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Jain SS, Mahaffey KW, Pieper KS, Shimizu W, Potpara T, Ruff CT, Kamel H, Lewis BS, Cornel JH, Kowey PR, Horrow J, Strony J, Plotnikov AN, Li D, Weng S, Donahue J, Gibson CM, Steg PG, Mehran R, Weitz JI, Johnston SC, Hankey GJ, Harrington RA, Lam CSP. Milvexian vs apixaban for stroke prevention in atrial fibrillation: The LIBREXIA atrial fibrillation trial rationale and design. Am Heart J 2024; 277:145-158. [PMID: 39214801 DOI: 10.1016/j.ahj.2024.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 08/13/2024] [Accepted: 08/14/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Direct oral anticoagulants are the standard of care for stroke prevention in eligible patients with atrial fibrillation and atrial flutter; however, bleeding remains a significant concern, limiting their use. Milvexian is an oral Factor XIa inhibitor that may offer similar anticoagulant efficacy with less bleeding risk. METHODS LIBREXIA AF (NCT05757869) is a global phase III, randomized, double-blind, parallel-group, event-driven trial to compare milvexian with apixaban in participants with atrial fibrillation or atrial flutter. Participants are randomly assigned to milvexian 100 mg or apixaban (5 mg or 2.5 mg per label indication) twice daily. The primary efficacy objective is to evaluate if milvexian is noninferior to apixaban for the prevention of stroke and systemic embolism. The principal safety objective is to evaluate if milvexian is superior to apixaban in reducing the endpoint of International Society of Thrombosis and Hemostasis (ISTH) major bleeding events and the composite endpoint of ISTH major and clinically relevant nonmajor (CRNM) bleeding events. In total, 15,500 participants from approximately 1,000 sites in over 30 countries are planned to be enrolled. They will be followed until both 430 primary efficacy outcome events and 530 principal safety events are observed, which is estimated to take approximately 4 years. CONCLUSION The LIBREXIA AF study will determine the efficacy and safety of the oral Factor XIa inhibitor milvexian compared with apixaban in participants with either atrial fibrillation or atrial flutter. TRIAL REGISTRATION ClinicalTrials.gov NCT05757869.
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Affiliation(s)
- Sneha S Jain
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Stanford, CA; Stanford Center for Clinical Research, Stanford, CA
| | - Kenneth W Mahaffey
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Stanford, CA; Stanford Center for Clinical Research, Stanford, CA
| | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Tatjana Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia; Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Christian T Ruff
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, Cornell University, New York, NY
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and Technion-Israel Institute of Technology, Haifa, Israel
| | - Jan H Cornel
- Noordwest Ziekenhuisgroep, Alkmaar and Radboud, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter R Kowey
- Lankenau Institute for Medical Research, Thomas Jefferson University, Philadelphia, PA
| | | | - John Strony
- Janssen Research & Development, LLC, a Johnson & Johnson Company, Raritan, NJ
| | - Alexei N Plotnikov
- Janssen Research & Development, LLC, a Johnson & Johnson Company, Raritan, NJ
| | | | - Stephen Weng
- Janssen Research & Development, LLC, a Johnson & Johnson Company, Raritan, NJ
| | | | - C Michael Gibson
- Beth Israel Lahey Health Harvard Medical School and Baim Institute for Clinical Research, Harvard Medical School, Boston, MA
| | - P Gabriel Steg
- Université Paris-Cité, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Graeme J Hankey
- Centre for Neuromuscular and Neurological Disorders, The University of Western Australia, Perth, Western Australia, Australia; Perron Institute for Neurological and Translational Science, Perth, Western Australia, Australia
| | | | - Carolyn S P Lam
- National Heart Centre, Singapore, Duke-National University of Singapore (C.S.P.L), Singapore.
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Harm T, Lydia Mueller KA, Geisler T. Regulation of Platelet Activation and Coagulation: Current Concepts, Novel Targets, and Therapies. Interv Cardiol Clin 2024; 13:451-467. [PMID: 39245546 DOI: 10.1016/j.iccl.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
Antiplatelet and anticoagulant therapies are cornerstones of secondary prevention in high-risk cardiovascular patients. Whereas in former days the focus was set on effective antithrombotic effects, more recent trials and guidelines placed emphasis on a more balanced approach, thus including the bleeding risk for an individualized therapy. Type, strength, combination, and duration are important components to modify the individual bleeding risk. Novel antiplatelet and anticoagulant agents have shown promising results that might offer safer options in the future for high-risk cardiovascular patients. This review aims to give an overview about established drug target and pharmacologic approaches that are currently in the pipeline.
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Affiliation(s)
- Tobias Harm
- Department of Cardiology and Angiology, University Hospital Tübingen, Germany
| | | | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital Tübingen, Germany.
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Goel A, Tathireddy H, Wang SH, Vu HH, Puy C, Hinds MT, Zonies D, McCarty OJ, Shatzel JJ. Targeting the Contact Pathway of Coagulation for the Prevention and Management of Medical Device-Associated Thrombosis. Semin Thromb Hemost 2024; 50:989-997. [PMID: 37044117 PMCID: PMC11069398 DOI: 10.1055/s-0043-57011] [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] [Indexed: 04/14/2023]
Abstract
Hemorrhage remains a major complication of anticoagulants, with bleeding leading to serious and even life-threatening outcomes in rare settings. Currently available anticoagulants target either multiple coagulation factors or specifically coagulation factor (F) Xa or thrombin; however, inhibiting these pathways universally impairs hemostasis. Bleeding complications are especially salient in the medically complex population who benefit from medical devices. Extracorporeal devices-such as extracorporeal membrane oxygenation, hemodialysis, and cardiac bypass-require anticoagulation for optimal use. Nonetheless, bleeding complications are common, and with certain devices, highly morbid. Likewise, pharmacologic prophylaxis to prevent thrombosis is not commonly used with many medical devices like central venous catheters due to high rates of bleeding. The contact pathway members FXI, FXII, and prekallikrein serve as a nexus, connecting biomaterial surface-mediated thrombin generation and inflammation, and may represent safe, druggable targets to improve medical device hemocompatibility and thrombogenicity. Recent in vivo and clinical data suggest that selectively targeting the contact pathway of coagulation through the inhibition of FXI and FXII can reduce the incidence of medical device-associated thrombotic events, and potentially systemic inflammation, without impairing hemostasis. In the following review, we will outline the current in vivo and clinical data encompassing the mechanism of action of drugs targeting the contact pathway. This new class of inhibitors has the potential to herald a new era of effective and low-risk anticoagulation for the management of patients requiring the use of medical devices.
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Affiliation(s)
- Abhishek Goel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Harsha Tathireddy
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Si-Han Wang
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| | - Helen H. Vu
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| | - Cristina Puy
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| | - Monica T. Hinds
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| | - David Zonies
- Department of Surgery, Oregon Health and Science University, Portland, Oregon
| | - Owen J.T. McCarty
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
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Cella A, Marè A, Gigli GL, Zedde M, Valente M, Merlino G. A pharmacokinetic and pharmacodynamic evaluation of asundexian: a novel factor XIa inhibitor for stroke prevention. Expert Opin Drug Metab Toxicol 2024. [PMID: 39257338 DOI: 10.1080/17425255.2024.2402496] [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: 05/24/2024] [Revised: 08/24/2024] [Accepted: 09/05/2024] [Indexed: 09/12/2024]
Abstract
INTRODUCTION Antithrombotic therapy is the mainstay of ischemic stroke prevention. Current drugs (antiplatelets and oral anticoagulants) lead to increased bleeding risks, and the rates of stroke recurrence, despite antithrombotic therapy, are still elevated. There is a need for novel antithrombotic therapies with superior effectiveness but without increased bleeding risk. Factor XIa inhibitors might cover this gap. AREAS COVERED This manuscript examines the pharmacokinetic and pharmacodynamic properties of asundexian and the current clinical evidence regarding its application in preventing ischemic stroke. EXPERT OPINION Asundexian shows a very favoring pharmacokinetic profile. Despite asundexian being inferior to apixaban for cardioembolic ischemic stroke, it could be useful in patients with non-cardioembolic ischemic stroke. Although antiplatelet therapy is the recommended treatment to prevent non-cardioembolic ischemic stroke, adding an anticoagulant might have beneficial effects through the dual-pathway inhibition strategy. Due to the potential risk of hemorrhagic transformation, there is hesitation to administer anticoagulants early to patients who have recently had an ischemic stroke, especially if they are also on antiplatelet therapy. However, clinical trials on asundexian confirmed its safety for bleeding, even when used with antiplatelets. A phase 3 trial is currently investigating the efficacy of asundexian in preventing non-cardioembolic ischemic stroke.
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Affiliation(s)
- Arianna Cella
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Alessandro Marè
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | | | - Marialuisa Zedde
- Neurology Unit, Department of Neuromotor Physiology and Rehabilitation, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Mariarosaria Valente
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- DMED, University of Udine, Udine, Italy
| | - Giovanni Merlino
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
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Buckley GT, Crowley MP, Harte JV. Laboratory Evaluation of Interferences Associated with Factor XIa Inhibitors Asundexian and Milvexian in Routine Coagulation Assays. Diagnostics (Basel) 2024; 14:1991. [PMID: 39272775 PMCID: PMC11394090 DOI: 10.3390/diagnostics14171991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Revised: 08/25/2024] [Accepted: 08/27/2024] [Indexed: 09/15/2024] Open
Abstract
Direct oral anticoagulants (DOACs) are increasingly used for the treatment of thrombosis. While inhibitors of factor IIa and factor Xa have shown effectiveness, the risk of bleeding remains a significant concern. Recently, direct factor XIa inhibitors-including asundexian and milvexian-have emerged as potential anticoagulation therapies, based on clinical observations that patients with factor XIa deficiencies seldom present with spontaneous bleeding tendencies. The interferences associated with DOACs in routine and specialised coagulation assays are well-described; however, the interferences associated with emerging FXIa inhibitors are largely uncharacterised. Here, we briefly report the impact of asundexian and milvexian in routine coagulation assays using in vitro plasma-based systems. Asundexian and milvexian induce concentration-dependent prolongations in APTT-based assays with curvilinear regressions, which may be suitable for the measurement of pharmacodynamic effects at peak levels ex vivo. We also report differential sensitivities of APTT-based assays-particularly at higher FXIa inhibitor concentrations-highlighting the clinical need for an extensive evaluation of interferences associated with FXIa inhibitors in coagulation assays.
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Affiliation(s)
- Gavin T Buckley
- Department of Haematology, Cork University Hospital, Wilton, T12 DC4A Cork, Ireland
- EOLAS Research Group, Cork University Hospital, Wilton, T12 DC4A Cork, Ireland
| | - Maeve P Crowley
- Department of Haematology, Cork University Hospital, Wilton, T12 DC4A Cork, Ireland
- EOLAS Research Group, Cork University Hospital, Wilton, T12 DC4A Cork, Ireland
| | - James V Harte
- Department of Haematology, Cork University Hospital, Wilton, T12 DC4A Cork, Ireland
- EOLAS Research Group, Cork University Hospital, Wilton, T12 DC4A Cork, Ireland
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Schuermans A, Verstraete A, Lammi V, Nakanishi T, Ardissino M, Van den Eynde J, Sun BB, Georgakis MK, Van Weyenbergh J, Lewandowski AJ, Raman B, Ollila HM, Burgess S, Natarajan P, Honigberg MC, Freson K, Vanassche T, Verhamme P. WITHDRAWN: Proteogenomic analyses identify coagulation factor XI as a thromboinflammatory mediator of long COVID. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.17.24307553. [PMID: 38798608 PMCID: PMC11118620 DOI: 10.1101/2024.05.17.24307553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
The authors have withdrawn their manuscript due to analytical errors invalidating the main study findings. The authors of this work discovered the errors after submitting the initial version of the preprint. Therefore, the authors do not wish this work to be cited as reference for the project. If you have any questions, please contact the corresponding author.
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Stępień K, Siudut J, Zalewski J, Nowakowski T, Undas A. Elevated plasma factor XI is associated with postthrombotic syndrome. Thromb Res 2024; 241:109086. [PMID: 38968817 DOI: 10.1016/j.thromres.2024.109086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/12/2024] [Accepted: 07/02/2024] [Indexed: 07/07/2024]
Abstract
INTRODUCTION Postthrombotic syndrome (PTS), a common complication of deep vein thrombosis (DVT), is largely inflammatory by nature with contribution of prothrombotic mechanisms. The role of factor (F)XI in PTS has not been explored yet. We investigated whether elevated FXI is associated with PTS occurrence. MATERIALS AND METHODS We enrolled 180 consecutive patients (aged 43 ± 13 years) with first-ever DVT. After 3 months FXI levels were measured, along with inflammatory markers, thrombin generation, plasma clot permeability (Ks), clot lysis time (CLT), and fibrinolysis proteins. We assessed PTS using the Villalta score and recorded symptomatic venous thromboembolism (VTE) at a 1-year and venous ulcers at a median 53 months follow-up. RESULTS Baseline median FXI was 102 % [IQR 92-113 %] and showed positive association with Villalta score (R = 0.474, P < 0.001). Patients with PTS (n = 48, 26.7 %) had 16.1 % higher FXI (P < 0.001) and FXI ≥120 % occurred more often in PTS patients (odds ratio [OR] 5.55, 95 % confidence interval [CI] 2.28-13.47). There were associations of baseline FXI with Ks and CLT along with thrombin activatable fibrinolysis inhibitor (TAFI) activity, C-reactive protein, and interleukin-6, but not with fibrinogen, or thrombin generation. After age adjustment higher FXI was independently associated with PTS occurrence (OR per 1 % 1.06, 95 % CI 1.02-1.09) and VTE recurrence (OR 1.03, 95 % CI 1.01-1.06). At long-term follow-up, patients with venous ulcers had 13.6 % higher baseline FXI (P = 0.002). CONCLUSIONS Elevated FXI in association with inflammation and prothrombotic fibrin clot properties may contribute to the development of PTS following DVT.
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Affiliation(s)
- Konrad Stępień
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; Department of Coronary Artery Disease and Heart Failure, St. John Paul II Hospital, Krakow, Poland
| | - Jakub Siudut
- Krakow Centre for Medical Research and Technologies, St. John Paul II Hospital, Krakow, Poland
| | - Jarosław Zalewski
- Department of Coronary Artery Disease and Heart Failure, St. John Paul II Hospital, Krakow, Poland; Department of Coronary Artery Disease and Heart Failure, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Tomasz Nowakowski
- Department of Angiology, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland; Clinical Department of Angiology, University Hospital in Krakow, Krakow, Poland
| | - Anetta Undas
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; Krakow Centre for Medical Research and Technologies, St. John Paul II Hospital, Krakow, Poland.
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Parsa S, Jain SS, Akinrimisi O, Lam CSP, Mahaffey KW. Milvexian: An Oral, Bioavailable Factor XIa Inhibitor. Cardiol Ther 2024:10.1007/s40119-024-00379-0. [PMID: 39152241 DOI: 10.1007/s40119-024-00379-0] [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: 05/26/2024] [Accepted: 07/23/2024] [Indexed: 08/19/2024] Open
Abstract
Direct oral anticoagulants have a dose-dependent increased bleeding risk which limits use in certain populations. Studies in both animals and humans with inherited variations in factor XI levels provide a theoretical basis for a drug target capable of addressing current unmet needs. Milvexian is an oral factor XIa inhibitor that has the potential to provide robust anticoagulant effect without increased bleeding compared with current standard of care. Several key studies in the preclinical, phase I, and phase II stages have reported promising safety data in venous thromboembolism and stroke prevention without compromising hemostasis. The planned phase III trials will examine the efficacy of milvexian for prevention of thrombotic events in patients with acute stroke, acute coronary syndrome, and atrial fibrillation.
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Affiliation(s)
- Shyon Parsa
- Division of Cardiovascular Medicine, Stanford University Hospital, Stanford, CA, USA
| | - Sneha S Jain
- Division of Cardiovascular Medicine, Stanford University Hospital, Stanford, CA, USA
| | - Olu Akinrimisi
- Division of Cardiovascular Medicine, Stanford University Hospital, Stanford, CA, USA
| | - Carolyn S P Lam
- National Heart Center, Singapore, Singapore
- Duke-NUS Graduate Medical School, Singapore, Singapore
- Baim Institute for Clinical Research, Boston, MA, USA
| | - Kenneth W Mahaffey
- Duke-NUS Graduate Medical School, Singapore, Singapore.
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, 300 Pasteur Drive; Grant S-102, Stanford, CA, 94305, USA.
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Zandecki Ł, Ząbczyk M, Undas A. Elevated factor XI is associated with recurrent left ventricular thrombus of unknown origin. Eur J Clin Invest 2024; 54:e14196. [PMID: 38465770 DOI: 10.1111/eci.14196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/23/2024] [Accepted: 03/01/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Elevated factor XI (FXI) has been shown to predispose to thromboembolism. We investigated whether it is associated with left ventricular thrombus (LVT) formation, its recurrence and subsequent thromboembolic events. METHODS In 54 patients with prior LVT of unknown origin, who stopped anticoagulation and 54 controls, we determined FXI, along with plasma clot permeability (Ks), fibrinolysis time (CLT), endogenous thrombin potential (ETP), von Willebrand factor (vWF) and fibrinolysis proteins. During follow-up, the primary endpoint involving the recurrence of LVT a symptomatic ischemic stroke or systemic embolism was recorded. RESULTS Elevated (>120%) FXI levels were more often observed in LVT patients when compared to the control group (14 [25.9%] vs. 6 [11.1%], p = .048) in association with the presence of active FXI. FXI correlated with age (r = .406, p = .002), Ks (r = -.542, p < .001) and CLT (r = .406, p = .002), also after adjustment for age, but not with ETP, vWF or fibrinolysis proteins. During follow-up of 77.6 ± 18.5 months the primary endpoint occurred in 17 (31.5%) LVT patients, including 11 (20.4%) recurrent LVT, and in 4 (7.4%) controls (annual incidence rate 4.9% vs. 1.1%, respectively; p = .002). On multivariate logistic regression analysis, elevated FXI was independently associated with the primary endpoint (OR 1.18; 95% CI 1.09-1.28). CONCLUSIONS Elevated FXI in association with a prothrombotic state characterizes patients with prior LVT of unknown origin and predisposes to its recurrence and/or ischemic stroke during follow-up. It might be speculated that the measurement of FXI helps identify patients who could benefit from prolonged anticoagulation and FXI inhibitors in the future.
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Affiliation(s)
- Łukasz Zandecki
- Institute of Medical Sciences, Jan Kochanowski University, Kielce, Poland
| | - Michał Ząbczyk
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- St. John Paul II Hospital, Krakow, Poland
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- St. John Paul II Hospital, Krakow, Poland
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Sundler Björkman L, Pirouzifard M, Grover SP, Egesten A, Sundquist J, Sundquist K, Zöller B. Increased risk of venous thromboembolism in young and middle-aged individuals with hereditary angioedema: a family study. Blood 2024; 144:435-444. [PMID: 38767511 DOI: 10.1182/blood.2023022996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/23/2024] [Accepted: 04/10/2024] [Indexed: 05/22/2024] Open
Abstract
ABSTRACT Hereditary angioedema (HAE), caused by C1 inhibitor protein deficiency, was recently shown to be associated with an increased risk for venous thromboembolism (VTE). To our knowledge, this is the first national family study of HAE, which aimed to determine the familial risk of VTE. The Swedish Multi-Generation Register was linked to the Swedish National Patient Register for the period of 1964 to 2018. Only patients with HAE with a validated diagnosis were included in the study and were linked to their family members. Hazard ratios (HRs) and 95% confidence intervals (CIs) for VTE were calculated for patients with HAE in comparison with relatives without HAE. Among 2006 individuals (from 276 pedigrees of 365 patients with HAE), 103 individuals were affected by VTE. In total, 35 (9.6%) patients with HAE were affected by VTE, whereas 68 (4.1%) non-HAE relatives were affected (P < .001). The adjusted HR for VTE among patients with HAE was 2.51 (95% CI, 1.67-3.77). Patients with HAE were younger at the first VTE than their non-HAE relatives (mean age, 51 years vs 63 years; P < .001). Before the age of 70 years, the HR for VTE among patients with HAE was 3.62 (95% CI, 2.26-5.80). The HR for VTE for patients with HAE born after 1964 was 8.29 (95% CI, 2.90-23.71). The HR for VTE for patients with HAE who were born in 1964 or earlier was 1.82 (95% CI, 1.14-2.91). HAE is associated with VTE among young and middle-aged individuals in Swedish families with HAE. The effect size of the association is in the order of other thrombophilias. We suggest that HAE may be considered a new rare thrombophilia.
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Affiliation(s)
- Linda Sundler Björkman
- Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
- Division of Hematology, Department of Medicine, UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - MirNabi Pirouzifard
- Department of Clinical Sciences Malmö, Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Steven P Grover
- Division of Hematology, Department of Medicine, UNC Blood Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Arne Egesten
- Respiratory Medicine, Allergology, and Palliative Medicine, Department of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - Jan Sundquist
- Department of Clinical Sciences Malmö, Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Kristina Sundquist
- Department of Clinical Sciences Malmö, Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Bengt Zöller
- Department of Clinical Sciences Malmö, Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
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Zanetto A, Campello E, Spiezia L, Gavasso S, Bulato C, Burra P, Russo FP, Senzolo M, Simioni P. Coagulation factor XI in cirrhosis does not predict thrombo-hemorrhagic complications and hepatic decompensation. Dig Liver Dis 2024:S1590-8658(24)00780-1. [PMID: 38834381 DOI: 10.1016/j.dld.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/16/2024] [Accepted: 05/19/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Factor XI (FXI) is associated with thrombosis in patients without liver disease, but it alterations and prognostic value in cirrhosis are uncertain. PATIENTS AND METHODS We studied a prospective cohort of cirrhosis patients determining FXI and its association with portal vein thrombosis (PVT), bleeding, and hepatic decompensation/ACLF during 1-year follow-up. Odds ratios (OR) and 95 % CIs were calculated using logistic regression. RESULTS We included 183 patients (Child-Pugh [CP] A/B/C 57/59/57). FXI was reduced in cirrhosis, decreasing with CP stage (78 % [66-94] vs. 58 % [44-78] vs. 41 % [30-52] in CP A, B, and C, respectively; p < 0.001). FXI was correlated with MELD score (rho: -0.6, p < 0.001), INR (rho: -0.6, p < 0.001), and platelet count (rho: 0.4, p < 0.001). Sixteen patients (8.7 %) experienced PVT, which only predictor was baseline platelet count (OR: 0.94; CI95 %: 0.91-0.97, p < 0.001). Bleeding occurred in 7 patients (3.8 %). Cirrhosis severity, platelet count, fibrinogen, and FXI (60% vs. 78 %; p = 0.2) were comparable between bleeding and non-bleeding individuals. Finally, no association was found between FXI and hepatic decompensation/ACLF, which were predicted by lower albumin and platelet count, respectively. CONCLUSION FXI seems not to be responsible for thrombosis and cirrhosis progression. The lack of association between low FXI and bleeding events, however, indirectly opens to future studies evaluating FXI inhibitors in cirrhosis.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Elena Campello
- First Chair of Internal Medicine, Department of Medicine (DIMED), Padova University Hospital, Padova, Italy; Thrombotic and Haemorrhagic Disease Unit, Department of Medicine (DIMED), Padova University Hospital, Padova, Italy
| | - Luca Spiezia
- First Chair of Internal Medicine, Department of Medicine (DIMED), Padova University Hospital, Padova, Italy; Thrombotic and Haemorrhagic Disease Unit, Department of Medicine (DIMED), Padova University Hospital, Padova, Italy
| | - Sabrina Gavasso
- Thrombotic and Haemorrhagic Disease Unit, Department of Medicine (DIMED), Padova University Hospital, Padova, Italy
| | - Cristiana Bulato
- Thrombotic and Haemorrhagic Disease Unit, Department of Medicine (DIMED), Padova University Hospital, Padova, Italy
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Francesco Paolo Russo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Paolo Simioni
- First Chair of Internal Medicine, Department of Medicine (DIMED), Padova University Hospital, Padova, Italy; Thrombotic and Haemorrhagic Disease Unit, Department of Medicine (DIMED), Padova University Hospital, Padova, Italy.
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12
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Vlădăreanu AM, Roşca A. Factor XI and coagulation. Factor XI inhibitors - antithrombotic perspectives. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2024; 62:91-100. [PMID: 38153875 DOI: 10.2478/rjim-2023-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Indexed: 12/30/2023]
Abstract
Factor XI is a zymogen with an important role in the coagulation cascade. It is activated by FXII, thrombin and or it can be autoactivated. It has a prothrombotic effect after being activated by thrombin, but also through its antifibrinolytic action, stabilizing the formed clot. Hereditary deficiency of FXI causes haemophilia C - a disease manifested by an usually provoked, small to moderate mucosal bleeding. People with severe FXI deficiency have a low risk of thrombotic events. Conversely, increased FXI values have been found to be associated with increased risk of venous thromboembolism and ischemic stroke. Lowering serum FXI levels has become a treatment target for the prevention of thrombotic events. New pharmacological agents - FXI inhibitors - have been investigated in phase II clinical trials, with promising results in terms of efficacy and safety in the prevention of thrombotic events. FXI inhibitors are emerging as new anticoagulant agents with broad indication prospects beyond direct oral anticoagulants and vitamin K antagonists.
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Affiliation(s)
- Ana-Maria Vlădăreanu
- 1"Carol Davila" University of Medicine and Pharmacy, Department of Hematology, Emergency University Hospital of Bucharest, Romania
| | - Adrian Roşca
- 2"Carol Davila" University of Medicine and Pharmacy, Department of Functional Sciences, Division of Physiology, Bucharest, Romania
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13
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Goodman SG, Roy D, Pollack CV, Leblanc K, Kwaku KF, Barnes GD, Bonaca MP, True Hills M, Campello E, Fanikos J, Connors JM, Weitz JI. Current Gaps in the Provision of Safe and Effective Anticoagulation in Atrial Fibrillation and the Potential for Factor XI-Directed Therapeutics. Crit Pathw Cardiol 2024; 23:47-57. [PMID: 38381695 PMCID: PMC11191052 DOI: 10.1097/hpc.0000000000000351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
The global prevalence of atrial fibrillation is rapidly increasing, in large part due to the aging of the population. Atrial fibrillation is known to increase the risk of thromboembolic stroke by 5 times, but it has been evident for decades that well-managed anticoagulation therapy can greatly attenuate this risk. Despite advances in pharmacology (such as the shift from vitamin K antagonists to direct oral anticoagulants) that have increased the safety and convenience of chronic oral anticoagulation in atrial fibrillation, a preponderance of recent observational data indicates that protection from stroke is poorly achieved on a population basis. This outcomes deficit is multifactorial in origin, stemming from a combination of underprescribing of anticoagulants (often as a result of bleeding concerns by prescribers), limitations of the drugs themselves (drug-drug interactions, bioaccumulation in renal insufficiency, short half-lives that result in lapses in therapeutic effect, etc), and suboptimal patient adherence that results from lack of understanding/education, polypharmacy, fear of bleeding, forgetfulness, and socioeconomic barriers, among other obstacles. Often this adherence is not reported to treating clinicians, further subverting efforts to optimize care. A multidisciplinary, interprofessional panel of clinicians met during the 2023 International Society of Thrombosis and Haemostasis Congress to discuss these gaps in therapy, how they can be more readily recognized, and the potential for factor XI-directed anticoagulants to improve the safety and efficacy of stroke prevention. A full appreciation of this potential requires a reevaluation of traditional teaching about the "coagulation cascade" and decoupling the processes that result in (physiologic) hemostasis and (pathologic) thrombosis. The panel discussion is summarized and presented here.
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Affiliation(s)
- Shaun G. Goodman
- From the Division of Cardiology, St Michael’s Hospital, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
- Canadian VIGOUR Centre and Division of Cardiology, University of Alberta, Edmonton, AB, Canada
| | - Denis Roy
- Department of Medicine and Research Center, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Charles V. Pollack
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Kori Leblanc
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Kevin F. Kwaku
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Geoffrey D. Barnes
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI
| | - Marc P. Bonaca
- Division of Cardiology, CPC Clinical Research, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | | | - Elena Campello
- Department of Medicine, General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Padova University Hospital, Padova, Italy
| | - John Fanikos
- Department of Pharmacy, Brigham and Women’s Hospital
| | - Jean M. Connors
- Hematology Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Jeffrey I. Weitz
- Department of Medicine, McMaster University, Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
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14
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Ali AE, Awad MK, Ali K, Abouzid MR, Ahmed MH, Mazroua MS. Factor XI as a new target for prevention of thromboembolism in cardiovascular disease: a meta-analysis of randomized controlled trials. J Thromb Thrombolysis 2024:10.1007/s11239-024-02986-z. [PMID: 38762711 DOI: 10.1007/s11239-024-02986-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2024] [Indexed: 05/20/2024]
Abstract
Anticoagulant therapy is a mainstay in the management of patients with cardiovascular disease. The use of conventional anticoagulants carries potential side effects, mainly bleeding. Drugs targeting Factor XI (FXI) have been investigated in randomized controlled trials as a new option with more favorable outcomes. A comprehensive literature search was conducted to identify relevant studies comparing FXI inhibitors to placebo or standard therapy. The primary outcomes were incidence of all bleeding events, major bleeding, and thromboembolism. Secondary outcomes included incidence of all adverse events (AE), serious AE, and all-cause mortality. A total of 11 studies involving 10,536 patients were included. FXI inhibitors were associated with a trend toward reduction of bleeding events and incidence of thromboembolism compared to the control group (placebo/standard therapy). There was no statistically significant difference between both groups in terms of adverse events and all-cause mortality. When compared to enoxaparin, FXI inhibitors significantly reduced the risk of bleeding events (RR = 0.42, 95% CI: 0.23-0.76, P = 0.004) and thromboembolism (RR = 0.59, 95% CI: 0.44-0.77, P = 0.001). On the other hand, when compared to DOACs, FXI inhibitors were associated with a significant reduction in bleeding events but not thromboembolism. Whereas, compared to placebo, FXI inhibitors did not increase the risk of bleeding events, adverse events, or all-cause mortality (P > 0.05). FXI inhibitors could be a safer and more potent option for prevention of thromboembolism than conventional therapy.
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Affiliation(s)
- Ahmed E Ali
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed K Awad
- Department of Anesthesia and Critical Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Karim Ali
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed Riad Abouzid
- Department of Medicine, Baptist Hospitals of Southeast Texas, Beaumont, TX, USA
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Marwan H Ahmed
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Muhammad S Mazroua
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
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15
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Morelli VM, Snir O, Hindberg KD, Hveem K, Brækkan SK, Hansen JB. High microRNA-145 plasma levels are associated with decreased risk of future incident venous thromboembolism: the HUNT study. Blood 2024; 143:1773-1781. [PMID: 38211336 DOI: 10.1182/blood.2023022285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/08/2023] [Accepted: 12/26/2023] [Indexed: 01/13/2024] Open
Abstract
ABSTRACT MicroRNA-145 (miR-145) has been reported to downregulate the expression of tissue factor and factor XI in vitro and decrease venous thrombus formation in animal models. However, the association between miR-145 and risk of future venous thromboembolism (VTE) in the general population remains unknown. We investigated the association between plasma levels of miR-145 and risk of future VTE in a case-cohort study. Incident VTE cases (n = 510) and a subcohort (n = 1890) were derived from the third survey of the Trøndelag Health Study (HUNT3), a population-based cohort. The expression levels of miR-145 were measured in plasma samples obtained at baseline. The study population was divided into quartiles based on miR-145 levels in participants in the subcohort, and weighted Cox regression was used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). Plasma levels of miR-145 were inversely associated with VTE risk. Participants with miR-145 levels in the highest quartile had a 49% lower risk of VTE (HR, 0.51; 95% CI, 0.38-0.68) than those with miR-145 in the lowest quartile in age- and sex-adjusted analysis, and the inverse association was most pronounced for unprovoked VTE (HR, 0.39; 95% CI, 0.25-0.61). Risk estimates remained virtually the same after further adjustment for body mass index, and cancer and arterial cardiovascular disease at baseline. In conclusion, elevated expression levels of miR-145 in plasma were associated with decreased risk of future incident VTE. The protective role of miR-145 against VTE is consistent with previous experimental data and suggests that miR-145 has the potential to be a target for VTE prevention.
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Affiliation(s)
- Vânia M Morelli
- Thrombosis Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Thrombosis Research Center, Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Omri Snir
- Thrombosis Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Thrombosis Research Center, Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Kristian Dalsbø Hindberg
- Thrombosis Research Center, Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Kristian Hveem
- K. G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Levanger, Norway
- HUNT Research Center, Department of Public Health and Nursing, Norwegian University of Science and Technology, Levanger, Norway
- Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway
| | - Sigrid K Brækkan
- Thrombosis Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Thrombosis Research Center, Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - John-Bjarne Hansen
- Thrombosis Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Thrombosis Research Center, Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
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16
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Ali AE, Becker RC. Factor XI: structure, function and therapeutic inhibition. J Thromb Thrombolysis 2024:10.1007/s11239-024-02972-5. [PMID: 38622277 DOI: 10.1007/s11239-024-02972-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/17/2024]
Abstract
Arterial and venous thromboembolism is a major medical concern that requires therapeutic anticoagulation in various medical fields to prevent its drastic consequences. Despite significant advances in anticoagulant therapy, thrombosis remains a leading cause of morbidity and mortality worldwide. Traditional anticoagulants like heparin and vitamin K antagonists (VKAs) have shown efficacy in preventing and treating thrombosis but come with an inherent risk of bleeding due to their non-specific inhibition of multiple coagulation factors. Subsequent direct oral anticoagulants (DOACs), targeting specific factors such as Xa or thrombin, demonstrated improved safety profiles compared to VKAs, yet bleeding remains a concern. Accordingly, research is focused on developing anticoagulants with improved safety profiles. A safer class of anticoagulants would have broad appeal. The intrinsic pathway of coagulation, involving factor XI (FXI), has attracted attention as a potential target for safer anticoagulants. Preclinical studies and epidemiological data indicate that FXI deficiency or inhibition protects against thrombosis with minimal bleeding. Current research involves evaluating various FXI-directed strategies, and phase 2 studies have shown promising results in orthopedic surgery, atrial fibrillation, end-stage renal disease (ESRD), myocardial infarction, and ischemic stroke. Several agents, such as antisense oligonucleotides, monoclonal antibodies, small synthetic molecules, natural peptides, and aptamers, have been developed to inhibit FXI at different stages, offering potentially safer alternatives to traditional anticoagulants. However, the optimal balance between preventing thrombosis and the risk of bleeding associated with FXI inhibitors requires validation through extensive phase 3 clinical trials using definite clinical endpoints. Several of such trials are currently underway or planned to define the role of FXI inhibitors in clinical practice and determine the most suitable FXI inhibitor for each specific indication. The current review highlights the rationale behind developing FXI inhibitors, presenting the most advanced agents in development, summarizing completed clinical trials, and discussing ongoing research efforts.
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Affiliation(s)
- Ahmed E Ali
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Richard C Becker
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA.
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17
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Gailani D, Gruber A. Targeting factor XI and factor XIa to prevent thrombosis. Blood 2024; 143:1465-1475. [PMID: 38142404 PMCID: PMC11033593 DOI: 10.1182/blood.2023020722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/22/2023] [Accepted: 12/07/2023] [Indexed: 12/26/2023] Open
Abstract
ABSTRACT Direct oral anticoagulants (DOACs) that inhibit the coagulation proteases thrombin or factor Xa (FXa) have replaced warfarin and other vitamin K antagonists (VKAs) for most indications requiring long-term anticoagulation. In many clinical situations, DOACs are as effective as VKAs, cause less bleeding, and do not require laboratory monitoring. However, because DOACs target proteases that are required for hemostasis, their use increases the risk of serious bleeding. Concerns over therapy-related bleeding undoubtedly contribute to undertreatment of many patients who would benefit from anticoagulation therapy. There is considerable interest in the plasma zymogen factor XI (FXI) and its protease form factor XIa (FXIa) as drug targets for treating and preventing thrombosis. Laboratory and epidemiologic studies support the conclusion that FXI contributes to venous and arterial thrombosis. Based on 70 years of clinical observations of patients lacking FXI, it is anticipated that drugs targeting this protein will cause less severe bleeding than warfarin or DOACs. In phase 2 studies, drugs that inhibit FXI or FXIa prevent venous thromboembolism after total knee arthroplasty as well as, or better than, low molecular weight heparin. Patients with heart disease on FXI or FXIa inhibitors experienced less bleeding than patients taking DOACs. Based on these early results, phase 3 trials have been initiated that compare drugs targeting FXI and FXIa to standard treatments or placebo. Here, we review the contributions of FXI to normal and abnormal coagulation and discuss results from preclinical, nonclinical, and clinical studies of FXI and FXIa inhibitors.
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Affiliation(s)
- David Gailani
- The Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
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18
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Barg AA, Livnat T, Kenet G. Factor XI deficiency: phenotypic age-related considerations and clinical approach towards bleeding risk assessment. Blood 2024; 143:1455-1464. [PMID: 38194679 DOI: 10.1182/blood.2023020721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 12/22/2023] [Accepted: 12/29/2023] [Indexed: 01/11/2024] Open
Abstract
ABSTRACT Factor XI (FXI) deficiency is a rare bleeding disorder that presents complex challenges in patient assessment and bleeding risk management. Despite generally causing mild to moderate bleeding symptoms, clinical manifestations can vary, and bleeding tendency does not always correlate with FXI plasma levels or genotype. Our manuscript delves into the age-related nuances of FXI deficiency across an individual's lifespan. We emphasize issues faced by specific groups, including neonates and females of reproductive age experiencing abnormal uterine bleeding and postpartum hemorrhage. Older patients present unique challenges and concerns related to the management of bleeding as well as thrombotic complications. The current assortment of diagnostic laboratory assays shows limited success in predicting bleeding risk in the perisurgical setting of patients with FXI deficiency. This review explores the intricate interplay between individual bleeding profiles, surgical sites, and FXI activity levels. We also evaluate the accuracy of existing laboratory assays in predicting bleeding and discuss the potential role of investigational global assays in perioperative assessment. Furthermore, we outline our suggested diagnostic approach to refine treatment strategies and decision making. Available treatment options are presented, including antifibrinolytics, replacement products, and recombinant activated FVII. Finally, we discuss promising nonreplacement therapies for the treatment of rare bleeding disorders that can potentially address the challenges faced when managing FXI deficiency-related bleeding complications.
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Affiliation(s)
- Assaf Arie Barg
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institution of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tami Livnat
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institution of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institution of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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19
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Stępień K, Żółciński M, Ząbczyk M, Zalewski J, Undas A. Effect of Three-Day Atorvastatin Administration on Coagulation Factors in Patients With Prior Venous Thromboembolism and Healthy Subjects: A Preliminary Study. J Cardiovasc Pharmacol 2024; 83:289-296. [PMID: 38117119 DOI: 10.1097/fjc.0000000000001529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/02/2023] [Indexed: 12/21/2023]
Abstract
ABSTRACT Statins exert antithrombotic effects, which might contribute to reduced risk of venous thromboembolism (VTE). Rosuvastatin 20 mg/d administered for 4 weeks has been reported to decrease coagulation factors (F) VII, FVIII, and FXI in VTE patients. Moreover, in accordance with recent registry data in non-VTE subjects, statins usage was associated with lower FXI. We investigated whether 3 doses of a statin decrease coagulation factors activity and if such changes can alter fibrin clot properties in VTE patients and healthy subjects. We enrolled 28 consecutive first-ever prior VTE patients after 6 months of anticoagulation and 25 healthy controls well-matched for demographics and lipid profiles (aged 44 [interquartile range 34-51] years) in an interventional nonrandomized study. Before and after 3 doses of atorvastatin 40 mg/d, activity of FVII, FVIII, FIX, and FXI was measured, along with fibrin clot properties, including permeability (Ks) and clot lysis using 3 various assays. After a 3-day statin administration, we observed the decrease of FVII (by 6.2%, P = 0.046) and FXI (by 8.6%, P = 0.044), irrespective of low-density lipoprotein cholesterol reduction (by 24%, P < 0.001), whereas other coagulation factors remained unaltered. Reduction of FVII and FXI activity was inversely correlated with Ks alterations (R = -0.292, P = 0.034 and R = -0.335, P = 0.014, respectively). After adjustment for age, studied group, and fibrinogen level, the reduction of FXI was independently associated with an increase of fibrin clot permeability (B = -0.084, P = 0.027). In conclusion, a 3-day 40 mg atorvastatin administration is sufficient to reduce FVII and FXI activity in our pilot study, which is associated with favorable fibrin clot properties modification.
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Affiliation(s)
- Konrad Stępień
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
- Department of Coronary Artery Disease and Heart Failure, John Paul II Hospital, Kraków, Poland
| | | | - Michał Ząbczyk
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
- Krakow Center for Medical Research and Technologies, John Paul II Hospital, Kraków, Poland ; and
| | - Jarosław Zalewski
- Department of Coronary Artery Disease and Heart Failure, John Paul II Hospital, Kraków, Poland
- Department of Coronary Artery Disease and Heart Failure, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Anetta Undas
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
- Krakow Center for Medical Research and Technologies, John Paul II Hospital, Kraków, Poland ; and
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20
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Bahit MC, Gibson CM. Thrombin as target for prevention of recurrent events after acute coronary syndromes. Thromb Res 2024; 235:116-121. [PMID: 38335566 DOI: 10.1016/j.thromres.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/12/2024]
Abstract
The mechanism underlying thrombus formation in acute coronary syndrome (ACS) involves both platelets and thrombin. While both pathways are targeted in acute care, platelet inhibition has been predominantly administered in the chronic phase, yet thrombin plays a key role in platelet activation and fibrin formation. Among ACS patients, there is also a persistent chronic increase in thrombin generation, which is associated with a higher rate of adverse events. In the setting of post-ACS care with rivaroxaban or vorapaxar, targeting thrombin has been associated with decreased thrombin generation and reduced cardiovascular events, but has been associated with increased bleeding risk. We explored the evidence supporting thrombin generation in the pathophysiology of recurrent events post-ACS and the role of thrombin as a viable therapeutic target. One specific target is factor XI inhibition, which is involved in thrombin generation, but may also allow for the preservation of normal hemostasis.
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Affiliation(s)
- M Cecilia Bahit
- INECO Neurociencias, Rosario, Provincia de Santa Fe, Argentina.
| | - C Michael Gibson
- Baim Institute for Clinical Research, Harvard Medical School, Boston, MA, USA
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21
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Birchansky J, Frishman WH. Milvexian: A Focus on a New Oral Anticoagulant that Targets Factor XIa for Thromboembolism Prophylaxis. Cardiol Rev 2024:00045415-990000000-00162. [PMID: 38305253 DOI: 10.1097/crd.0000000000000588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Drugs that target factor XI and/or XIa have been evaluated as alternatives to existing anticoagulants, in light of studies that indicate that a decrease in Factor XI/XIa levels or activity may result in a lower risk of thrombosis without a significant increase in bleeding risk. Milvexian is an investigational small-molecule factor XIa inhibitor that has recently completed phase 2 clinical trials. Preclinical studies were suggestive of its potential to prevent arterial and venous thrombosis. It was well-tolerated in healthy participants, as well as in participants with mild or moderate hepatic impairment and moderate or severe renal impairment. Notably, patients who received milvexian after knee arthroplasty had a dose-proportional lower incidence of venous thromboembolism compared to patients who received postoperative enoxaparin, and they had a lower incidence of clinically relevant bleeding. A separate phase 2 trial was conducted that assessed the use of milvexian for secondary stroke prevention in patients who had ischemic stroke or transient ischemic attack. It failed its primary objective of establishing a dose-response relationship between milvexian and a composite endpoint of symptomatic ischemic stroke or covert brain infarction. The trial did, however, show a reduction in the relative risk of symptomatic ischemic stroke across most of the treatment groups receiving various dosages of milvexian compared to placebo. The efficacy of milvexian in secondary stroke prevention will be further assessed in an upcoming phase 3 trial. Additional upcoming phase 3 trials will also assess its efficacy in stroke prevention in patients with atrial fibrillation as well as in event reduction in patients with acute coronary syndrome.
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Affiliation(s)
| | - William H Frishman
- Departments of Medicine and Cardiology, New York Medical College, Westchester Medical Center, Valhalla, NY
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22
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Verstraete A, Engelen MM, Van Edom C, Vanassche T, Verhamme P. Reshaping Anticoagulation: Factor XI Inhibition in Thrombosis Management. Hamostaseologie 2024; 44:49-58. [PMID: 38122819 DOI: 10.1055/a-2202-8620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Affiliation(s)
- Andreas Verstraete
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Matthias M Engelen
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Charlotte Van Edom
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
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23
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Weitz JI, Tankó LB, Floege J, Fox KAA, Bhatt DL, Thadhani R, Hung J, Pap ÁF, Kubitza D, Winkelmayer WC. Anticoagulation with osocimab in patients with kidney failure undergoing hemodialysis: a randomized phase 2 trial. Nat Med 2024; 30:435-442. [PMID: 38365952 PMCID: PMC10878964 DOI: 10.1038/s41591-023-02794-7] [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: 07/12/2023] [Accepted: 12/22/2023] [Indexed: 02/18/2024]
Abstract
Individuals with kidney failure undergoing hemodialysis are at elevated risk for thromboembolic events. Factor (F) XI, which is in the intrinsic pathway of coagulation, is emerging as an attractive target for new anticoagulants that may be safer than existing agents. Osocimab-an inhibitory FXIa antibody-is a potential treatment option for such patients. We conducted a phase 2b, double-blind, placebo-controlled trial, in which 704 participants (448 male, 256 female) with kidney failure undergoing hemodialysis were randomized to receive lower- or higher-dose osocimab or placebo. In total, 686 participants (436 male, 250 female) received treatment for ≤18 months (planned minimal treatment period of 6 months). The co-primary outcomes were clinically relevant bleeding (a composite of major and clinically relevant nonmajor bleeding) and a composite of the incidence of moderate, severe or serious adverse events. Clinically relevant bleeding occurred in 16/232 (6.9%) and 11/224 (4.9%) participants who received lower- and higher-dose osocimab, respectively, and in 18/230 participants (7.8%) who received a placebo. For the composite adverse event endpoint, incidences were 51%, 47% and 43% in the lower-dose osocimab, higher-dose osocimab and placebo groups, respectively. These results suggest that osocimab is associated with a low risk of bleeding and is generally well tolerated in this population; findings that require confirmation in larger trials. ClinicalTrials.gov identifier, NCT04523220 .
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Affiliation(s)
- Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Ontario, Canada.
| | - László B Tankó
- Clinical Development and Operations, Bayer Consumer Care AG, Basel, Switzerland
| | - Jürgen Floege
- Division of Nephrology and Rheumatology, RWTH Aachen University Hospital, Aachen, Germany
| | - Keith A A Fox
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Ravi Thadhani
- Emory University School of Medicine, Atlanta, GA, USA
| | - James Hung
- Clinical Development and Operations, Bayer SA, São Paulo, Brazil
| | - Ákos F Pap
- Clinical Data Sciences and Analytics, Bayer AG, Wuppertal, Germany
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Poston JN, Kruse-Jarres R. How I treat von Willebrand disorders in older adults. Blood 2024; 143:197-204. [PMID: 37672774 DOI: 10.1182/blood.2022018534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 05/09/2023] [Accepted: 07/10/2023] [Indexed: 09/08/2023] Open
Abstract
ABSTRACT von Willebrand disease (VWD) is the most common bleeding disorder and especially milder type 1 VWD might not be cared for in specialty clinics. VW factor levels rise with age, but the rise of these levels does not necessarily correlate with bleeding risk. A recent bleeding history combined with recent labs are important for hemostatic management decision during surgical interventions. Antifibrinolytics appear safe in the population of older adults, whereas desmopressin (DDAVP) should be used cautiously. Where needed, factor concentrates present a great treatment option. Acquired von Willebrand syndrome is vastly underrecognized, but likely to surface in the aging, especially in the setting of comorbidities, such as plasma-cell dyscrasias. Intravenous immunoglobulin can be an effective treatment in this scenario, but potentially increases thrombotic risk.
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Affiliation(s)
- Jacqueline N Poston
- Division of Hematology/Oncology, Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
- Division of Clinical Pathology, Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Rebecca Kruse-Jarres
- Washington Center for Bleeding Disorders, Seattle, WA
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
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25
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Wei X, Zhang H, Chen W, Zhang J, Dai J. A study of recurrent life-threatening thrombosis accompanied with the duplication of the factor IX gene. Thromb J 2024; 22:1. [PMID: 38169400 PMCID: PMC10759697 DOI: 10.1186/s12959-023-00570-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024] Open
Abstract
Hereditary predisposition play an important role in thrombosis, especially in younger patients. Here we studied a young patient who experienced three different episodes of severe thromboses, some of which were life-threatening (pulmonary artery thrombosis, portal and mesenteric vein thrombosis, and arterial thrombosis of the lower leg). Blood levels of clotting related indicators were assessed. We screened 35 genes linked to thrombosis. We discovered a 756 kb duplication that spanned the F9 gene in region q27.1 of the X chromosome. The repeat includes the full F9 gene, thus, the patient had two functional copies of FIX with the FIX activity 192%. An identical repetition was found in the patient's mother. Both the patient and his mother had high, but variable, plasma FIX activities that promote coagulation. The patient's frequent, severe thrombolic events maybe attributed to the duplication of a big portion of the F9 gene and lupus anticoagulant positive.
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Affiliation(s)
- Xuqian Wei
- Department of Clinical Laboratory, Shanghai Jiaotong University Affiliated Sixth People' Hospital, Shanghai, China
| | - Houliang Zhang
- Anti-aging Innovation Center, Shanghai Jiaotong University Subei Research Institute, Jiangsu, China
| | - Weibin Chen
- Department of Clinical Laboratory, Shanghai Jiaotong University Affiliated Sixth People' Hospital, Shanghai, China
| | - Jian Zhang
- Department of Vascular Surgery, Shanghai Jiaotong University Affiliated Sixth People' Hospital, Shanghai, China.
| | - Jing Dai
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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26
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Mäder J, Rolling CC, Voigtländer M, Schulenkorf A, Lehr C, Regenhardt J, Bokemeyer C, Beckmann L, Langer F. Effect of factor XI inhibition on tumor cell-induced coagulation activation. J Thromb Haemost 2024; 22:199-212. [PMID: 37751848 DOI: 10.1016/j.jtha.2023.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/29/2023] [Accepted: 09/12/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Cancer-associated thrombosis is a frequent complication in patients with malignancies. While factor XI (FXI)/FXIa inhibition is efficacious in preventing postoperative venous thromboembolism, its role in tumor cell-induced coagulation is less defined. OBJECTIVES We thus aimed to provide mechanistic insights into FXI/FXIa inhibition in tumor cell-induced coagulation activation. METHODS Procoagulant activity (PCA) of 4 different tissue factor (TF) expressing tumor cell lines was analyzed by single-stage clotting and thrombin generation assay in the presence of a FXIa inhibitor, BMS-262084 (BMS), an inhibitory FXI antibody (anti-FXI), or peak and trough concentrations of rivaroxaban or tinzaparin. Further, tumor cell-induced platelet aggregation was recorded. Recombinant human TF served as positive control. RESULTS Although BMS and anti-FXI potently inhibited FXIa amidolytic activity, both inhibitors efficiently mitigated recombinant human TF- and tumor cell-induced fibrin clot formation and platelet aggregation only in the presence of low TF PCA. The anticoagulant effects showed an inverse correlation with the magnitude of cellular TF PCA expression. Similarly, BMS markedly interfered with tumor cell-induced thrombin generation, with the most prominent effects on peak and total thrombin. In addition, anticoagulant effects of FXIa inhibition by 10 μM BMS were in a similar range to those obtained by 600 nM rivaroxaban and 1.6 μM tinzaparin at low TF PCA levels. However, rivaroxaban and tinzaparin also exerted marked anticoagulant activity at high TF PCA levels. CONCLUSION Our findings indicate that FXI/FXIa inhibition interferes with tumor cell-induced coagulation activation only at low TF PCA expression levels, a finding with potential implications for future in vivo studies.
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Affiliation(s)
- Jonathan Mäder
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Christina C Rolling
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Minna Voigtländer
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Anita Schulenkorf
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Carina Lehr
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Judith Regenhardt
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Carsten Bokemeyer
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Lennart Beckmann
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Florian Langer
- II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Hamburg, Germany.
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27
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Kello N, Cho YM. Natural supplements in antiphospholipid syndrome: A case for further study. Clin Immunol 2024; 258:109848. [PMID: 38036277 DOI: 10.1016/j.clim.2023.109848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/27/2023] [Accepted: 11/07/2023] [Indexed: 12/02/2023]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by thrombotic events and/or pregnancy complications in the presence of persistently positive antiphospholipid antibodies (aPL). Although long-term anticoagulation with vitamin K antagonists is considered standard of care, there is an unmet need for safe therapeutics as primary thromboprophylaxis or adjuncts to standard of care in APS. APS is driven by oxidative stress, procoagulant, proinflammatory and angiogenic pathways. For these reasons there has been an increased interest into the investigation of antithrombotic, anti-inflammatory and anti-oxidant properties of natural supplements in APS. The objective of this review is to summarize the mechanistic, epidemiologic and clinical evidence behind the use of natural supplements in APS, with a specific focus on vitamin D, omega-3 fatty acids, coenzyme Q10, gingerol, and isoquercetin. This review should serve as a compelling argument for the future study of natural supplements in APS.
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Affiliation(s)
- Nina Kello
- Northwell Health, Division of Rheumatology, Donald and Barbara Zucker School of Medicine, Great Neck, NY, United States of America.
| | - Young Min Cho
- Northwell Health, Division of Rheumatology, Donald and Barbara Zucker School of Medicine, Great Neck, NY, United States of America
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28
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Pagán-Escribano J, Corral J, Miñano A, Padilla J, Roldán V, Hernández-Vidal MJ, Lozano J, de la Morena-Barrio I, Vicente V, Lozano ML, Herranz MT, de la Morena-Barrio ME. Factor XI in Carriers of Antiphospholipid Antibodies: Elevated Levels Associated with Symptomatic Thrombotic Cases, While Low Levels Linked to Asymptomatic Cases. Int J Mol Sci 2023; 24:16270. [PMID: 38003459 PMCID: PMC10670960 DOI: 10.3390/ijms242216270] [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: 10/06/2023] [Revised: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023] Open
Abstract
Antiphospholipid syndrome (APS) is a thromboinflammatory disorder caused by circulating antiphospholipid autoantibodies (aPL) and characterized by an increased risk of thrombotic events. The pathogenic mechanisms of these antibodies are complex and not fully understood, but disturbances in coagulation and fibrinolysis have been proposed to contribute to the thrombophilic state. This study aims to evaluate the role of an emerging hemostatic molecule, FXI, in the thrombotic risk of patients with aPL. Cross-sectional and observational study of 194 consecutive and unrelated cases with aPL recruited in a single center: 82 asymptomatic (AaPL) and 112 with primary antiphospholipid syndrome (APS). Clinical and epidemiological variables were collected. The profile of aPL was determined. Plasma FXI was evaluated by Western blotting and two coagulation assays (FXI:C). In cases with low FXI, molecular analysis of the F11 gene was performed. FXI:C levels were significantly higher in patients with APS than in patients with AaPL (122.8 ± 33.4 vs. 104.5 ± 27.5; p < 0.001). Multivariate analysis showed a significant association between symptomatic patients with aPL (APS) and high FXI (>150%) (OR = 11.57; 95% CI: 1.47-90.96; p = 0.020). In contrast, low FXI (<70%), mostly caused by inhibitors, was less frequent in the group of patients with APS compared to AaPL (OR = 0.17; 95%CI: 0.36-0.86; p = 0.032). This study suggests that FXI levels may play a causal role in the prothrombotic state induced by aPLs and holds the promise of complementary treatments in APS patients by targeting FXI.
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Affiliation(s)
- Javier Pagán-Escribano
- Servicio de Medicina Interna, Unidad de Enfermedad Tromboembólica, Hospital General Universitario José María Morales Meseguer, 30008 Murcia, Spain; (J.P.-E.); (M.J.H.-V.); (J.L.)
| | - Javier Corral
- Servicio de Hematología Hospital General Universitario José María Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Pascual Parrilla, CIBERER-ISCIII, CEI Campus Mare Nostrum, 30003 Murcia, Spain; (J.C.); (A.M.); (J.P.); (V.R.); (V.V.); (M.L.L.)
| | - Antonia Miñano
- Servicio de Hematología Hospital General Universitario José María Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Pascual Parrilla, CIBERER-ISCIII, CEI Campus Mare Nostrum, 30003 Murcia, Spain; (J.C.); (A.M.); (J.P.); (V.R.); (V.V.); (M.L.L.)
| | - José Padilla
- Servicio de Hematología Hospital General Universitario José María Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Pascual Parrilla, CIBERER-ISCIII, CEI Campus Mare Nostrum, 30003 Murcia, Spain; (J.C.); (A.M.); (J.P.); (V.R.); (V.V.); (M.L.L.)
| | - Vanessa Roldán
- Servicio de Hematología Hospital General Universitario José María Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Pascual Parrilla, CIBERER-ISCIII, CEI Campus Mare Nostrum, 30003 Murcia, Spain; (J.C.); (A.M.); (J.P.); (V.R.); (V.V.); (M.L.L.)
| | - María Julia Hernández-Vidal
- Servicio de Medicina Interna, Unidad de Enfermedad Tromboembólica, Hospital General Universitario José María Morales Meseguer, 30008 Murcia, Spain; (J.P.-E.); (M.J.H.-V.); (J.L.)
| | - Jesús Lozano
- Servicio de Medicina Interna, Unidad de Enfermedad Tromboembólica, Hospital General Universitario José María Morales Meseguer, 30008 Murcia, Spain; (J.P.-E.); (M.J.H.-V.); (J.L.)
| | | | - Vicente Vicente
- Servicio de Hematología Hospital General Universitario José María Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Pascual Parrilla, CIBERER-ISCIII, CEI Campus Mare Nostrum, 30003 Murcia, Spain; (J.C.); (A.M.); (J.P.); (V.R.); (V.V.); (M.L.L.)
| | - María Luisa Lozano
- Servicio de Hematología Hospital General Universitario José María Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Pascual Parrilla, CIBERER-ISCIII, CEI Campus Mare Nostrum, 30003 Murcia, Spain; (J.C.); (A.M.); (J.P.); (V.R.); (V.V.); (M.L.L.)
| | - María Teresa Herranz
- Servicio de Medicina Interna, Unidad de Enfermedad Tromboembólica, Hospital General Universitario José María Morales Meseguer, 30008 Murcia, Spain; (J.P.-E.); (M.J.H.-V.); (J.L.)
| | - María Eugenia de la Morena-Barrio
- Servicio de Hematología Hospital General Universitario José María Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Pascual Parrilla, CIBERER-ISCIII, CEI Campus Mare Nostrum, 30003 Murcia, Spain; (J.C.); (A.M.); (J.P.); (V.R.); (V.V.); (M.L.L.)
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29
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Turkut Tan T, Pariltay E, Avci Durmusaliogu E, Isik E, Cogulu O, Kavakli K, Atik T. A unique case of thrombophilia: the role of F9 gene duplication and increased factor IX activity in cerebral venous thrombosis. J Thromb Haemost 2023; 21:2913-2916. [PMID: 37414287 DOI: 10.1016/j.jtha.2023.06.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/17/2023] [Indexed: 07/08/2023]
Abstract
Cerebral venous thrombosis (CVT) is a rare cerebrovascular disorder characterized by the obstruction of venous channels in the brain. Genetic factors play a significant role in CVT development, and recent studies have identified gain-of-function mutations in coagulation factors, including factor IX (FIX). This case report focuses on a unique neonatal case of CVT, where an X-chromosome duplication involving the F9 gene resulted in increased FIX activity. The neonate presented with feeding difficulties, weight loss, nystagmus, and seizures. Imaging and laboratory tests confirmed a 554-kb X-chromosome duplication encompassing the F9 gene. This genetic abnormality likely contributed to the elevated FIX activity level and subsequent CVT development. Understanding the relationship between coagulation factor abnormalities and CVT risk expands our knowledge of thrombophilia's genetic basis and may aid in the development of targeted treatment strategies for CVT management.
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Affiliation(s)
| | - Erhan Pariltay
- Department of Medical Genetics, Ege University, Bornova, Türkiye
| | | | - Esra Isik
- Department of Pediatric Genetics, Ege University, Bornova, Türkiye
| | - Ozgur Cogulu
- Department of Pediatric Genetics, Ege University, Bornova, Türkiye
| | - Kaan Kavakli
- Department of Pediatric Hematology and Oncology, Ege University, Bornova, Türkiye
| | - Tahir Atik
- Department of Pediatric Genetics, Ege University, Bornova, Türkiye
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30
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Lova A, Pagán J, de la Morena G, Vázquez DJ, Cerezo-Manchado JJ, Bravo-Pérez C, Miñano A, Tomás A, Vicente V, Lozano ML, Corral J, de la Morena-Barrio ME. Congenital factor XI deficiency and risk of heart failure in humans. J Thromb Haemost 2023; 21:2626-2629. [PMID: 37336435 DOI: 10.1016/j.jtha.2023.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 06/21/2023]
Affiliation(s)
- Alejandro Lova
- Unidad de Cardiología, Hospital Virgen del Castillo, Yecla, Spain
| | - Javier Pagán
- Servicio de Medicina Interna, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | | | | | | | - Carlos Bravo-Pérez
- Servicio de Hematología, Hospital General Universitario Morales Messeguer, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, CIBERER-ISCIII, Universidad de Murcia, Murcia, Spain
| | - Antonia Miñano
- Servicio de Hematología, Hospital General Universitario Morales Messeguer, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, CIBERER-ISCIII, Universidad de Murcia, Murcia, Spain
| | - Ana Tomás
- Unidad de Cardiología, Clínica Nueva Seda, Murcia, Spain
| | - Vicente Vicente
- Servicio de Hematología, Hospital General Universitario Morales Messeguer, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, CIBERER-ISCIII, Universidad de Murcia, Murcia, Spain
| | - María Luisa Lozano
- Servicio de Hematología, Hospital General Universitario Morales Messeguer, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, CIBERER-ISCIII, Universidad de Murcia, Murcia, Spain
| | - Javier Corral
- Servicio de Hematología, Hospital General Universitario Morales Messeguer, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, CIBERER-ISCIII, Universidad de Murcia, Murcia, Spain
| | - María Eugenia de la Morena-Barrio
- Servicio de Hematología, Hospital General Universitario Morales Messeguer, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, CIBERER-ISCIII, Universidad de Murcia, Murcia, Spain.
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31
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Marlar RA. Laboratory Evaluation of Antithrombin, Protein C, and Protein S. Semin Thromb Hemost 2023; 49:641-650. [PMID: 36940716 DOI: 10.1055/s-0043-1764468] [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: 03/23/2023]
Abstract
Thrombophilia is a complex disease process, clinically manifesting in various forms of venous thromboembolism. Although both genetic and acquired (or environmental) risks factors have been reported, the presence of a genetic defect (antithrombin [AT], protein C [PC], protein S [PS]) is considered three of the major contributing factors of thrombophilia. The presence of each of these risk factors can be established by clinical laboratory analysis; however, the clinical provider and laboratory personnel must understand the testing limitations and shortcomings associated with the assays for these factors to be able to ensure an accurate diagnosis. This article will describe the major pre-analytical, analytical, and post-analytical issues associated with the various types of assays and discuss evidence-based algorithms for analyzing AT, PC, and PS in plasma.
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Affiliation(s)
- Richard A Marlar
- Department of Pathology, University of New Mexico, TriCore Reference Laboratories, Albuquerque, New Mexico
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32
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D'Allesandro N, Cave B, Hough A. Asundexian: an oral small molecule factor XIa inhibitor for the treatment of thrombotic disorders. Future Cardiol 2023; 19:477-486. [PMID: 37830334 DOI: 10.2217/fca-2023-0051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023] Open
Abstract
Oral anticoagulants, including warfarin and direct oral anticoagulants, are the standard of care for thrombosis prevention and treatment; however, concerns of bleeding often dictate treatment decisions. Inhibition of the intrinsic coagulation system via factor XIa may allow for selective inhibition of the coagulation cascade without significantly impacting hemostasis after injury. Asundexian is an oral small molecule factor XIa inhibitor that, via this novel mechanism, may prove to be a safe and effective option compared with available anticoagulants. Early clinical data for asundexian was promising as a safer alternative to current therapies and prompted further analysis in certain patient populations at increased thrombotic risk. Currently, studies are ongoing to evaluate the safety and efficacy in stroke prevention in atrial fibrillation and in patients following an acute noncardioembolic ischemic stroke or high-risk transient ischemic attack.
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Affiliation(s)
- Nicasia D'Allesandro
- West Palm Beach Veterans Affairs Medical Center, 7305 N Military Trail, West Palm Beach, FL 33410, USA
| | - Brandon Cave
- West Palm Beach Veterans Affairs Medical Center, 7305 N Military Trail, West Palm Beach, FL 33410, USA
| | - Augustus Hough
- West Palm Beach Veterans Affairs Medical Center, 7305 N Military Trail, West Palm Beach, FL 33410, USA
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33
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Spiezia L, Forestan C, Campello E, Simion C, Simioni P. Persistently High Levels of Coagulation Factor XI as a Risk Factor for Venous Thrombosis. J Clin Med 2023; 12:4890. [PMID: 37568292 PMCID: PMC10420025 DOI: 10.3390/jcm12154890] [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: 06/06/2023] [Revised: 07/12/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
Coagulation factor XI (FXI) promotes fibrin formation and inhibits fibrinolysis. Elevated plasma FXI levels, limited to a single measurement, are associated with a higher thrombotic risk. Our case-control study aimed to identify the effect of persistently increased plasma FXI levels on the risk of deep vein thrombosis (DVT). All patients evaluated between January 2016 and January 2018 for a first episode of proximal DVT of the lower extremity were considered for enrolment. Plasma FXI levels were measured at least 1 month after the discontinuation of anticoagulant treatment (T1). The patients with increased plasma FXI levels (>90th percentile of controls) were tested again 3 months later (T2). Among the 200 enrolled patients (M/F 114/86, age range 26-87 years), 47 patients had increased plasma FXI levels at T1 and16 patients had persistently increased plasma FXI levels at T2. The adjusted odds ratio for DVT was 2.4 (95% CI, 1.3 to 5.5, p < 0.001) for patients with increased FXI levels at T1 and 5.2 (95% CI, 2.3 to 13.2, p < 0.001) for patients with persistently high FXI levels at T2. Elevated FXI levels constitute a risk factor for deep vein thrombosis, and this risk nearly doubled in patients with persistently increased plasma FXI levels. Larger prospective studies are needed to confirm our findings.
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Affiliation(s)
- Luca Spiezia
- General Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, University of Padova, 35138 Padova, Italy; (C.F.); (E.C.); (C.S.); (P.S.)
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34
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Wang TF, Khorana AA, Agnelli G, Bloomfield D, Bonaca MP, Büller HR, Connors JM, Goto S, Jing ZC, Kakkar AK, Khder Y, Raskob GE, Soff GA, Verhamme P, Weitz JI, Carrier M. Treatment of Cancer-Associated Thrombosis: Recent Advances, Unmet Needs, and Future Direction. Oncologist 2023; 28:555-564. [PMID: 37171998 PMCID: PMC10322141 DOI: 10.1093/oncolo/oyad116] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 03/24/2023] [Indexed: 05/14/2023] Open
Abstract
Cancer-associated thrombosis, with the incidence rising over the years, is associated with significant morbidity and mortality in patients with cancer. Recent advances in the treatment of cancer-associated venous thromboembolism (VTE) include the introduction of direct oral anticoagulants (DOACs), which provide a more convenient and effective option than low-molecular-weight heparin (LMWH). Nonetheless, important unmet needs remain including an increased risk of bleeding in certain patient subgroups such as those with gastroesophageal cancer, concerns about drug-drug interactions, and management of patients with severe renal impairment. Although DOACs are more convenient than LMWH, persistence can decline over time. Factor XI inhibitors have potential safety advantages over DOACs because factor XI appears to be essential for thrombosis but not hemostasis. In phase II trials, some factor XI inhibitors were superior to enoxaparin for the prevention of VTE after knee replacement surgery without increasing the risk of bleeding. Ongoing trials are assessing the efficacy and safety of factor XI inhibitors for the treatment of cancer-associated VTE.
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Affiliation(s)
- Tzu-Fei Wang
- Department of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Alok A Khorana
- Department of Hematology and Medical Oncology Taussig Cancer Institute Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | | | - Marc P Bonaca
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
- CPC Clinical Research, Aurora, CO, USA
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jean M Connors
- Hematology Division, Brigham and Women’s Hospital, Boston, MA, USA
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Isehara, Japan
| | - Zhi-Cheng Jing
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | | | - Gary E Raskob
- Hudson College of Public Health University of Oklahoma Health Sciences Center Oklahoma City, OK, USA
| | - Gerald A Soff
- General Hematology Service, University of Miami Health System/Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Peter Verhamme
- Department of Cardiovascular Sciences, Vascular Medicine and Hemostasis, KU Leuven, Leuven, Belgium
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Canada
| | - Marc Carrier
- Department of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, Canada
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Grover SP, Snir O, Hindberg K, Englebert TM, Braekkan SK, Morelli VM, Jensen SB, Wolberg AS, Mollnes TE, Ueland T, Mackman N, Hansen JB. High plasma levels of C1-inhibitor are associated with lower risk of future venous thromboembolism. J Thromb Haemost 2023; 21:1849-1860. [PMID: 37003465 PMCID: PMC11112258 DOI: 10.1016/j.jtha.2023.03.024] [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: 01/10/2023] [Revised: 03/02/2023] [Accepted: 03/20/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND C1-inhibitor (C1INH) is a broad-acting serine protease inhibitor with anticoagulant activity. The impact of C1INH plasma levels within the normal physiological range on risk of venous thromboembolism (VTE) is unknown. We assessed the association of plasma C1INH levels and VTE risk and evaluated the impact of C1INH on thrombin and plasmin generation in ex vivo assays. METHODS A nested case-control study with 405 patients with VTE and 829 age- and sex-matched controls was derived from the Tromsø Study. Odds ratios (ORs) with 95% confidence intervals (95% CI) for VTE were estimated across plasma C1INH quartiles. Genetic regulation of C1INH was explored using quantitative trait loci analysis of whole exome sequencing data. The effect of plasma C1INH levels on coagulation was evaluated ex vivo by calibrated automated thrombography. RESULTS Individuals with C1INH levels in the highest quartile had a lower risk of VTE (OR 0.68, 95% CI: 0.49-0.96) compared with those with C1INH in the lowest quartile. In subgroup analysis, the corresponding ORs were 0.60 (95% CI: 0.39-0.89) for deep vein thrombosis and 0.85 (95% CI: 0.52-1.38) for pulmonary embolism, respectively. No significant genetic determinants of plasma C1INH levels were identified. Addition of exogenous C1INH to normal human plasma reduced thrombin generation triggered by an activator of the intrinsic coagulation pathway, but not when triggered by an activator of the extrinsic coagulation pathway. CONCLUSIONS High plasma levels of C1INH were associated with lower risk of VTE, and C1INH inhibited thrombin generation initiated by the intrinsic coagulation pathway ex vivo.
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Affiliation(s)
- Steven P Grover
- Division of Hematology, Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, North Carolina, USA. https://twitter.com/StevenPGrover
| | - Omri Snir
- Thrombosis Research Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Kristian Hindberg
- Thrombosis Research Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway. https://twitter.com/KristianHindbe1
| | - Tatianna M Englebert
- Division of Hematology, Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, North Carolina, USA. https://twitter.com/OlsonTatianna
| | - Sigrid K Braekkan
- Thrombosis Research Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway.
| | - Vânia M Morelli
- Thrombosis Research Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Søren B Jensen
- Thrombosis Research Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, North Carolina, USA. https://twitter.com/aswolberg
| | - Tom Eirik Mollnes
- Research Laboratory, Nordland Hospital, Bodø, Norway; Department of Immunology, Oslo University Hospital and University of Oslo, Norway; Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Thor Ueland
- Thrombosis Research Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway. https://twitter.com/ThorUeland
| | - Nigel Mackman
- Division of Hematology, Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill, North Carolina, USA. https://twitter.com/NMackman
| | - John-Bjarne Hansen
- Thrombosis Research Center, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
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Tantry US, Duhan S, Navarese E, Ramotowski B, Kundan P, Bliden KP, Gurbel P. An update on novel therapies for treating patients with arterial thrombosis. Expert Rev Hematol 2023; 16:593-605. [PMID: 37335893 DOI: 10.1080/17474086.2023.2227788] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/16/2023] [Indexed: 06/21/2023]
Abstract
INTRODUCTION Antithrombotic therapy field is undergoing rapid and significant changes during the past decade. In addition to new therapeutic strategies with existing targets, investigators are exploring the potential use of new targets to address unmet needs to treat patients with arterial diseases. AREAS COVERED We aim to provide an update on and a comprehensive review of the antithrombic agents that are being explored in patients with arterial diseases. We discuss latest developments with respect to upstream antiplatelet agents, and collagen and thrombin pathway inhibitors. We searched PubMed databases for English language articles using keywords: antiplatelet agents, thrombin pathway inhibitors, collagen receptors, arterial disease. EXPERT OPINION Despite implementation of potent P2Y12 inhibitors, there are numerous unmet needs in the treatment of arterial diseases including ceiling effect of currently available antiplatelet agents along with and an elevated risk of bleeding. The latter observations encouraged investigators to explore new targets that can attenuate the generation of platelet-fibrin clot formation and subsequent ischemic event occurrences with minimal effect on bleeding. These targets include collagen receptors on platelets and thrombin generation including FXa, FXIa, and FXIIa. In addition, investigators are studying novel antiplatelet agents/strategies to facilitate upstream therapy in high-risk patients.
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Affiliation(s)
- Udaya S Tantry
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Sanchit Duhan
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Eliano Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Bogumil Ramotowski
- Department of Cardiology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Parshotam Kundan
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Kevin P Bliden
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Paul Gurbel
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, USA
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Tavares V, Assis J, Pinto R, Freitas-Silva M, Medeiros R. Venous thromboembolism-related genetic determinant F11 rs4253417 is a potential prognostic factor in ischaemic stroke. Mol Cell Probes 2023; 70:101917. [PMID: 37364690 DOI: 10.1016/j.mcp.2023.101917] [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: 10/09/2022] [Revised: 06/23/2023] [Accepted: 06/24/2023] [Indexed: 06/28/2023]
Abstract
Ischaemic stroke (IS) and venous thromboembolism (VTE) are two forms of thromboembolism that, although distinct, seem to share numerous risk factors. Concerning genetic risk factors, while many VTE genetic markers have been reported, inclusively by genome-wide association studies (GWAS), the identification and validation of genetic determinants underlying IS pathogenesis have been challenging. Considering that IS and VTE shared biological pathways and aetiological factors, the severity of IS might be also influenced by VTE-related genetic variants. Thus, the present study was designed to analyse the impact of six VTE GWAS-identified genetic variants on the clinical outcome of 363 acute IS patients. Results revealed that the single-nucleotide polymorphism (SNP) F11 rs4253417 was an independent predictor of the 5-year risk of death among patients with total anterior circulation infarct (TACI). Namely, the ones carrying the SNP C allele presented a fourfold increase in the 5-year risk of death compared to TT genotype carriers (CC/CT vs. TT; adjusted HR, 4.240; 95% CI, 1.260-14.270; P = 0.020). This SNP is known to be associated with coagulation factor XI (FXI) levels, thus with implications in haemostasis and inflammation. As such, F11 rs4253417 might be a promising prognostic biomarker among TACI patients to aid in clinical decision-making. However, additional investigation is required to confirm the study's results and dissect the underlying mechanisms.
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Affiliation(s)
- Valéria Tavares
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP), Pathology and Laboratory Medicine Dep., Clinical Pathology SV, RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto), Porto Comprehensive Cancer Center (Porto.CCC), 4200-072, Porto, Portugal; ICBAS, Abel Salazar Institute for the Biomedical Sciences, 4050-313, Porto, Portugal; FMUP, Faculty of Medicine, University of Porto, 4200-072, Porto, Portugal
| | - Joana Assis
- Clinical Research Unit, Research Center of IPO Porto (CI-IPOP), RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto), Porto Comprehensive Cancer Center (Porto.CCC), 4200-072, Porto, Portugal
| | - Ricardo Pinto
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP), Pathology and Laboratory Medicine Dep., Clinical Pathology SV, RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto), Porto Comprehensive Cancer Center (Porto.CCC), 4200-072, Porto, Portugal
| | - Margarida Freitas-Silva
- FMUP, Faculty of Medicine, University of Porto, 4200-072, Porto, Portugal; Department of Medicine, Centro Hospitalar São João, Porto, Portugal
| | - Rui Medeiros
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP), Pathology and Laboratory Medicine Dep., Clinical Pathology SV, RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto), Porto Comprehensive Cancer Center (Porto.CCC), 4200-072, Porto, Portugal; ICBAS, Abel Salazar Institute for the Biomedical Sciences, 4050-313, Porto, Portugal; FMUP, Faculty of Medicine, University of Porto, 4200-072, Porto, Portugal; Research Department, Portuguese League Against Cancer (NRNorte), 4200-172, Porto, Portugal; CEBIMED, Faculty of Health Sciences, Fernando Pessoa University, 4200-150, Porto, Portugal.
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Neto BV, Tavares V, da Silva JB, Liz-Pimenta J, Marques IS, Carvalho L, Salgado L, Pereira D, Medeiros R. Thrombogenesis-associated genetic determinants as predictors of thromboembolism and prognosis in cervical cancer. Sci Rep 2023; 13:9519. [PMID: 37308506 DOI: 10.1038/s41598-023-36161-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/30/2023] [Indexed: 06/14/2023] Open
Abstract
Venous thromboembolism (VTE) is a leading cause of death among cancer patients. Khorana score (KS) is the most studied tool to predict cancer-related VTE, however, it exerts poor sensitivity. Several single-nucleotide polymorphisms (SNPs) have been associated with VTE risk in the general population, but whether they are predictors of cancer-related VTE is a matter of discussion. Compared to other solid tumours, little is known about VTE in the setting of cervical cancer (CC) and whether thrombogenesis-related polymorphisms could be valuable biomarkers in patients with this neoplasia. This study aims to analyse the effect of VTE occurrence on the prognosis of CC patients, explore the predictive capability of KS and the impact of thrombogenesis-related polymorphisms on CC-related VTE incidence and patients' prognosis regardless of VTE. A profile of eight SNPs was evaluated. A retrospective hospital-based cohort study was conducted with 400 CC patients under chemoradiotherapy. SNP genotyping was carried on by using TaqMan® Allelic Discrimination methodology. Time to VTE occurrence and overall survival were the two measures of clinical outcome evaluated. The results indicated that VTE occurrence (8.5%) had a significant impact on the patient's survival (log-rank test, P < 0.001). KS showed poor performance (KS ≥ 3, χ2, P = 0.191). PROCR rs10747514 and RGS7 rs2502448 were significantly associated with the risk of CC-related VTE development (P = 0.021 and P = 0.006, respectively) and represented valuable prognostic biomarkers regardless of VTE (P = 0.004 and P = 0.010, respectively). Thus, thrombogenesis-related genetic polymorphisms may constitute valuable biomarkers among CC patients allowing a more personalized clinical intervention.
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Affiliation(s)
- Beatriz Vieira Neto
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/ Pathology and Laboratory Medicine Dep., Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), 4200-072, Porto, Portugal
- FMUP, Faculty of Medicine, University of Porto, 4200-072, Porto, Portugal
- Research Department, Portuguese League Against Cancer (NRNorte), 4200-172, Porto, Portugal
| | - Valéria Tavares
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/ Pathology and Laboratory Medicine Dep., Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), 4200-072, Porto, Portugal
- FMUP, Faculty of Medicine, University of Porto, 4200-072, Porto, Portugal
- ICBAS, Abel Salazar Institute for the Biomedical Sciences, Rua de Jorge Viterbo Ferreira, 228, 4050-313, Porto, Portugal
- Research Department, Portuguese League Against Cancer (NRNorte), 4200-172, Porto, Portugal
| | - José Brito da Silva
- Oncology Department, Portuguese Institute of Oncology of Porto (IPOP), 4200-072, Porto, Portugal
| | - Joana Liz-Pimenta
- FMUP, Faculty of Medicine, University of Porto, 4200-072, Porto, Portugal
- Department of Medical Oncology, Centro Hospitalar de Trás-os-Montes e Alto Douro (CHTMAD), 5000-508, Vila Real, Portugal
| | - Inês Soares Marques
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/ Pathology and Laboratory Medicine Dep., Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), 4200-072, Porto, Portugal
- FCUP, Faculty of Sciences, University of Porto, 4169-007, Porto, Portugal
| | - Luísa Carvalho
- External Radiotherapy Department, Portuguese Institute of Oncology of Porto (IPOP), 4200-072, Porto, Portugal
| | - Lurdes Salgado
- External Radiotherapy Department, Portuguese Institute of Oncology of Porto (IPOP), 4200-072, Porto, Portugal
| | - Deolinda Pereira
- Oncology Department, Portuguese Institute of Oncology of Porto (IPOP), 4200-072, Porto, Portugal
| | - Rui Medeiros
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/ Pathology and Laboratory Medicine Dep., Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), 4200-072, Porto, Portugal.
- FMUP, Faculty of Medicine, University of Porto, 4200-072, Porto, Portugal.
- ICBAS, Abel Salazar Institute for the Biomedical Sciences, Rua de Jorge Viterbo Ferreira, 228, 4050-313, Porto, Portugal.
- FCUP, Faculty of Sciences, University of Porto, 4169-007, Porto, Portugal.
- Research Department, Portuguese League Against Cancer (NRNorte), 4200-172, Porto, Portugal.
- CEBIMED, Faculty of Health Sciences, Fernando Pessoa University, 4200-150, Porto, Portugal.
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Xia Y, Hu Y, Tang L. Factor XIa Inhibitors as a Novel Anticoagulation Target: Recent Clinical Research Advances. Pharmaceuticals (Basel) 2023; 16:866. [PMID: 37375813 DOI: 10.3390/ph16060866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/03/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND While current clinically administered anticoagulant medications have demonstrated effectiveness, they have also precipitated significant risks: severe bleeding complications including, but not limited to, gastrointestinal hemorrhaging and intracranial and other life-threatening major bleedings. An ongoing effort is being made to identify the best targets for anticoagulant-targeted drugs. Coagulation factor XIa (FXIa) is emerging as an important target of current anticoagulant treatment. OBJECTIVE This review will summarize the development of anticoagulants and recent advances in clinical trials of experimental factor XI inhibitors from a clinical application perspective. RESULTS As of 1 January 2023, our search screening included 33 clinical trials. We summarized the research progress of FXIa inhibitors from seven clinical trials that evaluated their efficacy and safety. The results showed no statistically meaningful distinction in the primary efficacy between patients receiving FXIa inhibitors compared to controls (RR = 0.796; 95% CI: 0.606-1.046; I2 = 68%). The outcomes did not indicate a statistical difference in the occurrence of any bleeding between patients receiving FXIa inhibitors compared to controls (RR = 0.717; 95% CI: 0.502-1.023; I2 = 60%). A subgroup analysis found significant differences in severe bleeding and clinically relevant hemorrhaging in subjects receiving FXIa inhibitors compared to Enoxaparin (RR = 0.457; 95% CI: 0.256-0.816; I2 = 0%). CONCLUSIONS Clinical trials to date have indicated that factor XIa is a potential anticoagulation target, and factor XIa inhibitors may play an important role in the development of anticoagulants.
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Affiliation(s)
- Yunqing Xia
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
- Collaborative Innovation Center of Hematology, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Liang Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
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Coleman JR, Moore EE, Kelher MR, Jones K, Cohen MJ, Banerjee A, Silliman CC. Elucidating the molecular mechanisms of fibrinolytic shutdown after severe injury: The role of thrombin-activatable fibrinolysis inhibitor. J Trauma Acute Care Surg 2023; 94:857-862. [PMID: 36787438 PMCID: PMC10205661 DOI: 10.1097/ta.0000000000003911] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND The mechanisms underlying trauma-induced coagulopathy remain elusive. Hyperfibrinolysis has been linked to increased plasminogen activation and antiprotease consumption; however, the mechanistic players in its counterpart, fibrinolysis shutdown, remain unclear. We hypothesize that thrombin-activatable fibrinolysis inhibitor (TAFI) plays a major role in fibrinolytic shutdown after injury. METHODS As part of this observational cohort study, whole blood was collected from trauma activation patients at a single, level 1 trauma center. Citrated rapid thrombelastography and the following enzyme-linked immunosorbent assays were conducted: thrombin, antithrombin, thrombin-antithrombin complex, TAFI, plasminogen, antiplasmin, plasmin-antiplasmin (PAP), tissue plasminogen activator, plasminogen activator inhibitor 1, and tissue plasminogen activator-plasminogen activator inhibitor 1 complex. Univariate and cluster analysis were performed. RESULTS Overall, 56 patients (median age, 33.5 years; 70% male) were included. The majority (57%) presented after blunt mechanism and with severe injury (median New Injury Severity Score, 27). Two clusters of patients were identified: Group 1 (normal fibrinolysis, n = 21) and Group 2 (fibrinolysis shutdown, n = 35). Group 2 had significantly lower fibrinolysis with a median LY30 of 1.1% (interquartile range [IQR], 0.1-1.9%) versus 2.1% (IQR, 0.5-2.8%) in Group 1; while the median LY30 was within physiologic range, 45% of patients in Group 2 were in shutdown (vs. 24% in Group 1, p = 0.09). Compared with Group 1, Group 2 had significantly higher PAP (median, 4.7 [IQR, 1.7-9.3] vs. 1.4 [1.0-2.1] μg/mL in Group 1; p = 0.002) and higher TAFI (median, 152.5% [IQR, 110.3-190.7%] vs. 121.9% [IQR, 93.2-155.6%]; p = 0.04). There was a strong correlation between PAP and TAFI ( R2 = 0.5, p = 0.0002). CONCLUSION The presented data characterize fibrinolytic shutdown, indicating an initial plasmin burst followed by diminished fibrinolysis, which is distinct from hypofibrinolysis (inadequate plasmin burst and fibrinolysis). After an initial thrombin and plasmin burst (increased PAP), fibrinolysis is inhibited, mediated in part by increased TAFI.
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Affiliation(s)
- Julia R Coleman
- From the Department of Surgery (J.R.C., E.E.M., M.J.C., A.B., C.C.S.), University of Colorado-Denver, Aurora; Department of Surgery (E.E.M.), Ernest E Moore Shock Trauma Center at Denver Health; Department of Cell Biology (K.J.), University of Oklahoma; Vitalant Research Institute (M.R.K.); and Department of Pediatrics (C.C.S.), School of Medicine, University of Colorado Denver, Aurora, Colorado
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Tamargo J, Agewall S, Borghi C, Ceconi C, Cerbai E, Dan GA, Ferdinandy P, Grove EL, Rocca B, Sulzgruber P, Semb AG, Sossalla S, Niessner A, Kaski JC, Dobrev D. New pharmacological agents and novel cardiovascular pharmacotherapy strategies in 2022. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:pvad034. [PMID: 37169875 PMCID: PMC10236523 DOI: 10.1093/ehjcvp/pvad034] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/10/2023] [Accepted: 05/10/2023] [Indexed: 05/13/2023]
Abstract
Cardiovascular diseases (CVD) remain the leading cause of death worldwide and pharmacotherapy of most of them is suboptimal. Thus, there is a clear unmet clinical need to develop new pharmacological strategies with greater efficacy and better safety profiles. In this review, we summarize the most relevant advances in cardiovascular pharmacology in 2022 including the approval of first-in-class drugs that open new avenues for the treatment of obstructive hypertrophic cardiomyopathy (mavacamten), type 2 diabetes mellitus (tirzepatide), and heart failure (HF) independent of left ventricular ejection fraction (sodium-glucose cotransporter 2 inhibitors). We also dealt with fixed dose combination therapies repurposing different formulations of "old" drugs with well-known efficacy and safety for the treatment of patients with acute decompensated HF (acetazolamide plus loop diuretics), atherosclerotic cardiovascular disease (moderate-dose statin plus ezetimibe), Marfan syndrome (angiotensin receptor blockers plus β-blockers), and secondary cardiovascular prevention (i.e. low-dose aspirin, ramipril and atorvastatin), thereby filling existing gaps in knowledge, and opening new avenues for the treatment of CVD. Clinical trials confirming the role of dapagliflozin in patients with HF and mildly reduced or preserved ejection fraction, long-term evolocumab to reduce the risk of cardiovascular events, vitamin K antagonists for stroke prevention in patients with rheumatic heart disease-associated atrial fibrillation, antibiotic prophylaxis in patients at high risk for infective endocarditis before invasive dental procedures, and vutrisiran for the treatment of hereditary transthyretin-related amyloidosis with polyneuropathy were also reviewed. Finally, we briefly discuss recent clinical trials suggesting that FXIa inhibitors may have the potential to uncouple thrombosis from hemostasis and attenuate/prevent thromboembolic events with minimal disruption of hemostasis.
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Affiliation(s)
- Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón, Plaza de Ramón y Cajal s/n, Madrid 28040, Spain
| | - Stefan Agewall
- Department of Cardiology, Oslo University Hospital and Institute of Clinical Medicine, Oslo University, Oslo, Norvay
| | - Claudio Borghi
- Department of Cardiovascular Medicine, University of Bologna-IRCCS AOU S. Orsola, Bologna, Italy
| | - Claudio Ceconi
- Unit of Cardiologia, ASST Garda, Desenzano del Garda, Italy
| | - Elisabetta Cerbai
- Department Neurofarba, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
| | - Gheorghe A Dan
- “Carol Davila” University of Medicine, Colentina University Hospital, Bucharest, Romania
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Bianca Rocca
- Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Patrick Sulzgruber
- Department of Medicine, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Anne Grete Semb
- Preventive Cario-Rheuma Clinic, Division of Research and Innovation, REMEDY Centre, Diakonhjemmet Hospital, Oslo, Norway
| | - Samuel Sossalla
- Department of Internal Medicine II, University Regensburg, Regensburg, Germany
| | - Alexander Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St. George's, University of London, Cranmer Terrace, London SW17 0RE, UK
| | - Dobromir Dobrev
- Institute of Pharmacology, West-German Heart and Vascular Centre, University Duisburg-Essen, Essen, Germany
- Department of Medicine, Montreal Heart Institute and Université de Montréal, Montréal, Canada
- Department of Molecular Physiology & Biophysics, Baylor College of Medicine, Houston, TX, USA
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Litvak M, Shamanaev A, Zalawadiya S, Matafonov A, Kobrin A, Feener EP, Wallisch M, Tucker EI, McCarty OJT, Gailani D. Titanium is a potent inducer of contact activation: implications for intravascular devices. J Thromb Haemost 2023; 21:1200-1213. [PMID: 36696212 PMCID: PMC10621279 DOI: 10.1016/j.jtha.2022.12.014] [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: 09/26/2022] [Revised: 12/07/2022] [Accepted: 12/15/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Titanium (Ti) and its alloys are widely used in manufacturing medical devices because of their strength and resistance to corrosion. Although Ti compounds are considered compatible with blood, they appear to support plasma contact activation and may be thrombogenic. OBJECTIVES The objective of this study was to compare Ti and titanium nitride (TiN) with known activators of contact activation (kaolin and silica) in plasma-clotting assays and to assess binding and activation of factor XII, (FXII), factor XI (FXI), prekallikrein, and high-molecular-weight kininogen (HK) with Ti/TiN. METHODS Ti-based nanospheres and foils were compared with kaolin, silica, and aluminum in plasma-clotting assays. Binding and activation of FXII, prekallikrein, HK, and FXI to surfaces was assessed with western blots and chromogenic assays. RESULTS Using equivalent surface amounts, Ti and TiN were comparable with kaolin and superior to silica, for inducing coagulation and FXII autoactivation. Similar to many inducers of contact activation, Ti and TiN are negatively charged; however, their effects on FXII are not neutralized by the polycation polybrene. Antibodies to FXII, prekallikrein, or FXI or coating Ti with poly-L-arginine blocked Ti-induced coagulation. An antibody to FXII reduced FXII and PK binding to Ti, kallikrein generation, and HK cleavage. CONCLUSION Titanium compounds induce contact activation with a potency comparable with that of kaolin. Binding of FXII with Ti shares some features with FXII binding to soluble polyanions but may have unique features. Inhibitors targeting FXII or FXI may be useful in mitigating Ti-induced contact activation in patients with titanium-based implants that are exposed to blood.
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Affiliation(s)
- Maxim Litvak
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aleksandr Shamanaev
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandip Zalawadiya
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anton Matafonov
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anton Kobrin
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Edward P Feener
- KalVista Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | - Michael Wallisch
- Aronora, Inc., Portland, Oregon, USA; Department of Biomedical Engineering, Oregon Health & Science University, Oregon, USA
| | - Erik I Tucker
- Aronora, Inc., Portland, Oregon, USA; Department of Biomedical Engineering, Oregon Health & Science University, Oregon, USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Oregon, USA
| | - David Gailani
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Thienel M, Müller-Reif JB, Zhang Z, Ehreiser V, Huth J, Shchurovska K, Kilani B, Schweizer L, Geyer PE, Zwiebel M, Novotny J, Lüsebrink E, Little G, Orban M, Nicolai L, El Nemr S, Titova A, Spannagl M, Kindberg J, Evans AL, Mach O, Vogel M, Tiedt S, Ormanns S, Kessler B, Dueck A, Friebe A, Jørgensen PG, Majzoub-Altweck M, Blutke A, Polzin A, Stark K, Kääb S, Maier D, Gibbins JM, Limper U, Frobert O, Mann M, Massberg S, Petzold T. Immobility-associated thromboprotection is conserved across mammalian species from bear to human. Science 2023; 380:178-187. [PMID: 37053338 DOI: 10.1126/science.abo5044] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/10/2023] [Indexed: 04/15/2023]
Abstract
Venous thromboembolism (VTE) comprising deep venous thrombosis and pulmonary embolism is a major cause of morbidity and mortality. Short-term immobility-related conditions are a major risk factor for the development of VTE. Paradoxically, long-term immobilized free-ranging hibernating brown bears and paralyzed spinal cord injury (SCI) patients are protected from VTE. We aimed to identify mechanisms of immobility-associated VTE protection in a cross-species approach. Mass spectrometry-based proteomics revealed an antithrombotic signature in platelets of hibernating brown bears with heat shock protein 47 (HSP47) as the most substantially reduced protein. HSP47 down-regulation or ablation attenuated immune cell activation and neutrophil extracellular trap formation, contributing to thromboprotection in bears, SCI patients, and mice. This cross-species conserved platelet signature may give rise to antithrombotic therapeutics and prognostic markers beyond immobility-associated VTE.
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Affiliation(s)
- Manuela Thienel
- Department of Cardiology, University Hospital, LMU Munich, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, 80802 Munich, Germany
| | - Johannes B Müller-Reif
- Department of Proteomics and Signal Transduction, Max Planck Institute of Biochemistry, 82152 Martinsried, Germany
- Omicera Diagnostics, 82152 Martinsried, Germany
| | - Zhe Zhang
- Department of Cardiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Vincent Ehreiser
- Department of Cardiology, University Hospital, LMU Munich, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, 80802 Munich, Germany
| | - Judith Huth
- Department of Cardiology, University Hospital, LMU Munich, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, 80802 Munich, Germany
| | - Khrystyna Shchurovska
- Department of Cardiology, University Hospital, LMU Munich, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, 80802 Munich, Germany
| | - Badr Kilani
- Department of Cardiology, University Hospital, LMU Munich, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, 80802 Munich, Germany
| | - Lisa Schweizer
- Department of Proteomics and Signal Transduction, Max Planck Institute of Biochemistry, 82152 Martinsried, Germany
| | - Philipp E Geyer
- Department of Proteomics and Signal Transduction, Max Planck Institute of Biochemistry, 82152 Martinsried, Germany
- Omicera Diagnostics, 82152 Martinsried, Germany
| | - Maximilian Zwiebel
- Department of Proteomics and Signal Transduction, Max Planck Institute of Biochemistry, 82152 Martinsried, Germany
| | - Julia Novotny
- Department of Cardiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Enzo Lüsebrink
- Department of Cardiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Gemma Little
- Institute for Cardiovascular and Metabolic Research, School of Biological Sciences, Health and Life Sciences Building, University of Reading, RG6 6UR, UK
| | - Martin Orban
- Department of Cardiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Leo Nicolai
- Department of Cardiology, University Hospital, LMU Munich, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, 80802 Munich, Germany
| | - Shaza El Nemr
- Department of Cardiology, University Hospital, LMU Munich, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, 80802 Munich, Germany
| | - Anna Titova
- Department of Cardiology, University Hospital, LMU Munich, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, 80802 Munich, Germany
| | - Michael Spannagl
- Anesthesiology and Transfusion Medicine, Cell Therapeutics and Hemostaseology, Ludwig-Maximilians-University Munich, 80336 Munich, Germany
| | - Jonas Kindberg
- Norwegian Institute for Nature Research, 7034 Trondheim, Norway
- Scandinavian Brown Bear Research Project, Tackåsen 2, SE-79498 Orsa, Sweden
- Department of Wildlife, Fish and Environmental Studies, Swedish University of Agricultural Sciences, SE-90183 Umeå, Sweden
| | - Alina L Evans
- Department of Forestry and Wildlife Management, Faculty of Applied Ecology and Agricultural Sciences, Inland Norway University of Applied Sciences, 2480 Koppang, Norway
| | - Orpheus Mach
- Zentrum für Rückenmarkverletzte mit Neuro-Urologie, BG Unfallklinik Murnau, 82418 Murnau am Staffelsee, Germany
| | - Matthias Vogel
- Zentrum für Rückenmarkverletzte mit Neuro-Urologie, BG Unfallklinik Murnau, 82418 Murnau am Staffelsee, Germany
| | - Steffen Tiedt
- Neurologische Klinik und Poliklinik, Klinikum der Universität München, Ludwig-Maximilians- University Munich, 81377 Munich, Germany
| | - Steffen Ormanns
- Pathologisches Institut, Klinikum der Universität München, Ludwig-Maximilians- University Munich, 81377 Munich, Germany
| | - Barbara Kessler
- Gene Center, Ludwig-Maximilians-University Munich, 81377 Munich, Germany
| | - Anne Dueck
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, 80802 Munich, Germany
- Institute of Pharmacology and Toxicology, Technical University of Munich, 80802 Munich, Germany
| | - Andrea Friebe
- Norwegian Institute for Nature Research, 7034 Trondheim, Norway
- Scandinavian Brown Bear Research Project, Tackåsen 2, SE-79498 Orsa, Sweden
| | - Peter Godsk Jørgensen
- Herlev and Gentofte University Hospital, Borgmester Ib Juuls Vej 1, DK-2730, Herlev, Copenhagen, Denmark
| | - Monir Majzoub-Altweck
- Institute of Veterinary Pathology, Center for Clinical Veterinary Medicine, LMU Munich, 80539 Munich, Germany
| | - Andreas Blutke
- Institute of Veterinary Pathology, Center for Clinical Veterinary Medicine, LMU Munich, 80539 Munich, Germany
| | - Amin Polzin
- Division of Cardiology, Pulmonology, and Vascular Medicine, Heinrich Heine University Medical Center Dusseldorf, 40225 Dusseldorf, Germany
| | - Konstantin Stark
- Department of Cardiology, University Hospital, LMU Munich, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, 80802 Munich, Germany
| | - Stefan Kääb
- Department of Cardiology, University Hospital, LMU Munich, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, 80802 Munich, Germany
| | - Doris Maier
- Zentrum für Rückenmarkverletzte mit Neuro-Urologie, BG Unfallklinik Murnau, 82418 Murnau am Staffelsee, Germany
| | - Jonathan M Gibbins
- Institute for Cardiovascular and Metabolic Research, School of Biological Sciences, Health and Life Sciences Building, University of Reading, RG6 6UR, UK
| | - Ulrich Limper
- Institute of Aerospace Medicine, German Aerospace Center (DLR), 51147 Cologne, Germany
- Department of Anesthesiology and Intensive Care Medicine, Merheim Medical Center, Hospitals of Cologne, University of Witten/Herdecke, 51109 Cologne, Germany
| | - Ole Frobert
- Faculty of Health, Department of Cardiology, Örebro University, 701 85 Örebro, Sweden
- Department of Clinical Medicine, Faculty of Health, Aarhus University, 8000 Aarhus, Denmark
- Department of Clinical Pharmacology, Aarhus University Hospital, 8000 Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, 8000 Aarhus, Denmark
| | - Matthias Mann
- Department of Proteomics and Signal Transduction, Max Planck Institute of Biochemistry, 82152 Martinsried, Germany
| | - Steffen Massberg
- Department of Cardiology, University Hospital, LMU Munich, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, 80802 Munich, Germany
| | - Tobias Petzold
- Department of Cardiology, University Hospital, LMU Munich, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, 80802 Munich, Germany
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Wang X, Li Q, Du F, Shukla N, Nawrocki AR, Chintala M. Antithrombotic Effects of the Novel Small-Molecule Factor XIa Inhibitor Milvexian in a Rabbit Arteriovenous Shunt Model of Venous Thrombosis. TH OPEN 2023; 7:e97-e104. [PMID: 37101592 PMCID: PMC10125780 DOI: 10.1055/a-2061-3311] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/20/2023] [Indexed: 04/28/2023] Open
Abstract
Background Factor XIa (FXIa) is an emerging therapeutic target, and FXIa inhibition is a promising mechanism to improve therapeutic index over current anticoagulants. Milvexian (BMS-986177/JNJ-70033093) is an oral small-molecule FXIa inhibitor. Objective Milvexian's antithrombotic efficacy was characterized in a rabbit arteriovenous (AV) shunt model of venous thrombosis and compared with the factor Xa inhibitor apixaban and the direct thrombin inhibitor dabigatran. Methods The AV shunt model of thrombosis was conducted in anesthetized rabbits. Vehicle or drugs were administered as intravenous bolus plus a continuous infusion. Thrombus weight was the primary efficacy endpoint. Ex vivo activated partial thromboplastin time (aPTT), prothrombin time (PT), and thrombin time (TT) were measured as the pharmacodynamic responses. Results Milvexian dose dependently reduced thrombus weights by 34.3 ± 7.9, 51.6 ± 6.8 ( p < 0.01; n = 5), and 66.9 ± 4.8% ( p < 0.001; n = 6) versus vehicle at 0.25 + 0.17, 1.0 + 0.67, and 4.0 ± 2.68 mg/kg bolus + mg/kg/h infusion, respectively. Ex vivo clotting data supported a dose-dependent prolongation of aPTT (with 1.54-, 2.23-, and 3.12-fold increases from baseline upon the AV shunt start), but no changes in PT and TT. Dose-dependent inhibition in thrombus weight and clotting assays was also demonstrated for both apixaban and dabigatran as the references for the model validation. Conclusion Results demonstrate that milvexian is an effective anticoagulant for prevention of venous thrombosis in the rabbit model, which supports the utility of milvexian in venous thrombosis, as seen in the phase 2 clinical study.
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Affiliation(s)
- Xinkang Wang
- Cardiovascular & Metabolism Therapeutic Area, Janssen Research & Development, LLC, Spring House, Pennsylvania, United States
- Address for correspondence Xinkang Wang, PhD Janssen Research & Development, LLC1400 McKean Road, 42-2522, Spring House, PA 19002United States
| | - Qiu Li
- Cardiovascular & Metabolism Therapeutic Area, Janssen Research & Development, LLC, Spring House, Pennsylvania, United States
| | - Fuyong Du
- Cardiovascular & Metabolism Therapeutic Area, Janssen Research & Development, LLC, Spring House, Pennsylvania, United States
| | - Neetu Shukla
- Formulation, Janssen Research & Development, LLC, Spring House, Pennsylvania, United States
| | - Andrea R. Nawrocki
- Cardiovascular & Metabolism Therapeutic Area, Janssen Research & Development, LLC, Spring House, Pennsylvania, United States
| | - Madhu Chintala
- Cardiovascular & Metabolism Therapeutic Area, Janssen Research & Development, LLC, Spring House, Pennsylvania, United States
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45
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Muscente F, De Caterina R. The new in anticoagulation: factor XI inhibitors. Eur Heart J Suppl 2023; 25:B65-B68. [PMID: 37091652 PMCID: PMC10120978 DOI: 10.1093/eurheartjsupp/suad070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Haemostasis and thrombosis are closely linked, so that any anticoagulant strategy available today that reduces the thrombotic risk inevitably increases the bleeding risk. However, epidemiological and experimental evidence suggests that inhibiting the contact pathway-the first phase of the intrinsic coagulation pathway-and especially factor XI (FXI) achieves the objective of preventing thrombosis with minimal interference on the haemostatic process. Several pharmacological strategies that act by inhibiting FXI are being studied in clinical trials. Specifically, Phase 2 clinical trials in patients undergoing major orthopaedic surgery, end-stage renal disease, atrial fibrillation (AF), and acute coronary syndrome have shown promising results, allowing clinical research to advance into Phase 3 clinical trials. FXI inhibitors will not necessarily replace currently available direct oral anticoagulants: this would appear too ambitious as of today. However, it is possible to hypothesize that FXI inhibitors are a useful addition to our therapeutic armamentarium in contexts where current anticoagulants have failed or have not been adequately tested, as well as in categories of patients who are at a high risk of bleeding even with current direct oral anticoagulants.
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46
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Modrzycka S, Kołt S, Adams TE, Potoczek S, Huntington JA, Kasperkiewicz P, Drąg M. Fluorescent Activity-Based Probe To Image and Inhibit Factor XIa Activity in Human Plasma. J Med Chem 2023; 66:3785-3797. [PMID: 36898159 PMCID: PMC10041521 DOI: 10.1021/acs.jmedchem.2c00845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
Anticoagulation therapy is a mainstay of the treatment of thrombotic disorders; however, conventional anticoagulants trade antithrombotic benefits for bleeding risk. Factor (f) XI deficiency, known as hemophilia C, rarely causes spontaneous bleeding, suggesting that fXI plays a limited role in hemostasis. In contrast, individuals with congenital fXI deficiency display a reduced incidence of ischemic stroke and venous thromboembolism, indicating that fXI plays a role in thrombosis. For these reasons, there is intense interest in pursuing fXI/factor XIa (fXIa) as targets for achieving antithrombotic benefit with reduced bleeding risk. To obtain selective inhibitors of fXIa, we employed libraries of natural and unnatural amino acids to profile fXIa substrate preferences. We developed chemical tools for investigating fXIa activity, such as substrates, inhibitors, and activity-based probes (ABPs). Finally, we demonstrated that our ABP selectively labels fXIa in the human plasma, making this tool suitable for further studies on the role of fXIa in biological samples.
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Affiliation(s)
- Sylwia Modrzycka
- Department of Chemical Biology and Bioimaging, Faculty of Chemistry, Wrocław University of Science and Technology, Wybrzeże Wyspiańskiego 27, 50-370 Wrocław, Poland
| | - Sonia Kołt
- Department of Chemical Biology and Bioimaging, Faculty of Chemistry, Wrocław University of Science and Technology, Wybrzeże Wyspiańskiego 27, 50-370 Wrocław, Poland
| | - Ty E Adams
- Department of Haematology, Cambridge Institute for Medical Research, University of Cambridge, The Keith Peters Building, Hills Road, Cambridge CB2 0XY, U.K
| | - Stanisław Potoczek
- Department of Haematology, Blood Neoplasms, and Bone Marrow Transplantation, Wrocław Medical University, Pasteura 1, 50-367 Wrocław, Poland
| | - James A Huntington
- Department of Haematology, Cambridge Institute for Medical Research, University of Cambridge, The Keith Peters Building, Hills Road, Cambridge CB2 0XY, U.K
| | - Paulina Kasperkiewicz
- Department of Chemical Biology and Bioimaging, Faculty of Chemistry, Wrocław University of Science and Technology, Wybrzeże Wyspiańskiego 27, 50-370 Wrocław, Poland
| | - Marcin Drąg
- Department of Chemical Biology and Bioimaging, Faculty of Chemistry, Wrocław University of Science and Technology, Wybrzeże Wyspiańskiego 27, 50-370 Wrocław, Poland
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47
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Affiliation(s)
- Eugene Braunwald
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Hale Building for Transformative Medicine, Suite 7022, 60 Fenwood Road, Boston, MA 02115, USA
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48
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Greco A, Laudani C, Spagnolo M, Agnello F, Faro DC, Finocchiaro S, Legnazzi M, Mauro MS, Mazzone PM, Occhipinti G, Rochira C, Scalia L, Capodanno D. Pharmacology and Clinical Development of Factor XI Inhibitors. Circulation 2023; 147:897-913. [PMID: 36913497 DOI: 10.1161/circulationaha.122.062353] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Therapeutic anticoagulation is indicated for a variety of circumstances and conditions in several fields of medicine to prevent or treat venous and arterial thromboembolism. According to the different mechanisms of action, the available parenteral and oral anticoagulant drugs share the common principle of hampering or blocking key steps of the coagulation cascade, which unavoidably comes at the price of an increased propensity to bleed. Hemorrhagic complications affect patient prognosis both directly and indirectly (ie, by preventing the adoption of an effective antithrombotic strategy). Inhibition of factor XI (FXI) has emerged as a strategy with the potential to uncouple the pharmacological effect and the adverse events of anticoagulant therapy. This observation is based on the differential contribution of FXI to thrombus amplification, in which it plays a major role, and hemostasis, in which it plays an ancillary role in final clot consolidation. Several agents were developed to inhibit FXI at different stages (ie, suppressing biosynthesis, preventing zymogen activation, or impeding the biological action of the active form), including antisense oligonucleotides, monoclonal antibodies, small synthetic molecules, natural peptides, and aptamers. Phase 2 studies of different classes of FXI inhibitors in orthopedic surgery suggested that dose-dependent reductions in thrombotic complications are not paralleled by dose-dependent increases in bleeding compared with low-molecular-weight heparin. Likewise, the FXI inhibitor asundexian was associated with lower rates of bleeding compared with the activated factor X inhibitor apixaban in patients with atrial fibrillation, although no evidence of a therapeutic effect on stroke prevention is available so far. FXI inhibition could also be appealing for patients with other conditions, including end-stage renal disease, noncardioembolic stroke, or acute myocardial infarction, for which other phase 2 studies have been conducted. The balance between thromboprophylaxis and bleeding achieved by FXI inhibitors needs confirmation in large-scale phase 3 clinical trials powered for clinical end points. Several of such trials are ongoing or planned to define the role of FXI inhibitors in clinical practice and to clarify which FXI inhibitor may be most suited for each clinical indication. This article reviews the rationale, pharmacology, results of medium or small phase 2 studies, and future perspectives of drugs inhibiting FXI.
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Affiliation(s)
- Antonio Greco
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Claudio Laudani
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Marco Spagnolo
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Federica Agnello
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | | | - Simone Finocchiaro
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Marco Legnazzi
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Maria Sara Mauro
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | | | | | - Carla Rochira
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Lorenzo Scalia
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Davide Capodanno
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
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49
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Role of factor VIII, IX, and XI in venous thrombosis recurrence risk in adults and children: A systematic review. Res Pract Thromb Haemost 2023; 7:100064. [PMID: 36852262 PMCID: PMC9958483 DOI: 10.1016/j.rpth.2023.100064] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/05/2022] [Accepted: 01/03/2023] [Indexed: 02/05/2023] Open
Abstract
Background Predicting recurrent venous thromboembolic events (VTEs) is challenging in clinical practice for both adults and children, but it is relevant for clinical management. Identifying laboratory risk factors for VTE recurrence may aid in clinical decision-making. Objective The goal of this systematic review is to investigate the predictive role of FVIII, IX, or XI in recurrent VTE in adult and pediatric patients with a first VTE. Methods A systematic review of the published literature was conducted in databases MEDLINE In-Process, Other Nonindexed Citations, MEDLINE Epub Ahead of Print, EMBASE Classic + EMBASE (OvidSP), and Cochrane (Wiley). We included observational and interventional studies that comprised adults or children with a first VTE, FVIII, FIX, and/or FXI and objectively confirmed VTE recurrence. The quality in prognosis studies tool was used to assess the risk of bias. Results We identified 2177 unique studies, of which 19 were included (18 for adults and 1 for children). The risk of bias was overall low to moderate. The studies were heterogenous with regards to population (provoked/unprovoked primary VTE), exposure (type of assay and cut-off values), and statistical analysis results (measures of association and modeling strategy). In adults, contradictory evidence was found for FVIII and FXI as outcome predictors, while no research could establish if FIX predicts VTE recurrence. Data in pediatrics were limited. Given the extensive heterogeneity of the literature, a meta-analysis was not performed. Conclusions Overall, there is contradictory evidence that FVIII, FIX, or FXI predict recurrent VTE in adults and children. Addressing heterogeneity is a relevant aspect to consider in future studies investigating prognostic factors for VTE recurrence.
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50
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Koulas I, Spyropoulos AC. A Review of FXIa Inhibition as a Novel Target for Anticoagulation. Hamostaseologie 2023; 43:28-36. [PMID: 36807817 DOI: 10.1055/a-1984-7021] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Limitations of vitamin K antagonists as chronic oral anticoagulant therapy have largely been supplanted by direct factor IIa and factor Xa inhibitor oral anticoagulants with similar efficacy but an overall better safety profile, lack of routine monitoring, and very limited drug-drug interactions compared with agents such as warfarin. However, an increased risk of bleeding remains even with these new-generation oral anticoagulants in fragile patient populations, in patients requiring dual or triple antithrombotic therapy, or high bleed risk surgeries. Epidemiologic data in patients with hereditary factor XI deficiency and preclinical studies support the notion that factor XIa inhibitors have the ability to be an effective but potentially safer alternative to existing anticoagulants, based on their ability to prevent thrombosis directly within the intrinsic pathway without affecting hemostatic mechanisms. As such, various types of factor XIa inhibitors have been studied in early phase clinical studies, including inhibitors of the biosynthesis of factor XIa with antisense oligonucleotides or direct inhibitors of factor XIa using small peptidomimetic molecules, monoclonal antibodies, aptamers, or natural inhibitors. In this review, we discuss how different types of factor XIa inhibitors work and present findings from recently published Phase II clinical trials across multiple indications, including stroke prevention in atrial fibrillation, dual pathway inhibition with concurrent antiplatelets post-myocardial infarction, and thromboprophylaxis of orthopaedic surgery patients. Finally, we refer to ongoing Phase III clinical trials of factor XIa inhibitors and their potential to provide definitive answers regarding their safety and efficacy in preventing thromboembolic events in specific patient groups.
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Affiliation(s)
- Ioannis Koulas
- The Institute of Health Systems Science at the Feinstein Institutes for Medical Research, Manhasset, New York, United States
| | - Alex C Spyropoulos
- The Institute of Health Systems Science at the Feinstein Institutes for Medical Research, Manhasset, New York, United States.,Northwell Health at Lenox Hill Hospital, New York, New York, United States.,The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
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