A quantitative study of the anticholinergic action of several tricyclic antidepressants on the rat isolated fundal strip

Empirically Supported Use of Psychiatric Medications in Adolescents and Adults with IBD

BACKGROUND

The use of psychotropic medications, particularly antidepressants, is common in patients with inflammatory bowel disease (IBD) in spite of a lack of their robust efficacy in this population. This review provides an overview of the use trends of different classes of antidepressant and anti-anxiety medication and their effects on mood, nervous system function, gastrointestinal physiology and immunity drawing from the literature available in the general population, other medical conditions, and when available, patients with IBD. It also covers the evidence base for the actions, efficacy, and potential complications of antidepressants organized by different classes.

METHODS

We conducted a PubMed search of articles relating the different drug classes probed to the terms above in different populations of interest. All types of articles were accepted including case reports and series, open and randomized trials, reviews, and expert opinion. We also examined the reference lists of the publications found.

RESULTS

Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) are the most commonly prescribed agents for anxiety and depression in patients with IBD, though their efficacy for these conditions in the general population are mild to moderate at best. SSRIs are generally well tolerated, though at higher doses, they, like most antidepressant classes, can be associated with activation, serotonergic syndrome, and increased suicidal ideation. TCAs have many more serious side effects but have some shown efficacy for functional GI symptoms. A newer class, the serotonin noradrenergic reuptake inhibitors (SNRIs), can be effective for refractory depression, anxiety and chronic pain syndromes with a side effect profile similar to both SSRIs and more mild manifestations of TCAs. Mirtazapine has moderate efficacy for depression if sedation and weight gain side effects are tolerated and some small support for use in nausea and vomiting. Bupropion targets dopamine and noradrenaline reuptake and has moderate efficacy for depression, and some small support for use in fatigue and smoking cessation. Buspirone has an indication for generalized anxiety disorder though studies show only a minimal benefit. It has some growing evidence for use in functional dyspepsia. Most of these agents have physiological effects on the brain, immune system, and gastrointestinal tract (with the exception of bupropion) hence their therapeutic and side effects manifested in these systems.

CONCLUSION

Antidepressant medications are frequently prescribed for depression, anxiety disorders, and chronic pain syndromes, but overall support for their efficacy is modest at best. Psychological interventions have growing support for having much more robust effects without the side effects of antidepressants and should be considered first-line treatment or at least an adjunct to psychotropic medications for these conditions.

Effects of clonidine and tricyclic antidepressants on gastric smooth muscle contractility

To determine if and how clonidine and tricyclic antidepressants affect gastric contractility. Guinea pig fundic and antral circular muscle strips were studied in vitro. The effects of clonidine or amitriptyline added in graded concentrations on contractions to electric field stimulation (EFS), acetylcholine (ACh), and SP in the presence of N(epsilon)-nitro-l-arginine methyl ester (l-NAME) were studied. EFS produced frequency dependent contractions of fundic and antral muscle that were abolished by atropine or tetrodotoxin (TTX). ACh contractions were abolished by atropine but not TTX. Clonidine reduced contractile response to EFS but had no effect on ACh contractions. The threshold concentration of clonidine to inhibit EFS contractions was lower in the fundus than in the antrum. Amitriptyline reduced contractions to both EFS and ACh but not to SP. The threshold concentration of amitriptyline to inhibit EFS contractions was lower in the antrum than in the fundus. Both clonidine and amitriptyline affect gastric contractility. At threshold concentrations, clonidine affects fundic contractility whereas amitriptyline affects antral contractility. Clonidine affects gastric contractility in response to EFS but not to ACh, suggesting alpha-2 receptors on cholinergic nerves that reduce ACh release. Amitriptyline inhibits gastric contractility to EFS and ACh suggesting an inhibitory muscle effect.

Neurobiologic effects of bright artificial light

Bright light is an effective treatment of winter depression. Study of the effects of this treatment on mechanisms thought to be involved in the pathophysiology of depressive disorders is reviewed. Measurement of a physiological parameter, namely the change in core temperature using an intraperitoneally implanted radio transmitter sensitive to temperature in freely moving rats, indicates that treatment with bright light under various experimental conditions tends to powerfully subsensitize muscarinic and nicotinic mechanisms. Pulses of bright light during the phase delay portions of the PRC blunt sensitivity to clonidine. Our studies with bright light are consistent with those indicating that heterocyclic antidepressants and a monoamine oxidase inhibitor produce subsensitivity to the thermic effects of nicotine. Reports of the influences of full-spectrum bright light and its impact on targeted neurotransmitter mechanisms call attention to the anatomical substratum mediating its effects. Possible receptor changes are measurable using receptor binding techniques and quantitative autoradiography. The physiological effects of this interesting treatment raises questions of its impact on coupling mechanisms and second messengers.

Antidepressant withdrawal syndromes: phenomenology and pathophysiology

The literature reporting signs and symptoms produced by the abrupt or gradual withdrawal of antidepressants is reviewed. Patients with antidepressant withdrawal syndromes are presented and principles governing their care are highlighted. Finally, the author summarizes evidence that antidepressant-induced supersensitivity of central and peripheral muscarinic cholinergic mechanisms may account for commonly observed antidepressant withdrawal phenomena.

Temperature as a dependent variable in the study of cholinergic mechanisms

1. Change in core temperature over time can be used as a dependent variable when studying the effects of manipulations on neurotransmitter systems. This article focuses on the measurement of core temperature as a strategy for detecting changes in the status of cholinergic systems. 2. Cholinergic neurons participate in the process of thermoregulation and interventions affecting them alter the thermal response to cholinomimetics. For example, chronic treatment with amitriptyline, chronic swim stress and inescapable footshock supersensitize rats to the hypothermic effects of oxotremorine. 3. This is consistent with the hypothesis that the pathophysiologies of tricyclic antidepressant withdrawal phenomena and stress involve supersensitivity of muscarinic mechanisms. 4. Uses of thermoregulation paradigms for investigating the actions of lithium ion, electroconvulsive shock and substances of abuse on muscarinic mechanisms are discussed. Applications to problems in the arena of clinical research are highlighted.

Amitriptyline supersensitizes a central cholinergic mechanism

The withdrawal of tricyclic antidepressants produces symptoms characteristic of cholinergic overdrive states. The authors previously proposed that these states are the consequence of the pharmacological induction of cholinergic system supersensitivity by chronic treatment with antidepressants, combined with a reduction in the plasma level of a competitive muscarinic receptor antagonist when the dose of a tricyclic is decreased. This is consistent with the facts that all tricyclic antidepressants are antimuscarinic agents and that classical antimuscarinic compounds, such as scopolamine, up-regulate and supersensitize muscarinic cholinergic systems. The authors present evidence that chronic treatment with amitriptyline supersensitizes a central cholinergic mechanism. Core body temperature is subject to influence by a central (hypothalamic) muscarinic mechanism, which is rendered supersensitive to cholinomimetic challenge by treatment with scopolamine. The authors telemetrically measured the hypothermic responses of adult male rats to various doses of the muscarinic agonist oxotremorine before and in the course of chronic treatment with amitriptyline. Treatment with amitriptyline resulted in marked enhancement of the cholinomimetic-induced hypothermia. Methylscopolamine nitrate, a peripherally active antimuscarinic agent, did not block the hypothermic response to oxotremorine, whereas scopolamine, a centrally active antimuscarinic compound, did. This study indicates that the chronic administration of amitriptyline can produce supersensitivity of a central muscarinic cholinergic mechanism. Clinical and theoretical implications of this finding are discussed.

Cholinergic properties of desipramine and amoxapine: assessment using a thermoregulation paradigm

1. The withdrawal of tricyclic antidepressants (TCAs) produces symptoms suggesting cholinergic rebound. 2. Amitriptyline (AMI), the most potent antimuscarinic agent among this class of drugs, produces supersensitivity to the muscarinic agonist, oxotremorine. 3. Enhancement of the sensitivity of cholinoceptive neurons to acetylcholine as a consequence of treatment with TCAs would account for many of the symptoms following the withdrawal of these drugs. 4. Desipramine (DMI) is the least potent antimuscarinic compound among the TCAs, yet its withdrawal produces withdrawal symptoms. 5. Recently, it was reported that amoxapine (AMX) weakly binds to muscarinic acetylcholine receptors (mAchR) in vitro. This may indicate that this drug lacks the effects antimuscarinic effects in vivo, and that it will not supersensitize cholinergic networks. 6. A thermoregulation paradigm was used to assess the sensitivity of a central muscarinic mechanism to oxotremorine before and after treatment with DMI and AMX. Treatment with either drug increased the hypothermic response to this agonist. 7. Mechanisms whereby drugs can produce cholinergic system supersensitivity, and the use of thermoregulation paradigms in assessing the properties of therapeutic agents is discussed.

Cholinergic mechanisms in depression

Evidence supporting a cholinergic hypothesis of depression is presented. First, cholinergic overdrive produces behavioral, neuroendocrine, and polysomnographic features of melancholia, and melancholics exhibit state-independent supersensitivity to cholinergic overdrive. Drugs inducing up-regulation and supersensitivity of cholinergic systems produce behavioral, polysomnographic, and neuroendocrine effects of melancholia when withdrawn. These observations also implicate cholinergic system supersensitivity as a factor in the pathophysiology of certain affective disorders. Cholinergic and monoaminergic mechanisms reciprocally regulate drive-reduction, and substances of abuse either activate monoaminergic networks or antagonize cholinergic systems. These points are consistent with the hypothesis that dynamic interaction between cholinergic and monoaminergic systems is involved in the regulation of mood and affect. Finally, antimuscarinic agents have antidepressant effects. Thus, the hypothesis that supersensitivity of cholinergic systems is involved in the pathophysiology of affective disorders is supported by several lines of evidence. This evidence is reviewed; directions for future research and promising methods of investigation are discussed.

Comparison of the effects of binodaline and amitriptyline on peripheral autonomic functions in healthy volunteers

Twelve healthy male volunteers participated in five experimental sessions separated by weekly intervals. At the beginning of each session the subjects received one single oral dose of the following drugs, according to a double-blind, balanced cross-over design: binodaline hydrochloride (50 mg or 100 mg); amitriptyline hydrochloride (50 mg or 100 mg); lactose placebo. Salivation and resting pupil diameter were assessed before and 2 h after the ingestion of the drugs; baseline sweating, carbachol- or phenylephrine-evoked sweating were measured 2 h following drug taking. Binodaline, like placebo, had little effect on salivary output, whereas amitriptyline caused a dose-dependent decrease in salivation. None of the drugs caused any significant change in resting pupil diameter or in baseline sweating. Carbachol-evoked sweating did not differ significantly following the ingestion of binodaline or placebo; on the other hand responses to carbachol were significantly reduced following amitriptyline. Phenylephrine-evoked sweating was reduced by both binodaline and amitriptyline. The lack of effect of binodaline on salivation, resting pupil diameter, baseline and carbachol-evoked sweating is in agreement with the results of animal experiments indicating the lack of an interaction of this drug with cholinergic mechanisms. The reduction in phenylephrine-evoked sweating would be indicative of an alpha-adrenoceptor blocking property of this drug.

Antagonism by antidepressants of muscarinic acetylcholine receptors of human brain

1 Twenty-two compounds classified as antidepressants, metabolites of antidepressants or putative antidepressants were assayed for their ability to antagonize the binding of (-)-[3H]-quinuclidinyl benzilate to muscarinic receptors in homogenates of human caudate nucleus. 2 Sixteen of these compounds were assayed for their ability to antagonize carbachol-stimulated cyclic guanosine 3',5'-monophosphate (cyclic GMP) synthesis by intact murine neuroblastoma cells (clone N1E-115). 3 Equilibrium dissociation constants (KDs) for these drugs and the muscarinic receptors of human brain spanned over 4 orders of magnitude, with the tertiary amine tricyclic antidepressant, amitriptyline (KD = 18 nM) being the most potent compound tested and trazodone (KD = 324 microM) the least potent. 4 There was a significant correlation between the data for human and murine receptors and for eight compounds (imipramine, desipramine, maprotiline, mianserin, 3-chloro-2-hydroxyimipramine, amoxapine, 2-hydroxyimipramine and iprindole). KD values measured by the two techniques were not significantly different.

The effect of some antidepressants on prejunctional muscarinic receptors on the sympathetic nerves of the isolated rabbit ear artery

The antimuscarinic activity of amitriptyline, desipramine, iprindole, mianserin and viloxazine on prejunctional sympathetic nerve endings were compared in the isolated rabbit ear artery. In the presence of cocaine (10 micro M) and yohimbine (1 micro M), amitriptyline (0.5-1 micro M), desipramine (1-3 micro M) and iprindole (5-10 micro M) produced parallel rightward shifts of the concentration-response curve for the inhibitory effect of carbachol (CCh) on responses to electrical stimulation of the preparation at 3 Hz. Mianserin (3 micro M) produced some inhibition but altered the slope of the concentration-responses curve to CCh while viloxazine (less than or equal to 10 micro M) produced no inhibition. The depression of tritium efflux by CCh from arteries preincubated in 3H-noradrenaline was inhibited significantly (P less than 0.05) by amitriptyline (0.1 micro M) and desipramine (1 micro M) and not by iprindole (17 micro M), mianserin (3 micro M) or viloxazine (10 micro M). Amitriptyline was 10-fold more active than desipramine and at least 30-fold more active than the other antidepressants as a muscarine receptor blocking drug in this preparation. Thus, mianserin, viloxazine and iprindole exhibit much weaker antimuscarinic activity relative to amitriptyline on prejunctional muscarine receptors on sympathetic nerve endings compared with that observed by others for excitatory muscarine receptors in sympathetic ganglia. The findings support an earlier suggest that these receptors differ.

The effects of several muscarinic antagonists on pre- and postsynaptic receptors in the isolated rabbit heart

In order to reveal possible differences between pre- and postsynaptic muscarine receptors, seven antagonists were tested for their affinities on these receptor sites in the rabbit isolated perfused heart. Methacholine was used as an agonist to inhibit the noradrenaline overflow evoked by electrical stimulation (3 Hz, 3 min) of the sympathetic nerves (presynaptic parameter) and to decrease the systolic tension development of the right atrium (postsynaptic parameter). The affinity of an antagonist was expressed as pA2. A decreasing order of potency was obtained with ipratropium, scopolamine, atropine, trihexyphenidyl, amitriptyline, and gallamine, both for pre- and postsynaptic responses. The antagonists acted competitively and their effects were reversible. Furthermore, for none of the drugs did the pA2 (pre) differ from the pA2 (post). With QNB (3-quinuclidinyl benzilate) a pA2 (post) of 11.65 was obtained. However, the affinity to presynaptic receptors could not be determined as a pA2 value due to the very prolonged exposure time required for the equilibrium with QNB and for that with methacholine in the presence of QNB. It is concluded that the antagonists employed do not reveal differences between pre- and postsynaptic muscarine receptors of the rabbit heart, in spite of their greatly varying chemical structure and their individual affinities ranging over 5 orders of magnitude. The findings confirm the view of a homogeneous muscarine receptor population characterized by functional parameters.

The peripheral anticholinergic activity of tricyclic antidepressants: comparison of amitriptyline and desipramine in human volunteers

The effects of three single oral doses (25 mg, 50 mg and 100 mg) of amitriptyline and desipramine, and of placebo, were compared on a range of cholinergic functions (resting pupil diameter, pilocarpine-evoked miosis, baseline-sweating, carbachol-evoked sweating, salivation, heart rate) in eight healthy volunteers. Three measures (pilocarpine-evoked miosis, carbachol-evoked sweating and salivation) reflected the antimuscarinic property of the antidepressants; in two tests (pilocarpine-evoked miosis and salivation) amitriptyline appeared to be more potent than desipramine. Resting pupil diameter was not affected by amitriptyline, whereas desipramine caused mydriasis, indicating that pupil size is not a reliable measure of anticholinergic activity in the case of drugs which also affect adrenergic mechanisms. Baseline-sweating and heart rate were not affected by the antidepressants.

Tricyclic antidepressants: potent blockade of histamine H1 receptors of guinea pig ileum

Six tricyclic antidepressants were tested for their ability to antagonize histamine actions at histamine H1 receptors in a bioassay for these receptors (histamine-induced contractions of guinea pig ileum). All compounds were competitive antagonists with equilibrium dissociation constants in the range of 5.6 x 10(-11) M to 1.5 x 10(-7) M. Doxepin hydrochloride and amitriptyline hydrochloride were the most potent compounds of the series and may be the most potent antihistamines known. Antagonism at histamine H1 receptors by these compounds may explain their sedative effects.

Modification of cortical neuron responses to acetylcholine by viloxazine

Viloxazine, an antidepressant with no peripheral antiacetylcholine activity, was capable of reducing responses of single cortical neurons to acetylcholine. Acetylcholine responses could also be potentiated by viloxazine. Both potentiation and reduction by viloxazine were often seen in the same study, reduction of responses invariably preceding potentiation. These results suggest that viloxazine may have selective effects on central cholinergic receptors. Responses of cortical neurons to monoamines could also be potentiated by viloxazine although it has little effect on monoamine uptake. These results are compatible with the idea that potentiation of monoamine responses may occur by a postsynaptic mechanism.

Structure-activity relationships for the anticholinoceptor action of tricyclic antidepressants

1 The anticholinoceptor action of 15 tricyclic antidepressants and derivatives has been studied on the guinea-pig ileum. At the muscarinic receptors the compounds were found to exert antagonism which was reversible and apparently competitive up to dose-ratios of around 100 but non-competitive above this level. 2 Log affinity constants were derived from log dose-response curves at dose-ratios less than 100, where parallel curves were obtained. Amitriptyline, the most potent compound, had 214 X the potency of the weakest, hydroxyimipramine, but was itself 20 X weaker than atropine. 3 Structure-activity studies showed that dibenzocycloheptane derivatives were more potent than dibenzazepines and that S or O substitution for C-11 or other major changes in the central ring of the tricyclic nucleus greatly reduced activity. Side-chain N-methylation increased potency markedly. This and other findings indicate that both tricyclic nucleus and side-chain receptor attachments are largely non-polar in type.

Tricyclic antidepressant drugs as antagonists of muscarinic receptors in sympathetic ganglia

Close arterial injection of McN-A-343 into the superior cervical ganglion of the cat resulted in contractions of the nictitating membrane. The ganglionic effects of McN-A-343 but not those of DMPP were antagonized in a dose-related manner by 2-10 mug of desipramine, imipramine, chlorimpramine, iprindole and viloxazine. No correlation was found between the dose of each drug which blocked the effects of McN-A-343 and that required to potentiate the responses of the nictitating membrane to intra-arterial administration of noradrenaline. It is concluded that clinically effective antidepressant agents can block muscarinic receptors in neural tissue, even if they do not do so in smooth muscle and gland cells.

[The effect of coffee and coffee components on the stomach muscle]

The isolated stomach muscle strip preparation works well when given pure compounds which are stable and non-toxic. When complex test mixtures such as coffee are used, however, the results are more difficult to interpret. This is probably due to non-specific effects of such mixtures, e.g. induction of changes in organ bath pH, etc. In spite of the above remark, differences in the effects of decaffeinated and normal instant coffees were clearly seen. The so-called "wholesome" coffees gave results identical to those obtained with normal instant coffee. In general, coffee induced muscle contraction followed by relaxation. Choline (possibly together with potassium) would appear to be responsible for the contractions observed, and caffeine for the relaxation.

Effect of anticholinergic drugs on gastro-intestinal absorption of L-dopa in rats and in man

Plasma L-DOPA levels in rats receiving L-DOPA by the oral route were decreased by the concomitant administration of trihexyphenidyl. Following systemic L-DOPA administration no differences were observed between control and trihexyphenidyl-treated rats. Effects similar to those of trihexyphenidyl were observed with atropine. These results indicate that trihexyphenidyl decreases L-DOPA gastrointestinal absorption probably by delaying gastric emptying. The presence in humans of this interaction between the two antiparkinsonian drugs was suggested by similar findings made either in a group of normal volunteers or in a group of parkinsonian patients. These observations suggest that at the clinical level in selected cases the concomitant administration of trihexyphenidyl to patients receiving L-DOPA may decrease the therapeutic efficacy of L-DOPA by reducing its gastrointestinal absorption.

Effects of desipramine on neuronal responses to dopamine, noradrenaline, 5-hydroxytryptamine and acetylcholine in the caudate nucleus of the rat

1 The sensitivity of single neurones to microelectrophoretically applied dopamine, noradrenaline (NA), 5-hydroxytryptamine (5-HT) and acetylcholing (ACh) was investigated in the caudate nucleus of the rat, anaesthetized with halothane. Both excitatory and depressant responses could be observed to each of the agonists. There was a high correlation between the direction of responses to dopamine and noradrenaline, whereas there was no significant correlation between the direction of responses to dopamine and ACh. 2 The effect of desipramine was studied on both excitatory and depressant responses to dopamine, NA and 5-HT, and on excitatory responses to ACh. Both potentiation and antagonism of neuronal responses to monoamines and ACh could be observed after a brief application of desipramine. 3 Excitatory responses to glutamate were not affected by desipramine. 4 The observation that responses to dopamine and NA can be potentiated by desipramine in the caudate nucleus suggests that uptake blockade is not a prerequisite for potentiation. 5 It is suggested that the potentiation of neuronal responses to dopamine by desipramine may be responsible for the therapeutic efficacy of desipramine in Parkinson's disease.

The effect of tricyclic antidepressants on cholinergic responses of single cortical neurones

1 The technique of microelectrophoresis was used in order to study the effects of tricyclic antidepressants on responses of single cortical neurones to acetylcholine. 2 Both potentiation and antagonism of excitatory responses to acetylcholine could be observed after a brief application of imipramine or desipramine. A higher dose of the antidepressant was required to evoke antagonism than to evoke potentiation. 3 Responses to carbachol were affected by desipramine similarly, suggesting the inhibition of cholinesterase is not responsible for the potentiation of cholinergic responses. 4 A brief application of atropine also had a dual effect on responses to acetylcholine. 5 It is suggested that the potentiation of excitatory cholinergic responses by atropine and the antidepressants may be due to the blockade of masked inhibitory receptors.