| Alpha blockers α-blockers | |
|---|---|
| Drug class | |
| Class identifiers | |
| Use | • Hypertension • Vasoconstriction • BPH • Raynaud's Disease • Pheochromocytoma • CHF • Erectile Dysfunction |
| Mechanism of action | • Receptor antagonist • Inverse agonist • Neutral antagonist |
| Biological target | α-adrenoceptors |
| Legal status | |
| In Wikidata | |
Alpha blockers, also known asα-blockers orα-adrenoreceptor antagonists, are a class ofpharmacological agents that act asantagonists onα-adrenergic receptors (α-adrenoceptors).[2]
Historically, alpha-blockers were used as a tool for pharmacologic research to develop a greater understanding of the autonomic nervous system. Using alpha blockers, scientists began characterizing arterial blood pressure and central vasomotor control in the autonomic nervous system.[3] Today, they can be used as clinical treatments for a limited number of diseases.[2]
Alpha blockers can treat a small range of diseases such ashypertension,Raynaud's disease,benign prostatic hyperplasia (BPH) anderectile dysfunction.[2] Generally speaking, these treatments function by binding an α-blocker to α receptors in the arteries and smooth muscle. Ultimately, depending on the type of alpha receptor, this relaxes the smooth muscle or blood vessels, which increases fluid flow in these entities.[2]
When the term "alpha blocker" is used without further qualification, it can refer to anα1 blocker, anα2 blocker, a nonselective blocker (bothα1 andα2 activity), or anα blocker with some β activity.[2] However, the most common type of alpha blocker is usually anα1 blocker.
Non-selective α-adrenergic receptor antagonists include:
Selective α1-adrenergic receptor antagonists include:
Selective α2-adrenergic receptor antagonists include:
Finally, the agentscarvedilol andlabetalol are both α andβ-blockers.
Below are some of the most common drugs used in the clinic.
| Drug Name | Common Brands | Structure | Mechanism of Action | Effects | Clinical Applications | Toxicity |
|---|---|---|---|---|---|---|
| Phenoxybenzamine | Dibenzyline |  | Nonselective covalent binding to α1 and α2 receptors. | Lowers blood pressure by decreasing peripheral resistance. Blocks alpha induced vasconstriction.[2] |
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| Phentolamine | Regitine |  | Competitive blocking of α1 and α2 receptors. | Reversal of epinephrine induced effects. Lowers blood pressure by decreasing peripheral resistance.[2][10] |
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| Prazosin | Minipress |  | Inverse agonist of α1 receptor.[10] | Lowers blood pressure.[2] | ||
| Doxazosin | Cardura Cardura XL |  | Competitive blocking of α1 receptor.[10] | Lowers blood pressure.[2] |
| |
| Terazosin | Hytrin |  | Competitive blocking of α1 receptor.[10] | Lowers blood pressure.[2] | ||
| Tamsulosin | Flomax |  | A blocker that has slight selectivity for α1 receptors.[2] | Relaxation of prostatic smooth muscle.[2] |
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| Yohimbine | Yocon |  | Blocks α2 receptor, and increases norepinephrine release, thus increasing CNS activity.[2] | Raises blood pressure and heart rate.[2] |
| |
| Labetalol | Trandate |  | Blocks some α1 receptor activity, but binds more strongly to β receptors.[2] | Lowers blood pressure, increases heart rate slightly.[2] |
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| Carvedilol | Coreg Coreg CR |  | Blocks some α1 receptor activity, but binds more strongly to β receptors.[2] | Can interfere with noradrenergic mechanisms.[2] |
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While there are limited clinical α-blocker uses, in which most α-blockers are used forhypertension orbenign prostatic hyperplasia, α-blockers can be used to treat a few other diseases, such asRaynaud's disease,congestive heart failure (CHF),pheochromocytoma, anderectile dysfunction.[15][16][17]
Furthermore, α-blockers can occasionally be used to treat anxiety and panic disorders, such asposttraumatic stress disorder (PTSD) inducednightmares.[6] Studies have also had great medical interest in testing alpha blockers, specifically α2 blockers, to treattype II diabetes andpsychiatric depression.[2]
Hypertension is due to an increase in vascular resistance and vasoconstriction. Using α1 selective antagonists, such asprazosin, has been efficacious in treating mild to moderate hypertension. This is because they can decrease vascular resistance and decrease pressure.[2][18] However, while these drugs are generally well tolerated, they have the potential to produce side effects such as orthostatic hypotension and dizziness.[2] However, unlike other treatments for hypertension such asACE inhibitors,ARBs,calcium channel blockers,thiazide diuretics orbeta blockers, alpha blockers have not demonstrated the same mortality and morbidity benefits, and are therefore not generally used as first or even second line agents.
Another treatment for hypertension is using drugs that have both α1 blocking activity, as well as nonselective β activity, such asLabetalol orcarvedilol.[19] In low doses, labetalol and carvedilol can decrease the peripheral resistance and block the effects of isoprenaline to reduce hypertensive symptoms.[19]
Pheochromocytoma is a disease in which a catecholamine secreting tumor develops.[2][20] Specifically, norepinephrine and epinephrine are secreted by these tumors, either continuously or intermittently.[21] The excess release of these catecholamines increases central nervous system stimulation, thus causing blood vessels to increase in vascular resistance, and ultimately giving rise to hypertension.[20] In addition, patients with these rare tumors are often subject to headaches, heart palpitations, and increased sweating.[2]
Phenoxybenzamine, a nonselective α1 and α2 blocker, has been used to treat pheochromocytoma.[21] This drug blocks the activity of epinephrine and norepinephrine by antagonizing the alpha receptors, thus decreasing vascular resistance, increasing vasodilation, and decreasing blood pressure overall.[21]
Blockers that have both the ability to block both α and β receptors, such ascarvedilol,bucindolol, andlabetalol, have the ability to mitigate the symptoms incongestive heart failure.[22] By binding to both the α and β receptors, these drugs can decrease the cardiac output and stimulate the dilation of blood vessels to promote a reduction in blood pressure.[22]
Yohimbine, an α2 blocker derived from the bark of thePausinystalia johimbe tree, has been tested to increase libido and treat erectile dysfunction. The proposed mechanism for yohimbine is blockade of the adrenergic receptors that are associated withneurotransmitters inhibition, includingdopamine andnitric oxide, and thus aiding with penile erection and libido.[23] By doing so, they can alter the blood flow in the penis to aid in achieving an erection. However, some side effects can occur, such aspalpitation,tremor,elevated blood pressure, andanxiety.[23]Yohimbe bark contains both α1 and α2adrenergic receptors blockingalkaloids.
Phentolamine, a non-selective alpha blocker, has also been tested to treat erectile dysfunction. By reducing vasoconstriction in the penis, there appears to be increased blood flow that aids in penile erection. Side effects associated with phentolamine include headache, flushing, and nasal congestion.[23]
Phenoxybenzamine, a non-competitive α1 and α2 blocker was used by Dr.Giles Brindley in the first intracavernosal pharmacotherapy for erectile dysfunction.[24]
Inbenign prostatic hyperplasia (BPH), men experience urinary obstruction and are unable to urinate, thus leading to urinary retention.[2] α1 specific blockers have been used to relax the smooth muscle in the bladder and enlarged prostate.[25]Prazosin,doxazosin, andterazosin have been particularly useful for patients with BPH, especially in patients with hypertension.[2] In such patients, these drugs can treat both conditions at the same time.[2] In patients without hypertension,tamsulosin can be used, as it has the ability to relax the bladder and prostate smooth muscle without causing major changes in blood pressure.[25]
Both α1 blockers and α2 blockers have been examined to treatRaynaud's disease. Although α1 blockers, such asprazosin, have appeared to give slight improvement for the sclerotic symptoms of Raynaud's disease, there are many side effects that occur while taking this drug. Conversely, α2 blockers, such as yohimbine, appear to provide significant improvement of the sclerotic symptoms in Raynaud's Disease without excessive side effects.[26]
Patients withposttraumatic stress disorder (PTSD) have often continued to be symptomatic despite being treated with PTSD-specific drugs.[27] In addition, PTSD patients often have debilitating nightmares that continue, despite their treatments.[27] High doses of the α1 blocker,prazosin, have been efficacious in treating patients with PTSD induced nightmares due to its ability to block the effects of norepinephrine.[27]
Adverse effects of prazosin to treat PTSD nightmares includedizziness,first dose effect (a sudden loss of consciousness),weakness,nausea, andfatigue.[27]
Although alpha blockers have the ability to reduce some disease pathology, there are some side effects that come with these alpha blockers.[28] However, because there are several structural compositions that make each alpha blocker different, the side effects are different for each drug. Side effects that arise when taking alpha blockers can include thefirst dose effect, cardiovascular side effects, genitourinary side effects, as well as other side effects.[28]
One of the most common side effects with alpha blockers is thefirst dose effect.[29] This is a phenomenon in which patients with hypertension take an alpha blocker for the first time, and suddenly experience an intense decrease in blood pressure. Ultimately, this gives rise toorthostatic hypotension,dizziness, and a sudden loss of consciousness due to the drastic drop in blood pressure.[29]
Alpha blockers that possess these side effects includeprazosin,doxazosin, andterazosin.[30]
There are some alpha blockers that can give rise to changes in the cardiovascular system, such as the induction of reflex tachycardia, orthostatic hypotension, or heart palpitations via alterations of the QT interval.[28][31] Alpha blockers that may have these side effects includeyohimbine,phenoxybenzamine, andphentolamine.[2]
When alpha blockers are used to treat BPH, it causes vasodilation of blood vessels on the bladder and the prostate, thus increasing urination in general.[32] However, these alpha blockers can produce the exact opposite side effect, in whichedema, or abnormal fluid retention, occurs.[33]
In addition, due to the relaxation of the prostate smooth muscle, another side effect that arises in men being treated for BPH is impotence, as well as the inability to ejaculate.[32][34] However, if any ejaculation activity does occur, oftentimes, it results in a phenomenon calledretrograde ejaculation, in which semen flows into the urinary bladder instead of exiting through the urethra.[34]
Drugs that may produce such side effects includeprazosin,terazosin,tamsulosin, anddoxazosin.[34]
Finally, there are other general side effects that can be caused by most alpha blockers (however, more frequently in alpha-1 blockers). Such side effects includedizziness,drowsiness,weakness,fatigue, psychiatricdepression, anddry mouth.[28][34]
Priapism, an unwanted, painful long term erection not brought on by sexual arousal and lasting several hours has been associated with alpha blocker use. While this is extremely rare, particularly with tamsulosin, it can cause permanent impotence if not treated in a hospital setting. Male patients should be made aware of this as it can result from a single dose or develop over time.
There is only one compelling indication for alpha blockers, which is forbenign prostatic hyperplasia.[33] Patients who need alpha blockers for BPH, but have a history ofhypotension orpostural heart failure, should use these drugs with caution, as it may result in an even greater decrease in blood pressure or make heart failure even worse.[35][36] The most compellingcontraindication isurinary incontinence and overall fluid retention.[35][36] To combat such fluid retention, patients can take a diuretic in combination with the alpha-blocker.[36]
In the absence of compelling indications or contraindications, patients should take alpha blockers as astep 4 therapy to reduce blood pressure, but only if the use of ACE inhibitors, angiotensin-II receptor blockers, calcium channel blockers, or thazide diuretics (in full dose or in combinations) have not been efficacious.[33][35][36]
As with any drug, there are drug interactions that can occur with alpha blockers. For instance, alpha blockers that are used for the reduction of blood pressure, such asphenoxybenzamine orphentolamine can have synergy with other drugs that affect smooth muscle, blood vessels, or drugs used forerectile dysfunction (i.e.sildenafil,tamsulosin, etc.). This stimulates exaggeratedhypotension.[2]
Alternative alpha blockers, such asprazosin,tamsulosin,doxazosin, orterazosin can have adverse interactions withbeta blockers,erectile dysfunction drugs,anxiolytics, andantihistamines.[2] Again, these interactions can cause dangeroushypotension. Furthermore, in rare cases, drug interactions can cause irregular, rapid heartbeats or an increase blood pressure.[2]
Yohimbine can interact withstimulants,hypertension drugs,naloxone, andclonidine. Interactions with such drugs can cause either an unintended increase in blood pressure or potentiate an increase in blood pressure.[2]
Finally, in drugs with both alpha and beta blocking properties, such ascarvedilol andlabetalol, interactions with other alpha or beta blockers can exaggerate a decrease in blood pressure.[2] Conversely, there are also drug interactions with carvedilol or labetalol in which blood pressure is increased unintentionally (such as with cough and cold medications).[2] Finally, there may also be some alpha/beta blocker drug interactions that can worsen previous heart failure.[2]
Alpha blockers work by blocking the effect of nerves in the sympathetic nervous system. This is done by binding to the alpha receptors in smooth muscle or blood vessels.[37] α-blockers can bind both reversibly and irreversibly.[2]
There are several α receptors throughout the body where these drugs can bind. Specifically, α1 receptors can be found in most vascular smooth muscle, the pupillary dilator muscle, the heart, the prostate, and pilomotor smooth muscle.[2] On the other hand, α2 receptors can be found in platelets, cholinergic nerve terminals, some vascular smooth muscle, postsynaptic CNS neurons, and fat cells.[2]
The structure of α receptors is a classicG protein–coupled receptors (GPCRs) consisting of 7 transmembrane domains, which form three intracellular loops and three extracellular loops.[2] These receptors couple to heterotrimeric G proteins composed of α, β, and γ subunits.[2] Although both of the α receptors are GPCRs, there are large differences in their mechanism of action. Specifically,α1 receptors are characterized as Gq GPCRs, signaling throughPhospholipase C to increaseIP3 andDAG, thus increasing the release of calcium. Meanwhile,α2 receptors are labeled as Gi GPCRs, which signal throughadenylyl cyclase to decreasecAMP.[38]
Because the α1 and α2 receptors have different mechanisms of action, their antagonists also have different effects.[39] α1 blockers can inhibit the release ofIP3 andDAG to decrease calcium release, thus, decreasing overall signaling. On the other hand, α2 blockers prevent the reduction of cAMP, thus leading to an increase in overall signaling.
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