Muscle relaxants Tubocurarine

Bisbenzylisoquinoline alkaloids are dimeric benzyltetrahydroisoquinoline alkaloids that are known for their pharmacological activities. A well-described example is the muscle relaxant (+)-tubocurarine, which in crude form serves as an arrow poison for South American Indian tribes. In the biosynthesis of this broad class of dimeric alkaloids, it has been postulated that the mechanism of phenol coupling proceeds by generation of phenolate radicals followed by radical pairing to form either an inter- or intramolecular C - O or C - C bond. Enzyme studies on the formation of bisbenzylisoquinoline alkaloids indicated that a cytochrome P-450-dependent oxidase catalyzes C - O bound formation in the biosynthesis of berbamunine in Berberis cell suspension culture.15 This enzyme, berbamunine synthase (CYP80A1), is one of the few cytochromes P-450 that can be purified to... 

Another interesting alkaloid is tubocurarine chloride (14), with a bisbenzyliso-quinoline structure. It is the active principle of tubocurare, an arrow poison used by Indians in South America and medicinally used as a muscle relaxant. However, the source, the leaves of the tropical rainwood liane Chondodenron tomento-sum, is not easily accessible and the compound exhibits unwanted side-effects. Investigations showed that the basic structure can be replaced by an appropriate steroid skeleton with two nitrogen substituents at the right distance (see next section). 

Curare-like muscle relaxants act by blocking acetylcholine receptor sites, thus eliminating transmission of nerve impulses at the neuromuscular junction. There are two acetylcholine-like groupings in the molecules, and the drugs, therefore, probably span and block several receptor sites. The neurotransmitter acetylcholine is also a quaternary ammonium compound. The natural material present in curare is tubocurarine, a complex alkaloid that is a mono-quaternary salt. Under physiological conditions, the tertiary amine will be almost completely protonated (see Section 4.9), and the compound will similarly possess two positively charged centres. 

Tubocurarine acts as a competitive inhibitor in the nicotinic acetylcholine receptor, meaning that the nerve impulse is blocked by this alkaloid. Tubocurarine is used in surgical practice as a muscle relaxant. These alkaloids have an observably large spectrum of activity and possible applications. Their utilization in the development of new applications is therefore relatively active in modern medicine. 

Tubocurarine-containing drugs such as Tubarine or Jexin are used in surgical procedures as muscle relaxants. 

On the other hand, if a chemical is somewhat less similar to acetylcholine, it may interact with the receptor but be unable to induce the exact molecular change necessary to allow the inward movement of sodium. In this instance the chemical does not cause contraction, but because it occupies the receptor site, it prevents the interaction of acetylcholine with its receptor. Such a drug is termed an antagonist. An example of such a compound is d-tubocurarine, an antagonist of acetylcholine at the end-plate receptors. Since it competes with acetylcholine for its receptor and prevents acetylcholine from producing its characteristic effects, administration of d-tubocurarine results in muscle relaxation by interfering with acetylcholine s ability to induce and maintain the contractile state of the muscle cells. 

Newborn children are extremely sensitive to nondepolarizing muscle relaxants but may require three times as much depolarizing agent as an adult for an equivalent degree of block. Like newborn children, patients with myasthenia gravis are very sensitive to paralysis by d-tubocurarine but are resistant to succinylcholine. This altered responsiveness is probably due to the fewer number of functional AChRs at the end plate. Since neonates are very sensitive to d-tubocurarine, the dosage must be reduced and the degree of block closely monitored. 

Tubocurarine was the first muscle relaxant used in clinical anaesthesia, although it is now rarely used and is not available in many countries. The ED95 of tubocurarine is approximately Table 6.3 Classification of non-depolarising relaxants... 

This type of response may be caused by several mechanisms. For instance, the muscle relaxation induced by succinylcholine, discussed in more detail in chapter 7, is due to blockade of neuromuscular transmission. Alternatively, acetylcholine antagonists such as tubocurarine may compete for the receptor site at the skeletal muscle end plate, leading to paralysis of the skeletal muscle. Botulinum toxin binds to nerve terminals and prevents the release of acetylcholine the muscle behaves as if denervated, and there is paralysis. This will be discussed in more detail in chapter 7. 

In the mice head-drop test for curare-like activity compounds 210, 212 and 213 were found to be very potent. In analogy to d-tubocurarine, decamethonium and other muscle relaxants, these compounds cause a neuromuscular block when administered intraperitoneally. 

Decamethonium (Figure 6.49) was the first synthetic curare-like muscle relaxant, but has since been superseded. In tubocurarine, the two nitrogens are also separated by ten atoms, and at physiological pHs it is likely that both centres will be positively charged. Obviously, the interatomic distance (1.4 nm in tubocurarine) is very dependent on the structure and stereochemistry rather than just the number of atoms separating the centres, but an extended conformation of decamethonium approximates to this distance. Suxamethonium... 

Among the agents cited, only d-tubocurarine is useful as a drug (skeletal muscle relaxant) the rest are useful only as research tools. Cholinesterase, found in liver and plasma, can hydrolyze other esters such as succinylcholine (a skeletal muscle relaxant). Cholinergic peripheral receptors are located on (1) postganglionic parasympathetic fibers, (2) postganglionic sympathetic fibers, (3) all autonomic ganglia, and (4) skeletal end plates. 

Antiarrhythmic agents such as quinidine, procainamide, and propranolol have all been shown to augment d-tubocurarine-induced blockade. Quinidine has also been reported to unmask or worsen the symptoms of myasthenia gravis and to cause postoperative respiratory depression after the use of muscle relaxants. 

---