Drug Receptors & Pharmacodynamics

Drug Receptors & Pharmacodynamics

Therapeutic and toxic effects of drugs result from their interac-tions with molecules in the patient. Most drugs act by associating with specific macromolecules in ways that alter the macromole-cules’ biochemical or biophysical activities. This idea, more than a century old, is embodied in the term receptor: the component of a cell or organism that interacts with a drug and initiates the chain of events leading to the drug’s observed effects.

Receptors have become the central focus of investigation of drug effects and their mechanisms of action (pharmacodynamics). The receptor concept, extended to endocrinology, immunology, and molecular biology, has proved essential for explaining many aspects of biologic regulation. Many drug receptors have been isolated and characterized in detail, thus opening the way to pre-cise understanding of the molecular basis of drug action.The receptor concept has important practical consequences for the development of drugs and for arriving at therapeutic decisions in clinical practice. These consequences form the basis for under-standing the actions and clinical uses of drugs described. They may be briefly summarized as follows:

1. Receptorslargely determine the quantitative relations between dose or concentration of drug and pharmacologic effects. The receptor’s affinity for binding a drug determines theconcentration of drug required to form a significant number of drug-receptor complexes, and the total number of receptors may limit the maximal effect a drug may produce.

2. Receptors are responsible for selectivity of drug action. Themolecular size, shape, and electrical charge of a drug determine whether—and with what affinity—it will bind to a particular receptor among the vast array of chemically different binding sites available in a cell, tissue, or patient. Accordingly, changes in the chemical structure of a drug can dramatically increase or decrease a new drug’s affinities for different classes of receptors, with resulting alterations in therapeutic and toxic effects.

3. Receptors mediate the actions of pharmacologic agonists and antagonists. Some drugs and many natural ligands, suchas hormones and neurotransmitters, regulate the function of receptor macromolecules as agonists; this means that they activate the receptor to signal as a direct result of binding to it. Some agonists activate a single kind of receptor to produce all their biologic functions, whereas others selectively promote one receptor function more than another.

Other drugs act as pharmacologic antagonists; that is, they bind to receptors but do not activate generation of a signal; con-sequently, they interfere with the ability of an agonist to activate the receptor. The effect of a so-called “pure” antagonist on a cell or in a patient depends entirely on its preventing the binding of agonist molecules and blocking their biologic actions. Other antagonists, in addition to preventing agonist binding, sup-press the basal signaling (“constitutive”) activity of receptors. Some of the most useful drugs in clinical medicine are phar-macologic antagonists.

CASE STUDY

A 51-year-old man presents to his medical clinic due to dif-ficulty breathing. The patient is afebrile and normotensive, but tachypneic. Auscultation of the chest reveals diffuse wheezes. The physician provisionally makes the diagnosis of bronchial asthma and administers epinephrine by intramus-cular injection, improving the patient’s breathing over several minutes. A normal chest X-ray is subsequently obtained, and the medical history is remarkable only for mild hyperten-sion that was recently treated with propranolol. The physi-cian instructs the patient to discontinue use of propranolol, and changes the patient’s antihypertensive medication to verapamil. Why is the physician correct to discontinue propranolol? Why is verapamil a better choice for managing hypertension in this patient?