Skip to Main Content

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android. Learn more here!



ACh: acetylcholine

AChE: acetylcholinesterase

anti-ChE: anticholinesterase

BChE: butyrylcholinesterase

ChE: cholinesterase

CNS: central nervous system

CYP: cytochrome P450

DFP: diisopropyl fluorophosphate (diisopropyl phosphorofluoridate)

EPA: Environmental Protection Agency

FDA: Food and Drug Administration

2-PAM: pralidoxime

PON1: paraoxonase isoform 1

TOCP: triorthocresyl phosphate


The hydrolytic activity of AChE terminates the action of ACh at the junctions of the various cholinergic nerve endings with their effector organs or postsynaptic sites (Chapter 8). Drugs that inhibit AChE are called anti-ChEs, since they inhibit both AChE and BChE. BChE is not found in nerve ending synapses but in liver and plasma, where it metabolizes circulating esters. AChE inhibitors cause ACh to accumulate in the vicinity of cholinergic nerve terminals and thus are potentially capable of producing effects equivalent to excessive stimulation of cholinergic receptors throughout the central and peripheral nervous systems. In view of the widespread distribution of cholinergic neurons across animal species, it is not surprising that the anti-ChE agents have received extensive application as toxic agents, in the form of agricultural insecticides, pesticides, and potential chemical warfare “nerve gases.” Moreover, several compounds of this class are used therapeutically; others that cross the blood-brain barrier have been approved or are in clinical trials for the treatment of Alzheimer disease.

Prior to World War II, only the “reversible” anti-ChE agents were generally known, of which physostigmine is the prototype (Box 10-1). Shortly before and during World War II, a new class of highly toxic chemicals, the organophosphates, was developed, first as agricultural insecticides and later as potential chemical warfare agents. The extreme toxicity of these compounds was found to be due to their “irreversible” inactivation of AChE, which resulted in prolonged enzyme inhibition. Because the pharmacological actions of both the reversible and irreversible anti-ChE agents are qualitatively similar, they are discussed here as a group. Interactions of anti-ChE agents with other drugs acting at peripheral autonomic synapses and the neuromuscular junction are described in Chapters 9 and 11.

BOX 10–1 History

Physostigmine, also called eserine, is an alkaloid obtained from the Calabar or ordeal bean, the dried, ripe seed of Physostigma venenosum, a perennial plant found in tropical West Africa. This Calabar bean once was used by native tribes of West Africa as an “ordeal poison” in trials for witchcraft, in which guilt was judged by death from the poison, innocence by survival after ingestion of a bean. A pure alkaloid was isolated by Jobst and Hesse in 1864 and named physostigmine. The first therapeutic use of the drug was in 1877 by Laqueur in the treatment of glaucoma, one of its clinical uses today. Karczmar (1970) and Holmstedt (2000) have presented accounts of the history of physostigmine.

After basic research elucidated the chemical basis of the activity of physostigmine, scientists began systematic investigations of a series of substituted aromatic esters of alkyl carbamic acids. Neostigmine ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.