Adenosine

Adenosine
Clinical data
Pregnancy; category	C;
Routes of; administration	IV or injection
ATC code	C01EB10 (WHO) ;
Legal status
Legal status	Australia - Legal; UK - Legal; US - Rx only;
Pharmacokinetic data
Bioavailability	Rapidly cleared from circulation via cellular uptake
Protein binding	No
Metabolism	Rapidly converted to inosine and andenosine monophosphate
Elimination half-life	cleared plasma <30 seconds - half life <10 seconds
Excretion	can leave cell intact or can be degraded to hypoxanthine, xanthine, and ultimately uric acid
Identifiers
	IUPAC name (2R,3R,4R,5R)-2-(6-aminopurin-9-yl)- 5-(hydroxymethyl)oxolane-3,4-diol;
CAS Number	58-61-7;
PubChem CID	60961;
DrugBank	APRD00132;
CompTox Dashboard (EPA)	DTXSID1022558 ;
ECHA InfoCard	100.000.354
Chemical and physical data
Formula	C10H13N5O4
Molar mass	267.242 g/mol g·mol−1

Adenosine is a nucleoside comprised of adenine attached to a ribose (ribofuranose) moiety via a β-N₉-glycosidic bond.

Adenosine plays an important role in biochemical processes, such as energy transfer - as adenosine triphosphate (ATP) and adenosine diphosphate (ADP) - as well as in signal transduction as cyclic adenosine monophosphate, cAMP.

Pharmacological effects

Adenosine is an endogenous purine nucleoside that has evolved to modulate many physiologic processes. Cellular signaling by adenosine occurs through four known adenosine receptor subtypes (A1, A2A, A2B, and A3), all of which are seven transmembrane spanning G-protein coupled receptors. These four receptor subtypes are further classified based on their ability to either stimulate or inhibit adenylate cyclase activity. The A2A and A2B receptors couple to Gάs and mediate the stimulation of adenylate cyclase, while the A1 and A3 adenosine receptors couple to Gάi which inhibits adenylate cyclase activity. Additionally, A1 receptors couple to Gάo, which has been reported to mediate adenosine inhibition of Ca2+ conductance, whereas A2B and A3 receptors also couple to Gάq and stimulate phospholipase activity Extracellular adenosine concentrations from normal cells are approximately 300 nM; however, in response to cellular damage (e.g. in inflammatory or ischemic tissue), these concentrations are quickly elevated (600-1,200 nM). Thus, in regards to stress or injury, the function of adenosine is primarily that of cytoprotection preventing tissue damage during instances of hypoxia, ischemia, and seizure activity. Activation of A2A receptors produces a constellation of responses that in general can be classified as anti-inflammatory.

Anti-inflammatory Properties

Adenosine is a potent anti-inflammatory agent, acting at its four G-protein coupled receptors. Topical treatment of adenosine to foot wounds in diabetes mellitus has been shown in lab animals to drastically increase tissue repair and reconstruction. Topical administration of adenosine for use in wound healing deficiencies and diabetes mellitus in humans is currently under clinical investigation.

Action on the heart

When administered intravenously, adenosine causes transient heart block in the AV node. It also causes endothelial dependent relaxation of smooth muscle as is found inside the artery walls. This causes dilatation of the "normal" segments of arteries where the endothelium is not separated from the tunica media by atherosclerotic plaque. This feature allows physicians to use adenosine to test for blockages in the coronary arteries, by exaggerating the difference between the normal and abnormal segments.

In individuals suspected of suffering from a supraventricular tachycardia (SVT), adenosine is used to help identify the rhythm. Certain SVTs can be successfully terminated with adenosine. This includes any re-entrant arrhythmias that require the AV node for the re-entry (e.g., AV reentrant tachycardia (AVRT), AV nodal reentrant tachycardia (AVNRT). In addition, atrial tachycardia can sometimes be terminated with adenosine.

Adenosine has a indirect effect on atrial tissue causing a shortening of the refractory period. When administered via a central lumen catheter, adenosine has been shown to initiate atrial fibrillation because of its effect on atrial tissue. In individuals with accessory pathways, the onset of atrial fibrillation can lead to a life threatening ventricular fibrillation.

Fast rhythms of the heart that are confined to the atria (e.g., atrial fibrillation, atrial flutter) or ventricles (e.g., monomorphic ventricular tachycardia) and do not involve the AV node as part of the re-entrant circuit are not typically converted by adenosine, however the ventricular reponse rate will be temporarily slowed.

Because of the effects of adenosine on AV node-dependent SVTs, adenosine is considered a class V antiarrhythmic agent. When adenosine is used to cardiovert an abnormal rhythm, it is normal for the heart to enter asystole for a very brief period. While the adenosine is necessary to save to patient, the event of the heart stopping for several seconds is very disconcerting to a normally conscious patient. This effect of temporary arrest is often overlooked and not mentioned, except in professional medical literature.

The pharmacological effects of adenosine are blunted in individuals who are taking methylxanthines (e.g., caffeine (found in coffee) and theophylline (found predominantly in tea)).

Caffeine's stimulatory effects are primarily (although not entirely) credited to its inhibition of adenosine by binding to the same receptors. By nature of caffeine's purine structure it binds to some of the same receptors as adenosine, effectively blocking adenosine receptors in the central nervous system. This reduction in adenosine activity leads to increased activity of the neurotransmitter dopamine.

Dosage

When given for the evaluation or treatment of an SVT, the initial dose is 6 mg, given as a fast IV/Intraosseous IO push. Due to adenosine's extremely short half-life, start the IV line as proximal to the heart as possible, such as the antecubital fossa. If this has no effect (e.g., no evidence of transient AV block), a 12mg dose can be given 1-2 minutes after the first dose. If the 12mg dose has no effect, a second 12mg dose can be administered 1-2 minutes after the previous dose. Some clinicians may prefer to administer a higher dose (typically 18 mg), rather than repeat a dose that apparently had no effect. When given to dilate the arteries, such as in a "stress test", the dosage is typically 0.14 mg/kg/min, administered for 4 or 6 minutes, depending on the protocol.

Consider increasing the recommended dose in patients on theophylline since methylxanthines prevent binding of adenosine at receptor sites. Consider decreasing the dose in patients on dipyridamole (Persantine) and diazepam (Valium) because adenosine potentiates the effects of these drugs.

Consider decreasing the recommended dose in half in patients who are presenting Congestive Heart Failure, Myocardial Infarction, shock, hypoxia, and/or hepatic or renal insufficiency.

Consider decreasing the recommended dose in half for elderly patients.

Drug Interactions

Beta blockers and dopamine may precipitate toxicity in the patient.

Contraindications

Poison/Drug induced tachycardia, Asthma (relative contraindication), 2nd or 3rd degree heart block, Atrial fibrillation, atrial flutter, Ventricular tachycardia, Sick sinus syndrome, Stokes-Adams Attack, Wolf-Parkinson-White syndrome, bradycardia with Premature Ventricular Contractions (PVCs).

WPW- adenosine may be administered if equipment for cardioversion is immediately available as a backup.
A-flutter W/rvr - when it first presents with SVT

Side effects

Many individuals experience facial flushing, lightheadedness, diaphoresis, or nausea after administration of adenosine. These symptoms are transitory, usually lasting less than one minute.

Metabolism

When adenosine enters the circulation, it is broken down by adenosine deaminase, which is present in red cells and the vessel wall.

Dipyridamole, an inhibitor of adenosine deaminase, allows adenosine to accumulate in the blood stream. This causes an increase in coronary vasodilatation.

External links

Computational Chemistry Wiki

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