Skeletal neuromuscular junction

Since ACh is the transmitter at the skeletal neuromuscular junction one might also expect it to be released from any axon collaterals arising from the motor nerve to it. Such collaterals innervate (drive) an interneuron (the Renshaw cell) in the ventral horn of the spinal cord, which provides an inhibitory feedback onto the motoneuron. Not... 

If the poisoning is due to an organophosphate, prompt administration of pralidoxime chloride will result in dephosphorylation of cholinesterases in the periphery and a decrease in the degree of the blockade at the skeletal neuromuscular junction. Since pralidoxime is a quaternary amine, it will not enter the CNS and therefore cannot reactivate central cholinesterases. In addition, pralidoxime is effective only if there has been no aging of the phosphorylated enzyme. Pralidoxime has a greater effect at the skeletal neuromuscular junction than at autonomic effector sites. 

Unlike the receptors at postganglionic neuroeffector junctions or at skeletal neuromuscular junctions, both types of cholinergic receptors, that is, nicotinic and mus-... 

Succinylcholine acts primarily at the skeletal neuromuscular junction and has little effect at autonomic ganglia or at postganglionic cholinergic (muscarinic) junctions. Actions at these sites attributed to succinylcholine may arise from the effects of choline. Succinylcholine has no direct action on the uterus or other smooth muscle structures. It does not enter the CNS and does not cross the placental barrier. It may, however, release histamine from mast cells. Because succinylcholine works by stimulating rather than blocking end plate receptors, anti-AChEs will not reverse muscle paralysis and may actually prolong the block. 

Some sedative-hypnotics, particularly members of the carbamate (eg, meprobamate) and benzodiazepine groups, exert inhibitory effects on polysynaptic reflexes and internuncial transmission and at high doses may also depress transmission at the skeletal neuromuscular junction. Somewhat selective actions of this type that lead to muscle relaxation can be readily demonstrated in animals and have led to claims of usefulness for relaxing contracted voluntary muscle in muscle spasm (see Clinical Pharmacology). Muscle relaxation is not a characteristic action of zolpidem, zaleplon, and eszopiclone. 

Acetylcholine is the neurotransmitter found in many areas of the brain as well as in the periphery (skeletal neuromuscular junction, some autonomic synapses). In the brain, acetylcholine is abundant in the cerebral cortex, and seems to play a critical role in cognition and memory.22 32 Neurons originating in the large pyramidal cells of the motor cortex and many neurons originating in the basal ganglia also secrete acetylcholine from their terminal axons. In general, acetylcholine synapses in the CNS are excitatory in nature. 

Release. Certain drugs will increase synaptic activity by directly increasing the release of neurotransmitter from the presynaptic terminal. Amphetamines appear to exert their effects on the CNS primarily by increasing the presynaptic release of catecholamine neurotransmitters (e.g., norepinephrine). Conversely, other compounds may inhibit the synapse by directly decreasing the amount of transmitter released during each action potential. An example is botulinum toxin (Botox), which can be used as a skeletal muscle relaxant because of its ability to impair the release of acetylcholine from the skeletal neuromuscular junction (see Chapter 13). 

Injection of botulinum toxin is a rather innovative way to control localized muscle hyperexcitability. Botulinum toxin is a purified version of the toxin that causes botulism. Systemic doses of this toxin can be extremely dangerous or fatal because botulinum toxin inhibits the release of acetylcholine from presynaptic terminals at the skeletal neuromuscular junction. Loss of presynaptic acetylcholine release results in paralysis of the muscle fiber supplied by that terminal. Systemic dissemination of botulinum toxin can therefore cause widespread paralysis, including loss of respiratory muscle function. Injection into specific muscles, however, can sequester the toxin within these muscles, thus producing localized effects that are beneficial in certain forms of muscle hyperexcitability. 

Mechanism of action. The cellular actions of bot-ulinum toxin at the neuromuscular junction have recently been clarified.84 This toxin is attracted to glycoproteins located on the surface of the presynaptic terminal at the skeletal neuromuscular junction.33 Once attached to the membrane, the toxin enters the presynaptic terminal and inhibits proteins that are needed for acetylcholine release (Figure 13-4).84 Normally, certain proteins help fuse presynaptic vesicles with the inner surface of the presynaptic terminal, thereby allowing the vesicles to release acetylcholine via exocytosis. Botulinum toxin cleaves and destroys these fusion proteins, thus making it impossible for the neuron to release acetylcholine into the synaptic cleft.32,84 Local injection of botulinum toxin into specific muscles will therefore decrease muscle excitation by disrupting synaptic transmission at the neuromuscular junction. The affected muscle will invariably undergo some degree of paresis and subsequent... 

FIGURE 13-4 Mechanism of action of botulinum toxin at the skeletal neuromuscular junction. At a normal synapse (shown on left], fusion proteins connect acetylcholine (ACh] vesicles with the presynaptic membrane, and ACh is released via exocytosis. Botulinum toxin (represented by BTX on the right] binds to the presynaptic terminal, and enters the terminal where it destroys the fusion proteins so that ACh cannot be released. See text for details. 

Acetylcholine A neurotransmitter in the somatic and autonomic nervous systems principal synapses using acetylcholine include the skeletal neuromuscular junction, autonomic ganglia, and certain pathways in the brain. 

Methantheline and propantheline are synthetic derivatives that, besides their antimuscarinic effects, are ganglionic blocking agents and block the skeletal neuromuscular junction. Propantheline and oxyphenonium reduce gastric secretion, whereas pirenzepine, in addition to reducing gastric secretion, also reduces gastric motility. 

Propantheline bromide (Pro-banthine) resembles methantheline chemically (isopropyl groups replace the ethyl substituents on the quaternary N atom). Its pharmacological properties are also similar to those of methantheline, but it is two to five times more potent. It is one of the more widely used of the synthetic muscarinic receptor antagonists. Very high doses block the skeletal neuromuscular junction. The usual clinical dose (15 mg) acts for about 6 h. 

Regeneration of the Skeletal Neuromuscular Junction and the Innervated Muscle Fibers... 

Adverse effects The effects of physostigmine on the CNS may lead to convulsions when high doses are used. Bradycardia may also occur. Inhibition of acetylcholinesterase at the skeletal neuromuscular junction causes the accumulation of acetylcholine and ultimately results in paralysis of skeletal muscle. However, these effects are rarely seen with therapeutic doses. 

Qll Would the drug you have identified in Question 10 have actions on the skeletal neuromuscular junction Give reasons for your answer. 

It is an autoimmune disease in which antibodies attack the acetylcholine receptors at the skeletal neuromuscular junction and therefore acetylcholine fails to bind to them. The condition results in muscle weakness, particularly of the eye, lips, tongue, throat, neck and shoulders. 

Skeletal muscle twitching is due to effects at the skeletal neuromuscular junction, which is innervated by the somatic nervous system, via motor nerves. The anticholinesterase prolongs and intensifies the actions of released acetylcholine at the junction, causing fasciculation (strong, jerky contractions) of skeletal muscle. Normally at the skeletal neuromuscular junction, the released acetylcholine is rapidly hydrolysed by cholinesterases to choline and acetate. This allows repolarization of the muscle membrane to occur following initial stimulation. In the presence of anticholinesterases the acetylcholine remains at the junction for a very prolonged period and produces repeated twitching of the muscle fibres via nicotinic receptors. 

Anticholinesterases such as malathion are used in commercial insecticide sprays. Unprotected operators may absorb malathion via the eyes, skin, respiratory tract and mucous membranes of the mouth. Effects include intestinal cramps and diarrhoea following stimulation of intestinal motility and secretion. Stimulation of lacrimal and salivary glands causes the eyes to water profusely (lacrimation) and saliva to drool. Bradycardia, bronchoconstriction, dyspnoea and increased sweating also occur. Skeletal muscle twitching (fasciculation) is due to the prolonged action of released acetylcholine at the skeletal neuromuscular junction. 

Many of the physiological effects of anti-ChEs are attributable to excess neurotransmitter ACh (Taylor 1996). The precise symptoms and the time course depend on the chemicals and the localization of the receptors affected. Early symptoms of cholinergic poisoning represent stimulation of muscarinic neuro-effectors of the parasympathetic system. Effects include slowing of the heart (bradycardia), constriction of the pupil of the eye, diarrhea, urination, lacrimation, and salivation. Actions at nicotinic skeletal neuromuscular junctions (motor end plates) result in muscle fasciculation (disorganized twitching) and, at higher doses. 

The main acute pharmacologic actions of anti-ChE agents that are of concern here are those on the eye, the Intestine and ocher organs Innervated by the autonomic division of the FMS, the skeletal neuromuscular Junction, and the brain. Effects of cholinergic and adrenergic stimulation on effector organs are summarized in Table 1. 

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