Interaction of the neuromuscular blocking drugs alcuronium,decamethonium, gallamine,pancuronium, ritebronium,tercuronium and d-tubocurarine with muscarinic acetylcholine receptors in the heart and ileum

Neuromuscular blocking drugs have a high affinity for muscarinic acetylcholine receptors in the heart atria and ileal smooth muscle. In experiments on homogenates, alcuronium, gallamine, pancuronium, tercuronium and ritebronium inhibited the binding of the muscarinic antagonist (3H)quinuclidinyl benzilate (QNB) to rat heart atria with IC50 values of 0.15-0.53 mumol X 1(-1) and to ileal longitudinal muscles with IC50 values of 0.12-0.45 mumol X 1(-1). d-Tubocurarine and decamethonium inhibited (3H)QNB binding to these tissues with IC50 values of 6.2-8.5 mumol X 1(-1). For each neuromuscular blocking drug, the IC50 values were virtually identical for (3H)QNB displacement in the homogenates of the atria and of the ileal muscle. Alcuronium and gallamine differed from the other blocking agents in that they produced less steep (3H)QNB displacement curves both in the atria and the ileal muscle; Hill coefficients for the binding of alcuronium and gallamine to atrial and ileal homogenates were lower than unity. On isolated atria, gallamine, pancuronium, ritebronium and tercuronium antagonized the inhibition of tension development caused by the muscarinic agonist, methylfurmethide, with Kd values which were of the same order of magnitude as the IC50 values for the displacement of (3H)QNB binding to homogenates; the Kd of alcuronium was 12.5 times higher. d-Tubocurarine and decamethonium did not antagonize the effects of methylfurmethide at concentrations up to 100 mumol X 1(-1). On isolated ileal longitudinal muscle, gallamine and pancuronium antagonized the effects of methylfurmethide with Kd values that were 53 times and 100 times higher than their respective Kd values in the atria.(ABSTRACT TRUNCATED AT 250 WORDS)     

Verapamil intensifies neuromuscular blockade produced by gallamine and pancuronium at the chick neuromuscular junction

Experiments were performed to study the effect of verapamil on neuromuscular transmission and muscle contraction at a chick skeletal muscle-nerve preparation. In addition, the effects and interactions of verapamil with some muscle relaxants were studied in the same preparation. These effects were explored by studying the effects of verapamil on: directly-and indirectly-elicited twitch contractions, and neuromuscular blockade produced by gallamine and pancuronium. The results showed that verapamil (2-200 microM) had a differential effect on the twitch responses; more reductions occurred in the indirectly-elicited twitch tension, whereas the directly-elicited twitch response was reduced only by 20-30% of maximum indirectly-elicited twitch tension. Furthermore, in low concentrations (1-20 microM), verapamil significantly increased the neuromuscular blockade produced by gallamine (28-1280 nM) and pancuronium (18-573 nM). In high concentrations (greater than 200 microM), verapamil completely blocked the indirectly-elicited twitch response and produced a marked contracture in the chick skeletal muscle (1.0 +/- 0.1 g, n = 6). It was concluded that by reducing twitch tension and inhibiting neuromuscular transmission, verapamil increases (intensifies) neuromuscular blockade produced by muscle relaxants, e.g. gallamine and pancuronium.     

Allosteric binding sites on muscarinic receptors

The classical (acetylcholine) binding sites of all five subtypes of muscarinic receptors are known to be subject to allosteric regulation by a variety of small molecules. The hallmarks of such modulation in binding assays are that the allosteric ligands can alter both the affinities and the rates of association and dissociation of classical ligands. By the use of suitable combinations of allosteric ligands and appropriate models, it has been demonstrated that at least some of these ligands act via a single well-defined site. On the basis of protein-modification and mutational studies, it appears that these allosteric ligands bind to a part of the receptor that is extracellular to the classical binding site. The location of the allosteric site is likely the reason that the few ligands that have been found to increase the affinity of classical antagonists also cause a dramatic slowing of the kinetics of these classical ligands; the slowing can be so profound as to appear to reverse the increases in affinity. Fortunately, the effects of allosteric ligands on the kinetics of acetylcholine itself are not so problematic. Recent studies have described allosteric ligands that are capable of enhancing the affinity of acetylcholine in binding and response assays. Ligands of this class may prove to have quite useful applications, for example in restoring function lost due to depletion of acetylcholine. Drug Dev. Res. 40:193–204, 1997. © 1997 Wiley-Liss, Inc.     

Allosteric binding sites on muscarinic acetylcholine receptors

In this issue of Molecular Pharmacology, Tr?nkle et al. (p. 1597) present new findings regarding the existence of a second allosteric site on the M2 muscarinic acetylcholine receptor (M2 mAChR). The M2 mAChR is a prototypic class A G protein-coupled receptor (GPCR) that has proven to be a very useful model system to study the molecular mechanisms involved in the binding of allosteric GPCR ligands. Previous studies have identified several allosteric muscarinic ligands, including the acetylcholinesterase inhibitor tacrine and the bis-pyridinium derivative 4,4'-bis-[(2,6-dichloro-benzyloxy-imino)-methyl]-1,1'-propane-1,3-diyl-bis-pyridinium dibromide (Duo3), which, in contrast to conventional allosteric muscarinic ligands, display concentration-effect curves with slope factors >1. By analyzing the interactions of tacrine and Duo3 with other allosteric muscarinic agents predicted to bind to the previously identified ;common' allosteric binding site, Tr?nkle et al. provide evidence suggesting that two allosteric agents and one orthosteric ligand may be able to bind to the M2 mAChR simultaneously. Moreover, studies with mutant mAChRs indicated that the M2 receptor epitopes involved in the binding of tacrine and Duo3 may not be identical. Molecular modeling and ligand docking studies suggested that the additional allosteric site probably represents a subdomain of the receptor's allosteric binding cleft. Because allosteric binding sites have been found on many other GPCRs and drugs interacting with these sites are thought to have great therapeutic potential, the study by Tr?nkle et al. should be of considerable general interest.     

Effect of pirenzepine and gallamine on cardiac and pulmonary muscarinic receptors in the rabbit.

1. The effect of muscarinic antagonists considered to be selective for M1 receptors (pirenzepine) and for M2 receptors (gallamine) were studied on bronchoconstriction and bradycardia elicited by stimulation of the vagal nerves and by i.v. acetylcholine (ACh) in anaesthetized rabbits. 2. Pirenzepine was equipotent as an antagonist of ACh-induced responses at postjunctional muscarinic receptors in the heart, lung and blood vessels, whereas gallamine was at least ten times less potent at pulmonary and vascular muscarinic receptors. Thus, gallamine never caused complete inhibition of bronchoconstrictor or hypotensive responses to i.v. ACh, whereas doses of pirenzepine in excess of 1 mumol kg-1 abolished all muscarinic responses. 3. In the lung, both antagonists inhibited bronchoconstriction caused by vagal stimulation and ACh-induced bronchoconstriction to the same extent (pirenzepine, mean ED50 65 +/- 22 and, 130 +/- 28 nmol kg-1 respectively; gallamine, ED50 greater than 10,000 nmol kg-1 for both responses). Enhancement of vagally-induced bronchoconstriction was never observed. 4. In the heart, however, both pirenzepine and gallamine were ten times less potent as antagonists of vagally-induced bradycardia than of ACh-induced bradycardia. This differential blockade was unaltered by propranolol (1 mg kg-1) pretreatment. 5. It is concluded that there is no evidence for M1 or M2 muscarinic receptors in the pulmonary innervation of the rabbit and the potency of the antagonists in abolishing in abolishing vagally-induced bronchoconstriction was consistent with blockade of M3 muscarinic receptors on airway smooth muscle. 6. The results suggest that M2 muscarinic receptors may exert an inhibitory effect on transmission in the parasympathetic nerves innervating the heart in the rabbit.(ABSTRACT TRUNCATED AT 250 WORDS)     

Allosteric interaction of the neuromuscular blockers vecuronium and pancuronium with recombinant human muscarinic M2 receptors

Neuromuscular blocking drugs produce muscle weakness by interaction with nicotinic-acetylcholine receptors. Cardiovascular side effects have been reported. In this study the neuromuscular blocking drug vecuronium and the controls gallamine and pancuronium slowed the rate of atropine induced [(3)H]N-methylscopolamine dissociation from Chinese hamster ovary cells expressing recombinant human muscarinic M2 receptors K(off) values min(-1); vecuronium (125 nM), atropine 0.45+/-0.07+blocker 0.04+/-0.02; gallamine (21 nM), atropine 0.42+/-0.05+blocker 0.15+/-0.04; pancuronium(21 nM), atropine 0.36+/-0.03+blocker 0.03+/-0.01). These data indicate that vecuronium, gallamine and pancuronium interact with an allosteric site on the muscarinic M2 receptor (located on the heart) and this may explain some of their cardiac side effects.     

The inhibitory effect of gallamine on muscarinic receptors.

1 The inhibitory effect of gallamine (1.1 muM-1.1 mM) on negative inotropic responses to acetylcholine (ACh) or carbachol (CCh) was investigated in isolated electrically stimulated atria of the guinea-pig. Gallamine caused parallel rightward shifts of the dose-response curves to the agonists, with no depression of the maximal response. 2 Gallamine (0.11 - 1.1 mM) produced a greater degree of antagnism towards CCh than towards ACh. With either agonist, the degree of antagonism produced by gallamine in high concentrations was less than that expected for a competitive antagonist.. 3 Similar findings were made when either negative inotropic or chronotropic responses were recorded in spontaneously beating guinea-pig atria. The inhibitory effect of gallamine against the negative inotropic response to cholinomimetics in electrically stimulated atria was not altered either in the presence of propranol (17 muM) or in atria obtained from guinea-pigs pretreated with diisopropylphosphorofluoridate (DEP) 12.5 mumol/kg, in divided doses over 3 days). 4 When ACh was used as the agonist, combination of gallamine with atropine (0.05-0.4 muM) produced dose-ratios which were less than expected for combination of two competitive antagonists. The same phenomenon was observed in atria obtained from guinea-pigs pretreated with DFP. 5 It is suggested that the antagonism produced by gallamine is a type of non-competitive inhibition, which has been termed "metaffinoid antagonism". An antagonist of this type allosterically alters the affinity of the agonist for its binding site, rather than changing the effectiveness of the agonist-receptor interaction.     

Direct binding studies on ileal and cardiac muscarinic receptors

1 Functional studies have indicated that muscarinic receptors in cardiac tissue differ from those in the ileum. In the present study ileal and cardiac muscarinic receptors identified by [3H]-N-methyl scopolamine ([3H]-NMS) were characterized and the selectivity of currently available ileal and atrial selective antagonists determined. 2 In terms of the current functional classification of muscarinic receptors both ileal and cardiac muscarinic receptors were of the M2 subtype based upon their low affinity for pirenzepine. 3 Cyclohexylphenyl(2-piperidinoethyl)silanol (CPPS), a highly ileal selective antagonist in functional studies, was unable to distinguish between ileal and atrial muscarinic receptors identified in binding studies. Furthermore, although AF-DX 116 and dicyclomine were able to differentiate atrial and ileal muscarinic receptors, neither compound was more than 2 fold selective. These data indicate that it is not possible to subclassify ileal and atrial muscarinic receptors using direct ligand binding studies with these antagonists. 4 In circular ileal smooth muscle, apparent heterogeneity of the M2 muscarinic receptor population was observed. Thus AF-DX 116 identified two populations of sites with affinities differing by 30 fold. These two populations of M2 muscarinic receptors may represent the typical M2 muscarinic receptors identified in cardiac tissue and the more recently discovered 'gland type' M2 muscarinic receptors. 5 The circular ileal smooth muscle tissue homogenate was able to decrease dramatically the apparent affinity of adiphenine. This activity, which appeared to result from a phenylmethylsulphonylfluoride (PMSF) sensitive protease effect, should be considered when conducting studies using this tissue preparation and compounds of similar structure to adiphenine.     

Effect of neuromuscular blocking agents pancuronium bromide and its monoquaternary analogue Org NC 45 on regional blood flow and cardiac metabolism in pigs

The effects of pancuronium bromide (60, 120, 300, and 600 μg.kg^?1, i.v.) and its monoquaternary analogue Org NC 45 (300,750, and 1500 μg.kg^?1, i.v.) on the systemic and regional hemodynamic variables were studied in the anesthetized pig. Pancuronium exhibited a dose-dependent positive chronotropic and inotropic activity. The enhanced oxygen requirement of the myocardium was successfully met by a combination of higher blood supply to, and oxygen extraction by, the tissue. No changes were noticed in cerebral, renal or hepatic arterial blood flow. On the other hand, Org NC 45, which unlike pancuronium lacks vagolytic and sympathomimetic actions, did not cause an increase in heart rate or left ventricular dP/dt_max (LV dp/dt_max). Instead, in the two highest doses (750 and 1500 μg.kg^?1) Org NC 45 decreased arterial blood pressure, LV dP/dt_max and the blood supply to the brain, kidneys, and liver. Neither compounds showed any effect on cardiac metabolism of glucose, lactate, or free fatty acids (FFA), although arterial blood glucose concentration did decrease following the two highest doses of each compound. Since Org NC 45, in a dose of 300 μg/kg^?1, which is seven to ten times the ED₉₀ for neuromuscular paralysis in man, is completely devoid of systemic and regional hemodynamic effects, and pancuronium in similar dose ratio is not, Org NC 45 might be preferred for use in cardiac anesthesia.     

Regional distribution of muscarinic receptors preferring gallamine in the rat brain

The regional distribution of muscarinic receptors recognized by the antagonist gallamine was determined autoradiographically by the ability of gallamine to reduce the binding of [3H]quinuclidinyl benzilate in rat brain slices. The inhibition data obtained from indirect binding assays on whole slices indicated that gallamine distinguished at least two sites with differing affinities. Analysis using a two-site model gave Kh = 0.6 microM, K1 = 10 microM. The regions of highest and lowest affinity for gallamine were apparent qualitatively by visual inspection of the autoradiograms. A number of regions in coronal sections at three different levels were compared by microdensitometry. Gallamine possessed greater overall affinity for the diencephalon and brainstem than for the forebrain. Within the forebrain, the septal nucleus was unique in that it displayed high affinity for gallamine. Within the brainstem, the superior colliculus had the greatest proportion of sites with high affinity for gallamine. In general, the binding profile of gallamine was opposite to that of the antagonist pirenzepine and similar to that of the agonist carbachol, suggesting that gallamine is selective for M2 muscarinic receptors.     

Cardiac effects of non-depolarizing neuromuscular blocking agents pancuronium,vecuronium, and rocuronium in isolated rat atria.

Pancuronium, vecuronium, and rocuronium produce different cardiac effects. Using spontaneously beating right and electrically stimulated left rat atria, while measuring developed force, effective refractory period, and heart rate, we determined and compared the concentration-dependent cardiac effects of the compounds. The preparations were exposed to five progressively increasing concentrations of these compounds (10(-9), 10(-8), 10(-7), 10(-6), and 10(-5) mol/L). Pancuronium increased heart rate; vecuronium and rocuronium produced positive inotropic effects; and vecuronium shortened refractoriness. These effects may be the result of a blockade of the M2 muscarinic receptors. However, the concentrations required to produce changes were higher than those observed in patients under neuromuscular blockade.     

Interaction studies of multiple binding sites on m4 muscarinic acetylcholine receptors

This study investigated the reciprocal cross-interactions between two distinct allosteric sites on the M(4) muscarinic acetylcholine receptor (mAChR) in the absence or presence of different orthosteric ligands. Initial studies revealed that two novel benzimidazole allosteric modulators, 17-beta-hydroxy-17-alpha-ethy nyl-delta(4)-androstano[3,2-b]pyrimido[1,2-a]benzimidazole (WIN 62,577) and 17-beta-hydroxy-17-alpha-ethynyl-5-alpha-androstano[3,2-b]pyrimido[1,2-a]benzimidazole (WIN 51,708), exhibited different degrees of positive, negative, or close-to-neutral cooperativity with the orthosteric site on M(1) or M(4) mAChRs, depending on the chemical nature of the orthosteric radioligand that was used [[(3)H]N-methylscopolamine ([(3)H]NMS) versus [(3)H]quinuclidinylbenzilate ([(3)H]QNB)]. The largest window for observing an effect (negative cooperativity) was noted for the combination of WIN 62,577 and [(3)H]QNB at the M(4) mAChR. Experiments involving the combination of these two ligands with unlabeled agonists [acetylcholine, 4-(m-chlorophenylcarbamoyloxy)-2-butynyltrimethylammonium (McN-A-343), or xanomeline] revealed low degrees of negative cooperativity between WIN 62,577 and each agonist, whereas stronger negative cooperativity was observed against atropine. It is interesting that when these experiments were repeated using the prototypical modulators heptane-1,7-bis-(dimethyl-3'-phthalimidopropyl)-ammonium bromide (C(7)/3-phth), alcuronium, or brucine (which act at a separate allosteric site), WIN 62,577 exhibited negative cooperativity with each modulator when the orthosteric site was unoccupied, but this switched to neutral cooperativity when the receptor was occupied by [(3)H]QNB. Dissociation kinetic experiments using [(3)H]NMS and combination of C(7)/3-phth with WIN 62,577 also provided evidence for neutral cooperativity between the two allosteric sites when the orthosteric site is occupied. Together, these results provide insight into the nature of the interaction between two distinct allosteric sites on the M(4) mAChR and how this interaction is perturbed upon occupancy of the orthosteric site.     

The effect of renal failure on the disposition and neuromuscular blocking action of pancuronium bromide

Summary Plasma concentrations of pancuronium following single dose administration in six patients, and following multiple dose administration in four patients, all undergoing renal transplantation surgery, were measured using a fluorimetric method. A two-compartment open model was used in the pharmacokinetic analysis of the data. Comparison of the pharmacokinetic findings with data previously obtained for patients undergoing elective surgery but having normal renal function indicated that the clearance of the drug was reduced significantly in the patients with renal failure, and that in these individuals the half-life was increased significantly. Measurement of the evoked mechanical twitch response concurrently with plasma concentration monitoring of pancuronium confirmed that the prolongation of half-life in the patients with renal failure was often but not always associated with an extended duration of neuromuscular blockade and furthermore that the rate of recovery from block might also be prolonged. The clinical implications of these findings are discussed.     

Irreversible binding of acetylethylcholine mustard to cardiac cholinergic muscarinic receptors

The interaction of acetylethylcholine mustard (Aech-M) with cardiac muscarinic receptors was studied with radioligand binding techniques and with isolated beating atria. Aech-M and acetylcholine competed about equally for (-)-[3H]quinuclidinyl benzilate (QNB)-binding sites and 5'-guanylylimidodiphosphate reduced the ability of both compounds to compete by 30-fold. Pretreatment of cardiac membranes with 0.25 microM Aech-M, followed by washing, reduced the [3H]QNB binding capacity by 60% without changing the ligand affinity of the receptors left. In the same membranes, a similar fraction of receptors was lost as measured by [3H]N-methyoscopolamine, but a greater fraction was lost when measured by [3H]oxotremorine-M. The loss of [3H]QNB binding capacity was dose, time, and temperature dependent, blocked by atropine and carbachol, and modulated by several guanine nucleotides but not affected by membrane pretreatment with several group-selective reagents. Superfusion of spontaneously beating atria with Aech-M (100 microM) initially reduced the beating rate which returned to control values by 17 min. Atropine blocked the initial reduction in beating rate. In contrast, both carbachol and acetylcholine produced sustained decreases in the beating rate. After pretreatment of atria for 30 min with 100 microM Aech-M alone or 10 microM Aech-M plus 10 microM edrophonium followed by washing, the EC50 value for carbachol inhibition of the beating rate was increased 15.8- and 10.3-fold, respectively, with no change in the ability of isoproterenol to increase the spontaneous beating rate. In addition, there was a 46-47% and a 37-41% reduction in the binding capacity of both [3H]QNB and [3H]oxotremorinel-M in the 100 and 10 microM Aech-M-pretreated atria, respectively. The data indicated that Aech-M is a muscarinic agonist which appears to irreversibly bind to the muscarinic receptor.     

Synthesis and structure-activity relationships of neuromuscular blocking agents

The first use of neuromuscular blocking agents (muscle relaxants) in clinical practice (1942) revolutionised the practice of anaesthesia and started the modern era of surgery. Since 1942 introduction of tubocurarine (18) neuromuscular blocking agents have been used routinely to provide skeletal muscle relaxation during surgical procedures allowing access to body cavities without hindrance from voluntary or reflex muscle movement. After the introduction of tubocurarine and the depolarizing suxamethonium chloride (4) (1949) several nondepolarizing steroidal and nonsteroidal neuromuscular blocking agents with different onset time and duration of effect were introduced e.g. gallamine triethiodide (1) (1949), methocurine (2) (1949), alcuronium chloride (3) (1963), pancuronium bromide (9) (1968), vecuronium bromide (11) (1982), pipecuronium bromide (10) (1982), atracurium besylate (5) (1982), doxacurium chloride (6) (1991), mivacurium chloride (8) (1992), rocuronium bromide (12) (1994) cisatracurium besylate (7) (1996), and rapacuronium bromide (13) (2000). SZ 1677 (14) a steroid type nondepolarizing neuromuscular blocking agent under development (preclinical phase). This review article deals with a comprehensive survey of the progress in chemical, pharmacological and, in some respects, of clinical studies of neuromuscular blocking agents used in the clinical practice and under development, including the synthesis, structure elucidation, pharmacological actions, structure activity relationships studies of steroidal and nonsteroidal derivatives.     

Cardioacceleratory effect of muscarinic blocking agents in the dog

To test whether the tachycardia in response to atropine after adrenergic blockade is partly due to a central excitatory action, the effects of atropine, methylatropine and methylscopolamine were compared in dogs in neurolept-anesthesia. The latter two agents proved to have effect, similar to atropine. A central action is therefore improbable. It was possible to partly abolish the tachycardia by hexamethonium. The cardioacceleration by atropine, methylatropine and methylscopolamine, so far as it is not caused by muscarinic receptor blockade, can be explained by the unmasking of an underlying acceleratory tone.