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Lee M, Ayad M, Diz Ferre JL, Oliver LA, Ayad S. Paravertebral Block for Multiple Rib Fractures in an Anticoagulated Trauma Patient. Cureus 2024; 16:e61834. [PMID: 38975483 PMCID: PMC11227343 DOI: 10.7759/cureus.61834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2024] [Indexed: 07/09/2024] Open
Abstract
This case report presents the complex analgesia management of a 52-year-old male with a significant medical history including atrial fibrillation treated with apixaban, essential trigeminal neuralgia, non-ischemic cardiomyopathy, and chronic systolic heart failure. The patient experienced a loss of control while riding a motorized bicycle, resulting in a fall and head injury with no loss of consciousness. Upon admission, he tested positive for ethanol, cannabinoids, and oxycodone. The physical exam was significant for right cephalohematoma and right elbow hematoma. Imaging revealed multiple injuries, including right rib fractures (T3-12) with hemothorax. Right paravertebral catheters were placed in the intensive care unit (ICU).
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Affiliation(s)
- Malcolm Lee
- Outcomes Research, Ohio University Heritage College of Osteopathic Medicine, Cleveland, USA
| | - Michael Ayad
- Outcomes Research, Lake Erie College of Osteopathic Medicine, Cleveland, USA
| | | | - Lori Ann Oliver
- Anesthesiology, Cleveland Clinic Fairview Hospital, Cleveland, USA
| | - Sabry Ayad
- Outcomes Research and Anesthesiology, Cleveland Clinic, Cleveland, USA
- Anesthesiology, Cleveland Clinic Fairview Hospital, Cleveland, USA
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2
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Jankowski W, Surov SS, Hernandez NE, Rawal A, Battistel M, Freedberg D, Ovanesov MV, Sauna ZE. Engineering and evaluation of FXa bypassing agents that restore hemostasis following Apixaban associated bleeding. Nat Commun 2024; 15:3912. [PMID: 38724509 PMCID: PMC11082157 DOI: 10.1038/s41467-024-48278-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 04/26/2024] [Indexed: 05/12/2024] Open
Abstract
Direct oral anticoagulants (DOACs) targeting activated factor Xa (FXa) are used to prevent or treat thromboembolic disorders. DOACs reversibly bind to FXa and inhibit its enzymatic activity. However, DOAC treatment carries the risk of anticoagulant-associated bleeding. Currently, only one specific agent, andexanet alfa, is approved to reverse the anticoagulant effects of FXa-targeting DOACs (FXaDOACs) and control life-threatening bleeding. However, because of its mechanism of action, andexanet alfa requires a cumbersome dosing schedule, and its use is associated with the risk of thrombosis. Here, we present the computational design, engineering, and evaluation of FXa-variants that exhibit anticoagulation reversal activity in the presence of FXaDOACs. Our designs demonstrate low DOAC binding affinity, retain FXa-enzymatic activity and reduce the DOAC-associated bleeding by restoring hemostasis in mice treated with apixaban. Importantly, the FXaDOACs reversal agents we designed, unlike andexanet alfa, do not inhibit TFPI, and consequently, may have a safer thrombogenic profile.
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Affiliation(s)
- Wojciech Jankowski
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Stepan S Surov
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Nancy E Hernandez
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Atul Rawal
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Marcos Battistel
- Laboratory of Bacterial Polysaccharides, Division of Bacterial, Parasitic and Allergenic Products, Office of Vaccines Research and Review, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Daron Freedberg
- Laboratory of Bacterial Polysaccharides, Division of Bacterial, Parasitic and Allergenic Products, Office of Vaccines Research and Review, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Mikhail V Ovanesov
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Zuben E Sauna
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA.
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Schreuder M, Jourdi G, Veizaj D, Poole DA, Cheung KL, Poenou G, Verhoef D, Thomassen S, Janssen LFH, Stepanian A, Hackeng TM, Gaussem P, Reitsma PH, Geerke DP, Siguret V, Bos MHA. Minimally modified human blood coagulation factor X to bypass direct factor Xa inhibitors. J Thromb Haemost 2024:S1538-7836(24)00254-X. [PMID: 38729577 DOI: 10.1016/j.jtha.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 04/09/2024] [Accepted: 04/23/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Direct oral factor (F)Xa inhibitors are widely used as alternatives to conventional vitamin K antagonists in managing venous thromboembolism and nonvalvular atrial fibrillation. Unfortunately, bleeding-related adverse events remain a major concern in clinical practice. In case of bleeding or emergency surgery, rapid-onset reversal agents may be required to counteract the anticoagulant activity. OBJECTIVES The ability of FXa variants to bypass the direct oral FXa inhibitors was assessed. METHODS Human FXa variants were generated through substitution of phenylalanine 174 (F174) for either alanine, isoleucine, or serine. FXa variants were stably expressed in HEK293 cells and purified to homogeneity using ion-exchange chromatography. RESULTS F174-substituted human FX variants demonstrated efficacy in restoring thrombin generation in plasma containing direct FXa inhibitors (apixaban, rivaroxaban, edoxaban). Their ability to bypass the anticoagulant effects stems from a significantly reduced sensitivity for the direct FXa inhibitors due to a decrease in binding affinity determined using molecular dynamics simulations and free energy computation. Furthermore, F174 modification resulted in a partial loss of inhibition by tissue factor pathway inhibitor, enhancing the procoagulant effect of F174-substituted FX. Consequently, the F174A- and F174S-substituted FX variants effectively counteracted the effects of 2 widely used anticoagulants, apixaban and rivaroxaban, in plasma of atrial fibrillation and venous thromboembolism patients. CONCLUSION These human FX variants have the potential to serve as a rescue reversal strategy to overcome the effect of direct FXa inhibitors in case of life-threatening bleeding events or emergency surgical interventions.
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Affiliation(s)
- Mark Schreuder
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Georges Jourdi
- Assistance publique - Hôpitaux de Paris (AH-HP) Centre, Service d'hématologie biologique, Hôpital Cochin, Paris, France; Innovative Therapies in Haemostasis, Institut national de la santé et de la recherche médicale (INSERM) U1140, Université Paris Cité, Paris, France; Assistance publique - Hôpitaux de Paris (AH-HP) Nord, Service d'hématologie biologique, Hôpital Lariboisière, Paris, France
| | - Dejvid Veizaj
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - David A Poole
- Amsterdam Institute of Molecular and Life Sciences (AIMMS), Division of Molecular and Computational Toxicology, Department of Chemistry and Pharmaceutical Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ka Lei Cheung
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Géraldine Poenou
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands; Innovative Therapies in Haemostasis, Institut national de la santé et de la recherche médicale (INSERM) U1140, Université Paris Cité, Paris, France
| | - Daniël Verhoef
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands; VarmX B.V., Leiden, The Netherlands
| | - Stella Thomassen
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Laura F H Janssen
- Amsterdam Institute of Molecular and Life Sciences (AIMMS), Division of Molecular and Computational Toxicology, Department of Chemistry and Pharmaceutical Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Alain Stepanian
- Assistance publique - Hôpitaux de Paris (AH-HP) Nord, Service d'hématologie biologique, Hôpital Lariboisière, Paris, France; EA3518 Institut Universitaire d'Hématologie, Hôpital Saint Louis, Paris-Diderot, Paris, France
| | - Tilman M Hackeng
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Pascale Gaussem
- Innovative Therapies in Haemostasis, Institut national de la santé et de la recherche médicale (INSERM) U1140, Université Paris Cité, Paris, France; Assistance publique - Hôpitaux de Paris (AP-HP) Centre, Service d'hématologie biologique, Hôpital Européen Georges Pompidou, Paris, France
| | - Pieter H Reitsma
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands; VarmX B.V., Leiden, The Netherlands
| | - Daan P Geerke
- Amsterdam Institute of Molecular and Life Sciences (AIMMS), Division of Molecular and Computational Toxicology, Department of Chemistry and Pharmaceutical Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Virginie Siguret
- Innovative Therapies in Haemostasis, Institut national de la santé et de la recherche médicale (INSERM) U1140, Université Paris Cité, Paris, France; Assistance publique - Hôpitaux de Paris (AH-HP) Nord, Service d'hématologie biologique, Hôpital Lariboisière, Paris, France
| | - Mettine H A Bos
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands.
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Gackowski M, Madriwala B, Studzińska R, Koba M. Novel Isosteviol-Based FXa Inhibitors: Molecular Modeling, In Silico Design and Docking Simulation. Molecules 2023; 28:4977. [PMID: 37446638 DOI: 10.3390/molecules28134977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
Direct oral anticoagulants are an important and relatively new class of synthetic anticoagulant drugs commonly used for the pharmacotherapy of thromboembolic disorders. However, they still have some limitations and serious side effects, which continuously encourage medicinal chemists to search for new active compounds acting as human-activated coagulation factor X (FXa) inhibitors. Isosteviol is a nontoxic hydrolysis product of naturally occurring stevioside and possesses a wide range of therapeutic properties, including anticoagulant activity. The present contribution describes the in silico design of novel oxime ether isosteviol derivatives as well as a molecular modeling approach based on QSAR analysis and a docking simulation for searching for novel isosteviol-based compounds as potential FXa inhibitors. The elaborated ANN model, encompassing topological and geometrical information, exhibited a significant correlation with FXa-inhibitory activity. Moreover, the docking simulation indicated six of the most promising isosteviol-like compounds for further investigation. Analysis showed that the most promising derivatives contain heterocyclic, aromatic, five-membered moieties, with substituents containing chlorine or fluorine atoms. It is anticipated that the findings reported in the present work may provide useful information for designing effective FXa inhibitors as anticoagulant agents.
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Affiliation(s)
- Marcin Gackowski
- Department of Toxicology and Bromatology, Faculty of Pharmacy, L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, A. Jurasza 2 Street, 85089 Bydgoszcz, Poland
| | - Burhanuddin Madriwala
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Nitte College of Pharmaceutical Sciences, Yelahanka, Bengaluru 560064, Karnataka, India
| | - Renata Studzińska
- Department of Organic Chemistry, Faculty of Pharmacy, L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, A. Jurasza 2 Street, 85089 Bydgoszcz, Poland
| | - Marcin Koba
- Department of Toxicology and Bromatology, Faculty of Pharmacy, L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, A. Jurasza 2 Street, 85089 Bydgoszcz, Poland
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Ripoll JG, Klompas AM, Smith BB, Smith MM. Contemporary Perioperative Management of Direct Oral Anticoagulants. Adv Anesth 2022; 40:93-109. [PMID: 36333054 DOI: 10.1016/j.aan.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Direct oral anticoagulants (DOACs) have rapidly emerged as popular alternatives to warfarin in the setting of nonvalvular atrial fibrillation, prevention and treatment of venous thromboembolism, and secondary prevention of arterial thrombosis. It is now estimated that more patients in the United States take DOACs than warfarin for approved indications. Studies to date have shown that these drugs are similarly efficacious with perhaps a lower bleeding risk than warfarin. The purpose of this review is to provide insight into the currently available DOACs and discuss the management and reversal strategies for patients in the perioperative period.
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Affiliation(s)
- Juan G Ripoll
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Allan M Klompas
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Bradford B Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA.
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Favaloro EJ. 2021 Eberhard F. Mammen Award Announcements: Part II-Young Investigator Awards. Semin Thromb Hemost 2022. [PMID: 35413734 DOI: 10.1055/s-0042-1743175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, Westmead, Australia
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Favaloro EJ. 2020 Eberhard F. Mammen Award Announcements: Part II-Young Investigator Awards. Semin Thromb Hemost 2021; 47:229-237. [PMID: 33794547 DOI: 10.1055/s-0041-1724120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Emmanuel J Favaloro
- Sydney Centres for Thrombosis and Haemostasis, Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, Westmead, Australia
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Affiliation(s)
- Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
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