This study guide will
facilitate the understanding of sympathomimetics and sympatholytics and the
adrenergic receptors at which these drugs interact. The educational goal is to
understand the uses in dental practice of drugs that interact at the adrenergic
receptors as well as toxicities that could occur as a result of these
interactions. In addition, dental patients are likely to be taking drugs that
act at these receptors. The presence of these drugs could modify the actions of
drugs prescribed in dental practice as well as produce interactions that could
have serious consequences.
Learning Objectives,
Lecture I
1. Integrate pharmacodynamic principles to understand the actions of drugs that
interact with the adrenergic receptors and how these interactions are relevant
to dental practice.
2. Understand the effects of epinephrine and norepinephrine on the
cardiovascular system.
3. Understand the rationale and potential toxicities for the use of epinephrine
in dental practice.
4. Understand the mechanisms for drug interactions involving drugs used in
cardiovascular therapeutics as they relate to dental practice.
Key drugs
Epinephrine - Adrenalin
Norepinephrine- Levophed
The adrenergic receptors which subserve the
response of the sympathetic nervous system have
been divided into two discrete subtypes: alpha adrenergic receptors (alpha
receptors) and beta adrenergic receptors (beta receptors). The classification of
these receptors, and indeed receptors in general, is based on the interaction of
agonists and antagonists with the receptors. The actions of epinephrine,
widely used in combination with local anesthetic drugs, are produced as a
result of interactions with these receptors.
Beta Receptor Systems
Most tissues express multiple receptors. However, the dominant beta receptor
in the normal heart is the beta1 receptor while the beta2 receptor is the
dominant regulatory receptor in vascular and non vascular smooth muscle.
Epinephrine activates both the beta1 and beta2-receptors. Norepinephrine
activates only the beta1-receptor.
Effect of Beta1 Receptor Activation on the Heart: Activation of the
beta1 receptor leads to increases in contractile force and heart rate.
Drugs that activate the beta1 receptor can be used in heart failure to improve
the contractile state of the failing heart. Drugs that activate the beta1
receptor also increase heart rate. Indeed, excess stimulation the beta1
receptor can induce significant increases in heart rate and arrhythmias.
Arrhythmias are a major concern with drugs such as epinephrine that
can be absorbed systemically after intra-oral injection.
Effect of Beta2 Receptor
Activation on Smooth Muscle: Activation of the beta2 receptor leads to
vascular and nonvascular smooth muscle relaxation. Drugs that activate the
beta2 receptor can be used to treat as asthma (by relaxing airway smooth
muscle) and premature labor (by relaxing uterine smooth muscle).
ALPHA RECEPTORS SYSTEMS:
The receptor mediating the vasconstrictor actions
of catecholamines is referred to as an alpha receptor.
Alpha receptors have been further subdivided into alpha1 and alpha2 receptors.
Both epinephrine and norepinephrine activates both the alpha1 and alpha2
receptors.
Presynaptic Alpha2 Receptors
Alpha2 receptors also exist presynaptically associated with nerve terminals.
Activation of these receptors inhibits the release of norepinephrine.
Norepinephrine acts at presynaptic alpha2 receptors to inhibit its own release.
Norepinephrine acts at presynaptic alpha2
receptors to inhibit its own release.
Postsynaptic Alpha1 Receptors on Vascular Smooth Muscle:
Associated with vascular smooth muscle are a large number of alpha1 receptors
relative to beta2 receptors. Activation of these receptors by sympathetic
nervous system transmission or drugs will result in vasoconstriction and an
increase in peripheral resistance and systemic arterial blood pressure.
Applications to Therapeutics
Oral dosing of norepinephrine or epinephrine is not possible due to the rapid
metabolism of catechol nucleus in gastrointestinal mucosa and liver. Therefore,
these agents are given I.V., I.M., topically and in aerosol sprays.
Epinephrine is often used in combination local anesthetic agents to prolong the
duration of anesthetic action. This would include articaine, bupivacaine or
lidocaine. This combination is used because epinephrine can induce
vasoconstriction thus limiting the diffusion of the local anesthetic from the
site of injection. This not only prolongs the actions of the local anesthetic
but also to reduce the toxicity of the local anesthetic by limiting its systemic
absorption. Lidocaine in toxic doses can produce cardiac arrthythmias and
convulsions.
Epinephrine can
also be topically applied in surgical procedures to induce vasoconstriction and
thus reduce blood loss. Epinephrine is used in the treatment of shock and in
emergency situations related to bronchial asthma.
Clinical studies have shown that epinephrine blood levels increase following its
intraoral administration. The risk of this increase is dependent on
characteristics of the patient. For example, hypertensive patients or those with
other cardiovascular disease or patients taking other drugs that affect
sympathetic nervous system function are at higher risk than patients without
these conditions. Systemically absorbed epinephrine could also increase heart
rate and exacerbate cardiac rhythm disturbances or myocardial ischemia.
Learning
Objectives Lecture II
1. Understand the potential sites of action for sympathomimetics and the
difference between a direct and indirect acting agonist.
2. Understand the pharmacologic actions and therapeutic actions of drugs that
act at the beta1 and beta2 -adrenergic receptors as well as the alpha1
-adrenergic receptor.
3. Know the mechanism of action and effects of amphetamine and cocaine.
4. Understand how the pressure of sympathomimetics alters the dental management
of patients.
Key Drugs*
Amphetamine-Adderall
Albuterol - Ventolin - 13th leading prescription drug in the US in 2003- source-
rxlist.com
Cocaine
Dopamine - Intropin
Methylphenidate - Ritalin - 102nd leading prescription drug in the US in 2003-
source- rxlist.com
Phenylephrine - Neosynephrine
* A more complete list of sympathomimetics and their trade names can be found on
p. 110-111 of the Yagiela text.
Sympathomimetics: synthetic analogs of naturally occurring catecholamines
that mimic the actions of the endogenous neurotransmitters. These agents can be
divided into direct and indirect acting sympathomimetics.
1. Direct acting agonists or antagonists can act at postsynaptic receptors.
2. Indirect acting agonists release neurotransmitters from presynaptic nerve
terminals to produce a sympathomimetic effect.
3. Inhibition of the membrane uptake of catecholamines by drugs such as cocaine
and tricyclic antidepressants produce a sympathomimetic effect.
4. Inhibition of monoamine oxidase by drugs such as Tranylcypromine.
SYMPATHOMIMETICS ACTING AT BETA RECEPTOR SYSTEMS
EXAMPLES:
Dopamine
Dobutamine
Beta2 agonists
Uses of Dopamine and Dobutamine
Congestive heart failure and cardiogenic shock.
In congestive heart failure, the failing heart is not able to eject blood as
efficiently as the normal heart. As a result there is a decrease in cardiac
output which triggers a host of compensatory actions. These include fluid
retention, vasoconstriction, an increase in peripheral vascular resistance, an
increase in the levels of circulating catecholamines and tissue hypoxia.
Dopamine and dobutamine activate the myocardial beta1 receptor and thus increase
the force of contraction of the failing heart. This will result in an increase
in cardiac output. These drugs are reserved for use in the acute management of
heart failure.
SELECTIVE BETA2 AGONISTS
These agents have a higher affinity (lower equilibrium dissociation constant)
for beta2 receptors when compared to beta1. Therefore, they selectively activate
beta2 receptors when compared to beta1.
Uses
1. Airways dysfunction; bronchial asthma, chronic bronchitis, emphysema
In airways dysfunction, beta2 selective agonists relax airways thus decreasing
airways resistance.
2. Premature labor
In premature labor, the beta2 selective agonists relax uterine smooth muscle.
Drugs that relax uterine smooth muscle are referred to as tocolytic agents.
Side effects related to dental practice
1. Xerostomia, with inhaler usage.
ALPHA1 AGONISTS
Direct Acting Agents
These are synthetic agents that directly activate the alpha1 -adrenergic
receptor. These structural modifications of the parent catecholamine nucleus
result in drugs that are orally active and have longer plasma half-lives.
However, these same modifications result in lower affinity for the receptor than
do the endogenous agonists (epinephrine or norepinephrine). There are two
structural classes of alpha1 agonists phenethylamines which are closely aligned
in structure to epinephrine and the imidazolines, compounds structurally
unrelated to epinephrine. Levonordeferin is a phenyethylamine that has been used
in dental practice in combination with local anesthetics.
Uses
1. Hypotension-to increase blood pressure during a surgical procedure where a
general anesthetic has induced hypotension
2. Ophthalmic preparations-to induce mydrasis also in topical preparations for
symptomatic release of eye irritation.
3. Cough and cold preparations-Induces constriction of nasal mucosa decreases
resistance to air flow.
Indirect Acting Sympathomimetics
These agents require the presence of endogenous
catecholamines to produce their effects. They have little activity if
catecholamines are depleted.
Cautions Relevant to
Dentistry
1) Cocaine and amphetamine-like agents (tricyclic antidepressants as well) could
potentiate the effects of direct acting agonists such as epinephrine. Recall
that epinephrine can be absorbed systemically after intraoral administration.
This epinephrine can be taken up by nerve terminals and this uptake contributes
to the the termination of the actions of epinephrine. Thus, the risk of
hypertension and other problems associated with systemic absorption of
epinephrine will be greater in patients taking cocaine or amphetamine-like
drugs.
2) An analog of amphetamine, methamphetamine, is produced illegally and is a
widely abused substance. Methamphetamine can be produced from over the counter
cough and cold medications such as pseudoephedrine. Lithium, muriatic acid,
sulfuric acid, red phosphorus and lye are used in this preparation. When smoked
these highly corrosive agents are vaporized resulting in significant damage to
teeth and gums.
Sympatholytics:
synthetic analogs which bind to beta or alpha receptors or act through other
mechanisms to block the actions of endogenous neurotransmitters or other
sympathomimetics.
Learning Objectives Lecture III
1. Review the pharmacodynamic properties and characteristics of antagonists.
2. Understand the pharmacologic properties and therapeutic uses of clonidine,
prazosin analogs, the beta blockers and MAO-inhibitors.
3. Understand the special precautions that exist for sympatholytic drugs in
dental practice.
Key Drugs*
Atenolol - Tenormin and various trade names - 4th leading prescription drug in
the US in 2003- source- rxlist.com
Clonidine - Minipres, various trade names
Propranolol - Inderal - various trade names
Terazosin - Hytrin
* A more complete list of sympatholytics and their trade names can be
found on p. 123 of the Yagiela text.
ALPHA2 AGONISTS AS SYMPATHOLYTICS
Clonidine
Actions and Therapeutic Uses
1. This drug stimulates alpha2 receptors in the nucleus tractus solitarius (NTS)
to decrease sympathetic outflow to the heart and blood vessels.
2. The decrease in sympathetic tone results in a decrease in peripheral vascular
resistance.
3. Clonidine is used in dental practice in the management of chronic pain. It
can be given orally or in patch form. Clonidine is a second-line
antihypertensive that has many other uses including opiate withdrawal, nicotine
withdrawal, vascular headaches, diabetic diarrhea, glaucoma, ulcerative colitis
and Tourette's syndrome.
Side Effects
The use of clonidine may result in clinical symptoms related to dry mouth, such
as difficulty in swallowing and speech. Chronic use of xerostomia-producing
drugs is associated with a higher incidence of oral candidiasis and dental
caries.
SELECTIVE ALPHA1-ANTAGONISTS
Prazosin and analogs, terazosin, doxazosin, trimazosin.
Effects on the Cardiovascular System:
1. Relaxes arterial and venous smooth muscle as well as nonvascular smooth
muscle.
2. Decreases peripheral vascular resistance and venous return with a resultant
decrease in systemic arterial blood pressure.
Uses
1. Hypertension
2. Benign prostatic hypertrophy
Tamsulosin specifically blocks the alpha1-receptor associated with the prostate
and is used to treat benign prostatic hypertropy.
The Relevance of Orthostatic Hypotension to Dental Practice
Orthostatic hypotension is a problem with prazosin analogs and to a lesser
extent tamsulosin. Significantly, orthostatsis is a problem that can be seen
with any vasodilator that affects the tone on venous smooth muscle. This would
include, organic nitrates, hydralazine, clonidine, minixodil and the many
drugs used to treat impotence. Orthostatic hypotension or postural
hypotension occurs when systemic arterial blood pressure falls by more than 20
mmHg upon standing. In this situation, cerebral perfusion falls and an
individual may become light headed, dizzy or pass out. In changing from the
supine to the standing position, gravity tends to cause blood to pool in the
lower extremities. However, several reflexes, including sympathetically mediated
venoconstriction minimize this pooling and maintain cerebral perfusion. If these
reflex actions do not occur, then orthostatic hypotension could result. By
blocking the alpha1-receptors associated with venous smooth muscle, prazosin-like
drugs, inhibit the sympathetically mediated vasoconstriction associated with
postural changes. Hence, orthostatic hypotension can occur. Drugs like clonidine
cause orthostasis due to its CNS actions that block the sympathetic reflexes.
Vasodilators such as nitrates, minoxidil, hydralazine or impotence medications
cause orthostasis because of their actions directly on the vasculature. A
consideration for patients being treated with some sympatholytics is the
patient's position during and after dental procedures. Suddenly standing
upright after being in a supine position in the dental chair is very apt to
cause syncope.
BETA ADRENERGIC RECEPTOR
BLOCKERS
Cardiovascular Uses
Hypertension, ischemic heart disease, supraventricular tachyarrhythmias.
1. These drugs are competitive antagonists of the beta adrenergic receptors
2. Beta blockers are either selective for the beta1 receptor or nonselective
beta1 and beta2
antagonists.
3. Propranolol is the
prototype Beta Blocker as well as the prototype of a nonselective beta blocker.
4. By blocking the myocardial beta1 receptor beta blockers, a) decrease the
force and rate of myocardial contraction, b) Decreases renal renin secretion
with the net result of c) decreasing systemic arterial blood pressure
5. A major disadvantage of nonselective beta blockers is the fact that they will
block beta2
receptors associated with airway or vascular smooth muscle. This is a
problem in treating patients with airway dysfunction or peripheral vascular
disease such as alpha1 adrengeric
receptor-mediated vasoconstrictor tone will be unoppsed by the beta2 receptors.
To overcome this disadvantage, antagonists that selectively block the beta1
receptor have been developed.
6. Atenolol is the prototype selective beta1 receptor beta blocker.
Applications to Dentistry
Because nonselective β-blockers block β2-receptor mediated vasodilation,
there is a risk of a hypertensive episode following administration of
local anesthetic agents that contain epinephrine. In this situation, the
vasoconstrictor actions of epinephrine at α1 -receptors are not opposed
by the vasodilatory actions of β2-receptors resulting in an exaggerated blood
pressure response that could be deleterious in patients with hypertension or
ischemic heart disease.
Side Effects
1. Sedation, fatigue
2. Exacerbation of peripheral vascular disease, airway dysfunction
Monoamine Oxidase
Inhibitors
1. These drugs inhibit monoamine oxidase and are used as antidepressants in
psychiatric practice.
2. A side effect that is not clearly understood is that these drugs can also
produce hypotension.
3. Can precipitate a hypertensive crisis. Patients taking MAO inhibitors must
not be given
drugs that have indirect sympathomimetic activity or are inactivated by MAO.
Occasionally,
the dentist may find reason to use the vasoconstrictor phenylephrine. Because it
causes even
a minor release of norepinephrine from adrenergic nerves and is subject to
metabolism by MAO,
phenylephrine must be avoided in patients taking MAO inhibitors. Epinephrine and
levonordefrin, which are most commonly found in local anesthetic solutions, are
not contraindicated, since they are direct agonists and are largely inactivated
by catechol-O-methyltransferase. Nonetheless, the avoidance of hemostatic
preparations containing high concentrations of epinephrine is
recommended.
4. Opioids and other CNS depressants should be used cautiously and usually at
lower doses in
patients who are taking MAO inhibitors. Meperidine is absolutely
contraindicated. The dentist
should reinforce the physician's instructions to the patient about dietary
restrictions and
contraindications of several drugs for patients taking MAO inhibitors.
Uses
1. Hypertension
2. Depression
The following is a list of trade names for the drugs mentioned in this handout.
It is provided for your information.
