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RMM Art 2.Indd Modern Medicine | 2017, Vol. 24, No. 1 REVIEWS Pharmacodynamics of Serotonin. Emphasis on 5HT-3 Antagonists and SSRI Medication (II) Mihnea Costescu1, Horia Paunescu1, Sorina Vasile2, Aurelian Zugravu1, Oana Andreia Coman1, Ion Fulga1 Abstract This paper is a specialized literature review of the pharmacology of serotonin, that focuses on pharmacodyna- mics. The main aspects discussed here are the metabolism and transport of serotonin, along with the structure and functions of 5-HT receptors and their clinical implications. We also included the substances that influence the serotonin neurotransmission and the autacoid function, which may be prove useful in treating various disorders. In this second part of the review, we present the types of 5-HT receptors (5-HT4, 5-HT5, 5-HT6, 5-HT7), along with the tendencies and prospects in influencing serotonin transporter (SERT) through selective serotonin reuptake in- hibitors (SSRIs). In order to achieve better safety and effectiveness of antidepressant therapy, recent research is studying substances that not only target SERT, but can also act on certain serotonergic receptors. Keywords: serotonin, 5-HT receptors, cisapride, selective serotonin reuptake inhibitors (SSRI), tedatioxetine, vortio- xetine, vilazodone, amitifadine Rezumat Acest articol reprezintă o recenzie de literatură privind farmacologia și, în special, farmacodinamia serotoninei. Principalele aspecte abordate sunt metabolizarea, transportul serotoninei, precum și structura, funcţiile recepto- rilor 5-HT și implicaţiile clinice ale acestora. S-au inclus date despre substanţe care influenţează neurotransmisia serotoninergică și funcţia de autacoid a serotoninei, care se pot dovedi utile în tratamentul anumitor afecţiuni. În această a doua parte a recenziei, sunt prezentate celelalte tipuri de receptori serotoninergici (5-HT4, 5-HT5, 5-HT6, 5-HT7), alături de tendinţele și perspectivele actuale în influenţarea transportorului serotoninei prin inhibitori selec- tivi ai recaptării serotoninei. Pentru a obţine o mai mare siguranţă și efi cacitate a tratamentului antidepresiv, studii recente au descris substanţe care, pe lângă efectul asupra transportorului serotoninei, acţionează direct și asupra unor anumiţi receptori serotoninergici. Cuvinte cheie: serotonină, receptori serotoninergici, cisapridă, inhibitori selectivi ai recaptării serotoninei, tedatioxe- tină, vortioxetină, vilazodonă, amitifadină SEROTONERGIC RECEPTORS AND It has two isoforms (5-HT4S and 5-HT4L), diff ering in the length and sequence of their C-termini1. 5-HT THEIR IMPLICATIONS IN THERAPY 4 are present both in the central nervous system and pe- (PART II) ripheral tissues; in the brain, are found mostly in basal 2 5-HT4 receptors are a G-protein-coupled family of re- ganglia and the hippocampus . In the periphery, 5HT4 ceptors coupled with Gs protein that stimulates the pro- play an important role in the functioning of gastroin- duction of the intracellular signaling molecule cAMP. testinal tract, urinary bladder, heart and adrenal gland. 1 Department of Pharmacology and Pharmacotherapy, "Carol Da- Corresponding author: vila" University of Medicine and Pharmacy, Bucharest, Romania Horia Paunescu 2 Clinical Pharmacology, Bucharest, Romania Faculty of Medicine, 8th Eroilor Sanitari Boulevard, 5th District, Bucharest, Romania. E-mail: [email protected] 5 Mihnea Costescu et al. Gastrointestinal 5-HT4 receptors potentiate peristalsis, selective agonists or antagonists are commercially avai- and electrolyte secretion. In the urinary bladder, acti- lable for the 5-HT5A receptor, but extensive research is 13 vation of 5-HT4 receptors modulates cholinergic and being done in this direction . purinergic transmission. Stimulation of atrial 5-HT4 Th e 5-HT6 receptors are Gs coupled proteins and receptors produces tachycardia and arrhythmias. In the are present in the brain, most prominently in the ca- adrenal gland, activation of 5-HT4 receptors releases udate nucleus, but also in striatum, olfactory tubercle, cortisol, aldosterone and corticosterone3. nucleus accumbens and hippocampus14,15. Because of Cisapride is a 5-HT4 agonist that increases moti- its abundance in limbic and cortical regions, it has been lity of the upper gastrointestinal tract. It was widely suggested that 5-HT6 receptors play a role in regula- prescribed as a prokinetic agent. Cisapride was wi- ting glutamatergic and cholinergic neuronal activity thdrawn in 2000 because of reports of the side-eff ect and are involved in the cognition, feeding and, possi- long QT syndrome, which may cause arrhythmias, e.g. bly, aff ective state and seizures16. Indeed, studies with 4 torsade des pointes . Other 5-HT4 agonists are suppo- 5-HT6 receptor antagonists have shown encouraging sed to be antidepressants with early onset of eff ects5. results in improving cognitive performance in patients 17 Cisapride's mechanism of action include increasing the with Alzheimer's . 5-HT6 receptor antagonists po- phosphorylation of the CREB protein, desensitization tentiate the antidepressant eff ects of SERT inhibition. of 5-HT1A autoreceptors and promoting neurogenesis Also, it has been suggested that co-administration of a 6 in the hippocampus . lower dose of an antidepressant with a 5-HT6 receptor Because of their properties, 5-HT4 receptor agonists antagonist might speed up the onset of action and re- 5 and antagonists may also be useful in the treatment duce the side-eff ects . Stimulation of 5-HT6 receptors of cardiac arrhythmias, urinary incontinence, irritable might play a role in some of the behavioral and chemi- bowel syndrome and gastroparesis3. However, because cal eff ects of antidepressants such as fl uoxetine18. of the severity of the adverse eff ects, extensive research Th e 5-HT7 receptors are receptors coupled with 19 is being done in fi nding a safe new-generation 5-HT4 protein Gs protein . Th e 5-HT7 receptors are found receptor ligands that can be used in medical treat- especially in the brain, the gastrointestinal tract, in ments7. blood vessels andin the intestinal immune cells20. Th e- For the clinical treatment of IBS-C (irritable bowel re is also evidence that 5-HT signaling (including syndrome with constipation predominance) 5-HT4 re- 5-HT7) plays an important role in various gut disorders ceptor agonists are sometimes employed. 5-HT4 recep- such as infl ammatory bowel diseases, IBS, and enteric tor agonists (e.g. tegaserod) potentiate peristalsis, initi- infections21. ated by 5HT1 receptor stimulation, eases the abdomi- 5-HT7 receptors control body temperature, regu- nal pain and increases the number of bowel movements late sleep and circadian rhythms. Preclinical data also 8 and decreses stool consistency . support the antidepressant actions of 5-HT7 receptor 5-HT4 receptor agonists (e.g. tegaserod) have been antagonists, but clinical effi cacy has not been yet esta- associated with cardiovascular adverse events proba- blished. Other evidences have implicated the 5-HT7 bly because of changes in the function of the cardiac receptor in learning and memory. Blockade of this re- hERG (human Ether-à-go-go Related Gene) potas- ceptor may be benefi cial against schizophrenia-like cog- sium channel. New-generation 5-HT4 receptor ago- nitive defi cits; other possible indications include pain, nists (e.g. prucalopride, velusetrag) are devoid of these epilepsy, migraine, and autism spectrum disorders22. adverse eff ects9. Th e 5-HT5A receptors are Gi/Go coupled proteins, SELECTIVE SEROTONIN REUPTAKE that inhibit the manufacture of the cAMP intracellular INHIBITORS (SSRIS) signaling molecule10. Despite the fact that humans have also a gene coding for the 5-HT5B subtype, the 5-HT5A Selective serotonin reuptake inhibitors (SSRIs) modu- subtype is the only one expressed in the human brain. lates serotonin levels and are one of the most used class Th is is because the coding sequence of 5-HT5B subtype of antidepressants, probably because they induce fewer is interrupted by stop codons, making the gene non- adverse eff ects than classical tricyclic agents23. SSRI 11 functional . Th e 5-HT5 receptors have not been exten- generics include fl uoxetine, fl uvoxamine, citalopram, sively characterized pharmacologically. LSD (lysergic sertraline, paroxetine and escitalopram. acid diethylamide) appears to act as a partial agonist at the 5-HT5A receptor. Another partial agonists are va- lerian extract and valerenic acid12. However, few highly 6 Modern Medicine | 2017, Vol. 24, No. 1 Pharmacodynamics of Serotonin. Emphasis on 5HT-3 Antagonists and SSRI Medication (II) MECHANISM OF ACTION In addition, SSRIs in higher dosage than recom- mended worsen preexistent suicidal ideation36. Epi- SSRIs inhibit the reuptake of serotonin and, as a result, demiologic studies show that SSRI treatment is linked serotonin lasts longer in the synaptic cleft and can sti- with upper gastrointestinal bleeding; other bleeding mulate several times the presynaptic and postsynaptic sites has been less commonly reported, as has a pos- receptors. Th e supposed mechanism of the antidepres- sibly increased risk of bleeding associated with sur- sive eff ect is the serotonergic reinforcement. gical procedures37. Patients who take both SSRI and Serotonergic reinforcement does not take place blood thinners and/or NSAIDs (nonsteroidal anti-in- immediately after the initiation of treatment, as increa- fl ammatory drugs), as well as those suff ering from liver sed serotonin levels stimulate 5-HT1A autoreceptors as failure or cirrhosis are more vulnerable
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