The history of acetylcholinesterase inhibitors in the treatment of myasthenia gravis.

The beneficial effects of acetylcholinesterase inhibitors for the treatment of myasthenia gravis (MG) was a major discovery that came about through one young physician putting together a string of previous observations. To understand how this discovery came to light, we must first go back to earlier times when men hunted by bow-and-arrow to capture their prey. The substance used to poison the prey was eventually was identified as curare. Centuries later, a connection was made between the physiological effects of curare and a disease entity with no known pathological mechanism or treatment, myasthenia gravis. In 1935, house officer Dr. Mary Walker was the first physician to try physostigmine in the treatment of MG, which had previously been used to treat curare poisoning. What she saw was a dramatic improvement in the symptoms experienced in patients with MG, and thus became the first documented case of use of physostigmine, an acetylcholinesterase inhibitor, in the treatment of MG. This article is a summary of the history of the use of acetylcholinesterase inhibitors in the treatment of myasthenia gravis. This article is part of the special issue entitled 'Acetylcholinesterase Inhibitors: From Bench to Bedside to Battlefield'.

Acetylcholinesterase inhibitors (nerve agents) as weapons of mass destruction: History, mechanisms of action, and medical countermeasures.

Nerve agents are organophosphorus acetylcholinesterase inhibitors. Acute exposure to nerve agents can cause rapid death. In this review, we summarize the history of nerve agent development and use in warfare, the mechanisms by which these agents cause death or long-term brain damage, and the treatments for preventing death or long-term morbidity. The G-series nerve agents, tabun, sarin, soman, ethyl sarin, and cyclosarin, were developed by the Nazis. VX, the best-known of the V-series agents, was synthesized in the 1950's by a British scientist. Little is known about the development of the novichoks (the "A-series") by the former Soviet Union. Nerve agents were used for the first time in the battlefield by the Iraqi government in the Iran-Iraq War, in the 1980s. The Chemical Weapons Convention, in 1993, banned all chemical weapons production and use, yet, sarin was subsequently used in terrorist attacks in Japan and, recently, in the war in Syria. Pyridostigmine has been used as a prophylactic treatment, and bioscavengers are presently investigated as a better alternative. Atropine, along with an oxime, can prevent rapid death from the nerve agent-induced peripheral cholinergic crisis. Treatment with diazepam or midazolam for the cessation of nerve agent-induced status epilepticus cannot protect against brain damage, and, therefore, these benzodiazepines should be replaced by novel anticonvulsants and neuroprotectants. The AMPA/GluK1 receptor antagonist LY293558 (tezampanel) has shown superior antiseizure and neuroprotective efficacy against soman, particularly when administered in combination with caramiphen, an antagonist of muscarinic and NMDA receptors. This article is part of the special issue entitled 'Acetylcholinesterase Inhibitors: From Bench to Bedside to Battlefield'.

Mary Broadfoot Walker: 83 years since a historical discovery.

Mary Broadfoot Walker was a Scottish physician who, in 1935, described in great detail the effect of an anticholinesterase drug (physostigmine) on the signs and symptoms of myasthenia gravis. An original five-minutes movie is available online and the skepticism of her contemporary British medical doctors is understandable when the drastic effect of the treatment is shown in this movie. What Mary Walker taught us, more than eight decades ago, about myasthenia gravis continues to be the basis of a pharmacological diagnostic test and treatment of this disease.

Mary Broadfoot Walker: 83 years since a historical discovery / Mary Broadfoot Walker: 83 anos desde uma descoberta histórica

ABSTRACT Mary Broadfoot Walker was a Scottish physician who, in 1935, described in great detail the effect of an anticholinesterase drug (physostigmine) on the signs and symptoms of myasthenia gravis. An original five-minutes movie is available online and the skepticism of her contemporary British medical doctors is understandable when the drastic effect of the treatment is shown in this movie. What Mary Walker taught us, more than eight decades ago, about myasthenia gravis continues to be the basis of a pharmacological diagnostic test and treatment of this disease.

RESUMO Mary Broadfoot Walker foi uma médica escocesa que em 1935 descreveu em grande detalhe o efeito de uma droga anticolinesterásica (fisostigmina) nos sinais e sintomas da myasthenia gravis. Um filme original com cinco minutos de duração está disponível online e a reação cética dos colegas médicos contemporâneos de Mary é compreensível dado o drástico efeito terapêutico mostrado neste filme. O que Mary Walker nos ensinou mais de oito décadas atrás continua a ser a base de um teste diagnóstico farmacológico e do tratamento da myasthenia gravis.

Synthesis of tetraethyl pyrophosphate (TEPP): from physician Abbot and pharmacist Riegel to chemist Nylen.

Tetraethyl pyrophosphate (TEPP) made history not only as the first man-made organophosphate cholinesterase inhibitor but also as a most successful commercial product traded under a good number of names. The substance was first synthesized by a Russian chemist, Wladimir Petrovich Moshnin, while studying in Paris as an eleve (student) of Wurtz. The synthesis was soon thereafter repeated and reported to the Academy of Sciences by Philippe de Clermont, another student of Wurtz, who acknowledged the earlier work of Moshnin. Holmstedt in his chapter dealing with the beginnings of organophosphate chemistry in Koelle's Textbook Cholinesterases and Anticholinesterase Agents concluded his remarks by noting that after the initial synthesis by Moshnin and de Clermont, over the years, a good half-a-dozen of other pharmacists and chemists also managed the feat (of synthesizing TEPP). This led to my attempts at identifying those involved in the synthesis of TEPP. The compiled list turned out to be quite long: Abbot (1879), Riegel (1896), Cavalier (1906), Rosenheim A, Stadler & Jacobsohn (1906), Rosenheim & Pritze (1908), Balareff (1914), Nylen (1930), Arbusow & Arbusow (1931), Schrader (1938), Woodstock (1946) and Toy (1948). This report while summarizing the synthetic approach used in obtaining TEPP by the respective scientists mainly attempts to shed light on the life of the less known pharmacists and chemists involved in the synthesis of TEPP. The focus is on the pre-industrial synthesis period ending with Nylen largely because details on the Arbusow family, as well as on Schrader and Toy are fairly well known or have recently been described.

Pharmacists Adolf Schall and Ernst Ratzlaff and the synthesis of tabun-like compounds: a brief history.

The history of the synthesis of organophosphate inhibitors of cholinesterase starting with the synthesis of tetraethyl-pyrophosphate by Moschnin(e) and de Clermont and leading to the recognition about half a century later of the toxicity of the phosphor ester by Lange and von Krueger has been told in great detail previously. An almost parallel history -described originally by Bo Holmstedt--exists for organophosphonate inhibitors of cholinesterase starting with the synthesis (1898) in Rostock of diethylamido-ethoxy-phosphoryl-cyanide by the pharmacist Adolph Schall (1870-1957), a graduate student of August Michaelis (1847-1916), the re-examination of the chemical structure of the Schall compound (1903) by Michaelis, recognition (1937) of the toxicity of class by Gerhard Schrader (1903-1990) and confirmation (1951) of the structure by Bo Holmstedt (1919-2002). This short report attempts to shed some light on the life of the pharmacists and chemists involved in the synthesis of the first P-CN organophosphonate inhibitor of cholinesterase, focusing on the two less known pharmacists, the graduate students of Professor Michaelis Adolph Schall and Ernst Ratzlaff (1870-1948).

Research on cholinesterases in the Soviet Union and Russia: a historical perspective.

Research on cholinesterases and effects of their inhibition in the USSR and Russia since 1930-1940s till present is exposed in historical aspects. The first physiological and toxicological effects of cholinesterase inhibition were reported by Alexander Ginetsinsky during World War II, when academic institutions were evacuated from Leningrad to Kazan. The main scientific schools that initiated research on chemistry, enzymology and physiology of cholinesterases and their inhibitors were leaded by Alexandr and Boris Arbuzovs, Victor Rozengart, Viktor Yakovlev, Michael Michelson, Martin Kabachnik, Mikhail Voronkov, Ivan Knunyants, Alexandr Bretskin and others. They investigated the main physiological effects of cholinesterase inhibitors, and analyzed the catalytic mechanisms of cholinesterases and related enzymes. Their contributions are landmarks in the history of cholinesterase research. At the present time revival of research on cholinesterases in different universities and institutes is vivid, in particular at the Moscow State University, research institutes of Russian Academy of Sciences and Kazan Scientific Center.

Anticholinesterase insecticide retrospective.

The anticholinesterase (antiChE) organophosphorus (OP) and methylcarbamate (MC) insecticides have been used very effectively as contact and systemic plant protectants for seven decades. About 90 of these compounds are still in use - the largest number for any insecticide chemotype or mode of action. In both insects and mammals, AChE inhibition and acetylcholine accumulation leads to excitation and death. The cholinergic system of insects is located centrally (where it is protected from ionized OPs and MCs) but not at the neuromuscular junction. Structural differences between insect and mammalian AChE are also evident in their genomics, amino acid sequences and active site conformations. Species selectivity is determined in part by inhibitor and target site specificity. Pest population selection with OPs and MCs has resulted in a multitude of modified AChEs of altered inhibitor specificity some conferring insecticide resistance and others enhancing sensitivity. Much of the success of antiChE insecticides results from a suitable balance of bioactivation and detoxification by families of CYP450 oxidases, hydrolases, glutathione S-transferases and others. Known inhibitors for these enzymes block detoxification and enhance potency which is particularly important in resistant strains. The current market for OPs and MCs of 19% of worldwide insecticide sales is only half of that of 10 years ago for several reasons: there have been no major new compounds for 30 years; resistance has eroded their effectiveness; human toxicity problems are still encountered; the patents have expired reducing the incentive to update registration packages; alternative chemotypes or control methods have been developed. Despite this decline, they still play a major role in pest control and the increasing knowledge on their target sites and metabolism may make it possible to redesign the inhibitors for insensitive AChEs and to target new sites in the cholinergic system. The OPs and MCs are down but not out.

Symptomatic and nonamyloid/tau based pharmacologic treatment for Alzheimer disease.

In this work we consider marketed drugs for Alzheimer disease (AD) including acetylcholinesterase inhibitors (AChE-Is) and antiglutamatergic treatment involving the N-methyl-d-aspartate (NMDA) receptor. We discuss medications and substances available for use as cognitive enhancers that are not approved for AD or cognitive impairment, and other neurotransmitter-related therapies in development or currently being researched. We also review putative therapies that aim to slow disease progression by mechanisms not directly related to amyloid or tau.

Toxicity of phosphor esters: Willy Lange (1900-1976) and Gerda von Krueger (1907-after 1970).

In 1851 Williamson serendipitously discovered a new and efficient way to produce ethers using ethyl iodide and potassium salts. Based on this new synthetic approach, the Frenchman Philippe de Clermont and the Muscovite Wladimir Moschnin, both élèves of Adolphe Wurtz in his Paris School of Chemistry, achieved the synthesis of the first ester of pyrophosphoric acid (TEPP). de Clermont "tasted" the new compound and although TEPP is a potent cholinesterase inhibitor he failed to recognize its toxicity. Almost a century later, in 1932, Willy Lange (1900-1976) and his graduate student Gerda v. Krueger (1907-after 1970) described the toxicity of organophosphonates. While the classic paper of the two "Uber Ester der Monofluorphosphorsäure." is cited by almost everybody working in the field, little is known about Lange and almost nothing about v. Krueger. This brief communication attempts to shed some light on the life of both.

The synthesis of phosphor ethers: who was Franz Anton Voegeli?

The synthesis of the first organophosphate cholinesterase inhibitor (tetraethyl pyrophosphate, TEPP) is credited to the French organic chemist Philippe de Clermont (1831-1921) and to the Russian chemist Wladimir P. Moshnin from Moscow, both working in the laboratories of Adolphe Wurtz in Paris. In his publications de Clermont describes however not only the TEPP synthesis but also that of the related compound triethyl phosphate (TEP). TEP was previously synthesized by the Swiss chemist Franz Anton Voegeli (1825-1874), working in the laboratory of Gustav Magnus in Berlin. While TEPP is a potent organophosphate cholinesterase inhibitor with an IC50 in the low nanomolar range, TEP has no anticholinesterase activity up to millimolar concentrations. Therefore de Clermont and Moschnin are indeed the fathers of the first organophosphate cholinesterase inhibitor (TEPP), but are not entitled to claim paternity of the first compound in the class of phosphoric acid esters (TEP), an honor which belongs to Franz Anton Voegeli.

Cholinesterase inhibitors and beyond.

Cholinesterase inhibitors (ChEIs) were introduced in the therapy of Alzheimer Disease (AD) in the nineteen nineties with great expectations. The hopes and large interest raised by these drugs are well demonstrated by 12,000 references listed by PubMed under 'ChEI' for 1995-2007. The list is reduced to 2500 if we confine ourselves to 'ChEIs and dementia'. Of them, about 500 were published in the last two years. Whereas an increase in brain acetylcholine and an improvement of cognitive deficits have been consistently demonstrated in animal models of AD, from aging rats to transgenic mice, the clinical effectiveness of ChEIs has been and is still a matter of contrasting opinions. These range from the negative conclusions of the AD2000 trial on donepezil, claiming that it is not cost effective, with benefits below a minimally relevant threshold, to the NICE appraisal of 2007 declaring that donepezil, rivastigmine, galantamine are efficacious for mild to moderate AD, irrespective of their different selectivity for acetyl- (AChE) and butyrylcholinesterase (BuChE). The possibility that ChEIs may exert their effects through mechanisms beyond cholinesterase inhibition has been envisaged. However, according to the information presented in this review, the "classical" ChEIs, donepezil, rivastigmine and galantamine, show no pharmacological actions beyond cholinesterase inhibition which may play an important role in their therapeutic efficacy. The diverging opinions on clinical efficacy do not discourage from developing new ChEIs, and particularly the so called multifunctional ChEIs. They represent the future of the cholinergic therapy for AD but other indications for these drugs may be considered, including vascular dementia, mild cognitive impairment, and the ethically sensitive improvement of memory and learning in healthy subjects.

Dr Lazar Remen (1907-74): a forgotten pioneer in the treatment of myasthenia gravis.

Dr Lazar Remen (1907-74) was the first, in 1932, to describe the beneficial effect of prostigmine on a myasthenia gravis patient. His observation actually preceeded by two years Mary Broadfoot Walker's (1888-1974) paper, which is considered to be the landmark article on this association.