How do Anesthetics Work?

Ask a simple question, and get an answer that gets weirder the deeper you dig.

Anesthesia is wonderful. Quite simply, it makes bearable, even unnoticeable, what would be impossible or excruciating. It is also one of the most mysterious phenomena short of consciousness itself. All animals can be anesthetized, from bacteria on up. All sorts of chemicals can be used, from xenon to simple ethers, to complex fluoride-substituted forever chemicals, all with similar effects. Yet there are also complex sub-branches of anesthesia, like pain relief, muscular immobilization, shutdown of consciousness, and amnesia against remembering what happened, that chemicals affect differentially. It resembles sleep, and shares some circuitry with that process, but is of course is induced quite differently.

The first red herring was the Meyer–Overton rule, established back in 1899, that showed that anesthetic potency correlates closely with the lipophilicity of the chemical, from nitrogen (not very good) to xenon (pretty good) to chloroform (very good). All the forever (heavily fluorinated) chemicals used as modern anesthetics, like isoflurane and sevoflurane, have extremely high lipophilicity. This suggested that the mechanism of action was simply mixing into membranes somehow, altering their structure or something. 

Structures of several general anesthetics. 8 is isoflurane.

But when researchers looked more closely there were some chemical differences that did not track with this hypothesis. Chiral enantiomers behaved differently in some cases, indicating that these chemicals do bind to something (that is, a protein) specifically. Also, variant genes started cropping up that conferred resistance to anesthesia or were found to bind particular anesthetics at working concentrations. So while anesthetics clearly partition to membranes, and the binding sites are often at protein-membrane interfaces, the modern theory of how they work is that they bind to ion channels and neurotransmitter receptors and affect their functions. Proteins generally have hydrophobic interiors, so the lipophilicity of these chemicals may track with binding / disrupting protein interiors as much as membrane interiors.

But which key protein do they bind? Here again, mysteries abound, as they do not bind just one, but many. And not just that, they turn some of their targets on, others off. One target is the GABA receptor, which characterizes the major inhibitory neurons of the central nervous system. These are turned on. At high concentrations, anesthetics can even turn these receptors on without any GABA neurotransmitter present. Another is the NMDA receptor, which is the target of opioids, and of ketamine. These receptors are turned off. So, for some reason, still somewhat obscure, the net result of many specific bindings to an array of channels by an array of chemicals results in ... anesthesia.

A recent paper raised my interest in this area, as its authors demonstrated yet another target for mainstream anesthetics like isoflurane and dove with exquisite detail into its mechanism. They were working on the ryanodine receptor, which isn't even a cell surface protein, but sits in the endoplasmic reticulum (or sarcoplasmic reticulum in muscles) and conducts calcium out of these organelles. This receptor is huge- the largest known, coding over five thousand amino acids (RYR1 of humans), due to numerous regulatory structures built in. For example, it is sensitive to caffeine, but in a different location than where it is sensitive to isoflurane. Calcium is a very important signal within cells, key to muscle activity, and also to neuronal activation. The endoplasmic reticulum serves as a storehouse of calcium, from which signals can be sparked as needed by outside signals, including a spike in calcium itself (thus creating a positive feedback loop). These receptors (a family of three in human) are named for an obscure chemical (indeed a poison) that activates these channels all of which are expressed in the brain. 

The authors were led to this receptor because mutations were known to cause malignant hyperthermia, a side effect of a few of the common anesthesia drugs where body temperature rises uncontrollably, driven by muscle tissue, where ryodine receptors in the sarcoplasmic reticulum are particularly common and heavily used to regulate muscle activity and metabolism. That suggested that anesthetics such as isoflurane might bind to this receptor directly, turning it on. That was indeed the case. They started with cultured cells expressing each receptor family member in turn, and tested their response to isoflurane. Internal (cytoplasmic) calcium rose especially with the family member RYR1. That led to various control experiments and a hunt (by mutating and doctoring the RYR1 protein) for the particular region being bound by the anesthetic. After a lengthy search, they found residue 4000 was a critical one, as a mutation from methionine to phenylalanine reduced the isoflurane response about ten-fold. This is part of a binding pocket as shown below.

Structure of isoflurane, (B), bound to the RYR1 protein pocket. This is a pocket that happens to also bind another activator of this channel, 4-CMC. A layout of the whole active binding pocket is given on the right. At bottom are calcium channel responses of the wild-type and point mutant forms of RYR1, showing the dramatic effect these single site mutations have on isoflurane response.

Fine, but what about anesthesia? The next step was to test this mutation in whole mice, where, lo and behold, isoflurane anesthesia of otherwise normal mice was made slightly more difficult by this mutant form of RYR1. Additionally, these mice had no other observable problems- not in behavior, not in sleep. That is remarkable as a finding about anesthesia, but the effect was quite small- about 10% or so shift in the needed concentration. They go on to mention that this is similar in scale to knockouts or mutations in other known targets of anesthetic drugs:

• 10% shift in the curve from the M4000F mutation of RYR1
• 14% shift in the isoflurane curve from a mutation in GABA receptor, GABAAR.
• 5% shift in the isoflurane curve (though a 20% or more shift for halothane) for mutations in KCNK9, a potassium channel.

What this is telling us is that there are many targets for anesthetic drugs. They are spread over many neurotransmitter and physiological systems. They each contribute modestly (and variably, depending on the drug) to the net effect of any one drug. The various affected channels and membrane receptors curiously combine to achieve anesthesia across all animals and even microorganisms, which naturally also rely on channels and transmembrane receptors for their various sensing and motion activation needs. We are left with a blended hypothesis where yes, there are specific protein targets for each anesthetic that mediate their action. On the other hand, these targets are far from unique, spread across many proteins, yet are also highly conserved, looking almost like they are implicit in the nature of transmembrane proteins in general. 

One gets the distinct impression that there should be endogenous equivalents, as there are for opioids and cannabinoids- some internal molecule that provides sedation when needed, such as for deep illness or end-of-life crisis. That molecule has not yet been found, but the natural world abounds in sedatives, (alcohol is certainly one), so the logic of anesthesia becomes one of evolutionary and biological logic, as much as one of chemical mechanism.

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