PARASIMPATHETIC NERVOUS

SYSTEM

Prof. Pierangelo Geppetti

 AUTONOMIC NERVOUS SYSTEM

PARASYMPATHETIC

CHOLINERGIC
SYMPATHETIC

NORADRENERGIC
SYMPATHETIC

DOPAMINERGIC
SYMPATHETIC

Katsung et al, Basic and Clinical Pharmacology 12th edition

 PERIPHERAL
CHOLINERGIC TRANSMISSION

A large number of peripheral neurons synthesize and

release acetylcholine

In the autonomic nervous system

• Preganglionic fibres
• Parasympathetic postganglionic fibres
• Few sympathetic postganglionic fibres → in sweat
glands and skeletal muscle vessels - CHOLINERGIC
SYMPATHETIC -
In the somatic nervous system
• Motor fibres to skeletal muscle
 CHOLINERGIC PATHWAYS
Projections from
→ nuclei of the basal forebrain (including the nucleus basalis of Meynert)
to the hippocampus, cortical regions and some subcortical nuclei
→ brainstem to the
thalamus, midbrain and
other brainstem regions
→ interneurons in the
striatum and the
nucleus accumbens
• Learning processes
and short-term
memory elaboration
• Regulation of
wakefulness
• Motor control
• Sensory processing
• Regulation of pain
circuits
Scarr, Front Cell Neurosci 2013
 SYNTHESIS AND RELEASE OF
ACETYLCHOLINE
1. Acetylcholine (Ach) is made
from choline (Ch) and
acetylcoenzyme A (Acetyl CoA),
and stored in vesicles
2. When voltage-sensitive
calcium channels in the terminal
membrane are opened, the
1 fusion of vesicles with the
4 surface membrane occurs
↑↑↑ Ca2+
2 3. In the synaptic cleft Ach is
rapidly broken down by the
enzyme acetylcholinesterase
3 (AchE)
4. Ch is transported back into
the axon terminal and is used to
synthesize Ach again

Adapted from http://faculty.pasadena.edu/dkwon/chap%208_files/textmostly/slide58.html

 CHOLINERGIC RECEPTORS

NICOTINIC (nAchR) MUSCARINIC (mAchR)

• Ligand-gated cationic • G protein-coupled receptors

channels
• Mainly located in
o autonomic ganglia
o adrenal medulla
o neuromuscular junction
o CNS areas
• Activity reproduced by
injection of nicotine, alkaloid
from the leaves of Nicotiana
Tabacum
• Mainly located in
o peripheral organs
o CNS areas
• Activity reproduced by
injection of muscarine,
alkaloid from Amanita
Muscaria mushrooms
 STRUCTURE OF THE NICOTINIC
RECEPTORS
a The threading pattern of
receptor subunits through the
membrane

b A schematic representation of
the quaternary structure, showing
the arrangement of the subunits in
the muscle-type receptor, the
location of the two acetylcholine
(ACh)-binding sites (between an
α- and a γ-subunit, and an α- and
a δ- subunit), and the axial cation-
conducting channel
Adapted from Karlin, Nature 2002
 NICOTINIC EFFECTS

Ganglioni Neuronal
Muscular
c (α4)2 (β2)3
(α1)2β1δε
(α4)2 (β4)3 (α7)5

Increased cationic
(Na+and K +/Ca 2+) permeability

Excitatory effect

Sympathetic Skeletal
and muscle Central
parasympathet contractio effects
ic effects n
 MUSCARINIC RECEPTORS

M1 M3 M5 M2 M4

Gq Gi
protein-coupled protein-coupled
↑ IP3, DAG ↓ cAMP
Excitatory effect Inhibitory effect

• CNS • Smooth
muscle • CNS
• Gastric • Gastric • CNS • PNS • CNS
and and (substanti • Heart (forebrain)
salivary salivary a nigra) • Smooth
glands glands muscle
 MUSCARINIC EFFECTS
HEART Detrusor contraction
Chronotropic and dromotropic Sphincteric relaxation
negative effect
SWEAT GLANDS
Weak inotropic negative effect
Induction of secretion
VASCULAR BEDS
SALIVARY GLANDS
Vasodilation
Induction of serous secretion
BRONCHIAL TREE
EYE MUSCLES
Bronchoconstriction
Myosis (sphincter of the pupil)
Increase of secretions
Accommodation (ciliary muscle)
GASTROINTESTINAL TRACT
CENTRAL NERVOUS
Increase of peristalsis
SYSTEM
Increase of secretions
Increase of motor activity,
Sphincteric relaxation
tremor,
MALE REPRODUCTIVE SYSTEM improvement of memory,
Erection hypothermia
BLADDER
 DRUGS OF THE CHOLINERGIC
SYNAPSIS
DIRECT-
ACTING

MUSCARINIC NICOTINIC

GANGLIONIC NEUROMUSCULAR
Agonists Antagonis
ts
Depolarizin Non
Stimulant
Blockers g Depolarizin
s
Blockers* g Blockers

* Neuromuscular depolarizing blockers act as nicotinic agonists

 Muscarinic Agonists

NATURAL ALKALOIDS SYNTHETIC CHOLINE ESTERS

Katsung et al, Basic and Clinical Pharmacology 12th edition

 Muscarinic Agonists

CLINICAL USES
PILOCARPINE
• Glaucoma
• Ocular and oral dryness in Sjögren syndrome
• Oral dryness after radiotherapy of head and neck cancer
BETHANECHOL M3 agonist
• Urinary retention resulting from general anaesthetic,
diabetic neuropathy (sporadic use)
METHACOLINE
• Bronchial challenge test used to make diagnosis of
asthma
 Muscarinic Antagonists

TWO PROTOTYPIC NATURAL MOLECULES

• Vegetal
alkaloids
• Tertiary amines
• High
liposolubility
• BEE entrance
ATROPINE SCOPOLAMINE • Similar kinetics
(HYOSCYAMINE) (HYOSCINE) and clinical
• Occurs in the plant • Occurs in the plant uses
Atropa belladonna Hyoscyamus niger
 Muscarinic Antagonists

LARGE NUMBER OF SEMISINTHETIC AND SINTHETIC

MOLECULES
 Muscarinic Antagonists

CLINICAL USES
CARDIOVASCULAR
Increase of heart rate → Sinus bradycardia Atropine

OPHTALMOLOGICAL
Dilation of the pupil → Retinal examination Atropine, Scopolamine,
Homatropine, Tropicamide,
Cyclopentolate
RESPIRATORY
Bronchodilation → Acute asthma/ COPD Ipratropium, Tiotropium
worsening
Bronchodilation → Pre-anaesthetic medication Atropine
 Muscarinic Antagonists

CLINICAL USES
GASTROENTEROLOGICAL AND GENITOURINARY
Reduction of smooth muscle and secretory Hyoscine butylbromide
activity of gut → Irritable bowel syndrome,
diverticular disease, renal cramps, abdominal
cramps
Reduction of detrusor smooth muscle tone, Oxybutynin
spasms → Overactive bladder

NEUROLOGICAL
Antidote for cholinesterase inhibitor poisoning Atropine, Pralidoxime
Parkinsonism in antipsychotic therapy (Atropine),
Benzatropine,
Orphenadrine
Prevention of motion sickness and Scopolamine
postoperative
nausea and vomiting
 Muscarinic Antagonists

SIDE EFFECTS
• Dryness of mouth and skin
• Tachycardia
• Constipation
• Difficulties of urination Increasing
• Tachycardia doses of the drug
• Mydriasis
• Blur vision
• Confusion and memory deficit
• Agitation
• Hallucination
• Delirium
 Neuromuscular Blockers

NON
DEPOLARIZIN
G BLOCKERS

DEPOLARIZING BLOCKERS

Bowman, Br J Pharmacol 2006

 Neuromuscular Blockers
DEPOLARIZING
Activation of nAchR in
the neuromuscular
junction
Prolonged depolarization
of muscular cell
membrane
Muscular repetitive
contractions
Block of neuromuscular
transmission
Flaccid paralysis
NON DEPOLARIZING
Reversible competitive
antagonism of nAchR
in the neuromuscular
junction
Block of nAchR in the
presynaptic membrane
Direct block of
neuromuscular
transmission
 Neuromuscular Blockers
PHARMACOKINETICS

http://www.us.elsevierhealth.com/media/us/samplechapters/9780323053747/ Chapter%2012.pdf
 Depolarizing Neuromuscular Blockers

CLINICAL USES

• Muscle relaxation in anaesthesia and intensive care for

facilitation of endotracheal intubation, mechanical
ventilation, surgical operations

SUCCINYLCHOLINE/SUXAMETHONIUM
• Peculiar use also during electrical or pharmacological
convulsive therapy, thanks to its ultrashort duration of
action
 DRUGS OF THE CHOLINERGIC
SYNAPSIS
INDIRECT-
ACTING

ANTICHOLINERGICS CHOLINOMIMETICS

Inhibitors of Inhibitors of Inducers of Inhibitors of

Ach synthesis Ach release* Ach release Ach Esterase

* Inhibitors of Ach release are indirect-acting neuromuscular blockers

 Inhibitors of Acetylcholine Release

BOTULINUM TOXIN

• Protein produced by the spore forming, obligate anaerobe,

gram positive bacterium Clostridium botulinum

• Seven distinct antigenic types (A, B, C, D, E, F, G)

• Simple dichain polypeptide → 100-kd heavy chain joined by a

single disulfide bond to a 50-kd light chain

• The light chain is an endopeptidase that blocks acetylcholine-

containing vesicles from fusing with the terminal membrane of
the motor neuron, resulting in flaccid muscle paralysis
 Inhibitors of Acetylcholine Release

Arnon, JAMA 2001

Release of acetylcholine at the neuromuscular junction is mediated by the

assembly of a synaptic fusion complex, which is a set of SNARE proteins,
including
synaptobrevin, SNAP-25, and syntaxin
 Inhibitors of Acetylcholine Release

Arnon, JAMA 2001

The light chain of botulinum toxin cleaves specific sites on the SNARE
proteins in the neuronal terminal, preventing complete assembly of the
synaptic fusion complex and thereby blocking acetylcholine release
 Inhibitors of Acetylcholine Release
BOTULISM

Poisoning caused by the absorption of botulinum toxin into the

circulation from a mucosal surface (gut, lung) or a wound

• Foodborne botulism, due to the ingestion of improperly

preserved food, is the most common cause (botulus =
sausage)

• The medical case is characterized by an acute, afebrile,

symmetric, descending flaccid paralysis (+++ onset in bulbar
musculature) in a patient with clear sensorium (no cerebral
action)

• Disease manifestations are similar regardless of botulinum

toxin type
 Inhibitors of Acetylcholine Release
Symptoms and Signs of Foodborne Botulism, Types A
and B*
Cases, % Cases, %

Arnon, JAMA 2001

 Inhibitors of Acetylcholine Release

BOTULINUM TOXIN TYPE A: BOTOX® (BoNT-A)

• It selectively cleaves SNAP-25 in order to block the

formation of SNARE complex
• High neuronal selectivity

• The capability of blocking muscular contraction

is a recognised mechanism of action
• The capability of inhibiting the sensitive
transmission has to be better defined
 Inhibitors of Acetylcholine Release

Model of anti-nociceptive action of BOTOX®

Release of
Afferent transmitters (e.g.
Peripheral pain stimulus signals glutammate) →
towards CNS CENTRAL
SENSIBILIZATIO
Neuronal feedback →
N
PERIPHERAL
BoNT-A may block the SENSIBILIZATION
transmitter release in the and increasing afferent input
peripheral terminations, with towards CNS PAIN
direct reduction of peripheral
sensibilization and indirect
reduction of central
sensibilization

Wheeler A and Smith HS. Toxicology 2013;306:124–46

Dolly O and Aoki KR. Eur J Neurol 2006;13(Suppl 4):1–9
 Inhibitors of Acetylcholine Release

BOTULINUM TOXIN TYPE A: BOTOX® (BoNT-A)

Locally injected
No systemic use
Different formulations for different clinical indications:
• Blepharospasm
• Facial hemispasm
• Cervical dystonia
• Spasticity after stroke
• Equinus foot in children affected by cerebral palsy
• Underarm hyperidrosis
• Chronic migraine
• Neurogenic urinary incontinence
 Inhibitors of Acetylcholine Esterase

CHOLINESTERASES
Family of enzymes that catalyses the hydrolysis of
acetylcholine into choline and acetic acid, in order to
allow the cholinergic neuron to return to its resting state
after activation
Acetylcholinesterase (AchE)
• In the neuromuscular junctions, peripheral and central
cholinergic synapses, red blood cell membranes
• High selectivity for Ach and its esters
Pseudocholineserase/Butyrylcholinesterase (BuChE)
• In the liver, skin, brain, gastrointestinal smooth muscle,
plasma
• It metabolizes the synthetic compound butyrylcholine
more quickly than Ach
 Inhibitors of Acetylcholine Esterase

ACETYLCHOLINE ESTERASE: STRUCTURAL

FEATURES

Acidic
site
Esterasic
site Ser
Glu

Hys

Soreq, Nat Rev Neurosci 2001

 Inhibitors of Acetylcholine Esterase

ACETYLCHOLINE ESTERASE: ENZYMATIC REACTION

1 The acetic group of

Ach is transferred,
through the imidazole
ring of His, to the
1 2 hydroxyl group of Ser →
Displacement of the
choline moiety from the
substrate with formation
of an acetyl-enzyme
intermediate
2 An hydrolysis of the intermediate releases the acetate group

Soreq, Nat Rev Neurosci 2001

 Inhibitors of Acetylcholine Esterase

ALCOHOLS CARBAMATES, ORGANOPHOSPHAT

(PYRIDINE ES
DERIVATIVES,
ALKALOIDS)
Electrostatic and Covalent bond to the Covalent bond to the
hydrogen bond to active site active site
the active site
Reversible Reversible Irreversible
Inhibition Inhibition Inhibition
Short-acting Intermediate-acting Long-acting
EDROPHONIUM NEOSTIGMINE ECHOTHIOPHATE
PYRIDOSTIGMINE MALATHION
PHYSOSTIGMINE PARATHION
TACRINE SARIN
RIVASTIGMINE SOMAN
GALANTAMINE
DONEPEZIL
 Reversible Inhibitors of Acetylcholine
Esterase
EDROPHONIUM

• It reversibly binds electrostatically AchE and by hydrogen

bonds to the active site, thus preventing access of
acetylcholine
• Duration of enzyme-inhibitor bond: 2-10 minutes
• Short duration of action: 5-15 minutes

• Amplification of somatic neuromuscular transmission

• Amplification of parasympathetic activity
• No CNS activity
• Toxicity: cardiorespiratory depression

CLINICAL USE
Diagnostic test of myasthenia gravis
 Reversible inhibition Irreversible inhibition
Active enzyme

NEOSTIGMINE DYFLOS
Phosphorilate
d enzyme

Anionic
site
Catalytic
site

Carbamilic group Pralidoxim

transferred e
to -OH of Ser

Reactivatio
n
Slow Reactivated
Hydrolys enzyme
Modified from Rang and Dale, 2005 is
 Reversible Inhibitors of Acetylcholine
Esterase
Compound Chemical Structure AchE Inhibition Application

Colovic, Current Neuropharmacolog 2013

 Irreversible Inhibitors of Acetylcholine
Esterase
Compound Chemical Structure AchE Inhibition Application

Colovic, Current Neuropharmacolog 2013tim