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Coimbra FCP, Sanchez EE, Lomonte B, Gutiérrez JM, Calvete JJ, Fry BG. Blood Lines: Intraspecific and Interspecific Variations in Anticoagulant Actions of Agkistrodon Viperid Venoms. Toxins (Basel) 2024; 16:291. [PMID: 39057931 PMCID: PMC11281148 DOI: 10.3390/toxins16070291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/23/2024] [Accepted: 06/25/2024] [Indexed: 07/28/2024] Open
Abstract
This study investigated the intraspecific and interspecific variability in the venom effects of Agkistrodon viperid snake species and subspecies (eleven venoms total) on plasma clotting times, fibrinogen levels, and fibrin clot strength. Significant delays in plasma clotting time were observed for A. conanti, A. contortrix mokasen, A. contortrix phaeogaster, A. howardgloydi, A. piscivorus leucostoma, and A. piscivorus piscivorus. Notably, the phylogenetically disjunct lineages A. conanti, A. contortrix mokasen, and A. howardgloydi exhibited the most potent anticoagulant effects, indicating the independent amplification of a basal trait. Inhibition assays with the activated clotting enzymes Factors XIa, IXa, Xa, and IIa (thrombin) revealed that FXa inhibition is another basal trait amplified independently on multiple occasions within the genus, but with A. howardgloydi, notably more potent than all others. Phospholipid degradation and zymogen destruction were identified as mechanisms underlying the variability in venom effects observed experimentally and in previous clinical reports. Thromboelastography demonstrated that the venoms did not clot fibrinogen directly but affected fibrin clot strength by damaging fibrinogen and that thrombin was subsequently only able to cleave into weak, unstable clots. The ability to activate Protein C, an endogenous anticoagulant enzyme, varied across species, with some venoms exceeding that of A. contortrix contortrix, which previously yielded the protein diagnostic agent Protac®. Phylogenetic analysis suggested that both fibrinogen degradation and Protein C activation were each amplified multiple times within the genus, albeit with negative correlation between these two modes of action. This study highlights the evolutionary, clinical, and biodiscovery implications of venom variability in the Agkistrodon species, underscoring their dynamic evolution, emphasising the need for tailored clinical approaches, and highlighting the potential for novel diagnostic and therapeutic developments inspired by the unique properties of snake venoms.
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Affiliation(s)
- Francisco C. P. Coimbra
- Adaptive Biotoxicology Lab, School of the Environment, University of Queensland, St Lucia, QLD 4072, Australia;
| | - Elda E. Sanchez
- National Natural Toxins Research Center, Department of Chemistry, Texas A&M University-Kingsville, MSC 224, 975 West Avenue B, Kingsville, TX 78363, USA;
| | - Bruno Lomonte
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José 11501, Costa Rica; (B.L.); (J.M.G.)
| | - José María Gutiérrez
- Instituto Clodomiro Picado, Facultad de Microbiología, Universidad de Costa Rica, San José 11501, Costa Rica; (B.L.); (J.M.G.)
| | - Juan J. Calvete
- Laboratorio de Venómica Evolutiva y Traslacional, Instituto de Biomedicina de Valencia, CSIC, 46010 Valencia, Spain;
| | - Bryan G. Fry
- Adaptive Biotoxicology Lab, School of the Environment, University of Queensland, St Lucia, QLD 4072, Australia;
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No Change in the Use of Antivenom in Copperhead Snakebites in Ohio. Wilderness Environ Med 2021; 32:315-321. [PMID: 34301478 DOI: 10.1016/j.wem.2021.03.010] [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: 08/14/2020] [Revised: 03/08/2021] [Accepted: 03/25/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Historically, copperhead snake (Agkistrodon contortrix) envenomations were not treated with antivenom owing to related adverse events and little benefit. However, recent studies have shown improved outcomes with antivenom use. We hypothesized that the frequency of antivenom use for copperhead envenomation in Ohio has increased as benefits of administration became more widely known. METHODS All copperhead snakebites reported to the Ohio poison control centers from 2006 through 2016 were compiled. Antivenom use, bite severity, and disposition were abstracted. A nonparametric test for trend was used to evaluate changes over time for the number of patients treated with antivenom and patient disposition. Logistic regression was used to assess the odds of admission vs discharge with antivenom administration, bite severity, age, and sex as independent variables. RESULTS Ninety-eight patients reported copperhead snakebites to the poison control centers. The test of trend showed no change in the proportion of patients treated with antivenom by year (P=0.42). There was no difference in the proportion of patients discharged home (P=0.38) per year. Logistic regression showed antivenom use was associated with an odds ratio for admission of 46.7 (95% CI: 7.3-296.4). CONCLUSIONS The frequency of antivenom use for copperhead bites did not significantly increase between 2006 and 2016. Administration of antivenom was associated with a large increase in the odds of admission to the hospital, even when controlling for bite severity. Further education regarding the benefits and safety of antivenom may increase its use for copperhead snakebites, but may lead to an increase in hospital admissions.
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Wilson BZ, Larsen J, Smelski G, Dudley S, Shirazi FM. Use of Crotalidae equine immune F(ab') 2 antivenom for treatment of an Agkistrodon envenomation. Clin Toxicol (Phila) 2021; 59:1023-1026. [PMID: 33703984 DOI: 10.1080/15563650.2021.1892718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Anavip (F(ab')2AV) is a lyophilized F(ab')2 immunoglobulin fragment derived from horses immunized with venom from Bothrops asper and Crotalus durissus. It was approved by the FDA in 2015 for treatment of North American rattlesnake envenomation but not for Agkistrodon envenomation. Published data regarding the efficacy and safety of Anavip in treating Agkistrodon envenomations is limited. We present a case of a patient treated with Anavip after confirmed Agkistrodon laticinctus envenomation. CASE DETAILS A 77 year-old man was bitten on his fifth finger by a captive A. laticinctus. He was taken to a local emergency department where he received a 10 vial initial dose of F(ab')2AV for pain and swelling and was transferred. At the receiving facility, his pain had improved and his swelling had not progressed. Over the next 30 h, his platelets declined to 132,000/mm3 and he received an additional 4 vials of F(ab')2AV. The remainder of his course was unremarkable with complete recovery by 3 months. DISCUSSION This case provides an additional published datapoint on the use of this F(ab')2AV in the treatment of envenomation by Agkistrodon.
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Affiliation(s)
- B Z Wilson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.,Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
| | - J Larsen
- Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
| | - G Smelski
- Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
| | - S Dudley
- Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
| | - F M Shirazi
- Arizona Poison and Drug Information Center, University of Arizona, Tucson, AZ, USA
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Cocchio C, Johnson J, Clifton S. Review of North American pit viper antivenoms. Am J Health Syst Pharm 2020; 77:175-187. [PMID: 31974558 DOI: 10.1093/ajhp/zxz278] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE For the first time in nearly 20 years, 2 antigen-binding fragment (Fab) antivenoms are available to treat patients who incur North American pit viper snakebites: Crotalidae polyvalent immune Fab (ovine), or simply FabAV; and Crotalidae immune F(ab')2 (equine), or simply F(ab')2. Pharmacists are in a key position for the selection, dosing, reconstitution, administration, and monitoring of antivenom therapy; however, they encounter inconsistent exposure and experience with these drugs. Thus, an updated review of the literature is necessary. METHODS The search strategy and selection incorporated both controlled vocabulary terms and keywords to describe concepts relevant to the search. Retrieval was limited to literature published from 1997 to the present in English, Portuguese, or Spanish. RESULTS Given the paucity of available prospective literature, the authors elected to include all prospective evidence to best describe the role of antivenom. For the primary literature review, manuscripts were excluded if they were observational studies, conference abstracts, narrative or opinion articles, letters to the editor, or in-progress studies. CONCLUSION While there is limited evidence-based guidance on the superiority of F(ab')2 to FabAV, or vice versa, individual and regional considerations should contribute to formulary decisions. Pharmacists must play a role in the development of clinical pathways to ensure appropriate evaluation, supportive care, and antivenom procurement, administration, and monitoring.
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Affiliation(s)
| | - Jami Johnson
- Oklahoma Center for Poison and Drug Information, Oklahoma City, OK, and University of Oklahoma College of Pharmacy, Oklahoma City, OK
| | - Shari Clifton
- Reference & Instructional Services, Robert M. Bird Health Sciences Library, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Mullins ME, Freeman WE. Thromboelastometry (ROTEM) and thromboelastography (TEG) in copperhead snakebites: a case series. Clin Toxicol (Phila) 2020; 58:931-934. [DOI: 10.1080/15563650.2020.1713332] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Michael E. Mullins
- Section of Medical Toxicology, Division of Emergency Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - William E. Freeman
- Section of Medical Toxicology, Division of Emergency Medicine, Washington University School of Medicine, Saint Louis, MO, USA
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Freiermuth CE, Lavonas EJ, Anderson VE, Kleinschmidt KC, Sharma K, Rapp-Olsson M, Gerardo C. Antivenom Treatment Is Associated with Fewer Patients using Opioids after Copperhead Envenomation. West J Emerg Med 2019; 20:497-505. [PMID: 31123552 PMCID: PMC6526891 DOI: 10.5811/westjem.2019.3.42693] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/29/2019] [Accepted: 03/20/2019] [Indexed: 11/11/2022] Open
Abstract
Introduction Copperhead envenomation causes local tissue destruction, leading people to seek treatment for the pain and swelling. First-line treatment for the pain is opioid medications. There is rising concern that an initial opioid prescription from the emergency department (ED) can lead to long-term addiction. This analysis sought to determine whether use of Fab antivenom (FabAV) for copperhead envenomation affected opioid use. Methods We performed a secondary analysis using data from a randomized clinical trial designed to determine the effect of FabAV on limb injury recovery following mild to moderate copperhead envenomation. Opioid use was a defined secondary outcome in the parent trial. Patients were contacted after discharge, and data were obtained regarding medications used for pain and the patients’ functional status. This analysis describes the proportion of patients in each treatment group reporting opioid use at each time point. It also assesses the interaction between functional status and use of opioids. Results We enrolled 74 patients in the parent trial (45 received FabAV, 29 placebo), of whom 72 were included in this secondary analysis. Thirty-five reported use of any opioids after hospital discharge. A smaller proportion of patients treated with FabAV reported opioid use: 40.9% vs 60.7% of those in the placebo group. The proportion of patients using opioids remained smaller in the FabAV group at each follow-up time point. Controlling for confounders and interactions between variables, the model estimated that the odds ratio of using opioids after hospital discharge among those who received placebo was 5.67 times that of those who received FabAV. Patients who reported higher baseline pain, those with moderate as opposed to mild envenomation, and females were more likely to report opioid use at follow-up. Patients with ongoing limitations to functional status had an increased probability of opioid use, with a stronger association over time. Opioid use corresponded with the trial’s predefined criteria for full recovery, with only two patients reporting opioid use in the 24 hours prior to achieving full limb recovery and no patients in either group reporting opioid use after full limb recovery. Conclusion In this study population, the proportion of patients using opioids for pain related to envenomation was smaller in the FabAV treatment group at all follow-up time points.
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Affiliation(s)
| | - Eric J Lavonas
- Denver Health and Hospital Authority, Rocky Mountain Poison and Drug Center, Denver, Colorado
| | - Victoria E Anderson
- Denver Health and Hospital Authority, Rocky Mountain Poison and Drug Center, Denver, Colorado
| | - Kurt C Kleinschmidt
- University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
| | - Kapil Sharma
- University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
| | - Malin Rapp-Olsson
- Denver Health and Hospital Authority, Rocky Mountain Poison and Drug Center, Denver, Colorado
| | - Charles Gerardo
- Duke University, Division of Emergency Medicine, Durham, North Carolina
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Sartim MA, Cezarette GN, Jacob-Ferreira AL, Frantz FG, Faccioli LH, Sampaio SV. Disseminated intravascular coagulation caused by moojenactivase, a procoagulant snake venom metalloprotease. Int J Biol Macromol 2017; 103:1077-1086. [PMID: 28552727 DOI: 10.1016/j.ijbiomac.2017.05.146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 04/27/2017] [Accepted: 05/18/2017] [Indexed: 02/07/2023]
Abstract
Snake venom toxins that activate coagulation factors are key players in the process of venom-induced coagulopathy, and account for severe clinical manifestations. The present study applies a variety of biochemical, hematological, and histopathological approaches to broadly investigate the intravascular and systemic effects of moojenactivase (MooA), the first described PIIId subclass metalloprotease isolated from Bothrops sp. venom that activates coagulation factors. MooA induced consumption coagulopathy with high toxic potency, characterized by prolongation of prothrombin and activated partial thromboplastin time, consumption of fibrinogen and the plasma coagulation factors X and II, and thrombocytopenia. MooA promoted leukocytosis and expression of the proinflammatory cytokines interleukin-6 and tumor necrosis factor-α, accompanied by tissue factor-dependent procoagulant activity in peripheral blood mononuclear cells. This metalloprotease also caused intravascular hemolysis, elevated plasma levels of creatine kinase-MB, aspartate transaminase, and urea/creatinine, and induced morphopathological alterations in erythrocytes, heart, kidney, and lungs associated with thrombosis and hemorrhage. Diagnosis of MooA-induced disseminated intravascular coagulation represents an important approach to better understand the pathophysiology of Bothrops envenomation and develop novel therapeutic strategies targeting hemostatic disturbances.
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Affiliation(s)
- Marco A Sartim
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Universidade de São Paulo, Ribeirão Preto, SP, 14040-903, Brazil
| | - Gabriel N Cezarette
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Universidade de São Paulo, Ribeirão Preto, SP, 14040-903, Brazil
| | - Anna L Jacob-Ferreira
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Universidade de São Paulo, Ribeirão Preto, SP, 14040-903, Brazil
| | - Fabiani G Frantz
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Universidade de São Paulo, Ribeirão Preto, SP, 14040-903, Brazil
| | - Lucia H Faccioli
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Universidade de São Paulo, Ribeirão Preto, SP, 14040-903, Brazil
| | - Suely V Sampaio
- Departamento de Análises Clínicas, Toxicológicas e Bromatológicas, Universidade de São Paulo, Ribeirão Preto, SP, 14040-903, Brazil.
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Gerardo CJ, Vissoci JRN, Brown MWJ, Bush SP. Coagulation parameters in copperhead compared to other Crotalinae envenomation: secondary analysis of the F(ab') 2 versus Fab antivenom trial. Clin Toxicol (Phila) 2016; 55:109-114. [PMID: 27806644 DOI: 10.1080/15563650.2016.1250275] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONTEXT Coagulation derangements in copperhead envenomation are considered less severe than other crotaline envenomations, resulting in recommendations to limit both coagulation testing and antivenom treatment. A prospective, blinded, multicenter, randomized clinical trial comparing the effectiveness of F(ab')2 versus Fab antivenom in crotaline envenomation patients was completed in 2011. We determined the difference between coagulation parameters in copperhead compared to other crotaline envenomations. METHODS We performed a post hoc analysis comparing the coagulation parameters (platelets and fibrinogen) prospectively obtained in the aforementioned trial. All the patients received antivenom in one of three treatment arms [F(ab')2 with maintenance, F(ab')2 with placebo maintenance, or Fab with maintenance]. Coagulation parameters were measured at pretreatment baseline, during acute hospitalization, day 5, day 8, and day 15 post-envenomation. Mean platelet count and fibrinogen levels for the copperhead and other crotaline groups were compared. The platelet and fibrinogen point estimates with distribution are presented graphically over time. RESULTS 122 patients were enrolled in the study. There were 22 patients with copperhead envenomation, 93 with other crotaline envenomations, and 7 that could not be definitively determined. The mean age was 42 (SD 20) years. There was a minor pretreatment difference in mean baseline platelet count between the copperhead group (246 × 109/L 95% CI 215, 277) compared to other crotaline envenomation patients (184 × 109/L 95% CI 167, 202). There was a modest pretreatment difference in mean fibrinogen level between copperhead patients (345 mg/dL 95% CI 277, 415) and other crotaline patients (261mg/dL 95% CI 241, 281). Pretreatment coagulation parameter means were normal and converged post treatment. CONCLUSION On average, copperhead envenomations have less severe initial coagulation derangements. However, in mild envenomations, differences in laboratory values are minimal and there is substantial variation in individual patients regardless of species. Species alone should not be used to determine the need for laboratory testing or treatment in crotaline snakebite.
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Affiliation(s)
- Charles J Gerardo
- a Division of Emergency Medicine , Duke University , Durham , NC , USA
| | - Joao R Nickenig Vissoci
- a Division of Emergency Medicine , Duke University , Durham , NC , USA.,b Duke Global Health Institute, Duke University , Durham , NC , USA
| | - Michael W J Brown
- c Department of Emergency Medicine , Brody School of Medicine, East Carolina University , Greenville , NC , USA
| | - Sean P Bush
- c Department of Emergency Medicine , Brody School of Medicine, East Carolina University , Greenville , NC , USA
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