Drug General Information (ID: DDIB285LC4)
  Drug Name Fentanyl Drug Info Tubocurarine Drug Info
  Drug Type Small molecule Small molecule
  Therapeutic Class Narcotic Analgesics Neuromuscular Blocking Agents
  Structure

 Mechanism of Fentanyl-Tubocurarine Interaction (Severity Level: Moderate)
     Additive hypotensive effects Click to Show/Hide Mechanism Graph
Could Not Find 2D Structure
      Drug Name Fentanyl Tubocurarine
      Mechanism 1 Hypotensive effects
Opioid receptor mu  Agonist
Hypotensive effects
Neuronal acetylcholine receptor  Antagonist
      Key Mechanism Factor 1
Factor Name Opioid receptor mu
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Structure Sequence
MDSSAAPTNASNCTDALAYSSCSPAPSPGSWVNLSHLDGNLSDPCGPNRTDLGGRDSLCPPTGSPSMITAITIMALYSIVCVVGLFGNFLVMYVIVRYTKMKTATNIYIFNLALADALATSTLPFQSVNYLMGTWPFGTILCKIVISIDYYNMFTSIFTLCTMSVDRYIAVCHPVKALDFRTPRNAKIINVCNWILSSAIGLPVMFMATTKYRQGSIDCTLTFSHPTWYWENLLKICVFIFAFIMPVLIITVCYGLMILRLKSVRMLSGSKEKDRNLRRITRMVLVVVAVFIVCWTPIHIYVIIKALVTIPETTFQTVSWHFCIALGYTNSCLNPVLYAFLDENFKRCFREFCIPTSSNIEQQNSTRIRQNTRDHPSTANTVDRTNHQLENLEAETAPLP
Gene Name OPRM1
Uniprot ID OPRM_HUMAN
KEGG Pathway hsa:4988
Protein Family G-protein coupled receptor 1 family
Protein Function
Receptor for endogenous opioids such as beta-endorphin and endomorphin. Receptor for natural and synthetic opioids including morphine, heroin, DAMGO, fentanyl, etorphine, buprenorphin and methadone (PubMed:7905839, PubMed:7957926, PubMed:7891175, PubMed:12589820, PubMed:9689128). Agonist binding to the receptor induces coupling to an inactive GDP-bound heterotrimeric G-protein complex and subsequent exchange of GDP for GTP in the G-protein alpha subunit leading to dissociation of the G-protein complex with the free GTP-bound G-protein alpha and the G-protein beta-gamma dimer activating downstream cellular effectors (PubMed:7905839). The agonist- and cell type-specific activity is predominantly coupled to pertussis toxin-sensitive G(i) and G(o) G alpha proteins, GNAI1, GNAI2, GNAI3 and GNAO1 isoforms Alpha-1 and Alpha-2, and to a lesser extent to pertussis toxin-insensitive G alpha proteins GNAZ and GNA15 (PubMed:12068084). They mediate an array of downstream cellular responses, including inhibition of adenylate cyclase activity and both N-type and L-type calcium channels, activation of inward rectifying potassium channels, mitogen-activated protein kinase (MAPK), phospholipase C (PLC), phosphoinositide/protein kinase (PKC), phosphoinositide 3-kinase (PI3K) and regulation of NF-kappa-B. Also couples to adenylate cyclase stimulatory G alpha proteins. The selective temporal coupling to G-proteins and subsequent signaling can be regulated by RGSZ proteins, such as RGS9, RGS17 and RGS4. Phosphorylation by members of the GPRK subfamily of Ser/Thr protein kinases and association with beta-arrestins is involved in short-term receptor desensitization. Beta-arrestins associate with the GPRK-phosphorylated receptor and uncouple it from the G-protein thus terminating signal transduction. The phosphorylated receptor is internalized through endocytosis via clathrin-coated pits which involves beta-arrestins. The activation of the ERK pathway occurs either in a G-protein-dependent or a beta-arrestin-dependent manner and is regulated by agonist-specific receptor phosphorylation. Acts as a class A G-protein coupled receptor (GPCR) which dissociates from beta-arrestin at or near the plasma membrane and undergoes rapid recycling. Receptor down-regulation pathways are varying with the agonist and occur dependent or independent of G-protein coupling. Endogenous ligands induce rapid desensitization, endocytosis and recycling whereas morphine induces only low desensitization and endocytosis. Heterooligomerization with other GPCRs can modulate agonist binding, signaling and trafficking properties. Involved in neurogenesis. Isoform 12 couples to GNAS and is proposed to be involved in excitatory effects (PubMed:20525224). Isoform 16 and isoform 17 do not bind agonists but may act through oligomerization with binding-competent OPRM1 isoforms and reduce their ligand binding activity (PubMed:16580639).
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      Key Mechanism Factor 2
Factor Name Neuronal acetylcholine receptor Structure Sequence
Protein Family Ligand-gated ion channel (TC 1.A.9) family
Protein Function
After binding acetylcholine, the AChR responds by an extensive change in conformation that affects all subunits and leads to opening of an ion-conducting channel across the plasma membrane.
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      Mechanism Description
  • Additive hypotensive effects by the combination of Fentanyl and Tubocurarine 
     Increased risk of bradycardia Click to Show/Hide Mechanism Graph
Could Not Find 2D Structure
      Drug Name Fentanyl Tubocurarine
      Mechanism 2 Bradycardia Bradycardia
      Key Mechanism Factor 3
Factor Name Bradycardia
Factor Description Bradycardia is a slow heart rate in which the heart beats less than 60 times per minute. If the heart rate is very slow and the heart is not pumping enough oxygen-rich blood to the body, and you may feel dizzy, very tired or weak, and short of breath.
      Mechanism Description
  • Increased risk of bradycardia by the combination of Fentanyl and Tubocurarine 

Recommended Action
      Management The patient should be monitored closely for altered hemodynamics.

References
1 Product Information. Alfenta (alfentanil). Janssen Pharmaceutica, Titusville, NJ.
2 Reid C, Crosby E, Reid D "Sinus arrest following administration of alfentanil." Can J Anaesth 38 (1991): 540-1. [PMID: 2065427]
3 Taylor B, MacEwen P "Asystole after alfentanil-succinylcholine." Can J Anaesth 36 (1989): 255-6. [PMID: 2565170]