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Crivellari M, Landoni G, Ursoleo JD, Ferrante L, Oriani A. Protamine and Heparin Interactions: A Narrative Review. Ann Card Anaesth 2024; 27:202-212. [PMID: 38963354 PMCID: PMC11315261 DOI: 10.4103/aca.aca_117_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 11/18/2023] [Accepted: 12/08/2023] [Indexed: 07/05/2024] Open
Abstract
ABSTRACT Protamine, first isolated from salmon fish sperm and now produced through recombinant biotechnology, is an antidote that neutralizes the anticoagulant properties of heparin. Protamine function is based on the capacity to dissociate the heparin-antithrombin III (AT III) complex (an important link that promotes blood fluidification by inhibiting coagulation), forming the inactive heparin-protamine complex. Protamine has itself dose-dependent anticoagulant properties: It interferes with coagulation factors and platelet function; it stimulates fibrinolysis; it can lead to thrombocytopenia and reduction in thrombin-related platelet aggregation; it decreases platelet response to thrombin receptor agonist in a dose-dependent manner. In this review, we will focus on protamine and its interaction with heparin. Notably, protamine is able to antagonize not only unfractionated heparin (UFH) but also low molecular weight heparins to various degrees. Protamine-allergic and anaphylactoid systemic reactions may affect up to 1 in 10 people and should be prevented and treated early.
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Affiliation(s)
- Martina Crivellari
- IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
| | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Via Olgettina, 58, 20132, Milan, Italy
| | | | - Luca Ferrante
- Vita-Salute San Raffaele University, Via Olgettina, 58, 20132, Milan, Italy
| | - Alessandro Oriani
- IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
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2
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Oliveira SNMCG, Bezerra FF, Piquet AA, Sales RA, Valle GCT, Capillé NV, Tovar AMF, Mourão PAS. A Unique Enoxaparin Derived from Bovine Intestinal Heparin: A Single Purification Step of the Starting Material Assures a Bovine Enoxaparin Like the Standard from Porcine Origin. ACS OMEGA 2024; 9:23111-23120. [PMID: 38826523 PMCID: PMC11137703 DOI: 10.1021/acsomega.4c02128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 06/04/2024]
Abstract
Low-molecular-weight heparin represent a significant advancement in anticoagulant therapy with enoxaparin being a prominent example obtained exclusively through the fragmentation of porcine intestinal heparin. However, escalating demand and limited resources have raised concerns about enoxaparin supplementation. The current challenge involves exploring alternative heparin sources for large-scale enoxaparin production with bovine intestinal heparin emerging as a promising option. Our study demonstrates that enoxaparin derived from the available bovine heparin preparation differs significantly from the reference compound. Yet, the implementation of a straightforward purification step yields a preparation termed "high-anticoagulant bovine heparin". Fragmentation of this purified product through β-elimination produces enoxaparin akin to the standard from a porcine origin. To ensure physicochemical similarity, we employed various spectroscopic, enzymatic, and chromatographic tests to compare the new bovine-derived enoxaparin with the original porcine compound. Biological activity was confirmed through in vitro coagulation assays and assessments using an animal model of venous thrombosis. Our study affirms that the β-elimination reaction cleaves the bovine heparin chain without preferential breaks in regions with different sulfation patterns. Additionally, we scrutinized decasaccharides purified from enoxaparin preparations, providing a comprehensive demonstration of the similarity between products obtained from porcine and bovine heparin. In summary, our findings indicate that an enoxaparin equivalent to the original porcine-derived product can be derived from bovine heparin, given that the starting material undergoes a simple purification step.
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Affiliation(s)
| | | | - Adriana A. Piquet
- Laboratório de Tecido
Conjuntivo, Hospital Universitário Clementino Fraga Filho and
Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | - Rodrigo A. Sales
- Laboratório de Tecido
Conjuntivo, Hospital Universitário Clementino Fraga Filho and
Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | - Gabrielly C. T. Valle
- Laboratório de Tecido
Conjuntivo, Hospital Universitário Clementino Fraga Filho and
Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | - Nina V. Capillé
- Laboratório de Tecido
Conjuntivo, Hospital Universitário Clementino Fraga Filho and
Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | - Ana M. F. Tovar
- Laboratório de Tecido
Conjuntivo, Hospital Universitário Clementino Fraga Filho and
Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
| | - Paulo A. S. Mourão
- Laboratório de Tecido
Conjuntivo, Hospital Universitário Clementino Fraga Filho and
Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-913, Brazil
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3
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Pineda S, Staňo R, Murmiliuk A, Blanco PM, Montes P, Tošner Z, Groborz O, Pánek J, Hrubý M, Štěpánek M, Košovan P. Charge Regulation Triggers Condensation of Short Oligopeptides to Polyelectrolytes. JACS AU 2024; 4:1775-1785. [PMID: 38818083 PMCID: PMC11134362 DOI: 10.1021/jacsau.3c00668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/24/2024] [Accepted: 02/26/2024] [Indexed: 06/01/2024]
Abstract
Electrostatic interactions between charged macromolecules are ubiquitous in biological systems, and they are important also in materials design. Attraction between oppositely charged molecules is often interpreted as if the molecules had a fixed charge, which is not affected by their interaction. Less commonly, charge regulation is invoked to interpret such interactions, i.e., a change of the charge state in response to a change of the local environment. Although some theoretical and simulation studies suggest that charge regulation plays an important role in intermolecular interactions, experimental evidence supporting such a view is very scarce. In the current study, we used a model system, composed of a long polyanion interacting with cationic oligolysines, containing up to 8 lysine residues. We showed using both simulations and experiments that while these lysines are only weakly charged in the absence of the polyanion, they charge up and condense on the polycations if the pH is close to the pKa of the lysine side chains. We show that the lysines coexist in two distinct populations within the same solution: (1) practically nonionized and free in solution; (2) highly ionized and condensed on the polyanion. Using this model system, we demonstrate under what conditions charge regulation plays a significant role in the interactions of oppositely charged macromolecules and generalize our findings beyond the specific system used here.
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Affiliation(s)
- Sebastian
P. Pineda
- Department
of Physical and Macromolecular Chemistry, Faculty of Science, Charles University, Hlavova 8, Prague 2 128 40, Czech Republic
| | - Roman Staňo
- Faculty
of Physics, University of Vienna, Boltzmanngasse 5, Vienna 1090, Austria
- Vienna
Doctoral School in Physics, University of
Vienna, Boltzmanngasse 5, Vienna 1090, Austria
| | - Anastasiia Murmiliuk
- Jülich
Centre for Neutron Science JCNS at Heinz Maier-Leibnitz Zentrum (MLZ), Forschungszentrum Jülich GmbH, Lichtenbergstraße 1, Garching 85748, Germany
| | - Pablo M. Blanco
- Department
of Physical and Macromolecular Chemistry, Faculty of Science, Charles University, Hlavova 8, Prague 2 128 40, Czech Republic
- Department
of Material Science and Physical Chemistry, Research Institute of
Theoretical and Computational Chemistry (IQTCUB), University of Barcelona, C/Martí i Franquès 1, Barcelona 08028, Spain
- Department of Physics, NTNU - Norwegian University of Science and Technology, NO-7491 Trondheim, Norway
| | - Patricia Montes
- Department
of Physical and Macromolecular Chemistry, Faculty of Science, Charles University, Hlavova 8, Prague 2 128 40, Czech Republic
| | - Zdeněk Tošner
- Department
of Physical and Macromolecular Chemistry, Faculty of Science, Charles University, Hlavova 8, Prague 2 128 40, Czech Republic
| | - Ondřej Groborz
- Institute
of Macromolecular Chemistry AS CR, Heyrovský square 2, 162 06 Prague 6, Czech Republic
| | - Jiří Pánek
- Institute
of Macromolecular Chemistry AS CR, Heyrovský square 2, 162 06 Prague 6, Czech Republic
| | - Martin Hrubý
- Institute
of Macromolecular Chemistry AS CR, Heyrovský square 2, 162 06 Prague 6, Czech Republic
| | - Miroslav Štěpánek
- Department
of Physical and Macromolecular Chemistry, Faculty of Science, Charles University, Hlavova 8, Prague 2 128 40, Czech Republic
| | - Peter Košovan
- Department
of Physical and Macromolecular Chemistry, Faculty of Science, Charles University, Hlavova 8, Prague 2 128 40, Czech Republic
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Bösch J, Bachler M, Fries D. Thrombosis prophylaxis following trauma. Curr Opin Anaesthesiol 2024; 37:139-143. [PMID: 38390905 DOI: 10.1097/aco.0000000000001351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW This review explores the persistent occurrence of venous thromboembolic events (VTE) in major trauma patients despite standard thrombosis prophylaxis with low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). It investigates the inadequacies of standard pharmacologic prophylaxis and proposes alternative approaches not covered in current trauma guidelines. RECENT FINDINGS Recent studies highlight the effectiveness of monitoring and adjusting subcutaneous LMWH doses based on anti-Xa levels for the purpose of reducing VTE in trauma patients. The need for dose adaptation arises due to factors like fluctuating organ function, varying antithrombin levels, interaction with plasma proteins, and altered bioavailability influenced by oedema or vasopressor use. Additionally, promising alternatives such as intravenous LMWH, UFH, and argatroban have shown success in intensive care settings. SUMMARY The standard dosing of subcutaneous LMWH is often insufficient for effective thrombosis prophylaxis in trauma patients. A more personalised approach, adjusting doses based on specific effect levels like anti-Xa or choosing an alternative mode of anticoagulation, could reduce the risk of insufficient prophylaxis and subsequent VTE.
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Affiliation(s)
- Johannes Bösch
- Department for Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Mirjam Bachler
- Institute for Sports Medicine, Alpine Medicine and Health Tourism, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Dietmar Fries
- Department for Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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Mondal S, Abuelkasem E, Vesselinov R, Henderson R, Choi S, Mousa A, Zaza KJ, Tanaka KA. Protamine dosing and its impact in cardiac surgery transfusion practice-A retrospective bi-institutional analysis. Transfusion 2024; 64:467-474. [PMID: 38264767 DOI: 10.1111/trf.17730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 12/29/2023] [Accepted: 12/29/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Bleeding after cardiac surgery is common and continues to require 10-20% of the national blood supply. Transfusion of allogeneic blood is associated with increased morbidity and mortality. Excessive protamine in the absence of circulating heparin after weaning off CPB can cause anticoagulation and precipitate bleeding. Hence, adequate dose calculation of protamine is crucial yet under evaluated. STUDY DESIGN Retrospective cohort study. METHODS We conducted a retrospective bi-institutional analysis of cardiac surgical patients who underwent cardiopulmonary bypass (CPB)-assisted cardiac surgery to assess the impact of protamine dosing in transfusion practice. Total 762 patients were identified from two institutions using electronic medical records and the Society of Thoracic Surgery (STS) database who underwent cardiac surgery using CPB. Patients were similar in demographics and other baseline characteristics. We divided patients into two groups based on mg of protamine administered to neutralize each 100 U of unfractionated heparin (UFH)-low-ratio group (Protamine: UFH ≤ 0.8) and high-ratio group (Protamine: UFH > 0.8). RESULTS We observed a higher rate of blood transfusion required in high-ratio group (ratio >0.8) compared with low-ratio group (ratio ≤0.8) (p < .001). The increased requirement was consistently demonstrated for intraoperative transfusions of red blood cells, plasma, platelets, and cryoprecipitate. CONCLUSION High protamine to heparin ratio may cause increased bleeding and transfusion in cardiac surgical patients. Protamine to heparin ratio of 0.8 or lower is sufficient to neutralize circulating heparin after weaning off cardiopulmonary bypass.
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Affiliation(s)
- Samhati Mondal
- Department of Anesthesiology, Cardiothoracic Division, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ezeldeen Abuelkasem
- Department of Anesthesiology, Cardiothoracic Division, University of Pittsburgh School of Medicine and UPMC, Pennsylvania, USA
| | - Roumen Vesselinov
- Department of Epidemiology and Public Health, Biostatistics Division; Department of Anesthesiology, National Study Center, University of Maryland, Baltimore, Maryland, USA
| | - Reney Henderson
- Department of Anesthesiology, Cardiothoracic Division, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Seung Choi
- Department of Anesthesiology, WakeMed Health System, Raleigh, North Carolina, USA
| | - Ahmad Mousa
- Department of Anesthesiology, Cardiothoracic Division, University of Pittsburgh School of Medicine and UPMC, Pennsylvania, USA
| | - Khaled J Zaza
- Department of Anesthesiology, Cardiothoracic Division, University of Pittsburgh School of Medicine and UPMC, Pennsylvania, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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6
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Amaral S, Lozano-Fernández T, Sabin J, Gallego A, da Silva Morais A, Reis RL, González-Fernández Á, Pashkuleva I, Novoa-Carballal R. End-on PEGylation of heparin: Effect on anticoagulant activity and complexation with protamine. Int J Biol Macromol 2023; 249:125957. [PMID: 37499705 DOI: 10.1016/j.ijbiomac.2023.125957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/20/2023] [Accepted: 07/15/2023] [Indexed: 07/29/2023]
Abstract
Heparin is the most common anticoagulant used in clinical practice but shows some downsides such as short half-life (for the high molecular weight heparin) and secondary effects. On the other hand, its low molecular weight analogue cannot be neutralized with protamine, and therefore cannot be used in some treatments. To address these issues, we conjugated polyethylene glycol (PEG) to heparin reducing end (end-on) via oxime ligation and studied the interactions of the conjugate (Hep-b-PEG) with antithrombin III (AT) and protamine. Isothermal titration calorimetry showed that Hep-b-PEG maintains the affinity to AT. Dynamic light scattering demonstrated that the Hep-b-PEG formed colloidal stable nanocomplexes with protamine instead of large multi-molecular aggregates, associated with heparin side effects. The in vitro (human plasma) and in vivo experiments (Sprague Dawley rats) evidenced an extended half-life and higher anticoagulant activity of the conjugate when compared to unmodified heparin.
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Affiliation(s)
- Sandra Amaral
- 3B's Research Group, I3B's Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, 4805-017 Barco, Portugal; ICVS/3B's - PT Government Associate Laboratory, University of Minho, Portugal
| | - Tamara Lozano-Fernández
- NanoImmunoTech, Edificio CITEXVI Fonte das Abelleiras s/n, Campus Universitario de Vigo, 36310 Vigo, Pontevedra, Spain
| | - Juan Sabin
- AFFINImeter Scientific & Development Team, Software 4 Science Developments, Santiago de Compostela, A Coruña 15782, Spain; Departamento de Física Aplicada, Facultad de Física, Universidad de Santiago de Compostela, Santiago de Compostela, Spain
| | - Amanda Gallego
- NanoImmunoTech, Edificio CITEXVI Fonte das Abelleiras s/n, Campus Universitario de Vigo, 36310 Vigo, Pontevedra, Spain
| | - Alain da Silva Morais
- 3B's Research Group, I3B's Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, 4805-017 Barco, Portugal; ICVS/3B's - PT Government Associate Laboratory, University of Minho, Portugal
| | - Rui L Reis
- 3B's Research Group, I3B's Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, 4805-017 Barco, Portugal; ICVS/3B's - PT Government Associate Laboratory, University of Minho, Portugal
| | - África González-Fernández
- NanoImmunoTech, Edificio CITEXVI Fonte das Abelleiras s/n, Campus Universitario de Vigo, 36310 Vigo, Pontevedra, Spain; CINBIO, Universidade de Vigo, Campus Universitario de Vigo, 36310 Vigo, Pontevedra, Spain; Instituto de Investigación Sanitaria Galicia Sur (IIS-GS), Hospital Alvaro Cunqueiro, Estrada Clara Campoamor, 36312 Vigo, Pontevedra, Spain
| | - Iva Pashkuleva
- 3B's Research Group, I3B's Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, 4805-017 Barco, Portugal; ICVS/3B's - PT Government Associate Laboratory, University of Minho, Portugal.
| | - Ramon Novoa-Carballal
- 3B's Research Group, I3B's Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, 4805-017 Barco, Portugal; ICVS/3B's - PT Government Associate Laboratory, University of Minho, Portugal.
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7
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Levy JH, Ghadimi K, Kizhakkedathu JN, Iba T. What's fishy about protamine? Clinical use, adverse reactions, and potential alternatives. J Thromb Haemost 2023; 21:1714-1723. [PMID: 37062523 DOI: 10.1016/j.jtha.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/30/2023] [Accepted: 04/04/2023] [Indexed: 04/18/2023]
Abstract
Protamine, a highly basic protein isolated from salmon sperm, is the only clinically available agent to reverse the anticoagulation of unfractionated heparin. Following intravenous administration, protamine binds to heparin in a nonspecific electrostatic interaction to reverse its anticoagulant effects. In clinical use, protamine is routinely administered to reverse high-dose heparin anticoagulation in cardiovascular procedures, including cardiac surgery with cardiopulmonary bypass. Despite the lack of supportive evidence regarding protamine's effectiveness to reverse low-molecular-weight heparin, it is recommended in guidelines with low-quality evidence. Different dosing strategies have been reported for reversing heparin in cardiac surgical patients based on empiric dosing, pharmacokinetics, or point-of-care measurements of heparin levels. Protamine administration is associated with a spectrum of adverse reactions that range from vasodilation to life-threatening cardiopulmonary dysfunction and shock. The life-threatening responses appear to be hypersensitivity reactions due to immunoglobulin E and/or immunoglobulin G antibodies. However, protamine and heparin-protamine complexes can activate complement inflammatory pathways and inhibit other coagulation factors. Although alternative agents for reversing heparin are not currently available for clinical use, additional research continues evaluating novel therapeutic approaches.
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Affiliation(s)
- Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina, USA.
| | - Kamrouz Ghadimi
- Departments of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jayachandran N Kizhakkedathu
- Centre for Blood Research, Department of Pathology and Laboratory Medicine, The School of Biomedical Engineering, The University of British Columbia, Vancouver, British Colombia, Canada
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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Frackiewicz A, Kalaska B, Miklosz J, Mogielnicki A. The methods for removal of direct oral anticoagulants and heparins to improve the monitoring of hemostasis: a narrative literature review. Thromb J 2023; 21:58. [PMID: 37208753 DOI: 10.1186/s12959-023-00501-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 05/10/2023] [Indexed: 05/21/2023] Open
Abstract
The assessment of hemostasis is necessary to make suitable decisions on the management of patients with thrombotic disorders. In some clinical situations, for example, during thrombophilia screening, the presence of anticoagulants in sample makes diagnosis impossible. Various elimination methods may overcome anticoagulant interference. DOAC-Stop, DOAC-Remove and DOAC Filter are available methods to remove direct oral anticoagulants in diagnostic tests, although there are still reports on their incomplete efficacy in several assays. The new antidotes for direct oral anticoagulants - idarucizumab and andexanet alfa - could be potentially useful, but have their drawbacks. The necessity to remove heparins is also arising as heparin contamination from central venous catheter or therapy with heparin disturbs the appropriate hemostasis assessment. Heparinase and polybrene are already present in commercial reagents but a fully-effective neutralizer is still a challenge for researchers, thus promising candidates remain in the research phase.
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Affiliation(s)
| | - Bartlomiej Kalaska
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland.
| | - Joanna Miklosz
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Andrzej Mogielnicki
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
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Shute JK. Heparin, Low Molecular Weight Heparin, and Non-Anticoagulant Derivatives for the Treatment of Inflammatory Lung Disease. Pharmaceuticals (Basel) 2023; 16:ph16040584. [PMID: 37111341 PMCID: PMC10141002 DOI: 10.3390/ph16040584] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/06/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Unfractionated heparin has multiple pharmacological activities beyond anticoagulation. These anti-inflammatory, anti-microbial, and mucoactive activities are shared in part by low molecular weight and non-anticoagulant heparin derivatives. Anti-inflammatory activities include inhibition of chemokine activity and cytokine synthesis, inhibitory effects on the mechanisms of adhesion and diapedesis involved in neutrophil recruitment, inhibition of heparanase activity, inhibition of the proteases of the coagulation and complement cascades, inhibition of neutrophil elastase activity, neutralisation of toxic basic histones, and inhibition of HMGB1 activity. This review considers the potential for heparin and its derivatives to treat inflammatory lung disease, including COVID-19, ALI, ARDS, cystic fibrosis, asthma, and COPD via the inhaled route.
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Affiliation(s)
- Janis Kay Shute
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth PO1 2UP, UK
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10
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Hogwood J, Mulloy B, Lever R, Gray E, Page CP. Pharmacology of Heparin and Related Drugs: An Update. Pharmacol Rev 2023; 75:328-379. [PMID: 36792365 DOI: 10.1124/pharmrev.122.000684] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 02/17/2023] Open
Abstract
Heparin has been used extensively as an antithrombotic and anticoagulant for close to 100 years. This anticoagulant activity is attributed mainly to the pentasaccharide sequence, which potentiates the inhibitory action of antithrombin, a major inhibitor of the coagulation cascade. More recently it has been elucidated that heparin exhibits anti-inflammatory effect via interference of the formation of neutrophil extracellular traps and this may also contribute to heparin's antithrombotic activity. This illustrates that heparin interacts with a broad range of biomolecules, exerting both anticoagulant and nonanticoagulant actions. Since our previous review, there has been an increased interest in these nonanticoagulant effects of heparin, with the beneficial role in patients infected with SARS2-coronavirus a highly topical example. This article provides an update on our previous review with more recent developments and observations made for these novel uses of heparin and an overview of the development status of heparin-based drugs. SIGNIFICANCE STATEMENT: This state-of-the-art review covers recent developments in the use of heparin and heparin-like materials as anticoagulant, now including immunothrombosis observations, and as nonanticoagulant including a role in the treatment of SARS-coronavirus and inflammatory conditions.
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Affiliation(s)
- John Hogwood
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Barbara Mulloy
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Rebeca Lever
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Elaine Gray
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
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11
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Roux C, Verollet K, Prouvot J, Prelipcean C, Pambrun E, Moranne O. Choosing the right chronic medication for hemodialysis patients. A short ABC for the dialysis nephrologist. J Nephrol 2023; 36:521-536. [PMID: 36472789 DOI: 10.1007/s40620-022-01477-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 10/01/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Adapting drug treatments for patients on hemodialysis with multiple chronic pathologies is a complex affair. When prescribing a medication, the risk-benefit analysis usually focuses primarily on the indication of the drug class prescribed. However, the pharmacokinetics of the chosen drug should also be taken into account. The purpose of our review was to identify the drugs to be favored in each therapeutic class, according to their safety and pharmacokinetic profiles, for the most common chronic diseases in patients on chronic hemodialysis. METHODS We conducted a narrative review of the literature using Medline and Web of Science databases, targeting studies on the most commonly-prescribed drugs for non-communicable diseases in patients on chronic hemodialysis. RESULTS The search identified 1224 articles, 95 of which were further analyzed. The main classes of drugs included concern the cardiovascular system (anti-hypertensives, anti-arrhythmics, anti-thrombotics, hypocholesterolemics), the endocrine and metabolic pathways (anti-diabetics, gastric anti-secretory, anticoagulant, thyroid hormones, anti-gout) and psychiatric and neurological disorders (antidepressants, anxiolytics, antipsychotics and anti-epileptics). CONCLUSION We report on the most often prescribed drugs for chronic pathologies in patients on chronic hemodialysis. Most of them require adaptation, and in some cases one better alternative stands out among the drug class. More pharmacokinetic data are needed to define the pharmacokinetics in the various dialysis techniques.
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Affiliation(s)
- Clarisse Roux
- Service Pharmacie, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France.
- Institut Desbrest d'Epidemiologie et Santé publique (IDESP), INSERM, Montpellier, France.
| | - Kristelle Verollet
- Service Pharmacie, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France
| | - Julien Prouvot
- Institut Desbrest d'Epidemiologie et Santé publique (IDESP), INSERM, Montpellier, France
- Service Néphrologie Dialyse Apherese, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France
| | - Camelia Prelipcean
- Service Néphrologie Dialyse Apherese, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France
| | - Emilie Pambrun
- Service Néphrologie Dialyse Apherese, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France
| | - Olivier Moranne
- Institut Desbrest d'Epidemiologie et Santé publique (IDESP), INSERM, Montpellier, France.
- Service Néphrologie Dialyse Apherese, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France.
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12
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da Cruz Renó L, Tustumi F, Waisberg DR, Rocha-Santos V, Pinheiro RS, Macedo RA, Nacif LS, Ducatti L, De Martino RB, Trevisan AM, Carneiro-D’Albuquerque L, Andraus W. Venous thromboembolism in in-hospital cirrhotic patients: A systematic review. Front Med (Lausanne) 2022; 9:1027882. [PMID: 36419795 PMCID: PMC9676642 DOI: 10.3389/fmed.2022.1027882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/14/2022] [Indexed: 08/30/2023] Open
Abstract
INTRODUCTION Patients with liver cirrhosis are at a higher risk of hospitalization. The present review aimed to assess the risk of thromboembolism and its burden on hospitalized cirrhotic patients. MATERIALS AND METHODS A systematic review (PROSPERO: CRD42021256869) was conducted in PubMed, Embase, Cochrane, Lilacs, and a manual search of references. It evaluated studies that compare cirrhotic patients with venous thromboembolism (VTE) with cirrhotic patients without VTE or studies that compare cirrhotic patients with non-cirrhotic patients. No restrictions were set for the date of publication or language. The last search was conducted in June 2021. RESULTS After selection, 17 studies were included from an initial search of 5,323 articles. The chronic liver disease etiologies comprise viral, alcohol, autoimmune, NASH (non-alcoholic steatohepatitis), cryptogenic, hemochromatosis, cholestasis, and drug-related. The included studies were conflicted regarding the outcomes of VTE, pulmonary embolism, or bleeding. Patients with cirrhosis associated with VTE had prolonged length of hospital stay, and patients with cirrhosis were at higher risk of portal thrombosis. CONCLUSION In-hospital cirrhotic patients are a heterogeneous group of patients that may present both thrombosis and bleeding risk. Clinicians should take extra caution to apply both prophylactic and therapeutic anticoagulation strategies. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42021256869].
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Affiliation(s)
| | - Francisco Tustumi
- Transplantation Unit, Department of Gastroenterology, Universidade de São Paulo, São Paulo, Brazil
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13
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Leentjens J, Middeldorp S, Jung C. A short review of ciraparantag in perspective of the currently available anticoagulant reversal agents. Drug Discov Today 2022; 27:103332. [PMID: 35933085 DOI: 10.1016/j.drudis.2022.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/29/2022] [Indexed: 12/15/2022]
Abstract
Despite the improved safety-profile of direct oral anticoagulants (DOACs), bleeding complications remain an important side effect of anticoagulant treatment. Although anticoagulant-specific antidotes are available, an universal anticoagulant reversal agent in case of life-threatening bleeding or emergency surgery is not yet available. Ciraparantag, a synthetic small molecule that inactivates heparins and DOAC, is a promising new reversal agent that has been investigated in phase 2 trials. In this short review we provide an overview of the preclinical and clinical evidence of ciraparantag, and compare strengths and weaknesses of ciraparantag and the currently available anticoagulant reversal strategies.
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Affiliation(s)
- J Leentjens
- Department of Internal Medicine & Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - S Middeldorp
- Department of Internal Medicine & Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - C Jung
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Duesseldorf, Germany
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14
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Lasica R, Asanin M, Djukanovic L, Radovanovic N, Savic L, Polovina M, Stankovic S, Ristic A, Zdravkovic M, Lasica A, Kravic J, Perunicic J. Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application. Pharmaceuticals (Basel) 2022; 15:ph15091146. [PMID: 36145366 PMCID: PMC9501350 DOI: 10.3390/ph15091146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/03/2022] [Accepted: 09/06/2022] [Indexed: 11/24/2022] Open
Abstract
Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option.
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Affiliation(s)
- Ratko Lasica
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Correspondence:
| | - Milika Asanin
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lazar Djukanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nebojsa Radovanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lidija Savic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marija Polovina
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Sanja Stankovic
- Center for Medical Biochemistry, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Arsen Ristic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | | | | | - Jelena Kravic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Jovan Perunicic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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15
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Iqbal Z, Sadaf S. Commercial Low Molecular Weight Heparins - Patent Ecosystem and Technology Paradigm for Quality Characterization. J Pharm Innov 2022; 18:1-33. [PMID: 35915630 PMCID: PMC9330979 DOI: 10.1007/s12247-022-09665-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 11/29/2022]
Abstract
Heparin is a subject of ever-growing interest for laboratory researchers and pharmaceutical industry. One of the driving factors is its critical life-saving drug status, which during the COVID-19 pandemic has assumed a central role in disease treatment and/or prevention. Apart, heparin is one amongst few drugs enjoying a "demand constant" status. In 2020, heparin market size was valued to US$6.5 bn., and given the ongoing stability in the COVID-19 health crisis, it is expected to reach US$11.43 bn. by 2027 with yearly growth rate momentum (CAGR) of 3.9% during the forecast period (Pepi et al., Mol Cell Proteomics 20:100,025, 2021). As patent is a limited monopoly, every year, many patents on low molecular weight heparin (LMWH; a chemically or enzymatically degraded product of unfractionated heparin) are losing market exclusivity worldwide, inviting the generic/biosimilar drug manufacturers to capture market share with cheaper drug products. By tracking patent expiration, drugs in patent litigation, regulatory setbacks for innovator companies (such as those seeking data exclusivity or patent term extension), or other unexpected events affecting market demand and competition, generics can make investment decisions in manufacturing off-patent LMWH drug products of commercial significance. However, given the US Food and Drug Administration (FDA), European Medicine Agency (EMA), Drug Regulatory Authority of Pakistan (DRAP), and other regulatory authorities scientifically rigorous standards for generic/biosimilar LMWH drug products marketing approval, the market is secured and momentous for drug makers that could demonstrate through scientific and clinical dataset that the generic/biosimilar LMWH drug product is of the same quality and purity as the innovator drug product. This study presents an overview of the patent landscape of commercially available LMWHs and advanced analytical techniques for their structural and biochemical characterization for quality control and quality assurance during manufacturing and post-marketing. The study also covers FDA, EMA, Health Canada, and DRAP's current approaches to evaluating the generic/biosimilar LMWH drug products for quality, safety including immunogenicity, and efficacy.
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Affiliation(s)
- Zarina Iqbal
- IP and Litigation Department, PakPat World Intellectual Property Protection Services, Lahore, Pakistan
| | - Saima Sadaf
- Biopharmaceutical and Biomarkers Discovery Lab, School of Biochemistry and Biotechnology, University of the Punjab, Lahore, 54590 Pakistan
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16
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Amerali M, Politou M. Tinzaparin—a review of its molecular profile, pharmacology, special properties, and clinical uses. Eur J Clin Pharmacol 2022; 78:1555-1565. [PMID: 35871241 PMCID: PMC9308487 DOI: 10.1007/s00228-022-03365-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/16/2022] [Indexed: 11/05/2022]
Abstract
Purpose Low molecular weight heparins (LMWHs) are a group of heterogenous moieties, long used in the prevention and treatment of thrombosis. They derive from heparin and since they are prepared by different methods of depolymerization, they differ in pharmacokinetic properties and anticoagulant profiles, and thus are not clinically interchangeable. Methods In this review we provide an overview of tinzaparin's main characteristics and uses. Results Tinzaparin which is produced by the enzymatic depolymerization of unfractionated heparin (UFH) can be used for the treatment and prevention of deep venous thrombosis (DVT) and pulmonary embolism (PE); it has been also used in special populations such as elders, obese, pregnant women, and patients with renal impairment and/or cancer with favorable outcomes in both safety and efficacy, with a once daily dose regimen. Furthermore, LMWHs are extensively used in clinical practice for both thromboprophylaxis and thrombosis treatment of COVID-19 patients. Conclusion Tinzaparin features support the hypothesis for having a role in immunothrombosis treatment (i.e. in the context of cancer ,COVID-19), interfering not only with coagulation cascade but also exhibiting anti-inflammatory potency.
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17
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Smetana KS, Counts J, Sodhi A, May CC. Review of Target-Specific Anticoagulation Reversal Agents. Crit Care Nurs Q 2022; 45:180-188. [PMID: 35212657 DOI: 10.1097/cnq.0000000000000400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bleeding related to direct oral anticoagulants accounts for nearly half of emergency department visits annually and until recently there were no reversal antidotes available. As there continues to be a shift in prescribing practices away from warfarin, it is essential to have these reversal agents readily available for the treatment of life-threatening bleeds associated with these anticoagulants. In addition, for agents that continue to lack a targeted reversal agent (eg, low-molecular-weight heparin, antiplatelets, and new antithrombotics), it is imperative that research continues to evaluate improved reversal strategies. This review focuses on target-specific anticoagulation reversal agents currently available in the United States (protamine, idarucizumab, and andexanet alfa) and summarizes agents that are in the pipeline for these anticoagulants and antiplatelets.
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Affiliation(s)
- Keaton S Smetana
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus
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18
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Kietaibl S, Ferrandis R, Godier A, Llau J, Lobo C, Macfarlane AJ, Schlimp CJ, Vandermeulen E, Volk T, von Heymann C, Wolmarans M, Afshari A. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022; 39:100-132. [PMID: 34980845 DOI: 10.1097/eja.0000000000001600] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia. DESIGN A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline. RESULTS Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%. DISCUSSION Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. CONCLUSION In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University, Vienna, Austria (SK), Department of Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, Valencia, Spain (RF), Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris (AG), INSERM UMRS-1140 Paris University, Paris, France (AG), Department of Anaesthesiology and Critical Care, Doctor Peset University Hospital (JL), Department of Surgery, Valencia University, Valencia, Spain (JL), Serviço de Anestesiologia Hospital das Forças Armadas, Pólo Porto, Porto, Portugal (CL), Department of Anaesthesia Pain Medicine and Critical Care, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK (AM), Department of Anaesthesia and Intensive Care Medicine, AUVA Trauma Centre Linz, Linz (CJS); Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria (CJS), Department of Anaesthesia, University Hospitals Leuven. Catholic University of Leuven, Leuven, Belgium (EV), Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar (TV), Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany (CVH), Department of Anaesthesia, Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK (MW), and Department of Pediatric and Obstetric Anesthesia, Juliane Marie Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (AA)
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19
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Ruseska I, Fresacher K, Petschacher C, Zimmer A. Use of Protamine in Nanopharmaceuticals-A Review. NANOMATERIALS (BASEL, SWITZERLAND) 2021; 11:1508. [PMID: 34200384 PMCID: PMC8230241 DOI: 10.3390/nano11061508] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/27/2021] [Accepted: 05/27/2021] [Indexed: 12/18/2022]
Abstract
Macromolecular biomolecules are currently dethroning classical small molecule therapeutics because of their improved targeting and delivery properties. Protamine-a small polycationic peptide-represents a promising candidate. In nature, it binds and protects DNA against degradation during spermatogenesis due to electrostatic interactions between the negatively charged DNA-phosphate backbone and the positively charged protamine. Researchers are mimicking this technique to develop innovative nanopharmaceutical drug delivery systems, incorporating protamine as a carrier for biologically active components such as DNA or RNA. The first part of this review highlights ongoing investigations in the field of protamine-associated nanotechnology, discussing the self-assembling manufacturing process and nanoparticle engineering. Immune-modulating properties of protamine are those that lead to the second key part, which is protamine in novel vaccine technologies. Protamine-based RNA delivery systems in vaccines (some belong to the new class of mRNA-vaccines) against infectious disease and their use in cancer treatment are reviewed, and we provide an update on the current state of latest developments with protamine as pharmaceutical excipient for vaccines.
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Affiliation(s)
| | | | | | - Andreas Zimmer
- Department of Pharmaceutical Technology and Biopharmacy, Institute of Pharmaceutical Sciences, Karl-Franzens-University Graz, Universitätsplatz 1, 8010 Graz, Austria; (I.R.); (K.F.); (C.P.)
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20
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Várnai B, Grabarics M, Szakács Z, Pagel K, Malanga M, Sohajda T, Béni S. Structural characterization of fondaparinux interaction with per-6-amino-beta-cyclodextrin: An NMR and MS study. J Pharm Biomed Anal 2021; 197:113947. [PMID: 33601159 DOI: 10.1016/j.jpba.2021.113947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/28/2021] [Accepted: 01/30/2021] [Indexed: 11/18/2022]
Abstract
The highly anionic synthetic pentasaccharide fondaparinux (FDPX) - representing the antithrombin binding sequence of heparin - is in clinical use as a potent anticoagulant. Contrary to the unfractionated heparin, FDPX lacks potent antidote completely reversing its anticoagulant activity, therefore it is of great importance to identify new structures exhibiting strong intermolecular interactions towards FDPX. The polycationic heptakis(6-amino-6-deoxy)-beta-cyclodextrin (NH2-β-CD) can serve as an excellent model compound to mimic these interactions between the oppositely charged oligosaccharides. Herein, extensive NMR spectroscopic and nano-electrospray ionization mass spectrometric (nESI-MS) studies were conducted to understand the molecular-level interactions in the FDPX - NH2-β-CD systems. NMR experiments were performed at pD 7.4 and 2.0. Job's method of continuous variation and 1H NMR titration experiments suggested the formation of FDPX∙NH2-β-CD complex at pD 7.4, while the presence of multiple complexes was assumed at pD 2.0. Stability constants were determined by separate 1H NMR titrations, yielding log β11=3.65 ± 0.02 at pD 7.4, while log β11 ≥ 4.9 value suggested a high-affinity system at pD 2.0. 2D NOESY NMR studies indicated spatial proximities between the anomeric resonance α-l-iduronic acid residue and the cyclodextrin's methylene unit in the proximity of the cationic amino function. Acidic degradation of FDPX was investigated by NMR and MS for the first time in detail confirming that desulfation occurs involving one to two sulfate moieties. The desulfation of FDPX was inhibited by the cationic cyclodextrin in the case of equimolar ratio at pD 2.0. This is the first report on the stabilizing effect of cyclodextrin complexation on heparin degradation.
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Affiliation(s)
- Bianka Várnai
- Semmelweis University, Department of Pharmacognosy, Üllői út. 26, H-1085, Budapest, Hungary
| | - Márkó Grabarics
- Freie Universität Berlin, Institute of Chemistry and Biochemistry, Arnimallee 22, 14195, Berlin, Germany; Fritz Haber Institute of the Max Planck Society, Department of Molecular Physics, Faradayweg 4-6, 14195, Berlin, Germany
| | - Zoltán Szakács
- Gedeon Richter Plc., Spectroscopic Research Department, H-1475, Budapest, P.O.B. 27, Hungary
| | - Kevin Pagel
- Freie Universität Berlin, Institute of Chemistry and Biochemistry, Arnimallee 22, 14195, Berlin, Germany; Fritz Haber Institute of the Max Planck Society, Department of Molecular Physics, Faradayweg 4-6, 14195, Berlin, Germany
| | - Milo Malanga
- CycloLab, Cyclodextrin R&D Ltd, Budapest, H-1097, Illatos út 7, Hungary
| | - Tamás Sohajda
- CycloLab, Cyclodextrin R&D Ltd, Budapest, H-1097, Illatos út 7, Hungary
| | - Szabolcs Béni
- Semmelweis University, Department of Pharmacognosy, Üllői út. 26, H-1085, Budapest, Hungary.
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21
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De Simone F, Nardelli P, Licheri M, Frau G, Redaelli MB, Monaco F, Zangrillo A, Landoni G. Less is more: We are administering too much protamine in cardiac surgery. Ann Card Anaesth 2021; 24:178-182. [PMID: 33884973 PMCID: PMC8253032 DOI: 10.4103/aca.aca_26_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context Protamine is routinely administered to neutralize the anticlotting effects of heparin, traditionally at a dose of 1 mg for every 100 IU of heparin-a 1:1 ratio protamine sparing effects-but this is based more on experience and practice than literature evidence. The use of Hemostasis Management System (HMS) allows an individualized heparin and protamine titration. This usually results in a decreased protamine dose, thus limiting its side effects, including paradox anticoagulation. Aims This study aims to assess how the use of HMS allows to reduction of protamine administration while restoring the basal activated clotting time (ACT) at the end of cardiac surgery. Settings and Design A retrospective observational study in a tertiary care university hospital. Subjects and Methods We analyzed data from 42 consecutive patients undergoing cardiopulmonary bypass (CPB) for cardiac surgery. For all patients HMS tests were performed before and after CPB, to determine how much heparin was needed to reach target ACT, and how much protamine was needed to reverse it. Results At the end of cardiopulmonary bypass, 2.2 ± 0.5 mg/kg of protamine was sufficient to reverse heparin effects. The protamine-to-heparin ratio was 0.56:1 over heparin total dose (a 44% reduction) and 0.84:1 over heparin initial dose (a 16% reduction). Conclusion A lower dose of protamine was sufficient to revert heparin effects after cardiopulmonary bypass. While larger studies are needed to confirm these findings and detect differences in clinically relevant outcomes, the administration of a lower protamine dose is endorsed by current guidelines and may help to avoid the detrimental effects of protamine overdose, including paradox bleeding.
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Affiliation(s)
- Francesco De Simone
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pasquale Nardelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Margherita Licheri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanna Frau
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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22
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Claudel SE, Miles LA, Murea M. Anticoagulation in hemodialysis: A narrative review. Semin Dial 2020; 34:103-115. [PMID: 33135208 DOI: 10.1111/sdi.12932] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/28/2020] [Accepted: 10/11/2020] [Indexed: 12/18/2022]
Abstract
Systemic anticoagulation in maintenance hemodialysis (HD) has historically been considered necessary to maintain the extracorporeal circuit (ECC) and preserve dialysis efficiency. Unfractionated heparin (UFH) is the most commonly used anticoagulant due to low cost and staff familiarity. Despite widespread use, there is little standardization of heparin dosing protocols in the United States. Although the complication rates with UFH are low for the general population, certain contraindications have led to exploration in alternative anticoagulants in patients with end-stage kidney disease (ESKD). Here we review the current evidence regarding heparin dosing protocols, complications associated with heparin use, and discuss alternatives to UFH including anticoagulant-free routine HD.
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Affiliation(s)
- Sophie E Claudel
- Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Lauren A Miles
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Abstract
A 24-year-old primigravid woman at 29-weeks gestation presented with headache, hypertension and proteinuria. A diagnosis of pre-eclampsia was made. Later that day she developed a left hemiparesis and neuroimaging demonstrated an intracerebral haemorrhage in the right frontal lobe as well as thrombosis of the superior sagittal sinus. She was commenced on an IV heparin infusion to manage the sinus thrombosis, and nifedipine and labetalol to treat the hypertension. GCS remained 15/15. However, 12 hours later, she became progressively agitated. Her GCS decreased to 10/15 (E3V2M5). Repeat imaging demonstrated enlargement of the haematoma, causing significant mass effect and midline shift. A decision was made to perform decompressive hemicraniectomy to save the life of the mother, and caesarean section to protect the foetus as well as providing definitive treatment of pre-eclampsia. Due to further neurological deterioration of the mother it became necessary to perform the two procedures simultaneously. We present the first reported case of decompressive craniectomy and caesarean section performed simultaneously. After discussing the case, we consider why this clinical scenario is rare and why it became necessary in this patient to perform the two procedures simultaneously.
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Affiliation(s)
- Bennett Choy
- University of Sheffield Medical School, Sheffield, United Kingdom of Great Britain and Northern Ireland
| | - Kenneth Burns
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom of Great Britain and Northern Ireland
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24
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Therapeutic strategies for thrombosis: new targets and approaches. Nat Rev Drug Discov 2020; 19:333-352. [PMID: 32132678 DOI: 10.1038/s41573-020-0061-0] [Citation(s) in RCA: 178] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2020] [Indexed: 12/19/2022]
Abstract
Antiplatelet agents and anticoagulants are a mainstay for the prevention and treatment of thrombosis. However, despite advances in antithrombotic therapy, a fundamental challenge is the side effect of bleeding. Improved understanding of the mechanisms of haemostasis and thrombosis has revealed new targets for attenuating thrombosis with the potential for less bleeding, including glycoprotein VI on platelets and factor XIa of the coagulation system. The efficacy and safety of new agents are currently being evaluated in phase III trials. This Review provides an overview of haemostasis and thrombosis, details the current landscape of antithrombotic agents, addresses challenges with preventing thromboembolic events in patients at high risk and describes the emerging therapeutic strategies that may break the inexorable link between antithrombotic therapy and bleeding risk.
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25
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Abstract
PURPOSE OF REVIEW Anticoagulants in general, but especially the relatively new direct oral anticoagulants and platelet inhibitors, pose a great challenge for physicians in the hemorrhaging patient. The aim of the present review is to provide an overview on recent studies dealing with the reversal of anticoagulation in the hemorrhaging patient and to describe our therapeutic emergency strategy for those patients. RECENT FINDINGS A specific antidote for dabigatran is already on the market and antidotes for the direct and indirect factor Xa inhibitors are in development. Moreover, bleeding under platelet inhibitors remains critical with very little evidence on effective reversal strategies. SUMMARY To reverse anticoagulation in the hemorrhaging patient, specific antidotes should be the first option if available, followed by four-factor prothrombin complex concentrate (PCC), activated PCC and recombinant activated factor seven as the emergency strategy. Fibrinogen concentrate, antifibrinolytics and oral charcoal, respectively, can be considered as an additional measure. Massive blood loss and thrombocytopenia should be treated independently according to the respective, local guidelines for (massive) transfusion of blood and blood products.
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26
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Abstract
Venous thromboembolism accounts for significant morbidity and mortality in patients with acute medical illnesses requiring hospital admission. American College of Chest Physicians guidelines recommend prophylaxis with heparins as first line and mechanical methods as second line. The risk of major bleeding with anticoagulants is less than 1% and not significantly different between agents. Although data support the use of all heparins, there is a trend toward superiority of low-molecular-weight heparins (LMWHs). Because acute illness and immobility do not end at hospital discharge, extended-duration therapy with LMWHs and direct oral anticoagulants remains under investigation.
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27
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Chen J, Yu Y, Fareed J, Hoppensteadt D, Jeske W, Kouta A, Jin C, Jin Y, Yao Y, Xia K, Zhang F, Chen S, Ye X, Linhardt RJ. Comparison of Low-Molecular-Weight Heparins Prepared From Ovine Heparins With Enoxaparin. Clin Appl Thromb Hemost 2019; 25:1076029619840701. [PMID: 30987427 PMCID: PMC6714994 DOI: 10.1177/1076029619840701] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 02/27/2019] [Accepted: 03/01/2019] [Indexed: 01/01/2023] Open
Abstract
Heparin and its low-molecular-weight heparin derivatives are widely used clinical anticoagulants. These drugs are critical for the practice of medicine in applications, including kidney dialysis, cardiopulmonary bypass, and in the management of venous thromboembolism. Currently, these drugs are derived from livestock, primarily porcine intestine and less frequently bovine intestine and bovine lung. The worldwide dependence on the pig as a single dominant animal species has made the supply chain for this critical drug quite fragile, leading to the search for other sources of these drugs, including the expanded use of bovine tissues. A number of laboratories are now also examining the similarities between heparin and low-molecular-weight heparins prepared from porcine and ovine tissues. This study was designed to compare low-molecular-weight heparin prepared from ovine heparin through chemical β-elimination, a process currently used to prepare the low-molecular-weight heparin, enoxaparin. Using top-down, bottom-up, and compositional analyses as well as bioassays, low-molecular-weight heparin derived from ovine intestine was shown to closely resemble enoxaparin. Moreover, the compositions of daughter low-molecular-weight heparins prepared from three unfractionated ovine parent heparins were compared. Ovine enoxaparins had similar molecular weight and in vitro anticoagulant activities as Lovenox. Some disaccharide compositional, oligosaccharide composition at the reducing and nonreducing ends and intact chain compositional differences could be observed between porcine enoxaparin and ovine low-molecular-weight heparin. The similarity of these ovine and porcine heparin products suggests that their preclinical evaluation and ultimately clinical assessment is warranted.
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Affiliation(s)
- Jianle Chen
- Department of Food Science and Nutrition, Zhejiang University, Hangzhou,
China
- Department of Chemistry and Chemical Biology, Rensselaer Polytechnic
Institute, Troy, NY, USA
| | - Yanlei Yu
- Department of Chemistry and Chemical Biology, Rensselaer Polytechnic
Institute, Troy, NY, USA
| | - Jawed Fareed
- Department of Pathology, Loyola University Medical Center, Maywood, IL,
USA
| | - Debra Hoppensteadt
- Department of Pathology, Loyola University Medical Center, Maywood, IL,
USA
| | - Walter Jeske
- Department of Pathology, Loyola University Medical Center, Maywood, IL,
USA
| | - Ahmed Kouta
- Department of Pathology, Loyola University Medical Center, Maywood, IL,
USA
| | - Caijuan Jin
- Ronnsi Pharma Co, Ltd, Suzhou Industrial Park, Suzhou, China
| | - Yongsheng Jin
- Ronnsi Pharma Co, Ltd, Suzhou Industrial Park, Suzhou, China
| | - Yiming Yao
- Ronnsi Pharma Co, Ltd, Suzhou Industrial Park, Suzhou, China
| | - Ke Xia
- Department of Chemistry and Chemical Biology, Rensselaer Polytechnic
Institute, Troy, NY, USA
| | - Fuming Zhang
- Department of Chemical and Biological Engineering, Rensselaer Polytechnic
Institute, Troy, NY, USA
| | - Shiguo Chen
- Department of Food Science and Nutrition, Zhejiang University, Hangzhou,
China
| | - Xingqian Ye
- Department of Food Science and Nutrition, Zhejiang University, Hangzhou,
China
| | - Robert J. Linhardt
- Department of Chemistry and Chemical Biology, Rensselaer Polytechnic
Institute, Troy, NY, USA
- Department of Chemical and Biological Engineering, Rensselaer Polytechnic
Institute, Troy, NY, USA
- Department of Biology, Rensselaer Polytechnic Institute, Troy, NY, USA
- Department of Biomedical Engineering, Center for Biotechnology and
Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, NY, USA
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28
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Glauser BF, Santos GRC, Silva JD, Tovar AMF, Pereira MS, Vilanova E, Mourão PAS. Chemical and pharmacological aspects of neutralization of heparins from different animal sources by protamine. J Thromb Haemost 2018; 16:1789-1799. [PMID: 29968421 DOI: 10.1111/jth.14221] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Indexed: 01/21/2023]
Abstract
Essentials Bovine (HBI) and porcine (HPI) heparins differ in structure and anticoagulant activity. Protamine-neutralization was evaluated on a variety of physical-chemical methods. HBI requires more protamine than HPI to fully neutralize its anticoagulant activity. Protamine preferentially removes higher-sulfated chains of HBI while HPI is evenly precipitated. SUMMARY Background Protamine neutralization is an essential step for the safe use and inactivation of the unfractionated heparin (UFH) that is widely employed in surgical and non-surgical procedures involving extracorporeal circulation. Objective To compare protamine neutralization of different pharmaceutical-grade UFHs prepared from porcine or bovine intestine (HPI and HBI, respectively). HBI has approximately half the anticoagulant potency of HPI, mostly as consequence of its fraction enriched with N-sulfated α-glucosamine disaccharides. Methods Protamine neutralization of HPI and HBI was evaluated with in vitro, ex vivo and in vivo assays. We also performed in-depth assessments of the complexation of protamine with these distinct UFHs by using nuclear magnetic resonance and mass spectroscopy. Results HPI and HBI interact similarly with protamine on a mass/mass basis; however, HBI requires more protamine than HPI to have its anticoagulant activity fully neutralized, because of its lower potency, which entails the use of higher doses. Nuclear magnetic resonance spectra revealed that HPI precipitates homogeneously with protamine. On the other hand, the low-sulfated fraction of HBI, enriched with N-sulfated α-glucosamine, precipitates at higher concentrations of protamine than the fraction more like HPI, with a preponderance of N,6-disulfated α-glucosamine disaccharides. Finally, mass spectroscopy spectra showed that some of the different peptide components of protamine interact preferentially with the heparins, irrespective of their animal origin. Conclusion Our results have important medical implications, indicating that protamine neutralization of HBI, determined exclusively by point-of-care coagulation assessments, must fail because of its lower-sulfated fraction with reduced anticoagulant activity that could remain in the circulation after the neutralization procedure.
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Affiliation(s)
- B F Glauser
- Laboratório de Tecido Conjuntivo, Hospital Universitário Clementino Fraga Filho and Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Cidade Universitária, Rio de Janeiro, Brazil
| | - G R C Santos
- Laboratório de Tecido Conjuntivo, Hospital Universitário Clementino Fraga Filho and Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Cidade Universitária, Rio de Janeiro, Brazil
- Laboratório de Apoio ao Desenvolvimento Tecnológico, Laboratório Brasileiro de Controle de Dopagem, Instituto de Química, Universidade Federal do Rio de Janeiro, Cidade Universitária, Rio de Janeiro, Brazil
| | - J D Silva
- Laboratório de Tecido Conjuntivo, Hospital Universitário Clementino Fraga Filho and Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Cidade Universitária, Rio de Janeiro, Brazil
| | - A M F Tovar
- Laboratório de Tecido Conjuntivo, Hospital Universitário Clementino Fraga Filho and Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Cidade Universitária, Rio de Janeiro, Brazil
| | - M S Pereira
- Laboratório de Tecido Conjuntivo, Hospital Universitário Clementino Fraga Filho and Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Cidade Universitária, Rio de Janeiro, Brazil
| | - E Vilanova
- Laboratório de Tecido Conjuntivo, Hospital Universitário Clementino Fraga Filho and Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Cidade Universitária, Rio de Janeiro, Brazil
| | - P A S Mourão
- Laboratório de Tecido Conjuntivo, Hospital Universitário Clementino Fraga Filho and Instituto de Bioquímica Médica Leopoldo de Meis, Universidade Federal do Rio de Janeiro, Cidade Universitária, Rio de Janeiro, Brazil
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29
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Anticoagulant and side-effects of protamine in cardiac surgery: a narrative review. Br J Anaesth 2018; 120:914-927. [DOI: 10.1016/j.bja.2018.01.023] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 01/10/2018] [Accepted: 01/29/2018] [Indexed: 01/10/2023] Open
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30
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Ofosu F. A review of the two major regulatory pathways for non-proprietary low-molecular-weight heparins. Thromb Haemost 2017; 107:201-14. [DOI: 10.1160/th11-06-0409] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Accepted: 11/12/2011] [Indexed: 11/05/2022]
Abstract
SummaryWith the expiry or pending expiry of originator low-molecular-weight heparin (LMWH) patents, pharmaceutical companies have invested in developing non-proprietary versions of LMWHs. LMWHs are manufactured by depolymerising highly purified unfractionated heparin. In contrast to traditional synthetic drugs with well-defined chemical structures, LMWHs contain complex oligosaccharide mixtures and the different manufacturing processes for LMWHs add to the heterogeneity in their physicochemical properties such that the European Medicines Agency (EMA) and the US Food and Drug Administration (FDA) consider existing originator LMWHs to be distinct medicinal entities that are not clinically interchangeable. The FDA views LMWHs as drugs and has approved two non-proprietary (generic) LMWHs, using the Abbreviated New Drug Application pathway. In contrast, the World Health Organization and the EMA view LMWHs as biological medicines. Therefore, the EMA and also the Scientific and Standardization Subcommittee on Anticoagulation of the International Society on Thrombosis and Haemostasis and the South Asian Society of Atherosclerosis and Thrombosis have all published specific guidelines for assessing non-proprietary (biosimilar) LMWHs. This manuscript reviews why there are two distinct pathways for approving non-proprietary LMWHs. Available literature on non-proprietary LMWHs approved in some jurisdictions is also reviewed in order to assess whether they satisfy the requirements for LMWHs in the three guidance documents. The review also highlights some of the significant difficulties the two pathways pose for manufacturers and an urgent need to develop a consensus governing the manufacture and regulation of non-proprietary LMWHs to make them more widely available.
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31
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Kim JH, Lim KM, Gwak HS. New Anticoagulants for the Prevention and Treatment of Venous Thromboembolism. Biomol Ther (Seoul) 2017; 25:461-470. [PMID: 28365976 PMCID: PMC5590789 DOI: 10.4062/biomolther.2016.271] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 01/21/2017] [Accepted: 01/26/2017] [Indexed: 12/14/2022] Open
Abstract
Anticoagulant drugs, like vitamin K antagonists and heparin, have been the mainstay for the treatment and prevention of venous thromboembolic disease for many years. Although effective if appropriately used, traditional anticoagulants have several limitations such as unpredictable pharmacologic and pharmacokinetic responses and various adverse effects including serious bleeding complications. New oral anticoagulants have recently emerged as an alternative because of their rapid onset/offset of action, predictable linear dose-response relationships and fewer drug interactions. However, they are still associated with problems such as bleeding, lack of reversal agents and standard laboratory monitoring. In an attempt to overcome these drawbacks, key steps of the hemostatic pathway are investigated as targets for anticoagulation. Here we reviewed the traditional and new anticoagulants with respect to their targets in the coagulation cascade, along with their therapeutic advantages and disadvantages. In addition, investigational anticoagulant drugs currently in the development stages were introduced.
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Affiliation(s)
- Joo Hee Kim
- College of Pharmacy & Institute of Pharmaceutical Science and Technology, Ajou University, Suwon 16499, Republic of Korea.,College of Pharmacy, Ewha Womans University, Seoul 03760, Republic of Korea
| | - Kyung-Min Lim
- College of Pharmacy, Ewha Womans University, Seoul 03760, Republic of Korea
| | - Hye Sun Gwak
- College of Pharmacy, Ewha Womans University, Seoul 03760, Republic of Korea
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32
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Abstract
Heparin and heparan sulfate glycosaminoglycans are long, linear polysaccharides that are made up of alternating dissacharide sequences of sulfated uronic acid and amino sugars. Unlike heparin, which is only found in mast cells, heparan sulfate is ubiquitously expressed on the cell surface and in the extracellular matrix of all animal cells. These negatively-charged glycans play essential roles in important cellular functions such as cell growth, adhesion, angiogenesis, and blood coagulation. These biomolecules are also involved in pathophysiological conditions such as pathogen infection and human disease. This review discusses past and current methods for targeting these complex biomolecules as a novel therapeutic strategy to treating disorders such as cancer, neurodegenerative diseases, and infection.
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Affiliation(s)
- Ryan J Weiss
- Department of Cellular and Molecular Medicine, Glycobiology Research and Training Center, University of California, San Diego, La Jolla, CA 92093-0358, USA
| | - Jeffrey D Esko
- Department of Cellular and Molecular Medicine, Glycobiology Research and Training Center, University of California, San Diego, La Jolla, CA 92093-0358, USA
| | - Yitzhak Tor
- Department of Chemistry and Biochemistry, University of California, San Diego, La Jolla, CA 92093-0358, USA.
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33
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Precipitation and Neutralization of Heparin from Different Sources by Protamine Sulfate. Pharmaceuticals (Basel) 2017; 10:ph10030059. [PMID: 28671597 PMCID: PMC5620603 DOI: 10.3390/ph10030059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 01/06/2023] Open
Abstract
Current therapeutic unfractionated heparin available in Europe and US is of porcine mucosal origin. There is now interest, specifically in the US, to use bovine mucosa as an additional source for the production of heparin. The anticoagulant action of heparin can be neutralized by protamine sulfate, and in this study the ability of protamine to bind and neutralize the anticoagulant activities of heparin from porcine mucosa, bovine mucosa and bovine lung were assessed. Protamine sulfate was able to bind and precipitate similar amounts of heparins from different sources on a mass basis. However, differential amounts of anticoagulant activities were neutralized by protamine sulfate, with neutralization of porcine mucosa more effective than for bovine lung and bovine mucosa. For all heparins, potentiation of thrombin inhibition by antithrombin and heparin cofactor II was preferentially neutralized over antithrombin-mediated inhibition of factor Xa or plasma clotting time. Whole blood thromboelastography showed that neutralization by protamine sulfate was more effective than the antithrombin dependent thrombin inhibition assays indicated. While there was no absolute correlation between average or peak molecular weight of heparin samples and neutralization of anticoagulant activity, correlation was observed between proportions of material with high affinity to antithrombin, specific activities and neutralization of activity.
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34
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Sommers CD, Ye H, Liu J, Linhardt RJ, Keire DA. Heparin and homogeneous model heparin oligosaccharides form distinct complexes with protamine: Light scattering and zeta potential analysis. J Pharm Biomed Anal 2017; 140:113-121. [DOI: 10.1016/j.jpba.2017.03.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 02/06/2017] [Accepted: 03/09/2017] [Indexed: 12/17/2022]
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35
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Elalamy I, Mahé I, Ageno W, Meyer G. Long-term treatment of cancer-associated thrombosis: the choice of the optimal anticoagulant. J Thromb Haemost 2017; 15:848-857. [PMID: 28222250 DOI: 10.1111/jth.13659] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Indexed: 01/20/2023]
Abstract
Patients with cancer-associated thrombosis (CAT) carry a higher risk of recurrence, bleeding and mortality as compared with non-cancer patients. The specific profiles of cancer patients, combining frequent co-morbidities, the use of anti-tumoral therapies and the cancer progression itself, represent a major therapeutic challenge for choosing a long-term anticoagulant treatment. This review discusses the practical basis of making a choice between the available drugs for a long-term antithrombotic strategy, linked to their pharmacology, mechanism of action, evidence of clinical benefits, and advantages and limitations in such a complex clinical context. In patients with cancer, low-molecular-weight heparins (LMWHs) are the preferred option for the secondary prevention of venous thromboembolism according to current guidelines, because their efficacy is significantly superior to vitamin K antagonists (VKAs). Even though LMWHs are effective and safe in cancer patients, they require daily subcutaneous injections, which may be problematic for a long-term therapy that may exceed 6 months' duration. Compared with VKAs, non-vitamin-K antagonist oral anticoagulants or direct oral anticoagulants (DOACs) are more target specific and do not require laboratory monitoring, whereas the oral route of administration makes them potentially attractive alternatives to LMWH. In randomized controlled trials in the general population DOACs have been shown to be non-inferior to VKAs in terms of efficacy with a lower rate of clinically relevant or major bleeding. However, given the limited number of cancer patients enrolled in these studies (with poorly defined active cancer), available trials are inconclusive regarding the usefulness of DOACs in the cancer setting. Ongoing head-to-head comparisons vs. LMWH in patients with CAT may allow an informed choice to be made regarding the DOAC option.
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Affiliation(s)
- I Elalamy
- Biological Hematology Department, Hôpital TENON APHP Hôpitaux Universitaires de l'Est Parisien, INSERM UMRS 938 Université Pierre et Marie Curie, Paris 6, Paris, France
| | - I Mahé
- Internal Medicine Department, Hôpital Louis Mourier, APHP, Colombes, France
- Université Paris-Diderot Paris 7, EA 7334, Sorbonne Paris Cité, Paris, France
| | - W Ageno
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - G Meyer
- Respiratory and Intensive Care, Hôpital Européen Georges Pompidou, APHP, Paris, France
- Université Paris Descartes Paris 5, Sorbonne Paris Cité, Paris, France
- INSERM UMRS 970, CIC 1418, Paris, France
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36
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Mulloy B, Hogwood J, Gray E, Lever R, Page CP. Pharmacology of Heparin and Related Drugs. Pharmacol Rev 2016; 68:76-141. [PMID: 26672027 DOI: 10.1124/pr.115.011247] [Citation(s) in RCA: 221] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Heparin has been recognized as a valuable anticoagulant and antithrombotic for several decades and is still widely used in clinical practice for a variety of indications. The anticoagulant activity of heparin is mainly attributable to the action of a specific pentasaccharide sequence that acts in concert with antithrombin, a plasma coagulation factor inhibitor. This observation has led to the development of synthetic heparin mimetics for clinical use. However, it is increasingly recognized that heparin has many other pharmacological properties, including but not limited to antiviral, anti-inflammatory, and antimetastatic actions. Many of these activities are independent of its anticoagulant activity, although the mechanisms of these other activities are currently less well defined. Nonetheless, heparin is being exploited for clinical uses beyond anticoagulation and developed for a wide range of clinical disorders. This article provides a "state of the art" review of our current understanding of the pharmacology of heparin and related drugs and an overview of the status of development of such drugs.
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Affiliation(s)
- Barbara Mulloy
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., C.P.P.); National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, United Kingdom (J.H., E.G.); and University College London School of Pharmacy, London, United Kingdom (R.L.)
| | - John Hogwood
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., C.P.P.); National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, United Kingdom (J.H., E.G.); and University College London School of Pharmacy, London, United Kingdom (R.L.)
| | - Elaine Gray
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., C.P.P.); National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, United Kingdom (J.H., E.G.); and University College London School of Pharmacy, London, United Kingdom (R.L.)
| | - Rebecca Lever
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., C.P.P.); National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, United Kingdom (J.H., E.G.); and University College London School of Pharmacy, London, United Kingdom (R.L.)
| | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., C.P.P.); National Institute for Biological Standards and Control, Potters Bar, Hertfordshire, United Kingdom (J.H., E.G.); and University College London School of Pharmacy, London, United Kingdom (R.L.)
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Flebus L, Lombart F, Martinez-Jothar L, Sevrin C, Delierneux C, Oury C, Grandfils C. In vitro study of the specific interaction between poly(2-dimethylamino ethylmethacrylate) based polymers with platelets and red blood cells. Int J Pharm 2015; 492:55-64. [PMID: 26136199 DOI: 10.1016/j.ijpharm.2015.06.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 06/19/2015] [Accepted: 06/20/2015] [Indexed: 01/24/2023]
Abstract
Poly(2-dimethylamino)ethyl methacrylate (PDMAEMA) is an attractive polycation frequently proposed as a non-viral vector for gene therapy. As expected for other cationic carriers, intravenous administration of PDMAEMA can result in its ionic complexation with various negatively charged domains found within the blood. To gain more insight into this polycation hemoreactivity, we followed the binding kinetics of a free form (FF) of fluorescein labelled PDMAEMA (Mn below 15 kDa) in normal human blood using flow cytometry. This in vitro study highlighted that platelets display higher affinity for this polycation compared to red blood cells (RBCs), with an adsorption isotherm characteristics of a specific saturable binding site. PDMAEMA (1-20 μg/mL) exerted a concentration dependent proaggregant effect with a biphasic aggregation of washed platelets. Activation of platelets was also noticed in whole blood with the expression of P-selectin and fibrinogen on platelet surface. Although additional studies would be needed in order to elucidate the mechanism of PDMAEMA mediated activation of platelets, our manuscript provides important information on the hemoreactivity of FF PDMAEMA.
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Affiliation(s)
- Luca Flebus
- Interfacultary Research Center of Biomaterials, University of Liège, Institute of Chemistry, Building B6C, Sart-Tilman, Liège 4000, Belgium.
| | - François Lombart
- Interfacultary Research Center of Biomaterials, University of Liège, Institute of Chemistry, Building B6C, Sart-Tilman, Liège 4000, Belgium.
| | - Lucía Martinez-Jothar
- Interfacultary Research Center of Biomaterials, University of Liège, Institute of Chemistry, Building B6C, Sart-Tilman, Liège 4000, Belgium.
| | - Chantal Sevrin
- Interfacultary Research Center of Biomaterials, University of Liège, Institute of Chemistry, Building B6C, Sart-Tilman, Liège 4000, Belgium.
| | - Céline Delierneux
- Laboratory of Thrombosis and Haemostasis, GIGA-Cardiovascular Sciences, University of Liège, Belgium.
| | - Cécile Oury
- Laboratory of Thrombosis and Haemostasis, GIGA-Cardiovascular Sciences, University of Liège, Belgium.
| | - Christian Grandfils
- Interfacultary Research Center of Biomaterials, University of Liège, Institute of Chemistry, Building B6C, Sart-Tilman, Liège 4000, Belgium.
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Modern analytics for naturally derived complex drug substances: NMR and MS tests for protamine sulfate from chum salmon. Anal Bioanal Chem 2014; 407:749-59. [DOI: 10.1007/s00216-014-8172-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 08/01/2014] [Accepted: 08/07/2014] [Indexed: 10/24/2022]
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Balla I, Karafotias I, Christopoulos C. Intentional overdose with tinzaparin: management dilemmas. J Emerg Med 2014; 46:197-201. [PMID: 24084058 DOI: 10.1016/j.jemermed.2013.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 05/12/2013] [Accepted: 08/14/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Low-molecular-weight heparin (LMWH) is increasingly being prescribed for prophylaxis and treatment of thromboembolic diseases. Despite the fact that its therapeutic use is considered to be safe, it can be complicated by major hemorrhage and, in contrast to unfractionated heparin, it can only partially be neutralized by protamine. Recent reports of LMWH overdose illustrate the need for a consensus on its management. OBJECTIVES To describe a case of self-poisoning with a very large dose of tinzaparin and discuss management options in patients with LMWH overdose. CASE REPORT A 69-year-old woman was brought to the Emergency Department 2 h after injecting herself with 280,000 IU of tinzaparin subcutaneously in an attempt to commit suicide. Despite an unrecordable activated partial thromboplastin time (APTT > 180 s) and prolonged prothrombin time, there was no evidence of active bleeding. She was given an intravenous infusion of 100 mg protamine sulfate and was admitted to the intensive care unit, where further infusions of protamine were administered. Normalization of the APTT occurred 40-50 h post admission, reflecting normal tinzaparin clearance rather than neutralization by protamine. No hemorrhagic complications occurred during her hospitalization except for prolonged bleeding from venipuncture sites. CONCLUSION In this case of massive tinzaparin overdose, conventional doses of protamine failed to rapidly normalize the deranged coagulation parameters. The favorable clinical outcome suggests that, regardless of the LMWH amount injected, no active treatment is needed in the absence of hemorrhage. This is in accordance with the limited published data concerning cases of overdose with other LMWHs.
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Affiliation(s)
- Iliana Balla
- First Department of Internal Medicine, "Amalia Fleming" General Hospital, Athens, Greece
| | - Ioasaf Karafotias
- First Department of Internal Medicine, "Amalia Fleming" General Hospital, Athens, Greece
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Johansen KB, Balchen T. Tinzaparin and other low-molecular-weight heparins: what is the evidence for differential dependence on renal clearance? Exp Hematol Oncol 2013; 2:21. [PMID: 23927414 PMCID: PMC3750714 DOI: 10.1186/2162-3619-2-21] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 08/02/2013] [Indexed: 01/13/2023] Open
Abstract
Since low-molecular-weight heparins (LMWHs) are eliminated preferentially via the kidneys, the potential for accumulation of these agents (and an increased risk of bleeding) is of particular concern in populations with a high prevalence of renal impairment, such as the elderly and patients with cancer. The risk of clinically relevant accumulation of anticoagulant activity as a result of a reduction in renal elimination appears to differ between LMWHs. This review describes the elimination pathways for LMWHs and assesses whether the relative balance between renal and non-renal (cellular) clearance may provide a mechanistic explanation for the differences in accumulation that have been observed between LMWHs in patients with impaired renal function. Clearance studies in animals, cellular binding studies and clinical studies all indicate that the balance between renal and non-renal clearance is dependent on the molecular weight (MW): the higher the MW of the LMWH, the more the balance is shifted towards non-renal clearance. Animal studies have also provided insights into the balance between renal and non-renal clearance by examining the effect of selective blocking of one of the elimination pathways, and it is most likely that cellular clearance is increased to compensate for decreased renal function. Tinzaparin (6,500 Da) has the highest average MW of the marketed LMWHs, and there is both clinical and preclinical evidence for significant non-renal elimination of tinzaparin, making it less likely that tinzaparin accumulates in patients with renal impairment compared with LMWHs with a lower MW distribution. On the basis of our findings, LMWHs that are less dependent on renal clearance may be preferred in patient populations with a high prevalence of renal insufficiency.
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Affiliation(s)
| | - Torben Balchen
- DanTrials ApS, c/o Bispebjerg Hospital, Copenhagen, Denmark
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Lee AYY, Bauersachs R, Janas MS, Jarner MF, Kamphuisen PW, Meyer G, Khorana AA. CATCH: a randomised clinical trial comparing long-term tinzaparin versus warfarin for treatment of acute venous thromboembolism in cancer patients. BMC Cancer 2013; 13:284. [PMID: 23764005 PMCID: PMC3691586 DOI: 10.1186/1471-2407-13-284] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 05/28/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Low-molecular-weight heparin (LMWH) is recommended and commonly used for extended treatment of cancer-associated thrombosis (CAT), but its superiority over warfarin has been demonstrated in only one randomised study. We report here the rationale, design and a priori analysis plans of Comparison of Acute Treatments in Cancer Haemostasis (CATCH; NCT01130025), a multinational, Phase III, open-label, randomised controlled trial comparing tinzaparin with warfarin for extended treatment of CAT. METHODS/DESIGN The primary objective is to assess the efficacy of tinzaparin in preventing recurrent venous thromboembolism (VTE) in patients with active cancer and acute, symptomatic proximal deep vein thrombosis and/or pulmonary embolism. The secondary objectives are to determine: safety of tinzaparin given over 6 months; clinical and laboratory markers for recurrent VTE and/or major bleeding; 6-month overall mortality; incidence and severity of post-thrombotic syndrome; patient-reported quality of life; and healthcare resource utilisation. Nine hundred patients are randomised to receive tinzaparin 175 IU/kg once daily for 6 months or initial tinzaparin 175 IU/kg once daily for 5-10 days and dose-adjusted warfarin (target INR 2.0-3.0) for 6 months. The primary composite outcome is time to recurrent VTE, including incidental VTE and fatal pulmonary embolism. All patients are followed up to 6 months or death, whichever comes sooner. Blinded adjudication will be performed for all reported VTE, bleeding events and causes of death. Efficacy will be analysed using centrally adjudicated results of all patients according to intention-to-treat analysis. An independent Data Safety Monitoring Board is reviewing data at regular intervals and an interim analysis is planned after 450 patients have completed the study. DISCUSSION The results will add significantly to the knowledge of the efficacy, safety and cost effectiveness of tinzaparin in the prevention of recurrent VTE in patients with cancer and thrombosis. Prospective data will emerge on the clinical significance of incidental VTE and risk stratification in patients with CAT. Results on post-thrombotic syndrome, quality of life and healthcare resource utilisation will inform decision makers on how to secure better patient care. If tinzaparin is shown to be more effective than warfarin, CATCH will provide valuable confirmatory data to support the use of the LMWH tinzaparin for extended treatment of CAT.
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Effect of cellulose sulfate on the induction of hydrolysis of plasmin-specific chromogenic substrate and anticoagulant activity in rabbit blood plasma. Pharm Chem J 2012. [DOI: 10.1007/s11094-012-0739-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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A case series of five episodes of massive LMWH non-fatal self-induced overdose in a single patient. Thromb Res 2012; 129:668-70. [PMID: 22261479 DOI: 10.1016/j.thromres.2011.12.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2011] [Revised: 12/13/2011] [Accepted: 12/22/2011] [Indexed: 11/22/2022]
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Sommers CD, Montpas N, Adam A, Keire DA. Characterization of currently marketed heparin products: adverse event relevant bioassays. J Pharm Biomed Anal 2012; 67-68:28-35. [PMID: 22591805 DOI: 10.1016/j.jpba.2012.04.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 04/18/2012] [Indexed: 10/28/2022]
Abstract
The polyanion oversulfated chondroitin sulfate (OSCS) was identified as a contaminant in heparin products and was associated with severe hypotensive responses and other symptoms in patients receiving the drug. The OSCS associated adverse reactions were attributed to activation of the contact system via the plasma mediator, activated factor XII (FXIIa), which triggers kallikrein (KK) activity. Unlike heparin alone, OSCS, is able to activate FXII in plasma and stably bind to FXIIa enhancing plasma KK activity and the induction of vasoactive mediators such as bradykinin (BK), C3a and C5a. Similarly OSCS can interfere with heparin neutralization by the polycationic drug protamine. Here, we assess heparin (heparin sodium, dalteparin, tinzaparin or enoxaparin)-protamine complex formation and plasma based bioassays of KK, BK and C5a in a 96-well plate format. We establish the normal range of variation in the optimized bioassays across multiple lots from 9 manufacturers. In addition, because other oversulfated (OS) glycosaminoglycans (GAGs) besides OSCS could also serve as possible economically motivated adulterants (EMAs) to heparin, we characterize OS-dermatan sulfate (OSDS), OS-heparan sulfate (OSHS) and their native forms in the same assays. For the protamine test, OS-GAGs could be distinguished from heparin. For the KK assay, OSCS and OSDS were most potent followed by OSHS, and all had similar efficacies. Finally, OSDS had a greater efficacy in the C5a and BK assays followed by OSCS then OSHS. These data established the normal range of response of heparin products in these assays and the alteration in the responses in the presence of possible EMAs.
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Affiliation(s)
- Cynthia D Sommers
- Division of Pharmaceutical Analysis, CDER, Food and Drug Administration, St Louis, MO 63101, USA
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Abstract
The molecular basis for the anticoagulant action of heparin lies in its ability to bind to and enhance the inhibitory activity of the plasma protein antithrombin against several serine proteases of the coagulation system, most importantly factors IIa (thrombin), Xa and IXa. Two major mechanisms underlie heparin's potentiation of antithrombin. The conformational changes induced by heparin binding cause both expulsion of the reactive loop and exposure of exosites of the surface of antithrombin, which bind directly to the enzyme target; and a template mechanism exists in which both inhibitor and enzyme bind to the same heparin molecule. The relative importance of these two modes of action varies between enzymes. In addition, heparin can act through other serine protease inhibitors such as heparin co-factor II, protein C inhibitor and tissue factor plasminogen inhibitor. The antithrombotic action of heparin in vivo, though dominated by anticoagulant mechanisms, is more complex, and interactions with other plasma proteins and cells play significant roles in the living vasculature.
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Affiliation(s)
- Elaine Gray
- National Institute for Biological Standards and Control, Potter's Bar, Hertfordshire, UK.
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