Beta2-agonist eutomers: a rational option for the treatment of asthma?

Functional selectivity of GPCR ligand stereoisomers: new pharmacological opportunities

It is now well established that any given ligand for a G-protein-couple receptor (GPCR) does not simply possess a single defined efficacy. Rather, a ligand possesses multiple efficacies, depending on the specific down-stream signal transduction pathway analyzed. This diversity may be based on ligand-specific GPCR conformations and is often referred to as "functional selectivity." It has been known for a century that stereoisomers of catecholamines differ in their potency and, in some systems, also in their efficacy. However, the molecular basis for efficacy differences of GPCR ligand stereoisomers has remained poorly defined. In an elegant study published in this issue of Molecular Pharmacology, Woo et al. (p. 158) show that stereoisomers of the beta(2)-adrenoceptor selective agonist fenoterol differentially activates G(s)- and G(i)-proteins in native rat cardiomyocytes. This study is so important because it is the first report to show that even the subtle structural differences within a ligand stereoisomer pair are sufficient to discriminate between GPCR conformations with distinct G-protein coupling properties. The study highlights of how important it is to examine the "more active" (eutomer) and the "less active" (distomer) stereoisomer to understand the mechanisms of action and the cellular effects of GPCR ligands. The study by Woo et al. will ignite a renaissance of the analysis of ligand stereoisomers, using sensitive pharmacological and biophysical assays. The available literature supports the notion that meticulous analysis of ligand stereoisomers is a goldmine for understanding mechanisms of GPCR activation, analysis of signal transduction pathways, development of new therapies for important diseases, and drug safety.

(R)-albuterol for asthma: pro [a.k.a. (S)-albuterol for asthma: con]

Is there scientific evidence to support the replacement of the beta-agonist racemic albuterol with levalbuterol--that is, (R)-albuterol? The argument presented further refines the question as "Do we wish to continue to treat asthma with a mixture of albuterol, of which half is an agent with no known benefit--that is, (S)-albuterol--and which may exacerbate the disease?"

Single-enantiomer drugs: elegant science, disappointing effects

Most new drugs are marketed as single enantiomers but many older agents are still available in racemic form. As these drugs reach the end of their patent life manufacturers become interested in marketing single enantiomer equivalents. This is called 'chiral switching' and it has been claimed that it will bring clinical benefits in terms of improved efficacy, more predictable pharmacokinetics or reduced toxicity. We reviewed the clinical evidence and prices for three recently marketed single enantiomer versions of widely used racemic drugs: escitalopram, esomeprazole and levosalbutamol. Claims of increased efficacy were based on comparisons of non-equivalent doses and any advantages seemed small and clinically unimportant. Prices of esomeprazole and levosalbutamol were higher than their racemic alternatives and we predict that these prices will remain high despite the market presence of generic versions of the racemates. Patent protection and a perception of superiority based on promotion rather than evidence will maintain price premiums for single enantiomer drugs that are not justified on the basis of clinical performance.