Pharmacodynamics
and Signal Transduction
CONTENTS
DOSE-RESPONSE RELATIONSHIPS
TIME-RESPONSE RELATIONSHIPS
DRUGS AS AGONISTS
DRUGS AS ANTAGONISTS
SIGNALING AND RECEPTORS
THE FUTURE IS NOW
TOP FIVE LIST
Signal transduction is all about the targets. The targets may be
membrane or cytosolic receptors, ion channels, transporters,
signal transduction kinases, enzymes, or specific sequences
of RNA or DNA, but the pharmacodynamic principles that
govern these interactions remain the same (Table 2-1). Drugs
bind to specific targets, activating (stimulating) or inactivating
(blocking) their functions and altering their biologic
responses.
lll DOSE-RESPONSE
RELATIONSHIPS
Often, the lock-and-key concept is useful to understand the
way drugs work. In this analogy, the target is the lock and
the drug is the key. If the key fits the lock and is able to open
it (i.e., activate it), the drug is called an agonist. If the key fits
the lock but can’t get the lock to open (i.e., just blocks the
lock), the drug is called an antagonist.
The pharmacodynamic properties of drugs define their in-
teractions with selective targets. Pharmaceutical companies
identify and then validate, optimize, and test drugs for specific
targets via rational drug design or high-throughput drug
screening. Table 2-2 identifies some pharmacodynamic con-
cepts that determine the properties of drugs.
Terms such as affinity and potency (see Table 2-2) are most
appreciated in graphic form. Figure 2-1A illustrates a graded
(quantitative) dose-response curve. Often, this type of curve is
graphed as a semi-log plot (see Fig. 2-1B). Notice that the
y-axis is depicted as a percentage of the maximal effect of
the drug, and the x-axis is the dose or concentration of the
2
drug. Several important relationships can be appreciated
through graded dose-response curves:
1. Affinity is a measure of binding strength that a drug has for
its target.
2. Affinity can be defined in terms of the KD (the dissociation
constant of the drug for the target). In this instance, affinity
is the inverse of the KD (1/KD). The smaller the KD, the
greater affinity a drug has for its receptor.
3. The dose of a drug that produces 50% of the maximal ef-
fect is known as the ED50 (effective dose to achieve 50%
response). If concentrations are used, then the concentra-
tion to achieve 50% of the maximal effect is known as
the EC50.
4. When plotted on a linear graph, the dose-response rela-
tionship for most drugs is exponential, often assuming
the shape of a rectangular hyperbola.
5. By plotting response versus log dose, a graded dose-response
curve can be translated into more linear (sigmoidal) relation-
ships. This facilitates comparison of the dose-response
curves for drugs that work by similar mechanisms of action.
Without knowing anything about the mechanisms of opioids
or aspirin, Figure 2-1C shows that hydromorphone, mor-
phine, and codeine work by the same mechanism, but aspirin
works by a different mechanism. Often, the slope of the
curves and the maximal effects are identical for drugs that
work via the same mechanism. These curves also show that
of the three opioids, hydromorphone is the most potent.
That is, responses are observed at lower doses compared
with the other agents. Potency is a comparative term that
is used to compare two or more drugs that have different af-
finities for binding to the same target.
6. Below the threshold dose, there is no measurable response.
7. Emax is a measure of maximal response or efficacy, not a
dose or concentration. After the maximal response is
achieved, increasing the concentration/dose of the drug be-
yond the Emax will not produce a further therapeutic effect
but can lead to toxic effects.
Does the curve depicted in Figure 2-1B look familiar? The
same mathematical relationships that define how a drug
(ligand) interacts with a receptor to elicit or diminish a bio-
logic response also govern the ways in which substrates
(ligands) interact with enzymes to generate metabolic end
 18 Pharmacodynamics and Signal Transduction

TABLE 2-1. Examples of Drug Targets

GENERAL TARGET CLASS SPECIFIC TARGET DRUG EXAMPLE

Plasma membrane receptor b-Adrenergic receptor Isoproterenol

Cytosolic receptor Corticosteroid receptor Prednisone
Enzyme Cyclooxygenase Aspirin
Ion channel GABA receptor Barbiturates
Transporter Serotonin transporter Fluoxetine
Nucleic acid Alkylating chemotherapeutics Chlorambucil
Signal transduction kinases Bcr-Abl Imatinib
mTOR Sirolimus

GABA, g-aminobutyric acid.

products. In fact, the terms KD and Emax (ceiling effect) can

TABLE 2-2. Pharmacodynamic Concepts for easily be redefined as Km and Vmax, as per Michaelis-Menten
Determining Properties of Drugs enzyme kinetics.
Another useful mathematical concept is quantal (“all-
TERM DEFINITION or-none”) dose-response curves. These population-based,
dose-response curves include data from multiple patients, of-
Affinity The attraction (ability) of a drug to ten plotting percentages of patients who meet a predefined
interact (bind) with its target. The
criterion (e.g., a 10 mm Hg reduction in systolic blood pres-
greater the affinity, the greater the
binding sure, going to sleep after taking a sleep aid) on the y-axis ver-
Efficacy The ability of a drug to interact with its
sus the dose of drug that produced the biologic response on the
target and elicit a biologic response x-axis (Fig. 2-2A). These curves often take the shape of a nor-
Agonist A drug that has both affinity and efficacy mal frequency distribution (i.e., bell shape). These all-or-none
Antagonist A drug that has affinity but not efficacy
responses can easily be thought of in terms of drugs that are
sleep aids. The drug either puts people to sleep or it doesn’t.
Selectivity Interaction of drug with receptor elicits
primarily one effect or response There is no in-between. However, the dosage that induced
(preferably a therapeutic response) sleep may differ among various people. Most people will fall
Specificity Interaction of a drug with preferentially asleep with a medium-range dose, but there will be outliers—
one receptor class or a single some will be very sensitive to the drug at low doses, whereas
receptor subtype others will be relatively resistant to hypnotic effects until
Potency Term for comparing efficacies of two higher drug levels are achieved.
or more drugs that work via the same These data can be transformed into a cumulative frequency
receptor or through the same
distribution (see Fig. 2-2B), where cumulative percent maxi-
mechanism of action*
mal patient responses are plotted versus dose. This type of
*When comparing potency between two drugs, the drug that can achieve sigmoidal curve yields useful safety information when the
the same biologic effect at the lower concentration/dosage is considered
more potent.
all-or-nothing responses are defined as therapeutic maximal

Hydromorphone Codeine
Morphine Aspirin
(percent of maximum)

(percent of maximum)

(percent of maximum)

100 100 100

Response

Response

Response

50 50 50

0 0 0
1 10 50 100 .01 .1 1 10 100 1,000 .01 .1 1 10 100 1,000
Dose (μmol/L) Log [dose] (μmol/L) Log [dose] (μmol/L)

A B C
Figure 2-1. Graded dose-response curves, in which the KD value is 1 mmol/L.
 Drugs as agonists 19

Cumulative Therapeutic effect Lethal effect

100 100 distribution Toxic effect
Total number responding

Total number responding

Percent maximal response

100
80 80
(all or none)

(all or none)
60 60

(mice)
Frequency 50
40 distribution 40

20 20

0 0 0
Dose Dose ED50 TD50 LD50
Dose

A B C
Figure 2-2. Quantal dose-response curves.

responses, toxic responses, or lethal responses. In this way, for

a single drug, cumulative frequency distributions can be com- Toxicity
pared for therapeutic efficacy, toxicity, and lethality (see Maximal effect
Fig. 2-2C). This type of analysis can be used to compute the
therapeutic index for any drug. The therapeutic index is de- Minimal
fined as the TD50 (the dose that results in toxicity in 50% Response detectable
of the population) divided by the ED50 (the dose at which effect
(threshold)
50% of the patients meet the predefined criteria). As a rule
of thumb, when a drug’s therapeutic index is less than 10 Latent
(meaning that less than a 10-fold increase in the therapeutic
dose will lead to 50% toxicity), then the drug is defined as Time to peak action
having a narrow therapeutic window. Examples of drugs with
narrow therapeutic windows are listed in Box 2-1. Plasma Duration of effect
concentrations are routinely assessed for drugs with narrow Time
therapeutic windows. This is especially critical for patients
whose pharmacokinetic parameters are compromised by Figure 2-3. Time-response curve.
renal or hepatic diseases.

lll DRUGS AS AGONISTS

lll TIME-RESPONSE RELATIONSHIPS How does a practitioner interpret two drugs that have equal
For some analyses, it is advantageous to graph time to drug affinities (binding) for a specific target but have different effi-
action versus defined response. This time-response curve cacies (degree of response) (Fig. 2-4)? In this example, even
(Fig. 2-3) depicts the latent period (time to onset of action), though all these drugs are agonists for the target, the drugs
the time to peak effect, as well as the duration of action. Often that elicit a maximal response are full agonists (drugs C
the y-axis for this type of relationship is given as the plasma and D), whereas those that do not elicit a maximal response
concentration of the drug (because plasma concentration is are often referred to as partial agonists (drugs A and B in
directly related to response). The maximal peak response Fig. 2-4). In other words, despite occupying all of the receptors
should be below the toxic dose and above the minimal effec- for the drug at the target site, the biologic response for partial
tive dose. If it isn’t obvious why the processes of absorption, agonists is muted or lower than that of full agonists. Often the
distribution, metabolism, and excretion determine the shape reasons for this muted or weak biologic response at full recep-
of this curve, refer back to Chapter 1. tor occupancy (saturation) is unknown. However, the key
point is that partial agonists are often used clinically to inhibit
competitively the responses of full agonists; thus they can be
thought of as competitive pharmacologic antagonists. Buspir-
Box 2-1. DRUGS WITH NARROW
one is an example of a partial agonist; buspirone exhibits full
THERAPEUTIC WINDOWS
agonist properties at presynaptic 5HT1A serotonin receptors
but very weak agonist activity at postsynaptic 5HT1A recep-
Theophylline Digoxin
tors. The net result of these disparate biologic responses leads
Warfarin Carbamazepine
Valproate Phenytoin to classification of this drug as a partial agonist.
Lithium Gentamicin Continuing with Figure 2-4, there can be cases when partial
agonists (drug A) display greater potency (greater effect at a
 20 Pharmacodynamics and Signal Transduction

100 D Competitive Reversible Antagonists

C 100
Percent maximal response

No antagonist
Antagonist A
B Antagonist B

Percent of maximal response

50 A

50

0
Log [dose]

Figure 2-4. Graded dose-response curves for four drugs of the 0

same class. Drugs C and D are full agonists, whereas drugs Log [dose]
A and B are partial agonists. Drug A is the most potent agent,
despite being a partial agonist. Drug D is more potent than A
C, even though both are full agonists.

Irreversible Antagonists
lower concentration) than full agonists (drug D). Understand- 100
ing these dose-response curves requires an appreciation of the No antagonist
Antagonist A
two-state model for receptor activation. Receptors can be Percent of maximal response Antagonist B
thought to undergo a dynamic conformational or structural
transition between inactive and active states in the presence
of ligands. This model can be useful to explain why partial ag-
onists exhibit weak biologic responses at full saturation of re- 50
ceptors. In this model, full agonists preferentially bind to the
active form of the target with high affinity, whereas partial ag-
onists have affinities to both the active and the inactive con-
formations of the target. By extending this model, drugs can
be designed to stabilize the inactive form of targets. These
drugs theoretically would exhibit negative efficacy and are 0
called inverse agonists. For inverse agonism to be observed, Log [dose]
there must be some level of constitutive activity in the absence
of agonist. Although these issues are frequently incorporated B
into test questions, there are few, if any, demonstrated exam- Figure 2-5. Antagonists shift dose-response curves of
ples of inverse agonism in vivo. agonists. A, Competitive reversible antagonists. B, Irreversible
antagonists.

lll DRUGS AS ANTAGONISTS Antagonists, such as b-adrenergic receptor antagonists

Often physicians prescribe a drug that blocks or competes with
an endogenous metabolite or pathway or exogenous xenobiotic
(foreign substance) or drug. These agents are antagonists in that
they block (or antagonize) the natural signal. These antagonists
change the shape of dose-response curves. For example, a com-
petitive, reversible antagonist shifts the dose-response curve to
the right, indicating that the agonist must now be given at a
higher dose to elicit a similar response in the presence of the an-
tagonist (Fig. 2-5A). In contrast, an irreversible antagonist shifts
the dose-response curve downward, indicating that the agonist
can no longer exert maximal effects at any therapeutic dose (see
Fig. 2-5B). There are also allosteric interactions (binding at an
alternative or “distant” site), where different drugs bind to dis-
tinct sites on one target in a reversible but not competitive man-
ner. In these cases, the action of one drug positively or
negatively affects the binding of a second drug to the target,
a phenomenon known as cooperativity.
(b-blockers) have affinity, but no efficacy, for b-adrenergic
receptors. These drugs compete for and block endogenous
norepinephrine or epinephrine from stimulating adrenergic
receptors. Because membrane receptors may be recycled after
drug binding (desensitization), may be newly transcribed, or
may have amplified responses through actions at multiple
effectors, the actual magnitude of antagonism corresponding
to a reduced biologic response may not always be linear
and, in fact, may be less than expected. The term spare recep-
tor is often used to describe this phenomenon.
lll SIGNALING AND RECEPTORS
The critical concepts of signal transduction pathways are am-
plification, redundancy, cross-talk, and integration of biologic
signals. From a pharmacologic perspective, identification of
individual signal transduction elements often uncovers
 Signaling and receptors 21

Tyrosine kinase Adenylyl

receptor Cytokine cyclase
G-protein receptor
receptor Ligand

γ
P P β
P P Grb-2/RAS αs
GDP
G-protein PI3K
Phospholipase C
JAK/STAT
Adenylyl
GTP
cyclase
IP3 DAG Adenylyl
cyclase
Cyclic
AMP Ligand

PKA Ca++ PKC AKT MAP kinase

αs
γ
β
GTP ATP
Altered gene expression cAMP

Figure 2-6. Signal transduction: it all leads to altered gene
expression. IP3, inositol-trisphosphate; DAG, diacylglycerol;
AMP, adenosine monophosphate; PKA, protein kinase A;
PKC, protein kinase C; PI3K, phosphatidylinositol-3-kinase;
AKT, a cell-survival kinase; JAK/STAT, dimerized proteins that
couple cytokine receptors to downstream targets; Grb-2/Ras,
scaffold network of proteins that couple tyrosine kinase
receptors to downstream targets such as the MAP kinases;
MAP kinases, mitogen-activated protein kinases.
potential targets for drugs to selectively disrupt the integrated
circuits that control cell growth, survival, and differentiation.
To appreciate fully the complexity of signaling networks re-
quires an understanding of a “subway map” of interconnected
receptors, effectors, targets, and scaffold proteins. The physi-
cian should understand the critical concepts of cell signaling as
well as some of the therapeutic targets that can now be mod-
ified with drugs.
Figure 2-6 depicts several intracellular signals that are reg-
ulated via receptor activation. A major family of membrane
receptors is the seven-transmembrane–spanning domain
G-protein–coupled receptors. These receptors couple to het-
erotrimeric guanosine triphosphate (GTP)-binding proteins,
which regulate downstream effectors, including adenylate
cyclase. This is a critical element in the discussion of the auto-
nomic (see Chapter 6) and central nervous systems (see
Chapter 13).
As depicted in Figure 2-7, amplification of the signal occurs
as one receptor interacts with multiple G-proteins that remain
activated even after the receptors dissociate. In a cyclical fash-
ion, activated receptors couple to the a/b/g subunits of the
inactivated G-protein (bound to guanosine diphosphate
[GDP]). This interaction induces GDP dissociation, followed
by GTP binding, and activation of the G-protein. The activated
GTPase
Adenylyl
cyclase
γ
β
αs
GDP
Figure 2-7. A G-protein–centric view of signaling. GTP, guano-
sine triphosphate; GDP, guanosine diphosphate; ATP, adenosine
triphosphate; cAMP, cyclic adenosine monophosphate.
G-protein dissociates into distinct a and b/g subunits. The a
subunit interacts with adenylyl cyclase, the enzyme that pro-
duces cyclic adenosine monophosphate (cAMP), the biologic
cofactor for protein kinase A. Hydrolysis of GTP to GDP
dissociates the a subunit from adenylyl cyclase and permits
reassociation with the b/g subunits, resetting the cycle for sub-
sequent activation by another receptor. Leading to further
complexity is that distinct a subunits couple to different and
specific effectors (Fig. 2-8) as well as the fact that b/g subunits
themselves can interact with other downstream effectors,
including phospholipases.
Examples of a receptor class that couples to Gs (“s” stands for
“stimulatory” as opposed to Gi, in which the “i” stands for
“inhibitory”) to activate adenylate cyclase and generate cAMP
are the b-adrenergic receptors. Pharmacologic intervention
with a b-agonist such as isoproterenol activates b-adrenergic
 22 Pharmacodynamics and Signal Transduction

receptor kinases. The hyperphosphorylated receptors interact

Effector with arrestin, a molecule that either prevents activation of
G-proteins by the receptor and/or induces receptor internali-
zation. One of the critical concepts in signal transduction is
that posttranslational modifications of targets by phosphory-
lation alter receptor function.
β γ Besides coupling to adenylate cyclase, G-protein–linked re-
α ceptors can regulate lipid turnover in membranes. Another
critical concept in signaling is that altered lipid metabolism
generates lipid-derived second messengers that amplify pri-
GTP GDP mary signals. Simply put, it’s all about metabolism of a phos-
phorylated lipid that makes up less than 0.01% of the total
G-protein and subunits lipid content of the membrane. G-protein–coupled receptors,
as Adenylate cyclase such as the angiotensin II receptor, activate phospholipase C
αi Adenylate cyclase via Gq, which preferentially hydrolyzes phosphatidylinositol
αq Phospholipase Cβ 4,5-bisphosphate (PIP2) to form two distinct lipid-derived sec-
α11 ond messengers (Fig. 2-10A): inositol 1,4,5-trisphosphate and
α13 diacylglycerol. Inositol 1,4,5,-triphosphate, being hydro-
αT cGMP phosphodiesterase philic, leaves the membrane and interacts with Caþþ channels
T= transducin for vision on the endoplasmic reticulum, producing an increase in intra-
αO Adenylyl cyclase cellular free Caþþ. Calcium-regulated kinases impact multiple
O = olfaction systems responsible for blood clotting, neuronal function, and
proton secretion in the stomach. In contrast, diacylglycerol,
Figure 2-8. G-proteins come in different flavors. The G-protein being hydrophobic, remains at the plasma membrane, where
complex is composed of a, b, and g subunits. The a-subunits are it is a lipid cofactor that activates protein kinase C.
distinct proteins that subserve different functions by coupling to To complicate matters, growth factor receptors, such as
different effectors. GTP, guanosine triphosphate; GDP, guanosine
platelet-derived growth factor, which are tyrosine kinases, also
diphosphate; cGMP, cyclic guanosine monophosphate.
couple to phospholipases to form lipid-derived second messen-
receptors, whereas antagonists such as propranolol, a b- gers (see Fig. 2-6). Another critical concept in signaling is that
blocker, prevent endogenous activation of these receptors. dimerization and resultant autophosphorylation of tyrosine
Understanding the mechanisms by which these receptors kinase receptors often leads to propagation of the signal. Many
undergo desensitization or internalization helps explain of the latest therapeutic approaches work through inhibiting
why receptor responses dissipate over prolonged activation these tyrosine kinase receptor activation mechanisms. In
(Fig. 2-9). Interaction of b-adrenergic receptors with epineph- addition, these tyrosine kinase receptors also activate
rine promotes phosphorylation of the receptor by b-adrenergic phosphatidylinositol-3-kinase (PI3K; Fig. 2-10B), which can

Initial Interaction Chronic Interaction

Ligand

Ligand

P
GS
P b-Arrestin
GS

Phosphatases de-phosphorylate b-Arrestin binding

Coupled to effector receptor, allowing receptor to prevents interaction with
separate from b-arrestin and G-protein or leads to
now interact with another ligand. receptor internalization.

Figure 2-9. Hyperphosphorylation of G-protein receptors leads to desensitization. S, stimulatory.

 Signaling and receptors 23

Protein
Diacylglycerol (DAG) kinase C

O C C O
O C C O
O O
O O
Phospholipase C CH2 CH CH2
CH2 CH CH2
OH
P P

P P P P

Phosphatidylinositol Inositol 1,4,5-trisphosphate (IP3)

4,5-bisphosphate
(PIP2)
Activates Ca;; receptors
at endoplasmic reticulum

J J
J J
J
J J
J
J J
J
J
O C C O
O C C O
PI3K
O O AKT
O O
CH2 CH CH2
CH2 CH CH2
P
O
P P O P O P

O P
Phosphatidylinositol
4,5-bisphosphate
P

Phosphatidylinositol
3,4,5-trisphosphate

B
Figure 2-10. Phosphatidylinositol 4,5-bisphosphate, a lipid substrate for multiple enzymes. PI3K, phosphatidylinositol-3-kinase;
AKT, a cell survival kinase.

form a third messenger from phosphatidylinositol 4,5-bispho-
sphate. The generated phosphatidylinositol 3,4,5-trisphosphate
can interact with proteins containing pleckstrin homology
domains, such as AKT (a cell survival kinase), which are critical
kinases for cell survival. Growth factor receptors are overex-
pressed in cancerous lesions. Figure 2-11 depicts several of the
pro-mitogenic cascades activated by this class of receptors as
well as designated targets for therapeutic intervention.
Figure 2-12 illustrates another lipid metabolite formed from
hydrolysis of PIP2. Phospholipase A2 hydrolyzes fatty acids
from lipids, such as PIP2 or phosphatidylcholine. These fatty
acids are often highly unsaturated, containing multiple double
bonds. Fatty acids containing 20 carbons with 4 double bonds
that occur starting 6 carbons from the carboxyl terminus are
known as arachidonic acid. These fatty acids can be oxidized
by multiple enzymes to form prostaglandins, leukotrienes,
and epoxides (hydroxy-eicosatetraenoic acids) by cyclooxy-
genase, lipoxygenase, and epoxygenases, respectively.
The onslaught of lipid-derived messengers is referred to as
arachidonophobia. Multiple drugs, either irreversibly (aspi-
rin) or reversibly (nonsteroidal antiinflammatory agents) in-
hibit cyclooxygenase and are reviewed in Chapter 10.
 24 Pharmacodynamics and Signal Transduction
Erb-B2
Trastuzumab
Gefitinib
PLCg
PI3K CRK
Src
AKT
Sirolimus
Everolimus
MTOR Imatinib
Myc bcr-Abl
S6 kinase
Protein
eif4E Gene expression
synthesis
Figure 2-11. Targeted cancer therapy. Erb-B2, a tyrosine kinase
receptor; PLCg, phospholipase C subtype that couples to tyrosine
kinases; CRK/Src, another group of scaffold proteins that couple
tyrosine kinases to downstream effectors; cABL, Myc, mTOR, S6
kinase, various downstream kinases and transcriptional factors
that can serve as selective “targets” for drugs; PI3K,
phosphatidylinositol-3-kinase; AKT, a cell survival kinase.
Inhibitors of leukotriene synthesis, such as montelukast, are
effective in asthmatic patients.
Another signaling concept is that lipid-derived second mes-
sengers such as prostaglandins can themselves activate G-
protein–coupled receptors, again amplifying responses
(Fig. 2-13). It should be noted that lipid-derived messengers
can signal by creating structured membrane microdomains
(also called lipid rafts), directly interacting with lipid-binding
domains on proteins, or by posttranslationally modifying pro-
teins. Examples of posttranslational modifications include
proteins made hydrophobic by covalent modifications with
14-carbon (myristoylate) or 16-carbon (palmitoylate) fatty
acids. A critical example of a myristoylated target protein is
Ras, which is overexpressed or mutated in multiple cancers.
Signal transduction cascades can interact with and dramat-
ically impact ion channels. In fact, ligand-gated ion channels
themselves serve as targets for both intracellular signal trans-
duction cascades as well as therapeutic drugs. Pharmacologic
regulation of ion channels serves as one approach to control-
ling cardiac (verapamil, a Caþþ channel blocker), renal (furo-
semide, an Naþ/Kþ/Cl– cotransporter antagonist), and
neuronal (benzodiazepines, a Cl– channel allosteric modula-
tor) function. Modifying pathologic ion channel activity with
therapeutics can be affected by direct interaction with the
channel itself or upstream/downstream signal transduction
targets of that ion channel. Ligand-gated ion channels can
be regulated by Caþþ, cAMP, lipid mediators, and tyrosine
phosphorylation signal transduction mechanisms.
A detailed example of ion channel modulation with thera-
peutics is g-aminobutyric acid (GABA)–activated neuronal
Cl– channels. Benzodiazepines are examples of drugs that
work via modulation of GABA-activated Cl– channels. GABA
serves as the endogenous ligand for this ligand-gated ion chan-
nel (Fig. 2-14). Benzodiazepines cannot activate GABA re-
ceptors in the absence of GABA, but benzodiazepines do
facilitate the actions of GABA to alter the conformation of
the receptor-ion channel, increasing the frequency of Cl–
channel opening events. The enhanced Cl– flux hyperpolar-
izes the membrane, diminishing neuronal transmission and
inducing sedation or cessation of anxiety (anxiolytic). The tar-
get of benzodiazepines, then, is a ligand-gated ion channel.
This is also an example of positive cooperativity between
the GABA neurotransmitter and a drug.
CLINICAL MEDICINE
Why Do Physicians Need to Know Signaling 101?
More and more drugs that alter signal transduction cascades
are being validated, tested, approved, and marketed. These
drugs offer the promise of specificity, selectivity, and reduced
toxicity because signaling elements are often mutated or
overexpressed in disease states, including cancer and
inflammation. In this way, normal tissues may not be
dramatically affected by the drug, resulting in reduced side
effects. Examples of some approved designer drug targets
include the following:
Target Signal Approved Pathology
Erb-B2 receptor Breast cancer
Erb-B2 receptor Non–small-cell lung
cancer
Erb-B2 receptor Colorectal cancer
BCR-ABL Chronic myelogenous
leukemia
mTOR Restenosis after coronary
stenting
Peroxisome proliferator activator Diabetes
receptors
The Her2/neu gene product, the Erb-B2 receptor, a member
of the human epidermal growth factor family of tyrosine kinases,
is overexpressed in multiple cancers and is associated with a
poor prognosis. Erb-B2 forms a heterodimer with other Erb
receptors that exhibit enhanced mitogenic signaling potential.
Several different strategies have been used to target this
receptor. Monoclonal antibodies (trastuzumab) as well as
low-molecular-weight inhibitors (gefitinib) have been designed
to block these actions. Additional strategies, including coupling
a specific antibody to cytotoxins or ligands that activate immune
cells, are being investigated.
lll THE FUTURE IS NOW
It’s no longer just about small molecules (pure, structurally de-
fined, drugs that are produced through industrial scale chem-
istry) that affect receptors, ion channels, and signal
transduction cascades. New strategies in biotechnology and
 The future is now 25

P
CH2JCHJCH2JOJPJOJ P

J J

J J

K
O O O

OKC JCKO
JJ J J
OH

J
Phospholipase A2
JJ J
J JCKO
K K K K
J
JJ J J J J
J J
J
J

K K K K
J J
J J J
J J
J
JJ J J J
J J
JJ J
JJ
J
J J
J J
Arachidonic acid
C20:4

Aspirin
Montelukast
NSAIDs
Lipoxygenase Cyclooxygenase Epoxygenase

Leukotrienes Prostaglandins Thromboxanes HETEs

O
K

COOH

OH OH
Prostaglandin E2

Figure 2-12. Arachidonophobia: 20 carbons, 4 double bonds, and the precursor to multiple lipid-derived second messengers
(leukotrienes, prostaglandins, thromboxanes, and hydroxy-eicosatrienoic acids) that regulate myriad physiologic responses from
vasoreactivity, to bronchial constriction, to labor, to protection of the gastrointestinal tract, to inflammation, and so on. The inset
prostaglandin E2 is an example of the types of structures that are created. NSAIDs, nonsteroidal antiinflammatory drugs; HETEs,
hydroxyeicosatetraenoic acids.

PGE2

Arachidonic Cyclooxygenase PGE2 Adenylyl

acid PGE2
cyclase
isomerase
Phospholipase
A2
PIP2
β
α γ

cAMP

Figure 2-13. Lipid-derived second messengers can interact with their own G-protein–coupled receptors. PGE2, prostaglandin E2;
cAMP, cyclic adenosine monophosphate. PIP2, phosphatidylinositol 4,5 bisphosphate.
 26 Pharmacodynamics and Signal Transduction

Benzodiazepine Closed Open

binding site chloride chloride
GABA channel channel
binding site
γ
β α
α β GABA binding

Figure 2-14. Ligand-gated channels regulate the flow of ions through plasma membrane channels. This example depicts the
g-aminobutyric acid (GABAA) receptor, which modulates Cl– conductance.

molecular biology have expanded a class of drugs, known as
biologics, that are themselves endogenous natural substances
such as growth factors, receptors, enzymes, cytokines, or pep-
tides. Biologics are often produced in living cells through re-
combinant DNA technologies. As examples, biologics are
produced to treat endocrine disorders, rheumatoid arthritis,
oral mucositis, and cancer complications (Table 2-3). These
and other biologics are discussed in more detail throughout
this book.
Recombinant enzyme biologics have also revolutionized the
treatment of lysosomal enzyme diseases, a group of congenital
defects in which enzyme deficiencies result in dysfunctional
metabolism of glycosphingolipids. These sugar-conjugated
lipids are major components of neuronal cells and contribute
to immunogenicity and autoimmunity. Recent Food and Drug
Administration (FDA)-approved examples of recombinant
enzymes to treat lysosomal enzyme diseases are listed in
Table 2-3. The term enzyme replacement therapy is often used
to define therapeutic approaches that use these recombinant
enzyme biologics. An alternate strategy known as substrate re-
duction therapy has also recently been approved for Gaucher
disease, in which an inhibitor (miglustat) of the rate-limiting
enzyme in glycosphingolipid metabolism, glucosylceramide
synthase is used to reduce total glycosphingolipid content.
The new biologics that have been approved by the FDA
offer the potential of more specific and selective cell targeting.
Recent examples include monoclonal antibodies that specifi-
cally target and neutralize growth factor receptors or bind
up their ligands (see Table 2-3). Another use of the monoclo-
nal antibody approach is to employ these biologics to achieve
more targeted delivery of conventional small-molecule ther-
apy. For example, gemtuzumab ozogamicin is a biologic in
which the antitumor substance calicheamicin is coupled to
an antibody that binds to CD33, a protein epitope preferen-
tially expressed on acute myeloid leukemic blast cell popu-
lations. Other targeted monoclonal approaches include
iodine-131 tositumomab or yttrium-90 ibritumomab tiuxetan,
in which radiotherapy is coupled to a CD20 antibody, whose

TABLE 2-3. Biologics (Examples of the Revolution)

Growth factors Sermorelin (a recombinant form of growth hormone–releasing factor used to treat dwarfism)
Mecasermin (a recombinant form of insulin-like growth factor [IGF] for children with IGF deficiency)
Palifermin (a recombinant form of human keratinocyte growth factor used to treat oral mucositis)
Filgrastim and sargramostim (recombinant forms of colony-stimulating factor used to treat cancer-
therapy–induced neutropenia)
Growth factor receptors Etanercept, a recombinant form of tumor necrosis factor receptor that binds up circulating tumor
necrosis factor, used for rheumatoid arthritis
Enzymes (lysosomal storage Agalsidase b (Fabry disease)
diseases) Alglucosidase alpha (Pompe disease)
Imiglucerase (Gaucher disease)
Idursulfase, laronidase, galsulfase (mucopolysaccharidosis)
Cytokines Denileukin diftitox (interleukin-2 coupled to diphtheria toxin)
Peptides Synthetic insulin used to treat diabetes
Antibodies Trastuzumab (Erb-B2 receptor)
Gefitinib (epidermal growth factor receptor)
Bevacizumab or ranibizumab (vascular endothelial growth factor)
Gemtuzumab ozogamicin (CD33)
131
I-tositumomab or 90yttrium ibritumomab tiuxetan (CD20)

receptor is preferentially expressed on B-cell non-Hodgkin
lymphoma cells. A similar approach is used by the biologic
denileukin diftitox, in which recombinant cytokine
interleukin-2 protein sequences are coupled to diphtheria
toxin to direct the toxin to cutaneous T-cell lymphomas.
The holy grail of the pharmacology revolution involves
molecular-based therapeutics that have the potential to target
gene products. As an example, aptamers, which are stabilized
RNA sequences that bind to proteins, have now been approved
as therapeutics. Pegaptanib is an aptamer-based therapeutic
that targets vascular endothelial growth factor and is used for
treatment of age-related macular degeneration. The upside of
molecular-based therapeutics is the potential to selectively
target mutated gene products. The downside of using
molecular-based therapeutics, such as aptamers or small inter-
fering RNAs, is systemic degradation by RNAases or Toll-like
receptor-mediated inflammatory side effects. Thus, a new
modality has been embraced to deliver and protect these labile
substances. The burgeoning field of nanomedicine uses nano-
scale (<100 nm) delivery systems (liposomes, colloids, dendri-
mers, polymers) to protect labile bioactive cargos, such as
RNAs. Several nanoscale products have now been approved
by the FDA, including a nanoliposome that encapsulates the
cancer-agent doxorubicin, as well as a nanoscale bioconju-
gate between albumin and the cancer agent docetaxel. Both
nano “solutions” improve the pharmacokinetic parameters
of the encapsulated drug. The future for design of small mol-
ecule inhibitors, biologics, and molecular-based therapeutics
can only get brighter as the “omic” revolution defines new
targets in diseased tissues. Functional genomic, proteomic,
transcriptomic, metabolomic, and lipidomic approaches offer
the potential to define a myriad of new dysfunctional cell
signaling cascades in disease.
Top five list 27
BIOCHEMISTRY
Gene Targeting
The future of pharmacology may well be to target signaling
elements at transcriptional or translational levels. Strategies
being investigated to selectively silence genes include:
n Antisense oligonucleotides
n siRNAs (small interfering RNAs)
n RNAzymes (enzymes that degrade RNA)
n DNAzymes (enzymes that degrade DNA)
These strategies are presently limited by the technology
needed to selectively and efficiently deliver these nucleic acids
to specific tissues without inducing toxicity.
lll TOP FIVE LIST
1. Drugs bind to targets; these targets can be receptors, ion
channels, transporters, signaling molecules, enzymes, or
specific nucleic acid sequences.
2. Interactions between drugs and targets can be agonistic or
antagonistic.
3. Pharmacodynamic terms used to define drug-target inter-
actions include affinity, potency, and efficacy.
4. Drugs with a narrow therapeutic window (therapeutic
index equals toxic dose [TD50] divided by effective dose
[ED50]) must be closely monitored by the practitioner.
5. The future will be defined by designer drugs applied to
individuals, tailored to a specific molecular or metabolic
pathology. This is the essence of personalized medicine.
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