The In Vitro Effect of Ticlopidine on Fibrinogen and Factor VIII Binding to Human Platelets

Pleiotropic effects of clopidogrel

Clopidogrel is a widely prescribed prodrug with anti-thrombotic activity through irreversible inhibition of the P2Y₁₂ receptor on platelets. It is FDA-approved for the clinical management of thrombotic diseases like unstable angina, myocardial infarction, stroke, and during percutaneous coronary interventions. Hepatic clopidogrel metabolism generates several distinct metabolites. Only one of these metabolites is responsible for inhibiting the platelet P2Y₁₂ receptor. Importantly, various non-hemostatic effects of clopidogrel therapy have been described. These non-hemostatic effects are perhaps unsurprising, as P2Y₁₂ receptor expression has been reported in multiple tissues, including osteoblasts, leukocytes, as well as vascular endothelium and smooth muscle. While the "inactive" metabolites have been commonly thought to be biologically inert, recent findings have uncovered P2Y₁₂ receptor-independent effects of clopidogrel treatment that may be mediated by understudied metabolites. In this review, we summarize both the P2Y₁₂ receptor-mediated and non-P2Y₁₂ receptor-mediated effects of clopidogrel and its metabolites in various tissues.

The thienopyridine ticlopidine selectively prevents the inhibitory effects of ADP but not of adrenaline on cAMP levels raised by stimulation of the adenylate cyclase of human platelets by PGE1

After oral administration, ticlopidine specifically inhibits ADP-induced platelet aggregation, prolongs the bleeding time and prevents thrombosis in man. Its mechanism of action is not well known. Ticlopidine inhibits ADP-induced binding of fibrinogen to platelet glycoprotein GP IIb-IIIa but not shape change and increases deaggregation. Ticlopidine has no direct effect on the GP IIb-IIIa complex. We studied the effects of ticlopidine (500 mg/day for 8 days) in four healthy male volunteers on washed platelet aggregation induced by 5 microM ADP or thrombin (0.1 units/mL) and potentiated by 1 microM adrenaline (Adr), on basal and 1 microM PGE1-stimulated cAMP levels and on elevation of cytosolic free Ca2+ concentration ([Ca2+]i). We found that: (i) ticlopidine inhibits aggregation by ADP but not the potentiation by Adr of ADP-induced aggregation; (ii) ADP, Adr or thrombin decreases cAMP levels raised by PGE1, an effect inhibited by ticlopidine only for ADP and not for Adr or thrombin; and (iii) Ca2+ influx and Ca2+ mobilization from internal stores were not affected. These results suggested that ticlopidine or a metabolite impairs the coupling mechanism of the ADP aggregation pathway at an unknown level.

The thienopyridine PCR 4099 selectively inhibits ADP-induced platelet aggregation and fibrinogen binding without modifying the membrane glycoprotein IIb-IIIa complex in rat and in man

The thienopyridines, ticlopidine and PCR 4099, inhibit ex vivo aggregation in response to ADP and other agonists. It has been shown that ticlopidine induces a functional defect in the binding of fibrinogen to its platelet membrane receptor. We have studied the effects on platelet functions of PCR 4099 in rat and in man. The aim of the study was to check the possibility of a direct modification of the fibrinogen binding site on the GP IIb-IIIa complex. Washed platelet suspensions were used for aggregation and fibrinogen binding studies. Platelet lysates were submitted to SDS-polyacrylamide gel electrophoresis, crossed immunoelectrophoresis and immunoprecipitation. We found that administration of PCR 4099 inhibited selectively and irreversibly ADP-induced aggregation. Although the effect of ADP on aggregation was blocked, PCR 4099 did not modify ADP-induced shape change. Only the effects of low concentrations of thrombin on platelet aggregation were inhibited. Fibrinogen binding was dramatically inhibited in rat and in man when platelets were stimulated with ADP and low concentrations of thrombin. At high concentration of thrombin there still remained a part of fibrinogen binding inhibition although aggregation was not impaired. Electrophoretic and immunoelectrophoretic studies showed no difference before and after treatment by PCR 4099. In particular, the GP IIb-IIIa-complex was not dissociated, its electrophoretic mobility was not changed and three monoclonal anticomplex antibodies recognized it in the same manner before and after treatment. We conclude that PCR 4099 selectively inhibits the ADP aggregation pathway and that the inhibition of fibrinogen binding is probably not due to a direct modification of the GP IIb-IIIa complex.

Ticlopidine prevents renal disease progression in rats with reduced renal mass

Functional and morphological studies were done in three groups of male Sprague-Dawley rats after removal of the right kidney and infarction of approximately five-sixths of the left. Group 1 received no specific therapy. Group 2 was treated with ticlopidine, 150 mg/kg per os, for 50 days starting 10 days after surgical ablation. Group 3 was given the thromboxane antagonist, GR 32191, 3 mg/kg b.i.d. orally for 50 days, like ticlopidine. Untreated Group 1 rats developed renal insufficiency, systemic hypertension, progressive proteinuria and glomerulosclerosis. In Group 2 treatment with ticlopidine was associated with less severe impairment of renal function. Proteinuria was significantly lower and animals were partially protected from the development of glomerulosclerosis. These animals had significantly prolonged skin bleeding time. In vitro ADP and arachidonic acid (AA)-induced platelet aggregation was inhibited. Systemic blood pressure was significantly lower than in controls. In Group 3 rats GR 32191 failed to influence progressive proteinuria and severity of glomerulosclerosis which were comparable to those in Group 1. Bleeding time was not prolonged, and in vitro platelet aggregation was inhibited only when AA was used as aggregating agent. Systemic blood pressure was not influenced. These studies suggest that a drug like ticlopidine, which has a broad spectrum of pharmacological actions on platelets and platelet-cell interactions, does retard the development of progressive renal injury when nephron number is reduced. Specific blocking of thromboxane A2 (TxA2) biological activity does not influence progressive renal disease in rats with remnant kidney.

Broad spectrum anti-platelet activity of ticlopidine and PCR 4099 involves the suppression of the effects of released ADP

Aggregation and serotonin secretion were studied in washed rat platelets after oral administration of ticlopidine or its more potent analog PCR 4099. Besides a complete suppression of the ADP-induced aggregation, the two drugs significantly inhibited aggregation and secretion induced by three protein kinase C activators (1-oleoyl-2-acetyl-sn-glycerol, OAG; 12-0-tetradecanoyl phorbol-13-acetate, TPA; phospholipase C), by the calcium ionophore A 23187 and by thrombin. The highest inhibition was observed at low stimuli concentrations but could be partly or almost completely overcome by increasing their concentrations. The combination of aspirin (ASA) with the ADP scavenging system, creatine phosphate/creatine phosphokinase (CP/CPK) in vitro resulted in an inhibition similar to that observed ex vivo after ticlopidine or PCR 4099 treatment. Moreover, these in vitro and ex vivo treatments were not additive. As identical results were obtained with CP/CPK alone but not with ASA, it is concluded that ticlopidine and PCR 4099 do not interfere with protein kinase C or calcium movements but specifically inhibit the effects of released ADP, which might explain the broad spectrum anti-platelet activity of these drugs.

Spin label study of the effect of ticlopidine on platelets

The effect of ticlopidine on platelet membrane fluidity was investigated using a spin label technique. Ticlopidine, when orally administered to rats, increased both the order parameter and the motion parameter, indicating a decrease in the membrane fluidity of platelets. On the other hand, the order parameter and the motion parameter decreased markedly when the platelets were aggregated by thrombin. Ticlopidine inhibited the thrombin-induced aggregation of platelets and caused a slight increase in order parameter and motion parameter in thrombin-aggregated platelets. Judging from sodium dodecyl sulfate polyacrylamide gel electrophoresis, ticlopidine did not modify the electrophoretic pattern of platelet proteins appreciably. Ticlopidine decreased cholesterol/phospholipids molar ratio and increased slightly total amounts of proteins of the platelets. These results indicate that the inhibitory action by ticlopidine was accompanied by changes in membrane fluidity, and these changes were due to a perturbation of the membrane phospholipid core of the platelets by ticlopidine and/or its metabolites.

Inhibitory effect of sodium salicylate on ADP-induced platelet aggregation and on 45Ca2+ uptake into platelets

The effects of sodium salicylate (SS) on ADP-induced platelet aggregation and on a metabolism of calcium in platelets were studied, using gel-filtrated platelets (GFP). SS inhibited dose-responsively ADP-induced aggregation in the presence of fibrinogen and Ca2+. It was found that extracellular 45Ca2+ was rapidly taken up into platelets after stimulation by ADP, while SS significantly inhibited this activity. On the other hand, SS had no effect on platelet aggregation induced by 0.11-1.0 microM ionophore A23187. Therefore, it was found that the inhibitory effect of SS on ADP-induced platelet aggregation may be due to the inhibition of the active influx of extracellular Ca2+ into platelets during aggregation.

Effects of long-term ticlopidine treatment on platelet function and its tolerability in cerebrovascular disease

A trial was performed on thirty-two patients with cerebrovascular disease (transient ischaemic attack and stroke) to assess the effect of ticlopidine, a new inhibitor of platelet aggregation, on some platelet functions and coagulation, and its safety in long-term use (6 months). The results show that ticlopidine was highly effective in inhibiting ADP-induced platelet aggregation, platelet adhesiveness and circulating platelet aggregates, but it had no effect on fibrinogen levels. No serious side-effects were observed. Ticlopidine may therefore prove to be a useful antiplatelet drug in the management of patients with cerebrovascular disease.

Inhibition by ticlopidine of Paf-acether-induced in vitro aggregation of rabbit and human platelets

Ticlopidine was incubated in vitro with rabbit or human washed platelets and aggregations were triggered by submaximal concentrations of adenosine-5'-diphosphate (ADP), arachidonic acid (AA) and Paf-acether (platelet-activating factor), the mediators of the three known pathways of platelet activation. Inhibition of Paf-acether-induced rabbit platelet aggregation was proportional to the concentrations of Ticlopidine used. The same range of inhibition by Ticlopidine was observed when aggregations were triggered by the two other agonists. Human platelet aggregation induced by Paf-acether was also inhibited by Ticlopidine. Inhibition was increased when platelets were rendered insensitive to ADP and AA. Our results show that Ticlopidine inhibits human and rabbit platelet aggregation triggered by Paf-acether through a mechanism not related to the inhibition of the ADP and prostaglandin pathways.

The effect of ticlopidine on human endothelial cells in culture

The effect of ticlopidine at various concentrations (150, 30, 6 microM), has been studied on cultured endothelial cells derived from human umbilical cord vein. Ticlopidine affects the initial attachment of endothelial cells to artificial substrata and has an inhibitory effect on endothelial cell growth rate which correlates to the concentration of the chemical in the culture medium. These effects are related to a marked reduction of intra- and extracellular fibronectin as evidentiated by immunofluorescence. The drug seems to interfere with the formation of fibronectin filaments from intracellular granules. The reduction of fibronectin availability could affect platelet adhesion to subendothelium as well as endothelial cell repair, and subsequently influence the bleeding time. The inhibition of cell proliferation and its possible effect on the thickness of the vessel wall should be considered as additional mechanisms of action for this substance.

Effect of a collagen derived octapeptide on different steps of the platelet/collagen interaction

The interaction of platelets with collagen involves short aminoacid sequences which recur along the fibres. Platelet aggregation by collagen and serotonin release is inhibited by a synthetic octapeptide LYS-PRO-GLY-GLU- PRO-GLY-PRO-LYS- derived from type III collagen. In contrast, this octapeptide inhibits only weakly the retention of platelets labelled with 111Indium to collagen, suggesting that it has a limited effect on platelet adhesion. Preincubation of the octapeptide with platelets inhibits the rise of cAMP level caused by activating adenylate cyclase by various concentrations of PGI2. The octapeptide at 5 mM reverses the inhibition by PGI2 of the adhesion of platelets to collagen. These results suggest that the octapeptide affects the intrinsic activity (manifested as platelet aggregation and secretion) more than the recognition of collagen by its receptor (manifested by adhesion).

Study of platelet aggregation induced by platelet activating factor (PAF) after administration of ticlopidine or aspirin

Platelet aggregation induced by platelet activating factor (PAF) was studied in 95 subjects: 39 controls, 23 patients receiving aspirin and 33 receiving ticlopidine. Potentiation of aggregation by concentrations of adrenaline unable to induce aggregation when used alone was also assessed. The 33 patients treated with ticlopidine showed a highly significant fall of platelet aggregation (p less than 0.001) at the three concentrations of PAF used. The 23 subjects receiving aspirin showed a diminution of platelet aggregation induced by PAF due to inhibition of ADP release. In these last two groups, adrenaline often potentiated platelet aggregation. However, this phenomenon was absent in subjects having taken aspirin in the hours before blood was drawn. This study demonstrates ticlopidine's inhibitory action on PAF-induced aggregation and confirms ticlopidine's role in reducing platelet aggregation by ADP, which has previously been demonstrated.

Ticlopidine hydrochloride: relationship between dose, kinetics, plasma concentration and effect on platelet function

This is a review of the available data about the pharmacodynamic profile of ticlopidine in man in relation to its pharmacokinetic and metabolic characteristics. There is a rapid dose-dependent onset of effect on platelet function and a time-dependent effect on bleeding. The ticlopidine effect appears to be due to the direct action on circulating platelets. The contributions of a metabolite, a 2-keto derivative, is also discussed.