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Thanavaro JL. Direct oral anticoagulant drugs for the management of venous thromboembolism. Nurse Pract 2023; 48:27-35. [PMID: 37227313 DOI: 10.1097/01.npr.0000000000000060] [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: 05/26/2023]
Abstract
ABSTRACT Direct oral anticoagulants (DOACs) are effective for both prevention and treatment of venous thromboembolism (VTE) and have favorable safety in comparison with warfarin. Although drug-drug interactions with DOACs are not as frequent as with warfarin, certain drugs can interfere with DOAC metabolism, affect DOAC efficacy, and potentially cause adverse reactions when used in combination with DOACs. The NP must determine which agent is most beneficial for the individual patient with VTE based on a number of factors. A knowledge of periprocedural management of DOACs will assist the NP in providing a smooth transition for patients undergoing minor and major procedures and surgeries.
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Affiliation(s)
- Joanne L Thanavaro
- Joanne L. Thanavaro is a professor of nursing and Associate Dean for Graduate Education at Saint Louis University Trudy Busch Valentine School of Nursing in St. Louis, Mo
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High-Throughput Docking and Molecular Dynamics Simulations towards the Identification of Potential Inhibitors against Human Coagulation Factor XIIa. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2020:2852051. [PMID: 32549905 PMCID: PMC7261338 DOI: 10.1155/2020/2852051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 03/22/2020] [Accepted: 04/07/2020] [Indexed: 11/17/2022]
Abstract
Human coagulation factor XIIa (FXIIa) is a trypsin-like serine protease that is involved in pathologic thrombosis. As a potential target for designing safe anticoagulants, FXIIa has received a great deal of interest in recent years. In the present study, we employed virtual high-throughput screening of 500,064 compounds within Enamine database to acquire the most potential inhibitors of FXIIa. Subsequently, 18 compounds with significant binding energy (from -65.195 to -15.726 kcal/mol) were selected, and their ADMET properties were predicted to select representative inhibitors. Three compounds (Z1225120358, Z432246974, and Z146790068) exhibited excellent binding affinity and druggability. MD simulation for FXIIa-ligand complexes was carried out to reveal the stability and inhibition mechanism of these three compounds. Through the inhibition of activated factor XIIa assay, we tested the activity of five compounds Z1225120358, Z432246974, Z45287215, Z30974175, and Z146790068, with pIC50 values of 9.3∗10−7, 3.0∗10−5, 7.8∗10−7, 8.7∗10−7, and 1.3∗10−6 M, respectively; the AMDET properties of Z45287215 and Z30974175 show not well but have better inhibition activity. We also found that compounds Z1225120358, Z45287215, Z30974175, and Z146790068 could be more inhibition of FXIIa than Z432246974. Collectively, compounds Z1225120358, Z45287215, Z30974175, and Z146790068 were anticipated to be promising drug candidates for inhibition of FXIIa.
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Periprocedural Anticoagulation and Antiplatelet Medications Management for Interventional Radiology Procedures. CURRENT RADIOLOGY REPORTS 2021. [DOI: 10.1007/s40134-021-00380-8] [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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Dabigatran mitigates cisplatin-mediated nephrotoxicity through down regulation of thrombin pathway. J Adv Res 2021; 31:127-136. [PMID: 34194837 PMCID: PMC8240102 DOI: 10.1016/j.jare.2020.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 12/19/2020] [Accepted: 12/26/2020] [Indexed: 12/20/2022] Open
Abstract
Introduction Cisplatin (CDDP) nephrotoxicity is one of the most significant complications limiting its use in cancer therapy. Objectives This study investigated the pivotal role played by thrombin in CDDP-mediated nephrotoxicity. This work also aimed to clarify the possible preventive effect of Dabigatran (Dab), a direct thrombin inhibitor, on CDDP nephrotoxicity. Methods Animals were grouped as follow; normal control group, CDDP nephrotoxicity group, CDDP + Dab 15, and CDDP + Dab 25 groups. Four days following CDDP administration, blood and urine samples were collected to evaluate renal function. Moreover, tissue samples were collected from the kidney to determine apoptosis markers, oxidative stress and histopathological evaluation. An immunofluorescence analysis of tissue factor (TF), thrombin, protease-activated receptor-2 (PAR2), fibrin, pERK1/2 and P53 proteins expression was also performed. Results Thrombin, pERK, cleaved caspase-3, and oxidative stress markers were significantly elevated in CDDP-treated group. However, pretreatment of animals with either low or high doses of Dab significantly improved kidney function and decreased oxidative stress and apoptotic markers. Conclusion We conclude that thrombin is an important factor in the pathogenesis of CDDP kidney toxicity via activation of ERK1/2, P53 and caspase-3 pathway, which can be effectively blocked by Dab.
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Key Words
- BUN, Blood urea nitrogen
- CDDP, Cisplatin
- Cisplatin
- Cr, creatinine
- Crcl, Creatinine clerance
- Dab, Dabigatran
- Dabigatran
- FXa, activated form of Factor X
- GSH, Reduced Glutathion
- H&E, Hematoxylin–Eosin
- INR, International normalized ratio
- KIM-1, kidney injury molecule-1
- PAR, protease-activated receptor
- PAR2
- Pt, Prothrombin time
- Ptt, Partial thromboplastin time
- ROS, Reactive oxygen species
- SOD, Superoxide dismutase
- TF, Tissue factor
- Thrombin
- pERK1/2
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Sun X, Ze B, Zhang LJ, BaiMa YZ, Zuo W, Zhao B, GeSang LB. Hemorrhage Risk Profiles among Different Antithrombotic Regimens: Evidence from a Real-World Analysis of Postmarketing Surveillance Data. Cardiovasc Drugs Ther 2020; 36:103-112. [PMID: 33226545 DOI: 10.1007/s10557-020-07110-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although the use of direct oral anticoagulants (DOACs) has been reported in patients with atrial fibrillation (AF), there is currently no consensus on the occurrence or characteristics of the hemorrhage risk in different antithrombotic regimens. METHODS Disproportionality and Bayesian analyses were performed in mining data of suspected hemorrhagic events after antithrombotic drug use from the FDA Adverse Event Reporting System (FAERS) from January 2004 to September 2019. The time to onset and fatality rate of hemorrhage following different antithrombotic regimens were also compared. RESULTS A total of 84,998 reports of hemorrhage-related adverse events with the use of antithrombotic drugs were identified. The patients included were mostly from the Americas (80.87%) and Europe (13.22%), with most data submitted by nonhealthcare professionals. Among the seven antithrombotic drug monotherapies, betrixaban had the highest association with hemorrhage based on the highest reporting odds ratio (ROR, 829.95; 95% CI = 113.61-6063.15), proportional reporting ratio (PRR, 24.68, χ2 = 804.24), and multi-item gamma Poisson shrinker (MGPS, 24.68, 95% one-sided CI = 4.67). The combination therapies of clopidogrel plus new oral anticoagulants had higher RORs, PRRs, and empirical Bayesian geometric means (EBGMs) than the antithrombotic drug monotherapies. Hemorrhage associated with rivaroxaban plus clopidogrel appeared to have an earlier onset (171 days vs 219 days, 95% two-sided CI =68.68-27.34, p < 0.0001) and a lower fatality rate (15.30% vs 17.74%, p<0.05) than that associated with rivaroxaban monotherapy. CONCLUSION This study provides a relevant overview of the hemorrhagic complications/fatalities associated with different antithrombotic regimens in their real-world use. Among the combination therapies, clopidogrel plus DOACs were found to have stronger associations with hemorrhage than traditional dual antithrombotic therapies. Rivaroxaban showed a stronger association with hemorrhage than other antithrombotic drug monotherapies, and apixaban monotherapy appeared to have weaker associations with hemorrhage than others.
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Affiliation(s)
- Xue Sun
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China
| | - Bi Ze
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China
| | - Ling-Jun Zhang
- Internal Medicine Branch of Cadiovascular Diseases/Plateau Medicine, People's Hospital of Tibet Autonomous Region, Lhasa, 850000, China
| | - Yang-Zhong BaiMa
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China
| | - Wei Zuo
- Department of Pharmacy, Peking Union Medical College Hospital, No.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Bin Zhao
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China. .,Department of Pharmacy, Peking Union Medical College Hospital, No.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Luo-Bo GeSang
- Internal Medicine Branch of Cadiovascular Diseases/Plateau Medicine, People's Hospital of Tibet Autonomous Region, Lhasa, 850000, China
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Lynch AM, Ruterbories LK, Griffith EH, Hanel RM, Stablein AP, Brooks MB. Evaluation of point-of-care coagulation tests as alternatives to anti-Xa activity for monitoring the anticoagulant effects of rivaroxaban in healthy dogs. J Vet Emerg Crit Care (San Antonio) 2020; 31:18-24. [PMID: 33118685 DOI: 10.1111/vec.13011] [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] [Received: 02/04/2019] [Revised: 05/03/2019] [Accepted: 05/10/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate a panel of coagulation assays for their potential utility in rivaroxaban monitoring as alternatives to the rivaroxaban-specific anti-Xa activity (RIVA). DESIGN Prospective experimental study. SETTING University research laboratory. ANIMALS Five healthy neutered male Beagles. INTERVENTIONS Dogs were administered a median dose of 1.8 mg/kg rivaroxaban (range, 1.6-1.8 mg/kg) orally once daily for 2 consecutive days as part of a pharmacodynamic study. Blood was collected from a preplaced jugular catheter at time points relative to their rivaroxaban administration (0, 2, 4, 8, 24, 36, and 48 h) for measurement of RIVA, prothrombin time (PT), activated partial thromboplastin time, RapidTEG, and thrombin generation variables. MEASUREMENTS AND MAIN RESULTS One hundred forty data points were available for analysis. There was poor correlation between RIVA and RapidTEG variables: R time (R) (min) (r = 0.554, P < 0.0001), K time (K) (min) (r = -0.204, P = 0.016), alpha angle (degrees) (r = 0.152, P = 0.073), Maximum amplitude (MA) (mm) (r = 0.106, P = 0.215), and G value (G) (dynes/s) (r = 0.108, P = 0.205). A good correlation was noted between thrombin generation variables and RIVA: lag time (min) (r = 0.827, P < 0.0001), peak (nM) (r = -0.752, P < 0.0001), and endogenous thrombin potential (nM·min) (r = -0.762, P < 0.0001). There was an excellent correlation between PT and RIVA (r = 0.915, P < 0.0001) and a good correlation between activated partial thromboplastin time and RIVA (r = 0.772, P < 0 .0001). CONCLUSIONS Of all the coagulation tests investigated, the PT correlated best with RIVA. There is potential for PT being a convenient second-line monitoring option in dogs receiving rivaroxaban, but further work is necessary to validate other PT assays. Thromboelastography performed with strong activators correlated poorly with anti-Xa activity.
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Affiliation(s)
- Alex M Lynch
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Laura K Ruterbories
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina
| | - Emily H Griffith
- Department of Statistics, North Carolina State University, Raleigh, North Carolina
| | | | - Alyssa P Stablein
- Comparative Coagulation Section, College of Veterinary Medicine, Cornell University, Ithaca, New York
| | - Marjory B Brooks
- Comparative Coagulation Section, College of Veterinary Medicine, Cornell University, Ithaca, New York
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Lynch AM, Ruterbories LK, Griffith E, Hanel RM, Stablein AP, Brooks MB. The influence of feeding and gastroprotectant medications on the Factor Xa inhibitory activity of orally administered rivaroxaban in normal dogs. J Vet Emerg Crit Care (San Antonio) 2020; 31:59-65. [PMID: 33107158 DOI: 10.1111/vec.13019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/21/2019] [Accepted: 04/23/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Rivaroxaban is a new anticoagulant option for dogs, yet its reported oral bioavailability is as low as 60%. The objective of this study was to examine the influence of feeding and gastroprotectant medications on the bioactivity (anti-Xa activity) of rivaroxaban in healthy dogs. DESIGN Prospective experimental study. SETTING University research laboratory. ANIMALS Five healthy neutered male purpose-bred Beagles. INTERVENTIONS Dogs were administered a median dose of 1.8 mg/kg rivaroxaban (range, 1.6-1.8 mg/kg) orally once daily for 2 consecutive days with either (1) no food, (2) food, (3) sucralfate 30 minutes before rivaroxaban, or (4) omeprazole at the same time as rivaroxaban. Blood was collected from preplaced jugular catheters immediately before and at 6 time points after rivaroxaban administration (2, 4, 8, 24, 36, and 48 hours). A rivaroxaban calibrated anti-Xa activity assay (RIVA) was used to monitor anticoagulant effect. MEASUREMENTS AND MAIN RESULTS Rivaroxaban administration resulted in significant increases in RIVA (P = 0.02), with peak activities occurring 2 to 4 hours after dosingduring each study arm. No feeding was associated with significantly higher RIVA at the 36-hour time point compared to all other treatment arms (P < 0.0001), and feeding resulted in high RIVA at the 48-hour time point compared with sucralfate administration (P = 0.003). No significant changes in RIVA were otherwise identified with respect to feeding or gastroprotectant administration (P = 0.2). CONCLUSIONS AND CLINICAL IMPORTANCE Although administration without food demonstrated an apparent increase in RIVA 36 hours after drug administration, clinically relevant differences among treatment groups were not identified in combined analyses of time points. Based on these results, dogs treated with rivaroxaban do not require special modification of feeding practices or gastroprotectant drug administration.
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Affiliation(s)
- Alex M Lynch
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - Laura K Ruterbories
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - Emily Griffith
- Department of Statistics, North Carolina State University, Raleigh, NC
| | | | - Alyssa P Stablein
- Comparative Coagulation Section, College of Veterinary Medicine, Cornell University, Ithaca, NY
| | - Marjory B Brooks
- Comparative Coagulation Section, College of Veterinary Medicine, Cornell University, Ithaca, NY
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The blood compatibility challenge. Part 1: Blood-contacting medical devices: The scope of the problem. Acta Biomater 2019; 94:2-10. [PMID: 31226480 DOI: 10.1016/j.actbio.2019.06.021] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 02/07/2023]
Abstract
Blood-contacting medical devices are an integral part of modern medicine. Such devices may be used for only a few hours or may be implanted for life. Despite advances in biomaterial science, clotting on medical devices remains a common problem. Systemic administration of antiplatelet drugs or anticoagulants is often needed to reduce the risk of clotting. Although effective, such therapy increases the risk of bleeding, which can be fatal. This chapter (a) describes some of the commonly used blood-contacting devices and their potential complications, (b) provides an overview of the mechanisms that drive device-associated clotting, and (c) reviews the strategies employed to attenuate clotting on blood-contacting medical devices. STATEMENT OF SIGNIFICANCE: This paper is part 1 of a series of 4 reviews discussing the problem of biomaterial associated thrombogenicity. The objective was to highlight features of broad agreement and provide commentary on those aspects of the problem that were subject to dispute. We hope that future investigators will update these reviews as new scholarship resolves the uncertainties of today.
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Salifu EY, Agoni C, Olotu FA, Dokurugu YM, Soliman MES. Deciphering the canonical blockade of activated Hageman factor (FXIIa) by benzamidine in the coagulation cascade: A thorough dynamical perspective. Chem Biol Drug Des 2019; 94:1905-1918. [PMID: 31148409 DOI: 10.1111/cbdd.13573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/09/2019] [Accepted: 05/15/2019] [Indexed: 12/11/2022]
Abstract
The experimental inhibitory potency of benzamidine (BEN) paved way for further design and development of inhibitors that target β-FXIIa. Structural dynamics of the loops and catalytic residues that encompass the binding pocket of β-FXIIa and all serine proteases are crucial to their overall activity. Employing molecular dynamics and post-MD analysis, this study sorts to unravel the structural and molecular events that accompany the inhibitory activity of BEN on human β-FXIIa upon selective non-covalent binding. Analysis of conformational dynamics of crucial loops revealed prominent alterations of the original conformational posture of FXIIa, evidenced by increased flexibility, decreased compactness, and an increased exposure to solvent upon binding of BEN, which could have in turn interfered with the essential roles of these loops in enhancing their procoagulation interactions with biological substrates and cofactors, altogether resulting in the consequential inactivation of FXIIa. A sustained interaction of the catalytic triad residues and key residues of the autolysis loop impeded their roles in catalysis which equally enhanced the inhibitory potency of BEN toward β-FXIIa evidenced by a favorable binding. Findings provide essential structural and molecular insights that could facilitate the structure-based design of novel antithrombotic compounds with enhanced inhibitory activities and low therapeutic risk.
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Affiliation(s)
- Elliasu Y Salifu
- Molecular Bio-computation and Drug Design Laboratory, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Clement Agoni
- Molecular Bio-computation and Drug Design Laboratory, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Fisayo A Olotu
- Molecular Bio-computation and Drug Design Laboratory, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Yussif M Dokurugu
- College of Pharmacy and Pharmaceutical Sciences, Florida Agricultural and Mechanical University, FAMU, Tallahassee, FL, USA
| | - Mahmoud E S Soliman
- Molecular Bio-computation and Drug Design Laboratory, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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Abstract
Activated factor XIIa (FXIIa) is a serine protease that has received a great deal of interest in recent years as a potential target for the development of new antithrombotics. Despite the strong interest in obtaining structural information, only the structure of the FXIIa catalytic domain in its zymogen conformation is available. In this work, reproducible experimental conditions found for the crystallization of human plasma β-FXIIa and crystal growth optimization have led to determination of the first structure of the active form of the enzyme. Two crystal structures of human plasma β-FXIIa complexed with small molecule inhibitors are presented herein. The first is the noncovalent inhibitor benzamidine. The second is an aminoisoquinoline containing a boronic acid-reactive group that targets the catalytic serine. Both benzamidine and the aminoisoquinoline bind in a canonical fashion typical of synthetic serine protease inhibitors, and the protease domain adopts a typical chymotrypsin-like serine protease active conformation. This novel structural data explains the basis of the FXII activation, provides insights into the enzymatic properties of β-FXIIa, and is a great aid toward the further design of protease inhibitors for human FXIIa.
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Oliveira D, Alvarez-Flores M, Lopes A, Chudzinski-Tavassi A. Functional characterisation of Vizottin, the first factor Xa inhibitor purified from the leech Haementeria vizottoi. Thromb Haemost 2017; 108:570-8. [DOI: 10.1160/th12-04-0235] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Accepted: 05/17/2012] [Indexed: 11/05/2022]
Abstract
SummaryThe strategic position of factor Xa (FXa) in blood coagulation makes it a compelling target for the development of new anticoagulants. Bloodsucking animals have in their salivary glands mixtures of anticoagulants, which could be used for designing novel antithrombotic compounds. Herein, we describe Vizottin, the first FXa inhibitor from the salivary complex of the leech Haementeria vizottoi. Vizottin was purified by gel filtration and reverse-phase chromatography, and shown to have anticoagulant effects in human plasma, prolonging the recalcification time in a dose-dependent manner (IC50 40 nM). Vizottin induced blood incoagulability in FX-deficient plasma, whereas in normal and reconstituted plasma, Vizottin doubled the prothrombin time at 160 nM. This peptide competitively inhibited human FXa (Ki 2 nM) like FXa inhibitors from other leeches, albeit via a distinct mechanism of action. At high concentrations, vizottin inhibited the amidolytic activity of factor VIIa/tissue factor (IC50 96.4 nM). Vizottin inhibited FXa in the prothrombinase complex and Gla-domainless FXa. Moreover, vizottin did not interfere with FX activation induced by RVV-X, a known enzyme that requires the Gla-domain of FX for activation. Competition experiments in the presence of FXa and GGACK-FXa (active site blocked) demonstrated that the inhibition of FXa by vizottin is through binding to the active site rather than an exosite. This novel inhibitor appears to exert its inhibitory effects through direct binding to the active site of FXa in a time-dependent manner, but not involving a tight-binding model. In this context, vizottin is a promising model for designing novel anticoagulants for the treatment of thrombotic diseases.
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Husted S, Wallentin L, Andreotti F, Arnesen H, Bachmann F, Baigent C, Huber K, Jespersen J, Kristensen S, Lip GYH, Morais J, Rasmussen L, Siegbahn A, Verheugt FWA, Weitz JI, De Caterina R. General mechanisms of coagulation and targets of anticoagulants (Section I). Thromb Haemost 2017; 109:569-79. [PMID: 23447024 DOI: 10.1160/th12-10-0772] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 12/25/2012] [Indexed: 01/02/2023]
Abstract
SummaryContrary to previous models based on plasma, coagulation processes are currently believed to be mostly cell surface-based, including three overlapping phases: initiation, when tissue factor-expressing cells and microparticles are exposed to plasma; amplification, whereby small amounts of thrombin induce platelet activation and aggregation, and promote activation of factors (F)V, FVIII and FXI on platelet surfaces; and propagation, in which the Xase (tenase) and prothrombinase complexes are formed, producing a burst of thrombin and the cleavage of fibrinogen to fibrin. Thrombin exerts a number of additional biological actions, including platelet activation, amplification and self-inhibition of coagulation, clot stabilisation and anti-fibrinolysis, in processes occurring in the proximity of vessel injury, tightly regulated by a series of inhibitory mechanisms. ″Classical″ anticoagulants, including heparin and vitamin K antagonists, typically target multiple coagulation steps. A number of new anticoagulants, already developed or under development, target specific steps in the process, inhibiting a single coagulation factor or mimicking natural coagulation inhibitors.
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Husted S, Wallentin L, Andreotti F, Arnesen H, Bachmann F, Baigent C, Huber K, Jespersen J, Kristensen S, Lip GYH, Morais J, Rasmussen L, Siegbahn A, Verheugt FWA, Weitz JI, De Caterina R. Parenteral anticoagulants in heart disease: Current status and perspectives (Section II). Thromb Haemost 2017; 109:769-86. [DOI: 10.1160/th12-06-0403] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 12/25/2012] [Indexed: 11/05/2022]
Abstract
SummaryAnticoagulants are a mainstay of cardiovascular therapy, and parenteral anticoagulants have widespread use in cardiology, especially in acute situations. Parenteral anticoagulants include unfractionated heparin, low-molecular-weight heparins, the synthetic pentasaccharides fondaparinux, idraparinux and idrabiotaparinux, and parenteral direct thrombin inhibitors. The several shortcomings of unfractionated heparin and of low-molecular-weight heparins have prompted the development of the other newer agents. Here we review the mechanisms of action, pharmacological properties and side effects of parenteral anticoagulants used in the management of coronary heart disease treated with or without percutaneous coronary interventions, cardioversion for atrial fibrillation, and prosthetic heart valves and valve repair. Using an evidence-based approach, we describe the results of completed clinical trials, highlight ongoing research with currently available agents, and recommend therapeutic options for specific heart diseases.
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Nehaj F, Sokol J, Ivankova J, Mokan M, Kovar F, Stasko J, Mokan M. First Evidence: TRAP-Induced Platelet Aggregation Is Reduced in Patients Receiving Xabans. Clin Appl Thromb Hemost 2017; 24:914-919. [PMID: 29050502 PMCID: PMC6714725 DOI: 10.1177/1076029617734310] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The availability of direct oral anticoagulants has caused a paradigm shift in the management of thrombosis. Rivaroxaban and apixaban are 2 direct oral anticoagulants whose target specificity is activated factor X (FXa). However, it is still not fully understood if and how xabans impact platelet function. This observational study aimed to assess the in vitro platelet function in patients with atrial fibrillation receiving xabans. This was a single-center study quantifying platelet aggregation in 41 patients treated with apixaban or rivaroxaban by light transmission aggregometry. The thrombin receptor activating peptide (TRAP)-induced platelet aggregation was significantly lower 2 hours after taking rivaroxaban or apixaban compared to baseline value (56.15% [8.53%] vs 29.51% [12.9%]; P = .000). Moreover, concomitant use of angiotensin-converting enzyme blockers, proton pump inhibitors, and statins reduces the efficiency of xabans. The TRAP-induced platelet aggregation was reduced in patients with cardiovascular disease 2 hours after receiving xabans.
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Affiliation(s)
- Frantisek Nehaj
- 1 First Department of Internal Medicine, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Juraj Sokol
- 2 Department of Haematology and Transfusion Medicine, National Centre of Haemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Jela Ivankova
- 2 Department of Haematology and Transfusion Medicine, National Centre of Haemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Michal Mokan
- 1 First Department of Internal Medicine, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Frantisek Kovar
- 1 First Department of Internal Medicine, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Jan Stasko
- 2 Department of Haematology and Transfusion Medicine, National Centre of Haemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Marian Mokan
- 1 First Department of Internal Medicine, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
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Adcock DM, Gosselin RC. The danger of relying on the APTT and PT in patients on DOAC therapy, a potential patient safety issue. Int J Lab Hematol 2017; 39 Suppl 1:37-40. [PMID: 28447415 DOI: 10.1111/ijlh.12658] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 01/23/2017] [Indexed: 12/18/2022]
Abstract
Prolongation of the activated partial thromboplastin time (APTT) and prothrombin time/international normalized ratio (PT/INR) correlates poorly with plasma concentrations of direct oral anticoagulant agents (DOACS) including direct thrombin and direct Xa inhibitors. It has been repeatedly demonstrated that patients can have normal APTT and PT/INR with a therapeutic plasma concentration of a DOAC. Clinicians can no longer rely on a normal APTT and PT to determine that an anticoagulated patient is safe to undergo an invasive procedure. Laboratory scientists need to play a key and active role in educating clinicians about the limitations of the APTT and PT in patients on DOAC prophylaxis or therapy.
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Affiliation(s)
- D M Adcock
- Colorado Coagulation, Laboratory Corporation of America® Holdings, Englewood, CO, USA
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Conversy B, Blais MC, Dunn M, Gara-Boivin C, Del Castillo JRE. Anticoagulant activity of oral rivaroxaban in healthy dogs. Vet J 2017; 223:5-11. [PMID: 28671072 DOI: 10.1016/j.tvjl.2017.03.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 03/17/2017] [Accepted: 03/28/2017] [Indexed: 01/06/2023]
Abstract
Rivaroxaban is an oral, direct factor Xa inhibitor used in human thrombotic disorders. In view of the in vitro concentration dependent anticoagulant effects of rivaroxaban in dogs, the time course of its anticoagulant effects was characterized in healthy dogs. Twenty-four healthy Beagles were randomized into three groups (n = 8 per group) and received orally either a placebo or 20 mg rivaroxaban once or twice at an 8 h interval. Fifteen blood samples were collected over a 30 h period, and blindly assayed for prothrombin time (PT), activated partial thromboplastin time (aPTT), tissue factor induced thrombin generation (TG) and anti-factor Xa activity. Thromboelastography (TEG) was evaluated at 0, 1, 4, 8 and 24 h. Peak/baseline anticoagulant effect ratios were analyzed with generalized linear models using β distributions and times to return to baseline with survival analyses (α = 0.05). Peak/baseline anticoagulant effect ratios of PT, aPTT, anti-factor Xa activity, TG and R (TEG) differed significantly between placebo and both rivaroxaban groups (P <0.0001). The peak anticoagulant effect of rivaroxaban occurred 1.5 to 2 h after dosing. The median return to baseline occurred significantly sooner (P <0.01) with 20 mg rivaroxaban administered once (7.9-18.7 h) versus twice (17.5-26.8 h). The inter-individual variability differed amongst assays, but overall was moderate to large. No adverse effects were recorded. Twice oral administration of 2 mg/kg rivaroxaban at an 8 h interval maintained 24 h anticoagulant activity, but larger studies are needed to establish guidelines for the use of rivaroxaban in dogs.
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Affiliation(s)
- B Conversy
- Department of Clinical Sciences, Faculté de Médecine Métérinaire, Université de Montréal, C.P. 5000, Saint-Hyacinthe, Québec J2S 7C6, Canada.
| | - M C Blais
- Department of Clinical Sciences, Faculté de Médecine Métérinaire, Université de Montréal, C.P. 5000, Saint-Hyacinthe, Québec J2S 7C6, Canada
| | - M Dunn
- Department of Clinical Sciences, Faculté de Médecine Métérinaire, Université de Montréal, C.P. 5000, Saint-Hyacinthe, Québec J2S 7C6, Canada
| | - C Gara-Boivin
- Department of Pathology and Microbiology, Faculté de Médecine Vétérinaire, Université de Montréal, C.P. 5000, Saint-Hyacinthe, Québec J2S 7C6, Canada
| | - J R E Del Castillo
- GREPAQ - Department of Veterinary Biomedecine, Faculté de Médecine Vétérinaire, Université de Montréal, C.P. 5000, Saint-Hyacinthe, Québec J2S 7C6, Canada
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Radulović ŽM, Mulenga A. Heparan sulfate/heparin glycosaminoglycan binding alters inhibitory profile and enhances anticoagulant function of conserved Amblyomma americanum tick saliva serpin 19. INSECT BIOCHEMISTRY AND MOLECULAR BIOLOGY 2017; 80:1-10. [PMID: 27845251 PMCID: PMC5214524 DOI: 10.1016/j.ibmb.2016.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 10/25/2016] [Accepted: 11/11/2016] [Indexed: 06/06/2023]
Abstract
Some serine protease inhibitor (serpin) regulators of essential life pathways bind glycosaminoglycans (GAGs) to enhance inhibitory functions and achieve physiologically relevant rates. This study demonstrates that highly conserved Amblyomma americanum tick saliva serpin 19 (AAS19), a broad-spectrum inhibitor of hemostasis and inflammation system proteases and anticoagulant, can bind heparan sulfate/heparin (HS)GAGs and that this interaction alters its function. Substrate hydrolysis and unpaired t-test analyses revealed that HSGAG binding caused rAAS19 inhibitory activity to: (i) significantly increase against blood clotting factors (f) IIa (thrombin) and fIXa, (ii) significantly reduce against fXa and fXIIa and (iii) moderate to no effect against trypsin, kallikrein, papain, and plasmin. Stoichiometry of inhibition (SI) analyses show that HSGAG binding improved the rAAS19 inhibitory efficiency against thrombin 2.7-4.3 fold as revealed by SI change from 13.19 in absence of HSGAGs to 4.83-3.04 in their presence. Our data show that HSGAG binding dramatically enhanced rAAS19 anticoagulant function. In the recalcification time assay, rAAS19 pre-incubated with HSGAGs prior to the assay, delayed plasma clotting by an additional 176-457 s above HSGAGs or rAAS19 alone. Our data suggest that formation of the HSGAGs and rAAS19 complex is important for the observed enhanced anticoagulant effect. Delay of plasma clotting was higher when HSGAGs and rAAS19 were co-incubated to allow complex formation prior to blood clotting assay as opposed to no co-incubation. We have discussed our finding with reference to tick feeding physiology and utility of the rAAS19 in blood clotting disorder therapy.
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Affiliation(s)
- Željko M Radulović
- Department of Veterinary Pathobiology, College of Veterinary Medicine & Biomedical Sciences, Texas A&M University, 422 Raymond Stotzer, TAMU 4467, College Station, TX 77843, USA
| | - Albert Mulenga
- Department of Veterinary Pathobiology, College of Veterinary Medicine & Biomedical Sciences, Texas A&M University, 422 Raymond Stotzer, TAMU 4467, College Station, TX 77843, USA.
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Abstract
Thrombosis is a complex process involving multiple pathways. Currently, therapy relies on the combination of two or more antithrombotic drugs, showing that inhibiting more than one target provides benefits in the prevention and treatment of thrombosis. This review focuses on structure-activity relationship studies of molecules possessing multiple actions against thrombosis, namely, dual inhibitors of coagulation, dual inhibitors of coagulation and platelet aggregation, and also dual inhibitors of platelet aggregation. EP217609 has just entered clinical trials, which raise the expectations on the multitarget strategy to prevent or treat thrombosis.
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Lee J, Kim B, Kim TH, Lee SH, Park HD, Chung K, Lee SH, Paek S, Kim EE, Yoon S, Kim A. A Food Effect Study of an Oral Thrombin Inhibitor and Prodrug Approach To Mitigate It. Mol Pharm 2016; 13:1197-205. [PMID: 26886576 DOI: 10.1021/acs.molpharmaceut.5b00637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
LB30870, a new direct thrombin inhibitor, showed 80% reduction in oral bioavailability in fed state. The present study aims to propose trypsin binding as a mechanism for such negative food effect and demonstrate a prodrug approach to mitigate food effect. Effect of food composition on fed state oral bioavailability of LB30870 was studied in dogs. Various prodrugs were synthesized, and their solubility, permeability, and trypsin binding affinity were measured. LB30870 and prodrugs were subject to cocrystallization with trypsin, and the X-ray structures of cocrystals were determined. Food effect was studied in dogs for selected prodrugs. Protein or lipid meal appeared to affect oral bioavailability of LB30870 in dogs more than carbohydrate meal. Blocking both carboxyl and amidine groups of LB30870 resulted in trypsin Ki values orders of magnitude higher than that of LB30870. Prodrugs belonged to either Biopharmaceutical Classification System I, II, or III. X-ray crystallography revealed that prodrugs did not bind to trypsin, but instead their hydrolysis product at the amidine blocking group formed cocrystal with trypsin. A prodrug with significantly less food effect than LB30870 was identified. Binding of prodrugs to food components such as dietary fiber appeared to counteract the positive effect brought with the prodrug approach. Further formulation research is warranted to enhance the oral bioavailability of prodrugs. In conclusion, this study is the first to demonstrate that the negative food effect of LB30870 can be attributed to trypsin binding. Trypsin binding study is proposed as a screening tool during lead optimization to minimize food effect.
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Affiliation(s)
- Jihye Lee
- College of Pharmacy, CHA University , 521 CHA Bio Complex, 335 Pangyo-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 13488, Korea
| | - Bongchan Kim
- LG Life Sciences, R&D Center ,188, Munji-ro, Yuseong-gu, Daejeon 34122, Korea
| | - Tae Hun Kim
- LG Life Sciences, R&D Center ,188, Munji-ro, Yuseong-gu, Daejeon 34122, Korea
| | - Sun Hwa Lee
- LG Life Sciences, R&D Center ,188, Munji-ro, Yuseong-gu, Daejeon 34122, Korea
| | - Hee Dong Park
- LG Life Sciences, R&D Center ,188, Munji-ro, Yuseong-gu, Daejeon 34122, Korea
| | - Kyungha Chung
- LG Life Sciences, R&D Center ,188, Munji-ro, Yuseong-gu, Daejeon 34122, Korea
| | - Sung-Hack Lee
- LG Life Sciences, R&D Center ,188, Munji-ro, Yuseong-gu, Daejeon 34122, Korea
| | - Seungyup Paek
- LG Life Sciences, R&D Center ,188, Munji-ro, Yuseong-gu, Daejeon 34122, Korea
| | - Eunice EunKyeong Kim
- Korea Institute of Science and Technology, Hwarangno 14-gil 5, Seongbuk-gu, Seoul 02792, Korea
| | - SukKyoon Yoon
- New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation , 41061 Daegu, Korea
| | - Aeri Kim
- College of Pharmacy, CHA University , 521 CHA Bio Complex, 335 Pangyo-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 13488, Korea
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Schwarb H, Tsakiris DA. New Direct Oral Anticoagulants (DOAC) and Their Use Today. Dent J (Basel) 2016; 4:dj4010005. [PMID: 29563447 PMCID: PMC5851208 DOI: 10.3390/dj4010005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 03/05/2016] [Accepted: 03/09/2016] [Indexed: 12/19/2022] Open
Abstract
The ideal anticoagulant is oral, has a wide therapeutic range, predictable pharmacokinetics and pharmacodynamics, a rapid onset of action, an available antidote, minimal side effects and minimal interactions with other drugs or food. With the development of the novel direct oral anticoagulants (DOAC), we now have an alternative to the traditional vitamin K antagonists (VKA) for the prevention and treatment of thrombosis. DOACs have limited monitoring requirements and very predictable pharmacokinetic profiles. They were shown to be non-inferior or superior to VKA in the prophylaxis or treatment of thromboembolic events. Particularly in terms of safety they were associated with less major bleeding, including intracranial bleeding, thus providing a superior benefit for the prevention of stroke in patients with atrial fibrillation. Despite these advantages, there are remaining limitations with DOACs: their dependence on renal and hepatic function for clearance and the lack of an approved reversal agent, whereas such antidotes are successively being made available. DOACs do not need regular monitoring to assess the treatment effect but, on the other hand, they interact with other drugs and interfere with functional coagulation assays. From a practical point of view, the properties of oral administration, simple dosing without monitoring, a short half-life allowing for the possibility of uncomplicated switching or bridging, and proven safety overwhelm the disadvantages, making them an attractive option for short- or long-term anticoagulation.
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Affiliation(s)
- Heike Schwarb
- Heike Schwarb, Diagnostic Hematology, University Hospital Basel, CH-4031 Basel, Switzerland.
| | - Dimitrios A Tsakiris
- Heike Schwarb, Diagnostic Hematology, University Hospital Basel, CH-4031 Basel, Switzerland.
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De Caterina R, Husted S, Wallentin L, Andreotti F, Arnesen H, Bachmann F, Baigent C, Collet JP, Halvorsen S, Huber K, Jespersen J, Kristensen SD, Lip GYH, Morais J, Rasmussen LH, Ricci F, Sibbing D, Siegbahn A, Storey RF, Ten Berg J, Verheugt FWA, Weitz JI. Oral anticoagulants in coronary heart disease (Section IV). Position paper of the ESC Working Group on Thrombosis - Task Force on Anticoagulants in Heart Disease. Thromb Haemost 2016; 115:685-711. [PMID: 26952877 DOI: 10.1160/th15-09-0703] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 01/29/2016] [Indexed: 11/05/2022]
Abstract
Until recently, vitamin K antagonists (VKAs) were the only available oral anticoagulants evaluated for long-term treatment of patients with coronary heart disease (CHD), particularly after an acute coronary syndrome (ACS). Despite efficacy in this setting, VKAs are rarely used because they are cumbersome to administer. Instead, the more readily manageable antiplatelet agents are the mainstay of prevention in ACS patients. This situation has the potential to change with the introduction of non-VKA oral anticoagulants (NOACs), which are easier to administer than VKAs because they can be given in fixed doses without routine coagulation monitoring. The NOACs include dabigatran, which inhibits thrombin, and apixaban, rivaroxaban and edoxaban, which inhibit factor Xa. Apixaban and rivaroxaban were evaluated in phase III trials for prevention of recurrent ischaemia in ACS patients, most of whom were also receiving dual antiplatelet therapy with aspirin and clopidogrel. Although at the doses tested rivaroxaban was effective and apixaban was not, both agents increased major bleeding. The role for the NOACs in ACS management, although promising, is therefore complicated, because it is uncertain how they compare with newer antiplatelet agents, such as prasugrel, ticagrelor or vorapaxar, and because their safety in combination with these other drugs is unknown. Ongoing studies are also now evaluating the use of NOACs in non-valvular atrial fibrillation patients, where their role is established, with coexistent ACS or coronary stenting. Focusing on CHD, we review the results of clinical trials with the NOACs and provide a perspective on their future incorporation into clinical practice.
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Affiliation(s)
- Raffaele De Caterina
- Raffaele De Caterina, MD, PhD, Institute of Cardiology, "G. d'Annunzio" University - Chieti, Ospedale SS. Annunziata, Via dei Vestini, 66013 Chieti, Italy, E-mail:
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Brekelmans MPA, Middeldorp S, Coppens M. Direct factor Xa inhibitor edoxaban: from bench to clinical practice. Expert Rev Hematol 2015; 8:707-25. [DOI: 10.1586/17474086.2015.1111756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kim J, Lee SH, Boyce M, Warrington S, Cho KH, Yoon SK, Park HD, Kim A. Pharmacokinetics, pharmacodynamics and food effect of LB30870, a novel direct thrombin inhibitor, after single oral doses in healthy men. Xenobiotica 2015; 45:663-71. [PMID: 25673087 DOI: 10.3109/00498254.2015.1010110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
1. The safety, tolerability, pharmacokinetics, pharmacodynamics, and food effect of LB30870, a new selective thrombin inhibitor, were studied in 16 healthy men. 2. A double-blind, placebo-controlled single ascending dose study was done at oral doses of 5, 15, 30, 60, 120, and 240 mg under fasting conditions. An open, randomized, balanced cross-over food effect study was done at 60 mg dose. Plasma and urinary concentrations were measured up to 48 h post-dose. Coagulation and thrombin activity markers were measured at selected time points. 3. Cmax of LB30870 was at 1.3-3.0 h post-dose with a mean apparent terminal half-life (t1/2) of 2.8-4.1 h. AUC after doses above 15 mg appeared greater than dose-proportional. In fed state, AUC showed 80% reduction relative to fasting condition. 4. At doses 60 and 120 mg, peak activated partial thromboplastin time (aPTT) increased by 1.5- and 2-fold, respectively, from baseline. The aPTT and international normalized ratio (INR) were concentration-dependent, with less within-individual variability than ecarin clotting time (ECT), prothrombin time (PT), or thrombin time (TT). 5. Single oral doses of LB30870 up to 240 mg were well tolerated. The food effect must be overcome if LB30870 is to be used as an oral anti-coagulant.
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Affiliation(s)
- John Kim
- Drug Metabolism & Pharmacokinetics, LG Life Sciences , Daejeon , Korea
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Hull RD, Gersh MH. The current landscape of treatment options for venous thromboembolism: a focus on novel oral anticoagulants. Curr Med Res Opin 2015; 31:197-210. [PMID: 25299352 DOI: 10.1185/03007995.2014.975786] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major cause of morbidity, mortality, and healthcare expenditure. Anticoagulant therapy is recommended for at least 3 months in patients with acute VTE to prevent recurrence. Conventional anticoagulants are associated with inherent limitations including route of administration, required monitoring and dose adjustments, potential for food-drug and drug-drug interactions, unpredictable pharmacokinetics and pharmacodynamics, and possible severe adverse events. SCOPE This manuscript reviews the pharmacology of the novel oral anticoagulants (NOACs), and analyzes the differences in phase 3 clinical trial designs, outcomes, and specific patient populations investigated for the treatment of acute and prevention of secondary VTE. METHODS A literature search was performed in PubMed using the key words dabigatran, apixaban, rivaroxaban, edoxaban, and venous thromboembolism in PubMed. The search included all years, English language, and peer-reviewed articles relating to phase 3 clinical trials, subanalyses, and meta-analyses of these NOACs for the treatment of acute VTE and secondary prevention. FINDINGS NOACs have demonstrated comparable efficacy and comparable or superior safety in large, randomized clinical trials in the treatment and prevention of VTE compared with conventional therapy. New oral anticoagulants, including the direct thrombin (dabigatran etexilate) and direct factor Xa inhibitors (rivaroxaban, apixaban, and edoxaban), have advantages over conventional agents such as oral administration at fixed doses, predictable pharmacokinetics and pharmacodynamics, minimal potential for food-drug and drug-drug interactions, and lack of required monitoring. CONCLUSIONS NOACs offer additional oral anticoagulation treatment options for patients with VTE.
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A plasmin-activatable thrombin inhibitor reduces experimental thrombosis and assists experimental thrombolysis in murine models. J Thromb Thrombolysis 2014; 39:443-51. [DOI: 10.1007/s11239-014-1157-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hong X, Shan PR, Huang WJ, Zhu QL, Xiao FY, Li S, Zhou H. Influence of Body Mass Index on the Activated Clotting Time Under Weight-Based Heparin Dose. J Clin Lab Anal 2014; 30:108-13. [PMID: 25425223 DOI: 10.1002/jcla.21823] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 10/22/2014] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Activated clotting time (ACT) has been successfully applied during percutaneous coronary intervention (PCI) to monitor the extent of thrombin inhibition and anti-coagulation from unfractionated heparin (UFH) aiming to reduce the incidence of thrombotic adverse events and hemorrhagic complications. And this investigation was to explore the influence of body mass index (BMI) on ACT in patients received weight-based dose of UFH during PCI treatment. METHODS 78 male patients undergoing coronary angiography or PCI treatment with a mean age of 63.86 ± 6.89 years were enrolled in this study. The patients were statistically divided into four quartiles according to their BMI. The ACT values were recorded as ACT0 , ACT5 , ACT10 , ACT30 and ACT60 , respectively. Taking the preoperative ACT0 as reference, and the differences of the other ACT values with ACT0 was indicated as ΔACTs. ACT values peaked at 5 min in 33.33% of the patients, 10 min in 51.33% of the patients and 30 min in 15.34% of the patients, respectively. RESULTS In addition, significant differences were found in overall maximum post-UFH ACT values among all BMI quartiles. UFH doses per blood volume were significantly different among the BMI quartiles, showing a positive association with BMI quartiles; further evidence revealed that the areas under the ΔACT-time curves increased gradually from quartile I to quartile IV. The proportions of ACT60 > 250 s and ACT60 > 300 s were found to be positively correlated with the increased BMI at 60 min after heparin loading. CONCLUSIONS The results of our study have shown that a standardized dosing nomogram that uses the actual body weight to calculate the heparin doses may result in UFH overdose for patients with higher BMI compared to patients with lower BMI.
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Affiliation(s)
- Xia Hong
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Pei-Ren Shan
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Wei-Jian Huang
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Qian-Li Zhu
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Fang-Yi Xiao
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Sheng Li
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Hao Zhou
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
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Dzeshka MS, Lip GY. Warfarin versus dabigatran etexilate: an assessment of efficacy and safety in patients with atrial fibrillation. Expert Opin Drug Saf 2014; 14:45-62. [PMID: 25341529 DOI: 10.1517/14740338.2015.973847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Oral anticoagulation is the mainstay for stroke and thromboembolic event prevention in patients with atrial fibrillation (AF). Given limitations of warfarin therapy, non-vitamin K oral anticoagulants have been developed including direct thrombin inhibitors (i.e., dabigatran etexilate). Dabigatran etexilate has been tested thoroughly in terms of efficacy and safety in clinical trials and studies, involving 'real-world' cohorts. In this review, currently available evidence in patients with non-valvular AF is discussed. AREAS COVERED The pharmacology, efficacy and safety, and current aspects of use of dabigatran etexilate in patients with non-valvular AF are reviewed in a comparative manner to warfarin both for chronic anticoagulation and in different clinical settings. EXPERT OPINION Dabigatran etexilate appeared to have several pharmacokinetic and pharmacodynamic advantages over warfarin, as well as a favorable efficacy and safety profile being at least noninferior and often superior to warfarin in patients with non-valvular AF. The latter was shown in the clinical trials, meta-analyses and studies with 'real-world' data. Currently ongoing trials will expand the body of evidence on warfarin and will aid decision making in currently controversial areas. Important limitations of dabigatran etexilate include contraindications for its use in patients with prosthetic heart valves and end-stage chronic kidney disease.
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Affiliation(s)
- Mikhail S Dzeshka
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital , Birmingham B18 7QH , UK
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Abstract
Anticoagulation for the prevention of stroke is an important aspect of the management of atrial fibrillation. Novel anticoagulants including oral factor Xa inhibitors rivaroxaban and apixaban and the direct thrombin inhibitor dabigatran have emerged as important therapeutic treatment options for prevention of stroke in non-valvular atrial fibrillation. These agents offer practical advantages over traditional vitamin K antagonists, however an understanding of their individual pharmacokinetic and other agent-specific differences is essential for identifying appropriate candidates for therapy, and for selecting the appropriate agent that will be effective and safe. Here, we review the pharmacokinetic process of oral medication use, summarize the newer anticoagulants, their pharmacology, individual pharmacokinetic features, and explore possible explanations for the differences in bleeding outcomes observed in the clinical trials.
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Affiliation(s)
- Tracy A DeWald
- Divisions of Clinical Pharmacology (TAD) and Cardiovascular Medicine (RCB) Duke University Medical Center, Duke Clinical Research Institute (RCB), Durham, NC, USA,
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Structure-function relationships of factor Xa inhibitors: implications for the practicing clinician. J Thromb Thrombolysis 2014; 37:234-41. [PMID: 23996500 DOI: 10.1007/s11239-013-0991-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The recent development and approval of novel oral anticoagulants represents a significant success in the intelligent design of target-specific therapeutics. However, while these agents obviate many of the shortcomings of their predecessor (warfarin), they present novel challenges in pharmacologic management as well. Each was designed to have high oral bioavailability and high affinity for its target molecule, conveying significant anticoagulant effects. Yet, such unique drug-ligand binding, coupled with unfamiliar drug interactions and renal-based clearance, represent challenges to clinical management. The current review describes the development and pharmacokinetic properties of these agents, in the context of their clinical utility and pitfalls.
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Veltkamp R, Horstmann S. Treatment of Intracerebral Hemorrhage Associated with New Oral Anticoagulant Use. Clin Lab Med 2014; 34:587-94. [DOI: 10.1016/j.cll.2014.06.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Gurbel PA, Tantry US. Antiplatelet and Anticoagulant Agents in Heart Failure. JACC-HEART FAILURE 2014; 2:1-14. [DOI: 10.1016/j.jchf.2013.07.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 07/25/2013] [Accepted: 07/25/2013] [Indexed: 01/11/2023]
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Meneyrol J, Follmann M, Lassalle G, Wehner V, Barre G, Rousseaux T, Altenburger JM, Petit F, Bocskei Z, Schreuder H, Alet N, Herault JP, Millet L, Dol F, Florian P, Schaeffer P, Sadoun F, Klieber S, Briot C, Bono F, Herbert JM. 5-Chlorothiophene-2-carboxylic acid [(S)-2-[2-methyl-3-(2-oxopyrrolidin-1-yl)benzenesulfonylamino]-3-(4-methylpiperazin-1-yl)-3-oxopropyl]amide (SAR107375), a selective and potent orally active dual thrombin and factor Xa inhibitor. J Med Chem 2013; 56:9441-56. [PMID: 24175584 DOI: 10.1021/jm4005835] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Compound 15 (SAR107375), a novel potent dual thrombin and factor Xa inhibitor resulted from a rational optimization process. Starting from compound 14, with low factor Xa and modest anti-thrombin inhibitory activities (IC50's of 3.5 and 0.39 μM, respectively), both activities were considerably improved, notably through the incorporation of a neutral chlorothiophene P1 fragment and tuning of P2 and P3-P4 fragments. Final optimization of metabolic stability with microsomes led to the identification of 15, which displays strong activity in vitro vs factor Xa and thrombin (with Ki's of 1 and 8 nM, respectively). In addition 15 presents good selectivity versus related serine proteases (roughly 300-fold), including trypsin (1000-fold), and is very active (0.39 μM) in the thrombin generation time (TGT) coagulation assay in human platelet rich plasma (PRP). Potent in vivo activity in a rat model of venous thrombosis following iv and, more importantly, po administration was also observed (ED50 of 0.07 and 2.8 mg/kg, respectively). Bleeding liability was reduced in the rat wire coil model, more relevant to arterial thrombosis, with 15 (blood loss increase of 2-fold relative to the ED80 value) compared to rivaroxaban 2 and dabigatran etexilate 1a.
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Affiliation(s)
- Jerome Meneyrol
- Sanofi-Aventis R&D , 195 Route d'Espagne, 31036 Toulouse Cedex, France
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Kumar S, Howell J, Mattock C. Recent pharmacological advances for treating venous thromboembolism: are we witnessing the demise of warfarin? J R Soc Med 2013; 106:441-6. [PMID: 24025228 DOI: 10.1177/0141076813498232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Vitamin K antagonists, such as warfarin, have been the mainstay in treatment and prophylaxis of venous thromboembolism. However, warfarin has many disadvantages including a narrow therapeutic window, numerous potential drug interactions, modulation of effect by alcohol and foods containing vitamin K and genetic variation in metabolism of warfarin, all of which contribute to the unpredictability of therapy. This has provided the impetus for developing new oral anticoagulants with a rapid onset of action, wide therapeutic window, predictable and reversible action, with few drug or dietary interactions, no requirement for routine coagulation monitoring or dose adjustment and acceptable cost. No single agent incorporates all these characteristics, but new factor Xa and direct thrombin inhibitors are being introduced into clinical practice that fulfil some of these aims. Here, we briefly discuss the current practice with its limitations and pitfalls, and then review important trials that have launched new oral anticoagulants into clinical practice.
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Affiliation(s)
- Shankar Kumar
- Medical School, St. George's, University of London, London, SW17 0RE, UK
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Park HD, Lee SH, Kim TH, Lee SH, Cho KH, Kim A. Antithrombotic effects of LB30870, a potent, orally active, selective and direct thrombin inhibitor, and pharmacokinetics of its prodrug. Bioorg Med Chem Lett 2013; 23:4779-84. [DOI: 10.1016/j.bmcl.2013.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 06/17/2013] [Accepted: 07/02/2013] [Indexed: 10/26/2022]
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Doraiswamy VA, Slepian MJ, Gesheff MG, Tantry US, Gurbel PA. Potential role of oral anticoagulants in the treatment of patients with coronary artery disease: focus on dabigatran. Expert Rev Cardiovasc Ther 2013; 11:1259-67. [PMID: 23968500 DOI: 10.1586/14779072.2013.827469] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The pharmacologic management of patients with high-risk coronary artery disease consists of aspirin and a P2Y12 receptor inhibitor. Chronic oral anticoagulation with warfarin is the major treatment strategy to attenuate thromboembolism or stroke in patients with deep vein thrombosis, pulmonary embolism, heart failure and atrial fibrillation. A substantial percentage of the latter group of patients have coronary artery disease and may require stenting with long-term dual antiplatelet therapy in addition to therapy with warfarin to reduce arterial ischemic events in addition to stroke. These new oral anticoagulants have been developed for long-term therapy to overcome the limitations of warfarin. Dabigatran is a direct thrombin inhibitor and its role in patients with acute coronary syndrome is being explored.
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Palladino M, Merli G, Thomson L. Evaluation of the oral direct factor Xa inhibitor – betrixaban. Expert Opin Investig Drugs 2013; 22:1465-72. [DOI: 10.1517/13543784.2013.825605] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Rivaroxaban demonstrates in vitro anticoagulant effects in canine plasma. Vet J 2013; 198:437-43. [PMID: 24053991 DOI: 10.1016/j.tvjl.2013.08.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 07/31/2013] [Accepted: 08/03/2013] [Indexed: 11/22/2022]
Abstract
Rivaroxaban is an oral direct factor X inhibitor used in human thrombotic disorders and its oral administration makes it an attractive potential anticoagulant for dogs. The objective of this study was to evaluate the in vitro anticoagulant effect of rivaroxaban on canine pooled platelet-poor plasma (PPP). Pooled PPP was collected from 20 healthy adult Beagle dogs. Aliquots of pooled citrated PPP were treated in vitro with DMSO solutions of rivaroxaban (98% purity) to obtain 19 final concentrations ranging from 0 to 1000 mg/L of drug. Samples were immediately submitted for the following coagulation assays: prothrombin time (PT), activated partial thromboplastin time (aPTT), tissue factor-induced thrombin generation and anti-factor Xa activity. Concentration-effect data were analyzed with various nonlinear regression models for stimulatory or inhibitory effects. Rivaroxaban caused a concentration-dependent prolongation of all coagulation parameters. Rivaroxaban concentration for 50% baseline inhibition of the propagation phase of thrombin (rate index) was 0.024 mg/L, and for 50% baseline inhibition of the optical density in the anti-factor Xa activity assay was 0.053 mg/L. At these concentrations, PT and aPTT remained within the reference range. Two-fold prolongation from baseline of PT and aPTT was achieved with higher concentrations, i.e. 1.24 and 1.69 mg/L, respectively. Thrombin generation was completely suppressed by concentrations ≥0.8 mg/L. In conclusion, rivaroxaban showed an in vitro concentration-dependent anticoagulant effect on canine plasma. Thrombin generation and anti-factor Xa activity were more sensitive and accurate than PT and aPTT in detecting the anticoagulant effect of rivaroxaban.
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Denas G, Pengo V. Investigational anticoagulants for hematological conditions: a new generation of therapies. Expert Opin Investig Drugs 2013; 22:1281-94. [PMID: 23876036 DOI: 10.1517/13543784.2013.821463] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The introduction of novel anticoagulants has had contrasting effects on the agents in the pipeline, fueling the development of some and sinking the others. The complexity of the coagulation cascade offers interesting inhibition choices that might become valid treatment options. AREAS COVERED This review will highlight some of the anticoagulants in the pipeline. Following the success of the direct thrombin and FXa inhibitors already in the market, new agents are being tested. These include AZD0837, betrixaban, letaxaban, darexaban, and LY517717. Targeting other components of the hemostatic pathway might lead to better safety profiles without influencing efficacy. Inhibitors to FVIIa-tissue factor (FVIIa/TF) complex, FIX, FXI, and FXII are being assessed. New inspiring inhibitors are antisense oligonucleotides (ASOs) and aptamers. These are highly specific agents with readily reversible effect and might be engineered to inhibit any coagulation factor. Currently tested ASOs and aptamers are inhibitors of FXI, FXII, thrombin, FIXa, and platelet GPIV. EXPERT OPINION Some of the agents in the pipeline offer valid treatment option for long-term therapy, overcoming some of the drawbacks of the novel anticoagulants. Research is being driven by an expanding market in the anticoagulation field that has been unexploited for a long time.
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Affiliation(s)
- Gentian Denas
- Padua University Hospital, Cardiology Clinic, Department of Cardiac, Thoracic, and Vascular Sciences , Via Giustiniani 2, 35128 Padova , Italy +390498215658 ; +390498215658 ;
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Säily VMJ, Pétas A, Joutsi-Korhonen L, Taari K, Lassila R, Rannikko AS. Dabigatran for thromboprophylaxis after robotic assisted laparoscopic prostatectomy: Retrospective analysis of safety profile and effect on blood coagulation. Scand J Urol 2013; 48:153-9. [DOI: 10.3109/21681805.2013.817482] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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New oral anticoagulants in non-valvular atrial fibrillation. High Blood Press Cardiovasc Prev 2013; 20:53-60. [PMID: 23653173 DOI: 10.1007/s40292-013-0011-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 03/04/2013] [Indexed: 12/31/2022] Open
Abstract
Atrial fibrillation (AF) is associated with an increased risk of embolic stroke. Dose-adjusted vitamin K antagonists (VKAs) to a target international normalized ratio (INR) range of 2.0-3.0 reduce the risk of ischemic stroke and are currently recommended in all patients with AF at moderate-high risk for stroke or systemic embolism. However, VKAs have several drawbacks, including unpredictable anticoagulant response, food and drug interactions, need for regular laboratory monitoring and dose adjustment. These limitations prompted the introduction of new oral anticoagulants (NOA) that target thrombin and factor Xa, key-enzymes in the coagulation pathway. NOA have predictable pharmacodynamics, allowing fixed dosing without the need of laboratory monitoring, and have few drug and food interactions. The present review focuses on pharmacological properties, safety, and appropriate clinical use of dabigatran, rivaroxaban and apixaban.
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Pharmacokinetics and dose-dependency of LB30870 in rats, dogs, and monkeys. JOURNAL OF PHARMACEUTICAL INVESTIGATION 2013. [DOI: 10.1007/s40005-013-0066-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Vitamin K antagonists, such as warfarin, have been the mainstay of oral anticoagulation for many decades. Although effective, warfarin has numerous limitations, including a variable dose requirement from patient to patient because of differences in dietary vitamin K intake, common genetic polymorphisms, and multiple drug interactions that affect its pharmacodynamics and metabolism. Consequently, warfarin requires frequent monitoring to ensure that a therapeutic anticoagulant effect has been achieved because excessive anticoagulation can lead to bleeding, and because insufficient anticoagulation can result in thrombosis. Such monitoring is burdensome for patients and physicians and is costly for the health care system. These limitations have prompted the development of new oral anticoagulants that target either factor Xa or thrombin. Although the path to the development of these drugs has been long, the new drugs are at least as effective and safe as warfarin, but they streamline clinical care because they can be administered in fixed doses without routine coagulation monitoring. This article focuses on rivaroxaban, apixaban, and edoxaban, the oral factor Xa inhibitors in the most advanced stages of development. After 20 years of discovery research, these agents are already licensed for several indications. Thus, the long path to finding replacements for warfarin has finally reached fruition. Therefore, development of the oral factor Xa inhibitors represents a translational science success story.
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Affiliation(s)
- Calvin H Yeh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Kwong JSW, Lam YY, Yan BP, Yu CM. Bleeding of New Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials. Cardiovasc Drugs Ther 2012; 27:23-35. [DOI: 10.1007/s10557-012-6426-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Keeling D, Cotter F. Management of bleeding in patients taking FXa and FIIa inhibitors. Br J Haematol 2012; 160:1-2. [DOI: 10.1111/bjh.12106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- David Keeling
- Oxford Haemophilia and Thrombosis Centre; Oxford University Hospitals; Oxford; UK
| | - Finbarr Cotter
- Centre for Haemato-Oncology; Barts Cancer Institute; Barts and the London School of Medicine and Dentistry; London; UK
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Dabigatran etexilate: another double-edged drug? : editorial to: "the beneficial effects of a direct thrombin inhibitor, dabigatran etexilate, on the development and stability of atherosclerotic lesions in apolipoprotein E-deficient mice" by N. Kadoglou et al. Cardiovasc Drugs Ther 2012; 26:361-4. [PMID: 22986913 DOI: 10.1007/s10557-012-6416-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Bathala MS, Masumoto H, Oguma T, He L, Lowrie C, Mendell J. Pharmacokinetics, biotransformation, and mass balance of edoxaban, a selective, direct factor Xa inhibitor, in humans. Drug Metab Dispos 2012; 40:2250-5. [PMID: 22936313 DOI: 10.1124/dmd.112.046888] [Citation(s) in RCA: 144] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
This study determined the mass balance and pharmacokinetics of edoxaban in humans after oral administration of [¹⁴C]edoxaban. After oral administration of 60 mg (as active moiety) of [¹⁴C]edoxaban to six healthy male subjects, serial blood/plasma and urinary and fecal samples were collected for up to 168 h postdose. All samples were analyzed for total radioactivity by liquid scintillation counting and for concentrations of edoxaban and four metabolites in plasma, urine, and fecal samples by either high-performance liquid chromatography/tandem mass spectrometry method using multiple reaction modes, or a liquid chromatography radiometric method. The mean recovery of radioactivity was >97% of the administered radioactive dose, with 62.2% eliminated in feces and 35.4% in urine. Unchanged edoxaban accounted for the majority of radioactivity, with 49.1 and 23.8% of the dose as parent observed in feces and urine, respectively. Unchanged edoxaban was the most abundant species in plasma, with a mean area under the curve (AUC)(0-∞) of 1596 ng · h/ml. The next most abundant species was metabolite M4, with a mean AUC(0-∞) 147 ng · h/ml. The mass balance of edoxaban was well described, with unchanged edoxaban as the most abundant component of total radioactivity. Edoxaban is eliminated through multiple pathways, but each accounts for only a small amount of overall elimination.
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