Drug antagonism refers to a medicine stopping the action or effect of another substance, preventing a biological response. The stopping actions are carried out by four major mechanisms, namely chemical, pharmacokinetic, receptor and physiological antagonism. The four mechanisms are widely used in reducing overstimulated physiological actions. Drug antagonists can be used in a variety of medications, including anticholinergics, antihistamines, etc. The antagonistic effect can be quantified by pharmacodynamics. Some can even serve as antidotes for toxicities and overdose.
Receptor antagonism
Mechanism of action
Receptors bind with endogenous ligands to produce a physiological effect and regulate the body and cellular homeostasis. In a ligand-receptor interaction, the ligand binds with the receptors to form a drug-receptor complex, producing a biological response.Receptor Theory. In: Stringer JL. eds. Basic Concepts in Pharmacology: What You Need to Know for Each Drug Class, 5e. McGraw-Hill Education; 2017. Accessed April 08, 2024. https://accessmedicine-mhmedical-com.eproxy.lib.hku.hk/content.aspx?bookid=2147§ionid=161350965Gopalakrishnan M, Kumar V, Issar M. Relationship Between Pharmacokinetics and Pharmacodynamics. In: Shargel L, Yu AC. eds. Applied Biopharmaceutics & Pharmacokinetics, 7e. McGraw-Hill Education; 2016. Accessed April 08, 2024. https://accesspharmacy.mhmedical.com/content.aspx?bookid=1592§ionid=100674439 The biological nature of receptors can be enzymes, nucleic acids or cellular proteins. Common types of receptors include G-protein coupled receptors, nuclear receptors and ion channels.
Functional antagonists would not produce a biological response after binding with a receptor. It blocks the binding of endogenous ligands to the receptors and thus inhibits the subsequent physiological effect.
Types of receptor antagonism
Reversible and irreversible competitive antagonism Both agonist and antagonist bond the same active site. Adding agonist dose can reverse the effect of reversible competitive antagonism. Irreversible competitive antagonism occurs when the antagonist binds to the same spot on the receptor as the agonist but dissociates from the receptors very slowly or not. As a result, when the agonist is delivered, there is no change in the antagonist occupancy. Since a receptor can only hold one molecule at a time, competitive antagonists can reduce the agonist occupancy (percentage of receptors to which the agonist is bound). Raising the agonist concentration can bring back the agonist occupancy and the subsequent tissue response due to their competition. Thus, the opposition is surmountable. The amount to which the competitive antagonist causes the agonist log concentration–effect curve to shift to the right while maintaining its maximum slope is a measure of the dosage ratio. The antagonist concentration causes the dosage ratio to rise linearly.
Non-competitive (irreversible) antagonism
Allosteric antagonists Different active sites are bonded by agonist and antagonist, which means the antagonist obstructs the chain of events that triggers the agonist to produce a response at a point downstream from the agonist binding site on the receptor. It irreversibly binds to the active site.
One examples is when Ketamine enters the NMDA receptor's ion channel pore and blocks it, stopping ions from passing through the channels. Also, medication like nifedipine and verapamil stops Ca2+ from entering the cell membrane and so non-selectively prevent medications that act at any receptor that binds to these calcium channels from causing smooth muscle contraction.
Partial agonists and full agonists In the presence of a full agonist exerting its maximal effect, a partial agonist can behave like a competitive antagonist to lower the effect of receptor binding, generating merely a submaximal reaction. These variations can be evaluated regarding effectiveness, indicating the agonist-receptor complex's "strength" in causing a tissue response. It relies on receptor occupancy and response. A particular medication of intermediate efficacy may appear as a partial agonist in one tissue (lower level of receptor expression) and a full agonist in another (high level of receptor expression) across distinct cell types expressing the same receptor but at varying densities.
Clinical use
Reversible and irreversible competitive antagonism Competitive antagonists are usually structurally similar to the active compound since they are structural analogues that have to bind to the same pocket. Examples of reversible competitive antagonists like antihistamines (Figure 1) compete with histamine (Figure 2) to bind to histamine receptors, blocking the allergic response by histamine. They are used in treating histamine-mediated allergies and allergic rhinitis. Irreversible competitive antagonists like phenoxybenzamine do not dissociate from alpha-adrenergic receptors. It is used to block the activity of alpha receptors in sympathetic pathway and is used in the treatment of paroxysmal hypertension and sweating resulting from pheochromocytoma and benign prostate hyperplasia.
Chemical antagonism
Mechanism of action Chemical antagonism occurs when a chemical antagonist combines with a ligand to form an inactive product compound, inhibiting the response. In chemical antagonism, the receptors are not involved in the process, and the antagonist directly binds with or removes the ligand. It prevents the ligand from binding to the receptor. As the ligand cannot stimulate the receptor, no physiological effect is generated by the receptors and thus provides an inhibitory effect.Growth, Survival, and Death of Microorganisms. In: Riedel S, Hobden JA, Miller S, Morse SA, Mietzner TA, Detrick B, Mitchell TG, Sakanari JA, Hotez P, Mejia R. eds.Jawetz, Melnick, & Adelberg's Medical Microbiology, 28e. McGraw-Hill Education; 2019. Accessed April 08, 2024. https://accesspharmacy.mhmedical.com/content.aspx?bookid=2629§ionid=217769460 The common types of chemical antagonism include chelating agents, neutralising antibodies and salt aggregation.
Clinical use
Chelating agent
"Chelating agents are organic compounds which are capable of linking to metal ions". They are usually useful for removing toxic heavy metal ions from body. Dimercaprol is a common chelating agent to treat toxic exposure to arsenic, mercury, gold, and lead. It is in the chelating class of drugs. From Figure 3, the SH-ligands of dimercaprol can compete with -SH groups in natural enzymes for heavy metal, forming a stable metal complex to be excreted through urine. The action antagonises the toxic metal ions and helps remove them from body circulation. However, dimercaprol has a narrow TI and is later replaced by its derivative, 2,3-dimercaptosuccinic acid (DMSA).
Neutralising antibodies
Neutralising antibodies block pathogen entry into cells to prevent further infection and replication. Infliximab is a monoclonal antibody binding with tumour necrosis factor-alpha (TNF-alpha), inhibiting its pro-inflammatory action. Its efficacious anti-inflammatory action is clinically used in Crohn's Disease, active rheumatoid arthritis, psoriatic arthritis, and active ankylosing spondylitis.
Salt aggregation Salt aggregation refers to reactions between a drug and an active compound forming a salt. Strongly anionic unfractionated heparin reacts with the positive cationic protamine arginine peptide to generate a salt aggregation. The resulting salt aggregate is not anticoagulant and is inactive. Protamine acts quickly, taking only five minutes to neutralize unfractionated heparin, and its half-life is only ten minutes.
Pharmacokinetics antagonism
Mechanism of action A drug which can affect the pharmacokinetics (absorption, digestion, metabolism, excretion) profile of another chemical (or drugs), thereby reducing the action of the target chemical. There could be a rise in the active drug's rate of metabolic breakdown. As an alternative, there may be a decrease in the rate at which the active medication is absorbed from the digestive system or a rise in the rate at which the drug is excreted by the kidneys.
Clinical use
Drugs affecting Absorption: antacid Most drugs are taken orally and are absorbed through the gastrointestinal tract. Antacids would increase the pH environment in the stomach and cause premature release of enteric coated drugs, which are designed to be protected from an acidic environment in stomach. For example, proton-pump inhibitors (PPIs) are enteric coated to protect them from decomposition under an acidic environment. Co-administration of antacids with PPIs would lead to premature release into acidic gastric environments and inactivate PPIs before absorption. These types of pharmacokinetics antagonism should be carefully avoided to prevent loss of drug efficacy.
Since most drugs are either weakly acidic or weakly basic, modified pH would also affect the location at which the drug is deionised, thus affecting the required time for absorption and onset.
Drugs affecting metabolism: phenytoin Many drugs are metabolised by a set of liver enzymes called CYP450s. The activity of these enzymes would determine the rate of pro-drug activation and the rate of inactivation of active drugs. For example, warfarin, a commonly used anticoagulant drug in atrial fibrillation, is metabolised by an enzyme called CYP2C9. Phenytoin, a CYP2C9 inducer, would increase its activity and the rate of warfarin breakdown, thereby reducing its efficacy. Patients should avoid the co-administration of warfarin and phenytoin. In cases where both drugs must be used together, warfarin dosing may be titrated up to cope with the reduced efficacy.
Drugs affecting excretion: intravenous sodium bicarbonate The kidney excretes most drugs through urine. Since urine is weakly alkaline in nature, weakly acid drugs would ionise in urine, making it difficult for them to be reabsorbed. Therefore, in cases of aspirin (weak acid) toxicity, injecting intravenous sodium bicarbonate could increase urine pH, thereby increasing the excretion of aspirin through urine. A similar approach can be used in other weakly acidic drug toxicity.
Physiological antagonism
Mechanism of action Physiologic antagonism refers to the behaviour in which an antagonist behaves the opposite of the agonist but does not bind to the same active site as the agonist does. A physiologic antagonist binds to a different receptor but not the original agonist receptor.
Clinical use Both insulin and glucagon are synthesised naturally in the human body to regulate blood glucose levels at homeostasis. Insulin binds to insulin receptors to decrease blood glucose levels, whilst glucagon binds to glucagon receptors to increase blood glucose levels. In cases of insulin-induced hypoglycaemia, glucagon injection could help increase blood glucose levels.
Another example is epinephrine (a bronchodilator) and histamine (a bronchoconstrictor). Epinephrine binds to adrenergic receptors to promote bronchodilation whilst histamine binds to histamine receptors which leads to bronchoconstriction. Since they have opposite effects in different pathways, they are considered physiological antagonists, and they are not advised to be taken together.
Quantifying effects of antagonists using pharmacodynamics
Pharmacodynamics Pharmacodynamics (PD) is the core principle of quantifying the effects of antagonists by measuring the drug's efficacy and safety. PD emphasises the relationship between the dose and response of a certain drug, which can be illustrated using a dose-response curve.
Efficacy Efficacy is the maximal effect (Emax) that an agonist can produce. As a receptor antagonist does not affect receptors after binding, it is said to have zero efficacy.