitary gland
(neurohypophysis) secretes only two hormones, antidiuretic
hormone (ADH) and oxytocin. ADH is an important regu-
lator of plasma volume and osmolality, while oxytocin has
physiologic effects on uterine contraction and lactation.
Antidiuretic Hormone (ADH)
ADH is a peptide hormone produced by magnocellular cells
of the hypothalamus. Cells in this region possess osmorecep-
tors that sense changes in extracellular osmolality. Increased
osmolality stimulates ADH secretion from nerve terminals
in the posterior pituitary gland. ADH binds to two types of
receptors, V1 and V2. V1 receptors, located in systemic arte-
rioles, mediate vasoconstriction. This property gives ADH
its alternative name, vasopressin. V2 receptors, located in
the nephron, stimulate the cell surface expression of water
channels in order to increase water reabsorption in the col-
lecting duct, as discussed in Chapter 20, Pharmacology of
Volume Regulation. These two actions of ADH combine to
maintain vascular tone by: (1) increasing blood pressure;
and (2) increasing water reabsorption.
Disruption of ADH homeostasis results in two important
pathophysiologic conditions. Excessive secretion of ADH
causes the syndrome of inappropriate ADH (SIADH);
deficient secretion of ADH or decreased responsiveness to
ADH causes diabetes insipidus. In SIADH, ADH secretion
occurs irrespective of plasma volume status or osmolality.
One of the most common causes of SIADH is the ectopic
secretion of ADH by small cell carcinoma of the lung, but
SIADH may be caused by a medication effect or result from
almost any pulmonary process, central nervous system in-
sult, or pituitary surgery. Excessive ADH secretion results
in persistent stimulation of V1 and V2 receptors, causing hy-
pertension and excessive water retention. The inappropriate
water retention can result in low extracellular sodium con-
centration. Until recently, if the source of excess ADH could
not be removed, the only effective therapy for SIADH was
restriction of fluid intake or administration of hypertonic sa-
line. Over the past decade, the discovery and clinical use of
vasopressin receptor antagonists has provided more weap-
ons in the arsenal to combat SIADH.
Conivaptan and tolvaptan are vasopressin receptor an-
tagonists that have recently been approved by the FDA for
SIADH-induced hyponatremia. Tolvaptan is a specific V2
receptor antagonist approved for use in heart failure, while
conivaptan is a mixed V1a and V2 receptor antagonist ap-
proved for use in euvolemic and hypervolemic hypona-
tremia. Both are available as oral agents. Demeclocycline
(a tetracycline antibiotic; see Chapter 33, Pharmacology of
Bacterial Infections: DNA Replication, Transcription, and
Translation) and lithium (see Chapter 14, Pharmacology
of Serotonergic and Central Adrenergic Neurotransmission)
are two other pharmacologic treatments that can also be used
to treat SIADH.
Both diabetes insipidus and diabetes mellitus are char-
acterized by symptoms of thirst, polydipsia, and polyuria.
Despite their phenotypic similarities, however, the etiologies
of diabetes mellitus and diabetes insipidus are unrelated. Di-
abetes insipidus is a disorder of vasopressin deficiency or
resistance, whereas diabetes mellitus is caused by deficient
production of insulin or target tissue insensitivity to insulin
(see Chapter 30, Pharmacology of the Endocrine Pancreas
and Glucose Homeostasis). Diabetes insipidus is character-
ized by polyuria and polydipsia secondary to an inability to
concentrate urine and retain free water at the level of the
renal collecting duct. A distinction is made between two
types of diabetes insipidus. Neurogenic diabetes insipidus
results from an inability of hypothalamic neurons to synthe-
size or secrete ADH. In this condition, administration of the
exogenous ADH analogue, desmopressin, results in stimu-
lation of V2 receptors and a robust concentration of urine
and decrease in thirst (Fig. 26-7). Nephrogenic diabetes in-
sipidus results from an inability of renal collecting duct cells
to respond to ADH (or, in other words, resistance to ADH).
Nephrogenic diabetes insipidus can be caused by a mutation
in the V2 receptor, such that ADH is unable to bind the recep-
tor or stimulate receptor signaling, or by medication-induced
resistance; lithium is one such medication.
In nephrogenic diabetes insipidus, administration of des-
mopressin results in little or no change in urine concentra-
tion or thirst because of receptor insensitivity to ADH and its
analogues. Patients with nephrogenic diabetes insipidus can
be treated with diuretics such as amiloride or hydrochloro-
thiazide. The proposed mechanism by which these diuret-
ics prevent excessive loss of free water is paradoxical: they
induce a volume-contracted state, which promotes enhanced
absorption of water in the proximal tubule and thereby
decreases delivery of water to the site of ADH resistance, the
collecting ducts.
 CHAPTER 26 / Pharmacology of the Hypothalamus and Pituitary Gland 475

ADH

A Water V2-receptor D

Pituitary gland
No change in water
channel expression
Collecting duct cell
ADH ADH

Water
C
Water V2-receptor Water Missing or
unresponsive
Pituitary gland V2-receptor

Increased water No change in water

Water channel expression channel expression
Collecting duct cell

Desmopressin
Water

Water V2-receptor

Increased water
Water channel expression

FIGURE 26-7. Comparison of neurogenic and nephrogenic diabetes insipidus. A. Antidiuretic hormone (ADH), released by nerve terminals in the posterior pituitary
gland, stimulates V2 receptors on renal collecting duct cells, and thereby increases expression of water channels in the apical membrane of these cells. Increased water channel
expression increases water flux through the cell. B. In neurogenic diabetes insipidus, the posterior pituitary gland is unable to secrete ADH. Consequently, there is no stimula-
tion of renal V2 receptors by ADH, and the collecting duct cells do not increase water channel expression. C. Exogenous administration of desmopressin, an ADH analogue, can
replace the deficiency of posterior pituitary gland-derived ADH, and thereby treat neurogenic diabetes insipidus. D. In nephrogenic diabetes insipidus, the V2 receptor is either
missing or unresponsive to stimulation by ADH. The lack of functional V2 receptors prevents the cell from responding to ADH with an increase in water channel expression.

Oxytocin causes contraction of myoepithelial cells surrounding the

Oxytocin is a peptide hormone produced by paraventricu-
lar cells of the hypothalamus. Many of the known physio-
logic roles of oxytocin involve muscular contraction; two
such effects are milk release during lactation and uterine
contraction. In the milk letdown response, stimuli to the
hypothalamus cause oxytocin release into the blood from
nerve terminals in the posterior pituitary gland. Oxytocin
mammary gland alveoli. This is an important physiologic
action during breast feeding. In addition, it has long been
known that administration of oxytocin causes uterine con-
traction. Oxytocin release is probably not the physiologic
stimulus for initiation of labor during pregnancy; how-
ever, oxytocin is used pharmacologically to induce labor
artificially.
476 Principles of Endocrine Pharmacology
 CONCLUSION AND FUTURE DIRECTIONS
Hormones of the hypothalamus and pituitary gland can be
used as pharmacologic agents to modify the respective en-
docrine axes of each hormone. Recognizing the relationships
and effects of primary, secondary, and tertiary disorders of
any hypothalamicpituitary axis is of paramount importance
in understanding the appropriate diagnostic and treatment
choices. Hypothalamic hormones can be used as diagnostics
to determine the causes of underlying endocrine pathology
(CRH, GHRH, TRH) or as therapeutics to suppress an axis
(GnRH, somatostatin, dopamine). Hormones of the anterior
pituitary gland can be given as replacement therapy in cases
of deficiency (GH) or used diagnostically (ACTH, TSH). The
posterior pituitary gland produces two hormones, ADH and
oxytocin, which can be used to treat neurogenic diabetes in-
sipidus and to induce labor, respectively. Future directions in
hypothalamic and pituitary gland pharmacology will include:
design of new drug delivery systems; synthesis of orally
active, nonpeptide analogues of hormones; and investiga-
tions to better understand hormone receptor mechanisms and
signaling to assist in the design of new pharmacotherapies.
Acknowledgment
We thank Ehrin J. Armstrong and Armen H. Tashjian, Jr.
for their valuable contributions to this chapter in the First
and Second Editions of Principles of Pharmacology: The
Pathophysiologic Basis of Drug Therapy.
Suggested Reading
Hays R. Vasopressin antagonists progress and promise. N Engl J Med
2006;355:21462148. (Perspective on SIADH and the future of vasopressin
antagonists.)
Melmed S. Acromegaly. N Engl J Med 2006;355:25582273. (Review of
growth hormone pathophysiology and treatment for acromegaly.)
Verhelst J, Abs R. Hyperprolactinemia. Treat Endocrinol 2003;2:2332.
(Review of the pathophysiology and management of hyperprolactinemia.)
27
Pharmacology of the
Thyroid Gland
Ehrin J. Armstrong, Armen H. Tashjian, Jr., and William W. Chin
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 480-481
THYROID GLAND PHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . 480
Synthesis and Secretion of Thyroid Hormones . . . . . . . . . 480
Metabolism of Thyroid Hormones . . . . . . . . . . . . . . . . . . . 482
Effects of Thyroid Hormones on Target Tissues. . . . . . . . . 482
Hypothalamic-PituitaryThyroid Axis . . . . . . . . . . . . . . . . 483
PATHOPHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 484
Treatment of Hypothyroidism . . . . . . . . . . . . . . . . . . . . . . 484
 INTRODUCTION
The thyroid gland has diverse and important effects on many
aspects of metabolic homeostasis. Follicular thyroid cells
constitute the majority of thyroid tissue; these cells produce
and secrete the classical thyroid hormones: thyroxine (T4),
triiodothyronine (T3), and reverse triiodothyronine (rT3). Thy-
roid hormones regulate growth, metabolism, and energy ex-
penditure, from oxygen consumption to cardiac contractility.
Parafollicular C cells of the thyroid gland secrete calcitonin, a
regulator of bone mineral homeostasis. Calcitonin is discussed
in Chapter 31, Pharmacology of Bone Mineral Homeostasis.
The major diseases of the thyroid gland involve disrup-
tion of the normal hypothalamic-pituitarythyroid axis (see
Chapter 26, Pharmacology of the Hypothalamus and Pitu-
itary Gland). Replacement of deficient thyroid hormone is
an effective and established therapy for hypothyroidism.
Treatment of hyperthyroidism is more complex, with options
including antithyroid drugs, radioactive iodide, and surgical
excision of abnormal tissue. Understanding the pathways
and mechanisms of feedback regulation of thyroid hormone
synthesis and thyroid hormone actions serves to explain the
rationale for effective drug treatment of thyroid diseases.
 THYROID GLAND PHYSIOLOGY
Synthesis and Secretion of Thyroid Hormones
The thyroid is an endocrine gland located in the neck in-
ferior to the larynx and spanning the ventral surface of the
480
Treatment of Hyperthyroidism . . . . . . . . . . . . . . . . . . . . . 485
Inhibitors of Iodide Uptake . . . . . . . . . . . . . . . . . . . . . 485
Inhibitors of Organification and Hormone Release . . . . 485
Inhibitors of Peripheral Thyroid Hormone Metabolism . 486
Other Drugs Affecting Thyroid Hormone Homeostasis. . . . 487
Lithium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
Amiodarone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 487
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
trachea. The main function of the thyroid gland is to pro-
duce the thyroid hormones, T3 and T4. Structurally, the
thyroid hormones are built on a backbone of two tyrosine
molecules that are iodinated and connected by an ether link-
age (Fig. 27-1). An important structural feature of thyroid
hormones is the placement of iodines on this backbone.
The position and relative orientation of iodines attached to
the tyrosine residues determine the specific form of thy-
roid hormone. 3,5,3,5-Tetraiodothyronine (thyroxine,
T4) has four iodines attached to the tyrosine backbones
and is the major form of thyroid hormone secreted by the
thyroid gland. 3,5,3-Triiodothyronine (T3) has three io-
dines. Most T3 is produced by peripheral 5 deiodination
of T4 (see below). A biologically inactive form of thyroid
hormone is 3,3,5-triiodothyronine, also referred to as
reverse triiodothyronine (rT3) because the single iodine
is on the opposite tyrosine in the backbone relative to T3.
In a normal individual, circulating thyroid hormone con-
sists of about 90% T4, 9% T3, and 1% rT3, and most of the
hormone is bound to plasma proteins (both specific binding
proteins and albumin).
Iodide is a trace element that is a crucial component of
thyroid hormone structure. Thyroid follicular cells, which
synthesize and secrete thyroid hormones, selectively con-
centrate iodide (I) via a Na/I symporter located on the
basolateral membrane of the cell (Fig. 27-2). This active
transport mechanism has the ability to concentrate iodide to
intracellular concentrations up to 500 times that of plasma;
most individuals have thyroid gland to plasma iodide ratios
of approximately 30.
 O
H2N
OH I
I 3' OH
3

O 5' I
5
I
Thyroxine (T4)

Outer ring Inner ring

deiodination deiodination

O
H2N O
OH I
H2N
3 I 3' OH OH I
I 3' OH
3
O
5
I O 5' I

3,5,3'-Triiodothyronine (T3) 3,3',5'-Triiodothyronine (rT3)

(biologically active) (biologically inactive)
482 Principles of Endocrine Pharmacology
I- Na+
Na+/ I- symporter
Extracellular
space
TG I- Na+
Thyroid peroxidase
(organification)
TG-MIT,
Colloid TG-DIT
space
Thyroid peroxidase
(coupling)
T3 T4
TG
T3,T4
Follicular cell
T3
T4
Peripheral conversion
T3
FIGURE 27-2. Thyroid hormone synthesis, storage, and release. Follicular
cells of the thyroid gland concentrate iodide (I) from plasma via a basolateral
membrane Na/I symporter. In a reaction (called organification) catalyzed by Effects of Thyroid Hormones on Target Tissues
thyroid peroxidase, intracellular iodide reacts covalently with tyrosine residues on
thyroglobulin (TG) molecules at the apical membrane. Addition of one I to tyrosine
results in the formation of monoiodinated tyrosine (MIT); addition of two I to ty-
rosine results in the formation of diiodinated tyrosine (DIT). MIT and DIT associate
covalently on thyroglobulin via a mechanism known as coupling, which is also
catalyzed by thyroid peroxidase. The derivatized thyroglobulin is stored as colloid
within follicles in the thyroid gland. Upon stimulation by TSH, thyroid follicular
cells endocytose colloid into lysosomal compartments, where the thyroglobulin is
degraded to yield free T4, free T3, and uncoupled MIT and DIT. T3 and T4 are se-
creted into the plasma, and MIT and DIT are deiodinated intracellularly to yield free
iodide for use in new thyroid hormone synthesis (not shown). The thyroid gland
secretes more T4 than T3, although T4 is converted to T3 in peripheral tissues.
the follicular cells endocytose colloid. The ingested thy-
roglobulin enters lysosomes, where proteases digest the
thyroglobulin. Proteolytic digestion releases free T3, T4,
MIT, and DIT. T3 and T4 are transported across the fol-
licular cell basolateral membrane and into the blood. Free
MIT and DIT are rapidly deiodinated within the cell, al-
lowing the iodide to be recycled for new thyroid hormone
synthesis.
Most endocrine organs concurrently synthesize and re-
lease new hormone when activated, rather than storing large
quantities of precursor hormone. The thyroid gland is un-
usual among endocrine glands in that it stores large quanti-
ties of thyroid prohormone in the form of thyroglobulin. It is
not understood why the thyroid gland maintains this elabo-
rate pathway for hormone synthesis and release, but doing
so makes it possible to maintain plasma thyroid hormone
at a constant level despite fluctuations in the availability of
dietary iodide.
Metabolism of Thyroid Hormones
Thyroid hormone circulates mostly bound to plasma pro-
teins, notably thyroid binding globulin (TBG) and trans-
thyretin. Although T4 is the predominant thyroid hormone
found in the blood, T3 has four times the physiologic activ-
ity of T4 on target tissues. Some serum T4 is inactivated by
deamination, decarboxylation, or conjugation and excretion
by the liver. Most T4, however, is deiodinated to the more
active T3 form in several locations in the body. This deiodi-
nation reaction is catalyzed by the enzyme iodothyronine
5-deiodinase (Fig. 27-1).
There are three subtypes of deiodinase. Type I 5-
deiodinase, expressed in the liver and kidneys, is important
for converting T4 to the majority of serum T3. Type II 5-
deiodinase is expressed primarily in the pituitary gland, brain,
and brown fat. This enzyme is located intracellularly and con-
verts T4 to T3 locally. Type III 5-deiodinase is responsible
largely for conversion of T4 to the biologically inactive rT3.
The presence of T4 in the blood provides a buffer, or res-
ervoir, for thyroid hormone effects. Most T4 to T3 conver-
sion occurs in the liver, and many pharmacologic agents that
increase hepatic cytochrome P450 enzyme activity also in-
crease T4 to T3 conversion. In addition, T4 has a half-life in
the plasma of approximately 6 days, whereas plasma T3 has
a half-life of only 1 day. Because T4 has a long plasma half-
life, changes in thyroid hormone-regulated functions caused
by pharmacologic intervention are generally not observed
for a period of 1 to 2 weeks, as seen with Ms. L in the intro-
ductory case.
Thyroid hormones have effects on virtually every cell of the
body. While the majority of the effects of thyroid hormones
likely occur at the level of gene transcription, there is grow-
ing evidence that these hormones also act at the plasma mem-
brane. Both modes of action are mediated by hormone binding
to thyroid hormone receptors (TRs). Free hormone enters the
cell by both passive diffusion and active transport, the latter
mediated by hormone-specific and nonspecific carriers such
as organic anion and monocarboxylate transporters.
TRs are proteins containing thyroid hormone-binding,
DNA-binding, and dimerization domains. There are two
classes of thyroid hormone receptor, termed TR and TR.
In addition, both TR and TR can be expressed as multiple
isoforms. TR monomers can interact in a dimerization reac-
tion to form homodimers, or with another transcription factor,
retinoid X receptor (RXR), to form heterodimers. These TR
dimers bind to gene promoter regions and are activated by
binding of thyroid hormones. Together, the multiple different
combinations of TRs and the variability in their tissue distri-
butions create tissue specificity for thyroid hormone effects.
In the absence of hormone, thyroid hormone receptor dim-
ers associate with corepressor molecules and constitutively
bind to (and thereby inactivate) thyroid hormone-stimulated
genes. Binding of thyroid hormone to TR:RXR or TR:TR dim-
ers promotes dissociation of the corepressors and recruitment
of coactivators to the DNA. Thus, thyroid hormone binding
to TR dimers serves as a molecular switch from inhibition to
activation of gene transcription (Fig. 27-3). Thyroid hormone
also acts to down-regulate gene expression by a TR-dependent
mechanism, the exact nature of which is not fully understood.
For example, thyroid hormone is able to down-regulate TSH
 CHAPTER 27 / Pharmacology of the Thyroid Gland 483

gene expression, causing negative feedback of thyroid hor-

RxR mone on the hypothalamic-pituitarythyroid axis (see Chap-
Decreased
TR Corepressor
transcription ter 26). Increasing evidence suggests that thyroid hormone
also has nongenomic effects on mitochondrial metabolism
and that it interacts with plasma membrane receptors to stim-
5' 3'
ulate intracellular signal transduction.
No thyroid hormone Thyroid hormone is important in infancy for growth and
development of the nervous system. Congenital deficiency
of thyroid hormone results in cretinism, a severe but pre-
ventable form of mental retardation. In the adult, thyroid
T3 hormone regulates general body metabolism and energy ex-
penditure. Enzymes regulated by thyroid hormone include
Coactivator Corepressor the Na/K ATPase and many of the enzymes of intermedi-
T3
ary metabolism, both anabolic and catabolic. At high levels
RxR of thyroid hormone, this effect can result in futile cycling and
TR DNA transcription a consequent increase in body temperaturethis is why Ms.
L started turning down the heat in her home. Many of the ef-
fects of thyroid hormone resemble the effects of sympathetic
5' 3' neural stimulation, including increased cardiac contractility
and heart rate, excitability, nervousness, and diaphoresis
With thyroid hormone
(sweating). These symptoms were also seen in Ms. Lshe
FIGURE 27-3. Thyroid hormone receptor actions. In the absence of thyroid was nervous all the time and was startled by slight provoca-
hormone, the thyroid hormone receptor (TR):retinoid X receptor (RXR) heterodi- tions. Conversely, low levels of thyroid hormone result in
mer associates with a corepressor complex, which binds to promoter regions of myxedema, a hypometabolic state characterized by leth-
DNA and inhibits gene expression. In the presence of thyroid hormone (T3), the argy, dry skin, coarse voice, and cold intolerance.
corepressor complex dissociates from the TR:RXR heterodimer, coactivators are
recruited, and gene transcription occurs. This example demonstrates the action of
T3 on a TR:RXR heterodimer, but similar mechanisms are probable for TR:TR ho-
Hypothalamic-PituitaryThyroid Axis
modimers. A useful therapeutic strategy in the future may involve pharmacologic Thyroid hormone secretion follows a negative regulatory
targeting of tissue-specific corepressors or coactivators. feedback scheme similar to that of the other hypothalamic-
pituitarytarget organ axes (Fig. 27-4). Thyrotropin-releasing

A Normal axis B Graves' disease C Hashimoto's thyroiditis

TRH TRH TRH

TSH Thyroid TSH Thyroid TSH Thyroid

hormone hormone hormone

Stimulatory Destructive
Thyroid autoantibody Thyroid autoantibody Thyroid
Thyroid gland hormone hormone hormone

Target tissues Target tissues Target tissues

FIGURE 27-4. The hypothalamic-pituitarythyroid axis in health and disease. A. In the normal axis, thyrotropin-releasing hormone (TRH) stimulates thyro-
tropes of the anterior pituitary gland to release thyroid-stimulating hormone (TSH). TSH stimulates synthesis and release of thyroid hormone by the thyroid gland. Thyroid
hormone, in addition to its effects on target tissues, inhibits further release of TRH and TSH by the hypothalamus and anterior pituitary gland, respectively. B. In Graves
disease, a stimulatory autoantibody autonomously activates the TSH receptor in the thyroid gland, resulting in sustained stimulation of the thyroid gland, increased
plasma thyroid hormone (thick lines), and suppression of TRH and TSH release (dashed lines). C. In Hashimotos thyroiditis, a destructive autoantibody attacks the thyroid
gland, causing thyroid insufficiency and decreased synthesis and secretion of thyroid hormone (dashed lines). Consequently, feedback inhibition on the hypothalamus
and anterior pituitary gland does not occur, and plasma TSH levels rise (thick lines).
 Perchlorate
Thiocyanate
Pertechnetate
I- Na+

Extracellular
space
TG I- Na+

Thyroid peroxidase
(organification)

TG-MIT, Thioamines
TG-DIT Iodides (high)
Thyroid peroxidase
(coupling)

Colloid T3 T4
space
TG

Iodides (high)
131I-

T3,T4

Follicular cell

T3 T4
Peripheral conversion

Propylthiouracil T3

-adrenergic stimulation (e.g., sweating, tremor, tachycar-
dia). It has also been demonstrated that -blockers can re-
duce peripheral conversion of T4 to T3, but this effect is not
thought to be clinically relevant. Because of its rapid onset
of action and short elimination half-life (9 minutes), esmolol
is a preferred -adrenergic antagonist for the treatment of
thyroid storm.
Ipodate
Ipodate is a radiocontrast agent formerly used for visualiza-
tion of the biliary ducts in endoscopic retrograde cholang-
iopancreatography (ERCP) procedures. In addition to its
usefulness as a radiocontrast agent, ipodate significantly
inhibits conversion of T4 to T3 by inhibiting the enzyme
5-deiodinase. Although ipodate was sometimes used in the
past to treat hyperthyroidism, it is no longer commercially
available.
Other Drugs Affecting Thyroid
Hormone Homeostasis
Lithium
Lithium, a drug used in the treatment of bipolar affective
disorder (see Chapter 14, Pharmacology of Serotonergic and
Central Adrenergic Neurotransmission), can cause hypo-
thyroidism. Lithium is actively concentrated in the thyroid
gland, and high levels of lithium have been shown to inhibit
thyroid hormone release from thyroid follicular cells. There
is some evidence that lithium may inhibit thyroid hormone
synthesis as well. The mechanism(s) responsible for these
actions is unknown.
Amiodarone
Amiodarone is an antiarrhythmic drug (see Chapter 23,
Pharmacology of Cardiac Rhythm) that has both positive and
negative effects on thyroid hormone function. Amiodarone
structurally resembles thyroid hormone and, as a result, con-
tains a large concentration of iodine (each 200-mg tablet of
amiodarone contains 75 mg of iodine). Metabolism of amio-
darone releases this iodine as iodide, resulting in increased
plasma concentrations of iodide. The increased plasma io-
dide is concentrated in the thyroid gland; this can result in
hypothyroidism by the WolffChaikoff effect.
Amiodarone can also cause hyperthyroidism by two
mechanisms. In type I thyrotoxicosis, the excess iodide load
provided by amiodarone leads to increased thyroid hormone
synthesis and release. In type II thyroiditis, an autoimmune
thyroiditis is induced that leads to release of excess thyroid
hormone from the colloid. Because of its close structural
similarity to thyroid hormone, amiodarone may also act as a
homologue of thyroid hormone at the level of the receptor.
CHAPTER 27 / Pharmacology of the Thyroid Gland 487
In addition, amiodarone competitively inhibits type I 5-
deiodinase. This results in decreased peripheral conversion
of T4 to T3 and increased plasma concentrations of rT3.
Corticosteroids
Corticosteroids, such as cortisol and glucocorticoid ana-
logues, inhibit the 5-deiodinase enzyme that converts T4
to the metabolically more active T3. Because T4 has less
physiologic activity than T3, treatment with corticosteroids
reduces net thyroid hormone activity. In addition, the de-
creased serum T3 results in increased release of TSH. The
increased TSH stimulates greater T4 synthesis, until the
amount of T4 produced generates a sufficient level of T3
to inhibit the hypothalamus and pituitary gland. Thus, when
faced with decreased peripheral conversion of T4 to T3, the
thyroid gland releases T4 at a higher rate, and serum T4 and
T3 levels reach a new steady state.
 CONCLUSION AND FUTURE DIRECTIONS
Thyroid hormone synthesis consists of a complex set of syn-
thesis and degradation steps. This pathway creates numerous
points for pharmacologic intervention, from iodide uptake
to peripheral conversion of T4 to T3. Thyroid hormone re-
placement is a safe and effective long-term therapy for thy-
roid hormone deficiencies. Several effective therapies exist
for the management of thyrotoxicosis. Radioactive iodide
and thioamines are commonly used for this purpose, leading
to selective destruction of the thyroid gland and antagonism
of organification and coupling, respectively. Future poten-
tial therapies for diseases of the thyroid gland may focus on
treating the etiology of autoimmune thyroid diseases, such
as Graves disease and Hashimotos thyroiditis, and better
defining the molecular targets of thyroid hormone action.
Suggested Reading
Anonymous. Drugs for hypothyroidism and hyperthyroidism. Treat Guidel
Med Lett 2006;4:1724. (Review of therapeutic considerations, including
important drug interactions.)
Brent GA. Graves disease. N Engl J Med 2008;358:25942605. (Reviews
the clinical approach to Graves disease and discusses other causes of
hyperthyroidism.)
Cooper DS. Antithyroid drugs. N Engl J Med 2005;352:905917. (An excel-
lent, detailed summary of the clinical uses and adverse effects of methima-
zole and propylthiouracil.)
Davis PJ, Leonard JL, Davis FB. Mechanisms of nongenomic actions of
thyroid hormone. Front Neuroendocrinol 2008;29:211218. (Review of re-
cent developments in thyroid hormone signaling.)
Jonklaas J, Davidson B, Bhagat S, Soldin SJ. Triiodothyronine levels in
athyreotic individuals during levothyroxine therapy. JAMA 2008;299:769
777. (Clinical study suggesting that levothyroxine replacement alone is suf-
ficient in individuals without a thyroid gland.)

Pharmacology of the
Adrenal Cortex
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 489-490
OVERVIEW OF THE ADRENAL CORTEX . . . . . . . . . . . . . . . . 489
GLUCOCORTICOIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
Synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
Metabolism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
Physiologic Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492
Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493
Adrenal Insufficiency. . . . . . . . . . . . . . . . . . . . . . . . . . 493
Glucocorticoid Excess . . . . . . . . . . . . . . . . . . . . . . . . . 494
Pharmacologic Classes and Agents . . . . . . . . . . . . . . . . . 494
Cortisol and Glucocorticoid Analogues. . . . . . . . . . . . . 494
Inhibitors of Adrenocortical Hormone Synthesis . . . . . . 498
Glucocorticoid Receptor Antagonists . . . . . . . . . . . . . . 499
MINERALOCORTICOIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
Synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
 INTRODUCTION
Like the pituitary gland, the adrenal gland consists of two
organs fused together during embryologic development.
The outer adrenal cortex originates from mesoderm, and the
inner adrenal medulla is derived from neural crest cells. The
adrenal cortex synthesizes and secretes steroid hormones es-
sential for salt balance, intermediary metabolism, and, in fe-
males, androgenic actions. The adrenal medulla synthesizes
and secretes the catecholamine epinephrine, which is im-
portant, although not essential, for maintaining sympathetic
tone. This chapter focuses on the adrenal cortex; because of
its importance in neuropharmacology, the adrenal medulla is
discussed in Chapter 10, Adrenergic Pharmacology.
The therapeutic utility of adrenocortical hormones spans
almost every area of medicine. This is largely because of the
usefulness of glucocorticoid analogues as efficacious and
potent anti-inflammatory agents. Unfortunately, long-term
systemic glucocorticoid therapy also produces a number of
predictable but undesirable adverse effects. The physiol-
ogy of mineralocorticoids has been studied in the etiology
of hypertension, cardiovascular disease, and renal disease,
28
Rajesh Garg and Gail K. Adler
Metabolism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
Physiologic Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
Aldosterone Hypofunction . . . . . . . . . . . . . . . . . . . . . . 500
Aldosterone Hyperfunction . . . . . . . . . . . . . . . . . . . . . 500
Pharmacologic Classes and Agents . . . . . . . . . . . . . . . . . 500
Mineralocorticoid Receptor Agonists . . . . . . . . . . . . . . 500
Mineralocorticoid Receptor Antagonists . . . . . . . . . . . 500
ADRENAL ANDROGENS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501
Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501
Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501
Pharmacologic Classes and Agents . . . . . . . . . . . . . . . . . 502
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 502
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 502
and there is considerable interest in the use of mineralocor-
ticoid receptor antagonists as therapies for these disorders.
Adrenal androgens, although lacking a definitive therapeutic
indication at present, are the focus of investigation for use
in female sexual dysfunction. Both deficiency and excess
of adrenocortical hormones can cause human disease. De-
ficiency states are treated by replacing the hormones in the
form of therapeutic agents, while inhibitors of adrenocortical
biosynthetic enzymes can be used to treat hormone excess.
 OVERVIEW OF THE ADRENAL CORTEX
The adrenal cortex synthesizes three classes of hormones:
mineralocorticoids, glucocorticoids, and androgens. His-
tologically, the adrenal cortex is divided into three zones.
Moving from the capsule toward the medulla, these re-
gions are the zona glomerulosa, zona fasciculata, and zona
reticularis (Fig. 28-1). The glomerulosa is responsible for
mineralocorticoid production and is under the control of
angiotensin II, blood potassium concentration, and, to a
lesser extent, adrenocorticotropic hormone (ACTH). The
489
Zona
glomerulosa
Aldosterone Aldosterone
Angiotensin II synthase
K+

ACTH

Zona
11-hydroxylase Cortisol,
fasciculata/
17-hydroxylase androgens
reticularis
 CHAPTER 28 / Pharmacology of the Adrenal Cortex 491

Feedback inhibition
ACTH

Anterior pituitary gland

Adrenal gland

Aminoglutethimide
Ketoconazole (high) Cholesterol

Trilostane
Ketoconazole
Pregnenolone
17
Progesterone 17-hydroxypregnenolone Dehydroepiandrosterone
21 17
Trilostane Trilostane

11-deoxycorticosterone 17-hydroxyprogesterone Androstenedione

Metyrapone 11 21

Corticosterone 11-deoxycortisol

Metyrapone 11

Aldosterone Cortisol Testosterone

Mineralocorticoids Glucocorticoids Sex steroids

FIGURE 28-2. Hormone synthesis in the adrenal cortex. The hormones of the adrenal cortex are steroids derived from cholesterol. The rate-limiting step in adrenal
hormone biosynthesis is the modification of cholesterol to pregnenolone by side-chain cleavage enzyme. From this step, pregnenolone metabolism can be directed toward
the formation of aldosterone, cortisol, or androstenedione. The flux of metabolites through each of these pathways depends on the tissue-specific expression of enzymes
in the different cell types of the cortex and on the relative activity of the different synthetic enzymes. Note that several enzymes are involved in more than one pathway and
that defects in these enzymes can affect the synthesis of more than one hormone. For example, a defect in steroid 21-hydroxylase prevents the synthesis of both aldoster-
one and cortisol. This overlap of synthetic activities also contributes to the nonselective action of glucocorticoid synthesis inhibitors such as trilostane. Enzymes are shown
as numbers: 17, steroid 17-hydroxylase; 21, steroid 21-hydroxylase; 11, steroid 11-hydroxylase. Aminoglutethimide and high levels of ketoconazole inhibit side-chain
cleavage enzyme. Ketoconazole also inhibits 17, 20-lyase. Trilostane inhibits 3-hydroxysteroid dehydrogenase. Metyrapone inhibits steroid 11-hydroxylase.

overall capacity, whereas albumin has low cortisol affinity
but high overall capacity. Only molecules of cortisol that are
unbound to protein (the so-called free fraction) are bioavail-
able, that is, available to diffuse through plasma membranes
into cells. Thus, the affinity and capacity of plasma bind-
ing proteins regulate the availability of active hormone and,
consequently, hormone activity.
The liver and kidneys are the primary sites of peripheral
cortisol metabolism. Through reduction and subsequent con-
jugation to glucuronic acid, the liver is responsible for inacti-
vating cortisol in the plasma. The conjugation reaction makes
cortisol more water soluble, thus enabling renal excretion.
Importantly, the liver and kidneys express different isoforms
of the enzyme 11-hydroxysteroid dehydrogenase, a regu-
lator of cortisol activity. The two isoforms catalyze opposing
reactions. In distal collecting duct cells of the kidney, 11-
hydroxysteroid dehydrogenase type 2 (11-HSD 2) converts
cortisol to the biologically inactive compound cortisone,
which (unlike cortisol) does not bind to the mineralocorticoid
receptor (see below, Fig. 28-3B). Expression of 11-HSD 2
protects the mineralocorticoid receptor from activation by
cortisol in a variety of cell types, including endothelial cells
and vascular smooth muscle cells. In contrast, cortisone can
be converted back to cortisol (also referred to as hydrocorti-
sone) in the liver by 11-hydroxysteroid dehydrogenase type
1 (11-HSD 1, Fig. 28-3A). The interplay between these op-
posing reactions determines overall glucocorticoid activity.
In addition, as discussed below, the activity of these enzymes
is important in glucocorticoid pharmacology.
Physiologic Actions
Like other steroid hormones, unbound cortisol diffuses
through the plasma membrane into the cytosol of target cells,
where the hormone binds to a cytosolic receptor. There are
two types of glucocorticoid receptors: the Type I (mineralo-
corticoid) and Type II glucocorticoid receptors. The Type
I receptor is expressed in the organs of excretion (kidney,
colon, salivary glands, sweat glands) and other tissues in-
cluding the hippocampus, vasculature, heart, adipose tissue,
and peripheral blood cells. The Type II receptor has a broader
A
O O
OH OH
OH OH
O HO
H 11-HSD 1 H

(liver)
H H H H
O O
Cortisone Cortisol

B O O
OH OH
OH OH
HO O
H 11-HSD 2 H

(kidney)
H H H H
O O
Cortisol Cortisone
(agonist at mineralocorticoid (inactive at mineralocorticoid
receptor) receptor)

Hypothalamus
CRH
Pituitary ACTH
gland
Cortisol
Adrenal
gland
FIGURE 28-4. The immuneadrenal axis. Cortisol has profound immunosuppressive effects. Cortisol inhibits the action of several mediators of inflammation
(eicosanoids, serotonin, platelet activating factor [PAF], bradykinin). Cortisol also inhibits the release of a number of cytokines from macrophages, including IL-1, IL-
1, IL-6, and TNF-. Because these cytokines in turn promote the hypothalamic release of CRH and thereby increase serum cortisol levels, it is hypothesized that the
stress-induced increase in cortisol limits the extent of the inflammatory response.
CRH then travels through the hypothalamicpituitary por-
tal system and binds to G protein-coupled receptors on the
surface of corticotroph cells in the anterior pituitary gland.
CRH binding stimulates the corticotrophs to synthesize proo-
piomelanocortin (POMC), a precursor polypeptide that is
cleaved into multiple peptide hormones including ACTH. The
neurons in the paraventricular nucleus that respond to stress
by synthesizing and secreting CRH can also respond to stress
by synthesizing and secreting vasopressin. This vasopressin
is released into the hypothalamicpituitary portal system to-
gether with CRH, and it synergizes with CRH to increase the
release of ACTH by the anterior pituitary gland. Interestingly,
the stress-responsive parvocellular neurons that secrete CRH
and vasopressin into the hypothalamicpituitary portal system
are different from the osmolality-responsive magnocellular
neurons that synthesize vasopressin and transport this hor-
mone to the posterior pituitary gland (see Chapter 26), even
though both types of neurons are located in the paraventricu-
lar nucleus of the hypothalamus. Potential crosstalk between
the parvocellular and magnocellular systems in the paraven-
tricular nucleus is an area of active investigation.
Proteolytic cleavage of POMC yields not only ACTH but
also -melanocytestimulating hormone (MSH), lipotropin,
and -endorphin. MSH binds to receptors on skin melano-
cytes, promoting melanogenesis and thereby increasing skin
pigmentation. Because of the similarities between the ACTH
and MSH peptide sequences, high concentrations of ACTH
can also bind to and activate MSH receptors. This action
becomes apparent in primary hypoadrenalism (see below),
in which increased ACTH levels result in increased skin
pigmentation. The role of lipotropin in human physiology
is uncertain but is thought to involve control of lipolysis. -
Endorphin is an endogenous opioid that is important for pain
modulation and for regulation of reproductive physiology.
Because steroid hormones are able to diffuse freely
through cell membranes and because the adrenal gland
CHAPTER 28 / Pharmacology of the Adrenal Cortex 493
Thermoregulatory Immune
centers stimulus
Fever
Macrophages
Inflammatory
cytokines
(IL-1, IL-1, IL-6, TNF-)
Mediators of inflammation
(eicosanoids, serotonin,
PAF, bradykinin)
stores little cortisol, ACTH regulates cortisol production
by promoting synthesis of the hormone. ACTH also has a
trophic effect on the zona fasciculata and zona reticularis of
the adrenal cortex, and hypertrophy of the cortex can occur
in response to chronically elevated levels of ACTH.
As in other endocrine axes, the hormone (cortisol) pro-
duced by the target organ (adrenal cortex) exerts negative
feedback regulation at the level of both the hypothalamus
and the anterior pituitary gland. High cortisol levels de-
crease both synthesis and release of CRH and ACTH. Be-
cause ACTH has important trophic effects on the adrenal
cortex, the absence of ACTH leads to atrophy of the cortisol-
producing zona fasciculata and the androgen-producing zona
reticularis. However, the aldosterone-producing zona glom-
erulosa cells continue to function in the absence of ACTH,
because angiotensin II and blood potassium continue to
stimulate the production of aldosterone.
Pathophysiology
Diseases affecting glucocorticoid physiology can be divided
into disorders of hormone deficiency and disorders of hor-
mone excess. Addisons disease is the classic example of
adrenocortical insufficiency, while Cushings syndrome ex-
emplifies cortisol excess.
Adrenal Insufficiency
Addisons disease is an example of a primary adrenal insuf-
ficiency in which the adrenal cortex is selectively destroyed,
most commonly due to a T cell-mediated autoimmune reac-
tion but alternatively due to infection, infiltration, cancer, or
hemorrhage. Destruction of the cortex results in decreased
synthesis of all classes of adrenocortical hormones. By
comparison, secondary adrenal insufficiency is caused by
hypothalamic or pituitary disorders or by prolonged admin-
istration of exogenous glucocorticoids. In secondary adrenal
insufficiency, the decrease in ACTH levels causes decreased
 O
OH
OH
HO
H 16

F H
6
O
 CHAPTER 28 / Pharmacology of the Adrenal Cortex 495

A O
OH
O O OH
OH OH HO
OH OH 11
HO HO H
11 11
H H
H H
H H H H O
O O
Cortisol Prednisolone Methylprednisolone

O O
OH OH
OH OH
HO HO
11 11
H H

F H F H

O O
Dexamethasone Fludrocortisone

B O O
OH OH
OH OH
O O
11 11
H H

H H H H
O O
Prednisone Cortisone

FIGURE 28-6. Glucocorticoid analogues. Panel A shows a number of 11-hydroxy glucocorticoids, while panel B shows two 11-keto congeners. Note that the
drugs in A are physiologically active, while the drugs in B are prodrugs that must be activated by 11-HSD 1 to become active compounds. The structural class to which
a glucocorticoid analogue belongs can be an important consideration in therapeutic decision making. For example, because the skin lacks significant 11-HSD 1 activity,
only 11-hydroxy glucocorticoids can be used in topical glucocorticoid creams. HSD, hydroxysteroid dehydrogenase.

example, addition of a double bond between carbons 1 and
2 of cortisol creates prednisolone (Fig. 28-6), which has
45 times the anti-inflammatory potency of cortisol. Further
addition of an -methyl group (where is defined as the
side-group orientation axial to the compound, while is the
equatorial orientation) to carbon 6 of prednisolone creates
methylprednisolone, which has an anti-inflammatory po-
tency 56 times that of cortisol.
Although prednisolone and methylprednisolone have sig-
nificantly greater glucocorticoid potency than cortisol, their
potency at the mineralocorticoid receptor is lower than that of
cortisol. In contrast, addition of an -fluorine (F) to carbon 9
of cortisol increases both the glucocorticoid and mineralocor-
ticoid potencies of the resulting compound, known as fludro-
cortisone (Fig. 28-6). Because of its remarkably enhanced
mineralocorticoid activity, fludrocortisone is useful in the
treatment of mineralocorticoid deficiency states (see below).
Dexamethasone incorporates two of the above changes
to the cortisol backbone (1,2 double bond, 9 fluorine) as
well as the addition of an -methyl group at the 16-carbon
position (Fig. 28-6). This compound has more than 18 times
the glucocorticoid potency of cortisol, but virtually no min-
eralocorticoid activity.
A number of other permutations have been made to the
cortisol backbone in other synthetic glucocorticoids, but the
above discussion highlights the pertinent structural differ-
ences among the most common synthetic glucocorticoids.
Clinically, it is most important to be aware of the potency of
each agent relative to cortisol, especially when considering
a change from one analogue to another that has different
relative glucocorticoid and mineralocorticoid activities. In
general, glucocorticoids used at pharmacologic doses should
have minimal mineralocorticoid activity to avoid the conse-
quences of mineralocorticoid excess (i.e., hypokalemia, vol-
ume expansion, and hypertension). Table 28-1 summarizes
the relative glucocorticoid potencies and mineralocorticoid
activities of several common glucocorticoid analogues.
Duration of Action
The duration of glucocorticoid action is a complex pharma-
cokinetic variable that depends on:
1. Fraction of the drug bound to plasma proteins. More than
90% of circulating cortisol is protein-bound, primarily to
CBG and, to a lesser degree, to albumin. In contrast, gluco-
corticoid analogues generally bind to CBG with low affin-
ity. As a result, approximately 2/3 of a typical glucocorticoid
498 Principles of Endocrine Pharmacology

O FIGURE 28-7. Structures of common inhaled glucocorticoids. Most of the

inhaled glucocorticoids are halogenated analogues of cortisol that are highly po-
O
O tent glucocorticoid agonists with little mineralocorticoid activity (halogen atoms
O are shown in blue). Their high potency allows low doses of the inhaled gluco-
HO
corticoids to inhibit the local inflammatory response that is a critical component
H of asthma pathophysiology. In addition, because a number of these compounds
O
are subject to almost complete first-pass metabolism in the liver, the fraction of
inhaled glucocorticoid that is inadvertently swallowed (80% of the inhaled dose)
Cl H
becomes inactivated so that it is not systemically bioavailable. The fraction of in-
O haled glucocorticoid delivered to the lung is eventually absorbed into the systemic
circulation.
Beclomethasone dipropionate

OH
O dosing at many-fold higher local concentrations than could
O be achieved safely with systemic administration. The glu-
HO cocorticoid that is administered must be biologically active
O because the skin has little, if any, of the 11-HSD 1 enzyme
H
needed to convert glucocorticoid prodrugs to active com-
pounds. Hydrocortisone, methylprednisolone, and dexa-
H H methasone are effective steroids for cutaneous use.
O
Budesonide Depot Glucocorticoids. Depot intramuscular preparations of
glucocorticoid analogues last for days to weeks and can be
OH an alternative to daily or alternate-day oral glucocorticoids
O
in the treatment of inflammatory diseases. Although depot
O
formulations reduce the necessity for daily oral administra-
HO tion, these preparations are seldom used because the dose
O cannot be titrated on a frequent basis. Depot preparations
H of methylprednisolone suspended in polyethylene glycol are
commonly used, however, for intra-articular administra-
H H tion. This approach can be indicated for inflammatory pro-
O
cesses restricted to the joints, such as rheumatoid arthritis
or gout. Intra-articular glucocorticoid injection is useful in
F acute attacks of gout that are unresponsive to colchicine or
Flunisolide
indomethacin. Intra-articular and bursa injections require the
O use of active glucocorticoid, because joint tissue lacks 11-
HSD 1.
O
O
Pregnancy. The placentalmaternal barrier provides another
HO S F example of selective glucocorticoid targeting. During preg-
H nancy, the placenta metabolically separates the fetus from
the mother. Because of this, prednisone can be administered
F H to the mother during pregnancy without fetal side effects.
The maternal liver activates the prednisone to prednisolone,
O but placental 11-HSD 2 converts the prednisolone back to
F inactive prednisone. Because the liver does not function dur-
ing fetal life, the fetus does not, in turn, activate prednisone.
Fluticasone propionate
Therefore, use of prednisone in pregnancy does not result in
O delivery of an active glucocorticoid to the fetus.
OH Glucocorticoids promote lung development in the fetus.
OH If glucocorticoid therapy is indicated to promote fetal lung
HO
maturation, dexamethasone is commonly administered to
H OH
the mother. Dexamethasone is a poor substrate for placen-
tal 11-HSD 2, and therefore crosses the placenta in active
F H form from the maternal circulation to the fetal circulation,
O where it stimulates lung maturation. The dose of dexameth-
Triamcinolone asone must be titrated carefully because exposure to exces-
sive glucocorticoid can have deleterious effects on fetal
development.

Inhibitors of Adrenocortical Hormone Synthesis

Several compounds are available to inhibit hormone biosyn-
thesis by the adrenal cortex. Although these drugs have some
specificity for individual adrenal enzymes (Table 28-2), it is
500 Principles of Endocrine Pharmacology
cell surface. The physiologic and pathophysiologic roles of
this second signaling mechanism are an active area of inves-
tigation.
In the kidney, aldosterone increases Na/KATPase ex-
pression in the basolateral membrane of distal nephron cells.
Enhanced Na/K ATPase activity secondarily increases so-
dium reabsorption and potassium secretion across the lume-
nal epithelium of the nephron (see Chapter 20). As a result,
sodium retention, potassium excretion, and H excretion are
all enhanced by aldosterone. Increased sodium retention is
accompanied by increased water retention and, thus, extra-
cellular volume expansion. Excess aldosterone can cause
hypokalemic alkalosis and hypertension, while hypoaldos-
teronism can cause hyperkalemic acidosis and hypotension.
The mineralocorticoid receptor is also expressed in cells not
involved in sodium reabsorption, including endothelial cells,
vascular smooth muscle cells, cardiomyocytes, adipocytes, neu-
rons, and inflammatory cells. Preclinical studies demonstrate
a role for the mineralocorticoid receptor in the pathophysiol-
ogy of vascular injury, atherosclerosis, heart disease, renal dis-
ease, and stroke. Activation of the mineralocorticoid receptor
increases oxidative stress, promotes inflammation, regulates
adipocyte differentiation, and reduces insulin sensitivity. In
humans, antagonists of aldosterone action at the mineralocor-
ticoid receptor, such as spironolactone and eplerenone, reduce
morbidity and mortality in heart failure, improve vascular
function, reduce cardiac hypertrophy, and reduce albuminuria.
These beneficial effects of mineralocorticoid receptor blockade
appear to be independent of changes in blood pressure.
Regulation
Three systems regulate aldosterone synthesis: the renin
angiotensin system, blood potassium levels, and ACTH.
The renin-angiotensinaldosterone system is a central
regulator of extracellular fluid volume. Decreases in ex-
tracellular fluid volume decrease perfusion pressure at the
afferent arteriole of the renal glomerulus, which acts as a
baroreceptor. This stimulates the juxtaglomerular cells to
secrete renin, a protease that cleaves the prohormone angio-
tensinogen to angiotensin I. Angiotensin I is then converted
to angiotensin II by angiotensin converting enzyme, which
is expressed at high concentrations by the capillary endothe-
lium of the lungs. Angiotensin II has direct arteriolar pressor
effects, and it stimulates aldosterone synthesis by binding to
and activating a G protein-coupled receptor in zona glom-
erulosa cells of the adrenal cortex.
Potassium loading increases aldosterone synthesis indepen-
dent of renin activity. Because aldosterone activity at the distal
nephron promotes potassium excretion, this control mechanism
serves a homeostatic role in regulating potassium balance.
Finally, ACTH acutely stimulates aldosterone synthesis
in the zona glomerulosa. Changes in ACTH levels contribute
to the circadian regulation of aldosterone and to the aldoster-
one rises associated with acute stress, such as hypoglycemia.
Unlike cortisol, aldosterone does not negatively regulate
ACTH secretion.
Pathophysiology
Aldosterone Hypofunction
Aldosterone hypofunction (hypoaldosteronism) can result
from a primary decrease in aldosterone synthesis or action,
or from a secondary decrease in aldosterone regulators such
as angiotensin II. Most cases of hypoaldosteronism result
from decreased aldosterone synthesis. Defects in the gene
coding for steroid 21-hydroxylase, an enzyme necessary
for both aldosterone and glucocorticoid synthesis, lead to
congenital adrenal hyperplasia (discussed under adrenal an-
drogen pathophysiology) and cause salt wasting as a result
of aldosterone deficiency. Addisons disease, or primary
adrenal insufficiency, results in hypoaldosteronism second-
ary to destruction of the zona glomerulosa. Most cases of
Addisons disease are caused by autoimmune adrenalitis;
other causes of adrenal cortex destruction include tuber-
culosis, metastatic cancer, and hemorrhage. In each case,
aldosterone hypofunction can lead to salt wasting, volume
depletion, hyperkalemia, and acidosis. Hypoaldosteronism
can also result from states of decreased renin production (so-
called hyporeninemic hypoaldosteronism, which is common
in diabetic renal insufficiency). Both resistance to the action
of aldosterone at the level of the mineralocorticoid receptor
and inactivating mutations of the aldosterone-regulated epi-
thelial sodium channel (ENaC) in the cortical collecting duct
of the nephron result in clinical hypoaldosteronism, despite
normal to elevated aldosterone levels in the blood.
Aldosterone Hyperfunction
Primary hyperaldosteronism results from excess aldos-
terone production by the adrenal cortex. Bilateral zona glo-
merulosa adrenal hyperplasia and an aldosterone-producing
adenoma are the two most common causes. Increased al-
dosterone synthesis leads to positive sodium balance, with
consequent extracellular volume expansion, suppression of
plasma renin activity, potassium wasting and hypokalemia,
and hypertension. Independent of its effect on blood pressure,
primary hyperaldosteronism also has adverse cardiovascular
effects, including endothelial dysfunction, increased intima-
media thickness, vascular stiffness, and increased left ven-
tricular wall thickness. Primary hyperaldosteronism is also a
cause of insulin resistance.
Pharmacologic Classes and Agents
Mineralocorticoid Receptor Agonists
Pathophysiologic conditions leading to hypoaldosteronism
necessitate replacement with physiologic doses of a min-
eralocorticoid. It is not possible to administer aldosterone
itself as a therapeutic agent, because the liver converts more
than 75% of oral aldosterone to an inactive metabolite dur-
ing first-pass metabolism. Instead, the cortisol analogue
fludrocortisone, which has minimal first-pass hepatic me-
tabolism and a high mineralocorticoid-to-glucocorticoid po-
tency ratio, is used. The adverse effects of fludrocortisone
therapy are all related to the ability of this agent to mimic
a state of mineralocorticoid excess, including hypertension,
hypokalemia, and even cardiac failure. To ensure that an
appropriate dose of drug is being administered, it is impor-
tant to monitor serum potassium and blood pressure levels
closely in all patients receiving fludrocortisone.
Mineralocorticoid Receptor Antagonists
Spironolactone (also discussed in Chapters 20 and 29) is a
competitive antagonist at the mineralocorticoid receptor, but
the drug also binds to and inhibits the androgen and proges-
terone receptors. The latter actions, which result in adverse
effects such as gynecomastia in males, limit the usefulness
 CHAPTER 28 / Pharmacology of the Adrenal Cortex 501

of this agent in some patient subsets. Eplerenone is a miner-
alocorticoid receptor antagonist that binds selectively to the
mineralocorticoid receptor; this selectivity may make epler-
enone free of the unwanted adverse effects of spironolac-
tone. Both spironolactone and eplerenone can be used as
antihypertensive agents, and both are approved for use in
patients with heart failure.
Antagonism of the mineralocorticoid receptor can re-
sult in significant hyperkalemia. Because many patients
with heart failure are prescribed both spironolactone or
eplerenone and an angiotensin converting enzyme inhibitor
(which also raises blood potassium levels), it is important to
monitor potassium levels closely in these patients.
 ADRENAL ANDROGENS
Physiology
Sex steroids produced by the adrenal cortex, primarily
dehydroepiandrosterone (DHEA), have an uncertain role in
human physiology. DHEA seems to be a prohormone that is
converted to more potent androgens, primarily testosterone,
in the periphery. Adrenocortical androgens are an important
source of testosterone in females; these hormones are neces-
sary for the development of female axillary and pubic hair
at the time of puberty, when adrenal androgen secretion is
activated (adrenarche).
Pathophysiology
Congenital adrenal hyperplasia (CAH) and polycystic
ovarian syndrome are two important diseases related to
adrenocortical androgen production. Congenital adrenal hy-
perplasia is a clinical term denoting a number of inherited
enzyme deficiencies in the adrenal cortex. Enzyme defects
leading to increased adrenocortical androgen production
cause hirsutism and virilization in females. Polycystic ovar-
ian syndrome, discussed in Chapter 29, may be caused by
congenital adrenal hyperplasia in a subset of patients.
The most common form of congenital adrenal hyper-
plasia results from a deficiency of steroid 21-hydroxylase.
Deficiency of 21-hydroxylase results in the inability of ad-
renocortical cells to synthesize both aldosterone and cortisol
(Fig. 28-8). Because cortisol is the main negative feedback

Feedback inhibition
ACTH

Anterior pituitary gland

Hyperplastic adrenal cortex

Cholesterol

Pregnenolone

Progesterone 17-hydroxypregnenolone Dehydroepiandrosterone

21

11-deoxycorticosterone 17-hydroxyprogesterone Androstenedione

21

Corticosterone 11-deoxycortisol

Aldosterone Cortisol Testosterone

Mineralocorticoids Glucocorticoids Sex steroids

FIGURE 28-8. Congenital adrenal hyperplasia. Steroid 21-hydroxylase deficiency, the most common cause of congenital adrenal hyperplasia, results in impaired
biosynthesis of aldosterone and cortisol (dashed lines). Therefore, steroid hormone synthesis in the adrenal cortex is shunted toward increased production of sex steroids
(thick lines). The lack of cortisol production decreases the negative feedback on corticotroph cells of the anterior pituitary gland (dashed line), causing increased ACTH
release (thick blue arrow). Increased levels of ACTH induce adrenal hyperplasia and further stimulate the synthesis of sex steroids. This pathway can be interrupted by
administering exogenous cortisol. The deficient enzyme is shown as a number: 21, steroid 21-hydroxylase.
502 Principles of Endocrine Pharmacology
regulator of pituitary ACTH release, the decreased cortisol
synthesis that results from 21-hydroxylase deficiency disin-
hibits ACTH release. Increased ACTH restores the level of
cortisol in patients with partial enzyme defects, but there is
also shunting of precursor compounds into the unblocked
androgen pathway, resulting in greater production of DHEA
and androstenedione. The liver subsequently converts these
compounds into testosterone. In severe 21-hydroxylase de-
ficiency, there may be a virilizing effect on the developing
female fetus. As a result, female neonates with severe 21-
hydroxylase deficiency typically have masculinized or am-
biguous external genitalia. In the male neonate, however,
increased adrenal androgens may have little or no notice-
able phenotypic effect. Infants with severe 21-hydroxylase
deficiency are commonly diagnosed in infancy during an
acute salt-wasting crisis, which results from the inability to
synthesize aldosterone and cortisol. Mild 21-hydroxylase
deficiency may manifest later in life as hirsutism, acne, and
oligomenorrhea in young women after menarche.
Treatment of congenital adrenal hyperplasia due to severe
enzyme defects requires physiologic replacement doses of
glucocorticoids and mineralocorticoids. Treatment of con-
genital adrenal hyperplasia in patients with mild enzyme
defects may include therapy with exogenous glucocorticoid
to suppress excessive hypothalamic and pituitary release of
CRH and ACTH, and thus to decrease production of adrenal
androgens.
Pharmacologic Classes and Agents
The androgens synthesized by the adrenal gland can be
viewed as prohormones. Because no specific receptors for
either DHEA or androstenedione have been described, the
activity of these hormones depends on their conversion to
testosterone, and subsequently to dihydrotestosterone, in
peripheral target tissues. As discussed above, adrenal andro-
gen excess can cause a variety of syndromes in women; the
pharmacologic interruption of excessive androgenic activity
is discussed in Chapter 29.
DHEA is not regulated by the Food and Drug Administra-
tion (FDA) and is commonly used as an over the counter
drug. Population cross-sectional studies have shown a recip-
rocal relationship between an age-related decline in DHEA
levels and the risk of cardiovascular disease and cancer. Re-
placement therapy with DHEA may be indicated for cases
of Addisons disease in which there is bona fide DHEA de-
ficiency. Exogenous DHEA can be converted to testosterone
by the liver. As a result, DHEA is commonly abused for its
anabolic effects.
 CONCLUSION AND FUTURE DIRECTIONS
Aldosterone, cortisol, and the adrenal androgens regu-
late many aspects of basic homeostasis. Aldosterone
regulates extracellular fluid volume by promoting sodium
reabsorption and fluid retention. Cortisol regulates diverse
physiologic processes, including energy homeostasis and
inflammatory responses. The physiologic role of adre-
nal androgens is unknown, but pathophysiologic states
causing increased adrenal androgen production have
significant masculinizing effects in women. Antagonists
of aldosterone are currently used to control high blood
pressure. However, accumulating evidence suggests that
antagonists specific for the aldosterone receptor may also
become important therapies for cardiovascular and reno-
vascular diseases in heart failure and diabetes as well as
hypertension. Aldosterone synthase inhibitors are being
developed and may be used in the future to reduce aldos-
terone production. Glucocorticoid pharmacology is an im-
mense field, primarily because glucocorticoids are used
to suppress inflammation in a number of disease states.
Chronic glucocorticoid use is associated with a multitude
of predictable adverse effects, and future research in this
area will attempt to minimize the adverse effects of gluco-
corticoid therapy while maintaining the anti-inflammatory
actions. Such efforts could include the development of
tissue-selective glucocorticoid agonists and antagonists
(analogous to the selective estrogen receptor modulators),
as well as further refinement of drug delivery methods.
The pharmacology of adrenal androgens needs to be stud-
ied more extensively to determine the indications, if any,
for DHEA therapy.
Acknowledgments
We thank Ehrin J. Armstrong and Robert G. Dluhy for their
valuable contributions to this chapter in the First and Second
Editions of Principles of Pharmacology: The Pathophysi-
ologic Basis of Drug Therapy.
Suggested Reading
Barnes PJ. Corticosteroids: the drugs to beat. Eur J Pharmacol
2006;533:214. (Review of glucocorticoid pharmacology, with emphasis
on inhaled steroids.)
Fuller PJ, Young MJ. Mechanisms of mineralocorticoid action. Hyperten-
sion 2005;46:12271235. (Molecular mechanisms of mineralocorticoid ac-
tion, including cardiovascular effects.)
Nair KS, Rizza RA, OBrien P, et al. DHEA in elderly women and DHEA
or testosterone in elderly men. N Engl J Med 2006;355:16471659. (Large
clinical trial of DHEA.)
Salvatori R. Adrenal insufficiency. JAMA 2005;294:24812488. (Pathophys-
iology and treatment of adrenal insufficiency.)
Sapolsky R. How do glucocorticoids influence stress responses? Integrat-
ing permissive, suppressive, stimulatory, and preparative actions. Endocrine
Rev 2000;21:5589. (Thorough review discussing the numerous roles of
glucocorticoids in stress responses.)
Stellato C. Post-transcriptional and nongenomic effects of glucocorticoids.
Proc Am Thorac Soc 2004;1:255263. (Details of recent advances in glu-
cocorticoid signaling.)
Williams JS, Williams GH. 50th anniversary of aldosterone. J Clin Endo-
crinol Metab 2003;88:23642372. (Historical review of mineralocorticoids.)

Pharmacology of Reproduction
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 505-506
PHYSIOLOGY OF REPRODUCTIVE HORMONES . . . . . . . . . . 505
Synthesis of Progestins, Androgens, and Estrogens . . . . . 505
Hormone Action and Metabolism . . . . . . . . . . . . . . . . . . . 506
Hypothalamic-PituitaryReproduction Axis . . . . . . . . . . . . 508
Integration of Endocrine Control: The Menstrual Cycle . . . 509
PATHOPHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 510
Disruption of the Hypothalamic-
PituitaryReproduction Axis . . . . . . . . . . . . . . . . . . . . . . . 511
Inappropriate Growth of Hormone-Dependent Tissues . . . 511
Decreased Estrogen or Androgen Secretion . . . . . . . . . . . 512
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 512
Inhibitors of Gonadal Hormones . . . . . . . . . . . . . . . . . . . . 512
Synthesis Inhibitors. . . . . . . . . . . . . . . . . . . . . . . . . . . 512
Receptor Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . 513
 INTRODUCTION
This chapter presents endocrine pharmacology relevant
to both the male and female reproductive tracts. Although
men and women differ in their hormonal profiles, andro-
gens and estrogens are both under the control of the an-
terior pituitary gland gonadotropins, luteinizing hormone
(LH) and follicle-stimulating hormone (FSH), and ulti-
mately regulated by hypothalamic release of gonadotropin-
releasing hormone (GnRH). Female hormone patterns are
temporally more complex and cyclic than male patterns:
hormonal control of the menstrual cycle is an illustrative
example of how sex hormones are integrated into a com-
plex physiologic system. Understanding the menstrual
cycle also provides a basis for understanding the pharma-
cology of contraception.
A number of diseases are treated pharmacologically via
modification of reproductive hormone activity; these range
from infertility and endometriosis to breast and prostate can-
cer. Key concepts in this chapter include: (1) the interactions
between estrogen and the pituitary gland; (2) the effects of
GnRH release frequency on gonadotropin release; (3) the
tissue selectivity of estrogen receptor agonists and antago-
nists; and (4) the various strategies used to antagonize the ef-
fects of endogenous sex hormones, from suppression of the
hypothalamic-pituitaryreproduction axis to antagonism at
the target tissue receptor. Because of its historical role in the
prevention of osteoporosis, estrogen replacement therapy
29
Ehrin J. Armstrong and Robert L. Barbieri
Hormones and Hormone Analogues: Contraception . . . . . 516
Combination EstrogenProgestin Contraception . . . . . 516
Progestin-Only Contraception . . . . . . . . . . . . . . . . . . . 517
Emergency (Morning-After) Contraception. . . . . . . . . . 517
Male Contraception . . . . . . . . . . . . . . . . . . . . . . . . . . . 518
Hormones and Hormone Analogues: Replacement . . . . . . 518
Estrogens and Progestins . . . . . . . . . . . . . . . . . . . . . . 518
Androgens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 519
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
is discussed both here and in Chapter 31, Pharmacology of
Bone Mineral Homeostasis. Androgen replacement therapy
is discussed at the end of this chapter.
 PHYSIOLOGY OF REPRODUCTIVE
HORMONES
Synthesis of Progestins, Androgens,
and Estrogens
The synthesis of progestins, androgens, and estrogens is
closely intertwined. All three groups are steroid hormones
derived from the metabolism of cholesterol. The synthesis
of these hormones is similar to that of adrenal sex hormones,
which is discussed in Chapter 28, Pharmacology of the Ad-
renal Cortex.
The terminology progestins, androgens, and estro-
gens denotes a number of related hormones, rather than a
single molecule in each group (Fig. 29-1). The progestins
consist of progesterone, a common precursor to testosterone
and estrogen synthesis (see also Fig. 28-2), and a number of
synthetically altered progesterone derivatives used for thera-
peutic purposes. Progestins generally exert antiproliferative
effects on the female endometrium by promoting the endome-
trial lining to secrete rather than proliferate (see below). Pro-
gesterone is also required for the maintenance of pregnancy.
Androgens, all of which have masculinizing properties,
505
 CHAPTER 29 / Pharmacology of Reproduction 507

HO
Cholesterol

Cholesterol side chain

cleavage enzyme

HO
Pregnenolone

17-hydroxylase 3-HSD

O O

OH

HO O
17-Hydroxypregnenolone Progesterone
Progestins

17-hydroxylase
17, 20-lyase
O

OH

O
17-Hydroxyprogesterone

HO
Dehydroepiandrosterone

O OH

3-HSD
Androgens
17-HSD
O O
Androstenedione Testosterone

Aromatase Aromatase

O OH

Estrogens

HO HO
Estrone Estradiol

FIGURE 29-1. Synthesis of progestins, androgens, and estrogens. Progestins, androgens, and estrogens are steroid hormones derived from cholesterol.
The major progestins include progesterone and 17-hydroxyprogesterone. The androgens include dehydroepiandrosterone (DHEA), androstenedione, and testosterone.
Estrogens include estrone and estradiol. Estrogens are aromatized forms of their conjugate androgens: androstenedione is aromatized to estrone, and testosterone is
aromatized to estradiol. Estradiol and estrone are both metabolized to estriol, a weak estrogen (not shown). Some of the precursorproduct relationships among the
hormones are omitted for clarity (see Fig. 28-2). HSD, hydroxysteroid dehydrogenase.
508 Principles of Endocrine Pharmacology
SHBG
Testosterone
Plasma
Cytoplasm
Dihydrotestosterone
Androgen receptor
5-reductase
Finasteride Nucleus
Dutasteride
Promoters Coding sequences
Transcription of
testosterone-dependent
genes
FIGURE 29-2. Intracellular conversion of testosterone to dihydrotes-
tosterone. Testosterone circulates in the plasma bound to sex hormone-binding
globulin (SHBG) and albumin (not shown). Free testosterone diffuses through the
plasma membrane of cells into the cytosol. In target tissues, the enzyme 5-
reductase converts testosterone to dihydrotestosterone, which has increased
androgenic activity relative to testosterone. Dihydrotestosterone binds with high
affinity to the androgen receptor, forming a complex that is transported into the
nucleus. Homodimers of dihydrotestosterone and androgen receptor initiate tran-
scription of androgen-dependent genes. Finasteride and dutasteride, drugs used
in the treatment of benign prostatic hyperplasia and male pattern hair loss, inhibit
the enzyme 5-reductase.
thoroughly as those of the estrogen receptor, it is likely that
the same complexities exist for these receptors. The recogni-
tion that differential binding of modular transcription factors
to ERs could alter estrogenic effects will likely prove a bur-
geoning area of pharmacologic research in the near future,
as pharmaceutical researchers continue to develop receptor
agonists and antagonists with selective actions in specific
tissues. Selective estrogen receptor modulators (SERMs, see
below) are the first drugs to take advantage of the tissue se-
lectivity of sex hormone receptor function.
Hypothalamic-PituitaryReproduction Axis
The hypothalamic-pituitaryreproduction axis regulates sex
hormone synthesis. Gonadotropin-releasing hormone (GnRH)
resides at the top of this three-tiered hierarchy. The hypothala-
mus secretes GnRH in pulses (Fig. 29-3). GnRH travels via
the hypothalamicpituitary portal system to stimulate gonado-
troph cells of the anterior pituitary gland. Stimulation of go-
nadotroph cells via a G protein-coupled cell surface receptor
increases the synthesis and secretion of LH and FSH, which
are jointly referred to as the gonadotropins.
Although one cell type produces both LH and FSH, the
synthesis and release of these two hormones are controlled in-
dependently. Current research suggests that the rate of GnRH
secretion may preferentially alter the secretion patterns of LH
and FSH. Pulsatile secretion of GnRH is critical for the proper
functioning of the hypothalamic-pituitaryreproduction axis.
When GnRH is administered continuously, gonadotroph re-
lease of LH and FSH is suppressed rather than stimulated.
This effect has the important pharmacologic consequence that
pulsatile administration of exogenous GnRH stimulates go-
nadotropin release, whereas continuous GnRH administration
inhibits LH and FSH release and thereby blocks target cell
function.
LH and FSH have analogous but somewhat different
effects in males and females. The pertinent target cells in the
male are the Leydig and Sertoli cells of the testis, while the
thecal and granulosa cells of the ovary mediate gonadotro-
pin function in the female (Fig. 29-4). In each case, a two-
cell system is coordinated to mediate sex hormone actions.
In the male, LH stimulates testicular Leydig cells to increase
the synthesis of testosterone, which then diffuses into neigh-
boring Sertoli cells. In the Sertoli cell, FSH stimulation in-
creases the production of androgen binding protein (ABP),
which is important for maintaining the high testicular con-
centrations of testosterone necessary for spermatogenesis. In
addition, FSH stimulates the Sertoli cell to produce other
proteins necessary for sperm maturation. In the female, LH
GnRH
(pulsatile)
LH/FSH
Estrogen or
testosterone
Estrogen
(at ovulation)
LH
FSH
Activin
Inhibin
Ovaries or testes
FIGURE 29-3. The hypothalamic-pituitaryreproduction axis. The hypo-
thalamus secretes gonadotropin-releasing hormone (GnRH) into the hypothalamic
pituitary portal system in a pulsatile pattern. GnRH stimulates gonadotroph cells in
the anterior pituitary gland to synthesize and release luteinizing hormone (LH) and
follicle-stimulating hormone (FSH). These two hormones, referred to as gonadotro-
pins, promote ovarian and testicular synthesis of estrogen and testosterone, respec-
tively. Estrogen and testosterone inhibit release of GnRH, LH, and FSH. Depending
on the time in the menstrual cycle, the concentration of estrogen in the plasma, and
the rate at which estrogen concentration increases in the plasma, estrogen can also
stimulate pituitary gonadotropin release (e.g., at ovulation). Both the ovaries and
testes secrete inhibin, which selectively inhibits FSH secretion, and activin, which
selectively promotes FSH secretion.

LH FSH
Male
LH-R FSH-R
ABP
Testosterone Testosterone
synthesis
Testosterone-ABP
Leydig cell Sertoli cell
LH FSH
Female
LH-R FSH-R
Aromatase
Androgen Androgen
synthesis
Estrogen
Thecal cell Granulosa cell
FIGURE 29-4. Two-cell systems for gonadal hormone action. In the male,
the binding of luteinizing hormone (LH) to the LH receptor (LH-R) activates tes-
tosterone synthesis in Leydig cells. Testosterone then diffuses into nearby Ser-
toli cells, where the binding of follicle-stimulating hormone (FSH) to its receptor
(FSH-R) increases levels of androgen binding protein (ABP). ABP stabilizes the
high concentrations of testosterone that, together with other FSH-induced proteins
synthesized in Sertoli cells, promote spermatogenesis in the nearby germinal epi-
thelium (not shown). In the female, LH acts in an analogous manner to promote
androgen (androstenedione) synthesis in thecal cells. Androgen then diffuses into
nearby granulosa cells, where aromatase converts androstenedione to estrone,
which is then reduced to the biologically active estrogen, estradiol. FSH increases
aromatase activity in granulosa cells, promoting the conversion of androgen to
estrogen. Note that dihydrotestosterone is not a substrate for aromatase.
stimulates the thecal cells to synthesize the androgen andro-
stenedione, which is then aromatized to estrone and estradiol
in the granulosa cells under the influence of FSH.
Both Sertoli cells and granulosa cells synthesize and
secrete the regulatory proteins inhibin A, inhibin B, and
activin. Inhibins secreted by the gonad act on the anterior
pituitary gland to inhibit the release of FSH, while activin
stimulates FSH release. Neither the inhibins nor activin has an
effect on anterior pituitary gland LH release (Fig. 29-3). The
role of these regulatory proteins in controlling hormone ac-
tion is still not completely understood. In the male, testoster-
one is also an important negative regulator of pituitary gland
and hypothalamic hormone release. The role of estrogen in
CHAPTER 29 / Pharmacology of Reproduction 509
the female is more complex and can involve either positive
or negative feedback depending on the prevailing hormonal
milieu; this topic is addressed below as part of the menstrual
cycle discussion. In the female, the combination of estradiol
and progesterone synergistically suppresses GnRH, LH, and
FSH secretion by actions at both the hypothalamus and pi-
tuitary gland.
Integration of Endocrine Control: The
Menstrual Cycle
The female menstrual cycle is governed by the cycling of
hormones with an approximate periodicity of 28 days (nor-
mal range, 2435 days). This cycle begins at the onset of
puberty and continues uninterrupted (with the exception of
pregnancy) until menopause (Fig. 29-5). The start of the
cycle, cycle day 1, is arbitrarily defined as the first day of
menstruation. Ovulation occurs at the midportion (about
day 14) of each cycle. The portion of the menstrual cycle
before ovulation is often referred to as the follicular or
proliferative phase; during this time, the developing ovar-
ian follicle produces most of the gonadal hormones, which
stimulate cellular proliferation of the endometrium. Subse-
quent to ovulation, the corpus luteum produces progester-
one, and the endometrium becomes secretory rather than
proliferative. The second half of the menstrual cycle is thus
often referred to as the luteal or secretory phase, depend-
ing on whether the ovary or the endometrium is considered
as the frame of reference.
At the start of the menstrual cycle, there is low produc-
tion of estrogen and inhibin A. As a result, the anterior
pituitary gland secretes increasing amounts of FSH and
LH. These hormones stimulate the maturation of four to six
follicles, each of which contains an ovum arrested in the
first stage of meiosis. Maturing follicles secrete increasing
concentrations of estrogen, inhibin A, and inhibin B. Es-
trogen causes the follicles to increase the expression of
LH and FSH receptors on thecal and granulosa cells, re-
spectively. Receptor up-regulation increases the follicu-
lar response to pituitary gland gonadotropins and allows
one follicle to secrete increasing quantities of estrogen.
The increased plasma estrogen and inhibin levels partially
suppress pituitary gland LH and FSH release. In turn, the
decreased gonadotropin levels cause other follicles to be-
come atretic, so that usually only one follicle matures. At
the same time, increased estrogen levels stimulate the uter-
ine endometrium to proliferate rapidly.
As the dominant follicle continues to grow, it secretes
high, sustained levels of estrogen. Although the mechanism
is still not completely understood, the combination of high
estrogen levels and the rapid rate of increase of estrogen lev-
els causes a brief positive feedback effect on gonadotroph
release of gonadotropins, stimulating rather than inhibiting
release of LH and FSH. The resulting midcycle surge of LH
and FSH stimulates the dominant follicle to swell and to in-
crease the activity of its proteolytic enzymes. Approximately
40 hours after the onset of the LH surge, the follicle ruptures
and ovulation occurs. The ovum is released into the perito-
neal cavity and is then taken up by a fallopian tube, where
it begins its route toward the uterus. If the oocyte becomes
fertilized in the fallopian tube, it reaches the uterus approxi-
mately 4 days after ovulation and implants into the endome-
trium approximately 56 days after ovulation.
 Follicular phase Ovulation Luteal phase

Ovarian follicle

Growing Mature Corpus luteum

Estrogen Progesterone
(+ estrogen)

60
(mlU/ml)
LH

40

20

20
(mlU/ml)
FSH

10

20
Estrogen
(pg/ml)

10

0
Progesterone

10
(ng/ml)

Proliferative Secretory Menses

Endometrium

2 6 10 14 18 22 26
Day
512 Principles of Endocrine Pharmacology

bleeding, and the formation of adhesions in the peritoneal
cavity. In turn, adhesion formation can lead to infertility. Be-
cause endometriosis is usually estrogen-dependent, treatment
with long half-life GnRH agonists often achieves regression
of the disease (see below).
Decreased Estrogen or Androgen Secretion
The effects of decreased sex hormone production vary de-
pending on the age of the patient at the onset of symptoms.
Hypogonadism results if sex hormone production is im-
paired before adolescence. Patients with hypogonadism do
not undergo sexual maturation, but proper hormone replace-
ment can, in many cases, allow the development of second-
ary sexual characteristics.
Menopause is a normal physiologic response to exhaus-
tion of the ovarian follicles. Throughout a womans lifetime,
follicles are arrested in meiosis. Only a small percentage of
follicles mature during the menstrual cycle; the rest eventu-
ally become atretic. Menstrual cycles cease when all of the
follicles are depleted from the ovaries. Follicle depletion leads
to a decrease in estrogen and inhibins (because developing
follicles are the main estrogen and inhibin source in premeno-
pausal women) and an increase in LH and FSH (because
estrogen and inhibins suppress gonadotropin release). After
menopause, androstenedione continues to be converted to
estrone by aromatase in peripheral (mainly adipose) tissues.
However, estrone is a less potent estrogen than estradiol. Be-
cause of the relative lack of estrogen after menopause, many
women experience hot flashes, vaginal dryness, and decreased
libido. Postmenopausal women are also at risk for osteoporo-
sis. The role of estrogen in the maintenance of bone mass is
discussed in further detail in Chapter 31.
Men do not experience a sudden decrease in sex hormones
in a manner analogous to the female menopause, but andro-
gen secretion does decline gradually with age. Although con-
troversy currently exists over the role of androgen therapy in
normal elderly men, androgen replacement is indicated in
cases of adult hypogonadism where both low testosterone
levels and symptoms of hypogonadism are present.
 PHARMACOLOGIC CLASSES AND AGENTS
Pharmacologic agents have been developed to target most of
the steps in gonadal physiology and pathophysiology. The
relevant drug classes include modulators of anterior pituitary
gland gonadotroph activity and specific antagonists of periph-
eral hormone action. In addition, sex hormones are often used
as replacement therapy or to modify gonadotropin release
(Fig. 29-6).
Inhibitors of Gonadal Hormones
Synthesis Inhibitors
GnRH Agonists and Antagonists
Under physiologic conditions, the hypothalamus releases GnRH
in a pulsatile fashion. The frequency of GnRH pulses controls
the relative release of LH and FSH by the anterior pituitary

GnRH
(pulsatile; endogenous)

Anterior pituitary gland

GnRH agonists
(continuous; leuprolide, goserelin, nafarelin)
LH/FSH GnRH receptor antagonists (cetrorelix, ganirelix)

Ovaries / testes

Aromatase
inhibitors Testosterone Progesterone Testosterone
(exemestane,
formestane, Aromatase 5-reductase inhibitors
anastrozole, (finasteride, dutasteride)
letrozole) Estrogen Dihydrotestosterone
Mifepristone Androgen receptor
SERMs (+/-) antagonists (flutamide,
spironolactone)

Gene transcription Gene transcription Gene transcription

FIGURE 29-6. Pharmacologic modulation of gonadal hormone action. Pharmacologic modulation of gonadal hormone action can be divided into inhibitors
of hormone synthesis and hormone receptor antagonists. Continuous administration of GnRH suppresses LH and FSH release from the anterior pituitary gland, thus
preventing gonadal hormone synthesis. GnRH receptor antagonists (cetrorelix, ganirelix) are also used for this purpose. Finasteride and dutasteride inhibit the enzyme
5-reductase, thus preventing conversion of testosterone to the more active dihydrotestosterone. Aromatase inhibitors (exemestane, formestane, anastrozole, letrozole)
inhibit production of estrogens from androgens. A number of hormone receptor antagonists and modulators prevent the action of endogenous estrogens (some SERMs),
androgens (flutamide, spironolactone), and progesterone (mifepristone).
514 Principles of Endocrine Pharmacology

A Bone: both X and Y cofactors expressed

Estrogen SERM

Cofactor Y
Cofactor Y
Estrogen Estrogen
Cofactor X Cofactor X
receptor receptor
Nucleus Nucleus

DNA DNA

X Gene 1 Y Gene 2 X Y Gene 3 X Gene 1 Y Gene 2 X Y Gene 3

Genes 1, 2, and 3 expressed: Only gene 1 expressed:

Full agonist Partial agonist

B Breast: only Y cofactor expressed

Estrogen SERM

Cofactor Y
Cofactor Y
Estrogen Estrogen
receptor receptor
Nucleus Nucleus

DNA DNA

X Gene 1 Y Gene 2 X Y Gene 3 X Gene 1 Y Gene 2 X Y Gene 3

Gene 2 expressed: No genes expressed:

Full agonist Antagonist

FIGURE 29-7. A model for the tissue specificity of action of SERMs. Selective estrogen receptor modulators (SERMs) exhibit tissue-specific estrogen receptor
antagonist or partial agonist activity. This tissue specificity of action seems to be explained by the following observations: (1) transcriptional coactivators and/or corepres-
sors are expressed in a tissue-specific manner; (2) a SERMestrogen receptor (ER) complex can associate with some coactivators or corepressors, but not others; and
(3) genes can be activated or inhibited by different combinations of SERMER and coactivators or corepressors. In the example shown, assume that bone cells express
coactivators (cofactors) X and Y, whereas breast cells express only coactivator Y. The estrogenER complex can associate with X and Y, whereas the SERMER complex
can associate with only X. A. In bone cells, estrogen binding to ER and recruitment of coactivators X and Y induce expression of genes 1, 2, and 3. The SERMER complex
cannot bind coactivator Y, and the SERMERcofactor X complex induces expression of only gene 1. In bone, then, estrogen is a full agonist, whereas the SERM is a
partial agonist. B. In breast cells, estrogen binding to ER and recruitment of coactivator Y induce expression of gene 2, but the SERM is unable to promote expression of
any gene. In breast, then, the SERM acts as an antagonist. For simplicity, this model shows only coactivators, although corepressors are also involved in SERM action.

even cardiovascular disease. The three SERMs in current
clinical use are tamoxifen, raloxifene, and clomiphene.
Tamoxifen is the only SERM currently approved for use in
the treatment and prevention of breast cancer. Tamoxifen has
been employed in the palliative treatment of metastatic breast
cancer and as adjuvant therapy after lumpectomy. Tamoxifen
is an estrogen receptor antagonist in breast tissue, but a par-
tial agonist in the endometrium and bone. These pharmaco-
dynamic effects result in inhibition of the estrogen-dependent
growth of breast cancer, but also stimulation of endometrial
growth. Because of the latter effect, tamoxifen administration
is associated with a four-fold to six-fold increase in the inci-
dence of endometrial cancer. Therefore, in order to minimize
the risk of iatrogenic endometrial cancer, tamoxifen is typi-
cally administered for no more than 5 years.
Raloxifene is a newer SERM that possesses estrogen re-
ceptor agonist activity in bone, but antagonist activity in both
breast and endometrial tissue. Its mechanism of action is
illustrated in Figure 29-7, and its molecular structure is shown
in Figure 29-8. Consistent with this profile of tissue specifici-
ties, raloxifene does not appear to increase the incidence of
endometrial cancer. The agonist activity of raloxifene in bone
decreases bone resorption, and thus delays or prevents the
progression of osteoporosis in postmenopausal women (dis-
cussed in more detail in Chapter 31). Raloxifene is approved
for use in the prevention of breast cancer and the prevention
and treatment of osteoporosis. In a large clinical trial com-
paring raloxifene and tamoxifen for the prevention of breast
cancer in women at high risk, both agents resulted in a 50%
reduction in the development of invasive breast cancer. Ta-
moxifen treatment was associated with more cases of endome-
trial hyperplasia, endometrial cancer, cataracts, and deep vein
thrombosis than raloxifene. However, tamoxifen prevented
more cases of noninvasive breast cancer than raloxifene.
Clomiphene is a SERM used to induce ovulation. The drug
acts as an estrogen receptor antagonist in the hypothalamus
 O OH
OCCH3 C CH
O

O O

CH3
Medroxyprogesterone Norethindrone
acetate

O OCCH3

OCCH3 C CH
O

O O

CH3
Megestrol acetate Norethindrone acetate

OH OH
H2C C CH C CH

Desogestrel Levonorgestrel
O
OH OCCH3

OH OH C CH C CH

C CH C CH

O HON
HO CH3O
Gestodene Norgestimate
Ethinyl estradiol Mestranol

Androgens
Androgen replacement is an effective therapy for hypogo-
nadism. Oral testosterone is ineffective because of its high
first-pass metabolism by the liver. Two esters of testoster-
one, testosterone enanthate and testosterone cypionate,
can be administered intramuscularly. A preparation of either
of these agents, injected every 24 weeks, increases plasma
testosterone to physiologic concentrations in hypogonadal
men. Transdermal testosterone patches have also been
developed; this drug delivery system has the advantages
that plasma testosterone levels remain relatively constant
and first-pass hepatic metabolism is bypassed. Testoster-
one is also available in a topical gel formulation; using this
preparation on a once-a-day application schedule, plasma
testosterone levels gradually increase until they reach
physiologic replacement levels after 1 month of applica-
tion. Testosterone can also be administered as a tablet that
adheres to the buccal mucosa, resulting in rapid systemic
absorption of the drug.
Aging men sometimes develop symptoms and signs of hy-
pogonadism, such as decreased energy, decreased libido, gyne-
comastia, decreased muscle mass, and facial hair growth. Recent
guidelines recommend that androgen replacement therapy be
offered to men only with consistent symptoms and signs of hy-
pogonadism and low plasma testosterone levels (3.0 ng/mL).
Testosterone should not be administered to men with prostate
cancer, because it may stimulate growth of the tumor.
Some athletes abuse androgens by self-administration
at supratherapeutic levels. Androgens have been demon-
strated to increase muscle mass and fat-free mass. In one
survey, approximately 5% of high school athletes reported
that they had used androgen supplements. Almost every
type of androgen has been abused in an attempt to enhance
athletic performance, including the adrenal hormone pre-
cursors androstenedione and dehydroepiandrosterone. Co-
vert laboratories are continuously inventing new synthetic
androgens that have not yet been recognized by standard
drug testing programs. These designer androgens are
meant to enhance athletic performance and to be undetect-
able by sports regulatory authorities. Pharmacologic doses
of androgens suppress the hypothalamic-pituitaryrepro-
duction axis, resulting in suppression of testicular function,
decreased sperm production, and impaired fertility. Be-
cause many androgens can be converted to estrogens by ar-
omatase, pharmacologic doses of androgens can also cause
an increase in plasma estrogen, resulting in gynecomastia.
In addition, high plasma levels of androgens are associated
with erythrocytosis, severe acne, and derangements in lipid
metabolism (increased low-density lipoprotein [LDL] and
decreased high-density lipoprotein [HDL]). Some athletes
have recently started to use injections of hCG to stimu-
late endogenous Leydig cell testosterone production, hop-
ing to avoid detection by sports authorities. SERMs and
aromatase inhibitors have also been used by athletes in an
attempt to increase endogenous LH secretion and Leydig
cell testosterone production.
 CONCLUSION AND FUTURE DIRECTIONS
The male and female hormones of reproduction share sig-
nificant mechanistic overlap with one another. Androgens,
estrogens, and progestins are all steroid hormones that
CHAPTER 29 / Pharmacology of Reproduction 519
exert their physiologic action by binding to intracellular
receptors, translocating to the nucleus, and altering gene
transcription. Recent evidence suggests that estrogens
may also act on membrane receptors to mediate nonge-
nomic effects. Derangements in the physiologic effects
of reproductive hormones can involve disruption of the
hypothalamic-pituitaryreproduction axis, inappropriate
growth of hormone-dependent tissue, or decreased activ-
ity of gonadal hormones at target tissues. Currently avail-
able pharmacologic agents can modify the endocrine axis
(e.g., GnRH agonists), inhibit synthesis of active hormones
(e.g., 5-reductase inhibitors, aromatase inhibitors), or in-
hibit end-organ effects at the receptor level (e.g., SERMs,
anti-androgens, mifepristone). Oral contraceptives, such as
estrogenprogestin combinations and progestin-only con-
traception, disrupt the exquisite cyclicity of the menstrual
cycle and thus suppress ovulation. The development of an
effective male contraceptive has met a number of obstacles
but should represent a major pharmacologic advance in the
future. Exciting progress is also being made in the design
of new SERMs that possess a variety of tissue-specific ac-
tivities; such research may result in new agents effective
for both prevention of breast cancer and treatment of post-
menopausal osteoporosis.
Suggested Reading
Anderson GL, Limacher M, Assaf AR, et al. Effects of conjugated equine
estrogen in postmenopausal women with hysterectomy: the Womens
Health Initiative randomized controlled trial. JAMA 2004;291:17011712.
(Reports the Estrogen Alone vs. Placebo data shown in Table 29-3.)
Archer DF, Pinkerton JV, Utian WH, et al. Bazedoxifene, a selective es-
trogen receptor modulator: effects on the endometrium, ovaries and breast
from a randomized controlled trial in osteoporotic postmenopausal women.
Menopause 2009;16:11091115. (Bazedoxifene is one of many new SERMs
being developed to treat problems associated with menopause. Bazedox-
ifene is an estrogen agonist in bone and an antagonist in endometrium
and breast.)
Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy in
adult men with androgen deficiency syndromes: an Endocrine Society
Clinical Practice Guideline. J Clin Endocrinol Metab 2006;91:1995
2010. (Aging men should have both consistent symptoms of hypogonad-
ism and low serum testosterone in order to be treated with androgen
replacement.)
Chlebowski RY, Kuller LH, Prentice RL, et al. Breast cancer after use
of estrogen plus progestin in postmenopausal women. N Engl J Med
2009;360:573587. (After the results of the WHI trial were published in
2002, there was a marked decrease in the number of menopausal women
using estrogenprogestin therapy and a parallel reduction in the number of
cases of diagnosed breast cancer.)
Ehrmann DA. Polycystic ovary syndrome. N Engl J Med 2005;352:1223
1236. (A clinically oriented review of the polycystic ovarian syndrome, the
diagnosis for the patient presented in this chapter.)
Gu Y, Liang X, Wu W, et al. Multicenter contraceptive efficacy trial of
injectable testosterone undecanoate in Chinese men. J Clin Endocrinol
Metab 2009;94:19101915. (The administration of testosterone is an ef-
fective contraception. The safety profile of this approach has not been
fully explored.)
Struthers RS, Nicholls AJ, Grundy J, et al. Suppression of gonadotro-
pins and estradiol in premenopausal women by oral administration of the
nonpeptide gonadotropin-releasing hormone antagonist, elagolix. J Clin
Endocrinol Metab 2009;94:545551. (An orally active nonpeptide GnRH
antagonist would represent an important new drug for suppressing the
pituitaryreproduction axis.)
Writing Group for the Womens Health Initiative Investigators. Risks and
benefits of estrogen plus progestin in healthy postmenopausal women: prin-
cipal results from the Womens Health Initiative randomized controlled trial.
JAMA 2002;288:321333. (Reports the Continuous EstrogenProgestin
vs. Placebo data shown in Table 29-3.)
30
Pharmacology of
the Endocrine Pancreas
and Glucose Homeostasis
Aimee D. Shu and Steven E. Shoelson
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 524-525
BIOCHEMISTRY AND PHYSIOLOGY . . . . . . . . . . . . . . . . . . . 524
Pancreatic Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 524
Energy Homeostasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
Energy Repletion and the Fed State. . . . . . . . . . . . . . . 525
Fasting and Starvation . . . . . . . . . . . . . . . . . . . . . . . . 525
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 526
Biochemistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 526
Secretion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 526
Action at Target Tissues . . . . . . . . . . . . . . . . . . . . . . . 529
Glucagon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
Amylin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
Somatostatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
Glucagon-Like Peptide-1 (GLP-1) . . . . . . . . . . . . . . . . . . . 530
PATHOPHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530
Type 1 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
 INTRODUCTION
This chapter reviews the physiology and pharmacology of in-
sulin, glucagon, and the other major hormones that regulate
glucose homeostasis. Because diabetes mellituscaused by an
absolute or relative deficiency in insulin secretionis clinically
the most common disease of these endocrine axes, the majority
of the chapter is devoted to the physiology and pharmacology of
insulin. Medical students may be interested to note that Charles
Best, a fourth-year medical student in Canada, had a signifi-
cant role in the identification of insulin. Along with his mentor,
Frederick Banting, Best isolated a pancreatic extract from dogs
that could reduce blood glucose in diabetic dogs and humans.
Although the 1923 Nobel Prize in Medicine or Physiology was
jointly awarded to surgeon Frederick Banting and physiologist
J. J. R. MacLeod, Banting shared his award with Best.
524
Type 2 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
Morbidity and Mortality . . . . . . . . . . . . . . . . . . . . . . . . 532
Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 532
Therapy for Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
Inhibitors of Intestinal Glucose Absorption . . . . . . . . . . 533
Insulin Replacement: Exogenous Insulin . . . . . . . . . . . 533
Insulin Secretagogues: Sulfonylureas and Meglitinides . . 535
Reduction of Hepatic Glucose Production: Biguanides . . . 535
Amylin Analogue: Pramlintide . . . . . . . . . . . . . . . . . . . 535
GLP-1-Based Incretin Therapies . . . . . . . . . . . . . . . 535
Insulin Sensitizers: Thiazolidinediones . . . . . . . . . . . . . 536
Combination Therapy . . . . . . . . . . . . . . . . . . . . . . . . . 536
Therapy for Hyperinsulinemia . . . . . . . . . . . . . . . . . . . . . 536
Glucagon as a Therapeutic Agent . . . . . . . . . . . . . . . . . . . 537
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 537
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
 BIOCHEMISTRY AND PHYSIOLOGY
Pancreatic Anatomy
The pancreas is a glandular organ that contains both exocrine
and endocrine tissue. The exocrine portionwhich consti-
tutes 99% of the pancreatic masssecretes bicarbonate and
digestive enzymes into the gastrointestinal (GI) tract. Scat-
tered within the exocrine tissue are nearly one million small
islands of endocrine tissue that secrete hormones directly
into the blood. These tiny endocrine glands, collectively
called islets of Langerhans, include several different cell
types that secrete different hormones: -cells release glu-
cagon, -cells release insulin and amylin; -cells release
somatostatin and gastrin; and PP cells release pancreatic
polypeptide.
 CHAPTER 30 / Pharmacology of the Endocrine Pancreas and Glucose Homeostasis 527

Gastric
GLP-1 analogue,
GI tract emptying
amylin analogue

Dietary
complex
carbohydrates

-glucosidase
inhibitors
Glucosidases

Other tissues Blood

cell
Glucose Endogenous insulin
(from GI tract (from cell) or Glucose Metabolism
Glucose and liver) Exogenous insulin
Insulin ATP
secretion
Metabolism
To tissues To tissues

Sulfonylureas,
Diazoxide
meglitinides,
GLP-1 analogue,
DPP-4 inhibitor
Insulin Insulin Insulin

Muscle cell Adipose cell Liver cell

Glucose Glycogen Glucose Triglyceride Glucose Glycogen

Glucose Glucagon

PPAR Gluconeogenesis

Thiazolidinediones Biguanides GLP-1 analogue,

DPP-4 inhibitor,
amylin analogue

FIGURE 30-1. Physiologic and pharmacologic regulation of glucose homeostasis. Dietary complex carbohydrates are broken down to simple sugars in the GI
tract by the action of glucosidases; simple sugars are then absorbed by GI epithelial cells and transported into the blood. Glucose in the blood is taken up by metaboli-
cally active tissues throughout the body. Glucose metabolism in pancreatic -cells increases cytosolic ATP, which stimulates insulin secretion. Released insulin acts
on plasma membrane insulin receptors in target tissues (muscle, adipose, liver) to increase glucose uptake and storage as glycogen or triglyceride. Glucose is also
taken up by other cells and tissues to fuel metabolism. In muscle and liver, insulin promotes glucose storage as glycogen. In adipose cells, insulin promotes glucose
conversion to triglycerides. Peroxisome proliferator-activated receptor (PPAR) also promotes the conversion of glucose to triglycerides in adipocytes. Glucagon
promotes both hepatic gluconeogenesis and glycogen breakdown; the newly generated glucose is transported out of the liver cell into the blood. Note that glucose
from dietary complex carbohydrates and insulin secreted by pancreatic -cells both enter the liver in high concentrations through the portal circulation (not shown).
Pharmacologic interventions that decrease blood glucose levels include: delaying gastric emptying with a GLP-1 analogue or an amylin analogue; inhibiting intestinal
-glucosidases with an -glucosidase inhibitor; administering exogenous insulin; augmenting -cell insulin secretion with sulfonylureas, meglitinides, or incretins;
suppressing glucagon and gluconeogenesis with incretins, an amylin analogue, or biguanides; and enhancing the action of insulin in adipose cells using thiazolidin-
ediones. To treat hyperinsulinemic hypoglycemia, diazoxide inhibits pancreatic -cell insulin secretion.

closed, the cell depolarizes and insulin is released. Because
ATP inhibits the channel and ADP activates the channel, a
high intracellular ATP/ADP ratio closes the K/ATP chan-
nel. The resulting depolarization of the cell activates volt-
age-gated Ca2 channels, leading to an influx of extracel-
lular Ca2. The increase in intracellular [Ca2] signals the
insulin-containing vesicles to fuse with the plasma mem-
brane, which releases insulin into the circulation. In con-
trast, under conditions of relatively low extracellular glucose
concentrations (e.g., in the fasting state), the -cell has a low
ATP/ADP ratio. In this case, the K/ATP channels remain
open, and the -cell is maintained in a hyperpolarized state
that prevents Ca2 influx and insulin secretion (Fig. 30-3).
-cell K/ATP channels are octameric structures contain-
ing four subunits of Kir6.2 and four subunits of the sulfo-
nylurea receptor, SUR1. The Kir6.2 tetramer forms the pore
of the K/ATP channel, while the associated SUR1 proteins
regulate the channels sensitivity to ADP and pharmacologic
agents. Kir6.2 binds ATP, which inhibits K conductance.
SUR1 enhances the sensitivity of the Kir6.2 channel to ATP,
and it also confers sensitivity to sulfonylurea and related insu-
lin secretagogue drugs. SUR1 binds ADPMg2 complexes,
528 Principles of Endocrine Pharmacology

Dipeptide SUR1 Kir6.2

cleavage
site
NH2 Arg Lys Inhibitors Activators
1
2 Mg2+-ADP
Sulfonylurea/
3
meglitinide
Diazoxide

Cys
Cys
Cys ATP
Cys
K+/ATP
channel

GLUT2
transporter K+ conductance
Arg Arg
Glucose
Proinsulin COOH Lys Dipeptide
Cys Membrane
Asn
Pro cleavage ATP
Cys site depolarization

Metabolism
Ca2+ influx
ADP Insulin
vesicles

COOH Ca2+
B chain A chain
NH2 NH2
1 1 Pancreatic cell
2 2 Insulin
Asn 3 secretion
C peptide
4
FIGURE 30-3. Physiologic and pharmacologic regulation of insulin
Changed release from pancreatic cells. When the K/ATP channel is open in its basal
Cys Cys
to lysine in Cys Changed to state, less insulin is released; when the K/ATP channel is closed, more insulin
insulin glutamic acid in is released. In the basal state, the plasma membrane of the -cell is hyperpolar-
glulisine Cys insulin glulisine
ized, and the rate of insulin secretion from the cell is low. However, when glucose
Myristoylated in is available, it enters the cell via GLUT2 transporters in the plasma membrane
insulin detemir and is metabolized to generate intracellular ATP. ATP binds to and inhibits the
Two additional plasma membrane K/ATP channel. Inhibition of the K/ATP channel decreases
Changed to arginine residues plasma membrane K conductance; the resulting depolarization of the mem-
glycine in
insulin glargine
in insulin glargine brane activates voltage-gated Ca2 channels and thereby stimulates an influx
COOH NH2 of Ca2. Ca2 mediates fusion of insulin-containing secretory vesicles with the
plasma membrane, leading to insulin secretion. The K/ATP channel, an octamer
19
Cys
COOH Lys composed of Kir6.2 and SUR1 subunits, is the target of several physiologic and
Asn
Pro Reversed in pharmacologic regulators. ATP binds to and inhibits Kir6.2, while sulfonylureas
Insulin Cys
27 insulin lispro and meglitinides bind to and inhibit SUR1; all three of these substances promote
26 insulin secretion. The GLP-1 mimetic exenatide, acting as an agonist at G protein-
Changed to coupled GLP-1 receptors in the plasma membrane of the pancreatic -cell, also
aspartic acid in
stimulates glucose-dependent insulin secretion. This action of exenatide appears
insulin aspart
to be mediated by an increase in intracellular cyclic AMP and may involve an
FIGURE 30-2. Processing of human insulin. Preproinsulin is synthesized indirect effect on the K/ATP channel (not shown). Mg2-ADP and diazoxide bind
and exported into the endoplasmic reticulum, where the signal peptide (not to and activate SUR1, thereby inhibiting insulin secretion. (For clarity, only four of
shown) is cleaved to generate proinsulin (top panel). Intramolecular disulfide the eight K/ATP channel subunits are shown.)
bonds (cyscys) aid in the proper folding of proinsulin. Proinsulin is transported
to secretory vesicles, where prohormone convertases act on dipeptide cleav-
age sites in proinsulin (boxes) to generate insulin and connecting (C) peptide.
Two disulfide bonds aid in holding the A-chain and B-chain of insulin together. which activate the channel and further inhibit insulin secre-
Insulin and C-peptide are secreted together from the pancreatic -cell (bot- tion when the ATP/ADP ratio is low. Mutations in Kir6.2 or
tom panel). Modifications to insulins amino acid sequence result in the altered SUR1 can result in hyperinsulinemic hypoglycemia, because
pharmacokinetics of the various insulin analogues; lispro, aspart, and glulisine the channel remains closed and the -cell remains continu-
are rapid-acting insulins, whereas glargine and detemir have slower absorption.
ally depolarized even when the extracellular glucose concen-
The substitutions are: in lispro, the positions of ProB28 and LysB29 are reversed;
in aspart, ProB28 is replaced by aspartic acid; in glulisine, AsnB3 and LysB29
tration and the intracellular ATP/ADP ratio are low.
are replaced by lysine and glutamic acid, respectively; in glargine, AsnA21 is In addition to blood glucose, nutrient sugars, amino acids,
replaced by glycine, and two extra arginines are added to the carboxyl terminus and fatty acids increase the intracellular ATP/ADP ratio and
of the B-chain; and in detemir, a fatty acid (myristic acid) is esterified to the - thereby stimulate insulin release. Acting via G protein-mediated
amino group of LysB29. pathways, parasympathetic activity and the GI hormones GLP-1
 Insulin

Glucose
Insulin receptor
GLUT4

P P Translocation
GLUT4
Glucose
P P Hexokinase

Shc IRS proteins Glucose-6-

phosphate
Grb-2 Grb-2 SHP-2 p85 p110

SOS SOS PI3-kinase Glucose

transport Metabolism/
?
storage

Mitogenesis Protein Glycogen

synthesis synthesis
 CHAPTER 30 / Pharmacology of the Endocrine Pancreas and Glucose Homeostasis 535
The major danger with insulin therapy is that administra-
tion of insulin in the absence of adequate carbohydrate in-
take can result in hypoglycemia. While tight glycemic control
that aims to maintain normoglycemia decreases the incidence
of diabetic complications, it also increases the frequency of
hypoglycemic attacks. Therefore, patients taking insulin,
whether they are type 1 or type 2 diabetics, must be cautioned
not to take too much. Indeed, it is challenging to maintain the
fine balance between insufficient and excessive insulin.
In type 2 diabetic patients such as Mrs. S, insulin resis-
tance is typically more severe in muscle and liver than in fat
cells. For this reason, insulin preferentially deposits calories
in adipose tissue, and insulin therapy in insulin-resistant pa-
tients (especially those who are already obese, like Mrs. S)
often results in weight gain.
Insulin Secretagogues: Sulfonylureas and Meglitinides
Sulfonylureas
Sulfonylureas have been available in the United States since
the 1950s for the treatment of type 2 diabetes. Sulfonylureas
stimulate insulin release from pancreatic -cells, thereby in-
creasing circulating insulin to levels sufficient to overcome
the insulin resistance. At the molecular level, sulfonylureas
bind to the SUR1 subunit, thereby inhibiting the -cell K/
ATP channel (Fig. 30-3). Sulfonylureas may act by displacing
endogenous Mg2-ADP, which binds to SUR1 and activates
the channel. The sulfonylureas used to treat type 2 diabetes
bind with a higher affinity to SUR1 than to SUR2 isoforms,
accounting for their relative -cell specificity. The inhibition
of the K/ATP channel by sulfonylureas is functionally simi-
lar to the molecular events induced physiologically in the fed
state, in which increased glucose metabolism causes -cell
accumulation of intracellular ATP, membrane depolarization,
Ca2 influx, fusion of insulin-containing vesicles with the
plasma membrane, and insulin secretion (see above).
Sulfonylureas are orally available and are metabolized
by the liver. Their major adverse effect is hypoglycemia re-
sulting from oversecretion of insulin. Thus, these medica-
tions should be used cautiously in patients who are unable to
recognize or respond appropriately to hypoglycemia, such
as those with impaired sympathetic function, mental status
changes, or advanced age. Studies show that sulfonylurea
use is associated with a marginal decrease in circulating
lipids. These agents can cause weight gain secondary to in-
creased insulin activity on adipose tissue; this adverse effect
is counterproductive in obese patients such as Mrs. S. There-
fore, sulfonylureas are better suited for nonobese patients.
Because first-generation sulfonylureas bind with lower affin-
ity to SUR1 than second-generation agents, first-generation
agents are administered in higher doses to achieve the same
degree of glucose lowering. Sulfonylureas are generally ef-
fective, safe, and inexpensive (generically available) drugs
and, along with metformin, are mainstays of treatment for
type 2 diabetes.
Meglitinides
Like sulfonylureas, meglitinides stimulate insulin release
by binding SUR1 and inhibiting the -cell K/ATP chan-
nel. Although sulfonylureas and meglitinides both act on the
SUR1 subunit, these two classes of drugs bind to distinct
regions of the SUR1 molecule. The absorption, metabolism,
and adverse-effect profiles of meglitinides are similar to
those of sulfonylureas.
Reduction of Hepatic Glucose Production: Biguanides
Hepatic glucose production may be abnormally elevated in
type 2 diabetes. Metformin acts to decrease glucose produc-
tion in the liver by activating the energy-regulating enzyme
AMPK. By triggering hepatic AMPK, metformin inhibits
gluconeogenesis, fatty-acid synthesis, and cholesterol syn-
thesis. Metformin also improves glucose uptake in peripheral
muscle; the molecular mechanism responsible for this effect
is less well understood. Metformin increases insulin signal-
ing (i.e., it increases the activity of the insulin receptor) and
is especially effective at lowering glucose in type 2 diabetics
who are obese and insulin resistant. Unlike insulin and insu-
lin secretagogues, biguanides are associated with a lowering
of serum lipids and a decrease in weight. Metformin is also
used for the off-label (not FDA-approved) treatment of other
conditions, such as polycystic ovarian syndrome, that are
associated with insulin resistance and hyperinsulinemia.
The most common adverse effect of metformin is mild
gastrointestinal distress, which is usually transient and can be
minimized by slow titration of the dose. A potentially more
serious adverse effect is lactic acidosis. Because biguanides
decrease the flux of metabolic acids through gluconeogenic
pathways, lactic acid can accumulate to dangerous levels in
biguanide-treated patients. This complication is rarely seen
with metformin (as opposed to phenformin, which is not
approved for use in the United States). Lactic acidosis may
occur more frequently when metformin is taken by patients
who have other conditions predisposing to metabolic acido-
sis, such as hepatic disease, heart failure, respiratory disease,
hypoxemia, severe infection, alcohol abuse, a tendency to
ketoacidosis, or renal disease (the latter because biguanides
are excreted by the kidneys). Biguanides do not directly af-
fect insulin secretion, and their use is not associated with
hypoglycemia.
Amylin Analogue: Pramlintide
Pramlintide was designed as a stable analogue of human
amylin, the -cell hormone that is co-secreted with insu-
lin and helps regulate postprandial glucose levels. Type 1
diabetics lack endogenous amylin, and type 2 diabetics are
relatively deficient in amylin. Thus, pramlintide is approved
for use in both type 1 diabetics and insulin-requiring type 2
diabetics. Pramlintides structure is similar to amylins with
the exception of three amino acid substitutions that confer
improved solubility and stability (three prolines replace an
alanine and two serines). Pramlintide slows gastric empty-
ing, reduces postprandial glucagon and glucose release, and
promotes satiety. It is administered as a subcutaneous injec-
tion before meals. Use of pramlintide often results in mod-
est weight loss. The most common adverse effect is nausea,
which is often limiting but may improve in some patients
with prolonged use. Pramlintide is not associated with hypo-
glycemia unless it is used in conjunction with other agents
that can cause hypoglycemia.
GLP-1-Based Incretin Therapies
GLP-1 Analogues
Exenatide is a long-acting analogue of GLP-1 that was orig-
inally isolated from the salivary gland of the Gila monster. It
acts as an agonist at human GLP-1 receptors. Exenatide was
approved for use in type 2 diabetics in the United States in
2005. The drug must be injected, typically twice a day, and
is used in combination with metformin, a sulfonylurea, or a
 CHAPTER 30 / Pharmacology of the Endocrine Pancreas and Glucose Homeostasis 537
openers of this type are known, but most are specific for
SUR2 isoforms and thus are not useful to target the SUR1/
Kir6.2 channel expressed by pancreatic -cells. Diazoxide
binds channels containing either SUR1 or SUR2 isoforms
and is therefore used not only to decrease insulin secre-
tion by pancreatic -cells but also to hyperpolarize SUR2-
expressing cardiac and smooth muscle cells. By maintaining
these cells in a more relaxed state, off-label use of diazoxide
may decrease blood pressure in hypertensive emergencies.
In a rare form of genetic hyperinsulinemic hypoglycemia, a
mutant SUR1 isoform is relatively insensitive to Mg2-ADP
but does respond to diazoxide; in most forms of this disease,
however, the mutant channel is not transported to the cell
surface, and diazoxide is ineffective.
Octreotide is a somatostatin analogue that is longer act-
ing than endogenous somatostatin. Like somatostatin, this
agent blocks hormone release from endocrine-secreting tu-
mors, such as insulinomas, glucagonomas, and thyrotropin-
secreting pituitary adenomas. Octreotide has several other
clinical indications (see Chapter 26).
Glucagon as a Therapeutic Agent
Glucagon is used to treat severe hypoglycemia when oral or
intravenous glucose administration is not possible. As with
insulin, glucagon is administered by subcutaneous injec-
tion. The hyperglycemic action of glucagon is transient, and
it requires a sufficient hepatic store of glycogen. Glucagon
is also used as an intestinal relaxant before radiographic or
magnetic resonance imaging (MRI) of the gastrointestinal
tract. The mechanism by which glucagon mediates intestinal
relaxation remains uncertain.
 CONCLUSION AND FUTURE DIRECTIONS
Fuel homeostasis involves the pancreatic hormones insulin,
glucagon, amylin, and somatostatin and the GI hormones
GLP-1 and GIP. When the levels of these hormones are patho-
logically altered, an individual can become hyperglycemic
(as in diabetes mellitus) or hypoglycemic. Various pharma-
cologic agents act at several different cellular and molecu-
lar sites to normalize blood glucose levels. -Glucosidase
inhibitors slow the intestinal absorption of carbohydrates.
Exogenous insulin, sulfonylureas, meglitinides, and GLP-
1-based therapies increase insulin levels, while diazoxide
reduces insulin levels. Thiazolidinediones and biguanides in-
crease insulin sensitivity at target tissues. Amylin analogues
reduce postprandial glucose levels. Octreotide, a synthetic
form of somatostatin, has wide-ranging inhibitory effects
on hormone secretion. Exogenous glucagon can be used to
increase plasma glucose levels.
Research on new pharmacologic treatments for early type
1 diabetes include efforts to develop immune modulatory
therapies aimed at reversing -cell dysfunction. For type 2
diabetes, agents may be developed: to inhibit the enzymes
of glycogen synthesis and glycogenolysis in order to restrain
glucose production (e.g., inhibitors of glycogen synthase ki-
nase 3 to promote glycogen synthesis and inhibitors of he-
patic glycogen phosphorylase to suppress glycogenolysis);
to facilitate excretion of glucose in the renal proximal tubule
(e.g., inhibitors of sodiumglucose cotransporter-2); or to
target inflammation using small-molecule anti-inflamma-
tory drugs or selected biologicals that block the actions of
certain cytokines.
Acknowledgment
We thank Martin G. Myers, Jr. for his valuable contributions to
this chapter in the First and Second Editions of Principles of
Pharmacology: The Pathophysiologic Basis of Drug Therapy.
Suggested Reading
DeWitt DE, Hirsch IB. Outpatient insulin therapy in type 1 and type 2
diabetes mellitus: scientific review. JAMA 2003;299:22542264. (Reviews
currently available insulin preparations and their pharmacodynamic and
pharmacokinetic profiles.)
Drucker DJ. The biology of incretin hormones. Cell Metab 2006;3:153
165. (Reviews basic physiology of GLP-1 and related hormones.)
Hardie DG. Minireview: the AMP-activated protein kinase cascade: the key
sensor of cellular energy status. Endocrinology 2003;144:51795183. (Re-
views function and mechanism of action of probable biguanide target.)
Krentz AJ, Bailey CJ. Oral antidiabetic agents: current role in type 2 dia-
betes mellitus. Drugs 2005;65:385411. (Thorough review of the pharma-
cology of oral agents for the treatment of diabetes, with an emphasis on
therapeutics.)
Krentz AJ, Patel MB, Bailey CJ. New drugs for type 2 diabetes mellitus.
Drugs 2008;68:21312162. (Reviews currently available oral and inject-
able pharmacologic agents, their indications, and adverse effects.)
Nathan DM. Initial management of glycemia in type 2 diabetes mellitus.
N Engl J Med 2002;347:13421349. (Clinically oriented approach to treat-
ment of type 2 diabetes, including diet, exercise, insulin, oral agents, and
combination therapy.)

Pharmacology of Bone
Mineral Homeostasis
Robert M. Neer, Ehrin J. Armstrong, and Armen H. Tashjian, Jr.
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 541-542
PHYSIOLOGY OF BONE MINERAL HOMEOSTASIS . . . . . . . . 541
Structure of Bone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 541
Mineral Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 542
Regulation of Bone Remodeling . . . . . . . . . . . . . . . . . . . . 542
Hormonal Control of Calcium and Phosphate . . . . . . . . . . 543
Parathyroid Hormone . . . . . . . . . . . . . . . . . . . . . . . . . 544
Vitamin D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546
Fibroblast Growth Factor 23 and Phosphatonins . . . . . 547
Calcitonin, Glucocorticoids, Thyroid Hormone,
and Gonadal Steroids . . . . . . . . . . . . . . . . . . . . . . . . . 547
PATHOPHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548
Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548
Chronic Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 550
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 551
Antiresorptive Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . 551
Hormone Replacement Therapy (HRT) . . . . . . . . . . . . . 552
 INTRODUCTION
The 206 bones of the human skeleton are far from the lifeless
structures they are commonly imagined to be. Bones are remod-
eled continuously and are involved in many functions besides
structural support and protection of internal organs, including he-
matopoiesis and mineral storage. The focus of this chapter is on
the critical role of bone in mineral homeostasis, the process and
regulation of bone remodeling, the diseases that can result when
the delicate balances of mineral homeostasis and bone remodel-
ing are perturbed, and the pharmacologic therapies employed to
treat these conditions. A key concept regarding the pharmacologic
agents discussed in this chapter is the distinction between bone
antiresorptive agents, which slow bone loss, and bone anabolic
agents, which have the potential to increase overall bone mass.
 PHYSIOLOGY OF BONE MINERAL
HOMEOSTASIS
Specialized cells called osteoblasts and osteoclasts continually
remodel the human skeleton in response to mechanical forces
and endocrine and paracrine factors. Two of the endocrine
31
Selective Estrogen Receptor Modulators . . . . . . . . . . . 552
Bisphosphonates . . . . . . . . . . . . . . . . . . . . . . . . . . . . 552
RANKL Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . 555
Calcitonin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555
Bone Anabolic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . 555
Fluoride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 555
Parathyroid Hormone . . . . . . . . . . . . . . . . . . . . . . . . . 555
Treatment of Secondary Hyperparathyroidism in
Chronic Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 556
Oral Phosphate Binders . . . . . . . . . . . . . . . . . . . . . . . 556
Calcitriol and Its Analogues . . . . . . . . . . . . . . . . . . . . . 556
Calcimimetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 556
Calcium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557
Inorganic Phosphate . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557
Vitamin D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 557
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 558
factorsparathyroid hormone and vitamin Dcontrol bone
metabolism for the purpose of maintaining extracellular cal-
cium homeostasis. Other hormones, such as glucocorticoids,
thyroid hormone, gonadal steroids, and fibroblast growth
factor 23, also have important effects on bone integrity. This
section reviews the cellular and molecular mechanisms that
mediate bone formation and bone resorption and the mecha-
nisms by which hormones (especially parathyroid hormone
and vitamin D) maintain plasma calcium levels within a nar-
row concentration range.
Structure of Bone
Bone consists of 25% organic and 75% inorganic compo-
nents. The organic component includes the cells (osteoblasts,
osteoclasts, osteocytes, bone lining cells, bone stromal cells)
and osteoid (a matrix consisting primarily of type I collagen
fibers and several low-abundance proteins). The inorganic
component consists of crystalline calcium phosphate salts,
primarily hydroxyapatite. The chemical formula of hydroxy-
apatite is (Ca)5(PO4)3OH. Ninety-nine percent of the calcium
in the body is stored in the skeleton, mostly as hydroxyapa-
tite. Figure 31-1 illustrates the structure of a long bone.
541
 CHAPTER 31 / Pharmacology of Bone Mineral Homeostasis 543

A
Articular cartilage
are concomitantly secreted by the villi. Although this pro-
Proximal
teolysis totally degrades much of the exposed bone matrix,
epiphysis Epiphyseal plate some of the type I collagen peptide chains escape into the
Spongy trabecular bone
circulation after partial proteolysis. The blood level of such
type I collagen metabolites (e.g., NTX, CTX) is an index
of type I collagenolysis and total body bone resorption. Be-
Compact cortical bone
cause of its large hydroxyapatite-covered surface area, bone
normally adsorbs various nonskeletal proteins and peptides
Medullary cavity
from its environment, including IGF-I and TGF-. Demin-
Diaphysis eralization exposes these adsorbed growth factors to the
proteolytic enzymes secreted by osteoclast villi, but some
Osteon escape proteolysis and affect the cellular activity of neigh-
(Haversian system) Lamellae boring osteoclasts, osteoblasts, and osteocytes.
After about 3 weeks of such bone resorption, cytokines and
growth factors liberated from the matrix, together with hor-
monal and other factors (see below), begin to stimulate local
accumulation of osteoblasts via proliferation, differentiation,
Distal and reduced apoptosis. These osteoblasts replace the osteo-
epiphysis
clasts in the resorption cavity (lacuna) and begin to refill the
cavity with concentric layers, or lamellae, of unmineralized
organic matrix (osteoid) (Fig. 31-3). As osteoblasts fill the cav-
ity with new osteoid, they also secrete alkaline phosphatase,
which hydrolyzes phosphate esters including pyrophosphate
Trabecular bone
(a potent inhibitor of bone mineralization). The hydrolysis of
Central (Haversian) canal
pyrophosphate also increases the local concentration of inor-
ganic phosphate. Together, the alkaline phosphatase-catalyzed
Cortical bone Periosteum hydrolysis of pyrophosphate and the liberation of inorganic
phosphate promote the crystallization of calcium phosphate
salts and mineralization of the bone matrix.
B As osteoblasts continue to lay down matrix, some eventu-
Osteoblasts
ally become completely surrounded by it and are then called
osteocytes (Fig. 31-1). Osteocytes help control the balance
between bone formation and resorption via their secretion of
sclerostin (a protein that inhibits bone formation) and other
factors. Genetic mutations that delete or inactivate sclerostin
Osteoclast increase bone formation, without a corresponding increase in
bone resorption. Such uncoupling leads to a marked increase
in bone mass and bone strength in humans and experimental
animals. A monoclonal antibody that inactivates sclerostin,
and thereby increases bone mass and bone strength through-
Resorption
lacuna out the skeleton, is being evaluated as a potential treatment
for osteoporosis. Mature osteocytes normally alter their se-
cretion of sclerostin in bone regions subjected to mechanical
Osteocyte
loads, and thereby play a critical role in skeletal adaptations
to gravity and other mechanical loads by localizing bone re-
FIGURE 31-1. Structure of bone. A. The upper panel depicts the structure modeling responses to such loads.
of a long bone (exemplified by the humerus). Note that the diaphysis consists of a
thick outer layer or cortex of compact cortical bone surrounding the bone marrow.
In the epiphysis, the cortex is thinner and surrounds trabecular bone as well as Hormonal Control of Calcium and Phosphate
bone marrow; trabecular bone is also found in the vertebral bodies and much of the
Calcium is essential for many important physiologic pro-
pelvis. B. The lower panel shows the detailed structure of bone. Bone remodeling
is a dynamic balance between the catabolic activity of osteoclasts and the anabolic
cesses, such as neurotransmitter release, muscle contraction,
activity of osteoblasts. Osteoblasts and osteoclasts are found on all inner bone sur- and blood coagulation, and deviations in extracellular calcium
faces, including the endosteum that lines cortical bone and the many surfaces in levels can have serious consequences. Therefore, the blood
trabecular bone. Bone remodeling is most intense in trabecular bone. Consequently, calcium level is tightly regulated. Inorganic phosphate con-
conditions that disrupt bone remodeling and/or bone mineralization affect trabecu- centrations must also be regulated, in part because changes in
lar bone preferentially. For example, osteoporotic fractures occur most commonly plasma inorganic phosphate concentrations affect plasma cal-
in vertebral bodies, which are predominantly trabecular bone. cium levels (see below). Three main hormonesparathyroid
hormone (PTH), vitamin D, and FGF-23mediate calcium
According to Le Chateliers principle, OH consumption drives and phosphate homeostasis. In addition, calcitonin, gluco-
this reaction to the right. This is an important mechanism ex- corticoids, thyroid hormone, and gonadal steroids have lesser
ploited by osteoclasts to resorb the mineral component of bone. effects on calcium and phosphate homeostasis. Table 31-1
Demineralization of the bone matrix exposes it to prote- summarizes the mechanisms and effects of these hormones
olysis by cathepsin K, collagenases and other proteases that on calcium and phosphate homeostasis.
544 Principles of Endocrine Pharmacology

Calcium intake FIGURE 31-2. Daily whole-body calcium bal-

1000 mg PTH ance. In a state of whole-body calcium balance, the
1,25(OH)2D (exogenous; once-daily) fluxes of calcium include net uptake of 200 mg per day
from the GI tract and excretion of 200 mg per day by
300 mg 300 mg the kidneys. Calcitriol [1,25(OH)2D3] enhances absorp-
(Absorption) (Accretion) tion of Ca2 from the GI tract. Continuous secretion
Plasma
calcium of parathyroid hormone (PTH) increases bone forma-
100 mg 300 mg tion and (even more) bone resorption, and stimulates
(Secretion) (Resorption) renal tubular reabsorption of calcium; both effects
Small Bone
intestine raise plasma Ca2. Continuous secretion of PTH also
enhances renal clearance of inorganic phosphate
CT PTH (PO4). In contrast, once-daily injection of PTH (in blue)
(exogenous) (endogenous;
continuous) stimulates new bone formation (accretion) more than it
800 mg
200 mg stimulates bone resorption and has only transient (and
Fecal excretion
Renal excretion consequently minor) effects on renal clearance of Ca2
and PO4. Exogenous calcitonin (CT; also in blue) inhibits
PTH bone resorption.
(stimulates Ca2+ reabsorption
and enhances PO4 excretion)

Parathyroid Hormone of chief cells in the parathyroid gland; when bound by ex-
The most important endocrine regulator of calcium homeo- tracellular calcium ions, these G protein-coupled receptors
stasis is parathyroid hormone, an 84-amino acid peptide mediate increases in the level of intracellular free calcium,
hormone secreted by the parathyroid glands. The secretion of which, in turn, decreases secretion of preformed PTH. By
PTH is finely regulated in response to plasma calcium levels. this mechanism, high plasma calcium concentration sup-
Calcium-sensing receptors reside on the plasma membrane presses PTH secretion, while low plasma calcium stimulates
PTH secretion. (Note: In many other secretory tissues, an in-
crease in intracellular calcium enhances secretion. Thus, the
Osteoblast
PTH, shear
precursor parathyroid chief cell is unusual in its response to changes in
stress, TGF- intracellular calcium.)
PTH acts on three organs to raise the plasma calcium con-
centration: it acts directly on kidney and bone, and indirectly
Osteoblast 1 on the gastrointestinal (GI) tract (Fig. 31-4). The most rapid
precursor physiologic effects of PTH are to increase reabsorption of
5 calcium and to decrease reabsorption of inorganic phosphate
RANKL by the kidney tubules. These actions decrease renal clear-
ance of calcium while increasing renal clearance of inorganic
phosphate. In this manner, PTH raises plasma calcium levels
Mature and decreases plasma inorganic phosphate concentrations.
osteoblasts
Another important, although slower, effect of PTH results
2 Osteoclast from its direct actions on bone cells. Physiologic levels of
precursor PTH stimulate cell surface PTH receptors on osteoblasts,
TGF-, IGF-1, causing these cells to increase their expression of the os-
Mature growth factors,
osteoclast cytokines teoclast differentiation factor RANKL (Fig. 31-3) and de-
crease their expression of its antagonist OPG. The resulting
RANK 4 increase in osteoclastic activity increases bone resorption
3 and thereby increases the release of calcium and inorganic
Osteoblast M-CSF phosphate into the circulation. PTH also induces bone mar-
precursor row stromal cells to secrete cytokines such as IL-6, and these
cytokines ultimately stimulate osteoclast proliferation and
bone resorption.
Finally, PTH raises plasma calcium by an indirect effect on
the intestine. PTH stimulates the kidney not only to increase
FIGURE 31-3. Interaction of osteoblasts and osteoclasts in bone remodel- calcium reabsorption and decrease phosphate reabsorption,
ing. Bone resorption and bone formation are coupled by the interactions between as described above, but also to increase the enzymatic con-
osteoblasts and osteoclasts: (1) Factors such as parathyroid hormone (PTH), shear version of 25-hydroxy vitamin D to 1,25-dihydroxy vitamin
stress, and transforming growth factor (TGF-) cause osteoblast precursors to D (calcitriol). This hydroxylation takes place in cells of the
express the osteoclast differentiation factor RANK-ligand (RANKL). (2) RANKL binds proximal renal tubules. Calcitriol, in turn, increases small
to RANK, a receptor expressed on osteoclast precursors. (3) The RANKLRANK
intestinal absorption of calcium and (to a lesser extent) inor-
binding interaction, together with macrophage colony-stimulating factor (M-CSF),
causes osteoclast precursors to differentiate into mature osteoclasts. (4) As mature
ganic phosphate (discussed below).
osteoclasts resorb bone, matrix-bound factors such as TGF-, insulin-like growth Although the release of skeletal calcium and inorganic
factor 1 (IGF-1), other growth factors, and cytokines are released. (5) These liber- phosphate could be considered catabolic, PTH simultane-
ated factors stimulate osteoblast precursors to develop into mature osteoblasts, ously stimulates new bone formation by promoting differ-
which begin to refill the resorption cavities excavated by the osteoclasts. entiation of osteoblast precursors to mature osteoblasts and
 Thyroid gland

Parathyroid glands

Plasma [Ca2+]
Plasma [Ca2+]

PTH

Osteoclastic activity
liberates PO4 and Ca2+

Bone

PO4/ Ca2+ reabsorption

Hydroxylation of
25(OH) vitamin D to
Kidney 1,25(OH)2 vitamin D

Mucosal Ca2+ uptake and

transport proteins
Ca2+ absorption

Intestine
546 Principles of Endocrine Pharmacology

extracellular PTH increase bone formation more than bone

resorption and cause a net increase in bone mass. Conse-
quently, intermittent PTH administration by once-daily in-
jection or by some other drug delivery technology increases H H

bone matrix production, bone mass, bone mineral density, HO

and bone strength (see below). In contrast, continuous eleva- 7-dehydrocholesterol

tion of extracellular PTH increases bone formation equally, Skin UV-B

but increases bone resorption more, and causes net bone loss
in patients with primary or secondary hyperparathyroidism.

Vitamin D
Despite its name, vitamin D3 is produced in the skin and is
H
not required in the diet if sun exposure is generous. Because
it is produced endogenously and travels in the blood to effect
responses in distant target tissues, vitamin D3 is more cor-
rectly considered a hormone. The term vitamin D applies to HO
Vitamin D3
two related compounds, cholecalciferol and ergocalciferol. (cholecalciferol)
Cholecalciferol, or vitamin D3, is generated nonenzymati- Circulation
cally in the skin when 7-dehydrocholesterol absorbs a photon Dietary
Vitamin D3
of short ultraviolet light (UV-B; Fig. 31-5). Ergocalciferol, (animal sources)
or vitamin D2, is produced when ergosterol in plants absorbs Vitamin D2
Side-chain of Vitamin D2
such a photon. Vitamins D2 and D3 are each added to dairy (plant sources)
(ergocalciferol)
products and some other foods; each is available as a dietary
supplement; and each is available (in much higher doses) as a
prescription drug. Vitamins D2 and D3 have equal biological
activities, and vitamin D in subsequent paragraphs refers to Vitamin D 25-hydroxylase
storage
both the D2 and D3 forms of the hormone.
Whether from an endogenous (skin) or an exogenous
(dietary) source, vitamin D travels to the liver, where it is Liver
either stored or converted to calcifediol [25-hydroxy vitamin OH

D, or 25(OH)D] by the first of two enzymatic hydroxylation

steps. The second enzymatic hydroxylation converts calcife- H
diol to the final, active form of vitamin D called calcitriol
[1,25-dihydroxy vitamin D, or 1,25(OH)2D]. This second
hydroxylation takes place in many tissues, particularly in the
proximal tubule of the kidney (where it is PTH-dependent), HO
25-hydroxy vitamin D
but does not take place in the intestines because they lack (calcifediol)
the enzyme required for the second hydroxylation. Calcit-
riols primary effect on calcium balance is in the small in-
testine, where it increases the absorption of dietary calcium. 1-hydroxylase PTH, hypophosphatemia
Calcitriol enhances Ca2 absorption by acting on nuclear
receptors in the enterocyte to up-regulate the expression of
Kidney
genes coding for a number of brush border proteins. Calcit-
riol also promotes the transcellular transport of Ca2 through
OH
the enterocyte by inducing the expression of: (1) a calcium
uptake pump on the luminal surface of the enterocyte; (2)
calbindin, an intracellular Ca2-binding protein; and (3) H
an ATP-dependent Ca2 pump that extrudes Ca2 from the
enterocyte into the surrounding capillaries. Because entero-
cytes do not express the enzyme needed to form 1,25(OH)2D
HO
from 25(OH)D, their absorption of calcium is regulated by OH

blood levels of 1,25(OH)2D, which in turn depend on renal 1,25-dihydroxy vitamin D

tubular function and blood levels of PTH.
Calcitriol has important effects on other target organs, in-
cluding the parathyroid gland, bone, kidneys, and the immune
system. Calcitriol binds to nuclear receptors in parathyroid
cells, and thereby inhibits PTH synthesis and release. In bone,
calcitriol increases osteoclast number and activity, resulting in
increased bone resorption. High blood levels of calcitriol, and
lower levels of certain calcitriol analogues, increase bone for-
mation. In the distal tubule of the kidney, calcitriol increases
the reabsorption of both calcium and phosphate. In the im-
mune system, calcitriol production by macrophages may act
(calcitriol)
FIGURE 31-5. Photobiosynthesis and activation of vitamin D. Both
endogenous and exogenous vitamin D are converted to 25-hydroxy vitamin D in the
liver and then to calcitriol in the kidney. Calcitriol is the active metabolite of vitamin
D. Endogenous vitamin D3 is synthesized in the skin from 7-dehydrocholesterol,
in a reaction that is catalyzed by ultraviolet light (UV-B). Exogenous vitamin D can
be provided as D3 (from animal sources) or as D2 (from plant sources); D3 and D2
have the same biological activity. Parathyroid hormone (PTH) increases the activity
of 1-hydroxylase in the kidney and thereby stimulates the conversion of 25-
hydroxy vitamin D to calcitriol, as does hypophosphatemia.
 Increased production
of cytokines Longer lifespan
of osteoclasts
Growth spurt Perimenopause ( apoptosis)
Shorter lifespan
in women of osteoblasts
( apoptosis)

Activation of Shorter lifespan

osteoclasts of osteocytes
( apoptosis)
Bone mass

Men
Deeper, larger resorption
cavities in bone Mechanosensing

Women
More fragile bone Microdamage
in bone

Bone fracture

0 25 50 75 100

Age (years)
 CHAPTER 31 / Pharmacology of Bone Mineral Homeostasis 551

Chronic kidney disease FIGURE 31-8. Pathophysiologic basis for

osteomalacia and osteitis fibrosa cystica in
Oral phosphate binders 1,25(OH)2 D production chronic kidney disease. In chronic kidney disease,
FGF-23 compromised renal function leads to decreased
Active
vitamin D
1,25(OH)2 vitamin D synthesis and decreased
Active vitamin D
Phosphate retention analogues analogues
phosphate excretion. The decrease in 1,25(OH)2
vitamin D causes decreased gastrointestinal (GI)
absorption of Ca2, while the increased phos-
Plasma phosphate and phate retention causes an increase in the levels
binding to calcium GI Ca2+ absorption of plasma phosphate, which complexes with Ca2.
By these two mechanisms, chronic kidney disease
leads to hypocalcemia. Hypocalcemia stimulates
Plasma [Ca2+] secretion of parathyroid hormone (PTH). Decreased
Synthesis of PTH levels of 1,25(OH)2 vitamin D stimulate PTH syn-
Secretion of PTH thesis and parathyroid gland hyperplasia, and
Cinacalcet
Parathyroid gland hyperplasia lead to a decreased number of Ca2 receptors on
parathyroid gland chief cells and an elevated set-
point for Ca2 regulation. Hyperphosphatemia may
Synthesis of PTH stimulate increased synthesis and secretion of PTH
Secretion of PTH directly and also increase levels of FGF-23, lead-
Degradation of PTH
ing to decreased levels of 1,25(OH)2 vitamin D. This
combination of complex regulatory events leads to
Ca2+ receptors on hyperparathyroidism, a syndrome characterized by
parathyroid cells and increased bone resorption, increased amounts of
Set-point for Ca2+ unmineralized osteoid, and osteitis fibrosa cystica.
regulation
Synthesis of PTH Oral phosphate binders lower plasma phosphate
Parathyroid gland levels by preventing dietary phosphate absorption.
hyperplasia Active vitamin D analogues bypass the defect in
Cinacalcet
Hyperparathyroidism renal 1-hydroxylase activity that accompanies
chronic kidney disease. Calcimimetics (cinacalcet)
modulate the activity of the Ca2-sensing receptor
Bone resorption on chief cells, such that the receptor is activated at
Osteomalacia lower plasma Ca2 concentrations.
Osteitis fibrosa cystica

activity in the kidneyand the calcimimetic cinacalcet
which adjusts the sensitivity of the calcium-sensing receptor
on parathyroid chief cells (see below).
Hyperphosphatemia, resulting from decreased renal ex-
cretion of phosphate, further exacerbates the hypocalcemia
of chronic kidney disease. Hyperphosphatemia induces hy-
pocalcemia by altering the equilibrium for hydroxyapatite
formation and dissolution, as described in Equation 31-1.
Hyperphosphatemia leads to the formation of toxic calcium
phosphate precipitates in extraskeletal tissues, as in tumoral
calcinosis, but in chronic kidney disease, hyperphosphatemia
also stimulates increased secretion of FGF-23. Elevated blood
FGF-23 suppresses renal secretion of 1,25-(OH)2D and has the
toxic cardiovascular effects described above. Paradoxically,
osteomalacia may coexist with ectopic calcium phosphate de-
posits, because bone matrix does not mineralize normally. Al-
though metabolic acidosis due to chronic kidney disease does
inhibit bone mineralization, other mineralization inhibitors
are also involved but are not yet adequately defined.
 PHARMACOLOGIC CLASSES AND AGENTS
Significant advances have occurred in recent years in the treat-
ment of osteoporosis and chronic kidney disease. For osteopo-
rosis, the relevant pharmacologic agents can be divided into two
main categories: drugs that inhibit bone resorption and drugs
that stimulate bone formation. Antiresorptive agents consist
of hormone replacement therapy (HRT), selective estrogen
receptor modulators, bisphosphonates, RANKL antagonists,
calcitonin, and cathepsin K inhibitors (in development). Bone
anabolic agents consist of fluoride and parathyroid hormone.
For chronic kidney disease, the relevant pharmacologic agents
include drugs that lower plasma phosphate levels (oral phos-
phate binders) and drugs that decrease parathyroid hormone
synthesis and secretion (vitamin D, vitamin D analogues, and
calcimimetics). Oral calcium and vitamin D also have an im-
portant role in the prevention and treatment of osteoporosis,
rickets, and hypoparathyroidism.
Antiresorptive Agents
Antiresorptive agents prevent or arrest bone loss by suppress-
ing osteoclastic bone resorption. However, because bone re-
sorption and bone formation are closely coupled processes,
a decrease in one typically leads to a decrease in the other,
via molecular mechanisms that are unclear. As a result, hor-
mone replacement therapy (HRT), selective estrogen receptor
modulators, bisphosphonates, RANKL antagonists, and cal-
citonin induce little increase in bone tissue. The increase in
bone mineral density seen during the first 1218 months of
therapy with these drugs represents filling of resorption cavi-
ties produced during the previous period of excessive bone
resorption, mineralization of this new bone, and completion of
mineralization (secondary mineralization) in old bone formed
and partially mineralized during the 1218 months preceding
antiresorptive therapy. After the first 1218 months of therapy
with these agents, bone mineral density increases slowly, re-
flecting the slow formation and mineralization of new bone
when resorption is suppressed. Cathepsin K inhibitors are an
unusual exception, because they suppress osteoclastic bone
resorption without suppressing bone formation.
 OH

H H
HO
17-estradiol

OH

HO O
N
O
Raloxifene
 O O O O
-O O- -O O-
P P P P
HO O OH HO OH
R1 R2

Pyrophosphate Bisphosphonate

Bisphosphonate R1 R2

Etidronate OH CH3

Pamidronate OH CH2 CH2 NH2

Alendronate OH CH2 CH2 CH2 NH2

CH3
Ibandronate OH CH2 CH2 N
(CH2)4 CH3

N
Risedronate OH CH2

N
Zoledronate OH CH2 N

Tiludronate H S Cl
556 Principles of Endocrine Pharmacology
to fracture and osteitis fibrosa cystica. In contrast, although
intermittent exposure of bone cells to PTH also increases
bone remodeling, more new bone is formed than old bone
resorbed. Thus, once-daily subcutaneous administration of
PTH favors bone anabolism, while continuous exposure to
PTH favors bone catabolism.
Native PTH is an 84-amino acid peptide, but N-terminal
fragments containing the first 3134 amino acids of PTH re-
tain essentially all the important functional properties of the
native protein. The 134 fragment has been shown in clini-
cal trials to act as a powerful anabolic agent that builds new
bone. Because PTH(134) is a peptide, the bioavailability
of this agent is close to zero when administered orally. The
currently available formulation is a subcutaneous injection
that is designed to be self-administered. Alternative dosage
forms (e.g., transcutaneous) are in advanced stages of clini-
cal development.
Human PTH(134) is approved under the generic name
teriparatide for the treatment of osteoporosis in postmeno-
pausal women, idiopathic and hypogonadal osteoporosis in
men, and glucocorticoid-induced osteoporosis in patients
of either sex, and approved for the reduction of spine and
nonspine fractures in postmenopausal osteoporotic women
at high risk of fracture. Full-length human PTH(184) is ap-
proved for such uses in some countries, but not in the United
States (because of hypercalcemia and other adverse effects
from the marketed dose). Because prolonged treatment of
rodents with either of these peptides causes dramatic bone
overgrowth followed by osteosarcomas, teriparatide is used
only in patients at high risk of fractures. However, there is no
evidence that any parathyroid hormone increases osteosar-
comas in humans. In humans, the anabolic skeletal effects of
teriparatide are attenuated by concomitant alendronate ther-
apy. It is unclear whether concomitant therapy with other
bisphosphonates, or prior therapy with any bisphosphonate,
does the same.
Treatment of Secondary Hyperparathyroidism
in Chronic Kidney Disease
There are currently three pharmacologic approaches to pre-
venting and modifying the metabolic sequelae of chronic
kidney diseaseoral phosphate binders, calcitriol and its
analogues, and calcimimetics.
Oral Phosphate Binders
In patients with chronic kidney disease, or chronic hyper-
phosphatemia of any cause, the increased plasma phos-
phate can complex with circulating calcium. The resulting
decrease in plasma calcium concentration can lead to hyper-
parathyroidism, and the precipitation of calcium phosphate
in extraskeletal tissues can impair their function. Dietary
phosphate restriction and oral phosphate binders can limit
both processes.
Aluminum hydroxide was one of the first agents used to
treat hyperphosphatemia. Aluminum precipitates phosphate
in the gastrointestinal tract, forming nonabsorbable com-
plexes. Although effective at lowering plasma phosphate
levels, this approach has been abandoned (except in cases of
refractory hyperphosphatemia) because of aluminum toxic-
ity: over the course of years, chronic use of aluminum-based
phosphate binders can lead to chronic anemia, osteomalacia,
and neurotoxicity.
Oral preparations of calcium carbonate and calcium ac-
etate can control plasma phosphate. These agents, when ad-
ministered with meals, bind to dietary phosphate and thereby
inhibit its absorption. At the doses required for phosphate bind-
ing, however, these agents can also cause iatrogenic hypercal-
cemia and may increase the risk of vascular calcification.
Sevelamer is a nonabsorbable cationic ion-exchange resin
that binds intestinal phosphate, thereby decreasing the absorp-
tion of dietary phosphate. Sevelamer also binds bile acids,
leading to interruption of the enterohepatic circulation and to
decreased cholesterol absorption. Its principal disadvantage is
its expense. Sevelamer is used to treat hyperphosphatemia in
patients with chronic kidney disease. Sevelamer is also used
to correct hyperphosphatemia in patients with the hyperphos-
phatemia-hyperostosis syndrome (also known as tumoral cal-
cinosis with hyperphosphatemia), who are deficient in FGF-23
secretion or action (Table 31-2).
Calcitriol and Its Analogues
Because impaired synthesis of 1-vitamin D derivatives is
one of the main homeostatic disturbances leading to second-
ary hyperparathyroidism in chronic kidney disease, vitamin
D is a logical replacement therapy in this disease. Three
active (i.e., 1-hydroxylated) vitamin D congeners are ap-
proved for treatment of secondary hyperparathyroidism.
All of these agents bypass the need for 1-hydroxylation
in the kidney and are therefore useful in the treatment of
bone diseases that complicate renal failure. Active vitamin
D increases dietary absorption of calcium, and the result-
ing increase in plasma calcium suppresses the secretion of
PTH by chief cells of the parathyroid gland. In addition,
these agents bind to and activate vitamin D receptors on
the chief cells, and thereby suppress PTH gene transcrip-
tion and parathyroid hyperplasia. Care should be taken to
avoid hypercalcemia when administering any of the active
vitamin D congeners.
Calcitriol [1,25(OH)2D3] is the dihydroxylated form of
vitamin D3. Calcitriol is available in oral and intravenous
forms; some data suggest that the intravenous formulation
may be more effective in patients on hemodialysis. Calcitriol
should not be administered to patients with chronic kidney
disease until hyperphosphatemia has been controlled with
diet and/or drugs, because the addition of calcitriol can cause
increased plasma levels of both calcium and phosphate.
Paricalcitol [19-nor-1,25(OH)2D2] is a synthetic ana-
logue of vitamin D. Doxercalciferol [1-(OH)D2] is the 1-
hydroxylated form of vitamin D2; it is 25-hydroxylated to
the fully active 1,25-dihydroxy form in the liver. Both pari-
calcitol and doxercalciferol may lower plasma PTH levels
without significantly raising plasma calcium levels.
Calcimimetics
Although vitamin D and its analogues can be effective in the
treatment of secondary hyperparathyroidism, these agents
can also lead to unwanted hypercalcemia and hyperphos-
phatemia. The so-called calcimimeticsagents that modulate
the activity of the calcium-sensing receptor on chief cells
are effective treatments for hyperparathyroidism that do not
cause these unwanted effects. Cinacalcet, the first Food and
Drug Administration (FDA)-approved calcimimetic, binds to
the transmembrane region of the calcium-sensing receptor, and
thereby modulates receptor activity by increasing its sensitivity
to calcium. Because the cinacalcet-bound receptor is activated
558 Principles of Endocrine Pharmacology
mass because of increased bone resorption or decreased
bone formation or (2) the formation of architecturally un-
sound bone because of excessively rapid bone formation
(woven bone) or deficient bone mineralization (rickets and
osteomalacia). In turn, structural weakening of the bone
predisposes to bone fracture or deformity.
Bone disorders can be treated by correcting the underlying
hormonal or mineral imbalances (e.g., vitamin D, calcium) or
by modulating bone remodeling (e.g., SERMs, bisphospho-
nates, RANKL antagonists). Pharmacologic interventions
directed at the physiology of bone remodeling can be divided
into two main categories: antiresorptive agents and bone
anabolic agents. The majority of drugs currently approved
by the FDA for the treatment of osteoporosis are antiresorp-
tive agents. These drugs act by inhibiting osteoclastic bone
resorption, and thus slowing the loss of bone mass. However,
these drugs do not stimulate new bone formation and do not
increase true bone mass (matrix plus mineral). Hence, antire-
sorptive agents do not represent optimal therapy for individu-
als who have already sustained severe loss of bone mass. The
only FDA-approved bone anabolic agent is once-daily PTH,
which acts by increasing bone formation and is therefore the
most beneficial agent for patients with very low bone mass.
The structurally related natural protein, PTH-related protein,
has similar effects in animals, and a synthetic analogue of
PTHrP increases bone mass in humans and is undergoing
additional trials in humans. Most drugs that reduce bone re-
sorption subsequently reduce bone formation. Two important
exceptions are currently undergoing clinical trials in humans:
a fully-humanized monoclonal antibody that neutralizes scle-
rostin and an oral inhibitor of cathepsin K. The former in-
creases bone formation without increasing bone resorption,
and the latter decreases bone resorption without decreasing
bone formation. The action of these agents suggests that it
is possible to uncouple bone resorption from bone formation
and thereby effectively treat osteoporosis.
Acknowledgment
We thank Allen S. Liu and Ariel Weissmann for their valu-
able contributions to this chapter in the First and Second
Editions of Principles of Pharmacology: The Pathophysi-
ologic Basis of Drug Therapy.
Suggested Reading
Andress DL. Vitamin D treatment in chronic kidney disease. Semin Dial
2005;18:315321. (Reviews progression of chronic kidney disease and indi-
cations for vitamin D therapy.)
Bergwitz C, Juppner H. Disorders of phosphate homeostasis and tissue min-
eralisation. Endocr Dev 2009;16:133156. (Current understanding of the
pathophysiology, diagnosis, and treatment of abnormal phosphate homeo-
stasis and tissue mineralization.)
Bilezikian JP. Efficacy of bisphosphonates in reducing fracture risk in
postmenopausal osteoporosis. Am J Med 2009;122(Suppl 2):14S21S.
(Summarizes effects on fracture incidence, effects of less-frequent dosing
regimens, and efficacy during long-term treatment.)
Cranney A, Weiler HA, ODonnell S, Puil L. Summary of evidence-based
review on vitamin D efficacy and safety in relation to bone health. Am J
Clin Nutr 2008;88:513S519S. (Current clinical evidence for use of vitamin
D in prevention and treatment of osteoporosis.)
Drake MT, Clarke BL, Khosla S. Bisphosphonates: mechanism of action
and role in clinical practice. Mayo Clin Proc 2008;83:10321045. (Selec-
tive review of medical literature from the preceding decade.)
Ebeling PR. Osteoporosis in men. N Engl J Med 2008;358:14741482.
(Review of an underappreciated public health problem.)
Maclean C, Newberry S, Maglione M, et al. Systematic review: compara-
tive effectiveness of treatments to prevent fractures in men and women
with low bone density or osteoporosis. Ann Intern Med 2008;148:197213,
423425, 884887. (Excellent overview of the comparative effectiveness of
various agents for the treatment of osteoporosis.)
Querfeld U. The therapeutic potential of novel phosphate binders. Pediatr
Nephrol 2005;20:389392. (Review of agents used to lower serum phos-
phate levels.)
Rahmani P, Morin S. Prevention of osteoporosis-related fractures among
postmenopausal women and older men. Can Med Assn J 2009;181:
815820. (Focus on prevention of fractures rather than prevention of
bone loss.)
Raisz LG. Pathogenesis of osteoporosis: concepts, conflicts, and prospects.
J Clin Invest 2005;115:33183325. (Current understanding of osteoporosis
pathophysiology.)
Rosen CJ. Postmenopausal osteoporosis. N Engl J Med 2005;353:595603.
(Succinct overview of the clinical management of osteoporosis.)
Steddon SJ, Cunningham J. Calcimimetics and calcilyticsfooling the cal-
cium receptor. Lancet 2005;365:22372239. (New approaches to pharma-
cologic modulation of the calcium-sensing receptor.)
V

Principles of Chemotherapy

Principles of Antimicrobial and
Antineoplastic Pharmacology
Quentin J. Baca, Donald M. Coen, and David E. Golan
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 563-564
MECHANISMS OF SELECTIVE TARGETING . . . . . . . . . . . . . 564
Unique Drug Targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565
Selective Inhibition of Similar Targets . . . . . . . . . . . . . . . . 565
Common Targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566
PATHOGENS, CANCER CELL BIOLOGY,
AND DRUG CLASSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566
Bacteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566
Fungi and Parasites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567
Viruses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 568
Cancer Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 568
Carcinogenesis and Cell Proliferation . . . . . . . . . . . . . 568
Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 570
Log Cell Kill Model . . . . . . . . . . . . . . . . . . . . . . . . . . . 571
MECHANISMS OF DRUG RESISTANCE . . . . . . . . . . . . . . . . . 572
Genetic Causes of Drug Resistance . . . . . . . . . . . . . . . . . 572
Reduced Intracellular Drug Concentration . . . . . . . . . . 572
Target-Based Mechanisms . . . . . . . . . . . . . . . . . . . . . 573
Insensitivity to Apoptosis . . . . . . . . . . . . . . . . . . . . . . . 573
Practices That Promote Drug Resistance . . . . . . . . . . . . . 574
 INTRODUCTION
Although infectious diseases and cancers have different
underlying etiologies, from a pharmacologic perspective,
the broad principles of treatment are similar. The common
thread in these pharmacologic strategies is the targeting of
selective differences between the microbe or cancer cell and
the normal host cell. Because both microbes and cancer cells
can evolve resistance to drug therapies, the development of
new treatments is also a continually evolving process.
Infectious diseases and cancers are among the most deadly
afflictions plaguing human societies. The World Health Or-
ganization (WHO) has estimated that, in the year 2004, five
major infectious diseases caused almost 11 million of the
59 million total deaths worldwide, and malignant neoplasms
were responsible for 7.4 million deaths. Among the infec-
tious diseases, the most common causes of mortality world-
wide included lower respiratory infections (4.18 million),
diarrheal diseases (2.16 million), HIV/AIDS (2.04 million),
32
METHODS OF TREATMENT . . . . . . . . . . . . . . . . . . . . . . . . . 574
Combination Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . 574
Prophylactic Chemotherapeutics . . . . . . . . . . . . . . . . . . . 574
INHIBITORS OF FOLATE METABOLISM:
EXAMPLES OF SELECTIVE TARGETING AND
SYNERGISTIC DRUG INTERACTIONS . . . . . . . . . . . . . . . . . . 574
Folate Metabolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575
Inhibitors of Folate Metabolism . . . . . . . . . . . . . . . . . . . . 575
Unique Drug Targets: Antimicrobial
Dihydropteroate Synthase Inhibitors . . . . . . . . . . . . . . 575
Selective Inhibition of Similar Targets: Antimicrobial
Dihydrofolate Reductase Inhibitors . . . . . . . . . . . . . . . 576
Common Targets: Antineoplastic Dihydrofolate
Reductase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . 577
Synergy of DHFR Inhibitors and Sulfonamides . . . . . . . 577
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 578
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 578
tuberculosis (1.46 million), and malaria (1.0 million). In the
developed world, although infectious disease mortality is
increasing, cancer (along with heart disease and stroke) is
a more significant cause of death. The most deadly cancers
in the United States presently include lung cancer (159,390
estimated deaths in 2009), colon cancer (49,920), breast can-
cer (40,610), pancreatic cancer (35,240), and prostate cancer
(27,360). Both infectious and neoplastic patterns of disease
will likely change as increasingly effective treatments and
preventive measures are developed and distributed.
This chapter focuses on the principles of antimicrobial and
antineoplastic pharmacology, but there are also many important
and effective nonpharmacologic strategies to combat microbes
and cancer. These strategies include public health measures,
vaccinations, and screening procedures. Most public health
and vaccination programs aim to prevent infections rather than
treat existing infections. Smallpox, for example, was eradi-
cated worldwide in 1977 through aggressive vaccination pro-
grams, although concerns have been raised about the potential
563
566 Principles of Chemotherapy
Infections: DNA Replication, Transcription, and Transla-
tion). Macrolide antibiotics such as erythromycin bind to
the 50S bacterial ribosomal subunit and block translocation
by preventing emergence of the protein from the ribosome.
Aminoglycoside antibiotics such as streptomycin and gen-
tamicin bind to the 30S bacterial ribosomal subunit and dis-
rupt the decoding of mRNA. More generally, the bacterial
protein synthesis inhibitors include a wide variety of individ-
ual drugs with diverse mechanisms, and the selectivity and
dose-limiting toxicities of these drugs are often class- and/or
drug-specific. For example, the macrolides rarely cause seri-
ous adverse effects, whereas some of the aminoglycosides
have dose-limiting ototoxicity and nephrotoxicity. Some ad-
verse effects appear to result from drug binding to human
mitochondrial ribosomes in addition to bacterial ribosomes.
Thus, selective inhibition of similar targets, as exemplified
by DHFR inhibitors and protein synthesis inhibitors, can re-
sult in effects characterized by therapeutic indices that range
from low to high, depending on the individual drug or drug
class under consideration.
Common Targets
When the host and pathogen or cancer share common bio-
chemical and physiologic pathways, a basis for selectivity
may be found if the pathogen or cancer requires a metabolic
activity or is affected by its inhibition to a greater degree
than the host. These relatively minor differences are often
exploited in cancer pharmacology, explaining the narrow
therapeutic indices of many of these drugs. Tumor cells arise
from normal cells that have been transformed by genetic
mutations into cells with dysregulated growth. These cells
utilize the same machinery for growth and replication as do
normal cells. Therefore, selective inhibition of cancer cell
growth is a major challenge.
Recent discoveries have identified a number of mutated or
overexpressed proteins in cancer cells, and selective inhibi-
tors of these proteins are entering clinical use with increas-
ing frequency (see Chapter 39, Pharmacology of Cancer:
Signal Transduction). Nonetheless, it is still the case that
the basis for the selectivity of most currently used antine-
oplastic drugs arises not from biochemical differences, but
rather from variations in cancer cell growth behavior and
from increased susceptibility of cancer cells to induction of
apoptosis or senescence. Cancer, as a disease of persistent
proliferation, requires continued cell division. Therefore,
drugs targeting processes involved in DNA synthesis, mi-
tosis, and cell cycle progression may kill rapidly cycling
cancer cells preferentially over their normal relatives. (An
important correlate to this statement is that many chemo-
therapeutic strategies are more successful against rapidly
growing than slowly growing cancers.) Antimetabolites
such as 5-fluorouracil (5-FU) inhibit DNA synthesis in di-
viding cells (see Chapter 38, Pharmacology of Cancer: Ge-
nome Synthesis, Stability, and Maintenance). 5-FU inhibits
thymidylate synthase, the enzyme responsible for convert-
ing dUMP to dTMP, a pyrimidine building block of DNA.
As a pyrimidine analogue, 5-FU is also incorporated into
growing RNA and DNA strands, thereby interrupting the
synthesis of these strands. By causing DNA damage, 5-FU
induces the cell to activate its apoptotic pathway, resulting
in programmed cell death. 5-FU is toxic to all human cells
undergoing DNA synthesis and, thus, is selectively toxic
both for rapidly cycling tumor cells (therapeutic effect) and
for high-turnover host tissues such as the bone marrow and
gastrointestinal mucosa (adverse effect).
These examples illustrate the importance of studying the
cell biology, molecular biology, and biochemistry of mi-
crobes and cancer cells to identify specific targets for selec-
tive inhibition. Clinically, an awareness of drug mechanisms
and the basis of drug selectivity can help to explain the nar-
row or broad therapeutic indices that have an impact on drug
dosing and treatment strategies. Understanding the selectiv-
ity of drugs for their targets is also important in combating
drug resistance. Thus, the fundamental pharmacologic prin-
ciples of drugreceptor interactions, therapeutic and adverse
effects, and drug resistance form the basis for selective tar-
geting in antimicrobial and antineoplastic drug therapy.
 PATHOGENS, CANCER CELL BIOLOGY,
AND DRUG CLASSES
Pharmacologic interventions target specific differences be-
tween the host and the microbial pathogen or cancer cell.
This section examines some of the unique characteristics
evolution has bestowed on organisms, and the major drug
classes that target these molecular differences among host
cells, pathogens, and cancer cells.
Bacteria
Bacteria are organisms that often contain unique targets for
pharmacologic intervention. Some of these drug targets have
been discussed previously and are illustrated in Figure 32-1.
Currently available drugs act to interrupt bacterial DNA rep-
lication and repair (this chapter and Chapter 33), transcrip-
tion and translation (Chapter 33), and cell wall synthesis
(Chapter 34).
Depending on the role of the drug target in bacterial
physiology, antibacterial drugs can produce bacteriostatic
or bactericidal effects. Drugs that inhibit the growth of the
pathogen without causing cell death are called bacteriostatic.
These drugs target metabolic pathways that are necessary for
bacterial growth but not for bacterial survival. Most protein
synthesis inhibitors (aminoglycosides are an exception) have
a bacteriostatic effect. The clinical effectiveness of these
drugs relies on an intact host immune system to clear the
nongrowing (but viable) bacteria. In contrast, bactericidal
drugs kill bacteria. For example, cell wall synthesis inhibi-
tors (e.g., penicillins and cephalosporins) cause bacterial
lysis when the bacteria grow in or are exposed to hypertonic
or hypotonic environments. Thus, bacterial infections in im-
munocompetent hosts can often be treated with bacteriostatic
drugs, whereas the treatment of bacterial infections in immu-
nocompromised hosts often requires bactericidal drugs.
Bacteriostatic and bactericidal effects are also important
to consider when antibiotics are used clinically in combi-
nation (see Chapter 40, Principles of Combination Chemo-
therapy). The combination of a bacteriostatic drug with a
bactericidal drug can result in antagonistic effects. For ex-
ample, the bacteriostatic drug tetracycline inhibits protein
synthesis and thereby retards cell growth and division. The
action of this drug antagonizes the effects of a cell wall syn-
thesis inhibitor, such as penicillin, which requires bacterial
growth in order to be effective. In contrast, the combina-
tion of two bactericidal drugs can be synergistic; that is, the
 CHAPTER 32 / Principles of Antimicrobial and Antineoplastic Pharmacology 567

Peptidoglycan cell wall

PABA
Inhibitors of cell
wall synthesis
Fosfomycin Monobactams
Cycloserine Carbapenems
Vancomycin Ethambutol Pteridine
Penicillins Pyrazinamide Plasmid
Cephalosporins Isoniazid
THF DHF

Protein
Inhibitors of
Ribosome DNA synthesis
50S Purines Pyrimidines and integrity

30S Sulfonamides
Inhibitors of
Trimethoprim
transcription
Quinolones
and translation
mRNA
Rifampin Chloramphenicol
Aminoglycosides Lincosamides
Spectinomycin Streptogramins
DNA
Tetracyclines Oxazolidinones
Macrolides Pleuromutilins

FIGURE 32-1. Sites of action of antibacterial drug classes. Antibacterial drug classes are often divided into three general groups. Drugs in one group inhibit
specific enzymes involved in DNA synthesis and integrity: sulfonamides and trimethoprim inhibit the formation or use of folate compounds that are necessary for
nucleotide synthesis; quinolones inhibit bacterial type II topoisomerases. Drugs targeting transcription and translation inhibit bacterial processes that mediate RNA and
protein synthesis: rifampin inhibits bacterial DNA-dependent RNA polymerase; aminoglycosides, spectinomycin, and tetracyclines inhibit the bacterial 30S ribosomal
subunit; macrolides, chloramphenicol, lincosamides, streptogramins, oxazolidinones, and pleuromutilins inhibit the bacterial 50S ribosomal subunit. A third group of
drugs inhibits specific steps in bacterial cell wall synthesis: fosfomycin and cycloserine inhibit early steps in peptidoglycan monomer synthesis; vancomycin binds
to peptidoglycan intermediates, inhibiting their polymerization; penicillins, cephalosporins, monobactams, and carbapenems inhibit peptidoglycan cross-linking; and
ethambutol, pyrazinamide, and isoniazid inhibit processes necessary for synthesis of the cell wall and outer membrane of Mycobacterium tuberculosis. There are several
clinically useful antibacterial drugs that do not fit into one of these three groups; one recent example is daptomycin. The development of resistance is a problem for all
antibacterial agents. Many bacteria carry plasmids (small, circular segments of DNA) with genes that confer resistance to an antibacterial agent or class of agents. PABA,
para-aminobenzoic acid; DHF, dihydrofolate; THF, tetrahydrofolate.

effect of the combination is greater than the sum of the ef-
fects of each drug alone (at the same doses of the two drugs).
For example, a penicillinaminoglycoside combination can
have a synergistic effect because inhibition of bacterial cell
wall synthesis by the penicillin allows increased entry of
the aminoglycoside. The combination of two bacteriostatic
drugs can also be synergistic (see Synergy of DHFR Inhibi-
tors and Sulfonamides, below).
Fungi and Parasites
Eukaryotes, which include pathogenic fungi (yeasts and
molds) and parasites (protozoa and helminths) as well as all
multicellular organisms, are more complex than bacteria.
Cells in these organisms contain a nucleus and membrane-
bound organelles, as well as a plasma membrane. Eukaryotic
cells reproduce by mitotic division rather than binary fission.
Because of the similarities among human, fungal, and para-
sitic cells, infections caused by fungi and parasites can be
more difficult to target than bacterial infections. However,
the burden of disease from these organisms is vast. Para-
sitic infections caused by protozoa and helminths (worms)
affect some 3 billion people worldwide, especially in less
developed countries where morbidity and mortality can be
devastating. In both developed and less developed parts of
the world, increasing numbers of patients are immunocom-
promised from AIDS, cancer chemotherapy, organ trans-
plants, and old age. Such patients are especially susceptible
to fungal and parasitic infections, which are becoming more
prominent and will require greater attention in the future.
The currently available antifungal drugs can be divided
into four main classes. As mentioned above, polyenes (e.g.,
amphotericin, nystatin) and azoles (e.g., miconazole,
fluconazole) selectively target ergosterol in the fungal cell
membrane, and echinocandins (e.g., caspofungin, mica-
fungin) inhibit the synthesis of -(1,3)-D-glucans in the fun-
gal cell wall. Pyrimidines such as 5-fluorocytosine inhibit
DNA synthesis. Another class of miscellaneous antifungals,
mostly acids, are used only topically because of their unac-
ceptable systemic toxicity. As with antibacterials, antifungals
can be fungistatic or fungicidal; this distinction is usually
determined empirically. For example, the azoles interfere
with fungal cytochrome P450-mediated ergosterol metabo-
lism. Many azoles (e.g., itraconazole and fluconazole) are
fungistatic. Newer azole agents (e.g., voriconazole and
ravuconazole) may have fungicidal activity against some
fungal species. As compared to fungistatic drugs, fungicidal
drugs are more efficacious and faster acting and allow more
favorable dosing regimens. Antifungal drugs are discussed
in further detail in Chapter 35.
Parasites exhibit complex and diverse life cycles and
metabolic pathways, and the treatment of parasitic infec-
tions utilizes a wide array of antiparasitic drugs (see Chap-
ter 36, Pharmacology of Parasitic Infections). Malaria is an
example of a complex parasite that, while theoretically sus-
ceptible to numerous classes of drugs, is becoming resistant
568 Principles of Chemotherapy
to many currently available therapies. Malaria is transmitted
when the female Anopheles mosquito deposits Plasmodia
sporozoites in the human bloodstream. The parasites leave
the circulation and develop into tissue schizonts in the liver.
The tissue schizonts rupture, releasing merozoites that again
enter the circulation to infect red blood cells (erythrocytes).
The parasites then mature to trophozoites and, finally, to ma-
ture schizonts. The mature schizonts are released into the
bloodstream when the erythrocytes rupture, causing the typ-
ical cyclic fever associated with malaria. Antimalarial drugs
target different stages of the protozoal life cycle; several
classes of drugs can be used, depending on the local pattern
of resistance. Aminoquinolines (such as the previous first-
line drug, chloroquine) inhibit the polymerization of heme
within the erythrocyte; it is thought that nonpolymerized
heme is toxic to intraerythrocytic Plasmodia. Dihydrofolate
reductase inhibitors, protein synthesis inhibitors, artemisi-
nins, and other classes of drugs are also used in malaria
treatment. As chloroquine resistance is now common and re-
sistance to most antimalarial agents has increased, the WHO
recommends against all single-agent treatment regimens in
the first line of therapy for malaria. Instead, combination
therapies are now recommended as first-line treatments. Re-
sistance to artemisinin and its derivatives has been observed,
and the WHO recommends artemisinin-based combination
treatments both to increase the efficacy of therapy and to
reduce the spread of drug-resistant malaria. Combinations of
an artemisinin-based drug with amodiaquine, mefloquine,
or sulfadoxine-pyrimethamine are recommended. Malaria
is but one example that illustrates the complexities of both
the parasitic life cycle and the use of drugs to treat parasitic
infections.
Viruses
Viruses are noncellular organisms that typically consist
of a nucleic acid core of RNA or DNA enclosed in a pro-
teinaceous capsid. Some viruses also possess a host cell-
derived lipid envelope containing viral proteins. Viruses
lack the capability to synthesize proteins themselves,
relying instead on the host cell machinery. Most viruses
also encode distinct or even unique proteins not normally
produced by human cells, however. Many of these pro-
teins are involved in the viral life cycle, mediating virus
attachment and entry into the host cell, viral capsid un-
coating, viral genome replication, viral particle assembly
and maturation, and release of viral progeny from the host
cell. These virus-specific processes are often targeted by
antiviral drugs. A schematic diagram of the general viral
life cycle is presented to illustrate the stages of viral rep-
lication that can be targeted by antiviral drugs (Fig. 32-2).
Because these targets are present only during active viral
replication, viruses that exhibit latency are not well con-
trolled by antiviral drugs.
One distinct viral protein is the HIV protease. This enzyme
cleaves viral precursor proteins to generate the structural pro-
teins and enzymes necessary for virus maturation. Without
HIV protease, only immature and noninfective virions (in-
dividual virus particles) are produced. HIV protease inhibi-
tors structurally mimic natural substrates of the protease, but
contain a noncleavable bond. These drugs are competitive
inhibitors at the active site of the enzyme (see Chapter 37,
Pharmacology of Viral Infections). In combination with other
classes of anti-HIV drugs, protease inhibitors helped to revo-
lutionize the treatment of patients with HIV/AIDS.
Several classes of drugs target distinct proteins that are
encoded by the influenza virus. Zanamivir and oseltamivir
target a viral neuraminidase that is vital for virion release
from host cells. Amantadine and rimantadine act on the
influenza virus membrane protein M2 (a proton channel) to
inhibit viral uncoating. Although these anti-influenza drugs
are highly effective inhibitors of the viral neuraminidase and
proton channel, respectively, they have not revolutionized
influenza therapy to the extent that anti-HIV drugs have for
HIV. Because most flu infections are identified clinically
when the immune system has already begun to eradicate the
virus, these drugs have only a limited effect on flu symp-
toms. This example illustrates the point that even selective
inhibitors with high therapeutic indices do not necessarily
become highly effective drugs in the clinic.
Currently, the most important antiviral drugs are the
polymerase inhibitors. Most viruses use a viral polymerase,
either an RNA or DNA polymerase, to replicate their ge-
netic material. Polymerase inhibitors are especially effec-
tive against human herpesviruses, HIV, and hepatitis B
virus. Two types of polymerase inhibitors are the nucleo-
side analogues and the nonnucleoside reverse transcriptase
(NNRT) inhibitors. Nucleoside analogues (such as zidovu-
dine [AZT or ZDV] and acyclovir) become phosphorylated
and thereby activated by viral or cellular kinases (phospho-
rylating enzymes), at which point they competitively inhibit
the viral polymerase and, in some cases, are incorporated
into the growing DNA strand. Selectivity is dependent on
the relative affinities of the nucleoside analogue for the
viral and cellular kinases and polymerases. Nonnucleoside
reverse transcriptase inhibitors (such as efavirenz) inhibit
viral reverse transcriptase, preventing DNA replication.
Mutations in viral polymerase genes are a major mechanism
of resistance to polymerase inhibitors.
Chapter 37 provides a detailed discussion of the pharma-
cology of antiviral drugs.
Cancer Cells
Cancer is a disease of cell proliferation in which normal cells
are transformed by genetic mutation into cells with dysregu-
lated growth. Neoplastic cells compete with normal cells
for energy and nutrition, resulting in deterioration of normal
organ function. Cancers also impinge on vital organs by mass
effects. Carcinogenesis, chemotherapy, and the log cell kill
model of tumor regression are discussed below to provide an
overview of cancer pharmacology. Chapters 38 and 39 should
be read with these principles in mind, and Chapter 40 provides
integrated examples of the clinical applications of combina-
tion antineoplastic chemotherapy.
Carcinogenesis and Cell Proliferation
Carcinogenesis occurs in three main stepstransformation,
proliferation, and metastasis. Transformation denotes a
change in phenotype from a cell with normal growth controls
to a cell with dysregulated growth. Nonlethal genetic dam-
age (mutations) can be inherited in the germ line, can occur
spontaneously, or can be caused by environmental agents
such as chemicals, radiation, or viruses. If the DNA damage
is not repaired, the mutated genes (e.g., genes involved in
growth regulation and DNA repair) can express altered gene
 CHAPTER 32 / Principles of Antimicrobial and Antineoplastic Pharmacology 569

Virus

Receptor
Attachment and entry inhibitors
Maraviroc Attachment and entry
Enfuvirtide (T-20) Host cell

Ion channel blockers

Amantadine Uncoating
Rimantadine

Polymerase inhibitors
Acyclovir Genome replication
Zidovudine
Efavirenz

RNA synthesis
Integrase inhibitors
Raltegravir Host ribosome Protein synthesis

Assembly and maturation

Protease inhibitors
Saquinavir
Ritonavir Egress and release

Neuraminidase inhibitors
Zanamivir
Oseltamivir

FIGURE 32-2. Stages of the viral life cycle targeted by antiviral drug classes. The viral life cycle begins with attachment of the virus to a host cell receptor and
entry of the virus into the cell. The virus then uncoats, sometimes in an endosomal compartment. The uncoated viral nucleic acid undergoes genome replication; viral
genes are transcribed (RNA synthesis); and virally coded RNA is translated into proteins on host cell ribosomes. The replicated viral genome and viral proteins are as-
sembled into a virion (viral particle), which is then released from the host cell. The process of virion assembly and/or release is often accompanied by maturation of the
virus into an infective agent that is able to repeat this life cycle with a new host cell. The anti-HIV drugs maraviroc and enfuvirtide (T-20) block the attachment and entry of
HIV into host cells. The ion channel blockers amantadine and rimantadine inhibit influenza virus uncoating. Polymerase inhibitors are a large class of antiviral agents that
include acyclovir, zidovudine, and efavirenz; these drugs inhibit viral genome replication by interfering with viral DNA polymerase (acyclovir) and reverse transcriptase
(zidovudine and efavirenz). The anti-HIV drug raltegravir inhibits viral genome replication by interfering with the viral integrase. Protease inhibitors, such as the anti-HIV
drugs saquinavir and ritonavir, inhibit viral maturation. Neuraminidase inhibitors block the release of influenza virus particles from the host cell.

products that allow abnormal cell growth and proliferation.
Mutations can activate growth-promoting genes, inactivate
growth-inhibiting genes, alter apoptosis-regulating genes,
confer immortalization, and inactivate DNA repair genes.
Expression of altered gene products and/or loss of regula-
tory proteins can cause genetic instability and dysregulated
growth. Most cancers are initially clonal (i.e., genetically
identical to a single precursor cell), but evolve to heteroge-
neity as new mutations increase the genetic variation among
daughter cells. When progeny cells with higher survival ca-
pacity are selected, increased cell proliferation ensues, and
the tumor progresses to greater and greater heterogeneity.
Thus, carcinogenesis, the progression from a normal cell to a
malignant tumor, is a multistep process that requires an accu-
mulation of multiple genetic alterations. As more is learned
about the molecular basis for carcinogenesis, these genetic
differences can be targeted for selective drug therapy.
The growth of transformed cells into a tumor requires
proliferation, or an increase in the number of cells.
Dividing human cells progress through a cell cycle (or
mitotic cycle) consisting of distinct phases. The two key
events in the cell cycle are the synthesis of DNA during S
phase and the division of the parent cell into two daugh-
ter cells during mitosis or M phase. The phase between
cell division and DNA synthesis is called gap 1 (G1), and
the phase between DNA synthesis and mitosis is called
G2. Proteins called cyclins and cyclin-dependent kinases
(CDKs) govern progression through the phases of the cell
cycle; mutations in cyclin and/or CDK genes can result in
neoplastic transformation.
A proliferating cancer cell has three potential fates: the
daughter cell can become quiescent by entering a resting
phase called G0; the cell can enter the cell cycle and prolif-
erate; or the cell can die. The ratio of the number of cells that
are proliferating to the total number of cells in the tumor is
called the growth fraction. An average tumor growth frac-
tion is about 20%, because only one in five cells participates
in the cell cycle at any given time. Most antineoplastic drugs
570 Principles of Chemotherapy

target dividing cells. Hence, tumor cells in a quiescent (G0)
state, such as nutrient-starved cells in the center of a large
tumor, are not easily killed by chemotherapy. Small or rap-
idly growing cancers (i.e., cancers with high growth frac-
tions, such as leukemias) often respond more favorably to
chemotherapy than do large bulky tumors. Unfortunately,
cells in normal tissues characterized by high growth frac-
tions, such as the bone marrow and gastrointestinal mucosa,
are also killed by antineoplastic drugs, resulting in dose-
limiting toxicities.
Tumor cells do not proliferate in isolation. Transformed
cancer cells secrete and induce a variety of chemical media-
tors to induce a specialized local environment. These chemi-
cal mediators include growth factors such as epidermal
growth factor (EGF), and inhibitors of growth factor signal-
ing have been developed for clinical use as cancer chemo-
therapeutic agents. Some tumors create a protective fibrous
connective tissue stroma; for example, this property makes
breast cancer nodules palpable. Most solid tumors also re-
quire the induction of blood vessel growth (angiogenesis) to
deliver nutrients into the center of the tumor; for this reason,
angiogenesis inhibitors represent a valuable class of antine-
oplastic drugs.
Cancer cells may acquire the capability to invade tissues
and metastasize throughout the body. In order to metasta-
size, tumor cells must acquire mutations that allow invasion
into tissues and vessels, seeding of cavities, spread through
lymph or blood vessels, and growth in a new environment.
Aggressive, rapidly growing primary tumors are generally
more likely to metastasize than indolent, slowly growing tu-
mors. In the process of gaining mutations, tumor cells can
also evolve differential receptor expression patterns and drug
sensitivities. Often, although the primary tumor may respond
well to chemotherapy, the more dedifferentiated metastatic
cells respond poorly. Thus, metastatic spread often represents
a poor prognostic sign.
Chemotherapy
By the time a typical solid tumor is clinically evident, it
contains at least 109 cells, has progressed to heterogeneity,
and has developed surrounding stroma. The tumor may or
may not have metastasized from its site of origin (primary
site) to one or more secondary sites. These factors can ren-
der the cancer difficult to treat pharmacologically. Many of
the traditional chemotherapeutic agents interfere with cell
proliferation and rely on rapid cell cycling and/or promo-
tion of apoptosis for their relative selectivity against cancer
cells (Fig. 32-3). As noted above, tumors are most sensitive
to chemotherapy when they are growing rapidly, primarily
because they are progressing through the cell cycle. These
metabolically active cells are thus susceptible to drugs that
interfere with cell growth and division (the mitotoxicity hy-
pothesis). Many antineoplastic drugs interfere with the cell
cycle at a particular phase; such drugs are called cell-cycle
specific. Other antineoplastic drugs act independently of the
cell cycle and are called cell-cycle nonspecific (Fig. 32-4).

Purine Pyrimidine
precursors precursors
Folate

N N
N

N N N

R R
Purine Pyrimidine
nucleotides nucleotides
Inhibitors of DNA synthesis
and integrity
Microtubules Inhibitors of
Antimetabolites and
folate pathway inhibitors microtubule function
Topoisomerase inhibitors Vinca alkaloids
mRNA
Taxanes

DNA

DNA damaging agents

Alkylating agents
Antitumor antibiotics
Platinum complexes

FIGURE 32-3. Antineoplastic drug classes. Many cancer cells divide more frequently than normal cells, and cancer cells can often be killed preferentially by
targeting three critical processes in cell growth and division. DNA-damaging agents alter the structure of DNA and thereby promote apoptosis of the cell. These drugs
include alkylating agents (which covalently couple alkyl groups to nucleophilic sites on DNA), antitumor antibiotics (which cause free radical damage to DNA), and plati-
num complexes (which cross-link DNA). Inhibitors of DNA synthesis and integrity block intermediate steps in DNA synthesis; these agents include antimetabolites and
folate pathway inhibitors (which inhibit purine and pyrimidine metabolism) and topoisomerase inhibitors (which induce damage to DNA during winding and unwinding).
Inhibitors of microtubule function interfere with the mitotic spindle that is required for cell division. This group of drugs includes vinca alkaloids, which inhibit microtubule
polymerization, and taxanes, which stabilize polymerized microtubules. Additional classes of antineoplastic agentssuch as hormones, tumor-specific monoclonal
antibodies, growth factor receptor antagonists, signal transduction inhibitors, proteasome inhibitors, and angiogenesis inhibitorsare not shown (see Chapter 39).
 CHAPTER 32 / Principles of Antimicrobial and Antineoplastic Pharmacology 571
Inhibitors of
microtubule function
M may undergo apoptosis, whereas a normal cell can repair its
Antitumor Glucocorticoids
antibiotics
G1
G2
S
Topoisomerase
inhibitors
Antimetabolites and
folate pathway inhibitors
Alkylating agents
Platinum complexes
(cell-cycle nonspecific)
FIGURE 32-4. Cell-cycle specificity of some antineoplastic drug classes.
The cell cycle is divided into four phases. Cell division into two identical daughter
cells occurs during mitosis (M phase). Cells then enter the gap 1 (G1) phase, which
is characterized by active metabolism in the absence of DNA synthesis. Cells rep-
licate their DNA during the synthesis (S) phase. After completion of S phase, the
cell prepares for mitosis during the gap 2 (G2) phase. Some antineoplastic drugs
exhibit specificity for different phases of the cell cycle, depending on their mecha-
nism of action. Inhibitors of microtubule function affect cells in M phase; gluco-
corticoids affect cells in G1; antimetabolites and folate pathway inhibitors affect
cells in S phase; antitumor antibiotics affect cells in G2; topoisomerase inhibitors
affect cells in S phase and G2. Alkylating agents and platinum complexes affect
cell function in all phases and are therefore cell-cycle nonspecific. The differential
cell-cycle specificity of the various drug classes allows them to be used in com-
bination to target different populations of cells. For example, cell-cycle specific
drugs can be administered to target actively replicating neoplastic cells, whereas
cell-cycle nonspecific agents can be used to target quiescent (nonreplicating)
neoplastic cells. Additional classes of antineoplastic agentssuch as hormones,
tumor-specific monoclonal antibodies, growth factor receptor antagonists, signal
transduction inhibitors, proteasome inhibitors, and angiogenesis inhibitorsare
not shown (see Chapter 39).
Inhibitors of DNA synthesis, such as antimetabolites and
folate pathway inhibitors, are S-phase specific. Microtubule
poisons, such as taxanes and vinca alkaloids, interfere with
spindle formation during M phase. The alkylating agents
that damage DNA and other cellular macromolecules act
during all phases of the cell cycle. These various classes of
drugs can be administered in combination, using cell-cycle
specific drugs to target mitotically active cells and cell-cycle
nonspecific agents to kill both cycling and noncycling tumor
cells (see Chapter 40).
The mitotoxicity hypothesis of anticancer therapy leaves
some puzzles unresolved, however. Although cancer che-
motherapy is often toxic to the bone marrow, gastrointesti-
nal mucosa, and hair follicles, these tissues usually recover,
while (in successful treatment) cancers with similar growth
kinetics are eradicated. It has now been established that al-
most all chemotherapeutic drugs also cause apoptosis of
cancer cells. DNA damage is normally sensed by molecules,
such as p53, that arrest the cell cycle in order to allow time
for the damage to be repaired. If the damage is not repaired,
a cascade of biochemical events is triggered, which can
result in apoptosis (programmed cell death). Therefore, a
cancer cell that is defective in its capability for DNA repair
DNA and recover. Cancers that express wild-type p53, such
as most leukemias, lymphomas, and testicular cancers, are
often highly responsive to chemotherapy. In contrast, can-
cers that acquire a mutation in p53, including many pancre-
atic, lung, and colon cancers, are often minimally responsive
or even resistant to DNA-damaging drugs, because apopto-
sis is not triggered in response to DNA damage.
Advances in cancer cell biology over the past several de-
cades have led to the development of new classes of therapeu-
tic agents that are targeted more specifically to the molecular
pathways responsible for the dysregulated growth of cancer
cells. The concept is emerging that specific cancers may be-
come dependent on one particular growth factor or signal
transduction pathway for their growth and survival and that
selective targeting of these pathways may provide the basis
for selective killing of cancer cells while sparing normal cells
(which are less dependent on any one particular pathway).
This concept and the many new classes of antineoplastic
agents that have recently been developedincluding tumor-
specific monoclonal antibodies, growth factor receptor antag-
onists, signal transduction inhibitors, proteasome inhibitors,
and angiogenesis inhibitorsare discussed in Chapter 39.
Log Cell Kill Model
The log cell kill model is based on experimentally observed
rates of tumor growth and tumor regression in response to
chemotherapy. Tumor growth is typically exponential, with
a doubling time (i.e., time required for the total number of
cancer cells to double) that depends on the type of cancer. For
example, testicular cancer often has a doubling time of less
than 1 month, whereas colon cancer tends to double every
3 months. In solid tumors, the cancer may grow exponentially
until a clinically observable tumor size is achieved. The log
cell kill model states that the cell destruction caused by cancer
chemotherapy is first-order; that is, that each dose of chemo-
therapy kills a constant fraction of cells. If the tumor starts
with 1012 cells and 99.99% are killed, then 108 malignant cells
will remain. The next dose of chemotherapy will then kill
99.99% of the remaining cells, and so on. Unlike antibacterial
drugs, which can often be used in a constant high dose until
the bacteria are eradicated, most antineoplastic drugs must
be used intermittently to reduce toxic side effects. Intermit-
tent dosing allows partial recovery of normal cells, but also
provides time for cancer cell regrowth and for evolution of
drug resistance in the cancer cells. As shown in Figure 32-5,
intermittent cycles of chemotherapy are administered until
all the cancer cells are killed or the tumor develops resistance.
Drug-resistant cells continue to grow exponentially despite
treatment, eventually resulting in death of the host. Improve-
ments in the rates of eradication of malignant cell populations
are likely to require either higher doses of chemotherapeutic
agents (which are limited by toxicity and drug resistance) or
initiation of therapy at a time when the tumor contains fewer
cells (which implies earlier detection). Adjuvant therapies,
such as surgery and radiation, are other important modalities
used to reduce the number of tumor cells before chemotherapy
is initiated. Surgery and radiation may also recruit more tumor
cells into the cell cycle and thus increase the susceptibility of
these cells to cell-cycle specific agents.
572 Principles of Chemotherapy
Number of cancer cells
A
1012 Detectable cancer
10 10 Local treatment
Nondetectable
108
cancer
106
Resistance
104
102 B C
Cure
Cure
Surgery
Radiation
therapy
Time
FIGURE 32-5. Log cell kill model of tumor growth and regression. The
log cell kill model predicts that the effects of antineoplastic chemotherapy can
be modeled as a first-order process. That is, a given dose of drug kills a constant
fraction of tumor cells, and the number of cells killed depends on the total number
of cells remaining. The four curves (AD ) represent four possible outcomes of an-
tineoplastic therapy. Curve A is the growth curve of untreated cancer. The cancer
continues to grow over time, eventually resulting in the death of the patient. Curve
B represents curative local treatment (surgery and/or radiation therapy) before
metastatic spread of the malignancy. Curve C represents local treatment of the
primary tumor, followed immediately by systemic chemotherapy administered in
cycles (down arrows) to eradicate the remaining metastatic cancer cells. Note that
each cycle of chemotherapy reduces the number of cancer cells by a constant
fraction (here, by about two logs, or by about 99%) and that some cancer growth
occurs as the normal tissues are given time to recover between cycles of chemo-
therapy. Curve D represents local treatment followed by systemic chemotherapy
that fails when the tumor becomes resistant to the drugs or when toxic drug ef-
fects occur that are intolerable to the patient. Note that 109 to 1010 cancer cells
must typically be present for a tumor to be detectable; for this reason, multiple
cycles of chemotherapy are required to eradicate the cancer, even when there is
no detectable tumor remaining.
 MECHANISMS OF DRUG RESISTANCE
Having provided a general introduction to the pharmacol-
ogy of drug targets in bacteria, fungi, parasites, viruses, and
cancer, the discussion now turns to the mechanisms of drug
resistance, which is a major problem in all of antimicro-
bial and antineoplastic pharmacology. Although resistance
to current drug therapies is emerging relatively rapidly, the
rate of introduction of new drugs (especially antimicrobial
drugs) is relatively slow. Formerly curable diseases such as
gonorrhea and typhoid fever are becoming more difficult to
treat, and old killers such as tuberculosis and malaria are
growing increasingly resistant worldwide. In some parts of
China, up to 99% of gonorrhea isolates are multidrug resis-
tant. In the United States, 60% of hospital-acquired (noso-
comial) infections due to Gram-positive bacteria are caused
by drug-resistant microbes. Tuberculosis, the fourth lead-
ing cause of infectious disease deaths worldwide, currently
has an estimated 5% overall multidrug resistance (MDR)
rate, although the rate of MDR in new cases of tuberculo-
sis ranges from 14.6% (Uzbekistan) to 22.3% (Azerbaijan)
in some Asian countries. The appearance of MDR tubercu-
losis in the United States is of special concern because of
the airborne spread of this organism. Despite these ominous
trends, only five new classes of antibioticsoxazolidinones
(linezolid), lipopeptides (daptomycin), pleuromutilins
(retapamulin), streptogramins (quinupristin/dalfopristin),
and glycylcyclines (tigecycline)have entered clinical use
in the past four decades. The numerous examples of rapidly
Death emerging drug-resistant organisms suggest that this problem
must be addressed promptly.
Palliation Because pathogens and cancer cells are primed to evolve
D rapidly in response to adaptive pressure, resistance can
eventually appear with the use of any antimicrobial or anti-
or toxicity neoplastic drug. In a population of microbes or transformed
cells, the cells that contain random mutations promoting fit-
ness will survive. Thus, high cell number, rapid growth rate,
and high mutation rate all promote the development of a
heterogeneous population of cells that can acquire resistance
through mutational escape. Because the use of a drug inher-
ently selects for organisms that can survive in the presence of
high concentrations of that drug, resistance is an omnipresent
consequence of drug therapy. In many cases, the emergence
of drug resistance confounds effective treatment.
Genetic Causes of Drug Resistance
The recent explosion in drug resistance has both genetic and
nongenetic causes. Genetic mechanisms of resistance arise
from chromosomal mutations and from exchange of genetic
material. Table 32-2 lists the major mechanisms of genetic
drug resistance that can be caused by either chromosomal
mutation or genetic exchange.
Chromosomal mutations typically occur in the gene(s)
that code(s) for the drug target or in genes that code for drug
transport or metabolism systems. These mutations can then
be transferred to daughter cells (vertical transmission) to
create drug-resistant pathogens or cancer cells. Alternatively,
bacteria can acquire resistance by gaining genetic material
from other bacteria (horizontal transmission). For example,
methicillin-resistant Staphylococcus aureus (MRSA) and
vancomycin-resistant enterococcus (VRE) are able to cause
highly feared nosocomial infections because these bacteria
have acquired resistance genes. Bacteria acquire genetic
material by three main mechanisms: conjugation, transduc-
tion, and transformation. In conjugation, chromosomal or
plasmid DNA is transferred directly between bacteria. DNA
can also be transferred from one cell to another by a bacterial
virus, or bacteriophage, in a process called transduction. In
transformation, naked DNA in the environment is taken up
by the bacteria.
Drug resistance in bacteria is most often caused by the
transfer of plasmids, which are extrachromosomal strands of
DNA that contain drug resistance genes. Transfer of a DNA
plasmid is especially important for drug resistance because
this mechanism occurs at high rates both within and between
bacterial species and because multidrug resistance genes can
be transferred.
Reduced Intracellular Drug Concentration
Drugs must reach their targets in order to be effective. When
an insufficient amount of drug reaches the target, the growth
of pathogens or cancer cells and the emergence of resistant
strains are allowed. Microbes and cancer cells have evolved
a number of mechanisms to inactivate drugs before the
drugs can bind to their targets. Many bacteria are resistant to
penicillins and cephalosporins because they produce a hy-
drolytic enzyme, -lactamase, which cleaves the -lactam
ring and thereby disables the drugs active site. A single -
lactamase enzyme can hydrolyze 103 penicillin molecules
574 Principles of Chemotherapy
design of new drugs and the evolution of changes leading to
drug resistance.
Practices That Promote Drug Resistance
One of the most important causes of drug resistance is the
overprescription of antibiotics that are not indicated for the
clinical situation. Overprescription is a problem not only in
humans, but also in the treatment and prophylaxis of animal
infections. Such widespread use promotes drug resistance,
which is then transferred from one bacterium to another by
the mechanisms described above. Other mechanisms of re-
sistance involve pharmacologic and anatomic drug barriers,
such as the wall of an abscess or the bloodbrain barrier.
Poor patient adherence can also promote resistance, as can
the erratic drug availability found in parts of the develop-
ing world (and even in some communities in the developed
world). International travel promotes a global disease com-
munity, ensuring that the multidrug-resistant tuberculosis
found in Russia or Peru will eventually emerge in hospitals
in the United States. Finally, demographic shifts and other
trends have created large populations that are susceptible to
infections, such as immunocompromised cancer patients,
AIDS patients, and the elderly population.
 METHODS OF TREATMENT
Combination Chemotherapy
The development of drug resistance depends on such factors
as the number of microorganisms or cancer cells in the pre-
treatment population, the rate of replication or generation
time of the organism or cell, the intrinsic rate of mutation
in the population, and the fitness of the resistant organism or
cell. Compared to treatment with a single agent, treatment
with a combination of drugs can significantly decrease the
probability that resistance will develop. Combination che-
motherapy is the standard-of-care in tuberculosis and HIV
therapy and most antineoplastic drug regimens. There are
several major reasons to administer multiple drugs simul-
taneously in a combination chemotherapy regimen; the ra-
tionales are discussed in further detail in Chapter 40. First,
the use of multiple drugs with different mechanisms of ac-
tion targets multiple steps in microbial or cancer cell growth,
leading to the maximum possible rate of cell killing. Second,
the use of combinations of drugs that target different path-
ways or molecules in the pathogen or cancer cell makes it
more difficult for resistance to develop. Even if the likeli-
hood of development of a resistance mutation to one drug is
relatively high, the concurrent emergence of separate muta-
tions against several different drugs is less likely. Third, the
use of lower doses of synergistically acting drugs in the com-
bination can reduce drug-associated adverse effects. This is
especially important in antimicrobial chemotherapy, where
synergistic activity of drug combinations has been clearly
demonstrated. Fourth, because many antineoplastic drugs
have different dose-limiting adverse effects (toxicities), it
is often possible to give each drug to its maximally toler-
ated dose and thereby achieve increased overall cell killing.
Finally, the concept of combination chemotherapy is being
redefined as new treatments become available. In the future,
immunotherapies, hormone therapies, and biotherapies will
become increasingly integrated into combination chemo-
therapy regimens (see Chapter 53, Protein Therapeutics).
Prophylactic Chemotherapeutics
In most instances, antimicrobial and antineoplastic drugs are
used to treat overt disease. These classes of drugs can also be
used to prevent diseases from occurring (chemoprophylaxis),
both before a potential exposure and after a known exposure.
The potential benefit of chemoprophylaxis must always be
weighed against the risk of creating drug-resistant pathogens
or cancer cells and the potential for toxicity attributable to
the chemoprophylactic agent. Antimicrobial chemoprophy-
laxis is frequently used in high-risk patients to prevent infec-
tion. Travelers to malaria-infested areas, for example, often
take prophylactic antimalarial drugs such as mefloquine (see
Chapter 36). Chemoprophylaxis is also used in some types
of surgery to prevent wound infections. Antibiotics are com-
monly administered prophylactically during surgical proce-
dures that could release bacteria into the wound site, such as
colon resection. Antibiotics have also been used prophylac-
tically before dental procedures in patients at high risk for
endocarditis, because such procedures can produce a tran-
sient bacteremia. In certain situations, immunocompromised
patients are given antibacterial, antifungal, antiviral, and/or
antiparasitic drugs prophylactically to prevent opportunistic
infections. For example, acyclovir can protect previously in-
fected immunocompromised patients against disease caused
by reactivation of latent herpes simplex virus.
Chemoprophylaxis or preemptive therapy can also be
used in healthy persons after exposures to certain patho-
gens. Prophylactic therapy after known or suspected ex-
posure to gonorrhea, syphilis, bacterial meningitis, HIV,
and other infections can often prevent disease. The risk
of seroconversion after a single needle stick exposure to
HIV-infected blood is approximately 0.3% (95% confi-
dence interval [CI] 0.20.5%). Although limited data are
available regarding the reduction of risk achievable with
prophylaxis, the Centers for Disease Control and Preven-
tion (CDC) currently recommends postexposure treatment
with a two- or three-drug antiretroviral therapy regimen
(e.g., zidovudine [AZT] and lamivudine [3TC] for basic
postexposure treatment or AZT, 3TC, and lopinavir/rito-
navir or another HIV protease inhibitor or non-nucleoside
reverse transcriptase inhibitor for expanded postexposure
treatment) for 4 weeks. Two-drug regimens are recom-
mended for lower risk exposures (to minimize adverse ef-
fects), and the addition of a third drug is appropriate after
a high-risk exposure (e.g., large-bore hollow needle stick,
deep puncture wound, visible blood on device, or needle
stick from an individual with a high viral load or a symp-
tomatic HIV infection). Zidovudine has also been shown to
reduce maternal transmission of HIV, representing chemo-
prophylaxis for the fetus (see Chapter 37).
 INHIBITORS OF FOLATE METABOLISM:
EXAMPLES OF SELECTIVE TARGETING
AND SYNERGISTIC DRUG INTERACTIONS
Folic acid is a vitamin that participates in a number of en-
zymatic reactions involving the transfer of one-carbon units.
These reactions are essential for the biosynthesis of DNA and
RNA precursors; the amino acids glycine, methionine, and glu-
tamic acid; the formyl-methionine initiator tRNA; and other es-
sential metabolites. Given the importance of folate metabolism
A Folic acid

H2 N N N

H
N N
N
H
OH N COOH
Pteridine moiety
O COOH
PABA
Glutamate

B PABA analogues
NH2
NH2

NH2
O
O S
S O NH
O NH

N
O N N
S O
O NH2

Sulfanilamide Sulfadiazine Sulfamethoxazole

C Folate analogues

H2 N N N

N N
N
H
NH2 N COOH

O COOH
Methotrexate

O
H2 N N
H2N N O

N
N
O
NH2
NH2 Cl
Trimethoprim Pyrimethamine
Bacteria
Pteridine + PABA
Dihydropteroate
synthase Sulfonamides

Dihydropteroic acid

Glutamate

Bacteria Dihydrofolate
and
humans Dihydrofolate Trimethoprim
reductase Methotrexate
(DHFR) Pyrimethamine

Tetrahydrofolate
5-Fluorouracil
Flucytosine

Purines Methionine Thymidine

Glycine
fMet-tRNA

DNA Proteins DNA

RNA

Pharmacology of Bacterial
Infections: DNA Replication,
Transcription, and Translation
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 581-582
BIOCHEMISTRY OF BACTERIAL DNA REPLICATION,
TRANSCRIPTION, AND TRANSLATION . . . . . . . . . . . . . . . . . 581
DNA Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581
DNA Replication, Segregation, and Topoisomerases . . . . . 582
Bacterial Transcription . . . . . . . . . . . . . . . . . . . . . . . . . . . 583
Bacterial Protein Synthesis . . . . . . . . . . . . . . . . . . . . . . . 583
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 586
Inhibitors of Topoisomerases: Quinolones . . . . . . . . . . . . . 587
 INTRODUCTION
The central dogma processesDNA replication, transcription,
and translationare generally similar in bacteria and humans.
DNA is replicated and transcribed into RNA, and messenger
RNA is translated into protein. However, there are important
differences in the biochemistry of bacterial and human central
dogma processes, and these differences can be exploited for
the development and clinical use of antibiotics. Three such dif-
ferences are targeted by the currently available antibacterial
chemotherapeutic drugs: (1) topoisomerases, which regulate
supercoiling of DNA and mediate segregation of replicated
strands of DNA; (2) RNA polymerases, which transcribe DNA
into RNA; and (3) ribosomes, which translate messenger RNA
(mRNA) into protein. This chapter briefly reviews the bio-
chemistry of central dogma processes in bacteria and discusses
certain relevant differences between these processes in bacte-
ria and humans. With this background, the chapter discusses
the mechanisms by which pharmacologic inhibitors interrupt
bacterial DNA replication, transcription, and translation.
 BIOCHEMISTRY OF BACTERIAL DNA
REPLICATION, TRANSCRIPTION,
AND TRANSLATION
The central dogma of molecular biology begins with the
structure of DNA, which is the macromolecule that carries
33
Marvin Ryou and Donald M. Coen
Inhibitors of Transcription: Rifamycin Derivatives . . . . . . . 587
Inhibitors of Translation . . . . . . . . . . . . . . . . . . . . . . . . . . 588
Antimicrobial Drugs Targeting
the 30S Ribosomal Subunit . . . . . . . . . . . . . . . . . . . . . 589
Antimicrobial Drugs Targeting
the 50S Ribosomal Subunit . . . . . . . . . . . . . . . . . . . . . 592
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 595
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 595
genetic information. To transmit all of the genetic informa-
tion in a cell to two progeny cells, the parental DNA must be
copied in its entirety (replicated), and the two resulting copies
must be segregatedone copy going to each progeny cell.
In order to express the genes that are embedded in the DNA,
these specific portions of the DNA are copied (transcribed)
into RNA. Some RNAs (mRNAs) are then read (translated)
by the protein synthesis machinery in order to produce pro-
teins. Other RNAs, such as transfer RNAs (tRNAs) and ribo-
somal RNAs (rRNAs), perform complex functions essential
to protein synthesis. It is important to note that the following
discussion of these bacterial processes is greatly simplified
to emphasize the steps that are inhibited by antibiotics.
DNA Structure
DNA is composed of two strands of polymerized deoxyribo-
nucleotides that wind around one another in a double helix
conformation. The 5-hydroxyl group of each nucleotides
deoxyribose ring is joined by a phosphate group to the 3-
hydroxyl group of the next nucleotide, thereby forming the
phosphodiester backbone of each side of the double helical
ladder (Figs. 33-1 and 33-2). The purines adenine (A) and
guanine (G) and the pyrimidines thymine (T) and cytosine
(C), which are covalently linked to the deoxyribose ring, as-
sociate with one another (A with T, G with C) via hydrogen
bonds to form the rungs of the ladder (Fig. 33-2). It is the
linear sequence of bases that encodes the genetic information
581
 O 5'
O
4' H H 1'

H 3' 2' H
O H

-D-2-deoxyribose
5' End

O base

O P O
O
O - H H
H H base
O H
O P O
O
O - H H
H H base
O H
O P O
O
O- H H
3'-5' Phosphodiester H H
O H
bond
3' End
 CHAPTER 33 / Pharmacology of Bacterial Infections: DNA Replication, Transcription, and Translation 583

A This passage of double-stranded DNA through a double-

stranded break is what permits separation of intertwined
O
copies of DNA following replication and, thereby, segrega-
H H
N tion of DNA into progeny cells.
N N There are two main bacterial type II topoisomerases.
H deoxyribose
N
N
The first to be identified, DNA gyrase, is a bacterial type II
O topoisomerase that is unusual in that it can introduce nega-
N Thymine
tive supercoils before the DNA strands separate, and thereby
N
neutralize positive supercoils that form as the strands unwind.
deoxyribose The second major type II topoisomerase is topoisomerase
Adenine IV. DNA gyrase is particularly crucial for segregation in
some bacteria, while topoisomerase IV is the critical enzyme
B
in other bacteria.
H Because supercoiling is important for transcription as
well as segregation, topoisomerases influence this central
N dogma process as well. Given their multiple functions, to-
H
O
poisomerases are usually engaged with DNA, and this is
N N important for their roles as drug targets. These enzymes are
H deoxyribose
N not only important as antibacterial drug targets, but also as
N
O targets for cancer chemotherapy (see Chapter 38).
H Cytosine
N N N
Bacterial Transcription
deoxyribose H Gene expression begins with transcription, which involves
Guanine the synthesis of single-stranded RNA transcripts from a
DNA template. Transcription is catalyzed by the enzyme
RNA polymerase. In bacteria, five subunits (2 , 1 , 1 ,
C and 1 ) associate to form the holoenzyme. As discussed
below, the subunit is instrumental for initiating transcrip-
tion, while the rest of the RNA polymerase enzymealso
known as the core enzymecontains the catalytic machin-
base ery for RNA synthesis.
The process of transcription occurs in three stages: initi-
O
O ation, elongation, and termination (Fig. 33-5). During initia-
H H
se tion, the RNA polymerase holoenzyme separates the strands
H
O H
H base of a short segment of double-helical DNA after its subunit
O P O
recognizes an upstream site. Once the double helix is un-
O wound to form a single-stranded template, RNA polymerase
O- H H
initiates RNA synthesis at a start site on the DNA. During
H H
O H elongation, RNA polymerase synthesizes a complementary
O P O RNA strand by joining together ribonucleoside triphosphates
-
via phosphodiester bonds. In the process, the subunit dis-
O
sociates from the holoenzyme. RNA synthesis proceeds in
the 53 direction, with the nascent RNA strand emerging
from the enzyme, until a termination sequence is reached.
The RNA polymerase enzyme differs between bacteria
FIGURE 33-2. Hydrogen bonding between DNA strands. A and B. The and humans and thus can serve as a selective target for an-
dashed lines indicate hydrogen bonds between complementary bases on opposite tibacterial drug action. In bacteria, one RNA polymerase
DNA strands. Adenine (A) and thymine (T) form two hydrogen bonds, while guanine synthesizes all of the RNA in the cell (except for the short
(G) and cytosine (C) form three hydrogen bonds. C. These A-T and G-C base pairs RNA primers needed for DNA replication, which are made
form the rungs of the DNA double helical ladder. Note that the deoxyribose moi-
by primase). Furthermore, bacterial RNA polymerase is
eties and phosphodiester bonds are located on the outside of the DNA double helix,
while the purine and pyrimidine bases stack in the center of the DNA molecule.
composed of only five subunits. In contrast, eukaryotes ex-
press three different nuclear RNA polymerases, and each en-
zyme is considerably more complex in its subunit structure
than the bacterial counterpart. For example, eukaryotic RNA
are both more complex and more versatile than type I topoi-
polymerase II, which synthesizes the precursors of mRNA,
somerases, and the type II enzyme serves as a more frequent
consists of 12 subunits.
molecular target for chemotherapeutic agents.
The mechanism of action of a type II topoisomerase pro-
ceeds in two steps. First, the enzyme binds a segment of Bacterial Protein Synthesis
DNA and forms covalent bonds with phosphates from each Once the mRNA transcripts are synthesized, these tran-
strand, thereby nicking both strands. Second, the enzyme scripts are translated by the bacterial translational machin-
causes a second stretch of DNA from the same molecule to ery. Although the overall process of translation is similar
pass through the break, relieving supercoiling (Fig. 33-4). between bacteria and higher organisms, there are a number
584 Principles of Chemotherapy

Strand-rotation Strand-passage FIGURE 33-3. Regulation of DNA supercoiling by type I

mechanism mechanism topoisomerases. Two mechanisms have been proposed for the
action of type I topoisomerases. In the strand-rotation model,
type I topoisomerase binds to opposite strands of the DNA
Bind Bind
double helix. The topoisomerase then nicks one strand and re-
Melt
Type I topoisomerase mains bound to one of the nicked ends (filled green circle). The
unbound end of the nicked strand is able to unwind by one or
more turns and is then joined (religated) to its parent strand. In
the strand-passage model, type I topoisomerase binding to the
DNA double helix results in melting (separation) of the two DNA
strands. The DNA-bound topoisomerase then introduces a nick
into one strand, while remaining bound to each end of the bro-
Break ken DNA strand (filled green circles). The broken strand is then
Rotate
Break passed through the helix and joined (religated), resulting in a net
unwinding of the DNA. Camptothecins, which are used in cancer
chemotherapy (see Chapter 38), inhibit the joining of the broken
strand of DNA after strand passage.

Rotate
Join Pass Camptothecins
Join

A B C
G-segment
T-segment
ATPase
domain
B' domain
ATP
Type II
ATP ATP
topoisomerase

A' domain

ADP + Pi

F E D

ATP ATP ATP ATP ATP ATP

Quinolones (inhibit bacterial enzyme)

Anthracyclines
Epipodophyllotoxins (inhibit human enzyme)
Amsacrine

FIGURE 33-4. Regulation of DNA supercoiling by type II topoisomerases. A. The type II topoisomerase enzymes contain A, B, and ATPase domains. The A and B
domains engage a segment of the DNA double helix (G-segment). B. Interaction with the G-segment induces a conformational change in the type II isomerase, causing it to
lock around the DNA G-segment. C. ATP binds to the ATPase domains of the topoisomerase, and a second segment of the DNA double helix (T-segment) enters and is locked
into the B domains. D. Once the enzyme is engaged with both DNA segments, the topoisomerase cuts both strands of the G-segment DNA. E. This double-stranded break in
the G-segment allows the T-segment to pass through the G-segment to the opposite side of the topoisomerase. F. The T-segment is released from the topoisomerase, and the
G-segment nick is religated. ATP is hydrolyzed to ADP, ADP dissociates from the topoisomerase, and the cycle begins anew. The result of each cycle is to change the coiling of
DNA or, when two separate circular DNA molecules are involved, to resolve catenanes. Quinolone antibiotics inhibit passage of the T-segment and religation of the G-segment by
bacterial type II topoisomerases. At therapeutic concentrations, quinolones also promote topoisomerase subunit dissociation, resulting in double-stranded breaks in the DNA and
killing of the bacteria. Several classes of cancer chemotherapeutic agents, including the anthracyclines, epipodophyllotoxins, and amsacrine, inhibit passage of the T-segment and
religation of the G-segment by human type II topoisomerases, thereby causing double-stranded DNA breaks and inducing apoptosis of the cancer cells (see Chapter 38).
 CHAPTER 33 / Pharmacology of Bacterial Infections: DNA Replication, Transcription, and Translation 585
RNA polymerase
(2' holoenzyme)
A Initiation
Start
2'
B Elongation
3'
Nascent RNA
Elongation site
5' Template strand
Movement of polymerase
C Termination
RNA
2'
FIGURE 33-5. Bacterial transcription. A. During initiation, the RNA poly-
merase holoenzyme (2) searches for and recognizes promoter sequences
on DNA. The holoenzyme then separates the strands of the double helical DNA,
exposing the start site for transcription, and begins synthesis of the new RNA
strand. B. During elongation, the core enzyme (without the subunit) extends
the new RNA strand in the 5 3 direction, using the unwound DNA strand as
a template. RNA polymerase separates the strands of the DNA double helix as it
moves along the template strand, extruding the 5 end of the transcript behind it.
Rifampin blocks elongation by complexing with the subunit of RNA polymerase
(not shown). C. Upon reaching a termination sequence, the DNA, core enzyme, and
newly synthesized RNA separate from one another.
of pharmacologically exploitable differences in the details of
the mechanisms. In particular, the number and composition
of the rRNA molecules differ between bacterial and human
ribosomes. Thus, bacterial ribosomes can also serve as se-
lective targets for antibiotics.
The ribosome of a representative bacterium, Escherichia
coli, has a sedimentation coefficient of 70S and is composed
of a 30S subunit and a 50S subunit. The 30S subunit contains
a single 16S rRNA molecule and 21 different proteins, while
the 50S subunit contains two rRNA molecules23S rRNA
and 5S rRNAand more than 30 different proteins. Impor-
tantly, it is the rRNA rather than the protein components of
the ribosome that are responsible for the ribosomes key ac-
tivities, namely, decoding the mRNA, linking together amino
acids, and translocating the translation machine. The 70S
ribosome contains two sites that bind tRNAs during transla-
tion: the P or peptidyl site, which contains the growing
peptide chain, and the A or aminoacyl site (also known
as the acceptor site), which binds incoming tRNA mol-
ecules carrying the various amino acids (Fig. 33-6). (There
is also an E or exit site, which binds the tRNAs that have
been used during translation before they are ejected from the
ribosome.)
Translation, like transcription, can be divided into three
steps (Fig. 33-7). During initiation, the components of the
translation system assemble together. First, the mRNA joins
with the 30S subunit of the bacterial ribosome and with a
specific tRNA molecule linked to formylated methio-
nine (fMet), the first amino acid encoded by every bacterial
mRNA. The tRNA-formylated methionine molecule (fMet-
tRNAf) binds to its initiation codon (AUG) on the mRNA.
Next, the 50S subunit joins with the 30S subunit to form the
complete 70S ribosome. The fMet-tRNAf now occupies the
P site of the 70S ribosome.
Elongation involves the addition of amino acids to the
carboxyl end of the growing polypeptide chain, as the ri-
bosome moves from the 5-end to the 3-end of the mRNA
that is being translated. tRNA molecules carrying specific
amino acids (aminoacyl tRNAs) enter the ribosomal A site
and base-pair to their complementary codons on the mRNA.
Utilization of the correct tRNA requires not only anticodon-
codon recognition between tRNA and mRNA, respectively,
but also decoding functions provided by the 16S rRNA in
the 30S ribosomal subunit. Peptidyl transferase, an en-
zyme whose activity derives from the 23S rRNA of the 50S
70S ribosome
P A 50S subunit
(23S rRNA, 5S rRNA,
more than 30 proteins)
Macrolides
Chloramphenicol
Lincosamides
Streptogramins
Oxazolidinones
Pleuromutilins
30S subunit
(16S rRNA, 21 proteins)
Aminoglycosides
Spectinomycin
Tetracyclines
FIGURE 33-6. The bacterial 70S ribosome. The bacterial 70S ribosome con-
sists of a 30S subunit and a 50S subunit. Each subunit is composed of ribosomal
RNA (rRNA) and numerous proteins. The rRNAs are responsible for most of the
important activities of the ribosome and are the targets of antibiotic drugs that
inhibit translation. Aminoglycosides, spectinomycin, and tetracyclines bind to and
inhibit the activity of 16S rRNA in the 30S subunit. Macrolides, chloramphenicol,
lincosamides, streptogramins, oxazolidinones, and pleuromutilins bind to and in-
hibit the activity of 23S rRNA in the 50S subunit. A, aminoacyl site (site of binding
of aminoacyl tRNA); P, peptidyl site (site of binding of tRNA that is covalently joined
to the elongating peptide chain).
586 Principles of Chemotherapy

fMet subunit (i.e., peptidyl transferase is a ribozyme), catalyzes

fMet-tRNA the formation of a peptide bond between fMet and the next
mRNA amino acid. The peptide bond links fMet to the next amino
+ 50S acid, which, in turn, is linked to the tRNA in the A site (i.e.,
30S the tRNA in the A site has accepted the fMet). After the
peptide bond has been formed, the ribosome advances three
nucleotides toward the 3-end of the mRNA. In the process,
the tRNAf that was originally linked to the fMet is ejected
from the P site (and binds to the E site), the tRNA that is now
P A linked to two amino acids shifts from the A site to the unoc-
Initiation complex cupied P site, the A site becomes available, and the growing
70S ribosome
peptide emerges from the exit tunnel of the ribosome. This
process is known as translocation. In this manner, polypep-
tide chain elongation results from multiple cycles of amino-
Amino acid
acyl tRNA binding to the A site, peptide bond formation, and
Charged translocation.
tRNA tRNA During termination, proteins called release factors rec-
binding
Tetracyclines (30S) tRNA
ognize the termination codon in the A site and activate dis-
charge of the newly synthesized protein and dissociation of
P A the ribosomemRNA complex. In at least some cases, this
Aminoglycosides (30S) process seems to involve structural mimicry of tRNAs by
the release factors.
Chloramphenicol Three general points are worth noting about bacterial
(50S, A site) translation. First, the two ribosomal subunits demonstrate
Lincosamides segregated functions: the 30S subunit is responsible for faith-
(50S, A and P sites) Decoding
Oxazolidinones ful decoding of the mRNA message, while the 50S subunit
(50S, A site) catalyzes peptide bond formation. Translocation, however,
Streptogramins seems to involve both subunits. Second, the catalytic ma-
(50S, A and P sites) Peptide bond tRNA
Pleuromutilins formation binding
Charged
chinery resides in the RNA component of the ribosome, not
(50S, A and P sites) tRNA in the ribosomal proteins. In other words, it is the rRNA that
does the work. Third, inhibitors of protein synthesis block
P A P A the process of translation at different steps.
Translocation and
peptide movement  PHARMACOLOGIC CLASSES AND AGENTS
(egress)
There are three general categories of drugs that target bacte-
rial DNA replication, transcription, and translation: (1) qui-
Spectinomycin (30S) Macrolides (50S, polypeptide exit tunnel) nolones, (2) rifamycin derivatives, and (3) drugs that target
bacterial ribosomes. Quinolone antibiotics are broad-spec-
FIGURE 33-7. Bacterial translation. Bacterial translation begins with trum agents; they not only inhibit certain topoisomerases but
the assembly of a complex containing a 30S ribosomal subunit, mRNA, formyl- also convert these enzymes into DNA-damaging agents. Ri-
methionine-linked tRNA, and a 50S ribosomal subunit. This assembly step is depen- famycin derivatives bind to and inhibit bacterial RNA poly-
dent on the binding of fMet-tRNA f to an initiator codon in the mRNA. The assembled
merase. One such derivative, rifampin, is a mainstay in the
70S ribosome contains the aminoacyl (A) and peptidyl (P) sites. The A site accepts
incoming triplet codons of mRNA and allows the corresponding amino acid-linked
therapy of tuberculosis. A number of classes of drugs bind
tRNA (i.e., charged tRNA) to bind to its corresponding triplet. The decoding function bacterial ribosomes to inhibit protein synthesis. Specifically,
of 16S rRNA helps ensure that the mRNA codon binds to the correct tRNA. Once aminoglycosides, spectinomycin, and tetracyclines bind the
a charged tRNA has entered the A site, the peptidyl transferase activity of the 23S 30S ribosomal subunit, while macrolides, chloramphenicol,
rRNA catalyzes the formation of a peptide bond between the amino acid occupying lincosamides, streptogramins, oxazolidinones, and pleuro-
the A site and the carboxy-terminus of the nascent peptide residing in the P site. mutilins target the 50S ribosomal subunit. These inhibitors
Once the peptide bond has formed, the tRNAmRNA complex translocates from the of protein synthesis generally act on both Gram-positive and
A site to the P site, the tRNA molecule that had occupied the P site dissociates from Gram-negative organisms and are therefore in wide clinical
the P site, and the elongating polypeptide chain moves out through the exit tunnel. use (see Chapter 34 for a discussion of Gram-positive and
The A site is now empty, and introduction of the next charged tRNA molecule into
Gram-negative bacteria).
the A site completes the cycle. Translation continues until a stop codon is encoun-
tered in the mRNA, at which point the newly synthesized protein is released from
Elucidation of the mechanisms of action of the agents
the ribosome. described below has depended crucially on the field of bac-
Pharmacologic agents that inhibit translation interfere with the activities of the terial genetics. In particular, the molecular targets of antibi-
bacterial ribosome. Aminoglycosides bind to rRNA in the 30S subunit and enable otics have been identified by the isolation of bacteria that are
the binding of incorrect tRNAs to mRNA; tetracyclines block aminoacyl tRNA bind- resistant to the particular antibiotic (e.g., rifampin), followed
ing to the A site; chloramphenicol, lincosamides, oxazolidinones, streptogramins, by showing that the target molecule (e.g., RNA polymerase)
and pleuromutilins inhibit the peptide bond formation activity of the 50S subunit. exhibits biochemical resistance to the antibiotic, and, finally,
Spectinomycin and macrolides inhibit peptide translocation. The binding site of showing that the drug-resistance mutation lies within the
a second component of the streptogramins overlaps with that of the macrolides gene encoding the target. More recent work, using nuclear
(not shown).
magnetic resonance spectroscopy and x-ray crystallography,
 O
CH3COO
COOH
CH3O OH OH O
OH OH
NH
N N
O O N N N
OH
O

Nalidixic acid Rifampin

O
CH3COO
F COOH
CH3O OH OH O
OH O
NH
N
N
O O NH
HN
N
O
N

Ciprofloxacin Rifabutin
 NH
HO
NH NH2 OH
HO
O OH HO O
O
HN HO
CHO H 2N H2 N
NH O
H2N HO NH2
HO O
O
HO O O
HO NHCH3 HO OH
HO NHCH3
Streptomycin Gentamicin A

HO OH N
H H H H H
N O O OH

NH2
HO O
H HO OH
NH O OH O OH O O

Spectinomycin Tetracycline

OH N N N
H H H H
OH OH
O
H
NH2 N NH2
N
OH H OH
OH O OH O O OH O OH O O
Doxycycline Tigecycline
590 Principles of Chemotherapy

A B

C1054

G530

A1493 PAR
A1492

S12

C D

ASL ASL

mRNA mRNA
PAR

Cell wall
E Inner membrane Outer membrane F

Incorrect
amino acid
Polysome incorporated

Aminoglycoside
G H

Membrane pore Aminoglycoside

(abnormal protein) "monosome"
(nonfunctional)
 CHAPTER 33 / Pharmacology of Bacterial Infections: DNA Replication, Transcription, and Translation 593

HO OH
OH
N
OH HO
O O O
OH
O O O
HN CHCl2
O2N
O O OH

Chloramphenicol Erythromycin A

O N
CH3 CH3 O N N
N
N H H C Cl
HN O O N S
H
C NH CH N
CH3CH2CH2 O O O O
O HO H
H H O NH O

H OH H SCH3
HO
N
H OH

Clindamycin Quinupristin

O
OH
N
O
O O
O
N
O O N
O N N H N O
N S
F O O
O
Linezolid Dalfopristin

OH
N
O

S H
O

O
Retapamulin

FIGURE 33-11. Structures of antimicrobial drugs targeting the 50S ribosomal subunit. Chloramphenicol, erythromycin (a macrolide), clindamycin (a lincos-
amide), quinupristin (a streptogramin), dalfopristin (a streptogramin), linezolid (an oxazolidinone), and retapamulin (a pleuromutilin) each inhibit bacterial translation by
targeting the 50S ribosomal subunit.

alternatives are not available, as in the case of resistance or
serious drug allergy.
Chloramphenicol binds to 23S rRNA and inhibits pep-
tide bond formation, apparently by occupying a site that in-
terferes with proper positioning of the aminoacyl moiety of
tRNA in the A site (Fig. 33-12B).
Microbes have developed resistance to chlorampheni-
col by two major mechanisms. Low-level resistance has
emerged in large chloramphenicol-susceptible populations
by the selection of mutants with decreased permeability to
the drug. The more clinically significant type of chloram-
phenicol resistance has arisen from the spread of specific
plasmid-encoded acetyltransferases (at least three types of
which have been characterized) that inactivate the drug.
The fundamental mechanism underlying the toxicity
of chloramphenicol appears to involve inhibition of mito-
chondrial protein synthesis. One manifestation of this tox-
icity is the gray baby syndrome, which can occur when
chloramphenicol is administered at high doses to newborn
infants. Because newborns lack an effective glucuronic acid
594 Principles of Chemotherapy
A Lincosamides
B Macrolides
Clindamycin
Chloramphenicol
CC-puromycin
CHCl2
P-site tRNA
A-site tRNA
FIGURE 33-12. Mechanism of action of erythromycin, clindamycin, and
chloramphenicol revealed by crystallographic analysis of drug binding to
the 50S ribosomal subunit. A. Erythromycin binds to a specific segment of 23S
rRNA and blocks the exit tunnel from which nascent peptides emerge. B. Clin-
damycin and chloramphenicol have partially overlapping binding sites on the 50S
ribosomal subunit. These sites are near the macrolide binding site. The positions
of the A-site tRNA and P-site tRNA are also shown.
conjugation mechanism for the degradation and detoxifica-
tion of chloramphenicol, the drug can accumulate to toxic
levels and cause vomiting, flaccidity, hypothermia, gray
color, respiratory distress, and metabolic acidosis. More
frequently, chloramphenicol causes dose-related, reversible
depression of erythropoiesis and gastrointestinal distress
(nausea, vomiting, and diarrhea). Aplastic anemia, a rare
but potentially fatal toxicity, occurs via an idiopathic mecha-
nism that is unrelated to dose.
Of special interest are the adverse effects that chloram-
phenicol can cause in tandem with other drugs. Like the
macrolides, chloramphenicol increases the half-life of cer-
tain drugs, such as phenytoin and warfarin, by inhibiting
the cytochrome P450 enzymes that metabolize these drugs.
Chloramphenicol also antagonizes the bactericidal effects of
penicillins and aminoglycosides, as do other bacteriostatic
inhibitors of microbial protein synthesis.
The major lincosamide in clinical use is clindamycin
(Fig. 33-11). Clindamycin blocks peptide bond formation,
apparently through interactions with both the A site (like
chloramphenicol) and the P site (Fig. 33-12B).
The most important indications for clindamycin are the
treatment of serious anaerobic infections caused by Bacter-
oides and the treatment of mixed infections involving other
anaerobes. Clindamycin has been implicated as a potential
cause of pseudomembranous colitis caused by Clostridium
difficile superinfection. An infrequent member of the normal
fecal flora, C. difficile is selected for during the administra-
tion of clindamycin or other broad-spectrum oral antibiotics.
C. difficile elaborates a cytotoxin that can cause colitis char-
acterized by mucosal ulcerations, severe diarrhea, and fever.
This serious adverse effect is a major concern in the use of
oral clindamycin.
Streptogramins
In 1999, the FDA approved the first drug in the strepto-
gramin class of protein synthesis inhibitors. The drug is a
mixture of two distinct chemicals: dalfopristin, a group A
streptogramin, and quinupristin, a group B streptogramin
(Fig. 33-11). Dalfopristin/quinupristin was approved for the
treatment of serious or life-threatening infections caused by
vancomycin-resistant Enterococcus faecium or Streptococ-
cus pyogenes. The streptogramins inhibit protein synthesis
by binding to the peptidyl transferase center of bacterial 23S
rRNA. Mutations and modifications affecting this region can
confer resistance. The binding site for the B component over-
laps with that of the macrolides, and it is thought that, like the
macrolides, the streptogramins block emergence of nascent
peptides from the ribosome. The A component binds to a lo-
cation overlapping both the A and P sites in the peptidyl trans-
ferase center, and it can inhibit peptidyl transferase in vitro.
Streptogramins are unusual among the 50S antibiotics in
that they are bactericidal against many, but not all, suscep-
tible bacterial species. A clear explanation for this phenom-
enon remains elusive; the current hypothesis is that, unlike
the other 50S antibiotics, the streptogramins induce a con-
formational change in the ribosome that is reversible only
after subunit dissociation.
Oxazolidinones
In 2000, the FDA approved linezolid (Fig. 33-11), the first
drug in the oxazolidinone class of antibacterial agents. Lin-
ezolid demonstrates excellent activity against drug-resistant
Gram-positive bacteria, including methicillin-resistant S.
aureus (MRSA), penicillin-resistant streptococcus, and
vancomycin-resistant enterococcus (VRE). Although there
was initially controversy regarding the precise mechanism
of action of linezolid, crystallographic analyses have located
the binding site of the drug in a pocket in the A site where
the amino acid moiety in aminoacyl tRNA normally binds.
Moreover, mutations in 23S rRNA can confer drug resistance.
These results and those of biochemical studies suggest that
linezolid blocks productive interactions of aminoacyl tRNAs
with the A site in the peptidyl transferase active center.
Pleuromutilins
In 2007, the FDA approved retapamulin (Fig. 33-11), the
first drug in the pleuromutilin class of antibiotics. This drug
is used as a topical treatment for bacterial skin infections,
 CHAPTER 33 / Pharmacology of Bacterial Infections: DNA Replication, Transcription, and Translation 595
and its mechanism of action is relatively well understood.
Like linezolid, pleuromutilins bind to a pocket in the A site
of the peptidyl transferase active center where aminoacyl
tRNA normally binds. Distinct from linezolid, pleuromutilin
binding also extends into the P site. Thus, the binding site of
pleuromutilins is similar to that of group A streptogramins.
The locations of mutations conferring resistance to pleuro-
mutilins are consistent with this binding site. These com-
pounds inhibit peptide bond formation, but once elongation
is under way and the A and P sites are occupied, pleuromuti-
lins are no longer active.
The fact that three of the most recently developed antibi-
otics inhibit the ribosome emphasizes the continuing value of
this complex structure as a target for new drug development.
There is much continuing effort to discover new protein syn-
thesis inhibitors, and this work is aided by the availability of
structures of ribosomes bound to drugs.
 CONCLUSION AND FUTURE DIRECTIONS
A number of classes of antibiotics target the bacterial ma-
chinery responsible for the central dogma processes, disrupt-
ing bacterial gene expression at multiple steps. Most of these
drugs demonstrate selective binding to bacterial enzymes or
RNAs and have relatively few adverse effects. All are as-
sociated with some degree of toxicity, however, and some
(e.g., chloramphenicol) have limited clinical use because of
their potential to cause life-threatening adverse effects. Sev-
eral of these antibiotic classesthe quinolones, rifamycin
derivatives, and several of the protein synthesis inhibitors
are bactericidal, but most protein synthesis inhibitors are
bacteriostatic. Drug resistance is a persistent and serious
problem for all of these agents. Although the emergence of
resistance is an expected consequence of antibiotic use, judi-
cious drug administration, multidrug therapies, and the con-
tinued development of new antibacterial agents can combat
the emergence of resistance. The development of the new
glycylcycline, streptogramin, oxazolidinone, and pleuro-
mutilin classes of bacterial ribosome inhibitors represents an
important advance in the search for drugs that are effective
against resistant bacteria. Further elucidation of the mecha-
nism of action of these drugs will both inform the basic bi-
ology of translation and define new biochemical targets for
pharmacologic intervention.
Suggested Reading
Campbell EA, Korzheva N, Mustaev A, et al. Structural mechanism for ri-
fampicin inhibition of bacterial RNA polymerase. Cell 2001;104:901912.
(Mechanism of rifampin action.)
Kohanski MA, Dwyer DJ, Wierzbowski J, et al. Mistranslation of mem-
brane proteins and two-component system activation trigger antibiotic-
mediated cell death. Cell 2008;135:679690. (Presents a new model for
bactericidal action of aminoglycosides.)
Ogle JM, Murphy FV, Tarry MJ, et al. Selection of tRNA by the ribosome
requires a transition from an open to a closed form. Cell 2002;111:721
732. (Structural basis for the mechanism of aminoglycoside-induced codon
misreading.)
Steitz TA, Moore PB. RNA, the first macromolecular catalyst: the ribosome
is a ribozyme. Trends Biochem Sci 2003;28:411418. (Reviews function of
RNA as a target of antibiotic action in the 50S subunit.)
Walsh CT. Antibiotics: actions, origins, resistance. Washington, DC:
ASM Press; 2003. (Reviews antibiotic synthesis, action, and mechanisms
of resistance.)

Pharmacology of Bacterial
and Mycobacterial Infections:
Cell Wall Synthesis
Tania Lupoli, David C. Hooper, Ramy A. Arnaout, Daniel Kahne, and Suzanne Walker
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 599-600
BIOCHEMISTRY OF BACTERIAL
CELL WALL SYNTHESIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599
Cell Wall Structure and Function . . . . . . . . . . . . . . . . . . . 599
Peptidoglycan Biosynthesis . . . . . . . . . . . . . . . . . . . . . . . 601
Synthesis of Murein Monomers . . . . . . . . . . . . . . . . . . 601
Polymerization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 603
Cross-Linking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 604
Mycobacterial Cell Wall Synthesis . . . . . . . . . . . . . . . . . . 604
Autolysins and Cell Wall Degradation . . . . . . . . . . . . . . . . 606
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 606
Inhibitors of Murein Monomer Synthesis . . . . . . . . . . . . . 606
Fosfomycin and Fosmidomycin . . . . . . . . . . . . . . . . . . 606
 INTRODUCTION
In 1928, Alexander Fleming made a chance discovery that
would revolutionize the treatment of bacterial infections.
He observed that certain molds produce a compound that
inhibits the growth of bacteria. The compound he isolated
was penicillin, the first in a long line of antibiotics that act
by inhibiting the biosynthesis of peptidoglycan, the major
component of the bacterial cell wall. The unique chemi-
cal and structural properties of peptidoglycan make it an
attractive and prominent target for antibacterial chemother-
apy. The emergence and spread of antibiotic resistance in-
creasingly complicate the clinical use of cell wall synthesis
inhibitors, however. This chapter reviews the biochemistry
of peptidoglycan synthesis and describes the mechanisms
of action, uses, and limitations of the antibiotics that in-
terfere with this pathway. These limitations include resis-
tance, toxicity, and drugdrug interactions. Antibiotics that
target other essential components of the bacterial cell wall
are also discussed.
34
Cycloserine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 607
Bacitracin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 607
Inhibitors of Murein Polymerization . . . . . . . . . . . . . . . . . 607
Vancomycin, Teicoplanin, and Telavancin . . . . . . . . . . 607
Inhibitors of Polymer Cross-Linking . . . . . . . . . . . . . . . . . 608
-Lactam Antibiotics: General Considerations . . . . . . . 608
-Lactam Antibiotics: Specific Agents . . . . . . . . . . . . . 610
Inhibitors of Cell Membrane Stability . . . . . . . . . . . . . . . . 612
Antimycobacterial Agents. . . . . . . . . . . . . . . . . . . . . . . . . 612
Ethambutol, Pyrazinamide, and Isoniazid. . . . . . . . . . . 612
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 613
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
 BIOCHEMISTRY OF BACTERIAL CELL
WALL SYNTHESIS
Cell Wall Structure and Function
Peptidoglycan, named for its peptide and sugar composition,
is a three-dimensional meshwork of peptidecross-linked
sugar polymers that surrounds the bacterial cell just outside
its cytoplasmic membrane (Fig. 34-1). Peptidoglycan is also
known as murein, after the Latin murus (wall). Nearly all
clinically important bacteria produce peptidoglycan. The
major exceptions are Mycoplasma pneumoniae, which can
cause atypical pneumonia, and the intracellular form (or re-
ticulate body) of Chlamydia trachomatis, which can cause
a sexually transmitted disease. Peptidoglycan is critically
important for the survival of bacteria, which experience
large fluctuations in osmotic pressure depending on their
environment. The peptidoglycan layers wrapped around the
cell provide the tensile strength required to withstand high
turgor pressures that would otherwise cause the plasma
599
 Gram-positive Gram-negative Mycobacteria
bacteria bacteria
Lipopolysaccharide
Murein Pore
Pore
Extractable
Outer phospholipids
membrane
Mycolic acids
Lipoprotein
Periplasm Arabinogalactan
Murein
Murein

Cytoplasmic membrane Cytoplasmic membrane Cytoplasmic membrane

 CHAPTER 34 / Pharmacology of Bacterial and Mycobacterial Infections: Cell Wall Synthesis 601
binding capacity and accessibility of the thick murein layer
are much greater in Gram-positive organisms, these bacteria
stain purple.
The outer membrane of Gram-negative bacteria not only
limits the penetration of Gram stain into the periplasm, but
it also prevents the penetration of many other molecules,
including antibiotics that target peptidoglycan synthesis,
such as vancomycin and bacitracin. Hence, although Gram-
negative organisms contain the molecular targets for these
antibiotics, they are not susceptible. To enable uptake of
hydrophilic nutrients and excretion of hydrophilic waste
products, Gram-negative bacteria contain outer membrane
porinsbeta barrel proteins that traverse the outer mem-
brane and allow certain molecules to pass in and out (see
Fig. 34-1). Porins are important pharmacologically because
it is through these pores that most hydrophilic antibiotics that
have activity against Gram-negative organisms gain access
to the murein layer and to the structures beneath this layer.
Also important pharmacologically are the lipopolysaccha-
rides (LPS) that compose the outer leaflet of the outer mem-
brane of Gram-negative bacteria. Lipopolysaccharides are
amphipathic molecules that protect bacteria from toxic hy-
drophilic host molecules such as bile salts. Lipopolysaccha-
rides are also important for bacterial adherence to host cells
and evasion of the host immune response. Polymyxin is a
topically used antibiotic that facilitates its own entry into the
periplasm by binding to LPS and disrupting the integrity of
the outer membrane. Once in the periplasm, polymyxin per-
meabilizes the inner membrane, discharging the membrane
potential so that cells no longer produce the energy required
for survival. Although polymyxin is too toxic for systemic
use in people, its mechanism of action suggests that it may
be possible to develop less toxic molecules that breach the
outer membrane and allow the passage of antibiotics to their
molecular targets in Gram-negative bacteria.
Gram-positive bacteria do not contain an outer membrane;
the extracellular enzymes involved in cell wall synthesis
are therefore accessible to a wider range of antibiotics than
can penetrate Gram-negative organisms. However, the cell
wall of Gram-positive organisms is not simply composed of
peptidoglycan; there is a set of other cell wall polymers that
play important roles in adherence to host tissue and other
aspects of pathogenicity. These include lipoteichoic acids
and wall teichoic acids, anionic polymers that are typically
composed of acyclic sugar-phosphate repeats functionalized
with D-alanine and cyclic sugars such as glucose. Lipotei-
choic acids are anchored in the bacterial membrane and ex-
tend up into the peptidoglycan layers. Wall teichoic acids are
covalently attached to peptidoglycan and extend through and
beyond its outermost layer. These polymers are important
for host infection, and the biosynthetic pathways are pos-
sible targets for antibiotics. In some Gram-positive organ-
isms, including Staphylococcus aureus, the peptidoglycan
layers are also functionalized with proteins that are required
for pathogenesis. These proteins are covalently attached to
uncross-linked peptides in peptidoglycan by enzymes called
sortases. Sortases have also been suggested as targets for
antibiotics that could prevent the spread of infection.
These important structural differences between the cell
envelopes of Gram-negative and Gram-positive bacteria lead
to differential access of antibiotics to cellular targets and also
present different opportunities for the development of new
antibiotics. However, peptidoglycan biosynthesis, which is
conserved among Gram-negative and Gram-positive organ-
isms, remains the most important antibacterial cell envelope
target. In fact, the peptidoglycan biosynthetic pathway is one
of a very small number of broad-spectrum antibacterial targets
that exist in bacterial pathogens. The other broad-spectrum tar-
gets include DNA synthesis, RNA synthesis, and protein syn-
thesis (see Chapter 33, Pharmacology of Bacterial Infections:
DNA Replication, Transcription, and Translation). Of these
processes, only peptidoglycan synthesis is unique to bacteria.
Peptidoglycan Biosynthesis
Peptidoglycan biosynthesis occurs in three major stages. The
first stage is intracellular and involves the synthesis of murein
monomers from amino acids and sugar building blocks; the
second and third stages involve the export of these murein
monomers to the surface of the inner membrane, followed by
their polymerization into linear peptidoglycan polymers and
their cross-linking into two-dimensional lattices and three-
dimensional mats (Fig. 34-2). Because the details of bacterial
cell wall synthesis can be daunting, it is helpful to keep in mind
the three major stagesmonomer synthesis, glycan polymer-
ization, and polymer cross-linkingduring the discussion that
follows. In principle, any of the biochemical steps in peptido-
glycan synthesis could be targets for antibiotics; in practice,
clinically used antibiotics target only a few of the steps in these
stages. A vast number of secondary metabolites produced by
soil and marine microorganisms also block peptidoglycan
synthesis, providing a reservoir of structurally and function-
ally novel compounds for possible clinical development as our
existing antibiotics fail due to the spread of resistance.
Synthesis of Murein Monomers
The murein monomer is a disaccharide comprising N-
acetylglucosamine connected via a beta linkage to the C4
hydroxyl of N-acetyl muramic acid, which is functionalized
on the C3 lactate moiety with a peptide (Fig. 34-2). The first
phase of peptidoglycan synthesis takes place in the cytoplasm
and involves the conversion of UDP-N-acetylglucosamine
(UDP-NAG), a nucleotide-sugar used as a building block
in many cell wall polymers, to UDP-N-acetyl muramic acid
pentapeptide (UDP-NAM-peptide; also known as the Park
nucleotide). The first two enzymes in this process, MurA
and MurB, convert the C3 hydroxyl of NAG to lactate.
MurA, also known as enolpyruvate transferase, transfers
enolpyruvate from phosphoenolpyruvate (PEP) to UDP-
NAG to form UDP-NAG pyruvate enol ether (Box 34-1).
Second, the flavoenzyme MurB (also known as UDP-NAG-
enolpyruvate reductase) reduces the double bond to produce
UDP-NAM, which has a free carboxylate to serve as the
handle for the peptide chain. UDP-NAM is a sugar unique
to bacteria, and its biosynthesis thus provides opportunities
for selective antibiotics. One clinically used antibiotic that
blocks the biosynthesis of UDP-NAM is fosfomycin, a PEP
analog that inhibits MurA.
The peptide component of UDP-NAM-peptide is assembled
on the C3 lactate from amino acids and dipeptides by a series of
ATP-dependent ligases. MurC, MurD, and MurE sequentially
add the amino acids L-alanine, D-glutamate, and a diamino
acideither L-lysine or diaminopimelic acid (DAP)to
UDP-NAM. DAP differs from lysine in having a carboxyl
group as well as an amine on the side chain. Most Gram-positive
bacteria use L-lysine, whereas a minority of Gram-positive and
all known Gram-negative bacteria use DAP. This is noteworthy
602 Principles of Chemotherapy

A Murein monomer synthesis (cytoplasmic phase)

O
L-Ala, D-Glu, L-Lys, HO
O
HO NH
O O ATP ATP ATP O O O O
HO -OOC OPO3-2 HO HO AcHN
HO O HO O HO O O P O P O N O
NH
PEP NADPH NH NH MurF, ATP O
HO
AcHN
O O O
AcHN
O O O
AcHN
O O
HN
O O- O-
O P O P O N O O P O P O N O O P O P O N O OH OH
O O O
O- O- rA rB HO O O- O- rC rD rE O O- O- O
OH OH Mu Mu OH OH Mu Mu Mu HN
OH OH HO NH
O D-Ala-D-Ala
UDP-NAG UDP-NAM HO NH Cycloserine O H
N
DdlB, ATP NH2
O H O
N D-Ala + D-Ala O
Fosfomycin NH2 HN
H O
Fosmidomycin O O Alanine N
HO OH
racemase O
L-Ala + L-Ala
Park nucleotide

B Completion of murein monomer synthesis, and murein monomer export, polymerization, and crosslinking

-lactams:
Penicillins
NAG Cephalosporins
NAM L-Ala--D-Glu-L-Lys-D-Ala-D-Ala Monobactams
Periplasm
NAG (L-Gly)5 Carbapenems Vancomycin
O
NH
NAG D-Ala Teicoplanin
D-Ala D-Ala D-Ala
D-Ala D-Ala
D-Ala NAM L-Ala--D-Glu-L-Lys-D-Ala-D-Ala D-Ala D-Ala
(L-Gly)5 L-Lys (L-Gly)5 L-Lys
(L-Gly)5 L-Lys NAG (L-Gly)5 (L-Gly)5 L-Lys (L-Gly)5 L-Lys
-D-Glu -D-Glu
-D-Glu NH2 -D-Glu -D-Glu
L-Ala L-Ala
L-Ala L-Ala L-Ala
NH TP NH PGT
NH NH NH
O O
O O O
HO O HO HO O HO
HO O O HO O HO O HO O HO HO O HO
O O O O HO O O O O
HO O HO O O O HO O O
AcHN AcHN HO O O AcHN HO HO
AcHN AcHN AcHN AcHN O O AcHN O O
AcHN AcHN
P2O7-3 O P O P O P2O7-3 O P O P O O P O P O
O- O- O- O- O- O-

Cytoplasmic membrane
O HO HO
P2O7-3 PO4-2 HO HO HO O HO HO O HO
O O O O
Bactoprenyl HO NH HO HO
AcHN
O HO
AcHN
O
O O O O O O O O O O O O
phosphate AcHN AcHN AcHN AcHN
O P O P O N O O P O P O O P O P O Staph O P O P O
O
Dephosphorylase HN
O O- O- MraY HN
O O- O- MurG HN
O O- O- FemABX HN
O O- O-
OH OH
L-Ala L-Ala L-Ala L-Ala
-D-Glu -D-Glu -D-Glu -D-Glu
UDP-NAG UDP Gly-tRNA tRNA
L-Lys Park nucleotide L-Lys L-Lys L-Lys (L-Gly)5
Bacitracin D-Ala D-Ala D-Ala D-Ala
Lipid II Murein monomer
D-Ala D-Ala D-Ala D-Ala

Cytoplasm

FIGURE 34-2. Bacterial cell wall biosynthesis and its inhibition by pharmacologic agents. Bacterial cell wall biosynthesis can be divided into three major
stages. A. In the cytoplasmic phase of murein monomer synthesis, glucose is amidated and phosphorylated to glucosamine-1-phosphate (not shown), which is acety-
lated and conjugated to a uridine diphosphate (UDP) nucleotide by the enzyme GlmU (not shown) to form UDP-N-acetylglucosamine (UDP-NAG). Addition of phospho-
enolpyruvate (PEP) by enolpyruvate transferase (MurA) and reduction of the resulting product by MurB form UDP-N-acetyl muramic acid (UDP-NAM). NAG and NAM
are the two sugar building blocks for subsequent cell wall synthesis. MurC, MurD, and MurE sequentially add the amino acids L-alanine, D-glutamate, and L-lysine to
UDP-NAM. In some bacteria, diaminopimelic acid (DAP) is added instead of L-lysine. Alanine racemase converts L-alanine to D-alanine, and D-Ala-D-Ala ligase B (DdlB)
forms the dipeptide D-Ala-D-Ala. This dipeptide is then added to the L-Ala-D-Glu-L-Lys (or L-Ala-D-Glu-DAP) tripeptide by MurF, resulting in a UDP-NAM molecule linked
to five amino acids (Park nucleotide). Fosfomycin and fosmidomycin are selective inhibitors of MurA. Cycloserine inhibits both alanine racemase and D-Ala-D-Ala ligase
B, thereby preventing the addition of alanine residues to the growing peptide chain. B. The NAMpentapeptide complex is transferred from UDP to the lipid carrier
bactoprenol by the enzyme MraY, and NAG is added from UDP-NAG by MurG. In some bacteria, one to five amino acids can then be added to L-lysine or DAP to form a
branched peptidoglycan; the amino acids are added from amino acyl tRNA. (Here, as an example, five glycine residues are added from glycyl-tRNA.) This completes the
synthesis of the murein monomer.
In the murein monomer export and polymerization stage, the bactoprenolpeptidoglycan complex is transported from the bacterial inner membrane to the periplas-
mic space, where peptidoglycan glycosyltransferases (PGTs) join the murein monomer to the growing peptidoglycan chain. Simultaneously, the bactoprenol is liberated
to facilitate another round of murein monomer translocation. Bactoprenyl diphosphate is dephosphorylated to bactoprenyl phosphate by dephosphorylase, regenerating
the form of the lipid carrier that can react with the Park nucleotide.
In the final stage of cell wall biosynthesis, adjacent glycopeptide polymers are cross-linked in a reaction catalyzed by bacterial transpeptidases (TPs). In the example
shown, a transpeptidase cross-links a glycine pentapeptide on one peptidoglycan chain to a D-Ala residue on an adjacent peptidoglycan chain; as shown in detail in
Figure 34-3, the terminal D-Ala residue is displaced in this reaction.
Bacitracin inhibits bactoprenol dephosphorylation and thereby interrupts murein monomer synthesis and export. Vancomycin, telavancin (not shown), and teicoplanin
bind the D-Ala-D-Ala terminus of the bactoprenol-conjugated murein monomer unit and thereby prevent the PGT-mediated addition of murein monomer to the growing
peptidoglycan chain. The -lactam antibiotics (penicillins, cephalosporins, monobactams, and carbapenems) inhibit the transpeptidase enzymes that cross-link adjacent
peptidoglycan polymers.
604 Principles of Chemotherapy
Polymerization is catalyzed by enzymes called peptidoglycan
glycosyltransferases (PGTs, or formerly, transglycosylases).
These enzymes are processive and catalyze several rounds
of elongation by addition of disaccharide subunits to the
reducing end of the growing polymer without releasing it.
With each glycosylation reaction, bactoprenyl diphosphate is
released and returns to the inner surface of the cytoplasmic
membrane, where it loses a phosphate group to form bactopre-
nyl phosphate; this step is catalyzed by a dephosphorylase.
Bactoprenyl phosphate is now ready to accept another Park
nucleotide (Fig. 34-2B).
The PGTs are often found as N-terminal catalytic do-
mains in bifunctional proteins that also include a C-terminal
transpeptidation domain; however, they can also be found as
monofunctional PGTs (known as MGTs). Most bacteria con-
tain a number of structurally related PGTs, some bifunctional
and some monofunctional. Their enzymatic activities are
similar in vitro, but they are presumed to play different roles
in cells. For example, in rod-shaped organisms, some PGTs
are dedicated to the synthesis of side-wall peptidoglycan,
whereas others are dedicated to the synthesis of septal pepti-
doglycan. Nevertheless, these enzymes can partially substi-
tute for one another, complicating a detailed understanding
of their specific roles. One possible way of understanding
this biological complexity is that bacteria have evolved to
have multiple overlapping systems to ensure survival should
specific problems arise in an individual machine. This partial
redundancy can be both an advantage and a disadvantage
from the standpoint of antibiotic treatment, depending on the
particular case.
Cross-Linking
In the final stage of cell wall synthesis, murein chains are
cross-linked to one another by enzymes called transpepti-
dases (TPs). Because transpeptidases were first identified
as the molecular targets of penicillin, they are also called
penicillin-binding proteins (PBPs). The PGT domain cou-
ples murein monomers to produce glycan strands. These
oligosaccharide chains must then be cross-linked through
their stem peptides to produce the murein found in bacte-
rial cell walls. The transpeptidation reaction takes place in
two steps: activation and coupling. In the activation step, a
serine hydroxyl in the active site of a TP enzyme attacks the
D-Ala-D-Ala amide bond of one of the stem peptides on the
glycan polymer, forming a covalent enzyme-peptidoglycan
intermediate and releasing alanine. In the coupling step, a
free amino group on the terminal amino acid of the inter-
bridge peptide (glycine for many Gram-positive bacteria)
or on DAP (Gram-negative bacteria) then attacks this inter-
mediate, producing a new amide bond cross-link between
the two stem peptides and regenerating the active enzyme
(Figs. 34-2B and 34-3). Penicillin, a -lactam, apparently
mimics the terminal D-Ala-D-Ala substrate: it binds in the
TP active site, where it then reacts with the serine nucleophile
to form a covalent enzymepenicillin complex (Fig. 34-3).
This modification inactivates the enzyme, thereby resulting
in lower degrees of cell wall cross-linking; in turn, this com-
promises the integrity of the cell wall and eventually causes
cell lysis (see discussion below).
Bacteria typically contain several TPs with differ-
ent but overlapping specificities. As described for PGTs,
these different enzyme isoforms are used to build differ-
ent parts of the wall. Escherichia coli, for example, has six
transpeptidases, some of which build the cylindrical middle
of this rod-shaped bacteria, and others of which build its
hemispherical ends. It is believed that differences in the
number and type of cross-links and glycan chain length
give each bacterial species its characteristic shape and size
and the cell wall of each species its characteristic thickness.
Consistent with this hypothesis, it has been found that the
suite of transpeptidases differs from species to species and
especially between rods such as E. coli and C. perfringens
and spherical cocci such as streptococci and staphylococci.
It is thought that, in some cases, bacteria exploit the pres-
ence of multiple TPs in order to develop antibiotic resis-
tance in the clinic. A major form of resistance develops in
S. aureus when strains acquire a resistant TP that is capable
of cross-linking peptidoglycan even when exposed to the
-lactam methicillin, which typically inactivates TPs in a
manner similar to penicillin (see discussion below). The cell
wall produced by methicillin-resistant S. aureus (MRSA) in
the presence of drug has lower levels of cross-linking than in
the absence of drug, which is presumed to be due to the inef-
ficiency of the resistant TP. One possible strategy for over-
coming MRSA is to further weaken the cross-linking ability
of this resistant TP.
Mycobacterial Cell Wall Synthesis
The cell wall structures described above are found in the
vast majority of clinically relevant bacteria, including Gram-
positive cocci such as streptococci and staphylococci, Gram-
negative rods such as E. coli and Pseudomonas aeruginosa,
and Gram-positive rods such as C. perfringens. However, a
discussion of cell wall structure would not be complete with-
out mentioning the unusual cell envelopes of the Coryne-
bacteriae, a group of bacteria that includes the important
pathogens Mycobacterium tuberculosis and Mycobacterium
leprae. These bacteria are classified as high GC (i.e.,
a high percentage of guanine and cytosine in their DNA)
Gram-positives, but their cell envelopes have characteristics
of both Gram-positive and Gram-negative bacteria.
Unlike other Gram-positives, the Corynebacteriae have
an outer membrane. The NAM sugars in the peptidogly-
can layer that surrounds the cytoplasmic (inner) membrane
have covalently attached NAG-arabinogalactan polymers, to
which are attached mycolic acids. The mycolic acids have
long alkyl chains containing as many as 90 carbons, and
these alkyl chains form a waxy layer that make the bacte-
ria resistant to acid decolorization (acid-fast). The mycolic
acids are essential for the assembly of the outer membrane,
but the organizational details are unclear. In addition to
mycolic acids, the outer membrane of mycobacteria con-
tains secreted phospholipids, called extractable lipids (see
Fig. 34-1). Mycobacteria have outer membrane porins, but
their structures are different from the porins found in Gram-
negative bacteria.
The synthesis of NAG-arabinogalactan begins with the
transfer of a molecule of NAG phosphate from UDP-NAG
to mycobacterial bactoprenyl phosphate. Next, a molecule
of the sugar rhamnose is added, followed by the addition
of the several galactose and arabinose units that make up
arabinogalactan. Arabinosyl transferase catalyzes the addi-
tion of the arabinose units. Mycolic acid is a long, complex,
branched fatty acid. The starting materials for its synthesis
include a number of long, saturated hydrocarbon chains that
 CHAPTER 34 / Pharmacology of Bacterial and Mycobacterial Infections: Cell Wall Synthesis 605

Normal transpeptidation Penicillin action

HO HO HO HO H
O O O O O O R N
O O O O S
HO O HO O
Two AcHN AcHN AcHN AcHN N
O
peptidoglycan O
HN O HN O COOH
chains
L-Ala HO L-Ala
Ser HO
-D-Glu Enzyme -D-Glu Ser
O O
H
(L-Gly)5 L-Lys
N H 2N (L-Gly)4 L-Lys Enzyme
N OH N
H H D-Ala
O
D-Ala
D-Ala-D-Ala Gly

Activation step

HO HO HO HO
O O O O O O
O O O O
HO O HO O R
AcHN AcHN AcHN AcHN
Enzyme- O NH
HN O HN O
peptidoglycan O S
intermediate L-Ala L-Ala O HN
Ser
-D-Glu -D-Glu
O COOH
(L-Gly)5 L-Lys O Ser H 2N (L-Gly)4 L-Lys Enzyme
N N
H H D-Ala
O Enzyme
D-Ala
O Gly
Dead-end
+ H 2N enzyme penicillin
OH
complex
Displaced D-Ala

Coupling step

HO HO
O O O
O O
HO O HO HO
AcHN AcHN O O O
O O
Crosslinked HO O
O AcHN AcHN
peptidoglycan HN
chains HN O
L-Ala
L-Ala + HO
-D-Glu Ser
O -D-Glu
(L-Gly)5 L-Lys H Enzyme
N (L-Gly)4 L-Lys
N N
H O H D-Ala
D-Ala-L-Gly crosslink D-Ala

FIGURE 34-3. Transpeptidase action and its inhibition by penicillin. The left side of the figure shows the mechanism by which transpeptidases catalyze
transpeptidation, a reaction that occurs in bacteria but not in mammalian cells. A nucleophilic hydroxyl group in the active site of the transpeptidase (Enzyme) attacks
the peptide bond between the two D-Ala residues at the terminus of a pentapeptide moiety on one peptidoglycan chain (top panel). The terminal D-alanine residue is
displaced from the peptidoglycan chain, and an enzyme-D-alanine-peptidoglycan intermediate is formed. This intermediate is then attacked by the amino terminus of
a polyglycine pentapeptide linked at its carboxy terminus to L-lysine or diaminopimelic acid on an adjacent peptidoglycan chain (see Fig. 34-2) (middle panel). As the
enzyme is liberated from the intermediate, a new peptide bond (cross-link) is formed between the terminal glycine residue on one peptidoglycan chain and the enzyme-
activated D-alanine residue on the adjacent peptidoglycan chain. The free enzyme can then catalyze another transpeptidation reaction (bottom panel). The right side of
the figure shows the mechanism by which penicillin interferes with transpeptidation, leading to the formation of a penicilloyl-enzyme dead-end complex. In this form,
the enzyme is incapable of catalyzing further transpeptidation (cross-linking) reactions.

are synthesized from two-carbon units carried by acetyl CoA.
The enzyme fatty acid synthetase 1 (FAS1) catalyzes the
formation of these saturated hydrocarbon chains, and the en-
zyme fatty acid synthetase 2 (FAS2) catalyzes the linkage of
these chains. The linked product then undergoes several enzy-
matic transformations to become mycolic acid. Mycolic acid
is eventually added to NAG-arabinogalactan, which, in turn,
is attached to NAM to organize and form a major component
of the mycobacterial outer membrane (Figs. 34-1 and 34-4).
In principle, any step in this process is susceptible to phar-
macologic intervention. As discussed below, standard antimy-
cobacterial treatment regimens include antibiotics that target
both the synthesis of NAG-arabinogalactan and the early re-
actions of mycolic acid synthesis.
The mycobacterial cell envelope is thick, asymmetric, and
highly impermeable to both hydrophilic and hydrophobic
substances. M. tuberculosis is among the most challenging
pathogens to eradicate because its cell envelope resists entry
606 Principles of Chemotherapy
O punch small holes in the cell wall that allow for remodeling
O
N SCoA
NH 2
Acetyl CoA
N L-alanine amidases cleave the stem peptide from murein dur-
Pyrazinamide FAS1
O tion must be carefully balanced for bacteria to survive. In-
O
NH2
N synthesis (for example, by drugs like penicillin) results in
H R OH
N
Fatty acids
Isoniazid
FAS2
Mycolic acids Phospholipids
FIGURE 34-4. Mycolic acid synthesis and antimycobacterial drug action.
Mycolic acids are produced by the cross-linking of fatty acid chains derived from
acetyl coenzyme A (Acetyl CoA). Each of the arrows in this simplified representa-
tion denotes multiple synthetic steps; the focus is on the fatty acid synthetases
(FAS1 and FAS2) because of their importance as drug targets. Specifically, FAS1 is
inhibited by pyrazinamide, and FAS2 is inhibited by isoniazid.
of many antibiotics, and the organism grows very slowly;
note that cell-wall-active antibiotics are typically most ef-
fective against bacteria that are actively growing and making
new cell wall rapidly. Special treatment regimens, involving
long-term therapy with combinations of antibiotics, are re-
quired to cure tuberculosis.
Autolysins and Cell Wall Degradation
Although it provides stability, the cell wall is a dynamic struc-
ture; it is continuously modified by synthetic and degradative
enzymes that are finely tuned to allow the sacculus to grow
and divide without lysing. For bacteria to grow, bacterial cell
walls must expand; for expansion to occur, new murein units
must be incorporated into the existing cell wall. This is dif-
ficult to accomplish in a finished cell wall, which is com-
posed of specific lengths of glycan polymers with particular
degrees of cross-linked stem peptides. In addition, for a bac-
terium to divide, its cell wall must at some point be broken to
allow two daughter cells to separate. Bacteria address these
issues by using highly regulated autolysins. These enzymes
and expansion. Different autolysins exhibit preferences for
different bonds in murein. Similar to the synthetic enzymes,
many are functionally redundant, but play necessary roles in
the cell. For example, in E. coli, three autolysins called NAM-
ing division to promote daughter cell separation. Loss of these
three amidases causes a noticeable defect in cell division,
while loss of one usually has little or no effect.
New murein synthesis and autolysin-mediated destruc-
deed, studies have shown that unilaterally blocking murein
autolysin-mediated autolysis and cell death. The molecular
events that initiate autolysis are poorly understood. The cur-
rent belief is that specific proteins recruit the degradative
machinery only after the cell has assembled the machinery
responsible for cell wall synthesis. This ordered recruitment
ensures that degradation does not occur unless new cell wall
is being made. The bactericidal effect of cephalexin, a first-
generation cephalosporin, involves targeting the synthetic
machinery by specifically inhibiting the transpeptidation step
of cell wall synthesis and subverting this regulatory mecha-
nism (see discussion below). Cephalexin does not perturb
the normal assembly of the synthetic machinery, but instead
simply inactivates this complex by inhibiting transpeptidase
enzymes. Apparently, the regulatory mechanisms of the cell
can determine only that the machinery for new cell wall syn-
thesis is present and not whether it is functional. As a result,
the cell recruits the degradative machinery without ongoing
synthesis, and lysis ensues. Many of the -lactams discussed
in this chapter interfere with the balance between cell wall
synthesis and degradation.
 PHARMACOLOGIC CLASSES
AND AGENTS
The pharmacology of the drug classes that inhibit bacte-
rial cell wall synthesis is discussed in the same order as the
biochemistry of cell wall synthesis (Fig. 34-2). Although
drugs have been identified that inhibit a number of steps in
the biochemistry of cell wall synthesis, the polymer cross-
linking (transpeptidation) step is, by far, the most clinically
important biochemical target. For this reason, most of the
discussion focuses on the panoply of agents that inhibit the
cross-linking of peptidoglycan polymers.
Inhibitors of Murein Monomer Synthesis
Fosfomycin and Fosmidomycin
Two agents inhibit the production of murein monomers by
inhibiting the synthesis of UDP-NAM from UDP-NAG
(Fig. 34-2A). Fosfomycin (also written phosphomycin) is a
phosphoenolpyruvate (PEP) analogue that inhibits bacterial
enolpyruvate transferase (also known as MurA) by covalent
modification of the enzymes active site. Given that PEP is
a key intermediate in (mammalian) glycolysis, it may come
as a surprise that this agent does not interfere with carbo-
hydrate metabolism in human cells; this selectivity of an-
tibacterial action is likely caused by structural differences
between the mammalian and bacterial enzymes that act on
PEP. Thus, fosfomycin has no appreciable effect on human
enolase, pyruvate kinase, or carboxykinase, and the drug is
 CHAPTER 34 / Pharmacology of Bacterial and Mycobacterial Infections: Cell Wall Synthesis 607
relatively nontoxic. Fosfomycin has been shown to have an-
tibacterial synergy in vitro with -lactams, aminoglycosides,
and fluoroquinolones.
Fosfomycin enters the cell via transporters for glycero-
phosphate or glucose-6-phosphate that are normally used
by bacteria to take up these nutrients from the environment.
Fosfomycin is especially effective against Gram-negative
bacteria that infect the urinary tract, including E. coli and
Klebsiella and Serratia species, because it is excreted un-
changed in the urine. A single 3-g oral dose has been shown
to be as effective as multiple doses of other agents in the
treatment of urinary tract infections. As a rule, fosfomycin
is less effective against Gram-positive bacteria because
these bacteria generally lack selective glycerophosphate
and glucose-6-phosphate transporters. Although resistance
is typically caused by mutations in these transporters, a
temperature-sensitive E. coli strain has been found in which
a mutation in enolpyruvate transferase results in reduced af-
finity of the enzyme for PEP and therefore for fosfomycin.
Adverse effects of fosfomycin are uncommon; between 1%
and 10% of patients develop headache, diarrhea, or nausea.
Significant drug interactions are also rare; the drug can pre-
cipitate when co-ingested with antacids or calcium salts, and
its absorption can be decreased by co-administration with
promotility agents such as metoclopramide.
Fosmidomycin, another PEP analogue, acts by the same
mechanism as fosfomycin, and resistance typically arises
via mutations in glycerophosphate or glucose-6-phosphate
transporters. Again, however, there are exceptions: at least
one strain of resistant E. coli appears to contain a protein that
actively pumps fosmidomycin out of the cell.
Cycloserine
Cycloserine, a structural analogue of D-Ala, is a second-
line agent used to treat multidrug-resistant M. tuberculosis
infection (Fig. 34-5). Cycloserine inhibits both the alanine
racemase that converts L-Ala to D-Ala and the D-Ala-D-Ala
ligase that joins together two D-Ala molecules (Fig. 34-2A).
Cycloserine is an irreversible inhibitor of these enzymes
and, in fact, binds these enzymes more tightly than does their
natural substrate, D-Ala. Resistance to cycloserine occurs
by multiple mechanisms, some of which are still unknown;
known mechanisms include overexpression of alanine race-
mase and mutations in the alanine uptake system. As with
many small molecules, including fosfomycin, cycloserine is
excreted in the urine. Adverse effects include seizures, neu-
rological syndromes including peripheral neuropathy, and
psychosis. Patients with underlying neuropsychiatric dis-
ease, alcoholism, and chronic kidney disease should avoid
OH
OH
H2N
H2N
N O
O
D-Cycloserine D-Alanine
FIGURE 34-5. Structure of cycloserine. Cycloserine is a structural analogue
of D-alanine that inhibits the racemic interconversion of L-alanine to D-alanine by
alanine racemase. Cycloserine also inhibits the activity of D-Ala-D-Ala ligase B,
the enzyme that catalyzes the formation of the D-Ala-D-Ala dipeptide that is sub-
sequently utilized in the synthesis of murein monomers (see Fig. 34-2A).
the drug. Alcohol, isoniazid, and ethionamide potentiate its
toxicity; pyridoxine may mitigate cycloserine-induced pe-
ripheral neuropathy. Cycloserine inhibits the hepatic me-
tabolism of phenytoin.
Bacitracin
So named because it was first identified in a species of
Bacillus, bacitracin is a peptide antibiotic that interferes
with the dephosphorylation of bactoprenyl diphosphate, ren-
dering the bactoprenol lipid carrier useless for further rounds
of murein monomer synthesis and export (Fig. 34-2B). Baci-
tracin is therefore notable among the anti-cell wall agents for
having a lipid, rather than a protein or peptide, as its target.
Bacitracin inhibits dephosphorylation by forming a complex
with bactoprenyl diphosphate that involves bacitracins imi-
dazole and thiazoline rings. This interaction requires a diva-
lent metal ion, usually Zn2 or Mg2; hence, drugs that act
as metal chelators could interfere with the activity of baci-
tracin. Due to its significant kidney, neurological, and bone
marrow toxicity, bacitracin is not used systemically. It is
most commonly used topically for superficial dermal or oph-
thalmologic infections. Because bacitracin is not absorbed
orally, it remains within the gut lumen and is occasionally
administered orally to treat Clostridium difficile colitis or to
eradicate vancomycin-resistant enterococci (VRE) in the
gastrointestinal tract. It should not be co-administered with
other nephrotoxic medications or neuromuscular blocking
agents, since the latter may result in synergistic neuromus-
cular blockade.
Inhibitors of Murein Polymerization
Vancomycin, Teicoplanin, and Telavancin
Vancomycin and teicoplanin are glycopeptides with bac-
tericidal activity against Gram-positive rods and cocci.
Telavancin is a related lipoglycopeptide with a spectrum of
action similar to that of vancomycin. Gram-negative rods are
resistant to the action of these drugs. These agents interrupt
cell wall synthesis by binding tightly to the D-Ala-D-Ala
terminus of the murein monomer unit, inhibiting peptido-
glycan polymerization and thereby blocking the addition of
murein units to the growing polymer chain. Telavancin has
an additional lipid side chain that interacts with the bacterial
cell membrane; this lipid anchor both enhances drug binding
to the D-Ala-D-Ala terminus and effects depolarization of
the membrane, resulting in greater antibacterial potency than
vancomycin. Intravenous vancomycin is most commonly
used to treat sepsis or endocarditis caused by methicillin-
resistant Staphylococcus aureus (MRSA) (see discussion
below). Intravenous telavancin is used to treat serious skin
infections involving staphylococci and streptococci. Oral
vancomycin is used to treat gastrointestinal infections with
C. difficile; like bacitracin (see above), the drug is poorly
absorbed and therefore remains within the gastrointestinal
tract. Teicoplanin is not used clinically in the United States.
As a rule, the toxicity of vancomycin causes this agent
to be used only when an infection is found to be resistant
to other agents. Its adverse effects include skin flushing or
rashthe so-called red-man syndromewhich is due to
release of histamine and can be avoided by slowing the rate
of intravenous infusion or preadministering antihistamines.
Vancomycin has also been associated with nephrotoxicity and
ototoxicity, particularly when other nephrotoxic or ototoxic
A B

H H
R N S R N S

O N O N
O O
COOH COOH
Penicillins -lactamases
cleave this bond
H
R1 N S

O OH
O N
O R2
N
COOH O
Cephalosporins COOH
Clavulanic acid
H
R N

O N O
O SO3H
S O
Monobactams
N
OH O
COOH
Sulbactam
SR
N
O
COOH
Carbapenems
610 Principles of Chemotherapy
Antibody
N Clostridium, most anaerobes (except Bacteroides), and spiro-
Beta-lactam
antibiotic
NH2 Modified human protein
(antigenic)
Human protein
(non-antigenic)
FIGURE 34-7. -Lactam toxicity. In the absence of modification, human pro-
teins are generally nonantigenic. -Lactams can modify amino groups on human
proteins, creating an immunogenic -lactam hapten. This new antigenic determi-
nant can be recognized as nonself by antibodies of the host immune system.
with amino groups on human proteins to create a haptencar-
rier complex (Fig. 34-7). The -lactamprotein conjugate can
then provoke a hypersensitivity response. The most dreaded
of these reactions is anaphylaxis, which typically occurs
within an hour of administration and leads to bronchospasm,
angioedema, and/or cardiovascular collapse. Urticaria, mor-
billiform drug rash, serum sickness, and drug fever may also
occur. Proteins on the surface of red blood cells can also be
modified by penicillin, leading to drug-induced autoimmune
hemolytic anemia. Rarely, -lactam antibiotics cause drug-
induced lupus. For most individuals, this process is strongly
dose-dependent: the likelihood of a hypersensitivity reaction
increases with each administration of a -lactam. -Lactams
of a given class often cross-react with each other, but -lac-
tams of one class are less often cross-reactive with -lactams
of another class. Patients with a penicillin allergy should not
receive ampicillin or other penicillins due to the high risk of
cross-reactivity. Patients with a penicillin allergy other than
anaphylaxis may receive a cephalosporin. Aztreonam (a
monobactam) is unique in that it has no cross-reactivity with
either penicillins or carbapenems; however, cross-reactivity
between aztreonam and ceftazidime (a cephalosporin), due
to a shared side chain, has been seen. Although allergic re-
actions to carbapenems can occur in patients with penicillin
allergy, they are infrequent.
-Lactam Antibiotics: Specific Agents
Penicillins
As noted above, there are four structurally distinct sub-
classes of -lactam antibiotics (see Fig. 34-6A). The first of
these subclasses, the penicillins, can be further divided into
five groups according to their spectra of action.
The first group of penicillins includes penicillin G,
which is intravenously administered, and penicillin V, its
gastric acid-stable oral counterpart. Penicillin G is in more
widespread use than penicillin V; the latter is used mostly
to treat mixed aerobicanaerobic infections of the head and
neck, such as dental abscesses. Additionally, penicillin V is
used to prevent recurrent rheumatic fever in patients with
a prior episode and recurrent streptococcal cellulitis in pa-
tients with lymphedema. Penicillin G is used to treat serious
infections with Gram-positive bacteria such as pneumococ-
cus and S. pyogenes (some strains of each), Gram-negative
diplococci such as Neisseria species (except penicillinase-
producing N. gonorrhoeae), Gram-positive rods of the genus
chetes such as syphilis and Leptospira. High-dose penicillin
G may cause seizures, in addition to the already mentioned
hypersensitivity reactions and rash. All penicillins can cause
acute interstitial nephritis. Drugdrug interactions are rare,
but the anticoagulant effects of warfarin may be potentiated
by concomitant penicillin administration.
The second group consists of the antistaphylococcal
penicillins, including oxacillin, cloxacillin, dicloxacillin,
nafcillin, and methicillin. These drugs are structurally re-
sistant to staphylococcal -lactamase, which is encoded by
plasmid genes in most clinical isolates. Because of their
relative hydrophobicity, however, antistaphylococcal peni-
cillins lack activity against Gram-negative bacteria. (Recall
also that methicillin binds to only a single transpeptidase.)
Thus, these agents are used mostly for skin and soft-tissue
infections or documented methicillin-sensitive S. aureus
infections. Use of the oral antistaphylococcal penicillins
(cloxacillin and dicloxacillin) is limited by their gastroin-
testinal adverse effects (nausea, vomiting, and antibiotic-
associated diarrhea) as well as secondary development of
C. difficile colitis. Adverse effects of intravenous (IV) naf-
cillin include phlebitis at the injection site; agranulocytosis
and acute interstitial nephritis occur at a higher rate than
with the other penicillins. Oxacillin can cause hepatotox-
icity, which is reversible with discontinuation of the drug.
The utility of antistaphylococcal penicillins in treating S.
aureus has been compromised by the emergence of MRSA
strains. When a case of MRSA is found in the hospital, spe-
cial precautions are taken to prevent its spread to other pa-
tients. Patients with MRSA infection are typically treated
with vancomycin.
Ampicillin and amoxicillin are members of the third
group of penicillins, the amino penicillins, which have a
positively charged amino group on the R side chain (see
Fig. 34-6A). This positive charge enhances diffusion through
porin channels but does not confer resistance to -lactamases.
These agents are effective against a variety of Gram-positive
cocci, Gram-negative cocci such as Neisseria gonorrhoeae
and N. meningitidis, and Gram-negative rods such as E. coli
and Haemophilus influenzae, but their spectrum is limited
by sensitivity to most -lactamases. IV ampicillin is used
most commonly to treat invasive enterococcal infections
and Listeria meningitis; oral amoxicillin is used to treat
uncomplicated ear, nose, and throat infections, to prevent
endocarditis in high-risk patients undergoing dental work,
and as a component of combination therapy for Helicobacter
pylori infection. Nonurticarial rash is the most common ad-
verse effect. The spectrum of both agents is broadened when
they are co-administered with -lactamase inhibitors such
as clavulanic acid (with amoxicillin) or sulbactam (with am-
picillin) to treat -lactamase-producing organisms such as
S. aureus, H. influenzae, E. coli, Klebsiella, and anaerobes.
Sulbactam itself has activity against Acinetobacter.
Agents in the fourth group of penicillins, the carboxy
penicillins, are also broad in spectrum. The carboxyl group
on the R side chain provides a negative charge that confers re-
sistance to some -lactamases but is less effective than a pos-
itively charged amino group in facilitating diffusion through
 CHAPTER 34 / Pharmacology of Bacterial and Mycobacterial Infections: Cell Wall Synthesis 611
porin channels. To overcome this limitation in diffusion, high
doses are used. Resistance to the chromosomally encoded
-lactamases of Enterobacter and Pseudomonas adds these
organisms to the spectrum of the carboxy penicillins. This
group has two members, carbenicillin and ticarcillin.
A fifth group, the ureido penicillins, is represented by
piperacillin and mezlocillin. These drugs have both positive
and negative charges on their R side chains and are generally
more potent than the carboxy penicillins. Their spectrum of
action is similar to that of the carboxy penicillins; in addi-
tion, they have activity against Klebsiella and enterococci.
Cephalosporins
Cephalosporins differ structurally from penicillins by hav-
ing a six-membered rather than a five-membered accessory
ring attached to the -lactam ring (Fig. 34-6A).
First-generation cephalosporins (cefazolin and cephalexin)
are active against Gram-positive species as well as the Gram-
negative rods Proteus mirabilis and E. coli, both of which
cause urinary tract infections, and Klebsiella pneumoniae,
which causes pneumonia in addition to urinary tract infec-
tions. These agents are sensitive to many -lactamases but
are not degraded by the chromosomally encoded -lactamase
of K. pneumoniae and the common staphylococcal -lacta-
mase. Cephalexin and cefazolin are both used to treat skin
and soft-tissue infections; cefazolin is also used for surgical
prophylaxis.
Second-generation cephalosporins can be divided into
two groups. Cefuroxime, which represents the first group,
has increased activity against H. influenzae compared to the
first-generation cephalosporins; cefotetan and cefoxitin,
which represent the second group, demonstrate increased
activity against Bacteroides. Also, second-generation cepha-
losporins are generally resistant to more -lactamases than
are first-generation cephalosporins. Thus, cefuroxime is
often used to treat community-acquired pneumonia, and ce-
fotetan is used to treat intra-abdominal and pelvic infections,
including pelvic inflammatory disease. Adverse effects of
these agents include diarrhea, mild liver enzyme elevation,
and hypersensitivity reactions; rarely, agranulocytosis or in-
terstitial nephritis can occur.
Third-generation cephalosporins (ceftriaxone and ce-
fotaxime) are resistant to many -lactamases and are thus
highly active against Enterobacteriaceae (E. coli, indole-
positive Proteus, Klebsiella, Enterobacter, Serratia, and
Citrobacter) as well as Neisseria and H. influenzae. The
third-generation cephalosporins are less active against Gram-
positive organisms than are the first-generation drugs; despite
that, they have good activity against penicillin-intermediate
S. pneumoniae (although cephalosporin resistance can
occur). Common uses include treatment of lower respira-
tory tract infection, community-acquired meningitis due to
S. pneumoniae, uncomplicated gonococcal infection, cul-
ture-negative endocarditis, and complicated Lyme disease.
In addition to the adverse effects already mentioned, ceftri-
axone can cause cholestatic hepatitis, albeit uncommonly.
Ceftazidime is the third commonly used third-generation
cephalosporin; its spectrum differs from that of the other
two agents in that it has significant antipseudomonal activ-
ity and minimal activity against Gram-positive organisms.
It is used predominantly to treat hospital-acquired Gram-
negative bacterial infections and documented infections
with P. aeruginosa and as empiric therapy for neutropenic
patients with fever. Gram-negative bacteria that have ac-
quired extended-spectrum -lactamase activity are resistant
to third-generation cephalosporins.
Cefepime is the only currently available fourth-generation
cephalosporin. Like ceftriaxone, it is highly active against
Enterobacteriaceae, Neisseria, H. influenzae, and Gram-
positive organisms; additionally, it is as active as ceftazidime
against P. aeruginosa. Cefepime is also more resistant to the
chromosomally encoded -lactamases of Enterobacter than
are third-generation cephalosporins. Unlike ceftazidime,
however, cefepime is not approved for treatment of men-
ingitis. An uncommon adverse effect is the development
of autoantibodies against red blood cell antigens, typically
without significant hemolysis.
Ceftaroline and ceftobiprole, are fifth-generation ce-
phalosporins. These drugs are distinct in having antimicro-
bial activity against multidrug-resistant S. aureus, including
methicillin-resistant, vancomycin-intermediate S. aureus and
vancomycin-resistant strains, as well as S. pneumoniae and
respiratory Gram-negative pathogens such as Moraxella ca-
tarrhalis and H. influenzae, including -lactamase-expressing
strains. Both compounds must be administered intravenously.
Ceftaroline is approved for treatment of community-acquired
pneumonia and skin infections; ceftobiprole is under evalu-
ation by the U.S. Food and Drug Administration (FDA).
Clinical trials suggest a safety profile similar to that of other
cephalosporins.
As noted above, cephalosporins can generally be used
in patients with non-life-threatening allergy to penicillins.
Nevertheless, cephalosporins can cause hypersensitivity
reactions themselves and should be avoided in patients
with known cephalosporin hypersensitivity. Interestingly,
cefotetan and cefoperazone contain an N-methylthiotetra-
zole (NMTT) side chain that causes two unique adverse ef-
fects. The first is an alcohol intolerance syndrome known
as the disulfiram-like reaction (disulfiram is a drug that
inhibits alcohol metabolism; see Chapter 18, Pharmacology
of Drugs of Abuse). The second involves an effect on vita-
min K metabolism that results in decreased synthesis of vi-
tamin K-dependent coagulation factors; thus, cefotetan and
cefoperazone should be used with caution in patients taking
warfarin and in patients with underlying coagulation abnor-
malities (see Chapter 22, Pharmacology of Hemostasis and
Thrombosis). Cefotetan, like most of the cephalosporins,
can also cause antibody-mediated hemolysis.
Monobactams and Carbapenems
The only available monobactam, aztreonam, is active against
most Gram-negative bacteria, including P. aeruginosa, but it
has no activity against Gram-positive organisms. Aztreonam
is particularly useful in patients with serious penicillin al-
lergy who have infections due to resistant Gram-negative
organisms because of its lack of cross-allergenicity with
penicillins; however, Gram-negative bacteria with extend-
ed-spectrum -lactamases are resistant to the drug. Its use
is limited by IV-site phlebitis, and its short half-life neces-
sitates frequent dosing.
There are four carbapenems used in clinical practice:
imipenem, meropenem, doripenem, and ertapenem. All
four are broad-spectrum and cover most Gram-positive,
Gram-negative, and anaerobic organisms. None is active
against MRSA, VRE, or Legionella; and Gram-negative
bacteria with carbapenemases (especially K. pneumoniae)
 CHAPTER 34 / Pharmacology of Bacterial and Mycobacterial Infections: Cell Wall Synthesis 613
The combination of these two agents, which are administered
intravenously, is currently in phase 2 clinical trials.
 CONCLUSION AND FUTURE DIRECTIONS
The bacterial cell wall presents a number of unique antibac-
terial targets. This structure consists of a three-dimensional
mat of cross-linked peptide-sugar polymers called murein
and is synthesized in three stages: (1) synthesis of murein
monomers; (2) polymerization of monomers into murein
polymers; and (3) cross-linking of polymers to complete
the wall.
Antibacterial agents act in all three stages of cell wall
synthesis: fosfomycin and cycloserine act in the first stage;
vancomycin, teicoplanin, telavancin, and bacitracin act in
the second stage; and the -lactams, the largest and most
important group, act in the third stage. -Lactamswhich
include the penicillins, cephalosporins, monobactams, and
carbapenemsare bactericidal; autolytic cell death most
likely results from the unopposed action of wall remodeling
proteins called autolysins. Structural and chemical differ-
ences among the -lactams determine their spectra of activ-
ity against bacteria with different cell wall architectures.
Resistance to -lactam antibiotics is generally conferred
by plasmid-encoded -lactamases. Pharmacologists have
addressed this mechanism of resistance: (1) by developing
new -lactam agents, for example, the second- and third-
generation cephalosporins that are resistant to degradation by
many -lactamases; and (2) by co-administering -lactam
decoys, such as clavulanic acid and sulbactam, that serve
as -lactamase inhibitors. Because -lactamases can be en-
coded on plasmids, they can spread through bacterial (and
human) populations with great speed, making antibiotic de-
velopment an ongoing arms race.
Antimycobacterial agents act by blocking various steps
in the synthesis of molecules, such as mycolic acid and
arabinogalactan, that are unique to the mycobacterial cell
wall. Resistance to these agents is typically due to chromo-
somal mutation, but combination therapy is critically im-
portant to avoid the development of mutational resistance.
Future innovations will likely include the development of
new agents directed against the additional unique molec-
ular targets that are presented by the biochemistry of the
bacterial cell wall.
Acknowledgment
We thank Robert R. Rando and Anne G. Kasmar for their
valuable contributions to this chapter in the First and Second
Editions of Principles of Pharmacology: The Pathophysi-
ologic Basis of Drug Therapy.
Suggested Reading
Brennan PJ. The envelope of mycobacteria. Annu Rev Biochem 1995;
64:2963. (Reviews the structure, composition, and synthesis of the myco-
bacterial cell wall.)
Bush K. Alarming -lactamase-mediated resistance in multidrug-resistant
Enterobacteriaceae. Curr Opin Microbiol 2010;13:558564. (Reviews -
lactam resistance in Gram-negative bacteria, focusing on recent reports of
ESBL- and carbapenemase-mediated resistance.)
El Zoeiby A, Sanschagrin F, Levesque RC. Structure and function of the Mur
enzymes: development of novel inhibitors. Mol Microbiol 2003;47:112.
(Reviews the structure, catalytic action, and inhibition of MurAMurF.)
Gale EF, Cundliffe E, Reynolds PE, et al. The molecular basis of antibiotic
action. 2nd ed. London: John Wiley; 1981. (Classic on antibiotics that de-
scribes the experiments that led to the determination of many of the mecha-
nisms of action discussed in this chapter.)
Howden BP, Davies JK, Johnson PD, et al. Reduced vancomycin sus-
ceptibility in Staphylococcus aureus: resistance mechanisms, laboratory
detection, and clinical implications. Clin Microbiol Rev 2010;23:99139.
(Reviews VISA and VRSA, including definitions, risk factors, and mecha-
nisms of resistance.)
Jacoby GA, Munoz-Price LS. The new beta-lactamases. N Engl J Med
2005;352:380391. (Reviews the pharmacology of -lactamases.)
Kelkar PS, Li JT. Cephalosporin allergy. N Engl J Med 2001;345:804809.
(Comprehensive literature review of cephalosporin reactions in patients
with a history of penicillin allergy.)
Ma Z, Lienhardt C, McIlleron H, et al. Global tuberculosis drug development
pipeline: the need and the reality. Lancet 2010;375:21002109. (Reviews
approved and investigational drugs for the treatment of tuberculosis.)
Paterson DL, Bonomo DA. Extended-spectrum beta-lactamases: a clinical up-
date. Clin Microbiol Rev 2005;18:657686. (Reviews the microbiology, transmis-
sion, and treatment of extended-spectrum -lactamase-producing organisms.)
Rattan A, Kalia A, Ahmad N. Multidrug-resistant Mycobacterium tuberculo-
sis: molecular perspectives. Emerg Infect Dis 1998;4:195209. (Discusses the
problem of resistance in tuberculosis.)
35
Pharmacology of
Fungal Infections
Ali Alikhan, Charles R. Taylor, and April W. Armstrong
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 618-619
BIOCHEMISTRY OF THE FUNGAL MEMBRANE
AND CELL WALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618
PATHOPHYSIOLOGY OF FUNGAL INFECTIONS . . . . . . . . . . . 620
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 620
Inhibitor of Fungal Nucleic Acid Synthesis: Flucytosine . . . 620
Inhibitor of Fungal Mitosis: Griseofulvin . . . . . . . . . . . . . . 622
 INTRODUCTION
Fungi are free-living microorganisms that exist as yeasts
(single-cell, round fungi), molds (multicellular filamentous
fungi), or a combination of the two (so-called dimorphic
fungi). All fungi are eukaryotic organisms. Because of their
phylogenetic similarity, fungi and humans have homologous
metabolic pathways for energy production, protein synthesis,
and cell division. Consequently, there is greater difficulty in
developing selective antifungal agents than in developing
selective antibacterial agents. The success of many antibac-
terial agents has resulted from the identification of unique
molecular targets in bacteria, emphasizing the necessity for
identifying unique fungal targets that can be exploited.
Certain patient populations are particularly susceptible
to fungal infections (mycoses). These populations include
surgical and intensive care unit (ICU) patients, patients with
prostheses, and patients with compromised immune de-
fenses. In the past three decades, the extensive use of broad-
spectrum antibiotics, the wider use of long-term intravenous
catheters, and infection with human immunodeficiency virus
(HIV) have correlated with an increasing incidence of op-
portunistic and systemic mycoses. Additionally, the suc-
cesses of organ transplantation, immunosuppressive therapy,
and cancer chemotherapy have contributed to an increasing
number of chronically immunosuppressed patients, who are
particularly susceptible to fungal infections.
Traditionally, the diagnosis of fungal infections has re-
lied on culture-based methods and direct examination of
specimens under light microscopy. However, the indolent
growth of fungi makes culturing inefficient, while direct mi-
croscopic examination may not be reliable or provide defini-
tive speciation. These disadvantages have important clinical
618
Inhibitors of the Ergosterol Synthesis Pathway . . . . . . . . . 622
Inhibitors of Squalene Epoxidase. . . . . . . . . . . . . . . . . 622
Inhibitors of 14-Sterol Demethylase . . . . . . . . . . . . . 622
Inhibitors of Fungal Membrane Stability: Polyenes . . . . . . 624
Inhibitors of Fungal Wall Synthesis: Echinocandins . . . . . . 625
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 625
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625
implications, because prognosis often correlates inversely
with the duration of time from clinical presentation to ac-
curate diagnosis. Consequently, one major focus of modern
mycology is the development of rapid, nonculture-based
methods of early diagnosis. New diagnostic techniques
rely on the polymerase chain reaction (PCR), western blot,
antigen detection, and identification of fungal metabolites.
Because many of these techniques are still investigational,
they must be performed in parallel with traditional culture-
based methods.
The treatment options for opportunistic and systemic fun-
gal infections were once thought to be limited. These options
are now expanding, however. Fungal processes that have
been exploited in the development of antifungal agents in-
clude nucleic acid synthesis, mitosis, and membrane synthe-
sis and stability. Traditional antifungal agents, such as azoles
and polyenes, are directed against molecular targets involved
in the synthesis and stability of the fungal membrane. The
echinocandins, a new class of antifungal agents, target an
enzyme complex involved in the synthesis of the fungal cell
wall. As the emergence of resistant fungi increases, it will
become increasingly important to identify and exploit new
molecular targets for antifungal therapy.
 BIOCHEMISTRY OF THE FUNGAL
MEMBRANE AND CELL WALL
Although fungi have a cellular ultrastructure similar to that
of animal cells, there are a number of unique biochemical
differences that have been exploited in the development
of antifungal drugs. To date, the most important biochemi-
cal difference lies in the principal sterol used to maintain
 Acetyl CoA

HMG CoA

Mevalonate

Allylamines
Squalene
Benzylamines
Squalene
epoxidase

Two representative triazoles:

OH
N N
N N

N F N
HO
H

Lanosterol
F
Imidazoles Fluconazole
14-sterol Triazoles
demethylase F
OH
N
N

N F N N

F
Voriconazole
H H
HO
Ergosterol

Membrane synthesis
 CHAPTER 35 / Pharmacology of Fungal Infections 621

Endoplasmic reticulum be demonstrated experimentally. The mechanism of this

(inhibit ergosterol synthesis)
synergistic interaction appears to involve enhancement
Allylamines
Benzylamines of flucytosine uptake by fungal cells due to amphotericin-
Imidazoles induced damage to the fungal plasma membrane. The
Triazoles
Nucleus spectrum of activity of flucytosine as a single agent is
limited to candidiasis, cryptococcosis, and chromomyco-
sis. Combination treatment with amphotericin B is recom-
mended in acute cryptococcal meningitis in HIV-infected
adults. A pharmacokinetic advantage of flucytosine is its
large volume of distribution, with excellent penetration
into the central nervous system (CNS), eyes, and urinary
tract. Dose-dependent adverse effects include bone marrow
suppression leading to leukopenia and thrombocytopenia,
nausea, vomiting, diarrhea, and hepatic dysfunction. Flu-
cytosine is contraindicated during pregnancy.

Mitotic spindle NH2

Griseofulvin Cell wall
Echinocandins F
DNA synthesis N
Flucytosine
Plasma membrane
N O
Polyenes (amphotericin B) H

OH Flucytosine
OH Cytosine
O OH
permease

HO O OH OH OH OH O OH
H Cell membrane
O

O
O Cytosine deaminase
NH2 OH

OH
O
Amphotericin B
F
NH
FIGURE 35-2. Cellular targets of antifungal drugs. The currently available
antifungal agents act on distinct molecular targets. Flucytosine inhibits fungal DNA
N O
synthesis. Griseofulvin inhibits fungal mitosis by disrupting mitotic spindles. Al- H
lylamines, benzylamines, imidazoles, and triazoles inhibit the ergosterol synthesis 5-Fluorouracil
pathway in the endoplasmic reticulum. Polyenes bind to ergosterol in the fungal (5-FU)
membrane and thereby disrupt plasma membrane integrity. Amphotericin B is a
representative polyene. Echinocandins inhibit fungal cell wall synthesis.
O
F
NH
(5-FU). (5-FU is itself an antimetabolite that is used in can-
cer chemotherapy; see Chapter 38, Pharmacology of Cancer: N O
O
Genome Synthesis, Stability, and Maintenance.) Subse-
-
quent reactions convert 5-FU to 5-fluorodeoxyuridylic acid O P O
O
(5-FdUMP), which is a potent inhibitor of thymidylate O- H H
synthase. Inhibition of thymidylate synthase results in in- H H
OH H
hibition of DNA synthesis and cell division (Fig. 35-3). Flu-
5-Fluorodeoxyuridylic acid
cytosine appears to be fungistatic under most circumstances. monophosphate
Although mammalian cells lack cytosine-specific permeases (5-FdUMP)
and cytosine deaminase, fungi and bacteria in the intestine
can convert flucytosine into 5-fluorouracil, which can cause
dUMP dTMP
adverse effects in host cells. Thymidylate
Flucytosine is typically used in combination with am- synthase
photericin B to treat systemic mycoses; when the drug
FIGURE 35-3. Mechanism of action of flucytosine. Flucytosine enters the
is used as a single agent, resistance emerges rapidly due fungal cell via a transmembrane cytosine permease. Inside the cell, cytosine deam-
to mutations in fungal cytosine permease or cytosine inase converts flucytosine to 5-fluorouracil (5-FU), which is subsequently converted
deaminase. Although flucytosine has no intrinsic activity to 5-fluorodeoxyuridylic acid monophosphate (5-FdUMP). 5-FdUMP inhibits thy-
against Aspergillus, synergistic killing of Aspergillus by midylate synthase and thereby blocks the conversion of deoxyuridylate (dUMP) to
the combination of flucytosine and amphotericin B can deoxythymidylate (dTMP). In the absence of dTMP, DNA synthesis is inhibited.
622 Principles of Chemotherapy
Inhibitor of Fungal Mitosis: Griseofulvin
Derived from Penicillium griseofulvum in the 1950s,
griseofulvin inhibits fungal mitosis by binding to tubulin
and a microtubule-associated protein and thereby disrupting
assembly of the mitotic spindle. The drug is also reported to
inhibit fungal RNA and DNA synthesis. Griseofulvin accu-
mulates in keratin precursor cells and binds tightly to keratin
in differentiated cells. The prolonged and tight association
of griseofulvin with keratin allows new growth of skin, hair,
or nail to be free of dermatophyte infection. Griseofulvin ap-
pears to be fungistatic under most circumstances.
The therapeutic use of oral griseofulvin is currently lim-
ited, due to the availability of topical antifungal medications
as well as other oral antifungal agents with fewer adverse
effects. Griseofulvin can be used to treat fungal infection of
the skin, hair, and nail due to Trichophyton, Microsporum,
and Epidermophyton. The drug is not effective against yeast
(such as Pityrosporum) and dimorphic fungi. Doses should
be taken at 6-hour intervals because blood levels of griseo-
fulvin can be variable; absorption is enhanced if the drug is
taken with a fatty meal. It is important to continue treatment
until the infected skin, hair, or nail is completely replaced by
normal tissue.
Griseofulvin use is not associated with a high incidence
of serious adverse effects. A relatively common (up to 15%)
adverse effect is headache, which tends to disappear as ther-
apy continues. Other nervous system effects include leth-
argy, vertigo, and blurred vision; these adverse effects can
be exacerbated by the consumption of alcohol. Occasionally,
hepatotoxicity or albuminuria without renal insufficiency
can be observed. Hematologic adverse effectsincluding
leukopenia, neutropenia, and monocytosiscan occur dur-
ing the first month of therapy. Serum sickness, angioedema,
exfoliative dermatitis, and toxic epidermal necrolysis are
extremely rare but potentially life-threatening adverse ef-
fects. Chronic use can sometimes result in increased fecal
protoporphyrin levels. Concurrent administration with bar-
biturates decreases the gastrointestinal absorption of griseo-
fulvin. Because griseofulvin induces hepatic cytochrome
P450 enzymes, it can increase the metabolism of warfarin
and potentially reduce the efficacy of low-estrogen oral con-
traceptive medications. Griseofulvin should be avoided dur-
ing pregnancy, since fetal abnormalities have been reported.
Inhibitors of the Ergosterol Synthesis Pathway
Inhibitors of Squalene Epoxidase
Allylamines and Benzylamines
In the ergosterol synthesis pathway (Fig. 35-1), squalene is
converted to lanosterol by the action of squalene epoxidase.
Inhibitors of squalene epoxidase prevent the formation of
lanosterol, which is a precursor for ergosterol. These drugs
also promote accumulation of the toxic metabolite squalene
in the fungal cell, making them fungicidal under most cir-
cumstances. The antifungal agents that inhibit squalene ep-
oxidase can be divided into allylamines and benzylamines
based on their chemical structures: terbinafine and naftifine
are allylamines, whereas butenafine is a benzylamine.
Terbinafine is available in both oral and topical formula-
tions. When taken orally, the drug is 99% protein-bound in
the plasma, and it undergoes first-pass metabolism in the
liver. Because of this first-pass metabolism, the oral bio-
availability of terbinafine is 40%. The drugs elimination
half-life is extremely long, approximately 300 hours, be-
cause terbinafine accumulates extensively in the skin, nails,
and fat. The oral form of terbinafine is used in the treat-
ment of onychomycosis, tinea corporis, tinea cruris, tinea
pedis, and tinea capitis. Terbinafine is not recommended in
patients with renal or hepatic failure or in pregnant women.
Very rarely, the oral form of terbinafine can lead to hepa-
totoxicity, StevensJohnson syndrome, neutropenia, and
exacerbation of psoriasis or subacute cutaneous lupus ery-
thematosus. Liver function enzymes should be monitored
during the treatment course. Plasma levels of terbinafine
are increased by co-administration with cimetidine (a cyto-
chrome P450 inhibitor) and decreased by co-administration
with rifampin (a cytochrome P450 inducer). Topical terbin-
afine is available in cream or spray form and is indicated for
tinea pedis, tinea cruris, and tinea corporis.
Similar to terbinafine, naftifine is a squalene epoxidase
inhibitor that has broad-spectrum antifungal activity. Nafti-
fine is only available topically as a cream or gel; it is effec-
tive in tinea corporis, tinea cruris, and tinea pedis.
Butenafine, a benzylamine, is a topical antifungal agent
with a mechanism of action and spectrum of antifungal activ-
ity similar to that of the allylamines. Topical allylamines and
benzylamines are more effective than topical azole agents
against common dermatophytes, especially those causing
tinea pedis. However, topical terbinafine and butenafine are
less effective than topical azoles against Candida skin infec-
tions (see below).
Inhibitors of 14 -Sterol Demethylase
Imidazoles and Triazoles
Another important molecular target in the ergosterol syn-
thesis pathway is 14-sterol demethylase, a microsomal
cytochrome P450 enzyme that converts lanosterol to ergos-
terol. The azoles are antifungal agents that inhibit fungal
14-sterol demethylase. The resulting decrease in ergosterol
synthesis and accumulation of 14-methyl sterols disrupt
the tightly packed acyl chains of the phospholipids in fungal
membranes. Destabilization of the fungal membrane leads
to dysfunction of membrane-associated enzymes, including
those in the electron transport chain, and may ultimately lead
to cell death. Azoles are not completely selective for the fun-
gal P450 enzyme, however, and they can also inhibit hepatic
P450 enzymes. While the extent of hepatic P450 enzyme
inhibition varies among the azoles, drugdrug interactions
are an important consideration whenever an azole antifun-
gal agent is prescribed. For example, cyclosporine is an
immunosuppressant drug used to prevent graft rejection in
recipients of allogeneic kidney, liver, and heart transplants.
It is metabolized by hepatic P450 enzymes and excreted in
the bile. To minimize the risk of cyclosporine-associated
nephrotoxicity and hepatotoxicity, patients concomitantly
receiving an azole antifungal agent should be treated with
lower doses of cyclosporine.
As a group, the azoles have a wide range of antifungal ac-
tivity and are clinically useful against B. dermatitidis, Cryp-
tococcus neoformans, H. capsulatum, Coccidioides species,
P. brasiliensis, dermatophytes, and most Candida species.
Azoles have intermediate clinical activity against Fusar-
ium, Sporothrix schenckii, Scedosporium apiospermum,
and Aspergillus species. Pathogens mediating zygomycosis
(invasive fungal infections caused by Zygomycetes species)
and Candida krusei are resistant to azoles. The azoles are

Nystatin, a structural relative of amphotericin B, is a
polyene antifungal agent that also acts by binding ergosterol
and causing pore formation in fungal cell membranes. The
drug is used topically to treat candidiasis involving the skin,
vaginal mucosa, and oral mucosa. Nystatin is not absorbed
systemically from the skin, vagina, or gastrointestinal tract.
Inhibitors of Fungal Wall Synthesis:
Echinocandins
The key components of the fungal cell wall are chitin, -
(1,3)-D-glucan, -(1,6)-D-glucan, and cell wall glycopro-
teins. Because human cells do not have a cell wall, fungal
cell wall components represent unique targets for antifungal
therapy, and antifungal agents directed at these targets are
likely to be relatively nontoxic. Echinocandins are a class
of antifungal agents that target fungal cell wall synthesis
by noncompetitively inhibiting the synthesis of -(1,3)-D-
glucans. Disruption of cell wall integrity results in osmotic
stress, lysis of the fungal cell, and ultimately fungal cell
death. The three antifungal agents in the echinocandin class
are caspofungin, micafungin, and anidulafungin; all are
semisynthetic lipopeptides derived from natural products.
The echinocandins have in vitro and in vivo antifungal activ-
ity against Candida and Aspergillus species. All three echi-
nocandins are fungicidal against Candida species, including
C. krusei and C. glabrata, and fungistatic against Aspergillus
species. They have poor activity against zygomycetes. All
three agents are currently available only in parenteral form
because they are insufficiently bioavailable for oral use.
Caspofungin was the first echinocandin to be approved.
The drug is used as primary therapy for esophageal can-
didiasis and candidemia, as salvage therapy for Aspergillus
infections, and as empiric therapy for febrile neutropenia.
Like the other echinocandins, caspofungin is highly protein-
bound (97%) in the plasma; it is metabolized in the liver
via peptide bond hydrolysis and N-acetylation; and it pen-
etrates poorly into the CSF (although animal data indicate
that the echinocandins do have some activity in the CNS).
Caspofungin does not require dose adjustment for renal in-
sufficiency, but dose adjustment is required for patients with
moderate hepatic dysfunction. Because co-administration
with cyclosporine significantly increases plasma concentra-
tions of caspofungin and elevates liver function enzymes,
this drug combination is generally not recommended un-
less the expected benefits outweigh the risks. Similarly,
co-administration with tacrolimus significantly increases
plasma concentrations of tacrolimus. To achieve therapeutic
plasma concentrations, caspofungin dosing may need to be
increased in patients receiving nelfinavir, efavirenz, pheny-
toin, rifampin, carbamazepine, or dexamethasone.
Micafungin is approved for the treatment of esophageal
candidiasis and as antifungal prophylaxis for recipients of he-
matopoietic stem cell transplants. It is also effective against
candidemia and pulmonary aspergillosis. Anidulafungin is
approved for the treatment of esophageal candidiasis and
CHAPTER 35 / Pharmacology of Fungal Infections 625
candidemia. Several small case series have reported the use
of echinocandins in combination with amphotericin B, flucy-
tosine, itraconazole, or voriconazole in patients with refrac-
tory fungal infections. Aminocandin is an investigational
echinocandin with a spectrum of activity similar to that of
the other echinocandins. It has a half-life three- to four-fold
greater than that of the other echinocandins, thus permitting
less frequent administration.
Echinocandins are generally well tolerated; their adverse-
effect profile is comparable to that of fluconazole. Because
echinocandins contain a peptide backbone, symptoms related
to histamine release can be observed (see Suggested Read-
ing). Other adverse effects include headache, fever (more
common with caspofungin), rash, abnormal liver function
tests, and, rarely, hemolysis.
 CONCLUSION AND FUTURE DIRECTIONS
The development of antifungal agents has progressed sig-
nificantly since the introduction of amphotericin B. As the
population of immunocompromised patients increases, op-
portunistic fungal infections that are resistant to conventional
antifungal therapy pose new challenges to researchers and
clinicians. For example, new antifungal therapy is greatly
needed in the treatment of zygomycosis. Effective topical
antifungal agents are eagerly sought for the treatment of nail
and hair dermatophytosis, because oral therapies for these
superficial fungal infections carry risks such as hepatotoxicity.
The development of protease inhibitors and phospholipase
inhibitors represent new frontiers in the treatment of Candida
and Cryptococcal species, respectively. As novel and unique
molecular targets are identified in fungal pathogens, newer
antifungal agents will be developed with the goal of minimiz-
ing mechanism-based (on-target) toxicity while expanding
antifungal spectrum of action.
Suggested Reading
Gauwerky K, Borelli C, Korting HC. Targeting virulence: a new paradigm
for antifungals. Drug Discov Today 2009;14:214222. (Discusses virulence
factors of fungi and their inhibitors, with an emphasis on new options for
antifungal development, including inhibitors of the secreted aspartic pro-
teinase of C. albicans.)
Mohr J, Jonson M, Cooper T, et al. Current options in antifungal pharma-
cotherapy. Pharmacotherapy 2008;28:614645. (Discusses mechanism of
action, clinical efficacy, and safety of polyenes, azoles, echinocandins, and
investigational antifungal drugs.)
Naeger-Murphy N, Pile JC. Clinical indications for newer antifungal agents.
J Hosp Med 2008;4:102111. (Discusses the use of newly available drugs in
the echinocandin class and newer generation triazoles in several common
and/or important clinical situations.)
Patterson TF. Advances and challenges in management of invasive mycosis.
Lancet 2005;366:10131025. (Focused discussion of fungal pathogens that
occur in immunocompromised hosts and management strategies for these
opportunistic pathogens.)
Ruiz-Herrera J, Victoria Elorza M, Valentin E, et al. Molecular organization
of the cell wall of Candida albicans and its relation to pathogenicity. FEMS
Yeast Res 2006;6:1429. (Comprehensive review of the fungal cell wall.)

Pharmacology of
Parasitic Infections
INTRODUCTION & CASES 1-2 . . . . . . . . . . . . . . . . . . . 629-630
MALARIAL PLASMODIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . 629
Physiology of Malarial Plasmodia . . . . . . . . . . . . . . . . . . . 629
Life Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 629
Heme Metabolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . 631
Electron Transport Chain . . . . . . . . . . . . . . . . . . . . . . . 631
Pharmacology of Antimalarial Agents . . . . . . . . . . . . . . . . 632
Inhibitors of Heme Metabolism . . . . . . . . . . . . . . . . . . 632
Inhibitors of Electron Transport . . . . . . . . . . . . . . . . . . 634
Inhibitors of Translation . . . . . . . . . . . . . . . . . . . . . . . . 635
Inhibitors of Folate Metabolism . . . . . . . . . . . . . . . . . . 636
Antimalarial Drug Resistance . . . . . . . . . . . . . . . . . . . . . . 636
OTHER PROTOZOA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 637
CASE 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 637
Physiology of Luminal Protozoa . . . . . . . . . . . . . . . . . . . . 637
Life Cycle of Entamoeba histolytica . . . . . . . . . . . . . . . 637
Fermentation Pathways . . . . . . . . . . . . . . . . . . . . . . . 637
 INTRODUCTION
More than one billion people worldwide are infected with
parasites. Parasites of medical importance include protozoa
(such as the organisms that cause malaria, toxoplasmosis, gi-
ardiasis, amebiasis, leishmaniasis, and trypanosomiasis) and
helminths (worms). Worms that infect humans include ces-
todes (flat worms or tape worms, such as the worm that
causes taeniasis), nematodes (round worms, which cause
filariasis, strongyloidiasis, and ascariasis), and trematodes
(flukes, such as the worms that cause schistosomiasis).
Ideally, antiparasitic drugs should be targeted to struc-
tures or biochemical pathways present or accessible only
in parasites. Many antiparasitic drugs act by unknown or
poorly defined mechanisms of action, however. This chapter
focuses on a number of the better-defined agents, including
those active against Plasmodia species (which cause ma-
laria), Entamoeba histolytica (which causes amebiasis), and
Onchocerca volvulus (which causes onchocerciasis, a filarial
infection referred to as river blindness). In each of these
cases, antiparasitic agents interfere with metabolic require-
ments of the parasite: the dependence of malarial plasmodia
on heme metabolism, the dependence of luminal parasites
36
Louise C. Ivers and Edward T. Ryan
Pharmacology of Antiprotozoal Agents . . . . . . . . . . . . . . . 638
Metronidazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 638
Tinidazole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 639
Nitazoxanide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 639
Other Antiprotozoal Agents . . . . . . . . . . . . . . . . . . . . . 639
HELMINTHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 640
CASE 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 640
Physiology of Helminths . . . . . . . . . . . . . . . . . . . . . . . . . . 641
Life Cycle of Onchocerca volvulus . . . . . . . . . . . . . . . . 641
Neuromuscular Activity . . . . . . . . . . . . . . . . . . . . . . . . 641
Pharmacology of Antihelminthic Agents . . . . . . . . . . . . . . 641
Agents That Interrupt Neuromuscular Activity . . . . . . . 641
Other Antihelminthic Agents . . . . . . . . . . . . . . . . . . . . 642
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 643
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 643
on specific fermentation pathways, and the dependence of
helminths on neuromuscular activity. These three examples
are not all-inclusive, but rather emphasize opportunities to
use or design pharmacologic agents to interrupt metabolic
requirements specific to parasites.
 MALARIAL PLASMODIA
Each year, approximately 300 million individuals in more
than 90 countries develop malaria, and almost one million
individuals die of malaria. Malaria is the most important par-
asitic disease of humans and one of the most important in-
fections of humans. Human malaria is caused by one of five
species of plasmodial parasites: Plasmodium falciparum, P.
vivax, P. ovale, P. malariae, and P. knowlesi. The most seri-
ous type of malaria is that caused by P. falciparum.
Physiology of Malarial Plasmodia
Life Cycle
The life cycle of malaria involves a parasite, a mosquito vec-
tor, and a human host (Fig. 36-1). An Anopheles spp. mosquito
can ingest sexual forms of malarial parasites (gametocytes)
629
Infection

Sporozoites

Liver Circulation

Merozoites

Transmission to Asexual
mosquito cycle

Gametocytes

Plasmodium food vacuole

ADP
Hemoglobin
Proton Proteolytic enzymes
ATPase Plasmepsins
ATP
Falcipain
H+ Falcilysin
PfCRT
Chloroquine Amino acids
+
Ferriprotoporphyrin IX
(heme)
Protonated
chloroquine

Hemozoin
(polymerized heme)
632 Principles of Chemotherapy
cytochromes (large protein complexes involved in elec-
tron transport and oxidative phosphorylation). These cyto-
chromes, together with a number of mitochondrial-targeted
proteins derived from the plasmodial nuclear genome, make
up a rudimentary electron transport chain similar in organi-
zation to that found in mammals (Fig. 36-3). In this electron
transport chain, integral proteins of the mitochondrial inner
membrane are reduced and then oxidized as they transport
electrons from one intermediate protein to another. The en-
ergy liberated by electron transport is used to drive proton
pumping across the mitochondrial membrane, and the en-
ergy stored in the proton gradient drives ATP synthesis. In
this electron transport chain, oxygen is the final electron ac-
ceptor, resulting in the reduction of oxygen to water.
Plasmodia derive most of their ATP directly from glycoly-
sis and probably do not use mitochondrial electron transport
as a significant source of energy. However, plasmodia do
rely on electron transport for the oxidation of key enzymes
involved in nucleotide synthesis. For example, dihydrooro-
tate dehydrogenase (DHOD), the enzyme that mediates an
early step in pyrimidine synthesis (see Chapter 38, Pharma-
cology of Cancer: Genome Synthesis, Stability, and Mainte-
nance), catalyzes the oxidation of dihydroorotate to orotate.
As part of this reaction, DHOD is reduced, and the enzyme
must be reoxidized before it can continue with another cycle
of catalysis. Ubiquinone, an integral membrane protein lo-
cated near the beginning of the electron transport chain, ac-
cepts electrons from reduced DHOD, thus regenerating the
oxidized form of DHOD necessary for pyrimidine synthesis.
Dihydroorotate
Orotate
DHOD DHOD
(oxidized) (reduced)
H+ H+
Outside e-
Cyt
e-
c
e-
Cyt c
Mitochondrial e- oxidase
membrane Q Cyt bc1
Inside
H+
H+
Atovaquone 2e-+ 2H+ + 1/2O2 H2O
FIGURE 36-3. The mitochondrial electron transport chain in plasmodia.
The electron transport chain consists of a series of oxidation/reduction steps that
culminate in the donation of electrons to oxygen, forming water. In plasmodia,
the electron transport chain acts as an electron acceptor for reduced dihydrooro-
tate dehydrogenase (DHOD), an enzyme that is essential for plasmodial pyrimi-
dine synthesis. In this cascade, reduced ubiquinone (Q ) transfers electrons to the
cytochrome bc1 complex (Cyt bc1), which then passes electrons to cytochrome
c (Cyt c) and, finally, to cytochrome c oxidase (Cyt c oxidase). In a 4-electron
reduction of molecular oxygen (shown here as the half-reaction), cytochrome c
oxidase donates electrons to oxygen to form water. This chain of electron transfers
also involves the pumping of protons across the mitochondrial membrane by Cyt
bc1 and Cyt c oxidase; the resulting electrochemical gradient of protons is used
to generate ATP (not shown). Atovaquone antagonizes the interaction between
ubiquinone and the plasmodial cytochrome bc1 complex, thereby disrupting py-
rimidine synthesis by preventing the regeneration of oxidized DHOD.
Because plasmodia depend on de novo pyrimidine synthesis
for DNA replication, interrupting the ability of ubiquinone
to oxidize DHOD can disrupt plasmodial DNA replication
(see below).
Pharmacology of Antimalarial Agents
The currently available antimalarial agents target four physi-
ologic pathways in plasmodia: heme metabolism (chloro-
quine, quinine, mefloquine, and artemisinin), electron
transport (primaquine and atovaquone), protein translation
(doxycycline, tetracycline, and clindamycin), and folate
metabolism (sulfadoxine-pyrimethamine and proguanil).
The following section discusses the pharmacologic agents
that target these pathways.
Clinically, antimalarials can be classified into agents used
for prophylaxis (to prevent malaria in individuals residing in
or traveling through a malaria zone), agents used for treating
individuals with acute blood-stage malaria, and agents used
to eliminate hypnozoite liver-stage malarial infections. Gen-
erally, agents used for prophylaxis must be well tolerated
and easy to administer.
Inhibitors of Heme Metabolism
For many centuries, agents that disrupt intraerythrocytic
malarial parasites have been the foundation of antimalarial
treatment regimens. Most of these compounds are conge-
ners of quinoline and, as a result, are all believed to possess
similar mechanisms of action. Artemisinin, discussed at the
end of this section, is also thought to act by inhibiting heme
metabolism, although its structure is different from that of
the quinolines.
Chloroquine
For the past 2,000 years, humans have used the roots of
Dichroa febrifuga or the leaves of hydrangea in the treat-
ment of individuals with malaria. More recently, the bark
of the cinchona tree was found to be a more effective rem-
edy. In all these plants, a quinoline compound is the phar-
macologically active antiplasmodial agent. Chloroquine,
a 4-aminoquinoline, was introduced in 1935 for use in the
treatment of malaria. Chloroquine is a weak base that, in
its neutral form, freely diffuses across the membrane of the
parasites food vacuole. Once inside the acidic environment
of the vacuole, chloroquine is rapidly protonated, making it
unable to diffuse out of the vacuole. As a result, protonated
chloroquine accumulates to high concentrations inside the
parasites food vacuole, where it binds to ferriprotoporphy-
rin IX and inhibits the polymerization of this heme metabo-
lite. Accumulation of unpolymerized ferriprotoporphyrin
IX leads to oxidative membrane damage and is toxic to the
parasite. Chloroquine thus poisons the parasite by prevent-
ing the detoxification of a toxic product of hemoglobin ca-
tabolism (Fig. 36-2).
Chloroquine is concentrated by as much as 100-fold in
parasitized erythrocytes compared to uninfected erythro-
cytes. In addition, the concentration of chloroquine required
to alkalinize lysosomes of mammalian cells is much higher
than that needed to raise the pH in malarial food vacuoles.
Therefore, chloroquine is relatively nontoxic to humans,
although the drug commonly causes pruritus in darkly
pigmented individuals, and it can exacerbate psoriasis
and porphyria. Taken in supratherapeutic doses, however,
chloroquine can cause vomiting, retinopathy, hypotension,

confusion, and death. In fact, chloroquine is used globally in
suicides each year (largely because it is inexpensive, avail-
able, and toxic at high doses), and accidental ingestion by
children can be fatal.
When initially introduced, chloroquine was a first-line
drug used against all types of malaria; however, it is now
ineffective against most strains of P. falciparum in Africa,
Asia, and South America (Fig. 36-4). Hypotheses regard-
ing the mechanisms responsible for chloroquine resistance
are based on the finding that chloroquine-resistant plasmo-
dia accumulate less chloroquine inside food vacuoles than
chloroquine-sensitive plasmodia do. In the food vacuole,
protonated amino acids are generated by the parasite as it
degrades hemoglobin. These protonated amino acids exit
the lysosome by means of a transmembrane protein called
PfCRT, encoded by pfcrt on P. falciparum chromosome 7.
A number of mutations in PfCRT have been associated with
chloroquine resistance; for example, a substitution of threo-
nine for lysine at position 76 (K76T) is highly correlated
with chloroquine resistance. This mutated PfCRT probably
pumps protonated chloroquine out of the food vacuole. This
altered pump action could also be detrimental to the para-
site, perhaps because of altered amino acid export and/or
changes in vacuole pH. Many P. falciparum strains with mu-
tations in pfcrt carry a second mutation in the gene pfmdr1
encoding Pgh1, a food vacuole membrane protein involved
in pH regulation. It is speculated that this second mutation
provides a corrective action that allows chloroquine-
resistant P. falciparum to continue growth in the presence
of a pfcrt mutation.
Strains of P. vivax with decreased susceptibility to chlo-
roquine are now reported with increasing frequency in areas
of Papua New Guinea, Indonesia, and other focal areas of
Oceania and Latin America, although the exact mechanism
of decreased susceptibility to chloroquine in these strains
has not yet been established. Despite concerns regarding in-
creasing resistance, chloroquine remains the drug of choice
for treating most individuals with malaria caused by P. vivax,
Resistance to
sulfadoxine/
pyrimethamine
Resistance to
sulfadoxine/
pyrimethamine
Resistance to chloroquine
FIGURE 36-4. Geographic distribution of drug-resistant Plasmodium falciparum. Historically, chloroquine has been the drug of choice for prophylaxis and
treatment of individuals with P. falciparum malaria. Unfortunately, P. falciparum is now resistant to chloroquine in most areas of the world (blue shading). In many areas,
P. falciparum is also resistant to other antimalarial agents, including sulfadoxinepyrimethamine, mefloquine, and halofantrine. (Halofantrine is associated with poten-
tially lethal cardiac toxicity and is therefore seldom used.)
CHAPTER 36 / Pharmacology of Parasitic Infections 633
P. ovale, P. malariae, and P. knowlesi and by chloroquine-
sensitive strains of P. falciparum. It can also be used pro-
phylactically to prevent malaria caused by sensitive strains
of plasmodia.
Quinine and Quinidine
Quinine is an alkaloid that consists of a quinoline ring
linked by a secondary carbinol to a quinuclidine ring. Its
optical isomer, quinidine, has identical pharmacologic ac-
tions. Because of quinines structural similarity to other an-
timalarial quinolines, quinine is thought to attack plasmodia
by the mechanism described above. Quinine has also been
shown to intercalate into DNA through hydrogen bonding,
thus inhibiting DNA strand separation, transcription, and
translation. The overall effect is a decrease in the growth
and replication of the erythrocytic form of plasmodia. Qui-
nine and quinidine have been used to treat individuals with
acute blood-stage malaria but are not used prophylactically.
Use of quinine can cause cinchonism, a syndrome that in-
cludes tinnitus, deafness, headaches, nausea, vomiting, and
visual disturbances. Quinine and quinidine can also prolong
the cardiac QT interval (see Chapter 23, Pharmacology of
Cardiac Rhythm).
Mefloquine
Mefloquine is a quinoline compound that is structurally
related to other antimalarial agents. Unlike quinine, meflo-
quine does not bind to DNA. Its exact mechanism of ac-
tion is unknown, although mefloquine appears to disrupt
polymerization of hemozoin in intraerythrocytic malarial
parasites. Mefloquine has a number of adverse effects, in-
cluding nausea, cardiac conduction abnormalities (including
bradycardia, prolongation of the QT interval, and arrhyth-
mia), and neuropsychiatric effects, including vivid dreams/
nightmares, insomnia, anxiety, depression, hallucinations,
seizures, and, rarely, psychosis. The mechanism(s) respon-
sible for these adverse effects is unknown. Mefloquine can
be used both therapeutically and prophylactically. Strains of
Resistance to Resistance to
sulfadoxine/ sulfadoxine/
pyrimethamine pyrimethamine,
mefloquine,
and halofantrine
634 Principles of Chemotherapy
P. falciparum resistant to both chloroquine and mefloquine
have been reported in areas of Southeast Asia.
Artemisinin
Artemisinin, from the wormwood plant Artemisia annua,
has been used in China (where it is known as qinghao) for
centuries in the treatment of individuals with fever. Ar-
temisinin derivatives have now become the first-line drug
for treating individuals with falciparum malaria in many
parts of the world. The compound is both a sesquiterpene
lactone and a cyclic endoperoxide. When activated by free
or heme-bound iron, it forms a carbon-centered free-radical
compound (Fig. 36-5). This free radical has the ability to
alkylate many proteins as well as heme. The mechanism of
specificity of the drug for plasmodia-infected erythrocytes is
unknownpotential sources of specificity include artemisi-
nins requirement for heme for free radical formation and
artemisinins preferential accumulation in plasmodia. Drug
action may relate to free radical production in the food vacu-
ole of the parasite and subsequent inhibition of PfATP6, the
parasite Ca2 ATPase that is the ortholog of the mammalian
SERCA calcium pump (see Chapter 24, Pharmacology of
Cardiac Contractility). Administration of artemisinin and its
derivatives (artesunate, artemether, dihydroartemisinin)
is associated with a rapid decrease in the level of malaria
parasites in the blood of an infected individual and rapid res-
olution of symptoms in patients with blood-stage malaria.
Unlike many of the other antimalarials, artemisinins affect
blood-stage gametocytes, and thus can decrease transmis-
sion of malaria from an infected human. Artemisinin is not
effective as a prophylactic agent against malaria.
Due to the short half-life of artemisinins and the subse-
quent risk of recrudescence of malaria, and to decrease the
likelihood of drug resistance, the World Health Organization
Fe
Heme
Activation
Fe
(free or heme-bound)
Artemisinin Artemisinin
(free radical or
electrophillic intermediate)
O O
O
H H
O
O
FIGURE 36-5. Proposed mechanism of action of artemisinin. Artemisinin is a cyclic endoperoxide that forms a free radical after activation by iron (Fe). The
mechanism of action of artemisinin is not known with certainty, but may involve alkylation of macromolecules such as heme and proteins, resulting in the formation of
artemisininheme adducts and artemisininprotein adducts that are toxic to plasmodia. One such adduct may involve PfATP6, a parasite Ca2ATPase (not shown).
(WHO) strongly recommends against use of artemisinins as
monotherapy. Artemisinins should be used as fixed combi-
nations, usually including a rapidly acting artemisinin and a
second agent with a longer half-life (referred to as artemisi-
nin combination therapy [ACT]). Combinations include ar-
temetherlumefantrine, artesunatemefloquine, artesunate
amodiaquine, and dihydroartemisininpiperazine. Oral,
parenteral, and rectal suppository formulations are available.
The WHO now recommends that ACT should be used as the
first-line treatment for chloroquine-resistant P. falciparum
malaria. In comparison to quinine, artesunate is superior
and associated with a decreased risk of death, more rapid
parasite clearance, and lower incidence of adverse events.
In vitro resistance to artemisinin has been associated with
mutations in the parasite calcium pump PfATP6 (see above),
and there have been recent reports of relative artemisinin re-
sistance in patients in Asia.
Overall, artemisinin and its derivatives are better toler-
ated than most other antimalarial agents. In laboratory ani-
mals, intramuscular injection of oil-based formulations of
artemisinin has been shown to cause brainstem neuropathy;
this potentially lethal effect has not been observed in hu-
mans, but some studies have found evidence suggesting that
artemisinins may be associated with auditory impairment
and other neurotoxic effects in humans. Hypoglycemia oc-
curs less often than with quinine-based therapy. Safety data
in pregnancy are lacking.
Inhibitors of Electron Transport
Although the electron transport chain is a ubiquitous fea-
ture of eukaryotic cells, two agents have been developed
that appear to selectively interrupt the plasmodial electron
transport chain. This selectivity is due to different molecu-
lar structures of the same biochemical target, rather than the
Drug-heme adduct
Fe
Alkylation
Drug-protein adduct
Protein
636 Principles of Chemotherapy
an increased risk of antibiotic-associated diarrhea and colitis
caused by Clostridium difficile. Clindamycin is not used as a
malaria chemoprophylactic.
Inhibitors of Folate Metabolism
Folic acid is a vitamin involved in the transfer of one-carbon
units in a variety of biosynthetic pathways, including those
of DNA and RNA precursors and certain amino acids (see
Chapter 32). In humans, folate is an essential vitamin and
must be ingested in the diet. In parasites and bacteria, folate
is synthesized de novo, providing a useful target for selec-
tive drug action. Inhibition of folate metabolism can result
in successful treatment of parasitic infections. In the context
of malaria, antifolate drugs act against parasite-specific iso-
forms of dihydropteroate synthetase and dihydrofolate re-
ductase. Combination therapies that include a sulfonamide
and pyrimethamine are used. Two antimalarial formulations
are available, sulfadoxinepyrimethamine and the less fre-
quently used sulfalenepyrimethamine.
SulfadoxinePyrimethamine
Sulfadoxine is a para-aminobenzoic acid (PABA) analogue
that competitively inhibits parasite dihydropteroate syn-
thetase, an essential enzyme in the folic acid synthesis path-
way. Pyrimethamine is a folate analogue that competitively
inhibits parasite dihydrofolate reductase, the enzyme that
converts dihydrofolate to tetrahydrofolate (see Figs. 32-6
and 32-7). In combination, sulfadoxine and pyrimethamine
act synergistically to inhibit growth of the malarial parasite.
Sulfonamidepyrimethamine combinations are highly
effective against blood schizont stages of P. falciparum
malaria, but not against gametocytes, and are less effec-
tive against other species of malaria. Both drugs are highly
protein-bound, resulting in long elimination half-lives. The
long half-life of the combination provides selective pressure
for the development of drug resistance in areas with high-
level malaria transmission, and increasing resistance to this
combination has made it ineffective for treatment and pro-
phylaxis in many parts of the world (Fig. 36-4).
Individuals infected with sensitive strains of malaria may
be treated with sulfadoxinepyrimethamine as a convenient
single dose. The most serious drug reactions involve hyper-
sensitivity to the sulfonamide component of the combination.
Severe skin reactions such as StevensJohnson syndrome or
erythema multiforme have been reported, but the incidence
of these adverse effects is rare after single-dose therapy for
malaria. Adverse hematologic effects include megaloblastic
anemia, leukopenia, and thrombocytopenia. Sulfonamide
pyrimethamine is not used as a chemoprophylactic agent
against malaria.
Proguanil
Proguanil is a derivative of pyrimidine and, like pyrimeth-
amine, is an inhibitor of dihydrofolate reductase. Proguanil
acts against the hepatic, pre-erythrocytic forms of P. falci-
parum and P. vivax. Proguanil has been used for prophy-
laxis in combination with chloroquine in areas of the world
where chloroquine resistance is not widespread. However,
other prophylactic agents are significantly more effective,
and this combination is not recommended. Proguanil may
be used in a synergistic combination with atovaquone for
both treatment and prevention of malaria (discussed above).
Proguanil is usually well tolerated, but it has been associated
with oral ulcerations, pancytopenia, thrombocytopenia, and
granulocytopenia.
Antimalarial Drug Resistance
Antimalarial drug resistance is a major public health prob-
lem and a significant barrier to the effective treatment of in-
dividuals with malaria. In association with the collapse of
effective prevention efforts, lack of political will, and socio-
economic factors, the waning efficacy of antimalarial drugs
has contributed significantly to the increasing burden of ma-
laria morbidity and mortality worldwide.
Chloroquine was the standard therapy for treating individ-
uals with malaria for many years after its introduction in 1946.
Resistance was first reported in the 1950s and has steadily
increased since then; at present, resistance has been reported
everywhere in the world except on the island of Hispaniola
and in focal parts of Central America, South America, and
Asia. The chloroquine-resistance P. falciparum haplotype
has recently been detected in Haiti, but clinical resistance
has not yet been reported. The risk of therapeutic failure
with chloroquine is over 60% in many areas of Sub-Saharan
Africa and over 80% in Southeast Asia. Childhood mortal-
ity doubled in Eastern and Southern Africa in the 1980s and
1990s as chloroquine and sulfadoxinepyrimethamine resis-
tance increased; chloroquine resistance was associated with
an overall doubling of childhood mortality from malaria,
with increases as high as 11-fold in certain areas. Similarly,
P. vivax resistance to chloroquine was unknown until 1989
but is now endemic in Indonesia and Papua New Guinea.
Reports of chloroquine-resistant P. vivax have also emerged
in South America, Brazil, Myanmar, and India.
Resistance to sulfadoxinepyrimethamine was reported
after the combination was introduced in 1971 as a second-line
therapy for treating individuals with chloroquine-resistant P.
falciparum. Resistance to sulfadoxinepyrimethamine was
initially reported in Southeast Asia but is now relatively wide-
spread in South America and prevalent in Africa as well.
Strains of P. falciparum resistant to mefloquine were noted
in Southeast Asia following the widespread introduction of this
agent in the 1980s. Mefloquine resistance has not spread more
widely as yet, in large measure due to the fact that the drug is
not now routinely used to treat individuals with malaria.
Strains of P. falciparum with relative resistance to ar-
temisinin were reported in Cambodia in 2008.
Many factors contribute to the development of drug re-
sistance by malaria parasites, including inappropriate and/or
unsupervised drug use, inconsistent drug availability, poor
adherence to treatment regimens due to adverse effects and
other factors, inconsistent quality of drug manufacturing,
presence of counterfeit drugs, and prohibitive drug costs.
Combining therapies to reduce the development of resistance
is a strategy that has long been employed in the treatment of
individuals with tuberculosis, leprosy, and HIV infection,
and this approach is strongly recommended in the treatment
of individuals with malaria. The World Health Organization
(WHO) has demanded cessation of production of all stand-
alone artemisinin products and has requested that only two-
drug, fixed-combination, artemisinin-containing products be
manufactured. Although rapidly acting artemisinins reduce
parasite burden by a factor of 104 with every treatment cycle,
resulting in rapid clearance of parasites from the bloodstream,
the short half-life of artemisinins favors the possibility of
 Nucleus Karyosome

Excretion in feces Cyst Ingestion by human

of contaminated
food or water

Pseudopodium
Encystation in Excystation in
colon small intestine

Nucleus

Vacuole

Trophozoite

Asymptomatic Intestinal Intestinal perforation

colonization amebiasis and/or liver abscess
 PFOR-dependent Nitroreductase-dependent
activation activation

Pyruvate Reduced
Ferredoxin metronidazole NADP+
(active)
PFOR Nitroreductase
Reduced
ferredoxin Metronidazole NADPH
Acetyl CoA (inactive)

ADHE

Ethanol Acetate
 Stratum corneum

Epidermis

Dermis

Adult filaria

Subcutaneous nodule
Subcutaneous
Fat cells space

Microfilaria
(in tissues)

Ivermectin

Corneal inflammation with Dermatitis

sclerosing keratitis

 CONCLUSION AND FUTURE DIRECTIONS
The development of new antiparasitic agents will rely on
continued exploitation of molecular and metabolic differ-
ences between parasites and hosts. Recent advances in the
application of molecular biological and genetic techniques
to study parasitic eukaryotes, and detailed knowledge of
parasite, vector, and host genomes, transcriptomes, and pro-
teomes, should facilitate the development of more selective
agents effective against many parasitic infections. The de-
velopment of resistance to antiparasitic agents is of increas-
ing concern, most notably among malarial and leishmanial
parasites, and will necessitate both the judicious use of cur-
rently available agents and the development of new agents,
including antiparasitic vaccines.
Despite long-standing efforts to develop effective treat-
ments for malaria, the disease remains a major global cause
of morbidity and mortality. Development of an effective
malaria vaccine could have a major impact on this global
burden. However, the development of an effective vaccine
has been hampered by a number of difficult scientific chal-
lenges, including the diversity of parasite species and strains,
the diversity of parasite life forms, the intracellular loca-
tion of the parasites, and the ability of P. falciparum to un-
dergo antigenic variation. The situation has been worsened
by the lack of meaningful economic incentives for vaccine
CHAPTER 36 / Pharmacology of Parasitic Infections 643
development. Unfortunately, the complexity of the parasites
and of their intimate relationship with infected hosts sug-
gests that the development of effective antiparasite vaccines
(especially against malaria) will be difficult.
Suggested Reading
Anderson VR, Curran MP. Nitazoxanide: a review of its use in the treatment
of gastrointestinal infections. Drugs 2007;67:19471967. (Reviews antipar-
asitic and antianaerobic bacterial properties of this interesting agent.)
Hoerauf A. Filariasis: new drugs and new opportunities for lymphatic fi-
lariasis and onchocerciasis. Curr Opin Infect Dis 2008;6:673681. (Reports
antibacterial treatment targeting endosymbionts for filarial infections.)
Noedl H, Se Y, Schaecher K, Smith BL, Socheat D, Fukuda MM. Evi-
dence of artemisinin-resistant malaria in western Cambodia. Artemisi-
nin Resistance in Cambodia 1 (ARC1) Study Consortium. N Engl J Med
2008;359:26192620. (Reports disturbing harbinger of resistance to ar-
temisinin derivatives.)
Nosten F, White NJ. Artemisinin-based combination treatment of falci-
parum malaria. Am J Trop Med Hyg 2007;77(6 Suppl):181192. (Reviews
artemisinin combination treatment of malaria.)
Omura S. Ivermectin: 25 years and still going strong. Int J Antimicrob
Agents 2008;3:9198. (Reviews a major antiparasitic agent with a num-
ber of uses.)
Whitty CJ, Chandler C, Ansah E, Leslie T, Staedke SG. Deployment of
ACT antimalarials for treatment of malaria: challenges and opportunities.
Malar J 2008;7(Suppl 1):S7. (Addresses challenges of delivering artemisi-
nin combination treatment courses.)

Pharmacology of
Viral Infections
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 649-650
PHYSIOLOGY OF VIRAL REPLICATION . . . . . . . . . . . . . . . . . 649
Viral Life Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 650
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 651
Inhibition of Viral Attachment and Entry . . . . . . . . . . . . . . 651
Maraviroc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 651
Enfuvirtide (T-20) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 652
Inhibition of Viral Uncoating . . . . . . . . . . . . . . . . . . . . . . . 653
Inhibition of Viral Genome Replication . . . . . . . . . . . . . . . 655
Antiherpesvirus Nucleoside and Nucleotide
Analogues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 655
Anti-HIV and -HBV Nucleoside
and Nucleotide Analogues . . . . . . . . . . . . . . . . . . . . . . 659
Nonnucleoside DNA Polymerase Inhibitors . . . . . . . . . 661
 INTRODUCTION
Viral infections are among the leading causes of morbidity
and mortality worldwide. Although progress has been made
on antiviral drug development, public health measures and
prophylactic vaccines remain the primary means by which
society controls the spread of viral infections. The persis-
tence of the acquired immunodeficiency syndrome (AIDS)
epidemic makes this painfully clear. Despite advances in
anti-HIV drug therapies, AIDS continues to be a common
cause of death, particularly in some African nations, where
as many as one person in five is infected with the human
immunodeficiency virus (HIV). This enormous prevalence
is largely attributable to failures in public health measures
and the lack of an effective vaccine against HIV, in a setting
where anti-HIV drugs are too expensive.
Despite this bleak statistic, the array of drugs available to
combat viruses has been instrumental in saving millions of
lives each year and in improving the quality of life for count-
less others with viral illnesses. This chapter describes the
physiology of viral replication and the steps in the viral life
cycle that are targeted by current antiviral medications. Key
concepts for the chapter include: (1) viruses replicate intra-
cellularly by utilizing host cell machinery; (2) despite this
mode of replication, a number of potential targets have been
exploited for antiviral drug therapy; and (3) most current
37
Robert W. Yeh and Donald M. Coen
Nonnucleoside Reverse Transcriptase
Inhibitors (NNRTIs) . . . . . . . . . . . . . . . . . . . . . . . . . . . 661
HIV Integrase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . 661
Inhibition of Viral Maturation . . . . . . . . . . . . . . . . . . . . . . 662
Inhibition of Viral Release . . . . . . . . . . . . . . . . . . . . . . . . . 664
Antiviral Drugs with Unknown
Mechanisms of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . 665
Fomivirsen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665
Docosanol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 667
Ribavirin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 667
Drugs That Modulate the Immune System . . . . . . . . . . . . 668
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 669
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 669
antiviral drugs exploit differences between the structures
and functions of viral and human proteins to achieve selec-
tivity of antiviral action.
 PHYSIOLOGY OF VIRAL REPLICATION
Viruses replicate by co-opting the host cells metabolic ma-
chinery. As a result, there are fewer differences between vi-
ruses and their human hosts to exploit for drug development
than between bacteria and humans. It is also more difficult
to develop agents that are active against a broad spectrum of
viruses than it is against bacteria. This difficulty arises be-
cause viruses are a heterogeneous group of infectious agents,
whereas most bacteria share a common cell wall structure
and distinct transcriptional and translational machinery.
Despite these obstacles, all viruses encode proteins that
are substantially different from their human counterparts.
Additionally, certain host proteins are more important for
viral replication than they are for human health. In principle,
antiviral drugs could target many of these proteins. In prac-
tice, however, relatively few viral proteins and even fewer
host proteins have thus far served as useful targets for therapy.
Nevertheless, it is a testament to the remarkable progress in
antiviral drug development that more viral proteins have been
exploited for antiviral therapy than the number of bacterial
proteins that have been exploited for antibacterial therapy.
649
 CHAPTER 37 / Pharmacology of Viral Infections 651

Virus

Receptor
Attachment and entry inhibitors
Maraviroc Attachment and entry
Enfuvirtide (T-20) Host cell

Ion channel blockers

Amantadine Uncoating
Rimantadine

Polymerase inhibitors
Acyclovir Genome replication
Zidovudine
Efavirenz

RNA synthesis
Integrase inhibitors
Raltegravir Host ribosome Protein synthesis

Assembly and maturation

Protease inhibitors
Saquinavir
Ritonavir Egress and release

Neuraminidase inhibitors
Zanamivir
Oseltamivir

FIGURE 37-1. Viral life cycle and pharmacologic intervention. The viral life cycle can be divided into a sequence of individual stages, each of which is a potential
site for pharmacologic intervention. Shown is a generic replication cycle of viruses in cells, alongside which are listed the names of drug classes and examples of indi-
vidual agents that block each stage. Many of the currently approved antiviral agents are nucleoside analogues that target genome replication, typically by inhibiting viral
DNA polymerase or reverse transcriptase. Several other drug classes target other stages in the viral life cycle, including attachment and entry, uncoating, assembly and
maturation, and egress and release. It should be noted that the details of viral replication differ for each type of virus, often presenting unique targets for pharmacologic
intervention and drug development.

typically involves cleavage of viral polyproteins by pro-
teases. For some viruses, maturation occurs within the host
cell; for others, such as HIV, it occurs outside the host cell.
Viruses egress from the cell either by cell lysis or by bud-
ding through the cell membrane. For influenza viruses, the
newly formed virions require an additional step of release
from the extracellular surface of the host cell membrane.
In summary, nearly all viruses replicate via the follow-
ing stages: attachment, entry, uncoating, genome replication,
transcription, translation, assembly, and egress. Some viruses
have additional stages such as maturation and release. The
stages of retrovirus infection occur in a different order from
those of most other viruses, and retroviruses have additional
stages in their life cycle. For example, replication of HIV in-
cludes the additional stage of integration, in which the viral
genome is incorporated into the host genome (Fig. 37-2).
Specific host and/or viral proteins are involved in each of
these stages. Differences between viral and host proteins at
any of these stages can be targeted for antiviral therapy.
Different viruses have vastly different arrays of genes.
Some, such as hepatitis B virus (HBV), have compact ge-
nomes that encode only coat proteins and a few proteins used
in gene expression and genome replication. Others, such as
herpesviruses, encode scores of proteins that perform many
different functions. The viral proteins that have thus far served
as the best targets for antiviral drugs are enzymes involved in
genome replication or maturation, although other stages in the
viral life cycle can also serve as targets for antiviral agents.
 PHARMACOLOGIC CLASSES AND AGENTS
Inhibition of Viral Attachment and Entry
All viruses must infect cells to replicate. Therefore, inhibit-
ing the initial stages of viral attachment and entry provides a
conceptual preventive measure against infection and could
limit the spread of virus throughout the body. Two anti-HIV
drugs, maraviroc and enfuvirtide (T-20), act at these stages.
Both drugs have unusual properties for antiviral drugs: mar-
aviroc targets a host protein rather than a viral protein, and
enfuvirtide is a peptide.
Maraviroc
Maraviroc targets the chemokine receptor CCR5. The devel-
opment of maraviroc stemmed from clinical studies of indi-
viduals who had been exposed repeatedly to HIV, yet did not
develop AIDS. It was found that some of these individuals
652 Principles of Chemotherapy

1 Attachment 2 Fusion
HIV
ssRNA

gp120

gp41
Protease

Matrix protein
Chemokine
Integrase
receptor
Core protein CD4

Reverse transcriptase
3 Reverse
transcription

DNA

Integrase
5 Transcription
4 Integration

RNA (genomic and mRNA)

Protease 6 Translation
Integrase

Core protein

Reverse transcriptase

7 Virion assembly
and budding

8 Maturation
(Protease)

FIGURE 37-2. Life cycle of HIV. HIV is a retrovirus that infects CD4 cells. 1. Virus attachment is dependent on binding interactions between viral gp41 and gp120
proteins and host cell CD4 and certain chemokine receptors. 2. Fusion of the viral membrane (envelope) with the host cell plasma membrane allows the HIV genome
complexed with certain virion proteins to enter the host cell. 3. Uncoating permits the single-stranded RNA (ssRNA) HIV genome to be copied by reverse transcriptase
into double-stranded DNA. 4. The HIV DNA is integrated into the host cell genome, in a reaction that depends on HIV-encoded integrase. 5. Gene transcription and post-
transcriptional processing by host cell enzymes produce genomic HIV RNA and viral mRNA. 6. The viral mRNA is translated into proteins on host cell ribosomes. 7. The
proteins assemble into immature virions that bud from the host cell membrane. 8. The virions undergo proteolytic cleavage, maturing into fully infective virions. Currently
approved anti-HIV drugs target viral attachment and fusion, reverse transcription, integration, and maturation. The development of drug resistance can be significantly
retarded by using combinations of drugs that target a single stage (e.g., two or more inhibitors of reverse transcription) or more than one stage in the HIV life cycle (e.g.,
reverse transcriptase inhibitors and protease inhibitors).

have a deletion in the CCR5 gene. Absence of the CCR5
gene product prevents infection by the strains of HIV that
are most frequently transmitted between individuals. The de-
letion otherwise has little negative impact on human health.
Drug companies then performed screens for compounds that
could prevent binding of chemokines to CCR5 and chemi-
cally modified the leading candidate compounds to optimize
their pharmacodynamic and pharmacokinetic properties.
(Such target-based screens had earlier achieved success
in the development of anti-HIV nonnucleoside reverse tran-
scriptase inhibitors; see Box 37-2.) Maraviroc, the end re-
sult of this process, blocks infection of HIV strains that use
CCR5 for attachment and entry (Fig. 37-3). However, mara-
viroc is not active against HIV strains that use the CXCR4
receptor. It is approved for use in combination with other
anti-HIV drugs in patients who have continued detectable
viral loads or who have multidrug-resistant virus.
Enfuvirtide (T-20)
Enfuvirtide is a peptide that is structurally similar to a seg-
ment of gp41, the HIV protein that mediates membrane fusion.
The proposed mechanism for gp41-mediated membrane fu-
sion and T-20 action is illustrated in Figure 37-3. In the native
virion, gp41 is held in a conformation that prevents it from
fusing membranes or binding T-20. Attachment of HIV to its
cellular receptors triggers a conformational change in gp41
that exposes a segment that can insert into membranes (fusion
peptide), a heptad repeat region (HR1), and a second heptad
 CHAPTER 37 / Pharmacology of Viral Infections 653

G CCR5 Maraviroc F F

O NH

N
N
N
N
Maraviroc

CCR5 blocked by maraviroc

Host cell
plasma membrane
A Chemokine B Fusion peptide F Enfuvirtide (T-20)
CD4 receptor

gp120 HR1

gp41
gp41 HR2

Viral membrane Intermediate Trapped intermediate

(envelope)

C D E

Hemifusion stalk Fusion pore

FIGURE 37-3. Model for HIV gp41-mediated fusion and maraviroc and enfuvirtide (T-20) action. A. HIV glycoproteins exist in trimeric form in the viral mem-
brane (envelope). Each gp120 molecule is depicted as a ball attached noncovalently to gp41. B. The binding of gp120 to CD4 and certain chemokine receptors in the
host cell plasma membrane causes a conformational change in gp41 that exposes the fusion peptide, heptad-repeat region 1 (HR1) and heptad-repeat region 2 (HR2).
The fusion peptide inserts into the host cell plasma membrane. C. gp41 undergoes further conformational changes, characterized mainly by unfolding and refolding
of the HR2 repeats. D. Completed refolding of the HR regions creates a hemifusion stalk, in which the outer leaflets of the viral and host cell membranes are fused.
E. Formation of a complete fusion pore allows viral entry into the host cell. F. Enfuvirtide (T-20) is a synthetic peptide drug that mimics HR2, binds to HR1, and prevents
the HR2HR1 interaction (dashed arrow). Therefore, the drug traps the virushost cell interaction at the attachment stage, preventing membrane fusion and viral entry.
G. Maraviroc is a small-molecule antagonist of the CCR5 chemokine receptor; the drug blocks cellular infection of HIV strains that use CCR5 for attachment and entry
(dashed arrow). The structure of maraviroc is shown.

repeat region mimicked by T-20 (HR2). The gp41 then refolds,
so that the HR2 segments bind directly to the HR1 segments. If
the fusion peptide has properly inserted into the host cell mem-
brane, this refolding brings the virion envelope and the cell
membrane into close proximity, allowing membrane fusion to
occur (by mechanisms that remain poorly understood). When
T-20 is present, however, the drug binds to the exposed HR1
segments and prevents the refolding process, thereby prevent-
ing fusion of the HIV envelope with the host cell membrane.
Enfuvirtide is approved for use in combination with other
anti-HIV drugs in patients whose HIV infection has not
been controlled by first-line anti-HIV medications. Because
enfuvirtide is a peptide, it must be administered parenterally,
typically by twice daily subcutaneous injections.
Inhibition of Viral Uncoating
The adamantanes, amantadine and rimantadine (structures
in Fig. 37-4) are inhibitors of viral uncoating that are active
exclusively against influenza A virus (and not against influ-
enza B or C viruses).
A well-supported model for the mechanism of action
of these drugs is diagrammed in Figure 37-4. Influenza vi-
rions enter cells via receptor-mediated endocytosis and are
654 Principles of Chemotherapy

ADP Viral membrane

NA
H+ M2
HA bound CH3
ATP to sialic acid on
cell receptor CHNH2
Matrix protein
NH2
Internalized
cell receptor
RNP

Amantadine Endosomal Rimantadine

membrane

Early endosome

Low pH Low pH + amantadine or rimantadine

ADP ADP
Amantadine or
H+ H+ rimantadine
H+
ATP Acid-induced ATP H+
dissociation of
matrix structure H+ H+

H+
H+ H+ H+
H+
H+
H+ H+ H+
H+ H+ H+
H+ H+
RNP released
M2 channel opens to from endosome
permit entry of protons

Acid-induced structural change Late endosome

in HA triggers membrane fusion

FIGURE 37-4. Uncoating of influenza virus and effect of amantadine and rimantadine. The structures of the adamantanes, amantadine and rimantadine,
are shown. Influenza virus enters host cells by receptor-mediated endocytosis (not shown) and is contained within an early endosome. The early endosome contains
an H-ATPase that acidifies the endosome by pumping protons from the cytosol into the endosome. A low pH-dependent conformational change in the viral envelope
hemagglutinin (HA) protein triggers fusion of the viral membrane with the endosomal membrane. Fusion alone is not sufficient to cause viral uncoating, however. In
addition, protons from the low-pH endosome must enter the virus through M2, a pH-gated proton channel in the viral envelope that opens in response to acidification.
The entry of protons through the viral envelope causes dissociation of matrix protein from the influenza virus ribonucleoprotein (RNP), releasing RNP and thus the genetic
material of the virus into the host cell cytosol. Amantadine and rimantadine block M2 ion channel function and thereby inhibit acidification of the interior of the virion,
dissociation of matrix protein, and uncoating. Note that the drug is shown as plugging the channel (lower right panel, upper channel graphic); however, there is also
evidence that the drug may bind to the outside of the channel instead (lower right panel, lower channel graphic). NA, neuraminidase.

internalized into endosomes (see Chapter 1, DrugReceptor
Interactions). As endosomes acidify because of the action
of an endosomal proton pump, two events occur. First, the
conformation of the viral envelope protein hemagglutinin
changes drastically. This conformational change permits
fusion of the influenza virus envelope with the endosome
membrane (see the above discussion of HIV-mediated mem-
brane fusion). By itself, this action could liberate viral ribo-
nucleoprotein (including the virions RNA genome), but that
would not be sufficient to permit its transcription: a second
pH-dependent event within the virion is also required. This
entails the influx of protons through a proton channel called
M2 in the viral envelope, which causes dissociation of the
virion matrix protein from the rest of the ribonucleoprotein.
Amantadine and rimantadine inhibit the influx of protons
through M2. Exactly how this inhibition occurs is not clear.
As hydrophobic molecules with a positive charge at one end,
these drugs resemble blockers of cellular ion channels (see
Chapters 11 and 23). However, the currently available data
are controversial regarding the details of how the adaman-
tanes block the M2 channel. One set of studies has been
interpreted to support a model in which the adamantanes
simply plug (physically occlude) the channel. The other
set of studies supports a model in which the drugs bind to
the outside of the channel and allosterically prevent it from
opening.
Amantadine can cause lightheadedness and difficulty con-
centrating; these adverse effects are likely due to its effects on
host ion channels. Indeed, the unintended effects of amantadine
on host channels likely account for this drugs other therapeu-
tic usethe treatment of Parkinsons disease (see Chapter 13,
Pharmacology of Dopaminergic Neurotransmission). Riman-
tadine is an analogue of amantadine that has a similar antiviral
mechanism and has gained much wider use than amantadine in
656 Principles of Chemotherapy

A Native nucleosides
NH2 O NH2 O

N N
N NH N NH
HO N HO
N N N NH2 HO HO N O
N O
O O
O O

OH OH
OH OH
Deoxyadenosine Deoxyguanosine Deoxycytidine Deoxythymidine

O O
B Antiherpesvirus nucleoside and nucleotide analogues
N N
NH NH
O O
HO O
N N N NH2 H2N N N NH2
N NH O O
NH O
HO O
N H2N N N NH2
N NH2 O
O
O OH OH
Acyclovir Valacyclovir Ganciclovir Valganciclovir
(prodrug) (prodrug)

N NH2
O N
O
N N N
NH N NH2
HO O
N OH N O
N NH2
P O
O HO
O
OH O HO
Penciclovir Famciclovir Cidofovir
(prodrug)

C Anti-HIV nucleoside and nucleotide analogues

O O NH2 NH2 NH2

F
NH NH N N N

HO HO HO HO N O HO
N O N O N O N O
O O O S S

O O
N3
Zidovudine (AZT) Stavudine (d4T) Zalcitabine (ddC) Lamivudine (3TC) Emtricitabine (FTC)

NH2

N
N
O NH
O O N N
N N
NH N P O
HO O O O
HO N O O O
N N N NH2
O
O
Didanosine (ddI) Abacavir Tenofovir disoproxil

D Anti-hepatitis B nucleoside and nucleotide analogues E Anti-RNA virus nucleoside analogue

O
NH2 O

N N N NH2
N NH
N
HO
N
O N N CH2 N N NH2 O
P O
HO
OH OH OH

Adefovir HO Entecavir Ribavirin

HO

FIGURE 37-5. Antiviral nucleoside and nucleotide analogues. A. The nucleosides used as precursors for DNA synthesis are depicted in their anti conformations.
Each nucleoside consists of a purine (adenine and guanine) or pyrimidine (cytosine and thymidine) base attached to a deoxyribose sugar. These deoxynucleosides are
phosphorylated in stepwise fashion to the triphosphate forms (not shown) for use in nucleic acid synthesis. B. Except for cidofovir, the antiherpesvirus nucleoside and
nucleotide analogues are structural mimics of deoxyguanosine. For example, acyclovir consists of a guanine base attached to an acyclic sugar. Cidofovir, which mimics
the deoxynucleotide deoxycytidine monophosphate, uses a phosphonate (CP) bond to mimic the physiologic PO bond of the native nucleotide. Valacyclovir, famciclovir,
and valganciclovir are more orally bioavailable prodrugs of acyclovir, penciclovir, and ganciclovir, respectively. C. Anti-HIV nucleoside and nucleotide analogues mimic a
variety of endogenous nucleosides and nucleotides and contain variations not only in the sugar but also in base moieties. For example, AZT is a deoxythymidine mimic
that has a 3-azido group in place of the native 3-OH. Stavudine, zalcitabine, and lamivudine also contain modified sugar moieties linked to natural base moieties.
Tenofovir, which is shown as its prodrug tenofovir disoproxil, is a phosphonate analogue of deoxyadenosine monophosphate. Of the analogues that contain modified
base moieties, didanosine mimics deoxyinosine and is converted to dideoxyadenosine, while emtricitabine contains a fluoro-modified cytosine and abacavir contains a
cyclopropyl-modified guanine. D. Adefovir is a phosphonate analogue of the endogenous nucleotide deoxyadenosine monophosphate, while entecavir is a deoxyguanos-
ine analogue with an unusual moiety substituting for deoxyribose. These two compounds and lamivudine (see panel C) are approved for use in the treatment of HBV
infection. E. Ribavirin, which contains a purine mimic attached to ribose, is approved for use against the RNA viruses HCV and RSV.
 CHAPTER 37 / Pharmacology of Viral Infections 657

A O
O N
NH
N
NH HSV or VZV
thymidine kinase N N NH2
OH
N N NH2 HO O
P O
HO
O O
Acyclovir Acyclovir monophosphate

Cellular kinase

O O

N N
NH NH

N N NH2 N N NH2
OH OH OH Cellular kinase OH OH
HO O O O HO O O
P P P O P P O
O O O O O
Acyclovir triphosphate (pppACV) Acyclovir diphosphate

Viral DNA polymerase

B pppACV ACV ACV

pppdG

pppdC

dC dG dC dG dC dG

1 2 3
Binding of pppACV to viral ACV is incorporated into When the next deoxynucleoside
DNA polymerase competes growing DNA chain, blocking triphosphate binds, viral DNA
for binding of pppdG. further chain growth. polymerase is "frozen."

FIGURE 37-6. Mechanism of action of acyclovir. A. Acyclovir is a nucleoside analogue that is selectively phosphorylated by HSV or VZV thymidine kinase
to generate acyclovir monophosphate. Host cellular enzymes then sequentially phosphorylate acyclovir monophosphate to its diphosphate and triphosphate
(pppACV) forms. B. Acyclovir triphosphate has a three-step mechanism of inhibition of herpesvirus DNA polymerase in vitro: (1) it acts as a competitive inhibi-
tor of dGTP (pppdG) binding; (2) it acts as a substrate and is base-paired with dC in the template strand to become incorporated into the growing DNA chain,
causing chain termination; and (3) it traps the polymerase on the ACV-terminated DNA chain when the next deoxyribonucleoside triphosphate (shown here as
dCTP, or pppdC ) binds.

Next, ACV triphosphate acts as a substrate and is incorpo-
rated into the growing DNA chain opposite a C residue. The
polymerase translocates to the next position on the template
but cannot add a new deoxyribonucleoside triphosphate be-
cause there is no 3-hydroxyl on ACV triphosphate; hence,
ACV triphosphate is also a chain terminator. Finally, provided
that the next deoxyribonucleoside triphosphate is present, the
viral polymerase freezes in a dead-end complex, leading to
apparent inactivation of the enzyme (Fig. 37-6B). (The mech-
anism of polymerase freezing remains unknown.) Interest-
ingly, cellular DNA polymerase does not undergo inactiva-
tion to the dead-end complex. It is not yet known whether the
inactivating step is important in vivo, or whether ACV incor-
poration and chain termination are sufficient to inhibit viral
replication. Regardless, studies of ACV-resistance mutations
in the viral DNA polymerase gene show that the effects of
ACV triphosphate on viral polymerase constitute a major
component of acyclovir selectivity.
All acyclovir-resistant mutants studied to date contain
mutations in the thymidine kinase (TK) gene, the DNA poly-
merase gene, or both. Because TK is not essential for virus
replication in cell culture, mutations that completely or par-
tially inactivate the enzyme do not prohibit virus replication.
Also, some TK mutations render the enzyme incapable of
658 Principles of Chemotherapy
phosphorylating acyclovir while permitting the phosphoryla-
tion of thymidine. Because DNA polymerase is essential for
virus replication, resistance mutations do not inactivate but
instead only alter this enzyme, so that higher concentrations
of ACV triphosphate are required to inhibit the enzyme.
Clinically, acyclovir-resistant HSV is mainly a problem
in immunocompromised hosts. In animal models of HSV
infection, acyclovir-resistant mutants are frequently found
to have reduced pathogenicity, but the degree of attenuation
depends greatly on the type of mutation. These studies sug-
gest that there are multiple mechanisms by which the virus
can mutate to retain both drug resistance and pathogenicity.
Valacyclovir is a prodrug form of acyclovir that has ap-
proximately fivefold greater oral bioavailability than acyclo-
vir (Fig. 37-5). This compound, which contains an acyclovir
structure covalently attached to a valine moiety, is rapidly
converted to acyclovir after oral administration.
Famciclovir and Penciclovir
Famciclovir (Fig. 37-5) is the diacetyl 6-deoxy analogue of
penciclovir, the active form of the drug. Famciclovir is well
absorbed orally and subsequently modified by an esterase
and an oxidase to yield penciclovir. In humans, this results
in approximately 70% oral bioavailability. Like acyclovir,
the structure of penciclovir consists of a guanine linked to an
acyclic sugar-like molecule that lacks a 2' CH2 moiety.
Penciclovirs mechanism of action is similar to that of
acyclovir (Fig. 37-6), with only quantitative differences de-
tected by both biochemical assays and analyses of resistant
mutants. Penciclovir is more efficiently activated by HSV
and VZV TK than is acyclovir, but penciclovir triphosphate
is a less selective inhibitor of the viral DNA polymerases than
is ACV triphosphate. Famciclovir is used in the treatment of
HSV infections and shingles (which is caused by reactivation
of VZV), and penciclovir ointment is used to treat cold sores
caused by HSV.
Ganciclovir
Human CMV infections are inapparent in most adults, but
CMV can cause life-threatening diseases such as pneumonia
or sight-threatening retinitis in immunocompromised indi-
viduals. CMV is much less sensitive to acyclovir than are
HSV and VZV, primarily because much less phosphorylated
acyclovir accumulates in CMV-infected cells than in HSV-
or VZV-infected cells. Ganciclovir is a nucleoside analogue
that was originally synthesized as a derivative of acyclovir
with the intention of developing another anti-HSV drug, but
it proved too toxic for that indication. It turned out, however,
that ganciclovir is much more potent than acyclovir against
CMV, and ganciclovir was the first antiviral drug approved
for use against CMV.
Like acyclovir, ganciclovir contains a guanine linked to an
acyclic sugar-like molecule that lacks a 2' moiety. However,
ganciclovir contains the 3' CHOH group that is missing in acy-
clovir (Fig. 37-5). Thus, ganciclovir more closely resembles
the natural compound, deoxyguanosine, and this resemblance
may account for its greater toxicity. (In fact, ganciclovir is so
toxic that it should be used only for serious infections.)
CMV does not encode a homolog of the HSV TK (which
phosphorylates ganciclovir very efficiently). However, ge-
netic studies have revealed the existence of a viral protein
kinase called UL97 that phosphorylates ganciclovir, lead-
ing to a 30-fold increase in the amount of phosphorylated
ganciclovir in infected cells compared to uninfected cells.
Ganciclovir triphosphate inhibits CMV DNA polymerase
more potently than it does cellular DNA polymerases. Thus,
as with acyclovir and HSV, ganciclovir is selective against
CMV at two steps: phosphorylation and DNA polymeriza-
tion. However, the selectivity against CMV at each step
is not as great as the selectivity of acyclovir against HSV;
accordingly, the drug is more toxic than acyclovir. Toxicity
is most commonly manifested as bone marrow suppression,
especially neutropenia. Ganciclovir resistance is a clinical
problem in a substantial fraction of patients.
Valganciclovir is a prodrug form of ganciclovir that has
greater oral bioavailability than ganciclovir. Valganciclovir
is a valine ester of ganciclovir, making the relationship be-
tween valganciclovir and ganciclovir similar to that between
valacyclovir and acyclovir (Fig. 37-5).
Cidofovir
Also known as hydroxyphosphonylmethoxypropylcytosine
(HPMPC), this phosphonate-containing acyclic cytosine an-
alogue represents a twist on the mechanism of action of an-
tiherpesvirus nucleoside analogues. Indeed, cidofovir can be
considered a nucleotide rather than a nucleoside analogue.
With its phosphonate group, cidofovir mimics deoxycyti-
dine monophosphate; thus, in effect, it is already phosphory-
lated (Fig. 37-5). Therefore, cidofovir does not require viral
kinases for its phosphorylation, and, accordingly, it is ac-
tive against kinase-deficient viral mutants that are resistant
to ganciclovir. Although cidofovir structurally resembles a
phosphorylated compound, this drug enters cells with rea-
sonable efficiency. It is further phosphorylated (twice) by
cellular enzymes to yield an analogue of dCTP, which in-
hibits herpesvirus DNA polymerases more potently than
cellular DNA polymerases. Selectivity has been confirmed
by mapping cidofovir-resistance mutations to the DNA poly-
merase gene in CMV.
Cidofovir is approved for use in the treatment of CMV
retinitis in patients with HIV/AIDS. Cidofovir diphosphate
has a long intracellular half-life. Therefore, its use requires
relatively infrequent dosing (only once each week or less).
Because of its mechanism of renal clearance, cidofovir must
be co-administered with probenecid. (Probenecid inhibits
a proximal tubule anion transporter and thereby decreases
cidofovir excretion.) Nephrotoxicity is a major problem, and
great care must be taken in administering this drug.
Two related phosphonate-containing drugs are the acyclic
deoxyadenosine monophosphate analogues tenofovir and
adefovir (Fig. 37-5). Tenofovir, which was approved as an
anti-HIV drug in 2001, can be administered just once each
day, an important advantage for HIV-infected individuals
who must comply with complex combination chemotherapy
regimens. Adefovir was approved as an anti-HBV drug in
2002. The mechanisms of action of these drugs against their
respective viruses are similar to that of cidofovir against
CMV. (See discussions below of HIV and HBV replication,
and of other drugs active against these viruses.)
Other Antiherpesvirus Nucleoside Analogues
Several other nucleoside analogues with antiherpesvirus ac-
tivity were developed and approved before the development
of acyclovir. These agents have greater toxicity than acy-
clovir, and so are not widely used, but are listed in the Drug
Summary Table.
 CHAPTER 37 / Pharmacology of Viral Infections 661

is a potent inhibitor of the HBV polymerase. Two other anti- O

HBV drugs are adefovir and entecavir (Fig. 37-5).
HN
Nonnucleoside DNA Polymerase Inhibitors
Nucleoside analogues can inhibit cellular as well as viral en- O
zymes. As a result, efforts have been made to discover com-
P OH N
pounds with different structures that can selectively target N N
viral enzymes. The first such compound to be used clinically HO
OH
was foscarnet (phosphonoformic acid [PFA]; Fig. 37-7). O
Foscarnet inhibits both DNA and RNA polymerases encoded
by a wide variety of viruses. It has a relatively broad spec- Foscarnet Nevirapine
trum of activity in vitro (including against HIV), but clini-
cally, it is used for certain serious HSV and CMV infections NH2
where therapy with acyclovir or ganciclovir has not succeeded N
(e.g., because of resistance). It should also be noted that some Br
acyclovir-resistant and ganciclovir-resistant polymerase mu- N
tants exhibit at least moderate resistance to foscarnet.
Mechanistically, foscarnet differs from nucleoside ana- N N O
logues in that it does not require activation by cellular or H
viral enzymes; rather, foscarnet inhibits viral DNA poly-
merase directly by mimicking the pyrophosphate product of
DNA polymerization. Selectivity results from the increased
sensitivity of viral DNA polymerase relative to cellular en-
zymes; this biochemical result was confirmed by the exis- Etravirine
tence of foscarnet-resistant DNA polymerase mutants. As
might be expected of a compound that so closely mimics a N
natural compound (pyrophosphate), foscarnets selectivity is
not as high as acyclovirs; it inhibits cell division at concen-
trations not much higher than its effective antiherpesvirus N
concentration. Major drawbacks to foscarnet use include its
lack of oral bioavailability and its poor solubility; renal im-
pairment is its major dose-limiting toxicity. N HN

Nonnucleoside Reverse Transcriptase Inhibitors (NNRTIs) O H

The nonnucleoside reverse transcriptase inhibitors (NNRTIs) N N
efavirenz, nevirapine, delavirdine, and etravirine were S
developed using the rational approach of target-based, high- O
throughput screening (Box 37-2 and Fig. 37-7). Indeed, the N O
H
NNRTIs were among the first successes of this now widely
used approach. Unlike the nucleoside analogues, these drugs Delavirdine
inhibit their target directly, without the need for chemical
modification. X-ray crystallographic studies have shown that
NNRTIs bind near the catalytic site of RT. NNRTIs permit
RT to bind a nucleoside triphosphate and primer template, but
inhibit the joining of the two. The NNRTIs are orally bioavail- F3C
able, and their adverse effects (most commonly, rash) are typi-
Cl
cally less serious than those of foscarnet and most nucleoside O
analogues. The main limitation of NNRTI use is that resistance
develops rapidly, requiring the use of these drugs in combi-
nation with other anti-HIV drugs (Box 37-1). One NNRTI, N O
H
efavirenz, was the first anti-HIV drug to be taken once a day.
In 2006, a single pill combining efavirenz, tenofovir, and FTC Efavirenz
was approved by the FDA for once-a-day administration. FIGURE 37-7. Nonnucleoside DNA polymerase and reverse transcriptase
inhibitors. Foscarnet is a pyrophosphate analogue that inhibits viral DNA and RNA
HIV Integrase Inhibitors polymerases. Foscarnet is approved for the treatment of HSV and CMV infections
Integrase, the enzyme that carries out HIV genome integration, that are resistant to antiherpesvirus nucleoside analogues. The nonnucleoside
is an essential enzyme for HIV genome replication. Integrase reverse transcriptase inhibitors (NNRTIs) efavirenz, nevirapine, delavirdine, and
assembles onto sequences at the ends of HIV DNA, cleaves etravirine inhibit HIV-1 reverse transcriptase. The NNRTIs are approved in combi-
dinucleotides from each 3' strand, transfers these strands to nation with other antiretroviral drugs for the treatment of HIV-1 infection. Note that
target (cellular) DNA, and covalently ligates the HIV DNA the structures of the NNRTIs are significantly different from those of the anti-HIV
to target DNA (Fig. 37-8). Scientists developed an assay for nucleoside and nucleotide analogues (compare with Fig. 37-5).
inhibition of the DNA strand transfer reaction of integrase,
and this assay was used to screen for active compounds.
 CHAPTER 37 / Pharmacology of Viral Infections 663

HIV DNA

CAGT3' 5'ACTG
GTCA5' 3'TGAC
5'LTR 3'LTR

3' end processing

CA3' 5'ACTG
GTCA5' 3'AC
5'LTR 3'LTR

Strand transfer Raltegravir

Target (cellular) DNA
p VWXYZ
VWXYZ p

'A 5
C TG CAVWXYZ
VWXYZAC GTCA
5'
5'LTR 3'LTR
Repair/ligation

VWXYZTG CAVWXYZ
VWXYZAC GTVWXYZ
5'LTR 3'LTR

B
D D E

N-terminal zinc- Core domain C-terminal

finger domain domain

C O-K+ F
N
N N
H H
N N
O N

O O

Raltegravir

FIGURE 37-8. Integration of HIV DNA into cellular DNA and effect of anti-HIV integrase inhibitor. A. Schematic rendering of the action of HIV integrase.
Double-stranded HIV DNA is generated by reverse transcription as a blunt-ended, linear molecule with repeated sequences known as long terminal repeats (LTR) at
both ends. The 5 LTR includes the promoter/enhancer for HIV transcription, and the 3 LTR includes the polyadenylation signal. At the termini of both LTRs are identical
sequences of four base pairs. In the first step of integration (3 end processing), HIV integrase removes the two terminal nucleotides from the 3 strands from both ends
of the viral DNA, resulting in two-base (AC), 5 overhangs. In the second step (strand transfer), integrase creates a staggered cleavage of host DNA, and then catalyzes
the attack of the 3 OH ends of the viral DNA on phosphodiester bonds in the host DNA, resulting in the formation of new phosphodiester bonds linking host and viral
DNA at both ends of the viral genome. The AC overhang of viral DNA is not joined, and the process also results in single stranded gaps in the host DNA on each side of
the viral genome. This leads to the third step (repair/ligation), in which the AC overhangs are removed and the gaps in host DNA filled in, creating a short duplication of
host sequences on either side of the integrated viral DNA. Raltegravir inhibits the strand transfer reaction. B. Domain structure of an HIV integrase monomer. Raltegravir
binds at the active site in the catalytic core domain and inhibits the strand transfer reaction. The catalytic triad Asp-64, Asp-116, and Glu-152 is shown as D-D-E in the
core domain. C. Structure of raltegravir.
664 Principles of Chemotherapy

NH2
O
O H
HN O H
O
S N
N N N H
O N H
O NH2 OH
OH
O N
O H

Amprenavir Saquinavir

OH
N N OH
O O H
H N N
N O
HN N N
O H O
OH
O NH

Lopinavir Indinavir

H
S O N
O O O
H HO
N N S
N N N O N N
H H H H
O
S OH N OH
H

Ritonavir Nelfinavir

N
OH

O OH O
H H O O
N N N OCH3 NH
H3CO N N
H H SO2
O O
N
F 3C

Atazanavir Tipranavir

FIGURE 37-9. Anti-HIV protease inhibitors. Shown are the structures of the anti-HIV protease inhibitors amprenavir, saquinavir, lopinavir, indinavir, ritonavir,
nelfinavir, atazanavir, and tipranavir. These compounds mimic peptides (peptidomimetics), and all but tipranavir contain peptide bonds. Two additional anti-HIV protease
inhibitors, darunavir and fosamprenavir (a prodrug form of amprenavir), are not shown.

Inhibition of Viral Release
Rational design has also led to the development of inhibitors
of influenza virus neuraminidases. The rationale for these in-
hibitors, which block viral release from the host cell, follows
from the mechanism of viral attachment and release. Influenza
virus attaches to cells via interactions between hemagglutinin,
a protein on the viral envelope, and sialic acid moieties, which
are present on many cell surface glycoproteins. Upon egress of
influenza virus from cells at the end of a round of replication,
the hemagglutinin on nascent virions again binds to the sialic
acid moieties, thereby tethering the virions to the cell surface
and preventing viral release. To overcome this problem, in-
fluenza virus encodes an envelope-bound enzyme, called
neuraminidase, which cleaves sialic acid from the membrane
glycoproteins and thereby permits release of the virus. Without
neuraminidase, the virus remains tethered and cannot spread to
other cells. In 1992, the structure of the neuraminidasesialic
acid complex was solved. The structure showed that sialic acid
occupies two of three well-formed pockets on the enzyme.
Based largely on this structure, a new sialic acid analogue was
designed to maximize energetically favorable interactions in
all three of the potential binding pockets (Fig. 37-11). This
compound, now known as zanamivir, inhibits neuraminidase
with a Ki of about 0.1 nM. Zanamivir is active against both
influenza A and influenza B, with potencies of about 30 nM.
Studies of resistant mutants confirm the mechanism of action
described above. However, zanamivir has poor oral bioavail-
ability and must be administered by inhaler.
Efforts to improve on zanamivirs pharmacokinetics re-
sulted in a new drug, oseltamivir (Fig. 37-11), whose oral
666 Principles of Chemotherapy

H
O N H
O Ile O N
H HO OH Ile
Leu N H
Asn N Leu N
Protease attack Asn N

Rotational axis of symmetry

P-3 P-2 P-1 (phe) P1 (pro) P2

Model of transition state

pol Substrate sequence on substrate sequence

OH OH
H H OH O
H2N NH2 Cbz N N Cbz H
Val Val Cbz N Val
Val N N Cbz
H H
OH

A-74702 A-74704 A-75925

Protease IC50 > 200 M Protease IC50 = 5 nM Protease IC50 < 1 nM
Antiviral activity < 1 M Antiviral activity < 1 M
Poor aqueous solubility

O OH O
H H
N N N N
N N N N
H H
O OH O

A-77003
Protease IC50 < 1 nM
Antiviral activity = 0.1 M
Good solubility
Poor oral bioavailability

O O
H
N N S
N N N O
H H
S O OH N

Ritonavir
Protease IC50 < 1 nM
Antiviral activity = 25 nM
Fair solubility
Good oral bioavailability

FIGURE 37-10. Steps in the evolution of ritonavir. A. The HIV pol gene product has a phenylalanine (Phe)-proline (Pro) sequence that is unusual as a cleavage site
for human proteases. HIV protease cleaves this Phe-Pro bond. The transition state of the protease reaction includes a rotational axis of symmetry. B. Structure-based
development of a selective HIV protease inhibitor began with a compound (A-74702) that contained two phenylalanine analogues and a CHOH moiety between them.
This compound, which had weak inhibitory activity, was then modified to maximize antiprotease activity while also maximizing antiviral activity, aqueous solubility, and
oral bioavailability. The maximization of antiprotease activity was measured as a progressive reduction in IC50, the drug concentration required to cause 50% inhibition
of the enzyme. See Box 37-3 for details.
 CHAPTER 37 / Pharmacology of Viral Infections 667

HO
B HO
HO OH
COOH O
HO OH COOH
H O
N O O
H O OH H
HN
N N
HO O NH H2N
O H2N O
Sialic acid Zanamivir Oseltamivir

Hydrophobic group
Glycerol Glycerol
C Carboxylate Carboxylate Carboxylate

Hydro-
phobic
Guanidino pocket
Hydroxyl

Active site of
Sialic acid neuraminidase Zanamivir GS4071
(active metabolite of
prodrug oseltamivir)

FIGURE 37-11. Structure-based design of neuraminidase inhibitors. A. Shown is a model of sialic acid (space-filling structure) bound to the influenza A virus
neuraminidase, with the amino acids that bind sialic acid depicted in stick form. This structure was used to design transition state analogues that bind more tightly to
neuraminidase than sialic acid does, resulting in potent inhibitors of the enzyme. B. Structures of sialic acid and the neuraminidase inhibitors zanamivir and oseltamivir.
C. Schematic diagram of the active site of influenza virus neuraminidase, depicting the binding of sialic acid, zanamivir, and GS4071 to several different features of the
active site. (Oseltamivir is the ethyl ester prodrug of GS4071.)

Docosanol
n-Docosanol is a 22-carbon saturated alcohol with activity
against HSV and certain other enveloped viruses. Although
shorter chain saturated alcohols have long been known to
inactivate virion infectivity, but also exhibit cytotoxicity,
docosanol has been reported to lack significant cytotoxicity.
Cell culture studies suggest that docosanol acts, at least in
part, between the stage of HSV attachment and the stage of
viral protein translation, with some effects on virus entry at
certain doses. Cells must be pretreated with docosanol for
hours for an antiviral effect to become manifest, and there
is evidence that, during this time, docosanol is metabolized
and incorporated into host cell membranes. However, it is
not clear what basis, if any, exists for selectivity of antiviral
action; no docosanol-resistant mutants have been reported
that could shed light on the drugs mechanism of action.
Docosanol is FDA-approved as an over-the-counter topi-
cal treatment for recurrent oralfacial HSV episodes (cold
sores), although its clinical efficacy is controversial, as is the
relationship of any such efficacy to an antiviral effect.
Ribavirin
Ribavirin has been touted as a broad-spectrum antiviral
and, indeed, it exhibits activity against many viruses in vitro
and efficacy against several in vivo. In patients, however,
ribavirin has been approved only in aerosol form (in effect,
668 Principles of Chemotherapy
topical application to the lungs) for severe respiratory syncy-
tial virus (RSV) infection, and only in combination with an
interferon for chronic hepatitis C virus (HCV) infection.
Structurally, ribavirin differs from the other nucleoside
analogues in that it has a natural sugar moiety (ribose) at-
tached to a nonnatural base-like moiety that most resembles
purines (adenine or guanine) (Fig. 37-5). Its mechanism of
action is still not well understood. Ribavirin is converted to
a monophosphate by cellular adenosine kinase and is known
to inhibit cellular inosine monophosphate dehydrogenase,
thereby lowering cellular GTP pools (see Chapter 38). That
this mechanism should confer selective antiviral activity
might seem unlikely at first, although there is some support
for this notion from studies of certain viral mutants. It is pos-
sible that particular viral enzymes, such as the enzyme that
adds 7-methylguanosine caps to mRNA, have higher Km val-
ues (and thus lower affinities) for GTP than do most cellular
enzymes. Hence, lowering intracellular GTP concentrations
below the Km values of these viral enzymes could have a
selective antiviral effect.
Inhibition of viral RNA polymerase could represent a
second possible selective mechanism for ribavirin action. In-
terestingly, both ribavirin diphosphate and ribavirin triphos-
phate have inhibitory activity against the RNA polymerases
of certain viruses.
A third possible mechanism also involves viral RNA
polymerase. The error-prone nature of this enzyme leads
to high mutation rates, and ribavirin has been shown to in-
crease the mutation rates of several viruses (including HCV)
when studied in an in vitro replication system. The increased
mutation rates are thought to be caused by incorporation of
ribavirin into RNA (without chain termination), although
ribavirins effects on GTP pools could also contribute. The
proposed mechanism, called error catastrophe, postulates
that the increased mutation rate pushes the already high
error rate of the polymerase over the edge of an error [KSHV], also known as human herpesvirus 8). Interferon-
threshold, so that few or no functional viral genomes are
produced. This concept is interesting but controversial. For
example, mutations that cause replication of HCV RNA to
become resistant to ribavirin have not been found in the viral
RNA polymerase gene.
Whether any of the proposed mechanisms of ribavirin ac-
tion are relevant for the therapeutic effect of the drug on human
RSV or HCV infections is not known. Indeed, for HCV, it is
possible that some of the therapeutic effects of ribavirin are
mediated by the immune system. Learning more about the
mechanisms of ribavirin action may lead to improved antivi-
ral therapies.
Drugs That Modulate the Immune System
Three classes of drugs that make explicit use of host immune
processes are used to treat viral infections. These classes in-
clude immunization, interferons, and imiquimod. For back-
ground on the immune system, see Chapter 41, Principles of
Inflammation and the Immune System.
Active and passive immunization inhibit viral infection
by providing antibodies against viral envelope proteins;
these antibodies then block the attachment and penetration
of virions into cells and increase virion clearance. Some
antibodies are directly virucidal, causing virions to be de-
stroyed or inactivated before the virus can interact with its
receptor(s) on target cells. There are, of course, many vac-
cines that are examples of active immunization against vi-
ruses (e.g., measles, mumps, rubella, hepatitis B), and most
of these vaccines are used prophylactically. One example
of a vaccine used therapeutically is rabies vaccine, which
can save the lives of individuals who are already infected
with rabies virus. Examples of passive immunization are
the prophylactic use of either pooled human immune glob-
ulins with anti-RSV activity or a humanized monoclonal
antibody, palivizumab, to prevent RSV infection in high-
risk children.
The interferons and imiquimod make use of the innate
immune response (see Chapter 41) and do not directly tar-
get viral gene products. Interferons were first recognized
as proteins that are produced in response to virus infection
and that can inhibit replication of the same or other viruses.
There are two major types of interferons. Type I interferons
include interferon- and interferon-, which are produced
by many cell types and interact with the same cell-surface
receptor. Type II interferons include interferon-, which
is typically produced by cells of the immune system, espe-
cially T cells, and interacts with a different receptor. Interac-
tion of interferons with their receptors induces a series of
signaling events that activate and/or induce the expression
of proteins that combat viral infections. One relatively well
understood example of such a protein is a protein kinase,
called PKR, which is activated by double-stranded RNA.
(Double-stranded RNA is often produced during viral infec-
tions.) PKR phosphorylates a component of the host trans-
lational machinery, thereby turning off protein synthesis and
thus the production of virus in infected cells.
Interferon- is used as a therapeutic agent in the treatment
of HCV, HBV, condyloma acuminata (which is caused by cer-
tain human papillomaviruses [HPVs]), and Kaposis sarcoma
(which is caused by Kaposis sarcoma-associated herpesvirus
is usually administered in a form that has been modified with
polyethylene glycol (pegylated) to improve its pharmacoki-
netic profile following injection. Although the mechanism
by which interferons inhibit the replication of certain viruses
is reasonably well understood (e.g., by inducing PKR), the
mechanisms by which interferons act against HCV, HBV,
HPVs, and KSHV remain poorly understood. Interestingly,
all of these viruses encode proteins that inhibit interferon ac-
tion. Understanding the mechanism of this inhibition may aid
understanding of the action of interferons in inhibiting viral
replication. This is an active area of investigation.
Interferon- is also used to treat certain relatively rare
malignancies, and interferon- is used to treat multiple
sclerosis. Again, the mechanisms by which interferons exert
their therapeutic effects in these clinical settings are poorly
understood.
Imiquimod is approved for the treatment of certain dis-
eases caused by HPVs. Imiquimod interacts with the Toll-
like receptors TLR7 and TLR8 to boost innate immunity,
including the secretion of interferons. Toll-like receptors
are membrane proteins that recognize pathogen-associated
molecular patterns. Activation of Toll-like receptors induces
intracellular signaling events that are important for defense
against pathogens. In the case of imiquimod, it is not clear
exactly how this stimulation results in effective treatment of
disease caused by HPV.

 CONCLUSION AND FUTURE DIRECTIONS
The various stages in the viral life cycle provide a basis for
understanding the mechanisms of action of currently avail-
able antiviral drugs and for developing new antiviral thera-
pies. The vast majority of antiviral drugs available today
inhibit viruses at the genome replication stage, by taking
advantage of structural and functional differences between
viral and host polymerases. In addition, maraviroc and enfu-
virtide (T-20) inhibit viral attachment and entry, adamantanes
inhibit viral uncoating, protease inhibitors inhibit viral matu-
ration, and neuraminidase inhibitors inhibit viral release. It
is important to bear in mind, however, that many of these
drugs inhibit only one virus (e.g., HIV), and, in some cases,
only one species of that virus (e.g., HIV-1 but not HIV-2).
Only a tiny fraction of viruses known to cause human dis-
ease can be treated effectively with the antiviral therapies
that are currently available. Nevertheless, great strides have
been made. At this writing, new specific anti-HCV drugs are
under review at the FDA. In the case of Mr. M, the treatment
of HIV with a combination of drugs could reduce viral loads
to undetectable levels and delay the progression of AIDS for
many years. Although antiviral therapies do not yet represent
CHAPTER 37 / Pharmacology of Viral Infections 669
either prevention or cure for this disease, such therapies have
already decreased the morbidity and mortality of HIV/AIDS
in millions of individuals.
Suggested Reading
Coen DM, Richman DD. Antiviral agents. In: Knipe DM, Howley PN, Grif-
fin DE, et al., eds. Fields virology. 5th ed. Philadelphia: Lippincott Williams
& Wilkins; 2006. (Detailed review of the general and specific aspects of the
mechanisms and uses of antiviral drugs.)
Hay AJ, Wolstenholme AJ, Skehel JJ, et al. The molecular basis of the spe-
cific anti-influenza inhibition of amantadine. EMBO J 1985;4:30213024.
(This classic paper illustrates how viral genetics can be used to identify a
drug target.)
LaBranche C, Galasso G, Moore JP, et al. HIV fusion and its inhibition.
Antiviral Res 2001;50:95115. (Summarizes the understanding of HIV fu-
sion and includes a discussion of fusion inhibitors under investigation.)
von Itzstein M, Wu WY, Kok GB, et al. Rational design of potent sialidase-
based inhibitors of influenza virus replication. Nature 1993;363:418423.
(Describes the structure-based design of zanamivir.)
Yazdanpanah Y, Sissoko D, Egger M, et al. Clinical efficacy of antiretro-
viral combination therapy based on protease inhibitors or non-nucleoside
analogue reverse transcriptase inhibitors: indirect comparison of controlled
trials. Br Med J 2004;328:249256. (Reviews combination therapies used
in the treatment of HIV.)
38
Pharmacology of Cancer:
Genome Synthesis, Stability,
and Maintenance
David A. Barbie and David A. Frank
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 674-675
BIOCHEMISTRY OF GENOME SYNTHESIS,
STABILITY, AND MAINTENANCE . . . . . . . . . . . . . . . . . . . . . 675
Nucleotide Synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 675
Purine Ribonucleotide Synthesis . . . . . . . . . . . . . . . . . 675
Pyrimidine Ribonucleotide Synthesis . . . . . . . . . . . . . . 675
Ribonucleotide Reduction and Thymidylate Synthesis . . . 676
Nucleic Acid Synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . 676
DNA Repair and Chromosome Maintenance . . . . . . . . . . . 676
Mismatch Repair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 678
Base Excision Repair. . . . . . . . . . . . . . . . . . . . . . . . . . 678
Nucleotide Excision Repair . . . . . . . . . . . . . . . . . . . . . 679
Double-Strand Break Repair . . . . . . . . . . . . . . . . . . . . 679
Telomere Biology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681
Microtubules and Mitosis . . . . . . . . . . . . . . . . . . . . . . . . . 682
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 683
Inhibitors of Thymidylate Synthase . . . . . . . . . . . . . . . . . . 684
Inhibitors of Purine Metabolism . . . . . . . . . . . . . . . . . . . . 684
 INTRODUCTION
Cancer therapy has traditionally been based on the principle
that tumor cells are traversing the cell cycle frequently and
are thus more sensitive than normal cells to interference with
DNA synthesis and mitosis. Indeed, the antimetabolites, a
class of agents that are analogues of endogenous folates,
purines, and pyrimidines, and that function as inhibitors of
the enzymes of nucleotide synthesis, were some of the first
drugs to be tested as chemotherapeutic agents. In the late
1940s, Sidney Farber and colleagues administered the anti-
folate compound aminopterin to patients with acute leuke-
mia and observed temporary remissions in more than half of
the patients.
Because of their rapid growth and division, cancer cells
are also thought to be more sensitive than normal cells to
the effect of DNA-damaging agents. Also in the late 1940s,
nitrogen mustardsderivatives of agents that had been
674
Inhibitors of Ribonucleotide Reductase . . . . . . . . . . . . . . . 685
Purine and Pyrimidine Analogues That Are
Incorporated into DNA . . . . . . . . . . . . . . . . . . . . . . . . . . . 686
Agents That Directly Modify DNA Structure . . . . . . . . . . . 686
Alkylating Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . 686
Platinum Compounds . . . . . . . . . . . . . . . . . . . . . . . . . 689
Bleomycin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 690
Topoisomerase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . 691
Camptothecins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691
Anthracyclines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691
Epipodophyllotoxins . . . . . . . . . . . . . . . . . . . . . . . . . . 691
Amsacrine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 692
Microtubule Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . 692
Inhibitors of Microtubule Polymerization:
Vinca Alkaloids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 692
Inhibitors of Microtubule Depolymerization: Taxanes . . . . 692
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 693
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 693
found to cause bone marrow suppression through wartime
exposureswere tested in patients with lymphoma and leu-
kemia and shown to induce remissions.
These and other findings have since led to the develop-
ment of multiple classes of antineoplastic drugs designed to
interfere with the building blocks of DNA synthesis and mi-
tosis, or to produce DNA damage and chromosomal instabil-
ity, and thereby to promote cytotoxicity and programmed cell
death (apoptosis). Unfortunately, the therapeutic window of
these drugs is narrow because they affect normal cells in tis-
sues such as the gastrointestinal tract and bone marrow that
undergo cell division. Use of combination chemotherapy
with agents from different classes has helped to enhance effi-
cacy while minimizing overlapping dose-limiting toxicities,
but the ability to cure patients with most forms of advanced
cancer remains limited. In part, this limited efficacy is due
to the development of multiple resistance mechanisms, in-
cluding the failure of tumor cells to undergo apoptosis in
676 Principles of Chemotherapy

A role in pyrimidine synthesis. UMP is itself a nucleotide

component of RNA, as well as the common precursor of the
RNA and DNA components cytidylate (CMP), deoxycytidy-
Purine Pyrimidine
precursors precursors
late (dCMP), and deoxythymidylate (dTMP). CTP is formed
Folate
by the amination of UTP.

Ribonucleotide Reduction and Thymidylate Synthesis

The ribonucleotides ATP, GTP, UTP, and CTP, which are re-
Inosine monophosphate Pyrimidines quired for RNA synthesis, are assembled on a DNA template
(IMP)
and linked to form RNA. Alternatively, ribonucleotides can
be reduced at the 2 position on ribose to form the deoxyri-
Ribonucleotides bonucleotides dATP, dGTP, dUTP, and dCTP. The conver-
sion of ribonucleotides to deoxyribonucleotides is catalyzed
Deoxyribonucleotides by the enzyme ribonucleotide reductase. (In actuality, ri-
bonucleotide reductase uses as substrates the diphosphate
DNA forms of the four ribonucleotides to produce dADP, dGDP,
dUDP, and dCDP; nucleotides can, however, be readily in-
RNA
terconverted among their monophosphate, diphosphate, and
triphosphate forms.)
Note, in Figures 38-2 through 38-4, that ribonucleotide re-
Protein
ductase catalyzes the formation of the DNA precursors dATP,
dGTP, and dCTP. The DNA precursor dTTP is not synthe-
B
sized directly by ribonucleotide reductase, however. Rather,
dUMP must be modified to form dTMP. As can be seen in
Methotrexate Table 38-1, dTMP is the product of dUMP methylation. The
Purine Pyrimidine methylation of dUMP to dTMP is catalyzed by thymidylate
precursors precursors synthase, with methylenetetrahydrofolate (MTHF) serving as
Folate the donor of the methyl group (Fig. 38-4). As MTHF donates
6-Mercaptopurine
Thioguanine its methyl group, it is oxidized to dihydrofolate (DHF). DHF
must be reduced to THF by dihydrofolate reductase (DHFR)
and then converted to MTHF in order to serve as the cofactor
IMP Pyrimidines
for another cycle of dTMP synthesis. Inhibition of DHFR pre-
vents the regeneration of tetrahydrofolate and thereby inhibits
6-Mercaptopurine
Thioguanine
the conversion of dUMP to dTMP, eventually resulting in an
Ribonucleotides insufficient cellular level of dTMP for DNA replication.
Hydroxyurea

Deoxyribonucleotides
Fludarabine
Cytarabine
Cladribine
DNA
RNA
Protein
FIGURE 38-1. Overview of de novo nucleotide biosynthesis. A. Folate is
an essential cofactor in the synthesis of inosine monophosphate (IMP), from which
all purine nucleotides are derived. Pyrimidine synthesis does not require folate,
although folate is required for the methylation of deoxyuridylate (dUMP) to deoxy-
thymidylate (dTMP) (see Fig. 38-2). Ribonucleotides contain one of the purine or
pyrimidine bases linked to ribose phosphate. Subsequent reduction of the ribose at
the 2 position produces deoxyribonucleotides. Deoxyribonucleotides are polymer-
ized into DNA, while ribonucleotides are used to form RNA (not shown). The central
dogma of molecular biology states that the DNA code determines the sequence
of RNA (transcription) and that RNA is then translated into protein. B. Methotrex-
ate inhibits dihydrofolate reductase (DHFR) and thereby prevents the utilization of
folate in purine nucleotide and dTMP synthesis. 6-Mercaptopurine and thiogua-
nine inhibit the formation of purine nucleotides. Hydroxyurea inhibits the enzyme
that converts ribonucleotides to deoxyribonucleotides. Fludarabine, cytarabine,
and cladribine are purine and pyrimidine analogues that inhibit DNA synthesis.
5-Fluorouracil inhibits the enzyme that converts dUMP to dTMP (not shown).
Nucleic Acid Synthesis
Provided that sufficient levels of nucleotides are available,
DNA and RNA can be synthesized, and protein synthesis,
cell growth, and cell division can occur. Many drugs, includ-
ing the antimetabolites discussed in this chapter, can inhibit
both DNA and RNA synthesis. To avoid repetition, a detailed
discussion of DNA and RNA synthesis is provided in Chap-
ter 33, Pharmacology of Bacterial Infections: DNA Repli-
cation, Transcription, and Translation. For the purposes of
this chapter, the reader should be aware that RNA and DNA
are formed by polymerization of ribonucleotides and deoxy-
ribonucleotides, respectively. RNA polymers are elongated
by the enzyme RNA polymerase, and DNA is elongated by
DNA polymerase. Although antimetabolites primarily in-
hibit the enzymes that mediate nucleotide synthesis, some
antimetabolites also inhibit DNA and RNA polymerases (see
below).
DNA Repair and Chromosome Maintenance
Mutations and other DNA lesions can arise spontaneously or
as a result of exposure to DNA-damaging chemical agents or
radiation. Several general pathways exist for repair of these
lesions, including mismatch repair (MMR) for DNA rep-
lication errors, base excision repair (BER) for small base
modifications and single-strand breaks, nucleotide excision
repair (NER) for removal of bulky adducts, and homologous
 Base Ribonucleoside Ribonucleotide Deoxyribonucleoside Deoxyribonucleotide
NH2 NH2 NH2 NH2

N N N N
N N N N
NH2
N N O N N N N O N N
N HO HO
- -
N O P O O P O
O O O O
H H O - H H H H O- H H
N N
H H H H H H H H H
OH OH OH OH OH H OH H

Adenine (A) Adenosine Adenylate (AMP) Deoxyadenosine Deoxyadenylate (dAMP)

Purines
O O O O

N N N N
NH NH NH NH
O
N N NH2 O N N NH2 N N NH2 O N N NH2
N HO HO
NH -
O P O -
O P O
O O O O
H H O- H H H H O- H H
N N NH2
H H H H H H H H H
OH OH OH OH OH H OH H

Guanine (G) Guanosine Guanylate (GMP) Deoxyguanosine Deoxyguanylate (dGMP)

NH2 NH2 NH2 NH2

N N N N

NH2 N O N O N O N O
O O
HO - HO
O P O -
N O O P O
O O O
H H O- H H H H O- H H
N O H H H H H H
H OH OH OH OH H H OH H
OH H

Cytosine (C) Cytidine Cytidylate (CMP) Deoxcytidine Deoxycytidylate (dCMP)

O O O O

NH NH NH NH

O
N O N O N O O N O
O
Pyrimidines NH
HO
-
O P O
HO -
O P O
O O O O
H H O- H H H H O- H H
N O H H
H H H H H H H
OH OH OH OH OH H OH H

Uracil (U) Uridine Uridylate (UMP) Deoxyuridine Deoxyuridylate (dUMP)

O
O

NH
NH
O
N O
O N O
NH NONE NONE HO -
O P O
O O
H H O- H H
N O
H H H H H
OH H OH H

Thymine (T) Deoxythymidine Deoxythymidylate (dTMP)

Purine synthesis Pyrimidine synthesis

Amino acids PRPP Folate PRPP Amino acids

IMP

Ribonucleotides AMP GMP UMP CMP

dUMP

Deoxyribonucleotides dAMP dGMP dTMP dCMP

DNA
678 Principles of Chemotherapy

6-Mercaptopurine
Thioguanine 6-Mercaptopurine
GTP ATP

Inosine
GMP XMP monophosphate Adenylosuccinate AMP
IMP
dehydrogenase (IMP)
Ribonucleotide Ribonucleotide
Hydroxyurea (IMPDH) Hydroxyurea
reductase reductase

dGMP dAMP

dGTP dATP
Fludarabine
Cladribine
DNA
DNA

FIGURE 38-3. Details of purine synthesis. Inosine monophosphate, or IMP, occupies a central position in the synthesis of purine nucleotides. IMP is oxidized by
IMP dehydrogenase (IMPDH) to xanthylate (XMP), which is converted to guanosine monophosphate (GMP). GMP can be incorporated into DNA or RNA as deoxyguanosine
triphosphate (dGTP) or guanosine triphosphate (GTP), respectively. Alternatively, IMP can be aminated to adenosine monophosphate (AMP) through an adenylosuccinate
intermediate. AMP can be incorporated into DNA or RNA as deoxyadenosine triphosphate (dATP) or adenosine triphosphate (ATP), respectively. 6-Mercaptopurine and
thioguanine inhibit IMPDH and thus interrupt GMP synthesis. 6-Mercaptopurine also inhibits the conversion of IMP to adenylosuccinate and thus interrupts AMP syn-
thesis. Hydroxyurea inhibits ribonucleotide reductase and thus inhibits formation of the deoxyribonucleotides required for DNA synthesis. Fludarabine and cladribine are
halogenated adenosine analogues that inhibit DNA synthesis.

Aspartate recombination or nonhomologous end-joining for double-

Carbamoyl phosphate strand breaks (Fig. 38-5). DNA repair pathways are important
not only because they can alter the efficacy of chemotherapy,
Orotate
but also because loss of these pathways frequently contrib-
PRPP utes to tumor development via impairment of genomic in-
tegrity and facilitation of mutations in oncogenes and tumor
suppressor genes. Telomeres, the repeat sequences that cap
UMP UTP CTP
the ends of chromosomes, also play an important role in ge-
Ribonucleotide
Hydroxyurea
Ribonucleotide nome stability and prevention of chromosome fusions. The
reductase reductase
enzyme telomerase, which prevents telomere shortening in
dUMP dCTP cancer cells, represents a key component in the process of
MTHF
immortalization and oncogenic transformation.
THF Thymidylate Cytarabine
synthase
DHFR Mismatch Repair
DHF
dTMP
5-Fluorouracil
DNA
During DNA replication, errors such as single-base mis-
matches and insertions or deletions of microsatellite repeat
Methotrexate sequences (microsatellite instability) are recognized and re-
dTTP paired by proteins of the mismatch repair (MMR) system. For
single-base mismatches, recognition involves a heterodimer
between the MSH2 protein and MSH6, while for insertion/de-
DNA letion loops, MSH2 can also partner with MSH3 (Fig. 38-6).
These complexes recruit the proteins MLH1 and PMS2 (as
FIGURE 38-4. Details of pyrimidine synthesis. Aspartate (an amino acid)
and carbamoyl phosphate combine to form orotate, which then combines with
well as MLH3 for insertion/deletion loops), which, in turn,
phosphoribosylpyrophosphate (PRPP) to form uridylate (UMP). UMP occupies a recruit exonucleases and components of the DNA replication
central position in the synthesis of pyrimidine nucleotides. UMP can be sequen- machinery for excision and repair of the lesion. Germline mu-
tially phosphorylated to uridine triphosphate (UTP). UTP is incorporated into RNA tations in MLH1, PMS2, MSH2, or MSH6 are associated with
(not shown) or aminated to form cytidine triphosphate (CTP). CTP is incorporated 7080% of cases of hereditary nonpolyposis colon cancer.
into RNA (not shown) or reduced by ribonucleotide reductase to deoxycytidine In addition, microsatellite instability, a hallmark of defective
triphosphate (dCTP), which is incorporated into DNA. Alternatively, UMP can MMR, is observed in 1525% of sporadic colorectal cancers.
be reduced to deoxyuridylate (dUMP). Thymidylate synthase converts dUMP to
deoxythymidylate (dTMP), in a reaction that depends on folate. dTMP is phospho- Base Excision Repair
rylated to deoxythymidine triphosphate (dTTP), which is incorporated into DNA. Hy- DNA single-strand breaks (SSB), which may be formed di-
droxyurea inhibits the formation of deoxyribonucleotides and thereby inhibits DNA
rectly by ionizing radiation or indirectly due to enzymatic
synthesis. Cytarabine, a cytidine analogue, inhibits the incorporation of dCTP into
DNA. 5-Fluorouracil inhibits dTMP synthesis by inhibiting thymidylate synthase.
excision of a modified base by a DNA glycosylase, activate
Methotrexate inhibits dihydrofolate reductase (DHFR), the enzyme responsible for the enzyme poly(ADP-ribose) polymerase 1 (PARP1)
regenerating tetrahydrofolate (THF) from DHF. By inhibiting DHF reductase, this (Fig. 38-7). At the site of the breakage, PARP1 transfers
drug inhibits the formation of methylenetetrahydrofolate (MTHF), which is the fo- ADP-ribose moieties from NAD to itself and to a number of
late compound that is required for dTMP synthesis. other proteins involved in DNA and chromatin metabolism.
 CHAPTER 38 / Pharmacology of Cancer: Genome Synthesis, Stability, and Maintenance 679

Oxygen radicals Ionizing radiation

Ionizing radiation UV radiation Chemicals (bioflavonoids,
Chemicals (nitrosamines) Chemicals (2-AAF, radiomimetic chemicals)
Chemotherapeutic agents benzo(a)pyrene) Chemotherapeutic agents
(alkylating agents, Chemotherapeutic agents (bleomycin, topoisomerase I
Replication errors temozolomide) (platinum agents) and II inhibitors)

Abasic sites
Base pair mismatches
Base modifications Bulky adducts Double-strand breaks
Insertion/deletion loops
Single-strand breaks

Mismatch repair Base excision repair Nucleotide excision repair Double-strand break repair

FIGURE 38-5. Mechanisms of DNA damage and repair. In response to DNA damage, there are several general pathways that mediate repair of DNA lesions.
Replication errors typically result in base pair mismatches or insertion/deletion loops in regions of microsatellite DNA repeats; these lesions are repaired by the mismatch
repair (MMR) pathway. Oxygen radicals, ionizing radiation, and various chemicals and chemotherapeutic agents can cause abasic site formation, base modifications, and
single-strand breaks, which are repaired by the base excision repair (BER) pathway. Ultraviolet (UV) irradiation and certain DNA-modifying chemicals and chemothera-
peutic agents can cause the formation of bulky adducts that are excised and repaired by the nucleotide excision repair (NER) pathway. Ionizing radiation, radiomimetic
chemicals, bleomycin, and natural (bioflavonoids) and chemotherapeutic (camptothecins, anthracyclines, epipodophyllotoxins) topoisomerase inhibitors can induce
double-strand DNA breaks that trigger repair by the double-strand break repair (DSBR) pathway. 2-AAF, 2-acetylaminoflourene.

Single-base mismatch Insertion/deletion loop

The covalent addition of negatively charged ADP-ribose oli-
gomers alters the interactions of these proteins with DNA
T A and with other proteins. PARP1 recruits the BER protein
A T XRCC1; together with DNA polymerase and DNA ligase
T A III, XRCC1 facilitates repair of the lesion. PARP1 has also
MSH2 MSH6 MSH2 A T MSH3/6
T A
been implicated in the recognition of DNA double-strand
A T TGC T T AGGC A T A T A T A T A T A breaks (DSB) and in the recruitment of DNA-dependent
T A ACGCA T CCG T A T A T A T A T A T A T
protein kinase in DSB repair (see below), as well as in cell
death pathways, modification of chromatin structure, tran-
scriptional regulation, and mitotic apparatus function.

T A Nucleotide Excision Repair

A T PMS2/ In response to the formation of bulky adducts that distort
MLH1 PMS2 MLH1 T A MLH3
A T
the DNA double helix, such as those induced by ultravio-
MSH2 MSH6 MSH2 MSH3/6 let radiation and DNA-damaging chemotherapeutic agents,
T A
A T TGC T T AGGC A T A T A T A T A T A a complex set of proteins recognizes and initiates repair of
T A ACGCA T CCG T A T A T A T A T A T A T the lesion via a process termed nucleotide excision repair
(NER). Repair involves local opening of the double helix
around the site of the damage, incision of the damaged strand
on both sides of the lesion, excision of the oligonucleotide
containing the lesion, and, finally, DNA repair synthesis and
A T TGC T T AGGC A T A T A T A T A T A T A
ligation. The endonuclease ERCC1 plays an important role
T A ACGA A T CCG T A T A T A T A T A T A T
in targeted excision of the DNA lesion. The genes involved
in nucleotide excision repair were in part identified from
FIGURE 38-6. Mismatch repair pathway. Replication errors can result in study of the clinical syndromes xeroderma pigmentosa and
single base pair mismatches or insertion/deletion loops in microsatellite repeat Cockayne syndrome, which are rare photosensitivity disor-
regions as a result of intrastrand complementary base-pairing. Single-base mis- ders that exhibit defects in NER.
matches are recognized by an MSH2/MSH6 heterodimer, and insertion/deletion
loops are recognized by an MSH2/MSH3 or MSH2/MSH6 heterodimer. Additional Double-Strand Break Repair
components of the mismatch repair machinery are then recruited, including MLH1/ In response to a double-strand break, activation of the ataxia
PMS2 for single-base mismatches or MLH1/PMS2 or MLH1/MLH3 for insertion/
telangiectasia mutated (ATM) kinase results in generation
deletion loops. Exonucleases and components of the DNA replication machinery
are subsequently recruited for excision and repair of the lesions.
of the phosphorylated histone gamma-H2AX at the site of
the break. Together with the protein MDC1, gamma-H2AX
recruits to the locus of DNA damage a complex (MRN) con-
taining the proteins Mre11, Rad50, and Nijmegen breakage
syndrome gene 1 (NBS1) (Fig. 38-8). The breast and ovarian
680 Principles of Chemotherapy

PARP1 Histone Sister

chromatids
A T TGC T AGGC
T A ACGA A T CCG DSB

NAD

Nicotinamide
ATM
Histone
ADPr ADPr P H2AX
modification
ADPr ADPr
ADPr ADPr
ADPr ADPr
PARP1 Histone

A T TGC T AGGC
T A ACGA A T CCG
MDC1
RAD50
MRN complex P
MRE11
recruitment NBS1
ADPr ADPr
ADPr ADPr
ADPr ADPr
ADPr ADPr
XRCC1 PARP1 Histone

A T TGC T AGGC
Nuclease-mediated
T A ACGA A T CCG RAD52
resection

A T TGC T T AGGC ATM

BRCA1-P BRCA1
T A ACGA A T CCG ATR, CHK2
RAD51-BRCA2
RAD54
FIGURE 38-7. Base excision repair pathway. The enzyme poly(ADP-ribose) BRCA2
polymerase 1 (PARP1) is recruited to single-strand break sites resulting from ion- Strand
izing radiation or base lesion excision. PARP1 poly-ADP ribosylates (ADPr) a variety invasion RAD51
of targets at the site of injury, including itself and histones. The ADPr-modified
proteins then recruit additional proteins, such as XRCC1, which, in turn, recruit
DNA polymerase and DNA ligase III to repair the lesion.

DNA polymerase
DNA synthesis; DNA ligase
branch migration

FIGURE 38-8. Double-strand break repair pathway. The ataxia telangiecta-

sia mutated (ATM) kinase recognizes and binds to double-strand DNA break sites.
Upon activation, the ATM kinase marks the site by generating the phosphorylated Ligation;
histone gamma-H2AX. Gamma-H2AX and the protein MDC1 recruit the Mre11/ junction resolution
Rad50/Nijmegen breakage syndrome gene 1 (NBS1) complex (MRN) to the site of
injury. After RAD52 is recruited and nucleases mediate DNA resection, BRCA1 is
recruited to the site and phosphorylated by ATM, ATR, and CHK2 kinases. Together
with RAD51 and BRCA2, phosphorylated BRCA1 facilitates repair of the double-
strand break by homologous recombination (depicted in the figure) or nonhomolo-
gous end-joining (NHEJ; not shown). Accurately repaired DNA
 CHAPTER 38 / Pharmacology of Cancer: Genome Synthesis, Stability, and Maintenance 681

[TTAGGG]n 2-30 kb 3' cancer susceptibility gene product BRCA1 is also phospho-
Unknown
[AATCCC]n
5'
nuclease rylated by the kinases ATM, ATR, and CHK2 in response
ss [TTAGGG]n 3' to the double-strand break, and phosphorylated BRCA1,
5' RAD51, and BRCA2 are also recruited to the break site. Sub-
50-300 nt
sequent repair is mediated either by homologous recombi-
TRF1 nation, with formation and resolution of a Holliday junction
Folding (Fig. 38-8), or by nonhomologous end-joining (NHEJ), in
+
other factors which DNA-dependent protein kinase and a complex of pro-
teins, including XRCC4, catalyze nucleolytic processes that
allow end-joining by DNA ligase IV. The DNA repair ef-
3'
fected by homologous recombination is more accurate than
5' that mediated by NHEJ.

Telomere Biology
TRF2 Human telomeres consist of the simple repeat sequence
+ Strand invasion TTAGGG. These repeats are shaped, folded, and bound by
other factors a complex of proteins to form a unique structure termed a
t-loop (Fig. 38-9). In the t-loop structure, a long single-
ds stranded overhang at the 3 end of the DNA invades the
proximal double-stranded DNA component; this process is
t-loop
ss
facilitated by TRF1, TRF2, and other protein factors. The
5' 3' D loop t-loop and its associated complex of proteins are thought to
play important roles in capping and protecting the chromo-
FIGURE 38-9. Telomere structure. Human telomeres are 2 to 30 kilobases some end, as well as protecting telomeres from recognition
(kb) in length and consist of the simple sequence repeats TTAGGG. A 3-terminal by the DNA damage checkpoint machinery.
50- to 300-nucleotide (nt) single-stranded overhang is generated by an as yet un- Because DNA polymerase is unable to replicate the
identified nuclease. The telomere binding proteins TRF1, TRF2, and other factors ends of linear chromosomes completely, telomeres shorten
facilitate folding and proximal invasion of double-stranded telomeric DNA by the with each division in normal cells. Telomere shortening
single-stranded overhang to generate a stable t-loop structure. This structure
ultimately results in disruption of the telomeric caps, acti-
plays an important role in capping and protecting the ends of chromosomes.
vation of a DNA damage checkpoint, and a state of cycle
arrest termed cellular senescence (Fig. 38-10). When cells
are able to bypass this checkpoint via inactivation of the
tumor suppressor protein p53, which normally regulates

Telomerase
p53 loss, pRB loss activation

p53 activation,
Early Late pRB activation Crisis Immortalization
population population
doubling doubling

Senescence

Telomeres Long Medium Short Short Long

Proliferation Yes Yes No Yes Yes

Cell death No No No Yes No

FIGURE 38-10. Chromosome maintenance and its relationship to immortalization. As primary cells undergo successive population doublings, telomeres pro-
gressively shorten due to the inability of DNA polymerase to replicate the ends of linear chromosomes. Ultimately, a checkpoint is triggered, mediated by the proteins
p53 and pRB, which results in a state of growth arrest termed cellular senescence. Senescence can be bypassed by inactivation of p53 and pRB; ultimately, however,
the critically short telomeres cause the cells to enter a state termed crisis and to die. Activation of telomerase allows cells to maintain adequate telomere length and
divide indefinitely, resulting in immortalization. Notably, exogenous expression of telomerase alone in primary cells is sufficient for these cells to bypass senescence
and become immortalized.
682 Principles of Chemotherapy
cell cycle arrest or apoptosis in response to DNA damage,
chromosome fusions are observed. It is thought that the pro-
gressive shortening of telomeres with age promotes genomic
instability and contributes to oncogenesis. However, cells
also continue to die under these conditions. Activation of
the enzyme telomerase, which is a reverse transcriptase that
uses an RNA template to synthesize TTAGGG repeats, al-
lows cells to restore telomere length and divide indefinitely.
Telomerase activation is observed in normal germline cells
and some stem cell populations and has been shown to main-
tain the presence of the 3 overhang in normal cells. The im-
mortalization process associated with telomerase activation
is also essential for tumor formation and maintenance. In a
minority of tumors, an alternative lengthening of telomeres
(ALT) pathway is activated.
Microtubules and Mitosis
Once a cell has replicated its DNA, it is prepared to undergo
mitosis. In this process, chromosomes condense and are
segregated into two identical daughter cells. The cell-cycle
transitions from DNA replication (S phase) to G2 phase and
then to mitosis (M phase) are complex and depend on the co-
ordinated action of a number of so-called cyclin-dependent
kinases (CDKs; see Chapter 32). Progression through mito-
sis is also facilitated by enzymes that include aurora kinases
and polo-like kinases. Many cancer cells exhibit dysregula-
tion of cell-cycle timing and abnormalities in mitosis. Thus,
pharmacologic inhibition of these regulatory kinases is an
active area of cancer research. Currently, however, the mi-
crotubule machinery represents the primary target of agents
that act in mitosis.
Microtubules are cylindrical, hollow fibers composed of
polymers of tubulin, which is a heterodimeric protein con-
sisting of -tubulin and -tubulin subunits (Fig. 38-11).
-Tubulin and -tubulin are encoded by separate genes, but
they have similar three-dimensional structures. Both - and
-tubulin bind GTP; in addition, -tubulin (but not -tubulin)
can hydrolyze GTP to GDP. Microtubules originate from
a central microtubule organizing center (the centrosome,
which includes two centrioles and associated proteins),
where -tubulin (a protein with homology to -tubulin and
-tubulin) nucleates tubulin polymerization. Nascent micro-
tubules assemble into protofilaments, which are longitudinal
polymers of tubulin subunits. Each protofilament interacts
laterally with two other protofilaments to form a hollow-core
tube, 24 nm in diameter, which consists of 13 protofilaments
arranged concentrically. Because tubulin is a heterodimer,
this tube has inherent asymmetry; the end of a microtubule
nearest the centrosome is bordered by -tubulin and is called
the () (minus) end, while the end of a microtubule ex-
tending from the centrosome is bordered by -tubulin and
is called the () (plus) end (Fig. 38-11). Tubulin units are
added at different rates to the () and () ends; the () end
grows (adds tubulin) twice as fast as the () end.
Microtubules are not static structures. Rather, they pos-
sess an inherent property known as dynamic instability
(Fig. 38-12). Tubulin heterodimers add to the end of the mi-
crotubule with GTP bound to both -tubulin and -tubulin
subunits. As the microtubule grows, the -tubulin of each
tubulin heterodimer hydrolyzes its GTP to GDP. The hydro-
lysis of GTP to GDP introduces a conformational change
in tubulin that destabilizes the microtubule. The exact
Subunit
-tubulin 24 nm
(GTPase activity)
GDP
GTP
-tubulin
GTP
GTP
FIGURE 38-11. Microtubule structure. Microtubules are hollow cylindrical
tubes that polymerize from tubulin subunits. Each tubulin subunit is a heterodimer
composed of -tubulin (shades of purple) and -tubulin (shades of blue). Both
-tubulin and -tubulin bind GTP (dark shades of purple and blue); -tubulin
hydrolyzes GTP to GDP after the tubulin subunit is added to the end of a microtu-
bule (lighter shades of purple and blue). Microtubules are dynamic structures that
grow and shrink lengthwise; the cylindrical tubes are composed of 13 subunits
arranged concentrically, resulting in a diameter of 24 nm. Note that microtubules
have an inherent structural asymmetry. One end of a microtubule is limited by -
tubulin and is referred to as the () (minus) end; the opposite end is limited by
-tubulin and is referred to as the () (plus) end.
mechanism of this destabilization is unknown, but it may be
related to a decrease in the strength of lateral protofilament
interactions or an increase in the tendency for protofila-
ments to curve away from the straight microtubule.
Therefore, microtubule stability is determined by the rate
of microtubule polymerization relative to the rate of GTP hy-
drolysis by -tubulin. If a microtubule polymerizes tubulin
faster than -tubulin hydrolyzes GTP to GDP, then, in the
steady state, there is a cap of GTP-bound -tubulin at the ()
end of the microtubule. This GTP cap provides stability to the
microtubule structure, allowing further polymerization of the
microtubule. Conversely, if tubulin polymerization proceeds
more slowly than the hydrolysis of GTP to GDP by -tubulin,
then, in the steady state, the () end of the microtubule is en-
riched with GDP-bound -tubulin. This GDP-bound tubulin
conformation is unstable and causes rapid depolymerization of
the microtubule. The ability of microtubules to assemble and
disassemble rapidly is important for their many physiologic
roles. Pharmacologic agents can disrupt microtubule function
either by preventing the assembly of tubulin into microtubules
or by stabilizing existing microtubules (and thereby prevent-
ing microtubule disassembly).
Microtubules have important physiologic roles in mitosis,
intracellular protein trafficking, vesicular movement, and
cell structure and shape. Mitosis is the physiologic role that
is targeted pharmacologically; the other physiologic roles,
however, predict many of the adverse effects of drugs that
interrupt microtubule function.
Recall that microtubules nucleate from centrosomes,
which consist of centrioles and other associated proteins. In
 CHAPTER 38 / Pharmacology of Cancer: Genome Synthesis, Stability, and Maintenance 683

GTP-bound
tubulin cap
A
Preexisting
microtubule

High concentrations of -tubulin Low concentrations of

GTP-bound tubulin GTP-bound tubulin
-tubulin

B C

Lengthened microtubule Rate of GTP hydrolysis > Rate of polymerization

Rate of GTP hydrolysis = Rate of polymerization GTP cap shrinks
GTP cap preserved

Loss of GTP cap

Unstable microtubule; depolymerization

FIGURE 38-12. Dynamic instability of microtubules. A. A preexisting microtubule is characterized by tubulin subunits that have predominantly hydrolyzed the
GTP on -tubulin to GDP (light purple and light blue). However, -tubulin subunits that have recently been added to the microtubule have not yet hydrolyzed GTP (dark
purple and dark blue). The GTP-bound tubulin subunits form a GTP-bound tubulin cap at the () end of the microtubule. B. In the presence of a high concentration
of GTP-bound free tubulin subunits, new GTP-bound tubulin is added to the () end of the microtubule at a rate that equals or exceeds the rate of GTP hydrolysis by
-tubulin. Maintenance of a GTP-bound tubulin cap results in a stable microtubule. C. In the presence of a low concentration of GTP-bound free tubulin subunits, new
GTP-bound tubulin is added to the () end of the microtubule at a rate less than the rate of GTP hydrolysis by -tubulin. This results in shrinkage of the GTP-bound
tubulin cap. D. A microtubule that lacks a GTP-bound tubulin cap is unstable and undergoes depolymerization.

mitosis, the two centrosomes align at opposite ends of the

cell. Microtubules are extremely dynamic during M phase;
they grow and shrink during M phase at rates much greater
than during other phases of the cell cycle. This increased
dynamic instability during M phase allows microtubules to
locate and attach to the chromosomes. The microtubules em-
anating from each centrosome bind to kinetochores, which
are proteins that attach to the centromere of a chromosome.
Once the kinetochore of each chromosome is attached to a
microtubule, microtubule-associated proteins act as motors
to align the kinetochore-bound chromosomes at the equa-
tor of the cell (defined by the midpoint between the two
centrosomes). When every chromosome has aligned at the
equator, the microtubules shorten, separating a diploid pair
of chromosomes into each half of the cell. Finally, cytoki-
nesis (division of the cytoplasm) occurs, and two daughter
cells are formed. Although many other proteins are involved
in the regulation of mitosis, microtubules have a critical role
in the process. Disruption of microtubule function freezes
cells in M phase, leading eventually to the activation of pro-
grammed cell death (apoptosis).
 PHARMACOLOGIC CLASSES AND AGENTS
Traditional antineoplastic chemotherapy can be subdivided
into several classes of agents. The antimetabolite drugs
are compounds that either inhibit the enzymes involved
in nucleotide synthesis and metabolism or are incorpo-
rated as analogues into DNA and result in chain termina-
tion or strand breaks. These drugs act primarily during
the S phase of the cell cycle, when cells are undergoing
DNA replication. Another broad class of agents, which
induce cytotoxicity by modification of DNA structure and
generation of DNA damage, includes alkylating agents,
platinum compounds, bleomycin, and topoisomerase in-
hibitors. These drugs exert their effects during multiple
phases of the cell cycle. The final category of agents in-
hibits microtubule assembly or depolymerization, dis-
rupting the mitotic spindle and interfering with mitosis.
For a summary of the major classes of chemotherapeutic
agents, their cell cycle specificity, and major toxicities,
see Table 40-2 (Chapter 40, Principles of Combination
Chemotherapy).
684 Principles of Chemotherapy

Inhibitors of Thymidylate Synthase of the use of mechanistic knowledge to improve the clinical
effectiveness of a drug.
Thymidylate (dTMP) is synthesized by the methylation of
Pemetrexed is a folate analogue that, similar to endog-
2-deoxyuridylate (dUMP). This reaction, which is cata-
enous folate and the dihydrofolate reductase (DHFR) in-
lyzed by thymidylate synthase, requires MTHF as a cofac-
hibitor methotrexate (see Chapter 32), is transported into
tor (Fig. 38-4). 5-Fluorouracil (5-FU; Fig. 38-13) inhibits
cells by the reduced folate carrier and polyglutamated by
DNA synthesis, primarily by interfering with the biosyn-
the intracellular enzyme folylpolyglutamate synthase. Poly-
thesis of thymidylate. 5-FU is first converted to 5-fluoro-2-
glutamated pemetrexed is a potent inhibitor of thymidylate
deoxyuridylate (FdUMP) by the same pathways that convert
synthase and a much weaker inhibitor of DHFR; similar to
uracil to dUMP. FdUMP then inhibits thymidylate syn-
5-FU, its cytotoxic effect is likely due to the induction of
thase by forming, together with MTHF, a stable, covalent
thymineless cell death. (Note that the 5-FU derivative
ternary enzymesubstratecofactor complex. Cells deprived
5-FdUMP inhibits thymidylate synthase by binding to the
of dTMP for a sufficient period of time undergo so-called
dUMP [substrate] site on the enzyme, whereas pemetrexed
thymineless death. 5-FU can also be metabolized to floxu-
inhibits thymidylate synthase by binding to the MTHF [co-
ridine triphosphate (FUTP), which can be incorporated into
factor] site on the enzyme.) Pemetrexed is approved for the
mRNA in place of uridylate and can thereby interfere with
treatment of all subtypes of non-small cell lung cancer ex-
RNA processing. Either inhibition of thymidylate synthase
cept for the squamous subtype, due to lack of efficacy of the
by FdUMP or interference with RNA processing by FUTP,
drug in this subtype. Pemetrexed is also used in combina-
or a combination of the two mechanisms, could explain the
tion with cisplatin (see below) in the treatment of malignant
toxic effect of 5-FU on cells. However, certain 5-FU conge-
pleural mesothelioma. To reduce toxicity to normal cells,
ners that inhibit thymidylate synthase but are not incorpo-
patients treated with pemetrexed are also given folic acid
rated into RNA show antitumor efficacy similar to that of
and vitamin B12 supplementation.
5-FU. This finding points to thymidylate synthase inhibition
as the dominant mechanism of 5-FU action.
5-FU is used as an antineoplastic agent, especially in the Inhibitors of Purine Metabolism
treatment of carcinomas of the breast and gastrointestinal 6-Mercaptopurine (6-MP) and azathioprine (AZA), a
tract. 5-FU has also been used in the topical treatment of pre- prodrug that is nonenzymatically converted to 6-MP in tis-
malignant keratoses of the skin and of multiple superficial sues, are inosine analogues that inhibit interconversions
basal cell carcinomas. Because 5-FU depletes thymidylate among purine nucleotides (Fig. 38-14). 6-Mercaptopurine
from normal cells as well as cancer cells, this agent is highly contains a sulfur atom in place of the keto group at C-6 of
toxic and must be used with care. the purine ring. After its entry into cells, mercaptopurine
Capecitabine is an orally bioavailable prodrug of 5-FU. It
is absorbed across the gastrointestinal mucosa and converted
by a series of three enzymatic reactions to 5-FU. Capecit- O S
abine is approved for the treatment of metastatic colorectal
cancer and as second-line therapy in metastatic breast can- N N
HN HN
cer. Clinical trials have demonstrated that the efficacy of oral
capecitabine is similar to that of intravenous 5-FU. H2N N N N
H H2N N H
Elucidation of the mechanism of action of 5-FU has led to
the use of a 5-FU/folinic acid (leucovorin) combination as Guanine Thioguanine
first-line chemotherapy for colorectal cancer. Because 5-FU
inhibits thymidylate synthase by forming a ternary com-
plex involving the enzyme (thymidylate synthase), substrate
(5-FdUMP), and cofactor MTHF, it was hypothesized that N N O2
increasing the levels of MTHF would potentiate the activ-
ity of 5-FU. Clinical trials proved this hypothesis to be cor- N
rect, by showing that the efficacy of the combined regimen is S S
greater than that of 5-FU alone. This is an important example
N N
N HN

O N N N N
H H
O Azathioprine Mercaptopurine
HN NH (prodrug)
HN NH
O FIGURE 38-14. Structures of guanine, thioguanine, azathioprine, and
mercaptopurine. Thioguanine, azathioprine, and mercaptopurine are structural
O F analogues of purines. Thioguanine resembles guanine and can be ribosylated and
Uracil 5-Fluorouracil phosphorylated in parallel with endogenous nucleotides. The nucleotide forms of
(5-FU) thioguanine irreversibly inhibit IMPDH (see Fig. 38-3) and, upon incorporation into
DNA, inhibit DNA replication. Azathioprine is a prodrug form of mercaptopurine;
FIGURE 38-13. Structures of uracil and 5-fluorouracil. Note the structural azathioprine reacts with sulfhydryl compounds in the liver (e.g., glutathione) to re-
similarity between uracil and 5-fluorouracil (5-FU). Uracil is the base in dUMP, the lease mercaptopurine. The nucleotide form of mercaptopurine, thioinosine mono-
endogenous substrate for thymidylate synthase (see Fig. 38-4), and 5-FU is me- phosphate (T-IMP), inhibits the enzymes that convert IMP to AMP and GMP (see Fig.
tabolized to FdUMP, an irreversible inhibitor of thymidylate synthase. 38-3). T-IMP also inhibits the first committed step in purine nucleotide synthesis.
 CHAPTER 38 / Pharmacology of Cancer: Genome Synthesis, Stability, and Maintenance 685

is converted by the enzyme hypoxanthine-guanine phos- A NH2

phoribosyl transferase (HGPRT; see Chapter 48) to the
N
nucleotide form, 6-thioinosine-5-monophosphate (T-IMP). N
OH
T-IMP is thought to inhibit purine nucleotide synthesis by
N
several mechanisms. First, T-IMP inhibits the enzymes that N
N
HO
convert IMP to AMP and GMP, including inosine mono- NH
O
phosphate dehydrogenase (IMPDH) (Fig. 38-3). Second, H H N
T-IMP (as with AMP and GMP) is a feedback inhibitor H H HO
N
of the enzyme that synthesizes phosphoribosylamine, which OH OH
O
is the first step in purine nucleotide synthesis. Both of these Adenosine H H
mechanisms lead to marked decreases in the cellular levels H H
of AMP and GMP, which are essential metabolites for DNA OH H

synthesis, RNA synthesis, energy storage, cell signaling, and Pentostatin

other functions. 6-MP may also inhibit DNA and RNA syn-
thesis by less well-characterized mechanisms.
The major clinical application of 6-MP is in acute lym-
phoblastic leukemia (ALL), especially in the maintenance
phase of a prolonged combination chemotherapy regimen.
6-MP is also active against normal lymphocytes and can be
used as an immunosuppressive agent. For unknown reasons,
the prodrug AZA is a superior immunosuppressant compared
to 6-MP and is typically the drug of choice for this applica-
tion. AZA is discussed in detail in Chapter 45, Pharmacol-
ogy of Immunosuppression.
Both the effectiveness and the toxicity of 6-MP are poten-
tiated by allopurinol. Allopurinol inhibits xanthine oxidase,
thereby preventing the oxidation of 6-MP to its inactive me-
tabolite 6-thiouric acid. (In fact, allopurinol was discovered
in an effort to inhibit the metabolism of 6-MP by xanthine
oxidase.) Co-administration of allopurinol with 6-MP al-
lows the dose of 6-MP to be reduced by two-thirds (although
toxicity is proportionally increased as well). Allopurinol is
often used as a single agent to prevent the hyperuricemia
that could result from the destruction of cancer cells by che-
motherapeutic agents (tumor lysis syndrome). The use of
allopurinol in the treatment of gout is presented in Chapter
48, Integrative Inflammation Pharmacology: Gout.
Pentostatin (Fig. 38-15) is a selective inhibitor of
adenosine deaminase. The drug is a structural analogue of
the intermediate in the reaction catalyzed by ADA and binds
to the enzyme with high affinity. The resulting inhibition
of ADA causes an increase in intracellular adenosine and
2-deoxyadenosine levels. The increased adenosine and 2-
deoxyadenosine have multiple effects on purine nucleotide
metabolism. In particular, 2-deoxyadenosine irreversibly in-
hibits S-adenosylhomocysteine hydrolase, and the resulting
increase in intracellular S-adenosylhomocysteine is toxic to
lymphocytes. This action may account for the effectiveness
of pentostatin against some leukemias and lymphomas. Pen-
tostatin is especially effective against hairy cell leukemia.
Inhibitors of Ribonucleotide Reductase
Hydroxyurea inhibits ribonucleotide reductase by scaveng-
ing a tyrosyl radical at the active site of the enzyme. In the
absence of this free radical, ribonucleotide reductase is un-
able to convert nucleotides to deoxynucleotides, and DNA
synthesis is thereby inhibited.
Hydroxyurea is approved for use in the treatment of adult
sickle cell disease and certain neoplastic diseases. The mech-
anism of action of hydroxyurea in the treatment of sickle
cell disease may or may not be related to inhibition of ribo-
nucleotide reductase. As an alternative to this mechanism,
(2'-Deoxycoformycin)
B
NH2
N
N
NH2
N
N Cl
HO N
N
O
H H O N N F
H H
OH H P
HO O O
Cladribine OH H HO
H
OH H
H
Fludarabine-5'-phosphate
FIGURE 38-15. Structures of adenosine, pentostatin, cladribine, and flu-
darabine. A. Pentostatin inhibits adenosine deaminase (ADA), the enzyme that
converts adenosine and 2-deoxyadenosine to inosine and 2-deoxyinosine, re-
spectively. Pentostatin binds to ADA with very high affinity (Kd 2.5 1012 M)
because it structurally resembles the intermediate (transition state) in this enzy-
matic reaction. B. Cladribine and fludarabine-5-phosphate are also adenosine
analogues. Cladribine is a chlorinated purine analogue that is incorporated into
DNA and causes DNA strand breaks. Fludarabine phosphate is a fluorinated purine
analogue that is incorporated into DNA and RNA; this drug also inhibits DNA poly-
merase and ribonucleotide reductase.
hydroxyurea has been shown to increase the expression of
the fetal isoform of hemoglobin (HbF), which inhibits the
polymerization of sickle hemoglobin (HbS) and thereby de-
creases red blood cell sickling under conditions of hypoxia.
Hydroxyurea significantly decreases the incidence of painful
(vaso-occlusive) crisis in patients with sickle cell disease.
The mechanism by which hydroxyurea increases HbF pro-
duction is unknown. The role of hydroxyurea in the treat-
ment of sickle cell disease is discussed further in Chapter 44,
Pharmacology of Hematopoiesis and Immunomodulation.
Hydroxyurea is most commonly used in the treatment of
myeloproliferative disorders such as polycythemia vera and
essential thrombocytosis, or for palliative control of blood
counts in acute myelogenous leukemia. In myeloprolifera-
tive disorders, hydroxyurea can be used as a single agent
or in combination with other agents to inhibit the excessive
growth of myeloid cells in the bone marrow. The applica-
tions of hydroxyurea for these indications have been limited
somewhat by concerns that long-term hydroxyurea use may
be leukemogenic; this is an example of the phenomenon that
certain antitumor agents can also cause cancer.
686 Principles of Chemotherapy

Purine and Pyrimidine Analogues That Are NH2

NH2
Incorporated into DNA N
N N
A number of antimetabolites exert their major therapeutic
effect by acting as rogue nucleotides. These drugs are sub- N O
strates for the various pathways of nucleotide metabolism, N O
including ribosylation, ribonucleotide reduction, and nucleo- HO
HO
side and nucleotide phosphorylation. The sugar triphosphate O
O
forms of these drugs can then be incorporated into DNA. H H
H H
Once incorporated into DNA, these compounds disrupt the H H
H H
OH OH
structure of DNA, resulting in DNA chain termination, DNA OH OH
strand breakage, and inhibition of cell growth. Thiogua- Cytidine 5-Azacytidine
nine is a guanine analogue in which a sulfur atom replaces
the oxygen atom at C-6 of the purine ring (Fig. 38-14). As
with mercaptopurine, thioguanine is converted by HGPRT NH2
to its nucleotide form, 6-thioguanosine-5-monophosphate
(6-thioGMP). Unlike T-IMP, the nucleotide form of mercap- N
topurine, 6-thioGMP is a good substrate for guanylyl kinase,
the enzyme that catalyzes the conversion of GMP to GTP. N O
By this mechanism, 6-thioGMP is converted to 6-thioGTP, HO
which is incorporated into DNA. Within the structure of
O
DNA, 6-thioGTP interferes with RNA transcription and H HO
DNA replication, resulting in cell death. 6-ThioGMP also
H H
irreversibly inhibits IMPDH and thereby depletes cellular OH H
pools of GMP (Fig. 38-3). Thioguanine is used in the treat- Cytosine arabinoside
ment of acute myelogenous leukemia. Major adverse effects (cytarabine, AraC)
of thioguanine include bone marrow suppression and gastro-
intestinal injury. FIGURE 38-16. Structures of cytidine, cytarabine, and azacytidine.
Fludarabine phosphate (Fig. 38-15) is a fluorinated pu- Cytarabine and azacytidine are both analogues of the nucleoside cytidine. Cytara-
rine nucleotide analogue that is structurally related to the bine has an arabinose sugar in place of ribose (note the chirality of the hydroxyl
group highlighted in blue). The incorporation of cytarabine triphosphate (araCTP)
antiviral agent vidarabine (see Chapter 37, Pharmacology
into DNA inhibits further nucleic acid synthesis, because the replacement of 2-
of Viral Infections). The triphosphate form of fludarabine is deoxyribose by arabinose interrupts strand elongation. Azacytidine has an azide
incorporated into DNA and RNA, causing DNA chain ter- group (highlighted in blue) within the pyrimidine ring; this drug is incorporated into
mination. Fludarabine triphosphate also inhibits DNA poly- nucleic acids and interferes with the methylation of cytosine bases.
merase and ribonucleotide reductase and thereby decreases
nucleotide and nucleic acid synthesis in cells. The relative
importance of these actions in mediating the cellular toxicity
cell differentiation. Azacytidine and its 2-deoxy derivative
of the drug remains to be elucidated. Fludarabine phosphate
decitabine (5-aza-2-deoxycytidine) are approved for the
is used in the treatment of lymphoproliferative disorders,
treatment of myelodysplastic disease.
especially chronic lymphocytic leukemia (CLL) and low-
Gemcitabine is a fluorinated cytidine analogue in which
grade B-cell lymphomas.
the hydrogen atoms on the 2 carbon of deoxycytidine are
Cladribine is a chlorinated purine analogue that is
replaced by fluorine atoms. The diphosphate form of gem-
structurally related to fludarabine phosphate (Fig. 38-15).
citabine inhibits ribonucleotide reductase; the triphosphate
Cladribine triphosphate is incorporated into DNA, causing
form of gemcitabine is incorporated into DNA, interfering
strand breaks. Cladribine also depletes intracellular pools of
with DNA replication and resulting in cell death. Gemcit-
the essential purine metabolites NAD and ATP. Cladribine is
abine is active in several solid tumors, including pancreatic,
approved for use in the treatment of hairy cell leukemia and
breast, bladder, and non-small cell lung cancer, and is also
has been used experimentally in the treatment of other types
incorporated into regimens for hematologic malignancies
of leukemia and lymphoma.
such as Hodgkins disease.
Cytarabine (araC) is a cytidine analogue that is metabo-
lized to araCTP (Fig. 38-16). AraCTP competes with CTP
for DNA polymerase, and incorporation of araCTP into Agents That Directly Modify DNA Structure
DNA results in chain termination and cell death (Fig. 38-4). Alkylating Agents
Synergism between cytarabine and cyclophosphamide has The advent of modern chemotherapy dates to the 1940s,
been noted, presumably because of the reduced DNA re- when highly reactive alkylating agents were first noted to
pair caused by cytarabines inhibition of DNA polymerase. induce remissions in otherwise untreatable malignancies.
Cytarabine is used to induce and maintain remission in acute The clinical use of these agents was sparked by observations
myelogenous leukemia; it is especially effective for this in- that nitrogen mustards, derivatives of wartime agents that
dication when combined with an anthracycline. caused dramatic suppression of hematopoietic cells, could
5-Azacytidine is a cytidine analogue whose triphosphate have therapeutic utility in blood-derived malignancies such
metabolite is incorporated into DNA and RNA (Fig. 38-16). as leukemias and lymphomas. Soon thereafter, it was sug-
Once incorporated into DNA, azacytidine interferes with cy- gested that alkylating agents could also be useful in treat-
tosine methylation, altering gene expression and promoting ing epithelial tumors, mesenchymal tumors, carcinomas,
 CHAPTER 38 / Pharmacology of Cancer: Genome Synthesis, Stability, and Maintenance 687
and sarcomas; in fact, alkylating agents are commonly used
against all of these diseases today.
Alkylating agentssuch as cyclophosphamide, mechlor-
ethamine, melphalan, chlorambucil, and thiotepaare
electrophilic molecules that are attacked by nucleophilic
sites on DNA, resulting in the covalent attachment of
an alkyl group to the nucleophilic site. Depending on the
particular agent, alkylation can take place on nitrogen or
oxygen atoms of the base, the phosphate backbone, or a
DNA-associated protein. The N-7 and O-6 atoms of guanine
bases are particularly susceptible to alkylation. Alkylating
agents typically have two strong leaving groups (Fig. 38-17).
This structure confers the ability to bis-alkylate (perform
two alkylating reactions), enabling the agent to cross-link
the DNA molecule either to itselfby linking two guanine
residues, for exampleor to proteins. Bis-alkylation (cross-
linking) seems to be the major mechanism of cytotoxicity
(Fig. 38-18A). Alkylation of guanine residues can also re-
sult in cleavage of the guanine imidazole ring, abnormal
base-pairing between the alkylated guanine and thymine,
or depurination (i.e., excision of the guanine residue) (Fig.
32-18BD). Ring cleavage disrupts the molecular structure
of DNA; anomalous DNA base-pairing causes miscod-
ing and mutation; and depurination leads to scission of the
sugarphosphate DNA backbone. Importantly, the mutations
caused by these processes can increase the risk of develop-
ing new cancers.
Although all nitrogen mustards are relatively reactive, the
individual agents vary in the speed with which they react with
nucleophiles; this fact has significant impact on their clinical
use. Highly unstable compounds, such as mechlorethamine,
cannot be administered orally because such agents alkylate
target molecules within seconds to minutes. Because of this
high reactivity, these molecules are powerful vesicants (caus-
ing blisters) and can severely damage skin and soft tissue if
they leak outside of blood vessels. The rapid reactivity of al-
kylating agents can be exploited by infusing the drug directly
into the site of a tumor. For example, thiotepa can be instilled
into the bladder to treat superficial bladder cancers. In con-
trast to mechlorethamine and thiotepa, chlorambucil and
melphalan are much less reactive and can be administered
orally. Cyclophosphamide is particularly useful because it is
a nonreactive prodrug that requires activation by the hepatic
cytochrome P450 system; this agent can be administered ei-
ther orally or intravenously (Fig. 38-19).
Cl
H O
O Alkylating agent toxicity is dose-dependent and can be
N Cl Cl
P N
N N
H alkylating agents. First, toxicity typically manifests in rap-
O N
O idly proliferating tissues, such as bone marrow, gastrointesti-
Cl
BCNU
Cyclophosphamide (Carmustine, a nitrosourea)
FIGURE 38-17. Structures of cyclophosphamide and BCNU. Cyclophosph-
amide and BCNU (carmustine) each have two chloride leaving groups (blue). The
presence of two leaving groups allows these alkylating agents to bis-alkylate and
thereby cross-link macromolecules such as DNA. The ability to cross-link DNA is
crucial to the DNA damage caused by these agents.
Nitrosoureas, such as BCNU (carmustine; Fig. 38-17),
target DNA in much the same way as do cyclophosphamide
and other alkylating agents. Like cyclophosphamide, these
compounds require bioactivation. Unlike most alkylating
agents, however, nitrosoureas also attach carbamoyl groups
to their DNA-associated targets. It is not clear whether
carbamoylation contributes significantly to the activity of
nitrosoureas.
Some alkylating agents are better than others at targeting
specific tumors. For example, nitrosoureas are useful in the
treatment of brain tumors, because their high lipid solubil-
ity enables them to cross the bloodbrain barrier. Similarly,
the alkylating antibiotic mitomycin targets hypoxic tumor
cells, such as those at the center of a solid tumor, because it
requires bioreductive activation, which occurs more readily
in low-oxygen environments.
Several nonclassical alkylating agents also deserve men-
tion as clinically useful drugs. The first is dacarbazine, a
synthetic molecule that is a component of a potentially cu-
rative combination chemotherapy regimen for Hodgkins
disease. Dacarbazine also has some activity in treating mela-
noma and sarcomas. Procarbazine is an orally active drug
that is used against Hodgkins disease. A metabolite of pro-
carbazine functions as a monoamine oxidase inhibitor, and
toxicity related to this activitysuch as tyramine sensitivity,
hypotension, and dry mouthcan occur. Temozolomide, an
oral alkylating agent, is an imidazotetrazine derivative of
dacarbazine. Temozolomide is widely used in the treatment
of gliomas and of glioblastoma multiforme in particular. Its
action is synergistic with radiation, and it enhances survival
in glioblastoma when used in combination with radiotherapy
for this disease. Finally, altretamine is useful for treating
refractory ovarian cancer. Although it is structurally related
to alkylating agents of the triethylenemelamine class (such
as thiotepa), whether the mechanism of action of this drug
involves DNA alkylation remains controversial.
Through natural selection, tumor cells can develop resis-
tance to a single alkylating agent as well as cross-resistance
to other drugs in the same class. Several mechanisms for
resistance have been reported. Highly reactive drugs can be
deactivated by intracellular nucleophiles such as glutathi-
one. Alternatively, cells can become resistant by reducing
uptake of the drug or accelerating DNA repair. One enzyme,
O6-methylguanine-DNA methyltransferase (MGMT),
prevents permanent DNA damage by removing alkyl ad-
ducts to the O6 position of guanine before DNA cross-links
are formed. Increased expression of this enzyme in neoplas-
tic cells is associated with resistance to alkylating agents.
Conversely, MGMT gene silencing predicts clinical benefit
from temozolomide in glioblastoma.
severe. As a rule, adverse effects result from damage to DNA
of normal cells. Three cell types are preferentially affected by
nal and genitourinary tract epithelium, and hair follicles. This
results in myelosuppression, gastrointestinal distress, and al-
opecia (hair loss). Second, organ-specific toxicity can result
from low activity of a DNA damage repair pathway in that
tissue. Third, a tissue can be preferentially affected because
the toxic compound accumulates in that tissue; for example,
acrolein (a byproduct of the activation of cyclophosphamide
or its analogue ifosfamide) can produce hemorrhagic cystitis
688 Principles of Chemotherapy

N
NH
Cl Cl
N N N NH2
DNA chain
Mechlorethamine Guanine

Cl
N OH

N
N

N N NH2
DNA chain
Alkylated guanine
A D Cl
OH N OH N OH

N N N
N N N
B C
H2N N N N N NH2 N N NH2
DNA chain DNA chain Guanine excision from DNA
Crosslinked DNA

O
Cl H
Cl O
N OH N N N
H DNA chain
N N
N N
O
O
H
HN N N N
N NH2
DNA chain DNA chain H
Ring cleavage Abnormal base pairing (alkylated guanine
hydrogen-bonded to thymine)

FIGURE 38-18. Biochemical outcomes of guanine alkylation. In reactions such as those exemplified here with mechlorethamine, guanine alkylation can cause
several types of DNA damage. The nitrogen of mechlorethamine performs a nucleophilic attack on one of its own -carbons, resulting in an unstable intermediate that
is highly electrophilic (not shown). The nucleophilic N-7 of guanine reacts with this unstable intermediate, resulting in an alkylated guanine. There are four potential
outcomes that can result from this initial alkylation, all of which cause structural damage to DNA. A. The process of alkylation can be repeated, with a second guanine
acting as a nucleophile. The resulting cross-linking of DNA appears to be a major mechanism by which alkylating agents damage DNA. B. Cleavage of the imidazole ring
disrupts the structure of the guanine base. C. The alkylated guanine can hydrogen-bond to thymine rather than cytosine, leading to a mutation in the DNA. D. Excision
of the alkylated guanine residue results in a depurinated DNA strand.

because of accumulation and concentration in the bladder
(Fig. 38-19). This toxicity can be treated by using the sulfhy-
dryl-containing molecule mesna, which is also concentrated
in the urine and rapidly inactivates the acrolein.
The immune response requires rapid proliferation of lym-
phocytes; this makes lymphocytes especially vulnerable to
damage by alkylating agents. Thus, in addition to their anti-
cancer activity, alkylating agents such as cyclophosphamide
are also effective at immunosuppression. This toxicity has
been put to clinical use: administered at doses lower than
those needed for antineoplastic therapy, alkylating agents
are used to treat autoimmune diseases and organ rejection
(see Chapter 45, Pharmacology of Immunosuppression).
One approach to limiting toxicity has been to develop
alkylating agents that accumulate preferentially inside
tumor cells. An example of one such agent is melphalan,
or phenylalanine mustard; this agent was designed to target
melanoma cells, which accumulate phenylalanine for the
biosynthesis of melanin. Another example is estramustine,
in which the mustard component is conjugated to estrogen;
this agent was designed to target breast cancer cells that ex-
press the estrogen receptor. Interestingly, neither melphalan
nor estramustine works as intended, although they both have
clinical utility; through mechanisms that are still poorly un-
derstood, melphalan is active against multiple myeloma, and
estramustine is used to treat prostate cancer.
 Cl

H O
N
P N
O

Cl
Cyclophosphamide
Prodrug (inactive)

Liver cytochrome
P450 oxidase

Cl Cl

H O H O
HO N O N
P N P N
O O

Cl Cl
4-Hydroxycyclophosphamide 4-Ketocyclophosphamide
(active) (inactive)

O O

P Cl P Cl
H2N N H2N N
O OH
H O

H +
O
Cl Cl
Aldophosphamide Acrolein Phosphoramide mustard
(active) (cytotoxic) (cytotoxic)

Aldehyde oxidase

O
P Cl
H2N N
HO O

O
Cl
Carboxyphosphamide
(inactive)

O
H3N O
H3N Cl Pt
Pt H3N O
H3N Cl
O
Cisplatin Carboplatin
690 Principles of Chemotherapy

A B

FIGURE 38-21. Interactions of bleomycin, platinum compounds, and anthracyclines with DNA. A. Bleomycin (highlighted in orange) binds to the DNA double
helix and thereby exposes nucleotides in the DNA to the iron (II) atom (large red ball ) that is complexed to bleomycin. In the presence of molecular oxygen, the iron
bleomycin complex generates activated oxygen species that cause single-stranded and double-stranded breaks in the DNA by a free radical mechanism. B. Platinum
complexes (highlighted in orange) cross-link N-7 atoms on adjacent guanine residues, forming intrastrand DNA cross-links. C. Daunorubicin, an anthracycline (high-
lighted in orange), intercalates into DNA structure (see expanded view on right ) and thereby prevents the strand passage and religation steps that are part of the catalytic
cycle of type II topoisomerase (see Fig. 33-4). Anthracyclines may also damage DNA by a free radical mechanism.

nephrotoxicity without diminishing its antitumor effects.
Carboplatin, a cisplatin analogue associated with less neph-
rotoxicity, has replaced cisplatin in many chemotherapy regi-
mens. Oxaliplatin, a third platinum compound, has activity
in the treatment of colorectal cancer. Like cisplatin, oxalipla-
tin causes cumulative neurotoxicity; oxaliplatin also induces
a unique acute neurotoxicity that is exacerbated by exposure
to cold temperatures.
In non-small cell lung cancer, it has been suggested that
levels of the nucleotide excision repair protein ERCC1 predict
responsiveness to adjuvant platinum-based chemotherapy.
As described earlier, the NER pathway functions to remove
bulky DNA adducts formed by agents such as cisplatin.
In fact, lower levels of ERCC1 have been associated with
greater benefit from platinum-based therapy, presumably
since cells with dysfunctional NER cannot repair platinum-
induced DNA damage.
Bleomycin
The bleomycins, a family of natural glycopeptides synthe-
sized by a species of Streptomyces, have prominent cyto-
toxic activity. A mixture of several of these glycopeptides,
Vinca alkaloids
Exchangeable
GTP binding site
V

Taxanes T
-tubulin

Nonexchangeable
C GTP binding site

-tubulin
 CHAPTER 38 / Pharmacology of Cancer: Genome Synthesis, Stability, and Maintenance 693
important adverse effects. An acute hypersensitivity reac-
tion occurs commonly in response to paclitaxel, or more
likely to the vehicle in which paclitaxel is solubilized; this
effect can be obviated by administration of dexamethasone
(a glucocorticoid receptor agonist) and a histamine H1 re-
ceptor antagonist before treatment with paclitaxel. Many
patients experience myalgias and myelosuppression from
paclitaxel, and high doses of the drug can cause pulmonary
toxicity. Peripheral neuropathy, typically manifesting as a
stocking and glove sensory deficit in the extremities, can
limit the cumulative amount of drug that can be adminis-
tered safely.
Abraxane is an albumin-bound form of paclitaxel with
a mean particle size of 130 nanometers. The albumin-bound
paclitaxel nanoparticles do not cause a hypersensitivity reac-
tion, do not require premedication, and cause less myelosup-
pression than traditional, solvent-based paclitaxel. Abraxane
is currently approved for the treatment of metastatic breast
cancer and is being tested for activity in other tumor types.
Docetaxel is most commonly used in the treatment of breast
cancer and non-small cell lung cancer. As with paclitaxel, do-
cetaxel causes an acute hypersensitivity reaction that can be
obviated by preadministration of glucocorticoids. Docetaxel
occasionally exhibits the drug-specific adverse effect of fluid
retention, which likely arises from increased capillary perme-
ability. Docetaxel does not cause neuropathy as frequently as
paclitaxel. The myelosuppression associated with docetaxel
is profound, however, and is usually dose-limiting.
 CONCLUSION AND FUTURE DIRECTIONS
The antineoplastic agents described in this chapter exert
their effects on the genome by preventing efficient DNA
replication, inducing DNA damage, and interfering with mi-
tosis. Because many normal cells as well as cancer cells are
transiting through the cell cycle, these agents are associated
with multiple dose-limiting toxicities. In addition, although
cancer cells are susceptible to DNA damage, in some in-
stances, mutations in key checkpoint proteins such as p53
can prevent the apoptosis that would otherwise be induced
by these agents.
Novel approaches are being developed to target DNA
damage more specifically. For example, it has been shown
that mice deficient in PARP1 are able to overcome the de-
fect in single-strand break repair by converting single-strand
breaks to double-strand breaks and then repairing the DNA
by the DSB repair pathway. Furthermore, normal human
cells treated in culture with PARP1 inhibitors are capable
of undergoing normal cell division, although these cells
do manifest increased susceptibility to DNA damage as a
consequence of defective single-strand break repair. In
contrast, cells deficient in BRCA1 or BRCA2, which are
involved in DSB repair, are killed in response to treatment
with PARP1 inhibitors; compared to normal cells, BRCA1
or BRCA2 cells are up to 1,000-fold more sensitive to the
action of PARP1 inhibitors. Presumably, the BRCA1 and
BRCA2 cells are more sensitive due to impairment of both
single-strand break and DSB repair pathways, resulting in
lethal accumulation of DNA damage. Based on these find-
ings, PARP1 inhibitors are currently in clinical trials for the
treatment of BRCA-deficient breast or ovarian cancer and
may be effective in other tumors in which the DNA damage
response is compromised.
The observation that telomerase is expressed in most
cancer cells and is a key component of the process of im-
mortalization highlights this enzyme as an important target
in future cancer therapy. Although telomerase is expressed
to some degree in stem cells and in normally cycling cells,
most normal cells lack telomerase expression. Therefore, the
dependency of tumor cells on the immortalized state could
provide telomerase inhibitors with a favorable therapeutic
index. However, effective agents have yet to be discovered,
and one concern is that multiple cell divisions may be re-
quired for telomere length to shorten to a level that is critical
for cell survival. Combinations of telomerase inhibitors with
traditional cytotoxic agents or newer molecularly targeted
therapies could yield synergistic effects. Such strategies,
as well as those described in Chapter 39, Pharmacology of
Cancer: Signal Transduction, will help to advance cancer
therapy by moving beyond general cytotoxic approaches and
focusing treatment instead on the molecular abnormalities
responsible for driving oncogenesis.
Suggested Reading
Brody LC. Treating cancer by targeting a weakness. N Engl J Med
2005;353:949950. (Advances in targeted cancer therapy.)
Gazdar A. DNA repair and survival in lung cancer. N Engl J Med
2007;356:771773. (DNA repair pathway status in relationship to survival
and chemotherapy responsiveness.)
Hahn WC. Role of telomeres and telomerase in the pathogenesis of human
cancer. J Clin Oncol 2003;21:20342043. (Possible therapeutic applica-
tions of telomerase inhibitors.)
Peltomaki P. Role of DNA mismatch repair defects in the pathogenesis of
human cancer. J Clin Oncol 2003;21:11741179. (Insights into pathophysi-
ology of DNA repair mechanisms.)
Venkitaraman AR. Cancer susceptibility and the functions of BRCA1 and
BRCA2. Cell 2002;108:171182. (Pathophysiology of BRCA1 and BRCA2.)

Pharmacology of Cancer:
Signal Transduction
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 699-700
BIOCHEMISTRY OF INTERCELLULAR
AND INTRACELLULAR SIGNAL TRANSDUCTION . . . . . . . . . 699
Growth Factors and Growth Factor Receptors . . . . . . . . . 699
Intracellular Signal Transduction Pathways. . . . . . . . . . . . 700
Proteasome Structure and Function . . . . . . . . . . . . . . . . . 701
Angiogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 705
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 707
Growth Factor Receptor and Signal
Transduction Antagonists . . . . . . . . . . . . . . . . . . . . . . . . . 707
EGF Receptor Antagonists . . . . . . . . . . . . . . . . . . . . . . 707
BCR-ABL/C-KIT/PDGFR Inhibition . . . . . . . . . . . . . . . . 708
 INTRODUCTION
Traditional antineoplastic therapy has consisted of agents
directed against DNA replication and cell division. These
drugs exhibit some degree of selectivity against cancer cells,
which tend to have a higher growth fraction and, in some
cases, an increased susceptibility to DNA damage compared
to normal cells. However, the therapeutic window of these
drugs is narrow, resulting in toxicity to normal stem cells
and in hematologic and gastrointestinal adverse effects. With
the impressive advances in basic tumor cell biology over the
last several decades and the identification of numerous on-
cogenes and tumor suppressor genes, the potential exists for
development of agents that are targeted more specifically
at the molecular circuitry responsible for the dysregulated
proliferation of cancer cells. An early example of such a
drug is the selective estrogen receptor modulator tamoxifen
(see Chapter 29, Pharmacology of Reproduction), which
has been one of the most active agents in the treatment of
hormone receptor-positive breast cancer, with a relatively
modest adverse effect profile. More recently, the remarkable
success of imatinib mesylate in the treatment of chronic
myelogenous leukemia has suggested that, in some cases,
tumor cells are dependent on oncogenes such as BCR-ABL
for their survival. This chapter highlights basic principles of
targeted cancer therapy, detailing recent advances and direc-
tions for the future.
39
David A. Barbie and David A. Frank
FLT3 Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 708
JAK2 Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 709
RAS/MAP Kinase Pathway Inhibition . . . . . . . . . . . . . . 709
mTOR Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 709
Proteasome Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . 710
Angiogenesis Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . 710
Anti-VEGF Antibodies . . . . . . . . . . . . . . . . . . . . . . . . . 710
VEGFR Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 711
Thalidomide and Lenalidomide . . . . . . . . . . . . . . . . . . 711
Tumor-Specific Monoclonal Antibodies . . . . . . . . . . . . . . . 711
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 712
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 712
 BIOCHEMISTRY OF INTERCELLULAR
AND INTRACELLULAR SIGNAL
TRANSDUCTION
Growth Factors and Growth Factor Receptors
Stimulation of cell growth and proliferation by external sig-
nals is mediated by the interaction of growth factors with spe-
cific cell surface receptors. Growth factor receptors typically
contain an extracellular ligand-binding domain, a hydropho-
bic transmembrane domain, and a cytoplasmic tail that has
either intrinsic tyrosine kinase activity or an associated pro-
tein tyrosine kinase (Fig. 39-1A, B). In general, binding of
the growth factor ligand results in receptor oligomerization,
a conformational change in the cytoplasmic domain of the
receptor, and tyrosine kinase activation. Intracellular targets
are subsequently phosphorylated, propagating a signal that
culminates in progression through the cell cycle and cellular
proliferation.
One example of a receptor tyrosine kinase is the epider-
mal growth factor receptor (EGFR), which possesses in-
trinsic tyrosine kinase activity and is a member of the broader
ErbB family of proteins, including EGFR (ErbB1), HER2/neu
(ErbB2), ErbB3, and ErbB4. Binding of epidermal growth
factor (EGF) or transforming growth factor- (TGF-) to
EGFR results in receptor homodimerization and propagation
of a growth signal. In addition, heterodimerization between
699
 Ligand
A (e.g., EGF)

Ligand-
binding
domain
Trans-
membrane
domain

Tyr Tyr P Tyr Tyr P

Tyrosine
kinase
domain Tyrosine kinase
activity
Tyr P Tyr

Intracellular
B Ligand target protein
(e.g., EPO)

Ligand-
binding
domain
Trans-
membrane
domain

Tyr Tyr P Tyr Tyr P

Inactive protein Tyrosine kinase

tyrosine kinase activity
(e.g., JAK2)
Tyr P Tyr
Intracellular
target protein
702 Principles of Chemotherapy

A Cetuximab (anti-ErbB1)
B
IGF1 EGF
Trastuzumab (anti-ErbB2)
EGFR
IGF1R EGFR

P P
P Tyr Tyr P Gefitinib P Tyr Tyr P
Erlotinib

Farnesyltransferase
inhibitors
PI3K RAS
ABL RAS SRC

Imatinib PIP3 PTEN

Dasatinib
RAF Sorafenib

PDK

MEK MEK inhibitors

mTOR
AKT inhibitors
MAPK

Foxo mTOR

Nucleus
MAPK

MYC
Nucleus Transcription of
JUN genes needed for
apoptosis and cell
FOS
Foxo cycle arrest
Synthesis of proteins
needed for cell growth
Myc/ Gene transcription
and cell cycle
Jun/Fos progression

C
EPO EPOR EGF FIGURE 39-2. Intracellular signaling pathways. A. The RAS-MAP kinase pathway is ac-
tivated by multiple growth factor receptors (here exemplified by the EGF receptor, EGFR) as well
EGFR
as several intracellular tyrosine kinases such as SRC and ABL. RAS is recruited to the plasma
membrane by farnesylation and activated by binding to GTP. Activated RAS stimulates a sequence
of phosphorylation events mediated by RAF, MEK, and ERK (MAP) kinases. Activated MAP kinase
(MAPK) translocates to the nucleus and activates proteins such as MYC, JUN, and FOS that pro-
mote the transcription of genes involved in cell cycle progression. Cetuximab and trastuzumab
P Tyr Tyr P
P Tyr Tyr P
act as antagonists at the EGF receptor (ErbB1) and HER2 receptor (ErbB2), respectively. Gefitinib
and erlotinib inhibit the receptor tyrosine kinase. Farnesyltransferase inhibitors prevent RAS ac-
JAK2
tivation. Imatinib and dasatinib inhibit ABL kinase; sorafenib inhibits RAF kinase; and several
JAK2 agents under development (see text) inhibit MEK kinase. B. The PI3 kinase (PI3K) pathway is
inhibitors
activated by RAS and by a number of growth factor receptors (here exemplified by the insulin-like
P STAT STAT P SRC growth factor receptor 1 [IGF1R] and the epidermal growth factor receptor [EGFR]). Activated
PI3K generates phosphatidylinositol-3,4,5-trisphosphate (PIP3), which activates phosphoinositide
dependent kinase-1 (PDK). In turn, PDK phosphorylates AKT. PTEN is an endogenous inhibitor of
AKT activation. Phosphorylated AKT transduces multiple downstream signals, including activation
of the mammalian target of rapamycin (mTOR) and inhibition of the FOXO family of transcrip-
tion factors. mTOR activation promotes the synthesis of proteins required for cell growth and
cell cycle progression. Because the FOXO family of transcription factors activates the expres-
Nucleus sion of genes involved in cell cycle arrest, stress resistance, and apoptosis, inhibition of FOXO
promotes cell proliferation and resistance to apoptosis. Rapamycin (sirolimus) and its derivatives
Gene transcription are mTOR inhibitors that inhibit cell cycle progression and promote apoptosis. C. The STAT path-
P STAT STAT P way is activated by SRC and by a number of growth factor receptors (here exemplified by the
erythropoietin receptor [EPOR], which signals to STAT proteins through JAK2 kinase, and by the
EGF receptor [EGFR], which signals to STAT proteins indirectly). Phosphorylation of STAT induces
SH2 domain-mediated homodimerization, and phosphorylated STAT homodimers translocate to
the nucleus and activate transcription. JAK2 inhibitors are under development for the treatment
of polycythemia vera and other myeloproliferative disorders, many of which share a common
activating mutation in JAK2 (V617F).
 CHAPTER 39 / Pharmacology of Cancer: Signal Transduction 703

p16
specificity. The E3 ubiquitin ligase component is largely re-
MAPK Cyclin D CDK4/6
sponsible for target protein specificity. The RING family of
E3 ligases contains a characteristic RING finger domain with
conserved histidine and cysteine residues complexed with
Cyclin D two central Zn2 ions. RING E3 ligases can be subdivided
CDK4/6 into single-subunit E3 ligases and multisubunit complexes
such as the Skp1-Cullin-F-box protein family (SCF) E3 li-
gases. In the latter complexes, the RING finger component,
P Rbx, is distinct from the specificity component, the F-box
P RB P
protein, which is so named because of a characteristic motif
first identified in cyclin F.
P
RB Once proteins are selectively ubiquitinated, they are tar-
S phase genes S phase genes geted for degradation by the 26S proteasome, which is a cy-
E2F E2F lindrical particle present in both the cytoplasm and nucleus.
The core 20S subunit is the catalytic component with multiple
proteolytic sites, while the 19S regulatory component medi-
G1 phase S phase ates binding to ubiquitin-conjugated proteins and has mul-
FIGURE 39-3. Regulation of the G1S cell cycle transition. Activation of tiple ATPases involved in substrate unfolding and delivery
MAP kinase results in increased expression of the D-type cyclins. Cyclin D binds to the central 20S chamber. Substrates are cleaved progres-
to its catalytic partners cyclin-dependent kinase 4 and 6 (CDK4 and CDK6), which sively, with one protein being completely degraded before
phosphorylate the retinoblastoma protein (RB). Phosphorylation of RB releases its the next protein enters. Short peptide segments, on average
transcriptional repression of S-phase genes, allowing the transcription factor E2F 6 to 10 amino acids in length, are extruded and subsequently
to activate the transcription of genes needed for entry into S phase. These genes hydrolyzed to individual amino acids in the cytosol.
include cyclin E as well as DNA polymerase and the enzymes involved in nucle-
Regulation of protein degradation occurs largely at the
otide synthesis. Cyclin E binds to its catalytic partner CDK2, which further phos-
phorylates RB, creating a positive feedback loop that drives cells into S phase (not
level of the E3 ubiquitin ligase and governs key aspects of
shown). The CDK2/CDK4/CDK6 system is counterbalanced by cyclin-dependent cell cycle control, apoptosis, and other important cellular
kinase inhibitors (CDKIs) such as p16, which inhibits CDK4/6, and p21 and p27, processes (Fig. 39-4B). For example, CBL is a single-subunit
which inhibit CDK2 (not shown). RING E3 ubiquitin ligase that targets phosphorylated EGFR
family members for degradation. In addition, both cyclins
and cyclin-dependent kinase inhibitors are major targets for

B Single-subunit Multisubunit
RING E3 ligases RING E3 ligases
Ub Ub
Ub Ub
A Ub
Ub Ub
Ub
Ub Ub
Step 1 Step 2 Step 3 Ub
Ub Skp1 Ub
Ub
PPi Ub Ub Ub E3 Target Rbx F-box Target
+
AMP E1 E2 Target Target Cullin

E3
Single subunit ligase Target F-box protein ligase Target
ATP E1 E2 Target CBL EGFR SKP2 p27, FOXO
+ MDM2 p53 Fbw7 Cyclin E
Ub
Ub
TrCP -catenin, IB
Ubiquitin
Bortezomib
26S proteasome SCF-like ligase Target

Anaphase Cyclin B
promoting
Ub complex
Ub
VHL HIF-
Target protein fragments

FIGURE 39-4. The ubiquitinproteasome pathway. A. Ubiquitin (Ub) is activated by ATP-dependent conjugation to E1, the first enzyme in the pathway. Activated
ubiquitin is then passed from the active-site cysteine of E1 to the active-site cysteine of the ubiquitin-conjugating enzyme E2, which functions coordinately with the ubiq-
uitin ligase E3 to attach ubiquitin to protein targets. Polyubiquitination of target proteins results in their recognition by the 26S proteasome, which consists of a 19S outer
regulatory subunit and a 20S internal core chamber. The proteasome mediates proteolytic degradation of the target protein into short peptide fragments. Bortezomib is
a proteasome inhibitor that has been approved for use in multiple myeloma and is under investigation for use in other malignancies. B. The RING family of E3 ubiquitin
ligases consists of single-subunit enzymes (left) and multisubunit protein complexes (right). Single-subunit ligases include CBL, which targets EGFR for degradation,
and MDM2, which targets p53 for degradation. Multisubunit RING E3 ligase complexes include SCF and SCF-like family members, which are named for their Skp1, Cullin,
and F-box protein subunits. The F-box protein component mediates target protein specificity; for example, SKP2 targets p27 and FOXO for degradation, Fbw7 targets
cyclin E for degradation, and TrCP targets -catenin and IB for degradation. SCF-like ligase complexes include the anaphase promoting complex, which targets
cyclin B for degradation, and VHL, which targets the subunit of hypoxia-inducible factor-1 (HIF-1) for degradation.
704 Principles of Chemotherapy

ubiquitin-mediated proteasomal degradation. The anaphase-
promoting complex is a multiprotein RING-containing E3
ligase that is activated by phosphorylation late in mitosis,
triggering degradation of cyclin B and progression through
mitosis. Regulation of the G1S cell cycle transition is in
part mediated by the cyclin-dependent kinase inhibitor p27,
which inhibits cyclin ECDK2 and cyclin ACDK2 com-
plexes. Degradation of p27 is regulated by another SCF E3
ligase, which binds p27 via its F-box specificity component
Skp2. Thus, overexpression of Skp2, which is found in
a number of tumor types, can promote cell cycle progres-
sion by degrading p27. Degradation of FOXO by Skp2 is a
second mechanism by which overexpression of Skp2 may
promote tumorigenesis. Yet another SCF E3 ligase complex
regulates cyclin E activity by targeting it for degradation via
the F-box protein Fbw7. Loss of Fbw7 has been implicated
in tumor progression due to high levels of cyclin E.
Another example of an E3 ligase with a critical role in the
regulation of apoptosis and cell cycle regulation is MDM2,
a single-subunit RING finger E3 ligase that targets p53 for
degradation. Activation of MDM2 is linked to impairment
of apoptosis and promotion of tumorigenesis via loss of p53.
MDM2 is inhibited by the p14ARF protein, which shares the
same genomic locus as the CDK4/6 inhibitor p16. Disruption
of this locus, which is one of the most common events in
cancer, leads ultimately to both p53 and pRB inactivation.
Other key cellular pathways regulated by ubiquitin-
mediated proteasomal degradation include the WNT sig-
naling and nuclear factor-kappa B (NFB) pathways. Both
pathways are targeted by the common F-box protein TrCP,
which recognizes phosphorylated substrates (Fig. 39-5).
Activation of WNT signaling prevents phosphorylation of
-catenin, which allows it to escape recognition by TrCP
and ubiquitin ligation by SCF E3 ligase. Unphosphorylated
-catenin then translocates to the nucleus with its part-
ners TCF/LEF and activates transcription of genes such as
myc and cyclin D1. This pathway is also regulated by the
adenomatous polyposis coli (APC) gene, which forms part

A Wnt

Frizzled
Absence of Wnt

APC
complex -catenin
(active) Disheveled P

-catenin P
APC
complex
(inactive) -catenin
Ub
TrCP Ub
complex
Ub
Ub
Ub

-catenin P

Nucleus

26S proteasome Transcription of genes

-catenin TCF/
LEF
promoting cell cycle
progression
Ub
Ub

-catenin fragments

FIGURE 39-5. WNT signaling and NFB pathways. A. In the absence of WNT signaling, -catenin is phosphorylated by the adenomatous polyposis coli (APC)
protein complex. Phosphorylated -catenin is recognized by TrCP and thereby targeted for ubiquitin-mediated proteasomal degradation. Activation of WNT signaling
inhibits APC function, allowing -catenin to accumulate and translocate to the nucleus. In the nucleus, -catenin complexes with its partners TCF/LEF and activates
the transcription of genes promoting cell cycle progression. Hereditary or acquired loss of APC allows accumulation of -catenin, contributing to oncogenesis in colon
cancer. (continued)

B Absence of stimuli
IB
kinase IB NFB
(inactive)
Inactive complex
26S proteasome
IB fragments
FIGURE 39-5. (continued) B. Similarly, the IB protein is targeted for ubiquitin-mediated proteasomal degradation as a result of phosphorylation by IB kinase and
recognition by TrCP. In the absence of stimuli, IB binds to and inhibits NFB. In the presence of stimuli, proteasomal degradation of IB allows NFB to translocate to
the nucleus and activate the transcription of genes involved in proliferation and inflammation.
of the complex that promotes phosphorylation and subse-
quent destruction of -catenin. Loss of APC in colorectal
cells prevents phosphorylation of -catenin, leading to its
accumulation and promotion of cancer.
The F-box protein TrCP also regulates signaling through
NFB, which is inhibited by its association with the inhibitor
of NFB (IB). Phosphorylation of IB by a family of IB
kinases (IKKs) allows TrCP to bind to IB and activate its
proteasome-mediated destruction. The release of IB inhibi-
tion allows NFB to translocate to the nucleus and activate
transcription of genes involved in inflammation, prolifera-
tion, and survival. Specific IKKs may be aberrantly activated
in cancer cells and thereby generate an environment that fa-
vors tumor cell survival.
Angiogenesis
Solid tumors require development of a neovasculature in order
to sustain growth and survive conditions of hypoxia. Tumor
angiogenesis is a complex process involving a number of dif-
ferent pro- and antiangiogenic factors. The vascular endothe-
lial growth factor (VEGF) family of proteins and receptors
has emerged as a key regulator of this process. The VEGF
family consists of seven ligands, including VEGF-A, -B, -C,
-D, and -E and placenta growth factor (PlGF)-1 and -2 (Table
CHAPTER 39 / Pharmacology of Cancer: Signal Transduction 705
Multiple stimuli
IB
kinase IB NFB
(active)
IB P
TrCP
Ub
complex
Ub
Ub
Ub
Ub
IB P
Nucleus
Transcription of genes
NFB involved in proliferation
and inflammation
Ub
Ub
39-2). These ligands have varying affinities for the major
VEGF receptors, VEGFR1 (also known as Flt-1), VEGFR2
(Flk-1/KDR), and VEGFR3 (Flt-4). The VEGF receptors are
receptor tyrosine kinases. Neuropilins (NRP-1 and -2) are
coreceptors that lack an intracellular signaling domain and
enhance the binding of ligand to VEGFR1 and VEGFR2.
VEGFR1 and VEGFR2 are expressed on the vascular en-
dothelium and play key roles in angiogenic signaling, while
signaling through VEGFR3 appears to play a major role in
lymphangiogenesis (i.e., development of new lymphatic
vessels). VEGFR2, which appears to be the major proangio-
genic receptor that is targeted by VEGF-A, has been shown
to signal via both a RAF/MAP kinase pathway to promote
proliferation of endothelial cells and a PI3K/AKT pathway to
promote endothelial cell survival. VEGF also potently induces
vascular permeability, utilizing similar signaling pathways
both to promote the formation of transendothelial vesicular
organelles and to open interendothelial junctions. Invasion
and migration of endothelial cells is promoted by activation of
matrix metalloproteinases and serine proteases and by reorga-
nization of intracellular actin.
Activation of VEGF is mediated by stimuli such as hy-
poxia, by cytokines and growth factors, and by a variety of
oncogenes and tumor suppressor genes. Regulation of the
response to hypoxia is mediated by von Hippel-Lindau
 Normal or high O2 Low O2

HIF-1 HIF-1
PHD PHD
O2

HIF-1 OH

VHL
complex Ub
Ub
Ub
Ub
Ub

HIF-1 OH

Nucleus
26S proteasome
Transcription of VEGF,
HIF-1 HIF-1 PDGF-, TGF-, EPO
genes
Ub
Ub

HIF-1 fragments
708 Principles of Chemotherapy
Trastuzumab, another chimeric mouse/human IgG mono-
clonal antibody, is directed against ErbB2 (HER2) (Fig. 39-2A).
Approximately 2530% of breast cancers are associated with
amplification and overexpression of Her2/neu; these cancers
also display more aggressive behavior. HER2 amplifies the
signal generated by other ErbB family members via the forma-
tion of heterodimers. Trastuzumab down-regulates HER2 and
thereby disrupts this signaling. In vivo, trastuzumab also ap-
pears to induce antibody-dependent cellular cytotoxicity and
inhibit angiogenesis.
Trastuzumab has significant activity in breast cancers with
high levels of HER2 amplification. In addition to this intrin-
sic activity of trastuzumab in the advanced and metastatic
breast cancer settings, treatment of HER2-amplified breast
cancers with trastuzumab in the adjuvant setting (i.e., after
surgical resection of the tumor) enhances the efficacy of che-
motherapy and reduces rates of cancer recurrence by 50%.
The principal adverse effect of trastuzumab is cardiotoxicity,
particularly when used in combination with anthracyclines.
Trastuzumab does not cross the bloodbrain barrier, and
thus CNS relapse of breast cancer may occur. Lapatinib, a
small-molecule dual EGFR/HER2 inhibitor, has also been
approved for the treatment of metastatic breast cancer with
HER2 overexpression. Lapatinib crosses the bloodbrain
barrier and shows activity against brain metastases.
BCR-ABL/C-KIT/PDGFR Inhibition
Imatinib
Imatinib is a small-molecule tyrosine kinase inhibitor that
was initially developed as a 2-phenylaminopyrimidine deriv-
ative specific for PDGFR. Imatinib was subsequently found
to be a potent inhibitor of ABL kinases, including the BCR-
ABL fusion protein generated as a result of the t(9;22) chro-
mosomal translocation (Philadelphia chromosome) found in
chronic myelogenous leukemia (CML), and was also found
to inhibit the receptor tyrosine kinase C-KIT (Fig. 39-2A).
Imatinib is the canonical example of a targeted therapeutic
agent, because BCR-ABL is uniquely expressed by leukemic
cells and is essential for their survival.
Initial in vitro studies demonstrated that imatinib potently
and specifically inhibits the growth of cells expressing BCR-
ABL. Subsequent evaluation of an oral formulation in mice
demonstrated suppression of growth of human BCR-ABL-
positive tumors with minimal adverse effects. Early stud-
ies of imatinib in patients with chronic-phase CML yielded
impressive results, with normalization of blood counts
(a hematologic response) in 95% of patients and significant
reduction in cells expressing the Philadelphia chromosome
(a cytogenetic response) in 41% of patients. In a phase III
study, imatinib was superior to standard treatment with in-
terferon and cytarabine in patients with chronic-phase CML,
with a hematologic response rate of 95% and a complete
cytogenetic response in 76% of patients. Treatment of ac-
celerated or blast-phase CML with imatinib is less effective
but is associated with some responses. Imatinib is relatively
well tolerated; its principal adverse effects are myelosup-
pression, superficial edema, nausea, muscle cramps, skin
rash, and diarrhea.
Given the relatively recent development of imatinib, lon-
ger-term follow-up is needed to determine how sustained the
responses will be over time. Indeed, a significant fraction
of patients still show evidence of the BCR-ABL transcript
when sensitive tests such as reverse transcriptase polymerase
chain reaction (RT-PCR) are used for detection, even in cases
where a complete cytogenetic response is observed.
Mutation of C-KIT, the receptor for stem cell factor
(SCF), is found frequently in gastrointestinal stromal tumor
(GIST) and in the myeloproliferative disorder systemic
mastocytosis. In GIST, mutations and in-frame deletions of
C-KIT are typically found in the juxtamembrane domain, re-
sulting in constitutive activation of the tyrosine kinase in the
absence of ligand. In contrast, in systemic mastocytosis, the
characteristic D816V activating C-KIT mutation is within
the tyrosine kinase domain itself. Imatinib has shown sig-
nificant activity in advanced gastrointestinal stromal tumor,
but it has proven largely ineffective in the treatment of sys-
temic mastocytosis. Indeed, biochemical studies show that
the drug is not effective at targeting C-KIT kinases with the
D816V mutation.
Both the idiopathic hypereosinophilic syndrome and a
variant of systemic mastocytosis with eosinophilia are char-
acterized by the expression of the FIPL1-PDGFRA fusion
protein. This protein, which is generated by an interstitial
chromosomal deletion, causes constitutive signaling through
PDGFRA. Inhibition of PDGFRA by imatinib has been a
successful therapeutic approach in both conditions.
Dasatinib and Nilotinib
Crystallographic studies show that imatinib targets the ATP-
binding site of ABL only when the activation loop of the
kinase is closed, thereby stabilizing the protein in an inactive
conformation (see Fig. 1-2). Clinical resistance to imatinib
has been recognized in some patients with CML, occasion-
ally due to amplification of BCR-ABL, but more commonly
due to the acquisition of resistance mutations. Only a frac-
tion of these mutations directly interfere with drug binding;
instead, most mutations affect the ability of ABL to adopt the
closed conformation to which imatinib binds.
A second class of tyrosine kinase inhibitors, the dual
SRCABL inhibitors, can bind to the ATP-binding site in
ABL irrespective of the conformational status of the activa-
tion loop. One of these drugs, dasatinib, has significantly
greater efficacy than imatinib against wild-type BCR-ABL,
and it inhibits the activity of most clinically relevant ima-
tinib-resistant BCR-ABL isoforms, with the exception of the
T315I mutation (Fig. 39-2A).
Another structure-based approach to improve the efficacy
of imatinib has been to substitute alternative binding groups
for the N-methylpiperazine group, resulting in the develop-
ment of nilotinib. Similar to dasatinib, the affinity of nilo-
tinib for wild-type BCR-ABL is significantly higher than
that of imatinib, and nilotinib inhibits most imatinib-resistant
mutants with the exception of T315I. Both dasatinib and ni-
lotinib have shown activity in patients with CML who have
developed resistance to imatinib, and both are undergoing
further clinical testing. Both drugs also inhibit C-KIT kinases
with the D816V mutation in vitro and are being tested in pa-
tients with systemic mastocytosis.
FLT3 Inhibitors
One of the most common mutations in acute myelogenous
leukemia (AML), occurring in approximately 2530% of
patients, involves internal tandem duplication within the jux-
tamembrane domain of the FLT3 receptor tyrosine kinase.
This mutation results in ligand-independent dimerization
and activation of signaling via the RAS/MAPK and STAT
 CHAPTER 39 / Pharmacology of Cancer: Signal Transduction 709
pathways. A number of FLT3 inhibitors have been devel-
oped and demonstrate anti-leukemia cell activity in vitro.
Several experimental agents, such as PKC412, have demon-
strated single-agent activity in patients with relapsed/refrac-
tory AML carrying FLT3 mutations. Studies are under way
to examine whether FLT3 inhibitors may improve outcomes
in AML in combination with standard chemotherapy.
JAK2 Inhibitors
Despite the success of imatinib in the treatment of CML, the
genetic basis of the other major myeloproliferative disorders
(polycythemia vera, essential thrombocythemia, and myeloid
metaplasia with myelofibrosis) has, until recently, remained
obscure. It is now apparent that a common activating muta-
tion in JAK2 (V617F) underlies the aberrant signaling and
proliferation in most cases, although how one mutation leads
to this spectrum of disorders remains unclear (see Fig. 39-2C).
The V617F mutation is found in the pseudokinase domain
of JAK2, and disruption of this autoinhibitory region leads
to unchecked activity of the kinase. In vitro, selective JAK2
inhibitors cause cells containing the JAK2 V617F mutation
to be growth inhibited and undergo apoptosis; and in animal
models, JAK2 inhibitors demonstrate therapeutic efficacy
against JAK2(V617F)-induced hematologic disease. Thus,
JAK2 inhibitors are under development for the treatment of
polycythemia vera, essential thrombocythemia, and myeloid
metaplasia with myelofibrosis.
RAS/MAP Kinase Pathway Inhibition
Oncogenic mutation of ras is one of the most common
events in malignancy, occurring in approximately 30% of
human cancers. K-ras mutations are frequently observed in
non-small cell lung cancer, colorectal cancer, and pancre-
atic carcinoma, while H-ras mutations are found in kidney,
bladder, and thyroid cancers, and N-ras mutations occur in
melanoma, hepatocellular carcinoma, and hematologic ma-
lignancies. However, despite the frequency of these muta-
tions, inhibition of RAS has thus far been difficult to achieve
and has yielded minimal clinical success. Most efforts have
been focused on targeting farnesylation of RAS and inhibit-
ing downstream effectors.
Farnesylation of RAS is essential for its association with
the plasma membrane and subsequent activation. A number
of farnesyltransferase inhibitors (FTIs) have been devel-
oped that inhibit RAS farnesylation (Fig. 39-2A). While
these inhibitors demonstrate activity against RAS in vitro,
some RAS mutants exhibit resistance. Moreover, there are
many other targets of farnesylation that could be inhibited
by FTIs and are likely responsible for the cytotoxic effects
of these drugs. FTIs that have been tested clinically include
tipifarnib and lonafarnib. Tipifarnib has demonstrated ac-
tivity in relapsed/refractory AML, although responses ap-
pear to be independent of ras mutations. Clinical testing of
FTIs in solid tumors has not yet met with success.
Immediately downstream of RAS is the serine/threo-
nine kinase RAF, which phosphorylates MEK, which in
turn phosphorylates MAP kinase, leading to transcription
factor activation (Fig. 39-2A). There are three RAF family
membersA-RAF, B-RAF, and C-RAF. Activating muta-
tions in B-RAF have been found in a significant proportion
of malignant melanomas and are also observed at a lower
frequency in lung, colorectal, ovarian, and thyroid cancers.
Sorafenib was initially designed as a C-RAF inhibitor, but it
also demonstrates high inhibitory activity on both wild-type
and mutant B-RAF. Sorafenib has shown significant activity
against melanoma cell lines that contain activating B-RAF
mutations, and the drug is currently in clinical testing for
use in melanoma. Sorafenib also inhibits the tyrosine kinase
activity of VEGFR-2 and PDGFR- and has demonstrated
clinical efficacy in the treatment of advanced renal cell car-
cinoma and hepatocellular carcinoma.
There are two MEK homologues, MEK1 and MEK2,
both of which have dual serine-threonine and tyrosine ki-
nase activity, phosphorylating and activating ERK1 and
ERK2. CI-1040 is a highly active inhibitor of both MEK1
and MEK2 (Fig. 39-2A). Early clinical testing of CI-1040 in
patients with solid tumors has shown some activity but un-
favorable pharmacokinetic characteristics. More potent and
bioavailable second-generation MEK inhibitors have been
developed and are in clinical trials.
An important emerging concept is the need to identify
specific subsets of cancers that are susceptible to specific tar-
geted agents, exemplified by the sensitivity of EGFR-mutant
NSCLC to gefitinib and erlotinib. One current approach is
to identify gene expression profiles that are markers of on-
cogene activation. For example, a specific gene expression
profile has been characterized for RAS activation, and this
profile correlates with RAS mutation and RAS pathway ac-
tivation in cell lines and tumor specimens. Only cell lines
displaying gene expression profiles concordant with RAS ac-
tivation respond to FTIs in vitro. Thus, selection of patients
for clinical trials based on such an approach may enrich for
clinical activity of agents such as FTIs. Another approach
has been to identify subsets of RAS pathway activation pro-
files that predict responsiveness to downstream inhibition of
targets such as MEK. Comparison of cell lines with activat-
ing N-RAS mutations and those with activating B-RAF mu-
tations has shown that only the latter cell lines exhibit high
sensitivity to the MEK inhibitor CI-1040, possibly because
MEK is more immediately downstream of RAF. Therefore,
selection of patients with tumors containing B-RAF muta-
tions for clinical trials of MEK inhibitors will potentially
yield greater efficacy. Finally, it is possible that unanticipated
pathways will represent particularly important targets in the
presence of oncogenes such as K-RAS. The advent of ge-
netic screening in mammalian cells using RNA interference
(RNAi) provides an opportunity to identify particular signal-
ing pathways upon which a tumor may be dependent.
mTOR Inhibitors
Signaling via the PI3K/AKT pathway leads to downstream
activation of the mammalian target of rapamycin (mTOR)
(Fig. 39-2B). mTOR is a serine-threonine kinase that regu-
lates multiple cellular functions, including cell growth and
proliferation, via activation of protein synthesis. mTOR
regulation is accomplished in part by activation of the 40S
ribosomal protein S6 kinase (p70S6k) and inactivation of the
4E-binding protein (4E-BP1), which regulates translation of
certain mRNAs. Dysregulated mTOR activity is seen in a
wide variety of malignancies in which the PI3K pathway is
activated or PTEN is lost. In addition, hamartoma syndromes
such as tuberous sclerosis result in activation of mTOR. The
tuberous sclerosis protein complex (TSC1/2) acts as an in-
termediary between AKT and mTOR: native TSC1/2 inhib-
its mTOR, and activation of AKT results in phosphorylation
of TSC1/2 and subsequent de-repression of mTOR.
712 Principles of Chemotherapy
found almost exclusively on mature B cells. The anti-CD20
IgG1 monoclonal antibody rituximab has demonstrated sig-
nificant single-agent activity and enhancement of the effects
of chemotherapy in B-cell non-Hodgkins lymphoma (NHL),
and is now routinely incorporated in the therapy of this disor-
der. Principal adverse effects include immunosuppression due
to the targeting of normal mature B cells and hypersensitivity
reactions related to the chimeric nature of the antibody.
Conjugation of radioactive isotopes to anti-CD20 antibod-
ies, such as iodine-131 (131I) tositumomab and yttrium-90
(90Y) ibritumomab tiuxetan, has allowed targeted radioim-
munotherapy of B-cell NHL. These agents are being incor-
porated into treatment regimens of patients with refractory
disease and as induction therapy for stem cell transplantation.
Alemtuzumab is a humanized monoclonal antibody di-
rected against the pan-leukocyte antigen CD52. This agent
has been used in the treatment of chronic lymphocytic leu-
kemia (CLL) and as a component of conditioning regimens
for stem cell transplantation. Because alemtuzumab induces
lysis of both T-cell and B-cell populations, its principal ad-
verse effect is significant immunosuppression, including in-
creased risk for Pneumocystis jiroveci pneumonia and for
fungal, cytomegalovirus, and herpesvirus infections. There-
fore, prophylaxis for opportunistic infections is required.
Two additional examples of antibody conjugates are denileu-
kin diftitox and gemtuzumab ozogamicin. Denileukin difti-
tox, a recombinant fusion protein composed of fragments of
diphtheria toxin and human IL-2, targets the CD25 component
of the IL-2 receptor and has demonstrated activity in T-cell
NHL. Gemtuzumab ozogamicin is a conjugate between the
antitumor antibiotic calicheamicin and a monoclonal antibody
directed against CD33, which is found on the surface of leuke-
mic blasts in more than 80% of patients with AML.
 CONCLUSION AND FUTURE DIRECTIONS
Elucidation of the molecular and biochemical circuitry that
regulates normal cell proliferation and identification of the
key mutations that promote oncogenesis have provided the
ability to target specific pathways that are dysregulated in
tumors. The success of imatinib in the treatment of CML
demonstrates that cancers can become dependent on onco-
genes such as BCR-ABL, requiring oncoprotein signaling
for continued proliferation and survival. Although inhibitors
of receptor tyrosine kinases and intracellular kinases have
a greater therapeutic index than traditional antineoplastic
therapies and have had some success in certain tumors, in
many cases, responses are neither durable nor complete. The
identification of subsets of tumors in which specific path-
ways are activated, such as the EFGR mutation in NSCLC,
will guide therapy and improve response rates. Oncogenic
microarray signatures and correlations between specific mu-
tations and sensitivity to targeted agents will facilitate the
design of clinical trials focusing on subsets of patients with
the highest likelihood of response. Efficacy will also be im-
proved with second- and third-generation drugs that have
higher specificity for targets and the ability to overcome re-
sistance mutations.
It is clear, however, that multiple factors contribute to tumor
development, including downstream mutations in pathways
regulating cell cycle progression, apoptosis, proteasomal deg-
radation, and angiogenesis. The biology of these processes and
of tumor cell invasion and acquisition of metastatic potential
will likely provide novel targets for directed therapy. As with
combination chemotherapy, the successful targeted therapies
of the future will likely involve inhibition of multiple pathways
using a combination of agents directed at the defects found
in individual tumors. Furthermore, systematic approaches in-
volving RNAi and chemical screens may identify previously
unanticipated vulnerabilities associated with specific cancer
genotypes, a concept derived from synthetic lethal screen-
ing in yeast. The higher degree of specificity inherent in such
strategies will likely give them a superior therapeutic index
compared to traditional combination antineoplastic chemo-
therapy and will hopefully be met with a greater degree of
clinical success.
Suggested Reading
Bartlett JB, Dredge K, Dagleish AG. The evolution of thalidomide and its
IMiD derivatives as anticancer agents. Nat Rev Cancer 2004;4:314322.
(Historic and scientific overview of thalidomide and its derivatives.)
Hanahan D, Weinberg RA. The hallmarks of cancer. Cell 2000;100:5770.
(Seminal overview of the characteristic genetic changes leading to onco-
genesis.)
Hicklin DJ, Ellis LM. Role of the vascular endothelial growth factor path-
way in tumor growth and angiogenesis. J Clin Oncol 2005;23:10111027.
(Overview of VEGF pathways.)
Kaelin WG. The concept of synthetic lethality in the context of anticancer
therapy. Nat Rev Cancer 2005;5:689698. (Novel approaches to cancer
genotype-guided drug development.)
Krause DS, van Etten RA. Tyrosine kinases as targets for cancer therapy. N
Engl J Med 2005;353:172187. (Advances in tyrosine kinase inhibition.)
Mani A, Gelmann EP. The ubiquitin-proteasome pathway and its role in
cancer. J Clin Oncol 2005;23:47764789. (Biochemical details of ubiquitin
pathways.)
Wullchleger S, Loewith R, Hall M. TOR signaling in growth and metabo-
lism. Cell 2006;124:471484. (Possible applications of mTOR inhibitors.)
40
Principles of Combination
Chemotherapy
Quentin J. Baca, Donald M. Coen, and David E. Golan
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 716-717
ANTIMICROBIAL COMBINATION THERAPY . . . . . . . . . . . . . 716
Minimum Inhibitory Concentration and Minimum
Bactericidal Concentration . . . . . . . . . . . . . . . . . . . . . . . . 716
Types of Drug InteractionsSynergy, Additivity,
and Antagonism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 718
Examples of Antimicrobial Combination Therapy . . . . . . . 719
Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719
Synergistic Combinations . . . . . . . . . . . . . . . . . . . . . . 720
Co-administration of Penicillins with
-Lactamase Inhibitors. . . . . . . . . . . . . . . . . . . . . . . . 721
Polymicrobial and Life-Threatening Infections . . . . . . . 721
Unfavorable Drug Combinations . . . . . . . . . . . . . . . . . . . . 721
 INTRODUCTION
Many infections and some cancers can be successfully treated
with single-drug therapies. Such regimens often fail, however,
when pathogens or tumors develop resistance to chemothera-
peutic agents, when multiple pathogens with different drug
susceptibilities are simultaneously present, or when the dose
of the therapeutic agent is limited by toxicity. Under these cir-
cumstances, combination chemotherapy may offer decisive
advantages. The drugs in a multidrug regimen can interact syn-
ergistically to enhance the antimicrobial or antineoplastic effec-
tiveness of the combination and can decrease the likelihood that
resistance will emerge. Combinations are frequently used when
treatment must be initiated before the definitive identification
of the pathogen, and synergistic combinations can be used to
reduce toxicity when the individual drugs in the combination
have low therapeutic indices. Although combination chemother-
apy opens new avenues for the expedient elimination of a patho-
gen or tumor, it also introduces the potential for multiple adverse
effects and drug interactions. The goal of any combination drug
regimen should be to efficiently remove the offending pathogen
or tumor without incurring unacceptable host toxicity.
 ANTIMICROBIAL COMBINATION THERAPY
In the treatment of microbial infections, drug combinations
are used (1) to prevent the emergence of drug resistance;
716
ANTIVIRAL COMBINATION THERAPY: HIV . . . . . . . . . . . . . . 721
ANTINEOPLASTIC COMBINATION CHEMOTHERAPY . . . . . . 722
General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . 722
Rationale for Combination Chemotherapy . . . . . . . . . . . . 724
Examples of Antineoplastic Combination Chemotherapy. . 725
Hodgkins Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 725
Testicular Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . 726
Treatment of Refractory or Recurrent Disease . . . . . . . . . 726
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 726
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727
(2) to enhance the activity (efficacy) of the drug therapy
against a specific infection (synergy); (3) to reduce toxicity
to the host; (4) to treat multiple simultaneous infections
(sometimes called polymicrobial infections); and (5) to
treat a life-threatening infection empirically before the
microorganism causing the infection has been identified.
Because microbes are genetically distant from humans, an-
timicrobial drug combinations can target several different
molecules that are specific to the microbe(s), potentially
without a concomitant increase in adverse effects. In con-
trast, antineoplastic drug combinations are often limited
by adverse effects (see below). The following section pro-
vides a conceptual framework for the different types of
antimicrobial drug interactions and discusses specific ex-
amples of antimicrobial combination therapy.
Minimum Inhibitory Concentration and
Minimum Bactericidal Concentration
Antimicrobial agents with activity against a pathogenic
bacterial, protozoal, or fungal microorganism can be char-
acterized by the minimum inhibitory concentration (MIC)
and the minimum bactericidal concentration (MBC) for
the drugpathogen pair. The MIC is defined as the lowest
concentration of drug that inhibits growth of the microor-
ganism after 1824 hours of incubation in vitro. The MBC is
defined as the lowest concentration of drug that kills 99.9%
718 Principles of Chemotherapy
Add Remove
drug drug
Number of live bacteria
Bacteriostatic
drug
Bactericidal
drug
Time
FIGURE 40-1. Comparison of the effects of bacteriostatic and bacteri-
cidal drugs on bacterial growth kinetics in vitro. In the absence of drug, bacte-
ria grow with exponential (first-order) kinetics. A bactericidal drug kills the target
organism, as demonstrated by the time-dependent decrease in the number of live
bacteria. A bacteriostatic drug prevents microbial growth without killing the bacte-
ria. Removal of a bacteriostatic drug is followed by an exponential increase in bac-
terial number as the previously inhibited bacteria resume growth. Bacteriostatic
drugs eradicate infections by limiting the growth of the infecting organism for a
long enough period of time to allow the host immune system to kill the bacteria.
concentration-dependent (Fig. 40-2). Time-dependent
bactericidal agents exhibit a constant rate of killing that is
independent of drug concentration, provided that the drug
concentration is greater than the minimum bactericidal con-
centration (MBC). Thus, the overriding consideration for the
clinical use of such agents is not the absolute drug concen-
tration that is achieved, but for how long the drug concen-
tration remains in the therapeutic range (which is defined
as [drug] MBC). In contrast, concentration-dependent
Concentration-dependent
drug
Microbial killing rate
Time-dependent
drug
MBC
Drug concentration
FIGURE 40-2. Relationship between rate of microbial killing and drug
concentration for time-dependent and concentration-dependent bacteri-
cidal drugs. Time-dependent bactericidal agents exhibit a constant rate of mi-
crobial killing at concentrations of drug greater than the minimum bactericidal
concentration (MBC) (solid line). In contrast, concentration-dependent bactericidal
agents show increased killing with increasing drug concentration (dashed line).
Note that the efficacy of concentration-dependent bactericidal agents eventually
plateaus, because the effective concentration of the drug becomes limited by the
rate of drug diffusion to its molecular target
bactericidal agents have a rate of killing that increases with
drug concentration for [drug] MBC. For such agents, a
single very large dose may be sufficient to eliminate the in-
fection.
Types of Drug InteractionsSynergy,
Additivity, and Antagonism
The discussion has thus far considered the general properties
of drugs used as single agents to treat a microbial infection.
When such drugs are used in combination with other agents,
these effects can be modified (either enhanced or diminished).
In fact, drugs that have little or no activity against an organ-
ism when used as single agents can show high activity when
used in combination with another agent. One example of this
concept involves the treatment of Enterococcus faecalis, a
Gram-positive organism that exhibits little susceptibility to
aminoglycosides. Recall that aminoglycosides are thought
to kill bacteria by inducing misreading of the genetic code
and translation of defective proteins, which cause further
cellular damage (see Chapter 33). In the case of E. faeca-
lis, aminoglycosides are unable to penetrate the organisms
thick cell wall to reach their target, the 30S ribosomal sub-
unit. However, when used in combination with a cell wall
synthesis inhibitor such as vancomycin or a -lactam anti-
biotic, aminoglycosides are able to reach the bacterial ribo-
somes and effectively kill the bacteria (see Chapter 34). The
potentiating effect of the cell wall synthesis inhibitor on the
activity of the aminoglycoside is an example of the impor-
tant pharmacologic concept of synergy.
From this example, one could ask whether combining
two drugs with individual activity against a particular mi-
crobe always results in a more efficacious drug combination.
Surprisingly, for many combinations, this turns out not to
be the case. In fact, when two drugs with activity against
the same pathogen are combined, the drugs can interact to
enhance the efficacy of the combination (synergy) or to di-
minish the efficacy (antagonism). Alternatively, the drugs
may not interact, and the effect of the combination is sim-
ply the sum of the effects of each drug used individually
(additivity). The interaction between two antimicrobial
drugs is often quantified by selecting a particular endpoint
(e.g., inhibition of bacterial growth) and then measuring the
effect of various combinations of the two drugs that reach
this endpoint. When such data are plotted, additional infor-
mation can be obtained (Fig. 40-3). The x- and y-intercepts
correspond to the MICs of the two drugs, and the concavity
of the curve indicates the nature of the interaction between
the two drugsconcave-up is synergistic; concave-down
is antagonistic; linear is additive. The following discussion
provides a mathematical rationale for these relationships.
Suppose that drugs A and B inhibit a particular enzyme
required for bacterial growth. In this case, the ratio [A]/MICA
would represent the fraction of bacterial growth inhibition that
can be attributed to the presence of drug A. This is known as
the fractional inhibitory concentration of A (FICA). Similarly,
FICB [B]/MICB is the fraction of growth inhibition that can
be attributed to drug B. Now, suppose that the concentration
of A is decreased by a small amount, d[A]. To compensate
for this loss of growth inhibition (dFICA d[A]/MICA), the
concentration of B must be increased by an amount d[B].
For additive drugs, the ratio d[A]/d[B] (which is the same
as the slope of the curve in Fig. 40-3) is a constant because one
 A0
Antagonistic
MIC of drug A

Additive

Synergistic

0
0 B0
MIC of drug B

infections caused by Gram-negative enteric organisms. An
analogous combination, sulfadoxine and pyrimethamine,
is used in the treatment of malaria, toxoplasmosis, and other
protozoal infections. These combinations illustrate a second
mechanism whereby drugs can exert a synergistic effect.
The mechanism of synergy is based on the inhibition of two
steps in folic acid biosynthesis affecting the cellular concen-
tration of the same critical metabolite, dihydrofolate (see
Chapter 32). The reduced form of this metabolite, tetrahy-
drofolate, is a required substrate for purine biosynthesis and
for many one-carbon transfer reactions and is thus necessary
for DNA replication and cell division (see Fig. 32-7).
Co-administration of Penicillins with -Lactamase Inhibitors
The combination of a -lactam antibiotic and a -lactamase
inhibitor (e.g., clavulanic acid, sulbactam, tazobactam) il-
lustrates a mechanism of drug interaction that is not techni-
cally synergistic (because the -lactamase inhibitor has no
antibacterial activity of its own) but that shares a functional
similarity with the drug combinations discussed above.
Clavulanic acid is an inhibitor of -lactamase, an enzyme
used by many -lactam-resistant Gram-positive and Gram-
negative bacteria to inactivate penicillins (see Chapter 34).
By preventing the hydrolysis and inactivation of penicillins,
clavulanic acid (and other -lactamase inhibitors) greatly
increases the potency of penicillins (and other -lactams)
against bacteria that express -lactamase. This combina-
tion has been effective in the treatment of infections due to
penicillin-resistant Streptococcus pneumoniae, which is a
common cause of otitis media in infants. Such organisms
have typically acquired resistance to penicillins through a
plasmid-encoded -lactamase.
Polymicrobial and Life-Threatening Infections
Combinations of antimicrobial drugs are used not only to
prevent the emergence of resistance and to act synergistically
against a specific, known pathogen, but also to treat polymi-
crobial infections and infections in which treatment must be
initiated before the microbe causing the infection is identi-
fied. Consider, for example, the case of a ruptured appen-
dix or colonic diverticulum that has leaked bacteria into the
peritoneal cavity. Such an intra-abdominal abscess is likely
to contain a wide spectrum of microorganismsmuch too
broad to be targeted effectively by a single antibiotic. After
draining the abscess, treatment with a combination of anti-
bacterial agents such as an aminoglycosideto kill aerobic
Gram-negative Enterobacteriaceae (e.g., Escherichia coli)
and clindamycin or metronidazoleto kill anaerobes (e.g.,
Bacteroides fragilis; see Chapter 36)often results in clear-
ance of the infection. (Note that it may sometimes be neces-
sary to treat with antagonistic drug combinations in order to
cover the spectrum of microorganisms that are likely to be
present.) In cases where presumptive treatment is indicated
before the causative microorganism is identified, body fluids
such as blood, sputum, urine, and cerebrospinal fluid (CSF)
should be submitted for culture before initiating therapy. A
combination of drugs with activity against the microbes that
are most likely to be involved in the infection (or that could
result in the most serious outcome) is then administered
until a positive bacteriologic identification is made and drug
susceptibility results are obtained. At that point, it may be
possible to discontinue unnecessary drugs and to implement
specific monotherapy.
CHAPTER 40 / Principles of Combination Chemotherapy 721
Unfavorable Drug Combinations
Antagonism can sometimes result from combination chemo-
therapy, although this situation is to be avoided if possible.
Antagonism is most commonly observed when static drugs
are used in combination with cidal drugs. For example,
tetracyclines are bacteriostatic antimicrobials that antago-
nize the bactericidal activity of penicillins (see Chapter 33).
Recall that the bactericidal activity of penicillins depends
on cell growth. By inhibiting the transpeptidation reaction
involved in bacterial cell wall cross-linking, the penicillins
create an imbalance between cell wall synthesis and autolysin-
mediated cell wall degradation. If the bacterial cell continues
to grow, this leads to spheroplast formation and eventually to
osmotic lysis. A protein synthesis inhibitor such as tetracy-
cline, which arrests cell growth, would therefore antagonize
the effect of a -lactam. Similarly, imidazoles and triazoles
are fungistatic agents that antagonize the fungicidal activity
of amphotericin B (see Chapter 35). The mechanism of
antagonism can be appreciated by noting that amphotericin
B acts by binding ergosterol and forming pores in the fungal
membrane, whereas imidazoles and triazoles inhibit a mi-
crosomal cytochrome P450-dependent enzyme, 14-sterol
demethylase, which is involved in ergosterol biosynthesis.
Thus, the imidazoles and triazoles oppose the action of am-
photericin B by decreasing the concentration of the target
for the latter drug. Despite these considerations, static and
cidal antimicrobial drugs are sometimes used clinically in
combination when no good alternatives exist. In such cases,
it may be required to increase the dose of one or both drugs
to overcome the antagonistic drugdrug interaction. The re-
sulting increase in the therapeutic drug concentration(s) can
also increase the likelihood of adverse effects.
 ANTIVIRAL COMBINATION THERAPY: HIV
As discussed in Chapter 37, Pharmacology of Viral
Infections, no anti-HIV drug shows long-term suppressive
benefit when used as a single agent. This is due largely to the
development of drug resistance.
The viral life cycle is central to understanding the reason
that monotherapy for HIV fails to suppress long-term viral
replication (see Chapter 37; Fig. 37-2). After virus attach-
ment and fusion, the viral enzyme reverse transcriptase (RT)
synthesizes double-stranded DNA from the single-stranded
viral RNA genome. The DNA is then integrated into the
host cell genome and transcribed over and over using the
host cells transcription machinery. These complete genomic
transcripts are eventually packaged into virions that infect
new cells. However, HIV RT is relatively unfaithful, so rep-
lication error rates are quite high. In addition, transcription
of the integrated DNA into RNA is also error-prone. As a
result, on average, every new HIV particle contains one mu-
tation relative to its parental virus. Although the resulting
error rate is not so high as to be intolerable to the virus, it
is sufficiently high that, after repeated cycles of infection,
reverse transcription, and transcription, a substantial num-
ber of viruses encode altered targets of anti-HIV therapy and
thereby acquire resistance, even prior to treatment.
In the setting of high mutation rates, combination chemo-
therapy is beneficial. Combinations of RT inhibitors (e.g., AZT
and 3TC) are more effective than one RT inhibitor alone, in
part because resistance to one nucleoside analogue does not
722 Principles of Chemotherapy
necessarily confer resistance to another. The current standard
of care for treatment of HIV infection is triple therapy. Tri-
ple therapy can use many combinationsfor example, two
nucleoside analogue RT inhibitors and a nonnucleoside re-
verse transcriptase inhibitor (NNRTI), a nucleoside analogue
in combination with an NNRTI and a protease inhibitor, or two
nucleoside analogues and a protease inhibitor. Clinical trials
have shown that such combinations are able to reduce viral
RNA plasma levels below the limit of detection (typically, 50
copies/mL). At such low levels of viral replication, the prob-
ability of resistance emerging to any one of the drugs is greatly
reduced. Thus, for example, it has been shown that combina-
tions remain effective for much longer periods of time than
does any single agent. However, the complicated administra-
tion schedules and adverse effects of some combinations can
reduce adherence. Although combination formulations of com-
mon anti-HIV therapies have reduced pill burden, simplified
treatment, and increased adherence, the optimal time to begin
therapy remains unclear. Early treatment for symptomatic pa-
tients with low CD4 T-cell counts (350 cells/L) does reduce
HIV-associated morbidity and mortality, but the relative risks
and benefits of aggressive treatment for asymptomatic patients
with high CD4 counts have not been well established.
 ANTINEOPLASTIC COMBINATION
CHEMOTHERAPY
Antineoplastic chemotherapy faces several intrinsic difficul-
ties. Cancer cells can be thought of as altered self cells
that maintain a number of similarities to normal, noncan-
cerous cells, making it difficult to target the cancer cells
specifically. Also, many of the currently available cancer
chemotherapeutic agents have serious adverse effects that
limit their dose and frequency of administration. Despite
these hurdles, combination chemotherapy has led to remark-
able advances in the treatment of cancer, including the ex-
amples of Hodgkins disease and testicular cancer discussed
at the end of this section. Table 40-2 provides an overview
of the major antineoplastic drug classes, including their
mechanisms of action, cell cycle specificities, major resis-
tance mechanisms, and dose-limiting toxicities. Note that all
of these drug classes have been discussed in previous chap-
ters; the following discussion integrates relevant informa-
tion about the individual drugs in a clinical context.
General Considerations
To appreciate the challenges that must be faced in treating
cancer with drug therapies, it is useful to examine the current
model for oncogenic transformation. Normal somatic cells
undergo differentiation as they mature from a small regener-
ating stem cell population. Because cells lose the ability to
divide as they progress along their differentiation pathway,
malignancies tend to arise in populations of immature or un-
differentiated cells (perhaps even stem cells). At the molecu-
lar level, the process of malignant transformation involves
multiple steps, including the loss of tumor suppressor gene
products (e.g., p53 and Rb) and the activation of proto-on-
cogenes (e.g., ras and c-myc) through such processes as so-
matic mutation, DNA translocation, and gene amplification.
Acquired alterations in genes that regulate the progression
of cells through the cell cycle confer a growth advantage on
malignant cells, which proliferate in the absence of normal
growth regulatory signals. Some of the most aggressive
transformed cells multiply at a rate of about two divisions a
day. At this rate, a single such cell could give rise to a clini-
cally detectable mass of 1 g (109 cells) in just 15 days, and a
tumor burden of 1 kg (1012 cells), which is often incompat-
ible with life, could be achieved in 20 days.
Fortunately, oncogenesis usually occurs much more
slowly than thisa fact that supports the concept of screen-
ing for many types of cancer (e.g., cervical, prostate, and
colon). A malignant cell can give rise to a small colony of
cells (106 cells) rather quickly, but further growth is held in
check by the limited availability of oxygen and nutrients.
Because oxygen can diffuse passively in tissues over a
distance of only 23 mm, cells in the center of the grow-
ing tumor mass become hypoxic and enter the G0 (resting)
phase. Accordingly, the percentage of cells that are actively
dividing (i.e., the growth fraction of the tumor) decreases as
tumor size increases. Moreover, the continued proliferation
of cells at the tumor margins causes a further decrease in
the pO2 in the center of the tumor, and hypoxic tumor cells
begin to die (central necrosis). The tumor continues to grow,
albeit at a slower rate, because the rate of cell division at
the margins exceeds the rate of central necrosis. At some
point, hypoxic tumor cells can express or induce the stromal
expression of angiogenic factors (e.g., vascular endothelial
growth factor [VEGF]) that induce vascularization of the
tumor. Vascularization can be accompanied by a sudden in-
crease in the growth fraction, as cells are pulled out of G0
phase and into the cell cycle.
Because a single malignant cell can expand clonally to
give rise to a tumor, it is thought that every malignant cell
must be destroyed to effect a cure of the cancer. This hy-
pothesis, together with the log-kill hypothesis for tumor
cell killing (see Chapter 32), suggests that multiple cycles of
chemotherapy must be administered at the highest tolerable
doses and the most frequent tolerable intervals to achieve a
cure. Antineoplastic chemotherapy usually follows first-order
kinetics (i.e., a constant fraction of tumor cells is killed with
each cycle of chemotherapy). These kinetics of tumor cell
killing are unlike the time-dependent killing characteristic of
many antimicrobial drugs, which follows zero-order kinetics
(i.e., a fixed number of microbes is killed per unit time).
Adding to the difficulty of successful cancer treatment is
the phenomenon of tumor progression, in which a clonally
derived population of malignant cells becomes heterogeneous
through the accumulation of multiple genetic and epigenetic
alterations. When subjected to selective pressure by immune
surveillance or the administration of an antineoplastic agent,
subclones of the tumor with relatively nonantigenic or drug-
resistant phenotypes are selected for. Mutations that confer
drug resistance are of particular concern, because many trans-
formed cells, having lost the ability to repair DNA damage,
are characterized by genomic instability. Thus, deletions, gene
amplifications, translocations, and point mutations are not in-
frequent events and can result in antineoplastic drug resistance
through any of the mechanisms shown in Table 40-3.
With the possible exception of more recently developed
classes of therapies based on molecular targets selectively
expressed by a malignant clone of cells (e.g., a monoclonal
antibody directed against a tumor cell antigen or an enzyme
inhibitor directed against a mutated signal transduction mol-
ecule; see Chapter 1, DrugReceptor Interactions; Chapter 39,
Pharmacology of Cancer: Signal Transduction; and Chapter 53,
726 Principles of Chemotherapy
Before the introduction of alkylating agents in the mid-
1960s, single-agent chemotherapy for advanced HD resulted
in a median survival of 1 year. With the development of MOPP
(mechlorethamine, vincristine, procarbazine, and predni-
sone), the first successful antineoplastic drug combination,
half of these patients were cured of their disease. Treatment
remained limited by significant toxicity, however, including
early gastrointestinal and neurological complications as well
as late sterility and secondary malignancies (myelodysplastic
syndrome, acute nonlymphocytic leukemia, and non-Hodg-
kins lymphoma). Further investigation led to the develop-
ment of the ABVD (doxorubicin, bleomycin, vinblastine,
and dacarbazine) combination, which is less toxic and more
effective than MOPP. ABVD is the current standard of care
for advanced HD, although trials of novel combination thera-
pies are under way. The rationale for the ABVD drug com-
bination comes from the knowledge that it combines both
cell cycle selective and nonselective agents as well as drugs
with different dose-limiting toxicities. Compared to MOPP,
ABVD is associated with significantly fewer hematological
and gonadal complications and secondary malignancies.
Testicular Cancer
The principles of antineoplastic combination chemotherapy
are also exemplified in the treatment of testicular cancer. This
tumor arises from the spermatogenic epithelium of the testis
and is usually detected as a testicular mass on physical ex-
amination. The tumor metastasizes through lymphatic chan-
nels to pelvic and periaortic lymph nodes before disseminat-
ing widely through hematogenous routes. Treatment of local
disease (without evidence of metastasis) involves surgical re-
moval of the affected testis with or without pelvic radiation.
Advanced disease requires systemic treatment with combina-
tion chemotherapy. The standard of care is BEP (Fig. 40-4).
Of the three drugs in this regimen (bleomycin, etoposide,
and cisplatin), cisplatin is the cell cycle nonspecific drug that
may draw nondividing tumor cells into the actively cycling
pool, where they are susceptible to the synergistic action of
Drug
Bleomycin
Day Day Day
2 9 16
Etoposide Day 1-5
Cisplatin Day 1-5
1 8 15 22
Time (days)
FIGURE 40-4. The bleomycin-etoposide-platinum (BEP) combination
chemotherapy regimen for testicular cancer. The BEP regimen used to treat
testicular cancer consists of a combination of bleomycin, etoposide, and cispla-
tin. Cisplatin is a cell cycle nonspecific agent; this drug may draw nondividing
cells into the cell cycle, where they can be killed by the G2-phase specific agent
bleomycin and the S/G2-phase specific agent etoposide. The intermittent dosing
schedule limits drug toxicity and allows time for the bone marrow to recover from
drug-induced myelosuppression. The 3-week cycle shown is typically adminis-
tered four times in succession (12 weeks total).
the cell cycle specific agents bleomycin and etoposide. The
drugs in this combination have different molecular targets,
act on different phases of the cell cycle, and have different
dose-limiting toxicities. Intermittent dosing allows each af-
fected organ (lung, bone marrow, and kidney, respectively)
time to recover between cycles. After surgical removal of the
primary tumor, such a regimen usually results in a cure.
Treatment of Refractory or Recurrent Disease
Despite the fact that combination chemotherapy has resulted
in vastly improved survival for some cancers, many cancers
become refractory to standard combination chemotherapy. If
a standard chemotherapy regimen fails, options include ex-
perimental drug therapies, palliative care, or novel drugs ap-
proved for use after treatment failure. Many patients choose
to enroll in experimental clinical trials. This decision may
be based on the hope that an investigational agent could
prove efficacious, but with the understanding that the true
benefit may be realized only by future patients. Palliative
and hospice care are alternatives to continued drug treatment
in cases of advanced metastatic disease. An increasing num-
ber of agents with novel mechanisms of action are becoming
available for disease that is otherwise refractory to treat-
ment. Many of these agents selectively target tumor-specific
antigens and signal transduction pathways, as discussed in
Chapters 39 and 53. Optimizing combinations of these and
other antineoplastic agents for efficacy and safety will be an
important challenge for the future.
 CONCLUSION AND FUTURE DIRECTIONS
The principles of combination chemotherapy highlight the
importance of combination drug treatment in a variety of
clinical situations. The use of drug combinations has greatly
enhanced the effectiveness of treatment of both infectious
and neoplastic diseases. The advantages offered by multi-
drug regimens over individual drug therapy (monotherapy)
include increased antimicrobial, antiviral, and antineoplas-
tic efficacy, decreased overall drug resistance, decreased
host toxicity, and broader coverage of suspected patho-
genic organisms. These advantages are illustrated in the
rational use of drug combinations to treat infections with
Mycobacterium tuberculosis and HIV, as well as neoplastic
disorders such as Hodgkins disease and testicular cancer.
Treatment of multidrug-resistant microorganisms such as
MDR-TB and MDR-HIV remains a special challenge, as
does treatment of genetically heterogeneous cancers with
low growth fractions such as lung, colon, breast, and pros-
tate cancers. Continued refinement of combination chemo-
therapy regimens will rely on increased understanding of
molecular targets and metabolic pathways used by microor-
ganisms and cancer cells.
Acknowledgment
The authors thank Shreya Kangovi and Gia Landry for initial
drafts of the case of Mr. M and the discussion in the chapter
related to his case. We thank Ryan L. Albritton for his valuable
contributions to this chapter in the First and Second Editions
of Principles of Pharmacology: The Pathophysiologic Basis
of Drug Therapy.

Suggested Reading
Bergers G, Hanahan D. Modes of resistance to anti-angiogenic therapy. Nat
Rev Cancer 2008;8:592603. (Reviews adaptive and intrinsic mechanisms
that may explain cancer resistance to bevacizumab and other antiangio-
genic therapies.)
Canellos GP, Anderson JR, Propert KJ, et al. Chemotherapy of advanced
Hodgkins disease with MOPP, ABVD, or MOPP alternating with ABVD.
N Engl J Med 1992;327:14781484. (These antineoplastic drug combina-
tions remain the standard of care for advanced Hodgkins disease.)
Centers for Disease Control and Prevention (CDC). Emergence of Myco-
bacterium tuberculosis with extensive resistance to second-line drugs
worldwide, 20002004. MMWR Morb Mortal Wkly Rep 2006;55:301305.
(Surveys international network of tuberculosis [TB] laboratories for inci-
dence and prevalence of multidrug-resistant [MDR] and extensively drug-
resistant [XDR] TB isolates.)
Chou R, Huffman LH, Fu R, et al. Screening for HIV: a review of the
evidence for the U.S. Preventive Services Task Force. Ann Intern Med
2005;143:5573. (Compares benefits and risks of screening for HIV and re-
views efficacy of highly active antiretroviral therapy [HAART] for patients
with advanced HIV infection.)
Chou TC, Talalay P. Quantitative analysis of dose-effect relationships: the
combined effects of multiple drugs or enzyme inhibitors. Adv Enzyme Regul
1984;22:2755. (Detailed analysis of models for synergistic, antagonistic,
and additive drug combinations.)
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Chou TC. Theoretical basis, experimental design, and computerized simu-
lation of synergism and antagonism in drug combination studies. Pharma-
col Rev 2006;58:621681. (Detailed analysis of models for synergistic,
antagonistic, and additive drug combinations.)
Dancey JE, Chen HX. Strategies for optimizing combinations of molec-
ular targeted anticancer agents. Nat Rev Drug Discov 2006;5:649659.
(Discusses principles for determining combinations of antineoplastic
agents that could be most promising to test in preclinical and clinical
trials.)
Harvey RJ. Synergism in the folate pathway. Rev Infect Dis 1982;4:255
260. (Describes the kinetics of synergism between trimethoprim and the
sulfonamides.)
Luo J, Solimini NL, Elledge SJ. Principles of cancer therapy: oncogene and
non-oncogene addiction. Cell 2009;136:823837. (Reviews antineoplastic
therapies targeting the 12 hallmarks of cancer and proposes principles for
developing new antineoplastic therapies and combinations.)
Ormerod LP. Multidrug-resistant tuberculosis (MDR-TB): epidemiology,
prevention and treatment. Br Med Bull 2005;73/74:1724. (Reviews epide-
miology, prevention, and treatment of multidrug-resistant tuberculosis.)
Yazdanpanah Y, Sissoko D, Egger M, et al. Clinical efficacy of antiretro-
viral combination therapy based on protease inhibitors or non-nucleoside
analogue reverse transcriptase inhibitors: indirect comparison of controlled
trials. Br Med J 2004;328:249256. (Reviews combination therapies used
in the treatment of HIV.)
VI

Principles of Inflammation
and Immune Pharmacology

Principles of Inflammation and
the Immune System
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 729-730
OVERVIEW OF THE IMMUNE SYSTEM . . . . . . . . . . . . . . . . . 730
Innate Immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 730
Antigen-Presenting Cells. . . . . . . . . . . . . . . . . . . . . . . 731
Activation of the Innate Immune Response . . . . . . . . . 732
Adaptive Immunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 732
Major Histocompatibility Complex . . . . . . . . . . . . . . . . 732
Immune Diversity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 733
Humoral and Cellular Immunity . . . . . . . . . . . . . . . . . . 733
Tolerance and Costimulation . . . . . . . . . . . . . . . . . . . . 734
CHEMICAL MEDIATORS OF INFLAMMATION . . . . . . . . . . . . 736
Histamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 736
Complement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 736
 INTRODUCTION
Inflammation and the immune system are closely intertwined.
Inflammation is a complex web of responses to tissue injury
and infection, characterized by the classic signs of rubor (red-
ness), calor (heat), tumor (swelling), dolor (pain), and functio
laesa (loss of function). The immune system comprises the
cells and soluble factors, such as antibodies and complement
proteins, that mediate the inflammatory response; these cells
and factors both eliminate the inciting inflammatory stimulus
and initiate the process of immunologic memory.
A normal inflammatory response is an acute process that
resolves after removal of the inciting stimulus. Diseases of
inflammation and immunity can occur due to inappropriate
inflammation or when the normal inflammatory response pro-
gresses to chronic inflammation, either because of a long-term
inappropriate response to a stimulus (for example, allergies)
or because the offending agent is not removed (for example,
chronic infection, transplantation, and autoimmunity).
Two pharmacologic strategies are used to target the
pathophysiology of immune diseases. The first involves
modification of the signaling mediators of the inflamma-
tory process or suppression of components of the immune
system. This is the rationale for drugs that affect eicosanoid
pathways (Chapter 42, Pharmacology of Eicosanoids),
histamine (Chapter 43, Histamine Pharmacology), and
41
Ehrin J. Armstrong and Lloyd B. Klickstein
Eicosanoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 737
Cytokines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 737
Other Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 737
THE INFLAMMATORY RESPONSE . . . . . . . . . . . . . . . . . . . . 737
Dilation of Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 737
Recruitment of Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . 737
Chemotaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 737
Phagocytosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 737
Resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 738
CHRONIC INFLAMMATION . . . . . . . . . . . . . . . . . . . . . . . . . . 738
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 738
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 739
cells of the immune system (Chapter 44, Pharmacology of
Hematopoiesis and Immunomodulation, and Chapter 45,
Pharmacology of Immunosuppression). This approach (be-
cause it is dependent on understanding the molecular events
in the relevant pathways) is still in its infancy but promises to
yield a number of new drugs in the foreseeable future.
The second pharmacologic approach, used in diseases such
as peptic ulcer disease (Chapter 46, Integrative Inflammation
Pharmacology: Peptic Ulcer Disease), asthma (Chapter 47,
Integrative Inflammation Pharmacology: Asthma), and gout
(Chapter 48, Integrative Inflammation Pharmacology: Gout),
involves modification of the underlying pathophysiologic
stimulus, thus removing the impetus for inflammation. The
difference between these two approaches is, at times, indistinct
and will continue to blur as the pathophysiology of chronic in-
flammatory disease is better understood at a molecular level.
This chapter provides sufficient background in the physi-
ology of inflammation and the immune system to understand
the subsequent chapters in this section of the textbook. The
treatment is necessarily brief, with an emphasis on pharma-
cologically relevant targets of the inflammatory response.
The chapter is organized into four parts. First, a general
overview of the immune system is presented. Second, the
molecular signals mediating cellular communication and
inflammation are introduced. Third, the immune and in-
flammatory cells and signaling molecules are discussed in
729
 CHAPTER 41 / Principles of Inflammation and the Immune System 731

Bone marrow

Pluripotent hematopoietic
stem cell

Lymphoid Trilineage Megakaryocyte Erythroblast

stem cell myeloid stem cell

Blood and tissues Blood

Monocyte/
Lymphocytes
y Granulocytes Mast cell
macrophage

B cell T cell Platelets Erythrocyte

Neutrophil Eosinophil Basophil Precursor Monocyte

Effector cells Tissue cells

Plasma cell Activated Mast cell Macrophage

T cell

FIGURE 41-1. Development of cells of the immune system. All hematopoietic cells develop from the pluripotent hematopoietic stem cell. This cell gives rise to the
lymphoid stem cell and the trilineage myeloid stem cell. The lymphoid stem cell and its progenitor cells (not shown) give rise to mature lymphocytes (B cells and T cells),
the cells that mediate adaptive immune responses. When exposed to specific antigens, B cells differentiate into antibody-producing plasma cells, and T cells adopt an
activated phenotype. The myeloid stem cell and its progenitor cells, including megakaryocytes, erythroblasts, and myeloid precursors (not shown), proliferate and dif-
ferentiate into mature neutrophils, eosinophils, basophils, mast cells, monocytes, platelets, and erythrocytes. In the tissues, monocytes differentiate into macrophages,
and mast cell precursors differentiate into mast cells. (See Fig. 44-1 for more details about the differentiation of cell lineages in the bone marrow.)

innate immune roles; the biology of these cell types is be-
yond the scope of this text.
Granulocyte is a descriptive term based on the ap-
pearance of the cytoplasmic granules within these cells.
Neutrophils, the most abundant cell type of the innate im-
mune system, are phagocytic cells primarily responsible
for defense against bacterial infection. These cells envelop
invading bacteria in phagocytic vesicles and destroy the bac-
teria within these vesicles using enzymes such as myeloper-
oxidase. Eosinophils are circulating granulocytes primarily
involved in defense against parasitic infections. Because
parasites are often too large to engulf, eosinophils attach to a
parasites exterior and secrete cytotoxic substances directly
on the parasite. Both basophils (circulating) and mast cells
(tissue-resident) bind IgE antibody, display this IgE on the
cell surface, and maintain histamine-containing granules
that are released when exogenous antigen binds to and cross-
links the IgE. Basophils and mast cells are important in
allergic responses. Eosinophils and basophils are so named
because they exhibit eosinophilic and basophilic patterns,
respectively, when stained with Wright-Giemsa stain.
Antigen-Presenting Cells
Antigen-presenting cells (APCs) process the macromole-
cules (especially proteins) of an invading agent to display the
processed fragments on the surface of the APC. In this form,
the fragments serve as molecular fingerprints used by cells
of the adaptive immune system to recognize the invading
agent. APCs are important initiators of immune responses
because, in addition to displaying nonself antigens to T cells
(see below), they provide the costimulatory signals that are
necessary for T-cell activation. The concept of costimula-
tion, in which two separate signals are required to initiate an
immune response to a stimulus, is discussed below.
Monocytes that exit the bloodstream and take up resi-
dence in the tissues can differentiate into macrophages.
 CHAPTER 41 / Principles of Inflammation and the Immune System 733

A MHC class I
Protein fragment
MHC class I proteins at the surface of the cell, and the im-
mune system will recognize that cell as virally infected. Anti-
CD8 binding site MHC class I protein gens presented by MHC class I proteins are recognized by T
2 microglobulin cells bearing the cell surface protein CD8. (The designation
CD stands for cluster of differentiation or cluster des-
Protein ignation and is a system for naming an ever-growing list of
fragments cell-associated antigensnow numbering in the hundreds
Cytoplasmic
that are present on leukocytes and other cell types. Each an-
protein tigen must be defined by at least two different monoclonal
antibodies in order to earn the CD designation.)
MHC class II proteins display protein fragments derived
from endocytic vesicles. In contrast to class I proteins, which
are expressed on all nucleated cells, MHC class II proteins
are expressed mostly on antigen-presenting cells (e.g., mac-
rophages and dendritic cells), although some other cell types
can be induced to express MHC class II proteins. Endocytic
Secretory vesicles contain antigenic protein fragments derived from in-
protein fectious agents after phagocytosis and proteolytic processing
Endoplasmic
reticulum of those agents. Therefore, the protein fragments expressed
on MHC class II proteins generally identify extracellular
Nucleated cell foreign agents (e.g., bacteria). As discussed below, T cells
bearing the cell surface protein CD4 recognize antigens pre-
sented by MHC class II proteins. In the process, these T cells
B MHC class II
CD4 binding site
stimulate the antigen-presenting cells to produce soluble fac-
Protein fragment
tors called cytokines and chemokines, which, in turn, aid the
MHC class II
T cells in responding to the antigen. In general, then, the
Protein protein protein fragments bound to MHC class I identify infected
cells, whereas the fragments bound to MHC class II identify
Endocytosis infectious agents. However, because of the phenomenon of
cross-presentation, some proteins generated in the cytosol
can be presented by MHC class II to CD4 T cells, and some
Degradation
phagocytosed antigens can be presented by MHC class I to
CD8 T cells.
Protein
fragments Immune Diversity
While MHC proteins provide a mechanism for distinguish-
ing infected cells and infectious agents from uninfected
cells, somatic gene recombination and other processes for
generating diversity provide a mechanism for generating a
specific response to an infection. By recombination, immu-
noglobulin and T-cell receptor genes semirandomly create
millions of modular three-dimensional protein structures,
referred to as variable regions. Recombined variable regions
may undergo somatic hypermutation to create additional
Antigen-presenting cell diversity that, in the aggregate, can recognize almost any
structure. This is the primary mechanism by which the im-
FIGURE 41-2. Class I and class II major histocompatibility complex pro-
teins. A. A representative fraction of cytoplasmic proteins are proteolytically de-
mune system generates an astounding diversity of immune
graded in the cytosol, and the protein fragments are transported to the endoplasmic responses.
reticulum (ER). A fraction of secretory proteins are degraded directly in the ER.
MHC class I protein, in association with 2 microglobulin, binds a fragment of the Humoral and Cellular Immunity
degraded cytoplasmic or secretory protein in the ER. The MHC class I:protein frag- Adaptive immunity is generally divided into humoral immu-
ment complex is transported to the cell surface, where it serves as a fingerprint nity and cellular immunity. In the basic (simplified) model
for the diversity of proteins expressed by that cell. The CD8 binding site on MHC of the immune system, the primary cells mediating these
class I ensures that the class I protein:antigen complex interacts only with cytotoxic branches of the immune system are referred to as B cells and
T cells, which express CD8. All nucleated human cells express MHC class I proteins. T cells, respectively (Table 41-1). The humoral response in-
B. Antigen-presenting cells phagocytose and degrade bacteria and other foreign
volves the production of antibodies specific for an antigen.
agents, generating protein fragments that bind to MHC class II protein in the ER. The
MHC class II:protein fragment complex is transported to the cell surface, where it
These antibodies are secreted by plasma cells (differentiated
serves to display all the potentially nonself antigens that have been ingested by that B cells) and are therefore effective primarily against extracel-
cell. The CD4 binding site on MHC class II ensures that the class II protein:antigen lular infectious agents (such as many bacteria). In contrast,
complex interacts only with helper T cells, which express CD4. Professional an- the cellular response involves activation and clonal expansion
tigen-presenting cells (B cells, macrophages, and dendritic cells) are usually the of T cells that recognize a specific antigen. Some T cells rec-
only cell types that express MHC class II proteins, but other cells can be induced to ognize infected cells and then lyse those cells using cytotoxic
express class II proteins and present antigens under some circumstances. proteins called perforins and granzymes. Cellular immune
734 Principles of Inflammation and Immune Pharmacology
responses are therefore effective against many intracellular
infectious agents (such as viruses).
In addition to their role in cellular immunity, T cells control
the extent of immune responses. Each T cell evolves so that
it is activated by only one specific MHC:antigen complex.
All T cells express an MHC:antigen-specific T-cell recep-
tor (TCR). T cells are divided into cytotoxic T cells (TC) and
helper T cells (TH) based on the type of coreceptor expressed
and the function imparted by that coreceptor (Fig. 41-3).
TC cells are the mediators of cellular adaptive immunity.
These cells express the CD8 coreceptor, which recognizes a
constant (i.e., antigen-independent) domain on MHC class I
proteins. This coreceptor function allows the antigen-specific
TCR on TC cells to bind a specific class I MHC:antigen com-
plex with sufficiently high affinity that the TC cell is activated
by the cell expressing the class I MHC:antigen complex.
A Cytotoxic T cell
MHC class I 2 microglobulin
protein
T cell
Antigen
receptor
CD8
Cytotoxic T cell Virus-infected cell
B Helper T cell
MHC class II
T cell protein
receptor Antigen
CD28 B7 CD4
IL-2R
IL-2 Antigen-presenting
Helper T cell cell
FIGURE 41-3. Activation of cytotoxic and helper T cells. T cells mediate
and regulate the cellular immune response. A. Cytotoxic T cells (TC) are the pri-
mary mediators of cellular immunity. These cells express T-cell receptors (TCR)
and CD8. The TCR identifies nonself antigens bound to MHC proteins, and CD8
ensures that TC cells interact only with cells expressing MHC class I proteins. In
the example shown, the interaction of a TC cell with the MHC class I protein of a
virus-infected cell leads to activation of the TC cell and subsequent killing of the
virus-infected cell. B. Helper T cells (TH) are the primary regulators of cellular im-
munity. These cells express TCR and CD4. CD4 binds to MHC class II proteins on
antigen-presenting cells (APC); this interaction ensures that TH cells interact only
with cells expressing MHC class II proteins. An additional degree of specificity is
provided by the interaction of CD28 on TH cells with proteins of the B7 family on
APC; this costimulatory signal is required for TH activation. In the example shown,
the interaction of a TH cell with the MHC class II and B7 proteins of an antigen-
presenting cell leads to activation of the TH cell. The activated TH cell secretes IL-2
and expresses the IL-2 receptor (IL-2R); this autocrine pathway stimulates further
TH-cell proliferation and activation. IL-2 and other cytokines secreted by the TH cell
activate not only TH cells, but also TC cells and B cells.
Specific activation of the TC cell initiates a chain of events,
including the secretion of membrane-penetrating perforins
and apoptosis-inducing granzymes, that results in the death
of the cell displaying the foreign antigen.
TH cells are primarily the regulators of adaptive immunity.
TH cells are identified by their expression of the CD4 core-
ceptor, which recognizes an antigen-independent domain on
MHC class II proteins. This coreceptor function allows the
antigen-specific TCR on TH cells to bind a specific class II
MHC:antigen complex with sufficiently high affinity that the
TH cell is activated by the antigen-presenting cell. In addi-
tion to initiating and strengthening the immune response, TH
cells control the type of immune response by producing one
or another set of cytokines. TH cells can be generally divided
into TH1 and TH2 subtypes based on the cytokines produced
by the cells. TH1 cells characteristically produce IFN- and
IL-2, and these cytokines influence the development of cell-
mediated immune responses of both CD8 TC cells and
other CD4 TH cells. In contrast, TH2 cells characteristically
produce IL-4, IL-5, and IL-10, and these cytokines enhance
antibody production by B cells. The TH2 cell subtype is more
often associated with autoimmunity (see Chapter 45). In ad-
dition to regulating adaptive immunity, TH cells can mediate
immunity by secreting cytokines that activate phagocytic
cells to kill infecting microbes more efficiently. Subtypes of
TH cells other than TH1 and TH2 have been discovered, and
some of these subtypes are important in human disease. For
example, the cytokine IL-23 stimulates naive CD4 cells to
differentiate into TH17 cells, and these cells produce IL-17
isoforms that recruit neutrophils and amplify the immune re-
sponse. Drugs that block the maturation or growth of TH17
cells are becoming available for clinical use.
Tolerance and Costimulation
Diversity in the variable regions of immunoglobulins and
T-cell receptors creates the potential for some of these mole-
cules to recognize and attack native proteins, a circumstance
termed autoimmunity. There are two primary mechanisms
for avoiding autoimmunity. The first is clonal deletion, in
which T cells die during development when they express
high-affinity receptors that recognize self-antigen. In a sec-
ond process referred to as tolerance or anergy, cells of the
immune system undergo a carefully regulated series of steps
during development to ensure that mature immune cells do
not recognize native proteins.
Costimulationthe requirement for multiple simulta-
neous signals to initiate an immune responseensures that
stimulation of a single immune receptor does not activate a
damaging immune reaction. Signal 1 provides specificity,
while signal 2 is permissive, ensuring that an inflammatory re-
sponse is appropriate. Regulation of costimulatory molecules
is a mechanism whereby the innate immune system regulates
the extent of an immune response. If antigen is presented with-
out a coincident costimulatory signal (i.e., without innate im-
mune activation), then anergy results, whereby a cell becomes
unreactive and will not respond to further antigenic stimuli.
Drugs that induce anergy could be therapeutically attractive,
because such agents could allow long-term acceptance of an
organ graft or limit the extent of an autoimmune disease.
For T cells, signal 1 is mediated by the MHC:antigen:TCR
interaction. Signal 2 is mediated predominantly by the inter-
action of CD28 on T cells with B7-1 (also called CD80) or
B7-2 (CD86) on activated antigen-presenting cells (Fig. 41-4).
 CHAPTER 41 / Principles of Inflammation and the Immune System 735

Antigen recognition T cell response

Cytokine receptor

A No costimulation MHC TCR

CD4
Naive
Resting T cell No response
APC

MHC TCR
B With costimulation

B7 CD28 IL-2R
CD4

Activated Activated
APC IL-2
Cytokines T cell
T cell proliferation
and differentiation

FIGURE 41-4. Costimulation in the T-cell activation pathway. Two signals are required for activation of a T-cell response to antigen. A. If an antigen-presenting
cell (APC) presents an antigen to a T cell in the absence of an appropriate costimulatory signal, the T cell does not respond and may become anergic. B. If an APC
presents both the antigen and a costimulatory molecule such as B7, the T cell proliferates and differentiates in response to the antigenic stimulus. Cytokines secreted
by the activated APC augment T-cell activation.

Resting T cells present CD28, which can bind either B7-1 or
B7-2. B7-1 and B7-2 are not normally present on antigen-
presenting cells, but their expression is increased by the innate
immune system during an immune response to a pathogen.
The lack of expression of B7 molecules in the absence of an
innate immune response may help to limit inappropriate adap-
tive immune responses. When a T cell receives both signal 1
and signal 2, expression of IL-2, T-cell activation, and clonal
expansion of TH cells specific for that foreign epitope occur.
Activated T cells eventually down-regulate CD28 expression
and up-regulate CTLA-4 expression. CTLA-4, like CD28,
binds B7-1 and B7-2 but with much higher affinity than
CD28. In contrast to the activating CD28 signal, interaction
of CTLA-4 with B7-1 or B7-2 inhibits T-cell proliferation.
This may be a physiologic mechanism for self-limitation of
the immune response.
CD40 ligand (CD40L) is another mediator of costimula-
tion. Activated T cells express CD40L (CD154). CD40 is
expressed on antigen-presenting cells, including B cells and
macrophages (Fig. 41-5). Interaction of TH-cell CD40L with

C APCs express B7 and secrete

A T cells recognize antigen B Activated T cells express CD40L
T cell-activating cytokines
Signal leading to
expression of CD40L Signal leading to expression of B7
Cytokine
receptor
CD40 CD40 CD40L CD40 CD40L
Antigen

CD4 CD28 CD28

B7 CD28

APC T cell APC Activated

T cell APC Activated
Cytokines
T cell
Enhanced T cell proliferation
and differentiation

FIGURE 41-5. Costimulation and the CD40CD40L interaction. A. An antigen-presenting cell (APC) presents MHC class II-bound antigen to a CD4 T cell. T-cell
recognition of antigen initiates an intracellular signaling cascade that leads to expression of CD40 ligand (CD40L) at the T-cell surface. B. CD40L on the activated T cell
binds to CD40 on the surface of the APC. Activation of CD40 generates an intracellular signaling cascade that leads to expression of B7 on the APC surface. C. Enhanced
T-cell proliferation and differentiation are promoted by costimulation of the T cell by MHC class II antigen (which binds to the T-cell receptor), CD40 (which binds to T-cell
CD40L), and B7 (which binds to T-cell CD28). Cytokines secreted by the activated APC augment T-cell proliferation and differentiation.
738 Principles of Inflammation and Immune Pharmacology

A Normal B Inflammation
Rolling Tight Diapedesis Migration
Blood flow adhesion binding
sialyl-Lewisx (s-Lex)
Blood vessel lumen IL-8R
Neutrophil IL-8
LFA-1
ICAM-1

E-selectin

Endothelial cells Subendothelial space CD31

Basement membrane
Chemokine
(IL-8)

FIGURE 41-6. Overview of the inflammatory response. A. Leukocytes circulating in the blood interact with selectins expressed on the surface of vascular
endothelial cells. In the absence of inflammation, the interaction between leukocytes and endothelial cells is weak, and leukocytes either flow past or roll along the
endothelium. Neutrophil rolling is mediated by the interaction between endothelial cell E-selectin and neutrophil sialyl-Lewisx (s-Lex). B. During the inflammatory re-
sponse, endothelial cells up-regulate their expression of intercellular adhesion molecules (ICAMs). ICAM expression increases the potential for strong binding interactions
between leukocytes and the activated endothelial cells. For example, ICAM-1 on endothelial cells binds tightly to LFA-1 on neutrophils. The enhanced cellcell interac-
tion leads to margination of leukocytes onto endothelial cell surfaces and initiates the process of leukocyte diapedesis and transmigration from the vascular space into
extravascular tissues. Leukocytes migrate through injured tissue in response to chemokines such as IL-8, which are inflammatory mediators released by injured cells
and by other immune cells that have already reached the site of injury.

one further stimulus to activate their killing machinery. For-
eign substances must be coated by an opsonin before they
can be ingested (phagocytosed) by leukocytes. Opsonins
are molecular adaptors that coat foreign surfaces and sig-
nal leukocytes that a particle should be attacked. The major
opsonins consist of complement, immunoglobulins (anti-
bodies), and collectins (plasma proteins that bind to certain
microbial carbohydrates). The interaction of a phagocytic
cell with an opsonized particle initiates engulfment and de-
struction of the offending agent. This step is also a crucial
point of interaction between innate and adaptive immunity.
Antigen-presenting cells process engulfed particles and
present their antigens to B cells and T cells, which then react
to the antigens. In the introductory case, Marks cut presum-
ably allowed bacteria to penetrate his skin barrier, leading to
infection. The presence of these bacteria initiated an inflam-
matory response that included phagocytosis of bacteria by
APCs, presentation of bacterial antigens to TH cells, activa-
tion and expansion of TH cells, TH-cell activation of further
APC-mediated phagocytosis, and synthesis and secretion of
antibodies specific for the bacteria.
Resolution
Tissue repair and re-establishment of homeostasis are the
final events in the acute inflammatory response. The same
mediators that activate inflammation also initiate a cascade
of tissue repair; this process is mediated by the release of
growth factors and cytokines, including epidermal growth
factor (EGF), platelet-derived growth factor (PDGF), basic
fibroblast growth factor-2 (bFGF-2), transforming growth
factor-1 (TGF-1), IL-1, and TNF-. These factors act
as mitogens for endothelial cells and fibroblasts and ul-
timately stimulate healing and scar formation through
angiogenesis (formation of new blood vessels) and the for-
mation of granulation tissue. In the introductory case, the
granulation tissue and eventual scar will be the only record
of Marks acute inflammatory event. Of note, angiogenesis
can be a pathologic state when it is associated with abnor-
mal blood vessel growth or tumor growth, and pharmaco-
logic inhibitors of angiogenesis are currently being used
to treat age-related macular degeneration (where abnormal
blood vessels obscure vision) and as antineoplastic agents
(see Chapter 39, Pharmacology of Cancer: Signal Trans-
duction).
 CHRONIC INFLAMMATION
Chronic inflammation is a pathologic state characterized
by the continued and inappropriate response of the im-
mune system to an inflammatory stimulus. Chronic inflam-
mation accounts for the symptoms of many autoimmune
diseases and may be an important cause of organ transplant
rejection. In contrast to the acute inflammatory response,
which is dominated by neutrophils, one of the hallmarks of
chronic inflammation is the predominance of macrophages.
Activated macrophages secrete collagenases and growth
factors in addition to inflammatory mediators such as pro-
teases and eicosanoids. These secreted products initiate
and maintain a cycle of tissue injury and repair, leading
to tissue remodeling. Over time, chronic inflammation can
cause relentless tissue destruction. Promising treatments
for chronic inflammation could include cytokine inhibitors
that neutralize mediators of the signaling cascades that per-
petuate chronic inflammation. These agents are discussed
in Chapter 45.
 CONCLUSION AND FUTURE DIRECTIONS
The immune system intricately regulates the response to tis-
sue injury and infection. A complete review of immunology
is beyond the scope of this text; instead, the discussion in this
chapter presents a broad overview and highlights elements
of immunity that may be addressed pharmacologically. In-
nate immune mechanisms respond to patterned elements
 CHAPTER 41 / Principles of Inflammation and the Immune System 739
shared among a class of infectious agents, such as bacterial
lipopolysaccharide or viral RNA. The innate immune system
also processes these agents and presents them to lympho-
cytes, thereby activating the adaptive immune system. The
adaptive immune system develops a response specific to an
infectious agent or inflammatory stimulus. As part of the
inflammatory response, the adaptive immune response also
has mechanisms that mediate tolerance to distinguish self
from nonself; dysregulation of these mechanisms may lead
to chronic inflammation and autoimmune disease. Many
anti-inflammatory drugs work in whole or in part by deplet-
ing populations of innate or adaptive immune cells; this con-
cept is discussed in more detail in Chapter 45, Pharmacology
of Immunosuppression.
The chemical mediators of the inflammatory response
including histamine, complement, eicosanoids, and cytokines
are also major targets of current pharmacologic therapies.
Macromolecules are playing an increasingly important role
in modulation of these chemical mediators; for example, a
number of anticytokine antibodies, including inhibitors of
tumor necrosis factor-, have been developed for the treat-
ment of rheumatoid arthritis, psoriatic arthritis, and inflam-
matory bowel disease. A second approach to modulation of
inflammatory responses has been to target the intracellular
signaling cascades responsible for initiation of immune re-
sponses. An example of such a drug is cyclosporine, dis-
cussed in Chapter 45. As the number of agents available for
treatment of immune disorders grows, it will become increas-
ingly important to determine whether macromolecular agents
and small-molecule signaling inhibitors can be used in com-
bination to target multiple steps in inflammatory pathways.
Disclosure
Lloyd B. Klickstein is an employee and stockholder of No-
vartis, Inc., which manufactures or distributes drugs that
act by mechanisms discussed in this chapter (for example,
ranibizumab).
Suggested Reading
Akira S, Uematsu S, Takeuchi O. Pathogen recognition and innate immu-
nity. Cell 2006;124:783801. (Advances in understanding the innate im-
mune system.)
Dinarello CA. Anti-inflammatory agents: present and future. Cell 2010;
140:935950. (A signaling-oriented overview of targets for development of
new anti-inflammatory agents.)
Ibelgaufts H. COPE: Cytokines & Cells Online Pathfinder Encyclopedia.
Available at: http://www.copewithcytokines.de/cope.cgi. (Website that de-
scribes all known actions of cytokines.)
Littman DR, Rudensky AY. Th17 and regulatory T cells in mediating and
restraining inflammation. Cell 2010;140:845858. (Discusses advances in
T-cell subsets and regulatory T-cell biology.)
Murphy KM, Travers P, Walport M. Janeways immunobiology. 7th ed. New
York: Garland Publishing; 2007. (A general immunology textbook.)
Pier GB, Lyczak JB, Wetzler L. Immunology, infection and immunity. Wash-
ington, DC: ASM Press; 2004. (A detailed text with a focus on immunologic
mechanisms.)
Zola H, Swart B, Banham A, et al. CD molecules 2006: human cell differen-
tiation molecules. J Immunol Meth 2007;319:15. (Summarizes classifica-
tion of molecules with the CD designation.)
42
Pharmacology of Eicosanoids
David M. Dudzinski and Charles N. Serhan
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 740-741
PHYSIOLOGY OF EICOSANOID METABOLISM . . . . . . . . . . . 740
Generation of Arachidonic Acid and Omega-3
Fatty Acids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741
Cyclooxygenase Pathway . . . . . . . . . . . . . . . . . . . . . . . . . 742
Prostaglandins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 744
Thromboxane and Prostacyclin . . . . . . . . . . . . . . . . . . 744
Lipoxygenase Pathway. . . . . . . . . . . . . . . . . . . . . . . . . . . 745
Leukotrienes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 745
Lipoxins, Resolvins, Protectins, and Maresins . . . . . . . 748
Epoxygenase Pathway . . . . . . . . . . . . . . . . . . . . . . . . . . . 748
Isoprostanes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 748
Metabolic Inactivation of Local Eicosanoids . . . . . . . . . . . 748
Integrated Inflammation Schema . . . . . . . . . . . . . . . . . . . 752
PATHOPHYSIOLOGY OF EICOSANOIDS . . . . . . . . . . . . . . . . 752
Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 753
Inflammatory Bowel Disease . . . . . . . . . . . . . . . . . . . . . . 753
Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 753
Glomerulonephritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 753
Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 754
Cardiovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . 754
 INTRODUCTION
Autacoids are substances that are rapidly synthesized in re-
sponse to specific stimuli, act quickly in the immediate environ-
ment, and remain active for only a short time before degradation.
Eicosanoids represent a chemically diverse family of autacoids
that are mostly derived from arachidonic acid. Research on
eicosanoids continues to elucidate their critical roles in inflamma-
tory, neoplastic, and cardiovascular physiology and pathophysi-
ology. Numerous pharmacologic interventions in eicosanoid
pathwaysincluding the nonsteroidal anti-inflammatory drugs
(NSAIDs), cyclooxygenase-2 (COX-2) inhibitors, leukotriene
inhibitors, and othersare useful in the clinical management of
inflammation, pain, and fever. Given the diverse bioactivities of
eicosanoids, future research in eicosanoid physiology and phar-
macology may lead to the development of new therapeutics for
the treatment of asthma, inflammatory diseases, autoimmune
diseases, glomerulonephritis, cancer, cardiovascular diseases,
and other clinical conditions.
740
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 754
Phospholipase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . 754
Cyclooxygenase Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . 754
Traditional Nonselective Inhibitors: NSAIDs . . . . . . . . . 754
Acetaminophen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 756
Selection of the Appropriate NSAID . . . . . . . . . . . . . . . 756
COX-2 Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 757
Prostanoid Receptor Mimetics . . . . . . . . . . . . . . . . . . . . . 758
Thromboxane Antagonists . . . . . . . . . . . . . . . . . . . . . . . . 758
Leukotriene Inhibition . . . . . . . . . . . . . . . . . . . . . . . . . . . 758
Lipoxygenase Inhibition. . . . . . . . . . . . . . . . . . . . . . . . 758
5-Lipoxygenase Activating Protein (FLAP)
Inhibition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 759
Leukotriene Synthesis Inhibitors . . . . . . . . . . . . . . . . . 759
Leukotriene Receptor Antagonists . . . . . . . . . . . . . . . . 759
Lipoxins, Aspirin-Triggered Lipoxins, Resolvins/
Protectins/Maresins, and Lipoxin-Stable Analogues . . . . . 759
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 759
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 760
 PHYSIOLOGY OF EICOSANOID
METABOLISM
Eicosanoids are centrally involved in a number of metabolic
pathways that exhibit diverse roles in inflammation and cel-
lular signaling. The vast majority of these pathways center
on reactions involving the metabolism of arachidonic acid
(Fig. 42-1). The following section considers the biochemical
steps leading to arachidonic acid generation, and then dis-
cusses the cyclooxygenase, lipoxygenase, epoxygenase, and
isoprostane pathways of arachidonic acid metabolism. The
word eicosanoid arises from the Greek root for twenty, and
the term classically refers to 20-carbon molecules derived
from arachidonic acid oxygenation. The term eicosanoid
also applies broadly to various other moleculessuch as
resolvins, protectins, and maresinsthat are derived from
docosahexaenoic acid, a 22-carbon precursor. The term
docosanoids is sometimes also used to describe these 22-
carbon structures.
 O Cleavage site
R P O
O O Arachidonate
O-
R = choline or Acyl
ethanolamine O

Phospholipids

Phospholipase A2

COOH

Cytochrome P450
Non-enzymatic epoxygenases

Isoprostanes Arachidonic acid Epoxyeicosa-

tetraenoic acids
(EETs)
Lipoxygenase Cyclooxygenase
pathways pathways

Lipoxins
Prostaglandins
Prostacyclin
Leukotrienes Thromboxane
 CHAPTER 42 / Pharmacology of Eicosanoids 743

COOH

Vasodilation Smooth muscle contraction

Inhibits platelet aggregation Inhibits platelet aggregation
Arachidonic acid

IP
DP

COOH HO

COX-1 and COX-2: NSAIDs, COOH

O cyclooxygenase activity COX-2 inhibitors

O OH

PGD2
HO OH
O COOH
PGI2
O

OOH
Hydrolysis
Prostacyclin PGG2 PGD2
synthase isomerase
O COOH (endothelium) (brain, mast cells)
HO

COX-1 and COX-2:

peroxidase activity

HO OH Inactive
6-keto-PGF1

O COOH
O

Vasoconstriction
Platelet activation OH
Thromboxane PGF2
synthase PGH2 reductase
Thromboxane TP
antagonists (platelets) (uterus, lung)

HO
COOH PGE2
O COOH
isomerase
O (macrophages, mast cells)
OH
HO OH
TxA2
O PGF2

Nonenzymatic COOH
hydrolysis
FP
OH HO Smooth muscle contraction
OH
Bronchoconstriction
COOH PGE2 Abortion

HO O
EP1 EP4
OH EP2 EP3
Inactive
TxB2
Vasodilation
Hyperalgesia
Fever
Diuresis
Immunomodulation

FIGURE 42-2. Prostaglandin biosynthesis, function, and pharmacologic inhibition. The biosynthetic pathways from arachidonic acid to prostaglandins, prosta-
cyclin, and thromboxane are depicted. Tissue-specific enzyme expression determines the tissues in which the various PGH2-derived products are biosynthesized. NSAIDs
and COX-2 inhibitors are the most important classes of drugs that modulate prostaglandin production. Thromboxane antagonists and PGE2 synthase inhibitors are
promising pharmacologic strategies that are currently in development. COX, cyclooxygenase; PG, prostaglandin; Tx, thromboxane; DP, PGD2 receptor; EP, PGE2 receptor;
FP, PGF2 receptor; IP, PGI2 receptor; TP, TxA2 receptor; NSAID, nonsteroidal anti-inflammatory drug. Note that DP, EP, FP, IP, and TP, are all G protein-coupled receptors.
 COOH

OH
Prostanoid backbone
746 Principles of Inflammation and Immune Pharmacology

Stimuli

Ca2+ PLA2

COOH

Arachidonic acid

5-Lipoxygenase Zileuton, FLAP inhibitors

OOH

COOH

5-HPETE

5-Lipoxygenase Zileuton, FLAP inhibitors

O
COOH
LTA4

LTA4 hydrolase H2O Glutathione LTC4 synthase

OH
COOH
OH OH
S
COOH
H
N COOH
HN
H2N O
LTB4 O
COOH
-glutamyl LTC4
transpeptidase Carboxypeptidase A
BLT1
OH
OH
COOH
COOH
Major source: Neutrophils (BLT1) S
S
Actions: Activation of neutrophils OH
H
- Margination N COOH HN
H2N
- Migration H2N O
O O
- Degranulation
- Superoxide anion generation LTD4 COOH

- Eicosanoid synthesis LTF4

Plasma exudation -glutamyl
Dipeptidase
transpeptidase
OH
COOH

OH
H2N
O

LTE4

Major source: Mast cells, basophils, eosinophils Zafirlukast

Actions: Bronchoconstriction Montelukast
Vasoconstriction
Decreased coronary blood flow CysLT1
Decreased cardiac contractility
Plasma exudation

FIGURE 42-4. Leukotriene biosynthesis, function, and pharmacologic inhibition. The biosynthetic pathways from arachidonic acid to the leukotrienes are
shown. Zileuton and 5-lipoxygenase activating protein (FLAP) inhibitors prevent the conversion of arachidonic acid to 5-HPETE and LTA4; zileuton has been used in the
chronic management of asthma. Zafirlukast and montelukast are antagonists at CysLT1, the receptor for all cysteinyl leukotrienes (mainly LTC4 and LTD4); these drugs are
used in the chronic management of asthma. The cysteinyl leukotrienes also interact with CysLT2 (not shown). BLT1 and BLT2 are LTB4-related G protein-coupled receptors;
BLT1 is the major LTB4 receptor. BLT2 is the G protein-coupled receptor for HHT, a cyclooxygenase product (see text for details; not shown).
 CHAPTER 42 / Pharmacology of Eicosanoids 747

COOH

Arachidonic acid

15-Lipoxygenase

5-Lipoxygenase
Peroxidase
OOH

COOH COOH

OH 5-HPETE
15-HETE

5-Lipoxygenase 5-Lipoxygenase

OOH

COOH O
COOH

LTA4
OH
5-hydroperoxy, 15-hydroxyeicosatetraenoic acid

5-Lipoxygenase 15-Lipoxygenase

COOH
O

OH
Epoxytetraene
Hydrolysis Hydrolysis

OH OH
COOH
COOH
OH
OH

OH OH

LXA4 FPR2/ALX LXB4

FIGURE 42-5. Lipoxin biosynthesis. Two main routes lead to biosynthesis of the lipoxins. In each pathway, sequential lipoxygenase reactions are required,
followed by hydrolysis. The immediate precursor of the lipoxins is epoxytetraene; hydrolysis of epoxytetraene yields the lipoxins. Left pathway: Arachidonic acid is
converted to 15-HETE by sequential activity of 15-lipoxygenase and peroxidase. 15-HETE is converted by 5-lipoxygenase to the chemical intermediate 5-hydroperoxy,
15-hydroxyeicosatetraenoic acid, and 5-lipoxygenase acts on this intermediate to form an epoxytetraene. Right pathway: Arachidonic acid is converted to 5-HPETE
by 5-lipoxygenase, and 5-HPETE is converted to LTA4 by further action of 5-lipoxygenase. LTA4 is converted to epoxytetraene by 15-lipoxygenase. Common pathway:
Epoxytetraene is hydrolyzed to the active lipoxins LXA4 and LXB4. The lipoxins have both anti-inflammatory and pro-resolving roles, are counter-regulators of leukotriene
action, and regulate many cytokines and growth factors. LXA4 is a highly selective agonist for the G protein-coupled receptor FPR2/ALX. In a transcellular reaction,
platelet 12-lipoxygenase can also catalyze the formation of LXA4 from neutrophil-derived LTA4; the detailed mechanism remains to be elucidated (not shown; see also
Fig. 42-7).
 CHAPTER 42 / Pharmacology of Eicosanoids 749

H H
COOH

H(O)O

Aspirin-acetylated COX-2
COOH
Eicosapentaenoic acid 18-hydroperoxy-EPA
(EPA)

5-lipoxygenase

HOOC
O(O)H

5(6)-epoxyresolvin E-
synthase reaction
COOH

OH O

HO

5(6)-epoxy-18-hydroxy-EPA 5-hydroperoxy, 18-hydroxy-EPA

Enzymatic Peroxidase
epoxide hydrolysis

OH
OH

COOH
HO
OH

COOH HO

Resolvin E1 (RvE1) Resolvin E2 (RvE2)

Regulates neutrophil infiltration Regulates neutrophil infiltration

Regulates dendritic cell function and IL-12 production
Promotes resolution
Reduces colitis
Protects from osteoclast-mediated bone destruction

FIGURE 42-6. Resolvins, protectins, and maresins: biosynthesis and actions of novel families of omega-3-derived mediators. A. EPA is the precursor
to E-series resolvins. B and C. DHA is the precursor to D-series resolvins, protectins, and maresins. Some of the major endogenous anti-inflammatory and pro-
resolving functions are listed below some of the mediators. In addition, resolvin D1 regulates neutrophil infiltration and resolvin D2 enhances microbial phagocytosis
and clearance. (continued)
750 Principles of Inflammation and Immune Pharmacology

HOOC
HOOC HO
OH

HO HO

OH

OH

Resolvin D1 (RvD1) Resolvin D2 (RvD2)

7(8)-epoxide intermediate

5-lipoxygenase

H H

HOOC

Lipoxygenase
COOH
OOH

Docosahexaenoic acid 5-lipoxygenase 17-hydroperoxy-DHA

(DHA)

4(5)-epoxide intermediate

OH

HOOC COOH
OH
OH

HO
OH
OH

Resolvin D3 (RvD3) Resolvin D4 (RvD4)

FIGURE 42-6. (continued)

 CHAPTER 42 / Pharmacology of Eicosanoids 751

H H H H

COOH
COOH

Docosahexaenoic acid Docosahexaenoic acid

(DHA) (DHA)

Lipoxygenase 12/15-lipoxygenases

O(O)H

HOOC
COOH

OOH
17-hydroperoxy-DHA 14-hydroperoxy-DHA

Enzymatic Enzymatic
epoxidation epoxidation
and hydrolysis and conversion

COOH

OH COOH
OH
OH

OH

Protectin D1 (PD1) Maresin 1 (MaR1)

Regulates neutrophil and T cell infiltration Regulates neutrophil infiltration

Regulates TNF and interferon production Promotes resolution
Promotes resolution
Reduces peritonitis and airway inflammation
Protects brain from ischemia/reperfusion injury
Mitigates kidney ischemia injury

FIGURE 42-6. (continued)

 Platelet

LTC4
LTA4
LXA4
AA
A
LXB4

Leukocyte

LTA4
5-Lipoxygenase/FLAP
LTA4 hydrolase

Prostacyclin LTB4

Prostacyclin
synthase

LTA4 LTC4
COX
AA LTC4 synthase

Endothelial cell
 Salicylate class Propionic acid class

O
OH
OH

O
O

O Ibuprofen

Aspirin

Acetic acid class Oxicam class

(Phenyl acetic acids)

O OH O

HO Cl N N
H H
N N
S
O O
Cl
Piroxicam
Diclofenac

Acetic acid class Aminophenol class

(Indole acetic acids)
O O
OH
NH
O
N

Cl OH

Indomethacin Acetaminophen

Fenamate class Ketone class

O OH
O
H
N

O
Nabumetone

Mefenamate
756 Principles of Inflammation and Immune Pharmacology
inactivated by aspirin, the aspirin-modified COX-2 enzyme
retains a distinct part of its catalytic activity and can form a
new product, 15-(R)-HETE, from arachidonic acid. By anal-
ogy to lipoxin biosynthesis (Fig. 42-5), 5-LOX then converts
15-(R)-HETE to 15-epi-lipoxins, which are relatively stable
stereoisomers (carbon 15-position epimers) of lipoxins that
are collectively called aspirin-triggered lipoxins (ATLs).
15-Epi-lipoxins mimic the functions of lipoxins as anti-
inflammatory agents. 15-Epi-lipoxins may represent another
endogenous mechanism of anti-inflammation, and their pro-
duction mediates at least part of the anti-inflammatory ef-
fects of aspirin. Development of 15-epi-lipoxin analogues
could lead to anti-inflammatory drugs that do not have the
adverse effects associated with COX-1 inhibition.
Aspirin is generally well tolerated. Its major toxicities are
the gastropathy and nephropathy common to all NSAIDs.
Long-term aspirin therapy can lead to gastrointestinal ulcer-
ation and hemorrhage, nephrotoxicity, and hepatic injury.
NSAIDs should be used cautiously, if at all, in patients with
renal insufficiency and heart failure. Two unique toxicities
are aspirin-induced airway hyperreactivity in asthmatics
(so-called aspirin-sensitive asthma) and Reyes syndrome.
The prevalence of aspirin sensitivity among patients with
asthma is approximately 10%. Exposure to aspirin in these
patients leads to ocular and nasal congestion along with se-
vere airway obstruction. Aspirin-sensitive patients are also
reactive to some other NSAIDs, including indomethacin,
naproxen, ibuprofen, mefenamate, and phenylbutazone. One
possible etiology of aspirin/NSAID sensitivity in asthmat-
ics is that exposure to these drugs leads to increased levels
of leukotrienes, which are implicated in the pathogenesis of
asthma (see Fig. 42-1).
Reyes syndrome is a condition characterized by he-
patic encephalopathy and liver steatosis in young children.
Aspirin therapy during the course of a febrile viral infec-
tion has been implicated as a potential etiology of the liver
damage. Although a causal link between aspirin and Reyes
syndrome has not been definitively established, aspirin is
generally not administered to children because of the fear of
Reyes syndrome. Acetaminophen is widely used in children
instead of aspirin.
Propionic Acid Derivatives
Propionic acid NSAIDs include ibuprofen, naproxen, ke-
toprofen, and flurbiprofen. Ibuprofen is a relatively potent
analgesic used in rheumatoid arthritis (as in the case of Ms.
G, to relieve intermittent pain), osteoarthritis, ankylosing
spondylitis, gout, and primary dysmenorrhea. Naproxen has
a long plasma half-life, is 20 times more potent than aspirin,
directly inhibits leukocyte function, and causes less severe
gastrointestinal adverse effects than aspirin.
Acetic Acid Derivatives
Acetic acid NSAIDs include the indole acetic acids
indomethacin, sulindac, and etodolacand the phenyla-
cetic acids diclofenac and ketorolac (a substituted pheny-
lacetic acid derivative). Besides inhibiting cyclooxygenase,
many of the acetic acid NSAIDs promote the incorporation
of unesterified arachidonic acid into triglyceride, thus re-
ducing the availability of the substrate for cyclooxygenase
and lipoxygenase. Indomethacin is a direct inhibitor of neu-
trophil motility, but it is not tolerated by patients as well as
ibuprofen. Diclofenac also reduces intracellular arachidonic
acid concentrations by altering cellular fatty acid transport.
Diclofenac is a more potent anti-inflammatory than indo-
methacin and naproxen and is used widely in the treatment
of pain associated with renal stones. Ketorolac is primarily
employed for its strong analgesic properties, particularly in
postsurgical patients; however, in part due to its potency and
adverse effects, ketorolac is used for no more than 35 days.
The acetic acid NSAIDs are mostly used to relieve symp-
toms in the long-term treatment of rheumatoid arthritis,
osteoarthritis, ankylosing spondylitis, and other musculo-
skeletal disorders. Use of acetic acid NSAIDs causes gas-
trointestinal ulceration and, rarely, hepatitis and jaundice.
Indomethacin also has a specific use in promoting the clo-
sure of a patent ductus arteriosus in newborns by inhibiting
the vasodilatory eicosanoids PGE2 and PGI2.
Oxicam Derivatives
Piroxicam is as efficacious as aspirin, naproxen, and ibupro-
fen in the treatment of rheumatoid arthritis and osteoarthritis,
but may be better tolerated. Piroxicam has additional effects
in the modulation of neutrophil function by inhibiting colla-
genase, proteoglycanase, and the oxidative burst. Because of
its extremely long half-life, piroxicam can be administered
once daily. As with other NSAIDs, piroxicam displays gas-
trointestinal adverse effects such as gastric ulceration, and it
prolongs the bleeding time because of its antiplatelet effect.
Fenamate Derivatives
The two fenamate NSAIDs are mefenamate and meclofena-
mate. Both inhibit cyclooxygenases but also antagonize pros-
tanoid receptors to various degrees. Because fenamates have
less anti-inflammatory activity and are more toxic than aspi-
rin, there is little advantage to their use. Mefenamate is used
only for primary dysmenorrhea, and meclofenamate is used
in the treatment of rheumatoid arthritis and osteoarthritis.
Ketone NSAIDs
Nabumetone is a ketone prodrug that is oxidized in vivo
to the active acid form. Compared to other nonselective
NSAIDs, nabumetone has preferential activity against
COX-2. The incidence of gastrointestinal adverse effects
is relatively low, although headache and dizziness are fre-
quently reported.
Acetaminophen
Acetaminophen is sometimes classified with the NSAIDs,
but it is technically not an NSAID: although acetaminophen
has analgesic and antipyretic effects similar to aspirin, the
anti-inflammatory effect of acetaminophen is insignificant
because of its weak inhibition of cyclooxygenases. None-
theless, acetaminophen therapy can be valuable in patients,
such as children, who are at risk for the adverse effects of
aspirin. The most important adverse effect of acetaminophen
is hepatotoxicity. Modification of acetaminophen by hepatic
cytochrome P450 enzymes produces a reactive metabolite,
which is normally detoxified by conjugation with glutathi-
one. An overdose of acetaminophen can overwhelm glutathi-
one stores, leading to cellular and oxidative damage and, in
severe cases, to acute hepatic necrosis (see Chapter 5, Drug
Toxicity).
Selection of the Appropriate NSAID
The anti-inflammatory, analgesic, and antipyretic effects
of the NSAIDs appear to vary among the many agents in
 O O O O
S S
H2N

N
N
CF3 O

Celecoxib Rofecoxib

O O
S
H2N
OH O S

N N O
H
N N
S
O O
Meloxicam Valdecoxib
 CHAPTER 42 / Pharmacology of Eicosanoids 759

A O via its receptors on neutrophils, inhibits LTB4 biosynthesis

HO
by regulating arachidonic acid release and, possibly, by in-
N NH2 terfering with the influx of calcium. Furthermore, adenosine
is thought to have a role in limiting cell and tissue injury dur-
S
ing inflammation. High cell turnover at inflammatory sites
generates high local concentrations of adenosine, which
may decrease LTB4 biosynthesis and reduce leukocyte re-
cruitment and activation. Selective adenosine receptor ago-
Zileuton nists could be considered for development as pharmacologic
agents in the control of inflammation.

B Leukotriene Receptor Antagonists

Leukotriene receptor antagonism represents a receptor-based
O O O mechanism for inhibiting leukotriene-mediated bronchocon-
striction and other effects (Fig. 42-4). Cysteinyl leukotriene
S O
N receptor (CysLT1) antagonists are effective against asthma
N
H induced by antigen, exercise, cold, or aspirin. These agents
significantly improve bronchial tone, pulmonary function
tests, and asthma symptoms. Montelukast and zafirlukast
(Fig. 42-10B) are the currently available cysteinyl leuko-
triene receptor antagonists; the main clinical application for
HN O these antagonists is in the treatment of asthma.
More potent CysLT1 antagonists are in development,
O including pobilukast, tomelukast, and verlukast. Further
Zafirlukast
research will likely elucidate cysteinyl leukotriene recep-
tor subtypes and their respective tissue distributions, which
could offer the possibility of tissue-targeted antagonism and
S COOH the application of these tissue-selective antagonists to other
conditions such as rheumatoid arthritis, inflammatory bowel
Cl N disease, and various allergic disorders.

Lipoxins, Aspirin-Triggered Lipoxins,

HO
Montelukast
FIGURE 42-10. Leukotriene pathway inhibitors. A. Zileuton is a 5-
lipoxygenase inhibitor that blocks the biosynthesis of leukotrienes from arachi-
donic acid. B. Zafirlukast and montelukast are CysLT1 receptor antagonists. All
three drugs are approved for the prophylaxis and chronic treatment of asthma in
both adults and children. None of these drugs is effective in the treatment of acute
asthma attacks.
zileuton is not as widely used as the other antileukotriene
asthma drugs (see below).
5-Lipoxygenase Activating Protein (FLAP) Inhibition
Interfering with the role of FLAP could represent an alter-
native approach to the selective inhibition of 5-LOX activ-
ity and leukotriene function. Recall that 5-LOX is activated
after the enzyme translocates to the nuclear membrane and
docks with FLAP and that FLAP binds arachidonic acid
released by phospholipase A2 and shuttles it to the 5-LOX
active site. FLAP inhibitors have been developed that both
prevent and reverse LOX binding to FLAP and block the
arachidonic acid binding site, but no FLAP inhibitors are
currently available for clinical use.
Leukotriene Synthesis Inhibitors
Other than zileuton, no specific inhibitors of the enzymes in-
volved in leukotriene synthesis are available for clinical use.
Specific LTA4 hydrolase inhibitors, which block LTB4 bio-
synthesis, are currently in development. Adenosine, acting
Resolvins/Protectins/Maresins,
and Lipoxin-Stable Analogues
Lipoxins, ATLs, and the omega-3-derived resolvins, protec-
tins, and maresins all offer the potential to antagonize the in-
flammatory actions of leukotrienes and other inflammatory
mediators and to promote resolution of inflammation. Stable,
oral and parenteral analogues of these compounds could rep-
resent a new approach to treatment, since they are agonists of
endogenous anti-inflammation and pro-resolution pathways
rather than direct enzyme inhibitors or receptor antagonists.
Because lipoxins are endogenous regulators, they would be
expected to have selective actions with few adverse effects.
Stable analogues of lipoxins and ATLs are currently being
developed, and second-generation lipoxin-stable analogues
have shown efficacy in enhancing the resolution of recur-
ring bouts of acute inflammation in skin inflammation and
gastrointestinal inflammation models. This new approach to
the treatment of inflammation remains to be established in
human trials.
 CONCLUSION AND FUTURE DIRECTIONS
Eicosanoids are critical mediators of homeostasis and of many
pathophysiologic processes, especially those involving host
defense and inflammation. Arachidonic acid is the important
substrate and is converted into prostaglandins, thrombox-
anes, prostacyclin, leukotrienes, lipoxins, isoprostanes, and
epoxyeicosatetraenoic acids (EETs). Prostaglandins have
diverse roles in vascular tone regulation, gastrointestinal
regulation, uterine physiology, analgesia, and inflammation.
760 Principles of Inflammation and Immune Pharmacology
Prostacyclin and thromboxane coordinately control vascular
tone, platelet activation, and thrombogenesis. Leukotrienes
(LTC4, LTD4) are the chief mediators of bronchoconstriction
and airway hyperactivity; LTB4 is a major activator of leu-
kocyte chemotaxis and infiltration. Lipoxins antagonize the
effects of leukotrienes, reduce the extent of inflammation,
and activate resolution pathways.
Pharmacologic interventions at many critical points
in these pathways are useful in limiting inflammatory se-
quelae. Glucocorticoids inhibit several steps in eicosanoid
generation, including the rate-determining step involving
phospholipase A2. However, chronic glucocorticoid use
is associated with many serious adverse effects, including
osteoporosis, muscle wasting, and abnormal carbohydrate
metabolism. Cyclooxygenase inhibitors block the first step
of prostanoid synthesis and prevent the generation of pros-
tanoid mediators of inflammation. Lipoxygenase inhibitors,
FLAP inhibitors, leukotriene synthesis inhibitors, and leu-
kotriene receptor antagonists prevent leukotriene signaling,
thereby limiting inflammation and its deleterious effects.
Future drug development efforts will allow selective tar-
geting of eicosanoid pathways involved in many clinical
conditions.
Systems biology has revealed mechanisms underlying
inflammatory disease and has created a new discipline of
resolution pharmacology. Essential omega-3 fatty acids,
in particular eicosapentaenoic acid and docosahexaenoic
acid, are precursors to pro-resolving and anti-inflammatory
SPM that serve a physiologic role leading to programmed
resolution of inflammation (Fig. 42-6). These new bioactive
mediators are many times more potent than their respective
omega-3 precursors and, hence, may mediate the essential
and beneficial effects of omega-3 fatty acids. In the near
future, resolvins and protectins may be developed as new
therapeutic agents to promote resolution of inflammation.
Suggested Reading
Brink C, Dahlen SE, Drazen J, et al. International Union of Pharmacology
XXXVII. Nomenclature for leukotriene and lipoxin receptors. Pharmacol
Rev 2003;55:195227. (International consensus report on eicosanoid re-
ceptors and their antagonists.)
Gilroy DW, Perretti M. Aspirin and steroids: new mechanistic findings and
avenues for drug discovery. Curr Opin Pharmacol 2005;5:17. (Reviews
the anti-inflammatory actions of aspirin-triggered lipoxins and the discov-
ery of annexin and related compounds in the actions of glucocorticoids.)
Patrono C, Baigent C. Low-dose aspirin, coxibs, and other NSAIDS: a clin-
ical mosaic emerges. Mol Interv 2009;9:3139. (Reviews the data regarding
cardiovascular risks of NSAIDs and coxibs.)
Psaty BM, Furberg CD. COX-2 inhibitorslessons in drug safety. N Engl
J Med 2005;352:11331135. (Reviews issues surrounding withdrawal of
COX-2 selective inhibitors.)
Serhan CN. Resolution phases of inflammation: novel endogenous anti-
inflammatory and pro-resolving lipid mediators and pathways. Annu Rev
Immunol 2007;25:101137. (Reviews the pathways mediating resolution of
inflammation.)
Serhan CN, Chiang N, Van Dyke TE. Resolving inflammation: dual an-
ti-inflammatory and pro-resolution lipid mediators. Nat Rev Immunol
2008;8:249261. (Reviews advances in the role of eicosanoid pathways and
novel lipid mediators in resolution programs of inflammation.)
Vane JR, Bakhle YS, Botting RM. Cyclooxygenases 1 and 2. Ann Rev Phar-
macol Toxicol 1998;38:97120. (Historic overview of prostaglandin research,
including discussion of the pharmacologic manipulation of these pathways.)

Histamine Pharmacology
Cindy Chambers, Joseph C. Kvedar, and April W. Armstrong
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 765-766
PHYSIOLOGY OF HISTAMINE . . . . . . . . . . . . . . . . . . . . . . . . 765
Histamine Synthesis, Storage, and Release . . . . . . . . . . . 765
Actions of Histamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 765
Histamine Receptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 767
PATHOPHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 768
Clinical Manifestations of Histamine Pathophysiology. . . . 769
Histamine and Anaphylaxis . . . . . . . . . . . . . . . . . . . . . . . 769
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 769
H1-Antihistamines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 769
Mechanism of Action . . . . . . . . . . . . . . . . . . . . . . . . . 769
 INTRODUCTION
Histamine is a biogenic amine found in many tissues, includ-
ing mast cells, basophils, lymphocytes, neurons, and gastric
enterochromaffin-like cells. It is an autacoidthat is, a mol-
ecule secreted locally to increase or decrease the activity of
nearby cells. Histamine is a major mediator of allergic and
inflammatory processes: it also has significant roles in the
regulation of gastric acid secretion, neurotransmission, and
immune modulation. Knowledge of the diverse actions of
histamine has led to the development of a number of widely
used pharmacologic agents that regulate the effects of hista-
mine in pathologic states. This chapter focuses on the phar-
macologic actions of H1-antihistamines; H2-antihistamines
are discussed in Chapter 46, Integrative Inflammation Phar-
macology: Peptic Ulcer Disease.
 PHYSIOLOGY OF HISTAMINE
Histamine Synthesis, Storage, and Release
Histamine is synthesized from the amino acid L-histidine.
The enzyme histidine decarboxylase catalyzes the decar-
boxylation of histidine to 2-(4-imidazolyl)ethylamine, com-
monly known as histamine (Fig. 43-1). The synthesis of
histamine occurs in mast cells and basophils of the immune
system, enterochromaffin-like (ECL) cells in the gastric
mucosa, and certain neurons in the central nervous system
(CNS) that use histamine as a neurotransmitter. Oxidative
pathways in the liver rapidly degrade circulating histamine
to inert metabolites. One major metabolite of histamine,
imidazole acetic acid, can be measured in the urine, and the
43
Classification of First- and Second-Generation
H1-Antihistamines . . . . . . . . . . . . . . . . . . . . . . . . . . . . 770
Pharmacologic Effects and Clinical Uses . . . . . . . . . . . 771
Pharmacokinetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 771
Adverse Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 771
Other Antihistamines . . . . . . . . . . . . . . . . . . . . . . . . . . . . 772
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 773
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 773
level of this metabolite is used to determine the amount of
histamine that has been released systemically.
Histamine synthesis and storage can be divided into two
pools: a slowly turning over pool and a rapidly turning
over pool. The slowly turning over pool is located in mast
cells and basophils. Histamine is stored in large granules in
these inflammatory cells, and the release of histamine in-
volves complete degranulation of the cells. Degranulation
can be triggered by allergic processes, anaphylaxis, or cellu-
lar destruction from trauma, cold, or other insults. This pool
is termed slowly turning over because several weeks are re-
quired to replenish the stores of histamine after degranula-
tion has occurred. The rapidly turning over pool is located
in gastric ECL cells and in histaminergic CNS neurons.
These cells synthesize and release histamine as required for
gastric acid secretion and neurotransmission, respectively.
Unlike mast cells and basophils, ECL cells and histaminer-
gic neurons do not store histamine. Instead, the production
and release of histamine in these cells depend on physiologic
stimuli. In the gut, for example, histidine decarboxylase is
activated after the ingestion of food.
Actions of Histamine
Histamine has a wide spectrum of actions involving many
organs and organ systems. To understand the roles of his-
tamine, it is useful to consider the physiologic effects of
histamine in each tissue (Table 43-1). These effects include
actions on smooth muscle, vascular endothelium, afferent
nerve terminals, heart, gastrointestinal tract, and CNS.
On smooth muscle, histamine causes some muscle fibers
to contract and others to relax. Histamine dilates all terminal
765
 N NH2

HN
HO O

Histidine

Decarboxylation
(L-histidine decarboxylase)

N NH2

HN

Ring methylation
Histamine Oxidative deamination
(Imidazole-N- (mainly Diamine oxidase)
methyltransferase)

N NH2 N OH

N HN O
Methyl histamine ImAA

Oxidation
(Monoamine oxidase) Conjugation
with ribose

N OH

O ImAA
N riboside
Methyl ImAA
768 Principles of Inflammation and Immune Pharmacology

expressed on cardiac muscle cells, on some immune cells,
and on certain postsynaptic neurons in the central nervous
system. H2 receptors on parietal cells activate a G protein-
dependent cyclic AMP cascade, leading to enhanced proton
pump-mediated delivery of protons into the gastric fluid.
Whereas H1 and H2 receptor subtypes have been well
characterized, H3 and H4 receptor subtypes and their down-
stream actions are areas of active investigation. H3 receptors
are predominantly located on presynaptic neurons in distinct
regions of the CNS, including the cerebral cortex, basal gan-
glia, and tuberomammillary nucleus of the hypothalamus.
H3 receptors appear to function as both autoreceptors and
heteroreceptors, thereby limiting the synthesis and release
of histamine as well as other neurotransmitters, including
dopamine, acetylcholine, norepinephrine, GABA, and se-
rotonin. This complex interaction between histamine and
various neurotransmitter systems contributes to histamines
widespread effects on CNS functions, including wakeful-
ness, appetite, and memory. H3 receptors have also been
localized in the peripheral nervous system and appear to
limit histaminergic actions in gastric mucosa and bronchial
smooth muscle. The downstream effects of H3 receptor acti-
vation are mediated via a decrease in Ca2 influx.
H4 receptors are localized to cells of hematopoietic origin,
primarily mast cells, eosinophils, and basophils. H4 recep-
tors share 40% homology with H3 receptors and bind many
H3 receptor agonists, although with lower affinity. Coupling
of the H4 receptor to Gi/o leads to decreased cAMP and acti-
vation of phospholipase C, and downstream events result
in increased intracellular Ca2. H4 receptors are of particular
interest because they are thought to play an important role
in inflammation; activation of H4 receptors mediates hista-
mine-induced leukotriene B4 production, adhesion molecule
up-regulation, and chemotaxis of mast cells, eosinophils,
and dendritic cells.
 PATHOPHYSIOLOGY
Histamine is an essential mediator of immune and inflamma-
tory responses. Histamine plays a prominent role in the IgE-
mediated type I hypersensitivity reaction, also known as
the allergic reaction. In a localized allergic reaction, an al-
lergen (antigen) first penetrates an epithelial surface (e.g.,
skin, nasal mucosa). The allergen can also be delivered sys-
temically, as in the case of an allergic response to penicillin.
With the aid of T-helper (TH) cells, the allergen stimulates
B lymphocytes to produce IgE antibodies that are specific
for that allergen. The IgE then binds to Fc receptors on mast
cells and basophils, in a process known as sensitization.
Once these immune cells are sensitized with IgE antibod-
ies, they are able to detect and respond rapidly to a subse-
quent exposure to the allergen. Upon such an exposure, the
allergen binds to and cross-links the IgE/Fc receptor com-
plexes, triggering cell degranulation (Fig. 43-2).

A Initial exposure

Allergen

B cell IgE

Mast cell

Mast cell
Capillary Granules

IgE

B Subsequent exposure

Allergen

Edema fluid

Crosslinked IgE

Degranulated
Histamine mast cell
Mast cell degranulation

FIGURE 43-2. Pathophysiology of the IgE-mediated hypersensitivity reaction. Allergen-induced mast cell degranulation requires two separate exposures
to the allergen. A. On initial exposure, the allergen must penetrate mucosal surfaces so that it can encounter cells of the immune system. Activation of the immune
response causes B lymphocytes to secrete allergen-specific IgE antibodies. These IgE molecules bind to Fc receptors on mast cells, leading to sensitization of the
mast cells. B. On subsequent exposure, the multivalent allergen cross-links two IgE/Fc receptor complexes on the mast cell surface. Receptor cross-linking causes
the mast cell to degranulate. Local histamine release results in an inflammatory response, shown here as edema.
A

q/11 q/11

GDP GTP

Inactive state Active state

X
Agonist N N
(histamine)
B Histamine

General structure
(X = C, O, or omitted)

q/11 q/11 Alkylamines Ethers or ethanolamines

GDP GTP Cl

O
Inactive state Active state N N

N
Inverse agonist
H1-antihistamine (H1-antihistamines)
C Diphenhydramine
Chlorpheniramine

Ethylenediamines Phenothiazines

N
N
q/11 q/11
N
GDP GTP N N
S
Inactive state Active state
Tripelennamine

Promethazine

Piperazines Piperidines

N
N

N
Cyclizine
Cyproheptadine
 H H
N N N
S

HN N
C
N
Cimetidine

H H
O N N
N S

NO2

Ranitidine

Similar to H3 receptors, H4 receptors couple with Gi/o
to decrease intracellular cAMP concentrations. Because H4
receptors are selectively expressed on cells of hematopoi-
etic origin, especially mast cells, basophils, and eosinophils,
there is considerable interest in elucidating the role of the
H4 receptor in the inflammatory process. H4 receptor an-
tagonists represent a promising area of drug development
to treat inflammatory conditions that involve mast cells and
eosinophils.
 CONCLUSION AND FUTURE DIRECTIONS
Histamine plays a key role in diverse physiologic processes
including allergy, inflammation, neurotransmission, and
gastric acid secretion. Drugs targeting H1 and H2 receptors
have substantially increased the pharmacologic options for
treatment of allergy and peptic ulcer disease. While most H1-
antihistamines demonstrate similar efficacy in the treatment
of allergic rhinitis and urticaria, significant differences exist
in the adverse effect profiles of first- and second-generation
H1-antihistamines.
The more recent elucidation of the H3 and H4 recep-
tor subtypes has renewed interest in the role of histamine
in CNS-related disorders. H3-specific receptor targeting
may provide new therapies for a number of cognitive,
neuroendocrine, and neuropsychiatric conditions. Clini-
cal and preclinical research is currently under way evalu-
ating prototypic H3 antagonists in pathological processes
such as sleep-wake disorders (narcolepsy and insomnia),
CHAPTER 43 / Histamine Pharmacology 773
neuropsychiatric diseases (Alzheimers disease, ADHD,
dementia, depression, and schizophrenia), neurologic dis-
orders (epilepsy), nociceptive processes (neuropathic pain),
and feeding and energy homeostasis (obesity and diabetes).
The H4 receptor is also an exciting molecular target for drug
development, as it is thought to play an important role in
inflammatory conditions involving mast cells and eosino-
phils. Agents directed against H4 receptors might one day
be employed to treat a variety of inflammatory conditions,
such as asthma, allergic rhinitis, inflammatory bowel dis-
ease, and rheumatoid arthritis.
Suggested Reading
Leurs R, Church MK, Taglialatea M. H1-antihistamines: inverse ago-
nism, anti-inflammatory actions and cardiac effects. Clin Exp Allergy
2002;32:489498. (Mechanism-based discussion of H1-antihistamines as
inverse agonists.)
Nicolas JM. The metabolic profile of second-generation antihistamine. Al-
lergy 2000;55:4652. (Discussion of differences among second-generation
drugs.)
Sander K, Kottke T, Stark H. Histamine H3 receptor antagonists go to clin-
ics. Biol Pharm Bull 2008;31:21632181. (Comprehensively reviews the
current state of H3 receptor antagonist research.)
Simons FE. Advances in H1-antihistamines. N Engl J Med 2004;351:2203
2217. (Comprehensively summarizes the mechanism of action and clinical
uses of H1-antihistamines.)
Thurmond RL, Gelfand EW, Dunford PJ. The role of histamine H1 and
H4 receptors in allergic inflammation: the search for new antihistamines.
Nat Rev Drug Discov 2008;7:4153. (Reviews the role of histamine in
inflammation and immune modulation, with emphasis on the role of the
H4 receptor.)
44
Pharmacology of Hematopoiesis
and Immunomodulation
Andrew J. Wagner, Ramy A. Arnaout, and George D. Demetri
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 776-777
PHYSIOLOGY OF HEMATOPOIESIS . . . . . . . . . . . . . . . . . . . . 776
Central Role of Hematopoietic Growth Factors . . . . . . . . . 778
Multilineage Growth Factors . . . . . . . . . . . . . . . . . . . . 779
Lineage-Specific Growth Factors . . . . . . . . . . . . . . . . 779
Erythrocyte Production (Erythropoiesis) . . . . . . . . . . . . . . 779
Erythropoietin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 779
Leukocyte Production (Myelopoiesis and
Lymphopoiesis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 781
Granulocyte-Stimulating Factors . . . . . . . . . . . . . . . . . 781
Lymphocyte-Stimulating Factors . . . . . . . . . . . . . . . . . 782
Platelet Production (Thrombopoiesis) . . . . . . . . . . . . . . . . 782
Thrombopoietin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 782
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 782
Agents That Stimulate Erythrocyte Production . . . . . . . . . 783
Recombinant Human Erythropoietin (rhEPO) and
Darbepoetin (NESP). . . . . . . . . . . . . . . . . . . . . . . . . . . 783
 INTRODUCTION
A number of clinical situations are characterized by defi-
ciencies of red blood cells, white blood cells, or platelets
cells of the hematopoietic system. This chapter describes
the pharmacologic agents that can be used to stimulate
production of hematopoietic cells; it is also important to
note the nonpharmacologic alternatives, which could in-
clude transfusion and bone marrow transplantation. Blood
cell production is controlled physiologically by hematopoi-
etic growth factors, a diverse but functionally overlapping
group of glycoproteins produced by the body in response
to certain signals. For example, hypoxia stimulates produc-
tion of the erythroid lineage growth factor erythropoietin,
which in turn stimulates the production of erythrocytes in
an attempt to relieve the hypoxia. The main pharmacologic
strategy used to stimulate the production of blood cells is
to administer exogenous growth factors or synthetic growth
factor analogues. This chapter provides an introduction to
the cells of the hematopoietic system, the growth factors
776
Agents That Induce Fetal Hemoglobin (HbF) . . . . . . . . . . . 783
5-Azacytidine and Decitabine . . . . . . . . . . . . . . . . . . . 784
Hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 784
Butyrates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 784
Agents That Stimulate Leukocyte Production . . . . . . . . . . 784
Recombinant Human G-CSFs (Filgrastim and
PEG-Filgrastim) and GM-CSF (Sargramostim) . . . . . . . 784
Agents That Stimulate Platelet Production . . . . . . . . . . . . 785
Thrombopoietin and Pharmacologic Analogues . . . . . . 785
Interleukin-11 (rhIL-11 [Oprelvekin]) . . . . . . . . . . . . . . 785
Immunomodulatory Agents with Antineoplastic
Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 785
Interferons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 785
Levamisole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 785
Interleukin-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 785
Tretinoin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 786
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 786
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 786
that stimulate their production, and the pharmacologic
agents used to increase blood cell production. An outline of
the immunomodulatory agents used in anticancer therapy is
also presented.
 PHYSIOLOGY OF HEMATOPOIESIS
The cells of the hematopoietic system are functionally di-
verse (Table 44-1). Red blood cells, or erythrocytes, carry
oxygen; many types of white blood cells, from granulocytes
and macrophages to lymphocytes, fight infection and help
protect against cancer; and platelets help control bleeding.
Nonetheless, these cells all have one feature in common:
they all develop from a common cell in the bone marrow
called the pluripotent hematopoietic stem cell (Fig. 44-1).
Hematopoietic stem cells are induced to differentiate along
committed lineages into red blood cells, white blood cells,
or platelets through interactions with glycoproteins called
hematopoietic growth factors.
778 Principles of Inflammation and Immune Pharmacology

Bone marrow

Pluripotent hematopoietic stem cell

Multipotent stem cells

SCF, IL-6, Flt3L

Trilineage myeloid Lymphoid

stem cell (CFU-S) stem cell

IL-3, GM-CSF, IL-6 SCF, Flt3L, IL-7

IL-5 GM-CSF TPO, IL-11

Committed progenitor cells

CFU-Eo CFU-G/M CFU-Mix Pro-B Pro-NK Pro-T

IL-5
M-CSF G-CSF Flt3L IL-15 IL-7

CFU-
CFU-M CFU-G BFU-E
Mega

TPO EPO

Thymus
CFU-E

EPO
Morphologically

precursor cells
recognizable

Eosinophiloblast Monoblast Myeloblast Megakaryoblast Proerythroblast

Blood and tissues

Mature cells

Eosinophil Monocyte/ Neutrophil Platelets Erythrocyte B cell NK cell T cell

macrophage

FIGURE 44-1. Development of cells of the hematopoietic system. Mature cells of the hematopoietic system all develop from pluripotent stem cells that reside in
the bone marrow. The type of mature cell that develops is dependent on the extracellular milieu and the exposure of stem cells and progenitor cells to specific growth
factors. The pluripotent stem cell differentiates into a trilineage myeloid stem cell (CFU-S) or a lymphoid stem cell. Depending on the growth factors that are present,
CFU-S cells differentiate into granulocytes (eosinophils, neutrophils), monocyte/macrophages, platelets, or erythrocytes. Lymphoid stem cells differentiate into B cells,
natural killer (NK) cells, or T cells. Except for the terminal differentiation of pro-T cells to mature T cells, which takes place in the thymus, the differentiation of all he-
matopoietic stem cells, progenitor cells, and precursor cells occurs in the bone marrow. Of the growth factors illustrated here, G-CSF, GM-CSF, erythropoietin (EPO), and
IL-11 are currently used as therapeutic agents. BFU, burst-forming unit; CFU, colony-forming unit; CSF, colony-stimulating factor; IL, interleukin; SCF, stem cell factor;
TPO, thrombopoietin.

Central Role of Hematopoietic Growth Factors
Hematopoietic growth factors and cytokines constitute a
heterogeneous group of molecules that regulate blood cell
production, maturation, and function. Nearly 36 such fac-
tors have been identified, ranging in size from 9 to 90 kDa.
The membrane-associated receptors for these factors belong
to at least six receptor superfamilies, and genes encoding
the factors are found on 11 different chromosomes. Con-
ceptually, growth factors can be divided into two groups:
multilineage (also called general or early-acting or pleio-
tropic) growth factors, which stimulate multiple lineages,
and lineage-specific (also called lineage-dominant or
late-acting) growth factors, which stimulate differentiation
and survival of a single lineage. Many growth factors and
 Normal or high O2 Low O2

CoCl2 HIF-1 HIF-1

Iron chelation PHD PHD
Antioxidants O2 or CO

HIF-1 OH

VHL
complex Ub
Ub
Ub
Ub
Ub

HIF-1 OH

Nucleus
26S proteasome
Transcription of VEGF,
HIF-1 HIF-1 PDGF-, TGF-, EPO
genes
Ub
Ub

HIF-1 fragments
782 Principles of Inflammation and Immune Pharmacology
IL-5 is produced by a subset of helper T cells. This growth
factor selectively promotes the differentiation, adhesion, de-
granulation, and survival of eosinophils. As such, IL-5 is be-
lieved to have an important role in the pathophysiology of
allergic reactions and asthma.
Lymphocyte-Stimulating Factors
Regulatory proteins called interleukins control lymphocyte
development and activation. To date, more than 30 members of
this family have been defined. Family members are numbered
IL-1, IL-2, and so forth. Interleukins regulate not only lym-
phocyte differentiation but also multiple and overlapping as-
pects of the innate and adaptive immune responses, including
stimulation of T cells and macrophages. Several interleukins
are described above as granulocyte-stimulating factors; others
are discussed below in the context of platelet production.
IL-2 and IL-7 are two interleukins critical to white blood
cell differentiation. IL-2 is a 45-kDa protein produced by
T cells. Because it drives proliferation of T cells and B cells,
IL-2 once received much attention as a potential immuno-
stimulant. Investigations of this hypothesis showed, how-
ever, that mice lacking IL-2 exhibit lymphoproliferative
rather than lymphopenic diseases. This unexpected finding
underscores the principle that growth factors and immune
cells have diverse functions in vivo, including, as in this
case, regulatory or suppressive (tolerogenic) effects as well
as stimulatory effects. This finding also points out that un-
controlled proliferation can ensue if differentiation is not
regulated normally, a process that may underlie some types
of cancer. IL-7, produced by cells in the spleen, thymus, and
bone marrow stroma, is a multilineage lymphostimulatory
growth factor that enhances the growth and differentiation
of B cells and T cells.
The interferons constitute a second family of regulatory
proteins that modulate lymphocyte growth and activity. Like
the interleukins, these proteins can stimulate the activity of T
cells and macrophages. Interferons have prominent antiviral
actions and are used in the treatment of infections such as
hepatitis B and C (see Chapter 37, Pharmacology of Viral
Infections). Other effects of interferons include promoting
the terminal differentiation of lymphocytes, suppressing cell
division (in some situations), and exerting direct cytotoxic
effects on cells under stress. The three types of interferons
called IFN-, IFN-, and IFN-have different biologi- CSF. It is found both on platelet progenitorsCFU-S, CFU-
cal actions. The cellular effects of interferons, like those of
growth factors, are mediated by specific cell surface recep-
tors and JAK-STAT signal transduction cascades.
Platelet Production (Thrombopoiesis)
Plateletssometimes called thrombocytesare essential
for clot formation. These small cells, which lack a nucleus
and do not synthesize new proteins, have a half-life of about
9 or 10 days in the circulation. The production of platelets,
like that of all formed elements of the hematopoietic sys-
tem, is controlled by both multilineage and lineage-specific
growth factors (Fig. 44-3). The most important multilineage
growth factors that stimulate platelet production are IL-11,
IL-3, GM-CSF, stem cell factor, and IL-6. Not surprisingly,
these factors also stimulate the production of erythrocytes be-
cause platelets and erythrocytes share a common progenitor,
the CFU-Mix cell. Whether CFU-Mix cells become eryth-
rocytes or platelets depends on their subsequent exposure to
Myeloid Megakaryoblast Platelets
stem cell
IL-11
IL-11 TPO TPO
IL-3 IL-6
GM-CSF
SCF
Early Late
Stage of megakaryocytopoiesis
FIGURE 44-3. Growth factors involved in platelet production. A number of
growth factors are involved in platelet production (megakaryocytopoiesis). IL-11
acts primarily in the early stages; this growth factor stimulates production of GM-
CSF and acts synergistically with IL-3 and stem cell factor (SCF) to increase the
proliferation and differentiation of megakaryocyte progenitors. IL-6 and throm-
bopoietin (TPO) act primarily in the late stages of megakaryocytopoiesis. Both
recombinant human IL-11 (oprelvekin) and TPO receptor agonists (eltrombopag
and romiplostim) can be used therapeutically to increase platelet production.
lineage-specific growth factors. Differentiation into BFU-E
and other cells of the erythroid lineage is promoted by eryth-
ropoietin. In contrast, differentiation into CFU-Mega cells
and then into megakaryocytes (which then form platelets) is
promoted by the lineage-specific growth factor thrombopoi-
etin (Fig. 44-1).
Thrombopoietin
Thrombopoietin (TPO) is produced in the liver and, to a
lesser extent, in the proximal convoluted tubule of the kid-
ney. Like erythropoietin, thrombopoietin is a heavily glyco-
sylated protein (35 kDa) that has its major effect on a single
cell lineage; also like erythropoietin, thrombopoietin signals
through a JAK-STAT transduction cascade. However, unlike
erythropoietin, thrombopoietin is not regulated in its activ-
ity at the level of gene expression, because thrombopoietin
is expressed constitutively. Instead, by an interesting func-
tional mechanism, circulating levels of thrombopoietin are
regulated by the thrombopoietin receptor (also known as
Mpl), which is the protein product of the gene c-mpl.
Structurally and functionally, the thrombopoietin receptor
resembles the receptors for IL-3, erythropoietin, and GM-
Mix, CFU-Mega, and megakaryocytesand on platelets
themselves. Thrombopoietin has different effects on these
cell types, however. On platelet progenitors, the binding of
thrombopoietin to its receptor promotes cell growth and dif-
ferentiation. In contrast, thrombopoietin receptors on plate-
lets act as molecular sponges to bind excess thrombopoietin
and thereby prevent platelet overproduction if platelets are
in adequate supply. Thrombopoietin also enhances platelet
function by sensitizing these cells to the proaggregatory ef-
fects of thrombin and collagen (see Chapter 22, Pharmacol-
ogy of Hemostasis and Thrombosis).
 PHARMACOLOGIC CLASSES
AND AGENTS
The hematopoietic growth factors used clinically can be
divided into two groups. First, recombinant or synthetic
growth factor analogues are used to treat deficiencies of
 CHAPTER 44 / Pharmacology of Hematopoiesis and Immunomodulation 785
G-CSF. Of note, however, these patients also received a higher
dose of cyclophosphamide than patients who did not develop
AML/MDS. GM-CSF is associated with fever, arthralgia,
edema, and pleural and pericardial effusion. G-CSF and GM-
CSF are proteins and must be administered parenterally, typi-
cally by daily injection over the course of several weeks.
Agents That Stimulate Platelet Production
A low platelet count, or thrombocytopenia, is an important
adverse effect of many cancer chemotherapeutic agents,
occasionally limiting the doses that can be delivered with
acceptable safety and tolerability. The complications of
thrombocytopenia include increased bleeding risk and plate-
let transfusion requirement; in turn, platelet transfusion is
associated with an increased risk of infection, febrile reac-
tion, and, rarely, graft-versus-host disease.
Research into the pharmacologic management of che-
motherapy-induced thrombocytopenia has focused on the
thrombopoietin (TPO) analogues recombinant human
thrombopoietin (rhTPO) and pegylated recombinant
human megakaryocyte growth and development factor
(PEG-rHuMGDF) (see below). To date, however, only re-
combinant human IL-11 (rhIL-11 or oprelvekin) has been
approved by the FDA for this indication. These agents all
have the potential to increase megakaryocytopoiesis (plate-
let production) in a dose-dependent fashion; although these
drugs stimulate some multipotent as well as committed pre-
cursor cells, they do not significantly increase the hematocrit
or white blood cell count. Importantly, these agents must
all be administered prophylactically because there is a 12
week delay from drug administration to a clinically signifi-
cant increase in platelet count.
Thrombopoietin and Pharmacologic Analogues
Cloning of the thrombopoietin gene in 1994 led to the de-
velopment of two thrombopoietin analogues. The first,
rhTPO, is a full-length, glycosylated analogue; the second,
PEG-rHuMGDF, consists of the N-terminal 163 amino
acids of thrombopoietin conjugated to polyethylene glycol
(PEG). Like natural thrombopoietin, both rhTPO and PEG-
rHuMGDF bind to Mpl (the endogenous receptor for throm-
bopoietin, named for its role in murine myeloproliferative
leukemia), and activation of Mpl is the basis for the effect
of these drugs. Both rhTPO and PEG-rHuMGDF have been
tested as prophylactic agents to minimize chemotherapy-
induced thrombocytopenia, and both can cause a 2- to 10-fold
increase in the platelet count.
One caution is that stimulation of platelet production
could lead to thrombosis if the platelets that are produced
are also activated. A small trial of PEG-rHuMGDF suggests
that this drug is safe to use in treating the thrombocytopenia
associated with AML, even though AML cells may also ex-
press the TPO receptor. The heavily bioengineered variants
of natural TPO (e.g., PEG-rHuMGDF) have recently been
dropped from clinical development because of an excess risk
of developing anti-TPO autoantibodies, which could sup-
press natural platelet production. The testing of full-length
rhTPO continues; there are no reports to date of neutralizing
antibodies in patients who receive this lightly bioengineered
agent, which differs from native human TPO only in its gly-
cosylation pattern.
Two new TPO receptor agonists have recently been ap-
proved by the FDA for treatment of thrombocytopenia due
to refractory immune thrombocytopenic purpura (ITP),
an autoimmune disease caused by autoantibodies directed
against the patients own platelets. These drugs include el-
trombopag, a small-molecule TPO receptor agonist, and
romiplostim, a recombinant IgG1 Fc-peptide fusion protein
that also binds and activates the TPO receptor. By activating
the TPO receptor, both molecules induce a transient increase
in the platelet count. However, worsening thrombocytopenia
may develop after cessation of treatment with these agents,
and bone marrow toxicity manifesting as bone marrow fi-
brosis and other conditions has also been reported.
Interleukin-11 (rhIL-11 [Oprelvekin])
Recombinant human IL-11 (rhIL-11), also called oprelvekin,
is the only drug currently approved for the prevention of se-
vere thrombocytopenia in patients receiving myelosuppres-
sive chemotherapy. Oprelvekin is produced in Escherichia
coli and differs from natural IL-11 only in its lack of the N-
terminal proline residue. rhIL-11 causes a dose-dependent
increase in the platelet count and in the number of mega-
karyocytes in the bone marrow. The practical goal of treat-
ment with oprelvekin is to maintain the platelet count above
20,000/L (normal range, 150,000450,000/L) in order to
minimize the risk of life-threatening bleeding. However, the
use of rhIL-11 is associated with significant adverse effects,
especially fatigue and fluid retention. Atrial fibrillation has
also been observed, and rhIL-11 should be used with cau-
tion in any patient with underlying heart disease. The un-
desirable actions of rhIL-11 likely result from pleiotropic
effects of this factor on receptors distributed outside the
hematopoietic system. It is unclear whether the therapeutic
benefit of this agent outweighs the risk of systemic adverse
effects.
Immunomodulatory Agents with
Antineoplastic Applications
Interferons
Clinical investigation has led to the use of interferons as
therapeutic agents against a number of different malignan-
cies, with moderate success. However, the multiple and
overlapping effects of these proteins have made it difficult
to determine the drugs mechanism of action in any given
clinical situation. Induction of antitumor-directed immunity,
terminal differentiation of cycling tumor cells, and direct cy-
totoxic effects have all been hypothesized to have important
roles in the treatment of different malignancies. Interferons
are also used to treat certain viral infections and are dis-
cussed in greater detail in Chapter 37.
Levamisole
Levamisole was known as an antihelminthic agent for de-
cades before its anticancer effects were discovered. In com-
bination with the antimetabolite 5-fluorouracil (see Chapter
38), this drug is now approved for use in the treatment of
colon cancer. Although its mechanism of action remains un-
certain, levamisole is thought to cause macrophages and T
cells to secrete cytokines (such as IL-1) and other factors
that suppress tumor growth.
Interleukin-2
Interleukin-2 (IL-2) is approved by the FDA for the treat-
ment of melanoma. At therapeutic doses, however, this cy-
tokine has relatively low efficacy and relatively high toxicity.
786 Principles of Inflammation and Immune Pharmacology
See Chapter 45, Pharmacology of Immunosuppression, for
more information about IL-2.
Tretinoin
Tretinoin, or all-trans retinoic acid (ATRA), is a ligand
of the retinoic acid receptor (RAR). ATRA is used in the
treatment of acute promyelocytic leukemia. This disease
is characterized by a translocation t(15;17) in which part
of the RAR gene is fused to the PML gene, creating a
fusion protein that induces a block to differentiation and
thereby allows development of the leukemia. Treatment
with ATRA stimulates differentiation of these cells into
more normal granulocytes. In some patients, the induc-
tion of differentiation can lead to a life-threatening over-
production of white blood cells. ATRA can also induce a
rapidly progressive syndrome of fever, acute respiratory
distress with pulmonary infiltrates, edema and weight
gain, and multisystem organ failure. Therapy with high
doses of glucocorticoids is often an effective treatment for
this ATRA syndrome.
 CONCLUSION AND FUTURE DIRECTIONS
The production of cells of the hematopoietic system
red blood cells (erythrocytes), white blood cells (neutro-
phils, monocytes, lymphocytes, and other cell types), and
plateletsis controlled by a variety of proteins called
growth factors and cytokines. Cancer chemotherapy, ma-
lignant infiltration of the bone marrow, and other condi-
tions can cause deficiencies in these cell populations (ane-
mia, neutropenia, and/or thrombocytopenia). The agents
currently used to treat these deficiencies are mainly re-
combinant analogues of the natural growth factors or ago-
nists of the growth factor receptors. Thus, the erythropoi-
etin analogues rhEPO and darbepoetin treat anemia; the
G-CSF and GM-CSF analogues filgrastim, PEG-filgrastim,
and sargramostim treat neutropenia; and rhIL-11 and the
thrombopoietin receptor agonists rhTPO, eltrombopag, and
romiplostim treat thrombocytopenia. Several agents affect-
ing the hematopoietic system are also used to treat sickle
cell disease, a common autosomal recessive disease caused
by a point mutation in the globin gene. These agents (hy-
droxyurea, 5-azacytidine, and decitabine) increase expres-
sion of fetal hemoglobin (HbF) and thereby restore normal
erythrocyte structure and function. Several other drugs,
including recombinant forms of the immunostimulatory
interferon proteins, levamisole, and retinoic acid, are used
to treat certain cancers, although their precise mechanisms
of action remain unknown.
Other agents that activate hematopoiesis continue to be
identified. Preclinical evidence suggests that daily injections
of a parathyroid hormone analogue (PTH 1-34) promote
blood cell development, perhaps by activating stimulatory
receptors on osteoblasts that neighbor hematopoietic stem
cells. These observations have led to clinical trials of PTH
in enhancing stem cell production for transplantation and in
protecting hematopoietic stem cells from the cytotoxic effects
of chemotherapy. Studies designed to tease apart the com-
plex overlapping functionalities of hematopoiesis-regulating
proteins are likely to provide a source of more selective
pharmacologic interventions in the future.
Suggested Reading
Demetri GD. Anaemia and its functional consequences in cancer patients:
current challenges in management and prospects for improving therapy. Br
J Cancer 2001;84:3137. (Reviews the use and effectiveness of recombinant
human erythropoietin.)
Hankins J, Aygun B. Pharmacotherapy in sickle cell diseasestate of the
art and future prospects. Br J Haematol 2009;145:296308. (Reviews use of
hydroxyurea and decitabine.)
Henke M, Laszig R, Rube C, et al. Erythropoietin to treat head and neck
cancer patients with anaemia undergoing radiotherapy: randomised,
double-blind, placebo-controlled trial. Lancet 2003;362(9392):12551260.
(Describes unfavorable outcome in head and neck cancer patients receiving
epoetin beta.)
Kaushansky K. Lineage-specific hematopoietic growth factors. N Engl J
Med 2006;354:20342045. (Reviews hematopoietic growth factors.)
Kuter DJ. Thrombopoietin and thrombopoietin mimetics in the treatment
of thrombocytopenia. Annu Rev Med 2009;60:193206. (Reviews recent
advances in treatment of thrombocytopenia, including use of romiplostim
and eltrombopag.)
Singh AK, Szczech L, Tang KL, et al. Correction of anemia with epoetin
alfa in chronic kidney disease. N Engl J Med 2006;355:20852098.
Pfeffer MA, Burdmann EA, Chen CY, et al. A trial of darbepoetin alfa in type
2 diabetes and chronic kidney disease. N Engl J Med 2009;361:20192032.
(Clinical trials of erythropoiesis-stimulating agents in patients with anemia
and chronic kidney disease.)
Smith TJ, Khatcheressian J, Lyman GH, et al. Update of recommendations
for the use of white blood cell growth factors: an evidence-based clinical
practice guideline. J Clin Oncol 2006;24:31873205. (American Society of
Clinical Oncology guidelines for the use of myeloid growth factors.)
Vansteenkiste J, Pirker R, Massuti B, et al. Double-blind, placebo-controlled,
randomized phase III trial of darbepoetin alfa in lung cancer patients receiv-
ing chemotherapy. J Natl Cancer Inst 2002;94:12111220. (Evidence for
clinical effectiveness of darbepoetin.)
45
Pharmacology of
Immunosuppression
April W. Armstrong, Ehrin J. Armstrong, and Lloyd B. Klickstein
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 790-791
PATHOPHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 790
Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 790
Solid Organ Rejection . . . . . . . . . . . . . . . . . . . . . . . . . 790
Graft-Versus-Host Disease (GVHD) . . . . . . . . . . . . . . . 792
Autoimmunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 792
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 792
Inhibitors of Gene Expression . . . . . . . . . . . . . . . . . . . . . . 793
Glucocorticoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 793
Cytotoxic Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 794
Antimetabolites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 794
Alkylating Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . 796
Specific Lymphocyte-Signaling Inhibitors . . . . . . . . . . . . . 796
Cyclosporine and Tacrolimus . . . . . . . . . . . . . . . . . . . . 796
mTOR Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 797
 INTRODUCTION
Patients with autoimmune disease and patients who have re-
ceived transplanted tissues or organs typically require ther-
apy with immunosuppressive drugs. Immunosuppressive
agents have been in use for more than 50 years, beginning
with corticosteroids, antimetabolites, and alkylating agents.
These early agents assisted in the treatment of previously
incurable conditions, but their lack of specificity led to many
serious adverse effects. Over the past 20 years, the field of
immunosuppression has shifted to specific inhibitors of im-
munity that affect distinct immune pathways. This shift is
important both because of the greater efficacy and reduced
toxicity of these agents, and because, as the mechanisms
of these agents are discovered, insights are gained into the
operation of the immune system.
 PATHOPHYSIOLOGY
Transplantation
The first transplant performed successfully in humans was a
kidney transplant between identical twins. No immunosup-
pression was used, and the individuals did well. Currently,
790
Cytokine Inhibition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 798
TNF- Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 798
IL-12/IL-23p40 Inhibitors . . . . . . . . . . . . . . . . . . . . . . 799
IL-1 Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800
Cytokine Receptor Antagonists . . . . . . . . . . . . . . . . . . 800
Depletion of Specific Immune Cells . . . . . . . . . . . . . . . . . 800
Polyclonal Antibodies . . . . . . . . . . . . . . . . . . . . . . . . . 800
Monoclonal Antibodies . . . . . . . . . . . . . . . . . . . . . . . . 800
LFA-3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801
Inhibition of Costimulation . . . . . . . . . . . . . . . . . . . . . . . . 801
Abatacept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 801
Blockade of Cell Adhesion . . . . . . . . . . . . . . . . . . . . . . . . 802
Natalizumab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
Inhibition of Complement Activation . . . . . . . . . . . . . . . . . 802
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 802
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 802
most organ transplantation occurs between unrelated indi-
viduals. Donor and recipient tissues express different MHC
class I molecules, and recipient immune cells therefore rec-
ognize the transplanted tissues as foreign. This is termed
alloimmunity, and it occurs when the recipients immune
system attacks a transplanted organ. In the case of a bone
marrow or stem cell transplant, graft-versus-host disease
(GVHD) can result when donor lymphocytes mount an as-
sault on recipient tissues.
Solid Organ Rejection
Transplant rejection of solid organs can be divided into three
major phases according to the time to onset. These phases,
hyperacute, acute, and chronic rejection, are caused by dif-
ferent mechanisms and are therefore treated differently. The
following three sections examine each of these processes,
and Table 45-1 summarizes their differences.
Hyperacute Rejection
Hyperacute rejection is mediated by preformed recipient
antibodies against donor antigen. Because these antibodies
are present at the time of organ implantation, hyperacute
rejection occurs almost immediately after reperfusion of
the transplanted organ. In fact, the surgeon can observe the
792 Principles of Inflammation and Immune Pharmacology
directed against endothelial cells and is thus also known as
acute vascular rejection. Like acute cellular rejection, acute
humoral rejection can usually be prevented by immunosup-
pression of the recipient after transplantation. Even with im-
munosuppression, however, episodes of acute rejection can
occur months or even years after transplantation.
Chronic Rejection
Chronic rejection is believed to be both humoral and cel-
lular in nature and does not occur until months or years after
transplantation. Because hyperacute and acute rejection are
generally well controlled by donor/recipient matching and
immunosuppressive therapy, chronic rejection is now the
most common life-threatening pathology associated with
organ transplantation.
Chronic rejection is thought to result from chronic inflam-
mation caused by the response of activated T cells to donor
antigen. Activated T cells release cytokines that recruit mac-
rophages into the graft. The macrophages induce chronic
inflammation that leads to intimal proliferation of the vascu-
lature and scarring of the graft tissue. The chronic changes
eventually lead to irreversible organ failure. Other contrib-
uting nonimmune factors can include ischemia-reperfusion
injury and infection.
No effective treatment regimens are currently available
to eliminate chronic rejection. It is believed, however, that
several experimental therapies have a reasonable chance of
reducing chronic rejection. Especially promising is the pos-
sibility of developing tolerance through elimination of co-
stimulation (see below).
Graft-Versus-Host Disease (GVHD)
Leukemia, primary immunodeficiency, and other conditions
can be treated with bone marrow or peripheral stem cell
transplantation. In this procedure, hematopoietic and im-
mune function is restored after the patients bone marrow has
been eradicated by aggressive chemotherapy and/or radiation
therapy. GVHD is a major complication of allogeneic bone
marrow or stem cell transplantation. GVHD is an alloim-
mune inflammatory reaction that occurs when transplanted
immune cells attack the cells of the recipient. The severity of
GVHD ranges from mild to life-threatening and typically in-
volves the skin (rash), gastrointestinal tract (diarrhea), lungs
(pneumonitis), and liver (veno-occlusive disease). GVHD can
often be ameliorated by removing T cells from the donor bone
marrow before transplantation. Mild-to-moderate GVHD can
also be beneficial when donor immune cells attack recipient
tumor cells that have survived the aggressive chemotherapy
and radiation therapy. (In the case of leukemia, this is called
the graft-versus-leukemia effect, or GVL.) Therefore, al-
though removing donor T cells from the graft reduces the
risk of GVHD, this may not be the best approach for marrow
transplants used in antineoplastic therapy.
Autoimmunity
Autoimmune diseases occur when the host immune system
attacks its own tissues, mistaking self-antigen for foreign.
The typical result is chronic inflammation in the tissue(s)
expressing the antigen.
Autoimmune diseases are most commonly due to a break-
down of self-tolerance, both central and peripheral. Central
tolerance refers to the specific clonal deletion of autoreactive
T and B cells during their development from precursor cells
in the thymus (T cells) and bone marrow (B cells). Central
tolerance ensures that the majority of immature autoreactive
T and B cells do not develop into self-reactive clones. The
thymus and bone marrow do not express every antigen in
the body, however; a number of proteins are expressed only
in specific tissues. For this reason, peripheral tolerance is
also important. Peripheral tolerance results from deletion of
autoreactive T cells by Fas-Fas ligand-mediated apoptosis,
activation of T suppressor cells, or induction of T-cell anergy
due to antigen presentation in the absence of costimulation.
Although breakdown in tolerance lies at the center of vir-
tually all autoimmune diseases, the inciting stimulus leading
to loss of tolerance is often unknown. Genetic factors may
play a role, in that the presence of certain MHC subtypes may
predispose T cells to the loss of self-tolerance. For example,
human leukocyte antigen (HLA)-B27 is causally related to
many forms of autoimmune spondylitis. Several other autoim-
mune diseases are linked to specific HLA loci, supporting an
association, if not a causal role, for genetic predisposition to
autoimmunity. Molecular mimicry, whereby epitopes from
infectious agents are similar to self-antigens, can also lead to
a breakdown of tolerance and may be the mechanism underly-
ing poststreptococcal glomerulonephritis. A number of other
processes, including failure of T-cell apoptosis, polyclonal
lymphocyte activation, and exposure of cryptic self-antigens,
have also been hypothesized to lead to autoimmunity. The de-
tails of these mechanisms are beyond the scope of this book;
however, the result of each is a loss of tolerance.
Once self-tolerance has been compromised, the specific
expression of autoimmunity can take one of three general
forms (Table 45-2). In some diseases, production of autoanti-
bodies against a specific antigen causes antibody-dependent
opsonization of cells in the target organ, with subsequent cy-
totoxicity. One example is Goodpastures syndrome, which
results from autoantibodies against collagen type IV in the
renal glomerular basement membrane. In some autoimmune
vasculitis syndromes, circulating antibodyantigen complexes
deposit in blood vessels, causing inflammation and injury to
the vessels. Two examples of immune-complex disease are
mixed essential cryoglobulinemia and systemic lupus erythe-
matosus. Finally, T-cell-mediated diseases are caused by cy-
totoxic T cells that react with a specific self-antigen, resulting
in destruction of the tissue(s) expressing that antigen. One
example is type 1 diabetes mellitus, in which the cytotoxic
T cells react against self-antigens in pancreatic -cells.
The pharmacologic therapy for autoimmune diseases
does not yet match the exquisite specificity of the offending
biological process. Most currently available pharmacologic
agents cause generalized immunosuppression and do not tar-
get the specific pathophysiology. Better understanding of the
molecular pathways leading to autoimmune diseases should
reveal new pharmacologic targets that can be used to suppress
the specific autoimmune response before disease arises.
 PHARMACOLOGIC CLASSES AND AGENTS
Pharmacologic suppression of the immune system utilizes
eight mechanistic approaches (Fig. 45-1):
1. Inhibition of gene expression to modulate inflammatory
responses
2. Depletion of expanding lymphocyte populations with
cytotoxic agents
 4
Cytokines

Cytokine receptor

T cell
MHC class II
TCR

3
1

B7 CD28
CD4 5
6
Antigen-presenting cell

2 Cell surface
receptor
Cl

on
al
ex
pa
n si
o n of
cells

Tissues

N N O2
N
S which regulates inducible nitric oxide synthase (iNOS), the
N tion by neutrophils. Endothelial NOS (eNOS), which controls
N
N N
H the considerable selectivity of MPA.
Azathioprine + Glutathione
S that chronic rejection is also reduced more effectively in re-
N
HN
N N
H
Mercaptopurine
FIGURE 45-2. Formation of mercaptopurine from azathioprine. Azathio-
prine is a prodrug form of the antimetabolite 6-mercaptopurine. Mercaptopurine
is formed by the cleavage of azathioprine in a nonenzymatic reaction with gluta-
thione. Although mercaptopurine can also be used directly as a cytotoxic agent,
azathioprine has greater oral bioavailability and a longer duration of action and is
more immunosuppressive than mercaptopurine.
5-fluorouracil, 6-mercaptopurine, and mycophenolic acid, also
promote apoptosis of activated T cells. MTX may be such a ver-
satile drug because of its combined antineutrophil, anti-T-cell,
and antihumoral effects.
Mycophenolic Acid and Mycophenolate Mofetil
Mycophenolic acid (MPA) is an inhibitor of inosine mono-
phosphate dehydrogenase (IMPDH), the rate-limiting en-
zyme in the formation of guanosine (see Fig. 38-3). Because
MPA has low oral bioavailability, it is usually administered as
a sodium salt or in its prodrug form, mycophenolate mofetil
(MMF), both of which have greater oral bioavailability
(Fig. 45-3). MMF is increasingly used in the treatment of
immune-mediated disease because of its high selectivity and
profound effect on lymphocytes.
MPA and MMF both act primarily on lymphocytes. Two
main factors contribute to this selectivity. First, as discussed
in Chapter 38, lymphocytes are dependent on the de novo
pathway of purine synthesis, whereas most other tissues rely
heavily on the salvage pathway. Because IMPDH is required
for de novo synthesis of guanosine nucleotides but not for
the salvage pathway, MPA affects only cells such as lympho-
cytes that rely on de novo purine synthesis. Second, IMPDH
is expressed in two isoforms, type I and type II. MPA pref-
erentially inhibits type II IMPDH, the isoform expressed
mainly in lymphocytes. Together, these factors confer on
MPA and MMF selectivity against T and B cells, with rela-
tively low toxicity to other cells.
Inhibition of IMPDH by MPA reduces intracellular guano-
sine levels and elevates intracellular adenosine levels, with
many downstream effects on lymphocyte activation and activ-
ity. MPA has a cytostatic effect on lymphocytes, but can also
induce apoptosis of activated T cells leading to the elimination
of reactive clones of proliferative cells. Because guanosine
is required for some glycosylation reactions, the reduction
in guanosine nucleotides leads to decreased expression of
CHAPTER 45 / Pharmacology of Immunosuppression 795
adhesion molecules that are required for recruitment of several
immune cell types to sites of inflammation. Furthermore, be-
cause guanosine is a precursor of tetrahydrobiopterin (BH4),
reduction in guanosine levels leads to decreased NO produc-
vascular tone and is regulated by Ca2 and calmodulin, is not
affected by changes in guanosine levels, again demonstrating
As noted above, clinical studies comparing MMF and
AZA have shown MMF to be more efficacious in preventing
acute rejection of kidney transplants. Animal models show
cipients treated with MMF than in those treated with AZA
or cyclosporine. The efficacy of MMF in treating chronic
rejection may be related to its inhibition of both the lympho-
cyte and the smooth muscle cell proliferation characteristic
of chronic rejection.
MMF is also efficacious in the treatment of autoimmune
disease. In rheumatoid arthritis, levels of rheumatoid factor,
immunoglobulin, and T cells are reduced by treatment with
MMF. MMF is frequently used in the initial therapy of lupus
nephritis. There have also been isolated reports of successful
treatment of myasthenia gravis, psoriasis, autoimmune hemo-
lytic anemia, and inflammatory bowel disease with MMF.
The most common adverse effect of MMF is gastrointes-
tinal discomfort, which is dose-dependent and can include
nausea, diarrhea, soft stools, anorexia, and vomiting.
Leflunomide
Activated lymphocytes both proliferate and synthesize large
quantities of cytokines and other effector molecules, and
these processes require increased DNA and RNA synthesis.
Therefore, agents that reduce intracellular nucleotide pools
have effects on these activated cells. Leflunomide is an
O OH
O
N
O
O O
O
Mycophenolate mofetil
Plasma esterases
OH
O
OH
O
O
O
Mycophenolic acid
FIGURE 45-3. Mycophenolic acid and mycophenolate mofetil. Myco-
phenolate mofetil (MMF) has greater oral bioavailability than mycophenolic acid
(MPA). Orally administered mycophenolate mofetil is absorbed into the circulation,
where plasma esterases rapidly cleave the ester bond to yield mycophenolic acid.
Both agents inhibit inosine monophosphate dehydrogenase type II (IMPDH II), an
enzyme crucial for de novo synthesis of guanosine. Because of its greater oral
bioavailability, MMF (or the sodium salt of MPA) is typically used.
796 Principles of Inflammation and Immune Pharmacology

O O- FIGURE 45-4. Inhibition of pyrimidine synthesis by leflunomide. De novo

O O
pyrimidine synthesis depends on the oxidation of dihydroorotate to orotate, a re-
action that is catalyzed by dihydroorotate dehydrogenase. Leflunomide inhibits
H2N N O-
H dihydroorotate dehydrogenase and thereby inhibits pyrimidine synthesis. Because
N-Carbamoylaspartate
lymphocytes are dependent on de novo pyrimidine synthesis for cell proliferation and
clonal expansion after immune cell activation, depletion of the pyrimidine pool inhib-
H+ its lymphocyte expansion. Experimentally, leflunomide appears to inhibit preferen-
Dihydroorotase tially the proliferation of B cells; the reason for this preferential action is unknown.

H2O

O inhibitor of pyrimidine synthesis, specifically blocking the

synthesis of uridylate (UMP) by inhibiting dihydroorotate
HN dehydrogenase (DHOD). DHOD is a key enzyme in the syn-
O- thesis of UMP (Fig. 45-4), which is essential for the syn-
O N thesis of all pyrimidines. (See Chapter 38 for a review of
H
O pyrimidine synthesis.) Experimentally, leflunomide has been
Dihydroorotate shown to be most effective in reducing B-cell populations,
NAD+
but a significant effect on T cells has also been observed.
Leflunomide Dihydroorotate Leflunomide is currently approved for use in rheumatoid
dehydrogenase arthritis, but the drug has also shown significant efficacy in
NADH the treatment of other immune diseases, including systemic
O
lupus erythematosus and myasthenia gravis. Leflunomide
prolongs transplant graft survival and limits GVHD in ani-
HN mal models.
The most significant adverse effects of leflunomide are
O-
O N diarrhea and reversible alopecia. Leflunomide undergoes
H
O
significant enterohepatic circulation, resulting in a pro-
longed pharmacologic effect. If leflunomide must be re-
Orotate
moved quickly from a patients system, cholestyramine may
PRPP be administered. By binding to bile acids, cholestyramine
Orotate phosphoribosyl interrupts the enterohepatic circulation and causes a wash-
transferase out of leflunomide.
PPi

O Alkylating Agents
Cyclophosphamide
HN Cyclophosphamide (Cy) is a highly toxic drug that alky-
O- lates DNA. The mechanism of action and uses of Cy are
O-
O N discussed extensively in Chapter 38; therefore, the discus-
-
O O O sion here is limited to Cys utility in treating diseases of the
P
O immune system. Because Cy has a major suppressive effect
O H H
on B-cell proliferation but can enhance T-cell responses, the
H H
OH OH use of Cy in immune diseases is limited to disorders of hu-
Orotidylate moral immunity, particularly systemic lupus erythematosus.
H+ Another use under consideration for Cy is the suppression
of antibody formation against xenotransplant grafts. Adverse
Orotidylate decarboxylase
effects of Cy are severe and widespread, including leukope-
CO2
nia, cardiotoxicity, alopecia, and an increased risk of can-
O cer because of mutagenicity. The risk of bladder cancer is
especially notable because Cy produces a carcinogenic me-
HN tabolite, acrolein, which is concentrated in the urine. When
high-dose Cy is administered by intravenous infusion, ac-
O-
O N rolein can be detoxified by co-administration of mesna (a
-
O O sulfhydryl-containing compound that neutralizes the reac-
P
O tive moiety of acrolein).
O H H
H H
OH OH Specific Lymphocyte-Signaling Inhibitors
Uridylate
(UMP)
Cyclosporine and Tacrolimus
The discovery in 1976 that cyclosporine (CsA; also referred
to as cyclosporin A) is a specific inhibitor of T-cell-mediated
immunity enabled widespread whole-organ transplantation. In
fact, CsA made heart transplantation a legitimate alternative in
the treatment of end-stage heart failure. CsA is a cyclic deca-
peptide isolated from a soil fungus, Tolypocladium inflatum.
 Cyclosporine Tacrolimus (FK506)

Cyclophilin
FKBP

Calcineurin
(inactive)

Ca2+

Calmodulin
Calcineurin
(active)

Inactive NFAT Active NFAT IL-2 mRNA

IL-2 gene
Nucleus
798 Principles of Inflammation and Immune Pharmacology
IL-2
Sirolimus IL-2 receptor
mTOR
FKBP
p70 S6 kinase PHAS-1
Translation of selected mRNAs
needed for cell cycle progression
FIGURE 45-6. Mechanism of action of sirolimus. IL-2 receptor signal
transduction involves a complex set of proteinprotein interactions that lead to
increased translation of selected mRNAs encoding proteins required for T-cell
proliferation. Specifically, IL-2 receptor activation initiates an intracellular signal-
ing cascade that leads to phosphorylation of the molecular target of rapamycin
(mTOR). mTOR is a kinase that phosphorylates and thereby regulates the activity
of PHAS-1 and p70 S6 kinase. PHAS-1 inhibits the activity of a factor (eIF4E) re-
quired for translation, and p70 S6 kinase phosphorylates proteins involved in pro-
tein synthesis (not shown). The net effect of mTOR activation is to increase protein
synthesis, thereby promoting the transition from G1 to S phase of the cell cycle.
Sirolimus (also known as rapamycin) crosses the plasma membrane and binds
to intracellular FK-binding protein (FKBP). The sirolimusFKBP complex inhibits
mTOR, thereby inhibiting translation and causing T cells to arrest in G1. Everolimus
and zotarolimus are sirolimus analogues that act by the same mechanism.
artery smooth muscle cells and thereby reducing the rate of
in-stent restenosis that results from neointimal proliferation
of vascular smooth muscle cells.
Cytokine Inhibition
Cytokines are critical signaling mediators in immune func-
tion. Cytokines are also pleiotropic; that is, they exert differ-
ent effects depending on the target cell and overall cytokine
milieu. For this reason, pharmacologic uses of cytokines or
cytokine inhibitors may have unpredictable effects. Anticy-
tokine therapy has been in clinical use for immunologically
mediated diseases for more than a decade. The first anticy-
tokine agent approved for clinical use was etanercept, an
anti-TNF- drug developed for rheumatoid arthritis. During
the initial clinical studies, some patients with severe, drug-
refractory rheumatoid arthritis literally got up from their
wheelchairs and walked after receiving etanercept. This dra-
matic efficacy ushered in a new age of biological therapies
for autoimmune disease, and the number of new drugs that
inhibit proinflammatory cytokines continues to grow rapidly.
TNF- Inhibitors
Tumor necrosis factor- (TNF-) is a cytokine central to
many aspects of the inflammatory response. Macrophages,
mast cells, and activated TH cells (especially TH1 cells) secrete
TNF-. TNF- stimulates macrophages to produce cytotoxic
metabolites, thereby increasing phagocytic killing activity.
TNF- also stimulates production of acute-phase proteins,
has pyrogenic effects, and fosters local containment of the
inflammatory response. Some of these effects are indirect and
are mediated by other cytokines induced by TNF-.
TNF- has been implicated in numerous autoimmune
diseases. Rheumatoid arthritis, psoriasis, and Crohns dis-
ease are three disorders in which inhibition of TNF- has
demonstrated therapeutic efficacy. Rheumatoid arthritis il-
lustrates the central role of TNF- in the pathophysiology
of autoimmune diseases (Fig. 45-7). Although the initial
stimulus for joint inflammation is still debated, it is thought
that macrophages in a diseased joint secrete TNF-, which
activates endothelial cells, other monocytes, and synovial
fibroblasts. Activated endothelial cells up-regulate adhesion
molecule expression, resulting in recruitment of inflamma-
tory cells to the joint. Monocyte activation has a positive
feedback effect on T-cell and synovial fibroblast activation.
Activated synovial fibroblasts secrete interleukins, which re-
cruit additional inflammatory cells. With time, the synovium
hypertrophies and forms a pannus that leads to destruction
of bone and cartilage in the joint, causing the characteristic
deformity and pain of rheumatoid arthritis.
Five therapies interfering with TNF- activity have been
approved. Etanercept is a soluble TNF receptor dimer that
Macrophage
TNF
Endothelial cells
Monocyte/macrophage
IL-1
Activated endothelial cells
Synovial
fibroblast
T cell
IL-8 Matrix metalloproteases
PGE2
IL-6
Cartilage
degradation
Leukocyte adhesion
and diapedesis
FIGURE 45-7. Proposed roles for tumor necrosis factor in rheumatoid
arthritis. Tumor necrosis factor (TNF) is secreted by activated macrophages in an
affected joint, where this cytokine has multiple proinflammatory effects. First, TNF
activates endothelial cells to up-regulate their expression of cell surface adhesion
molecules (shown as projections on endothelial cells) and undergo other pheno-
typic changes that promote leukocyte adhesion and diapedesis. Second, TNF has a
positive feedback effect on nearby monocytes and macrophages, promoting their
secretion of cytokines such as IL-1. In turn, IL-1 activates T cells (among other
functions), and the combination of IL-1 and TNF stimulates synovial fibroblasts to
increase their expression of matrix metalloproteases, prostaglandins (especially
PGE2), and cytokines (such as IL-6) that degrade the joint cartilage. Synovial fibro-
blasts also secrete IL-8, which promotes neutrophil diapedesis.
 CHAPTER 45 / Pharmacology of Immunosuppression 799

links the extracellular, ligand-binding domain of human TNF Although all of these agents target TNF-, etanercept is
receptor type II to the Fc domain of human immunoglobu- somewhat less specific because it binds to both TNF- and
lin G1 (IgG1); infliximab is a partially humanized mouse TNF-. Infliximab, adalimumab, certolizumab, and goli-
monoclonal antibody against human TNF-; adalimumab mumab are specific for TNF- and do not bind TNF-. The
is a fully human IgG1 monoclonal antibody against TNF- Fc portions of infliximab, adalimumab, and golimumab may
(Fig. 45-8). Certolizumab pegol is a pegylated anti-TNF- also have specific activity with respect to complement fixa-
monoclonal antibody fragment that lacks the Fc portion of the tion and binding to Fc receptors on effector cells. The im-
antibody; as a result, unlike infliximab and adalimumab, cer- mune effector actions of these agents may be relevant to their
tolizumab does not cause antibody-dependent cell-mediated mechanisms of action because TNF- is expressed on the
cytotoxicity or fix complement in vitro. Golimumab is a surface of cells, especially macrophages, and the cell-surface
fully human IgG1 monoclonal antibody against TNF- that form is cleaved to yield the soluble cytokine. Anti-TNF-
has a longer half-life than the other anti-TNF- agents. agents with effector functions may have different biologi-
cal effects than agents that do not bind Fc receptors or fix
complement.
Etanercept is approved for use in rheumatoid arthritis, ju-
venile idiopathic arthritis, plaque psoriasis, psoriatic arthritis,
and ankylosing spondylitis; infliximab is approved for use
in rheumatoid arthritis, Crohns disease, ulcerative colitis,
Extracellular domain plaque psoriasis, and ankylosing spondylitis; adalimumab is
of human p75 TNF approved for use in rheumatoid arthritis, juvenile idiopathic
receptor arthritis, psoriatic arthritis, ankylosing spondylitis, plaque
psoriasis, and Crohns disease. Certolizumab is approved for
the treatment of Crohns disease. Golimumab is approved for
use in adults with rheumatoid arthritis (in combination with
s s methotrexate), psoriatic arthritis, and ankylosing spondylitis.
s s It is important to note that high levels of TNF- are likely
Fc domain CH2 CH2 mediators of underlying pathophysiologic processes. How-
of human IgG1 ever, although treatment with an anti-TNF- agent often
CH3 CH3 improves disease symptoms, it may not reverse the underly-
ing pathophysiology. Therefore, upon drug discontinuation,
maintenance of clinical response is uncertain. Etanercept,
Etanercept infliximab, adalimumab, certolizumab, and golimumab are
proteins and must be administered parenterally. Orally ac-
tive inhibitors of TNF- and inhibitors of TNF- converting
VH VH enzyme (TACE) are under investigation.
A number of important adverse effects must be consid-
VL
CH1 CH1
VL
ered when administering TNF inhibitors. All patients should
undergo screening for tuberculosis before initiating therapy
CL CL because of increased risk of reactivating latent tuberculosis.
Any patient developing an infection while taking a TNF-
s s inhibitor should undergo evaluation and aggressive anti-
s s
biotic treatment. Epidemiologic surveillance has also sug-
CH2 CH2 gested that there may be an increased risk of demyelinating
disease with anti-TNF therapy, although it has not yet been
CH3 CH3
determined whether the relationship is causal.

Infliximab IL-12/IL-23p40 Inhibitors

Human Mouse
FIGURE 45-8. Anti-TNF agents. Shown is the molecular domain organization
of etanercept and infliximab. Etanercept consists of the extracellular domain of the
human TNF receptor fused to the Fc domain of human IgG1. This decoy receptor
binds TNF- and TNF- in the circulation, preventing the access of these cyto-
kines to target tissues. Infliximab is a partially humanized monoclonal antibody
against TNF-. The variable heavy chain (VH) and variable light chain (VL) regions
are derived from mouse antihuman sequences, while the remainder of the anti-
body (the constant regions, denoted by CH and CL) is composed of human antibody
sequences. This modification of the original mouse anti-TNF- monoclonal anti-
body reduces the development of neutralizing antibodies against infliximab. Ad-
ditional TNF- inhibitors include adalimumab, a fully human monoclonal antibody;
certolizumab pegol, a pegylated monoclonal antibody fragment; and golimumab,
a fully human monoclonal antibody (not shown).
New biological therapies for the treatment of T-cell-medi-
ated diseases include antibodies to IL-12 and IL-23. IL-12
and IL-23 are cytokines involved in natural killer cell activa-
tion and CD4 T-cell differentiation and activation. IL-12, a
heterodimer composed of p40 and p35 subunits, directs the
differentiation of nave T cells into TH1 cells, which secrete
IL-2, IFN-, and TNF-. IL-23 is also a heterodimer that
has the same p40 subunit covalently linked to a p19 sub-
unit. IL-23 directs the differentiation of nave T cells into
TH17 cells, which secrete IL-17 and IL-22. Ustekinumab is
a high-affinity IgG1 human monoclonal antibody that binds
to the p40 subunit shared by IL-12 and IL-23. Ustekinumab
is approved for use in psoriasis and is in late-stage clini-
cal trials for the treatment of multiple sclerosis and psori-
atic arthritis. Adverse effects include an increased risk of
infections.

antibody not involved in binding to the antigen are changed
to the corresponding human sequences. Antibodies can be
partially or fully humanized, depending on the extent of
these changes. Humanization limits the likelihood of pro-
duction of human antibodies against the therapeutic anti-
body, increasing the clinical effectiveness of the antibody
and allowing its long-term use (see Chapter 53, Protein
Therapeutics). A more recent approach to the preparation of
therapeutic antibodies is to prepare the antibody in an ex-
perimental animal bearing a human immune system or to use
an in vitro human antibody system. This strategy generates
fully human antibodies that do not require further manipu-
lation to render them nonimmunogenic.
Anti-CD20 mAb
Rituximab is a chimeric, partially humanized anti-CD20
monoclonal antibody. CD20 is expressed on the surface of all
mature B cells, and administration of rituximab causes pro-
found depletion of circulating B cells. Originally approved for
the treatment of CD20 non-Hodgkins lymphoma (see Chap-
ter 39), rituximab has also been approved for use in rheumatoid
arthritis refractory to TNF- inhibitors. Several additional an-
ti-CD20 antibodies are in clinical development; ofatumumab
is a fully human anti-CD20 monoclonal antibody that recog-
nizes an epitope distinct from that of rituximab. Ofatumumab
is approved for use in chronic lymphocytic leukemia.
Anti-CD25 mAb
Daclizumab and basiliximab are monoclonal antibodies
against CD25, the high-affinity IL-2 receptor. IL-2 mediates
early steps in T-cell activation. Because CD25 is expressed
only on activated T cells, anti-CD25 antibody therapy selec-
tively targets T cells that have been activated by an MHC-
antigen stimulus.
Daclizumab is administered prophylactically in renal
transplantation to inhibit acute organ rejection. It is also used
as a component of general immunosuppressive regimens
after organ transplantation. Daclizumab is typically admin-
istered in a five-dose regimen, with the first administration
immediately after transplantation and then four additional
doses at 2-week intervals. This type of dosing regimen, in
which drug is administered for a limited period immediately
after transplantation, is referred to as induction therapy.
Anti-CD52 mAb
Campath-1 (CD52) is an antigen expressed on most mature
lymphocytes and on some lymphocyte precursors. An anti-
body against this antigen was originally tested in rheumatoid
arthritis and found to cause prolonged and sustained deple-
tion of all T cells, often lasting for years. The reason for
the sustained lymphocyte depletion is unknown. Anti-CD52
mAb therapy did lead to some improvement in the symptoms
of arthritis; however, the sustained depletion of lymphocytes
and concern about infections precluded further study of this
antibody in autoimmune conditions. Under the generic name
alemtuzumab, anti-CD52 mAb has been approved as an ad-
junctive therapy in the treatment of B-cell chronic lympho-
cytic leukemiaa condition in which sustained suppression
of the leukemic cells is desirable.
LFA-3
LFA-3 (also called CD58) is the counter-receptor for
CD2, an antigen expressed at high levels on the surface
CHAPTER 45 / Pharmacology of Immunosuppression 801
of memory effector T cells. Interaction of CD2 on T cells
with LFA-3 on antigen-presenting cells promotes increased
T-cell proliferation and enhanced T-cell-dependent cyto-
toxicity. Because the memory effector T-cell population is
elevated in patients with psoriasis, a pharmacologic agent
that disrupts the CD2LFA-3 interaction was tested for use
in psoriasis.
Alefacept is an LFA-3/Fc fusion protein that interrupts
CD2LFA-3 signaling by binding to T-cell CD2, and thereby
inhibits T-cell activation. Additionally, the Fc portion of ale-
facept may activate NK cells to deplete the immune system
of memory effector T cells. Clinically, alefacept significantly
decreases the severity of chronic plaque psoriasis. Because
CD2 is expressed on other adaptive immune cells, admin-
istration of alefacept also causes a dose-dependent reduc-
tion in CD4 and CD8 T-cell populations. Its use is therefore
contraindicated in patients with HIV, and patients taking
alefacept may have an increased risk of serious infection.
Alefacept therapy may also be associated with an increased
risk of malignancy, primarily skin cancer.
Inhibition of Costimulation
Costimulation refers to the paradigm that cells of the im-
mune system typically require two signals for activation
(see Chapter 41, Principles of Inflammation and the Im-
mune System). If a first signal is provided in the absence of
a second signal, the target immune cell may become anergic
rather than activated. Because induction of anergy could lead
to long-term acceptance of an organ graft or limit the ex-
tent of an autoimmune disease, inhibition of costimulation
represents a viable strategy for immunosuppression. Several
therapeutic agents inhibit costimulation by blocking the sec-
ond signal required for cell activation, and more such agents
are under development.
Abatacept
Abatacept consists of CTLA-4 fused to an IgG1 constant re-
gion. Abatacept complexes with costimulatory B7 molecules
on the surface of antigen-presenting cells. When the antigen-
presenting cell interacts with a T cell, MHC:antigenTCR
interaction (signal 1) occurs, but the complex of B7 with
abatacept prevents delivery of a costimulatory signal (signal
2), and the T cell develops anergy or undergoes apoptosis.
By this mechanism, abatacept therapy appears to be effective
in down-regulating specific T-cell populations.
Abatacept is approved for the treatment of rheuma-
toid arthritis that is refractory to methotrexate or TNF-
inhibitors. Clinically, abatacept significantly improves
symptoms of rheumatoid arthritis in patients who fail to
respond to methotrexate or TNF- inhibitors. The major
adverse effects of abatacept are exacerbations of bronchitis
in patients with preexisting obstructive lung disease and
increased susceptibility to infection. Abatacept should not
be administered concurrently with TNF- inhibitors or
anakinra because the combination carries an unacceptably
high risk of infection.
Belatacept is a close structural congener of abatacept that
has increased affinity for B7-1 and B7-2. In a large clinical
trial, belatacept was as effective as cyclosporine at inhibiting
acute rejection in renal transplant recipients. Belatacept is
currently under further investigation as an immunosuppres-
sant for organ transplantation.
802 Principles of Inflammation and Immune Pharmacology
Blockade of Cell Adhesion
The recruitment and accumulation of inflammatory cells at
sites of inflammation is an essential element of most autoim-
mune diseases; the only exceptions to this rule are autoim-
mune diseases that are purely humoral, such as myasthenia
gravis. Drugs that inhibit cell migration to sites of inflamma-
tion may also inhibit antigen presentation and cytotoxicity,
thus providing multiple potential mechanisms of beneficial
action.
Natalizumab
Alpha-4 integrins are critical to immune-cell adhesion and
homing. The 41 integrin mediates immune-cell interac-
tions with cells expressing vascular cell adhesion molecule
1 (VCAM-1), while the 47 integrin mediates immune-cell
binding to cells expressing mucosal addressin cell adhesion
molecule 1 (MAdCAM-1). Natalizumab is a monoclonal
antibody against 4 integrin that inhibits immune-cell inter-
actions with cells expressing VCAM-1 or MAdCAM-1.
Natalizumab was approved for the treatment of relaps-
ing multiple sclerosis. During postmarketing surveillance of
the drug, however, several patients treated with natalizumab
developed progressive multifocal leukoencephalopathy
(PML), a rare demyelinating disorder caused by infection
with JC virus. This finding resulted in voluntary withdrawal
of the drug. After further FDA investigation, it was decided
to resume testing of natalizumab and to add a warning to
the product label regarding the possible association. Natali-
zumab was subsequently reapproved for use in the treatment
of multiple sclerosis and Crohns disease.
Inhibition of Complement Activation
The complement system mediates a number of innate immune
responses (see Chapter 41). Recognition of foreign proteins
or carbohydrates leads to sequential activation of comple-
ment proteins and eventual assembly of the membrane
attack complex, a multiprotein structure that can cause cell
lysis. Patients with paroxysmal nocturnal hemoglobinuria
(PNH) have acquired defects in complement regulatory pro-
teins, leading to inappropriate activation of complement and
complement-mediated lysis of erythrocytes. Eculizumab is
a humanized monoclonal antibody against C5, a complement
protein that mediates late steps in complement activation and
triggers assembly of the membrane attack complex. Eculi-
zumab is approved for the treatment of PNH; it significantly
decreases hemoglobinuria and the need for erythrocyte
transfusions in patients with this disorder. Genetic evidence
indicates that complement activation may play an etiologic
role in age-dependent macular degeneration, suggesting that
inhibitors of the complement cascade could be useful local
therapies for this disease.
 CONCLUSION AND FUTURE DIRECTIONS
Several approaches are available for the pharmacologic sup-
pression of adaptive immunity, ranging from the relatively
low-specificity approaches represented by glucocorticoids
and cytotoxic agents to the more specific approaches rep-
resented by cell-signaling inhibitors and antibody therapies.
Glucocorticoids induce profound suppression of the in-
flammatory response and immune system, but cause many
adverse effects, most of which are due to drug effects on
cells outside the immune system. Glucocorticoid receptor
modulators are being sought that retain the anti-inflamma-
tory effects of glucocorticoids but have less severe adverse
effects on metabolism and bone mineral homeostasis. Cyto-
toxic agents target DNA replication; although immune cells
are highly susceptible to these drugs, so too are other normal
cells such as those in the gastrointestinal epithelium. The
cytotoxic agent mycophenolate mofetil is highly selective,
both because lymphocytes depend on de novo purine synthe-
sis and because mycophenolic acid preferentially targets the
inosine monophosphate dehydrogenase isoenzyme expressed
in lymphocytes. Lymphocyte-signaling inhibitorssuch as
cyclosporine, tacrolimus, sirolimus, and everolimus, which
target intracellular signal transduction pathways necessary
for T-cell activationare also reasonably selective. Many
new inhibitors of intracellular signaling in lymphocytes are
under investigation; inhibition of the Janus kinase family
appears particularly promising. Cytokine inhibitors interrupt
soluble signals mediating immune-cell activation. TNF-
inhibitorssuch as etanercept, infliximab, and adalimu-
mabrepresent an expanding class of drugs. Promising new
targets include cytokines associated with TH17 cells, among
others. The concept of preventing immune-cell activation has
also been extended to the blockade of costimulation repre-
sented by the antirheumatic agent abatacept. Specific deple-
tion of B cells is a well-established therapy for lymphomas
and rheumatoid arthritis. Specific depletion of T cells may be
beneficial in organ transplantation: antithymocyte globulin,
OKT3, and daclizumab are antibodies against T-cell-specific
epitopes. Several antibody therapeutics and small molecules
are available that block immune-cell adhesion and homing,
and more such agents are under development.
New research is yielding novel ideas for the manipu-
lation of the immune system. For example, microRNAs
(miRNAs) have been shown to have important regulatory
roles in immunity, and experimental manipulations of ani-
mal models of disease have suggested that selective modu-
lation of miRNA may enable a greater degree of control of
immunosuppression.
Disclosure
Lloyd Klickstein is an employee and stockholder of Novar-
tis, Inc., which manufactures or distributes drugs discussed
in this chapter, including cyclosporine, mycophenolate so-
dium, everolimus, canakinumab, and basiliximab.
Suggested Reading
Allison AC. Mechanisms of action of mycophenolate mofetil. Lupus
2005;14(Suppl 1):s28. (Review of mycophenolate mofetil.)
Murphy K, Travers P, Walport M. Janeways immunobiology: the immune
system in health and disease. 7th ed. New York: Garland Publishing; 2007.
(Discussion of autoimmunity and transplantation immunity.)
Lindsay MA. microRNAs and the immune response. Trends Immunol
2008;29:343351. (Discusses role that microRNAs may have in regulating
inflammation.)
Nucleotide biosynthesis. In: Berg JM, Tymoczko JL, Stryer L, eds. Bio-
chemistry. 6th ed. New York: W. H. Freeman and Company; 2007. (Review
of nucleotide biosynthesis.)
Vincenti F, Larsen C, Durrbach A, et al. Costimulation with belatacept in
renal transplantation. N Engl J Med 2005;353:770781. (Clinical trial dem-
onstrating noninferiority of belatacept relative to cyclosporine.)

Integrative Inflammation
Pharmacology: Peptic
Ulcer Disease
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 807-808
PHYSIOLOGY OF GASTRIC ACID SECRETION . . . . . . . . . . . 807
Neurohormonal Control of Gastric Acid Secretion . . . . . . . 807
Phases of Gastric Acid Secretion . . . . . . . . . . . . . . . . . . . 809
Protective Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 809
PATHOPHYSIOLOGY OF PEPTIC ULCER DISEASE . . . . . . . . 810
Helicobacter pylori . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 810
NSAIDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 811
Acid Hypersecretion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 811
Other Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 811
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 812
Agents That Decrease Acid Secretion . . . . . . . . . . . . . . . . 812
H2 Receptor Antagonists . . . . . . . . . . . . . . . . . . . . . . . 812
 INTRODUCTION
A peptic ulcer is a break in the mucosa of the stomach (gas-
tric ulcer) or duodenum (duodenal ulcer). Four-and-a-half
million people in the United States suffer from active peptic
ulcer disease, and 500,000 new cases of peptic ulcer disease
are diagnosed each year. The lifetime prevalence of peptic
ulcer disease is approximately 10%, and the estimated an-
nual cost for treatment exceeds one billion dollars.
There are several pathophysiologic mechanisms for pep-
tic ulcer disease, and clinical management therefore requires
multiple pharmacologic strategies. This chapter describes the
physiology of gastric acid secretion and the pathophysiology
underlying the formation of peptic ulcers. The pharmaco-
logic agents used in the treatment of peptic ulcer disease are
then discussed in relation to the pathophysiology that is in-
terrupted by these drugs.
46
Dalia S. Nagel and Helen M. Shields
Proton Pump Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . 813
Anticholinergic Agents . . . . . . . . . . . . . . . . . . . . . . . . 816
Agents That Neutralize Acid . . . . . . . . . . . . . . . . . . . . . . . 816
Agents That Promote Mucosal Defense . . . . . . . . . . . . . . 816
Coating Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 816
Prostaglandins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 816
Agents That Modify Risk Factors . . . . . . . . . . . . . . . . . . . 816
Diet, Tobacco, and Alcohol. . . . . . . . . . . . . . . . . . . . . . 816
Treatment of H. pylori Infection . . . . . . . . . . . . . . . . . . 816
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 817
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 817
 PHYSIOLOGY OF GASTRIC ACID
SECRETION
Neurohormonal Control of Gastric
Acid Secretion
Hydrochloric acid is secreted into the stomach by parietal
cells, which are located in oxyntic glands in the fundus and
body of the stomach. The parietal cell actively transports H
across its apical canalicular membranes via H/K ATPases
(proton pumps) that exchange intracellular H for extracel-
lular K. Three neurohormonal secretagogues regulate this
process: histamine, gastrin, and acetylcholine (ACh). Each
of these secretagogues binds to and activates specific recep-
tors on the basolateral membrane of the parietal cell, thereby
initiating the biochemical changes necessary for active trans-
port of H out of the cell.
807
 CHAPTER 46 / Integrative Inflammation Pharmacology: Peptic Ulcer Disease 809

Lumen

Cl- K+ Apical
membrane

Canaliculus

H+/K+ ATPase K+

Parietal
cell Translocation/ Endoplasmic
fusion reticulum

Tubulovesicle ATP H+ ADP

Ca2+
containing
inactive Protein kinases
H+/K+ ATPase ATP
cAMP IP3
Basolateral
s
membrane
GTP
q

AC GTP

H2 DAG
M3 CCKB
PLC
Histamine

ACh Gastrin

ECL cell Nerve Blood vessel

FIGURE 46-1. Control of parietal cell acid secretion. Stimulation of parietal cell acid secretion is modulated by paracrine (histamine), neuroendocrine (acetylcho-
line [ACh]), and endocrine (gastrin) pathways, which activate their respective receptors (H2, M3, and CCKB). H2 receptor activation increases cAMP, which activates protein
kinase A. M3 and CCKB receptor activation stimulates release of Ca2 by the Gq-mediated IP3/DAG pathway; these signals may also stimulate protein kinase C activity.
Protein kinase activation results in translocation of cytoplasmic tubulovesicles containing inactive H/K ATPase to the apical membrane. Fusion of tubulovesicles with
the apical membrane activates H/K ATPase, which pumps H ions into the stomach lumen. An apical membrane Cl channel couples Cl efflux to H efflux, and an
apical membrane K channel recycles K out of the cell. The net result of this process is the rapid extrusion of HCl into the stomach lumen. In addition to its direct effect
on CCKB receptors on parietal cells, gastrin also stimulates CCKB receptors on ECL cells to promote histamine release (not shown).

Phases of Gastric Acid Secretion Protective Factors

Gastric secretions increase considerably during a meal. There
are three phases of gastric acid secretion.
The cephalic phase includes responses to sight, taste,
smell, and thought of food. Sham feedings, experiments
in which food is chewed but not swallowed, trigger an in-
crease in acid secretion mediated by vagal stimulation and
increased gastrin secretion.
Mechanical distension of the stomach and ingestion of
amino acids and peptides stimulate the gastric phase. Dis-
tension activates stretch receptors in the wall of the stomach
that are linked to short intramural nerves and vagal fibers.
Luminal nutrients, such as amino acids, are strong stimulants
for gastrin release. Gastrin travels via the blood to the oxyn-
tic mucosa and stimulates ECL cells to release histamine. An
important negative feedback on acid secretion in this phase
is acid (pH 3)-mediated inhibition of gastrin release from
antral G cells. Acid secretion is also inhibited by release of
somatostatin from antral D cells.
The intestinal phase involves stimulation of gastric acid
secretion by digested protein in the intestine. Gastrin plays a
major role in mediating this phase as well.
Factors that protect the gastric mucosa include gastric
mucus, prostaglandins (discussed above and in Chapter 42,
Pharmacology of Eicosanoids), gastric and duodenal bicar-
bonate, restitution (repair), and blood flow. The epithelial
cells of the stomach secrete mucus, which acts as a lubricant
that protects the mucosal cells from abrasions. Composed
of hydrophilic glycoproteins that are viscous and have gel-
forming properties, the mucus layer enables formation of an
uninterrupted layer of water at the luminal surface of the epi-
thelium. Together, the mucus and water layers attenuate po-
tential damage due to the acidic environment of the gastric
lumen. Prostaglandins stimulate mucus secretion, whereas
NSAIDs and anticholinergic medications inhibit mucus pro-
duction. In addition, H. pylori disrupts the mucus layer (see
below).
Bicarbonate protects the gastric epithelium by neutraliz-
ing gastric acid. Bicarbonate is secreted by epithelial cells at
the luminal surface of the gastric mucosa, in gastric pits, and
at the luminal surface of the duodenal mucosa. Bicarbonate
secretion in the duodenum serves to neutralize acid entering
the intestine from the stomach.
Urease activity pH G cell
Gastrin
Cell proliferation

Somatostatin

Helicobacter pylori Acid secretion

D cell Parietal cell

Inflammatory mediators Duodenal ulcer
disease
 A Systemic effects

Gastric acid secretion

Inhibition of Prostaglandins Bicarbonate/mucus
cyclooxygenase production
Blood flow

NSAID

Expression of Neutrophil Mucosal damage

intercellular adhesion adherence to due to neutrophil-
molecules in gastric vascular derived free radicals
vascular endothelium endothelial cells and proteases

B Topical injury

Stomach lumen Gastric epithelial cell

(pH ~ 2) (pH ~ 7)

O O

OH O-
H+ +
O O

Cell damage
O O

NSAID (aspirin)
weak acid
812 Principles of Inflammation and Immune Pharmacology

Bismuth Antacids
H. pylori Lumen
Antibiotics

Coating agents

Cl- K+
Proton pump
inhibitors

Canaliculus
Mucus cell Mucus cell
K+
H+/K+ ATPase

Parietal Translocation/
cell fusion Endoplasmic
reticulum
Tubulovesicle ATP H+ ADP
containing Ca2+
inactive
H+/K+ ATPase Protein kinases
ATP
cAMP IP3
s
GTP
q

AC GTP

H2 DAG
M3 CCKB
H2 blockers PLC
Histamine Muscarinic
antagonists

ACh
Gastrin
Nerve
ECL cell Blood vessel

FIGURE 46-4. Sites of action of drugs used to treat peptic ulcer disease. H2 receptor antagonists (H2 blockers) inhibit activation of the histamine H2 receptor by
endogenous histamine. Muscarinic antagonists inhibit signaling through the M3 muscarinic acetylcholine (ACh) receptor. Proton pump inhibitors decrease the activity of the
H/K ATPase on the canalicular membrane of the parietal cell. Antacids neutralize acid in the stomach lumen. Coating agents provide a protective layer on the epithelial
surface of the gastric mucosa. Bismuth and antibiotics act to eradicate H. pylori from the mucus layer coating the gastric mucosa. H. pylori infection is an important con-
tributing factor in the pathogenesis of peptic ulcer disease.

 PHARMACOLOGIC CLASSES
AND AGENTS
Several pathophysiologic mechanisms can lead to peptic
ulcer disease, and clinical management requires consid-
eration of multiple pharmacologic options. The available
agents can be divided into drugs that: (1) decrease acid se-
cretion; (2) neutralize acid; (3) promote mucosal defense;
and (4) modify risk factors (Fig. 46-4).
Agents That Decrease Acid Secretion
H2 Receptor Antagonists
The discovery of H2 receptor antagonists by Black and col-
leagues in the 1970s significantly changed the treatment of
peptic ulcer disease. These investigators identified a second
histamine receptor (H1 was the first; see Chapter 43, Hista-
mine Pharmacology) and elucidated its role in gastric acid
secretion. H2 receptor antagonists (also called H2 blockers)
reversibly and competitively inhibit the binding of histamine
to H2 receptors, resulting in suppression of gastric acid secre-
tion. H2 receptor antagonists also indirectly decrease gastrin-
and acetylcholine-induced gastric acid secretion.
Four H2 receptor antagonists are available: cimetidine, ra-
nitidine, famotidine, and nizatidine (Fig. 46-5). H2 receptor
antagonists are absorbed rapidly from the small intestine. Peak
plasma concentrations are achieved within 13 hours. Elimi-
nation of H2 receptor antagonists involves both renal excretion
and hepatic metabolism. It is therefore important to decrease
the dose of these drugs for patients with liver or kidney failure.
An exception is nizatidine, which is eliminated primarily by
the kidney.
All four drugs are well tolerated in general. Occasional
minor adverse effects include diarrhea, headache, muscle
pain, constipation, and fatigue. H2 receptor antagonists may
induce confusion and hallucinations in some patients. These
adverse effects in the central nervous system are uncom-
mon, however, and are typically associated with intravenous
administration of the H2 receptor antagonist. Additional
adverse effects specific to cimetidine, the first H2 receptor
antagonist to be developed, are discussed below.
Several clinically significant drugdrug interactions can
occur with H2 receptor antagonists. For example, ketocon-
azole, a drug that requires an acidic medium for gastric ab-
sorption, has reduced uptake in the alkaline environment
created by H2 receptor antagonists. As a second example, H2
receptor antagonists compete for renal tubular secretion of
procainamide and certain other drugs.
Cimetidine inhibits many cytochrome P450 enzymes and
thus can interfere with the hepatic metabolism of numerous
 CHAPTER 46 / Integrative Inflammation Pharmacology: Peptic Ulcer Disease 813

N NH2 proton pump inhibitors have also been developed, including

esomeprazole (the [S]-enantiomer of omeprazole), rabepra-
HN zole, lansoprazole, dexlansoprazole (the [R]-enantiomer of
lansoprazole), and pantoprazole (Fig. 46-6).
Histamine All of the proton pump inhibitors are prodrugs that re-
(imidazole ring)
quire activation in the acidic environment of the parietal
cell canaliculus. Oral formulations of these drugs are en-
H H teric-coated to prevent premature activation. The prodrug
N N N
S is converted to its active sulfenamide form in the acidic
N canalicular environment, and the sulfenamide reacts with a
HN
C cysteine residue on the H/K ATPase to form a covalent
N
Cimetidine
(imidazole ring)
NH O

H H S N
O N N
O N
N S

NO2 O
Ranitidine Omeprazole
(furan ring)

NH O
NH2 O O
S N
N S
S N NH2 O N
N
H2N S
NH2 O
Famotidine Esomeprazole
(thiazole ring)

NO2 O HN
H
N N N S
S
O N
N S HN

Nizatidine O
(thiazole ring)
Rabeprazole
FIGURE 46-5. Histamine H2 receptor antagonists. H2 receptor antagonists
share moieties related to histamine, providing a structural rationale for inhibition
of the H2 receptor. For a more detailed description of the structure of these agents, NH O
see the legend to Figure 43-5. S N
N

drugs. For example, cimetidine can decrease the metabolism

O
of lidocaine, phenytoin, quinidine, theophylline, and warfa- F
rin, facilitating the accumulation of these drugs to toxic lev-
F
els. Cimetidine appears to inhibit P450 enzymes to a greater Lansoprazole F
extent than the other H2 receptor antagonists, and an H2
receptor antagonist other than cimetidine may be preferred
when the patient is receiving other medications. O
Cimetidine crosses the placenta and is secreted into breast O
O
milk, and is therefore not recommended for use during preg-
nancy or when nursing. Cimetidine can have antiandrogenic F O N S
N
effects because of its action as an antagonist at the androgen
receptor, resulting in gynecomastia (enlarged breasts) in men F NH
and, rarely, galactorrhea (discharge of milk) in women.

Proton Pump Inhibitors Pantoprazole

Proton pump inhibitors block the parietal cell H/K AT-
Pase (proton pump). Compared to H2 receptor antagonists,
proton pump inhibitors are superior at suppressing acid
secretion and promoting peptic ulcer healing. Omeprazole
is the prototype proton pump inhibitor. Several other
FIGURE 46-6. Proton pump inhibitors. The proton pump inhibitors are a
family of structurally related prodrugs that are all activated by the mechanism
shown in Figure 46-7. Note that esomeprazole is the (S )-enantiomer of omepra-
zole, which is formulated as a racemic mixture of (R )- and (S )-enantiomers.
Dexlansoprazole (not shown ) is the (R )-enantiomer of lansoprazole.
 Canaliculus
Parietal
pH < 2.0
cell
Omeprazole

K+

ATP H+ ADP

Omeprazole
pH 7.1
(cytoplasm)
Freely crosses
cell membrane

pH 7.4
(blood)
Omeprazole

O
O O
H+

S
H+/K+
N Exposed to Reacts
N+ N+ S ATPase
N S acidic rapidly
O S
environment N N to form a N NH
NH
of parietal cell covalent
canaliculus disulfide
O

O O
Omeprazole
(prodrug) Active Sulfenamide-H+/K+
sulfenamide ATPase complex
(inactive enzyme)
816 Principles of Inflammation and Immune Pharmacology
of this interaction remains uncertain, however, as observa-
tional studies have revealed conflicting results, and at least
one large clinical trial has found no significant difference in
adverse clinical outcomes (cardiovascular death, myocardial
infarction, or stroke) between individuals treated with clopi-
dogrel alone and individuals treated concomitantly with
clopidogrel and a proton pump inhibitor.
Some studies also suggest an increased risk of hip fracture
in patients who take proton pump inhibitors for an extended
period of time. Research on this topic has yielded conflicting
evidence to date: some studies suggest that proton pump in-
hibitor therapy may decrease gastric absorption of insoluble
calcium by raising gastric pH, but other studies suggest that
omeprazole may decrease bone resorption by inhibiting os-
teoclastic vacuolar H/K ATPase.
Use of proton pump inhibitors during hospital admission
has been shown to increase the risk for hospital-acquired
pneumonia, C. difficile infection, and enteric infections with
Salmonella and Escherichia coli. This increased risk may be
related to compromise of a normal defense mechanism (i.e.,
gastric acid) by the proton pump inhibitor, allowing ingested
organisms to escape acid-mediated destruction.
Anticholinergic Agents
Anticholinergic agents such as dicyclomine antagonize mus-
carinic ACh receptors on parietal cells and thereby decrease
gastric acid secretion. However, anticholinergic agents are
seldom used in the treatment of peptic ulcer disease because
they are not as effective as H2 receptor antagonists or proton
pump inhibitors. These agents also have many adverse ef-
fects, including dry mouth, blurred vision, cardiac arrhyth-
mia, and urinary retention.
Agents That Neutralize Acid
Antacids are used on an as-needed basis for symptomatic re-
lief of dyspepsia. These agents neutralize hydrochloric acid
by reacting with the acid to form water and salts. The most
widely used antacids are mixtures of aluminum hydrox-
ide and magnesium hydroxide. The hydroxide ion reacts
with hydrogen ions in the stomach to form water, while the
magnesium and aluminum react with bicarbonate in pancre-
atic secretions and with phosphates in the diet to form salts.
Common adverse effects associated with these antacids in-
clude diarrhea (magnesium) and constipation (aluminum).
When antacids containing aluminum and magnesium are
taken together, constipation and diarrhea may be avoided.
Antacids containing aluminum can bind phosphate; the re-
sulting hypophosphatemia can cause weakness, malaise, and
anorexia. Patients with chronic kidney disease should avoid
magnesium-containing antacids because they can lead to
hypermagnesemia.
Sodium bicarbonate reacts rapidly with HCl to form
water, carbon dioxide, and salt. Antacids containing sodium
bicarbonate have high amounts of sodium; in patients with
hypertension or fluid overload, sodium-containing antacids
can result in significant sodium retention.
Calcium carbonate is less soluble than sodium bicarbon-
ate; it reacts with gastric acid to produce calcium chloride
and carbon dioxide. Calcium carbonate is not only useful as
an antacid, but can also serve as a calcium supplement for
prevention of osteoporosis. The high calcium content of this
antacid formulation may cause constipation.
Agents That Promote Mucosal Defense
Agents that promote mucosal defense are used in the symp-
tomatic relief of peptic ulcer disease. These drugs include
coating agents and prostaglandins.
Coating Agents
Sucralfate, a complex salt of sucrose sulfate and aluminum
hydroxide, is a coating agent used to alleviate the symptoms
of peptic ulcer disease. Sucralfate has little ability to alter
gastric pH. Instead, in the acidic environment of the stom-
ach, this complex forms a viscous gel that binds to positively
charged proteins and thereby adheres to gastric epithelial
cells (including areas of ulceration). The gel protects the lu-
minal surface of the stomach from degradation by acid and
pepsin. Because sucralfate is poorly soluble, there is little
systemic absorption and no systemic toxicity. Constipation
is one of the few adverse effects. In addition, sucralfate may
bind to drugs such as quinolone antibiotics, phenytoin, and
warfarin and limit their absorption.
Colloidal bismuth is a second coating agent used in pep-
tic ulcer disease. Bismuth salts combine with mucus glyco-
proteins to form a barrier that protects an ulcer from further
damage by acid and pepsin. Bismuth agents may stimulate
mucosal bicarbonate and prostaglandin E2 secretion and
thereby also protect the mucosa from acid and pepsin deg-
radation. Colloidal bismuth has been found to impede the
growth of H. pylori and is frequently used as part of a mul-
tidrug regimen for the eradication of H. pylori-associated
peptic ulcers (see below).
Prostaglandins
Prostaglandins can be used in the treatment of peptic ulcer
disease (see Chapter 42), specifically in the treatment of
NSAID-induced ulcers. NSAIDs are ulcerogenic because
they inhibit prostaglandin synthesis and thereby interrupt
the gastroprotective functions of PGE2, which include re-
duced gastric acid secretion and enhanced bicarbonate se-
cretion, mucus production, and blood flow.
Misoprostol is a prostaglandin analogue used to prevent
NSAID-induced peptic ulcers. Its most frequent adverse
effects are abdominal discomfort and diarrhea. In clinical
practice, these adverse effects often interfere with patient
adherence. Misoprostol is contraindicated in women who
are (or may be) pregnant because of the possibility of gen-
erating uterine contractions that could result in abortion (see
Chapter 29, Pharmacology of Reproduction).
Agents That Modify Risk Factors
Diet, Tobacco, and Alcohol
As in the introductory case, diet therapy typically involves
recommendations to avoid caffeine-containing products be-
cause of their ability to increase acid secretion. Avoidance of
alcohol and cigarette smoking is also advised. Excessive al-
cohol intake is directly toxic to the mucosa and is associated
with erosive gastritis and an increased incidence of peptic
ulcers. Cigarette smoking is thought to decrease the produc-
tion of duodenal bicarbonate and diminish mucosal blood
flow, leading to a delay in ulcer healing.
Treatment of H. pylori Infection
Elimination of H. pylori can lead to cure of H. pylori-
associated peptic ulcers. Treatment for H. pylori infection
47
Integrative Inflammation
Pharmacology: Asthma
Joshua M. Galanter and Stephen Lazarus
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 820-821
PHYSIOLOGY OF AIRWAY SMOOTH MUSCLE TONE
AND IMMUNE FUNCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . 820
Physiology of Airway Smooth Muscle Contraction. . . . . . . 820
Immune Function in the Airway . . . . . . . . . . . . . . . . . . . . 821
PATHOPHYSIOLOGY OF ASTHMA. . . . . . . . . . . . . . . . . . . . . 822
Asthma as a Bronchoconstrictive Disease . . . . . . . . . . . . 822
Asthma as an Inflammatory Disease . . . . . . . . . . . . . . . . 824
TH2 Cells and the Origin of Asthma . . . . . . . . . . . . . . . 824
Plasma Cells, IgE, Mast Cells, and Leukotrienes . . . . . 825
Eosinophils . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 826
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 827
Bronchodilators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827
Anticholinergics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 827
 INTRODUCTION
Asthma is a chronic disease of the airways that is charac-
terized by marked airway inflammation and exaggerated
variability in airway caliber due to bronchial smooth muscle
hyperresponsiveness. The symptoms of asthma include dys-
pnea and wheezing as well as mucus production and cough,
particularly at night. Asthma is both an obstructive lung dis-
ease and an inflammatory disease; the obstructive component
is characterized by bronchoconstriction, whereas the inflam-
matory component is marked by airway edema, goblet cell
hyperplasia, mucus secretion, and infiltration and cytokine
release by immune and inflammatory cells. Although the
airway obstruction is generally reversible, asthma may, over
time, cause airway remodeling and permanent deterioration
in pulmonary function.
Medications used to treat asthma act in one of two
ways: by relaxing bronchial smooth muscle or by prevent-
ing and treating inflammation. This chapter approaches
asthma as both a bronchoconstrictive and an inflamma-
tory disease. After discussing the physiologic control of
bronchial tone and the function of immune pathways in
the airways, the chapter turns to the pathophysiology of
asthma. Current therapies are then discussed, including
the pharmacology of both bronchodilators and airway
anti-inflammatory agents.
820
-Adrenergic Agonists . . . . . . . . . . . . . . . . . . . . . . . . 827
Methylxanthines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 829
Magnesium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 829
Anti-Inflammatory Agents . . . . . . . . . . . . . . . . . . . . . . . . 829
Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 829
Cromolyns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 830
Leukotriene Pathway-Modifying Agents . . . . . . . . . . . 830
Anti-IgE Antibodies . . . . . . . . . . . . . . . . . . . . . . . . . . . 831
Drug Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 831
Clinical Management of Asthma . . . . . . . . . . . . . . . . . . . . 832
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 832
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 833
 PHYSIOLOGY OF AIRWAY SMOOTH
MUSCLE TONE AND IMMUNE FUNCTION
Asthma involves dysfunction in the pathways that regulate
both smooth muscle tone and immune function in the air-
ways. It is therefore important to review the normal physiol-
ogy of these systems before discussing the pathophysiology
of asthma.
Physiology of Airway Smooth Muscle
Contraction
As discussed in Chapter 8, Principles of Nervous System
Physiology and Pharmacology, involuntary responses of
smooth muscle are regulated by the autonomic nervous sys-
tem. In the airways, sympathetic (adrenergic) tone causes
bronchodilation and parasympathetic (cholinergic) tone
causes bronchoconstriction. Bronchial smooth muscle tone is
also regulated by nonadrenergic, noncholinergic (NANC)
fibers that innervate the respiratory tree.
Adrenergic innervation of the lung is concentrated primar-
ily on pulmonary blood vessels and the submucosal glands.
There is little direct adrenergic innervation of the bronchial
smooth muscle. However, airway smooth muscle cells
express 2-adrenergic receptors (and, to a lesser extent,
1-adrenergic receptors) that are responsive to circulating
 CHAPTER 47 / Integrative Inflammation Pharmacology: Asthma 823

Airway Allergen

Airway epithelium

Goblet cell
Naive
T-cell
Antigen-presenting cell

CD4

IL-4 IL-12

Activated TH2 Activated TH1

lymphocyte CD4 CD4 lymphocyte
IL-10

TH2 cytokines
(IL-4, IL-5, IL-6, IFN- TH1 cytokines
IL-9, IL-10, IL-13) (IFN-, IL-2,
TNF-)

Inflammatory cell
independent
mechanisms Low-level
E i hil
Eosinophil Plasma cellll
Pl (IL-13) IgG response
(MBP, ECP, Mast cell (IgE) (physiologic response) M h
Macrophage
leukotrienes, (histamine,
cytokines) leukotrienes,
cytokines) Low level
TH1 response
(physiologic
response)
Blood vessels

Submucosal
Goblet cell gland
hyperplasia
Airway
edema Epithelium
Subepithelial
fibrosis
Cartilage

Smooth muscle Smooth muscle

hyperplasia and/or
hypertrophy Asthma Normal airway
(no asthma)

FIGURE 47-1. Origins of the asthmatic immune response. In nonatopic individuals, antigens derived from allergens are presented by antigen-presenting dendritic
cells to engender a low-level, physiologic TH1 response. This response does not cause airway inflammation or bronchoconstriction (right side). Interferon-, produced
by activated TH1 lymphocytes, inhibits a TH2 response. In individuals susceptible to asthma, allergen-derived antigens that are presented to immature CD4 T cells
cause these cells to differentiate into activated TH2 lymphocytes. The TH2 lymphocytes release cytokines that recruit other inflammatory cells, including eosinophils,
mast cells, and IgE-producing B cells. Together, these cells produce an inflammatory response in the airway. Activated TH2 cells also induce an asthmatic response
directly, in part through release of IL-13. The net resultairway hyperresponsiveness, mucus production by goblet cells, airway edema, subepithelial fibrosis, and
bronchoconstrictionconstitutes the asthmatic response (left side).
Airway smooth muscle contraction

Asthmatic response
(hyperresponsiveness)

Hyperreactivity

Hypersensitivity

Normal response

Stimulus (e.g., methacholine)

 CHAPTER 47 / Integrative Inflammation Pharmacology: Asthma 825

Plasma Cells, IgE, Mast Cells, and Leukotrienes
As noted above, an IgE-mediated type I hypersensitivity re-
sponse is one mechanism by which allergens cause the patho-
logic and clinical manifestations of asthma (Fig. 47-3). The
allergic response is initiated when a dendritic cell phagocytoses
an inhaled allergen. The dendritic cell presents the processed
allergen to TH2 cells and activates them. The activated TH2 cells
bind to and activate B lymphocytes via CD40 on the B-cell sur-
face. Activated TH2 cells also generate IL-4 and IL-13, which
induce B-cell transformation into IgE-producing plasma cells.

Airway

Airway epithelium

Allergen
MHC class II
molecule
IgE crosslinked
Antigen- by allergen
presenting
TH2 cell
T-cell FcRI-bound
receptor IgE

Neurotrophins
Omalizumab Mast cell
IgE
Histamine-releasing IL-4
factor, neuropeptides, IL-4, IL-13
IL-9 IL-5
IL-5

Pla
Plasma cell
IL-4

Neuron
ECP Histamine,
leukotrienes,
Mastt cellll platelet-activating
Eosinophil
i hil
factor
IL-5

Neuropeptides Histamine, MBP, ECP,

leukotrienes, leukotrienes,
cytokines cytokines

Chronic asthmatic reaction Acute asthmatic reaction

Bronchoconstriction Bronchoconstriction
Vasogenic edema Airway edema
Mucus hypersecretion Mucus production
Chronic inflammation
Airway remodeling

FIGURE 47-3. The allergic response in asthma. Asthma produces acute and chronic inflammatory responses in the airways. Antigen-presenting cells phagocy-
tose and process allergens, presenting the antigens to CD4 T cells. These cells differentiate into cytokine-producing TH2 lymphocytes. The activated TH2 cells release
IL-4, IL-13, and IL-5, which recruit B cells and eosinophils. The B cells differentiate into IgE-producing plasma cells. The IgE binds to FcRI receptors on mast cells
and antigen-presenting cells. Upon re-exposure to the allergen, the IgE-bound FcRI is cross-linked, inducing the mast cell to degranulate and release preformed and
newly generated inflammatory mediators including histamine, cysteinyl leukotrienes, platelet-activating factor, and other cytokines. These cytokines cause acute airway
inflammation and produce acute asthmatic symptoms (an asthma attack or exacerbation). Chronically, activated TH2 cells and mast cells produce circulating IL-5 that
recruits eosinophils, and TH2 cells release products that stimulate local mast cells and neurons. Together, the inflammatory mediators and catabolic enzymes produced
by eosinophils, mast cells, and neurons cause chronic airway inflammation and lead to airway remodeling.
Omalizumab is a humanized monoclonal antibody against the FcRI-binding domain of IgE. By preventing IgE from binding to the IgE receptor (FcRI) on mast cells,
omalizumab inhibits mast cell degranulation upon re-exposure to allergen and thereby modulates the acute asthmatic reaction. Omalizumab also down-regulates FcRI
on antigen-presenting cells, thereby diminishing antigen processing and presentation to CD4 lymphocytes. Because fewer immature T cells are induced by allergen to
differentiate into TH2 lymphocytes, the chronic asthmatic reaction is also blunted.
826 Principles of Inflammation and Immune Pharmacology

IgE circulates briefly in the bloodstream before binding Nucleus Cytosol

to high-affinity IgE receptors (FcRI) on mast cells. Upon Prostaglandins
Aspirin
re-exposure, the allergen binds to mast cell-bound IgE and
cross-links the FcRI receptors, thereby activating the mast Cyclooxygenase
PLA2
cell. The activated mast cell degranulates, releasing its pre- Arachidonic acid
5-Lipoxygenase
formed inflammatory mediators. These molecules include activating protein (FLAP)
histamine, proteolytic enzymes, and certain cytokines (such
5-Lipoxygenase
as platelet-activating factor). The activated mast cell also
releases arachidonic acid from its plasma membrane and Zileuton
produces leukotrienes and prostaglandin D2 (Fig. 47-4). Glutathione
Acutely, mast-cell degranulation produces bronchocon- Leukotriene A4
striction and airway inflammation. Histamine released by
the mast cells promotes capillary leakage, leading to air- Leukotriene C4
way edema. Mast cells also release leukotriene C4 (LTC4), Leukotriene C4
synthase
which is subsequently converted into LTD4 and LTE4 (see Epoxide
(mast cells,
hydrolase Transporter
Chapter 42, Pharmacology of Eicosanoids). These three (neutrophils,
eosinophils)
leukotrienes, called cysteinyl leukotrienes, are central to monocytes)
the pathophysiology of asthma because they induce marked Extracellular
Leukotriene B4
bronchoconstriction. Leukotriene D4 is 1,000 times more space
potent than histamine in producing bronchoconstriction. Leukotriene C4
Leukotrienes also cause mucus hypersecretion, capillary
leakage, and vasogenic edema, and recruit additional in- Leukotriene D4
flammatory cells. The effect of the leukotrienes, though
slower in onset, is more powerful and sustained than that Leukotriene E4
of the preformed mediators. Because of their delayed yet
potent inflammatory effect, leukotrienes were once called BLT1
slow-reacting substance of anaphylaxis (SRS-A) before CysLT1

their actual structures were identified. Montelukast

Mast cells recruit other inflammatory cells via the release
of cytokines. This produces a delayed reaction that develops
4 to 6 hours after exposure to allergen (Fig. 47-3). Mast cells
also release tryptase, a protease that activates receptors on
epithelial and endothelial cells, inducing the expression of
adhesion molecules that attract eosinophils and basophils.
Tryptase is also a smooth muscle mitogen, causing hyper-
plasia of airway smooth muscle cells and contributing to
airway hyperresponsiveness. The production of IL-1, IL-2,
IL-3, IL-4, IL-5, GM-CSF, interferon-, and TNF- by mast
cells contributes to chronic inflammation and the chronic
asthmatic reaction. Finally, mast cells release proteases and
proteoglycans that act on supporting airway structures to
produce chronic changes in the airway (also called airway
remodeling). Unlike the reversible component of broncho-
constriction that characterizes the acute asthmatic reaction,
airway remodeling induced by chronic inflammation may
cause irreversible impairment in pulmonary function.
Eosinophils
The major physiologic role of eosinophils is to defend
against parasitic infections. Eosinophils originate in the
bone marrow and are stimulated by IL-4, IL-5, and GM-CSF
produced by TH2 lymphocytes and mast cells. Eosinophils
migrate from the bloodstream to the airway by binding to
specific adhesion molecules, particularly VCAM-1, and by
traveling along chemokine gradients to sites of inflamma-
tion. Once recruited to the airway, eosinophils have a com-
plex, multifunctional role in asthma. Activated eosinophils
secrete cytotoxic granules that cause local tissue damage and
induce airway remodeling, lipid mediators and neuromodu-
lators that affect airway tone, and cytokines and chemokines
that recruit other inflammatory cells.
The toxic granules of eosinophils contain a number of
cationic proteinsincluding major basic protein (MBP),
Zafirlukast
Leukocyte Airway
Chemotaxis Smooth muscle contraction
Eosinophil migration
Airway edema
FIGURE 47-4. The leukotriene pathway in asthma. Leukotrienes are some
of the most potent bronchoconstrictors known and are important mediators of
inflammation in the airway. Drugs that inhibit leukotriene production or leukotriene
receptor binding have a role in asthma therapy. Leukotrienes are formed when
arachidonic acid is released from the inner leaflet of the plasma membrane by the
action of phospholipase A2 (PLA2). Arachidonic acid is converted to leukotriene A4
by the action of 5-lipoxygenase. 5-Lipoxygenase is activated by the membrane-
bound enzyme 5-lipoxygenase activating protein (FLAP). Leukotriene A4 is con-
verted to leukotriene C4 by the action of leukotriene C4 synthase in mast cells and
eosinophils, and leukotriene C4 is transported out of the cell. Leukotriene C4 is
converted to leukotriene D4 and then to leukotriene E4; all three of these cysteinyl
leukotrienes bind to CysLT1 receptors expressed on airway smooth muscle cells,
leading to bronchoconstriction and airway edema. Leukotriene A4 is converted to
leukotriene B4 by epoxide hydrolase in neutrophils and monocytes. Leukotriene B4
is transported out of the cell and binds to BLT1 receptors expressed on leukocytes,
leading to leukocyte chemotaxis and recruitment. The leukotriene pathway can
be inhibited by the 5-lipoxygenase inhibitor zileuton or by the CysLT1 receptor
antagonists montelukast and zafirlukast.
eosinophilic cationic protein (ECP), eosinophil peroxi-
dase, and eosinophil-derived neurotoxinthat are directly
damaging to the bronchial epithelium. For example, ECP
can breach the integrity of target cell membranes by forming
ion-selective, voltage-insensitive pores, and eosinophil per-
oxidase catalyzes the production of highly reactive oxygen
species that oxidize target cell proteins and induce apoptosis.
828 Principles of Inflammation and Immune Pharmacology
but because it does not stimulate -receptors, it does not
cause peripheral vasoconstriction. Isoproterenol is not used
frequently in current practice because of the availability of
agents that are more selective for 2-receptors.
The first agents to offer relative 2 selectivity were iso-
etharine and metaproterenol, although both drugs had
moderate 1 effects. The newer drugs terbutaline, albuterol
(also referred to as salbutamol), pirbuterol, and bitolterol
bind to 2-adrenergic receptors 200400 times more strongly
than to 1-receptors and cause significantly fewer cardiac ef-
fects than the less selective adrenergic agonists. Albuterol
was the first of the strongly 2-selective agents to be avail-
able in inhaled form, further reducing systemic effects.
Modern inhaled 2-selective agonists were the first drugs
to allow regular treatment of asthma with an acceptable ad-
verse-effect profile. Nonetheless, at high doses, especially if
taken orally, even these drugs can cause cardiac stimulation.
In addition, since 2-adrenergic receptors are expressed in
peripheral skeletal muscle, activation of these receptors by
2-selective agents can result in a tremor.
Albuterol is a racemic mixture of two stereoisomers, R-
albuterol (or levalbuterol) and S-albuterol. Levalbuterol,
which is now available as a pure enantiomer, has tighter
binding to 2-receptors and is more 2-selective. In contrast,
the S isomer induces airway hyperresponsiveness in animal
models, although in clinical practice this effect has not been
significant. Although racemic albuterol and levalbuterol pro-
duce similar response and adverse-effect profiles for most
patients, a subset of patients may be more sensitive to the 1
effects of S-albuterol and may experience decreased tachy-
cardia and palpitations when taking levalbuterol.
-Adrenergic receptors are coupled to the stimulatory G
protein Gs (see Chapter 10). The subunit of Gs activates
adenylyl cyclase, which catalyzes the production of cyclic
adenosine monophosphate (cAMP). In the lung, cAMP
causes a decrease in the intracellular calcium concentration
and, via activation of protein kinase A, inactivates myosin
light chain kinase and activates myosin light chain phospho-
rylase (Fig. 47-5). In addition, the 2-agonists open large-
conductance calcium-activated potassium channels (KCa)
and thereby hyperpolarize airway smooth muscle cells. The
combination of decreased intracellular calcium, increased
membrane potassium conductance, and decreased myosin
light chain phosphorylation leads to smooth muscle relax-
ation and bronchodilation.
2 agonist
2-adrenergic Adenylyl cyclase
receptor
s Phosphodiesterase
GTP
ATP cAMP AMP
Theophylline
PKA
Bronchodilation
There appears to be variability in clinical response among
patients using 2-agonists. Some of this variability may be
mediated through variants in the gene for the 2-adrenergic
receptor. Researchers studying the effect of single nucle-
otide polymorphisms (SNPs) in the gene have found a
common genetic variant that is associated with increased
susceptibility to nocturnal asthma. Subjects homozygous
for this genetic variant who receive regularly scheduled
albuterol doses develop a decline in their peak expiratory
flow rate (a measure of bronchoconstriction), while subjects
without the polymorphism develop increased peak flow rates
with scheduled albuterol use. Although the pharmacogenet-
ics of the 2-adrenergic receptor are complicated and have
yielded inconsistent associations, it is likely that some of the
variability in drug response results from genetic influences.
Most 2-adrenergic agonists have a rapid onset of action
(15 to 30 minutes), a peak effect at 30 to 60 minutes, and a
duration of action of approximately 4 to 6 hours. This time
course of drug action makes the 2-agonists good candidates
for use as asthma relievers (or rescue inhalers) during acute
attacks. However, this profile also makes the 2-agonists poor
candidates for control of nocturnal asthma and for prevention
of attacks, although they can be used prophylactically before
exposure to a known trigger such as exercise. Several newer
agents, formoterol (and its enantiomerically pure form ar-
formoterol, approved only for COPD) and salmeterol, are
known as long-acting beta-agonists (LABAs). The LABAs
were engineered with lipophilic side chains that resist degra-
dation. As such, these agents have a 12- to 24-hour duration
of action, making them good candidates for prevention of
bronchoconstriction. Although formoterol and salmeterol are
reasonable asthma controllers, these agents do not treat the
underlying inflammation. In fact, regular use of formoterol
or salmeterol may be associated with an increase in asthma
deaths. Although the exact mechanism for this observation is
unknown, it may occur because long-acting -agonists can
improve the chronic symptoms of asthma without affecting
the underlying risk of a severe asthma exacerbation. Because
patients may feel better on long-acting -agonists, they may
receive lower doses of inhaled corticosteroids or no inhaled
corticosteroids at all. Since inhaled corticosteroids reduce
the risk of an asthma exacerbation (see below), the reduction
or withdrawal of inhaled corticosteroids may place patients
at increased risk of asthma hospitalization and fatal asthma
attack. For this reason, an FDA advisory committee has
FIGURE 47-5. Mechanism of the 2-agonists and theophylline.
In airway smooth muscle cells, activation of protein kinase A by cAMP
leads to phosphorylation of a number of intracellular proteins and thus
to smooth muscle relaxation and bronchodilation. Any therapy that in-
creases the level of intracellular cAMP can be expected to lead to bron-
chodilation. In practice, this can be accomplished in one of two ways:
by increasing the production of cAMP or by inhibiting the breakdown of
cAMP. cAMP production is stimulated by 2-agonist-mediated activa-
tion of 2-adrenergic receptors, which are G protein-coupled recep-
tors. cAMP breakdown is inhibited by theophylline-mediated inhibition
of phosphodiesterase.
 CHAPTER 47 / Integrative Inflammation Pharmacology: Asthma 829
recommended that formoterol and salmeterol should be used
only in combination with an inhaled corticosteroid.
Because salmeterol has a slower onset of action than al-
buterol, it should not be used for acute asthma flares. For-
moterol does have a rapid onset of action and can be used as
a rescue inhaler, although it is not yet approved for this in-
dication in the United States. One strategy has been to com-
bine formoterol with an inhaled corticosteroid (budesonide)
for use as needed in patients with mild asthma. Every time
the patient uses this combination, the formoterol is available
to provide acute relief of symptoms, but the patient also re-
ceives a dose of the inhaled corticosteroid to help quell the
underlying inflammation.
Methylxanthines
Two methylxanthines, theophylline and aminophylline, are
occasionally used in asthma treatment. The mechanism of
action of these drugs is complex, but their primary broncho-
dilatory effect appears to be due to nonspecific inhibition
of phosphodiesterase isoenzymes. Inhibition of phospho-
diesterase types III and IV prevents cAMP degradation in
airway smooth muscle cells, leading to smooth muscle re-
laxation by the cellular and molecular mechanisms detailed
above (i.e., decreased intracellular calcium, increased mem-
brane potassium conductance, and decreased myosin light
chain phosphorylation). As shown in Figure 47-5, the bron-
chodilatory effect of methylxanthines results from pertur-
bation of the same pathway that is initiated by 2-agonists,
although methylxanthines act downstream of 2-adrenergic
receptor stimulation.
Methylxanthines also inhibit phosphodiesterase isoen-
zymes in inflammatory cells. Inhibition of phosphodiesterase
type IV in T lymphocytes and eosinophils has an immuno-
modulatory and anti-inflammatory effect. By this mechanism,
theophylline can control chronic asthma more effectively
than would be expected on the basis of its bronchodilatory
effect alone. Some of the adverse effects of methylxanthines,
including cardiac arrhythmias, nausea, and vomiting, are also
mediated by phosphodiesterase inhibition, although the re-
sponsible isoenzymes remain to be elucidated.
Theophylline is a structural relative of caffeine, differ-
ing only by a single methyl group, and both caffeine and
theophylline are adenosine receptor antagonists. Adeno-
sine receptors are expressed on airway smooth muscle cells
and mast cells, and antagonism of these receptors could
play a role in preventing both bronchoconstriction and in-
flammation. In fact, coffee has been used to treat asthma.
However, experiments with specific adenosine receptor an-
tagonists that do not inhibit phosphodiesterase have shown
little bronchodilation, suggesting that phosphodiesterase
inhibition is the primary mechanism of action of meth-
ylxanthines. Nonetheless, adenosine receptor antagonism
is responsible for many secondary effects of theophylline,
including increased ventilation during hypoxia, improved
endurance of diaphragmatic muscles, and decreased ad-
enosine-stimulated mediator release from mast cells. In
addition, some adverse effects of theophylline, such as
tachycardia, psychomotor agitation, gastric acid secre-
tion, and diuresis, are mediated through adenosine receptor
antagonism.
Because methylxanthines are nonselective and have
multiple mechanisms of action, they cause multiple ad-
verse effects and have a relatively narrow therapeutic index.
Moreover, there is significant interindividual variation in the
metabolism of theophylline by the P450 isoenzyme CYP3A,
and theophylline use is susceptible to drugdrug interactions
with CYP3A inhibitors such as cimetidine and the azole an-
tifungals. At supratherapeutic levels, theophylline produces
nausea, diarrhea, vomiting, headache, irritability, and insom-
nia. At even higher doses, seizures, toxic encephalopathy,
hyperthermia, brain damage, hyperglycemia, hypokalemia,
hypotension, cardiac arrhythmias, and death can occur.
For this reason, the role of theophylline in the treatment of
chronic asthma has diminished. Theophylline is still used
occasionally with routine monitoring of plasma drug levels
when -adrenergic agonists and corticosteroids are ineffec-
tive or contraindicated.
Magnesium
Magnesium ions inhibit calcium transport into smooth mus-
cle cells and can interfere with intracellular phosphorylation
reactions that induce smooth muscle contraction. For this
reason, magnesium sulfate is commonly used as a tocolytic
to cause uterine relaxation and to delay preterm labor. Mag-
nesium has similar effects on airway smooth muscle, and it
has been used experimentally in acute asthma exacerbations.
Although the results of clinical studies have been variable,
two meta-analyses have suggested a benefit to using mag-
nesium sulfate in patients with severe asthma exacerbations
presenting to the emergency department. Magnesium was
not used in the introductory case, but it would have been a
reasonable therapeutic option at the time of Mr. Ys visit to
the emergency department.
Anti-Inflammatory Agents
As detailed above, allergic inflammation of the airways
forms the pathophysiologic basis for asthma. To control per-
sistent asthma and prevent exacerbations of acute asthma,
treatment of all but the mildest forms of the disease should
generally include anti-inflammatory agents. Corticosteroids
have long been mainstays of asthma treatment, although the
profound adverse effects of systemically administered cor-
ticosteroids remained problematic until the development of
inhaled formulations. Three additional classes of drugs with
anti-inflammatory mechanisms of action are used for the
treatment of asthma: cromolyns, leukotriene pathway modi-
fiers, and a humanized monoclonal anti-IgE antibody.
Corticosteroids
Inhaled corticosteroids are the chief preventive treatment for
the vast majority of patients with asthma. Because inhaled
corticosteroids produce higher local drug concentrations in
the airway than an equivalent dose of systemically admin-
istered corticosteroids, a lower overall dose can be adminis-
tered, reducing the likelihood of significant systemic effects.
Corticosteroids alter the transcription of many genes. In
general, corticosteroids increase the transcription of genes
coding for the 2-adrenergic receptor and a number of
anti-inflammatory proteins such as IL-10, IL-12, and IL-1
receptor antagonist (IL-1Ra). Corticosteroids decrease the
transcription of genes coding for many pro-inflammatory
(and other) proteins; examples include IL-2, IL-3, IL-4,
IL-5, IL-6, IL-11, IL-13, IL-15, TNF-, GM-CSF, SCF, en-
dothelial adhesion molecules, chemokines, inducible nitric
oxide synthase (iNOS), cyclooxygenase (COX), phospho-
lipase A2, endothelin-1, and NK1-2 receptor. As described
 CHAPTER 47 / Integrative Inflammation Pharmacology: Asthma 833
cure for asthma, but a therapeutic approach that treats both
aspects of asthma by using anti-inflammatory medications
and bronchodilators, along with the avoidance of known
triggers, can be successful in achieving long-term clinical
control and enabling successful management of the disease
in most patients.
As our understanding of the pathophysiology of asthma
has improved, new targets for therapeutic intervention have
become available. In general, research has focused on three
areas: improving existing therapies by altering the ratio of
benefit to adverse effect, devising new targeted therapies, and
attempting to prevent or reverse permanent airway remodeling
in long-standing asthma. One example of the first approach
is the development of novel inhaled corticosteroids with re-
duced systemic effects. For example, research is continuing
on selective glucocorticoid receptor modulators that retain
anti-inflammatory activity while minimizing adverse effects.
A number of inflammatory cytokine inhibitors are under
development as potential new targeted therapeutics for
asthma. However, the complex nature of asthma means that
inhibition of a single pathway may not significantly affect
the disease. For example, the anti-IL-5 monoclonal antibody
mepolizumab has been explored as a potential treatment for
asthma. Unfortunately, this drug showed no efficacy in mul-
tiple clinical trials, despite successfully reducing the number
of circulating and airway eosinophils. A recent trial did find
that mepolizumab could reduce the frequency of asthma ex-
acerbations in a rare subgroup of patients with prednisone-
dependent asthma and sputum eosinophilia. Other studies
are ongoing with inhibitors of IL-13 and IL-4 and with
the inhibitory cytokine IL-10. For example, pitrakinra,
a variant of IL-4 that blocks binding of IL-4 and IL-13 to
the IL-4 receptor alpha, has shown some promise in early
clinical studies. TNF- (see Chapter 45) is a cytokine that is
up-regulated in asthma and that recruits neutrophils and eo-
sinophils into the airways. Etanercept (a recombinant fusion
protein that inhibits TNF-) and infliximab (an anti-TNF-
monoclonal antibody) have also shown promising results in
early clinical studies.
Inhibition of phosphodiesterase type IV (PDE IV) is a
new pharmacologic approach to reducing inflammation
in asthma. PDE IV hydrolyzes cAMP in a number of the
inflammatory cell types involved in asthma pathophysiol-
ogy, and studies have shown that increased intracellular
cAMP inhibits the release of TNF- and other cytokines
from these cell types. Two PDE IV inhibitors, roflumilast
and cilomilast, have been evaluated in advanced clini-
cal trials for asthma and COPD. Unfortunately, the utility
of both compounds has been limited by the development
of dose-limiting nausea and vomiting that are thought
to be due to inhibition of PDE IV in the brain. Thus, re-
search is now focused on the discovery of nonemetogenic
PDE IV inhibitors and on the development of an inhaled
formulation.
Suggested Reading
Barnes PJ. The cytokine network in asthma and chronic obstructive pul-
monary disease. J Clin Invest 2008;118:35463556. (Reviews the role of
cytokines in the chronic asthmatic reaction and suggests targets for new
drug development.)
Chu EK, Drazen JM. Asthma: one hundred years of treatment and onward.
Am J Respir Crit Care Med 2005;171:12031208. (Historic view of the evo-
lution of asthma therapy over the last 100 years.)
Fanta CH. Asthma. N Engl J Med 2009;360:10021014. (Discusses the clini-
cal management of asthma, focusing on commonly prescribed therapeutics.)
Guidelines for the Diagnosis and Management of Asthma (EPR-3). Avail-
able at: http://www.nhlbi.nih.gov/guidelines/asthma/ (This is most recent
set of practice guidelines for the diagnosis and treatment of asthma, from
the expert panel convened by the National Heart Lung and Blood Institute
of the National Institutes of Health.)
Hanania NA. Targeting airway inflammation in asthma: current and future
therapies. Chest 2008;133:989998. (A review of anti-inflammatory thera-
pies for asthma, including inhaled corticosteroids, anti-IgE therapy, and
novel treatments focused on immunomodulation.)
Lemanske RG. Asthma therapies revisited: what have we learned. Proc
Am Thorac Soc 2009;6:312315. (Discusses the treatment of asthma,
focusing on who and when to treat, and identifying the appropriate
treatment.)
Locksley RM. Asthma and allergic inflammation. Cell 2010;140:777783.
(Reviews the dysregulated interactions between airway epithelia and innate
immune cells that initiate and maintain asthma.)
Rhen T, Cidlowski JA. Anti-inflammatory action of glucocorticoidsnew
mechanisms for old drugs. N Engl J Med 2005;353:17111723. (Discusses
the molecular mechanisms by which glucocorticoids act and efforts to
develop novel glucocorticoids with improved adverse-effect profiles.)

Integrative Inflammation
Pharmacology: Gout
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 837-838
PHYSIOLOGY OF PURINE METABOLISM . . . . . . . . . . . . . . . 837
PATHOPHYSIOLOGY OF GOUT . . . . . . . . . . . . . . . . . . . . . . . 839
PHARMACOLOGIC CLASSES AND AGENTS . . . . . . . . . . . . . 840
Management of Acute Gout: Suppressors of Leukocyte
Recruitment and Activation . . . . . . . . . . . . . . . . . . . . . . . 840
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) . . . . . 840
Colchicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 840
Glucocorticoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 841
 INTRODUCTION
Gout is a uniquely human disease. Most mammals pos-
sess uricase, an enzyme that metabolizes purine breakdown
products into a freely water-soluble substance, allantoin.
Humans, in contrast, excrete most purines as sparingly
soluble uric acid. High plasma levels of uric acid can lead
to deposition of uric acid crystals in joints, most frequently
the first metatarsophalangeal joint (great toe). Acute attacks
of gout cause intense pain but typically occur infrequently.
A number of rational therapies exist for the treatment of
gout. These therapies are broadly divided into two groups:
those that treat acute gout attacks and those that prevent re-
current attacks. Drugs that suppress the immune response to
crystal deposition or limit the extent of inflammation may be
used for both indications, although they are more commonly
used to treat acute attacks. Agents that reduce uric acid syn-
thesis or increase the renal excretion of uric acid prevent
monosodium urate crystal formation and are useful for pre-
vention of recurrent attacks. These pharmacologic interven-
tions provide effective therapy for most cases of gout.
 PHYSIOLOGY OF PURINE METABOLISM
Gout is a disease caused by imbalances in purine metabo-
lism. To understand the cause and treatment of gout, it is
necessary to recall the principles of nucleotide biochemistry.
Although pyrimidines such as cytosine, thymidine, and ura-
cil are straightforward for the body to metabolize and ex-
crete, it is a challenge to metabolize purines (most notably
48
Ehrin J. Armstrong and Lloyd B. Klickstein
Management of Chronic Gout: Agents That Lower
Plasma Urate Concentration. . . . . . . . . . . . . . . . . . . . . . . 841
Agents That Decrease Uric Acid Synthesis. . . . . . . . . . 841
Agents That Increase Uric Acid Excretion. . . . . . . . . . . 842
Agents That Enhance Uric Acid Metabolism . . . . . . . . . 842
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 843
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 843
the nucleotides guanine and adenine). The intermediates of
purine metabolism are toxic to some cells, necessitating tight
regulation of purine synthesis and degradation. Furthermore,
the final breakdown product of purine metabolism is uric
acid, which is barely soluble in blood or urine. Increased
plasma levels of uric acid are the strongest risk factor for
gout, although, for poorly understood reasons, not everyone
with high plasma uric acid levels develops gout.
Purines are synthesized via two general pathways: de
novo synthesis and the salvage pathway (Fig. 48-1). The
first step in the de novo pathway is the reaction of phos-
phoribosyl pyrophosphate (PRPP, a ribose sugar with two
pyrophosphates attached) with glutamine. PRPP provides
the ribose sugar as one precursor for the nascent nucleotide.
Hydrolysis of the pyrophosphate in a later step makes the
de novo pathway irreversible. Glutamine is the precursor
for inosine monophosphate (IMP), a precursor that is com-
mon to adenine and guanine biosynthesis. The reaction of
PRPP with glutamine is catalyzed by the enzyme amido-
phosphoribosyltransferase (amidoPRT). AmidoPRT is ac-
tivated allosterically by high levels of PRPP; PRPP is thus
both a substrate and an activator of amidoPRT. In general,
the cellular level of PRPP is the most important determinant
of de novo purine synthesis. High PRPP levels result in en-
hanced de novo purine synthesis, whereas low PRPP levels
decrease the rate of synthesis.
The salvage pathway is the second important mode of
purine synthesis. The first step in the salvage pathway is
catalyzed by the key regulatory enzyme hypoxanthine-
guanine phosphoribosyltransferase (HGPRT). HGPRT
837
 Diet

Degradation De novo
Adenine ATP synthesis PRPP
Salvage +
Guanine GTP Amido PRT Glutamine
HGPRT

Hypoxanthine

Xanthine oxidase

Allopurinol Xanthine

Xanthine oxidase

Uric acid Renal excretion

Probenecid
Uricase Sulfinpyrazone

Allantoin
 Toll-like receptor
1 Recognition of
MSU crystals monosodium urate (MSU)

Monocyte
Phagocytosis 2
of MSU

NALP-3 3 pro-IL-1
inflammasome
activation
Caspase
IL-1

4 IL-1 release

8 Cytokine release
(e.g., IL-1)

IL-1 receptor

7 Neutrophil
recruitment and
accumulation
within joint
Signal transduction
and gene activation 6 Pro-inflammatory
mediator release
(e.g., IL-8)

Endothelium
Cyclosporine Cyclosporine ATP GTP
Tacrolimus Tacrolimus
Verapamil
O O
O
Colchicine N Xanthine
HN
N Xanthine H
HN oxidase oxidase HN N
O
MDR GFR N O N N
N H H H O N N
H H

Excretion in bile Excretion in urine Hypoxanthine Xanthine Uric acid

OH OH

Xanthine
N oxidase N
N N

N N HO N N
H H

Allopurinol Oxypurinol
842 Principles of Inflammation and Immune Pharmacology
N N O2
N S
S H
Xanthine
N HN
N
oxidase
N
N N O N
N N H H
H
Azathioprine 6-Mercaptopurine
OH OH
Xanthine
N oxidase N can predispose to formation of urate stones in the kidney or
N N
N N
N H
HO N H
Allopurinol Oxypurinol
FIGURE 48-5. Interaction between 6-mercaptopurine and allopurinol.
6-Mercaptopurine and azathioprine (a prodrug) are metabolized and elimi-
nated from the body via the same pathways as other purines. Allopurinol and
its metabolite, oxypurinol, inhibit xanthine oxidase, thereby inhibiting the break-
down of 6-mercaptopurine. Decreased degradation causes plasma levels of 6-
mercaptopurine to rise. When co-administering 6-mercaptopurine and allopurinol
(for example, in cancer chemotherapy), the dose of 6-mercaptopurine should be
substantially reduced.
drug, such as mycophenolic acid (see Chapter 45, Pharma-
cology of Immunosuppression), is another option.
Although allopurinol is generally well tolerated, several
important adverse effects should be considered when pre-
scribing this agent. A small percentage of patients taking
allopurinol may develop a hypersensitivity reaction char-
acterized by a rash that, in rare instances, can progress to
StevensJohnson syndrome. For this reason, all patients who
develop a cutaneous reaction to allopurinol should discon-
tinue the drug. Rarely, allopurinol may also cause leukope-
nia, eosinophilia, and/or hepatic necrosis.
Febuxostat is a nonpurine small-molecule inhibitor of
xanthine oxidase that has recently been approved for the
treatment of chronic gout. In a large clinical trial, febuxostat
was as effective as allopurinol in preventing recurrent flares
of gout. Unlike allopurinol, febuxostat undergoes extensive
hepatic metabolism, and it may not require dose adjustment
in renal insufficiency. Because of its nonpurine structure,
febuxostat use might not be associated with development
of cutaneous reactions. As with allopurinol, initiation of fe-
buxostat therapy should be accompanied by a suppressive
medication such as colchicine in order to reduce the risk of
gout flares in the first several months after initiation of urate-
lowering therapy.
Agents That Increase Uric Acid Excretion
Because the kidney reabsorbs a substantial amount of fil-
tered uric acid, a pharmacologic agent that blocks tubular
reabsorption increases uric acid excretion. Such drugs are
called uricosuric agents.
Probenecid was one of the first drugs used to increase
urate excretion. Individuals lacking the URAT1 anion trans-
porter protein have very low serum uric acid levels and do
not respond to uricosuric agents, including probenecid, in-
dicating that URAT1 is the molecular target for this class of
drugs. Probenecid is not specific for URAT1; it also inhibits
other transporters, including some of the renal organic anion
transporters (OATs) responsible for penicillin secretion.
S
Decades ago, when penicillin was in limited supply, it was
co-administered with probenecid to prolong the half-life of
N
HN
O
the antibiotic and decrease the penicillin dose required to
N
achieve therapeutic levels of the drug.
H In patients with gout, probenecid is useful for the treat-
6-Thiouric acid
ment of chronic hyperuricemia. Probenecid shifts the bal-
ance between renal excretion and endogenous production of
urate, thereby lowering plasma urate levels. Uric acid levels
Excretion lower than 6.06.5 mg/dL support dissolution of urate crys-
tals, thereby reversing the process of crystal deposition in
synovial joints. However, increasing renal urate excretion
ureter. The likelihood of this complication can be diminished
by recommending that patients increase their fluid intake and
make their urine less acidic, commonly by co-administration
of oral calcium citrate or sodium bicarbonate: uric acid has
a pKa of 5.6, and it remains predominantly in the more
soluble neutral form if the urine pH is above 6.0. Because
probenecid inhibits the secretion of many organic anions,
the dose of other drugs excreted by this pathway should be
reduced when probenecid is co-administered. Low-dose as-
pirin may antagonize probenecid action; the mechanism of
this antagonism is unknown.
Sulfinpyrazone is a uricosuric agent that acts by the same
mechanism as probenecid. It is more potent than probenecid,
and it is effective in mild-to-moderate renal insufficiency. In
addition to acting as a uricosuric, sulfinpyrazone has anti-
platelet effects; it should therefore be used with caution in
patients taking other antiplatelet agents or anticoagulants.
Benzbromarone is a uricosuric agent with a mechanism
of action similar to that of probenecid and sulfinpyrazone.
Benzbromarone may have greater uricosuric efficacy than
probenecid and sulfinpyrazone, particularly in patients with
impaired renal function. However, the frequent incidence of
hepatotoxicity has limited widespread use of the drug, and it
is currently not available in the United States.
Losartan is an angiotensin II receptor antagonist (see
Chapter 21, Pharmacology of Vascular Tone) that has a mod-
est uricosuric effect. Losartan may be a logical therapeutic
choice in patients with concomitant hypertension and gout,
although no controlled studies have been performed to prove
that losartan reduces the incidence of acute gout attacks.
Agents That Enhance Uric Acid Metabolism
Most mammals other than humans express the enzyme
uricase. This enzyme oxidizes uric acid to allantoin, a com-
pound that is easily excreted by the kidney. In cancer che-
motherapy, the rapid lysis of tumor cells can liberate free
nucleotides and greatly increase plasma urate levels. By
this mechanism, tumor lysis syndrome can lead to massive
renal injury. Exogenous uricase can be co-administered with
cancer chemotherapy to reduce plasma urate levels rapidly,
and thereby to prevent renal damage. Allopurinol can also be
used to prevent this component of tumor lysis syndrome.
Currently, uricase is available in Europe as a protein
purified from the fungus Aspergillus flavus. A recombinant
version of the Aspergillus uricase, rasburicase, is available
in the United States. A small percentage of patients have
allergic reactions to the foreign protein and antidrug anti-
bodies are common. Pegloticase, a pegylated formulation
of recombinant porcine uricase, was recently approved for
treatment of gout refractory to conventional therapy.
 CHAPTER 48 / Integrative Inflammation Pharmacology: Gout 843
 CONCLUSION AND FUTURE DIRECTIONS
Gout can be thought of as a disorder of purine metabo-
lism and excretion. An imbalance between urate synthesis
and excretion leads to hyperuricemia; in some individu-
als, hyperuricemia progresses to gout. Acute therapeutic
interventions are aimed at symptomatic treatment of gout
attacks; these treatments interrupt inflammatory pathways
by inhibiting neutrophil and monocyte activation. Treat-
ments for chronic gout lower plasma urate levels by re-
establishing the balance between urate synthesis and ex-
cretion. Allopurinol and febuxostat inhibit urate synthesis;
probenecid increases renal urate excretion. Recombinant
uricase rapidly decreases plasma urate levels by converting
uric acid to allantoin, thereby preventing the adverse renal
consequences of tumor lysis syndrome. New therapies are
under development; for example, IL-1 antagonists such as
anakinra, canakinumab, and rilonacept are being studied for
the treatment of acute gout flares unresponsive to standard
therapies or for patients in whom standard therapies are
contraindicated.
Suggested Reading
Chohan S, Becker MA. Update on emerging urate-lowering therapies. Curr
Opin Rheumatol 2009;21:143149. (Provides clinical details on febuxostat
and uricases.)
Eggebeen AT. Gout: an update. Am Fam Physician 2007;76:801808.
(Excellent clinical summary of gout, including criteria for diagnosis and
clinical guidelines.)
Martinon F. Mechanisms of uric acid crystal-mediated autoinflammation.
Immunol Rev 2010;233:218232. (Detailed review of uric acid-induced
inflammation and inflammasome biology.)
Neogi T. Gout. N Engl J Med 2011;364:443452. (Recent clinical practice
review of gout.)
So A, Busso N. A magic bullet for gout? Ann Rheum Dis 2009;68:15171519.
(Reviews advances in gout pathophysiology, including the role of IL-1 and
development of IL-1 antagonists.)
VII

Fundamentals of
Drug Development
and Regulation

Drug Discovery and
Preclinical Development
John L. Vahle, David L. Hutto, Daniel M. Scott, and Armen H. Tashjian, Jr.
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . 847-848
THE DRUG DISCOVERY PROCESS . . . . . . . . . . . . . . . . . . . . 848
Compound-Centered Drug Design . . . . . . . . . . . . . . . . . . 849
Natural and Synthetic Compounds . . . . . . . . . . . . . . . 849
Analogues of Natural Ligands . . . . . . . . . . . . . . . . . . . 849
Target-Centered Drug Design. . . . . . . . . . . . . . . . . . . . . . 851
High-Throughput Screening . . . . . . . . . . . . . . . . . . . . 851
Combinatorial Chemistry. . . . . . . . . . . . . . . . . . . . . . . 852
Structure-Based Drug Design . . . . . . . . . . . . . . . . . . . 853
Lead Optimization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 853
PHASES OF DRUG DEVELOPMENT . . . . . . . . . . . . . . . . . . . 853
 INTRODUCTION
Over the past decade, the U.S. Food and Drug Administration
(FDA) has approved approximately 240 new drugs and biolog-
ics for therapeutic use. Many such drugs have enabled treat-
ments for diseases that were previously untreatable. Others have
yielded expanded treatment options because they are more ef-
ficacious and/or less toxic than previously available treatments.
In the fight against infectious diseases, for example, pharma-
ceutical and biotechnology companies, university laboratories,
and others have continued to develop new agents to treat dis-
eases that have become resistant to existing treatments. With the
availability of new technologies, knockout animal models, and
information from the human genome project, it is anticipated
that important new classes of drugs will continue to be discov-
ered and developed in the coming decades.
The development of a new drug is difficult and costly. Very
few molecules that reach the development stage are ultimately
approved as drugs: of 10,000 compounds considered promising
from the results of initial screening assays, fewer than 10 make it to
clinical trials and only two are eventually approved. Furthermore,
the costs associated with discovering and developing a new drug
averages approximately 800 million U.S. dollars. Although the
development of new drugs is a risky venture, successful drugs
can be quite profitable for those willing to take such risks. The
most commercially successful drugs, such as atorvastatin, have
annual sales of more than 12 billion dollars each.
49
KEY DISCIPLINES IN DRUG DISCOVERY AND
DEVELOPMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 854
Discovery Chemistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 854
Discovery Biology: Biochemical Assays,
Cellular Assays, and Animal Models . . . . . . . . . . . . . . . . . 855
Absorption, Distribution, Metabolism, and
Excretion (ADME) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 856
Toxicology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 856
Development Chemistry: Chemical Synthesis,
Scale-Up, and Manufacturing . . . . . . . . . . . . . . . . . . . . . . 857
Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 858
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 859
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 859
Increased attention has recently been focused on the inabil-
ity of the biomedical research community to produce innova-
tive new therapies. The challenges involved in drug discovery
and development were highlighted (along with potential solu-
tions) in the 2004 report of the FDA Critical Path Initiatives
(see Suggested Reading). This report noted that both the
National Institutes of Health (NIH) budget and pharmaceu-
tical company research and development spending approxi-
mately doubled over a 10-year period beginning in 1993. The
added investment did not increase the rate of development of
new medicines, however, as evidenced by a decline in major
drug and biological product submissions to the FDA. While
several potential solutions have been offered to address this
issue, it is important to note that a joint report by the FDA and
the Association of American Medical Colleges highlighted the
critical role of physician-scientists in improving the effective-
ness of drug discovery and development.
This chapter describes the phases of drug discovery and
development and the scientific disciplines that are involved in
these phases. Drug discovery spans the period from the iden-
tification of a potential therapeutic target to the selection of
a single molecule for testing in humans. Drug development
is generally defined as the period from the preclinical studies
that support initial clinical trials through approval of the drug
by regulatory authorities. The process of drug discovery and
development is complex, requiring contributions from many
otherwise disparate scientific disciplines.
847
 CHAPTER 49 / Drug Discovery and Preclinical Development 849

Drug discovery Drug development

Phase Target-centered Preclinical

Compound-centered Lead optimization development Phase I Phase II Phase III

Discovery
chemistry

Target Assay
Discovery development Animal models of disease
biology identification
and screening

In vitro Pharmacokinetics Metabolism

ADME metabolism (animal) (human) Drug-drug interactions

Development Carcinogenesis
Toxicology and reproduction
Screening Preclinical GLP toxicology

Development
chemistry

Safety Efficacy
Medical Registration
Exposure Dose trials
selection

IND NDA

FIGURE 49-2. Sequence of phases of drug discovery and development. The important points to note are the general sequence of activities and the consider-
able overlap of functions with time. The process is highly interactive among several disciplines in an attempt to obtain the molecule with the greatest efficacy, fewest
adverse effects, and greatest safety. The clinical trials and regulatory approval phases are described in Chapter 50. The entire process from hit to drug approval can take
812 years and cost more than $1 billion. IND, investigational new drug application; NDA, new drug application; ADME, absorption, distribution, metabolism, excretion;
GLP, good laboratory practices.

Compound-Centered Drug Design
Natural and Synthetic Compounds
Traditionally, drugs were discovered using a compound-
centered approach. Many of the earliest drugs discovered
were natural products isolated from plants, molds, or other
organisms. Often, the discoveries were made serendipitously.
For example, penicillin (see Chapter 34, Pharmacology of
Bacterial and Mycobacterial Infections: Cell Wall Synthesis)
was discovered when Alexander Fleming observed that
spores of the contaminant mold Penicillium notatum inhib-
ited bacterial growth in a petri dish. Other natural products
that have been transformed into successful drugs include
paclitaxel, a chemotherapeutic agent derived from the Pacific
yew tree, morphine, an opioid analgesic obtained from the
opium poppy, streptokinase, a thrombolytic agent obtained
from streptococcal bacteria, and cyclosporine, an immuno-
suppressive agent obtained from a fungus. Table 49-1 lists a
number of drugs obtained from natural products.
There are several advantages to examining natural prod-
ucts as a source for potential drugs. First, natural products
have a reasonable likelihood of biological activity. Second,
it may be easier to isolate a compound from its natural
source than to synthesize a compound de novo, especially
if the structure of the compound is complex or requires dif-
ficult synthetic manipulations. Paclitaxel, for example, has
a complex structure that contains four fused rings, one of
which contains eight carbons. A chemical synthesis of the
compound took over 50 steps to complete and had a total
yield of less than 1%. Third, it may be feasible to use the nat-
ural compound as a starting point for synthetic fine-tuning,
i.e., to form a semisynthetic product. Of course, natural
products also have disadvantages: it often takes significant
effort to isolate a natural product, without a guarantee of suc-
cess. Although natural products are more likely than many
synthetic compounds to have biological activity, it may be
difficult to predict which assay system would be optimal for
testing the function of these molecules. Even if it is found to
be pharmacologically active, a natural product can be expen-
sive to isolate and modify.
Synthetic compounds are now frequently used to search
for new drugs. Researchers can construct a library consisting
of thousands of compounds with differing structural char-
acteristics, tailored for a particular type of investigation. A
library could, for example, consist of numerous compounds
that have a phenylalanineproline bond or that are likely
agonists or antagonists of a particular class of receptors.
Analogues of Natural Ligands
An alternative compound-centered approach uses the natural
ligand (often an agonist) of a receptor as the starting point for
drug development. For example, because lack of dopamine
is associated with Parkinsons disease (see Chapter 13,
Pharmacology of Dopaminergic Neurotransmission), one of
the first effective treatments involved administering the drug
levodopa (L-DOPA), a metabolic precursor of dopamine.
 Drug Clinical Use and Chapter Reference Source

Cyclosporine Immunosuppressant (Chapter 45) Beauveria nivea (fungus)

O O Antiarrhythmic, cardiac inotrope Digitalis lanata (white foxglove),

(Chapters 23, 34) Digitalis purpurea (purple foxglove),
OH
numerous other plants

OH H

H
O O O O
HO O O

OH OH OH

Digoxin

N Analgesic (Chapter 17) Papaver somniferum (poppy plant)

HO O H OH

Morphine

Cancer chemotherapeutic (Chapter 38) Taxus brevifolia (Pacific yew tree)

O
O O OH

O NH O

O H O
OH O O
OH O O

Paclitaxel

H H Antibacterial (Chapter 34) Penicillium chrysogenum (mold)

N S

O N
O
COOH
Penicillin G

Antihypertensive (Chapter 25) Rauwolfia serpentina (plant)

H3CO

N
N
H
H H
O
H
H3CO OCH3
O
O OCH3
OCH3
OCH3
Reserpine

Streptokinase Thrombolytic (Chapter 22) Beta-hemolytic streptococci (bacteria)

 O

Br O
Br

O
O
O
O
O

H
H N
N
H2N H2N

O O

O
N N
H

OH OH

O O

O
N N
H

OH OH
H
O

OH O
H
Simple
Complex

OH

Linear synthesis
B C D
A A-B A-B-C A-B-C-D

Convergent synthesis
B
A A-B

D A-B-C-D

C C-D
 CHAPTER 49 / Drug Discovery and Preclinical Development 859
hemolysis. The solution must also be sterile for intravenous
injection. Finally, a drug is often less stable in solution than
as a solid, so formulation chemists must test its stability
in solution. If the drug is unstable, it may be prepared as a
lyophilized powder that can be dissolved in water or buffer
immediately before administration.
 CONCLUSION AND FUTURE DIRECTIONS
The discovery and development of new drugs is a complex,
interdisciplinary process that often requires 10 or more
years and hundreds of millions of dollars. Researchers start
by searching for a biologically active compound. This may
involve a compound-centered approach or a target-centered
approach. New pharmacologic targets are currently being
identified by gene sequencing, by analysis of genetic factors
that predispose to disease, by gene knockout experiments in
laboratory animals, and by other techniques. For example, it
is now possible to target proteins that enable the expression
of genes rather than the gene products themselves. In addi-
tion, information about genetic polymorphisms may enable
the products of specific, mutant genes to be the targets of
new drugs (see Chapter 6, Pharmacogenomics). Finally,
new methods to discover compounds that interact with these
targets are also becoming available.
Suggested Reading
Drews J. Drug discovery: a historical perspective. Science 2000;287:1960
1964. (Historical description of the major methods of drug discovery.)
International Conference on Harmonization: guidance on nonclinical safety
studies for the conduct of human clinical trials and marketing authorization
for pharmaceuticals 2009. http://www.ich.org/cache/compo/276-254-1.
html (Describes the types of animal studies required by regulatory authori-
ties to support clinical testing and registration of pharmaceuticals.)
Levine RR. Pharmacology, drug actions and reaction. 6th ed. New York:
Parthenon Publishing; 2000. (Explains how new drugs are discovered and
describes the drug development process through clinical development.)
Pritchard JF, Jurima-Romet M, Reimer ML, et al. Making better drugs:
decision gates in nonclinical drug development. Nat Rev Drug Discov
2003;2:542553. (Explores the key scientific questions that are addressed
during drug discovery and preclinical development.)
Rademann J, Gnther J. Integrating combinatorial synthesis and bioas-
says. Science 2000;287:19471948. (Novel techniques for screening large
libraries of compounds.)
Sams-Dodd F. Strategies to optimize the validity of disease models in the
drug discovery process. Drug Discov Today 2006;11:355363. (Discusses
how to optimize animal models of human disease to allow selection of better
drug candidates.)
United States Food and Drug Administration, United States Department
of Health and Human Services. Innovation or stagnation: challenge and
opportunity on the critical path to new medical products. 03/16/04. http://
www.fda.gov/oc/initiatives/criticalpath/whitepaper.pdf. (Discusses current
challenges and opportunities in the development of new drugs, biologic
products, and medical devices.)
50
Clinical Drug Evaluation and
Regulatory Approval
Mark A. Goldberg, Alexander E. Kuta, and John L. Vahle
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . 860-861
HISTORY OF THE U.S. FOOD AND DRUG LAW . . . . . . . . . . . 861
ETHICS IN CLINICAL DRUG INVESTIGATION . . . . . . . . . . . . 862
DRUG EVALUATION AND CLINICAL DEVELOPMENT . . . . . . 863
Authorizations to Initiate Clinical Trials . . . . . . . . . . . . . . . 863
Clinical Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . 863
Target Product Profile . . . . . . . . . . . . . . . . . . . . . . . . . 864
Development of a Clinical Trial . . . . . . . . . . . . . . . . . . 864
Phase 1 Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 865
Phase 2 Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 866
Phase 3 Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 866
Clinical Pharmacology. . . . . . . . . . . . . . . . . . . . . . . . . 866
Challenges in the Development of Drugs to
Treat Rare Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . 866
Successful Drug Development: Design and Execution . . . 867
 INTRODUCTION
Controlled clinical trials provide the scientific and legal
basis by which regulatory authorities around the world eval-
uate new prescription drugs and approve them for sale. In the
United States, the regulatory review of drugs and devices is
the responsibility of the U.S. Food and Drug Administra-
tion (FDA). Over the past 50 years, improved methods for
large-scale clinical studies have precipitated a shift toward
evidence-based medicine and helped to accelerate the pace
of drug development. This greater emphasis on clinical trials
to appropriately assess the safety and efficacy of new drugs
has resulted in a dramatic rise in the costs associated with
drug development. Various reports have estimated that the
cost of successfully developing a new drug product from
discovery, through preclinical and clinical development, to
regulatory filing and approval costs in the range of $0.5 to
$2.0 billion. The time for the clinical development phase of
drug development alone averages 78 years. Moreover, only
about one in ten drugs that enters the clinic for testing ulti-
mately receives regulatory approval and is marketed. Given
the tremendous cost and duration of clinical drug develop-
ment, it is imperative that every effort is made to plan care-
fully and execute effectively. Drug development programs
860
DRUG APPROVAL PROCESS . . . . . . . . . . . . . . . . . . . . . . . . 867
FDA Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 867
FDA Approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 868
Approval in Other Countries . . . . . . . . . . . . . . . . . . . . . . . 869
Compassionate Use Protocols . . . . . . . . . . . . . . . . . . . . . 869
Drug Labeling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 869
Drug Naming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 869
Additional Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . 870
REGULATORY ASPECTS OF DRUG PRODUCTION AND
QUALITY CONTROL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 870
GENERIC DRUGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 870
NONPRESCRIPTION DRUGS AND SUPPLEMENTS . . . . . . . . 870
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 871
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 871
must be well designed not only to appropriately demonstrate
safety and clinical efficacy, but also, through the use of ap-
propriate biomarkers, pharmacodynamic markers, and safety
monitoring, to allow for the early discontinuation of devel-
opment of drugs that are destined to fail.
This is an exciting and challenging time to be involved in
drug development. Major advances in the biological sciences
have yielded a much greater understanding of the molecular
basis of many diseases and provide the opportunity to have
an unprecedented impact on the alleviation of human suffer-
ing. However, translating these scientific advances into new
and more effective therapies for human diseases has proven
to be daunting. In the 10 years between 1993 and 2003, there
was a steady decline in the number of new small-molecule
drugs and biologic agents submitted for approval to regula-
tory agencies around the world. This decline has translated
into fewer new drugs being approved and made available
to patients. To close this apparent gap between innovative
basic-science discoveries and the stagnating approvals of in-
novative new therapies will require diligent clinical drug de-
velopment programs that include rigorous, well-controlled
trials, integrated clinical development plans, the use of novel
statistical methods, and the inclusion of novel pharmacody-
namic and other biomarkers at the various stages of drug
 Drug discovery Drug development Post-approval
(2-5 years) (5-9 years) regulation

Compound identification Biological

Chemistry and biology

End of phase II meeting

and optimization characterization

ANDA filed
NDA filed
Toxicology
Toxicology
studies

IND Phase I Phase II Phase III FDA Phase IV Phase IV

Clinical
filed trials trials trials approval

Manufacturing
Develop manufacturing
Manufacturing
Develop QA/QC program, GMP practices

begins

Patent expires

Generics
available
Patent Patent
Legal
application granted
 CHAPTER 50 / Clinical Drug Evaluation and Regulatory Approval 863
Contains safeguards for vulnerable populations, such as
children and the mentally disabled
IRB/IEC oversight and approval begins before the com-
mencement of human trials and continues for the duration
of clinical trials. The membership of an IRB/IEC consists
of five or more experts and laypersons from various back-
grounds. Federal regulations stipulate that IRB membership
must include at least one member whose primary expertise is
in a scientific area, one member whose primary expertise is
in a nonscientific area, and one member who is not affiliated
with the institution overseeing the clinical research protocol.
In addition, the other members qualifications must be such
that the IRB is able to evaluate research proposals in terms
of institutional requirements, applicable law, standards of
professional practice, and community attitudes. Thus, many
IRBs include clergy, social workers, and attorneys as well as
physicians, scientists, and other health care professionals.
Clinical trials must be appropriately designed and rig-
orously executed in order to optimize the ratio of benefit
to risk and to satisfactorily answer the scientific questions
under study. Scientific clinical trial design must include
appropriate control or comparator arm(s), randomization
and blinding, and sample size, among other elements (see
below). Some institutions have a scientific review commit-
tee that must approve all protocols involving human subjects
to ensure that the protocol is appropriately designed to an-
swer the questions being asked. To further assure that the
findings of clinical trials are accurate and credible and that
the rights of clinical trial subjects are protected, regulatory
agencies require that clinical trials leading to the approval
of new drugs be conducted according to good clinical prac-
tices (GCP). Guidelines for GCP have been developed by
the International Conference on Harmonization (ICH) to
provide a standard for the design, conduct, recording of find-
ings, monitoring of data, analysis, auditing, and reporting of
results of clinical trials.
 DRUG EVALUATION AND CLINICAL
DEVELOPMENT
The investigation of a new drug candidate comprises several
phases, beginning with preclinical evaluation and proceed-
ing through phase 3 clinical studies. At the conclusion of this
process, the FDA may consider the molecule for approval as
a new drug.
Authorizations to Initiate Clinical Trials
Preclinical research establishes the potential efficacy and
safety of a compound for use in human trials. During this
stage of testing, described in Chapter 49, a compound is
studied to determine its biological actions, chemical proper-
ties, and metabolism, and a process is developed for its syn-
thesis and purification. A major focus of preclinical testing is
determining whether the molecule has an acceptable safety
profile in animals prior to initiating testing in humans. The
International Conference on Harmonization has established
requirements for the animal studies used to support different
types of clinical trials. The primary studies used to support
clinical drug development are animal toxicity studies and
investigations on the absorption, distribution, metabolism,
and excretion (ADME) of the compound. As described in
Chapter 49, the duration of animal studies is determined by
the length of the clinical trials being undertaken. For this rea-
son, it is essential that there is close coordination among the
preclinical and clinical scientists on the drug development
team. Many potential drug candidates either do not proceed
to human trials or are removed from clinical testing due to
adverse safety findings in animal studies. The preclinical re-
search phase is also an important time to explore potentially
important pharmacodynamic markers and other biomarkers
that could help facilitate clinical development.
The mechanism for seeking approval to initiate clinical
trials in the United States is the submission of an Inves-
tigational New Drug application (IND) to the FDA. The
IND contains data from the preclinical studies, data from
prior clinical investigations (if available), the proposed pro-
tocol for human trials, and other background information.
The IND also contains a document referred to as the Inves-
tigators Brochure (IB). The IB is provided to regulators,
clinical investigators, and IRBs/IECs; it represents a sum-
mary of all available information on the investigational drug
and may be several hundred pages in length. The IND must
also contain information on the composition and stability
of the drug and evidence that the drug can be manufactured
in consistent batches for clinical trials. Commercial INDs
are submitted by sponsors with the ultimate goal of obtain-
ing approval for marketing and sale of a new drug product.
Noncommercial filings, such as Investigator, Emergency
Use, and Treatment INDs, are used for different purposes,
as described below.
The FDA must review the IND within 30 days and de-
cide whether human trials may begin. Figure 50-2 is a flow-
chart representing the process used by the FDA to review
an IND. The areas of review include a chemistry review, a
pharmacology/toxicology review, and a medical review. If
the IND review does not identify any safety concerns, the IND
is considered open or active after the 30-day wait period. If
the review reveals the potential for unreasonable risk to par-
ticipants, the FDA contacts the sponsor, and a clinical hold
is issued, preventing initiation of human studies. The sponsor
must address any issues in question before the clinical hold is
lifted. A clinical hold may be issued at any time during clinical
drug development; such a hold can be based on new findings
from animal studies, clinical data indicating an unacceptable
risk profile, or a finding that a sponsor did not accurately dis-
close the risk of the study to investigators or subjects.
Clinical Development
Given the time, cost, and risks associated with clinical
drug development, it is imperative to plan carefully and
execute meticulously. The goals of clinical drug develop-
ment include:
Assessment of the doseresponse profile
Assessment of the toxicity profile for a given dosing
regimen
Assessment of pharmacokinetic/pharmacodynamic rela-
tionships
Establishment of the safety and efficacy profile in well-
controlled studies in well-defined patient populations
These goals are accomplished through the conduct of
clinical trials. Each clinical trial must be designed to answer
specific questions. In turn, each trial should be part of an
integrated development plan leading to the ultimate demon-
stration of safety and efficacy in well-controlled trials.
 Applicant (drug sponsor)

IND

Pharmacology/
Medical Chemistry
toxicology

Safety review Sponsor submits

new data

Safety
acceptable Clinical
for study NO hold
to proceed? decision

YES

Study starts
Notify sponsor

Complete reviews

Notify sponsor of
review results
866 Fundamentals of Drug Development and Regulation
drugs volume of distribution and clearance enables study
designers to determine an appropriate maintenance dose
and dosing frequency for phase 2 and 3 trials (see Chapter 3,
Pharmacokinetics).
Although phase 1 trials focus on safety and tolerability,
biomarkers of the desired pharmacologic effect are increas-
ingly being used to provide data early in drug development
on the potential effectiveness of the molecule. One example
of a simple marker would be the phenotyping of peripheral
blood lymphocytes in a trial of an agent designed to inhibit
B cells; more generally, biochemical or cell-based assays are
used to detect whether the drug has effectively regulated the
targeted enzyme, cell type, or tissue.
Phase 2 Studies
Phase 2 studies may involve up to several hundred sub-
jects with the medical condition of interest. Phase 2 clini-
cal trials have multiple objectives, including the acquisition
of preliminary data regarding the effectiveness of the drug
for treatment of a particular condition. Like phase 1 trials,
phase 2 trials continue to monitor safety. Because phase 2
studies enroll more patients, they are capable of detecting
less common adverse events. Phase 2 studies also evaluate
doseresponse and dosing regimens, which are critically
important in establishing the optimum dose or doses and fre-
quency of administration of the drug.
A typical phase 2 design may involve either single-blind
or double-blind trials in which the drug of interest is evalu-
ated against placebo and/or an existing therapy. The trial usu-
ally compares several dosing regimens to obtain optimum
dose range and toxicity information. The results of phase 2
studies are critically important in establishing a specific pro-
tocol for phase 3 studies. Specifically, phase 2 studies should
be designed to obtain a reasonable estimate of the size of
the treatment effect of the experimental therapy. This critical
information will then be used to determine the appropriate
sample size for the phase 3 studies. Phase 2 results can also
be used to pinpoint additional data that must be collected in
phase 3 trials, such as monitoring of liver function tests if
phase 2 data suggest possible hepatotoxicity.
Throughout the process of drug development, the spon-
sors of the program have the opportunity to consult with
the regulatory agencies through formal meetings. After the
completion of phase 2 studies and before the initiation of
phase 3 (pivotal) studies, the sponsor will typically request a
meeting with the FDA to discuss the results obtained to date
and to outline for the FDA reviewers the plans for the phase
3 program. Given the time and expense of phase 3 clinical
trials, it is critical that there is agreement between the FDA
and the sponsor on the appropriate trial design(s) before the
trial is initiated.
Phase 3 Studies
Phase 3 studies involve several hundred to several thousand
patients and are conducted at multiple sites and in settings
similar to those in which the drug will ultimately be used.
Phase 3 studies utilize specific clinical endpoints as the pri-
mary endpoints of the trial. Examples of accepted clinical
endpoints include survival, improvement in patient func-
tional status, or improvement in how patients feel (e.g., qual-
ity of life assessments). Occasionally, surrogate endpoints
for clinical benefit may be used. Examples of surrogate end-
points include markers for decreased disease burden, such
as a reduction in the plasma levels of biochemical markers
(e.g., glucose and LDL cholesterol), an increase in cardiac
output, or a reduction in size of a tumor. Surrogate endpoints
that have been validated in prior clinical trials (e.g., reduc-
tion in serum LDL cholesterol as a surrogate for clinically
meaningful improvement in cardiac outcomes) may be
acceptable endpoints in phase 3 pivotal trials.
In situations of life-threatening diseases for which no ac-
ceptable therapy is available, surrogate endpoints that are
reasonably likely to predict clinical benefit (but that are not yet
validated) may be used as endpoints in pivotal trials. In such
instances, the FDA may grant accelerated approval. Acceler-
ated approval allows the drug to be approved more quickly
and to be made available to patients in need in a more timely
manner. Drugs being considered for accelerated approval may
often be given priority review status, in which case the review
period is 6 months rather than the standard review period of
10 months. This approach has been used to approve drugs
for the treatment of acquired immunodeficiency syndrome
(AIDS) and several types of cancer, among other indications.
However, under accelerated approval, the sponsor is required
to conduct postapproval phase 4 studies to verify and con-
firm the clinical benefit of the drug. In the introductory case,
imatinib was granted accelerated approval based on surrogate
clinical endpoints and was then granted full approval upon the
successful completion of postapproval studies.
Clinical Pharmacology
Many pharmaceutical and biotechnology companies have
developed groups dedicated to studying the clinical pharma-
cology of their products in development. These groups may
be called by names such as Experimental Medicine, Molec-
ular Medicine, or Clinical Pharmacology. The groups typi-
cally investigate aspects of the drugs clinical pharmacol-
ogy, including: fasting and fed single-dose and repeat-dose
pharmacokinetics; drugdrug interactions, with a special
emphasis on the role of cytochrome P450 isoforms on drug
metabolism; and the impact of renal or hepatic impairment
on drug metabolism. They perform comprehensive QT stud-
ies to assess the impact of the drug on cardiac electrophysi-
ological function. The groups make careful assessments of
immunogenicity, particularly if the drug is a protein thera-
peutic, and of the drugs clinical pharmacology in pediatric
patients and in specific ethnic groups such as Asian popula-
tions. Clinical pharmacology groups also work closely with
preclinical scientists to develop appropriate biomarkers to
better assess the impact of the drug at the earliest stages
of clinical development. Biomarker assessments may take
a variety of forms, including exploration of the population
of patients most likely to benefit or most likely to be sus-
ceptible to toxicity as well as pharmacodynamic markers
of drug activity. The groups may attempt to correlate gene
polymorphisms or expression profiles with responsiveness.
These and other clinical pharmacology studies are performed
throughout the clinical development program and are incor-
porated into phase 1, 2, and 3 studies.
Challenges in the Development of Drugs to Treat
Rare Diseases
Historically, pharmaceutical companies had typically been
disinterested in developing products for diseases with small
patient populations, since the cost of developing drugs for
small markets was similar to that for developing drugs for
 CHAPTER 50 / Clinical Drug Evaluation and Regulatory Approval 869

Applicant (drug sponsor) to the type and amount of data required in product labeling.
In Europe, many drugs are first evaluated by the European
Medicines Evaluation Agency and then approved by the
NDA European Union. In Canada, Health Canada adminis-
ters the regulations embodied in the Canadian Food and
Drugs Act. In Japan, approval of new drugs is granted by
the Ministry of Health and Welfare. Importantly, Japa-
Application
NO
Refuse to file nese regulatory authorities require studies to be performed
fileable? letter issued in ethnic Japanese patients in order to demonstrate that the
pharmacokinetic and safety profiles observed in a Japanese
population are similar to those observed in a western popu-
YES lation. Demonstration of efficacy in Japanese patients may
also be required.
Medical Biopharmaceutical

Compassionate Use Protocols

Pharmacology Statistical
The FDA has created compassionate use protocols, also
known as treatment investigational new drug applications
Chemistry Microbiology (treatment INDs), to expand access to investigational drugs.
These protocols permit promising investigational therapies
Advisory committee Meetings to be used, before general approval, for extremely sick pa-
meeting with sponsor tients who are not eligible for an ongoing clinical trial. Three
conditions must be satisfied in order for an investigational
drug to be eligible for a compassionate use protocol: (1) the
drug must show preliminary evidence of efficacy; (2) pa-
Additional info or
Reviews revisions requested
tients must be likely to die or suffer rapid disease progres-
Sponsor revises complete and NO or submitted sion within several months, or to die prematurely without
acceptable? (amendment) treatment; and (3) there must be no comparable approved
YES YES therapy to treat the disease at that stage.
NO

Labeling Inspection Drug Labeling

review of sites
acceptable? acceptable?
NO
YES
Pending
satisfactory
results
NDA action
FIGURE 50-3. Process of new drug application (NDA) review. When a
new drug application is filed, the drug sponsor provides data regarding the drugs
medical, pharmacologic, chemical, biopharmaceutical, statistical, and microbio-
logical characteristics; these data are reviewed by separate committees at the
FDA. The FDA or an FDA Advisory Committee (optional) may meet with the sponsor.
If the review is complete and acceptable, then the drug application is reviewed
for acceptable labeling (official instructions for use). The manufacturing sites and
sites where significant clinical trials were performed also undergo inspections
and audits. Blue boxes correspond to actions by the drug sponsor; white boxes
correspond to actions by the FDA.
Approval in Other Countries
Before drugs may be sold in countries outside the United
States, they must first be evaluated and approved by the
appropriate regulatory authorities in that country. In some
countries, this may include a comprehensive review of all
the data, similar to the NDA/BLA review. In other coun-
tries, a more limited review may occur if the drug has al-
ready been approved in one of the major foreign markets
(United States, Europe, Japan). During these reviews, a
regulatory authority may require additional types of studies
that were not required for U.S. approval. In addition, dif-
ferent regulatory agencies may have different approaches
Each countrys regulatory bodies establish a standard format
and organization for labeling an approved drug in that coun-
try. A drug label must include the drugs proprietary and
chemical name, formula and ingredients, clinical pharma-
cology, indications and usage, contraindications, warnings,
precautions, adverse reactions, drug abuse/dependence po-
tential, overdosage, dosage, rate and route of administration,
and how the drug is supplied. In the United States, this infor-
mation is also known as the drugs package insert. When a
new drug approaches approval, the FDA reviews and negoti-
ates the final package insert with the sponsor to ensure that
the labeling is justified by the data submitted in the NDA. To
provide more accessible and informative drug information,
the FDA has instituted structured product labeling, which
provides key information important to prescribers in a stan-
dardized format.
Regulatory agencies may use additional methods to
ensure that the important attributes of the drug are clearly
communicated. For example, in the United States, pack-
age inserts for drugs that have certain safety risks include
a black box warning, in which key safety information is
prominently displayed. In addition, the FDA may require
sponsors to create Medication Guides for mandatory distri-
bution to patients; these guides communicate critical safety
information in language that is readily understandable.
Drug Naming
Another facet of drug approval involves the determination
of a drugs name. A drug is known by two principal names,
the generic name and the brand name (or trade name).
A drugs generic name is based on its chemical name and
is unprotected by a trademark. In contrast, a drugs brand
870 Fundamentals of Drug Development and Regulation
name refers to the exclusive name of a substance or drug
product owned by a company under trademark law. For
example, imatinib mesylate is the generic name, while
Gleevec is the brand name, of the drug discussed in the
introductory case.
Additional Indications
Once a drug is approved, physicians and certain other
health care professionals are permitted to prescribe the
drug in various doses or dosage regimens. Providers may
also prescribe the drug for additional clinical indications,
known as off-label use. Physicians are also permitted
to conduct investigational studies with the drug, provided
that they follow the rules of informed consent and obtain
IRB approval for the studies. Although health care provid-
ers are permitted to use a drug off-label, such use may
nonetheless subject them to medical malpractice liability,
just as any other treatment decision could. Pharmaceutical
companies, however, may not market the drug for any in-
dications other than those for which it has been approved
by the FDA. Current regulations prohibit pharmaceutical
companies from providing any marketing materials, in-
cluding scientific articles, on the off-label use of a drug,
unless such materials are requested by a physician. In
order to market a drug for a new indication, a pharma-
ceutical company must conduct an additional program of
development to prove that the drug is safe and efficacious
for that new indication. These data are then submitted to
regulatory authorities as a supplemental NDA (sNDA)
and subjected to additional review prior to the granting of
approval for the new indication.
 REGULATORY ASPECTS OF DRUG
PRODUCTION AND QUALITY CONTROL
In addition to demonstrating a drugs safety and efficacy,
manufacturers must also comply with FDA regulations for
manufacturing as a requirement for drug approval. The Good
Manufacturing Practice (GMP) guidelines govern quality
management and control for all aspects of drug manufactur-
ing, and the FDA has the authority to inspect manufacturing
facilities in order to determine compliance. FDA regulations
specify impurity tolerance levels, quality control procedures,
and testing of sample batches.
A company must obtain prior FDA approval before im-
plementing any manufacturing change that is determined
by the FDA to have substantial potential to affect the safety
or effectiveness of a drug through alterations in its identity,
strength, quality, purity, or potency. Other changes may be
implemented either with or without submission of a supple-
mental NDA. Changes not requiring a supplement may be
noted in the report filed annually with the FDA or on another
date determined by the agency.
 GENERIC DRUGS
The FDA also oversees approval of generic drugs, which
the agency defines as drugs that are comparable to innova-
tor drugs in dosage form, safety, strength, route of admin-
istration, quality, performance characteristics, and intended
use. Under the Drug Price Competition and Patent Term
Restoration Act of 1984, also known as the HatchWaxman
Act, a company may submit an Abbreviated New Drug
Application (ANDA) before the patent governing the
brand-name drug expires. However, the company must wait
for the original drugs patent to expire before it can market a
generic version. The first company to file an ANDA has the
exclusive right to market the generic drug for 180 days.
ANDAs for generic drugs are not required to provide
data establishing safety and efficacy, because this has been
established in the NDA for the innovator drug. To establish
bioequivalence, which is required in the ANDA, sponsors may
submit a formulation comparison, comparative dissolution
testing (where there is a known correlation between in vitro
and in vivo effects), in vivo bioequivalence testing (comparing
the rate and extent of absorption of the generic with that of the
reference product), and, for nonclassically absorbed products,
a head-to-head evaluation of comparative effectiveness based
on clinical endpoints. In addition, an ANDA sponsor must
provide evidence that its manufacturing processes and facili-
ties, as well as any outside testing or packaging facilities, are
in compliance with federal GMP regulations.
Generic versions of biologic drugs, primarily proteins,
present much greater challenges than generic versions of
small-molecule drugs. Whereas small molecules can read-
ily be shown to be comparable to the innovator drug as de-
scribed above, this is not so easy with recombinant proteins,
which usually have many post-translational modifications.
Small changes in post-translational modifications may re-
sult in marked differences from the innovator drug in safety
and efficacy. Changes in cell lines used to manufacture such
proteins and changes in any step of the production process
may alter post-translational modifications. As a result, the
precise regulatory path for the development of biosimilars
is currently being actively debated in Congress and within
the FDA.
 NONPRESCRIPTION DRUGS
AND SUPPLEMENTS
The 1951 Durham-Humphrey Amendment to the Food,
Drug, and Cosmetic Act defined prescription drugs as drugs
that are unsafe for use except under professional supervi-
sion. In determining which drugs do not require a prescrip-
tion, the FDA examines a drugs toxicity and the facility
with which a condition may be self-diagnosed. Because
over-the-counter (OTC) drugs are sold in lower doses than
their prescription counterparts and are used primarily to
treat symptoms of disease, the FDA requires their labels to
contain the following:
Intended uses of the product, as well as the products
effects
Adequate directions for use
Warnings against unsafe use
Adverse effects
Although OTC products present a potential danger of mis-
use or misdiagnosis in the absence of physician oversight,
the increased availability of these products has provided
many U.S. citizens with access to effective and relatively
inexpensive treatments.
The Dietary Supplement Health and Education Act of
1994 defines a dietary supplement as any product intended
for ingestion as a supplement to the diet, including vitamins,
minerals, herbs, botanicals, other plant-derived substances,
 CHAPTER 50 / Clinical Drug Evaluation and Regulatory Approval 871
amino acids, concentrates, metabolites, and constituents and
extracts of these substances. The FDA oversees the safety,
manufacturing, and health claims made by dietary supple-
ments. The FDA does not, however, evaluate the efficacy of
supplements as it does for drugs. The FDA may restrict or
halt the sale of unsafe supplements, but it must demonstrate
that such supplements are unsafe before taking action. This
occurred in December 2003, when the FDA announced a rule
banning dietary supplements containing ephedrine alkaloids
(ephedra) after reviewing the substantial number of adverse
events (including deaths) associated with these products.
 CONCLUSION AND FUTURE DIRECTIONS
Specific laws and regulations have been established to pro-
vide for the development of new drugs, while at the same
time assuring privacy and safety for the individuals partici-
pating in clinical trials. Regulatory approval of new drugs
follows a lengthy process of preclinical and clinical studies.
Each phase of development provides critical information
that defines the study protocol for subsequent investigations.
However, no amount of animal and clinical data can guaran-
tee complete safety for all future patients. Thus, the FDA and
drug manufacturers continue to monitor the adverse effects,
manufacturing processes, and overall safety of a drug for its
lifetime (see Chapter 51, Systematic Detection of Adverse
Drug Events). In the future, there will be an increased focus
on evaluating the safety of new medicines, both during clini-
cal trials and after the drug is approved and introduced into
larger, more diverse patient populations.
Acknowledgment
We thank Armen H. Tashjian, Jr. for his valuable contri-
bution to this chapter in the Second Edition of Principles
of Pharmacology: The Pathophysiologic Basis of Drug
Therapy.
Suggested Reading
Adams CP, Brantner VV. Estimating the cost of new drug development: is
it really $802 million? Health Aff 2006;25:420428. (Finds that developing
a new drug costs between $500 million and $2 billion, depending on the
indication.)
Center for Drug Evaluation and Research, Food and Drug Administra-
tion, United States Department of Health and Human Services. The
CDER Handbook. Revised 03/16/98. Available at http://www.fda.gov/
downloads/AboutFDA/CentersOffices/CDER/UCM198415.pdf. (Describes
the processes by which the FDA evaluates and regulates drugs, includ-
ing new drug evaluation and postmarketing monitoring of drug safety and
effectiveness.)
Cohen MH, Williams G, Johnson JR, et al. Approval summary for imatinib
mesylate capsules in the treatment of chronic myelogenous leukemia. Clin
Cancer Res 2002;8:935942. (Summarizes the approval of imatinib mesy-
late, the drug discussed in the introductory case.)
DiMasi JA, Grabowski HG. The cost of biopharmaceutical R&D: is biotech
different? Manag Decis Econ 2007;28:469479. (First paper to estimate
costs of biopharmaceutical development compared to costs of traditional
pharmaceutical development.)
Dixon JR. The International Conference on Harmonization Good Clinical
Practice guideline. Qual Assur 1999;6:6574. (Guidelines for standard de-
sign of drug development.)
Innovation/stagnation: challenge and opportunity on the critical path to new
medical products. U.S. Department of Health and Human Services, Food
and Drug Administration. March 2004. (An FDA report that addresses the
recent slowdown in innovative drug development.)
51
Systematic Detection of
Adverse Drug Events
Jerry Avorn
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . 872-873
CHALLENGES IN THE ASCERTAINMENT OF DRUG SAFETY . . . 872
Study Size and Generalizability . . . . . . . . . . . . . . . . . . . . 872
Surrogate Outcomes and Comparators . . . . . . . . . . . . . . 873
Duration and Postapproval Studies. . . . . . . . . . . . . . . . . . 874
PHARMACOEPIDEMIOLOGY. . . . . . . . . . . . . . . . . . . . . . . . . 874
Sources of Pharmacoepidemiologic Data . . . . . . . . . . . . . 875
Spontaneous Reports . . . . . . . . . . . . . . . . . . . . . . . . . 875
Automated Databases . . . . . . . . . . . . . . . . . . . . . . . . . 875
Patient Registries . . . . . . . . . . . . . . . . . . . . . . . . . . . . 875
Ad Hoc Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 876
Study Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 876
Cohort and Case-Control Studies . . . . . . . . . . . . . . . . 876
Evaluation of Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . 876
 INTRODUCTION
Because medications act by interfering with one or more as-
pects of molecular and cellular function, it is difficult to do
so without also causing an undesirable effect either by that
perturbation or by another (perhaps unexpected) drug action.
Because all drugs have risks, the goal of pharmacotherapy
cannot be to prescribe a risk-free regimen. Instead, it is to
ensure that the risks of drug therapy are as low as possible
and are acceptable in the context of a medications clinical
benefit.
Some adverse effects of a drug are apparent during its early
development and often result from the same on-target mech-
anism responsible for its therapeutic effect (e.g., cytotoxic
cancer chemotherapy). Even in such situations, however, it
is necessary to know how those expected adverse effects will
be manifested when the drug is in routine usein terms of
both their frequency and their severity. After a drug has been
approved for clinical use, the goal becomes detecting and
quantifying the risks as quickly and rigorously as possible.
Serious or even life-threatening adverse effects have led
to the withdrawal of widely used drugs. This has heightened
the sensitivity of clinicians and patients to the emerging field
of pharmacoepidemiologythe measurement of drug ef-
fects in large real-world populations of patients. Advances
872
Issues in Study Design and Interpretation . . . . . . . . . . . . 877
Confounding by Indication. . . . . . . . . . . . . . . . . . . . . . 877
Selection Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 877
The Healthy User Effect . . . . . . . . . . . . . . . . . . . . . . 877
Interpreting Statistical Significance . . . . . . . . . . . . . . . 878
ADVERSE DRUG EFFECTS AND THE HEALTH
CARE SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 878
Balancing Benefits and Risks . . . . . . . . . . . . . . . . . . . . . . 878
Role of the FDA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 879
Legal and Ethical Issues. . . . . . . . . . . . . . . . . . . . . . . . . . 879
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 879
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 879
in informatics and analytic techniques in this field hold
promise for enhancing our understanding of drug risks so
that they can be better understood and managed, with the
goal of putting a drugs benefits into context and guiding
clinical decision-making and regulatory action.
 CHALLENGES IN THE ASCERTAINMENT
OF DRUG SAFETY
The randomized controlled trial (RCT) is the gold standard
for determining the efficacy of a drug and is the sole crite-
rion used by regulatory agencies, such as the U.S. Food and
Drug Administration (FDA), in deciding whether to approve
a new medication for use. But this valuable tool also has
limits, and it is important to understand those limits when
assessing the benefits and risks of a given agent.
Study Size and Generalizability
Compared to the number of patients who eventually use a
drug, the number of subjects in clinical trials supporting
the approval of that drug is relatively modest. Approval
decisions are generally made on the basis of trials that
include 2,0004,000 participants, or fewer for rare condi-
tions. If a particular adverse event occurs just once in every
876 Fundamentals of Drug Development and Regulation
Ad Hoc Studies
Some important questions in pharmacoepidemiology cannot
be addressed by these methods, but must instead be answered
by collecting data de novo on particular groups of patients
with a given disease, or patients taking a particular class of
medications. One example is the definition of sudden un-
controllable somnolence (sometimes called sleep attacks)
in patients taking dopamine agonists for Parkinsons disease
(PD). Such events were not systematically documented in
most large clinical trials of these drugs, and were not likely
to be recorded as a new diagnosis in an office visit. Deter-
mining whether some drugs cause this problem more than
others required interviewing a large sample of PD patients
using different classes of medications.
Study Strategies
Once a source of pharmacoepidemiologic data has been
identified, statistical methods are used to evaluate those data
and reach conclusions about the associations between a drug
and possible adverse effects. The two most common types
of analyses used to evaluate these observational data are
cohort studies and case-control studies. Each is designed to
evaluate statistically the risk of a particular adverse outcome
associated with exposure to a given drug.
Cohort and Case-Control Studies
In cohort studies, one identifies a group of patients exposed
to a given drug (e.g., patients with arthritis treated with a
particular NSAID), and another group of patients who are as
similar as possible to the exposed group but who did not take
the drug of interest (e.g., patients with arthritis of compa-
rable severity who were treated with another NSAID). Both
groups are then followed over time to determine how many in
each group develop an adverse effect of interest (e.g., myo-
cardial infarction; Fig. 51-1). While this can be done on a
real-time basis, more commonly, exposure (or nonexposure)
that occurred in the past is defined from an existing database,
so that subsequent events can be analyzed retrospectively.
Cohort studies make it possible to measure actual incidence
rates (i.e., the likelihood of a given outcome following use of
a particular drug) and to track multiple outcomes.
In case-control studies, one specifies the case-defining
outcome event (e.g., myocardial infarction) and identifies a
group of patients in a population who have experienced that
event; these are the cases. The controls are patients in the
same population who are as similar as possible to the cases
but have not had the outcome of interest (e.g., patients of
similar age and gender, and with similar cardiac risk factors,
who have not had a myocardial infarction). One then looks
back in time prior to the occurrence (or nonoccurrence) of
the event of interest to review all the medications that were
taken by cases and by controls, to determine whether use
of a given drug was higher than expected among cases than
among controls (Fig. 51-1). The case-control design is more
efficient than the cohort design if the outcome of interest is
rare and one has to interview all study participants, because
it is possible to focus on a selected group of patients known
to have had the outcome of interest.
Evaluation of Risk
At the most basic level, cohort and case-control studies yield
data that comprise a 2 2 table defining the presence or
absence of exposure to the drug of interest as well as the
Case-control study
Cases
(e.g., M.I.)
= filled prescription for drug X
Controls
(no M.I.)
Time
Cohort (follow-up) study
Exposed
(taking drug X)
= outcome event (e.g., M.I.)
Unexposed
(not taking drug X)
Time
FIGURE 51-1. Schematic design of case-control and cohort studies.
Top. In a case-control study, cases are identified as patients in a population who
have experienced the case-defining outcome event (e.g., myocardial infarction);
controls are patients in the same population who are as similar as possible to the
cases but have not had the outcome of interest. All medications taken by cases
and controls are reviewed retrospectively to determine whether use of a given
medication was higher among cases than among controls. Bottom. In a cohort
study, two groups of patients are identified: those who were exposed to a given
drug and another group who are as similar as possible to the exposed group but
did not take the drug of interest. All patients are followed over time to determine
how many in each group develop a specified outcome event of interest (e.g., myo-
cardial infarction).
presence or absence of the adverse outcome. The data can be
arranged in four cells, as shown in Figure 51-2: patients who
took the drug of interest and had the outcome (A); patients
who took the drug but did not have the outcome (B); patients
who did not take the drug but had the outcome anyway (C);
and patients who did not take the drug and did not have the
outcome of interest (D).
Cells A and D are concordant for the drugoutcome re-
lationship, and cells B and C are discordant for this asso-
ciation. The product A D divided by the product B C
reflects the strength of such an association. For cohort stud-
ies, this is referred to as the relative risk; for case-control
studies (as long as the case outcome is not common), this
is known as the odds ratio. A relative risk (or odds ratio) of
2 means that patients using the drug are twice as likely to
have the outcome as patients not using that drug; a relative
risk or odds ratio of 0.5 means that users of the drug are half
as likely as nonusers to experience that outcome (i.e., the
drug has a protective effect for that outcome).
 Adverse No adverse
outcome outcome

A B
Drug Exposure + Exposure +
exposure Outcome + Outcome

C D
No drug Exposure Exposure
exposure
Outcome + Outcome
878 Fundamentals of Drug Development and Regulation
Alzheimers disease in patients taking statins. Such studies
often seem to be flawed by what has been called the healthy
user effect. Patients who are regular users of any preventive
medication appear to be different from those who do not ex-
hibit this behavior: they are more likely to visit their doctor
seeking preventive therapy, or are at least open to receiving
it, and their physicians are sufficiently prevention-oriented
to write such a prescription. Such patients are probably also
more likely to engage in other health-promoting behaviors,
such as tobacco avoidance, weight control, exercise, and
adherence to their other prescribed drug regimens.
Several large randomized trials have proven a similar
point: patients randomized to placebo who comply with
their dummy-pill regimen have better outcomes (including
mortality) than patients who do not comply with their pla-
cebo regimen. Because the content of the placebo could
not have produced this effect, these findings provide clear
evidence that patients who consistently behave in a health-
promoting manner are more likely to have better clinical out-
comes, apart from the therapeutic effect of a specific drug in
their regimen. To address this issue in observational studies,
some research groups have begun to use only active con-
trols as comparator groupsfor example, comparing pa-
tients adherent to statin regimens with patients adherent to
regimens of other preventive drugs, rather than simply com-
paring such patients with patients who are not statin users.
Interpreting Statistical Significance
In evaluating the results of both observational studies and
randomized trials, it is conventional to use a p value of 0.05
as a threshold or benchmark for statistical significance. This
criterion is often mistakenly interpreted to mean that a find-
ing is real if the p value for the difference between groups
is below that value, and not real if it is above. However,
more sophisticated readers of the literature understand that
such a cut-point is largely arbitrary (compared to, for ex-
ample, a p value of 0.03 or 0.07), and that attention must
also be paid to the magnitude of the difference. For example,
a p 0.05 difference between a new drug and placebo may
be clinically meaningless if there is only a 2% difference in
effect size.
The situation is even more critical in assessing the statis-
tical significance of data about adverse events, whether from
a randomized trial or from an observational analysis. It is
useful to recall that the p value is determined by both sample
size and the magnitude of an observed difference. Most clin-
ical trials are powered to be large enough to detect a differ-
ence between a study drug and its comparator in producing
a clinical outcome that is relatively common (e.g., reduction
in blood pressure or LDL level). As a result, however, such
studies are not likely to have adequate statistical power to
find a significant difference between groups for outcomes
that are much more rare (e.g., reduction in renal function).
Adherence to a p 0.05 standard for uncommon adverse
effects can lead to dismissal of important risks that a study
may not have been powered to detect.
The solution is not to embrace all differences in ad-
verse effect rates regardless of their statistical properties.
Instead, it is to consider such rate differences thoughtfully
and to seek additional evidence to clarify worrisome rela-
tionships even if they are not significant in p value terms.
For example, when the FDA was evaluating the risk of sui-
cidal thoughts and actions in adolescents and children taking
SSRI antidepressants in placebo-controlled trials, the rates of
these relatively rare outcomes were generally higher in the
treated patients than in those randomized to placebo. Each
individual study did not find a p 0.05 level of significance
for these differences. However, when the FDA aggregated
the data from all such trials (in some cases, years after the
studies were completed), it became clear that the risk across
all studies was clear and consistent (and also met the con-
ventional p 0.05 level).
The opposite problem arises when considering the sta-
tistical significance of data from large population-based
epidemiological studies. Here, sample size (power) is not
a limitation, especially when studies employ data on sev-
eral hundred thousand patients through use of an automated
claims database. A 4% or 5% difference in rates of a given
effect (either therapeutic or adverse) may achieve a p value
0.001, simply because of the huge size of the population
studied. But here, even if the finding appears to have statisti-
cal significance, a difference of such small magnitude may
have little or no clinical importance.
 ADVERSE DRUG EFFECTS AND THE
HEALTH CARE SYSTEM
The series of safety-related withdrawals of commonly used
drugs in the 1990s and early 2000s led to renewed interest in
developing ways to prevent such problems, or at least to limit
the number of patients exposed to risk by identifying adverse
effects earlier. As a result, the concept of risk management
has become an important theme in drug development and
regulation.
Balancing Benefits and Risks
As noted above, new products are often not compared with
existing alternatives when they are evaluated for approval,
and such studies are not commonly performed after approval
either. For drugs with known risks, it is therefore difficult
to know whether an adverse effect occurs more commonly
with a new drug than with another drug in the same class
(e.g., gastrointestinal hemorrhage with NSAIDs, or rhab-
domyolysis with statins). A higher rate of a given adverse
event might be acceptable for a particular drug if it were
accompanied by substantially greater efficacy. In this case,
however, the absence of head-to-head clinical trials makes it
difficult to make such an evaluation. Thus, in most instances,
the individual clinician is left to make therapeutic decisions
without the data needed to make such choices rigorously.
A recent development designed to remedy this problem is
the movement toward comparative effectiveness researcha
program of publicly funded studies that systematically eval-
uates therapies against one another. It was initiated in 2009
with a $1.1 billion federal investment and is expected to be
an important ongoing component of the research agendas of
several federal agencies.
The clinical use of medications is heavily influenced by
the $30 billion spent annually by the pharmaceutical industry
to market its products. This expenditure is heavily front-end
loaded, with vast sums spent soon after a drug is launched in
order to maximize sales for as many years as possible while
the companys patent is still in effect. Ironically, this means
that the heaviest promotion of a drug occurs during the period
in which there is least experience with its use and effects in
VIII

Environmental Toxicology
 A

O O
O C
N N N N
Fe2+ Fe2+
N N N N

Oxyhemoglobin Carboxyhemoglobin

B
100
Hemoglobin oxygen saturation (%)

75 Normal O2 delivery

50

25 Decreased O2 delivery

0
0 20 40 60 80 100 120
Partial pressure oxygen (torr)

Normal hemoglobin 50% carboxyhemoglobin


Cyanide
 should also be avoided in pregnant women and infants, who
The cyanide ion (CN ) is a highly toxic and frequently le-
thal poison. It may be inhaled, ingested, or absorbed through
the skin from sources as diverse as hydrogen cyanide gas, cy-
anide salts, apricot pits, peach pits, cherry pits, cassava, fire
smoke, and vapors from industrial metal plating operations.
Cyanide is also a metabolite of nitriles and nitroprusside.
Cyanide binds to the ferric iron in the heme a3/CuB center of
cytochrome c oxidase, thereby blocking aerobic respiration
and preventing cellular use of oxygen. This causes a shift to
anaerobic metabolism and a resulting metabolic acidosis. As
with CO poisoning, cyanide poisoning damages tissues with
high oxygen demand, such as the brain and heart.
Signs and symptoms of cyanide poisoning depend on
dose and route of exposure, and are somewhat nonspecific:
headache, confusion, altered mental status, hypertension
(early) or hypotension (late), nausea, and other symptoms
are all possible. Pallor or cyanosis is not present (assuming
no co-exposure to carbon monoxide). Unless cyanide expo-
sure is reported or witnessed, or is likely to have occurred
given the patients occupation or recent activities, diagno-
sis may be difficult. Sometimes, an odor of bitter almonds
may be noted. Because cyanide is cleared rapidly from the
blood, and because of technical challenges, measurements of
cyanide in the blood may be both time-consuming and mis-
leading. Moreover, some endogenous production of cyanide
occurs in healthy individuals, and smokers blood contains
elevated cyanide concentrations. There is some debate about
the blood concentrations of cyanide deemed toxic or poten-
tially lethal, but 1 mg/L (39 mol/L) is typically regarded as
a potentially toxic level.
Treatment for acute cyanide poisoning may include de-
contamination, supportive therapy, and administration of an
antidote. Decontamination may entail simply the removal of
contaminated clothes, and care should be taken to avoid in-
advertent exposure of responders to the cyanide-containing
material. Supportive therapy, including supplemental oxy-
gen, should aim to avoid organ failure and may be needed to
address toxicities such as coma, lactic acidosis, hypotension,
and respiratory failure.
The traditional antidotal treatment for acute cyanide poi-
soning in the United States is a cyanide antidote kit (CAK)
that contains amyl nitrite, sodium nitrite, and sodium
thiosulfate. The nitrites act by oxidizing hemoglobin to
methemoglobin to provide a substrate that can compete with
heme a3 in cytochrome c oxidase for cyanide molecules.
Amyl nitrite is usually given by inhalation and acts (and is
cleared from the bloodstream) rapidly, while sodium nitrite
is administered intravenously and has a longer duration of
action. The methemoglobin-bound cyanide is oxidized to the
relatively nontoxic thiocyanate by the enzyme rhodanese
(also known as transsulfurase) and excreted in urine. Sodium
thiosulfate provides a ready source of sulfur for the detoxica-
tion reaction and enhances cyanide metabolism.
Importantly, use of the CAK may pose significant risk to
the patient, since a substantial fraction of hemoglobin must
be converted to methemoglobin to compete effectively for the
cyanide ion. Smoke inhalation victims (who have high levels
of exposure to carbon monoxide) are sometimes presumed to
have been poisoned by cyanide gas. Such patients may already
be suffering from hypoxia before CAK treatment is begun.
Exacerbation of hypoxia by forcing conversion of hemoglobin
CHAPTER 52 / Environmental Toxicology 883
to methemoglobin may be detrimental to such patients. CAK
may carry fetal hemoglobin and have immature methemoglobin
reductase activity. Furthermore, the CAK may cause severe hy-
potension and lead to cardiovascular collapse.
Concerns regarding possible terrorist use of cyanide led
to the relatively recent (2006) approval by the U.S. Food
and Drug Administration (FDA) of an alternative antidote,
hydroxocobalamin (Cyanokit). This member of the vitamin
B12 family is an endogenous compound that was already in
use at lower doses for treatment of vitamin B12 deficiency.
The mechanism of action of this drug differs from that of
the compounds in the CAK: the cobalt moiety in hydroxo-
cobalamin has a strong affinity for cyanide and competes
directly with the ferric iron in cytochrome c oxidase for
cyanide, forming nontoxic cyanocobalamin that is excreted
in the urine. Hydroxocobalamin is generally well tolerated,
but anaphylactic reactions are possible. The compound also
causes urine to have a bright red color for about a week and
may discolor the skin at the site of injection. Interference
with spectrophotometric tests and assays for oxyhemoglobin,
carboxyhemoglobin, and methemoglobin may also occur.
Lead
Lead is ubiquitous in the environment because of its per-
sistence, its formerly widespread and unnecessary use as a
gasoline additive, and its use in pigments, paints, plumbing,
solder, and other products. Lead is toxic to the central nervous
system, making exposure a particular concern for fetuses and
children up to the age of about 7 years. Young children are
also at risk because they are more likely than adults to ingest
lead-contaminated paint dust and other nonfood materials.
Despite a five-fold decrease in the exposure to lead in the
United States and elsewhere since the mid-twentieth century,
children today may still be at risk of developing lead-induced
neurocognitive deficits. This is especially true for children
who live near active, poorly controlled lead mines or smelt-
ers, or in countries where leaded fuels are, or recently were,
used. (Leaded gasoline was not banned in China until 2000,
for example.) Lead-glazed clay cookware and solder remain
common in some areas, and some of this lead contaminates
food and water. Exposures to lead that present no overt symp-
toms may nonetheless be toxic, and testing young childrens
blood lead levels is essential. Although the half-life of lead
in soft tissues is relatively short, its half-life in bone is more
than 20 years; a substantial exposure in early childhood can
result in elevated bone lead levels for decades.
Lead causes a disruption of the bloodbrain barrier, al-
lowing both lead and other potential neurotoxins to reach
the CNS. There, lead can block voltage-dependent calcium
channels, interfere with neurotransmitter function, and,
most importantly, interfere with cellcell interactions in the
brain; the latter effect causes permanent changes in neuronal
circuitry. Overt lead encephalopathy, which is rare in the
United States today, results in lethargy, vomiting, irritabil-
ity, and dizziness, and can progress to altered mental sta-
tus, coma, and death. Low- and moderate-level exposures to
young children are believed to result in IQ deficits of two to
four points for every 10 g/dL increase in blood lead con-
centration. Whether some blood lead levels are so low as
to present essentially no risk of neurobehavioral deficit is a
matter of debate and ongoing research.
884 Environmental Toxicology

Lead interferes with the synthesis of hemoglobin at A B N

multiple steps, causing a microcytic, hypochromic anemia. H2N NH2
L
Specifically, lead inhibits the action of delta-aminolevulinic Cu+2
acid dehydratase (ALA-D), which catalyzes the synthesis M N
L L
L H2
of porphobilinogen, a heme precursor. Lead also inhibits the
incorporation of iron into the porphyrin ring.
In the kidney, lead causes both reversible and irreversible
toxicity. Lead can interfere reversibly with energy production C Na+O- O-Na+ NH2
N N
in proximal tubular cells by interfering with mitochondrial SH OH
O Ca2+ O
function, resulting in decreased energy-dependent reabsorp- HS OH
O O- O- O SH O
tion of ions, glucose, and amino acids. Chronic exposure to
lead results in interstitial nephritis, with the eventual devel- Dimercaprol Calcium disodium edetate Penicillamine
opment of fibrosis and chronic kidney disease. (EDTA)
When indicated clinically, body burdens of metals such
as lead, mercury, or cadmium can be reduced using electron
donors such as an amine, hydroxide, carboxylate, or mercap-
tan to form metalligand complexes. A chelator, which in
Greek means claw, is a multidentate structure with mul-
tiple binding sites (Fig. 52-2). Binding the metal at multiple Mercury complex Lead complex Copper complex
sites shifts the equilibrium constant in favor of metal ligation.
High-affinity metalligand binding is critical because the O OH
chelator must compete with tissue macromolecules for bind- H
N N
ing. In addition, the chelator should be nontoxic and water- H2N N
soluble, and the complex should be readily cleared. Finally, OH O
2 O
an ideal chelator should have a low binding affinity for en- Deferoxamine
dogenous ions such as calcium. To prevent the depletion
of tissue calcium, many chelators are administered as their
calcium complexes. The target metal is then exchanged for
calcium, and the bodys calcium stores are not depleted.
The most important heavy metal chelators are edetate
disodium (the calcium, disodium complex of EDTA), which can
be used to bind lead; dimercaprol (also known as British anti-
Lewisite or BAL), which binds gold, arsenic, lead, and mercury
to its two thiol groups; and succimer (2,3-dimercaptosuccinic
acid), which has supplanted dimercaprol for the removal of Iron complex
lead, cadmium, mercury, and arsenic. Deferoxamine is used
for the removal of toxic levels of iron, such as would occur FIGURE 52-2. Heavy metal chelators. A. A ligand (L) is a compound contain-
ing a Lewis base (such as amine, thiol, hydroxyl, or carboxylate groups) that can
in accidental overdoses of iron-containing supplements or in
form a complex with a metal (M). B. A chelator is a multidentate ligand, that is,
patients with transfusion-dependent anemias. Deferasirox a ligand that can bind to a metal through multiple atoms, as in this example of a
is an orally bioavailable iron chelator that has recently been tetra-amino ligand bound to copper (Cu 2) via its four amine groups. C. The struc-
approved by the U.S. FDA; this agent may supplant deferox- tures of dimercaprol, calcium EDTA, penicillamine, and deferoxamine are shown;
amine for many conditions associated with chronic iron over- the atoms that form bonds with the metal are identified in blue. Three-dimensional
load. Removal of copper, typically in patients with Wilsons structures of the mercury complex of dimercaprol, the lead complex of EDTA, the
disease, is accomplished with penicillamine or, for patients copper complex of penicillamine, and the iron complex of deferoxamine are also
who do not tolerate penicillamine, trientine. shown. Here, the heavy metal is highlighted in red. For simplicity, hydrogen atoms
are not shown.

Food Contaminants
An estimated one in four Americans experience significant
foodborne illnesses each year. The mechanisms of food poi-
soning involve either infection, which typically manifests 1
to several days after exposure, or intoxication from a pre-
formed microbial or algal toxin, with symptoms occurring
within a few hours of exposure. Infectious food poison-
ing is typically caused by species of Salmonella, Listeria,
Cryptosporidium, or Campylobacter. Less common but quite
virulent are poisonings by enteropathogenic Escherichia
coli, which can cause sometimes fatal hemorrhagic colitis
and hemolytic-uremic syndrome (HUS), likely through the
uptake of pathologic bacterial proteins by host cells.
Food intoxication is often caused by toxins elaborated by
Staphylococcus aureus or Bacillus cereus, or by marine algal
toxins ingested via seafood. S. aureus produces a variety of
toxins; the staphylococcal enterotoxins (SE) cause emesis
by stimulating receptors in the abdominal viscera. Improper
food handling after cooking, followed by poor refrigeration,
contaminates high-protein foods such as meats, cold cuts,
and egg and dairy products.
B. cereus is a common contaminant of cooked rice. It
produces several toxins that cause vomiting and diarrhea.
Of particular concern is the production of cerulide, a small,
cyclic peptide that stimulates intestinal 5-HT3 receptors, re-
sulting in emesis. The peptide is heat-stable to 259F for up
to 90 minutes, so reheating of contaminated cooked rice will
typically not prevent intoxication.
Most algal toxins are neurotoxic and heat-stable, so,
again, cooking leaves the toxins intact. Algal toxins such

as saxitoxins are a group of approximately 20 heterocyclic
guanidine derivatives that bind with high affinity to the volt-
age-gated sodium channel, thus inhibiting neuronal activity
and causing tingling and numbness, loss of motor control,
drowsiness, incoherence, and, with sufficient doses (greater
than about 1 mg), respiratory paralysis.
Many foodborne illnesses appear to be caused by
pathogens that are not yet characterized. Moreover, novel
pathogens can emerge because of changing ecologies or
technologies, or can arise via transfer of mobile virulence
factors such as bacteriophages.
Toxic Plants and Fungi
Acute illness can also be caused by mistaken ingestion of
nonfood items, such as poisonous mushrooms collected by
amateur mycologists or any number of poisonous plants. The
highly toxic death cap mushroom, for instance, Amanita
phalloides, produces numerous cyclopeptide toxins that
are not destroyed by cooking or drying, have no distinctive
taste, and are taken up by hepatocytes. The amatoxins bind
strongly to RNA polymerase II, substantially slowing RNA
and protein synthesis and leading to hepatocyte necrosis.
The somewhat less toxic phallotoxins and virotoxins inter-
fere with F- and G-actins in the cytoskeleton. Consumption
of Amanita species or their relatives can thus cause severe
liver dysfunction, even hepatic (and renal) failure and death.
Initial symptoms of poisoning, such as abdominal pain, nau-
sea, severe vomiting and diarrhea, fever, and tachycardia,
may occur 624 hours after consumption of the mushrooms.
Hepatic and renal function may deteriorate even while the
initial symptoms abate, leading to jaundice, hepatic en-
cephalopathy, and fulminant liver failure; death may occur
49 days after consumption. There is no specific antidote.
An anticholinergic syndrome may be caused by deliberate
or accidental ingestion of jimson weed, a plant belonging to
the Datura family. All parts of the plant are toxic, but the seeds
and leaves, in particular, contain atropine, scopolamine, and
hyoscyamine. These compounds are rapidly absorbed and
produce anticholinergic symptoms such as mydriasis, dry,
flushed skin, agitation, tachycardia, hyperthermia, and hal-
lucinations. The mnemonic for anticholinergic effects, blind
as a bat, dry as a bone, red as a beet, mad as a hatter, and hot
as a hare, is applicable to jimson weed poisoning.
Some plants in the families Umbelliferae (such as parsley,
parsnip, dill, celery, and giant hogweed), Rutaceae (such
as limes and lemons), and Moraceae (such as figs) contain
psoralen isomers (furocoumarins) in leaves, stems, or sap
that can be absorbed into the skin after contact. Subsequent
exposure to ultraviolet (UV) A radiation of wavelength
320 nm (generally via sunlight) can excite furocoumarins,
resulting in epidermal tissue damage. Within 2 days, burning,
redness, and blistering are observed in areas of contact with
the plant and light; after healing, hyperpigmentation may
persist for months. The response is greater with increasing
plant contact, humidity, and duration and intensity of radia-
tion exposure. This nonallergic phytophototoxic mecha-
nism is the basis of psoralen  UV-A (PUVA) therapy for
eczema and other dermatological disorders.
Acids and Bases
Strong acids, alkalis (caustic agents), oxidants, and reducing
agents damage tissue by altering the structure of proteins,
CHAPTER 52 / Environmental Toxicology 885
lipids, carbohydrates, and nucleic acids so severely that
cellular integrity is lost. These substances, such as potas-
sium hydroxide in drain cleaners and sulfuric acid in car
batteries, produce chemical burns by hydrolyzing, oxidiz-
ing, or reducing biological macromolecules or by denaturing
proteins. High concentrations of detergents can also cause
nonspecific tissue damage by disrupting and dissolving the
plasma membrane of cells.
Although some of these agents may target particular
macromolecules, direct tissue-damaging agents tend to be
relatively nonspecific. Thus, the systems most commonly
affected are those most exposed to the environment. Skin
and eyes are frequently affected by splashes or spills. The
respiratory system is affected when toxic gases or vapors are
inhaled, and the digestive system is affected by accidental or
deliberate ingestion of toxic substances.
Many agents can cause damage to deep tissues after break-
ing through the barrier formed by the skin. Other agents are
able to pass through the skin causing relatively little local
damage, but destroy deeper tissues such as muscle or bone.
For example, hydrofluoric acid (HF; found in, among other
products, grout cleaner) causes milder skin burns than an
equivalent amount of hydrochloric acid (HCl). However,
once HF reaches deeper tissue, it destroys the calcified ma-
trix of bone. In addition to the direct effects of the acid, the
release of calcium stored in bone can cause life-threatening
cardiac arrhythmias. For this reason, HF can be more dan-
gerous than an equivalent amount of HCl.
Three characteristics determine the extent of tissue dam-
age: the compounds identity, its concentration/strength, and
its buffering capacity, or its ability to resist change in pH or
redox potential. As mentioned above, HF is more injurious
than an equivalent amount of HCl. In general, a stronger acid
or base (measured by pH) or oxidant or reductant (measured
by redox potential) will cause more damage than an equiva-
lent compound at a more physiologic pH or redox potential.
A solution of 102 M sodium hydroxide in water has a pH of
12 but has a low capacity to cause tissue damage, because it
has a small buffering capacity and is rapidly neutralized by
body tissue. In contrast, a buffered solution of pH 12, such
as that found in wet ready-set concrete [made with buffered
Ca(OH)2], can cause more serious alkali burns because tis-
sues cannot readily neutralize the materials extreme pH.
Pesticides
Pesticides include insecticides, herbicides, rodenticides, and
other compounds designed to kill unwanted organisms in the
environment. By their nature, pesticidesof which there are
hundreds (vastly more natural than synthetic)are biologi-
cally active; however, the degree of their specificity toward
target organisms varies, and many of these compounds cause
toxicity in humans and other nontarget organisms. Some of
the more common acute poisonings involve organophos-
phate and pyrethroid insecticides and rodenticides.
Organophosphate insecticides, derived from phosphoric
or thiophosphoric acid, include parathion, malathion,
diazinon, fenthion, chlorpyrifos, and many other chemi-
cals. These widely used compounds are acetylcholinesterase
(AChE) inhibitors due to their ability to phosphorylate AChE
at its esteratic active site (Fig. 52-3). Inhibition of AChE,
and consequent accumulation of acetylcholine at cholinergic
junctions in nerve tissue and effector organs, produces acute
886 Environmental Toxicology

A
O O

P R1 R2
R1 R3 N O
H
R2
Organophosphonate Carbamate

B
O O O
O
P P P N
P N O O
O O S
CN F
F
Sarin Tabun Soman VX

O
C
NO2
S S O

P P O
O O O S
O O
O
Parathion Malathion

D O
H
N
O O
P
HO R1 OR2
O
Acetylcholinesterase N+ O
P N
active site (serine)
R1 OR2
X
Organophosphate Organophosphate-bound
pralidoxime
1

2 3
O
O O P
H H R1 OR2
N N
O O OH
4
O O N+ OH
OH OR2 N
P HOR2 P
O R1 O R1

After aging Organophosphate-bound Pralidoxime

acetylcholinesterase

FIGURE 52-3. Structures and mechanisms of acetylcholinesterase inhibitors. A. Structures of typical acetylcholinesterase inhibitors, an organophosphonate on
the left and a carbamate on the right. B. Structures of the principal nerve gases sarin, tabun, soman, and VX, which are potent inhibitors of human acetylcholinesterase.
C. Structures of the organophosphate insecticides parathion and malathion. The thiophosphate bonds between sulfur and phosphorus are oxidized more efficiently by
arthropod oxygenases than by mammalian oxygenases, so the compounds are less toxic to humans than the structurally related nerve gases. D. Organophosphates
attack the serine active site in acetylcholinesterase, forming a stable phosphorusoxygen bond (1). Pralidoxime abstracts the organophosphate from serine, restoring
active acetylcholinesterase (2). Organophosphate-bound pralidoxime is unstable and spontaneously regenerates pralidoxime (3). Organophosphate-bound acetylcholin-
esterase can lose an alkoxy group, in a process called aging. The end product of aging is more stable and cannot be detoxified by pralidoxime (not shown).

muscarinic, nicotinic, and central nervous system (CNS)
effects such as bronchoconstriction, increased bronchial se-
cretions, salivation, lacrimation, sweating, nausea, vomiting,
diarrhea, and miosis (muscarinic signs), as well as twitch-
ing, fasciculations, muscle weakness, cyanosis, and elevated
blood pressure (nicotinic signs). CNS effects can include
anxiety, restlessness, confusion, and headache. Symptoms
usually occur within minutes or hours of exposure and re-
solve within a few days in nonlethal poisonings.
Toxic exposures may occur by inhalation, ingestion, or
dermal contact, depending on the product formulation and
manner of use or misuse. Toxic secondary exposures have
occasionally occurred in people coming into close contact
with the victim of direct exposure; for example, emergency
responders and emergency department staff have suffered
organophosphate toxicity after contactingor simply being
nearcontaminated clothing, skin, secretions, or gastric
contents.
888 Environmental Toxicology

and nonionizing), and occupational exposures to specific fi-
bers, dusts, and chemicals. Carcinogenesis due to the toxic
byproducts of oxygen and other endogenous or unavoidable
causes (such as spontaneous errors in DNA replication and
repair) also accounts for a presumably sizable share of cancers
that arise in humans and all other animals. All aerobic organ-
isms, including bacteria, have developed defenses against oxi-
dative and other damage to DNA, and these defenses work to
counter at least low-level exposures to endogenous and many
exogenous mutagens and carcinogens.
As shown in Figure 52-4, carcinogens vary widely in
their modes of action. Many organic chemical carcinogens
are not genotoxic per se, but only via one or more electro-
philic metabolites that form addition-productsadducts
with one or more bases of DNA. These adducts can cause
mutations, some of which lead ultimately to tumors. Inter-
estingly, some such electrophiles have very short half-lives,
and so are mutagenic only in the organ, such as the liver or
kidney, in which they are formed; others are stable enough to
migrate to other tissues and organs, increasing risks of can-
cers at these distal sites. Carcinogenic metals can be directly
Carcinogen exposure
Excretion
Metabolism
Genes
Genotoxic Non-genotoxic
mechanisms mechanisms
Cell cycle
DNA adducts DNA repair Inflammation
Differentiation
Chromosome breakage, Immunosuppression
fusion, deletion, Apoptosis Reactive oxygen species
mis-segregation,
Receptor activation
non-disjunction
Epigenetic silencing
Genomic Altered signal
damage transduction
Hypermutability
Genomic instability
Loss of proliferation control
Resistance to apoptosis
Cancer
FIGURE 52-4. Overview of genotoxic and nongenotoxic effects of
carcinogens. When chemical carcinogens are internalized by cells, they are
often metabolized, and the resulting metabolic products are either excreted
or retained. Retained carcinogens or their metabolic products can directly or
indirectly affect the regulation and expression of genes involved in cell-cycle
control, DNA repair, cell differentiation, and apoptosis. Some carcinogens act by
genotoxic mechanisms, such as forming DNA adducts or inducing chromosome
breakage, fusion, deletion, mis-segregation, and nondisjunction. Others act by
nongenotoxic mechanisms such as induction of inflammation, immunosuppres-
sion, formation of reactive oxygen species, activation of receptors such as aryl
hydrocarbon receptor (AhR) or estrogen receptor (ER), and epigenetic silencing.
Together, these genotoxic and nongenotoxic mechanisms can alter signal trans-
duction pathways, thus leading to hypermutability, genomic instability, loss of
proliferation control, and resistance to apoptosissome of the characteristic
features of cancer cells.
toxic, or toxic via metabolism such as methylation, and can
alter chromosomal structure via hypermethylation of DNA
and deacetylation of histone. Carcinogenic viruses and the
carcinogenic bacterium, Helicobacter pylori, may act via
many mechanisms, including induction of inflammation, it-
self a risk factor for cancer. Worldwide, chronic infections
contribute to an estimated 15% of all cancers.
Carcinogenesis occurs via progressive stages broadly
characterized as tumor initiation, promotion, and progression
(Fig. 52-5). The sequence involves multiple rounds of sto-
chastic mutations and selection, notably in proto-oncogenes
and tumor suppressor genes. Infrequent mutations in other
genes and cancer pathways are also involved, and determin-
ing which mutations are cancer-drivers and which are
mere passengers is a subject of active research.
The evolution from a normal cell to a clinically apparent
tumor typically occurs over decades, so that cancer risk in-
creases with age for the majority of cancers. Cigarette smok-
ers, for example, develop lung cancer on average 30 years
after first exposures. This explains why people who success-
fully quit smoking (a notoriously difficult task) reduce but do
not eliminate their increased cancer risks relative to lifelong
nonsmokers. Cancer deaths in dogs, cats, and laboratory ro-
dents also occur largely in old ageand occur despite the
animals lack of deliberate exposures to exogenous chemical
carcinogens. Exceptions to long latencies include cancers of
childhood and acute myelogenous leukemias that develop
secondary to treatment of another cancer with alkylating
agents: such leukemias may arise in as little as 25 years
after therapy.
Tobacco
It is difficult to overstate the toxicity of tobacco. Worldwide,
tobacco kills 5 million people annually. Cigarette smoke is
the most significant cause of cancer known: 30% of cancer
deaths in developed countries are caused by cigarettes; and
the burden of deaths due to cigarettes in developing nations
is expected to rise in proportion to increasing prevalence of
cigarette use. Smoking also causes nonmalignant pulmonary
disease (such as COPD) and increases smokers risks of
cardiovascular disease and death such that about half of all
people addicted to tobacco die of tobacco-related diseases.
The carcinogenicity of cigarette smoke is likely due to the
combined actions of at least 60 carcinogens and countless free
radicals. Among the former are two tobacco-specific (that is,
derived from nicotine) nitrosamines, 4-(methylnitrosamino)-
1-(3-pyridyl)-1-butanone (NNK) and N-nitrosonornicotine
(NNN). Other carcinogenic components of cigarette smoke
include polycyclic aromatic hydrocarbons (PAHs), aromatic
amines, benzene, aldehydes and other volatile organic com-
pounds, and various metals. Benzo(a)pyrene (Fig. 52-6) is
among the carcinogenic PAHs in tobacco smoke, and is also
believed to account, in part, for the carcinogenicity of soots
and coal tars. The important carcinogens and other toxins in
tobacco smoke appear to be both in the solid tar phase of
the smoke and in the gases and vapors. Thus, low tar ciga-
rettes are apparently no less potent as carcinogens or causes
of cardiovascular disease than are regular cigarettes.
Smokeless tobacco, which is variously dipped, used
as snuff, or chewed (alone, or with betel quid or other sub-
stances), contains significant concentrations of carcinogenic
nitrosamines (and nicotine), and causes oral cancer as well
 CHAPTER 52 / Environmental Toxicology 889

A Tumor initiation
BP Men+ (e.g. Ni2+)

OH O

OH Benzo[a]pyrene
Benzo[a]pyrene-4,5-epoxide
OH
NER

Decoy
Mutations in cancer-
susceptibility genes
Glutathione
S
Alterations in p53 or RAS OH

B Tumor promotion
Glucuronate
TCDD CYP1A1, O
AhR CYP1B1, OH
O
CYP1A2
Benzo[a]pyrene-7,8-epoxide Conjugated products (noncarcinogenic)
ARNT

AhR ARNT
XRE
O

Extracellular HO
signalling Proliferation Apoptosis Cell cycle
OH

PAI1 GEF TNF Cyclin B2 Benzo[a]pyrene-7,8-diol-

MT-II COT HSP40 NEK2
HEF1 KRAS2
FIGURE 52-5. Tumor initiation and tumor promotion. Genotoxic carcin-
ogens can induce damage in tumor suppressor genes or oncogenes in various
ways, some of which contribute to the transformation of normal cells into tumor
cells: this is known as tumor initiation. Some chemical carcinogens can also pro-
mote the outgrowth of transformed cell clones: this is termed tumor promotion.
A. Tumor initiation typically occurs via mutations. For example, the benzo(a)-
pyrene (BP)DNA adduct can cause mutations in cancer-susceptibility genes
such as p53 or RAS. The potency of such adducts can be increased due
to inhibition of nucleotide excision repair (NER) by metals such as nickel
(Ni2) or as a result of NER factor immobilization at repair-resistant DNA-
adduct sites, also known as decoy adducts. B. Chemical compounds such
as 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) can serve as tumor promot-
ers through aryl hydrocarbon receptor (AhR)-mediated signal transduction.
Binding of TCDD to AhR leads to activation and translocation of the complex
into the nucleus. After heterodimerization with the AhR nuclear transloca-
tor (ARNT), the complex binds to xenobiotic-responsive elements (XREs) and
induces the expression of a variety of different genes involved in carcino-
gen metabolism, including cytochrome P450 (CYP) isoforms 1A1, 1B1, and
1A2. It also changes the expression pattern of factors involved in cellular
growth and differentiation, such as plasminogen-activator inhibitor type 1
(PAI1), metallothionein II (MT-II), human enhancer of filamentation 1 (HEF1),
guanine nucleotide exchange factor (GEF), COT (a serine/threonine protein
kinase), and K-RAS (KRAS2). Pro-apoptosis factors such as tumor necrosis
factor (TNF) and heat shock protein 40 (HSP40) are down-regulated, and cell-
cycle genes can either be up-regulated (such as cyclin B2) or down-regulated
(such as NEK2, another serine/threonine protein kinase).
9,10-epoxide
(carcinogen)
FIGURE 52-6. Metabolism of benzo[a]pyrene. Benzo[a]pyrene is me-
tabolized into several products (not all shown). Epoxidation at carbons 4 and 5,
followed by conjugation with glutathione or glucuronate, leads to nontoxic deriva-
tives that are readily excreted. In contrast, oxidation at the bay region generates
the proximate carcinogen benzo[a]pyrene-7,8-diol-9,10-epoxide, which goes on
to form a repair-resistant adduct with guanine. Subsequent DNA replication, in
the presence of this bulky polycyclic aromatic adduct, leads to G to T base pair
transversions, including in the cancer genes p53 and RAS.
as gum disease. The fraction of oral cancer that is attribut-
able to smokeless tobacco in any given population depends on
the prevalence of the habit, the potency of the local tobacco
products (such as tobacco in betel quid and tobacco-areca nut
mixtures), and competing causes of oral cancer. Thus, in the
United States, smokeless tobacco accounts for 7% of oral can-
cer cases, while in India, more than 50% of oral cancers, in
both men and women, are attributable to smokeless tobacco.
Ethanol
Excessive consumption of ethyl alcohol is a common and
complex problem. Binge drinking occurs in a sizable minor-
ity of adolescents and young adults, at least in some cultures.
In adults with coronary artery disease, binge drinking can
cause myocardial ischemia and angina. Acutely, alcohol is a
sedative and causes psychomotor retardation. A sizable frac-
tion of morbidity and mortality from alcohol intoxication re-
sults from injuries suffered (and inflicted) while impaired.
890 Environmental Toxicology
Chronic excess drinking results in fatty liver disease in
almost 100% of such consumers. Some 30% of those af-
flicted go on to develop fibrosis; 1020% progress to hepatic
cirrhosis; and a significant fraction of those with cirrhosis
develop and die of liver cancer (hepatocellular carcinoma).
As expected, risk of liver disease increases with increasing
dose-rates of alcohol: on average, chronic drinkers increase
their risk of hepatocellular carcinoma by two-fold; this risk
increases to six-fold for people drinking five drinks or more
per day.
Ethanol metabolism produces several reactive species, in-
cluding acetaldehyde, hydroxyl radicals, superoxide anions,
and hydrogen peroxide. Acetaldehyde in particular is geno-
toxic and believed to be the proximate carcinogen in some
cases of alcohol-associated cancer. Chronic excess drinking
up-regulates the production of CYP2E1, which generates
not only acetaldehyde from ethanol but also transforms
various nitrosamines and polycyclic aromatic hydrocarbons
into their proximate genotoxic metabolites. Although ac-
etaldehyde can be further metabolized to nontoxic acetate,
the requisite enzymes, aldehyde dehydrogenases, may be
inherently impaired or inactive in certain groups of people
(notably East Asians), leading to substantially increased can-
cer risks from alcoholic beverages.
Ethanol is a teratogen as well; it causes fetal alcohol
syndrome (FAS), which is characterized by retardation of
craniofacial growth, both pre- and postnatally, and neurocog-
nitive impairment. General physical growth is also retarded
in children with FAS, affecting boys more severely than girls.
Children with FAS present with a range of disabilities, pre-
sumably due to both the amount and the timing of maternal
alcohol ingestion. With regard to the latter, women may drink
immoderately in the early stages of pregnancies of which they
are as yet unaware. Thus, the simplest prevention strategy
(elimination of exposure) may not always be practical. FAS
can be generated in laboratory rats and mice, and mechanis-
tic studies using animal models have led to several working
hypotheses. The facial abnormalities of FAS are believed to
be due to apoptosis of neural crest cells during gastrulation or
neurulation. Embryonic exposure to alcohol can result in re-
duced production of retinoic acid, and retinoic acid is essen-
tial for normal morphogenesis. Other postulated mechanisms
involve ethanol-induced free-radical formation, altered gene
expression, disruption of cell membrane lipid bilayers, and
interference with the activity of growth factors.
Excess drinking also increases the risks of pancreatitis,
hemorrhagic stroke, and heart failure. The pathophysiology of
alcoholic cardiomyopathy is complex and appears to involve
cell death and pathologic changes in myocyte function.
Light-to-moderate ingestion of alcohol, on the other hand,
appears to protect against cardiovascular disease. Red wine
is believed by some to be particularly protective, perhaps be-
cause it contains not only ethanol but also resveratrol and other
polyphenols; various cardioprotective mechanisms have been
hypothesized, including improvements in endothelial function
and effects on hemostasis. However, to the extent that evidence
of the benefits of moderate drinking derives from observa-
tional rather than experimental studies, one must be mindful of
the possibility that moderate drinkers are, by genetics or other
habits or factors, less susceptible to cardiovascular disease in
general, so that the association with moderate drinking and
health protection is confounded rather than causal. If so, then
encouraging nondrinkers to start may do them no good.
Aflatoxins
In 1960, a mysterious disease killed more than 100,000 farmed
turkeys in England; other birds and farm animals also suc-
cumbed. The deaths were linked to specific batches of peanut
meal, and, eventually, to secondary metabolites of the mold
Aspergillus flavus: these compounds are termed aflatoxins.
The most important form, aflatoxin B1 (AFB1, where B de-
notes blue fluorescence under ultraviolet light), causes both
acute liver toxicity and liver cancer (hepatocellular carcinoma)
in myriad mammalian and other species. The proximate me-
tabolite is an unstable, exocyclic epoxide that reacts with
DNA, forming a potent mutagenic adduct on the N-7 posi-
tion of guanine. Minuscule concentrations of AFB1 in the feed
of laboratory rodents induce liver tumors. Co-administration
of drugs that induce glutathione S-transferases, such as the
antihelminthic oltipraz [5-(2-pyrazinyl)-4-methyl-1,2-dithiol-
3-thione], renders rodents resistant to AFB1-tumorigenesis.
Trials to determine whether such chemoprevention works in
humans are ongoing.
As suggested above, various aflatoxin metabolites are
nontoxic, including the glutathione conjugate and a hydro-
lysis product that binds to lysine residues on proteins such
as serum albumin. Aflatoxin adducts and other biomarkers
in blood and urine reflect a persons exposures to dietary
aflatoxins over the prior 23 months and, in tropical regions
where aflatoxin contamination is endemic and rural diets
contain few foods, over many years. Epidemiological stud-
ies using these markers in populations in Africa and China
have demonstrated that aflatoxin causes hepatocellular car-
cinoma, both directly and acting synergistically with liver
damage due to hepatitis B virus (HBV). Both vaccination
against HBV and reduction in aflatoxin exposure reduce the
risk of liver cancer, which worldwide accounts for approxi-
mately 500,000 deaths annually.
Arsenic
In several regions of the world, such as parts of Bangladesh,
Taiwan, West Bengal, Chile, Argentina, and the United States,
the groundwater contains naturally high concentrations of
inorganic arsenic (up to thousands of micrograms per liter,
g/L). Some of this water is tapped by underground wells
and, inadequately treated, serves as drinking water. Safer
water supplies may sometimes be found and utilized, but
various constraints have resulted in hundreds of thousands of
people developing chronic arsenic poisoningarsenicosis
and millions being at risk of arsenic-induced cancers.
Arsenicosis is characterized by skin lesions, peripheral
vascular disease, cerebrovascular disease, cardiovascular
disease, and other chronic conditions. Arsenic-induced skin
lesions and peripheral vascular diseases are well recognized
and include abnormal pigmentation, keratoses, blackfoot
disease, and Raynauds syndrome of fingers and toes. Both
hyper- and hypopigmentation may result, typically on the
soles of the feet, the palms, and the torso. Hyperkeratosis
also occurs on the soles and palms. Epidemiologic study
suggests that these skin lesions may develop at lower ar-
senic concentrations (tens of g/L) than do other arsenic-
induced toxicities. Blackfoot disease used to be endemic
in southwestern Taiwan, where arsenic occurred at high
concentration in artesian wells, and reached its highest inci-
dence in the late 1950s before the introduction of tap water
from safer sources. The disease has a typical progression:

the first signs are preclinical peripheral vascular disease,
followed by progressive discoloration of the skin from the
toes toward the ankles. Feelings of numbness or coldness
develop in the legs, followed by intermittent claudication,
and eventually gangrene, ulceration, and surgical or spon-
taneous amputation. It is not clear why blackfoot disease is
not seen in other regions with high, chronic oral exposures
to arsenic.
Epidemiologic studies have indicated associations be-
tween exposure to high concentrations of arsenic (hundreds
of g/L) and various cardiovascular diseases such as hy-
pertension and ischemic heart disease, and between urinary
levels of arsenic and levels of circulating markers of inflam-
mation and endothelial damage, such as soluble intercel-
lular adhesion molecule-1 (sICAM-1) and soluble vascular
adhesion molecule-1 (sVCAM-1), both of which correlate
with cardiovascular disease risk. In addition, recent studies
of ApoE-knockout mice (which are vulnerable to develop-
ment of atherosclerosis) exposed to inorganic arsenic sup-
port an association between this environmental contaminant
and cardiovascular disease. Mechanisms remain to be elu-
cidated, however, as does the degree of cardiovascular risk
posed by drinking water containing lesser concentrations
of arsenic.
Inorganic arsenic is a recognized human carcinogen that
is causally associated with cancers of the skin, bladder, and
lung. Associations with other cancers (e.g., liver, prostate) are
less certain. The links to cancer were established in commu-
nities with extensive exposure to arsenic in drinking water,
particularly in Taiwan and Chile, with clear doseresponse
patterns. Skin cancers may, but do not always, arise at sites of
nonmalignant keratotic lesions and tend to be nonmelanomas.
Interestingly, no adequate animal models have been identified
for arsenic-induced cancers. However, experimental models
have been used (and human cohorts have been observed) to
shed light on the potential carcinogenic mechanisms: arsenic
has indirect genotoxicity, effects on cell-cycle control, and
the ability to cause oxidative damage, and it interferes with
DNA repair or methylation. Other factors, such as nutritional
status, genetic polymorphisms, and co-exposure to other tox-
ins, may also influence the risk of arsenic-induced cancer.
Workplace Exposures
Various occupational exposures increase workers risks of
developing cancer and other diseases. As a general matter,
exposure levels in industry are much higher than those in
the general environment. To the extent that important and
harmful occupational exposures have been characterized and
minimized, the toll of occupational carcinogenesis has de-
creased. Needless to say, enforcement or even presence of
occupational exposure limits is not guaranteed, and groups
of workers in certain industries or nations continue to be at
excess risk of developing one or more forms of cancer.
An eighteenth-century English surgeon, Percivall Pott,
was among the first to recognize occupational carcinogen-
esis, deducing that lodgment of soot in the rugae of the
scrotum caused scrotal cancer in young men employed as
chimney sweeps (who typically worked naked, to avoid soil-
ing their clothes). In the nineteenth and twentieth centuries,
industrial workers overexposed (1) to benzene were found to
develop bone marrow disease, including aplastic anemia and
acute myelogenous leukemia; (2) to 2-naphthylamine in dye-
CHAPTER 52 / Environmental Toxicology 891
making were at high risk for bladder cancer; (3) to various
metals were susceptible to lung cancer; and (4) to asbestos
developed lung cancer and mesothelioma. Other occupa-
tional carcinogens (including specific chemicals, industries,
and industrial processes) were also identified.
Asbestos, Silica, Dusts, and Metals
Numerous cases of occupational lung injury are (or were)
caused by inhalation of fibers or dusts, such as asbestos,
crystalline silica, talc, and coal dust, and various metals.
Asbestos is carcinogenic to the lung and mesothelium after
long-term exposure to respirable fibers of specific dimen-
sions. The formerly widespread use of asbestos-containing
products in shipbuilding, construction, textiles, and other
industries caused perhaps 200,000 cancer deaths in industri-
alized countries; because of latency, such deaths continue to
occur. Current occupational exposures to asbestos are prob-
lematic in parts of India and elsewhere in Asia. Asbestos and
cigarette smoking act synergistically, such that the risk of
lung cancer (although, interestingly, not of mesothelioma,
which is not caused by smoking) due to co-exposure is much
larger than the risk from either factor alone. The toxic and
carcinogenic potency of asbestos fibers and fiber-types var-
ies with their dimensions, surface chemistry, and biopersis-
tence. The mechanisms by which asbestos fibers damage the
lung or pleura involve production of reactive oxygen and
nitrogen species by macrophages attempting to destroy the
fibers. Asbestos also causes severe nonmalignant respiratory
disease, asbestosis, characterized by fibrotic lesions in the
lung parenchyma that limit gas exchange.
Black lung, or coal workers pneumoconiosis (CWP),
is another nonmalignant (but potentially fatal) fibrotic lung
disease induced by excessive exposure to coal dust. The
simple form of CWP may not markedly limit respiration and
may affect only small areas of the lung, whereas progressive
CWP can develop and worsen even in the absence of contin-
ued exposure, leading to severe emphysema. Interestingly,
coal dust does not appear to increase the risk of lung cancer.
Although worker exposures to coal dust have been limited
by U.S. regulations in recent decades and underground min-
ing is less common than in the past, thousands of coal miners
in other countries, especially China, are at risk for CWP and
related illnesses.
Occupational exposures to metals such as arsenic, cad-
mium, chromium (VI), and nickel increase workers risks
of cancers of the lung and, in some cases, nasal cavity and
paranasal sinuses. A large number of mechanisms have been
identified, both genetic and epigenetic.
Overexposures to certain metals can also cause nonma-
lignant disease. Chronic exposure to cadmium, for example,
causes kidney disease. Abnormal renal function, characterized
by proteinuria and decreased glomerular filtration rate (GFR),
was first reported in cadmium workers in 1950 and has been
confirmed in numerous investigations. The proteinuria con-
sists of low-molecular-weight proteins such as 2-microglob-
ulin, retinol binding protein, lysozyme, and immunoglobu-
lin light chains; these proteins are normally filtered in the
glomerulus and reabsorbed in the proximal tubule. Cadmi-
um-exposed workers also have a higher rate of kidney stone
formation, perhaps due to disruption of calcium metabolism
as a consequence of renal damage. Renal tubular dysfunc-
tion appears only after a threshold concentration of cadmium
is reached in the renal cortex. The threshold varies among
892 Environmental Toxicology
individuals but has been estimated to be approximately 200
g/g wet weight. Several studies of the prevalence of protei-
nuria in worker populations suggest that inhalation exposure
in excess of about 0.03 mg/m3 for 30 years is associated with
increased risk of tubular dysfunction. Unfortunately, removal
from exposure does not necessarily halt disease in workers
with cadmium-induced kidney damage, and progressive de-
creases in GFR and end-stage renal disease may occur. Pro-
gression of disease may depend on both the body burden of
cadmium and the severity of proteinuria at last exposure. Un-
less renal damage is significant, urinary cadmium concentra-
tion reflects the body burden of the metal.
Although renal damage is clearly due to accumulation
of cadmium in the kidney, the molecular mechanism of this
damage is unclear. Metallothionein may be involved; this cad-
mium-binding protein, which is synthesized in the liver and
kidney, appears both to facilitate transport of cadmium to the
kidney and to promote retention of cadmium in the kidney.
Chlorinated Hydrocarbons
Low-molecular-weight chlorinated hydrocarbons are widely
used in industrial and other settings. Vinyl chloride, for ex-
ample, is a gas used to make the plastic polyvinylchloride
(PVC). Vinyl chloride gas is neither irritating nor acutely
toxic (except at extremely high, narcotizing concentrations),
and PVC workers were initially exposed to quite high con-
centrations. In the 1970s, exposures to vinyl chloride were
found to cause angiosarcoma, a rare form of liver cancer, in
both laboratory rats and workers; strict workplace exposure
limits have since been imposed in most settings. Carcino-
genesis is due to the epoxide metabolite of vinyl chloride.
Some 98% of the DNA adducts formed from vinyl chloride
epoxide are benign, but the other 2% are highly mutagenic
etheno-adducts with guanine and cytosine. Interestingly,
these adducts are the same as those formed from everyday
oxidative stress and lipid peroxidation. These etheno-adducts
are normally eliminated by base excision repair, but at suf-
ficiently high rates of DNA damage, repair fails to be 100%
effective. Thus, high-level exposures to vinyl chloride and
similar genotoxins are demonstrably carcinogenic, while
low-level exposures may not be. For example, laboratory rats
exposed to low doses of vinyl chloride develop precancerous
changes (altered hepatic foci) at rates indistinguishable from
those seen in unexposed laboratory controls.
Trichloroethylene (TCE) and tetrachloroethylene (per-
chloroethylene) are solvents used for degreasing and dry
cleaning. All of us are exposed to trace concentrations of
TCE and perchloroethylene in ambient air. Exposures to high
concentrations of TCE cause kidney tumors, but moderate
and low-level exposures apparently do not. This is because
at low doses, trichloroethylene is converted to nontoxic me-
tabolites that are readily eliminated, whereas at high doses,
the detoxification pathway becomes overwhelmed and a sec-
ond pathway becomes operative. The latter pathway forms
a nephrotoxic metabolite, S-(1,2-dichlorovinyl)-L-cysteine
(DCVC), and the subsequent kidney damage appears to be
a necessary precursor to TCE-induced kidney tumors. Non-
toxic exposures to trichloroethylene up-regulate genes as-
sociated with stress, DCVC metabolism, cell proliferation
and repair, and apoptosis, affording protection against renal
tubular cell damage. Perchloroethylene does not appear to
cause tumors in people, probably because virtually all of it is
eliminated without metabolic activation.
Air Pollution
Toxicity due to ambient air pollution depends on both the
types and concentrations of pollutants. As with other envi-
ronmental exposures, air pollution takes much of its toll in
regions lacking adequate environmental protection or re-
sources. Combustion of fuels is an important source of air
pollution; in most cities and suburbs, exhaust from gasoline-
and diesel-powered vehicles is the largest source of pollut-
ants. New and recently manufactured motor vehicles burn
much more cleanly than vehicles made prior to the 1970s,
but the number of vehicles in use continues to grow, and tail-
pipe emissions are, of course, close to ground level, limiting
dilution into cleaner air.
Combustion of low-quality fuels indoors is not uncom-
mon in some settings. For example, soft coal, charcoal,
or dried cow dung are burned for cooking and heating in
poorly ventilated homes in China, Nepal, Mexico, and else-
where. Measurements indicate indoor pollutant levels that
exceed outdoor concentrations by two orders of magnitude.
As a result of these residential exposures, women and chil-
dren in particular are at risk of developing chronic bron-
chitis, dyspnea, and, eventually, interstitial lung disease.
Moreover, the carcinogenic potency of soft coal smoke
is 1,000 times greater than cigarette smoke (in a mouse
skin-tumor assay). Women in China who use soft coal in-
doors have extraordinarily high body burdens of benzo(a)-
pyrene-adducted guanine, and their rates of death due to
lung cancer are eight times higher than the national average
for women.
Combustion generates thousands of chemicals, some of
which depend on the material burned, and others of which
are inherent to combustion. These include carbon monox-
ide, organic irritants such as formaldehyde and acrolein, ni-
trogen oxides, sulfur dioxide, ammonia, hydrogen cyanide,
and hydrogen fluoride, among other potentially toxic sub-
stances. Semi-volatile and nonvolatile chemicals also form
in abundance, and adsorb to the particle phase of smoke.
Metals present in the combusted material are, of course, not
destroyed by combustion, and so may add to the acute and
chronic toxicity of inhaled smoke.
Under certain meteorological and chemical conditions,
polluted air may become unusually acidic, and inhalation of
acidic aerosols can induce bronchoconstriction and reduce
the efficacy of mucociliary clearance. The action of ultra-
violet radiation (sunlight) on reactive hydrocarbons and ni-
trogen oxides results in the formation of smog, containing
significant concentrations of oxidizing chemicals such as
ozone, peroxides, and peroxyacetyl nitrate. Acute and sub-
chronic exposures to toxic levels of such oxidants can cause
inflammation and irritation, sloughing of epithelium, and
loss of cilia. Chronic overexposures can result in fibrosis or
chronic obstructive pulmonary disease, perhaps via altered
metabolism of collagen and elastin.
The pulmonary effects of air pollutants depend in part on
their water solubility. Sulfur dioxide, for example, dissolves
readily in the mucous membranes of the upper airways and
so does not typically reach the lung. Dissolution of the gas is
not instantaneous, however, so that exercising or otherwise
hyperventilating permits some of the inhaled sulfur dioxide
to reach the lower respiratory tract where, at sufficient con-
centrations, it can induce bronchoconstriction. Asthmatics
are particularly sensitive to this effect.

 CONCLUSION AND FUTURE DIRECTIONS
Much of the treatment for toxic exposures focuses on the
acutely poisoned patient. Much of the morbidity associated
with environmental factors, however, is caused by chronic
exposures and may be clinically apparent only years or de-
cades after the initial insult. In fact, there is generally no spe-
cific treatment for injury caused by chronic toxic exposures,
and treatment modalities for cancers are independent of the
underlying causes.
In theory, cancers and other chronic diseases caused
by habits such as tobacco smoking and excessive drink-
ing are entirely preventable, and although progress has
been made in this regard, more remains to be done, and
complete eradication of these threats seems unrealistic.
Occupational exposures are well controlled in most of the
developed world but remain problematic in industrializ-
ing nations. Epidemiologic evidence indicates that some
specific foodssuch as Chinese-style salted fish (contain-
ing high concentrations of the carcinogen dimethylnitro-
samine) and foods contaminated with aflatoxinsincrease
peoples risk of cancer, and that consumption of fruits and
vegetables in general decreases risks of cancer, but the
specific dietary components or characteristics that modify
risk remain areas of active research. Obesity (and perhaps
sedentary lifestyle) is an increasingly important risk factor
for cancer, presumably in combination with environmental
exposures or other factors.
Environmental exposures typically involve complex mix-
tures of only partially characterized chemicals and char-
acteristics. Traditional toxicological testing of individual
chemicals or simple mixtures may yield results of incom-
plete or uncertain relevance. Additional information may
be generated via microarray technologies and other tools of
genomics, proteomics, and metabolomics applied to toxico-
logical inquiry. Our microbiomesthat is, the microor-
ganisms within us that, in toto, outnumber our own cells ten
to onepresumably affect our responses to environmental
exposures in many ways yet to be elucidated. More broadly,
basic, mechanistic, and applied research is expected to con-
tinue to unravel the interconnections between and among ge-
netic, environmental, and random factors involved in disease
causation, with the hope that safer environments will lead to
healthier lives.
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potential utility of antibody therapy.)
Weaver LK, Hopkins RO, Chan KJ, et al. Hyperbaric oxygen for acute car-
bon monoxide poisoning. N Engl J Med 2002;347:10571067. (Although
hyperbaric oxygen had been postulated to help treat carbon monoxide
poisoning and has been used since 1960, this study established its clinical
efficacy in reducing cognitive deficits at 6 weeks and 12 months.)
Wogan GN, Hecht SS, Felton JS, et al. Environmental and chemical car-
cinogenesis. Semin Cancer Biol 2004;14:473486. (Review by major re-
searchers in the field.)
IX

Frontiers in Pharmacology

Protein Therapeutics
Quentin J. Baca, Benjamin Leader, and David E. Golan
INTRODUCTION & CASE . . . . . . . . . . . . . . . . . . . . . . . . 895-896
USES OF PROTEINS IN MEDICINE . . . . . . . . . . . . . . . . . . . . 897
Group I: Enzymes and Regulatory Proteins . . . . . . . . . . . . 897
Group II: Targeted Proteins . . . . . . . . . . . . . . . . . . . . . . . . 904
Group III: Protein Vaccines . . . . . . . . . . . . . . . . . . . . . . . . 911
Group IV: Protein Diagnostics . . . . . . . . . . . . . . . . . . . . . . 912
 INTRODUCTION
Proteins have the most dynamic and diverse role of any mac-
romolecule in the body, catalyzing biochemical reactions,
constituting receptors and channels in membranes, providing
intracellular and extracellular scaffolding support, and trans-
porting molecules within a cell or from one organ to another.
It is currently estimated that there are approximately 25,000
protein-coding genes in the human genome, and with alterna-
tive splicing of genes and post-translational modification of
proteins (for example, by cleavage, phosphorylation, acyla-
tion and glycosylation), the number of functionally distinct
proteins is likely much greater. Viewed from the perspective
of disease mechanisms, these estimates pose an immense
challenge to modern medicine, as disease may result when
any one of these proteins contains mutations or other abnor-
malities, or is present in an abnormally high or low concentra-
tion. Viewed from the perspective of therapeutics, however,
these estimates represent a tremendous opportunity in terms
of harnessing protein therapeutics to alleviate disease. At pres-
ent, more than 145 different proteins or peptides are approved
for clinical use by the U.S. Food and Drug Administration
(FDA), and many more are in development.
Protein therapeutics have several advantages over small-
molecule drugs. First, proteins often serve a highly specific
and complex set of functions that cannot be mimicked by
simple chemical compounds. Second, because the action of
proteins is highly specific, there is often less potential for
protein therapeutics to interfere with normal biological pro-
cesses and cause adverse effects. Third, because the body
naturally produces many of the proteins that are used as
therapeutics, these agents are often well tolerated and are
less likely to elicit immune responses. Fourth, for diseases in
which a gene is mutated or deleted, protein therapeutics can
provide effective replacement treatment without the need
for gene therapy, which is not currently available for most
genetic disorders. Fifth, the clinical development and FDA
53
CHALLENGES FOR PROTEIN THERAPEUTICS . . . . . . . . . . . 912
CONCLUSION AND FUTURE DIRECTIONS . . . . . . . . . . . . . . 915
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 916
approval time of protein therapeutics may be faster than that
of small-molecule drugs. A study published in 2003 showed
that the average clinical development and approval time was
more than 1 year faster for 33 protein therapeutics approved
between 1980 and 2002 than for 294 small-molecule drugs
approved during the same time period. Last, because pro-
teins are unique in form and function, companies are able to
obtain far-reaching patent protection for protein therapeu-
tics. The last two advantages make proteins attractive from a
financial perspective compared with small-molecule drugs.
A relatively small number of protein therapeutics are pu-
rified from their native source, such as pancreatic enzymes
from hog and pig pancreas and -1-proteinase inhibitor
from pooled human plasma. Instead, most therapeutic pro-
teins are now produced by recombinant DNA technology
and purified from a wide range of organisms. Production
systems for recombinant proteins include bacteria, yeast,
insect cells, mammalian cells, and transgenic animals and
plants. The system of choice can be dictated by the cost of
production or the modifications of the protein (for example,
glycosylation, phosphorylation or proteolytic cleavage) that
are required for biological activity. For example, bacteria do
not perform glycosylation reactions, and each of the other
biological systems listed above produces a different type or
pattern of glycosylation. Protein glycosylation patterns can
have a dramatic effect on the activity, half-life and immu-
nogenicity of the recombinant protein in the body. For ex-
ample, the half-life of native erythropoietin, a growth factor
important in erythrocyte production, can be lengthened by
increasing the glycosylation of the protein. Darbepoetin-
is an erythropoietin analogue that is engineered to contain
two additional amino acids that are substrates for N-linked
glycosylation reactions. When expressed in Chinese hamster
ovary cells, the analogue is synthesized with five rather than
three N-linked carbohydrate chains; this modification causes
the half-life of darbepoetin to be three times longer than that
of erythropoietin.
895
912 Frontiers in Pharmacology
provide immunity in an individual without exposing the in-
dividual to the risks of infection or toxic reaction.
Proteins in Group IIIa are used to generate protection
against infectious diseases or toxins. One successful ex-
ample is the hepatitis B vaccine. This vaccine was cre-
ated by producing recombinant hepatitis B surface antigen
(HBsAg), a noninfectious protein of the hepatitis B virus.
When immunocompetent humans are challenged and rechal-
lenged with this protein, significant immunity results in the
large majority of individuals. Similarly, the noninfectious
lipoprotein on the outer surface of Borrelia burgdorferi has
been engineered into a vaccine for Lyme disease (OspA).
A recently approved vaccine against human papillomavirus
(HPV) combines the major capsid proteins from four HPV
strains that commonly cause genital warts (strains 6 and 11)
and cervical cancer (strains 16 and 18).
In addition to generating protection against foreign invad-
ers, recombinant proteins can induce protection against an
overactive immune system that attacks its own body or self.
One theory is that administration of large amounts of this self-
protein causes the bodys immune system to develop toler-
ance to that protein by eliminating or deactivating cells that
react against the self-protein. Proteins in Group IIIb are used
to treat patients with disorders that arise from this type of au-
toimmune phenomenon. Immunological acceptance of a fetus
during pregnancy represents a special situation with respect to
vaccine use. Occasionally, a pregnant woman can reject a fetus
after she has been immunized against certain antigens carried
by a fetus from a previous pregnancy. Administration of an
anti-Rhesus D antigen Ig prevents the sensitization of an
Rh-negative mother at the time of delivery of an Rh-positive
neonate. Because the woman fails to develop antibodies di-
rected against the fetal Rh antigens, immune reactions and
pregnancy loss do not occur in subsequent pregnancies, even
when the new fetus carries the Rh antigens.
Proteins in Group IIIc could be used as therapeutic antican-
cer vaccines. Although there are currently no FDA-approved
recombinant anticancer vaccines, there are promising clinical
trials that use patient-specific cancer vaccines. For example, a
vaccine for B-cell non-Hodgkins lymphoma uses transgenic
tobacco plants (Nicotiana benthamiana). Each patient with
this type of lymphoma has a malignant proliferation of an
antibody-producing B cell that displays a unique antibody on
its surface. By subcloning the idiotype region of this tumor-
specific antibody and expressing the region recombinantly in
tobacco plants, a tumor-specific antigen is produced that can
be used to vaccinate a patient. This process requires only 68
weeks from biopsy of the lymphoma to a ready-to-use, pa-
tient-specific vaccine. As the genomes of infectious organisms
and the nature of autoimmune diseases and cancer are more
fully elucidated, more recombinant proteins will undoubtedly
be developed for use as vaccines.
Group IV: Protein Diagnostics
Proteins in Group IV are not used to treat disease, but puri-
fied and recombinant proteins used for medical diagnostics
(both in vivo and in vitro) are mentioned here because they
are invaluable in the decision-making process that precedes
the treatment and management of many diseases. Table 53-7
provides selected examples.
A classic example of an in vivo diagnostic is the purified
protein derivative (PPD) test, which determines whether
an individual has been exposed to antigens from Mycobac-
terium tuberculosis. In this example, a noninfectious protein
component of the organism is injected under the skin of an
immunocompetent individual. An active immune reaction
is interpreted as evidence that the patient has been previ-
ously infected by M. tuberculosis or exposed to the antigens
of this organism.
Several stimulatory protein hormones are used to diagnose
endocrine disorders. Growth hormone releasing hormone
(GHRH) stimulates somatotroph cells of the anterior pitu-
itary gland to secrete growth hormone. Used as a diagnos-
tic, GHRH can help to determine whether pituitary growth
hormone secretion is defective in patients with clinical signs
of growth hormone deficiency. Similarly, the recombinant
human protein secretin is used to stimulate pancreatic secre-
tions and gastrin release, and thereby aid in the diagnosis
of pancreatic exocrine dysfunction or gastrinoma. In pa-
tients with a history of thyroid cancer, recombinant thyroid-
stimulating hormone (TSH) is an important component of
the surveillance methods used to detect residual thyroid can-
cer cells. Before the advent of recombinant TSH, patients
with a history of thyroid cancer were required to stop taking
replacement thyroid hormone in order to develop a hypo-
thyroid state to which the anterior pituitary would respond
by releasing endogenous TSH. TSH-stimulated cancer cells
could then be detected by radioactive iodine uptake. Unfor-
tunately, this method required patients to experience the ad-
verse consequences of hypothyroidism. Use of recombinant
TSH instead of endogenous TSH not only allowed patients
to remain on replacement thyroid hormone but also resulted
in the improved detection of residual thyroid cancer cells.
Imaging agents are a broad group of protein diagnostics that
can be used to help identify the presence or localization of a
pathologic condition. For example, apcitide is a technetium-
labeled synthetic peptide that binds glycoprotein IIb/IIIa recep-
tors on activated platelets and is used to image acute venous
thrombosis. Capromab pendetide is an indium-111-labelled
anti-PSA (prostate-specific antigen) antibody that can be used
to detect prostate cancer. Protein-based imaging agents are
often used to detect otherwise hidden disease so it can be treated
early, when treatment is most likely to succeed. Imaging agents
are currently used to detect cancer, image myocardial injury, or
identify sites of occult infection; these agents are presented in
more detail in Table 53-7.
There are numerous in vitro protein diagnostics, and two
are presented here as examples of a much larger class. Natu-
ral and recombinant HIV antigens are essential components
of common screening (enzyme immunoassay) and confir-
matory (western blot) tests for HIV infection. In these tests,
the antigens serve as bait for specific antibodies to HIV
gag, pol, and env gene products that have been elicited in
the course of infection. Hepatitis C infection is diagnosed
by using recombinant hepatitis C antigens to detect antibod-
ies directed against this virus in the serum of potentially
infected patients.
 CHALLENGES FOR PROTEIN
THERAPEUTICS
There are now many examples in which proteins have been
used successfully in therapy. Nonetheless, potential protein
therapies that have failed far outnumber the successes so far,
 CHAPTER 53 / Protein Therapeutics 915

must be synthesized in a genetically engineered cell type is not a clear regulatory pathway in the United States that
for large-scale production. The host system must produce addresses the development of generic versions of protein
not only biologically active protein but also a sufficient therapeutics (so-called biosimilars). Due to the complexity
quantity of this protein to meet clinical demand. Also, the of protein manufacture and the costs and risks associated
system must allow purification and storage of the protein in with development and testing, relatively small changes in
a therapeutically active form for extended periods of time. the regulatory landscape for protein therapeutics may have
The proteins stability, folding, and tendency to aggregate strong impacts on the investment in and development of pro-
may be different in large-scale production and storage sys- tein therapeutics.
tems than in those used to produce the protein for animal
testing and clinical trials. Some have proposed engineering
host systems that co-express a chaperone or foldase with the  CONCLUSION AND FUTURE DIRECTIONS
therapeutic protein of interest, but these approaches have
Medicine is entering a new era in which approaches to
had limited success.
manage disease are being used at the level of the genetic
Potential solutions could include the development of
and protein information that underlies all biology, and
systems in which entire cascades of genes involved in
protein therapeutics are playing an increasingly impor-
protein folding are induced together with the therapeutic
tant role. Already, recombinant human proteins make up
protein; the impetus for this work is the observation that
the majority of FDA-approved biotechnology medicines,
plasma cells, which are natural protein production facili-
which include monoclonal antibodies, natural interferons,
ties, use such gene cascades to produce large quantities
vaccines, hormones, modified natural enzymes, and vari-
of monoclonal antibody. Although bacteria and yeast are
ous cell therapies. The future potential for such therapies
generally considered easy to culture, certain mammalian
is huge, given the thousands of proteins produced by the
cell types can be more difficult and more costly to culture.
human body and the many thousands of proteins produced
Other methods of productionsuch as genetically engi-
by other organisms.
neered animals and plantscould provide a production
Furthermore, recombinant proteins not only provide al-
advantage. Transgenic cows, goats, and sheep have been
ternative (or the only) treatments for particular diseases,
engineered to secrete protein in their milk, and transgenic
but can also be used in combination with small-molecule
chickens that lay eggs filled with recombinant protein are
drugs to provide additive or synergistic benefit. Treatment
anticipated in the future. Transgenic plants can inexpen-
of EGFR-positive colon cancer is illustrative of this point:
sively produce vast quantities of protein without waste or
combination therapy with the small-molecule drug iri-
bioreactors, and potatoes can be engineered to express re-
notecan, which prevents DNA repair by inhibiting DNA
combinant proteins and thereby make edible vaccines. Fi-
topoisomerase, and the recombinant monoclonal antibody
nally, by using fluid-shaking bioreactors, microliter-sized
cetuximab, which binds to and inhibits the extracellular
culture systems might be able to predict the success of
domain of the EGFR, results in increased survival in pa-
large-scale culture systems and thereby provide substantial
tients with colorectal cancer. The therapeutic synergy be-
cost savings by focusing investment on systems that are
tween irinotecan and cetuximab may be due to the fact
more likely to succeed.
that both drugs inhibit the same EGFR signaling pathway,
A fourth important challenge is the costs involved in
with one drug (cetuximab) inhibiting the initiation of the
developing protein therapies. For example, switching to
pathway and the other drug (irinotecan) inhibiting a target
recombinant methodology from laborious purification of
downstream in the pathway.
placentally derived protein has allowed the production of
The early success of recombinant insulin production
sufficient -glucocerebrosidase to treat Gauchers disease in
in the 1970s created an atmosphere of enthusiasm and
many patients. Even so, the cost of the recombinant protein
hope, which was unfortunately followed by an era of dis-
can be greater than $100,000 per patient per year.
appointment when the vaccine attempts, nonhumanized
The example of Gauchers disease also illustrates aspects
monoclonal antibodies, and cancer trials in the 1980s
of a fifth issue associated with protein therapeutics: ethics
were largely unsuccessful. Despite these setbacks, sig-
(although these ethical issues are not exclusive to protein
nificant progress has been made recently. As well as the
therapeutics). For example, the possibility of efficacious
major successes with protein therapeutics described in
but expensive protein therapeutics for small but severely
this chapter, new production methods are changing the
ill patient populations, such as patients with Gauchers
scale, cost, and even route of administration of recom-
disease, can present a dilemma with respect to allocation
binant protein therapeutics. With the large number of
of financial resources of health care systems. In addition,
protein therapeutics both in current clinical use and in
the definition of illness or disease could be challenged by
clinical trials for a range of disorders, one can confidently
protein therapeutics that can improve upon conditions
predict that protein therapeutics will have an expanding
previously viewed as variants of normal. For example, the
role in medicine for years to come.
definition of short stature may begin to change with the
possibility of using growth hormone to increase the height
of a child. Acknowledgment
Finally, the regulatory landscape that governs protein We thank Armen H. Tashjian, Jr. for many helpful discus-
therapies will likely continue to have a significant impact sions. Portions of this chapter have been published as a
on the development of new therapies and their cost. As the review article (Leader B, Baca QJ, Golan DE. Protein ther-
field of protein therapeutics matures and certain therapies apeutics: a summary and pharmacological classification.
lose patent protection, the role of follow-on or generic pro- Nat Rev Drug Discov 2008;7:2139) and are adapted with
tein therapies in medicine will be decided. As of 2010, there permission.
916 Frontiers in Pharmacology
Suggested Reading
Hansel TT, Kropshofer H, Singer T, et al. The safety and side effects of mono-
clonal antibodies. Nat Rev Drug Discov 2010;9:325338. (Reviews mecha-
nisms, safety, and adverse effects of therapeutic monoclonal antibodies.)
Keen H, Glynne A, Pickup JC, et al. Human insulin produced by recombi-
nant DNA technology: safety and hypoglycaemic potency in healthy men.
Lancet 1980;2:398401. (A milestone in the use of a recombinantly pro-
duced protein therapeutic.)
Mascelli MA, Zhou H, Sweet R, et al. Molecular, biologic, and pharmacoki-
netic properties of monoclonal antibodies: impact of these parameters on
early clinical development. J Clin Pharmacol 2007;47:553565. (Discusses
trends in antibody formulation and how specific properties of candidate
drugs guide early drug development.)
Walsh CT. Posttranslational modification of proteins: expanding natures
inventory. Greenwood Village, CO: Roberts & Company; 2005. (Reviews
mechanisms and biological roles of covalent modifications of proteins.)
Woodcock J, Griffin J, Behrman R, et al. The FDAs assessment of fol-
low-on protein products: a historical perspective. Nat Rev Drug Discov
2007;6:437442. (Discusses challenges of developing protein therapeutics,
including difficulties in demonstrating bioequivalence in follow-on protein
therapeutics.)
920 Frontiers in Pharmacology

A B C
Polymer capsule Polymer matrix Polymer backbone

Drug Water or enzyme

Drug in Drug dissolved

reservoir or dispersed in
polymer

D E F
Polymer matrix Semipermeable Water
Water
membrane
Water

Drug dissolved Drug dissolved Swollen polymer Osmotic Osmotic Drug solution
or dispersed in in polymer from which drug delivery core containing leaves
polymer is being released orifice drug

FIGURE 54-1. Polymer release mechanisms. In all panels except C, the simplified diagrams represent polymeric systems in cross section. The most common
release mechanism is diffusion, whereby the drug migrates from its initial location in the polymer system to the polymers outer surface and then to the body. A, B. Dif-
fusion can occur from a reservoir, in which a drug core is surrounded by a polymer film, or from a matrix, where the drug is uniformly distributed through the polymeric
system. C, D. Drugs can also be released by chemical mechanisms such as cleavage of the drug from a polymer backbone or hydrolytic degradation of the polymer.
E. Exposure to a solvent can also activate drug release. For example, the drug can be retained in place by polymer chains; upon exposure to environmental fluid, the outer
polymer regions begin to swell, allowing the drug to diffuse outward. F. An osmotic system in the form of a tablet with a laser-drilled hole in the polymer surface can
provide constant drug release rates. Water diffuses through the semipermeable membrane into the tablet along its osmotic gradient, swelling the osmotic core inside the
tablet and forcing drug solution out through the hole. Combinations of the previously described approaches are possible. Release rates can be controlled by the nature
of the polymeric material and the design of the system.

In one common matrix system design, the drug is con-
tained in a series of interconnecting pores within the poly-
mer, rather than in one large reservoir (Fig. 54-1B). This
system is less limited by the size of the drug molecules be-
cause each pore can accommodate molecules with molecu-
lar weights of several million daltons. The rate of diffusion
between the poresand thus through the matrix and out of
the systemis controlled architecturally; tight constrictions
and tortuous connections between pores prevent rapid re-
lease of the stored drug. One such system is used clinically
to administer gonadotropin-releasing hormone (GnRH)
analogues. GnRH analogues are peptide hormones that,
when administered continuously, inhibit anterior pituitary
gland production of gonadotropins (LH and FSH) and are
useful in the treatment of sex-hormone-dependent diseases
such as prostate cancer. A major previous limitation of this
therapeutic approach was the short in vivo half-life of GnRH
analogues following intramuscular injection. When the drug
is incorporated into polymer microcapsules, and the cap-
sules are injected intramuscularly, the half-life of GnRH is
extended significantly, so that therapeutic concentrations are
maintained over a period of 14 months. Drug delivery by
the microcapsule system utilizes two mechanisms: first, the
drug diffuses out of the microcapsules; and second, the poly-
mer matrix itself degrades slowly. The second mechanism of
polymer-based drug delivery involves a chemical reaction
between the polymer and water (see below).
Chemical Reaction
In chemical reaction-based systems, part of the system is
designed to degrade over time. Degradation can involve either
a chemical or enzymatic reaction. In some designs, covalent
bonds that connect the drug to a polymer are cleaved in the
body by endogenous enzymes (Fig. 54-1C). Such polymer
drug complexes are typically administered intravenously,
and the use of water-soluble polymers such as polyethylene
glycol (PEG) increases the biological half-life of the drug
considerably. For example, PEG-Intron, a pegylated form
of interferon-2b, has been approved by the U.S. Food and
Drug Administration (FDA) for weekly administration; this
treatment for hepatitis C infection previously required injec-
tions three times as often. In the case of the intramuscular
GnRH microcapsules discussed above, the polymer itself is
degraded in a reaction with water (Fig. 54-1D).
Most insoluble polymers considered for these applications
exhibit bulk erosion (i.e., the entire matrix dissolves at the
same rate), which results in larger pores and a more sponge-
like and unstable structure. This pattern of degradation makes
constant release rates difficult to achieve and creates the po-
tential risk of undesirable dose dumping. Novel polymers
have been designed to overcome this problem by optimiz-
ing degradation for controlled drug delivery (i.e., through
surface erosion). For example, a polymer with desirable
erosion properties can be engineered by using hydrophobic
monomers connected by anhydride bonds. The hydrophobic

monomers exclude water from the interior of the polymer
matrix, eliminating bulk erosion. In contrast, the anhydride
bonds are highly water reactive, allowing surface erosion in
the aqueous environment of the body. This design allows the
polymer to degrade from the outside only (Fig. 54-2). The
rate of degradation can be controlled by using a combina-
tion of monomers, one more hydrophobic than the other. The
length of time over which the polymer persists is specified
by the ratio of monomers used, and a drug that is uniformly
distributed within such a polymer matrix will be released
constantly over time. Based on these principles, Gliadel
has become the first local controlled-release system for an
anticancer drug to receive FDA approval. After surgeons re-
move glioblastoma multiforme, an aggressive form of brain
cancer, they place up to eight small polymerdrug wafers at
the tumor site. As the polymer surface erodes over 1 month,
the drug carmustine (an alkylating agent; see Chapter 38,
Pharmacology of Cancer: Genome Synthesis, Stability, and
Maintenance) is slowly released. The concentration of car-
mustine at the tumor site is maintained at a level high enough
to kill many of the remaining tumor cells, while adverse ef-
fects of systemic delivery are avoided. This treatment signifi-
cantly prolongs the lives of patients with this cancer.
Solvent Activation
The third mechanism for polymer-based drug delivery is
solvent activation, in which the solvent does not react with
the polymer chemically, but rather initiates drug release via
swelling (Fig. 54-1E) or osmosis (Fig. 54-1F) of the system.
A where the insulin was slowly released by diffusion out of
Surface erosion Bulk erosion
B O O O O O O
O R O R O R O
Polyanhydride
H2O
O O
HO R OH
Breakdown products
FIGURE 54-2. Surface erosion using polyanhydride polymers. A. Surface
erosion of degradable polymer delivery devices allows for more accurately con-
trolled release rates and is therefore preferable to bulk erosion. B. Polyanhydrides
are used to promote surface erosion. They have hydrophobic monomers that
exclude water from the interior of the polymer matrix and prevent bulk erosion.
However, the monomers are linked by water-soluble anhydride bonds, allowing
breakdown at exposed surfaces.
CHAPTER 54 / Drug Delivery Modalities 921
One widely used example of such a system is an extended
release oral formulation of nifedipine, a calcium channel
blocker (see Chapter 21, Pharmacology of Vascular Tone).
The drug is mixed with an osmotically active agent, such
as a salt, and coated with a membrane that is permeable to
water but not the drug. A small hole is then drilled in the
capsule membrane with a laser. After ingestion, the con-
stant osmotic influx of water through the membrane forces
the drug out of the pill through the hole, thereby controlling
release. This delivery technique, when compared to con-
ventional (immediate release) oral formulations, provides
patients greater relief from ischemic events with fewer ad-
verse effects. Concerta, an extended release formulation
of methylphenidate, uses a similar system to treat children
with attention deficit hyperactivity disorder (ADHD).
Intelligent Delivery
There are situations in which pulsatile delivery is desirable
to mimic the bodys natural pattern of producing chemicals.
In the case of Mr. F, the insulin pump he wore provided a
constant, basal rate of insulin to maintain his blood glucose
levels between meals. When Mr. F ate, he could set the pump
to provide an additional bolus of insulin and thereby pre-
vent a sudden, excessive rise in blood glucose concentration.
Several innovative approaches have been taken to incorpo-
rate such versatility in polymer-based drug delivery systems,
which have traditionally been designed to deliver drugs at
constant or decreasing release rates.
In one early design, magnetic beads were incorporated
in the polymer matrix together with a 2-year supply of insu-
lin. The system was then implanted subcutaneously in rats,
the matrix, as discussed above. When an oscillating mag-
netic field was applied externally, movement of the magnetic
beads within the matrix caused alternating expansion and
contraction of the drug-carrying pores. The insulin could
thus be effectively squeezed out of the matrix, resulting in
higher dose delivery for as long as the oscillating magnetic
field was applied. This system significantly lowered blood
glucose levels in the treated rats compared to control rats and
may eventually become a viable method of insulin delivery.
In Mr. Fs hypothetical future, the implanted magnetic oscil-
lator allowed him to administer a rapid bolus of insulin sim-
ply by selecting the appropriate program on his wristwatch
controller, which sent the instructions to the implanted de-
vice via a radiofrequency signal.
Other methods of increasing the rate of drug diffusion
from a polymer matrix include the application of either
ultrasound or electric current. Ultrasound delivered at an
appropriate frequency can have an effect similar to that of
the magnetic bead system. Ultrasound causes cavitation (the
formation of tiny air pockets) in the polymer, disrupting the
porous architecture to facilitate faster drug release. Apply-
ing an electric current to certain polymers can induce elec-
trolysis of water at the polymer surface, lowering local pH
and disrupting hydrogen bonding within the complex. The
polymer subsequently degrades at a faster than normal rate,
allowing transient release of larger drug doses. Pulsatile de-
livery can also be achieved via local environmental stimuli.
For example, hydrogels (materials composed of polymers
and water) can be designed to sense changes in temperature,
pH, and even specific molecules by virtue of their structure.
922 Frontiers in Pharmacology
A silicon microchip delivery system that offers even more
control over release rates has also been designed. The micro-
chip contains up to 1,000 tiny drug reservoirs, each covered
with a thin gold film. Applying a small external voltage to an
individual implanted reservoir dissolves the gold film elec-
trochemically, releasing the drug stored in that reservoir. Be-
cause the reservoirs can be loaded and opened individually,
almost limitless possibilities exist for both dosing of single
drugs and combining multiple drugs.
Targeting
Accurate targeting allows for larger, more effective doses to
reach the tissues of interest without risking the toxic effects
of systemic delivery. The first variable that can be controlled
is the anatomic placement of the polymer-based drug delivery
system; the carmustine wafer delivery system discussed earlier
makes use of this basic consideration. Other notable examples
include Estring, a vaginal ring that delivers estradiol for
vaginal dryness; Vitrasert, an eye implant that delivers gan-
ciclovir for the treatment of cytomegalovirus retinitis in AIDS
patients (see Chapter 37, Pharmacology of Viral Infections);
and drug-eluting stents that deliver sirolimus, everolimus,
zotarolimus, or paclitaxel for the prevention of in-stent rest-
enosis in coronary angioplasty (see Chapter 45, Pharmacology
of Immunosuppression). Many tissues are accessed practically
only via the bloodstream, however, making targeted delivery
more difficult. Both passive and active targeting techniques
have been developed to direct polymer-based systems to spe-
cific tissues following intravenous administration.
Passive targeting exploits vascular differences between
the target tissue and other tissues to deliver drugs selectively.
For example, high molecular mass polymerdrug complexes
accumulate in some tumor tissues to a greater extent than in
normal tissues because the tumor has more permeable capil-
lary beds. Therefore, rather than using lower doses of low
molecular mass anticancer drugs, which rapidly pass through
all cell membranes and distribute throughout the body, larger
and more effective doses of high molecular mass polymer
drug conjugates can be used to target tumors. In addition, the
polymerdrug conjugates can be constructed in such a way
as to allow enzymatic cleavage of the drug after the complex
has left the bloodstream and been taken up by tumor cells
(Fig. 54-1C). In one example of such a system, the antican-
cer drug doxorubicin (see Chapter 38) is conjugated to a
water-soluble, nonimmunogenic polymer through a peptidyl
linker. The polymerdrug complex accumulates in mouse
melanoma tumors at concentrations up to 70 times greater
than in normal tissue because of the relatively leaky micro-
vasculature in the tumor. Once inside the tumor cells, the
peptidyl linker is cleaved by lysosomal proteases, releasing
the cytotoxic drug. The polymer portions of the complex ei-
ther degrade or are eliminated by the kidneys.
In active targeting, the polymerdrug conjugate is linked
to a molecule that is recognized specifically by cell surface
receptors in the tissue of interest. For example, a human IgM
antibody directed against a tumor-associated antigen can be
used to target a polymerdoxorubicin complex to malignant
tissues. Linked to the polymer with an acid-labile bond, the
doxorubicin is selectively released in the acidic environment
of the tumor. In another system, galactose is used to target a
polymerdrug complex to the liver via the hepatocyte cell-
surface asialoglycoprotein receptor.
 LIPOSOME-BASED DELIVERY SYSTEMS
Drugs attached to a single polymer chain are stable struc-
tures that can remain in the circulation for long periods
of time; the drugpolymer complexes discussed above in
the context of tissue targeting are examples of such sys-
tems. However, these polymer chains can accommodate
only small amounts of drug, thus limiting the dose per unit
volume administered. The potentially high drug-carrying
capacity of liposomes, small vesicles with lipid bilayer
membranes, makes them an attractive option for a circulat-
ing drug delivery system.
Important considerations in the design of liposome-
based delivery systems include tissue targeting and protec-
tion from the immune system. Highly specific antibodies,
analogous to those used for active targeting of polymer
drug complexes, can be used to improve tissue targeting.
For example, antibodies against the Her2 proto-oncogene,
implicated in the progression of breast cancer and other
cancers, are being explored for tumor targeting. Similarly,
antibodies against E-selectin, an endothelial-specific sur-
face molecule, can be used to target vascular endothelial
cells. Protection of liposomes from the immune system
can be accomplished by the addition of water-soluble
polymers to the liposomal surface. As discussed above,
moieties such as PEG increase the hydrophilicity of the
structures to which they are attached; in this case, lipo-
somes are made more hydrophilic in the blood and are
therefore less liable to be taken up by the reticuloen-
dothelial system. Because liposomes with the PEG moiety
(stealth liposomes) have a prolonged circulation time
(days), larger doses can be administered without the risk of
drug toxicity. These principles have been used to develop
liposomes loaded with daunorubicin and doxorubicin for
the treatment of several tumors, including HIV-associated
Kaposis sarcoma. Liposomal amphotericin B, used to
treat fungal infections, has also been approved for clini-
cal application (see Chapter 35, Pharmacology of Fungal
Infections). Liposomal cyclosporine is being studied for
targeted immunosuppression following transplant surgery
(see Chapter 45).
 CONCLUSION AND FUTURE DIRECTIONS
The delivery modalities described in this chapter represent
selected novel approaches to optimizing absorption, distribu-
tion, metabolism, and excretion of drugs. There are several
advantages of improved drug delivery:
Drug levels can be continuously maintained in a therapeu-
tically desirable range. Sustained release oral formulations,
large particles that can be inhaled, and many polymer-
based designs have this desirable property.
Harmful adverse effects can be reduced by preventing
transient high peak blood levels of drug. Designs that
alter absorption kinetics, targeted delivery systems (e.g.,
antibody-labeled polymerdrug complexes), and sys-
tems that avoid first-pass liver metabolism (e.g., trans-
dermal delivery of drugs normally taken orally) achieve
this goal.
The total amount of drug required can be reduced, as with
advanced inhaler designs. Both a decrease in the num-
ber of required dosages and a less invasive administration

route contribute to improved patient adherence. Mr. Fs
case illustrates the influence of lifestyle factors on patient
adherence.
Pharmaceuticals with short half-lives, such as peptides and
proteins, can be successfully delivered using controlled-
release polymer-based delivery systems.
Advanced drug delivery technologies also introduce
new concerns that must be considered in their design. For
example, each material put in the body, as well as its deg-
radation products, must be evaluated for toxic effects; this
factor is especially important for synthetic materials such as
polymers. Other potential dangers must be avoided, such as
unwanted rapid release of the drug from a system intended
for sustained release. Discomfort caused by the delivery sys-
tem or its insertion is another potential disadvantage: Mr. Fs
insulin pump, while providing better control of his diabetes,
was uncomfortable to him. Finally, advanced technology is
often accompanied by increased cost, which can be a prob-
lem for patients, their insurance companies, and hospitals.
Despite these obstacles, advanced drug delivery tech-
nologies play an increasingly valuable role in making the
CHAPTER 54 / Drug Delivery Modalities 923
pharmacologic management of disease safer, more effective,
and more agreeable to patients.
Suggested Reading
Edwards DA, Ben-Jabria A, Langer R. Recent advances in pulmonary drug
delivery using large, porous inhaled particles. J Appl Physiol 1998;84:379
385. (Review of aerodynamic diameter principles and the potential advan-
tages and applications of large, porous inhaled particles.)
Langer R. Drug delivery and targeting. Nature 1998;392:510. (Review of
drug delivery techniques, with emphasis on polymer and liposome-based
systems as well as novel use of delivery routes.)
Langer R. Where a pill wont reach. Sci Am 2003;April:5057. (Broad over-
view of concepts in drug delivery.)
Leong KW, Brott BC, Langer R. Bioerodible polyanhydrides as drug-carrier
matrices: I. Characterization, degradation, and release characteristics.
J Biomed Mater Res 1985;24:14631481. (Good starting point for learning
more about polymer matrix design.)
Prausnitz M, Langer R. Transdermal drug delivery. Nat Biotech
2008;26:12611268. (Reviews advances in transdermal drug delivery.)
Santini JT Jr, Cima MJ, Langer R. A controlled-release microchip. Nature
1999;397:335338. (More detailed information about intelligent drug de-
livery using silicon microchips with arrays of drug reservoirs.)
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Figure 57-19.
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oriented organic synthesis in drug discovery.
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Figure 50-3: Adapted from the CDER handbook by
the U.S. Food and Drug Administration, available
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Index
Note: Page numbers followed by f denote figures; those followed by t denote tables; and those followed by b indicate boxes.

A muscarinic receptors, effects of, 119f mechanism of action, 657f

muscle contraction, quantal release and, 118f viruses and, 655658
AA. See Alcoholics Anonymous
neuromuscular junction and, 115, 117f ad hoc studies, drug study and, 876
AADC. See aromatic amino acid decarboxylase
neuronal systems and, 101, 101f, 101t ADA. See adenosine deaminase
abacavir, 77, 671t
neurotransmitters and, 101102, 101t, 102f, 103t adalimumab, 758, 762t, 804t, 907t
abatacept, 801, 806t, 907t
peripheral nervous system and, 106 adaptive immunity, 732736
Abbreviated New Drug Application (ANDA), 870
storage and release, 111112, 112f addiction, 284287
ABC. See ATP binding cassette
synaptic cleft and, 9091 case study, 285
abciximab
synthesis, 110111, 112f drug summary table, 307309t
platelets and, 396t
acetylcholinesterase (AChE), 13, 110, 114 future directions, 306
protein therapeutics and, 909t
acetylcholinesterase (AChE) inhibitors, 13, 92, mechanisms, 291295
thrombus formation and, 386
Abelcet, 624 120122, 121f opioids and, 274
A-fibers, 267 structures and mechanisms, 886f pharmacology of, 284309
aBMD. See areal bone mineral density acetyl-CoA-cholesterol acyltransferase treatments of, 302306
abraxane, 693, 698t (ACAT), 314 Addisons disease, 493, 500
absence seizures acetyltransferases, 593 additive drug interactions, quantification,
mechanism of, 230f ACh. See Acetylcholine; Muscarinic acetylcholine 718719, 719f
T-type calcium channel and, 230, 230f AChE. See acetylcholinesterase additivity, 718
absorption. See drug(s) AChE inhibitors. See acetylcholinesterase inhibitors adducts, carcinogens and, 888
absorption/distribution/metabolism/excretion. acid hypersecretion, peptic ulcer disease and, 811 adefovir, 655, 671t
See ADME acids, tissue damage and, 885 adenine, 581, 675
ABVD (Doxorubicin, bleomycin, vinblastine, acid-sensitive ion channels (ASICs), 266 adenosine, 759
dacarbazine), 726 acquired genes, antibiotic resistance, 609 cardiac rhythm and, 416, 421t
AC. See adenylyl cyclase acquired immunodeficiency syndrome (AIDS), 649 DNA structure, 685f
acamprosate marijuana and, 269 neurotransmitters and, 102, 103t
addiction and, 305 acquired tolerance, 287 adenosine 5-monophosphate-activated protein
drug dependence and, 308t acrivastine, 775t kinase (AMPK), 526
acarbose, 538t ACS. See acute coronary syndromes adenosine deaminase (ADA), 675
ACAT. See acetyl-CoA-cholesterol acyltransferase ACTH. See adrenocorticotropin hormone adenosine deaminase, protein therapeutics and, 901t
accelerated approval, clinical drug development, 866 actin, cardiac myocyte contraction and, 425t adenosine diphosphate (ADP)
accessory electrical pathways, 408 action potentials (AP), 84f, 8689, 87f, 88f, 89f nucleotide synthesis, 675
bundle of Kent, 408, 408f cells and, 82 receptor pathway inhibitors
ACE (Angiotensin converting enzyme), 13, 39f, local anesthetics, 147 drug table summary, 395396t
335, 371t sodium channels and, 226, 226f thrombus formation and, 386
ACE inhibitors (Angiotensin converting enzyme voltage-gated sodium channel, 153 UA/NSTEMI, 453
inhibitors), 343344, 343f, 371t activated partial thromboplastin time (aPTT) assay, adenosine triphosphate (ATP)
acute coronary syndromes and, 452f heparin and, 391 neurotransmitters and, 102, 103t
blood pressure and, 343f activated protein C (drotrecogin), 898 adenylyl cyclase (AC), 910, 10f, 427
drug summary table, 349t active metabolites, 60 A-fibers, 149, 149t
heart failure and, 341, 460t, 461 active site, drug and, 4 ADHD. See attention-deficit hyperactivity disorder
indications and contraindications, 445t active targeting, drug delivery and, 922 adhesins, fungus and, 620
pharmacologic effects, 441f active transport, 28 adhesion, 13
vasodilators and, 444 activin, 473, 509 adhesion receptors, 13
acebutolol, 141t, 142, 146t acute adrenal insufficiency, 497 adjuvant drugs, anesthesia, 255256
cardiac rhythm and, 413, 419t acute coronary syndromes (ACS), 448449 ADME (Absorption/distribution/metabolism/
acetaminophen, 276, 276f, 282t, 756, 762t pathogenesis of, 449f excretion), 27, 28f, 856
conjugation reactions and, 73t pharmacologic management, 452f ADP. See adenosine diphosphate
cytochrome P450 enzymes and, 52t acute humoral rejection, 791 adrenal androgens, 501502
drug binding and, 33f acute lithium intoxication, 218 adrenal cortex
opioids vs., 275 acute mountain sickness, 345 case study, 490
oxidation/reduction enzyme and, 73t acute myeloid leukemia (AML) hormone synthesis in, 491f
poisoning, mechanism, 65, 65f cancer drugs and, 67 pharmacology of, 489504
toxicity, echinacea and, 62 receptor tyrosine kinase FLT3 and, 708709 regions of, 490f
acetazolamide, 351t acute rejection, solid organ transplantation and, adrenal gland
acetic acid derivatives, 756, 761t 791792 function, drugs testing, 479t
acetic acids, 761t acute renal failure pharmacology, drug summary tables for,
acetohexamide, 538t aminoglycoside use and, 591 503504t
acetylcholine (ACh) loop diuretics and, 346 adrenal insufficiency, 493494
degradation, inhibitors of, 128t acute urticaria (Hives), IgE-mediated adrenal medulla, 95f, 96
degradation of, 114115 hypersensitivity reaction and, 768f, 769 adrenal sex steroid, 504t
inhibitors, of synthesis, storage and release, 112f, acute withdrawal syndrome, 289 adrenaline. See Epinephrine
120, 128t acyclovir (ACV), 568, 670t adrenergic agonists, 277278
928
 Index 929

adrenergic drugs alkylating agents, 723t amino acid neurotransmitters, 102

pain relief and, 269 DNA structure and, 686688, 696t amino penicillins, 610
pharmacology, 132142 immunosuppression and, 794, 796 aminoacyl site, 585
table, 143146t allergic reaction, 768 aminocandin, 625
adrenergic neurons, drug abuse and, 301 allergic rhinitis, 769 aminocaproic acid, 393, 400t
adrenoceptor, 135136, 136t allergy disease, 771 aminoglutethimide, 499, 499t, 504t
adrenocortical hormone synthesis inhibitors, 498499 allodynia, peripheral sensitization and, 271 aminoglycosides, 596t, 717t
adrenocorticotropin hormone (ACTH) alloimmunity, 790 30S ribosomal subunit, 589591, 590f, 596t
adrenal cortex and, 489490 allopregnanolone, 168 antimicrobial combination therapy, 720
aldosterone synthesis and, 500 allopurinol, 685 beta-lactams and, 609
anterior pituitary gland, 467, 472f 6-mercaptopurine, interaction, 841, 842f aminophylline, 829, 835t
Adriamycin, 691 gout and, 841, 841f amiodarone
adult-onset diabetes. See diabetes mellitus immune responses, immunotoxicity and, 64 cardiac rhythm and, 414415, 415t, 421t
adverse effects, 56 uric acid synthesis and, 844t cytochrome P450 enzymes and, 5152t
AEDs. See antiepileptic drugs allostasis, addiction and, 291 thyroid hormone homeostasis, 487
affective disorders allosteric antagonist, 21f amitriptyline, 144t, 215, 221t, 277
clinical characteristics of, 211212 all-trans retinoic acid (ATRA), 786 cytochrome P450 enzymes and, 5152t
pathophysiology of, 211213 allylamines, 622, 626t AML. See acute myeloid leukemia
affective flattening, schizophrenia, 195, 196b allylglycine, GABAergic transmission and, 169t amlodipine, 363, 369t, 443
afferent neurons, 147 almotriptan, 217, 223t amobarbital, GABAA receptors and, 183t
affinity, drug-receptor interaction, 3 alogia, schizophrenia, 195 amodiaquine, 568
A-fibers, 149, 149t alosetron, irritable bowel syndrome and, 218, 224t amoxicillin, 609, 610, 615t
aflatoxins, 890 ALOX5 gene, 76 H. pylori, 817
African-Americans, drug metabolism and, 53 alpha 2-antiplasmin, 380 AMPA receptors
afterdepolarization, 406 alpha cells, glucagon from, 524 epilepsy and, 179180
afterload, 354, 422423, 456 alpha helix, 4f, 9 glutamate-gated ion channels, 176, 177t
contractile dysfunction, 461 alpha-1-proteinase inhibitor, 895 interaction, glutamate receptors and, 180f
2AG. See 2-arachidonylglycerol alpha-1-proteinase inhibitor, protein therapeutics stroke and trauma, 179
agalsidase B, protein therapeutics and, 900t and, 900t amphetamine, 139, 143t
age alpha-adrenergic agonists, 139140, 144t drug abuse and, 299302
anesthesia induction and, 251252, 252f alpha-adrenergic antagonists, 140141, 145t schizophrenia and, 196
drug metabolism and, 53 blood pressure and, 443 serotonin storage and, 213214
aging, 120 drug summary table, 371t Amphotec, 624
agonist dose-response relationship, 22f relative indications and contraindications, 445t amphotericin B, 567, 624, 628t, 640, 720, 922
agonist dose-response relationship, competitive vascular tone, 365366 drug combinations and, 721
antagonist vs., 22, 22f alpha-adrenoceptors, actions, 135136, 136t immune responses, immunotoxicity and, 64
agonists, 6, 20 alpha-galactosidase A, protein therapeutics and, 900t Leishmania and, 640
action, 26t alpha-glucosidase inhibitors, 533, 538t renal toxicity, drug-induced, 66
AIDS. See acquired immunodeficiency syndrome alpha-linolenic acid, 741 ampicillin, 609, 610, 615t
air pollution, toxicity and, 892 alpha-methyldopa, 140 AMPK. See adenosine 5-monophosphate-activated
airway alpha-methyltyrosine, 137, 143t protein kinase
hyperresponsiveness, asthma and, 824f alpha-tubulin, 682 amprenavir, 662, 672t
immune function in, 821822 alphaxalone, 175 amrinone, 362
airway smooth muscle, immune function and GABAA receptors and, 184t amsacrine, 692, 697t
physiology, 820822 alprazolam, 51t amygdala, 98
ALA-D. See delta-aminolevulinic acid dehydratase clinical uses for, duration of action, 172t amyl nitrate, 883
alanine aminotransferase (ALT), 66 cytochrome P450 enzymes and, 51t amylase, protein therapeutics and, 901t
alanine racemase, 603 GABAA receptors and, 183t amylin, 529, 539t
albendazole, 642, 648t alprenolol, cytochrome P450 enzymes and, 51t anakinra, 758, 762t, 800, 805t, 908t
albuterol, 140, 145t, 828, 834t alprostadil, 763t analgesia, 150151
asthma, 821 ALT. See alanine aminotransferase case presentation, 265
bronchioles and, 96 alteplase, 393 morphine and, 274
alcohol Group Ib proteins, 898 pharmacology of, 264283
coronary artery disease, 302 STEMI, 454 analgesic index, 241242
dependence, 289 alteplase, protein therapeutics and, 903t analgesics, 150, 275277
drug user subtypes and, 295 altretamine, 687, 696t anandamide families, 269, 301
drugs of abuse and, 286t aluminum hydroxide, 816, 818t anaphylaxis, 62
metabolism, inhibitor, 307t drug summary table, 560t beta-lactams and, 610
peptic ulcer disease, 816 secondary hyperparathyroidism and, 556 H1-antihistamines and, 771
psychiatric disease and, 284 alveolar partial pressure, 241 histamine and, 769
alcohol dehydrogenase, 47 equilibration, anesthesia and, 246247 anastrozole, 511, 520t, 723t
alcoholics, 295. See also fetal alcohol syndrome of isoflurane, 243f ANDA. See Abbreviated New Drug Application
Alcoholics Anonymous (AA), 285, 303 ventilation and cardiac output vs., 251, 251f androgen, 489490
alcoholism alveolar ventilation, anesthesia and, 247248 conjugation enzyme and, 73t
type 1, 295 alvimopan, 275, 282t hormone replacement, 523t
type 2, 295 Amanita phalloides, 885 hypogonadism, 519
aldosterone, 499 amantadine, 125, 203t, 568, 670t synthesis, 505506
aldosterone hyperfunction, 500 NMDA receptor antagonists, 185t androgen receptor antagonists, 515, 522t
aldosterone hypofunction (hypoaldosteronism), 500 Parkinsons disease, 195 anesthesia, 150151. See also General anesthesia;
aldosterone receptor antagonists viral uncoating and, 654f Local anesthesia; Topical anesthesia;
acute coronary syndromes and, 452f amatoxins, 885 specific e.g. Infiltration anesthesia
heart failure and, 460461 ambenonium, 121, 128t abbreviations and symbols, 262
alefacept, 801, 806t, 908t AmBisome, 624 adjuvant drugs, 255256
alemtuzumab, 712, 715t, 806t, 907t ambrisentan, 365, 370t age and, 251252, 252f
alendronate, 559t amebiasis, 638, 638f drug summary table, 260261t
alendronate, bone mineral homeostasis and, 552, 559t amide-linked local anesthetics, 151152, 151f, 156, equations, 263
alfentanil, 275, 280t 158159, 161162t induction, children and, 251252, 252f, 252t
alglucosidase alfa, protein therapeutics and, 900t amidophosphoribosyltransferase (amidoPRT), 837 induction rate, physiologic and pathophysiologic
aliskiren, 342343, 349t, 444 amidoPRT. See amidophosphoribosyltransferase variables in, 251253, 252t
alkaline phosphatase, 66, 543 amikacin, 589, 596t, 720 inhibitory GABAA, 257, 258, 258f
alkylamines, 774t, 775t amiloride, 347, 352t, 442t, 474 ion channels, 257258, 258f
930 Index
anesthesia (continued)
muscle group and, 246, 246f
stages of, 242f
vessel-poor group and, 246f
vessel-rich group and, 246, 246f
V/Q mismatch, 252, 252t
anesthesiologist, uptake model and, 245250, 250253
anesthetics, 8. See also Amide-linked local
anesthetics; General anesthetics; Inhaled
general anesthetics; Local anesthetics;
Perfusion-limited anesthetics;
Ventilation-limited anesthetics
cys-loop superfamily, 259
future directions, 258259
induction times, 250f
intravenous, 255, 255f
angina pectoris, 354, 447, 447f
angiogenesis, 705706
angiogenesis inhibitors, 710711, 715t
angiotensin converting enzyme. See ACE
angiotensin converting enzyme inhibitors. See ACE
inhibitors
angiotensin I, 335
angiotensin II (AT II), 335
zona glomerulosa, 489
angiotensin II receptor antagonists, 344
cytochrome P450 enzymes and, 52t
drug summary table, 350t
subtype I, vasodilators and, 358, 444
angiotensinogen, 335
anhedonia, 291
anidulafungin, 625, 628t
animal models, drug discovery and, 856
anisoylated plasminogen streptokinase activator
complex (APSAC), 906t
anistreplase, protein therapeutics and, 906t
Ann Arbor staging system, Hodgkins disease
and, 725
ANP. See A-type natriuretic peptide
antacids, 816, 818819t
antagonism, 718
antagonists
action, 21, 21f, 26t
competitive receptor, 2122
noncompetitive receptor, 2223
nonreceptor, 23
drug interactions, quantification, 718719, 719f
anterior pituitary gland, 465, 467
cell types, hormonal targets of, 467t
individual axes and, 468474
anthracyclines, 690f, 691, 723t
antianginal drugs, UA/NSTEMI, 453
antiarrhythmic drugs, 277
cardiac rhythm and, 408409
class I, 409410, 410f
class IA, 410411, 411f, 418t
drug summary table, 418t
class IB, 411f, 412
drug summary table, 419t
class IC, 411f, 412413
drug summary table, 419t
class II, 413
drug summary table, 419t
pacemaker cell action potential and, 413f
class III, 413415
drug summary table, 420421t
class IV, 415416
drug summary table, 421t
pacemaker cell action potentials and, 415f
cytochrome P450 enzymes and, 51t
antibacterial agents. See antibiotics
antibacterial drug classes, sites of action, 567f
antibiotics
broad-spectrum, warfarin, 389t
digoxin and, 430
future directions, 595
resistance, 609
translation, 588
antibodies, 733
anti-CD20 monoclonal antibody, 801
anti-CD25 monoclonal antibodies, 801
anti-CD52 monoclonal antibodies, 801
anticholinergic drugs
asthma, 821, 827, 834t
gastric acid and, 816, 819t
geriatric, cognitively impaired patients, 126b
anticoagulants
drug summary table, 397t, 400t
thrombus formation and, 387392
anticoagulation inhibitors, 393, 400t
anticonvulsants. See antiepileptic drugs (AEDs)
antidepressants, 105, 277
cytochrome P450 enzymes and, 5152t
oxidation/reduction enzyme and, 73t
sites of action, 215f
antidigoxin antibodies, 430
antidiuretic hormone (ADH), 334
posterior pituitary gland, 474
signaling pathways, natriuretic peptide and,
336f, 337
antiepileptic drugs (AEDs), 277
antimuscarinic toxicity and, 126
cytochrome P450 enzymes and, 51t
drug summary table for, 239t
future directions, 235
immune responses, immunotoxicity and, 64
Na channels and, 231, 232t
sites of action on pain pathways, 278f
anti-factor VIII antibodies, 914
antifungal drugs
cellular targets of, 621f
cytochrome P450 enzymes and, 5152t, 51t
antigen-antibody complexes, 62
antigen-presenting cells (APCs), 730732
anti-HBV nucleoside analogues, 659, 671t
antihelminthic drugs, 647648t
onchocerciasis and, 641
pharmacology of, 641642
antiherpesvirus nucleoside analogues, 655, 670671t
antihistamines, 769
anti-HIV agents
cytochrome P450 enzymes and, 51t
viral genome replication inhibition, 655
anti-HIV nucleoside analogues, 655, 659, 671t
anti-HIV protease inhibitors, 664f
antihypertensive agents
classes of, 440t
demographic factors, 445
homeostatic responses to, 441f
indications, contraindications, 445t
pharmacologic effects, 441f
anti-IgE antibodies, 831, 836t
anti-inflammatory agents, asthma and, 829831
antimalarial agents, 644645t
P. falciparum, 633f
pharmacology of, 632636
antimalarial drug resistance, 636637
antimetabolites, 575, 674, 723t, 794
antimicrobial combination therapy, 719721
antimicrobial dihydropteroate synthase inhibitors,
579t, 596t
drug targets, 575576
antimicrobial drugs
30S ribosomal subunit and, 589592
50S ribosomal subunit and, 592, 593f
selective targeting, mechanism of, 564566, 564t
targeting 30S ribosomal subunit, 596597t
targeting 50S ribosomal subunit, 597598t
antimuscarinics, 124126
antimycobacterial drugs, 612
drug summary table, 617t
mycolic acid synthesis and, 606f
antineoplastic combination chemotherapy, 722725
examples of, 725726
antineoplastic dihydrofolate reductase inhibitor, 580t
antineoplastic drugs
classes of, 570f
pharmacology
drug summary table, 579580t
principles of, 563578
selective targeting, mechanism of, 564t
structural proteins, 13
antiparkinsonian medications, drug summary
table, 203t
antiplatelet agents
drug summary table, 395t
mechanism of action, 385f
thrombus formation and, 381386
antiprotozoal agents, 638640, 646646t
antipsychotics
adverse effects, 197198
atypical, 199200
chemical structure, 199f
drug summary table, 204205t
schizophrenia and, 197
antiresorptive agents, bone homeostasis disorders
and, 551556
Anti-Rh IgG vaccine, 911t
anti-Rhesus D antigen Ig, 912
antisense oligonucleotides, 851b
antistaphylococcal penicillins, 610
antithrombin III, 379, 379f
protein therapeutics and, 900t
antithrombotic mechanisms, 373
antithymocyte globulin (ATG), 800, 805t, 908t
anti-TNF agents, 799f
anti-VEGF antibodies, 710711
antivenins, 62
antiviral combination therapy, HIV and, 721722
antiviral drugs
classes of, viral life cycle and, 569f
future directions, 668669
immune system and, 673t
mechanism of action, unknown, 665668,
672673t
apcitide, 912, 913t
APCs. See antigen-presenting cells
apoB editing complex-1 (apobec-1), 313314
apoB gene. See apolipoprotein B gene
apobec-1. See apoB editing complex-1
apoCII deficiency, 322323
apolipoprotein B gene (apoB gene), editing,
313314, 313f
apolipoprotein B-containing lipoproteins (apoB), 313
assembly and secretion, 313315, 314f
intravascular metabolism, 315316, 315f
LDL particles, formation and clearance,
317318, 317f
receptor mediated clearance, 316317, 316f
apomorphine, schizophrenia and, 196
apoptosis, 571
cell toxicity and, 62, 63t
drug insensitivity to, 573574
aprotinin, 393, 400t
APSAC. See anisoylated plasminogen streptokinase
activator complex
aPTT assay. See activated partial thromboplastin
time assay
aquaporin water channel, 338
aquaretics, heart failure and, 460t
araC. See cytarabine
arachidonic acid, 373
generation, 741742
metabolism, physiology of, 740, 740f
2-arachidonylglycerol (2AG), 269
arcitumomab, 913t
arcuate nuclei, central dopamine pathways and, 190
area postrema, 191
area under the curve (AUC), 30f
areal bone mineral density (aBMD), 548
arformoterol, 834t
argatroban, 392, 398t
arginine, 470
aripiprazole, 200, 206t
aromatase inhibitors, 506, 513, 520t
aromatic amino acid decarboxylase (AADC)
dopamine synthesis and, 187
Parkinsons disease and, 193
aromatic L-amino acid decarboxylase, 107
serotonin and, 208, 209f
arsenic, toxicity and, 890891
artemether, malaria and, 634, 644t
artemisinin, 644t
malarial plasmodia and, 634, 634f
artesunate, malaria and, 634, 644t
articaine, 159, 162t

asbestos, toxicity of, 891892
asbestosis, 891
ASICs. See acid-sensitive ion channels
asoprisnil, 516, 522t
aspartate aminotransferase (AST), 66
aspartate, neurotransmitters and, 102, 103t
Aspergillus, 621
aspirin, 23, 275, 276, 395t, 755, 761t
coronary artery disease and, 451
hydrolysis reactions and, 46t
overdose, 37
prostaglandin synthesis pathway, 382, 384f
UA/NSTEMI, 453
aspirin exacerbated respiratory disease, 831
aspirin-induced airway hyperreactivity, 756
aspirin-triggered lipoxins (ATLs), 756, 759
AST. See aspartate aminotransferase
asthma, 753, 820
airway hyperresponsiveness, 824f
allergic response of, 825f
as bronchoconstrictive disease, 822824
case study, 821
clinical management, 832, 832t
conclusions and future directions, 832833
drug delivery, 831832
drug summary table, 834836t
H1-antihistamines and, 771
as inflammatory disease, 824827
leukotriene pathway, 826f
origin, TH2 cells and, 823f, 824
pathophysiology of, 822827
astroglia, 106
AT II. See angiotensin II
AT II receptor subtype I (AT1 receptor), 335, 371t
AT1 receptor. See AT II receptor subtype I
AT1 receptor antagonists
drug summary table, 371t
indications and contraindications, 445t
atazanavir, 662, 672t
atenolol, 141t, 142, 146t, 371t
cardiac rhythm and, 413, 419t
down-regulation of sympathetic tone, 442
ATG. See antithymocyte globulin
ATLs. See aspirin-triggered lipoxins
atomoxetine, 217, 222t
atopy, 824
atorvastatin, 51t, 78, 325326, 330t
atovaquone, malarial plasmodia and, 635, 645t
ATP. See adenosine triphosphate
ATP binding cassette (ABC), biliary excretion
and, 37
ATP/ADP ratio, 526
ATP-modulated K channels. See ATP-sensitive
K channel (K/ATP channel)
ATP-sensitive K channel (K/ATP channel), 365,
526527
ATRA. See all-trans retinoic acid
atrial fibrillation, 409b
atrial flutter, 409b
atropine, 96, 116, 124, 130t, 827
attention-deficit hyperactivity disorder (ADHD),
213214
A-type natriuretic peptide (ANP), 335336
atypical antidepressants, 217
drug summary table, 222223t, 309t
atypical antipsychotics, 199200
drug summary table, 205206t
schizophrenia and, 197
atypical depression, 212
AUC. See area under the curve
aura, 228
autoimmune disease, 792
tissue damage, characterization by, 793t
autoimmune reactions, 62
autoimmunity, 64, 792. See also Hypersensitivity
response
autolysins, cell wall degradation, 606
automated databases, pharmacoepidemiology
and, 875
autonomic ganglion
neurotransmission, 115116
synaptic signals, 118f
autonomic ganglionic blockade, tissues and, 119t
autonomic nervous system, 9495
cellular organization, 99
vascular tone and, 357358
autoreceptors, 90
dopamine receptor proteins and, 189
Avandia. See rosiglitazone
avolition, schizophrenia, 196
awake states, primary generalized seizures, 230, 230f
axitinib, 711t
AZA. See azathioprine
azacytidine, 695t
5-Azacytidine, 686, 686f, 784, 787t
azathioprine (AZA), 74, 684, 694t, 794, 795f, 803t
conjugation enzyme and, 73t
DNA structure, 684f
azelastine, 775t
azidothymidine (AZT), 659, 660b
azithromycin, 592, 597t
AZT. See azidothymidine; zidovudine
aztreonam, 610, 611, 616t
B general anesthesia and, 255
B cells, 732t, 733
bacitracin, 607, 614t, 717t
baclofen, 175, 184t
GABAA receptors and, 184t
GABAergic transmission and, 169t
bacteria
pharmacologic intervention, targets for, 566567
ribosomes, 588
bacterial cell wall
architecture, 600f
biosynthesis, pharmacologic agent inhibition
and, 602f
synthesis
bacterial infections and, 599617
biochemistry, 599606
pharmacologic agents, classes of, 606612
bacterial DNA, topoisomerases and, 582583
bacterial growth kinetics, bacteriostatic vs.
bactericidal drugs, 718f
bacterial infections
case study, 582
cell wall synthesis and, 599613
drug summary table, 596598t, 614617t
pharmacology of, 581595
bacterial protein synthesis, 583586
bactericidal antibiotics, 717t
bactericidal drugs, 566, 589
bacteriostatic antibiotics, 717t
Bacteroides, lincosamides and, 592, 594
bactoprenol phosphate, 603
balanced anesthesia, 256
barbiturates, 165, 170, 173175, 238t
clinical uses, duration of action and, 174t
CNS and, 98
drugs of abuse and, 286t, 296299
GABAA receptors, 183t
GABAergic transmission and, 169t
immune responses, immunotoxicity and, 64
intravenous anesthesia and, 255
seizures and, 234235
basal ganglia, 9798, 97f, 189
basal insulins, 533, 538t
basal nucleus of Meynert, 101
base excision repair (BER), 676, 680f
bases, tissue damage and, 885
basic multicellular units (BMU), 542
basiliximab, 801, 806t, 908t
basophil/mast cell, 732t
basophils, 731, 781
bazedoxifene, 515, 521t
BBB. See blood-brain barrier
B-cell non-Hodgkins lymphoma, 912
BCR-Abl tyrosine kinase, 5, 6, 713714t
imatinib and, interaction with, 5f
intracellular signaling pathways and, 3
BCR-Abl/C-KIT/PDGFR inhibitors, 708, 724t
BDNF. See brain-derived neurotrophic factor
becaplermin, 904t
Index 931
beclomethasone, 497, 498f, 503t, 830
asthma and, 835t
befloxatone, 139, 144t
serotonin degradation and, 214, 221t
behavioral tolerance, 287
belatacept, 801, 806t
benazepril, 349t
bendroflumethiazide, 352t
benign prostatic hyperplasia, 511
benperidol, 198f
benzbromarone
uric acid excretion and, 842
benzo[a]pyrene, metabolism of, 889f
benzocaine, dentistry, 157b
benzodiazepines, 165, 167f, 232t, 233f, 238t, 261t
adverse effects, 180
CNS and, 98
cytochrome P450 enzymes and, 51t
drugs of abuse and, 286t, 296299
duration of action and, clinical uses and, 172t
GABAA receptor activation, 171f
GABAA receptors, 170173, 170f
GABAergic transmission and, 169t
pharmacokinetics and metabolism, 172
seizures and, 234
benzothiazepines, 363, 370t, 405
benztropine, Parkinsons disease, 125, 195, 203t
benzylamines, 622, 626t
BER. See base excision repair
beta adrenergic agonists
asthma and, 834t
heart failure and, 452f
beta adrenergic antagonists, heart failure and, 452f
beta barrel, 3
beta pleated sheet, 3
beta thalassemia, 779
beta-1 receptors, off-target effects and, 58
beta-(1,3)-D-glucan, 619620
beta-(1,6)-D-glucan, 619
beta-2 receptors, off-target effects and, 58
beta-adrenergic receptor agonists, 140, 145t
asthma and, 827829, 834t
cAMP and, 429
cardiac contractility, 431432, 435t
drug summary table, 435436t
beta-adrenergic receptor antagonists. See beta-blockers
beta-adrenergic receptor kinase, cardiac contractile
dysfunction and, 429
beta-adrenergic receptor(s)
actions, 136137, 136t
epinephrine and, 14, 15f
local anesthesia and, 155
off-target effects and, 60
regulation, 15f
tissue localization and action, 10t
beta-agonists. See Beta-adrenergic receptor agonists
beta-antagonists. See beta-blockers
(Beta-adrenergic receptor antagonists)
beta-arrestin, 137
beta-blockers (Beta-adrenergic receptor
antagonists), 23, 141142, 141t, 146t, 413
acute coronary syndromes and, 452f
class II antiarrhythmic drugs, 413, 419t
coronary artery disease, 450
heart failure and, 459f, 460t, 461
hypertension, 442443
hyperthyroidism and, 486487
indications and contraindications, 445t
off-target effects and, 60
oxidation/reduction enzyme and, 73t
thyroid gland and, 488t
vascular tone and, 366, 371t
beta-cells, insulin and amylin from, 524
beta-endorphin, 269, 472
beta-glucocerebrosidase, 896
protein therapeutics and, 900t
beta-lactam antibiotics, 718
bacterial cell wall and, 600
specific agents, 610612
structural features, 608f
toxicity, 610f
932 Index

beta-lactam ring, 608, 608f future directions, 557558 Caenorhabditis elegans, 642
beta-lactamase inhibitors, 609 physiology of, 541548 caffeine
drug combinations and, 721 bone remodeling asthma and, 829
beta-lactamases, 572 osteoblasts vs. osteoclasts, 542 drugs of abuse and, 286t, 301
DNA plasmids and, 609 regulation of, 542543 CAH. See congenital adrenal hyperplasia
beta-tubulin, 682 bortezomib, 710, 714t, 724t CAII. See carbonic anhydrase II
betaxolol, 142, 146t bosentan, 365, 370t CAIV. See carbonic anhydrase IV
bethanechol, 96, 122123, 129t botulinum toxin, 120, 128t calcifediol, 557, 560t
bevacizumab, 710711, 715t, 724t, 907t protein therapeutics and, 905t calcimimetics
bezafibrate, 328 BP. See blood pressure drug summary table, 561t
B-fibers, 149, 149t BPAD. See bipolar affective disorder secondary hyperparathyroidism, 556557
biased libraries, 853 brachial plexus blocks, 152153 calcineurin, 797
bicarbonate, gastric acid secretion and, 809 bradykinin calcitonin, 555
bicuculline, 170 asthma, 821 calcium homeostasis and, 547548
GABAA receptors, 182t nociceptors and, 148 drug summary table, 559t
GABAergic transmission and, 169t receptors, 267 calcitonin gene-related peptide (CGRP), 267, 480
Biers block, 157 brain asthma, 821
biguanides, 532533, 535, 539t blood-brain barrier and, compounds and, 107f calcitonin-salmon, protein therapeutics and, 903t
bile acid absorption inhibitors, 326, 330t catecholamine pathways in, 186 calcitriol, 560t
biliary excretion, drug reabsorption and, 37 dopamine receptor proteins and, 189, 190f calcium absorption and, 546547
biliary lipid secretion, 320321, 321f seizures and, 225226 secondary hyperparathyroidism, 556
bimatoprost, 763t brain capillary, peripheral capillary vs., 107f vitamin D, 557
binders, 858 brain reward pathways calcium (Ca2), 542. See also calcium channel
binding site, 3 opioids and, 296f blockers; calcium channels; calcium
bioavailability psychological dependence and, 289 gluconate
drug absorption and, 2930, 30f brain-derived neurotrophic factor (BDNF), bone mineral homeostasis, disease of, 561t
equation, 29 neurotransmission and, 267 carbonate, hypocalcemic states, 557
biochemical assays, 855 brainstem, 97, 97f, 99 chloride, hypocalcemic states, 557
bioequivalence, ANDA and, 870 brand name, drugs, 869 citrate, hypocalcemic states, 557
biogenic amines, 102, 103t, 104106 breast carcinoma, 511 cycling, regulation of, 426427
biological membranes bretylium, cardiac rhythm and, 414, 420t homeostasis
centran nervous system, 29 British anti-Lewisite, 884 cardiac contractile dysfunction and, 427429
diffusion, 2829, 29f brofaromine, 139, 144t hormonal control of, 543548, 545t
traversing, 28 serotonin degradation and, 214, 221t hormonal control of, 543548
Biologics License Application (BLA), 867 bromocriptine, 194, 470, 471, 478t, 511 hypocalcemic states, 557
biomarkers, clinical trials and, 866 brompheniramine, 774t lactate, hypocalcemic states, 557
biopharmaceutical review, IND and, 867 bronchial smooth muscle, local anesthetics, 158 oral, hypocalcemic states, 557
biosimilars, 915 bronchodilators, asthma, 827829 phosphate, hypocalcemic states, 557
biotransformation, drugs and, 34, 43 B-type natriuretic peptide (BNP), 335336, 344 release, 425426
biperiden, 125 drug summary table, 350t storage, 425426
bipolar affective disorder (BPAD), 207, 211, 212b BuChE. See butyrylcholinesterase calcium acetate, bone mineral homeostasis and,
birth defects, off-target effects and, 60 bucindolol, 78 556, 560t
bis-alkylate, 687 budesonide, 498f, 503t, 835t calcium carbonate, 557, 560t, 561t, 816, 819t
bisoprolol, cardiac rhythm and, 413, 419t buffering capacity, tissue damage and, 885 bone mineral homeostasis and, 556
bisphosphonates bufuralol, cytochrome P450 enzymes and, 51t calcium channel blockers
drug summary table, 559t bumetanide, 346, 351t, 442t chemical classes, 363364
hypercalcemia, 554b bundle of Kent, accessory electrical pathways, class IV antiarrhythmic agents, 415, 421t
structures, 552555, 553f 408, 408f coronary artery disease and, 450451
bitolterol, 828, 834t bupivacaine, 159, 161162t cytochrome P450 enzymes and, 51t
bivalirudin, 392 central nerve blockade, 157 drug summary table, 369370t
drug summary table, 398t infiltration anesthesia, 156 epilepsy and, 233234
protein therapeutics and, 905t on-target adverse effect, 58 grapefruit juice effect and, 53
UA/NSTEMI, 453 buprenorphine, 275, 281t mechanism of action, 363
BLA. See Biologics License Application addiction and, 297f, 305 oxidation/reduction enzyme and, 73t
black box warning, 869 drug dependence and, 308t pharmacokinetics, 364
black lung, 891 bupropion, 217, 222t relative indications and contraindications, 445t
bleomycin, 690691, 690f, 697t, 723t addiction and, 305 selectivity of, 364t
combination chemotherapy, 726, 726f atypical depression and, 212 sites of action, 364f
blood flow drug dependence and, 309t toxicities and contraindications, 364365
abnormal, 381 serum sickness and, 62 vasodilators and, 358f, 359, 443
drug distribution and, total and burn patients, ketamine and, 265 calcium channel inhibitors, 237t
weight-normalized, 32t buspirone, 217, 223t calcium channels, 89
blood pressure (BP) butaclamol, 198f local anesthetics and, 158
ACE inhibitors, 343f butenafine, 622, 626t calcium citrate-malate, 561t
determination, 439, 439f butoconazole, 623, 627t calcium gluconate, 557, 561t
essential hypertension, 439 butorphanol, 275, 281t calcium pump, 424, 424f
blood-brain barrier (BBB), 29, 106107, 107f, 911 butyl trimethyl ammonium (TMA), partial calcium-sensitizing agents, 433
BMU. See basic multicellular units agonists, 23f drug summary table, 436t
BNP. See B-type natriuretic peptide butyrates, 784 cAMP (cyclic AMP), 9, 10f
bone butyrophenones, schizophrenia and, 197, dopamine receptors and, 189
mineral balance, 542 199f, 204t phosphodiesterase inhibitors and, 362
structure of, 541, 543f butyrylcholinesterase (BuChE), 114 physical dependence, 289
bone anabolic agents, 555556, 560t SERCA and, 426
bone mass campath-1 (CD52), 801
age and, 546, 550f C camptothecins, 691, 723t
PTH and, 546 C fiber nociceptors, 149, 149t, 267 Canadian Food and Drugs Act, 869
bone mineral C1 inhibitor, protein therapeutics and, 900t canakinumab, 800, 805t, 908t
homeostasis CA. See Cocaine Anonymous cancer, chemotherapeutic agents. See also
case study, 542 Ca2. See calcium chemotherapeutic agents; tumor(s);
diseases, 548551, 549550t cabergoline, 470, 471, 478t, 511 specific e.g. prostate cancer
drug summary table, 559561t CAD. See coronary artery disease carcinogen and, 67
 Index 933

cells, 568571 cardiac rhythm cellular assays, 855

chemotherapeutic agents case study, 402 cellular communication, 82
classes, 723724t, 723t drug summary table, 418421t cellular excitability, 8289
drug metabolism and, 74 pharmacology of, 401417 cellular immunity, 733734
drug summary table, 694698t cardiovascular disease, 754 cellular senescence, 681
environmental exposures and, 887t lipoproteins and, 311 Center for Biologics Evaluation and Research
NSAID therapy and, 754 cardiovascular toxicity, drug-induced, 67 (CBER), 862
pharmacologic treatment, 674693 carmustine, 687, 687f, 696t, 921 Center for Drug Evaluation and Research (CDER), 862
pharmacology of, signal transduction and, 699715 carteolol, 142, 146t center-surround signaling, 100
receptor tyrosine kinases and, 701t carvedilol, 141t, 142, 146t central adrenergic neurotransmission,
candesartan, volume regulation and, 350t cardiac rhythm and, 413, 419t pharmacology of, 207224
cannabinoid receptors, 269, 299, 300f, 301 cytochrome P450 enzymes and, 51t central diabetes insipidus, vasopressin, 347
cannabinoids, 286t, 301 case-control studies central dopamine pathways, 189191, 191f
capecitabine, 684, 694t data analysis from, 876, 876f central monoamine neurotransmission, future
capillary fluid filtration, 333334, 334f schematic design, 876, 876f directions, 219
capreomycin, 720 caspofungin, 567, 625, 628t central nerve blockade, 157
capromab pendetide, 912, 913t catatonic behavior, schizophrenia, 195 central nervous system (CNS)
CAPS. See cryopyrin-associated periodic fever catecholamines acetylcholine and, 100f, 116119
syndromes conjugation enzyme and, 73t adenosine, caffeine and, 301
capsid, 650 metabolism, 189f amino acid neurotransmitters, 102103, 104f
captopril, 349t, 371t, 444 metabolism, inhibitors, 139 anatomy, 9699, 97f
carbachol, 122, 123f, 123t, 129t receptors, 135137 capillaries in, peripheral vasculature vs., 107f
carbamazepine, 232t, 236t, 277 reuptake inhibitors, 134f, 139, 144t cellular organization, 99, 100f
BPAD and, 218 reuptake, metabolism and, 133135, 134f, 138f depression, barbiturates and, 165
cytochrome P450 enzymes and, 51t storage, inhibitors, 138139, 138f, 143t drugs and, 29, 124126, 125b, 126b
immune responses, immunotoxicity and, 64 synthesis, 105f, 132133, 134f, 186, 188f electrical neurotransmission in
P450 enzymes and, 39, 50 inhibitors, 134f, 137, 143t case study, 226
sodium channels and, 231232, 232t, 236t catechol-O-methyltransferase (COMT), 135 pharmacology of, 225239
trigeminal neuralgia, 272 catecholamine metabolism and, 187189 GABA and, 164165
carbapenems, 608, 611612, 616t monoamines and, 210 local anesthetics and, 157
carbenicillin, 609, 611, 615t Caucasians, drug metabolism and, 52, 73 neurotransmitters and, 100, 103t, 180
carbidopa, 107 caudate, 98 partial pressure, 241
L-DOPA metabolism, 194f CBER. See Center for Biologics Evaluation and small molecule neurotransmitters, 102, 103t, 104f
Parkinsons disease, 193 Research central sensitization, 271272, 272f
carbinoxamine, 774t CBG. See corticosteroid-binding globulin central sympatholytics, 443
carbon monoxide (CO) CCD. See cortical collecting duct central tolerance, autoimmunity and, 792
poisoning, 881882 CCR5 antagonist, NNRTIs and, 662b cephalexin, 611, 616t
mechanism of, 882f CD. See collecting duct cephalic phase, gastric acid secretion, 809
carbonic anhydrase II (CAII), 338 CD4 cell count, 44 cephalosporins, 608, 611, 616t
carbonic anhydrase inhibitors CD40 ligand (CD40L), 735736, 735f cerebellar hemispheres, 98, 98f
drug summary table, 351t CD52. See campath-1 cerebellar vermis, 98, 98f
renal Na reabsorption and, 345 CDER. See Center for Drug Evaluation and Research cerebellum, 98, 98f
carbonic anhydrase IV (CAIV), 338 cefaclor, serum sickness and, 62 cerebral cortex, 97, 97f
carboplatin, 689f, 690, 696t cefazolin, 611, 616t cerebral hemispheres, 96, 97f
carboprost, 763t cefepime, 611, 616t cerebral white matter. See white matter
carboxy penicillins, 610 cefoperazone, 616t cerebrum, 9798, 97f
carcinogen, 67 cefotaxime, 616t certolizumab, 762t, 799, 804t, 907t
carcinogenesis, due to drug therapy, 67 cefotetan, 616t cervical spinal nerves, 95f, 96
cell proliferation and, 568570 cefoxitin, 616t cestodes (Tapeworms), 640
carcinogenicity, chronic toxicology and, ceftaroline, 616t cetirizine, 771, 775t
887892, 888f ceftazidime, 611, 616t CETP. See cholesterol ester transfer protein
cardiac action potentials, 402405 ceftizoxime, 616t cetrorelix, 474, 479t, 520t, 909t
phase 0, 404405 ceftriaxone, 616t cetuximab, 707, 713t, 724t, 906, 907t, 915
phase 1, 405 cefuroxime, 611, 616t cevimeline, 123, 129t
phase 2, 405 Celebrex. See celecoxib CFR. See coronary flow reserve
phase 3, 402, 405 celecoxib (Celebrex), 757, 762t cGMP. See cyclic guanosine monophosphate
phase 4, 402, 405 drug study and, 877 cGMP phosphodiesterase type V (PDE5), 362
cardiac compensation, 457 immune responses, immunotoxicity and, 64 cGMP-dependent protein kinase, 355
cardiac remodeling, hypertrophy, 457458 peripheral sensitization, 271, 276 CGRP. See calcitonin gene-related peptide
Frank-Starling mechanism and, 457 celiac ganglion, 96 channel selectivity, 8486, 85f, 85t, 86f
neurohumoral activation, 458 celiprolol, 141t ChAT. See choline acetyltransferase
cardiac contractility cell adhesion blockade, 802, 806t chelators, heavy metal, 884f
case study, 423 cell membrane chemical antagonist, 21, 23
pharmacology of, 422433 electric circuit model of, 84f chemical burns, 885
cardiac contraction, physiology of, 422427 ion channels and, 84, 84f chemical dependence. See addiction
cardiac death, 449 stability, inhibitors of, 612, 617t chemical reaction-based systems, drug delivery
cardiac disease, drug metabolism and, 54 cell recruitment, inflammatory response and, 737 and, 920921
cardiac function, blood pressure elevation and, 439 cell surface adhesion receptors, 13 chemical transmission, cells and, 83
cardiac glycosides, 429431 cell wall chemical-synapse, neuromuscular junction and, 90
drug summary table, 434t bacterial, 599 chemistry review, IND and, 863, 867
heart failure and, 462 biosynthesis, 601 chemokines, inflammatory response and, 737
cardiac ion currents, molecular identity of, enzymes of, 603b chemosensitive transduction receptors, nociceptor
416, 416t pharmacologic agent inhibition and, 602f neurons, 266, 266t
cardiac myocytes, contraction, functional degradation, autolysins and, 606 chemotaxis, inflammatory response and, 737
anatomy, 425 synthesis, cross-linking, 604 chemotherapeutic agents. See also antineoplastic
cardiac output (CO) cell-cycle nonspecific drugs, 570571 drugs; chemotherapy; combination
anesthesia induction and, 251, 251f cell-cycle specific drugs, 570, 571f chemotherapy
determinants, 457f cell(s) cancer, 66
distribution, volume capacity and, general drug binding and, 1415 classes of, 723724t, 723t
anesthesia and, 246f, 247 drugs and, 2829 selective targeting mechanisms, 564566, 564t
cardiac remodeling, 457458 of immune system, 730732, 731f, 732t tumor resistance, mechanisms of, 725t
934 Index
chemotherapy, 570571
case study, 700
cytotoxic agents and, 67
children, anesthesia induction in, 251252, 252f
chitin, 619
Chlamydia trachomatis, 599
chloral hydrate, GABA physiology and, 176
chlorambucil, 696t
cancer and, 67
conjugation reactions and, 46t
DNA structure and, 687
chloramphenicol, 107f, 231, 592594, 593f, 594f,
597t, 719
drug metabolism and, 53
oxidation/reduction reactions, 45t
chlordiazepoxide, 231
clinical uses for, duration of action, 172t
GABAA receptors and, 183t
chlorinated hydrocarbons, toxicity and, 892
2-chloroprocaine (Nesacaine), 158, 161t
chloroquine, 567, 644t
antimalarial drug-resistance and, 636
drug-resistance and, geographic, 633, 633f
malarial plasmodia and, 632633
Vd of, 33
chlorothiazide, 442t
chlorpheniramine, 770, 774t
chlorpromazine, 197, 198f, 204t
chlorpropamide, 538t
chlorprothixene, 204t
chlorpyrifos, 885
chlortetracycline, 591, 597t
chlorthalidone, 346, 352t, 442t
cholecalciferol, 546, 560t
cholesterol
absorption, 314f, 326327, 330t
balance, 321
metabolism
case study, 312
pharmacology, 311329
cholesterol ester transfer protein (CETP), 320
cholesterol synthesis inhibitors, 324326, 330t
cholestyramine, 326, 330t, 485
choline, 111
choline acetyltransferase (ChAT), 110111, 112f
cholinergic neurotransmission, 110119
cholinergic pharmacology, 110127, 128130t
cholinergic receptors, 113119
cholinergic toxicity, 125b
cholinergic transmission, physiological effects,
115119
cholinesterase inhibitor poisoning, 125b
cholinesterases, 52, 114
choreoathetosis-with-salivation syndrome (CS), 887
chromosomal genes, antibiotic resistance, 609
chromosome maintenance, 681f
DNA repair, 676679
chronic bronchitis, 822b
chronic coronary artery disease (CAD)
clinical management, 450452
pathophysiology of, 446448
chronic inflammation, 738
chronic kidney disease, 550551
agents for, 551556
secondary hyperparathyroidism, 556557
chronic myeloid leukemia (CML), 708
chronic obstructive pulmonary disease
(COPD), 822b
chronic rejection, 792
chylomicron, 314f
chylomicron remnant, 316, 316f
ciclesonide, 830, 835t
cidofovir, 658, 671t
cigarette smoke, toxicity of, 888889
cilastatin, 617t
pharmacodynamic drug-drug interactions, 61
pharmacokinetic drug-drug interactions, 61
cilomilast, 833
cimetidine, 39, 231, 772, 775t, 818t
cytochrome 450 enzymes and, 51t
development of, 851
oxidation/reduction reactions and, 45t
peptic ulcer disease and, 812813
cinacalcet
drug summary table, 561t
secondary hyperparathyroidism, 556
cingulate gyrus, 97f, 98
ciprofloxacin, 2, 39, 587, 596t
cytochrome P450 enzymes and, 52t
immune responses, immunotoxicity and, 64
off-target effects and, 60
ciproxifan, 772
circulatory failure, contractile dysfunction and,
455, 455t
circumventricular organs, 191
cirrhosis, 341342
drug metabolism and, 54
Na retention and, mechanisms, 341342, 342f
cisapride, 217
drug metabolism and, 54
cisatracurium, 261t
cisplatin, 689, 689f, 696t, 723t
citalopram, 216, 221t, 277
c-kit inhibitors, 713714t
c-kit ligand, 779
cladribine, 685f, 686, 695t, 867
clarithromycin, 51t, 597t
H. pylori, 817
class effects, 58
clavulanic acid, 609, 615t, 721
clearance, of drugs, 34f, 3738
clear-core synaptic vesicles, 91
clemastine, 774t
clevidipine, 363, 369t
clindamycin, 593f, 594f, 597t, 721
malarial plasmodia and, 635636, 645t
clinical drug
development, 863867
evaluation, regulatory approval and, 860871
testing, in humans, 864866, 865t
clinical hold, 863
clinical pain syndromes, 270
clinical pharmacology, 866
clinical trials
authorizations for, 863
development of, 864865, 865t
in humans, 864866, 865t
planning and execution, 868t
clobenpropit, 772
clomiphene, 514515, 521t
clomipramine, 215, 221t
cytochrome P450 enzymes and, 5152t
clonazepam, 172, 238t
clinical uses for, duration of action, 172t
GABAA receptors and, 183t
seizures and, 234
clonidine, 105, 139, 144t, 277278, 443, 470
detoxification and, 303
hypothalamus and, 98
pain and, 269
clopidogrel, 375, 383384, 396t
cytochrome P450 enzymes and, 52t, 53
UA/NSTEMI, 453
clorazepate
clinical uses for, duration of action, 172t
GABAA receptors and, 183t
clorgyline, 139, 144t
closed state, CNS and, 226
Clostridium difficile, 594, 607
clotrimazole, 623, 627t
cloxacillin, 609, 610, 615t
clozapine, 198f, 205t
cytochrome P450 enzymes and, 52t
schizophrenia and, 200
CML. See chronic myeloid leukemia
CMP. See cytidylate
CMV. See cytomegalovirus
CNP. See C-type natriuretic peptide
CNS. See central nervous system
CNS partial pressure, 241
CO. See carbon monoxide; cardiac output
coagulation cascade, 372, 375379, 378f
coal workers pneumoconiosis (CWP), 891
coating agents, 816, 819t
cocaethylene, 302
cocaine, 144t, 147, 156, 158, 161t, 299302
mechanism of action, 134f
norepinephrine transporter and, 139
physical dependence, 293
route of administration, drugs and, 294f
schizophrenia and, 196
single-source divergent neuronal systems, 101
Cocaine Anonymous (CA), 303
codeine (Methylmorphine), 74, 274, 280t
cytochrome P450 enzymes and, 51t
oxidation/reduction enzyme and, 73t
cognitive function, cholinergic link, 117
cohort studies
data analysis from, 877f
schematic design, 876, 876f
colchicine, gout and, 840841, 841f, 844t
colesevelam, 326, 330t
colestipol, 326, 330t
collagenase, 898, 905t
collecting duct (CD), nephron and, 339340, 340f
collecting duct (CD) diuretics, 347
drug summary table, 352t
colloid, thyroglobulin and, 481
colloidal bismuth, 816, 819t
combination chemotherapy. See also antineoplastic
combination chemotherapy
case study, 717
drug resistance and, 574
future directions, 726
HIV and, 721722
principles, 716726
combination therapy
diabetes mellitus and, 536
heart failure and, 462
combinatorial chemistry, 848, 852853, 852f
Common Technical Document (CTD), 867
compassionate use protocols, 869
competitive antagonist, 7, 21, 21f
agonist dose-response relationship vs., 2122, 22f
complement, inflammatory response and, 736737
complement inhibition activation, 802, 806t
compound-centered drug design, 848
COMT. See catechol O-methyltransferase
concentration (of gas), partial pressure vs., 242b
concentration effect, anesthesia, 254
concentration-dependent bactericidal agents,
718, 718f
concentric hypertrophy, 457458
conditioned opponent response, 287
conditioned tolerance, 287
conduction block, impulse and, 408
confounding by indication, 877
congenital adrenal hyperplasia (CAH), 501, 501f
congenital nephrogenic diabetes insipidus, 344
conivaptan, 350t, 479t
conjugation, 572
conjugation/hydrolysis reactions, 3435, 47, 49f
consensus interferon, 902t
contraception. See also male contraception; oral
contraceptives; specific e.g. combination
contraceptive formulations
emergency, 517
hormones and analogues, 516517
contractile dysfunction
cellular pathophysiology of, 427429, 428f
etiologies, 455457
contractile state, 422
contractility, regulation of, 424427, 456
contrast media, 66
controllers, asthma treatment, 827
convergent signaling, 100
convergent synthesis, 857, 857f
COPD. See chronic obstructive pulmonary disease
coronary artery disease (CAD), alcohol and, 302
coronary artery occlusion, 448, 448f
coronary flow reduction, 447448
coronary flow reserve (CFR), 447
coronary steal phenomenon, 359

corpus callosum, 97, 228
corpus luteum, menstrual cycle and, 509
cortical collecting duct principal cell, 337,
339340, 340f
cortical spreading depression, migraine headaches
and, 272
corticosteroid-binding globulin (CBG), 490491
corticosteroids
asthma and, 829830, 835t
thyroid hormone homeostasis, 487
corticotropin-releasing hormone (CRH), 106, 472
cortical secretion, 492493
cortisol
analogues, 494, 495f
backbone, synthetic modifications,
494495, 494f
hypothalamic-pituitary unit and, 492493
immune responses and, 492, 493f
cortisone, 495f
costimulation
immune system and, 731
T cell activation pathway and, 734, 735f
costimulation inhibition, 806t
cosyntropin, 479t, 913t
cough variant asthma, 824
counter-regulatory hormones, 525
coupling, thyroglobulin and, 481
covalent bonding, 3
COX. See cyclooxygenase
COX-1, 742t
COX-2, 742t
COX-2 selective inhibitors, 757758, 757f, 762t
adverse effects, 742t
COX-3, 742744
cranial nerves, 99
craniosacral system, 95f, 96
cravings (for drug), addiction and, 289
Cremophor, immune responses, immunotoxicity
and, 64
CRH. See corticotropin-releasing hormone
cromakalim, 365, 370t
cromolyns, 769, 836t
asthma and, 830
cross-dependence, 296
crossover design, clinical trials and, 864
cross-tolerance, 303
crotalidae polyvalent immune Fab (Ovine), 909t
cryopyrin-associated periodic fever syndromes
(CAPS), 800
CS. See choreoathetosis-with-salivation syndrome
CTD. See Common Technical Document
C-type natriuretic peptide (CNP), 336
13
C-urea breath test, 810811
Cushings syndrome, 494, 811
CWP. See coal workers pneumoconiosis
cyanide poisoning and treatment, 883
cyclases, activation of, 9, 11f
cyclic AMP. See cAMP
cyclic guanosine monophosphate (cGMP), 355
cyclizine, 775t
cyclooxygenase enzymes, NSAIDs and, 271, 275
cyclooxygenase inhibitors, 395t, 754758
thrombus formation and, 382383, 384f
cyclooxygenase pathway, 742745
cyclophosphamide, 687, 687f, 696t, 723t, 796, 803t
activation and metabolism, 689f
DNA damage and, 67
oxidation/reduction enzyme and, 73t
structure and, 687f
cycloserine, 607, 607f, 614t
cyclosporine, 51t, 796797, 797f, 803t, 849
immune responses, immunotoxicity and, 64
immunosuppression, 922
oxidation/reduction enzyme and, 73t
cyfluthrin, 887
CYP2D6. See cytochrome P450 2D6
CYP3A4 enzymes, 61
cypermethrin, 887
cyproheptadine, 774t
cys-loop superfamily, anesthetics and, 259
cytarabine (araC), 686, 686f, 695t
cytidine, DNA structure of, 686, 686f
cytidylate (CMP), 676
cytochrome P450 2D6 (CYP2D6), 7276
drug metabolism, 74
pharmacogenetics, 74f
cytochrome P450 enzymes, 72
drugs and, 4950, 5152t
oxidation/reduction reactions, 34, 45t, 47, 48f
cytochromes, adrenal cortex and, 490
cytokine antagonists, 762t
cytokine inhibitors, 758
immune function and, 798801, 805t
cytokine receptor antagonists, 800, 805t
cytokine release, glucocorticoids and, 496
cytokine release syndrome, 800
cytokines, 737
cytomegalovirus (CMV), 655
cytoprotective roles, 744
cytosine, 581
cytotoxic agents, 794796, 803t
cytotoxic T cells, 732t
D dexfenfluramine, serotonin storage and, 214, 220t
D1 receptors, 189, 190f
D2 receptors, schizophrenia and, 189, 190f
DA. See dopamine
dabigatran, 392, 399t
dacarbazine, 687, 696t, 726
daclizumab, 801, 806t, 909t
dalfopristin, 572, 593f, 594, 598t
dalteparin, 391, 398t
dantrolene, 254
DAP. See diaminopimelic acid
dapsone, 73t, 576, 579t
daptomycin, 572, 612, 617t
darbepoetin (NESP), 783, 787t
darbepoetin alfa, protein therapeutics and, 901t
darbepoetin-alpha, 895
darifenacin, 125, 130t
darunavir, 662, 672t
dasatinib, 708, 714t
DAT. See dopamine transporter
daunorubicin, 697t, 922
dazoxiben, 758, 763t
dCMP. See deoxycytidylate
DCT. See distal convoluted tubule
de novo synthesis, 837
dead-end complex, 608
debrisoquine, 73, 74f
oxidation/reduction enzyme and, 73t
DEC. See diethylcarbamazine
decitabine, 695t, 784, 787t
Declaration of Helsinki, 862
deep vein thrombosis, contraceptives, 517
deferasirox, 884
deferoxamine, 884
degarellx (GnRH receptor antagonist), 907t
degenerin/ENaC, 266267
dehydroepiandrosterone (DHEA), 168, 501, 504t
delavirdine, 661, 671t
cytochrome P450 enzymes and, 51t
delayed afterdepolarization, 407, 407f
delayed rectifier K channels, 88
delayed-type hypersensitivity. See hypersensitivity
response type IV
delta-aminolevulinic acid dehydratase (ALA-D), 884
deltamethrin, 887
delusions, schizophrenia, 195
demeclocycline, 344, 591, 597t
dendritic cells, 732, 732t, 781
denileukin diftitox, 712, 715t, 723t, 910, 910t
denosumab, 555, 559t
dense-core synaptic vesicles, 91
dentistry, local anesthetics and, 157b
deoxycytidylate (dCMP), 676
deoxyribonuclease I (DNAse1), 898
deoxythymidylate (dTMP), 676
dependence
mechanisms, 288291, 288f, 290f
medical complications, 302
Index 935
pharmacologic treatment of, 304306
treatment, 302303
dependence syndrome, 289
dephosphorylase, 604
depolarized membrane, 83
depolarizing blockade, 123
depression. See specific e.g. melancholic depression
dermatomal distribution, 96
desensitization, drug-receptor interactions, 14, 15f
desflurane, 249, 255, 260t
desipramine, 74, 215, 221t, 277
addiction and, 305
cytochrome P450 enzymes and, 51t
drug dependence and, 309t
desirudin, 398t, 905t
desloratadine, 771, 775t
desmethyldiazepam, 172
desmopressin, 347
desogestrel, 516, 516f, 523t
desvenlafaxine, 216, 222t
detergents, tissue damage and, 885
detoxification, dependence and, 303
dexamethasone, 494, 495, 495f, 503t, 754, 762t, 803t
dexlansoprazole, 813, 818t
dexmedetomidine, 140, 144t
dexrazoxane, 691
dextroamphetamine, serotonin storage and,
213214, 220t
dextromethorphan, 74, 272, 277, 283t
cytochrome P450 enzymes and, 51t
oxidation/reduction enzyme and, 73t
DGAT. See diacylglycerol acyltransferase
DHA. See docosahexaenoic acid
DHDOC. See 5-dihydrodeoxycorticosterone
DHEA. See dehydroepiandrosterone
DHF. See dihydrofolate
DHFR. See dihydrofolate reductase
DHOD. See dihydroorotate dehydrogenase
DHT. See dihydrotestosterone
diabetes insipidus, 474, 475f. See also central
diabetes insipidus
diabetes mellitus
morbidity and mortality, 532
pathophysiology, 530532, 530t
therapy for, pharmacologic classes and agents in,
532536
type 1, 530531, 530t
protein therapeutics, 896
type 2, 531532
protein therapeutics, 896
diabetic ketoacidosis (DKA), 531
diacylglycerol acyltransferase (DGAT), 314
Diagnostic and Statistical Manual of Mental
Disorders
bipolar disorder and, 212b
MDD and, 211b
schizophrenia and, 196b
substance dependence and, 287b
diaminopimelic acid (DAP), 601
diastolic heart failure, 427, 456
diazepam, 171172, 238t, 261t
clinical uses for, duration of action, 172t
GABAA receptors and, 183t
general anesthesia and, 255
seizures and, 234
withdrawal and, 303
diazinon, 885
diazoxide, 540t
diclofenac, 276, 756, 761t
dicloxacillin, 609, 610, 615t
dicyclomine, 816, 819t
didanosine, 671t
diencephalon, 96, 97f, 98
dopamine receptor proteins and, 189
diet
drug metabolism and, 5354
peptic ulcer disease, 816
dietary supplement. See supplements
Dietary Supplement Health and Education Act of
1994, 870
936 Index

diethyl ether, 240, 249, 260t structure drug addiction. See addiction
diethylcarbamazine (DEC), filarial infections, drugs modifying, 582f, 686691, 687t drug approval
642, 648t supercoiling, type II topoisomerases and, drug review and, 896f
differential functional blockade, 153 regulation, 584f life cycle of, 862f
differentiating agents, 723t transcription, 581595 process, 867870, 869f
diffuse neuronal systems, 101f translation, 581595 drug delivery systems
diffuse system of organization, 100 DNA polymerase, 655 asthma, 831832
diffusion, drug delivery, 919920 DNAse1. See deoxyribonuclease I case study, 918
diffusion hypoxia, 254 dobutamine, 140, 145t, 432, 435t conclusion and future directions, 922923
diffusion rate, equation, 245 heart failure and, 460t, 462 intelligent, 921922
digitoxin, 429, 431, 434t docetaxel, 692693, 698t liposome-based, 922
oxidation/reduction reactions and, 45t docosahexaenoic acid (DHA), 331t modalities, 917923
digoxin, 33, 49, 50, 424, 429431, 434t docosanol, 667, 673t oral, 917918
conjugation reactions and, 46t dofetilide polymer-based, 919922
heart failure and, 460t cardiac rhythm and, 414, 420t pulmonary, 918919
pharmacokinetics of, 430t domoate, 225226 transdermal, 919
positive inotropic mechanism, 429f donepezil, 106, 121, 122t, 129t drug design
digoxin immune Fab, 434t, 910t DOPA (dihydroxyphenylalanine), 132 compound-centered, 849851
dihydroartemisinin, 644t decarboxylase, 107 structure-based, 853
malarial plasmodia and, 634 dopamine (DA), 137, 186189, 188f, 431432, target-centered, 851853
5-dihydrodeoxycorticosterone (DHDOC), 168 435t, 470 drug development, 857858
dihydrofolate (DHF), 576, 676 conjugation enzyme and, 73t case study, 848
dihydrofolate reductase (DHFR), 575, 576577, future directions, 200201 rare diseases and, 866867
639, 676 hypothalamic-releasing factors, 471, 471f drug discovery
dihydrofolate reductase (DHFR) inhibitors, 565 metabolism inhibitors, 195 efficacy models in, 856t
future of, 565b drug summary table, 202203t phases of, 849f
sulfonamides and, synergy of, 577578 neurotransmitters and, 102, 103t preclinical development and, 847859
values for, 577t Parkinsons disease, 191195, 192f process, 848853
dihydroorotate dehydrogenase (DHOD), 632 precursors, 193194 drug dose. See dose
dihydropyridines, 363, 369t, 405 drug summary table, 202t drug formulation, 858859, 858t
cardiac rhythm and, 415 receptor agonists, 194195 drug naming, 869870
dihydrotestosterone (DHT), 506, 508f drug summary table, 202t Drug Price Competition and Patent Term
dihydroxyphenylalanine (DOPA), 132 receptors, 189, 190f Restoration Act of 1984, 870
diiodotyrosine (DIT), 481 thought disorders and, 195200 drug production, regulatory aspects, 870
diisopropyl fluorophosphate, 120, 129t dopamine beta hydroxylase, 104, 132, 187 drug resistance
diltiazem, 39, 51t, 363, 364t, 370t, 405, 443 dopamine dysregulation syndrome, 195 drug therapies and, 572574
cardiac rhythm and, 415, 421t dopamine hypothesis, 196 genetic causes, 572574
dimenhydrinate, 771, 774t dopamine neurons, Parkinsons disease and, 191 mechanisms of, 572, 573t
dimercaprol, 884 dopamine transporter (DAT), 187, 210, 300 drug study
dipeptidyl peptidase-4 (DPP-4), 530 dopaminergic neurotransmission, 186 design and interpretation, 877878
dipeptidyl peptidase-4 (DPP-4) inhibitors, 536, 539t biochemistry and cell biology, 186191 duration and post approval, 874
diphenhydramine, 58, 126b, 770, 771, 774t case study, 187 size and generalization, 872873
dipyridamole, 359, 395t drug summary table, 202206t strategies, 876877, 876f, 877f
direct thrombin inhibitors, 391392 pharmacology, 193195 surrogate, 872873
drug summary table, 398t dopaminergic pathways, movement regulation drug targeting
UA/NSTEMI, 453 and, 191f passive, 922
Directly Observed Therapy Short Course. See DOTS doripenem, 611, 617t pharmacology, drug resistance mechanisms,
discovery biology, 855856 dornase alfa, protein therapeutics and, 905t 572574
diseases, affecting drug metabolism, 54 dorsal columns, 96 similar, selective inhibition of, 565566
disodium cromoglycate dorsal horn neurons, central sensitization, 271, 272f unique, 565
asthma and, 830 dorsal root ganglia, sensory neurons and, 96 drug toxicity, 5657
disopyramide, 411, 418t dorsal roots, somatic nervous system and, 96 contexts of, 6069
disorganized speech, schizophrenia, 195 dose, 3942, 40f future directions of, 6970
distal convoluted tubule (DCT), 337, 339f tolerance, 285 mechanisms of, 5760, 58f, 59f
distribution systems, drug absorption, 27, 28f toxicity, 61, 63f online resources, 70t
disulfiram dose-response curves, 241, 243f treatment, principles of, 69
addiction treatment and, 304 dose-response relationships, 1820 drug transport, 4749
alcohol metabolism, inhibition, 307t DOTS (Directly Observed Therapy Short Course), 720 drug user, subtypes, alcohol and, 293
cytochrome P450 enzymes and, 52t double-blind study, clinical trials, 864, 866 drug-drug interactions, 6162, 718719, 719f
drug dependence and, 307t double-strand break repair, 679681, 680f H2 receptor antagonists, 812
DIT. See diiodotyrosine down-regulation, 1415 plasma protein binding and, 3334
diuretics. See also specific type e.g. collecting duct doxazosin, 141, 145t, 371t, 443 drug-eluting stent, 454
diuretics doxecalciferol, 560t drug-herb interactions, 6162
heart failure and, 459460 doxepin, 221t, 771, 775t drug-receptor(s)
hypertension and, 441442, 442t doxercalciferol, 560t, secondary hyperparathyroid- affinity
intravascular volume, reduction of, 441442 ism, 556 bond strength of, 34, 5t
nonreceptor mediated mechanisms in, 15 doxorubicin, 697t, 723t, 922 interactions, 216, 7t
relative indications and contraindications, 445t combination chemotherapy, 726 binding, 1718, 19f
divergent signaling, 100 heart failure and, 691 binding curves, 18, 19f
DKA. See diabetic ketoacidosis doxycycline, 242, 591, 592, 597t interactions, 15f, 20
DNA malarial plasmodia and, 635636, 645t cellular regulation of, 1415
alkylating agent, 50 doxylamine, 771 membrane effects on, 56
damage and repair mechanisms, 679f DPP-4. See dipeptidyl peptidase-4 signal processing, 1314, 14f
gyrase, 583, 587 DPPD (recombinant purified protein derivative), 913t types of, 613, 7f, 7t
plasmid dronedarone, cardiac rhythm and, 415, 421t drug(s). See also antineoplastic drugs; chemothera-
drug resistance and, 572 droperidol, 198f, 204t peutic agents; chemotherapy; clinical drug;
purine analogues, 686 general anesthesia and, 256 oral drug; specific drug e.g. penicillin
pyrimidine analogues, 686 droperidol and fentanyl combination therapy, 256 absorption
repair, chromosome maintenance and, 676679 drospirenone, 515, 516, 523t bioavailability, 2930, 30f
replication, 581595 drug abuse, 274, 284309 local factors affecting, 3132
strands, hydrogen bonding, 583f medical complications, 286t, 302 mechanism, 27, 28f
 Index 937

administration routes and, 3031, 30t, 31f eculizumab, 802, 806t, 908t endothelial dysfunction, 448
adrenergic table, 143146t ED. See erectile dysfunction endothelial injury, 381
adverse effects ED50. See median effective dose endothelial isoform of nitric oxide synthase. See eNOS
case study, 873 edema endothelial-derived relaxing factor. See EDRF
future directions, 879 loop diuretics and, 345346 endothelin, 357, 357f
health care system, 878879 pathophysiology, 340342 endothelin receptor antagonists, 365, 370t
bacterial cell wall biosynthesis and, 602f edetate disodium, heavy metal chelators and, 884 endothelin-converting enzyme, 357
binding Edinger-Westphal nucleus, 96 end-plate potential (EPP), 91, 115, 118f
cells and, 1415 EDRF (Endothelial-derived relaxing factor), 356 end-plate region, 117f
receptor and, impact of, 45 edrophonium, 96, 120121, 128t end-systolic pressure-volume relationship
cancer, 674693 EEG. See electroencephalogram (ESPVR), 456, 457f
signal transduction and, 699715 efalizumab, 65, 908t energy homeostasis, 525526, 526t
CNS and, 124126, 125b, 126b efavirenz, 51t, 568, 661, 662, 671t enflurane, 249, 255, 260t
combinations, unfavorable, 721 effective refractory period, 409b cytochrome P450 enzymes and, 52t
conformation and chemistry, 26 efficacy (Emax), 19 enfuvirtide (T-20), 652653, 653f, 670t, 906, 909t
dependence, pharmacology of, 284309 efflux pumps, tetracycline-resistant microbes and, 592 enkephalins, 106, 269
distribution eflornithine, African trypanosomiasis and, 640, 647t eNOS (endothelial isoform of nitric oxide
to body compartments, 3233, 32t EGFR. See epidermal growth factor receptor synthase), 356
four-compartment model, 34, 36f eicosanoids enoxacin, cytochrome P450 enzymes and, 52t
kinetics and thermodynamics of, 34, 34f, 35f, 36f case study, 741 enoxaparin, 391, 398t
plasma protein binding, 33f drug summary table, 761764t entacapone, 195, 203t
schematic model, 35f future directions, 759760 Entamoeba histolytica, 629, 637
volume of, 3334 inflammation and, roles of, 752t entecavir, 655, 671t
distribution phase, 34, 34f inflammatory response and, 737 enteral drug administration, 3031, 30t
electrical signaling, 82 metabolic inactivation, 748 enteral formulations, 858
elimination, 34, 34f, 35f, 36, 36f pathophysiology of, 752754 enteric coating, 858
erythrocyte production, 779781 pharmacologic classes and agents, 754759 enterochromaffin-like (ECL) cells, histamine and, 808
excretion, 36 pharmacology, 740760 enterohepatic circulation, 37, 321
generic, 870 eicosapentaenoic acid (EPA), 331t, 741 envelope, capsid and, 650
interactions, 718719, 719f EKG. See electrocardiogram environment, drug metabolism and, 5354
intravenous, bioavailability, 30f elderly environmental toxicology, 881
ion channels and, 84 anticholinergic drugs, adverse effects and, 126b acute and subchronic toxicology, 881887
labeling, 869 antimuscarinics and, 125 carcinogenicity and chronic toxicology, 887892
metabolism, 3436, 4354 drug metabolism and, 53 case study, 882
conjugation/hydrolysis reactions, 34, 46t plasma drug concentration and, 39b conclusion and future directions, 893
diseases affecting, 54 renal excretion, drugs and, 36 enzyme activity assays, 855
factors affecting, 5054 electrical dysfunction, pathophysiology of, 406408 enzyme inhibition, 50
future directions, 54 electrocardiogram (ECG or EKG), 405b, 405f structural basis of, 5f
oxidation/reduction reactions, 34, 45t electrochemical gradient, 84 enzyme variation, drug metabolism and, 7275, 73t
pathways, 4450, 45t, 46t electrochemical transmission, 8892 enzymes, 13
sites of, 43, 44f electroencephalogram (EEG) of cell wall biosynthesis, 603b
mucosal defense, gastric acid and, 816 absence seizures and, 230f eosinophil, 732t
overdose, 61 focal seizures and, 227 eosinophils, 731, 781, 826827
oxidation, cytochrome P450 system and, 48f electrogenic transport, 85 EPA. See eicosapentaenoic acid
pH trapping, 29 electron transport chain inhibitors, 644645t ephedra, FDA and, 871
physiologic barriers to, 2729 malarial plasmodia and, 634635 ephedrine, 139, 827
poisoning by, 881893 electron transport chain, malarial plasmodia and, EPI. See epinephrine
in pregnancy, 6869, 68b 631632, 632f epidermal growth factor receptor (EGFR)
reabsorption, biliary excretion and, 37 electroporation, 919 inhibitors, 699, 707, 713t
route of administration, plasma cocaine electrostatic force, 84, 85f epilepsy
concentrations and, 294f eletriptan, 217, 223t agents for, 233
safety challenges, 872874 elimination half-life, drugs and, 38 lamotrigine and, 180
selectivity, molecular and cellular determinants, 6 elongation, 585 epileptic seizures, classification of, 228t
trapping, plasma protein binding and, 33f eltrombopag, 788t epinephrine (EPI), 10, 132, 137, 156, 186, 432,
tumors and, 707712 Emax. See efficacy 435t, 821, 827, 834t
viral life cycle and, 651f EMEA. See European Medicines Agency beta adrenergic receptors and, 14
viruses and, 651668 emergency (morning-after) contraception, 517 conjugation enzyme and, 73t
drug-seeking behavior, 274, 285, 293f emesis, 191 neurotransmitters and, 102, 103t
dTMP. See deoxythymidylate EMLA (eutectic mixture of local anesthetic), 156, epipodophyllotoxins, 691692, 723t
d-tubocurarine, 126 162t epirubicin, 697t
duloxetine, 216, 222t, 269, 277 emphysema, 822b epitope, 732
Durham-Humphrey Amendment, 870 emtricitabine (FTC), 659, 671t eplerenone, 347, 352t, 442t, 500, 504t
dusts, toxicity of, 891892 enalapril, 349t, 371t, 444 epoetin alfa, drug development and, 867
dutasteride, 511, 520t encainide epoetin alfa, protein therapeutics and, 901t
dynamic instability, of microtubules, 682, 683f cardiac rhythm and, 412, 419t epoprostenol, 763t
dynorphins, 106, 269 drug study and, 874 epoxygenase pathway, 748
dyskinesias, 193 endocrine axis, 468 EPP. See end-plate potential
dyslipidemia, 324 endocrine disorders EPSPs. See excitatory postsynaptic potentials
dysphoria, addiction and, 301 protein therapeutics and, 903904t, 909t eptifibatide, 386, 396t
endocrine pancreas equilibration of alveolar, with inspired partial
case study, 525 pressure, 246247, 247f
E drug summary table, 538540t equilibration of tissue, with alveolar partial
early afterdepolarization, 406407, 407f pharmacology of, 524537 pressure, 247248, 248t
early-acting growth factors, 778 endocytosis, 28 ER. See endoplasmic reticulum; estrogen receptor
ebastine, 775t endogenous catecholamines, 137 erectile dysfunction (ED), 362
EC50. See potency of drug endogenous pathway modifiers, 723t EREs. See estrogen response elements
ECG. See electrocardiogram endometriosis, 511512 ergocalciferol, 546, 560t
echinacea, hepatic glutathione stores and, 6162 endoperoxide, 373 vitamin D, 557
echinocandins, 620, 625, 628t endoplasmic reticulum (ER), 47 ergosterol synthesis
ECL cells. See enterochromaffin-like cells endorphins, 106 inhibitors, 622624
econazole, 623, 627t endothelial cell contraction, 766 pathway, 619, 619f
938 Index

ergotamine, 217, 278 excitotoxicity, 178 fesoterodine, 125, 130t

ergots, 217 ischemic stroke, 179, 179f fetal alcohol spectrum disorder, 302
eribulin, 692, 698t excretion, drug, 27, 28f fetal alcohol syndrome (FAS), 890
erlotinib, 707, 713t exemestane, 511, 520t fetal hemoglobin (HbF), agents inducing, 783784,
ertapenem, 611, 617t exenatide, 535536, 539t 787788t
erythrocyte production, 779781 protein therapeutics and, 904t fetus, teratogenesis and, 6768, 68b
agents stimulating, 783, 787t exogenous glucagon, 540t fexofenadine, 775t
erythrocytes, 776 exogenous insulin, 533534, 538t off-target effects, 60
erythromycin, 51t, 566, 592, 594f, 597t, 719 extended release formulations, drug delivery FG. See fat group
metabolic drug interactions, 54 and, 917 FGF-23. See fibroblast growth factor 23
erythromycin A, 593f extended-spectrum -lactamases (ESBLs), 609 FH. See familial hypercholesterolemia
erythropoiesis, 779781, 781t external advisory committees, FDA and, 867868 fibrates, 326, 331t
erythropoietin, 779781, 787t, 895, 898, 901t extracellular enzymes, 13 lipid metabolism and, 327328, 327f
synthesis, regulation of, 780f extraction ratio, 38 fibrin sealant
erythropoietin, protein therapeutics and, 901t extrapyramidal effects protein therapeutics and, 903t
ESBLs. See extended-spectrum -lactamases antipsychotics and, 199 fibrinogen, 375
Escherichia coli, 585, 604, 609 schizophrenia and, 197 protein therapeutics and, 900t
escitalopram, 216 extrinsic pathway, coagulation cascade and, fibrinoid arteriolar necrosis, 446
esmolol, 141t, 142, 146t 377, 378f fibrinolysis inhibitors, 393, 400t
esomeprazole, 813, 818t ezetimibe, 326327, 330t fibroblast growth factor 23 (FGF-23), 547
off-target effects, 60 conjugation reactions and, 46t Ficks law, 245, 254, 263
ESPVR. See end-systolic pressure-volume relationship filgrastim, 784785
essential hypertension, blood pressure and, 439 drug-induced toxicity, 69
estazolam, 171 F immunotoxicity and, 65
clinical uses for, duration of action, 172t facilitated diffusion, 28, 107 filgrastim (rhG-CSF), 788t
GABAA receptors and, 183t factor IX, protein therapeutics and, 898, 899t protein therapeutics and, 901t
ester-linked local anesthetics, 151, 151f, 156, factor V Leiden, 381 finasteride, 511, 520t
158, 161t factor VII, coagulation cascade and, 377 first pain, A-fibers and, 149, 150f
estradiol, 922 factor VIII, protein therapeutics and, 898, 899t first-order kinetics, 37
estramustine, 688, 696t factor Vlla, protein therapeutics and, 903t first-pass effect, 43
estrogen receptor (ER), 506 factor X, coagulation cascade and, 377 first-pass liver metabolism, enteral drug
antagonists, drug summary table for, 521t factor XII, coagulation cascade and, 377 administration, 31
estrogen response elements (EREs), 506 famciclovir, 658, 670t FK-binding proteins (FKBP), 797
estrogen-progestin contraception, 516517, 523t familial combined hyperlipidemia (FCH), 323 FKBP. See FK-binding proteins
estrogen(s). See also ethinyl estradiol familial hypercholesterolemia (FH), 322 FLAP inhibition. See 5-lipoxygenase activating
contraception, 516f familial hypertriglyceridemia, 322323 protein inhibition
decrease of, 512 familial lipoprotein lipase deficiency, 322323 flecainide
hormone replacement, 518 famotidine, 775t cardiac rhythm and, 412, 419t
oxidation/reduction enzyme and, 73t peptic ulcer disease and, 812, 818t cytochrome P450 enzymes and, 51t
synthesis, 505506 FAS. See fetal alcohol syndrome drug study and, 874
ET-1, 357 FAS1. See fatty acid synthetase 1 flocculonodular lobe, 98, 98f
ET-2, 357 FAS2. See fatty acid synthetase 2 flow rate, global equilibration and, 245
ET-3, 357 fasting state, 525526 FLT3 inhibitors, 708709
etanercept, 758, 762t, 798799, 804t, 906, 907t fat group (FG), anesthesia and, 246 fluconazole, 567, 623624, 627t
ethacrynic acid, 346, 351t, 442t fatty acid synthetase 1 (FAS1), 605 cytochrome P450 enzymes and, 52t
conjugation reactions, 46t fatty acid synthetase 2 (FAS2), 605 flucytosine, 620621, 621f, 626t, 720
ethambutol, 612, 617t, 719 FCH. See familial combined hyperlipidemia fludarabine, DNA structure, 685f
ethanol FDA (U.S. Food and Drug Administration), 847 fludarabine phosphate, 695t
cytochrome P450 enzymes and, 52t approval, 868869 DNA structure of, 686, 686f
GABA physiology and, 176 approved drugs, pharmacokinetics, 37, 860 fludrocortisone, 494, 495, 495f, 500, 504t
metabolic drug interactions, 54 major legislation and, 861862 flukes. See trematodes
oxidation/reduction enzyme and, 73t review process, 867868, 869f flumazenil, 172
toxicity, 889890 role of, 879 benzodiazepine overdose and, 69
ethanolamines, 774t FDA Amendments Act (FDAAA), 862, 879 GABAA receptors and, 183t
ethinyl estradiol, 516, 523t FDAAA. See FDA Amendments Act general anesthesia and, 255
ethionamide, 612, 617t, 720 febuxostat, 842, 844t flunisolide, 497, 503t, 835t
ethnicity, drug metabolism and, 53 fed state, 525 flunitrazepam, GABA physiology and, 176
ethosuximide, 232t, 237t felbamate, 232t, 235, 239t fluoride, bone and, 555, 560t
absence seizures and, 234 NMDA receptor antagonists, 185t 5-fluorocytosine, 567
ethyl ether, 255 NMDA receptors and, 103 fluoroquinolones, 587
ethylenediamines, 774t felodipine, 51t, 369t off-target effects and, 60
ethynodiol, 516, 523t cytochrome P450 enzymes and, 51t 5-fluorouracil (5-FU), 566, 694t
etodolac, 756, 761t FemA enzyme, 603 combination chemotherapy, 725
etomidate, 175, 261t FemB enzyme, 603 DNA structure, 684f
GABAA receptors and, 184t femoral blocks, 157 fluoxetine, 39, 92, 216, 221t, 277
intravenous anesthesia and, 255 FemX enzyme, 603 addiction and, 305
etonogestrel, 517, 523t fenamate derivatives, 756 cytochrome P450 enzymes and, 5152t
etoposide, 697t, 723t fenamates, 761t drug dependence and, 309t
oxidation/reduction enzyme and, 73t fenestrae, 106 flupentixol, 198f
etoposide (VP-16), 691 fenfluramine fluphenazine, 198f, 204t
etravirine, 661, 671t off-target effects and, 60 schizophrenia and, 197, 199
European Medicines Agency (EMEA), 70, 869 serotonin storage and, 214 flurazepam, 171
European Union, 869 fenofibrate, 326, 328 clinical uses for, duration of action, 172t
eutectic mixture of local anesthetic. See EMLA lipoprotein metabolism and, 331t GABAA receptors and, 183t
everolimus, 12, 710, 714t, 804t, 922 fentanyl, 256, 261t, 275, 280t flurbiprofen, 756, 761t
STEMI, 454 fenthion, toxicity, 885 flutamide, 511, 515, 522t, 723t
everolimus-eluting stents, 797798 fermentation enzymes fluticasone, 497, 498f, 503t, 830, 835t
excitability. See cellular excitability anaerobic organisms and, 638, 639f fluticasone propionate, 498f
excitatory neurotransmitters, 164165, 165f luminal parasites and, 637638 fluvastatin, 325326, 330t
excitatory nicotinic acetylcholine receptors, 257 fertility fluvoxamine, 216, 221t
excitatory postsynaptic potentials (EPSPs), 90, 116 protein therapeutics and, 902t cytochrome P450 enzymes and, 52t
 Index 939

fMet. See formylated methionine G6PD deficiency (Glucose-6 phosphate
foam cell, 318 dehydrogenase deficiency), primaquine
focal seizures, 227228, 228t and, 635
focal seizures, pathophysiology of, 227228 GABA (-aminobutyric acid), 89, 268
focus, 227 agonists, drug table for, 308t
folate binding site, 177
analogues, structures of, 575577, 575f channel potentiators, drug summary table for, 238t
metabolism inhibitors ivermectin and, 642
malarial plasmodia and, 636, 645t metabolism, inhibitors, 166, 166f, 182t
selective targeting, synergistic drug neurotransmission, 164165, 165f
interactions and, 574578 alcohol and, 289
structures of, 575577, 575f drug summary table, 183185t
synthesis and functions, 576f opioids and, 295
folic acid. See Folate pharmacologic classes and agents affecting,
follicle-stimulating hormone (FSH) 168176, 169t
anterior pituitary gland, 467, 474 physiology, 165168
Group Ib proteins, 898 neurotransmitters and, 102, 103t
follicular phase, menstrual cycle and, 509 pathways, benzodiazepines and, 234
follitropin (rFSH), 474, 479t pharmacologic classes and agents affecting,
fomivirsen, 665, 672t 177178, 178t
fondaparinux, 391, 398t physiology, 176
Food and Drug Administration. See FDA receptors, 166168
Food and Drug Law, history, 861862 helminths and, 641
food contaminants, 884885 structure, 167f
Food, Drug, and Cosmetic Act, 862 GABA transporter (GAT), 166
food illnesses, 884 GABAA. See also Inhibitory GABAA
formestane, 511, 520t channels, alcohol and, 299
formoterol, 828, 834t receptor, 166168, 167f
formylated methionine (fMet), 585 agonists and antagonists, 182t
fosamprenavir, 662, 672t barbiturates, 183184t
foscarnet, 661, 671t benzodiazepines, 183t, 298, 298f
fosfomycin, 606607, 614t receptor modulators, 183184t
fosinopril, 349t GABAA-mediated chloride conductance,
fosmidomycin, 606607, 614t structure, 167f
four-compartment model, drug distribution, 36f GABAB
Frank-Starling law, 424, 456, 457, 458f receptor agonists, 175, 184t
FRC. See functional residual capacity receptor antagonists, 175
free ligand, concentration (L), 17 receptors, 166, 168, 168f
frontal cortex, dopamine receptor proteins and, 189 GABAC, receptor, 166168, 167f
frontal lobe, 97, 97f GABA-mediated surround inhibition, 229, 229f
frovatriptan, 217, 223t drugs enhancing, 234
FSH. See follicle-stimulating hormone; human gabapentin, 232t, 234, 237t, 277
follicle-stimulating hormone; urofollitropin GABA-transaminase (GABA-T), 166, 166f
FTC. See emtricitabine gabazine, 182t
5-FU. See 5-fluorouracil GABAergic transmission and, 169t
5-FU/folinic acid, 684 gaboxadol, 170
full agonist, 67 GABAA receptors and, 182t
full agonist dose-response curves, 23f GABAergic transmission and, 169t
fulvestrant, 511, 521t GAD. See glutamic acid decarboxylase
functional residual capacity (FRC), anesthesia galantamine, 121, 122t, 129t
and, 247 gallbladder disease, 517
fungal cell wall, biochemistry, 618620 galsulfase, protein therapeutics and, 900t
fungal infections gamma ()-hydroxybutyric, GABA physiology
case study, 619 and, 176
drug summary table, 626628t gamma-vinyl GABA (Vigabatrin), 182t, 234
pathophysiology of, 620 GABA metabolism and, 169170
pharmacology of, 618625 GABAergic transmission and, 169t
fungal membrane seizures and, 235
biochemistry of, 618620 ganciclovir, 658, 670t, 922
stability, inhibitors, 628t ganglionic blockade, 116
stability, polyenes and, 624625, 628t ganirelix, 474, 479t, 909t
fungal mitosis inhibitor, 622, 626t gastric acid, secretion, 807810
fungal nucleic acid synthesis inhibitor, 620621, gastric phase, gastric acid secretion, 809
621f, 626t gastrins, 106, 807
fungal wall synthesis inhibitors, 625, 628t gastrointestinal stromal tumor (GIST), 708
fungi, 885 gatifloxacin, 596t
drugs and, 567568 GATs. See GABA transporter
toxic, 885 G-CSF. See granulocyte colony-stimulating factor
furosemide, 346, 351t, 441, 442t gefitinib, 76, 707, 713t
gemcitabine, 686, 695t
gemfibrozil, 326, 328
G lipoprotein metabolism and, 331t
G protein receptor kinase (GRK), 137 gemtuzumab ozogamicin, 712, 715t, 723t,
G protein-coupled receptors (GPCRs), 910, 9f, 910, 910t
113, 427 gender, drug metabolism and, 53
G proteins, 9, 10t, 14, 113 gene expression inhibitors, 793794, 803t
adenylyl cyclase and, 10f general anesthesia
dopamine receptors and, 189 cardiac output distribution and, volume capacity
peripheral sensitization and, 271 and, 246f
second messengers and, 9, 10f pharmacology, 254256
G1-S cell cycle transition, 703f recovery, 253254, 254f
general anesthetics
CNS and, 98
cytochrome P450 enzymes and, 52t
mechanism of action, 256258
pharmacology, 240263
structures, 257f
general growth factors, 778
generalized seizures, 227, 228t
generic drugs, 870
generic name, drugs, 869
genes
alcohol dependence and, 294
drug metabolism and, 53
genetic polymorphisms
drug metabolism and, 73t
examples of, drug targets and, 76t
genome(s)
biochemistry, 675683
replication, viral life cycle and, 650
synthesis, 674693
gentamicin, 39f, 589, 596t
renal toxicity, drug-induced, 66
geranylgeranylation, 59
gestodene, 516, 516f, 523t
GFR. See glomerular filtration rate
GH. See growth hormone
GHRH. See growth hormone-releasing hormone
Giardia, 638
ginkgo biloba, platelet aggregation and, 61
GIST. See gastrointestinal stromal tumor
glibenclamide (Glyburide), 538t
gliclazide, 538t
glimepiride, 538t
glipizide, 538t
gliquidone, 538t
global equilibration, anesthesia and, 245
globus pallidus, 98, 191
glomerular dysfunction, 342
glomerular filtration rate (GFR)
digoxin and, 430
natriuretic peptides and, 336
renal excretion, drugs and, 36
glomerulonephritis, 753754
glossopharyngeal nerve, 96
GLP-1. See glucagon-like peptide-1
glucagon, 470, 529, 537, 540t, 913t
glucagon-like peptide-1 (GLP-1), 530, 535536
glucocorticoid receptor agonists, drug table, 503t
glucocorticoid receptor antagonists, drug
table, 503t
glucocorticoid response elements (GREs), 492
glucocorticoid(s), 489490, 754, 762t
analogues, 494, 495f
potencies and durations of action,
495496, 496t
bone mineral metabolism and, 547
dosing, 496497
gene expression and, 793794
gout and, 841
pathophysiology, 493494
physiology, 490493
routes of administration, 497498
structure and potency, 494495
synthesis, inhibitors of, 503504t
withdrawal, 497
glucose homeostasis, regulation of, 525526, 527f
glucose-6 phosphate dehydrogenase deficiency. See
G6PD deficiency
glutamate, 155, 164, 239t
metabolism and, 176
neurotransmitters and, 102103, 103t
glutamate receptors, 176178
classes of, interaction of, 179f
drugs inhibiting, 235, 239t
glutamate synthesis, 166f, 176
glutamate-gated chloride channels, ivermectin
and, 642
glutamatergic neurotransmission
pathophysiology and pharmacology, 178180
pharmacology, 182185t
physiology of, 176178
940 Index

glutamic acid decarboxylase (GAD), 166, 166f growth hormone (GH) hemagglutinin, viral uncoating and, 653655
glutaminase, 166f, 176 agents decreasing, 477t hematopoiesis
glutamine synthetase, 166f, 176 anterior pituitary gland, 467 case study, 777
Glyburide. See glibenclamide deficiency, pathophysiology and pharmacology drug summary table, 788789t
glycine of, 469470 future directions, 786
neurotransmitters and, 102, 103t excess, pathophysiology and pharmacology of, pharmacology, 776786
pain and, 268 470471 physiology, 776782
glycine, neurotransmitters and, 103t protein therapeutics and, 899t hematopoiesis, protein therapeutics and, 901902t
glycohemoglobin (HbA1c), 532 replacement, 477t hematopoietic cells, 777t
glycopeptides, 607608 growth hormone-releasing hormone (GHRH), 106, hematopoietic growth factors, 776, 778779
glycoprotein IIb-IIIa (GPIIb-IIIa) antagonists 912, 913t hematopoietic system, cells of, 778t
drug summary table, 396t anterior pituitary gland, 467468 heme metabolism inhibitors, 644t
thrombus formation and, 386 growth regulation, protein therapeutics and, 904t malarial plasmodia and, 631632, 631f
UA/NSTEMI, 453 guanabenz, 140, 144t, 443 heme protein mono-oxygenases, 47
glycopyrrolate, 124, 130t guanadrel, 138, 143t hemicholinium-3, 112f, 120, 128t
glycylcyclines, 572, 591592, 592, 597t guanethidine, 138, 143t, 443 hemochromatosis, drug metabolism and, 54
GM-CSF. See granulocyte-macrophage colony- guanfacine, 140, 144t hemoglobin, 779
stimulating factor; granulocyte-monocyte guanine, 581, 675 hemoglobin A (HbA), 779
colony-stimulating factor guanine alkylation, DNA and, 688f hemoglobin F (HbF), 779
GMP. See Good Manufacturing Practice guanylyl cyclase, 355 hemoglobin S (HbS), 779
GnRH. See gonadotropin-releasing hormone GVHD. See graft-versus-host disease hemolysis, primaquine and, 635
Goldman equation, 86 GVL. See graft-versus-leukemia effect hemophilia A, 898
Goldman-Hodgkin-Katz equation, 85f, 86 hemophilia B, 898
golimumab, 758, 762t, 799, 804t, 907t hemorrhagic disorders, 381, 383b
gonadal hormone action, pharmacologic modula- H hemostasis, 372, 374f
tion of, 512f H1-antihistamines. See histamine 1 pharmacology of, 372394
gonadal hormone inhibitors, 512516 (H1) -antihistamines physiology of, 372380
gonadorelin, 479t H1N1 swine flu, 665 protein therapeutics and, 903t, 909t
gonadotropin expression, drugs altering, 479t H2-receptor antagonists. See histamine 2 (H2) regulation of, 379380, 395400t
gonadotropin-releasing hormone (GnRH), 106, -receptor antagonists Henderson-Hasselbalch equation, drugs and, 29
479t, 508, 508f, 904t, 920 H3 receptors. See histamine 3 receptors heparin, 23, 389
gonadotropin-releasing hormone (GnRH) agonists, H4 receptors. See histamine 4 receptors clinical uses, 391
512516, 520t H5N1 avian influenza, 665 mechanism of action, 389391
gonadotropin-releasing hormone (GnRH) Haemophilus influenzae, 592594 UA/NSTEMI, 453
antagonists, 512516, 520t, 909t half-life, of drugs heparin-induced thrombocytopenia (HIT), 391
gonadotropins, 473 factors altering, 3839, 38t heparin-induced thrombocytopenia syndrome, 381
Good Manufacturing Practice (GMP), 870 local anesthetics and, 158 hepatic enzymes, drugs and, 54
goserelin, 479t, 904t hallucinations, schizophrenia and, 195 hepatic metabolism, routes, 156
gout, 837839 haloperidol, 58, 74, 198f, 204t hepatitis B immune globulin, 909t
case study, 838 cytochrome P450 enzymes and, 51t hepatitis B virus (HBV), 651, 898
conclusion and future directions, 843 parenteral drug administration and, 31t vaccine, 912
drug summary table, 844845t schizophrenia and, 197, 199 hepatitis C antigens, 898, 914t
natural history, 849t halothane, 73t, 242, 248f, 249, 249f, 251f, 254, 260t hepato-renal reflex, cirrhosis and, Na retention
pathophysiology of, 839840 cytochrome P450 enzymes and, 52t and, 341342
pharmacologic agent, and classes, 840842 oxidation/reduction reactions and, 73t hepatotoxicity, thioamines and, 6566
GPCRs. See G protein-coupled receptors haptens, 62 HER2/neu inhibitors, 713t
GPIIb-IIIa, 396t. See glycoprotein IIb-IIIa Hashimotos thyroiditis, 483f, 484 hERG channels, 59
antagonists Hatch-Waxman Act, 870 heroin, 286t
graded dose-response relationships, 19, 19f HbA. See hemoglobin A case study, 285
graft-versus-host disease (GVHD), 790, 792 HbA1c. See glycohemoglobin methadone vs., pharmacodynamics of,
graft-versus-leukemia effect (GVL), 792 HbF. See fetal hemoglobin; hemoglobin F 304305, 304f
gram-negative bacteria, 600 HbS. See hemoglobin S morphine vs., 296
gram-positive bacteria, 600 HBsAg vaccine, 911t herpesvirus, 655
grandiosity, 212 HBV. See hepatitis B virus heterologous desensitization, 14
granulocyte colony-stimulating factor (G-CSF), 781 HC1. See hydrochloric acid HETEs. See hydroxyeicosatetraenoic acids
granulocyte colony-stimulating factor (G-CSF), hCG. See human chorionic gonadotropin hexamethonium, 115, 133, 443
protein therapeutics and, 901t HDL. See high-density lipoprotein tetanic fade, 118f
granulocyte-macrophage colony-stimulating factor Health Canada, 869 hexose transporter, 106
(GM-CSF) healthy user effect, 877878 HF. See heart failure
protein therapeutics and, 902t heart, 401 HGPRT. See hypoxanthine-guanine
granulocyte-monocyte colony-stimulating factor electrical physiology of, 401406 phosphoribosyltransferase
(GM-CSF), 779, 781, 784785 heart failure (HF), 422 Hibernian fever, 800
granulocytes, 730, 776 afterload reduction, 461 HIF-1alpha. See hypoxia-inducible factor-1alpha
granulocyte-stimulating factors, 781782 case study, 45 high innate tolerance, 294
granulosa cells, gonadal hormone action and, clinical management, 458462 high-density lipoprotein (HDL), 311
508509 doxorubicin, 691 drug abuse and, 302
granzymes, 733 Frank-Starling relationship in, 458f formation, 318320
grapefruit juice, cytochrome P450 enzymes and, 51t neurohumoral effects of, 458, 459f intravascular maturation, 320
grapefruit juice effect, 53 pharmacologic modulation of, 459f liver and, 319f, 320
Graves disease, 484 pathophysiology of, 455458 mediated cholesterol efflux, 320
gray baby syndrome, 53, 593 pharmacologic agents, 460t metabolism
grepafloxacin, 60 preload reduction, 459461 disorders, 323
GREs. See glucocorticoid response elements sodium retention, mechanisms, 340341, 341f reverse cholesterol transport and, 318320, 319f
GRH. See growth hormone-releasing hormone heavy metal chelators, 884f high-throughout screening, 851852
griseofulvin, 622, 626t Helicobacter pylori, 638 high-voltage-activated (HVA) calcium channel,
GRK. See G protein receptor kinase peptic ulcer, 810811, 810f 232t, 233
growth factor receptor antagonists, 707710 treatment, 816817 hippocampal formation, 98
growth factor(s) helminths (worms), 640641 hippocampus, 98
growth factor receptors, 699700, 700f case study, 640 dopamine receptor proteins and, 189
RAS-MAP kinase pathway, 702703f physiology of, 641 histamine 1 (H1)-antihistamines
structure and function, 700f helper-T cells (TH1 cells), 732t, 734f, 821, 824 adverse effects, 771772

first generation, 770f, 774775t
structure, 770, 770f
pharmacologic effects, clinical uses and, 771
receptor, model, 770f
second generation, 770771
histamine 2 (H2)-receptor antagonists, 772, 775t
peptic ulcer disease and, 812813, 813f, 818t
structure, 772f
histamine 3 receptors (H3 receptors), 768, 772
histamine 4 receptors (H4 receptors), 768, 772773
histamine(s)
anaphylaxis and, 769
case study and, 766
conjugation enzyme and, 73t
drug summary table, 774775t
gastric acid and, 807808
inflammation response and, 736
neuronal systems and, 102
neurotransmitters and, 102, 103t, 104, 106
oxidation/reduction reactions and, 45t
pathophysiology, 768769
clinical manifestations of, 769
pharmacology, 765769
agents and classes, 769773
strategies, 769t
physiology of, 765
actions in, 765767, 767t
receptors, 767768
subtypes, 767t
histidine decarboxylase enzyme, histamine and, 765
histrelin, 479t, 904t
HIT. See heparin-induced thrombocytopenia
hit-to-lead development, 852
HIV (Human immunodeficiency virus), 649
case study, 44
combination chemotherapy, 660b
enfuvirtide, 652653
gp41-mediated fusion, 653f
integrase inhibitors, 661662, 663f
life cycle, 652f
protease inhibitor, 662
HIV antigens, 914t
HIV DNA, 663f
HIV pol gene product, ritonavir and, 666f
HIV protease inhibitor, 662
hives. See acute urticaria
HLA. See human leukocytic antigen
HMG-CoA (hydroxymethylglutaryl-coenzyme A)
on-target effects and, 5859
reductase, 22
Hodgkins disease
Ann Arbor staging system for, 725t
antineoplastic combination chemotherapy and, 725
homologous desensitization, 14
homologous recombination, 676678, 681
homovanillic acid (HVA), 189, 189f
horizontal transmission, 572
hormone release inhibitors, 485486
hormone replacement therapy (HRT), 559t. See
also reproduction hormones
bone homeostasis disorders and, 552
hormone deficiency and, 518
hormone synthesis, in adrenal cortex, 490491,
491f
hormone-dependent tissues, inappropriate growth
of, 511512
hormone(s). See also specific e.g. steroid hormones
action and metabolism, 506508
bone mineral metabolism and, 547548
islets of Langerhans, 524
modulators, 723t
HPA axis. See hypothalamic-pituitary-adrenal axis
HPETEs. See hydroperoxyeicosatetraenoic acids
hPTH 1-34, 560t
hPTH 1-84, 560t
HPV vaccine, 911t
HSV. See herpesvirus
5-HT. See serotonin (5HT)
human albumin, protein therapeutics and, 901t
human chorionic gonadotropin (hCG), 510
protein therapeutics and, 902t
human deoxyribonuclease I, protein therapeutics
and, 905t
human follicle-stimulating hormone (FSH), protein
therapeutics and, 902t
human immunodeficiency virus. See HIV
human leukocytic antigen (HLA), 531
human parathyroid hormone residues 1-34
protein therapeutics and, 903t
human solute linked carrier (SLC), 28
humoral immunity, 733734
HVA. See homovanillic acid
HVA calcium channel. See high-voltage-activated
calcium channel
hyaluronidase, protein therapeutics and, 905t
hydralazine, 371t, 443
conjugation enzyme and, 73t
drug metabolism and, 53, 72
immune responses, immunotoxicity and, 64
vascular tone and, 365
hydrochloric acid (HC1), tissue damage and, 885
hydrochlorothiazide, 346, 352t, 441, 442t, 474
hydrocodone, 274, 280t
hydrocortisone, 503t
hydroflumethiazide, 352t
hydrofluoric acid, tissue damage and, 885
hydrogen bonds, 3
hydromorphone, 274
hydroperoxyeicosatetraenoic acids (HPETEs), 745
hydrophilic protein segments, 3
hydrophobic effect, 34
hydrophobic protein segments, 3
hydroxyapatite, 541
hydroxyeicosatetraenoic acids (HETEs), 745
hydroxy-methylglutaryl-coenzyme A. See
HMG-CoA
11-hydroxysteroid dehydrogenase, 491, 492f
4-hydroxytamoxifen, 50
5-hydroxytryptamine. See Serotonin
5-hydroxytryptophan, 208
hydroxyurea, 685, 695t, 723t, 784, 787t
hydroxyzine, 770, 771, 775t
hyperacute rejection, 790791
hyperalgesia, 271
hyperbaric pressure, anesthesia and, 256
hypercalcemia
loop diuretics, 346
treatment, 554b
hypercalcemia of malignancy, 553
hypercholesterolemia, 322, 342
hypercoagulability, 381, 382t
hyperinsulinemia, therapy for, 536537
hyperkalemia
digoxin and, 430
diuretics and, 346, 347
loop diuretics, 346
hyperphosphatemia, 551
hyperpolarized membrane, 83
hyperreactivity, asthmatic airways and, 824
hyperresponsiveness, asthmatic airways and,
822824, 824f
hypersensitivity
asthmatic airways and, 824
pain, pathophysiology and, 269
hypersensitivity reactions, 62
mechanisms of, 59f
types of, 64t
hypersensitivity response. See also IgE-mediated
type I hypersensitivity
type I, 62
asthma and, 824
type II, 62
hypersensitivity response type III (immune
complex mediated hypersensitivity), 62
hypersensitivity response type IV (delayed-type
hypersensitivity), 62, 824
hypertension
adults and, classification of, 439, 439t
case study, 438
clinical management, 440446
diuretics for, 441442, 442t
pathophysiology, 438440
Index 941
hypertensive crisis, 445446
tyramine toxicity and, 215
hyperthyroidism
drug metabolism and, 54
treatment of, 485487
hypertriglyceridemia, 322323
hypocalcemia, treatment, 554b
hypoglycemia, 470, 532
hypogonadism, 512
hypokalemia
digoxin and, 430
potassium and, 442
hypomanic episode, 212
hypoparathyroidism, 557
hypotension
ACE inhibitors and, 344
nesiritide and, 344
hypothalamic physiology, 465468
hypothalamic-pituitary portal vascular system,
465, 466f
hypothalamic-pituitary-adrenal axis, 472473,
472f, 494
hypothalamic-pituitary-gonadal axis, 473474, 473f
hypothalamic-pituitary-growth axis, 468469, 469f
hypothalamic-pituitary-prolactin axis, 471472, 471f
hypothalamic-pituitary-reproduction axis,
508509, 508f
disruption of, 511
hypothalamic-pituitary-target organ feedback, 468
hypothalamic-pituitary-thyroid axis, 472
in health and disease, 483484, 483f
hypothalamus, 98
dopamine cell bodies in, 190191
dopamine receptor proteins and, 189
pituitary gland vs., 465468
hypothyroidism, treatment, 484485
hypoventilation, anesthetic and, 251
hypoxanthine-guanine phosphoribosyltransferase
(HGPRT), 685, 837838
hypoxia, 354
hypoxia-inducible factor-1alpha (HIF-1alpha),
706, 706f
I
IB. See Investigators Brochure
ibandronate, 552, 559t
ibritumomab tiuxetan, 712, 715t, 910, 910t
IBS. See irritable bowel syndrome
ibuprofen (Motrin), 276, 756, 761t
conjugation enzyme and, 73t
cytochrome P450 enzymes and, 52t
drug study and, 877
gout and, 844t
immune responses, immunotoxicity and, 64
ibutilide, cardiac rhythm and, 414, 420t
ICH. See International Conference on
Harmonization
idiopathic hypereosinophilic syndrome, 708
idiosyncratic drug reactions, 77
idiosyncratic toxicity, 60
IDL. See intermediate-density lipoprotein
idoxuridine, 671t
idursulfase, protein therapeutics and, 900t
IECs. See Independent Ethics Committees
ifosfamide, 696t
IgE-mediated type I hypersensitivity, 768, 768f
asthma, 825826
IGF-1. See insulin-like growth factor 1
IHD. See ischemic heart disease
IL-1 inhibitors. See interleukin-1 inhibitors
IL-2. See interleukin-2
IL-3. See interleukin-3
IL-5. See interleukin-5
IL-11. See interleukin-11
IL-12 inhibitors. See interleukin-12 inhibitors
IL-23p40 inhibitors. See interleukin-23p40 inhibitors
iloperidone, 206t
imatinib, 708, 713t
BCR-Abl kinase and, interaction with, 2, 3f
receptor affinity, 4, 5f
942 Index

imatinib mesylate, 699 pharmacodynamics of, 240244, 242f interferon-alpha, 668, 673t, 723t
imciromab pentetate, 913t pharmacokinetics of, 244254 interferon-beta, 668
IMiD. See immunomodulatory drug properties of, 243t interferons, 785, 789t
imidazole, 622624, 627t recovery rate from, 254f interferon-, 668, 821
unfavorable drug combinations, 721 inhaled general anesthetics, 260t type I, 668
imiglucerase, drug development and, 867 inhaled nitric oxide gas, 360, 369t type II, 668
imipenem, 611, 617t inhibin A protein, 509 interictal spikes, 227
cilastatin and, 61 inhibin B protein, 509 interleukin-1 (IL-1) inhibitors, 800, 805t
imipramine, 52t, 74, 144t, 213, 215, 221t, 277 inhibin, hypothalamic-pituitary-reproductive axis interleukin-2 (IL-2), 723t, 785, 903t
cytochrome P450 enzymes and, 5152t and, 473 interleukin-3 (IL-3), 779
imiquimod, 668, 673t inhibitory G protein, 429 interleukin-5 (IL-5), 781
immediate hypersensitivity, 62 inhibitory GABAA, anesthesia and, 257258, 258f interleukin-11 (rhIL-11), 785, 898, 902t, 903t
immune cells, depletion of, 800801, 805806t inhibitory neurotransmitters, 164, 165f, 268 interleukin-12 (IL-12) inhibitors, 799, 805t
immune complex mediated hypersensitivity. See inhibitory postsynaptic currents (IPSCs), 167 interleukin-23p40 (IL-23p40) inhibitors, 799, 805t
hypersensitivity response type III inhibitory postsynaptic potentials (IPSPs), 90, interleukins, 737, 779, 782
immune diversity, 733 116, 167 intermediate-density lipoprotein (IDL), 317
immune rejection, modes of, 791t initiation, translation system and, 585 intermediolateral columns, 95
immune responses initiators, cancer and, 67 International Conference on Harmonization (ICH),
activation of, 732 injury, pain and, 270 854b, 862
cortisol and, 492, 493f innate immunity, 730732 international normalized ratio (INR), 389
harmful, 6263 innate responses, 730 intestinal phase, gastric acid secretion, 809
immune system, 730 innate tolerance, 287 intra-arterial injection (IT injection), 31
adaptive branch, cells of, 732736 inorganic phosphate, 557, 561t intra-articular administration, 498
antiviral drugs and, 673t iNOS. See inducible nitric oxide synthase intracellular bacteria, 609
cells of, 731f, 732t inosinate (IMP), 675 intracellular communication, cellular excitability
drugs modulating, 668 inotropic agents, heart failure and, 462 and, 82
innate branch, cells of, 730732 inotropic receptors, 92 intracellular drug concentration, reduced, 572573
immunoglobulin, 733 INR. See international normalized ratio intracellular receptors, 1213, 13f
immunomodulatory drug (IMiD), 711, 723t insomnia, H1-antihistamines and, 771 intracellular signal transduction
with antineoplastic applications, 785786 inspired partial pressure, 241 biochemistry, 699706
drug summary table, 789t alveolar with, equilibration of, 246247, 247f pathways, 700701
immunoregulation, protein therapeutics and, 902903t rate of approach to, anesthetic agents and, 249f intravascular volume
immunosuppressants, cytochrome P450 enzymes tissue groups with, equilibration of, 247249, 249f determinants of, 332333
and, 51t Institutional Review Boards (IRBs), 862 reduction of, 441442
immunosuppression insulin, 106 intravenous anesthetic agents, 255, 255f, 260261t
case study, 791 analogues, 5 intravenous injection (IV injection), drugs and, 31
cytotoxic agents and, 794796 beta-cells, 524 intravenous regional anesthesia, 157
drug summary table, 803806t biochemistry, 526 intrinsic pathway, coagulation cascade and, 377, 378f
future directions, 802 cytochrome P450 enzymes and, 52t inverse agonists, 7, 24
pharmacology, 790802, 794f development of, 851 inverse tolerance, 285
immunotoxicity, 6465 human, processing of, 528f Investigational New Drug (IND) application, 863
IMP. See inosinate protein-based therapies and, 898, 899t Investigators Brochure (IB), 863
impulse conduction, defects in, 407408 release, pancreatic beta cells, 528f iodide, 480
impulse formation, defects in, 406407 replacement, 533535, 534t thyroid hormone and, 488t
inactivated state, CNS and, 226 exogenous insulin as, 533534 iodide uptake inhibitors, 478t, 485, 488t
inactivation, 8, 14 resistance, 531 iodoquinol, malarial plasmodia and, 639
inactive state, 20 secretagogues, 535, 538t iodothyronine, 482
inamrinone, 436t secretion, 526529 ion channels, 7, 8t
heart failure and, 460t, 462 sensitizers, 539t cell membranes and, 84, 84f
increased intracranial pressure, 345 theory, 511 effects on, anesthesia and, 257258, 258f
incretins, 539t insulin aspart, 534, 538t, 899t inactivated period, 8
IND application. See Investigational New Drug insulin detemir, 534, 538t, 899t pharmacology of, 89
application insulin glargine, 534, 538t, 899t refractory period, 8
indapamide, 352t, 442t insulin glulisine, 534, 538t ionic interactions, 3
Independent Ethics Committees (IECs), 862 insulin lispro, 534, 538t ionization state (pKa), 4
indinavir, 51t, 662, 672t insulin receptor substrate (IRS) proteins, 11 ionotropic GABA receptors (GABAA and GABAC),
indium-111-octreotide, 913t insulin receptors, 11 166168, 167f
indomethacin, 276, 756, 761t activation, downstream effects, 529, 529f ionotropic glutamate receptors, 173f, 176,
induced fit, 4 target tissues, 529 176177, 177t
inducible nitric oxide synthase (iNOS), 429 insulin-like growth factor 1 (IGF-1), 468 ionotropic receptors, 90
induction times, anesthetics, 250f replacement, 477t ions, Nernst potential for, 91, 113
inferior cervical ganglion, 96 integrase, viral enzyme, 659 iontophoresis, 919
inferior mesenteric ganglion, 96 integrated inflammation ipodate
infiltration anesthesia, 156 pharmacology, 807819 hyperthyroidism and, 487
inflammation asthma, 820836 thyroid gland and, 488t
chemical mediators, 736737, 736t gout, 837845 ipratropium, 96, 124, 130t, 827, 834t
eicosanoids and, roles of, 752t schema, 752 iproniazid, 139, 144t, 213
histamine and, 736 integration, viral proteins and, 651 serotonin degradation and, 214, 220t
immune system and intelligent drug delivery, 921922 IPSCs. See inhibitory postsynaptic currents
case study, 730 intercellular communication, cellular excitability IPSPs. See inhibitory postsynaptic potentials
principles of, 729739 and, 82, 92 irbesartan, 350t
inflammatory bowel disease, 753 intercellular signal transduction, biochemistry, cytochrome P450 enzymes and, 52t
TNF- and, 906 699706 IRBs. See Institutional Review Boards
inflammatory response, 737738, 738f interferon alfa-2b, 902t irinotecan, 691, 697t, 915
infliximab, 758, 762t, 799, 799f, 804t, 906, 908t interferon alfacon-1, 902t genetic polymorphisms, drug metabolism and, 73t
influenza virus, viral uncoating, 653654, 654f interferon alfa-n3, 902t irreversible antagonist, 21, 21f
informed consent, 862 interferon-alpha, 673t irritable bowel syndrome (IBS), 218
INH. See isoniazid interferon alpha-2a, 902t IRS proteins. See insulin receptor substrate proteins
inhalants, drugs abuse and, 286t, 301302 interferon beta-1a, 903t ischemia, 354
inhaled anesthetics interferon beta-1b, 903t ischemic heart disease (IHD)
alveolar partial pressure of, determinants of, interferon gamma-1b, 903t classification of, 447f
247, 247f interferon-2b, 920 clinical management, 449454

pathophysiology of, 446449 NMDA receptor antagonists, 185t
islets of Langerhans, 524 seizures and, 180
isocarboxazid, serotonin degradation and, 214, 220t sodium channels and, 232, 236t
isoetharine, 828, 834t Langerhans cells, 781
isoflurane, 241, 245f, 249, 249f, 255, 257f, 260t lanreotide, 470
alveolar partial pressure, 243f protein therapeutics and, 904t
cytochrome P450 enzymes and, 52t lansoprazole, 813, 818t
isoflurophate, 121f cytochrome P450 enzymes and, 52t
isolated systolic hypertension, 438 lapatinib, 707, 713t
isoniazid (INH), 231, 612, 617t Laplaces law, 457
conjugation reactions and, 46t laronidase, protein therapeutics and, 900t
cytochrome P450 enzymes and, 52t L-asparaginase, 898, 905t
drug metabolism and, 5253, 72 latanoprost, 763t
GABAergic transmission and, 169t late perimenopause, 548
immune responses, immunotoxicity and, 64 late-acting growth factors, 778
rifampin and, 588 latency, herpesviruses, 655
tuberculosis and, 44 latent pacemaker, 406
isoprostanes, 748 laterodorsal tegmental area, nicotinic receptors
isoproterenol, 140, 145t, 432, 436t, 827828, 834t and, 299
isosorbide 5-mononitrate, 360, 360f, 361, 368t LCAT. See lecithin-cholesterol acyltransferase
isosorbide dinitrate, 360, 360f, 361, 368t LD50. See median lethal dose
drug metabolism and, 53 LDL. See low-density lipoprotein
isotretinoin, pregnancy and, 68 LDL-receptor-related protein (LRP), 317
IT injection. See intra-arterial injection particles, formation and clearance, 317318,
itch, 766, 771 317f
itraconazole, 51t, 567, 623, 627t L-DOPA. See Levodopa
IV injection. See intravenous injection lead
ivermectin, helminths and, 641642, 647t drug discovery and, 848
poisoning by, 883884
J lead optimization, 853
Jacksonian march, 228 leak channels, 87
JAK2 inhibitors, 709 learned tolerance, 287
JAK-STAT pathway, 701 lecithin-cholesterol acyltransferase (LCAT), 320
jimson weed, toxicity and, 885 leflunomide, 794, 795796, 796f, 803t
Joint National Commission (JNC), 441 left ventricular pressure-volume loop, 456f
juxtaglomerular apparatus, 334 Legionella, 592
juxtaglomerular cell renin release, mechanisms, Leishmania, 640
334335, 335f lenalidomide, 711, 715t
lepirudin, 392, 398t, 898, 905t
K leptin, 525
Lesch-Nyhan syndrome, 839
K. See potassium letrozole, 511, 520t
kainate receptors, glutamate-gated ion channels, leukocyte(s)
176177, 177t, 179 production, 781782
kanamycin, 589, 596t, 720 agents stimulating, 784785, 788t
KATP channels, 365 suppressors of, acute gout and, 840841, 844t
Kayexalate. See sodium polystyrene sulfonate leukotriene B4, 822b
Kefauver-Harris Amendments, 862 leukotriene inhibitors, 758759, 759f
keratinocyte growth factor (KGF), 904t leukotriene pathway-modifying agents,
kernicterus, 47, 576 830831, 836t
ketamine, 255, 261t, 277, 283t leukotriene receptor antagonists, 764t
ketanserin, 218, 223t leukotriene synthesis inhibitors, 759
ketoconazole, 473, 499, 499t, 504t, 623, 627t leukotriene(s), 745748, 764t
cytochrome P450 enzymes and, 50, 51t, 61 asthma, 825826, 826f
ketolides, 592, 597t biosynthetic pathways, 746f
ketones, 756, 761t leuprolide, 473, 479t, 723t, 904t
ketoprofen, 756, 761t levalbuterol, 834t
ketorolac, 276, 756, 761t levamisole, 785, 789t
KGF. See keratinocyte growth factor levetiracetam, 232t, 239t
kidney levobunolol, 142, 146t
drugs and, 36, 36f, 39f levobupivacaine, 157, 159
local anesthetics and, 156 levocabastine, 775t
toxicity, tetracyclines and, 592 levocetirizine, 775t
kidney disease, chronic, drug use in, 39b levodopa (L-DOPA), 98, 104, 105f, 186187, 193,
kininase II, 335 202t, 849
kinins, 267 blood-brain barrier and, 106107, 107f
Kirsten ras gene, 700701 genetic polymorphisms, drug metabolism
Klebsiella pneumoniae, 609 and, 73t
Krebs cycle, glutamate synthesis, 166, 166f Parkinsons disease and, 193
levofloxacin, 60, 587, 596t, 720
L levonorgestrel, 523t, 919
LABAs. See long-acting beta-agonists contraception, 516, 516f
labetalol, 141t, 142, 146t, 442 morning after contraception, 517
cardiac rhythm and, 413, 419t levorphanol, 281t
laclase, protein therapeutics and, 900t levosimeridan, 436t
lacosamide, sodium channels and, 232, 232t, 237t levothyroxine
lactic acidosis, 535 hypothyroidism and, 485
lactotrophs, 189 thyroid gland and, 488t
lamellae, 543 Leydig cells, gonadal hormone action and, 508
lamivudine, 574, 659661, 671t LFA-3, 801
lamotrigine, 232t, 236t, 277 LH. See luteinizing hormone
mood disorders and, 218 LH hypothesis, 511
Index 943
lidocaine, 156, 158159, 161t, 277
cardiac rhythm and, 412, 419t
dentistry and, 157b
genetic polymorphisms and drug metabolism, 73t
hydrolysis reactions and, 46t
infiltration anesthesia, 156
loading dose, 41
on-target adverse effect, 58
oxidation/reduction reactions and, 45t
patch, 156
toxicity, 158
life-threatening infections, combination
antimicrobial drugs and, 721
ligand. See drug(s)
ligand-binding domain, 8
ligand-gated channels, 7, 8t
ligand-gated nicotinic acetylcholine receptor, 8f
ligand-receptor complex concentration (LR), 17
limbic system, 98
dopamine receptor proteins and, 189
lincosamides, 594, 597t
lineage-dominant growth factors, 778
lineage-specific growth factors, 779
linear synthesis, 857f
linezolid, 572, 593f, 594, 598t
linoleic acid, 741
liothyronine, thyroid gland and, 488t
lipase, protein therapeutics and, 901t
lipid-lowering agents, coronary artery disease
and, 451
lipid(s), 311
solubility hypothesis, anesthesia and, 256257
theories, 256
lipopeptides, 572
lipopolysaccharides (LPS), 601
lipoprotein lipase (LPL), 315316
lipoprotein(s)
ApoB-containing, metabolism of, 313318
characteristics, 311313, 312t
metabolism
case study, 312
pharmacology, 311329
particles, structure of, 313, 313f
liposome-based delivery systems, 922
liposomes, oral drug delivery and, 917
lipoteichoic acids, 601
lipotropin, 472
lipoxins, 748, 759
biosynthesis, 747f
lipoxin-stable analogues, 759
5-lipoxygenase activating protein (FLAP)
inhibition, 759
lipoxygenase inhibition, 758759, 764t
lipoxygenase pathway, 745748, 745t
liraglutide, 539t
lisdexamfetamine, serotonin storage and,
213214, 220t
lisinopril, 349t, 371t, 444
lithium, 207
drug summary table, 224t
mood disorders and, 218219
thyroid hormone homeostasis, 487
liver
drug metabolism and, 43, 44f, 54
failure, toxicity and, 6566
HDL cholesterol and, 319f, 320
local anesthetics and, 156
oxidation/reduction reactions, 34
phenylalanine and, 186
liver cytochrome P450 oxidases, 47
LMW heparin. See low molecular weight heparin
loading dose, 40f, 41
local anesthesia
phasic inhibition, 153155, 155f
sodium channels, 151, 152f
tonic inhibition, 154, 155f
local anesthetic hydrophobicity, 151, 152f
local anesthetics, 8, 147. See also amide-linked
local anesthetics; ester-linked local
anesthetics
administration of, 156157
amine group of, 151152
944 Index
local anesthetics (continued)
calcium channels, 158
chemistry, 151152, 151f
in dentistry, 157f
drug summary table, 161162t
future directions, 159160
hydrophobicity, diffusion, binding, 152f
individual agents, 158159
major toxicities, 157158
mechanism of action, 152155, 153f
nociception, 147151, 148f
pharmacokinetics of, 155156
pharmacology of, 147160
toxicities, 157158
voltage-gated ion channels, 8
local circuit neurons, 99, 100, 100f
local control mechanisms, vascular tone and, 358
local equilibration, anesthesia and, 245
locus ceruleus, 99, 101, 101f, 208, 300
lofexidine, withdrawal and, 303
log cell kill model, 571, 572f
lonafarnib, 709
long tract neuronal systems, 99100, 100f
long-acting beta-agonists (LABAs), 828
loop diuretics, 345346, 351t, 440t, 441442, 442t
lopinavir, 50, 574, 662, 672t
loratadine, 51t, 771, 775t
lorazepam, 183t, 238t, 261t
clinical uses for, duration of action, 172t
general anesthesia and, 255
seizures and, 234
losartan, 50, 51t, 350t, 371t, 845t
cytochrome P450 enzymes and, 52t
uric acid excretion and, 842, 845t
lovastatin, 51t, 325326, 330t
oxidation/reduction enzyme and, 73t
low molecular weight heparin (LMW heparin),
389, 391
coagulation factor inactivation and, 390t
drug summary table, 398t
low-density lipoprotein (LDL), 311
low-threshold mechanoreceptors, 148
loxapine, 204t
LPL. See lipoprotein lipase
LPS. See lipopolysaccharides
LR. See ligand-receptor complex concentration
LRP. See LDL-receptor-related protein
luminal protozoa, physiology, 637638
luteal phase, menstrual cycle, 509
luteinizing hormone (LH)
anterior pituitary gland, 467
reproduction, 509
lutropin alfa, protein therapeutics and, 902t
Lyme disease, 912
lymphocytes, 776
lymphocyte-signaling inhibitors, 796798,
803804t
lymphocyte-stimulating factors, 782
lymphoid stem cells, 781
lymphopoiesis, 781782
lyophilized powder, 859
lysine analogues, 393, 400t
M medulla, 96, 97t
M2 proton channel, viral uncoating and, 654
MAC. See minimum alveolar concentration
mAChR. See muscarinic cholinergic receptors
macrolide antibiotics
cytochrome P450 enzymes and, 51t
grapefruit juice effect and, 53
macrolides, 592
oxidation/reduction enzyme and, 73t
macromolecular therapies, 852t
macrophages, 731732, 732t, 776
macula densa cells, 335
magnesium hydroxide, 816, 818t, 835t
magnesium sulfate, 835t, hypocalcemia, 554b
maintenance dose, 4142
major depressive disorder (MDD), 207
case study, 208
clinical characteristics, 211212
criteria, 211b
future directions, 219
major histocompatibility complex (MHC), 531,
732733, 733f
major mood disorders, 207
malarial plasmodia
electron transport chain, 631632, 632f
heme metabolism, 631, 631f
life cycle, 629631, 631f
malathion, toxicity, 885
male contraception, 518
malignant hyperthermia, 254
mammalian target of rapamycin inhibitors.
See mTOR inhibitors
mania, 207
manic episode, 212
mannitol, 15, 345, 351t
mannoproteins, 619
MAO. See monoamine oxidase
MAO-A inhibitors. See monoamine oxidase
A inhibitors
MAO-B inhibitors. See monoamine oxidase
B inhibitors
MAOIs. See monoamine oxidase inhibitors
maprotiline, 215, 277
maraviroc, 651652, 670t
maresins, 759
biosynthesis, 748, 749751f
margin of safety, 56
marijuana, AIDS and, 269
mast cells
asthma and, 825826
degranulation, tissue damage, 730731
matrix metalloproteinases, 822b
matrix protein, viral uncoating and, 654
MBC. See minimum bactericidal concentration
M-CSF. See monocyte colony-stimulating factor
MDD. See major depressive disorder
MDMA (methylenedioxymethamphetamine), 214,
286t, 301
MDR. See multidrug resistance
MDR transporters. See multiple drug resistance
transporters
MDR1. See multidrug resistance protein 1
MDR-TB. See multidrug-resistant tuberculosis
mebendazole, 642, 648t
mecamylamine, 126, 131t, 133
mecasermin, 470, 477t
mecasermin rinfabate, protein therapeutics
and, 899t
mechanisms of desensitization, types of, 14
mechlorethamine, 687, 696t
combination chemotherapy, 726
meclizine, 771, 775t
meclofenamate, 756, 761t
medial forebrain bundle, 289
median effective dose (ED50), 20
median lethal dose (LD50), 241
median toxic dose (TD50), 20
medical review, IND and, 863
Medication Guides, drugs and, 869
medications. See drug(s)
medroxyprogesterone acetate, 517, 523t
mefenamate, 756, 761t
mefloquine, 568, 644t
malarial plasmodia and, 633634
meglitinides, 535, 539t
meglumine antimonate, leishmaniasis and, 640, 647t
melancholic depression, 211
melanocyte-stimulating hormone (MSH), 472
melarsoprol, African trypanosomiasis, 639640, 646t
meloxicam, 757
melphalan, 696t
DNA damage and, 67
DNA structure and, 687, 696t
memantine
Alzheimers disease and, 178
NMDA receptor antagonists, 185t
membrane attack complex, 736, 802
membrane excitability, 88
membrane hyperpolarization, 165
membrane resistance, 165, 165f
memory, cholinergic link, 117
menopause, 512
menstrual cycle, 509510, 510f
meperidine, 261t, 275, 281t
mepivacaine, dentistry, 157b
mepolizumab, 833
MEPP. See miniature end-plate potential
mercaptopurine, 723t
DNA structure, 684f
formation of, from azathioprine, 795f
genetic polymorphisms, drug metabolism and, 73t
6-mercaptopurine, 684685, 694t, 841, 842f
meropenem, 611, 612, 617t
mescasermin, protein therapeutics and, 899t
mesna, 688
mesocortical system, schizophrenia and, 197
mesolimbic system, schizophrenia and, 196
mesoridazine, 204t
mestranol, 516, 523t
metabolic acidosis, diuretics and, 347
metabolic drug interactions, 54
metabolic syndrome, 323
metabolism, drug absorption, 27, 28f
metabotropic GABA receptors (GABAB), 166
metabotropic glutamate receptors (mGluR),
177178, 177f, 178t
metabotropic receptors, 90, 92
metal, toxicity of, 891892
metal-ligand complexes, chelator and, 884
metaproterenol, 140, 145t, 828, 834t
metastasis, tumor and, 570
metformin, 535, 539t
methacholine, 120, 122, 129t
methacycline, 591, 597t
methadone, 275, 280t
addiction, pharmacologic treatment of,
304305, 304f
detoxification and, 298f, 303
drug dependence and, 307t
opioids and, 303
methamphetamine, 139
oxidation/reduction reactions and, 45t
methanol, 47
metabolic drug interations, 54
methemoglobinemia, 576
methicillin, 609, 610, 615t
methimazole, 486
thyroid hormone and, 488t
methohexital, 173, 174
clinical uses for, duration of action, 174t
GABAA receptors and, 183t
methotrexate, 39f, 565, 573, 576, 580t, 723t, 803t
combination chemotherapy, 725
methotrexate (MTX), 794795
DHFR and, 577
methoxamine, 139, 144t
methoxy polyethylene glycol-epoetin beta, protein
therapeutics and, 901t
methoxyflurane, 254f
cytochrome P450 enzymes and, 52t
methscopolamine, 124, 130t
methyldopa, 144t, 443
genetic polymorphisms, drug metabolism and, 73t
immune responses, immunotoxicity and, 64
methylenedioxymethamphetamine. See MDMA
methylenetetrahydrofolate (MTHF), 676
methylmorphine. See codeine
methylnaltrexone, 275, 282t
methylphenidate, 139, 143t, 921
atypical depression and, 212
serotonin storage and, 213214
methylprednisolone, 495, 503t, 762t
methylxanthines, 829, 835t
metolazone, 352t, 442t
metoprolol, 7374, 141t, 142, 146t, 371t, 442
cardiac rhythm and, 413, 419t
cytochrome P450 enzymes and, 51t
metronidazole, 638639, 646t, 721
 Index 945

anaerobic organisms and, 639f modafinil, serotonin storage and, 213214, 220t agonists, 122123, 123f, 123t, 129t
H. pylori, 817 moderation management, addiction and, 303 antagonists, 119t, 124126, 130t
metyrapone, 473, 499, 499t, 504t modulated receptor hypothesis, local anesthesia asthma, 821
mevalonate pathway, 552 and, 153, 154f, 155t muscarinic cholinergic toxicity, 125b
mexiletine, 277 moexipril, 349t muscimol, 170, 182t
cardiac rhythm and, 412, 419t molds, 618 GABAergic transmission and, 169t
cytochrome P450 enzymes and, 51t molecular mimicry, autoimmunity and, 792 muscle contraction, ACh and, 115, 118f
Meyer-Overton Rule, 242244, 245f, 256257 molindone, 204t muscle group (MG), anesthesia and, 246
mezlocillin, 609, 611, 615t mometasone, 830, 835t muscles, myotomal distribution, 96
MG. See muscle group monoamine hypothesis, 211 myasthenia gravis, treatment, 111f
mGluR. See metabotropic glutamate receptors monoamine neurotransmission, monoamine theory Mycobacterium leprae, 604
MGMT. See O6-methylguanine-DNA of depression and, 213 Mycobacterium tuberculosis, 604, 612
methyltransferase monoamine oxidase (MAO), 47, 133f, 187189, mycophenolate mofetil (MMF), 794, 795f, 803t
MHC. See major histocompatibility complex 189f, 210, 431 mycophenolate sodium, 803t
MIC. See minimum inhibitory concentration monoamine oxidase A inhibitors (MAO-A mycophenolic acid (MPA), 795, 795f, 803t
micafungin, 567, 625, 628t inhibitors), 215 Mycoplasma pneumoniae, 599
Michaelis-Menten kinetics monoamine oxidase B inhibitors (MAO-B myeloid stem cells, 781
clearance of drug and, 37, 38f inhibitors), L-DOPA metabolism myelopoiesis, 781782
drug toxicity and, 42f and, 194f myelosuppression, 692, 784
miconazole, 567, 623, 627t monoamine oxidase inhibitors (MAOIs), 105, myocardial ischemia, 354
cytochrome P450 enzymes and, 52t 139, 144t myocyte
microbiology review, IND and, 867 atypical depression and, 212 anatomy, 423
microsatellite instability, 678 serotonin degradation and, 214215, 215f contraction, 423424, 424f
microsomal triglyceride transfer protein (MTP), 313 monoamine theory of depression, 212213 myofibrils, 425t
microspheres, drug delivery and, 917 monobactams, 608, 611612 myosin, cardiac myocyte contraction and, 425t
microtubule depolymerization inhibitors, monoclonal antibodies, 800801, 851b myosin light chain kinase, 355
692693, 698t monocyte colony-stimulating factor (M-CSF), 781 myosin light chain phosphatase, 356
microtubule polymerization inhibitors, monocyte/macrophages, 781 myotomal distribution, 96
692, 692f, 697t monoiodotyrosine (MIT), 481
microtubule(s) monotherapy, hypertension and, 444445
dynamic instability, 683f montelukast, 759, 764t, 831, 836t N
mitosis and, 682683 mood stabilizers, 218219, 224t NA. See Narcotics Anonymous
structure, 682f moperone, 198f Na channel-mediated inhibition, 231232
midazolam, 51t, 171, 238t, 261t MOPP regimen, 726 nabumetone, 756, 761t
clinical uses for, duration of action, 172t morbidity, major depressive disorder and, 207 NAc. See nucleus accumbens
GABAA receptors and, 183t moricizine, cardiac rhythm and, 412, 419t N-acetylcysteine (NAC), 362
general anesthesia and, 255 morphine, 261t, 269, 273274, 280t, 849 acetaminophen overdose and, 69
oxidation/reduction enzyme and, 73t drugs of abuse, 286t N-acetyl-p-benzoquinoneimine (NAPQI)
seizures and, 234 general anesthesia and, 256 hepatotoxicity and, 6566
midbrain, 96, 97f genetic polymorphisms, drug metabolism and, 73t N-acetyltransferase, 52
middle cervical ganglion, 96 parenteral drug administration and, 31t nAChR. See nicotinic cholinergic receptors;
mifepristone (RU-486), 499, 503t, 515, 522t motion sickness, H1-antihistamines and, 771 nicotinic receptors
cytochrome P450 enzymes and, 51t Motrin. See ibuprofen NAD. See nicotinamide adenine dinucleotide
miglitol, 538t moxifloxacin, 596t, 720 nadolol, 141t, 142, 146t
migraine headache, 217, 272273 6-MP. See 6-Mercaptopurine NADPH. See nicotinamide adenine dinucleotide
therapy, 278 MPA. See mycophenolic acid phosphate
milnacipran, 216, 222t MPTP, Parkinsons disease, 193 nafarelin, 479t, 904t
milrinone, 362, 436t MSH. See melanocyte-stimulating hormone nafcillin, 609, 610, 615t
heart failure and, 460t, 462 MTHF. See methylenetetrahydrofolate naftifine, 622, 626t
miltefosine, 640, 647t mTOR inhibitors, 709710, 714t, 797798 NAG-arabinogalactan, 604
mineralocorticoid receptor, 499 MTP. See microsomal triglyceride transfer protein Na/KATPase, 500
mineralocorticoid receptor agonists, 500, 504t MTX. See methotrexate nalbuphine, 281t
mineralocorticoid receptor antagonists, 500501, 504t mu-opioid receptor agonists, 280t nalidixic acid, 587
mineralocorticoids, 489490 Muckle-Wells syndrome, 800 naloxone, 275, 282t
pathophysiology, 500 mucosal defense, agents promoting, gastric acid drug dependence and, 307t
pharmacologic classes, agents, 500501 and, 816 opioid overdose and, 69
physiology, 499500 mucous membrane, drug administration, 30t, 31 naltrexone, 275, 282t
miniature end-plate potential (MEPP), 115 multidrug resistance (MDR), biliary excretion addiction treatment and, 304
minimum alveolar concentration (MAC), 241 and, 37 drug dependence and, 307t
minimum bactericidal concentration (MBC), 716718 multidrug resistance protein 1 (MDR1), 49 general anesthesia and, 256
minimum inhibitory concentration (MIC), 716718 multidrug-resistant tuberculosis (MDR-TB), 720 NANC fibers, 820
Ministry of Health and Welfare, Japan, 869 multilineage growth factors, 778779 NAPQI. See N-acetyl-p-benzoquinoneimine
minocycline, 591, 597t multiple drug resistance transporters (MDR naproxen, 276, 755, 756, 761t
minoxidil, 365, 370t, 443 transporters), 107 genetic polymorphisms, drug metabolism
mirtazapine, 217, 223t MurA enzyme, 601 and, 73t
mismatch repair pathway, 676678, 679f MurB enzyme, 601 naratriptan, 278
misoprostol, 515, 763t MurC enzyme, 601 Narcotics Anonymous (NA), 303
peptic ulcer disease, 816 MurD enzyme, 601 natalizumab, 65, 802, 806t, 908t
MIT. See monoiodotyrosine MurE enzyme, 601 nateglinide, 539t
mitomycin C, 50 murein, bacterial cell wall and, 599 National Cholesterol Education Program Adult
tumor cells and, 687, 696t murein monomers, 612 Treatment Panel III (ATP III) guidelines,
mitosis, microtubules and, 682683 synthesis inhibitors, 614t 324, 324t
mitotane, 473, 499, 499t, 503t synthesis of, 601603 native pacemaker, 406
mivacurium, 126, 131t, 261t murein polymer synthesis inhibitors, 607608, 614t natriuresis, 334
mixed agonists, 275, 281t MurF enzyme, 603 natriuretic peptide uroguanylin (UGN), 336
mixed episode, 212 muromonab-CD3, 909t natriuretic peptides, 335336, 336f
mixed hyperlipidemia, 323 muscarine, 123 natural ligands, analogues of, 849851
mizolastine, 775t muscarinic acetylcholine (ACh) receptors, partial natural products, as drugs, 723t, 849, 850t
MMF. See mycophenolate mofetil agonists, 23, 23f nausea, H1-antihistamines and, 771
moclobemide, 139, 144t muscarinic cholinergic receptors (mAChR), 110, NBCe1, 338
serotonin degradation and, 214, 221t 113, 114t, 127 NBM. See nucleus basalis of Meynert
946 Index
NDA. See New Drug Application
NE. See norepinephrine
nebivolol, 142, 146t, 442
cardiac rhythm and, 413, 419t
necrosis, cell toxicity and, 62, 63t
nedocromil, 769, 836t
asthma and, 830
nefazodone, 217, 223t
cytochrome P450 enzymes and, 51t
negative membrane potential, 84
negative reinforcement, drug addiction and, 291
negative symptoms, schizophrenia, 195
Neisseria meningitidis, 592
nelfinavir, 51t, 662, 672t
nematodes (Roundworms), 640
neomycin, 589, 596t
neonatal jaundice, phenobarbital and, 47
neostigmine, 96, 120, 121, 128t, 256
nephrogenic diabetes insipidus, 219, 347
nephrolithiasis, thiazides, 346
nephron anatomy, 337338, 337f
nephrotic syndrome, 342
NER. See nucleotide excision repair
Nernst equation, 84
Nernst equilibrium potential, 402
Nernst potential, 84, 85f, 85t
nerve cell membranes, local anesthetics and, 151
nerve injury, pain in, 272, 273f
nervous system, physiology and pharmacology,
principles, 93108
Nesacaine, 158
nesiritide, 12, 344, 350t, 904t
NESP. See darbepoetin
NET. See norepinephrine transporter
netilmicin, 589, 596t
neural networks, CNS and, 226227
neuraminidase inhibitors, 664, 667f
neuroactive peptides, 102
neuroactive steroid, 180
neuroanatomy, 93107
neurodegenerative diseases, 178
neuroendocrine system, blood pressure and, 440
neurogenic diabetes insipidus, 474, 475f
neurohormonal mediators, vascular tone and, 358
neurohumoral activation, heart failure and, 458, 459f
neuroleptic malignant syndrome (NMS), 198
neuroleptics, schizophrenia and, 197
neuromuscular blockers, 261t
neuromuscular junction (NMJ)
ACh and, 115, 117f
chemical synapse, 90, 117f
neuronal excitability, anesthesia and, 257
neurons, 8990
surround inhibition and, 227, 227f
neuropathic pain, 272, 273f
neuropeptides, 106, 267
neuroprotective therapies, 193
neurorestorative therapies, 193
neurosteroids, 167f, 168
neurotoxicity, drug-induced, 66
neurotransmission
central adrenergic, 207219
central monoamine, 219
cholinergic, 110119
CNS, electrical neurotransmission and, 225235
dopaminergic, 186201, 188f
GABA, 164165
alcohol and, 294
drug summary table, 182184t
pharmacologic classes and agents affecting,
168169
physiology of, 165168
GABAergic, 227
glutamatergic, 178180, 182184t
monoamine, 213
serotonergic, 207219
spinal cord dorsal horn, 268f
neurotransmitter release, mechanism, 91f
neurotransmitters, 89, 102, 102f, 103t, 104f
amino acid, 102103
biogenic amines, 104106
CNS, 100, 102f
excitatory, 164165, 165f, 180
inhibitory, 165, 165f
neuropeptides, 106
peripheral nervous system, 102f
small molecule, 102, 104f, 106
neutropenia, leukocyte production and, 784
neutrophil, 732t
neutrophils, 731, 781
nevirapine, 661, 671t
cytochrome P450 enzymes and, 51t
New Drug Application (NDA), 867
NFAT (nuclear factor of activated T cells), 797
NHE3 Na/H exchanger, 338
niacin, 331t
lipid metabolism and, 328329, 328f
nicorandil, 365, 370t
nicotinamide adenine dinucleotide (NAD), 328
nicotinamide adenine dinucleotide phosphate
(NADPH), 47, 48f, 328
nicotine, 73t, 292f, 299
drugs of abuse and, 286t
oxidation/reduction enzyme and, 73t
nicotine replacement therapy, 305
nicotinic acetylcholine receptor
channel opening, kinetics, 116f
structure of, 8, 115f
nicotinic cholinergic receptors (nAChR), 110,
113114, 114t
agonists, 123124, 129t
antagonists, 124126, 131t
nicotinic cholinergic toxicity, 125b
Niemann-Pick C1-like 1 protein (NPC1L1), 314
nifedipine, 51t, 363, 364t, 369t, 405, 443, 921
cardiac rhythm and, 415
nifurtimox, Chagas disease and, 640, 647t
nigrostriatal pathways, physiology of, 191192
nigrostriatal system, 189
nigrostriatal tract, 98
nilotinib, 708, 714t
nitazoxanide, 639, 646t
nitrates
contraindications, 362
coronary artery disease and, 451
effects of, vasodilation and, 362
heart failure and, 461
nitric oxide, 106, 356357, 357f
asthma, 821
neurotransmitters and, 102, 103t
nitrofurantoin, oxidation/reduction reactions, 45t
nitrogen mustards, 674
DNA damage and, 67
nitroglycerin (NTG), 354, 356, 368t
heart failure and, 461
pharmacodynamic drug-drug interactions, 61
nitrosoureas, 687
DNA damage and, 67
nitrous oxide, 255, 260t
MAC, 241
partition coefficients, 244b, 248t
properties of, 243t
rate-limiting step, 249, 249f
recovery from, 254, 254f
nizatidine, 775t
peptic ulcer disease and, 812, 818t
NKCC2, 339
NMDA receptor antagonists, 277
drug summary table, 185t, 283t
hyperalgesia and, 179
NMDA receptor(s)
alcohol and, 299
central sensitization, 271272
dorsal horn neurons and, 267
glutamate-gated ion channels, 176177, 177t
neurodegenerative disease and, 178
NMJ. See neuromuscular junction
NMR. See nuclear magnetic resonance
NMS. See neuroleptic malignant syndrome
NNRTIs. See nonnucleoside reverse transcriptase
inhibitors
NO. See nitric oxide
nociception, 147151, 148f, 269
nociceptive circuit, 265f
nociceptive pain, 269
nociceptor cell bodies, 147
nociceptor neurons
chemical stimuli and, 266, 266t
peripheral sensitization and, 271
nociceptors, 265, 265f
nofetumomab, 913t
nonanesthetics, 257
nonarteritic ischemic optic neuropathy, 362
nonblinded trials, phase I studies and, 865
noncompetitive antagonists, 7, 21f, 2223, 22f
nondepolarizing (competitive) neuromuscular
blockade, 126
nonhomologous end-joining, 678, 681
nonimmobilizers, 257
noninsulin-dependent diabetes mellitus. See
diabetes mellitus
nonnucleoside DNA polymerase inhibitors, 661,
661f, 671t
nonnucleoside reverse transcriptase inhibitors
(NNRTIs), 661, 661f, 671t
CCR5 antagonist and, 662b
nonopioid analgesics, 275277
nonpacemaker cells, 401402
nonprescription drugs, 870871
nonreceptor antagonist, 21, 23
nonreceptor tyrosine kinases, 11f, 12
nonreceptor-mediated mechanisms, 15
nonselective COX inhibitors, adverse effects, 742t
non-ST elevation myocardial infarction (NSTEMI),
448449
clinical management, 452453
nonsteroidal analgesics, 282t
nonsteroidal anti-inflammatory drugs. See NSAIDs
norelgestromin, 517
norepinephrine (NE), 10, 137, 186, 207, 432, 435t
metabolic cycle, 208209, 209f
metabolism, 132, 134f
neurotransmission, presynaptic regulation, 210f
neurotransmitters and, 102, 102f, 103t
pain and, 268
synthesis of, 209f
norepinephrine transporter (NET), 135, 210, 300
norepinephrine-selective reuptake inhibitors. See NRIs
norethindrone, 516, 516f, 523t
cytochrome P450 enzymes and, 52t
norethindrone acetate, 516, 516f, 523t
norfloxacin, 596t
cytochrome P450 enzymes and, 5152t
norgestimate, 516, 516f, 523t
norgestrel, 516, 523t
nortriptyline, 215, 221t, 277
cytochrome P450 enzymes and, 51t
Novocain. See procaine
NPC1L1. See Niemann-Pick C1-like 1 protein
NPH (neutral protamine Hagedorn) insulin, 534, 538t
NPR-A, 336
NPR-B, 336
NPR-C, 336
NRIs (Norepinephrine-selective reuptake
inhibitors), 217, 222t
NSAID-induced gastropathy, 755
NSAIDs (nonsteroidal anti-inflammatory drugs),
73t, 754755, 761t
chronic kidney disease, 39b
classes of, 276277
cytochrome P450 enzymes and, 52t
general features, 275276, 276f
ginkgo and, 61
gout and, 840
immune responses, immunotoxicity and, 64
niacin and, 328
oxidation/reduction enzyme and, 73t
pain, 270
peptic ulcer disease and, 811, 811f
selection, 756757
structural classes, 755f
NSTEMI. See non-ST elevation myocardial infarction
NTG. See nitroglycerin
 Index 947

N-type voltage-gated calcium channels, 267 oral drug nerve injury, 264
nuclear factor of activated T cells. See NFAT administration nociceptors and, 265, 265f
nuclear factor-kappa B (NFB) pathways, 704, 704f enteral, 3031, 30t pathophysiology, 269273
nuclear magnetic resonance (NMR), 853 delivery, 917918 pathways, 150f
nucleic acid synthesis, 676 oral drug, administration, enteral, 3031, 30t perception, 149150
nucleosides, 675 oral hydrocortisone, 496 physiology, 264269
analogues, 655, 656f oral phosphate, 560t sensation, transmission of, 149
nucleotide excision repair (NER), 679682 binders treatment, future directions, 278279
nucleotide(s), 675 drug summary table, 560t pain management
synthesis, 675676, 676f, 677f secondary hyperparathyroidism, 556 drug classes, sites of action for, 278f
nucleus accumbens (NAc), 189, 289291 hypercalcemia, 554b drug summary table, 280283f
nucleus basalis of Meynert (NBM), 117 organ toxicity, 6269 palifermin, 904t
nutrition, drug metabolism and, 53 organic anion transporter (OAT), 28, 49 paliperidone, 206t
nutritional rickets, vitamin D and, 557 organic anion transporting polypeptide (OATP), 49 palivizumab, 668, 906, 909t
nystatin, 567, 623624, 628t organic anion transporting polypeptide 1 (OATP1), 61 pamidronate, 552, 559t
organic cation transporter (OCT), 28, 49 pancreas, 524
organic nitrates pancreatic anatomy, biochemistry and physiology,
O biotransformation, 359f 524530
O6-methylguanine-DNA methyltransferase drug summary table, 368t pancreatic enzymes, 895
(MGMT), 687 heart failure and, 460t pancreatic enzymes, protein therapeutics and, 901t
OAT. See organic anion transporter mechanism of action, 359361 pancreatic polypeptide, PP cells from, 524
OATP. See organic anion transporting polypeptide sites of action, 360f pancuronium, 96, 126, 131t, 261t
OATP1. See organic anion transporting polypeptide 1 vasodilators and, 359 general anesthesia and, 256
observer bias, 864 organification, 481, 488t pancytopenia, 779
occipital lobe, 97, 97f organification inhibitors, 485486 panitumumab, protein therapeutics and, 907t
OCT. See organic cation transporter organophosphate insecticides, 885 pantoprazole, 813, 818t
octopamine, 138 ornithine decarboxylase, 640 cytochrome P450 enzymes and, 52t
octreotide, 470, 477t, 537, 540t orphan diseases, drug development and, 867 papain, 898, 905t
protein therapeutics and, 904t Orphan Drug Act, 867 para-aminobenzoic acid (PABA), 158, 575
oculomotor nerve, 95f, 96 oseltamivir, 568, 664665, 672t parafollicular C cells, 480
odds ratio, drug study and, 876 osmotic diuresis, 345 parasites, 629
ofatumumab, 806t OspA vaccine, 911t drugs and, 567568
off-label use, 870 ospemifene, 515, 521t parasitic infections
off-target adverse effects, 56, 57, 58f, 5960 osteitis fibrosa cystica, 550 drug summary table, 644648t
ofloxacin, 587, 596t osteoblasts, bone remodeling, 542, 544f pharmacology of, 629643
cytochrome P450 enzymes and, 52t osteoclasts, bone remodeling, 542, 544f parasympathetic nervous system, anatomy of,
Ohms law, cells and, 83, 83f osteomalacia, 550 94, 95f, 96
oil/gas partition coefficient, 242 osteoporosis, 548 parathion, 885
OKT3, 800801, 805t pathophysiologic basis for, 551f parathyroid hormone (PTH)
olanzapine, 198f, 200, 205t vitamin D and, 557 action of, 545f
olfactory tubercle, dopamine receptor proteins osteoprotegerin (OPG), 542 bone and, 555556
and, 189 ovarian hyperstimulation syndrome, 474 calcium homeostasis, 544546
olopatadine, 775t ovarian hypothesis, 511 parathyroid hormone-related peptide (PTHrP), 553
omalizumab, 831, 836t, 909t overdrive suppression, 406 paraventricular nuclei, 190
omega-3 fatty acids, 329, 331t overflow model, cirrhosis and, Na retention and, parenteral drug administration, 30t, 31, 31t
generation, 741742 341, 342f parenteral formulations, 858
omeprazole, 73t, 813, 814f, 818t oxacillin, 609, 610, 615t paricalcitol, 560t
cytochrome P450 enzymes and, 52t oxaliplatin, 690, 696t secondary hyperparathyroidism, 556
off-target effects, 60 oxazolidinones, 572, 594, 598t parietal cell acid secretion, 809f
oxidation/reduction enzyme and, 73t oxcarbazepine, 277 parietal lobe, 97, 97f
Onchocerca volvulus, 629, 640 cytochrome P450 enzymes and, 51t Park nucleotide, 603
life cycle, 641, 641f trigeminal neuralgia, 272 Parkinsons disease, 186
ondansetron, 218, 223t oxicam derivatives, 756 nigrostriatal pathways and, 191192, 192f
one-pot synthesis, 858 oxicams, 761t nondopaminergic pharmacology, 195
on-target adverse effects, 56, 5759, 58f oxiconazole, 623, 627t pathophysiology, 192193
open state, sodium channel and, 226 oxidation reactions, 44, 45t pharmacology and, 193195
opioid agonists oxidation/reduction reactions, 34, 45t, 47 treatment, 195
drug summary table, 280t oxybutynin, 125, 130t paromomycin, 589, 596t, 639
long-acting, drug table and, 307t oxycodone, 274, 280t, 292f paroxetine, 216, 221t, 277
pain relief and, 273275 oxymetazoline, 139, 144t cytochrome P450 enzymes and, 51t
spinal cord and, mechanism of action, 274f, 275 oxypurinol, 841, 844t paroxysmal depolarizing shift (PDS), 227
opioid antagonists, 275, 282t oxytetracycline, 591, 597t paroxysmal nocturnal hemoglobinuria (PNH), 802
long-acting, drug table, 307t oxytocin, 475 paroxysmal supraventricular tachycardia (PSVT), 409b
opioid hyperalgesia, 295 PARP1 inhibitors, 693
opioid partial agonists, drug table for, 308t pars compacta, 189
opioid peptide family, 106, 268269 P partial agonists, 7, 2324, 23f, 275, 281t
opioids, 106, 261t P wave, 405b, 405f partial nicotine agonists, 309t
cytochrome P450 enzymes and, 51t P2X ligand-gated channels, 267 partial pressure (of gas) concentration vs., 242b
drugs of abuse and, 286t, 292f, 295296, 296f, 297f P2Y G protein-coupled purinergic receptors, 267 partition coefficients, 244b
general anesthesia and, 256 P2Y1 receptors, 375 pasireotide, 470
methadone and, 304 P2Y(ADP) receptors, 375 passive targeting, drug delivery and, 922
pain and, 268 PABA. See Para-aminobenzoic acid patient registries, pharmacoepidemiology and, 875
pathways and, 296f pacemaker cells, 401402 pattern recognition, innate immune response and, 732
prescription, 296 paclitaxel, 73t, 692693, 698t, 723t, 849, 922 pazopanib, 711t, 715t
sites of action, 278f immune responses, immunotoxicity and, 64 PBPs. See penicillin-binding proteins
withdrawal, 296 oxidation/reduction enzyme and, 73t PCP. See phencyclidine
oprelvekin, 785, 789t STEMI, drug-eluting stent and, 454 PCSK9. See proprotein convertase subtilisin-like
protein therapeutics and, 902t PAI. See plasminogen activator inhibitor kexin type 9
opsonins, inflammatory response and, 738 pain. See also clinical pain syndromes; first pain; PDE inhibitors. See phosphodiesterase inhibitors
optic tract, 100 second pain PDE5. See cGMP phosphodiesterase type V
oral contraceptives, 231 adrenergic drugs, 277278 PDGF. See platelet-derived growth factor
948 Index
PDGFR inhibitors, 713714t
PDS. See paroxysmal depolarizing shift
pedunculopontine nucleus, 101, 101f
peg-asparaginase, 905t
PEG-filgrastim, 784785, 788t
protein therapeutics and, 902t
Peg-G-CSF, protein therapeutics and, 902t
PEG-interferon, 914
peginterferon alfa-2a, 902t
pegloticase, uric acid metabolism and, 842, 845t
PEG-rHuMGDF. See pegylated recombinant human
megakaryocyte growth and development
factor
pegvisomant, 470471, 477t, 909t
pegylated recombinant human megakaryocyte
growth and development factor
(PEG-rHuMGDF), 785, 788t
pemetrexed, 684, 694t
penbutolol, 142, 146t
cytochrome P450 enzymes and, 51t
penciclovir, 658, 670t
penicillamine, 884
penicillin G, 609, 610, 615t
penicillin V, 610, 615t
penicillin-binding proteins (PBPs), 604
penicillin(s), 599, 604, 608, 720
discovery, 849
drug combinations, 721
hypersensitivity reactions and, 62
pharmacokinetic drug-drug interactions, 61
seizure and, 225226
transpeptidase action and, 605f
unfavorable drug combinations, 721
pentamidine, African sleeping sickness and,
639, 646t
pentobarbital, 173
clinical uses for, duration of action, 174t
GABAA receptors and, 183t
phenobarbital vs., 174t
pentostatin, 685, 685f, 694t
PEP. See phosphoenolpyruvate
pepsin, 811
peptic ulcer disease
case studies, 808
drug summary table, 818819t
pathophysiology of, 810811
pharmacologic classes, and agents,
812817, 812f
risk factor modification, agents for, 816817
peptides, 851b
peptidoglycan, 599
biosynthesis, 601604
peptidoglycan glycosyltransferases (PGTs), 604
peptidoglycan polymerization, 607
peptidyl site, 585
peptidyl transferase, 585586
perceived volume depletion, heart failure and,
341, 341f
perchlorate, 485, 488t
perforins, 733
perfusion-limited anesthetics, 249, 249f
pergolide, 194
periaqueductal gray, 99
perindopril, 349t
peripheral nerve blockade, 156157
peripheral nerve fibers
local anesthetics and, 153f
types of, 149, 149t
peripheral nervous system, anatomy of, 9396
peripheral neuropathy, 692
peripheral sensitization, 270271, 270f
peripheral testosterone conversion to DHT,
inhibitors, drug summary table for, 520t
peripheral thyroid hormone metabolism inhibitors,
486, 488t
peripheral tolerance, autoimmunity and, 792
peripheral transduction, 266f
permanent plug, 373
permethrin, 887
peroxisome proliferator-activated receptor-
(PPAR), 525
peroxynitrite, 362
perphenazine, 204t
cytochrome P450 enzymes and, 51t
pertechnetate, 485, 488t
pesticides, 885887, 886f
petit mal seizures, 230
PGG2. See prostaglandin G2
P-glycoprotein, 49, 691
pharmacokinetic drug-drug interactions, 61
PGTs. See peptidoglycan glycosyltransferases
pH trapping, 29, 29f
phagocytosis, inflammatory response and, 737738
pharmacodynamic interactions, drug-drug, 61
pharmacodynamic tolerance, 287
pharmacodynamics, 6, 1726
pharmacoepidemiology, 874875
data sources, 875876
pharmacology vs., 874, 874t
study design and interpretation, 877878
study strategies, 876, 876f, 877f
pharmacogenetics-pharmacogenomics,
pathway-based, 7677, 77f
pharmacogenomics, 42, 71
future directions, 79
pharmacology and, 7178
physiology, 71
pharmacokinetic tolerance, 287
pharmacokinetics, 2742
clinical applications, 3742
drug-drug interactions, 61
future directions, 42
relationships, 42t
pharmacology and pharmacogenomics, 7172
drug targets, variation in, 7576, 76t
idiosyncratic drug reactions, 77
pathway-based pharmacogenetics-
pharmacogenomics, 7677, 77f
pharmacogenetics-pharmacogenomics, 7778
pharmacogenomics, regulatory science and, 78
variation in enzymes, of drug metabolism,
7275, 73t, 74f, 75f
pharmacology review, IND and, 867
pharmacology/toxicology review, IND and, 863
phase I reactions. See biotransformation
phase I studies, clinical trials and, 865866
phase II reactions. See biotransformation
phase III studies, clinical trials and, 866
phase IV studies, 874
phasic inhibition, local anesthesia and, 153155, 155f
phencyclidine (PCP), 301
drugs of abuse and, 286t
phenelzine, 139, 144t
serotonin degradation and, 214, 220t
phenindamine, 774t
phenobarbital, 173, 232t, 238t
cytochrome P450 enzymes and, 5152t
GABAA receptors and, 183t
pentobarbital vs., 174t
seizures and, 234235
phenothiazines, 204t, 774t
schizophrenia and, 197
phenoxybenzamine, 140, 145t, 443
phentolamine, 141, 145t, 443
phenylalanine, 186
phenylalkylamines, 363, 370t, 405
phenylbutazone, 755
cytochrome P450 enzymes and, 52t
phenylephrine, 139, 144t
phenylethanolamine N-methyltransferase (PNMT),
132, 187
phenylethylamines, drugs of abuse and, 286t
phenylpropanolamine, 139
phenytoin, 108, 232t, 236t, 485
cardiac rhythm and, 412, 419t
cytochrome P450 enzymes and, 39, 45t, 51t
immune responses, immunotoxicity and, 64
oxidation/reduction enzyme and, 73t
sodium channels and, 236t
phosphate homeostasis, hormonal control of,
543548, 545t
phosphatidylinositol 3-kinase (PI3-kinase), 529
phosphatidylinositol 3-kinase (PI3K)-AKT path-
way, 700, 702703f
phosphodiesterase inhibitors (PDE inhibitors),
362363, 432433, 436t
drug summary table, 369370t, 395t
heart failure and, 462
thrombus formation and, 383
phosphoenolpyruvate (PEP), 601
phospholamban, 426
phospholipase, 741
phospholipase inhibitors, inflammation and, 754
phospholipid transfer protein (PLTP), 320
phosphomycin, 606607
phosphoribosyl pyrophosphate (PRPP), 837839
phosphorylation, 11
phthalazinones, 775t
physical dependence, 285
mechanisms, 289291
opioids and, 274
psychostimulants and, 300301
physiologic antagonist, 21, 23
physostigmine, 111f, 120121, 128t
PI3-kinase. See phosphatidylinositol 3-kinase
picrotoxin, 170, 182t
GABAergic transmission and, 169t
pilocarpine, 106, 123, 129t
pimozide, 198f, 204t
pinacidil, 365, 370t
pindolol, 141t, 142, 146t
cardiac rhythm and, 413, 419t
pioglitazone, 536, 540t
piomelanocortin, 493
piperacillin, 609, 611, 615t
piperazines, 642, 648t, 775t
piperidines, 774t, 775t
pirbuterol, 828, 834t
pirenzepine, 120, 124, 130t
pirmagrel, 758, 763t
piroxicam, 276, 755, 756, 761t
pitavastatin, 325326, 330t
pitrakinra, 833
pituitary gland, hypothalamus vs., 465468
pituitary physiology, 465468
pivotal trials, 865
pKa. See ionization state
PKR. See protein kinase R
plant sterols, 326327
plasma lipoproteins, characteristics of, 312t
plasma protein binding, drug trapping and, 3334, 33f
plasmin, 380
plasminogen activator inhibitor (PAI), 380
Plasmodium falciparum, 629631
platelet granule release reaction, 373374
platelet-derived growth factor (PDGF), 904t
platelet(s), 373, 776
activation, 373, 375f
adhesion, 373, 375f
aggregation, 375376, 375f
production, 782, 782f
drugs stimulating, 785, 788t
platinum compounds, 689, 690f, 696t, 723t
pleiotropic growth factors, 778
pleuromutilins, 572, 594595, 598t
PLTP. See phospholipid transfer protein
pluripotent hematopoietic stem cell, 776
PNH. See paroxysmal nocturnal hemoglobinuria
PNMT. See phenylethanolamine N-methyltransferase
podagra, 839
Podophyllum, 691
polyanhydride polymers, surface erosion and, 921f
polyclonal antibodies, 800
polycystic ovarian syndrome (PCOS), 511
polydipsia, 531
polyenes, 624625, 628t
polymer cross-linking inhibitors, 608612, 615617t
polymer release mechanisms, 920f
polymerase chain reaction (PCR) analysis, 44f
polymer-based drug delivery system, 919922, 920f
polymerization, cell wall biosynthesis and, 603604
polymicrobial infections, combination
antimicrobial drugs and, 721

polyphagia, 531
polythiazide, 352t
polyuria, 531
POMC. See proopiomelanocortin
pons, 96, 97f
pooled immunoglobulins, protein therapeutics and,
901t
porins, outer membrane, 601
posaconazole, 623, 627t
positive chronotropic effect, 426
positive inotropic effect, 426
positive lusitropic effect, 427
positive reinforcement, drug addiction and, 291
positive symptoms, schizophrenia, 195
posterior horn, 96
posterior pituitary gland, 465, 474475
postganglionic neuron, 9495
postmyocardial infarction management, 454
postsynaptic receptors, 92
potassium (K), cardiac rhythm and, 416
potassium channel openers, 365, 370t
drug summary table, 370371t
vasodilators, 443444
potassium hydroxide, 885
potassium loading, aldosterone synthesis and, 500
potassium phosphate, 561t
potassium-sparing diuretics, 440t, 442, 442t
potency of drug (EC50), 19
PP cells, 524
PPAR. See peroxisome proliferator-activated
receptor-
PPD test. See purified protein derivative test
PR interval, 405b, 405f
pralidoxime, 887
pramipexole, 194, 202t
pramlintide, 535, 539t
protein therapeutics and, 899t
prandial bolus insulins, 533, 538t
prasugrel, 375, 386, 396t
UA/NSTEMI, 453
pravastatin, 22, 325326, 330t
praziquantel, adult cestode and, 642, 648t
prazosin, 141, 145t, 365, 371t, 443
pRB. See retinoblastoma protein
preclinical research, 863
prednisolone, 494495, 495f, 503t, 754, 762t
prednisone, 39, 494, 503t, 723t, 754, 762t
combination chemotherapy, 726
cytochrome P450 enzymes and, 52t
pregabalin, 232t, 234, 237t, 277
preganglionic neuron, 94
pregnancy
ACE inhibitors, 69
drugs, 68b
glucocorticoids and, 498
pregnane X receptor (PXR), 49
preload, 354, 422, 456
preventers, asthma treatment, 827
prevertebral ganglia, 96
prilocaine, 159, 161t
primaquine, 635, 644t
primary generalized seizures, pathophysiology of,
229230, 229f
primary hemostasis, 373376
primary hemostatic plug, 372, 375
primary hyperaldosteronism, 500
primary percutaneous intervention, STEMI, 454
primary prevention, statins and, 325
primary structure, amino acid and, protein structure
of, 2
primase, 583
probenecid
pharmacokinetic drug-drug interactions, 61
uric acid excretion and, 842, 845t
procainamide, 418t
conjugation enzyme and, 73t
immune responses, immunotoxicity and, 64
procaine (Novocain), 147, 156, 158, 161t
procarbazine, 687, 696t
combination chemotherapy, 726
prochlorperazine, 198f
procyclidine, 125
prodrugs, 34, 50
progesterone receptor antagonists, 522t
progestin-only contraception, 517, 523t
progestins
contraconception, 516517, 516f
hormone replacement, 518
synthesis, 505506
proguanil, malarial plasmodia and, 636, 645t
prolactin
agents decreasing, 478t
anterior pituitary gland, 467
schizophrenia and, 198
prolactinomas, 511
proliferation, tumor and, 569
proliferative phase, menstrual cycle and, 509
promethazine, 770, 771, 774t
promoters, cancer and, 67
proopiomelanocortin (POMC), 472
propafenone
cardiac rhythm and, 412, 419t
cytochrome P450 enzymes and, 51t
propantheline, 125, 130t
prophylactic chemotherapeutics, drug resistance
and, 574
propionic acid derivatives, 756
propionic acids, 761t
propofol, 175, 260t
GABAA receptors and, 184t
intravenous anesthesia and, 255
propoxyphene, 281t
propranolol, 73t, 141t, 142, 146t, 371t, 442
cardiac rhythm and, 413, 419t
cytochrome P450 enzymes and, 5152t
oxidation/reduction enzyme and, 73t
proprotein convertase subtilisin-like kexin type 9
(PCSK9), 318
propylthiouracil, 486
thyroid hormone and, 488t
prostacyclin (PGI2), 379
cyclooxygenase pathway and, 744745
prostaglandin G2 (PGG2), 382
prostaglandins
biosynthesis, pharmacologic inhibition and, 743f
cyclooxygenase pathway and, 744
gastric acid and, 808809
peptic ulcer disease, 816
products/synthesis/receptors/function, 744t
prostanoid structure, 744f
prostanoid, 763t
cyclooxygenase pathway and, 744, 744f
receptor mimetics, 758, 763t
prostate cancer, 511, 912
protamine, 23, 393, 400t, 906t
protease
protein therapeutics and, 901t
viral proteins and, 659
proteasome
inhibitors, 710, 714t
structure and function, 701705
protectins, 748, 749751f, 759
protein C, 380
protein therapeutics and, 900t, 903t
protein diagnostics, 897b, 912, 913914t
protein kinase R (PKR), immune system
modulation, 668
protein S, hemostasis and, 380
protein therapeutics, 895897
case study, 896
challenges for, 912915
conclusion and future directions, 915
functional classification of, 897b
group I, enzymes and regulatory proteins,
897904, 899901t, 901904t, 905906t
group II, targeted proteins, 904911, 907910t,
910t
group III, protein vaccines, 911912, 911t
group IV, protein diagnostics, 912, 913914t
protein(s)
as drug receptors, 23
in medicine, 897912
Index 949
structure, 23, 4f
vaccines, 897b, 911912, 911t
prothrombin G20210A mutation, 381
prothrombin time (PT), 388389
protirelin, 478t
proton pump inhibitors
cytochrome P450 enzymes and, 52t
metabolism of, 815b
peptic ulcer disease and, 813816, 813f, 818t
protozoa, 637638
protracted withdrawal syndrome, 289
protriptyline, 221t
proximal tubule, 337, 338, 338f
proxyfan, 772
PRPP. See phosphoribosyl pyrophosphate
prucalopride, irritable bowel syndrome and, 218, 224t
pseudoephedrine, 139, 143t
Pseudomonas aeruginosa, 604
psoralen isomers, 885
PSVT. See paroxysmal supraventricular tachycardia
psychedelic agents, drugs of abuse and, 286t
psychological dependence, mechanisms, 285286
psychostimulants
drugs of abuse and, 286t
physical dependence, 300301
psychotic depression, 212
PT. See prothrombin time
PTH. See parathyroid hormone
PTHrP. See parathyroid hormone-related peptide
pulmonary drug delivery, 918919
pulmonary embolism, 517
pulmonary fibrosis, bleomycin and, 691
pulmonary toxicity, drug-induced, 67
pump-based hypertension, 439
Pure Food and Drugs Act, 861
purified protein derivative (PPD) test, 912
purine analogues, 695t, 723t
DNA and, 686
purine derivatives, 675, 677t
purine metabolism inhibitors, 684685, 694t
purine metabolism, physiology, 837839, 838f
purine ribonucleotide synthesis, 675
putamen, 98
PXR. See pregnane X receptor
pyrantel pamoate, 642, 648t
pyrazinamide, 612, 617t, 719
pyrethroid insecticides, 887
pyridostigmine, 121, 128t
pyrilamine, 771, 774t
pyrimethamine, 565, 576, 577, 579t, 720721
malarial plasmodia and, 636
pyrimidine analogues, 723t
pyrimidine(s)
analogues, 695t
DNA and, 686
ribonucleotide synthesis, 675676
Q
QRS complex, 405b, 405f
QT interval, 405b, 405f
quadruple therapy, H. pylori, 817
quantal dose-response relationships, 1920, 20f
quaternary structure, polypeptides and, 3, 4f
quazepam, 171
clinical uses for, duration of action, 172t
GABAA receptors and, 183t
quetiapine, 205t
schizophrenia and, 200
quinagolide, 471
quinapril, 349t
quinidine, 51t, 410411, 418t, 644t
cytochrome P450 enzymes and, 51t
malarial plasmodia and, 633
oxidation/reduction enzyme and, 73t
quinine, 644t
malarial plasmodia and, 633
quinolones, 587, 596t, 717t
cytochrome P450 enzymes and, 52t
quinone, malarial plasmodia and, 635
quinupristin, 572, 593f, 594, 598t
950 Index
R remodeling. See bone remodeling
RAAS. See renin-angiotensin-aldosterone system
rabeprazole, 813, 818t
race, drug metabolism and, 53
raclopride, 198f
radioactive iodide, thyroid gland and, 488t
raloxifene, 24, 514
drug summary table, 521t, 559t
SERMs and, 552
structure of, 552f
raltegravir, 662, 672t
ramipril, 349t
randomization of subjects, clinical trials and, 864
randomized controlled trial (RCT), 872
ranibizumab, 910t
ranitidine, 772, 775t, 818t
peptic ulcer disease and, 812
RANK ligand (RANKL), calcium homeostasis, 542
RANK ligand (RANKL) antagonists, 555, 559t
ranolazine, cardiac rhythm and, 416, 421t
rapamycin, 710, 714t
r-APC. See recombinant activated protein C
raphe nuclei, 101, 101f
serotonin and, 208
RAR. See retinoic acid receptor
rasagiline, 195, 202t
rasburicase
protein therapeutics and, 905t
uric acid metabolism and, 842, 845t
RAS/MAP kinase pathway inhibition, 709, 714t
rate of equilibration, partial pressure in alveoli
and, 249f
rational drug design, 6
ravuconazole, 567, 623624
RCT. See randomized controlled trial
receptor agonists
adrenergic, 136t, 139140
cholinergic, 122124, 123f, 123t, 124t
receptor antagonists, 21
adrenergic, 140142
cholinergic, 119t, 124126
selective estrogen receptor modulators, 513515
types, 21f
receptor binding assays, 855
receptor guanylyl cyclases, 10f, 12
receptor regulation, mechanism of, 15t
receptor serine/threonine kinases, 12
receptor tyrosine kinases, 1112
cancer and, 701t
receptor tyrosine phosphatases, 12
recombinant activated protein C (r-APC), 392, 399t
recombinant human bone morphogenic protein 2
(rhBMP-2), 904t
recombinant human bone morphogenic protein 7
(rhBMP-7), 904t
recombinant human erythropoietin (rhEPO), 783
recombinant human G-CSF, 784785
recombinant human IL-11 (rhIL-11), 785
recombinant human thrombopoietin (rhTPO),
785, 788t
recombinant insulin, 896
recombinant tissue plasminogen activator (t-PA),
393, 399t
recurrent disease treatment, cancer and, 726
red man syndrome, 64, 607
5-reductase inhibitors, 513
re-entrant electrical pathways, 407408
normal vs., 407f
reflex tachycardia, 360
refractory cancers, treatment, 726
refractory period, 14
refractory state, 8, 14, 88
regular insulin, 533, 538t
relapse, addiction and, 291
relative risk, drug study and, 876
release factors
termination and, 586
viral proteins and, 651
relievers, asthma treatment, 827
remifentanil, 261t, 269, 275, 281t
ribosomes, 581
remoxipride, 198f ridogrel, 763t
REMS. See Risk Evaluation and Mitigation Strategies rifabutin, 596t
renal excretion, drugs and, 3637, 36f cytochrome P450 enzymes and, 51t
renal parenchymal disease, 440 rifamycin B and, 587, 587f
renal sodium (Na) reabsorption, agents rifampin, 39, 485, 596t, 719
cytochrome P450 enzymes and, 50, 52t
decreasing, 344347
renal sympathetic nerves, 337 immune responses, immunotoxicity and, 64
renal toxicity, drug-induced, 66 metabolic drug interactions, 54
renin, 334 rifamycin B and, 587, 587f
inhibitors, 342343, 349t, 444 rifamycin B, 587
renin-angiotensin system blockers, vascular tone rifamycin derivatives, transcription inhibitors as,
and, 366 587588
renin-angiotensin-aldosterone system (RAAS) rifapentine, cytochrome P450 enzymes and, 51t
extracellular fluid volume, 500 rilonacept, 800, 805t, 908t
inhibitors of, 342 riluzole, 185t
modulation, 444 rimantadine, 568, 670t
volume regulators and, 334335, 334f viral uncoating and, 653655, 654f
renovascular disease, 440 rimonabant, 269, 301
repaglinide, 539t risedronate, 552, 559t
repeat-dose toxicity studies, 857 Risk Evaluation and Mitigation Strategies
repolarization, inhibitors, 413414 (REMS), 862
class III antiarrhythmic drugs, drug table, 420t risperidone, 205t
reproduction cytochrome P450 enzymes and, 51t
case study, 506 schizophrenia and, 200
pharmacology, 505523 ritonavir, 574, 672t
reproduction hormones cytochrome P450 enzymes and, 50, 5152t
drug summary table, 520523t development of, 665b, 666f
male and female, future directions with, 519 HIV and, 662
physiology of, 505510 rituximab, 65, 712, 715t, 801, 806t, 906, 907t
reproductive tract rivastigmine, 121, 122t, 129t
disorders, 510t rizatriptan, 217, 223t, 278
pathophysiologic process, 510512 RNA, 581
reserpine, 138, 143t, 209, 213, 443 viral life cycle and, 650
resolution, inflammatory response and, 738 RNA polymerases, 581, 583
resolvins, 759 rocuronium, 126, 131t
biosynthesis, 747f, 748, 749751f rofecoxib (Vioxx), 78, 271, 276, 757
respiratory physiology, concepts, 245 drug study and, 874, 877
rest angina, 362 withdrawal of, 879
resting membrane potential, 8486, 402 roflumilast, 833
electrochemical basis, 85f, 86f romiplostim, 788t, 914
relative contribution of K and Na, 86f protein therapeutics and, 902t
restitution, gastric acid and, 809 ROMK channel, 339
retapamulin, 572, 594595, 598t ropinirole, 194, 202t
reteplase, 393 ropivacaine, 157, 159
drug summary table, 399t rosiglitazone (Avandia), 536, 540t, 874
protein therapeutics and, 903t rosuvastatin, 325326, 330t
STEMI, 454 roundworms. See nematodes
reticular activating system, 99, 101f, 117 RT. See reverse transcriptase
retinoblastoma protein (pRB), 701 rT3. See reverse triiodothyronine
retinoic acid (vitamin A), 73t rufinamide, 232t, 235, 239t
oxidation/reduction enzyme and, 73t R-warfarin, cytochrome P450 enzymes and, 52t
teratogenesis and, 68 RXR. See retinoid X receptor
retinoic acid receptor (RAR), 786 ryanodine receptor, 254, 425
retinoid X receptor (RXR), 68, 482
retrosynthetic analysis, 857, 857f
reuptake inhibitors, 215217 S
reversal potential, 91 SA nodal cells. See sinoatrial nodal cells
reverse cholesterol transport, 318, 319f, 320 salicylate, 755756
reverse transcriptase (RT), 659 saline diuresis, 554b
reverse triiodothyronine (rT3), 480 salmeterol, 140, 145t, 828, 834t
reversible antagonist, 21, 21f salmon calcitonin, 559t
Reyes syndrome, 756 salvage pathway, 837
rFSH. See follitropin saquinavir, 51t, 53, 662, 672t
rhBMP-2. See recombinant human bone sarcoendoplasmic reticulum calcium ATPase.
morphogenic protein 2 See SERCA
rhBMP-7. See recombinant human bone sarcolemma, cardiac myocyte contraction and, 425t
morphogenic protein 7 sarcomere, cardiac myocyte contraction and, 425t
rhEPO. See recombinant human erythropoietin sargramostim, 784785, 788t
rheumatoid arthritis, 753, 906 protein therapeutics and, 902t
rhIL-11. See interleukin-11; recombinant human satumomab pendetide, 913t
IL-11 saturation kinetics, 42, 42f
rhodanese, 883 saxagliptin, 536, 539t
rhTPO. See recombinant human thrombopoietin saxitoxins, 885
ribavirin, 667668, 673t scavenger receptor class B, type I (SR-BI), 318
ribonucleotide reductase, 676 SCF. See stem cell factor
ribonucleotide reductase inhibitors, 685, 695t schizophrenia
ribonucleotide reduction, thymidylate synthesis central dopamine pathways and, 190
and, 676 criteria for, 196b
30S ribosomal subunit, antimicrobial drugs and, dopamine receptors and, 189
585586 dopamine systems and, 186

pathophysiology, 195197
pharmacology, 197200
scopolamine, 106, 124, 130t
secobarbital
cytochrome P450 enzymes and, 52t
GABAA receptors and, 183t
second messenger, regulated ion channels, 7, 8t, 9
second pain, 149, 150f
secondary generalized seizures, pathophysiology
of, 228229, 229f
secondary hemostasis, 372, 375379
secondary hyperlipidemia, 323324, 323t
secondary hyperparathyroidism, 548, 550, 556557
secondary hypertension, 439
secondary osteoporosis, 548
secondary prevention, statins and, 324
secondary structure, amino acid and, protein struc-
ture of, 3, 4f
secretins, 106, 913t
secretory phase, menstrual cycle, 509
seizure propagation, pathways of, 229f
seizure(s). See also secondary generalized seizures
brain and, 225227
epileptic, classification of, 228t
pathophysiology of
focal, 227228
primary generalized, 229230, 229f
secondary generalized, 228229, 229f
pharmacologic classes and agents, 231235, 232t
selection bias, 877
selective estrogen receptor modulator. See SERM
selective factor Xa inhibitors, 391
drug summary table, 398t
selective serotonin reuptake inhibitors. See SSRIs
selective toxicity, 564, 887
selegiline, 139, 144t, 195, 202t
serotonin degradation and, 214, 221t
sensitization, 285
sensory nerve stimulation, 766
sensory transduction, 265267, 266f
sequential blockade, 578
SERCA (sarcoendoplasmic reticulum calcium AT-
Pase), calcium storage/release and, 425
serine-protease inhibitors, 393, 400t
SERM (selective estrogen receptor modulator), 24
bone homeostasis disorders and, 552
drug summary table, 521t, 559t
reproduction hormones and, 513515, 513t
tissue specificity, model for, 514f
sermorelin, 470, 477t
serotonergic neurotransmission, pharmacology of,
207224
serotonin (5HT), 101, 207, 208
degradation inhibitors, 214215
drug summary table, 220221t
metabolic cycle, 208
monoamine theory of depression, 212213
neurotransmitters and, 102, 103t
pain and, 268
pathways, future directions, 219
receptor agonists, 217
drug summary table, 223t
receptor antagonists, 217218
drug summary table, 223224t
receptors, signaling mechanisms, 210, 210t
regulation, 208210, 209f, 210f
reuptake inhibitors, 215217
drug summary table, 221t
storage inhibitors, 213214
drug summary table, 220t
synthesis of, 105, 105f, 208210, 209f
varicosities and, 208
serotonin syndrome, 139, 216
serotonin transporter (SERT), 210
serotonin-norepinephrine reuptake inhibitors.
See SNRIs
SERT. See serotonin transporter
sertaconazole, 623, 627t
Sertoli cells, gonadal hormone action and, 508509
sertraline, 216, 221t
cytochrome P450 enzymes and, 52t
serum sickness, 62
sevelamer, 560t
sevoflurane, 249, 254, 255, 260t
cytochrome P450 enzymes and, 52t
sex hormone-binding globulin (SHBG), 506
SHBG. See sex hormone-binding globulin
shotgun approach, 848, 853
shunting, 167
SIADH (Syndrome of inappropriate ADH
secretion), 474
sickle cell anemia, 779
side effects, 56
signal transduction
antagonists, 707710
molecules, 12
cancer, 699715
sildenafil, 362, 369t
cytochrome P450 enzymes and, 51t
pharmacodynamic drug-drug interactions, 61
silica, toxicity of, 891892
simvastatin, 78, 325326, 330t
single nucleotide polymorphisms (SNPs), 71, 828
single-blind trials, 866
single-source divergent neuronal systems, 99,
100102, 100f, 101t
sinoatrial nodal cells (SA nodal cells)
action potential, ion currents and, 403f
action potential phases, ventricular myocytes
and, 404t
firing cycle of, phases, 402
resting ventricular muscle action potential, 403f
sinus tachycardia, 409b
sirolimus, 797798, 798f, 804t, 922
STEMI, drug-eluting stent and, 454
sirolimus-eluting stents, 797798
sitagliptin, 536, 539t
skeletal muscle toxicity, drug-induced, 6667
skin rashes, immune responses, immunotoxicity
and, 64
SLC. See human solute linked carrier
slow-reacting substance of anaphylaxis (SRS-A), 826
slow-wave sleep, 117, 230
SNAREs, synaptic vesicles and, 9192, 91f
sNDA. See supplemental NDA
SNPs. See single nucleotide polymorphisms
SNRIs (Serotonin-norepinephrine reuptake inhibi-
tors), 216217, 222t
sodium bicarbonate, 816, 819t
sodium channel inhibitors, 231232, 236237t
sodium channel(s), local anesthetics and, 147,
153, 154f
sodium excretion, renal control of, 337338, 337f
sodium nitrate, 883
sodium nitroprusside, 360361, 361f, 368t
sodium polystyrene sulfonate, 485
sodium pump, 424
sodium retention
cirrhosis and, mechanisms, 341342, 342f
heart failure and, mechanisms, 341
sodium stibogluconate, leishmaniasis and, 640, 647t
sodium thiosulfate, 883
sodium-calcium exchange, 424
solid organ rejection, 790
solifenacin, 125, 130t
solvent activation, drug delivery and, 921
solvent/gas partition coefficient, 242b, 243f, 244b
somatic gene recombination, 733
somatic nervous system, 96
somatostatin, 106, 529530, 540t
-cells, 524
gastrin, 524
somatostatin receptor ligands (SRLs), 470
somatostatin-secreting D cells, gastric acid and, 808
somatotropin, protein therapeutics and, 899t
somatrem, 477t
somatrem, protein therapeutics and, 899t
somatropin, 470, 477t
somatropin, protein therapeutics and, 899t
sonophoresis, 919
sorafenib, 711t, 714t
sotalol, cardiac rhythm and, 414, 420t
Index 951
space of Disse, 316
spare receptors, 19, 2425, 25f
sparteine, 73
specific lymphocyte-signaling inhibitors, 796798,
803804t
specificity, drug-receptor binding, 6
spectinomycin, 596t
spinal cord
anatomy, 96, 97t, 99, 99f
descending inhibitory regulation in, 268269
local inhibitory regulation in, 268269
opioid receptor agonists and, mechanism of
action, 274f
periphery to, conduction from, 267
spinal cord dorsal horn, transmission in, 267268, 267f
spinal nerves, 96
spironolactone, 347, 352t, 442t, 500, 504t, 515, 522t
heart failure and, 460461, 460t
spiroperidol, 198f
spontaneous pain, 269
spontaneous reports, pharmacoepidemiology and,
875
sporozoites, 630
squalene epoxidase inhibitors, 622, 626t
SR-BI. See scavenger receptor class B, type I
SREBP2. See sterol regulatory element binding
protein 2
SRLs. See somatostatin receptor ligands
SRS-A. See slow-reacting substance of anaphylaxis
SSRIs (Selective serotonin reuptake inhibitors),
105, 216
drug summary table, 221t, 309t
drug-herb interactions, 62
melancholic depression, 211
psychotic depression, 212
ST elevation myocardial infarction (STEMI), 449
clinical management, 453454
St. Johns wort
cytochrome P450 enzymes and, 51t, 53
drug-herb interactions, 62
ST segment, 405b, 405f
stabilizers, 858
stable exertional angina, nitrates and, 451
Staphylococcus aureus, 39f, 572, 587, 601, 607608
starvation state, 525526
state-dependent binding, 8
state-dependent ion channel block, 408
statins
cytochrome P450 enzymes and, 51t
LDL lowering and, 324325, 325f
on-target adverse effects, 58
statistical review, IND and, 867
statistical significance, interpreting, 878
stavudine, 671t
steel factor, 779
stem cell factor (SCF), 708, 779
STEMI. See ST elevation myocardial infarction
stereochemistry, 4
steroid 21-hydroxylase, 501
steroid hormones, 12
steroids, oxidation/reduction enzyme and, 73t
14-sterol demethylase
fungus and, 622624
inhibitors, 627t
sterol regulatory element binding protein 2
(SREBP2), 324
Stevens-Johnson syndrome, 64
Streptococcus pyogenes, 594
streptogramin B, 592
streptogramins, 572, 594, 598t
streptokinase, 62, 392, 849, 898
drug summary table, 399t
protein therapeutics and, 905t
STEMI, 454
Streptomyces, 691
streptomycin, 589, 596t, 719720
striatum, 98, 189
structural proteins, antineoplastic drugs and, 13
subject bias, 864
substance dependence. See Addiction
substance P, 155, 267, 821
952 Index

substantia nigra pars compacta, 98, 101, 189, 192, 192f tacrine, 121, 129t tetrahydrofolate (THF), 675
subthalamic nucleus, 191 cytochrome P450 enzymes and, 52t tetrahydrozoline, 139, 144t
succinylcholine, 123, 129t, 261t tacrolimus, 796797, 797f, 804t 3,5,3,5-tetraiodothyronine (T4), 480
drug metabolism and, 52, 72 cytochrome P450 enzymes and, 51t tetrodotoxin, 89
general anesthesia and, 256 oxidation/reduction enzyme and, 73t TFPI. See tissue factor pathway inhibitor
sucralfate, 816, 819t tactile mechanoreceptors, 148 TH. See tyrosine hydroxylase
sufentanil, 275, 280t tadalafil, 362, 369t TH cells. See T-helper cells
suicide substrate inhibition, 608 TAL. See thick ascending limb thalamocortical projections, 228
suicide substrates, 4 tamoxifen, 24, 50, 511, 514, 521t, 699, 723t thalamus, 98
sulbactam, 609, 615t, 721 carcinogenesis, drug therapy and, 67 thalidomide, 60, 711, 715t
sulconazole, 623, 627t cytochrome P450 enzymes and, 52t THC. See tetrahydrocannabinol
sulfa drugs, bacteria and, 575576 drug metabolism and, 74 THDOC, 5tetrahydrodeoxycorticosterone
sulfadiazine, 575, 576, 579t oxidation/reduction enzyme and, 73t thecal cells, gonadal hormone action and, 508
sulfadoxine, 579t, 721 pharmacogenetics, 75f T-helper (TH) cells, 768
malarial plasmodia and, 636, 645t tamsulosin, 141, 145t theophylline, 436t, 828f, 829, 835t
sulfadoxine-pyrimethamine, 568 tapeworms. See cestodes therapeutic dosing, 3942, 40f, 41f, 42f
antimalarial drug resistance and, 636 tardive dyskinesia, 198 therapeutic index (TI), 2526, 241242, 564
malarial plasmodia and, 636, 645t target product profile, 864 therapeutic ratio (TR), 2526
sulfalene, 579t target-centered drug design, 848 therapeutic window, 2526
sulfalene-pyrimethamine, malarial plasmodia and, taxanes, 692693, 723t THF. See tetrahydrofolate
636, 645t tazobactam, 609, 721 thiabendazole, 642, 648t
sulfamethoxazole, 575, 576, 579t, 720 TBG. See thyroid binding globulin thiazides, 346347, 352t, 440t, 441, 442t
conjugation enzyme and, 73t TCAs. See tricyclic antidepressants thiazolidinediones (TZD), 536, 540t
sulfanilamide, 579t TCE. See trichloroethylene thick ascending limb (TAL), 335, 337339, 339f
sulfinpyrazone, uric acid excretion and, 842, 845t TD50. See median toxic dose thioamines, 486
sulfonamide derivatives, 346 technetium fanolesomab, 914t thiocyanate, 485, 488t
sulfonamides, 576, 579t, 720 tegaserod, IBS and, 218 thioguanine, 695t
conjugation enzyme and, 73t tegaserod, irritable bowel syndrome and, 224t conjugation enzyme and, 73t
DHFR inhibitors and, synergy of, 577578 teichoic acids, 601 DNA structure, 684f
immune responses, immunotoxicity and, 64 teicoplanin, 607608, 614t thiopental, 173, 261t
sulfones, 576, 579t immune responses, immunotoxicity and, 64 clinical uses for, duration of action, 174t
sulfonylureas, 535, 538t telavancin, 614t GABAA receptors and, 183t
sulfuric acid, 885 telithromycin, 592, 597t intravenous anesthesia and, 255
sulindac, 756, 761t telmisartan, 350t thioperamide, 772
sulpiride, 198f telomerase, 678 thiopurine S-methyltransferase (TPMT), 7275, 75f
sumatriptan, 217, 223t, 278 telomerase inhibitors, 693 thioridazine, 198f, 204t
sunitinib, 711t, 715t telomere biology, 681682, 681f thiotepa, 687, 696t
supercoils, DNA strands and, 581 telomeres, 678 thiothixene, 198f, 204t
superior cervical ganglion, 95f, 96 temafloxacin, off-target effects and, 60 thioxanthenes, schizophrenia and, 197
superior mesenteric ganglion, 96 temazepam, 171 thoracolumbar system, 95
supplemental NDA (sNDA), 870 clinical uses for, duration of action, 172t threshold potential, 86, 88
supplements, 870871 GABAA receptors and, 183t thrombin, 374
suprofen, cytochrome P450 enzymes and, 52t temozolomide, 687, 696t protein therapeutics and, 903t
suramin, African trypanosomiasis and, 639, 646t temporal lobe, 97, 97f thrombocytopenia, 785
surround inhibition, neurons, 227 temsirolimus, 710, 714t thrombolytics, 392393
S-warfarin, cytochrome P450 enzymes and, 52t tenecteplase, 393, 898 drug summary table, 399t
sympathetic nervous system, 9596, 95f drug summary table, 399t STEMI, 453454
sympathetic tone, down-regulation of, 442443 protein therapeutics and, 903t thrombomodulin, 380
sympatholytic, 138 STEMI, 454 thrombopoiesis, 782
sympathomimetic amines, heart failure and, 462 teniposide (VM-26), 691, 697t thrombopoietin (TPO), 779, 782, 785, 788t
sympathomimetics, 138, 138f, 431t tenofovir, 671t thrombosis, 372
synapses, 89 teratogenesis, due to drug therapy, 6769 drug summary table, 395400t
synapsin, 91 terazosin, 141, 145t, 371t, 443 pharmacology of, 372394
synaptic cleft, 91 terbinafine, 622, 626t protein therapeutics and, 903t, 909t
synaptic neuromodulators, 267 terbutaline, 140, 145t, 828, 834t thromboxane A2 (TxA2), 373
synaptic transmission, stages, 90f terconazole, 623, 627t thromboxane antagonists, 758, 763t
synaptic vesicles, 89, 91f terfenadine, off-target effects, 59 thromboxanes, cyclooxygenase pathway and,
syndrome of inappropriate ADH secretion. See teriparatide, 556, 560t 744745
SIADH protein therapeutics and, 903t thrombus, 380
synergistic drugs terlipressin, 344 thymidine kinase, 655
aminoglycosides, 589 terodiline, 125, 130t thymidylate synthase, 621, 676, 684
combinations, 720721 tertiary structure, amino acids and, 3, 4f inhibitors, 621, 684, 694t
interactions, quantification, 718719, 719f tesamorelin, 477t thymine, 581
synergy, 718 testicular cancer, antineoplastic combination thyroglobulin, 481
synthetic agonists, 275, 280281t chemotherapy and, 726 thyroid binding globulin (TBG), 482
systemic absorption, local anesthetics, 155156 testosterone cypionate, 519, 523t thyroid function, drugs testing, 478t
systemic mastocytosis, 708 testosterone enanthate, 523t thyroid gland
systemic vascular resistance, equation, 353 hypogonadism, 519 case study, 481
systolic heart failure, 455456 male contraception and, 518 diseases, future treatment, 487
testosterone patches, hormone replacement and, 519 pathophysiology, treatment agents, 484
testosterone undecanoate, contraception, 518 pharmacology of, 480487
T tetanic fade, 115 physiology, 480484
T cell activation pathway, 735f tetanus toxin, GABAergic transmission and, 169t thyroid hormone
T cells, 733735, 734f tetracaine, 156, 158, 161t bone mineral metabolism and, 547548
T lymphocytes, 821 tetracyclines, 591592, 597t, 719 effects on target tissues, 482483
T wave, 405b, 405f 30S ribosomal subunits and, 597t homeostasis, drugs affecting, 487
T3. See triiodothyronine H. pylori, 817 metabolism, 482
T4. See thyroxine malarial plasmodia and, 635636, 645t receptor actions, 483f
TAC, 156 unfavorable drug combinations, 721 release inhibitors, drug table for, 488t
tachykinins, 106, 821 tetrahydrocannabinol (THC), 301 replacements, drug table, 488t
tachyphylaxis, 14, 301 5-tetrahydrodeoxycorticosterone (THDOC), 168 structure and metabolism of, 481f
 Index 953

synthesis, 480482, 482f conclusion and future directions, 883 trospium, 125, 130t
pharmacologic interventions, 485f drug discovery and development, 856857 trovafloxacin, off-target effects and, 60
synthesis, storage, release, 482f environmental, 881892 TRP. See transient receptor potential
thyroid peroxidase, 481, 482f t-PA. See recombinant tissue plasminogen activator; TRPV1 cation channels, 266
thyroid-stimulating hormone (TSH), 484, 912, 913t tissue plasminogen activator TRPV2 cation channels, 266
anterior pituitary gland, 467, 472 TPH. See tryptophan hydroxylase Trypanosoma brucei gambiense, 639
thyroid-stimulating immunoglobulin (TsIg), 484 TPMT. See thiopurine S-methyltransferase Trypanosoma cruzi, 640
thyrotropin (TSH), 472, 478t, 913t TPO. See thrombopoietin trypsin, 904t
thyrotropin-releasing hormone (TRH), 106, 483484 TR. See therapeutic ratio tryptophan hydroxylase (TPH), 208, 209
thyroxine (T4), 480 trade name, drugs, 869 TSH. See thyroid-stimulating hormone
TI. See therapeutic index tramadol, 269, 276277, 280t TsIg. See thyroid-stimulating immunoglobulin
tiagabine, 182t, 232t, 239t trandolapril, 349t T-type calcium channel, 230
GABA metabolism and, 169 tranexamic acid, 393, 400t tuberculosis, antimicrobial combination therapy,
GABAergic transmission and, 169t transcellular biosynthesis 719720
ticarcillin, 609, 611, 615t examples, 752f tuberoinfundibular pathway, 191
ticlopidine, 383384, 395t routes, eicosanoids and, 752 tuberomammillary nucleus, 101, 101f
tigecycline, 572, 592, 597t transcription, 596t tubocurarine, 126, 131t, 256, 261t
time constant, global equilibration and, 245 inhibitors, 596t tubuloglomerular feedback mechanism, 335
time-dependent bactericidal agents, 717718, 718f rifamycin derivative and, 587588 tumor lysis syndrome, 842
timolol, 141t, 142, 146t viral life cycle, 650 tumor necrosis factor- (TNF-), 798799, 798f,
cytochrome P450 enzymes and, 51t transcription factors, 6, 12 804t
tinidazole, malarial plasmodia and, 639, 646t transcription regulators, 12 tumor(s)
tinzaparin, 391, 398t transdermal drug administration, 30t, 31, 919 initiation and promotion, 889f
tiotropium, 124, 130t, 827, 834t transduction, 572 pharmacologic classes and agents, 707712
tipifarnib, 709 transformation, DNA and, 568, 572 tumor-specific monoclonal antibodies, 715t
tipranavir, 662, 672t transient receptor potential (TRP), 266 TxA2. See thromboxane A2
tirofiban, 386, 396t transitional anesthetics, 257 type I 5-deiodinase, 482
tissue translation type I alpha-interferon, 902t
autonomic ganglionic blockade and, 119t inhibitors, 588595, 588t type II 5-deiodinase, 482
compartments, general anesthetics and, 246, 246f malarial plasmodia and, 635636, 645t type III 5-deiodinase, 482
mass, volume of distribution and, 33 viral life cycle, 650 typical antipsychotics
tissue factor, 372374 transmembrane ion channels, 79, 8t schizophrenia and, 197
tissue factor pathway inhibitor (TFPI), 380 transmembrane receptors, with enzymatic cytosolic typical depression, 211
tissue plasminogen activator (t-PA), 380 domains, 1012, 11f tyramine, 138
protein therapeutics and, 903t transmission mode, neurons and, 230 MAO inhibition and, 188
tissue schizonts, 630 transmitter metabolism, reuptake and, 92 toxicity, 214
tissue toxicity, 6269 transpeptidase enzymes, bacterial cell wall and, 600 tyrosine hydroxylase (TH), 132, 186187, 209
TLRs. See toll-like receptors transpeptidases, cell wall synthesis and, 604 tyrosine kinase-associated receptors, 12
TMA. See butyl trimethyl ammonium transplantation, 790792 TZD. See thiazolidinediones
TNF-. See tumor necrosis factor- tranylcypromine, 139, 144t
tobacco, 299 trastuzumab, 708, 713t, 724t, 906
peptic ulcer disease, 816 travoprost, 763t U
toxicity of, 888889 trazodone, 217, 223t U fibers, 228
tobramycin, 589, 596t trematodes (Flukes), 640 UA/NSTEMI. See unstable angina/non-ST
tocilizumab, 800, 805t, 908t tremor (T) syndrome, 887 elevation myocardial infarction
tolazamide, 538t tretinoin, 723t, 786, 789t ubiquinone, malarial plasmodia and, 632, 635
tolbutamide, 538t TRH. See thyrotropin-releasing hormone ubiquitin-proteasome pathway, 701705, 703f
tolcapone, 195, 203t triamcinolone, 497, 498f, 503t, 830, 835t UDP-glucuronyl transferase (UDPGT), 47
tolerance, 54 triamterene, 347, 352t, 442t UDPGT. See UDP-glucuronyl transferase
drug dose and, 285 triazolam, 171 UGN. See natriuretic peptide uroguanylin
mechanisms, 287, 288f, 290f clinical uses for, duration of action, 172t UMP. See uridylate
opioids and, 273 cytochrome P450 enzymes and, 51t uncoating. See viral uncoating
toll-like receptors (TLRs), 732 GABAA receptors and, 183t uncompetitive antagonists, 7
tolterodine, 125, 130t triazoles, 622624, 627t underfill theory, cirrhosis, Na retention and,
tolvaptan, 350t, 479t unfavorable drug combinations, 721 341, 342f
tonic inhibition, local anesthesia and, 153155, 155f trichloroethylene (TCE), 892 unfractionated heparin, 389, 391
tonic phase, seizure propagation, 229 tricyclic antidepressants (TCAs), 105, 139, coagulation factor inactivation and, 390f
tonic-clonic seizures, 228, 229f 215216, 221t drug summary table, 397t
tophi, 839 antiadrenergic effects, 216 unitary hypothesis, 256
topical anesthesia, 156, 157b anticholinergic effects, 216 unstable angina, 362, 452453
topiramate, 232t, 239t, 345 antihistaminergic effects, 216 unstable angina/non-ST elevation myocardial
addiction and, 305 drug metabolism and, 53 infarction (UA/NSTEMI), 449, 452453
topoisomerase inhibitors, 596t drug summary table, 282t, 309t unstable plaques, acute coronary syndromes
DNA and, 691692 trientine, 884 and, 448
drug summary table, 697t trifluoperazine, 198f, 204t uptake model, 244250
topoisomerases trifluperidol, 198f applications of, 250253, 251f
bacterial DNA, 582583 trifluridine, 671t uracil, DNA structure, 684f
IV, 583, 587 trihexyphenidyl, 125, 195, 203t urate crystals, 839840, 840f
type I, 582, 691 3,5,3-triiodothyronine (T3), 480, 481f ureido penicillins, 611
type II, 582, 691 trilostane, 499, 499t, 504t uric acid, 839
DNA supercoiling and, 584f trimethaphan, 126, 131t, 443 excretion, agents increasing, 842, 845t
topotecan, 691, 697t trimethoprim, 565, 576, 577, 579t, 720 metabolism, agents enhancing, 842, 845t
torsades de pointes, 407, 409b, 413414 trimipramine, 221t synthesis, agents decreasing, 841842, 844t
torsemide, 346, 351t, 442t tripelennamine, 774t uricase, uric acid metabolism and, 842
tositumomab, 712, 715t, 910t triple therapy, H. pylori, 817 uricosuric agents, 842
toxic effects, 56 triptans, 217, 278 uridylate (UMP), 675676
toxic epidermal necrolysis, 64 troglitazone, toxicity and, 56 urofollitropin (FSH), 479t
toxic metabolites, 50 troleandomycin, cytochrome P450 enzymes and, 51t anterior pituitary gland, 474
toxic plants, 885 tropomyosin, cardiac myocyte contraction and, 425t urokinase, protein therapeutics and, 903t
toxicology troponin complex, cardiac myocyte contraction use-dependent block, 88
case study, 882 and, 425t ustekinumab, 805t, 908t
954 Index

V verapamil, 363, 364t, 370t, 405, 443 volume-contraction alkalosis, 346

cardiac rhythm and, 415, 421t von Hippel-Lindau protein (VHL), 705706
vacuolar H -ATPase (vH ATPase), 338
cytochrome P450 enzymes and, 51t von Willebrand factor (vWF), 373
vagomimetic, 122
vertical transmission, 572 voriconazole, 567, 623, 624, 627t
vagus nerve, 96
very-low-density lipoproteins (VLDL) VP-16. See etoposide
valacyclovir, 658, 670t
lipoproteins and, 315 VPG. See vessel-poor group
valdecoxib, 64, 271, 276, 757 V/Q mismatch. See ventilation/perfusion
remnants, 316
valganciclovir, 670t secondary hyperlipidemia and, 323324, 323t mismatch
valproic acid, 232t, 237t vesamicol, 111, 120, 128t VRE. See vancomycin-resistant enterococcus
bipolar affective disorder and, 218 vesicular monoamine transporter (VMAT), 133, 187 VRG. See vessel-rich group
seizures and, 234, 237t vesnarinone, 436t VT. See ventricular tachycardia
valsartan, 350t, 371t vessel dilation, inflammatory response, 737 VTA. See ventral tegmental area
van der Waals forces, 34 vessel-poor group (VPG), anesthesia and, 246 vulnerable plaques, acute coronary syndromes,
vancomycin, 8, 39f, 607608, 614t, 718 vessel-rich group (VRG), anesthesia and, 246 448
immune responses, immunotoxicity and, 64 vH ATPase. See vacuolar H-ATPase vWF. See von Willebrand factor
red man syndrome and, 64 VHL protein. See von Hippel-Lindau protein VZV. See varicella zoster virus
vancomycin-resistant enterococcus (VRE), 572, vidarabine, 671t
607
vandetanib, 707, 711t
vigabatrin, 182t, 232t, 234, 238t W
GABA metabolism and, 169170
vardenafil, 362, 369t warfarin, 4, 12, 77f, 397t
GABAergic transmission and, 169t
varenicline anticoagulation effect
seizures and, 235
addiction and, 305 drugs diminishing, 389t
vinblastine, 692, 698t
drug dependence and, 309t drugs enhancing, 389t
combination chemotherapy, 726
variant angina, 450 clinical uses, 387389
vinca alkaloids, 692, 723t
varicella zoster virus (VZV), 655 drug metabolism and, 53
vincristine, 692, 698t, 723t
vascular capacitance, vascular resistance and, mechanism of action, 387, 388f
combination chemotherapy, 726
353354 oxidation/reduction enzyme and, 73t
Vioxx. See rofecoxib
vascular endothelial growth factor (VEGF) pathway-based pharmacogenetics-
VIP. See vasoactive intestinal polypeptide
inhibitors, 711, 711t pharmacogenomics, 7677
viral attachment and entry inhibitors, 651653
receptors, 705706, 706t weak positive allosteric agonists, 171, 171f
viral attachment inhibition, 670t
vascular endothelium, 356 wheal-and-flare reaction, 62, 766
viral genome replication inhibition, 655662
vascular resistance-based hypertension, 439440 white matter, 9798, 97f
viral infections
vascular smooth muscle cells WHO (World Health Organization), tuberculosis
case study, 650
Ca2 for, 356f drug summary table, 670673t
treatment, 720
contraction and relaxation, mechanism, withdrawal
pharmacology, 649669
354356, 356f case study, 285
viral integration inhibitors, 672t
sites in, vasodilators and, 358f mechanisms, 288f
viral life cycle, 650651, 651f
vascular tone syndromes, 289
viral maturation, 650651
autonomic nervous system and, 357358 withdrawal, pharmacoepidemiology and,
inhibition, 662
cardiovascular physiology parameters and, 355t 874875, 875t
viral release inhibition, 664665, 672t
case study, 354 Withering, William, 422
viral replication, physiology of, 649651
drug summary table, 368371t WNT signaling, nuclear factor-kappa B (NFB)
viral uncoating
future directions, 366367 pathways and, 704, 704f
inhibitors, 670t
modulation, 443444 Wolff-Chaikoff effect, 486
viral life cycle and, 650
pharmacologic agents/classes and, 358366 Womens Health Initiative study, hormone
Virchows triad, 380, 380f
pharmacology of, 353367 replacement, 518, 518t
virions, 650
regulation of, 356368 workplace exposures, 891
viruses, host cells and, 568
vasoactive intestinal polypeptide (VIP) World Health Organization. See WHO
vitamin D
asthma, 821 worms. See helminths
and analogues, 560t
vasoconstriction, 373 hypoparathyroidism, 546547, 557
vasodilators, 355, 766 vitamin D-dependent rickets, 557 X
heart failure and, 461 vitamin K xanthine oxidase, 838
vascular tone, 358, 358f mechanism of action, 387 xenobiotics, 43
vasopressin (ADH), 334. See also SIADH vitamin K epoxide reductase complex 1 x-ray crystallography, 853
antagonists, 479t (VKORC1), 77
CNS and, 98 VKORC1. See vitamin K epoxide reductase Y
receptor agonists, 344 complex 1
receptor antagonists, 344 yeasts, 618
VLDL. See very-low-density lipoproteins
vasopressin receptor 2 antagonists, 350t yohimbine, 141, 145t
VM-26. See teniposide
vatalanib, 711t VMAT. See vesicular monoamine transporter
vecuronium, 126, 131t, 261t voglibose, 538t Z
VEGF. See vascular endothelial growth factor voltage-clamping, 87 zafirlukast, 764t
venlafaxine, 216, 222t, 277 voltage-dependent function, cellular communica- zalcitabine, 671t
atypical depression and, 212 tion and, 82 zanamivir, 568, 664, 672t
cytochrome P450 enzymes and, 51t voltage-gated Ca2-selective channels, 354 zero-order kinetics, 37
venodilators, heart failure and, 461 voltage-gated channels, 7, 8t ziconotide, 133, 267
venous capacitance, 354 voltage-gated L-type Ca2-channels, 355 zidovudine (AZT), 568, 659, 671t
vental tegmental area (VTA), 189190 voltage-gated sodium channel, 153, 154f zileuton, 764t, 830, 836t
ventilation, change effects in, anesthetic and, volume capacity, global equilibration and, 245 ziprasidone, 200, 205t
251, 251f volume of distribution (Vd), of drug, 3334 zoledronate, 552, 559t
ventilation-limited anesthetics, 249 volume regulation Zollinger-Ellison syndrome, 811
ventilation/perfusion mismatch (V/Q mismatch), case study, 333 zolmitriptan, 217, 223t, 278
anesthesia induction and, 252 drug summary table, 349352t zolpidem, 171, 171172, 183t
ventral horn, 96 pharmacology of, 332348 zona fasciculata, 489
ventral roots, 96 physiology of, 332340 zona glomerulosa, 489
ventral tegmental area (VTA), 189190, 289291 volume regulators, 334337 zona reticularis, 489
ventricular action potential, ion currents and, 404f agents modifying, 342344 zonisamide, 232t, 239t
ventricular fibrillation, 409b volume sensors, 333334 zotarolimus, 454, 804t, 922
ventricular tachycardia (VT), 409b volume-based hypertension, 440 zotarolimus-eluting stents, 797798