Extracerebral dopa decarboxylase inhibitors

Figure 15.4 The central and peripheral metabolism of levodopa and its modification by drugs, (a) Levodopa alone. After oral administration alone most dopa is rapidly decarboxylated to DA in the gut and blood with some o-methylated (COMT) to o-methyl/dopa (OMD). Only a small amount (3%) enters the CNS to be converted to DA. (b) After an extracerebral dopa decarboxylase inhibitor. Blocking just the peripheral dopa decarboxylase (DD) with inhibitors like carbidopa and benserazide, that cannot enter the CNS (extra cerebral dopa decarboxylase inhibitors, ExCDDIs), stops the conversion of levodopa to DA peripherally, so that more enters the CNS or is o-methylated peripherally to OMD.

Blocking the conversion to DA would appear stupid unless this could be restricted to the periphery. More dopa would then be preserved for entry into the brain, where it could be decarboxylated to DA as usual. Drugs like carbidopa and benserazide do precisely that and are used successfully with levodopa. They are known as extracerebral dopa decarboxylase inhibitors (ExCDDIs). Carbidopa (a-methyldopa hydrazine) is structurally similar to dopa but its hydrazine group (NHNH2) reduces lipid solubility and CNS penetration (Fig. 15.4). 

L-Dopa. Dopamine itself cannot penetrate the blood-brain barrier however, its natural precursor, L-dihydroxy-phenylalanine (levodopa), is effective in replenishing striatal dopamine levels, because it is transported across the blood-brain barrier via an amino acid carrier and is subsequently decarboxy-lated by DOPA-decarboxylase, present in striatal tissue. Decarboxylation also takes place in peripheral organs where dopamine is not needed, likely causing undesirable effects (tachycardia, arrhythmias resulting from activation of Pi-adrenoceptors [p. 114], hypotension, and vomiting). Extracerebral production of dopamine can be prevented by inhibitors of DOPA-decarboxylase (car-bidopa, benserazide) that do not penetrate the blood-brain barrier, leaving intracerebral decarboxylation unaffected. Excessive elevation of brain dopamine levels may lead to undesirable reactions, such as involuntary movements (dyskinesias) and mental disturbances. 

Fears have been expressed [510, 511] that long-term administration of L-dopa may induce a state of pyridoxine deficiency, since excess dietary pyridoxine, which is rapidly converted in vivo to the decarboxylase coenzyme pyridoxine-5 -phosphate [512], can nullify the beneficial effects of the amino acid [513-515]. Pyridoxine apparently both complexes with L-dopa and produces an accelerated decarboxylation of the amino acid in extracerebral tissues, both processes effectively reducing the amount of available dopamine in the striatum [512, 516]. The decarboxylase inhibitor MK-485 (37) prevents this reversal of the therapeutic effect by pyridoxine [517] and, more significantly, pyridoxine actually enhances the effects of L-dopa when given in conjunction with such an inhibitor [518]. The mechanism involved in this potentiation reflects enhancement by pyridoxine of dopa decarboxylase activity within the striatum in the presence of complete inhibition of extracerebral decarboxylase. The use of combinations of L-dopa, pyridoxine, and inhibitors of aromatic L-amino-acid decarboxylase, may lead to a more... 

It has already been mentioned that inhibitors of extracerebral aromatic L-amino acid decarboxylase potentiate the therapeutic actions of L-dopa... 

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