Pharmacodynamics
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Transcript of Pharmacodynamics
Pharmacodynamics
Pharmacodynamics
Pharmacodynamics – deals with the action of a drug on the body; what the drug does to the body;
Mechanisms of Drug Action on the bory:Receptor interactionsDose-related phenomenaTherapeutic actionToxic effects
Definitions Agonist – drug that triggers the same events
as the native ligand when it binds to a receptorAntagonist – drug that prevents binding of the
native ligand to the receptor so that it cannot produce its normal action
Affinity – ability of a drug to bind to a receptor (how well a drug & a receptor recognize each other)
Potency – quantity of a drug needed to achieve a desired effect; more potent, lower EC50
Quality – bioavailability of the drugEfficacy – maximal effect an Agonist can
achieve at the highest practical concentration ( a measure of how well a drug produces a response); high Emax
Definitions
2nd messenger – small nonprotein water-soluble molecule or ion that readily spreads a ‘signal’ throughout the cell by diffusion (e.g. cyclic AMP; Calcium ions)
Signal transduction – process by which extracellular inputs (e.g. drug-receptor interactions) lead to intracellular messages that moderate cell physiology sequencing
Mechanisms of Signal Transduction
1 – Drug crosses the cell membrane, activates an intracellular receptor e.g. steroid hormones
2 – transmembrane receptor protein with intracellular enzyme activity is affected by a drug binding to a site on the enzyme that can alter its activity e.g. Ouabain
3 – A drug-transmembrane receptor protein complex binds & stimulates a 2nd protein such as Tyrosine kinase
4 – A drug binding to a transmembrane ion channel changes ion conductance, affecting membrane potentials e.g. nicotinic ACh receptor stimulation
5 – An agonist drug binds to a transmembrane receptor, stimulating a G protein, leading to increased intracellular 2nd messengers that result in many 2ºintracellular responses e.g. adrenergic stimulation
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G protein Signal transduction
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Benefits of a Signal Transduction Pathway
Signal amplification Increased cellular processesProteins persist in active form long enough to process
numerous molecules of substrateEach step activates more products than the preceding
stepSignal specificity
Specific cellular components (& therefore specific cellular processes) are affected
Drug Binding Covalent bonds – sharing of a pair of
electrons between 2 atoms; very stable, very strong- requires hundreds of kilojoules to disrupt
nonCovalent bonds – generally weak – Hydrogen bondsVan der Waals forces Ionic / Electrostatic interactionsHydrophobic interactions
Effects of Binding:Conformation – binding locks a mobile flexible molecule into a
restricted conformationConfiguration / Stereochemistry – change may alter biologic effects
Targets for Drug Action
“A drug will exert its activity through interactions at one or more molecular targets – macromolecular species that control the function of cells: surface-bound receptors & ion channels or internal structures like enzymes & nucleic acids”
Targets for Drug action: Processes of Drug Action:
Receptors *chemicalIon channels *enzymaticEnzymes *thru receptorsCarriers * thru ion channels
*thru 2nd messengers
Receptor targets for Drug Action
receptor agonist antagonist
Nicotinic Ach receptor
Acetylcholine; Nicotine
Tubocurarine
β blocker Noradrenalin Propranolol
Opiate Morphine Naloxone
5 HT2 receptor
5 HT Ketanserin
Dopamine2 receptor
Dopamine Chlorpromazine
Ion channel targets for Drug Action
Ion channel Effectors: blockers
Modulators
Voltage-gated Na channel
Local anaesthetics
Veratridine
Renal tubular Na channel
Amiloride Aldosterone
Voltage-gated Ca channel
Divalent cations
Dihydropyridines
GABA-gated Cl channel
Picrotoxin Benzodiazepines
ATP-sensitive K channel
ATP Sulfonylureas
Glutamate-gated channel
Dizoclipine, Ketamine
Glycine
Enzyme targets for Drug Action
Enzyme Effectors: inhibitors
False substrates
Acetylcholinesterase (AChE)
Neostigmine; Organophosphates
cycloOxygenase Aspirin
Angiotensin-converting enzyme (ACE)
Captopril
Xanthine oxidase Allopurinol
Choline acetyl transferase
hemicholinium
Reverse transcriptase
Didanosine
Carrier targets for Drug Action
Carrier Inhibitors False substrates
Choline carrier Hemicholinium
Noradrenalin uptake
TCA; Cocaine Amphetamine; Methyldopa
Noradrenalin uptake (vesicular)
Reserpin
Weak acid carrier
Probenecid
Na-K pump Cardiac glycoside
Proton pump in gastric mucosa
Omeprazole
Drug ReceptorsDrug receptor – macromolecular component
of a cell with which a drug interacts to produce a response; usually a protein, a drug interacts with it in a “lock-&-key” fashion, initiating a chain of events that leads to a pharmacologic response.
Types of Receptors:Type I : Ionotropic /Ligand-gated ion
channelsType II : Metabotropic / coupled to G-proteinType III: Tyrosine Kinase-linked (e.g. Insulin
receptor)Type IV: Steroid receptors (e.g. Thyroxine;
Cortisol)
Protein Receptors
Receptors for endogenous regulatory ligands – hormones, growth factors, neurotransmitters;
Enzymes of crucial metabolic or regulatory pathways – Acetylcholinesterase,
Enzymes in transport processes – Na/K pump;
Structural proteins – Tubulin;
Drug – Receptor InteractionsThe binding of a drug to a specific receptor
causes some event which leads to a responseResponse to a drug is graded or dose-
dependentDrug-Receptor interactions follow simple
mass-action relationships: Only one drug molecule occupies each receptor siteBinding is reversible
For a given drug, the magnitude of response is directly proportional to the number of receptor sites occupied by drug molecules
The number of drug molecules is assumed to be much greater than the number of receptor sites
Drug – Receptor Interactions
Receptor – specific macromolecule ( Proteins – 90% - membrane, cytoplasmic or extracellular enzyme, nucleic acid; Lipids; Carbohydrates) which is the site of action of most drugs: Only around 10% of drug actions & effects are NOT mediated thru receptors.
For most drugs, the magnitude of the pharmacological response increases as the dose (drug concentration) increases
Only one drug molecule occupies each receptor site, & binding is reversible
The Dissociation Constant
The Dissociation Constant – KD – drug concentration at which half maximal binding occurs: the smaller the KD, the greater the affinity of the drug to the receptor; the smaller the KD for a reaction, the lower the concentration of drug required in order to produce half maximal binding
Log dose – Response curvecharacteristics:Maximal effect (plateau)Potency – the location of the drug response
curve along the horizontal axis: drug effect with respect to dose (vs. Efficacy – maximal ceiling effect)
Slope Standing curve – minute changes in dose result in large effects Inclining curve – large changes in dose needed for an effect
Variability – the curve is different from drug to drug, from patient to patient, & from time to time in the same patient. So if you want to fix the pharmacologic response at a certain level, you have to use a Range of Dose
Log dose – Response Curve
Log dose
slope
potency
variability
Maximal effect
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of
effe
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Dose – Response Relationship
No drug can create a new effect: a drug only modulates a pre-existing function
Drug-receptor interaction leads to enhancement, inhibition, or blockade of molecular signals, which is then amplified thru biochemical & physiologic events to produce the pharmacological (clinical) effect
The magnitude of a response is graded, i.e. increases continuously as the concentration of unbound drug increases at the receptor site
Definitions GRADED-RESPONSE CURVE: A plot of
efficacy (some measured value, such as blood pressure) -vs- drug concentration. EC50 = drug concentration at which 50% efficacy is attained. The
lower the EC50, the more potent the drug. Emax = the maximum attained biological response out of the
drug. QUANTAL DOSE-RESPONSE CURVE: A
graph of discrete (yes-or-no) values, plotting the number of subjects attaining the condition (such as death, or cure from disease) -vs- drug concentration. ED50: dosage at which 50% of the population attains the desired
effect LD50: dose at which 50% of the population is killed from a drug.
Agonists & AntagonistsAgonists – drugs that interact with &
activate receptorsFull agonists – maximal efficacy (Emax)Partial agonists – less than maximal efficacy - At low
concentrations, it increases the overall biological response from the receptor. At high concentrations, as all receptors are occupied, it acts as a competitive inhibitor and decreases the overall biological response from the receptor.
Antagonists – drugs that prevent the agonists from having an effect by binding to the receptor or to part of the effector mechanism; have no effect themselves
AGONIST ANTAGONIST
Agonist has affinity plus intrinsic activity
Antagonist has affinity but NO intrinsic activity
Partial agonist has affinity & (less) intrinsic activity
Competitive antagonists may be overcome (surmountable)
Agonists tend to desensitize receptors
Antagonists tend to up-regulate receptors
InhibitionCOMPETITIVE INHIBITORS: They bind to
the same site as the endogenous molecule, preventing the endogenous molecule from binding. The Dose-Response Curve SHIFTS TO THE RIGHT in the
presence of a competitive inhibitor. EC50 is increased: more of a drug would be required to achieve same effect. Emax does not change: maximum efficacy is the same, as long as you have enough of the endogenous molecules around.
The effect of a competitive inhibitor is REVERSIBLE and can be overcome by a higher dose of the endogenous substance.
The intrinsic activity of a competitive inhibitor is 0. It has no activity in itself, but only prevents the endogenous substance from having activity.
InhibitionNON-COMPETITIVE INHIBITORS: They
either (1) bind to a different (allosteric) site, or (2) they bind irreversibly to the primary site. The Dose Response Curve SHIFTS DOWN in the presence of a
non-competitive inhibitor. EC50 is increased: more of a drug would be required for same effect. Emax decreases: The non-competitive inhibitor permanently occupies some of the receptors. The maximal attainable response is therefore less.
The intrinsic activity of the non-competitive inhibitor is actually a negative number, as the number of functional receptors, and therefore the maximum attainable biological response, is decreased.
Properties of a DrugSafety:
Therapeutic Index (TI) = LD50 / ED50 The ratio of median lethal dose to median effective dose. The higher the therapeutic index, the better. That means that a
higher dose is required for lethality, compared to the dose required to be effective.
minimum dose that produces toxicity over the minimum dose that produces an effective therapeutic response; TI < 4 =relatively greater potential for toxicity
Margin of Safety = LD1 / ED99 The ratio of the dosage required to kill 1% of population,
compared to the dosage that is effective in 99% of population. The higher the margin of safety, the better. greater difference
between therapeutic effective dose (ED) & toxic dose (TD)
Drug interactionsSynergism/Potentiation – concomitant
administration of another drug will increase the clinical effect e.g. multi-regimen TB treatment
Addition – effects of two drugs administered at the same time will be added to each other e.g. DOLCET
Inhibition – simultaneous administration of another drug will decrease the effects of the first e.g. Warfarin & vitamin K
Pharmacokinetic interaction – giving of another drug will affect the first’s absorption, distribution, metabolism, &/or excretion
Adverse Effects & Drug Interactions
Side effect - part of the pharmacologic action of the drug but not the effect the drug is being used for; may be undesirable (adverse) e.g. gastric irritation from NSAIDS
Hypersensitivity reactions / Drug Allergy: An exaggerated, immune-mediated response to a drug. TYPE-I: Immediate IgE-mediated anaphylaxis. e.g.Penicillin
anaphylaxis.
Immunologic ReactionsTYPE-II: Antibody-Dependent Cellular Cytotoxicity (ADCC). IgG or
IgM mediated attack against a specific cell type, usually blood cells (e.g.Hemolytic anemia: induced by Penicillin or Methyldopa; Thrombocytopenia: induced by Quinidine; Drug-induced SLE caused by Hydralazine or Procainamide.
TYPE-III: Immune-complex drug reaction Serum Sickness: Urticaria, arthralgia, lymphadenopathy, fever. Steven-Johnson Syndrome: Form of immune vasculitis induced by sulfonamides. May be fatal. Symptoms: Erythema multiforme, arthritis, nephritis, CNS abnormalities, myocarditis.
TYPE-IV: Contact dermatitis caused by topically-applied drugs or by poison ivy.
Drug Toxicity
Drug Toxicity: dose-dependent adverse response to a drug. Organ-Directed Toxicity: Aspirin induced GI toxicity (due to
prostaglandin blockade); Epinephrine induced arrhythmias (due to beta-agonist); Propanolol induced heart-block (due to beta-antagonist); Aminoglycoside-induced renal toxicity; Chloramphenicol-induced aplastic anemia.
Neonatal Toxicity: Drugs that are toxic to the fetus or newborn. Sulfonamide-induced kernicterus;Chloramphenicol-induced Grey-Baby Syndrome; Tetracycline-induced teeth discoloration and retardation of bone growth.
Teratogens
TERATOGENS: Drugs that adversely affect the development of the fetus: especially dangerous during organogenesis (3rd to 8th week)
• Thalidomide: • Antifolates such as Methotrexate. • Phenytoin: Malformation of fingers, cleft palate. • Warfarin: Hypoplastic nasal structures. • Diethylstilbestrol: Oral contraceptive is no longer used
because it causes reproductive cancers in daughters born to mothers taking the drug.
• Aminoglycosides, Chloroquine: Deafness
Idiosyncrasy
Drug Idiosyncrasies: An unusual response to a drug due to genetic polymorphisms, or for unexplained reasons. Isoniazid: N-Acetylation affects the metabolism of isoniazid
• Slow N-Acetylation: Isoniazid is more likely to cause peripheral neuritis. • Fast N-Acetylation: Some evidence says that Isoniazid is more likely to
cause hepatotoxicity in this group. However, other evidence says that age (above 35 yrs old) is the most important determinant of hepatotoxicity.
Alcohol can lead to facial flushing, or Tolbutamide can lead to cardiotoxicity, in people with an oxidation polymorphism.
Drug IdiosyncrasiesSuccinylcholine can produce apnea in people with abnormal serum
cholinesterase. Their cholinesterase is incapable of degrading the succinylcholine, thus it builds up and depolarization blockade results.
Primaquine, Sulfonamides induce acute hemolytic anemia in patients with Glucose-6-Phosphate Dehydrogenase deficiency.
• They have an inability to regenerate NADPH in RBC's ------> all reductive processes that require NADPH are impaired.
• Note that this is Acute Hemolytic Anemia, yet it is not classified as an allergic reaction -- it is an idiosyncrasy when caused by sulfonamides or primaquine. Other anemias are Type-II hypersensitivity reactions.
• G6PD deficiency is most prevalent in blacks and Semites. It is rare in Caucasians and Asians.
Barbiturates induce porphyria (urine turns dark red on standing) in people with abnormal heme biosynthesis.
• Psychosis, peripheral neuritis, and abdominal pain may be found.
Tolerance Pharmacokinetic Tolerance: Increase in the
enzymes responsible for metabolizing the drug. e.g. Warfarin doses must be increased in patients taking barbiturates or phenytoin, because these drugs induce the enzymes responsible for metabolizing warfarin.
Pharmacodynamic Tolerance: Cellular tolerance, due to down-regulation of receptors, or down-regulation of the intracellular response to a drug.
Physiologic Tolerance: Two agents yield opposite physiologic effects.
Tolerance
Competitive Tolerance: Occurs when an agonist is administered with an antagonist. Example: Naloxone and Morphine are chemical antagonists, and one induces tolerance to the other.
Tachyphylaxis (Refractoriness / Desensitization) – progressive reduction in drug effect due to receptor desensitization Homologous – decrease in number of receptorsHeterologous – decreased signal transduction e.g. Tyramine can cause depletion of all NE stores if you use it long
enough, resulting in tachyphylaxis.
Habituation & Addiction
Habituation – getting used to a drug such that one becomes emotionally dependent on the drug
Addiction – true physical as well as emotional dependence on a drug; will need pharmacologic support during withdrawal
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pharmacogenomics