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Vol. 296, Issue 1, 132-140, January 2001
Department of Pharmacology and Toxicology, Medical College of Virginia of Virginia Commonwealth University, Richmond, Virginia
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Abstract |
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The present study conducted a comprehensive examination of the putative
sex differences in the potency of nicotine between male and female ICR
mice using several pharmacological and behavioral tests. Among the
responses to nicotine where significant sex differences were observed
are the antinociceptive and the anxiolytic effects of nicotine. Female
mice were found less sensitive to the acute effects of nicotine in
these tests after s.c. administration. Similar gender differences were
found after i.t. injection. Influence of gonadal hormones could
underlie sex differences observed in our studies. Indeed, our data
clearly indicate that sex hormones can modulate the effects of nicotine
and nicotinic receptors in a differential manner. Progesterone and
17
-estradiol were found to block nicotine's antinociception in
mice. Testosterone failed to do so. In addition, progesterone and
17
-estradiol blocked nicotine activation of
4
2 neuronal acetylcholine nicotinic
receptors expressed in oocytes. Our findings contribute
to our search for receptor mechanisms in drug dependence and in the
discovery of better pharmacological agents for nicotine dependence.
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Introduction |
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In
spite of heightened education and prevention strategies, cigarette
smoking remains a major health risk. Nicotine is believed to be the
primary reason that people consume tobacco products. Indeed,
substantial evidence now shows that nicotine is the addictive substance
found in tobacco. In 1974, 31% of U.S. women and 43% of U.S. men were
tobacco smokers. Current estimates indicate that the difference between
men and women has narrowed considerably to a comparable rate (21-25%)
(CDC, 1998
). Furthermore, poorer outcome of women in smoking cessation
trials, especially those involving nicotine replacement, has also been
reported. In other words, nicotine replacement is less effective for
smoking cessation than in men. There are several potential causes for
this shift toward more women smokers. There are several possible
explanations for this trend. Factors such as women's greater concern
about weight gain, greater difficulty with negative mood (and higher prevalence of affective disorders), and greater need for social support
to quit smoking could be of influence. Reduced availability of social
support for cessation in women and greater impact of advertising on
promoting smoking in women versus men may also have an influence. Broad
cultural influences also have been advanced as an explanation for sex
differences in smoking prevalence. Although cultural factors are
clearly important in explaining the historical differences between the
smoking patterns of American men and women earlier this century and in
non-Western countries, they do not seem to be a likely explanation.
Indeed, cultural restrictions in smoking behavior specific to women in
Western societies are no longer in existence. One obvious possibility
is the involvement of biological differences between the sexes might
contribute to this gender difference.
Animal studies have found that male and female rodents have different
sensitivities to the effects of nicotine. For example, female rats are
less sensitive than male rats to the discriminative stimulus effects of
nicotine (Schechter and Rosecrans, 1971
), consistent with findings in
humans (Perkins et al., 1999
). Female mice were less sensitive to
nicotine-induced suppression of Y-maze activity (Hatchell and Collins,
1980
) and increase in active avoidance learning (Yilmaz et al., 1997
).
In addition, sex differences in receptor up-regulation after chronic
exposure to nicotine was also reported with only male rats showing
up-regulation of brain [3H]cytisine binding
sites (Koylu et al., 1997
). Conversely, female rats were more sensitive
to nicotine's effects on prepulse inhibition (Faraday et al., 1999
)
and food intake (Grunberg et al., 1984
). Female rats were also more
sensitive to nicotine-induced antinociception compared with males in
acute and chronic pain models (Craft and Milholland, 1998
; Chiari et
al., 1999
; Lavand'homme and Eisenach, 1999
). In addition,
sensitization to nicotine-induced increase in locomotor activity was
found to be greater in female rats after chronic i.v. administration of
nicotine (Booze et al., 1999
), but not after chronic s.c. injection
(Kanyt et al., 1999
). Such complexity and variability in the response
of male and female rodents to nicotine may be due to differences in the
dose and elimination profile of nicotine, age and specie of the test
animal, route or duration of administration, time of evaluation, or the behavioral task used.
Another biological factor that could underlie sex differences is the
influence of gonadal hormones. Levels of sex hormones change through
the menstrual (human) or estrous (rodent) cycle. Human studies
examining the effects of the phase of the menstrual cycle on cigarette
smoking and on the psychoactive actions of nicotine are conflicting.
However, most studies report that menstrual cycle phase may influence
self-reported withdrawal symptoms in women (Benowitz and Hatsukami,
1998
). Animal studies suggest that ovarian hormones could influence
nicotine acute effects and reinforcement. Dluzen and Anderson (1997)
reported that estrogen treatment to ovariectomized female rats
increased the in vitro nicotine-induced release of dopamine from
striatal slices, whereas the opposite effect was seen in castrated males.
Therefore, the aim of the present study was to conduct a comprehensive
examination of the putative sex differences in the potency of nicotine
between male and female mice using several pharmacological and
behavioral tests. For that, the potency of nicotine in various
pharmacological effects measures (antinociception, hypothermia,
seizures, and motor activity, plus-maze activity) in animals was
examined after systemic and intrathecal administration. A wide range of
nicotinic effects is important to consider because it is believed that
various nicotinic receptor subtypes mediate different pharmacological
effects of nicotine. Because gonadal hormones may also mediate such sex
differences, the effects of testosterone, 17
-estradiol, and
progesterone on nicotine's effects were examined. The in vivo effect
of hormones was correlated with in vitro studies using the oocyte
expression system. For that, the effect of sex hormones on the
functional activity of the neuronal nAChRs
4
2 (the major
nicotinic receptor subtype in the brain) expressed receptors was studied.
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Materials and Methods |
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Animals
Male and female ICR mice (20-25 g) matched for age were obtained from Harlan Laboratories (Indianapolis, IN). They were housed in groups of six and had free access to food and water. Animals were housed in an American Association of Laboratory Animal Care-approved facility, and the study was approved by the Institutional Animal Care and Use Committee of Virginia Commomwealth University.
Drugs
(
)-Nicotine was obtained from Aldrich Chemical Co., Inc.
(Milwaukee, WI) and converted to the ditartrate salt as described by
Aceto et al. (1979)
. (
)-Epibatidine (hemi oxalate salt) was supplied
by Dr. S. Fletcher (Merck Sharp and Dohme & Co., Essex, UK).
Mecamylamine hydrochloride was supplied as a gift from Merck, Sharp and
Dohme & Co. (West Point, PA). Testosterone, 17
-estradiol, and
progesterone water-soluble (cyclodextrin-encapsulated) and oil-soluble
(testosterone decanoate) forms were purchased from Sigma Chemical Co.
(St. Louis, MO); neostigmine was purchased from Research Biochemicals
International (Natick, MA). Oil-soluble hormones were diluted in sesame
oil (Sigma Chemical Co.). All other drugs were dissolved in
physiological saline (0.9% sodium chloride) and given in a total
volume of 1 ml/100 g of body weight for s.c. injections. All doses are
expressed as the free base of the drug.
Intrathecal Injections
Intrathecal injections were performed free-hand between the L5
and L6 lumbar space in unanesthetized male mice according to the method
of Hylden and Wilcox (1980)
. The injection was performed using a
30-gauge needle attached to a glass microsyringe. The injection volume
in all cases was 5 µl. The accurate placement of the needle was
evidenced by a quick "flick" of the mouse's tail.
Antinociceptive Tests
Tail-Flick Test.
Antinociception was assessed by the
tail-flick method of D'Amour and Smith (1941)
as modified by Dewey et
al. (1970)
. A control response (2-4 s) was determined for each mouse
before treatment, and a test latency was determined after drug
administration. To minimize tissue damage, a maximum latency of 10 s was imposed. Antinociceptive response was calculated as percentage
maximum possible effect (%MPE), where %MPE = [(test
control)/(10
control)] × 100. Groups of 8 to 12 animals were
used for each dose and for each treatment. The mice were tested 5 min
after either s.c. or i.t. injections of nicotine.
Hot-Plate Test.
The method is a modification of that
described by Eddy and Leimbach (1953)
and Atwell and Jacobson
(1978)
. Mice were placed into a 10-cm-wide glass cylinder on a
hot-plate (Thermojust Apparatus, Richmond, VA) maintained at
55.0°C. Two control latencies at least 10 min apart were determined
for each mouse. The normal latency (reaction time) was 6 to 10 s.
Antinociceptive response was calculated as %MPE, where %MPE = [(test
control)/(40
control) × 100]. The
reaction time was scored when the animal jumped or licked its paws.
Eight mice per dose were injected s.c. with nicotine and tested 5 min
after injection.
-estradiol, and progesterone on
nicotine's antinociceptive effects were examined. Female
(17
-estradiol and progesterone) and male (testosterone) mice were
pretreated with different doses of hormones given i.p. and then
challenged with s.c. nicotine at different times. After determining the
time-course effect of hormones, the potency of these hormones in
blocking nicotine-induced antinociception was performed at the maximum time.
Behavioral Testing
Locomotor Activity. Mice were placed into individual Omnitech photocell activity cages (28 × 16.5 cm) 5 min after s.c. administration of either 0.9% saline or nicotine. Interruptions of the photocell beams (two banks of eight cells each) were then recorded for the next 10 min. Data are expressed as number of photocell interruptions.
Body Temperature. Rectal temperature was measured by a thermistor probe (inserted 24 mm) and digital thermometer (Yellow Springs Instrument Co., Yellow Springs, OH). Readings were taken just before and at 30 min after the s.c. injection of either saline or nicotine. The difference in rectal temperature before and after treatment was calculated for each mouse. The ambient temperature of the laboratory was 21-24°C from day to day.
Seizure Activity. After a s.c. injection of nicotine at a dose of 9 mg/kg, each animal was placed in a 30- × 30-cm Plexiglas cage and observed for 5 min. Whether a clonic seizure occurred within a 5-min time period was noted for each animal after s.c. administration of different drugs. This amount of time was chosen because seizures occur very quickly after nicotine administration. Results are expressed as percentage seizure.
Elevated Plus-Maze.
An elevated plus-maze, prepared with
gray Plexiglas, consisted of two open arms (23 × 6.0 cm) and two
enclosed arms (23 × 6 × 15 cm) that extended from a central
platform. It was mounted on a base raised 60 cm above the floor.
Fluorescent lights (350-lux intensity) located in the ceiling of the
room provided the only source of light to the apparatus. The animals
were placed in the center of the maze and the following variables were
scored: 1) time spent in the open arms, 2) time spent in the closed
arms, and 3) total number of crossings between arms. These variables are automatically recorded by a photocell beam system. The test lasted
5 min and the apparatus was thoroughly cleaned after removal of each
animal. Readings were taken 15 min after the s.c. injection of either
saline or nicotine. Anxiolytic response was calculated as the
percentage of time spent in the open arm, where % time = [(test
300 s) × 100].
Oocyte Expression Studies
Oocyte Preparation.
Oocytes preparation was performed
according to the method of Mirshahi and Woodward (1995)
with minor
modifications. Briefly, oocytes were isolated from female adult
oocyte-positive Xenopus laevis frogs. Frogs were
anesthetized in a 0.2% 3-aminobenzoic acid ethyl ester solution (Sigma
Chemical Co.) for 30 min and a fraction of the ovarian lobes was
removed. The eggs were rinsed in Ca2+-free ND96
solution, treated with collagenase type IA (Sigma Chemical Co.) for
1 h to remove the follicle layer, and then rinsed again. Healthy
stage V-VI oocytes were selected and maintained for up to 14 days after
surgery in 0.5× L-15 media (Sigma Chemical Co.).
mRNA Preparation and Microinjection.
4 and
2 rat subunit
cDNA contained within a pcDNAIneo vector were kindly supplied by Dr.
James Patrick (Baylor College of Medicine, Houston, TX). The template
was linearized downstream of coding sequence and mRNA was synthesized
using an in vitro transcription kit from Ambion (Austin, TX). The
quantity and quality of message were determined via optical density
(spectrophotometer; Beckman Instruments Inc., Chaumburg, IL) and
denaturing formaldehyde gel analysis. Oocytes were injected with either
51 ng (41 nl) of
4 and
2 mRNA mixed in a 1:1 ratio using a Variable
Nanoject (Drummond Scientific Co., Broomall, PA). Oocytes were
incubated in 0.5× L-15 media IA supplemented with penicillin,
streptomycin, and gentimycin for 4 to 6 days at 19°C before recording.
Electrophysiological Recordings.
Oocytes were placed within
a Plexiglas chamber (total volume 0.2 ml) and continually perfused (10 ml/min) with buffer consisting of 115 mM NaCl, 1.8 mM
CaCl2, 2.5 mM KCl, 1.0 µM atropine, and 10.0 mM
HEPES at pH 7.2. Oocytes were impaled with two microelectrodes containing 3 M KCl (0.3-3 M
) and voltage-clamped at
70 mV using an Axon Geneclamp amplifier (Axon Instruments Inc., Foster City, CA).
Oocytes were stimulated for 10 s with various concentrations of
acetylcholine using a six-port injection valve. Except where noted,
applications were separated by 5-min periods of washout. Currents were
filtered at 10 Hz and collected by a Macintosh Centris 650 with a
16-bit analog digital interface board, and data were analyzed using
Pulse Control voltage-clamp software running under the Igor Pro graphic
platform (Wavemetrics, Lake Oswego, OR). Water-soluble forms of
hormones were applied at different concentrations and
concentration-response curves were normalized to the current induced by
1 µM ACh. The normalizing concentration of ACh was applied before and
after drug application to each oocyte to check for desensitization.
Data were rejected if responses to the normalizing dose fell below 75%
of the original response. IC50 values were determined using data from four to six oocytes.
Statistical Analysis
Data were analyzed statistically by an analysis of variance
followed by the Fisher protected least-significant difference multiple
comparison test. For time course studies, Dunnett's test was used. The
null hypothesis was rejected at the 0.05 level. IC50 (antagonist concentration 50%) and
ED50 (effective dose 50%) values with 95%
confidence limits (CL) were calculated by unweighted least-squares
linear regression as described by Tallarida and Murray (1987)
. Tests
for parallelism were calculated according to the method of Tallarida
and Murray (1987)
. If confidence limit values did not overlap, then the
shift in the dose-response curve was considered significant.
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Results |
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Antinociception Studies
Tail-Flick Test.
Nicotine time course of action after an
equipotent dose in male (2 mg/kg) and female (3.5 mg/kg) mice was
evaluated in the tail-flick after s.c. injection. As seen in Fig.
1A, no significant difference was seen
between male and female mice. Nicotine's effect disappeared completely
within 30 min after s.c. administration in both sexes. Dose-response
relationships were then established for nicotine in male and female
mice by measuring antinociception at the time of maximal effect (5 min)
(Fig. 1B). Nicotine was 3 times less potent in females compared with
males. Nicotine produced a dose-responsive increase in the tail-flick
latency in both male and female mice with ED50
(±CL) values of 1.0 (0.6-1.3) and 2.9 (1.4-5.8) mg/kg, respectively.
The basal latencies between male and female mice were not statistically
different (2.5 ± 0.2 and 2.7 ± 0.2 s for male and
female, respectively). Pretreatment with the centrally active
noncompetitive nicotinic receptor antagonist mecamylamine (1 mg/kg
s.c.) 10 min before nicotine blocked its antinociceptive activity in
both male and female mice (Fig. 1C). Although mecamylamine seems to be
more potent in blocking nicotine's effects in female mice
[AD50 (±CL) = 0.09 (0.01-0.4) compared with male AD50 (±CL) = 0.2 (0.04-1.1)],
the difference was not significant because confidence limits of the two
curves overlapped. A similar sex difference was also observed with
epibatidine, a very potent nicotinic agonist. Epibatidine produced a
dose-responsive increase in the tail-flick latency (Fig.
2) in both male and female mice with
ED50 (±CL) values of 0.8 (0.5-1.1) and 1.7 (1.2-2.6) µg/kg, respectively.
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Hot-Plate Test.
Nicotine was then evaluated in both male and
female mice in another acute pain test, the hot-plate assay.
Dose-response relationships were established for nicotine in male and
female mice by measuring antinociception at the time of maximal effect
(5 min) (Fig. 3). Similar to that
observed with the tail-flick test, female mice were less sensitive to
the effect of nicotine compared with males. The difference of potency
between the two sexes was less (1.8 times) than the one determined for
the tail-flick test. Nicotine produced a dose-responsive increase in
the hot-plate latency in both male and female mice with
ED50 (±CL) values of 0.5 (0.4-0.6) and 0.9 (0.8-1.2) mg/kg, respectively. The basal latencies between male and
female mice were not statistically different (12.9 ± 0.8 and
11.5 ± 3.2 s for male and female, respectively).
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Antinociceptive Effects after i.t. Injection in the Tail-Flick
Test.
Nicotine potency was then evaluated in the tail-flick after
i.t. injection in male and female mice. Similar to that observed with
s.c. administration, female mice were less sensitive to the effect of
nicotine compared with males (Fig. 4A).
Nicotine produced a dose-responsive increase in the tail-flick latency
in both male and female mice with ED50 (±CL)
values of 11.4 (9.5-13.7) and 23 (15.1-34.2) µg/animal,
respectively. To determine whether the sex differences extended to
cholinesterase inhibitors, neostigmine was evaluated by i.t. injection.
The ED50 values for neostigmine-induced antinociception in male and female mice were 0.004 and 0.003 µg/animal, respectively. Therefore, the effects of elevating
endogenous ACh were not influenced by gender.
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Other Behavioral Effects of Nicotine
To further characterize sex differences, additional experiments were conducted to determine nicotine potency in other behavioral responses.
Effect on Plus-Maze Activity.
Nicotine increased the time
spent in the open arm of the maze when administered s.c. to male and
female mice (Fig. 5A). Nicotine potency
was higher in male mice compared with female mice with ED50 (±CL) values of 0.40 (0.2-0.6) and 0.95 (0.8-1.2) mg/kg, respectively. No gender differences were seen for
total crossings between the different arms in the plus-maze test (data
not shown).
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Effect on Body Temperature, Seizure Activity, and Locomotor
Activity.
Unlike the antinociceptive and anxiolytic effects,
nicotine potency in male and female mice was similar in inducing
hypothermia, hypomotility, and seizures production after s.c.
administration (Fig. 5, B-D; Table 1).
No sex differences were observed in baseline values in the spontaneous
activity and body temperature (data not shown).
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In Vivo Interaction of Sex Hormones with Nicotine with Expressed Neuronal Nicotinic Receptors
The interaction between nicotine and different sex hormones
(testosterone, 17
-estradiol, and progesterone) was studied in the
tail-flick test after s.c. administration of nicotine. Time course
studies were performed to determine the time of maximal blockade and
then dose-response curves for each hormone in blocking nicotine-induced
antinociception were carried out to determine the blockade potency.
Effect of Progesterone.
Progesterone was evaluated for its
ability to antagonize a 3.5-mg/kg dose of nicotine in female mice using
the tail-flick procedure after i.p. injection. As shown in Fig.
6A, progesterone time dependently blocked
nicotine-induced antinociception. The duration of action of
progesterone in the tail-flick test was time-dependent with maximum
blockade occurring between 3 and 4 h after injection of a dose of
20 mg/kg. Nicotine's effect started to recover within 6 h after
pretreatment with progesterone. Additionally, as showed in Fig. 6B,
progesterone dose dependently blocked nicotine-induced antinociception
with an AD50 (±CL) of 4.8 (2.8-8.4) mg/kg when given s.c. 4 h before nicotine.
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Effect of 17
-Estradiol and Testosterone.
Similar to
progesterone, 17
-estradiol time and dose dependently blocked
nicotine-induced antinociception in female mice. The duration of effect
of 17
-estradiol (20 µg/kg i.p.) was briefer than that of
progesterone, with a maximum effect at 3 h after injection and a
full recovery of nicotine's effects 6 h later (Fig.
8A). Additionally, as showed in Fig. 8B,
17
-estradiol dose dependently blocked nicotine-induced
antinociception with an AD50 (±CL) of 5.5 (4.0-6.6) µg/kg when given s.c. 4 h before nicotine. In
contrast to progesterone and 17
-estradiol, testosterone (up to 500 mg/kg i.p.) did not significantly decrease nicotine-induced antinociception at the times (Fig. 9A)
and doses tested (Fig. 9B).
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Interaction of Sex Hormones with Neuronal Nicotinic Receptors Expressed in Oocytes
Because progesterone and 17
-estradiol blocked nicotine's
behavioral effects, their potency as a blocker at expressed neuronal nicotinic receptors was investigated. Progesterone and 17
-estradiol at 50 µM elicited little current when applied for 10 s to
oocytes expressing the
4
2 subunit
combinations (
5 ± 2 nA). Although they did not activate these
expressed receptors, they antagonized the effects of nicotine in a
concentration-related manner. The concentration that blocked 50% of
the nicotinic current was determined to be 1.8 (1.1-2.9) and 25 (15-43) µM for progesterone and 17
-estradiol, respectively (Fig.
10, A and B). At the lower
concentration of 17
-estradiol (0.01 µM), there was a small (12%
increase) enhancement in the nicotinic current when the two drugs were
coapplied (Fig. 10B). This enhancement disappeared at 0.1 µM
17
-estradiol. The effect of progesterone and 17
-estradiol on
4
2 receptors was reversible after 5-min wash period (Fig. 10, A and B).
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Discussion |
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The primary findings of this study are that there are sex
differences in nicotine's acute pharmacological effects, but these differences are response-dependent. This study also confirms that sex
hormones are functional blockers of nicotinic receptors in in vivo and
in vitro tests. Previous work suggested that gender was an important
factor that influences certain behavioral effects of nicotine, such as
those on feeding behavior (Grunberg et al., 1984
), locomotor
sensitization (Booze et al., 1999
), and cognition (Kanyt et al., 1999
).
Among the responses to nicotine where significant sex differences were
observed in our studies are the antinociceptive and the anxiolytic
effects of nicotine. Female mice were found less sensitive to the acute
effects of nicotine in these tests. Although gender differences in the
plus-maze test have been not described before, the difference in
nicotine-induced antinociception agrees well with a recent human study
where women were less sensitive to nicotine than men (Jamner et al.,
1998
).
This sex difference is not limited to nicotine, but other nicotinic
agonists such as epibatidine showed a similar difference. In addition,
the fact that a similar sex difference was seen after spinal injection
would also confirm the involvement of spinal mechanisms in mediating
such a difference. However, no central administration of nicotine was
performed in the present study. Furthermore, the lack of sex difference
in the case of neostigmine suggests that sex interacted significantly
with nicotinic and not muscarinic drugs because neostigmine-induced
antinociception is mediated through muscarinic and not nicotinic
receptors (Yaksh et al., 1985
; Naguib and Yaksh, 1994
).
Proposed Mechanisms Underlying Sex Differences in Nicotine
Analgesia.
One obvious possibility is that nicotine
bioavailability might differ between the sexes. Although a sex
difference in nicotine kinetics is probably not a major influence in
humans, there is evidence of sex difference in nicotine metabolism in
rats, where studies showed that male rats eliminate nicotine faster
than females (Kyerematen et al., 1988
; Nwoso and Crooks, 1988
).
Although plasma and brain concentrations of nicotine were not measured
in our studies, our data argue against an exclusive role for
pharmacokinetics in accounting for the differential analgesic response
of male and female mice to nicotine. Indeed, the following arguments
suggest that kinetic factors are probably playing a minor role: 1) the fact that sex differences were not seen in a uniform manner in all
behavior responses measured; 2) sex differences were seen with more
than one nicotinic agonist (epibatidine and nicotine); and 3) sex
differences were seen in nicotine potency in the tail-flick test after
i.t. administration.
4
2-type nicotinic
receptors (Bullock et al., 1997
4
2 nicotinic
receptors, with an IC50 of 9 and 46 µM,
respectively. Our results extended these observations and we found that
progesterone and 17
-estradiol are functional blockers of nicotinic
receptors in in vivo and in vitro conditions, with progesterone being a more potent antagonist of
4
2 receptors (1.8 versus 25 µM). Testosterone failed to block nicotine's behavioral
effects at very high doses, which correlates well with previous
studies. We also report that chronic exposure to progesterone enhances
its in vivo effects on nicotine consistent with what is reported in in
vitro tests (Ke and Lukas, 1996| |
Acknowledgments |
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We greatly appreciate the technical assistance of Dr. Tie Han and Gray Patrick.
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Footnotes |
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Accepted for publication September 10, 2000.
Received for publication April 12, 2000.
This work was supported by National Institute on Drug Abuse Grant DA-05274.
Send reprint requests to: Dr. M. Imad Damaj, Department of Pharmacology and Toxicology, Medical College of Virginia, Virginia Commonwealth University, Box 980613, Richmond, VA 23298-0613. E-mail: mdamaj{at}hsc.vcu.edu
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Abbreviations |
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nAChR, acetylcholine nicotinic receptor; %MPE, percentage maximum possible effect; i.t., intrathecal; CL, confidence limit; AD50, antagonist dose 50%; ACh, acetylcholine.
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