1. 1 Dr. Ishfaq A. Bukhari Dep of Medical Pharmacology, KSU

2. Currently Alcohol ( Ethyl alcohol or ethanol) is the most commonly abused drug in the world. Alcohol in low-moderate amounts relieves anxiety & fosters a feeling of well-being/ euphoria. Alcohol abuse and alcoholism cause severe detrimental health effects such as alcoholic liver and heart disease, increased risk for stroke,chronic diarrhoea and alcohol dementia 2

3. Pharmacokinetic of Alcohol water-miscible molecule, completely absorbed from GIT Volume of distribution = Total Body Water Metabolism (in gastric mucosa & liver). 1- Oxidation of ethanol to acetaldehyde via ADH;;. Mainly in liver. 2- Acetaldehyde is converted to acetate via ALDH, w also reduce NAD + to NADH. Acetate ultimately is converted to CO 2 + water. 3

4. Acetaldehyde in more toxic than ethanol Alcohol Metabolism; 90-98% metabolized in liver ADH ALDH CH3CH2OH  CH3CHO  CH3COOH Ethanol Acetaldehyde Acetic Acid

5. Mitochondrion EtOH Acetaldehyde Acetate Cytosol ER ADH NAD + NADH AlDH NAD + NADH MEOS NADP + NADPH O2O2 P450 Extra-hepatic tissue Disulfiram (antabuse) Chlorpropamide (diabetes)

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7. Genetic variation in alcohol metabolizing enzymes Aldehyde Dehydrogenase.(ALDH) Acute acetaldehyde toxicity, associated with the ‘flushing reaction’ immediately following alcohol intake (due to increased acetaldehyde) Mostly Asian populations have genetic variation.

8.  Chronic ethanol consumption induces cytochrome P450 2E1, whic leads to ! generation of recative oxygen specie (ROS)  contribute to DNA damage, hepatocyte injury & liver disease. . Hyperlipidemia & fat deposition are common in chronic alcohol  because of excess acetate & FA synthesis + direct oxidation of ethanol for energy instead of using body fat stores 8

9. Effects of alcohol greatly depends on dose and frequency of use. In order of increasing dose (or number of drinks),alcohol is anxiolytic mood- enhancing sedative slows reaction time produces motor incoordination impairs judgment (making it dangerous and illegal to drive a car). At very high doses alcohol produces loss of consciousness 9

10.  Medical complications of chronic alcoholism: - Liver disease: ! most common medical complication. Accumulated acetaldehyde: hepatotoxicity. - Fatty liver/ alcoholic steatosis,then hepatic cirrhosis - liver failure & death within 10 yrs. Cardiovascular: - Chronic abuse; c ardiomyopathy; compromised ventricular contractility ;. Due to ! direct toxic effects of alcohol on cardiac muscle. 10

11. 11 Alcoholic Liver Disease Steatosis Steatohepatitis Cirrhosis Normal

12. @AMSP 201012

13. @AMSP 201013

14. Hematological complication:  Iron deficiency anemia; inadequate dietary intake & GI blood loss  Hemolytic anemia; liver damage  Megaloblastic anemia; folate deficiency in chronic alcoholism,, impaired folate abs, & hemolysis.  Thrombocytopenia & prolong bleeding times; suppressing platelet formation  Alcohol can diminish ! production of Vit-K dependent clotting factors; due to hepatotoxic action 14

15.  Cardiovascular:  Arrhythmia  CHD: Excess drinking is associated e higher mortality risk from CHD. 15

16.  Fetal Alc Syndrome (FAS): IRREVERIBLE  Ethanol rapidly crosses placenta  Pre-natal exposure to alcohol causes: - intrauterine growth retardation, congenital malformation (wide-set eyes, microcephaly, impaired facial development) & teratogenicity - fetal growth by inducing hypoxia. - More severe cases include congenital heart defects & physical + mental retardation. 16

17. Fetal Alcohol Syndrome ( FAS )

18.  Gastritis & ulcer diseases, Alcohol causes: - Malabs of water-soluble vit - Acute/ chronic hemorrhagic gastritis - Gastroesophageal reflux disease, esophageal bleeding (reversible).  Cancer - Excessive consumption of alc ! risk of developing cancers (tongue, mouth, oropharynx, esophagus, liver, & breast). 18

19.  Endocrine: hypogonadism - In women : amenorrhea, anovulation, hyperprolactinemia & ovarian dysfunction, infertility & spontaneous abortion + impairment fetal growth. - In men : hypogonadism, loss of facial hair, gynecomastia, muscle & bone mass, testicular atrophy & sexual impotence... Also alc may testesterone & inhibit pituitary release of LH. 19

20.  Wernicke-Korsakoff syndrome is a manifestation of thiamine deficiency,(severe alcoholism). thiamine Result from: (inadequate nutritional intake; uptake of thiamine from GIT, liver thiamine stores are due to hepatic steatosis or fibrosis). ! syndrome is manifestation of 2 disorders: Wernicke's encephalopathy ; acute neurologic disorder ( CNS depression, mental sluggishness, confusion, Coma), impairment of visual acuity & ataxia & polyneuropathy.Wernicke's encephalopathy confusion Korsakoff's PsychosisKorsakoff's Psychosis main symptoms are amnesia & executive dysfunction.(cognitive and behavioral)amnesia executive dysfunction Tr: thiamine + dextrose-containing IV fluids. 20

21.  Acute ethanol intoxication: - CNS depression: sedation, relief anxiety, higher conc: slurred speech, ataxia, & impaired judgment - Resp depression leading to resp acidosis & coma - Death can occur from resp depression - Vasodilation due to depression of vasomotor center & direct smooth muscle relaxation caused by acetaldehyde. - Suppresses Cardiac contractality 21

22.  ! person must drink progressively > alcohol to obtain a given effect on brain function  Tolerance develops e steady alcohol intake via:  Metabolic tolerance, hepatic enzyme induction  Functional tolerance, change in CNS sensitivity (Neuro-adaptation )  Tolerance appear to involve NMDA R, GABA R, 5- HT, DA in brain reward & reinforcement. 22

23.  Alcohol effects on Central NTs: Alcohol causes: inhibition of NMDA (Glutamate) & activation of GABA A receptors (Rs) in brain this will lead to: - Sedative effect & CNS depression - Disruption in memory, consciousness, alertness & learning by alcohol. “Blackouts” 23

24. Chronic use of alcohol leads to UP- REGULATION of NMDA-Rs & voltage- sensitive Ca Channels ;; 1- increased NMDA activity significantly Ca influx to ! nerve cells, Ca excess can lead to cell toxicity & death. (Ca related brain damage ). 2- This also contribute to alcohol tolerance & withdrawal symptoms (tremors, exaggerated response & seizures). 24

25. Cont’ NTs release: Alcohol increases release of: -- Dopamine (DA): role in motivational behavior/ reinforcement, i.e. rewarding stimuli & contribute to addiction -- Serotonin: alcohol rewarding effects, tolerance & withdrawal 5-HT system modulates the DAergic activity of the VTA and the NAC. -- Opioid peptides; feeling of euphoria & increase ! rewarding effect of alcohol. 25

26. 26 Control Ethanol enhances Dopamine (DA) release in ! “pharmacological reward” pathway Ethanol appears to release DA from ! VTA & NAC via interactions e multiple NT Rs Ethanol has direct excitatory actions on DA containing neurons in the VTA Ethanol enhances Dopamine (DA) release in ! “pharmacological reward” pathway Ethanol appears to release DA from ! VTA & NAC via interactions e multiple NT Rs Ethanol has direct excitatory actions on DA containing neurons in the VTA Nucleus accumbens (NAC) Ethanol interactions e NTs release Ethanol ++ Ventral Tegmental Area (VTA) Dopamine

27.  Alc Withdrawal occurs > 2/3 Alcohol Dependence patients  Symptoms :  Autonomic hyperactivity & craving for alcohol  Hand tremor  Insomnia, anxiety, agitation  vomiting & thirst  transient visual/ auditory illusions  Grand mal seizures (after 7-48 hr alc cessation) hypoactivity of GABAergic Rs  Rebound supersensitivity of glutamate Rs & hypoactivity of GABAergic Rs are possibly involved 27

28. - Substituting a long-acting sedative hypnotic drug for alc & then tapering ! dose. - Such as BDZs (chlor-diazepoxide, diazepam) OR short acting are preferable (lorazepam) - Efficacy: IV/ po manage withdrawal symptoms & prevent irritability, insomnia, agitation & seizures. ! dose of BDZs should be carefully adjusted to avoid respiratory depression & hypotension. 28

29.  Cont’ Management: - Clonidine (centrally acting sympatholytic drug); inhinbits enhanced sympathetic NT release - Propranolol; inhibits ! action of exaggerated symp activity - Naltrexone; po, an opioid antagonist, e weak partial agonist activity, reduce psychic craving for alcohol in abstinent patients & reduce relapse (note alcohol increase endogenous opiates that produce dependence) - Acamprosate; a weak NMDA-R antagonist & GABA activator, reduce psychic craving (woks like alcohol). 29

30. Good drug for Transient reduction in drinking Reduction in drinking in alcoholics with a family history of Alcohol Dependence 5-HT and Human Alcohol Consumption ---- Reduced 5-HIAA levels 30

31.  For adjunctive Tr of alc dependence: Disulfiram therapy: 250 mg daily  Disulfiram blocks hepatic ALDH, this will increase blood acetaldehyde conc.  If alc + disulfiram = extreme discomfort & disulfiram ethanol rx: VD, flushing, hotness, cyanosis, tachyC, dyspnea, palpitations & throbbing headache.  Disulfiram-induced symptoms render alcoholics afraid from drinking alc. 31

32.  Chronic uses of alcohol induces liver enzymes and increase metabolism of drugs such as propranolol and warfarin etc  Acute alcohol us causes inhibition of liver enzyme and incraeses toxicity of some drugs such as bleeding with warfarin  Alcohol suppresses gluconeogenesis, which may increase risk for hypoglycemia in diabetic patients 32

33.  Increase in the risk of developing a major GI bleed or an ulcer when NSAIDs are used with alcohol  Increases hepatotoxicity when Acetaminophen and alcohol used concurrently (chronic use).  Alcohol increases the risk of respiratory and CNS depression effects of narcotic drugs (codeine and methahdone). 33