1. Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Chapter 16 Drugs That Block Nicotinic Cholinergic Transmission: Neuromuscular Blocking Agents and Ganglionic Blocking Agents

2. 2Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Neuromuscular Blockers  Prevent acetylcholine from activating nicotinic M  Cause muscle relaxation (paralysis)  No oral forms  Cannot cross  Blood-brain barrier No impact on CNS (paralysis, not sedation) No impact on CNS (paralysis, not sedation)  Placenta Minimal effects on fetus Minimal effects on fetus

3. 3Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Control of Muscle Contractions  Basic concepts (see Fig. 16-1)  Polarization  Depolarization  Repolarization  Steps in muscle contraction (see Fig. 16-2)

4. 4Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Classification of Neuromuscular Blocking Agents Competitive neuromuscular blockers I: tubocurarine (no longer used) Competitive neuromuscular blockers II: others Depolarizing neuromuscular blockers: succinylcholine

5. 5Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Fig. 16-1. The depolarization-repolarization cycle of the motor end-plate and muscle membrane. (ACh = acetylcholine.)

6. 6Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Fig. 16-2. Steps in excitation-contraction coupling. (ACh = acetylcholine.)

7. 7Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Competitive Neuromuscular Blockers I: Tubocurarine  Oldest competitive neuromuscular blocker (NMB)  No longer used in United States  Replaced by newer NMBs  One of active principles found in curare, a poison used by primitive arrow hunters

8. 8Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Competitive Neuromuscular Blockers  Chemistry  Quaternary nitrogen atom  Mechanism of action  Competes with ACh for nicotinic M receptors  Pharmacologic effects  Muscle relaxation: flaccid paralysis  Hypotension  Central nervous system

9. 9Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Competitive Neuromuscular Blockers  Pharmacokinetics  Rapid onset of paralysis  Adverse effects  Respiratory arrest  Cardiovascular effects

10. 10Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Competitive Neuromuscular Blockers I: Tubocurarine  Precautions and contraindications  Myasthenia gravis  Electrolyte disturbances  Drug interactions  General anesthetics  Antibiotics  Cholinesterase inhibitors

11. 11Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Competitive Neuromuscular Blockers I: Tubocurarine  Toxicology  Overdose Prolonged apnea, massive histamine release, and cardiovascular collapse Prolonged apnea, massive histamine release, and cardiovascular collapse  Preparations, dosage, and administration  No longer used in the United States

12. 12Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Competitive Neuromuscular Blockers II: Others Long-acting agents Doxacurium Metocurine Pipecuronium Intermediate- acting agents Cisatracurium Pancuronium Rocuronium Vecuronium Short-acting agents Mivacurium

13. 13Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Fig. 16-3. Structural formulas of representative neuromuscular blocking agents. Note that all of these agents contain quaternary nitrogen atoms and therefore cross membranes poorly. Consequently, they must be administered parenterally and have little effect on the central nervous system or a developing fetus.

14. 14Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Fig. 16-4. Mechanism of competitive neuromuscular blockade. Tubocurarine competes with acetylcholine (ACh) for binding to nicotinic M receptors on the motor end-plate. Binding of tubocurarine does not depolarize the end-plate and therefore does not cause contraction. At the same time, the presence of tubocurarine prevents ACh from binding to the receptor, hence contraction is prevented.

15. 15Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Depolarizing Neuromuscular Blockers: Succinylcholine  Mechanism of action  Pharmacologic effects  Ultrashort-acting (peak 1 min, fades 4–10 min) (peak 1 min, fades 4–10 min)  Muscle relaxation  Central nervous system  Pharmacokinetics  Eliminated by plasma cholinesterases  Therapeutic uses  Muscle relaxation during intubation

16. 16Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Depolarizing Neuromuscular Blockers: Succinylcholine  Adverse effects  Prolonged apnea in patients with low pseudocholinesterase activity  Malignant hyperthermia  Postoperative muscle pain  Hyperkalemia

17. 17Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Depolarizing Neuromuscular Blockers: Succinylcholine  Drug interactions  Cholinesterase inhibitors  Antibiotics  Toxicology  Preparations, dosage, and administration

18. 18Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Therapeutic Uses of Neuromuscular Blockers  Muscle relaxation during surgery  Facilitation of mechanical ventilation  Adjunct to electroconvulsive therapy  Endotracheal intubation  Diagnosis of myasthenia gravis

19. 19Copyright © 2013, 2010 by Saunders, an imprint of Elsevier Inc. Ganglionic Blocking Agents  Mechanism of action  Pharmacologic effects  Pharmacokinetics  Therapeutic use  Adverse effects Antimuscarinic effects Antimuscarinic effects Orthostatic hypotension Orthostatic hypotension CNS effects CNS effects  Preparations, dosage, and administration