Effects of beta-adrenoceptor agonists on airway smooth muscle and on slow-contracting skeletal muscle: in vitro and in vivo results compared

Beta-adrenoceptor agonists and asthma--100 years of development

Inhaled beta(2)-adrenoceptor agonists are by far the most effective and safe bronchodilators currently available. They have not been surpassed by any other bronchodilating principle. The way to this position has been long and started with the first successful treatment of acute, severe asthma with s.c. injections of adrenaline 100 years ago. Over the years, synthetic congeners of adrenaline have been produced and tested for their pharmacological properties. During the first decades, little attention was given airway smooth muscle. The discovery of isoprenaline in 1940 was the first major step towards selective bronchodilation. This compound became a key tool for the classification of adrenoceptors into alpha and beta. Salbutamol and terbutaline were the first to show a significant attenuation of the cardiostimulant effect and confirmed the subdivision of beta-adrenoceptors into beta(1) and beta(2). Much effort was made to eliminate the next dose-limiting side effect, skeletal muscle tremor but in vain. Prolonged duration of action was achieved in three ways: with bambuterol, an orally active carbamate ester prodrug of terbutaline, salmeterol, an inhaled beta(2)-adrenoceptor agonist emerging from a purposeful research project, and formoterol which was found, accidentally, to have a long duration of action when inhaled. Throughout the 20th century, beta-adrenoceptor agonists have been developed and marketed as racemates. The pharmacological activity usually resides in the (R)-enantiomer. Despite claims for the opposite, there is so far no compelling evidence that the presence of the less active (S)-enantiomer is of any harm to the patient. One hundred years of experience of structural modifications of adrenaline has shown that the possibilities to modify the properties of this endogenous prototype appear to be unlimited.

Comparison of the effects of salbutamol and adrenaline on airway smooth muscle contractility in vitro and on bronchial reactivity in vivo

BACKGROUND

The effect of adrenergic agonists in asthma depends on their net effect on microvascular leakage, mucosal oedema, vascular clearance of spasmogens, inhibition of cholinergic neurotransmission, and airway smooth muscle contractility. It has been postulated that adrenaline, by virtue of its alpha effects on the vasculature and cholinergic neurotransmission, may have additional useful properties in asthma compared with selective beta agonists such as salbutamol.

METHODS

The airway effects of adrenaline (a non-selective adrenoreceptor agonist) were compared with the selective beta 2 agonist salbutamol. Their airway smooth muscle relaxant potencies and effect on histamine contraction in human bronchi in vitro were compared with their effects on airway calibre and histamine reactivity in asthmatic subjects in vivo. For the in vitro studies changes in tension were measured in response to these agents in thoracotomy specimens of human airways. In vivo the effects of adrenaline and salbutamol on airway calibre and histamine reactivity were measured in eight subjects with mild to moderate asthma in a randomised crossover study.

RESULTS

Salbutamol and adrenaline had approximately equivalent airway smooth muscle relaxant potencies in vitro and bronchodilator potency in vivo. However, their effects on histamine induced contraction in vitro were significantly different from their effects on histamine reactivity in vivo. Salbutamol was less potent in vitro producing a mean (SE) 2.4 (0.15) doubling dose increase in the histamine EC20 and adrenaline a 5.2 (0.18) doubling dose increase (mean difference between salbutamol and adrenaline 2.8 doubling doses; 95% CI 1.1 to 4.5). Salbutamol had no effect on the maximal response to histamine whereas adrenaline reduced it by 54%. In contrast, salbutamol was more potent in vivo producing a mean (SE) increase in PD20 histamine of 1.84 (0.5) doubling doses whereas adrenaline was without effect increasing PD20 by only 0.06 (0.47) doubling doses (mean difference between adrenaline and salbutamol 1.78, 95% CI 0.26 to 3.29 doubling doses).

CONCLUSIONS

These findings suggest that the alpha adrenergic airway effects of non-selective adrenoreceptor agonists such as adrenaline offer no additional protection against histamine-induced broncho-constriction in vivo than beta 2 selective drugs such as salbutamol, despite adrenaline providing greater protection against histamine-induced contraction in vitro. The differences between the effects of these agents in vitro and in vivo may be related to their opposing vascular effects in vivo.

The use of beta-agonists and the risk of death and near death from asthma

BACKGROUND

Morbidity and mortality from asthma appear to be increasing, and it has been suggested that medications used to treat asthma are contributing to this trend. We investigated a possible association between death or near death from asthma and the regular use of beta 2-agonist bronchodilators.

METHODS

Using linked health insurance data bases from Saskatchewan, Canada, we conducted a matched case-control study of subjects drawn from a cohort of 12,301 patients for whom asthma medications had been prescribed between 1978 and 1987. We matched 129 case patients who had fatal or near-fatal asthma with 655 controls (who had received medications for asthma but had not had fatal or near-fatal events) with respect to region of residence, age, receipt of social assistance, and previous hospitalization for asthma.

RESULTS

The use of beta-agonists administered by a metered-dose inhaler was associated with an increased risk of death from asthma (odds ratio, 2.6 per canister per month; 95 percent confidence interval, 1.7 to 3.9) and of death or near death from asthma, considered together (odds ratio, 1.9; 95 percent confidence interval, 1.6 to 2.4). For death from asthma, use of the beta-agonist fenoterol was associated with an odds ratio of 5.4 per canister, as compared with 2.4 for the beta-agonist albuterol. On a microgram-equivalent basis, the odds ratio for this outcome with fenoterol was 2.3, as compared with 2.4 with albuterol.

CONCLUSIONS

An increased risk of death or near death from asthma was associated with the regular use of inhaled beta 2-agonist bronchodilators, especially fenoterol. Regardless of whether beta-agonists are directly responsible for these adverse effects or are simply a marker for more severe asthma, heavy use of these agents should alert clinicians that it is necessary to reevaluate the patient's condition.

Skeletal muscle tremor and the influence of adrenergic drugs

Physiologic postural skeletal muscle tremor is enhanced by beta 2 receptor agonist such as those used in the treatment of asthma. This is a peripheral response rather than one occurring at the central nervous system level. It is greatest when drugs are administered by the oral or parenteral routes, and is the most important dose-limiting factor for oral administration. Clinically important tremor is minimal after aerosolized administration of clinically recommended doses of aerosolized beta 2 receptor agonists, but can be significant when larger doses are administered. Sympathomimetic drugs which can selectively stimulate airway beta 2 receptors, as opposed to skeletal muscle beta 2 receptors, do not currently exist. Combining orally administered beta 2 agents with theophylline potentiates the effects on muscle tremor. There does not seem to be a clinical advantage, in terms of reduced side effects such as muscle tremor, to combining "small doses" of oral beta agonists and theophylline as opposed to using either agent alone in optimal doses. Tolerance to the tremoregenic effects of beta 2 agonists appears to occur when these agents are administered on a chronic basis. Thus, there may be some rationale for beginning oral beta agonists initially with lower doses and progressively increasing to full doses over a period of days to weeks.

Effects of oral terbutaline in chronic airflow limitation

A randomized, double-blind, crossover study was conducted to assess the efficacy of five weeks' treatment with terbutaline, 15 mg daily, compared with placebo in 17 evaluable patients with moderate to severe chronic airflow limitation (CAL) with a minor reversible component. A significant improvement after terbutaline treatment compared with placebo was observed in subjective assessments of breathlessness after two of the activities of daily living, and in daily peak flow measurements recorded in patient diaries. At the clinical assessment after five weeks' terbutaline therapy, 12 of 17 patients had improved pulmonary symptom scores compared with placebo, and a slight increase in FEV1 was observed relative to placebo (0.09 L, p less than 0.05). Thus, five weeks' treatment with oral terbutaline in patients with CAL resulted in significant improvements in several subjective assessments, despite a lack of effect on the majority of the objective variables.

An investigation of the beta-adrenoceptor that mediates metabolic responses to the novel agonist BRL28410 in rat soleus muscle

The beta-adrenoceptor agonist BRL26830A selectively stimulates metabolic rate in the rat and this thermic effect is resistant to blockade by propranolol. These effects of BRL26830A are partly due to selective stimulation by its metabolite BRL28410, of brown adipocyte beta-adrenoceptors, these receptors being resistant to propranolol. To investigate whether the metabolic effects of BRL28410 in skeletal muscle are also mediated by atypical beta-adrenoceptors, the potencies of BRL28410 and isoprenaline were compared for beta-adrenoceptor mediated responses in rat stripped soleus muscle. In addition, pA2 values for antagonism by propranolol of these responses were determined. Isoprenaline had similar EC50 values for stimulation of lactate formation (4.3 X 10(-9) M) and inhibition of glycogen synthesis (3.4 X 10(-9) M) and these values are similar to its reported EC50 values for stimulation of atrial rate (beta 1-adrenoceptor-mediated) and relaxation of the uterus (beta 2-adrenoceptor-mediated). BRL28410 had similar EC50 values for stimulation of lactate formation (3.7 X 10(-6) M) and inhibition of glycogen synthesis (3.8 X 10(-6) M). These values are only about two-fold less than reported values for relaxation of the uterus, but ten-fold less than reported values for stimulation of atrial rate. The pA2 value of dl-propranolol for antagonism of the effect of isoprenaline on glycogen synthesis (8.38 +/- 0.13) was in the range expected for beta 1- or beta 2-adrenoceptors, but with BRL28410 as agonist the pA2 value was about one unit lower (7.39 +/- 0.11). The beta-adrenoceptors that mediate the metabolic effects of BRL28410 in soleus muscle therefore differ from those that mediate atrial rat, uterine relaxation and adipocyte lipolysis. In addition, the low pA2 value of dl-propranolol versus BRL28410 in rat soleus muscle, which contrasts with the normal pA2 value previously reported for guinea-pig trachea, suggests that beta 2-adrenoceptors in these two tissues can be differentiated with suitable pharmacological agents.

Partial agonism and functional selectivity: a study on beta-adrenoceptor mediated effects in tracheal, cardiac and skeletal muscle

Colterol, procaterol, sulfonterol, terbutaline and three monophenolic derivatives of terbutaline were examined with respect to their ability to react in vitro on beta-adrenoceptors in tissues isolated from guinea-pig. The effects measured were a) relaxation of the tracheal smooth muscle (mostly beta 2), b) depression of subtetanic contractions of the soleus muscle (beta 2), and c) increase in the force of the papillary muscle of the left ventricle (beta 1). Antagonistic effects were measured against isoprenaline as an agonist. The compounds studied showed a wide variation in selectivity, potency and intrinsic activity. All agonists showed a pronounced beta 2-selectivity, in general characterized by a higher intrinsic activity at beta 2- than at beta 1-adrenoceptors, while differences in affinity, as judged from the pA2-values were small. Partial agonists, such as sulfonterol, which did not cause a complete relaxation of a moderately contracted tracheal muscle, produced identical concentration-response curves from the trachea and soleus muscle. It is concluded that partial agonism at beta 1-adrenoceptors is an important factor for functional selectivity of beta 2-adrenoceptor agonists. On the other hand there seems to be no useful differences between the maximum effect elicited by a partial beta 2-adrenoceptor agonist on the skeletal muscle as compared with airway smooth muscle.

Further studies on the cardiomegaly induced by beta-adrenoceptor agonists

Rats received continuous infusions of beta-adrenoceptor agonists by means of Alzet osmotic minipumps implanted subcutaneously. After 7 days of isoprenaline infusion (2 mg/kg per day) the heart/body weight ratio increased about 40 per cent compared with placebo treatment. The difference persisted after freeze-drying indicating a true hypertrophy and not merely an oedema. When terbutaline (20 mg/kg per day) was substituted for isoprenaline, the increase in wet weight ratio reached only about 5 per cent. Procaterol (2 mg/kg per day) and pirbuterol (20 mg/kg per day) had no effect on the heart weight. It is concluded that in doses expected to cause comparable stimulation of beta 2-adrenoceptors the unselective agonist isoprenaline is able, more than the beta 2-selective agonists terbutaline, procaterol and pirbuterol to cause cardiac hypertrophy thus indicating the involvement of beta 1-adrenoceptors.

Pharmacological characterization of the postjunctional beta-adrenoceptors in the rat gastric fundus

In order to characterize the postjunctional beta-adrenoceptors in the rat gastric fundus, we studied the influence of beta-agonists and beta-antagonists on methacholine-contracted fundus strips. The mixed beta-agonist isopropylnoradrenaline and the beta 2-selective agonist fenoterol had a concentration-dependent relaxing effect and at higher concentrations completely inhibited the methacholine-induced tone. The reputedly beta 1-selective agonist prenalterol only produced about 50% inhibition and another reputedly beta 1-selective agonist, tazolol, had almost no relaxing effect. The beta-antagonists propranolol (beta 1 + beta 2), practolol (beta 1), H35/25 (beta 2) and ICI 118,551 (beta 2) all shifted the concentration-response curves for isopropylnoradrenaline and fenoterol in a parallel way to the right, but the slope of the Schild plot was not significantly different from 1 only for the antagonism of isopropylnoradrenaline by H35/25. The relaxing effect of prenalterol was only clearly antagonized by ICI 118,551. The results suggest that postjunctional beta 1- and beta 2-adrenoceptors are present in the rat gastric fundus.

Some problems encountered in the evaluation of new bronchodilating beta-adrenoceptor agonists

A series of phenylethanolamine derivatives were examined with respect to their bronchospasmolytic effect and their ability to depress the contractions of the soleus muscle in cat and guinea-pig. One group of compounds including D2343 (1-(4-hydroxyphenyl)-2-[1,1-dimethyl-3-(2-methoxyphenyl) propylamino]-ethanol HCl), a new beta 2-adrenoceptor agonist, appeared to be more effective in combating bronchospasm induced by histamine than in depressing the contractions of the soleus muscle in anaesthetized cat. This difference disappeared when serotonin was used to induce bronchospasm. Terbutaline antagonized histamine and serotonin equally well. Experiments in vivo and in vitro with guinea-pigs gave ambiguous results. Slowly developing effects was a common feature of the compounds showing the apparent effect separation. None of the available beta-adrenoceptor agonists appears to distinguish between the adrenoceptors in the airway smooth muscle mediating bronchial relaxation and those in the skeletal muscle associated with tremor.

Selective development of tolerance to beta-adrenoceptor agonists in skeletal muscle as compared with airway smooth muscle from the guinea-pig

1. Guinea-pig were fed with a diet containing terbutaline or placebo for 4--5 days. The trachea, soleus muscle and the extensor digitorum longus (EDL) from these animals were prepared for recording of isometric contractions in vitro. 2. After treatment with terbutaline in vivo, the response of the pilocarpine-contracted trachea to terbutaline and isoprenaline was slightly suppressed with no change in maximum relaxation. 3. After treatment with terbutaline in vivo the maximum depression of the incomplete tetanic contractions of the soleus muscle brought about by terbutaline or isoprenaline was diminished by about 70%. The response of the EDL was also attenuated after previous treatment with terbutaline in vivo. 4. These data indicate a selective development of tolerance to the effects of beta-adrenoceptor agonists in skeletal muscle as compared with tracheal smooth muscle. 5. The present results provide an experimental analogue to the clinical observation that patients being treated with beta-adrenoceptor agonists become tolerant to the tremorogenic rather than to the bronchodilating effect.

Beta-adrenergic activity in human proximal urethra: a study with terbutaline

Beta-adrenergic activity in the proximal urethra was studied in 15 patients with neurogenic bladder dysfunction owing to spinal cord injury or to neurogenic disease. Maximum urethral closure pressure was recorded before and after the administration of terbutaline, a beta-2 agonist. The average decrease in maximum urethral closure pressure after subcutaneous injection of terbutaline was 40.46 per cent and this was significant (p less than 0.001). The clinical implications of this finding are discussed.

Functional and metabolic effects of terbutaline and propranolol in fast- and slow-contracting skeletal muscle in vitro

The soleus, a slow-contracting, and the extensor digitorum longus (EDL), a fast-contracting skeletal muscle from guinea-pig were prepared for isometric recording of sub-tetanic contractions in vitro. The contents of adenosine-triphosphate (ATP) and creatinephosphate (CP) together with their metabolites and the contents of lactate, pyruvate and cyclic adenosine-monophosphate (c-AMP) in the muscles were determined. It was found that the energy and redox state of the isolated soleus and EDL muscles is very stable and does not significantly differ from the normal state in vivo. Moreover, there were no consistent changes in these variables after treatment with terbutaline (a beta 2-adrenoceptor agonist) or propranolol or both. Thus, effects on energy metabolism do not seem to cause the changes in muscle contraction, characteristic for beta-adrenoceptor stimulation. On the other hand, the functional effects were accompanied by elevation of the c-AMP level of the muscles.

Beta 2-adrenoceptors mediate the stimulating effect of adrenaline on active electrogenic Na-K-transport in rat soleus muscle

The relative role of beta 1- and beta 2-adrenoceptors in mediating the stimulating effect of adrenaline on active electrogenic Na-K-transport has been assessed in experiments on rat soleus muscles in vitro and in vivo. 2 In the rat isolated soleus muscle, adrenaline (10(-6) M) increases the resting membrane potential (EM) by 5.8 mV and stimulates 22Na-efflux and ouabain-suppressible 42K-uptake by 91 and 94%, respectively. 3 All of these effects are completely blocked by propranolol (10(-5) M), whereas the beta 1-selective adrenoceptor antagonist, metoprolol, was found to be at least 50 times less potent. 4 The beta 2-adrenoceptor agonist, salbutamol, was at least 100 times as potent as H133/22 (a beta 1-selective agonist) in stimulating 22Na-efflux and 42K-influx. 5 In experiments performed under pentobarbitone anaesthesia, the intravenous injection of adrenaline (5 microgram) or salbutamol (0.5 to 50 microgram) led to a rapid and marked increase in the EM of the exposed soleus muscle. This hyperpolarizing effect could not be accounted for by the concomitant, relatively modest change in extracellular K.

The adrenoceptor blocking properties of the new beta 2-selective antagonist, IPS 339 on tracheal smooth muscle and on slow contracting skeletal muscle

The beta-adrenoceptor blocking properties of IPS 339 and propranolol were studied on isolated preparations of trachea and of the slow-contracting soleus muscle from the guinea-pig. Both compounds antagonized the relaxation of the trachea and the depression of subtetanic contractions of the soleus produced by the beta2-selective agonist, terbutaline. On the soleus muscle the pA2-values for IPS 339 and propranolol were similar and close to those obtained for propranolol on the trachea. However, on the trachea the slope of the Schildplot for IPS 339 against terbutaline became less than one and a reliable pA2-value could not be calculated.