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McCullock TW, Cardani LP, Kammermeier PJ. Signaling Specificity and Kinetics of the Human Metabotropic Glutamate Receptors. Mol Pharmacol 2024; 105:104-115. [PMID: 38164584 PMCID: PMC10794986 DOI: 10.1124/molpharm.123.000795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/13/2023] [Accepted: 11/08/2023] [Indexed: 01/03/2024] Open
Abstract
Metabotropic glutamate receptors (mGluRs) are obligate dimer G protein coupled receptors that can all function as homodimers. Here, each mGluR homodimer was examined for its G protein coupling profile using a bioluminescence resonance energy transfer-based assay that detects the interaction between a split YFP-tagged Gβ 1γ2 and a Nanoluciferase tagged free Gβγ sensor, MAS-GRK3-ct- nanoluciferase with 14 specific Gα proteins heterologously expressed, representing each family. Canonically, the group II and III mGluRs (2 and 3 and 4, 6, 7, and 8, respectively) are thought to couple to Gi/o exclusively. In addition, the group I mGluRs (1 and 5) are known to couple to the Gq/11 family and generally thought to also couple to the pertussis toxin-sensitive Gi/o family some reports have suggested Gs coupling is possible as cAMP elevations have been noted. In this study, coupling was observed with all eight mGluRs through the Gi/o proteins and only mGluR1 and mGluR5 through Gq/11, and, perhaps surprisingly, not G14 None activated any Gs protein. Interestingly, coupling was seen with the group I and II but not the group III mGluRs to G16 Slow but significant coupling to Gz was also seen with the group II receptors. SIGNIFICANCE STATEMENT: Metabotropic glutamate receptor (mGluR)-G protein coupling has not been thoroughly examined, and some controversy remains about whether some mGluRs can activate Gαs family members. Here we examine the ability of each mGluR to activate representative members of every Gα protein family. While all mGluRs can activate Gαi/o proteins, only the group I mGluRs couple to Gαq/11, and no members of the family can activate Gαs family members, including the group I receptors alone or with positive allosteric modulators.
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Affiliation(s)
- Tyler W McCullock
- Department of Pharmacology and Physiology, University of Rochester Medical Center, Rochester, New York
| | - Loren P Cardani
- Department of Pharmacology and Physiology, University of Rochester Medical Center, Rochester, New York
| | - Paul J Kammermeier
- Department of Pharmacology and Physiology, University of Rochester Medical Center, Rochester, New York
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2
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McCullock TW, Cardani LP, Kammermeier PJ. Signaling specificity and kinetics of the human metabotropic glutamate receptors. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.07.24.550373. [PMID: 37546908 PMCID: PMC10402105 DOI: 10.1101/2023.07.24.550373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Metabotropic glutamate receptors (mGluRs) are obligate dimer G protein coupled receptors that can all function as homodimers. Here, each mGluR homodimer was examined for its G protein coupling profile using a BRET based assay that detects the interaction between a split YFP-tagged Gβ1γ2 and a Nanoluc tagged free Gβγ sensor, MAS-GRK3-ct-NLuc with 14 specific Ga proteins heterologously expressed, representing each family. Canonically, the group II and III mGluRs (2&3, and 4, 6, 7&8, respectively) are thought to couple to Gi/o exclusively. In addition, the group I mGluRs (1&5) are known to couple to the Gq/11 family, and generally thought to also couple to the PTX-sensitive Gi/o family; some reports have suggested Gs coupling is possible as cAMP elevations have been noted. In this study, coupling was observed with all 8 mGluRs through the Gi/o proteins, and only mGluR1&5 through Gq/11, and perhaps surprisingly, not G14. None activated any Gs protein. Interestingly, coupling was seen with the group I and II, but not the group III mGluRs to G16. Slow but significant coupling to Gz was also seen with the group II receptors.
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Affiliation(s)
- Tyler W. McCullock
- Department of Pharmacology and Physiology, University of Rochester Medical Center, Rochester, NY 14642
| | - Loren P. Cardani
- Department of Pharmacology and Physiology, University of Rochester Medical Center, Rochester, NY 14642
| | - Paul J. Kammermeier
- Department of Pharmacology and Physiology, University of Rochester Medical Center, Rochester, NY 14642
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3
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Hellyer SD, Albold S, Sengmany K, Singh J, Leach K, Gregory KJ. Metabotropic glutamate receptor 5 (mGlu 5 )-positive allosteric modulators differentially induce or potentiate desensitization of mGlu 5 signaling in recombinant cells and neurons. J Neurochem 2019; 151:301-315. [PMID: 31376155 DOI: 10.1111/jnc.14844] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/17/2019] [Accepted: 07/31/2019] [Indexed: 12/14/2022]
Abstract
Allosteric modulators of metabotropic glutamate receptor 5 (mGlu5 ) are a promising therapeutic strategy for a number of neurological disorders. Multiple mGlu5 -positive allosteric modulator (PAM) chemotypes have been discovered that act as either pure PAMs or as PAM-agonists in recombinant and native cells. While these compounds have been tested in paradigms of receptor activation, their effects on receptor regulatory processes are largely unknown. In this study, acute desensitization of mGlu5 mediated intracellular calcium mobilization by structurally diverse mGlu5 orthosteric and allosteric ligands was assessed in human embryonic kidney 293 cells and primary murine neuronal cultures from both striatum and cortex. We aimed to determine the intrinsic efficacy and modulatory capacity of diverse mGlu5 PAMs [(R)-5-((3-fluorophenyl)ethynyl)-N-(3-hydroxy-3-methylbutan-2-yl)picolinamide (VU0424465), N-cyclobutyl-6-((3-fluorophenyl)ethynyl)picolinamide (VU0360172), 1-(4-(2,4-difluorophenyl)piperazin-1-yl)-2-((4-fluorobenzyl)oxy)ethanone (DPFE), ((4-fluorophenyl) (2-(phenoxymethyl)-6,7-dihydrooxazolo[5,4-c]pyridin-5(4H)-yl)methanone) (VU0409551), 3-Cyano-N-(1,3-diphenyl-1H-pyrazol-5-yl)benzamide (CDPPB)] on receptor desensitization and whether cellular context influences receptor regulatory processes. Only VU0424465 and VU0409551 induced desensitization alone in human embryonic kidney 293-mGlu5 cells, while all PAMs enhanced (S)-3,5-dihydroxyphenylglycine (DHPG)-induced desensitization. All mGlu5 PAMs induced receptor desensitization alone and enhanced DHPG-induced desensitization in striatal neurons. VU0424465 and VU0360172 were the only PAMs that induced desensitization alone in cortical neurons. With the exception of (CDPPB), PAMs enhanced DHPG-induced desensitization in cortical neurons. Moreover, differential apparent affinities, efficacies, and cooperativities with DHPG were observed for VU0360172, VU0409551, and VU0424465 when comparing receptor activation and desensitization in a cell type-dependent manner. These data indicate that biased mGlu5 allosteric modulator pharmacology extends to receptor regulatory processes in a tissue dependent manner, adding yet another layer of complexity to rational mGlu5 drug discovery.
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Affiliation(s)
- Shane D Hellyer
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences and Department of Pharmacology, Monash University, Parkville, Victoria, Australia
| | - Sabine Albold
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences and Department of Pharmacology, Monash University, Parkville, Victoria, Australia
| | - Kathy Sengmany
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences and Department of Pharmacology, Monash University, Parkville, Victoria, Australia
| | - Junaid Singh
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences and Department of Pharmacology, Monash University, Parkville, Victoria, Australia
| | - Katie Leach
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences and Department of Pharmacology, Monash University, Parkville, Victoria, Australia
| | - Karen J Gregory
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences and Department of Pharmacology, Monash University, Parkville, Victoria, Australia
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4
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Benjamin ER, Haftl SL, Xanthos DN, Crumley G, Hachicha M, Valenzano KJ. A Miniaturized Column Chromatography Method for Measuring Receptor-Mediated Inositol Phosphate Accumulation. ACTA ACUST UNITED AC 2016; 9:343-53. [PMID: 15191651 DOI: 10.1177/1087057103262841] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Inositol phosphates (IPs), such as 1,4,5-inositol-trisphosphate (IP3), comprise a ubiquitous intracellular signaling cascade initiated in response to G protein-coupled receptor-mediated activation of phospholipase C. Classical methods for measuring intracellular accumulation of these molecules include time-consuming high-performance liquid chromatography (HPLC) separation or large-volume, gravity-fed anion-exchange column chromatography. More recent approaches, such as radio-receptor and AlphaScreen™ assays, offer higher throughput. However, these techniques rely on measurement of IP3itself, rather than its accumulation with other downstream IPs, and often suffer from poor signal-to-noise ratios due to the transient nature of IP3. The authors have developed a miniaturized, anion-exchange chromatography method for measuring inositol phosphate accumulation in cells that takes advantage of signal amplification achieved through measuring IP3and downstream IPs. This assay uses centrifugation of 96-well-formatted anion-exchange mini-columns for the isolation of radiolabeled inositol phosphates from cell extracts, followed by low-background dry-scintillation counting. This improved assay method measures receptor-mediated IP accumulation with signal-to-noise and pharmacological values comparable to the classical large-volume, column-based methods. Assay validation data for recombinant muscarinic receptor 1, galanin receptor 2, and rat astrocyte metabotropic glutamate receptor 5 are presented. This miniaturized protocol reduces reagent usage and assay time as compared to large-column methods and is compatible with standard 96-well scintillation counters.
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MESH Headings
- Animals
- Astrocytes/metabolism
- Base Sequence
- CHO Cells
- Cell Line
- Chromatography, Ion Exchange/instrumentation
- Chromatography, Ion Exchange/methods
- Cricetinae
- DNA, Complementary/genetics
- Humans
- Inositol 1,4,5-Trisphosphate
- Inositol Phosphates/analysis
- Inositol Phosphates/metabolism
- Miniaturization/instrumentation
- Miniaturization/methods
- Rats
- Receptor, Galanin, Type 2/genetics
- Receptor, Galanin, Type 2/metabolism
- Receptor, Metabotropic Glutamate 5
- Receptor, Muscarinic M1/metabolism
- Receptors, G-Protein-Coupled/metabolism
- Receptors, Metabotropic Glutamate/metabolism
- Recombinant Proteins/genetics
- Recombinant Proteins/metabolism
- Signal Transduction
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Affiliation(s)
- Elfrida R Benjamin
- Purdue Pharma Discovery Research, 6 Cedarbrook Drive, Cranbury, NJ 08512, USA.
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5
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Jong YJI, Sergin I, Purgert CA, O'Malley KL. Location-dependent signaling of the group 1 metabotropic glutamate receptor mGlu5. Mol Pharmacol 2014; 86:774-85. [PMID: 25326002 DOI: 10.1124/mol.114.094763] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Although G protein-coupled receptors are primarily known for converting extracellular signals into intracellular responses, some receptors, such as the group 1 metabotropic glutamate receptor, mGlu5, are also localized on intracellular membranes where they can mediate both overlapping and unique signaling effects. Thus, besides "ligand bias," whereby a receptor's signaling modality can shift from G protein dependence to independence, canonical mGlu5 receptor signaling can also be influenced by "location bias" (i.e., the particular membrane and/or cell type from which it signals). Because mGlu5 receptors play important roles in both normal development and in disorders such as Fragile X syndrome, autism, epilepsy, addiction, anxiety, schizophrenia, pain, dyskinesias, and melanoma, a large number of drugs are being developed to allosterically target this receptor. Therefore, it is critical to understand how such drugs might be affecting mGlu5 receptor function on different membranes and in different brain regions. Further elucidation of the site(s) of action of these drugs may determine which signal pathways mediate therapeutic efficacy.
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Affiliation(s)
- Yuh-Jiin I Jong
- Department of Anatomy and Neurobiology, Washington University School of Medicine, St. Louis, Missouri
| | - Ismail Sergin
- Department of Anatomy and Neurobiology, Washington University School of Medicine, St. Louis, Missouri
| | - Carolyn A Purgert
- Department of Anatomy and Neurobiology, Washington University School of Medicine, St. Louis, Missouri
| | - Karen L O'Malley
- Department of Anatomy and Neurobiology, Washington University School of Medicine, St. Louis, Missouri
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6
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Herrold AA, Voigt RM, Napier TC. Brain region-selective cellular redistribution of mGlu5 but not GABA(B) receptors following methamphetamine-induced associative learning. Synapse 2011; 65:1333-43. [PMID: 21780181 DOI: 10.1002/syn.20968] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 06/16/2011] [Indexed: 12/21/2022]
Abstract
Alterations in receptor expression and distribution between cell surface and cytoplasm are means by which psychostimulants regulate neurotransmission. Metabotropic glutamate receptor group I, subtype 5 (mGluR5) and GABA(B) receptors (GABA(B) R) are critically involved in the development and expression of stimulant-induced behaviors, including conditioned place preference (CPP), an index of drug-seeking. However, it is not known if psychostimulant-induced CPP alters the trafficking of these receptors. To fill this gap, this study used methamphetamine (Meth)-induced CPP in rats to ascertain if receptor changes occur in limbic brain regions that regulate drug-seeking, the medial prefrontal cortex (mPFC), nucleus accumbens (NAc), and ventral pallidum (VP). To do so, ex vivo tissue was assessed for changes in expression and surface vs. intracellular distribution of mGluR5 and GABA(B) Rs. There was a decrease in the surface to intracellular ratio of mGluR5 in the mPFC in Meth-conditioned rats, commensurate with an increase in intracellular levels. mGluR5 levels in the NAc or the VP were unaltered. There were no changes for GABA(B) R in any brain region assayed. This ex vivo snapshot of metabotropic glutamate and GABA receptor cellular distribution following induction of Meth-induced CPP is the first report to determine if these receptors are differentially altered after Meth-induced CPP. The results suggest that this Meth treatment paradigm likely induced a compensatory change in mGluR5 surface to intracellular ratio such that the surface remains unaltered while an increase in intracellular protein occurred.
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Affiliation(s)
- Amy A Herrold
- Department of Pharmacology, Rush University Medical Center, Chicago, Illinois 60612, USA
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7
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Kim CH, Lee J, Lee JY, Roche KW. Metabotropic glutamate receptors: phosphorylation and receptor signaling. J Neurosci Res 2008; 86:1-10. [PMID: 17663464 DOI: 10.1002/jnr.21437] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Metabotropic glutamate receptors (mGluRs) play important roles in neurotransmission, neuronal development, synaptic plasticity, and neurological disorders. Recent studies have revealed a sophisticated interplay between mGluRs and protein kinases: activation of mGluRs regulates the activity of a number of kinases, and direct phosphorylation of mGluRs affects receptor signaling, trafficking, and desensitization. Here we review the emerging literature on mGluR phosphorylation, signaling, and synaptic function.
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Affiliation(s)
- Chul Hoon Kim
- Department of Pharmacology, Brain Research Institute, Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea.
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8
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Ferguson SSG. Phosphorylation-independent attenuation of GPCR signalling. Trends Pharmacol Sci 2007; 28:173-9. [PMID: 17350109 DOI: 10.1016/j.tips.2007.02.008] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2006] [Revised: 01/02/2007] [Accepted: 02/21/2007] [Indexed: 02/03/2023]
Abstract
The uncoupling of G-protein-coupled receptors (GPCRs) from their cognate heterotrimeric G proteins provides an essential physiological 'feedback' mechanism that protects against both acute and chronic overstimulation of receptors. The primary mechanism by which GPCR activity is regulated is the feedback phosphorylation of activated GPCRs by kinases that are dependent on second messengers, GPCR kinases (GRKs) and arrestins. It has recently become apparent, however, that GRK2-mediated regulation of GPCR responsiveness also involves a phosphorylation-independent component that requires both heterotrimeric G-protein alpha-subunit interactions and GPCR binding. Moreover, in addition to GRK2, a growing number of GPCR-interacting proteins might contribute to the phosphorylation-independent G-protein uncoupling of GPCRs. Here, new information about the mechanisms underlying this phosphorylation-independent regulation of receptor and G-protein coupling is reviewed.
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Affiliation(s)
- Stephen S G Ferguson
- J. Allyn Centre for Cell Biology, Robarts Research Institute, 100 Perth Drive, PO Box 5015, London, Ontario N6A 5K8, Canada.
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9
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Morita M, Susuki J, Amino H, Yoshiki F, Moizumi S, Kudo Y. Use of the exogenous Drosophila octopamine receptor gene to study Gq-coupled receptor-mediated responses in mammalian neurons. Neuroscience 2006; 137:545-53. [PMID: 16289891 DOI: 10.1016/j.neuroscience.2005.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2004] [Revised: 08/31/2005] [Accepted: 09/03/2005] [Indexed: 10/25/2022]
Abstract
Diverse excitatory and inhibitory neuronal responses are mediated via Gq-coupled receptors, but the lack of a systematic comparison of different receptors or neurons has hindered a better understanding of these responses. Such a comparison may be provided by an exogenous receptor that is activated by compounds that have no effect on endogenous receptors. We therefore expressed an invertebrate biogenic amine receptor, the Drosophila octopamine receptor, in rat cortical neurons and compared octopamine receptor-mediated responses with those mediated by the group I metabotropic glutamate receptor, the endogenous Gq-coupled receptor in rat cortical neurons. Stimulation of either receptor did not result in a calcium response in octopamine receptor-expressing neurons, although octopamine preferentially elicited a calcium increase in octopamine receptor-expressing PC12h cells, while enhancing the neuronal depolarization-induced calcium increase and the electrical excitability. The increased excitability was caused by inward currents resulting from a reduction in the leak current, which was voltage-independent and blocked by genistein, a non-selective tyrosine kinase inhibitor. These results show that, in cortical neurons, exogenous octopamine receptor in mushroom bodies activated the same cell signaling pathway as endogenous metabotropic glutamate receptor, suggesting that the diverse neuronal responses mediated by Gq-coupled receptors are due to the properties of different neurons, rather than to the properties of the receptors.
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Affiliation(s)
- M Morita
- Laboratory of Cellular Neurobiology, School of Life Science, Tokyo University of Pharmacy and Life Science, 1432-1, Horinouchi, Hachioji, 192-0392, Japan.
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10
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Abstract
Why is the characteristic timescale of neural information processing in the millisecond range, corresponding to a 'clock speed' of about 1 kHz, whereas the clock speed of modern computers is about 3 GHz? Here we investigate how the brain's energy supply limits the maximum rate at which the brain can compute, and how the molecular components of excitatory synapses have evolved properties that are matched to the information processing they perform.
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Affiliation(s)
- David Attwell
- Department of Physiology, University College London, London WC1E 6BT, UK.
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11
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Sánchez-Prieto J, Paternain AV, Lerma J. Dual signaling by mGluR5a results in bi-directional modulation of N-type Ca2+ channels. FEBS Lett 2004; 576:428-32. [PMID: 15498574 DOI: 10.1016/j.febslet.2004.09.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2004] [Accepted: 09/09/2004] [Indexed: 10/26/2022]
Abstract
We have studied how N-type Ca2+ channels are modulated by the metabotropic glutamate receptor 5a (mGluR5a) in Xenopus oocytes. Stimulation of the receptor with glutamate initiated two parallel responses, a rapid inhibition followed by an upregulation of the Ca2+ current. Although a subsequent stimulation did not upregulate the Ca2+ current, it did still produce a reduction in the amplitude of the current. The upregulation of Ca2+ channels was prevented by the protein kinases inhibitor staurosporine and it was mimicked by the activation of PKC with phorbol esters. In contrast, the inhibition of the Ca2+ current was insensitive to staurosporine. These results show that mGluR5a exerts a bi-directional influence on Ca2+ channels, which may explain how group I mGluRs facilitate and inhibit glutamate release at central synapses.
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Affiliation(s)
- J Sánchez-Prieto
- Instituto Cajal, Consejo Superior de Investigaciones Científicas, 28002 Madrid, Spain.
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Lu Y, Rubel EW. Activation of metabotropic glutamate receptors inhibits high-voltage-gated calcium channel currents of chicken nucleus magnocellularis neurons. J Neurophysiol 2004; 93:1418-28. [PMID: 15371493 DOI: 10.1152/jn.00659.2004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Using whole cell patch-clamp recordings, we pharmacologically characterized the voltage-gated Ca2+ channel (VGCC) currents of chicken nucleus magnocellularis (NM) neurons using barium as the charge carrier. NM neurons possessed both low- and high-voltage-activated Ca2+ channel currents (HVA I(Ba2+)). The N-type channel blocker (omega-conotoxin-GVIA) inhibited more than half of the total HVA I(Ba2+), whereas blockers of L- and P/Q-type channels each inhibited a small fraction of the current. Metabotropic glutamate receptor (mGluR)-mediated modulation of the HVA I(Ba2+) was examined by bath application of glutamate (100 microM), which inhibited the HVA I(Ba2+) by an average of 16%. The inhibitory effect was dose dependent and was partially blocked by omega-conotoxin-GVIA, indicating that mGluRs modulate N and other type HVA I(Ba2+). The nonspecific mGluR agonist, (1S,3R)-1-aminocyclopentane-1,3-dicarbosylic acid (1S,3R-ACPD), mimicked the inhibitory effect of glutamate on HVA I(Ba2+). Group I-III mGluR agonists showed inhibition of the HVA current with the most potent being the group III agonist L(+)-2-amino-4-phosphonobutyric acid. 1S,3R-ACPD (200 microM) had no effect on K+ or Na+ currents. The firing properties of NM neurons were also not altered by 1S,3R-ACPD. We propose that the inhibition of VGCC currents by mGluRs limits depolarization-induced Ca2+ entry into these highly active NM neurons and regulates their Ca2+ homeostasis.
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Affiliation(s)
- Yong Lu
- Virginia Merrill Bloedel Hearing Research Center and Department of Otolaryngology-Head and Neck Surgery, University of Washington, Box 357923, Seattle, WA 98195, USA
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