NEUROMUSCULAR BLOCKING AGENTS & ANTI-

CHOLINESTERASES – REBECCA A LESLIE

WHAT IS THE NEUROMUSCULAR JUNCTION?

It is imperative you now this topic inside out, which is why we have included an overview in this section.
Ideally draw a diagram as you are describing the neuromuscular junction, remembering to label all the
important features.

1
The neuromuscular junction (NMJ) forms a connection between the motor neurone and a skeletal muscle fibre. The
neurotransmitter at this junction is acetylcholine.
The terminal axon of the fast A motor neurone lies in a groove situated in the middle of the surface of the single
muscle fibre that it is innervating. In most muscles a single terminal axon innervates a single muscle fibre. However,
in some muscles such as intra-ocular, intrinsic laryngeal and some facial muscle fibres innervation is by multiple
slower A motor fibres.
The post-synaptic membrane is folded to form peaks and troughs on its surface. The membrane over the peaks
contains acetylcholine receptors whilst within the troughs the enzyme acetylcholinesterase is present.
When an action potential arrives at the terminal axon the depolarization causes an influx of calcium ions. The
calcium ions combine with proteins present to facilitate the fusion of synaptic vesicles, containing acetylcholine,
with the pre-synaptic membrane.
Following the release of acetylcholine into the synaptic cleft it binds to the acetylcholine receptors present on the
peaks of the post-synaptic membrane.

2
 The central ion channel of the receptor opens allowing the movements of ions across the membrane. The movement
of these ions allows the generation of a miniature end-plate potential. The summation of several end-plate potentials
continues until the threshold potential is reached. At this point voltage-gated sodium channels open causing rapid
depolarization of the cell membrane. This depolarization spreads throughout the muscle fibre and eventually reaches
the sarcoplasmic reticulum causing calcium release and muscle contraction.

HOW IS ACETELYCHOLINE BROKEN DOWN?

3
Acetylcholine is broken down by the acetyl-cholinesterase present within the troughs of the post-synaptic
membrane. Acetyl-cholinesterase binds to either the ester group of the acetylcholine molecule or the quaternary
ammonium group. The choline is removed and recycled whilst the acetylated enzyme is hydrolysed to acetic acid.

4
HOW WOULD YOU CLASSIFY DRUGS WHICH PRODUCE NEUROMUSCULAR BLOCKADE?

When asked this question it is tempting to jump in and describe depolarizing and non-depolarizing muscle relaxants
but remember there are other ways to bock the neuromuscular junction, which become obvious if you know the
physiology of the neuromuscular junction.
The passage of neuronal transmission to skeletal muscle can be blocked in a number of ways that can be classified
according to their mechanism of action into these four groups:
 prevent acetylcholine synthesis - Hemicholinium
 Prevent acetylcholine release – Magnesium ions, aminoglycosides, botulinum toxin
 Deplete acetylcholine stores – tetanus toxin
 Block the acetylcholine receptor.

Acetylcholine is formed by the combination of choline and acetyl CoA in a reaction that is catalyzed by the enzyme
choline acetyl transferase.

5
 Acetylcholine is synthesized within the axoplasm of the motor neurone and is transported to the terminal axon
where it is stored in synaptic vesicles.

Choline is derived from the diet and is recycled from the breakdown of other acetylcholine molecules.
Hemicholinium is an example of a drug which prevents acetylcholine synthesis. It is a synthetic compound
which prevents the uptake of choline into the cholinergic nerve ending hence reducing acetylcholine synthesis.

Magnesium ions and aminoglycosides inhibit calcium entry into the synaptic terminal, and by doing so prevent
the release of acetylcholine. In contrast botulinum toxin binds irreversibly to the nicotinic nerve terminals to
prevent acetylcholine release.
The tetanus toxin is an example of a toxin which depletes acetylcholine stores rendering the muscle paralyzed.
Neuromuscular blocking drugs which block the acetylcholine receptor fall into two categories depending upon
their mode of action:
 Non-depolarizing
 Depolarizing

TELL ME ABOUT DEPOLARISING NEUROMUSCULAR BLOCKADE

This topic is covered in a lot more detail in the Suxamethonium section.
The only depolarizing drug in routine clinical use in the UK is suxamethonium (succinylcholine).
Suxamethonium in molecular structure is essential two acetylcholine molecules joined by an ester linkage. It is
used to produce rapid and profound muscle relaxation facilitating intubation of the trachea, to produce paralysis
for very short surgical procedures and to modify the effect of seizures following electro-convulsive therapy. It is
presented as a colourless solution of the chloride salt at a concentration of 50 mg/ml and should be stored at 4 o
C to prevent deterioration. Suxamethonium solutions are destroyed by an alkaline pH and therefore should not
be mixed with thiopentone.

6
The mechanism of action of suxamethonium is by reversibly binding to the acetylcholine receptor present on the
post-synaptic membrane, causing depolarization of the membrane. Due to the mechanism of breakdown of
suxamethonium the depolarization is prolonged and creates a membrane potential, which will not allow generation
of further action potentials and hence muscle relaxation.

Suxamethonium is broken down by plasma cholinesterase (butyrylcholinesterase), which is present within the
plasma but not the neuromuscular junction. The lack of plasma cholinesterase within the neuromuscular junction
explains the prolonged duration of action of suxamethonium at the acetylcholine receptor. The hydrolysis of
suxamethonium by plasma cholinesterase produces a weakly active metabolite, succinylmonocholine, and choline,
which is further hydrolysed by plasma cholinesterase to succinic acid and choline. Following administration of a
dose of suxamethonium only approximately 20 % of it reaches the neuromuscular junction. Due to the rapid
metabolism of suxamethonium only between 2 and 10% is excreted in the urine.

HOW DO NON-DEPOLARISING MUSCLE RELAXANTS WORK?

Non-depolarizing muscle relaxants are competitive antagonist at the neuromuscular junction. They bind to the -
subunit of the nicotinic receptor on the post-junctional membrane.

HOW WOULD YOU CLASSIFY NON-DEPOLARIZING MUSCLE RELAXANTS?

Non-depolarizing muscle relaxants can be classified as:
 Amino steroidal compounds
o Pancuronium

7
 o Vecuronium
o Rocuronium

 Benzyl quinoliniums
o Atracurium
o Mivacurium
o Tubocurarine

They can further be classified according to their duration of action. Mivacurium is very short-acting non-
depolarizing muscle relaxant, whilst atracurium and rocuronium are intermediate-acting and Pancuronium is a long-
acting muscle relaxant

HOW ARE THE NON-DEPOLARIZING NEUROMUSCULAR BLOCKERS METABOLISED?

Non-depolarizing muscle relaxants are metabolized in two different ways. Some, such as mivacurium and
atracurium are hydrolysed in the plasma, while others like rocuronium and vecuronium are metabolized to varying
degrees in the liver. The unmetabolized fraction of the drug is excreted in the urine or the bile.

TELL ME MORE ABOUT HOW ATRACURIUM IS METABOLISED

Atracurium is metabolized by two metabolic pathways:
 Ester hydrolysis
 Hoffmann elimination
At body pH and temperature atracurium undergoes spontaneous degradation into laudanosine and a quaternary
monoacrylate in a process called Hoffmann elimination. Both acidosis and hypothermia will slow down Hoffmann
elimination.
Ester hydrolysis accounts for up to 60 % of the metabolism of atracurium and occurs as a result of non-specific
esterases which are unrelated to plasma cholinesterases. Ester hydrolysis results in the production of laudanosine, a
quaternary alcohol and a quaternary acid. Unlike Hoffmann elimination, ester hydrolysis is accelerated in acidosis,
however in the clinical range of pH this is unlikely to make a dramatic difference.

IS LAUDANOSINE AN ACTIVE METABOLITE:

No, laudanosine has no neuromuscular blocking properties. It is a tertiary amine and has a half-life of between 2 – 3
hours. Concerns were made about the effects of laudanosine after it was found that at very high plasma
concentrations the EEG of anaesthetised dogs demonstrated epileptiform changes, however even after several days’
infusion of atracurium in humans the plasma concentration never reaches these levels.

WHAT ARE THE SIDE EFFECTS OF ATRACURIUM?

Atracurium has the propensity to cause histamine release. This can either be localized or systemic.
Systemic histamine release can affect both the cardiovascular and respiratory system, leading to hypotension and
bronchospasm.
Atracurium is also associated with critical illness myopathy.

WHAT IS CIS-ATRACURIUM?
Atracurium is a mixture of 10 stereoisomers because the atracurium molecule has 4 chiral molecules. The cis-
atracurium is one of the stereoisomers. It has a more favorable side-effects profile and its potential for histamine
release is extremely low.

HOW DOES THE DOSE OF CIS-ATRACURIUM COMPARE TO THE DOSE OF ATRACURIUM?

The cis-atracurium is 3 – 4 times more potent than atracurium. The intubating dose of cis-atracurium is only 0.2
mg/kg, whereas the intubating dose of atracurium is approximately 0.5 mg/kg. As a result, the speed of onset of cis-

8
atracurium is slower than atracurium. However, the onset time can be improved by giving a larger dose as the
potential to cause histamine release is very low.

WHAT IS THE INTUBATING DOSE OF ROCURONIUM?

The intubating dose of rocuronium is 0.6 mg/kg, and intubating conditions are reached within approximately 100 –
120 seconds. If a dose of 1 mg/kg is given then intubating conditions can be reached within 60 seconds.

WHAT ARE THE SIDE EFFECTS OF AMINOSTEROIDAL NEUROMUSCULAR BLOCKERS?

Remember to discuss drug side effects system by system, in this case the most important system are the central
nervous system, cardiovascular system and the respiratory system.
The aminosteroidal neuromuscular blocking agents have no effect on the central nervous system and do not increase
intra-cranial or intra-ocular pressure.
Vecuronium and rocuronium have very limited cardiovascular effects. In contrast, Pancuronium causes a
tachycardia due to vagolytic effects.
All the aminostereoidal agents cause respiratory paralysis, but unlike the benzylquinoliniums they do not cause
histamine-induced bronchospasm.

HOW DO ANTIBIOTICS MODIFY THE ACTION OF NON-DEPOLARISING NEUROMUSCULAR

BLOCKERS?
Aminoglycosides and tetracyclines prolong the muscle relaxation produced by non-depolarizing agents. This is
thought to be as a result of the antibiotics competing with calcium and thus prevent the release of acetylcholine.

WHICH OTHER DRUGS MODIFY THE ACTION OF NON-DEPOLARIZING NEUROMUSCULAR

BLOCKERS?
Drugs which prolong the neuromuscular blockade include:
 Volatile agents
 Lithium
 Local anaesthetics
 Calcium channels antagonists.
Volatile agents reduce the neurotransmitter release at the neuromuscular junction by depressing the somatic reflexes
in the central nervous system and as a result prolong the block. Calcium channels antagonists reduce the calcium
influx into the nerve terminal and hence reduce acetylcholine release whilst lithium blocks sodium channels. At low
doses local anaesthetics also block sodium channels and can prolong the neuromuscular blockade.

WHICH PHYSIOLOGICAL FACTORS INFLUENCE NEUROMUSCULAR BLOCKADE?

Hypothermia, hypermagnesaemia, hypokalaemia and acidosis all prolong the neuromuscular block.
Prolong neuromuscular block:
 Hypothermia
 Hypermagnesaemia
 Hypokalaemia
 Acidosis

Hypothermia reduces the metabolism of the muscle relaxants; magnesium reduces acetylcholine release by
competing with calcium and reduced levels of potassium makes the resting potential more negative.

WHAT ARE THE PROPERTIES OF AN IDEAL NEUROMUSCULAR BLOCKER?

It is important you have a good classification for answering questions about the ideal properties of a specific type of
drug. This will then lend itself to all the different drugs and make answering the question significantly easier. I think
the easiest classification is division into the:
 Physical properties

9
  Pharmacokinetic properties
 Pharmacodynamic properties.
The ideal properties of a muscle relaxant can be divided into the physical properties, the pharmacokinetic properties
and the pharmacodynamic properties.
The physical properties of an ideal neuromuscular blocking agent are that it is:
 Cheap
 Water soluble
 Long shelf life with no specific storage requirements.
The pharmacokinetic properties of an ideal muscle relaxants are that it has:
 Short duration of action with a predictable reversal that it is non-cumulative so can be given as an infusion
when necessary.
 It is completely metabolized into non-active metabolites and
 Its metabolism is not affected by hepatic or renal failure.

The pharmacodynamic properties of an ideal neuromuscular blocking agent include a:

 Rapid onset of action.
 High potency
 No cardiovascular or reparatory side effects.
 It must be safe to use in children and during pregnancy.
 Have a non-depolarizing mechanism of action.

SUXAMETHONIUM – CAROLINE SG JANES

Suxamethonium is a very common structured oral examination (OSCE) topic and examiners will expect good
knowledge of this drug and will be very unforgiving if you cannot provide it. We recommend you study the podcast
on the neuromuscular junction and neuromuscular monitoring prior to this podcast.

WHAT CLASS OF DRUG IS SUXAMETHONIUM?

A depolarizing neuromuscular blocker.

10
 WHAT IS THE STRUCTURE OF SUXAMETHONIUM?
Suxamethonium is made up of two molecules of acetylcholine (Ach) joined by an acetyl group bond, as shown
above. Each Ach molecule contains an ester bond.

TELL ME ABOUT THE PRESENTATION AND USES OF SUXAMETHONIUM

It is an odourless, colourless solution that should be stored at 4 o c. In the UK it is available as a chloride in 2-ml
ampoules of 50 mg/ml, the dosage is 1 – 2 mg/kg intravenously. It is used predominantly in rapid sequence
induction and for short surgical procedures.

WHAT IS THE MECHANISM OF ACTION AND KINETICS OF SUXAMETHONIUM?

Suxamethonium acts the nicotinic Ach receptor present on the post-synaptic membrane of the neuromuscular
junction. It causes depolarization and subsequent prevention of transmission of further action potentials.
It has a short duration of action of 3 – 5 minutes and is hydrolysed by plasma cholinesterase to succinic acid and
choline. Only 10% is excreted in the urine.

WHAT ARE THE CHARACTERISTICS OF A PARTIAL DEPOLARISING BLOCK?

11
 A depolarizing block is also described as a phase 1 block. It is characterized by equal but reduced twitch height
with train of four count and with single pulse stimulation, and it causes a sustained but reduced tetanic
contraction with no fade or post-tetanic potentiation.

Following administration of large doses of suxamethonium a phase II block may occur whereby features of non-
depolarizing blockade gradually replace that of depolarizing blockade. The mechanism of phase II block is
uncertain but may involve pre or post-junctional receptor modulation.

PLEASE LIST THE SIDE EFFECTS OF SUXAMETHONIUM

Remember the magic number ‘8’ and make sure you start with the commonest side effects first, don’t jump in
with malignant hyperthermia or the examiner may stop you and take you down a path you would rather avoid.
1. Myalgia - this is most common in young females.
2. Cardiac arrhythmias – the main arrhythmia is a bradycardia, which is usually sinus or nodal, but can
also be ventricular in origin; bradycardia occurs most commonly in paediatrics and with a second dose.
3. Hyperkalaemia – in normal individuals a transient increase of 0.5 mmol/l occurs which rapidly
resolves, this however may be enough to cause cardiac arrest in patients with high levels to start with
and those in renal failure.

12
 4. Increased intra-ocular pressure; this can increase by approximately 10 – 15 mmHg but only transiently.
Suxamethonium should therefore be used cautiously in open eye injuries. Concurrent administration of
thiopentone offsets this rise.
5. Intra-gastric pressure – this rises by approximately 10 cmH 2O but is offset by an increase in the lower
oesophageal sphincter tone.
6. Anaphylaxis.
7. Suxamethonium apnoea.
8. Malignant hyperpyrexia (MH).

WHAT ARE THE CONTRA-INDICATIONS OF SUXAMETHONIUM?

If you know the side effects of suxamethonium you can more or less work out the contra-indications.
It is contraindicated in patients with:
 Raised potassium levels
 Severe muscle trauma
 History of malignant hyperthermia or suxamethonium apnoea.
 Spinal cord trauma or Burns > 10 % (avoid from  24 hours – 18 months) after the injury.
 Its use should also be avoided in patient with muscle disease if at all possible.

WHAT IS MALIGNANT HYPERTHERMIA OR MH?

This is an open question which might tempt you to tell the examiner everything you know about MH, try to
resist listing lots of random facts and keep to the basics – if the examiners want more details he/she can ask you
for it.

MH is a life-threatening, autosomal dominant condition that occurs only in susceptible individual and is
triggered by volatile anaesthetics or suxamethonium. It results from uncontrolled skeletal muscle metabolism. It
is important to be able to recognize and treat it promptly as if left untreated it can quickly progress to circulatory
collapse and death.

WHAT ARE THE FEATURES OF MH?

The classic features of MH are:
 Masseter spasm + muscle rigidity
 Raising temperature of more than 2 o C per hour and
 Raising end-tidal CO2.
However, the first symptom of MH may just be unexplained tachycardia so it is important to have a high index
of suspicion. As oxygen demand outstrips supply the oxygen saturation will start to fall.
Blood results typically show
 Elevated levels of serum
o Calcium
o Potassium
o Creatine kinase
o Myoglobin
 Metabolic acidosis (as the disease progresses)
 Renal failure (finally)

HOW IS MH MANAGED?
o The triggering agent should be withdrawn immediately.
o Dantrolene is the only definitive treatment and should be given as soon as possible.
o Supportive treatment should include:
o Correction of acidosis
o Aggressive cooling
o Respiratory support with 100 % oxygen and hyperventilation
o Inotropic support.

13
 o Correct hyperkalaemia.
o Treat acute renal failure and DIC as necessary.
o Patient should be transferred to the intensive care unit and treated until there is complete resolution of
symptoms.
o Anaesthesia should be maintained throughout.

WHAT IS DANTROLEINE AND HOW DOES IT WORK

Dantrolene is a muscle relaxant that works by uncoupling the excitation-contraction process preventing calcium
release from the sarcoplasmic reticulum in skeletal muscle. The dose in MH is 2 – 3 mg/kg repeated as necessary up
to a maximum dose of 10 mg/kg. it is available as an orange powder in 20 -mg vials containing mannitol and sodium
hydroxide. Reconstitution requires 60 ml of water per via and is very laborious due to its insolubilities. Since its
introduction the mortality of MH has reduced from 90 % to 10 %.

14
The Dihydropyridine (DHP) receptor, normally a voltage-dependent calcium channel, functions in skeletal muscle
essentially as a voltage sensor, triggering intracellular calcium release for excitation-contraction coupling.

WHAT IS THE PATHOPHYSIOLOGY OF MH?

MH is caused by a mutation in the gene coding for the ryanodine receptor found on chromosome 19. The ryanodine
receptor is located on the sarcoplasmic reticulum and plays a crucial role in calcium control.

15
WHAT TESTS ARE AVAILABLE TO CONFIRM MH?
The caffeine-halothane contracture test is the standard in diagnosing MH. A biopsied piece of muscle is subjected to
22 % halothane and caffeine and tension in the muscle is measured - contracture occurs in susceptible muscle.
Patients are labelled:
 Susceptible
 Non-susceptible
 Equivocal
Tests should be carried out in all suspected cases and immediate relatives.

WHAT IS SUXAMETHONIUM APNOEA?

Suxamethonium apnoea occurs in genetically susceptible patients who have a decreased plasma
pseudocholinesterase activity. In these individual suxamethonium is not broken down and causes prolonged
neuromuscular blockade and hence paralysis and apnoea. It can result from genetic variability or acquired
conditions. Acquired deficiency results from:
 Liver or cardiac failure.
 Renal disease
 Pregnancy
 Thyrotoxicosis
 Malnutrition
 Burns
 Following:
o Plasmapheresis
o Cholinesterases inhibitors.

TELL ME MORE ABOUT GENETIC CAUSES OF SUXAMETHONIUM APNOEA?

Suxamethonium apnoea is caused by single amino substitutions in the genes coding for pseudocholinesterase
activity, these are located on the E1 locus of chromosome 3. several autosomal recessive alleles have been identified
and the degree of enzymatic inhibition by dibucaine and fluoride has been used to describe the genetic variations.
There are 4 alleles described:

16
 Usual [Eu] - also known as normal (96 %) – full enzyme activity.
Atypical [Ea] - also known as dibucaine-resistant
Fluoride resistant [Ef]
Silent [Es] (0.001 %) – no enzyme function.

96% of the population are homozygous for the normal gene with full enzyme function and 0.001 % are homozygote
for the silent gene with no enzyme function.
Dibucaine and fluoride numbers denote the percentage of inhibition – the higher the number the better the enzyme
function.

An individual can be homozygous for any of these alleles or the alleles can exist in any heterozygous combination
with each other. In homozygotes for the silent and atypical gene paralysis can last up to 4 hours, in homozygotes for
fluoride-resistant gene paralysis can last up to 2 hours.
Ea 4 hours
Es 4 hours
Ef 2 hours
Heterozygotes with abnormal genes make up approximately 4 % of the population and exhibit mildly prolonged
paralysis of up to 10 minutes.

HOW WOULD YOU MANAGE A PATIENT THAT MAY HAVE A PROLONGED BLOCK FOLLOWING
SUXAMETHONIUM ADMINISTRATION?
Anaesthesia and ventilatory support should be continued until the block wears off. This is usually done in the
Intensive Care Unit. Alternatively, fresh frozen plasma can be given as it contains plasma cholinesterase.

ANTI-CHOLINESTERASES – REBECCA A LESLIE

WHAT TYPES OF ACETYLCHOLINE RECEPTORS ARE THERE?

There are two types of acetylcholine receptors:
 Nicotinic
 Muscarinic

Muscarinic receptors are G-protein coupled receptors that act via secondary messengers, whereas nicotinic
receptors are ligand-gated ion channels.
DESCRIBE THE STRUCTURE OF THE NICOTINIC RECEPTOR
Your answer here should start with a diagram showing the structure of the nicotinic receptor. As you draw it
give details of the different components as they are described here.

17
Nicotinic receptors are membrane proteins that are made up of five subunits. There are:
 2
 1
 1
 1
The acetylcholine binding sites are on the two -subunits of the receptor. When one acetylcholine binds to the -
subunit it increases the affinity for acetylcholine at the other -subunit. As acetylcholine binds to these binding sites
they cause a conformational change that causes a central channel in the receptor to open. The channel then allows
the passage of sodium ions and other cations through the cell membrane, which causes depolarization and generates
an action potential.

18
HOW IS ACETYLCHOLINE FORMED?
Acetylcholine is an acetyl ester of choline. It is synthesized in the cytoplasm of nerve endings from acetyl-coenzyme
A (CoA) and choline. The reaction is catalyzed by the enzyme choline acetyl transferase.

Acetyl CoA is synthesized from pyruvate in the mitochondria of the axon terminal whilst choline is derived
from the breakdown of acetylcholine and from the diet.

WHAT HAPPENS TO ACETYLCHOLINE AFTER ITS SYNTHESIS?

19
 An active transport system moves acetylcholine into the synaptic vesicles, where it is stored until is released in
response to an action potential. Each vesicle contains 10,000 acetylcholine molecules, and approximately 200
vesicles are released after every action potential. Once the acetylcholine is released it enters into the synapse
and binds to the post-synaptic acetylcholine receptors in order to propagate the action potential. After binding to
the post synaptic receptors, the acetylcholine molecules is hydrolysed by acetylcholinesterase to form choline
and acetate.

TELL ME ABOUT THE ACETYLCHOLINESTERASE ENZYME. WHAT ARE THE BINDING SITES
CALLED?
Acetylcholinesterase is the enzyme that breaks down acetylcholine. It has an esteratic and an anionic binding site.
The anionic site binds with the positively charged quaternary ammonium end, and the esteratic site binds to the
acetate end.

TELL ME ABOUT ACETYLCHOLINESTRASE INHIBITORS. WHAT USES DO THEY HAVE IN

CLINICAL PRACTICE?
Acetylcholinesterase inhibitors are also known as anti-cholinesterases. They antagonize the acetylcholinesterase
enzyme at the neuromuscular junction, inhibiting the breakdown of acetylcholine. This increase in synaptic
acetylcholine allows displacement of the neuromuscular blocking agents from the nicotinic receptor, and thus
restores the transmission across the NMJ. Therefore, one important use of acetylcholinesterase inhibitors is for the
reversal of neuromuscular blockade during anaesthesia.
Acetylcholinesterase inhibitors are also useful in clinical practice in situations where there is not enough
acetylcholine, such as myasthenia gravis. By giving an acetylcholinesterase inhibitor and preventing the breakdown
of acetylcholine you can increase the action of the limited acetylcholine that is available.

20
WHAT ARE SOME DISADVANTAGES OF ACETYLCHOLINESTERASE INHIBITORS?
The effects of acetylcholinesterase inhibitors are not specific to the neuromuscular junction so the effects of
increased acetylcholine concentration are also seen at muscarinic receptors. This causes:
 Bradycardia
 Arrhythmia
 Bronchospasm
 Nausea
 Vomiting
 Increased gut motility
 Salivation.

To prevent these side effects, it is common to give an anti-cholinergic drug at the same time as giving an
acetylcholinesterase inhibitor.

CAN YOU CLASSIFY THE 3 DIFFERENT TYPES OF ACETYLCHOLINESTERASE INHIBITORS?

Acetylcholinesterase inhibitors can be classified according to their mechanism of action:
o Competitive antagonism
o Formation of a carbamylated enzyme complex
o Irreversible inactivation of acetylcholinesterase.
Competitive antagonism.
The only drug in this group is edrophonium, which is used to perform a diagnostic test for myasthenia gravis. It
rapidly and transiently improves muscle power.

Formation of a carbamylated enzyme complex.

Examples include neostigmine and pyridostigmine. These work by forming a carbamylated complex with
acetylcholinesterase.

Irreversible inactivation of acetylcholinesterase.

Examples include organophosphates, which due to their mechanism of action have no role in clinical practice but are
used as insecticides and chemical weapons.

The first two groups are structurally similar and are both quaternary ammonium compounds.

HOW DOES NEOSTIGMINE ACT TO REVERESE NEUROMUSCULAR BLOCKS?

Neostigmine is an acetylcholinesterase inhibitor. It is used to increase acetylcholine concentrations at the NMJ by
preventing its breakdown by acetylcholinesterase.

21
Hydrolysis of acetylcholine by acetylcholinesterase. B. Interaction of neostigmine with acetylcholinesterase.

Neostigmine is a quaternary amine and is structurally similar to acetylcholine. It can therefore bind to
acetylcholinesterase. The cationic part of neostigmine binds to the anionic site, and the terminal carbon atom binds
to the esteratic site. The phenol group, which is the middle of the neostigmine molecule, breaks away leaving both
binding sites of the acetylcholinesterase enzyme occupied by fragments.
This impairs the ability of acetylcholinesterase to metabolize acetylcholine, allowing acetylcholine to accumulate
and displace the non-depolarizing muscle relaxants, which has competitively bound to the acetylcholine receptor. In
doing so, neuromuscular transmission is restored and paralysis is reversed.

HOW DO ORGANOPHOSPHATES WORK AND HOW CAN YOU TREAT ORGANOPHOSPHATE

POISONING?

22
Organophosphorus compounds are extremely toxic and are used in insecticides and nerve gases.
Organophosphates phosphorylate the esteratic site of the acetylcholinesterase enzyme. This inhibits the actions of
the enzyme. The enzyme complex is very stable unlike the carbamylated complex formed when neostigmine
attaches to the acetylcholinesterase. This makes it resistant to hydrolysis.
Toxic effects include:
 Muscle weakness
 Polyneuropathy
 Respiratory failure
 Cholinergic crisis (muscarinic and nicotinic effects)
In practice, treatment of organophosphate poisoning relies upon the production of new cholinesterase enzyme.
Supportive treatment is required in the interim and may include ventilation. Atropine can be given to counteract the
muscarinic effects, and pralidoxime is a specific drug that promotes hydrolysis of phosphorylated enzyme complex.

WHAT DO YOU KNOW ABOUT SUGAMMADEX?

Sugammadex is a selective relaxant binding agent (SRBA) which is used for the reversal of neuromuscular blockade
by aminosteroidal agents. It is a modified -cyclodextrin.
Cyclodextrins are oligosaccharides that have a tube-like structure. The tube has a lipophilic core and a water-soluble
hydrophilic exterior.

23
They -cyclodextrin has been modified from its natural form with the addition of 8 glucopyranose units. These
extensions increase the cavity size allowing greater encapsulation of rocuronium within the cavity.
When Sugammadex is administered it rapidly encapsulates rocuronium molecules within its lipophilic core
rendering it unavailable to bind to the acetylcholine receptors at the NMJ. The kidneys rapidly excrete the
rocuronium-Sugammadex complex.

24
Rocuronium Sugammadex complex as obtained by X-ray

25
 WHAT ARE THE ADVANTAGES OF SUGAMMADEX?
The main advantage of Sugammadex is the reversal of neuromuscular blockade without having to rely on
the inhibition of acetylcholinesterase. As a result, its administration does not risk causing bradycardia,
increased secretions, increased gastrointestinal motility and bronchospasm, which can occur if
neostigmine’s action are unopposed at muscarinic receptors.
Secondly, Sugammadex can be administered individually and an anti-muscarinic agent such as
glycopyrrolate does not have to be co-administered. This reduces the risk of drug errors that can occur
when administering two drugs simultaneously.
In addition, when fast onset and short duration of muscle relaxation is required, there is now an alternative
option to the use of suxamethonium, which has a number of undesirable effects. When given at high doses
rocuronium has a rapid onset of action and with Sugammadex available it can be rapidly reversed,
therefore, could be used as a potential alternative to suxamethonium.

CAN SUGAMMADEX BE USED WITH OTHER NEUROMUCULAR BLOCKING AGENTS

OTHER THAN ROCURONIUM?
Sugammadex also has affinity for other aminosteroidal neuromuscular blocking agents such as vecuronium,
however, its affinity is lower than its affinity for rocuronium. Vecuronium is more potent than rocuronium,
therefore fewer molecules are present at the neuromuscular junction for an equivalent blockade.
Sugammadex encapsulates at a ratio of 1:1 and will reverse vecuronium despite the reduced affinity
because there are fewer molecules to bind compared to rocuronium.

WHAT ARE THE DISADVANTAGES OF SUGAMMADEX?

Sugammadex is currently very expensive and is not recommended in patients with severe renal impairment
(GFR < 30 ml/min). In addition, some commonly used drugs such as flucloxacillin and Fusidic acid may
displace rocuronium or vecuronium from the Sugammadex molecule and reoccurrence of the blockade may
occur.
Another disadvantage is that it may decrease progesterone levels in women taking the oral contraceptive
pill, so women should act as though one pill has been missed after Sugammadex administration.
Dysgeusia, a metal taste in the mouth, was the most commonly reported adverse event during the clinical
trials.

WHAT IS THE DOSE OF SUGAMMADEX?

Neuromuscular monitoring is recommended for dose calculation prior to Sugammadex administration. If
there are two twitches during a train of four the dose of Sugammadex is 2 mg/kg.
If the neuromuscular blockade is more profound and there are only two twitches after a post-tetanic count,
then 4 mg/kg is required.
If immediate reversal is required the dose of Sugammadex is 16 mg/kg.

Sugammadex is supplied as 2-ml (200-mg) or 5-ml (500 mg) vials. It must be remembered that if a rapid
reversal is required then multiple vials will need to be used. For example in an 80-kg man requiring rapid
reversal a dose of 1,280 mg (16 mg/kg) is needed which equals to approximately 21/2 5-ml vials.

26