Since their discovery, GPCRs have been considered to be primarily G protein-signaling entities. This knowledge has been demonstrated to be exceptionally successful in allowing the creation of a huge variety of effective pharmacotherapeutics. Hauser et al. evaluated in 2017 that 475 FDA-approved drugs target GPCRs, which is 34% of all FDA-approved drugs
[32]. Even with this specific G protein focus, agents have been generated that can control the bias amongst diverse forms of G protein-signaling output
[23,33][23][33]. In the last decade, our appreciation of GPCR-signaling complexity has been enhanced by the demonstration of simultaneous signaling activities emanating from GPCRs that are either G protein-based or controlled by non-G protein-signaling adaptors. Even with just the primary consideration of G protein activation, it is evident that the receptor conformations for G protein activation are different between specific G protein pools and that synthetic and naturally occurring ligands can selectively facilitate the formation of different receptor coupling conformations
[23,34][23][34]. Multiple distinct forms of agonist ligands for a single GPCR type have now been discovered to only activate a subset of G proteins or a subset of downstream signaling effectors or induce G protein coupling without initiating internalization and desensitization
[23,35,36][23][35][36]. Given the successful exploitation of the therapeutic intervention of GPCR-based G protein signaling, it is likely that it will be possible to improve this index even further by exploiting the true complexity and diversity of GPCR signaling
[32,37][32][37]. Apart from the classical G protein signaling, multiple research lines have pointed towards the presence of non-G protein-based signaling, mainly through β-arrestins
[38,39,40][38][39][40]. One of the first studied examples of this novel signaling activity was the β-arrestin-dependent activation of extracellular signal-regulated kinases 1/2 (ERK 1/2)
[29,41][29][41]. Compared to the rapid and transient manner of G protein signaling
[39], β-arrestin-linked pathway activation has a later onset but is sustained over a long period and entrains long-term l cellular transcriptional and proteomic effects
[42,43,44,45][42][43][44][45]. β-arrestin also serves as a negative regulatory protein for signaling through G proteins and is responsible for GPCR internalization
[45,46,47][45][46][47]. However, there is still some dispute in the field with respect to the interdependence of G protein and β-arrestin signaling; recently, complete G protein independence could not be proven in a serum-starved in vitro G protein knockout model
[41]. Evidence has also been revealed recently that suggests that certain specific forms of orphan receptors (D6R and C5aR2) appear to be able to functionally interact with β-arrestins but not with G proteins
[48]. This data reinforces the posit that there are likely a diverse range of receptorsome entities that are prewired to specific independent downstream signaling pathways.