The wonderland of neuronal nicotinic acetylcholine receptors

Nearly 30 years of experimental evidence supports the argument that ligands of nicotinic acetylcholine receptors (nAChRs) have potential as therapeutic agents. However, as in the famous Lewis Carroll novel "Alice in Wonderland", there have been many unexpected adventures along the pathway of development, and few nAChR ligands have been approved for any clinical condition to date with the exception of nicotine dependence. The recent failures of nAChR ligands in AD and schizophrenia clinical trials have reduced enthusiasm for this therapeutic strategy and many pharmaceutical companies have now abandoned this field of research. As with other clinical failures, multiple questions arise as to the basis for the failure. More generic questions focus on a potential translational gap between the animal models used and the human clinical condition they are meant to simulate, or the clinical trial mindset that large Ns have to be achieved for statistical power (often requiring multiple trial sites) as opposed to smaller patient cohorts at limited sites where conditions can be better controlled and replicated. More specific to the nAChR field are questions about subtype selectivity, dose selection, whether an agonist, antagonist, or allosteric modulator strategy is best, etc. The purpose of this review is to discuss each of these questions, but also to provide a brief overview of the remarkable progress that has been made over the last three decades in our understanding of this unique ligand-gated ion channel and how this new knowledge may help us improve drug development successes in the future.