Adrenoceptor blockers

A pure alpha agonist will cause reflex bradycardia in a subject with intact cardiac innervation, but no change in hean rate if this innervation is severed, eg, in a heart transplant patient. The other drugs listed have direct beta agonist effects and will increase heart rate in the denervated heart. The answer is (D). 

Skill Keeper Answer Blood Pressure Control Mechanisms in Pheochromocytoma 

Describe the effects of an alpha-blocker on the hemodynamic responses to epinephrine. Describe the effects of an alpha-blocker on the hemodynamic responses to norepinephrine. Compare the effects of propranolol, labetalol, metoprolol, and pindolol. 

Compare the pharmacokinetics of propranolol, atenolol, esmolol. and nadolol. 

Describe the clinical indications and toxicides of typical alpha- and beta-blockers. 

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L A. Verapamil is an L-type calcium channel blocker. Nitroglycerin and isosorbide are both organic nitrates and have no direct effect on L-type calcium channels at the SA node, while propranolol and metoprolol are (3-adrenoceptor blockers and will slow heart rate by blocking the actions of norepinephrine and epinephrine on (3-receptors at the SA node. 

D. As a 3-adrenoceptor blocker, propranolol can relieve many of the symptoms of stage fright. For this use it can be taken once a few hours before the performance. Chronic dosing is usually not necessary. The other agents produce sedation. 

B. The symptoms of thyrotoxicosis are largely mediated through the adrenergic nervous system, and 3-adrenoceptor blockers may ameUorate some of... 

Oxidation CYP2D6 Bufuralol (3-adrenoceptor blocker) Exacerbation of 3 blockade, nausea... 

Symptoms and signs are, of course, less valuable as guides if the patient is also taking a (3-adrenoceptor blocker, and reliance is then put on biochemical tests. 

No patient should be operated on with a resting pulse of 90/min or above, and no dose of (3-adrenoceptor blocker, including the important postoperative dose, should be omitted. Toft A D et al 1978 New England Journal or Medicine 298 643. 

Several mechanisms of action have been proposed for /3-adrenoceptor blockers (/S-blockers), but none of them alone has been shown to be associated consistently with a reduction in arterial BP. /3-Blockers have negative chronotropic and inotropic cardiac effects that reduce cardiac output, which explains some of the antihypertensive effect. However, cardiac output falls equally in patients treated with /3-blockers regardless of BP lowering. Additionally, /3-blockers with intrinsic sympathomimetic activity (ISA) do not reduce cardiac output, yet they lower BP and decrease peripheral resistance. 

Because labetalol, an adrenoceptor-blocking agent structurally related to epinephrine, has two asymmetric centers, four diastereomers exist (Fig. 4.4). The formulation available for use as a mixed a- and (3-adrenoceptor blocker contains equal amounts of each diastereomer. The R,R isomer accounts for much of the (3-adrenoceptor blocking activity, whereas the S.R isomer has the greatest effect on a-adrenoceptors. The S,S isomer has some a-adrenoceptor blocking activity but no activity at [3-adrenoceptors. The R.S isomer is essentially devoid of activity at both a- and (3-adrenoceptors. 

Hypotensive activity of shepherd s purse observed in rats is inhibited by a 3-adrenoceptor blocker but not by atropine, dismissing earlier reports of cholinergic activity (Jurisson 1971 Kuroda and Takagi 1968). 

Mitrovic. V. Oehm, E. Thormann. J. Pitschner. H. Haberbosch. W. Comparison of the potassium channel blocker tedisamil with the 3-adrenoceptor blocker esmolol and the calcium antagonist gallopamil in patients with coronary artery disease. Clin. Cardiol. 1998. 27, 492-502. 

Some P-adrenoceptor blockers have intrinsic sympathomimetic activity (ISA) or partial agonist activity (PAA). They activate P-adrenoceptors before blocking them. Theoretically, patients taking P-adrenoceptor blockers with ISA should not have cold extremities because the dmg produces minimal decreases in peripheral blood flow (smaller increases in resistance). In addition, these agents should produce minimal depression of heart rate and cardiac output, either at rest or during exercise (36). 

There have been a number of long-term trials with various P-adrenoceptor blockers in patients surviving acute MI (37—39) that demonstrated a reduction in mortaUty, sudden death, and nonfatal re-infarctions. The term cardioprotective has been used to describe this effect for the dmgs studied. The... 

Prolonged exposure of -adrenoceptor agonists down-regulates -adrenoceptors, ie, their number decreases and they become less responsive. On the other hand, prolonged exposure to -adrenoceptor antagonists (those without ISA) upregulates -adrenoceptors, ie, their numbers increase and they become more responsive. Therefore, patients on -adrenoceptor blocker therapy should be withdrawn from this medication gradually (40). 

The properties of -adrenoceptor blockers that contribute to antiarrhythmic effects are antagonism of neural/humoral P-adrenergic activity, and antagonism of catecholamine-mediated electrophysiological properties, ie, increase refractory period and decrease in the rate of diastoHc depolarization, ie, decrease automaticity and slow atrioventricular conduction (1,2). 

Propranolol. Propranolol hydrochloride, considered the prototype of the P-adrenoceptor blocking agents, has been in use since 1964. It is a nonselective, highly Hpid-soluble P-adrenoceptor blocker having no ISA. It is a mixture of (+) and (—) enantiomers, and the (—) enantiomer is the active moiety. The local anesthetic effects of propranolol are equipotent to those of Hdocaine [137-58-6] C 4H22N20, (see Anesthetics). Therapeutic effects include termination of catecholamine-induced arrhythmias, conversion of SA nodal tachycardias (including flutter and fibrillation) and AV nodal tachyarrhythmias to normal sinus rhythm, digitahs-induced arrhythmias, and ventricular arrhythmias (1,2). The dmg also has cardioprotective properties (37,39). 

Acebutolol. Acebutolol hydrochloride is a hydrophilic, cardioselective P-adrenoceptor blocker that has about 1/25 the potency of propranolol in this regard. The dmg has moderate ISA and weak membrane stabilizing activities. It is approved for the treatment of hypertension and ventricular arrhythmias, especially PVCs. Acebutolol should produce minimal depression of heart rate because of its ISA (32). 

Elestolol sulfate is a nonselective, ultrashort acting P-adrenoceptor blocker. It has no ISA and produces weak inhibition of the fast sodium channel. The dmg is under clinical investigation for supraventricular tachyarrhythmias, unstable angina, and acute MI. In humans, flestolol has hemodynamics and electrophysiologic effects similar to those of other P-adrenoceptor blockers. The pharmacokinetics of flestolol are similar to those of esmolol. It is 50 times more potent than esmolol and the elimination half-life is 7.2 min. Recovery from P-adrenoceptor blockade is 30—45 min after stopping iv infusions. The dmg is hydrolyzed by tissue esterases and no active metabohtes of flestolol have been identified (41). 

Bopindolol is a long-acting, nonselective P-adrenoceptor blocker. It has mild membrane stabilizing activity and ISA. In vivo, the compound is hydrolyzed to its active metabohte. Because of this prodmg feature the onset of action is slower than other available P-adrenoceptor blockers. Preliminary pharmacokinetic studies indicate that the compound is weU absorbed, is 70% bioavailable, and peak plasma levels are achieved in about 2 h. Whereas its elimination half-life is 4—8 h, P-adrenoceptor blocking action (- 40%) is stiU apparent after 48 h. The dmg is being studied in hypertension, angina, and arrhythmias (43). 

Sotalol is rapidly and almost completely (>90%) absorbed. Bioavahabhity of absorbed dmg is 89—100%. Peak plasma levels are achieved in 2—4 h. Sotalol is 50% bound to plasma proteins. Plasma half-life of the compound is about 5.2 h. No metabolites of sotalol have been identified indicating littie metabolism. The dmg is excreted mainly by the kidneys (80—90%) and about 10% is eliminated in the feces. The plasma half-life is prolonged in patients having renal failure. Kinetics of the compound are not affected by changes in liver function (1,2). Sotalol has ah the adverse effects of -adrenoceptor blockers including myocardial depression, bradycardia, transient hypotension, and proarrhythmic effects (1,2). 

The cardiac effects of the calcium antagonists, ie, slowed rate (negative chronotropy) and decreased contractile force (negative inotropy), are prominent in isolated cardiac preparations. However, in the intact circulation, these effects may be masked by reflex compensatory adjustments to the hypotension that these agents produce. The negative inotropic activity of the calcium antagonists may be a problem in patients having heart failure, where contractility is already depressed, or in patients on concomitant -adrenoceptor blockers where reflex compensatory mechanisms are reduced. 

Betaxolol hydrochloride is a lipophilic, cardioselective -adrenoceptor blocker having no ISA and Httie membrane-stabilizing activity. The dmg is as equieffective and equipotent as atenolol. It is well absorbed from the GI tract, but does not undergo extensive first-pass metaboHsm in the Hver. Its elimination half-Hfe is 15—20 h. It is metabolized in the Hver ( 84%) to two principal inactive metaboHtes and one minor active metaboHte. About 16% of the dmg is excreted unchanged urine. Excretion of the dmg is unchanged in patients having renal or Hver impairment (43). 

Bisoprolol fumarate is a long-acting, cardioselective -adrenoceptor blocker, and is the most potent cardioselective -adrenoceptor blocker available. Bisoprolol has no ISA. At high concentrations it has membrane-stabilizing activity. The dmg has a "balanced clearance", ie, half is excreted by the kidneys and half is eliminated by the Hver and its excretion is not affected by functional impairment of either organ. It is approved in Europe for hypertension and is being studied in angina (43). 

Bevantolol hydrochloride is a moderately lipophilic, long-acting, cardioselective -adrenoceptor blocker. It has no ISA but has membrane-stabilizing activity. The dmg is in use in Europe for the treatment of hypertension and angina. It is rapidly absorbed from the GI tract. Peak plasma levels occur in 1—2 h. It is metabolized extensively in the Hver to a metaboHte that has some ISA. It is excreted by the Hver and the kidneys and excretion is delayed in patients having kidney failure. 

ACE inhibitors can be administered with diuretics (qv), cardiac glycosides, -adrenoceptor blockers, and calcium channel blockers. Clinical trials indicate they are generally free from serious side effects. The effectiveness of enalapril, another ACE inhibitor, in preventing patient mortaUty in severe (Class IV) heart failure was investigated. In combination with conventional dmgs such as vasodilators and diuretics, a 40% reduction in mortaUty was observed after six months of treatment using 2.5—40 mg/d of enalapril (141). However, patients complain of cough, and occasionally rash and taste disturbances can occur. 

Patients having high plasma renin activity (PRA) (>8 ng/(mLh)) respond best to an ACE inhibitor or a -adrenoceptor blocker those having low PRA (<1 ng/(mLh)) usually elderly and black, respond best to a calcium channel blocker or a diuretic (184). -Adrenoceptor blockers should not be used in patients who have diabetes, asthma, bradycardia, or peripheral vascular diseases. The thiazide-type diuretics (qv) should be used with caution in patients having diabetes. Likewise, -adrenoceptor blockers should not be combined with verapamil or diltiazem because these dmgs slow the atrioventricular nodal conduction in the heart. Calcium channel blockers are preferred in patients having coronary insufficiency diseases because of the cardioprotective effects of these dmgs. 

OC-Adrenoceptor Blockers. Nonselective a-adrenoceptor blockers (Table 6), such as phentolamine, which block both a - and a2 adrenoceptors, produce vasodilation by antagonizing the effects of endogenous norepinephrine. They also produce severe tachycardia and have been replaced by selective a -adrenoceptor blockers, such as prazosin, terazosin, and doxazosin, which do not usually cause severe tachycardia. 

Terazosin is selective a -adrenoceptor blocker having hypotensive efficacy equal to that of prazosin. Terazosin has a longer duration of action and better gastrointestinal absorption profile than prazosin. 

P-Adrenoceptor Blockers. There is no satisfactory mechanism to explain the antihypertensive activity of P-adrenoceptor blockers (see Table 1) in humans particularly after chronic treatment (228,231—233). Reductions in heart rate correlate well with decreases in blood pressure and this may be an important mechanism. Other proposed mechanisms include reduction in PRA, reduction in cardiac output, and a central action. However, pindolol produces an antihypertensive effect without lowering PRA. In long-term treatment, the cardiac output is restored despite the decrease in arterial blood pressure and total peripheral resistance. Atenolol (Table 1), which does not penetrate into the brain is an efficacious antihypertensive agent. In short-term treatment, the blood flow to most organs (except the brain) is reduced and the total peripheral resistance may increase. 

Better antihypertensive effect of P-adrenoceptor blockers is found in patients having high PRA and most are not efficacious in patients having low PRA or in elderly patients. P-Adrenoceptor blockers usually lower arterial blood pressure about 10 mm Hg (1.3 kPa). Side effects include lethargy, dyspnea, nausea, dizziness, headache, impotency, cold hands and feet, vivid dreams and nightmares, bronchospasm, bradycardia, and sleep disturbances. 

P-Adrenoceptor blockers for the treatment of hypertension include (/) the cardioselective P -adrenoceptor blockers without intrinsic sympathomimetic activity (ISA), ie, atenolol (Table 3), bisoprolol (Table 3), and metoprolol (Table 1) (2) the cardioselective with ISA, ie, acebutolol (Table 1) (J) the noncardioselective without ISA, ie, propranolol (Table 1) and timolol [26839-75-8] C23H24N4O2S and (4) the noncardioselective with ISA, ie, oxprenolol [6452-71-7] C 3H23N03, and pindolol. 

Verapamil (Table 1), the first slow channel calcium blocker synthesized to selectively inhibit the transmembrane influx of calcium ions into cells, lowers blood pressure in hypertensive patients having good organ perfusion particularly with increased renal blood flow. Sustained-release verapamil for once a day dosing is available for the treatment of hypertension. Constipation is a prominent side effect. Headache, dizziness, and edema are frequent and verapamil can sometimes cause AV conduction disturbances and AV block. Verapamil should not be used in combination with -adrenoceptor blockers because of the synergistic negative effects on heart rate and contractile force. 

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