Pharmacodynamics

How do drugs produce their effects? receptors ion channel linked receptors (atracurium) G-protein coupled receptors (adrenaline) kinase linked receptors (insulin) cytosolic or nuclear receptors that regulate gene transcription (steroid) direct ion channel actions (LA) enzyme inhibition (neostigmine) carrier molecules (diuretics and digoxin) colligative properties (mannitol) structural analogs (acyclovir, chemotherapy agents) chemical reactions (heparin and protamine) chelation (penicillamine, desferrioxamine) structural proteins (colchicine) Drug receptor: any cellular macromolecule to which a drug binds to initiate its effects Drug-receptor complex for drug-receptor association D + R DR, rate of association = k1 [D][R] for drug-receptor dissociation DR D + R, rate of dissociation = k2 [DR] at equilibrium, k1 [D][R] k2 [DR] [D][R] k = 2 = Kd k1 [DR] [DR] = [R] when 50% receptor are occupied, and Kd=[D] Kd, equilibrium dissociation constant, is equal to the free drug concentration required to half saturate receptors k1 [D] + [R] [DR] effect k2 relationship between effect and concentration of free drug can be described as

Types of drug receptors receptors for endogenous regulatory ligands maximal effect . [D] Effect = (hormones, growth factors, and neurotransmitters) Kd + [D] act catalytically and are biochemical signal amplifiers (ligand-gated ion channel, analogous to Michaelis-Menten equation that is used nicotinic cholinergic receptors, GABAA to describe the interaction of enzyme and substrate receptor, receptor for glutamate, aspartate, where no product is formed and glycine) Graded dose-response curve enzymes of metabolic or regulatory pathways the relation between drug concentration, C, and dihydrofolate reductase, acetylcholinesterase, effect, E, is described by a hyperbolic curve protein kinases, G protein-coupled receptors) Emax Emax C %E proteins involved in transport processes (Na+/K+E= C + EC50 50 ATPase) proteins that serve structural roles (tubulin) EC50 C nucleic acids (for chemotherapeutic agents) Emax is the maximal response that can be Clarks receptor occupancy theory produced by the drug, the intensity of effect produced by drug binding to EC50 is the concentration of the drug that the receptor is dependent on the fraction of produces 50% of its maximal effect (potency) receptors occupied by the drug explains potency, ceiling effect, tolerance (minimal linear relationship between occupancy and returns beyond a certain drug concentration) response saturation of receptors maximal effect the relation between drug bound to receptors B, and half-maximal receptor occupancy half- the concentration of free unbound drug, C, is also maximal effect described by a hyperbolic curve has limitations with respect to explaining intrinsic %B Bmax B C activity receptors B = max 100% C + Kd 50 50% Kd C 0% Bmax is the total concentration of receptor sites effect Kd (equilibrium dissociation constant) represents the concentration of free drug at which half-maximal binding is observed explains saturable protein binding of drugs

2007 HNC

Logarithmic conversion plotting the drug effect (ordinate, y-axis) against the logarithm of the dose or concentration (abscissa, x-axis) transform the hyperbolic curve into a sigmoid curve with a linear mid-portion easier to compare dose-response curves graphically because it expands the scale of the concentration axis at low concentrations (where the effect is changing rapidly and compresses it at high concentrations (where the effect is changing slowly) Emax model to log linear model hyperbolic relationship (Emax model) sigmoid relationship (Log linear model)

Reversible competitive antagonism the binding of the antagonist can be eliminated by increasing the concentration of agonist
Emax for drug A stays the same A in the presence of a competitive antagonist

Effect

ED502
ED501 Log [Drug] ED502 ED 1 50

= dose ratio

the ratio of the 2 agonist concentrations (dose ratio) is related to the dissociation constant (KI) of the antagonists by the Schild equation

100 50 0 Clarks model

EC
50

E/ C Emax= /(C+EC50)

0 EC50 500

1000

10

100

1000

concentration

log concentration

Definitions - full and partial agonists agonists - drugs that bind to physiological receptors and mimic the effects of endogenous regulatory compounds partial agonists - agents that produce a lower response at full receptor occupancy, only partly as effective as agonists extent to which response is demonstrated depends on the relative affinity of the drug for active or inactive state of the receptor Antogonists an antagonist can act via chemical, functional or physiological inhibition as well as at the receptor to inhibit the action of the agonist whilst exerting no effect itself antagonism can be competitive and non competitive competitive antagonism can be reversible (quaternary acetylcholinesterase inhibitor) and irreversible (tertiary acetylcholinesterase inhibitor) Competitive antagonism based on the principle that an agonist or antagonist can bind to the same recognition site(s) on the receptor, and when both agonist and antagonist are present concomitantly, they can compete for such sites

ED502 [I] =1+ ED501 KI [I] is the fixed concentration of the competitive antagonist KI can be determined degree of inhibition produced by antagonist is dose dependent plasma concentration reduced by rate of metabolic clearance and excretion the antagonist dissociates as the free concentration decreases, influencing extent and duration of action changes in endogenous agonist concentration can influence the therapeutic response e.g. propranolol and endogenous catecholamine release during exercise Irreversible competitive antagonism the receptors affinity for the antagonist may be so high that the receptor is unavailable for binding of agonist after binding to the receptor, the antagonist forms covalent bonds with it the number of remaining unoccupied receptors may be too low to permit the previous maximal response to be obtained, unless spare receptors are present

% of maximal effect

Effect

maximal effect for drug A in the presence of irreversible antagonist EC50 Log [Drug]

once the irreversible antagonist has occupied the receptor, the duration of action is relatively independent of its own rate of elimination and more dependent upon the rate of turnover of receptor molecules
phenoxybenzamine in the control of hypertension in pheochromocytoma

2007 HNC

Non-competitive antagonism blockade of agonist response is produced by the interaction of the antagonist with binding sites intimately associated with the receptor, but distinct from the agonist binding site the binding of the antagonist to this site precludes the activation of the receptor by the agonist the agonist operates normally at receptor units that are not influenced by the antagonist the affinity of the remaining receptors for the agonist, and the potency of the agonist are not altered the maximal capacity of the receptor to respond is decreased due to a progressive decline in agonist fractional receptor occupancy this type of antagonism is not surmountable by increasing the concentration of agonist Non-competitive antagonism in the presence of spare receptors the presence of a non-competitive antagonist will first shift to the right the dose response of the agonist without a change in the maximal response (pseudo competitive antagonism) increasing concentration of the non competitive antagonist will eventually reduce the number of available receptors so that the maximal response can not be obtained

Negative antagonists / inverse agonists drugs with affinity for receptors will actually produce an effect opposite to that of agonists Relative affinity of agonists and antagonists for receptors
Ra Ri
log [Drug] A P C N

Log [Drug]

Concentration-effect of partial agonist

Response full agonist partial agonist log (dose)

Signalling mechanism different molecular mechanisms transduce extracellular signals into intracellular messages that control cell function involves receptors on cell surface and within the cell enzymes other proteins that generate, amplify, coordinate and terminate post-receptor signalling by second messengers in the cytoplasm 5 known signalling mechanisms lipid-soluble ligand crosses the cell membrane to act on the intracellular receptor a transmembrane enzyme with its intracellular activity being allosterically regulated by a ligand binding to a site on the enzymes extracellular domain a transmembrane receptor protein that binds and stimulates a protein tyrosine kinase a ligand-gated trans-membrane ion channel that can be induced to open or close by the binding of a ligand a transmembrane receptor protein that stimulates a GTP-binding G-protein, which in turn generates an intracellular second messenger
1 Outside cell 2 Drug 3 4 5

% of maximal binding

Effect

partial agonist

G
Inside cell A B Y Y-P X Y

full agonist log (dose)

Response

total response partial agonist full agonist in presence of partial agonist

log (dose)

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Intracellular receptors lipid-soluble substances can cross the plasma membrane and act on intracellular receptors
nitric oxide that acts by stimulating intracellular guanylyl cyclase, which produces cGMP steroids (corticosteroids, mineralocorticoids), vitamin D, thyroid hormone, stimulate transcription of genes in the nucleus by binding to specific DNA sequences near the gene whose expression is to be regulated

these hormones produce their effects after a characteristic lag time of 30 minutes to several hours the time required for synthesis of new proteins the effect of these agents can persist for hours or days after the agonist concentration has been reduced to zero
primarily due to the relatively slow turnover of most enzymes and proteins, which can remain active in cells for hours or days after they have been synthesized may also be due to high affinity of receptor for the hormone

a tyrosine kinase (from the Janus-kinase family, JAK) binds noncovalently to the receptor mechanism of action after activation cytokine receptors dimerize, and the bound kinase become activated and phosphorylated the phosphorylated tyrosine kinases then bind and phosphorylate another set of protein, called STAT (signal transducers and activators of transcription) the 2 STAT molecules dimerize and the STAT-STAT dimer dissociates from the receptor and travels to the nucleus, where it regulates transcription of specific genes

Y-P

Transmembrane enzymes these receptors (which may be a protein tyrosine kinase, a serine kinase, or a guanylyl cyclase) are polypeptides consisting of an extracellular hormone-binding domain and a cytoplasmic enzyme domain ligands include insulin, epidermal growth factor, platelet-derived growth factor, atrial natriuretic factor, transforming growth factor mechanism of activation upon activation (e.g. by insulin), the receptor converts from its inactive monomeric state to an active dimeric state 2 receptor polypeptides bind noncovalently in the plane of the membrane the cytoplasmic domain become phosphorylated on the (tyrosine) residue and their enzymatic activities are activated, catalyzing phosphorylation of substrate proteins

S ATP ADP

S-P

Cytokine receptors respond to a heterogenous group of peptide ligands (growth hormone, erythropoietin, interferon, and other regulators of growth and differentiation) these receptors have extracellular and intracellular domains
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Ligand-gated channels ligands activating these receptors are synaptic transmitters acetylcholine, gamma-aminobutyric acid, excitatory amino acids (glycine, aspartate, glutamate) on activation, transmembrane conductance of the relevant ion is increased thereby altering the electrical potential across the membrane the time elapsed between the binding of the agonist to a ligand-gated channel and the cellular response is measured in milliseconds G proteins mechanism of action upon activation, the receptor triggers the activation of a G protein the activated G protein then changes the activity of an effector element, usually enzyme or ion channel this element then changes the concentration of the intracellular second messenger cyclic adenosine-3,5-monophosphate (cAMP), calcium ion, or phosphoinositides G proteins use a molecular mechanism which involves binding and hydrolysis of GTP this mechanism separates ligand excitation of the receptor from G proteinmediated activation of the effector, thereby allowing the transduced signal to be amplified the duration of activation of adenylyl cyclase depends upon the duration of GTP binding to Gs rather than the receptors affinity for the ligand (e.g. noradrenaline) GTP-bound Gs remains active for tens of seconds, which enormously amplifies the original signal

Y-P Y-P

Y-P

slow hydrolysis of GTP provides one explanation regarding the phenomenon of spare receptors slow hydrolysis of GTP causes the active G protein to persist long after the receptor has dissociated from its agonist molecule if the proportion of active G proteins correlates with pharmacologic response, receptors will appear to be spare, that is, a small fraction of receptors occupied by agonist at any given time will appear to produce a larger response Relation between drug dose and clinical response Spare receptor theory explains the high efficacy of receptor-effector interaction more receptors than are needed to produce a maximal drug effect maximal response can be elicited by an agonist at a concentration that does not result in occupancy of all available receptors allows explanation for agonists with low affinity for receptors to produce full response at low concentrations, to the extent that EC50 (dose-response) is lower than KD (drug-receptor dissociation) even if receptors are partially blocked by irreversible antagonists, high concentrations of agonist can still produce an undiminished maximal response (spare beta receptors in myocardium) fraction of receptors which can be irreversibly blocked without reduction in the maximal effect produced Occupancy and dose response because occupancy is often not directly related to response, and signal amplification occurs between receptor occupancy, effector activation, and response, dose-response curve often fall to the left of receptor-occupancy profiles

Affinity, potency the greater is the drugs affinity for the receptor the lower the drug concentration which half saturates the receptors (Kd), the lower the drug concentration required to produce half-maximal effect (E50), affinity describes potency EC50 of two drugs
100 % Effect A 50 0 0 500 EC50 EC50 1000 1500 [Drug] 2000 2500 Potency of A > B B

Log dose response of two drugs

100 % Effect A 50 0 EC50 Log [Drug] EC50 Potency of A > B B

Potency, efficacy
% of maximal effect L M N

log [agonist]

EC50

Kd

log [agonist]

Kd, affinity and dose response the ligand with low receptor-ligand affinity (high Kd) rapidly dissociates from the receptor allowing rapid termination of biological response high binding affinity (low Kd) would result in slow dissociation of agonist from receptor and correspondingly a slower reversal of biological effect

drug L is more potent than drug M and N drugs L and N are more efficacious than drug M drug M is a partial agonist Intrinsic activity, efficacy the concept of intrinsic activity or efficacy is used to compare the maximal effect of a group of drugs (such as opioids) when they bind to the same receptors full activity = full agonist intermediate activity = partial agonist no activity = antagonist cannot be explained by Clarks theory alone may be explained by two states theory of the occupation activation model
Emax for drug A % Effect Emax for drug B A B Efficacy A > B If EC50 for drugs A and B are the same, then the affinity for the receptor is the same.

Log [Drug] 2007 HNC

% of individuals responding

Occupation activation model - two states theory attempts to explain intrinsic activity when a drug binds to the nonactivated receptor, full agonist activates all of the receptors partial agonist activates some of the receptors antagonist converts none the ability of the drugs to cause coupling of the receptor to the guanine nucleotide regulatory proteins (Gs proteins) may explain the differences Possible mechanism for the partial agonist phenomenon
Pure antagonist Partial agonist Ligand LRi No effect LRa Ri Ra Full agonist Partial agonist Ligand

occur due to slow receptor kinetics drugs that take many minutes to approach equilibrium (buprenorphine) intensity thus depends upon plasma concentration and recent history of that concentration Quantal dose-effect curves/plots
Cumulative % exhibiting 100 therapeutic effect 50 Cumulative % dead at each dose cumulative frequency distribution frequency distribution

% requiring dose to achieve desired effect ED50 [Drug] LD50

% requiring dose for a lethal effect

Effect

Non-linearity and hysteresis of dose response curves caused by

cooperativity of receptors receptor interaction

Cooperativity of receptors occupancy of receptors at low concentrations increases the apparent receptor affinity at higher concentrations multiple sites within a tightly coupled group of receptors must be occupied in order to initiate an event acetylcholine receptors at neuromuscular junction Receptor interaction when a drug occupies more than one receptor type, the pharmacological outcome may be the result of interaction between different receptor subtypes. opioids (buprenorphine) Hysteresis drug must enter another biophase (site of action), and then occupy one or more species of receptors in order to initiate an effect when plasma concentration declines, whole process reverses but the effect lags behind the plasma concentration occur due to access limitation movement of ionized drug (pancuronium) from capillary to junctional cleft movement of non-ionized but poorly lipid soluble drug (morphine) across the blood brain barrier

median effective dose (ED50) dose at which 50% of individuals exhibit specified quantal effects median toxic dose (TD50) dose required to produce a particular toxic effect in 50% of individuals / animals median lethal dose (LD50) therapeutic index = TD50 / ED50 (clinical studies) or LD50 / ED50 (preclinical studies) Beneficial and toxic effects overdosage anticoagulation therapy and bleeding, insulin and hypoglycaemia drugs acting on same receptor type in different tissues inhibition of Na+/K+ ATPase by digoxin (augmentation of cardiac contractility, cardiac arrhythmias, gastrointestinal effects, and changes in vision) drugs acting on different types of receptors opioids and different subtypes of opioid receptors Variation in response to drugs idiosyncratic response hypo-reactive, hyper-reactive hypersensitivity tolerance tachyphylaxis desensitization additive effect synergistic effect potentiation antagonism

2007 HNC

Idiosyncratic response an unusual drug response, one that is infrequently observed in most patients, usually caused by genetic differences in metabolism of the drug or by immunologic mechanisms, including allergic reactions 10% black males with deficiency of erythrocyte glucose-6-phosphate dehydrogenase develop haemolytic anaemia with primaquine resistance to warfarin due to alteration in vitamin K epoxide reductase Hypo-reactive, hyper-reactive the diminished or increased intensity of effect of a given dose of drug in comparison to the effect seen in most individuals Hypersensitivity refers to allergic or other immunologic responses to drugs Tolerance responsiveness decreases as a consequence of continued drug administration Tachyphylaxis acute tolerance, responsiveness diminishes rapidly after administration of a drug Desensitization after reaching an initial high level, the drug effect gradually diminishes over seconds or minutes, even in the continued presence of the agonist, usually reversible Additive effect combined effect of two drugs that is equal to the sum of the effect of each drug alone, most common Synergistic effect combined effect of two drugs that is greater than the sum of effect of each drug administered alone carbon tetrachloride and ethanol are hepatotoxins, together produce much more liver injury than expected Potentiation increased effect of a toxic agent acting simultaneously with a nontoxic one isopropanol (not hepatotoxic) increases the hepatotoxicity of carbon tetrachloride Antagonism interference of one drug with the action of another an antagonistic agent often desirable as an antidote

2007 HNC

4 mechanisms to explain variation to response to drugs alteration in the concentration of the drug that reaches the receptor variation in concentration of an endogenous receptor ligand receptor regulation alterations in number or function of receptors changes in components of response distal to receptors antibodies to receptors Alteration in the drug concentration due to alterations in pharmacokinetics (absorption, distribution, and clearance) age, gender, liver and kidney functions, disease states Variation in the concentration of endogenous ligand this mechanism contributes greatly to the variability in responses to pharmacologic antagonists propranolol controls hypertension, but no effect in resting heart rate of well-trained athlete Receptor regulation effects of some drugs do not remain constant despite constant plasma concentration changes in drug responsiveness caused by receptor regulation increased or decreased in the number of receptor sites alterations in the efficiency of coupling of receptors to distal effector mechanisms, e.g. G proteins Receptor up-regulation changes in receptor numbers can be caused by Hormones, e.g. thyroid hormone increases both the number of receptors in heart muscle and the sensitivity of the heart to catecholamines (up-regulation) chronic receptor blockade chronic -blockade (increased receptor density) chronic phentolamine therapy (development of secondary beta adrenergic effects) Disastrous effects of up regulation overshoot phenomenon an antagonist may increase the number of receptors in a cell or tissue by preventing down regulation caused by an endogenous agonist when the antagonist is withdrawn, the elevated number of receptors can produce an exaggerated response to physiological concentrations of agonist

Receptor down-regulation agonist ligand itself induces a decrease in the number (down regulation) or coupling efficiency of its receptors chronic exposure to sympathomimetic agents (decreased receptor density) allow cells to adapt to changes in rates of stimulation by hormones and neurotransmitters reversible with removal of agonist contributes to tachyphylaxis, refractoriness, or tolerance to the effects of some drugs Disastrous effects of down-regulation the number of receptors, which has been decreased by drug-induced down-regulation, is too low for endogenous agonist to produce effective stimulation e.g. withdrawal of clonidine and hypertensive crisis, probably because of drug down-regulation of 2 adrenoceptors wean slowly from the drug, and watch for signs of withdrawal reaction Desensitisation possible mechanisms decrease in number of receptors receptor sequestration, a rapid and transient event wherein the receptors are made temporarily unavailable for activation by agonists action of enzymes on the receptor decreased synthesis of receptors impair coupling of (-adrenergic) receptors with GS protein phosphorylation of the receptor -adrenergic receptor desensitization possible mechanism receptor phosphorylation by -adrenergic receptor kinase or cAMP-dependent protein kinase A, followed by coupling of receptor to -arrestin, leading to receptorGS protein uncoupling
Agonist N OH OH OH Gs ARK ATP OP N OP OP -arr Agonist Agonist Pase N OH OH OH Agonist

-opioid receptor desensitisation opioid receptor is a member of the rhodopsin subfamily of the super family of G proteincoupled receptors (GPCRs) receptor undergoes ligand-induced receptor endocytosis in an agonist-dependent manner recruitment of arrestin to the vicinity of the receptor is the key for triggering the receptor desensitization process Special situations antibodies to receptors (-receptors, acetylcholine receptors) impaired receptor-G protein coupling in the elderly

Gs

rr -a

Pi Gs

2007 HNC