Peripherally acting μ-opioid receptor antagonists (PAMORAs) are a class of chemical compounds that are used to reverse adverse effects caused by opioids interacting with receptors outside the central nervous system (CNS), mainly those located in the gastrointestinal tract. PAMORAs are designed to specifically inhibit certain opioid receptors in the gastrointestinal tract and with limited ability to cross the blood–brain barrier. Therefore, PAMORAs do not affect the analgesic effects of opioids within the central nervous system.
Discovery and development Opioid drugs are known to cause opioid-induced constipation (OIC) by inhibiting gastric emptying and decreasing peristaltic waves leading to delayed absorption of medications and more water absorption from the feces. That can result in hard and dry stool and constipation for some patients. OIC is one of the most common adverse effects caused by opioids, so the discovery of PAMORAs can prevent the effects that often compromise pain management. Methylnaltrexone bromide was the first medication in the drug class approved by the FDA. It was discovered in 1979 by Leon Goldberg, a pharmacologist at the University of Chicago. Having witnessed the suffering of a dying friend with OIC, Goldberg tested various derivatives of naltrexone, a drug known to block the effects of opioids. His objective was to find a drug that could not pass the blood brain barrier, without affecting the analgesic effects of the opioids. After Goldberg died, his colleagues at the university continued to develop the compound. It was approved by the FDA in April 2008, originally for OIC in adult patients with advanced illness and later in adult patients with chronic noncancer pain. In the late 1970s, Dennis M. Zimmerman and his co-workers from Lilly Research Laboratories, Indiana, did research on structural concepts for narcotic antagonists defined in a 4-phenylpiperidine series. They reported N-methyl-trans-3,4-dimethyl-4-phenylpiperidine to be pure opioid receptor antagonist with a new pharmacophore. To increase the potency they attached a phenolic group to the aromatic ring, N-methyl-trans-3,4-dimethyl-4-(3-hydroxyphenyl)piperidine. That structure was used to design and develop other opioid receptors antagonists such as alvimopan. Alvimopan was approved later in 2008 for in-hospital use to increase the gastrointestinal function following a partial large or small bowel resection with primary anastomosis. Naloxegol was approved in September 2014 and naldemedine in March 2017, both for the treatment of OIC in adult patients with chronic cancer.
Mechanism of action PAMORAs act by inhibiting the binding of opioids agonist to the μ-opioid receptor (MOR). The objective of PAMORAs treatment is to restore the enteric nervous system function (ENS). The MOR is found in several places in the body and PAMORAs is a competitive antagonist for binding to the receptor. The MORs in the gastrointestinal tract are the main receptors that PAMORAs are intended to block and prevent the binding of opioid agonists. PAMORAs are used in the treatment of opioid-induced bowel dysfunction (OIBD), a potential adverse effect caused by chronic opioid use. PAMORAs act on the three pathophysiological mechanisms of this adverse effect. They act on gut motility, gut secretion and sphincter function. PAMORAs effect on gut motility is that it can increase the resting tone in the circular muscle layer. The antagonist enhances the effect on tonic inhibition of the muscle tone. This will normalize the tone in the circular muscle layer and therefore prevent opioid-induced rhythmic contractions. When these two factors are combined, it results in decreased transit time. Impliedly these effects will decrease the passive absorption of fluids which helps with decreasing OIBD symptoms such as constipation, gut spasm and abdominal cramp. PAMORAs effect on gut secretion will help reverse the decreased cAMP formation that opioid agonists induce. Also, the antagonist will establish a normal secretion of chloride. Opioids agonists can also reduce the secretion of peptides by increasing the sympathetic nervous system through the μ-receptors in the ENS, which can lead to drier and harder stool. PAMORAs work against it so the stool becomes softer and less dry. PAMORAs effect on the function of the sphincter is in theory to regulate the movement coordination. The antagonist can prevent sphincter of Oddi dysfunction that is caused by opioids. Antagonists can also reduce opioid-induced anal sphincter dysfunction. The dysfunction is tied to straining, hemorrhoids and incomplete emptying.
Structure–activity relationship Even though μ-opioid receptor (MOR) targeting drugs have been used for a long time, not much is known about the structure-activity relationship and the ligand-receptor interactions on the basis of well-defined biological effects on receptor activation or inhibition. Also, the distinction in the receptor-ligand interaction patterns of agonists and antagonists is not known for sure. One theory states that the morphinans biological activity could be determined by the size of the N-substituents. For example, antagonists usually have larger substituents, such as allyl- or cyclopropyl methyl at the morphinan nitrogen, while agonists generally contain a methyl group. On the other hand, agonist activity is also shown in ligands with larger groups at the morphinan nitrogen, and therefore this hypothesis is challenged.
Structure
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